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RES E AR C H A R T I C L E Open Access
Using the mood disorder questionnaire and
bipolar spectrum diagnostic scale to detect
bipolar disorder and borderline personality
disorder among eating disorder patients
Toshihiko Nagata
1*
, Hisashi Yamada
2
, Alan R Teo
3
, Chiho Yoshimura
2
, Yuya Kodama
1
and Irene van Vliet
4
Abstract
Background: Screening scales for bipolar disorder including the Mood Disorder Questionnaire (MDQ) and Bipolar
Spectrum Diagnostic Scale (BSDS) have been plagued by high false positive rates confounded by presence of
borderline personality disorder. This study examined the accuracy of these scales for detecting bipolar disorder
among patients referred for eating disorders and explored the possibility of simultaneous assessment of co-morbid
borderline personality disorder.
Methods: Participants were 78 consecutive female patients who were referred for evaluation of an eating disorder.
All participants completed the mood and eating disorder sections of the SCID-I/P and the borderline personality
disorder section of the SCID-II, in addition to the MDQ and BSDS. Predictive validity of the MDQ and BSDS was
evaluated by Receiver Operating Character istic analysis of the Area Under the Curve (AUC).
Results: Fifteen (19%) and twelve (15%) patients fulfilled criteria for bipolar II disorder and borderline personality
disorder, respectively. The AUCs for bipolar II disorder were 0.78 (MDQ) and 0.78 (BDSD), and the AUCs for
borderline personality disorder were 0.75 (MDQ) and 0.79 (BSDS).
Conclusions: Among patients being evaluated for eating disorders, the MDQ and BSDS show promise as screening
questionnaires for both bipolar disorder and borderline personality disorder.
Keywords: Bipolar disorder, Borderline personality disorder, Eating disorder, Comorbidity, Screening scale
Background
As bipolar disorders are serious mental disorders that can
cause severe lifelong functional impairment, early recogni-
tion of the diagnosis and early introduction of mood
stabilizers are crucial for improvement of outcomes [1].
Nonetheless, most patients with bipolar disorder go years
before receiving an appropriate diagnosis and starting
mood stabilizers [1]. Borderline personality disorder is the
most common personality disorder in clinical settings,
and causes marked distress and impairment in social,
occupational, and role functioning [2]. Yet, similar to bi-
polar disorder, borderline personality disorder is often
incorrectly diagnosed or underdiagnosed in clinical prac-
tice [2]. Both bipolar and borderline personality disorders
are associated with high rates of completed suicide [1,2]
and are common among patients with mood disorders
[1,2] and eating disorders [3,4].
Recently, the boundary of these disorders has been a
focus of debate [5-9]. There are two viewpoints about
the relationship between bipolar disorder, especially bi-
polar II disorder, an d borderline personality disorder.
The first one is that underlying cyclothymic tempera-
ment can explain the relationship, and borderline per-
sonality disorder [9] (as well as bulimia nervosa [8]) are
variants of bipolar disorders. Others insist that there is
clear boundary between bip olarity and borderline per-
sonality disorder, and they resist the expansion of bipolar
* Correspondence: TOSHI@med.osaka-cu.ac.jp
1
Department of Neuropsychiatry, Osaka City University Graduate School of
Medicine, 1-4-3 Asahimachi, Abunoku, Osaka 545-8585, Japan
Full list of author information is available at the end of the article
© 2013 Nagata et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Nagata et al. BMC Psychiatry 2013, 13:69
http://www.biomedcentral.com/1471-244X/13/69
disorder as an invasion of “bipolar imperialism” toward
other diagnostic categories [5].
Two screening scales, the MoodDisorderQuestionnaire
(MDQ) [10] and Bipolar Spectrum Diagnostic Scale (BSDS)
[11], have been developed to ameliorate the underdiagnosis
of bipolar disorders. T hese instruments show good psycho-
metric properties to detect bipolarity among patients with
unipolar depression and are recommended as screening
tools for bipolar disorders among patients with unipolar de-
pression [1]. However, Zimmerman et al. (2011) [12,13]
reported that the false positive rates of these two scales
were not negligible because of the symptomatic overlap
of bipolar disorder and other conditions [1]. Patients
diagnosed with bipolar disorder by previous doctors were
significantly more likely to be diagnosed with borderline
personality disorder compared to patients who were not
diagnosed with bipolar disorder (24.4% vs. 6.1%) [14].
Viewed another way, these results suggest the possibility
that both bipolar and borderline personality disorders can
be simultaneously detected by these scales.
To the best of our knowledge, the MDQ and BSDS
have never been used to detect bipolar disorders or bor-
derline personality disorder among eating disorder
patients, despite the relatively high comorbidity rates of
these disorders [3,4]. In contrast to common attention
towards impulsivity and borderline personality disorder
among eating disorder patients [4], the presence of
comorbid bipolar disorder has rarely received attention
of eating disorder specialists [15]. However, some evi-
dence suggests increased prevalence of bip olar II dis-
order [16], ego-syntonic hypomania may escape clinical
detection, and comorbid bipolar disorder requires spe-
cial therapeutic considerations [3]. Thus, screening
scales for bipolar disorder might be more important
than eating disorder specialists traditionally thought.
The aim of the current study was to examine the diag-
nostic accuracy (includin g sensitivity and specificity) of
the MDQ and BSDS to detect bipolar disorders among
patients that were referred for evaluation of an eating
disorder. We also explored the possibility that the two
scales can detect borderline personality disorder among
this population. We hypothesized that the diagnostic ac-
curacy of the two screening tests (MDQ and BSDS) for
borderline personality disorder might be similar to that
for bipolar disorders.
Methods
Participants
Participants were recruited from a consecutive series of
ninety female patients who were referred for evaluation
and/or treatment of an eating disorder to the first and
second authors (T. N. and H. Y.) at the Department of
Neuropsychiatry, Osaka City University Hospital from Feb-
ruary to June 2011. To maximize real world applicability of
findings, exclusion criteria were minimal: 1) substance use
disorder requiring acute detoxification (if such cases
hospital receptionists recommended patients to visit an
alcohol treatment facility), 2) self-reported history of schi-
zophrenia, schizoaffective disorder, schizophreniform dis-
order, or organic mental illnesses, as determined by the
screening questionnaire of the SCID-I/P, or 3) inability or
unwillingness to complete self-rating scales. The patients
with eating disorder not otherwise specified (EDNOS) were
not excluded as prior research has shown these patients
often are referred for eating disorder treatment and may
have comorbid bipolar or borderline personality disorder
[17] . Of the ninety patients who were screened, seventy-
Table 1 Demographic and clinical characteristics of
participants (n = 78) with eating disorders
Mean (SD) or N (%)
Age, years 29.5 (7.4)
Education, years 13.8 (2.4)
Marital status, single 58 (74%)
Occupational status
Unemployed 37 (47%)
Part-time worker (or student) 16 (21%)
Full-time worker (or student) 25 (32%)
Age at onset of eating disorder 19.1 (4.8)
Body mass index 17.3 (4.4)
Subtype of eating disorder
Anorexia nervosa restricting type 11 (14%)
Anorexia nervosa binge-eating purging subtype 24 (31%)
Bulimia nervosa purging subtype 27 (35%)
Restricting EDNOS 2 (3%)
Binge-eating / purging EDNOS 14 (18%)
Frequency of binge eating (episodes/week) 4.6 (4.6)
Frequency of vomiting (episodes/week) 4.9 (4.2)
History of major depressive episode(s) 55 (71%)
Age at onset, years 20.5 (4.8)
History of manic episode(s) 0 (0%)
History of hypomanic episode(s) 15 (19%)
Age at onset, years 23.1 (5.6)
Borderline personality disorder 12 (15%)
Histrionic personality disorder 23 (30%)
BSDS total score 9.2 (6.2)
BSDS≥13 22 (28%)
BSDS≥11 31 (40%)
MDQ≥7 with moderate functional impairment 15 (19%)
MDQ≥5 with minor functional impairment 30 (39%)
MDQ: Mood Disorder Questionnaire, BSDS: Bipolar Spectrum Diagnostic Scale,
EDNOS: Eating disorder not otherwise specified.
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eight patients enrolled in the study, and all enrollees
completed the study. Of the twelve patients that did not
participate in the study, six deemed their psychiatric prob-
lem minor and opted to cope with the difficulty, four were
reluctant to undergo detailed psychiatric assessment, and
two declined to participate for unknown reasons. As part
of routine clinical care, patients received cognitive behav-
ioral therapy, dialectical behavioral therapy, or medication
management depending on the results of their assessment,
even when their provisional primary diagnosis (defined as
the disorder most influencing their global functioning) was
other than an eating disorder. All patients provided written
informed consent before entering the study. This study
was approved by the institutional review committee of the
Osaka City University Graduate School of Medicine.
Measurements
Two self-report screening scales for bipolar disorder, the
Mood Disorder Questionnaire (MDQ) [10,18] and Bipolar
Spectrum Diagnostic Scale (BSDS) [11,19], were competed
by all participants. The MDQ screens for a lifetime history
of mania or hypomania using 13 dichotomous (yes/no)
symptom questions reflecting the DSM-IV inclusion cri-
teria. The symptom questions are followed by a single
question about whether the symptoms clustered during
the same period. The final question evaluates the level of
impairment resulting from the symptoms on a 4-point
scale (no, minor, moderate, or serious problems). A score
of 7 or more on the first 13 items, “yes” to symptom
clustering, and moderate or greater problems was
proposed as the cut-off level in the original study [10]. In
a Japanese study of unipolar depressive patients, a lower
cut-off of more than 5 with minor or greater problems
was proposed [19]. The BSDS was developed to target
bipolar II disorder and bipolar disorder not otherwise
specified and supplement clinicians’ semi-structured
interviews [11]. The BSDS consists of two parts: first, a
paragraph containing 19 statements describing many of
the symptoms of bipolar disorder, and, second, a single
multiple-choice question asking respondents how well the
paragraph describes them. The total score ranges from 0
to 25. A score of 13 for the original version [11], 12 for
the Chinese version [20], and 11 for the Japanese version
[19] have been proposed as cut-off points.
All participants underwent a direct (face-to-face) assess-
ment conducted by T. N. or H. Y. who each have more
than ten years’ experience treating eating disorders. This
assessment included the mood and eating disorder
Figure 1 Diagnoses of patients (n=78) based on MDQ and BSDS scores. MDQ: Mood Disorder Questionnaire, BSDS: Bipolar Spectrum
Diagnostic Scale.
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sections of the Structured Clinical Interview for DSM-IV,
(SCID-I/P) [21,22], and the borderline and histrionic
personality sections of the Structured Clinical Interview
for DSM-IV Personality Disorders (SCID-II) [23,24].
These limited portions of the SCID-II were selected be-
cause our previous study found that the prevalence of
other personality disorders such as antisocial and narcis-
sistic personality disorder were low (0 and 3%, respect-
ively) in our setting [25] while previous studies [7,26] have
suggested a relationship between bipolarity and histrionic
personality disorder.
Statistical analysis
We examined the diagnostic accuracy of the MDQ and
BSDS for bipolar as well as personality disorders, using
the SCID-I and II as the gold standard diagnostic tool.
Sensitivity, specificity and likelihood ratio for a positive
test [LR+, sensitivity/(1-specificity)] [27] were calculated
Table 2 Sensitivity and specificity of the MDQ and BSDS to diagnose bipolar disorder, borderline personality disorder,
and histrionic personality disorder according to several cut-off points
BPII BPD Histrionic
N (sensitivity, specificity, LR+)
15 12 23
MDQ≥7 with moderate functional impairment 3 (0.20, 0.81, 1.1) 5 (0.42, 0.85, 2.8) 6 (0.26, 0.84, 1.6)
MDQ≥6 with moderate functional impairment 8 (0.53, 0.78, 2.4) 7 (0.58, 0.80, 2.9) 7 (0.30, 0.76, 2.1)
MDQ≥6 with minor functional impairment 8 (0.53, 0.78, 2.4) 7 (0.58, 0.77, 2.5) 8 (0.35, 0.75, 1.4)
MDQ≥5 with minor functional impairment 10 (0.67, 0.68, 2.1) 8 (0.67, 0.67, 2.0) 12 (0.52, 0.67, 1.6)
BSDS≥13 8 (0.53, 0.78, 2.4) 8 (0.67, 0.79, 3.2) 10 (0.44, 0.78, 2.0)
BSDS≥12 10 (0.67, 0.73, 2.9) 10 (0.83, 0.74, 3.2) 12 (0.52, 0.73, 1.9)
BSDS≥11 12 (0.80, 0.70, 2.7) 11 (0.92, 0.70, 3.1) 15 (0.65, 0.71, 2.2)
BSDS≥10 12 (0.80, 0.64, 2.2) 11 (0.92, 0.64, 2.6) 15 (0.65, 0.64, 1.8)
BSDS≥9 13 (0.88, 0.59, 2.2) 11(0.92, 0.58, 2.2) 18 (0.78, 0.82, 4.3)
BPII only BPD only
N (sensitivity, specificity, LR+)
10 7
MDQ≥7 with moderate functional impairment 2 (0.20, 0.81, 1.1) 4 (0.57, 0.78, 2.6)
MDQ≥5 with minor functional impairment 7 (0.70,0.66, 2.1) 5 (0.71, 0.65, 2.0)
BSDS≥13 5 (0.50, 0.75, 2.0) 5 (0.71, 0.70, 2.4)
BSDS≥12 6 (0.60, 0.69, 1.9) 6 (0.86, 0.70, 2.9)
BSDS≥11 7 (0.70, 0.67, 2.1) 6 (0.86, 0.65, 2.5)
MDQ: Mood Disorder Questionnaire, BSDS: Bipolar Spectrum Diagnostic Scale, BPII: bipolar II disorder, BPII only: bipolar II disorder without borderline personality
disorder, BPD: borderline personality disorder, BPD only: borderli ne personality disorder without bipolar II disorder, Histrionic; Histrionic personality disorder, LR+:
Likelihood Ratio for a positive test.
Figure 2 Receiver Operating Characteristic (ROC) curve of diagnostic accuracy of score on question one of the mood disorder
questionnaire; Bipolar II disorder (left) and borderline personality disorder (right).
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according to several cut-off points suggested by previous
studies [10,11,18-20]. To the best of our knowledge, no
previous study has explored the possibility that the two
scales might detect borderline or histrionic personality
disorders. Given this, we used the same cut-off point to
detect the personality disorders as for bipolar disorder.
In addition, the Receiver Operating Characteristic (ROC)
curve and Area Under the Curve (AUC) of both scales for
bipolar and personality disorders were calculated. AUC is
a preferred measure of accuracy as it is uninfluenced by
prevalence, which would be expected to be higher in this
study’s patient population. All data were analyzed with
SPSS 16.0 (SPSS, Inc., Chicago in USA).
Results
The patients’ demographic and clinical characteristics are
depicted in Table 1. A high level of functional impairment
was suggested by the high rate of single participants
(around two-thirds), unemployment (around half) and
chronicity (around ten years).
Fifty-five (71%) had a lifetime history of a major depres-
sive episode and 15 (19%) a hypomanic episode (bipolar II
disorder). No patients had bipolar I disorder. Twelve
(15%) had borderline personality disorder and 23 (29%)
histrionic personality disorder. Five (6%) had both lifetime
bipolar II disorder and borderline personality disorder.
Similarly, eight (10%) had both lifetime bipolar II disorder
and histrionic personality disorder. No patients with
anorexia nervosa restricting subtype or restricting EDNOS
had bipolar, borderline, or histrionic personality disorders.
Figure 1 shows the monomodal distribution (rather
than bimodal) of patients’ score on the MDQ and BSDS.
As Table 2 shows , both the MDQ and BSDS exhibited
similar sensitivity, specificity, and likelihood ratios (LR+)
for detecting bipolar II disorder. Further, these two
scales showed comparable accuracy in detecting border-
line personality disorder. Since accuracy for detecting his-
trionic personality disorder was relatively low, just bipolar
II disorder and borderline personality disorder were the
focus of the following analyses. Results were similar for
detecting bipolar II disorder without comorbid borderline
personality disorder and borderline personality disorder
without comorbid bipolar II disorder.
To evaluate the ability to detect bipolar II disorders,
ROC curves and the AUCs (95% Confidence Interval) of
the MDQ (Figure 2) and BSDS (Figure 3) were calculated.
Figure 3 Receiver Operating Characteristic (ROC) curve of diagnostic accuracy of score on the mood disorder questionnaire; Bipolar II
disorder without borderline personality disorder (left) and borderline personality disorder without bipolar II disorder (right).
Figure 4 Receiver Operating Characteristic (ROC) curve of diagnostic accuracy of score on question one of the bipolar spectrum
diagnostic scale; Bipolar II disorder (left) and borderline personality disorder (right).
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The AUC of the MDQ was determined using the total
score of part one because using level of impairment data
would require multiple ROC curves [13].
The AUCs for the MDQ and BSDS in detecting bipolar
II disorder were 0.779 (0.674-0.885) and 0.778 (0.662-
0.895), respectively (Figures 2 and 3).
Similarly, to explore the ability to detect borderline per -
sonality disorder with or without co-morbid bipolar II dis-
order, ROC curves and the AUC (95% Confidence
Interval) of the MDQ (Figures 2 and 4) and BSDS
(Figures 3 and 5) were calculated. In detecting borderline
personality, the AUCs for the MDQ and BSDS disorder
were 0.750 (0.597-0.903) and 0.787 (0.640-0.934), respec-
tively (Figures 2 and 3). In order to control for the effect of
co-morbidity accounting for the diagnostic accuracy of the
scales, ROC curves were also calculated for patients with
bipolar II disorder but not borderline personality disorder
and vice versa. Results remained statistically significant
except for the MDQ detecting borderline personality
disorder without comorbid bipolar II disorder. Specifi-
cally, the AUC for the MDQ was 0.737 (0.605-0.868)
for the bipolar II disorder but not borderline personality
disorder and 0.691 (0.460-0.923) for borderline persona-
lity disorder without comorbid bipolar II disorder. For
the BSDS, the AUC was 0.715 (0.566-0.865) for bipolar
II disorder but not borderline personality disorder and
0.723 (0.506-0.940) for borderline personality disorder
without comorbid bipolar II disorder.
Discussion
Prior research has suggested that the MDQ and BSDS
are useful instruments to detect bipolar disorders among
patients with recurrent depressive episodes [10,11]. The
current study expands on this work by showing that
these two scales can detect bipolar disorder among
patients with eating disorders. Both the MDQ and BSDS
screening scales exhibited similar value in terms of pre-
dictive validity in a population of patients presenting to
a psychiatric clinic in a tertiary-care setting. Thus, the
MDQ and BSDS offer reasonably comparable diagnostic
accuracy in the form of a self-report measure that requires
much less time, expertise, and resources to administer
than the SCID or Composite International Diagnostic
Interview (CIDI). By comparison, the AUC was 0.834 for
concordance of bipolar II disorder diagnosis between the
SCID and CIDI in a community population [28].
In addition, this study suggests that bipolar disorder
and borderline personality disorder can both be detected
with moderate accuracy by use of a brief screening in-
strument, although it was difficult for these scales to de-
tect histrionic personality disorder. Results were similar
even after controlling for co-morbidity. This study im-
portantly shows that the two scales can be used as
screening tools for borderline personality disorder in a
real world setting where eating disorder specialists work.
In addition, results showed the assessment of affective
instability is useful in terms of bipolar and borderline
personality disorder [3], although impulsivity has trad-
itionally been focused in the eating disorder field [4].
Accurate diagnosis and distinction of bipolar disorder
and borderline personality disorder is important because
of the differing treatment approaches. Psychotherapeutic
approaches for these two disorders are very differ ent
[1,4,29]. Also, pharmacotherapy is a core component of
treatment for bipolar disorder, but only adjunctive and
symptom-targeted for border line personality disorder
[1,29]. These two scales are useful to detect cases that re-
quire careful assessment before starting antidepressants,
although these scales cannot differentiate between bipolar-
ity and borderline personality disorder.
There are a number of important limitations regarding
this study. Sens itivity of these two scales may not be
considered sufficiently high usin g the cut-off point that
the original studies suggested. It remains to be known
whether the lower sensitivity is due to differences of cul-
ture, population, or clinical setting where the participants
were recruited. Results are from a single treatment center,
and males and patients with bipolar I disorder were not
Figure 5 Receiver Operating Characteristic (ROC) curve of diagnostic accuracy of score on the bipolar spectrum diagnostic scale;
Bipolar II disorder without borderline personality disorder (left) and borderline personality disorder without bipolar II disorder (right).
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included. Results were not analyzed in relationship with
eating disorder subtypes (such as restricting or b inge/
purging) due to a modest sample size. Assessment was
cross-sectional, and careful longitudinal consideration is
essential because patients with either bipolar or borderline
personality disorder can present with similar symptom-
atology at a given time [6]. This is especially true in the
case of comorbid eating disorder because chaotic eating
behaviors and starvation might influence symptomatology
[30,31] including dysphoria [32] and anger [9].
Conclusions
Nonetheless, current results show that these two scales
(MDQ and BSDS) are helpful to detect cases that need
careful assessment. In addition, we believe these results
should encourage further attempts to reconsider the rela-
tionship between and symptomatology of bipolar disorder
and borderline personality disorder.
Abbreviations
MDQ: Mood Disorder Questionnaire; BSDS: Bipolar Spectrum Diagnostic
Scale; EDNOS: Eating disorder not otherwise specified; SCID-I/P: Structured
Clinical Interview for DSM-IV; SCID-II: Structured Clinical Interview for DSM-IV
Personality Disorders; LR+: Likel ihood ratio for a positive test; ROC: Receiver
Operating Characteristic; AUC: Area Under the Curve; CIDI: Composite
International Diagnostic Interview.
Competing interests
All authors declare that there is no conflict of interest.
Authors’ contribution
All authors contributed to the design of this study. TN and AT drafted the
manuscript. All authors contributed to revision of the manuscript. All authors
read and approved the final manuscript.
Acknowledgement
We are thankful to Dr. T. Inada and Dr. T. Tanaka for their permission to use
the Japanese versions of the MDQ and BSDS scales.
This work was supported by JSPS KAKENHI Grant Number 24591725.
Author details
1
Department of Neuropsychiatry, Osaka City University Graduate School of
Medicine, 1-4-3 Asahimachi, Abunoku, Osaka 545-8585, Japan.
2
Department
of Neuropsychiatry, Hyogo College of Medicine, Nishinomiya, Japan.
3
Department of Internal Medicine and Department of Psychiatry, University
of Michigan, Ann Arbor, USA.
4
Department of Psychiatry, Leiden University
Medical Center, Leiden, the Netherlands.
Received: 31 July 2012 Accepted: 14 February 2013
Published: 25 February 2013
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doi:10.1186/1471-244X-13-69
Cite this article as: Nagata et al.: Using the mood disorder questionnaire
and bipolar spectrum diagnostic scale to detect bipolar disorder and
borderline personality disorder among eating disorder patients. BMC
Psychiatry 2013 13:69.
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