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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

    l i h h i l i i f h l f

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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-

    i i h b f l d i

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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

    li bili f d bili f A i I d A i II di d i

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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,