Judith Mohring

Welcome to Priory Bitesize, your monthly e-bulletin in which a mental health expert will discuss dealing with certain conditions to support your patient discussions.

This month, Dr Judith Mohring, Consultant Psychiatrist at the Priory Wellbeing Centre Fenchurch Street in London, talks challenges in diagnosing Borderline Personality and Bipolar Disorder.
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A common question asked by GPs is whether a patient has Borderline Personality or Bipolar Disorder?

Having worked in a specialist Borderline Personality Disorder service and having set up a service in Holloway prison for women who self harm, it was a question I felt reasonably confident to approach.

Despite this, teasing out different symptoms and making a clear diagnosis takes time and is complex. Changes in the understanding and description of Bipolar Disorder have added to this complexity. A thorough assessment by a specialist in general adult psychiatry can be enormously helpful to patients and GPs in guiding further treatment.

This article focuses on the diagnosis of the 2 conditions including:

  • Controversy over diagnosing Borderline Personality Disorder
  • The benefits of making a distinction between personality and mood disorder
  • The core features of Borderline Personality Disorder
  • The core features of Bipolar Disorder
  • Distinguishing between the features of each condition
  • A brief overview of treatment options for each condition

Controversy over diagnosing Borderline Personality Disorder

During my early training I was told that we should not diagnose a personality disorder without having conducted a longitudinal assessment. There was reticence to label people as personality disordered because it was believed;

  • The label was pejorative
  • Personality disorders don’t get better
  • There was no effective treatment

However the evidence suggests the opposite is true.

Borderline PD gets better with age and there is a range of therapy with a good evidence base. If there is still stigma it lies with us as professionals. Patients generally welcome knowing why they feel as they do, and will often have researched their diagnosis on the internet prior to coming to see us.

The benefits of making a distinction between personality and mood disorder

Patients welcome knowing what is wrong. Qualitatively, patients tell me they feel a sense of relief when they meet a specialist who is clear about what is going on and comfortable making a diagnosis.

I usually ask the patient what they think the problem is. Often they will say they suspect BPD. If the patient doesn’t find the label useful I don’t use it. It is their experience and condition.

The advantages of a diagnosis include:

  1. It enables self help
  2. It gives clear signposts for treatment
  3. It enables discussion of prognosis and outcomes

The core features of Borderline Personality Disorder

Borderline Personality Disorder has very specific symptoms, which make it easy to distinguish from other conditions.  It is common not to screen for the core features but to diagnose based on “countertransference feeling”. This is particularly the case when people present with self-harming behavior.

I was trained in DSM 4 which is a more user friendly diagnostic tool than ICD 10 for Borderline Personality Disorder as it doesn’t subdivide it into 2 conditions.

The criteria for Borderline Personality Disorder in DSM 4

In addition to the core features of all personality disorders the criterion are:

  1. Frantic efforts to avoid real or imagined abandonment
  2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
  3. Identity disturbance: markedly and persistently unstable self image
  4. Impulsivity in at least two areas that are potentially self- damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self- mutilating behavior covered in Criterion 5
  5. Recurrent suicidal behavior, gestures, or threats, or self- mutilating behavior.
  6. Affective instability due to 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)
  7. Chronic feelings of emptiness
  8. Inappropriate, intense anger (e.g. frequent displays of temper, constant anger, recurrent physical fights).
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Someone must have 5 of these 9 features to merit the full diagnosis.

Symptoms of Borderline Personality Disorder in more detail

The mood swings of BPD have a particular character - they are abrupt and often occur without warning over a period of seconds or minutes. The patient experiences a “state shift” from one emotional state to another. Often this is rapid and unpleasant.

Clients can sometimes clearly describe their different self states e.g.: numb, angry, self loathing and cut off. The different self states are not integrated into an overarching sense of self, they can be perceived as “other” - the patient may not recognise themselves within each state.

State shifts cause a great deal of anxiety and can lead to dissociation - clients require an empathetic approach. In the DSM 5 anxiety is included as a core feature of Borderline Personality Disorder.

The core features of Bipolar Disorder

Effective diagnosis of mood disorder relies on taking a proper longitudinal mood history from adolescence with particular attention to any hypomanic episodes. This is where a specialist assessment is useful.

Bipolar I Disorder

Bipolar I disorder involves one or more manic episodes or mixed (mania and depression) episodes. The episodes are not due to another medical condition or substance use.

Bipolar II Disorder

Bipolar II disorder has one or more major depressive episodes with at least one hypomanic episode. There are no manic or mixed episodes.

A hypomanic episode is characterized by a distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days. It differs from a manic episode because:

  1. The mood usually isn’t severe enough to cause problems with the person working or socializing with others (e.g., they don’t have to take time off work during the episode), or to require hospitalization
  2. There are never any psychotic features present in a hypomanic episode

Rapid-Cycling Bipolar Disorder

At least four distinct mood episodes within a year. Rapid cycling affects more women than men, and appears to be more persistent in those who have their first bipolar episode at a young age.

Distinguishing between the features of each condition

  1. Borderline Personality Disorder has no mania, and is characterized by its own distinct features - see DSM 4
  2. Mood variability in Borderline Personality Disorder is over a period of minutes or hours, in the form of state shifts between emotions. Distinct mood episodes in bipolar last days or weeks
  3. Family history of one or other can be a guide as there is a genetic component to each
  4. Age at onset and natural history
  5. BPAD often presents later and worsens with age and recurrent episodes
  6. BPD often presents in adolescence and improves with age

Pitfalls

Patients with Borderline Personality Disorder frequently have co-morbid mood disorders including depression and bipolar 2. Suicidal behavior can be a feature of a range of conditions and on its own does not suggest a particular diagnosis.

Borderline Personality Disorder is not always associated with childhood abuse or trauma. Diagnoses can change over time as presentations evolve.

Mixed affective states can be very hard to distinguish from Borderline Personality Disorder. A really good mood history is key to getting the diagnosis right.

A brief overview of treatment options

A thorough specialist assessment is essential to establish the diagnosis

Borderline Personality Disorder

  1. Pharmacotherapy tailored to the patient’s presenting symptoms. This may include antidepressants, mood stabilising antipsychotics like quetiapine or anxiolytics including pregabalin. Avoid drugs toxic in overdose and tailor treatment closely to response. Patients often require a case management approach.
  2. Psychotherapy with an evidence base. Dialectical behaviour therapy is the treatment of choice and is a 16-24 week group and individual outpatient programme available through a number of Priory sites.

Bipolar Affective Disorder

  1. Bipolar depression - a mood stabilising antidepressant is required either as a single drug (quetiapine, olanzapine, lamotrigine) or as a combination (fluoxetine and olanzapine) Lithium may be required but should not be started in primary care. Avoid unopposed antidepressants. Beware of weight gain with olanzapine.
  2. Mania or hypomania - consider stopping any antidepressant. Start an antipsychotic such as quetiapine, olanzapine, haloperidol or risperidone.
  3. Consider referral to secondary care. Lithium or sodium valproate may be required. Sodium valproate should be avoided in women of child bearing age.
  4. Psychotherapy for Bipolar Affective Disorder needs to come from a therapist experienced in the condition and could include CBT for depression and relapse prevention, crisis planning and early intervention for mania.

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