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Journal of Abnormal Psychology August 2000 Vol. 109, No. 3, 451-460
© by the American Psychological Association For personal use only--not for distribution.
Borderline Personality Disorder Symptoms as Predictors of 4-Year Romantic Relationship Dysfunction in Young Women Addressing Issues of Specificity Shannon E. Daley Department of Psychology University of Southern California Dorli Burge Department of Psychology University of California Constance Hammen Department of Psychology University of California ABSTRACT The relationships between romantic relationship dysfunction and symptoms of borderline personality disorder (BPD), other personality disorders, and depression were examined prospectively in a community sample of 142 late adolescent women. Although BPD symptoms predicted 4-year romantic dysfunction (romantic chronic stress, conflicts, partner satisfaction, abuse, and unwanted pregnancy), the associations were not unique to BPD. Instead, relationship dysfunction was better predicted by a cumulative index of non-BPD Axis II pathology. Depression did not predict outcomes uniquely when Axis II symptoms were included, except in the case of unplanned pregnancy. The results suggest that although BPD is associated with relationship dysfunction, the effect is a more general phenomenon applying rather broadly to Axis II pathology. The results also highlight the importance of subclinical psychopathology in the construction of early intimate relationships.
Portions of this article were presented at the annual meeting of the Society for Research in Psychopathology, October 1997. This research was supported by a National Research Service Award (NRSA) postdoctoral fellowship (through National Institute of Mental Health NRSA Grant 5 T32 MH 14584) and by an award from the William T. Grant Foundation. We gratefully acknowledge Joanne Davila, David S. Herzberg, Nangel Lindberg, Blair Paley, and Karen D. Rudolph for their involvement in conducting interviews and thank Aimee Keen and Dina Schultz for administrative support and data entry. Correspondence may be addressed to Shannon E. Daley, Department of Psychology, University of Southern California, Seeley G. Mudd Building 501, Los Angeles, California, 90089-1061. Electronic mail may be sent to
[email protected] Received: March 16, 1998 Revised: December 15, 1999 Accepted: January 7, 2000
Borderline personality disorder (BPD) is conceptualized to a substantial degree in terms of maladaptive interpersonal functioning. For instance, the presence of unstable, intense interpersonal relationships is among the most useful criteria in identifying individuals with BPD ( Modestin, 1987 ; Nurnberg, Hurt, Feldman, & Suh, 1988 ; Widiger & Frances, 1989 ). Theoretical conceptualizations of BPD often suggest the existence of disturbed working models of attachment relationships ( Sabo, 1997 ; Westen,
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1991 ). Indeed, empirical work has demonstrated that individuals with BPD have more malevolent or hostile representations of significant others and of relationships ( Benjamin & Wonderlich, 1994 ; Nigg, Lohr, Westen, Gold, & Silk, 1992 ; Segal, Westen, Lohr, Silk, & Cohen, 1992 ) and demonstrate a more insecure attachment style ( Patrick, Hobson, Castle, Howard, & Maughan, 1994 ; Sack, Sperling, Fagen, & Foelsch, 1996 ) than psychiatric or normal controls. However, despite the diagnostic and theoretical centrality of interpersonal disturbance to BPD, the actual relationship behavior of individuals with BPD has received limited empirical attention. The purpose of this article is to examine the impact of subclinical BPD features on one aspect of interpersonal functioning, romantic relationships, in a community sample of late adolescent women. The extant empirical data certainly suggest that interpersonal disturbance is present in the context of BPD. For instance, BPD has been shown to be associated with a lower likelihood of being married ( Schwartz, Blazer, George, & Winfield, 1990 ; Zimmerman & Coryell, 1989 ) and a higher number of breakups of important relationships ( Labonte & Paris, 1993 ) in adults, as well as a shorter duration of friendships, lack of a confidant or romantic partner, and fewer social activities in adolescents ( Bernstein et al., 1993 ). Likewise, undergraduates with greater BPD features have been shown to report more interpersonal distress, both at the time of the BPD assessment ( Trull, 1995 ) and 2 years later ( Trull, Useda, Conforti, & Doan, 1997 ). There are several limitations, however, in the literature to date pertaining to BPD and interpersonal functioning. First, most of the available investigations of BPD features and interpersonal adjustment have relied on cross-sectional or retrospective methods of assessment ( Perry, 1993 ). Accordingly, the direction of the relationship between BPD features and interpersonal functioning is unclear. Second, most of the available studies have relied on limited measures of self-reported social functioning. Much of the work on descriptive psychopathology in general, and on personality disorders (PDs) in particular, has inadequately measured interpersonal functioning. Such measures often have been limited to marital status and the participant's own report of interpersonal functioning. The contexts of individuals' lives are poorly captured in such summary measures and may be distorted by the subjective impressions or mood of the person at the time of completing a questionnaire. A third limitation of the literature to date pertains to the issue of specificity. Extensive empirical data indicate significant comorbidity between depression and Axis II disorders ( Farmer & Nelson-Gray, 1990 ; Gunderson & Phillips, 1991 ), an association that has been demonstrated in the present sample as well ( Daley et al., 1999 ). A relationship between depression and interpersonal dysfunction also has been amply demonstrated (e.g., Barnett & Gotlib, 1988 ; Beach, Sandeen, & O'Leary, 1990 ; Segrin & Abramson, 1994 ), including the association between depression and the subsequent generation of stressful interpersonal events ( Daley et al., 1997 ; Davila, Bradbury, Cohan, & Tochluk, 1997 ; Hammen, 1991 ; Potthoff, Holahan, & Joiner, 1995 ) and that between adolescent depression and young adult relationship dysfunction ( Kandel & Davies, 1986 ). Given these associations, it is important to consider whether a relationship between BPD and interpersonal disturbance might be merely a function of comorbid depression. A similar problem exists with regard to non-BPD Axis II symptomatology. The extent of comorbidity among the Axis II disorders and the substantial correlations between criteria of different PDs are significant enough to raise questions about the degree to which individual diagnoses actually represent discrete entities ( Clark, 1992 ; Clark, Livesley, & Morey, 1997 ; Livesley & Jackson, 1991 ; Widiger et al., 1991 ). Consistent with the high rates of co-occurrence of various Axis II disorders, several studies have found that the presence of any PD is associated with interpersonal impairment, including poorer social support and greater severity of psychosocial stressors ( Pfohl, Stangl, & Zimmerman, 1984 ); risk of being single, separated, or divorced ( Flick, Roy-Byrne, Cowley, Shores, & Dunner, 1993 ; Pfohl et al., 1984 ; Samuels, Nestadt, Romanoski, Folstein, & McHugh, 1994 ); decreased reciprocity in the
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social network ( Reich, 1990 ); and poorer social adjustment ( Andreoli, Gressot, Aapro, Tricot, & Gognalons, 1989 ; Shea et al., 1990 ). Indeed, in comparing BPD with other Axis II disorders, Modestin and Villiger (1989) found similar levels of global social adjustment. Thus, in investigations of interpersonal disturbance, it appears important not only to account for co-occurring Axis I symptomatology, such as depression, but also to consider coexisting Axis II pathology. A fourth issue in the BPD literature to date is that the majority of research has been based on individuals meeting formal diagnostic criteria for BPD, typically in treatment-seeking populations. Such clinical populations may be characterized by a greater level of dysfunction than would be seen in the community ( Cohen & Cohen, 1984 ). In addition, the existing literature indicates that PD symptomatology is best conceptualized as existing along a continuum, with meaningful individual differences being observed beyond the simple presence or absence of a categorical diagnosis ( Klein, 1993 ; Widiger & Frances, 1985 ). Given that many of the thresholds for diagnosing PDs are fairly arbitrary ( Widiger, 1992 ), "subclinical" PD symptoms may be important in terms of distress and dysfunction. Indeed, among Axis I disorders, increasing evidence points to considerable dysfunction associated with subclinical symptoms, prompting interest in the study of these conditions in their own right ( Depue et al., 1981 ; Gotlib, Lewinsohn, & Seeley, 1995 ; Johnson, Weissman, & Klerman, 1992 ). In light of the dimensional nature of Axis II disorders, it seems likely that a range of subclinical BPD symptomatology exists in the community at large and that these symptoms may have important ramifications for functioning, an area that cannot be addressed adequately by studies of clinical samples. Thus, in this study, we examined the significance of subclinical BPD features in a community sample of late adolescent women. In the present study, we sought to describe the topography of romantic relationships in young women, as a function of initial BPD symptomatology, through detailed life stress interviews conducted by trained staff unaware of the degree of participants' PD symptomatology. These interviews, conducted at six points over a 4-year period, yielded information about the nature and timing of relationship changes and associated events, such as arguments, pregnancies, and abuse. Informant reports also were obtained from romantic partners. Although highly labor intensive, such interview and assessment procedures reliably map the rich details of interpersonal functioning and help to examine the hypothesis that BPD features are associated with relationship maladjustment. In addition, we examined questions of specificity in regard to both depression and co-occurring non-BPD Axis II symptomatology. Our specific hypotheses about particular aspects of relationship functioning in conjunction with borderline symptoms stem largely from the clinical description of BPD. The impulsivity associated with BPD might lead individuals to enter into relationships with less forethought and evaluation of the appropriateness of potential partners. Coupled with inappropriate expression of anger and fluctuations between idealization and devaluation of partners, this may lead to more conflictual relationships, greater romantic stress, and risk of being involved in an abusive relationship. The impulsivity seen in BPD also might be related to risk of unplanned pregnancy, irrespective of relationship status. How BPD symptoms may relate to the duration of relationships is less clear; whereas shorter relationships might be predicted by impulsivity, difficulty expressing anger appropriately, and shifts between idealization and devaluation, fear of abandonment might promote the continuation of relationships despite poor quality thereof. On the basis of these clinical features of BPD symptomatology, we generated the following questions: (a) Are BPD symptoms associated with differences in the frequency of, length of, or amount of time spent in relationships? (b) Do young women with BPD symptoms demonstrate greater chronic stress in the romantic domain? (c) Do they have more frequent fights and arguments with romantic partners? (d) Are they more likely to be victims of abuse in romantic relationships? (e) Are they more likely to have unwanted pregnancies? and (f) Do their partners report less satisfaction in the relationships?
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Method Overview Participants were recruited in two cohorts (in 1991 and 1992, respectively) from the senior classes of three local public high schools chosen to be demographically representative of the Los Angeles County schools in terms of ethnicity, graduation rate, and proportion of students attending college after graduation. During the spring semester, staff members entered 12th-grade classrooms at each school on a given day and distributed 902 screening questionnaires to all female students. Students were told that the study was designed to look at the postgraduation transition period and examine factors that affected adjustment. Completed screening questionnaires with appropriate parental consent were returned by 513 women (57%). Of this group, 341 agreed to be contacted to schedule an extensive interview during the summer. Of these women, 103 refused to participate when contacted or failed to attend interviews, 47 could not be scheduled within our target 3-month period, and 36 were unreachable. Finally, 155 of those who volunteered to take part in the study were actually included at the initial interview, 94 in the first cohort and 61 in the second cohort. The final sample represented 17% of the total number of women to whom packets were distributed and 45% of the number who returned questionnaires with appropriate consent to be contacted. 1 Although self-selection played a role in recruitment, there were no significant differences among the women who completed the screening material between those who were and were not eventually interviewed or between the two cohorts in terms of socioeconomic status (SES; measured by Hollingshead's 1975 guidelines), ethnicity, Beck Depression Inventory (BDI; Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961 ) score, or a checklist of behavior problems. All interviews were conducted by graduate students in clinical psychology or by licensed clinical psychologists. Participants were paid at each phase of the study except the initial screening. Follow-up interviews, conducted largely by telephone, took place 6 months, 1 year, 2 years, 3 years, and 4 years after the initial interview. Questionnaires were mailed following each interview. At the 6-month follow-up, 140 women were interviewed, with 137 at the 1-year, 134 at the 2-year, 133 at the 3-year, and 128 at the 4-year follow-ups. Over the 4-year period, only 7 interviews were actually refused; for other missing interviews, the participant could not be reached by phone or mail. Participants who were not interviewed at early follow-ups were occasionally interviewed subsequently; in those cases, reports of the entire between-interviews period were obtained. In the present study, we excluded cases in which there were no interviews after the 6-month assessment ( n = 12) and cases in which the initial PD measure was not completed ( n = 1), yielding a total of 142 participants. The mean length of follow-up of the 142 included women was 46.9 months. These women did not differ from the excluded group in terms of initial BPD symptomatology, t (152) = 0.91, ns, or initial depression, t (153) = 0.44, ns. Of the 142 women included, we also compared the group that was assessed at every time point ( n = 112) with the group that missed one or more interviews ( n = 30); these groups did not differ on BPD scores, t (140) = 0.34, ns, or depression, t (140) = 0.29, ns. Participants The participants began with a mean age of 18.3 years ( SD = 0.48; range = 16 to 19) and were predominantly middle class (mean Hollingshead score of 46.0, SD = 13.18). Two percent of the participants were African American, 9% were Asian American, 46% were Caucasian, 21% were Chicana or Latina, and 22% of other or mixed ethnic backgrounds. 2 Measures Axis II symptomatology. Axis II symptomatology was assessed at the initial interview via the Personality Diagnostic
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Questionnaire (PDQ; Hyler, Rieder, Spitzer, & Williams, 1982 ) for Cohort 1 and the PDQ—Revised (PDQ-R; Hyler & Rieder, 1987 ) for Cohort 2. 3 The PDQ and PDQ-R are true—false questionnaires adapted from PD criteria of the third and revised third editions of the Diagnostic and Statistical Manual of Mental Disorders ( DSM—III and DSM—III—R ; American Psychiatric Association, 1980 , 1987 ), respectively. In comparison with interview-based measures, these self-report measures appear to have high sensitivity and moderate specificity ( Zimmerman, 1994 ). In this sample, the correlation ( r ) between initial PDQ and PDQ-R BPD score and PDQ-R score 2 years later was .60 ( p < .001, n = 128), indicating moderate stability. Initial BPD PDQ or PDQ-R score was also significantly correlated ( r = .53, p < .001) with degree of symptoms endorsed on the BPD scale of the Structured Clinical Interview for DSM-III-R —Personality Disorders (SCID-II; Spitzer, Williams, Gibbon, & First, 1990b ), which was administered blind to a subset of 63 participants at the 3-year interview (the 2-year PDQ-R and 3-year SCID-II data are not reported here because of our focus on prospective analyses; analyses using these measures to address correlates of the PD clusters were reported in Daley, Hammen, Davila, & Burge, 1998 ). Scores based on the number of BPD items answered in a pathological direction for the different versions of the measure were combined in the present analyses; prior research with this sample showed no meaningful differences between the two versions of the measure in predicting variables of interest ( Daley et al., 1999 ). The items corresponding to DSM—III—R BPD Criterion 1 (unstable and intense interpersonal relationships characterized by alternating between extremes of overidealization and devaluation) were not included in the total BPD score so that there would be no question of whether these particular items accounted for associations with relationship dysfunction. BPD symptomatology was not associated with ethnicity; Caucasian ( M = 2.60, SD = 1.99, n = 66) and non-Caucasian ( M = 3.05, SD = 2.03, n = 76) participants did not differ in regard to number of items endorsed on the BPD scale, t (140) = 1.32, ns. Likewise, there was no relationship between BPD symptoms and SES (Hollingshead score; r = −.05, ns ) or months retained in the study ( r = .01, ns ). It should be emphasized that the level of symptomatology in this sample was generally subclinical; only 1 of the 63 participants who were administered the SCID-II interview met criteria for a diagnosis of BPD, and only 4 met criteria for any PD. Depressive symptomatology. Depressive symptomatology was assessed at the initial interview with the version of the Structured Clinical Interview for DSM-III-R developed for nonclinical samples (SCID-NP; Spitzer, Williams, Gibbon, & First, 1990a ; hereafter referred to as the SCID). Interrater reliability of SCID diagnoses was assessed in the present study via a weighted kappa, according to no symptoms, some symptoms, or diagnosis based on independent ratings of SCID interviews made from audiotapes; the weighted kappa value was .89 ( n = 46). In addition to the categorical data derived from the SCID, depressive symptomatology was coded along a dimensional scale as follows: no symptoms (0), one or two symptoms (1), three or four symptoms (2), diagnosable depressive disorder (3), and diagnosable depression combined with hospitalization or suicide attempt (4). At the initial interview, the level of depressive symptomatology in the sample was mild ( M = 0.42, SD = 0.93). Caucasian ( M = 0.30, SD = 0.80, n = 66) and non-Caucasian ( M = 0.53, SD = 1.01, n = 76) participants did not differ in initial 5point SCID depression, t (140) = 1.44, ns. Likewise, there was no relationship between depressive symptoms and SES ( r = .04, ns ). Initial symptoms of BPD and depression were significantly correlated ( r = .28, n = 142, p = .001). Episodic events. The episodic stress interview was developed and has been used extensively by Hammen and colleagues,
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based on the methods of Brown's contextual threat assessment ( Brown & Harris, 1978 ). Participants were systematically probed about the occurrence of particular life events over each follow-up period using the list developed by Paykel and Mangen (1980) , adapted for an adolescent population. To be included in analyses, an event had to have an impact of at least 1 day and had to involve at least mild stress, as judged by a team of raters unaware of the participant's diagnostic status. 4 The rates and timing of unplanned pregnancies, relationship onsets, and romantic conflicts and breakups were derived from these data. Content codes for each event identifying the nature of the event were assigned by a team of raters unaware of participants' diagnostic status. Most events used in this study were classified in a straightforward manner (e.g., pregnancy). However, decisions about whether an event should be categorized as involving interpersonal conflict required some degree of judgment. Accordingly, reliability of conflict coding was assessed by having a second team of raters code the events for randomly selected participants. This procedure yielded a kappa of .96 for 63 events. Romantic chronic stress. Chronic stress was measured at the initial assessment and each follow-up via an interview developed by Hammen and colleagues ( Hammen et al., 1987 ) designed to assess the level of ongoing objective stress experienced by each young woman in a given follow-up period in several domains, including romantic life. Romantic relationship functioning was systematically assessed and rated by the interviewer on a 5point scale (1 = optimal circumstances, 5 = the most stressful circumstances ), with specific behavioral descriptions for each point pertaining to both women who were and were not in a relationship. For women in a relationship, we probed such areas as relationship stability, amount and mutuality of investment, emotional support, and conflict resolution. For women not in a relationship, we probed frequency and quality of dates, 5 perceived availability of dating partners, and pressure (imposed both by the woman herself and by family and friends) to be in a relationship. Reliability analyses were performed on the chronic stress interview by having a second set of interviewers rate tape recordings of interviews, yielding an intraclass correlation of .82 ( n = 57). Partner-reported satisfaction. At each follow-up interview, any participant who was in a relationship was sent the Dyadic Satisfaction subscale of the Dyadic Adjustment Scale (DAS; Spainer, 1976 ) to give to her partner, to be returned to the project in a separate stamped, addressed envelope. The Dyadic Satisfaction subscale was designed to assess the amount of tension in a relationship and the extent to which the partner may have considered terminating the relationship. In the present sample, the average internal consistency (alpha) of the Dyadic Satisfaction subscale across the five follow-up time points was .83. An index of partner satisfaction was calculated by averaging across every DAS returned by a participant's partner over the 4year period. Thus, in some instances this index represents the reports of several partners, and in others it reflects the views of only one. In the present sample, at least one partner-completed DAS was available for 76 participants. Time lines. Information from both the chronic and episodic stress interviews was used in generating time lines. Using the time lines, we determined several indexes for each woman, including presence of an unwanted pregnancy, presence of abuse by a partner, number of romantic conflicts and breakups (combined) for women who had been involved in at least one relationship, mean romantic chronic stress, number of relationships during the study, proportion of time spent in a relationship, and mean duration of relationships. To qualify as being in a "relationship," the couple had to have been dating for at least 1 month and had to have an agreement of monogamy (although the occurrence of infidelity did not disqualify the relationship). Abuse by a romantic partner was defined as physical assaults (e.g., slapping,
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punching, or kicking), verbal attacks including verbal denigration and humiliation (not simply mutual name calling), limiting of the woman's freedom to leave the home or see friends and relatives, or threats of violence. An independent rater coded a randomly selected set of 30 participants for the presence of abuse, yielding a kappa of .92. During the study, 132 women had at least one romantic partner. The presence of abuse by a romantic partner was coded only among these women. Thus, in analyses of the mean length of relationships, the number of romantic partner conflicts, and the presence of abuse, the sample size was 132. In analyses of partner-reported satisfaction, the sample size was 76, owing to the number of partners who did not return a DAS. In analyses of romantic chronic stress (coded for dating and nondating participants) and unplanned pregnancy (occurring both in and out of "relationships"), the sample size was 142. Correlations among the dependent variables are shown in Table 1 .
Results BPD as a Predictor of Subsequent Romantic Functioning Results of analyses predicting relationship variables from BPD symptomatology alone are shown in the first row of Table 2 . Relationship course. BPD symptomatology was positively correlated with the number of relationships participants were involved in during the study (see Table 2 ). BPD symptomatology was not associated with the proportion of time women spent in relationships over the 4 years ( r = .02, n = 142, ns ) or the mean length of relationships ( r = −.06, n = 132, ns ). Romantic domain stress, relationship quality, and stressful events. We examined chronic stress in hierarchical multiple regression analyses predicting the mean chronic stress rating for the romantic domain across all interviews in the subsequent 4 years (6-month through 4year follow-ups), after accounting for initial romantic chronic stress in the first step, R 2 = .07, F (1, 140) = 11.32, n = 142, p = .001. When initial BPD status was entered in the second step, it explained an additional 9% of the variance in 4-year romantic chronic stress. In regard to episodic stress, BPD pathology was positively correlated with number of romantic conflict events among the women who had been involved in any romantic relationship in the 4 years ( n = 132). 6 The associations between BPD symptoms and risk of pregnancy and abuse were assessed via logistic regression, with the presence of pregnancy or of abuse serving as the dichotomous dependent variable. Over the 4-year period, greater initial BPD symptomatology was associated with increased risk of having an unwanted pregnancy. Furthermore, among women who had been involved in a relationship, initial BPD symptomatology predicted greater risk of experiencing abuse by a romantic partner (see Table 2 ). Partner satisfaction. On average, over 4 years, partners of women with greater initial BPD traits reported less relationship satisfaction (see Table 2 ). Non-BPD Axis II Symptoms as Predictors of Subsequent Romantic Functioning Next, we examined the question of whether romantic dysfunction was predicted by symptoms of PDs
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other than BPD. As would be expected, given the considerable correlations between symptoms of the various PDs ( Table 3 ), the associations with romantic dysfunction were by no means specific to BPD. As shown in Table 2 , symptoms of every PD were associated with at least one index of romantic relationship functioning. Specificity of BPD as a Predictor of Subsequent Romantic Functioning Versus Initial Depression and Non-BPD Symptomatology In this series of analyses, we assessed specificity by predicting outcome variables in either hierarchical multiple (for continuous dependent variables) or logistic (for dichotomous dependent variables) regression. We entered initial depression first, followed by initial non-BPD Axis II symptomatology, and then BPD symptoms. Results are shown in Table 4 . Relationship course. Controlling for both initial depression and non-BPD Axis II symptoms, there was a nonsignificant trend for BPD symptoms to predict greater frequency of relationships. Romantic domain stress, relationship quality, and stressful events. Controlling for initial depression and non-BPD Axis II symptoms, there was a nonsignificant trend for BPD symptoms to predict more frequent romantic conflicts. BPD symptoms did not predict greater romantic chronic stress after controlling for initial chronic stress, depression, and non-BPD Axis II symptoms. In logistic regression analyses controlling for initial depression and non-BPD Axis II symptoms, BPD symptoms did not predict the presence of an unwanted pregnancy. Likewise, BPD symptoms did not predict the presence of an abusive relationship after controlling for initial depression and non-BPD Axis II symptoms. Partner satisfaction. Controlling for initial depression and non-BPD Axis II symptoms, BPD symptoms did not predict poorer partner-reported satisfaction. Summary. In no case did BPD symptoms significantly predict romantic functioning after controlling for initial depression and non-BPD symptomatology although there was a trend in this direction for number of relationships and conflict events. These findings are not surprising given the high correlation between BPD and non-BPD symptomatology ( r = .63, p < .001) and the association between PD symptoms and depression in this sample ( Daley et al., 1999 ). However, these results reveal little about whether any more specific forms of Axis II pathology have stronger associations with dysfunction in the romantic domain. Accordingly, in an effort to elucidate further which particular Axis II features might contribute to the occurrence of romantic dysfunction, we conducted a series of post hoc analyses focusing on the three clusters of disorders specified in the DSM. This approach organizes the PDs into three clusters: Cluster A (paranoid, schizoid, and schizotypal), representing odd and eccentric features; Cluster B (antisocial, BPD, histrionic, and narcissistic), representing dramatic and erratic features; and Cluster C (avoidant, dependent, and obsessive—compulsive), representing anxious and fearful features, a grouping that has received moderate empirical support ( O'Connor & Dyce, 1998 ).
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Analyses Comparing Clusters A, B, and C In these analyses, we simultaneously entered three variables representing Cluster A, B, and C symptoms in either multiple or logistic regressions and examined the relative predictive power of each cluster, controlling for the other clusters. In instances in which depression had been shown to have a significant association with an outcome variable ( Table 4 ), we included depression in the equation as well. Results are shown in Table 5 . (We did not examine the number of relationships in this section as a result of the lack of significant prediction in the final equation shown in Table 4 .) Romantic domain stress, relationship quality, and stressful events. Controlling for the effects of the other clusters, Cluster B symptoms made an independent contribution to the prediction of conflict events; Cluster A and Cluster C symptomatology did not. In predicting 4year romantic chronic stress controlling initial depression, initial chronic stress, and the effects of the other clusters, Cluster A and Cluster B symptoms predicted greater romantic chronic stress, whereas Cluster C did not have any unique effect. Although depression had been a significant predictor of romantic chronic stress over initial stress, when entered alone ( Table 4 ) it did not predict chronic stress when Axis II symptoms were controlled ( Table 5 ). Controlling for depression and the other clusters, symptoms in Clusters A and C did not have independent effects in the prediction of unplanned pregnancy. There was a nonsignificant trend for Cluster B symptoms to be associated with unplanned pregnancy controlling for the other predictors. Depression significantly predicted unplanned pregnancy controlling for Axis II symptoms. Regarding abuse by a partner, Cluster B symptomatology was the only independent predictor, controlling for depression and the other clusters. Although depression had predicted abuse when entered alone ( Table 4 ), it had no predictive value when Axis II symptoms were controlled (see Table 5 ). Partner satisfaction. Cluster B symptoms uniquely predicted poorer satisfaction controlling for Cluster A and Cluster C. There was a nonsignificant trend for initial Cluster A symptomatology to predict partner dissatisfaction controlling for Clusters B and C (see Table 5 ).
Discussion The goals of this study were, first, to illuminate the behavioral patterns and evaluate the extent of maladaptive functioning in intimate relationships of young women as a function of subclinical symptoms of BPD and, second, to address questions of the specificity of any such findings. When examined independently of depression and other Axis II symptomatology, BPD symptoms predicted a wide range of relationship variables. However, these effects were not at all unique to BPD; scores on subscales tapping symptoms of every other Axis II disorder also predicted aspects of poor functioning. When initial depression and non-BPD Axis II symptomatology were accounted for, BPD symptoms never retained significant predictive power, although there was a nonsignificant trend for prediction of the frequency of relationships and romantic conflicts. These results might be expected, given the substantial correlation between BPD and non-BPD Axis II pathology. Still, the results suggest that, rather than there being a privileged association between BPD and romantic dysfunction, general, nonspecific severity of personality pathology is a better marker of interpersonal disturbance (see also Modestin & Villiger, 1989 ).
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These results are consistent with an increasing body of work showing rather general associations between forms of psychopathology and adverse outcomes. For instance, in data from the National Comorbidity Survey, a variety of Axis I disorders, especially early-onset disorders, have shown associations with early first marriage ( Forthofer, Kessler, Story, & Gotlib, 1996 ), divorce ( Kessler, Walters, & Forthofer, 1998 ), low educational attainment ( Kessler, Foster, Saunders, & Stang, 1995 ), and teenage parenthood ( Kessler et al., 1997 ). Likewise, Thompson and Bland (1995) found a general relationship between many different Axis I disorders and social problems, leading them to call for increased attention to a common underlying factor. Regarding Axis II, several authors have found that the presence of any PD is associated with poor interpersonal adjustment (e.g., Mauri et al., 1991 ; Tyrer, Merson, Onyett, & Johnson, 1994 ) and that the total number of Axis II criteria met is associated with severity of functional impairment ( Nakao et al., 1992 ). The present data are consistent with this body of work, suggesting that although some specific disorder—outcome relationships may exist, the presence and extent of general psychopathology may be an especially robust indicator of romantic impairment. In distinguishing among aspects of Axis II pathology, the only tenable differentiation made was at the broad cluster level. In post hoc comparisons of the three DSM -based clusters, controlling for depression where appropriate, symptoms in Cluster B, including BPD, were most consistently associated with dysfunction in the romantic domain. Cluster A symptoms were less consistently predictive, and symptoms in Cluster C had no apparent unique predictive value. There are several implications of these findings. First, at the most basic level, the present results support the utility of viewing BPD (and other PDs) as a continuum of severity rather than simply as a categorical diagnosis ( Widiger & Frances, 1989 ). Almost none of the women in our study would have met criteria for a PD diagnosis. However, the women with greater subclinical PD features clearly conducted their romantic lives in maladaptive ways. These data suggest that a categorical approach to measuring PD based on the formal diagnostic thresholds is insufficiently sensitive to meaningful variations among individuals in terms of relationship behavior. Such a perspective echoes the increasing recognition of the importance of subclinical symptoms in the study of depression ( Gotlib et al., 1995 ; Judd, Paulus, Wells, & Rapaport, 1996 ). Second, at subclinical levels, BPD symptoms do not appear to share a unique association with romantic dysfunction. Every PD was associated with some index of romantic dysfunction, and BPD did not significantly contribute beyond other Axis II pathology. This suggests that a common factor of personality disturbance underlying the Axis II disorders is important in determining relationship adjustment. Such a pattern of findings adds to concerns about the validity of the current approach to categorizing aspects of personality disturbance ( Clark et al., 1997 ); if the sets of DSM Axis II criteria truly reflect discrete, individual disorders, one might expect better discrimination among them with regard to outcomes. Third, these results suggest that depression research would benefit from continuing the increasing attention that is being paid to depression comorbidity (e.g., Hammen & Compas, 1994 ). Much work on depression has focused on interpersonal aspects, considering interpersonal dysfunction as both an antecedent to and a consequence of depression ( Joiner & Coyne, 1999 ). The present findings suggest that co-occurring Axis II symptoms may contribute to, or even account for, some of these relationships. For instance, the relationships between depression and both romantic chronic stress and abuse by a partner were diminished after accounting for Axis II symptoms. In studies of adolescent depression and Axis I comorbidity, similar findings have been shown for stressful life events ( Lewinsohn, Gotlib, & Seeley, 1997 ), interpersonal conflicts ( Daley et al., 1997 ), and family support ( Aseltine, Gore, & Colten, 1998 ). These data raise concerns that other findings with regard to depression may, in part, be a function of an additive or interactive effect of comorbid psychopathology. These results also suggest
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that, in terms of consideration of depression comorbidity, attention should not be limited to Axis I disorders. For instance, in a larger scale community-based study, Gotlib, Lewinsohn, and Seeley (1998) found that depression in adolescence, but not other Axis I disorders, predicted aspects of marital status and distress in early adulthood. Although those data demonstrate a specific relationship between marital functioning and adolescent depression versus other Axis I pathology, our data indicate that Axis II pathology is a potent indicator of romantic maladjustment, even after accounting for depression, and should not be neglected, as is often the case in research on adolescents. Several important limitations of this study should be noted. First, we used the PDQ and PDQ-R selfreport measures of PD. PDQ and PDQ-R BPD scores were moderately stable over 2 years and were correlated with SCID-II BPD scores 3 years later, but concerns regarding self-report methodology are significant ( Zimmerman, 1994 ). Second, our sample was limited to women of a specific age undergoing a unique transition period; it is unclear whether or not similar processes would be observed in other samples. Third, our set of outcome variables focused on one particular aspect of functioning: romantic relationships. There may be other arenas in which adjustment would be predicted differentially by individual disorders. Fourth, our sample was self-selected. Among the women who were screened, we observed no differences between those who were and were not included in the study, but undetected selection biases may have existed, thus limiting generalizability. Fifth, many of our findings are relatively small in magnitude; clearly, Axis II pathology is but one of many factors that influence romantic functioning in this stage. Sixth, our data do not provide information about the pathways by which PD symptoms become expressed in stressful events and circumstances. For instance, do women with Cluster B symptoms differentially select and attract partners with their own psychiatric disturbance, consistent with the notion of assortative mating ( Merikangas, 1982 ), or do more proximal behaviors, such as initiating physical aggression, have a greater impact in shaping relationship adjustment? Further research examining specific relationship behaviors and partner choice is necessary to help elucidate trajectories to relationship disturbance as a function of personality pathology. However, several methodological strengths of the study should be noted as well. First, our dependent variables were derived either from detailed life stress interviews conducted by staff unaware of level of initial PD symptoms or from partner reports. This methodology helps to attenuate concerns about symptom-biased reporting of stress and shared method variance with the self-report personality pathology measure. Second, we made use of longitudinal data from multiple interviews across 4 years, thus allowing more confident inferences regarding the direction of observed relationships. Third, we included tests of specificity in regard to both non-BPD Axis II disorders and depression. In conclusion, despite the theoretical conceptualization of BPD as being characterized by interpersonal disturbance, romantic relationship dysfunction was more powerfully predicted by a broader index of personality pathology. This lack of specificity, however, should not obscure the broader implications of the present findings, that, consistent with models of stress generation ( Hammen, 1991 ; see also Buss, 1987 ; Monroe & Simons, 1991 ), psychopathology plays a significant role in how young women construct their early intimate relationships. Stressful romantic events that, at least partially, resulted from the individual's behavior occurred more frequently in the lives of women with greater PD symptoms, especially in Cluster B while their chronic romantic stress was higher, and their partners were relatively dissatisfied. Women with more depressive symptomatology were at increased risk of experiencing an unwanted pregnancy. Thus, young women with greater, although often subclinical, psychopathology were increasingly differentiated from their less symptomatic counterparts in terms of stressful experiences in the romantic domain as they made the transition to young adulthood, in part as a result of their own behaviors. Given the critical ramifications of choices and experiences in the romantic domain during this developmental period, including parenthood and marriage, it appears that subclinical PD symptoms are an important factor in setting the stage for an adverse developmental trajectory.
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1 The rate of participation was probably adversely affected by several factors. First, we could contact students only in class, unlike, for instance, the Oregon study ( Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993 ) in which investigators could send consent forms and information directly to the parent's home. Second, only one of the three schools allowed students to complete questionnaires in class; in the other schools, we gave packets to students to take home and then return by mail. Third, we were required to obtain active (vs. passive) parental consent to contact the students less than 18 years of age after screening. Fourth, we scheduled interviews during a time of frequent geographic moves and vacations (the summer after high school). Fifth, we typically required participants to travel to our offices at the University of California, Los Angeles (UCLA), for the initial interview; this may have represented a prohibitive inconvenience for potential participants, the distance from one recruitment area to UCLA being 17 miles.
2 In the year before the study, the ethnicity of seniors in Los Angeles County ( Los Angeles County Office of Education, 1990—1991 ) was as follows: African American, 12%; Asian American, 14%; Caucasian,
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35%; Chicana—Latina, 37%; and other, 3%. Thus, it appears that our sample had a somewhat greater proportion of Caucasians than in the county overall, despite lack of a significant difference in ethnicity between women who were and were not interviewed among the group that returned screening measures.
3 In this article, we report only on the scales corresponding to the 10 PDs deemed adequately validated for inclusion in the fourth edition of the DSM.
4 The judgment about stressfulness was reliably assessed; the intraclass correlation for ratings made by two independent teams was .92 ( n = 74 events).
5 The probes for quality of dates included aspects of the date itself (e.g., common interests to discuss or pressure for sex) as well as perceived appropriateness of the dating partner for a longer term relationship.
6 It should be noted that this finding does not appear to be accounted for by a bias on the part of high-BPD participants to report more events generally; frequency of fateful, or independent, events was not associated with BPD symptoms ( r = .10, ns ). Table 1. Descriptive Data for and Correlations Among the Dependent Variables
Table 2. Associations Between Initial Personality Disorder Scales and 4-Year Romantic Relationship Variables
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Table 3. Descriptive Data for and Correlations Among the Personality Disorder Scales
Table 4. Results From Hierarchical Multiple and Logistic Regression Analyses Predicting 4-Year Romantic Relationship Variables as a Function of Initial Depression, Non-BPD Axis II Symptoms, and BPD Symptomatology
Table 5. Partial Correlations From Multiple and Logistic Regression Analyses Predicting 4-Year Romantic Relationship Variables as a Function of Each Initial PD Cluster, Controlling for the Effects of the Other Clusters, and, When Applicable, Initial Depression
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