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Transcript of Borderline Construct
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8 VALIDATION STUDIES OF THE BORDERLINE
PERSONALITY DISORDER CONSTRUCT IN
ADOLESCENTS
IMPLICATIONS FOR THEORY AND PRACTICE
DANIEL F. BECKER AND CARLOS M. GRILO
We examine evidence for the validity of the borderline personality disorder
(BPD) construct in adolescents. Mainly, we focus on the validity of this construct
in hospitalized adolescentsa severely ill population in which this diagnosis
should be meaningful if it is meaningful at all. A great deal of the data for this
examination were derived from our own work and that of our collaborators in
the Yale Psychiatric Institute (YPI) Adolescent Follow-Up Studythough some
material is drawn from other sources as well.
When investigators speak of a construct, they are referring to something
that exists theoretically but is not directly observable. Also inherent
in this notion is the sense that a construct has been developedorconstructedto describe phenomena or the relationships between phe-
nomena (Gliner & Morgan, 2000). Diseasesor disorders, or syn-
dromescan clearly be seen as constructs. These diagnostic entities
have been developed to describe pathological events, but the disease
processes are rarely observable directly. In a general medical context,
a disorder is a characteristic symptom set that may or may not have
a known etiology, pathology, or course. Like some medical conditions
but unlike many others, mental disorders are mainly defined in terms
of symptom presentation and not in terms of structural pathology,
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VALIDATION STUDIES
deviance from a physiological norm, or etiology (American Psychiatric
AssociationAPA, 1994). Most mental disorders, then, seek to define
specific forms of psychopathological phenomena by delineating clustersof symptoms. As a result, the validation of mental disorders often
involves analyzing the psychometric performance of symptom sets.
When we inquire into the validity of a diagnostic entityor disor-
derwe are concerned with whether the diagnostic construct describes
the phenomena of the disorder in an accurate, comprehensive, and
consistent manner, across a range of individual occurrences. We should
distinguish our topic herethe validity of the BPD constructfrom
the concept ofconstruct validity
, a technical term that refers to anelement of measurement validity. The latter is not unrelated to our
subject; indeed, three types of construct validityconvergent, discrimi-
nant, and factorial validitywill enter our inquiry. However, we will
be considering the validity of the BPD construct in a broader senseone
that encompasses many narrower senses of validity and reliability.
What, then, are some of the elements ofor potential contributors
tothe validity of a construct such as the BPD symptom set? One
such element is frequency, meaning that the disorder being described
occurs in a population at a rate that is nontrivial. Another is stability,
meaning that the disorder persists over time, at least to some extent.
And another is reliability, meaning that the measurement of the disorder
(in this case, the symptom set) should consistently be able to identify
the disorder. Specific types of reliability include interrater reliability,
test-retest reliability, and internal consistency. Internal consistency
refers to coherence among the items within a measureor, in this case,
the symptoms within a disorder. Later we examine internal consistency
directly, but also by looking at diagnostic efficiency.Concurrent validity and predictive validity concern the relationship
between the disorder and an independent criterion; as the terms imply,
the former involves an independent criterion measured at the same time
as the diagnostic assessment, while the latter involves an independent
criterion measured at some future date. Discriminant validity can be
claimed when the diagnostic criteria can differentiate between groups
that, theoretically, should be differentiable. We touch on this concept
through the examination of criterion overlap, and diagnostic overlap(or comorbidity). Finally, factorial validity can be claimed when factor
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BECKER AND GRILO
Why is diagnosis important? The need for disease classification
systems has been clear throughout the history of medicine, including
the treatment of mental disorders (APA, 1994). An accurate diagnosticsystem has many worthwhile applications, including epidemiological
and clinical research. For the practicing clinician as well, accurate
and reliable diagnosis has many advantages. While diagnosis is not a
substitute for formulationa more comprehensive understanding of
the developmental and biopsychosocial contexts of the patients distress
and dysfunctionit does often serve to assist the clinician in predicting
course and response to treatment. In most cases, it is diagnosis that
connects the individual patient to a broader set of research data, sothat the clinician can determine the relevance of a body of literature
to a particular clinical case. Diagnosis is, essentially, a communication
tool, facilitating communication between clinician and patient, between
clinicians, and between clinician and researcher. It behooves our diag-
nostic system, as a set of research and clinical communication tools,
to be as consistent and precise as possible.
Finally, why study BPD in particular? BPD is a serious mental
disorder, marked by pervasive instability in the regulation of emotions,
impulses, self-image, and interpersonal relationships (Skodol et al.,
2002). It is estimated to occur in 12% of the general population
(Torgersen, Kringlen, and Cramer, 2001) but is observed much more
frequently in clinical settings. Patients with BPD have profound func-
tional impairments, high levels of treatment utilization, and a mortality
rateby suicideof almost 10% (Work Group on Borderline Personal-
ity Disorder, 2001). Through a wide range of research efforts (Zanarini
et al., 2003: Grilo et al., 2004), BPD has recently become the focus
of intensifying study (Skodol et al., 2002). But, despite its commonclinical application in adolescent treatment settings, BPD has been
studied infrequently in adolescent populations.
EVALUATION OF THE BPD DIAGNOSIS
IN ADOLESCENTS
DSM-IVallows BPD to be diagnosed in younger patients when maladap-
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VALIDATION STUDIES
the clinical significance of this diagnosis in adolescents has remained
largely unclear, in recent years there have been several empirical investi-
gations of personality disordersand BPD, specificallyin adoles-cents (Korenblum et al., 1990; Ludolph et al., 1990; Bernstein et al.,
1993; Pinto et al., 1996; Meijer, Goedhart, and Treffers, 1998).
The YPI Adolescent Follow-up Study explored outcomes of the
hospital treatment of adolescents and also investigated several aspects
of adolescent psychopathology, including BPD (Mattanah et al., 1995).
At that time, YPI was a tertiary-care hospital that specialized in the
treatment of severely disturbed adolescents and young adults. In the
late 1980s, the hospital used structured interviews to conduct diagnosticassessments of all adolescents and adults who were admitted to its
inpatient units. During the baseline phase of the study, there were 165
such adolescent subjects, ages 13 to 18 years. A two-year follow-up
of most of these adolescents was conducted during the early 1990s.
Study measures included the Schedule for Affective Disorders and
Schizophrenia for School-Age ChildrenEpidemiologic Version (K-
SADS-E; Orvaschel and Puig-Antich, 1987) and the Personality Disor-
der Examination (PDE; Loranger et al., 1988) for assessing DSM-III-
R (APA, 1987) Axis I and Axis II disorders, respectively, along with
several other instruments. Assessments were performed by a trained
and monitored research evaluation team that was independent of the
clinical team. Final research diagnoses were assigned at an evaluation
conference, attended only by the research team, approximately four
weeks after admission. These diagnoses were established by the best-
estimate method, based on structured interviews and any additional
relevant data from the clinical record, following the LEAD (longitudi-
nal, expert, all data) standard (Spitzer, 1983; Pilkonis et al., 1991).
VALIDATION STUDY RESULTS
Reliability, Frequency, and Stability
One of the earliest papers that resulted from this study reported on the
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BECKER AND GRILO
chance; a value close to 1 indicates nearly perfect agreement, while a
value close to 0 indicates that agreement is no better than would be
expected by chance. For this study, the interrater reliability of Axis Idiagnoses averaged .77; that for Axis II personality disorders averaged
.84. In a later paper, the kappa for BPD in particular was also reported
to be .84 (Becker et al., 2002). These reliabilities, including that for
BPD, are acceptable. These findings suggest that Axis II personality
disorders, like Axis I disorders, can be reliably diagnosed using stan-
dardized semistructured interviews. These reliabilities are comparable
to those generally reported when similar assessment methods are used
with adults (Zanarini et al., 2000).The frequency of BPD in this severely ill adolescent study group
was high: 48% (Mattanah et al., 1995). A subsequent paper demon-
strated that this rate was comparable to that in adult patients in the
same hospital, during the same time period (Grilo, McGlashan, Quinlan,
et al., 1998). Two years later, at the follow-up assessment, the rate of
BPD had fallen to 23% (Mattanah et al., 1995)lower than at baseline,
though still a relatively high frequency of occurrence.
This brings us to the issue of diagnostic stability. There are various
ways to measure this concept, the simplest being percent stabilitythe
percentage of subjects diagnosed at baseline who meet criteria for the
same diagnosis at follow-up. When measured in this way, the two-
year stability of BPD in hospitalized adolescents was only 23%. A
subsequent analysis that examined dimensional measures of BPD also
revealed low stability (Grilo et al., 2001). It is instructive to compare
our stability results for BPD to our results for other disorders. The
only other personality disorder that occurred frequently enough to allow
analysis was passive-aggressive personality disorder, which has sincebeen removed from the DSM. The stability of this disorder was again
fairly low, at 21%. For Axis I disorders, diagnostic stability was some-
what higher: substance use disorders (collectively) had a stability of
53%, major depression had a stability of 46%, and conduct disorder
had a stability of 31% (Mattanah et al., 1995).
Our results regarding the diagnostic stability of personality disorders
were generally consistent with the findings of other investigators who
studied community samples of adolescents (Korenblum et al., 1990;Bernstein et al., 1993). For instance, Bernstein and colleagues (1993)
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the prevalence of personality disorder traits declines steadily through
adolescence into young adulthood, there is some relative stability, in
that adolescents with these traits often have elevated personality disor-der trait levels in adulthood.
Concurrent and Predictive Validity
The concurrent and predictive validity of personality disorders in hospi-
talized adolescents was the topic of a subsequent paper from the follow-
up study (Levy et al., 1999). Although this study examined all personal-
ity disorders taken together, the general results are likely applicable to
BPD in particular. Here, we were concerned with the relationships
between adolescent personality disorders and independent measures of
distress or dysfunctionthat is, measures that are independent of the
diagnostic criteria themselves. For this study, we employed a variety
of clinician-rated and self-report measures of psychiatric distress and
dysfunction, including the Global Assessment of Functioning (GAF)
scale (APA, 1987) and the SCL-90-R (Derogatis, 1983).
We found considerable evidence for concurrent validity of the per-sonality disorder construct at baseline assessment (Levy et al., 1999).
Specifically, patients diagnosed with these disorders had significantly
lower GAF scores, as well as higher levels of almost all self-report
measures of symptom severity and distress. These results are consistent
with findings from some community-based studies of adolescents (Kor-
enblum et al., 1990; Bernstein et al., 1993), which have demonstrated
that the personality disorder diagnosis is associated with high levels
of distress as well as social, academic, and occupational impairment.We did not, however, find strong evidence for the predictive validity
of the personality disorder construct in adolescents. At follow-up, pa-
tients who had been diagnosed with personality disorders two years
previously showed no significant differences in GAF scores or in any
of the SCL-90-R scales or summary indices. Indeed, the only differ-
ences, at follow-up, between those with and without personality disor-
ders were higher levels of inpatient treatment utilization and drug use
in the former group. There is little in the adolescent literature withwhich to compare these longitudinal results. A series of papers from
h Child i h C i S d h d h h BPD
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Skodol, et al., 1999; Johnson, Cohen, Kasen, et al., 2000; Johnson,
Cohen, Smailes, et al., 2000).
Internal Consistency and Criterion Overlap
The results cited thus far suggest that, in adolescents, BPD occurs
frequently, can be reliably diagnosed, and is associated with functional
impairment and subjective distress, but that the stability and predictive
validity of this diagnostic construct are modest at best (Korenblum et
al., 1990; Bernstein et al., 1993; Mattanah et al., 1995; Levy et al.,1999). Given these mixed results, we sought to evaluate further the
question of adolescent BPD validity through psychometric study of the
diagnostic criteria. The first such study evaluated internal consistency
and criterion overlap of the personality disorder criterion sets (Becker
et al., 1999). Again, this study examined all personality disorders,
though it is possible to separate the results for BPD. Another feature
of this study is that it compared the adolescent inpatients to a group
of adult inpatients in the same hospital during the same time period,who underwent identical assessment procedures.
Internal consistency involves the cohesion of an item setin this
case, the criteria, or symptoms, of a personality disorder. Based on inter-
item correlations, the Cronbach alpha coefficient provides a measure
of internal consistency (Cronbach, 1951). It varies between 0 and 1,
increasing as the mean inter-item correlation increases. But alpha also
increases as the number of items increases. For this reason, we addition-
ally determined the mean intercriterion correlation (MIC) to facilitatecomparison between criterion lists of different lengths (Morey, 1988).
The MIC was calculated by taking the mean of the correlations for
each possible pair of criteria within a given disorder. These two coeffi-
cientsalpha and MICwere calculated for each personality disorder
diagnosis, for both adolescents and adults. We generally found that the
personality disorder criteria were less coherent in adolescents than in
adults, by either metric. In the case of the BPD criteria, however, this
was not so; for BPD, the adolescent group had a coefficient alpha of.76 and an MIC of .28, compared with .74 and .26, respectively, for
th d lt (B k t l 1999) I th d th i t l
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This study also evaluated criterion overlap, which provides a measure
of discriminant validity. While internal consistency concerns the corre-
lation of the criteria within a diagnostic category, criterion overlapconcerns the correlation of criteria between disorders. To measure
this, we determined an intercategory mean intercriterion correlation
(ICMIC), which was calculated in a manner analogous to the calculation
of the MIC (Becker et al., 1999). In general, we found that criterion
overlap between personality disorders is greater in adolescents than in
adults. This also appeared to be true for BPD specifically. Moreover,
for the adults, we found the highest intercorrelation between the criteria
of BPD and the criteria of other Cluster B personality disorders. Foradolescents, the criteria of BPD correlated best with the criteria of a
broad range of personality disorders, spanning all three clusters (Becker
et al., 2000).
To summarize the implications of this particular study for BPD in
adolescents: we found that the BPD criteria had internal consistency
comparable to that for adults, but also that they were relatively lacking
in discriminant validity (Becker et al., 1999, 2000). Next, we will
consider two studies that explored further the issues examined in this
study of internal consistency and criterion overlap. The first extended
the examination of criterion overlap to a consideration of diagnostic
overlap, or comorbidity. The second expanded our study of internal
consistency by examining diagnostic efficiency.
Comorbidity
Again, our study of BPD comorbidity involved a comparison betweenthe adolescent study group and an analogous group of adult inpatients
drawn from the same hospital and evaluated in an identical manner
(Becker et al., 2000). By studying the Axis II diagnostic overlap with
BPD, we hoped to expand the on findings mentioned previously, regard-
ing criterion overlap. For the adolescent group, we found a fairly broad
pattern of diagnostic overlap, encompassing aspects of Clusters A and
C. After Bonferroni-corrected chi-square analysis, BPD showed statisti-
cally significant co-occurrence with schizotypal and passive-aggressivepersonality disorders. In the adult group, by contrast, we found a rela-
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BECKER AND GRILO
der only. These results confirmed our criterion-level findings,
suggesting that the BPD construct may represent a more diffuse range
of psychopathology in adolescents than in adults.
Diagnostic Efficiency
Our study of the diagnostic efficiency of the BPD criteria provided an
alternative view of BPD internal consistency. Here, we used conditional
probabilities to examine the diagnostic efficiency of the BPD criteria
in our group of adolescent inpatients, and also in our comparison group
of hospitalized adults (Becker et al., 2002). Diagnostic efficiency is
the extent to which diagnostic criteria (or symptoms) are able to discrim-
inate individuals with a given disorder from those without that disorder,
as determined by the application of conditional probabilities. Four
such conditional probabilities can be useful in studying the diagnostic
efficiency of symptomssensitivity, specificity, positive predictive
power, and negative predictive power.
Despite their common use in research settings, sensitivity and speci-
ficity have limited utility in the process of clinical diagnosis (Widigeret al., 1984). Diagnosticians are more interested in the likelihood of a
disorder, given that the patient has a symptom (or positive predictive
power), than in the likelihood of a symptom, given that the patient has
a disorder (or sensitivity). Similarly, negative predictive power is more
useful than specificity. A symptoms positive predictive power indicates
whether it will have utility as an inclusion criterion. Moreover, the
relative values of the positive predictive powers for various symptoms
of a disorder can provide information about which symptoms are thestrongest predictors of the disorder. This feature represents a potential
improvement over the symptom lists provided in the DSM, in which
all inclusion criteria are generally viewed as equivalent in predictive
capacity. Similarly, a symptoms negative predictive power tells us
whether the absence of that symptom will have utility as an exclusion
criterion. Finally, some authors (e.g., Faraone et al., 1993) have em-
ployed total predictive value as an overall index of a symptoms utility
in making a correct diagnosis. Although not a conditional probability,total predictive value is a measure of percent agreement and represents
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base rates of any of the BPD criteria. There were, however, several
interesting differences at the level of the diagnostic efficiency of the
BPD criteria (Becker et al., 2002). Although the details of many ofthese differences are beyond the scope of this paper, two findings are
relevant here: (1) the adolescents showed greater variability than the
adults in the diagnostic efficiency of the BPD criteria, and (2) the
criteria that were the best overall predictors of BPD varied between
the groups. For the adults, the highest total predictive value was found
for impulsiveness. For the adolescents, the highest values were
found for affective instability, uncontrolled anger, and identity
disturbance.That identity disturbance has specific value in discriminating the
diagnosis of BPD in adolescents is of interest because this trait is often
viewed as a common and nonspecific manifestation in this age group.
That two symptoms of affective dysregulation also have specific value
in discriminating the diagnosis of BPD may shed light on the underlying
nature of this syndrome in adolescents. Various investigators have
suggested that BPD has statistically meaningful components, and that
such components or symptom groupings may be clinically significant
and may respond to specific treatment interventions (Sanislow and
McGlashan, 1998; Links, Heslegrave, and van Reekum, 1999; Links
and Heslegrave, 2000; Sanislow, Grilo, and McGlashan, 2000; Soloff,
2000). For instance, some have argued that impulsiveness is a core
feature of BPD in adults, and that the course of BPD in this age group
can best be influenced by pharmacologic and psychosocial interventions
aimed at this area of symptomatology (Links et al., 1999; Links and
Heslegrave, 2000). Indeed, our own total predictive value results in
the adult group support this view. To the extent that BPD in adolescentshas core features that differ from BPD core features in adults, this may
suggest an alternative set of preferred interventions in this age group
(Becker et al., 2002).
Factor Analysis
The final study that we consider here is one that explored further thisquestion of BPD core features (Becker et al., 2003). Factor analysis
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and Miller, 1989; Clarkin, Hull, and Hurt, 1993; Fossati et al., 1999;
Sanislow et al., 2000; Sanislow et al., 2002). One of these investigations
made use of the adult comparison group from the follow-up study(Sanislow et al., 2000). Sanislow and colleagues (2000) reported three
homogeneous components of BPDdisturbed relatedness, behavioral
dysregulation, and affective dysregulation. Inasmuch as such factors
may reflect core dimensions of borderline psychopathology, this type
of analysis has important theoretical and clinical implications (Skodol
et al., 2002).
In our study, we explored the factor structure of BPD in our group
of adolescent inpatients. We also added to our theoretical and clinicalunderstanding of homogeneous components by determining whether
these are related to specific forms of Axis I pathology. This aspect of
the study was prompted by some of the BPD comorbidity research in
adults, and by studies from our own group (Grilo et al., 1995; Grilo,
Becker, Fehon, Edell, et al., 1996; Grilo et al., 1997) and others (Bern-
stein et al., 1996; Johnson et al., 1999) indicating that BPD in adoles-
cents may be associated with certain Axis I disorders such as depression,
conduct disorder, and substance use disorders.
With respect to the factor analysis, a four-factor solution accounted
for 67.0% of the overall variance (Becker et al., 2003). Factor 1 con-
sisted of suicidal threats or gestures and emptiness or boredom. This
factor reflected self-negating or depressive aspects of the borderline
presentation. Factor 2 embodied aspects of affective dysregulation or
irritability and consisted of affective instability and uncontrolled
anger, along with identity disturbance. Factor 3 reflected the border-
line patients interpersonal dysregulation and consisted of unstable
relationships and abandonment fears. Impulsiveness loaded mostheavily on Factor 4, though identity disturbance loaded on this factor
as well. This four-factor solution differed from the findings reported
for the factor analyses of BPD criteria in adults (Rosenberger and
Miller, 1989; Clarkin et al., 1993; Fossati et al., 1999; Sanislow et al.,
2000; Sanislow et al., 2002).
Logistic regression analyses used the four BPD factors as indepen-
dent variables and Axis I disorders as dependent variables (Becker et
al., 2003). Major depression and dysthymia were significantly associ-ated with Factor 1 only. Anxiety disorders were predicted by Factors
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by Factor 4 alone. Thus, each factor was associated with characteristic
Axis I pathology. Recent controversies concerning the potential merits
of broadening the bipolar disorder construct in pediatric populations(e.g., Leibenluft et al., 2003)and frequent observations, especially
among working clinicians, about the phenomenologic similarities be-
tween bipolar disorder and BPDraise the question of whether there are
associations between BPD and bipolar disorder in adolescent patients.
Unfortunately, this interesting research question is not one that we
were able to address with our data. Research diagnoses were based on
strict DSM-III-R criteria, and our diagnoses of bipolar disorder, there-
fore, corresponded to a narrow phenotype (Leibenluft et al., 2003).Accordingly, the rate of bipolar disorder in our study group was too low
(about 2%) to allow this diagnosis to be incorporated into these analyses.
In summary, our factor analysis produced a four-factor solution that
was substantially different from the results of similar factor analytic
studies in adults. The subsequent logistic regression analyses contrib-
uted to our conceptualization of these four factors and also contributed
to our understanding of potential underlying relationships between BPD
and Axis I pathology in adolescents (Becker et al., 2003).
CONCLUSIONS
What can we conclude about the validity of the BPD construct in
adolescents? Our own reports from the YPI Adolescent Follow-up
Study suggest that personality disorders in this population, includingBPD, can be reliably diagnosed, occur frequently, and have concurrent
validity, but have only modest predictive validity and stability over
time (Mattanah et al., 1995; Grilo, Becker, Fehon, Walker, et al., 1996;
Levy et al., 1999). These findings for hospitalized adolescents are
generally consistent with those of other studies involving community
samples of adolescents (Korenblum et al., 1990; Bernstein et al., 1993)
and are also generally consistent with findings from the adult literature
(Grilo, McGlashan, and Oldham, 1998; Grilo and McGlashan, 1999).Given the concurrent validity that BPD seems to possess in adolescents,
it i lik l th t li i i ill fi d th t t f l i h t i i
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BECKER AND GRILO
validity suggest that we should use caution when employing this diagno-
sis to make predictions about longer-term clinical course.
In addition, some of our findings suggest that the BPD constructmay represent a more diffuse range of psychopathology in adolescents
than in adults. We found that, in comparison with BPD in an analogous
group of adult inpatients, BPD in adolescents had a broader pattern of
criterion overlap with other personality disorders (Becker et al., 1999),
a broader pattern of Axis II diagnostic comorbidity (Becker et al.,
2000), and greater variability in the diagnostic efficiency of its criteria
(Becker et al., 2002). These findings suggest the need to explore BPD
heterogeneity in adolescents.Our exploratory factor analysis of BPD in adolescent inpatients
revealed four BPD factors that differ from those reported for similar
studies of adults (Becker et al., 2003), suggesting that BPD in adoles-
cents may be different in its nature and underlying structure than BPD
in adults (Becker et al., 1999, 2000, 2002). Our four factors represent
homogenous components of self-negation, irritability, poorly modulated
relationships, and impulsivity, each of which is associated with charac-
teristic Axis I pathology. These cross-sectional associations may be
interpreted as suggesting that some of these BPD components can be
affected by co-occurring Axis I disorders. Alternatively, these associa-
tions may suggest specific and meaningful overlapping of Axis I disor-
ders and BPD components in adolescents. A variety of comorbidity
models, including spectrum models (Siever and Davis, 1991), could
be employed to describe the confluence of Axis I related components
in adolescent BPD. Work along these lines is beginning to emerge in
the adult literature (Shea et al., 2004; Grilo et al., 2005), but studies
of these comorbidity models are also needed across adolescence intoadulthood.
As noted previously, some investigators have suggested that the
statistically meaningful components of BPD may be clinically signifi-
cant and may respond to specific treatment interventions. Indeed, there
is a broad literature on the treatment of adult BPD (Work Group, 2001;
Lieb et al., 2004) and some research that addresses the targeted treatment
of adult BPD core features (Links et al., 1999; Links and Heslegrave,
2000; Soloff, 2000). Less is known about the extent to which BPDcomponents may respond to medications or to symptom-focused psy-
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Longitudinal studies are needed to trace the evolution of these BPD
components over time, and to examine their interactions with the vicissi-
tudes of development and the ebb and flow of Axis I disturbance. Suchan understanding of the interplay between these developmental and
pathological processes would contribute to the validation of this diag-
nostic construct, point toward specific therapeutic interventions, and
help to close the gap between diagnosis and clinical formulation. Fi-
nally, future research needs to move beyond categorical or DSM-based
diagnoses to consider more fully dimensional aspects of personality
disturbance (Johnson, Cohen, Kasen, et al., 2000; Grilo, Sanislow, et
al., 2005).
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