Perceived social support as related to social wellbeing in patients with Emotionally Unstable Personality Disorder (EUPD)

People diagnosed with EUPD also known as borderline personality disorder (BPD) experience different challenges in their lives. These challenges include compulsive behavior, irritability, depression, sadness, guilt, shame, loneliness, grandiosity, and feeling of worthlessness. It is noteworthy that such challenges trigger among them a self-destructive behaviour, in addition to social isolation, and impaired social relationships. It is also found to significantly impact their physical, mental, and social wellbeing. This study is a humble attempt to examine the role of perceived social support in improving the social wellbeing of BPD outpatients. Through the purposive sampling technique, 100 BPD outpatients were selected for the study. The mean age of the participant was 25 years. It was found that perceived social support (family, friends, and significant others) plays a vital role in the wellbeing of these participants. The correlation between the two is positive as well as statistically significant. This means higher the support these patients experience from their relatives, the better is their social wellbeing. This study has practical implications for counselors, clinical psychologists, and psychiatrists working in the field.


Background
Borderline personality disorder (BPD) is a diagnostic classification defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [1]. It is a severe psychological illness specified by prevalent instability in a frame of mind, Intelligence Quotient, romantic and social relationships, and self-concept. BPD is defined as uncertainty in an association, mood swings, together with an unpredictable behavior.
Aforementioned instability frequently disturbs family relations, business, and profession, long-term foresight, as well as the particular's sense of self-identity. Persistent maladjustment in a societal-relations is a key attribute of BPD [2]. This personality disorder has been linked to a higher degree of social disability like disability in psychological functioning, insufficient companionship and affiliation, difficulties in family connections although a drop in symptoms of BPD was connected in ameliorating of psychosocial operating pessimistic unfairness in the processing of social information detected in patients with BPD [3][4][5]. There is research by [6] which put forward that exploitation by companions in teenage enlarge the possibility of developing BPD features in the adolescence.
Studies had suggested that mutual alliance amid disproving parenting behaviours upshots in BPD features in the teenage period of an individual [7]. Particulars diagnosed with BPD have conflict in close relations, which could differently deduce robust psychological health wellbeing [8]. The harmful consequences of interpersonal *Correspondence: gullmubashir@gmail.com difficulties habitually happening in conditions of attributes of BPD might share to decrease in meaning of life.
Density mentions to the level of interrelatedness amid individuals in the network, as well as it is notion to specify group cohesion [9]. On the other hand, the level of centrality is one of the most ordinal ways for measuring the place of a particular alter within a central to an individual social network. One study has observed that individuals who are experiencing depression tend to be insignificant in social networks although individuals who change to sizeable inseparability tend to afterward too came to be contented [10,11]. Taking into consideration previously mentioned results, inseparability is expected to be insignificant amid particular diagnosed with BPD, a stigma together with relational complications, namely, acute exasperation and inconsistent connections [12]. Therefore, individuals who are attached to more inseparable figures are expected to practice more optimistic consequences [13].

Perceived social support and BPD
Social support, extracted from ancestries, boon companion and an instructional-groups, which certainly affects wellbeing [14][15][16]. Social support is a multifaceted conception, mentioning support which is social as well as subjective that particulars acquire as accessible to themselves from ancestry, peers, and the individual communal groups [17,18].
Perceived social support indicates to the opinion that aid would be obtainable when desired [19]. There is a considerable verification that call attention to a character of social support in encouraging mental health with defensive upshots in social support [20][21][22][23][24][25][26]. Greater level of social aid has been appeared to be correlated with ameliorated mental wellbeing [27][28][29][30]. Individuals diagnosed with BPD and had poorer support have more quarrels in their connectivity and less relationships with prime individuals [31].
Social support and social interactions are crucial in adolescent folk for robust personality development [32]. Patients with BPD patients are ordinarily prone to adverse stimuli, have hardships in acknowledging a definite affective wellness in alternatives [4] together with these patients are at lower levels in perceived social support as compared to widespread population. Patients with BPD receive their social connections as more inconsistent and more unsteady as compared to healthy beings [33]. BPD patient's level of pliability and capacity to manage with complications as well as gloomy emotions may amplify with an increment in perceived social support [34,35]. Inpatients detected with the BPD address higher rate of rejection sensitivity detected rejection sensitivity to be crucial in individuals through which BPD attributes upshots to lower levels of social support [36].
Robust social supports and connections together with involvement in comforting and counseling, release of the past, and engagement in purposeful pursuits ease recovery, ultimately keeping dysfunctional relationships with members of a family was impairment to recovery [37].
Taking into consideration the contemporary social connections with mothers and fathers, it is detected that youngsters who are evolving with personality disorders are further expected to contact with disputes with their family members all over the transformation to maturation [38]. BPD attributes were also interconnected in boosting pessimistic connections with the mother [38]. Parental aid is a safeguarding element for dissimilar displays of mental illness and particularly in mother-daughter connections definite motherly emotional attitudes and constructive dual emotional attitudes appear to be correlated with minimizing in the female's BPD seriousness over time [39,40]. Thus, social support is constantly connected with fine psychological health and social wellbeing [41]. Optimistic communal interactions with members of the family decreases apprehension and advance the feeling of invulnerability and protection [42][43][44]. Individuals with more absolute moral communal connections and higher social support have the advantage of more effective interpersonal skills, and directs them aside from psychological and mental complications [45].
In the modern time, the corroboration has revealed that BPD attributes bestows in teenagers and that the recognition of BPD is as a consequence justified before to teenage [46]. For youngsters, a fundamental standard in the diagnosis of BPD-uncertainty of mutual connections [1]-might be evident not only in romantic relations perceived in person with BPD or in an association standard with ancestry of origin, but in connections with friends. Peer associations in teens and youth, the foundation of optimistic, supportive peer associations marks one of the crucial advancement jobs in teens and youth [47]. Infants and adolescents operate to obtain social competence in beginning and keeping and continuing relationships, cooperating and functioning productively with others, reducing and sorting out a quarrel, and assisting and experiencing aid when required [48]. At the comprehensive level, sufficient social competence is considered in acceptance and incorporation in a peer group. Infancy period complications in building and keeping boon companions is still a retroactive gauge for caregivers of infants who go on to evolve with BPD [49]. There is a corroboration that deficient relationships are ordinary amid adolescents with BPD. The particular intervention was encouraging, through be in need of duplication with a control group incorporated, putting forward that therapy for BPD in youngster might be constructive in ameliorating companion's relations [50]. Behavioral economic and neuroeconomic approaches to the research of incentive valuation might be relevant to study on youngster BPD, demonstrating intense insights into neural and mental processes which may influence on positive peer associations [51]. One research has spotlighted that character of disintegration of belief and an expected refusal as drivers of defective social consequences while in specific manner as bring about irritation and hostile social communication between adolescent folk diagnosed with personality disorders [52]. The idea that particulars with BPD are tactful to refusal cues and predict social refusal [53].

Social wellbeing and BPD
Wellbeing is the systematized elements of physical, psychological, and social wellbeing which expands away from a conventional definition of health [54]. It is the capacity of an individual to be independent from a desire for primary needs and exist side by side peacefully with the chance for betterment. Therefore, Wellbeing refers to the devoid of pessimistic state and affection, the consequence of adaptation on to a dangerous society. The mental tradition begins wellbeing as the personal appraisal of life by mean of contentment and emotions [55][56][57][58].
Having an existence with a feeling of a meaning that an individual's existence has worth, importance with motives is a salient feature of wellness [59]. A sense of meaning might have constructive upshots on particular's wellbeing over the lifetime [60]. Individuals diagnosed with attributes of BPD, frequently fights with a feeling of void together with self-devastating action in 40% and 85% of particulars diagnosed with BPD have numerous suicidal strives [61,62]. Research has revealed that people diagnosed with BPD have been detected to have lower levels of sense of meaning in mental existence than those who were with alternative mental illness [63]. Researches on the sense of purpose in life has revealed the existence of meaning has the sense of affect (feeling contented and accomplished in life) that individual's existence is purposeful is strongly connected with personal wellbeing results [64]. Durkheim talked over some aspect social wellbeing and health that are social integration, social cohesion, a sense of belongingness and interdependence, and collective destiny [65]. Keyes put forward feasible aspects of social wellbeing that are social integration, social acceptance, social contribution and social actualization [66].
Social integration refers to the appraisal of the standard of individual association to societal and communal groups. It uses notion of social cohesion, cultural alienation and social isolation and class consciousness [65,67].
It is the level to which an individual is cordially involved in a span of relations and feeling of belongingness. Cohen contended that social integration has a straight influence on wellbeing by promising the advancement of identity, meaning, self-trust and confidence together with optimistic influence. All these psychological variables are identified as complications amid particulars diagnosed with BPD. Social acceptance refers to other individuals that one, desire to incorporate in their category and connections [68]. Social accepting individuals clasp approving perspectives of person's nature feeling cosiness with others [69,70].
Social contribution means appraisal of the individual's social value. Social contribution considers, to which level, individual sense that anything they carry out in this society is valued by the community and adds up to the nation [66]. Social actualization means assessment of the possibilities and the course of the community [66]. Social coherence denotes the opinion of the standard, firms, and functioning of the communal world it also incorporate a care for the significant about the society [66].
Social network approaches have been employed widely, specifically in analysis of physical health in that enumerators have observed that the attributes of a particular's social networks have vigorous effects on numerous ailments together with health conditions [71,72]. In developing a thought, the process of the upshot of social networks on wellbeing, numerous scholars have come up with models which could notify the investigation of the mental influence on social networks in persons with BPD. Thus, researchers have expanded a model in that societal aid, gloomy communications, together with social integration influence wellbeing through mental factors [31,71]. In Cohen's model, social aid is elucidated as contributory, enlightening together with affective aid from alternatives deliberated to aid a particular to handle with stress, and is notion to influence social wellbeing and well-being through the techniques of diminishing worry. A gloomy communication, consisting of contending, condemnation, and negative effect, rising stress, which expand danger of ailments and mental problems.
Attachment theory constitutes one more description of the role of close friendships and the particular's portrayals of those friendships and relations could impact stress, coping and psychological wellbeing. Scholars identified a strong attachment with one more as looking for closeness to the individual during worry, feeling impatient and apprehension concerning serious separation, being able to employ the individual as a protected base to repay to when anxious together with concerning the individual as an asylum with whom to analyze complications [73]. Accommodating psychological models of togetherness others as sympathetic, reliable, accessible, and cooperative have been vigorously correlated with optimistic psychological fitness and wellbeing upshots [74]. Scholars and enumerators have steadily attributed BPD as an acute attachment disruption [75]. Problems in close relations, BPD symptoms are connected with struggling and sustaining a robust attachment in other individuals who are in their network [31]. This study is an attempt to examine the relationship of perceived social support with social wellbeing among the BPD outpatients.

Tools used Perceived social support
Multifaceted scale of perceived social support developed by [18] was employed to compute the perceived social support among the BPD outpatients. This scale comprises of 12-item along with three dimensions with 7-point response format ranging from (1 = very strongly disagree to 7 = very strongly agree). Through this scale, we assess the level of support from the family, peers, and a significant alternative. Range of score is between 4 and 28. The higher score in each of these scales indicates the higher quality of perceived social support and vice versa. The scale showed good internal reliability.

Social wellbeing scale
The short form of social well-being questionnaire developed by [66] was used to measure social well-being among the patients. This scale contains of 15 items with 5 dimensions with seven-point rating scale ranging from strongly disagree to strongly agree. Participants responded to these questions using options ranging from (1 = strongly disagree to 7 = strongly agree). Pessimistic items were reversely encrypted prior to the analysis. The social well-being dimensions comprise of social integration, social coherence, social acceptance, social contribution, and social actualization. The original reliability as reported by the author of the scale was 0.84 whereas, the calculated reliability of the respective dimensions varied from 0.54 to 0.62.

McLean screening instrument for BPD (MSI-BPD)
The 10-item MSI-BPD developed by [76] was used to assess the BPD patients. A score of 7 or higher on this scale indicates that the person meets the diagnostic criteria of borderline personality disorder.

Procedure
For the data collection, participants from the Department of Psychiatry, Jawaharlal Nehru Medical College, Aligarh Muslim University-Uttar Pradesh, India, were contacted. As accessibility of the pure BPD patients is very difficult, comorbid patients were also added to the study. Patients who were already diagnosed by psychiatrists, and clinical psychologists were examined for the study. In order to further validate the diagnosis of BPD patients, these patients were screened through McLean screening instrument. Subsequently, a cordial rapport was established with all the participants. They were requested to provide preliminary information. Followed by this, all the respective scales were administered to the participants and they were advised to read the instructions carefully and provide their responses candidly. After the completion of the process, they were thanked for their cooperation and were taken for further psychological consideration.

Data analysis
Appropriate statistics like Spearman's correlational analysis were employed to examine the association between the variables. Table 1 and Fig. 1, shows the relationship of perceived social support with social wellbeing among BPD patients. It can be seen from the table as well as the figure that a statistically significant positive correlation was erected amid overall perceived social support with overall social wellbeing (r = .41; p < .001). The results indicated that patients having the high level of perceived social support have a strong social networking, which tends to live them longer and respond better to anxiety, stress, and depression. Although ample studies have been conducted on these variables independently in difference settings, there is a bleak state of literature available on these two variables together in general and BPD patients in particular. In one study, a systematic review has been conducted to examine the association of loneliness and perceived social support with the outcome of psychological well-being complications [44]. They found that folk with depression who discern their social support as poor have bad outcome in terms of manifestations, recuperation, and social operating. Hence, greater isolation predicts the poor depression outcome.

Correlation of perceived social supports with social wellbeing
The present study is one of the first study to examine the association of perceived social support with social wellbeing among BPD patients. As can be seen from the table and figure also, there is a statistically significant positive relationship between perceived social support and social wellbeing among BPD patients (r = .41; p < .001). This means the higher the support BPD patients would experience from their friends, relatives, and other people, greater would be their social wellbeing. Perceived social support denotes to how individuals discern peers, members of the family and alternatives as an origin of support (material, mental along with overall support) in times of need. The results of the present study can be corroborated with the results of previous studies [25,77]. According to Siedlecki, perceived levels of support, love, and care could give optimistic contacts and exposure [77]. An arbitrating character of self-esteem in the connections amid social support and depressive symptoms was studied. They also revealed that perceived social support from ancestry and peers were significantly associated to lower depressive symptoms. The aforementioned perceived social support was erected to be more safeguarding against depressive manifestations where the level of worry and apprehension was presented. Other researchers suggested that a high level of perceived social support is linked to stronger physical and psychological fitness consequences [25]. Accommodating psychological models of togetherness alternatives as encouraging, reliable, accessible, and together have been vigorously correlated with optimistic psychological fitness and wellbeing upshots [75]. Cohen contended that social integration has a straight influence on wellbeing by promising the advancement of identity, meaning, self-trust along with confidence together with optimistic influence [71]. Inseparability is expected to be reduced amid particular diagnosed with BPD, a stigma together with relational complications, namely, acute exasperation along with inconsistent connections [12]. Individuals who are attached to more inseparable figures are expected to contact more optimistic consequences in social support and wellbeing [13].
In another study, an association was examined between familial social support with psychological wellbeing among hepatitis C. A statistically significant moderate correlation was found between the two variables [78]. They found a moderate correlation of the family social support in psychological wellbeing. A high sense of psychological wellbeing was found among the educated patients as compared to uneducated patients. Furthermore, their study depicted a positive association of socioeconomic status with psychological wellbeing. Lastly, sufferers from the nuclear family system have a high level of familial social support as compared to those patients residing with joint families. Hence, keeping in view, the results of this study, it can be said that social support plays a very important role in psychological wellbeing. Hence, it can be said that by providing a higher level of perceived social support, the wellbeing of BPD patients can be improved.
The results of the study also illustrates a statistically significant relationship between dimensions of perceived social support and dimensions of perceived social wellbeing. When examining the relationship of the family dimension with the dimensions of social wellbeing. The results indicated a statistically significant positive relationship with social integration (r = .24; p < .05), social actualization (r = .44; p < .01), social coherence (r = .21; p < .05), and social wellbeing (r = .28; p < .01).
The results of our study reflect with the review of literature; optimistic communal interactions with members of the family decreases apprehension and advance the feeling of invulnerability and protection [42][43][44]. Individuals with more absolute moral communal connections and higher social support have the advantage of more effective interpersonal skills and directs them aside from psychological and mental complications [45]. Additionally, BPD attributes were also interconnected to increased pessimistic connections with the mother [38]. Parental aid is a safeguarding element for dissimilar displays of mental illness and particularly in mother-daughter connections definite motherly emotional actions and constructive dual emotional attitudes seem to be associated with minimizing in the female's BPD seriousness over time [39,40]. Consequently, social support is constantly connected with fine psychological health and social wellbeing [41].
Studies that support the outcomes of our investigation reported that the prevalence of social connections with peers was notable for positive clinical recovery over a span of 2 years in the first episodes of psychosis [41,79]. The particular intervention research by Bo and Kongerslev was encouraging, though in need of duplication with a control group incorporated, putting forward that therapy for BPD in youngsters might be constructive in ameliorating companion relations [50]. Behavioral economic and neuroeconomic approaches to the research of incentive valuation might be relevant to the study on youngster BPD, demonstrating intense insights into neural and mental processes, which may influence positive peer connections [51]. One research has spotlighted the character of disintegration of belief and an expected refusal as drivers of defective social consequences while in a specific manner as bringing about irritation and hostile social communication among adolescent folk diagnosed with personality disorders [52]. The idea is that particulars with BPD are tactful to refusal cues and predict social refusal [53].

Conclusions
This study was designed to examine the association of perceived social support with social wellbeing among BPD outpatients. Results revealed a statistically significant moderate positive correlation between perceived social support and social wellbeing. This means higher the support these patients experience from their family, friends and relatives, better will be their social wellbeing. It is noteworthy to mention here that getting support from companions and family members in times of crises will have a buffering effect on patients' negative emotions and thoughts, which could have a significant impact on patients' wellbeing. Hence creating such type of relationship or support from family and peers in one's life is necessary due to its worth benefits to one's psychological fitness and wellbeing. This study has a practical implication for counselors, clinical psychologists, and psychiatrists working in the field. Psychologists working in different clinical settings should consider perceived social support as an important means to cope up with the stressors and stress reactions. They should encourage their caregivers to maintain healthy and close relationship with their offspring. Investigation could have some suggestions for prevention and treatment for BPD patients. Our findings highlight the significance of assessing BPD attributes in medical settings, mainly in the individuals who reports perceived social support. Contemporary investigation gives a program on the significance of evolving a span of successful social aid. Certain interventions could be employed at ameliorating BPD manifestations along with social aid in a patient. For instance, dialectical behavioral therapy. Upgrading robust levels of functional variables during nursing the personality pathology could aid sufferers maintain utility along with reduction in the time required for patients to attain standard levels.

Limitations
As the sample was collected from the Department of Psychiatry, Jawaharlal Nehru Medical College, Aligarh Muslim University, Uttar Pradesh, India, only, there is a threat to external validity of the results. This study was limited to perceived social support and social wellbeing only. Researchers should consider other variables like emotional state, etc.