Differentiating symptom clusters of borderline personality disorder

DIFFERENTIATING SYMPTOM CLUSTERS OF BORDERLINE PERSONALITY DISORDER

KATHLEEN M. RUSCH, STEPHEN J . GUASTELLO AND PAUL T. MASON

Morquelle University Milwoukee, Wisconsin

This study is an attempt to delineate symptom clusters that may be considered most distinctive of patients diagnosed with borderline personality disorder (BPD). Medical records were examined to assess the extent to which each of the eight DSM-111-R BPD criteria was present in 89 psychiatric in- patients diagnosed with BPD. Structural analysis revealed three symptom clusters that can explain symptomatology for a majority of the sample. BPD patients can be identified initially by a core factor and separated subsequently into several BPD subtypes based on the patients’ remaining symptomatology. A hierarchical diagnostic scheme for delineating BPD subtypes is proposed, and the implications of these findings for a theoretical separation of several BPD subtypes are discussed.

Over the past decade, the diagnosis and treatment of Borderline Personality Disorder (BPD) has emerged as a major area of professional interest and controversy (Barasch, Frances, Hurt, Clarkin, & Cohen, 1985; Berg, 1983; Clarkin, Widiger, Frances, Hurt, & Gilmore, 1983; Gunderson &Elliot, 1985; Kroll et al, 1981; McGlashan, 1983; Patrick, 1984; Pope, Jonas, Hudson, Cohen, & Gunderson, 1983; Serban, Conte, & Plutchnik, 1987). The term “borderline” originally was used to describe a type of disorder that represents a midpoint on a continuum between neuroses and psychoses (Gunderson & Singer, 1975; Kernberg, 1976). More recently, some investigators argue that the borderline diagnosis represents an independent, relatively stable entity (Masterson, 1981 ; Torger- son, 1984), whereas others assert that it describes a variant of schizophrenia (Baron, Gruen, Asnis, & Kane, 1983), affective disorders (Akiskal, 1981; Carroll, Gruden, & Feinberg 1981; Klein, 1977), or perhaps both (McGlashan, 1983). The DMS-111 (American Psychiatric Association, 1980) defined Borderline Personality Disorder by the presence of at least five of eight behavioral symptoms including intense and unstable interpersonal relationships, identity disturbance, inappropriate anger, intolerance of being alone, and chronic feelings of loneliness. Several years later, the revision committee for DSM-I11 replaced two of the criteria, intolerance of being alone and chronic feelings of loneliness, with the symptoms fear of abandonment and chronic feelings of emptiness, respectively. However, in spite of efforts to describe objectively the clinical characteristics of the disorder, the reliability and validity of the borderline personality diagnosis remain much debated issues (Barasch et al., 1985; Frances, Clarkin, & Gilmore, 1984; McGlashan, 1983; Pope et al., 1983). One explanation for these difficulties may be that the diagnosis requires any five of eight symptoms, which allows for 93 different criteria combinations.

In an effort to bring unity to this apparently heterogeneous diagnostic category, investigators have emphasized the use of psychological test procedures in direct comparative studies (Berg, 1983, 1985; Edell, 1987; Patrick, 1984), as well as diagnostic interviews (Gunderson, Kolb, & Austin, 1981; Pfohl, Stangl, & Zimmerman, 1983) so as to iden- tify better a prototypic borderline profile. The consensus of these studies is that persons

Reprint requests should be addressed to Kathleen M. Rusch, Psychology Department, Marquette University, Milwaukee, WI 53233.

730

Diflerentiating Symptom Clusters 73 1

with BPD can be distinguished from patients with other DSM-III Axis I disorders across a variety of instruments, i.e., Minnesota Multiphasic Personality Inventory (MMPI); Schedule for Interviewing Borderlines (SIB); Diagnostic Interview for Borderlines (DIB), which lends support to the validity of the borderline construct (Edell, 1987; Gunderson et al., 1981; Patrick, 1984). However, studies (Angus & Marzial, 1988; Barasch, Kroll, Carey, & Sines, 1983; Widiger, Sanderson, & Warner, 1986) that attempted to differen- tiate BPD from other personality disorders for the most part have indicated that patients with BPD differed meaningfully from other personality disordered patients in degree, but not in type, of symptomatology. Therefore, although recent diagnostic studies of BPD have made important discoveries about the relation between BPD and other diagnostic categories, the best diagnostic criteria for BPD remain unspecified.

According to Rosenberger and Miller (1989), comparing BPD with other diagnoses across different variables is an important and necessary step in the diagnostic validation process; however, understanding the structure of the diagnostic criteria is equally important. By doing so, investigators can determine the most distinctive features of this category and explore the areas of considerable overlap, therefore allowing for a purer type of diagnostic refinement (Rosenberger & Miller, 1989).

Given the considerable overlap that appears to exist among the symptoms of BPD with other personality disorders, it may be that BPD constitutes a general diagnostic category that indicates a marginally adaptive level of personality functioning (Patrick, 1984). If so, the heterogeneity found within a group of patients diagnosed as BPD may be the result of patients’ having symptom clusters that fit different clinical subgroups (Spitzer, Endicott, & Gibbon, 1979). Therefore, a promising direction in the assessment of the validity and reliability of BPD is exploring the links among personality characteristics and assessing these symptom clusters.

Although attempts (Grinker, Werble, & Drye, 1968; Spitzer et al., 1979) have been made to delineate several subtypes of patients diagnosed as borderline, these studies investigated borderline syndrome, which is not synonymous with BPD in that the former refers to symptomatology that vacillates from neurotic to psychotic and also pre-dates the diagnosis of BPD. However, in a recent study that used college students diagnosed with BPD, Rosenberger and Miller (1989) analyzed the structure of the diagnostic criteria through a method of factor analysis. Their results indicated that, although two factors were found to be underlying the BPD criteria, the majority of the eight symptoms loaded highly on both factors, which suggests that the symptomatology could not be distinguished clearly by underlying factors. In addition, Rosenberger and Miller (1989) assert that because the structure of the diagnostic criteria is likely to vary with the particular sample utilized, replications of the study that use clinical samples are necessary to determine the stability of the factors they revealed.

The present study is an attempt to delineate symptom clusters that. may be considered most distinctive of clinical patients diagnosed with BPD. By first understanding the relationship among these symptoms and then by examining the extent to which these symptom clusters exist within a sample of patients, clinicians may approach a better understanding of the heterogeneity that exists within the borderline classification.

METHOD

Subjects Subjects were 89 patients admitted to the inpatient service of the Department of

Psychiatry at a large public psychiatric hospital between 1985 and 1989. All participating subjects had given written informed consent to allow investigators access to their medical records for research purposes and had been given the DSM-111-R Axis I1 diagnosis of BPD. All diagnoses (i.e., Axis I and Axis 11) were made by consensus at staffings by the attending psychiatrist and the remainder of the treatment team. Of the 89 subjects,

732 Journal of Clinical Psychology, November 1992, Vol. 48, No. 6

82% were female, and the mean age of the sample was 27.8 years. In addition, 88% were Caucasian, 1 1 070 were Black, and 19’0 were Oriental. Seventy-one percent were single, 16% were married, 11% were divorced, and 2% were separated. The average number of previous admissions for these patients was 4.5 with an average length of hospitalization of 14 days. These characteristics appear to be quite consistent with the demographic profiles found in 23 studies of patients diagnosed with BPD (Akhtar, Byrne, & Doghramji, 1986)

Although 15 patients were given no Axis I diagnoses, 74 patients were given at least one such diagnosis, and 10 patients were given two. The Axis I diagnoses were: affective disorder (48 patients), substance abuse (22), schizoaffective disorder (9, eating disorder (4), schizophrenia (3), conduct disorder (1). and paranoid disorder ( I ) .

Procedure Patients’ medical records were compiled and information on each patient’s most

recent psychiatric admission was examined; this included the attending psychiatrist’s admission note, the psychiatry resident’s admission note, and the attending psychiatrist’s discharge summary. Subsequently, a symptom checklist was used to assess the presence of the eight criteria for DSM-111-R BPD. Each case was assessed individually by three graduate students in clinical psychology.

The evaluators rated the degree to which each diagnostic criterion was present on a 0-3 scale. A rating of 0 indicated the absence of the trait, and a rating of 3 indicated that the subject met the criterion at a definite level. A symptom was considered present when the subject had been given a rating of at least 2 (somewhat present) on the diagnostic criterion. In order to determine diagnostic reliability, ratings were completed by each of the three evaluators, and phi coefficients were computed to assess interrater agreement. It is interesting to note that, of the 89 patients previously diagnosed as BPD by the psychiatric treatment team, only 36 patients met DMS-111-R criteria for BPD (i.e., at least five of eight behavioral symptoms).

RESULTS

All of the eight BPD behavioral symptoms for all 89 cases were factor analyzed to determine the underlying relationships among the symptoms. In addition, a frequency analysis was conducted to examine the extent to which these symptom clusters or factors existed within this sample of patients. Furthermore, the relationships among the factors were examined, and a symptom classification hierarchy was attempted. Finally, square tests were performed to determine whether any relationships existed among the factors and the Axis I diagnoses.

Reliability BPD criterion ratings were collapsed into absent and present categories, and the

phi coefficients ranged from .61 to .89 with a mean inter-judge reliability coefficient of .81. (See Table 1 .) In addition, Cronbach’s coefficient alpha was 3 8 , an indication of relatively weak internal consistency among the BPD symptoms.

Symptom Structure The intercorrelations among the BPD criteria for the full sample are presented in

Table 2. In general, the majority of the BPD criteria were not correlated significantly with each other. However, inspection of Table 2 revealed two groups of BPD criteria that clustered together. The first cluster, labeled the volatility component, included unstable interpersonal relationships, behavioral impulsivity, and inappropriate anger. The second cluster, which described a self-destructive unpredictability component, con- sisted of affective instability and self-mutilating acts.

Diflerentiating Symptom Clusters 733

Table I Interjudge Reliability Coefficients of the BPD Criteria

Criterion Phi coefficient ~

1 .

2. 3 . 4.

5 . 6. 7 .

8.

Unstable interpersonal relationships

Behavioral impulsivity

Affective instability

lnappropriate anger Self-mutilating acts

ldentity disturbance Chronic feelings of emptiness Fear of abandonment

Mean interjudge reliability

.89*

.78*

.77*

.87*

.87*

,781

.88*

.61*

.81*

Table 2 Intercorrelations among the BPD Criteria

Criterion 1 2 3 4 5 6 7 8

1. Unstable

2. Impulse 3. Affect 4. Anger 5 . Damage 6. Identity

7. Empty

8. Abandon -

-

.43'* -

.13 -.13 -

.49** .42** .15 -

.I6 .09 .52** .12 -

.17 .25* .08 .09 .06 -

.09 .07 .04 . I 3 .09 -.06 -

.04 -.02 .07 .01 .03 .29* .08 -

*p < .01. **p < .001.

In order to investigate their structure further, a principal-axis analysis of the BPD criteria was conducted initially. However, the solution produced communality estimates greater than 1.0 (i.e., Heywood case, as cited in Harman, 1976, p. 117-1 18), which pro- hibited the program from completing the analysis. Therefore, a maximum likelihood analysis was chosen because this procedure has been known to handle such cases most effectively (Harman, 1976).

The maximum likelihood analysis of the BPD criteria revealed four factors, which accounted for 55% of the variance. (See Table 3.) Although only two clusters of symptoms were clearly identifiable based on their intercorrelations, a total of four factors emerged from the solution. Two of the four factors paralleled the BPD symptom clusters described earlier. The first factor was labeled the Volatility (V) factor, on which inappropriate anger, unstable interpersonal relationships, and behavioral impulsivity loaded highly (.66 and above). The second factor was labeled the Self-Destructive Unpredica- bility (SDU) factor, on which affective instability and self-mutilating acts loaded highly (.99 and .52, respectively). Each of the remaining two factors was composed of a single symptom, with identity disturbance (I) and fear of abandonment (FA) loading .97 and .73 on their factors, respectively. Because of its low eigenvalue, factor four was omitted from subsequent analyses.


Table 3 Varimax Solution for the BPD Crireria

Criterion Factor loadings

I 2 3 4 Communali t y

Anger Unstable Impulse

Empty Affect Damage Identity Abandon Eigenvalues

.68

.68

.66

.16

- .02 . I 3 . I 7

- .05 I .38

.I6

. I 4

- . I 2

.04

.99

.52

.06 to2

1.14

.05

.06

. I6

- . I2

.02

.01

.97

.I6

I .35

.06 .49

.03 .48

.02 .48

.15 .06

.05 .99

.02 .29

.I9 .99

.73 .57

.50

Percent of total variance 17.2 14.3 16.9 6.3

Classif cation A n alyses A frequency analysis was conducted to examine the prevalence of each factor in

all 89 cases. In order for a factor to be considered present in a case, the patient must have possessed all the relevant symptoms of that particular factor. Figure 1 displays the frequency of each factor within the sample. As indicated, the SDU factor was the most common among the BPD patients and was present in 82 of the 89 cases. Therefore, affective instability and self-mutilating acts are identified quite frequently and appear to be core features of the BPD diagnosis. In contrast, the V and I factors were present in only 25 and 21 of the 89 cases, respectively.

Given that SDU was the most common component, a second frequency analysis was conducted to assess what remaining factor combinations best described the 82 cases with the SDU factor present. Fifty-five percent of cases ( n = 45) did not possess either V or I symptoms, only 7 cases displayed both V and I symptoms, and the remaining 30 cases displayed either V (n = 17) or I (n = 13). These 4 different SDU outcomes are based on their respective factor combinations and may be conceptualized as different subtypes because a phi coeffiicent (.07, ns) showed no association between V or I.

Several chi-square analyses were conducted to determine whether the Axis I diagnoses could explain the frequency differences found for the various factor combinations (i.e., subtypes). Three 5 x 2 contingency tables were formed that compared five Axis I categories (i.e., only affective disorders, only substance-abuse disorders, affective and substance-abuse disorders together, Axis I disorders other than affective and substance-abuse disorders, and the absence of an Axis I disorder) to the presence or absence of one of the three BPD factors (i.e., SDU, V or I). However, chi-square tests revealed no significant associations between the 5 Axis I categories and the Volatility factor (x2[4,ns] = 2.72, n = 82); the SDU factor (x2[4,ns] = 1.66, n = 89); or the Identity factor (x2[4,ns] = 7.52, n = 82). Therefore, no particular Axis I diagnosis was associated with the presence of a particular factor as part of a patient’s symptomatology.

DISCUSSION

At the diagnostic level, the present study indicated that many of the BPD symptoms could be assessed reliably by several raters on a simple criteria checklist. However,

Differentiating Symptom Clusters 735

Frcaucncy

90

80

70

60

50

40

30

20

10

0

V SDU I

V = Volatility

N = 89

SDU = Self-destructive Unpredictability I = Identity Disturbance

FIG. 1. Frequency of each of three factors within sample.

one symptom (fear of abandonment) posed a diagnostic challenge for judges and resulted in a lower than desired rate of agreement (.61). This low rate of agreement, perhaps, could be accounted for by the methodology utilized in this study, which relied on several clinicians’ abilities to assess and document this symptom in their admission and discharge summaries. Given that fear of abandonment is relatively more abstract and less objectively defined than, for example, self-injury, it may be a more difficult, although important, symptom to discern during the diagnostic process. Other studies that utilize different diagnostic methodologies may reveal more satisfactory agreement on the existence of this symptom among judges than was shown here.

Beyond these difficulties at the diagnostic level, it was shown that several BPD criteria were found to be mildly correlated with each other; four factors were identified via structural analysis. However, the fourth factor (fear of abandonment) revealed an eigenvalue less than one and accounted for only 6% of the total variance. In addition, this factor was present in only 16 of the 89 cases and, therefore, was not included in subsequent analyses. It should be noted that the BPD symptom “chronic feelings of emptiness” did not load higher than .16 on any of the factors and was present in only 7 of the 89 cases. It is not suggested that chronic feelings of emptiness is an insignificant feature of BPD, but, rather, may have escaped the scrutiny of the diagnosticians due


to its relatively abstract nature compared with other, more concrete (and presumably more easily discerned) symptoms, such as self-injury or unstable interpersonal relationships.

Nevertheless, the structural analysis revealed three strong factors that were shown to describe 82 of the 89 cases adequately. The SDU factor was present in 82 of the 89 cases; therefore, affective instability and self-mutilating acts may represents core features of borderline personality disorder. The second and third factors were found less frequently in the sample and were conceptualized as lower-order components that subsequently were utilized to separate patients into four different BPD subtypes. The four subtypes were delineated on the basis of whether the second and/or third factors were present in the patient’s symptom make-up after it had been determined that the SDU factor definitely was present. Therefore, based on their factor contributions, the four subtypes appear to be describing (a) a highly unstable type, identified by the V and SDU factors; (b) an identity type composed by the I and SDU factors; (c) a severely impaired type that possessed the V, I and SDU factors; and (d) an undifferentiated type identified only by the presence of the SDU factor. The undifferentiated type, however, could possess other BPD symptoms that do not meet the necessary criteria for inclusion in one of the other subtypes. Although these findings should be viewed as preliminary and only suggestive of the existence of different BPD subtypes, the separation of BPD patients into subtypes could have future implications for differential treatment planning and inter- vention strategies.

The finding that this sample was not a homogenous group was not surprising and was consistent with earlier studies (Grinker et al., 1968; Spitzer et al., 1979) wherein several borderline subtypes emerged. However, as previously discussed, the type and nature of the borderlines studied were conceptually different from those described in DSM-111-R, and, therefore, a comparison of those findings with this study is not appropriate.

Given that affective instability and self-mutilating behaviors were primary features found in the majority of this sample’s patients diagnosed with BPD, it is suggested that a hierarchical diagnostic scheme may prove to be more effective for reliably diagnosing BPD and its proposed subtypes. Therefore, if a clinician determines that the two primary symptoms (affective instability and self-mutilating acts) are present, then further investiga- tion into the client’s presenting behaviors, cognitions, and emotions would be necessary to determine which BPD subtype best represents the client.

By utilizing a hierarchical diagnostic scheme that places primary importance on the SDU factor symptoms, clinicians may approach a better consensus as t o what best constitutes the BPD diagnosis. Currently, the literature is riddled with several different conceptualizations of the borderline construct and, therefore, relies on the reader’s discrimination to define accurately the term’s intended meaning. Furthermore, different meanings of the same term may result in inappropriate comparisons of studies that all claim to utilize borderline samples. In general, the meaning of the term “borderline” appears to have lost its value as a diagnostic descriptor and may need to be replaced if clinicians fail to reach an agreement on its meaning.

If future studies of BPD criteria replicate the structural and frequency data found in this study, then future revisions of the DSM-111-R diagnostic system for determining borderline personality disorder should consider a hierarchical diagnostic approach. Because questions about the effectiveness and reliability of this diagnostic scheme were beyond the scope of this study, future investigations that compare several diagnostic approaches that utilize both clinical and normal samples are needed to address this topic adequately.

The generalizability of these findings may be limited due to the modest sample size and, more importantly, the fact that only 36 of the 89 patients previously diagnosed as BPD actually met five of the eight BPD symptoms when later assessed via a symptom

Differentiating Symptom Clusters 737

checklist. This finding is, in itself, interesting and suggests some discrepancies between the requirements specified for a diagnosis by DSM-111-R and the way the DSM actually is used by clinicians in the field, an issue raised by other authors (e.g., Morey, 1988). One possible explanation for this finding may be that the strength of the methodology used was related directly to the thoroughness and clarity of medical documentation, which may or may not have been representative of the patients’ full symptomatology. Furthermore, one cannot rule out the possibility that certain symptoms were assigned more weight than others by the diagnosticians and, therefore, that the presence of certain symptoms resulted in the treatment team’s assigning the diagnosis of BPD regardless of the number of required symptoms, perhaps doing informally what this study’s results support more empirically. An interesting contribution of this study is precisely this fact - that in actual clinical use diagnosticians (psychologists, psychiatrists) may not adhere completely to the DSM-111-R criteria when they assign a diagnosis of BPD. Future studies that investigate clinicians’ actual compliance with diagnostic criteria would be valuable, particularly when they are unaware, as in the present study, that their compliance will be checked. If , in fact, diagnosticians do deviate from strict adherence to DSM-111-R procedures, then, given these findings, it is suggested that clinicians assign more weight to the SDU factor symptoms (affective instability and self-mutilating behaviors) because these appear to be the core indicators of BPD.

REFERENCES

AKHTAR, S., BYRNE, J. P., B DOGHRAMJI, K. (1986). The demographic profile of borderline personality disorder. Journal of Clinical Psychiatry, 47, 196-198.

AKISKAL, H. S. (1981). Subaffective disorders: Dysthymic, cyclosthymic, and bipolar I I disorders in the “borderline” realm. Psychiafric Clinics of Norfh America, 4, 25-46.

AMERICAN PsYcHrATRrc ASOCIATION. (1980). Diagnosfic and sfafisfical manual of menfal disorders (3rd ed.). Washington: Author.

AMERICAN PSYCHIATRIC ASSOCIATION. (1987). Diagnosfic and sfatisfical manual of menfal disorders (3rd ed. rev.). Washington: Author.

ANGUS, L., & MARZIAL, E. (1988). A comparison of three measures for the diagnosis of borderline personality disorder. American Journal of Psychiatry, 145, 1453-1454.

BARASCH, A., FRANCES, A.. HURT, S . , CLARKIN, J . , BCOHEN, S. (1985). Stability and distinctness of borderline personality disorder. American Journal of Psychiafry, 142, 1484-1486.

BARASCH, J., KROLL, J. , CAREY, K., & SINES, L. (1983). Discriminating borderline disorder from other personality disorders: Cluster analysis of the Diagnostic Interview for Borderlines. Archives of Generul Psychiatry, 40, 1297-1302.

BARON, M., GRUEN, R., ASNIS, L., & KANE, J . (1983). Familial relatedness of schizophrenic and schizotypal states. American Journal of Psychiafry, 140, 1437-1442.

BERG, M. (1983). Borderline psychopathology as displayed on psychological tests. Journal of Personality Assessmenf, 47, 120-133.

BERG, M. (1985). Assessment of borderline psychopathology. In D. Swiercinsky (Ed.), Tesfing adulfs: A reference guide for special psychodiagnosfic assessmenfs (pp. 20-33). Kansas City: Test Corporation of America.

CARROLL, B. J., GRUDEN, J. T., & FEINBERG, M. (1981). Neuroendocrine evaluation of depression in borderline patients. Psychiafric Clinics of North America, 4, 89-99.

the borderline personality disorder. Journal o/ Abnormal Psychology, 92, 263-275. Relationship of borderline syndrome disorders to early schizophrenia on the MMPI. Journal

of Clinical Psychology, 43, 163-176. Reliability of criteria for borderline personality disorder:

A comparison of DSM-Ill and the Diagnostic Interview for Borderline patients. American Journal of Psychiafry. 141, 1080-1084.

GRINKER, R. R., WERBLE, B., B DRYE, R. (1968). The borderlinesyndrome: A behavioralsfudy of ego func- tions. New York: Basic Books.

GUNDERSON, J . G., & ELLOT, G . R. (1985). The interface between borderline personality disorder and affective disorder. American Journal of Psychiafry, 142, 277-288.

CLARKIN, J . F . , WIDIGER, T. A., FRANCES, A, , HURT, s., & GILMORE, M . (1983). Prototypic typology and

EDELL, W. (1987).

FRANCES, A., C L m t N , J. F., B GLLMORE, M. (1984).


GUNDERSON, J . G . , KOLB, J . E., 81 AUSTIN, V. (1981). The diagnostic interview for borderline patients. American Journal of Psychiatry, 138, 896-903.

GUNDERSON, J . G., & SINGER, M. T. (1975). Defining borderline patients: An overview. American Journal of Psychiatry, 135, 1-9.

HARMAN, H. (1976). Modern factor analysis (3rd ed.). Chicago: University of Chicago Press. KERNBERC, 0. (1976). Borderline conditions and pathological narcissism. New York: Jason Aronson. KLEIN, D. F. (1977). Psychopharmocological treatment and delineation of borderline disorder. In P.Har-

tocollis (Ed.), Borderline personality disorder: The concept, the syndrome, the patient (pp. 365-383). New York: International Universities Press.

KROLL, J., SINES, L., MARTIN, K., STEVEN, L., PYLE. R., & ZANDER, J . (1981). Borderline personality disorder. Archives of General Psychiatry, 38, 1021-1026.

MASTERSON, J . F. (1981). The narcissistic and borderline disorders. An integrated developmental approach. New York: Brunner/Mazel.

MCGLASHAN, T. H . (1983). The borderline syndrome: Is it a variant of schizophrenia or affective disorder? Archives of General Psychiatry, 40, 1319-1323.

MOREY, L. C. (1988). The categorical representation of personality disorder: A cluster analysis of DSM-111-R personality features. Journal of Abnormal Psychology, 97, 3, 314-321.

PATRICK, J. (1984). Characteristics of DSM-111 borderline MMPI profiles. Journal of Clinical Psychology,

PFOHL, B., STANGL, D., & ZIMMERMAN, M. (1983). Structured interview for DSM-III Personality Disorders. Unpublished manuscript, University of Iowa.

POPE, H. G., JONAS, J . M., HUDSON, J . L., COHEN, B. M., & GUNDERSON, J. G. (1983). The validity of DSM-111 borderline personality disorder. A phenomological, family history, treatment response, and long-term follow-up study. Archives of General Psychiatry, 40. 23-30.

ROSENBERGER, P. H., & MILLER, G. A. (1989). Comparing borderline definitions: DSM-111 borderline and schizotypal personality disorders. Journal of Abnormal Psychology, 98, 161-169.

SERBAN, G., CONTE, H., & PLUTCHNM, R. (1987). Borderline and schizotypal personality disorders: Mutually exclusive of overlapping? Journal of Personalily Assessment, 51, 15-22.

SPITZER, R. L., ENDICOTT, J., & GIBBON, M. (1979). Crossing the border into borderline personality disorder and borderline schizophrenia: The development of criteria. Archives of General Psychiatry, 36, 17-24.

TORCERSON, S. (1984). Genetic and nosologica! aspects of schizotypal and borderline personality disorders. A twin study. Archives of General Psychiatry, 41, 546-554.

WIDIGER, T., SANDERSON, C., & WARNER, L. (1986). The MMPI, prototypal typology, and borderline personality disorder. Journal of Personality Assessment, 50, 540-553.

40, 655-658.

Documents

Differentiating symptom clusters of borderline personality disorder