Comparison of three systems for diagnosing borderline personality disorder

The authors assessed three systems for diagnosing borderline personality disorder: DSM-III, the checklist criteria of Spitzer et al., and the Diagnostic Interview for Borderline Patients. In an inpatient sample of 51 patients, 43 (84%) met the criteria of at least one of these systems; analyses were carried out on 28 of these patients. Twelve (43%) of these 28 patients met criteria for all three systems, seven (25%) for two systems, and nine (32%) for only one system. Kernberg's structural criteria showed reasonable overlap with the other diagnostic criteria. Affective disorders were prominent across diagnostic measures in this sample of borderline patients.     

Is borderline a distinct entity?

There is no agreement in American psychiatry as to whether borderline should be regarded as a distinct entity. A review of the major viewpoints in the field reveals that borderline is variously used to designate: (1) a clinical disorder distinguishable by behavioral criteria; (2) a milder form of schizophrenia; (3) a nonspecific term encompassing several atypical affective disorders; (4) a psychostructural distinction. When the St. Louis approach to diagnostic validity is used as a guideline, the conclusion reached is that available data do not weigh conclusively for or against borderline's status as an independent entity. In particular, borderline, as defined by several investigators, appears distinct from schizophrenia, but requires further delimitation from the affective disorders.     

The dissociative experiences of borderline patients

The study objective was to assess the severity and quality of dissociative experiences reported by borderline patients. Two hundred ninety criteria-defined borderline patients and 72 axis II controls completed the Dissociative Experiences Scale (DES), a 28-item self-report measure with demonstrated reliability and validity. Thirty-two percent of borderline patients had a low level of dissociation, 42% a moderate level, and 26% a high level similar to that reported by patients meeting criteria for posttraumatic stress disorder (PTSD) or dissociative disorders. The controls had a significantly different distribution of overall DES scores: 71% reported a low level of dissociation, 26% reported a moderate level, and only 3% reported a high level. In addition, borderline patients had a significantly higher score than the controls on 21 of 28 DES items and a significantly higher overall DES score, as well as the score on the 3 factors that have been found to underlie the DES, absorption, amnesia, and depersonalization. The results of this study suggest that the severity of dissociation experienced by borderline patients is more heterogeneous than previously reported. They also suggest that borderline patients have a wider range of dissociative experiences than are commonly recognized, including experiences of absorption and amnesia, as well as experiences of depersonalization.     

Discriminant efficiency of antisocial and borderline personality disorder criteria in Hispanic men with substance use disorders

The authors examined the discriminant efficiency of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV ) criteria for borderline personality disorder (BPD) and antisocial personality disorder (APD). Subjects were 74 men admitted to an outpatient substance abuse program for monolingual Hispanic adults. All were reliably assessed with the Spanish-language version of the Diagnostic Interview for DSM-IV Personality Disorders. Conditional probabilities were calculated to determine the diagnostic efficiency and discriminant efficiency of BPD and APD symptoms. Twenty-five (34%) subjects met diagnostic criteria for BPD, and 16 (22%) met criteria for APD. The diagnostic co-occurrence of these disorders was statistically significant. Whereas the diagnostic efficiency of the BPD criterion set was comparable to that reported in other clinical studies, these criteria were not significantly more efficient in diagnosing BPD than APD. By contrast, the APD criteria were more efficient in diagnosing APD than BPD; this was true for both the "adult" and the "conduct disorder" APD criterion subsets. In male Hispanic outpatients with substance use disorders, BPD and APD show significant diagnostic overlap. The APD criteria are useful in discriminating these 2 disorders, whereas the BPD criteria are not. These findings have implications for the discriminant validity of the BPD and APD criteria and support the value of the conduct disorder criteria in predicting APD in adulthood.     

Borderline--a diagnostic entity?

In the last years, there has been considerable controversy as to whether the term "borderline" should be introduced into psychiatric diagnostic nomenclature to designate psychiatric disorders not classifiable as psychoses, neuroses or traditional forms of personality disorders. Whereas many psychiatrists, especially those who are psychodynamically oriented, have been using this term for a long time, the more phenomenologically oriented psychiatrists refuse to do so while pointing to its lack of clear-cut definitions and its confusing abundance of meanings. The definitions of the term "borderline" used in the various "borderline" -concepts are reviewed. Some authors (Knight, Kety et al.) consider "borderline schizophrenia" to be a subgroup of schizophrenic psychoses. Others (Klein, Stone) take "borderline" disorders as a heterogeneous group of psychiatric illness encompassing especially some atypical affective disorders. Thirdly the concepts of those authors who conceive "borderline" as a distinct diagnostic entity are reviewed: Kernberg's "Borderline personality organization", Grinker's "Borderline syndrome", Gunderson and Singer's "Borderline personality disorders", Spitzer and Endicott's "Borderline (unstable) personality disorder" and "Schizotypical personality". The "borderline" definitions of all concepts are examined as to whether they fulfil the requirements of a "useful" (according to Kendell) diagnostic category, i.e. whether they yield reliably defined diagnostic criteria, and whether they can be validated by genetic and biological studies, therapy response, and long-term studies. It is pointed out that attempts have been made to establish operationally defined diagnostic criteria for some of the "borderline" concepts, but that research aiming at their validation is still in an initial stage.     

Auditory P300 does not differentiate borderline personality disorder from schizotypal personality disorder

The P300 response to an auditory two-tone discrimination task has previously been reported to have prolonged latency and reduced amplitude in schizophrenia and borderline personality disorder. In this study, P300 was recorded from 23 subjects with borderline personality disorder, 12 subjects fulfilling criteria for both borderline and schizotypal personality, and 11 subjects with schizotypal personality. The mean P300 latency was similar in each of these groups and was significantly longer than in 32 patients with neuroses and other personality disorders and 74 nonpatient controls. These findings suggest that borderline and schizotypal patients share a similar abnormality in auditory stimulus evaluation and question whether or not these disorders are separate.     

Developmental histories of borderline patients

The developmental histories of 45 borderline inpatients, as defined by Gunderson-Singer criteria and the Diagnostic Interview for Borderlines, were compared to 42 schizophrenic and 32 depressed controls defined by RDC. Three currently popular hypotheses for borderline personality development were systematically studied: a neurobehavioral model, a separation hypothesis, and a family-dynamic theory. A neurobehavioral survey revealed some complications of pregnancy; prematurity, persistent rocking, and temper tantrums in borderline patients but no increased incidence of hyperactivity, clumsiness, or learning difficulties compared to controls. Borderline patients experienced more early life parental loss and had greater difficulties with normal developmental separations. Their relationships with parents were negative and conflictual, with over-involved mothers and under-involved (or absent) fathers. While supporting the importance of separation trauma and a pathologic family structure, our data do not provide consistent support for a neurobehavioral origin of borderline development.     

Diagnosing personality disorders in the community. A comparison of self-report and interview measures

The rapidly expanding empirical study of personality disorders is the result of the publication of operational diagnostic criteria in DSM-III and the development of instruments to assess these criteria. Few researchers have examined the comparability of measures of personality disorders, and to our knowledge there are no studies of the factors associated with discordance between measures. In the present study, 697 relatives of psychiatric patients and healthy controls were interviewed with the Structured Interview for Personality Disorders (SIDP) and completed the Personality Disorders Questionnaire (PDQ). Significantly more individuals had a personality disorder according to the SIDP; however, multiple personality disorders were more frequently diagnosed on the PDQ. Schizotypal, compulsive, dependent, and borderline personality disorders were significantly more frequently diagnosed by the PDQ, whereas the SIDP more frequently diagnosed antisocial and passive-aggressive personality disorder. The corresponding dimensional scores of the two measures were all significantly correlated; however, the concordance for categorical diagnoses was poor. Discrepancies between the PDQ and the SIPD dimensional scores were significantly associated with current level of depressive symptoms and PDQ lie scale scores.     

The borderline syndrome. I. Testing three diagnostic systems

Diagnostic systems require testing on several factors: reliability, comprehensiveness, concordance with established use, specificity, and validity. Three sets of diagnostic criteria for the borderline have been proposed recently: the Gunderson et al criteria, the DSM-III criteria for borderline personality (BP) disorder, and the DSM-III criteria for schizotypal personality (SP) disorder. This article reviews work to date testing these systems on these factors. New data are presented from the retrospective application of these criteria to the clinical records of 400 diagnostically heterogeneous former inpatients at Chestnut Lodge, Rockville, Md; 330 of them also received systematic follow-up by interview an average of 15 years after discharge. Results strongly supported the validity of the DSM-III division of borderline into BP and SP. Although the BP and Gunderson et al criteria demonstrated high concordance, the latter appeared to offer some slight advantages for defining BP disorder.     

Psychopharmacologic approaches to borderline syndromes

Psychopharmacologic approaches to the treatment of patients with “borderline personality” have been aided by increasing refinement of the diagnostic term. The broadly conceived category of borderline personality organization includes numerous clinical syndromes with specific patterns of symptoms and response to medications. This paper reviews these syndromes in relationship to four psychopathologic “borders” of borderline personality disorder: schizophrenia, affective disorders, organic mental disorders, and personality disorders. Current psychopharmacologic approaches to the treatment of these syndromes are reviewed, and medication choice is discussed with respect to target symptoms. Compliance with treatment, often a problem with borderline patients, is discussed with respect to medication use.     

Diagnostic efficiency of borderline personality disorder criteria in hospitalized adolescents: comparison with hospitalized adults

OBJECTIVE: The authors examined the diagnostic efficiency of borderline personality disorder criteria in adolescent inpatients. For comparison, diagnostic efficiency of borderline personality disorder criteria was also examined in a group of concurrently recruited adult inpatients. METHOD: Adolescents (N=123) and adults (N=106) were reliably assessed with the Personality Disorder Examination, a semistructured diagnostic interview for DSM-III-R personality disorders. Sixty-five adolescents and 50 adults met diagnostic criteria for borderline personality disorder. Conditional probabilities were calculated to determine which borderline personality disorder criteria were most efficient as inclusion criteria and as exclusion criteria. Adolescents and adults were analyzed separately, and the results were compared. RESULTS: There were no significant differences between groups with regard to the base rates of the borderline personality disorder diagnosis nor for any borderline personality disorder criterion. The best inclusion criterion for the adolescents was abandonment fears, though for the adults all symptoms were approximately equivalent in this regard. The most efficient exclusion criterion was uncontrolled anger for the adolescents and impulsiveness for the adults. CONCLUSIONS: In hospitalized patients, borderline personality disorder and its symptoms appear to be as frequent for adolescents as for adults. Despite these surface similarities between groups with respect to symptom patterns, several differences were found at the level of the diagnostic efficiency for individual borderline personality disorder criteria. These differences may shed light on the nature of borderline psychopathology during adolescence.     

The dexamethasone suppression and thyrotropin-releasing hormone tests in depressed borderline patients

Borderline patients can be both a diagnostic and a therapeutic enigma. We investigated a group of 24 depressed women with borderline personality disorder or strong borderline features by DSM III criteria for the presence of either an abnormal dexamethasone suppression test (DST) or a blunted TSH response to TRH, abnormalities which have been reported in major depression. Thirteen of the 24 borderlines failed to suppress on the DST, compared with one of 14 normal women (p < 0.01). Nine of the 24 borderlines had a blunted TSH response to TRH, compared with one of 11 normal women. Neuroendocrine abnormalities were found in a total of 75% of the borderline women, independent of whether or not they met DSM III criteria for major depressive disorder. The results of this study support the notion that many borderline patients with depression have a genuine affective component to their illness, perhaps biologically similar to major depression in non-borderlines.     

Assessment and diagnosis of borderline personality disorder

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, the authors discuss the reliability and validity of structured interviews and self-report instruments and suggest the use of a self-report questionnaire as a cost-effective screening test. Assessment problems, such as the need for longitudinal observation, are reviewed. Essential features of the recommended diagnostic approach include clarity about the diagnostic concept, consideration of the full range of diagnostic criteria, incorporation of recently developed diagnostic methodologies, care in distinguishing personality disorders from comorbid axis I syndromes, and complete assessment of the full range of axis II disorders.     

The prevalence of cyclothymia in borderline personality disorder

Sixty patients with personality disorders were evaluated by several different diagnostic instruments to determine the prevalence of cyclothymia in borderline personality disorder (BPD) and in other personality disorders (OPD). Cyclothymia occurred more frequently in BPD than in OPD, regardless of which diagnostic system was used. In contrast, the prevalence of major, minor, and intermittent depression, hypomania, and bipolar disorder was not significantly different in BPD as compared with OPD. Cyclothymic borderlines and noncyclothymic borderlines could not be distinguished on behavioral or functional measures. These results have implications for the diagnostic validity of both BPD and cyclothymia.     

DSM-III personality disorders in opiate addicts

Using the new DSM-III criteria for personality disorders, the rates of these disorders were evaluated in opiate addicts applying for treatment. Consistent with previous studies, 68% of the sample met diagnostic criteria for a personality disorder. Contrary to older theories of an “addictive personality,” a range of personality disorders was found and 24% of the addicts met the criteria for multiple personality disorders. To compare addicts with differing personality patterns, the eleven DSM-III personality disorders were categorized into five mutually exclusive groups: antisocial (39%), borderline (14%), narcissistic (9%), other personality disorder (6%) and no personality disorder (32%). Addicts in these groups differed demographically and in distributions of concurrent psychiatric diagnoses.     

Validation of diagnostic criteria for apathy in Parkinson’s disease

BackgroundApathy is a common neuropsychiatric syndrome in Parkinson’s Disease (PD) that affects quality of life. Research into apathy has been hampered by a lack of broadly accepted diagnostic criteria. Recently, diagnostic criteria for apathy in neuropsychiatric disorders have been proposed, which to date have not been validated in PD.AimTo validate the proposed diagnostic criteria for apathy in PD.Design and methodsIn a cross-sectional study, outpatients with PD visiting a movement disorders clinic underwent a protocolized assessment of motor function, activities of daily living (ADL), cognition and mood. In addition, the diagnostic criteria for apathy were administered as well as two apathy rating instruments: the Lille Apathy Rating Scale (LARS) and the apathy section of the Neuropsychiatric Inventory (NPI).ResultsOf the included patients 17.2% were diagnosed with apathy according to the criteria. Acceptability and internal consistency of the criteria was good, as was the concurrent validity with the LARS and apathy section of the NPI. Discriminant validity of the criteria with depression was moderate to good. All domains of criterion B (behavior, cognition, emotion) contributed to the diagnosis of apathy, of which reduced goal-directed behavior was the most frequently observed symptom.ConclusionThe recently proposed diagnostic criteria for apathy are useful in clinical practice and in research with PD patients with and without cognitive impairment.