Longitudinal diagnostic efficiency of DSM-IV criteria for borderline personality disorder: a 2-year prospective study.

OBJECTIVE: To examine the longitudinal diagnostic efficiency of the DSM-IV criteria for borderline personality disorder (BPD). METHODS: At baseline, we used semistructured diagnostic interviews to determine criteria and diagnoses; blinded assessments were performed 24 months later with 550 participants. Diagnostic efficiency indices (specifically, conditional probabilities, total predictive power, and kappa) were calculated for each criterion determined at baseline, with the independent BPD diagnosis at follow-up used as the standard. RESULTS: Longitudinal diagnostic efficiencies for the BPD criteria varied, with the criteria of suicidality or self-injury and unstable relationships demonstrating the most predictive utility. CONCLUSIONS: BPD criteria differ in their predictive utility for the diagnosis of BPD when considered longitudinally. These findings have implications both for clinicians who are considering diagnoses and for researchers concerned with forthcoming revisions of our nosological system.     

A comparison of four measures to diagnose DSM-III-R borderline personality disorder in outpatients

After three decades of clinical controversy and research, a clinical consensus has formed that borderline personality disorder (BPD) exists as a unique entity which can be defined by DSM-III-R diagnostic criteria. The purpose of this study was to evaluate the relative abilities of four different approaches to the identification of borderlines and to differentiate a DSM-III-R BPD group from a control group of other diagnoses. The approaches were the Kernberg's Structural Interview, the Diagnostic Interview for Borderline Personality Disorders (DIB), the Borderline Syndrome Index (BSI), and the Million Clinical Multiaxial Inventory (MCMI). Sixty outpatient volunteers (27 men and 33 women) from a community mental health center served as subjects. The volunteers included 30 BPDs and 30 other diagnoses, including 11 non-BPD personality disorders. Point biserial correlations indicated that the best method for identifying DSM-III-R BPD was the DIB, and the second best was the Kernberg Structural Interview, although all four identified DSM-III-R BPDs at better than chance levels. Multiple regression results showed that the DIB accounted for 61.5% of the BPD variance, while the Kernberg approach added 4.9% more unique variance prediction. MCMI dimensions and personal history characteristics were used to identify differentiators of BPD from all other diagnoses and from other personality disorders.     

Relationship between Clinical Symptoms and EEG Findings in Borderline Personality Disorder

Abstract: Borderline personality disorder (BPD) was diagnosed in female patients (N=41) between the ages of 18 and 30 using the Diagnostic Interview for Borderline Patients (DIB) and DSM-III. Comparing the EEG findings of BPD (N=18) and non-BPD (N=21) groups, there were no EEG findings characteristic of BPD. We also assessed the relationship between the EEG findings and DIB items. Positive spikes appeared in patients with high scores for Impulse Action Patterns, while wave and spike phantoms were observed in patients with high scores for Interpersonal Relations. Dividing the patients into BPD and non-BPD groups, a similar tendency to that observed from an analysis of all patients was observed in the non-BPD group, but no such tendency was observed in the BPD group. The results suggest that BPD patients include those in whom vulnerability of cerebral function plays an important role in the development of these two clinical symptoms as well as those in whom vulnerability of cerebral function plays almost no pathogenic role.     

An investigation of the prototype validity of the borderline DSM-IV construct

Objective: To investigate the prototype validity of the borderline personality disorder (BPD) DSM‐IV construct. Method: Patients (n = 930) from the Norwegian Network of Psychotherapeutic Day Hospitals. Exploratory/confirmatory factor analyses, correlation and reliability statistics, chi‐square, and frequency distributions. Results: Number of BPD criteria showed no distinct threshold between No‐BPD and BPD patients among whom 136 different combinations of criteria occurred. Both factor analyses supported that one component/latent variable accounted for the variance of the BPD criteria, showing a high convergent and discriminant validity. The criterion of unstable relationships displayed the highest diagnostic efficiency, and that of chronic feelings of emptiness the lowest. Conclusion: The prototype theoretical model for BPD fitted the data well and appeared to be satisfactory described by the current criteria. The emptiness criterion needs a more appropriate definition and the hierarchy of the criteria in DSM‐IV should be revised.     

The longitudinal pattern of suicidal behaviour in borderline personality disorder: a prospective follow-up study

The aim was to study the longitudinal course of suicidal behaviour and ideation in patients with borderline personality disorder (BPD) compared with patients with other diagnoses. Ninety-seven patients (41 BPD, 33 other personality disorders, 23 no personality disorder) consecutively admitted to a day unit were given a prospective personal interview follow-up with evaluations at admission, discharge and at follow-up after 2–5 years. Even when controlled for Axis I disorders, BPD patients showed significantly more often a lifetime history of suicide attempts. BPD patients with a history of suicide attempts were more suicidal at index admission, continued to be so over the follow-up period and differed systematically in an unfavourable direction from other BPD patients on the major outcome measures. BPD patients without suicidal behaviour had an outcome nearly as good as non-BPD patients, and only 41% of them retained the BPD diagnosis at follow-up. Suicidal behaviour and ideation are highly prevalent in BPD. These suicidal expressions are of an enduring nature and seem as a diagnostic criterion to enhance the predictive capacity of the BPD diagnosis.     

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.     

Motor features in psychotic disorders. II. Development of diagnostic criteria for catatonia

Existing diagnostic criteria for catatonia have been based exclusively on theoretical assumptions. The present study aimed to develop empirical criteria for diagnosing catatonia. The same patient population (n=187) described in Part I (Peralta, V., Cuesta, M.J., Motor features in psychotic disorders. I. Factor structure and clinical correlates. Schizophr. Res., 00, 000-000) was used in this study. Fourteen catatonic signs with potential diagnostic value were cluster-analyzed to derive groups with and without a catatonic syndrome. Taking the cluster solution as the reference standard, the diagnostic value for individual signs was examined by means of multiple discriminant analysis, ROC analysis, and the parameters of sensibility, specificity, positive predictive power and negative predictive power. Cluster analysis divided the sample into a catatonic group (n=32) and a noncatatonic group (n=155). Discriminant analysis showed that 11 of the 14 potential diagnostic signs discriminated among groups: immobility/stupor, mutism, negativism, oppositionism, posturing, catalepsy, automatic obedience, echophenomena, rigidity, verbigeration and withdrawal. ROC analysis showed that any combination of three or more of these symptoms best fitted the cluster-derived catatonic syndrome. In conclusion, patients displaying three or more classical motor signs may be diagnosed with confidence as suffering from a catatonic syndrome.     

The difficulty of diagnosing NCSE in clinical practice; external validation of the Salzburg criteria

To improve the diagnostic accuracy of electroencephalography (EEG) criteria for nonconvulsive status epilepticus (NCSE), external validation of the recently proposed Salzburg criteria is paramount. We performed an external, retrospective, diagnostic accuracy study of the Salzburg criteria, using EEG recordings from patients with and without a clinical suspicion of having NCSE. Of the 191 EEG recordings, 12 (12%) was classified as an NCSE according to the reference standard. In the validation cohort, sensitivity was 67% and specificity was 89%. The positive predictive value was 47% and the negative predictive value was 95%. Ten patients in the control group (n = 93) were false positive, resulting in a specificity of 89.2%. The interrater agreement between the reference standards and between the scorers of the Salzburg criteria was moderate; disagreement occurred mainly in patients with an epileptic encephalopathy. The Salzburg criteria showed a lower diagnostic accuracy in our external validation study than in the original design, suggesting that they cannot replace the current practice of careful weighing of both clinical and EEG information on an individual basis.     

Testing DSM-III symptom criteria for schizotypal and borderline personality disorders

Schizotypal and borderline personality disorders (SPD and BPD, respectively) appear to be different at follow-up, yet they are poorly discriminated from each other by current DSM-III symptom criteria. In the Chestnut Lodge Follow-up Study, three axis II study cohorts (pure SPD, n = 10; pure BPD, n = 81; mixed SPD/BPD, n = 18) with distinctive outcomes are defined using current borderline systems. This study compares the relative frequency with which individual symptom criteria from each system discriminate across study cohorts. Findings suggest that for SPD, the most characteristic (core) DSM-III symptoms are odd communication, suspiciousness/paranoid ideation, and social isolation, while the least discriminating symptom is illusions/depersonalization/derealization; the core DSM-III symptoms for BPD are unstable relationships, impulsivity, and self-damaging acts, while the least discriminating symptoms are inappropriate anger and intolerance of aloneness; depression as a symptom does not discriminate between SPD and BPD; and transient psychoses and brief paranoid experiences and/or regression in treatment discriminate for SPD but against BPD and therefore fit better as SPD criteria. Results support the retention of some, but the elimination of other, DSM-III symptom criteria for the diagnosis of SPD and BPD.     

Internal consistency, intercriterion overlap and diagnostic efficiency of criteria sets for DSM-IV schizotypal, borderline, avoidant and obsessive-compulsive personality disorders.

OBJECTIVE: To evaluate performance characteristics of DSM-IV Personality Disorders (PDs) criteria. METHOD: Six hundred and sixty-eight adults recruited for the Collaborative Longitudinal Personality Disorders Study (CLPS) were assessed with diagnostic interviews. RESULTS: Within-category inter-relatedness was evaluated by Cronbach's alpha and median intercriterion correlations (MIC). Cronbach's alpha ranged from 0.47 to 0.87 (median=0.71); seven of the 10 PDs had alphas greater than 0.70. Between-category criterion overlap was evaluated by "inter-category" intercriterion correlations between all PD pairs (ICMIC). ICMIC values (median=0.08) were lower than MIC values (median=0.23). Diagnostic efficiency statistics (sensitivity, specificity, positive predictive power and negative predictive power were calculated for schizotypal, borderline, avoidant and obsessive-compulsive PDs. CONCLUSION: DSM-IV PD criteria sets have some convergent validity and discriminant validity: criteria for individual PDs correlate better with each other than with criteria for other PDs. Diagnostic efficiency statistics provide guidance regarding usefulness of criteria for inclusion or exclusion.     

Borderline personality disorder and depression severity predict suicidal outcomes: A six-month prospective cohort study of depression,bipolar depression,and borderline personality disorder

Background

Suicide risk is high in patients with major depressive disorder (MDD), bipolar disorder (BD) and borderline personality disorder (BPD). Whether risk levels of and risk factors for suicidal ideation (SI) and suicide attempts (SA) are similar or different in these disorders remains unclear, as few directly comparative studies exist. The relationship of short-term changes in depression severity and SI is underinvestigated, and might differ across groups, for example, between BPD and non-BPD patients.

Methods

We followed, for 6 months, a cohort of treatment-seeking, major depressive episode (MDE) patients in psychiatric care (original n = 124), stratified into MDE/MDD, MDE/BD and MDE/BPD subcohorts. We examined risks of suicide-related outcomes and their risk factors prospectively. We examined the covariation of SI and depression over time with biweekly online modified Patient Health Questionnaire 9 surveys and analysed this relationship through multi-level modelling.

Results

Risk of SA in BPD (22.2%) was higher than non-BPD (4.23%) patients. In regression models, BPD severity was correlated with risk of SA and clinically significant SI. During follow-up, mean depression severity and changes in depression symptoms were associated with SI risk regardless of diagnosis.

Conclusions

Concurrent BPD in depression seems predictive for high risk of SA. Severity of BPD features is relevant for assessing risk of SA and SI in MDE. Changes in depressive symptoms indicate concurrent changes in risk of SI. BPD status at intake can index risk for future SA, whereas depressive symptoms appear a useful continuously monitored risk index.     

Integration of suck and swallow rhythms during feeding in preterm infants with and without bronchopulmonary dysplasia

The aim of this study was to define quantitative measures for assessing the integration and maturation of suck and swallow rhythms in preterm infants as they relate to each other. Fourteen preterm infants (eight males, six females; gestational age range 26 to 32 weeks) with bronchopulmonary dysplasia (BPD) and an age-matched cohort of 20 infants (10 males, 10 females; gestational age range 26 to 33 weeks) without BPD were studied weekly from time of initiation of oral feeding using simultaneous recordings of nipple and pharyngeal pressure. The integration of suck and swallow rhythms was quantified by using the coefficient of variation (COV) of the suck-swallow dyad interval. Infants without BPD had a significant correlation between increasing postmenstrual age (PMA) and decreasing COV of the dyadic interval (increasing stabilization; r=0.45; p=0.008). In the non-BPD cohort 35 weeks or less PMA, the mean dyadic COV was 0.42 (SD 0.12) versus 0.34 (SD 0.09) in those more than 35 weeks PMA (p=0.039). In contrast, dyadic stability in infants with BPD was not correlated with PMA. Infants with BPD of more than 35 weeks PMA had less dyadic stability (0.45, SD 0.10) than did age-matched controls (p<0.001). Dyadic stability was also correlated with feeding efficiency in the non-BPD group (r=0.46;p=0.007) but not in the BPD cohort. Therefore, ontogeny of rhythmic suckle feeding can be described quantitatively in preterm infants, allowing comparison with at-risk populations. Infants with BPD do not follow predicted maturational patterns of suck-swallow rhythmic integration.     

Body image and borderline personality disorder among psychiatric inpatients

Objective

With the exclusion of studies in individuals with eating disorders, few investigators have examined body image issues in patients with borderline personality disorder (BPD). In this study, we examined among psychiatric inpatients relationships between body image and BPD.

Method

In a cross-sectional sample of convenience, we surveyed 126 women in an inpatient psychiatric unit using 5 measures for body image and 2 measures for BPD.

Results

Using standardized cutoffs for BPD diagnosis, participants with BPD demonstrated a number of differentiating features with regard to body image issues. Explicitly, BPD did not seem to be related to being self-conscious about one's appearance, although BPD was related to being more self-conscious, in general. Individuals with BPD were not more invested in their appearance as a source of self-definition but evaluated their own appearance more negatively and were more likely to believe that attractiveness is an important factor for happiness and acceptance. Although BPD was not related to perceptions about the strength and competence of one's own body, those with BPD indicated less comfort and trust in their own bodies. In general, it appeared that body image measures that were more perceptually grounded were more likely to be similar to non-BPD participants, whereas body image measures that were more cognitively grounded were more likely to be statistically significantly different in comparison with non-BPD participants.

Conclusions

Psychiatric inpatients with BPD demonstrate a number of disturbances in body image.     

Exploratory factor analysis of borderline personality disorder criteria in hospitalized adolescents

OBJECTIVE: The authors examined the factor structure of borderline personality disorder (BPD) in hospitalized adolescents and also sought to add to the theoretical and clinical understanding of any homogeneous components by determining whether they may be related to specific forms of Axis I pathology. METHOD: Subjects were 123 adolescent inpatients, who were reliably assessed with structured diagnostic interviews for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition Axes I and II disorders. Exploratory factor analysis identified BPD components, and logistic regression analyses tested whether these components were predictive of specific Axis I disorders. RESULTS: Factor analysis revealed a 4-factor solution that accounted for 67.0% of the variance. Factor 1 ("suicidal threats or gestures" and "emptiness or boredom") predicted depressive disorders and alcohol use disorders. Factor 2 ("affective instability," "uncontrolled anger," and "identity disturbance") predicted anxiety disorders and oppositional defiant disorder. Factor 3 ("unstable relationships" and "abandonment fears") predicted only anxiety disorders. Factor 4 ("impulsiveness" and "identity disturbance") predicted conduct disorder and substance use disorders. CONCLUSIONS: Exploratory factor analysis of BPD criteria in adolescent inpatients revealed 4 BPD factors that appear to differ from those reported for similar studies of adults. The factors represent components of self-negation, irritability, poorly modulated relationships, and impulsivity--each of which is associated with characteristic Axis I pathology. These findings shed light on the nature of BPD in adolescents and may also have implications for treatment.     

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.     

Proposed diagnostic criteria of Internet addiction for adolescents

The aims of the present study were to develop diagnostic criteria of Internet addiction for adolescents and to examine the discriminating potential and validity of diagnostic criteria by an empirical community study among adolescent populations. We developed 13 candidate diagnostic criteria for characteristic symptoms of Internet addiction in adolescents. A total of 468 adolescents completed the Chen Internet Addiction Scale (CIAS) and were systematically assessed for Internet-using behaviors by seven psychiatrists using the diagnostic interview schedule. The sensitivity, specificity, and diagnostic accuracy of the 13 candidate diagnostic criteria were analyzed with references to the interviewers' global clinical impressions and CIAS results. The cutoff point of the diagnostic criteria to differentiate the Internet-addicted subjects with nonaddicted ones was then determined by the best diagnostic accuracy and the receiver operating characteristic curve. This study selected nine of the 13 candidate diagnostic criteria to construct the diagnostic criteria of Internet addiction for adolescents, which were composed of three main criteria: characteristic symptoms of Internet addiction, functional impairment secondary to Internet use, and exclusive criteria. The diagnostic criteria had high diagnostic accuracy, specificity, negative predictive value, accepted sensitivity, and accepted positive predictive rate. The validity of the diagnostic criteria proposed in this study was further confirmed by comparing the demographic and Internet-using characteristics between those with and without Internet addiction. The diagnostic criteria for Internet addiction can provide health care professionals with a means to communicate and make comparisons of clinical cases.     

Identifying personality disorders: towards the development of a clinical screening instrument

The study objective was to identify a set of personality disorder (PD) criteria from the DSM PD diagnostic sets that can be used to detect subjects with an increased likelihood of having a PD diagnosis. In a series of outpatients evaluated systematically in two waves for every criteria item for 12 DSM-III-R PDs, stepwise logistic regression identified 45 criteria as discriminative for their specific PDs, which are selected for further analysis to assess their ability to discriminate for any PD. Receiver operating characteristic (ROC) analysis is used to evaluate their discriminative power in an independent conjoined sample (N = 1,342) from six centers that assessed every PD criteria item by structured instrument (Structured Clinical Interview for DSM-III-R PDs [SCID-II, Personality Disorder Examination [PDE], and Structured Interview for DSM-III-R PDs [SIDP-R]). The cutoff that maximizes information gain is used to determine the diagnostic threshold (DT). Initially, 15 of 45 criteria are identified. At the 0.43 PD prevalence, a DT of 2 or more of the 15 PD criteria across samples is optimal. The maximum information gain (MIG) is .42 bits, and the AUR is 0.94+/-.007. Other performance indices at this cutoff are .90 sensitivity, .84 specificity, .81 positive predictive power (PPP), .91 negative predictive power (NPP), and .86 hit rate (HR). Taken collectively, the 15 PD criteria selected by the data reduction techniques suggest a narrowed set to be assessed in screening for the presence or absence of any PD with comparable or better psychometric properties than other tests routinely used for diagnosing medical and psychiatric disorders. If specific PD categorization is needed, a second-step comprehensive assessment should follow.     

A systematic evaluation of the DSM-III-R criteria for alcohol dependence

The diagnostic efficiency of the nine DSM-III-R criteria (signs and symptoms) for alcohol dependence was systematically investigated in a sample of 215 psychiatric outpatients. Specificity was generally greater than 0.90, but two groups of criteria were distinguished according to high v moderate sensitivity rates. The diagnostic relevance of all DSM-III-R criteria was strongly supported by a comparison with additional characteristics of alcoholism. Features referring to impaired control over alcohol use and to physical dependence (tolerance and withdrawal) were found to be most clearly discriminating between subjects with and without alcohol dependence. There is strong evidence that two positive criteria are sufficient to reliably diagnose alcohol dependence. A computer-simulated analysis was performed to demonstrate predictive power of single symptoms under different base rate conditions, and results were promising for the most common settings in clinical research.     

The Aberrant Behavior Checklist and the Behavior Problems Inventory: convergent and divergent validity

This study was designed to compare and cross-validate two rating instruments [the Aberrant Behavior Checklist (ABC) and the Behavior Problems Inventory (BPI)] for assessing maladaptive behavior. The BPI assesses three types of behavior problems: Self-Injurious Behavior (SIB), Stereotyped Behavior and Aggressive/Destructive Behavior. The ABC assesses five domains including these three. We collected data on 226 adults, mostly with severe or profound mental retardation, from a medium-sized developmental center. Individuals with elevated BPI scores generally had higher ABC scores; however, the extent of covariation differed across subscales. Similarly, multiple regression analyses showed that BPI subscales significantly but selectively predicted ABC subscale scores. Measures of differential diagnostic value (positive and negative predictive power, sensitivity, specificity and overall correct diagnostic efficiency) confirmed the anticipated partial overlap between instruments. Both instruments were used to rate participants with and without a Diagnosis of Stereotyped Movement Disorder. BPI, SIB and Stereotypy subscale composite had stronger positive predictive power than the ABC Stereotypy scale, while the ABC had higher negative predictive power and greater overall diagnostic efficiency. Thus, the ABC and the BPI cross-validated one another where expected, and they diverged for subscales thought to have little relationship.     

Evaluation of diagnostic criteria for borderline personality disorder

A comparison of 17 narrowly defined borderline patients with 20 nonpatient control subjects indicated that certain individual and combinations of criteria may be more highly correlated with the disorder than others. Requiring any four or certain specific combinations of two or three of the five most discriminating criteria provided the optimal balance of sensitivity, specificity, predictive power, and diagnostic efficiency considerations. Fewer than five DSM-III-R criteria adequately identified the patients.