Improving the recognition of borderline personality disorder

Screening for BPD as part of your diagnostic interview

An alternative approach to using self-administered questionnaires for screening is for clinicians to include questions in their evaluation as part of a psychiatric review of systems. When conducting a diagnostic interview, clinicians typically screen for disorders that are comorbid with the principal diagnosis by asking about the comorbid disorders’ necessary features or “gate criteria.” For example, in a patient with a principal diagnosis of MDD, the clinician would inquire about the presence of panic attacks, excessive worry, or substance use to screen for the presence of panic disorder, generalized anxiety disorder, or a substance use disorder. In contrast, for polythetically defined disorders such as BPD, there is no single gate criterion, because the disorder is diagnosed based on the presence of at least 5 of 9 criteria and no single one of these criteria is required to be present to establish the diagnosis.

As part of the MIDAS project, the psycho­metric properties of the BPD criteria were examined to determine if it was possible to identify 1 or 2 criteria that could serve as gate criteria to screen for the disorder. If the sensitivity of 1 criterion or a combination of 2 BPD criteria was sufficiently high (ie, >90%), then the assessment of this criterion (or these criteria) could be included in a psychiatric review of systems, thus potentially improving the detection of BPD. Researchers hypothesized that affective instability, considered first by Linehan⁵³ and later by other theorists⁵⁴ to be of central importance to the clinical manifestations of BPD, could function as a gate criterion. In the sample of 3,674 psychiatric outpatients who were evaluated with a semi-structured interview, the sensitivity of the affective instability criterion was 92.8%, and the negative predictive value of the criterion was 99%.

Identifying a single BPD criterion that is present in the vast majority of patients diagnosed with BPD will allow clinicians to follow their usual clinical practice when conducting a psychiatric review of systems and inquire about the gate criteria of various disorders. Several studies have found that >90% of patients with BPD report affective instability. However, this does not mean that the diagnosis of BPD can be abbreviated to an assessment of the presence or absence of affective instability. Many patients who screen positive will not have BPD when a more definitive diagnostic evaluation is conducted. In the case of BPD, the more costly definitive diagnostic procedure simply entails inquiry of the other diagnostic criteria.