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SELF REPORT MEASURE FOR BORDERLINE PERSONALITY TRAITS IN CLINICAL POPULATION.

Byline: Mirrat Gul Butt, Zahid Mahmood and Sadia Saleem

ABSTRACT

Objective: To develop an indigenous self-report measure for borderline personality traits in a clinical sample.

Methodology: During the first phase, phenomenology was explored by conducting in-depth interviews of 15 diagnosed patients. The repeated and dubious responses were screened out that resulted in the production of a league table. Five experienced clinical psychologists and five psychiatrists validated the items and as a result, 33 items of the scale were retained out of 44 items. This preliminary study was conducted on 81 diagnosed participants (24 males and7 females) who were selected through purposive sampling technique. All the participants were diagnosed by expert psychologists and psychiatrists.

Results: Factor analysis revealed two factors namely mood liability and insecure dependence respectively. Significant positive correlation was found between Borderline personality traits scale (BPTS) and Zanirini borderline personality disorder scale (ZAN-BPDS). The internal consistency of the scale was excellent with Cronbach's alpha value of .87.

Conclusion: The scale can be used on Pakistani population without any language or comprehension barrier.

Key Words: Mood liability, Insecure dependence, Borderline personality traits.

INTRODUCTION

In the course of recent two decades, borderline personality disorder (BPD) has got the center place in the psychiatric and psychological issues. In contrast to previous ignorance, current evidences suggest that individuals with borderline personality disorder are being adequately treated and a considerable number of patients with BPD are recovering after getting advance interventions1. New discoveries arouse out of psychometrics to hereditary qualities, are incredibly helping to expand insight into the neurobiology and etiology of BPD2.

Borderline personality disorder (BPD) is characterized as unavoidable feeling of insecurity, poor interpersonal connections, low self-view and low motivational control in both clinical and non-clinical tests1-3. BPD is connected with extreme useful impedance, high rates of suicide and co-happening psychiatric clutters, concentrated utilization of treatment and high expenses to society4. Reaction towards sensitivity is very important characteristic of BPD, level of self-esteem found to be a relevant factor in the relationship between rejection sensitivity and BPD symptoms severity5.

During the late 1980s and early 1990s, the percentage of BPD patients visiting psychiatric settings for treatment was around 20% as inpatients and 10% as outpatients6,7.

A few analysts recommend that BPD (like other personality disorder) can be simplifed by boundaries of common individuality and effectively assessed by utilizing self-report scales8. Researchers shared that the great fluctuation in BPD cannot be clarified by typical identity measurements9. There is no single highest quality level for analyzing BPD crosswise over clinical and group tests as both expressive convention and self-report measures have few limitations10.

The efficacy of interpersonal measures for the assessment of other personality disorders stresses the importance of new BPD scale development. Many researchers evaluated the interpersonal manifestation of BPD and trusted that the BPD scale would give a moderately proficient and adaptable method to assess BPD features in that it was planned to allow scoring in view of any liberal interpersonal collaboration e.g., the interview at the time of admission, organized clinical interview and treatment session11-13.

As far as Pakistan is concerned, literature review shows no research with a scale development to assess and measure BPD characteristics with a cultural perspective and norms. Borderline personality disorder is such a complex phenomenon that it has a long lasting impact on the growth and development of an individual. This complexity also highlights the importance of further research on this disorder. It is a nature's phenomenon that culture shapes and determines our way of relating with other people. The clash between interests of the individual and the group is universal at the bio-psycho-social levels; where the group exerts influence to control and regulates the behavior of the individual. While the individual strives for developing the growth of the self and its uniqueness.

Therefore, it would be interesting to develop a BPD scale. As mentioned earlier, there is a dearth of local literature on BPD scale and also keeping in mind the cultural influence of the experience and expression of psychologic l phenomena, there is a need of developing a valid and reliable scale. This will also help in identifying symptoms of individuals suffering from BPD at early stages leading to early treatment rather than touching BPD's intensity levels where the damage would be in its prime.

METHODOLOGY

In-depth interviews with 15 participants, 4 males and 11 females within the age range of 18-25 years, were conducted in order to explore the phenomenology of borderline personality. All these participants were selected through purposive sampling technique were diagnosed independently by a psychiatrist and a clinical psychologist in order to control any biasness. Approximately 80% correlation was found between the diagnosis of psychiatrists and a clinical psychologists, the clinical psychologists used the diagnostic criteria mentioned in DSM-511 and most of the psychiatrists preferred to follow ICD-10 to diagnose these participants14.

While developing an indigenous scale to assess borderline personality, the participants suffering from BPD were asked open ended questions about their presenting complaints, feelings and symptoms. The questions were like, how they mostly feel? How they usually express their emotions? What are their usual complaints? What do they know about their illness and its treatment? How they express themselves; particularly how they experience emotional states and their reactions; their views about themselves and about the people around them; their relationships; and their childhood experiences. It was done to gain a broader and actual unstructured view about the BPD presentation in Pakistani culture. An item pool of 44 items was prepared after content analysis and exclusion of dubious, confusing and jargon statements.

In second phase of the scale development, 8 clinical psychologists and 5 psychiatrists from Lahore working at different psychiatry departments and dealing with indoor and out-door patients for the last 5 years in the public sector were approached for expert validation of the items. Two clinical psychologists were busy and one had no experience working with people suffering from borderline personality disorder. After getting consent, five clinical psychologists and five psychiatrists were approached and were explained about the study and their contribution. While showing them the 44 items league table they were instructed to choose that how well a statement defines the symptoms of borderline personality; which item is more relevant and explains borderline personality and clearly elucidates its traits.

They have to categorize each item on 4 points Likert scale ranging from 0 to 3 points (from strongly agree to strongly disagree). In this way, the highest score of the scale would be 30 points showing the intens BPD; high score, high BPD and low score, low BPD. After collecting the responses of 10 experts, 33 items were retained which scored high in the league table. The cutoff point was 10.

Phase 3 constituted a pilot study which was conducted on 10 diagnosed patients (4 males and 6 females) suffering from borderline personality disorder to ensure the comprehension of the instructions and items. Zanarini rating scale for borderline personality disorder (ZAN-BPD)14 and Gul Mahmood borderline personality traits scale (GM-BPTS) were administrated. Each participant on average took maximum 10 minutes to complete both the scales. Both the scales were applied on bilingual participants therefore the instructions were simply given to them bilingually for the better understanding of participants. Participants reported no difficulties to respond the items of the scales. Same scales were used in the main study too.

A Bio-data form made by the researcher was used to collect the information about the participant. The psychiatrists and clinical psychologists diagnosed participants through the criteria mentioned in International classification of mental and behavioral disorders (ICD10)15 and diagnostic and statistical manual of mental disorders fifth edition (DSM-5)11 respectively to assess and diagnose borderline personality traits.

Zanarini rating scale for borderline personality disorder (ZAN-BPDS)14 is a proficient self-report measure that helps to measure the changes in intensity and severity of borderline psychopathology. It includes 09 major areas with a five point Likert scale ranges from 0 to 4 that helps to assess the severity level. The scale is based on DSM-4 criteria. Its convergent validity is high (with a median value of 0.70). The internal consistency of the 09 criteria is good (Cronbach's alpha=0.84). In this present study, ZAN-BPD14 is used for developing construct validity of GM-BPTS.

Gul Mahmood Borderline Personality Traits Scale (GM-BPTS) is an indigenous self-report measure which will be used to collect the data for developing its psychometric properties.

The participants were selected through purposive sampling technique. The sample (n =81) was collected from teaching hospitals, psychiatric rehabs and drug addiction centers, with the age range of 18 to 45 years. Both males and females partcipated in the study. The patients suffering from any general medical condition, intellectual disability, active psychotic symptoms and organic brain syndrome were not included in the study.

Subjects diagnosed by a psychiatrist and a clinical psychologist, suffering from borderline personality traits/disorder were included in the research with an informed consent mentioning the purpose of the study and their role and rights. Confidentiality, privacy and anonymity of participants were assured. Clear instructions and assistance were given to the participants in order to minimize the errors and lie responses. The demographic form was then filled by the therapist. ZAN-BPD14 was used in its original form therefore the bilingual participants were asked to fill both ZAN-BPD and GM-BPTS, for the purpose of construct validity (62 participants). It took 5 minutes to complete ZAN-BPD to the participants and maximum 7minutes time to complete GM-BPTS.

SPSS version 22 was used to develop psychometric properties of the scale and for data analysis. The data was analyzed through scree plot, factorial structure, correlation and independent t-test. Pearson correlation was used to analyze the relationship between GMBPTS and ZAN-BPDS to find out the concurrent validity of the scale. Exploratory factor analysis was done and varimax rotation was used to obtain the main factors of the scale. Scree plot and Eigen value greater than 1 criteria was used. Initially 5, 4 and 3 factors solutions were tried but 2 factors solution was proved to be the best fit, showing the clear factorial structure. In the final scale, 33 items were retained whose factor loading was more than .40.

As the population was specific and results were more skewed therefore to see a better picture of the scale, the factor loading was raised to .40 but the Eigen value remained 1. On the basis of close examination of the items corresponding to each factor and the theme, each factor was assigned a label on the basis of the commonality of the themes emerged by the researcher.

RESULTS

The Scree plot is showing Eigen values and number of factors that could be retained. The Scree plot helped in determining the number of factors. Kaiser-Guttman's retention criterion of Eigen values, results revealed six factors having Eigen value greater than 1. The KaiserMeyer-Olkin (KMO) value was found to be .77 and Barttlet test was found significant at p <001. The results indicated a .868 Cronbach's [alpha] which indicates an excellent internal consistency.

Item analysis was also carried out with computation of item-total correlation on 33 items; 28 items showed significant item-total correlation. Two Factor solution was obtained. Table 1 shows high inter-item correlation. The criteria for retaining items in a factor was .30 or above and the items falling within this range was retained in that particular factor. Those items with dubious loading, the content of the item was considered for the appropriateness of the retention in a particular factor.

The first factor of the scale (mood liability) consisted of 14 items. A high score on this sub-scale refers to a tendency and feeling of inferiority, irritability, impulsivity, unmanageable mood shifts and angriness in the presence of others. The sample items include, for example, I have felt angry immediately; irritated by people; getting aggressive every time; fear of people loss; difficulty in decision making and so on.

The second factor of the BPD (insecure dependence) consists of 14 items. A high score in this sub-scale denotes to a feeling of inferiority, worthlessness, and low self-esteem in the presence of others. The sample items include, looking up to others; feeling inferior; unable to relate to others; unable to convince others; unable to communicate with others; worrying about what other people think of me; and so on.

The split half reliability of GM-BPTS was calculated by odd and even method. The test was divided into two halves, form A and form B, the internal consistency of form A was .73 and form B was .86 respectively. The correlation between the two halves was found to be r =.69 indicating high split half reliability of the scale. The concurrent validity of GM-BPTS r=.68 (p <.01) showing significantly high relationship between the GM-BPTS and ZAN-BPDS scales.

Independent sample t-test was applied to measure the gender difference among personality traits of males and females and results indicated no significant difference between borderline personality traits in both the genders.

DISCUSSION

Borderline personality disorder (BPD) is a common and genuine psychiatric issue. It could be a legitimate psychiatric issue with a very much portrayed clinical picture14-16. Researchers emphasized that although the number BPD symptoms are present in psychiatric comorbidity and functional disability at a moderate level, still it needs to be identified and assessed in clinical practice and research17. When we associated BPD with interpersonal issues, there was tendency to overlook certain "sorts" which may otherwise actually be the major intervening factors. Hence the behaviors observed on the general level to be categorized as symptoms of BPD requires expanding the spectrum of behaviors.

Table 1: Factor structure, Eigen values and item correlation of 33 items

S.###Mood Liability###Insecure Dependence

No.###Item No.###FI###Item No.###FII

1.###2###.48###3###-.33

2.###4###.45###5###-.51

3.###8###.65###6###-.35

4.###14###.62###7###-.31

5.###17###.56###9###-.52

6.###19###.64###10###-.28

7.###22###.61###11###-.33

8.###23###.55###12###-.08

9.###24###.37###13###-.06

10.###26###.40###16###.1

11.###28###.60###21###-.29

12.###30###.58###25###.16

13.###32###.57###29###-.09

14.###33###.54###31###-.25

Eigen Values###3.39###3.35

Variance###1.19###1.25

In the current study, the common borderline personality traits as experienced by patients were fear of people loss, feelingof inferiority, irritability, impulsivity, unmanageable mood shifts and angriness in the presence of others and transformed into a 4-point self-report scale. Factor analysis of 33 items revealed two factors namely; mood liability and insecure dependence. The factor structure is found to be different from previous measures18. The common pattern of mood liability is to leave one's aim before completion. Other pattern is always having a feeling of emotional torture. BPD is connected with serious sort of mistakes at work place10,19. The lack of social interactions and the expression of mood liability are related to making impulsive decisions without thinking.

It is also interesting to note that contrary to literature, getting aggressive about everything, ups and downs in behavior and feeling broken into parts were found in people with BPD, but Zaranini scale did not found these traits. Yet one of the most striking features of the patterns was the feeling of emptiness in life. The people who face emptiness in life may lose their interest in life as well. They thought that people will not live up to their expectations. They also feel that no one understands them and most of the time, complain about others. This may lead them to frustration which could be released by torturing themselves.

Insecure dependence on the other hand, would invite rejection from those whom they love and this makes them more vulnerable of being isolated that worsen their internal suffering20. They become more sensitive and face problems while making decisions. Another important difficulty associated with all this is inferiority complex. They tend to seek support from others and are afraid of losing someone, at most of the times in life. They want to develop a long term relation with others and don't want to lose any of their important relation. It is the key to create and shore up one's singularity and is to keep up unmistakenly characterized limits.

Generally the relationship turns out to be to some degree of puerile, weak and introverted21. Consequently, such type of relationship might be agreeable in short run, however could be backward and choking over the long haul. Such nerves and dread tend to raise their heads every once in a while and one needs to figure out how to manage the issues viably and in a developed ways. In a dependable and tasteful relationship, it is crucial to indicate shared regard for distinction, bolster, cooperative way to deal with conformity, and space for self-improvement22,23.

People facing insecure dependency also suffer from feeling of loneliness and regretting after taking decisions. Moreover, they are unable to control their negative thoughts. They felt deprived themselves and have fear of refusal and rejection. Previous literature indicates that BPD is connected with expanded danger for self-hurting and self-destructive practices24. However, the results of Pearson correlation revealed a significant positive relation between BPTD and ZAN-BPD scale. On the other hand, t-tests outcomes indicated that female were more vulnerable and have to face borderline personality traits as compared to males. This might be due to the different living style as in Pakistan both male and female have their own style of living as well as social interaction and responsibility.

CONCLUSION

The current research was a pulverized contravention work to measure borderline personality traits in BPD patients. Psychometric properties ensure the suitability of the scale for measuring borderline personality traits among adolescents in clinical and counseling settings. The scale can be used on Pakistani population without any language or comprehension barrier.

RECOMMENDATIONS

This was pioneer step towards measuring personality traits of adolescents and adults. The scale can be translated in local different languages to apply for screening and assessing the patients on larger levels. This research will further help in better understanding of the multifaceted and dynamic nature of borderline personality traits. The study can be replicated and as it can provide new direction to researchers investigating personality traits as determinants of clinical practice outcomes. These findings may be useful for psychiatrist, psychologist, counselors to develop intervention strategies and training programs. The sample was a reliable representation of the city of Lahore but may lose generalizability in other cities of the country.

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Publication:Journal of Postgraduate Medical Institute
Article Type:Report
Geographic Code:9PAKI
Date:Dec 31, 2017
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