The Clinical Utility of a Dimensional Classification of BPD - A Literature Review

With the upcoming release of DSM-5, many personality disorder experts have posited the potential success of a dimensional classification system. Borderline Personality Disorder (BPD) is often at the forefront of discussion because it is the most prevalent personality disorder (Skodol et al., 2002) and individuals with BPD have a notoriously low quality of life (Masthoff et al., 2007). While many propositions for specific dimensional models have been introduced, few have examined the clinical utility of such models, which is a continuing concern of many psychologists and psychiatrists. Through a review of existing literature, with consideration for the major aspects of clinical utility, it is evident that a dimensional model of BPD would improve clinical utility and improve the validity of diagnoses.

The BPD construct has caused significant disagreement among researchers and clinicians. These disagreements include not only the clinical utility of the classification of the disorder but also conceptual issues regarding its classification (Griffiths, 2011). Many researchers assert that any taxonomy of psychological disorders is only practical if appropriate for the clinical settings in which patients’ improvement depends upon the quality of their assessment (First et al., 2004; Verheul, 2005).

While clinical utility has been defined in a variety of ways, it generally refers to the ability of the DSM to aid clinicians in carrying out diverse functions in practice (Verheul, 2005; First et al., 2004). Four factors in particular encompass traditional definitions of clinical utility including the following:  (1) ease of usage; (2) case conceptualization; (3) communication; and (4) treatment planning (Widiger & Mullins-Sweatt, 2010; Samuel & Widiger, 2006; Verheul, 2005). With the possible exception of ease of usage, these considerations are undoubtedly predicted by the validity and reliability of the classifications themselves (Verheul, 2005). Additionally, especially with enduring diagnoses, there is growing consideration for the role of stigmatization (Perry, 2011; Rusch et al., 2006; Servais & Saunders, 2007). Though stigma is not a conventional factor of clinical utility, recent research has underscored the impact of a permanent label on a patient’s progression (Kendell, 2002; Aviram, Brodsky, & Stanley, 2006; Servais & Saunders, 2007).

In terms of clinical utility, ease of usage is often cited as an advantage of the current categorical system of DSM-IV-TR (First et al., 2004; Spitzer et al., 2008). A classification system that is easy to use should never be pursued at the cost of validity or patient treatment, but remains a priority. Currently, the taxonomy is conceptually simple, but at the expense of scientific value (Verheul, 2005). Additionally, the DSM-IV-TR model is often rated easier to use as a result of clinicians’ familiarity with these criteria. The adoption of a new, dimensional model for BPD would call for clinicians to become familiar with a novel set of criteria; however, this is not a sufficient reason to uphold invalid criteria that do not serve the patient as well. Once accustomed to a dimensional trait model of BPD, it is likely that clinicians would find it as easy to use as the DSM-IV-TR, but with added benefits in other areas of diagnosis.

Case conceptualization refers to the ability of practitioners to comprehend the pathology of the client. With regard to the DSM-IV-TR criteria for BPD, a patient with five out of nine symptoms leads to one of 151 possible diagnosis combinations (Krueger & Eaton, 2010). BPD is a unified concept and therefore, can homogenize a diverse group of people (Widiger & Trull, 2007; Aggen et al., 2009). Moreover, the current classification focuses on observable behavior (Rottman et al., 2011). This approach further limits the impression of a disorder through lack of consideration for other aspects (Skodol et al., 2002) such as stable underlying traits. Some studies have shown that the persistent aspects of BPD are trait-like, while the observable behaviors are often periodic (McGlashan et al., 2005; Zanarini et al., 2007). Dimensional trait-system models excel in the amount of imperative information supplied to clinicians (Clark, 1993; Widiger & Mullins-Sweatt, 2010). With a trait-system for BPD, a clinician can appreciate a patient’s relative levels of relevant traits. This provides information regarding the areas that need the most attention as well as areas that are affected, but possibly at a lower threshold. Therefore clinicians approach BPD through a phenomenological lens (Mackenzie, 1987) with a richer, more specific description of the patient’s pathology (Stone, 1997).

A clinician’s ability to accurately conceptualize BPD undoubtedly guides the quality of communication between practitioners and between the client and the practitioner. While the DSM-IV-TR criteria allow the clinician to readily report a client’s status as “BPD” or “not BPD,” this distinction does not relay much information to the patient nor to other clinicians.  Clients often do not fit neatly into either category. The descriptive, individual nature of dimensional, trait-based diagnoses allows for the client to feel more understood, which may facilitate a deeper therapeutic alliance (Stone, 1997). Furthermore, the detailed client profile of a trait-centered model improves communication between clinicians through more meaningful descriptions. Rather than a polarized presence or absence of a diagnosis, clinicians can offer more specific, vivid information about the patient.

Disappointingly, a permanent label may be the only influential information a DSM-IV-TR BPD diagnosis communicates. From the client’s perspective, the diagnosis of a “personality disorder” in general is often received as a fundamental error of the client’s structure. This opposes the notion that it can be changed (Adebowale, 2010; Kendell, 2002). For BPD patients particularly, a pervasive brand can perpetuate a hopeless outlook and the internalization of such a label can interfere with therapeutic progress (Servais & Saunders, 2007). Because trait-systems lack a diagnostic label, patients are no longer pushed to accept a diagnosis as a deficiency of their being. They are instead told that they score at a certain point on a trait dimension – one on which all people have a score.

In terms of treatment planning, a dimensional trait model of BPD provides the clinician with salient information to help predict a client’s progress in therapy (Mackenzie, 1987). Treatment plans are made according to specific symptoms rather than a whole diagnostic construct. Treatments that are most successful for people with a similar level of a trait can be made available to the clinician who can therefore customize treatments to the client. The clinician can be aware of issues that may arise, level of response to treatment (Widiger, 1997), and choose techniques in accordance with the client’s strengths and weaknesses. Research reflecting the effectiveness of different kinds of therapy for people with BPD has emphasized the importance of customizing treatment plans to the specific symptom pattern of the individual (Goldman & Gregory, 2010; Soloff, 1998).

The primary goal of the DSM-IV-TR is to aid clinical practice (APA, 2000). Unfortunately, categorical classification of Borderline Personality Disorder is not the most effective taxonomy to accomplish this task. Higher clinical utility of any diagnostic system means psychologists and psychiatrists can better understand their client’s individual needs and more easily lead the client to congruous treatment in a timely matter (Clark, 1993; Verheul, 2005). A dimensional model of BPD would likely improve clinical utility in nearly all aspects. Most importantly, it has the potential to improve the prognosis of BPD.

Colleen Coyne is a recent graduate of the University of Minnesota with a major in Psychology and a minor in Spanish studies. She currently works at the University of Minnesota Amplatz Children’s Hospital as a Psychiatric Associate in an adolescent mental health unit. She plans to apply to Ph.D. programs in the future to pursue a combination of research and clinical experience in psychology. 


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