The relationship between self-reported borderline personality features and prospective illness course in bipolar disorder
Riemann et al. Int J Bipolar Disord
The relationship between self-reported borderline personality features and prospective illness course in bipolar disorder
Georg Riemann 0 8
Nadine Weisscher 7
Robert M. Post 12 13
Lori Altshuler 11
Susan McElroy 10 15
Marc A. Frye 14
Paul E. Keck Jr. 9 10
Gabriele S. Leverich 13
Trisha Suppes 5
Heinz Grunze 6
Willem A. Nolen 3
Ralph W. Kupka 1 2 4
0 Saxion, University of Applied Science , Handelskade 75, 7417 DH Deventer , The Netherlands
1 GGZ inGeest, Center for Mental Health Care , Amsterdam , The Netherlands
2 Altrecht Institute for Mental Health Care , Utrecht , The Netherlands
3 University Medical Center, University of Groningen , Groningen , The Netherlands
4 Department of Psychiatry, VU University Medical Center , Amsterdam , The Netherlands
5 Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine , Palo Alto, CA , USA
6 Paracelsus Medical University , Salzburg , Austria
7 GGZ Centraal, Center for Mental Health , Hilversum , The Netherlands
8 Dimence Mental Health, Center for Bipolar Disorders , Deventer , The Netherlands
9 Psychiatry & Neuroscience, University of Cincinnati College of Medicine , Cincinnati, OH , USA
10 Lindner Center of HOPE , Mason, OH , USA
11 Former Head UCLA Mood Disorders Research Program, VA Medical Center , Los Angeles, CA , USA
12 Psychiatry and Behavioral Sciences, George Washington University , Washington, DC , USA
13 Bipolar Collaborative Network , 5415 W. Cedar Ln, Suite 201-B, Bethesda, MD 20814 , USA
14 Psychiatry, Mayo Clinic , Rochester, MI , USA
15 Biological Psychiatry Program, University of Cincinnati Medical College , Cincinnati, OH , USA
Background: Although bipolar disorder (BD) and borderline personality disorder (BPD) share clinical characteristics and frequently co-occur, their interrelationship is controversial. Especially, the differentiation of rapid cycling BD and BPD can be troublesome. This study investigates the relationship between borderline personality features (BPF) and prospective illness course in patients with BD, and explores the effects of current mood state on self-reported BPF profiles. Methods: The study included 375 patients who participated in the former Stanley Foundation Bipolar Network. All patients met DSM-IV criteria for bipolar-I disorder (n = 294), bipolar-II disorder (n = 72) or bipolar disorder NOS (n = 9). BPF were assessed with the self-rated Personality Diagnostic Questionnaire. Illness course was based on 1-year clinician rated prospective daily mood ratings with the life chart methodology. Regression analyses were used to estimate the relationships among these variables. Results: Although correlations were weak, results showed that having more BPF at baseline is associated with a higher episode frequency during subsequent 1-year follow-up. Of the nine BPF, affective instability, impulsivity, and self-mutilation/suicidality showed a relationship to full-duration as well as brief episode frequency. In contrast all other BPF were not related to episode frequency. Conclusions: Having more BPF was associated with an unfavorable illness course of BD. Affective instability, impulsivity, and self-mutilation/suicidality are associated with both rapid cycling BD and BPD. Still, many core features of BPD show no relationship to rapid cycling BD and can help in the differential diagnosis.
Bipolar disorder; Borderline personality disorder; Illness course; Life chart methodology
Bipolar mood disorder (BD) and borderline personality
disorder (BPD) are severe psychiatric disorders
characterized by a chronic and recurrent illness course. Both
disorders have a considerable impact on daily functioning
and quality of life and necessitate long-term treatment in
most patients. Lifetime-prevalence of BD in an American
population based on DSM-IV criteria was 2.4%
(Merikangas et al. 2007)
. Point-prevalence of BPD based on
a US-American sample was 1.6%
(Lenzenweger et al.
. Moreover, there is a considerable co-occurrence
of personality disorders (PD) and BD. The prevalence of
any PD in patients with BD is estimated between 30 and
(Dunayevich et al. 2000; Garno et al. 2005; George
et al. 2003; Kay et al. 2002; Schiavone et al. 2004)
concerns mainly cluster B and C personality disorders
and in particular BPD. A literature review
(Paris et al.
reported a prevalence of bipolar I disorder (BD-I)
in patients with BPD ranging from 5.6 to 16.1% (median
9.2%) in eight studies
(Pope et al. 1983; McGlashan 1986;
Links et al. 1988; Alnaes and Torgersen 1991; Hudziak
et al. 1996; Zimmerman and Mattia 1999; Deltito et al.
2001; McGlashan et al. 2000)
, and a prevalence of bipolar
II disorder (BD-II) ranging from 8 to 19% (median 10.7%)
in six studies
(Links et al. 1988; Zimmerman and Mattia
1999; Deltito et al. 2001; McGlashan et al. 2000; Zanarini
et al. 1998; Akiskal 1992)
. According to these authors, the
most methodologically rigorous study
(McGlashan et al.
found that 12% of BPD patients met criteria for
BD-I, and another 8% met criteria for BD-II. Conversely,
they found that 0.5–30% (median 10.7%) of BD-I patients
in 12 studies met criteria for BPD
(George et al. 2003;
Alnaes and Torgersen 1991; Gaviria et al. 1982;
Koenigsberg et al. 2002; Jackson et al. 1991; Pica et al. 1990;
O’Connell et al. 1991; Turley et al. 1992; Ucok et al. 1998;
Vieta et al. 2001; Rossi et al. 2001; Brieger et al. 2003)
well as 12–23% (median 16%) of BD-II patients in three
(Peselow et al. 1995; Vieta et al. 1999; Benazzi
. Paris et al. (2007) concluded that nearly 20% of the
patients diagnosed with either BD or BPD also met
criteria for the other diagnosis.
According to DSM-IV diagnostic criteria, BPD and BD
share phenomenological characteristics with mood
instability as the most prominent overlapping feature.
In clinical practice, it can be difficult to differentiate
between mood instability that is associated with BPD
and the mood fluctuations that occur in rapid cycling
BD. Especially, differentiation between BPD and BD-II or
unstable forms of BD such as (ultra) rapid cycling can be
difficult. Controversy exists whether BPD and BD
represent distinct entities or can be seen as part of one
(Benazzi 2006; Deltito et al.
2001; Akiskal 2004; Perugi et al. 2003)
. Still, both
disorders need a different therapeutic approach, with more
emphasis on psychotherapy in BPD and more on
pharmacotherapy in BD.
Co-occurrence of BD and BPD may further
complicate the diagnosis and treatment in a given patient. Most
studies of PD in patients with BD report that comorbid
PD has an unfavorable effect on the course of BD.
Moreover, there is evidence that the presence of BPD in patients
diagnosed with BD is linked with histories of childhood
emotional abuse, physical abuse, and emotional neglect,
which may further worsen overall outcome
(Garno et al.
. Cluster BPD comorbidity was associated with
significantly more lifetime suicide attempts and current
(Garno et al. 2005)
. A recent literature review
concluded that comorbidity of PD in patients with BD
is associated with a more complicated course of illness,
such as earlier age at onset, longer episodes, and less
time euthymic, and increased rates of substance abuse,
suicidality, and aggression
(Latalova et al. 2013)
. This was
particularly present in BD patients with comorbid BPD
(Latalova et al. 2013)
Less is known about the impact of the nine individual
DSM-IV borderline personality features (BPF) on illness
course of BD, even if patients do not meet full criteria
for BPD. A recent study
(Fonseka et al. 2015)
correlations of borderline personality spectrum
symptoms (BPSS) in adolescents with BD showed that high
rates of BPSS (identity confusion, interpersonal
problems, impulsivity, and emotional lability) was
associated with greater mood symptom burden and functional
impairment, although in that study no differentiation
was made between individual BPF. Another study
et al. 2015)
found different profiles on a self-assessment
of impulsivity in BPD and BD, whereas BPD patients
exhibited markedly elevated scores of impulsivity
compared to BD-II patients and healthy controls. In terms
of illness course, suicidality is the most studied
symptom in BD with comorbid BPD. A study from the Rhode
Island Methods to Improve Diagnostic Assessment and
Services (MIDAS) concluded that compared to bipolar
patients without BPD, patients diagnosed with both BD
and BPD were significantly more likely to have made a
prior suicide attempt
(Zimmerman et al. 2014)
(Zeng et al. 2015)
found that among patients with
severe mood disorders (major depressive disorder, BD
or schizoaffective disorder), the presence of comorbid
BPF or BPD substantially increased the risk of suicide
Aims of the study
To gain further insight in the association between rapid
cycling BD and BPD, we investigated the prevalence of
the nine BPF in relationship to prospectively assessed
mood episode frequency in outpatients with BD.
The study used data from the Stanley Foundation
Bipolar Network (SFBN), a longitudinal naturalistic follow-up
study of a large cohort of patients with BD (BD-I, BD-II,
and BD-NOS). Data were obtained from patients with
BD-I, BD-II, or BD-NOS, who completed at least one full
year of daily prospective mood ratings after entering the
study. This sample (n = 539) was described in detail
(Kupka et al. 2005)
. Of this subset those patients
who had completed the Personality Disorder
Questionnaire (PDQ-4+) as well as mood ratings at baseline were
included in the present study (n = 375). There were no
baseline differences in overall characteristics as shown
Table 1 between this sample and the original sample as
(Kupka et al. 2005)
Procedure and instruments
Patients were recruited from private, academic, and
community outpatient settings by referral and
advertisements. All patients were diagnosed with BD-I, BD-II,
or BD-NOS according to DSM-IV criteria. Participants
were included if they were 18 years or older, were able to
perform daily mood ratings, and were capable of
providing written informed consent. Diagnoses of BD and other
axis-I diagnoses were made using the Structured Clinical
Interview for DSM-IV
(First et al. 1995)
To assess the presence of BPF, patients completed at
baseline the PDQ-4+
. The PDQ-4+ assesses
all DSM-IV personality disorder criteria by 99 true/false
questions. For the current study, we only used the nine
DSM-IV BPD features. Episode frequency was calculated
by an computer program according to DSM-IV criteria
for mania, hypomania, depression, and mixed episodes
was based on prospective daily mood ratings with the
life chart methodology (LCM)
(Kupka et al. 2005;
Denicoff et al. 1997)
. The LCM is a graphic representation of
manic and depressive symptom severity and can be used
both retrospectively and prospectively. It also provides
information about subsyndromal symptoms, medication
and psychological treatment, and the presence of
possible stressful life events. The LCM was prospectively
selfreported on a daily basis and then monthly evaluated and
if necessary adjusted by a clinical investigator together
with the patient. For this study, both DSM-IV full
duration criteria and criteria for brief episodes are used to
calculate the number of episodes. According to DSM-IV,
following minimum criteria are used to identify mood
episodes: 4 days of mild ratings for hypomania, 1 week
of moderate ratings or any hospitalization for mania, and
2 weeks of moderate ratings for depression (American
Psychiatric Association 2000). In addition, using
DSMIV full duration criterion, an algorithm used in previous
NIMH studies as described elsewhere
(Kupka et al. 2005;
Denicoff et al. 1997)
was used to calculate the number
of brief duration mood episodes. In short, according to
these criterions, a manic episode requires at least 1 day
of moderate or severe mania. Depressive episodes were
counted if they included at least 2 days of moderate or
1 day of severe depression. In case of switching mood
polarity as well as at least 2 weeks of euthymic mood, an
episode is considered ended. If euthymic mood lasted
less than 2 weeks but was at least 1 day greater than the
longest contiguous duration of the adjacent episode, an
episode was also considered ended. This method can
detect more subtle and short mood switches
(Kupka et al.
2005; Denicoff et al. 1997)
. LCM data of the first
prospective year after study baseline were used.
Mood state at baseline and at follow-up was measured
by the inventory of depressive symptomatology
et al. 1986; Bernstein et al. 2006)
(IDS-SR) and the Young
Mania Rating Scale (Young et al. 1978) (YMRS).
Depression was defined as an IDS-SR scores of ≥14; (hypo)
mania as an YMRS score of ≥12, and mixed states as
both IDS-SR ≥14 and YMRS ≥12.
Analyses were conducted on all patients who completed
all diagnostic assessments at baseline and the subsequent
1-year prospective LCM (n = 375). Mood episode
frequency was measured continuously. Mood episodes were
defined according to both full-duration DSM-IV criteria
and brief-duration NIMH-criteria. Regression analyses
were used to test the correlation between BPF and
episode frequency. Mood state at the moment of rating the
PDQ-4+ is tested as a possible confounder on the
outcome measure (Kruskal–Wallis test). All statistical
analyses were performed by using Statistical Package for the
Social Science (SPSS), version 22.
Demographic and clinical characteristics
We included 159 (42.4%) males and 216 (57.6%) females
with a mean age of 42.8 years (range 19–82), and
diagnosed with BD-I (n = 294; 78.4%), BD-II (n = 72; 19.2%),
or BD-NOS (n = 9; 2.4%). Self-rated BPD as defined by at
least 5 of 9 BPD items on the PDQ-4+ was present in 140
patients (37.3%). Table 1 shows demographic and clinical
Borderline personality features and mood state
Current mood state at the time of completing the
PDQ4+ was divided into four groups: euthymic (n = 169;
45.1%), hypomanic/manic (n = 16; 4.3%), depressed
(n = 163; 43.5%), and mixed depressed and (hypo)manic
(n = 27; 7.2%). Figure 1 shows the proportion of self-rated
BPF in those mood states. A Kruskal–Wallis one-way
ANOVA was performed to examine the effect of mood
upon BPF scores. Current mood state had no influence
on BPF sumscore measured by PDQ-4+ (χ2(3) = 5.533,
p = .1378). Focusing on individual BPF, we found a
significant effect of mood state on the feature paranoid/
dissociation. Kruskal–Wallis one-way ANOVA showed
a significant group difference (χ2(3) = 9.005, p = .029).
Mean rank was for euthymic (n = 160) 177.38, depressed
(n = 163) 190.52, mixed (n = 27) 216.33, and (hypo)
manic (n = 16) 226.78. No further significant effect on
any individual BPF between the groups of euthymic,
(hypo)manic, depressed, and mixed patients was found
(.596 < p > .115).
Relationship between BPD/BPF and episode
Prevalence of self-reported BPD (≥5 BPF) at baseline
increased gradually with increasing episode frequency
in the subsequent year (Fig. 2). T test showed that there
was a significant group difference (t(232.63) = −5.80;
p < 0.01) between patients who had a positive BPD
screening (≥5 BPF) and those who had not (<5 BPF).
Patients with a positive screening on BPD had more
(M = 5.64; SD = 4.26) episodes than those who had not
(M = 3.22; SD = 3.20). Group differences were valid
for (hypo-)manic episodes (t(226.66) = −4.52; p < .01)
as well as for depressive episodes (t(230.79) = −3.57;
p < .01). BPD positives had more (hypo-)manic episodes
(M = 4.44; SD = .356) than BPD negatives (M = 2.47;
SD = 0.199) and had more depressive episodes
(M = 4.44; SD = 4.22) than BPD negatives (M = 2.47;
SD = 3.06). Furthermore, the number of BPF was
positively correlated to prospective episode frequency (0 to
10+ episodes/year). Pearson’s product moment revealed
that there was significant, although weak, positive
correlation between the number of BPF and number of
episodes (r(375) = .343, p < .01). Correlation for (hypo-)
manic episodes was stronger (r(375) = .301, p < .01) than
for depressive episodes (r(375) = .184, p < .01).
Predictors for unfavorable illness course
A multiple regression of all BPF was conducted to
analyses which of the nine BPF at baseline best predicted the
total number of full-duration DSM-IV and
brief-duration mood episodes at follow-up. Using the stepwise
method, we found that affective instability,
impulsivity, and self-mutilation/suicidality explain a significant
amount of the variance in DSM-IV episode frequencies
(F(3, 371) = 27.156, p < .01, R2 = .180, R2Adjusted = .173). In
case of depressive episodes, only
self-mutilation/suicidality, chronic emptiness, and interpersonal instability were
significant predictors (F(3, 371) = 8,82, p < .01, R2 = .067,
RAdjusted = .059). In case of hypomanic/manic episodes,
only self-mutilation/suicidality and impulsivity were
significant predictors (F(2, 372) = 13, 72, p < .01, R2 = .069,
RAdjusted = .064). Figure 3 shows individual BPF in
relationship to the total number of DSM-IV hypomanic,
manic, depressive, and mixed episodes. Additionally, a
multiple regression analyses of all BPF was conducted
to analyses witch BPF can predict brief mood episodes
following the NIMH method. We found the same BPF
(affective instability, impulsivity, and self-mutilation/
suicidality) witch explain the variance in DSM-IV
episodes also explain a significant amount of variance in the
amount of brief episodes (F(3, 371) = 24.200, p < .001,
R2 = .164, R2Adjusted = .157).
In line with other publications
(Latalova et al. 2013;
Fonseka et al. 2015)
, our study confirmed that the presence
of BPD is associated with an unfavorable impact on
subsequent illness course in BD. In this sample of patients
0 1 2 3 4 5 6 7 8 9 10+
Fig. 2 Proportion of bipolar patients with ≥5 self-rated BPD criteria
in relationship to prospective full-duration DSM-IV episode frequency
with a primary diagnosis of BD, analyses of correlations
showed that there is a positive relationship between the
number of BPF at baseline and the number of subsequent
mood episodes during 1-year prospective follow-up.
Furthermore, analyses of group differences showed that
patients who screened positive on BPD at baseline had
significant more episodes during the following year than
those who screen negative on BPD.
Current mood state when completing the PDQ-4+
had no effect on sumscore of BPF. In our sample,
current mood state was not a confounder when analyzing
episode frequency. When analyzing the effect of mood
state on individual BPF, a single significant difference
was found on paranoid/dissociation between euthymic,
(hypo)manic, depressed and mixed depressed and (hypo)
manic patients. Patients who were (hypo)manic score
most on that item, followed by depressed, mixed, and
euthymic patients. No further group differences on any
other BPF were found.
Focusing on the prediction of an unfavorable illness
course especially features related to affective
instability had a relevant contribution. We found no differences
between predicting full-duration DSM-IV episodes and
brief episodes according to the NIMH-algorithm. Of the
nine BPF, affective instability, impulsivity, and
self-mutilation/suicidality showed a clear relationship to overall
mood episode frequency. Our study can not reveal the
direction of the relationship between rapid cycling and
personality characteristics, i.e., a causal relationship.
It may be that a rapid cycling course of BD is driving
these personality characteristics or conversely that these
personality characteristics induce rapid cycling. In
contrast, many core features of BPD such as avoiding
abandonment, interpersonal instability, identity disturbance,
chronic emptiness, intense anger, and
paranoid/dissociation are not related to rapid cycling BD. Our findings
suggest that focusing on the shared core phenomenon
of mood instability per se, and related phenomena such
as impulsivity and suicidality, does not help to
differentiate (ultra)rapid cycling BD from BPD. In contrast, one
should look for other features of BPD (avoiding
abandonment, interpersonal instability, identity disturbance,
chronic emptiness, intense anger, and
paranoid/dissociation) that are not typically present in rapid cycling BD.
Our study has several limitations. First, and most
importantly, the use of a self-reported screening
measure of BPD may overestimate the prevalence of BPD. Low
agreement has been observed between PDQ-4+ and
Structured Clinical Interview for DSM-IV Axis II
(First et al. 1997)
, and hence, the PDQ-4+
has been criticized for its tendency to overdiagnose PDs
(Fossati et al. 1998)
. However, this may be more relevant
in the detection of full-criteria PD’s than in isolated
PDfeatures. Still, it is plausible that analyses based on BPD
ratings obtained from a diagnostic interview for BPD
instead of self-report may have yielded different findings.
Second, the interpretation of some questions of PDQ-4+
may be somewhat different when answered in the context
of BP than BPD. Third, given the naturalistic nature of the
study, all patients received state-of-the-art
pharmacological treatment tailored to their individual needs. Because
of the complexity and high degree of inter-and
intra-individual variation among treatment strategies, even during
1 year of follow-up, we could not take this into account
in our analyses. The same is true for a highly
heterogeneous illness course preceding baseline assessments among
participants. Fourth, we focused on episode frequency
and did not take into account the severity of illness
episodes. Finally, there was no comparison group of patients
with a primary or single diagnosis of BPD, although our
main outcome measure, mood episode frequency, does
not apply to patients with BPD without comorbid mood
Our study suggests that when differentiating (rapid
cycling) BD from BPD, one should rely on those
diagnostic features unrelated to mood instability. Our results
show that especially avoiding abandonment,
interpersonal instability, identity disturbance, chronic emptiness,
intense anger, and paranoid/dissociation are features that
are not typically present in (rapid cycling) BD. This may
be especially relevant in the differentiation of BPD from
(rapid cycling) bipolar II disorder, given the difficulty of
retrospectively diagnosing hypomania in the absence of a
history of mania.
BD: bipolar disorder; BPD: borderline personality disorder; BPF: borderline
personality features; SFBN: Stanley Foundation Bipolar Network; PDQ-4+:
Personality Diagnostic Questionnaire; LCM: life chart methodology; YMRS: Young
Mania Rating Scale; IDS-SR: inventory of depressive symptomatology.
Following authors make substantial contributions to conception and design,
and/or acquisition of data, and/or analysis and interpretation of data: GR, NW,
RMP, LA, SM, MAF, PEK, GSL, TS, HG, WAN, RWK. Following authors participate
in drafting the article or revising it critically for important intellectual content:
GR, NW, RMP, SM, MAF, PEK, GSL, TS, HG, WAN, RWK. Following authors give
final approval of the version to be submitted and any revised version: GR, NW,
RMP, SM, MAF, PEK, GSL, TS, HG, WAN, RWK. All authors read and approved the
The authors declare that they have no competing interests.
Availability of data and materials
Due to agreements within the SFBN-consortium data cannot be shared.
Consent for publication
Consent to publish has been obtained from the participants.
Ethics approval and consent to participate
All participating centers obtained approval from their Institutional Review
Boards and all patients gave a written informed consent to participate in this
naturalistic observational non-interventional study. The data used for this
paper were derived from a naturalistic observational non-interventional study,
which at the time of inclusion (1995–2002) was not registered.
This research was supported by the Netherlands Organization for Scientific
Research (NWO) and the Stanley Medical Research Institute. The supporters
had no role in the design, analysis, interpretation, or publication of this study.
Springer Nature remains neutral with regard to jurisdictional claims in
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Akiskal HS . Borderline: an adjective still in search of a noun . In: Silver D , Rosenbluth M , editors. Handbook of borderline disorders . Madison: International Universities Press; 1992 . p. 155 - 77 .
Akiskal HS . Demystifying borderline personality: critique of the concept and unorthodox reflections on its natural kinship with the bipolar spectrum . Acta Psychiatr Scand . 2004 ; 110 ( 6 ): 401 - 7 .
Alnaes R , Torgersen S. Personality and personality disorders among patients with various affective disorders . J Personal Disord . 1991 ; 5 ( 2 ): 107 - 21 .
American Psychiatric Association . Task Force on DSM-IV. Diagnostic and statistical manual of mental disorders: DSM-IV-TR . 4th ed. Washington, DC: American Psychiatric Association; 2000 .
Benazzi F. Borderline personality disorder and bipolar II disorder in private practice depressed outpatients . Compr Psychiatry . 2000 ; 41 ( 2 ): 106 - 10 .
Benazzi F. Borderline personality -bipolar spectrum relationship . Prog Neuro Psychopharmacol Biol Psychiatry . 2006 ; 30 ( 1 ): 68 - 74 .
Bernstein IH , Rush AJ , Thomas CJ , Woo A , Trivedi MH . Item response analysis of the inventory of depressive symptomatology . Neuropsychiatr Dis Treat . 2006 ; 2 ( 4 ): 557 - 64 .
Boen E , Hummelen B , Elvsashagen T , Boye B , Andersson S , Karterud S , et al. Different impulsivity profiles in borderline personality disorder and bipolar II disorder . J Affect Disord . 2015 ; 170 : 104 - 11 .
Brieger P , Ehrt U , Marneros A . Frequency of comorbid personality disorders in bipolar and unipolar affective disorders . Compr Psychiatry . 2003 ; 44 ( 1 ): 28 - 34 .
Deltito J , Martin L , Riefkohl J , Austria B , Kissilenko A , Morse PC . Do patients with borderline personality disorder belong to the bipolar spectrum? J Affect Disord . 2001 ; 67 ( 1-3 ): 221 - 8 .
Denicoff KD , Smith-Jackson EE , Disney ER , Suddath RL , Leverich GS , Post RM . Preliminary evidence of the reliability and validity of the prospective lifechart methodology (LCM-p) . J Psychiatr Res . 1997 ; 31 ( 5 ): 593 - 603 .
Dunayevich E , Sax KW , Keck PE Jr, McElroy SL , Sorter MT , McConville BJ , et al. Twelve-month outcome in bipolar patients with and without personality disorders . J Clin Psychiatry . 2000 ; 61 ( 2 ): 134 - 9 .
First MB , Gibbo M , Spitzer RL , Williams JBW . Structured clinical interview for DSM-IV axis I disorders: SCID-I/P (version 2 .0). New York: Biometrics Research Department; 1995 .
First MB , Gibbon M , Spitzer RL , Williams JBW , Benjamin LS . SCID-II personality questionnaire . Washington, DC: American Psychiatric Press; 1997 .
Fonseka TM , Swampillai B , Timmins V , Scavone A , Mitchell R , Collinger KA , et al. Significance of borderline personality-spectrum symptoms among adolescents with bipolar disorder . J Affect Disord . 2015 ; 170 : 39 - 45 .
Fossati A , Maffei C , Bagnato M , Donati D , Donini M , Fiorilli M , et al. Brief communication: criterion validity of the personality diagnostic questionnaire-4+ (PDQ-4+) in a mixed psychiatric sample . J Pers Disord . 1998 ; 12 ( 2 ): 172 - 8 .
Garno JL , Goldberg JF , Ramirez PM , Ritzler BA . Bipolar disorder with comorbid cluster B personality disorder features: impact on suicidality . J Clin Psychiatry . 2005 ; 66 ( 3 ): 339 - 45 .
Gaviria M , Flaherty JA , Val E. A comparison of bipolar patients with and without a borderline personality disorder . Psychiatr J Univ Ott . 1982 ; 7 ( 3 ): 190 - 5 .
George EL , Miklowitz DJ , Richards JA , Simoneau TL , Taylor DO . The comorbidity of bipolar disorder and axis II personality disorders: prevalence and clinical correlates . Bipolar Disord . 2003 ; 5 ( 2 ): 115 - 22 .
Hudziak JJ , Boffeli TJ , Kreisman JJ , Battaglia MM , Stanger C , Guze SB . Clinical study of the relation of borderline personality disorder to Briquet's syndrome (hysteria), somatization disorder, antisocial personality disorder, and substance abuse disorders . Am J Psychiatry . 1996 ; 153 ( 12 ): 1598 - 606 .
Hyler SE . Personality diagnostic questionnaire-4 (Unpublished test) . New York: New York State Psychiatric Institute (NYSPI); 1994 .
Jackson HJ , Whiteside HL , Bates GW , Bell R , Rudd RP , Edwards J . Diagnosing personality disorders in psychiatric inpatients . Acta Psychiatr Scand . 1991 ; 83 ( 3 ): 206 - 13 .
Kay JH , Altshuler LL , Ventura J , Mintz J . Impact of axis II comorbidity on the course of bipolar illness in men: a retrospective chart review . Bipolar Disord . 2002 ; 4 ( 4 ): 237 - 42 .
Koenigsberg HW , Harvey PD , Mitropoulou V , Schmeidler J , New AS , Goodman M , et al. Characterizing affective instability in borderline personality disorder . Am J Psychiatry . 2002 ; 159 ( 5 ): 784 - 8 .
Kupka RW , Luckenbaugh DA , Post RM , Suppes T , Altshuler LL , Keck PE Jr, et al. Comparison of rapid-cycling and non-rapid-cycling bipolar disorder based on prospective mood ratings in 539 outpatients . Am J Psychiatry . 2005 ; 162 ( 7 ): 1273 - 80 .
Latalova K , Prasko J , Kamaradova D , Sedlackova J , Ociskova M. Comorbidity bipolar disorder and personality disorders . Neuro Endocrinol Lett . 2013 ; 34 ( 1 ): 1 - 8 .
Lenzenweger MF , Lane MC , Loranger AW , Kessler RC . DSM-IV personality disorders in the National Comorbidity Survey Replication . Biol Psychiatry . 2007 ; 62 ( 6 ): 553 - 64 .
Links PS , Steiner M , Offord DR , Eppel A . Characteristics of borderline personality disorder: a Canadian study . Can J Psychiatry . 1988 ; 33 ( 5 ): 336 - 40 .
McGlashan TH. The Chestnut Lodge follow-up study. III. Long-term outcome of borderline personalities . Arch Gen Psychiatry . 1986 ; 43 ( 1 ): 20 - 30 .
McGlashan TH , Grilo CM , Skodol AE , Gunderson JG , Shea MT , Morey LC , et al. The Collaborative Longitudinal Personality Disorders Study: baseline Axis I/II and II/II diagnostic co-occurrence . Acta Psychiatr Scand . 2000 ; 102 ( 4 ): 256 - 64 .
Merikangas KR , Akiskal HS , Angst J , Greenberg PE , Hirschfeld RM , Petukhova M , et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication . Arch Gen Psychiatry . 2007 ; 64 ( 5 ): 543 - 52 .
O'Connell RA , Mayo JA , Sciutto MS . PDQ-R personality disorders in bipolar patients . J Affect Disord . 1991 ; 23 ( 4 ): 217 - 21 .
Paris J , Gunderson J , Weinberg I. The interface between borderline personality disorder and bipolar spectrum disorders . Compr Psychiatry . 2007 ; 48 ( 2 ): 145 - 54 .
Perugi G , Toni C , Travierso MC , Akiskal HS . The role of cyclothymia in atypical depression: toward a data-based reconceptualization of the borderlinebipolar II connection . J Affect Disord . 2003 ; 73 ( 1-2 ): 87 - 98 .
Peselow ED , Sanfilipo MP , Fieve RR . Relationship between hypomania and personality disorders before and after successful treatment . Am J Psychiatry . 1995 ; 152 ( 2 ): 232 - 8 .
Pica S , Edwards J , Jackson HJ , Bell RC , Bates GW , Rudd RP . Personality disorders in recent-onset bipolar disorder . Compr Psychiatry . 1990 ; 31 ( 6 ): 499 - 510 .
Pope HG Jr, Jonas JM , Hudson JI , Cohen BM , Gunderson JG . The validity of DSM-III borderline personality disorder. A phenomenologic, family history, treatment response, and long-term follow-up study . Arch Gen Psychiatry . 1983 ; 40 ( 1 ): 23 - 30 .
Rossi A , Marinangeli MG , Butti G , Scinto A , Di Cicco L , Kalyvoka A , et al. Personality disorders in bipolar and depressive disorders . J Affect Disord . 2001 ; 65 ( 1 ): 3 - 8 .
Rush AJ , Giles DE , Schlesser MA , Fulton CL , Weissenburger J , Burns C. The inventory for depressive symptomatology (IDS): preliminary findings . Psychiatry Res . 1986 ; 18 ( 1 ): 65 - 87 .
Schiavone P , Dorz S , Conforti D , Scarso C , Borgherini G. Comorbidity of DSM-IV personality disorders in unipolar and bipolar affective disorders: a comparative study . Psychol Rep . 2004 ; 95 ( 1 ): 121 - 8 .
Turley B , Bates GW , Edwards J , Jackson HJ . MCMI-II personality disorders in recent-onset bipolar disorders . J Clin Psychol . 1992 ; 48 ( 3 ): 320 - 9 .
Ucok A , Karaveli D , Kundakci T , Yazici O . Comorbidity of personality disorders with bipolar mood disorders . Compr Psychiatry . 1998 ; 39 ( 2 ): 72 - 4 .
Vieta E , Colom F , Martinez-Aran A , Benabarre A , Gasto C . Personality disorders in bipolar II patients . J Nerv Ment Dis . 1999 ; 187 ( 4 ): 245 - 8 .
Vieta E , Colom F , Corbella B , Martinez-Aran A , Reinares M , Benabarre A , et al. Clinical correlates of psychiatric comorbidity in bipolar I patients . Bipolar Disord . 2001 ; 3 ( 5 ): 253 - 8 .
Young RC , Biggs JT , Ziegler VE , Meyer DA. A rating scale for mania: reliability, validity and sensitivity . Br J Psychiatry . 1978 ; 133 : 429 - 35 .
Zanarini MC , Frankenburg FR , Dubo ED , Sickel AE , Trikha A , Levin A , et al. Axis I comorbidity of borderline personality disorder . Am J Psychiatry . 1998 ; 155 ( 12 ): 1733 - 9 .
Zeng R , Cohen LJ , Tanis T , Qizilbash A , Lopatyuk Y , Yaseen ZS , et al. Assessing the contribution of borderline personality disorder and features to suicide risk in psychiatric inpatients with bipolar disorder, major depression and schizoaffective disorder . Psychiatry Res . 2015 ; 226 ( 1 ): 361 - 7 .
Zimmerman M , Mattia JI . Axis I diagnostic comorbidity and borderline personality disorder . Compr Psychiatry . 1999 ; 40 ( 4 ): 245 - 52 .
Zimmerman M , Martinez J , Young D , Chelminski I , Morgan TA , Dalrymple K. Comorbid bipolar disorder and borderline personality disorder and history of suicide attempts . J Personal Disord . 2014 ; 28 ( 3 ): 358 - 64 .