We’re getting there. So let’s move along!
Identity
Disturbance in Borderline Personality Disorder: An Empirical Investigation –
Part 3
Tess Wilkinson-Ryan, A.B.; Drew Westen, Ph.D.
RESULTS
The patients described by the clinician respondents ranged
in age from 18 to 66 years. We initially intended simply to compare patients
with borderline personality disorder (N=34) to patients without the disorder.
However, when we examined the data, we found that the nonborderline group
(N=61) included 20 patients diagnosed by their clinicians with personality
disorders other than borderline personality disorder, which allowed us to test
hypotheses more conservatively. Although the reliability of the "other
personality disorders" category is unknown, we were able to assess whether
these patients differed in their general social adjustment and level of
psychopathology from the subjects with no personality disorder. In any event,
diagnostic unreliability and smaller group sizes would foster type II, rather
than type I, errors; thus, any findings that emerged with this three-group
comparison would be very conservative. Given the preliminary nature of this
study, which constitutes the first (to our knowledge) systematic effort to
explore the precise nature of identity disturbance in patients with borderline
personality disorder, this conservatism seemed warranted. As a secondary
analysis, we ran analyses with just two groups (borderline personality disorder
versus no borderline personality disorder). The results were the same or
stronger in all cases, so here we report the more conservative findings.
In short, they took the safe approach to get the most accurate
comparison between Borderline and Non-Borderline groups.
As expected, gender ratios differed somewhat among the
groups. In the borderline personality disorder group, 82.4% of subjects (N=28)
were female, which resembles the gender ratio for this disorder in the
population (approximately 75%, according to DSM-IV). Half of the subjects with
other personality disorders were female; the corresponding percentage in the no
personality disorder group was 65.9% (N=27). Thus, we used sex as a covariate
in subsequent analyses.
To distinguish patients with borderline personality
disorder from other patients, we first asked clinicians to fill in an axis II
diagnosis. As a validity check, we then asked them to 1) indicate whether each
of the nine DSM-IV criteria for borderline personality disorder was present or
absent, 2) rate the extent to which the patient showed symptoms of borderline
personality disorder as well as symptoms of each of the other axis II
personality disorders, and 3) report on level of functioning (Global Assessment
of Functioning scores, employment history, and number and quality of peer
relationships).
Data relevant to diagnostic reliability for the 95
subjects are presented in t2.
To be diagnosed with borderline personality disorder, a patient must manifest
at least five of the nine DSM-IV criteria. In this study, patients diagnosed
with borderline personality disorder fulfilled an average of 7.4 criteria.
Patients with other personality disorders or no personality disorder averaged
fewer than five. Differences among these means were statistically significant.
Similar findings emerged when we compared the severity ratings of each
borderline personality disorder criterion.
Standard DSM you
have BPD, stand you don’t have BPD.
To compare personality pathology, we averaged all the
personality disorder symptom ratings for the three groups for each of the 10
personality disorders, which produced a composite index of the extent to which
patients in each group had personality disorder symptoms of any kind. As
expected, the borderline personality disorder group had the highest mean
ratings, followed by the subjects with other personality disorders and then
those with no personality disorder. The differences among these means were significant.
As a specific validity check on the diagnosis of "other personality
disorders," we then recomputed these means excluding borderline
personality disorder symptom ratings. Post hoc comparisons revealed significant
differences but only between the no personality disorder group on the one hand
and both personality disorder groups on the other. Thus, both personality
disorder groups appeared to score higher on personality disorder
characteristics than the no personality disorder group, and the borderline
personality disorder group was specifically higher than both other groups on
borderline characteristics.
This is all about comparing averages if you’re interested in
averages. BPD “wins” on having more disordered traits, yay us, compared to
people without BPD and people with “other personality disorders”.
Level of functioning variables also provided support
for diagnostic reliability. Mean scores on the Global Assessment of Functioning
were significantly different for the three groups as were the quality of peer
relationships and the number of close relationships; employment stability,
however, did not differ.
One peculiarity of the data did emerge: 19.7% of the
patients without borderline personality disorder (N=12, split roughly evenly
between the subjects with other personality disorders and those with no
personality disorder) fulfilled five borderline criteria. We suspect this
reflects both the high comorbidity of borderline personality disorder with nearly
all other personality disorders and the tendency of clinicians to prioritize
axis II diagnoses, giving such diagnoses as "narcissistic personality
disorder with borderline features". We addressed this in two ways. First,
in line with our strategy of minimizing type I errors and maximizing
conservatism of the findings, we kept patients in the diagnostic categories to
which clinicians assigned them. If some subjects with no personality disorder
really met borderline personality disorder criteria, that would reduce mean
differences between the two groups, not overestimate them. Second, as planned,
we supplemented categorical analyses with continuous analyses, with number of
borderline criteria as the dependent variable, and used multiple regression to
predict the number of borderline personality disorder criteria from identity
factor scores. Thus, our findings are applicable not only to categorical but to
dimensional analyses of borderline personality disorder symptoms.
There is no way you’re going to be classified as having BPD in this
study if you don’t actually have it. Really? It’s true. They’re being super
stringent.
The prevalence and confirmation of abuse history for
the patients are reported in t1.
Of the 24 clinicians who marked "Yes" on the sexual abuse question,
all reported confirmation from at least one outside source. Four clinicians who
completed this section marked the sexual abuse history as "Unsure."
None of these four patients entered treatment with clear, conscious memories or
documenting evidence of abuse. The data thus suggest that clinicians were using
sensible (although of course not infallible) algorithms in determining degree
of likelihood of sexual abuse history.
Hmmm. I wonder if they were correcting for sexual abuse in
childhood, adolescence, or adulthood. I have a history of sexual abuse, but not
in childhood. My BPD symptoms were already full blown by the time that
happened. Either way, I’m sure it has a significant effect. I know it affected
me.
To ascertain the extent to which our measure of
identity disturbance was really capturing the construct it was designed to
assess, we used clinicians’ ratings of whether the identity disturbance
criterion from DSM-IV was present or absent, which divided patients into two
groups. We then compared the mean ratings for each identity disturbance item
for these two groups in an effort to assess the extent to which our items were
capturing the same construct clinicians classify as identity disturbance.
Twenty-eight of the 35 items significantly discriminated between patients with
and without identity disturbance at the 0.05 level (conservatively using
two-tailed tests, even though predictions were directional), which indicates
that our items did in fact address identity disturbance as clinicians conceptualize
it.
Yay the tests work!
The items that did not predict identity disturbance
tended to describe unusual phenomena with low base rates, such as "patient
‘displays’ identity in ways that appear unusual or deviant (e.g., multiple
tattoos, piercings, highly peculiar hair style or coloring)," on which
most subjects received a rating of "1." Although deviant appearance
may be an indicator of identity disturbance in the general (or psychiatric)
population, our study group size may not have been large enough to detect this.
I like this quite a bit actually. Tattoos, piercings, crazy hair,
and things like that did NOT indicate identity disturbance! That’s absolutely
fabulous. Well, not really anyways.
Distinguishing Identity Disturbance in Borderline Personality
Disorder: Item, Factor, and Construct Analyses
To examine the nature of identity disturbance in
borderline personality disorder, as a first step we compared means for each
item for patients with borderline personality disorder with means for each of
the other two diagnostic groupings (t3).
To be conservative, we only considered those items that distinguished borderline
personality disorder from both of the other groups as clear markers of
borderline identity disturbance, again by using two-tailed tests despite
directional hypotheses. Thirty-two of the 35 items distinguished subjects with
borderline personality disorder from those with no personality disorders; of
these, 17 items also distinguished subjects with borderline personality
disorder from those with other personality disorders. Thus, the data suggest
that robust differences do exist between patients with borderline personality
disorder and other patients, whether or not they have a personality disorder.
It is important to note that the data did not support potential concerns about
clinician response bias. Respondents did not simply give high ratings to all 35
indicators of identity disturbance if they had diagnosed the patient with
borderline personality disorder and give low ratings otherwise; over half
the items that discriminated patients with borderline personality disorder
from those with no personality disorder did not discriminate patients with
borderline personality disorder from those with other personality disorders,
who clinicians clearly identified as nonborderline.
To discern whether identity disturbance was a unitary
or multidimensional construct they went on to determine a variety of factors.
1. The first factor was role absorption, in which
patients appeared to absorb themselves in, or define themselves in terms of, a
specific role, cause, or unusual group.
2. The second factor, painful incoherence, reflected
patients’ subjective experience and concern about a lack of coherence.
3. The third factor, inconsistency, was characterized
less by subjective than objective incoherence (i.e., did not imply distress).
4. The fourth factor was lack of commitment (i.e., to
jobs or values).
The factors all showed high internal consistency, with
the following reliabilities (coefficient alpha): factor 1=0.85, factor 2=0.90,
factor 3=0.88, factor 4=0.82. t4 describes
the items that loaded above 0.50 on each factor.
Basically the closer to 1 = closer to 100%. This is all mostly
about data analysis if you’re interested.
To see whether patients diagnosed with borderline
personality disorder would differ from other patients on these four dimensions
of identity disturbance, we compared the means of the three groups by using a
one-way analysis of variance (ANOVA) for an omnibus F, and then tested specific
hypotheses by using contrast analysis. The ANOVA showed a significant
difference between the three groups on the first (F=3.87, df=2, 92, p=0.02),
second (F=16.14, df=2, 92, p<0.001), and third (F=4.82, df=2, 92, p=0.01)
factors and approached significance on the fourth (F=2.65, df=2, 92, p=0.08).
The more important analysis is the contrast analysis,
which asks more focused questions than the omnibus F. We tested three competing
hypotheses for each factor, specified in advance. Borderline patients would
score higher than the other two groups, who would not differ from each other
(contrast weights: 2, –1, –1). 2) Scores for the three groups would be linearly
related, such that borderline personality disorder patients would have the
highest scores, followed by patients with other personality disorders and then
those with no personality disorder (contrast weights: 1, 0, –1). 3) Mean scores
would follow the same order as in the previous contrast but with a larger mean
difference between patients with borderline personality disorder and those with
other personality disorders than between patients with other personality
disorders and those with no personality disorders (contrast weights: 4, –1,
–3). The second, linear model, tended to be the most robust, revealing
predicted differences among all three groups. These differences are all the
more striking given the limited diagnostic reliability data for the group with
other personality disorders. The results of these analyses are detailed in t5.
(For simplicity, we only report the first two contrasts in each case, because
contrasts two and three were largely redundant.)
Analyzing the data a second way, we used multiple
regression to predict borderline pathology, measured dimensionally by the
number of DSM-IV borderline symptoms, from patients’ scores on the four
identity factors. The four factors together (R=0.71) accounted for 50.2% of the
variance, with the first three factors contributing significantly to the
variance (p<0.05) and the fourth showing a trend (p=0.10).
Basically no matter which way they analyzed the data people with
BPD had much higher degrees of identity disturbance than people with “other
personality disorders” and as much as four times the degree of identity disturbance
as those with no personality disorder.
Disentangling Borderline Personality Disorder and Sexual Abuse
The data thus far indicate that patients
with borderline personality disorder do indeed differ from both subjects with
other personality disorders and those with no personality disorder in multiple
dimensions of identity disturbance. What is not indicated is whether, or to
what extent, those findings reflect the greater incidence of sexual abuse in
patients with borderline personality disorder (or gender differences, given the
higher prevalence of borderline personality disorder among women).
We thus wanted to examine the extent to
which a diagnosis of borderline personality disorder contributed to factor
scores independent of a patient’s gender and sexual abuse history. To
accomplish this, we used multiple regression to assess the predictive value of
gender (dummy coded 0=male, 1=female), sexual abuse history (coded 0=no,
1=unsure, 2=yes), and diagnosis (borderline personality disorder=1, no
borderline personality disorder=0) for each factor, entering gender and sexual
abuse history in the first step and diagnosis in the second.
Sexual abuse history was correlated to varying degrees
with each factor; however, in all cases, the model that included borderline
personality disorder diagnosis was significantly more predictive than the model
that included only patient gender and sexual abuse history (t6).
For the first factor, role absorption, gender and sexual abuse contributed
substantially less than the borderline diagnosis to the predictive power of the
model. The second factor, characterized by painful feelings of identity
incoherence, was highly correlated with sexual abuse history, although
inclusion of borderline personality disorder diagnosis significantly improved
the model’s predictive power. For the other two factors, patient gender and
sexual abuse history did not account for enough variance to reach significance.
The fourth factor was best predicted by the model that included borderline personality
disorder diagnosis, but this model did not account for a significant amount of
the variance.
In a second set of analyses, we assessed
the relationship between sexual abuse and severity of the disorder (total
number of symptoms). A history of sexual abuse predicted a higher likelihood of
borderline features (r=0.49, df=90, p<0.001). A regression
model including patient gender and sexual abuse (R=0.51) accounted for 25.6% of
the total variance on number of symptoms present (F=12.75, df=2, 74, p=0.001).
In contrast, a model including patient gender, sexual abuse history, and the
four identity factors (R=0.73) accounted for 53.1% of the total variance
(F=13.20, df=6, 70, p<0.001); this change was highly significant (F=10.24,
df=4, 70, p<0.001). Comparable findings emerged when we used gender, sexual
abuse, and the four identity factors to predict the presence or absence of the
borderline diagnosis. The combined model (R=0.73) explained 53.1% of the
variance (F=13.20, df=6, 70, p<0.001). The same was true when we used these
variables to predict number of borderline symptoms excluding the identity
disturbance criterion. Gender and sexual abuse alone in this analysis explained
25.0% of the variance, whereas adding the identity variables (R=0.67) explained
an additional 20.0% (F=15.20, df=4, 75, p<0.001), a highly significant
change (F=7.61, df=4, 70, p<0.001).
Basically in this study they compared Sexual Abused to a number of
factors like BPD, Gender, Identity, etc; on their own, and combined and
compared them to see where sexual abuse had significant impacts. A history of
sexual abuse predicted a higher likelihood of borderline features and a higher
severity of borderline features. That shouldn’t be a surprise to many of us. It
was also found that when they combined gender, sexual abuse history and
identity issues over 50% were impacted significantly. Comparable findings also
emerged for distinguishing a borderline diagnosis; that is with gender, sexual
abuse history, and identity issues. Something to keep an eye on I’d say.
Identity Disturbance and Borderline Subtypes
As an exploratory analysis, we followed up on findings
of two recent studies that isolated two distinct types of patients currently
diagnosed with borderline personality disorder, one with more dysphoric
features and the other with more histrionic features. The first type
(emotionally dysregulated) includes patients who have intense, painful, and
poorly regulated emotions that they attempt to escape by using various
maladaptive affect-regulatory strategies. The second (histrionic) type have
emotions that are intense and dramatic but not very troubling to them; for
these patients, dramatic emotions may even be self-defining.
To examine identity disturbance in patients who
approximate the emotionally dysregulated type, we examined the partial
correlations between ratings of borderline personality disorder and each
identity disturbance factor, holding constant ratings of the extent to which
the patient had histrionic features. (To maximize the comparability of
dimensional diagnoses of borderline personality disorder and histrionic
personality disorder, we used clinicians’ 1–7 ratings of each.) As predicted,
this analysis indicated a very strong relationship (r=0.58, df=70, p<0.001)
between severity of borderline personality disorder and the second factor,
painful incoherence, after controlling for histrionic features. The only other
significant partial correlation was with the fourth factor, lack of commitment
(r=0.24, df=70, p=0.05).
Conversely, to examine identity disturbance in patients
who approximate the histrionic type, we examined the partial correlations
between ratings of histrionic personality disorder and each identity factor,
holding constant borderline personality disorder ratings. For the first factor,
role absorption, the partial correlation with the histrionic rating was
significant (r=0.24, df=82, p=0.03). Strikingly, the second factor, which
correlated so strongly with borderline personality disorder, showed a slightly
negative correlation with histrionic ratings (r=–0.07, df=82, p=0.50). The last
two factors correlated slightly positively with the histrionic rating (r=0.19,
df=82, p=0.08; and r=0.13, df=82, p=0.28, respectively. Thus, some elements of identity
disturbance appear more closely associated with histrionic than with borderline
features, particularly role absorption, and, secondarily, inconsistency.
On the one hand I feel I like that they’re exploring more than one
expression of BPD but I think they’re sort of missing the point at the same
time. Personally I could be both dysphoric and histrionic at times, especially
when I was younger. In fact it was either one or the other. I was either in
intense pain or incredibly angry and moody… or I was really attention-seeking
and involved in my relationships and sexually involved and the life of the
party. Being Borderline is rarely so cleanly cut. So it’s not surprising that
they they would still have a correlation with the control factor of the
dysphoric or histrionic feature for the other group. I will say though that
even when I was in my more histrionic phases I did have a very self-loathing
streak. I don’t know if that’s present in people with histrionic personality disorder.
I was trying to escape my pain which they were definitely spot on for.
I know this post was a lot of Analysis and numbers and data
collection and it’s hard to wade through. Next is the Discussion! That’s the
good stuff!