Resolved. Borderline Personality Disorder and Bipolar II Disorder are Indistinguishable

Resolved Borderline Personality Disorder and Bipolar II Disorder are Indistinguishable Alternate Resolution (#1) Borderline Personality Disorder and...
Author: Jerome Ellis
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Resolved Borderline Personality Disorder and Bipolar II Disorder are Indistinguishable

Alternate Resolution (#1) Borderline Personality Disorder and Bipolar II Disorder are Sometimes Difficult to Distinguish

Alternate Resolution (#2) Borderline Personality Disorder is not a Valid Diagnostic Entity

Alternate Resolution (#3) Borderline Personality Disorder is not a Personality Disorder

Resolved Borderline Personality Disorder and Bipolar II Disorder are Indistinguishable

Is There Evidence of Diagnostic Error?

Is BD Underrecognized? Yes Sometimes

BD = bipolar disorder.

Studies of Underdiagnosis of BD • Albanese MJ, et al (2006)

• Ghaemi SN, et al (1999)

• Angst J, et al (2010)

• Hantouche EG, et al (1998)

• Angst J, et al (2011)

• Manning JS, et al (1997)

• Benazzi F (1997)

• Mantere O, et al (2008)

• Ghaemi SN, et al (2000)

• McCombs JS, et al (2007)

Albanese MJ, et al. J Psychiatr Pract. 2006;12(2):124-127. Angst J, et al. Am J Psychiatry. 2010;167(10):1194-1201. Angst J, et al. Arch Gen Psychiatry. 2011;68(8):791-798. Benazzi F. J Affect Disord. 1997;43(2):163-166. Ghaemi SN, et al. J Clin Psychiatry. 2000;61(10):804-808. Ghaemi SN, et al. J Affect Disord. 1999;52(1-3):135-144. Hantouche EG, et al. J Affect Disord. 1998;50(2-3):163-173. Manning JS, et al. Compr Psychiatry. 1997;38(2):102-108. Mantere O, et al. Bipolar Disord. 2008;10(2):238-244. McCombs JS, et al. J Affect Disord. 2007;97(1-3):171-179.

Is BD Overdiagnosed? Yes Sometimes

Zimmerman M, et al. J Clin Psychiatry. 2008;69(6):935-940.

Agreement between SCID and Self-Report of Prior BD Diagnosis SCID BD Diagnosis (“Gold Standard”)

Yes Self-reported prior diagnosis of No BD Total

Present

Absent

Total

63

82

145

27

528

555

90

610

700

Zimmerman M, et al. J Clin Psychiatry. 2008;69(6):935-940.

Family History of BD in First-Degree Relatives SCID BD A

BD

Previous BDNot Confirmed B

Not BD C

Relatives at risk

Morbid risk

Relatives at risk

Morbid risk

Relatives at risk

Morbid risk

326

8.0%

345

3.5%

1996

2.5%

3-group X2 = 27.1, P < .001 A>CX2 = 27.3, P < .001 A>BX2 = 6.34, P < .02 B=CX2 = 1.21, P = NS

NS = not significant. Zimmerman M, et al. J Clin Psychiatry. 2008;69(6):935-940.

Why is BD Overdiagnosed? • Well funded “campaign” to improve diagnostic recognition

Clinical Implications of Underrecognizing Bipolar Disorder • Undertreatment with mood stabilizer agents • Possible overtreatment with antidepressant medications • Poorer outcome

• Increased costs of care

Clinical Implications of Underrecognizing BPD • Overtreatment with mood stabilizer agents • Overprescription of medications generally • Overexposure to medication side effects

• Never-ending search for the “magic pill” • Undertreatment with psychotherapy

Research on the Bipolar-BPD Interface

Bipolar Spectrum and Its Relationship to Borderline Personality Disorder

Bipolar Spectrum

Bipolar Spectrum

Subthreshold Manic Sx/Mixed Sx

Bipolar Spectrum

Subthreshold Manic Symptoms/Mixed Sx

Treatment-Resistant Depression

BPD

Bipolar Spectrum

Subthreshold Manic Sx/Mixed

Treatment-Resistant Depression

Comorbidity between BD and BPD • Different ways to examine the issue – Frequency of BPD in patients with BD – Is BPD the most frequent PD in patients with BD? – Frequency of BD in patients with BPD

Zimmerman M, et al. Dialogues Clin Neurosci. 2013;15(2):155-169.

Frequency of BPD in Patients with BD • 24 studies, 1255 patients • BD-I: 10.7% • BD-II: 22.9%

Zimmerman M, et al. Dialogues Clin Neurosci. 2013;15(2):155-169.

Is BPD the Most Frequent PD in Patients with BD? • 15 studies of the full range of PDs in BD patients – BPD: most common PD in 4 studies – Histrionic PD: most common PD in 4 studies, and tied for most common in 2 studies – OCPD: most common PD in 3 studies, and tied for most common in 2 studies

OCPD = obsessive-compulsive personality disorder. Zimmerman M, et al. Dialogues Clin Neurosci. 2013;15(2):155-169.

Frequency of BD in Patients with BPD • 12 studies of BPD in patients with BD – 1151 patients – BD-I: 9.3% – BD-II: 10.1%

Zimmerman M, et al. Dialogues Clin Neurosci. 2013;15(2):155-169.

Review: Comparison of BD vs BPD Factors Suggesting BD

Factors Suggesting BPD

1. Manic symptoms

1. Multiple suicide attempts

2. Family history of BD

2. History of sexual abuse

3. Neurobiological abnormality 3. Psychotherapy is necessary for positive treatment 4. Medication is necessary for response positive treatment response

Non-differentiating factors 1. Mood lability

2. Impulsivity

Ghaemi SN, et al. Acta Psychiatr Scand. 2014;

Review: Comparison of BD-II vs BPD Factors Suggesting BD-II 1. Family history of BD or major mood disorder 2. Clear onset

3. Failure to remit 4. Melancholic, agitated, and mixed features when depressed

5. Uncharacteristic euphoria, creativity, grandiosity 6. Autonomous mood swings 7. Responds to mood stabilizers

8. Increased rate of ADHD ADHD = attention-deficit/hyperactivity disorder. Bayes A, Parker, G, et al. Curr Opin Psychiatry. 2014;27(1):14-20.

Review: Comparison of BD-II vs BPD (continued) Factors Suggesting BPD 1. Family history of antisocial PD, substance use disorder, unipolar depression 2. Depressed entire life 3. Attenuation over time 4. Blames others. Cognitive Sx of depression

5. Reactive moods, generally triggered by interpersonal events 6. Impulsivity to manage negative affect

7. Rarely remits on mood stabilizers

Bayes A, Parker, G, et al. Curr Opin Psychiatry. 2014;27(1):14-20.

Review: Comparison of BD-II vs BPD (continued) Non-differentiating factors 1. Atypical features 2. Suicidality and self-mutilation

3. Childhood trauma 4. Comorbidity with anxiety and substance use disorders

Bayes A, Parker G, et al. Curr Opin Psychiatry. 2014;27(1):14-20.

Direct Comparisons of Patients with BPD and BD • 6 studies • Small sample sizes – 2 studies with a total sample size

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