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Personality functioning in bipolar 1 disorder and borderline personality disorder

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Title: Personality functioning in bipolar 1 disorder and borderline personality disorder
Authors: Karin Feichtinger, Clarissa Laczkovics, Johanna Alexopoulos, Maria Gruber, Miriam Klauser, Karoline Parth, Antonia Wininger, Michael Ossege, Josef Baumgartner, Stephan Doering, Victor Blüml
Source: BMC Psychiatry, Vol 24, Iss 1, Pp 1-8 (2024)
Publisher Information: BMC, 2024.
Publication Year: 2024
Collection: LCC:Psychiatry
Subject Terms: Bipolar disorder, Borderline personality disorder, Identity, Personality functioning, STIPO, Psychiatry, RC435-571
More Details: Abstract Background Differentiation of borderline personality disorder (BPD) and bipolar I disorder (BD) has been challenging. The assessment of shared symptoms in the context of the overall personality functioning, the patient’s sense of self, and the quality of his object (interpersonal) relations is proposed to be valuable for the differential diagnosis of these disorders. Methods We empirically investigated the level of personality organization (PO), identity integration, and quality of object relations in patients suffering from BD or BPD using the Structured Interview of Personality Organization (STIPO) and the Level of Personality Functioning Scale (LPFS) in 34 BPD and 28 BD patients as well as 27 healthy control persons. Group comparisons and a logistic regression model were calculated to analyze group differences. Results The BPD group showed significantly greater impairment in several domains of personality functioning, namely “identity”, and “self- and other-directed aggression”, while showing lower impairment in “moral values”. The overall level of PO in the BPD group was significantly lower when excluding not only BPD but any personality disorder (PD) in the BD sample. Severity of impaired personality structure had a major impact on symptom load independent of the main diagnosis BD or BPD. Conclusions Our data show greater impairment in personality functioning in BPD than in BD patients. BD patients present with varying levels of PO, whereas in BPD severe deficits in PO are pathognomonic. The level of PO has a significant impact on symptom severity in both BD and BPD patients. Therefore, careful assessment of PO should be considered for differential diagnosis and adequate treatment planning.
Document Type: article
File Description: electronic resource
Language: English
ISSN: 1471-244X
Relation: https://doaj.org/toc/1471-244X
DOI: 10.1186/s12888-024-06297-8
Access URL: https://doaj.org/article/5dcf137561624dfbb67060dc08db1580
Accession Number: edsdoj.5dcf137561624dfbb67060dc08db1580
Database: Directory of Open Access Journals
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  Value: <anid>AN0181118870;[1cij]25nov.24;2024Nov28.04:51;v2.2.500</anid> <title id="AN0181118870-1">Personality functioning in bipolar 1 disorder and borderline personality disorder </title> <p>Background: Differentiation of borderline personality disorder (BPD) and bipolar I disorder (BD) has been challenging. The assessment of shared symptoms in the context of the overall personality functioning, the patient's sense of self, and the quality of his object (interpersonal) relations is proposed to be valuable for the differential diagnosis of these disorders. Methods: We empirically investigated the level of personality organization (PO), identity integration, and quality of object relations in patients suffering from BD or BPD using the Structured Interview of Personality Organization (STIPO) and the Level of Personality Functioning Scale (LPFS) in 34 BPD and 28 BD patients as well as 27 healthy control persons. Group comparisons and a logistic regression model were calculated to analyze group differences. Results: The BPD group showed significantly greater impairment in several domains of personality functioning, namely "identity", and "self- and other-directed aggression", while showing lower impairment in "moral values". The overall level of PO in the BPD group was significantly lower when excluding not only BPD but any personality disorder (PD) in the BD sample. Severity of impaired personality structure had a major impact on symptom load independent of the main diagnosis BD or BPD. Conclusions: Our data show greater impairment in personality functioning in BPD than in BD patients. BD patients present with varying levels of PO, whereas in BPD severe deficits in PO are pathognomonic. The level of PO has a significant impact on symptom severity in both BD and BPD patients. Therefore, careful assessment of PO should be considered for differential diagnosis and adequate treatment planning.</p> <p>Keywords: Bipolar disorder; Borderline personality disorder; Identity; Personality functioning; STIPO</p> <p>Karin Feichtinger and Clarissa Laczkovics contributed equally to this study.</p> <hd id="AN0181118870-2">Background</hd> <p>Borderline personality disorder (BPD) and bipolar disorder (BD) are both debilitating psychiatric illnesses. Differentiation of these disorders has been challenging, especially regarding BD type 2, but also BD type 1, as there are many shared symptoms [[<reflink idref="bib1" id="ref1">1</reflink>]]. These include emotional and affective instability, aggression and anger, changes in self-esteem, impulsivity such as sexual disinhibition, antisocial behavior, alcohol and substance misuse, self-harm behavior and suicidality [[<reflink idref="bib3" id="ref2">3</reflink>]]. On the contrary, these disorders are also known to have major differences, namely neurobiological, genetic, epidemiological, etiological, regarding the course of illness and the therapeutic targets [[<reflink idref="bib5" id="ref3">5</reflink>]–[<reflink idref="bib8" id="ref4">8</reflink>]]. Nevertheless, the accurate diagnosis in the clinical setting remains challenging, and further studies addressing these issues from a clinical point of view are called for [[<reflink idref="bib9" id="ref5">9</reflink>]–[<reflink idref="bib11" id="ref6">11</reflink>]]. Neuropsychological profiles appeared to be more similar than different in BD and BPD [[<reflink idref="bib12" id="ref7">12</reflink>]], screening instruments for BD have been shown to be ineffective in distinguishing between BD and BPD [[<reflink idref="bib13" id="ref8">13</reflink>]], and anger and Cluster B personality traits were associated with the conversion from unipolar depression to BD [[<reflink idref="bib14" id="ref9">14</reflink>]]. Furthermore, BD and BPD have a high incidence of co-occurrence [[<reflink idref="bib15" id="ref10">15</reflink>]–[<reflink idref="bib17" id="ref11">17</reflink>]]. Euthymic bipolar patients assessed by a structured interview had rates of comorbid personality disorder (PD) around 30% [[<reflink idref="bib17" id="ref12">17</reflink>]], including BPD. These observations even resulted in a debate among clinicians and researchers, whether the two disorders really are separate entities [[<reflink idref="bib18" id="ref13">18</reflink>]].</p> <p>The correct diagnosis of these disorders is of importance, since treatment differs significantly. Psychopharmacological treatment is recommended in BD [[<reflink idref="bib6" id="ref14">6</reflink>]], whereas patients with BPD appear to have lower response rates to medication [[<reflink idref="bib20" id="ref15">20</reflink>]] and first line treatment consists of specific psychotherapeutic modalities [[<reflink idref="bib21" id="ref16">21</reflink>]] such as Transference Focused Psychotherapy (TFP; [[<reflink idref="bib22" id="ref17">22</reflink>]]), Dialectical Behavioral Treatment (DBT; [[<reflink idref="bib24" id="ref18">24</reflink>]]), Schema- Focused Therapy (SFT; [[<reflink idref="bib26" id="ref19">26</reflink>]]), and Mentalization Based Treatment (MBT; [[<reflink idref="bib27" id="ref20">27</reflink>]]).</p> <p>Recently, it has been proposed that the assessment of symptoms in the context of the overall personality functioning, the patient's sense of self, and the quality of his object (interpersonal) relations is valuable for the differential diagnosis of the two disorders [[<reflink idref="bib18" id="ref21">18</reflink>], [<reflink idref="bib29" id="ref22">29</reflink>]–[<reflink idref="bib32" id="ref23">32</reflink>]]. Focusing on the dimensions of identity, self-concept and self-esteem, a recent review [[<reflink idref="bib33" id="ref24">33</reflink>]] found identity diffusion as a pathognomonic feature in BPD as opposed to BD, where a more unified and coherent self-concept is present. Identity diffusion refers to a marked lack of an integrated concept of the self and severe, chronic discrepancies in the assessment of the self [[<reflink idref="bib34" id="ref25">34</reflink>]]. The authors conclude that comparative studies examining the core symptom of identity diffusion are needed as heterogeneity in methods, measures and theories limited the comparability of the reviewed studies [[<reflink idref="bib33" id="ref26">33</reflink>]]. Studies comparing BD and BPD regarding relations to significant others found that BPD patients had more difficulties in establishing and maintaining reciprocal relationships [[<reflink idref="bib1" id="ref27">1</reflink>]].</p> <p>The recognition of the importance of the concept of personality functioning, identity, and interpersonal functioning converges with psychoanalytic or psychodynamic viewpoints of mental disorders. One of the most influential models for the assessment of personality functioning was developed by Kernberg and colleagues [[<reflink idref="bib34" id="ref28">34</reflink>]–[<reflink idref="bib36" id="ref29">36</reflink>]]. Based on empirical and theoretical literature on the development of personality and psychic functioning Kernberg proposed three basic levels of personality organization (PO): neurotic, borderline, and psychotic PO [[<reflink idref="bib34" id="ref30">34</reflink>], [<reflink idref="bib37" id="ref31">37</reflink>]]. They differ in terms of identity integration, quality of object relations, maturity of defense mechanisms, and the capacity for reality testing [[<reflink idref="bib36" id="ref32">36</reflink>]]. In recent years, standardized instruments for the assessment of PO were designed with good psychometric properties which have been used for the study of diverse psychopathological phenomena. These considerations are in line with a renewed interest in questions of personality functioning in mental disorders published in the diagnostic classification systems DSM-5 [[<reflink idref="bib38" id="ref33">38</reflink>]] and ICD-11 [[<reflink idref="bib39" id="ref34">39</reflink>]]. Section III of the DSM-5 and ICD-11 propose a model for personality disorders focusing on the impairment in personality functioning consisting of the domains of self and interpersonal functioning [[<reflink idref="bib40" id="ref35">40</reflink>]].</p> <p>In light of the current discussion we want to expand the knowledge of differential diagnostics with an in-depth comparison of personality functioning in BPD versus BD. We empirically investigated the level of PO, identity integration, and quality of object relations in patients suffering from BD or BPD. Based on empirical and clinical considerations, we hypothesized that there exist significant differences in these areas between the two disorders [[<reflink idref="bib1" id="ref36">1</reflink>], [<reflink idref="bib18" id="ref37">18</reflink>], [<reflink idref="bib29" id="ref38">29</reflink>], [<reflink idref="bib33" id="ref39">33</reflink>]]. We specifically hypothesized that disturbances in the domain of identity would be more prominent in BPD than in BD. Furthermore, we expected more severe impairment in the quality of object relations in BPD patients than in BD.</p> <hd id="AN0181118870-3">Methods</hd> <p></p> <hd id="AN0181118870-4">Subjects</hd> <p>Patients were recruited from the Department of Psychiatry and Psychotherapy and the Department of Psychoanalysis and Psychotherapy of the Medical University of Vienna and from several psychiatric departments of hospitals situated in Vienna and surroundings. Participants of the healthy control group (HC) were recruited via announcements. This study was part of a larger research project investigating personality functioning in severe mental disorders, of which first results have previously been published [[<reflink idref="bib41" id="ref40">41</reflink>]].</p> <p>All participants met the following inclusion criteria: Age ≥ 18 years and sufficient command of German. Exclusion criteria were comorbidity between BPD and BD, severe cognitive impairment, psychiatric symptoms due to any organic condition or acute intoxication. For secondary analyses a sub-sample of BD patients without any comorbid PD was formed (BD-). The secondary analysis was done to elucidate deficiencies in personality structure, that are relevant in all PDs, in BD without any comorbid PD.</p> <p>Participants of the HC group were included if they had no diagnosis of a current psychiatric disorder according to SCID-I and -II [[<reflink idref="bib42" id="ref41">42</reflink>]] and subjects were excluded with a Global Severity Index (GSI) > 0.32 on the Brief Symptom Inventory (BSI [[<reflink idref="bib44" id="ref42">44</reflink>]]).</p> <p>Interviews were conducted by psychiatrists or psychotherapists who were trained in administration of each interview and passed interrater reliability testing (ICC for the overall Structured Interview of Personality Organization (STIPO) rating: 0.760).</p> <p>Out of 116 individuals who agreed to participate in the study after initial information, 98 completed at least one interview appointment. After data entry and verification, 9 participants were excluded due to missing data on the main instruments (SCID, STIPO; e.g. when patients only completed one of the interviews and did not show up for the follow-up-date) or for not fulfilling the inclusion/exclusion criteria (e.g. a co-morbidity of BPD and BD was shown in the SCID-interview). Valid data of 89 participants (34 BPD, 28 BD patients and 27 HC) could finally be included for statistical analysis.</p> <hd id="AN0181118870-5">Procedures</hd> <p></p> <hd id="AN0181118870-6">Structured interview for DSM-IV (SCID-I and -II [42, 43])</hd> <p>The SCID was used for categorial diagnosis of psychiatric disorders according to DSM-IV on axis I (SCID I) and personality disorders (SCID II).</p> <hd id="AN0181118870-7">Structured interview of personality organization [36]</hd> <p>The STIPO [[<reflink idref="bib36" id="ref43">36</reflink>], [<reflink idref="bib45" id="ref44">45</reflink>]] is grounded in Kernberg's model of PO [[<reflink idref="bib34" id="ref45">34</reflink>]]. The German version [[<reflink idref="bib37" id="ref46">37</reflink>]] consists of 100 items, seven domains and specific subdomains: 1. Identity, 1.A. Capacity to invest, 1.B. Sense of self, a) Coherence and continuity, b) Self valuation, 1.C. Sense of others, 2. Object relations, 2.A. Interpersonal relationships, 2.B. Intimate relationships and sexuality, 2.C. Internal working model of relationships, 3. Primitive defenses, 4. Coping / rigidity, 5. Aggression, 5.A. Self-directed aggression, 5.B. Other-directed aggression, 6. Moral values, 7. Reality testing. Each domain is rated on a five-point scale from healthy functioning (1 point) to severe impairment (5 points). Finally, the overall level of PO is assessed ranging from a normal level to severely impaired personality functioning: (<reflink idref="bib1" id="ref47">1</reflink>) normal, (<reflink idref="bib2" id="ref48">2</reflink>) neurotic 1, (<reflink idref="bib3" id="ref49">3</reflink>) neurotic 2, (<reflink idref="bib4" id="ref50">4</reflink>) borderline 1, (<reflink idref="bib5" id="ref51">5</reflink>) borderline 2, and (<reflink idref="bib6" id="ref52">6</reflink>) borderline 3. Satisfactory reliability and validity have been demonstrated [[<reflink idref="bib37" id="ref53">37</reflink>], [<reflink idref="bib46" id="ref54">46</reflink>]].</p> <p>STIPO-interrater reliability between the six raters (VB, AF, KF, MG, MK, KP) was assessed after an intensive STIPO training under the supervision of a senior STIPO-scholar (SD) and was based on six training cases which were not part of this study. ICC were calculated in SPSS with a two way mixed model with single measure and absolute agreement with the following results for all STIPO domains: overall level of PO: 0.760; identity: 0.707; object relations: 0.706; defense mechanisms: 0.708; coping: 0.636; aggression: 0.899; moral values: 0.482; reality testing: 0.785. To minimize skewed assessment, the STIPO interview was administered first, followed by the SCID interview afterwards.</p> <hd id="AN0181118870-8">Level of personality functioning scale (LPFS [47, 48])</hd> <p>The LPFS [[<reflink idref="bib47" id="ref55">47</reflink>]] is part of the DSM-5, section III [[<reflink idref="bib48" id="ref56">48</reflink>]] and assesses personality functioning on a five-point scale from healthy functioning (level = 0) to extreme impairment (level = 4) in two domains and four sub-facets: "Self-functioning" with the facets: "Identity" and "Self-direction"; and "Interpersonal-functioning" with the facets: "Empathy" and "Intimacy". The German version of the LPFS with good psychometric properties was rated on the basis of the STIPO interviews [[<reflink idref="bib49" id="ref57">49</reflink>]].</p> <hd id="AN0181118870-9">The personality inventory for DSM-5 – brief form (PID-5-BF [50, 51])</hd> <p>The Personality Inventory for DSM-5 Brief Form (PID-5-BF) is a 25-item self-rated personality trait assessment scale for adults age 18 and older [[<reflink idref="bib50" id="ref58">50</reflink>]]. It is part of the alternative model for the assessment of personality disorders in DSM-5, section III [[<reflink idref="bib38" id="ref59">38</reflink>]]. It assesses 5 personality trait domains including "Negative affect", "Detachment", "Antagonism", "Disinhibition", and "Psychoticism", with each trait domain consisting of 5 items and each item being assessed on a 4-point scale (from 0 = very false or often false to 3 = very true or often true). The psychometric properties of the PID-5-BF have been shown to be adequate [[<reflink idref="bib51" id="ref60">51</reflink>]].</p> <hd id="AN0181118870-10">Brief symptom inventory (BSI [44, 53])</hd> <p>The Brief Symptom Inventory is the short version of the Symptom Checklist 90 (SCL-90 [[<reflink idref="bib53" id="ref61">53</reflink>]]). The questionnaire consists of 53 items with nine symptom scales (Somatization, Obsessive–Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and Psychoticism). It provides the Global Severity Index (GSI) that assesses overall psychological distress level, the Positive Symptom Total (PST) which covers the number of self-reported symptoms, and the Positive Symptom Distress Index (PSDI) which evaluates the intensity of symptoms. The psychometric properties of the BSI were shown to be good [[<reflink idref="bib54" id="ref62">54</reflink>]].</p> <hd id="AN0181118870-11">Statistical analysis</hd> <p>Statistical analyses were carried out with IBM SPSS Statistics 28 software (IBM Corp., Armonk, NY, USA). Significance threshold was set to p ≤ 0.05.</p> <p>Sociodemographic features, psychiatric diagnosis, and overall level of PO were described based on measures of frequency distribution. Differences between groups in sociographic characteristics, psychiatric diagnosis and symptom severity were investigated using t-test, Mann–Whitney tests and, where appropriate, the χ2 test (for ordinal variables). To counteract the multiple comparison problem a Bonferroni correction was applied. To test the main hypothesis a logistic regression was conducted to analyze the relationship between personality organization (seven domains of the STIPO), personality functioning (LPFS) and diagnosis.</p> <hd id="AN0181118870-12">Results</hd> <p></p> <hd id="AN0181118870-13">Demographics and psychiatric diagnostics</hd> <p>34 patients diagnosed with a BPD, 28 patients diagnosed with a BD, and 27 HC agreed to participate in the study. The age ranged from 18 to 39 years (M<subs>age</subs> =. 27.15 years, SD = 6.42) in the BPD sample, from 24 to 68 years (M<subs>age</subs> = 42.0 years, SD = 14.56) in the BD sample and from 20 to 60 years (M<subs>age</subs> = 30.71 years, SD = 11.68) in the HC sample. In all groups, participants were predominantly female (for details refer to Table 1). Sociodemographic characteristics showed significant differences in age with participants in the BD sample being significantly older than participants in the BPD sample (<emph>t</emph> = −5.35, <emph>p</emph> < 0.001) and HC sample (<emph>t</emph> = 3.16, <emph>p</emph> = 0.001). Participants in the BD sample were more likely to have received psychiatric (χ2(<reflink idref="bib1" id="ref63">1</reflink>) = 5.471, <emph>p</emph> = 0.019) or psychopharmacological treatment (χ2(<reflink idref="bib1" id="ref64">1</reflink>) = 6.498, <emph>p</emph> = 0.011). Patients in the BPD sample were more frequently diagnosed with a depressive disorder (U = 287.0, <emph>p</emph> = 0.002) and an eating disorder (U = 384.0, <emph>p</emph> = 0.049). Diagnoses according to DSM-IV (<reflink idref="bib55" id="ref65">55</reflink>) are given in Table 2. No differences were found between groups in terms of partnership, education, and employment.</p> <hd id="AN0181118870-14">Group differences in symptom severity, overall personality organization and personality trait...</hd> <p>Overall, patients in the BPD sample reported a higher number of symptoms and higher level of distress according to the BSI (<emph>t</emph> = 4.2, <emph>p</emph> < 0.001, <emph>d</emph> = 1.151). With the exception of "Somatization", "Hostility", and "Phobic anxiety" all symptom dimension scores on the BSI were significantly higher in the BPD patient sample than in the BD sample; with effect sizes ranging from medium to large. Differences were even greater when comparing the BPD with the BD- sample (see Table 3). For the five domain scales of the PID-5-BF we again found generally higher scores in the BPD patients with significantly increased scores on the domain "Negative affectivity" (<emph>t</emph> = 4.476, <emph>p</emph> < 0.001, <emph>d</emph> = 1.187; Table 3).</p> <p>The overall PO of the BPD, the BD, the BD- and the HC group is given in Table 4. In the HC group, nobody was rated on a borderline level. The difference between groups in the overall level of PO did reach significance (χ2(<reflink idref="bib2" id="ref66">2</reflink>) = 29.196, <emph>p</emph> < 0.001). HC had significantly less impairment of personality structure, reflected in a higher level of PO, compared to BPD as well as to BD patients (HC vs. BD: U = 2.0, <emph>p</emph> < 0.001, HC vs. BPD: U = 0.0, <emph>p</emph> < 0.001). However, no significant difference was found between BPD and BD patients.</p> <hd id="AN0181118870-15">Specific contribution of domains of personality functioning and organization in predicting ps...</hd> <p>In Table 5 descriptive statistics of the domains of the STIPO and the LPFS are given. Higher scores in the STIPO reflect greater deficiencies. Across the seven dimensions of the STIPO, patients in the BPD sample had higher scores than patients in the BD sample. Table 6 shows results from a logistic regression analysis with dimension of the STIPO (Identity, Object relations, Primitive defenses, Coping, Self-directed aggression, Other-directed aggression, Moral values, and Reality testing) and the LPFS (Self-direction, Interpersonal-functioning, Empathy, and Intimacy) predicting group membership. Odds ratios for four predictors were significant, suggesting that lower scores on identity (OR = 0.036,<emph>p</emph> = 0.023), self-directed aggression (OR = 0.273, <emph>p</emph> = 0.008), other-directed aggression (OR = 0.211, <emph>p</emph> = 0.042) and higher scores on moral values (OR = 10.97, <emph>p</emph> = 0.008) were associated with the diagnosis of a BD. Taken together, the model showed considerable predictive value, with Nagelkerke´s R2 = 0.633 (Model χ2 (<reflink idref="bib12" id="ref67">12</reflink>) = 34.151, <emph>p</emph> < 0.001) and 85% of patients with a diagnosis of BD being correctly predicted.</p> <hd id="AN0181118870-16">Group differences in personality functioning and organization between BPD and BD-</hd> <p>Comparison of the BPD with the BD- sample revealed even greater differences in personality functioning. BD- patients were shown to have a significantly higher overall level of PO than BPD patients (U = 160.00, <emph>p</emph> = 0.002), with 72,3% of the BD- sample vs. 32,4% of BDP sample assigned a level of "Borderline 1" or higher. Furthermore, significant differences were found in several sub-dimensions of the STIPO with the BPD sample being more impaired on the dimensions "Identity", "Primitive Defenses", "Self-directed aggression", and "Other-directed aggression". Statistical analysis revealed medium to large effect sizes. Significant differences were also found in the domains of the LPFS with patients of the BPD sample showing higher impairment in the domains "Identity" and "Intimacy" with medium effect sizes.</p> <hd id="AN0181118870-17">Discussion</hd> <p>This study examined personality functioning in BD and BPD patients to contribute to a better differential diagnosis of the two disorders. First, we looked at the total sample of BPD and BD patients and the results confirm our main hypothesis. We found that BPD patients show more severe impairment in personality functioning with significant differences in the dimensions of "Identity", "Self-directed aggression", "Other-directed aggression", and "moral values". The other domains and overall STIPO level were higher, indicating more deficiency, in the BPD sample compared to the BD group, but differences did not reach statistical significance. Identity was more impaired in patients with BPD, referring to the syndrome of identity diffusion, which is considered to be pathognomonic for patients with severe personality disorders. These results also confirm recent reports which pointed to the relevance of the concept of integrated identity versus identity diffusion for distinguishing BPD from BD patients [[<reflink idref="bib29" id="ref68">29</reflink>], [<reflink idref="bib33" id="ref69">33</reflink>]]. Self- and other-directed aggression was found to be more severe in BPD. While aggression is known to also occur in acute phases of BD as well as after remission [[<reflink idref="bib55" id="ref70">55</reflink>]], severe unintegrated, i.e. split-off, mainly self-directed aggression as a core personality characteristic is typical for severe BPD, presenting as chronic suicidal tendencies and parasuicidal behavior, such as repeated cutting, especially under emotional conditions such as frustrations and interpersonal challenges [[<reflink idref="bib4" id="ref71">4</reflink>], [<reflink idref="bib29" id="ref72">29</reflink>]]. Finally, in our sample, BD patients showed more impairment of moral functioning, i.e. the capacity to adhere to common norms of interpersonal behavior and to experience guilt feelings when appropriate. This finding might reflect the increased risk of norm-transgressing behavior of BD patients during manic episodes, but more detailed follow-up research is necessary to corroborate these results, especially given the rather poor interrater-reliability in our sample for this STIPO domain.</p> <p>More than a third of the BD patients (35,7%) presented with a comorbid personality disorder (PD) other than BPD, which is higher than previously reported [[<reflink idref="bib17" id="ref73">17</reflink>]]. In order to further investigate the association between BD and personality functioning in the absence of any PD, we performed a secondary analysis comparing BD patients without any PD (BD-) with the BPD sample. In the secondary analysis, the differences between the groups became even clearer with significantly higher impairment in several important domains of the STIPO in the BPD patients. Notably, the overall level of PO was significantly worse in the BPD group with 68% having a level of "borderline 2" or lower versus 27.8% of the BD- sample. Again, "Identity" was significantly more impaired and "Self- and other-directed aggression" was found to be more severe in BPD patients [[<reflink idref="bib33" id="ref74">33</reflink>]]. Additionally, "Primitive defenses" were significantly more dominantly used in BPD, confirming the use of immature defense mechanisms such as splitting and projective identification as pathognomonic characteristics of BPD [[<reflink idref="bib34" id="ref75">34</reflink>], [<reflink idref="bib57" id="ref76">57</reflink>]]. Defense mechanisms are used to prevent anxiety and to maintain psychological stability, but immature defense mechanisms skew an individual´s perception of reality, of the self and others [[<reflink idref="bib58" id="ref77">58</reflink>]]. On the other hand, more mature defense mechanisms in BD patients lead to greater affective stability and the capacity for mature relationships with others [[<reflink idref="bib29" id="ref78">29</reflink>]]. This was further confirmed by the significantly less impairment of BD patients in the domains "Identity" and "Intimacy" in the LPFS. These results are in line with previous reports that found that BPD patients had significantly more difficulties in interpersonal relationships as compared to patients with BD [[<reflink idref="bib1" id="ref79">1</reflink>], [<reflink idref="bib59" id="ref80">59</reflink>]]), namely in establishing and maintaining reciprocal relationships, as well as coping emotionally with interpersonal stress. Somewhat surprisingly, we found no significant differences in the domain "object relations", referring to relationships to significant others, comparing the BPD and the BD patients. However, object relations were significantly impaired in both groups compared to the HC sample, therefore relationships to others were equally impaired and not helpful in distinguishing BPD from BD.</p> <p>Regarding personality traits, our results show a strong association of negative affectivity and BPD compared to BD. This finding is in line with previous reports of high levels of negative affectivity and disinhibition in BPD patients [[<reflink idref="bib60" id="ref81">60</reflink>]]. Notably, a recent meta-analysis also reported higher scores of neuroticism and lower scores of conscientiousness and extraversion in BD patients when compared to healthy controls [[<reflink idref="bib61" id="ref82">61</reflink>]].</p> <p>The clinical implications of the level of impairment of personality functioning are known in BPD [[<reflink idref="bib62" id="ref83">62</reflink>]], less is known about its impact in BD [[<reflink idref="bib64" id="ref84">64</reflink>]–[<reflink idref="bib67" id="ref85">67</reflink>]]. Our study revealed that, on a symptomatic level, BPD patients were significantly more impaired in all domains of the BSI except for somatization compared with the BD total sample. The differences were even greater in the secondary analysis, when comparing the subgroup of BD patients without any comorbid PD with the BPD sample. Impairment in personality functioning was thus associated with higher severity of symptoms, indicating that the level of PO has a major impact on symptom load in BPD and BD.</p> <p>According to modern psychodynamic object relations theory, severe personality disorders including BPD are characterized by a PO on a borderline level as opposed to neurotic or psychotic PO [[<reflink idref="bib34" id="ref86">34</reflink>], [<reflink idref="bib68" id="ref87">68</reflink>]]. This was confirmed in our sample with 100% of the BPD patients showing a PO on a borderline level. Mood disorders are known to occur on different severity grades, from psychotic to less symptomatic manifestations. Especially acute manic episodes oftentimes present symptomatically psychotic with denial leading to a loss of reality testing that is regained in the euthymic phase [[<reflink idref="bib69" id="ref88">69</reflink>]]. Patients remitted from acute phases of illness therefore are thought to present with a wider range of personality pathology [[<reflink idref="bib70" id="ref89">70</reflink>]]. Patients in our BD sample presented with a PO ranging from neurotic 2 to borderline 3 supporting this hypothesis. Only two of the BD patients showed the most severe impairment in personality functioning which is theoretically on the border to a psychotic personality structure. Therefore, we could not find empirical evidence in our sample of euthymic patients for BD to be generally associated with a psychotic PO. This implies that after the manic episode when reality testing might be skewed, reality testing is fully reestablished in remission. Nevertheless, 90% of patients in the BD group showed impairment in personality functioning corresponding to a PO on a borderline level. A high number of BD patients thus presents with severe problems in the areas of identity integration, intimacy and aggression based on primitive defense mechanisms. These patients might also – besides mood stabilizing psychopharmacological treatment—benefit from specialized psychotherapeutic interventions targeting pathological self and interpersonal functioning as established for personality disorders such as BPD [[<reflink idref="bib21" id="ref90">21</reflink>], [<reflink idref="bib72" id="ref91">72</reflink>]].</p> <hd id="AN0181118870-18">Limitations</hd> <p>The BPD patients were significantly younger in age. Literature regarding the course of BPD across the lifetime report a decline of impulsive symptoms and aggression in BPD patients over the lifespan and therefore less presentation in the clinical setting [[<reflink idref="bib73" id="ref92">73</reflink>]]. Furthermore, there is evidence that there are characteristic patterns of change in personality traits over the life span, notably including an increase in emotional stability [[<reflink idref="bib75" id="ref93">75</reflink>]]. Therefore, an age-related bias of the differences in personality functioning cannot be ruled out.</p> <p>Another limitation is that the same rater performed STIPO and SCID assessment, due to practical reasons. To minimize skewed ratings, the STIPO interview was first administered, followed by the SCID interview.</p> <p>Furthermore, the LPFS ratings were based on STIPO interviews and not on an independent assessment interview, which had not yet been available at the time of the realization of this study [[<reflink idref="bib76" id="ref94">76</reflink>]]. While this approach has been demonstrated to be reliable [[<reflink idref="bib76" id="ref95">76</reflink>]], the results of the LPFS in this study need to be interpreted with caution and should not be seen as an independent validation of the STIPO results. The LPFS score in this study was used primarily as a measure to build a conceptual bridge from STIPO results based on object relations theory to the diagnostic standards of the AMPD in the DSM-5.</p> <p>The interrater agreement on the domain moral values in the STIPO was only fair, compared to all other domains that reached good interrater reliability. Our results on the significant differences between BD and BPD patients concerning moral issues therefore have to be interpreted with caution.</p> <p>Further limitations of the current study include its cross-sectional design and its rather small sample size due to the time-consuming assessment procedures. Longitudinal studies are needed to investigate the impact of personality pathology on the course of treatment and outcome in BD patients.</p> <hd id="AN0181118870-19">Conclusion</hd> <p>Differential diagnosis of BD and BPD can be clinically challenging. Assessing personality functioning is a promising perspective to supplement categorical, symptom-oriented approaches. Our data show that in BPD severe deficits in overall PO and identity integration are pathognomonic whereas BD patients present with varying levels of PO. The level of PO has a significant impact on symptom severity in both BD and BPD patients. Careful assessment of personality functioning should therefore be considered in BD for differential diagnostics and adequate treatment planning. For those BD patients that have impairments in PO, specific psychotherapeutic treatment should be considered targeting personality pathology in addition to treatment as usual.</p> <hd id="AN0181118870-20">Acknowledgements</hd> <p>We thank S. Funk and F. Resch for help with data management.</p> <hd id="AN0181118870-21">Authors' contributions</hd> <p>Conception and design of the study: SD, VB; Acquisition and analysis of data: KF, CL, JA, MG, MK, KP, AW, JB, MO, VB; Drafting the manuscript or tables: KF, CL, JA, VB. All authors have reviewed and approved the final manuscript.</p> <hd id="AN0181118870-22">Funding</hd> <p>This study was generously supported by funding from the Heigl-Foundation, the Köhler-Foundation, and the International Psychoanalytical Association (IPA). The funders had no role in the design, data collection, data analysis, and reporting of this study.</p> <hd id="AN0181118870-23">Data availability</hd> <p>The data that support the findings of this study are available from the corresponding author, VB, upon reasonable request.</p> <hd id="AN0181118870-24">Declarations</hd> <p></p> <hd id="AN0181118870-25">Ethics approval and consent to participate</hd> <p>The study was reviewed and approved by the Ethics Committee of the Medical University of Vienna (Approval number: 1116/2015).</p> <hd id="AN0181118870-26">Consent for publication</hd> <p>Written informed consent was obtained from all participants.</p> <hd id="AN0181118870-27">Competing interests</hd> <p>The authors declare no competing interests.</p> <hd id="AN0181118870-28">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0181118870-29"> <title> References </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Massó Rodriguez A. Clinical Features, Neuropsychology and Neuroimaging in Bipolar and Borderline Personality Disorder: A Systematic Review of Cross-Diagnostic Studies. Front Psychiatry. 2021; 12. 34177664. 8220090. 10.3389/fpsyt.2021.681876</bibtext> </blist> <blist> <bibl id="bib2" idref="ref48" type="bt">2</bibl> <bibtext> L. M. Lopes, M.M, M. Marques, I. M. Lopes, J. Reis, Bipolar Disorder and Borderline Personality Disorder: A Diagnostic Challenge. European Psychiatry, 2023. 66: p. S701-S701.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref2" type="bt">3</bibl> <bibtext> Miller JN, B.D, Bipolar Disorder and Suicide: a Review. Curr Psychiatry Rep, 2020. Jan 18;22(2):6.</bibtext> </blist> <blist> <bibl id="bib4" idref="ref50" type="bt">4</bibl> <bibtext> Reichl C, Kaess M. Self-harm in the context of borderline personality disorder. Curr Opin Psychol. 2021; 37: 139-144. 33548678. 10.1016/j.copsyc.2020.12.007</bibtext> </blist> <blist> <bibl id="bib5" idref="ref3" type="bt">5</bibl> <bibtext> Coryell W. Age transitions in the course of bipolar I disorder. Psychol Med. 2009; 39; 8: 1247-1252. 1:STN:280:DC%2BD1MvlslGrtQ%3D%3D. 19335937. 3551474. 10.1017/S0033291709005534</bibtext> </blist> <blist> <bibl id="bib6" idref="ref14" type="bt">6</bibl> <bibtext> Geddes JR, Miklowitz DJ. Treatment of bipolar disorder. Lancet. 2013; 381; 9878: 1672-1682. 1:CAS:528:DC%2BC3sXnslertLk%3D. 23663953. 10.1016/S0140-6736(13)60857-0</bibtext> </blist> <blist> <bibl id="bib7" type="bt">7</bibl> <bibtext> Ripoll LH, Triebwasser J, Siever LJ. Evidence-based pharmacotherapy for personality disorders. Int J Neuropsychopharmacol. 2011; 14; 9: 1257-1288. 21320390. 10.1017/S1461145711000071</bibtext> </blist> <blist> <bibl id="bib8" idref="ref4" type="bt">8</bibl> <bibtext> Paris J, Black DW. Borderline personality disorder and bipolar disorder: what is the difference and why does it matter?. J Nerv Ment Dis. 2015; 203; 1: 3-7. 25536097. 10.1097/NMD.0000000000000225</bibtext> </blist> <blist> <bibl id="bib9" idref="ref5" type="bt">9</bibl> <bibtext> Ghaemi SN. Bipolar or borderline: a clinical overview. Acta Psychiatr Scand. 2014; 130; 2: 99-108. 1:STN:280:DC%2BC2cvot1WqsQ%3D%3D. 24571137. 10.1111/acps.12257</bibtext> </blist> <blist> <bibtext> Renaud S, Corbalan F, Beaulieu S. Differential diagnosis of bipolar affective disorder type II and borderline personality disorder: analysis of the affective dimension. Compr Psychiatry. 2012; 53; 7: 952-961. 22560773. 10.1016/j.comppsych.2012.03.004</bibtext> </blist> <blist> <bibtext> Saunders KE. Distinguishing bipolar disorder from borderline personality disorder: A study of current clinical practice. Eur Psychiatry. 2015; 30; 8: 965-974. 1:STN:280:DC%2BC28vptVejtg%3D%3D. 26647873. 10.1016/j.eurpsy.2015.09.007</bibtext> </blist> <blist> <bibtext> Michopoulos I. Similar or Different Neuropsychological Profiles? Only Set Shifting Differentiates Women With Bipolar vs. Borderline Personality Disorder Front Psychiatry. 2021; 12. 34393854</bibtext> </blist> <blist> <bibtext> Zimmerman M. Screening for Bipolar Disorder and Finding Borderline Personality Disorder: A Replication and Extension. J Pers Disord. 2019; 33; 4: 533-543. 30036171. 10.1521/pedi_2018_32_357</bibtext> </blist> <blist> <bibtext> Mesbah R. Anger and cluster B personality traits and the conversion from unipolar depression to bipolar disorder. Depress Anxiety. 2021; 38; 6: 671-681. 33503287. 8248435. 10.1002/da.23137</bibtext> </blist> <blist> <bibtext> Carbone EA, et al. Antisocial Personality Disorder in Bipolar Disorder: A Systematic Review. Medicina (Kaunas). 2021:57(2).</bibtext> </blist> <blist> <bibtext> Parker G, Bayes A, Spoelma MJ. Why might bipolar disorder and borderline personality disorder be bonded?. J Psychiatr Res. 2022; 150: 214-218. 35397334. 10.1016/j.jpsychires.2022.03.051</bibtext> </blist> <blist> <bibtext> George EL. The comorbidity of bipolar disorder and axis II personality disorders: prevalence and clinical correlates. Bipolar Disord. 2003; 5; 2: 115-122. 12680901. 10.1034/j.1399-5618.2003.00028.x</bibtext> </blist> <blist> <bibtext> Bassett, D, Borderline personality disorder and bipolar affective disorder. Spectra or spectre? A review. Aust N Z J Psychiatry, 2012. 46(4): p. 327–39.</bibtext> </blist> <blist> <bibtext> 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: 401-407. 15521823. 10.1111/j.1600-0447.2004.00461.x</bibtext> </blist> <blist> <bibtext> Lieb K. Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials. Br J Psychiatry. 2010; 196; 1: 4-12. 20044651. 10.1192/bjp.bp.108.062984</bibtext> </blist> <blist> <bibtext> Stoffers, J.M, et al, Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev, 2012(8): p. CD005652.</bibtext> </blist> <blist> <bibtext> Clarkin JF. Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry. 2007; 164; 6: 922-928. 17541052. 10.1176/ajp.2007.164.6.922</bibtext> </blist> <blist> <bibtext> Doering, S, et al, Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial. Br J Psychiatry, 2010. 196(5): p. 389–95.</bibtext> </blist> <blist> <bibtext> Linehan MM. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry. 1991; 48; 12: 1060-1064. 1:STN:280:DyaK3s3ptVCquw%3D%3D. 1845222. 10.1001/archpsyc.1991.01810360024003</bibtext> </blist> <blist> <bibtext> Linehan MM. 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. 2006; 63; 7: 757-766. 16818865. 10.1001/archpsyc.63.7.757</bibtext> </blist> <blist> <bibtext> Giesen-Bloo J. Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Arch Gen Psychiatry. 2006; 63; 6: 649-658. 16754838. 10.1001/archpsyc.63.6.649</bibtext> </blist> <blist> <bibtext> Bateman A, Fonagy P. 8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual. Am J Psychiatry. 2008; 165; 5: 631-638. 18347003. 10.1176/appi.ajp.2007.07040636</bibtext> </blist> <blist> <bibtext> Bateman A, Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry. 2009; 166; 12: 1355-1364. 19833787. 10.1176/appi.ajp.2009.09040539</bibtext> </blist> <blist> <bibtext> Kernberg OF, Yeomans FE. Borderline personality disorder, bipolar disorder, depression, attention deficit/hyperactivity disorder, and narcissistic personality disorder: Practical differential diagnosis. Bull Menninger Clin. 2013; 77; 1: 1-22. 23428169. 10.1521/bumc.2013.77.1.1</bibtext> </blist> <blist> <bibtext> Bayes A, Parker G, Paris J. Differential Diagnosis of Bipolar II Disorder and Borderline Personality Disorder. Curr Psychiatry Rep. 2019; 21; 12: 125. 31749106. 10.1007/s11920-019-1120-2</bibtext> </blist> <blist> <bibtext> Fowler JC. Differentiating bipolar disorder from borderline personality disorder: Diagnostic accuracy of the difficulty in emotion regulation scale and personality inventory for DSM-5. J Affect Disord. 2019; 245: 856-860. 30699870. 10.1016/j.jad.2018.11.079</bibtext> </blist> <blist> <bibtext> Henriques-Calado J. In light of the DSM-5 dimensional model of personality: Borderline personality disorder at the crossroads with the bipolar spectrum. J Affect Disord. 2021; 294: 897-907. 34375218. 10.1016/j.jad.2021.07.047</bibtext> </blist> <blist> <bibtext> Wright L. Differential diagnosis of borderline personality disorder and bipolar disorder: Self-concept, identity and self-esteem. Clin Psychol Psychother. 2022; 29; 1: 26-61. 33811707. 10.1002/cpp.2591</bibtext> </blist> <blist> <bibtext> Kernberg OF. Severe Personality Disorders. 1984: New Haven; Yale University Press</bibtext> </blist> <blist> <bibtext> Kernberg OF. Object-Relations Theory and Clinical Psychoanalysis. 1976: New York; Jason Aronson</bibtext> </blist> <blist> <bibtext> Clarkin JF, Caligor E, Stern B, Kernberg OF. Structured interview of personality organization (STIPO). Unpublished Manuscript. New York: Personality Disorders Institute, Weill Medical College of Cornell University; 2004.</bibtext> </blist> <blist> <bibtext> Doering S. Reliability and validity of the German version of the Structured Interview of Personality Organization (STIPO). BMC Psychiatry. 2013; 13: 210. 23941404. 3751705. 10.1186/1471-244X-13-210</bibtext> </blist> <blist> <bibtext> APA, A.P.A. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, DC: American Psychiatric Association Publishing; 2013.</bibtext> </blist> <blist> <bibtext> WHO, W.H.O, International Classification of Diseases and Related Health Problems, 11th ed. WHO: Geneva, Switzerland, 2019. Available online: https://icd.who.int/.</bibtext> </blist> <blist> <bibtext> Bluml V, Doering S. ICD-11 Personality Disorders: A Psychodynamic Perspective on Personality Functioning. Front Psychiatry. 2021; 12. 33935839. 8085265. 10.3389/fpsyt.2021.654026</bibtext> </blist> <blist> <bibtext> Gruber, M.A, J; Doering, Feichtinger, K; Friedrich, F; Klauser, M; Hinterbuchinger, B; Litvan, Z; Mossaheb, N; Parth, K; Wininger, A; Blüml, V, Personality functioning and self-disorders in individuals at ultra-high risk for psychosis, with first-episode psychosis and with borderline personality disorder. BJPsych Open in press.</bibtext> </blist> <blist> <bibtext> Wittchen H, Zaudig M, Fydrich T. SKID-I: Strukturiertes Klinisches Interview für DSM-IV, Achse I. Göttingen: Hogrefe; 1997.</bibtext> </blist> <blist> <bibtext> Fydrich T, Renneberg B, Schmitz B, Wittchen H. Strukturiertes Klinisches Interview für DSM-IV, Achse II: Persönlichkeitsstörungen. Göttingen: Hogrefe; 1997.</bibtext> </blist> <blist> <bibtext> Franke R. BSI: Brief Symptom Inventory von Derogatis - Deutsche Version. Göttingen: Beltz; 2000.</bibtext> </blist> <blist> <bibtext> Kernberg OF. Structural interviewing. Psychiatr Clin North Am. 1981; 4; 1: 169-195. 1:STN:280:DyaL3M7pvFSntQ%3D%3D. 7232235. 10.1016/S0193-953X(18)30944-4</bibtext> </blist> <blist> <bibtext> Stern BL. Structured Interview of Personality Organization (STIPO): preliminary psychometrics in a clinical sample. J Pers Assess. 2010; 92; 1: 35-44. 20013454. 10.1080/00223890903379308</bibtext> </blist> <blist> <bibtext> Bender DS, Morey LC, Skodol AE. Toward a model for assessing level of personality functioning in DSM-5, part I: a review of theory and methods. J Pers Assess. 2011; 93; 4: 332-346. 22804672. 10.1080/00223891.2011.583808</bibtext> </blist> <blist> <bibtext> Bowles T. Book Review: Diagnostic and statistical manual of mental disorders. 20135: Canada.; American Psychiatric Association Publishing, Toronto</bibtext> </blist> <blist> <bibtext> Di Pierro, R, et al, The Level of Personality Functioning Scale Applied to Clinical Material From the Structured Interview of Personality Organization (STIPO): Utility in Detecting Personality Pathology. J Pers Disord, 2020: p. 1–15.</bibtext> </blist> <blist> <bibtext> Krueger RF. Initial construction of a maladaptive personality trait model and inventory for DSM-5. Psychol Med. 2012; 42; 9: 1879-1890. 1:STN:280:DC%2BC38zosFOgsQ%3D%3D. 22153017. 10.1017/S0033291711002674</bibtext> </blist> <blist> <bibtext> Quilty LC. The psychometric properties of the personality inventory for DSM-5 in an APA DSM-5 field trial sample. Assessment. 2013; 20; 3: 362-369. 23588687. 10.1177/1073191113486183</bibtext> </blist> <blist> <bibtext> Hyatt CS. Psychometric Properties of the Personality Inventory for DSM-5-Brief Form in a Community Sample with High Rates of Trauma Exposure. J Pers Assess. 2021; 103; 2: 204-213. 31995393. 10.1080/00223891.2020.1713138</bibtext> </blist> <blist> <bibtext> Derogatis LR, Lipman RS, Covi L. SCL-90: an outpatient psychiatric rating scale–preliminary report. Psychopharmacol Bull. 1973; 9; 1: 13-28. 1:STN:280:DyaE3s%2FmsFeqtA%3D%3D. 4682398</bibtext> </blist> <blist> <bibtext> Franke GH. Psychometric analysis of the brief symptom inventory 18 (BSI-18) in a representative German sample. BMC Med Res Methodol. 2017; 17; 1: 14. 28125960. 5270206. 10.1186/s12874-016-0283-3</bibtext> </blist> <blist> <bibtext> Johnson SL, Carver CS. Emotion-relevant impulsivity predicts sustained anger and aggression after remission in bipolar I disorder. J Affect Disord. 2016; 189: 169-175. 26437231. 10.1016/j.jad.2015.07.050</bibtext> </blist> <blist> <bibtext> Khalsa HK. Aggression among 216 patients with a first-psychotic episode of bipolar I disorder. Int J Bipolar Disord. 2018; 6; 1: 18. 30097737. 6161985. 10.1186/s40345-018-0126-8</bibtext> </blist> <blist> <bibtext> Zanarini MC, Frankenburg FR, Fitzmaurice G. Defense mechanisms reported by patients with borderline personality disorder and axis II comparison subjects over 16 years of prospective follow-up: description and prediction of recovery. Am J Psychiatry. 2013; 170; 1: 111-120. 23223866. 3537850. 10.1176/appi.ajp.2012.12020173</bibtext> </blist> <blist> <bibtext> Malone JC. Adaptive midlife defense mechanisms and late-life health. Pers Individ Dif. 2013; 55; 2: 85-89. 24031102. 3767455. 10.1016/j.paid.2013.01.025</bibtext> </blist> <blist> <bibtext> Bayes AJ. Differentiating the bipolar disorders from borderline personality disorder. Acta Psychiatr Scand. 2016; 133; 3: 187-195. 1:STN:280:DC%2BC283osVCitA%3D%3D. 26432099. 10.1111/acps.12509</bibtext> </blist> <blist> <bibtext> Allen TA. Negative affectivity and disinhibition as moderators of an interpersonal pathway to suicidal behavior in borderline personality disorder. Clin Psychol Sci. 2022; 10; 5: 856-868. 36172259. 9514132. 10.1177/21677026211056686</bibtext> </blist> <blist> <bibtext> Hanke N. Personality traits differentiate patients with bipolar disorder and healthy controls - A meta-analytic approach. J Affect Disord. 2022; 302: 401-411. 35041870. 10.1016/j.jad.2022.01.067</bibtext> </blist> <blist> <bibtext> Ferrer M. Clinical Components of Borderline Personality Disorder and Personality Functioning. Psychopathology. 2018; 51; 1: 57-64. 29393279. 10.1159/000486243</bibtext> </blist> <blist> <bibtext> Hörz S. Personality structure and clinical severity of borderline personality disorder. Z Psychosom Med Psychother. 2010; 56; 2: 136-149. 20623459</bibtext> </blist> <blist> <bibtext> Loftus ST, Jaeger J. Psychosocial outcome in bipolar I patients with a personality disorder. J Nerv Ment Dis. 2006; 194; 12: 967-970. 17164638. 10.1097/01.nmd.0000243814.35854.10</bibtext> </blist> <blist> <bibtext> Sparding T. Personality traits in bipolar disorder and influence on outcome. BMC Psychiatry. 2017; 17; 1: 159. 28468681. 5415752. 10.1186/s12888-017-1332-0</bibtext> </blist> <blist> <bibtext> Bieling PJ. Longitudinal outcome in patients with bipolar disorder assessed by life-charting is influenced by DSM-IV personality disorder symptoms. Bipolar Disord. 2003; 5; 1: 14-21. 12656933. 10.1034/j.1399-5618.2003.00014.x</bibtext> </blist> <blist> <bibtext> Latalova K. Comorbidity bipolar disorder and personality disorders. Neuro Endocrinol Lett. 2013; 34; 1: 1-8. 1:CAS:528:DC%2BC3sXmvFOgur0%3D. 23524617</bibtext> </blist> <blist> <bibtext> Caligor E. Object Relations Theory Model of Personality Disorders. Am J Psychother. 2023; 76; 1: 26-30. 36052452. 10.1176/appi.psychotherapy.20220027</bibtext> </blist> <blist> <bibtext> Burton CZ. Psychosis in bipolar disorder: Does it represent a more "severe" illness?. Bipolar Disord. 2018; 20; 1: 18-26. 28833984. 10.1111/bdi.12527</bibtext> </blist> <blist> <bibtext> Etzersdorfer, E.S, G, Psychoanalytische Überlegungen zur bipolaren affektiven Erkrankung- Neues seit Abraham? Georg Thieme Verlag- New York, 2002. 13: Sonderheft 1.</bibtext> </blist> <blist> <bibtext> Willick MS. Psychoanalytic concepts of the etiology of severe mental illness. J Am Psychoanal Assoc. 1990; 38; 4: 1049-1081. 1:STN:280:DyaK3M7jvFyqsQ%3D%3D. 2286739. 10.1177/000306519003800407</bibtext> </blist> <blist> <bibtext> Caligor E, Kernberg OF, Clarkin JF, Yeomans FE. Psychodynamic therapy for personality pathology: Treating self and interpersonal functioning. American Psychiatric Pub. 2018.</bibtext> </blist> <blist> <bibtext> Biskin RS. The Lifetime Course of Borderline Personality Disorder. Can J Psychiatry. 2015; 60; 7: 303-308. 26175388. 4500179. 10.1177/070674371506000702</bibtext> </blist> <blist> <bibtext> Videler AC. A Life Span Perspective on Borderline Personality Disorder. Curr Psychiatry Rep. 2019; 21; 7: 51. 31161404. 6546651. 10.1007/s11920-019-1040-1</bibtext> </blist> <blist> <bibtext> Roberts BW, Walton KE, Viechtbauer W. Patterns of mean-level change in personality traits across the life course: a meta-analysis of longitudinal studies. Psychol Bull. 2006; 132; 1: 1-25. 16435954. 10.1037/0033-2909.132.1.1</bibtext> </blist> <blist> <bibtext> Preti E. Using the Structured Interview of Personality Organization for DSM-5 Level of Personality Functioning Rating Performed by Inexperienced Raters. J Pers Assess. 2018; 100; 6: 621-629. 29617170. 10.1080/00223891.2018.1448985</bibtext> </blist> </ref> <aug> <p>By Karin Feichtinger; Clarissa Laczkovics; Johanna Alexopoulos; Maria Gruber; Miriam Klauser; Karoline Parth; Antonia Wininger; Michael Ossege; Josef Baumgartner; Stephan Doering and Victor Blüml</p> <p>Reported by Author; Author; Author; Author; Author; Author; Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib11" firstref="ref6"></nolink> <nolink nlid="nl2" bibid="bib12" firstref="ref7"></nolink> <nolink nlid="nl3" bibid="bib13" firstref="ref8"></nolink> <nolink nlid="nl4" bibid="bib14" firstref="ref9"></nolink> <nolink nlid="nl5" bibid="bib15" firstref="ref10"></nolink> <nolink nlid="nl6" bibid="bib17" firstref="ref11"></nolink> <nolink nlid="nl7" bibid="bib18" firstref="ref13"></nolink> <nolink nlid="nl8" bibid="bib20" firstref="ref15"></nolink> <nolink nlid="nl9" bibid="bib21" firstref="ref16"></nolink> <nolink nlid="nl10" bibid="bib22" firstref="ref17"></nolink> <nolink nlid="nl11" bibid="bib24" firstref="ref18"></nolink> <nolink nlid="nl12" bibid="bib26" firstref="ref19"></nolink> <nolink nlid="nl13" bibid="bib27" firstref="ref20"></nolink> <nolink nlid="nl14" bibid="bib29" firstref="ref22"></nolink> <nolink nlid="nl15" bibid="bib32" firstref="ref23"></nolink> <nolink nlid="nl16" bibid="bib33" firstref="ref24"></nolink> <nolink nlid="nl17" bibid="bib34" firstref="ref25"></nolink> <nolink nlid="nl18" bibid="bib36" firstref="ref29"></nolink> <nolink nlid="nl19" bibid="bib37" firstref="ref31"></nolink> <nolink nlid="nl20" bibid="bib38" firstref="ref33"></nolink> <nolink nlid="nl21" bibid="bib39" firstref="ref34"></nolink> <nolink nlid="nl22" bibid="bib40" firstref="ref35"></nolink> <nolink nlid="nl23" bibid="bib41" firstref="ref40"></nolink> <nolink nlid="nl24" bibid="bib42" firstref="ref41"></nolink> <nolink nlid="nl25" bibid="bib44" firstref="ref42"></nolink> <nolink nlid="nl26" bibid="bib45" firstref="ref44"></nolink> <nolink nlid="nl27" bibid="bib46" firstref="ref54"></nolink> <nolink nlid="nl28" bibid="bib47" firstref="ref55"></nolink> <nolink nlid="nl29" bibid="bib48" firstref="ref56"></nolink> <nolink nlid="nl30" bibid="bib49" firstref="ref57"></nolink> <nolink nlid="nl31" bibid="bib50" firstref="ref58"></nolink> <nolink nlid="nl32" bibid="bib51" firstref="ref60"></nolink> <nolink nlid="nl33" bibid="bib53" firstref="ref61"></nolink> <nolink nlid="nl34" bibid="bib54" firstref="ref62"></nolink> <nolink nlid="nl35" bibid="bib55" firstref="ref65"></nolink> <nolink nlid="nl36" bibid="bib57" firstref="ref76"></nolink> <nolink nlid="nl37" bibid="bib58" firstref="ref77"></nolink> <nolink nlid="nl38" bibid="bib59" firstref="ref80"></nolink> <nolink nlid="nl39" bibid="bib60" firstref="ref81"></nolink> <nolink nlid="nl40" bibid="bib61" firstref="ref82"></nolink> <nolink nlid="nl41" bibid="bib62" firstref="ref83"></nolink> <nolink nlid="nl42" bibid="bib64" firstref="ref84"></nolink> <nolink nlid="nl43" bibid="bib67" firstref="ref85"></nolink> <nolink nlid="nl44" bibid="bib68" firstref="ref87"></nolink> <nolink nlid="nl45" bibid="bib69" firstref="ref88"></nolink> <nolink nlid="nl46" bibid="bib70" firstref="ref89"></nolink> <nolink nlid="nl47" bibid="bib72" firstref="ref91"></nolink> <nolink nlid="nl48" bibid="bib73" firstref="ref92"></nolink> <nolink nlid="nl49" bibid="bib75" firstref="ref93"></nolink> <nolink nlid="nl50" bibid="bib76" firstref="ref94"></nolink>
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Items – Name: Title
  Label: Title
  Group: Ti
  Data: Personality functioning in bipolar 1 disorder and borderline personality disorder
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Karin+Feichtinger%22">Karin Feichtinger</searchLink><br /><searchLink fieldCode="AR" term="%22Clarissa+Laczkovics%22">Clarissa Laczkovics</searchLink><br /><searchLink fieldCode="AR" term="%22Johanna+Alexopoulos%22">Johanna Alexopoulos</searchLink><br /><searchLink fieldCode="AR" term="%22Maria+Gruber%22">Maria Gruber</searchLink><br /><searchLink fieldCode="AR" term="%22Miriam+Klauser%22">Miriam Klauser</searchLink><br /><searchLink fieldCode="AR" term="%22Karoline+Parth%22">Karoline Parth</searchLink><br /><searchLink fieldCode="AR" term="%22Antonia+Wininger%22">Antonia Wininger</searchLink><br /><searchLink fieldCode="AR" term="%22Michael+Ossege%22">Michael Ossege</searchLink><br /><searchLink fieldCode="AR" term="%22Josef+Baumgartner%22">Josef Baumgartner</searchLink><br /><searchLink fieldCode="AR" term="%22Stephan+Doering%22">Stephan Doering</searchLink><br /><searchLink fieldCode="AR" term="%22Victor+Blüml%22">Victor Blüml</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: BMC Psychiatry, Vol 24, Iss 1, Pp 1-8 (2024)
– Name: Publisher
  Label: Publisher Information
  Group: PubInfo
  Data: BMC, 2024.
– Name: DatePubCY
  Label: Publication Year
  Group: Date
  Data: 2024
– Name: Subset
  Label: Collection
  Group: HoldingsInfo
  Data: LCC:Psychiatry
– Name: Subject
  Label: Subject Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Bipolar+disorder%22">Bipolar disorder</searchLink><br /><searchLink fieldCode="DE" term="%22Borderline+personality+disorder%22">Borderline personality disorder</searchLink><br /><searchLink fieldCode="DE" term="%22Identity%22">Identity</searchLink><br /><searchLink fieldCode="DE" term="%22Personality+functioning%22">Personality functioning</searchLink><br /><searchLink fieldCode="DE" term="%22STIPO%22">STIPO</searchLink><br /><searchLink fieldCode="DE" term="%22Psychiatry%22">Psychiatry</searchLink><br /><searchLink fieldCode="DE" term="%22RC435-571%22">RC435-571</searchLink>
– Name: Abstract
  Label: Description
  Group: Ab
  Data: Abstract Background Differentiation of borderline personality disorder (BPD) and bipolar I disorder (BD) has been challenging. The assessment of shared symptoms in the context of the overall personality functioning, the patient’s sense of self, and the quality of his object (interpersonal) relations is proposed to be valuable for the differential diagnosis of these disorders. Methods We empirically investigated the level of personality organization (PO), identity integration, and quality of object relations in patients suffering from BD or BPD using the Structured Interview of Personality Organization (STIPO) and the Level of Personality Functioning Scale (LPFS) in 34 BPD and 28 BD patients as well as 27 healthy control persons. Group comparisons and a logistic regression model were calculated to analyze group differences. Results The BPD group showed significantly greater impairment in several domains of personality functioning, namely “identity”, and “self- and other-directed aggression”, while showing lower impairment in “moral values”. The overall level of PO in the BPD group was significantly lower when excluding not only BPD but any personality disorder (PD) in the BD sample. Severity of impaired personality structure had a major impact on symptom load independent of the main diagnosis BD or BPD. Conclusions Our data show greater impairment in personality functioning in BPD than in BD patients. BD patients present with varying levels of PO, whereas in BPD severe deficits in PO are pathognomonic. The level of PO has a significant impact on symptom severity in both BD and BPD patients. Therefore, careful assessment of PO should be considered for differential diagnosis and adequate treatment planning.
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  Data: English
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  Group: ISSN
  Data: 1471-244X
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  Data: https://doaj.org/toc/1471-244X
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1186/s12888-024-06297-8
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  Data: edsdoj.5dcf137561624dfbb67060dc08db1580
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    Identifiers:
      – Type: doi
        Value: 10.1186/s12888-024-06297-8
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 8
        StartPage: 1
    Subjects:
      – SubjectFull: Bipolar disorder
        Type: general
      – SubjectFull: Borderline personality disorder
        Type: general
      – SubjectFull: Identity
        Type: general
      – SubjectFull: Personality functioning
        Type: general
      – SubjectFull: STIPO
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      – TitleFull: Personality functioning in bipolar 1 disorder and borderline personality disorder
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              Y: 2024
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