Bordering on bipolar: the overlap between borderline personality and bipolarity

Discriminant diagnostic validity of paediatric bipolar disorder screening tests: A systematic review and meta-analysis

INTRODUCTION

Bipolar disorders (BD) are among the most significantly impairing of childhood and adolescent psychiatric disorders. Although BD symptoms may begin in adolescence, they are frequently not diagnosed until adulthood, and accordingly BD scales could aid diagnostic assessment in paediatric populations. This review aims to synthesis the evidence for the accuracy of BD symptom index tests for discriminating BD from non-BD (other diagnoses or healthy controls) in paediatric population. Additionally, several theoretically relevant moderators of diagnostic accuracy were evaluated.

METHODS

A systematic search across three databases were conducted from 1980 to 2022, augmented by grey literature database searches, citation chaining and contacting authors. Data from eligible studies were synthesized using meta-analysis. A multilevel model was fitted to account for nested effect sizes, with 31 potential moderators examined in univariate and multivariate models.

RESULTS

Twenty-Eight studies were eligible, yielding 115 effect sizes for analysis. Meta-analytic modelling indicated BD symptom index tests have a high diagnostic accuracy (g = 1.300; 95% CI: 0.982 - 1.619; p < .001) in paediatric population. Accuracy was relative to the type of comparison group, index test content, index test informant and index test's scale or subscale.

CONCLUSIONS

Screening tests based on mania content, caregiver report and non-healthy comparison groups have clinical utility in identifying paediatric BD. Other informant-and-content combination may not accurately identify paediatric BD. Unlike healthy controls, tests derived from studies using non-healthy comparison groups, represent BD symptom non-specificity and BD symptom overlap with other disorders, providing external validity and clinical utility.

The comparison of hot and cold executive functions in patients with bipolar II disorder, borderline personality disorder, and healthy individuals

Background

Differential diagnosis of bipolar II disorder (BD-II) and borderline personality disorder (BPD) has always been challenging for clinicians due to symptoms' overlap. This study aimed to compare hot and cold executive functions (EFs) in BD-II patients, as well as BPD and healthy controls (HCs), in order to differentiate these two disorders.

Methods

In the present study, 30 BD-II and 30 BPD patients undergoing the drug therapy with mood stabilizers, and 30 HC were examined using EFs evaluated tests. The data were then analyzed using ANOVA and Tukey post hoc test.

Results

The BD-II Patients performed significantly less in all cold EFs than the HC. Also, BPD patients had meaningfully lesser performance compared to HC in all cold EFs except sustained attention. No significant difference was perceived between the two patient groups in the cold EFs. In BD-II patients, the risky decision-making as a hot EFs' component was not significantly different from HC; nevertheless, its amount was significantly higher in BPD than in the HC and BD-II patients.

Conclusion

These findings underline the differences between the two mentioned disorders based on the hot EFs, which may indicate further disorder in the emotional information processing system among the BPD patients.

A Multi-View Learning Approach for Detecting Personality Disorders Among Arab Social Media Users

Multi-view fusion approaches have gained increasing interest in the last few years by researchers. This interest comes due to the many perspectives that datasets can be looked at and evaluated. One of the most urging areas that require constant leveraging with latest technologies and multi-perspective judgments, is the area of Psychology. In this paper, a novel multi-view fusion model using deep learning algorithms is presented to detect popular types of Personality Disorders among the Arab users of Twitter Platform in an expert driven fashion, based on the descriptions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The work presented is the first of its kind with no publicly available datasets that report statements around Personality Disorders in the Arabic Language, thus we created AraPerson, a dataset which consists of 8000 textual tweets coupled with 8000 images that prescribe mental statuses for a total of 150 users collected with regular expressions generated under the supervision of domain experts. The dataset was fed into a baseline multi-view model by combining a CNN model with a Bi-LSTM model to detect two types of popular personality disorders by analyzing textual and visual posts on 150 users’ profiles. The experiments were followed with fusing DenseNet model with Bi-LSTM model, with experimenting the effect of using Concatenation, Addition, and Multiplication methods for vectors’ combination. The work presented in this paper is unprecedented, specifically in a controversial area such as personality disorders detection among Arab communities. The best reported accuracy is 87% which is very promising as the two types of personality disorders, which were investigated, are highly overlapping.

Structural Features Related to Affective Instability Correctly Classify Patients With Borderline Personality Disorder. A Supervised Machine Learning Approach

Previous morphometric studies of Borderline Personality Disorder (BPD) reported inconsistent alterations in cortical and subcortical areas. However, these studies have investigated the brain at the voxel level using mass univariate methods or region of interest approaches, which are subject to several artifacts and do not enable detection of more complex patterns of structural alterations that may separate BPD from other clinical populations and healthy controls (HC). Multiple Kernel Learning (MKL) is a whole-brain multivariate supervised machine learning method able to classify individuals and predict an objective diagnosis based on structural features. As such, this method can help identifying objective biomarkers related to BPD pathophysiology and predict new cases. To this aim, we applied MKL to structural images of patients with BPD and matched HCs. Moreover, to ensure that results are specific for BPD and not for general psychological disorders, we also applied MKL to BPD against a group of patients with bipolar disorder, for their similarities in affective instability. Results showed that a circuit, including basal ganglia, amygdala, and portions of the temporal lobes and of the orbitofrontal cortex, correctly classified BPD against HC (80%). Notably, this circuit positively correlates with the affective sector of the Zanarini questionnaire, thus indicating an involvement of this circuit with affective disturbances. Moreover, by contrasting BPD with BD, the spurious regions were excluded, and a specific circuit for BPD was outlined. These results support that BPD is characterized by anomalies in a cortico-subcortical circuit related to affective instability and that this circuit discriminates BPD from controls and from other clinical populations.

Patients with borderline personality disorder and bipolar disorder: a descriptive and comparative study

BACKGROUND

Bipolar disorder and borderline personality disorder (BPD) are each significant public health problems. It has been frequently noted that distinguishing BPD from bipolar disorder is challenging. Consequently, reviews and commentaries have focused on differential diagnosis and identifying clinical features to distinguish the two disorders. While there is a burgeoning literature comparing patients with BPD and bipolar disorder, much less research has characterized patients with both disorders. In the current report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compare psychiatric outpatients with both BPD and bipolar disorder to patients with BPD without bipolar disorder and patients with bipolar disorder without BPD.

METHODS

Psychiatric outpatients presenting for treatment were evaluated with semi-structured interviews. The focus of the current study is the 517 patients with both BPD and bipolar disorder (n = 59), BPD without bipolar disorder (n = 330), and bipolar disorder without BPD (n = 128).

RESULTS

Compared to patients with bipolar disorder, the patients with bipolar disorder and BPD had more comorbid disorders, psychopathology in their first-degree relatives, childhood trauma, suicidality, hospitalizations, time unemployed, and likelihood of receiving disability payments. The added presence of bipolar disorder in patients with BPD was associated with more posttraumatic stress disorder in the patients as well as their family, more bipolar disorder and substance use disorders in their relatives, more childhood trauma, unemployment, disability, suicide attempts, and hospitalizations.

CONCLUSIONS

Patients with both bipolar disorder and BPD have more severe psychosocial morbidity than patients with only one of these disorders.

Differentiation of bipolar disorder versus borderline personality disorder: A machine learning approach

BACKGROUND

Differentiation of bipolar disorder (BP) from borderline personality disorder (BPD) is a common diagnostic dilemma. We undertook a machine learning (ML) approach to distinguish the conditions.

METHODS

Participants meeting DSM criteria for BP or BPD were compared on measures examining cognitive and behavioral BPD constructs, emotion regulation strategies, and parental behaviors during childhood. Two analyses used continuous and dichotomised data, with ML-allocated diagnoses compared to DSM.

RESULTS

82 participants met DSM criteria for BP and 52 for BPD. Accuracy of ML classification was 84.1% - 87.8% for BP, 50% - 57.7% for BPD, with overall accuracy of 73.1% - 73.9%. Importance of items differed between the analyses with the overall most important items including identity difficulties, relationship problems, female gender, feeling suicidal after a relationship breakdown and age.

LIMITATIONS

Participants were volunteers, preponderance of bipolar II (BP II) participants, comorbidity of BP and BPD not examined, and small BPD sample contributed to the relatively low classification accuracies for this group CONCLUSIONS: Study findings may assist distinguishing BP and BPD based on differences in cognitive and behavioral domains, emotion regulation strategies and parental behaviors. Future studies using larger datasets could further improve predictive accuracy and assist in differential diagnosis.

Similar or Different Neuropsychological Profiles? Only Set Shifting Differentiates Women With Bipolar vs. Borderline Personality Disorder

There is ongoing debate about the similarities and differences between bipolar disorder (BD) and borderline personality disorder (BPD). Very few studies have concurrently assessed their neuropsychological profile and only on a narrow array of neuropsychological tests. We aimed to investigate the differences of these two patient groups on visual memory, executive function, and response inhibition. Twenty-nine BD patients, 27 BPD patients and 22 controls (all female) were directly compared on paired associates learning (PAL), set shifting (ID/ED), problem solving (SOC), and response inhibition (SSRT) using Cambridge Neuropsychological Test Automated Battery (CANTAB). Rank-normalized outcomes were contrasted in one-way ANOVA tests. Discriminant analysis was finally performed to predict BD or BPD patient status. BD patients performed significantly worse than controls on all tasks. BPD patients performed significantly worse than HC on all tests except SST. Significant differences between the two patient groups were recorded only on ID/ED, where BPD patients performed worse (p = 0.044). A forward stepwise discriminant analysis model based on ID/ED and SOC predicted correctly patients' group at 67.9% of cases. In conclusion, BD and BPD female patients appear to be more similar than different as regards their neuropsychological functions. This study is the first to show that BPD patients display more deficits than BD patients when directly compared on the set shifting executive function test, a marker of cognitive flexibility. Discerning BD from BPD patients through neuropsychological performance is promising but would improve by using additional subtler tests and psychometric evaluation.

A Feasibility Study of the Addition of STEPPS in Outpatients With Bipolar Disorder and Comorbid Borderline Personality Features: Promises and Pitfalls

Background: Pharmacotherapy is a cornerstone in bipolar disorder (BD) treatment whereas borderline personality disorder (BPD) is treated primarily with psychotherapy. Given the overlap in symptomatology, patients with BD may benefit from psychotherapy designed for BPD. Aims: This paper reports the findings of a non-controlled open feasibility study of STEPPS training in patients with BD and borderline personality features (BPF). Methods: Outpatients with BD were screened for BPD, and if positive interviewed with SCID-II. Patients with at least three BPF, always including impulsivity and anger burst, were included in the intervention study. Severity of BD and BPD and quality of life were assessed. Descriptive statistics were performed. Results: Of 111 patients with BD 49.5% also screened positive on BPD according to PDQ-4+, and 52.3% of these had BPD according to SCID-II. Very few participants entered the intervention study, and only nine patients completed STEPPS. Descriptive statistics showed improvement on all outcome variables post treatment, but no longer at 6-month follow up. We reflect on the potential reasons for the failed inclusion. Conclusion: Features of BPD were highly prevalent in patients with BD. Still, recruiting patients for a psychological treatment originally designed for BPD proved to be difficult. Feedback of participants suggests that the association of STEPPS with "borderline" had an aversive effect, which may have caused limited inclusion for screening and subsequent drop-out for the treatment. Therefore, STEPPS should be adapted for BD to be an acceptable treatment option. Clinical Trial Registration: www.ClinicalTrials.gov/3856, identifier: NTR4016.

The Impact of Impulsivity and Emotional Dysregulation on Comorbid Bipolar Disorder and Borderline Personality Disorder

The symptomatic overlap between borderline personality disorder (BPD) and bipolar disorder (BD) is a topic of scientific and academic debates. Emotional dysregulation and impulsivity are common features of both disorders. Several studies have shown that both BPD and BD lie on a spectrum; others have suggested that they are separate entities that coexist.  BPD is characterized by impulsive and dangerous behaviors such as driving recklessly, inappropriate sexual behavior, eating disorders, and substance abuse. BD, during a manic episode, is known for their impulsive and risk-taking behavior like hypersexuality, excessive spending, and substance abuse.  The current literature review aims to provide an overview of the impact of impulsivity and emotional dysregulation on comorbid bipolar disorder and borderline personality disorder. Our study results showed that patients with comorbid BPD and BD struggle with impulsive actions and have difficulty controlling their emotions. They are also highly susceptible to anxiety disorders like obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and somatoform disorders. Patients with comorbid BPD and BD struggle with severe psychosocial morbidity and an increased risk of suicide. In patients with only one disease, misdiagnosis is a common phenomenon due to the overlapping symptoms of BPD and BD.

Differential Diagnosis of Bipolar II Disorder and Borderline Personality Disorder

PURPOSE OF REVIEW

Differentiating bipolar (BP) disorders (in particular BP II) from borderline personality disorder (BPD) is a common diagnostic dilemma. We sought to critically examine recent studies that considered clinical differences between BP II and BPD, which might advance their delineation.

RECENT FINDINGS

Recent studies focused on differentiating biological parameters-genetics, epigenetics, diurnal rhythms, structural and functional neuroimaging-with indicative differences not yet sufficient to guide diagnosis. Key differentiating factors include family history, developmental antecedents, illness course, phenomenological differences in mood states, personality style and relationship factors. Less differentiating factors include impulsivity, neuropsychological profiles, gender distribution, comorbidity and treatment response. This review details parameters offering differentiation of BP II from BPD and should assist in resolving a frequent diagnostic dilemma. Future studies should specifically examine the BP II subtype directly with BPD, which would aid in sharpening the distinction between the disorders.

Amygdala Resting State Connectivity Differences between Bipolar II and Borderline Personality Disorders

BACKGROUND

Borderline personality disorder (BPD) and bipolar II disorder (BD II) have significant clinical overlap, leaving the potential for diagnostic inaccuracies and inadequate treatment recommendations. However, few studies have probed for clinical and neurobiological differences between the two disorders. Clinically, some prior studies have linked BPD with greater impulsivity and more frequent negative affective shifts than BD II, whereas previous neuroimaging studies have highlighted both similar and distinct neural abnormalities in BPD and BD II. Notably, no prior study has specifically targeted cortico-limbic neural differences, which have been hypothesized to underlie these core clinical differences.

METHODS

Individuals with BPD (n = 14) and BD II (n = 15) completed various clinical measures and a resting state functional imaging scan at 3T. Whole-brain amygdala resting state functional connectivity (RSFC) was compared between the two groups.

RESULTS

Relative to the BD II group, BPD participants reported significantly higher levels of impulsivity, trait anxiety, more frequent negative affective shifts, greater interpersonally reactive affective instability, lower overall functioning, and were characterized by lower amygdala-middle frontal gyrus RSFC. Lower amygdala-middle frontal gyrus RSFC was associated with greater impulsivity, trait anxiety, affective shifts, interpersonal affective reactivity, and functional impairment.

LIMITATIONS

The current study consisted of small sample sizes and lacked a control group.

CONCLUSIONS

This preliminary study suggests that amygdala-frontal RSFC may distinguish BPD from BD II. These results may guide future work aimed at identifying neural markers that can help disentangle these two disorders, leading to greater diagnostic accuracy and appropriate treatment implementation.

Psychopharmacological treatment of patients with borderline personality disorder: comparing data from routine clinical care with recommended guidelines

Objectives: Borderline personality disorder (BPD) is a life-threatening mental disorder. Guideline recommendations for pharmacological treatment of patients with BPD vary widely. The objective of the present study was to investigate pharmacotherapy of BPD patients in a routine clinical care setting. Methods: Data on the pharmacological treatment of 110 patients (90% female) with BPD (F- 60.3), treated in an inpatient psychiatric-psychosomatic clinic in Austria were assessed. Results: Results show that clinicians frequently prescribe psychotropic medications to patients with BPD, in many cases multiple medications. The most commonly prescribed substance groups were antipsychotics, mood stabilisers and antidepressants. The most commonly prescribed individual drugs were Quetiapine, Lamotrigine and Setraline. There was no significant difference in the different types or overall number of medications prescribed to BPD patients with vs. without comorbid diagnoses. Pharmacotherapy was not related to comorbidity. Conclusions: The present study shows that in routine clinical care settings psychotropic medications are frequently prescribed to patients with BPD, very often resulting in polypharmacy. A positive association between the number of medications and the effectiveness of the inpatient treatment program, as well as the absence of a relationship between number of medications and comorbidity contradicts the often suggested iatrogenic effect of polypharmacy. Key points Guidelines for pharmacotherapy of borderline personality disorders lack consensus Yet, clinicians frequently prescribe psychotropic medications to BPD patients Types/number of medications prescribed to patients with vs. without comorbidities are similar Larger treatment effects are observed for patients with greater numbers of medications Further knowledge is needed about how and why clinicians prescribe medications.

The Limits between Bipolar Disorder and Borderline Personality Disorder: A Review of the Evidence

Bipolar disorder and borderline personality disorder are among the most frequently diagnosed psychiatric conditions. However, the nosological aspects and diagnostic boundaries of both conditions have historically been the object of considerable controversy. The present paper critically analyzes this debate, in light of available evidence. Clinical and neurobiological differences between bipolar disorder and borderline personality disorder are discussed, as well as the factors possibly involved in the overlap between both conditions and the potential implications of this.

Common and distinct patterns of grey matter alterations in borderline personality disorder and bipolar disorder: voxel-based meta-analysis

BACKGROUND

Whether borderline personality disorder (BPD) and bipolar disorder are the same or different disorders lacks consistency.AimsTo detect whether grey matter volume (GMV) and grey matter density (GMD) alterations show any similarities or differences between BPD and bipolar disorder.

METHOD

Web-based publication databases were searched to conduct a meta-analysis of all voxel-based studies that compared BPD or bipolar disorder with healthy controls. We included 13 BPD studies (395 patients with BPD and 415 healthy controls) and 47 bipolar disorder studies (2111 patients with bipolar disorder and 3261 healthy controls). Peak coordinates from clusters with significant group differences were extracted. Effect-size signed differential mapping meta-analysis was performed to analyse peak coordinates of clusters and thresholds (P &lt; 0.005, uncorrected). Conjunction analyses identified regions in which disorders showed common patterns of volumetric alteration. Correlation analyses were also performed.

RESULTS

Patients with BPD showed decreased GMV and GMD in the bilateral medial prefrontal cortex network (mPFC), bilateral amygdala and right parahippocampal gyrus; patients with bipolar disorder showed decreased GMV and GMD in the bilateral medial orbital frontal cortex (mOFC), right insula and right thalamus, and increased GMV and GMD in the right putamen. Multi-modal analysis indicated smaller volumes in both disorders in clusters in the right medial orbital frontal cortex. Decreased bilateral mPFC in BPD was partly mediated by patient age. Increased GMV and GMD of the right putamen was positively correlated with Young Mania Rating Scale scores in bipolar disorder.

CONCLUSIONS

Our results show different patterns of GMV and GMD alteration and do not support the hypothesis that bipolar disorder and BPD are on the same affective spectrum.Declaration of interestNone.

Impulsivity and its association with childhood trauma experiences across bipolar disorder, attention deficit hyperactivity disorder and borderline personality disorder

BACKGROUND

Impulsivity is a core feature of the attention-deficit/hyperactivity disorder (ADHD) and is one of the DSM-V diagnostic criteria for borderline personality disorder (BPD). Impulsivity is also present in bipolar disorder (BD). Impulsivity has been linked to adverse behavior (suicidality,…) and to traumatic childhood experiences. Our study explored impulsivity in BPD, BD, ADHD and healthy controls (CTRL) and investigated the impact of early trauma on impulsivity.

METHODS

744 patients with BD (n = 276), BPD (n = 168), ADHD (n = 173) or a combination (BPD_BD, n = 29; BPD_ADHD, n = 94, BD_BPD_ADHD n = 13) and 47 controls were included. All subjects were completed the Baratt Impulsivity Scale (BIS-10) and the Childhood Trauma Questionnaire (CTQ).

RESULTS

BD reported the same levels of impulsiveness as CTRL. When BPD and BD are co-morbid, impulsivity increased to reach the level of BPD. Impulsiveness was significantly associated to traumatic childhood event for BD and CTRL, not for BPD and AHDH.

LIMITATIONS

Impulsivity was assessed on the basis of a self-report questionnaire and not by the mean of an objective measure such as a neuropsychological test. Moreover, we don't know what treatment our pathological subjects were receiving. But, ADHD and BPD, despite the probable treatment, were more impulsive than healthy CTRLs who did not take medications.

CONCLUSIONS

Impulsivity is probably not a feature of BD but is associated with the presence of traumatic childhood experiences, especially for euthymic patients, unlike BPD and ADHD. So, it seems essential to assess the presence of early trauma to reduce the impulsivity and improve the evolution of BD.

Bipolar affective disorder and borderline personality disorder: Differentiation based on the history of early life stress and psychoneuroendocrine measures

INTRODUCTION

Borderline Personality Disorder (BPD) and Bipolar Affective Disorder (BD) have clinical characteristics in common which often make their differential diagnosis difficult. The history of early life stress (ELS) may be a differentiating factor between BPD and BD, as well as its association with clinical manifestations and specific neuroendocrine responses in each of these diagnoses.

OBJECTIVE

Assessing and comparing patients with BD and BPD for factors related to symptomatology, etiopathogenesis and neuroendocrine markers.

METHODOLOGY

The study sample consisted of 51 women, divided into 3 groups: patients with a clinical diagnosis of BPD (n = 20) and BD (n = 16) and healthy controls (HC, n = 15). Standardized instruments were used for the clinical evaluation, while the history of ELS was quantified with the Childhood Trauma Questionnaire (CTQ), and classified according to the subtypes: emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect. The functioning of the hypothalamic-pituitary-adrenal (HPA) axis was evaluated by measuring a single plasma cortisol sample.

RESULTS

Patients with BPD presented with more severe psychiatric symptoms of: anxiety, impulsivity, depression, hopelessness and suicidal ideation than those with BD. The history of ELS was identified as significantly more prevalent and more severe in patients (BPD and BP) than in HC. Emotional abuse, emotional neglect and physical neglect also showed differences and were higher in BPD than BD patients. BPD patients had greater severity of ELS overall and in the subtypes of emotional abuse, emotional neglect and physical neglect than BD patients. The presence of ELS in patients with BPD and BP showed significant difference with lower cortisol levels when compared to HC. The endocrine evaluation showed no significant differences between the diagnoses of BPD and BD. Cortisol measured in patients with BPD was significantly lower compared to HC in the presence of emotional neglect and physical neglect. A significant negative correlation between the severity of hopelessness vs cortisol; and physical neglect vs cortisol were found in BPD with ELS. The single cortisol sample showed a significant and opposite correlations in the sexual abuse diagnosis-related groups, being a negative correlation in BD and positive in BPD.

DISCUSSION

Considering the need for a multi-factorial analysis, the differential diagnosis between BPD and BD can be facilitated by the study of psychiatric symptoms, which are more severe in the BPD patients with a history of early life stress. The function of the HPA axis assessed by this cortisol measure suggests differences between BPD and BP with ELS history.

CONCLUSION

The integrated analysis of psychopathology, ELS and neuroendocrine function may provide useful indicators to differentiate BPD and BD diagnoses. These preliminary data need to be replicated in a more significant sample with improved and multiple assessments of HPA axis activity.

Bipolar Disorder and Comorbid Borderline Personality Disorder: Patient Characteristics and Outcomes in US Hospitals

Background and objectives: The quality of life and disease outcomes in bipolar patients, including increased risk of psychiatric hospitalizations and suicide, are adversely affected by the presence of borderline personality disorder (BPD). Our study aims to determine the impact of BPD on the inpatient outcomes of bipolar disorder patients. Methods: We used Nationwide Inpatient Sample from the US hospitals and identified cases with bipolar disorder and comorbid BPD (N = 268,232) and controls with bipolar disorder only (N = 242,379), using the International Classification of Diseases, 9th Revision, and Clinical Modification codes. We used multinomial logistic regression to generate odds ratios (OR) and evaluate inpatient outcomes. Results: The majority of the bipolar patients with BPD were female (84.2%), Caucasian (83.1%) and 18–35 years age (53.9%). Significantly longer inpatient stays, higher inpatient charges, and higher prevalence of drug abuse were noted in bipolar patients with BPD. The suicide risk was higher in bipolar patients with BPD (OR = 1.418; 95% CI 1.384–1.454; p < 0.001). In addition, utilization of electroconvulsive treatment (ECT) was higher in bipolar patients with comorbid BPD (OR = 1.442; 95% CI 1.373–1.515; p < 0.001). Conclusions: The presence of comorbid BPD in bipolar disorder is associated with higher acute inpatient care due to a longer inpatient stay and higher cost during hospitalization, and higher suicide risk, and utilization of ECT. Further studies in the inpatient setting are warranted to develop effective clinical strategies for optimal outcomes and reduction of suicide risk in bipolar patients with BPD.

Factors associated with false positives in MDQ screening for bipolar disorder: Insight into the construct validity of the scale

BACKGROUND

Identifying bipolar patients in the first phases of the illness is essential to establish adequate treatment. The goal of this study was to examine the discriminant ability of the Mood Disorders Questionnaire (MDQ) in recognizing bipolar patients referred to a tertiary care structure.

METHODS

Between 2006 and 2012, we assessed 843 individuals referred to the Mood Disorders Program by family physicians in the community. The Structured Clinical Interview for DSM-IV-TR (SCID) was used to assess diagnoses. A nurse collected the information about lifetime symptoms of (hypo)mania in 759 individuals using the MDQ. Univariate chi-square test and logistic regression were used for the statistical analysis.

RESULTS

Overall, 86% of the sample had a current anxiety or depressive disorder. When compared to the diagnoses formulated through the SCID, the sensitivity of the MDQ was 75.0%, the specificity was 74%, the positive predictive value was 55%, and the negative predictive value was 88%. Among non-bipolar patients, current post-traumatic stress disorder, borderline personality disorder, current or early remission substance use disorder, and the history of childhood abuse were independently associated with false positive screening using the MDQ.

LIMITATIONS

Individuals with current substance use disorders were under-represented, whether or not the patients were aware of their diagnosis of bipolar disorder was not recorded, and the history of childhood abuse was collected based on an open interview.

CONCLUSIONS

The self-rated measure of the symptoms listed by the MDQ seems to measure a dimension shared by both bipolar disorder and other conditions characterized by affective instability and impulsivity.

Impulsivity predicts illness severity in long-term course of bipolar disorder: A prospective approach

BACKGROUND

Bipolar disorder is a common, severe and chronic mental illness. Despite this, predictors of illness severity remain poorly understood. Impulsivity is reported to be associated with bipolar disorder and aggravating comorbidities. This study therefore sought to examine the predictive value of impulsivity for determining illness severity in euthymic bipolar disorder patients.

METHODS

Baseline trait impulsivity of 120 bipolar euthymic patients (81 bipolar disorder I [68%], 80 female [67%]) and 51 healthy controls was assessed using Barratt Impulsiveness Scale 11. The impact of impulsivity on illness severity (measured with morbidity index) was prospectively tested in 97 patients with sufficient follow-up data (average observation time: 54.4 weeks), using linear regression analysis.

RESULTS

Barratt Impulsiveness Scale 11 total (β = 0.01; p < 0.01) and in particular Barratt Impulsiveness Scale 11 attentional subscale scores (β = 0.04; p < 0.001) predicted illness severity in bipolar disorder, while controlling for other clinical variables. Only age at onset persisted as an additional, but less influential predictor. Barratt Impulsiveness Scale 11 total scores and Barratt Impulsiveness Scale 11 attentional subscale scores were significantly higher in euthymic patients compared to controls. This was not observed for the motor or non-planning subscale scores.

LIMITATIONS

The average year-long observation time might not be long enough to account for the chronic course of bipolar disorder.

CONCLUSION

Trait impulsivity and particularly attentional impulsivity in euthymic bipolar patients can be strong predictors of illness severity in bipolar disorder. Future studies should explore impulsivity as a risk assessment for morbidity and as a therapeutic target in bipolar disorder patients.

Risk stratification for the early diagnosis of borderline personality disorder using psychiatric co-morbidities

AIM

To develop a risk stratification model for the early diagnosis of borderline personality disorder (BPD) using Taiwan National Health Insurance Research Database.

METHODS

We conducted a retrospective case-control study of 6132 patients (292 BPD patients and 5840 control subjects) who were selected from the National Health Insurance Research Database. Psychiatric co-morbidities including depressive disorder, bipolar disorder, anxiety disorder, substance-use disorder, personality disorders other than BPD, sleep disorder, eating disorder, autistic spectrum disorder, mental retardation and attention-deficit hyperactivity disorder, which were diagnosed within 3 years before enrolment, were collected. A logistic regression was used to calculate the odds ratio of psychiatric co-morbidities between subjects with and without BPD. The classification and regression tree method was used to generate a risk stratification model.

RESULTS

The odds ratios for depressive disorder, bipolar disorder, anxiety disorder, substance-use disorder, personality disorders other than BPD, sleep disorder, eating disorder, mental retardation and attention-deficit hyperactivity disorder were greater for BPD patients than for the control subjects. Furthermore, the risk of BPD can be reliably estimated using age and psychiatric co-morbidities including bipolar disorder, substance-use disorder and depressive disorder.

CONCLUSIONS

Most psychiatric disorders were more common in BPD patients than in the control subjects. Using psychiatric co-morbidities, we identified four variables as significant risk predictors of BPD and permitted identification of subjects with low, intermediate or high risk for BPD. The accuracy of the risk stratification model is high and can be easily applied in clinical practice.

Is 'subthreshold' bipolar II disorder more difficult to differentiate from borderline personality disorder than formal bipolar II disorder?

Recent research indicates that borderline personality disorder (BPD) can be diagnostically differentiated from the bipolar disorders. However, no studies have attempted to differentiate participants with sub-threshold bipolar disorder or SubT BP (where hypomanic episodes last less than 4 days) from those with a BPD. In this study, participants were assigned a SubT BP, bipolar II disorder (BP II) or BPD diagnosis based on clinical assessment and DSM-IV criteria. Participants completed self-report measures and undertook a clinical interview which collected socio-demographic information, a mood history, family history, developmental history, treatment information, and assessed cognitive, emotional and behavioural functioning. Both bipolar groups, whether SubT BP or BP II, differed to the BPD group on a number of key variables (i.e. developmental trauma, depression correlates, borderline personality scores, self-harm and suicide attempts), and compared to each other, returned similar scores on nearly all key variables. Borderline risk scores resulted in comparable classification rates of 0.74 (for BPD vs BP II) and 0.82 (for BPD vs sub-threshold BP II). Study findings indicate that both SubT BP and BP II disorder can be differentiated from BPD on a set of refined clinical variables with comparable accuracy.

The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders: Acute and long-term treatment of mixed states in bipolar disorder

OBJECTIVES

Although clinically highly relevant, the recognition and treatment of bipolar mixed states has played only an underpart in recent guidelines. This WFSBP guideline has been developed to supply a systematic overview of all scientific evidence pertaining to the acute and long-term treatment of bipolar mixed states in adults.

METHODS

Material used for these guidelines is based on a systematic literature search using various data bases. Their scientific rigour was categorised into six levels of evidence (A-F), and different grades of recommendation to ensure practicability were assigned. We examined data pertaining to the acute treatment of manic and depressive symptoms in bipolar mixed patients, as well as data pertaining to the prevention of mixed recurrences after an index episode of any type, or recurrence of any type after a mixed index episode.

RESULTS

Manic symptoms in bipolar mixed states appeared responsive to treatment with several atypical antipsychotics, the best evidence resting with olanzapine. For depressive symptoms, addition of ziprasidone to treatment as usual may be beneficial; however, the evidence base is much more limited than for the treatment of manic symptoms. Besides olanzapine and quetiapine, valproate and lithium should also be considered for recurrence prevention.

LIMITATIONS

The concept of mixed states changed over time, and recently became much more comprehensive with the release of DSM-5. As a consequence, studies in bipolar mixed patients targeted slightly different bipolar subpopulations. In addition, trial designs in acute and maintenance treatment also advanced in recent years in response to regulatory demands.

CONCLUSIONS

Current treatment recommendations are still based on limited evidence, and there is a clear demand for confirmative studies adopting the DSM-5 specifier with mixed features concept.

Emotional dysregulation in those with bipolar disorder, borderline personality disorder and their comorbid expression

BACKGROUND

Differentiation of the bipolar disorders (BP) from a borderline personality disorder (BPD) can be challenging owing to shared features, with emotional dysregulation being the likely principal one.

AIM

To assess differences in emotion regulation strategies in those with BP alone, BPD alone and those comorbid for both.

METHODS

We interviewed participants previously receiving a BP or BPD diagnosis, studying those who met DSM criteria for one or both conditions.

RESULTS

The sample comprised 83 with bipolar disorder, 53 with BPD and 54 comorbid for both. Analyses established linear trends, with the greatest impairment in emotion regulation strategies in the comorbid group followed by the BPD group, and with the lowest in the BP group. Specific deficits in the comorbid group included impulsivity, difficulties with goal directed behaviour, and accessing strategies. A similar linear profile was quantified for maladaptive cognitive emotion regulation strategies, weighted to catastrophizing and rumination. Adaptive emotion regulation strategies were superior in the bipolar group, without significant differences observed between the comorbid and BPD groups.

LIMITATIONS

Reliance on self-report measures; combined BP I and II participants limits generalisability of results to each bipolar sub-type; use of DSM diagnoses risking artefactual comorbidity; while there was an over-representation of females in all groups.

CONCLUSIONS

Differences in emotion regulation strategies advance differentiation of those with either BP or BPD, while we identify the specificity of differing strategies to each condition and their synergic effect in those comorbid for both conditions. Study findings should assist the development and application of targeted strategies for those with either or both conditions.

Comorbidity between bipolar disorder and borderline personality disorder: Prevalence, explanatory theories, and clinical impact

BACKGROUND

The relationship between bipolar disorder (BD) and borderline personality disorder (BPD) has been controversial and widely debated. Specifically, the comorbidity between both disorders has yielded a plethora of research, but there are no comprehensive reviews on this issue.

OBJECTIVE

To determine the empirical evidence regarding the comorbidity between BD and BPD based on prevalence data, explanatory theories for their co-occurrence, and clinical impact of one disorder in the other.

METHOD

A comprehensive search of databases (PubMed and PsycINFO) was performed. Published manuscripts between January 1985 and August 2015 were identified. Overall, 70 studies fulfilled inclusion criteria.

RESULTS

Over a fifth of subjects showed comorbidity between BPD and BD. Empirical evidence from common underlying factors was inconclusive, but BPD appears to be a risk factor for BD. Data also indicated that the negative impact of BPD in BD (e.g., suicidality, worse mood course) was greater than vice verse.

CONCLUSIONS

Given the high prevalence of comorbidity between BD and BPD and the negative effects of BPD in subjects with BD, further studies are needed to clarify the factor associated with the comorbidity between these two disorders. This information is important to develop appropriate treatments for subjects with both disorders, improve their clinical course, and prevent the increased risk of suicidality commonly found in these subjects.

Clinical status of comorbid bipolar disorder and borderline personality disorder

BACKGROUND

The status and differentiation of comorbid borderline personality disorder and bipolar disorder is worthy of clarification.

AIMS

To determine whether comorbid borderline personality disorder and bipolar disorder are interdependent or independent conditions.

METHOD

We interviewed patients diagnosed with either a borderline personality disorder and/or a bipolar condition.

RESULTS

Analyses of participants grouped by DSM diagnoses established that those with comorbid conditions scored similarly to those with a borderline personality disorder alone on all key variables (i.e. gender, severity of borderline personality scores, developmental stressors, illness correlates, self-injurious behaviour rates) and differed from those with a bipolar disorder alone on nearly all non-bipolar item variables. Similar findings were returned for groups defined by clinical diagnoses.

CONCLUSIONS

Comorbid bipolar disorder and borderline personality disorder is consistent with the formal definition of comorbidity in that, while coterminous, individuals meeting such criteria have features of two independent conditions.

Improving the Recognition of Borderline Personality Disorder in a Bipolar World

Both bipolar disorder and borderline personality disorder (BPD) are serious mental health disorders resulting in significant psychosocial morbidity, reduced health-related quality of life, and excess mortality. Yet research on BPD has received much less funding from the National Institute of Health (NIH) than has bipolar disorder during the past 25 years. Why hasn't the level of NIH research funding for BPD been commensurate with the level of psychosocial morbidity, mortality, and health expenditures associated with the disorder? In the present article, the author illustrates how the bipolar disorder research community has done a superior job of "marketing" their disorder. Studies of underdiagnosis, screening, diagnostic spectra, and economics are reviewed for both bipolar disorder and BPD. Researchers of bipolar disorder have conducted multiple studies highlighting the problem with underdiagnosis, developed and promoted several screening scales, published numerous studies of the operating characteristics of these screening measures, attempted to broaden the definition of bipolar disorder by advancing the concept of the bipolar spectrum, and repeatedly demonstrated the economic costs and public health significance of bipolar disorder. In contrast, researchers of BPD have almost completely ignored each of these four issues and research efforts. Although BPD is as frequent as (if not more frequent than) bipolar disorder, as impairing as (if not more impairing than) bipolar disorder, and as lethal as (if not more lethal than) bipolar disorder, it has received less than one-tenth the level of funding from the NIH and has been the focus of many fewer publications in the most prestigious psychiatric journals. The researchers of BPD should consider adopting the strategy taken by researchers of bipolar disorder before the diagnosis is eliminated in a future iteration of the DSM or the ICD.

Differentiating the bipolar disorders from borderline personality disorder

OBJECTIVE

To identify features differentiating bipolar disorder (BP) from borderline personality disorder (BPD) and with each condition variably defined.

METHOD

Participants were assigned a BP or BPD diagnosis on the basis of DSM criteria and, separately, by clinical judgment, and undertook a diagnostic interview and completed self-report measures.

RESULTS

Predictors of BPD status varied according to diagnostic decisions, but with the most consistent items being childhood sexual abuse, childhood depersonalization, personality variables relating to relationship difficulties and sensitivity to criticism, and the absence of any BP family history. Across diagnostic groups, personality measure items alone predicted diagnostic allocation with an accuracy of 81-84%, the refined study variables other than hypo/manic features improved the classification rates to 88%, and when the presence or absence of hypo/manic features was added, classification rates increased to 92-95%.

CONCLUSION

Study findings indicate that BPD can be differentiated from BP with a high degree of accuracy.

Relationships between mixed features and borderline personality disorder in 2811 patients with major depressive episode

OBJECTIVE

The study focused on the relationship between mixed depression and borderline personality disorder (BPD).

METHOD

The sample comprised 2811 patients with a major depressive episode (MDE). Clinical characteristics were compared in patients with (BPD+) and without (BPD-) comorbid BPD and in BPD+ with (MXS+) and without (MXS-) mixed features according to DSM-5 criteria.

RESULTS

A total of 187 patients (6.7%) met the criteria for BPD. A DSM-IV-TR diagnosis of bipolar disorder (BD) was significantly more frequent in patients with BPD+ than in patients with BPD. Patients with BPD+ were significantly younger and reported lower age at onset than BPD-. Patients with BPD+ also showed more hypomania/mania in first-degree relatives in comparison with patients with BPD-, as well as more psychiatric comorbidity, mixed features, atypical features, suicide attempts, prior mood episodes and antidepressant-induced hypo/manic switches. Mixed features according to DSM-5 criteria were observed in 52 (27.8%) BPD+. In comparison with MXS-, MXS+ were significantly younger at age of onset and at prior mood episode and had experienced more mood episodes and hypo/manic switches with antidepressant treatments.

CONCLUSION

Major depressive episode patients with comorbid BPD reported a high prevalence of mixed features and BD. The presence of DSM-5 mixed features in MDE patients with BPD may be associated with complex course and reduced treatment response.

Does Borderline Personality Disorder Manifest Itself Differently in Patients With Bipolar Disorder and Major Depressive Disorder?

Perugi and colleagues (2013) recently reported that some features of borderline personality disorder (BPD) significantly predicted a diagnosis of bipolar disorder among depressed patients. They interpreted these findings as indicating that some BPD criteria are nonspecific and are indicators of bipolar disorder rather than BPD, whereas other criteria are more specific to BPD. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, the authors tested the hypothesis that BPD presents itself differently in psychiatric outpatients diagnosed with bipolar disorder or major depressive disorder. The authors found that the patients with bipolar disorder were significantly more likely to report impulsive behavior and transient dissociation. No criterion was significantly more common in the BPD patients with MDD. The authors therefore do not consider the BPD criteria to be nonspecific with regard to the distinction between BPD and bipolar disorder.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide guidance for the management of mood disorders, based on scientific evidence supplemented by expert clinical consensus and formulate recommendations to maximise clinical salience and utility.

METHODS

Articles and information sourced from search engines including PubMed and EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (MDC) (e.g., books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Information was reviewed and discussed by members of the MDC and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous successive consultation and external review involving: expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (Mood Disorders CPG) provide up-to-date guidance and advice regarding the management of mood disorders that is informed by evidence and clinical experience. The Mood Disorders CPG is intended for clinical use by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSIONS

The Mood Disorder CPG is the first Clinical Practice Guideline to address both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Professor Gin Malhi (Chair), Professor Darryl Bassett, Professor Philip Boyce, Professor Richard Bryant, Professor Paul Fitzgerald, Dr Kristina Fritz, Professor Malcolm Hopwood, Dr Bill Lyndon, Professor Roger Mulder, Professor Greg Murray, Professor Richard Porter and Associate Professor Ajeet Singh.

INTERNATIONAL EXPERT ADVISORS

Professor Carlo Altamura, Dr Francesco Colom, Professor Mark George, Professor Guy Goodwin, Professor Roger McIntyre, Dr Roger Ng, Professor John O'Brien, Professor Harold Sackeim, Professor Jan Scott, Dr Nobuhiro Sugiyama, Professor Eduard Vieta, Professor Lakshmi Yatham.

AUSTRALIAN AND NEW ZEALAND EXPERT ADVISORS

Professor Marie-Paule Austin, Professor Michael Berk, Dr Yulisha Byrow, Professor Helen Christensen, Dr Nick De Felice, A/Professor Seetal Dodd, A/Professor Megan Galbally, Dr Josh Geffen, Professor Philip Hazell, A/Professor David Horgan, A/Professor Felice Jacka, Professor Gordon Johnson, Professor Anthony Jorm, Dr Jon-Paul Khoo, Professor Jayashri Kulkarni, Dr Cameron Lacey, Dr Noeline Latt, Professor Florence Levy, A/Professor Andrew Lewis, Professor Colleen Loo, Dr Thomas Mayze, Dr Linton Meagher, Professor Philip Mitchell, Professor Daniel O'Connor, Dr Nick O'Connor, Dr Tim Outhred, Dr Mark Rowe, Dr Narelle Shadbolt, Dr Martien Snellen, Professor John Tiller, Dr Bill Watkins, Dr Raymond Wu.

Executive dysfunction in bipolar disorder and borderline personality disorder

Objective

The boundary between bipolar disorder (BD) and borderline personality disorder is a controversial one. Despite the importance of the topic, few studies have directly compared these patient groups. The aim of the study was to compare the executive functioning profile of BD and BPD patients.

Method

Executive functioning (sustained attention, problem-solving, planning, strategy formation, cognitive flexibility and working memory) was assessed in BD (n= 30) and BPD outpatients (n= 32) using a computerized assessment battery (Cambridge Neuropsychological Test Automated Battery, CANTAB). The groups were compared to one another as well as to healthy controls.

Results

BD patients showed deficits in strategy formation and in planning (indicated by longer execution time in the ToL task) in comparison to BPD patients and healthy controls. BPD patients showed deficits in planning (short deliberation time in the ToL task) in comparison to BD patients and in comparison to healthy controls. In comparison to healthy controls, BPD patients displayed deficits in problem-solving.

Conclusions

Differences in executive dysfunction between BD and BPD patients suggest that this cognitive dimension may be relevant for the clarification of the boundary between the disorders.

Differences and overlap in self-reported symptoms of bipolar disorder and borderline personality disorder

Background

Differential diagnosis between bipolar disorder (BD) and borderline personality disorder (BPD) is often challenging due to some overlap in symptoms and comorbidity of disorders. We investigated correlations in self-reported symptoms of BD and BPD in screening questionnaires at the levels of both total scores and individual items and explored overlapping dimensions.

Methods

The McLean Screening Instrument (MSI) for BPD and the Mood Disorder Questionnaire (MDQ) for BD were filled in by patients with unipolar and bipolar mood disorders (n = 313) from specialized psychiatric care within a pilot study of the Helsinki University Psychiatric Consortium. Pearson's correlation coefficients between total scores and individual items of the MSI and the MDQ were estimated. Relationships between MDQ and MSI were evaluated by exploratory factor analysis (EFA).

Results

The correlation between total scores of the MDQ and MSI was moderate (r = 0.431, P < 0.001). Significant correlations were found between the MSI items of “impulsivity” and “mood instability” and all MDQ items (P < 0.01). In the EFA, the MSI “impulsivity” and “mood instability” items had significant cross-loadings (0.348 and 0.298, respectively) with the MDQ factor. The MDQ items of “irritability”, “flight of thoughts” and “distractibility” (0.280, 0.210 and 0.386, respectively) cross-loaded on the MSI factor.

Conclusions

The MDQ and MSI items of “affective instability”, “impulsivity”, “irritability”, “flight of thoughts” and “distractibility” appear to overlap in content. The other scale items are more disorder-specific, and thus, may help to distinguish BD and BPD.

Psychosocial morbidity associated with bipolar disorder and borderline personality disorder in psychiatric out-patients: comparative study

BACKGROUND

The morbidity associated with bipolar disorder is, in part, responsible for repeated calls for improved detection and recognition. No such commentary exists for the improved detection of borderline personality disorder. Clinical experience suggests that it is as disabling as bipolar disorder, but no study has directly compared the two disorders.

AIMS

To compare the levels of psychosocial morbidity in patients with bipolar disorder and borderline personality disorder.

METHOD

Patients were assessed with semi-structured interviews. We compared 307 patients with DSM-IV borderline personality disorder but without bipolar disorder and 236 patients with bipolar disorder but without borderline personality disorder.

RESULTS

The patients with borderline personality disorder less frequently were college graduates, were diagnosed with more comorbid disorders, more frequently had a history of substance use disorder, reported more suicidal ideation at the time of the evaluation, more frequently had attempted suicide, reported poorer social functioning and were rated lower on the Global Assessment of Functioning. There was no difference between the two patient groups in history of admission to psychiatric hospital or time missed from work during the past 5 years.

CONCLUSIONS

The level of psychosocial morbidity associated with borderline personality disorder was as great as (or greater than) that experienced by patients with bipolar disorder. From a public health perspective, efforts to improve the detection and treatment of borderline personality disorder might be as important as efforts to improve the recognition and treatment of bipolar disorder.

Analysis of genome-wide significant bipolar disorder genes in borderline personality disorder

Supplemental Digital Content is available in the text.

The objective of this study was to investigate the hypothesis that borderline personality disorder (BPD) and bipolar disorder (BD) share genetic variation through analysis of known genetic risk factors for BD in a well-characterized BPD case–control cohort. Genotyping of five genome-wide significant variants identified for BD (in CACNA1C, ANK3, and ODZ4) was performed in 673 BPD cases and 748 controls. A nominally significant association with BPD was found for rs1006737 in CACNA1C (P=0.0498). Sex-specific analysis showed that this signal was present only in women. This is the first report of an association between a BD risk gene and BPD where selection was not based on a priori hypotheses about its function, but on an unbiased hypothesis-free screening of the genome. Genome-wide association data of large samples of BPD are warranted and will eventually identify new risk genes and the overlap between BPD and BD if it exists.

The borderline of bipolar: opinions of patients and lessons for clinicians on the diagnostic conflict

Aims and method It has been observed that some individuals self-diagnose with a bipolar affective disorder and many are later diagnosed with a borderline personality disorder. There is a background context of clinical and neurobiological overlap between these conditions, and fundamental debates on the validity of current diagnostic systems. This qualitative study is the first work to explore the views of patients caught at this diagnostic interface. We predicted that media exposure, stigma and attribution of responsibility would be key factors affecting patient understanding and opinion. Results Six core illness-differentiating themes emerged: public information, diagnosis delivery, illness causes, illness management, stigma, and relationship with others. Individuals did not 'want' to be diagnosed with a bipolar disorder, but wished for informed care. Clinical implications Understanding patient perspectives will allow clinical staff to better appreciate the difficulties faced by those we seek to help, identify gaps in care provision, and should stimulate thought on our attitudes to care and how we facilitate provision of information, including information about diagnosis.

Borderline personality disorder: a disorder in search of advocacy

Compared with bipolar disorder, borderline personality disorder (BPD) is as frequent (if not more frequent), as impairing (if not more impairing), and as lethal (if not more lethal). Yet, BPD has received less than one-tenth the funding from the National Institutes of Health than has bipolar disorder. More than other reviewers of the literature on the interface between bipolar disorder and BPD, Paris and Black (Paris J and Black DW (2015) Borderline Personality Disorder and Bipolar Disorder: What is the Difference and Why Does it Matter? J Nerv Ment Dis 203:3-7) emphasize the clinical importance of correctly diagnosing BPD and not overdiagnosing bipolar disorder, with a focus on the clinical feature of affective instability and how the failure to recognize the distinction between sustained and transient mood perturbations can result in misdiagnosing patients with BPD as having bipolar disorder. The review by Paris and Black, then, is more of an advocacy for BPD than other reviews in this area have been. In the present article, the author will illustrate how the bipolar disorder research community has done a superior job of advocating for and "marketing" their disorder compared with researchers of BPD. Specifically, researchers of bipolar disorder have conducted multiple studies highlighting the problem with underdiagnosis, written commentaries about the problem with underdiagnosis, developed and promoted several screening scales to improve diagnostic recognition, published numerous studies of the operating characteristics of these screening measures, attempted to broaden the definition of bipolar disorder by advancing the concept of the bipolar spectrum, and repeatedly demonstrated the economic costs and public health significance of bipolar disorder. In contrast, researchers of BPD have almost completely ignored each of these issues and thus have been less successful in highlighting the public health significance of the disorder.

Is research on borderline personality disorder underfunded by the National Institute of Health?

The relationship between bipolar disorder and borderline personality disorder has generated intense interest. Similar to patients with bipolar disorder, patients with borderline personality disorder are frequently hospitalized, are chronically unemployed, abuse substances, attempt and commit suicide. However, one significant difference between the two disorders is that patients with borderline personality disorder are often viewed negatively by mental health professionals. In the present paper we examined whether this negative bias against borderline personality disorder might be reflected in the level of research funding on the disorder. We searched the National Institute of Health (NIH) Research Portfolio Online Portfolio Reporting Tool (RePORT) for the past 25 years and compared the number of grants funded and the total amount of funding for borderline personality disorder and bipolar disorder. The yearly mean number of grants receiving funding was significantly higher for bipolar disorder than for borderline personality disorder. Results were the same when focusing on newly funded grants. For every year since 1990 more grants were funded for bipolar disorder than borderline personality disorder. Summed across all 25 years, the level of funding for bipolar disorder was more than 10 times greater than the level of funding for borderline personality disorder ($622 million vs. $55 million). These findings suggest that the level of NIH research funding for borderline personality disorder is not commensurate with the level of psychosocial morbidity, mortality, and health expenditures associated with the disorder.

Affective lability in patients with bipolar disorders is associated with high levels of childhood trauma

This study aimed to investigate associations between a history of childhood trauma and levels of affective lability in bipolar patients compared to controls. Forty-two patients and 14 controls were assessed using the Affective Lability Scale (ALS) and the Childhood Trauma Questionnaire (CTQ). Affective Lability Score was significantly associated with scores on the Childhood Trauma Questionnaire. A multivariate regression model indicated a relationship between childhood trauma scores and differences in affective lability between patients and controls.

Bipolar or borderline: a clinical overview

OBJECTIVE

To examine the empirical literature on diagnostic validators in borderline personality and bipolar illness.

METHOD

Using principles of evidence-based medicine, the highest levels of evidence were emphasized in interpretation of similarities or differences between bipolar illness and borderline personality on the five standard diagnostic validators in psychiatric nosology: symptoms, course, genetics, treatment response, and neurobiology.

RESULTS

Bipolar illness and borderline personality were found to be similar in the nosological validator of symptoms of mood lability and impulsivity, but differed notably on all other diagnostic validators, especially the course validator of past sexual abuse and the genetic validator of a bipolar family history. They also differ notably in the symptom validator of parasuicidal self-harm. Treatment response and neurobiological differences were also present and consistent.

CONCLUSION

This review of the literature indicates that these two conditions, bipolar illness and borderline personality, are different and can be distinguished. The much stronger biological and genetic evidence for bipolar illness in particular suggests that the two conditions can be reasonably seen as different kinds of clinical entities, namely a biological disease versus a psychosocially caused clinical picture. If this interpretation is correct, similarities between the two conditions, such as mood lability and impulsivity, are superficial, while differences are profound. Further, true comorbidity may be much less common than often presumed.

The relationship between borderline personality disorder and bipolar disorder

It is clinically important to recognize both bipolar disorder and borderline personality disorder (BPD) in patients seeking treatment for depression, and it is important to distinguish between the two. Research considering whether BPD should be considered part of a bipolar spectrum reaches differing conclusions. We reviewed the most studied question on the relationship between BPD and bipolar disorder: their diagnostic concordance. Across studies, approximately 10% of patients with BPD had bipolar I disorder and another 10% had bipolar II disorder. Likewise, approximately 20% of bipolar II patients were diagnosed with BPD, though only 10% of bipolar I patients were diagnosed with BPD. While the comorbidity rates are substantial, each disorder is nontheless diagnosed in the absence of the other in the vast majority of cases (80% to 90%). In studies examining personality disorders broadly, other personality disorders were more commonly diagnosed in bipolar patients than was BPD. Likewise, the converse is also true: other axis I disorders such as major depression, substance abuse, and post-traumatic stress disorder are also more commonly diagnosed in patients with BPD than is bipolar disorder. These findings challenge the notion that BPD is part of the bipolar spectrum.

Additive effects of childhood abuse and cannabis abuse on clinical expressions of bipolar disorders

BACKGROUND

Previous studies of bipolar disorders indicate that childhood abuse and substance abuse are associated with the disorder. Whether both influence the clinical picture, or if one is mediating the association of the other, has not previously been investigated.

METHOD

A total of 587 patients with bipolar disorders were recruited from Norway and France. A history of childhood abuse was obtained using the Childhood Trauma Questionnaire. Diagnosis and clinical variables, including substance abuse, were based on structured clinical interviews (Structured Clinical Interview for DSM-IV Axis I disorders or French version of the Diagnostic Interview for Genetic Studies).

RESULTS

Cannabis abuse was significantly associated with childhood abuse, specifically emotional and sexual abuse (χ 2 = 8.63, p = 0.003 and χ 2 = 7.55, p = 0.006, respectively). Cannabis abuse was significantly associated with earlier onset of the illness (z = -4.17, p < 0.001), lifetime history of at least one suicide attempt (χ 2 = 11.16, p = 0.001) and a trend for rapid cycling (χ 2 = 3.45, p = 0.06). Alcohol dependence was associated with suicide attempt (χ 2 = 10.28, p = 0.001), but not with age at onset or rapid cycling. After correcting for possible confounders and multiple testing, a trend was observed for an interaction between cannabis abuse and childhood abuse and suicide attempt (logistic regression: r 2 = 0.06, p = 0.039). Significant additive effects were also observed between cannabis abuse and childhood abuse on earlier age at onset (p < 0.001), increased rapid cycling and suicide attempt (logistic regression: r 2 = 0.03-0.04, p < 0.001). No mediation effects were observed; childhood abuse and cannabis abuse were independently associated with the disorder.

CONCLUSIONS

Our study is the first to demonstrate significant additive effects, but no mediation effects, between childhood abuse and cannabis abuse on increased clinical expressions of bipolar disorders.

Bipolar and borderline patients display differential patterns of functional connectivity among resting state networks

Bipolar disorder (BD) and borderline personality (BPD) disorder share clinical features such as emotional lability and poor interpersonal functioning but the course of illness and treatment differs in these groups, which suggests that the underlying neurobiology of BD and BPD is likely to be different. Understanding the neural mechanisms behind the pathophysiology of BD and BPD will facilitate accurate diagnosis and inform the administration of targeted treatment. Since deficits in social cognition or emotion regulation or in the self-referential processing system can give rise to these clinical features, and impairment in these domains have been observed in both patient groups, functional connectivity within and between networks subserving these processes during resting was investigated using functional magnetic resonance imaging. Data were acquired from 16 patients with BD, 14 patients with BPD, and 13 healthy controls (HC) and functional connectivity strength was correlated with scores using the Difficulties in Emotion Regulation Scale. Functional network connectivity (FNC) patterns differentiated BD and BPD patients from HC. In BD, FNC was increased while in BPD it was decreased. In BD impaired FNC was evident primarily among networks involved in self-referential processing while in BPD it also involved the emotion regulatory network. Impaired FNC displayed an association with impulsivity in BPD and emotional clarity and emotional awareness in BD. This study shows that BD and BPD can perhaps be differentiated using resting state FNC approach and that the neural mechanisms underpinning overlapping symptoms discernibly differ between the groups. These findings provide a potential platform for elucidating the targeted effects of psychological interventions in both disorders.

The bipolar spectrum: conceptions and misconceptions

OBJECTIVE

This review aims to address concerns about the potential overinclusiveness and vagueness of bipolar spectrum concepts, and also, concerns about the overlap between bipolar illness and borderline personality.

METHOD

Narrative review based on historical and empirical studies.

RESULTS

Bipolar disorder (BD) and major depressive disorder (MDD) came to be separate entities with the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM III), in contrast to the Kraepelinian manic-depressive insanity (MDI) concept, which included both. The bipolar spectrum concept is a return to this earlier Kraepelinian perspective. Further, very different features differentiate the disease of bipolar illness (family history of bipolar illness, severe recurrent mood episodes with psychomotor activation) from the clinical picture of borderline personality (dissociative symptoms, sexual trauma, parasuicidal self-harm). The term 'disorder' obfuscates an ontological difference between diseases, such as manic-depressive illness, and clinical pictures, such as hysteria/post-traumatic stress disorder/dissociation/borderline personality.

CONCLUSIONS

Bipolar spectrum concepts are historically rooted in Kraepelin's manic-depressive illness concept, are scientifically testable, and can be clearly formulated. Further, they differ in kind from traumatic/dissociative conditions in ways that can be both historically and scientifically established.

Clinical differentiation of bipolar II disorder from borderline personality disorder

PURPOSE OF REVIEW

Differentiating bipolar II disorder (BP II) from borderline personality disorder (BPD) is a common diagnostic dilemma. The purpose of this review is to focus on recent studies that have considered clinical differences between the conditions including family history, phenomenology, longitudinal course, comorbidity and treatment response, and which might advance their clinical distinction.

RECENT FINDINGS

Findings suggest key differentiating parameters to include family history, onset pattern, clinical course, phenomenological profile of depressive and elevated mood states, and symptoms of emotional dysregulation. Less specific differentiation is provided by childhood trauma history, deliberate self-harm, comorbidity rates, neurocognitive features, treatment response and impulsivity parameters.

SUMMARY

This review refines candidate variables for differentiating BP II from BPD, and should assist the design of studies seeking to advance their phenomenological and clinical distinction.

The spectrum of borderline personality disorder: a neurophysiological view

Borderline Personality Disorder (BPD) has been defined as a personality disorder in all editions of DSM since 1980; namely, DSM III through V. The criteria are a mixture of symptoms and traits; the etiology, a heterogeneous array of genetic, constitutional, and environmental factors. Until recently the diagnosis relied on clinical descriptions. In the last two decades, neurophysiological data, including MRI and fMRI, have established correlates in various brain regions, particularly those involving the frontal lobes and various limbic structures, that show promise of providing a more substantial basis for diagnosis-relying primarily on (internal) brain changes, rather than on (external) clinical observation. Some of the changes in BPD consist of decreased volume in the orbitofrontal and dorsolateral prefrontal cortices and smaller volume in both the amygdala and hippocampus, though with heightened reactivity in the amygdala. Similar abnormalities have been noted in bipolar disorders (BDs) and in ADHD, both of which often accompany BPD and share certain clinical features. Persons with strong genetic predisposition to BDs can develop BPD even in the absence of adverse environmental factors; those with extreme adverse environmental factors (chiefly, early sexual molestation) can develop BPD in the absence of bipolar vulnerability. In some BPD patients, both sets of factors are present. As ideal treatment depends on careful analysis of these factors, neurophysiological testing may permit both more rational, brain-based diagnostic decisions and more appropriate therapeutic strategies.