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Tuesday, August 10, 2021

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 CME/CE
Demystifying Borderline Personality:
The Cyclothymic-Bipolar II Connection
Authors: Hagop S Akiskal, MD Faculty and Disclosures

THIS ACTIVITY HAS EXPIRED

Introduction

Despite considerable overlap between

borderline personality disorder and
affective disorders based on Print
methodologically sound studies, as
prominent a borderline expert as
Gunderson[1] has downplayed such a
relationship. Such denial is all the more
surprising given the fact that his research
team[2] reported that borderline patients
at some point in their life met criteria for
dysthymia (80%) and/or major
depressive disorders (100%). For this
reason, it is generally conceded that the
nature of affective illness in borderline
patients is best described as "atypical."
The question of the relationship between
borderline and affective disorders then is
one of characterizing the nature of
"atypicality." The thrust of my argument
in this report[3] is that the atypicality of
the affective dysregulation of patients
given borderline diagnoses can be more
precisely delineated in terms of
cyclothymic and bipolar II disorders.
:
 cyclothymic and bipolar II disorders.

Defining the Borderline Terrain

In the Diagnostic and Statistical Manual

of Mental Disorders, fourth edition
(DSM-IV), borderline refers to a discrete
operationally defined construct within the
"dramatic cluster" of personality
disorders. This definition largely derives
from the work of Gunderson and Singer.
[4] Among its chief merits is the
stimulation of a plethora of data-based
investigations of borderline conditions
since 1980 as well as the development of
the Diagnostic Interview for Borderline
(DIB) as its structured measurement.
Among the limitations of this
operationalized approach is that the
concept has been oversimplified, even
banalized: it has an unwieldy
heterogeneity and overlaps significantly,
not only with personality disorders within
its own cluster, but also with the
schizotypal-paranoid and anxious
clusters. Of related concern is the fact
that DSM-IV criteria, rather than
restricting themselves to defining
personality attributes, mix traits,
symptoms and behaviors -- particularly
of an affective nature (Table 1).

Table 1. Core Characteristics of DSM-

IV Borderline Personality Rearranged
to Highlight Affective Loading

Unstable - "splitting"
intense - "object
:
 intense - "object
relationships hunger"
-
abandonment
depression
Affective - mercurial
instability moods
- reactive
dysphoria
- angry
outbursts
Behavioral -impulsivity
dyscontrol - substance
abuse
- binge
eating
- suicidality
Chronic -boredom
emptiness
Unstable sense - identity
of self disturbances
Micropsychosis -paranoid
sensitivity
- dissociation

Of even greater concern is that the

operational construct may not coincide
with what psychoanalysts mean when
they make the clinical diagnosis of
borderline personality organization. The
latter refers to Kernberg's pioneering
contributions[5] in delineating a
vulnerable psychic structure, rather than a
specific nosologic entity. It refers to a
class of personality dysfunctions with
:
 class of personality dysfunctions with
common defensive operations, reflecting
a vulnerable psychic structure that
functions at a "stably unstable" level
between the classic neuroses and
psychoses. Unlike Gunderson's concept
of borderline as a specific personality
disorder -- which does not lie on the
border of any specific mental disorder --
Kernberg's conceptualization maps a
large terrain of psychopathology with
affective, neurotic, and paraphiliac
disturbances. Kernberg's position appears
to be more compatible with
psychobiologic formulations of
borderline, which place this personality
disorder on the borders of such disorders
as schizophrenic, manic-depressive, and
epileptic psychoses. In this framework,[6]
borderline refers to formes frustes of the
major endogenous psychoses (ie,
subschizophrenic, subaffective, or
subictal disorders). This paper updates
previous contributions by the present
author,[6-10] and integrates them with
other emerging trends that emphasize the
central role of the cyclothymic
constitution in the genesis of borderline,
atypical, and bipolar II disorders.

Delineating the Affective Border

Initially, the borderline concept

developed as a dilute form of psychosis,
and its main usefulness was to exclude
such patients from the couch. Working in
New York, Stone[11] -- who reported that
these patients often came from families
:
 these patients often came from families
with manic-depressive and alcoholic
members -- can be credited for having
been the first to make a persuasive
argument about the need to shift from
borderline as a subschizophrenic to a
subaffective disorder.

Independently, the present author too

arrived at the same conclusion: curiously,
our work at the University of
Tennessee[6,7] had started off with the
hypothesis that many patients with
borderline personality had affinity to
schizophrenic disorders as defined in the
framework of the Danish adoption study
of schizophrenia. We studied 100
consecutive outpatients -- in a Memphis
mental health center -- meeting the
Gunderson and Singer criteria[4] for
borderline personality. They were
clinically evaluated using a
semistructured interview based on a
modified version of the Washington
University approach to psychiatric
diagnosis.[12]

Contradicting our starting hypothesis,

only 16% were schizotypal.[6] As for
other psychopathology, borderline
embraced a broader spectrum than we
had anticipated. At index evaluation, 66
met the criteria for recurrent depressive,
dysthymic, cyclothymic, or bipolar II
disorders; other patients met criteria for
sociopathic, panic-agoraphobic,
attention-deficit/hyperactivity and
:
 attention-deficit/hyperactivity and
epileptic disorders. During prospective
observation of up to 3 years, and
compared with nonborderline personality
subjects, borderline probands had a
significantly higher risk for developing
major affective disorders than
schizophrenia spectrum disorders;
furthermore, there were 4 completed
suicides. Prominent substance abuse
history, stormy biographies, and unstable
developmental history marked by
repeated object loss were common to all
borderline subgroups. From a familial
standpoint, borderline probands were
closest to the affective, especially the
bipolar, comparison group. This familial-
genetic bipolar link was reinforced by
antidepressant associated switches into
irritable-angry hypomanic and mixed
states in 20% of our sample during
prospective observation. (Of note,
"paradoxical" disinhibition on
antidepressants in borderline patients has
also been observed by others.[13,14])

To summarize, the recurrent nature of

affective disorder, coupled with familial
bipolarity and spontaneous and
pharmacologic excursions into brief
periods of elation, places the affective
pathology of borderline patients in the
soft bipolar realm (that can be broadly
defined as bipolar II).

The Nature of "Atypicality"

It is often assumed that micropsychotic
and dissociative episodes in patients
:
 and dissociative episodes in patients
given borderline diagnoses emanate from
psychotic processes. This is a
misconception. Grandiose or irritable
forms of hypomania occurred in a third
of our borderline probands with affective
diagnoses.[6] Transient drug-induced
psychoses secondary to alcohol, sedative
hypnotic, psychedelic or stimulant drug
use, or withdrawal were reported in
nearly half of all borderline cases.
Finally, depersonalization-derealization,
as well as brief reactive psychoses, were
not uncommon in the borderline
probands with concurrent panic-
agoraphobic diagnoses. Such data
provide a useful beginning framework for
understanding the "atypicality" of the
affective disorder in borderline patients.

To explain the atypicality of the affective

state of borderline patients, Gunderson
and Phillips[1] contrasted "empty"
depression in this personality with the
more classical "guilt" depressions in
"classical" affective disorder. Thus, their
unstable, hostile, and labile moods -- the
unrelenting tension and irritability with
superimposed paroxysms of rage -- are
relegated by these authors back into the
characterologic realm. The thrust of this
argument is based on a misconception
that only classical affective disorder is a
"true" affective disorder. In a forensic
population, Coid[15] recently provided a

compelling description of the affective

storms of borderline patients
:
 storms of borderline patients
(restlessness, irritability, explosive anger,
tension, psychotic anxiety), which lead to
-- and alternate with -- the deceptive
"calm" and "emptiness" following self-
mutilation. Whatever one ends up calling
such patients, one cannot but respect their
affectively driven temperamental
excesses (lest one becomes victimized by
them!). Since 1981, the present author[7]
has defended the position that a
significant proportion of these patients
suffer -- and make their loved ones suffer
-- as a result of temperamental
dysregulation along dysthymic-irritable-
cyclothymic lines. Mood lability and
hostile emotional avalanches, which
characterize borderline patients, seem to
derive from such temperamental
dysregulation, which is quintessentially
affective in nature.

The Atypical-Bipolar II Connection

Major depressive states with reverse

vegetative signs (so-called "atypical
features") are commonly encountered in
this unstable temperamental terrain.
Three recent studies have provided
greater clarification about this complex
interface of volatile affective
temperament and atypical affective
states.

1. In collaboration with clinical

researchers in Pisa,[16] we
demonstrated that 72% of 80
:
 demonstrated that 72% of 80
depressive patients with DSM-IV
atypical features simultaneously met
the criteria for bipolar II; 60% had
antecedent cyclothymic
temperament. In addition, 94% were
rated as interpersonally sensitive. As
expected, using the DSM-IV axis II
schema, both cluster B (borderline-
histrionic) and cluster C (avoidant)
personality disorders were
prevalent.

2. Deltito and colleagues[17] studied 20

consecutive patients diagnosed
borderline by experienced clinicians
at Westchester-Cornell, "validated"
independently by Gunderson's DIB.
They then rated them by descending
order of certainty of bipolarity: in
light of what the current literature
indicates as established bipolarity (
bipolar I + bipolar II), the
conservative rate for bipolarity in
this well-characterized, though
small. sample of borderlines was
44%; taking the most liberal
definition of bipolarity (including
pharmacologic-hypomania,
cyclothymic temperament, and
family history for bipolar disorder),
81% of borderline patients could be
considered lying on the border of
within the bipolar spectrum. This

provocative work, though

preliminary, represents the first
:
 preliminary, represents the first
head-to-head comparison of
borderline personality and
bipolarity[11] (and obviously is in
need of replication).

3. The author's research as part of the

National Institute of Mental Health
Collaborative Study of
Depression[18] has shown that
clinical features reminiscent of
borderline features (SADS Item 12)
were strongly predictive of which
major depressives would, over a
prospective observation period of 11
years, switch to bipolar II (Table 2).
The temperament of these patients
was a mélange of interpersonal
sensitivity and mood lability. This
study underscores the importance of
temperamental factors in borderline
psychopathology, as well as their
value in predicting bipolar outcome.
Stated more tersely, borderline
personality, interpersonal sensitivity,
mood labile temperamental traits,
and bipolar II seem to represent
overlapping expressions of the same
diathesis. (That mood lability is not
pathognomonic for borderline
personality, and occurs in bipolar II
as well, has been replicated by
Henry and colleagues.[19])

Table 2. Prospective Prediction of

Bipolar II Outcome in 8.6% of 559
:
 Bipolar II Outcome in 8.6% of 559
Patients With Major Depressive
Disorder*

- Younger age at onset

- High depressive recurrence
- Greater marital disruption
- Higher score on phobic
anxiety
- More "borderline" clinical
features
- Higher score on
interpersonal sensitivity
- High on trait energy-activity
and daydreaming
- High on trait mood lability
- 42% sensitivity
- 86% specificity

*Summarized from Akiskal et

al[18]

Borderline as a Casualty of the Axis I-

Axis II Distinction

One of the inadequacies of our current

nosologic schema of personality
disorders is that the long-term
functioning of patients suffering from
major mood disorders is described
primarily in "characterologic" language
(Axis II in DSM-IV), which is
conceptually removed from the
"temperamental" language that had been
used in classical European psychiatry
during the first part of this century. For
instance, today bipolar patients are often
:
 instance, today bipolar patients are often
described as "dramatic," "erratic,"
"unstable," impulsive," "passive-
aggressive," "histrionic," "narcissistic,"
or "borderline," as if affective
temperaments had little to contribute to
our understanding of these personality
disorders. O'Connell and colleagues[20]
appropriately pointed out that structured
interviews tend to misclassify
subthreshold affective disturbances as
dramatic personality disorders. The
author's work[21] and subsequent
research by Levitt and colleagues[22]
have actually shown significant overlap
between the cyclothymic temperament
and borderline personality disorder.

There are advantages to returning to the

more natural affective temperamental
language of describing the premorbid,
intermorbid, and postmorbid phases of
major affective disorders. In this
framework,[7,21,23] affective
temperaments represent the substrate
from which the more florid episodes
develop. Using the analogy of
earthquakes, I have elsewhere[9]
compared the predisposing terrain and
affective instability in 2 types of
depression. In many affective ill patients,
the temperamental terrain is not visibly
pathologic but refers to a vulnerable fault
that can be destabilized periodically,
erupting into extreme pathology that
could lead to self-destruction. In this
more classical affective type, the patient
:
 more classical affective type, the patient
has relatively normal -- or even
supernormal or hyperthymic --
functioning between episodes. In other
patients, the temperamental terrain is
characterized by greater instability and
intermittent or nearly continuous
emotional "mini-earthquakes"; these
patients seem "protected," though not
entirely, from major melancholic
episodes. The patient with this second
type of temperamental dysregulation
suffers from protracted intermittent
emotional disequilibrium and restlessness
without necessarily having full-blown
syndromal affective episodes. These are
then considered to be "atypical" or
"borderline" cases where the terrain is so
pathologically unstable that it may be
difficult to discern the superimposed
episodes that are an accentuation of the
basic pathology.

Borderline as the "Darker Side" of

Cyclothymia

Our work has actually demonstrated that

the temperamental terrain between
depression and manic-depression is
bridged by a spectrum of subtle bipolar
disorders with an extremely variable
course.[7,21,23] Mood switches are
recurrent, biphasic and abrupt, and may
be seasonal and sometimes exacerbated
by antidepressants. The term "explosive"
captures the abruptness of the affective
switches, each phase lasting for hours,
days, and, sometimes, weeks. These
:
 days, and, sometimes, weeks. These
patients are rarely euthymic. Their mood
shifts often follow a circadian pattern (ie,
waking up convinced of the futility of
existence), but can also be reactive to
interpersonal altercations, often rather
trivial in nature, but emotionally charged
for the patient. Even when provoked by
such situations, the resultant emotional
outbursts are more like avalanches than
understandable reactions proportional to
the proximate provoking situation.[23]
One must infer an endogenous propensity
to extreme emotional reactivity to these
patients. Given such emotional tempests,
it is no wonder that most clyclothymes
accumulate an extreme array of social
disturbances by their mid-20s[21]:
repeated romantic failure, episodic
promiscuity, financial extravagance,
uneven work or school record,
dilettantism, geographic instability,
polysubstance abuse, and joining various
eschatologic cults. Such instability
appeared to be secondary to lifelong
biphasic mood swings below the
threshold for full-blown bipolar disorder.
Subsequent studies in a community
sample[24] have reported similar
interpersonal havoc and social
disruptions.

The instability in the biography of

cyclothymics is especially accentuated in
those with predominantly irritable traits.
[23] These individuals are habitually
dysphoric, prone to anger, hypercritical
:
 dysphoric, prone to anger, hypercritical
and complaining, with a penchant for ill-
humored joking. They would thus easily
offend their loved ones, often leading to
verbally abusive behavior when only
minutes or hours earlier they had vowed
"eternal" love. At other times,
interpersonal crises escalate because of
their pouting and obtrusive behavior. In
brief, the morose temperamentality of the
irritable cyclothymic provides the
unstable base from which interpersonal
tempests arise.

Recent data[25] from a French national

collaborative study has shown that the
notion of cyclothymia and hypomania as
positive "sunny" traits and behaviors
represents just one facet of soft
bipolarity. This driven-euphoric facet
should be contrasted with the irritable-
tempestuous or "darker" side of
bipolarity. The correlation of cyclothymia
reaches significance (.37) only with the
latter facet. In brief, depressions arising
from a cyclothymic baseline are often
characterized by dysphoric hypomanic
periods, and are likely to be
misdiagnosed as erratic personality
disorders. Their high familial load for
affective (including bipolar) disorder
support their inclusion as a more unstable
variant of bipolar II that can be best be
characterized as "cyclothymic
depressions."

Another study[26] relevant to the "darker"

side of bipolarity, which is still
:
 side of bipolarity, which is still
unpublished, derives from the author's
collaboration with the University of Pisa.
In 107 atypical major depressive patients,
logistic regression revealed that
cyclothymic temperament accounted for
much of the relationship between
atypicality and borderline personality.
The cyclothymic-sensitive disposition
seems to represent the common
denominator in the complex syndromic
pattern of anxiety, mood, and impulse
disorders. We explained these findings
and considerations as support for the
contention that atypical depression,
borderline personality, cyclothymia, and
bipolar II represent overlapping
manifestations of a common underlying
psychobiologic diathesis.

Unless their temperamental

vulnerabilities are understood properly,
the comorbidity and erratic clinical
presentations of these borderline patients
can baffle clinicians. As a result, some
researchers prefer to characterize these
vulnerabilities along the lines of
sociopathy and related personality
disorders.[27] Such characterization, in
my opinion, misses the core emotionality
of borderline patients that can be
observed in both patients and in their
biologic kin.[28] I submit that
interpersonal sensitivity, mood reactivity,
and lability are more germane to the

origin of borderline psychopathology and

its comorbidities. It is their innate -- and,
:
 its comorbidities. It is their innate -- and,
to some extent, developmentally acquired
-- intense reactivity to others that creates
their turbulent relationships, and indeed
their entire biography.

As discussed elsewhere,[10] the tragedy

of borderline patients is that their
impulsive drive, which thrusts them into
the theater of human interactions --
coupled with their negative affectivity --
accentuates and thereby validates their
sense of being rejected emotionally,
maltreated, and abused; the more
unfortunate among them do get actually
abused by psychopathic family members
(usually a step-parent).

Concluding Remarks

Discussion of psychopharmacologic and

formal psychotherapeutic interventions in
borderline personality conceived as a soft
bipolar variant are beyond the scope of
this paper. Suffice it to say that the
affective framework for borderline
personality described in this paper has
major implications for clinical
management. Foremost among them is
that affective reconceptualization of
borderline pathology may substantially
reduce the therapists'
countertransference[29] because now the
patient is viewed as affectively ill, rather
than "character flawed." Treatment
should be undertaken with the requisite
competence and confidence for a serious
mental disorder. The suicide risk -- a
:
 mental disorder. The suicide risk -- a
potentially fatal consequence of the
intense affective dysregulation -- should
be conceptualized and clinically managed
as rigorously as in any patient with
serious mood disorder. The affective
dysregulation and the impulsivity that
underlies such risk may, in principle, be
preventable with mood stabilizers,
including carbamazepine and divalproex.
This is a vital public health priority.

These patients often come from disturbed

families and appear at risk for emotional
instability due to both genetic factors (eg,
bipolarity, alcoholism) and
developmental factors (eg, disruption in
early attachment bonds and other
traumatic experiences). The
neuroendocrine and sleep
neurophysiologic correlates of their
exquisite affective vulnerabilities have
been documented elsewhere.[10] Since
borderline patients -- in view of their
negative affectivity -- often develop
malevolent object representations of
significant others in their lives,[30]
clinicians must not assume that the
parents of borderline patients are or were
"monsters." Parents' guidance is often
crucial to these patients' mastery of
maturational tasks. On the other hand,
Kurt Schneider's[31] wise admonition
should not be forgotten: "On their bad
days, keep out of their way as far as

possible."
:
 References

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Abstract

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3. Akiskal HS. Borderline personality

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 validation studies. J Abnorm
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29. Gardner DL, Cowdry RW. Suicidal

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