Best Criterion for Flagging Borderline Personality Disorder Identified

Batya Swift Yasgur, MA, LSW

January 23, 2019

Rapid, repeated, and abrupt shifts in mood may be the most accurate diagnostic criterion for distinguishing borderline personality disorder (BPD) from bipolar (BD) or major depressive disorder (MDD), new research suggests.

Investigators found affective instability criterion had 90% sensitivity in identifying patients with BPD and ruling out those without the condition.

"The affective instability criterion enables screening for BPD during your initial clinical evaluation of a patient with MDD or BD in the same manner that you can or should screen for other comorbidities," lead author Mark Zimmerman, MD, professor of psychiatry and human behavior, Brown University, Providence, Rhode Island, told Medscape Medical News.

"It has both high sensitivity and high negative predictive value, making it particularly useful and easy to incorporate into a routine clinical examination," said Zimmerman, who is also the director of the Outpatient Division at the Partial Hospital Program at Rhode Island Hospital.

The study was published online January 15 in the Journal of Clinical Psychiatry.

Underrecognized, Underdiagnosed

"We were interested in trying to find a clinically useful way of screening for BPD because there are a number of studies demonstrating that BPD is underrecognized and underdiagnosed in clinical practice," Zimmerman said.

"Rather than focusing on developing a screening questionnaire, which would not end up getting used in clinical practice, we wanted to follow the usual paradigm that clinicians follow when conducting an assessment — identifying a criterion or couple of criteria seen so frequently with the disorder that they could be used for screening," he added.

He noted that screening criteria "must have high sensitivity and high predictive value so that almost anyone who screens negative on the assessment doesn't have the disorder and can then be ruled out."

He described a previous study by his team looking at criteria for BPD in a sample of more than 3600 patients.

The study showed that "the affective instability criterion met our desired goals — namely, high sensitive and high negative predictive value."

After publication of this initial study, "the question came up how well the affective instability criterion would perform in those patients where the greatest uncertainty may exist as to whether affective instability would be present — namely, in individuals without the disorder but with related problems, particularly mood disorders like MDD and BD."

A limitation of the first study was that the performance of BPD criteria was examined in all patients in the sample, including those with a low likelihood of having BPD.

The researchers therefore reanalyzed their original data, subdividing the sample into nonoverlapping groups of patients with MDD, BD, or neither of those disorders.

"We felt this would be particularly important in evaluating patients with BD because BD is also characterized by mood swings, although the mood swings differ in quality from the mood swings seen in BD," he said.

"At a superficial level, when you mention affective instability, many clinicians will think of BD, and we wanted to ensure that this criterion worked well for screening purposes in patients with BD," he reported.

"Another reason [for investigating this criterion in patients with BD] is that reviews of the literature have found that approximately 20% of individuals with BD also have BPD," he added.

Gate Criterion

To investigate the question, the researchers evaluated 3674 psychiatric outpatients between December 1995 and April 2014 using a semistructured diagnostic interview for DSM-IV BPD to perform a "psychometric analysis" and determine if it was possible to "identify a single criterion with sufficiently high sensitivity that it could function as a gate criterion to screen for the disorder."

The authors note that although the initial research was done during the DSM-IV era, the results apply equally to DSM-5 criteria.

Patients were interviewed using a modified version of the Structured Clinical Interview for DSM-IV (SCID) and the BPD section of the Structured Interview for DSM-IV Personality (SIDP-IV).

Two questions were used to assess the BPD criterion of affective instability:

  1. Has anyone ever told you that your moods seem to change a great deal? (If yes: What did they say?)

  2. Do you often have days when your mood changes a great deal — days when you shift back and forth from feeling like your usual self to feeling angry or depressed or anxious? (If yes: How intense are your mood swings? How often does this happen in a typical week? How long do the moods last?)

The majority of patients were female, white, and high school graduates.

The most common principal diagnosis was MDD, followed by adjustment disorder, BD, generalized anxiety disorder, and panic disorder (33.4%, 5.7%, 5.6%, 4.6%, 4.5%, respectively).

The frequency of BPD in the total sample was 10.6% and was highest in patients with BPD and patients with MDD and was lowest in patients with other principle diagnoses (29.1% and 11.3% vs 8.3%, respectively).

The sensitivity of the affective instability criterion was found to be > 90% in patients with MDD, BD, and other diagnoses.

Of the nine BPD diagnostic criteria, the affective instability criterion achieved the highest sensitivity as well as the highest negative predictive value, which was > 98% in patients with MDD and those with other diagnoses and a little lower (94%) in patients with BD.

"What we found, in fact, supported our original findings, which is that the affective instability criterion has very high sensitivity and high negative predictive value, not only in psychiatric outpatients broadly defined, but also in the subgroup of individuals with MDD and BD," Zimmerman reported.

"In any patient who presents with depression, whether it is major depression or bipolar depression, you should be screening for a history of trauma with potential PTSD, panic attacks, substance abuse disorders, and eating disorders, and there are usually a couple of questions that can be used to screen for each of these," he continued.

"To be sure, BPD doesn't have a 'necessary feature,' and all nine diagnostic criteria are all weighted equally, but asking the questions that assess affective instability can be used similarly to questions asked for these other disorders," he said.

Evidence-Based Therapies

Commenting on the study for Medscape Medical News, Joel Paris, MD, emeritus professor of psychiatry, McGill University, Montreal, Canada, who was not involved with the study, said it confirms that not all mood swings point to BD. “The pattern is different in BPD, with rapid mood changes related to the environment," he said.

He commended the researchers on contributing "greatly to unraveling this issue."

Also commenting on the study for Medscape Medical News, Donald W. Black, MD, professor of psychiatry, University of Iowa, Carver School of Medicine, Iowa City, said that the "upshot of the study is that these questions about affective instability, which is one of the identifying features of BPD, are simple, important, easy to ask, easy to add to your battery of questions to patients, and can identify most patients with BPD very accurately."

Black, who works on an inpatient unit, said that for over 30 years he has seen "with some frequency patients who, in my opinion, clearly have BPD and yet that diagnosis is nowhere to be found in the chart."

This is problematic because "without accurate diagnosis, patients may not be given correct treatment — specifically, in BPD, medications usually don't work very well and people need to be referred to evidence-based psychotherapy programs."

He emphasized that clinicians should "not take a report of 'mood swings' at face value and assume the patient has BD, rather should explore affective instability, how rapidly moods shift, and what the moods are."

Zimmerman agreed.

"Unlike anxiety disorders, where the same medications used to treat depression may be used for anxiety, BPD has specific evidence-based, empirically supported effective psychotherapies; but it is hard to utilize those therapies or refer patients if you're not aware of the presence of that disorder," he said.

Zimmerman, Paris, and Black have disclosed no relevant financial relationships.

J Clin Psychiatry. Published online January 15, 2019. Abstract

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