COMMENTARY
Borderline Personality Disorder and Bipolar Disorder Commentary on Paris and Black Gordon Parker, PhD, MD, DSc, FRANZCP
I
share the model argued by Drs. Paris and Black—that borderline personality disorder and the bipolar disorders (I and II) are separate conditions and that their clinical distinction is of key importance for two principal reasons. First, the benefits that accrue from an accurate diagnosis are both intrinsic and ongoing. As Montgomery (2006) noted, “Patients want to know what is wrong, if it's serious, how long it will last, whether it will alter their life plans.” Furthermore, she observed that “to know the cause of disease is to have control” as evidenced by one patient (“Just having a diagnosis means the rest of your life can start.”). Given a diagnosis, a patient can then evaluate management options more accurately. Second, and as emphasized by Paris and Black, the conditions under review are likely to show quite differing responses to specific and nonspecific therapies. For the bipolar disorders, the prioritized specific management modality is medication to provide mood stabilization, whereas, for a borderline personality disorder, the prioritized management modality is a psychotherapy, with dialectic behavior therapy seemingly providing the standard. Published studies have demonstrated that the bipolar disorders—and particularly, the bipolar II subtype—are frequently underdiagnosed, if diagnosed at all. Those who do obtain such a diagnosis often wait for 10 to 20 years, but such data (and any impact information) do not capture the consequences experienced by those who have a bipolar condition which has never been diagnosed and appropriately managed. Clinicians commonly suggest that a diagnosis of a bipolar II condition is intrinsically difficult and, in considering any differential diagnosis, generally position a borderline personality disorder as providing the greatest diagnostic confusion. This commonly reflects clinical identification of distinct “emotional dysregulation” (or “affective instability” as considered by Drs. Paris and Black) “polarizing” clinical judgment and a lack of clear clinical guidelines for judging the probability of one condition over the other. Paris and Black provide a comprehensive overview of features that assist the clinician to identify the most likely condition. I have elsewhere (Parker, 2011) suggested a number of features that I find helpful in differentiating the two conditions, and both reprise and extend such nuances here. Perhaps, reflecting the impact of Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria lists, assessment and differentiation by clinicians is commonly approached by judging the items weighting each diagnostic possibility. I favor a differing logic, respecting a model positioning bipolar disorder as a higher-order categorical mood “disease.” Operationally, the model involves first judging whether a bipolar disorder is present and then considering whether the individual has features evidencing and allowing a borderline personality style or disorder to be diagnosed independently. Such a model allows that a percentage of individuals have both conditions and thus avoids a strict differential diagnostic model. Second, in comparison with other criteria sets (e.g., DSM Fifth Edition), I argue for evaluation not only considering aspects of the “highs” but also focusing on the depressive clinical features and a number of background and illness course variables. Assessment nuances will now be overviewed. As most people with a bipolar condition present to a clinician for assistance with their depressed states, I initially inquire into their depressive symptoms and in some detail. I generally next ask whether they have periods—when neither depressed nor experiencing a normal mood—of feeling “more energized and wired.” If this probe question (or subsidiary ones) is affirmed, then I ask a set of symptoms associated with hypo/manic states and, if affirmed, ask the patient to detail nuances or provide examples. Symptoms include the individual a) talking more, b) talking over people, c) being loud, d) being verbally or socially indiscrete and often engaging in high-risk activities, e) feeling bullet proof and invincible, f) needing less sleep and not feeling tired, g) having an increased libido, h) spending more money and putting themselves at financial risk, i) feeling “one with nature, ”and j) feeling more creative and over estimating their abilities and potential (feeling “bullet proof ” and invulnerable). A key feature is that most patients with a bipolar disorder will acknowledge that their general levels of anxiety attenuate or disappear (feeling in a care-free zone) during true hypo/manic episodes. This feature is in sharp contrast to those who have a primary personality style of “emotional dysregulation” and who are likely to become
School of Psychiatry, University of New South Wales; and Black Dog Institute, Sydney, Australia. Send reprint requests to Gordon Parker, PhD, MD, DSc, FRANZCP, School of Psychiatry, University of New South Wales, Prince of Wales Hospital, Randwick 2031, Sydney, Australia. E-mail: [email protected]. Copyright © 2015 by Lippincott Williams & Wilkins ISSN: 0022-3018/15/20301–0013 DOI: 10.1097/NMD.0000000000000227
The Journal of Nervous and Mental Disease • Volume 203, Number 1, January 2015
www.jonmd.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
13
The Journal of Nervous and Mental Disease • Volume 203, Number 1, January 2015
Commentary
more anxious and irritable if not enraged during a dysregulated state. The distinction is not absolute, however; whereas most people with a bipolar condition experience euphoric “happy” hypo/manic states, a percentage are more likely to experience irritable “snappy” highs. Another intriguing feature (yet possessing diagnostic weighting) is tolerance for alcohol—in that those with a true bipolar condition will report being able to consume large (if not vast) amounts of alcohol during hypo/ manic states without significant functional impairment and in sharp contrast to when they are in a euthymic or depressed mood state. In distinguishing between those with a bipolar I as against a bipolar II condition, I pursue psychotic features with the view that a diagnosis of bipolar I should be reserved for those who have ever experienced psychotic features when high and that those with a bipolar II condition never experience psychotic features during elevated or depressed mood states. This is positioned as a categorical against a dimensional distinction—with the respective presence or absence of psychotic features when “high” weighting a diagnosis of bipolar I and II conditions. As most individuals with a true bipolar disorder experience psychotic or melancholic depressive episodes, I then factor clinical features of their depressive states into the diagnostic allocation. Symptoms that I find most useful in weighting a diagnosis of melancholic depression are the individual describing a) a nonreactive and anhedonic mood, b) profound anergia (having difficulty in getting out of bed or washing), c) diurnal variation of mood and energy (i.e., both worse in the morning), d) impaired concentration, and e) other psychomotor symptoms (e.g., becoming insular and asocial, speaking less and with less modulation of voice, and losing the “light in their eyes”). I position psychotic depression as evidencing a base of melancholic features and with added psychotic features (mood congruent or incongruent) of delusions and hallucinations. We find that some 50% of bipolar I patients will have experienced psychotic depressive episodes (and almost all of the remainder will have experienced melancholic depressive episodes), whereas those with a bipolar II condition do not experience psychotic depressive episodes but are likely to experience melancholic depressive episodes (albeit with “atypical” features such as hypersomnia and hyperphagia, as against insomnia and appetite/weight loss being common). Although DSM imposes a minimum duration of 4 days for hypomanic states and 7 days for manic states, a number of studies support the clinical impression that imposing such duration criteria risks a significant percentage of individuals with a true bipolar condition failing to obtain the diagnosis. We have previously reported (Parker, 2012) that some four fifths of those with a diagnosed bipolar II condition have not had their longest high (not just average high) last more than 4 days, and nearly half of those with a bipolar I condition have not had their longest high last more than a week. In the clinical arena, I have had many bipolar II and a few bipolar I patients (the latter reporting in relation to psychotic manic episodes) state that they have experienced hypo/manic states lasting minutes or hours only. Thus, imposing the DSM duration criteria will risk failing to make a valid diagnosis of a bipolar condition, although those patients reporting hypo/manic episodes lasting hours only are highly likely to have such episodes judged as reflecting personality-based “emotional dysregulation” and receive a diagnosis weighting such personality aspects. While I ask patients whether their elevated mood states have been observed and commented on by others, many with true highs will report that no one has ever brought such states to their attention or questioned their status. Thus, although the question is worth asking in that, if confirmed, it may firm the diagnosis, a negative answer should not be accepted at face value as excluding a bipolar disorder. I also look for “trend break”—where the individual with a true bipolar disorder effectively describes the rapid onset of distinctive mood swings (most commonly in adolescence for those with a bipolar II condition and in early adulthood for those with a bipolar I condition), with the first episode being either a hypo/manic or depressive one. Paris
14
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and Black note that “affective instability and impulsivity” in those with a borderline personality disorder is “apparent by late childhood.” The progressive emergence of such emotional dysregulation is thus in some contrast with the emergence of a quite categorical hypo/manic or melancholic depressive episode in those with a bipolar disorder, although I acknowledge that those with a bipolar disorder are likely to report earlier forme fruste or minor depressive episodes. I expect that, for those with a true bipolar condition, there will be a family history of bipolar or unipolar depressive mood states and with a significant percentage reporting suicide in first-degree relatives. Although we are aware that people who have a bipolar disorder are more likely to have premorbid difficulties emerging from drug and alcohol excess and to have high rates of anxiety and eating disorders, I do not weight the presence of such features as important in affirming or negating a bipolar diagnosis. Nor do I anticipate that an individual with a bipolar disorder will be more likely to have a distinctive personality style or a personality disorder. If diagnostic doubt remains—and this is most common when the individual seeks to “deny” a bipolar state—I will generally ask for a corroborative witness interview and undertake it with the patient present so that any reporting discrepancies or difficulties can be reconciled. Thus, a diagnosis of a bipolar disorder is made by assessment of mood symptoms (both hypo/manic and depressive), with such mood swings emerging as a distinct change (i.e., a “trend break”) and thus unlikely to reflect an underlying personality style, episodes being generally autonomous (although many bipolar patients will report episodes as having some “reactivity” component), and a family history of a mood disorder and/or suicide in a first-degree relative. Although response to a mood stabilizer advances the likelihood of a bipolar disorder, the diagnosis of a bipolar disorder should be able to be made independent of treatment response information, with the latter being viewed only as having a confirmatory role. Clinical assessment should therefore be able to judge the presence of a bipolar disorder as the principal diagnostic priority with some certainty. Judgment about personality style (or the presence of any personality disorder) is then a second-order diagnostic task but, as noted, should be undertaken to determine whether the individual has a borderline (or related personality) disorder in addition or in the absence of a bipolar disorder. In those with both a borderline personality disorder (BPD) and a bipolar disorder (BPD), rules and guidelines for defining such a compound diagnosis (BPD2) have not been explicated as far as I am aware, perhaps reflecting clinical parsimony (with clinicians more judging which of the two is the most likely diagnosis as against allowing their coterminous status). Development of such guidelines would have considerable clinical use. As noted earlier, I agree with Paris and Black that borderline personality disorder and the bipolar disorders (I and II) are distinctive. Those authors provide an informative and rich set of features that both argue for their distinction and which should inform clinical decision making. This commentary seeks to offer some operational clinical guidelines for making a diagnosis of a bipolar disorder and argues for weighting a judgment as to whether any such condition is present before any clinical assessment of a coterminous or independent personality disorder. DISCLOSURES The author makes reference to an edited monograph for which he receives royalties. REFERENCES Montgomery K (2006) How doctors think. Oxford, UK: Oxford University Press. Parker G (2011) Clinical differentiation of bipolar II disorder from personality-based “emotional dysregulation” conditions. J Affect Disord. 133:16–21. Parker G (2012) Defining and measuring bipolar II disorder. In Parker G (Ed). Bipolar II disorder. Modelling, measuring and managing (pp 35–45). Cambridge, UK: Cambridge University Press.
© 2015 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Borderline Personality Disorder and Bipolar Disorder Commentary on Paris and Black Gordon Parker, PhD, MD, DSc, FRANZCP
I
share the model argued by Drs. Paris and Black—that borderline personality disorder and the bipolar disorders (I and II) are separate conditions and that their clinical distinction is of key importance for two principal reasons. First, the benefits that accrue from an accurate diagnosis are both intrinsic and ongoing. As Montgomery (2006) noted, “Patients want to know what is wrong, if it's serious, how long it will last, whether it will alter their life plans.” Furthermore, she observed that “to know the cause of disease is to have control” as evidenced by one patient (“Just having a diagnosis means the rest of your life can start.”). Given a diagnosis, a patient can then evaluate management options more accurately. Second, and as emphasized by Paris and Black, the conditions under review are likely to show quite differing responses to specific and nonspecific therapies. For the bipolar disorders, the prioritized specific management modality is medication to provide mood stabilization, whereas, for a borderline personality disorder, the prioritized management modality is a psychotherapy, with dialectic behavior therapy seemingly providing the standard. Published studies have demonstrated that the bipolar disorders—and particularly, the bipolar II subtype—are frequently underdiagnosed, if diagnosed at all. Those who do obtain such a diagnosis often wait for 10 to 20 years, but such data (and any impact information) do not capture the consequences experienced by those who have a bipolar condition which has never been diagnosed and appropriately managed. Clinicians commonly suggest that a diagnosis of a bipolar II condition is intrinsically difficult and, in considering any differential diagnosis, generally position a borderline personality disorder as providing the greatest diagnostic confusion. This commonly reflects clinical identification of distinct “emotional dysregulation” (or “affective instability” as considered by Drs. Paris and Black) “polarizing” clinical judgment and a lack of clear clinical guidelines for judging the probability of one condition over the other. Paris and Black provide a comprehensive overview of features that assist the clinician to identify the most likely condition. I have elsewhere (Parker, 2011) suggested a number of features that I find helpful in differentiating the two conditions, and both reprise and extend such nuances here. Perhaps, reflecting the impact of Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria lists, assessment and differentiation by clinicians is commonly approached by judging the items weighting each diagnostic possibility. I favor a differing logic, respecting a model positioning bipolar disorder as a higher-order categorical mood “disease.” Operationally, the model involves first judging whether a bipolar disorder is present and then considering whether the individual has features evidencing and allowing a borderline personality style or disorder to be diagnosed independently. Such a model allows that a percentage of individuals have both conditions and thus avoids a strict differential diagnostic model. Second, in comparison with other criteria sets (e.g., DSM Fifth Edition), I argue for evaluation not only considering aspects of the “highs” but also focusing on the depressive clinical features and a number of background and illness course variables. Assessment nuances will now be overviewed. As most people with a bipolar condition present to a clinician for assistance with their depressed states, I initially inquire into their depressive symptoms and in some detail. I generally next ask whether they have periods—when neither depressed nor experiencing a normal mood—of feeling “more energized and wired.” If this probe question (or subsidiary ones) is affirmed, then I ask a set of symptoms associated with hypo/manic states and, if affirmed, ask the patient to detail nuances or provide examples. Symptoms include the individual a) talking more, b) talking over people, c) being loud, d) being verbally or socially indiscrete and often engaging in high-risk activities, e) feeling bullet proof and invincible, f) needing less sleep and not feeling tired, g) having an increased libido, h) spending more money and putting themselves at financial risk, i) feeling “one with nature, ”and j) feeling more creative and over estimating their abilities and potential (feeling “bullet proof ” and invulnerable). A key feature is that most patients with a bipolar disorder will acknowledge that their general levels of anxiety attenuate or disappear (feeling in a care-free zone) during true hypo/manic episodes. This feature is in sharp contrast to those who have a primary personality style of “emotional dysregulation” and who are likely to become
School of Psychiatry, University of New South Wales; and Black Dog Institute, Sydney, Australia. Send reprint requests to Gordon Parker, PhD, MD, DSc, FRANZCP, School of Psychiatry, University of New South Wales, Prince of Wales Hospital, Randwick 2031, Sydney, Australia. E-mail: [email protected]. Copyright © 2015 by Lippincott Williams & Wilkins ISSN: 0022-3018/15/20301–0013 DOI: 10.1097/NMD.0000000000000227
The Journal of Nervous and Mental Disease • Volume 203, Number 1, January 2015
www.jonmd.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
13
The Journal of Nervous and Mental Disease • Volume 203, Number 1, January 2015
Commentary
more anxious and irritable if not enraged during a dysregulated state. The distinction is not absolute, however; whereas most people with a bipolar condition experience euphoric “happy” hypo/manic states, a percentage are more likely to experience irritable “snappy” highs. Another intriguing feature (yet possessing diagnostic weighting) is tolerance for alcohol—in that those with a true bipolar condition will report being able to consume large (if not vast) amounts of alcohol during hypo/ manic states without significant functional impairment and in sharp contrast to when they are in a euthymic or depressed mood state. In distinguishing between those with a bipolar I as against a bipolar II condition, I pursue psychotic features with the view that a diagnosis of bipolar I should be reserved for those who have ever experienced psychotic features when high and that those with a bipolar II condition never experience psychotic features during elevated or depressed mood states. This is positioned as a categorical against a dimensional distinction—with the respective presence or absence of psychotic features when “high” weighting a diagnosis of bipolar I and II conditions. As most individuals with a true bipolar disorder experience psychotic or melancholic depressive episodes, I then factor clinical features of their depressive states into the diagnostic allocation. Symptoms that I find most useful in weighting a diagnosis of melancholic depression are the individual describing a) a nonreactive and anhedonic mood, b) profound anergia (having difficulty in getting out of bed or washing), c) diurnal variation of mood and energy (i.e., both worse in the morning), d) impaired concentration, and e) other psychomotor symptoms (e.g., becoming insular and asocial, speaking less and with less modulation of voice, and losing the “light in their eyes”). I position psychotic depression as evidencing a base of melancholic features and with added psychotic features (mood congruent or incongruent) of delusions and hallucinations. We find that some 50% of bipolar I patients will have experienced psychotic depressive episodes (and almost all of the remainder will have experienced melancholic depressive episodes), whereas those with a bipolar II condition do not experience psychotic depressive episodes but are likely to experience melancholic depressive episodes (albeit with “atypical” features such as hypersomnia and hyperphagia, as against insomnia and appetite/weight loss being common). Although DSM imposes a minimum duration of 4 days for hypomanic states and 7 days for manic states, a number of studies support the clinical impression that imposing such duration criteria risks a significant percentage of individuals with a true bipolar condition failing to obtain the diagnosis. We have previously reported (Parker, 2012) that some four fifths of those with a diagnosed bipolar II condition have not had their longest high (not just average high) last more than 4 days, and nearly half of those with a bipolar I condition have not had their longest high last more than a week. In the clinical arena, I have had many bipolar II and a few bipolar I patients (the latter reporting in relation to psychotic manic episodes) state that they have experienced hypo/manic states lasting minutes or hours only. Thus, imposing the DSM duration criteria will risk failing to make a valid diagnosis of a bipolar condition, although those patients reporting hypo/manic episodes lasting hours only are highly likely to have such episodes judged as reflecting personality-based “emotional dysregulation” and receive a diagnosis weighting such personality aspects. While I ask patients whether their elevated mood states have been observed and commented on by others, many with true highs will report that no one has ever brought such states to their attention or questioned their status. Thus, although the question is worth asking in that, if confirmed, it may firm the diagnosis, a negative answer should not be accepted at face value as excluding a bipolar disorder. I also look for “trend break”—where the individual with a true bipolar disorder effectively describes the rapid onset of distinctive mood swings (most commonly in adolescence for those with a bipolar II condition and in early adulthood for those with a bipolar I condition), with the first episode being either a hypo/manic or depressive one. Paris
14
www.jonmd.com
and Black note that “affective instability and impulsivity” in those with a borderline personality disorder is “apparent by late childhood.” The progressive emergence of such emotional dysregulation is thus in some contrast with the emergence of a quite categorical hypo/manic or melancholic depressive episode in those with a bipolar disorder, although I acknowledge that those with a bipolar disorder are likely to report earlier forme fruste or minor depressive episodes. I expect that, for those with a true bipolar condition, there will be a family history of bipolar or unipolar depressive mood states and with a significant percentage reporting suicide in first-degree relatives. Although we are aware that people who have a bipolar disorder are more likely to have premorbid difficulties emerging from drug and alcohol excess and to have high rates of anxiety and eating disorders, I do not weight the presence of such features as important in affirming or negating a bipolar diagnosis. Nor do I anticipate that an individual with a bipolar disorder will be more likely to have a distinctive personality style or a personality disorder. If diagnostic doubt remains—and this is most common when the individual seeks to “deny” a bipolar state—I will generally ask for a corroborative witness interview and undertake it with the patient present so that any reporting discrepancies or difficulties can be reconciled. Thus, a diagnosis of a bipolar disorder is made by assessment of mood symptoms (both hypo/manic and depressive), with such mood swings emerging as a distinct change (i.e., a “trend break”) and thus unlikely to reflect an underlying personality style, episodes being generally autonomous (although many bipolar patients will report episodes as having some “reactivity” component), and a family history of a mood disorder and/or suicide in a first-degree relative. Although response to a mood stabilizer advances the likelihood of a bipolar disorder, the diagnosis of a bipolar disorder should be able to be made independent of treatment response information, with the latter being viewed only as having a confirmatory role. Clinical assessment should therefore be able to judge the presence of a bipolar disorder as the principal diagnostic priority with some certainty. Judgment about personality style (or the presence of any personality disorder) is then a second-order diagnostic task but, as noted, should be undertaken to determine whether the individual has a borderline (or related personality) disorder in addition or in the absence of a bipolar disorder. In those with both a borderline personality disorder (BPD) and a bipolar disorder (BPD), rules and guidelines for defining such a compound diagnosis (BPD2) have not been explicated as far as I am aware, perhaps reflecting clinical parsimony (with clinicians more judging which of the two is the most likely diagnosis as against allowing their coterminous status). Development of such guidelines would have considerable clinical use. As noted earlier, I agree with Paris and Black that borderline personality disorder and the bipolar disorders (I and II) are distinctive. Those authors provide an informative and rich set of features that both argue for their distinction and which should inform clinical decision making. This commentary seeks to offer some operational clinical guidelines for making a diagnosis of a bipolar disorder and argues for weighting a judgment as to whether any such condition is present before any clinical assessment of a coterminous or independent personality disorder. DISCLOSURES The author makes reference to an edited monograph for which he receives royalties. REFERENCES Montgomery K (2006) How doctors think. Oxford, UK: Oxford University Press. Parker G (2011) Clinical differentiation of bipolar II disorder from personality-based “emotional dysregulation” conditions. J Affect Disord. 133:16–21. Parker G (2012) Defining and measuring bipolar II disorder. In Parker G (Ed). Bipolar II disorder. Modelling, measuring and managing (pp 35–45). Cambridge, UK: Cambridge University Press.
© 2015 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
