Empirical criteria that differentiating between Bipolar Illness and Borderline Personality Disorder (BPD):
Using sexual trauma, self-cutting/self-harm and soft psychotic symptoms
Multiple studies (see below) show that approximately two thirds of those diagnosed with BPD have a history of sexual trauma, as compared to 25-30% of those diagnosed with Bipolar, and 15-20% in the general population.
Approximately two thirds of those diagnosed with BPD engage in self-harm. BPD occurs in only 1% of the population and is present in up to 1/3rd of hospitalized patients.
The most validated criteria to differentiate BP from BPD are:
- sexual trauma, and
- dissociative, suspiciousness, (soft psychotic sx)
- Predictors of bipolar illness: euphoria, increased goal-directed activities, mood episodicity – i.e. if these are present the patient is not borderline-they are manic and not comorbid.
- Borderline patients do not have bipolar genetics, manic episodes, or recurrent depressive episodes, but may have chronic depressive symptoms.
(P Vohringer, The International Mood Network (IMN) Nosology Project: differentiating borderline personality from bipolar illness. Acta Psychiatr Scand, 134 (2016), pp. 504-510
“In a mood disorder clinic setting, manic criteria and episodic mood course distinguished bipolar illness from borderline personality disorder.”)
As in the prior blog, sexual trauma was not included in the DSM criteria in 1980 because it implied a psychoanalytic etiology, and Robert Spitzer wanted the DSM to be “atheroretical.”
So-called co-morbidity of BPD and BD (Bipolar Disorder) in the DSM is due to an overlap of similar criteria. However, when only validated criteria are used in the diagnosis, there is little comorbidity. The overlapping DSM criteria has led to an overdiagnosis of borderline personality. In a diagnostic hierarchy a mood illness, (depression, mixed, mild or full mania) supersedes any “personality disorder” because when the mood illness is fully treated, what looked like a personality problem usually goes away.
Remember from a previous blog, true medical comorbidity means two, independent, unrelated, simultaneously occurring, unrelated diseases. (Feinstein AR. J Chronic Dis 1970;23:455-68)
With regard to “borderline personality,” according to Ghaemi’s criteria and the clinical studies below, long term psychotherapy comes first i.e., DBT or CBT derived therapies. Additionally, ongoing medications usually make things worse, however, Ghaemi does recommend short-term, low-dose meds, but for symptomatic relief only.
Studies that focus on the DSM criteria have not first ruled out mood illnesses such as hypomania/mania, mixed states of depression, and/or Cyclothymic mood temperament as is recommended in a Diagnostic Hierarchy. Experts recommend that no personality disorder should be diagnosed when a temporary mood episode or illness is present because the supposed “personality disorder” may disappear when the full mood illness is treated. In addition, misunderstandings can occur when a chronic mood temperament is present.
Once, in a hospital setting, a nurse made a comment to me that she thought a female patient was “a little borderliny” (not a term in the DSM) because the patient was thought to be difficult with staff. Unfortunately, using the psychoanalytically derived term “borderline” is all too frequently used as an epithet for patients perceived to be unpleasant or disagreeable. The lack of understanding of personality traits evident on pages 761-781 in the DSM-5 and lack of knowledge of the historical and well researched concept of mood temperaments has led to these misunderstandings.
It is telling that the American Psychiatric Association Publishing site lists not one book devoted to Mood Temperaments. This, in spite of over 40 years of modern research across several continents and the historical descriptions from the late 19th century (such as Cyclothymia first recorded in the 1880’s) which has survived in every DSM I (1952) through 5 (2013).
A new model for personality traits (the first ever for any DSM) was originally intended to replace the traditional “personality disorders” in the 2013 DSM-5. However, with just a few weeks to go before final approval, the APA board of trustees got cold feet and requested the venerable personality disorders retain their prominent position in the manual and the research-based personality trait model be moved to the back of the book (bus) under Section III: Emerging Methods and Models. Another example of how sausage making trumped science.
Remember: Mood Temperaments and Personality Traits have more scientific evidence and validation than do the Freudian derived “personality disorders.”
“Results: The reported associations between trauma and personality pathology are illuminated by the following research findings: 1) personality is heritable; 2) only a minority of patients with severe personality disorders report childhood trauma; and 3) children are generally resilient, and traumatic experiences do not consistently lead to psychopathology.
Conclusions: The role of trauma in the personality disorders is best understood in the context of gene-environment interactions.”
In a future blog, I will offer a brief overview of the 40+ years of research by Hagop Akiskal, MD, in order to differentiate Mood Temperaments from the concept of Borderline personality.
References for this post:
P Vohringer, The International Mood Network (IMN) Nosology Project: differentiating borderline personality from bipolar illness. Acta Psychiatr Scand, 134 (2016), pp. 504-510
“In a mood disorder clinic setting, manic criteria and episodic mood course distinguished bipolar illness from borderline personality disorder.”
M Zanarini, ed, Role of sexual abuse in etiology of borderline personality disorder, American Psychiatric Press, 1997.
J Paris, Does Childhood Trauma Cause Personality Disorders in Adults? Can J Psychiatry 1998;43:148–153.
A Fossatti, Predicting borderline and antisocial personality disorder features in nonclinical subjects using measures of impulsivity and aggressiveness. Psychiatry Research Vol. 125, Issue 2, 15 February 2004, Pages 161-170