Abstract
Both borderline personality disorder (BPD) and bipolar disorder are considered clinically severe, chronic conditions associated with high functional impairment and public health costs. These disorders also share clinical features, most predominantly mood fluctuations and impulsivity across several areas. In this chapter we report research showing that BPD is chronically under-assessed and, as a result, underdiagnosed in clinical populations. Conversely, we also document literature showing the overdiagnosis of bipolar disorder, particularly in cases where, after careful interviewing, patients actually meet criteria for BPD. Reasons for this pattern vary and include insufficient diagnostic rigor, stigma associated with BPD, unfamiliarity with BPD as compared to bipolar disorder, the promotion of bipolar disorder (and not BPD) by pharmaceutical companies, and perceived difficulty in treating BPD as compared to bipolar disorder, among others. Nonetheless, diagnosing BPD and/or bipolar disorder has significant consequences for treatment planning and patient care, and close attention should be paid to making this differential diagnosis in clinical settings.
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References
Skodol AE, Gunderson JG, Pfohl B, Widiger TA, Livesley JW, Siever LJ. The borderline diagnosis I: psychopathology, comorbidity, and personality structure. Biol Psychiatry. 2002;51:936–50.
Skodol AE, Pagano ME, Bender DS, Shea MT, Gunderson JG, Yen S, et al. Stability of functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder over two years. Psychol Med. 2004;35:443–51.
Bender DS, Dolan RT, Skodol AE, Sanislow CA, Dyck IR, McGlashan TH, et al. Treatment utilization by patients with personality disorders. Am J Psychiatry. 2001;158:295–302.
Nakao K, Gunderson JG, Phillips KA, Tanaka N, Yorifuji K, Takaishi J, et al. Functional impairment in personality disorders. J Pers Disord. 1992;6:24–33.
Zimmerman M, Chelminski I, Young D, Martinez J, Morgan TA. Which DSM-IV personality disorders are most strongly linked with indices of psychosocial morbidity in psychiatric outpatients? Compr Psychiatry. 2012;53:940–5.
Gunderson JG. Borderline personality disorder: ontogeny of a diagnosis. Am J Psychiatry. 2009;166:530–9.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.
Grant BF, Chou SP, Goldstein RB, Huang B, Stinson FS, Saha TD, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave2 National Epidemiologic Survey on Alcohol and Related Conditions. Psychiatry. 2008;69:533–45.
Livesly J. Toward a genetically-informed model of borderline personality disorder. J Pers Disord. 2008;22:42–71.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. Washington, DC: American Psychiatric Association; 1987.
Westen D. Divergences between clinical and research methods for assessing personality disorders: implications for research and the evolution of axis II. Am J Psychiatry. 1997;154:895–903.
Zimmerman M, Mattia J. Differences between clinical and research practices in diagnosing borderline personality disorder. Am J Psychiatry. 1999;156:1570–4.
Oldham JM, Skodol AE. Personality disorders in the public sector. Hosp Community Psychiatry. 1991;42:481–7.
Koenigsberg HW, Kaplan RD, Gilmore MM, Cooper AM. The relationship between syndrome and personality disorder in DSM-III: experience with 2,462 patients. Am J Psychiatry. 1985;142:207–12.
Clark LA. Assessment and diagnosis of personality disorder: perennial issues and an emerging reconceptualization. Annu Rev Psychol. 2007;58:227–57.
Krueger RF, Eaton NR, Clark LA, Watson D, Markon KE, Derringer J, et al. Deriving an empirical structure of personality pathology for DSM-5. J Pers Disord. 2001;25:170–91.
Westen D, DeFife JA, Bradley B, Hilsenroth MJ. Prototype personality diagnosis in clinical practice: a viable alternative for DSM-5 and ICD-11. Prof Psychol Res Pr. 2010;41:482–7.
Chmielewski M, Bagby RW, Quilty LC, Paxton R, McGee Ng SA. A (re-)-evaluation of the symptom structure of borderline personality disorder. Can J Psychiatry. 2001;56:530–9.
Nurnberg HG. The comorbidity of borderline personality disorder and other DSM-III-R axis II personality disorders. Am J Psychiatry. 1991;148:1371–7.
Tyrer P. Borderline personality disorder: a motley diagnosis in need of reform. Lancet. 1999;354:18–25.
Paris J. The diagnosis of borderline personality disorder: problematic but better than the alternatives. Ann Clin Psychiatry. 2005;17:41–6.
Zanarini MC, Frankenburg FR, Khera GS, Bleichmar J. Treatment histories of borderline inpatients. Compr Psychiatry. 2001;42:144–50.
Aviram RB, Brodsky BS, Stanley B. Borderline personality disorder, stigma, and treatment implications. Harv Rev Psychiatry. 2006;14:249–56.
Paris J. The outcome of borderline personality disorder: good for most but not all patients. Am J Psychiatry. 2012;169:445–6.
Paris J, Gunderson J, Weinberg I. The interface between borderline personality disorder and bipolar spectrum disorders. Compr Psychiatry. 2007;48:145–54.
Lewis G, Appleby L. Personality disorder: the patients psychiatrists dislike. Br J Psychiatry. 1988;153:44–9.
Reiser DE, Levenson H. Abuses of the borderline diagnosis: a clinical problem with teaching opportunities. Am J Psychiatry. 1984;141:1528–32.
Morey LC, Ochoa ES. An investigation of adherence to diagnostic criteria: clinical diagnosis of the DSM-III personality disorders. J Pers Disord. 1989;3:180–92.
Gunderson JG, Frank AF, Ronningstam EF, Wachter S, Lynch VJ, Lynch PJ. Early discontinuance of borderline patients from psychotherapy. J Nerv Ment Dis. 1989;177:38–42.
Widiger TA, Weissman MM. Epidemiology of borderline personality disorder. Hosp Community Psychiatry. 1991;42:1015–21.
Akiskal HS, Bourgeois ML, Angst J, Post R, Moller H, Hirschfeld R. Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders. J Affect Disord. 2000;59:S5–30.
Zarata CA, Tohen M, Land M, Cavanagh S. Functional impairment and cognition in bipolar disorder. Psychiatr Q. 2000;71:309–29.
Bowden CL. Strategies to reduce misdiagnosis of bipolar depression. Psychiatr Serv. 2001;52:51–5.
Ghaemi S. Insight and psychiatric disorder: a review of the literature, with a focus on its clinical relevance for bipolar disorder. Psychiatr Ann. 1997;27:782–90.
Hirschfeld RM. Bipolar spectrum disorder: improving its recognition and diagnosis. J Clin Psychiatry. 2001;62:5–9.
Hirschfeld RM, Lewis L, Vornik LA. Perceptions and impact of bipolar disorder: how far have we really come? Results of the national depressive and manic-depressive association 2000 survey of individuals with bipolar disorder. J Clin Psychiatry. 2003;64:161–74.
Lish JD, Dime-Meenan S, Whybrow PC, Price RA, Hirschfeld RM. The national depressive and manic-depressive association (DMDA) survey of bipolar members. J Affect Disord. 1994;31:281–94.
Ghaemi SN, Sachs GS, Chiou AM, Pandurangi AK, Goodwin K. Is bipolar disorder still underdiagnosed? Are antidepressants overutilized? J Affect Disord. 1999;52:135–44.
Hirschfeld RM, Cass AR, Holt DC, Carlson CA. Screening for bipolar disorder in patients treated for depression in a family medicine clinic. J Am Board Fam Pract. 2005;18:233–9.
Stewart C, El-Mallakh RS. Is bipolar disorder overdiagnosed among patients with substance abuse? Bipolar Disord. 2007;9:646–8.
Goldberg J, Garno J, Callahn A, Kearns D, Kerner B, Ackerman S. Overdiagnosis of bipolar disorder among substance use disorder inpatients with mood instability. J Clin Psychiatry. 2008;69:1–7.
Zimmerman M, Ruggero CJ, Chelminski I, Young D. Is bipolar disorder overdiagnosed? J Clin Psychiatry. 2008;69:935–40.
Zimmerman M, Ruggero CJ, Chelminski I, Young D. Psychiatric diagnoses in patients previously overdiagnosed with bipolar disorder. J Clin Psychiatry. 2010;71:26–31.
Ruggero CJ, Zimmerman M, Chelminski I, Young D. Borderline personality disorder and the misdiagnosis of bipolar disorder. J Psychiatr Res. 2010;44:405–8.
Meyerson D. Is borderline personality disorder under diagnosed?. Paper presented at the annual conference of the American Psychiatric Association. 2009;Abstract SCR18-051.
Henry C, M’Bailara K, Desage A, Gard S, Misdrahi D, Vieta E. Towards a reconceptualization of mixed states, based on an emotional reactivity dimensional model. J Affect Disord. 2007;101:35–41.
Dowson J, Bazanis E, Rogers R, Prevost A, Taylore P, Meux C, et al. Impulsivity in patients with borderline personality disorder. Compr Psychiatry. 2004;45:29–36.
Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M. Borderline personality disorder. Lancet. 2004;364:453–61.
Zimmerman M, Galione JN, Ruggero CJ, Chelminski I, Dalrymple K, Young D. Overdiagnosis of bipolar disorder and disability payments. J Nerv Ment Dis. 2010;198:452–4.
Angst J, Cassano G. The mood spectrum: improving the diagnosis of bipolar disorder. Bipolar Disord. 2005;7 suppl 4:4–12.
Ghaemi SN, Ko JY, Goodwin FK. “Cade’s disease” and beyond: misdiagnosis, antidepressant use, and a proposed definition for bipolar spectrum disorder. Can J Psychiatry. 2002;47:125–34.
Benazzi F. Is 4 days the minimum duration of hypomania in bipolar II disorder? Eur Arch Psychiatry Clin Neurosci. 2001;251:32–4.
Zimmerman M, Ruggero CJ, Chelminski I, Young D. Clinical characteristics of depressed outpatients previously overdiagnosed with bipolar disorder. Compr Psychiatry. 2008;51:99–105.
Paris J. Borderline or bipolar? Distinguishing borderline personality disorder from bipolar spectrum disorders. Harv Rev Psychiatry. 2004;12:140–5.
Smith DJ, Muir WJ, Blackwood DH. Is borderline personality disorder part of the bipolar spectrum? Harv Rev Psychiatry. 2004;12:133–9.
Atre-Vaidya N, Hussain SM. Borderline personality disorder and bipolar mood disorder: two distinct disorders or a continuum? J Nerv Ment Dis. 1999;187:313–5.
Berrocal C, Ruiz Moreno MA, Rando MA, Benvenuti A, Cassano GB. Borderline personality disorder and mood spectrum. Psychiatry Res. 2008;159:300–7.
Nilsson AK, Jorgensen CR, Straarup KN, Licht RW. Severity of affective temperament and maladaptive self-schemas differentiate borderline patients, bipolar patients, and controls. Compr Psychiatry. 2010;51:486–91.
Perry JC, Cooper SH. A preliminary report on defenses and conflicts associated with borderline personality disorder. J Am Psychoanal Assoc. 1986;34:863–93.
Wilson ST, Stanley B, Oquendo MA, Goldberg P, Zalsman G, Mann JJ. Comparing impulsiveness, hostility, and depression in borderline personality disorder and bipolar II disorder. J Clin Psychiatry. 2007;68:1533–9.
Zimmerman M, Martinez JH, Morgan TA, Young D, Chelminski I, Dalrymple K. Distinguishing bipolar II depression from major depressive disorder with comorbid borderline personality disorder: demographic, clinical and family history differences. J Clin Psychiatry. 2013;74:880–6.
Zimmerman M. Would broadening the diagnostic criteria for bipolar disorder do more harm than good? Implications from longitudinal studies of subthreshold conditions. J Clin Psychiatry. 2012;73:437–44.
Hirschfeld RM, Vornick LA. Recognition and diagnosis of bipolar disorder. J Clin Psychiatry. 2004;65:5–9.
Moreno C, Laje G, Blanco C, Jiang H, Schmidt AB, Olfson M. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry. 2007;64:1032–9.
Gershon S, Chengappa KNR, Malhi GS. Lithium specificity in bipolar illness: a classic agent for the classic disorder. Bipolar Disord. 2009;11:34–44.
Soloff PH. Psychopharmacology of borderline personality disorder. Psychiatr Clin North Am. 2000;23:169–92.
Shea MT, Pilkonis PA, Beckham E, Collins JF, Elikin E, Sotsky SM, Docherty JP. Personality disorders and treatment outcome in the NIMH Treatment of Depression Collaborative Research Program. Am J Psychiatry. 1990;147:711–8.
Binks CA, Fenton M, McCarthy L, Lee T, Adams CE, Duggan C. Pharmacological interventions for people with borderline personality disorder. Cochrane Database Syst Rev. 2006;(1):CD005653.
Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs. therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63:757–66.
Stanley B, Brodsky B, Nelson JD, Dulit R. Brief dialectical behavior therapy (DBT-B) for suicidal behavior and non-suicidal self-injury. Arch Suicide Res. 2007;11:337–41.
Davidson K, Norrie J, Tyrer P, Gumley A, Tata P, Murray H, et al. The effectiveness of cognitive behavior therapy for borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial. J Pers Disord. 2006;20:450–65.
Weinberg I, Gunderson JG, Hennen J, Cutter CJ. Manual assisted cognitive treatment for deliberate self-harm in borderline personality disorder patients. J Pers Disord. 2006;20:482–92.
Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, van Asselt T, et al. Outpatient therapy for borderline personality disorder: randomized trial of schema-focused therapy vs, transference-focused psychotherapy. Arch Gen Psychiatry. 2006;63:649–58.
Blum N, Pfohl B, John DS, Monahan P, Black DW. STEPPS: a cognitive-behavioral systems-based group treatment for outpatients with borderline personality disorder—a preliminary report. Compr Psychiatry. 2002;43:301–10.
Blum N, St John D, Pfohl B, Stuart S, McCormick B, Allen J, et al. Systems training for emotional predictability and problem solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up. Am J Psychiatry. 2008;165:468–78.
Bateman A, Fonagy P. 8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual. Am J Psychiatry. 2008;165:631–8.
Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating three treatments for borderline personality disorder. Am J Psychiatry. 2007;164:922–8.
Torgersen S, Lygren S, Øien PA, Skre I, Onstad S, Edvardsen J, et al. A twin study of personality disorders. Compr Psychiatry. 2000;41:416–25.
Zimmerman M, Martinez J, Young D, Chelminski I, Dalrymple K. Differences between patients with borderline personality disorder who do and do not have a family history of bipolar disorder. Compr Psychiatry. 2014; Article in press.
Zanarinia MC, Williams AA, Lewis RE, Reich RB, Vera SC, Marino MF, et al. Reported pathological childhood experiences associated with the development of borderline personality disorder. Am J Psychiatry. 1997;154:1101–6.
Etain B, Mathieu F, Henry C, Raust A, Roy I, Germain A, et al. Preferential association between childhood emotional abuse and bipolar disorder. J Trauma Stress. 2010;23:376–83.
Perugi G, Toni C, Travierso MC, Akiskal HS. The role of cyclothymia in atypical depression: toward a data-based reconceptualization of the borderline-bipolar connection. J Affect Disord. 2003;73:87–98.
Zimmerman M, Mattia J. Psychiatric diagnosis in clinical practice: is comorbidity being missed? Compr Psychiatry. 1999;40:182–91.
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Morgan, T.A., Zimmerman, M. (2015). Is Borderline Personality Disorder Underdiagnosed and Bipolar Disorder Overdiagnosed?. In: Choi-Kain, L., Gunderson, J. (eds) Borderline Personality and Mood Disorders. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1314-5_4
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