Bridges Between Bipolar and Borderline Personality Disorders: Clarifying Comorbidity Through the Analysis of the Complex Network of Connections Between Symptoms

Daniel Castro, Filipa Ferreira, Ana Sofia Mendes, Tiago Bento Ferreira


Background: The reasons for the high rates of comorbidity between Bipolar (BD) and Borderline Personality (BPD) disorders remain elusive, due to the vast array of shared clinical features, which makes the differential diagnosis difficult. This constitutes an obstacle to provide quality of care services, which results in detrimental effects on individual’s mental health. The analysis of the complex network of connections between symptoms of both disorders is a promising pathway to uncover the mechanisms underlying the comorbidity structure of both disorders. 

Goals: In this study, we explored the comorbidity network that represents the connections between 32 DSM-5 symptoms of BD and BPD in order to (1) compare its modular structure (i.e., the constitution of cohesive subgroups of symptoms within the comorbidity network) with the nosographic proposal of the DSM-5; (2) distinguish between the different roles those symptoms have in the comorbidity network and identify the symptoms that overlap and bridge both disorders, as well as the distinctive symptoms that better discriminate them; (3) identify the most central symptoms and those with the highest impact on the strength or on the structure of the connections on the comorbidity network; and (4) analyze the association between symptoms roles and their centrality and impact.

Methods: An epidemiological sample from the National Comorbidity Survey: Baseline (NCS) was analyzed. Data regarding bipolar and borderline personality symptoms were collected through the Composite Network International Diagnostic Interview (CIDI). The network of complex interactions between symptoms was estimated using the Ising model with the L1-regularization penalty (EBIC) and the nosographic structure was detailed with Moduland algorithms. 

Results: Data regarding an overall sample of 7556 individuals was analyzed (48.6% male, Mage = 33.400 years, SDage = 10.447). Results revealed differences between the modular structure of the comorbidity network and the DSM-5 nosographic proposal, namely about unstable relationships and substance abuse, that were assigned to the module constituted by symptoms of manic episode (ME). Symptoms such as money spending and sexual indiscretions, that overlap ME and BPD in the DSM-5, were assigned to the ME module. Psychomotor agitation, which overlaps depressive episode (DE) and ME in the DSM-5, was assigned to the DE module. Additionally, emptiness and worthlessness were identified as bridge symptoms between DE and BPD; anger and substance abuse between ME and BPD; and unstable relationships and psychomotor agitation between DE and ME. Fatigue was the most distinctive symptom of the DE module, unstable relationships of the ME module, and anger of the BPD module. Strength centrality (r = .61, 95%CI [.33, .79], p < .001) and modular bridgeness (r = .64, 95%CI [.38, .81], p < .001) were positively correlated with the impact on the structure of the comorbidity network; and modular overlap was negatively correlated with the impact on the strength (r = -.43, 95%CI [-.10, -.68], p = .01) of its connections. 

Discussion: Results suggest a similar structure of the comorbidity network to the nosographic proposal of DSM-5. Distinctive and bridge symptoms were identified for each disorder which might help with the differential diagnosis. It can also help us to unveil possible development pathways of comorbidity that might promote an improvement in psychological treatments. 

Keywords: Bipolar disorder, Borderline personality disorder, Network analysis, Comorbidity.  


Borderline; Bipolar; Network Analysis; Comorbidity


Afzali, M., Sunderland, M., Teesson, M., Carragher, N., Mills, K., & Slade, T. (2016). A network approach to the comorbidity between posttraumatic stress disorder and major depressive disorder: the role of overlapping symptoms. Journal of Affective Disorders, 208, 490-496. doi: 10.1016/j.jad.2016.10.037

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(6), 401–407. doi: 10.1111/j.1600-0447.2004.00461.x

Akiskal, H. S., Benazzi, F., Perugi, G., & Rihmer, Z. (2005). Agitated “unipolar” depression re-conceptualized as a depressive mixed state: implications for the antidepressant-suicide controversy. Journal of Affective Disorders, 85(3), 245–258. doi: 10.1016/j.jad.2004.12.004

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th edition). Washington: United States of America.

Anderson, A., Locke, J., Kretzmann, M., Kasari, C. (2016). Social network analysis of children with autism spectrum disorder: predictors of fragmentation and connectivity in elementary school classrooms. Autism, 20(6), 700–709. doi: 10.1177/1362361315603568.Social

Angst, J. (2013). Bipolar disorders in DSM-5: strengths, problems and perspectives. International Journal of Bipolar Disorders, 1(12), 1-3. doi:10.1186/2194-7511-1-12

Armour, C., Fried, E., Deserno, K., Tsai, J., & Pietrzak, H. (2016). A network analysis of DSM-5 posttraumatic stress disorder symptoms and correlates in U.S. military veterans. Journal of Anxiety Disorders, 45, 49–59. doi: 10.1016/j.janxdis.2016.11.008

Barrat, A., Barthelemy, M., Pastor-Satorras, R., & Vespignani, A. (2004). The architecture of complex weighted networks. Proceedings of the National Academy of Sciences of the United States of America, 101(11), 3747-3752. doi: 10.1073/pnas.0400087101

Barroilhet, S., Vöhringer, P. A., & Ghaemi, S. N. (2013). Borderline versus bipolar: differences matter. Acta Psychiatrica Scandinavica, 128(5), 385–386. doi: 10.1111/acps.12107

Bayes, A. J., & Parker, G. B. (2017). Clinical vs. DSM diagnosis of bipolar disorder, borderline personality disorder and their co-occurrence. Acta Psychiatrica Scandinavica, 135(3), 259–265. doi: 10.1111/acps.12678

Beard, C., Millner, J., Forgeard, C., Fried, I., Hsu, J., Treadway, T., & Björgvinsson, T. (2016). Network analysis of depression and anxiety symptom relationships in a psychiatric sample. Psychological Medicine, 46(16), 3359–3369. doi: 10.1017/S0033291716002300

Bekhuis, E., Schoevers, A., van Borkulo, D., Rosmalen, M., & Boschloo, L. (2016). The network structure of major depressive disorder, generalized anxiety disorder and somatic symptomatology. Psychological Medicine, 46(14), 1–10. doi:10.1017/S0033291716001550

Benazzi, F. (2005). Borderline personality-bipolar spectrum relationship. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 30(1), 68–74. doi: 10.1016/j.pnpbp.2005.06.010

Benazzi, F. (2008). A relationship between bipolar II disorder and borderline personality disorder? Progress in Neuro-Psychopharmacology and Biological Psychiatry, 32(4), 1022–1029. doi: 10.1016/j.pnpbp.2008.01.015

Borda, J. P. (2016). Self over time: another difference between borderline personality disorder and bipolar disorder. Journal of Evaluation in Clinical Practice, 22(4), 603–607. doi: 10.1111/jep.12550

Borsboom, D. (2017). A network theory of mental disorders. World Psychiatry 16(1), 5–13. doi: 10.1002/wps.20375

Borsboom, D. & Cramer, A. O. J. (2013). Network analysis: an integrative approach to the structure of psychopathology. Annual Review of Clinical Psychology, 9(1), 91–121. doi: 10.1146/annurev-clinpsy-050212-185608

Borsboom, D., Epskamp, S., Kievit, R. A., Cramer, A. O. J., & Schmittmann, V. D. (2011). Transdiagnostic networks. Perspectives on Psychological Science, 6(6), 610–614. doi: 10.1177/1745691611425012

Boschloo, L., Schoevers, R. A., van Borkulo, C. D., Borsboom, D., & Oldehinkel, A. J. (2016). The network structure of psychopathology in a community sample of preadolescents. Journal of Abnormal Psychology, 125(4), 599–606. doi: 10.1037/abn0000150

Boschloo, L., Van Borkulo, C. D., Rhemtulla, M., Keyes, K. M., Borsboom, D., & Schoevers, R. A. (2015). The network structure of symptoms of the diagnostic and statistical manual of mental disorders. PLOS ONE, 10(9), 1–12. doi: 10.1371/journal.pone.0137621

Calvo, N., Valero, S., Sáez-Francàs, N., Gutiérrez, F., Casas, M., & Ferrer, M. (2016). Borderline personality disorder and personality inventory for DSM-5 (PID-5): dimensional personality assessment with DSM-5. Comprehensive Psychiatry, 70, 105–111. doi: 10.1016/j.comppsych.2016.07.002

Cassano, B., Mula, M., Rucci, P., Miniati, M., Frank, E., Kupfer, J., & Fagiolini, A. (2009). The structure of lifetime manic-hypomanic spectrum. Journal of Affective Disorders, 112(1–3), 59–70. doi: 10.1016/j.jad.2008.04.019

Collins, F. S. & Varmus, H. (2015). A new initiative on precision medicine. The New England Journal of Medicine, 372(9), 793-795. doi: 10.1056/NEJMp1500523

Cramer, A., Waldorp, L., Maas, H., & Borsboom, D. (2010). Comorbidity: a network perspective. Behavioral and Brain Sciences, 33(2), 137–193. doi:10.1017/S0140525X09991567

di Giacomo, E., Aspesi, F., Fotiadou, M., Arntz, A., Aguglia, E., Barone, L., Bellino, L., Carpiniero, B., Colmegna, F., Lazzari, M., Lorettu, L., Pinna, F., Sicaro, A., BRT Group, Clerici, M. (2017). Unblending borderline personality and bipolar disorders. Journal of Psychiatric Research, 91, 90–97. doi: 10.1016/j.jpsychires.2017.03.006

Eaton, R. (2015). Latent variable and network models of comorbidity: toward an empirically derived nosology. Social Psychiatry and Psychiatric Epidemiology, 50(6), 845–849. doi:10.1007/s00127-015-1012-7

Eisner, R., Johnson, L., Youngstrom, A., & Pearlstein, G. (2017). Simplifying profiles of comorbidity in bipolar disorder. Journal of Affective Disorders, 220, 102–107. doi: 10.1016/j.jad.2017.05.045

Epskamp, S., & Fried, I. (2017). bootnet: Bootstrap methods for various network estimation routines. Package for the free statistical environment R

Epskamp, S., Borsboom, D., & Fried, I. (2016). Estimating psychological networks and their accuracy: a tutorial paper. Behavior Research Methods, 1-18. doi: 10.3758/s13428-017-0862-1

Epskamp, S., Cramer, A., Waldorp, J., Schmittmann, D., & Borsboom, D. (2012). qgraph: network visualizations of relationships in psychometric data. Journal of Statistical Software, 48(4). doi: 10.18637/jss.v048.i04

Ferentinos, P., Fountoulakis, N., Lewis, M., Porichi, E., Dikeos, D., Papageorgiou, C., & Douzenis, A. (2017). Validating a two-dimensional bipolar spectrum model integrating DSM-5’s mixed features specifier for major depressive disorder. Comprehensive Psychiatry, 77, 89–99. doi: 10.1016/j.comppsych.2017.06.007

Fernandez, E., & Johnson, L. (2015). Anger in psychological disorders: prevalence, presentation, etiology and prognostic implications. Clinical Psychology Review, 46, 124–135. doi: 10.1016/j.cpr.2016.04.012

Fisher, A. J. (2015). Toward a dynamic model of psychological assessment: implications for personalized care. Journal of Consulting and Clinical Psychology, 83(4), 825–836. doi: 10.1037/ccp0000026

Fisher, A. J., & Boswell, J. F. (2016). Enhancing the personalization of psychotherapy with dynamic assessment and modeling. Assessment, 23(4), 496–506. doi: 10.1177/1073191116638735

Fonseka, T. M., Swampillai, B., Timmins, V., Scavone, A., Mitchell, R., Collinger, K. A., & Goldstein, B. I. (2015). Significance of borderline personality-spectrum symptoms among adolescents with bipolar disorder. Journal of Affective Disorders, 170, 39–45. doi: 10.1016/j.jad.2014.08.046

Frías, Á., 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. doi: 10.1016/j.jad.2016.05.048

Fried, E., Epskamp, S., Nesse, R., Tuerlinckx, F., & Borsboom, D. (2016). What good depression symptoms? comparing the centrality of dsm and non-dsm symptoms of depression in a network analysis. Journal of Affective Disorders, 189, 314-320. doi: 10.1016/j.jad.2015.09.005

Fried, E., van Borkulo, D., Cramer, A., Boschloo, L., Schoevers, A., & Borsboom, D. (2017). Mental disorders as networks of problems: a review of recent insights. Social Psychiatry and Psychiatric Epidemiology, 52(1), 1–10. doi: 10.1007/s00127-016-1319-z

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(6), 763–772. doi: 10.1521/pedi.2010.24.6.763

Ghaemi, N., Dalley, S., Catania, C., & Barroilhet, S. (2014). Bipolar or borderline: a clinical overview. Acta Psychiatrica Scandinavica, 130(2), 99–108. doi: 10.1111/acps.12257

Goekoop, R. & Goekoop, J. G. (2014). A network view on psychiatric disorders: network clusters of symptoms as elementary syndromes of psychopathology. PLOS ONE, 9(11), 1–47. doi: 10.1371/journal.pone.0112734

Goodwin, F. & Jamison, K. (2007). Manic-Depressive Illness Bipolar Disorders and Recorrent Depression. New York: Oxford.

Grant, B., Stinson, F., Dawson, D., Chou, P., Dufour, M., Compton, W. Pickering, R., Kaplan, K. (2006). Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the national epidemiologic survey on alcohol and related conditions. Alcohol Research & Health, 29(2), 107–120. doi: 10.1001/archpsyc.61.8.807

Hatchett, G. (2010). Differential diagnosis of borderline personality disorder from bipolar disorder. Journal of Mental Health Counseling, 32(3), 189–205. doi: 10.17744/mehc.32.3.n682682184554445

Henry, C., Mitropoulou, V., New, S., Koenigsberg, W., Silverman, J., & Siever, J. (2001). Affective instability and impulsivity in borderline personality and bipolar II disorders: similarities and differences. Journal of Psychiatric Research, 35(6), 307–312. doi: 10.1016/S0022-3956(01)00038-3

Hirschfeld, M., Lewis, L., & Vornik, L. (2003). Perceptions and impact of bipolar disorder: how far have we really come? results of the national depressive and maniac-depressive association 2000 survey of individuals with bipolar disorder. Journal of Clinical Psychology, 64(2), 161-74. doi: 10.4088/JCP.v64n0209

Isvoranu, M., Borsboom, D., van Os, J., & Guloksuz, S. (2016). A network approach to environmental impact in psychotic disorder: brief theoretical framework. Schizophrenia Bulletin, 42(4), 870–873. doi: 10.1093/schbul/sbw049

JASP Team. (2016). JASP (Version Retrieved from https://

Jones, P. (2017). Impact: a new network statistic for network analysis (networktools). Package for the free statistical software R.

Jones, J., Mair, P., Riemann, B. C., Mugno, B. L., & McNally, R. J. (2017). A network perspective on comorbid depression in adolescents with obsessive-compulsive disorder. Journal of Anxiety Disorders, 53, 1-8. doi: 10.1016/j.janxdis.2017.09.008

Kessler, B., Borges, E., & Walters, E. (1999). Prevalence of and risk factors for lifetime suicide attempts in the national comorbidity survey. Archives of General Psychiatry, 56(7), 617–626. doi: 10.1001/archpsyc.56.7.617

Kessler, R. C. & Üstün, B. B. (2004). The world mental health (WMH) survey initiative version of the world health organization (WHO) composite international diagnostic interview (CIDI). International Journal of Methods in Psychiatric Research, 13(2), 93–117. doi: 10.1002/mpr.168

Koenigsberg, H. W., Harvey, P. D., Mitropoulou, V., Schmeidler, J., New, A. S., Goodman, M., & Siever, L. J. (2002). Characterizing affective instability in borderline personality disorder. American Journal of Psychiatry, 159(5), 784–788. doi: 10.1176/appi.ajp.159.5.784

Levinson, A., Zerwas, S., Calebs, B., Kordy, H., Hofmeier, S., Collaborative, V., & Bulik, M. (2017). The core symptoms of bulimia nervosa, anxiety, and depression: a network analysis. Journal of Abnormal Psychology, 126(3), 340–354. doi: 10.1037/abn0000254

Lewis, K., Caputi, P., & Grenyer, B. (2012). Boderline personality disorder subtypes: a factor analysis of the DSM IV criteria. Personality and Mental Health, 6(3), 196-206. doi: 10.1002/pmh.1183

Malhi, S., Fritz, K., Allwang, C., Burston, N., Cocks, C., Devlin, J., & Lyndon, W. (2016). Are manic symptoms that “dip” into depression the essence of mixed features? Journal of Affective Disorders, 192, 104–108. doi: 10.1016/j.jad.2015.12.009

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. doi: 10.1016/j.comppsych.2015.01.004

Messer, T., Lammers, G., Müller-Siecheneder, F., Schmidt, R.-F., & Latifi, S. (2017). Substance abuse in patients with bipolar disorder: a systematic review and meta-analysis. Psychiatry Research, 253, 338–350. doi: 10.1016/j.psychres.2017.02.067

Morris, R., Yang, M., Chopra, A., Bentall, R., Paykel, E., & Scott, J. (2013). Differential effects of depression and mania symptoms on social adjustment: prospective study in bipolar disorder. Bipolar Disorders, 15(1), 80–91. doi: 10.1111/bdi.12036

Opsahl, T., Agneessens, F., & Skvoretz, J. (2010). Node centrality in weighted networks: Generalizing degree and shortest paths. Social Networks, 32, 245-25. doi: 10.1016/j.socnet.2010.03.006

Paris, J., Gunderson, J., & Weinberg, I. (2007). The interface between borderline personality disorder and bipolar spectrum disorders. Comprehensive Psychiatry, 48(2), 145–154. doi: 10.1016/j.comppsych.2006.10.001

Pennay, A., Cameron, J., Reichert, T., Strickland, H., Lee, N. K., Hall, K., & Lubman, D. I. (2011). A systematic review of interventions for co-occurring substance use disorder and borderline personality disorder. Journal of Substance Abuse Treatment, 41(4), 363–373. doi: 10.1016/j.jsat.2011.05.004

Perugi, G., Angst, J., Azorin, J. M., Bowden, C., Vieta, E., & Young, A. H. (2013). The bipolar-borderline personality disorders connection in major depressive patients. Acta Psychiatrica Scandinavica, 128(5), 376–383. doi: 10.1111/acps.12083

R Development Core Team. (2008). R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing.

Rhemtulla, M., Fried, E., Aggen, H., Tuerlinckx, F., Kendler, S., & Borsboom, D. (2016). Network analysis of substance abuse and dependence symptoms. Drug and Alcohol Dependence, 161, 230–237. doi: 10.1016/j.drugalcdep.2016.02.005

Richetin, J., Preti, E., Costantini, G., & De Panfilis, C. (2017). The centrality of affective instability and identity in borderline personality disorder: evidence from network analysis. PLOS ONE, 12(10). doi: 10.1371/journal.pone.018669

RStudio Team (2017). RStudio: Integrated Development for R. RStudio, Inc., Boston, MA URL

Ruggero, C. J., Zimmerman, M., Chelminski, I., & Young, D. (2010). Borderline personality disorder and the misdiagnosis of bipolar disorder. Journal of Psychiatric Research, 44(6), 405–408. doi: 10.1016/j.jpsychires.2009.09.011

Rugkåsa, J., Yeeles, K., Molodynski, A., & Burns, T. (2015). Reply. Acta Psychiatrica Scandinavica, 132(4), 310–310. doi: 10.1111/acps.12465

Shannon, P., Markiel, A., Owen Ozier, 2, Baliga, N. S., Wang, J. T., Ramage, D., Amin, N., Schwikowski, B, & Ideker, T. (2003). Cytoscape: a software environment for integrated models of biomolecular interaction networks. Genome Research, 13(11), 2498–2504. doi: 10.1101/gr.1239303.metabolite

Siegel, R., Hoeppner, B., Yen, S., Stout, R., Weinstock, L., Hower, H., Birmaher, B., Goldstein, T., Goldstein, B., Hunt, J., Strober, M., Axelson, D., Gill, M., & Keller, M. (2015). Longitudinal associations between interpersonal relationship functioning and mood episode severity in youth with bipolar disorder. Journal of Nervous and Mental Disease, 203(3): 194–204. doi:10.1097/NMD.0000000000000261

Soler, A., Soler, J., Elices, M., Pascual, J. C., Pérez, J., Martín-Blanco, A., & Portella, M. J. (2013). Differences in attention and impulsivity between borderline personality disorder and bipolar disorder. Psychiatry Research, 210(3), 1307–1309. doi: 10.1016/j.psychres.2013.09.011

Szalay-Beko, M., Palotai, R., Szappanos, B., Kovács, I. A., Papp, B., & Csermely, P. (2012). ModuLand plug-in for cytoscape: determination of hierarchical layers of overlapping network modules and community centrality. Bioinformatics, 28(16), 2202–2204. doi:10.1093/bioinformatics/bts352

van Borkulo, C. D., Borsboom, D., Epskamp, S., Blanken, T. F., Boschloo, L., Schoevers, R. a, & Waldorp, L. J. (2014). A new method for constructing networks from binary data. Scientific Reports, 4(5918). doi: 10.1038/srep05918

van Borkulo, C., Boschloo, L., Borsboom, D., Penninx, H., Waldorp, J., & Schoevers, A. (2015). Association of symptom network structure with the course of longitudinal depression. JAMA Psychiatry, 72(12), 1219-26. doi:10.1001/jamapsychiatry.2015.2079

Vöhringer, A., Barroilhet, A., Alvear, K., Medina, S., Espinosa, C., Alexandrovich, K., Riumallo, P., Leiva, F., Hurtado, E., Cabrera, J., Sullivan, M., Holtzman, N., & Ghaemi, S. N. (2016). The international mood network nosology project: differentiating borderline personality disorder from bipolar illness. Acta Psychiatrica Scandinavica, 134(6), 504-510. doi: 10.1111/acps.12643

Wilson, T., Stanley, B., Oquendo, A., Goldberg, P., Zalsman, G., & Mann, J. (2007). Comparing impulsiveness, hostility, and depression in borderline personality disorder and bipolar II disorder. Journal of Clinical Psychiatry, 68(10), 1533–9. doi: 10.1001/archpsyc.1992.01820080032005

World Health Organization. (1990). Composite international diagnostic interview (CIDI), Version 1.0) Geneva: World Health Organization.

Zimmerman, M., & Morgan, T. A. (2013). The relationship between borderline personality disorder and bipolar disorder. Dialogues in Clinical Neuroscience, 15(2), 155–169. doi: 10.1176/appi.ajp.163.7.1126

Zimmerman, M., Martinez, J., Young, D., Chelminski, I., Morgan, A., & Dalrymple, K. (2014). Comorbid bipolar disorder and borderline personality disorder and history of suicide attempts. Journal of Personality Disorders, 28(3), 358-364. doi: 10.1521/pedi_2013_27_122



  • There are currently no refbacks.