Borderline personality disorder in adolescents: evidence in support of the Childhood Interview for DSM-IV Borderline Personality Disorder in a sample of adolescent inpatients
Introduction
Borderline personality disorder (BPD) is a serious disorder that has been linked to high rates of suicide completion in adults, ranging from 4% to 10% [1]. BPD represents a significant burden to society in terms of distress and burden placed on medical and mental health communities, as well as families [2], [3], [4]. Despite the fact that BPD typically emerges in adolescence [5], it was not until the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) [6] that the diagnosis of BPD in youth was permitted. The same diagnostic criteria used in diagnosing adult BPD were retained in making this extension, but the duration of symptom presentation was reduced from 2 years to 1, with the qualification that the characteristic personality traits were expected to be pervasive, persistent, and not limited to the developmental period of adolescence or to an episode of an Axis I disorder.
Despite this allowance, diagnosing youth with BPD has engendered a great deal of reluctance for several reasons. First, the diagnosis of personality disorders in adolescents is associated with controversy [2], [7], [8] because of the perception that personality is unstable in adolescence [9], the stigma associated with a diagnosis of personality disorder, and the suggestion that symptoms of BPD are better explained by Axis I symptoms [10]. However, there has been a steady increase in evidence supporting the diagnosis of juvenile BPD [11], [12], [13], including evidence for longitudinal continuity [14], [15], [16], a genetic basis [17], [18], [19], overlap in the latent variables underlying symptoms [20], [21], [22] and the risk factors [23], [24], [25] for adolescent BPD and the full-blown adult disorder, and evidence for marked separation of course and outcome of adolescent BPD and other Axis I and Axis II disorders [10], [14], [26], [27]. As in adults, children and adolescents diagnosed with the disorder have increased rates of hospitalization because of suicidal ideation or attempts [28]; more severe Axis I pathology [29], as also shown by the work of Chanen et al [30]; and poorer clinical and psychosocial functioning compared with other personality disorders [10]. Together, the work of Chanen et al and the Child in the Community Study have pointed to the importance of early intervention and prevention of the disorder in youth [10], [30] because research has suggested the malleability of BPD symptoms in adolescence [31].
Early intervention is, however, hampered by a general lack of valid and reliable measures to identify adolescents with BPD traits. Currently, there is only 1 published interview-based measure specifically adapted for use in children and adolescents. The Childhood Interview for DSM-IV Borderline Personality Disorder (CI-BPD) [32] was developed specifically for use with youth, but published studies examining its psychometric properties are lacking. Three published studies that we are aware of have used it, but none of them have explicitly investigated the psychometric properties of the CI-BPD. Zanarini et al [33] used it in a sample of 6410 11-year-old children in the United Kingdom. Children were interviewed in person by a trained rater. This yielded 6330 (98.8%) interviews with complete data. Of those with complete data, 3273 (51.7%) were girls and 3057 (48.3%) were boys. Interrater reliability using taped interviews of 30 children revealed κ values ranging from 0.36 to 1.0, with a median value of 0.88. Overall, 86% of the κ values were in the excellent range of greater than 0.75. The CI-BPD was used in 2 additional studies, both showing significant κ's with clinician ratings of BPD diagnosis [34], [35]. Together, these studies are promising for the criterion validity of the CI-BPD, but as yet, no information exists on the internal factor structure of the CI-BPD, its concurrent and convergent validity, and interrater reliability in a study explicitly designed to examine the psychometric properties of the CI-BPD.
To this end, our study aimed to investigate the psychometric properties of the CI-BPD in a sample of adolescent inpatients ages 12 to 17 years. We used latent trait analyses to examine the measure's internal factor structure, expecting a unidimensional factor structure based on 6 studies supporting a unidimensional factor structure in adult patients [36], [37], [38], [39], [40], adult community samples [41], and a small adolescent sample of 60 French high school students [42]. Convergent validity was examined through the inclusion of 2 questionnaire-based measures of BPD especially designed for children and adolescents: the Borderline Personality Disorder Feature Scale for Children [27] and the Personality Assessment Inventory for Adolescents [43], in addition to clinician diagnosis. Concurrent validity was determined by examining relations with Axis I psychopathology, which included both parent-report and self-report questionnaire–based measures as well as an interview-based diagnostic measure. We expected that patients identified as borderline by the CI-BPD would have higher prevalence of both internalizing and externalizing problems as found by previous studies of adolescent BPD [44], [45]. Concurrent validity was further determined by examining whether those identified as borderline on the CI-BPD had significantly higher frequencies of self-harm, suicidal behavior as suggested in adult [46] and adolescent studies [47], as well as higher levels of emotion dysregulation, as suggested by work in adults [48].
Against the background of a growing trend to view psychiatric disorders, especially personality, from a dimensional perspective rather than categorically [49], [50], [51], [52], [53], we examined the performance of the CI-BPD both categorically (5 of more criteria met) and dimensionally (0-2 scale scores on 9 CI-BPD items). A dimensional perspective may be particularly important for conceptualizing BPD pathology among youth because it is better able to account for developmental fluctuations and increased heterogeneity, which have been reported in younger samples [54].
Section snippets
Participants
Consecutive admissions (n = 245) to an adolescent unit at an inpatient psychiatric clinic were administered a battery of self-report and interview-based assessments during the first 2 weeks of their stay. Parent reports were also obtained on this sample of 12- to 17-year olds. The average stay in the hospital was 4 to 6 weeks. In total, 44 subjects were excluded from the final analyses for various reasons. Following institutional review board protocol and ethical considerations, adolescents
Childhood Interview for DSM-IV Borderline Personality Disorder
The CI-BPD [32] is a semistructured interview developed specifically for use with children and adolescents to assess BPD. The interview was adapted from an adult assessment of DSM-IV personality disorders, with items modified from the borderline module of the Diagnostic Interview for Personality Disorders [55]. The youth version was adapted by Zanarini [32] for youth in the following ways: (1) the language was simplified, (2) 2 forms of impulsivity (ie, promiscuity and reckless driving) were
Preliminary analyses
Descriptive statistics are reported for main study variables in Table 1. Of the final sample (n = 190), 26% (n = 49) of adolescents met criteria for a diagnosis of BPD. The PAI-A was added to the assessment battery at a later time point, so subjects were grouped into pre- and post-PAI scores to examine systematic differences between those who received PAIs and those who did not. Chi-square analyses revealed no significant differences in CI-BPD scores between those who completed the PAI and
Discussion
To our knowledge, this is the only (and largest) inpatient study examining the psychometric properties of a promising diagnostic instrument for BPD in adolescents. Taken together, our findings support the validity and reliability of this instrument. First, the CFA supported a unidimentional factor structure for the CI-BPD, indicating that the DSM-IV criteria, on which the CI-BPD is based, constitute a coherent combination of traits and symptoms even in adolescents. This result is consistent
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