Borderline Personality in Patients with Poly-Diagnoses Treated for a Bipolar Disorder

Laura Ferraro, Chiara Zanghì, Rosa Lo Baido, Giuseppe Maniaci, Crocettarachele Sartorio, Fabio Seminerio, Giovanna Marrazzo, Daniele La Barbera, Caterina La Cascia


Some patients with dysphoria, explosive behaviour, or suicidal ideation, may receive a diagnosis of, and treatment for Bipolar Disorder (BD) and, not infrequently. The coexistence of these two diagnoses has been explained in different ways. Some authors include the BPD in the bipolar spectrum; others are sceptical about the existence of real comorbidity, suggesting a misdiagnosis. This study aimed to assess the personality of this group of poly-diagnosed patients (PolyD) and hypothesised they had a pathological borderline organisation. Via the administration of the Schedler Westen Assessment Procedure (SWAP-200), we compared PolyD patients with those suffering from BPD or BD only. We performed two different MANCOVAs to test PolyD, BPD and BD patients’ differences in PD-factors, Q-traits and age. The sample comprised 45 patients (Mean age=43.3, SD=15.7; Females 57.7%, N=26). BD patients (N=15) did not present any personality disorder, they had a higher functioning and Obsessive Q-traits, and a lower Histrionic PD-factor than both PolyD (N=20) and BPD (N=10) patients. Compared to PolyD patients, BD had inferior PD-Borderline, PD-Antisocial factor and Dependent-Masochistic Q-traits, but there were no other differences with BPD patients. PolyD did not differ from BPD patients in any of the PD-factors and Q-traits. Our results suggest that PolyD patients are different from BD patients and propose to consider the pathological borderline personality as a central core of their disease.


Personality inventory; Borderline; Bipolar; Affective dysregulation; Diagnosis.

Full Text:



Aguglia, A., Mineo, L., Rodolico, A., Signorelli, M. S., & Aguglia, E. (2018). Asenapine in the management of impulsivity and aggressiveness in bipolar disorder and comorbid borderline personality disorder: an open-label uncontrolled study. International Clinical Psychopharmacology, 33, 121–130.

Akiskal, H. S. (2004). Demystifying borderline personality: critique of the concept and unorthodox reflections on its natural kinship with the bipolar spectrum. Acta Psychiatrica Scandinavica, 110, 401–407.

American Psychiatric Association. (2002). DSM-IV-TR : manuale diagnostico e statistico dei disturbi mentali: text revision (V. Andreoli, G. B. Cassano, & R. Rossi, eds.). Milano: Masson.

American Psychiatric Association. (2014). DSM-5. Manuale diagnostico e statistico dei disturbi mentali. Quinta Edizione. (V. Andreoli, G. B. Cassano, & R. Rossi, eds.). Milano: Masson.

Bayes, A. J., & Parker, G. B. (2017). Clinical vs. DSM diagnosis of bipolar disorder, borderline personality disorder and their co-occurrence. Acta Psychiatrica Scandinavica, 135, 259–265.

Blagov, P. S., & Westen, D. (2008). Questioning the Coherence of Histrionic Personality Disorder. The Journal of Nervous and Mental Disease, 196, 785–797.
Brieger, P., Ehrt, U., & Marneros, A. (2003). Frequency of comorbid personality disorders in bipolar and unipolar affective disorders. Compr Psychiatry, 44, 28–34.

Busmann, M., Wrege, J., Meyer, A. H., Ritzler, F., Schmidlin, M., Lang, U. E., … Euler, S. (2019). Alternative model of personality disorders (DSM-5) predicts dropout in inpatient psychotherapy for patients with personality disorders. Frontiers in Psychology, 10, 952.

Cristea, I. A., Gentili, C., Cotet, C. D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of Psychotherapies for Borderline Personality Disorder: A Systematic Review and Meta-analysis. JAMA Psychiatry, 74, 319–328.

de la Rosa, I., Oquendo, M. A., García, G., Stanley, B., González-Pinto, A., Liu, S.-M., & Blanco, C. (2017). Determining if Borderline Personality Disorder and Bipolar Disorder Are Alternative Expressions of the Same Disorder. The Journal of Clinical Psychiatry, 78, e994–e999.

di Giacomo, E., Aspesi, F., Fotiadou, M., Arntz, A., Aguglia, E., Barone, L., … Clerici, M. (2017). Unblending Borderline Personality and Bipolar Disorders. Journal of Psychiatric Research, 91, 90–97.

Distel, M. A., Trull, T. J., Derom, C. A., Thiery, E. W., Grimmer, M. A., Martin, N. G., … Boomsma, D. I. (2008). Heritability of borderline personality disorder features is similar across three countries. Psychological Medicine, 38, 1219–1229.

Fornaro, M., Orsolini, L., Marini, S., De Berardis, D., Perna, G., Valchera, A., … Stubbs, B. (2016). The prevalence and predictors of bipolar and borderline personality disorders comorbidity: Systematic review and meta-analysis. Journal of Affective Disorders, 195, 105–118.

Fowler, J. C., Madan, A., Allen, J. G., Oldham, J. M., & Frueh, B. C. (2019). Differentiating bipolar disorder from borderline personality disorder: Diagnostic accuracy of the difficulty in emotion regulation scale and personality inventory for DSM-5. Journal of Affective Disorders, 245, 856–860.

González-Pinto, A., Oquendo, M. A., de la Rosa, I., Blanco, C., Liu, S.-M., Stanley, B., & García, G. (2017). Determining if Borderline Personality Disorder and Bipolar Disorder Are Alternative Expressions of the Same Disorder. The Journal of Clinical Psychiatry, 78, e994–e999.

Hopwood, C. J., Malone, J. C., Ansell, E. B., Sanislow, C. A., Grilo, C. M., McGlashan, T. H., … Morey, L. C. (2011). Personality Assessment in DSM-5: Empirical Support for Rating Severity, Style, and Traits. Journal of Personality Disorders, 25, 305–320.

Kernberg, O. F. (1975). Borderline Conditions and Pathological Narcissism. New York: Aronson.

Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R., Gonzalez, A. M., Morse, J. Q., … Bastian, L. A. (2001). Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behav. Ther., 32, 371–390.

Kupfer, D. J., & Regier, D. A. (2011). Neuroscience, Clinical Evidence, and the Future of Psychiatric Classification in DSM-5. American Journal of Psychiatry, 168, 672–674.

Lewinsohn, P. M., Seeley, J. R., & Klein, D. N. (2002). Bipolar disorder in a community sample of adolescents: epidemiology and suicidal behavior. In B. Geller & M. Del Bello (Eds.), Child and farly Adolescent Bipolar Disorder (pp. 7–24). New York, NY: Guilford.

Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., & Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch. Gen. Psychiatry, 63, 757–766.

Linehan, M. M., Korslund, K. E., Harned, M. S., Gallop, R. J., Lungu, A., Neacsiu, A. D., & Murray-Gregory, A. (2015). Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: A randomized clinical trial and component analysis. JAMA Psychiatry, 72, 475–482.

MacKinnon, D. F., & Pies, R. (2006). Affective instability as rapid cycling: theoretical and clinical implications for borderline personality and bipolar spectrum disorders. Bipolar Disorders, 8, 1–14.

Martinucci, M., Chiesa, M., Taponecco, C., Biagi, A., & Di Fiorino, M. (2011). Borderline personality disorder and bipolar spectrum: Preliminary data on temperament and core psychopathological features in a sample of borderline patients. Giornale Italiano Di Psicopatologia, 17, 383–388.

McDermid, J., Sareen, J., El-Gabalawy, R., Pagura, J., Spiwak, R., & Enns, M. W. (2015). Co-morbidity of bipolar disorder and borderline personality disorder: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Comprehensive Psychiatry, 58, 18–28.

Meissner, W. W. (1984). The borderline spectrum: differential diagnosis and developmental issues. New York: Aronson.

Möller, H.-J., & Curtis, V. A. (2004). The bipolar spectrum: diagnostic and pharmacologic considerations. Expert Review of Neurotherapeutics, 4, S3–S8.
28. Paris, J. (2011). Il disturbo borderline di personalità (Il Mulino). Bologna: Brossura.

Paris, J., & Black, D. W. (2015). Borderline personality disorder and bipolar disorder: What is the difference and why does it matter? Journal of Nervous and Mental Disease, 203, 3–7.

Paris, J., Gunderson, J., & Weinberg, I. (2007). The interface between borderline personality disorder and bipolar spectrum disorders. Comprehensive Psychiatry, 48, 145–154.

Reich, D. B., Zanarini, M. C., Hopwood, C. J., Thomas, K. M., & Fitzmaurice, G. M. (2014). Comparison of affective instability in borderline personality disorder and bipolar disorder using a self-report measure. Personality and Mental Health, 8, 143–150.

Richetin, J., Preti, E., Costantini, G., & De Panfilis, C. (2017). The centrality of affective instability and identity in Borderline Personality Disorder: Evidence from network analysis. PLoS ONE, 12, e0186695.

Rossi, A., Marinangeli, M. G., Butti, G., Scinto, A., Di Cicco, L., Kalyvoka, A., & Petruzzi, C. (2001). Personality disorders in bipolar and depressive disorders. J Affect Disord, 55, 3–8.

Saunders, K. E. A., Bilderbeck, A. C., Price, J., & Goodwin, G. M. (2015). Distinguishing bipolar disorder from borderline personality disorder: A study of current clinical practice. European Psychiatry, 30, 965–974.

Shedler, J., & Westen, D. (2004a). Dimensions of personality pathology: An alternative to the five-factor model. American Journal of Psychiatry, 161, 1743–1754.

Shedler, J., & Westen, D. (2004b). Reviews and Overviews Refining Personality Disorder Diagnosis: Integrating Science and Practice. Psychiatry: Interpersonal and Biological Processes, 161, 1350–1365.

Shedler, J., Westen, D., Lingiardi, V., & Gazzillo, F. (2014). La valutazione della personalità con la SWAP-200. Milano: R. Cortina.

Smits, M. L., Feenstra, D. J., Bales, D. L., de Vos, J., Lucas, Z., Verheul, R., & Luyten, P. (2017). Subtypes of borderline personality disorder patients: a cluster-analytic approach. Borderline Personality Disorder and Emotion Dysregulation, 4, 16.

Westen, D., & Arkowitz-Westen, L. (1998). Limitations of axis II in diagnosing personality pathology in clinical practice. Am J Psychiatry, 155, 1767–1771.

World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization.

Young, A. H., Vieta, E., Bowden, C., Azorin, J.-M., Angst, J., & Perugi, G. (2013). The bipolar-borderline personality disorders connection in major depressive patients. Acta Psychiatrica Scandinavica, 128, 376–383.

Youngstrom, E., Van Meter, A., & Algorta, G. P. (2010). The Bipolar Spectrum: Myth or Reality? Current Psychiatry Reports, 12, 479–489.

Zimmerman, M., Balling, C., Dalrymple, K., & Chelminski, I. (2019). Screening for Borderline Personality Disorder in Psychiatric Outpatients With Major Depressive Disorder and Bipolar Disorder. The Journal of Clinical Psychiatry, 80, 18m12257.

Zimmerman, M., Chelminski, I., Dalrymple, K., & Rosenstein, L. (2017). Principal diagnoses in psychiatric outpatients with borderline personality disorder: Implications for screening recommendations. Annals of Clinical Psychiatry : Official Journal of the American Academy of Clinical Psychiatrists, 29, 54–60.



  • There are currently no refbacks.