Affective instability serves as a clinically useful screening or gate criterion for borderline personality disorder (BPD) in patients with major depressive disorder or bipolar disorder, according to the results of a study published in the Journal of Clinical Psychiatry.

Mark Zimmerman, MD, from the Department of Psychiatry and Human Behavior, Brown Medical School, and the Department of Psychiatry, Rhode Island Hospital, Providence, Rhode Island, and colleagues evaluated 3674 psychiatric outpatients from December 1995 to April 2014, using a semi-structured diagnostic interview based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, for BPD. Patients came from 3 diagnostic groups: those with major depressive disorder, those with bipolar disorder, and all remaining patients.

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Of the 9 BPD criteria used to evaluate patients, affective instability had the highest sensitivity and negative predictive value in all 3 diagnostic groups. Its sensitivity and negative predictive value were greater than 90%. In contrast, avoiding abandonment had a positive predictive value of more than 60%, the highest among the 9 criteria, whereas it had the lowest sensitivity, at 35%. Using fear of abandonment as the gate criterion would result in missing approximately two-thirds of patients with BPD.

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The researchers maintain that more effective screening for BPD in patients with major depressive disorder or bipolar disorder is essential because BPD is associated with increased rates of suicide attempts and unemployment in both these diagnostic groups. They caution, however, that screening is not diagnosing, and that the positive predictive value of the affective instability criterion was below 50%, which is among the lowest of the 9 criteria. Most of those exhibiting this criterion were not ultimately diagnosed with BPD. However, they add that a clinician can feel highly confident in ruling out a diagnosis of BPD in the absence of affective instability.

Researchers noted that the study was limited by a sample of patients who were predominantly white, female, and insured, all of whom presented to a single clinical practice for outpatient treatment.


Zimmerman M, Balling C, Dalrymple K, Chelminski I. Screening for borderline personality disorder in psychiatric outpatients with major depressive disorder and bipolar disorder. J Clin Psychiatry. 2019;80(1):18m12257.