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The Clinical Significance of Subthreshold Borderline Personality

Disorder Features in Outpatient Youth

Article  in  Journal of Personality Disorders · July 2018

DOI: 10.1521/pedi_2018_32_330

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Journal of Personality Disorders, 32, 1-11, 2018
© 2018 The Guilford Press
CLINICAL SIGNIFICANCE OF SUBTHRESHOLD BPD FEATURES
THOMPSON ET AL.

THE CLINICAL SIGNIFICANCE OF

SUBTHRESHOLD BORDERLINE PERSONALITY
DISORDER FEATURES IN OUTPATIENT YOUTH
Katherine N. Thompson, PhD, Henry Jackson, PhD,
Marialuisa Cavelti, PhD, Jennifer Betts, DPsych,
Louise McCutcheon, DPsych, Martina Jovev, PhD,
and Andrew M. Chanen, MBBS, PhD, FRANZCP

Studies among adult patients have found that subthreshold borderline

personality disorder (BPD) features are associated with elevated psycho-
social morbidity compared with patients with no BPD features. However,
the clinical significance of subthreshold features of BPD has not been
investigated among real-world patients during the clinical emergence of the
disorder, which is usually between puberty and emerging adulthood. This
study aimed to replicate and extend previous research by comparing outpa-
tient youth aged 15–25 years with subthreshold BPD features with youth
with no BPD features. The sample included 499 potential participants, of
whom 111 had no DSM-IV BPD features at all, and 155 had between one
and four features. Results indicated that the group with subthreshold BPD
features had more severe mental illness and poorer social and occupational
functioning. These findings suggest that subthreshold BPD features are
clinically important and should be a focus of clinical intervention to reduce
continuing disability and improve outcome.

Keywords: borderline personality disorder, subthreshold, social

occupational functioning, youth, adolescence, psychiatry

Although the fifth edition of the Diagnostic and Statistical Manual of Men-
tal Disorders (DSM-5; American Psychiatric Association [APA], 2013) has
continued the tradition of syndrome-based categorical diagnosis of person-
ality disorder, it is widely acknowledged (including in the alternative model
in section III of the DSM-5) that the threshold for distinguishing patients
with and without a personality disorder is arbitrary and that there is no

From Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Australia (K. N. T.,
M. C., J. B., M. J., A. M. C.); Centre for Youth Mental Health, The University of Melbourne, Melbourne,
Australia (K. N. T., M. C., J. B., M. J., A. M. C.); School of Psychological Sciences, The University of
Melbourne (H. J.); and Orygen Youth Health, Melbourne, Australia (L. M., M. J., A. M. C.)
Address correspondence to Professor Andrew Chanen, Orygen, the National Centre of Excellence in
Youth Mental Health, Locked Bag 10, Parkville VIC 3052, Australia. E-mail: andrew.chanen@orygen.
org.au

1
2 CLINICAL SIGNIFICANCE OF SUBTHRESHOLD BPD FEATURES

strict demarcation between “cases” and “non-cases” (Clark, 2007). This is-
sue is especially salient for the prevention of and early intervention for se-
vere (a.k.a. borderline) personality disorder (BPD) because the absence of a
distinct threshold for “caseness” also means that there is no distinct point of
“onset.” This principle is foundational to the argument that early interven-
tion programs for BPD should have broad inclusion criteria that incorpo-
rate “subthreshold” forms of the disorder (Chanen & McCutcheon, 2013).
However, the clinical significance of subthreshold features has not been in-
vestigated among real-world patients during the clinical emergence of BPD,
which is usually between puberty and emerging adulthood (Newton-Howes,
Clark, & Chanen, 2015).
A series of publications from the Rhode Island Methods to Improve
Diagnostic Assessment and Services (MIDAS) project (Ellison, Rosenstein,
Chelminski, Dalrymple, & Zimmerman, 2016; Zimmerman, Chelminski,
Young, Dalrymple, & Martinez, 2012, 2013) has demonstrated that, in adult
patients (aged 18 years and older), subthreshold BPD features are clinically
important and are significantly correlated with indicators of psychosocial
morbidity, such as a greater number of current mental state (formerly known
as Axis I) disorders, lower global functioning, greater suicidal ideation, more
psychiatric hospitalizations, and more time unemployed (Zimmerman et al.,
2013). When patients with just one BPD feature were compared with pa-
tients with zero features, the former fared significantly worse on each of
these same indicators of psychosocial morbidity, indicating poorer function-
ing and greater mental health problems (Zimmerman et al., 2012, 2013).
Moreover, when the individual diagnostic features of anger, affective insta-
bility, impulsivity, and chronic emptiness were examined, each feature was
associated with aspects of impairment, but only chronic emptiness was found
to be associated with every aspect of psychosocial impairment that was as-
sessed (Ellison et al., 2016). These findings clearly indicate that subthreshold
BPD symptoms are clinically important among adults with features of BPD.
However, the MIDAS sample focuses neither on youth nor on individuals
presenting early in the course of BPD.
There has been a proliferation of evidence establishing that personality
disorder is both common and clinically important among adolescents (aged
12–18 years) and youth (aged 15–25 years) (Newton-Howes et al., 2015).
DSM-5 BPD is as valid and reliable a diagnosis in adolescence as it is in adult-
hood, based on similar prevalence, phenomenology, stability, and risk factors;
marked separation of course and outcome from other disorders; and efficacy
of disorder-specific treatment (Chanen, Sharp, Hoffman, & Global Alliance
for Prevention and Early Intervention for Borderline Personality Disorder,
2017). This knowledge, supported by recent research suggesting that BPD
captures the general “severity” factor of personality disorder (Sharp et al.,
2015), has ushered in the “first wave” of empirically supported treatments
that have focused on BPD in young people (Chanen & Thompson, 2014).
While these studies are often grouped under the rubric of “early inter-
vention,” it is noteworthy that not all treatment that occurs among young
people is necessarily preventive or early intervention in nature (Chanen,
2015; Chanen, Berk, & Thompson, 2016). Some young people can pres-
THOMPSON ET AL. 3

ent prior to age 18 years with severe, enduring, and sometimes treatment-
refractory problems. Those engaged in the research and treatment of young
people with BPD have been inconsistent about defining the theoretical and
practical thresholds for phase and stage of disorder or severity of BPD to be
used when framing the importance of prevention and early intervention for
BPD or inclusion/exclusion criteria for clinical trials (Chanen, 2015).
Among 15–18-year-old outpatients presenting for their first BPD treat-
ment, the BPD diagnosis (i.e., five to nine features) has been associated with
poor psychosocial functioning, as evidenced by school truancy and poor
peer and family relationships (Chanen, Jovev, & Jackson, 2007; Kaess et
al., 2013). Other studies have suggested that adolescents with BPD are more
likely to have a history of sexual trauma and sexual concerns (Venta, Ken-
kel-Mikelonis, & Sharp, 2012), to struggle with issues of sexual orientation
(Reuter, Sharp, Kalpakci, Choi, & Temple, 2016), and to have co-occurring
mood, anxiety, and substance use disorders, self-harm and suicidal ideation,
and poor functioning (Kaess et al., 2013; Winsper et al., 2016). However, to
date there has not been a large-scale study investigating the specific effects
of subthreshold (or one to four) BPD features on indicators of psychosocial
morbidity among youth. It remains unclear whether these indicators of psy-
chosocial morbidity are elevated in early-stage disorder, at first diagnosis of
BPD features, and prior to commencing BPD treatment.
The present study aimed to replicate the MIDAS study (Zimmerman
et al., 2012, 2013) in a sample spanning the age during which BPD typi-
cally emerges clinically, i.e., youth aged 15–25 years. Specifically, the study
aimed to compare psychosocial morbidity indicators among two groups of
patients, one with no BPD features and the other with subthreshold BPD fea-
tures. Psychosocial indicators included the number of mental state disorders,
social and occupational functioning, number of visits to an outpatient men-
tal health service, number of current medications, number of “days out of
[usual] role,” referral due to suicidal ideation, and referral due to disruptive
behavior. It was hypothesized that outpatient youth with subthreshold BPD
features would have more psychosocial morbidity than outpatient youth
with no BPD features.

METHOD
PARTICIPANTS

The sample comprised 499 potential participants from Orygen Youth Health,
a frontline state government–funded psychiatric service for youth in north-
west and western metropolitan Melbourne, Australia. Participants were
help-seeking outpatient youth, aged 15–25 years, with little prior psychiatric
treatment, who had participated in previous research studies. The current
study combined diagnostic, demographic, treatment, and functioning data
across a total of four research studies (Chanen et al., 2004, 2007, 2015;
Chanen, Jackson, et al., 2008). All participants provided written informed
consent to participate in each original study. Permission to combine these ex-
isting data for the current study was granted by Melbourne Health Research
4 CLINICAL SIGNIFICANCE OF SUBTHRESHOLD BPD FEATURES

and Ethics Committee (QA2015180). Participants were not re-interviewed

for the purpose of this study.
Of the total sample, 111 youth aged 15–25 years had no Diagnostic
and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; APA,
1994) BPD features, 44 had one feature, 30 had two, 47 had three, and 34
had four features. To allow for greater statistical power those participants
with BPD features were combined into a single group comprising 155 indi-
viduals with one to four BPD features. The remaining 233 youth with five to
nine BPD features were not included in this study because “full threshold”
BPD was not the focus of this study. The groups with no BPD features and
one to four subthreshold BPD features did not significantly differ with regard
to sex, education level, marital status, or age (Table 1).

PROCEDURE

Participants were assessed using the Structured Clinical Interviews for DSM-
IV Axis I and II Disorders (SCID-I/P, First, Gibbon, Spitzer, & Williams,
1996; SCID-II, First, Gibbon, Spitzer, & Benjamin, 1997). Demographic and
psychosocial morbidity information was collected consistent with the aims
of this study, and the Social and Occupational Functioning Assessment Scale
(SOFAS; Goldman, Skodol, & Lave, 1992) was rated. The assessments were
conducted by the principal investigator (A. C.), or one of eight graduate re-
searchers trained by the principal investigator and colleagues (e.g., H. J., J.
B.). The research assistants were supervised by the principal investigator and/
or a senior colleague (e.g., H. J), and where queries arose regarding diagno-
ses, a consensus decision was reached in consultation with senior colleagues
(e.g., A. C., H. J., L. Mc.). Testing of interrater reliability revealed good to
excellent results (e.g., an intraclass correlation [ICC] for individual SCID-II
items ranged from 0.64 to 0.94; Chanen et al., 2004).

MEASURES

Mental state and personality disorder diagnoses were derived from the SCID-
I/P and SCID-II (First et al., 1996, 1997). The SOFAS was used to assess so-
cial and occupational functioning (Goldman et al., 1992). This scale is rated
from 1 to 100, where 1 represents extremely poor functioning, and 100 is
extremely high functioning.
Demographic information included sex, age, marital status, and educa-
tion. Psychosocial morbidity indicators included number of DSM-IV mental
state disorders, number of DSM-IV BPD features, number of mental health
visits in the previous month, number of current medications, number of days
out of role (unable to carry out normal activities) in the past 6 months, and
referral due to suicide attempt/ideation or referral due to disruptive behavior.

DATA ANALYSIS

Minimum data required for a participant to be included in the data analyses

were age, number of current mental state disorders, and number of BPD fea-
THOMPSON ET AL. 5

TABLE 1. Demographic Characteristics of Outpatient

Youth With 0 or Subthreshold DSM-IV BPD Features
0 BPD features 1-4 BPD features
Characteristic n % n % χ2/U p
Sex
Female 64 57.66 101 65.16 1.55 .214
Male 47 42.34 54 34.84
Marital status
Never married 97 97.98 145 97.32 2.54 .467
Common law marriage 1 1.01 3 2.01
Married 1 1.01 0 0.00
Divorced/separated 0 0.00 1 0.67
Education
Year 10 or below 54 54.55 76 51.35 2.48 .289
Year 11 or 12 33 33.33 61 41.22
University/other certification 12 12.12 11 7.43
Age, years 18.00 2.92 17.72 2.59 8456.50 .810
Note. N = 266; 0 BPD n = 111; 1–4 BPD n = 155.

tures. The two groups (0 BPD features and one to four BPD features) were
compared according to sex, marital status, and education level using chi-
square analyses. Several continuous variables, including age, number of cur-
rent mental state disorders, number of current medications, number of days
out of role in the past 6 months, and number of mental health visits in the
past month were not normally distributed. For these variables, comparisons
were made according to group using Mann-Whitney U tests. The SOFAS
score was normally distributed and comparisons were made using t tests.

RESULTS

Both groups were comparable on most DSM-IV mental state diagnostic

groupings. Depressive disorders, substance abuse/dependence, and impulse
control disorders were more highly represented in the subthreshold BPD fea-
ture group (Table 2). The 0 BPD feature group had a significantly higher rate
of bipolar disorder. The frequency of individual DSM-IV BPD features for
the group with subthreshold BPD features is given in Table 3. BPD features
that were strongly represented included recurrent suicidality or self-muti-
lating behavior (43.87%), affective instability (38.71%), and inappropriate
anger (43.87%).
The two groups were compared across a variety of psychosocial morbid-
ity indicators (Table 4). These comparisons indicated that outpatient youth
with subthreshold BPD features have significantly more DSM-IV mental
state diagnoses than youth with no BPD features and poorer social and occu-
pational functioning. The group with subthreshold BPD features was signifi-
cantly more likely to be referred for mental health treatment due to suicide
attempt/ideation or for disruptive behavior. In contrast, there was no signifi-
cant difference between the two groups in regard to the number of mental
6 CLINICAL SIGNIFICANCE OF SUBTHRESHOLD BPD FEATURES

TABLE 2. Current DSM-IV Mental State Diagnoses in Outpatient

Youth With 0 or Subthreshold BPD Features
0 BPD features 1-4 BPD features
DSM-IV mental state diagnosis n % n % χ2 p
Nil mental state disorder 21 18.92 28 18.06 .03 .859
Psychotic disorder 18 16.22 18 11.61 1.17 .279
Bipolar disorder 9 8.11 4 2.58 5.36 .021*
Depressive disorder 29 26.13 66 42.58 7.63 .004**
Anxiety disorder 35 31.53 59 38.06 1.84 .606
Obsessive-compulsive disorder 4 3.60 7 4.52 .14 .712
Posttraumatic stress disorder 3 2.70 9 5.81 1.45 .229
Dissociative disorder 1 0.90 1 0.65 .06 .812
Somatoform disorder 0 0.00 2 1.29 2.17 .140
Eating disorder 13 11.71 11 7.10 1.68 .195
Substance abuse/dependence 13 11.71 69 44.52 20.51 < .0005**
Impulse control disorders 4 3.60 25 16.13 10.45 .001**
ADHD 1 0.90 0 0.00 1.40 .236
Other 1 0.90 4 2.58 .47 .494
Note. N = 266; 0 BPD n = 111; 1–4 BPD n = 155. Individuals could be given more than one diagnosis. Significant dif-
ference of rate occurrence of disorders between groups using chi-square, *p < .05, **p < .01.

health visits in the past month, the number of current psychotropic medica-
tions prescribed, or the number of days out of role in the past 6 months.

DISCUSSION

This study compared two groups of outpatient youth (one with subthreshold
BPD features and the other a mixed patient group with no BPD features)
on a range of psychosocial morbidity indicators. The key finding to emerge
from this study is that subthreshold BPD features in youth were associated
with greater psychosocial morbidity. This was indicated by poorer social and
occupational functioning; a greater likelihood of being referred for mental
health treatment due to suicidal ideation, a suicide attempt, or disruptive be-
haviour; and a higher number of co-occurring mental state (Axis I) disorders.
The current findings demonstrate that subthreshold BPD features are
clinically significant early in the course of BPD, when first presenting for psy-
chiatric care. The presence of subthreshold BPD features was associated with
the co-occurrence of almost two additional mental state disorders. The high-
est prevalence of these disorders among the BPD group included depression,
anxiety, substance abuse or dependence, and impulse control disorders. The
BPD features with highest prevalence were inappropriate anger, recurrent
suicidality and self-harm, affective instability, and unstable and intense in-
terpersonal relationships. This pattern of symptomatology is similar to that
reported in adults with one feature of BPD, who were also reported to have
higher rates of depression, anxiety, and adjustment disorder, together with
the BPD features of chronic emptiness, impulsivity, inappropriate anger, and
affective instability (Ellison et al., 2016; Zimmerman et al., 2012). Greater
THOMPSON ET AL. 7

TABLE 3. Frequency of Individual DSM-IV BPD Features in

Outpatient Youth With Subthreshold BPD Features
DSM-IV BPD criterion 1–4 BPD features
N = 155 %
Frantic efforts to avoid abandonment 23 14.84
Unstable and intense interpersonal relationships 46 29.68
Identity disturbance 23 14.84
Impulsivity in at least two areas that are self damaging 36 23.23
Recurrent suicidality or self-mutilating behavior 68 43.87
Affective instability 60 38.71
Chronic feelings of emptiness 39 25.16
Inappropriate anger 68 43.87
Stress-related paranoid ideation or dissociation 18 11.61

levels of externalizing behavior among the current (youth) sample than in

the MIDAS (adult) sample possibly reflect generally higher levels of this form
of psychopathology among youth (Eaton et al., 2011). This externalizing
behavior tends to moderate among the general population from adolescence
through to adulthood. This is also consistent with research showing that spe-
cific features of BPD, such as disruptive behavior, anger, impulsivity, and self-
harm and suicidality, tend to moderate from adolescence through to adult-
hood (Cohen, Crawford, Johnson, & Kasen, 2005; Gunderson et al., 2011;
Johnson et al., 2000; Zanarini et al., 2007).
The presence of subthreshold BPD features in this sample of youth aged
15–25 years was associated with poorer social and occupational functioning
than among a mixed clinical sample of youth without BPD features. Low
functioning from an early age has the potential to adversely affect subse-
quent development. A previous study from our group found that among
youth aged 15–18 years a diagnosis of BPD was associated with worse func-
tioning compared with individuals with other clinical diagnoses and with
other personality disorders, including significantly more days off school and
poorer peer relationships, self-care, and family relationships (Chanen et al.,
2007). As the current study focused on the age when BPD typically emerges
clinically, the association of factors such as functioning, referral for disrup-
tive behavior, and referral due to suicidal ideation with the occurrence of
subthreshold BPD features highlights their importance as precursor signs
and symptoms (Chanen, Jovev, McCutcheon, Jackson, & McGorry, 2008).
These findings partially replicate those of the MIDAS study (Zimmerman
et al., 2012, 2013), which reported that adult patients with subthreshold
BPD features had a greater number of co-occurring mental state disorders,
lower functioning, greater suicidal ideation, more suicide attempts and psy-
chiatric hospitalizations, and more time spent unemployed than comparison
patients. The current findings differ from those of the MIDAS study, as the
young people in this study had fewer psychiatric hospitalizations and lower
unemployment. These differences might be expected, as they are likely to
be attributable to the stage of illness and to the participants’ developmental
8 CLINICAL SIGNIFICANCE OF SUBTHRESHOLD BPD FEATURES

TABLE 4. Differences in Psychosocial Morbidity Between Outpatient

Youth With 0 or Subthreshold DSM-IV Features
Psychosocial morbidity indicator 0 BPD features 1–4 BPD features t/z/χ2 p
M (SD) M (SD)
Number of current mental state disorders 1.19 (.85) 1.79 (1.31) –3.70 .000**
SOFAS 69.47 (13.02) 63.93 (11.65) 3.57 .000**
Number of mental health visits (past month) 3.12 (2.26) 5.66 (9.77) –.43 .667
Number of current medications .54 (.67) .54 (.77) –.31 .761
Number of days out of role past 6 months 31.44 (40.32) 33.20 (38.72) –.95 .340
Referral due to suicidal ideation 16 (16.2%) 43 (28.9%) 5.29 .021*
Referral due to disruptive behavior 6 (6.1%) 22 (14.8%) 4.50 .034*
SOFAS: Social and Occupational Functioning Assessment Scale. *p < .05. **p < .01.

age and stage. While both the MIDAS study and the current youth sample
included young adults, aged 18–25 years, the present study differs because
it conceptualizes youth as ages 15–25 years and because these “first-pre-
sentation” patients, by definition, have had minimal prior contact with the
psychiatric system, including inpatient care. They are also unlikely to have
entered into the regrettably common pattern of combative engagement with
the mental health system that is often characteristic of the care of people with
either BPD or subthreshold features of BPD and that often leads to repeated
cycles of hospitalization and iatrogenic harm (Chanen, Jovev, et al., 2008).
Community-based epidemiological data from the Children in the Commu-
nity Study (Winograd, Cohen, & Chen, 2008) indicate that BPD features
in adolescence are associated with poor employment outcomes (days out
of role) in adult life, which is consistent with the longitudinal course of em-
ployment and adaptive functioning over the lifespan among adults with BPD
(Chanen, 2015; Sansone & Sansone, 2012; Zanarini, Jacoby, Frankenburg,
Reich, & Fitzmaurice, 2009). It might be that there is a general effect upon
days out of role for acute psychiatric presentations among youth and that the
effect of BPD features is to prolong this disability or to hinder recovery, caus-
ing “scarring” effects that increase the likelihood of future unemployment,
as seen among adults with BPD (Chanen, 2015).
These findings point to the clinical significance of subthreshold BPD fea-
tures in youth and, therefore, the need to provide clinical intervention. This
is termed “indicated prevention” (Mrazek & Haggerty, 1994) and involves
targeting individuals with subthreshold disorder. The current findings suggest
that this should aim to strengthen developmental trajectories with regard to
functioning and psychopathology. Such programs exist and are supported
by controlled clinical trials (Chanen, 2015; Chanen & Thompson, 2014).
For example, evidence from such trials shows reduction of BPD symptoms
and internalizing and externalizing behaviors and improved social and oc-
cupational functioning over a 2-year period (Chanen et al., 2009; Chanen,
Jackson, et al., 2008).
Taken together, the findings of the current study and those of the MIDAS
study (Zimmerman et al., 2012, 2013) suggest that subthreshold BPD fea-
tures are clinically meaningful indicators of psychopathology and poor
THOMPSON ET AL. 9

psychosocial functioning. While these effects might be recognizable in day-

to-day practice, they are not captured by a categorical BPD diagnosis. Di-
mensional measurement of BPD would capture such information. This has
led some authorities to question whether a BPD diagnosis provides enough
information about the origins of poor functioning or the heterogeneity of
personality disorder features (Trull, Tragesser, Solhan, & Schwartz-Mette,
2007), and whether a dimensional approach to diagnosis might be more
clinically informative (Zimmerman et al., 2012, 2013).
The current findings also have implications for the funding of treatment
services for people with BPD. Categorically diagnosed BPD has been reported
to be associated with high morbidity (Leichsenring, Leibing, Kruse, New, &
Leweke, 2011) and high direct and indirect costs (Soeteman, Hakkaart-van
Roijen, Verheul, & Busschbach, 2008; van Asselt, Dirksen, Arntz, & Seve-
rens, 2007), but these data do not capture the hidden morbidity and costs
of subthreshold BPD features. Many health systems require a categorical
diagnosis of BPD in order for patients to obtain health insurance coverage
for their care. Regardless of the primary diagnostic label given to patients,
the presence of BPD features contributes to poorer functioning and increased
complexity of clinical presentation, both of which are likely to increase the
costs of mental health treatment.
Strengths of this study include a relatively large sample of patients, re-
cruited from a frontline government-funded psychiatric service, relatively
early in the course of their psychiatric illness, with relatively low levels of ex-
posure to prior psychiatric treatment. This also allowed the construction of
a well-matched comparison group. A particular strength is the replication of
the MIDAS findings (Zimmerman et al., 2012, 2013) in a different country,
different health care system, and different age group.
Limitations to this study include the method of data aggregation. All
cases included in the analysis had common data for demographics, DSM-IV
mental state disorders, and BPD features, although there were limitations
to some other common variables and the capacity to precisely match these
variables to those used in MIDAS (Ellison et al., 2016; Zimmerman et al.,
2012). While the variables of referral due to suicide attempt or ideation and
referral due to disruptive behavior were based on clinical intake data, these
variables overlap to some degree with BPD criteria of impulsivity and self-
harm and suicidal thinking. Therefore data relating to these variables should
be interpreted with some caution. Although the sample was smaller than that
of MIDAS, it remains the largest dataset of youth aged 15–25 years with sub-
threshold BPD features that contains robust diagnostic and functioning data.
This study found that among outpatient youth the presence of sub-
threshold BPD features was associated with greater psychosocial morbidity
than among those with no BPD features. Youth aged 15–25 years with sub-
threshold BPD features had significantly more DSM-IV mental state disor-
ders and poorer social and occupational functioning and were more likely to
be referred for treatment due to suicidality and/or disruptive behavior than
outpatient youth with no BPD features. This replicates previous research in
adults outpatients (Ellison et al., 2016; Zimmerman et al., 2012) and sug-
gests that subthreshold BPD features are clinically important and should be
10 CLINICAL SIGNIFICANCE OF SUBTHRESHOLD BPD FEATURES
a focus of intervention to improve outcome and to reduce longer term dis-
ability and cost. Future studies could extend the findings of this study by ex-
amining the association between the number of BPD criteria and functioning
in youth.
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