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OBJECTIVE: To examine the comorbidity of borderline personality disorder and other personality disorders in a nonclinical sample of high-school students. METHOD: 311 high-school students who completed the French version of the CES-D (Center for Epidemiological Studies-Depression Scale), were asked to participate to interviews evaluating personality functioning: 60 subjects (19%) accepted to participate in the study. The mean CES-D score of these 60 subjects (16 boys, 44 girls, mean age=17.7 1.7) was significantly higher than the mean score of the whole sample (23.9 10.4 versus 16.7 9.8). Thus the interviewed sample was not representative of the population of high-school students. Subjects were assessed using the major depressive episode module of the MINI (Mini International Neuropsychiatric Interview) and the SIDP IV (Structured Interview for DSM IV Personality). Inter-rater reliability was determined by comparing the independent ratings of interviewers and an experienced clinician on a random sample of 20 interviews. For DSM IV borderline personality disorder diagnosis, the Cohen's kappa coefficient was 0.85. For personality disorder criteria, kappa ranged from 0.6 to 1.0 (average kappa=0.79). RESULTS: Sixteen of these subjects (26,7%, 4 males, 12 females) received a diagnosis of borderline personality disorder according to DSM IV criteria. The mean CES-D score of borderline subjects (30.6 10.2) was significantly higher than the mean score of nonborderline subjects (21.6 10.5). Of the 16 borderline subjects, 11 (75%) received a diagnosis of major depressive disorder versus 14 (31%) of the non borderline subjects. None of the other personality disorders approached the frequency of borderline personality disorder. The next most frequent diagnoses were depressive and dependent personality disorders which occurred in respectively in 16.6% and 10% of the 60 subjects. All the personality-disorders occurred at higher rates in the group with borderline personality disorder with the exception of obsessive-compulsive personality disorder which was diagnosed only in nonborderline subjects. Of the 16 borderline subjects, 11 (68.7%) met the criteria for another personality disorder which were depressive personality disorder (N=5), paranoid personality disorder (N=4), dependent personality disorder (N=3), antisocial personality disorder (N=2), histrionic personality disorder (N=2), avoidant personality disorder (N=2), negativistic personality disorder (N=2), schizotypal personality disorder (N=1), narcissistic personality disorder (N=1), self-defeating personality disorder (N=1). The optional diagnoses (self-defeating, depressive and negati-vistic personality disorders) accounted for 8 of 23 (34.7%) cases of personality disorders diagnosed among borderline subjects. Among these 11 adolescents, 5 received 2 diagnoses of personality disorders (borderline and paranoid personality disorders, N=1; borderline and dependent personality disorders, N=1; borderline and depressive personality disorders, N=3), 3 received 3 diagnoses (borderline, antisocial and histrionic personality disorders, N=1; borderline, avoidant and negativistic personality disorders, N=1; borderline, depressive and negativistic personality disorders, N=1), 3 received 5 diagnoses (borderline, paranoid, histrionic, narcissistic and dependent personality disorders, N=1; borderline, paranoid, dependent, avoidant and depressive personality disorders, N=1; borderline, paranoid, schizotypal, antisocial and self-defeating personality disorders, N=1). Among the 44 adolescents (12 boys, 32 girls) without borderline personality disorder, 10 (22.7%) (3 boys, 7 girls) met the criteria for another personality disorder which were depressive personality disorder (N=5) or cluster C disorders -obsessive-compulsive personality disorder (N=4), dependent personality disorder (N=2), avoidant personality disorder (N=1) - with the exception of one diagnosis of histrionic personality disorder. Two subjects received 2 diagnoses (obsessive-compulsive and depressive personality disorder). The internal consistency of personality disorders criteria was assessed with Cronbach's alpha coefficient. Borderline personality disorder criteria had high internal consistency (0.82). The factor structure of borderline personality disorder criteria was studied with an exploratory factorial analysis which extracted three factors. The eigenvalues were 3.70, 1.06, and 1.01. Confirmatory factorial analyses were conducted. The correlated two-factor model and the three-factor model fit the data well but the correlation between factors was, however, judged too high, ranging from 0.70 to 0.78. The one-factor model proved to have a good fit (Goodness of Fit Index=0.89, Comparative Fit Index=0.90, Root Mean Square Residual=0.07). As a previous study showed the frequency of two schizotypal personality disorder criteria (odd beliefs/magical thinking experiences and unusual perceptual experiences), an exploratory factorial analysis was performed on the combined set of criteria of borderline and schizotypal personality disorders. It yielded 2 factors: the first factor consisted of all the borderline personality disorder criteria, odd beliefs/magical thinking, and unusual perceptual experiences and could be called the borderline factor; the second factor consisted of the paranoid and the social avoidance criteria and could be called the interpersonal hypersensitivity factor. A confirmatory factor analysis showed that this two-factor model provided a good fit to the data (GFI=0.82, CFI=0,91, RMSR=0.10). The correlation between factors was weak (0.25). These results suggest that odd beliefs/magical thinking and unusual perceptual experiences are a component of borderline symptomatology in adolescents. DISCUSSION: The high frequency of major depressive disorder and personality disorders in the interviewed sample may be due to the possibility that adolescents with psychological problems have used the interview as a way to obtain attention and support from a psychologist. The interviewed sample, which was characterized by a high intensity of depressive symptomatology and by a high frequency of borderline personality disorder, could thus be seen as intermediate between a clinical and a community sample. Our results may be more generalizable to an outpatients population of adolescents. This study found conflicting results about the construct validity of borderline personality disorder in adolescent. The high internal consistency and the one-factor structure of the borderline personality disorder criteria argue for their validity in adolescents. However, the high rates of comorbidity of borderline personality disorder with depression and other personality disorders, extended to clusters A, B and C and to optional diagnoses, suggest the lack of construct validity of either borderline personality or cluster B disorders in adolescents. CONCLUSION: Borderline symptomatology in adolescents appears more in adequacy with a dimensional model than with a typological classification. More studies are needed to assess and improve the construct validity of borderline personality disorder in adolescents.

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OBJECTIVE: To evaluate the psychometric characteristics of the CES-D (Center for Epidemiological Studies - Depression Scale) in adolescents and to estimate the prevalence of major depression in French high-school students. METHOD: A random sample of 2 583 high-school students from the departments of Haute-Garonne and Pyrénées-Orientales, France, were asked to complete the CES-D. Of these subjects, 1 953 (75.6%) (966 boys and 987 girls, mean age=17 1.4) completed satisfactorily the questionnaire. A sub-sample of 60 adolescents volunteered for an interview and were assessed using the major depressive episode module of the MINI (Mini International Neuropsychiatric Interview). RESULTS: The internal consistency of the CES-D was satisfactory (Cronbach alpha=0.85). A principal component analysis produced consistent sub-scales. The factor structure was similar to that observed in previous studies in adults. Four factors were extracted which accounted for 49.6% of the variance: a depressive cognition factor (items 1, 9, 10, 15, 19); a positive affect factor (items 4, 8, 12, 16); a factor reflecting slowing of thought and reduction of energy (items 5, 7, 20); and a depressive affect factor (items 2, 3, 6, 11, 14, 17, 18). Among the 1 953 subjects, the mean score for girls was significantly higher than for boys (18,8 10,2 versus 14,4 7,7). Of the 60 subjects who were assessed with the MINI, 28 received the diagnosis of major depressive episode. The mean scores of depressed girls and boys in this sub-sample (respectively 35.5 8.7 and 27.7 9.6) were significantly higher than the mean scores of girls and boys for the total sample. According to the results, the best cut-off score was a score of 24 or higher, providing a sensibility of 0.74 and a specificity of 0.73. According to this cut-off score, 9.9% of boys and 24.2% of girls had a probable major depressive episode. DISCUSSION: This study showed a high level of depressive symptoms and a high frequency of probable depression in French adolescents. Two findings suggest the reliability of these results: first, the male-female ratio, close to 1:2 for probable depression, is in keeping with current epidemiological data; second, the high internal consistency and the factor structure are indicators of the reliability of CES-D in adolescents. Our study found a higher cut-off score than the previous French study of the CES-D in adolescents by Bailly et al. This discrepancy may be due to our small interview sample. However, the cut-off of 24, identified with our study, provided frequency rates more in agreement with epidemiological data than the cut-off of 21 proposed by Bailly et al. Mean CES-D scores of boys and girls in our study were respectively significantly higher than those obtained in boys (n=439, 12.4 7.5) and girls (n=305, 16.6 9.7) by Bailly et al. eleven years before. Given the similarities of mean age and representativeness of samples in both studies, this discrepancy may be due to an increase in depressive symptoms in French adolescents which may be linked to the parallel increase in substance use and particularly in cannabis use. CONCLUSION: The high internal consistency and the factor structure of the CES-D suggest its reliability in adolescents. This study found a high frequency of probable major depression in French high-school students.

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OBJECTIVE: To evaluate the connections between the frequency and patterns of cannabis use and dependence, and the beliefs linked to cannabis use in a sample of adolescents. METHOD: In 2001, 285 high school students (163 boys, 122 girls; mean age = 17.5 +/- 1.1 years) completed questionnaires assessing the patterns of cannabis use, and the symptoms of dependence and abuse, using a questionnaire derived from the Mini International Neuropsychiatric Interview. Cannabis-related beliefs were assessed using the Beliefs Questionnaire for Drug Addiction. RESULTS: Frequency of subjects who reported having used cannabis during the last year was 65.4% of boys and 42.6% of girls. Among users, 53.6% of boys and 39.3% of girls were regular users, 10.6% of boys and 7.8% of girls being daily users. Almost half of the users reported other means of consumption than "joints", in particular water-pipes or "bongs" (34.5% of boys, 26.4% of girls). Among users, near of 33% of boys and girls met the criteria for cannabis dependence. Dependence was more frequent in users practicing other means of consumption than "joints", increasing to 51% for "bong" users. Expectancies of pleasure or relief, and permissive beliefs reflecting the perception of cannabis use as risk free were higher in users and, particularly, in subjects with cannabis dependence. Regression analysis showed that these beliefs were the strongest predictors of cannabis use and dependence. Predictors of use in the total sample were expectancies of pleasure and permissive beliefs, being a male and the age of the subject. Predictors of dependence among users were expectancies of relief, frequency of use, and use of other means of consumption than "joints". CONCLUSIONS: Cannabis use in adolescents appeared to be characterized by the frequency of use, consumption by means other than "joints" and by the frequency of dependence. Cannabis use and dependence are linked to expectancies and permissive beliefs that could be targeted for prevention and treatment.

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1,363 high school students were solicited to complete a personality disorder questionnaire and were encouraged to continue in the study by signing up for interviews with Master's level psychology students. 107 students (7.8%, 34 males, 73 females, mean age = 16.7 +/- 1.8) manifested themselves for the interview and were assessed by using structured diagnostic interviews for borderline personality disorder and major depressive disorder (DIB-R, Revised Diagnostic Interview for Borderlines; MINI, Mini International Neuropsychiatric Interview). The interviews were audiotaped. Interrater reliability was determined by independent ratings of 12 borderline subjects and 12 non-borderline subjects (kappa: 0.795). The distribution of the 107 subjects based on the number of DSM IV borderline personality disorder criteria indicated a gradual dispersion suggesting a continuum from normality to borderline personality disorder: 8% of the subjects met none of the criteria; 16% met one criterion; 17% met two; 12.5%, three; 13.7%, four; 8.4%, five; 5.6%, six; 9.3%, seven; 4.6%, eight; 4.6%, nine. Thirty-five of these 107 subjects (32.7%, 6 males, 29 females, mean age = 16.7 +/- 1.7) received a diagnosis of borderline personality disorder according to DSM IV criteria. The most frequent symptoms were paranoid ideation or dissociative symptoms (97.1%), affective instability (88.6%), inappropriate, intense anger (85.6%), suicidal gestures or automutilation (82.9%), followed by frantic efforts to avoid abandonment (77%), impulsivity (65.7%), unstable and intense relationships (62.9%), identity disturbance (60%), and emptiness (57.1%). The comparison between borderline and non-borderline subjects showed that all borderline personality disorder criteria discriminated significantly between the two groups. The high incidence of paranoid ideation (97.1%) and dissociative experiences (65.7%) in the borderline group suggests the pertinence of criterion 9 in the diagnosis of borderline personality disorder in adolescents. Two criteria of schizotypal personality disorder were also frequent in this group: 68.6% of the borderline group reported odd beliefs or magical thinking, in particular beliefs in clairvoyance or telepathy and 88.6% reported unusual perceptual experiences, in particular sensing the presence of a force or person and bodily illusions. Moreover, 31.4% of the borderline group reported transient "quasi" psychotic experiences, mainly "quasi" visual hallucinations. Auditory hallucinations or delusional ideas were not observed. This symptomatology suggests a "quasi" psychotic dimension of adolescent borderline personality disorder. Affective instability was the next most frequent symptom which was usually marked by a cyclothymic appearance. Comorbidity with major depressive disorder was high: 85.7% of the borderline subjects had a concurrent diagnosis of major depression versus 45.8% of the non-borderline subjects. Thus, major depression is more frequent than most of the borderline personality disorder criteria, with the exception of the already noted paranoid ideation and affective instability. Hypomanic symptoms were frequent in the borderline group (65.7%) as well as in the non-borderline group (38.8%). This symptomatology suggests that adolescent borderline personality disorder is linked to an attenuated bipolar spectrum characterised by major depressive episodes and soft signs of bipolarity. However, hypomanic symptoms, which were quite frequent in non-borderline subjects, might also be due to a mechanism of defence, i.e. the denial of depression. Comorbidity with anxiety disorders appeared also to be high: anxiety symptoms were found in 91.4% of the borderline subjects who reported symptoms of generalised anxiety disorder, panic disorder, and somatoform disorders. The overall clinical appearance of these borderline adolescents not referred for treatment seemed to be quite similar to that of borderline adolescents in clinical samples. This study shows that adolescent borderline personality disorder in non-clinical population is a serious disorder characterised by the importance of mental suffering and behavioural disturbances the disorganising power of which may fix the developmental process in a pathological pathway. Adolescent borderline personality disorder appears in this study to be strongly associated with major depressive disorder and at-risk behaviours linked to impulsivity, affective instability, and suicidal ideation. However, this study found an absence of precise cut-off between borderline and non-borderline subjects. Two factors might have contributed to the appearance of a continuum. First, some degree of impulsivity and instability in affectivity, self-images and interpersonal relationships is part of normal adolescence. (ABSTRACT TRUNCATED)

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OBJECTIVE: To estimate the frequency of borderline personality disorder (BPD) in French high school students. METHOD: A random sample of high school students (n = 1363) ranging in age from 13 to 20 years agreed to complete a questionnaire, the Screening Test for Comorbid Personality Disorders (STCPD); 107 of them volunteered to be interviewed. We assessed this group using the Revised Diagnostic Interview for Borderlines (DIB-R). We conducted a regression analysis to determine a cut-off for BPD diagnosis with the STCPD. RESULTS: We estimated the overall frequency of BPD to be 10% for boys and 18% for girls. After a peak of frequency at age 14 years for both sexes, the frequency increased significantly again in late adolescence. CONCLUSION: This study found a high frequency of BPD in French adolescents, which adds to questions regarding the validity of diagnosing this disorder in adolescents.

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