Borderline Personality Disorder in Clinical Practice

Participants were 117 clinicians who constituted a random national sample of experienced psychiatrists and psychologists from the membership registers of the American Psychiatric Association and the American Psychological Association. Initial letters to clinicians described the study, presented them with the DSM-IV diagnostic criteria for borderline personality disorder and dysthymic disorder (which was selected as a comparison condition), and asked them to complete a postcard indicating whether they had at least one borderline personality disorder or dysthymic disorder patient in their practice who met the inclusion and exclusion criteria. Based on their postcard responses, we assigned the clinicians to describe either a borderline personality disorder patient (N=90) or a dysthymic disorder patient (N=27), again presenting them with the DSM-IV diagnostic criteria for borderline personality disorder and/or dysthymic disorder to ensure close attention to the diagnostic criteria. To ensure random selection of patients, we asked the clinicians who reported having more than one appropriate patient to consult their calendars and select the patient they saw most recently who met the study criteria. For the dysthymic disorder group, we asked clinicians to describe a current patient who met the DSM-IV criteria for dysthymic disorder and who had no diagnosable DSM-IV personality disorder and no more than three DSM-IV diagnostic criteria for borderline personality disorder. For patients in both groups, we asked clinicians to select a female patient (to avoid the confounding factor of gender and to maximize power, because 75%–80% of patients who receive a diagnosis of borderline personality disorder are female [20, DSM-IV]) between ages 18 and 55 years (to avoid the confounding factors associated with adolescent and late-life personality disorder diagnosis) whom they had seen for a minimum of eight sessions and a maximum of 2 years (to guarantee that they knew the patient well while minimizing the likelihood of substantial personality change in treatment) and who did not have a psychotic disorder. We asked clinicians to select a current psychotherapy patient to maximize the likelihood of their being able to provide detailed personality assessments. (We selected a comparison group of patients with dysthymic disorder because patients with depression have been the most common comparison group in studies of personality disorders, and patients with dysthymic disorder have enduring, moderate depression that is also common in patients with borderline personality disorder.) To maximize participation, we gave clinicians the option to participate by pen and paper or on our interactive web site (http://www. psychsystems.net). Consistent with the literature on computerized versus paper administration of questionnaires (35), we found no systematic differences between responses with the two methods.

Before analyzing the data, we excluded data on patients who were extreme outliers in age or length in treatment beyond the parameters we requested, data on patients who did not meet the diagnostic criteria for the borderline personality disorder or dysthymic disorder groups, and data suggesting extreme carelessness in responding (e.g., multiple pages not completed). To maximize power, however, we retained patients who exceeded within reasonable bounds the maximum limit for age (two patients whose ages were in the range of 55–61 years) and time in treatment (six patients whose time in treatment ranged from 25 to 48 months). Further, because several dysthymic disorder patients were one criterion short of the diagnostic criteria for the disorder or met the criteria for multiple personality disorders, we were faced with decisions about the “purity” of the dysthymic disorder sample. We ultimately chose to retain patients who had chronic depression if they were within one criterion of the dysthymic disorder diagnosis and to retain dysthymic disorder patients who met the DSM-IV criteria for a non-borderline-personality-disorder diagnosis (mostly avoidant and schizoid personality disorders) to maximize the number of subjects and the generalizability of the sample. The decision to include non-borderline-personality-disorder patients actually rendered findings more conservative and increased external validity, given the high rates of comorbidity (60%) for dysthymic disorder and personality disorders in prior research (36, 37). (In fact, we reran all analyses without the eight patients who did not meet the criteria, and significance values improved in three cases and decreased from 0.01 to 0.05 in one. However, to preserve consistency with other reports of data from this sample, we chose to avoid excluding these subjects for some analyses but not for others.)

Clinicians completed the following measures, presented in the following order. (We included other instruments for other studies but do not describe them here.)

The aims of the study were 1) to examine the nature of borderline personality disorder patients in everyday clinical practice and their resemblance to borderline personality disorder patients seen in research studies and 2) to see if we could identify candidate diagnostic criteria for a revision of DSM-IV. Thus, after conducting diagnostic validity checks, we examined their similarity to borderline personality disorder patients prototypically described in research accounts in terms of axis I and axis II comorbidity and adaptive functioning. We hypothesized that the borderline personality disorder group, compared to the dysthymic disorder group, would demonstrate lower levels of various indices of adaptive functioning in chi-square analyses for categorical variables and t tests for dimensional variables. We report Pearson’s r as an effect size estimate throughout. (For interpretations of r as a measure of effect size, see references 42, 43.) To create a composite personality portrait of borderline personality disorder in everyday practice and to see if we could identify candidate criteria for the disorder that might be more identifying than the DSM-IV criteria, we aggregated SWAP-200 item scores across all borderline personality disorder patients.

Of the 117 clinician-participants, 19% (N=22) were psychiatrists and 81% (N=95) were psychologists (the latter responded at a much higher rate to the initial solicitation); 42% (N=49) were female. The majority worked at least part time in private practice (88%, N=103), although many worked in other settings as well, with 18% (N=21) working in a clinic; 26% (N=30) in outpatient, inpatient, or partial hospital settings; 8% (N=9) in a forensic setting; and 16% (N=19) in other settings. Clinicians were diverse in theoretical orientation, with 21% (N=24) describing their psychotherapeutic orientation as cognitive behavioral or behavioral, 44% (N=52) as psychodynamic or psychoanalytic, 32% (N=37) as eclectic, and 3% (N=4) as other.

Patients were an average age of 38 years (SD=10.14). The sample was predominantly Caucasian (88%, N=103); about 5% (N=6) were Hispanic, and the remainder were African American, Asian, or another ethnicity. Patients were primarily working class (33%, N=39) and middle class (47%, N=55), with educational attainment ranging from high school degree (15%, N=18) to having some graduate education (26%, N=30). Patients had been in treatment for an average of 12 months (SD=7.8), so the clinicians knew them well.

As a validity check, we conducted two t tests to compare borderline personality disorder and dysthymic disorder patients on two measures of borderline personality disorder. Using the clinicians’ 7-point ratings of the extent to which patients matched the borderline personality disorder construct, we found that clinicians rated borderline personality disorder patients significantly higher than dysthymic disorder patients (t=27.72, df=29.15, p<0.001, r=0.97). The same pattern emerged when we instead used SWAP-200 borderline personality disorder scale scores as the criterion variable (t=12.26, df=115, p<0.001, r=0.75) (17).

To construct a composite personality portrait of borderline personality disorder in clinical practice, we aggregated scores for each of the 200 items of the SWAP-200 across all 90 borderline personality disorder patients by taking the mean across subjects and then arraying the items in descending order of magnitude (i.e., beginning with the items most characteristic of the borderline personality disorder patients). Table 5 lists the items with the highest average rankings. (Items ranked significantly higher for borderline personality disorder patients than for dysthymic disorder patients are starred in Table 5.)

Most DSM-IV diagnostic criteria for borderline personality disorder were represented among the SWAP-200 items with the highest average rankings. However, several SWAP-200 items with the highest average rankings were not reflected in the DSM-IV criteria. Table 6 presents the non-DSM-IV items that were rank-ordered among the top 20 items, all of which also ranked within the 20 most descriptive items in the largest prior sample to date in which this method was used (23), suggesting that the findings are robust and not attributable to particular characteristics of the present sample. In general, these items captured negative affect, emotion dysregulation, and poor self-esteem or self-loathing. Perhaps most striking, the two items most descriptive of borderline personality disorder patients in both samples were “Tends to feel unhappy, depressed, or despondent” and “Emotions tend to spiral out of control.”

Virtually all research on patients with borderline personality disorder has studied samples from hospital inpatient units or outpatient clinics. This study compared borderline personality disorder patients with dysthymic disorder patients treated in the community to see whether the phenomena observed in prior samples characterize borderline personality disorder patients as treated in the community or whether samples of borderline personality disorder patients from hospitals and university clinics provide an overly pathological portrait of the disorder. The results point to two primary conclusions.

First, the data from prior studies, which could be expected to oversample the more severe end of the borderline spectrum, nevertheless generalized well to the patients seen by randomly selected clinicians across a wide variety of settings. In terms of axis I comorbidity, the borderline personality disorder sample in our study was very similar to other borderline personality disorder samples reviewed by Gunderson (20), with a profile of high emotional distress (in the form of mood and anxiety disorders, including posttraumatic stress disorder) and problematic ways of managing it (e.g., dissociative disorders, substance abuse, eating disorders). The findings were also consistent with Gunderson’s review of research on axis II comorbidity in borderline personality disorder (20, 21, 47), in which 90%–97% of borderline personality disorder patients were found to meet the criteria for other DSM personality disorder diagnoses. In our sample, the axis II checklist identified substantial rates of comorbidity for every axis II personality disorder, with particularly high frequencies of avoidant, paranoid, and dependent personality disorders. The slightly higher rates of avoidant and dependent personality disorder diagnoses in this sample may reflect the possibility that the community treatment-seeking sample is more withdrawn and dysphoric than the more acute hospital or university clinic samples or may reflect changes in borderline personality disorder criteria between DSM-III-R and DSM-IV.

With respect to adaptive functioning, like the borderline personality disorder patients studied in prior investigations, the borderline personality disorder patients treated in everyday practice showed substantial deficits. More than two-thirds had attempted suicide, more than one-half had self-injured (mostly by cutting), and almost two-thirds had been hospitalized at least once. Clinicians reported that borderline personality disorder patients had lower quality of relationships and unstable work histories, with more than one-half having lost a job in the past 5 years because of interpersonal problems.

Of particular interest are findings on physical health and abusive experiences in adulthood, as these areas of functioning have not received as much empirical attention as other aspects of adaptation. Borderline personality disorder patients appeared to have frequent or chronic minor illnesses, leading to missed appointments, days off from work, visits to the doctor, or subjective distress. Forty percent of the borderline personality disorder patients in this sample also had been in abusive relationships in adulthood, with virtually all being victimized (whether or not they also at times perpetrated violence). Nearly one-third of the borderline personality disorder patients had been the victim of rape or other serious sexual assault in adulthood, with such experiences typically occurring multiple times. A recent study by Zanarini et al. (46) produced similar results.

Second, the data provide a portrait of the average patient with DSM-IV-diagnosed borderline personality disorder seen in clinical practice, and this portrait converges with the DSM-IV description in multiple respects but diverges in others. Of the 200 items in the SWAP-200, several designed to reflect DSM-IV diagnostic criteria appeared empirically among the 20 items that were most descriptive of patients who receive a borderline personality disorder diagnosis. These items describe rejection/abandonment fears, unstable relationships, unstable identity, impulsivity, labile emotions, feelings of emptiness or boredom, and intense anger. On the other hand, several DSM-IV criteria were not ranked highly among the SWAP-200 descriptors of actual borderline personality disorder patients, and other items not included in DSM-IV received higher rankings on average than many current criteria.

Among the DSM-IV criteria that did not receive high average rankings were items describing the tendency to see people as “all good” or “all bad” (either because empirically these concepts are not as central to the diagnosis or because splitting them into two items may have decreased the ranking of both) and items describing specific forms of impulsivity, such as alcohol abuse and promiscuous sex. The hybrid criterion added to DSM-IV regarding transient psychotic symptoms and dissociative episodes did not rank highly. However, a related item that ranked tenth in the borderline personality disorder sample better appears to capture an aspect of the construct originally intended by Gunderson (21) and should be considered as a replacement criterion for DSM-V: “tends to become irrational when strong emotions are stirred up; may show a noticeable decline from customary level of functioning.” Although clinicians reported significant self-injury and suicidality (on the Clinical Data Form), SWAP-200 items for these phenomena did not rank as highly as other items. These differences may reflect a sampling difference between prior studies and the present investigation or may reflect the differential salience of particular high-risk behaviors when reported to an interviewer on a single occasion, typically when the patient is most symptomatic and presents at a hospital or clinic for treatment, versus when the behavior is contextualized within a longitudinal portrait of the patient over time.

Several other SWAP-200 items emerged as more descriptive than some of the current borderline personality disorder criteria, despite the fact that we used DSM-IV criteria to define the patient sample. Perhaps most important was a set of items reflecting chronic (rather than transient) aspects of emotional experience, namely the tendency “to feel unhappy, depressed, despondent” (the item with the highest ranking of all the items in the SWAP-200 composite borderline personality disorder profile) and to feel anxious. These data suggest that DSM-IV may understate the pain and dysphoria borderline personality disorder patients feel. They also support the view that negative affect is a central trait in borderline personality disorder as currently defined (48, 49).

Another set of items that may not receive adequate representation among the criteria for borderline personality disorder in DSM-IV describes the related trait of emotion dysregulation (on the difference between negative affect and emotion dysregulation, see references 28, 34, 40). These items describe a person whose emotions tend to spiral out of control; who can become irrational when strong emotions are stirred; who tends to “catastrophize,” seeing problems as disastrous and insolvable; and who has difficulty self-soothing and hence may become overly dependent on others to help regulate emotion. These descriptions of emotion dysregulation appear clinically richer and more specific than the DSM-IV description of “affective instability due to a marked reactivity of mood.” All of these items distinguished borderline personality disorder patients from dysthymic disorder patients, who share the trait of negative affect, and occurred at a similarly high rate in previous efforts to develop an empirical prototype of borderline personality disorder (22).

The data from this study, like the data from a number of studies from our laboratory (e.g., references 22, 25, 27, 29), point to the potential utility of practice research network methods in research on personality disorders. The convergence of multiple informants would clearly be ideal (although most studies of psychopathology rely on a single observer—the patient—by means of either self-report or structured interviews); however, data from experienced clinical observers who interact with the patient over time and hence can provide a longitudinal portrait provide a complementary standpoint to that typically seen in psychiatric research.

Another set of limitations concerns the makeup of the current sample. Psychologists were disproportionately represented in the sample, relative to psychiatrists (80% and 20%, respectively), and the overall response rate was relatively low, compared to our previous studies. Although we cannot be sure that some unknown bias was not introduced by clinicians’ decisions to participate or not participate, the data provided by psychologists and by psychiatrists did not show any pattern of differences in this or any of our prior studies using this method, despite substantially different response rates, and our findings converged with those of research from medical centers that used completely different sampling methods. The similarities in these findings suggest that such biases are not likely substantial. Limiting the study to patients in psychotherapy also introduced the possibility that we were oversampling higher-functioning borderline personality disorder patients. However, the data suggested otherwise: The majority of the borderline personality disorder patients in the study reported histories of psychiatric hospitalizations, suicide attempts, and self-injurious behavior, and their average GAF score (mean=47.64, SD=9.68) indicated serious impairment. Finally, male and non-Caucasian borderline personality disorder patients are understudied groups, and broader sampling, including oversampling to maximize representativeness of the population, would strengthen future investigations.