#
2001 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 2001 Volume 5 Pages 273 ± 277
273
Diagnostic approaches to borderline personality and their relationship to self-harm behavior
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 10/31/14 For personal use only.
RANDY A SANSONE,1, DOUGLAS A SONGER1 AND GEORGE A GAITHER2 1
Wright State University School of Medicine, Dayton, Ohio and 2Ball State University, Muncie, Indiana, USA
This study was designed to explore the relationship, if any, between diagnostic approach to borderline personality disorder (BPD) and the extent of self-harm behavior among psychiatric inpatients. OBJECT:
Newly admitted psychiatric inpatients (N=77) were evaluated for BPD using a self-report measure, clinical diagnosis, and a DSM-IV checklist. All participants were assessed for self-harm behavior using the 22-item Self-Harm Inventory (SHI). METHOD:
Participants with a clinical diagnosis of BPD showed the highest prevalence of, and most potentially lethal, types of self-harm behavior, followed by those diagnosed as BPD by the DSM-IV checklist, and then by self-report measure. Participants diagnosed as BPD on all three measures showed the highest mean number of self-harm and potentially lethal behavior types. Prevalence and potential lethality decreased successively among those who were diagnosed as BPD on two measures versus one measure versus no diagnosis of BPD. RESULTS:
Correspondence Address Randy A. Sansone, MD, Sycamore Primary Care Center, 2115 Leiter Road, Miamisburg, OH 45342, USA Tel: (+1) 937 384 6850 Fax: (+1) 937 384 6938
Received 16 November 2000; revised 8 March 2001; accepted for publication 14 March 2001
Self-harm behavior appears to be a clinically concordant behavior type among the diagnostic approaches to BPD used in this study. Clinical diagnosis appears most sensitive to self-harm behavior, compared with self-report and DSM-IV checklist. (Int J Psych Clin Pract 2001; 5: 273 ± 277) CONCLUSION:
Keywords borderline personality
INTRODUCTION
A
s with most personality disorders, the diagnosis of borderline personality disorder (BPD) is an imprecise process. Indeed, when different diagnostic approaches are used to evaluate the same clinical sample, invariably there is overlap but not absolute concordance among the resulting BPD subsamples. 1 Neutzel2 reviewed the BPD criteria of four groups of investigators and determined that they were vastly dissimilar, which he attributed to conceptual differences. Dahl3 summarized available studies comparing sets of diagnostic criteria for BPD and concluded that while there was meaningful overlap, there was sufficient lack of concordance to make comparisons across studies problematic. Other investigators have also noted diagnostic dilemmas with regard to BPD.4 ± 8
self-harm behavior
Variability among the different diagnostic approaches has been attributed to many factors. These include the construct validity of the approach, rater variance for approaches entailing interview formats, subjective interpretation for those entailing self-report formats, and diagnostic variability due to state effects or changes.9 While there are clearly legitimate sources of variation among the diagnostic approaches to BPD, little is known about the clinical implications of such variation. Self-harm behavior is a clinically significant feature of BPD. Among the nine diagnostic criteria for BPD in DSMIV,10 two entail self-harm (self-damaging impulsivity; suicidal behavior or gestures). Among the remaining DSM-IV personality disorders, only antisocial personality disorder has a criterion for self-harm (i.e., physical fights or assaults). Gunderson and Singer 11 have indicated that self-
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 10/31/14 For personal use only.
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harm behavior is one of the characteristics most commonly and consistently associated with BPD. Mack12 has described self-harm behavior as the behavioral speciality of those with BPD. Numerous authors have highlighted the importance of self-harm behavior in relation to BPD.13 ± 17 Indeed, selfharm behavior is sufficiently consistent among individuals with BPD for many authors to recommend this feature as a means to distinguish individuals with BPD from other severely disturbed individuals. 18 ± 22 In summary, self-harm appears to be a meaningful type of behavior to examine among different diagnostic approaches to BPD to determine clinical concordance. The current study was undertaken to explore self-harm behavior, a behavioral marker for BPD, and its prevalence among three diagnostic subsamples (BPD diagnosis according to self-report measure; clinical diagnosis; and DSM-IV checklist) in a sample of psychiatric inpatients. We hypothesized that there would be variation in the frequency of self-harm behavior among the different BPD subgroups, with clinical diagnosis being the method of diagnosis the most sensitive to self-harm. We also suspected that selfharm behavior would be most frequent among those participants diagnosed as BPD by all three approaches (i.e., those individuals with `core’ BPD disorder).
METHOD PARTICIPANTS Study subjects (N=77) were newly admitted inpatients in an acute-care psychiatry unit of an urban community hospital, over the age of 18, and sufficiently cognitively intact (i.e., not overtly psychotic) to participate in the study. Shortly after admission, each was invited by a single attending psychiatrist to participate in a project ``exploring symptoms and self-harm behavior.’’ Candidates were recruited by the attending physician as time allowed (i.e., these were not consecutive patients, but rather represent a sample of convenience). These 77 participants represented 30.8% of the number of patients admitted during the 6-month study period. Although Axis I diagnoses were not recorded as study measures, the approximate diagnostic profile for the population admitted to this unit is as follows: 50% major depression, 50% substance abuse, 25% psychosis (e.g., schizophrenia, bipolar disorder), and 10% dementia. The majority of patients are admitted because of behavioral problems and/or suicidal ideation. The mean age of the sample was 33.57 years (SD=9.64). Of the 77 participants, 47 (61.%) were female and 30 (39.0%) were male. With regard to race, 58 (75.3%) participants indicated Caucasian, 15 (19.5%) AfricanAmerican, two (2.6%) Native American, and two (2.6%) other. Twenty (26.0%) participants were married, 23 (29.9%) divorced, 30 (39.0%) had never married, and three (3.9%) were widowed; information for one (1.2%) participant was missing. Only one (1.8%) participant did
not complete junior high school. The highest educational attainment of eight (10.4%) participants was junior high school, of 52 (67.5%) high school, of eight (10.4%) junior college, of six (7.8%) 4-year college, and of two (2.6%) graduate degree or higher. Of the 85 candidates asked to participate, 77 agreed to do so (a response rate of 90.6%).
MEASURES Each subject completed a research booklet and participated in a diagnostic interview. The research booklet consisted of three sections: a demographic inquiry, a measure investigating participants’ history of self-harm, and a self-report measure of borderline personality symptoms. The demographic inquiry investigated age, gender, race, and marital and educational status. Self-harm Self-harm behavior was measured using the Self-Harm Inventory (SHI),23 a 22-item, yes/no self-report measure. Each item in the inventory is preceded by the phrase: ``Have you ever intentionally, or on purpose . . .’’ and items include: ``overdosed, cut yourself on purpose, burned yourself on purpose, hit yourself’’ and ``attempted suicide.’’ Each endorsement is in the pathological direction. The resulting SHI score is the sum of endorsements with possible scores ranging from 0 to 22. Borderline Personality Symptomatology Borderline personality symptomatology was measured using three diagnostic approaches. The first was the borderline personality scale of the Personality Diagnostic Questionnaire ± Revised (PDQ-R),24 an 18-item, selfreport measure based upon the DSM-III-R25 criteria for borderline personality disorder. The PDQ-R has been found to be a useful screening tool for borderline personality in both clinical 26,27 and nonclinical 28 samples, including the use of the free-standing borderline subscale. 29 The second measure was a non-standardized clinical interview undertaken by first- and second-year psychiatry residents who were unaware of the purpose of the study. Clinical diagnosis was based upon the DSM-IV criteria for BPD. Previous research has indicated differences in BPD diagnosis when comparing clinical diagnosis with a semistructured interview, despite the use of the same criteria. Following psychiatric evaluation, the resident clinician completed the Axis II diagnoses for each participant on a research form. During the study, a total of six resident clinicians provided diagnoses; inter-rater reliability was not determined. The third measure, a DSM-IV checklist that listed the nine criteria for BPD, was also completed by the same resident clinician. 30 With regard to the three diagnostic approaches, note that while diagnostic approach varied, the diagnostic concept (i.e., DSM construct) did not. All study materials for each subject were placed in a secured envelope in preparation for data analysis. The
Borderline personality and self-harm
results of the study measures were not available to clinicians. All participants completed a consent form for participation that was approved by the institutional review boards of the community hospital as well as the university. Patients were not reimbursed for their participation.
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STATISTICAL STRATEGY In our first series of analyses, we examined the frequencies of BPD diagnoses (i.e., positive or negative) across the sample. We then examined BPD diagnoses by diagnostic approach (i.e., PDQ-R, clinical interview, DSM-IV checklist), as well as the overlap in diagnosis between approaches (i.e., the diagnosis capture rate for each measure as well as each possible combination of approaches). In our next series of analyses, we examined the relationship between diagnostic approach and self-harm behavior. More specifically, we examined the number of types of self-harm behavior (i.e., the total number of types of self-harm behavior, as well as the total number of potentially lethal types, reported by participants on the SHI) as a function of diagnostic approach. Finally, we ran a series of analyses to examine differences in the number of types of self-harm behavior reported versus the number of diagnostic approaches for which participants were positive for BPD.
RESULTS Of the 77 participants, 17 (22.1%) were not diagnosed as BPD on any measure. Only one (1.3%) participant was diagnosed as BPD from the clinical interview only, one (1.3%) only from the DSM-IV checklist, and 17 (22.1%) only from the PDQ-R. Three (3.9%) participants were diagnosed as BPD on both clinical interview and the DSMIV checklist, and six (7.8%) participants were diagnosed as BPD on both the DSM-IV checklist and the PDQ-R. No participants were diagnosed as BPD on both clinical interview and the PDQ-R. The largest number of participants (n=32, 41.6%) was diagnosed as BPD on all three measures. Table 1 displays the mean number of types of self-harm behavior (i.e., the total score on the SHI) endorsed by participants diagnosed as BPD according to each diagnostic approach. Because some participants were assigned to more Table 1 Mean (SD) total score* on Self-Harm Inventory (SHI) 17 and number of potentially lethal behavior types endorsed,** according to diagnostic approach, among participants diagnosed as BPD (n=60)
275
than one group by diagnostic approach, the statistical significance of differences between SHI scores among diagnostic approaches could not be determined. Note that the lowest SHI score was for BPD diagnosis using the PDQR, followed by the DSM-IV checklist, and the highest SHI score was for BPD diagnosis by clinical interview. We next examined four items of the SHI that are considered the most potentially lethal (i.e., ``overdosed, cut yourself on purpose, burned yourself on purpose’’ and ``attempted suicide’’) in relation to BPD diagnostic subgroups. The mean values for each group are also shown in Table 1. Note that the pattern of results for the most lethal behavior types was the same as the pattern for the total score on the SHI. In an effort to further explore the relationship between self-harm behavior and diagnostic approach, we examined the mean SHI total score and the mean number of potentially lethal behavior types in relation to the number of measures on which the participant scored positive for BPD. As such, we conducted separate oneway analyses of variance (ANOVAs) with SHI total score and the number of potentially lethal behavior types as the dependent variables, and the number of diagnostic approaches on which the participant was diagnosed as BPD as the independent variable. Results of the ANOVAs indicated that the groups were significantly different on both total SHI score (F(3,73)=21.20, P50.001) and number of lethal behavior types endorsed (F(3,73)=7.68, P50.001). Table 2 presents the means and standard deviations on the self-harm measures by number of diagnostic approaches on which the participants were diagnosed as BPD. Post hoc Tukey’s tests showed that for total SHI score, participants not diagnosed as BPD on any of the diagnostic approaches scored significantly lower than all individuals diagnosed as BPD, and individuals diagnosed as BPD by all three diagnostic approaches scored significantly higher than individuals diagnosed as BPD by only one or two of the diagnostic approaches. Note that for potentially lethal self-harm behavior types, the same pattern of results was found, but that participants diagnosed as BPD by only one of the diagnostic approaches did not differ significantly from either participants not diagnosed as BPD on any of the diagnostic approaches, or participants diagnosed as BPD by all three approaches.
Self-harm measure Total SHI score Potentially lethal SHI score
Clinical interview (n=36)
DSM-IV checklist (n=42)
PDQ-R (n=55)
11.15 (4.32) 2.67 (1.22)
10.68 (4.28) 2.57 (1.23)
9.58 (4.58) 2.24 (1.30)
BPD=borderline personality disorder; PDQ-R=borderline personality scale of the Personality Diagnostic Questionnaire-Revised;18 SD=standard deviation. *Range=0 ± 22. **Items are: overdosed, cut self, burned self, attempted suicide (range=0 ± 4).
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Table 2 Mean (SD) total score on Self-Harm Inventory (SHI) and number of potentially lethal behavior types endorsed according to number of BPDpositive diagnostic approaches (n=77)
Self-harm measure
No. of BPD-positive diagnostic approaches 0 (n=17) 1 (n=19) 2 (n=9) 3 (n=32)
Total SHI score 3.59 (2.45) Potentially lethal SHI score 1.06 (0.97)
6.79 (3.92) 1.63 (1.16)
7.56 (3.28) 11.75 (3.88) 2.44 (1.33) 2.63 (1.24)
F-value
P-value
Group differences
21.20 7.68
50.001 50.001
051, 2, 3; 1, 2,53 052, 3; 153
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For notes, see Table 1
DISCUSSION Our findings indicate that the prevalence of self-harm behavior varies as a function of the BPD diagnostic approach, and that diagnostic overlap between the different approaches is highlighted by a significantly higher prevalence of self-harm behavior (i.e., self-harm behavior demonstrates clinical concordance among the measures). In addition, potentially lethal behavior types were most frequent among those with a clinical diagnosis of BPD, followed by the DSM-IV checklist, followed by the PDQ-R. The prevalence of potentially lethal behavior types also increased with the number of measures on which the participants were diagnosed as BPD. These data appear to reinforce the impression that self-harm behavior is an integral and diagnostically critical facet of BPD. Among the three different diagnostic approaches, the clinician diagnosis yielded the patient subsample with the highest prevalence of, and most potentially lethal types of, self-harm behavior. We suspect that this reflects the clinician’s overall sense of risk among these patients. In other words, there may be a distinct emotional sense of risk, based on clinical presentation or history, that is not elicited by brief, specific criteria. If so, this might indicate that clinical intuition based on self-harm assessment is a reasonably reliable parameter for BPD diagnosis. In addition to self-harm behavior, there may be other clinical phenomena that lie within the overlap of various diagnostic systems for BPD. These might include chronic and/or atypical affective disturbance, distorted relational beliefs and experiences, and negative self-concept, which might be areas for future clinical investigation. A comparison of the prevalence of these preceding symptoms and self-harm behavior might indicate the diagnostic `weight’ of each among those with BPD. However, Links et al31 found that among the various features of BPD, impulsivity was the most stable feature over time. Self-harm behavior may be viewed as a diagnostic feature of BPD, although few diagnostic approaches to BPD rely on exclusive assessment of these behavior types. We have examined the SHI in terms of its ability to diagnose BPD23 and determined a diagnostic accuracy of 84% in comparison with the Diagnostic Interview for Borderline
Patients.32 This seems to confirm the diagnostic strength of self-harm behavior with regard to BPD. One unexpected finding is that the clinical diagnosis and the DSM-IV checklist diagnosis, completed by the same resident clinician for a given participant, lacked strict diagnostic concordance. Compared to other measures for BPD, the clinical interview was the most diagnostically restrictive in nature. Why this might be warrants further investigation, but previous research has indicated similar results ± that clinical interview captures fewer BPD subjects than semi-structured interview.30 There are several limitations to this study. First, several interviewers undertook the clinical assessments without our determining inter-rater reliability. However, such an approach allows a more naturalistic clinical assessment, as opposed to an empirical assessment, which could strengthen the validity of generalizing these data to a non-research environment. Second, the PDQ-R is known to be an overinclusive measure (i.e., false positives), which appears to be demonstrated in this study. Third, the patient sample was of inpatients and therefore represented the more disturbed end of the borderline population continuum. Indeed, this sample shows evidence of high levels of borderline personality pathology, which may reflect the changing terrain of brief psychiatric admissions to community hospitals. It is unknown whether healthier individuals with BPD would show these same patterns with regard to self-harm behavior. Fourth, the PDQ-R and the DSM-IV checklist are probably best perceived as screening measures for BPD rather than reliable diagnostic instruments. Finally, it is unknown whether other diagnostic approaches (e.g., semi-structured interviews) would yield similar results.
CONCLUSION We believe that the clinical significance of these results is that self-harm behavior is an integral facet of more severely disturbed borderline patients, as determined by the overlap of diagnostic subsamples in this study. Indeed, chronic self-harm behavior may be the defining characteristic for BPD, which would suggest that more
Borderline personality and self-harm
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specific assessment measures might be developed. In this regard, the assessment of self-harm behavior is not subject to interpretation or impression, but is simply historical in nature, reducing imprecision in assessment. As opposed to other approaches, the fact that the clinician assessment tapped into the diagnostic subsample with the greatest prevalence of, as well as the most potentially lethal, self-harm behavior suggests important but subtle differences in the diagnosis of BPD, which warrant further investigation.
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KEY POINTS . Borderline personality appears to be characterised by self-harm behavior . Diagnostic confirmation of borderline personality on multiple measures appears to be associated with greater rates of self-harm behavior, including high-lethal behavior
REFERENCES 1. Kroll J, Sines L, Martin K et al (1981) Borderline personality disorder. Construct validity of the concept. Arch Gen Psychiatry 38: 1021 ± 6. 2. Neutzel EJ (1985) DSM-III and the use of the term borderline. Bull Menninger Clin 49: 124 ± 34. 3. Dahl AA (1985) Borderline disorders ± the validity of the diagnostic concept. Psychiatr Dev 2: 109 ± 52. 4. Whewell P, Ryman A, Bonanno D, Heather N (2000) Does the ICD 10 classification accurately describe subtypes of borderline personality disorder? Br J Med Psychol 73: 483 ± 94. 5. Blais MA, Hilsenroth MJ, Fowler JC (1999) Diagnostic efficiency and hierarchical functioning of the DSM-IV borderline personality disorder criteria. J Nerv Ment Dis 187: 167 ± 73. 6. Fossati A, Marrei C, Bagnato M et al (1999) Latent structure analysis of DSM-IV borderline personality disorder criteria. Compr Psychiatry 40: 72 ± 9. 7. Trull TJ, Useda JD, Doan BT et al (1998) Two-year stability of borderline personality measures. J Pers Disord 12: 187 ± 97. 8. Burgmer M (1999) The operational diagnostic approach of the borderline personality disorder. Nervenarzt 70: 250 ± 5. 9. Perry JC (1992) Problems and considerations in the valid assessment of personality disorders. Am J Psychiatry 149: 1645 ± 53. 10. American Psychiatric Association (1994) The Diagnostic and Statistical Manual of Mental Disorders. Fourth edn. (DSM-IV). American Psychiatric Association, Washington, DC. 11. Gunderson JF, Singer MT (1975) Defining borderline patients: an overview. Am J Psychiatry 132: 1 ± 10. 12. Mack J (1975) Borderline States: An historical perspective. Grune & Stratton, New York. 13. Kernberg OF, Selzer MA, Koenigsberg HW et al (1989) Psychodynamic Psychotherapy of Borderline Patients. Basic Books, New York. 14. Linehan MM (1987) Dialectical behavior therapy for borderline personality disorder: theory and method. Bull Menninger Clin 51: 261 ± 76. 15. Schaffer CB, Carroll J, Abramowitz SI (1982) Self-mutilation and the borderline personality. J Nerv Ment Dis 170: 468 ± 73. 16. Simeon D, Stanley B, Frances A et al (1992) Self-mutilation in pesonality disorders: psychological and biological correlates. Am J Psychiatry 149: 221 ± 6. 17. Walsh BW, Rosen PM (1998) Self-mutilation. Guilford Press, New York.
18. Gunderson JG, Kolb JE (1978) Discriminating features of borderline patients. Am J Psychiatry 135: 792 ± 6. 19. Gunderson JG, Kolb JE, Austin V (1981) The diagnostic interview for borderline patients. Am J Psychiatry 138: 896 ± 903. 20. Perry J, Klerman G (1980) Clinical features of the borderline personality disorder. Am J Psychiatry 137: 165 ± 73. 21. Spitzer RL, Endicott J (1979) Justification for separating schizotypal and borderline personality disorders. Schizophr Bull 5: 95 ± 104. 22. Herpertz S (1995) Self-injurious behavior. Psychopathological and nosological characteristics in subtypes of self-injurers. Acta Psychiatr Scand 91: 57 ± 68. 23. Sansone RA, Wiederman MW, Sansone LA (1998) The SelfHarm Inventory (SHI): development of a scale for identifying self-destructive behaviors and borderline personality disorder. J Clin Psychol 54: 973 ± 83. 24. Hyler SE, Rieder RO (1987) Personality Diagnostic Questionnaire ± Revised. New York State Psychiatric Institute, New York. 25. American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders. Third edn. (Revised) (DSM-IIIR) American Psychiatric Association, Washington, DC. 26. Dubro AF, Wetzler S, Kahn MW (1988) A comparison of three self-report questionnaires for the diagnosis of DSM-III personality disorders. J Pers Disord 2: 256 ± 66. 27. Hyler SE, Lyons M, Rieder RO et al (1990) The factor structure of self-report DSM-III Axis II symptoms and their relationship to clinicians’ ratings. Am J Psychiatry 147: 751 ± 7. 28. Johnson JG, Bornstein RF (1992) Utility of the Personality Diagnostic Questionnaire ± Revised in a nonclinical sample. J Pers Disord 6: 450 ± 7. 29. Patrick J, Links P, Van Reekum R, Mitton MJE (1995) Using the PDQ-R BPD scale as a brief screening measure in the differential diagnosis of personality disorder. J Pers Disord 9: 266 ± 74. 30. Zimmerman M (1999) Differences between clinical and research practices in diagnosing borderline personality disorder. Am J Psychiatry 156: 1570 ± 4. 31. Links PS, Heslegrave R, van Reekum R (1999) Impulsivity: core aspect of borderline personality disorder. J Pers Disord 13: 1 ± 9. 32. Kolb JE, Gunderson JG (1980) Diagnosing borderline patients with a semistructured interview. Arch Gen Psychiatry 37: 37 ± 41.
2001 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 2001 Volume 5 Pages 273 ± 277
273
Diagnostic approaches to borderline personality and their relationship to self-harm behavior
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 10/31/14 For personal use only.
RANDY A SANSONE,1, DOUGLAS A SONGER1 AND GEORGE A GAITHER2 1
Wright State University School of Medicine, Dayton, Ohio and 2Ball State University, Muncie, Indiana, USA
This study was designed to explore the relationship, if any, between diagnostic approach to borderline personality disorder (BPD) and the extent of self-harm behavior among psychiatric inpatients. OBJECT:
Newly admitted psychiatric inpatients (N=77) were evaluated for BPD using a self-report measure, clinical diagnosis, and a DSM-IV checklist. All participants were assessed for self-harm behavior using the 22-item Self-Harm Inventory (SHI). METHOD:
Participants with a clinical diagnosis of BPD showed the highest prevalence of, and most potentially lethal, types of self-harm behavior, followed by those diagnosed as BPD by the DSM-IV checklist, and then by self-report measure. Participants diagnosed as BPD on all three measures showed the highest mean number of self-harm and potentially lethal behavior types. Prevalence and potential lethality decreased successively among those who were diagnosed as BPD on two measures versus one measure versus no diagnosis of BPD. RESULTS:
Correspondence Address Randy A. Sansone, MD, Sycamore Primary Care Center, 2115 Leiter Road, Miamisburg, OH 45342, USA Tel: (+1) 937 384 6850 Fax: (+1) 937 384 6938
Received 16 November 2000; revised 8 March 2001; accepted for publication 14 March 2001
Self-harm behavior appears to be a clinically concordant behavior type among the diagnostic approaches to BPD used in this study. Clinical diagnosis appears most sensitive to self-harm behavior, compared with self-report and DSM-IV checklist. (Int J Psych Clin Pract 2001; 5: 273 ± 277) CONCLUSION:
Keywords borderline personality
INTRODUCTION
A
s with most personality disorders, the diagnosis of borderline personality disorder (BPD) is an imprecise process. Indeed, when different diagnostic approaches are used to evaluate the same clinical sample, invariably there is overlap but not absolute concordance among the resulting BPD subsamples. 1 Neutzel2 reviewed the BPD criteria of four groups of investigators and determined that they were vastly dissimilar, which he attributed to conceptual differences. Dahl3 summarized available studies comparing sets of diagnostic criteria for BPD and concluded that while there was meaningful overlap, there was sufficient lack of concordance to make comparisons across studies problematic. Other investigators have also noted diagnostic dilemmas with regard to BPD.4 ± 8
self-harm behavior
Variability among the different diagnostic approaches has been attributed to many factors. These include the construct validity of the approach, rater variance for approaches entailing interview formats, subjective interpretation for those entailing self-report formats, and diagnostic variability due to state effects or changes.9 While there are clearly legitimate sources of variation among the diagnostic approaches to BPD, little is known about the clinical implications of such variation. Self-harm behavior is a clinically significant feature of BPD. Among the nine diagnostic criteria for BPD in DSMIV,10 two entail self-harm (self-damaging impulsivity; suicidal behavior or gestures). Among the remaining DSM-IV personality disorders, only antisocial personality disorder has a criterion for self-harm (i.e., physical fights or assaults). Gunderson and Singer 11 have indicated that self-
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 10/31/14 For personal use only.
274
RA Sansone et al
harm behavior is one of the characteristics most commonly and consistently associated with BPD. Mack12 has described self-harm behavior as the behavioral speciality of those with BPD. Numerous authors have highlighted the importance of self-harm behavior in relation to BPD.13 ± 17 Indeed, selfharm behavior is sufficiently consistent among individuals with BPD for many authors to recommend this feature as a means to distinguish individuals with BPD from other severely disturbed individuals. 18 ± 22 In summary, self-harm appears to be a meaningful type of behavior to examine among different diagnostic approaches to BPD to determine clinical concordance. The current study was undertaken to explore self-harm behavior, a behavioral marker for BPD, and its prevalence among three diagnostic subsamples (BPD diagnosis according to self-report measure; clinical diagnosis; and DSM-IV checklist) in a sample of psychiatric inpatients. We hypothesized that there would be variation in the frequency of self-harm behavior among the different BPD subgroups, with clinical diagnosis being the method of diagnosis the most sensitive to self-harm. We also suspected that selfharm behavior would be most frequent among those participants diagnosed as BPD by all three approaches (i.e., those individuals with `core’ BPD disorder).
METHOD PARTICIPANTS Study subjects (N=77) were newly admitted inpatients in an acute-care psychiatry unit of an urban community hospital, over the age of 18, and sufficiently cognitively intact (i.e., not overtly psychotic) to participate in the study. Shortly after admission, each was invited by a single attending psychiatrist to participate in a project ``exploring symptoms and self-harm behavior.’’ Candidates were recruited by the attending physician as time allowed (i.e., these were not consecutive patients, but rather represent a sample of convenience). These 77 participants represented 30.8% of the number of patients admitted during the 6-month study period. Although Axis I diagnoses were not recorded as study measures, the approximate diagnostic profile for the population admitted to this unit is as follows: 50% major depression, 50% substance abuse, 25% psychosis (e.g., schizophrenia, bipolar disorder), and 10% dementia. The majority of patients are admitted because of behavioral problems and/or suicidal ideation. The mean age of the sample was 33.57 years (SD=9.64). Of the 77 participants, 47 (61.%) were female and 30 (39.0%) were male. With regard to race, 58 (75.3%) participants indicated Caucasian, 15 (19.5%) AfricanAmerican, two (2.6%) Native American, and two (2.6%) other. Twenty (26.0%) participants were married, 23 (29.9%) divorced, 30 (39.0%) had never married, and three (3.9%) were widowed; information for one (1.2%) participant was missing. Only one (1.8%) participant did
not complete junior high school. The highest educational attainment of eight (10.4%) participants was junior high school, of 52 (67.5%) high school, of eight (10.4%) junior college, of six (7.8%) 4-year college, and of two (2.6%) graduate degree or higher. Of the 85 candidates asked to participate, 77 agreed to do so (a response rate of 90.6%).
MEASURES Each subject completed a research booklet and participated in a diagnostic interview. The research booklet consisted of three sections: a demographic inquiry, a measure investigating participants’ history of self-harm, and a self-report measure of borderline personality symptoms. The demographic inquiry investigated age, gender, race, and marital and educational status. Self-harm Self-harm behavior was measured using the Self-Harm Inventory (SHI),23 a 22-item, yes/no self-report measure. Each item in the inventory is preceded by the phrase: ``Have you ever intentionally, or on purpose . . .’’ and items include: ``overdosed, cut yourself on purpose, burned yourself on purpose, hit yourself’’ and ``attempted suicide.’’ Each endorsement is in the pathological direction. The resulting SHI score is the sum of endorsements with possible scores ranging from 0 to 22. Borderline Personality Symptomatology Borderline personality symptomatology was measured using three diagnostic approaches. The first was the borderline personality scale of the Personality Diagnostic Questionnaire ± Revised (PDQ-R),24 an 18-item, selfreport measure based upon the DSM-III-R25 criteria for borderline personality disorder. The PDQ-R has been found to be a useful screening tool for borderline personality in both clinical 26,27 and nonclinical 28 samples, including the use of the free-standing borderline subscale. 29 The second measure was a non-standardized clinical interview undertaken by first- and second-year psychiatry residents who were unaware of the purpose of the study. Clinical diagnosis was based upon the DSM-IV criteria for BPD. Previous research has indicated differences in BPD diagnosis when comparing clinical diagnosis with a semistructured interview, despite the use of the same criteria. Following psychiatric evaluation, the resident clinician completed the Axis II diagnoses for each participant on a research form. During the study, a total of six resident clinicians provided diagnoses; inter-rater reliability was not determined. The third measure, a DSM-IV checklist that listed the nine criteria for BPD, was also completed by the same resident clinician. 30 With regard to the three diagnostic approaches, note that while diagnostic approach varied, the diagnostic concept (i.e., DSM construct) did not. All study materials for each subject were placed in a secured envelope in preparation for data analysis. The
Borderline personality and self-harm
results of the study measures were not available to clinicians. All participants completed a consent form for participation that was approved by the institutional review boards of the community hospital as well as the university. Patients were not reimbursed for their participation.
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STATISTICAL STRATEGY In our first series of analyses, we examined the frequencies of BPD diagnoses (i.e., positive or negative) across the sample. We then examined BPD diagnoses by diagnostic approach (i.e., PDQ-R, clinical interview, DSM-IV checklist), as well as the overlap in diagnosis between approaches (i.e., the diagnosis capture rate for each measure as well as each possible combination of approaches). In our next series of analyses, we examined the relationship between diagnostic approach and self-harm behavior. More specifically, we examined the number of types of self-harm behavior (i.e., the total number of types of self-harm behavior, as well as the total number of potentially lethal types, reported by participants on the SHI) as a function of diagnostic approach. Finally, we ran a series of analyses to examine differences in the number of types of self-harm behavior reported versus the number of diagnostic approaches for which participants were positive for BPD.
RESULTS Of the 77 participants, 17 (22.1%) were not diagnosed as BPD on any measure. Only one (1.3%) participant was diagnosed as BPD from the clinical interview only, one (1.3%) only from the DSM-IV checklist, and 17 (22.1%) only from the PDQ-R. Three (3.9%) participants were diagnosed as BPD on both clinical interview and the DSMIV checklist, and six (7.8%) participants were diagnosed as BPD on both the DSM-IV checklist and the PDQ-R. No participants were diagnosed as BPD on both clinical interview and the PDQ-R. The largest number of participants (n=32, 41.6%) was diagnosed as BPD on all three measures. Table 1 displays the mean number of types of self-harm behavior (i.e., the total score on the SHI) endorsed by participants diagnosed as BPD according to each diagnostic approach. Because some participants were assigned to more Table 1 Mean (SD) total score* on Self-Harm Inventory (SHI) 17 and number of potentially lethal behavior types endorsed,** according to diagnostic approach, among participants diagnosed as BPD (n=60)
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than one group by diagnostic approach, the statistical significance of differences between SHI scores among diagnostic approaches could not be determined. Note that the lowest SHI score was for BPD diagnosis using the PDQR, followed by the DSM-IV checklist, and the highest SHI score was for BPD diagnosis by clinical interview. We next examined four items of the SHI that are considered the most potentially lethal (i.e., ``overdosed, cut yourself on purpose, burned yourself on purpose’’ and ``attempted suicide’’) in relation to BPD diagnostic subgroups. The mean values for each group are also shown in Table 1. Note that the pattern of results for the most lethal behavior types was the same as the pattern for the total score on the SHI. In an effort to further explore the relationship between self-harm behavior and diagnostic approach, we examined the mean SHI total score and the mean number of potentially lethal behavior types in relation to the number of measures on which the participant scored positive for BPD. As such, we conducted separate oneway analyses of variance (ANOVAs) with SHI total score and the number of potentially lethal behavior types as the dependent variables, and the number of diagnostic approaches on which the participant was diagnosed as BPD as the independent variable. Results of the ANOVAs indicated that the groups were significantly different on both total SHI score (F(3,73)=21.20, P50.001) and number of lethal behavior types endorsed (F(3,73)=7.68, P50.001). Table 2 presents the means and standard deviations on the self-harm measures by number of diagnostic approaches on which the participants were diagnosed as BPD. Post hoc Tukey’s tests showed that for total SHI score, participants not diagnosed as BPD on any of the diagnostic approaches scored significantly lower than all individuals diagnosed as BPD, and individuals diagnosed as BPD by all three diagnostic approaches scored significantly higher than individuals diagnosed as BPD by only one or two of the diagnostic approaches. Note that for potentially lethal self-harm behavior types, the same pattern of results was found, but that participants diagnosed as BPD by only one of the diagnostic approaches did not differ significantly from either participants not diagnosed as BPD on any of the diagnostic approaches, or participants diagnosed as BPD by all three approaches.
Self-harm measure Total SHI score Potentially lethal SHI score
Clinical interview (n=36)
DSM-IV checklist (n=42)
PDQ-R (n=55)
11.15 (4.32) 2.67 (1.22)
10.68 (4.28) 2.57 (1.23)
9.58 (4.58) 2.24 (1.30)
BPD=borderline personality disorder; PDQ-R=borderline personality scale of the Personality Diagnostic Questionnaire-Revised;18 SD=standard deviation. *Range=0 ± 22. **Items are: overdosed, cut self, burned self, attempted suicide (range=0 ± 4).
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Table 2 Mean (SD) total score on Self-Harm Inventory (SHI) and number of potentially lethal behavior types endorsed according to number of BPDpositive diagnostic approaches (n=77)
Self-harm measure
No. of BPD-positive diagnostic approaches 0 (n=17) 1 (n=19) 2 (n=9) 3 (n=32)
Total SHI score 3.59 (2.45) Potentially lethal SHI score 1.06 (0.97)
6.79 (3.92) 1.63 (1.16)
7.56 (3.28) 11.75 (3.88) 2.44 (1.33) 2.63 (1.24)
F-value
P-value
Group differences
21.20 7.68
50.001 50.001
051, 2, 3; 1, 2,53 052, 3; 153
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For notes, see Table 1
DISCUSSION Our findings indicate that the prevalence of self-harm behavior varies as a function of the BPD diagnostic approach, and that diagnostic overlap between the different approaches is highlighted by a significantly higher prevalence of self-harm behavior (i.e., self-harm behavior demonstrates clinical concordance among the measures). In addition, potentially lethal behavior types were most frequent among those with a clinical diagnosis of BPD, followed by the DSM-IV checklist, followed by the PDQ-R. The prevalence of potentially lethal behavior types also increased with the number of measures on which the participants were diagnosed as BPD. These data appear to reinforce the impression that self-harm behavior is an integral and diagnostically critical facet of BPD. Among the three different diagnostic approaches, the clinician diagnosis yielded the patient subsample with the highest prevalence of, and most potentially lethal types of, self-harm behavior. We suspect that this reflects the clinician’s overall sense of risk among these patients. In other words, there may be a distinct emotional sense of risk, based on clinical presentation or history, that is not elicited by brief, specific criteria. If so, this might indicate that clinical intuition based on self-harm assessment is a reasonably reliable parameter for BPD diagnosis. In addition to self-harm behavior, there may be other clinical phenomena that lie within the overlap of various diagnostic systems for BPD. These might include chronic and/or atypical affective disturbance, distorted relational beliefs and experiences, and negative self-concept, which might be areas for future clinical investigation. A comparison of the prevalence of these preceding symptoms and self-harm behavior might indicate the diagnostic `weight’ of each among those with BPD. However, Links et al31 found that among the various features of BPD, impulsivity was the most stable feature over time. Self-harm behavior may be viewed as a diagnostic feature of BPD, although few diagnostic approaches to BPD rely on exclusive assessment of these behavior types. We have examined the SHI in terms of its ability to diagnose BPD23 and determined a diagnostic accuracy of 84% in comparison with the Diagnostic Interview for Borderline
Patients.32 This seems to confirm the diagnostic strength of self-harm behavior with regard to BPD. One unexpected finding is that the clinical diagnosis and the DSM-IV checklist diagnosis, completed by the same resident clinician for a given participant, lacked strict diagnostic concordance. Compared to other measures for BPD, the clinical interview was the most diagnostically restrictive in nature. Why this might be warrants further investigation, but previous research has indicated similar results ± that clinical interview captures fewer BPD subjects than semi-structured interview.30 There are several limitations to this study. First, several interviewers undertook the clinical assessments without our determining inter-rater reliability. However, such an approach allows a more naturalistic clinical assessment, as opposed to an empirical assessment, which could strengthen the validity of generalizing these data to a non-research environment. Second, the PDQ-R is known to be an overinclusive measure (i.e., false positives), which appears to be demonstrated in this study. Third, the patient sample was of inpatients and therefore represented the more disturbed end of the borderline population continuum. Indeed, this sample shows evidence of high levels of borderline personality pathology, which may reflect the changing terrain of brief psychiatric admissions to community hospitals. It is unknown whether healthier individuals with BPD would show these same patterns with regard to self-harm behavior. Fourth, the PDQ-R and the DSM-IV checklist are probably best perceived as screening measures for BPD rather than reliable diagnostic instruments. Finally, it is unknown whether other diagnostic approaches (e.g., semi-structured interviews) would yield similar results.
CONCLUSION We believe that the clinical significance of these results is that self-harm behavior is an integral facet of more severely disturbed borderline patients, as determined by the overlap of diagnostic subsamples in this study. Indeed, chronic self-harm behavior may be the defining characteristic for BPD, which would suggest that more
Borderline personality and self-harm
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specific assessment measures might be developed. In this regard, the assessment of self-harm behavior is not subject to interpretation or impression, but is simply historical in nature, reducing imprecision in assessment. As opposed to other approaches, the fact that the clinician assessment tapped into the diagnostic subsample with the greatest prevalence of, as well as the most potentially lethal, self-harm behavior suggests important but subtle differences in the diagnosis of BPD, which warrant further investigation.
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KEY POINTS . Borderline personality appears to be characterised by self-harm behavior . Diagnostic confirmation of borderline personality on multiple measures appears to be associated with greater rates of self-harm behavior, including high-lethal behavior
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