Inter-rater and test-retest reliability of the Revised Diagnostic Interview for Borderlines

The baseline inter-rater reliability, test-retest reliability, follow-up inter-rater reliability, and follow-up longitudinal reliability (interrater reliability between generations of raters) of borderline symptoms and the diagnosis of borderline personality disorder (BPD) were assessed using the Revised Diagnostic Interview for Borderlines (DIB-R). Excellent kappa s (> .75) were found in each of these reliability substudies for the diagnosis of BPD itself. Excellent kappa s were also found in each of the three inter-rater reliability substudies for the vast majority of borderline symptoms assessed by the DIB-R. Test-retest reliability for these symptoms was somewhat lower but still very good. More specifically, one-third of the BPD symptoms assessed had a kappa in the excellent range and the remaining two-thirds had a kappa in the fair-good range (.57-.73). The dimensional reliability of BPD symptom areas was somewhat higher than for categorical measures of the subsyndromal phenomenology of BPD. More specifically, all five dimensional measures of borderline psychopathology had intraclass correlation coefficients in the excellent range for all four reliability substudies. Taken together, the results of this study suggest that both the borderline diagnosis and the symptoms of BPD can be diagnosed reliably when using the DIB-R. They also suggest that excellent reliability, once achieved, can be maintained over time for both the syndromal and subsyndromal phenomenology of BPD.     

Biparental failure in the childhood experiences of borderline patients

The purpose of this study was to assess the role of biparental abuse and neglect in the development of borderline personality disorder (BPD). A semistructured research interview was used to blindly assess the childhood experiences of biparental abuse and neglect reported by 358 borderline inpatients and 109 axis II controls. Eighty-four percent of borderline patients reported having experienced some type of biparental abuse or neglect before the age of 18; 55% reported a childhood history of biparental abuse; 77% reported a childhood history of biparental neglect. These experiences were also reported by a substantial percentage of Axis II controls (biparental abuse or neglect [61%], biparental abuse [31%], and biparental neglect [55%]). However, borderline patients were significantly more likely than axis II controls to report having been verbally, emotionally, and physically but not sexually abused by caretakers of both sexes. They were also significantly more likely than controls to report having caretakers of both sexes deny the validity of their thoughts and feelings, fail to provide them with needed protection, neglect their physical care, withdraw from them emotionally, and treat them inconsistently. It was also found that female borderlines who reported a previous history of neglect by a female caretaker and abuse by a male caretaker were at significantly higher risk for having been sexually abused by a noncaretaker. Taken together, the results of this study suggest that biparental failure may be a significant factor in the etiology of BPD. They also suggest that biparental failure may significantly increase a preborderline girl's risk of being sexually abused by someone other than her parents.     

Borderline psychopathology in the first-degree relatives of borderline and axis II comparison probands

The purpose of this study was to assess the prevalence of each of the nine DSM criteria for borderline personality disorder and the prevalence of the disorder itself in the first-degree relatives of borderline probands and Axis II comparison subjects. Four hundred and forty-five inpatients were interviewed about familial borderline psychopathology using the Revised Family History Questionnaire--a semistructured interview of demonstrated reliability. Of these 445 subjects, 341 met both DIB-R and DSM-III-R criteria for BPD and 104 met DSM-III-R criteria for another type of personality disorder (and neither criteria set for BPD). The psychopathology of 1,580 first-degree relatives of borderline probands and 472 relatives of Axis II comparison subjects was assessed. Both DSM-III-R and DSM-IV BPD were found to be more common among the relatives of borderline than Axis II comparison probands. However, five of the criteria for BPD (inappropriate anger, affective instability, paranoia/dissociation, general impulsivity, and intense, unstable relationships) and all four sectors of borderline psychopathology (affect, cognition, impulsivity, and interpersonal relationships) were found to be both more common and discriminating than the BPD diagnosis itself. Taken together, the results of this study suggest that the subsyndromal phenomenology of BPD may be more common than the borderline diagnosis itself.     

A preliminary, randomized trial of psychoeducation for women with borderline personality disorder

The main objective of this study was to determine whether being taught the latest information concerning borderline personality disorder (BPD) leads to a decline in core BPD symptoms and an improvement in psychosocial functioning. Fifty-five late adolescent women participated in a rigorous diagnostic assessment and 50 met DIB-R and DSM-IV criteria for BPD. All 50 were informed that they met criteria for BPD. Then 30 were randomized to a psychoeducation workshop that took place within a week of diagnostic disclosure. The other 20 were assigned to a waitlist and participated in the workshop at the end of this 12-week study. The two primary outcome measures were readministered each week of the trial: the Zanarini Rating Scale for DSM-IV Borderline Personality Disorder (ZAN-BPD) and the Sheehan Disability Scale (SDS). Immediate psychoeducation concerning the BPD diagnosis was associated with a significantly greater decline in general impulsivity and the storminess of close relationships. However, it did not result in significantly improved psychosocial functioning. Taken together, the results of this study suggest that informing patients about BPD soon after diagnostic disclosure may help to alleviate the severity of two of the core elements of borderline psychopathology-general impulsivity and unstable relationships. They also suggest that such instruction may prove to be a useful and cost-efficient form of pre-treatment.     

The essential nature of borderline psychopathology

We suggest that the core features of borderline personality disorder (BPD) are the intense inner pain commonly reported by borderline patients and the awkward means they use to manage and express this pain. In this model, the pain has both affective and cognitive components. The awkward means of managing and expressing this pain are behavioral and interpersonal in nature. The etiology of these core features of BPD seems to lie in the interaction of a kindling event or events, which can be traumatic or normative in nature, and a vulnerable or hyperbolic temperament. The treatment and nosological implications of this model are discussed.     

Reported childhood onset of self-mutilation among borderline patients

The purpose of this study was to determine the percentage of borderline patients who first engaged in self-mutilation as children and to compare the parameters of their self-harm to those of borderline patients who first harmed themselves at an older age. Two hundred and ninety inpatients meeting both Revised Diagnostic Interview for Borderlines (DIB-R; Zanarini, Gunderson, Frankenburg, & Chauncey, 1989) and Diagnostic and Statistical Manual of Mental Disorders (3rd ed. ref.) (DSM-III-R; APA, 1987) criteria for borderline personality disorder were interviewed about their history of self-mutilation. Of the 91% with a history of self mutilation, 32.8% reported first harming themselves as children (12 years of age or younger), 30.2% as adolescents (13-17 years of age), and 37% as adults (18 or older). Using logistic regression analyses and controlling for baseline age, it was found that those with a childhood onset reported more episodes of self-harm, a longer duration of self-harm, and a greater number of methods of self-harm than either those with an adolescent or adult onset to their self-mutilation. The results of this study suggest that a sizable minority of borderline patients first engage in self-harm as children and that the course of their self-mutilation may be particularly malignant.     

Degrading situations and antisocial behaviour: an experimental approach to delinquency

What are the social psychological processes likely to lead individuals to commit antisocial behaviour? Two experiments are presented showing that students experiencing a publicly degrading situation (a failure on a fictitious test) agreed more often than non-degraded students to participate in a theft to the detriment of a fellow student or even to the detriment of a teacher. We were able to exclude an interpretation in terms of imitation or revenge and suggest that a publicly degrading situation places subjects in a kind of social dependency state which is expressed by a vulnerability to influence. These results are discussed with due regard to the criminological and social psychological literature.     

Psychosocial functioning of borderline patients and axis II comparison subjects followed prospectively for six years

The purpose of this study was to determine the course of the psychosocial functioning of patients with borderline personality disorder (BPD) over 6 years of prospective follow-up. The psychosocial functioning of 290 patients meeting both DIB-R and DSM-III-R criteria for BPD and 72 patients meeting DSM-III-R criteria for another Axis II disorder (and neither criteria set for BPD) was assessed at baseline using a semistructured interview of demonstrated reliability. Over 94% of surviving patients were reinterviewed about their psychosocial functioning blind to all previously collected information at three distinct follow-up waves: 2-, 4-, and 6-year follow-up. The psychosocial functioning of borderline patients improved substantially over time, with the percentage meeting criteria for good overall psychosocial functioning increasing from 26% at baseline to 56% during the third wave of follow-up. Despite this improvement, borderline patients functioned significantly more poorly than Axis II comparison subjects, particularly in the area of vocational achievement. However, a more detailed examination revealed that borderline patients who had experienced a symptomatic remission during the course of the study functioned significantly better both socially and vocationally than never-remitted borderline patients. More specifically, they were significantly more likely to have a good relationship with a spouse/partner and at least one parent, good work/school performance, a sustained work/school history, a GAF score of 61 or higher (43% vs. 0% 6 years after their index admission), and to have good overall psychosocial functioning (66% vs. 27% at 6 year follow-up). Taken together, the results of this study suggest that psychosocial improvement is both common among borderline patients and strongly related to their symptomatic status.     

Obesity and obesity-related illnesses in borderline patients

The purpose of this study was to examine the prevalence, risk factors, and consequences of obesity in borderline patients 6 years after an index admission for psychiatric reasons. Two hundred and sixty-four borderline patients who met Revised Diagnostic Interview for Borderlines (DIB-R; Zanarini, Gunderson, Frankenburg, & Chauncy, 1989) and Diagnostic and Statistical Manual of Mental Disorders (3rd ed. ref.) (DSM-III-R; APA, 1987) criteria for BPD were interviewed concerning their body mass index (BMI) and related medical problems. Seventy-four of the 264 borderline patients at 6-year follow up were obese, having a BMI > or = 30 kg/m2. They were significantly more likely than the nonobese patients to report suffering from diabetes, hypertension, osteoarthritis, chronic back pain, carpal tunnel syndrome, urinary incontinence, gastroesophageal reflux disorder, gallstones, and asthma. Four significant risk factors were found: chronic PTSD, lack of exercise, a family history of obesity, and a recent history of psychotropic polypharmacy. These results suggest that obesity is common among heavily treated borderline patients and is associated with a number of chronic medical disorders.