Borderline Personality Disorder and Bipolar Disorder—Distinguishing Features of Clinical Diagnosis and Treatment
Borderline Personality Disorder and Bipolar Disorder—Distinguishing Features of Clinical Diagnosis and Treatment
Editor's note: CME testing has expired for this article. It is for informational purposes only.
Psychiatric Times - Category 1 Credit (expired)
Educational Objectives
After reading this article, you will be familiar with:
• Ways to distinguish between borderline personality disorder and bipolar disorder
• Diagnoses based on mood episodes, impulsivity, and longitudinal course of borderline personality disorder and bipolar disorder
• Treatment implications - pharmacological and psychosocial interventions
Who will benefit from reading this article?
Psychiatrists, psychologists, primary care physicians, nurse practitioners, and other health care professionals. To determine whether this article meets the continuing education requirements of your specialty, please contact your state licensing and certification boards.
Since the inclusion of the borderline personality disorder (BPD) diagnosis in DSM, there have been multiple efforts to recast the disorder as part of an Axis I illness category. While the initial focus was on the schizophrenia spectrum,1 more recent authors have attempted to link BPD to mood disorders. There is considerable literature on the relationship between major depressive disorder (MDD) and BPD, and although the current understanding posits distinct disorders, overlapping biological underpinnings do exist.2 Attention has now turned to bipolar disorder, with several vocal advocates who propose reclassifying BPD as bipolar spectrum disorder.3,4 This article discusses the overlapping phenomenology of bipolar disorder and BPD and highlights distinguishing features of clinical diagnosis and treatment.
Prevalence
According to DSM-IV-TR, the prevalence of BPD is estimated at 2% of the general population, compared with 1% to 2% for bipolar disorder. Other estimates are closer to 5% for bipolar spectrum disorder.5 Depending on the population studied, there are varying estimates of the co-occurrence of BPD and bipolar disorder. In a recent comprehensive review by Paris and colleagues,6 the rate of bipolar I disorder in BPD patients ranged from 5.6% to 16.1%, with a median of 9.2%. The rate of bipolar II disorder was only slightly higher, 8% to 19%, with a median of 10.7%. The 2 studies with the strongest methodologies that used structured diagnostic interviews with adequate sample sizes and a 6- to 7-year follow-up showed a low rate of new onset of bipolar disorder in patients with BPD, with no difference from the comparison groups.7,8 A recent study that used the large Collaborative Longitudinal Study of Personality Disorders (CLPS) database, however, showed an increased rate of bipolar I and II disorders in patients with BPD compared with patients who had personality disorders other than BPD, including schizotypal, avoidant, and obsessive-compulsive personality disorders (19.4% and 7.9%, respectively). In addition, BPD patients had a higher rate of bipolar I and II disorder onset (8.2% for BPD vs 3.1% for the other personality disorders) over 4 years.9 While these studies suggest a moderately increased risk for bipolar disorder in patients with BPD, it was not nearly as high as the risk for MDD or substance abuse.
The rate of BPD in patients with bipolar I disorder varies from 0.5% to 30%, with a median of 10.7%, while in patients with bipolar II disorder, the rates are 12% to 23%, with a median of 16%.6 The relationship of BPD and cyclothymia has been examined in 1 study, and the results revealed exceptionally high comorbidity rates with BPD of 62%.10 However, while elevated rates of comorbid personality disorders have been found in patients with bipolar disorder, no differences between rates of BPD and the other personality disorders studied have emerged.6 These findings suggest that while BPD and bipolar disorder can co-occur, in general, comorbidity is not common.
Diagnosis
Diagnosis of bipolar disorder or BPD can be difficult, because both can present with affective instability, irritability, and impulsivity. A comparison of DSM-IV-TR criteria is displayed in Table 1 and demonstrates considerable overlap.
The phenomenology of mania differs significantly from that of BPD. Factor analyses of manic symptoms have identified psychic and motor acceleration, psychosis, and irritability.11,12 A factor analysis and subsequent replication study revealed 3 factors for BPD: disturbed relatedness, behavioral dysregulation, and affective dysregulation.13,14 However, a number of recent studies have shown that the BPD factors correlate so highly with one another (with correlation coefficients of 0.92 to 0.98) that the factor analyses actually support a single overarching BPD construct.15-17
Recent studies that explored the overlap of BPD and bipolar disorder have outlined several parameters to distinguish the 2 diagnoses9,18,19:
• Quality of mood episodes
• Types of impulsivity
• Longitudinal course
Symptoms such as irritability and quality of depression have not proved helpful.
Dr. Motta-Castillo's comment is interesting, does he propose subsuming borderline personality disorder under the rubric of bipolar disorder, or are they two distinct entities?
The following comment is by Manuel Mota-Castillo, MD:
I welcome the question posted by Ms. Barash because this issue deserves more attention that what traditionally has received from psychiatric establishment. It is my impression that most colleagues have decided that the current knowledge of borderline style is sufficient and we should just accept what the book says.
Following the teachings of Dr. Hagop Akiskal I believe that there is a good separation between bipolar disorder and the so-called Borderline Personality Disorder (BPD). I believe BPD is not a real diagnosis but a psychological style of looking at problems and situations with a black and white approach. As I said in my previous reaction to this excellent paper, my experience for the past 20 years is that most "borderline"patients are in fact bipolar individuals taking antidepressants and for that reason most of the time irritable and impulsive. It could be argued that even if they are a small number still qualify for a diagnostic category I would not have a problem with that if a criteria to separate them from the bipolar patients is clearly introduced.
It is true that bipolar patients can have a "borderline organization" and will continue to see the world as "either good or bad" even after the mood is stable but they are a minority. I am also aware that most academics will dismiss this statement because "it lacks research support" but I would ask to them to explain me why thousands of patients have improved when I stopped the antidepressants and continue to be stable (no longer "borderline") after many years.
With regard to the symptoms listed for both, BPD and bipolar spectrum disorders, I find intriguing that this paper and most textbooks minimize the significance of racing thoughts. This is the case too with the ADHD labeling of everybody who presents as "hyperactive."
I believe that asking about racing thoughts and paying more attention to the worsening of symptoms when antidepressants are introduced (or excessive caffeine intake is reported) can be two useful tools in making a final diagnosis in a patient that is quick to temper, impulsive, restless, insomniac and moody.
Manuel Mota-Castillo, MD
Assistant Clinical Professor
University of Central Florida and St. Matthew University
Orlando, Florida
So then, some patients have been misdiagnosed as "borderline personality disorder", when in fact they turn out to be bipolar patients under the influence of antidepressants. For these people, perhaps a switch from antidepressants to mood stabilizers would be prudent.
I wish Secretary Eric Shinseki, head of the Department of Veterans Affairs would read this comment but that will be close to impossible. I say so because for a long time I have been trying to capture the attention of the VA system to an angle of the problem discussed by doctors Goodman, Jeong and Triebwasser. As a matter of fact, my stance is the complete opposite of the view postulated in their paper, in more than one way. As Dr. Hagop Akiskal (1) and several others have argued, individuals labeled as "borderline"are bipolar patients on antidepressants. The authors see a beneficial effect of SSRIs on the irritability of "borderline" patients whereas my data shows that over a period of 3 years 100% of the bipolar patients arriving to the ER with suicidal attempts (in a general hospital) were taking antidepressants.(2) Several of them were veterans with many years of treatment at several medical centers and clinics. The use of SSRIs in the VA is more prevalent than in other setting because these medications are considered the first line of pharmacological treatment of PTSD. Unfortunately, many traumatized patients also have bipolar spectrum disorders and they never achieve acceptable levels of stability while on antidepressants. Another compounding factor is substance abuse. Many veterans use alcohol, opiates and cannabis as tools of last resort to catch some sleep because the racings thoughts (exacerbated by antidepressants, nicotine and caffeine) drive them "crazy" at bed time. The VA expends vast amount of money in substance abuse treatments during which providers, either keep patient on antidepressants or expect they are going to stay "clean and sober" after a 30-days program, while the "sleep aid" is an anti-histaminic drug. I started with a reference to General Shinseki because he strikes me as a sensitive and honest person, who would be distraught with the realization of the pain, loss in productivity and family suffering many veterans experience because of the myth of Borderline Personality Disorder (BPD) and the obfuscation with the treatment of bipolar disorder. Dr. Gunderson deserved all the respect and admiration his brilliant career has earned but the veneration of an illustrious professor should not preclude the realization that numbers and tragic case reports do not lie. The Korean War veteran that was found by his wife with a construction block tied up to his neck and facing the bottom of his swimming pool had been released from a well-known teaching hospital a few weeks before his death. He also had been labeled "borderline" and bipolar and had a combination of 2 antidepressants and 3 mood stabilizers…so many medications and still he couldn't find a reason to be alive. Shouldn't this case be a wakeup call to re-think our approach to treatment of bipolar spectrum disorders and a revision of the validity of the so-called Borderline Personality Disorder? The psychoanalytic establishment made great contribution to the advance of psychiatrist but they are also responsible for the birth of faulty diagnoses such as Oppositional-Defiant Disorder (ODD) and Conduct Disorder (CD). These two labels were incorporated into the psychiatric nomenclature because the psychoanalysts decided that children could not develop depression or "manic-depressive" illness. Consequently, the evaluators of youths exhibiting mood swings, unprovoked aggression, and defiance of authority had to put a name to those behaviors. Ironically, in medicine we don't consider abdominal pain a disease but when it comes to psychiatry the symptoms of "defiant and oppositional" become an entity with its own merits. Wouldn't be a noble gesture if the psychoanalysts use their influence to dismantle those pseudo diagnoses that DSM-IV-TR calls ODD, CD and BPD? Manuel Mota-Castillo, M.D. Lake Mary, Florida References: 1- Akiskal, H.S.; Demystifying borderline personality: critique of the concept and
unorthodox reflections on its natural kinship with the bipolar spectrum, Acta Psychiatr. Scand.
110 (2004), pp. 401-407. 2004 2- Mota-Castillo, M., Bipolar Disorder and the Case Against Antidepressants, Psychiatric Times, "From Our Readers", October 2008.