Is Dimensional Scoring of Borderline Personality Disorder Important Only for Subthreshold Levels of Severity?

Journal of personality disorders (Impact Factor: 3.08). 04/2013; 27(2):244-51. DOI: 10.1521/pedi.2013.27.2.244
Source: PubMed


Studies comparing dimensional and categorical representations of personality disorders (PDs) have consistently found that PD dimensions are more reliable and valid. While comparisons of dimensional and categorical scoring approaches have consistently favored the dimension model, two reports from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project have raised questions as to when dimensional scoring is important. In the first study, Asnaani, Chelminski, Young, and Zimmerman (2007) found that once the diagnostic threshold for borderline PD was reached the number of criteria met was not significantly associated with indices of psychosocial morbidity. In the second study, Zimmerman, Chelminski, Young, Dalrymple, and Martinez (2012) found that patients with 1 criterion of borderline PD had significantly more psychosocial morbidity than patients with 0 criteria. The findings of these two studies suggest that dimensional ratings of borderline PD may be more strongly associated with indicators of illness severity for patients who do not versus do meet the DSM-IV criteria for borderline PD. In this third report from the MIDAS project, we tested this hypothesis in a study of 3,069 psychiatric outpatients evaluated with semi-structured diagnostic interviews. In the patients without borderline PD the number of borderline features was significantly associated with each of 6 indicators of illness severity, whereas in the patients with borderline PD 3 of the 6 correlations were significant. The mean correlation between the number of borderline PD criteria and the indicators of illness severity was nearly three times higher in the patients without borderline PD than the patients with borderline PD (0.23 versus 0.08), and 4 of the 6 correlation coefficients were significantly higher in the patients without borderline PD. These findings suggest that dimensional scoring of borderline PD is more important for subthreshold levels of pathology and are less critical once a patient meets the diagnostic threshold. The implications of these findings for DSM-5 are discussed.

18 Reads
  • Source
    • "Differences between DSM-III-R and DSM-5 diagnostic criteria for these 10 PDs are minor. This dimensional approach is consistent with the literature suggesting that PD dimensions are more reliable, more stable, and more strongly associated with psychosocial morbidity than categorical diagnoses [27] and that a dimensional approach to subthreshold PD symptoms may be particularly important [39] [40] [41]. Of note, a 3- point dimensional approach toward diagnosing PDs, such as was captured in DSM-III-R and DSM-IV-based structured clinical interviews (i.e., absent, subthreshold, or threshold symptoms [42]), and as will presumably also be captured in structured clinical interviews based on DSM-5, has been shown to be equally valid as more finely-grained approaches [27] "
    [Show abstract] [Hide abstract]
    ABSTRACT: We conducted a secondary analysis of data from a clinical trial to explore the relationship between degree of personality disorder (PD) pathology (i.e., number of subthreshold and threshold PD symptoms) and mood and functioning outcomes in Bipolar I Disorder (BD-I). Ninety-two participants completed baseline mood and functioning assessments and then underwent 4 months of treatment for an index manic, mixed, or depressed phase acute episode. Additional assessments occurred over a 28-month follow-up period. PD pathology did not predict psychosocial functioning or manic symptoms at 4 or 28 months. However, it did predict depressive symptoms at both timepoints, as well as percent time symptomatic. Clusters A and C pathology were most strongly associated with depression. Our findings fit with the literature highlighting the negative repercussions of PD pathology on a range of outcomes in mood disorders. This study builds upon previous research, which has largely focused on major depression and which has primarily taken a categorical approach to examining PD pathology in BD.
    Depression research and treatment 01/2014; 2014:816524. DOI:10.1155/2014/816524
  • [Show abstract] [Hide abstract]
    ABSTRACT: Personality disorder research favors a dimensional representation of the personality disorders over categorical classification, and this is one of the central justifications for changing the diagnostic approach in DSM-5. However, recent research has suggested that the most important loss of information in a categorical system is the failure to account for subthreshold levels of pathology. DSM-IV can be considered to already accommodate a quasi-dimensional system insofar as individuals who do not meet the threshold for diagnosis can be noted to have traits of the disorder. In the present report, we examined 2 questions related to dimensional scoring of the personality disorders and the association between personality pathology and psychosocial morbidity: (1) Is the DSM-IV 3-point dimensional convention (absent, subthreshold traits, present) more strongly associated with indicators of psychosocial morbidity than a categorical approach toward diagnosis? and (2) How does the 3-point dimensional scoring convention compare to the 5-point system proposed for DSM-5 and to a criterion count approach in which the dimensional score represents the sum of the number of criteria present? From September 1997 to June 2008, 2,150 psychiatric outpatients were evaluated with semistructured diagnostic interviews for DSM-IV Axis I and Axis II disorders and measures of psychosocial morbidity. The DSM-IV 3-point dimensional convention was more strongly associated with measures of psychosocial morbidity than was categorical diagnosis. There was no difference between the 3-point, 5-point, and criterion count methods of scoring the DSM-IV personality disorder dimensions. Dimensional scoring of the DSM-IV personality disorders was more highly correlated with measures of psychosocial morbidity than was categorical classification. The DSM-IV 3-point rating convention was as valid as scoring methods using more finely graded levels of severity. These findings argue against changing the current DSM-IV diagnostic approach and instead advocate for the increased recognition that DSM-IV already includes a valid dimensional rating.
    The Journal of Clinical Psychiatry 08/2011; 72(10):1333-9. DOI:10.4088/JCP.11m06974 · 5.50 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: This review summarizes recent neurocognitive research to better delineate the nosology, prognostication and cause underlying borderline personality disorder (BPD). BPD had marked clinical heterogeneity with high comorbidity. Executive dysfunction in this disorder was linked to suicidality and treatment adherence, and may serve as an endophenotype. BPD was also characterized by cognitive distortions such as risky decision-making, deficient feedback processing, dichotomous thinking, jumping to conclusion, monocausal attribution and paranoid cognitive style. Social cognition deficits recently described in BPD include altered social inference and emotional empathy, hypermentalization, poorer facial emotional recognition and facial expressions. In electrophysiological studies, BPD was found to have predominantly right hemispheric deficit in high-order cortical inhibition. Reduced left orbitofrontal activity by visual evoked potential and magnetoencephalography correlated with depressive symptoms and functional deterioration. Brain structures implicated in BPD include the hippocampus, dorsolateral prefrontal cortex and anterior cingulate cortex. Abnormal anatomy and functioning of frontolimbic circuitry appear to correlate with cognitive deficits. Frontolimbic structural and functional abnormalities underlie the broad array of cognitive abnormalities in BPD. Further research should espouse broader considerations of effects of comorbidity and clinical heterogeneity, and include community samples and, possibly, longitudinal designs.
    Current opinion in psychiatry 01/2013; 26(1):90-6. DOI:10.1097/YCO.0b013e32835b57a9 · 3.94 Impact Factor
Show more