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Patients with borderline personality disorder and bipolar disorder: a descriptive and comparative study

Published online by Cambridge University Press:  17 March 2020

Mark Zimmerman Open the ORCID record for Mark Zimmerman [Opens in a new window] ,
Caroline Balling ,
Iwona Chelminski  and
Kristy Dalrymple
Mark Zimmerman*
Affiliation:
Department of Psychiatry and Human Behavior, Brown Medical School, Rhode Island Hospital, Providence, RI, USA
Caroline Balling
Affiliation:
Department of Psychiatry and Human Behavior, Brown Medical School, Rhode Island Hospital, Providence, RI, USA
Iwona Chelminski
Affiliation:
Department of Psychiatry and Human Behavior, Brown Medical School, Rhode Island Hospital, Providence, RI, USA
Kristy Dalrymple
Affiliation:
Department of Psychiatry and Human Behavior, Brown Medical School, Rhode Island Hospital, Providence, RI, USA
*
Author for correspondence: Mark Zimmerman, E-mail: mzimmerman@lifespan.org
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Abstract

Background

Bipolar disorder and borderline personality disorder (BPD) are each significant public health problems. It has been frequently noted that distinguishing BPD from bipolar disorder is challenging. Consequently, reviews and commentaries have focused on differential diagnosis and identifying clinical features to distinguish the two disorders. While there is a burgeoning literature comparing patients with BPD and bipolar disorder, much less research has characterized patients with both disorders. In the current report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compare psychiatric outpatients with both BPD and bipolar disorder to patients with BPD without bipolar disorder and patients with bipolar disorder without BPD.

Methods

Psychiatric outpatients presenting for treatment were evaluated with semi-structured interviews. The focus of the current study is the 517 patients with both BPD and bipolar disorder (n = 59), BPD without bipolar disorder (n = 330), and bipolar disorder without BPD (n = 128).

Results

Compared to patients with bipolar disorder, the patients with bipolar disorder and BPD had more comorbid disorders, psychopathology in their first-degree relatives, childhood trauma, suicidality, hospitalizations, time unemployed, and likelihood of receiving disability payments. The added presence of bipolar disorder in patients with BPD was associated with more posttraumatic stress disorder in the patients as well as their family, more bipolar disorder and substance use disorders in their relatives, more childhood trauma, unemployment, disability, suicide attempts, and hospitalizations.

Conclusions

Patients with both bipolar disorder and BPD have more severe psychosocial morbidity than patients with only one of these disorders.

Keywords

Bipolar disorderborderline personality disordercomorbidity
Type
Original Articles
Information
Psychological Medicine , Volume 51 , Issue 9 , July 2021 , pp. 1479 - 1490
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Copyright
Copyright © The Author(s) 2020. Published by Cambridge University Press

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References

Agius, M., Lee, J., Gardner, J., & Wotherspoon, D. (2012). Bipolar II disorder and borderline personality disorder – Co-morbidity or spectrum? Psychiatria Danubina, 24(Suppl 1), S197–S201.Google ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.Google ScholarPubMed
Angst, J., Azorin, J. M., Bowden, C. L., Perugi, G., Vieta, E., Gamma, A., & Young, A. H. (2011). Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode: The BRIDGE study. Archives of General Psychiatry, 68, 791–798.CrossRefGoogle ScholarPubMed
Angst, J., Gamma, A., Benazzi, F., Ajdacic, V., Eich, D., & Rossler, W. (2003). Toward a re-definition of subthreshold bipolarity: Epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania. Journal of Affective Disorders, 73, 133–146.CrossRefGoogle Scholar
Baldessarini, R. J., Pompili, M., & Tondo, L. (2006). Suicide in bipolar disorder: Risks and management. CNS Spectrums, 11, 465–471.CrossRefGoogle ScholarPubMed
Bassett, D., Mulder, R., Outhred, T., Hamilton, A., Morris, G., Das, P., … Malhi, G. S. (2017). Defining disorders with permeable borders: You say bipolar, I say borderline!. Bipolar Disorders, 19, 320–323.CrossRefGoogle ScholarPubMed
Bayes, A., Graham, R. K., Parker, G. B., & McCraw, S. (2018). Is ‘subthreshold’ bipolar II disorder more difficult to differentiate from borderline personality disorder than formal bipolar II disorder? Psychiatry Research, 264, 416–420.CrossRefGoogle ScholarPubMed
Bayes, A., Parker, G., & Fletcher, K. (2014). Clinical differentiation of bipolar II disorder from borderline personality disorder. Current Opinion in Psychiatry, 27, 14–20.CrossRefGoogle ScholarPubMed
Bayes, A., Parker, G., & McClure, G. (2016a). Emotional dysregulation in those with bipolar disorder, borderline personality disorder and their comorbid expression. Journal of Affective Disorders, 204, 103–111.CrossRefGoogle Scholar
Bayes, A. J., McClure, G., Fletcher, K., Roman Ruiz Del Moral, Y. E., Hadzi-Pavlovic, D., Stevenson, J. L., … Parker, G. B. (2016b). Differentiating the bipolar disorders from borderline personality disorder. Acta Psychiatrica Scandinavica, 133, 187–195.CrossRefGoogle Scholar
Bayes, A. J., & Parker, G. B. (2016). Clinical vs. DSM diagnosis of bipolar disorder, borderline personality disorder and their co-occurrence. Acta Psychiatrica Scandinavica, 135, 259–265.CrossRefGoogle ScholarPubMed
Benazzi, F. (2007). Testing predictors of bipolar-II disorder with a 2-day minimum duration of hypomania. Psychiatry Research, 153, 153–162.CrossRefGoogle ScholarPubMed
Bender, D. S., Dolan, R. T., Skodol, A. E., Sanislow, C. A., Dyck, I. R., McGlashan, T. H., … Gunderson, J. G. (2001). Treatment utilization by patients with personality disorders. American Journal of Psychiatry, 158, 295–302.CrossRefGoogle ScholarPubMed
Bernstein, D. P., Fink, L., Handelsman, L., Foote, J., Lovejoy, M., Wenzel, K., … Ruggiero, J. (1994). Initial reliability and validity of a new retrospective measure of child abuse and neglect. American Journal of Psychiatry, 151, 1132–1136.Google ScholarPubMed
Boen, E., Hjornevik, T., Hummelen, B., Elvsashagen, T., Moberget, T., Holtedahl, J. E., … Malt, U. F. (2019). Patterns of altered regional brain glucose metabolism in borderline personality disorder and bipolar II disorder. Acta Psychiatrica Scandinavica, 139, 256–268.Google ScholarPubMed
Bowden, C. L. (2001). Strategies to reduce misdiagnosis of bipolar depression. Psychiatric Services, 52, 51–55.CrossRefGoogle ScholarPubMed
Bryant-Comstock, L., Stender, M., & Devercelli, G. (2002). Health care utilization and costs among privately insured patients with bipolar I disorder. Bipolar Disorders, 4, 398–405.CrossRefGoogle ScholarPubMed
Carpiniello, B., Lai, L., Pirarba, S., Sardu, C., & Pinna, F. (2011). Impulsivity and aggressiveness in bipolar disorder with co-morbid borderline personality disorder. Psychiatry Research, 188, 40–44.CrossRefGoogle ScholarPubMed
Carvalho, A. F., Takwoingi, Y., Sales, P. M., Soczynska, J. K., Kohler, C. A., Freitas, T. H., … Vieta, E. (2015). Screening for bipolar spectrum disorders: A comprehensive meta-analysis of accuracy studies. Journal of Affective Disorders, 172, 337–346.CrossRefGoogle ScholarPubMed
Coulston, C. M., Tanious, M., Mulder, R. T., Porter, R. J., & Malhi, G. S. (2012). Bordering on bipolar: The overlap between borderline personality and bipolarity. Australian and New Zealand Journal of Psychiatry, 46, 506–521.CrossRefGoogle ScholarPubMed
Das, P., Calhoun, V., & Malhi, G. S. (2014). Bipolar and borderline patients display differential patterns of functional connectivity among resting state networks. Neuroimage, 98, 73–81.CrossRefGoogle ScholarPubMed
Deltito, J., Martin, L., Riefkohl, J., Austria, B., Kissilenko, A., Corless, P., & Morse, C. (2001). Do patients with borderline personality disorder belong to the bipolar spectrum? Journal of Affective Disorders, 67, 221–228.CrossRefGoogle ScholarPubMed
Di Florio, A., Craddock, N., & van den Bree, M. (2014). Alcohol misuse in bipolar disorder. A systematic review and meta-analysis of comorbidity rates. European Psychiatry, 29, 117–124.CrossRefGoogle ScholarPubMed
Dunner, D. L. (2003). Clinical consequences of under-recognized bipolar spectrum disorder. Bipolar Disorders, 5, 456–463.CrossRefGoogle ScholarPubMed
Eich, D., Gamma, A., Malti, T., Vogt Wehrli, M., Liebrenz, M., Seifritz, E., & Modestin, J. (2014). Temperamental differences between bipolar disorder, borderline personality disorder, and attention deficit/hyperactivity disorder: Some implications for their diagnostic validity. Journal of Affective Disorders, 169, 101–104.CrossRefGoogle ScholarPubMed
Endicott, J., Andreasen, N., & Spitzer, R. L. (1978). Family history research diagnostic criteria (3rd ed.). New York: Biometrics Research, New York State Psychiatric Institute.Google Scholar
Endicott, J., & Spitzer, R. L. (1978). A diagnostic interview: The schedule for affective disorders and schizophrenia. Archives of General Psychiatry, 35, 837–844.CrossRefGoogle Scholar
Farren, C. K., Hill, K. P., & Weiss, R. D. (2012). Bipolar disorder and alcohol use disorder: A review. Current Psychiatry Reports, 14, 659–666.CrossRefGoogle ScholarPubMed
Feliu-Soler, A., Soler, J., Elices, M., Pascual, J. C., Perez, J., Martin-Blanco, A., … Portella, M. J. (2013). Differences in attention and impulsivity between borderline personality disorder and bipolar disorder. Psychiatry Research, 210, 1307–1309.CrossRefGoogle ScholarPubMed
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1995). Structured clinical interview for DSM-IV axis I disorders – Patient edition (SCID-I/P, version 2.0). New York: Biometrics Research Department, New York State Psychiatric Institute.Google Scholar
Fletcher, K., Parker, G., Bayes, A., Paterson, A., & McClure, G. (2014). Emotion regulation strategies in bipolar II disorder and borderline personality disorder: Differences and relationships with perceived parental style. Journal of Affective Disorders, 157, 52–59.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
Frankenburg, F. R., & Zanarini, M. C. (2002). Divalproex sodium treatment of women with borderline personality disorder and bipolar II disorder: A double-blind placebo-controlled pilot study. Journal of Clinical Psychiatry, 63, 442–446.CrossRefGoogle ScholarPubMed
Frias, A., Baltasar, I., & Birmaher, B. (2016). Comorbidity between bipolar disorder and borderline personality disorder: Prevalence, explanatory theories, and clinical impact. Journal of Affective Disorders, 202, 210–219.CrossRefGoogle ScholarPubMed
Galfalvy, H., Oquendo, M. A., Carballo, J. J., Sher, L., Grunebaum, M. F., Burke, A., & Mann, J. J. (2006). Clinical predictors of suicidal acts after major depression in bipolar disorder: A prospective study. Bipolar Disorders, 8, 586–595.CrossRefGoogle ScholarPubMed
Galione, J., & Zimmerman, M. (2010). A comparison of depressed patients with and without borderline personality disorder: Implications for interpreting studies of the validity of the bipolar spectrum. Journal of Personality Disorders, 24, 763–772.CrossRefGoogle ScholarPubMed
Ghaemi, S., Sachs, G., Chiou, A., Pandurangi, A., & Goodwin, F. (1999). Is bipolar disorder still underdiagnosed? Are antidepressants overutilized? Journal of Affective Disorders, 52, 135–144.CrossRefGoogle ScholarPubMed
Ghaemi, S. N., Dalley, S., Catania, C., & Barroilhet, S. (2014). Bipolar or borderline: A clinical overview. Acta Psychiatrica Scandinavica, 130, 99–108.CrossRefGoogle ScholarPubMed
Goldberg, J. F., & Garno, J. L. (2009). Age at onset of bipolar disorder and risk for comorbid borderline personality disorder. Bipolar Disorders, 11, 205–208.CrossRefGoogle ScholarPubMed
Goodman, G., Hull, J. W., Clarkin, J. F., & Yeomans, F. E. (1998). Comorbid mood disorders as modifiers of treatment response among inpatients with borderline personality disorder. Journal of Nervous and Mental Disease, 186, 616–622.CrossRefGoogle ScholarPubMed
Gunderson, J. G., Weinberg, I., Daversa, M. T., Kueppenbender, K. D., Zanarini, M. C., Shea, M. T., … Dyck, I. (2006). Descriptive and longitudinal observations on the relationship of borderline personality disorder and bipolar disorder. American Journal of Psychiatry, 163, 1173–1178.CrossRefGoogle ScholarPubMed
Guy, W. (1976). ECDEU assessment manual for psychopharmacology. Rockville, MD: National Institute of Mental Health.Google Scholar
Gvirts, H. Z., Braw, Y., Harari, H., Lozin, M., Bloch, Y., Fefer, K., & Levkovitz, Y. (2015). Executive dysfunction in bipolar disorder and borderline personality disorder. European Psychiatry, 30, 959–964.CrossRefGoogle ScholarPubMed
Henry, C., Mitropoulou, V., New, A. S., Koenigsberg, H. W., Silverman, J., & Siever, L. J. (2001). Affective instability and impulsivity in borderline personality and bipolar II disorders: Similarities and differences. Journal of Psychiatric Research, 35, 307–312.CrossRefGoogle ScholarPubMed
Hirschfeld, R. M., & Vornik, L. A. (2004). Recognition and diagnosis of bipolar disorder. Journal of Clinical Psychiatry, 65(Suppl 15), 5–9.Google ScholarPubMed
Joyce, P. R., Light, K. J., Rowe, S. L., Cloninger, C. R., & Kennedy, M. A. (2010). Self-mutilation and suicide attempts: Relationships to bipolar disorder, borderline personality disorder, temperament and character. Australian and New Zealand Journal of Psychiatry, 44, 250–257.CrossRefGoogle ScholarPubMed
Kessler, R. C., Akiskal, H. S., Ames, M., Birnbaum, H., Greenberg, P., Hirschfeld, R. M., … Wang, P. S. (2006). Prevalence and effects of mood disorders on work performance in a nationally representative sample of U.S. workers. American Journal of Psychiatry, 163, 1561–1568.CrossRefGoogle Scholar
Ketter, T. A. (2011). Strategies for the early recognition of bipolar disorder. Journal of Clinical Psychiatry, 72, e22.CrossRefGoogle ScholarPubMed
Magill, C. (2004). The boundary between borderline personality disorder and bipolar disorder: Current concepts and challenges. Canadian Journal of Psychiatry, 49, 551–556.CrossRefGoogle ScholarPubMed
Malhi, G. S., Tanious, M., Fritz, K., Coulston, C. M., Bargh, D. M., Phan, K. L., … Das, P. (2013). Differential engagement of the fronto-limbic network during emotion processing distinguishes bipolar and borderline personality disorder. Molecular Psychiatry, 18, 1247–1248.CrossRefGoogle ScholarPubMed
Mazer, A. K., Cleare, A. J., Young, A. H., & Juruena, M. F. (2019). Bipolar affective disorder and borderline personality disorder: Differentiation based on the history of early life stress and psychoneuroendocrine measures. Behavioural Brain Research, 357–358, 48–56.CrossRefGoogle ScholarPubMed
McDermid, J., & McDermid, R. C. (2016). The complexity of bipolar and borderline personality: An expression of ‘emotional frailty’? Current Opinion in Psychiatry, 29, 84–88.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
McIntyre, R. S. (2014). Improving the early recognition and diagnosis of bipolar disorder. Journal of Clinical Psychiatry, 75, e03.CrossRefGoogle Scholar
Miller, P. R., Dasher, R., Collins, R., Griffiths, P., & Brown, F. (2001). Inpatient diagnostic assessments: 1. Accuracy of structured vs. unstructured interviews. Psychiatry Research, 105, 255–264.CrossRefGoogle ScholarPubMed
Mneimne, M., Fleeson, W., Arnold, E. M., & Furr, R. M. (2018). Differentiating the everyday emotion dynamics of borderline personality disorder from major depressive disorder and bipolar disorder. Personality Disorders, 9, 192–196.CrossRefGoogle ScholarPubMed
Morey, L. C., Shea, M. T., Markowitz, J. C., Stout, R. L., Hopwood, C. J., Gunderson, J. G., … Skodol, A. E. (2010). State effects of major depression on the assessment of personality and personality disorder. American Journal of Psychiatry, 167, 528–535.CrossRefGoogle ScholarPubMed
Morgan, V. A., Mitchell, P. B., & Jablensky, A. V. (2005). The epidemiology of bipolar disorder: Sociodemographic, disability and service utilization data from the Australian National Study of Low Prevalence (Psychotic) Disorders. Bipolar Disorders, 7, 326–337.CrossRefGoogle ScholarPubMed
Neves, F. S., Malloy-Diniz, L. F., & Correa, H. (2009). Suicidal behavior in bipolar disorder: What is the influence of psychiatric comorbidities? Journal of Clinical Psychiatry, 70, 13–18.CrossRefGoogle ScholarPubMed
Nilsson, A. K., Jorgensen, C. R., Straarup, K. N., & Licht, R. W. (2010). Severity of affective temperament and maladaptive self-schemas differentiate borderline patients, bipolar patients, and controls. Comprehensive Psychiatry, 51, 486–491.CrossRefGoogle ScholarPubMed
Novick, D. M., Swartz, H. A., & Frank, E. (2010). Suicide attempts in bipolar I and bipolar II disorder: A review and meta-analysis of the evidence. Bipolar Disorders, 12, 1–9.CrossRefGoogle Scholar
Oldham, J. M. (2006). Borderline personality disorder and suicidality. American Journal of Psychiatry, 163, 20–26.CrossRefGoogle ScholarPubMed
Paris, J. (2004). Borderline or bipolar? Distinguishing borderline personality disorder from bipolar spectrum disorders. Harvard Review of Psychiatry, 12, 140–145.CrossRefGoogle ScholarPubMed
Paris, J. (2018). Differential diagnosis of borderline personality disorder. Psychiatric Clinics of North America, 41, 575–582.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
Paris, J., Gunderson, J., & Weinberg, I. (2007). The interface between borderline personality disorder and bipolar spectrum disorders. Comprehensive Psychiatry, 48, 145–154.CrossRefGoogle ScholarPubMed
Parker, G. (2014). Is borderline personality disorder a mood disorder? British Journal of Psychiatry, 204, 252–253.CrossRefGoogle ScholarPubMed
Parker, G. (2015). Borderline personality disorder and bipolar disorder: Commentary on Paris and Black. Journal of Nervous and Mental Disease, 203, 13–14.CrossRefGoogle ScholarPubMed
Parker, G., Bayes, A., McClure, G., Del Moral, Y. R., & Stevenson, J. (2016). Clinical status of comorbid bipolar disorder and borderline personality disorder. British Journal of Psychiatry, 209, 209–215.CrossRefGoogle ScholarPubMed
Perroud, N., Zewdie, S., Stenz, L., Adouan, W., Bavamian, S., Prada, P., … Dayer, A. (2016). Methylation of serotonin receptor 3a in ADHD, borderline personality, and bipolar disorders: Link with severity of the disorders and childhood maltreatment. Depression and Anxiety, 33, 45–55.CrossRefGoogle ScholarPubMed
Perugi, G., Angst, J., Azorin, J. M., Bowden, C., Vieta, E., & Young, A. H. (2013). Is comorbid borderline personality disorder in patients with major depressive episode and bipolarity a developmental subtype? Findings from the international BRIDGE study. Journal of Affective Disorders, 144, 72–78.CrossRefGoogle ScholarPubMed
Perugi, G., Toni, C., Travierso, M. C., & Akiskal, H. S. (2003). The role of cyclothymia in atypical depression: Toward a data-based reconceptualization of the borderline-bipolar II connection. Journal of Affective Disorders, 73, 87–98.CrossRefGoogle Scholar
Pfohl, B., Blum, N., & Zimmerman, M. (1997). Structured interview for DSM-IV personality. Washington, DC: American Psychiatric Press, Inc.Google Scholar
Pompili, M., Girardi, P., Ruberto, A., & Tatarelli, R. (2005). Suicide in borderline personality disorder: A meta-analysis. Nordic Journal of Psychiatry, 59, 319–324.CrossRefGoogle ScholarPubMed
Preston, G. A., Marchant, B. K., Reimherr, F. W., Strong, R. E., & Hedges, D. W. (2004). Borderline personality disorder in patients with bipolar disorder and response to lamotrigine. Journal of Affective Disorders, 79, 297–303.CrossRefGoogle ScholarPubMed
Radaelli, D., Poletti, S., Dallaspezia, S., Colombo, C., Smeraldi, E., & Benedetti, F. (2012). Neural responses to emotional stimuli in comorbid borderline personality disorder and bipolar depression. Psychiatry Research, 203, 61–66.CrossRefGoogle ScholarPubMed
Reich, D. B., Zanarini, M. C., & Fitzmaurice, G. (2012). Affective lability in bipolar disorder and borderline personality disorder. Comprehensive Psychiatry, 53, 230–237.CrossRefGoogle ScholarPubMed
Richard-Lepouriel, H., Kung, A. L., Hasler, R., Bellivier, F., Prada, P., Gard, S., … Etain, B. (2019). Impulsivity and its association with childhood trauma experiences across bipolar disorder, attention deficit hyperactivity disorder and borderline personality disorder. Journal of Affective Disorders, 244, 33–41.CrossRefGoogle ScholarPubMed
Riemann, G., Weisscher, N., Goossens, P. J., Draijer, N., Apenhorst-Hol, M., & Kupka, R. W. (2014). The addition of STEPPS in the treatment of patients with bipolar disorder and comorbid borderline personality features: A protocol for a randomized controlled trial. BMC Psychiatry, 14, 172.CrossRefGoogle ScholarPubMed
Rossi, R., Lanfredi, M., Pievani, M., Boccardi, M., Beneduce, R., Rillosi, L., … Frisoni, G. B. (2012). Volumetric and topographic differences in hippocampal subdivisions in borderline personality and bipolar disorders. Psychiatry Research, 203, 132–138.CrossRefGoogle ScholarPubMed
Shear, M. K., Greeno, C., Kang, J., Ludewig, D., Frank, E., Swartz, H. A., & Hanekamp, M. (2000). Diagnosis of nonpsychotic patients in community clinics. American Journal of Psychiatry, 157, 581–587.CrossRefGoogle ScholarPubMed
Skodol, A. E., Gunderson, J. G., McGlashan, T. H., Dyck, I. R., Stout, R. L., Bender, D. S., … Oldham, J. M. (2002). Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder. American Journal of Psychiatry, 159, 276–283.CrossRefGoogle ScholarPubMed
Smith, D. J., Muir, W. J., & Blackwood, D. H. (2004). Is borderline personality disorder part of the bipolar spectrum? Harvard Review of Psychiatry, 12, 133–139.CrossRefGoogle ScholarPubMed
Stromgren, E. (1950). Statistical and genetic population studies within psychiatry: Methods and principal results. Actualities Scientifiques et Industrelles, 1101 Congres International de Psychiatrie, 6, 155–157.Google Scholar
Trull, T. J., Sher, K. J., Minks-Brown, C., Durbin, J., & Burr, R. (2000). Borderline personality disorder and substance use disorders: A review and integration. Clinical Psychology Review, 20, 235–253.CrossRefGoogle Scholar
Wilson, S. T., Stanley, B., Oquendo, M. A., Goldberg, P., Zalsman, G., & Mann, J. J. (2007). Comparing impulsiveness, hostility, and depression in borderline personality disorder and bipolar II disorder. Journal of Clinical Psychiatry, 68, 1533–1539.CrossRefGoogle ScholarPubMed
Yatham, L. N. (2005). Diagnosis and management of patients with bipolar II disorder. Journal of Clinical Psychiatry, 66(Suppl 1), 13–17.Google ScholarPubMed
Zanarini, M. C., Frankenburg, F. R., Hennen, J., & Silk, K. R. (2004). Mental health service utilization by borderline personality disorder patients and Axis II comparison subjects followed prospectively for 6 years. Journal of Clinical Psychiatry, 65, 28–36.CrossRefGoogle ScholarPubMed
Zanarini, M. C., Jacoby, R. J., Frankenburg, F. R., Reich, D. B., & Fitzmaurice, G. (2009). The 10-year course of social security disability income reported by patients with borderline personality disorder and axis II comparison subjects. Journal of Personality Disorders, 23, 346–356.CrossRefGoogle ScholarPubMed
Zeng, R., Cohen, L. J., Tanis, T., Qizilbash, A., Lopatyuk, Y., Yaseen, Z. S., & Galynker, I. (2015). Assessing the contribution of borderline personality disorder and features to suicide risk in psychiatric inpatients with bipolar disorder, major depression and schizoaffective disorder. Psychiatry Research, 226, 361–367.CrossRefGoogle ScholarPubMed
Zimmerman, M. (2003). Integrating the assessment methods of researchers in routine clinical practice: The Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project. In First, M. (Ed.), Standardized evaluation in clinical practice (pp. 29–74). Washington, DC: American Psychiatric Publishing, Inc.Google Scholar
Zimmerman, M. (2015). Borderline personality disorder: A disorder in search of advocacy. Journal of Nervous and Mental Disease, 203, 8–12.CrossRefGoogle ScholarPubMed
Zimmerman, M. (2016). Improving the recognition of borderline personality disorder in a bipolar world. Journal of Personality Disorders, 30, 320–335.CrossRefGoogle Scholar
Zimmerman, M., Balling, C., Dalrymple, K., & Chelminski, I. (2019). Screening for borderline personality disorder in psychiatric outpatients with major depressive disorder and bipolar disorder. Journal of Clinical Psychiatry, 80, e1–e6.Google ScholarPubMed
Zimmerman, M., & Chelminski, I. (2003a). Clinician recognition of anxiety disorders in depressed outpatients. Journal of Psychiatric Research, 37, 325–333.CrossRefGoogle Scholar
Zimmerman, M., & Chelminski, I. (2003b). Generalized anxiety disorder in patients with major depressive disorder: Is DSM-IV's hierarchy correct? American Journal of Psychiatry, 160, 504–512.CrossRefGoogle Scholar
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, 29, 54–60.Google ScholarPubMed
Zimmerman, M., Ellison, W., Morgan, T. A., Young, D., Chelminski, I., & Dalrymple, K. (2015). Psychosocial morbidity associated with bipolar disorder and borderline personality disorder in psychiatric out-patients: Comparative study. British Journal of Psychiatry, 207, 334–338.CrossRefGoogle ScholarPubMed
Zimmerman, M., Galione, J. N., Chelminski, I., Young, D., Dalrymple, K., & Ruggero, C. J. (2010). Sustained unemployment in psychiatric outpatients with bipolar disorder: Frequency and association with demographic variables and comorbid disorders. Bipolar Disorders, 12, 720–726.CrossRefGoogle ScholarPubMed
Zimmerman, M., & Mattia, J. I. (1999a). Differences between clinical and research practice in diagnosing borderline personality disorder. American Journal of Psychiatry, 156, 1570–1574.CrossRefGoogle Scholar
Zimmerman, M., & Mattia, J. I. (1999b). Psychiatric diagnosis in clinical practice: Is comorbidity being missed? Comprehensive Psychiatry, 40, 182–191.CrossRefGoogle Scholar
Zimmerman, M., McGonigal, P., Moon, S. S., Mehring, L., LaHaye, J., Berges, A., & Schmidhofer, S. (2018). Does diagnosing a patient with borderline personality disorder negatively impact patient satisfaction with the initial diagnostic evaluation? Annals of Clinical Psychiatry, 30, 215–219.Google ScholarPubMed
Zimmerman, M., & Morgan, T. A. (2013). The relationship between borderline personality disorder and bipolar disorder. Dialogues in Clinical Neuroscience, 15, 79–93.Google ScholarPubMed