Fact or fiction: Diagnosing borderline personality disorder in adolescents

Available online at www.sciencedirect.com Clinical Psychology Review 28 (2008) 969 981 Fact or fiction: Diagnosing borderline personality disorder in adolescents Alec L. Miller a, Jennifer J. Muehlenkamp b,, Colleen M. Jacobson c a Department of Psychiatry, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA b Department of Psychology, University of North Dakota, Grand Forks, ND, USA c Department of Child & Adolescent Psychiatry, Columbia University/New York State Psychiatric Institute, New York, NY, USA Received 15 March 2007; received in revised form 7 February 2008; accepted 13 February 2008 Abstract Borderline Personality Disorder (BPD) has long been considered a mental health problem that results in considerable costs in terms of human suffering and psychiatric expenses among adult patients. Although the diagnosis of BPD for adolescents is frequently used in clinical settings, the field of mental health has questioned whether one should diagnose BPD among adolescents. This paper reviews the recent empirical literature (identified through PsycINFO 1980 to present) to evaluate prevalence, reliability, and validity of a BPD diagnosis in adolescents. It is concluded that the features BPD diagnoses in adolescents are comparable to those in adults. Furthermore, there appears to be a legitimate subgroup of adolescents for whom the diagnosis remains stable over time as well as a less severe subgroup that moves in and out of the diagnosis. While caution is warranted, formal assessment of BPD in adolescents may yield more accurate and effective treatment for adolescents experiencing BPD symptomatology. More longitudinal research is necessary to further explicate the issues of diagnosing BPD in adolescents. 2008 Elsevier Ltd. All rights reserved. Keywords: Borderline personality disorder; Adolescence; Reliability; Validity Contents 1. Borderline personality disorder diagnosis....................................... 970 2. BPD in adolescents.................................................. 971 3. Temperament and personality............................................. 971 4. Prevalence of BPD................................................... 973 5. BPD and reliability................................................... 974 6. BPD and validity.................................................... 976 Corresponding author. University of North Dakota, 319 Harvard St. Stop 8380, Grand Forks, ND 58202, USA. Tel.: +1 701 777 4496; fax: +1 701 777 3454. E-mail address: jennifer.muehlenkamp@und.edu (J.J. Muehlenkamp). 0272-7358/$ - see front matter 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.cpr.2008.02.004

970 A.L. Miller et al. / Clinical Psychology Review 28 (2008) 969 981 7. Summary....................................................... 978 References......................................................... 979 Due to the commonly held belief among mental health professionals that personality is still evolving during adolescence, there has been a reluctance to diagnose personality disorders among this age group. Our literature review suggests the need for mental health professionals to reconsider this issue with the help of contemporary research. From our clinical experience, both on psychiatric inpatient units and outpatient clinics, it appears that many adolescents meet criteria for a personality disorder but are diagnosed and treated for only Axis I disorders. By ignoring Axis II criteria, many adolescents may not receive specific treatment for their dysfunctional behaviors, or worse, receive inappropriate treatments. These oversights could exacerbate serious problems including suicidality, delinquency, academic failure, social dysfunction, and substance abuse (Kernberg, Weiner, & Bardenstein, 2000). Borderline Personality Disorder (BPD), in particular, has long been considered a public health problem that results in considerable costs in terms of human suffering and psychiatric expenses among adult patients. The early detection of BPD in adolescence would permit psychological interventions to be implemented before maladaptive behavior patterns become crystallized and refractory to treatment in later life. Therefore, it is incumbent upon mental health professionals to differentially diagnose normal transitory developmental symptoms from the more chronic, pervasive, and severe symptomatology of those suffering from clinically diagnosable personality disorders. While it is argued that the current criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; APA, 2000) for diagnosing borderline personality disorder are hard to differentiate from normal adolescent development and stress, some recent studies suggest the symptoms may have construct validity and can be reliability identified among adolescents (Becker, McGlashan, & Grilo, 2006; Bondurant, Greenfield, & Tse, 2004; Grilo et al., 1996; Ludolph et al., 1990). Yet others conclude that the diagnosis fails to demonstrate diagnostic stability (Bernstein et al., 1993; Bondurant et al., 2004; Meijer, Goedhart, & Treffers, 1998) rendering it useless as a clinical disorder for consideration. We suggest that these conclusions may be premature and that ignoring BPD as a possible disorder for consideration among adolescents may hamper effective clinical interventions. The purpose of this review article is to examine the reliability and validity of a BPD diagnosis in adolescence based on the current literature. Relevant articles evaluating the diagnosis of BPD in adolescents were identified by searching the PsychINFO database (1980 to present) using the terms: borderline personality disorder, borderline, adolescent(s), and personality disorder(s). Of the 205 articles identified, only those specifically reporting on the validity, reliability, and stability of BPD in adolescents and those comparing BPD in adolescents to adults with BPD were retained for the review. The article is divided into three sections. The first section provides a broad overview of the diagnostic criteria of BPD. In the second section, we focus on the questions in the field surrounding the reliability and validity of diagnosing BPD during adolescence. We briefly review data about temperament and personality development in adolescence, report epidemiological findings regarding prevalence of BPD among adolescents, and review research on the stability and specificity of a BPD diagnosis in adolescence. The final section summarizes the research and addresses several implications for adolescents and practitioners alike. 1. Borderline personality disorder diagnosis The term borderline was first used by Adolph Stern (1938) to describe a group of patients that fell between the psychotic and the neurotic groups. The term was used to describe patients who displayed psychotic thought processes and behavior under extreme stress and returned to healthier levels of functioning relatively quickly (Knight, 1953; Schmideberg, 1947). In the past six decades, numerous theorists and researchers have contributed their insight and research data in an effort to further expand our understanding and refine the term borderline. In fact, BPD has become the most widely researched and written about personality disorder to this day (Blashfield & Intoccia, 2000). An extensive review of each theory explaining BPD and its etiological processes is outside the scope of this article. Therefore, readers are referred to other sources for comprehensive reviews (e.g., Kernberg, 1967; Linehan, 1993). Despite decades of theorizing about borderline personality, the formal concept of BPD did not become an official part of the psychiatric diagnostic nomenclature until 1980 (DSM-III; American Psychiatric Association, 1980).

A.L. Miller et al. / Clinical Psychology Review 28 (2008) 969 981 971 Generally, successive editions of the DSM have strived for an empirical, atheoretical classification of BPD (Bleiberg, 1994). One goal of the DSM-IV-TR (APA, 2000) was to improve both the reliability and specificity of criteria sets defining personality disorders (Holdwick, Hilsenroth, Castlebury, & Blais, 1998), which has increased empirical studies of the diagnosis in both adults and adolescents. In the DSM-IV, nine criteria are cited for BPD, and only five need to be present to warrant a diagnosis. According to the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; APA, 2000), when personality traits become inflexible, maladaptive, and chronic, and cause significant functional impairment or subjective distress, they constitute a personality disorder, regardless of age. Note that DSM criteria emphasize onset of the disturbance is often traced to adolescence, suggesting that symptoms of the disorder are likely to be detectable at an early age. Supporting this notion, some studies have shown that specific features of BPD, such as self-harm or traits of impulsivity and affective instability present during childhood or adolescence, are predictive of receiving a BPD diagnosis as an adult (e.g, Siever, Torgersen, Gunderson, Livesley, & Kendler, 2002; Zanarini, Frankenburg, Hennen, Reich & Silk, 2006; Zanarini et al., 2006). Wording in the DSM continues to allow for personality disorder diagnoses in child and adolescent populations. Regarding age, the DSM-IV-TR states, personality disorder categories may be applied to children or adolescents in those relatively unusual instances in which the individual's particular maladaptive personality traits appear to be pervasive, persistent, and unlikely to be limited to a particular developmental stage or an episode of an Axis I disorder To diagnose a personality disorder in an individual under 18 years of age, the features must have been present for at least one year (APA, 2000, p. 687). The critical elements of this definition is that the identified BPD symptomatology is severe enough such that behavioral manifestations persistently interfere with an adolescent's daily functioning over the course of 1 year or longer. Assuming a comprehensive clinical assessment is conducted, the DSM-IV definition permits the diagnosis of BPD for adolescents; however it does remain vague, leaving much to clinical judgment. 2. BPD in adolescents Some clinical-researchers have questioned the validity of diagnosing a personality disorder in children or adolescents, reminding us that while personality disorders are defined as relatively enduring and pervasive patterns of experiencing, relating, and coping, children and adolescents are engaged in very fluid developmental processes (Bleiberg, 1994). Shapiro (1990) asserts that it is a mistake to use a diagnosis designed for adults that does not account for developmental issues of a stage of life, such as adolescence, which has more variability. Supporting this position, some researchers have provided evidence that diagnosis of BPD is not stable across the adolescent developmental period (Bernstein et al., 1993; Mattanah, Becker, Levy, Edell, & McGlashan, 1995), and that shifts in the symptom profiles among those adolescents meeting diagnostic criteria over time (Garnet, Levy, Mattanah, Edell, & McGlashan, 1994; Meijer et al., 1998) questions the validity and reliability of the diagnosis. Other clinical-researchers and personality theorists (e.g, Kernberg, 1990; Kernberg et al., 2000) assert that manifestations of personality disorders are often recognizable by adolescence or even earlier, and the DSM incorporates this notion within its personality disorder diagnostic criteria. To adequately highlight the question as to the existence of and potential value in diagnosing BPD in adolescents, one must first establish that adolescents have personalities that are relatively stable and influence adult functioning. It must also be shown that BPD is prevalent, can be reliably diagnosed, and has validity in adolescent populations. We will address each of these issues below. 3. Temperament and personality It is beyond the scope of this paper to provide a comprehensive review of the developmental literature addressing the connection between early temperament and personality, so readers are referred to Halverson, Kohnstamm, and Martin (1994) for a review, in addition to the more contemporary empirical sources referenced below. The current section will focus upon seminal and current findings elucidating this relationship. In order to conceive of adolescents having a personality disorder, such as BPD, one has to first assume that adolescents have a personality in general. It has been suggested that enduring personality patterns are apparent by the end of preschool (Kernberg et al., 2000). Numerous theorists purport that personalities, for the most part, congeal during adolescence (e.g., Mahler, Pine, & Bergman, 1975; Pine, 1985), which would imply that disruptions in normal personality functioning could be identified. For example, patterns of inflexible coping strategies and insecure

972 A.L. Miller et al. / Clinical Psychology Review 28 (2008) 969 981 attachment in the preschool years have been found to develop into persistent childhood characteristics that manifest themselves as depression, drug use, and criminal behaviors later in life (National Advisory Mental Health Council, 1995). The role of early temperamental characteristics in the development of adult personality structure has been extensively studied since the 1960s (Rothbart, Ahadi, & Evans, 2000). The growing body of literature on temperament and personality suggests that the main ingredients for the adult personality are present long before adolescence. Recent biological and genetic studies have contributed evidence that personality features, some representing symptoms of personality disorders such as BPD, are heritable (e.g., Siever et al., 2002; Torgersen, 2000) and could be identified as early as childhood. Additionally, studies of brain maturation processes in adolescent girls have provided evidence that adolescents with personality disorders, specifically BPD, demonstrate a deviant pattern of brain maturation (e.g., Houston, Ceballos, Hesselbrock, & Bauer, 2005). The current consensus is that temperament at infancy and early childhood is biologically driven and therefore highly predictive of basic personality traits during adulthood (Caspi, 2000). However, it is recognized that the social environment strengthens or weakens the degree of expression of each temperament domain (Rothbart et al., 2000), which may help to explain why similar temperamental styles can develop into either pathological or healthy personalities. Caspi and colleagues have conducted extensive empirical research addressing the connection between childhood temperament and adult personality (Caspi, 2000; Caspi et al., 2003). They have used data from the Dunedin study, which was an epidemiological investigation conducted in New Zealand over the course of 20-plus years, and included over 1000 participants who were followed from the ages of three through 26 years. Results over a 23-year period indicated that temperament-type at age 3 was predictive of adult personality structure, development of psychopathology, and engagement in antisocial behavior (Caspi, 2000; Caspi et al., 2003). When re-assessed in early adolescence (ages 13 15), those who were identified as undercontrolled were at far greater risk for subsequent externalizing disorders and those identified as inhibited were at far greater risk for subsequent internalizing disorders, which is consistent with previous findings (Bates, Wachs, & Emde, 1994). Additionally, those who had been identified as undercontrolled or inhibited at age three exhibited similar personality traits at age 18 as measured by the Multidimensional Personality Questionnaire (Tellegen & Waller, 1998). Specifically, those identified as undercontrolled scored higher on traits indicating negative emotionality and aggression, while those identified as inhibited scored higher on traits indicating constraint and harm-avoidance. These findings were maintained and replicated when participants were assessed at age 26 (Caspi et al., 2003). Results of Caspi et al.'s chain of longitudinal studies provide evidence that the foundations of adult personality and risk for psychopathology are laid and at least partially hardened well before adolescence. However, even those researchers who argue strongly for stability of personality over time recognize the importance of environmental and situational factors that impact development of personality and the behavioral manifestations thereof. Caspi (2000) made the point that temperament at age three does not perfectly predict actions or feelings at later ages, recognizing that the extent to which a person identifies with a personality characteristic may wax and wane somewhat over time. Even studies of individuals with BPD (e.g., Helgeland & Torgersen, 2004; Zanarini et al., 2006, 2006) find that environmental risk factors substantially contribute to the likelihood a child will manifest and retain a diagnosis of BPD as an adult above and beyond basic temperament. The view of personality during adolescence as malleable is consistent with a developmental psychopathology viewpoint, recognizing that adolescence is a time period associated with greater self and role experimentation and exploration. It is feasible that some aspects of personality and associated behaviors will fluctuate over time. Yet, research appears to indicate that some personality traits are relatively stable. It may be the extent to which the trait is expressed that varies given different environmental influences rather than the actual presence of the trait. Research conducted by McCrae et al. (2002) highlights both the stability and fluidity of adolescent personality development. McCrae et al. (2002) administered the NEO-FFI (Costa & McCrae, 1992) to 230 students between the ages of 10 and 13 years and again 4 years later. The authors note that the factor structure was not equivalent across time points, but was stable. Results also indicated relatively modest (r ranged from.31 to.63) test retest reliability of each personality domain across 4 years, leading the authors to conclude that these relatively low stability correlations point to the fluidity of personality characteristics over the ages of 12 16 years. At the same time, McCrae et al. also found that between 50 and 60% of the participants displayed no significant change in their personality domain scores over the 4-year period, implying stability in global personality. In summary, the degree to which adolescents endorsed each personality structure may have fluctuated depending upon the specific type of experiences undergone during

A.L. Miller et al. / Clinical Psychology Review 28 (2008) 969 981 973 adolescence. However, regardless of experience, mean levels of the main personality domains (extraversion, agreeableness, and conscientiousness) remained relatively stable. This suggests that core personality traits likely persist across developmental periods, as well as, exert an influence on behaviors or emotional experiences throughout a person's lifetime. In summary, the temperament literature indirectly supports validity of considering diagnosing BPD in adolescents since the research data suggest that personality traits remain relatively stable from childhood through adulthood. At the same time, some studies suggest variability in personality traits during adolescence, which may render the assumption of BPD as a persistent disorder invalid for adolescents. Inferring from the temperament data, it appears possible that there may be some adolescents for whom a personality disorder could develop and remain stable, whereas there may be other adolescents for whom the presentation of personality disorder symptoms may be transient. Hence, while caution should be utilized when assessing for BPD among this age group, it could be appropriate to diagnose BPD in adolescents based on point-in-time symptom presentations so that interventions can occur before the maladaptive personality characteristics are further solidified in adulthood. An in-depth review of the literature evaluating the presence and utility of diagnosing BPD in adolescence follows below. 4. Prevalence of BPD Historically, most epidemiological studies of psychiatric disorders in adolescents do not search for the presence of personality disorders (Kernberg et al., 2000), much less one as stigmatized as BPD. However, researchers are beginning to consider the possibility of detecting borderline symptoms in adolescents and a handful of studies suggest that it may be more prevalent then originally thought. Research has also supported this notion. For example, Lewinsohn, Rohde, Seeley, and Klein (1997) assessed 299 subjects between ages 14 and 18 and then at age 24, finding that early manifestations of some Axis II disorders, particularly BPD, were present by adolescence. In an early study, Marton et al. (1989) found that 30% of their depressed inpatient and outpatient adolescents met full criteria for BPD. However, generalizability of this prevalence rate is limited to a clinical sample. Bernstein et al. (1993) conducted a community-based longitudinal investigation of 733 youths ranging in age from 9 to 19 years. When the group reached a mean age of 16.3, at least one diagnosis of a moderate DSM-III-R personality disorder (defined as symptoms that were more than one standard deviation above the mean on continuous symptom scales, pg. 1238) was received by 31.2% of the subjects, 10.8% of which had BPD. While these findings appear to suggest a high prevalence of BPD pathology in adolescents, these results must be interpreted with some skepticism. The findings that approximately 1/3 of adolescents meet diagnostic criteria for an Axis II disorder or BPD are suspect, especially given the low prevalence rates listed in the DSM (APA, 2000). One explanation for the inflated prevalence is that the current DSM criteria are not valid for use with adolescents, leading to a high rate of false positives. Additionally, some of the methodology is questionable. In Bernstein et al.'s (1993) study, the authors created their own measures by selecting items from a handful of existing diagnostic interviews and selfreport measures rather than using already established measures. The fact that internal consistency of their Axis II measures ranged from.42 to.70 (α=.65 for BPD) suggests somewhat unreliable measurement of the symptoms. They also generated diagnostic algorithms unique to their study that did not always coincide with DSM decision points. Still, the results are somewhat supportive of the notion that BPD may be detectable in adolescence given sound assessment procedures. More recently, Chabrol, Montovany, Chouicha, Callahan, and Mullet (2001) surveyed over 1300 French high school students using the Screening Test for Comorbid Personality Disorders (STCPD; Dowson, 1992) and Revised Diagnostic Interview for Borderlines (DIB-R; Zanarini, Gunderson, Frankenburg, & Chauncey, 1989) estimating an overall frequency for BPD of 14% with diagnostic peaks in early and late adolescence. However, the sample that volunteered to complete the full diagnostic protocol (n=107) was significantly smaller than the total sample and could influence the estimation procedure. There is also a great likelihood of selection bias, which may have skewed the prevalence rates. In a similar study of 616 high school adolescents, Chabrol et al. (2004) found that 6% of their sample met the cut-off criteria on the Borderline Personality Inventory (BPI; Leichsenring, 1999) for receiving a BPD diagnosis. In a large epidemiological study, Zanarini (2003) reports 3.3% of the 10,000 11 year-olds assessed in Great Britain met full diagnostic criteria for BPD. These numbers are closer to, yet still higher than, the estimated 2% prevalence rate for BPD found in adults in the general population (APA, 2000). This slight difference could imply a potential for children and adolescents to mature out of the BPD diagnosis prior to or within adulthood especially if

974 A.L. Miller et al. / Clinical Psychology Review 28 (2008) 969 981 treatment is sought. Yet, it might also suggest that the BPD criteria are over-inclusive of symptoms that characterize the developmental period of adolescence. Another limitation to trusting the prevalence estimates inherent in all these studies is that the data are cross-sectional, which precludes detecting whether the prevalence rates vary within or across years. Research suggests that among juvenile delinquents (Eppright, Kashani, Robinson, & Reid, 1993) and inpatient adolescent populations (Grilo et al., 1995; Myers, Burkett, & Otto, 1993), females are significantly more likely to meet criteria for BPD than are males, even when controlling for depression. Rates of BPD in conduct disordered female adolescents and psychiatric inpatient samples range from 31% to 61%, while those of their male counterparts range from 0% to 39% (Eppright et al., 1993; McManus, Brickman, Alessi, & Grapentine, 1984; Myers et al., 1993; Pinto, Grapentine, Francis, & Picariello, 1996). This sex difference, however, was not demonstrated in an adolescent community sample, in which 11% met diagnostic criteria for BPD with no significant sex difference (Bernstein et al., 1993). Similarly, Chabrol et al., 2004 found an equal number of males and females meeting cut-off criteria for BPD in their sample of community adolescents. These disparate findings may suggests that BPD manifests itself differently among those seeking treatment and those in the community, or the sex differences may reflect differences in the numbers of females hospitalized, or a gender bias towards diagnosing females with BPD. However, the majority of findings regarding differences between sexes in BPD among adolescents are comparable to adult prevalence rates. Finally, Kasen, Cohen, Skodol, Johnson, and Brook (1999) investigated the relationship between childhood psychopathology and adult personality disorders in a sample of 551 youth age 9 to 16 years. Subjects were evaluated for DSM-III-R psychiatric disorders at three points over 10 years. Results indicated that a diagnosis of an adolescent personality disorder predicted young adult personality disorder within the same cluster independent of Axis I diagnosis. In addition, comorbidity of Axis I and Axis II disorders significantly heightened the odds of young adult personality disorder. Crawford, Cohen, and Brook (2001a,b) found very similar results for cluster B disorders over the course of 8 years in a community sample of adolescents, indicating that diagnosing personality disorders such as BPD during adolescence may not only be valid, but also may help inform treatment to prevent a chain of maladaptive behaviors from developing or becoming ingrained. 5. BPD and reliability Utilizing structured diagnostic interviews based on DSM-symptom criteria, research-clinicians report adequate inter-rater reliabilities (.85.88; Becker et al., 1999; Blais, Hilsenroth, & Fowlder, 1999; Garnet et al., 1994) for diagnosing BPD in adolescent samples, demonstrating that BPD can be reliably identified in adolescents. Additionally, factor analytic studies have demonstrated that structure of the BPD diagnosis can be replicated across samples (e.g., Becker et al., 2006; Chabrol et al., 2004). However, stability is a key defining feature of personality disorders (DSM- IV) (Grilo, Becker, Edell, & McGlashan, 2001, p. 366). Therefore, empirical studies of the persistence (i.e., temporal stability) of BPD would clarify concerns regarding the reliability of the diagnosis in adolescence. Studies informing this issue are presented below. Some research, using primarily community samples, has suggested that BPD is prevalent in adolescents and has concurrent validity (i.e., is a valid indicator of distress and dysfunction), but is relatively unstable over time (e.g., Bernstein et al., 1993; Bondurant et al., 2004; Korenblum, Marton, Golembeck, & Stein, 1990; Mattanah et al., 1995). This suggests that BPD in adolescence may reflect a point-in-time disturbance rather than chronic impairment (Levy et al., 1999). Supporting this view is Bernstein et al.'s (1993) community study of 733 youth, who were followed over a 2-year period to assess the prevalence and stability of personality disorders (PD) in adolescents. To ensure a comprehensive assessment of PD symptomatology, both a parent and the identified adolescent completed study measures. As mentioned earlier, slightly more than 48% of the adolescents received a diagnosis of an Axis II disorder, and 10.8% met criteria for BPD. At the 2-year follow-up, Bernstein and colleagues found that a diagnosis of moderate BPD (i.e., 1 SD above the mean on continuous measures of BPD) had a persistence rate of 29%, whereas a diagnosis of severe BPD (i.e., 2 SD above the mean on continuous measures) had a persistence rate of 24%. These findings indicate that BPD did not persist over time for most adolescents, although the diagnosis did remain for a clinically significant number of adolescents. Additionally, a majority of adolescents who no longer met full criteria still retained a sub-clinical number of symptoms. This could suggest that BPD symptoms are present but less persistent in adolescents or that the developmental nature and changes affiliated with adolescence are mistaken for BPD, which would render the current diagnostic criteria invalid for adolescents. However, these findings must be interpreted with

A.L. Miller et al. / Clinical Psychology Review 28 (2008) 969 981 975 caution, given the limitations of the methodology discussed earlier (e.g., use of self-created questionnaires to assess BPD symptoms). The methodological limitations may have also resulted in inflated rates of BPD in the sample at both assessments. Similar results were found by Meijer et al. (1998) within a sample of inpatient adolescents who were followed over 3 years. At the index hospitalization 17 (of 54) adolescents met criteria for BPD. At 3-year follow-up, only two of the 14 adolescent inpatients available for re-evaluation retained their baseline BPD diagnosis. However, the authors note that many continued to meet a sub-threshold number of BPD symptoms, which suggests that a sub-clinical level of disturbance associated with borderline personality dysfunction may persist over time. These results further support the idea that BPD symptoms as currently defined by the DSM are detectable in adolescents, and may indicate the potential for at least a mild degree of life-long disturbance in personality. A caveat to this study is that the sample is quite small, and a large number of participants were lost during follow-up. The limitations of the sample and attrition rates may have biased the results and greatly reduces their generalizability. In addition, the adolescents were inpatients so they received some form of treatment that may have had a positive effect on their symptoms resulting in a decrease of the presence of BPD at follow-up. Subsequent studies of psychiatric adolescent populations suggest that although persistence rates are generally low, they are consistent with those found in adult samples. For example, Zanarini, Frankenburg, Hennen, and Silk (2003) studied 362 adult inpatients over a 6-year period finding that 73.5% of those with BPD no longer met diagnostic criteria at follow-up. These findings were consistent with those reported by Paris, Brown, and Nowlis (1987), who found that after 15 years, only 25% of their sample continued to meet BPD criteria. In a sample of 668 inpatient and outpatient adults, Shea et al. (2002) found that only 41% meeting BPD criteria retained the diagnosis after 12 months. Important in their findings was a treatment by time interaction demonstrating that the longer one was in treatment the less likely one was to retain a BPD diagnosis. Recently, Zanarini, Frankenburg, Hennen, Reich, and Silk (2005), Zanarini et al. (2006, 2006) reported results of their 12-year longitudinal study of adults with BPD. A notable finding was that 88% of patients obtained remission of BPD symptoms over a 10-year period and once remitted, recurrence of symptoms occurred in only 6%. Zanarini et al.'s results led them to conclude that remission is more common and stable than originally believed, indicating that BPD may not be as constant a dysfunction as originally believed. Of note, Zanarini et al. (2005) were able to identify symptoms that were slower to remit (e.g., chronic anger, abandonment fears) and characterized the symptoms as those of temperament, which may suggest that temperamental/personality-based features of BPD have greater stability. Future research will need to explore this hypothesis. Taken in summary, the current research indicates that BPD is not particularly stable in adult samples either, and that symptoms are likely to be reduced through treatment efforts to a sub-clinical or non-clinical level of dysfunction. The fact that most studies examining persistence of BPD over time include individuals who are seeking treatment limits current conclusions regarding the reliability of the diagnosis over time because treatment has been shown to reduce the persistence of BPD symptoms over time (e.g., Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan et al., 2006; Linehan, Tutek, Heard, & Armstrong, 1994). Thus, longitudinal research on the stability of BPD in nontreatment seeking samples is needed to accurately establish temporal stability, but poses ethical concerns. Despite reports of low temporal stability, there appears to be a subset of adolescents for whom the diagnosis remains over time, as with adults. Garnet et al. (1994) examined the stability of BPD in a severely ill adolescent inpatient population. They examined 21 adolescent inpatients ranging in age from 15 19 years diagnosed with BPD and substantial comorbidity. Results demonstrated that while 33% of adolescents met BPD diagnostic criteria at 2-year follow-up, actual symptom profiles did not remain consistent. Whereas the percent of patients with borderline personality disorder at follow-up who met the criterion at baseline (i.e., average sensitivity) was high (84%), the average specificity for individual BPD criteria in predicting BPD at the final assessment was low (18%). These findings suggest that specific indicators of BPD may shift in their relative importance to the diagnosis for adolescents, but that the diagnostic construct of BPD remains intact. These results appears to mirror findings regarding general personality structures in adolescents (see Caspi et al., 2003; McCrae et al., 2002 discussed earlier), suggesting that clinicians may need to consider core dysfunctional areas of BPD (e.g., identity disturbance, affective instability, relationship difficulties, impulsivity) to achieve an accurate diagnosis rather than each unique symptom. Given the small sample size and specialized population of adolescents in Garnet et al.'s (1994) study, all results need to be interpreted with caution. A study conducted by Chabrol et al. (2004) examining the factor structure of the Borderline Personality Inventory in a community sample of adolescents supports the notion that the core elements of the BPD diagnosis have moderate stability for adolescents. Specifically, the researchers found that their 6-factor structure did not differ across

976 A.L. Miller et al. / Clinical Psychology Review 28 (2008) 969 981 age groups (15 19 years) in a cross-sectional comparison of participants. However, the individual items comprising each factor showed some variability across the age groups. Thus, it appears the global constructs of BPD may have some stability across the adolescent developmental period while individual symptoms may vary in their presentation. More recently, Grilo et al. (2001) examined the dimensional stability and change of DSM-III-R personality disorders using the Personality Disorder Examination (PDE) in 60 adolescent psychiatric inpatients followed up 2 years after hospitalization. Borderline personality disorder was the most frequently diagnosed among participants at both the index assessment and at follow-up. Similar to Garnet et al.'s (1994) results regarding the stability of individual BPD symptom criteria, Grilo et al.'s results indicated that the dimensional stability of BPD in adolescents was low (i.e., ICC =.16). Analysis of the difference in mean BPD symptoms from index to follow-up revealed that symptoms actually improved over time, which may have been due to the treatment subjects were receiving on the inpatient unit. Thus, the apparent lack of stability may be an artifact of an effective treatment response rather than limited diagnostic stability. Additionally, the authors point out that they did not obtain test retest reliability on their measure of BPD, which may have led to an underestimation of diagnostic stability. Crawford et al. (2001a) examined the dimensional stability of cluster B symptoms over an 8-year period in a sample of 408 community adolescents who were not receiving treatment. Results indicated cluster B symptoms have moderate stability (.63 for boys,.69 for girls) across time. Interestingly, the stability estimates for cluster B symptoms were drastically reduced when assessed as categorical diagnoses, which suggests there may be stability of personality dysfunction in adolescents that is better detected using a dimensional approach due to the fluid developmental period of adolescence. However, a significant weakness to Crawford et al.'s study is that they created their own symptom scales by pulling items from a range of existing measures. As such, their results are difficult to compare with previous findings that used already established tools to assess BPD. Finally, Chanen et al. (2004) assessed stability of personality disorder diagnoses among adolescent outpatients (n=101) over 2 years using the SCID-II, which allows for both categorical and dimensional assessment of BPD and other PDs. Eleven of the 101 participants met criteria for BPD at baseline, and 12 of 96 participants met criteria for BPD at follow-up. Keeping in mind the limitations of their small BPD sample size, results offer mild support the dimensional stability of BPD in adolescents. The categorical stability of meeting criteria for BPD at both baseline and follow-up was low (ICC =.28), which may have been due to low levels of inter-rater reliability of the categorical ratings of the PDs. However, consistent with Crawford and colleagues' work, Cluster B symptoms showed moderate stability across time (ICC =.61, r=.63). Both the mean level stability (ICC =.54) and the rank order stability (r=.54) of BPD over 2 years were moderate. The dimensional and rank order stability indicators of BPD among this adolescent sample are similar to those found in previous studies of both clinical and community adolescents (Bernstein et al., 1993; Grilo et al., 2001). Given the research reviewed, it appears that BPD symptoms can be reliably detected and diagnosed in adolescent samples. The temporal stability of BPD in adolescents is less clear, but the research seems to suggest that for a small, but clinically significant portion of adolescents, BPD symptoms persist into adulthood. Current conclusions regarding temporal stability are tenuous given methodological limitations and confounding effects of treatment. Additional longitudinal studies are needed to examine the reliability of the BPD diagnosis across time among individuals who do not receive treatment to obtain a more accurate estimate of diagnostic stability for BPD. However, the existing evidence points to BPD as a potentially reliable and stable diagnostic entity for adolescents. 6. BPD and validity Validity refers to the issue of whether the diagnosis of a personality disorder in adolescence measures what it is intending to measure. One issue preventing adoption of BPD as an acceptable disorder of adolescence is the argument that many symptoms of BPD may in fact fall within a range of normative developmental behaviors for adolescents. It is important to note that the field does lack clear, specific indicators to differentiate normative behavioral and emotional disruption from pathological disruptions, but this is true for most DSM-IV diagnoses. Again, the critical differentiating features of a personality disorder in adolescents are whether the severity and persistence of the dysfunctional behavioral and emotional symptoms persist over time (e.g., more than one year) and interfere with daily functioning. Researchers exploring the construct validity of BPD in adolescents point to the consistent relationships found between BPD and associated areas of dysfunction and distress as evidence of diagnostic validity (e.g., Becker et al., 2006; Chabrol et al., 2002). Levy et al. (1999) investigated both concurrent and predictive validity of personality

A.L. Miller et al. / Clinical Psychology Review 28 (2008) 969 981 977 disorder diagnosis in adolescents via baseline and 2-year follow-up assessments of 142 inpatient adolescents on various clinician-rated and self-rated measures of distress and dysfunction. From the total sample, 86 participants were diagnosed with a personality disorder; 71(89%) with BPD, so it is being assumed that the results pertain most closely to a diagnosis of BPD. Consistent with other research, support was found for the concurrent validity of a personality diagnosis in adolescent inpatients. At baseline, adolescents with a personality disorder (e.g., BPD) were more functionally impaired as measured by Global Assessment of Functioning Scale scores than those without a personality disorder. Additionally, adolescents with a personality disorder scored significantly higher on 10 of the 12 SCL-90-R subscales, indicating that a diagnosis of BPD is associated with the expected functional impairments. At follow-up, adolescents with a BPD diagnosis were more likely to have low GAF scores and score as more impaired on the SCL- 90-R than those without a diagnosis, although they demonstrated significant reductions in their dysfunctional symptoms over the 2-year time period. This finding provides moderate evidence of predictive validity for a personality disorder diagnosis, such that having BPD is somewhat predictive of future impairments. Bernstein et al. (1993) reported similar findings. Youth for whom a BPD diagnosis remained over the course of 2 years had significantly greater odds (OR =1.3 to 6.0) of experiencing the following difficulties: 1) social impairment as evidenced by fewer and shorter friendships, less enjoyment of others, a lack of a confidant, the absence of a romantic relationship, and fewer social activities; 2) school or work problems (repeating a grade or dropping out of school); 3) a comorbid Axis I diagnosis; and 5) contact with the police for antisocial behavior. Recently, Crawford et al. (2001b) examined the relationship between cluster B symptoms and internalizing and externalizing disorders in 407 community adolescents. Results demonstrated moderate to strong associations (.27 to.68) between cluster B personality dysfunction and both internalizing and externalizing symptoms that persisted over an 8-year period. In a sample of nonclinical adolescents, Chabrol and Leichsenring (2006) reported that adolescents meeting diagnostic criteria for BPD were also more likely to exhibit aspects of antisocial behavior as well as traits of callousness and impulsivity. These findings indicate that personality dysfunction, such as BPD, is closely tied to additional psychological disturbances from early adolescence into young adulthood. However, the high amount of comorbidity experienced by the adolescents in these samples limit the ability to attribute future impairments solely to the BPD diagnosis. Becker et al. (1999) examined validity of a BPD diagnosis in adolescent and adult inpatients by evaluating internal consistency and criterion overlap. Results suggested that BPD criteria in adolescents tended to have moderate internal consistency (α =.76) that was comparable to their adult participants (α =.74). Mean inter-criterion correlations were low, but also similar across adolescent and adult groups (.28 for adolescents,.26 for adults). Discriminant validity was adequate and similar between the adolescents and adults as evidenced by low diagnostic overlap measured through inter-category mean inter-criterion correlations (.07 for adolescents,.06 for adults). Through group comparisons, the authors concluded that internal consistency and discriminant validity of BPD criteria were lower for adolescents when compared to adults. However, they failed to correct for multiple comparisons and considered p-values of.076 to.150 to be evident of significant differences. If one utilized the standard p-value of.05 to indicate significance, a reinterpretation of Becker et al.'s results is that personality disorder criteria appear to exhibit adequate internal consistency and discriminant validity for adolescents that are comparable to adults. Using conditional probability analyses to evaluate diagnostic efficiency of BPD criteria between adolescent and adult inpatients, Becker, Grilo, Edell, and McGlashan (2002) found no significant differences in the base rates of BPD between the adolescents and adults, nor any of the BPD criteria. Although, Becker et al. noted the best inclusion/ exclusion criterion symptom did differ between the adolescent (abandonment fears/uncontrolled anger) and adult (all symptoms/impulsiveness) participants. They concluded that the diagnostic criteria for BPD appear to be valid for use with adolescents, contributing to accurate and efficient diagnostic conclusions. In a small chart review study (n = 40), Segal-Trivitz et al. (2006) found that adolescents and adults diagnosed with BPD were highly similar on both diagnostic and treatment characteristics. The only differences that emerged between groups were that adolescents were more likely to have current self-mutilation and obsessive compulsive symptoms whereas adults were more likely to report alcohol abuse. These studies suggests that the diagnostic criteria of BPD may have similar validity in adolescent samples as they do in adult samples, although additional research is needed to fully establish this point. The predictive validity of BPD symptoms has demonstrated more equivocal findings. In Levy et al. (1999) study, the predictive validity of BPD was modest; BPD diagnosis during adolescence did not predict greater impairment according to the Global Assessment of Functioning Scale or the SCL-90-R, but it was related to later drug use and to future psychiatric hospitalization. The authors caution that the general lack of predictive validity in their study may have been due to insensitive measures and the DSM's lack of attention to the developmental complexities of

978 A.L. Miller et al. / Clinical Psychology Review 28 (2008) 969 981 adolescence. Their sample of adolescents meeting BPD criteria was also low, reducing the power to detect small effects. Other researchers have provided evidence of a moderate degree of predictive validity for BPD in adolescent samples. For example, adolescents diagnosed with BPD at baseline continued to experience some level of affective disturbance or behavioral disruption (Crawford et al., 2001b; Meijer et al., 1998) even when they no longer met full diagnostic criteria for BPD. The findings that functional impairments persisted among adolescents who no longer met BPD criteria, particularly for affective disturbances, is consistent with findings in the adult literature (Shea et al., 2002; Zanarini et al., 2003). In their 8-year longitudinal study of cluster B dysfunction among adolescents, Crawford et al. (2001b) demonstrated that the presence of cluster B symptoms in early adolescence (age 10 14) was strongly and directly related to cluster B symptomatology in young adulthood (age 17 24), indicating that identified personality dysfunction in adolescence is predictive of later adult personality disturbance. However, these results provide only indirect support of the predictive validity of BPD from adolescence to adulthood because BPD was subsumed under the general cluster B criteria, and was not specifically assessed. Still, these data appear to support the validity of a BPD diagnosis over time in adolescents. Researchers have also evaluated the sensitivity and specificity of individual symptom criteria in predicting BPD diagnosis over time, finding similar results in adolescent and adult samples. For example, Garnet et al. (1994) found that symptoms with the highest predictive power (i.e., most stable symptoms) for adolescents were chronic emptiness or boredom (100% agreement) and inappropriate, intense anger (86% agreement). Interestingly, inappropriate, intense anger, suicidal behaviors, identity disturbance, and emptiness or boredom had 100% negative predictive power, accurately predicting the absence of a BPD diagnosis at 2-year follow-up. Additional studies have also consistently identified symptoms of identity disturbance, affective instability, and inappropriate, intense anger as having the greatest predictive power for BPD in adolescents (Becker et al., 2002; McManus, Alessi, Grapentine, & Brickman, 1984; Meijer et al., 1998; Pinto et al., 1996). The positive predictive power of these three symptoms is almost identical to those identified in the adult BPD literature (Becker et al., 2002; Blais et al., 1999), suggesting that apparent key symptom criteria are valid across age groups. The literature investigating validity of BPD in adolescence is an emerging body and at present is limited to those studies discussed above. The research reviewed provides preliminary, but not conclusive, evidence of concurrent and predictive validity for BPD. Construct validity of a BPD diagnosis can be approached via the study of comorbidity (Becker, Grilo, Edell, & McGlashan, 2000). BPD has been associated in the literature with depression, substance abuse, conduct disorder, and PTSD, with some studies providing evidence that BPD in adolescents can be reliably distinguished from other Axis I disorders (Becker et al., 2006; Chabrol et al., 2002; Grilo et al., 2001; Pinto et al., 1996). However, others note that there is substantial overlap among the individual symptom criteria of BPD and other Axis I and Axis II disorders (Becker et al., 2000; Crawford et al., 2001a); thus, additional research is needed to further establish the validity of BPD in this age group. At this time, evidence appears to be suggesting that BPD may be both a reliable and valid diagnostic entity for adolescents; however, additional research is needed to before strong conclusions can be made. 7. Summary In summary, diagnosis of BPD in adolescents has historically been a controversial issue. We believe that this article sheds some light on the questions regarding whether the diagnosis of BPD has utility for adolescents. Given the empirical literature reviewed, there appears to be preliminary support for the existence of BPD in adolescents. Interpreting these initial studies with caution, we find that prevalence, reliability, and validity of BPD in adolescent samples is adequate and largely comparable to those found among adult samples. Such comparability in and of itself may suggest that BPD, as a global disorder, operates in a similar fashion and has a similar course regardless of age and developmental period. However, we recognize that the literature suggests that individual symptom presentation is likely to vary substantially over time, particularly among adolescents. Studies also clearly indicate that while there is a legitimate subgroup of severely affected adolescents for whom the diagnosis remains stable over time, there appears to be a less severe subgroup that moves in and out of the diagnosis. Rate of diagnostic stability of BPD in adolescents is comparable to that in adults and a select few symptom criteria have consistently emerged as significant predictors of BPD retention in both adolescents and adult samples (e.g., Zanarini et al., 2006, 2006). Consequently, one implication is that it may be beneficial to conceptualize personality disorders in adolescents from a dimensional/continuous rather than categorical approach, as a dimensional approach may better account for the developmental variability and the heterogeneity found among adolescents.

A.L. Miller et al. / Clinical Psychology Review 28 (2008) 969 981 979 Based upon the current literature, we believe that mental health practitioners should strongly consider formally assessing for personality disorders, either categorically or continuously, when working with adolescents. Regardless of presence of a full-fledged disorder, borderline personality disorder symptoms (even if fewer than 5) in adolescents may indeed accurately reflect significant distress and dysfunction (e.g., suicidality, self-cutting, identity disturbance, academic failure, social dysfunction, and substance abuse) that requires intervention. We recognize that there is negative stigma associated with the diagnosis and that this poses a serious concern with regards to using the diagnosis. However, stigma should not preclude clinicians from assessing for the disorder and carefully considering the diagnosis when warranted. 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