Calvo et al. Borderline Personality Disorder Borderline Personality Disorder and Emotion Dysregulation (2023) 10:15 https://doi.org/10.1186/s40479-023-00223-2 and Emotion Dysregulation RESEARCH Open Access Discrimination of Borderline Personality Disorder (BPD) and Attention‑Deficit/ Hyperactivity Disorder (ADHD) in adolescents: Spanish version of the Borderline Personality Features Scale for Children‑11 Self‑Report (BPFSC‑11) Preliminary results Natalia Calvo1,2,3,4*, Jorge Lugo Marin1,2,3, Raquel Vidal1,2,3, Carla Sharp5, Juan D. Duque1, Josep‑Antoni Ramos‑Quiroga1,2,3,4 and Marc Ferrer1,2,3,4 Abstract Background Although the diagnosis of Borderline Personality Disorder (BPD) during adolescence has been ques‑ tioned, many recent studies have confirmed its validity. However, some clinical manifestations of BPD could be iden‑ tifiable in adolescents with other pathologies, such as Attention-Deficit/Hyperactivity Disorder (ADHD). The objective of the present study is to examine the capacity of the self-report Borderline Personality Features Scale Children-11 (BPFSC-11) to discriminate between BPD and ADHD adolescents. Methods One hundred and forty-five participants were grouped based on their diagnosis: 58 with BPD, 58 with ADHD, and 29 healthy volunteers as a control group. Between-group differences and the ROC curve were performed to test if the total score for the BPFSC-11 and/or its factors can significantly discriminate between BPD and other adolescent groups. Results The results show that the total BPFSC-11 score has good discriminant capacity among adolescents diag‑ nosed with BPD, ADHD and healthy volunteers. However, different patterns of discriminative capacity were observed between the three groups for emotional dysregulation and impulsivity/recklessness factors. Conclusions Our results support the hypothesis that the BPFSC-11 is an adequate instrument for discriminating between BPD and ADHD in adolescents, who can present significant psychopathological overlap. Tools to identify BPD in adolescence, as well as for better differential diagnosis, would improve the possibility of offering specific treat‑ ments targeting these populations. Keywords Borderline Personality Features Scale for Children-11 Self Report (BPFSC-11), Borderline Personality Disorder (BPD), Attention-Deficit/Hyperactivity Disorder (ADHD), Adolescence, Discriminate Capacity *Correspondence: Natalia Calvo natalia.calvo@vallhebron.cat Full list of author information is available at the end of the article © The Author(s) 2023. 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The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Calvo et al. Borderline Personality Disorder and Emotion Dysregulation (2023) 10:15 Page 2 of 11 Background [12]. Philipsen et al. [19] found that 41% of adults with Borderline Personality Disorder (BPD) is a severe men- BPD reported high rates of ADHD in childhood, and tal disorder characterized by a pervasive pattern of insta- the authors have reported that severe BPD symptoms bility in affect regulation, pronounced impulsive and in adulthood were related to a diagnosis of ADHD in self-damaging behavior, unstable identity and difficul- childhood. More specifically, Miller et al. [20] reported ties in emotion regulation [1]. Although historically the that 13.5% of children with ADHD, but only 1.2% of the diagnosis of BPD in adolescence has been long debated, control group, were diagnosed with BPD in adolescence. in recent years there has been increased evidence to sug- These authors also reported that youth who continued gest that BPD symptoms are present in childhood and to meet criteria for ADHD diagnosis in adolescence had adolescence, and that BPD can be reliably diagnosed in higher rates of BPD compared to youth who remitted adolescence [2–6]. In fact, Miller et al. (2008) had already from ADHD. As a result, research into the relationship pointed to the existence of a body of evidence indicating between BPD and ADHD has increased, and data has that BPD is reliably diagnosed in adolescence and its reli- even been presented on possible etiopathogenic bases ability and validity is comparable with adults [6]. In the that are common to both disorders [2, 12, 19, 21]. last two decades, there has been greater sensitivity of Although BPD and ADHD have common aspects, diagnosis which is legitimated in the psychiatric nomen- accurate diagnosis can be achieved considering the clature (DSM-5 and DMS-5-TR) [1, 7]. core dysfunctional areas of both conditions [15], as well It is recognized that BPD in adolescence contributes as differences related to the therapeutic strategies indi- to “adaptive failure” [8] and that it has a strong impact, cated for each, so it is essential to make a correct dif- with negative outcomes in different areas of function- ferential diagnosis between the two disorders to ensure ing and serious repercussions for psychopathological a subsequent comprehensive and specific approach to aspects, as well as in educational, occupational, social, each one. In this way, while adolescents can benefit and legal settings, and a high economic cost for the from psychotherapeutic intervention programs that are healthcare system [9–11]. Although prevalence stud- specially designed and adapted for BPD, such as Dia- ies in adolescents are still scarce, the information pub- lectical Behavior Therapy-Adolescents (DBT-A), Emo- lished to date indicates ranges of 1–3% for the general tion Regulation Training (ERT), Mentalization-Based adolescent population, with cumulative prevalence rates Therapy-Adolescents (MBT-A) and/or a combination of 1.4% by 16 years old, rising to 3.2% by the age of 22 of psychodynamic and cognitive behavioral therapy [4, 12–16]. In mental health settings, this disorder can such as Cognitive Analytic Therapy (CAT) [22, 23], the be found in about 11% of outpatients and in as many as clinical guides recommend multi-modal programs for 50% of inpatients (between 33% and 43–49% according ADHD patients which combine pharmacological with to studies) [4, 12–16]. Cumulative evidence also suggests psychosocial treatment [24, 25]. that BPD adolescents can benefit from early interven- While there are a significant number of validated tion when they are properly diagnosed [4, 10]. However, instruments for the diagnosis of ADHD [22], these are other recent studies have shown that there is a long way still scarce for BPD diagnosis in adolescents. The Border- to go before this evidence is introduced in routine clinical line Personality Features Scale for Children-11 (BPFSC- practice [12]. Unfortunately, diagnosis and consequent 11) [26] screening instrument has been specifically therapeutic intervention are often delayed, with adverse designed for BPD and uses self-reporting to evaluate bor- results for the patients, involving a high risk of progres- derline personality, as well as the subclinical levels of this sion to impairment, more severe psychiatric pathology pathology, in children from 9 years of age to adolescents. and comorbidity, and poorer clinical and psychosocial It is based on two previous instruments: the Personality functioning in early adulthood, among others [15]. Assessment Inventory Borderline Subscale (PAI-BOR) Identification of adolescents with BPD is still difficult. [27] and the Borderline Personality Features Scale for There is a remarkable clinical overlap between BPD and Children (BPFSC) [3]. After examining the structure of other psychopathological disorders that begin in child- the latter through a multidimensional confirmatory item hood or adolescence, such as attention-deficit/hyperac- response theory (IRT), its authors [26] proposed the tivity disorder (ADHD) and clinicians express concern current 11-item version, which has been shown to have over the distinction between BPD and ADHD [2]. ADHD adequate psychometric properties with regard to validity is a highly prevalent disorder in adolescence, and impul- (concurrent and criterion) and reliability for the screen- sivity and emotional instability, classically considered ing of BPD in the adolescent population [28]. core symptoms of BPD, are part of its clinical charac- The objective of this study is to test the capacity of the teristics [17, 18]. Studies report that BPD and ADHD Spanish version of the BPFSC-11 to discriminate between are commonly comorbid in both adults and adolescents BPD and ADHD in adolescents. Its psychometric Calvo et al. Borderline Personality Disorder and Emotion Dysregulation (2023) 10:15 Page 3 of 11 properties of reliability, validity, sensitivity and specificity was obtained from all parents before inclusion in the are also preliminarily analyzed. study. Table 1 presents the participants’ descriptive data. The total sample comprised 145 subjects, 62.1% female Methods (n = 90). The mean age was 15.51 years (SD = 2.21), and Participants 63.4% (n = 92) were mainly attending high school at the Participants in the current sample were recruited time of the study. Of these, 116 were outpatients being between October 2018 and February 2020 from the out- treated for BPD and ADHD (BPD and ADHD group; patient section of Psychiatry Department of a university 40%) in the psychiatry department of a general univer- teaching hospital in Barcelona, Spain. sity teaching hospital in Barcelona (Spain). And 29 were To study of the discriminative capacity of the BPFSC- healthy adolescent volunteers recruited from school pro- 11, a BPD group and an ADHD group were selected. grams and were also tested at the hospital (20%; healthy Participants were included if: (1) they were between the control group). ages of 9 and 18 years; (2) they did not present any learn- ing disability; (3) there was no simultaneous diagnosis Measures of BPD and ADHD; (4) there was no current diagnosis The Borderline Personality Features Scale for Children-11 of schizophrenia, bipolar I disorder, or active substance (BPFSC-11) [26] is an 11-item self-report instrument dependence disorder; and (5) they were not suffering using a 5-point Likert response format, ranging from from any organic condition that could better explain the 1 (not at all true) to 5 (always true). It takes less than symptoms. In addition, to assess discriminant capac- 10 min to administer. A cut-off point of 34 is considered ity between psychopathological characteristics and the optimal for the diagnostic identification of BPD (sensi- inherent developmental characteristics of adolescents, a tivity = 0.74; specificity = 0.71) [26]. Concurrent validity control group of healthy volunteers with no diagnosed was tested with the Childhood Interview for DSSM-IV psychiatric pathologies was included. Once the inclu- Borderline Personality Disorder (CI-BPD) [29], yield- sion and exclusion criteria had been reviewed, all admit- ing an Area Under the Curve (AUC) of 0.80 [30]. Due to ted subjects and their parents were invited to participate its rapid administration, factorial structure, and optimal in the study, which was approved by the hospital’s Ethics psychometric properties—especially reliability and con- Committee. Written informed consent for participation struct validity— the original version of the BPFCS-11 has Table 1 Sociodemographic and clinical characteristics of samples BPD (n = 58) ADHD (n = 58) Control group (n = 29) Post-hoc (Tukey’s test) Sex (n, %) F = 26.289 (p < .001) Female 49 (84.48) 18 (31.03) 23 (79.31) BPD = Control > ADHD Male 9 (15.52) 40 (68.97) 6 (20.69) ADHD > BPD = Control Age (mean, SD) 16.33 (1.66) 13.71 (1.83) 16.97 (1.74) F = 47.234 (p < .001) BPD = Control > ADHD Academic level (n, %) F = 1.057 (p = .35) Primary school 15 (25.9) 5 (8.6) 4 (13.8) High school 32 (55.2) 43 (74.1) 17 (58.6) Vocational training 5 (8.6) 4 (6.9) 1 (3.4) University 5 (8.6) 6 (10.4) 7 (24.1) BPD (n = 38) ADHD (n = 12) Control group (n = 21) KSADS/SCID-I (n, %) None 19 (50) 7 (58.33) 21 (100) F = 6.325 (p = .003) One disorder 14 (36.84) 4 (33.33) 0 (0) Two disorders 3 (7.89) 0 (0) 0 (0) BPD > Control Three or more disorders 2 (5.3) 1 (8.3) 0 (0) SCID-II (n, %) None 3 (7.9) 10 (83.3) 21 (100) F = 101.99 (p < .001) One or more PD (Other than BPD) 35 (92.1) 2 (16.7) 0 (0) BPD > ADHD = Control Discrimination of Borderline Personality Disorder (BPD) and Attention-Deficit/Hyperactivity Disorder (ADHD) in Adolescents: Spanish Version of the Borderline Personality Features Scale for Children-11 Self-Report (BPFSC-11) Calvo et al. Borderline Personality Disorder and Emotion Dysregulation (2023) 10:15 Page 4 of 11 been considered an appropriate instrument for the clini- and who followed same diagnostic procedure as the pre- cal diagnosis of BPD and is also useful in epidemiological vious groups. and follow-up studies [26]. With the authorization of the author, the BPFSC-11 was translated into Spanish by two Data analysis independent, native-Spanish speakers with clinical exper- Comparisons between the BPD, ADHD and control tise who were familiar both with the constructs being groups were evaluated using two side T-tests, chi-square measured and with the target population. The translators (χ2), or ANOVA tests, depending on the type of variable reached a consensus on a common version, which was to be studied (Sociodemographic and comorbidity vari- then blindly back-translated by a native English speaker ables) and the groups to be compared. Since this work and compared with the original scale. The above proce- is part of a larger validation project, the present study dures followed the standard recommendations for adap- included a preliminary analysis of the psychometric tation of questionnaires [31]. properties. Exploratory factorial analysis using princi- The Spanish version of the Structured Clinical Inter- pal components with oblique rotation was used with the view for DSM-IV Axis II Disorders (SCID-II) [32] was whole sample to study the BPFSC-11 factorial structure. used to assess the diagnosis of BPD and the other PDs The Kaiser–Meyer–Olkin (KMO) test was used to ana- according to Diagnostic and Statistical Manual of Mental lyze whether data was suitable for factor analyses and a Disorders IV and 5 (DSM-IV/DSM-5) criteria in subjects value greater than 0.80 was considered adequate. Cron- from 16 years of age. For younger individuals, personality bach’s alpha was used to analyze BPFSC-11 reliability. traits were explored through a clinical interview during Diagnostic performance was studied using the Receiver the assessment. Operating Characteristic (ROC) curve. Two analyses For the diagnosis of ADHD, the Schedule for Affec- were performed, one with the total sample (n = 145) and tive Disorders and Schizophrenia for School-Age Chil- the other with the participants from the BPD and ADHD dren-Present and Lifetime Version (K-SADS-PL) [33, Groups (n = 116; clinical sample). Sensitivity and 1-spec- 34] was used for adolescents under 16. In patients of 17 ificity plot was used to select the cut-offs and the AUC and 18 years, the Structured Clinical Interview for DSM- was used to analyze the validity of the measurement. An IV Axis I (SCID-I) [35] was used. Also, to complete this AUC of 0.7 was considered an adequate result for valid- diagnosis of ADHD, the Spanish version of the Child ity [37]. Although a more appropriate approach based Behavior Checklist (CBCL by Achenbach) was adminis- on odds of the studied disease has been proposed, in this tered to parents to assess internalizing and externalizing preliminary study the approach used was the maximiza- symptoms in patients between 4 and 18 years old [36]. tion of indices for both sensitivity and specificity [38]. For all participants in the study, both K-SADS-PL and Finally, between the groups (BPD, ADHD, and control SCID-I interviews were used to assess current comorbid groups) two-way ANOVA tests were used for the dis- disorders. criminative capacity of the BPFSC-11 total score and each of the scales. Statistical significance was established Procedure at p ≤ 0.05. Non-participants were excluded by missing This study is a preliminary analysis forming part of a data. general ongoing project to validate the Spanish v of the BPFSC-11. The adolescents had been diagnosed previ- Results ously with BPD and ADHD by the respective programs in Between‑group comparison the hospital Psychiatry Department. Initially, between-group comparison for sociodemo- Psychopathological evaluation of BPD and ADHD par- graphic variables was performed. Significant differences ticipants was performed in three consecutive sessions by between the groups were only observed for age (p < 0.001) a psychiatrist (first session) and a clinical psychologist and sex (p < 0.001). Post-hoc analyses indicated that the (second and third sessions), both with experience in the ADHD group was significantly younger than the healthy diagnosis of BPD and ADHD. Clinical and sociodemo- control group [ADHD group: 13.71 (1.83) vs. healthy graphic data were recorded in the first interview. During control group: 16.97 (1.74), p < 0.001] and the BPD group the second and third sessions, the K-SADS-PL or SCID- [16.33 (1.66), p < 0.001] (see Table 1). Also, a significantly I interviews, the SCID-II, and the self-reported BPFSC- higher frequency of females was observed for the BPD 11 were administered by the same clinical psychologist. and healthy control groups than for the ADHD group The material was administered in the same order for all (p < 0.001) (see Table 1). participants. In relation to the SCID-II interview, and following The healthy control group was made up of adolescents the criteria for its administration by age, a sub-sample with an absence of criteria for any psychiatric pathology, of clinical patients was used (see Table 1). The results Calvo et al. Borderline Personality Disorder and Emotion Dysregulation (2023) 10:15 Page 5 of 11 obtained indicate the presence of differences in comor- The correlation between the factors was r = 0.59. The fac- bidity with other PDs (p < 0.001) among clinical groups, torial loads of the BPFSC-11 items are shown in Table 2. with the highest being among BPD adolescents, and spe- The reliability of the total BPFSC-11 score based on cifically those with avoidant personality disorder (AvPD) the 11 items was α = 0.86 (mean α = 0.85) and did not (39.5%), while in the ADHD group it was observed in increase when any item was eliminated. However, when just 2 patients (16.7%) with Cluster C. With regard to the internal consistency of the BPFSC-11 was analyzed other comorbid disorders, no significant differences were by factors, a somewhat higher alpha value for the emo- found (p = 0.003), with anxiety disorder being the most tional dysregulation factor (α = 0.89; 8 items) than for the prevalent among both clinical groups (13.2% BPD vs. impulsivity/recklessness factor (α = 0.59; 3 items) was 8.3% ADHD). Table 1 shows the results for each group of obtained. participants. Discriminative capacity of BPFSC‑11 to distinguish between groups Preliminary psychometric analysis ROC curve analyses were performed to study the cut-off Analysis of the factor structure of the BPFSC-11 indi- point, sensitivity, and specificity of the BPFSC-11 and its cated a good fit index of the data (Kaiser–Meyer– factors. Two analyses were performed, the first with the Olkin = 0.88). Two factors were identified. Six of the total sample (n = 145) and the second with the partici- 11 items of the BPFSC-11 (items 1, 4, 6, 7, 9, 10) were pants from the BPD and ADHD groups (n = 116; clinical included in factor 1, and three were included in factor sample). 2 (items 5, 8, and 11). Two items presented very similar The first ROC curve analysis with the total sample loads in both factors (items 2 and 3). Factor 1 includes indicated a good diagnostic fit for the BPFSC-11, with the items that refer to aspects of instability in emotions an AUC of 0.80 (95% CI [0.73, 0.87], p < 0.001) and an and interpersonal relationships, fear of abandonment and emotional dysregulation factor of 0.82 (95% CI [0.75, loneliness, guilt, extreme emotions, feelings of emptiness, 0.89], p < 0.001). However, the AUC was lower than 0.70 and identity difficulties, and could therefore be called an for the impulsivity/recklessness factor (AUC = 0.66; 95% emotional dysregulation factor. Factor 2 includes items CI [0.58, 0.75], p = 0.001) than for factor 1. Sensitiv- that evaluate acting without thinking about the conse- ity and specificity analysis indicated an adequate cut-off quences, carelessness, cruelty, and lack of empathy, i.e., point of 30 to discriminate between BPD and all other an impulsivity/recklessness factor. The emotional dys- participants for the BPFSC-11 (sensitivity = 0.74; speci- regulation factor explained 42.54% of the variance of the ficity = 0.70), of 20 for factor 1 (sensitivity = 0.72; speci- BPFSC-11 (eigenvalue = 4.68), and the impulsivity/reck- ficity = 0.72), and of 11 for the impulsivity/recklessness lessness factor explained only 9.90% (eigenvalue = 1.09). factor (sensitivity = 0.64; specificity = 0.57) (Fig. 1). Table 2 Factorial loadings for the 11 BPFSC Items included in the Factor Analysis (n = 145) Items BPFSC-11 Spanish Version Factor 1 2 1) I feel very lonely .84 .31 4) I feel that there is something important missing about me, but I don’t know what it is .81 .43 10) How I feel about myself changes a lot .78 .40 6) People who were close to me have let me down .74 .37 7) I go back and forth between different feelings, like being mad or sad or happy .73 .52 9) I worry that people I care about will leave and not come back .63 11) Lots of times, my friends and I are really mean to each other .73 8) I get into trouble because I do things without thinking .39 .71 5) I’m careless with things that are important to me .38 .62 2) I want to let some people know how much they’ve hurt me .56 .52 3) My feelings are very strong. For instance, when I get mad, I get really really mad. When I get happy, I get really .46 .46 really happy Eigenvalue 4.68 1.09 % Variance 42.54 9.91 Factor 1: Emotional dysregulation. Factor 2: Impulsivity/recklessness factor. Items loading on each factor are in boldface Calvo et al. Borderline Personality Disorder and Emotion Dysregulation (2023) 10:15 Page 6 of 11 Fig. 1 ROC curve comparing BPD group with the other participants (n = 145) Compared to the results of the first ROC curve analy- with the other two [BPD group: 35.83 (SD 7.98) vs. sis, the second analysis, which only included the clinical ADHD group: 27.74 (6.91) vs. healthy control group: sample (n = 116), indicated a somewhat lower diagnos- 22.52 (8.34), all ps < 0.001], and for the emotional dys- tic fit compared with the results for the whole sample. regulation factor [BPD group: 24.15 (6.35) vs. ADHD Although it was optimal for the BPFSC-11 (AUC = 0.77, group: 17.26 (5.15) vs. healthy control group: 14.52 (5.78), 95% CI [0.69, 0.85], p < 0.001) and for the emotional all ps < 0.001]. However, despite the significantly higher dysregulation factor (AUC = 0.80, CI 95%: 0.672–0.88; mean impulsivity/recklessness factor in the BPD group p < 0.001), the diagnostic fit of the impulsivity/reckless- compared with the healthy control group [11.67 (2.96) ness factor was lower than that obtained in the previous vs. 8.03 (3.16), p < 0.001], no significant differences were analysis, without reaching a level of statistical significance observed in the mean impulsivity/recklessness factor (AUC = 0.60, 95% CI [0.50, 0.70], p > 0.05). Similarly, score between the BPD and ADHD groups [11.67 (2.96) while for the same cut-off point, the sensitivity of the vs. 10.59 (2.73), p > 0.05]. On the other hand, the BPFSC- BPFSC-11 (0.74), emotional dysregulation factor (0.72) 11 total score [27.74 (6.91) vs. 22.52 (8.34), p < 0.01] and and impulsivity/recklessness factor (0.64) remained the the score for the impulsivity/recklessness factor [10.59 same, the specificity value was lower for all three scores (2.73) vs. 8.03 (3.16), p < 0.001] were significantly higher (BPFSC-11: 0.64, emotional dysregulation factor: 0.69 in the ADHD group compared with the healthy control and impulsivity/recklessness factor: 0.52) (Fig. 2). group, but no differences between groups were observed Finally, a one-factor ANOVA was performed to com- for the emotional dysregulation factor score [17.26 (5.15) pare the BPFSC-11 scores among groups (Table 3). The vs. 14.52 (5.78), p = 0.10]. results yielded significant differences both for the com- As significant differences between groups were plete self-report and for each of the two factors obtained observed for sex and age, a post-hoc analysis was per- in the factor analysis [BPFSC-11: F (2,142) = 33.25, formed to test the effect of these variables. The results p < 0.001; emotional dysregulation factor: ­F(2,142) = 33.92, showed a significant effect of sex (­ F(3,140) = 9.09, p < 0.001), p < 0.001; impulsivity/recklessness factor: ­F(2,142) = 15.10, but not of age (­F(3,140) = 1.75, p = 0.16). Girls scored sig- p < 0.001]. Post-hoc tests indicated a significantly higher nificantly higher than boys in the total BPFSC-11 [32.41 BPFSC-11 total mean score in the BPD group compared (9.49) versus 25.87 (7.09); t­(143) = 4.41; p < 0.001] and Calvo et al. Borderline Personality Disorder and Emotion Dysregulation (2023) 10:15 Page 7 of 11 Fig. 2 ROC curve comparing BPD and ADHD groups (n = 116) Table 3 Mean (SD) of the total score of the complete BPFSC-11 Self-Report, Emotional Dysregulation Factor and Impulsivity/ Recklessness Factor by group; differences by ANOVA analysis BPD (n = 58) ADHD (n = 58) Control (n = 29) F(2, 142) BPFSC-11 Self Report 35.8 (7.9) 27.7 (6.9) 22.5 (8.3) 33.246 (p < .001) Factor 1: Emotional dysregulation 24.2 (6.4) 17.3 (5.1) 14.5 (5.8) 33.917 (p < .001) Factor 2: Impulsivity/recklessness 11.7 (3.0) 10.6 (2.7) 8.0 (3.2) 15.099 (p < .001) emotional dysregulation factor [25.45 (7.65) versus 19.27 early development, while they may still be flexible and (5.83); ­t(143) = 5.15; p < 0.001], but no significant dif- modifiable, may have negative repercussions when they ferences were observed between the two sexes for the evolve into a disruptive transition in adulthood [39]. impulsivity/recklessness factor [7.03 (2.72) versus 6.60 While research has been stepped up in recent years, the (2.17); ­t(143) = 1.00; p = 0.32]. scarcity of valid instruments for the detection and diag- nosis of adolescents who are subsyndromal or have BPD Discussion hinders its evaluation and limits the accuracy of identi- Although the diagnosis of BPD during adolescence is con- fication and discrimination procedures [39]. Knowledge sistently recognized in current studies [7, 8], it remains of the discriminative capacity of the existing instruments controversial in clinical settings. The overlap between is therefore necessary. The main objective of this prelimi- the clinical characteristics of BPD with other disorders, nary study was to analyze the capacity of the BPFSC-11 such as ADHD, can make BPD diagnoses unreliable. That to discriminate between BPD and ADHD in adolescents. is why early diagnosis and screening are necessary since The results obtained in this study suggest that the they represent the first step to adequate monitoring and BPFSC-11 total score seems to be a useful measure to the implementation of specific treatments. In that sense, discriminate between BPD and ADHD in adolescents. and coinciding with different authors, the non-identifica- On the other hand, while typically a unidimensional fac- tion of these disorders which emerge during periods of tor structure is supported, our preliminary results also Calvo et al. Borderline Personality Disorder and Emotion Dysregulation (2023) 10:15 Page 8 of 11 show a two-factor solution: emotional dysregulation and former group could manifest itself clinically at a later impulsivity/recklessness factors, which present differ- stage, because during the earlier stages of ADHD, clini- ences in their capacities to discriminate between both cal features of a more behavioral nature are exhibited that disorders. These two results, which are discussed below, are subsequently associated with that dysregulation. In should be considered the main strengths of our study. other words, an earlier behavioral expression could well Regarding the first result, to our knowledge and to date, be the cause of an inadequate emotional response in later this is the first preliminary study of the Spanish version life [43], explaining the results found here. of the BPFSC-11 instrument for identifying discrimi- Regarding the second factor, the results suggest that nant capacity between BPD and ADHD in adolescents. impulsivity/recklessness does not produce an adequate Therefore, there have been no other published measures discrimination between BPD and ADHD, but it does against which we can contrast our own results. However, between these two disorders and healthy adolescents. these results are of major interest since, as pointed out The literature indicates that impulsivity is a multifac- by some authors [40], it is essential to identify the clini- eted construct which constitutes a characteristic psy- cal conditions in adolescents at high risk of developing a chopathological feature, a symptom and diagnostic severe and heterogeneous mental disorder such as BPD, criterion for both disorders [25]. However, it does not and to differentiate this from other psychopathological represent the same psychopathological description for disorders, thereby avoiding diagnostic errors with clini- both. While studies suggest that the type of impulsiv- cal implications in terms of early intervention programs. ity in BPD individuals is related to stress dependence, Having instruments available that can help regular clini- in ADHD patients it would be better defined in rela- cal practice to distinguish between BPD and ADHD in tion to a motor type, adopting more behavioral aspects adolescents and control their possible comorbidities with such as impatience when waiting, talking and/or inter- other psychiatric disorders, such as substance use disor- rupting others [40]. Factor 2 of the Spanish version of der (SUD) and other affective disorders, could contribute the BPFCS-11 may, therefore, be more related to these to reducing poor psychopathological outcomes, as sig- behavioral characteristics and even more with antisocial naled in some recent studies [2]. As stated previously in behavior and lack of empathy, and less to those of BPD. the literature [25], by taking account of the developmen- It would therefore appear that our results reinforce the tal stage of adolescence described, the BPFSC-11 could idea that, while BPD and ADHD share psychopatho- help to improve this situation. Our results specifically logical traits, impulsivity/recklessness as evaluated in encourage us to consider that this instrument can help to the BPFSC-11 self-report should be considered more of improve detection and discrimination between BPD and core pathology of ADHD. However, taking into account ADHD, thereby contributing to a greater understand- the small number of items that make up this factor, ing of their endophenotypes [2]. Future studies with this which explain a small variance, and the aspects that instrument should replicate these results. they evaluate, our results would seem to suggest that In relation to the analysis of the factors’ discriminant they are more typical of ADHD than of BPD, differen- capacity, although the sample size and the fact that this tiating it even more clearly from the control group ado- is a preliminary study mean that the outcomes must be lescents. On the other hand, and although some authors taken with caution, the results obtained in relation to the have argued a greater association between the male sex two-factor solutions are interesting. The first emotional and impulsivity, in our study this factor does not seem dysregulation factor of the BPFSC-11 is that which best to discriminate in relation to sex either [26]. Therefore, discriminated between all groups, and especially between the results obtained should be interpreted with caution BPD and ADHD, and between BPD and healthy ado- and in the expectation of obtaining more robust out- lescents, but did not discriminate between ADHD and comes in future studies. One option to consider might healthy adolescents. These results would be consistent be to increase the number of items included with a view with the idea that although emotional dysregulation is a to increasing the weighting of a factor that may be rel- common dimension of both disorders, it is more clearly evant for discriminating between BPD and ADHD in related to BPD in adolescents as primary core pathology adolescents. [25, 41, 42]. In contrast, these results may coincide with Finally, and in relation both factors, while we agree those of other studies which indicate that while a con- with studies such as those by Chanen et al. (2016) siderable number of ADHD patients present emotional which indicate the importance of identifying adoles- dysregulation as a primary symptom, this does not occur cents with specific traits or subthreshold symptoms in all of them [25]. Meanwhile, the lack of discriminant as necessary for on-time intervention, [24, 44], future capacity observed between ADHD and healthy controls studies should also analyze their possible associa- may be due to the fact that emotional instability in the tion with some of the maladaptive traits of Criterion Calvo et al. Borderline Personality Disorder and Emotion Dysregulation (2023) 10:15 Page 9 of 11 B of the hybrid model of personality disorders of the Conclusions DSM-5 and DSM-5-TR. Specifically, emotional dysreg- To conclude, the results of this study seem to support ulation could be related to characteristics of negative the idea that the BPFSC-11 can be a useful instru- affectivity or neuroticism, as well as impulsiveness/ ment for the identification of adolescent BPD. Also, recklessness with lack of inhibition [45]. Both dimen- and related to disorders with overlapping symptoms, sions could be related to these BPD criteria, which the emotional dysregulation factor seem useful for dis- could be more interesting to study in the psycho- criminating between adolescents with BPD and those pathological discrimination of adolescence. Therefore, with ADHD. These results should be considered of recent studies such as Thomson et al. (2022) suggest interest since they can help to improve the evaluation the need to have available instruments that examine of this pathology in this population, and also support clinical usefulness and not just in detecting of person- the necessary discrimination from other disorders with ality disorders according to purely categorical concep- similar clinical features, thereby improving their diag- tualizations, but which also evaluate their capacity to nosis. Consequently, this could benefit the subsequent catch them in accordance with new dimensional con- implementation of psychotherapeutic interventions in structs such as impairment in personality functioning adolescents with these pathologies and improve their in adolescents [46]. situations and futures. This study has some limitations but also some Acknowledgements strengths. The first limitation is that the Spanish We thank the financial support was provided by public funds from the Depart‑ validation of the BPFSC-11 has not yet been final- ment of Mental Health and Addictions (Government of Catalonia, Health ized. However, its preliminary psychometric results Department). (internal consistency and reliability, sensitivity and Declaration of transparency specificity) were similar to the original version of the The corresponding author declares that this manuscript is an honest, accurate, BPFSC-11 [26]. The second limitation is the small and transparent report of the present study, that no relevant aspect of the study has been omitted, and that the differences from the pre-planned study size of the samples. Although the study was initially have been explained (and registered, if relevant). designed to be performed over a more extended time, the recruitment of participants, especially for the con- Authors’ contributions N.C. and M.F. designed the study. N.C., M.F., and R.V. participated in the recruit‑ trol group, was affected by the Covid-19 pandemic, ment of participants. J.L.M. analyzed the data. N.C., M.F. and J.L.M. reviewed meaning that the number was limited. Therefore, the scientific literature and wrote the first draft of the manuscript. All authors given the total lockdown, we decided only to include participated in the revision, discussion and approved the final manuscript. the participants recruited up to February. However, in Funding future studies the number of participants should be This project was supported by funding from the Bank of Mental Health Instru‑ higher, and the healthy control group increased to be ments of CIBERSAM, Code nr. SAM15PINT1505. able to confirm the results obtained more confidently Availability of data and materials and to understand the similarities or differences in the The data that support the findings of this study are available on reasonable clinical risk profiles. Therefore, the results related to request from the corresponding author. the two-factor solutions, although interesting, must be taken with caution and confirmed in future studies Declarations with higher sample sizes. The third limitation relates Ethics approval and consent to participate to the evaluation made using the SCID-II interview This study is part of a project approved by the Ethics Committee of the Hospi‑ in clinical samples. While this has been used success- tal Universitari Vall d’Hebrón of Barcelona, Spain (PR (AG) 321/2015). This study was not preregistered. All admitted patients and their parents were invited fully in in studies with adolescents, the age of many of to participate in the study. Written informed consent for participation was the participants in this study made its administration obtained from all parents and participants before study participation. impossible, especially for the ADHD group where the Consent for publication participants were the youngest. Future studies should No applicable. include other, more appropriate methods developed specifically to assess adolescent PD such as the CI- Competing interests The authors declare no competing interests. BPD, which could be interesting for the most objec- tive way of studying personality structure, as well as a Author details 1 larger study of comorbidities. Finally, as a fourth limi- Psychiatry Department, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Hospital Universitari Vall d’HebronUniversitat Autònoma tation, a significant effect of sex was observed in the de Barcelona, Passeig Vall d´Hebron 119‑129, 08035 Barcelona, Spain. 2 Psy‑ study, with an overrepresentation of girls in the BPD chiatry, Mental Health and Addictions Group. Vall d’Hebron Institut de Recerca group. Future studies should study more balanced (VHIR), Barcelona, Spain. 3 Psychiatry and Legal Medicine Department, Univer‑ sitat Autònoma de Barcelona (UAB), Barcelona, Spain. 4 Grup TLP Barcelona samples in terms of gender distribution. Calvo et al. Borderline Personality Disorder and Emotion Dysregulation (2023) 10:15 Page 10 of 11 (Grup TLP BCN), Barcelona, Spain. 5 Department of Psychology, University 22 Bélanger SA, Andrews D, Gray C, Korczack D. ADHD in children and youth: of Houston, Texas, USA. Part 1 – Etiology, diagnosis, and comorbidity. 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