A (Re)-Evaluation of the Symptom Structure of Borderline Personality Disorder

Abstract

Objective: Despite evidence of significant symptom heterogeneity and excessive diagnostic comorbidity, many contend that borderline personality disorder (BPD) is unidimensional, an assumption that rests primarily on results from factor analytic investigations of BPD symptom criteria. We note several limitations in the literature and argue that the symptom structure of BPD can be best clarified by using both factor analytic techniques and examining the BPD symptom dimensions in relation to external criteria (that is, personality traits). Our goals were to: examine if the symptoms of BPD are best conceptualized as unidimensional or multidimensional, and determine the extent to which personality traits account for any symptom dimensions that underlie BPD. Method:All published structural models of the BPD symptom criteria were identified and tested for statistical fit using confirmatory factor analysis in a sample of 373 patients who had completed the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-Axis II Personality Questionnaire BPD scale. Dimensions from the best fitting model were examined in relation to traits from the Five-Factor Model (FFM) and the Personality Psychopathology Five (PSY-5) using correlational and regression analyses.Results: Sanislow's 3-factor model, containing affect dysregulation, behavioural dysregulation, and disturbed relations symptom dimensions, provided the best fit; the unidimensional model produced the worst. The symptom dimensions of the 3-factor model were differentiable from one another and had unique associations with the FFM and PSY-5 personality traits.

Focusing Narrowly on Model Fit in Factor Analysis can Mask Construct Heterogeneity and Model Misspecification: Applied Demonstrations Across Sample and Assessment Types

“…Similarly, researchers sometimes conflate "good" internal consistency (e.g., as determined using coefficient alpha) with item homogeneity (Cortina, 1993;Dunn et al, 2014). As a result, an overreliance on these indices or their misinterpretation can result in problematic conclusions that an item set reflects a single, narrow construct even when that is not the case (e.g., interpreting item scores reflecting heterogeneous diagnostic criteria sets as homogeneous; Chmielewski et al, 2011). In such cases, heterogeneous item sets may then be summed to create global composite scores, even though more homogeneous item sets within broader composites may associate differentially with external criteria (Smith et al, 1995;Smith et al, 2009).…”

“…For example, different psychopathy dimensions (e.g., disinhibition, callousness) show distinct neural correlates that would be obscured when focusing analyses solely on global psychopathy scores (Latzman et al, 2019). Similarly, the borderline personality disorder (PD) criteria from the Diagnostic and Statistical Manual of Mental Disorders (currently fifth edition; DSM-5; American Psychiatric Association) are heterogenous in nature, and ratings of individual borderline PD criteria show distinctive associations with other variables (e.g., inappropriate anger shows specificity with aggression; Chmielewski et al, 2011;Sharp et al, 2015). However, item sets used to assess borderline PD criteria sometimes have been interpreted as being homogeneous because single-factor CFA models of borderline PD ratings show good fit, with fit for single-factor models appearing better than multidimensional model configurations in some studies (e.g., Clifton & Pilkonis, 2007;Feske et al, 2007;Johansen et al, 2004).…”

The mental health of preschoolers in a Norwegian population-based study when their parents have symptoms of borderline, antisocial, and narcissistic personality disorders: at the mercy of unpredictability

“…These disorders are characterized by features such as difficulty controlling anger (BPD, ASPD, NPD), impulsive and aggressive outbursts (BPD, ASPD), rage when being criticized (NPD), irritability (BPD), aggressiveness and physical assault (ASPD), being tough-minded, exploitive, and non-empathic (ASPD, NPD), lack of reciprocal interest and sensitivity to the wants and needs of others (ASPD, NPD), extreme sarcasm (BPD), being indifferent to having hurt another (ASPD), sudden and dramatic shifts in their view of others (BPD), emotional coldness (NPD, ASPD) and disdainful, arrogant behavior (NPD) [ 8 , 9 ]. A recent factor analytic study of BPD reveals three main factors that characterize the disorder: affect dysregulation (e.g., inappropriate anger); behavioral dysregulation and disturbed relations; and additional personality features, such as low conscientiousness and low agreeableness [ 10 ]. Interestingly, the disturbed and unstable relations factors are also associated with thought disorders [ 11 ], indicating flaws in the perception and interpretation of social relations.…”

Trastornos de personalidad en el DSM-5: una aproximación crítica

“…Si bien algunos autores habían impulsado una aproximación prototípica que trataba de englobar ambos modelos, acercándose más al funcionamiento cognitivo de los que van a aplicar la nueva nosotaxia, teniendo en cuenta tanto la investigación empírica como la práctica clínica y diferenciando niveles de aproximación al tipo ideal del trastorno en particular (12), esta propuesta parece desechada tras la revisión de criterios realizada en junio del 2011. A destacar es la alternativa propuesta por Gunderson (7) respecto del Trastorno de personalidad (TP) límite, que recoge una revisión de investigaciones relativas a sintomatología, análisis factoriales, estudios familiares, estudios sobre cognición y sobre tratamientos, para condensarlas en un modelo diagnóstico que recoge los tres fenotipos (hipersensitividad personal, desregulación emocional/afectiva y descontrol conductual) que más se repiten en los análisis factoriales (13,14) y le añade uno de carácter menos analítico pero más clínico, el de la alteración de la identidad. Con los resultados de los tres factores inscritos en el ámbito de la psicopatología del TP límite se pretende entender mejor la elevada comorbilidad que se da en el trastorno en cuestión (15).…”