Borderline Personality Disorder and Bipolar Disorder: Commentary on Paris and Black


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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.

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