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).
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,
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