Distinguishing Bipolar and BPD Disorders Tonjanika Boyd North Carolina Central University Introduction Bipolar and Borderline Personality Disorder are mood and personality disorder respectively, that have had many challenges amongst psychiatrist in differentiation. Not only does the two disorders share several symptoms and associated impairments, there is also continuing debates in the psychiatric literature about whether the two disorders actually represent different conditions (Hatchet, 2010).
The following paper compares and contrasts Bipolar and Borderline Personality Disorders and discusses implications of differential diagnosis of the disorders that can lead to long-term effects for the patient due to the fundamentally different treatment each disorder needs. Comparison of Bipolar and Borderline Personality Disorder Bipolar Disorder According to the Diagnostic and Statistics Manual of Mental Disorder, 4th edition Text Revision (DSM-IV-TR), bipolar is a recurrent mood disorder featuring one or more episodes of mania or mixed episodes of mania and depression (Antai-Otong, 2008).
The bipolar disorders include, bipolar I disorder, bipolar II disorder, cyclothymic, and bipolar NOS disorders. Bipolar I disorder includes one or more manic or mixed episodes, usually with a major depressive episode. Bipolar II disorder includes one or two major depressive episodes and at least one hypomanic episode. Cyclothymic disorder includes at least 2 years of hypomanic periods that do not meet the criteria for the other disorders. Bipolar NOS, does not meet any of the other bipolar criteria. The etiology of Bipolar disorder has been researched and documented for many years and has many theories and perspectives.
Causative factors include psychodynamic, existential, cognitive behavioral and developmental and complex biologic and genetic factors (Antai-Otong, 2008). Signs and Symptoms (s/s) of Bipolar disorder varies from the type of episode they patient is experiencing. Major depressive episodes include a depressed mood or lose of interest for at least 2 weeks and five or more of the following: Significant weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, worthless feelings or inappropriate guilt, problem concentrating or recurrent thoughts of death.
Manic episodes s/s includes, persistent elevated irritable mood of more than one week, increased self-esteem, decreased sleep, increased, increase talk and pressured speech, racing thoughts and ideas, distractibility, extreme goal-directed activity, excessive buying, sex and business investments (Pederson, 2012). In order to have successful treatment of bipolar disorder, a holistic approach is the best therapy. This includes, pharmacologic and psychotherapeutic interventions. Pharmacologic include mood stabilizers, anti-depressants, anti-psychotics and electroconvulsive therapy.
There has been a controversy with the use of anti-depressants for treatment due to its effect with mood stabilizers. It is not a mainstay, but is still prescribe when they are not sure if it is unipolar or bipolar, but becomes dangerous when switching from a depressive episode to a manic or hypomanic episode (Antai-Otong, 2011). Electroconvulsive therapy is the last resort if the mood stabilizers and anti-psychotics fail or when an immediate intervention is needed. Psychotherapeutic intervention is mostly where the nursing care is used more frequently.
Psychosocial and behavioral intervention, both fall under the umbrella of psychotherapeutic treatment and are important for more positive treatment outcomes. If a patient is in the acute phase, the nurses’ main focuses are safety and maintain a therapeutic milieu that facilitates resolution of symptoms and minimizes complications. The nurse also educated the client and family about medications, treatment options and other psychotherapies (Antai-Otong, 2011). Borderline Personality Disorder (BPD)
BPD originated in the 1930’s, when it was used to describe patients who were on the “border” between neuroses and psychosis. It is the most common complex and severely impairing personality disorders. According to DSM-IV, it is a pattern of instability in interpersonal relationships, self-image, affect and marked impulsivity (Swift, 2009). The etiology of BPD includes, genetic predisposition, family history of mood disorders and maybe related to bipolar disorder, physical and sexual abuse. About 2% of the population experiences BPD and mostly female.
The symptoms of BPD are maladaptive behavior learnt to make sense of the world and to manage the persistent negative messages received (Eastwick & Grant, 2005). Signs and symptoms, consists of patterns of unstable interpersonal relationships, fear of abandonment, splitting (love or hate), impulsiveness in sex, substance abuse, binge eating and reckless driving, suicidal gestures, such as self-mutilation, intense mood changes that last for hours, chronic emptiness, intense anger and transient paranoid ideation (Pedersen, 2012).
Managing BPD is challenging and can be emotionally and physically draining for the nurse involved and other members of the healthcare team. The nurse-patient relationship is frequently confrontational due to the patient difficulty with interpersonal relationships and dysfunctional emotional regulation, which results in aggression towards the nurse. Evidence has shown that people experiencing BPD are more likely to harm themselves than others (Swift, 2009). Treatment of BPD requires an integrated psychobiologic approach that includes, pharmacologic and psychotherapeutic interventions.
This combination is called psychopharmacologic therapy. There have been many variations of drugs used to treat BPD, due to limited success. There has been limited success in the use of psychotropic medications in clients with borderline personality disorder. Mood stabilizers, anti-depressants and anti-psychotics are only effective in providing relief in the symptoms of difficulty controlling behaviors, impulsivity, self-injurious behaviors and depression (Antai-Otong, 2011).
Diagnostic Dilemma of Bipolar and BPD Disorder According to the criteria outlined in the DSM-IV-TR there is a systematic difference between patients with BPD and bipolar disorder. It was found that patients with bipolar II exhibited mood swings that varied between euthymia, elation and depression and mood swings with BPD rotated between euthymia, anger and anxiety. A diagnosis between the two boiled down to how the emotional and behavioral instability exhibited by a client is conceptualized.
In other words, a counselor must decide whether the symptoms are best attributed to an acute mood disorder or they are just the latest manifestations of a more chronic problem (Hatchett, 2010). The challenge is not the case of being able to rule out acute episodes of mania, but when assessing the possibility of rapid-cycling bipolar disorder or a mixed episode. The actual definition of rapid cycling is often misunderstood in the mental health community and ruling out mixed episode is even a greater test in distinguishing between bipolar and BPD, due to many patients not having an accurate history of their symptoms.
This is important because, according to DSM-IV-TR (2000) “The individual experiences rapidly alternating moods (sadness, irritability, euphoria) accompanied by symptoms of a Manic Episode…and a Major Depressive Episode” (p. 362). It becomes difficult and nearly impossible to distinguish a mixed episode from the chronic anger and dysphoria common to those with BPD. Repercussions for differentiating between the disorders for treatment are evident for counselors who are responsible for creating and implementing treatment plans. Accurate diagnosis is fundamental for effective treatment.
A diagnosis of Bipolar disorder is treated with psychoactive medication, whereas for BPD patients, that is not effective as a mainstay of therapy. When BPD is appropriately diagnosed, it encompasses a more holistic approach of intervention strategies, such as dialectical behavior therapy (DBT). Those who consider BPD to be a variant of bipolar disorder contend that treatment should proceed with mood stabilizers and atypical anti-psychotics and those on the other side of the debate recommend an intensive psychotherapy model, such as DBT (Hatchett, 2010).
Conclusion Careful consideration to distinguish more accurately the difference between an acute mood disorder and a more chronic and pervasive personality disorder through the diagnostic process is essential. A mood disorder is discerned by distinct episodes of mania, hypomania, or depression that continue for specified periods and a personality disorder is characterized by persistent and rigid patterns of maladaptive behavior and intrapersonal experience that influence areas of functioning.
I feel the debate between differential diagnosis of these disorders can at least shift towards a solution by considering an overhaul in the definition and placement of mood and personality disorders in Axis I and II. Through Axis II was developed to encourage clinicians to consider more enduring personality characteristics that may impact treatment, as Fowler et al (2007) pointed out, some Axis I disorders are actually more chronic than many Axis II disorders, which are more likely to remit than is commonly believed.
Also, I noticed through my research that maybe there needs to be another type of assessment tool created when assessing patients for mood or personality disorders or specific training on how to distinguish between BPD an bipolar disorder to ensure more accurate diagnosis. For the DSM-V now being drafted, proposals have been made to either eliminate personality disorders altogether or integrate theme into Axis I. In that scenario BDP might be reclassified as a mood or impulse control disorder (Hatchett, 2010).
Distinguishing between Bipolar and BPD disorder is significant for the patient, treatment teams, family and mental health community, due to the major difference in the treatment plans for each disorder. Recognizing which disorder the patient has is fundamental in positive outcomes as they progress through the proper comprehensive psychopharmacologic therapy. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed. , text rev. ). doi:10. 1176/appi. books. 9780890423349.
Antai-Otong, D. (2008). Psychiatric Nursing: Biological and Behavioral Concepts, 2nd ed. , Thomson, Delmar Learning. Hatchett, G. T. (2010). Differential Diagnosis of Borderline Personality Disorder from Bipolar Disorder: Journal of Mental Health Counseling, 32:3, 189-205. Pederson, D. D. (2012). Psych Notes: Clinical Pocket Guide, 3rd ed. , F. A. Davis Co. Philadelphia. Swift, E. (2009). Borderline personality disorder: aetiology, presentation and therapeutic relationship: Mental Health Nursing, 13:3, 22-25.