36.

Kernberg OF: Severe Personality Disorders. New Haven, Conn, Yale University Press, 1984 37. Widiger T, Trull T: Personality and paychopathology: an application ofthe fivefactor model.Journal ofPersonality Disorders, in press 38. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed, rev. Washington, DC, American Psychiatric Association, 1987 39. Akhtar 5, Byrne J, Doghramji K: The demographic profile of borderline personalitydisorder.JoumalofQinical Psychiatry 47:196-198, 1986 40. LorangerA,OldhamJ,TulisE: Familial transmission ofDSM-ffl borderline personality disorder. Archives of General Psychiatry 39:795-799, 1982

41.

Kaplan M: A woman’s view of DSM-HI. American Psychologist 38:786-792, 1983

Dr. Skodol is associate professor and Dr. Oldham is professor of clinical psychiatry at Columbia University College of Physicians and Surgeons. Dr. Oldham is director ofthe New York State Psychiatric Institute, and Dr. Skodol is director of the institute’s unit for personality studies. Address correspondence to Dr. Skodol, stitute, Street, 10032.

York Box New This

cia.L section ality disorder.

Hospital

and

State 8,

Psychiatric

In-

722 York,

paper

West 168th New York is part ofa spe-

on borderline

Community

K, Cohen C: The role of labeling in diagnosing borderline perdisorder. American Journal of Psychiatry 140:1527-1529, 1983

47.

processes sonality

43. Reich J: Sex distribution

44.

of

DSM-IH

disorders

in psychiatric outpatients. AmericanJournal of Psychiatry 144:485-488, 1987 Kass F, Spitzer R, Williams J: An empirical studyofthe issueofsexbias in the diagnostic criteria of DSM-ffl axis II onality disorders. American Paypersonality

chologist

38:799-801,

48.

45. Widiger

T, Spitzer R: Sex bias in the of personality disorders: conceptual and methodological issues. ClinicalPsychologyReview 11:1-22,1991 Morey L, Ochoa E: An investigation of adherence to diagnostic criteria: clinical diagnosisofthe DSM-IHpersonalitydisorders. Journal of Personality Disorders

Identification

3:180-192,

1989

of borderline

terview

personality

Diagnostic American Journal

Schedule. Psychiatry 146:200-205,

49. Reich J: Measurement

50.

diagnosis

46.

Widiger T, Frances A, Warner L, et a!: Diagnostic criteria for the borderline and schizotypal personality disorders. Jouras! ofAbnormal Psychology 95:43-51, 1986 Swam M, Blazer D, George L, et al:

disorder with the NIMH

1983

a

M.D. M.D.

Borderline personality disorder is common in treatment settings and may be so in the general population. In this guide to assessment strategies for diagnosing borderline personality disorder, tile 4uthors discuss the reliability and validity ofstructured.interviews isnd self-report instruments and sug-

New

Henry

51.

Inof

1989

of DSM-IH, axis Psychiatry 26:352-

H. Comprehensive 363, 1985 Kendler K: Familial aggregation of schizophrenia and schizophrenia spectrum disorders: evaluation of conflicting results. Archives of General Psychiatry 45:377-383, 1988 Butcher J: Minnesota Multiphasic Personality Inventory-2, User’s Guide. Minnetonka, Minn, National Computer Systems, 1989

and Diagnosis of Personality Disorder

Assessment Borderline Andrew E. Skodol, John M. Oldham,

42.

person-

Psychiatry

gest the use of self-report questionnaire as a co3t-effective screening test. Assessment problems, such as the needfor longitudinal observation, are reviewed. Es,centialfeatures ofthe recommended diagnostic approach include clarity about the diagnostic concept, consideration ofthefull range of diagnostk criteria, incorporation of recently developed diagnostic met hodologies, care in distinguishing personality disorders from comorbid axis I syndromes, and complete assess. ment of the full range of axis ii disorders. Borderline personality disorder is certainly common in treatment settings and may be so in the general population.

In a 1989

review

of sys-

tematic studies, Widiger and Frances (1) estimated that 1 1 percent of all psychiatric outpatients and 19 percent of all inpatients have the diagnosis. Borderline personality disorder may account for one-third of all outpatient diagnoses of personality disorder and almost two-thirds of all such inpatient diagnoses. In the

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community, where less systematic research has been conducted, estimates vary widely from a low of .2 percent to a high of 15 percent. Not only is borderline personality disorder common, but it also presents a considerable clinical challenge. The disorder can be difficult to diagnosis and to treat and can predispose to, be accompanied by, or interfere with the treatment of many other mental disorders. The purpose of this paper is to offer a guide to assessment strategies for diagnosing borderline personality disorder. Concepts and criteria The prevalence ofborderline personality disorder varies not only by the setting in which an assessment is made but also by the definition of the disorder used. The borderline concept dates back 50 years. Over the years, however, the term borderline has had multiple meanings and has rcfrrred to diverse patient groups (2). Modern attempts to characterize borderline patients have emphasized definition by diagnostic criteria, culminating in the diagnostic criteria for borderline personality disorder

1021

states, or other cognitive which are not part of the DSM-lll concept. DSM-lll, on the other hand, includes a criterion of identity disturbance, which is not emphasized by Gunderson. Kernberg’s concept of borderline personairy organization emphasizes an unstable sense of self, use of primitive defense mechanisms, and temporary

lapses in-but overall maintenance of-reality testing. Kernberg’s conccpt is hypothesized to cut across a number of severe personality disorder subtypes as described in DSMill, for example, narcissistic, antisocia!, and schizoid personality disorders (12). Morcy (13) has shown that DSMIII-R criteria for borderline personality disorder identify virtually the same patients as DSM-lII criteria (k=.97). The relationship between borderline personality disorder as diagnosed by DSM-III and the disorder as diagnosed by other criteria has been studied but is less clear. Of six studies that have applied DSM-III criteria and Gunderson’s criteria to the same patients, two found the Gunderson concept to apply to more persons (14,1 5), one found that DSM-III fit more persons (16), and three found no difference (17-19). Our group used a self-report instrument and a semistructured interview to assess borderline personality organization and its three subcomponents in a sample ofpatients with personality disorders (20,21). We found that, as predicted, patients with personality disorders theoretically at the borderline level of functioning tended to be intermediate between patients with diagnoses at the neurotic and psychotic levels (8). Kernberg and associates (22) and Koenigsberg (23) reported modest agreement (k=.45 and .49, respectively) between structural diagnoses of borderline personality organization and Gunderson’s borderline diagnosis made by structured interview. Kullgren and Armelius (24) found that borderline personality organization described patients with a wide variety ofDSM-llI axis I and II disorders; 46 percent of patients with borderline personality organization had borderline personality disorder, but 20 percent of patients with borderline personality disorder did not have borderline personality organization. Cases fitting multiple definitions of borderline personality disorder may be considered likely to represent true cases, but when discrepancies exist, mere disagreement is not informative. It is necessary to deter-

1022

October

developed by Spitzer and colleagues (3) and adopted for DSM-III (4). Current concepts. The three most commonly described concepts of borderline personality today are those of Gunderson and associates (5,6), those ofKernbcrg (7,8), and those described in DSM-IIl and DSM-IIl-R (4,9). Based on the work of Spitzer and colleagues (3), DSMill divided patients often referred to as borderline into two groups, one characterized by instability of mood, interpersonal relat ionships, selfimage, and impulse control and the other characterized by deficits in interpersonal relatedness and peculiarities of ideation, appearance, and behavior. The disorder of the former group was given the name borderline personality

disorder,

which

was

believed to be comparable to the concept of borderline that grew out of the psychoanalytic literature. The disorder of the latter group was designated schizotypal personality disorder, which was thought to describe persons with so-called borderline schizophrenia in the Danish adoption studies of schizophrenia (10,1 1). In this paper, we focus primanly on a descriptive model for the diagnosis of borderline personality disorder, as represented by DSM -III and DSM-III-R criteria rather than on a model based on developmental history or unconscious motivation. Conceptually, the criteria of Gunderson and associates, Kernberg, and DSM-III for borderline personality disorder are similar but not identical. Gunderson’s diagnosis includes characteristic dysphoric affects, such as anger, depression, anxiety, and emptiness; unstable interpersonal relationships; and poor impulse control leading to self-damaging acts. All of these criteria are included in DSM-III, but Gunderson also cmphasizes

dissociative distortions,

briefpsychotic

experiences,

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mine whether disagreements occur in cases near the diagnostic thresholds of the various systems and whether one definition is more useful than another for clinical or research purposes. Criteria anddiagnostic categories. DSM-III and DSM-Ill-R both define borderline personality disorder with a polythetic criteria set; any five ofeight criteria are sufficient for the diagnosis. A polythetic format implies that all criteria are of equal diagnostic significance. Is this assumption warranted? Individual traits or behaviors might be considered diagnostically relevant because they are very typical ofa disorder or because they are very useful in differentiating one disorder from another. The most characteristic features need not be the most discriminating. The proportion of patients with the disorder who have a characteristic symptom is called the sensitivity ofthe symptom. A symptom’s positive and negative predicnyc power, that is, its value in identifying or ruling out a disorder, are measures of its discriminative value. In a review of 14 research studies, Widiger and Frances (1) found that impulsivity and affective instability were the most characteristic manifestations of borderline personality disorder but that physically selfdamaging acts, unstable-intense interpersonal relationships, and impulsivity were the most diagnostically useful. Surveys ofclinicians found that identity disturbance, intense and inappropriate anger, unstable relationships, and impulsivity were believed to be most typical (25,26). The majority of studies found the DSM-III criterion of intolerance of being alone to be poorly associated with a diagnosis of borderline personality disorder and to be rated as least typical by clinicians. This was the one criterion changed (to abandonment fr:ars) in DSM-III-R. Widiger and Frances (1) point out that the diagnostic importance of a symptom may vary depending on the setting in which a patient is seen and the differential diagnosis that is at issue. In outpatient settings, the relatively uncommon behaviors subsumed under physically seif-damag-

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ing acts have the highest positive predictive value for borderline personality disorder. Unstable-intense relationships are more rare and are more specific for borderline personality disorder among inpatients than among outpatients. Outpatients’ relationships are apparently more commonly unstable regardless of their personality disorder diagnoses. These analyses leave unanswered the question of whether there is a core set of symptoms for borderline personality disorder (27) and other symptoms that are a function of comorbid disorders, psychobiology, or severity, chronicity, or other nonspecific aspects ofa patient’s psychopathology. Some symptoms, such as affective

instability,

are

inevitably

present in patients with comorbid mood disorders (see below) and may not turn out to be central features of the borderline construct at all. Furthermore, the requirement that five of eight criteria define borderline personality disorder is admittedly arbitrary (28,29). Should a patient who meets the three or four most characteristic and distinctive criteria not receive the diagnosis? Until a system can be devised to weight particular criteria differentially and result in accurate diagnoses in a variety of settings and patient populations, the eight DSMIII-R criteria must be considered as defining a prototype. The more features a patient exhibits, the more certain the diagnosis. Subthreshold cases with highly typical or specific symptomatology may be viewed as provisional cases pending further evaluation. Subthreshold cases with mostly nonspecific symptoms, such as affective instability, anger, and ftars ofabandonment, strongly suggest that another disorder may be present. Morey and Ochoa (30) have studied how closely practicing psychiatrists and psychologists adhere to DSM-lII criteria in assigning diagnoses ofpersonality disorders. Although clinicians diagnosed borderline personality disorder fairly consistently in accord with diagnostic criteria, some misdiagnosis relative to other personality disorders occurred. Less experienced clinicians

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tended to diagnose borderline personality disorder when a patient did not meet the full criteria, and more experienced clinicians tended not to make the diagnosis even when patients actually met criteria. Poorer patients were more likely to receive a diagnosis without meeting criteria, while wealthier patients went undiagnosed despite sufficient symptomatology. There were weaker tendencies for psychodynamically onented clinicians to overdiagnose and for psychologists to underdiagnose. Borderline personality disorder is more commonly diagnosed in women than in men(3 1). Labeling processes have been implicated as contnibuting to the overrepresentation of women (32). Money and Ochoa (30) found a relationship, though ndatively weak, between a patient’s gender and misdiagnosis: female patients tended to receive the diagnosis undescrvedly. Interestingly, female clinicians tended to ovendiagnose the disorder, and male clinicians tended to undendiagnose it. However, in Money and Ochoa’s study (30), symptom patterns neflecting idiosyncratic diagnostic practice were more strongly associated with misdiagnosis than were demognaphic on practitioner variables. Among the symptoms of borderline personality disorder, suicidal threats and gestures were associated with ovendiagnosis when present and with underdiagnosis when absent. Other evidence of impulsivity and affective instability were also associated with ovendiagnosis. These results suggest that clinicians tend wrongly to equate mood disturbance and impulsive suicide attempts with borderline personality disorder. We return to the problem below. Diagnostic methods The burgeoning interest in borderline personality disorder as a research focus (33,34) has spawned a plethora of tools to assist in the diagnostic process. There are currently five structured or semistructured interviews available to diagnose bordenline personality disorder as well as the other personality disorders included in DSM-lII-R, three others focused solely on borderline concepts, five self-report questionnaires

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covering all of axis II, and one more self-report instrument specifically designed to assess borderline pathology. Table 1 lists these instruments and interviews along with some of their features. A major difference between the interviews for axis II disorders is the format by which the questions are organized. The Structured Interview for DSM-III-R Personality Disorders (35), the Personality Disorder Examination (PDE) (36), and the revised version of Personality Interview Questions (PIQ-II) (37) are organized on the basis ofsix to 17 areas offunctioning,

such

as work,

affects,

or interpersonal relations. Questions in the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-Il) (38) and the Diagnostic Interview for Personality Disorders (DIPD) (39) are organized by the personality disorder that they are meant to explore. All ofthe interviews are explicitly designed to be administered by expenienced clinical personnel, except for the PIQ-II, which has been used in studies by trained lay interviewers. The Diagnostic Interview for Bordenlines (DIB)(40) has recently been revised by Zananini and colleagues (41) to improve its ability to distinguish patients with borderline personality

disorder

from

patients

with

other axis II disorders. The DIB-R questions are grouped into sections on affect, cognition, impulse action patterns, and interpersonal relationships. The DIB-R differs from the DIB in that the nondiscniminating section on social adaptation has been deleted, impulse action patterns and characteristic disturbances in interpersonal relations have been given more diagnostic weight relative to the affect and cognition (formenly psychosis) sections, and the interview now focuses on the past two years ofthe patient’s life. Some specific items have also been changed. The characteristics of these instruments have been previously reviewed in detail (42-44). Here we mention briefly their ability to improve reliability of the diagnosis of borderline personality disorder and their validity. Reliability. The reliability of

1023

Table

1 ofinterviews

Features

Interview

and self-report

instruments

for the assessment

Author

or instrument

Interview for DSMIII-R Personality Disorders Personality Disorder Exammarion Structured Clinical Interview for DSM-HI-R Personality Disorders Diagnostic Interview for Personality Disorders Personality Interview Questions-Il Diagnostic Interview for Structured

Pfohl

Spitzen

features

All axis II disorders

Interview

All axis II disorders

Interview

All axis II disorders

Axis I section; axis ing questionnaire

Interview

All axis II disorders

Best

Interview

All axis II disorders

Nine-point

et a!. (38)

et at. (39)

Widiger(37)

range

Special

Interview

Patient and informant questions Detailed instruction manual

test-retest

and

Gunderson

et a!. (40)

Interview

Borderline

Gunderson

personality

Highly

screen-

reliability

scale behaviors

personality

II

for traits

criteria

disorder

Borderlines

Borderline

disorder

Diagnostic

(36)

Zananini

personality

Type en a!. (35)

Lonanger

ofbondenline

Personality

Scale

Perry

&

Cooper(85)

Borderline

Interview

structured

disorder

Schedule for Interviewing Borderlines Personality Diagnostic Questionnaire-Revised Millon Clinical Multiaxial Inventory-Il Wisconsin Personality Inventory

Self-report

Borderline personality disorder All axis II disorders

Companion schizotypal section Face valid items

Millon(51)

Self-report

All axis II disorders

Dimensions ofaxis I and axis II psychopathology

Klein

(87)

Self-report

All axis II disorders

Integrates structural analysis ofsocial behavior

Clank (89)

Self-report

All axis H disorders

Money et a!. (90)

Self-report

All axis II disorders

Normal and abnormal personality measures Constructed from MMPI item pool

Conte

Self-report

Borderline disorder

Baron

&

Gruen

Hyler

et a!. (48)

Interview

(86)

(Revised)

model1 Schedule normal

for Normal Personality

and

Ab-

Minnesota Multiphasic Pensonality Inventory (MMPI) scales for DSM-IH personalmy disorders Borderline

1

Benjamin

Syndrome

Index

en al. (91)

personality

Includes

schizotypal

items

(88)

diagnostic judgments is usually cxpressed by the kappa statistic, a measure ofagreement between two raters or ratings, corrected for the possibility of agreement by chance. A kappa ofO means agreement is strictly by chance; a kappa of 1 indicates perfect agreement. Generally, kappas below .40 are considered poor, .40 to .60 fair, .60 to .75 good, and above .75 excellent (45). Even though borderline personality disorder is defined by explicit diagnostic criteria in DSM-III, the reliability ofthe diagnosis as made in routine clinical practice has been found to be low (k= .29) (46). This poor reliability is due, in part, to error introduced into the diagnostic process by variations in the amount and kinds ofinformation available on which to base a diagnosis. Use of a

systematic routine for gathering information-that is, a semistructured interview or questionnaire-should reduce this source ofdiagnostic error.

1024

October

Several

studies

that

have

assessed

samples of patients and persons in the community using interviews for axis II disorders have found the reliability of the diagnosis of borderline personality disorder to be high (k=.70 to .96). The only exception appears to be the multisite reliability study of the SCID-Il, in which a below-average kappa of .48 was ohtamed at the various sites studied (First MB, personal communication, 1991). This study used the more rigorous test-retest design involving independent reinterviews of subjects rather than the joint interview design in which two raters observe the same interview. In the study by

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Zanarini and co-workers (39), however, test-retest reliability of the DIPD, which is very similar to the SCID-Il, was found to be .85, suggesting that rigorous training of interviewers can result in very reliable diagnosis even when independent assessments are made. Studies ofthe DIR have found reliability ranging from good to excellent (intenrater k=.71 to .80; testretest k=.71)(15,47). The only studies ofa self-report questionnaire that involved separate administrations and categorical (as opposed to dimensional) meurement used the preliminary version ofthe Personality Diagnostic Questionnaire-Revised (PDQ-R) (48). The reliabilities obtained were acceptable (k= . 5 5 to .59) (43, 49). Validity. Measures ofthe associa-

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tients believed to have borderline personality disorder. Since the cliical diagnosis ofbondenline personality disorder has traditionally been unreliable and of debatable validity itself, it has been difficult to arrive at an appropriate standard against which to measure an instrument’s performance. Agreement between diagnoses of borderline personality disorder based on self-report instruments and those based on structured interviews is modest. Widiger and Frances (1) report kappas for the earlier version of the Millon Clinical Multiaxial Inventory (51) of.05 and .32 based on the studies of Piersma (52) and Reich and asssociates (5 3), respectively, and .43 for the earlier version ofthe PDQ-R (53). Several studies have reported that compared with interviews, self-report inventories tend to overdiagnose borderline pensonality disorder. When diagnoses based on the PDQ-R were compared with structured-interview diagnoses based on the SCID-Il and the PDE, kappas of .53 and .46, respectively, were found (54). Using the convengence or divergence of interview results as measures of narrow and broad estimates ofpersonality disorder, respectively, we found high sensitivity (.98 and .95) and negative predictive power(.94 and .83)fbr the diagnosis of borderline personality disorder based on the PDQ-R. These results all suggest that a questionnaire diagnosis of borderline personality disorder may be a false positive, but the absence of a diagnosis by self-report is rarely associated with a diagnosis by structured in-

terview. Self-report questionnaires, therefore, seem to have a role in the assessment of borderline personality disorder as efficient and cost-effective screening tests. Diagnoses that are based on semistructured interviews have most commonly been compared with clinical diagnoses. For example, in revising the DIB, Zananini and coworkers (4 1 ) used clinicians’ pnincipal axis II diagnoses as the standards. At a cutoffscore of8 (ofa possible 10), the DIB-R had a sensitivity of .82, a specificity of .80, a positive predictive power of .74, and a negative predictive power of .87. The DIB-R is more effective than the DIB in discriminating patients with borderline personality disorder from patients with other types of personality disorders. The DIB was found by several investigators to be oveninclusive (5 5,56). Kavoussi and associates (57) and O’Boyle and Self(58) recently compared structured interviews. Kappas for borderline personality disorder measured by different instruments ranged from . 1 8 to .62. Without a standard for comparison, it is impossible to say which instrument is “best.” In searching for an appropniate validity standard for personality disorder instruments, our group (59-61) adapted Spitzer’s LEAD standard (longitudinal xpent evalnation using all data)(62). We found that diagnoses of borderline personality disorder made by using the SCID-Il on the PDE (which agreed with each other at k= .53) did not correspond particularly well to the diagnoses of an expert clinician who was given an opportunity to closely observe patients oven time and had access to a variety of informants and sources of information. Do these results mean that structured interviews are too variable to be useful? Such a conclusion would be premature since the reliability and validity of LEAD diagnoses are unknown. The soundest conclusion that might be drawn is that no single diagnostic instrument has clearly demonstrated superiority over others and that the results of research tools should be interpreted cautiously at present. A patient who is diagnosed

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tion between two diagnoses when one is considered indicative of true clinical status are sensitivity, specificity, and positive and negative predictive power. An instrument’s sensitivity and specificity quantify its ability to identify true cases and noncases, respectively. Positive and negative predictive power show the proportion ofputative cases and noncases, respectively, diagnosed by the instrument that are true cases and noncases according to the validity standard (50). One measure of an instrument’s validity is its ability to identify pa-

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with borderline personality disorder by more than one instrument is more likely to be a valid case than a patient about whom the instruments disagree.

Assessment

problems

The difficulty of interviewing patients suspected ofhaving borderline personality disorder can vary widely depending on circumstances. In a setting in which a motivated patient is applying for a highly desirable and selective treatment, the task is considerably easier than in an emergency room where a sullen patient is being evaluated involuntarily after a failed suicide attempt. In general, borderline patients are dramatic and emotional. It may be difficult to keep a patient focused on to distinguish exaggeration from fact. Every statement may be cxtreme, due to characteristic blackand-white and all-on-nothing thinking. Splitting may also lead to apparent contradictions. Confrontation is used as a diagnostic probe in structuna! interviews of borderline patients (8), but even experienced interviewers have provoked impulsive patients to walk out. Although the approach to diffenential diagnosis embodied in DSM-lII and DSM-III-R does not emphasize the diagnostic importance ofa patient’s here-and-now interactions with a clinician, an evaluation interview provides a first-hand sample ofa patient’s personality style that is often strongly suggestive of a diagnosis. However, four general determinations are critical in assessing most personality disorders according to DSM-IlI on DSM-lII-R criteria: pervasiveness; inflexible, enduring pattern; blind spots on socially undesirable features; and maladaptivity and impairment (63). Borderline personality disorder pervasively influences regulation of affects, sense of self, cognitive processes, control ofimpulses, and interpersonal relationships. As mentioned above, clinicians may be tempted to make a diagnosis in the face of a particularly dramatic on characteristic symptom. The manifestations of borderline personality disorder should not be limited to one particular situation or occur in rela-

1025

tionship to only one particular penson. For example, involvement in uniquely stressful circumstances, such as a physically or sexually abusive relationship, may evoke a dnamatic response from many people, not just those with borderline pensonality disorder. Evidence of borderline pensonality disorder should be observable oven time. Usually, two to five years is the minimum time necessary to indicate a stable personality pattern. Frequent changes in personality style, or evolution oven time, might suggest another mental or physical disorder. Physically self-damaging acts and other evidence of impulsivity might seem too onerous for some patients to admit, especially during initial contacts with mental health professionals. Difficulties in relationships may not be seen by the patient as his or her problem but as problems caused by others. An objective informant may be ofassistance, but it is unlikely that someone intensely involved with a borderline patient will be ohjective. Finally, although most behaviors ofpersons with borderline pensonality disorder seem maladaptive by defiition, due to extensive comorbidity of borderline personality with other disorders (see below), it is important to document distress and social and occupational impairment secondary to the personality disorder itself and distinguish it from distress due to a superimposed disorder. Longitudma! observation frequently is requined so that a patient may be seen after a psychosocial crisis or after an episode of an axis I disorder has resolved or improved (60). Comorbidity. Borderline personality disorder has been found to be associated with so many other axis I and II diagnoses that its validity as an independent diagnostic entity has been questioned (64). Resolution of this controversy awaits future nesearch. Using the DSM-lII-R multiaxial system, which encourages multiple diagnoses, the clinician evaluating a patient with suspected bonderline personality disorder should be alert to otherdiagnostic possibilities. There is ample evidence that patients with borderline personality

disorder may have comonbid axis I disorders, such as mood (65-67), anxiety (68,69), substance use (69, 70), and eating disorders (69,7 1). Dissociative, somatoform, factitious, and impulse control disorders have also been reported (69,72,73). When warranted, such diagnoses should be made in addition to borderline personality disorder. The incidence and nature of psychosis in borderline personality disorder has been a subject of controversy (74). Currently, psychotic symptoms occurring in patients with borderline personality disorder are believed to be transient, stress-related, “quasi-psychotic” cognitive-penceptual distortions (75), which in severity may fall short of DSM-IIl-R definitions ofpsychosis. Comorbid axis I syndromes may help to guide treatment selection, especially pharmacologic treatment, and to estimate prognosis (76). Borderline personality disorder has been shown to be associated with virtually all the other axis II disondens. In a review of 1 3 studies, Widigen and colleagues (77) reported that borderline personality disorden covanied most highly with histrionic, antisocial, and passive-aggressive personality disorders, followed by schizotypal, dependent, avoidant, narcissistic, and paranoid personality disorders. In an unpublished study (Oldham JM, Skodol AE, Kellman HD, Hyler SE, Rosnick L, Davies M, 1991), we found that when diagnoses were made using the SCID-Il, borderline personality disorder and antisocial personality disorder were ten times more likely to occur together than for either to occur alone; histrionic and passive-aggressive personality disorders were four to five times more likely to occur with borderline personality disorder as diagnosed by either the SCID-II or the PDE. Comonbid personality disorders influence the assessment of borderline personality disorder. Histrionic patients may exaggerate in reporting behaviors on traits, antisocial patients may lie, and passive-aggressive patients may resist efforts to evaluate them. Perry (78) has shown that patients with both borderline

personality disorder and antisocial personality disorder had less depression, on a lifetime basis, than patients with borderline personality disorder alone. Comonbid axis II conditions, therefore, may also influence course and outcome in borderline personality disorder.

1026

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Significance

and conclusions Establishing a psychiatric diagnosis is not an end, but a means. To be justified, a diagnosis should convey information valuable in planning treatment on predicting outcome. Personality disorders in general have been found to adversely affect the treatment outcome ofa number of axis I disorders, including major depression, panic disorder, and ohsessive-compulsive disorder (79). Less is known about individual pensonality disorders, but borderline personality disorder appears to follow this general rule. However, newer psychopharmacologic agents, such as fluoxetine, have shown promise for treating both the depressive and impulsive symptoms of borderline personality disorder (80,81). New psychotherapeutic strategies are also being developed (82). Long-term follow-up studies, such as those of McGlashan (83), Stone and associates (84), and others, have shown that borderline personality disorder may persist for years but may also ameliorate oven the long run, especially with treatment. Maximizing a patient’s chance for recovery begins with careful assessment and diagnosis to ensure that all potentially relevant diagnostic factors have been considered. Given the problems and challenges inherent in making an accurate diagnosis of borderline personality disorder, and the importance of doing so, we offer the following guidelines to assessment. . Clinicians should be aware that concepts underlying the term borderline overlap but are not identical. Clinicians should understand what information is needed to make the diagnosis according to the concept of interest. . Clinicians using DSM-lII-R criteria should make sure that the nequined features are pervasive, inflexible, and enduring and that they

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impairment in functioning. . Self-report and semistructured instruments for diagnosing borderline personality disorder can be useful in clinical settings, but they are not necessary ifaccurate information needed for diagnosis can be gathered with a standard clinical interview. . Comorbid axis I disorders, such as mood, anxiety, or psychoactive substance use disorders, should be identified in patients with borderline personality disorder; comorbid syndromes may help guide treatment. . Clinicians should be alert to otherpersonality disorders and traits, which may affect assessment and course in patients with borderline personality disorder.

The types and prevalences ofmental illness in the biological and adoptive fimilies of adopted schizophrenics, in the Transmission of Schizophrenia. Edited by Rosenthal D, Kety 58. London, Pergamon, 1968 Gunderson JG, Zanarini MC: Current overview of the borderline diagnosis. Journal of Qinical Psychiatry 48 (Aug suppl):5-11, 1987 MoreyLC: PersonalitydisordersinDSMIH and DSM-HI-R: convergence, coverage, and internal consistency. American Journal of Psychiatry 145:573-577, 1988 BarrashJ, KrollJ, CareyK,etal: Discriminating borderline personality cbsorder from other personality disorders: cluster analysis of the diagnostic interview forborderlines. Archives ofGeneral Psychiatry 40:1297-1302, 1983 KrollJ, Sines L, Martin K, et a!: Borderline personality disorder: construct validityoftheconcept. Archives ofGeneral Psychiatry 38:1021-1026, 1981 Nelson HF,Tennen H,TasmanA,etal: Comparison of three systems fordiagnosing borderline personality disorder. American Journal of Psychiatry 142:

cause

12.

13.

14.

15.

16.

References 1. Widiger TA, Frances AJ: Epidemiology, diagnosis, and comorbiditrofborderline personality disorder, in American Psychiatric Press Review of Psychiatry, vol 8. Edited by Tasman A, Hales RE, Frances AJ. Washington, DC, American Psychiatric Press, 1989 2. Perry JC, Klerman GL: The borderline patient: a comparative analysis of four sets of diagnostic cri#{231}eria. Archives of General Psychiatry 35:141-150, 1978 3. Spitzer R, EndicottJ, Gibbon M: Crossing the border into borderline personality and borderline schizophrenia: the development of cijteria. Archives of Gencml Psychiatry 36:17-24, 1979 4. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Washington, DC, American Psychiatric Association, 1980 5. Gunderson JG, Singer MT: Defining borderline patients: an overview. American Journal of Psychiatry 132:1-10, 1975 6. GundersonJG,KolbJE: Discriminating featuresofborderlinepatients. American Journal of Psychiatry 135:792-796, 1978 7. Kernberg OF: Borderline Conditions and Pathological Narcissism. NewYork, Aronson, 1975 8. Kernberg OF: Severe Personality Disorders. New Haven,Cpnn, Yale University Press, 1984 9. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed, rev. Washington, DC, American Psychiatric Association, 1987 10. Kety 88: Mental illness in the biological and adoptive relatives of schizophrenic adoptees: findings relevant #{231}o genetic and environmental fctors in etiology. American Journal of Psychiatry 140: 720-727,

1983

1 1. Kety 88, Rosenthal

Hospital

and

D, WenderPH,

Community

eta!:

Psychiatry

855-858,

17.

1985

The borderline syndrome, I: testing three diagnostic systems. Archives of General Psychiatry 40:13111318, 1983 18. Frances A, Clarkin J, Gilmore M, et al: Reliability ofcriteria for borderline personality disordec a comparison of DSMIII and the Diagnostic Interview for Borderlines. AmericaJournal of Psychiatry 141:l080-1083, 1984 19. Loranger AW, Oldham JM, Russakoff LM, etal: Structured interviewsand borderline personality disorder. Archives of General Psychiatry 41:565-568, 1984 20. Doidge NR, SkodQj AE, OIdhamJM, et a!: Personality organization in analytic patients and inpatlents. Presented at the annual meeting ofthe American Psychiatric Association, New York, May 1217, 1990 21 Oldham J, Clarkin J, Appelbaum A, et a!: A self-report instrument for borderMcGlashanT:

.

line

22.

23.

24.

25.

personality

organization,

in The

Borderline: Current Empirical Research. Edited by McGlashan TH. Washington, DC, American Psychiatric Press, 1985 Kernberg OF, Goldstein E, CarrA, et al: Diagnosing borderline personality.Jourtial ofNerydus and Mental Disease 169: 225-231, 1981 Koenigsberg H, Kernberg OF, Schomer J: Diagnosing borderline conditions in an outpatient setting. Archives of Genera! Psychiatry 4Q49-53, 1983 Kuligren G, Armeius B: The concept of personality organization: a long-term comparative follow-up study with apecia! reference to borderline personality organization.Journal ofPersonality Disorders 4:203-202, 1990 Livesley WJ, Reif1r L, Sheldon A, et al: Prototypicality ratings ofDSM-IH criteria for personality disorders. Journal of Neyous and Mental Disease 175:395-

October

1991

Vol.

42

No.

10

401, 1987 Hilbrand M, Flirt M: The borderline syndrome: an empirically derived prototype.Journal ofPersonaliry Disorders 1: 229-306, 1987 27. DahI AA: Empirical evidence for a core borderline syndrome. Journal of Personality Disorders 4:192-202, 1990 28. Finn SE: Base rates, utilities, and DSMHI: shortcomingsoffixed-rulesystemsof psychodiagnosis. Journal of Abnormal Psychology 91:294-302, 1982 29. Widiger TA, Hurt SW, Frances A, eta!: Diagnostic efficiency and DSM-HI. Archives of General Psychiatry 41:10051012, 1984 30. Morey IL, Ochoa ES: An investigation ofadherence to diagnostic criteria clinical diagnosis ofthe DSM-ffl personality disorders. Journal of Personality Disorders 3:180-192, 1989 31. Akhtar S, Byrne JP, Doghramji K: The demographic profile of borderline personalitydisorder.JournalofClinical Psychiatry 47:196-198, 1986 32. Henry KA, Cohen CI: The role of labeling processes in diagnosing borderline personality disorder. American Journal ofPsychiatry 140:1527-1529, 1983 33. Blashfield RK, McElroy LA: The 1985 journal literature on personality disorders. Comprehensive Psychiatry 28: 536-546, 1987 34. Gorton G, Akhtar 5: The literature on personality disorders, 1985-88: trends, issues, and controversies. Hospital and Community Psychiatry4l:39-51, 1990 35. Pfohl B, Blum N, Zimmerman M, et al: TheStructured Interview for DSM-ffl-R Personality Disorders. Iowa City, Urnversity oflowa Press, 1989 36. Loranger AW: Personality Disorder Examination (PDE)ManUaI. Yonkers, N DV Communications, 1988 37. Widiger TA: Personality Interview Questions-H. Lexington, University of Kentucky, 1987 38. Spitzer RI, WilliamsJBW, Gibbon M, et al: Structured Clinical Interview for DSM-HI-R (SUD). Washington, DC, American Psychiatric Press, 1990 39. Zanarini MC, Frankenburg FR, Chauncey DL, et a!: The Diagnostic Interview for Personality Disorders: interrater and test-retest reliability. Comprehensive Psychiatry 28:467-480, 1987 40. Gunderson J, KoIb J, Austin V: The Diagnostic Interview for Borderline Patients. American Journal of Psychiatry 26.

138:896-903,

41.

42.

43.

44.

1981

Zanarini MC, Gunderson JG, Frankenburg FR, et a!: The Revised Diagnostic Interview for Borderlines: discriminating borderline personality disorder from otheraxis H disorders.Joumal of Personality Disorders 3:10-18, 1989 Reich J: Measurement of DSM-IH, axis II. Comprehensive Psychiatry 26:352363, 1985 ReichJ: Update on instruments to measure DSM-III and DSM-1ll-R personality disorders. Journal of Nervous and Mental Disease 177:366-370, 1989 Widiger TA, Frances A: Interviews and

1027

inventories

for the measurement of perdisorders. Clinical Psychology Review 7:49-75, 1987 Fleiss JL: Statistical Methods for Rates and Proportions, 2nd ed. New York, Wiley, 1981 sonality

45.

46.

Mellsop G, Varghese F, Joshua 5, et a!: The reliability of axis II of DSM-III. American Journal of Psychiatry 139: 1360-1361, 1982 Cornell DG, Silk KR, Ludolph PS, et al: Test-retest reliability of the Diagnostic Interview for Borderlines. Archives of General Psychiatry 40:1307-1310, 1983

47.

48.

HylerSE, Rieder RO, WIIIiamSJBW, et a!: Personality Diagnostic Questionnaire-Revised (PDQ-R). New York, New York State Psychiatric Institute, 1987

49.

Hurt SW, HylerSE, FrancesA, et a!: Assessing borderline personality disorder with self-report, clinical interview, or semistructured interview. American Journal ofPsychiatry 141:1228-1231, 1984

50.

51

52.

53.

Bal4essarini RJ, Finkelstein 5, Arana GW: The predictive power of diagnostic tests and the effect of prevalence of illness. Archives ofGeneral Psychiatry 40: 569-573, 1983

.

Piersma H: The MCMI as a measure of DSM-III axis H diagnoses: an empirical companison.Journal ofClinical Psychology 43:478-483, 1987 ReichJ, Noyes R, Troughton E: Lack of agreement between instruments assess-

ing DSM-III

55.

61

personality

disorders,

Kolb JE, Gunderson JG: Diagnosing borderline patients with a semistructured interview. ArchivesofGeneral Psychiatry 37:37-41, 1980

sonality disorders: Journal ofPersonality 289, 1990

1988

AE, Rosnick L, Keilman D, et al: Diagnosis ofDSM-IH-R personality disorders: a comparison of two structured interviews. International Journal of Methods in Psychiatric Research, in SpitzerRL: Psychiatnicdiagnosis: areclinicians still necessary? Comprehensive Psychiatry 24:399-411, 1983

63.

Skodol AE: Problems in Differential Diagnosis: From DSM-III to DSM-III-R in Clinical Practice. Washington, DC, American Psychiatric Press, 1989

Perry JC: Depression in borderline personality disorder: lifetime prevalence at interview and longitudinal course of symptoms. AmericanJournal of Psychiamy 142:15-21, 1985

79.

ReichJH,GreenAl: Effectofpersonaliry disorders on outcome of treatment.Journa! ofNervous and Mental Disease 179: 74-82, 1991

80.

ComeliusJR, SoloffPH, PerelJM, et al: Fluoxetine trial in borderlinepersonality disorder. Psychopharmacology Bulletin 26:151-154, 1990

81.

Coccaro EF, AstillJL, HerbertJL, er a!: Fluoxetine treatment of impulsive aggression in DSM-III-R personality disorder patients. Journal ofClinical Psychopharmacology 10:373-375, 1990

82.

Linehan MM: Dialectical behavior therapy for borderline personality disorder, theory and method. Bulletin of the MenningerClinic 51:261-276, 1987

83.

McGlashan TH: The Chestnut Lodge follow-up study, III: long-term outcome of borderline patients. Archives of Genera! Psychiatry 43:20-30, 1986

84.

Stone MI-I, Hurt SW, Stone DK: The P1 500: long-term follow-up of borderline inpatients meeting DSM-ffl criteria, I: global outcome. Journal of Personality Disorders 1:291-298, 1987

85.

Perry JC, Cooper SH: Psychodynamics, symptoms, and outcome in borderline and antisocial personality disorders and bipolar type H affective disorder, in The Borderline: Current Empirical Research. Edited by MCG1aShan TH. Washington, DC, American Psychiatric Press, 1985

65. GundersonJG,

Elliot GR: The interflce borderline personality disorder and affective disorder. AmericanJournal ofPsychiatry 142:277-288, 1985 between

66. DavisGC,

Akiskal HS: Descriptive, biological, and theoretical aspects of borderline personality disorder. Hospital and Community Psychiatry 37:685-692, 1986

67.

McGlashan T: Borderline personality disorder and unipolar afictive disordec long-termefictsofcomorbidity.Journal of Nervous and Mental Disease 175: 457-473,

68.

1987

Grunhaus L, King D, Greden JF, er a!: Depression and panic in patients with borderline personality disorder. Biological Psychiatry 20:688-692, 1985

69.

Zanarini MC, Gunderson JG, Frankenburg FR: Axis I phenomenology of borderline personality disorder. Comprehensive Psychiatry 30:149-1 56, 1989

70.

Dulit RA, FyerMR, HaasGL, eta!: Substance use in borderline personality disorder. American Journa! of Psychiatry 147:1002-1007, 1990

4:273-

78.

64. FyerM,FrancesAJ,SullivanT,etal:

Comorbidity of borderline personality disorder. Archives of Genera! Psychiatry 45:348-352, 1988

description.

Disorders

WidigerTA, Frances AJ, Harris M, en a!: Comorbidity among axis II disorders, in Personality Disorders: New Perspectives on Diagnostic Validity. Edited by Oldham JM. Washington, DC, American Psychiatric Press, 1991

press

62.

beyond

77.

. Skodol

in

Hyler SE, Skodol AE, Kellman HD, et a!: Validity ofthe Personality Diagnostic Q uestionnaire-Revised: comparison with two structured interviews. American Journal of Psychiatry 147:10431048, 1990

145:1297-1299,

Skodol AE, Rosnick L, Keilman D, et al: Development of a procedure for validating structured assessments of axis II, in Personality Disorders: New Perspectives on Diagnostic Validity. Edited by Oldham JM. Washington, DC, Amencan Psychiatric Press, 1991

Millon T: Millon Clinical Multiaxial Inventory-Il Manual. Minnetonka, Mimi, National Computer Systems, 1987

Conference on the Millon Inventories. Edited by Green C. Minnetonka, Mimi, National Computer Systems, 1987 54.

chiatry 60.

86.

BaronM,

terviewing

Gruen

R: The Schedule

Borderlines.

York State Psychiatric

for In-

New York, New Institute,

1980

71.

Levin A, Hyler 5: DSM-HI personality diagnosis in bulimia. Comprehensive Psychiatry 143:47-53, 1986

87.

Klein M: Wisconsin Personality Inventory (Revised) (WISPI-R). Madison, University ofWisconsin, 1990

56. SoloffP,

Ulrich R: Diagnostic Interview for Borderline Patients: a replication study. Archives of General Psychiatry 38:686-692, 1981

72.

Pope H, Jonas J, Hudson J, et al: An empirical study of psychosis in borderlinepersonalitydisorder. AmericanJourna!ofPsychiatry 142:1285-1290, 1985

88.

BenjaminLS: Structural behavior. Psychological 425, 1974

89.

57.

Kavoussi RJ,CoccaroEF, KlarHM,etal: Structured interviews for borderline personality disorder. American Journal of Psychiatry 147:1522-1525, 1990

73.

Lohr NE, Westen D, et a!: Psychosis inborderlinepatientswithdepression. Journal ofPersonality Disorders 3: 92-100, 1989

Clark LA: Schedule normal Personality Southern Methodist

90.

O’Boyle M, SelfD: A comparison of two interviews for DSM-III-R personality disorders. Psychiatry Research 32:8592, 1990

74.

JonasJM, Pope HGJr: Psychosis in borderline personality disorder. Psychiatric Developments 4:295-308, 1984

Morey LC, Waugh MH, Blashfield RK: MMPI scales for DSM-IH personality disorders: their derivation and correlates. Journal of Personality Assessment 49: 245-251, 1985

75.

Zanarini MC, Gunderson JG, Frankenburg FR: Cognitive features of borderlinepersonalitydisorder. AmericanJournat ofPsychiatry 147:57-63, 1990

76.

Perry JC: Challenges

58.

59. Skodol AE, Rosnick

L, Kellman D, etal: Validating structured DSM-III-R personality disorder assessments with longitudinaldata. AmericanJourna! of Psy-

1028

Silk

October

KR,

1991

in validating

VoL 42

No.

per-

10

91

analysis ofsocial Review8l :392-

for Normal (SNAP). University,

and AbDallas, 1990

. Conte

HR, Plutchik R, KarasuTB, eta!: A self-report borderline scale: discniminative validity and preliminary norms. Journal of Nervous and Mental Disease 168:428-435, 1980

Hospital

and

Community

Psychiatry