Borderline or Bipolar: Objective Data Support a Difference
By James Phelps, MD
April 12, 2016
When a patient presents with episodes of depression, irritability, and emotional lability (especially tears and anger, with rapid changes), might he or she have borderline personality disorder (BPD)? Or could it be rapid cycling bipolar disorder (BD)?
Although there are other possibilities, such as substance use, differentiating these 2 common conditions can be extremely difficult. DSM criteria have a roughly 90% overlap: only 2 DSM criteria features are clearly present in one and absent in the other: namely, abandonment fear and chronic emptiness.
Indeed, Deltito and colleagues, as well as others, have argued that borderlinity is just another version of bipolarity or at least that the “broadening of the bipolar diagnosis to include a spectrum of poorly defined conditions has added to the plausibility of this idea.” In refutation of this notion, data that demonstrate a clear difference between the 2 conditions, involving interpersonal trust, have recently been published.
The social psychology research tool called Prisoner’s Dilemma is likely familiar to most readers.4 Briefly: imagine that 2 criminals are caught simultaneously. If both cooperate with one another and tell the same false story, each can get off with a light sentence. But if one finks on the other (dubbed “Defect”), he gets off scot-free while the other takes the rap. However, if both defect, both are punished.
This has been modeled in a game of cooperation. If both player and partner cooperate, each earns 40 pence. If both defect, each earns only 20 pence. But if one defects while the other cooperates, the defector earns 70 pence and the cooperator, nothing: he is punished for cooperating with a defector, whose score is actually better than could be achieved through mutual cooperation.
If such a game is played between 2 partners, just once, the best strategy is to defect: it limits losses. But if the game is played repeatedly, the best strategy in most circumstances is called “tit-for-tat”: play cooperation first and then follow the move of your partner. If he cooperates, do likewise. When he defects, also do likewise and continue thus until he plays cooperate—then follow that move as well.
The result is a test of willingness to cooperate. When euthymic bipolar patients played (ostensibly with another person, though the actual partner was a computer), they made choices very like control patients, choosing to cooperate almost 75% of the time. But patients with BPD cooperated only about 50% of the time (ANOVA difference, P = .03).
In 2024 the "Masters of Maestros", Hagop Akiskal published Demystifying Borderline Personality: critique of the concept and unorthodox reflections on its natural kinship with the bipolar spectrum (Acta Psych, Scand..) and a few years (from a very distant scholarly level than Professor Akiskal) I questioned the validity of this diagnosis (Journal of Bipolar Disorders). I said then, and still believe now that there is a Borderline Personality Organization, as clearly explained by professors Kernberg and Gunderson, among others. I realize that DBT helps individual with this type of mental "organization" but I have also seen the terrible consequences of given SSRIs to "borderlines" that actually are bipolar.
I find hard to understand those that rush to label a person as "borderline" because they have this "black and white" way of thinking, while ignoring the information about a family history that is positive for first-degree relatives with bipolar spectrum disorders.
I can understand that one person without a genetic endowment for bipolarity that was adopted and raised in an abusive environment, maybe raped or emotionally abused could developed that extreme way of saying the word that is known as Borderline Personality Organization... but if you try to tell that the daughter of a bipolar mother and schizophrenic father just has BPD and should do well on flouxetine, I will tell you that if the parents of a child are Tina Turner and Stevie Wonder he or she can't be blond with blue eye.
The same wise psychiatric establishment that gave us a DSM-5 that allows autistic children to be diagnosed with ADHD can continue preaching this and other fallacies but there is one reality that does not require a double blind study: in the past 30 years every "borderline" that I have encountered has become stable and "no longer borderline" when the antidepressants are d/c. Some of them continues to have the "borderline organization" but not the unpredictable, impulsive, angry mood swings.
I understand that a big majority thinks otherwise (sadly) but my patients are a living proof of how wrong that majority is.
Chair and Residency Program Director
Department of Psychiatry, Burrell College of Osteopathic Medicine
Las Cruces, NM
and Chief Medical Officer, Mesilla Valley Hospital
Fri, 2016-04-15 23:12
Thanks, Manuel. The child of Tina Turner and Stevie Wonder would have an interesting relationship with music, no matter how she/he turned out otherwise.
As you know, I share your enthusiasm for trials of tapering antidepressants (extremely slowly, as one should do in bipolar disorder unless manic or mixed symptoms are dramatic) in patients who appear to have borderlinity. Can't say I've batted 100% in 30 years, but I'd guess at least 60%, and that's trying hard to be honest about the ones I can't remember because they didn't work out as hoped (I'd be tempted to say over 80% otherwise, but selective recall is an extremely powerful bias).