Addictive Behaviors 30 (2005) 1709 – 1724

Adolescent alcohol use disorders predict

adult borderline personality
Dawn L. Thatcher T, Jack R. Cornelius, Duncan B. Clark
Pittsburgh Adolescent Alcohol Research Center (PAARC), Department of Psychiatry,
University of Pittsburgh Medical Center, United States

Abstract

Background: This study investigated adolescent alcohol use disorders (AUDs) and other character-
istics as predictors of adult borderline personality disorder (BPD) symptoms.
Methods: Adolescents with AUDs (n = 355) were recruited from clinical treatment sources and
adolescents without AUDs (n = 169) were recruited from the community. During an adolescent
assessment (age 16 F 1.3), childhood physical and/or sexual abuse history, AUDs and associated
psychiatric disorders were measured via semi-structured interviews. Symptoms of BPD were measured
in a young adult follow-up assessment (age 22 F 2.4). Latent class analysis was utilized to classify
individuals into four categories based upon BPD symptom profiles.
Results: Multinomial regression models indicated that adolescent AUDs and other psychiatric
disorders mediated the relationship between child physical and/or sexual abuse and adult BPD latent
class.
Conclusions: Results were consistent with a developmental conceptualization of BPD, with AUDs and
other adolescent psychopathology antecedents representing developmentally relevant forms of
dysregulation, and in their more severe forms culminating in borderline symptomatology.
D 2005 Elsevier Ltd. All rights reserved.

Keywords: Childhood sexual abuse; Alcohol use disorders; Borderline personality disorder; Adolescents;
Treatment; Prospective

T Corresponding author. PAARC, Western Psychiatric Institute and Clinics, 3811 O’Hara St., Pittsburgh, PA
15213; USA. Tel.: +1 412 246 5186; fax: +1 412 246 6550.
E-mail address: lindsaydl@upmc.edu (D.L. Thatcher).

0306-4603/$ - see front matter D 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.addbeh.2005.07.008
1710 D.L. Thatcher et al. / Addictive Behaviors 30 (2005) 1709–1724

Adolescent alcohol use disorders (AUDs) were studied as a predictor of adult borderline
personality disorder (BPD) symptoms. While adolescent AUDs, other psychiatric disorders,
and adult BPD are related, no strong theoretical model accounting for these relationships has
been developed. The relationship of BPD with adolescent AUD and other psychiatric
disorders, as well as with childhood maltreatment, is reviewed, and a developmental model is
presented involving the construct of dysregulation as the basis for the interrelationships
among environmental factors and phenotypes that might culminate in BPD.

1. Borderline Personality Disorder (BPD)

BPD is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)
as ba pervasive pattern of instability of interpersonal relationships, self-image, and affects,
and marked impulsivity beginning by early adulthood and present in a variety of contextsQ
(APA, 2000). The nine diagnostic criteria for BPD are shown in Table 1. The DSM-IV
requires that five of the nine criteria be clinically significant for a diagnosis of BPD. This
algorithm results in potentially significant heterogeneity among both diagnosed and
subthreshold individuals.
Prevalence of BPD using DSM-IV criteria in adult community samples is approximately
2% in studies utilizing DSM-IV criteria (Ekselius, Tillfors, Furmark, & Fredrikson, 2001;
Samuels et al., 2002). In contrast, prevalence of BPD in the Collaborative Longitudinal
Personality Disorders study (Gunderson et al., 2000), a large study of adult patients from a
range of clinical sites, is 26% (McGlashan et al., 2000). In clinical samples, BPD most
often co-occurs with other mental disorders (Joyce et al., 2003; Skodol et al., 1999).
We consider BPD in this study to be a disorder of adulthood. While it is acknowledged
that symptoms of BPD are likely to emerge during adolescence, the diagnosis cannot
reasonably be made during this developmental period during which many of the criteria
(e.g., unstable relationships) associated with BPD are normative or transient (Chabrol et al.,

Table 1
Diagnostic criteria of borderline personality disorder (BPD)
Criteria Brief descriptor (In Fig. 1)
Frantic efforts to avoid real or imagined abandonment Abandonment
A pattern of unstable and intense interpersonal relationships characterized Relationships
by alternating between extremes of idealization and devaluation
Identity disturbance: markedly and persistently unstable self-image or Identity
sense of self
Impulsivity in at lease two areas that are potentially self-damaging Impulsivity
Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior Suicidal
Affective instability due to a marked reactivity of mood Affective
Chronic feelings of emptiness Emptiness
Inappropriate, intense anger or difficulty controlling anger Anger
Transient, stress-related paranoid ideation or severe dissociative Paranoid
symptoms
 D.L. Thatcher et al. / Addictive Behaviors 30 (2005) 1709–1724 1711

2004). Additional psychometric studies have demonstrated poor inter-rater reliability of

personality disorder diagnosis using a structured interview format with adolescent
psychiatric inpatients (Brent, Zelenak, Bukstein, & Brown, 1990).
BPD has been proposed to be a severe manifestation of psychological dysregulation.
Skodol and colleagues (2002a, 2002b) discuss a core phenotype of affective dysregulation,
behavioral dyscontrol and impulsive aggression, and disturbed interpersonal relatedness that
characterizes individuals with BPD. Deficiency or delay in the ability to regulate affective,
behavioral, and cognitive regulation may be caused by environmental demands that exceed
an individual’s adaptive resources (Clark & Winters, 2002; Tarter et al., 2003). The three-
part (affective, behavioral, and cognitive) conceptualization of BPD symptom structure is
borne out in factor analyses of diagnostic criteria (Sanislow, Grilo, & McGlashan, 2000,
2002). We propose that other disorders reflecting psychological dysregulation occurring in
adolescence might exacerbate environmental risk factors such as child maltreatment, to
predict BPD.

1.1. BPD and AUDs

Among adults, BPD and AUDs have been noted to be associated. Adults with BPD have
higher rates of AUDs and other comorbid conditions indicative of psychological
dysregulation (Trull, Sher, Minks-Brown, Durbin, & Burr, 2000; van den Bosch, Verheul,
& van den Brink, 2001). Conversely, adults with AUDs and other substance use disorders
(SUDs) in clinical settings exhibit high rates of personality disorders, especially BPD (Grilo,
Martino et al., 1997; Grilo, Walker et al. 1997; Morgenstern, Langenbucher, Labouvie, &
Miller, 1997; Skinstad & Swain, 2001; Verheul, 2001). Among adults with severe AUDs,
estimated rates of BPD range from 17% to as high as 61% (Grilo, Martino et al., 1997; Grilo,
Walker et al. 1997; Morgenstern et al., 1997; Verheul, 2001). Community young adults with
AUDs also are significantly more likely to have BPD (Trull, Waudby, & Sher, 2004). These
findings strongly support the high degree of comorbidity of BPD and AUDs. Moreover, a
retrospective study found that among psychiatrically hospitalized adults with BPD,
approximately one-third reported alcohol and/or drug use prior to age 18 (Cornelius et al.,
1989), indicating perhaps that early AUDs place individuals at increased risk for the
development of BPD.
Adolescent AUDs have been demonstrated to predict personality disorders across
community and clinical samples. One community-based prospective study demonstrated
that AUDs during adolescence significantly predicted adult BPD symptoms in a sample of
940 (Rohde, Lewinsohn, Kahler, Seeley, & Brown, 2001). Among adolescents with AUDs at
the initial assessment (n = 82), 13% were diagnosed with BPD at the young adult follow-up
assessment. Subjects who had adolescent-onset AUDs were over three times more likely than
the bproblem-drinkingQ (n = 141) or non-drinking group (n = 685) to be diagnosed with BPD
in young adulthood. Another study by the same research group demonstrated similar
relationships with regard to BPD symptoms (Lewinsohn, Rohde, Seeley, & Klein, 1997).
While these studies are distinctive with respect to demonstrating a prospective association
between adolescent AUDs and adult BPD, other potentially important predictors, such as
1712 D.L. Thatcher et al. / Addictive Behaviors 30 (2005) 1709–1724

child maltreatment, were not assessed, and therefore the nature of the association between
AUDs and BPD is still unclear.
While AUDs have been found to predict BPD, only a small proportion of those with
AUDs actually developed BPD. Therefore, AUDs cannot be regarded as necessary or
sufficient predictors. The next step in an investigation of the effects of AUDs on
subsequent BPD is to determine environmental factors, as well as adolescent characteristics
reflecting psychological dysregulation, that might contribute to a prediction model. Child
maltreatment history is an early environmental factor that is associated both with adolescent
AUDs and adult BPD.

1.2. Childhood maltreatment, adolescent AUDs, and adult BPD

Childhood physical and/or sexual abuse is a primary feature of child maltreatment that has
long been identified as a risk factor for BPD. The association is strongly supported by clinical
evidence and retrospective studies (Laporte & Guttman, 1996; Zanarini, 2000; Zanarini et al.,
1997), as well as one report utilizing archival medical records to document child physical
and/or sexual abuse (Helgeland & Torgersen, 2004). In a community sample, retrospective
report of child maltreatment was significantly associated with BPD (Trull, 2001). This
relationship was supported in a community-based longitudinal study that showed subjects
reporting child maltreatment during a childhood assessment were four times more likely to
have a personality disorder during adulthood (Johnson, Cohen, Brown, Smailes, & Bernstein,
1999) compared to those without maltreatment. Further, subjects with physical and/or sexual
abuse reported twice as many BPD criteria.
Childhood physical and/or sexual abuse also has been found to be associated with
adolescent AUDs. In a study involving a subset of the subjects in the present report,
adolescents with AUDs were 6 to 12 times more likely to have a physical abuse history and 18
to 21 times more likely to have a sexual abuse history (Clark, Lesnick, & Hegedus, 1997).
While one study was found that investigated child maltreatment history, AUDs, and BPD
simultaneously in adults (Bernstein, Stein, & Handelsman, 1998), the design was retrospective.
Moreover, no study was found that investigated child maltreatment, adolescent AUDs, and
other adolescent psychiatric disorders as predictors of adult BPD in a prospective design.

1.3. Study aims

This study investigated adolescent AUDs as a predictor of adult BPD symptoms

utilizing a prospective design characterized by measures collected during two devel-
opmental periods, adolescence and early adulthood. AUDs and child maltreatment were
hypothesized to predict adult BPD symptoms independently, and presence of AUDs was
hypothesized as a mediator of the relationship between the environmental factor of child
maltreatment and adult BPD symptoms. Other adolescent disorders demonstrated to be
associated with dysregulation including depression, conduct disorder, and Attention Deficit
Hyperactivity Disorder were explored as contributors to the full prediction model. The
conceptualization of BPD as a disorder of severe dysregulation drove the selection of
 D.L. Thatcher et al. / Addictive Behaviors 30 (2005) 1709–1724 1713

variables for the model. In the current study, the assessment of BPD symptoms is restricted
to the adult developmental period, while the measurement of predictor variables was during
the adolescent developmental period.
Child maltreatment, adolescent AUDs, and adult BPD might be related through several
possible mechanisms. First, associations between adolescent AUDs and adult BPD may
be explained by the common risk factor of child maltreatment, implying that AUDs and
BPD would not be related after accounting for child maltreatment. Another theoretical
conceptualization of these associations is that a tendency toward psychological
dysregulation is exacerbated in the presence of child maltreatment, with developmentally
specific manifestations. Given the latter model, one would expect the relationship
between child maltreatment and BPD to be mediated by adolescent characteristics
reflecting psychological dysregulation, including AUDs, depression, and other mental
disorders.

2. Methods

2.1. Subjects

Subjects were 524 individuals (average age 16 F 1.3) participating in a longitudinal study
on adolescent AUDs at the Pittsburgh Adolescent Alcohol Research Center (PAARC).
Adolescents with AUDs (n = 355) were recruited from substance abuse and psychiatric
clinical treatment programs, including inpatient (n = 125), outpatient (n = 169), residential
(n = 16), and juvenile justice treatment programs (n = 45). Adolescents without AUDs
(n = 169) were recruited from the community utilizing marketing and survey sampling
databases. To simplify sample characteristics and interpretation of analyses, subjects recruited
from the community and found to meet criteria for AUDs and subjects from clinical treatment
sources without AUDs were not included in this report.

2.2. Recruitment and assessment procedures

The recruitment procedure for the longitudinal study included consent to contact, an
eligibility assessment via telephone, and a baseline assessment. Adolescents with AUDs
were recruited from licensed alcohol and drug treatment programs and other programs
providing treatment for mental disorders including AUDs. A recruiter identified
potentially eligible adolescents and obtained consent to contact the family by telephone.
Adolescents without AUDs were recruited through the use of telephone sampling frames,
and consent to contact was obtained by telephone.
All subjects completed an initial telephone interview to determine eligibility. Individuals
were eligible to participate in the study if they were between ages 12 and 18 at the time of
baseline assessment. Adolescents with psychosis, mental retardation, neurodevelopmental
disorders, uncorrectable sensory handicap, or severe medical illness, as indicated in baseline
or subsequent assessments, were not eligible.
1714 D.L. Thatcher et al. / Addictive Behaviors 30 (2005) 1709–1724

For the ongoing longitudinal study, subjects are interviewed at an initial baseline
assessment, and are followed up at 1, 3, and 5-year intervals, and at age 25 F 1. Interviewers
have Master’s level education in a mental health field, and were trained to obtain over 90%
interrater reliability with other interviewers. For this report, childhood physical and/or sexual
abuse was drawn from retrospective reports during the baseline assessment, adolescent
diagnoses were drawn from all available adolescent assessments (considered present if
diagnosed during adolescence), and BPD symptoms (used to construct DV) were drawn from
the most recent available follow-up assessment after the subject was 18 years old.
Informed consents were required from participants at each contact during the study, and
parental informed consents were also required while the subjects were under 18 years of age.
All study procedures were approved by the University of Pittsburgh Human Subjects
Institutional Review Board.

2.3. Subject characteristics

Subjects were classified into either the AUD group (i.e., alcohol abuse and/or alcohol
dependence diagnosis during any adolescent assessment) or reference group for descriptive
purposes. Demographic characteristics of these two groups are presented in Table 2. The
groups did not differ significantly on age at most recent assessment or race. On the other
hand, the AUD group contained proportionally more males than the reference group, and
the AUD group had a higher mean SES (lower number indicates higher SES). Subsequent
analyses therefore included gender and SES as covariates.

Table 2
Demographic characteristics by AUD group
Variable AUD subjects (n = 355) Reference Subjects (n = 169) t df p
Mean SD Mean SD
Age (young adult) 22.1 2.4 22.0 2.4 0.53 522 0.60
SES* 37.0 12.0 45.0 11.0 7.09 519 b 0.01

n % n % v2 df p
Sex
Male 218 61.4 76 45.0 12.56 1 b 0.01
Female 137 38.6 93 55.0
Race
European-American 304 85.6 142 84.0 0.69 2 0.71
African-American 49 13.8 25 14.8
Other race 2 0.6 2 1.2
PSA*
Yes 107 30.1 5 3.0 50.34 1 b 0.01
No 248 69.9 164 97.0
*SES: Socioeconomic Status (Hollingshead formula).
*PSA: History of Physical and/or Sexual Abuse before age 12.
 D.L. Thatcher et al. / Addictive Behaviors 30 (2005) 1709–1724 1715

2.4. Measurement and instruments

2.4.1. Alcohol Use Disorders (AUDs)

AUDs were defined as alcohol abuse and/or dependence during adolescence. Assessment
of AUDs was completed with an expanded version of the Structured Clinical Interview for the
DSM-IV for alcohol and substance use disorders (SCID) revised for adolescents (Martin,
Pollock, Bukstein, & Lynch, 2000). Diagnoses were made by consensus among the
interviewer and PAARC staff including an experienced psychiatrist or clinical psychologist
during diagnostic case conferences. For the purposes of these analyses, AUDs were
constrained to diagnoses made during an adolescent assessment.

2.4.2. Other psychiatric disorders

Assessment of other relevant psychiatric diagnoses, including depression (MDD), conduct
disorder (CD), and attention-deficit hyperactivity disorder (ADHD) were made using a version
of the Schedule for Affective Disorders and Schizophrenia for Children (K-SADS; Kaufman et
al., 1997). Diagnoses were made by consensus with the same process as for AUDs. Each of the
disorders was considered present if it was made during any adolescent assessment.

2.4.3. Child maltreatment

Child maltreatment was defined as presence of physical and/or sexual abuse up to and
including age 12. Physical abuse was defined as physical maltreatment that resulted in serious
injury, or bruises on more than one occasion. Sexual abuse was defined as forced or coerced
genital fondling, or oral, vaginal, or anal intercourse. Mutually agreed upon sexual exploration
with peers was not included. Date or stranger rape was included, although neither of these was
reported to have occurred prior to age 12. Assessment of child maltreatment was done
retrospectively using a trauma interview within the K-SADS (Kaufman et al., 1997). Physical
and/or sexual abuse (PSA) was coded present or absent up to and including age 12.

2.4.4. Borderline Personality Disorder (BPD)

Assessment of BPD symptoms was accomplished with the Structured Clinical Interview
for DSM-IV II— Personality Disorders (SCID-II; First, 1997). For this study, subjects were
administered the SCID-II if they were at least age 18 during an assessment. The dependent
variable of BPD symptoms was constructed utilizing LCA as described below.

2.5. Data analysis

Latent class analysis (LCA) was performed to categorize subjects based upon BPD
symptoms. LCA is one member of a family of methods known as latent structure analysis,
which use statistical models to characterize latent variables (McCutcheon, 1987). Latent class
analysis models categorical observed variables (in this case, symptoms) on a latent
classification variable with discrete categories. Like cluster analysis, this method enables
the characterization of empirical groupings of subjects according to symptom profiles over
and above information that can be obtained from diagnosis or symptom counts.
1716 D.L. Thatcher et al. / Addictive Behaviors 30 (2005) 1709–1724

LCA has increasingly been utilized to investigate psychiatric typology, with applications to
AUDs (Chung & Martin, 2001) and childhood anxiety and depression (Wadsworth, Hudziak,
Heath, & Achenbac, 2001). Fossati and colleagues (1999) evaluated the structure of BPD
with LCA. They found evidence for three classes: 1) a severe class, characterized by high
endorsement across symptoms; 2) a class defined by the presence of only impulsivity and
inappropriate anger; and 3) a largely asymptomatic class. Moreover, two classes composed of
subthreshold levels of symptoms were observed.
The LCA procedure was restricted to subjects reporting at least one BPD symptom, as these
were the only data that would substantially contribute to the latent class solution. Subjects with
no symptoms comprised a distinct category in the dependent variable. Latent class models
specifying between two and six classes were fit to nine dichotomous BPD symptom variables.
LCA output provides probabilities of class membership for each individual by class, as well as
model fit indices. The Bayesian information criterion (BIC), a maximum likelihood estimator
of model fit using in-sample statistics and corrected for sample size, was utilized to determine
the optimal latent class solution. After the optimal latent class model was chosen, each subject
was assigned to a BPD latent class according to the highest probability of class membership.
LCA was performed using Mplus 2.13 (Muthen, 2002; Muthen & Muthen, 2001).
Independent associations among predictor variables and the latent class variable were
initially investigated using multinomial logistic regression, a version of logistic regression for
dependent variables with greater than two categories. These individual associations were
utilized to test the mediation model with established criteria (Baron & Kenny, 1986).
Statistical mediators are utilized to identify mechanisms underlying key relationships among
variables. All adolescent diagnoses, including AUDs, MDD, CD, and ADHD were
considered as potential mediators. Mediation required that: a) the independent variable
(PSA) significantly predicted the mediator; b) the independent variable significantly predicted
the dependent variable (BPD latent class); c) the mediator significantly predicted the
dependent variable with the independent variable in the model; and d) the independent
variable in c) is not significant. With the information from the mediation analyses, a final
model was constructed with multinomial logistic regression. Analyses subsequent to the
construction of the dependent variable were performed using SPSS 11.0.

3. Results

3.1. Latent Class Analyses (LCA)— borderline personality symptoms

Of 524 subjects, 167 reported at least one symptom of BPD on the SCID-II, and were
therefore included in the LCA. Of these subjects, 158 were from the AUD group and 9 were
from the reference group. Latent class models specifying between two and six classes were fit
to nine dichotomous BPD symptom variables. A three-class model provided the best fit to the
data. The Bayesian information criterion (BIC) was lowest for the three-class solution
(BIC = 1350.06) relative to the four-, five-, or six-class solution (BIC = 1382.34, 1431.46, and
1462.54, respectively). As expected, the two-class model simply divided subjects into many
 D.L. Thatcher et al. / Addictive Behaviors 30 (2005) 1709–1724 1717

and few symptoms, and was not interpretively as useful, although the BIC was slightly lower
for this group (BIC = 1348.58).
Symptom profiles by latent classes are displayed in Fig. 1. The three-class solution was as
follows: 1) the Severe Class (n = 15) was characterized by high rates of endorsement across
symptoms; 2) the Moderate Class (n = 69) endorsed symptoms at relatively lower rates; and 3)
the Impulsivity Class (n = 83) endorsed only impulsivity and inappropriate anger at high rates.
The difference in symptom profile of the Impulsivity class relative to the Severe and Moderate
classes is well illustrated in Fig. 1. The remaining subjects, reporting no BPD symptoms by
definition, comprised the last class, which was labeled the Symptom-Free Class (n = 357).
Table 3 displays demographic characteristics by latent class. The Impulsivity class was
disproportionately males and had a significantly lower mean SES relative to the Symptom-Free
class. Additionally, each of the classes reporting BPD symptoms had higher rates of PSA
relative to the Symptom-free class. A significant linear-by-linear association was observed
between PSA and BPD latent class (v 2 = 10.46, p b 0.01). Table 3 also displays rates of AUDs
and other relevant psychiatric disorders by latent classes. As expected, all disorders considered
were exhibited at higher rates across all the symptom classes relative to the symptom-free class.

3.2. Independent associations and tests of mediation

Independent associations among predictor variables and with the BPD latent class variable
were evaluated with a series of individual multinomial regression models, including gender and
SES as covariates. The mediation model was evaluated according to Baron and Kenny’s (1986)
criteria as follows: a) PSA significantly predicted adolescent AUDs (v 2 = 58.47, p b 0.01), MDD

Severe
100
Moderate

80 Impulsivity
% endorsement

60

40

20

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ity

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en

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tit

es
iv

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id

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iv
hi

en

ct
nm

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ic

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ra
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io

Af

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at
an

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Ab

Fig. 1. BPD symptom profiles by BPD latent class.

1718 D.L. Thatcher et al. / Addictive Behaviors 30 (2005) 1709–1724

Table 3
Demographic characteristics and adolescent diagnoses by adult BPD latent class
Demographics Severe BPD Moderate BPD Impulsivity/Anger No BPD F df p
Sx (n = 15) Sx (n = 69) Sx (n = 83) Sx (n = 357)
Mean SD Mean SD Mean SD Mean SD
Age (young adult) 20.9 2.1 22.2 2.8 22.3 2.3 22.0 2.4 1.56 3520 0.20
SES* 40.9 11.7 37.2 13.6 36.5 12.7 40.6 12.2 3.32 3517 0.02

n % n % n % n % v2 df p
Sex
Female 7 46.7 37 53.6 16 19.3 170 47.6 25.13 3 b 0.01
Male 8 53.3 32 46.4 67 80.7 187 52.4
Race
European-American 13 86.7 56 81.2 77 92.8 300 84.0 6.84 6 0.34
African-American 2 13.3 13 18.8 5 6.0 54 15.1
Other race 0 0.0 0 0.0 1 1.2 3 0.8
PSA*
Yes 5 33.3 22 31.9 23 27.7 62 17.4 11.21 3 b 0.01
No 10 66.7 47 68.1 60 72.3 295 82.6

Diagnosis n % n % n % n % m2 df p
AUDs* 15 100.0 62 89.9 81 97.6 197 55.2 82.20 3 b 0.01
MDD* 11 73.3 39 56.5 46 55.4 122 34.2 27.17 3 b 0.01
PTSD* 2 13.3 24 34.8 7 8.4 33 9.2 35.81 3 b 0.01
CD* 11 73.3 50 72.5 72 86.7 141 39.5 76.84 3 b 0.01
ADHD* 7 46.7 21 30.4 31 37.3 49 13.7 34.85 3 b 0.01
*SES: Socioeconomic Status (Hollingshead formula).
*PSA: History of Physical and/or Sexual Abuse before age 12.
*AUDs: Alcohol Use Disorders (i.e., alcohol abuse and/or dependence).
*MDD: Major Depressive Disorder.
*CD: Conduct Disorder.
*ADHD: Attention Deficit Hyperactivity Disorder.

(v 2 = 36.95, p b 0.01), CD (v 2 = 33.94, p b 0.01), and ADHD (v 2 = 16.48, p b 0.01); b) PSA

significantly predicted BPD latent class (v 2 = 9.0, p b 0.01); c) Each of the potential mediators
predicted BPD latent class with PSA in the model, AUDs (v 2 = 80.13, p b 0.01), MDD (v 2 = 26.50,
p b 0.01), CD (v 2 = 60.32, p b 0.01), and ADHD (v 2 = 22.60, p b 0.01); and d) PSA was no longer
significant when any of the potential mediators was included, with AUDs (v 2 = 0.49, p = 0.92),
MDD (v 2 = 2.82, p = 0.42), CD (v 2 = 1.14, p = 0.70), and ADHD (v 2 = 4.45, p = 0.22). This series
of models supports the identification of adolescent diagnoses of AUDs, MDD, CD, and ADHD as
mediators of the relationship between childhood PSA and adult BPD latent class.

3.3. Multinomial regression model

The complete multinomial regression model, including gender and SES as covariates, is
summarized in Table 4. The model accounted for 32% of the variance in the BPD latent class
 D.L. Thatcher et al. / Addictive Behaviors 30 (2005) 1709–1724 1719

Table 4
Multinomial logistic regression model
Likelihood ratio tests on adult BPD latent class
Effect v2 Significance
PSA 0.58 0.90
AUD 26.06 b 0.01
MDD 9.83 b 0.01
CD 10.03 b 0.01
ADHD 9.76 b 0.01
Controlling for gender and SES.

variable. All variables in the model were significant with the exception of PSA. The 95%
confidence intervals of the odds ratios (O.R.) for the Severe class, relative to the Symptom-Free
class, were: for AUDs (O.R. = 6.09, C.I.: 0.62, 60.01), MDD (O.R. = 3.54, C.I.: 1.02, 12.34),
CD (O.R. = 1.36, C.I.: 0.36, 5.32), and ADHD (O.R. = 3.84, C.I.: 1.22, 12.11). The 95%
confidence intervals of the odds ratios for the Moderate class, relative to the Symptom-Free
class, were: for AUDs (O.R. = 3.27, C.I.: 1.23, 8.73), MDD (O.R. = 1.42, C.I.: 0.78, 2.58), CD
(O.R. = 2.34, C.I.: 1.13, 4.83), and ADHD (O.R. = 2.03, C.I.: 1.06, 3.88). The 95% confidence
intervals of the odds ratios for the Impulsivity class, relative to the Symptom-Free class, were:
for AUDs (O.R. = 11.19, C.I.: 2.43, 51.45), MDD (O.R. = 2.19, C.I.: 1.24, 3.88), CD
(O.R. = 2.58, C.I.: 1.20, 5.52), and ADHD (O.R. = 1.83, C.I.: 1.0, 3.34). If the confidence
interval of the odds ratio contains 1.0, the odds ratio is not significant. For example, subjects in
the Severe BPD class had greater odds of adolescent major depression and ADHD. Subjects in
the Moderate BPD latent class had greater odds of adolescent AUD, CD, and ADHD, and
subjects in the Impulsivity latent class had greater odds of adolescent AUD, major depression,
CD, and ADHD.

4. Discussion

This was the first investigation to include adolescent alcohol use disorders (AUDs), other
psychiatric disorders, and physical and/or sexual abuse (PSA) as predictors of borderline
personality disorder (BPD) latent class in a single sample spanning the developmental time
period from adolescence to young adulthood. In this sample, adolescent AUDs significantly
predicted adult BPD latent class. To our knowledge, only one other study prospectively
demonstrated a relationship between adolescent AUDs and adult BPD (Rohde et al., 2001).
The current results utilizing adolescents with AUDs recruited from clinical treatment sources
multinomial modeling techniques, and including childhood physical and/or sexual abuse, are
consistent with Rohde and colleagues’ study of community subjects.
Childhood physical and/or sexual abuse independently predicted adult BPD latent class,
although the relationship diminished to non-significance with the addition of AUDs to the
model. These data therefore best fit a statistical mediation model, where the more proximal
risk factors of adolescent alcohol and other psychiatric disorders play a larger role in the
1720 D.L. Thatcher et al. / Addictive Behaviors 30 (2005) 1709–1724

prediction of adult BPD symptoms. We propose that a range of adolescent psychiatric

disorders including AUDs represent a distinct phenotype that is exacerbated by the
environmental experience of childhood physical and/or sexual abuse. The adolescent
diagnoses as overlapping risk factors (Kraemer, Stice, Kazdin, Offord, & Kupfer, 2001)
support the notion of one underlying phenotype that accounts for a range of symptoms.The
current results utilizing latent class analysis were similar to those of Fossati and colleagues
(1999). The most striking similarity was that in both analyses, the optimal LCA solution
contained a relatively large class characterized by the symptoms of impulsivity and
inappropriate anger. This class was comprised mostly of males, and had high rates of AUDs.
While this class could simply be considered as a bmildQ BPD symptom class, it remains
unclear whether it is appropriate to interpret this class as such, or whether this particular
cluster of symptoms better reflects other diagnostic models such as ADHD.
The present study identified a total of four classes, including one class that was symptom-
free by design, while Fossati et al.’s (1999) study identified three classes, one of which was
largely asymptomatic. This difference is most likely due to the fact that the LCA in the
current study was performed only on subjects reporting at least one symptom, to provide a
parsimonious solution, as subjects with no symptoms would only have added noise to the
modeling procedure. Moreoever, LCA was shown in this study to be a useful technique in
identifying heterogeneous subgroups of individuals based on BPD symptom profiles.
These results are consistent with the conceptualization of BPD as a severe manifestation of
a multiplicity of phenotypes indicating psychological dysregulation. While still theoretical,
this conceptualization is gaining support from studies of affective, behavioral, and
neurocognitive correlates of BPD, as well as from brain imaging studies indicating abnormal
functioning in amygdala, frontal lobes, and connections between these regions in individuals
with BPD (Herpertz et al., 2001; van Elst et al., 2003). This conceptualization offers a
parsimonious way of dealing with high levels of co-occurrence by considering several
diagnoses not only as linked but as pieces of a larger syndrome or construct, the measurement
of which is limited by our current classification systems. It will ultimately allow the
development of endophenotypes and underlying genetic vulnerabilities for BPD (Siever,
Torgersen, Gunderson, Livesley, & Kendler, 2002).
The interpretation of these results should occur in the context of study limitations. While the
model of PSA, adolescent diagnoses, and BPD latent class is informative, causal inferences,
which require specific temporal and statistical criteria (Pearl, 2000) cannot be made. Although
ages of onset for PSA were constrained to be younger than ages of onset for adolescent
diagnoses, PSA information was gathered retrospectively. Additional variables, such as
parental AUD, which is associated both with PSA and adolescent AUD and other psychiatric
disorders (Sher, Gershuny, Peterson, & Raskin, 1997), must be considered for a complete
model.
The sampling method utilized has both advantages and disadvantages. The sampling
method allowed for a large group of adolescents with diagnosed AUD participating in
treatment programs to be studied, which would be difficult with traditional random
sampling methods. A sample of adolescents from the community was included as a
comparison group. However, this method also limits the scope of generalizability of the
 D.L. Thatcher et al. / Addictive Behaviors 30 (2005) 1709–1724 1721

findings. Thus, our severe and moderate BPD latent classes were qualitatively different
from patients with BPD that might be found in other contexts, such as an inpatient
psychiatry setting, with respect to gender distribution and other associated characteristics.
Confirmation of these findings with other samples is necessary to advance generalizability.
It is notable as well that the number of cases with BPD diagnosis was low, possibly
limiting the power to detect more intricate relationships, such as interactions, among these
variables. The average age of the current sample was below the typical age of onset of BPD,
which might preclude inclusion of subjects who are currently sub-threshold but may
eventually develop the full syndrome of BPD. On the other hand, approximately one-third of
the sample did report at least one symptom of BPD, making the use of LCA to construct the
dependent variable quite appropriate.
This study also had a number of strengths, including the use of a large sample of
subjects with AUDs in treatment, which may be considered at relatively high risk for the
development of personality dysfunction. Future study using this study context would
inform the specific nature of the relationships of adolescent AUDs and psychiatric
disorders, and how these risk factors work together as related to adult BPD outcomes. The
application of this type of approach to other personality disorder domains such as
antisocial personality would be useful.
These results investigated the nature of the relationships among childhood PSA, adolescent
AUD and associated psychopathology, and adult borderline personality. A model whereby
adolescent disorders representing a phenotype of psychological dysregulation mediated the
relationship between PSA and adult BPD latent class was supported. This study has
implications for clinicians providing treatment of adolescent AUDs and/or adult BPD. If
clinicians are aware of the association among adolescent AUDs and adult BPD, they will be
in a better position to adequately assess and treat these disorders. These results contribute to
the growing literature on adult outcomes of adolescent AUD.

Acknowledgements

This paper was supported by NIAAA grants T32-AA007453, P50-AA08746, R01-

AA13397, and K02-AA00291, and NIDA grant R01-DA14635. The authors gratefully
acknowledge the contributions of PAARC faculty and staff in the preparation of this paper.

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