Diagnostic accuracy of DSM-5 borderline personality disorder criteria: Toward an optimized criteria set

Fowler, J. Christopher; Carlson, Marianne; Orme, William H.; Allen, Jon G.; Oldham, John M.; Madan, Alok; Frueh, B. Christopher

doi:10.1016/j.jad.2020.09.138

Cited by 4 publications

(5 citation statements)

References 30 publications

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“…[17][18][19][20] Despite the presence of many low-probability combinations, prototypical presentations of mental disorders exist. 9 Our simulation predicted that few combinations have a remarkably high probability of occurring, in fact an order of magnitude higher than most other combinations. Moreover, such combinations were characterized by the presence of all or almost all symptoms specified in the definition.…”

Section: Discussionmentioning

confidence: 78%

“…Yet it cannot be assumed that these findings also apply to individuals with lowprobability combinations. 9 Thus, if an object of interest (eg, a biomarker) is mainly associated with prototypical combinations, a high cumulative prevalence of low-probability cases will reduce the power to infer this object. Similarly, an object of interest associated with specific low-probability combinations might be inferred in a specific sample, but replication in a sample with a similar share but different specific low-probability cases might fail.…”

Section: Discussionmentioning

confidence: 99%

“…7,8 For example, some have argued to define disorders narrowly, ie, focusing on prototypical presentations, resulting in a minimal set of symptoms and high specificity of a diagnosis. 9,10 Others prefer an inclusive definition covering more possible combinations, resulting in higher sensitivity but more heterogeneity. 11, 12 Similarly, there is a debate about whether mental disorders are better understood as distinct categories or as spectra of disordered states.…”

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confidence: 99%

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Unveiling the Structure in Mental Disorder Presentations

Spiller,

Duek,

Helmer

et al. 2024

JAMA Psychiatry

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ImportanceDSM criteria are polythetic, allowing for heterogeneity of symptoms among individuals with the same disorder. In empirical research, most combinations were not found or only rarely found, prompting criticism of this heterogeneity.ObjectiveTo elaborate how symptom-based definitions and assessments contribute to a distinct probability pattern for the occurrence of symptom combinations.Design, Setting, and ParticipantsThis cross-sectional study involved a theoretical argument, simulation, and secondary data analysis of 4 preexisting datasets, each consisting of symptoms from 1 of the following syndromes: posttraumatic stress disorder, depression, schizophrenia, and anxiety. Data were obtained from various sources, including the National Institute of Mental Health Data Archive and Department of Veteran Affairs. A total of 155 474 participants were included (individual studies were 3930 to 63 742 individuals in size). Data were analyzed between July 2021 and January 2024.ExposureFor each participant, the presence or absence of each assessed symptom and their combination was determined. The number of all combinations and their individual frequencies were assessed.Main Outcome and MeasureProbability or frequency of unique symptom combinations and their distribution.ResultsAmong the 155 474 participants, the mean (SD) age was 47.5 (14.8) years; 33 933 (21.8%) self-identified as female and 121 541 (78.2%) as male. Because of the interrelation between symptoms, some symptom combinations were significantly more likely than others. The distribution of the combinations’ probability was heavily skewed with most combinations having a very low probability. Across all 4 empirical samples, the 1% most common combinations were prevalent in a total of 33.1% to 78.6% of the corresponding sample. At the same time, many combinations (ranging from 41.7% to 99.8%) were reported by less than 1% of the sample.Conclusions and RelevanceThis study found that within-disorder symptom heterogeneity followed a specific pattern consisting of few prevalent, prototypical combinations and numerous combinations with a very low probability of occurrence. Future discussions about the revision of diagnostic criteria should take this specific pattern into account by focusing not only on the absolute number of symptom combinations but also on their individual and cumulative probabilities. Findings from clinical populations using common diagnostic criteria may have limited generalizability to the large group of individuals with a low-probability symptom combination.

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Section: Discussionmentioning

confidence: 78%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Unveiling the Structure in Mental Disorder Presentations

Spiller,

Duek,

Helmer

et al. 2024

JAMA Psychiatry

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“…Equally, populations that presented with one or more BPD/EUPD‐typical symptoms were also included: (1) emotion dysregulation, (2) impulsivity, (3) identity disturbance, (4) unstable relationships, (5) emptiness, and (6) fear of abandonment. These were chosen due to being identified in at least four of the following: core symptoms in DSM‐5/ICD‐10; typical symptom features in DSM‐5 alternative‐model; a strong, good, or moderate differentiator to nonclinical populations (Fowler et al, 2021); one of the three BPD core domains (Sanislow et al, 2002); one of the “clinical hallmarks” (Storebø et al, 2020); important core feature identified by clinicians (Schmahl et al, 2014); important psychopathology of BPD (Sharp et al, 2015); one of the BPD typical Symptoms (The Royal College Of Psychiatrists, 2015); found as a factor accounting for unique variance in BPD (Mulay et al, 2019); and/or found as a BPD‐relevant construct in subthreshold populations (B. N. Johnson & Levy, 2020). Excluded were populations with other primary mental health disorder diagnoses.…”

Section: Methodsmentioning

confidence: 99%

A systematic review and meta‐analysis of digital interventions targeted at individuals with borderline personality disorder (BPD), emotionally unstable personality disorder (EUPD), and related symptoms

2023

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Objectives The present review investigates the impact of digital interventions for individuals with features of borderline personality disorder (BPD)/emotional unstable personality disorder (EUPD) as digital interventions show promise as therapeutic tools in underserved groups. BPD/EUPD features are identified as clinically relevant, yet previous reviews on the use of digital interventions fail to include subthreshold symptomatology. Methods Five online databases were searched for terminology in three categories: BPD/EUPD and related symptoms, mental‐health interventions, and digital technology. Additionally, four relevant journals and two trial registers were searched for additional papers meeting the inclusion criteria. Results Twelve articles met all inclusion criteria. Meta‐analyses revealed statistically significant differences in symptom measures between intervention and control groups at postintervention and decreases in BPD/EUPD symptomatology and well‐being from pre‐ to postintervention. Service users' engagement, satisfaction, and acceptability of interventions were high. Results support the previous literature on the value of using digital interventions in populations with BPD/EUPD. Conclusion Overall, it was identified that digital interventions show promise for successful implementation with this population.

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“…Future studies exploring differences in DBT outcomes across sex and gender groups are critical, particularly individuals assigned male, as well as TGD individuals, as this may improve clinical decision making and, ultimately, treatment outcomes. Furthermore, given that there are 256 possible BPD symptom combinations (Fowler et al, 2020), it is worth investigating whether these varying presentations lead to differences in treatment response, and whether sex and gender play an influencing role in both the varying presentations and subsequent treatment response. More generally, whether treatment response occurs at the same rate of progress across genders, and whether genders respond differentially to individual or group therapy components of this treatment should also be explored.…”

Section: Future Directionsmentioning

confidence: 99%

Sex and gender in treatment response to dialectical behaviour therapy: current knowledge, gaps, and future directions

Penta,

Correia,

Schneider

et al. 2022

tCBT

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Borderline personality disorder (BPD) is a mental health condition characterized by emotion dysregulation, interpersonal impairment, and high suicidality. Dialectical behaviour therapy (DBT) is the most widely studied psychotherapeutic treatment for BPD. To date, the vast majority of DBT research has focused on cisgender women, with a notable lack of systematic investigation of sex and/or gender differences in treatment response. In order to encourage effective, equitable treatment of BPD, further investigation into treatment targets in this population is critical. Here, we employed a systematic strategy to delineate gaps in the DBT literature pertaining to sex and gender differences and propose directions for future research. Findings demonstrate a significant discrepancy in measurement of sex and gender, particularly among gender-diverse individuals. Exploring DBT treatment response across the full spectrum of genders will facilitate the provision of more tailored, impactful care to all individuals who suffer from BPD. Key learning aims (1) To date, DBT treatment literature has focused almost exclusively on cisgender women, with only two of 253 DBT studies in current literature accounting for transgender and gender diverse (TGD) individuals. (2) Recognize how gender minority stress may impact the prevalence of BPD among TGD individuals. (3) Learn how future research initiatives can be employed to rectify this gap in the DBT literature.

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Diagnostic accuracy of DSM-5 borderline personality disorder criteria: Toward an optimized criteria set

Cited by 4 publications

References 30 publications

Unveiling the Structure in Mental Disorder Presentations

Unveiling the Structure in Mental Disorder Presentations

A systematic review and meta‐analysis of digital interventions targeted at individuals with borderline personality disorder (BPD), emotionally unstable personality disorder (EUPD), and related symptoms

Sex and gender in treatment response to dialectical behaviour therapy: current knowledge, gaps, and future directions

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