Received: 27 May 2020 Revised: 28 November 2020 Accepted: 26 March 2021

DOI: 10.1002/cpp.2591

COMPREHENSIVE REVIEW

Differential diagnosis of borderline personality disorder and

bipolar disorder: Self-concept, identity and self-esteem

Livia Wright1 | Lisa Lari1 | Stefania Iazzetta1 | Marco Saettoni1,2 |

Andrea Gragnani1,2,3

1
Scuola di Psicoterapia Cognitiva SRL,
Grosseto, Italy Abstract
2
Unità Funzionale Salute Mentale Adulti, ASL Symptoms of borderline personality disorder (BPD) and bipolar disorder (BD) often
Toscana Nord-Ovest Valle del Serchio, Pisa,
overlap. In some cases, it is difficult to conduct a differential diagnosis based only on
Italy
3
Scuola di Psicoterapia Cognitiva SRL, Rome, current diagnostic criteria Therefore, it is important to find clinical factors with high
Italy discriminatory specificity that, used together with structured or semi-structured

Correspondence interviews, could help improve diagnostic practice.

Livia Wright, Scuola di Psicoterapia Cognitiva
(SPC), Via Giovanni Lanza 26, 58100 Grosseto,
Italy.
Email: liviawright@gmail.com;
studiogrosseto@scuola-spc.it
We propose that a clinical analysis of identity, self-concept and self-esteem may help
distinguish the two disorders, when they are not co-morbid. Our review of the stud-
ies that analyse these constructs in BD and BPD, separately, points in the direction
of qualitative differences between the two disorders. In BPD, there is a well-
documented identity diffusion, and the self-concept appears predominantly negative;
shifts in self-concept and self-esteem are often tied to interpersonal triggers. In BD,
patients struggle with their identity, but narrative identity might be less compromised
compared with BPD; the shifts in self-concept and self-esteem appear more linked to
internal (i.e. mood and motivational) factors. We end the paper by discussing the
implications for clinicians and ideas for future comparative research.

KEYWORDS
bipolar disorder, borderline personality disorder, differential diagnosis, identity, self-concept,
self-esteem

1 | I N T RO DU CT I O N There are epidemiological and aetiological differences between

Current international classifications (Diagnostic and Statistical Manual
for Mental Disorders Fifth Edition [DSM-5], American Psychiatric
Association, 2013; International Statistical Classification of Diseases
and Related Health Problems 11th Revision [ICD-11], World Health
Organization, 2019) consider bipolar disorder (BD) and borderline per-
sonality disorder (BPD) two different disorders. In the DSM-5, BPD is
one of the Cluster B personality disorders, together with antisocial
personality disorder, histrionic personality disorder (HPD) and narcis-
sistic personality disorder (NPD). Bipolar disorders are a separate diag-
nostic entity that includes bipolar disorder I (BD I), bipolar disorder II
(BD II) and cyclothymic disorder, among others.
BPD and BD (Paris & Black, 2015) that support this classification.
Environmental factors, together with a temperamental predisposition,
appear to be a core etiological feature of BPD (Linehan, 1993),
whereas BD has a strong familial pattern (Rowland &
Marwaha, 2018). The illness course also seems to differ: Many individ-
uals with BPD no longer meet criteria in middle age (Zanarini
et al., 2012), whereas BD does not seem to remit with age. On the
contrary, depressive symptoms appear to worsen over time (Coryell
et al., 2009). In addition, antidepressants, anticonvulsant mood stabi-
lizers and atypical antipsychotics appear beneficial for BD, although
patients with BPD have lower rates of response to pharmacological
treatment (Ripoll et al., 2011). These differences are clear in the

Clin Psychol Psychother. 2021;1–36. wileyonlinelibrary.com/journal/cpp © 2021 John Wiley & Sons, Ltd. 1
2 WRIGHT ET AL.
scientific research, but their utility is limited in the psychiatric practice,
where at a first glance the symptoms of the two disorders seem to
overlap (Borda, 2016).
The picture is further complicated by co-morbidity. Despite the
differences described, co-morbidity of the two disorders is very com-
mon (for a review, please see Bezerra-Filho et al., 2015 and
McDermid et al., 2015), and the negative impact of BPD on BD is
greater than vice versa (Frías et al., 2016).
Although we acknowledge that co-morbidity is very common and
clinically relevant, our aim is to aid differential diagnosis; therefore, in
this review article, we will consider patients with one of the two diag-
noses. In this case, it is easier to differentiate BD I from BPD than BD
II from BPD because of the characteristic manic symptoms and com-
mon psychotic symptoms in BD I (Goodwin et al., 2007). Hypomania,
however, has a milder presentation, cannot include psychotic symp-
toms (DSM-5, Criteria E ‘Hypomanic episode’) and therefore can
often be confused with the emotional dysregulation in BPD, and vice
versa (Kernberg & Yeomans, 2013).
Ruggero et al. (2010) found that in a sample of 82 patients with a
previous misdiagnosis of bipolar disorder, who did not have it
according to the Structured Clinical Interview for DSM-IV Axis I
(SCID-I), patients with BPD had a significantly greater risk of a mis-
diagnosis, regardless of how they met the borderline criteria. A correct
diagnosis is important because pharmacological and psychotherapeu-
tic treatment of BD and BPD differs (Bayes et al., 2016; Paris &
Black, 2015) and for the implications of the diagnosis for the patient's
quality of life (QoL), stigma, relationships etc. (Bilderbeck et al., 2014).
Diagnostic confusion also hinders research and knowledge develop-
ment of the two conditions.
Even though differential diagnosis of BD and BPD is challenging
and has many implications for clinical care and research, few studies
directly compare the two disorders (Paris & Black, 2015). Saunders
et al. (2015) conducted an original and methodologically sound study
of clinical practice. They analysed clinician interviews and adminis-
tered questionnaires to a sample of UK psychiatrists to investigate
how they approached the differential diagnosis of the two disorders
and to test their knowledge of DSM-IV-TR criteria. The study showed
that most of the psychiatrists in the sample demonstrated a compre-
hensive understanding of the diagnostic criteria, but they were very
sceptical towards them and often relied on their clinical judgement.
Following this impressionistic approach, symptoms of mania and BPD
were rarely sufficiently explored to establish the absence or presence
of each diagnosis. This approach can lead to diagnostic errors.
But if, indeed, current diagnostic criteria alone are not sufficient
for a differential diagnosis in some cases, it is important to find clinical
factors with high discriminatory specificity that, used together with
structured or semi-structured interviews, could help improve diagnos-
tic practice.
In this regard, we propose that a clinical analysis of identity, self-
concept and self-esteem may help distinguish the two disorders. The
comparison of these constructs in BPD and BD has already been con-
ducted in the context of broader reviews (Bassett, 2012; Bayes
et al., 2014) and one specific article (Borda, 2016). These suggest that
Key Practitioner Message
• Differences between borderline personality disorder and
bipolar disorder are clear in the scientific research, but
their utility is limited in the psychiatric practice, where at
a first glance the symptoms of the two disorders seem to
overlap.
• For diagnostic and treatment purposes, clinicians should
ideally conduct a thorough assessment to obtain a gen-
eral picture of each patient's intrapsychic and interper-
sonal functioning, including their self-concept as it has a
pivotal role in the clinical picture.
• In BPD, there is a well-documented identity diffusion,
and the self-concept appears predominantly negative;
shifts in self-concept and self-esteem are often tied to
interpersonal triggers. In BD, patients struggle with their
identity, but narrative identity might be less compromised
compared with BPD; the shifts in self-concept and self-
esteem appear more linked to internal (i.e. mood and
motivational) factors.
• There is some evidence that targeting these constructs in
therapy may be beneficial to the patient.
these constructs might have high discriminatory specificity, unlike
other clinical factors such as altered mood states and impulsivity that
are considered transdiagnostic (Bayes & Parker, 2019; Ghaemi
et al., 2014). We wish to analyse them in greater depth and connect
them to clinical findings to assist the design of studies that aim to
advance the clinical distinction. In support of our hypothesis, as we
were writing this article, Bayes and Parker (2019) published a study
on a sample of 53 participants with BPD and 83 participants with
BD. Results of a 113-item self-report questionnaire, comprising cogni-
tive and behavioural constructs weighted to a borderline personality
style, showed that identity disturbance is intrinsic and specific to BPD
and thus might help the differentiation with BD.
We offer a brief description of identity, self-concept and self-
esteem, as found in the literature. Then, we review studies that ana-
lyse these constructs in BD and BPD, separately. Lastly, we discuss
the results of the review. We adhere to a cognitivist theory that
believes that cognitions and goals, together with genetic and environ-
mental factors, can explain the origin and maintenance of psychologi-
cal suffering (Castelfranchi, 2012; Mancini, 2016). Therefore, we will
attempt to organize the results following this cognitivist perspective.
2 | METHODS
Preliminarily, we conducted a computerized search in the PubMed
database on 1/4/2019: ‘bipolar disorder AND borderline personality
disorder AND differential diagnosis’ that yielded 80 results. Of these,
WRIGHT ET AL.
32 studied the differential diagnosis of the two disorders. Based on
those articles, we hypothesized that the construct ‘identity’ could be
a suitable candidate to aid differential diagnosis. Therefore, we con-
ducted four separate computerized searches in the PubMed database:
(1) ‘bipolar disorder AND identity’, (2) ‘bipolar disorder AND self-
concept OR self-esteem’, (3) ‘borderline personality disorder AND
identity’ and (4) ‘borderline personality disorder AND self-concept
OR self-esteem’. The search was restricted to articles in English publi-
shed between 1/1/2000 and 1/1/2020. Using the Rayyan review
software (Ouzzani et al., 2016), we collapsed the results of the first
two and last two searches to identify unique results. We read all the
titles and abstracts and established if they were relevant. We included
FIGURE 1 Flow chart of the search strategy
3
research articles that in any way concerned identity, self-concept and
self-esteem in BPD or BD patients. To obtain as comprehensive a
review as possible, we included articles that did not appear in the
searches but were cited by the original articles, as others previously
did (e.g. Bech et al., 2015). We did not include studies on student
populations, studies on samples with BPD or BD features or case
reports. We did not include other constructs, such as dissociation,
splitting, early maladaptive schemas, metacognitive processes, insight
and autobiographical memory (in general, not identity related), trauma,
even though they are intimately related to the analysed constructs, as
the studies resulting from the search were limited compared with the
whole production on the subject. The process can be seen in Figure 1.
4 WRIGHT ET AL.
3 | A GL OS SA R Y F O R T H E R E A D ER
Many different definitions of self, self-concept and identity exist. These
concepts are often used interchangeably (Kerr et al., 2015). This is also
true in the reviewed studies, and part of the confusion concerning
these concepts in the two disorders can be traced back to this misuse.
This description is by no means an exhaustive analysis of these
complex constructs (for a more detailed analysis, see Kerr et al., 2015;
Leary & Tangney, 2012). It serves two purposes: (1) to establish a
common starting point with the reader and (2) to inform the reader
of the importance of a correct definition when designing future
studies.
Self-concept: It is a product of the reflexive activity of the self. It
involves mental concepts of ‘who one is, was and will become’
(Oyserman et al., 2012). Gecas (1982) conceptualizes it as ‘an organi-
zation (structure) of various identities and attributes, and their evalua-
tions, developed out of the individual's reflexive, social, and symbolic
activities. As such, the self-concept is an experiential, mostly cognitive
phenomenon accessible to scientific inquiry’ (p. 4).
Identity: The knowledge component of the self (‘Who am I?’;
‘Who was I?’; ‘Who am I going to become?’; ‘Who am I in every con-
text?’). Identities are the traits and characteristics, social relations,
roles and social group memberships that define who one is. Together,
identities make up a part of one's self-concept.
Narrative identity: ‘the capacity of the individual to integrate
contradictory aspects and tendencies into a coherent, overarching
sense and view of his or her self’ (Fuchs, 2007, p. 380). Thus, feelings
of self-coherence and self-continuity are an illusion, a product of this
capacity, that can be disrupted, as we will see further on.
Self-esteem: An evaluative component of the self-concept. It
answers the question: ‘How do I feel about my various identities?’
(Campbell & Lavallee, 1993). Self-esteem can be broken down in
implicit self-esteem (ISE) and explicit self-esteem (ESE). Measures of
ESE explicitly ask individuals about their assessment of themselves.
Measures of ISE assess ‘the degree to which the self is cognitively
associated with positive versus negative thoughts’ (Spalding &
Hardin, 1999).
Both components of the self, self-knowledge or identity and self-
esteem, can be treated as traits or states (for a discussion, see Winter
et al., 2017).
Self-stigma: Intimately related to self-esteem, it consists of agree-
ing with and applying to oneself the public negative stereotypes and
prejudices associated with the diagnosis (Rüsch et al., 2006).
With these definitions in mind, we can now turn to the descrip-
tion of self-concept, identity and self-esteem in BPD and BD.
4 | RESULTS
4.1 | Identity, self-concept and self-esteem in BPD
The nature of BPD is controversial (Shedler et al., 2010), but impair-
ments of self and identity are a central factor of the disorder
according to diagnostic approaches (American Psychiatric
Association, 2013; World Health Organization, 2019) and several the-
ories (Bender & Skodol, 2007; Jørgensen, 2010; Kernberg, 1967;
Linehan, 1993; Luyten et al., 2019; Meares et al., 2011). The DSM-5
describes BPD as ‘a pervasive pattern of instability of interpersonal
relationships, self-image and affect, and marked impulsivity, beginning
by early adulthood and present in a variety of contexts, as indicated
by five (or more) of the following [9 criteria]’, Criterion 3 being ‘Iden-
tity disturbance: markedly and persistently unstable self-image or
sense of self’. The shifts in self-image refer to sudden and dramatic
shifts in goals, aspirations and values. In the diagnostic features, the
DSM-5 goes on: ‘Although they usually have a self-image that is
based on being bad or evil, individuals with this disorder may at times
have feelings that they do not exist at all’. The authors of the DSM-5
do not offer a clear and precise definition of self and identity.
Turning to the literature, both the knowledge component and the
evaluative component of the self-concept appear to be compromised
in this disorder. Individuals with BPD seem to have great difficulties in
the process of creating the feeling of self-continuity and self-
coherence, especially in the presence of interpersonal stressors
(Luyten et al., 2019; Semerari et al., 2005). They have what can be
called an ‘identity diffusion’, that is, ‘a fragmentation rather than inte-
gration of the representations of the self and others’ (Yeomans
et al., 2002, p. 8). This is confirmed by several empirical studies
(e.g. Jørgensen, 2009). Identity disturbance seems to be present in
patients with and without a history of abuse (Wilkinson-Ryan &
Westen, 2000), but the degree may vary. There is also evidence that
higher levels of identity diffusion in BPD are associated with greater
symptom severity (Sollberger et al., 2012) and worse functional prog-
nosis (Esguevillas et al., 2018).
Patients with BPD report a trait-like predisposition towards nega-
tive affect (Dukalski et al., 2019) and high levels of current negative
affect (Walter et al., 2009). They have trouble describing themselves
(Dammann et al., 2011) and their self-concept is mostly negative
(Baumann et al., 2020; Beeney et al., 2016; van den Heuvel
et al., 2012; Vater et al., 2015) and unstable (Beeney et al., 2016;
Kanske et al., 2016) as is the content of their narrative identity
(Jørgensen et al., 2012). At a neural level, individuals with BPD may
utilize less organized and more complex strategies for representing
self and others (Beeney et al., 2016).
Nonetheless, they generally aspire to a future positive self-con-
cept, which is described as desired, probable and important (Janis
et al., 2006), but are generally unable to pursue it. Negative self-views
might be maintained by a bias for negative self-relevant information
(Auerbach et al., 2016; Korn et al., 2016; Winter, Herbert, et al., 2015;
Winter, Koplin, & Lis, 2015) and an excessive focus on negative social
feedback (van Schie et al., 2019). The negative self-concept is greater
in explicit measures (Sarkheil et al., 2019; Winter et al., 2018) com-
pared with implicit measures (Donges et al., 2016), meaning that it is
enhanced by cognitive processing.
Further insight concerning the content of the identity disturbance
and its' longitudinal course over 20 years is given to us by Gad
et al. (2019). The authors measured four maladaptive inner states that
WRIGHT ET AL.
are aspects of the self-concept, namely, ‘I feel like I am worthless’, ‘I
feel like I am a complete failure’, ‘I feel like I am a bad person’, and
‘I feel like I am evil’, in participants with BPD and a control group with
other personality disorders. The items were administered at baseline
and every 2 years for 20 years. The levels of these states were more
than three times higher in the BPD participants compared with con-
trols. For both groups, these states declined significantly over time,
and at the same rate for all states except ‘I feel like I am evil’, which
had a steeper decline in BPD participants. The negative perception of
self-worth differs in both intensity and trajectory in recovered versus
non-recovered patients (for criteria, see article). Although the authors
cannot determine whether the changes in these states precede, follow
or are concurrent with recovery, they do affirm that a negative iden-
tity is associated with less effective functioning in school, work and
interpersonal relationships.
We hinted at the interplay of self-concept and self-esteem in the
glossary. ESE fluctuates more compared with patients with avoidant
personality disorder (APD) (Lynum et al., 2008), is lower compared
with healthy controls (HCs) (Winter et al., 2018), is highly correlated
with affect instability and is related to general psychopathology
(Santangelo et al., 2017).
ESE measures might be influenced by the patients' volatile emo-
tions (Hedrick & Berlin, 2012). Measures of ISE, however, might reveal
a non-reflective knowledge about the self (Winter et al., 2017). Dis-
crepancies between the two measures might indicate maladjustment
and inner tension and be positively correlated with BPD symptom
severity, according to one study (Vater et al., 2010).
A study by Hedrick and Berlin (2012) did not find any differences
in ISE, measured using an implicit association task, between subjects
with BPD and HCs. But information regarding ISE lability was not col-
lected as the authors only measured ISE once, whereas Winter
et al. (2018) found lower ISE (initials preference task) compared
with HCs.
Even though the terminology and the theories used by the studies
are different, all studies agree that impaired identity and impaired
processing of self-relevant information are present in BPD and have a
relationship with BPD symptoms. In fact, the impairments in the self-
structure so typical of BPD patients have been linked to other core
features of the disorder, such as interpersonal problems, impulsive
behaviours, chronic feelings of emptiness, emotional dysregulation
and self-harm. We cannot address all these relationships in detail,
because it would go beyond the scope of the article, but we will dis-
cuss those that are directly mentioned and supported by the articles
included in our literature search.
In the absence of a coherent self-concept, made of different iden-
tities and moments in time, the individual is inevitably at the mercy of
the current moment and subsequently of impulses and emotions
(Fuchs, 2007). The ‘chronic feelings of emptiness’ (Criterion 7,
DSM-5) might be the result of this: If experiences cannot be inte-
grated in a coherent narrative, ‘they leave only emptiness behind’
(Fuchs, 2007, p. 386).
A correlation between high identity diffusion and interpersonal
problems has been found (De Meulemeester et al., 2017; Sollberger
5
et al., 2012), and identity diffusion correlates with mentalizing abilities
(De Meulemeester et al., 2017), supporting the impairment of the
mentalizing (i.e. of the human capacity to reflect on one's own and
others' internal intentional mental states such as feelings, wishes, atti-
tudes and goals) interpretation of BPD (Fonagy & Bateman, 2008;
Semerari et al., 2005).
Self-concept clarity appears to have a protective effect against
self-injurious urges when negative affect is high (Scala et al., 2018). In
another study, low self-esteem was a common characteristic of
patients with and without self-injurious behaviours, but those who
self-injured appeared to have an even more negative perception of
themselves (Almeida & Horta, 2018).
Self-related emotions, such as guilt and shame, are evidently inti-
mately related with the self-concept. For a comprehensive review of
these in BPD, see Winter et al., 2017.
Concerning internalized stigma, using a self-report questionnaire,
authors found it was greater in a group of patients with BPD com-
pared with social phobia (Rüsch et al., 2006) and also compared with
BD and attention deficit hyperactivity disorder (Quenneville
et al., 2020). Rüsch et al. (2006) hypothesize that this greater sensitiv-
ity could be linked to the shame proneness that several other studies
describe (Unoka & Vizin, 2017) and that diminished self-esteem is a
consequence of self-stigma in their sample.
4.2 | Identity, self-concept and self-esteem in
bipolar disorder
Contrary to BPD, studies on self-concept and identity in BD are
scarce (for a detailed review, see Dyga, 2019). This is surprising
because alterations of these constructs are reported in both the clini-
cal practice and the few studies that investigate them.
Most studies focus on the ‘constant synthesizing effort of the
contradictions between perceptions of oneself through different
affective episodes’ (Borda, 2016, p. 3).
For example, patients interviewed by Rusner et al. (2009) (10 peo-
ple with BD, six women, four men, aged 30–61, living at home and
not suffering from severe mania or depression at the time of the inter-
view) report that the illness is ‘intertwined with one's whole being’
and cannot be separated from one's identity. They also describe an
alternation of phases during which the identity is that of ‘bipolar and
ill’ and others during which they ‘have bipolar and are healthy’. The
latter are the moments during which they feel they are ‘in contact
with’ their self. But these moments are not free of pain, as they are
often ridden with guilt and shame for what they did when they had a
weak contact with their self and concern for their future actions. Simi-
lar experiences were reported by patients in other studies (Jönsson
et al., 2008; Lim et al., 2004). High-functioning patients with BD inter-
viewed by Michalak et al. (2011) described having an ‘illness identity’
imposed on them; many described actively contrasting this socially
imposed identity with their chosen identity. Their findings show that
the construction of identity in BD is a transformative process, made
of struggles and renegotiations. What is certain is that the diagnosis
6 WRIGHT ET AL.
of BD often marks a disruption in the person's life that requires a
renegotiation of identity, influenced by the sporadic and cyclical mood
changes (Fernandez et al., 2014), that is important for recovery (Etain
et al., 2018; Fernandez et al., 2014; Inder et al., 2008, 2011; Mansell
et al., 2010; Michalak et al., 2011; Rusner et al., 2009; Sajatovic
et al., 2008; Tse et al., 2014).
The earlier the onset of the disorder, the greater the general
impairment (Perlis et al., 2009). The disruption of the self-concept in
young patients (aged 15–35 years) seems to relate to the difficulty
in establishing continuity in the sense of self and dealing with socially
imposed identities, based on their illness (Inder et al., 2008). Earlier
age of onset is associated with greater co-morbidity with BPD (Moor
et al., 2012). This possibly indicates that, at an early age, the illness
interferes with the development of the self, thus increasing the over-
lap with BPD symptoms in this area. Co-morbidity of the two disor-
ders significantly increases the risk of self-harm behaviours that, as
we have seen in Section 4.1, are linked to a confused (Scala
et al., 2018) and negative (Almeida & Horta, 2018) self-concept.
Patients with bipolar disorder who are currently depressed have
significantly lower levels of consistency between self-actual and self-
ideal domains compared with HCs and to remitted or manic patients
(Bentall et al., 2005): The depressed self is feared and loathed by
patients. Instead, during mania, there is a high consistency between
self-actual and self-ideal or self-ought representations, meaning that
this state is preferred or that discrepancies are inaccessible due to loss
of insight (Silva et al., 2015). Another study (Fletcher et al., 2013) has
similar results: Hypomania ascent is described by some patients with
BD II as a moment during which the ideal self is present. During the
hypomania descent, instead, patients fear that others will not like
them and they themselves have a more negative self-concept.
Patients in a qualitative study describe a great fluctuation
between the two extremes of self-esteem (Rusner et al., 2009):
intense self-worth and intense self-deprecation. Great trust in one's
own ability, or life on ‘high mountains’, alternates with life ‘in the val-
leys’. Intense feelings of self-deprecation are accompanied by experi-
ences of intense sadness and the idea of being worthless. They
describe a recurring rhythm that is ‘both general and individual, con-
sisting both of bottom and top levels as well as different phases (like)
a roller coaster with a small roller coaster inside’ (pp. 163–164).
A review showed that self-esteem is significantly lower in remit-
ted BD patients compared with HCs and significantly higher than that
of MDD patients (Nilsson et al., 2010). Implicit and explicit measures
are often discordant (Jabben et al., 2014; Knowles et al., 2007; Park
et al., 2014) This can be due either to self-esteem instability or to a
discrepancy between high standards and negative reality, according to
the authors (Jabben et al., 2014). Blairy et al. (2004) found that
patients in remission for at least 3 months had lower self-esteem and
were less socially adjusted than HCs.
In a study on remitted, hypomanic and depressed patients with
BD (Pavlickova, Varese, Turnbull, et al., 2013) who were asked to
complete 10 diary entries a day for 6 days, depression was associated
with high negative self-esteem and low positive self-esteem. Contrary
to expectations, mania was associated with low mood and self-esteem
and their increased instability, possibly suggesting an underlying nega-
tive affect and self-concept during mania (Pavlickova, Varese, Smith,
et al., 2013; Pavlickova, Varese, Turnbull, et al., 2013). Although
Pavlickova, Varese, Turnbull, et al. (2013) do not distinguish between
the various subtypes of mania in their sample, to explain their finding,
we can speculate that the patients were experiencing dysphoric mania
or mixed mood states.
For clinical purposes, it is important to understand which environ-
mental stimuli determine changes in self-esteem and affect. According
to Ironside et al. (2020), some studies suggest that in people with BD,
self-worth is contingent on the achievement of certain goals. A study
also showed that a sample of patients with BD set more ambitious
goals than HCs (Tharp et al., 2015), independent of manic symptoms.
The authors hypothesize that these two characteristics might deter-
mine the instability of self-esteem reported in the disorder. These
studies are linked to the more general theory of Behavioural Approach
System (BAS) dysregulation in BD (Uroševi
c et al., 2008), according to
which individuals with this disorder are hyper-responsive to reward-
relevant environmental cues and this hyper-responsivity might trigger
manic or depressive episodes. Contingent self-worth, autonomy, mal-
adaptive perfectionism (Fletcher et al., 2019), ambitious goal setting
and emphasis on goal attainment all point to a specific BAS-related
cognitive style (Alloy et al., 2009).
Pavlova et al. (2011) elicited experiences of success or failure
using an anagram task and collected implicit and explicit measures of
self-esteem before and after. The results show an increased reactiv-
ity of affect and ESE to failure in remitted BD patients compared
with HCs, and no significant differences in ISE. This result was
predicted by a history of childhood trauma, meaning that early
adverse experiences are associated with a long-term tendency to
marked affective reactivity, even in response to small stressors. This
marked reactivity could possibly mediate the adverse outcomes
described in patients with BD and childhood trauma, such as early-
onset, frequent episodes, rapid cycling and suicide attempts (Garno
et al., 2005; Leverich et al., 2002). The symptom overlap with BPD
could be greater for these patients (Sansone & Sansone, 2010). Like
BPD, the relationship between self-related emotions and the self-
concept is very complex, but its description goes beyond the scope
of this review (for studies on internalized shame, see Fowke
et al., 2012 and Highfield et al., 2010).
Last, several studies focus on the experience of self-stigma in
people diagnosed with BD. This construct is correlated with QoL (Pal
et al., 2017; Post et al., 2018) and interpersonal relations (Sarısoy
et al., 2013), has strong psychosocial and psychiatric symptom associ-
ations (Howland et al., 2016) and contributes to treatment delay
(Latalova et al., 2013 for a review), concealment of the diagnosis to
others (Sajatovic et al., 2008) and poor functioning, even in remitted
patients (Au et al., 2019; Cerit et al., 2012). It appears to be less
intense than self-stigma experienced by patients with schizophrenia
(Karidi et al., 2015; Pal et al., 2017; Ran et al., 2018; for an alternative
finding in Taiwanese patients: Chang et al., 2016) and more intense
than that experienced by patients with an anxiety disorder (Pal
et al., 2017).
WRIGHT ET AL.
5 | DISCUSSION
In this practice-friendly review, we analysed and discussed publica-
tions on self-concept, identity and self-esteem in bipolar disorder and
BPD. The main results are summarized in Table 1.
The definitions and methods used by the studies are extremely
heterogeneous, and therefore, they could only be reported as a narra-
tive review.
The focus of the publications differs: In BD, a great number of
studies are on self-esteem, self-stigma and identity following diagno-
sis; in BPD, there are more studies on general identity and self-
concept, as can be seen in Tables 2 and 3 (appendix). One of the most
informative conclusions that we can draw from the reviewed studies
is that disturbances of self-concept, identity and self-esteem are
core features of BPD and mood-dependent features of BD.
Researchers and clinicians that adhere to different approaches all
agree on the presence of an identity disturbance in BPD. The identity
disturbance consists of not knowing who one is, in the sense that
patients with BPD do not possess a unified self-concept made of dif-
ferent identities in time. ‘They are forever on the edge of the abyss,
so to speak’ (Linehan, 1993, p. 36).
Patients with BD describe an effortful process of creating a sense
of continuity that is however present. The confusion is more related
to which identity is the most ‘authentic’: euthymic, euphoric or
depressed. But it would be incorrect to describe BD as a succession
of identities, without considering the impact these have at a holistic
level, the bigger ‘roller coaster’ in Rusner et al.'s (2009) description. A
common feature appears to be the avoidance of feelings of anergia
and anhedonia, which could trigger manic episodes (Mansell &
Pedley, 2008).
From a qualitative point of view, there is evidence that the shifts
in self-concept are closely tied to interpersonal relations in BPD. On
the other hand, the mood state appears to be the central defining fac-
tor for people with BD. To put it differently, changes in self-concept
follow an intrapsychic path in BD (e.g. Pavlickova, Varese, Turnbull,
et al., 2013) and an interpersonal path in BPD (e.g. Korn et al., 2016;
van Schie et al., 2019).
The pervasiveness of the negative self-concept appears to be
much more pronounced in BPD than BD, and biases in autobiographi-
cal memory (Jørgensen et al., 2012), in the processing of emotional
TABLE 1 Main results
BPD BD
Absence of a unified self- Presence of a unified self-concept,
concept, identity diffusion confusion is related to which
identity (euthymic, euphoric,
depressed) is the most authentic
Interpersonal factors trigger Intrapsychic (mood) factors trigger
changes in the self- changes in the self-concept
concept
Trait-like negative self- State-like negative self-concept
concept
Rapid shifts in self-concept Slow shifts in self-concept
7
stimuli (Sarkheil et al., 2019; Winter, Herbert, et al., 2015; Winter
et al., 2017) and of social feedback (e.g. Korn et al., 2016) maintain
and increase it. Studies on explicit and ISE conducted on patients with
BPD that use repeated measures point in the direction of a rapid fluc-
tuation between the two extremes, high and low, but more studies
are needed (e.g. to confirm there is indeed a fluctuation and under-
stand what triggers it).
In BPD, there appears to be a dichotomy between the perception
of being at fault, flawed, bad and aggressive (Baumann et al., 2020)
and a fleeting notion of being a good and adequate person, at least
partially. Stated otherwise, if patients with BPD believe they are
unlovable and bad, and therefore undeserving of a relationship in
which the other is kind and respectful, they will automatically go
in search of distancing, abandoning and maltreating partners. Unfortu-
nately, in this type of negative interpersonal cycle (Dimaggio
et al., 2007; Liotti, 1999; Safran & Muran, 2000; Safran & Segal, 1990)
that originates from the defectiveness/shame schema, they believe to
be understood for what they really are: a person undeserving and
unworthy of healthy affective proximity to another (Swenson, 2016).
But these patients are also capable of establishing shorter positive
interpersonal cycles (Dimaggio et al., 2007). These cycles activate a
fleeting and unstable positive self-concept (for an in-depth discussion
of self-related emotions, see Winter et al., 2017).
Instead, in BD, the self-concept is dichotomous during mood epi-
sodes and relatively stable during euthymia. On the one hand, we find
the ‘failed self’, typical of depressive episodes. It is characterized by
vulnerability, helplessness and a feeling of not being of any value,
which can lead to intense levels of self-deprecation, anergia and anhe-
donia. On the other hand, we find the ‘successful self’, typical of the
hypomanic and manic episodes. It is characterized by a feeling of
invulnerability and inflated personal value. The person believes to be
invincible and feels energetic and gratified, both at a physical and
mental level. Childhood trauma might interfere with the development
of the self in patients with BD; this aspect could be partially responsi-
ble for the high co-morbidity with BPD (McDermid et al., 2015;
Pavlova et al., 2011).
In the laboratory setting, self-esteem appears to be unstable and
lower than that of HCs, even in remitted patients. Concerning manic
episodes, it is not clear if self-esteem is really enhanced at this time or
if negative evaluations are inaccessible because of the loss of insight
(Silva et al., 2015).
The temporal dynamics of the shifts in self-concept and self-
esteem are also likely different (rapid in BPD, slower in BD, as in shifts
of affect), but comparative studies are needed to prove this.
What struck us the most was the almost complete absence of
studies (except Quenneville et al., 2020 and Rüsch et al., 2006) on
self-stigma in BPD, in contrast to the many studies in BD (see Tables 2
and 3, appendix). We only found one extra article (Grambal
et al., 2016 that shows that self-stigma is greater in BPD patients than
patients with anxiety disorders) using the keywords ‘self-stigma AND
borderline personality disorder’ in several search engines. This sur-
prised us because people with a diagnosis of BPD, just like people
with a diagnosis of BD, suffer recurrent hospitalizations, suicide
 8

TABLE 2 Salient characteristics of the studies on borderline personality disorder considered for the review

Experimental design and other

Authors Type Sample Excl BD diagnosis Main diagnostic and clinical measures measures
Self-concept
Auerbach Quantitative 26 BPD female 33 HC female ages 13– Yes MINI-KID; SCID-II; ZAN- BPD; BDI II Self-referential encoding task
et al., 2016 22
Baumann Quantitative 29 BPD female 21 HC female Excl mania and/or SCID-II self report questionnaire Aggressiveness implicit association test;
et al., 2020 psychotic symptoms Questionnaire for Factors of
Aggressiveness (FAF)
Beeney et al., 2016 Quantitative 17 BPD female 21 HC female Yes SCID; IPDE; LEAD standard Self-aspects card sort task;
Differentiation of Self Inventory (DSI)
Dammann Qualitative 12 BPD 12 MD (79% female overall Yes SCID-I and II STIPO interview
et al., 2011 sample)
Donges et al., 2016 Quantitative 33 BPD female 33 HC female Yes SCID I e II; BDI II; BLS -95; MWT-B Speed of classification of positive and
negative adjectives
Janis et al., 2006 Quantitative 15 BPD female 28 HC female No SCID-I and II PSQ
Kanske et al., 2016 Quantitative 27 BPD 25 HC Yes MINI; SCID-II; PAI-BOR Mind-wandering paradigm that probes
self-generated thoughts during a
choice reaction time task
Korn et al., 2016 Quantitative 24 BPD female 81 HC female Yes SCID-II; MINI; BDI Character trait task in a real-life social
interaction: self and other rating,
before and after social feedback; SCL-
90-R; BSL-95; RSES; MDMQ
Meares et al., 2011 Treatment 29 BPD conversational model (CM) 31 Not specified WSS; ZDQ Constellation of BPD diagnostic
quantitative BPD TAU features; changes in constellations
(WSS) and depressive symptoms
(ZDQ) following CM
Roepke et al., 2011 Treatment 20 BPD dbt program 20 BPD waiting list Yes SCID-II; MINI; BDI; SCL-90 MSES; BSE; ESE; SCC
quantitative all female
Sarkheil et al., 2019 Quantitative 40 BPD female 20 HC female Not specified BSL-95; BLS- 23; ERQ; BDI II Self-relevance and valence rating of 90
sentences (30 negative, 30 positive,
30 neutral)
Scala et al., 2018 Quantitative 36 BPD 18 AD (total 87% female) Yes ADIS-IV-PSU; SCID-I; IPDE; ALS; MSI- Electronic survey with items assessing
BPD; SCC negative affect, self-concept clarity,
self-harm (if affirmative rating of
intensity of urge) on touchpoint
continuums
van den Heuvel Quantitative 18 BPD 34 MD 35 both 50 HC No SCID-I and II ATSS; OGT
et al., 2012
van Schie Quantitative 26 BPD 22 low self-esteem (LSE) 32 HC Only for LSE and HC RSES; MINI; IPDE-IV; SCID-II; SAPAS-SR Social feedback task: participant
et al., 2019 all female received feedback from another
female participant (confederate) based
WRIGHT ET AL.
TABLE 2 (Continued)

Experimental design and other

Authors Type Sample Excl BD diagnosis Main diagnostic and clinical measures measures
WRIGHT ET AL.

on responses to nine personal

questions and three moral dilemmas;
same feedback for all participants (15
negative, 15 intermediate, 15 positive
words) was received in MRI scanner
Vater et al., 2015 Quantitative 28 BPD 28 MD 49 HC all female Not specified MINI; SCID-II Self-descriptive card sort task yielded
three measures of self-concept:
compartmentalization, content,
relative importance of neg and pos
self-aspects
Winter, Herbert, Quantitative 30 BPD female30 HC female Yes SCID-I; IPDE; BSL-23; DBI; ASF-E Valence judgement task: positive and
et al., 2015 negative valent as well as emotionally
neutral nouns were presented with
three different referential contexts.
Subjects had to rate the valence on a
9-point scale
Winter, Koplin, & Quantitative 30 BPD female 30 HC female Yes IPDE; SCID-I; BSL-23 Participants were asked to sit for final
Lis, 2015 diagnostic questions at the end of
Winter, Herbert, et al., 2015 study.
One chair faced a mirror; another
faced the room. They could choose to
sit on whichever one. The choice was
recorded and experimenter asked if it
was intentional
Identity
De Meulemeester Quantitative 176 BPD No SCID-II; PDSQ IPO; RFQ; IIP
et al., 2017
Esguevillas Quantitative 43 BPD (81% female) Yes CGI-BPD; clinical assessment GAF; STIPO
et al., 2018 questionnaire (self-injury, suicidal
attempts, substance use, ADHD); CTQ
Gad et al., 2019 Quantitative 290 BPD (for second aim divided in 152 Yes BIS; SCID-I; DIB-R; DIP-R; BIF-R Four items from the DAS; at the 10
recovered, 138 never recovered) 70 follow-ups (each 24 months apart)
PD controls clinical and recovery status were
reassessed
Jørgensen, 2009 Quantitative 66 BPD female 65 HC female Not specified SCID-II Identity Style Inventory (ISI)
Jørgensen Quantitative 17 BPD 14 OCD 23 HC Not specified SCID-II; BDI-II; ISI Authors examined emotional valence,
et al., 2012 specificity, life script correspondence
and narrative organization of
autobiographical memories, elicited
using a life story event task + life
script task
9

(Continues)
 (Continued)
10

TABLE 2

Experimental design and other

Authors Type Sample Excl BD diagnosis Main diagnostic and clinical measures measures
Lind et al., 2018 Treatment mixed 33 BPD at baseline, 23 participated in No SCID-II; BDI-II Semi-structured interviews and
methods follow-up at 12 months (91.3% questionnaires: participants were
female) 30 HC, 23 for follow-up asked to identify and describe up to
10 of their own life chapters and up to
10 of their parent's life chapters. Then
rate the emotional valence and the
causal connections of the chapter, and
for the parent's rate quality of
relationship and how sure they felt
about knowledge about the chapter.
Interviews were coded using five
codes: complexity, agency,
communion, communion fulfilment,
self and other confusion. At baseline
and follow-up
Lind et al., 2019 Mixed methods 30 BPD No SCID-II As described above + SCIM; TAS-20;
EQ; MSCEIT
Sollberger Quantitative 52 BPD No SCID-I; SCID-II SCL-90-R; BDI; STAI; IPO; association of IPO with clinical
et al., 2012 STAXI measures
Sollberger Treatment 32 BPD psychodynamic transference Yes SCID-I/P; SCID-II; BDI, STAI; STAXI IPO and clinical measures at baseline and
et al., 2014 quantitative focused psychotherapy + modules of after 12-week treatment
DBT skills training 12 BPD TAU
(79.5% female overall sample)
Walter et al., 2009 Quantitative 12 BPD 12 MDD no PD (80% female Yes SCID I; SCID II; STAI; BDI STIPO IPO
overall sample)
Wilkinson-Ryan & Quantitative 34 BPD 20 another PD 41 no PD as No Diagnosis by treating clinician; GAF Identity disturbance questionnaire
Westen, 2000 described by experienced clinicians designed for this study + GAF
(psychiatrists, psychologists, social + questions about patient's
workers) developmental history (particularly
sexual abuse), employment history,
peer relationships, social support
Self-esteem
Almeida & Quantitative 23 BPD no history self-injury behaviour No SCID II, STAXI, BIS-11, SCl-90, Global Rosenberg Self Esteem Scale (RSES) and
Horta, 2018 18 BPD history self-injury behaviour Symptom Index clinical measures
(78% female overall sample)
Hedrick & Quantitative 18 BPD (12 female) 18 DPD 35 HC Yes SCID-I; SCID-II Implicit association task (measures
Berlin, 2012 association of self and other with
positive and negative attributes); BIS-
11; Frontal Behaviour Questionnaire
(FBQ); Subjective Emotion
Questionnaire (SEQ); TCI
WRIGHT ET AL.
TABLE 2 (Continued)

Experimental design and other

Authors Type Sample Excl BD diagnosis Main diagnostic and clinical measures measures
WRIGHT ET AL.

Jacob et al., 2010 Treatment 13 BPD group therapy self-esteem Yes SCID II; MINI; BDI RSES; SSES
quantitative module 18 BPD control group all
female
Lynum et al., 2008 Quantitative 34 BPD 28 APD 17 BPD + APD (82% Yes MINI; SCID-II; SCL-90; BDI-II; GAF; CIP Index of self-esteem
female overall sample)
Santangelo Quantitative 60 BPD 60 HC Yes BDI-II; SCL-90; BSL-23 Electronic diaries completed for 4
et al., 2017 consecutive days. Current self-esteem,
valence and tense arousal levels were
reported 12 times a day in
approximately 1-hr interval
Vater et al., 2010 Quantitative 41 BPD female Not specified SCID-II; MINI Initials preference task (IPT), Heatherton
and Polivy Scale (HP); BDI; BSL-95;
SCL-90-R
Winter et al., 2018 Quantitative 31 BPD 30 HC all female Yes SCID-I; BPD section of IPDE; BSL-23; RSES; IPT; self-positivity measured with
BDI-II a self-referential processing task
where valence and referential context
were manipulated
Self-stigma
Quenneville Quantitative 69 BD 39 BPD (90% female) 136 ADHD Yes SCID II; MINI; BSL-23 ISMI; QoLB
et al., 2020
Rüsch et al., 2006 Quantitative 60 BPD 30 SP all female Yes MINI; SCID-II LPSQ; SSMIS; TOSCA-3; RSES; GSE;
SBQoL; AAQ; CES-D; SCL-90-R
Grambal et al., 2016 Quantitative 35 BPD (80% female) 30 BD 33 MD 49 No Clinical diagnosis by experienced ISMI
SC 27 AD psychiatrists using ICD-10 criteria;
demographic questionnaire; CGI
Self-compassion
Donald et al., 2018 Quantitative 19 BPD (17 female) Not specified SCID-II RAS; SCS; FSCRS
Feliu-Soler Treatment 16 BPD loving kindness/compassion Yes DIB-R; BSL-23 SCS; FSCRS; PHLMS
et al., 2016 quantitative meditations 16 BPD mindfulness
continuation training (30 of 32 total
female) all with prior 10 weeks of
mindfulness training

Note: Measures, abbreviations and references in Table 4.

Abbreviations: AD, anxiety disorder; APD, avoidant personality disorder; DBT, dialectical behaviour therapy; DPD, depersonalization disorder; OCD, obsessive–compulsive disorder; PD, personality disorder; SC,
schizophrenia; SP, social phobia; TAU, treatment as usual.
11
 Salient characteristics of the studies on bipolar disorder considered for the review
12

TABLE 3

Excl BPD
Authors Type Sample diagnosis Main diagnostic and clinical measures Experimental design and other measures
Self-concept
Bentall et al., 2005 Quantitative 65 BD 22 manic/hypomanic, 24 depressed, Not specified BDI; HRSD; M-DS; YMRS PQQ
19 remitted, 23 HC
Inder et al., 2008 Treatment 6 DB I phase 1: only assessment, 10 DB I No Diagnosis by treating psychiatrist 49 hr of therapy sessions was transcribed.
qualitative phase 2: 18 months therapy completed Questions prompted sense of self and a
coding sheet was used to code self-
identity in sessions
Jabben et al., 2014 Quantitative 99 BD (86 DB I) 1,236 MD 652 HC Not specified CIDI; IDS-SR IAT; explicit self-associations on a 5-point
scale
Lam et al., 2005 Treatment 51 DB I cognitive therapy 51 DB I control No SCID; BDI; MRS SHPSS; DAS: BD; MCQ; MRC-SPS
quantitative group
Lee et al., 2010 Quantitative 54 DB I No SCID; BDI; BRMRS ASRM; SHPSS; DAS:BD; scenarios rating
task
Pavlickova, Varese, Quantitative 48 DB (28 remission, 12 depressed, 8 No HAM-D; BRMRS Experience sampling method: diaries
Smith, et al., 2013 hypomanic) completed for 6 days, 10 times a day,
with scales assessing mood, self-esteem
and styles of coping with depressive
mood
Rusner et al., 2009 Qualitative 10 DB Not specified Diagnosis by treating psychiatrist Whole-parts-whole analysis of interview
transcripts
Stange et al., 2015 Quantitative 72 DB (58% DB II, 42% cyclothymia or DB No GBI; exp-SADS-L; BDI; RRS; DEQ; CSQ; exp-SADS-C
NOS)
Tse et al., 2014 Qualitative 14 DB Not specified Diagnosis by treating psychiatrist Narrative inquiry methodology and life
charts
Identity
Fernandez et al., 2014 Qualitative 10 DB (7 DB I, 2 DB II, 1 cyclot.) No ASRM; BDI-II; SUDS; PLMI Semi structured interview schedule derived
from the PLMI scale
Fletcher et al., 2013 Mixed methods 13 DB II No MINI, MDQ, ISS Interpretative phenomenological analysis
(IPA) of interview transcripts
Pedersen et al., 2018 Quantitative 15 DB female (ICD criteria) 15 HC female Yes SWLS; PANAS; MDI; ASRM Questionnaire 10 past and future life
chapters
Self-esteem
Blairy et al., 2004 Quantitative 144 BD Not specified SADS-LA or SCAN SAS-SR; RSES
Daskalopoulou Quantitative 28 BD 16 MD 50 HC Not specified SCAN SAS-SR; RSES
et al., 2002
Johnson et al., 2000 Quantitative 31 DB I (33.3% manic, 43.3% depressed, No SCID; MHRSD; BRMS ISEL; RSES
16.6% cycling, 3.3% mixed, 3.3% not full-
blown episode)
WRIGHT ET AL.
TABLE 3 (Continued)

Excl BPD
Authors Type Sample diagnosis Main diagnostic and clinical measures Experimental design and other measures
WRIGHT ET AL.

Knowles et al., 2007 Quantitative 18 DB remitted 16 MD remitted 19 HC Not specified SCID; HAM-D; BRMS; PANAS Daily diary kept for 1 week and completed
twice each day, measuring self-esteem
and positive and negative affect; PIT
Park et al., 2014 Quantitative 19 DB manic, 27 DB euthymic 27 HC Not specified MINI; YMRS; MADRS RSES; SES; IAT
Pavlova et al., 2011 Quantitative 24 BD remitted 24 HC No SCID; MADRS RSES; NLP; CTQ; PANAS; VAS
Serretti et al., 2005 Quantitative 199 BD remitted 132 MD remitted No SCID; HAM-D RSES
Self-stigma
Au et al., 2019 Quantitative 115 DB No YMRS; HAMD; C-SSMIS; FAST; SCOS C-MSPSS; FAST; SCOS
Cerit et al., 2012 Quantitative 8 DB No BDFQ; BDI;YMRS; ISMI; MSPSS; SAI
Chang et al., 2016 Quantitative 43 DB 161 SC 98 MD No Medical records ISMI
45 AD
Çuhadar & Çam, 2014 Treatment 47 DB remitted 24 intervention Yes Diagnosis by treating psychiatrist ISMI; BDFQ
quantitative psychoeducation booklet 23 control 7
session psychoeducation program
Howland et al., 2016 Mixed methods 15 DB No SCID; BPRS; MADRS; YMRS ISMI; GSE; TRQ; content analysis of
interview transcriptions
Karidi et al., 2015 Quantitative 60 DB 60 SC No HAM-D; PANAS; GAF; CGI-BP; GCI-SP; RSES; SIMI
YMRS
Michalak et al., 2011 Mixed methods 32 DB (25 DB I 7 DB II) Not specified MINI; MSIF; HAM-D, YMRS Q-LES-Q, SAS-SR thematic analysis of
individual interview or focus group
Pal et al., 2017 Quantitative 60 DB 33 SC 30 AD all remitted No HAM-D; YMRS; SAPS; SANS; HAM-A; ISMI; RSES; SS; PS; WHOQOL-BREF
MINI; SOFAS
Post et al., 2018 Quantitative 60 DB I 77 HC No MINI; MADRS; YMRS RS-25; BELP; ISMI
Quenneville et al., 2020 Quantitative 69 BD 39 BPD 136 ADHD Yes SCID-II; MINI ISMI; QoLB
Ran et al., 2018 Quantitative 39 BD 232 SC 182 MD Not specified ICD-10-Checklist-AM ISMI demographic characteristics
Sarısoy et al., 2013 Quantitative 119 BD 109 SC Not specified DSM-IV criteria diagnosis by treating ISMI; MRQ
psychiatrist
Self-compassion
Døssing et al., 2015 Quantitative 30 BD (ICD-10 criteria) 30 HC No SCAN; ASRM; MDI; SCS; WAS; SWLS; ISMI
Fletcher et al., 2019 Quantitative 302 DB Not specified MINI; QIDS-SR; MADRS; YMRS; DASS-21 SAPS; SCS; DERS
Yang et al., 2020 Quantitative 302 DB 372 HC No MINI; DASS-21; QIDS-SR; MADRS; YMRS SCS; NTS
Illness perception
Etain et al., 2018 Quantitative 103 DB Severe BPD Diagnosis by treating psychiatrist; MADRS; YMRS; STAI; CSEI; QFS; nr. of and
YMRS < 8 and MADRS < 15 or reasons for noncompletion; knowledge
intervention delayed by 3 months about BD questionnaire; IPQ
Lim et al., 2004 Qualitative 18 DB I Not specified MINI
13

(Continues)
 14 WRIGHT ET AL.

attempts and involuntary admissions to hospital, all factors that corre-

late with an elevated self-stigma (e.g. Chang et al., 2016). Stigmatiza-

Significant statements, meaning units and

fundamental structure of interview and
Experimental design and other measures

Semi-structured interview based on an

Interview based on an interview guide

tion by healthcare professionals is also very common (e.g. Koekkoek

Subjective experience of medication

integrative cognitive model of BD
et al., 2006; Ociskova et al., 2017; Treloar, 2009). We have seen that
in BPD, others' opinions of the self are important and influence one's
focus group transcriptions
own self-concept. It would not be a great leap to assume that the

interview; CGI; ITAQ

diagnosis negatively influences the self-concept, because it deter-
mines beliefs of the sort: ‘having this diagnosis is proof that I am
crazy, ill, bad’, or because others use the diagnosis against them, for
example, during conflicts. The biologization of mental illness is
thought to mitigate stigma and legitimize psychiatric symptoms
(Buchman et al., 2013), even though sometimes patients are ambiva-
lent towards medication as it strengthens their illness identity.
Regardless of research being conclusive, in the patient's mind, the
Main diagnostic and clinical measures

environmental component of BPD is thought to be greater than in

DSM-IV criteria diagnosis by treating

other disorders (such as BD), and this might increase negative self-
related emotions (guilt and shame) and worsen the idea of defective-
ness. Conversely, improper or no communication of the diagnosis is
also quite common in BPD (Sulzer et al., 2016), and this potentially
maintains identity confusion. Therefore, it is important to carry out a
MINI; HAM-D
psychiatrist

thorough communication of the diagnosis.

SCID-I

6 | IMPLICATIONS FOR TREATMENT

D I S C U S S E D I N T H E R E V I E W E D S T U DI ES
Not specified
Excl BPD
diagnosis

The reviewed studies describe ways in which a more positive and

No

No

developed self-concept could be promoted. In both conditions, recent

studies have shown that self-compassion and self-acceptance (for
BPD: Donald et al., 2018, for BD: Døssing et al., 2015; Fletcher
et al., 2019; Inder et al., 2011; Yang et al., 2020) might have the
potential to therapeutically modulate core symptoms of the disorders
and lead to recovery. Instead, self-criticism is negatively associated to
recovery in patients with BPD (Donald et al., 2018) and might increase
18 DB (11 DB I; 7 DB II)

the risk for suicidal ideation in patients with BD (Stange et al., 2015),
in synergy with a negative cognitive style and rumination. Therefore,
self-compassion should be promoted during therapy (Feliu-Soler
et al., 2016; Krawitz, 2012a, 2012b).
13 DB I
Sample

19 DB

Note: Measures, abbreviations and references in Table 5.

Abbreviations: AD, anxiety disorder; SC, schizophrenia.

7 | BPD
Mixed methods
Qualitative

Qualitative

Types of psychotherapy that have found to be effective with these

patients include dialectical behaviour therapy (DBT), mentalization-
Type

based therapy (MBT), transference-focused psychotherapy (TFP) and

schema therapy (ST) (Stoffers et al., 2012).
(Continued)

DBT can help the patient enhance self-concept clarity, as shown

Sajatovic et al., 2008

by Roepke et al. (2011) with techniques such as ‘validation (that) can

Jönsson et al., 2008
Mansell et al., 2010

be considered to be steady, self-verifying feedback from the therapist,

thus leading to a perception of coherence’ (p. 155). In a group of inpa-
TABLE 3

Authors

tients treated for 12 weeks with psychodynamic TFP with modules of

dialectical behaviour skills training, identity diffusion decreased signifi-
cantly (Sollberger et al., 2014).
WRIGHT ET AL. 15

TABLE 4 Studies on borderline personality disorder: measure names and references

Acronym Full name Authors

AAQ Acceptance and Action Questionnaire Hayes et al., 2004b Hayes, S., Strosahl, K., Wilson, K.G., Bissett,
R.T., Pistorello, J., Toarmino, D., Polusny,
M.A., Dykstra, T.A., Batten, S.V., Bergan, J.,
Stewart, S.H., Zvolensky, M.J., Eifert, G.H.,
Bond, F.W., Forsyth, J.P., Karekla, M., &
McCurry, S.M. (2004b). Measuring
experiential avoidance: A preliminary test of
a working model. Psychol Rec., 54:553–578.
DOI: 10.1007/BF03395492
ADIS-IV- Anxiety Disorders Interview Schedule for Brown et al., 1994 Brown, T. A., Di Nardo, P. A., & Barlow, D. H.
PSU DSM-IV-PSU Version (1994). Anxiety disorders interview schedule
for DSM-IV (ADIS-IV). Diagnostic
assessment instrument. New York, NY:
Oxford University Press.
ALS Affective Lability Scale Harvey et al., 1989 Harvey, P. D., Greenberg, B. R., & Serper, M. R.
(1989). The affective lability scales:
Development, reliability, and validity. Journal
of Clinical Psychology, 4:786–793. DOI:10.
1002/10974679(198909)45:5%3C786
ANGST Affective norms for German sentiment terms Schmidtke et al., 2014 Schmidtke, D.S., Schröder, T., Jacobs, A.M., &
Conrad, M. (2014). ANGST: Affective norms
for German sentiment terms, derived from
the affective norms for English words. Behav
Res Methods., 46:1108–1118. DOI: 10.
3758/s13428-013-0426-y
ASF-E Attributional Style Questionnaire Poppe et al., 2005 Poppe, P., Stiensmeier-Pelster, J., & Pelster, A.
(2005) Attributionsstilfragebogen für
Erwachsene. Göttingen: Hogrefe; 10.1111/
cei.12527
ATSS Attitudes Towards Self Scale Carver & Ganellen, 1983 Carver, C.S., & Ganellen, R.J. (1983).
Depression and components of self-
punitiveness: High standards, self-criticism,
and overgeneralization. Journal of Abnormal
Psychology, 92:330–337. DOI:10.
1037/0021-843X.92.3.330
BDI-II Beck Depression Inventory Second Ed. Beck et al., 1996 Beck, A.T., Steer, R.A., Brown, G.K. (1996):
Beck depression inventory manual, 2nd
edition.
BIF-R Revised Borderline Follow-up Interview Zanarini, 1994 Zanarini, M.C. (1994). The revised borderline
follow-up interview. Belmont, MA: McLean
Hospital.
BIS Background Information Schedule Zanarini et al., 2001 Zanarini, M.C., Frankenburg, F.R., Khera, G.S.,
& Bleichmar, J. (2001). Treatment histories
of borderline inpatients. Compr. Psychiatry,
42:144–150. DOI: 10.1053/comp.2001.
19749
BIS-11 Barratt Impulsiveness Scale Patton et al., 1995 Patton, J.H., Stanford, M.S., & Barratt, E.S.
(1995). Factor structure of the Barratt
impulsiveness scale. Journal of Clinical
Psychology, 51:768–764. DOI: 10.
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BPD-SI Borderline Personality Disorder-Severity Giesen-Bloo et al., 2010 Giesen-Bloo, J.H., Wachters, L.M., Schouten,
Interview E., & Arntz, A. (2010). The borderline
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BSL-95 Borderline Symptom List Bohus et al., 2001

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Bohus, M., Limberger, M.F., Frank, U.,
Sender, I., Gratwohl, T., & Stieglitz, R-D.
(2001). Entwicklung der borderline-
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BSL-23 Borderline Symptom List Short version Bohus et al., 2009 Bohus, M., Kleindienst, N., Limberger, M.F.,
Stieglitz, R-D., Domsalla M., Chapman A.L.,
et al. (2009). The short version of the
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Development and initial data on
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42:32–9. DOI: 10.1159/000173701
BSE Basic Self-Esteem Scale Forsman & Johnson, 1996 Forsman, L., & Johnson, M. (1996).
Dimensionality and validity of two scales
measuring different aspects of self-esteem.
Scandinavian Journal of Psychology, 37:1–
15. DOI: 10.1111/j.1467-9450.1996.
tb00635.x
CIDI Composite International Diagnostic Interview Wittchen, 1994 Wittchen, H.U. (1994). Reliability and validity
studies of the WHO-Composite
International Diagnostic Interview (CIDI): A
critical review. Journal of Psychiatric
Research, 28(1):57–84. DOI: https://doi.org/
10.1016/0022-3956(94)90036-1
CGI Clinical Global Impression Guy, 1976 Guy, W. (1976). “Clinical Global Impressions”.
ECDEU Assessment Manual for
Psychopharmacology—Revised. Rockville,
MD: U.S. Department of Health, Education,
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CGI-BPD Clinical Global Impression-Borderline Perez et al., 2007 Perez, V., Barrachina, J., Soler, J., Pascual, J.C.,
Personality Disorder Campins, M.J., Puigdemont, D., & Alvarez, E.
(2007). The clinical global impression scale
for borderline personality disorder patients
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CIP Circumplex of Interpersonal Problems Pedersen, 2002 Pedersen, G. (2002). Revised Norwegian
version of inventory of interpersonal
problems - circumplex (IIP-C) Tidsskrift for
Norsk Psykologforening, 39:25–34. DOI: 10.
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CES-D Center for Epidemiologic Studies Depression Radloff, 1977 Radloff, L.S. (1977). The CES-D scale: A self-
Scale report depression scale for research in the
general population. Appl Psychol Meas.,
1:385–401. DOI: 10.
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CTQ Childhood Trauma Questionnaire Hernandez et al., 2013 Hernandez, A., Gallardo-Pujol, D., Pereda, N.,
Arntz, A., Bernstein, D.P., Gaviria, A.M.,
Labad, A., Valero, J., Gutiérrez-Zotes, J.A.
(2013). Initial validation of the Spanish
childhood trauma questionnaire-short form:
Factor structure, reliability. J Interpers
WRIGHT ET AL. 17

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Violence, 28(7):1498–518. DOI: 10.
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DAS Dysphoric Affect Scale Zanarini et al., 1998 Zanarini, M.C., Frankenburg, F.R., DeLuca, C.J.,
Hennen, J., Khera, G.S., & Gunderson, J.G.
(1998). The pain of being borderline:
Dysphoric states specific to borderline
personality disorder. Harv. Rev. Psychiatry,
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3109/10673229809000330
DIB-R Diagnostic Interview for Borderlines Revised Zanarini et al.,1989 Zanarini, M.C., Frankenburg, F.R., DeLuca, C.J.,
Hennen, J., Khera, G.S., & Gunderson, J.G.
(1998). The pain of being borderline:
Dysphoric states specific to borderline
personality disorder. Harv. Rev. Psychiatry,
6:201–207. DOI: 10.
3109/10673229809000330
DIPD-R Diagnostic Interview for DSM-III-R Personality Zanarini & Frankenburg, 2001 Zanarini, M.C., & Frankenburg, F.R. (2001).
Disorders Attainment and maintenance of reliability of
axis I and II disorders over the course of a
longitudinal study. Compr. Psychiatry,
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DSI Differentiation of Self Inventory Skowron & Friedlander, 1998 Skowron, E.A., & Friedlander, M.L. (1998). The
differentiation of self inventory:
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EQ Empathy Quotient Baron-Cohen & Wheelwright, Baron-Cohen, S. & Wheelwright, S. (2004). The
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ESE Earning Self-Esteem Scale Forsman & Johnson, 1996 Forsman, L., & Johnson, M. (1996).
Dimensionality and validity of two scales
measuring different aspects of self-esteem.
Scandinavian Journal of Psychology, 37:1–
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ERQ Emotion Regulation Questionnaire Gross & John, 2003 Gross J.J., & John O.P. (2003). Individual
differences in two emotion regulation
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FAF Questionnaire for Factors of Aggressiveness- Hampel & Selg, 1998 Hampel, R., & Selg, H. (1998). FAF: Fragebogen
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FBQ Frontal Behaviour Questionnaire Berlin & Rolls, 2004 Berlin, H.A., & Rolls, E.T. (2004). Time
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FSCRS Forms of Self-Criticising/Attacking and Self- Gilbert et al., 2004 Gilbert, P., Clarke, M., Hemel, S., Miles, J.N.V.,
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oneself: And exploration of forms, style and

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reasons in female students. British Journal of
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GAF Global Assessment of Functioning American Psychiatric Association, American Psychiatric Association (2000).
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GSE Generalized Self-Efficacy Scale Schwarzer, 1993 Schwarzer, R. (1993). Measurement of
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HP Heatherton and Polivy Scale (HP) Heatherton & Polivy, 1991 Heatherton, T.F. & Polivy, J. (1991).
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ISE Index of Self-esteem Hudson, 1982 Hudson, W.W. (1982). The clinical
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ISI Identity Style Inventory Berzonsky, 1989 Berzonsky, M.D. (1989). Identity style:
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IPDE International personality disorder examination Loranger et al., 1997 Loranger, A. W., Janca, A., & Sartorius, N.
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IPT Initials Preference Task Nuttin, 1985 Nuttin, J.M. (1985). Narcissism beyond gestalt
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LEAD Spitzer, R. L. (1983). Psychiatric diagnosis: Are
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LPSQ Link's Perceived Stigma Questionnaire Link et al., 1989 Link, B.G., Cullen, F.T., Struening, E.L., &
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MDMQ Multidimensional Mood State Questionnaire Steyer et al., 1997
WRIGHT ET AL. 19

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Acronym Full name Authors

Steyer, R., Schwenkmezger, P., Notz, P. &
Eid, M. (1997)

MINI Mini-International Neuropsychiatric Interview Sheehan et al., 1998 Sheehan, D.V., Lecrubier, Y., Sheehan, K.H.,
Amorim, P., Janavs, J., Weiller, E., Hergueta,
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MINI-KID Mini International Neuropsychiatric Interview Sheehan et al., 2010 Sheehan, D.V., Sheehan, K.H., Shytle, R.D.,
for Children and Adolescents Janavs, J., Bannon, Y., Rogers, J.E., et al.
(2010). Reliability and validity of the mini
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MSCEIT Mayer–Salovey–Caruso Emotional Intelligence Mayer et al., 2000 Mayer, J.D., Salovey, P. & Caruso, D. R. (2000).
Test V2.0 The Mayer, Salovey, and Caruso emotional
intelligence test: Technical manual. Toronto:
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MSES Multidimensional Self-Esteem Scale Schütz & Sellin, 2006 Schütz, A., & Sellin, I. (2006). Die
multidimensionale Selbst-wertskala (MSWS)
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MSES]. Göttingen: Hogrefe.
MSI-BPD McLean Screening Instrument for Borderline Zanarini et al., 2003 Zanarini, M.C., Vujanovic, A.A., Parachini, E.A.,
Personality Disorder & Boulange, J.L. (2003). A screening measure
for BPD: The McLean screening instrument
for borderline personality disorder (MSI-
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MWT-B Multiple choice vocabulary test Lehr et al., 1995 Lehrl, S., Triebig G., & Fischer B. (1995).
Multiple choice vocabulary test MWT as a
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OGT Overgeneralization test Klar et al., 1997 Klar, Y., Gabai, T., & Baron, Y. (1997).
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Personality and Individual Differences,
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PAI-BOR Personality Assessment Inventory - Borderline Morey, 1991 Morey, L.C. (1991). The personality assessment
Features inventory: Professional manual.
Psychological Assessment Resources, Lutz,
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PDSQ Psychiatric Diagnostic Screening Questionnaire Zimmerman & Mattia, 2001 Zimmerman, M., & Mattia, J.I. (2001). A self-
report scale to help make psychiatric
diagnoses: The psychiatric diagnostic
screening questionnaire. Arch Gen
Psychiatry, 58:787–794. DOI: 10.1001/
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PHLMS Philadelphia Mindfulness Scale Cardaciotto et al., 2008 Cardaciotto, L., Herbert, J. D., Forman, E. M.,
Moitra, E., & Farrow, V. (2008). The
assessment of present-moment awareness
and acceptance: The Philadelphia

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mindfulness scale. Assessment, 15(2):204–
23. DOI: 10.1177%2F1073191107311467
PSQ Possible Selves Questionnaire Markus & Wurf, 1987 Markus, H., & Wurf, E. (1987). The dynamic
self-concept: A social psychological
perspective. Annual Review of Psychology,
38:299–337.
QoLB Quality of Life Brief Michalak & Murray, 2010 Michalak, E.E., & Murray G. (2010).
Development of the QoL.BD: A disorder-
specific scale to assess quality of life in
bipolar disorder. Bipolar Disorder,
12(7):727–740. DOI: 10.1111/j.1399-5618.
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RAS Recovery Assessment Scale Corrigan et al., 1999 Corrigan, P.W., Giffort, D., Rashid, F., Leary, M.,
Okeke, I. (1999). Recovery as a psychological
construct. Community Ment Health,
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RFQ Reflective Function Questionnaire Fonagy et al., 2016 Fonagy, P., Luyten, P., Moulton-Perkins, A.,
Lee, Y.W., Warren, F., Howard, S., Ghinai, R.,
Fearon, P., Lowyck, B. (2016). Development
and validation of a self-report measure of
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DOI: 10.1371/journal.pone.0158678
RSES Rosenberg Self-Esteem Scale Rosenberg, 1965 Rosenberg, M. (1965). The measurement of
self-esteem. In: Rosenberg M. (ed.), Society
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SAPAS-SR Self-report standardized assessment of Germans et al., 2008 Germans, S., van Heck, G.L., Moran, P., &
personality – Abbreviated scale Hodiamont, P.P.G. (2008). The self-report
standardized assessment of personality-
abbreviated scale: Preliminary results of a
brief screening test for personality disorders.
Personality and Mental Health, 2:70–76.
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SBQoL SmithKline Beecham Quality of Life Scale Stoker et al., 1992 Stoker, M.J., Dunbar, GC, Beaumont, G. (1992).
The SmithKline Beecham “quality of life”
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patients with affective disorder. Qual Life
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SCC Self-Concept Clarity Scale Campbell et al., 1996 Campbell, J.D., Trapnell, P.D., Heine, S.H., Katz,
I.M., Lavallee, L.F., & Lehman, D.R. (1996).
Self-concept clarity: Measurement,
personality correlates, and cultural
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SCID Structured Clinical Interview for DSM–IV Axis I First et al., 1997 First, M.B., Spitzer, R.L., & Williams, J.B. (1997).
Disorders Structured clinical interview for DSM–IV
axis I disorders SCID-I: Clinician version,
administration booklet. San Antonio, TX:
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SCID II Structured Clinical Interview for DSM–IV Axis First et al., 1997 First, M.B., Gibbon, M., Spitzer, R.L., Williams,
II Disorders J.B.W., & Benjamin, L. (1997). Structured
clinical interview for DSM-IV personality
disorders (SCID-II): Interview and
WRIGHT ET AL. 21

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questionnaire. Washington, DC: American
Psychiatric Press.
Self-Aspects Card Sort Task Shower et al., 1998 Showers, C., Abramson, L., & Hogan, M. (1998).
The dynamic self: How the content and
structure of the self-concept change with
mood. Journal of Personality and Social
Psychology, 75:478–493. DOI: 10.
1037/0022-3514.75.2.478
Self-descriptive Card Sort Task Shower, 1992 Showers, C.J. (1992). Compartmentalization of
positive and negative self- knowledge:
Keeping bad apples out of the bunch.
Journal of Personality and Social Psychology,
62:1036e1049. DOI: 10.1037//0022-3514.
62.6.1036
SCID-II Structured Clinical Interview for DSM-III-R First et al., 1997 First, M.B., Gibbon, M., Spitzer, R.L., Williams,
personality disorders J.B.W. & Benjamin, L.S. (1997). SCID-II
personality questionnaire. Washington, DC:
American Psychiatric Press.
SCIM Self-concept and identity measure Kaufman et al., 2014 Kaufman, E.A., Cundiff, J.M., & Crowell, S.E.
(2014). The development, factor structure,
and validation of the self-concept and
identity measure (SCIM): A self-report
assessment of clinical identity disturbance.
Journal of Psychopathology and Behavioral
Assessment, 37, 122–133. DOI: 10.1007/
s10862-014-9441-2
SCL-90 Symptom Checklist-90 Franke, 1995 Franke, G.H. (1995). Die Symptom-Checkliste
von Derogatis (SCL-90-R). Göttingen: Beltz.
SCS Self-Compassion Scale Neff, 2003 Neff, K. (2003). The development and
validation of a scale to measure self-
compassion. Self Identity, 2:223–50.
SEQ Subjective Emotion Questionnaire Berlin & Rolls, 2004 Berlin, H.A., & Rolls, E.T. (2004). Time
perception, impulsivity, emotionality, and
personality in selfharming borderline
personality disorder patients. J. Pers. Disord.
18:358–378. DOI: 10.1521/pedi.18.4.358.
40349
SSMIS Self-Stigma of Mental Illness Scale Corrigan et al., 2006 Corrigan, P.W., Watson, A.C., & Barr, L. (2006).
The self-stigma of mental illness:
Implications for self-esteem and self-
efficacy. Journal of Social and Clinical
Psychology, 25(8):875–884. DOI: 10.1521/
jscp.2006.25.8.875
SRET Self-referential Encoding Task Auerbach et al., 2015 Auerbach, R.P., Stanton, C.H., Proudfit, G.H., &
Pizzagalli, D.A. (2015). Self-referential
processing in depressed adolescents: A high-
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1037/abn0000023
SSES State Self-Esteem Scale Heatherton & Polivy, 1991 Heatherton, T.F., & Polivy, J. (1991).
Development and validation of a scale for
measuring state self-esteem. Journal of
Personality and Social Psychology, 60:895–
910. DOI:10.1037/0022-3514.60.6.895
STIPO Structured Interview of Personality Clarkin et al., 2003 Clarkin, J.F., Caligor, E., Stern, B., & Kernberg,
Organization O.F. (2003). Structured interview of
personality organization (STIPO). Cornell
University: Personality Disorders Institute.

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22 WRIGHT ET AL.

TABLE 4 (Continued)

Acronym Full name Authors

TAS-20 Toronto Alexithymia Scale Bagby et al., 1994 Bagby, M., Parker, J.D.A. & Taylor, G.J. (1994).
The twenty-item Toronto alexithymia scale-I.
item selection and cross-validation of the
factor structure. Journal of Psychosomatic
Research, 38:23. DOI: 10.1016/0022-3999
(94)90005-1
TCI Temperament and Character Inventory Cloninger et al., 1994 Cloninger, C.R., Przybeck, T.R., Svrakic, D.M., &
Wetzel, R.D. (1994). The temperament and
character inventory (TCI): A guide to its
development and use. St-Louis, MO:
Washington University.
TOSCA Test of Self-Conscious Affect Tangney et al., 2000 Tangney, J.P., Dearing, R.L., Wagner, P.E., &
Gramzow, R. (2000). The test of self-
conscious affect-3 (TOSCA-3). Fairfax:
George Mason University.
VKP Questionnaire for Personality traits (Vragenlijst Duijsens et al., 1996 Duijsens, I.J., Eurelings-Bontekoe, E.H.M., &
voor Kenmerken van de Persoonlijkheid Diekstra, R.F.W. (1996). The VKP, a self-
[VKP]) report instrument for DSM-III-R and ICD-10
personality disorders: Construction and
psychometric properties. Personality and
Individual Differences, 20:171–182. DOI:
10.1016/0191-8869(95)00161-1
WURST Wender Utah Rating Scale Ward et al., 1993 Ward, M.F., Wender, P.H., & Reimherr, F.W.
(1993). The Wender Utah rating scale: An
aid in the retrospective diagnosis. Am J
Psychiatry, 150(6):885–90. DOI: 10.1176/
ajp.150.6.885
ZAN-BPD Zanarini Rating Scale for Borderline Personality Zanarini et al., 2003 Zanarini, M.C., Vujanovic, A.A., Parachini, E.A.,
Disorder Boulanger, J.L., Frankenburg, F.R., & Hennen,
J. (2003). Zanarini rating scale for borderline
personality disorder (ZAN-BPD): A
continuous measure of DSM-IV borderline
psychopathology. J Pers Disord. 1(3): 233–
42. DOI: 10.1521/pedi.17.3.233.22147
ZDQ Zung Depression Questionnaire Zung, 1965 Zung, W.W. (1965). A self-rating depression
scale. Arch Gen Psychiatry, 12:63–70. DOI:
10.1001/archpsyc.1965.01720310065008

TFP and MBT directly target the self-concept. TFP (Clarkin 8 | BD

et al., 2006) aims to increase identity diffusion through different strat-
egies, tactics and techniques (such as interpretation and transference
analysis), MBT (Bateman & Fonagy, 2004) aims to increase the
patient's ability to infer one's own and others' mental states, and ST
aims to increase an adaptive self-concept (healthy adult mode)
through mode work (Young, 1999).
Given that negative beliefs concerning the self are core features
of BPD, it is important to conduct a thorough analysis of these beliefs
during therapy and to address them using several different techniques
that lead to generalized and long-lasting changes. Clinical interven-
tions that aim to increase self-esteem (Jacob et al., 2010) and agency
(constructed through life stories), or decrease dependency on others
(Lind et al., 2018, 2019) could be beneficial for BPD patients.
In psychotherapy, it is important to promote the integration of the ill-
ness identity in a more general self-concept (Inder et al., 2011). Clini-
cians should check and modify goal-attainment beliefs, particularly of
those who exhibit features of sense of hyper-positive self, as they
tend to desire high mood states and could engage in behaviours that
might ultimately lead to a manic episode (Lee et al., 2010; for a review
of the psychological aspects of mania, see Mansell & Pedley, 2008).
According to Lam et al. (2005), these patients' tendency to identify
with hypomanic traits as self-descriptors should be dealt with using
psychological techniques such as cognitive restructuring.
Psychosocial factors, such as social support as opposed to social
stigma, seem to be more relevant for the course of bipolar depression
WRIGHT ET AL. 23

TABLE 5 Studies on bipolar disorder: measure names and references

Acronym Full name Authors References

ASRM The Altman Self-Rating Mania Scale Altman et al., 1997 Altman, E.G., Hedeker, D., Peterson, J.L.,
Davis, J.M. (1997). The Altman self-rating
mania scale. Biol Psychiatry, 42:948–55.
DOI: 10.1016/S0006-3223(96)00548-3
ASRSv1.1 Adult ADHD self-report scale Adler et al., 2006 Adler, L.A., Spencer, T., Faraone, S.V., Kessler,
R.C., Howes, M.J., Biederman, J., Secnik, K.
(2006). Validity of pilot adult ADHD self-
report scale (ASRS) to rate adult ADHD
symptoms. Ann. Clin. Psychiatry, 18:145–
148. DOI: 10.1080/10401230600801077
BDI Beck Depression Inventory Beck, 1961 Beck, A.T. (1961). An inventory for measuring
depression. Arch Gen Psychiatry, 4:561–71.
DOI: 10.1001/archpsyc.1961.
01710120031004
BDFQ Bipolar Disorder Functioning Questionnaire Aydemir et al., 2007 Aydemir, Ö., Eren, _I., Savaş, H., Og
uzhanog
lu,
N.K., Koçal, N., Özgüven, H.D., et al. (2007).
Development of a questionnaire to assess
inter-episode functioning in bipolar
disorder: Bipolar disorder functioning
questionnaire. Turk Psikiyatri Derg,
18:344–52.
BELP Berliner Lebensqualitätsprofil Priebe et al., 1995 Priebe, S., Gruyters, T., Heinze, M., Hoffmann,
C., & Jakel, A. (1995). Subjective evaluation
criteria in psychiatric care-methods of
assessment for research and general
practice. Psychiat Prax, 22:140–144.
BRMRS Bech–Rafaelsen Mania Scale Bech et al., 1978 Bech, P., Bolwig, T.G., Kramp, P., Rafaelsen,
O.J. (1979). The Bech-Rafaelsen mania
scale and the Hamilton depression scale:
Evaluation of homogeneity and inter-
observer reliability. Acta Psychiatri.Scand.
59:420–430. DOI: 10.1111/j.1600-0447.
1979.tb04484.x
CIDI Composite International Diagnostic Interview Wittchen, 1994 Wittchen, H.U. (1994). Reliability and validity
studies of the WHO-composite
international diagnostic interview (CIDI): A
critical review. Journal of Psychiatric
Research, 28(1):57–84. DOI: 10.
1016/0022-3956(94)90036-1
CGI Clinical Global Impression Scale Guy, 1976 Guy, W. (Ed.) (1976). ECDEU assessment
manual for psychopharmacology. Rockville,
MD: US Department of Health, Education,
and Welfare Public Health Service Alcohol,
Drug Abuse, and Mental Health
Administration.
CGI-BP Clinical Global Impressions Scale-Bipolar Spearing et al., 1997 Spearing, M.K., Post, R.M., Leverich, G.S.,
Illness Brandt, D., Nolen, W. (1997). Modification
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diversity of symptoms present in

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WRIGHT ET AL. 25

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26 WRIGHT ET AL.

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WRIGHT ET AL. 27

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28 WRIGHT ET AL.

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QoLB Quality of Life Brief Michalak et al., 2010 Michalak, E.E., Murray, G., & Collaborative
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PS Participation Scale Van Brakel et al., 2006 van Brakel, W.H., Anderson, A.M., Mutatkar,
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PIT Pragmatic Inferential Test Winters & Neale, 1985 Winters, K. C., & Neale, J. M. (1985). Mania
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PLMI Personal Loss from Mental Illness scale Stein et al., 2005 Stein, C. H., Dworsky, D. O., Phillips, R. E., &
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PQQ The Personal Qualities Questionnaire (PQQ) Higgins et al., 1986 Higgins, E. T., Bond, R., Klein, R., & Strauman,
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SCOS Stigma Coping Orientation Scale Link et al., 2002 Link BG, Struening EL, Neese-Todd S,
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SIMI Stigma Inventory of Mental Illness Karidi et al., 2014 Karidia. M.V., Vasilopoulou, D., Savvidou, E.,
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SOFAS Social and Occupational Functioning Morosini et al., 2000 Morosini, P-L., Magliano, L., Brambilla, L.,
Assessment Scale Ugolini, S., Pioli, R. (2000). Development,

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30 WRIGHT ET AL.

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reliability and acceptability of a new version
of the DSM-IV social and occupational
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SWLS The Satisfaction With Life Scale Dienner et al., 1985 Diener, E., Emmons, R.A., Larsen, R.J., Griffin,
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WURS Wender Utah Rating Scale Ward et al., 1993 Ward, M.F., Wender, P.H., Reimherr, F.W.
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WRIGHT ET AL.
than mania (Johnson et al., 2000). In fact, for people who have accom-
plished important life goals, such as forming and continuing important
personal relationships and maintaining employment, the damaging
effects of stigma are smaller (Sajatovic et al., 2008). Self-stigma can be
targeted and reduced by psychoeducation (Çuhadar & Çam, 2014).
9 | C O N CL U S I O N S
There is evidence in the literature of qualitative differences in self-
concept, identity and self-esteem between the two disorders.
Future studies could examine factors such as environmental stim-
uli or internal representations that might play a role in precipitating
changes in these constructs. Some authors have already attempted to
do so in a laboratory setting (e.g. Pavlova et al., 2011); it would also
be informative to use more ecological measures, for example, a modi-
fied experience sampling method. Evidently, qualitative studies are
conducted on small numbers, and this limits their generalizability, but
they are nonetheless a source of precious information for clinicians.
Comparative studies are greatly needed, as the great heterogene-
ity of methods, measures and theories in existing studies of the same
concept (see Tables 2 and 3, appendix) limits their comparability. We
report the clinical and experimental measures used in the reviewed
studies (see also Tables 4 and 5, appendix) to give the reader an idea
of the variety. This information ‘at a glance’ could also be useful to
design new studies.
In general, for diagnostic and treatment purposes, clinicians
should ideally conduct a thorough assessment to obtain a general pic-
ture of each patient's intrapsychic and interpersonal functioning,
including their self-concept as it has a pivotal role in the clinical
picture.
10 | LIMITATIONS
This review has numerous limitations. We systematically retrieved
articles to draw a complete picture of the literature, but their discus-
sion as a narrative review could be affected by our personal view. We
carried out a general overview of the publications in this area to direct
future studies of clinical interest, but this led to the inclusion of a
great number of studies, which therefore could not all be analysed
and discussed in great depth. Most of the reviewed studies on BPD
used all-female samples and screened for and excluded co-morbid BD,
whereas studies on BD were mostly mixed gender, and some did not
screen for co-morbid BPD. In many, there was no differentiation
between BD I and II (see Tables 2 and 3, appendix). The results of
studies that use mixed samples might be scarcely informative, as BD I
and BD II are two distinct entities and BD II shares more characteris-
tics with BPD than BD I, as noted in Section 1. In general, the great
discordance in the terminology was quite confusing, to the point that
the demarcations between the concepts were not clear. As already
stated in Section 2, for thoroughness and length purposes, we did not
include other constructs, such as dissociation, splitting, early
31
maladaptive schemas, metacognitive processes, insight, autobiograph-
ical memory (in general, not identity related) and trauma, which are
intimately related to the analysed constructs.
ACKNOWLEDG MENTS
This research did not receive funding.
CONFLIC T OF INT ER E ST
The authors have no conflicts of interest to declare.
DATA AVAILABILITY STAT EMEN T
Data sharing is not applicable to this article as no new data were cre-
ated or analysed in this study.
OR CID
Livia Wright https://orcid.org/0000-0002-8286-0818
Lisa Lari https://orcid.org/0000-0001-8928-3040
Stefania Iazzetta https://orcid.org/0000-0001-6922-6487
Andrea Gragnani https://orcid.org/0000-0001-9129-8794
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How to cite this article: Wright L, Lari L, Iazzetta S,
Saettoni M, Gragnani A. Differential diagnosis of borderline
personality disorder and bipolar disorder: Self-concept,
identity and self-esteem. Clin Psychol Psychother. 2021;1–36.
https://doi.org/10.1002/cpp.2591