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Affective instability useful screening tool for borderline personality disorder

Clinicians should ask about affective instability when screening for borderline personality disorder, or BPD, in patients with major depressive disorder or bipolar disorder, according to findings from a report published in Journal of Clinical Psychiatry.

Clinicians establish a principal diagnosis and determine the presence of comorbid disorders when they conduct their initial patient evaluations, according to Mark Zimmerman, MD, from the department of psychiatry and human behavior, Brown Medical School, and the department of psychiatry, Rhode Island Hospital, and colleagues.

“To determine the presence of comorbid diagnoses, a clinician will typically ask screening questions assessing the necessary feature or ‘gate criterion’ of the diagnostic criteria for the disorder. ... However, not all psychiatric disorders have a necessary feature,” they wrote. “Such is the case for BPD, which is diagnosed when at least five of nine diagnostic criteria are present, none of which is required. In the absence of a gate criterion, it can be time consuming to screen for BPD.”

In this study, researchers evaluated the operating characteristics of the BPD criteria in 3,674 outpatients with MDD and bipolar disorder using semi-structured diagnostic interviews for DSM-IV BPD conducted from December 1995 to April 2014.

They assessed the operating features of the BPD criteria in three nonoverlapping groups of patients: those with principal diagnosis of MDD; those with principal diagnosis of bipolar disorder; and all remaining patients. For each of the nine BPD criteria, they computed sensitivity, specificity and positive/negative predictive values; however, they were most interested in determining each criterion’s sensitivity and negative predictive values.

The frequency of BPD was highest in patients with bipolar disorder (29.1%) followed by those with MDD (11.3%), then those with other psychiatric diagnoses (8.3%) in the sample.

Zimmerman and colleagues found that the sensitivity and negative predictive value of the affective instability criterion were higher than 90% in patients with MDD, bipolar disorder or other psychiatric diagnoses. Analysis showed that the affective instability criterion achieved the highest sensitivity and negative predictive value in all diagnostic groups.

Specifically, the negative predictive value of the affective instability criterion was more than 98% in those with MDD and those with other psychiatric diagnoses, and 94% in those with bipolar disorder, according to the results.

“We recommend that clinicians screen for BPD in the same way that they screen for other psychiatric disorders by inquiring about the single feature of the disorder that is present in most patients with the disorder and the absence of which effectively rules out the disorder,” the researchers wrote.

“The psychometric properties of the affective instability criterion of BPD suggest that it can function as such a screening criterion in patients with MDD and bipolar disorder, and thus it should be added to a psychiatric review of systems for patients presenting for the treatment of a mood disorder.” – by Savannah Demko

Disclosure: The authors report no relevant financial disclosures.