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Mark Zimmerman, MD, 146 West River Street, Providence, RI 02904, USA. Email: [email protected]
Declaration of interest
None.
Borderline personality disorder (BPD) is a serious illness resulting in high levels of psychosocial morbidity, 1 reduced health-related quality of life, 2 high use of services 3 and excess mortality. 4 The underrecognition of BPD has been identified as a significant clinical problem. 5 When clinicians conduct a diagnostic interview they typically screen for disorders that are comorbid with the principal diagnosis by asking about the comorbid disorders' necessary feature or ‘gate criterion’. For example, in a patient with a principal diagnosis of major depressive disorder the clinician would enquire about the presence of panic attacks, excessive worry or substance use to screen for the presence of panic disorder, generalised anxiety disorder (GAD) or a substance use disorder. In contrast, for polythetically defined disorders such as BPD there is no gate criterion because it is diagnosed on the basis of the presence of at least five of nine criteria, none of which is required to be present. The goal of the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project was to determine whether it is possible to identify one or two BPD criteria that could serve as ‘gate’ criteria to screen for the disorder. We hypothesised that affective instability, considered by Linehan to be of central importance to the clinical manifestations of BPD, 6 could function as such a gate criterion because prior small-scale studies have found that it is the most frequent of the BPD criteria. 7–9
Method
The Rhode Island MIDAS project represents an integration of research methodology into a community-based out-patient practice affiliated with an academic medical centre. A comprehensive diagnostic evaluation is conducted upon presentation for treatment. In total, 3674 patients were interviewed by a diagnostic rater who administered a modified version of the Structured Clinical Interview for DSM-IV (SCID) 10 and the BPD section of the Structured Interview for DSM-IV Personality (SIDP-IV). 11 The majority of the patients were female (60.2%), and White (87.1%), with a mean age of 38.8 years (s.d. = 3.4). The most common current diagnoses were major depressive disorder (41.8%), panic disorder (17.1%), social anxiety disorder (28.1%) and GAD (21.9%). By...