Structured

Interviews

J. Kavoussi,

Richard

for Borderline

Personality

M.D., Emil F. Coccaro, M.D., Howard M. Klar, Bernstein, Ph.D., and Larry J. Siever, M.D.

David

denlines

The authors compared three instruments used to diagnose borderline personality disorder-the Diagnostic Interview for Borderline Patients (DIB), the Schedule for Interviewing Borderlines, and the Structured Interview for DSM-III Personality Disorders-in 56 patients with personality disorders. A borderline diagnosis was made according to the DIB in 30%, the Structured Interview for DSM-III Personality Disorders in 48%, and the Schedule for Interviewing Borderlines in 55% of the patients. Diagnostic agreement was only 52%, which has implications for the generalizability of results of validation studies of the borderline diagnosis. Improvement in diagnostic agreement requires modification of current criteria sets and/or the use of dimensional models.

(AmJ

Psychiatry

1990;

147:1522-1525)

B

ondenline personality disorder nosed in clinical settings and most studied personality disorders nomenology, biological markers, family history, this diagnosis

cause

of

and has

inconclusive

across studies. sets are available Knight

outcome. not been

(1),

or

A major problem for the diagnosis,

Kennberg

(2),

is commonly diaghas been one of the in terms of phetreatment response,

Unfortunately, adequately

findings

Gninken

Disorder

however, validated be-

discordant

findings

is that many such as et al.

(3),

criteria those of

(8),

also

based

on

Each of these instruments terrater and test-retest condance

of

making

it

using

the

these

to

different

DIB) na

those

(using

evaluated,

results

of

and

studies

entry

concordance

diagnosed

et al.

good inthe con-

but

been

the

personality

clinicians’

Spitzer

been no studies theme have been

to Gundenson

and

not

to establish

diagnostic

borderline

according

has

measures

the with

of

demonstrated (9-14),

compare

Although there have these structured interviews, tients

criteria

has reliability

interviews

difficult

vestigating

the

M.D.,

criteria.

comparing studies inbetween

disorder

Singer’s

criteria

according

pa-

diagnosed (using

the

to DSM-III

judgments).

The

degree

cniteof

agree-

ment has varied in previous studies (14-20), with kappa values ranging from 0.45 to 0.83. One study (21) compared the borderline diagnoses made by using the DIB with those made by using the Personality Disorder Examination (22), a structured interview based on DSM-III criteria, and found poor concordance between the two instruments in a sample of 22 patients clinically

diagnosed

as

having

borderline

personality

disorder. Given that the DIB, the Structured Interview for DSM-III Personality Disorders, and the Schedule for Interviewing Bonderlines are widely used in studies of borderline personality disorder, the purpose of the present among

study these

was three

of borderline

to measure instruments

personality

the

degree in making

of

agreement a diagnosis

disorder.

Gunderson

and

Singer (4), and Spitzen et al. (5). One solution to this dilemma is to develop operationalized criteria in the form of structured interviews to increase diagnostic reliability from setting to setting. Various semistructuned interviews have been developed to correlate with the most widely used criteria sets. These include the denline Patients (DIB) Singer’s

criteria;

Personality

Spitzer

the

Structured

Disorders

et al.;

and

Diagnostic (6), based

the

Interview on Gunderson Interview

for

for

METHOD The who

Bor-

Presented at the 142nd annual meeting of the American Psychiatnc Association, San Francisco, May 6-1 1, 1989. Received July 6, 1989; revision received April 23, 1990; accepted May 10, 1990. From the Department of Psychiatry, Mount Sinai School of Medicine, New York. Address reprint requests to Dr. Kavoussi, Depression Evaluation Service, New York State Psychiatric Institute, 722 West 168th St., New York, NY 10032. Copyright © 1990 American Psychiatric Association.

1522

of

study

male

they

had

patients

referred

18-65

years

the

psychiatric

from

Administration

center patients

disorders. if

DSM-III mental on drug using

56

a Veterans

or another medical tion program for personality

of

were

consecutively

services

Bonand

DSM-III

(7), based on the criteria Schedule for Interviewing

subjects were

Patients major

medical

for inclusion with clinical were

from

illnesses

or

axis I diagnoses of schizophrenia, disorder, bipolar disorder, or current dependence. Axis I diagnoses were the

phrenia at the

Schedule

for

Affective

Disorders

(SADS) (23). All patients time of the study and gave

center

in an evaluadiagnoses of

excluded

medical

old

and

the major

organic alcohol made by Schizo-

were medication informed consent

free to

participate. Each

fenent

interview

set

of

was

raters

Am

conducted

conduced

J Psychiatry

by

each

147:11,

two

raters.

interview

November

A dif-

for

any

1990

KAVOUSSI,

given patient and were blind to data obtained from the other instruments. The interviews were conducted in random order for any given patient, and 2-7 days separated each interview. Intemraten reliability (kappa) was high for the diagnosis of borderline personality disorder for each of the three instruments (DIB, -0.79;

Structured

Interview

for

DSM-III

Personality

Disorders, -0.78; Schedule for Interviewing Bonderlines, -0.81). Structured Interview for DSM-III Pensonality

Disorders

informant

interviews

were

con-

ducted for 44 (79%) of the patients; these patients granted permission for such interviews. Disagreements on final scores or diagnoses derived from any specific instrument were resolved by consensus at a meeting of all members of the rating team supervised by a senior clinician (H.M.K.) For a categorical diagnosis of borderline personality disorder, patients were required to meet four on more of the eight criteria for borderline personality disorder on the Structured Interview for DSM-lII Personality Disorders, score 7 or more on the DIB, or score 23 or more on the summed severity scales of the schedule for borderline personality portion of the Schedule for Intenviewing

Borderlines.

To

determine

categorical

agree-

COCCARO,

KLAR,

ET AL.

Schizotypal (27 [48.2%] of the patients) and histrionic (27 [48.2%] of the patients) personality disorders were the most common, followed by paranoid (19 [33.9%] of the patients), compulsive (17 [30.4%]), antisocial (nine [16.1%]), and narcissistic (six [10.7%]) personality disorders. Other personality disorders were found in less than 5% of the patients. The three instruments agreed on the presence or absence of borderline personality disorder in 29 (51.8%) of the patients. Thirty-nine (69.6%) of the patients were diagnosed as having borderline personality disorder by at least one instrument; 24 (42.9%) were diagnosed as having borderline personality disorder by at least two instruments, and 12 (21.4%) were so diagnosed by all three. Seventeen (30.4%) of the patients were not diagnosed as having borderline personality disorder by any of the instruments. The DIB diagnosed borderline personality disorder in

17

(30.4%)

of

the

patients,

the

Structured

Inter-

view for DSM-III Personality Disorders in 27 (48.2%), and the Schedule for Interviewing Bordenlines in 31 (55.4%). Fourteen (82.4%) of the 17 patients diagnosed as having borderline personality disorder by the

DIB were

also

diagnosed

as having

the disorder

by the

ment on the overall diagnosis of bordeniine personality disorder and agreement between subscales common to any two instruments, two-by-two kappa values were computed by using the formula K=(pOBS-pCHA)/

Structured Interview dens, and 22 (81.5%) having the disorder

for DSM-III Personality Disorof the 27 patients diagnosed as by the Structured Interview for

DSM-III

Disorders

1-pCHA),

the

where

pCHA=chance

agreement

and

p OBS = observed agreement. Pearson correlations were made by comparing for each subject the number of criteria met on the Structured Interview for DSM-III Personality Disorders, the DIB scaled score, and the total schedule for borderline personality severity scone of the Schedule for Interviewing Bordemlines.

RESULTS The mean age of the patients was 37.7, and all were men. Twenty-seven (48.2%) of the patients were separated or divorced, 18 (32.1%) were currently manned, and I 1 (19.6%) had never been married. The racial composition reflected the general clinic population: 29 (51.8%) were white, 17 (30.4%) were Hispanic, and 10 (17.9%) were black. Affective disorders were common in the history of the 56 men in the study group: 24 (42.9%) had a diagnosis of major depressive disorder in remission. Also common were past substance abuse (17 [30.4%] of the patients) and anxiety disorders (12 [21.4%] of the patients). These diagnoses were not significantly more common in the patients with borderline personality disorder as diagnosed by any one of the instruments under study; however, the small sample sizes limited the power of these analyses. There was significant overlap with other personality disorder diagnoses made by using the Structured Interview for DSM-III Personality Disorders: 46 (82A%) of the patients had more than one personality disorder.

Am

J Psychiatry

147:1

1, November

1990

Personality

were

so diagnosed

by

Schedule for Interviewing Bordenlines. The degree of concordance (kappa) for the diagnosis of borderline personality disorder was 0.50 between the Structured Interview for DSM-III Personality Disorders and the Schedule for Interviewing Bordenlines, 0.42 between the DIB and the Structured Interview for

DSM-III

Personality

Disorders,

and only

0.18

between

the D1B and the Schedule for Interviewing Bordenlines. However, if the cutoff for a diagnosis of borderline personality disorder on the DIB was lowered to a score of 6, concordance was improved (for the Structured Interview for DSM-lII Personality Disorders and the

DIB,

0.47;

for the DIB and

the Schedule

for Interview-

ing Bordenlines, 0.73). Pearson’s correlations were r=0.65, df=54, p