Sunday, May 6, 2012

Ethical Use of Assessments: Assessing Borderline Personality Disorder by Nina Bingham

Abstract
This article will assess the interview instrument for diagnosis of Borderline Personality Disorder (BPD) entitled, “Diagnostic Interview for Borderline Patients (DIB)” (Gunderson, Ludolph, Silk, Lohr & Denny, 1982-1983).  I will show that it is both ethical, and a proven diagnostic instrument to determine BPD traits. It will show that the DIB has used the DSM-lll as its template to understand BPD, and that only experienced clinicians can use the DIB effectively, further adding to its reliability.

    Due to the prevalence and controversy of diagnosis of Borderline Personality Disorder (BPD), I chose to analyze the “Diagnostic Interview for Borderline Patients (DIB)” (Gunderson, Ludolph, Silk, Lohr & Cornell, 1982-1983). Of all personality disorders, there is more controversy over diagnosing Borderline Personality Disorder (BPD) than any other personality disorder, because, “When compared with research on other psychiatric disorders, such as depression and anti-social personality disorder, research on the development of BPD has been strikingly sparse. This is troubling, given the high rates of mortality associated with the disorder.  Currently, the developmental trajectories that lead to BPD in adulthood remain unclear” (Crowell, Beauchaine, Linehan, 2009). While still an etiological puzzle to researchers, “Data suggests that BPD affects from 1.2% to almost 6% of the general population, and approximately 10% of these seek outpatient services, and as many as 20% undergo inpatient treatment” (Grant et al., 2008; Leib, Zanarini, Schmahl, Linehan & Bohus, 2004). Also, clinicians may be misdiagnosing BPD: “CBT clinicians were more likely to diagnose PTSD than BPD or other disorders, and psychodynamic clinicians were more likely to diagnose BPD or other disorders than PTSD” (Woodward, Halley, Taft, Gordon and Meis, 2009). “The importance of training in personality disorders for clinicians is evidenced by epidemiological data, which indicate that personality disorders have a high lifetime prevalence ranging between 10% and 14% in the community” (Skodol et al., 2002). “These findings strongly suggest at least two evidence-based principles. The first is given the prevalence of personality disorders, all clinicians need to develop specific expertise in at least identifying and diagnosing patients with these disorders. Second, given that personality disorders are so frequently comorbid with a range of Axis 1 disorders, it is incumbent upon the clinician to assess for personality disorders because it would likely affect the course and treatment of the disorder. Failing to do so could be considered derelict” (Levy, 2010). In summary, “…clinicians everywhere have sought ways to psychometrically apprehend this elusive patient” (Peterson, 1982-1983).
    As a clinician in private practice, utilizing an empirically sound assessment tool to diagnose BPD is important, because once a client has been assigned the BPD “label” (diagnosis), it will shape their treatment trajectory within the mental healthcare system, follow them interminably in their medical records, and influence how other medical professionals approach and relate to them. It behooves the private practitioner, therefore, to be cautious, and as empirically sound as possible before assigning the BPD diagnosis to a client. It is both part of her ethical nomenclature as a medical professional to “do no harm” (Lasagna, 1964) and her ethical obligation to assess her own boundaries of competence: “Counselors practice only within the boundaries of their competence…Counselors gain knowledge, personal awareness, sensitivity, and skills pertinent to working with a diverse client population” (American Counseling Association, 2005, C.2.a., Boundaries of Competence).
    In meeting these ethical criteria, The Diagnostic Interview for Borderline Patients (DIB) calls for a clinical degree of skill: “The items vary in depth of influence and degree of clinical judgment, but, in the main, call for a high degree of clinical skill and favor a psychodynamic orientation” (Peterson, 1982-1983). In my opinion, inexperienced clinicians should not be diagnosing BPD, as it is a clinically complicated diagnosis, and a controversial designation. The DIB prohibits a “hasty” clinical assessment, and therefore, is ethically sounder than other less structured, less clinical instruments would be.
    In regards to test structure and reliability, the DIB is a complex, yet semi-structured interview as a rating scale, to confirm or deny the presence of borderline symptoms. It is considered “semi-structured” because, “The interviewers are given considerable leeway on how to conduct the interview and are encouraged to probe as needed. No suggestion is made as to who should use this test, and whether it is suited for research or clinical practice” (Peterson, 1982-1983).  It is considered complex in structure because five sections of the instrument provide estimates of, “Social Adaptation, Impulse Action Patterns, Affects, Psychosis, and Interpersonal Relations” (Deysach, 1982-1983). Also, twenty-nine statements indicative of BPD “…are rated on a three point scale reflecting presence or absence of symptoms…” (Peterson, 1982-1983).  The DIB has a high cut-off score (7 or higher out of 10 points) that identifies BPD. Higher cut-off scores can distinguish BPD symptoms from other clinical syndromes. The DIB can be administered in 50 to 90 minutes using an interview format. Descriptors help stabilize ratings of the five diagnostic clusters, and scoring Guidelines offer explicit criteria. Yet, “the complexity of the scale…renders it difficult for use by the inexperienced examiner” (Deysach, 1982-1983).  Other measures of test reliability show that while reliability on DIB total scores range from mid-80s to low 90%, Test-retest reliabilities have ranged from .47 to .64. “Overall, while reliabilities are generally of the order to warrant continued use of the DIB, cautiousness regarding the reliability would seem to be in order if the instrument were used to make individual treatment decisions” (Deysach, 1982-1983). However, “It has been reported in the literature that the DIB is useful in generating diagnostic judgments of BPD compatible to those based upon the criteria presented in DSM-lll” (Deysach, 1982-1983). So DSM-friendly is the DIB that Deysach (1982-1983) suggests using it as a training tool to attempt to differentiate borderline behavioral patterns: “…reliable and valid use of the DIB depends upon variables such as examiner experience…it is for the clinician-in-training that the DIB may be of greatest value.” Peterson (1982-1983) similarly comments, “ The several validity studies does suggest the DIB does distinguish BPD from Schizophrenia and other psychoses as well as from other personality disorders…the DIB does correlate significantly with the DSM-lll.” However, before the reader concludes that the DIB is free of criticism, Peterson (1982-1983) takes issue with the instrument’s “absence of scaling algorithm that equally weighs items or scales…the too simple advocacy of one cutting score…the absence of an adequate test manual.”
    Overall, I found that The Diagnostic Interview for Borderline Patients (DIB)” (Gunderson, Ludolph, Silk, Lohr & Denny, 1982-1983) is a valid and reliable interview for the assessment and diagnosis of BPD because it utilizes the DSM-lll diagnostic criteria, which requires clinical experience to interpret. It allows for a semi-structured interview with the patient, which builds rapport between client and clinician, and can be administered in an hour to 90 minutes. It is high in validity and reliability (although its test-retest scores were mid-range). Most importantly, the DIB is an ethically sound test, as it requires the clinician to be skilled in the language of diagnostics in order to administer the test. Overall, The Diagnostic Interview for Borderline Patients (DIB) is a clinical interview I would feel confident about using in my private practice to assess and diagnosis Borderline Personality Disorder.
                                                        
References:
Gunderson, John G., Ludolph, Pamela S., Silk, Kenneth R., Lohr, Naomi E., Cornell, Dewey G. (1982-1983). Diagnostic Interview for Borderline Patients. Mental Measurements Yearbook and Tests in Print. Yearbook: 10. Accession Number: 10120015.

Crowell, Shiela E., Beauchaine, Theodore P., Marsha M. Linehan. (2009). A biosocial developmental model of borderline personality: Elaborating and extending linehan’s theory. Psychological bulletin, Vol. 135 (3), p. 495-510.

Grant et al., (2008); Leib, Zanarini, Schmahl, Linehan & Bohus, (2004). Grant, B. F., Chou, P.,

Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., et al. ( 2008). Prevalence, correlates,

disability, and comorbidity of DSM–IV borderline personality disorder: Results from the Wave

2 National Epidemiologic Surveys on Alcohol and Related Conditions. Journal of Clinical

Psychiatry, 69, 533– 545.

Woodward, Halley E., Taft, Casey T., Gordon, Richard A., and Meis, Laura A. (2009). Psychological trauma. Theory, Research, Practice, and Policy, Vol. 1 (4), p. 282-290.
Skodol, A. E., Gunderson, J. G., McGlashan, T. H., Dyck, I. R., Stout, R. L., Bender, D. S.,

Grilo, C. M., et al. (2002). Functional impairment in patients with schizotypal, borderline,

avoidant, or obsessive-compulsive personality disorder. American Journal of Psychiatry, 159,

276–283.

Levy, Kenneth, N. (2010). Practice at the border: The art of integrating the science on

personality disorders for clinical practice. Professional Psychology: Research and Practice, Vol.

41 (1), p. 68-71.

Peterson, Charles, A. (1982-1983). Review of the diagnostic interview for borderline patients.

Mental Measurements Yearbook 1982-1983. American Psychological Association.

Lasagna, Louis. (1964). "The Hippocratic Oath: Modern Version". Doctors' Diaries. WGBH Educational Foundation. Retrieved 04-29-12.

American Counseling Association Governing Counsel. (2005). Code of ethics: C.2.a., boundaries of competence. American Counseling Association.

Deysach, Robert E. (1982-1983). Diagnostic Interview for borderline patients.  Mental

Measurements Yearbook 1982-1983. American Psychological Association.



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