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Published in final edited form as: Personal Disord. 2017 May 29;9(2):192–196. doi: 10.1037/per0000255

Differentiating The Everyday Emotion Dynamics of Borderline Personality Disorder from Major Depressive Disorder and Bipolar Disorder

Malek Mneimne 1, William Fleeson 2, Elizabeth Mayfield Arnold 3, R Michael Furr 4
PMCID: PMC5708157  NIHMSID: NIHMS871241  PMID: 28557468

Abstract

A major barrier to the understanding of emotion dynamics in borderline personality disorder (BPD) lies in its substantial comorbidity with major depressive disorder (MDD) and bipolar disorder (BD). While BPD has often been characterized in terms of dynamic emotional processes, including instability, reactivity, and inertia, its substantial comorbidity with MDD and BD makes it difficult to discern the specificity of these dynamics. To differentiate the emotion dynamics of BPD from those of MDD and BD, an experience sampling study of 38 participants with BPD, 15 participants with MDD, 14 participants with BD, and 62 healthy controls obtained reports of interpersonal challenges and emotions five times daily for two weeks. Interpersonal challenges included rejection, betrayal, abandonment, offense, disappointment, and self-image challenge; emotions included anger, excitement, guilt, happiness, irritability, and shame. Multilevel analyses revealed that heightened interpersonal reactivity of guilt and shame and heightened inertia of shame were relatively specific to BPD. These findings could not be accounted for by the presence of current MDD or BD. By contrast, heightened instability of anger and irritability and heightened inertia of irritability appeared to be largely transdiagnostic. Implications for clinical assessment, research, and theory are discussed.

Keywords: Emotion Dynamics, Borderline Personality Disorder, Bipolar Disorder, Major Depressive Disorder, Differential Diagnosis

A major barrier to the understanding of emotion dynamics in borderline personality disorder (BPD) lies in its substantial comorbidity with major depressive disorder (MDD) and bipolar disorder (BD). Researchers have documented considerable rates of co-occurrence between BPD and current MDD or BD ranging from as low as 4% to as high as 48% in clinical samples (Brieger, Ehrt, & Merneros, 2003; Fan & Hassell, 2008; Paris, Gunderson, & Weinberg, 2007; Zimmerman & Morgan, 2013). Perhaps reflecting this comorbidity, many researchers have characterized both BPD and BD in terms of heightened reactivity and instability of negative emotion (Broome, He, Iftikhar, Eyden, & Marwaha, 2015; Coifman, Berenson, Rafaeli, & Downey, 2012; Gershon et al., 2012; Tsanas et al., 2016; Wessa & Linke, 2009). With only a few exceptions, however, most research on the dynamic emotional processes of BPD has been undertaken by comparing people with BPD to people without any history of mental illness rather than to people with other disorders. The substantial comorbidity between BPD and current mood disorders makes it very difficult to tell whether past findings attributed to BPD were actually specific to BPD, specific to mood disorders, or indicative of more common pathology. This difficulty is compounded by the fact that most past research has not analyzed the dynamics of guilt and shame, despite evidence that abnormalities in these emotions are associated with BPD (Gratz, Rosenthal, Tull, Lejuez, & Gunderson, 2010; Peters & Geiger, 2016). If we wish to improve our understanding of BPD, then it is important to identify which dynamic processes are specific to BPD and which are indicative of more common pathology. Thus, in this study, we compared the emotional instability, reactivity, and inertia of BPD, current MDD, current BD, and healthy controls across specific emotions.

Variability is surprisingly not a simple concept, but rather can be characterized in different ways (Jahng, Wood, & Trull, 2008; Koval, Pe, Meers, & Kuppens, 2013). This study assessed three types of variability of emotion--instability, reactivity, and inertia--because of their prominence in descriptions of BPD, MDD, and BD (American Psychiatric Association, 2013). Emotional instability and emotional reactivity are closely related concepts. Emotional instability refers to abrupt variability in an emotional state, while emotional reactivity refers to abrupt variability in an emotional state that is temporally linked to one or more psychosocial events. For example, people often feel happy, guilty, or angry when they win a game, blame themselves for an event, or something obstructs their goals, respectively. Thus, reactivity is a more specific kind of variability than instability, in that it presumes one or more causes of variability, whereas instability implies unpredictability over time (Trull et al., 2008). In contrast, emotional inertia refers to the persistence of emotional experience over time and has been described in terms of “getting stuck” (Koval, Kuppens, Allen, & Sheeber, 2012). It reflects little or no variability.

Investigating emotion dynamics is difficult because it requires collecting enough assessments per person to adequately assess change and processes of change. There are three methods commonly used by researchers to investigate emotion dynamics. The first method involves the assessment of participants’ responses to emotional stimuli over very short time periods in a laboratory setting (e.g., Gratz et al., 2010; Koval et al., 2013). The second method involves the assessment of emotion dynamics using retrospective measures (Solhan, Trull, Jahng, & Wood, 2009). The third method, which was used in this study, is known as experience sampling methodology (ESM; Trull et al., 2008). ESM involves assessing participants’ experiences several times a day for a short period of time (e.g., 1–3 weeks). In contrast to experimental approaches, ESM involves assessing emotions over relatively longer time periods (hours as opposed to seconds or minutes) as people go about their lives. In contrast to retrospective approaches, ESM involves the assessment of current or recent emotions on many occasions. Doing so minimizes the effects of recall biases possibly contained in broad, retrospective reports (Solhan, Trull, Jahng, & Wood, 2009). Most importantly, it allows for the direct assessment of change in emotions and of the predictors of such changes.

Because of the importance of ecologically-valid and direct evidence about affective experiences in BPD, researchers have begun to assess the emotion dynamics of BPD using ESM. To date, ESM research on the emotion dynamics associated with BPD has assessed emotional instability or emotional reactivity, but not emotional inertia. Only a few studies have included clinical control groups. These studies found differences between BPD and BD in terms of instability (Tsanas et al., 2016) and between BPD and MDD in terms of instability (Cowdry, Gardner, O’Leary, Leibenluft, & Rubinow, 1991; Trull et al., 2008) and reactivity (Köhling et al., 2015). All three dynamics and disorders have not been included in a single study of BPD, however. Given their high rates of comorbidity, the extent to which abnormalities in emotional instability, reactivity, and inertia are specific to BPD or transdiagnostic remains unclear (Santangelo et al., 2014).

In addition to an overall negativity or positivity of emotion, BPD has been characterized by an affinity for discrete emotions. The self-conscious emotions of guilt and shame appear to be particularly relevant (Gratz et al., 2010; Peters & Geiger, 2016). The role of self-conscious emotions may be due to having learned and internalized an invalidating environment (Crowell, Beauchaine, & Linehan, 2009) or to a polarized view of oneself (Kernberg, 1984). Studies have yet to assess the dynamics of guilt or shame in people with BPD outside of the laboratory, however. There is also evidence that anger and happiness may be particularly problematic for people with BPD (e.g., Renneberg, Heyn, Gebhard, & Bachmann, 2005; Trull et al., 2008). Accordingly, rather than assessing overall negative or positive affect, we assessed discrete emotions considered important in understanding BPD, including anger, irritability, guilt, shame, happiness, and excitement.

Method

Participants

Of 282 individuals recruited from the local community and a local outpatient psychiatry clinic in the southeastern United States, 129 (86 females) had at least 20% valid ESM reports and either did not meet criteria for a past or current mental health disorder (healthy controls; HC) or met criteria for BPD, current MDD, or current BD as assessed by the Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998) and Structured Interview for DSM-IV Personality Disorders (SIDP-IV; Pfhol, Blum, & Zimmerman, 1997).

Table 1 presents characteristics of the sample by group. Based on the MINI and SIDP-IV, 62 participants did not meet criteria for any past or current disorders (HC), 15 met criteria for current MDD but not current BD or BPD, 14 met criteria for current BD but not current MDD or BPD, while 38 met criteria for BPD but not current MDD or BD. We selected only these participants for our analyses in an effort to ensure that any BPD-specific findings could not be explained by comorbidity with current BD or MDD. We combined the BD and MDD groups into a “clinical control” (CC) group for two reasons. First, to facilitate the evaluation of BPD-specific effects. Second, to enhance the reliability of our findings. In addition, we combined the BPD, BD, and MDD groups for the purposes of evaluating transdiagnostic effects.

Table 1.

Demographic and Clinical Characteristics of the Sample by Group

Variable BPD (n = 38) BD (n = 14) MDD (n = 15) BD+MDD= CC (n = 29) BPD+BD+MDD= DG (n = 67) HC (n = 62)
Age M (SD)1 38.2 (11.6) 42.6 (13.3) 44.0 (13.4) 44.07 (13.2) 40.6 (12.4)b 45.5 (10.9)
Female n (%) 29 (76.3) 11 (78.6) 10 (66.7) 21 (72.4) 50 (74.6) 36 (58.1)
Caucasian n (%) 27 (71.0) 6 (42.9) 8 (53.3) 14 (48.3) 41 (61.1) 34 (54.8)
Psychotropic Meds n (%)1 12 (46.2) 5 (55.6) 7 (100) 12 (70.5) 24 (54.5)b 3 (7.0)
Psychotherapy n (%)1 5 (20.8) 3 (33.3) 1 (14.3) 4 (25.0) 9 (21.9)b 2 (4.8)
ESM Reports M (SD) 40.7 (13.3) 45.2 (13.7) 44.1 (16.0) 45.4 (14.0) 42.9 (13.8) 45.0 (15.2)
Current Diagnoses n (%)
Major Depression 0 (0) 0 (0) 15 (100) 15 (51.7)a 15 (22.4)b
Bipolar I 0 (0) 7 (29.2) 0 (0) 7 (24.1)a 7 (10.4)b
Bipolar II 0 (0) 3 (21.4) 0 (0) 3 (10.3)a 3 (4.5)
Bipolar NOS 0 (0) 4 (28.6) 0 (0) 4 (13.8)a 4 (6.0)b
Any Bipolar Disorder 0 (0) 14 (100) 0 (0) 14 (48.3)a 14 (20.9)b
Anxiety Disorder 29 (76.3) 11 (78.6) 10 (66.7) 21 (72.4) 50 (74.6)b
Substance Use Disorder 3 (7.9) 0 (0) 2 (13.3) 2 (6.9) 5 (7.9)b
Eating Disorder 4 (10.5) 2 (14.3) 1 (6.7) 3 (10.3) 7 (10.4)b
Cluster A Disorder 8 (21.1) 5 (35.7) 4 (26.7) 9 (31.0) 17 (25.4)b
BPD 38 (100) 0 (0) 0 (0) 0 (0)a 38 (56.7)b
Other Cluster B Disorder 11 (28.9) 2 (14.3) 2 (13.3) 4 (13.8) 15 (22.4)b
Cluster C Disorder 21 (55.3) 8 (57.1) 6 (40.0) 14 (48.3) 35 (52.2)b
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Note. BD = Bipolar disorder; BPD = Borderline personality disorder; CC = Clinical control; DG = Disorder groups; ESM = Experience sampling methodology; HC = Healthy control; Meds = Medications; MDD = Major depressive disorder; NOS = Not-otherwise-specified.

1

Statistics for some groups are based upon missing data.

a

Differences between BPD and clinical control groups at the .05 level.

b

Differences between HC and disorder groups at the .05 level.

The study was approved by the institutional review board of Wake Forest University School of Medicine and all participants provided consent.

Measures

MINI

The MINI is a brief structured interview that assesses 18 mental disorders (Sheehan et al., 1998). Items are coded as present or absent and algorithms are used to determine the presence of a disorder. Twenty interviews were reviewed by a second rater for purposes of reliability estimation. Inter-rater reliability ranged from.82 to .86, mean = .84.

SIDP-IV

The SIDP-IV (Pfhol et al., 1997) is a semi-structured interview that assesses personality disorders based upon the DSM-IV criteria. For each symptom, interviewers with either a Ph.D. in Clinical Psychology or M.S.W. implemented the scoring guidelines provided by Pfhol et al. (1997) on the following scale (0–3): not present (absent or rare and limited examples), subthreshold (some evidence but not to the point of considering a symptom present), present (symptom present most of the time) and strongly present (symptom is clearly associated with distress or impairment of functioning). Twenty interviews were reviewed by a second rater for purposes of reliability estimation; inter-rater reliability ranged from.79 to .92, mean = .88.

ESM

Participants answered questions about their experiences during a pre-specified 60 minute timeframe. We considered ESM items invalid if they were answered in 500 milliseconds or less. We considered ESM reports invalid if they were completed more than 5 minutes before or 3 hours after the specified timeframe, multiple reports were completed for the same timeframe, or at least half of the items were answered too quickly. Across the 70 possible reports, participants’ average valid completion rate was 63%.

Interpersonal challenges included rejection, betrayal, abandonment, offense, disappointment, and self-image challenge. They were rated on a 6-point scale (1= disagree strongly; 6= agree strongly). We created a composite score by averaging the items (Cronbach’s alpha = .86). Discrete emotion items included angry, ashamed, excited, guilty, happy, and irritable. They were rated on a 6-point scale (1=very slightly or not at all; 6=extremely).

Procedure

A staff member with a M.S.W. or a Ph.D. in clinical psychology administered the MINI and SIDP-IV and provided instructions for completing the ESM reports. Subsequently, participants carried a Palm-Pilot for 14 days and were prompted to complete reports at 10 a.m., 1 p.m., 4 p.m., 7 p.m., and 10 p.m. They received up to $175 in giftcards for their participation.

Results

We specified two-level multi-level models, where reports at level one were nested within participants at level two. All models included random intercepts and diagnostic group at level two. For the analyses of reactivity and inertia, we centered level one predictors within-person. We contrasted the BPD group with the combination of the BD and MDD groups in order to evaluate BPD-specific effects. We also contrasted the combination of the disorder groups with the HC group in order to evaluate transdiagnostic effects. We calculated effect sizes (Cohen’s d) using the t-values and degrees of freedom from these contrasts (Rosenthal & Rosnow, 1991).

Emotional Instability

Emotional instability refers to frequent and abrupt variability in an emotion. We analyzed emotional instability using the mean squared successive difference (MSSD). The MSSD reveals the amount of change in emotion from one moment to the next (Jahng et al., 2008). We specified SSDs as the dependent variable in generalized multi-level models with a normal error distribution and a log link to account for skew (Santangelo et al., 2014; Trull et al., 2008). The results of these analyses are presented in the top portion of Table 2. As can be seen, for the negative emotions, the group means were most consistent with transdiagnostic patterns. There was no discernable pattern to the group means for the positive emotions, however.

Table 2.

Group Means and Mean Differences in Emotion Dynamics

Instability
BPD BD MDD CC DG HC dBPD v CC dDG v HC
Irritable 1.20 .93 .88 .90 1.07 .31 .04 .15**
Angry .87 .97 .83 .90 .89 .06 .00 .15**
Guilty .56 .07 −.21 −.06 .30 −.83 .08* .15**
Ashamed .52 −.11 .07 −.10 .31 −.45 .07* .11**
Happy 1.05 1.06 .77 .92 1.00 .85 .02 .04
Excited .97 1.01 .89 .95 .96 .83 .00 .03
Interpersonal Reactivity
BPD BD MDD CC DG HC dBPD v CC dDG v HC
Irritable .92 .94 .91 .93 .92 .80 −.01 .06*
Angry .85 .97 .74 .87 .86 .82 −.01 .02
Guilty .50 .19 .33 .25 .40 .23 .18** .10**
Ashamed .49 .16 .30 .21 .38 .22 .20** .10**
Happy −.28 −.46 −.14 −.33 −.30 −.51 −.02 .08**
Excited −.19 −.01 .01 .00 −.11 −.15 .08** −.01
Inertia
BPD BD MDD CC DG HC dBPD v CC dDG v HC
Irritable .20 .20 .17 .19 .19 .06 .01 .12**
Angry .15 .14 .08 .11 .13 .08 .03 .04
Guilty .25 .13 .25 .20 .24 .28 .05 −.03
Ashamed .24 .08 .12 .11 .20 .10 .10** .08*
Happy .27 .23 .28 .25 .26 .24 .01 .01
Excited .27 .24 .15 .21 .24 .19 .05 .06
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Note. d = Cohen’s d; BD = Bipolar disorder; BPD = Borderline personality disorder; CC = Clinical controls (Bipolar and Major Depressive Disorders); DG = Disorder groups; HC = Healthy control; MDD = Major depressive disorder. Estimates of instability are on a log scale and represent the average amount of time-detrended change across three-hour intervals. Estimates of interpersonal reactivity represent the average amount of concurrent change in interpersonal challenges and emotions. Estimates of inertia represent the average amount of persistence of emotion for each disorder across three-hour intervals. In general, if dBPD v CC > dDG v HC, then the pattern of group estimates is more consistent with a BPD-specific pattern than a transdiagnostic pattern; by contrast, if dDG v HC > dBPD v CC, then the pattern of group estimates is more consistent with a transdiagnostic pattern than a BPD-specific pattern.

**

Group contrasts are significant at p < .01,

**

Group contrasts are significant at p < .05.

Emotional Reactivity

Emotional reactivity is variability in response to an event. As in prior studies, we focused on emotional reactivity to interpersonal challenges. We included interpersonal challenges as a main effect at level one and as a cross-level interaction effect with diagnostic group at level two (Sadikaj, Russell, Moskowtiz, & Paris, 2010). The results of these analyses are presented in the middle portion of Table 2. These analyses revealed BPD-specific patterns of group means for guilt, shame, and excitement. There was also some evidence of transdiagnostic patterns of group means for irritability and happiness.

Emotional Inertia

Emotional inertia refers to the persistence of emotion over time. As in prior studies, we modeled inertia as the extent to which an emotion at any given time was maintained at the next report three hours later. We included lagged emotion as a main effect at level one and as a cross-level interaction with diagnostic group at level two. We excluded the last report of each day from the level one predictor in order to model inertia only within days (Koval et al., 2012). The results of these analyses are presented in the bottom portion of Table 2. These analyses revealed a BPD-specific pattern of group means for shame and a transdiagnostic pattern of group means for irritability.

Discussion

BPD has often been characterized as a disorder of heightened instability and reactivity. However, its substantial comorbidity with BD and MDD makes it difficult to discern the specificity of these dynamics. Our results confirm that the daily lives of individuals with BPD are indeed dominated by heightened instability and interpersonal reactivity of negative emotion. Generally, we found that BPD was chacterized by the dynamics of guilt and shame—high instability, interpersonal reactivity, and inertia.

Our findings extend past work in at least three ways. First, our findings suggest that abnormalities in the dynamics of guilt and shame are relatively specific to BPD and cannot be accounted for by the presence of current MDD or BD. Second, our findings imply that instability in anger and irritability and inertia in irritability may be largely transdiagnostic processes. Third, our findings suggest that the persistence of shame may be a defining characteristic of BPD.

Past researchers have found that manifestations of BPD symptoms were contingent upon interpersonal challenges (Miskewicz et al., 2015) and negative emotions (Law, Fleeson, Arnold, & Furr, 2016). Alongside our findings, these findings suggest that BPD could be defined, in part, by dynamic processes, including the following: 1) self-blame (i.e., guilt) and self-loathing (i.e., shame) in response to interpersonal challenges, 2) a persistence of self-loathing, and 3) continued symptom expression (Law et al., 2016). Past researchers have also found that emotional inertia and rumination co-occurred (Koval et al., 2012) and that BPD mostly occurred in the context of invalidating childhood environments (Crowell et al., 2009). Thus, the central role of guilt and shame in the everyday lives of those with BPD may reflect a heightened degree of reminders and rumination upon early invalidating experiences.

Our findings can assist clinicians in differentiating BPD from BD and MDD. Specifically, our findings suggest that differential diagnosis would be most effectively informed by asking people about the following: 1) the frequency and severity of specific emotional responses to interpersonal challenges, particularly guilt and shame; 2) the frequency and severity of persistent shame; and 3) the extent to which these dynamics are problematic in their lives. Subsequently, BPD would be most readily distinguishable by problems with heightened interpersonal reactivity of guilt and shame and shame inertia. For suspected comorbidity, assessing how problematic each dynamic-disorder pair is for the person could be used to facilitate decisions about primary and secondary diagnoses.

Limitations and Directions for Future Research

There are two limitations of this study. First, although our findings cannot be attributed to current MDD or BD, our sampling and analytic procedures likely reduce the generalizability of our findings to “pure BPD.” Second, the BD and MDD groups were somewhat small and the overall sample was not nationally representative. Together, these limitations warrant replication with other samples. Additional research is also needed to identify the common factors that account for the transdiagnostic findings.

Acknowledgments

Research presented in this manuscript was supported by the National Institute of Mental Health of the National Institutes of Health under award number R01MH70571. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. We thank Jennifer L. Wages and Michelle Anderson for their valuable contributions to this work.

Contributor Information

Malek Mneimne, University of Notre Dame.

William Fleeson, Wake Forest University.

Elizabeth Mayfield Arnold, Wake Forest School of Medicine.

R. Michael Furr, Wake Forest University.

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