Affective instability and impulsivity in borderline personality andbipolar II disorders: similarities and differences

Chantal Henrya,b, Vivian Mitropoulouc, Antonia S. Newc, Harold W. Koenigsbergc,Jeremy Silvermanc, Larry J. Sieverc,*

aService Universitaire de Psychiatrie, Centre Hospitalier Charles Perrens, 121 rue de la Bechade, 33076 Bordeaux, FrancebINSERM U-394, Neurobiologie Integrative, rue Camille Saint Saens, 33077 Bordeaux, FrancecThe Bronx VA Medical Center, 116A, 130 West Kingsbridge Road, Bronx, NY 10468, USA

Received 22 February 2001; received in revised form 11 June 2001; accepted 17 August 2001

Abstract

Objectives: many studies have reported a high degree of comorbidity between mood disorders, among which are bipolar dis-

orders, and borderline personality disorder and some studies have suggested that these disorders are co-transmitted in families.However, few studies have compared personality traits between these disorders to determine whether there is a dimensional overlapbetween the two diagnoses. The aim of this study was to compare impulsivity, affective lability and intensity in patients with bor-

derline personality and bipolar II disorder and in subjects with neither of these diagnoses. Methods: patients with borderline per-sonality but without bipolar disorder (n=29), patients with bipolar II disorder without borderline personality but with otherpersonality disorders (n=14), patients with both borderline personality and bipolar II disorder (n=12), and patients with neitherborderline personality nor bipolar disorder but other personality disorders (OPD; n=93) were assessed using the Affective Lability

Scale (ALS), the Affect Intensity Measure (AIM), the Buss–Durkee Hostility Inventory (BDHI) and the Barratt ImpulsivenessScale (BIS-7B). Results: borderline personality patients had significantly higher ALS total scores (P<0.05) and bipolar II patientstended to have higher ALS scores than patients with OPD (P<0.06). On one of the ALS subscales, the borderline patients dis-played significant higher affective lability between euthymia and anger (P<0.002), whereas patients with bipolar II disorder dis-played affective lability between euthymia and depression (P<0.04), or elation (P<0.01) or between depression and elation(P<0.01). A significant interaction between borderline personality and bipolar II disorder was observed for lability between anxietyand depression (P<0.01) with the ALS. High scores for impulsiveness (BISTOT, P<0.001) and hostility (BDHI, P<0.05) wereobtained for borderline personality patients only and no significant interactions between diagnoses were observed. Only borderlinepersonality patients tended to have higher affective intensity (AIM, P<0.07). Conclusions: borderline personality disorder andbipolar II disorder appear to involve affective lability, which may account for the efficacy of mood stabilizers treatments in both

disorders. However, our results suggest that borderline personality disorder cannot be viewed as an attenuated group of affectivedisorders. # 2001 Elsevier Science Ltd. All rights reserved.

Keywords: Borderline personality disorder; Bipolar disorder; Affective instability; Affective Intensity; Aggression; Impulsiveness

1. Introduction

Many studies have reported a high frequency ofcomorbidity between borderline personality disorderand major mood disorders (bipolar disorder and majordepression), from 35 to 51.5% (McGlashan, 1983; Pope

et al., 1983; Frances et al., 1984; Perry, 1985; Zanarini etal., 1998). Some family studies have also shown comor-bidity between affective disorders including bipolar dis-orders and borderline personality (Akiskal, 1981;Loranger et al., 1982; Amadeo et al., 1992). Moreover,in a clinical case conference Bolton and Gunderson(1996) have discussed how it is sometime difficult toestablish the differential diagnosis between bipolar dis-order and borderline personality.Some authors have suggested that borderline person-ality disorder is on the spectrum of affective disorders

0022-3956/01/$ - see front matter # 2001 Elsevier Science Ltd. All rights reserved.

PI I : S0022-3956(01 )00038-3

Journal of Psychiatric Research 35 (2001) 307–312

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* Corresponding author. Tel.: +1-718-584-9000 ext. 5225; fax: +1-

718-364-3576.

E-mail address: larry.siever@med.va.gov (L.J. Siever).

(Akiskal et al., 1981; McGlashan, 1983). This has led tothe following hypotheses: (1) borderline personality is avariant of affective disorder, (2) borderline personalitypredisposes the patient to depression, or (3) the twodisorders have etiologic features in common (Gunder-son and Phillips, 1991; Koenigsberg et al., 1999). Biolo-gical and treatment studies have shown that borderlinepersonality and affective disorders display similaritiesand differences in their underlying biology and treat-ment response (Koenigsberg et al., 1999).However, most studies assessing the relationshipbetween borderline personality and bipolar disorderraise the question of comorbidity or describe the impactof comorbid borderline personality on the features,progression or treatment response of bipolar disorder.Bipolar patients with a comorbid borderline personalityhave a less favorable outcome, with more suicideattempts, earlier onset and poorer response to treatmentthan those without borderline personality (Kutcher etal., 1990; Sato et al., 1999).To our knowledge, this is the first study to assessdimensional traits in these disorders, identified from apersonality disorder cohort, in an adequately largesample, to determine phenomenologically the simila-rities and differences between these disorders. Thisdimensional approach may make it possible to elucidatethe possible links between these two disorders and toidentify the biological features that they share. Thisapproach is based on the model that there are psycho-biological dimensions such as affective instability, thatpredispose individuals and may cut across Axis I/IIboundaries (Siever and Davis, 1991).Affective instability and impulsive behavior appear tobe appropriate traits for comparison in the two dis-orders. Indeed, affective instability is explicitly includedas a criterion for borderline personality, whereas‘‘autonomic lability’’ including a high level of inter-personal sensitivity and a low level of emotional stabi-lity has been suggested to be a valid antecedent ofunipolar depression and bipolar disorders (Clayton etal., 1994; Lauer et al., 1997). In addition, borderline andbipolar patients (more specifically bipolar II disorder)frequently display suicidal behavior. Moreover, poorimpulse control may be a strong risk factor for recur-rent suicidal behavior, suggesting that impulsivity is atrait that should be investigated in both disorders.Finally, it has been suggested that both affectiveinstability and impulsive personality disorder traitsrather than the personality disorder per se have anheritable component (Silverman et al., 1991; Torgersen,2000). Thus, affective instability and impulsivenessappear to be appropriate dimensions for investigation inthese disorders. We compared bipolar II disorderpatients (rather than patients with bipolar I disorder) toborderline personality patients, as these two disordersshare similar clinical presentations (Benazzi, 2000).

We hypothesized that (1) both borderline personalitydisorder and bipolar II patients would display higherlevels of affective lability and intensity, as measured bythe Affective Lability Scale (ALS) and the Affect Inten-sity Measure (AIM), than patients without these dis-orders; (2) borderline personality patients, but notbipolar II patients would display a higher level ofimpulsiveness compared to patients without these dis-orders; (3) and bipolar II patients would display affec-tive lability even between major affective episodes.

2. Methods

2.1. Subjects

We studied 148 patients with personality disordersfrom the Mood and Personality Disorder Program atthe Mount Sinai Medical Center and the Bronx VAMedical Center. All subjects were healthy outpatients atthe time of the study, as evaluated by laboratory tests,physical and neurological examination, and had nottaken any medication including psychotropic medica-tion, for at least 14 days.Patients with bipolar I disorder, schizophrenia, andother Axis I psychotic disorders were excluded from thisstudy sample; only bipolar II patients were included.The study was described in detail to the subjects andinformed written consent obtained.Diagnoses were determined by one or more trainedinterviewers, using the Structured Interview for theDiagnosis of Personality Disorders for DSM-III-R(SIPD-R, Stangl et al., 1989; kappa 0.81 for borderlinepersonality disorder) and the Schedule for AffectiveDisorders and Schizophrenia (SADS; Spitzer and End-icott, 1975; Kappa for BP II=0.72).

2.2. Dimensional assessments

Each subject completed the Affective Lability Scale(ALS, Harvey et al., 1989). This is a 54-item self-reportscale that measures changeable affects. ALS items assesssubjects perception of their tendency to change betweenwhat they consider to be their normal (euthymic) moodand affects of anger (ANG), depression (DEP), elation(ELA), and anxiety (ANX), and their tendency tooscillate between states of depression and elation (BIP),and between states of anxiety and depression(ANXDEP). Each item is rated on a four-point scale(scored 0–3 inclusive) from ‘‘very undescriptive’’ to‘‘very descriptive’’ of themselves. ALS total is the meanof the six subscales for individual affect shifts.Subjects also completed the Affect IntensityMeasure (AIM, Larsen and Diener, 1985; Larsen etal., 1986) a self-report scale consisting in a 40-items.Affect intensity refers to individual differences in the

308 C. Henry et al. / Journal of Psychiatric Research 35 (2001) 307–312

intensity of response to a given level of emotion-pro-voking stimulation.Aggressiveness and impulsiveness were assessed usingthe Buss–Durkee Hostility Inventory (BDHI, Buss andDurkee, 1957) and the Barratt Impulsiveness Scale(BIS-7B, Barratt et al., 1965), both of which are alsoself-report scales. The BDHI provides a dimensionalmeasure of lifetime history of aggression, and the sub-scale for irritability and assaultiveness includes compo-nents related to anger, hostility, physical and verbalaggression. It is widely used in the study of impulsiveaggression and high scores for the scale as a whole andfor the composite subscale, irritability and assaultive-ness, have been shown to be associated with a bluntedresponse to the serotonin releasing agent fenfluramine(Coccaro et al., 1989). The BIS characterizes fouraspects of impulsiveness: speed of cognitive response,lack of impulse control, extroversion, and risk taking.

3. Statistical analysis

Statistical analysis was performed with SPSS version9.0 computer software. As no other large studies haveassessed borderline personality and bipolar II disorderstogether, we conducted a two-way analysis of covar-iance with borderline personality disorder and bipolardisorder diagnoses (presence or absence) as factors, toinvestigate the contribution of each diagnosis separatelyand to test for possible interaction effects between thesediagnoses, after adjusting for age and sex.

4. Results

The sample consisted of 29 borderline patients whodid not meet the criteria for bipolar II disorder, 14

bipolar II disorder patients who did not meet the cri-teria for borderline personality disorder, 12 patientswho met the criteria for both borderline personalitydisorder and bipolar II disorder and 93 patients who didnot meet the criteria for either (but met criteria for otherpersonality disorders; see Table 1 for description of thestudy population).Age and sex distribution differed between groups, sowe adjusted the analysis for age and sex [borderlinepersonality patients were younger than bipolar II sub-jects, and a higher proportion were female F(1,3)=2.7,d.f.=148, P=0.1, Table 1.A two-way analysis of variance (with presence orabsence of borderline personality disorder and bipolarII disorder as factors), adjusted for sex and age, for totalALS score demonstrated a significant effect of border-line personality disorder diagnosis [F(1,5)=4.3,d.f.=148, P<0.04]; patients with borderline personalityhad significantly higher ALS scores than patients with-out this disorder. Patients meeting the criteria for bipo-lar II disorder tended to have higher ALS scorescompared to patients who did not meet criteria forbipolar II disorder [F(1,5)=3.6, d.f.=148, P<0.06].There was a tendency towards interaction between bor-derline personality and bipolar II disorder diagnosis,with patients meeting both diagnoses tending to havethe highest scores [F(1,5)=3.0, d.f.=148, P<0.09]. Thismodel was significant after adjustement for currentdepressive episode [F(1,4)=0.39, P<0.05].As borderline personality diagnosis had a significanteffect on total ALS score, we investigated whether therewas a difference in ALS subscore between the twodiagnoses. We investigated the subscale scores fordepression (DEP), anger (ANG), anxiety (ANX) andelation (ELA), and for shifts between elation anddepression (BIP) and between anxiety and depression(ANXDEP).Affective lability scores profiles differed between thetwo diagnostic groups (Table 2). Patients meeting thecriteria for bipolar II disorder had significantly higherscores for DEP, ELA and BIP [F(1,5)=4.3, d.f. 148,P=0.04 for DEP; F(1,5)=6.8, d.f. 148, P=0.01 forELA, F(1,5)=6.8, d.f. 148, P=0.01 for BIP]. In con-trast, patients meeting the criteria for borderline per-sonality disorder had significantly higher scores forANG [F(1,5)=9.7, d.f. 148, P=0.002) and a tended tohave higher scores for ANX (F(1,5)=2.8, d.f. 148,

Table 1

Characteristics of the four groups of patients

Mean age

(S.D.)

Sex

(% male)

Borderline no Bipolar II n=29 32.3 (�7.47) P=0.027 31

Bipolar II no Borderline n=14 42.6 (�11) P=0.021 64.3

Borderline and Bipolar II n=12 39.2 (�10.1) 58.3

OPD no Bipolar II n=93 39 (�10.61) 61.3

Table 2

Mean (SEM) for the subscales of ALS in the four groups patients

DEP ELAT ANXDEP ANX ANG BIP TOT

Borderline No Bipolar II (n=29) 1.6 (0.08) 1.3 (0.08) 2.0 (0.1) 1.6 (0.1) 1.6 (0.1) 1.3 (0.09) 1.6 (0.08)

Bipolar II no BPD (n=14) 1.7 (0.1) 1.4 (0.1) 1.9 (0.1) 1.4 (0.1) 1.2 (0.1) 1.3 (0.1) 1.5 (0.1)

BPD & BP II (n=12) 1.6 (0.1) 1.5 (0.1) 1.7 (0.1) 1.5 (0.1) 1.5 (0.1) 1.5 (0.1) 1.6 (0.1)

OPD, No BPII (n=93) 1.3 (0.05) 1.0 (0.05) 1.4 (0.7) 1.0 (0.06) 0.9 (0.07) 1.3 (0.1) 1.6 (0.1)

C. Henry et al. / Journal of Psychiatric Research 35 (2001) 307–312 309

P=0.09]. A significant interaction between the twodiagnoses was seen only for the ANXDEP subscale[F(1,5)=6.5, d.f. 148, P=0.01].A similar analysis with bipolar II disorder and bor-derline personality disorder diagnoses as factors, andtotal scores for AIM, BDHI and BISTOT as thedependent variables, demonstrated significant or trendeffects for borderline personality but not for bipolar IIdisorder [F(1,5)=3.2, d.f. 148, P=0.07 for AIM;F(1,5)=5.9, d.f. 146, P=0.018 for BDHI; F(1,5)=22.7,d.f. 147, P=0.000 for BISTOT]. For all these scales,patients meeting the criteria for borderline personalitydisorder had higher scores than those who did not.Bipolar II disorder diagnosis had no effect on scores forthe BDHI and BIS or for the irritability and aggressionsubscale of the BDHI (Table 3).

5. Discussion

In this study, we have found affective lability to be atrait shared by both borderline personality and bipolarII patients. However, the two diagnoses presented dif-ferent patterns of affective lability. Shifts to euthymiafrom anger and anxiety were associated with borderlinepersonality disorder in the absence of bipolar II dis-order diagnosis whereas shifts from euthymia todepression and elation, and shifts to elation fromdepression were characteristic of bipolar II patients.High scores on scales of impulsiveness and aggressive-ness were obtained only for borderline personality sub-jects. The difference between the groups was lessmarked for the affective intensity.Thus, affective lability may be a trait common to bothborderline personality and bipolar II disorders,accounting for the overlap in efficacy of mood stabi-lizers, and the high frequency of comorbidity for thesetwo diagnoses (46% for this sample). Mood stabilizerssuch as carbamazepine, lithium, and valproate havebeen reported to be effective in borderline personalitypatients, but they principally reduce impulsiveness orimprove overall function, rather than reduce depression(Cowdry and Gardner, 1988; Stein et al., 1995). Thus,mood stabilizers may be effective treatment for border-line personality disorder because they help to controlaffective instability.

However, this dimensional approach to borderlinepersonality and bipolar II disorders also shows differ-ences in emotional pattern between the two disorders.Emotional lability corresponds to short-term moodfluctuations with the same affective qualities, differingonly by degree, such as major mood episodes with bothpolarities, one tending towards elation and an the othertowards depression. All items in the ALS specify thatthe affective shifts occurred very rapidly. Thus, this isnot an evaluation of hypomanic and depressive epi-sodes, but of the pre-existing or residual instabilitybetween episodes. Akiskal (1994) suggested that bipolarII disorder often involves dysthymic, irritable andcyclothymic temperaments. However, this study showsthat affective lability occurs even between major moodepisodes in bipolar patients; hence, it could be con-sidered a temperamental trait. Thus, the emotionallability present in both borderline personality andbipolar disorders may be a more specific trait, for whichthere is some evidence of neurobiological dysregulation(for review see Gurvits et al., 2000) where the choliner-gic system may play a role (Steinnberg et al., 1997).Borderline personality disorder patients differed frombipolar patients and subjects with other personality dis-orders in being more impulsive and aggressive. Thesetraits, impulsiveness and aggressiveness, seem to be verycharacteristic of borderline personality disorder, as sug-gested by previous studies (Virkkunen, 1976; Pattisonand Kahan, 1983; New et al., 1999). This is not surpris-ing because self-mutilation, increased suicidal gestures(seen as acts of aggression against oneself) and impul-siveness are among the diagnostic criteria for borderlinepersonality disorder. Further evidence of the sig-nificance of impulsive aggressive symptoms in patientswith personality disorders is provided by the frequencyof borderline personality in the criminal population(Virkkunen et al., 1996; Dutton et al., 1996).These data suggest that the neurobiological basis ofborderline personality disorder and bipolar disordermay include elements common to both disorders,resulting in a common core of affective lability. How-ever, this affective lability is associated with greaterimpulsivity in borderline personality disorder patients,leading to potentially self-damaging impulsiveness,inappropriate or uncontrolled anger, recurrent suicidethreats or gestures. These data support the hypothesis

Table 3

Total scores for the various scales used in the four groups

ALSTOT Mean (S.E.M.) AIM Mean (S.E.M.) BDHI Mean (S.E.M.) BISTOT Mean (S.E.M.)

Borderline no Bipolar II n=29 1.6 (0.08) P=0.039 3.6 (0.09) P=0.07 41.6 (2.1) P=0.018 45.9 (3.5) P=0.000

Bipolar II no Borderline n=14 1.5 (0.1) P=0.058 3.4 (0.1) 35.1 (3.6) 30.8 (4.5)

Borderline and Bipolar II n=12 1.6 (0.1) P=0.08 3.4 (0.1) 43.6 (3.9) 55.6 (6.2)

OPD no Bipolar II n=93 1.1 (0.05) 3.4 (0.05) 34.8 (1.2) 32.7 (1.5)

310 C. Henry et al. / Journal of Psychiatric Research 35 (2001) 307–312

that there are biological predispositions (such as affec-tive instability in this instance) that cut across diag-nostic boundaries (Siever and Davis, 1991) and thataffective instability and impulsiveness are key dimen-sions of borderline personality disorder. In bipolarpatients, this affective instability, probably associatedwith different neurobiological disturbances, leads tomore enduring dysphoric mood tending towards eitherelation or depression. These results suggest that bor-derline personality disorder is not simply an attenuatedsubgroup of affective disorders. Our results are con-sistent with those of a preliminary study (Atre-Vaidyaand Hussain, 1999) reporting that borderline person-ality disorder could be distinguished from bipolar dis-order on the basis of temperament and character,assessed by the model of personality proposed by Clo-ninger (TPQ, Cloninger et al., 1994). It was found thatborderline personality disorder patients scored higherfor harm avoidance and lower for self-directedness andcooperativeness than bipolar patients. However, Vaidyaand Hussain only evaluated 10 borderline personalitypatients and 13 bipolar patients; it would be interestingto compare borderline personality, bipolar and controlsubjects in the same study to determine whether bor-derline personality and bipolar patients can be dis-tinguished from controls in term of harm avoidance.One limitation of this study is its reliance on self-reports to assess the various dimensions. However, theseALS measures are significantly associated with thediagnostic criterion of affective instability rated by adiagnostic interviewer (Koenigsberg, personal commu-nication), demonstrating the validity of ALS.These data also suggest other possible ways to explorethe boundaries of affective disorders. Indeed, affectiveinstability may be a trait in bipolar disorders and amarker of susceptibility to bipolar disorder in relatives.Further investigations are now required to explorebipolar I patients and the relatives of bipolar patientsdetermine whether this is indeed the case.

Acknowledgements

This work was supported by the Programme Hospi-talier de Recherche Clinique (PHRC 2000) and bygrants from the National Institutes of Health; NationalCenter for Research Resources (5 M01 RR00071), forthe Mt. Sinai General Clinical Research Center;National Institute of Mental Health grant R01-MH-41131; and Department of Veterans Affairs MeritAward 7609004.

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