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Dysphoria Dimensions: a Preliminary Inpatients Study to Diffrentiate

Borderline Personality and Bipolar Disorder Spectrum

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Psychiatria Danubina, 2019; Vol. 31, Suppl. 3, pp 044-243 Conference paper
© Medicinska naklada - Zagreb, Croatia

DYSPHORIA DIMENSIONS: A PRELIMINARY INPATIENTS

STUDY TO DIFFRENTIATE BORDERLINE PERSONALITY
AND BIPOLAR DISORDER SPECTRUM
Massimo C. Bachetti, Francesca Brufani, Giulio Spollon & Patrizia Moretti
Division of Psychiatry, Department of Medicine, University of Perugia, Perugia, Italy

SUMMARY
Background: Differentiating Borderline Personality Disorder (BPD) from Bipolar Disorder (BD) represents a very difficult
challenge for clinicians. Dysphoria could be a possible key to differentiate these disorders. We currently define dysphoria as a
complex and disorganized emotional state with proteiform phenomenology, characterized by a multitude of symptoms. Among them
irritability, discontent, interpersonal resentment and surrender prevail. These dimensions can be detected using the Neapen
Dysphoria Scale - Italian version (NDS-I). Dysphoria role in BPD has been highlighted by the recent theorization of the
Interpersonal Dysphoria Model, according to which dysphoria could represent the “psychopathological organizer” of the BPD. On
the other side, dysphoria role in BD has not yet been established. This is simply considered as an aspect, and not fundamental, of the
symptomatology characterizing BD, especially in mixed states patients. The phenomenological analysis of the dimensional spectrum
of dysphoria within BPD and DB could provide a valuable aid in the differential diagnosis between BPD and BD.
Aims: The aim of this paper is to verify if the dimensional spectrum of dysphoria differs between Borderline Personality
Disorder (BPD) and Bipolar Disorder Spectrum (BD) through an observational comparative study
Subjects and methods: In this study, 65 adult patients, males and females between the ages of 18 and 65, were enrolled from the
Psychiatric Service of the Santa Maria della Misericordia Hospital in Perugia (PG), Italy, from January 1st 2018 to April 30th 2019.
We have formed 2 groups. A BPD group composed of 33 patients (19 female patients, representing approximately 57.6 % of the
sample) and a BD group composed of 32 patients (18 Female patients, representing approximately 56.2% of the sample). Patient’s
comorbid with BD and BPD have been excluded from the study. After a preliminary assessment to exclude organic and psychiatric
comorbidity, and after at least 72 hours from hospitalization, we administered them the Neapen Dysphoria Scale - Italian Version
(NDS-I), a specific dimensional test for dysphoria. Starting from the dataset, with the aid of the statistical program SPSS 20, we have
carried out a comparison between disorders groups selected and their NDS-I total score and subscales (irritability, discontent,
interpersonal resentment, surrender); For this we have used the Mann-Whitney U test, a nonparametric test with 2 independent
samples, by setting a significance level p<0.05.
Conclusions: This study allowed us to explore and analyze dysphoria dimensions expressions in BPD and BD. Despite the small
sample analyzed, the results show a significant different dimensional spectrum expression of the dysphoria between the two dis-
orders. In particular, Surrender and Interpersonal Resentment dimensions show greater interest in BPD than BD spectrum. Further
studies with a larger and stratified sample are needed to confirm these results.

Key words: dysphoria - borderline personality disorder - bipolar disorder - NDS-I - neapen dysphoria scale italian version

* * * * *

INTRODUCTION 2018). Only studying these variations of dysphoria

dimension between BPD and BD patient groups we can
Differentiate Borderline Personality Disorder (BPD) think to move forward in the direction to considering
from Bipolar Disorder (BD) represents a very difficult dysphoria dimensional spectrum analysis a possible key
challenge for clinicians. feature to differentiate these two disorders.
Despite many clinicians and researchers claim that the Our group have already studied the possible diffe-
DPB belongs to the spectrum of bipolar disorder (Akiskal rent expression of dysphoria dimensions in three diffe-
2004, Perugi et al. 2013), several studies have been carr- rent psychopathological disorders (Moretti et al. 2018),
ied out in the attempt to find a valid diagnostic instrument but the three samples was too small for a valid and
that could easily distinguish these two disorders. generalized conclusion.
To date there are not genetic, imaging or blood tests This time, using a similar paradigm, we want to
that have provided such accuracy values to be consi- enlarge the samples by focusing on BPD and BD and
dered biomarkers of differentiation between BPD and observing the expression of their dysphoria patterns.
BD (Paris & Black 2015).
Our principal aim is not providing a clinical instru- DYSPHORIA
ment to obtain this differentiation but analyzing the
quantitative and qualitative expression of dysphoria A Possible Definition
dimensions within these disorders that can be useful in The word “dysphoria” came into English from the
the next future to helping clinicians to obtain a possible Ancient Greek word δυσφορία (dysphoria), which means
clinical tool for a differential diagnosis (Moretti et al. “excessive pain”. The Greek word itself is a compound

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 Massimo C. Bachetti, Francesca Brufani, Giulio Spollon & Patrizia Moretti: DYSPHORIA DIMENSIONS: A PRELIMINARY INPATIENTS
STUDY TO DIFFRENTIATE BORDERLINE PERSONALITY AND BIPOLAR DISORDER SPECTRUM
Psychiatria Danubina, 2019; Vol. 31, Suppl. 3, pp 203-213

noun: it’s made up of two Greek words δυσ- (dus-, represents the Italian version of the homonymous NDS
“bad”) and φέρω (phérō, “I bear, carry”). introduced in Australia by Starcevic et al. in 2007. This
Its usage in heterogeneous clinical areas contributes auto-administered test consists of 24 items in Likert
to the lack of clarity and imprecision that hovers around scale from 0 to 4. At the end of the test it is possible
the specific meaning of the term itself. obtain a specific Total Score, that provides a rough
Usually, the term is used to indicate a generic state assessment of the degree of dysphoria, and additional
of dissatisfaction and affective instability, characterized scores divided into 4 subscales that represent the dimen-
at the same time by anxiety and depression, without any sions of the dysphoria (irritability, discontent, personal
specific feature. This wide range of situations in which and interpersonal resentment, renunciation / surrender).
this term is applied often implies an implicit and shared The test has not any cut-off and represents a dimen-
meaning, with no need of definition. sional, non-nosographic tool. That means, hopefully,
We have already tried to define dysphoria, in our that it might show the severity of the symptomatology
previous work (Moretti et al. 2018), as a complex and and above all if some domains are more involved than
disorganized emotional state with proteiform phenome- others. Unfortunately, it has not been validated yet on
nology characterized by a multitude of symptoms: irri- a large scale. Although the psychometric properties are
tability, discontent, interpersonal resentment and surren- excellent for the healthy population, they have not
der (Starcevic et al. 2007, 2013). Dysphoria appears to been verified yet in the pathological population
be an unstable and unpredictable “entity”. Generally, we (D'Agostino et al. 2016).
consider it as a temperamental tract, but its manifesta-
tion arises in response to environmental stimuli, espe- Dysphoria Phenomenology in Borderline
cially to adverse ones, from which it is often modulated. Personality and Bipolar Disorder Spectrum
Many clinicians and researchers considered dys-
Dimensions of Dysphoria phoria as a nonspecific psychopathological phenome-
Generic traits apart, dysphoria could be characte- non inscribed in a multitude of psychiatric disorders
rized exquisitely by three specific components: tension, (D’Agostino et al. 2017) including, for example, Bipo-
irritability and urge (D’Agostino et al. 2016). lar Disorder (BD), in particular Mixed-States, Major
Tension is a condition of strong emotional pressure Depressive Disorder (MDD), Post-Traumatic Stress Dis-
caused by deflection of the mood, chronic and undefined order (PTSD), Feeding and Eating Disorders (FED),
unhappiness and extremely extended and persistent dis- Personality Disorders where Borderline Personality Dis-
content, which leads the subject to surrender. In addition, order (BPD) occupies a privileged position, but also in
there is a persistent state of oppressive, often ambivalent, others generic neurological and medical disorders.
painful expectation of the present and the future. This point of view represents a superficial generic
Irritability refers to a state of constant and annoying vision of the dysphoria’s manifestations, especially if
restlessness, worry and incessant anxiety. Similar to a we focus on its different dimensional expression in
sensation of adversity towards the world that leads the these various disorders.
subject to assume a suspicious, hostile and resentful atti- Considering BPD dysphoria appears to be a cha-
tude towards the environment and the people around him. racterizing and disabling psychopathological element.
Urge, finally, is characterized by impatience and in- BPD patient suffers continuous disturbances of his
tolerance, by an irresistible need to act, which often affective sphere. These disturbances are characterized
leads to the appearance of self-harm behaviour. The ac- by behavioral reactions often disproportionate and in-
tion, in the dysphoric patient, is always a violent action; adequate compared to the real gravity of the stimulus
violence not necessarily with a physical meaning, but event. Dysphoria fits between subjective perception and
rather referred to the great intensity of emotions that behavioral response.
invest the subject. The patient tries to get out from his Dysphoria replaces the normal neuromodulatory
discomfort state through the action, thus trying to mechanisms that leads a healthy subject to separate the
modulate, in some way, the dysphoric state. real distance between the severity of the external
objective event and the severity of the representation of
the same event to provide an adequate response. Thus,
NDS-I a New Clinical Tool for a
we can imagine that if these modulator mechanisms fail,
New Dysphoria Approach
or become dysregulated, the inability to control one's
As reported in our last work (Moretti et al. 2018), to emotions prevails. These can be so amplified as to make
differentiate various dysphoria dimensions, we need a the subject a slave to his emotions and to their
new test capable to detect the shades of dysphoria continuous variability base on environmental stimuli. In
spectrum. In our opinion, the best test suited for this job severe cases, the subject, who over time has learned to
seems to be, in our opinion, the Neapen Dysphoria identify him-self with the emotional reactions elicited
Scale - Italian Version (NDS-I). It has been translated by external event, ends up losing the boundaries
and adapted in Italian by D'Agostino et al. in 2016 and between the Self and the object (Moretti et al. 2018).

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 Massimo C. Bachetti, Francesca Brufani, Giulio Spollon & Patrizia Moretti: DYSPHORIA DIMENSIONS: A PRELIMINARY INPATIENTS
STUDY TO DIFFRENTIATE BORDERLINE PERSONALITY AND BIPOLAR DISORDER SPECTRUM
Psychiatria Danubina, 2019; Vol. 31, Suppl. 3, pp 203-213

In BD disorder, dysphoria seems play an important This summary wants to show the necessity of fin-
role during maniac phase and in the Mixed-State. This ding new tools that could help clinicians easily differen-
one seems very similar to BPD (Perugi et al. 2016), tiating patients affected by these two disturbs in order to
often is very difficult to differentiate these disorders start a correct and prompt treatment (Bassett et al. 2017).
only with clinical interview. Dysphoria phenomenology To do so, many authors, suggest the use of tests in
for BD is unknown yet. Our aim is trying to study its addition to clinical interview which is still to consider
spectrum to highlighting any differences compared with the gold standard (Vöhringer et al. 2016, Mneimne et al.
BPD, 2017, Di Giacomo et al. 2017).
Our aim is to show how the clinical dimension of
Bordeline Personality and Bipolar Disorder: dysphoria could be a helpful tool, useful in differentia-
A Comparison ting BPD and BD, as already shown in our preliminary
work (Moretti et al. 2018).
Looking at the recent scientific literature we must
highlight the difficulty that many researchers and Aims
clinicians have in marking a clear demarcation line
between Borderline Personality and Bipolar Disorder The primary goal of this work, starting from the
Spectrum. positive results of our previous work (Moretti et al.
Despite the very large number of studies on this 2018) with a larger patient’s sample, is to verify if the
topic the scientific community has yet to clarify if BPD dimensional spectrum that composes dysphoria differs
represents a part of the wider Bipolar Spectrum (Perugi between Borderline Personality Disorder (BPD) and
et al. 2013), or if it has its own phenomenology. It is Bipolar Disorder Spectrum (BD) through an observa-
even less clear the comorbidity interrelation between tional comparative study.
these two nosographic identities; epidemiological
comorbidity data shared by many authors tends not to SUBJECTS AND METHODS
correspond: some authors sustain a 20% prevalence
In this study, 65 males and female patients affected
(Fornaro et al. 2016, Frìas et al. 2016), others show a
by Borderline Personality Disorder (BPD) and Bipolar
prevalence as close as 14% (Brieger et al. 2003), some
Disorder Spectrum (BD) between the ages of 18 and 65,
other declares a prevalence as low as 3.6% (Di Giacomo
were enrolled from the Psychiatric Unit of the Santa
et al. 2017). Because of these differences, some author
Maria della Misericordia Hospital in Perugia, Italy,
supports the extreme conviction that a dichotomic from January 1st 2018 to April 30th, 2019. We have
vision of these two disturbs is not useful in the everyday formed 2 groups. A BPD group consisted of 33 pa-
clinical practice. tients (19 female patients, representing approximately
The difference shown in the data above probably 57.6 % of the sample), and a BD group consisted of 32
reflects the difficulty clinicians have in clinically diffe- patients (18 female patients, representing approxima-
rentiating symptoms overlapping between BPD and BD, tely 56.2% of the sample).
e.g. mood instability or impulsivity (Vöhringer et al. Once eligible patients were identified, we procee-
2016). In addition to this we would remark how difficult ded carrying out their history and clinical information,
could be making a differential diagnosis in the short through clinical interview and using other clinical tools
times required, for example, in an impatient clinic. In like Structured Clinical Interview for DSM-5-Clinical
fact, in a psychiatric ward, it is hard to immediately Version (SCID-5-CV) to detect major psychiatric dis-
differ these two disorders in a patient with a new onset orders, the Structured Clinical Interview for DSM - II
right because of this overlapping. In 2016 editorial three (SCID-II) and Minnesota Multiphasic Personality Inven-
characteristics were considered to be fundamental in tory - 2 (MMPI-2), to detect personality disorders.
order to differentiate BPD and BD: childhood sexual After selecting patients with BPD or BD, those who
abuse, repeated self-harm, depersonalization (Ghaemi had other medical, psychiatric comorbidities and current
2016). Particularly the author supported the presence of history of substance use were excluded from the study
childhood sexual abuse in the patience history as an to avoid confounding factors.
important factor helping the clinician in the diagnosis of Patients agreed to give their informed consent accor-
BPD compared to BD. ding to the current EU regulations on privacy through
Certainly, traumatic events, not only sexual ones, an information talk and related information form, with
significantly contribute in the development of BD, but the possibility for patients to withdraw at any stage of
this is not the only element involved and many patients the study.
do not have such a history, mainly because reluctant to Once the consents were obtained we continued ad-
talk about it, but also because they didn’t have such ministering the NDS-I test to the patients, prior instruc-
traumatic events. It is important to consider as well one ting them in its correct compilation. NDS-I test was
more difficulty when facing patients with traumatic given to patients at least after 78 hours from the hospi-
event in their history: the overlapping symptoms bet- talization, to avoid that the disorder’s burst phase could
ween BD and PTSD. alter test results. After that, we collected and re-pro-

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 Massimo C. Bachetti, Francesca Brufani, Giulio Spollon & Patrizia Moretti: DYSPHORIA DIMENSIONS: A PRELIMINARY INPATIENTS
STUDY TO DIFFRENTIATE BORDERLINE PERSONALITY AND BIPOLAR DISORDER SPECTRUM
Psychiatria Danubina, 2019; Vol. 31, Suppl. 3, pp 203-213

cessed the patients tests in a specific database. Since the

NDS-I test is a dimensional tool there is no cut-off,
therefore, its goal is not to define whether a subject is
dysphoric, but rather showing which dysphoria domains
are more relevant. To do that we extrapolated the scores
of the individual items expressed on the Likert scale and
we calculated the scores of the four subscales as
indicated by D'Agostino et al. 2016.
The data obtained have been reported in a specific
database. Because of the small size of the samples, it
has been decided to avoid the division by gender and to
consider males and females indiscriminately within the
reference group. Starting from the dataset, with the aid Figure 2. Comparison between groups of patients and
of the statistical program SPSS 20, we obtained data the NDS-I Irritability Subscale Score
showing the comparison between the two groups se-
lected and NDS-I total score and subscales.
Finally, we took the scores of NDS-I subscales and
total scores for each group and then we compared these
values. We did it using the Mann-Whitney U test, a
nonparametric test with 2 independent samples, by
setting a significance level p<0.05.

RESULTS
At first, we obtained graphs from data. From these
we tried to highlight some differential dimensional
aspects between the expression of the total score and the
various subscales of the NDS-I between BPD and BD Figure 3. Comparison between groups of patients and
patient’s groups. the NDS-I Discontent Subscale Score
In Figure 1 we can see how the group of BPD pa-
tients has a higher total score, therefore a higher decla-
red degree of dysphoria, compared to the other group in
line with our predictions.
In Figure 2 we have analyzed the dimension of irri-
tability. In this dimension, BPD group showed a greater
grade of irritability compared with BD patients.
In Figure 3 we can observe a substantial overlap bet-
ween the two disorders groups linear diagram regarding
the discontent dimension.
In Figure 4, analyzing the interpersonal resentment,
we noticed a very important difference between the ex-
pression of this dimension in the BPD group compared
with BD group, larger than a previous study (Moretti et Figure 4. Comparison between groups of patients and
al. 2018). the NDS-I Interpersonal Resentment Subscale Score

Figure 1. Comparison between groups of patients and Figure 5. Comparison between groups of patients and
the NDS-I Total Score the NDS-I Surrender Subscale Score

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 Massimo C. Bachetti, Francesca Brufani, Giulio Spollon & Patrizia Moretti: DYSPHORIA DIMENSIONS: A PRELIMINARY INPATIENTS
STUDY TO DIFFRENTIATE BORDERLINE PERSONALITY AND BIPOLAR DISORDER SPECTRUM
Psychiatria Danubina, 2019; Vol. 31, Suppl. 3, pp 203-213

Table 1. Arithmetic mean of the scores of the NDS-I test with reference to the BPD an BD groups
Borderline Personality Disorder Bipolar Disorder
NDS-I Total Score Mean 73.72 60.81
Irritability Score Mean 28.24 23.22
Discontent Score Mean 18.30 12.35
Interpersonal Resentment Score Mean 15.96 10.44
Surrender Score Mean 11.21 9.25

Table 2. Confrontation between BPD and BD groups using U Mann-Whitney test with a significance level p<0.05
NDS Total Score NDS Irritability NDS Discontent NDS Interpersonal Resent NDS Surrender
U di Mann-Whitney 98,500 172,000 479,000 121,500 326,000
Sig. Asint. 2 tails 0.000 0.000 0.514 0.000 0.008
(significance level)

In Figure 5, we observe a significant prevalence of normal statistical population, but there was too much
the surrender dimension in BPD patients compared to difference between two groups. Gender and age were
BD group. In this case data appears more widespread too widespread. Next studies must consider this problem
and clinically not worthy of value. and make more homogeneous samples.
In Table 1 we have translated and resumed in nume- The third limitation concerns the NDS-I test. This
rical language what we have analyzed until now, test, as already mentioned in a precedent work (Moretti
arithmetic means it’s been calculated to show the same et al. 2018), has not been validated yet in Italy and its
differences saw in graphs analysis. In particular, if we psychometric properties have been evaluated exclu-
pay attention to means values for each subscale, the sively in a sample of healthy subjects. This test was
different dysphoria expression is easily understandable selected to respond to the studies aim to analyze dys-
in these two disorders, even if only qualitatively. phoria dimensions construct and there is no other test
At last, data obtained with Mann-Whitney U test, currently validated by the literature with these charac-
resumed in Table 2, shows that the two disorders group teristics.
presents a different distribution of the values within the Finally, it must be considered that in a clinical set-
individual subscales. The differences in the statistical ting it is often difficult to observe symptoms pheno-
analysis confirm the qualitative observation previously menological continuity over time. In this regard, NDS-I
made. We observe a very strong significant statistically should be administered several times during the hospi-
difference in BPD group regarding NDS-I Total score, talization, but also in the psychiatric territory services
Irritability and Interpersonal Resentment subscales once the patient has been discharged, to detect signi-
compared with BD group. ficant variations in this continuity. In this study, due to
the short hospitalization of enrolled patients, a re-test
Study Limitations could not be performed. Next works must take in ac-
This paper shows several limitations. First, the very count this important aspect.
low amount of data from the literature about NDS-I test.
This limits our observations to our sample, making any CONCLUSION
review and meta-analysis impossible to prove or deny
our results. This study allowed us to explore dysphoria’ expres-
The second limitation concerns the small number of sions in patients affected by Borderline Personality and
samples taken into consideration, thus the impossi- Bipolar Disorder. Despite the small samples size diffe-
bility of carrying out a gender differential analysis. For rences between means of the two groups values obtai-
this reason, the study does not presume to be exhaus- ned through NDS-I subscales were statistically signifi-
tive and complete, rather as a preliminary work to be cant (p<0.05). These preliminary data showed that BPD
implemented over time. Consequently, data obtained patients have a greater pervasiveness and severity dys-
must not be considered definitive but suggestive for phoria symptoms compared to BD patients. In parti-
future works. Future work must aim to improve gender cular, Surrender and Interpersonal Resentment dimen-
sample to observe the reproducibility of our results in a sions show greater interest in BPD than BD spectrum.
large divided sample composed by BPD and BD male Although it has been reported in a recent study that
and female patients. the self-report measures presented a limited value for
Referring to the small number of samples, we de- the differential diagnosis (Fowler et al. 2019), NDS-I
cided to utilize the U Mann-Whitney test instead T could be a good adjunct tool for clinical diagnosis and
Student Test because we were at limit boundaries of follow-up to prevent possible relapses.

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 Massimo C. Bachetti, Francesca Brufani, Giulio Spollon & Patrizia Moretti: DYSPHORIA DIMENSIONS: A PRELIMINARY INPATIENTS
STUDY TO DIFFRENTIATE BORDERLINE PERSONALITY AND BIPOLAR DISORDER SPECTRUM
Psychiatria Danubina, 2019; Vol. 31, Suppl. 3, pp 203-213

Indeed, in this case we have proposed NDS-I test 6. Brieger P, Ehrt U, Marneros A: Frequency of comorbid
as an aid to differential diagnosis between BPD and personality disorders in bipolar and unipolar affective
BD, but the utility of this type of instrument could be disorders. Comprehensive Psychiatry 2003; 44:28–34
in patient’s follow up with the aim of detecting a 7. D’Agostino A, et al.: Development, cross-cultural adapt-
ation process and preliminary validation of the Italian
possible early relapse. This possible use as secondary
version of the Nepean Dysphoria Scale. Journal of
prevention instrument must be studied yet, but if our Psychopathology 2016; 22:149-156
predictions will be confirmed by other studies this test 8. D’Agostino A, Rossi Monti M & Starcevic V: Models of
could have obvious positive implications on patient’s borderline personality disorder: recent advances and new
management, not only for diagnostic stage. NDS-I test perspectives. Curr Opin Psychiatry 2017; 30:000-000
being a dimensional tool does not pretend to objectify 9. Di Giacomo E, et al.: Unblending Borderline Perso-
the patient's experience. The result must always be nality and Bipolar Disorders In: journal of psychiatric
interpreted based on the subjective experience of the research 2017; 91:90-97. issn 0022-3956
person facing the clinician, even within a dimensional 10. Di Giacomo E, et al.: The Italian version of the Border-
approach. line Personality Disorder Severity Index IV: psycho-
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Acknowledgements: None. 11. Fowler JC, Madan A, Allen JG, Oldham JM, Frueh BC:
Differentiating Bipolar Disorder from Borderline
Conflict of interest: None to declare. Personality Disorder: Diagnostic Accuracy of the
Difficulty in Emotion Regulation Scale and Personality
Contribution of individual authors: Inventory for DSM-5, Journal of Affective Disorders
Massimo Claudio Bachetti conceived and designed 2018. doi: https://doi.org/10.1016/j.jad.2018.11.079
the study. 12. Fornaro M, et al.: Prevalence and predictors of bipolar
Massimo Claudio Bachetti & Giulio Spollon wrote the and borderline personality disorders comorbidity: Syste-
first draft of the manuscript. matic review and meta-analysis. Journal of Affective
Massimo Claudio Bachetti & Francesca Brufani Disorders 2016; 195:105–118.
performed statistical analyses. http://dx.doi.org/10.1016/j.jad.2016.01.040
Massimo Claudio Bachetti, Francesca Brufani, Giulio 13. Frías A, Baltasar I & Birmaher B: Comorbidity between
Spollon & Patrizia Moretti visited patients and bipolar disorder and borderline personality disorder:
carried out clinical work. prevalence, explanatory theories, and clinical impact.
Massimo Claudio Bachetti, Francesca Brufani & Journal of Affective Disorders.
Giulio Spollon conducted testing. http://dx.doi.org/10.1016/j.jad.2016.05.048
Massimo Claudio Bachetti, Francesca Brufani & 14. Ghaemi SN: Bipolar vs. borderline – diagnosis is
Patrizia Moretti discussed results, prognosis once again. Acta Psychiatr Scand 2016;
Massimo Claudio Bachetti, Francesca Brufani, Giulio 133:171–173. DOI: 10.1111/acps.12560
Spollon & Patrizia Moretti supervised the writing of 15. Mneimne M, Fleeson W, Arnold EM & Furr RM:
the manuscript; all authors approved the final Differentiating the Everyday Emotion Dynamics of
version of the manuscript.. Borderline Personality Disorder From Major Depressive
Disorder and Bipolar Disorder. Personality Disorders:
Theory, Research, and Treatment 2017. Advance online
publication. http://dx.doi.org/10.1037/per0000255
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STUDY TO DIFFRENTIATE BORDERLINE PERSONALITY AND BIPOLAR DISORDER SPECTRUM
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DOI:10.1007/s11126-015-9344-6 32:1-11

Correspondence:
Patrizia Moretti, MD
Division of Psychiatry, Department of Medicine, University of Perugia
Piazzale Lucio Severi, 1, 06132, S. Andrea delle Fratte, Perugia (PG), Italy
E-mail: [email protected]

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