Skip to main content
Download PDF
Download ePub

Psychotic spectrum features in borderline and bipolar disorders within the scope of the DSM-5 section III personality traits: a case control study

Borderline Personality Disorder and Emotion Dysregulation volume 10, Article number: 2 (2023) Cite this article

Abstract

Background

Psychotic spectrum features in borderline personality disorder (PD) are a long-standing phenomenon, but remarkably, to date, they have not been the focus of many empirical studies. Moreover, the comparative studies that acknowledge their links to affective psychoses are even more scarce. Likewise, the contributions of empirical research on the DSM-5 dimensional approach to this topic are also uncommon. This study seeks to identify the best set of pathological personality traits and/or symptoms that are predictors of psychotic features (psychoticism and ideation paranoid symptoms) in borderline PD and in bipolar disorder, based on the framework of the DSM-5 section III personality traits.

Methods

A cross-sectional study of two clinical samples: 1) Borderline PD group of 63 participants; 2) Bipolar disorder group of 65 participants. Self-reported assessment: Personality Inventory for DSM-5 (PID-5); Brief Symptom Inventory (BSI). A series of linear and logistic regression analyses were computed.

Results

Overall, the data emerging as common predictors are detachment, negative affectivity, psychoticism, depressivity, grandiosity, suspiciousness and interpersonal sensitivity symptoms. Borderline PD has the highest score in BSI paranoid ideation which emerges as its discriminating trait (Nagelkerke R2 = .58): cognitive and perceptual dysregulation (OR: 13.02), restricted affectivity (OR: 12.09), withdrawal (OR: 11.70), anhedonia (OR: 10.98) and emotional lability (OR: 6.69).

Conclusions

Besides the commonality that appears to overlap both disorders with a psychosis superspectrum, the patterns of the pathological personality-symptoms underlying the psychotic features appear to reinforce a position between schizophrenia and bipolar disorders that borderline PD may occupy, highlighting the possibility of its intersection with schizoaffective/psychosis spectra. The pathological personality nature of the psychotic features emerges as a potential comprehensive trait of the phenomenological dimensions.

Background

The innermost relationship of the borderline concept and psychosis has been historically intertwined and can be traced back to the twentieth century [1]. Psychotic spectrum features in borderline personality disorder (PD) are a long-standing phenomenon, but remarkably, to date, they have not been the focus of many empirical studies. Moreover, the comparative studies that acknowledge their links to affective psychoses are even more scarce [1,2,3,4,5,6]. Likewise, the contributions of empirical research on the DSM-5 dimensional approach [7, 8] to this topic are also uncommon.

Returning to the influential review of Gunderson and Singer [9] in defining borderline patients, based on the main publications of psychiatric and psychoanalytic contributions, two characteristics have already been highlighted - brief psychotic experiences and the psychological testing performance with bizarre, dereistic, illogical or primitive responses - among the six features most often described as characterizing borderline conditions. The evidence reports that around 20–50% of patients with borderline PD experience psychotic symptoms [4], also that psychotic disorders are observed in 38% of these patients and the prevalence of 20% of psychotic disorder diagnosis not otherwise specified is the most common subtype [10]. In turn, other empirical studies point to approximately 75% of borderline cases experiencing transient dissociative and paranoid symptoms [5, 11]. More contemporary reviews have further emphasized that the most common symptoms are auditory hallucinations and paranoid delusions in borderline PD [2]. Although some studies [12] have noted that the psychotic symptoms seen in borderline patients are transient (quasi–or pseudohallucinations), other research [13] has drawn attention to the fact that psychotic symptoms in borderline PD patients, may not predict the development of a psychotic disorder but are often permanent and severe and call for careful consideration on the part of clinicians. Furthermore, the co-occurrence of borderline PD and psychotic symptoms is a marker of severe psychopathology and a poor outcome risk [3]. The presence of persistent psychotic symptoms in borderline PD has been attributed to their co-occurrence with other psychiatric disorders, such as mood disorders, post-traumatic stress disorder and substance use disorders [2]. Although chronic psychotic symptoms are typically associated with the schizophrenia spectrum and bipolar disorders [14], it is still difficult to distinguish psychotic-related phenomena in borderline PD from the corresponding experiences in psychotic disorders and schizophrenia, despite numerous attempts to do so [2]. Recently, state-of-the-art research has shown that in borderline PD, the psychotic symptoms in general, and the auditory verbal hallucinations in particular, display more similarities than differences to those symptoms in psychotic disorders [3, 15]. However, psychotic features in borderline PD appear to be significantly related to the context (usually stressful events) and emerge or intensify in response to situational crises [2].

Indeed, borderline PD and bipolar disorder are significant public health problems and, clinically, it has been frequently noted that distinguishing them from each other is challenging and a common diagnostic dilemma, due to their symptomatic overlap [5, 6, 16,17,18,19,20]. As mentioned by Marneros et al. [21], since accepting mood-incongruent symptoms as belonging to mood disorders as well as beyond schizophrenia, the risk of confusing diagnostic entities, such as “pure” mood disorders with schizoaffective disorders and to some extent with schizophrenia and schizophreniform disorders also increases. As a historical intersection, Stone [22] first reported that borderline patients often came from families with manic-depressive members and thus shifted borderline personality from a subschizophrenic to a subaffective disorder. In parallel, having observed the frequent association with recurrent mood disorders, coupled with family bipolarity and spontaneous and pharmacological excursions into brief periods of elation, Akiskal [23] placed the pathology of borderline patients in the bipolar realm. Differentiating bipolar disorder I from borderline PD is usually more straightforward due to the fact that bipolar disorder I is typically more severe and psychotic features during mania are frequently present [5, 24]. In bipolar disorder II, on the other hand, hypomanic episodes lack psychotic features and disorders are frequently incorrectly diagnosed as borderline PD due to shared features including impulsivity and emotional dysregulation [5, 24]. In an attempt to provide clarification, Benvenuti et al. [25] found that features of bipolarity were associated with psychotic experiences in borderline disorder and, also in the same vein, Perugi et al. [26] reported that borderline PD depressive patients frequently displayed a number of clinical variables classically associated with bipolarity, e.g., psychotic symptoms, mixed features and atypical features. Nevertheless, according to the literature reviews, the presence of certain borderline PD features (e.g., micropsychotic symptoms and interpersonal difficulties) with no clearly explainable link to mood fluctuations thereby challenges the condition being viewed as bipolar [17]. When dealing with this controversial and challenging subject, some authors also propose a schizophrenia spectrum psychopathology in borderline PD [27], or an approach to a schizoaffective disorder spectrum [28].

In light of the empirical evidence supporting the DSM-5 dimensional model of personality disorders [7, 8], few studies have examined maladaptive personality traits and psychosis conditions. Upon systematization of the data in the literature, it has become clear that psychotic symptomatology, schizophrenia spectrum disorders or higher risk for psychosis are linked to the psychoticism [14, 29], negative affectivity and detachment [30] domains which, in turn, are linked to the trait facets of unusual beliefs and experiences [14, 29], cognitive and perceptual dysregulation [14], suspiciousness [14] and distractibility [29]. Research has also pointed to a consideration of cognitive and perceptual dysregulation and suspiciousness traits for inclusion as the ninth borderline PD symptom criterion (i.e., stress-induced paranoia or dissociation) [31, 32]. Recently, Kotov et al. [33] proposed a psychosis superspectrum, stating that the thought disorder spectrum is composed of symptoms and maladaptive traits that range from normal reality testing to maladaptive trait psychoticism, to hallucinations and delusions. Some theories on the relationship between personality and psychotic disorders have hypothesized a latent discontinuity, with the risk of psychosis limited to a qualitatively distinct subgroup, however further research is needed in this regard [33].

Through self-report assessment, this paper seeks to identify the best set of pathological personality traits and/or symptoms that are predictors of psychotic features (psychoticism and ideation paranoid symptoms) in borderline PD and bipolar disorder, based on the framework of the DSM-5 pathological personality traits. To our knowledge, this is the first analysis of the DSM-5 dimensional model criterion B maladaptive traits to focus on the predictors of psychotic spectrum features associated with personality-psychopathology data in a simultaneous self-report of these disorders.

Method

Participants

This cross-sectional study consisted of a total of 128 patients distributed across two clinical samples: 1) Borderline PD sample of 63 participants aged between 18 and 64 years (Mage = 40.32 years, SD = 11.18), predominantly male (55.6%), with an average of 10 years of schooling; 2) Bipolar disorder sample of 65 participants aged between 19 and 76 years (Mage = 46.49 years, SD = 12.84), predominantly female (60%), with an average of 11 years of schooling.

Regarding the sociodemographic features, significant differences were observed in age between the borderline PD and bipolar disorder groups (t(126) = − 2.90, p = .004). No between-group differences were found in other sociodemographic variables such as sex or schooling.

Overall, the participants were of Portuguese nationality (94.5%), mostly single (54.3%), married/cohabiting (21.3%) or divorced (21.3%), while most were unemployed (50%), and lived predominantly in an urban environment (80.2%).

Measures

Socio-demographic questionnaire (e.g., age, sex, schooling)

Personality inventory for DSM-5 (PID-5)

The PID-5 [8, 34, 35] is a self-report measure, which operationalizes the Criterion B of the dimensional personality pathology model proposed in the DSM-5 Section III. It is composed of 220 items, rated on a 4-point Likert scale ranging from 0 (very false or often false) to 3 (very true or often true), which characterize 25 empirically derived lower-level traits (facets) grouped into five higher-order trait domains of maladaptive personality variation. In our study, Cronbach’s alphas (α) for the domains had a value of .86 (Negative Affectivity), .83 (Detachment), .89 (Antagonism), .88 (Disinhibition), and .94 (Psychoticism).

Brief symptom inventory (BSI)

The BSI [36, 37] identifies self-reported clinically relevant psychological symptoms. The BSI consists of 53 items covering nine symptom dimensions scales. Participants rank each feeling item on a 5-point Likert scale ranging from 0 (not at all) to 4 (extremely). Rankings characterize the intensity of distress during the past seven days. In our study, Cronbach’s alphas (α) for the domains had a value of .89 (Somatization), .79 (Obsession-Compulsion), .87 (Interpersonal Sensitivity), .90 (Depression), .88 (Anxiety), .87 (Hostility), .83 (Phobic anxiety), .80 (Paranoid ideation), and .77 (Psychoticism).

Procedure

The present study received approval and authorization from the Ethics Committee of the researchers’ affiliation institution and by the host institutions involved. The study was conducted in accordance with the latest version of the Declaration of Helsinki and in compliance with the European General Data Protection Regulation.

After the aims and procedures had been fully explained to the participants, their informed written consent was obtained containing both their and the researchers’ signatures. None of the participants received a reward for their contribution.

The samples were collected in Portuguese mental health units. In each affiliated mental health institution, there was a clinician who coordinated the sampling procedures, who selected the participants with the respective diagnoses contained in our study from the clinical databases of their institution, or from whom they were referred. In general, our collected clinical samples relied on the direct clinical evaluation of several psychiatrists, whose diagnosis had been previously discussed and agreed upon by a clinical team. It should be noted that each diagnosis is the result of a medical psychiatric evaluation, archived on the clinical records, conducted by at least three different clinicians: the assistant psychiatrist; the coding doctor, responsible for the respective Diagnosis-Related Groups (DRG) [38]; and the collaborating researcher. The codifying doctor of the hospital(s) based on WHO’s ICD-9 criteria, make diagnosis after reading all clinical records by other clinicians, either old paper (hardware) or new electronic (software) archives of each patient and, subsequently, re-encodes according to the DSM-5. Patients were selected according to their DSM-5 diagnosis (Sections I, II) and the study’s inclusion and exclusion criteria. It is emphasized that patients’ samples are exclusively based on the psychiatric clinical diagnostic method ant the comorbidity of diagnoses was eliminated at baseline. The study inclusion criteria were aged 18 years or above and the diagnostic criteria for borderline PD and bipolar disorder. The exclusion criteria for this study were intellectual disability, schizophrenia, and neurocognitive disorders. Patients with comorbid diagnoses of borderline PD and bipolar disorder were also excluded. Some patients answered the research protocol during their brief term hospitalizations, others were outpatients, admitted sequentially in the sample whenever they had a follow-up consultation. It is estimated that 25% is related to invalid protocols, dropouts and refusals to participate in the research.

Data analysis

The statistical analyses were conducted with the PASW Statistics Software (v. 24, SPSS Inc., Chicago, IL). Effects for p-values ≤ .05 were considered statistically significant.

The main objective was explored by means of the following: 1) For the purpose of description, a series of Pearson correlations and one-way Analysis of Variance (ANOVAs) were computed across the diagnostic groups (borderline PD and bipolar disorder) and scores on the PID-5 domains/facets and the BSI scales. The assumptions of this statistical method were validated by checking the normality and the homogeneity of variances. The adjusted alpha level with the Bonferroni correction procedure were used for adjustment of multiple comparisons; 2) To test the models that predict BSI’s psychoticism and paranoid ideation scales, for borderline PD and bipolar disorder groups respectively, twelve multiple linear regressions were performed using a stepwise method: model 1 - the PID-5 higher-order domains were entered as predictors; model 2 - the PID-5 lower-order trait facets were entered as predictors; model 3 - the PID-5 facets and BSI scales were entered as predictors. The sociodemographic variables (sex, age, schooling) were controlled. Collinearity diagnostics were analyzed using two indicators, VIF (Variance Inflation Factor) and Condition index values. The R2 was used to measure the global predictive capacity of the model; 3) To determine whether the PID-5 facets were able to classify the diagnostic status of borderline PD vs. bipolar disorder through the higher BSI paranoid ideation symptoms scale (M ≥ 1.69), as an exploration of the results observed in objective 1) - a binary logistic regression was performed using a backward wald method: the PID-5 facets were entered as predictors. Odds ratios (ORs) were obtained for each parameter, and the Nagelkerke R2 was used to measure the global predictive capacity of the model. The Hosmer–Lemeshow goodness-of-fit test (X2HL) was used to determine the suitability of the logistic regression model’s fit.

Results

Table 1 reports the means, standard deviations, analysis of variance and Pearson significant correlations between all variables in both groups under study.

Table 1 Summary of Correlations, Descriptive Statistics and Results of the Analysis of Variance on the Effect of the Clinical Groups on the Variables in Study
Full size table

Figure 1 shows between-groups score differences on the BSI paranoid ideation scale, with the borderline PD group having the highest mean score.

Fig. 1
figure 1

Boxplots of BSI’s psychoticism and paranoid ideation symptom scale scores for borderline PD and bipolar disorder groups. Between-group differences were observed on the BSI paranoid ideation scale (t(116) = 2.37, p = .02) (borderline PD M = 1.69, SD = .95; bipolar disorder M = 1.30, SD = .82), while no between-group differences are reported on the BSI psychoticism scale (t(126) = .73, p = .47) (borderline PD M = 1.20, SD = .65; bipolar disorder M = 1.12, SD = .61)

Full size image

Table 2 reports the results obtained by multiple linear regression models for the prediction of the BSI’s psychoticism and paranoid ideation scales as criterion variables, in the clinical groups under analysis. Overall, the DSM-5 personality pathological traits (PID-5) and psychopathological symptoms (BSI scales), which are predictors of psychotic symptom features (BSI’s psychoticism and paranoid ideation), in borderline PD and bipolar disorder groups are illustrated and summarized in Figs. 2 and 3.

Table 2 Summary of Predictive Models of BSI’s Psychoticism and Paranoid Ideation Symptom Scales for Borderline PD and Bipolar Disorder
Full size table
Fig. 2
figure 2

Illustration and summary of the best predictors of the BSI psychoticism symptom scale in borderline PD and bipolar disorders, based on the framework of the DSM-5 personality traits and psychopathological symptoms, regarding the specific features and similarities between these disorders

Full size image
Fig. 3
figure 3

Illustration and summary of the best predictors of the BSI paranoid ideation symptom scale in borderline PD and bipolar disorders, based on the framework of the DSM-5 personality traits and psychopathological symptoms, regarding the specific features and similarities between these disorders

Full size image

Table 3 presents the results of the logistic regression analysis and shows the significant coefficients of the PID-5 personality traits in the prediction of borderline PD vs. bipolar disorder through the higher mean score of BSI paranoid ideation symptoms. The regression model was significant (χ2 = 27.66, df = 9, p < .001, − 2 Log likelihood = 40.27), accounting for 58% of the variance (Nagelkerke’s R2 = .58; Cox & Snell R2 = .43), the Hosmer–Lemeshow test: X2HL(8) = 7.21, p = .514, suggests that the model is a good fit. The obtained model showed that 5 variables uniquely and significantly contributed to the model associated with higher odds of outcome (OR > 1), thus emerging as differential trait predictors of borderline PD.

Table 3 Summary of Logistic Regression Model Predicting Borderline PD vs. Bipolar Disorder through Higher Mean Score of BSI Paranoid Ideation Symptom Scale
Full size table

Discussion

General and common main findings of borderline PD and bipolar disorders

The main set of data emerging from this study as common predictors are the pathological personality traits of detachment, negative affectivity, psychoticism, depressivity, grandiosity, suspiciousness, and interpersonal sensitivity symptoms (Table 2; Figs. 2 and 3). The first general finding is that depressivity (the lower trait-based detachment domain) emerges as a common pathological personality trait marker predictor of psychotic phenomena symptomatology (psychoticism and paranoid ideation symptoms) in both borderline PD and bipolar disorders. Thus, there appears to be a commonality of these data with the proposed psychosis superspectrum framework [33], where thought disorder and detachment spectra are superimposed. In fact, the interpersonal domain of detachment, an internalizing psychopathological tendency [39], is also highlighted, and has been shown to have a closer relationship with the psychotic or thought disorder spectrum [40] in prior studies. In fact, on another level of analysis, in conjunction with psychoticism, it may also be conceptualized as a sub-dimension of the internalizing spectrum of disorders [41]. Additionally, other published studies found that bipolar disorder/mania symptoms loaded on either the psychosis or internalizing dimensions, with borderline PD and major depressive disorders equally fitting in this latter dimension, reflecting an affective dysregulation foundation [33, 40,41,42,43,44]. It can be argued that these data also feature psychoticism as a core trait domain posits as a general factor of personality disorder [45,46,47], or as a core personality dysfunction [48]. In this follow-up, there is evidence that psychoticism can capture clinically relevant aspects of severe mental illness associated with psychosis and other related characteristics, indicating possibly shared patterns of personality expression [14, 49], demonstrating a degree of non-specificity in the patterns across symptoms of personality disorders and non-personality disorders, similarly to some other evidence in the literature [49].

On further examination of these data, and focusing specifically on the psychoticism symptom, the latter appears to be related to the common DSM-5 personality predictors of detachment and depressivity in both pathologies of our research (Table 2; Fig. 2). It should be noted that the DSM-5 includes depression as a dimension of psychosis and, in turn, depression trait may be an important contributor to the clinical heterogeneity of schizophrenia [50]. Delusional and hallucinatory experiences are known to occur in both manic and depressive conditions [51]. Furthermore, findings suggest that a co-occurring genetic vulnerability for both depressive and psychotic symptomatology exists at both a clinical and subclinical level [52]. Clinically, this is reflected in diagnoses such as schizoaffective or mood disorders with psychotic features, in which depressive and psychotic symptoms co-occur [52]. It is possible that trait depression reflects chronically heightened affective reactivity and may influence the development of psychotic-like experiences via the affective pathway [50, 53, 54].

In turn, considering the paranoid ideation symptom in particular (Table 2; Fig. 3), in this study, from a general point of view, it appears to be related to several common DSM-5 personality predictors: the negative affectivity domain, grandiosity trait-based antagonism, depressivity and suspiciousness trait-based detachment, and interpersonal sensitivity symptoms. Taken together, these data may suggest the presence of an affective paranoia complex as a common background to both disorders. Recent studies have shown that the paranoia continuum has links with negative affectivity, depressed mood, stress and interpersonal sensitivity, mistrust and ideas of reference [55,56,57,58]. The paranoia mechanism is highlighted as an underlying co-occurrence of altered mood states and psychosis, reflecting the presence of difficulties in interpersonal relationships [58]. Interestingly, our data also reflect Kraepelin’s position towards the aetiology of paranoia on the one hand, understanding it more as personality development rather than a disease [59] and, on the other hand, more contemporary positions suggesting that emotional dysregulation plays a mediating role in hallucinations and paranoia [60].

Specific and differential main findings for borderline PD and bipolar disorders

A further finding stemming from our analyses involves other features associated with the psychotic phenomenon (psychoticism and paranoid ideation symptoms) that emerge as being specific to borderline PD and bipolar disorder. Overall, the specific traits of antagonism, eccentricity, perseveration, restricted affectivity, and symptoms of psychoticism and paranoid ideation are highlighted in borderline PD; and in turn, in bipolar disorder, the traits of disinhibition, impulsivity, hostility, submissiveness, and symptoms of depression, obsession-compulsion and phobic anxiety are shown as specific predictors (Table 2; Figs. 2 and 3).

It is noteworthy that the predictive models observed present a set of personality traits with and without associated symptoms that point to a differential pattern in the prediction of each psychotic feature under study and in each of the different disorders. In borderline PD, the interpretations of two dimensions may be advanced: 1) the schizoaffective/psychosis [33] dimension [related to the psychoticism symptom dimension] (detachment, psychoticism, depressivity, perseveration, eccentricity, restricted affectivity, and symptoms of somatization, interpersonal sensitivity and paranoid ideation) and; 2) the internalizing/antagonistic [61, 62] dimension [related to the paranoid ideation symptom] (negative affectivity, antagonism, depressivity, suspiciousness, eccentricity, attention seeking, grandiosity, and symptoms of interpersonal sensitivity and psychoticism). In bipolar disorder, the following interpretations are proposed: 1) the internalizing/disinhibition [61, 62] dimension [related to the psychoticism symptom] (disinhibition, detachment, depressivity, attention seeking, impulsivity and symptoms of phobic anxiety, depression, obsession-compulsion) and; 2) the emotional dysfunction (internalizing and somatoform spectra)/psychosis [33, 61] dimension [related to the paranoid ideation symptom] (negative affectivity, psychoticism, suspiciousness, grandiosity, depressivity, hostility, submissiveness, and symptoms of interpersonal sensitivity and somatization).

In this regard, some of our results are consistent with other studies suggesting that borderline PD loads onto the internalizing spectrum, while its association with externalization is via antagonism [61, 62], demonstrating a connection to unstable negative affect [63]. The antagonistic spectrum is also associated with paranoid PD, and negative affectivity and low effortful control predict borderline PD, representing a consistent constellation of temperamental traits that acts as an antecedent to the externalizing superspectrum [61, 62]. On the other hand, several studies have found that indicators of mania/bipolar disorder fall within the internalizing spectrum and often help to define its distress subfactor and have also important connections to thought disorder spectrum-psychosis [33, 61]. As far as the disinhibition identified in our study regarding bipolar disorder is concerned, it is likely to be associated with mania/hypomania [64, 65]. A hypothetical link between the schizoaffective-psychosis [33, 66] dimension and borderline PD and, in turn, the emotional dysfunction-psychosis [33, 61, 67] dimension and bipolar disorder, appears to arise in this study underpinning the psychotic spectrum features. This appears to reinforce the distinction between borderline PD and bipolar disorder, adding evidence to the literature review that underlines that these two conditions are different and can be distinguished [68,69,70].

The last hallmark in our results is the evidence that borderline PD has the highest score in the BSI’s paranoid ideation (Fig. 1), which is in line with some of the findings in the literature [2, 3, 5, 11, 15, 31, 32]. Thus, the investigation of discriminant pathological personality model predictors (Nagelkerke R2 = .58) for borderline PD and bipolar disorders through higher mean values of paranoid ideation symptoms is worthy of mention (Table 3): cognitive and perceptual dysregulation (OR: 13.02), restricted affectivity (OR: 12.09), withdrawal (OR: 11.70), anhedonia (OR: 10.98) and emotional lability (OR: 6.69). Psychoticism has been described as partially capturing features of borderline PD in terms of cognitive and perceptual dysregulation, which includes features of dissociation proneness [71]. This set of data, associated with the afore-mentioned evidence, appears to suggest a possible overlap of schizoaffective/psychosis spectra and is at the crossroads of the challenging debate that claims a borderline PD-schizophrenia-schizoaffective-bipolar spectra [16, 22, 23, 25,26,27,28, 72, 73]. It should be noted that schizoaffective disorder recognizes the diagnostic relevance of mood symptoms in psychotic patients, linked to schizophrenia (psychosis) and mood disorders, occupying an intermediate position between schizophrenia and affective disorders [66, 74,75,76]. In this regard, a bridge may be established with the concept recently proposed by Tyrer et al. [77], namely Galenic syndromes, which underlines the entwined relationship between personality and some mental disorders, acknowledging a broader link between personality pathology and psychopathology.

This study presents several limitations, such as the small size of the samples, the absence of data on the participants’ prior clinical history and current treatment, the fact that mood and psychotic states were not assessed, and bipolar disorder was assigned without the specification of subgroups. Additionally, the possibility of the sample being contaminated by undiagnosed pathologies such as psychosis/personality disorders of organic/toxic aetiology is a further limitation. Its cross-sectional design may also be a major limitation, as borderline and bipolar disorders are primarily characterized by a fluctuating long-term course of symptoms during the life-span, thereby possibly resulting in false-positive diagnoses. However, in this study, the comorbidity of diagnoses was eliminated, which may have facilitated the minimization of errors [69]. In addition, this design does not allow for conclusions to be drawn on temporal and causal relationships between the psychiatric diagnoses in terms of outcomes, thus constituting a potential confounder. Self-report may also be considered a potential and partial limitation as far as the psychiatric samples in this study are concerned, since although there is no consensus with regard to the DSM-5 assessment that diagnostic interviews are more valid than self-reports, the combined use of these methods is deemed optimal for assessing functional outcomes or criteria in borderline PD [78,79,80,81], hence the use of interview assessments in prospective studies is also recommended. Prudence is necessary in interpreting the relationship between the variables under study, given that some items are very similar in the two instruments used. However, this similarity also shows how difficult it is sometimes to distinguish a pathological personality trait from a symptom, following the intrinsic nature of psychopathology. Future research should focus on the efficacy of the framework of the DSM-5 section III personality traits (Criterion B) / personality impairment (Criterion A), as a potential psychotic nature discriminant of the affectivity instability-psychotic phenomenon in borderline pathology, through comparisons with the schizophrenia-affective disorders spectrum.

Conclusions

The findings support the DSM-5 section III personality traits as differentiating model predictors of psychotic phenomena in borderline PD through bipolar disorder. Furthermore, they reinforce the joint use of symptom-related pathological functioning and a dimensional range grounded on personality traits. Besides the commonality that appears to overlap both disorders with a psychosis superspectrum, the patterns of the pathological personality-symptoms underlying the psychotic features appear to reinforce a position between schizophrenia and bipolar disorders that borderline PD may occupy, highlighting the possibility of its intersection with schizoaffective/psychosis spectra. The pathological personality nature of the psychotic features emerges as a potential comprehensive trait of the phenomenological dimensions.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

References

  1. Zandersen M, Henriksen MG, Parnas J. A recurrent question: what is borderline. J Personal Disord. 2019;33:341–69. https://doi.org/10.1521/pedi_2018_32_348.

    Article  Google Scholar 

  2. D’Agostino A, Rossi MM, Starcevic V. Psychotic symptoms in borderline personality disorder: an update. Curr Opin Psychiatry. 2019;32:22–6. https://doi.org/10.1097/YCO.0000000000000462.

    Article  Google Scholar 

  3. Cavelti M, Thompson K, Chanen AM, Kaess M. Psychotic symptoms in borderline personality disorder: developmental aspects. Curr Opin Psychol. 2021;37:26–31. https://doi.org/10.1016/j.copsyc.2020.07.003.

    Article  Google Scholar 

  4. Schroeder K, Fisher HL, Schäfer I. Psychotic symptoms in patients with borderline personality disorder: prevalence and clinical management. Curr Opin Psychiatry. 2013;26:113–9. https://doi.org/10.1097/YCO.0b013e32835a2ae7.

    Article  Google Scholar 

  5. Bayes A, Parker G, Paris J. Differential diagnosis of bipolar II disorder and borderline personality disorder. Curr Psychiatry Rep. 2019;21:125. https://doi.org/10.1007/s11920-019-1120-2.

    Article  Google Scholar 

  6. Zimmerman M, Balling C, Chelminski I, Dalrymple K. Patients with borderline personality disorder and bipolar disorder: a descriptive and comparative study. Psychol Med. 2021;51:1479–90. https://doi.org/10.1017/S0033291720000215.

    Article  Google Scholar 

  7. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Association; 2013.

    Book  Google Scholar 

  8. Krueger RF, Derringer J, Markon KE, Watson D, Skodol AE. Initial construction of a maladaptive personality trait model and inventory for DSM-5. Psychol Med. 2012;42:1879–90. https://doi.org/10.1017/S0033291711002674.

    Article  CAS  Google Scholar 

  9. Gunderson JG, Singer MT. Defining borderline patients: an overview. Am J Psychiatry. 1975;132:1–10. https://doi.org/10.1176/ajp.132.1.1.

    Article  CAS  Google Scholar 

  10. Slotema CW, Blom JD, Niemantsverdriet MBA, Deen M, Sommer IEC. Comorbid diagnosis of psychotic disorders in borderline personality disorder: prevalence and influence on outcome. Front Psychiatry. 2018;9:84. https://doi.org/10.3389/fpsyt.2018.00084.

    Article  CAS  Google Scholar 

  11. Skodol AE, Gunderson JG, Pfohl B, Widiger TA, Livesley WJ, Siever LJ. The borderline diagnosis I: psychopathology, comorbidity, and personality structure. Biol Psychiatry. 2002;51:936–50. https://doi.org/10.1016/s0006-3223(02)01324-0.

    Article  Google Scholar 

  12. Zanarini MC, Frankenburg FR, Wedig MM, Fitzmaurice GM. Cognitive experiences reported by patients with borderline personality disorder and axis II comparison subjects: a 16-year prospective follow-up study. Am J Psychiatry. 2013;170:671–9. https://doi.org/10.1176/appi.ajp.2013.13010055.

    Article  Google Scholar 

  13. Barnow S, Arens EA, Sieswerda S, Dinu-Biringer R, Spitzer C, Lang S. Borderline personality disorder and psychosis: a review. Curr Psychiatry Rep. 2010;12:186–95. https://doi.org/10.1007/s11920-010-0107-9.

    Article  Google Scholar 

  14. Longenecker JM, Krueger RF, Sponheim SR. Personality traits across the psychosis spectrum: a hierarchical taxonomy of psychopathology conceptualization of clinical symptomatology. Personal Ment Health. 2020;14(1):88–105. https://doi.org/10.1002/pmh.1448.

    Article  Google Scholar 

  15. Beatson JA, Broadbear JH, Duncan C, Bourton D, Rao S. Avoiding misdiagnosis when auditory verbal hallucinations are present in borderline personality disorder. J Nerv Ment Dis. 2019;207:1048–55. https://doi.org/10.1097/NMD.0000000000001073.

    Article  Google Scholar 

  16. Bassett D. Borderline personality disorder and bipolar affective disorder: spectra or spectre? A review Aust NZJ Psychiatry. 2012;46:327–39. https://doi.org/10.1177/0004867411435289.

    Article  Google Scholar 

  17. Paris J, Black DW. Borderline personality disorder and bipolar disorder: what is the difference and why does it matter? J Nerv Ment Dis. 2015;203:3–7. https://doi.org/10.1097/NMD.0000000000000225.

    Article  Google Scholar 

  18. Saunders KE, Bilderbeck AC, Price J, Goodwin GM. Distinguishing bipolar disorder from borderline personality disorder: a study of current clinical practice. Eur Psychiatry. 2015;30:965–74. https://doi.org/10.1016/j.eurpsy.2015.09.007.

    Article  CAS  Google Scholar 

  19. Baryshnikov I, Aaltonen K, Koivisto M, Näätänen P, Karpov B, Melartin T, et al. Differences and overlap in self-reported symptoms of bipolar disorder and borderline personality disorder. Eur Psychiatry. 2015;30(8):914–9. https://doi.org/10.1016/j.eurpsy.2015.08.002.

    Article  CAS  Google Scholar 

  20. Ghaemi SN, Dalley S. The bipolar spectrum: conceptions and misconceptions. Aust NZJ Psychiatry. 2014;48(4):314–24. https://doi.org/10.1177/0004867413504830.

    Article  Google Scholar 

  21. Marneros A, Röttig S, Röttig D, Tscharntke A, Brieger P. Bipolar I disorder with mood-incongruent psychotic symptoms: a comparative longitudinal study. Eur Arch Psychiatry Clin Neurosci. 2009;259:131–6. https://doi.org/10.1007/s00406-007-0790-7.

    Article  Google Scholar 

  22. Stone MH. Assessing vulnerability to schizophrenia or manic-depression in borderline states. Schizophr Bull. 1979;5(1):105–10. https://doi.org/10.1093/schbul/5.1.105.

    Article  CAS  Google Scholar 

  23. Akiskal HS. Subaffective disorders: dysthymic, cyclothymic and bipolar II disorders in the "borderline" realm. Psychiatr Clin North Am. 1981;4:25–46. https://doi.org/10.1016/S0193-953X(18)30935-3.

    Article  CAS  Google Scholar 

  24. Bayes A, Parker G, Fletcher K. Clinical differentiation of bipolar II disorder from borderline personality disorder. Curr Opin Psychiatry. 2014;27:14–20. https://doi.org/10.1097/YCO.0000000000000021.

    Article  Google Scholar 

  25. Benvenuti A, Rucci P, Ravani L, Gonnelli C, Frank E, Balestrieri M, et al. Psychotic features in borderline patients: is there a connection to mood dysregulation? Bipolar Disord. 2005;7:338–43. https://doi.org/10.1111/j.1399-5618.2005.00217.x.

    Article  CAS  Google Scholar 

  26. Perugi G, Angst J, Azorin JM, Bowden C, Vieta E, Young AH, et al. Is comorbid borderline personality disorder in patients with major depressive episode and bipolarity a developmental subtype? Findings from the international BRIDGE study. J Affect Disord. 2013;144:72–8. https://doi.org/10.1016/j.jad.2012.06.008.

    Article  Google Scholar 

  27. Zandersen M, Parnas J. Borderline personality disorder or a disorder within the schizophrenia spectrum? A psychopathological study World Psychiatry. 2019;18:109–10. https://doi.org/10.1002/wps.20598.

    Article  Google Scholar 

  28. Gama Marques J, Ouakinin S. Schizophrenia–schizoaffective–bipolar spectra: an epistemological perspective. CNS Spectr. 2021;26:197–201. https://doi.org/10.1017/S1092852919001408.

    Article  Google Scholar 

  29. Bastiaens T, Smits D, De Hert M, Thys E, Bryon H, Sweers K, et al. The relationship between the personality inventory for the DSM-5 (PID-5) and the psychotic disorder in a clinical sample. Assessment. 2019;26:315–23. https://doi.org/10.1177/1073191117693922.

    Article  Google Scholar 

  30. Drvaric L, Bagby RM, Kiang M, Mizrahi R. Maladaptive personality traits in patients identified at lower-risk and higher-risk for psychosis. Psychiatry Res. 2018;268:348–53. https://doi.org/10.1016/j.psychres.2018.08.004.

    Article  Google Scholar 

  31. Watters CA, Bagby RM, Sellbom M. Meta-analysis to derive an empirically based set of personality facet criteria for the alternative DSM-5 model for personality disorders. Personal Disord. 2019;10:97–104. https://doi.org/10.1037/per0000307.

    Article  Google Scholar 

  32. Bach B, Sellbom M, Bo S, Simonsen E. Utility of DSM-5 section III personality traits in differentiating borderline personality disorder from comparison groups. Eur Psychiatry. 2016;37:22–7. https://doi.org/10.1016/j.eurpsy.2016.04.006.

    Article  CAS  Google Scholar 

  33. Kotov R, Jonas KG, Carpenter WT, Dretsch MN, Eaton NR, Forbes MK, et al. Validity and utility of hierarchical taxonomy of psychopathology (HiTOP): I. Psychosis superspectrum World Psychiatry. 2020;19:151–72. https://doi.org/10.1002/wps.20730.

    Article  Google Scholar 

  34. Pires R, Sousa Ferreira A, Gonçalves B. The factor structure of the Portuguese version of the personality inventory for DSM-5 (PID-5). Eur Psychiatry. 2017;41:S259–9. https://doi.org/10.1016/j.eurpsy.2017.02.064.

    Article  Google Scholar 

  35. Pires R, Sousa Ferreira A, Gonçalves B, Henriques-Calado J, Paulino M. The Portuguese version of the personality inventory for the DSM-5 in a community and a clinical sample. Personal Ment Health. 2019;13:40–52. https://doi.org/10.1002/pmh.1437.

    Article  Google Scholar 

  36. Derogatis LR. BSI: brief symptom inventory. 3rd ed. National Computers Systems: Minneapolis; 1993.

    Google Scholar 

  37. Canavarro MC. Inventário de sintomas psicopatológicos: BSI [brief symptom inventory: BSI]. In: Simões MR, Gonçalves MM, Almeida LS, editors. Testes e provas psicológicas em Portugal [Psychological tests and evidence in Portugal]. Portugal: SHO/APPORT; 1999. p. 87–109.

    Google Scholar 

  38. Fetter RB, Shin Y, Freeman JL, Averill RF, Thompso JD. Case mix definition by diagnosis-related groups. Med Care. 1980;18:1–53 http://www.jstor.org/stable/3764138.

    Google Scholar 

  39. Wright AG, Thomas KM, Hopwood CJ, Markon KE, Pincus AL, Krueger RF. The hierarchical structure of DSM-5 pathological personality traits. J Abnorm Psychol. 2012;121(4):951–7. https://doi.org/10.1037/a0027669.

    Article  Google Scholar 

  40. Wright AG, Simms LJ. A metastructural model of mental disorders and pathological personality traits. Psychol Med. 2015;45(11):2309–19. https://doi.org/10.1017/S0033291715000252.

    Article  CAS  Google Scholar 

  41. Keyes KM, Eaton NR, Krueger RF, Skodol AE, Wall MM, Grant B, et al. Thought disorder in the meta-structure of psychopathology. Psychol Med. 2013;43(8):1673–83. https://doi.org/10.1017/S0033291712002292.

    Article  CAS  Google Scholar 

  42. Kotov R, Ruggero CJ, Krueger RF, Watson D, Yuan QL, Zimmerman M. New dimensions in the quantitative classification of mental illness. Arch Gen Psychiatry. 2011;68:1003–11. https://doi.org/10.1001/archgenpsychiatry.2011.107.

    Article  Google Scholar 

  43. Wright AGC, Krueger RF, Hobbs MJ, Markon KE, Eaton NR, Slade T. The structure of psychopathology: toward an expanded quantitative empirical model. J Abnorm Psychol. 2013;122:281–94. https://doi.org/10.1037/a0030133.

    Article  Google Scholar 

  44. Eaton NR, Krueger RF, Markon KE, Keyes KM, Skodol AE, Wall M, et al. The structure and predictive validity of the internalizing disorders. J Abnorm Psychol. 2013;122:86–92. https://doi.org/10.1037/a0029598.

    Article  Google Scholar 

  45. Wright AGC, Hopwood CJ, Skodol AE, Morey LC. (2016). Longitudinal validation of general and specific structural features of personality pathology. J Abnorm Psychol. 2016;125(8):1120–34. https://doi.org/10.1037/abn0000165.

    Article  Google Scholar 

  46. Oltmanns JR, Smith GT, Oltmanns TF, Widiger TA. General factors of psychopathology, personality, and personality disorder: across domain comparisons. Clin Psychol Sci. 2018;6(4):581–9. https://doi.org/10.1177/2167702617750150.

    Article  Google Scholar 

  47. Asadi S, Bagby RM, Krueger RF, Pollock BG, Quilty LC. Reliability and construct validity of the general factor of personality disorder. Personal Disord. 2021. https://doi.org/10.1037/per0000539.

  48. Morey LC, Good EW, Hopwood CJ. Global personality dysfunction and the relationship of pathological and normal trait domains in the DSM-5 alternative model for personality disorders. J Pers. 2022;90(1):34–46. https://doi.org/10.1111/jopy.12560.

    Article  Google Scholar 

  49. Komasi S, Hemmati A, Rezaei F, Rahmani K, Miettunen J, Amianto F, et al. Comparison of the relative sensitivity of two dimensional personality models to the psychopathological symptoms: the section III DSM-5 maladaptive traits versus affective temperaments. BMC Psychiatry. 2022:503. https://doi.org/10.1186/s12888-022-04156-y.

  50. Chiappelli J, Kochunov P, DeRiso K, Thangavelu K, Sampath H, Muellerklein F, et al. Testing trait depression as a potential clinical domain in schizophrenia. Schizophr Res. 2014;159(1):243–8. https://doi.org/10.1016/j.schres.2014.08.003.

    Article  Google Scholar 

  51. Akiskal MHS, Puzantian VR. Psychotic forms of depression and mania. Psychiatr Clin North Am. 1979;2(3):419–39. https://doi.org/10.1016/S0193-953X(18)30987-0.

    Article  Google Scholar 

  52. Klaassen RM, Heins M, Luteijn LB, van der Gaag M, van Beveren NJ. Genetic risk and outcome of psychosis (GROUP) investigators; depressive symptoms are associated with (sub) clinical psychotic symptoms in patients with non-affective psychotic disorder, siblings and healthy controls. Psychol Med. 2013;43(4):747–56. https://doi.org/10.1017/S0033291712001572.

    Article  CAS  Google Scholar 

  53. Prochwicz K, Gawęda Ł. Depression and anxiety mediate the relationship between temperament and character and psychotic-like experiences in healthy subjects. Psychiatry Res. 2016;30(246):195–202. https://doi.org/10.1016/j.psychres.2016.09.037.

    Article  Google Scholar 

  54. Myin-Germeys I, van Os J. Stress-reactivity in psychosis: evidence for an affective pathway to psychosis. Clin Psychol Rev. 2007;27(4):409–24. https://doi.org/10.1016/j.cpr.2006.09.005.

    Article  Google Scholar 

  55. Fowler D, Hodgekins J, Garety P, Freeman D, Kuipers E, Dunn G, et al. Negative cognition, depressed mood, and paranoia: a longitudinal pathway analysis using structural equation modeling. Schizophr Bull. 2012;38(5):1063–73. https://doi.org/10.1093/schbul/sbr019.

    Article  Google Scholar 

  56. Kramer I, Simons CJ, Wigman JT, Collip D, Jacobs N, Derom C, et al. Time-lagged moment-to-moment interplay between negative affect and paranoia: new insights in the affective pathway to psychosis. Schizophr Bull. 2014;40(2):278–86. https://doi.org/10.1093/schbul/sbs194.

    Article  Google Scholar 

  57. Bebbington PE, McBride O, Steel C, Kuipers E, Radovanovic M, Brugha T, et al. The structure of paranoia in the general population. Br J Psychiatry. 2013;202:419–27. https://doi.org/10.1192/bjp.bp.112.119032.

    Article  Google Scholar 

  58. Masillo A, Day F, Laing J, Howes O, Fusar-Poli P, Byrne M, et al. Interpersonal sensitivity in the at-risk mental state for psychosis. Psychol Med. 2012;42(9):1835–45. https://doi.org/10.1017/S0033291711002996.

    Article  CAS  Google Scholar 

  59. Kendler KS. The clinical features of paranoia in the 20th century and their representation in diagnostic criteria from DSM-III through DSM-5. Schizophr Bull. 2017;43(2):332–43. https://doi.org/10.1093/schbul/sbw161.

    Article  Google Scholar 

  60. Bloomfield MAP, Chang T, Woodl MJ, Lyons LM, Cheng Z, Bauer-Staeb C, et al. Psychological processes mediating the association between developmental trauma and specific psychotic symptoms in adults: a systematic review and meta-analysis. World Psychiatry. 2021;20(1):107–23. https://doi.org/10.1002/wps.20841.

    Article  Google Scholar 

  61. Watson D, Levin-Aspenson HF, Waszczuk MA, Conway CC, Dalgleish T, Dretsch MN, et al. Validity and utility of hierarchical taxonomy of psychopathology (HiTOP): III. Emotional dysfunction superspectrum World Psychiatry. 2022;21(1):26–54. https://doi.org/10.1002/wps.20943.

    Article  Google Scholar 

  62. Krueger RF, Hobbs KA, Conway CC, Dick DM, Dretsch MN, Eaton NR, et al. Validity and utility of hierarchical taxonomy of psychopathology (HiTOP): II. Externalizing superspectrum World Psychiatry. 2021;20(2):171–93. https://doi.org/10.1002/wps.20844.

    Article  Google Scholar 

  63. Krueger RF, Eaton NR. Personality traits and the classification of mental disorders: toward a more complete integration in DSM-5 and an empirical model of psychopathology. Personal Disord. 2010;1(2):97–118. https://doi.org/10.1037/a0018990.

    Article  Google Scholar 

  64. Bebbington P. Recent findings in bipolar affective disorder. Psychol Med. 2004;34(5):767–76. https://doi.org/10.1017/S0033291704002855.

    Article  Google Scholar 

  65. Benazzi F. Impulsivity in bipolar-II disorder: trait, state, or both? Eur Psychiatry. 2007;22(7):472–8. https://doi.org/10.1016/j.eurpsy.2007.03.008.

    Article  Google Scholar 

  66. Malhi GS, Green M, Fagiolini A, Peselow ED, Kumari V. Schizoaffective disorder: diagnostic issues and future recommendations. Bipolar Disord. 2008;10:215–30. https://doi.org/10.1111/j.1399-5618.2007.00564.x.

    Article  Google Scholar 

  67. Pavlova B, Perlis RH, Mantere O, Sellgren CM, Isometsä E, Mitchell PB, et al. Prevalence of current anxiety disorders in people with bipolar disorder during euthymia: a meta-analysis. Psychol Med. 2017;47(6):1107–15. https://doi.org/10.1017/S0033291716003135.

    Article  CAS  Google Scholar 

  68. Ghaemi SN, Dalley S, Catania C, Barroilhet S. Bipolar or borderline: a clinical overview. Acta Psychiatr Scand. 2014;130(2):99–108. https://doi.org/10.1111/acps.12257.

    Article  CAS  Google Scholar 

  69. Zimmerman M, Morgan TA. The relationship between borderline personality disorder and bipolar disorder. Dialogues Clin Neurosci. 2013;15(2):155–69. https://doi.org/10.31887/DCNS.2013.15.2/mzimmerman.

    Article  Google Scholar 

  70. Zimmerman M, Martinez J, Young D, Chelminski I, Dalrymple K. Differences between patients with borderline personality disorder who do and do not have a family history of bipolar disorder. Compr Psychiatry. 2014;55(7):1491–7. https://doi.org/10.1016/j.comppsych.2014.05.012.

    Article  Google Scholar 

  71. Bach B, Kerber A, Aluja A, Bastiaens T, Keeley JW, Claes L, et al. International assessment of DSM-5 and ICD-11 personality disorder traits: toward a common nosology in DSM-5.1. Psychopathology. 2020;53(3):179–88. https://doi.org/10.1159/000507589.

    Article  Google Scholar 

  72. Perugi G, Fornaro M, Akiskal HS. Are atypical depression, borderline personality disorder and bipolar II disorder overlapping manifestations of a common cyclothymic diathesis? World Psychiatry. 2011;10(1):45–51. https://doi.org/10.1002/j.2051-5545.2011.tb00013.x.

    Article  Google Scholar 

  73. Henriques-Calado J, Gonçalves B, Marques C, Paulino M, Gama Marques J, Grácio J, et al. In light of the DSM-5 dimensional model of personality: borderline personality disorder at the crossroads with the bipolar spectrum. J Affect Disord. 2021;294:897–7. https://doi.org/10.1016/j.jad.2021.07.047.

    Article  Google Scholar 

  74. Rink L, Pagel T, Franklin J, Baethge C. Characteristics and heterogeneity of schizoaffective disorder compared with unipolar depression and schizophrenia: a systematic literature review and meta-analysis. J Affect Disord. 2016;191:8–14. https://doi.org/10.1016/j.jad.2015.10.045.

    Article  Google Scholar 

  75. Benabarre A, Vieta E, Colom F, Martínez-Arán A, Reinares M, Gastó C. Bipolar disorder, schizoaffective disorder and schizophrenia: epidemiologic, clinical and prognostic differences. Eur Psychiatry. 2001;16(3):167–72. https://doi.org/10.1016/S0924-9338(01)00559-4.

    Article  CAS  Google Scholar 

  76. Lake CR. Hypothesis: grandiosity and guilt cause paranoia; paranoid schizophrenia is a psychotic mood disorder; a review. Schizophr Bull. 2008;34(6):1151–62. https://doi.org/10.1093/schbul/sbm132.

    Article  Google Scholar 

  77. Tyrer P, Mulder R, Newton-Howes G, Duggan C. Galenic syndromes: combinations of mental state and personality disorders too closely entwined to be separated. Br J Psychiatry. 2022;220:309–10. https://doi.org/10.1192/bjp.2021.220.

    Article  Google Scholar 

  78. Hopwood CJ, Morey LC, Edelen MO, Shea MT, Grilo CM, Sanislow CA, et al. A comparison of interview and self-report methods for the assessment of borderline personality disorder criteria. Psychol Assess. 2008;20(1):81–5. https://doi.org/10.1037/1040-3590.20.1.81.

    Article  Google Scholar 

  79. Bach B, Anderson J, Simonsen E. Continuity between interview-rated personality disorders and self-reported DSM-5 traits in a Danish psychiatric sample. Personal Disord. 2017;8(3):261–7. https://doi.org/10.1037/per0000171.

    Article  Google Scholar 

  80. Fowler JC, Madan A, Allen JG, Patriquin M, Sharp C, Oldham JM, et al. Clinical utility of the DSM-5 alternative model for borderline personality disorder: differential diagnostic accuracy of the BFI, SCID-II-PQ, and PID-5. Compr Psychiatry. 2018;80:97–103. https://doi.org/10.1016/j.comppsych.2017.09.003.

    Article  Google Scholar 

  81. Calvo N, Valero S, Sáez-Francàs N, Gutiérrez F, Casas M, Ferrer M. Borderline personality disorder and personality inventory for DSM-5 (PID-5): dimensional personality assessment with DSM-5. Compr Psychiatry. 2016;70:105–11. https://doi.org/10.1016/j.comppsych.2016.07.002.

    Article  Google Scholar 

Download references

Acknowledgements

The authors wish to express their profound gratitude to all the study Participants, and to all the Staff and Host Institutions involved in the recruitment process and data collection. Special thanks to the remarkable Psychology research assistants Filipa Cameirinha, Inês Bouhon, Carina Cristino, and Inês Loureiro.

Funding

This work received national funding from FCT – Fundação para a Ciência e a Tecnologia, I. P [Foundation for Science and Technology] through the Research Center for Psychological Science of the Faculty of Psychology, University of Lisbon (UIDB/04527/2020; UIDP/04527/2020).

Author information

Authors and Affiliations

  1. Faculdade de Psicologia, Universidade de Lisboa, Alameda da Universidade, 1649-013, Lisboa, Portugal

    Joana Henriques-Calado, Rute Pires, Marco Paulino & Bruno Gonçalves

  2. CICPSI, Faculdade de Psicologia, Universidade de Lisboa, Alameda da Universidade, 1649-013, Lisboa, Portugal

    Joana Henriques-Calado, Rute Pires & Bruno Gonçalves

  3. Clínica Universitária de Psiquiatra e Psicologia Médica, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028, Lisboa, Portugal

    Marco Paulino & João Gama Marques

  4. Consulta de Esquizofrenia Resistente, Hospital Júlio de Matos, Centro Hospitalar Psiquiátrico de Lisboa, Avenida do Brasil, 53, 1749-002, Lisboa, Portugal

    João Gama Marques

Authors
  1. Joana Henriques-Calado
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rute Pires
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Marco Paulino
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. João Gama Marques
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Bruno Gonçalves
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

JHC designed the study, wrote the protocol, managed the literature searches, supervised the collection and evaluation of samples, performed the data analysis and interpretation, wrote the first draft of the manuscript; RP collaborated in the study design, project supervision and provided critical revisions; MP and JGM conducted and supervised the research process, provision of resources and provided critical revisions; BG collaborated in the study design, project supervision and provided critical revisions. All the authors contributed to and have approved the final manuscript.

Corresponding author

Correspondence to Joana Henriques-Calado.

Ethics declarations

Ethics approval and consent to participate

The present study received approval and authorization from the Ethics Committee of the researchers’ affiliation institution [Faculdade de Psicologia, Universidade de Lisboa, Portugal] and by the host institutions involved. The study was conducted in accordance with the latest version of the Declaration of Helsinki and in compliance with the European General Data Protection Regulation.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Henriques-Calado, J., Pires, R., Paulino, M. et al. Psychotic spectrum features in borderline and bipolar disorders within the scope of the DSM-5 section III personality traits: a case control study. bord personal disord emot dysregul 10, 2 (2023). https://doi.org/10.1186/s40479-022-00205-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s40479-022-00205-w

Keywords

Borderline Personality Disorder and Emotion Dysregulation

ISSN: 2051-6673