Outcome Measure
Borderline Symptom List
What it measures?
- The BSL-23 assesses 23 feelings and experiences that are typically reported by patients with Borderline Personality Disorder (BPD).
- Items cover diagnostic criteria, such as affective instability, recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour, and transient dissociative symptoms. In addition, items were added based on empirical findings—relating to self-criticism, problems with trust, emotional vulnerability, and proneness to shame, self-disgust, loneliness and helplessness.
- The BSL-23 is anchored to the past week, and is based on DSM-IV/DSM-5, the revised version of the Diagnositic Interview for Borderline Personality Disorder, and the experiences of of both clinical experts and BPD patients—who were included in the development of the instrument (Kleindienst et al., 2020).
Who is it for?
Adults aged 18 years +
Instrument Quality
- The BSL-23 has excellent psychometric properties, and is considered appropriate for assessing BPD symptoms and tracking change in treatment outcome studies (Bohus et al., 2009; Glenn et al., 2009; Heerebrand, Bray, Ulbrich, Roberts & Edwards, 2020; Hilden et al., 2021).
Structure
- 23 items
- 5-point Likert scale
- Respondents are asked how much (0 = “not at all”; 4 = “very strong”) they suffered from each problem (e.g. “I experienced stressful inner tension”) during the course of the past week.
Scoring instructions
Sum all item responses and then divide the result by 23 (the number of items) to derive a total mean score.
| Subscale | Item number |
|---|---|
Full-scale (BSL-23) |
1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23 |
Score Interpretation
What higher scores mean?
- More severe BPD symptom severity during the past week. Greater likelihood of meeting criteria of BPD. Kleindienst et al (2020) found that a cutoff value of 1.5 was optimal for discriminating BPD patients from a group of mixed clinical controls. However the value of of 0.64 resulted in the best separation of individuals with a diagnosis of BPD from healthy controls.
Identifying risk
A patient may be at risk if they endorse any of the following ‘red flag’ items. Further risk assessment should be undertaken.
| Item number | Item content |
|---|---|
| 5 | I thought of hurting myself |
| 7 | I didn’t believe in my right to live |
| 15 | I suffered from voices and noises from inside or outside my head |
| 18 | The idea of death had a certain fascination for me |
How to assess symptom severity & change?
| Description | Score Range | |
|---|---|---|
| Low | 0 | |
| Mild | 0.28 | |
| Borderline Personality Disorder | >=1.5 | Provisional Diagnosis |
| Moderate | 1.07 | |
| High | 1.87 | |
| Very high | 2.67 | |
| Extremely high | 3.47 | |
| Maximum | 4 |
Instrument developers
- Bohus, M., Kleindienst, N., Limberger, M. F., Stieglitz, R. D., Domsalla, M., Chapman, A. L., ... & Wolf, M. (2009). The short version of the Borderline Symptom List (BSL-23): development and initial data on psychometric properties. Psychopathology, 42(1), 32-39
Refrences
* Bohus, M., Kleindienst, N., Limberger, M. F., Stieglitz, R. D., Domsalla, M., Chapman, A. L., ... & Wolf, M. (2009). The short version of the Borderline Symptom List (BSL-23): development and initial data on psychometric properties. Psychopathology, 42(1), 32-39. * De Jongh, A., Groenland, G. N., Sanches, S., Bongaerts, H., Voorendonk, E. M., & Van Minnen, A. (2020). The impact of brief intensive trauma-focused treatment for PTSD on symptoms of borderline personality disorder. European Journal of Psychotraumatology, 11(1), 1721142. * Heerebrand, S. L., Bray, J., Ulbrich, C., Roberts, R. M., & Edwards, S. (2021). Effectiveness of dialectical behavior therapy skills training group for adults with borderline personality disorder. Journal of clinical psychology, 77(7), 1573-1590. * Hilden, H. M., Rosenström, T., Karila, I., Elokorpi, A., Torpo, M., Arajärvi, R., & Isometsä, E. (2021). Effectiveness of brief schema group therapy for borderline personality disorder symptoms: a randomized pilot study. Nordic journal of psychiatry, 75(3), 176-185. * Kleindienst, N., Jungkunz, M., & Bohus, M. (2020). A proposed severity classification of borderline symptoms using the borderline symptom list (BSL-23). Borderline personality disorder and emotion dysregulation, 7(1), 1-11. * Rizvi, S. L., Hughes, C. D., Hittman, A. D., & Vieira Oliveira, P. (2017). Can trainees effectively deliver dialectical behavior therapy for individuals with borderline personality disorder? Outcomes from a training clinic. Journal of Clinical Psychology, 73(12), 1599-1611 * Wolf, K., Scharoba, J., Noack, R., Keller, A., & Weidner, K. (2023). Subtypes of borderline personality disorder in a day-clinic setting—Clinical and therapeutic differences. Personality Disorders: Theory, Research, and Treatment
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Severity ranges
Kleindienst, Junkunz and Bohuys (2020) developed a severity classification for the BSL-23 based on the distribution of scores for 241 individuals with a diagnosis of Borderline Personality Disorder (BPD). Data from three independent samples were then used to validate the obtained severity grades. These samples consisted of a group of treatment-seeking patients with adiagnosis of BPD (n = 317), a sample of individuals with mental illnesses besides BPD (N = 176), and a healthy control group (N = 356). The severity grades were validated via comparison with established instruments, including the International Personality Disorders Examination, the STructured Clinical Interview for DSM-IV, the global severity index of the Symptom Checklist (GSI, SCL-90), the Global Assessment of Functioning (GAF), and the Beck Depression Inventory (BDI-II).
Provisional diagnosis
Kleindienst, Junkunz and Bohuys (2020) developed a severity classification for the BSL-23 based on the distribution of scores for 241 individuals with a diagnosis of Borderline Personality Disorder (BPD). Data from three independent samples were then used to validate the obtained severity grades. These samples consisted of a group of treatment-seeking patients with a diagnosis of BPD (n = 317), a sample of individuals with mental illnesses besides BPD (N = 176), and a healthy control group (N = 356). The authors found that a cutoff value of 1.5 was optimal for discriminating BPD patients from a group of mixed clinical controls. However the value of of 0.64 resulted in the best separation of individuals with a diagnosis of BPD from healthy controls.
Reliable change and clinically significant improvement
Wampold et al (2001) conducted a meta analysis of psychotherapy outcome studies and noted that the average improvement was reflected in an effect size (ES) of .80. Because a change of 1 SD corresponds to an ES of 1.0, and .80 is considered to be a large ES, Wise (2004) concludes that a change of 1 SD is a defensible indicator of clinically significant change.
Mean
Standard Deviation
Reliability