Psychiatric Times. Vol. 26 No.

7 July 13, 2009

Psychiatric Times. Vol. 26 No. 7 CME

Borderline Personality Disorder and Bipolar DisorderDistinguishing 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.

AcknowledgmentThis work was supported by a Veterans Administration Advanced Career Devel-op-ment Award to Dr Goodman.

Editor's note: CME testing has expired for this article. It can be used for informational purposes.

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5 AMA PRA Category 1 Credits™. nurse practitioners. LLC. Sponsored by CME LLC for 1. Approved for CME credit through July 2010. and although the current understanding posits distinct disorders. While the initial focus was on the schizophrenia spectrum.5 contact hours for nurses.5 Category 1 credits. CME LLC is approved by the California Board of Registered Nursing. with several vocal advocates who propose http://www. primary care physicians. Educational Objectives After reading this article. impulsivity. 2009 You must keep your own records of this activity. Physicians should only claim credit commensurate with the extent of their participation in the activity. Copy this information and include it in your continuing education file for reporting purposes.1 more recent authors have attempted to link BPD to mood disorders.pharmacological and psychosocial interventions Who will benefit from reading this article? Psychiatrists. Provider No. CEP12748. The American Academy of Physician Assistants (AAPA) accepts AMA PRA Category 1 Credits™ from organizations accredited by the ACCME. psychologists. You will be redirected to CME. please contact your state licensing and certification boards. overlapping biological underpinnings do exist. Click here to take the post-test. Since the inclusion of the borderline personality disorder (BPD) diagnosis in DSM. There is considerable literature on the relationship between major depressive disorder (MDD) and BPD.psychiatrictimes.2 Attention has now turned to bipolar disorder.Psychiatric Times. 26 No. and other health care professionals. CME LLC is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. you will be familiar with: • Ways to distinguish between borderline personality disorder and bipolar disorder • Diagnoses based on mood episodes. Vol. Original release date 07/09. To determine whether this article meets the continuing education requirements of your specialty. and longitudinal course of borderline personality disorder and bipolar disorder • Treatment implications . 7 July 13. CME LLC designates this educational activity for a maximum of 2 . The American Nurses Credentialing Center (ANCC) accepts AMA PRA Category 1 Credits™ toward recertification requirements. there have been multiple efforts to recast the disorder as part of an Axis I illness category. and designates this educational activity for 1.

7%. avoidant.5 Depending on the population studied. with a median of 9.6% to 16. the prevalence of BPD is estimated at 2% of the general population. 7 July 13.11. including schizotypal.1%. and impulsivity. BPD patients had a higher rate of bipolar I and II disorder onset (8.8 A recent study that used the large Collaborative Longitudinal Study of Personality Disorders (CLPS) database.10 However. behavioral dysregulation.4 This article discusses the overlapping phenomenology of bipolar disorder and BPD and highlights distinguishing features of clinical diagnosis and treatment.14 However. The phenomenology of mania differs significantly from that of BPD. A comparison of DSM-IV-TR criteria is displayed in Table 1 and demonstrates considerable overlap. 2009 reclassifying BPD as bipolar spectrum disorder. The 2 studies with the strongest methodologies that used structured diagnostic interviews with adequate sample sizes and a 6. and obsessive-compulsive personality disorders (19. Diagnosis Diagnosis of bipolar disorder or BPD can be difficult. In a recent comprehensive review by Paris and 3 . the rates are 12% to 23%.1% for the other personality disorders) over 4 years.6 The relationship of BPD and cyclothymia has been examined in 1 study. Prevalence According to DSM-IV-TR. comorbidity is not common. with a median of 10. The rate of BPD in patients with bipolar I disorder varies from 0.7%. irritability. The rate of bipolar II disorder was only slightly higher.12 A factor analysis and subsequent replication study revealed 3 factors for BPD: disturbed relatedness. Other estimates are closer to 5% for bipolar spectrum disorder.5% to 30%.9%.3. while elevated rates of comorbid personality disorders have been found in patients with bipolar disorder.Psychiatric Times. Vol. showed an increased rate of bipolar I and II disorders in patients with BPD compared with patients who had personality disorders other than BPD. 26 No. there are varying estimates of the co-occurrence of BPD and bipolar disorder. and irritability.7. with a median of 16%. while in patients with bipolar II disorder. it was not nearly as high as the risk for MDD or substance abuse.6 These findings suggest that while BPD and bipolar disorder can co-occur. psychosis. and the results revealed exceptionally high comorbidity rates with BPD of 62%.13.4% and 7. with no difference from the comparison groups. 8% to 19%. with a median of 10.psychiatrictimes. however. a number of recent studies have shown that http://www. Factor analyses of manic symptoms have identified psychic and motor acceleration. and affective dysregulation.6 the rate of bipolar I disorder in BPD patients ranged from 5. compared with 1% to 2% for bipolar disorder. because both can present with affective instability.2% for BPD vs 3.2%. no differences between rates of BPD and the other personality disorders studied have emerged. respectively).to 7-year follow-up showed a low rate of new onset of bipolar disorder in patients with BPD. In addition. in general.9 While these studies suggest a moderately increased risk for bipolar disorder in patients with BPD.

19: • Quality of mood episodes • Types of impulsivity • Longitudinal course Symptoms such as irritability and quality of de-pres-sion have not proved helpful.21 The mood swings of BPD and bipolar II disorder differ in emotion type as well. the phenomenologies of the mood episodes differ. especially for bipolar I disorder. the affective instability is part of a characteristic pattern of emotional responding. and BPD displayed non-planning impulsiveness. in bipolar disorder. mood swings are more spontaneous and of longer duration. while bipolar II disorder affective shifts are from euthymia to elation. BPD was distinguished from bipolar II disorder by the presence of hostility and differing patterns of impulsivity.23 The differentiation of BPD and rapid cycling bipolar disorder remains problematic. acute episodes and symptom-free intervals occur. which suggests that this group may be at the highest risk for self-damaging behaviors. http://www. 7 July 13. In addition.15-17 Recent studies that explored the overlap of BPD and bipolar disorder have outlined sever-al parameters to distinguish the 2 diagnoses9. Vol. and the 2 entities are likely to have significant biological and possibly genetic overlap. 28 This finding argues for the need to make both diagnoses when appropriate. and euthymia is infrequent. Similarly. usually of negative affect. Individuals with BPD swing from euthymia to anger. is inconsistent with context.psychiatrictimes. as both disorders involve a high degree of affective instability.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. qualitative emotional shifts. mood swings.98) that the factor analyses actually support a single overarching BPD construct.20.25 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. In bipolar disorder. 26 No.24 Findings from these 3 studies suggest that careful detailing of the duration of mood episodes. and are highly dependent on the environment. Impulsivity in BPD is also characterized as non-planning. and is seen in both BPD and bipolar disorder. Data suggest that these affective problems persist throughout the life course of the disorder and may be identified by par-ents of children with BPD as early as infancy. In BPD. and there are more extended periods of elation.22 Shifts triggered by interpersonal stressors in BPD. 2009 the BPD factors correlate so highly with one another (with correlation coefficients of 0. Mood episodes While both disorders cause mood instability and affective reactivity.Psychiatric Times. last from minutes to hours. while in BPD. Bipolar II disorder showed attentional impulsivity characterized by distractibility and inability to focus on a task. are triggered by interpersonal stressors or perceived stressors.92 to 4 .22-24 Impulsivity Impulsivity is behavior that occurs without reflection.18. although not rapid cycling forms of bipolar disorder. are transient. are less prevalent in bipolar disorder. and longitudinal patterns (episodic vs lasting) can help distinguish between BPD and bipolar disorder. recurrent triggering events. The highest rate of impulsivity was found in populations with comorbid BPD and bipolar IIdisorder. which often involve rejection or perceived abandonment.

http://www. Pharmacological treatment While randomized clinical trials of patients with BPD have been performed using mood stabili-zers. whereas multiyear follow-up studies of patients with BPD have found that most people eventually stop meeting threshold criteria for the disorder. with long-term morbidity and substantial inter-episode symptomatology. particularly in mixed depressive presentations.Psychiatric Times.30-32 Longitudinal course Long-term outcome studies in bipolar disorder and BPD seem to challenge the traditional Axis I/Axis II dichotomy. 2 for depressive phases. but in bipolar disorder these are predominantly found in the depressive phase. although inter-episode impulsivity is seen in bipolar disorder when comorbid substance abuse complicates the clinical picture. that persist even after the more dramatic impulsive or demanding behaviors have subsided.9 Treatment implications Differentiating BPD from bipolar disorder has ramifications for treatment planning. Eleven drugs are FDA-approved for the treatment of bipolar disorder: 9 for mania/mixed phases. their effect sizes have not been particularly robust. both pharmacological and psychosocial. prompted the recent Cochrane review to state that there are “insufficient data” to sup-port any recommendations for pharmacological treatment in BPD.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. 7 July 13.38 This can result in significant iatrogenic morbidity that may outweigh the marginal clinical benefits. 2009 Clinically. In contrast. and they are related to hopelessness while in BPD. study findings suggest that polypharmacy for BPD is rampant. impulsivity is believed to be more episodic in bipolar disorder than in BPD. they are often a function of the inability to tolerate distress. and 5 for maintenance therapy (several are approved for more than one phase of the illness). There also appears to be a subset of remission-resistant BPD patients who continue to show poor judgment and high treatment utilization. The report concluded that medication effects in BPD are “unimpressive. coupled with small sample sizes. whereas personality disorders are considered life-long and treatment refractory. especially in the affective and interpersonal realms. and it is not uncommon for patients with BPD to be treated with multiple 5 .psychiatrictimes. or number of hospitalizations or other treatment utilization except for mood-stabilizer medication.33. Vol. antidepressants. there appears to be a core subset of BPD symptoms.5. in which mood disorders are widely thought of as episodic and treatable. pharmacological treatment in bipolar dis-order is far more effective.”37 Despite this.35. This.34 However. Many cases of bipolar disorder assume a chronic course. although not empirically validated. remission rates. 26 No.29 Impulsive acts such as suicidal behavior occur in both disorders. and typical and atypical antipsychotics.

52. 2009 Although similar medications are used for both BPD and bipolar disorder. In contrast to the meager efficacy of pharmacological treatment for BPD. In BPD. The findings on medication treatment in patients with BPD suggest that an over-reliance on psychopharmacological strategies yields disappointing results. 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.33. Despite symptomatic overlap. but this does not seem to be the case for BPD. and it has been usefully extended to family members as well. stress management.53 In bipolar disorder. In bipolar I disorder patients. psychosocial treatments have shown substantial promise and many psychotherapeutic interventions that focus on teaching emotion-regulation skills exist. 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.psychiatrictimes. 7 July 13.44 A positive clinical response has been found for antidepressants of several classes including monoamine oxidase inhibitors and SSRIs.39-42 Similarly. rather than mood symptoms. Vol. 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. 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.Psychiatric Times. randomized controlled trials of valproate(Drug information on valproate) and carbamazepine(Drug information on carbamazepine) have targeted impulsivity and anger rather than affective instability. SSRIs in BPD appear to target anger and impulsivity. 26 No. for both the depressed phase of bipolar disorder and for BPD. a longitudinal study of 4107 persons with bipolar disorder that evaluated treatment effectiveness. the value of psychosocial interventions is gaining recognition as an im-portant adjuvant treatment. mood stabilizers are the first line of treatment. while a randomized controlled trial of lithium showed no benefit at all. The therapeutic aims of psychosocial approaches for bipolar disorder include psychoeducation. a similar finding was noted by Paris19 in a study of atypical antipsychotics for both BPD and bipolar disorder.43.45 The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).46 Psychosocial interventions Table 2 presents psychosocial treatments available to patients with bipolar disorder or BPD. and regularity in daily activitiesand biosocial rhythms. the clinical effectiveness of the medications and target symptoms of the disorders 6 . Medication efficacy is far more pronounced in patients with bipolar disorder.54-57 Case Vignette http://www. the types of interventions differ by disorder.

1981. Triebwaser J.46:41-48. The possibility of comorbid presentation also requires consideration because this may have an impact on the risk of self-damaging behaviors. Vol. Borderline and schizophrenic patients. Deltito J. and impulsivity manifested themselves. and they present diagnostic challenges because of their phenotypic overlap. J Pers Disord. endophenotype and genotype comparisons between borderline personality disorder and major depressive disorder. Davis GC. can affect treatment outcome. He denied any current or past suicidal or homicidal ideation but endorsed a past history of “mood swings. J Clin Psychiatry. Collins K. In press. Phenotype. Lithane. Sugarman A.169:705-711. 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. 2. John described his moods as never vacillating to periods of elation but rather as centered on feelings of hostility and anger. et al. 1985. never-married man who initially presented with irritability and depression. paying attention to the patient’s quality of mood shifts. his dependency on others.” He had been given a diagnosis of bipolar IIdisorder 10 years earlier. 26 No. others) 1. 2009 John is a 50-year-old. The failure to appreciate the BPD diagnosis. persons with BPD often receive a diagnosis of bipolar spectrum disorder. Lithobid) Topiramate (Topamax) Valproate/Valproic acid (Depakote. Lerner HD. his preoccupation with his partner’s fidelity and whereabouts. Riefkohl J. He had rapid mood shifts in session. BPD was diagnosed and John was referred for medication management and dialectical behavior therapy. As noted by Gunderson and colleagues. Borderline: an adjective in search of a noun. 4.psychiatrictimes. Siever LJ. white. et al. Do patients with borderline personality disorder belong to the bipolar spectrum? J Affect Disord. others) Lamotrigine (Lamictal) Lithium (Eskalith. identity confusion. whether from misdiagnosis or a hesitancy to offer a stigmatizing label. the effects can range from overuse of medication and potential poly-pharmacy to an underappreciation of empirically validated psychological treatments of BPD. 3. A comparative study of defensive structure. 5. Akiskal HS. Fountoulakis KN.Psychiatric Times. The contemporary face of bipolar illness: complex diagnostic and therapeutic http://www. As previously discussed. 2001. Over the next few sessions. Goodman MN. and longitudinal course may aid in distinguishing between the 2 disorders. J Nerv Ment Dis. particularly when the discussion centered on his current romantic relationship of 5 months. Conclusion BPD and bipolar disorder are both associated with significant levels of mortality and morbidity. Given the quality of his mood swings and associated symptoms. Gaughran J. Martin 7 . Tegretol. Drugs Mentioned in This Article arbamazepine (Carbatrol. Accurate diagnosis is important because each disorder has a distinct medication response and set of psychosocial interventions. types of impulsivity.67:221-228. 7 July 13. However. Chen SE.9 and as exemplified by this case.

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