تحلیل عاملی اکتشافی از معیارهای اختلال شخصیت مرزی در بیماران سرپایی اسپانیایی تک زبانه با اختلالات مصرف مواد

This study examined the factor structure of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for borderline personality disorder (BPD) in Hispanic patients. Subjects were 130 monolingual Hispanic adults who had been admitted to a specialty outpatient clinic that provides psychiatric and substance abuse services to Spanish-speaking individuals. All were reliably assessed with the Spanish-Language Version of the Diagnostic Interview for DSM-IV Personality Disorders. After evaluating internal consistency of the BPD criterion set, an exploratory factor analysis was performed using principal axis factoring. Results suggested a unidimensional structure, and were consistent with similar studies of the DSM-IV criteria for BPD in non-Hispanic samples. These findings have implications for understanding borderline psychopathology in this population, and for the overall validity of the DSM-IV BPD construct.

For well over a quarter century, considerable attention has been focussed on refining the ‘borderline’ construct. Based in part on the work of Gunderson and Singer (1975) and Spitzer et al. (1979), Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III) (American Psychiatric Association [APA], 1980) subdivided this area of psychopathology into borderline and schizotypal personality disorders. Despite this refinement – and despite subsequent adjustments to the diagnostic criteria in DSM-III-R (APA, 1987) and DSM-IV (APA, 1994) – the borderline personality disorder (BPD) construct remains heterogeneous (Sanislow and McGlashan, 1998). This heterogeneity is partly inherent in the polythetic nature of the diagnosis (Skodol et al., 2002). In addition, patients with BPD comprise a heterogeneous group, often manifesting a wide variety of co-morbid axis I and axis II disorders (Oldham et al., 1992 and Oldham et al., 1995). Such heterogeneity has been variously interpreted as demonstrating poor validity of the BPD construct and also as being one of its strengths (Clifton and Pilkonis, 2007). One approach to examining this clinical heterogeneity has been through factor analytic techniques. Factor analysis can empirically identify meaningful components or latent elements within a diagnostic construct. Several such studies, using DSM criteria for BPD, have been reported (Rosenberger and Miller, 1989, Clarkin et al., 1993, Fossati et al., 1999, Sanislow et al., 2000, Whewell et al., 2000, Sanislow et al., 2002, Johansen et al., 2004, Becker et al., 2006 and Clifton and Pilkonis, 2007). One study used DSM-III criteria in college students (Rosenberger and Miller, 1989), one used DSM-III-R criteria in adolescent inpatients (Becker et al., 2006), four used DSM-III-R criteria in adult patients (Clarkin et al., 1993, Sanislow et al., 2000, Whewell et al., 2000 and Clifton and Pilkonis, 2007), and three studied DSM-IV criteria in adult patients (Fossati et al., 1999, Sanislow et al., 2002 and Johansen et al., 2004). Three studies in adult populations – all of which used confirmatory factor analysis – were consistent with a unidimensional construct (Fossati et al., 1999, Johansen et al., 2004 and Clifton and Pilkonis, 2007). Other adult studies, however, have suggested multiple dimensions. Rosenberger and Miller's (1989) exploratory factor analysis revealed two factors — the first including interpersonal and identity criteria, and the second encompassing dysregulation of behaviour and affect. Because most of the criteria loaded on both factors, however, these authors suggested that the BPD criteria could not be clearly distinguished by these underlying factors. Whewell et al. (2000) used exploratory methods to identify two factors — roughly corresponding to the impulsive and borderline subtypes of ICD-10 emotionally unstable personality disorder. Clarkin et al.'s (1993) exploratory analysis revealed three factors — disturbed identity and interpersonal relationships, affective dysregulation (including suicidality), and impulsivity. Sanislow et al. (2000) also used exploratory methods and DSM-III-R criteria, but found three somewhat different factors — disturbed relatedness, behavioural dysregulation, and affective dysregulation. Using DSM-IV criteria and a separate sample, Sanislow et al. (2002) attempted to validate this three-factor model via confirmatory factor analysis. Although these authors noted that a unitary construct provided a good fit with their data, the three-factor model was significantly better. Our own exploratory study of adolescents revealed four factors that differ from those reported in the adult studies, suggesting that developmental processes may affect the underlying structure of BPD (Becker et al., 2006). Inasmuch as these components may reflect core dimensions of borderline psychopathology, this type of analysis has important theoretical and clinical implications (Skodol et al., 2002). The aim of this study was to examine the factor structure of the DSM-IV criteria for BPD in individuals who had been reliably assessed with semistructured interviews, and to do so with a study group of monolingual Hispanic patients. Subjects were Hispanic outpatients receiving mental health and addiction services in a community-based programme. Because research in this area of psychopathology has consistently documented the co-occurrence of BPD with substance use disorders (Grilo et al., 1997 and Skodol et al., 1999), we felt that this study group would represent a population in which BPD is clinically relevant. By using a Hispanic group, we hoped to contribute to a small body of literature on personality pathology in the nation's largest, and fastest growing, minority population. While considerable research has documented frequency differences by ethnicity for a broad range of psychiatric disorders (Baskin et al., 1981, Adams et al., 1984 and Karno et al., 1987), very few have made comparisons that included Hispanic subjects and the BPD diagnosis. Although one such study found no differences between Hispanics and other ethnic groups (Castaneda and Franco, 1985), another study found a higher rate of BPD among Hispanic subjects (Chavira et al., 2003). Potential explanations for the latter finding include the negative psychological effects of acculturation, as well as diagnostic bias due to language or cultural differences (Baskin et al., 1981 and Chavira et al., 2003). Beyond these studies of disorder frequency, many have argued that culture – which, in part, can be seen as the shared values, beliefs and attitudes of a group – will affect both personality development and the clinical phenomenology of mental illness (Marsella, 1988 and Sundbom et al., 1998). While some studies have demonstrated that the underlying structure of personality is similar across cultures (McCrae and Costa, 1997) – and between Hispanic and non-Hispanic cultures in particular (Benet-Martínez and John, 1998) – one study has suggested that cultural factors may be an important determinant of personality pathology within Hispanic populations (Gibbs, 1982). And, indeed, there are aspects of Hispanic (or Latino) cultures which may be relevant to the structure of BPD and other personality disorders (Long and Martinez, 1997, Benet-Martínez and John, 1998 and Grilo et al., 2003). In particular, the cultural psychology literature has documented that, compared to non-Hispanic Anglo groups, Hispanic/Latino groups tend to be less individualistic, and subscribe to a set of cultural values that are believed to play a significant role in their lives (Comas-Díaz, 1996). These values include confianza (trust and intimacy in a relationship), personalismo or simpatía (valuing interpersonal harmony, relating to others on a personal level, and the avoidance of interpersonal conflict), and familismo (placing a strong emphasis on the importance of family as the center of one's experience, and on the primacy of collective over individual values). Finally, Hispanic culture has been characterised as having distinct gender–role expectations, such as machismo for men and marianismo for women ( Andrés-Hyman et al., 2006). Given their importance in Hispanic populations, researchers have recommended that these values be understood and used in clinical work with Latino groups ( Bracero, 1998, Falicov, 1998, Santiago-Rivera et al., 2002, Añez et al., 2005, Andrés-Hyman et al., 2006 and Añez et al., 2008).