COMMENTARY
Borderline Personality Disorder A Disorder in Search of Advocacy Mark Zimmerman, MD Abstract: Compared with bipolar disorder, borderline personality disorder (BPD) is as frequent (if not more frequent), as impairing (if not more impairing), and as lethal (if not more lethal). Yet, BPD has received less than one-tenth the funding from the National Institutes of Health than has bipolar disorder. More than other reviewers of the literature on the interface between bipolar disorder and BPD, Paris and Black (Paris J and Black DW (2015) Borderline Personality Disorder and Bipolar Disorder: What is the Difference and Why Does it Matter? J Nerv Ment Dis 203:3–7) emphasize the clinical importance of correctly diagnosing BPD and not overdiagnosing bipolar disorder, with a focus on the clinical feature of affective instability and how the failure to recognize the distinction between sustained and transient mood perturbations can result in misdiagnosing patients with BPD as having bipolar disorder. The review by Paris and Black, then, is more of an advocacy for BPD than other reviews in this area have been. In the present article, the author will illustrate how the bipolar disorder research community has done a superior job of advocating for and “marketing” their disorder compared with researchers of BPD. Specifically, researchers of bipolar disorder have conducted multiple studies highlighting the problem with underdiagnosis, written commentaries about the problem with underdiagnosis, developed and promoted several screening scales to improve diagnostic recognition, published numerous studies of the operating characteristics of these screening measures, attempted to broaden the definition of bipolar disorder by advancing the concept of the bipolar spectrum, and repeatedly demonstrated the economic costs and public health significance of bipolar disorder. In contrast, researchers of BPD have almost completely ignored each of these issues and thus have been less successful in highlighting the public health significance of the disorder. Key Words: Borderline personality disorder, bipolar disorder, NIH funding, disorder advocacy (J Nerv Ment Dis 2015;203: 8–12)
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uring the past 30 years, prominent researchers of bipolar disorder have promoted an expanded concept of bipolar disorder, the so-called bipolar spectrum, and their efforts have been buffeted by the pharmaceutical industry, which has not only supported pro-bipolar disorder continuing medical education activities but also funded large-scale research studies to advance the recognition of bipolar disorder as a significant public health issue. To be sure, bipolar disorder is a public health problem, causing significant psychosocial morbidity and mortality (Baldessarini et al., 2006; Judd et al., 2008; McIntyre et al., 2008; Miklowitz, 2011; Morgan et al., 2005; Zimmerman et al., 2010). Bipolar disorder is also associated with disproportionately high healthcare costs (Dilsaver, 2011; Kleine-Budde et al., 2013). Increased efforts and research funding to develop new, more effective, treatments for bipolar disorder are welcome and to be embraced. However, in attempting to advance the cause of their disorder, the bipolar disorder advocates have attempted to usurp other forms of psychopathology under the bipolar umbrella. Suggestions have been made to include treatment-resistant depression, depression with a family history of bipolar disorder, and borderline personality disorder (BPD) in the bipolar spectrum (Akiskal and Pinto, 1999; Dudek et al., 2010; Kiejna et al., 2010). The article by Paris and Black (2015) addresses the last of these. Paris and Black (2015) counter the suggestion that BPD is largely a variant of bipolar disorder (Akiskal, 2004; Mackinnon and Pies, 2006; Smith et al., 2004). Instead, Paris and Black (2015) assert that both disorders are valid diagnostic entities and their distinction has clinical relevance because the recommended treatments are different. They review some of the literature supporting the validity of the distinction. Paris and Black are not the first to review the bipolar-BPD literature. The relationship between bipolar disorder and BPD has been the subject of intense interest with at least a dozen review articles examining and discussing their interface (Antoniadis et al., 2012; Barroilhet et al., 2013; Bayes et al., 2014; Belli et al., 2012; Coulston et al., 2012; Dolan-Sewell et al., 2001; Elisei et al., 2012; Fiedorowicz and Black, 2010; Ghaemi et al., 2014; Paris, 2004; Smith et al., 2004; Sripada and Silk, 2007). Nor are Paris and Black the only researchers supporting the validity of the distinction. Two recent reviews by Department of Psychiatry and Human Behavior, Brown Medical School; and Department of Psychiatry, Rhode Island Hospital, Providence. Send reprint requests to Mark Zimmerman, MD, 146 West River Street, Providence, RI 02904. E-mail: [email protected]. Copyright © 2015 by Lippincott Williams & Wilkins ISSN: 0022-3018/15/20301–0008 DOI: 10.1097/NMD.0000000000000226
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The Journal of Nervous and Mental Disease • Volume 203, Number 1, January 2015
eminent researchers of bipolar disorder have reached the same conclusion (Bayes et al., 2014; Ghaemi et al., 2014). With so many reviews of the bipolar-BPD distinction, why the need for another? More than other reviewers of the literature, Paris and Black (2015) emphasize the clinical importance of making the correct diagnosis, as reflected by the title of their article. In addition, they focus on the clinical feature of affective instability and how the failure to recognize the difference between sustained and transient mood perturbations can result in misdiagnosis. That is, more than other reviewers, they highlight concerns with the misdiagnosis of BPD as bipolar disorder. The review by Paris and Black (2015), then, is more of an advocacy for BPD than other reviews have been. The aforementioned morbidity and mortality due to bipolar disorder are matched by a similar literature focused on BPD (Ansell et al., 2007; Jeung and Herpertz, 2014; Pompili et al., 2005; Zanarini et al., 2009). However, these are independent literatures, and it is difficult to evaluate the relative morbidity of each disorder in the absence of direct comparisons. It is noteworthy that Paris and Black did not cite a single head-to-head comparison of the level of functional impairment attributable to the two disorders. The only study to directly compare psychosocial functioning in depressed patients with bipolar disorder and BPD is from our clinical research laboratory as part of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project (Zimmerman, 2003). We found that depressed patients with BPD less frequently graduated college, were diagnosed with more comorbid disorders, more frequently had a history of substance use disorders, reported more suicidal ideation at the time of the evaluation, more frequently had attempted suicide, reported poorer social functioning, and were rated lower on the Global Assessment of Functioning (Zimmerman et al., 2013). There was no difference between the groups in the number of psychiatric hospitalizations and time missed from work due to psychiatric illness. Although it is obvious to researchers of BPD and clinicians who treat patients with BPD that these patients accrue high healthcare costs and significant psychosocial morbidity (as great as that of bipolar disorder) and therefore represent a significant public health concern, research on BPD has received much less funding from the National Institutes of Health (NIH) than has bipolar disorder. A search of the NIH Research Portfolio Online Portfolio Reporting Tool for the past 25 years reveals that, for every year since 1990, more grants were funded for bipolar disorder than BPD (Zimmerman and Gazarian, in press). Summed across all 25 years, the level of funding for bipolar disorder was more than 10 times greater than the level of funding for BPD ($622 vs. $55 million). Why has the level of NIH research funding for BPD not been commensurate with the level of psychosocial morbidity, mortality, and health expenditures associated with the disorder? The author would suggest that one factor resulting in the disparity in research funding is that the bipolar disorder research community has done a superior job of “marketing” their disorder.
HOW TO PROMOTE A DIAGNOSIS Highlight Problems With Underdiagnosis An effective disorder-promotion strategy is to repeatedly claim that the disorder is being underdiagnosed and underrecognized. Multiple studies have been conducted with the goal of demonstrating that bipolar disorder is underrecognized and underdiagnosed in depressed patients (Angst et al., 2011; Benazzi and Akiskal, 2001; Ghaemi et al., 1999, 2000; Hantouche et al., 1998; Nasr et al., 2005). Complementing this empirical literature are the commentaries and review articles exhorting clinicians to improve their recognition of bipolar disorder (Bowden, 2001; Dunner, 2003; Hirschfeld, 2001, 2013; Hirschfeld and Vornik, 2004; Katzow et al., 2003; Yatham, 2005). Close examination of the footnotes of these articles reveals that many received support provided by the pharmaceutical industry. © 2015 Lippincott Williams & Wilkins
Commentary
There is no industry support to write commentaries about the underdiagnosis of BPD. It is therefore not surprising that a PubMed search did not identify a single article when the search terms included “recognition,” “underrecognition,” “underdiagnosis,” and “borderline personality.” The only study examining the underdiagnosis of BPD was published by our group as part of the MIDAS project more than 15 years ago (Zimmerman and Mattia, 1999). However, we were not good disorder marketers, and in contrast to researchers of bipolar disorder, we did not include terms such as underrecognition or underdiagnosis in the title of the article. We therefore failed to recognize and highlight the possible disorder-promotion possibilities of the research. Fifteen years ago, the author did not think in those terms.
Develop and Promote Screening Tools If a disorder is underdiagnosed and underdetected, the next logical step is to develop easy-to-use methods to improve diagnostic practice. The bipolar disorder research community has embraced the use of self-administered screening questionnaires. More than a half-dozen such scales have been developed (Angst and Cassano, 2005; Bowden et al., 2007; Depue et al., 1989; Hirschfeld et al., 2000; Parker et al., 2008, 2012; Phelps and Ghaemi, 2006), and articles calling for improved recognition have recommended their use (Angst et al., 2005; Dunner, 2003; Hirschfeld and Vornik, 2004). In fact, recent review articles of bipolar disorder by prominent researchers in prestigious medical journals such as the New England Journal of Medicine and the British Medical Journal have advocated the use of these measures (Anderson et al., 2012; Frye, 2011). These recommendations have come without a single study examining the overall impact of the use of a self-administered screening scale for bipolar disorder on short- or long-term outcome. How many patients whose bipolar disorder had been missed would have their bipolar disorder detected by a screening scale, correctly diagnosed, and therefore appropriately treated? As important, how many patients who were false positives on the screening questionnaire would be overdiagnosed with bipolar disorder and therefore experience side effects from an unwarranted medication? Although many studies have examined the performance of these screening scales and experts recommend their use, the bipolar disorder advocates seem unconcerned with false positive results on these screening measures and the potential for overdiagnosis. Advocates do not usually provide a balanced discussion of the benefits and risks associated with screening. A significant problem with the bipolar disorder screening scale literature is that many researchers have used screening instruments as case-finding measures and discussed the results as if they pertain to bipolar disorder proper (Zimmerman, 2012a). The scientific merit of these studies is limited; however, these articles effectively reinforce the notion that bipolar disorder is prevalent, underrecognized, undertreated, and associated with psychosocial morbidity. These publications effectively “promote” the notion that missing the diagnosis of bipolar disorder is to be avoided at all costs. In contrast to the robust literature on screening for bipolar disorder, there is little work in the area of screening for BPD. To their credit (or to their public relations detriment), researchers of BPD have not filled the journal pages with these types of studies that do not advance the scientific enterprise but that might promote their disorder.
Expand the Construct Controversy exists regarding the diagnostic boundary for bipolar disorder. Critics of the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition criteria accurately note that the required minimum number of features and minimum duration used to define a manic or hypomanic episode were arbitrarily chosen and not based on empirical study and are not sufficiently inclusive (Akiskal et al., 2000; Angst, 2007). Bipolar disorder advocates have recommended lowering www.jonmd.com
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the symptom count and duration thresholds (Akiskal et al., 2000; Angst, 2007; Angst et al., 2005; Angst and Gamma, 2002; Dunner, 2003; Moller and Curtis, 2004; Phelps et al., 2008). In support of this recommendation, both clinical and general population epidemiological studies have found that individuals with “subthreshold” levels of bipolar pathology (i.e., fewer than the DSM required number of symptoms or briefer than the DSM required number of days) differed from depressed subjects without subthreshold levels of bipolar symptoms in comorbidity, personality, family history, and longitudinal course (Angst et al., 2010, 2003; Joyce et al., 2007; Zimmermann et al., 2009). As with screening, there are possible risks and benefits to consider in expanding the diagnostic boundary for bipolar disorder. Both false-positive and false-negative diagnoses are associated with potential negative consequences. Unrecognized and underdiagnosed bipolar disorder (i.e., false negatives) is a serious concern because it is associated with the underprescription of mood-stabilizing medications, an increased risk for rapid cycling, and increased costs of care (Birnbaum et al., 2003; Ghaemi et al., 2000; Matza et al., 2005). However, bipolar disorder overdiagnoses (i.e., false positives) should be as great a concern as it is associated with overtreatment with unneeded medications and consequent exposure to possible side effects and medical risk as well as the failure to offer more appropriate treatments. The bipolar disorder advocates who promote the expansion of the bipolar spectrum do not consider and discuss the problem with both false-positive and false-negative diagnoses; they do not suggest that, in trying to decide where to set the diagnostic threshold, the goal should be to minimize diagnostic errors of all types (and not only false-negative diagnoses); and they do not consider whether one type of diagnostic error is likely to be more long lasting and difficult to undo than another. Elsewhere, the author has elaborated upon the risks and benefits to be considered in changing the diagnostic threshold for bipolar disorder (Zimmerman, 2012b). The bipolar disorder advocates only discuss the problems with underdiagnosis. Whereas there is a robust literature on the bipolar spectrum, curiously, there has been no suggestion of a BPD spectrum. Should BPD symptomatology that is not as severe as that manifested by individuals who meet diagnostic criteria for BPD be included on the BPD spectrum? Clinically, the recognition of the BPD spectrum is reflected by the notation in patients' charts of “borderline traits.” However, no studies have examined whether the correlates of subthreshold levels of BPD pathology are similar to the correlates of BPD. (A study by our group in which we compared patients with 0 and 1 BPD criterion could be considered an examination of the BPD spectrum (Zimmerman et al., 2012); however, the goal of this study was to challenge the potential adoption in DSM-5 of dimensional ratings of personality pathology. The Discussion section of the article did not consider the concept of a BPD spectrum. Thus, we again failed to recognize the disorderpromoting possibilities of our data). Rather, when discussing subthreshold pathology, BPD researchers use a different language than bipolar disorder researchers, and instead of talking about a spectrum, they refer to personality dimensions. There is no difference between the spectrum and dimensional conceptualizations, but from a “disorder promotion” perspective, it is more useful to adopt the spectrum terminology because one can then discuss prevalence rates. Bipolar disorder researchers, when discussing milder and subthreshold forms of bipolar disorder, have retained a categorical perspective, and this has allowed them to suggest that the prevalence of bipolar disorder is greater than had been previously suggested. Discussions of dimensions do not lend themselves as well to prevalence estimate discussions.
Highlight its Economic Cost to Society The direct and indirect costs of bipolar disorder are considerable. Bipolar disorder results in high healthcare costs and lost productivity. The economic costs due to bipolar disorder have been the focus of 10
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numerous studies. A recent review article identified 22 studies of the economic cost of bipolar disorder published between 2000 and 2012 (Kleine-Budde et al., 2013). Only one study has examined the economic costs of BPD, and this was done in the Netherlands (van Asselt et al., 2007). No study has examined the economic costs of BPD in the United States, in contrast to the 15 studies that have examined the cost of bipolar disorder (Kleine-Budde et al., 2013). Because of the extensive literature on the economic costs of bipolar disorder, its public health significance is well recognized and accepted. A comparable literature does not exist for BPD. Perhaps, because of this, bipolar disorder was included in the Burden of Disease study (Murray et al., 2012), whereas BPD was not.
CONCLUSIONS Compared with bipolar disorder, BPD is as frequent (if not more frequent), as impairing (if not more impairing), and as lethal (if not more lethal). Both disorders are significant public health problems. Yet, BPD has received much less funding from the NIH. The author would argue that this disparity in funding is, in part, due to the superior job bipolar disorder researchers have done in “marketing” their disorder than BPD researchers. This is not a criticism of bipolar disorder researchers. At the risk for being repetitive, the author will assert again that bipolar disorder is a significant public health problem that warrants the attention (and funding) that it receives. However, because funding resources are finite, disorders need advocates. Paris and Black (2015) provide an overview of the importance of distinguishing between bipolar disorder and borderline personality and the corollary, the risk for misdiagnosing BPD as bipolar disorder. Although other authors have tackled this topic, so many more researchers have promoted bipolar disorder and the bipolar spectrum construct that Paris and Black's review is important because it provides some counterweight to the bipolar spectrum public relations effort in the literature. DISCLOSURE The author declares no conflict of interest. REFERENCES Akiskal H, Bourgeois M, Angst J, Post R, Moller H, Hirschfeld R (2000) Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders. J Affect Disord. 59:S5–S30. Akiskal H, Pinto O (1999) The evolving bipolar spectrum. Prototypes I, II, and IV. Psychiatr Clin North Am. 22:517–534. Akiskal HS (2004) Demystifying borderline personality: Critique of the concept and unorthodox reflections on its natural kinship with the bipolar spectrum. Acta Psychiatr Scand. 110:401–407. Anderson IM, Haddad PM, Scott J (2012) Bipolar disorder. BMJ. 345:e8508. Angst J (2007) The bipolar spectrum. Br J Psychiatry. 190:189–191. Angst J, Adolfsson R, Benazzi F, Gamma A, Hantouche E, Meyer TD, Skeppar P, Vieta E, Scott J (2005) The HCL-32: Towards a self-assessment tool for hypomanic symptoms in outpatients. J Affect Disord. 88:217–233. Angst J, Azorin JM, Bowden CL, Perugi G, Vieta E, Gamma A, Young AH (2011) Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode: The BRIDGE Study. Arch Gen Psychiatry. 68:791–798. Angst J, Cassano G (2005) The mood spectrum: Improving the diagnosis of bipolar disorder. Bipolar Disord. 7:4–12. Angst J, Cui L, Swendsen J, Rothen S, Cravchik A, Kessler RC, Merikangas KR (2010) Major depressive disorder with subthreshold bipolarity in the National Comorbidity Survey Replication. Am J Psychiatry. 167:1194–1201. Angst J, Gamma A (2002) Prevalence of bipolar disorders: Traditional and novel approaches. Clin Appr Bipol Disord. 1:10–14.
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Borderline Personality Disorder A Disorder in Search of Advocacy Mark Zimmerman, MD Abstract: Compared with bipolar disorder, borderline personality disorder (BPD) is as frequent (if not more frequent), as impairing (if not more impairing), and as lethal (if not more lethal). Yet, BPD has received less than one-tenth the funding from the National Institutes of Health than has bipolar disorder. More than other reviewers of the literature on the interface between bipolar disorder and BPD, Paris and Black (Paris J and Black DW (2015) Borderline Personality Disorder and Bipolar Disorder: What is the Difference and Why Does it Matter? J Nerv Ment Dis 203:3–7) emphasize the clinical importance of correctly diagnosing BPD and not overdiagnosing bipolar disorder, with a focus on the clinical feature of affective instability and how the failure to recognize the distinction between sustained and transient mood perturbations can result in misdiagnosing patients with BPD as having bipolar disorder. The review by Paris and Black, then, is more of an advocacy for BPD than other reviews in this area have been. In the present article, the author will illustrate how the bipolar disorder research community has done a superior job of advocating for and “marketing” their disorder compared with researchers of BPD. Specifically, researchers of bipolar disorder have conducted multiple studies highlighting the problem with underdiagnosis, written commentaries about the problem with underdiagnosis, developed and promoted several screening scales to improve diagnostic recognition, published numerous studies of the operating characteristics of these screening measures, attempted to broaden the definition of bipolar disorder by advancing the concept of the bipolar spectrum, and repeatedly demonstrated the economic costs and public health significance of bipolar disorder. In contrast, researchers of BPD have almost completely ignored each of these issues and thus have been less successful in highlighting the public health significance of the disorder. Key Words: Borderline personality disorder, bipolar disorder, NIH funding, disorder advocacy (J Nerv Ment Dis 2015;203: 8–12)
D
uring the past 30 years, prominent researchers of bipolar disorder have promoted an expanded concept of bipolar disorder, the so-called bipolar spectrum, and their efforts have been buffeted by the pharmaceutical industry, which has not only supported pro-bipolar disorder continuing medical education activities but also funded large-scale research studies to advance the recognition of bipolar disorder as a significant public health issue. To be sure, bipolar disorder is a public health problem, causing significant psychosocial morbidity and mortality (Baldessarini et al., 2006; Judd et al., 2008; McIntyre et al., 2008; Miklowitz, 2011; Morgan et al., 2005; Zimmerman et al., 2010). Bipolar disorder is also associated with disproportionately high healthcare costs (Dilsaver, 2011; Kleine-Budde et al., 2013). Increased efforts and research funding to develop new, more effective, treatments for bipolar disorder are welcome and to be embraced. However, in attempting to advance the cause of their disorder, the bipolar disorder advocates have attempted to usurp other forms of psychopathology under the bipolar umbrella. Suggestions have been made to include treatment-resistant depression, depression with a family history of bipolar disorder, and borderline personality disorder (BPD) in the bipolar spectrum (Akiskal and Pinto, 1999; Dudek et al., 2010; Kiejna et al., 2010). The article by Paris and Black (2015) addresses the last of these. Paris and Black (2015) counter the suggestion that BPD is largely a variant of bipolar disorder (Akiskal, 2004; Mackinnon and Pies, 2006; Smith et al., 2004). Instead, Paris and Black (2015) assert that both disorders are valid diagnostic entities and their distinction has clinical relevance because the recommended treatments are different. They review some of the literature supporting the validity of the distinction. Paris and Black are not the first to review the bipolar-BPD literature. The relationship between bipolar disorder and BPD has been the subject of intense interest with at least a dozen review articles examining and discussing their interface (Antoniadis et al., 2012; Barroilhet et al., 2013; Bayes et al., 2014; Belli et al., 2012; Coulston et al., 2012; Dolan-Sewell et al., 2001; Elisei et al., 2012; Fiedorowicz and Black, 2010; Ghaemi et al., 2014; Paris, 2004; Smith et al., 2004; Sripada and Silk, 2007). Nor are Paris and Black the only researchers supporting the validity of the distinction. Two recent reviews by Department of Psychiatry and Human Behavior, Brown Medical School; and Department of Psychiatry, Rhode Island Hospital, Providence. Send reprint requests to Mark Zimmerman, MD, 146 West River Street, Providence, RI 02904. E-mail: [email protected]. Copyright © 2015 by Lippincott Williams & Wilkins ISSN: 0022-3018/15/20301–0008 DOI: 10.1097/NMD.0000000000000226
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The Journal of Nervous and Mental Disease • Volume 203, Number 1, January 2015
eminent researchers of bipolar disorder have reached the same conclusion (Bayes et al., 2014; Ghaemi et al., 2014). With so many reviews of the bipolar-BPD distinction, why the need for another? More than other reviewers of the literature, Paris and Black (2015) emphasize the clinical importance of making the correct diagnosis, as reflected by the title of their article. In addition, they focus on the clinical feature of affective instability and how the failure to recognize the difference between sustained and transient mood perturbations can result in misdiagnosis. That is, more than other reviewers, they highlight concerns with the misdiagnosis of BPD as bipolar disorder. The review by Paris and Black (2015), then, is more of an advocacy for BPD than other reviews have been. The aforementioned morbidity and mortality due to bipolar disorder are matched by a similar literature focused on BPD (Ansell et al., 2007; Jeung and Herpertz, 2014; Pompili et al., 2005; Zanarini et al., 2009). However, these are independent literatures, and it is difficult to evaluate the relative morbidity of each disorder in the absence of direct comparisons. It is noteworthy that Paris and Black did not cite a single head-to-head comparison of the level of functional impairment attributable to the two disorders. The only study to directly compare psychosocial functioning in depressed patients with bipolar disorder and BPD is from our clinical research laboratory as part of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project (Zimmerman, 2003). We found that depressed patients with BPD less frequently graduated college, were diagnosed with more comorbid disorders, more frequently had a history of substance use disorders, reported more suicidal ideation at the time of the evaluation, more frequently had attempted suicide, reported poorer social functioning, and were rated lower on the Global Assessment of Functioning (Zimmerman et al., 2013). There was no difference between the groups in the number of psychiatric hospitalizations and time missed from work due to psychiatric illness. Although it is obvious to researchers of BPD and clinicians who treat patients with BPD that these patients accrue high healthcare costs and significant psychosocial morbidity (as great as that of bipolar disorder) and therefore represent a significant public health concern, research on BPD has received much less funding from the National Institutes of Health (NIH) than has bipolar disorder. A search of the NIH Research Portfolio Online Portfolio Reporting Tool for the past 25 years reveals that, for every year since 1990, more grants were funded for bipolar disorder than BPD (Zimmerman and Gazarian, in press). Summed across all 25 years, the level of funding for bipolar disorder was more than 10 times greater than the level of funding for BPD ($622 vs. $55 million). Why has the level of NIH research funding for BPD not been commensurate with the level of psychosocial morbidity, mortality, and health expenditures associated with the disorder? The author would suggest that one factor resulting in the disparity in research funding is that the bipolar disorder research community has done a superior job of “marketing” their disorder.
HOW TO PROMOTE A DIAGNOSIS Highlight Problems With Underdiagnosis An effective disorder-promotion strategy is to repeatedly claim that the disorder is being underdiagnosed and underrecognized. Multiple studies have been conducted with the goal of demonstrating that bipolar disorder is underrecognized and underdiagnosed in depressed patients (Angst et al., 2011; Benazzi and Akiskal, 2001; Ghaemi et al., 1999, 2000; Hantouche et al., 1998; Nasr et al., 2005). Complementing this empirical literature are the commentaries and review articles exhorting clinicians to improve their recognition of bipolar disorder (Bowden, 2001; Dunner, 2003; Hirschfeld, 2001, 2013; Hirschfeld and Vornik, 2004; Katzow et al., 2003; Yatham, 2005). Close examination of the footnotes of these articles reveals that many received support provided by the pharmaceutical industry. © 2015 Lippincott Williams & Wilkins
Commentary
There is no industry support to write commentaries about the underdiagnosis of BPD. It is therefore not surprising that a PubMed search did not identify a single article when the search terms included “recognition,” “underrecognition,” “underdiagnosis,” and “borderline personality.” The only study examining the underdiagnosis of BPD was published by our group as part of the MIDAS project more than 15 years ago (Zimmerman and Mattia, 1999). However, we were not good disorder marketers, and in contrast to researchers of bipolar disorder, we did not include terms such as underrecognition or underdiagnosis in the title of the article. We therefore failed to recognize and highlight the possible disorder-promotion possibilities of the research. Fifteen years ago, the author did not think in those terms.
Develop and Promote Screening Tools If a disorder is underdiagnosed and underdetected, the next logical step is to develop easy-to-use methods to improve diagnostic practice. The bipolar disorder research community has embraced the use of self-administered screening questionnaires. More than a half-dozen such scales have been developed (Angst and Cassano, 2005; Bowden et al., 2007; Depue et al., 1989; Hirschfeld et al., 2000; Parker et al., 2008, 2012; Phelps and Ghaemi, 2006), and articles calling for improved recognition have recommended their use (Angst et al., 2005; Dunner, 2003; Hirschfeld and Vornik, 2004). In fact, recent review articles of bipolar disorder by prominent researchers in prestigious medical journals such as the New England Journal of Medicine and the British Medical Journal have advocated the use of these measures (Anderson et al., 2012; Frye, 2011). These recommendations have come without a single study examining the overall impact of the use of a self-administered screening scale for bipolar disorder on short- or long-term outcome. How many patients whose bipolar disorder had been missed would have their bipolar disorder detected by a screening scale, correctly diagnosed, and therefore appropriately treated? As important, how many patients who were false positives on the screening questionnaire would be overdiagnosed with bipolar disorder and therefore experience side effects from an unwarranted medication? Although many studies have examined the performance of these screening scales and experts recommend their use, the bipolar disorder advocates seem unconcerned with false positive results on these screening measures and the potential for overdiagnosis. Advocates do not usually provide a balanced discussion of the benefits and risks associated with screening. A significant problem with the bipolar disorder screening scale literature is that many researchers have used screening instruments as case-finding measures and discussed the results as if they pertain to bipolar disorder proper (Zimmerman, 2012a). The scientific merit of these studies is limited; however, these articles effectively reinforce the notion that bipolar disorder is prevalent, underrecognized, undertreated, and associated with psychosocial morbidity. These publications effectively “promote” the notion that missing the diagnosis of bipolar disorder is to be avoided at all costs. In contrast to the robust literature on screening for bipolar disorder, there is little work in the area of screening for BPD. To their credit (or to their public relations detriment), researchers of BPD have not filled the journal pages with these types of studies that do not advance the scientific enterprise but that might promote their disorder.
Expand the Construct Controversy exists regarding the diagnostic boundary for bipolar disorder. Critics of the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition criteria accurately note that the required minimum number of features and minimum duration used to define a manic or hypomanic episode were arbitrarily chosen and not based on empirical study and are not sufficiently inclusive (Akiskal et al., 2000; Angst, 2007). Bipolar disorder advocates have recommended lowering www.jonmd.com
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the symptom count and duration thresholds (Akiskal et al., 2000; Angst, 2007; Angst et al., 2005; Angst and Gamma, 2002; Dunner, 2003; Moller and Curtis, 2004; Phelps et al., 2008). In support of this recommendation, both clinical and general population epidemiological studies have found that individuals with “subthreshold” levels of bipolar pathology (i.e., fewer than the DSM required number of symptoms or briefer than the DSM required number of days) differed from depressed subjects without subthreshold levels of bipolar symptoms in comorbidity, personality, family history, and longitudinal course (Angst et al., 2010, 2003; Joyce et al., 2007; Zimmermann et al., 2009). As with screening, there are possible risks and benefits to consider in expanding the diagnostic boundary for bipolar disorder. Both false-positive and false-negative diagnoses are associated with potential negative consequences. Unrecognized and underdiagnosed bipolar disorder (i.e., false negatives) is a serious concern because it is associated with the underprescription of mood-stabilizing medications, an increased risk for rapid cycling, and increased costs of care (Birnbaum et al., 2003; Ghaemi et al., 2000; Matza et al., 2005). However, bipolar disorder overdiagnoses (i.e., false positives) should be as great a concern as it is associated with overtreatment with unneeded medications and consequent exposure to possible side effects and medical risk as well as the failure to offer more appropriate treatments. The bipolar disorder advocates who promote the expansion of the bipolar spectrum do not consider and discuss the problem with both false-positive and false-negative diagnoses; they do not suggest that, in trying to decide where to set the diagnostic threshold, the goal should be to minimize diagnostic errors of all types (and not only false-negative diagnoses); and they do not consider whether one type of diagnostic error is likely to be more long lasting and difficult to undo than another. Elsewhere, the author has elaborated upon the risks and benefits to be considered in changing the diagnostic threshold for bipolar disorder (Zimmerman, 2012b). The bipolar disorder advocates only discuss the problems with underdiagnosis. Whereas there is a robust literature on the bipolar spectrum, curiously, there has been no suggestion of a BPD spectrum. Should BPD symptomatology that is not as severe as that manifested by individuals who meet diagnostic criteria for BPD be included on the BPD spectrum? Clinically, the recognition of the BPD spectrum is reflected by the notation in patients' charts of “borderline traits.” However, no studies have examined whether the correlates of subthreshold levels of BPD pathology are similar to the correlates of BPD. (A study by our group in which we compared patients with 0 and 1 BPD criterion could be considered an examination of the BPD spectrum (Zimmerman et al., 2012); however, the goal of this study was to challenge the potential adoption in DSM-5 of dimensional ratings of personality pathology. The Discussion section of the article did not consider the concept of a BPD spectrum. Thus, we again failed to recognize the disorderpromoting possibilities of our data). Rather, when discussing subthreshold pathology, BPD researchers use a different language than bipolar disorder researchers, and instead of talking about a spectrum, they refer to personality dimensions. There is no difference between the spectrum and dimensional conceptualizations, but from a “disorder promotion” perspective, it is more useful to adopt the spectrum terminology because one can then discuss prevalence rates. Bipolar disorder researchers, when discussing milder and subthreshold forms of bipolar disorder, have retained a categorical perspective, and this has allowed them to suggest that the prevalence of bipolar disorder is greater than had been previously suggested. Discussions of dimensions do not lend themselves as well to prevalence estimate discussions.
Highlight its Economic Cost to Society The direct and indirect costs of bipolar disorder are considerable. Bipolar disorder results in high healthcare costs and lost productivity. The economic costs due to bipolar disorder have been the focus of 10
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numerous studies. A recent review article identified 22 studies of the economic cost of bipolar disorder published between 2000 and 2012 (Kleine-Budde et al., 2013). Only one study has examined the economic costs of BPD, and this was done in the Netherlands (van Asselt et al., 2007). No study has examined the economic costs of BPD in the United States, in contrast to the 15 studies that have examined the cost of bipolar disorder (Kleine-Budde et al., 2013). Because of the extensive literature on the economic costs of bipolar disorder, its public health significance is well recognized and accepted. A comparable literature does not exist for BPD. Perhaps, because of this, bipolar disorder was included in the Burden of Disease study (Murray et al., 2012), whereas BPD was not.
CONCLUSIONS Compared with bipolar disorder, BPD is as frequent (if not more frequent), as impairing (if not more impairing), and as lethal (if not more lethal). Both disorders are significant public health problems. Yet, BPD has received much less funding from the NIH. The author would argue that this disparity in funding is, in part, due to the superior job bipolar disorder researchers have done in “marketing” their disorder than BPD researchers. This is not a criticism of bipolar disorder researchers. At the risk for being repetitive, the author will assert again that bipolar disorder is a significant public health problem that warrants the attention (and funding) that it receives. However, because funding resources are finite, disorders need advocates. Paris and Black (2015) provide an overview of the importance of distinguishing between bipolar disorder and borderline personality and the corollary, the risk for misdiagnosing BPD as bipolar disorder. Although other authors have tackled this topic, so many more researchers have promoted bipolar disorder and the bipolar spectrum construct that Paris and Black's review is important because it provides some counterweight to the bipolar spectrum public relations effort in the literature. DISCLOSURE The author declares no conflict of interest. REFERENCES Akiskal H, Bourgeois M, Angst J, Post R, Moller H, Hirschfeld R (2000) Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders. J Affect Disord. 59:S5–S30. Akiskal H, Pinto O (1999) The evolving bipolar spectrum. Prototypes I, II, and IV. Psychiatr Clin North Am. 22:517–534. Akiskal HS (2004) Demystifying borderline personality: Critique of the concept and unorthodox reflections on its natural kinship with the bipolar spectrum. Acta Psychiatr Scand. 110:401–407. Anderson IM, Haddad PM, Scott J (2012) Bipolar disorder. BMJ. 345:e8508. Angst J (2007) The bipolar spectrum. Br J Psychiatry. 190:189–191. Angst J, Adolfsson R, Benazzi F, Gamma A, Hantouche E, Meyer TD, Skeppar P, Vieta E, Scott J (2005) The HCL-32: Towards a self-assessment tool for hypomanic symptoms in outpatients. J Affect Disord. 88:217–233. Angst J, Azorin JM, Bowden CL, Perugi G, Vieta E, Gamma A, Young AH (2011) Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode: The BRIDGE Study. Arch Gen Psychiatry. 68:791–798. Angst J, Cassano G (2005) The mood spectrum: Improving the diagnosis of bipolar disorder. Bipolar Disord. 7:4–12. Angst J, Cui L, Swendsen J, Rothen S, Cravchik A, Kessler RC, Merikangas KR (2010) Major depressive disorder with subthreshold bipolarity in the National Comorbidity Survey Replication. Am J Psychiatry. 167:1194–1201. Angst J, Gamma A (2002) Prevalence of bipolar disorders: Traditional and novel approaches. Clin Appr Bipol Disord. 1:10–14.
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