Severe borderline traits in bipolar disorder are linked to early maladaptive schemas

A recent study published in the Journal of Affective Disorders suggests that deep-seated negative beliefs formed in childhood play a role in how borderline personality traits appear in people with bipolar disorder. The research provides evidence that individuals with severe borderline traits experience a stronger psychological web of negative relationship patterns and self-harm compared to those with milder traits. These findings offer new insights into how mental health professionals might better tailor therapies for complex mood disorders.

Bipolar disorder is a mental health condition characterized by extreme mood swings, including emotional highs and depressive lows. Many people with this condition also exhibit borderline personality features. These features include emotional instability, a distorted sense of self, turbulent relationships, and behaviors that cause self-harm.

The authors of the new study wanted to understand why some patients with bipolar disorder display very severe borderline traits while others only show mild signs. The researchers hypothesized that early maladaptive schemas might explain these differences. Early maladaptive schemas are deeply ingrained, unhelpful patterns of thinking and feeling about oneself and the world. These negative beliefs usually develop in childhood when a child’s basic emotional needs are not met.

“Some patients with bipolar disorder exhibit severe borderline personality features, while others do not. I considered it important to explore the mechanisms underlying these differences, as the level of borderline personality features is associated with variations in patients’ clinical characteristics, such as mood symptoms, self-identity, and interpersonal relationships,” explained Myeongkeun Cho of the Asan Medical Center.

“I also hypothesized that differences in the level of borderline personality features might be related with early maladaptive schemas, as schema therapy posits that early maladaptive schemas influence several personality-related problems. Therefore, I decided to compare the levels and associations of borderline personality features and early maladaptive schemas between patients with bipolar disorder who have severe borderline personality features and those with nonsevere borderline personality features.”

To conduct the study, the researchers analyzed data from 557 outpatients receiving treatment at a hospital in Seoul, South Korea. All participants were between the ages of 18 and 49 and had a formal diagnosis of either bipolar I or bipolar II disorder. Bipolar I disorder involves severe manic episodes that are often accompanied by deep depression, while bipolar II involves a pattern of depressive episodes and less severe manic periods.

The patients completed standardized psychiatric questionnaires as part of their routine medical care. The scientists used a specific assessment tool to measure the severity of four borderline traits: emotional instability, identity problems, negative relationships, and self-harm. They also used a secondary questionnaire to evaluate 18 different early maladaptive schemas.

These 18 schemas included feelings of abandonment, emotional deprivation, social isolation, and a persistent sense of defectiveness. Based on the assessment scores, the researchers divided the participants into two separate categories. The final sample included 345 patients with severe borderline features and 212 patients with non-severe borderline features.

The researchers utilized a statistical method called network analysis to map out how these different traits and beliefs connected to one another. Network analysis is a mathematical technique that allows scientists to visualize complex relationships, treating each symptom or belief as a point on a map and drawing lines between them based on how strongly they link together.

The researchers found that the group with severe borderline traits scored higher on all four borderline features. This severe group also scored higher on every single one of the 18 early maladaptive schemas compared to the non-severe group.

The network analysis revealed several similarities between the two groups. In both sets of patients, the early negative beliefs were highly interconnected. Specifically, schemas related to a sense of defectiveness, shame, and subjugation tended to be central hubs in the psychological network.

Subjugation refers to a person’s tendency to surrender control to others to avoid conflict or rejection. Additionally, in both groups, a patient’s struggle with identity and negative relationships strongly linked to schemas involving disconnection and feelings of being rejected by others.

Another shared pattern involved self-harming behaviors. Across all participants, engaging in self-harm was directly connected to a schema characterized by insufficient self-control and a lack of self-discipline. This provides evidence that the belief that one cannot control their own impulses plays a role in self-destructive actions.

Despite these commonalities, the scientists discovered distinct differences in how the traits interacted. For patients in the severe group, negative relationship patterns were much more strongly tangled with early negative beliefs than in the non-severe group. This indicates that their interpersonal struggles are deeply rooted in chronic, unhelpful ways of seeing the world.

The way emotional instability manifested also differed based on the severity of the borderline traits. For the patients with severe borderline features, emotional instability was directly linked to self-harming behaviors. For those with non-severe features, emotional instability was instead linked to internal struggles with their own identity.

“I would like to highlight that, whether borderline personality features are severe or not, identity problems and negative relationships are directly related with the schema that ‘others will reject me’, and self-harm behavior is directly related with the schema that ‘I am unable to tolerate distress well,’” Cho told PsyPost. “Another takeaway is that patients with severe borderline personality features show greater severity across all maladaptive schemas, and their negative relationships with others are more closely related with maladaptive schemas.”

While the study provides extensive details about the psychological networks of these patients, there are some potential misinterpretations and limitations to consider. The research relied on cross-sectional data, meaning the information was gathered at a single point in time. Because of this design, the scientists cannot definitively prove that early maladaptive schemas cause borderline traits. It remains possible that having severe borderline traits alters how a person remembers and reports their childhood beliefs.

Additionally, the study solely included Korean outpatients from a single hospital. This specific sample might limit how well the findings apply to individuals from different cultural backgrounds or clinical settings.

Future research should involve long-term studies that track patients over months or years. Observing these changes over time would help clarify the direct cause-and-effect relationships between childhood schemas and personality traits. Scientists also recommend testing whether specific psychotherapies that target these deep-seated beliefs can successfully reduce borderline symptoms in patients with bipolar disorder.

The study, “Levels and associations of borderline personality features and early maladaptive schemas in bipolar disorder: A comparative network analysis“, was authored by Myeongkeun Cho, Chanhee Park, Eunbyeol Lee, and C. Hyung Keun Park.