Bipolar or Borderline: disagreement

update 2013, response to figures below

Summary: A reader forwarded the graph and the table below, inviting their inclusion.Although these are the work of a recognized authority on borderline personality disorder, I respectfully disagree.

If you’ve not come here from there, here is my main page comparing these conditions.


This diagram was forwarded by a reader. It is from Borderline Personality Disorder: A Clinical Guide, first edition, by John G. Gunderson, MD.

Border1

Okay, let’s take a look at this.

1. Is it true that patients with bipolar disorders have “interpersonal insensitivity”? Think of that, in distinction to “sensitivity to hostility and separations” as “thick skin.” . Okay, thick skin, is that a bipolar characteristic? Sorry, not only have I not observed this among my patients (if anything it’s the opposite) but I’m not aware of any data to support it. Maybe I missed something somewhere. Never heard of this idea. And it definitely does not jive with my experience.

There you go: warrring experts, or worse, an expert (Gunderson) versus your basic clinician.

2. Grandiose self-image. Well, at times, that’s true, it’s almost by definition (like do this around a psychiatrist and you might get a diagnosis). But “personality trait”? That is simply wrong. Dr. Akiskal in San Diego has written extensively about “temperament” in bipolar disorder. In his work, he identifies dysthymic temperament (relatively permanently bending toward depression); and cyclothymic temperament (moody); and hyperthymic temperament (full of self-confidence, most of the time — but not “grandiose” per se, and not guaranteed immune from depression with relative loss of that confidence).

So on this one I just flat disagree.

Likewise, a table comparison from Gunderson offers more detail:

Border2

The bipolar column describes Bipolar I more than bipolar II. Manic phases can
include all these features. In hypomania, if they are present at all they are
generally quite subtle, every one of them.

How about the other way around: do patients with bipolar disorder sometimes manifest the traits shown here to be BPD?

  • interpersonal sensitivity — possible for sure; not characteristic; and certainly not to the degree seen in borderline disorder
  • deep intense affect, invoking empathy — certainly seen in patients with bipolar disorder, though again, not to the degree as in BPD
  • care seeking — granted, not characteristic of bipolar disorder
  • splitting — well, some borderline experts regard “splitting” as a doctor-caused, not patient-caused phenomenon; but to the extent this is valid as a BPD trait, I would grant it’s not common in bipolar disorder.
  • polarizing realities — this is what happens when affect is driving the car. Anybody’s affect, any diagnosis.

So, on balance, I guess I just disagree with these characterizations. More importantly, as I’ve described on my main page on this subject, the distinction is not helpful. What matters is whether an antidepressant is likely to help, if added (less likely if the problem is more like bipolar disorder).

Even more commonly, the question is whether an antidepressant already in use could possibly be fueling the fire and making things look borderline — that, I have seen many times. So many times that I routinely try tapering off antidepressants (very gradually) in patients whom others have called “borderline.” Of course this doesn’t always make things better. Rather often, things are about the same. But quite often as well, while mood is not much better, a lot of the agitation and suicidal stuff diminishes.

However, I don’t work on an inpatient unit anymore. Everything I just said may apply more to outpatient mood instability than inpatient mood instability. People who work on inpatient units could think I really don’t “get” borderline PD. Of course, I can think they don’t really “get” the breadth of bipolarity. Different parts of the mood instability elephant, sometimes.