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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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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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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

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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

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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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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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VALIDATION STUDIES

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,

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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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