Borderline Personality Disorder in Clinical Practice: study
OBJECTIVE: Most studies of borderline personality disorder have drawn patients from among hospital inpatients or outpatients. The aims of this study were to examine the nature of borderline personality disorder patients in everyday clinical practice and to use data from a sample of borderline personality disorder patients seen in the community to refine the borderline construct.
METHOD: A random national sample of 117 experienced psychiatrists and psychologists from the membership registers of the American Psychiatric Association and American Psychological Association provided data on a randomly selected patient with borderline personality disorder (N=90) or dysthymic disorder (N=27) from their practice. The clinicians provided data on axis I comorbidity, axis II comorbidity, and adaptive functioning, as well as a personality description of the patient using the Shedler-Westen Assessment Procedure-200 (SWAP-200) Q-sort, an instrument designed for assessment and taxonomic purposes. Analyses compared borderline personality disorder and dysthymic disorder groups on variables of interest and aggregated SWAP-200 items across all borderline personality disorder patients to create a composite portrait of borderline personality disorder as seen in the community.
RESULTS: The borderline personality disorder sample strongly resembled previously studied borderline personality disorder samples with regard to comorbidity and adaptive functioning. However, the SWAP-200 painted a portrait of borderline personality disorder patients as having more distress and emotion dysregulation, compared to the DSM-IV description.
CONCLUSIONS: Borderline personality disorder patients in research samples are highly similar to those seen in a cross-section of clinical practice. However, several studies have now replicated a portrait of borderline personality disorder symptoms that places greater weight than the DSM-IV description on the intense psychological pain of these patients and suggests candidate diagnostic criteria for DSM-V.
Since the first research using a standardized interview for borderline personality disorder patients two decades ago (1), an immense body of research has emerged on the nature and etiology of borderline personality disorder. Most studies have drawn subjects from groups of outpatients or inpatients, usually associated with academic training departments (e.g., references 2–19). To what extent these patients, who are likely to have symptoms on the more disturbed end of the borderline spectrum, resemble the range of borderline personality disorder patients seen in everyday practice is largely unknown.
The aims of the current study were twofold. The first was to describe the nature of borderline pathology seen in clinical practice. We compared data from prior studies with data from a random national sample of borderline personality disorder patients treated in the community on three sets of criteria: axis I comorbidity, axis II comorbidity, and adaptive functioning. Gunderson’s review (20) indicated that the axis I disorders most frequently found in borderline personality disorder patient samples are dysthymic disorder, major depression, substance abuse, posttraumatic stress disorder, and eating disorders and that at least one-half of borderline personality disorder patients have major depressive disorder, dysthymia, or both. Although borderline personality disorder has been found to have high rates of comorbidity with virtually all axis II disorders, the highest diagnostic overlap appears to be with histrionic and avoidant personality disorders (20, 21). With regard to adaptive functioning, research findings have associated borderline personality disorder with self-injurious behavior such as skin cutting and burning and with psychiatric hospitalizations, suicidality, difficulty maintaining relationships, and difficulty maintaining appropriate employment. We thus expected to see similar patterns of findings in a community clinical sample if the descriptions of borderline personality disorder generated from hospital inpatients and outpatients generalize.
The second aim was to describe the personality characteristics of borderline personality disorder patients by using a large, relatively comprehensive item set and to refine the borderline construct empirically by using a broad sample of borderline personality disorder patients seen in the community. In a prior study (22, 23), a large random national sample of experienced clinicians described a personality disorder patient by using the Shedler-Westen Assessment Procedure-200 (SWAP-200) (22), a clinician-report personality pathology Q-sort instrument that includes items reflecting the roughly 80 DSM-IV criteria for all current axis II diagnoses as well as 120 additional items that provide candidate criteria for refining current diagnoses (i.e., potential alternative diagnostic criteria). Of 530 clinician-participants, 43 described a patient with borderline personality disorder. Among the items most characteristic of the borderline personality disorder patients in this sample were several that mirrored DSM-IV criteria. Other items, however, appeared to be more characteristic of the average borderline personality disorder patient than several of the DSM-IV criteria, notably items describing intense and poorly modulated affect and profound dysphoric affect. The data suggested that intense dysphoric affect is a core, rather than co-occurring, feature of borderline personality disorder. Similar findings emerged in a prior study that used the SWAP-167, the progenitor to the SWAP-200 (24). The results of these studies were in keeping with Gunderson’s finding that chronic major depression and chronic feelings of helplessness, hopelessness, worthlessness, guilt, loneliness, and emptiness appear to be central to the disorder (20).
In the present study, we asked a random national sample of experienced clinicians to provide data on phenomenology, comorbidity, and adaptive functioning in a randomly selected patient with DSM-IV-diagnosed borderline personality disorder, and we used data from the SWAP-200 Q-sort to develop an empirical portrait of the personality functioning of the average patient with borderline personality disorder. Given that the instrument includes items assessing all current axis II criteria, if personality descriptors that were not among the DSM-IV diagnostic criteria appeared to be more diagnostic than the current criteria in a sample specifically selected for meeting those criteria, and if these descriptors replicated those found to be more descriptive of borderline personality disorder patients in prior research, these findings would suggest the need for refining the borderline construct to mirror more closely the nature of patients seen in the community.
The present investigation relied on practice network methods to address taxonomic and other basic science questions. Elsewhere we addressed in detail the rationale for this clinician-report method, including its advantages and limitations (see references 22, 25–30). In brief, clinicians are experienced observers who observe patients longitudinally and in depth. Although unstructured clinical judgments have been shown to have poor reliability and validity, a host of recent studies suggested that clinicians can provide highly reliable and valid data when they quantify their judgments using psychometric instruments and that their data predict data from independent interviews (27, 31–33). In multiple studies, clinicians’ theoretical orientation has predicted little variance when clinicians were asked to describe a specific patient rather than their beliefs about or theories of psychopathology (see, e.g., references 24, 34).