LPCethics.com

This course is compiled of articles written by James R. Phelps, M.D. and may be found at www.Psycheducation.org

The "rule book" for diagnoses in psychiatry, the DSM, was developed primarily to help straighten out research. We needed clearly separate "diseases" to standardize research results. For example, you could ask how many people with "major depression" will respond to Drug A, or Therapy B. When that is known, then someone who has the same symptoms might be told she/he has that likelihood of responding to Drug A. The problem is, no two people have exactly the same pattern. And the patterns start to blend in with one another at their edges.

This led to the growing recognition that symptoms can occur along "spectra". Here are some "spectrum" examples (based on a presentation by Dr. Ketter, head of the Stanford Bipolar Clinic):

Thought
(Schizotypal PD)...Schizophrenia..........Schizoaffective Disorder....... Bipolar I

Mood
Sad..........Unipolar Depression.............Bipolar II............Bipolar I

"Personality"
Hyperthymic
Temperament............Bipolar II.............Borderline Personality Disorder

As an analogy, imagine that people are like cans of paint. Everybody starts out basically neutral, then genes and experiences add colors to their can. If you end up with too much of one color, you'll "stick out" compared to everybody else. We might call your difference a "symptom", if it causes you to have trouble with functioning in society.

Applying this analogy to the "spectrum" way of diagnosis, a person who has just a little anxiety pigment might be shy; but a person who has a lot is so afraid of groups that he merits a diagnosis of "social phobia". And if he gets a maximal amount of that pigment, he's so afraid to go out in public that he avoids doing so almost entirely: "avoidant personality disorder". A person could get any amount of this "pigment", but we only have three diagnostic terms for that continuous spectrum of differences between people:

Shyness...........................Social Phobia.............................Avoidant Personality Disorder

Borderline or bipolar? A "pigment" answer
Now let's take the "paint" approach to "borderline vs. bipolar", a common diagnostic disagreement. With that much overlap, these people must have basically the same "pigments". One person might have gotten them from genes, the other from experience -- we can't tell the difference yet.
However, one pigment seems to differ in each.

They both have red for hot emotions, and blue for depressive symptoms, and a sparkly pigment that makes them impulsive. But the "bipolar" person has a magic ingredient that makes her pigments vary cyclically over time. There is some consistency to the way this magic pigment works: she tends to be either one way, or another, all symptoms varying together. Remember, this magic stuff is another "pigment". She could get a big dose of it, and be bipolar I: extreme swings separated by years, looking much the same each time they reappear. If she got a small dose of the "vary" pigment instead, her symptoms might be less clearly "cyclic", more mixed and muddled.

On the other hand, the "borderline" person has a green ingredient that makes her feel empty, and feel much worse in this way when she is alone. Plenty of people who wouldn't be called "borderline" have quite a bit of green in them, but if you get a lot of this green pigment, you're more likely to have trouble in relationships. When two very green people get together, each will feel badly when the other goes away somehow (including emotionally; for example, if one gets mad at the other).

Imagine what happens in a relationship if one person is very green, and the other is not; this can be as troublesome as when both are green. You've heard these matches described as problems of "co-dependency". How much "green" a person has seems to depend on both genetics and experience: some kids just turn green no matter how good an upbringing they get; others can develop emptiness from experiences that they had growing up (lots of real or perceived abandonment may do it; certainly sexual abuse seems to do it).

Just to make it clear that this is not "always somebody's fault": the "match" between a child's temperament and the parenting they receive can be the problem, not the child's temperament or the parenting either. Some kids can handle a pretty distant parent okay; others can be devastated by this. Some kids will feel "smothered" by an involved parent; others will thrive with such attention. Children can show these differences right from birth. You can read more about this "match" in the superb scholarship of Marsha Linehan, Ph.D. Dr. Linehan repeats the same themes over and over, but for good reason: they're crucial themes to understanding this personality.

So, to summarize: diagnoses are not based on known chemical differences. They are conveniences for researchers, and are also supposed to help patients find the right treatment. But because symptoms are spread over spectra, from a little to a lot, labels can often be misleading. Finally, borderline patients have most of the features of bipolar, plus an emptiness streak; and may have less clear "cycling" of their symptoms.[1]

Research on the Overlap of Bipolar Disorder and Borderline Personality Disorder[2]

The term “borderline” used to be a very negative label, but now there's good evidence that specific treatment is possible and can help a lot.[3][4] So now the label is not as pessimistic and hopeless as it was even a few years ago. On the other hand, Dr. Akiskal, one of the most outspoken researchers on bipolar disorder, often states that he does not believe "borderline" exists.[5]

A recent review from Canada found substantial overlap between borderline and bipolar disorder diagnoses, though still concluded that borderline deserved to be regarded as a valid diagnosis, separate from bipolar disorder.[6] On the other hand, another recent opinion suggested that collapsing borderline into bipolar disorder would help both patients and doctors.[7] (However, a nearly opposite point of view was expressed in the same journal issue[8].

To me, the most interesting thing about these two commentaries is that the authors presumably were examining the very same data, at least when they began the task, and yet derive opposite conclusions). When a very broad concept of bipolarity was used, 80% of patients with a diagnosis of borderline personality were found to have bipolar features.[9] As a last relevant research study, here's one more: an Italian bipolar disorder specialist examined the specific symptoms found in bipolar disorder and in patients with "borderline traits" on a structured diagnostic interview. He found that mood instability was common to both, whereas impulsivity was more associated with the borderline traits[10] (although impulsivity has been characterized as a central feature of bipolarity by another research team[11]).

Interestingly, when a group of patients with a diagnosis of bipolar disorder was studied for "maladaptive personality traits", a substantial decrease was found when the patients' mood disorder was treated.[12] Kind of makes you wonder if the same might be true for patients diagnosed as "borderline"?

[Update: here's a stunning new research finding that in my opinion says a great deal about the nature of "borderline". A team from the National Institutes of Mental Health, including Dr. Bob Post, who has published a lot about bipolar disorder, studied a woman with "borderline personality disorder" for nearly a year in their research hospital. They found that when this woman had depression, and especially when she had psychotic symptoms (e.g. becoming paranoid, hearing voices), she had increased levels of an antibody to thyroid tissue in her bloodstream.[13]

What is the connection here? Well, we know that one type of thyroid disease is associated with these "autoantibodies" -- antibodies directed toward one's own tissues, in this case thyroid tissue. That is called Hashimoto's thyroiditis. There is some connection between thyroid problems and mood problems, that's clear, but the nature of the connection is not understood. So, it's a mystery as to why this woman's thyroid antibodies would vary along with her mood and other symptoms. Is the thyroid change causing the mood change? Or is it the other way around? Or is some third problem causing both at the same time? Just keep watching for more information on how thyroid, which is similarly mysteriously involved in bipolar disorder, affects complex mood conditions.]

The Overlap Between Diagnostic Criteria
There is tremendous overlap in the symptom patterns of bipolar and borderline personality disorder (Borderline PD). The overlap reflects a basic problem with the concept of a "diagnosis" in the first place. Notice in the table below that almost every symptom is found in each column:

Some doctors believe self-harm is "diagnostic" of borderline PD, or worse yet, synonymous: all borderlines cut, and anybody who cuts is borderline. It's hard, let me tell you, to convince them it isn't that simple.

However, I think there is indeed one symptom that differentiates the two (to the extent there's any point in doing so; more on that in a moment). You noticed the big yellow blank in the table, yes? People with profound fear of abandonment, and a feeling of chronic emptiness, have a different struggle in life from those who don't have these problems. Recently one of the most prominent borderline specialists, Dr. Glen Gabbard, emphasized these symptoms as the core of "borderline" experience.[14]

In my practice, I've had patients who do not have chronic emptiness or abandonment fears who do have self-harm behaviors, which show up when they are extremely agitated. These patients all seem to have figured out that cutting or other forms of self-harm (I had one patient who hit herself on the head with a rolling pin) somehow helped them cope with the intensity of the rest of their symptoms. I have no doubt now that self-harm behaviors are an attempt to "treat" the severe agitation somehow; but that behavior seems rather quickly to disappear when the agitation is controlled.

However, here's the crucial question: what difference does it make whether you have "borderline" or "bipolar", as far as treatment you might benefit from? That's the point of "diagnosis" anyway, right? -- to help match patients to treatments that have worked well for others before them. (Diagnoses also help predict how things are likely to go in the future -- "prognosis"; but that's a lot less crucial). And the answer is: it doesn't make that much difference.

There are good treatments for both conditions. Borderline PD is usually treated with psychotherapy as the main tool, with medications as needed or to the extent that they are helpful. Bipolar disorder is treated just the other way around: start with medications as the core ingredients in treatment, but using psychotherapy wherever it might be helpful.

Medications
All of the medications we routinely use in treating bipolar disorder have been shown in published studies to have some value in borderline PD[15] antidepressants, mood stabilizers, and (to a lesser extent, though much more so with the new ones) antipsychotics.

[UPDATE: At least two studies have been published both showing that "borderline personality disorder" patients respond to Depakote[16][17]. A pair of recent studies showed response to Zyprexa was greater than to placebo.[18][19] There is preliminary (not placebo-controlled) evidence that lamotrigine may have positive effects in borderline PD[20] Similarly, a research team looked back at "borderline" symptoms in the pair of large lamotrigine studies for bipolar patients, and found that "borderline" symptoms appeared to improve along with the bipolar symptoms.[21]

Lithium has not been studied in a controlled trial in borderline personality disorder, but is advocated for "targeting specific symptom domains" such as mood instability; I did not find anything newer about lithium than the old review by Soloff[22] in 1994, which also includes a review of the use of carbamazepine in borderline.]

Therefore it seems even safer now than several years ago to say that "mood stabilizer" medications typically thought of for bipolar disorder are also worth thinking of in borderline PD.

Psychotherapy
The best studied technique for borderline personality disorder is "dialectic behavior therapy", designed and studied initially by Dr. Marsha Linehan. This technique is distinguished from the approaches which proceeded it in (at least) three ways:

A group in Europe used the Linehan treatment approach, and got the same results as in Dr. Linehan's original research[23], namely a dramatic decrease in suicidal and self-harm behaviors, although they point out that the big improvements came for the patients with the most severe symptoms.[24] They suggest that the Linehan DBT approach may be best suited for patient with severe self-harm and suicidal behavior, and that other therapies might be more appropriate for patients without these behaviors -- because DBT does not seem to affect mood symptoms very much. Thus, there may be even more reason, supported by the Verheul study, to think about medications for mood, as well as psychotherapies for mood (after DBT for self-harm and suicidality, if present).

Imagine there really is a difference between these two conditions. We don't really know that now. But imagine there is one, some difference in the structure of the limbic system, the emotion system of the brain, perhaps. And imagine that we had some great lab test that could tell the two apart perfectly (that's rarely the case even with an excellent lab test, by the way, so don't hold your breath). Now, suppose you really have "borderline", but you get diagnosed with "bipolar ". What happens? You get treated primarily with medications. These might help, as those studies I mentioned a moment ago indicate. But you would still need some help with feelings of abandonment and emptiness (and the problems with relationships that come up when you have those feelings). Unless you had a really rigid psychiatrist or mental health system, you could then try to get some psychotherapy to address these.

What about the other way around? Suppose by our magic test a patient "really" has bipolar, but gets diagnosed borderline PD. Well, until recently, this was the big problem. Patients would get labeled as "personality disorder" and often medical care, from primary care as well as mental health providers, would change accordingly. Patients would get shunted to the bottom of the list of those someone might want to take into a practice. Patients were told that their situation was basically unchangeable except with years of psychotherapy, and then discharged from the hospital no matter what the symptoms were. (Even if a patient "really" has borderline PD she shouldn't be treated this way anymore: if our mental health system were perfect (right), she would be found in some deliberate screening program to have borderline PD and placed in a treatment program designed for the patient’s condition.)

But back to our example: you're patient "really" has bipolar, but gets diagnosed "borderline". Even if initially treated with psychotherapy, ideally it would be noticed that the patient was not improving fully, and might need medication treatment as well. And hopefully, since mood instability is the primary problem (not plain depression, nor psychosis), the patient would then be treated with mood stabilizers.

The point here is that your patient would not necessarily be led into a treatment that would harm him with the "wrong" diagnosis, either way. He might well get a treatment that could be helpful, even if it is not the "core treatment" eventually needed (and hopefully get).

Which diagnosis a patient gets depends a great deal on the orientation of the therapist or doctor! Psychiatrists might be better diagnosticians, in theory, because they have pliers as well as hammers ("when all you have is a hammer, everything looks like a nail"). But finding a psychiatrist who really does use her/his pliers just as much as his/her hammer can be difficult. Finding a psychiatrist at all can be difficult. In that case, a therapist who feels comfortable treating borderline personality disorder is a good starting place.[24]

Psychotherapy for Bipolar Disorder[25]
At least 5 psychotherapy approaches for bipolar disorder have recently been shown to be of benefit when added to medications, compared to medications alone. This essay will introduce you to each of these psychotherapies and show you some evidence of their success. Most of the material presented here is adapted from an elegant summary presented at a recent bipolar meeting, by Dr. Eduard Vieta. He is the Director of Research and Director of the Bipolar Disorders Program of the Hospital Clinic at the University of Barcelona, Spain.

Therapy	Reporting Authors	Usual # sessions	BP I / BP II
Prodrome Detection:	Perry and colleagues	9	not specified
Psychoeducation	Colom, Vieta, and colleagues	21	BPI and BP II
Cognitive Therapy	(Basco, Rush) Lam and colleagues	14	BP I
Interpersonal/Social Rhythm	Frank and colleagues	--	not specified
Family-Focused Therapy	Miklowitz and colleagues	21	BPI and BP II

None of these bears much resemblance to traditional "psychoanalytic" psychotherapy (the modern version of Freudian technique), which has not been shown to be of use in bipolar disorder. They are specific approaches developed to address known needs of bipolar patients and families. As you'll see, all the therapies emphasize similar ingredients:

1. Prodrome Detection: Perry and colleagues[26] (Bipolar I or Bipolar II not specified; emphasis seems on BPI)

In this study, a psychologist "with little previous clinical experience" met with patients up to 12 times (average 9) while the rest of the clinical team proceeded as usual. She discussed with the patient her/his personal experience of bipolar disorder and the signs preceding manic and depressive episodes in the past. They planned and rehearsed a plan for action should those symptoms appear again. The plan was written on a laminated card, carried by the patient. The therapist helped the patient keep a weekly diary, increasing to daily notes if symptoms were appearing. She informed the rest of the treatment team (a psychiatrist and mental health worker and primary care physician) of the plan. That was it, nothing any fancier than that, although it looks like she is a very smart person from the style of the write-up, of which she is the primary author.

In the control group that didn't get to meet with the psychologist, 50% of the group had relapsed in some way in about a year). By comparison, in the group who met with the psychologist, in one year only about 20% relapsed. We have to wonder if just anybody could get these results, besides Ms. Perry, but still, it's pretty impressive. I'm planning on adding some of her tricks, like the card thing, to my approach, based on this result -- for patients who have clearly identifiable "episodes" and pre-episode warning signs.

This research team added 21 sessions of education about bipolar disorder, in groups of 8-12 patients each, to routine treatment in their clinic. A control group received 21 sessions of "nonstructured" meetings with the same two therapists, but in these groups, they tried not to teach about bipolar disorder (think about it: this was a very rigorous test of the theory that education itself is the active ingredient in the different outcomes shown below).

Over the next 2 years the education group had about one third as many hospitalizations as the control group.

This technique was introduced in 1996 by Drs. Basco and Rush (Ph.D. and M.D. respectively) in their book Cognitive Therapy for Bipolar Disorder. For psychologists seeking training in this method -- or patients and families seeking the most thorough treatment possible and willing to teach their therapists while both patient and therapist learn by working through the a training manual -- another more recent book describes the technique used by the authors of the largest research study of this method: Cognitive Therapy for Bipolar Disorder: A Therapist's Guide to Concepts, Methods and Practice, by Dominic Lam and colleagues.

They too have shown a strikingly lower relapse rate in patients who had 14 sessions of this therapy added to their regular treatment. Note that this is not quite as rigorous a test as the PsychoEducation method above, since the control group here is getting no additional treatment, whereas Colom and colleagues conducted an identical group for the controls, without the education. Thus there is a chance that the improvement we're seeing here is simply due to 14 sessions with skilled, caring therapists, and not necessarily due to the treatment described in their book. However, in any case, the results are still impressive.

Here are some of the main focus points in this therapy (from an excellent summary by Otto and colleagues):

Focus	Technique	Details
Medication adherence	Motivational interviewing Habit-training Engage patient as co-therapist	e.g. Rollnick and Miller 1995 e.g. behavioral steps: colored dots, pill-minders e.g self-monitoring, report forms
Early Detection/Intervention	Treatment contracts	(see list below ) "Two Person Feedback Rule" "48-Hour Rule"
Stress	Stress/Lifestyle Management	Understand importance of sleep; protect sleep/wake cycle Problem-solving, communication skills, routine cognitive tools (Exercise)
Co-morbidity	CBT emphasis	Treating social phobia, panic disorder, substance use, eating
Depression	Standard CBT	Identifying dysfunctional beliefs, etc.

The Harvard program makes extensive use of written plans, with a separate "treatment contract" for each of the following:

4. Interpersonal and Social Rhythm Therapy (IPSRT) : Frank and colleagues[29] (BP subtype not specified)

The data supporting this method are not as strong for the other methods described in this essay. We will skip quickly on to another method which incorporates this approach.

5. Family-Focused Therapy (FFT) and Integrated FFT/IPSRT: Miklowitz and colleagues[30] (BP I and BPII)

As far back as 1990, Dr. Miklowitz and his research team at the University of Colorado were at work adapting a Behavioral Family Management technique, previously studied in patients with schizophrenia and their families, to bipolar disorder.[31]
How does Family-Focused Therapy work? As described in his book by that title (1997), FFT includes:

However, this therapy also includes the family in a major way, which is not a feature of any of the above approaches. In addition to involving family members in all the steps just listed, it also focuses on communication within the family, teaches communication skills, and prepares the entire family for relapse episodes so that all members (not just the patient) have a plan for what to do when symptoms start to reappear.

This method consisted of 21 therapy sessions over 9 months. Using this technique, his team reduced relapse rates in patients who'd been hospitalized for mania.[32] Another study using this method was published in 2000[33].

Over one year, many relapse, but the treatment group did so more slowly. Like almost all the others, this therapy also focuses on the importance of "adherence" -- staying on medications -- and showed a specific benefit there (it's a little unnerving to note that the control patients were not taking medications as directed half the time, and that even when improved by treatment, that was still a problem 25% of the time):

Which therapy is best?
To answer this properly, with the same kind of emphasis on evidence, will take additional research. Since these studies cost a lot and take years of work, I doubt we'll see "head-to-head" comparisons (we don't have that for many medications, either). For now it looks simpler to conclude that they all have some merit and that elements of each, at minimum the simpler ones, should be part of a treatment package that most patients with bipolar disorder receive.

Unfortunately, at least in my area, money problems are driving treatment programs in the opposite direction (e.g public mental health programs).

Is there one therapy that is better for bipolar II?
Some of the research did not include Bipolar II patients, and none focused on this subtype. The emphasis of most methods on relapse prevention is, I presume, a reflection of an emphasis on Bipolar I, as most of my patients with Bipolar II do not have discrete "episodes" in the fashion these methods are designed to detect.

However, in my experience, the emphasis on regular rhythms; on stress reduction; on involving the family; and on education about bipolar disorder, are all very appropriate for bipolar II. Based on the research shown here, I would expect that a study with only bipolar II patients would show positive results.

C. Does this mean that all patients with bipolar disorder should have one of these psychotherapies?

All these elements are appropriate to any treatment. However, I believe they should be individualized, so that some patients would notice an emphasis more on one than another. [3]

‘Moving from “your dianosis” to “your position on a spectrum”’ by James R. Phelps, M.D. From Psycheducation.org. Found on-line at: http://www.psycheducation.org/depression/diagnosis.htm
‘What’s the difference between bipolar disorder and “Borderline Personality Disorder”?’ by James R. Phelps, M.D, From Psycheducation.org. Found on-line at: http://www.psycheducation.org/depression/borderline.htm
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