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

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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 diagnoses^9,18,19:

• Quality of mood episodes
• Types of impulsivity
• Longitudinal course

Symptoms such as irritability and quality of de­pres­sion have not proved helpful.

Mood episodes
While both disorders cause mood instability and affective reactivity, the phenomenologies of the mood episodes differ. In BPD, mood swings, usually of negative affect, are triggered by interpersonal stressors or perceived stressors, are transient, last from minutes to hours, and are highly dependent on the environment. In bipolar disorder, mood swings are more spontaneous and of longer duration, especially for bipolar I disorder, and there are more extended periods of elation. In addition, in bipolar disorder, acute episodes and symptom-free intervals occur, while in BPD, the affective instability is part of a characteristic pattern of emotional responding. Data suggest that these affective problems persist throughout the life course of the disorder and may be identified by par­ents of children with BPD as early as infancy.^20,21

The mood swings of BPD and bipolar II disorder differ in emotion type as well. Individuals with BPD swing from euthymia to anger, and euthymia is infrequent, while bipolar II disorder affective shifts are from euthymia to elation.²² Shifts triggered by interpersonal stressors in BPD, which often involve rejection or perceived abandonment, are less prevalent in bipolar disorder.²³ The differentiation of BPD and rapid cycling bipolar disorder remains problematic, as both disorders involve a high degree of affective instability, and the 2 entities are likely to have significant biological and possibly genetic overlap.²⁴ Findings from these 3 studies suggest that careful detailing of the duration of mood episodes, qualitative emotional shifts, recurrent triggering events, and longitudinal patterns (episodic vs lasting) can help distinguish between BPD and bipolar disorder, although not rapid cycling forms of bipolar disorder.^22-24

Impulsivity
Impulsivity is behavior that occurs without reflection, is inconsistent with context, and is seen in both BPD and bipolar disorder.²⁵ Differential patterns of impulsivity have been characterized for the depressive and manic phases of bipolar disorder with motor impulsivity (tendency to act on the spur of the moment) specific to mania and non-planning impulsivity (lack of sense of the future) specific to depression. Impulsivity in BPD is also characterized as non-planning.^26-28 These data support the premise that BPD may have more symptomatic overlap with the depressive pole of bipolar disorder than with the manic pole.

Similarly, BPD was distinguished from bipolar II disorder by the presence of hostility and differing patterns of impulsivity. Bipolar II disorder showed attentional impulsivity characterized by distractibility and inability to focus on a task, and BPD displayed non-planning impulsiveness. The highest rate of impulsivity was found in populations with comorbid BPD and bipolar II disorder, which suggests that this group may be at the highest risk for self-damaging behaviors.²⁸ This finding argues for the need to make both diagnoses when appropriate.

Clinically, impulsivity is believed to be more episodic in bipolar disorder than in BPD, although inter-episode impulsivity is seen in bipolar disorder when comorbid substance abuse complicates the clinical picture.²⁹ Impulsive acts such as suicidal behavior occur in both disorders, but in bipolar disorder these are predominantly found in the depressive phase, particularly in mixed depressive presentations, and they are related to hopelessness while in BPD, they are often a function of the inability to tolerate distress.^30-32

Longitudinal course
Long-term outcome studies in bipolar disorder and BPD seem to challenge the traditional Axis I/Axis II dichotomy, in which mood disorders are widely thought of as episodic and treatable, whereas personality disorders are considered life-long and treatment refractory. Many cases of bipolar disorder assume a chronic course, with long-term morbidity and substantial inter-episode symptomatology, whereas multiyear follow-up studies of patients with BPD have found that most people eventually stop meeting threshold criteria for the disorder.^5,33,34 However, there appears to be a core subset of BPD symptoms, especially in the affective and interpersonal realms, that persist even after the more dramatic impulsive or demanding behaviors have subsided. There also appears to be a subset of remission-resistant BPD patients who continue to show poor judgment and high treatment utilization.^35,36

Findings from prospective studies on the interactive effects of both disorders indicate that comorbid bipolar disorder had no effect on the clinical course of BPD with respect to functional outcome, remission rates, or number of hospitalizations or other treatment utilization except for mood-stabilizer medication.⁹

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 and carbamazepine have targeted impulsivity and anger rather than affective instability, while a randomized controlled trial of lithium showed no benefit at all.^39-42 Similarly, randomized controlled trials of newer mood stabilizers such as topiramate and 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 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.

References:

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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