Borderline, bipolar, or both?

Jess G. Fiedorowicz, MD, Assistant professor, Department of psychiatry, University of Iowa, Carver College of Medicine, Iowa City, IA

Donald W. Black, MD, Professor, Department of psychiatry, University of Iowa, Carver College of Medicine, Iowa City, IA

Borderline personality disorder (BPD) and bipolar disorder are frequently confused with each other, in part because of their considerable symptomatic overlap. This redundancy occurs despite the different ways these disorders are conceptualized: BPD as a personality disorder and bipolar disorder as a brain disease among Axis I clinical disorders.

BPD and bipolar disorder—especially bipolar II—often co-occur and are frequently misidentified, as shown by clinical and epidemiologic studies. Misdiagnosis creates problems for clinicians and patients. When diagnosed with BPD, patients with bipolar disorder may be deprived of potentially effective pharmacologic treatments. Conversely, the stigma that BPD carries—particularly in the mental health community—may lead clinicians to:

• not even disclose the BPD diagnosis to patients

• lean in the direction of diagnosing BPD as bipolar disorder, potentially resulting in treatments that have little relevance or failure to refer for more appropriate psychosocial treatments.

To help you avoid confusion and the pitfalls of misdiagnosis, this article clarifies the distinctions between bipolar disorder and BPD. We discuss symptom overlap, highlight key differences between the constructs, outline diagnostic differences, and provide useful suggestions to discern the differential diagnosis.

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Listen to Dr. Fiedorowicz explains why a thorough and rigorous psychiatric history is essential to distinguish BPD from bipolar disorder

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STEPPS for patients with borderline personality disorder

Donald W. Black, MD, Professor, Department of psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA

Nancee Blum, MSW, Adjunct instructor, Department of psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA

Don St. John, MA, PA-C, Physician assistant, Department of psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA

Treatment of borderline personality disorder (BPD) often is viewed as challenging and the results so discouraging that some clinicians avoid referrals of BPD patients. Psychotherapy has been the treatment mainstay for decades, and supportive approaches are probably the most widely employed. Psychodynamic therapy often has been recommended.

This article introduces a new evidence-based group treatment program that we developed for BPD patients. Systems Training for Emotional Predictability and Problem Solving (STEPPS) is founded on the successes of better known psychoeducational models but is easier for practicing psychiatrists to implement.

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Risk factors for suicide in borderline personality disorder

Michele S. Berk, PhD
Assistant professor of psychiatry, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, CA

Bernadette Grosjean, MD
Assistant professor of psychiatry, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, CA

Heather D. Warnick, PsyD
Postdoctoral Fellow, Harbor-UCLA Medical Center, Torrance, CA

Manipulative, “just threats,” or suicide gestures are terms you may have heard or used to label suicidal thoughts and behavior in individuals with borderline personality disorder (BPD). These terms imply that the risk of injury or death is low, but evidence shows that BPD patients are at high risk for completed suicide—and clinicians who use these labels may underestimate this risk and respond inadequately.

Based on the literature and our clinical experience, this article offers recommendations for assessing and treating suicidal behavior in BPD patients. We review risk factors for suicide and suicide attempts and suggest strategies for safety management, psychotherapy, and pharmacotherapy. Because of the high-risk nature of this population, we recommend that all clinicians working with suicidal BPD patients obtain consultation and supervision as needed when using these strategies.

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Listen to Dr. Berk discuss suicide risk in BPD

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