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Journal of Personality Disorders, 17(3), 233-242, 2003

2003 The Guilford Press


ZANARINI RATING SCALE
ZANARINI

ZANARINI RATING SCALE FOR BORDERLINE


PERSONALITY DISORDER (ZAN-BPD):
A CONTINUOUS MEASURE OF DSM-IV
BORDERLINE PSYCHOPATHOLOGY
Mary C. Zanarini, EdD

The purpose of this study was to assess the psychometric properties of


the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD),
the first clinician-administered scale for the assessment of change in
DSM-IV borderline psychopathology. The questions for the measure
were adapted from the BPD module of the Diagnostic Interview for
DSM-IV Personality Disorders (DIPD-IV) to reflect a 1-week time frame
and each of the nine criteria for BPD is rated on a five-point anchored rat-
ing scale of 0 to 4, yielding a total score of 0 to 36. Two diagnostic inter-
views that assess the presence of BPD were administered to 200
nonpsychotic patients: the BPD module of the DIPD-IV and the Revised
Diagnostic Interview for Borderlines (DIB-R). The ZAN-BPD was also ad-
ministered, blind to diagnostic information. In addition, each patient
filled out a self-report measure of general psychopathology that is often
used in borderline treatment studies, the Symptom Checklist 90
(SCL-90). The convergent validity of the ZAN-BPD and relevant scales of
the SCL-90 and the DIB-R was assessed and found to be highly signifi-
cant. The discriminant validity of the various scores of the ZAN-BPD was
also found to be highly significant, easily discriminating the 139 patients
who met the DSM-IV criteria for BPD from the 61 patients who did not. In
addition, internal consistency of the ZAN-BPD was found to be high
(Cronbachs =0.85). The interrater reliability of the ZAN-BPD was as-
sessed using 32 conjoint interviews, while same day test-retest reliability
was assessed in a separate sample of 40 patients. All reliability raters
were blind to all previously collected information concerning each sub-
ject. All intraclass correlations were in the good to excellent range.
Finally, the sensitivity of the ZAN-BPD to change was assessed using a
third sample of 41 patients who were reinterviewed by a blind rater 7 to
10 days after the ZAN-BPD was first administered. The SCL-90 was also
readministered at this time. The correlations between difference scores of
the ZAN-BPD and difference scores of the SCL-90 were found to be signif-
icant, indicating that the ZAN-BPD measures change in a clinically
meaningful manner. Taken together, the results of this study suggest
that the ZAN-BPD is a promising clinician-administered scale for the as-
sessment of change in borderline psychopathology over time.

From Department of Psychiatry, McLean Hospital.


Address correspondence to Mary C. Zanarini, EdD, McLean Hospital, 115 Mill St., Belmont,
Massachusetts 02478; E-mail: zanarini@mclean.harvard.edu.

233
234 ZANARINI

Borderline Personality Disorder (BPD) is a common (Swartz, Blazer, George,


& Winfield, 1990) and serious psychiatric disorder (Bender et al., 2001;
Skodol et al., 2002; Zanarini, Frankenburg, Khera, & Bleichmar, 2001) that
has been the subject of hundreds of research studies according to a recent
Medline search. In general, it is now considered to be a valid psychiatric dis-
order with a well-described clinical picture that can be distinguished from
other psychiatric disorders, including other Axis II disorders (Zanarini,
Gunderson, Frankenburg, & Chauncey, 1990).
All five semistructured interviews based on the DSM criteria for axis II dis-
orders (Structured Interview for the DSM Personality Disorders [SIDP]; Per-
sonality Disorder Examination [PDE]; Diagnostic Interview for Personality
Disorders [DIPD]; Structured Clinical Interview for DSM Personality Disor-
ders [SCID-II]; and Personality Disorder Interview or [PDI]) have proven to
be reliable in assessing the presence of BPD and other DSM personality dis-
orders (Zimmerman, 1994). A self-report measure for assessing these disor-
ders, the Personality Diagnostic Questionnaire (PDQ), has also proven to be
reliable in diagnosing BPD (Hurt, Hyler, Frances, Clarkin, & Brent, 1984).
However, no assessment instrument specifically designed as a change
measure of borderline psychopathology has been available. Instead, most
treatment studies following borderline patients over time have used a bat-
tery of instruments that includes measures that were either designed to as-
sess the presence of an Axis I disorder, most commonly major depression, or
that each focus on one symptom area characteristic of BPD, such as hostil-
ity or impulsivity. In practice, this means that some areas of borderline psy-
chopathology, such as interpersonal relationships, are not assessed at all.
In addition, the use of a complex battery of assessment measures means
that treatment studies of borderline patients tend to have so large a number
of outcome variables that understanding the studys results is both difficult
and time consuming. This stands in contrast to the situation found in treat-
ment studies of Axis I disorders where one outcome measure summarizes
the overall change found in the symptoms of that disorder over time. For ex-
ample, the Young Mania Rating Scale (Young, Biggs, Ziegler, & Meyer, 1978)
is typically used in studies of bipolarity both for baseline assessment and for
assessment of change over time. This interview-based instrument yields re-
sults that are easily understood by both clinicians and researchers. An in-
strument of this type is needed for research studies concerning patients
with borderline personality disorder.
This report details the development of and psychometric properties asso-
ciated with an instrument for the assessment of change in the DSM-IV BPD
symptoms over time, the clinician-administered Zanarini Rating Scale for
Borderline Personality Disorder (ZAN-BPD).

DEVELOPMENT OF THE ZAN-BPD


The ZAN-BPD is based on the borderline module of the Diagnostic Interview
for DSM-IV Personality Disorders (DIPD-IV). The interrater and test-retest
reliability of the DSM-III (Zanarini, Frankenburg, Chauncey, & Gunderson,
1987), DSM-III-R (Zanarini & Frankenburg, 2001), and DSM-IV versions of
this interview (Zanarini et al., 2000) have all been carefully assessed and
ZANARINI RATING SCALE 235

TABLE 1. ZANBPD Section Pertaining to Selfdestructive Efforts

During the past week, have you


. . . deliberately hurt yourself without meaning to kill yourself (e.g., cut yourself, burned yourself,
punched yourself, put your hand through windows, punched walls, banged your head)?
Threatened to kill yourself? (If no) How about told someone that youre going to kill yourself to let
them know youre in pain? To see if they care?
Made any suicide gestures or attempts?
If yes to any question pertaining to selfmutilation or suicidal efforts, ask about intensity and frequency
of symptoms. Also ask for examples. Then circle the number that best represents the described
and/or observed symptom severity.
0 No Symptoms No selfmutilation or suicidal efforts reported or observed during interview.
1 Mild Symptoms One vague suicide threat. One instance of scratching or punching self.
2 Moderate Symptoms One clearcut suicide threat. two to three instances of scratching or punch-
ing self.
3 Serious Symptoms Multiple suicide threats. One instance of cutting or burning self. One suicide
gesture.
4 Severe Symptoms Two to three instances of cutting or burning self. One suicide attempt.

found to be in the good to excellent range according to the standards de-


scribed by Fleiss (1981).
We first took the questions from the BPD module of the DIPD-IV and re-
vised them to fit a 1-week format, rather than the 2-year format of the
DIPD-IV itself. We then developed a five-level set of anchored rating points
for each of the nine criteria for BPD found in the DSM-IV. In this system, 0 =
no symptoms, 1 = mild symptoms, 2 = moderate symptoms, 3 = serious
symptoms, and 4 = severe symptoms. For each anchored-rating point for
each criterion, the rating is intended to reflect both frequency and severity
of psychopathology. Table 1, which details the questions and anchored-rat-
ing points for self-destructive efforts, provides an example of this.
In addition to the criterion-based scales, the interview has four sector
scores reflecting the four core areas of borderline psychopathology
(Zanarini et al., 1990): affective, cognitive, impulsive, and interpersonal
symptoms. There are three affective symptoms in the ZAN-BPD (with a sec-
tor score ranging from 0 to 12): inappropriate anger/frequent angry acts,
chronic feelings of emptiness, and mood instability. There are two cognitive
symptoms (with a sector score ranging from 0 to 8): stress-related para-
noia/dissociation and severe identity disturbance. (Identity disturbance
was placed in the cognitive realm because it is based on a series of false be-
liefs, such as that one is good one minute and bad the next.) There are also
two impulsive symptoms (with a sector score ranging from 0 to 8):
self-mutilative/suicidal efforts and two other forms of impulsivity. Finally,
there are two symptoms in the interpersonal realm of BPD (with a sector
score ranging from 0 to 8): intense, unstable relationships and frantic ef-
forts of avoid abandonment. The four sector scores sum to provide a total
score of borderline psychopathology. This score ranges from 0 to 36.
Before proceeding to study the psychometric properties of the ZAN-BPD,
we had a panel of borderline researchers review the interview to assess its
face validity. These experts included Bruce Pfohl, Charles Schulz, Tracie
236 ZANARINI

TABLE 2. Demographic Characteristics and Treatment History of Sample (N = 200)

Characteristic
% Female 76.0
% Caucasian 84.0
Mean Age 33.6 (SD 11.1)
Mean SES 3.2 (SD 1.3)
Mean Years of Education 14.5 (SD 2.4)
Mean GAF 48.5 (SD 12.1)
% Individual Therapy 91.5
% Psychotropic Medication 72.5
% Psychiatric Hospitalization 47.0

Note. SES = socioeconomic status; GAF = Global Assessment of Functioning.

Shea, and Paul Soloff. We also had a kitchen cabinet of borderline patients
review the ZAN-BPD to assess its face validity. Both groups of experts found
that the questions of the ZAN-BPD covered the DSM-IV criteria for BPD well.
They also found that the 5-point anchored rating scale for each criterion ad-
equately assessed the continuum of borderline psychopathology likely to
occur in a 1-week time frame.

METHOD
Patients were recruited by an ad in a local newspaper and posters placed
around the McLean Hospital campus. The ad and poster, which specified
that we were looking for men and women between the ages of 18 and 60
years, asked: Are you extremely moody? Do you often feel distrustful of oth-
ers? Do you frequently feel out of control? Are your relationships painful
and difficult?
The exclusion criteria for the study were: (a) patients who ever met the
DSM-IV criteria for schizophrenia, schizoaffective disorder, or bipolar I dis-
order; (b) patients who met criteria for a substance use disorder in the pre-
ceding month; and (c) patients who had no history of psychiatric treatment.
The first two exclusion criteria follow standard practice in borderline re-
search of excluding patients whose Axis I state (i.e., psychosis, mania, or in-
toxication/withdrawal) is likely to interfere with an assessment of their
more enduring personality traits or symptoms. The third exclusion criteria,
excluding patients without a psychiatric treatment history, was intended to
try to equalize severity of impairment between patients judged to have or not
to have met the DSM-IV criteria for BPD.
Potential patients were prescreened by telephone to determine if they met
any of our exclusion criteria. Those who were not excluded were invited to
participate in a face-to-face-interview. After written informed consent was
obtained, four semistructured interviews of demonstrated reliability were
administered to each patient: (a) the Background Information Schedule
(BIS), which assesses psychosocial functioning and treatment history
(Zanarini et al., 2001) (b) the Structured Clinical Interview for DSM-IV Axis I
Disorders (SCID I) (Williams et al., 1992); (c) the BPD module of the DIPD-IV;
ZANARINI RATING SCALE 237

TABLE 3. Convergent Validity of ZANBPD and SCL90a (N = 200)

Measure Spearmans p Level


ZANBPD Affect and SCL90 Affect .80 < 0.001
ZANBPD Affect and SCL90 Anger .67 < 0.001
ZANBPD Affect and SCL90 Anxiety .70 < 0.001
ZANBPD Affect and SCL90 Depression .72 < 0.001
ZANBPD Cognition and SCL90 Cognition .64 < 0.001
ZANBPD Cognition and SCL90 Paranoia .62 < 0.001
ZANBPD Cognition and SCL90 Psychoticism .59 < 0.001
ZANBPD Impulsivity and SCL90 Anger .58 < 0.001
ZANBPD Interpersonal and SCL90 Interpersonal Sensitivity .51 < 0.001
ZANBPD Total and SCL90 BPD Total .83 < 0.001

Note. ZANBPD = Zanavini Rating Scale for Borderline Personality Disorder; SCLR90 = Symptom Check-
list 90. aBoth ZANBPD and SCL90 pertain to past week.

and (d) the Revised Diagnostic Interview for Borderlines (DIB-R) (Zanarini,
Gunderson, Frankenburg, & Chauncey, 1989).
A second rater, blind to all information concerning that patient, then ad-
ministered the ZAN-BPD, inquiring about symptom severity during the past
week. The Symptom Checklist 90 (SCL-90) (Derogatis, Lipman, & Covi,
1973), which is a well-known and widely used self-report measure of change
in general psychopathology, was also administered at this time.
In addition, three separate substudies were undertaken to assess the
interrater reliability of the ZAN-BPD, the same-day test-retest reliability of
the ZAN-BPD, and the 1-week sensitivity to change of the ZAN-BPD. In the
first of these substudies, a second blind rater observed and independently
scored the ZAN-BPD interview the first blind rater conducted. A total of 32
conjoint interviews of this type were conducted. In the second of these
substudies, the patient received a second administration of the ZAN-BPD a
number of hours after the first administration. A blind interviewer was also
used for these 40 interviews. In the third of these substudies, 41 patients re-
turned 7 to 10 days after their first interview for a second administration of
the ZAN-BPD. Again, a blind rater assessed the patient. The SCL-90 was
also readminstered at this time.
Correlations between the continuous scores of the ZAN-BPD and the con-
tinuous scores of the SCL-90 and the DIB-R were assessed using
Spearmans . Between-group differences on the various scales of the
ZAN-BPD were assessed using Students t-test. The internal consistency of
the ZAN-BPD was assessed using Cronbachs . The standard error esti-
mate for the statistic was obtained using bootstrapping methods. Both
interrater and test-retest reliability were assessed using intraclass correla-
tion coefficients (ICCs), which correct for chance levels of agreement.

RESULTS
In all, 283 patients were screened by telephone. A total of 41 patients were
excluded from further participation after reporting that they had a
long-standing clinical diagnosis of a psychotic/bipolar I disorder, whereas
238 ZANARINI

TABLE 4. Convergent Validity of ZANBPD and DIBR Scoresa (N = 200)

Measure Spearmans p Level


ZANBPD Affect and DIBR Affect 0.54 < 0.001
ZANBPD Cognition and DIBR Cognition 0.45 < 0.001
ZANBPD Impulsivity and DIBR Impulsivity 0.47 < 0.001
ZANBPD Interpersonal and DIBR Interpersonal Relationships 0.55 < 0.001
ZANBPD Total and DIBR Total 0.60 < 0.001

Note. ZANBPD = Zanavini Rating Scale for Borderline Personality Disorder; DIBR = Revised Diagnostice
Interview for Borderlines. aZANBPD pertains to past week and DIBR to past 2 years.

an additional 37 patients were excluded for not having a history of psychiat-


ric treatment. The 205 remaining patients were interviewed in person.
Three were excluded after administration of the SCID I for meeting the
DSM-IV criteria for a psychotic disorder. Two others were excluded for meet-
ing criteria for a current substance use disorder.
Table 2 details the demographic characteristics and treatment histories of
the 200 remaining patients. As can be seen, over 75% of these 200 patients
were female and over 80% were Caucasian. On average, they were in their
early 30s (age range 18 to 59 years), came from a middle class background,
and had completed about two years of college. However, they were, on aver-
age, only functioning in the marginal or serious symptom band (< 51) of the
Global Assessment of Functioning (GAF; American Psychiatric Association,
1994). In terms of psychiatric treatment, over 90% had a history of individ-
ual therapy, about three-fourths had taken psychotropic medications, and
approximately one-half had a history of psychiatric hospitalization.
Of these 200 patients, 139 (69.5%) met DSM-IV criteria for BPD as as-
sessed by the BPD module of the DIPD-IV and the remaining 61 patients
(30.5%) did not. All comparison patients met criteria for an Axis I disorder.
More specifically, 91.8% (N = 56) of these nonborderline patients met life-
time criteria for a mood disorder (mostly unipolar in nature), 32.8% (N = 20)
for a substance use disorder, 44.3% (N = 27) for an anxiety disorder, and
14.8% (N = 9) for an eating disorder.
Table 3 details the convergent validity of the ZAN-BPD with the scales of
the SCL-90 that are relevant to BPD. As can be seen, the convergent validity
of these two measures, both of which assess symptoms in the past week, is
high. This is particularly so for the overall borderline psychopathology
scores and the scores pertaining to affective symptomatology. Correlations
pertaining to cognition, impulsivity, and interpersonal relations, although
highly significant, are somewhat lower. This probably reflects the fact that
the relevant SCL-90 subscales do not cover these symptom areas as well as
those pertaining to the affective realm of BPD. For example, the ZAN-BPD
interpersonal sector includes both frantic efforts to avoid abandonment and
stormy relationships, whereas the SCL-90 interpersonal sensitivity scale
mostly assesses items related to rejection sensitivity. This difference in con-
vergent validity is also not surprising as only two SCL-90 scales pertain to
the cognitive symptoms of BPD, one pertains to the impulsive symptoms of
BPD, and, as mentioned above, one other pertains to the interpersonal
ZANARINI RATING SCALE 239

TABLE 5. Discriminant Validity of ZANBPD

BPD (n = 139) NonBPD (N = 61)


Measure Mean SD Mean SD t-Value (df = 198) p Value
Affect Sector Score 5.9 2.9 2.7 1.9 8.1 < 0.001
Chronic Anger/Frequent
Angry Acts 1.9 1.1 1.0 0.9 5.8 < 0.001
Affective Instability 2.2 1.2 1.2 1.0 6.1 < 0.001
Chronic Emptiness 1.8 1.5 0.5 1.0 6.2 < 0.001
Cognitive Sector Score 3.5 2.4 0.9 1.1 8.1 < 0.001
StressRelated
Paranoia/Dissociation 1.8 1.3 0.6 0.7 6.6 < 0.001
Serious Identity
Disturbance 1.7 1.4 0.3 0.7 7.6 < 0.001
Impulsivity Sector Score 1.7 1.4 0.5 0.7 6.0 < 0.001
SelfDestructive Efforts 0.4 1.0 0.1 0.1 2.7 0.0074
Other Impulsivity 1.3 1.1 0.5 0.7 5.3 < 0.001
Interpersonal Sector Score 3.2 2.0 1.0 1.2 8.1 < 0.001
Frantic Efforts to Avoid
Abandonment 1.4 1.2 0.4 0.7 6.2 < 0.001
Stormy Relationships 1.8 1.1 0.7 0.9 7.0 < 0.001
Total ZANBPD Score 14.3 6.8 5.2 3.5 10.0 < 0.001

Note. ZANBPD = Zanvini Rating Scale for Borderline Personality Disorder.

symptoms of BPD. In contrast, three scales of the SCL-90 (i.e., anger, anxi-
ety, and depression) were aggregated to correlate with the affective sector
score of the ZAN-BPD.
Table 4 details the convergent validity of the ZAN-BPD with the relevant
scores of the DIB-R, which has a 2-year time frame. Although all the correla-
tions are highly significant, they are substantially lower than those found
for the SCL-90. This is probably due to the vastly different time frames of the
ZAN-BPD and the DIB-R (1 week vs. 2 years).
Discriminant validity findings are presented in Table 5. All comparisons
between those meeting the DSM-IV criteria for BPD and those not meeting
this criteria set were found to be highly significant. This was so regardless of
which of the 14 ZAN-BPD scores were being compared; those pertaining to
the nine criteria, the four sectors, or the total BPD psychopathology score.
The internal consistency of the nine criteria scores of the ZAN-BPD was
found to be high (Cronbachs = 0.85, SE = 0.01, 95% CI = 0.82 to 0.89).
This means that scores on the nine scales were strongly and consistently re-
lated to one another. This also suggests that these scores appear to be as-
sessing the same construct, the DSM-IV BPD.
Table 6 details the interrater and test-retest reliability of the ZAN-BPD.
Using the criteria of Fleiss (1981), correlations below .40 are considered to
be poor, correlations between .40 and .75 are considered to be fair to good,
and correlations higher than .75 are considered to be excellent. Using these
standards, all but one of the interrater reliability figures were in the excel-
lent range. The criterion pertaining to self-destructive efforts, which were
extremely rare, was in the fair to good range. Again using the Fleiss guide-
lines, all but two of the test-retest figures were in the excellent range. Both of
these criteria (i.e., affective instability and frantic efforts to avoid abandon-
ment) were in the fair to good range.
240 ZANARINI

TABLE 6. Interrater and Testretest Reliability of ZANBPD

Interrater Reliability (N = 32) Testretest Reliability (N = 40)


Measure ICC p Level ICC p Level
Affect Sector Score 0.94 < 0.001 0.85 < 0.001
Chronic Anger/Frequent
Angry Acts 0.83 < 0.001 0.82 < 0.001
Affective Instability 0.83 < 0.001 0.59 < 0.001
Chronic Emptiness 0.96 < 0.001 0.86 < 0.001
Cognitive Sector Score 0.96 < 0.001 0.87 < 0.001
StressRelated Paranoia/
Dissociation 0.91 < 0.001 0.85 < 0.001
Serious Identity Disturbance 0.97 < 0.001 0.79 < 0.001
Impulsivity Sector Score 0.86 < 0.001 0.86 < 0.001
SelfDestructive Efforts 0.66 < 0.001 0.96 < 0.001
Other Impulsivity 0.90 < 0.001 0.88 < 0.001
Interpersonal Sector Score 0.89 < 0.001 0.84 < 0.001
Frantic Efforts to Avoid
Abandonment 0.91 < 0.001 0.75 < 0.001
Stormy Relationships 0.79 < 0.001 0.81 < 0.001
Total ZANBPD Score 0.96 < 0.001 0.93 < 0.001

Note. ZANBPD = Zanavini Rating Scale for Borderline Personality Disorder.

The ability to detect change reliably is one of the most important proper-
ties of a continuous measure of change of severity of psychopathology. Of
the 41 patients who were reinterviewed 7 to 10 days after their initial inter-
view, only 4 or 9.8% had exactly the same score on the ZAN-BPD at both ad-
ministrations. In contrast, 51.2% (N = 21) of these patients were less
symptomatic at the time of the second administration and 39.0% (N = 16)
were more symptomatic. Of the 90% (N = 37) of patients who reported a
change on the ZAN-BPD at the second administration, 35% (N = 13) were
judged to have experienced a 1- to 2-point difference, 30% (N = 11) a 3- to
4-point difference, and 35% (N = 13) a 5- to 15-point difference.
Table 7 shows data related to another way of assessing change. It exam-
ines the correlations between the difference scores of the interview-based
ZAN-BPD and the relevant scales of the self-report SCL-90, both of which
were readministered 7 to 10 days after their initial administration. As can be
seen, all of the correlations between the difference scores (baseline value mi-
nus value at second administration) of these measures were statistically
significant. This shows that the ratings on these two quite different mea-
sures of borderline psychopathology were changing in similar directions
and in somewhat similar amplitudes over time.

DISCUSSION
Three important issues need to be addressed in the development of a new
continuous measure of psychopathology that will be administered multiple
times during the course of a treatment study. These issues are validity, reli-
ability, and sensitivity to change. The ZAN-BPD has been shown to have both
convergent validity and discriminant validity. In terms of convergent validity,
ZANARINI RATING SCALE 241

TABLE 7. Sensitivity to Change Between ZANBPD and SCL90 Scores:


One Week Interval (N = 41)

Measure Spearmans p Level


ZANBPD Affect and SCL90 Affect 0.53 0.0004
ZANBPD Cognition and SCL90 Cognition 0.41 0.0076
ZANBPD Impulsivity and SCL90 Impulsivity 0.47 0.0019
ZANBPD Interpersonal and SCL90 Interpersonal Sensitivity 0.34 0.0487
ZANBPD Total and SCL90 BPD Total 0.59 0.0001

Note. ZANBPD = Zanavini Rating Scale for Borderline Personality Disorder; SCL90 = Symptom Checklist
90.

the scores on the various scales of the ZAN-BPD were highly correlated with
those obtained from both a self-report measure of general psychopathology
and an interview developed specifically to assess a somewhat different con-
ceptualization of BPD from that contained in the DSM-IV. In terms of
discriminant validity, the scores of the ZAN-BPD significantly discriminated
borderline patients from patients with a variety of serious Axis I disorders.
Reliability is an important concept in the development of any measure of
psychopathology. The ZAN-BPD was found to have high internal consis-
tency, an important component of reliability. In terms of forms of reliability
involving multiple raters, interrater reliability is a test of whether different
raters understand and score the same patient material in a similar manner.
Test-retest reliability is more complicated and depends on consistency of
patient self-report and interviewer differences in eliciting, understanding,
and scoring clinical material. High levels of both interrater and test-retest
reliability were obtained in the current study for the ZAN-BPD.
One cautionary comment is worth noting. Zimmerman (1994) has found
that reliability levels for diagnostic interviews for Axis II disorders are typi-
cally higher when reliability studies are conducted by the developer of that
measure and his or her colleagues. This suggests that the reliability of the
ZAN-BPD might well be somewhat lower (but still acceptable) when used by
other investigators.
The ZAN-BPD was developed for use in treatment studies involving bor-
derline patients. It hopefully will be equally useful whether the treatment in
question is psychosocial or pharmacologic in nature. However, its useful-
ness will depend on whether it can accurately assess symptomatic change
over time. The results of this study suggest that it has this capability. More
specifically, difference scores on the ZAN-BPD were significantly correlated
with difference scores on the BPD-related scales of a self-report measure of
general psychopathology (the SCL-90), which is often used in treatment
studies of borderline patients because of its validity as a measure of change.
A limitation of the current study is that we did not assess the full array of
Axis II disorders due to time constraints. Our clinical impression was that
the nonborderline patients did not have a substantial amount of Axis II
comorbidity. However, because we did not complete a full DIPD-IV assess-
ment, we cannot be sure of this. Another limitation is that all of the patients
in this study had a treatment history. Whether the ZAN-BPD would perform
as well in a community-based sample is an open question.
242 ZANARINI

Further research is needed to assess the psychometric properties of the


ZAN-BPD, particularly its sensitivity to change. For now, the ZAN-BPD
seems well-positioned to fill the void in BPD instrumentation created by the
absence of a measure of DSM-IV borderline psychopathology and its stabil-
ity or change over time.

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