OUTCOME MEASURES FOR BORDERLINE PERSONALITY DISORDER

Outcome Measures for Borderline Personality Disorder

Nicole Anderson

Smith College

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OUTCOME MEASURES FOR BORDERLINE PERSONALITY DISORDER

Outcome Measures for Borderline Personality Disorder

Borderline personality disorder is a severe personality disorder with symptoms

such as unhealthy patterns of instability within relationships, self-image, emotional

irregularity and impulsivity problems. BPD is one of the most commonly diagnosed

personality disorders with approximately 2% of the general population, 11% of all

psychiatric outpatients, and 19% of psychiatric inpatients being affected by this disorder

(Poreh et al., 2006; Linehan, Heard, & Armstrong, 1993). This illness can be especially

difficult to treat because patients are at such a high risk for parasuicidal and suicidal

behavior, which can create much tension between patient and therapist. However, this is

not an illness that can be “cured” per se, but is instead thought of as a lifetime disorder

typically diagnosed in young adulthood with greater impairment arising in adulthood.

Because of this high prevalence rate, gender differences, and risk of death, there has been

much speculation about how to successfully diagnose and treat borderline personality

disorder.

The most relied on treatment for borderline personality disorder is Linehan’s

Dialectical behavior therapy, which is designed specifically for patients with this

disorder. The treatment goals of DBT are “1. reduction of parasuicide and life-threatening

behaviors, 2. reduction of behaviors that interfere with the process of therapy, 3.

reduction of behaviors that seriously interfere with the quality of life” (Linehan et al.,

1993). However, borderline patients are known for dropping out of therapy prematurely

and being unresponsive to therapist’s attempts at treatment. This creates many problems

for the therapists, especially because they cannot force their patients to come to therapy,

but instead have to let them go if they decide to drop out. Dialectical behavior therapy

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OUTCOME MEASURES FOR BORDERLINE PERSONALITY DISORDER

tries to combat this problem by requiring at least a six-month commitment from patients

before they go into treatment.

Although DBT is typically the only form of therapy used to help borderline

personality disorder, there are many outcome measures that have been used in order to

diagnose this disease. Many studies have used a wide spectrum of scales in order to

diagnose the disease, as well as the severity and co morbid disorders that many be

involved. Using this wide spectrum of tests does enable a more in depth representation of

the illness, but can leave out very important characteristics of BPD, such as “feelings of

emptiness, fear of abandonment, or problems in interpersonal relationships” (Perez et al.,

2007). Leaving out these important symptoms could impair the results and not allow

therapists to gain full perspective on the severity of the disease each respective patient

has. These measure are also an important indication of change with borderline patients,

so it is imperative to find a measure that can reliably track change in the patient over time

to see if there has been improvement with treatment.

It is important to look at each individual measure to truly understand what it is

measuring, how valid and reliable of a measure it is, and what other measures can be used

in conjunction with each particular measure. There are arrays of measures used in studies,

many different from those used at ServiceNet, which indicates a dire need to find

measures that are valid, reliable, and sensitive to change. However, since many of these

patients have co morbid diseases, their ability to focus on many tests can be limited,

which can also limit the extent to which therapists understand their patients. By using a

battery of tests, patients may not be able to fully complete each test to the extent

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OUTCOME MEASURES FOR BORDERLINE PERSONALITY DISORDER

therapists need. Thus, it is important to not force too many tests on patients, but find one

or two successful measures.

In order to fully understand each outcome measure used in these studies, I will

document and explain each measure:

Clinical Global Impression Scale for Borderline Personality Disorder Patients

(CGI-BPD): A 10 item scale, the first 9 evaluate psychopathological domains of BPD

and the tenth measures an overall, balanced global evaluation. This measure has two

different formats: 1. CGI-BPD-S, which evaluates the present severity of each of the nine

symptoms and 2. CGI-BPD-I, which evaluates the improvement of each of the symptoms

compared to baseline value (Perez et al., 2007).

Diagnostic Interview for Borderlines-Revised (DIB-R): This is a semi-structured

interview designed specifically for borderline patients. It is composed of 125 items from

which 22 summarized statements are derived with 3 possible score values (0 = no, 1 =

probable, 2 = yes). These summarized statements produce four area scores (cognition,

affect, impulse action patterns, and interpersonal relationships. These area scores will

then determine the overall score on a scale from 0 to 10. Scores equal to or greater than 6

are diagnosed with borderline personality disorder (Perez et al., 2007).

Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-11):

This is a semi-structured interview for axis II personality disorders (Perez et al, 2007).

Hamilton Rating Scale-Depression (HRS-D), Hamilton Rating Scale-Anxiety

(HRS-A), and Montgomery-Asberg Depression Rating Scale (MADRS): These are scales

that measure the intensity of depressive and anxious symptoms (Perez et al., 2007).

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OUTCOME MEASURES FOR BORDERLINE PERSONALITY DISORDER

Brief Psychiatric Rating Scale (BPRS): A scale used to measure the intensity and

characteristics of psychotic symptoms (Perez et al., 2007).

Buss-Durkee Inventory (BDI): A self-administered questionnaire used to measure

overall hostility using seven subscale scores: attack/assault, indirect hostility irritability,

negativism, resentment, mistrust/suspiciousness, and verbal hostility (Perez et al., 2007).

Profile of Mood States (POMS): A questionnaire with 35 adjectives describing

subjective mood states, which get grouped into 6 categories: anxiety, depression,

hostility, vigor, fatigue, and confusion (Perez et al., 2007).

Behavioral Reports (BR): These are weekly recordings that include frequency of

suicide attempts, attendance at emergency services, aggressive-impulsive behavior, and

eating disorders (Perez et al, 2007).

Borderline Personality Questionnaire (BPQ): An 80-item true/false self-report

measure that assesses borderline personality traits as defined by the DSM, which includes

9 subscales: impulsivity, affective instability, abandonment, relationships, self-image,

suicide/self-mutilation, emptiness, intense anger, and quasi-psychotic states (Poreh et al.,

2006).

Minnesota Multiphasic Personality Inventory Borderline Personality Disorder

Scale (MMPI-2 BPD): A measure consisting of 12 dichotomous items that represent BPD

criteria from the DSM (Poreh et al., 2006).

Minnesota Multiphasic Personality Inventory Schizotypal Disorder Scale (MMPI-

2 STY): A measuring of 14 dichotomous items that represent SPD criteria from the DSM

(Poreh et al., 2006).

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OUTCOME MEASURES FOR BORDERLINE PERSONALITY DISORDER

Schizotypal Personality Questionnaire (SPQ): A measure consisting of 74

dichotomous items, with nine subscales measuring each of the nine DSM criteria for

Schizotypal personality disorder (Poreh et al., 2006).

Personality Assessment Inventory – Borderline Features Scale (PAI-BOR): A

measure that consists of four subscales (with 6 items in each), which reflect four

characteristics of borderline personality disorder: affective instability, identity problems,

negative relationships, and self-harm. There are four main categories used to rate answers

(0 = false, 1 = slightly true, 2 = mainly true, and 3 = very true). A total score of 38 or

more indicates presence of BPD symptoms, and a score of 60 or more indicates a

borderline personality disorder diagnosis (De Moor, Distel, Trull, & Boomsma, 2009).

Psycho-Social Wellbeing Scale (PSWS): A twelve item structured interview, rated

on a five-point scales (4 = excellent, 3 = good, 2 = marginal, 1 = impaired, 0 = poor) and

cover the following areas: mental status cognitive functioning, mental status: emotional

functioning, impulse control, substance abuse, coping skills, health, recreational

activities, living environment, immediate social network, extended social network,

activities of daily living, and work satisfaction. This assesses the client’s wellbeing over

the past 30 days (O’Hare et al., 2003).

Practice Skills Inventory (PSI): This 75-item questionnaire measures the

frequency at which practitioners use the three major categories of intervention skills with

their clients: supportive skills, coping skills, and case management. This questionnaire is

also used to measure the degree of emphasis placed on each specific intervention skills by

the practitioner (O’Hare & Sherrer, 2006).

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OUTCOME MEASURES FOR BORDERLINE PERSONALITY DISORDER

McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD): A

ten-item measure used specifically for borderline patients. There are 8 items for the first 8

criteria from the DSM and 2 items for the ninth criteria of paranoia/dissociation (Chanen,

Jovev, McDougall, Rawlings, 2008).

Most of these measures are used in conjunction with one another, so it is

important to evaluate the correlations between items, in addition to the reliability and

validity of each individual test. The correlations between the CGI-BPD and diagnostic

interviews (such as the DIB-R and SCID-II) show a high converging validity, which

means it can be used well with such diagnostic interviews to show changes between pre-

and post-treatment (see Table 1). In order to evaluate the converging validity, the study

compared the scores from the CGI-BPD with 39 items of the DIB-R for the evaluation of

similar symptoms: abandonment, unstable relationships, impulsivity, suicide, affective

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OUTCOME MEASURES FOR BORDERLINE PERSONALITY DISORDER

instability, emptiness, anger, and paranoid ideation. The item for identity on the CGI-

BPD was also compared with the equivalent on the SCID-II. (Perez et al., 2007).

The internal consistency of the CGI-BPD was calculated using the Chronbach’s alpha,

which resulted in a 0.85 for CGI-BPD-S and a 0.89 for the CGI-BPD-I indicating a better

reliability in the evaluation of severity than in the changes between pre- and post-

treatment (see Table 3). However, this internal consistency indicates a significant general

homogeneity of the measure. Overall, the CGI-BPD shows good psychometric

performance with validity, reliability, and sensitivity to change, making it a good

candidate for evaluating severity and change in borderline patients (Perez et al., 2007).

BPQ is a highly reliable and internally consistent test overall and within its

subscales. In order to evaluate discriminant validity, a Pearson correlation was used

comparing the total BPQ score to the total score of the MMPI-2 STY. Both coefficients

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were highly significant, which suggests the BPQ has good discriminant validity.

Convergent validity was examined by comparing the BPQ with the MMPI-2 BPD, which

gave a correlation of .85, and the STB, which gave a coefficient of .72 and .78,

suggesting high convergent validity for the BPQ. The BPQ also shows better agreement

when compared with the SCID-II, with a kappa of 0.57 as opposed to the SCID-II’s

kappa score being 0.45 (a kappa between 0.40 and 0.75 being moderate agreement).

Overall, the BPQ appears to have the best mix of characteristics, with high reliability,

validity, and agreement when compared to other measures (See Table 1).

This study also provided a plot of the ROC curves of the comparison of four instruments

(BPQ, MSI, SCID-II PQ-BPD, and IPDE-BPD), which assesses the diagnostic

performance of each of the tests. The table below shows the BPQ is above the MSI and

the SCID-II PQ, and almost above the IPDE. These results indicate that the BPQ is a

better measure than the other measures when it comes down to overall diagnostic

accuracy (Poreh et al., 2006; Chanen et al., 2008).

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OUTCOME MEASURES FOR BORDERLINE PERSONALITY DISORDER

ServiceNet uses the PSWS and the PSI as a means to measure borderline patient’s

wellbeing, as well as measuring the frequency practitioners use inventory skills with their

borderline patients. I’m first going to look at the PSWS, which demonstrated significant

internal consistency reliability and initial construct validity. Concurrent validity was

tested by correlating two PSWS subscales, psychological and social wellbeing, with other

scales (AUDIT, AUS, and SUD) and then finding its concurrent validity with substance

abuse. Based on statistical tests, the PSWS psychological subscale demonstrated

significant correlations with age of onset, having been hospitalized in the past year, and a

range of substance abuse. This indicates that those with poor psychological wellbeing are

more likely to engage in substance abuse. The PSWS social subscale also correlated with

having been hospitalized in the past year and a range of substance abuse problems, but

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OUTCOME MEASURES FOR BORDERLINE PERSONALITY DISORDER

not with age of onset. These results indicate that those with poor social wellbeing are

more likely to engage in substance abuse (See Table 2). (O’Hare et al., 2002; O’Hare et

al., 2003).

The PSI subscales showed good internal reliabilities when tested by Chronbach’s alpha

for the supportive subscale (correlation of 0.81), the therapeutic coping subscale

(correlation of 0.83), and the case management subscale (correlation of 0.86). There was

also significant discriminant validity within the subscales for supportive and therapeutic

coping, supportive and case management, and therapeutic coping and case management.

Overall, the PSI is consistent with reflecting the influences of interpersonal, cognitive-

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behavioral and case management interventions, as well as program evaluation. (O’Hare et

al., 2002).

It is important to find a measure that encompasses a complete picture of

borderline personality disorder by demonstrating the patient’s, as well as the

practitioner’s, point of view. This measure must also demonstrate high validity,

reliability, and be able useable by all borderline patients with co morbid disorders such as

mental retardation, ADD, etc. This measure should also be given to patients every three

months to ensure consistent assessment of improvement (or lack thereof) and patient

wellbeing. In my opinion, the best measure of self-report to give to patients is the BPQ; it

is not only a highly reliable and valid test, but also because it has one of the highest

diagnostic accuracies out of all previously mentioned measures. Although the 80-items

might make the test quite lengthy, it has a simple yes/no format, which allows patients to

complete the test in about ten minutes, and allows practitioners to score the test in about

five.

Overall the BPQ is the most balanced screening measure, and could be used in

conjunction with the PSWS, in order to evaluate client’s psychological and social

wellbeing. Using the PSWS would give the perspective of the practitioner and allow them

to assess patient’s wellbeing every 30 days, which could help chart any improvements or

setbacks. Putting these two tests together would give the perspective of the client as well

as the practitioner, which would give the full picture of the disorder. It also allows the

practitioner to understand the severity of the disorder, and which subscales the patient is

having the most problems with. I believe, in conjunction with each other, these two tests

could create a reliable and valid screening measure that also allows the practitioner to

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play a role in assessing the patient’s wellbeing, ensuring overall improvement for

borderline patients.

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OUTCOME MEASURES FOR BORDERLINE PERSONALITY DISORDER

References

Bornovalova, M. A., Daughters, S. B. (2007). How Does Dialectical Behavior

Therapy Facilitate Treatment Retention Among Individuals with Comorbid Borderline

Personality Disorder and Substance Use Disorders? Clinical Psychology Review, 27. 923-

943.

Chanen, A. M., Jovev, M., McDougall, E., Rawlings, D. (2008). Screening for

Borderline Personality Disorder in Outpatient Youth. Journal of Personality Disorders,

22(4). 353-364.

De Moor, M. H. M., Distel, M. A., Trull, T. J., Boomsma, D. I. (2009).

Assessment of Borderline Personality Features in Population Samples: Is the Personality

Assessment Inventory-Borderline Features Scale Measurement Invariant Across Sex and

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Feigenbaum, J. (2007). Dialectical Behavior Therapy: An Increasing Evidence

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Linehan, M. M., Heard, H. L., Armstrong, H. E. (1993). Naturalistic Follow-up of

a Behavioral Treatment for Chronically Parasuicidal Borderline Patients. Arch Gen

Psychiatry, 50. 971-974.

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OUTCOME MEASURES FOR BORDERLINE PERSONALITY DISORDER

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O’Hare, T., Sherrer, M. V., Connery, H. S., Thornton, J., LaButti, A., Emrick, K.

(2003). Further Validation of the Psycho-Social Well-Being Scale (PSWS) with

Community Clients. Community Mental Health Journal, 39(2). 115-127.

Perez, V., Barrachina, J., Soler, J., Pascual, J. C., Campins, M. J., Puigdemont, D.,

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Poreh, A.M., Rawlings, D., Claridge, G., Freeman, J. L., Faulkner, C., Shelton, C.

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IV Criteria. Journal of Personality Disorders, 20(3). 247-260.

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