Psychiatric Times. Vol. 26 No. 7

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CME

Borderline Personality Disorder and Bipolar Disorder—Distinguishing Features of Clinical Diagnosis and Treatment

By Marianne Goodman, MD, Jae Yeon Jeong, PhD, and Joseph Triebwasser, MD | July 13, 2009

Dr Goodman is associate clinical professor at Mount Sinai School of Medicine and medical director of the mental health outpatient department at the James J. Peters VA Medical Center in the Bronx; Dr Jeong is a research fellow at the James J. Peters VA Medical Center; and Dr Triebwasser is an attending physician at the James J. Peters VA Medical Center. The authors report no conflicts of interest concerning the subject matter of this article.

Acknowledgment—This work was supported by a Veterans Administration Advanced Career Development Award to Dr Goodman.

Treatment implications
Differentiating BPD from bipolar disorder has ramifications for treatment planning, both pharmacological and psychosocial.

Pharmacological treatment
While randomized clinical trials of patients with BPD have been performed using mood stabilizers, antidepressants, and typical and atypical antipsychotics, their effect sizes have not been particularly robust. This, coupled with small sample sizes, prompted the recent Cochrane review to state that there are “insufficient data” to support any recommendations for pharmacological treatment in BPD. The report concluded that medication effects in BPD are “unimpressive.”³⁷ Despite this, although not empirically validated, study findings suggest that polypharmacy for BPD is rampant, and it is not uncommon for patients with BPD to be treated with multiple agents.³⁸ This can result in significant iatrogenic morbidity that may outweigh the marginal clinical benefits. In contrast, pharmacological treatment in bipolar disorder is far more effective. Eleven drugs are FDA-approved for the treatment of bipolar disorder: 9 for mania/mixed phases, 2 for depressive phases, and 5 for maintenance therapy (several are approved for more than one phase of the illness).

Although similar medications are used for both BPD and bipolar disorder, the clinical effectiveness of the medications and target symptoms of the disorders differ. In bipolar I disorder patients, mood stabilizers are the first line of treatment. In BPD, randomized controlled trials of valproate(Drug information on valproate) and carbamazepine(Drug information on carbamazepine) have targeted impulsivity and anger rather than affective instability, while a randomized controlled trial of lithium showed no benefit at all.^39-42Similarly, randomized controlled trials of newer mood stabilizers such as topiramate(Drug information on topiramate) and lamotrigine(Drug information on lamotrigine) have been shown to target anger rather than affective instability.^43,44

A positive clinical response has been found for antidepressants of several classes including monoamine oxidase inhibitors and SSRIs, for both the depressed phase of bipolar disorder and for BPD. The propensity of antidepressants to produce manic symptoms in patients with bipolar disorder is always a consideration despite controversy about the magnitude or clinical importance of the risk, but this does not seem to be the case for BPD. SSRIs in BPD appear to target anger and impulsivity, rather than mood symptoms; a similar finding was noted by Paris¹⁹ in a study of atypical antipsychotics for both BPD and bipolar disorder.

The findings on medication treatment in patients with BPD suggest that an over-reliance on psychopharmacological strategies yields disappointing results. Medication efficacy is far more pronounced in patients with bipolar disorder.^33,45 The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), a longitudinal study of 4107 persons with bipolar disorder that evaluated treatment effectiveness, has generated valuable data on head-to-head medication trials and will continue to provide insights into optimal treatment strategies for the various phases of bipolar disorder.⁴⁶

Psychosocial interventions
Table 2 presents psychosocial treatments available to patients with bipolar disorder or BPD. Despite symptomatic overlap, the types of interventions differ by disorder.

In contrast to the meager efficacy of pharmacological treatment for BPD, psychosocial treatments have shown substantial promise and many psychotherapeutic interventions that focus on teaching emotion-regulation skills exist. These include:

• Dialectical behavior therapy⁴⁷
• Systems training for emotional predictability and problem solving (STEPPS)⁴⁸
• Schema-focused therapy⁴⁹
• Mentalization-based treatment⁵⁰
• Transference-focused psychotherapy⁵¹

Psychoeducation has been identified as an inte-gral component in the treatment of BPD, and it has been usefully extended to family members as well.^52,53

In bipolar disorder, the value of psychosocial interventions is gaining recognition as an important adjuvant treatment. The therapeutic aims of psychosocial approaches for bipolar disorder include psychoeducation, stress management, and regularity in daily activitiesand biosocial rhythms.^54-57

Case Vignette

John is a 50-year-old, white, never-married man who initially presented with irritability and depression. He denied any current or past suicidal or homicidal ideation but endorsed a past history of “mood swings.” He had been given a diagnosis of bipolar II disorder 10 years earlier. John described his moods as never vacillating to periods of elation but rather as centered on feelings of hostility and anger. He had a 20-year history of heavy alcohol(Drug information on alcohol) use and reported that he had completed a court-mandated alcohol rehabilitation program several years earlier.

Over the next few sessions, his preoccupation with his partner’s fidelity and whereabouts, his dependency on others, identity confusion, and impulsivity manifested themselves. He had rapid mood shifts in session, particularly when the discussion centered on his current romantic relationship of 5 months. Given the quality of his mood swings and associated symptoms, BPD was diagnosed and John was referred for medication management and dialectical behavior therapy.

As noted by Gunderson and colleagues,⁹ and as exemplified by this case, persons with BPD often receive a diagnosis of bipolar spectrum disorder. The failure to appreciate the BPD diagnosis, whether from misdiagnosis or a hesitancy to offer a stigmatizing label, can affect treatment outcome. As previously discussed, the effects can range from overuse of medication and potential polypharmacy to an underappreciation of empirically validated psychological treatments of BPD.

Conclusion
BPD and bipolar disorder are both associated with significant levels of mortality and morbidity, and they present diagnostic challenges because of their phenotypic overlap. However, paying attention to the patient’s quality of mood shifts, types of impulsivity, and longitudinal course may aid in distinguishing between the 2 disorders. Accurate diagnosis is important because each disorder has a distinct medication response and set of psychosocial interventions. The possibility of comorbid presentation also requires consideration because this may have an impact on the risk of self-damaging behaviors.

Pages: 1 2 3

by Yvonne Barash | March 04, 2012 2:49 PM EST

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.

by The Editors | February 02, 2012 12:38 PM EST

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

by Yvonne Barash | January 22, 2012 5:17 PM EST

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?

by Manuel Mota-Castillo | September 05, 2010 1:15 AM EDT

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.

Drugs Mentioned in This Article
arbamazepine (Carbatrol, Tegretol, others)
Lamotrigine (Lamictal)
Lithium (Eskalith, Lithane, Lithobid)
Topiramate (Topamax)
Valproate/Valproic acid (Depakote, others)

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Borderline Personality Disorder and Bipolar Disorder—Distinguishing Features of Clinical Diagnosis and Treatment

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