Distinguishing Between Borderline Personality Disorder and Bipolar Disorder

See reply by Gonzalez-Pinto et al and article by de la Rosa et al

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Distinguishing Between Borderline Personality Disorder and Bipolar Disorder

To the Editor: We read with interest a recent original research article published in JCP by de la Rosa and colleagues.1 They investigated the question of whether borderline personality and bipolar disorders might be alternative expressions of the same disorder. Using a 3-factor solution composed of 9 borderline personality symptoms, 8 depression symptoms, and 7 mania symptoms, they concluded that “the dimensions underlying bipolar disorder and borderline personality disorder are not separate entities, but rather correlated constructs.”1(p e997) The pattern of correlation among these factors was positive and consistent with the existence of 3 syndromes, 2 of which often co-occur (depression and mania). The authors concluded that the third syndrome, borderline personality disorder, is often comorbid with bipolar disorder and shares important clinical manifestations, but is an independent nosologic entity. Their sample was representative of the US adult population and was assessed by nonclinical interviewers with the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version.

Our research group investigated the possibility of discriminating between borderline personality and bipolar disorders.2 The academic debate regarding the inclusion of borderline personality disorder in the bipolar spectrum versus their discernment as 2 distinct nosologic entities3-11 encouraged us to conduct an in-depth analysis based on symptom categorization and essence. Our sample was representative of the psychiatric patient population and larger compared to previous studies. We explicitly selected only patients affected by borderline and bipolar disorders using the Structured Clinical Interview for DSM-IV Axis I Disorders and Axis II Personality Disorders, and we recruited them in 6 psychiatric departments across Italy. Bipolar patients had to satisfy criteria for a manic or mixed state, since most of the reported overlapping symptoms have pertained to emotional instability and impulsivity (although with different connotations), which are more evident during these states of bipolar illness.12,13 All of the patients were evaluated by clinicians using the Hamilton Depression and Anxiety Rating Scales, Young Mania Rating Scale (YMRS), Borderline Personality Disorder Severity Index (BPDSI-IV), and a semistructured interview.

We found a real comorbidity of 3.6% between these disorders.2 Importantly, though, our study, using common and well-recognized tests focused on symptom frequency and intensity, demonstrated that a precise analysis of symptom presentation permitted accurate discrimination between borderline personality and bipolar disorders. Some key symptoms were essential in differentiating the disorders. A sense of guilt, depersonalization, irritability, lack of insight, and paranoid ideation were able to separate even bipolar patients and borderline personality patients with a comorbid manic episode (YMRS score > 20). All of the borderline personality criteria (BPDSI-IV) differentiated bipolar and borderline personality patients with a comorbid manic episode with the exception of “emptiness,” which might be masked by manic symptoms.2

In conclusion, we believe that in the clinical psychiatric population a real comorbidity between bipolar and borderline personality disorders is rare, and even in cases in which it does exist, key symptoms still permit a distinction between bipolar patients and borderline patients with a comorbid manic episode. Together with administration of commonly used assessments, which yield immensely different scores between the two disorders, a timely and precise clinical examination focused on the essence, nature, and extent of the symptoms should allow an accurate understanding of the essential characteristics of these disorders.

References

1. de la Rosa I, Oquendo MA, Garcí­a G, et al. Determining if borderline personality disorder and bipolar disorder are alternative expressions of the same disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2017;78(8):e994-e999. PubMed CrossRef

2. di Giacomo E, Aspesi F, Fotiadou M, et al. Unblending borderline personality and bipolar disorders. J Psychiatr Res. 2017;91:90-97. PubMed CrossRef

3. Akiskal HS. The bipolar spectrum: the shaping of a new paradigm in psychiatry. Curr Psychiatry Rep. 2002;4(1):1-3. PubMed CrossRef

4. Akiskal HS. Demystifying borderline personality: critique of the concept and unorthodox reflections on its natural kinship with the bipolar spectrum. Acta Psychiatr Scand. 2004;110(6):401-407. PubMed CrossRef

5. Frias A, Baltasar I, Birmaher B. Comorbidity between bipolar disorder and borderline personality disorder: prevalence, explanatory theories, and clinical impact. J Affect Disord. 2016;202:210-219. PubMed CrossRef

6. Ghaemi SN. Bipolar vs borderline: diagnosis is prognosis once again. Acta Psychiatr Scand. 2016;133(3):171-173. PubMed CrossRef

7. Ghaemi SN, Barroilhet S. Confusing borderline personality with severe bipolar illness. Acta Psychiatr Scand. 2015;132(4):281-282. PubMed CrossRef

8. Mackinnon DF, Pies R. Affective instability as rapid cycling: theoretical and clinical implications for borderline personality and bipolar spectrum disorders. Bipolar Disord. 2006;8(1):1-14. PubMed CrossRef

9. Bayes A, Parker G, Fletcher K. Clinical differentiation of bipolar II disorder from borderline personality disorder. Curr Opin Psychiatry. 2014;27(1):14-20. PubMed CrossRef

10. Fulford D, Eisner LR, Johnson SL. Differentiating risk for mania and borderline personality disorder: the nature of goal regulation and impulsivity. Psychiatry Res. 2015;227(2-3):347-352. PubMed CrossRef

11. Paris J. Borderline or bipolar? distinguishing borderline personality disorder from bipolar spectrum disorders. Harv Rev Psychiatry. 2004;12(3):140-145. PubMed CrossRef

12. Leblanc A, Jarroir M, Vorspan F, et al. Emotional and impulsive dimensions in bipolar disorder and borderline personality disorder. Encephale. 2017;43(3):199-204. PubMed CrossRef

13. Saunders KE, Goodwin GM, Rogers RD. Borderline personality disorder, but not euthymic bipolar disorder, is associated with a failure to sustain reciprocal cooperative behaviour: implications for spectrum models of mood disorders. Psychol Med. 2015;45(8):1591-1600. PubMed CrossRef

Ester di Giacomo, MDa,b,c

[email protected]

Fabrizia Colmegna, MDc

Flora Aspesi, MDc

Antonios Dakanalis, MD, PhDb

Massimo Clerici, MD, PhDb,c

aPhD Program in Neuroscience, Doctoral School, University of Milano-Bicocca, Monza, Italy

bSchool of Medicine and Surgery, University of Milano Bicocca, Monza, Italy

cDepartment of Psychiatry, ASST Monza, Monza, Italy

Potential conflicts of interest: None.

Funding/support: None.

J Clin Psychiatry 2018;79(2):17lr11919

To cite: di Giacomo E, Colmegna F, Aspesi F, et al. Distinguishing between borderline personality disorder and bipolar disorder. J Clin Psychiatry. 2018;79(2):17lr11919.

To share: https://doi.org/10.4088/JCP.17lr11919

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