Hostname: page-component-78c5997874-j824f Total loading time: 0 Render date: 2024-11-05T16:30:32.679Z Has data issue: false hasContentIssue false

Borderline personality disorder co-morbidity: relationship to the internalizing–externalizing structure of common mental disorders

Published online by Cambridge University Press:  14 September 2010

N. R. Eaton*
Affiliation:
University of Minnesota, Minneapolis, MN, USA
R. F. Krueger
Affiliation:
University of Minnesota, Minneapolis, MN, USA
K. M. Keyes
Affiliation:
Columbia University, New York, NY, USA
A. E. Skodol
Affiliation:
Columbia University, New York, NY, USA University of Arizona, Tucson, AZ, USA
K. E. Markon
Affiliation:
University of Iowa, Iowa City, IA, USA
B. F. Grant
Affiliation:
National Institute on Alcohol Abuse and Alcoholism, USA
D. S. Hasin
Affiliation:
Columbia University, New York, NY, USA
*
*Address for correspondence: N. R. Eaton, M.A., Department of Psychology, 75 East River Road, University of Minnesota, Minneapolis, MN 55455-0344, USA. (Email: [email protected])

Abstract

Background

Borderline personality disorder (BPD) shows high levels of co-morbidity with an array of psychiatric disorders. The meaning and causes of this co-morbidity are not fully understood. Our objective was to investigate and clarify the complex co-morbidity of BPD by integrating it into the structure of common mental disorders.

Method

We conducted exploratory and confirmatory factor analyses on diagnostic interview data from a representative US population-based sample of 34 653 civilian, non-institutionalized individuals aged ⩾18 years. We modeled the structure of lifetime DSM-IV diagnoses of BPD and antisocial personality disorder (ASPD), major depressive disorder, dysthymic disorder, panic disorder with agoraphobia, social phobia, specific phobia, generalized anxiety disorder, post-traumatic stress disorder, alcohol dependence, nicotine dependence, marijuana dependence, and any other drug dependence.

Results

In both women and men, the internalizing–externalizing structure of common mental disorders captured the co-morbidity among all disorders including BPD. Although BPD was unidimensional in terms of its symptoms, BPD as a disorder showed associations with both the distress subfactor of the internalizing dimension and the externalizing dimension.

Conclusions

The complex patterns of co-morbidity observed with BPD represent connections to other disorders at the level of latent internalizing and externalizing dimensions. BPD is meaningfully connected with liabilities shared with common mental disorders, and these liability dimensions provide a beneficial focus for understanding the co-morbidity, etiology and treatment of BPD.

Type
Original Articles
Copyright
Copyright © Cambridge University Press 2010

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Andrews, G, Goldberg, DP, Krueger, RF, Carpenter, WT Jr., Hyman, SE, Sachdev, P, Pine, DS (2009). Exploring the feasibility of a meta-structure for DSM-V and ICD-11: could it improve utility and validity? Psychological Medicine 39, 19932000.CrossRefGoogle ScholarPubMed
Ansell, EB, Sanislow, CA, McGlashan, TH, Grilo, CM (2007). Psychosocial impairment and treatment utilization by patients with borderline personality disorder, other personality disorders, mood and anxiety disorders, and a healthy comparison group. Comprehensive Psychiatry 48, 329336.CrossRefGoogle Scholar
Barlow, DH, Allen, LB, Choate, ML (2004). Toward a unified treatment for emotional disorders. Behavior Therapy 35, 205230.CrossRefGoogle Scholar
Brown, TA (2006). Confirmatory Factor Analysis for Applied Research. Guilford Press: New York.Google Scholar
Canino, G, Bravo, M, Ramirez, R, Febo, VE, Rubio-Stipec, M, Fernandez, RL, Hasin, D (1999). The Spanish Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS): reliability and concordance with clinical diagnoses in a Hispanic population. Journal of Studies on Alcohol 60, 790799.Google Scholar
Chatterji, S, Saunders, JB, Vrasti, R, Grant, BF, Hasin, D, Mager, D (1997). Reliability of the alcohol and drug modules of the Alcohol Use Disorder and Associated Disabilities Interview Schedule – Alcohol/Drug-Revised (AUDADIS-ADR): an international comparison. Drug and Alcohol Dependence 47, 171185.CrossRefGoogle Scholar
Cottler, LB, Grant, BF, Blaine, J, Mavreas, V, Pull, C, Hasin, D, Compton, WM, Rubio-Stipec, M, Mager, D (1997). Concordance of DSM-IV alcohol and drug use disorder criteria and diagnoses as measured by AUDADIS-ADR, CIDI, and SCAN. Drug and Alcohol Dependence 47, 195205.Google Scholar
Crowell, SE, Beauchaine, TP, Linehan, MM (2009). A biosocial developmental model of borderline personality: elaborating and extending Linehan's theory. Psychological Bulletin 135, 495510.CrossRefGoogle ScholarPubMed
Eaton, NR, South, SC, Krueger, RF (2010). The meaning of comorbidity among common mental disorders. In Contemporary Directions in Psychopathology, 2nd edn (ed. Millon, T., Krueger, R. and Simonsen, E.), pp. 223241. Guilford Press: New York.Google Scholar
Grant, BF, Chou, SP, Goldstein, RB, Huang, B, Stinson, FS, Saha, TD, Smith, SM, Dawson, DA, Pulay, AJ, Pickering, RP, Ruan, J (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry 69, 533545.CrossRefGoogle ScholarPubMed
Grant, BF, Dawson, DA, Stinson, FS, Chou, PS, Kay, W, Pickering, R (2003). The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV): reliability of alcohol consumption, tobacco use, family history of depression and psychiatric diagnostic modules in a general population sample. Drug and Alcohol Dependence 71, 7–16.CrossRefGoogle Scholar
Grant, BF, Harford, TC, Dawson, DA, Chou, PS, Pickering, RP (1995). The Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS): reliability of alcohol and drug modules in a general population sample. Drug and Alcohol Dependence 39, 3744.CrossRefGoogle Scholar
Grant, BF, Kaplan, KD (2005). Source and Accuracy Statement for the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). National Institute on Alcohol Abuse and Alcoholism: Bethesda, MD.Google Scholar
Grant, BF, Kaplan, K, Shepard, J, Moore, T (2005). Source and Accuracy Statement for Wave 1 of the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions. National Institute on Alcohol Abuse and Alcoholism: Bethesda, MD.Google Scholar
Hasin, D, Carpenter, KM, McCloud, S, Smith, M, Grant, BF (1997 a). The alcohol use disorder and associated disabilities interview schedule (AUDADIS): reliability of alcohol and drug modules in a clinical sample. Drug and Alcohol Dependence 44, 133141.CrossRefGoogle Scholar
Hasin, D, Grant, BF, Cottler, L, Blaine, J, Towle, L, Üstün, B, Sartorius, N (1997 b). Nosological comparisons of alcohol and drug diagnoses: a multisite, multi-instrument international study. Drug and Alcohol Dependence 47, 217226.CrossRefGoogle ScholarPubMed
Hasin, D, Paykin, A (1999). Alcohol dependence and abuse diagnoses: concurrent validity in a nationally representative sample. Alcoholism: Clinical and Experimental Research 23, 144150.Google Scholar
Hasin, DS, Muthén, B, Wisnick, KS, Grant, B (1994). Validity of the bi-axial dependence concept: a test in the US general population. Addiction 89, 573579.Google Scholar
Hasin, DS, Stinson, FS, Ogburn, E, Grant, BF (2007). Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry 64, 830842.Google Scholar
Hasin, DS, Van Rossem, R, McCloud, S, Endicott, J (1997 c). Differentiating DSM-IV alcohol dependence and abuse by course: community heavy drinkers. Journal of Substance Abuse 9, 127135.CrossRefGoogle ScholarPubMed
Hu, L, Bentler, PM (1999). Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Structural Equation Modeling 6, 155.Google Scholar
James, LM, Taylor, J (2008). Revisiting the structure of mental disorders: borderline personality disorder and the internalizing/externalizing spectra. British Journal of Clinical Psychology 47, 361380.Google Scholar
Kendler, KS, Aggen, SH, Czajkowski, N, Røysamb, E, Tambs, K, Torgersen, S, Neale, MC, Reichborn-Kjennerud, T (2008). The structure of genetic and environmental risk factors for DSM-IV personality disorders: a multivariate twin study. Archives of General Psychiatry 65, 14381446.CrossRefGoogle ScholarPubMed
Kendler, KS, Prescott, CA, Myers, J, Neale, MC (2003). The structure of genetic and environmental risk factors for common psychiatric and substance use disorders in men and women. Archives of General Psychiatry 60, 929937.CrossRefGoogle ScholarPubMed
Krueger, RF (1999). The structure of common mental disorders. Archives of General Psychiatry 56, 921926.Google Scholar
Krueger, RF (2005). Continuity of Axes I and II: toward a unified model of personality, personality disorders, and clinical disorders. Journal of Personality Disorders 19, 233261.CrossRefGoogle Scholar
Krueger, RF, Caspi, A, Moffitt, TE, Silva, PA (1998). The structure and stability of common mental disorders (DSM-III-R): a longitudinal-epidemiological study. Journal of Abnormal Psychology 107, 216227.Google Scholar
Livesley, WJ (2005). From shifting diagnoses to empirically-based diagnostic constructs. In Personality Disorders (ed. Maj, M., Akiskal, H. S., Mezzich, J. E. and Okasha, A.), pp. 232235. John Wiley and Sons: West Sussex, UK.Google Scholar
Livesley, WJ (2008). Toward a genetically-informed model of borderline personality disorder. Journal of Personality Disorders 22, 4271.CrossRefGoogle Scholar
Markon, KE (2010). Modeling psychopathology structure: a symptom-level analysis of Axis I and II disorders. Psychological Medicine 40, 273288.CrossRefGoogle ScholarPubMed
Muthén, LK, Muthén, BO (2010). Mplus User's Guide, 5th edn. Muthén & Muthén: Los Angeles, CA.Google Scholar
Nelson, CB, Rehm, J, Ustun, TB, Grant, B, Chatterji, S (1999). Factor structures for DSM-IV substance disorder criteria endorsed by alcohol, cannabis, cocaine and opiate users: results from the WHO reliability and validity study. Addiction 94, 843855.Google Scholar
Paris, J (2007). The nature of borderline personality disorder: multiple dimensions, multiple symptoms, but one category. Journal of Personality Disorders 21, 457473.Google Scholar
Pull, CB, Saunders, JB, Mavreas, V, Cottler, LB, Grant, BF, Hasin, DS, Blaine, J, Mager, D, Üstün, BT (1997). Concordance between ICD-10 alcohol and drug use disorder criteria and diagnoses as measured by the AUDADIS-ADR, CIDI, and SCAN: results of a cross-national study. Drug and Alcohol Dependence 47, 207216.Google Scholar
Ruan, WJ, Goldstein, RB, Chou, SP, Smith, SM, Saha, TD, Pickering, RP, Dawson, DA, Huang, B, Stinson, FS, Grant, BF (2008). The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV): reliability of new psychiatric diagnostic modules and risk factors in a general population sample. Drug and Alcohol Dependence 92, 2736.CrossRefGoogle Scholar
Sanislow, CA, Grilo, CM, Morey, LC, Bender, DS, Skodol, AE, Gunderson, JG, Shea, T, Stout, RL, Zanarini, MC, McGlashan, TH (2002). Confirmatory factor analysis of DSM-IV criteria for borderline personality disorder: findings from the Collaborative Longitudinal Personality Disorders Study. American Journal of Psychiatry 159, 284290.CrossRefGoogle Scholar
Selby, EA, Joiner, TE Jr. (2009). Cascades of emotion: the emergence of borderline personality disorder from emotional and behavioral dysregulation. Review of General Psychology 13, 219229.CrossRefGoogle ScholarPubMed
Siever, LJ, Davis, KL (1991). A psychobiological perspective on the personality disorders. American Journal of Psychiatry 148, 16471658.Google Scholar
Skodol, AE, Gunderson, JG, Pfohl, B, Widiger, TA, Livesley, WJ, Siever, LJ (2002). The borderline diagnosis I: Psychopathology, comorbidity, and personality structure. Biological Psychiatry 51, 936950.Google Scholar
Slade, T, Watson, D (2006). The structure of common DSM-IV and ICD-10 mental disorders in the Australian general population. Psychological Medicine 36, 15931600.CrossRefGoogle ScholarPubMed
Torgersen, S, Czajkowski, N, Jacobson, K, Reichborn-Kjennerud, T, Røysamb, E, Neale, MC, Kendler, KS (2008). Dimensional representations of DSM-IV cluster B personality disorders in a population-based sample of Norwegian twins: a multivariate study. Psychological Medicine 38, 16171625.CrossRefGoogle Scholar
Torgersen, S, Kringlen, E, Cramer, V (2001). The prevalence of personality disorders in a community sample. Archives of General Psychiatry 58, 590596.CrossRefGoogle Scholar
Trull, TJ, Jahng, S, Tomko, RL, Wood, PK, Sher, KJ (2010). Revised NESARC personality disorder diagnoses: gender, prevalence, and comorbidity with substance dependence disorders. Journal of Personality Disorders 24, 412426.CrossRefGoogle ScholarPubMed
Üstün, B, Compton, W, Mager, D, Babor, T, Baiyewu, O, Chatterji, S, Cottler, L, Göğüş, A, Mavreas, V, Peters, L, Pull, C, Saunders, J, Smeets, R, Stipec, M-R, Vrasti, R, Hasin, D, Room, R, Van den Brink, W, Regier, D, Blaine, J, Grant, BF, Sartorius, N (1997). WHO study on the reliability and validity of the alcohol and drug use disorder instruments: overview of methods and results. Drug and Alcohol Dependence 47, 161169.Google Scholar
Vollebergh, WAM, Iedema, J, Bijl, RV, de Graaf, R, Smit, F, Ormel, J (2001). The structure and stability of common mental disorders: the NEMESIS study. Archives of General Psychiatry 58, 597603.CrossRefGoogle ScholarPubMed
Vrasti, R, Grant, BF, Chatterji, S, Üstün, BT, Mager, D, Olteanu, I, Badoi, M (1998). Reliability of the Romanian version of the alcohol module of the WHO Alcohol Use Disorder and Associated Disabilities: Interview Schedule – Alcohol/Drug-Revised. European Addiction Research 4, 144149.Google Scholar
Wittchen, H-U (1994). Reliability and validity studies of the WHO-Composite International Diagnostic Interview (CIDI): a critical review. Journal of Psychiatric Research 28, 5784.CrossRefGoogle ScholarPubMed
Yen, S, Shea, MT, Sanislow, CA, Grilo, CM, Skodol, AE, Gunderson, JG, McGlashan, TH, Zanarini, MC, Morey, LC (2004). Borderline personality disorder criteria associated with prospectively observed suicidal behavior. American Journal of Psychiatry 161, 12961298.Google Scholar
Zanarini, MC, Frankenburg, FR, Dubo, ED, Sickel, AE, Trikha, A, Levin, A, Rennolds, V (1998). Axis II comorbidity of borderline personality disorder. Comprehensive Psychiatry 39, 296302.Google Scholar
Zimmerman, M, Mattia, JI (1999). Axis I diagnostic comorbidity and borderline personality disorder. Comprehensive Psychiatry 40, 245252.CrossRefGoogle ScholarPubMed