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ersonality disorders (PDs) are characterized as enduring and inflexible patterns of thought, feelings, and behaviors that impair a
person's psychosocial or vocational functioning (American Psychiatric
Association, 2013). PDs are frequent in the community but especially
common in inpatient and clinic settings (Lenzenweger et al., 2007;
Zimmerman et al., 2005). These conditions are defined in Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as
chronic disorders with major effects on mood, behavior, cognition,
and interpersonal relationships. However, because state-dependent
and trait-dependent phenomena can coexist in many mental disorders,
it can be difficult to distinguish PDs from diagnoses associated with
active symptoms.
Much of the literature and research on PDs concern borderline
PD (BPD) classified in International Classification of Diseases 10th
Edition as emotionally unstable personality disorder, a term that better
reflects the underlying pathology (World Health Organization, 1992).
To receive a PD diagnosis in DSM-5, a patient must a) satisfy general
criteria (maladaptive patterns of behavior causing long-term difficulties
in personal relationships and/or social functioning) or b) meet specific
criteria for 1 of the 10 listed PDs, or if none of these criteria are met, a
residual category (unspecified or otherwise specified) can be used.
BPD, one of the most frequently diagnosed PDs, is characterized
by affective instability (AI), impulsive behavior, deliberate self-harm,
and disturbed relationships. Its community prevalence approaches
1%, similar to that of schizophrenia (Lenzenweger et al., 2007). Although one study found rates as high as 5.9% (Grant et al., 2004), this
result may be an overestimate; a later reanalysis of the data set brought
prevalence down to 2% (Trull et al., 2010). BPD generally has an onset
PHENOMENOLOGY
Because AI is a major symptom of BPD, some experts have considered this disorder to be a bipolar variant characterized by ultra-rapid
cycling (Akiskal, 2003). Others have conceptualized BPD as a separate
category characterized by unstable mood (Tyrer, 2009). This review
will suggest that both these conclusions are mistaken. Although few
studies have directly compared BPD and bipolar disorder, those that
have done so suggest that they are separate and unique (Paris et al.,
2007; Zimmerman and Morgan, 2013).
The underlying problem is that psychiatry continues to struggle
to understand the endophenotypes behind mental illness (Gottesman
and Gould, 2003). In their absence, specialists have had to rely on phenomenological similarities to classify disorders. This is one of the main
reasons for the uncertain validity of current diagnostic systems (Paris,
2013). Moreover, because of overlapping criteria sets, disorders often
seem comorbid with each other or are frequently confused (Black
and Grant, 2014).
The difference between AI and bipolarity is an example of this
problem. AI is defined in DSM-5 (p. 663) as a marked reactivity of
mood (e.g., intense episodic dysphoria, irritability, or anxiety usually
lasting a few hours and only rarely more than a few days). According
to one influential theory, AI is responsible for the emotion dysregulation underlying BPD, a core trait that is exaggerated by failures of psychological validation (Linehan, 1993).
Research confirms that AI is heritable (Livesley et al., 1998), and
it is the trait least likely to change over time (Paris, 2003). Ecological
momentary assessment methods show that AI is triggered by interpersonal stressors and that BPD patients have unusually high reactivity
to conflictual interactions (Russell-Archambault et al., 2007). Research
also shows that mood shifts in BPD usually move from euthymia to anger, not from depression to elation, as in bipolar disorder. Mood swings
in bipolar disorder tend to be more spontaneous and less responsive to
environmental cues (Koenigsberg, 2010).
The Journal of Nervous and Mental Disease Volume 203, Number 1, January 2015
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The Journal of Nervous and Mental Disease Volume 203, Number 1, January 2015
The time course of mood swings is crucial. A hypomanic episode, as defined in DSM-5 (p. 132), consists of persistently elevated,
expansive, or irritable mood, lasting throughout at least 4 days. Applying this definition, hypomania occurs only in a minority of patients with
BPD (Paris et al., 2007). Moreover, because assessment depends on accurate retrospective reporting by patients, the diagnosis of hypomania
can be unreliable without corroborating data from family members or
other informants (Dunner and Tay, 1993).
Some investigators have suggested that most forms of mood instability should be considered to fall within a bipolar spectrum (Angst
and Gamma, 2002). If mood shifts that occur on an hourly basis are
seen a subclinical form of bipolarity, then BPD would easily fall within
such a spectrum. One survey that applied these criteria found that 40%
of all patients at several sites have a bipolar spectrum disorder (Akiskal
et al., 2006). If this construct is valid, then bipolarity is very common
indeed. Bipolar disorder types I and II have a combined prevalence of
2%, but that figure doubles when subclinical cases are included
(Merikangas et al., 2007). DSM-5 also allows for a diagnosis of unspecified bipolar disorder that can be used to describe patients in the
spectrum, even when mood swings do not meet criteria for hypomania.
The bipolar spectrum concept has also been extended to behaviorally disturbed children who present with AI and impulsivity.
Follow-up of cohorts into adolescence (Birmaher et al., 2006; Geller
et al., 2008) has shown that these traits remain stable, but they tend
not to evolve into classical mania (although the authors of both studies
interpreted continued AI as a form of mania or hypomania). Concern
about overuse of the bipolar diagnosis in children prompted the DSM5 to include a new diagnosis, disruptive mood dysregulation disorder,
thought to better describe the recurrent temper outbursts and irritability
seen in this group.
Impulsivity, a heritable trait, is another central feature of BPD
(Crowell et al., 2009). These patients display a wide range of impulsive
behaviors, including repeated self-harm and multiple suicide attempts
(Zanarini et al., 1998). Although impulsive behaviors are also common
in bipolar disorders, they are more episodic than pervasive (Koenigsberg,
2010). BPD patients also have a very wide range of cognitive symptoms,
including micropsychotic phenomena (auditory hallucinations, depersonalization, or paranoid ideas), occurring in more than half of all cases
(Zanarini et al., 1990).
Another major domain of psychopathology in BPD is problems
in interpersonal relationships, characterized by rapid attachment, anxious dependency, and fear of abandonment (Gunderson and LyonsRuth, 2008), features that may not be a result of AI or impulsivity.
Patients with BPD also struggle with an identity disturbance, leading
them to question who they are and what their beliefs and core values
are (Jorgensen, 2006). Although bipolar patients also have difficult interpersonal relationships (Coryell et al., 1993), they do not usually have
these characteristics. Although both disorders show psychosocial
morbidity, there are more deficits in BPD patients (Zimmerman and
Morgan, 2013).
The proposal that BPD is a mood disorder assumes that all other
symptoms of this disorder are secondary to AI. However, that possibility does not explain why AI, impulsive behaviors, interpersonal conflicts, and micropsychotic symptoms co-occur in the same patients.
Nor does it explain why the diagnosis of BPD as a single construct
has been found to be both coherent and heritable (Reichborn-Kjennerud
et al., 2013). To understand why BPD may not fall within the spectrum,
one needs to see the construct as complex and multidimensional, based
on the co-occurrence of symptoms in several domains of psychopathology (Paris, 2007).
ETIOLOGY
There are insufficient data to define a precise etiology for either
BPD or bipolar disorder. This is not unexpected, given that psychiatry
has thus far been unable to determine an etiology for most mental
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disorders. Behavioral genetic studies have shown that almost all mental
disorders have a significant heritable component (Jang, 2005). The precise nature of the biological vulnerability to bipolar disorders and BPD
is unknown. Moreover, no consistent biomarkers are associated with either disorder; although some authors (e.g., Bassett, 2012) have claimed
that there could be biomarkers common to both patient groups, the evidence is insufficient to reach that conclusion. In BPD, although repetitive suicide attempts have sometimes been linked to alleles related to
serotonergic function (New et al., 2008), these associations do not provide an explanation for the complex psychopathology associated
with BPD.
Neuroimaging research in BPD also finds multiple abnormalities but little specificity. Structural and functional changes in the prefrontal cortex, amygdala, hippocampus, and other subcortical sites
have been reported (Schmahl and Bremner, 2006). There have been
no direct comparisons of these findings with samples diagnosed with
classical bipolar disorders. However, neuroimaging can be used to examine responses to standardized stimuli such as human faces, and
one study found that BPD patients have a lower threshold of amygdala
reactivity to angry faces (Donegan et al., 2003), whereas another found
that AI, in response to emotional stimuli, is slow to extinguish
(Koenigsberg et al., 2014).
A distinction between BPD and bipolar disorder is also supported by family studies. The most common disorders in the firstdegree relatives of people with BPD are depression and antisocial PD
(White et al., 2003), whereas the frequency of bipolar disorder in
first-degree relatives of BPD patients is similar to its lifetime prevalence
in the general population (Paris et al., 2007). The claim that first-degree
relatives of BPD patients are more likely to have bipolar spectrum disorders, even when classic bipolar disorders are absent (Akiskal, 2003),
begs the question as to whether these syndromes are true forms
of bipolarity.
Psychosocial risk factors play an important role in the etiology of
BPD, and this profile also helps differentiate the disorder from bipolar
disorder. Retrospective and prospective studies have each documented
high rates of childhood adversity, including abuse, neglect, and insecure
attachments (Zanarini, 2000). Although these risk factors are not present in all patients, childhood abuse has been associated with a more
severe prognosis (Soloff et al., 2002). There is also evidence for childhood adversities in bipolar disorder (Leverich and Post, 2006), but they
are much less frequent. Direct comparisons between the etiological factors associated with both disorders remain, however, rare in the literature. The evidence suggests that, whereas bipolar disorder has a very
strong heritability (Craddock and Sklar, 2013), BPD fits better with
a biopsychosocial model that takes account of genetic predispositions, adverse life events, and social stressors (Gunderson and
Lyons-Ruth, 2008).
RESPONSE TO MEDICATION
Pharmacological dissection has been described as a tool to help
determine whether mental disorders are related (Klein, 1987). This
method points to important differences between BPD and bipolar disorder. A recent Cochrane review (Stoffers et al., 2012) as well as the National Institute for Clinical Excellence (NICE) guidelines for BPD
(Kendall et al., 2010) conclude that antidepressants have limited value
for these patients. Moreover, mood stabilizers are not consistently efficacious. Nonresponse to lithium is of obvious significance, but the evidence for the effectiveness of anticonvulsants, such as lamotrigine, is
also weak (Kendall et al., 2010). This conclusion was clearer in the
NICE guidelines, which excluded several studies that had used a dubious methodology but were included in the Cochrane review. Claims for
the validity of a bipolar spectrum based on response to medication
would require large-scale randomized controlled trials, which have
not been conducted, and there are no studies comparing BPD and bipolar patients receiving the same medication.
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The Journal of Nervous and Mental Disease Volume 203, Number 1, January 2015
The most extensively studied group of drugs for BPD are the antipsychotics, which, like antidepressants and anticonvulsants, have sedative effects that can reduce impulsivity when prescribed in low doses
(Kendall et al., 2010). However, these effects are not specific, and pharmacological treatment of BPD has never been shown to lead the core
symptoms of the disorder to remit.
DISCLOSURES
Dr. Paris receives royalties from Oxford University Press and
Guilford Press. Dr. Black reports research funding from AstraZeneca,
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The Journal of Nervous and Mental Disease Volume 203, Number 1, January 2015
the Nellie Ball Trust, and the National Institute on Aging; he also reports royalties from American Psychiatric Publishing, Oxford University Press, and UpToDate.
The authors declare no conflict of interest.
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