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