Letters to the editor
Letters to the editor
A biopsychosocial approach to bipolar-borderline debate: psychological effect of a biological temperament DOI: 10.1111/acps.12298 Akiskal was the first to suggest borderline personality as an Axis I disorder within the bipolar affective spectrum about two decades ago. His idea has been derived mostly from the similarities of affective instability, inappropriate anger, impulsivity, and unstable relationship proposed as some borderline criteria with what is seen in bipolar II disorder. Four lines of evidence can be considered as supports for Akiskal’s theory. First, cyclothymic temperament has been found to be highly sensitive (88%) in identifying bipolar II disorder and has been the most common affective temperament among patients with this disorder. Second, there has been a high comorbidity between borderline personality and bipolar (particularly the broad definition of bipolarity). Third, there has been strong association between atypical depression and bipolarity (i.e. in one study 72% of atypical depressives met criteria of bipolar spectrum) and atypicality of depression has been assumed to be related to an affective temperamental dysregulation. Fourth, cyclothymic temperament has been associated with borderline personality among 107 atypical depressives (P = 0.001). Hence, Akiskal has explained all these findings as support for the conclusion that atypical depression, borderline personality, cyclothymia, and bipolar II disorder represent overlapping manifestations of cyclothymic temperament as a common underlying diathesis (1). On the other hand, emphasizing more on the differences than similarities, Ghaemi has stated that these two disorders are different. He has argued that the assumed ‘core’ presentations of mood lability and impulsivity are not pivotal to either illness (2). In contrast to bipolar disorder, affective instability in borderline personality is not episodic and includes mostly shifts from euthymia to anger and rarely from depression to elation (3). Furthermore, the greater importance of genetic vulnerability in the etiology of bipolar disorder than that of borderline personality, the four borderline features that are not predictive of bipolarity (abandonment, identity disturbance, recurrent suicidal or self-mutilating behavior, and dissociative symptoms), and the importance of psychoanalytic theories in the development of borderline personality as a psychological structure are the main differences on which Ghaemi’s opinion has been based (2). It seems that these two opinions are not necessarily contradictory. Having the same diathesis needs neither the similarity of the two disorders nor the overlapping within one spectrum. A third model can be proposed in which the psychoanalytic effect of cyclothymic temperament on the development of borderline personality might be noteworthy. As proposed by Kernberg, borderline personality evolves from the failure to integrate representations of good and bad aspects of self and others. From this view-point, a cyclothymic child might be assumed as developing two completely opposite representations of self and others – depending on high and low levels of mood – that cannot be integrated. Furthermore, a prolonged emotional dysregulation, which can be aggravated by cyclothymic temperament, might render self-soothing capacity
158
impaired. Without developing the capacity for self-soothing, borderline patients may have to depend on the actual presence of an object to manage and tolerate their intense emotions (4). Therefore, in the proposed third model, cyclothymic temperament through the biological pathway can lead to bipolar II disorder, and through the psychological pathway might contribute to borderline personality. On the other hand, some studies have found associations between temperamental profile of borderline personality (high novelty seeking and high harm avoidance) and cyclothymic temperament (5). This might indicate that people with cyclothymic temperament are biologically vulnerable to borderline personality as well. Affective temperaments as individual differences in emotional reactivity and regulation are expected to be evident from early childhood. The available data on cyclothymic disorder or temperament in youth are limited. However, a study by Goldberg showed that early onset bipolar disorder increases the probability of borderline personality disorder (3). One study of cyclothymia patients found 62% with borderline personality (3). A future direction of research will be the association of cyclothymic temperament and bipolar II disorder in borderline personality sample. A prospective study is required to investigate cyclothymic temperament in youth as a predictor of later borderline personality. Applying the third model in clinical practice, it can be proposed that all borderline patients need psychotherapy even though they have bipolar or cyclothymia comorbidity, because borderline personality in this situation is seen not as a symptom of the affective spectrum, but it is its psychological complication that needs a distinct approach. On the other hand, the bipolar or cyclothymic comorbidity of borderline personality requires separate biological treatment as it might have some predisposing or even perpetuating effects on the borderline personality. N. Khalili Department of Psychiatry, Shahid Beheshti Hospital, Kerman University of Medical Sciences, Kerman, Iran E-mail: [email protected]
References 1. Perugi G, Fornaro M, Akiskal HS. Are atypical depression, borderline personality disorder and bipolar II disorder overlapping manifestations of a common cyclothymic diathesis? World Psychiatry 2011;10:45–51. 2. Barroilhet S, V€ ohringer PA, Ghaemi SN. Borderline versus Bipolar: difference matter. Acta Psychiatr Scand 2013;128: 385–386. 3. Paris J, Gunderson J, Weinberg I. The interface between borderline personality disorder and bipolar spectrum disorders. Compr Psychiatry 2007;48:145–154. 4. Bradley R, Westen D. The psychodynamics of borderline personality disorder: a view from developmental psychopathology. Dev Psychopathol 2005;17:927–957.
Letters to the editor 5. Maremmani I, Akiskal HS, Signoretta S, Liguori A, Perugi G, Cloninger R. The relationship of Kraepelian affective temperaments (as measured by TEMPS-I) to the tridimensional
DOI: 10.1111/acps.12299 Reply With thanks to my colleagues for their insightful comments, I would suggest that the interpretation presented assumes the scientific validity of the DSM-5 (and prior) criteria for borderline personality. Elsewhere (1), I have presented my rationale for the present claim; here, I can only present my conclusions and refer readers there for my premises and evidence. Borderline personality evolved as a clinical picture that referred to women (mostly) who had experienced childhood (mostly) sexual abuse, and who tended to engage in repetitive self-injury (usually cutting), had dissociative experiences (including somatic symptoms in the past, such as paralysis), and had very complex emotional experiences with their psychotherapists (usually characterized by notable anger and even rage, even on the part of the clinician, referred to as countertransference hate). This summary picture of borderline personality has reasonably strong historical and scientific support (1). But with DSM definitions, the sexual abuse etiology was excluded, the experiences of the clinician were ignored, and self-injury and dissociative experiences are listed as only two of nine criteria, five of which are sufficient to make the diagnosis. In other words, in the extremely broad DSM-based definition, borderline personality can be diagnosed in any person
personality questionnaire 2005;85:17–27.
(TPQ).
J
Affect
Disord
who is moody and has unstable interpersonal relationships, without any sexual abuse or self-harm or dissociative symptoms. Of course, this definition is so broad that it includes many persons with bipolar and unipolar mood illnesses. I think DSM-based borderline personality disorder does not do justice to the scientific and clinical evidence about that clinical picture. If I am correct, then there would be no need to hypothesize different biological versus psychological pathways to explain the ‘comorbidity’ of a more or less validly described condition (cyclothymia) and a more or less invalidly described condition (DSM-defined borderline personality). S. N. Ghaemi Department of Psychiatry, Tufts Medical Center, Boston, MA, USA E-mail: [email protected]
Reference 1. Ghaemi SN, Dalley S, Catania C, Barroilhet S. Bipolar or borderline: a clinical overview. Acta Psychiatr Scand 2014; 130:25–29.
159
Letters to the editor
A biopsychosocial approach to bipolar-borderline debate: psychological effect of a biological temperament DOI: 10.1111/acps.12298 Akiskal was the first to suggest borderline personality as an Axis I disorder within the bipolar affective spectrum about two decades ago. His idea has been derived mostly from the similarities of affective instability, inappropriate anger, impulsivity, and unstable relationship proposed as some borderline criteria with what is seen in bipolar II disorder. Four lines of evidence can be considered as supports for Akiskal’s theory. First, cyclothymic temperament has been found to be highly sensitive (88%) in identifying bipolar II disorder and has been the most common affective temperament among patients with this disorder. Second, there has been a high comorbidity between borderline personality and bipolar (particularly the broad definition of bipolarity). Third, there has been strong association between atypical depression and bipolarity (i.e. in one study 72% of atypical depressives met criteria of bipolar spectrum) and atypicality of depression has been assumed to be related to an affective temperamental dysregulation. Fourth, cyclothymic temperament has been associated with borderline personality among 107 atypical depressives (P = 0.001). Hence, Akiskal has explained all these findings as support for the conclusion that atypical depression, borderline personality, cyclothymia, and bipolar II disorder represent overlapping manifestations of cyclothymic temperament as a common underlying diathesis (1). On the other hand, emphasizing more on the differences than similarities, Ghaemi has stated that these two disorders are different. He has argued that the assumed ‘core’ presentations of mood lability and impulsivity are not pivotal to either illness (2). In contrast to bipolar disorder, affective instability in borderline personality is not episodic and includes mostly shifts from euthymia to anger and rarely from depression to elation (3). Furthermore, the greater importance of genetic vulnerability in the etiology of bipolar disorder than that of borderline personality, the four borderline features that are not predictive of bipolarity (abandonment, identity disturbance, recurrent suicidal or self-mutilating behavior, and dissociative symptoms), and the importance of psychoanalytic theories in the development of borderline personality as a psychological structure are the main differences on which Ghaemi’s opinion has been based (2). It seems that these two opinions are not necessarily contradictory. Having the same diathesis needs neither the similarity of the two disorders nor the overlapping within one spectrum. A third model can be proposed in which the psychoanalytic effect of cyclothymic temperament on the development of borderline personality might be noteworthy. As proposed by Kernberg, borderline personality evolves from the failure to integrate representations of good and bad aspects of self and others. From this view-point, a cyclothymic child might be assumed as developing two completely opposite representations of self and others – depending on high and low levels of mood – that cannot be integrated. Furthermore, a prolonged emotional dysregulation, which can be aggravated by cyclothymic temperament, might render self-soothing capacity
158
impaired. Without developing the capacity for self-soothing, borderline patients may have to depend on the actual presence of an object to manage and tolerate their intense emotions (4). Therefore, in the proposed third model, cyclothymic temperament through the biological pathway can lead to bipolar II disorder, and through the psychological pathway might contribute to borderline personality. On the other hand, some studies have found associations between temperamental profile of borderline personality (high novelty seeking and high harm avoidance) and cyclothymic temperament (5). This might indicate that people with cyclothymic temperament are biologically vulnerable to borderline personality as well. Affective temperaments as individual differences in emotional reactivity and regulation are expected to be evident from early childhood. The available data on cyclothymic disorder or temperament in youth are limited. However, a study by Goldberg showed that early onset bipolar disorder increases the probability of borderline personality disorder (3). One study of cyclothymia patients found 62% with borderline personality (3). A future direction of research will be the association of cyclothymic temperament and bipolar II disorder in borderline personality sample. A prospective study is required to investigate cyclothymic temperament in youth as a predictor of later borderline personality. Applying the third model in clinical practice, it can be proposed that all borderline patients need psychotherapy even though they have bipolar or cyclothymia comorbidity, because borderline personality in this situation is seen not as a symptom of the affective spectrum, but it is its psychological complication that needs a distinct approach. On the other hand, the bipolar or cyclothymic comorbidity of borderline personality requires separate biological treatment as it might have some predisposing or even perpetuating effects on the borderline personality. N. Khalili Department of Psychiatry, Shahid Beheshti Hospital, Kerman University of Medical Sciences, Kerman, Iran E-mail: [email protected]
References 1. Perugi G, Fornaro M, Akiskal HS. Are atypical depression, borderline personality disorder and bipolar II disorder overlapping manifestations of a common cyclothymic diathesis? World Psychiatry 2011;10:45–51. 2. Barroilhet S, V€ ohringer PA, Ghaemi SN. Borderline versus Bipolar: difference matter. Acta Psychiatr Scand 2013;128: 385–386. 3. Paris J, Gunderson J, Weinberg I. The interface between borderline personality disorder and bipolar spectrum disorders. Compr Psychiatry 2007;48:145–154. 4. Bradley R, Westen D. The psychodynamics of borderline personality disorder: a view from developmental psychopathology. Dev Psychopathol 2005;17:927–957.
Letters to the editor 5. Maremmani I, Akiskal HS, Signoretta S, Liguori A, Perugi G, Cloninger R. The relationship of Kraepelian affective temperaments (as measured by TEMPS-I) to the tridimensional
DOI: 10.1111/acps.12299 Reply With thanks to my colleagues for their insightful comments, I would suggest that the interpretation presented assumes the scientific validity of the DSM-5 (and prior) criteria for borderline personality. Elsewhere (1), I have presented my rationale for the present claim; here, I can only present my conclusions and refer readers there for my premises and evidence. Borderline personality evolved as a clinical picture that referred to women (mostly) who had experienced childhood (mostly) sexual abuse, and who tended to engage in repetitive self-injury (usually cutting), had dissociative experiences (including somatic symptoms in the past, such as paralysis), and had very complex emotional experiences with their psychotherapists (usually characterized by notable anger and even rage, even on the part of the clinician, referred to as countertransference hate). This summary picture of borderline personality has reasonably strong historical and scientific support (1). But with DSM definitions, the sexual abuse etiology was excluded, the experiences of the clinician were ignored, and self-injury and dissociative experiences are listed as only two of nine criteria, five of which are sufficient to make the diagnosis. In other words, in the extremely broad DSM-based definition, borderline personality can be diagnosed in any person
personality questionnaire 2005;85:17–27.
(TPQ).
J
Affect
Disord
who is moody and has unstable interpersonal relationships, without any sexual abuse or self-harm or dissociative symptoms. Of course, this definition is so broad that it includes many persons with bipolar and unipolar mood illnesses. I think DSM-based borderline personality disorder does not do justice to the scientific and clinical evidence about that clinical picture. If I am correct, then there would be no need to hypothesize different biological versus psychological pathways to explain the ‘comorbidity’ of a more or less validly described condition (cyclothymia) and a more or less invalidly described condition (DSM-defined borderline personality). S. N. Ghaemi Department of Psychiatry, Tufts Medical Center, Boston, MA, USA E-mail: [email protected]
Reference 1. Ghaemi SN, Dalley S, Catania C, Barroilhet S. Bipolar or borderline: a clinical overview. Acta Psychiatr Scand 2014; 130:25–29.
159
