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Acta Psychiatr Scand 2015: 1–3

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DOI: 10.1111/acps.12428

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd


Confusing borderline personality with severe
bipolar illness
The paper by Hower et al. in this issue of the Acta
Psychiatrica Scandinavica is an example of an
increasingly obvious and disappointing fact: DSM5 (and, in retrospect IV and III) are impeding us
from conducting and interpreting meaningful
research in psychiatry (1). The analysis presented
simply accepts DSM assumptions and then claims
that borderline personality worsens bipolar disorder. Yet the specific features that predict poor outcome are mood instability and impulsivity, which
are quite non-specific for borderline personality
disorder (BPD) and which are central to the whole
concept of mania and bipolar disorder. As we will
explain below, the DSM definition of BPD is such
that it captures most patients with bipolar illness,
specifically those with severe symptoms.
So it becomes meaningless to say that ‘comorbid’ BPD ‘worsens’ bipolar illness, when the whole
concept of BPD is defined to be equivalent to
severe versions of bipolar illness. The observed
data could reflect simply worsened features of
bipolar illness (more impulsivity, more mood
swings), and not something specific to borderline
personality. (The authors acknowledge this limitation in parts of the manuscript, though not in the
abstract; this critique may not be appreciated by
many readers of the article, and others like it,
hence this commentary.)
This commentary provides a rationale for the
above conclusion.
The Course and Outcome of Bipolar Youth
(COBY) study is an important contribution to
our knowledge about childhood mood conditions.
In this report, DSM-IV personality disorder definitions were assessed as predictors of outcome.
This approach has been taken in many analyses,
with well-characterized and prospectively followed samples. In general, it is found that DSM
definitions of personality disorders, for example
borderline, predict poor outcomes in DSMdefined mood syndromes (whether ‘major depressive disorder’, MDD, or bipolar illness) (2). A
similar result is found in this paper for childhood
bipolar illness.
The usual conclusion is that BPD is a harmful
‘comorbidity’, predicting poor outcomes. Propo-

nents of the BPD concept then advocate for more
attention to its diagnosis and treatment (especially
with psychotherapies, often psychoanalytically
derived) (3).
The authors here make the same claim, presented as straightforward interpretation of the
data: ‘The number of BPD symptoms significantly
predicted poor clinical course of BP, above and
beyond BP characteristics. . ...BPD severity adds
significantly to the burden of BP illness and prospectively predicts a more chronic and severe
course and outcome beyond BP characteristics’.
This interpretation would have made sense in
1985, but stated baldly as it is in 2015, it fails to
The key assumption by the authors is that the
concept of ‘comorbidity’ validly applies to this
paper. The idea of comorbidity was proposed originally by the physician and epidemiologist Alvan
Feinstein about 40 years ago to mean the simultaneous occurrence of two independent and separate
diseases (4). Yet the DSM approach to BPD is
such that it negates a valid concept of comorbidity.
The diagnostic criteria given for BPD were developed by the DSM-III committee headed by Gunderson in the 1970s and have changed little under
his leadership for the next 40 years in the 4th and
5th revisions (5).
What does it mean to say that borderline symptoms predictor poor course ‘above and beyond’
bipolar symptoms? Readers should look at both
DSM criteria sets. For borderline personality, it is
perfectly feasible to meet diagnostic criteria simply
based on standard, long-proven, well-accepted
characteristics of the symptoms or consequences of
bipolar illness. All you need is five of nine criteria,
including: ‘affective instability’, ‘unstable interpersonal relationships’, anger, impulsivity (especially
around sex and spending) and suicidal behaviour.
The majority of patients with bipolar illness
(whether type I or type II) will meet the above five
criteria based on the symptoms or consequences of
repeated manic/hypomanic and depressive episodes, not to mention the impact of mood temperaments of cyclothymia or hyperthymia in up to
one-half of persons with bipolar illness.

Feinstein AR. This attitude is part of the problem in psychiatric research for the past two References 1. Other studies show the opposite. It is unavoidable that many researchers. chronic (not episodic) emptiness. severe. The world has changed. Yen S. Interactions of borderline personality disorder and mood disorders over ten years. and researchers should be at the forefront of change. rather researchers should take an agnostic approach. and 2 School of Psychology. Stout RL. Shea MT et al.12415 [Epub ahead of print]. 10). 4. DOI: 10. N. Borderline personality disorder in transition age youth with bipolar diroder.75:829–834. If not them. Ghaemi1. 2. But.71:1629–1635. University of Los Andes. Some argue for affective instability or interpersonal sensitivity as core criteria (7. as we have cited. The pre-therapeutic classification of co-morbidity in chronic disease. Some patients also have lung cancer who do not smoke cigarettes. despite a strong causal association. such as self-cutting. Barroilhet1. Stout RL. Markowitz JC et al. Chile E-mail: nghaemi@tuftsmedicalcenter. S.Commentary As we have argued previously (6). borderline personality always involved patients who were not seen in any way as having manic-depressive illness. Hower H et al. usually of the sexual variety. This non-DSM manner of defining borderline personality and differentiating it from bipolar illness would present an opportunity for some useful data analyses that actually answer the question raised by the researchers: Does borderline personality worsen the course of bipolar illness? What could be said against the view-point presented in this commentary? One approach would be to say that it is not the role of researchers to either endorse or criticize DSM. 10). who will do it? Another response to this commentary could be that there is disagreement as to what constitutes ‘core’ criteria for BPD. We would add the key importance of childhood sexual trauma. is more common in borderline personality than bipolar illness (6). current and future generations of psychiatrists would not be doing justice to their profession if they allowed time to stand still with criteria that were essentially set in 1980. identity disturbance and abandonment feelings. To a great extent. Santiago. 10). are attached to thinking about research only within the context of DSM criteria. such as bipolar illness? Sophistic interpretations often aim at proving a point. These perspectives conveniently ignore the history of BPD. rather than seeking the truth. We have not learned from this data analysis what the authors claim about the relationship between borderline personality and bipolar illness. MA.166:530–539. Acta Psychiatr Scand 2015. 8).23:455–468. Further. we need to learn to think and work outside of DSM definitions. and who had adult symptoms that involved either prepsychotic symptoms or dissociative-type symptoms of ‘hysteria’ (9. J Clin Psychiatry 2010. Grilo CM. As proposed by psychoanalytic thinkers like Kernberg and others (9. J Chronic Dis 1970. 3. J Clin Psychiatry 2014. How is it most specifically differentiated from other valid diagnoses. researchers claim it is not up to them to critique DSM. employing DSM criteria because they are the most widely used psychiatric nosological system. although there were always differing views about the condition.2 and S. and whatever is accepted by the majority is not thereby rendered more valid. Am J Psychiatry 2009. It is not legitimate to say that parasuicidal self-injury is not central to borderline personality because parasuicidal behaviours occur with similar prevalence in persons with and without BPD in some studies (11).1111/acps. Borderline personality disorder: ontogeny of a diagnosis. We have learned that to obtain new knowledge about that relationship. USA. some are proven more valid than others. not all approaches are equally valid in science. The original view of borderline personality had to do with people who had childhood traumatic experiences. the most effective way to distinguish borderline personality from bipolar illness is on the four borderline criteria that are not included above: dissociative symptoms. it is an empirical question as to what represents the core of BPD. science demands change. instead. and unrelated to sexual trauma – were something entirely different and were not 2 related to the borderline concept before DSM-III (9. which the DSM framers continue to refuse to include in borderline criteria. Boston. Gunderson JG. Personality disorders predict relapse after remission from an episode of major depressive disorder: S 6-year prospective study. with high rates of parasuicidal behaviour in borderline personality and quite low rates in bipolar illness (6). especially of the generation that has created and enforced DSM revisions. The problem with this approach is that it is unscientific: A scientific attitude is not agnostic. It is not valid to say that sexual trauma is not central to borderline personality because some purportedly borderline patients do not have sexual trauma (5). Gunderson JG. . We have simply refused to critique the DSM system in our research.2 1 Mood Disorders Program. Frazier E. 5. Manic and severe depressive episodes – genetically determined. we have reviewed data showing that recurrent parasuicidal behaviour. Tufts Medical Center.

130:99–108. Glenn CR. Bipolar or borderline: a clinical overview. Acta Psychiatr Scand 2014.7:351–365. Ghaemi SN.53:230–237. 3 . J Abnorm Psychol 2007.116:578–588. Sookman D. Modestin J. Paris J. Zanarini MC. 7. 10. DIB. Two kinds of borderline concepts. Klonsky ED. Reich DB. Compr Psychiatry 2012. Dalley S.42:496– 507. 11. Borderline: a concept analysis. Catania C. Zuroff DC. Moskowitz DS. Acta Psychiatr Scand 1980. Psychiatr Dev 1989. Barroilhet S. Russell JJ. and Kernberg. Nonsuicidal self-injury disorder: an empirical investigation in adolescent psychiatric patients. Conceptual and empirical agreement between DSM-III. Fitzmaurice G. Sandell R. 8. 9. Affective lability in bipolar disorder and borderline personality disorder.61:103–110. Stability and variability of affective experience and interpersonal behavior in borderline personality disorder.Commentary 6. J Clin Child Adolesc Psychol 2013.