Am I bipolar or what? Exploring the phenomenological, treatment and prognosis overlap of borderline personality disorder and bipolar disorder

Abstract

Purpose
The term borderline applied to personality dynamics was first introduced by Adolph Stern in 1938. This new term included a particular group of patients who, in an organizational blurring, remained in the limbo between neurosis and psychosis. To find a more assertive and holistic characterization of borderline personality disorder (BPD), the purpose of this paper is to explore borderline phenomenology, setting boundaries and discussing points of approach and divergence of this personality disorder comparing them specifically to bipolar affective disorder (BAD) and also explore the differences in their treatment and prognosis.

Design/methodology/approach
This paper is a review and synthesis of the extant literature, mapping out the similar and unique aspects of each pathology.

Findings
Although there are approximation parameters between BPD and BAD, the phenomenology and the course of both diseases appear to be different. Indeed, this paper seems to have some uncertainty about the sphere of each entity and the domain of comorbidity. Despite the overlapping rates found, it is the understanding that the consequences and strategies for managing comorbidity are underexplored.

Originality/value
As the association of both disorders can be difficult not only in terms of management and understanding of their consequences and implications but also in long-term negative perpetuation, this review has direct implications for clinicians so that they can understand the similarities and particularities of each entity, leading to a more correct psychopathological approach in these individuals.

Full text

Am I bipolar or what? Exploring
the phenomenological, treatment
and prognosis overlap of borderline
personality disorder and bipolar disorder
Pedro Mota and Sofia Lourenço
Abstract
Purpose –The term borderline applied to personality dynamics was first introduced by Adolph Stern in
1938. This new term included a particular group of patients who, in an organizational blurring, remained
in the limbo between neurosis and psychosis. To find a more assertive and holistic characterization of
borderline personality disorder (BPD), the purpose of this paper is to explore borderline phenomenology,
setting boundaries and discussing points of approach and divergence of this personality disorder
comparing them specifically to bipolar affective disorder (BAD) and also explore the differences in their
treatment and prognosis.
Design/methodology/approach –This paper is a review and synthesis of the extant literature, mapping
out the similar and unique aspects of each pathology.
Findings –Although there are approximation parameters between BPD and BAD, the phenomenology
and the course of both diseases appear to be different. Indeed, this paper seems to have some
uncertainty about the sphere of each entity and the domain of comorbidity. Despite the overlapping rates
found, it is the understanding that the consequences and strategies for managing comorbidity are
underexplored.
Originality/value –As the association of both disorders can be difficult not only in terms of
management and understanding of their consequences and implications but also in long-term
negative perpetuation, this review has direct implications for clinicians so that they can understand
the similarities and particularities of each entity, leading to a more correct psychopathological
approach in these individuals.
Keywords Affective instability, Bipolar affective disorder, Borderline personality disorder,
Emotional dysregulation
Paper type Literature review
Introduction
The term borderline applied to personality dynamics was first introduced by Stern (1938).
This new term included a particular group of patients who, in an organizational blurring,
remained in the limbo between neurosis and psychosis. Afterward, Kernberg (1975)
deepened the study of this theme by expanding the borderline formulation to the domain of
personality organization, which, within the psychopathological sphere, would represent a
behavioral functioning pattern determined by instability and an intensely disruptive
psychological conformation. Years later, research by authors such as Gunderson, Kolb and
Zanarini allowed the construction of contemporary classification criteria. Emerging as an
individualized psychiatric entity, borderline personality disorder (BPD) was eventually
accepted as a nosological term, integrating reference manuals such as the Diagnostic and
Pedro Mota is based at the
Department of Psychiatry
and Mental Health, Centro
Hospitalar do Ta
ˆmega e
Sousa, EPE, Guilhufe,
Portugal. Sofia Lourenc¸ois
based at the Faculdade de
Medicina, Universidade de
Coimbra, Coimbra,
Portugal.
Received 28 December 2019
Revised 23 April 2020
Accepted 6 May 2020
Conflict of interest: The authors
declare that they have no con-
flict of interest.
Funding: This study had no
funding.
DOI 10.1108/MHRJ-12-2019-0049 VOL. 25 NO. 2 2020, pp. 101-112, ©Emerald Publishing Limited, ISSN 1361-9322 jMENTAL HEALTH REVIEW JOURNAL jPAGE 101

Statistical Manual of Mental Disorders (DSM), 3rd edition (American Psychiatric Association,
1980).
While, on one hand, several authors consider that the adoption of a broadly descriptive
terminology intended to conceal truly insufficient knowledge, on the other, by highlighting
the broad levels of overlap, they still rejected its conceptual individualization. Additionally,
although there are objective diagnostic criteria in the latest DSM-5 (2013) manual (American
Psychiatric Association, 2013), this personality disorder demonstrates intense
heterogeneity. Its current definition, which encompasses a total of 151 possible
combinations of criteria, together with the lack of a fundamental or necessary parameter for
its identification, reflects a symptomatic polymorphism, high variability in presentation
frames and the absence of nuclear psychopathological domains.
To find a more assertive and holistic characterization of this personality disorder, we
propose to explore borderline phenomenology, setting boundaries and discussing points of
approach and divergence of this personality disorder comparing them specifically to
bipolar affective disorder (BAD) and also explore the differences in their treatment and
prognosis.
Overlap with bipolar disorder
BAD and BPD are two clearly distinct entities according to the view offered by DSM-5
(American Psychiatric Association, 2013). BAD corresponds to a very heterogeneous
disorder with multiple clinical presentations and different course and severity. In an attempt
to describe this multiple typology, which includes more severe and tenuous forms, DSM-5
(American Psychiatric Association, 2013) differentiates this phenomenological group into
Type I BAD –the classic form of the disease, formerly called manic-depressive psychosis,
which requires, for its diagnosis, the presence of a single episode of mania; Type II BAD –a
milder form that does not include the psychotic component or a marked decrease in
functionality, and involves the identification of one or more episodes of depression and at
least one episode of hypomania; and cyclothymia, a subsyndromic form of the disease.
In the past, some authors argued that BAD was an underdiagnosed psychopathology.
However, the trend proposed by a study by Moreno et al. (2007) showed a recent increase
in the number of diagnoses, reaching double in adults and around 40% in children and
adolescents. To interpret this discrepancy with previous data, some authors have argued
for a potential misdiagnosis of BAD, fueled by the underlying presence of other
psychopathologies with potentially overlapping criteria, namely, BPD (Ruggero et al.,2011).
Thus, taking a symptom affinity approach verified between BAD and BPD, Ruggero et al.
(2011) reinforced the idea that similar phenomenological characteristics may obscure the
correct diagnosis of some patients. In a study that clarified the true relevance of this
inaccuracy, BPD showed a greater vulnerability to misdiagnosis as bipolar disorder (about
40%) compared to other psychopathologies (about 10%). According to what they argued,
criteria such as affective instability, anger, impulsivity, recurrent suicidal behaviors and
interpersonal instability would be responsible for this nosological ambiguity. However, the
results also showed that, except for transient dissociation, all the criteria that define BPD
were associated with an error in the differentiation of both psychopathologies. This
phenomenological ambiguity that serves as a convergence of both disorders fades in
patients with a richer symptomatic range, as it has been found that simultaneous validation
of more than seven criteria would decrease diagnostic uncertainty. These authors argued
that the particular presence of a BPD would increase the likelihood that a patient, at a
certain point in life, would be mistakenly identified as having a BAD. Other articles went
further and postulated that the diagnostic difficulty arises mainly from the overlap between
Type II BAD and BPD (Antoniadis et al.,2012;Renaud et al., 2012), as Type I BAD has a
more flowery manifest, which fluctuates between more exuberant poles, which run through
a mood elevation compatible with mania, alternating with the identification of severe
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neurovegetative depressive symptoms and the presence of euthymic baseline periods
(Renaud et al.,2012).
Epidemiological perspective
Data from the World Mental Health Survey Initiative (Merikangas et al.,2011) reveals an
estimated 2% life prevalence for Type I and Type II BAD, more specifically 0.4% for Type II
BAD, in line with the results presented by Trull et al. (2010) related to BPD, which showed a
life prevalence of approximately 2%. Both psychopathologies are more common in females
and also share a broad presentation period, which foreshadows from adolescence to early
adulthood. Although a concise age of onset for borderline psychopathology is not known, at
BAD the risk range was calculated from 18 to 20 years of age. Considering, more precisely,
Type II BAD, it was estimated that its symptomatic presentation would occur around 20
(Merikangas et al.,2011).
Etiological perspective
Discussing the etiological perspectives of both psychopathologies, Paris and Black (2015)
investigated whether there was a common background that would allow them to be
approached. According to their review article, it was not possible to construct a precise
etiological model for both BPD and BAD. In fact, the biological vulnerability of each entity
remains unknown, as it was not possible to conclude the influence or association of these
mental formulations with certain biomarkers. Also, the analysis of family studies and
psychosocial risk factors allowed the expression of a basal withdrawal. Studying the most
common psychopathologies in first-degree relatives of individuals with BPD, it was possible
to observe that the prevalence of BAD was similar to that of the general population (Paris,
2007), refuting an intimate link between them or their agglutination in a spectrum.
Some authors argue that BPD seems to have its own psychopathological construction,
based on a pathological attachment and a childhood full of abuse and neglect (Zanarini,
2000). On the other hand, although BAD might be associated with an unfavorable past, this
association is not as strong as the BPD one (Leverich and Post, 2006). Still, on this topic, a
study by Bassett (2012),Perugi et al. (2003) analyzed the presence of childhood trauma
histories in patients with each of the pathologies and reached different conclusions.
Although patients with BPD actually had a higher frequency of traumatic history, estimated
at approximately 60 to 80%, patients with BAD would also report a prominent frequency of
around 50%. These data led the author to suggest that both psychiatric disorders were
closely related to past adversity experiences, and this indicator (trauma) should not be a
distinguishing point. Regardless of this approach, the author admits that the vulnerability
and form of traumatic experience can be consistently different and point perspectives on a
path of differentiation.
Phenomenological perspective
Affective instability is defined by DSM-5 (American Psychiatric Association, 2013)asa
mood swing of limited durability, often within hours, representing one of the main symptoms
that fuel uncertainty in both mental contexts. Some authors claim that this instability comes
from a common cyclothymic temperament (Perugi et al., 2003), while others argue that their
affective inconstancy is fundamentally distinct (Paris et al.,2007). Both psychopathologies
share a tenuous, chronic-course depressive tendency; However, BPD is surrounded by
emotions with a more charged basal negativity (Renaud et al.,2012;Reich et al.,2012), low
self-esteem and feelings of anger (Renaud et al.,2012;Gunderson and Phillips, 1991;Levy
et al., 2007;Wilson et al.,2007), emptiness (Gunderson and Phillips, 1991;Levy et al.,2007;
Silk, 2010;Rogers et al., 1995;Bayes et al.,2014), guilt (Bayes et al., 2014), discomfort,
irritability and anxiety (Antoniadis et al.,2012). In BAD, however, the formulation of his self-
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esteem, even though it is linked to the humor phase, includes an image of grandeur in the
phases of mania or hypomania (Renaud et al., 2012). Intending to differentiate affective
particularities, a study by Reich et al. (2014) demonstrated that individuals with a BPD
suffered from their own instability, which flowed toward a depressive dimension, fluctuating
mainly between eutymia-depression, anger-depression and anxiety-depression states. In
contrast, the emotional lability that characterizes Type II BAD varies more frequently and
intensely between periods of eutymia-euphoria and depression-euphoria (Reich et al.,
2012). The authors even argued that this depressive tendency would be the key point in
distinguishing both psychopathologies (Reich et al.,2014).
Regarding mood elevation states, a recent investigation by Fulford et al. (2015), evaluating
motivational issues, found that bipolar disorder is distinguished as it is associated with an
expansive pattern of personal goals. The data revealed that the setting of extremely
ambitious goals and the presence of positive generalizations were risk factors for the
development of mania, so this goal-oriented mental activity could not only be part of the set
of criteria that define it but also constitute a differentiation tool with the BPD. Patients with
Type II BAD report an energetic and overt euphoria, accompanied by increased creativity,
productivity, cohesion of ideas, in contrast with the emotional dysregulation associated with
borderline pathology (Parker, 2011). Although in Type II bipolar disorder, the existence of
periods of elated mood can translate feelings of anger, anxiety and irritability, they are
interpreted as episodic and limited, fading at the same rate of dispersion as the
symptomatic condition (Ruggero et al.,2010); however, in BPD, these symptoms tend to
last. Moreover, in this personality disorder, the experience of this extensive affect has a
short cadence of a few hours (Antoniadis et al., 2012), not finding enough constancy to
conceptualize as hypomania –defined as a high, irritable or expansive mood with a
minimum duration of four days (American Psychiatric Association, 2013).
Regarding the frequency of this affective inconstancy, some authors have argued that in
borderline patients their mood swings are particularly rapid and chaotic (Renaud et al.,
2012) and may alternate between joy and sadness (Antoniadis et al.,2012). In contrast, in
BAD there is a consistently different oscillation, materialized by cyclic mood instability,
which includes sustained episodes of truly hypomanic mood alternating with periods of
euthymia and depression. Still, other references indicate that patients with BAD, even in
these euthymic periods, had increased instability compared to general population (Renaud
et al.,2012
). A study aimed to quantify the frequency of affective instability experienced in
both pathologies and found that, on one hand, in patients with BAD, mood swings occurred
on average about once a week, and on the other, patients with BPD reported an average
oscillation of a daily episode (Reich et al.,2014). This corroborates an increased affective
disorganization in borderline patients.
Considered one of the core points of the BPD profile, impulsive conduct is described as a
clear difficulty in planning actions, anticipating their consequences, materializing as an
incessant state of disorientation, deconcentration and loss of ideas (Antoniadis et al., 2012).
It also can represent a strategy of mastery and processing of negative (Fulford et al., 2015),
intense and disruptive emotions (Peluso et al., 2007). In bipolar patients, impulsivity may
represent an episodic state phenomenon (Koenigsberg, 2010), such as hypomania. In
these events, cognitive states such as disinhibition, distractibility and tachypsychia appear
to motivate certain behavioral prototypes (Wilson et al.,2007). From planning to action,
defining individual procedures, while substance abuse and risky sexual practices are
common conduct in both psychopathologies, excessive spending patterns and the
practicing of risky sports (Antoniadis et al.,2012) are more associated with BAD. In
previous findings, a study by Bøen et al. (2015) proposed to study the clinical
characteristics of impulsivity of both psychopathologies, through the approach of four main
components, looking for a qualitative statement –urgency, lack of perseverance, lack of
premeditation and sensation seeking. As expected, the evaluation of impulsivity intensity
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revealed to be particularly higher in BPD, occupying an intermediate position in BAD, but
still higher than the basal levels found in the control group of healthy subjects. Despite the
transversally higher indices in the first three parameters evaluated, borderline patients
scored in a particularly increased way on urgency issues –which portray a reactive impulse
to circumstances of intensely negative affect and also in matters of lack of perseverance –
which refer to the inability to concentrate on performing difficult or tedious tasks. Moreover,
the evaluation of impulsivity as a result of the incessant search for certain sensations, with
the consequent adoption of risk behaviors, did not show significant group differences.
These aspects allow us to perceive the precipitous behaviors of BPD not only as an
expressive phenomenon that underlies a negative affective complex but also as an attempt
to relieve intense psychic pain. Indeed, the motivational complexity of these patients is not
limited to the phenomena of the true pursuit of extreme emotions, but in an attempt to
redirect disruptive inner feelings that cause a suffocating anguish. In contrast, in patients
with Type II BAD, the presence of impulsive urgency practices seems to be related to
depressive states or episodes and occur more frequently when there are fracturing
disruptive antecedents, such as aversive childhood experiences. This analysis strengthens
theses that found that threat sensitivity and reactivity to negative affect circumstances are
central characteristics of the borderline impulsivity paradigm (Fulford et al.,2015).
Observing the ability to maintain stable relationships and intimacies can also contribute to
the discrimination of both psychopathologies. In fact, PPB fits into a relational context that
brings together a vision based on immaturity, devaluation, fears of abandonment and
recurrent interpersonal conflicts. This pattern contradicts the tendency toward stability in the
union relations of patients with BAD, who, in eutymia, do not show a predisposition to
develop pathological relationships (Kernberg and Yeomans, 2013).
Another distinctive feature in the characterization of the borderline mind is the marked
tendency toward the elaboration of a self-injurious behavioral plan, translated by the
presence of repeated suicide attempts or parasuicidal behaviors (Zanarini et al., 1998).
Although some authors argue that BAD lacks the profound self-destructive practices of
borderline patients, others argue that suicidal behaviors appear to be very common in Type
II BAD as well, not offering a line of differentiation (Bassett, 2012). Additional references
studied the same problem, looking at it from a different view, provided by comorbidity.
Zimmerman et al. (2014) sought to understand if, with respect to the carriers of each of the
disorders, the group with the respective comorbidity would have an increased risk of
producing certain behaviors, specifically suicide attempts. From this investigation, it was
possible to verify the presence of a greater vulnerability in these individuals, compared to
the group diagnosed with a BAD in its isolated form. However, it should be noted that no
significant difference was observed in relation to the group that represented the BPD alone.
These evidences allowed the same authors to conclude that, in a bipolar patient, the
accessory diagnosis of a BPD has a stronger impact on self-destructive behaviors.
Comorbidity therefore increases susceptibility to suicidal practices. Following the same line
of analysis, a work by Zeng et al. (2015) not only confirmed but also deepened the results.
From a risk quantification perspective, they supported the idea that comorbidity entailed a
four-fold higher risk of previous suicide attempts, compared to that calculated for BAD.
Treatment
Considering affective instability, an overlapping factor between these entities, it can be
analyzed taking into account a new parameter –the response to mood stabilizers. Although
the response is positive for Type I BAD (Mo
¨ller and Nasrallah, 2003) and moderate for Type
II BAD (Suppes and Dennehy, 2002), in BPD no significant efficacy was demonstrated
(Links et al.,1990). Other references point out that after exposure to lithium, PPB does not
remit, nor does it show appreciable direct improvement (Davidson et al., 2006). On the
other hand, the use of anticonvulsants with similar objectives allowed the control of mood
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swings in Types I and II BAD (Mo
¨ller and Nasrallah, 2003). In BPD, however, the same
pharmacological class, instead of allowing affective stabilization, led to attenuating the
recurrence of impulsive behaviors (Paris et al.,2007). In addition, a recent randomized
placebo-controlled trial conducted by Crawford et al. (2018) did not find evidence to
support the use of lamotrigine for treatment the core symptoms of BPD.
Regarding the treatment of negative affectivity, the benefit of antidepressants was also the
object of study and revealed a possible approximation, as they demonstrated a similar
effectiveness in the treatment of BPD (Paris et al., 2007) and in the resolution of bipolar
depression (Thase and Sachs, 2000). Given another treatment goal, some studies have
supported the use of atypical antipsychotics to control impulsivity in borderline patients
(Zanarini et al.,2004). Other investigations, in turn, reinforced that these drugs could
constitute an effective therapeutic response to control mania in Type I BAD (Hirschfeld,
2003). According to the view proposed by a review article by Bassett (2012),
antidepressants, anticonvulsants, mood stabilizers and atypical antipsychotics appear to
play a beneficial role in BAD. In contrast, resorting to medication alone does not lead to
consistent BPD remission. Moreover, the differentiation with Type II BAD acquires more
problematic characteristics, as also the greater therapeutic juxtaposition makes it difficult to
differentiate with this personality disorder (Paris et al., 2007).
Regarding the fundamental psychotherapeutic principles, evidence has shown that
adherence to methods of psychotherapy directed to BPD, such as dialectical behavioral
therapy, are extremely effective (Paris and Black, 2015). However, the inherent response to
BAD seems different. It is possible to understand that, considering the psychopathological
basis that differentiate these clinical entities, the therapeutic approaches will be directed to
distinct pathological foci. Indeed, a possible restricted approach to BPD will discuss
problematic issues such as identity fragmentation and interpersonal conflict, non-existent
targets or enhancements in patients with BAD (Bassett, 2012). However, the presence of
common, coincident and nonspecific symptoms, together with the universal benefits of
behavioral therapies, end up fostering the adoption of generic psychotherapeutic methods,
which do not offer contributions in the context of differentiation (Bayes et al., 2014). Looking
at these issues from a globalizing perspective, we can infer that the therapeutic bases of
each condition are different and that a misdiagnosis can prevent access to the most
appropriate methods and, in addition, mask a false intractability. A BPD, falsely diagnosed
as a BAD, is likely to receive pharmacological treatment that will not dissolve its true
psychopathology. Similarly, a BAD, misdiagnosed as a BPD, will be deprived of access to
mood stabilizer therapy, which would be particularly effective in this context (Paris and
Black, 2015).
Prognosis
One study evaluated 81 patients with BPD over seven years and found that one patient had
a progression to Type I BAD, 4 patients to Type II BAD and 4 patients to a cyclothymic
disorder (Ball and Links, 2009). Also in this study, about 52.6% failed to meet the criteria of
a BPD and 4.6% eventually consummated suicide. Zanarini et al. (2003) also conducted a
prospective investigation that evaluated 290 patients over four to six years and showed that
only two developed a BAD. They also found that most patients (73.5%) went into remission
and, of this group, only 5.9% of individuals suffered recurrences. This paper points out that
the dissolution of borderline psychopathology is common and has its own stability, so the
prognosis turns out to be positive, even in the most compromised patients. Additionally,
Paris and Zweig-Frank (1997) analyzed a group of patients with BPD and concluded that
after 27 years, only 8% still met the criteria for identifying this personality disorder. Most
patients around the age of 40, and in some cases at even earlier ages, acquire greater
emotional stability, are less impulsive and are less vulnerable to self-injurious behaviors
(Paris and Black, 2015).
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At the same time, the course of BAD is distinct, more severe, lacking this tendency toward
remission highlighted in the prognosis of patients with BPD. BAD, although benefiting from
an essentially episodic course, has a prolonged amplitude, as it starts in early periods and
remains until late ages (Goodwin et al., 2007).
Available data indicate that concomitant diagnosis of a mood disorder, together with a
personality disorder, is common and generally implies a worst prognosis. The association of
both disorders can be difficult not only in terms of management and understanding of their
consequences and implications but also in long-term negative perpetuation (Yen et al.,
2015).
Discussion
Table 1 intends to more concisely represent the main points of confluence and the
distancing plans of these two psychopathological entities.
Comparative analysis of data relating to each of the psychopathologies does not show a
single trend. If, on one hand, epidemiological investigations announce a potentially similar
gender prevalence and age at onset (Merikangas et al.,2011;Trull et al.,2010), on the
other hand, family studies reject a relevant association of these psychopathologies in first-
degree relatives (Paris, 2007). To accentuate the problem, although many authors have
argued that borderline pathology emerged from a disruptive childhood, marked by
pathological patterns of attachment and trauma experiences, Bassett (2012) demonstrated
that this past, although more common in BPD, was shared by bipolar disorder. At this
confluence point, it is suggested that future studies be carried out to firstly deepen the
understanding of the influence of trauma on BAD, and second, to differentiate quality and/or
intensity parameters that may clarify their contributions in the genesis of these psychiatric
disorders.
The central issue that seems to us to be the great turning point between BPD and BAD lies
in the sphere of affective instability, which varies in terms of amplitude, fluctuation cadence
and basal feelings: in BPD we are facing a pattern of affective chaotic instability, which
goes through various states of affect in a fast and unpredictable way, with a continuous
return to basal negativity. Indeed, the internal depressive tendency of this personality
disorder is notorious; in BAD, symptomatology goes beyond the notion of affective
fluctuation and clumps into a state of mood instability. From our point of view, this
seems to us to be the pivotal feature that signals a bipolar disorder. We speak of a
cyclic, episodic mood swing, described by periods of sustained elevation, mania or
hypomania or uniform depressive intervals. Between these periods of state, there is a
tendency for a permanent basal eutymia, in which the individual is free of symptoms.
Disagreeing with this final point, some theories end up arguing that individuals with
BAD have greater affective instability than the general population (Renaud et al., 2012),
as opposed to those who argue that this phenomenology may correspond to an
unstable Type II BAD (Antoniadis et al.,2012).
In addition to signaling a deregulation of action planning and lack of perseverance, the
issues of impulsivity also meet the negative affect that characterizes borderline patients.
The impulsive urgency they present is the fulfillment of the search for relief from an
unbearable psychic pain. In BAD, the impulse is linked to a cognitive disorder that
accompanies the mood fluctuation phases. The range of behaviors these patients may
engage in is broader and includes, for example, over-spending patterns or risky sports
practices that are associated with a thought of disinhibition and grandiosity rather than an
attempt to avoid an internal toxicity. In fact, despite these points of differentiation, reporting
of urgent impulsive practices in Type II BAD ultimately aggravates the overlap between
both psychiatric disorders.
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Table 1 Main features of borderline personality disorder and bipolar disorder
Borderline personality disorder Bipolar affective disorder
Epidemiology
Lifetime prevalence
Age of onset
Gender prevalence
2% (Trull et al., 2010)
Early adolescence/adulthood (Trull et al.,
2010)
Female (Trull et al., 2010)
2% (Merikangas et al., 2011)
18-20 (Merikangas et al., 2011)
Female (Merikangas et al., 2011)
Personal background
Childhood and family dynamics
Pathological binding patterns (Zanarini,
2000)
Parental neglect (Zanarini, 2000)
History of childhood trauma (present in 60-
80% of patients) (Leverich et al., 2006)
History of childhood trauma (present in 50% of patients)
(Leverich et al., 2006)
Phenomenology
Affection
Basal feelings
Mood swings
Instability pattern
Interpersonal dynamics
Self-criticism
Impulsiveness behaviors
Fast and chaotic instability (Renaud et al.,
2012)
It changes dramatically between joy and
sadness (Antoniadis et al., 2012)
Chronic feelings of emptiness (Gunderson
and Phillips, 1991;Levy et al., 2007;Silk,
2010); Guilt (Bayes et al., 2014); Discomfort
(Antoniadis et al., 2012); Irritability
(Antoniadis et al., 2012); Anger (Renaud et
al., 2012;Gunderson and Phillips, 1991;
Levy et al., 2007;Wilson et al., 2007);
Anxiety (Antoniadis et al., 2012)
Euthymia-depression; anger-depression;
anxiety-depression (Reich et al., 2014)
Frequency: a daily episode (Reich et al.,
2014)
Reactive: interpersonal conflict situations in
50% of cases (Renaud et al., 2012;Reich
et al., 2014)
Expansive affect lasts a few hours
(Antoniadis et al., 2012)
Emotional dysregulation (Fulford et al.,
2015)
Recurrent interpersonal conflicts (Kernberg
and Yeomans, 2013); immaturity (Kernberg
and Yeomans, 2013); devaluation
(Kernberg and Yeomans, 2013);
abandonment intolerance (Silk, 2010;
Kernberg and Yeomans, 2013)
Low self-esteem (Ball and Links, 2009);
tendency toward negativity (Renaud et al.,
2012;Reich et al., 2012)
High intensity (Bøen et al., 2015)
Inability to concentrate on performing
difficult/tedious tasks (Bøen et al., 2015)
Difficulty in planning actions and
anticipating their consequences (Antoniadis
et al., 2012)
Substance use (Antoniadis et al., 2012)
Sexual risk behaviors (Antoniadis et al.,
2012)
Cyclic mood instability
Episodic and limited symptomatology
No changes in euthymia periods
Euthymia-euphoria; depression-euphoria (Reich et al.,
2012)
Frequency: one episode per week (Reich et al., 2014)
Influence of circadian instability, seasonal differences
and other biological conditions (Renaud et al., 2012)
Interpersonal conflict occurs in 25% of cases (Reich et
al., 2014)
Mania/hypomania: anger (Ruggero et al., 2010); anxiety
(Ruggero et al., 2010); irritability (Ruggero et al., 2010);
strong and overt euphoria (Fulford et al., 2015);
increasing creativity, productivity and cohesion of ideas
(Fulford et al., 2015); minimum duration of four days
(American Psychiatric Association, 2013)
Depression: severe neurovegetative depressive
symptoms in Type I BAD (Renaud et al., 2012)
Maintenance of stable relations (Gunderson and Phillips,
1991)
In the eutymistic phase, there is no predisposition for the
development of pathological relationships (Kernberg
and Yeomans, 2013)
The formulation of self-esteem is linked to the mood
phase (Fulford et al., 2015)
Deregulation of personal goals by setting ambitious
goals (Fulford et al., 2015)
Includes images of grandeur in the phases of mania
(Type I BAD) or
hypomania (Type II BAD) (Fulford et al., 2015)
Moderate intensity (higher than the general population)
(Bøen et al., 2015)
Motivated by disinhibition, distractibility and
tachypsychia (Wilson et al., 2007)
Urgency impulsivity seems to be related to depressive
episodes and disruptive antecedents in childhood
(Bøen et al., 2015)
Substance use (Antoniadis et al., 2012)
Sexual risk behaviors (Antoniadis et al., 2012)
Excessive expenses (Antoniadis et al., 2012)
Treatment
Pharmacotherapy Limited effectiveness Good response in type I BAP
Mood Stabilizers
Anticonvulsants
Atypical antipsychotics
Antidepressants
No significant effectiveness (Links et al.,
1990; Davidson et al., 2006)
Decrease impulsivity behaviors (Paris et al.,
2007)
Positive response in type I BAP (Mo
¨ller and Nasrallah,
2003)
Control of mood change in type I and type II BAP (Mo
¨ller
and Nasrallah, 2003)
(continued)
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Still, regarding the self-injurious behaviors from the perspective of impulsivity, it would make
sense that the intimate anguish experienced by patients with BPD originated a more
charged suicidal component, thus standing out from the BAD. However, the investigations
presented contradictory results, especially when compared with the Type II BAD. In this
sense, it seems important to us to clarify the intensity of negative affect in Type II BAD.
Given that, in periods of euthymia, there is no permanent tendency to depression described
for BPD, self-injurious or impulsive behaviors of urgency, even though they may occur in
periods of state, should be milder and less frequent than those observed in the context this
personality disorder.
Conclusion
The attempt to differentiate BPD from BAD ended up suggesting the sharing of some
common features. Questions concerning both the constitution of the criteria and their
application have been pointed out as the main responsible for this overlap. However, there
are no definitive conclusions and the proposal to agglutinate these clinical entities in a
single spectrum seems to us to be premature and, to that extent, hasty.
In therapeutic terms, the marked response of Type I BAD to pharmacotherapy contrasts
with the faint or accessory response of BPD. Type II BAD again translates an
intermediate sensitivity, which does not fully follow the pattern of any of the previous
psychopathologies. However, there are unwavering differences in the outcome of both
psychiatric disorders, with a better prognosis in BPD. Moreover, the likelihood that one
disease will evolve toward another is scarce and therefore insufficient to support a solid
approach.
Although there are approximation parameters with Type II BAD, the phenomenology and
the course of both diseases appear to be different. Indeed, we seem to have some
uncertainty about the sphere of each entity and the domain of comorbidity. Despite the
overlapping rates found, it is our understanding that the consequences and strategies for
managing comorbidity are underexplored. Thus, research on this subject is essential and
the way should approach the overlap more precisely with Type II BAD and clarify the
implications of comorbidity.
Table 1
Borderline personality disorder Bipolar affective disorder
Decrease impulsivity behaviors (Thase
et al., 2000)
Possible application in negative affectivity
(Paris et al., 2007)
Therapeutic basis of this personality
disorder (Bassett 2012)
Addresses issues such as identity
fragmentation and interpersonal conflict
(Bassett 2012)
Mania control in type I BAP (Zanarini, 2000)
Depression Resolution (Crawford et al. 2018)
Generic benefits in the absence of adequate
pharmacotherapy (Rogers et al., 1995)
Prognosis
Remission Indexes 52,6% - 73,5% More severe prognosis
Begins at early ages and remains until late ages
Comorbidity percentage 83%
Comorbility Worst Outcome (Goodwin et al., 2007)
Difficulty in treating both psychopathologies (Goodwin et al., 2007)
Increased frequency of suicidal behaviors (Zimmerman et al. 2014)
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Corresponding author
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