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VALIDATION STUDIES OF THE BORDERLINE PERSONALITY DISORDER CONSTRUCT IN ADOLESCENTS

IMPLICATIONS FOR THEORY AND PRACTICE
DANIEL F. BECKER AND CARLOS M. GRILO

We examine evidence for the validity of the borderline personality disorder (BPD) construct in adolescents. Mainly, we focus on the validity of this construct in hospitalized adolescentsa severely ill population in which this diagnosis should be meaningful if it is meaningful at all. A great deal of the data for this examination were derived from our own work and that of our collaborators in the Yale Psychiatric Institute (YPI) Adolescent Follow-Up Studythough some material is drawn from other sources as well.

When investigators speak of a construct, they are referring to something that exists theoretically but is not directly observable. Also inherent in this notion is the sense that a construct has been developedor constructedto describe phenomena or the relationships between phenomena (Gliner & Morgan, 2000). Diseasesor disorders, or syndromescan clearly be seen as constructs. These diagnostic entities have been developed to describe pathological events, but the disease processes are rarely observable directly. In a general medical context, a disorder is a characteristic symptom set that may or may not have a known etiology, pathology, or course. Like some medical conditions but unlike many others, mental disorders are mainly defined in terms of symptom presentation and not in terms of structural pathology,
This paper was presented in part at the Annual Meeting of the American Society for Adolescent Psychiatry, Los Angeles, California, March 2528, 2004.

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deviance from a physiological norm, or etiology (American Psychiatric AssociationAPA, 1994). Most mental disorders, then, seek to define specific forms of psychopathological phenomena by delineating clusters of symptoms. As a result, the validation of mental disorders often involves analyzing the psychometric performance of symptom sets. When we inquire into the validity of a diagnostic entityor disorderwe are concerned with whether the diagnostic construct describes the phenomena of the disorder in an accurate, comprehensive, and consistent manner, across a range of individual occurrences. We should distinguish our topic herethe validity of the BPD constructfrom the concept of construct validity, a technical term that refers to an element of measurement validity. The latter is not unrelated to our subject; indeed, three types of construct validityconvergent, discriminant, and factorial validitywill enter our inquiry. However, we will be considering the validity of the BPD construct in a broader senseone that encompasses many narrower senses of validity and reliability. What, then, are some of the elements ofor potential contributors tothe validity of a construct such as the BPD symptom set? One such element is frequency, meaning that the disorder being described occurs in a population at a rate that is nontrivial. Another is stability, meaning that the disorder persists over time, at least to some extent. And another is reliability, meaning that the measurement of the disorder (in this case, the symptom set) should consistently be able to identify the disorder. Specific types of reliability include interrater reliability, test-retest reliability, and internal consistency. Internal consistency refers to coherence among the items within a measureor, in this case, the symptoms within a disorder. Later we examine internal consistency directly, but also by looking at diagnostic efficiency. Concurrent validity and predictive validity concern the relationship between the disorder and an independent criterion; as the terms imply, the former involves an independent criterion measured at the same time as the diagnostic assessment, while the latter involves an independent criterion measured at some future date. Discriminant validity can be claimed when the diagnostic criteria can differentiate between groups that, theoretically, should be differentiable. We touch on this concept through the examination of criterion overlap, and diagnostic overlap (or comorbidity). Finally, factorial validity can be claimed when factor analysis supports the theoretical organization of the elements of a construct (Gliner & Morgan, 2000). In what follows, we consider most of these aspects of the notion of validity, as applied to diagnosis.

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Why is diagnosis important? The need for disease classification systems has been clear throughout the history of medicine, including the treatment of mental disorders (APA, 1994). An accurate diagnostic system has many worthwhile applications, including epidemiological and clinical research. For the practicing clinician as well, accurate and reliable diagnosis has many advantages. While diagnosis is not a substitute for formulationa more comprehensive understanding of the developmental and biopsychosocial contexts of the patients distress and dysfunctionit does often serve to assist the clinician in predicting course and response to treatment. In most cases, it is diagnosis that connects the individual patient to a broader set of research data, so that the clinician can determine the relevance of a body of literature to a particular clinical case. Diagnosis is, essentially, a communication tool, facilitating communication between clinician and patient, between clinicians, and between clinician and researcher. It behooves our diagnostic system, as a set of research and clinical communication tools, to be as consistent and precise as possible. Finally, why study BPD in particular? BPD is a serious mental disorder, marked by pervasive instability in the regulation of emotions, impulses, self-image, and interpersonal relationships (Skodol et al., 2002). It is estimated to occur in 12% of the general population (Torgersen, Kringlen, and Cramer, 2001) but is observed much more frequently in clinical settings. Patients with BPD have profound functional impairments, high levels of treatment utilization, and a mortality rateby suicideof almost 10% (Work Group on Borderline Personality Disorder, 2001). Through a wide range of research efforts (Zanarini et al., 2003: Grilo et al., 2004), BPD has recently become the focus of intensifying study (Skodol et al., 2002). But, despite its common clinical application in adolescent treatment settings, BPD has been studied infrequently in adolescent populations.

EVALUATION OF THE BPD DIAGNOSIS IN ADOLESCENTS

DSM-IV allows BPD to be diagnosed in younger patients when maladaptive traits have been present for at least one year and are pervasive, persistent, and unlikely to be limited to a particular developmental stage or an episode of an Axis I disorder (APA, 1994, p. 631). Although

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the clinical significance of this diagnosis in adolescents has remained largely unclear, in recent years there have been several empirical investigations of personality disordersand BPD, specificallyin adolescents (Korenblum et al., 1990; Ludolph et al., 1990; Bernstein et al., 1993; Pinto et al., 1996; Meijer, Goedhart, and Treffers, 1998). The YPI Adolescent Follow-up Study explored outcomes of the hospital treatment of adolescents and also investigated several aspects of adolescent psychopathology, including BPD (Mattanah et al., 1995). At that time, YPI was a tertiary-care hospital that specialized in the treatment of severely disturbed adolescents and young adults. In the late 1980s, the hospital used structured interviews to conduct diagnostic assessments of all adolescents and adults who were admitted to its inpatient units. During the baseline phase of the study, there were 165 such adolescent subjects, ages 13 to 18 years. A two-year follow-up of most of these adolescents was conducted during the early 1990s. Study measures included the Schedule for Affective Disorders and Schizophrenia for School-Age ChildrenEpidemiologic Version (KSADS-E; Orvaschel and Puig-Antich, 1987) and the Personality Disorder Examination (PDE; Loranger et al., 1988) for assessing DSM-IIIR (APA, 1987) Axis I and Axis II disorders, respectively, along with several other instruments. Assessments were performed by a trained and monitored research evaluation team that was independent of the clinical team. Final research diagnoses were assigned at an evaluation conference, attended only by the research team, approximately four weeks after admission. These diagnoses were established by the bestestimate method, based on structured interviews and any additional relevant data from the clinical record, following the LEAD (longitudinal, expert, all data) standard (Spitzer, 1983; Pilkonis et al., 1991).

VALIDATION STUDY RESULTS Reliability, Frequency, and Stability

One of the earliest papers that resulted from this study reported on the reliability, frequency, and stability of Axis I and Axis II disorders in the hospitalized adolescents (Mattanah et al., 1995). Interrater reliability is usually reported as kappa, a measure of agreement corrected for

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chance; a value close to 1 indicates nearly perfect agreement, while a value close to 0 indicates that agreement is no better than would be expected by chance. For this study, the interrater reliability of Axis I diagnoses averaged .77; that for Axis II personality disorders averaged .84. In a later paper, the kappa for BPD in particular was also reported to be .84 (Becker et al., 2002). These reliabilities, including that for BPD, are acceptable. These findings suggest that Axis II personality disorders, like Axis I disorders, can be reliably diagnosed using standardized semistructured interviews. These reliabilities are comparable to those generally reported when similar assessment methods are used with adults (Zanarini et al., 2000). The frequency of BPD in this severely ill adolescent study group was high: 48% (Mattanah et al., 1995). A subsequent paper demonstrated that this rate was comparable to that in adult patients in the same hospital, during the same time period (Grilo, McGlashan, Quinlan, et al., 1998). Two years later, at the follow-up assessment, the rate of BPD had fallen to 23% (Mattanah et al., 1995)lower than at baseline, though still a relatively high frequency of occurrence. This brings us to the issue of diagnostic stability. There are various ways to measure this concept, the simplest being percent stabilitythe percentage of subjects diagnosed at baseline who meet criteria for the same diagnosis at follow-up. When measured in this way, the twoyear stability of BPD in hospitalized adolescents was only 23%. A subsequent analysis that examined dimensional measures of BPD also revealed low stability (Grilo et al., 2001). It is instructive to compare our stability results for BPD to our results for other disorders. The only other personality disorder that occurred frequently enough to allow analysis was passive-aggressive personality disorder, which has since been removed from the DSM. The stability of this disorder was again fairly low, at 21%. For Axis I disorders, diagnostic stability was somewhat higher: substance use disorders (collectively) had a stability of 53%, major depression had a stability of 46%, and conduct disorder had a stability of 31% (Mattanah et al., 1995). Our results regarding the diagnostic stability of personality disorders were generally consistent with the findings of other investigators who studied community samples of adolescents (Korenblum et al., 1990; Bernstein et al., 1993). For instance, Bernstein and colleagues (1993) found that personality disorders in this age group did not tend to persist over a two-year interval. However, Johnson, Cohen, Kasen, et al. (2000), who also studied a community sample, found that, while

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the prevalence of personality disorder traits declines steadily through adolescence into young adulthood, there is some relative stability, in that adolescents with these traits often have elevated personality disorder trait levels in adulthood.

Concurrent and Predictive Validity

The concurrent and predictive validity of personality disorders in hospitalized adolescents was the topic of a subsequent paper from the followup study (Levy et al., 1999). Although this study examined all personality disorders taken together, the general results are likely applicable to BPD in particular. Here, we were concerned with the relationships between adolescent personality disorders and independent measures of distress or dysfunctionthat is, measures that are independent of the diagnostic criteria themselves. For this study, we employed a variety of clinician-rated and self-report measures of psychiatric distress and dysfunction, including the Global Assessment of Functioning (GAF) scale (APA, 1987) and the SCL-90-R (Derogatis, 1983). We found considerable evidence for concurrent validity of the personality disorder construct at baseline assessment (Levy et al., 1999). Specifically, patients diagnosed with these disorders had significantly lower GAF scores, as well as higher levels of almost all self-report measures of symptom severity and distress. These results are consistent with findings from some community-based studies of adolescents (Korenblum et al., 1990; Bernstein et al., 1993), which have demonstrated that the personality disorder diagnosis is associated with high levels of distress as well as social, academic, and occupational impairment. We did not, however, find strong evidence for the predictive validity of the personality disorder construct in adolescents. At follow-up, patients who had been diagnosed with personality disorders two years previously showed no significant differences in GAF scores or in any of the SCL-90-R scales or summary indices. Indeed, the only differences, at follow-up, between those with and without personality disorders were higher levels of inpatient treatment utilization and drug use in the former group. There is little in the adolescent literature with which to compare these longitudinal results. A series of papers from the Children in the Community Study have reported that the BPD diagnosis and BPD traits in adolescents predict Axis I disorders, suicidality, violence, and criminality in young adulthood (Johnson, Cohen,

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Skodol, et al., 1999; Johnson, Cohen, Kasen, et al., 2000; Johnson, Cohen, Smailes, et al., 2000).

Internal Consistency and Criterion Overlap

The results cited thus far suggest that, in adolescents, BPD occurs frequently, can be reliably diagnosed, and is associated with functional impairment and subjective distress, but that the stability and predictive validity of this diagnostic construct are modest at best (Korenblum et al., 1990; Bernstein et al., 1993; Mattanah et al., 1995; Levy et al., 1999). Given these mixed results, we sought to evaluate further the question of adolescent BPD validity through psychometric study of the diagnostic criteria. The first such study evaluated internal consistency and criterion overlap of the personality disorder criterion sets (Becker et al., 1999). Again, this study examined all personality disorders, though it is possible to separate the results for BPD. Another feature of this study is that it compared the adolescent inpatients to a group of adult inpatients in the same hospital during the same time period, who underwent identical assessment procedures. Internal consistency involves the cohesion of an item setin this case, the criteria, or symptoms, of a personality disorder. Based on interitem correlations, the Cronbach alpha coefficient provides a measure of internal consistency (Cronbach, 1951). It varies between 0 and 1, increasing as the mean inter-item correlation increases. But alpha also increases as the number of items increases. For this reason, we additionally determined the mean intercriterion correlation (MIC) to facilitate comparison between criterion lists of different lengths (Morey, 1988). The MIC was calculated by taking the mean of the correlations for each possible pair of criteria within a given disorder. These two coefficientsalpha and MICwere calculated for each personality disorder diagnosis, for both adolescents and adults. We generally found that the personality disorder criteria were less coherent in adolescents than in adults, by either metric. In the case of the BPD criteria, however, this was not so; for BPD, the adolescent group had a coefficient alpha of .76 and an MIC of .28, compared with .74 and .26, respectively, for the adult group (Becker et al., 1999). In other words, the internal consistency of the BPD criteria appears to be similarly acceptable for adults and adolescents.

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This study also evaluated criterion overlap, which provides a measure of discriminant validity. While internal consistency concerns the correlation of the criteria within a diagnostic category, criterion overlap concerns the correlation of criteria between disorders. To measure this, we determined an intercategory mean intercriterion correlation (ICMIC), which was calculated in a manner analogous to the calculation of the MIC (Becker et al., 1999). In general, we found that criterion overlap between personality disorders is greater in adolescents than in adults. This also appeared to be true for BPD specifically. Moreover, for the adults, we found the highest intercorrelation between the criteria of BPD and the criteria of other Cluster B personality disorders. For adolescents, the criteria of BPD correlated best with the criteria of a broad range of personality disorders, spanning all three clusters (Becker et al., 2000). To summarize the implications of this particular study for BPD in adolescents: we found that the BPD criteria had internal consistency comparable to that for adults, but also that they were relatively lacking in discriminant validity (Becker et al., 1999, 2000). Next, we will consider two studies that explored further the issues examined in this study of internal consistency and criterion overlap. The first extended the examination of criterion overlap to a consideration of diagnostic overlap, or comorbidity. The second expanded our study of internal consistency by examining diagnostic efficiency.

Comorbidity
Again, our study of BPD comorbidity involved a comparison between the adolescent study group and an analogous group of adult inpatients drawn from the same hospital and evaluated in an identical manner (Becker et al., 2000). By studying the Axis II diagnostic overlap with BPD, we hoped to expand the on findings mentioned previously, regarding criterion overlap. For the adolescent group, we found a fairly broad pattern of diagnostic overlap, encompassing aspects of Clusters A and C. After Bonferroni-corrected chi-square analysis, BPD showed statistically significant co-occurrence with schizotypal and passive-aggressive personality disorders. In the adult group, by contrast, we found a relatively narrower pattern of diagnostic overlap that was more concentrated on Cluster B. Bonferroni-corrected chi-square analysis revealed statistically significant comorbidity with BPD for antisocial personality disor-

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der only. These results confirmed our criterion-level findings, suggesting that the BPD construct may represent a more diffuse range of psychopathology in adolescents than in adults.

Diagnostic Efficiency
Our study of the diagnostic efficiency of the BPD criteria provided an alternative view of BPD internal consistency. Here, we used conditional probabilities to examine the diagnostic efficiency of the BPD criteria in our group of adolescent inpatients, and also in our comparison group of hospitalized adults (Becker et al., 2002). Diagnostic efficiency is the extent to which diagnostic criteria (or symptoms) are able to discriminate individuals with a given disorder from those without that disorder, as determined by the application of conditional probabilities. Four such conditional probabilities can be useful in studying the diagnostic efficiency of symptomssensitivity, specificity, positive predictive power, and negative predictive power. Despite their common use in research settings, sensitivity and specificity have limited utility in the process of clinical diagnosis (Widiger et al., 1984). Diagnosticians are more interested in the likelihood of a disorder, given that the patient has a symptom (or positive predictive power), than in the likelihood of a symptom, given that the patient has a disorder (or sensitivity). Similarly, negative predictive power is more useful than specificity. A symptoms positive predictive power indicates whether it will have utility as an inclusion criterion. Moreover, the relative values of the positive predictive powers for various symptoms of a disorder can provide information about which symptoms are the strongest predictors of the disorder. This feature represents a potential improvement over the symptom lists provided in the DSM, in which all inclusion criteria are generally viewed as equivalent in predictive capacity. Similarly, a symptoms negative predictive power tells us whether the absence of that symptom will have utility as an exclusion criterion. Finally, some authors (e.g., Faraone et al., 1993) have employed total predictive value as an overall index of a symptoms utility in making a correct diagnosis. Although not a conditional probability, total predictive value is a measure of percent agreement and represents the total probability of correct classification. Comparing the two age groups, our study revealed no statistically significant differences in the base rates of the BPD diagnosis or in the

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base rates of any of the BPD criteria. There were, however, several interesting differences at the level of the diagnostic efficiency of the BPD criteria (Becker et al., 2002). Although the details of many of these differences are beyond the scope of this paper, two findings are relevant here: (1) the adolescents showed greater variability than the adults in the diagnostic efficiency of the BPD criteria, and (2) the criteria that were the best overall predictors of BPD varied between the groups. For the adults, the highest total predictive value was found for impulsiveness. For the adolescents, the highest values were found for affective instability, uncontrolled anger, and identity disturbance. That identity disturbance has specific value in discriminating the diagnosis of BPD in adolescents is of interest because this trait is often viewed as a common and nonspecific manifestation in this age group. That two symptoms of affective dysregulation also have specific value in discriminating the diagnosis of BPD may shed light on the underlying nature of this syndrome in adolescents. Various investigators have suggested that BPD has statistically meaningful components, and that such components or symptom groupings may be clinically significant and may respond to specific treatment interventions (Sanislow and McGlashan, 1998; Links, Heslegrave, and van Reekum, 1999; Links and Heslegrave, 2000; Sanislow, Grilo, and McGlashan, 2000; Soloff, 2000). For instance, some have argued that impulsiveness is a core feature of BPD in adults, and that the course of BPD in this age group can best be influenced by pharmacologic and psychosocial interventions aimed at this area of symptomatology (Links et al., 1999; Links and Heslegrave, 2000). Indeed, our own total predictive value results in the adult group support this view. To the extent that BPD in adolescents has core features that differ from BPD core features in adults, this may suggest an alternative set of preferred interventions in this age group (Becker et al., 2002).

Factor Analysis
The final study that we consider here is one that explored further this question of BPD core features (Becker et al., 2003). Factor analysis can empirically identify meaningful components or latent elements in a diagnostic construct. Several studies had previously examined the factor structure of DSM-defined BPD in adult samples (Rosenberger

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and Miller, 1989; Clarkin, Hull, and Hurt, 1993; Fossati et al., 1999; Sanislow et al., 2000; Sanislow et al., 2002). One of these investigations made use of the adult comparison group from the follow-up study (Sanislow et al., 2000). Sanislow and colleagues (2000) reported three homogeneous components of BPDdisturbed relatedness, behavioral dysregulation, and affective dysregulation. Inasmuch as such factors may reflect core dimensions of borderline psychopathology, this type of analysis has important theoretical and clinical implications (Skodol et al., 2002). In our study, we explored the factor structure of BPD in our group of adolescent inpatients. We also added to our theoretical and clinical understanding of homogeneous components by determining whether these are related to specific forms of Axis I pathology. This aspect of the study was prompted by some of the BPD comorbidity research in adults, and by studies from our own group (Grilo et al., 1995; Grilo, Becker, Fehon, Edell, et al., 1996; Grilo et al., 1997) and others (Bernstein et al., 1996; Johnson et al., 1999) indicating that BPD in adolescents may be associated with certain Axis I disorders such as depression, conduct disorder, and substance use disorders. With respect to the factor analysis, a four-factor solution accounted for 67.0% of the overall variance (Becker et al., 2003). Factor 1 consisted of suicidal threats or gestures and emptiness or boredom. This factor reflected self-negating or depressive aspects of the borderline presentation. Factor 2 embodied aspects of affective dysregulation or irritability and consisted of affective instability and uncontrolled anger, along with identity disturbance. Factor 3 reflected the borderline patients interpersonal dysregulation and consisted of unstable relationships and abandonment fears. Impulsiveness loaded most heavily on Factor 4, though identity disturbance loaded on this factor as well. This four-factor solution differed from the findings reported for the factor analyses of BPD criteria in adults (Rosenberger and Miller, 1989; Clarkin et al., 1993; Fossati et al., 1999; Sanislow et al., 2000; Sanislow et al., 2002). Logistic regression analyses used the four BPD factors as independent variables and Axis I disorders as dependent variables (Becker et al., 2003). Major depression and dysthymia were significantly associated with Factor 1 only. Anxiety disorders were predicted by Factors 2 and 3. Conduct disorder was predicted only by Factor 4. Oppositional defiant disorder was associated with Factor 2. Alcohol use disorders were predicted by Factors 1 and 4, and drug use disorders were predicted

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by Factor 4 alone. Thus, each factor was associated with characteristic Axis I pathology. Recent controversies concerning the potential merits of broadening the bipolar disorder construct in pediatric populations (e.g., Leibenluft et al., 2003)and frequent observations, especially among working clinicians, about the phenomenologic similarities between bipolar disorder and BPDraise the question of whether there are associations between BPD and bipolar disorder in adolescent patients. Unfortunately, this interesting research question is not one that we were able to address with our data. Research diagnoses were based on strict DSM-III-R criteria, and our diagnoses of bipolar disorder, therefore, corresponded to a narrow phenotype (Leibenluft et al., 2003). Accordingly, the rate of bipolar disorder in our study group was too low (about 2%) to allow this diagnosis to be incorporated into these analyses. In summary, our factor analysis produced a four-factor solution that was substantially different from the results of similar factor analytic studies in adults. The subsequent logistic regression analyses contributed to our conceptualization of these four factors and also contributed to our understanding of potential underlying relationships between BPD and Axis I pathology in adolescents (Becker et al., 2003).

CONCLUSIONS
What can we conclude about the validity of the BPD construct in adolescents? Our own reports from the YPI Adolescent Follow-up Study suggest that personality disorders in this population, including BPD, can be reliably diagnosed, occur frequently, and have concurrent validity, but have only modest predictive validity and stability over time (Mattanah et al., 1995; Grilo, Becker, Fehon, Walker, et al., 1996; Levy et al., 1999). These findings for hospitalized adolescents are generally consistent with those of other studies involving community samples of adolescents (Korenblum et al., 1990; Bernstein et al., 1993) and are also generally consistent with findings from the adult literature (Grilo, McGlashan, and Oldham, 1998; Grilo and McGlashan, 1999). Given the concurrent validity that BPD seems to possess in adolescents, it is likely that clinicians will find the construct useful in characterizing certain aspects of adolescent psychopathology. But the mixed findings in the few available prospective studies of stability and predictive

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validity suggest that we should use caution when employing this diagnosis to make predictions about longer-term clinical course. In addition, some of our findings suggest that the BPD construct may represent a more diffuse range of psychopathology in adolescents than in adults. We found that, in comparison with BPD in an analogous group of adult inpatients, BPD in adolescents had a broader pattern of criterion overlap with other personality disorders (Becker et al., 1999), a broader pattern of Axis II diagnostic comorbidity (Becker et al., 2000), and greater variability in the diagnostic efficiency of its criteria (Becker et al., 2002). These findings suggest the need to explore BPD heterogeneity in adolescents. Our exploratory factor analysis of BPD in adolescent inpatients revealed four BPD factors that differ from those reported for similar studies of adults (Becker et al., 2003), suggesting that BPD in adolescents may be different in its nature and underlying structure than BPD in adults (Becker et al., 1999, 2000, 2002). Our four factors represent homogenous components of self-negation, irritability, poorly modulated relationships, and impulsivity, each of which is associated with characteristic Axis I pathology. These cross-sectional associations may be interpreted as suggesting that some of these BPD components can be affected by co-occurring Axis I disorders. Alternatively, these associations may suggest specific and meaningful overlapping of Axis I disorders and BPD components in adolescents. A variety of comorbidity models, including spectrum models (Siever and Davis, 1991), could be employed to describe the confluence of Axis I related components in adolescent BPD. Work along these lines is beginning to emerge in the adult literature (Shea et al., 2004; Grilo et al., 2005), but studies of these comorbidity models are also needed across adolescence into adulthood. As noted previously, some investigators have suggested that the statistically meaningful components of BPD may be clinically significant and may respond to specific treatment interventions. Indeed, there is a broad literature on the treatment of adult BPD (Work Group, 2001; Lieb et al., 2004) and some research that addresses the targeted treatment of adult BPD core features (Links et al., 1999; Links and Heslegrave, 2000; Soloff, 2000). Less is known about the extent to which BPD components may respond to medications or to symptom-focused psychosocial interventions in adolescents. Until further research data are available, caution should be exercised in applying these targeted strategies to adolescent patients.

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Longitudinal studies are needed to trace the evolution of these BPD components over time, and to examine their interactions with the vicissitudes of development and the ebb and flow of Axis I disturbance. Such an understanding of the interplay between these developmental and pathological processes would contribute to the validation of this diagnostic construct, point toward specific therapeutic interventions, and help to close the gap between diagnosis and clinical formulation. Finally, future research needs to move beyond categorical or DSM-based diagnoses to consider more fully dimensional aspects of personality disturbance (Johnson, Cohen, Kasen, et al., 2000; Grilo, Sanislow, et al., 2005).

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