Journal of Affective Disorders 245 (2019) 856–860

Contents lists available at ScienceDirect

Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

Differentiating bipolar disorder from borderline personality disorder: T

Diagnostic accuracy of the difficulty in emotion regulation scale and
personality inventory for DSM-5
⁎
J Christopher Fowlera, , Alok Madana, Jon G Allenb, John M Oldhamb, B Christopher Fruehc
a
Houston Methodist Behavioral Health, 6550 Fannin St Houston, TX 77030, United States
b
Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States
c
University of Hawaii, 200 West Kawili St., Hilo, HI 96720, United States

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Confusion abounds when differentiating the diagnoses of bipolar disorder (BD) from borderline
Bipolar disorder personality disorder (BPD). This study explored the relative clinical utility of affective instability and self-report
Borderline personality disorder personality trait measures for accurate identification of BD and BPD.
Diagnostic test Methods: Receiver operator characteristics and diagnostic efficiency statistics were calculated to ascertain the
Emotion dysregulation
relative diagnostic efficiency of self-report measures. Inpatients with research-confirmed diagnoses of BD
(n = 341) or BPD (n = 381) completed the Difficulty in Emotion Regulation Scale (DERS) and Personality
Inventory for DSM-5 (PID-5).
Results: The total score for DERS evidenced relatively poor accuracy for differentiating the disorders
(AUC = 0.72, SE = 0.02, p < .0001), while subscales of affective instability measures yielded fair discrimination
(AUC range = 0.70–0.59). The PID-5 BPD algorithm (consisting of emotional lability, anxiousness, separation
insecurity, hostility, depressivity, impulsivity, and risk taking) evidenced moderate-to-excellent accuracy
(AUC = 0.83, SE = 0.04, p < .0001) with a good balance of specificity (SP = 0.79) and sensitivity (SN = 0.77).
Conclusion: Findings support the use of the PID-5 algorithm for differentiating BD from BPD. Furthermore,
findings support the accuracy of the DSM-5 alternative model Criteria B trait constellation for differentiating
these two disorders with overlapping features.

The clinical features of bipolar disorder (BD) and borderline per-
sonality disorder (BPD) are easily confused for clinicians in the field.
The common feature of affective instability (AI), combined with the
difficulty of obtaining accurate information about duration and in-
tensity of episodes often makes differential diagnosis challenging and
leads to frequent misdiagnosis (Hirschfield et al., 2003). High co-
morbidity for BD and BPD has resulted in suggestions that BPD should
be considered a subtype of bipolar-spectrum disorder (Akiskal, 2004).
The search for actionable neuroimaging markers to differentiate the
disorders has yielded mixed results (see Paris & Black, 2015). However,
a recent genome wide association study (GWAS) yielded intriguing
results implicating several genes (genes coding for Plakophilin-4 on
chromosome 2 [PKP4], and dihydropyrimidine dehydrogenase on
chromosome 1 [DPYD]) that appear to be differentiate BPD from BD,
major depression and schizophrenia (Witt et al., 2017). While pro-
mising, the sample size was small for a GWAS study, and the author's
did not compute diagnostic efficiency statistics to identify the
sensitivity, specificity or odds ratios for the non-shared genetic influ-
ences in differentiating BPD from BD, major depression, or schizo-
phrenia. Future studies may yield new insights, but as of yet, the search
for genetic and neuroimaging features to differentiate the disorders thus
far have not yielded actionable biomarkers (Mazza et al., 2013; Phillips
& Kupfer, 2013).
Clinical experts in BPD (Paris & Black, 2015) argue that the BPD
pattern of brief episodes of affective instability driven by interpersonal
stressors (Russell et al., 2007) is distinctive from affective instability of
BD, in which mood swings tend to be of longer duration, are more
spontaneous, and less influenced by environmental stressors
(Konigsberg, 2010). In an attempt to differentiate DSM diagnosed BD
from BPD Bayes (Bayes et al., 2016) contrasted demographic, trauma
history, and specific details of mood episodes that were painstakingly
collected during research interviews with a research psychiatrist. The
results indicated that individuals with BPD were identified based on: 1.
positive for history of childhood sexual abuse, 2. childhood

⁎
Corresponding author.
E-mail address: jcfowler@houstonmethodist.org (J.C. Fowler).

https://doi.org/10.1016/j.jad.2018.11.079
Received 24 July 2018; Received in revised form 2 November 2018; Accepted 11 November 2018
Available online 13 November 2018
0165-0327/ © 2018 Elsevier B.V. All rights reserved.
J.C. Fowler et al.
depersonalization, 3. contemporary features of relationship difficulties,
4. sensitivity to rejection, and 5. a lower prevalence of bipolar disorder
among family members > This constellation of features constituted a
sensitive (SN = 83%) and specific (SP = 97%) algorithm for identifying
BPD. The major challenges for this study were the lack of generalization
for busy clinicians due to several factors: 1. The study excluded subjects
with co-occurring substance use disorders, which likely excludes up to
60% of patients in both groups, and 2. The time-intensive interviews
needed to gather historical data (such as childhood dissociation, family
history of BD).
A recent small scale study (Malhi et al., 2013) found that higher
scores on the difficulties in emotion regulation scale (DERS: Gratz and
Romer, 2004) was indicative of BPD (n = 13) diagnosis and lower
scores indicative of BD (n = 16) with approximately 90% accuracy. The
appeal of a simple and cost-efficient approach to differentiating BD
from BPD led the current authors to speculate that the DERS might be
an inexpensive and highly effective tool for differentiating the two
conditions. Further, the current authors speculated that the enduring
personality traits assessed by the Personality Inventory for DSM-5 (PID-
5: Krueger et al., 2012) and BPD algorithm (Fowler et al., 2018) also
might be a useful tool for differentiating between these disorders.
The current study investigates the possible diagnostic efficiency of
affective instability and personality trait facets, specifically the BPD
algorithm derived from the personality inventory for DSM-5
(Fowler et al., 2018) as a potent differentiator between the two dis-
orders. Given the prevalence estimates of 20% for co-occurring BPD/BD
(Frías et al., 2016) cases diagnosed with both disorders (n = 87) were
excluded. The authors utilized a well-characterized sample of adult
inpatients with research-confirmed diagnoses of bipolar disorder spec-
trum (n = 341) compared to a cohort of patients diagnosed with BPD
(n = 381). It was hypothesized that the BPD cohort would manifest
greater emotion dysregulation than the BD cohort due to the pervasive
and frequent episodic nature of their affective disruption. Further, the
PID-5 algorithm that differentiated BPD from a heterogeneous sample
of inpatients (Fowler et al., 2018) was hypothesized to differentiate BD
from BPD patients.
1. Methods
1.1. Participants
The sample consisted of 722 adult patients positive for either BD or
BPD consecutively admitted (July 2012–December 2017) to an in-
patient psychiatric hospital who completed research diagnostic inter-
views and baseline self-report measures. Gender distribution was rela-
tively even with 52.1% female. Average age was 27.8 years
(SD = 11.7). Participants were Caucasian (89.9%), multiracial (7.4%),
African American (0.5%), and Asian (2.1%); 7.3 percent identified as
being of Hispanic or Latino ethnicity. Education level was above the
national average with 86.3% indicating some college experience. The
majority (59.8%) of participants were not working in the 30 days prior
to admission.
1.2. Procedures
Data were collected as part of the hospital's ongoing Adult
Outcomes Project to assess treatment response. All measures used in the
current study were collected within 72 hours of admission. This project
was a hybrid clinical quality and research outcomes project, conducted
with all patients; accordingly, all assessments were designed and im-
plemented as an element of routine clinical care and integrated into
treatment planning and monitoring of progress such that less than 4%
of patients declined participation. Use of the project's data was ap-
proved by Baylor College of Medicine's Institutional Review Board.
857
Journal of Affective Disorders 245 (2019) 856–860
1.3. Measures
Demographic variables, history of psychiatric hospitalization, and
psychiatric service usage were assessed using a standardized patient
information survey (Fowler et al., 2015). Psychiatric disorders in-
cluding bipolar spectrum disorders were assessed using the research
version of the Structured Clinical Interview for DSM-IV Disorders
(First et al., 1997). Personality disorder diagnoses were assessed using
the research version of the Structured Clinical Interview for DSM-IV
Axis II Personality Disorders (First et al., 2002). Individual-level criteria
were coded as absent (0) or present (1) for Antisocial, Avoidant, Bor-
derline, Narcissistic, Obsessive-Compulsive, and Schizotypal with no
skip-outs (other PDs were not coded due to base-rates below 1% in the
hospital between 2010 and 2012). Master's level researchers conducted
all interviews and coded diagnoses after reviewing past psychiatric
history, collateral information from family, psychosocial assessment,
and nursing staff assessment. This process combined the ecologically
valid longitudinal evaluation of the “all available data” diagnostic ap-
proach (Pilkonis et al., 1991) with the rigorous research diagnostic
interviews. Several components of emotion regulation were monitored
throughout treatment using the Difficulties in Emotion Regulation Scale
(DERS: Gratz and Roemer, 2004). The DERS is a 36-item self-report
measure scored to produce an overall index of emotion dysregulation in
addition to six component scales: Nonacceptance of emotion responses
(range: 6 to 30); Difficulty engaging in goal directed behavior (range: 5
to 25); Impulse control difficulties (range: 6 to 30); Lack of emotional
awareness (range: 6 to 30); Limited access to emotion regulation stra-
tegies (range: 8 to 40); and Lack of emotional clarity (range: 5 to 25).
Total scores (range: 36 to 180) are calculated as the sum of individual
items with scores below 75 are indicative of normative functioning
(Gratz and Roemer, 2004). Research indicates strong psychometric
properties in both non-clinical (Gratz and Roemer, 2004) and inpatient
adult samples (Fowler et al., 2014). Internal consistencies of scales in
the current sample were high (α = 0.80 to 0.95). The PID-5
(Krueger et al., 2012) is 220-item dimensional measure comprised of 25
non-overlapping trait scales that load onto 5 higher-order dimensions
(negative affect, detachment, antagonism, disinhibition, and psychoti-
cism). Assessments of the clinical utility of the PID-5 indicated that trait
domains accounted for a substantial amount of variance in DSM-IV
personality disorder severity and are linked to DSM-IV personality
disorders (Few et al., 2013), and demonstrated incremental validity in
predicting DSM-IV PDs (Hopwood et al., 2012). The PID-5 was devel-
oped by members of the Diagnostic and Statistical Manual of Mental
Disorders Personality and Personality Disorders Work Group to map on
to personality disorders including BPD. The fifth edition of the Diag-
nostic and Statistical Manual of Mental Disorders (APA, 2013) included a
hybrid model for diagnosing personality disorders and several emerging
measures including the PID-5 (labeled the alternative model and lo-
cated in Section 3 “Emerging Measures and Models” of the manual).
According to the alternative model, elevations in traits of emotional
lability, anxiousness, separation insecurity, hostility, depressivity, im-
pulsivity, and risk taking are hypothesized to be predictive of BPD. The
above PID-5 constellation (summed average scores) was used in a re-
cent study to detect BPD among a large heterogeneous population of
adult patients and was found to manifest moderate to excellent pre-
diction of BPD (Fowler et al., 2018). The PID-5 yielded adequate in-
ternal consistency in the current sample (Cronbach's α = 0.98).
1.4. Data analysis
All analyses were conducted in IBM SPSS version 25.0. Descriptive
statistics and independent sample t-tests were performed to identify
potential differences between BD and BPD cohorts. Analysis of variance
was conducted to assess differences between groups on DERS Total
score, DERS subscales, and the PID-5 BPD algorithm. Receiver
Operating Characteristics (ROC) analyses were carried out (on the
J.C. Fowler et al. Journal of Affective Disorders 245 (2019) 856–860

variables yielding significant differences in the ANOVA models) to Table 2

obtain the area under the curve (AUC) and standard error (SE) using the Diagnostic efficiency statistics for variables differentiating bipolar from bor-
non-parametric method to assess the accuracy of the screening mea- derline personality disorder.
sures in differentiating BPD and BD diagnostic groups. Diagnostic effi- Measure SN SP PPP NPP OR
ciency statistics (Kessel and Zimmerman, 1993) were calculated for five
metrics: 1. Sensitivity (SN: the ability of a “positive” test result to Difficulty in Emotion Regulation (DERS)
Total Score ≥ 108 0.75 0.60 0.68 0.69 4.55
correctly identify BPD); 2. Specificity (SP: the ability of a “negative” test
Total Score ≥ 109 0.74 0.61 0.68 0.67 4.34
result to correctly identify those individuals without BPD); 3. Positive Impulse Control ≥ 14 0.85 0.37 0.59 0.69 3.24
predictive power (PPP: the probability that an individual has BPD when Impulse Control ≥ 15 0.78 0.47 0.61 0.66 3.03
the test result is “positive”); 4. Negative predictive power (NPP: the Strategies ≥ 24 0.80 0.47 0.61 0.68 3.42
Strategies ≥ 25 0.75 0.52 0.62 0.66 3.19
probability that an individual does not have BPD when the test result is
PID-5 BPD algorithm
“negative”); and 5. Odds Ratio (OR: the odds that BPD is predicted PID-5 ≥ 11 0.79 0.77 0.79 0.77 12.80
when the test result is “positive”, compared to the odds of diagnosing PID-5 ≥ 12 0.67 0.77 0.77 0.67 7.00
BPD when the test result is negative).
Note. SN = Sensitivity; SP = specificity; PPP = positive predictive power;
NPP = negative predictive power; OR = odds ratio; PID-5 BPD
2. Results
Algorithm = Personality Inventory for DSM 5 Borderline Personality Disorder
Algorithm
2.1. Descriptive statistics
p < .0001).
There were no significant differences in group composition for age,
gender, or racial composition. From the total sample, 90% of patients
2.3. Diagnostic efficiency statistics
were diagnosed with at least two co-occurring Axis I disorders with
average of 3.4 (SD = 1.6). The most prevalent disorders included sub-
Diagnostic efficiency statistics were calculated for 2 cut-points for
stance use disorders (72.6%), anxiety spectrum disorders (67.4%), and
each of the following: DERS Total, Impulse Control, Strategies, and PID-
major depressive disorders (MDD Spectrum = 47.4%).
5 BPD algorithm (variables with AUC ≥ . 70). Performance of the DERS
Total, Impulse Control and Strategies subscales (Table 2) indicated a
2.2. Analysis of variance and receiver operator characteristic (ROC) relatively poor balance between sensitivity and specificity with modest
analyses odds ratios. By contrast, results indicate scores ≥ 11 on the PID-5 BPD
algorithm increased the likelihood of the patient having BPD rather
The BPD group exhibited higher scores on all facets of the DERS as than BD. This cut-point provided a strong balance of sensitivity
well as the PID-5 BPD algorithm (Table 1), thus separate ROC analyses (SN = 79%), specificity (SP = 77%), and odds ratio (OR = 12.80),
were conducted for all variables. Area under the ROC curve indicated making the PID-5 algorithm a good screener for differentiating BD from
fair accuracy of the DERS Total (AUC = 0.72, SE = 0.02, p < .0001), BPD (Fig. 1).
Impulse control difficulties (AUC = 0.70, SE = 0.06, p < .0001), Lim-
ited access to emotion regulation strategies (AUC = 0.71, SE = 0.06,
3. Discussion
p < .0001), and poor accuracy for Nonacceptance of emotion responses
(AUC = 0.66, SE = 0.02, p < .0001), Difficulty engaging in goal di-
In light of the diagnostic challenges facing clinicians in the field, it is
rected behavior (AUC = 0.66, SE = 0.05, p < .0001), Lack of emotional
highly desirable to identify accurate and cost-effective self-report
awareness (AUC = 0.59, SE = 0.01, p < .0002), and Lack of emotional
screening measures that can aid in the differential diagnosis of bipolar
clarity (AUC = 0.65, SE = 0.02, p 0.0001). The PID-5 BPD algorithm
and borderline personality disorder. The implications of accurate dif-
evidenced good-to-excellent accuracy (AUC = 0.83, SE = 0.04,
ferential diagnosis and its impact on treatment selection is profound.
The primary treatment for bipolar disorder is a front-line mood stabi-
Table 1
lizer (Fountoulakis et al., 2005). Unmedicated bipolar disorder is as-
Bipolar and borderline personality disorder with effect sizes for between-group
sociated with more mood episodes, suicidal behavior and greater life-
comparisons.
time mood instability (Drancourt et al., 2013). By contrast
Bipolar Borderline ES psychotherapy, augmented by pharmacotherapy is the treatment of
N 341 381
choice (Oldham, 2005).
Gender (% female) 43.6 58.1 .29 To date, no genetic, imaging, or blood tests have reached the level of
Age 34.1 (14.2) 28.5 (11.2) .44 an actionable biomarker to differentiate BD from BPD (Paris and
Prior hospitalization (%) 79.4 74.7 .11 Black, 2015). In psychiatric emergency departments and outpatient
Race (% minority) 12.4 10.3 .08
clinics, relatively accurate screening tests such as the PID-5 BPD algo-
Married (%) 43.3 26.8 .39
ETOH/Substance Use (%) 62.4 73.2 .23 rithm could be used to aid in the differential diagnosis for individuals
Trauma history (%) 80.2 88.1 .25 presenting with overlapping symptoms and questionable historical ac-
DERS total 100.31 (27.74) 121.37 (22.07) .85 curacy of mood symptoms. The current results indicate that the PID-5
- Nonacceptance 16.15 (6.88) 19.99 (6.72) .57 BPD algorithm provided a good balance of specificity, sensitivity, and
- Goal directed behavior 17.16 (5.08) 19.83 (4.18) .58
- Impulse control 15.37 (6.02) 19.65 (5.72) .73
odds ratio. The diagnostic accuracy of the PID-5 BPD algorithm extends
- Strategies 22.50 (8.31) 28.42 (6.63) .29 the clinical validity and utility of the PID-5, and supports the alternative
- Emotional clarity 13.77 (5.36) 15.11 (5.77) .52 model characterization of BPD. The present findings also suggest that,
- Awareness 16.26 (5.56) 18.02 (5.52) .32 outside of the constellation of relevant personality-disorder traits, a
PID-5 BPD algorithm 8.08 (3.46) 12.50 (2.73) 1.43
self-report measure of affective instability is of limited value for dif-
Note: DERS = Difficulties in Emotion Regulation Scale; ferential diagnosis.
PID-5 BPD Algorithm = Personality inventory for DSM 5 borderline personality In order to contextualize the relative accuracy of this algorithm, we
disorder algorithm provide a comparison with a selection of psychiatric and general
Effects sizes (ES) are given as Cohen's d (small = 0.20, medium = 0.50, medical screening tests (Table 3). The PID-5 BPD algorithm's accuracy
large = 0.80) was within range but less effective than the Patient Health

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J.C. Fowler et al. Journal of Affective Disorders 245 (2019) 856–860

Fig. 1. Receiver operator characteristics differentiating bipolar spectrum disorders from borderline personality disorder.

Table 3 reported kappa values fit into the classification of “weak”

Diagnostic and screening characteristics of medical tests. (McHugh, 2012) for Bipolar disorder (kappa = 0.56) and “minimal” for
Test Sensitivity Specificity
BPD (kappa = 0.34) based on results from the DSM-5 field trial
(Regier et al., 2013).
Psychiatric screening measures While the current findings hold considerable promise for improving
PID-5 BPD algorithm for BD vs. BPD 0.79 0.77 diagnostic accuracy for differentiating BD from BPD, there is no sub-
PHQ-9 for predicting treatment-resistant depression: 0.85 0.73
stitute for a thorough interview of the patient and close informants
J.C. Fowler et al. (2015)
PHQ-9 for depression: Kroenke et al. (2001) 0.88 0.88 (Paris and Black, 2015; Phillips and Kupfer, 2013). Several notable
GAD-7 for Anxiety: Spitzer et al. (2006) 0.89 0.82 limitations of the study design bear mention: 1. Results may not gen-
Other Medical Tests eralize to more heterogeneous community samples, 2. Screening in-
urine dipsticks for UTI: Deville et al. (2004) Meta- 0.62 0.70
struments were limited to two self-report measures, and there are nu-
analysis of 35 studies
Multi-Test II in assessing timothy grass allergy: 0.87 0.86
merous measures that might yield comparable or better diagnostic
Krouse et al. (2004) properties.
Rapid tests for human influenza: Hurt et al. (2007) 0.67–0.71 0.99 – 1.0
PPD for tuberculosis: Rose et al. (1995) 0.59 0.95 - 1.0
Mammography for breast cancer: Kolb et al. (2002) 0.78 0.99 Conflicts of interest
Rapid HIV tests Branson (2005)
OraQuick Avance (whole blood) 0.996 1.0
Uni-Gold Recombigen (whole blood) 1.0 0.997 The authors have no financial interests to disclose.
Reveal G2 (serum) 0.998 0.991
Multispot (serum/plasma) 1.0 0.999
Author disclosure

Questionnaires for Depression (PHQ-9: Kroenke et al., 2001; Fowler Funding

et al., 2015) and anxiety (GAD-7: Spitzer et al., 2006). Compared to
urine dipstick test for urinary tract infection (Deville et al., 2004), the
Multi-Test II in screening for timothy grass allergy (Krouse et al.,
2004)], and the rapid tests for human influenza (Hurt et al., 2007), the
PID-5 BPD algorithm demonstrated superior screening characteristics,
but were inferior to mammography for detecting breast cancer
(Kolb et al., 2002) and blood tests for detecting HIV infection
(Branson, 2005). While promising, it is clear that BD-BPD screening
falls substantially short of the gold standard of the blood tests for HIV
and can be substantially improved. A rate-limiting factor that impedes
progress in advancing BD-BPD screening is the fact that the reliability of
bipolar spectrum and BPD diagnosis is far from optimal. For example,
This research was partially supported by the McNair Medical
Institute, Cullen Foundation, Brown Foundation, and Menninger Clinic
Foundation. At the time of study design and data collection Dr. Oldham
held the Barbara and Corbin Robertson Jr. Endowed Chair for
Personality Disorders, Drs. Madan and Frueh were McNair Scholars.
The study follows the guidelines on good publication practices. The
study sponsors were not involved in any aspect of the research activities
and did not approve the specific protocol or manuscript. Thus, the
authors were independent from study sponsors in the context of the
research. Drs. Fowler, Madan, Allen, Oldham, and Frueh have no con-
flicts of interest to report.

859
J.C. Fowler et al.
Acknowledgements
We thank the individuals who participated in this study. We also
thank Steve Herrera, Herman Adler, Anika Wiltgin, Ryan Smith, Chris
Frazier, Chris Shepard, and Kirk Booker for data collection and pro-
cessing.
Contributions
Drs. Fowler, Madan, Allen, Oldham, and Frueh designed the large-
scale study from which the data was drawn. Drs. Fowler, Madan, and
Frueh designed the current study. Dr. Fowler conducted the statistical
analyses and wrote the draft. Drs. Madan, Allen, Oldham, and Frueh
added substantial elements to the final draft.
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