Acta Psychiatr Scand 2015: 13

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DOI: 10.1111/acps.12428

2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
ACTA PSYCHIATRICA SCANDINAVICA

Commentary

Confusing borderline personality with severe

bipolar illness
The paper by Hower et al. in this issue of the Acta
Psychiatrica Scandinavica is an example of an
increasingly obvious and disappointing fact: DSM5 (and, in retrospect IV and III) are impeding us
from conducting and interpreting meaningful
research in psychiatry (1). The analysis presented
simply accepts DSM assumptions and then claims
that borderline personality worsens bipolar disorder. Yet the specic features that predict poor outcome are mood instability and impulsivity, which
are quite non-specic for borderline personality
disorder (BPD) and which are central to the whole
concept of mania and bipolar disorder. As we will
explain below, the DSM denition of BPD is such
that it captures most patients with bipolar illness,
specically those with severe symptoms.
So it becomes meaningless to say that comorbid BPD worsens bipolar illness, when the whole
concept of BPD is dened to be equivalent to
severe versions of bipolar illness. The observed
data could reect simply worsened features of
bipolar illness (more impulsivity, more mood
swings), and not something specic to borderline
personality. (The authors acknowledge this limitation in parts of the manuscript, though not in the
abstract; this critique may not be appreciated by
many readers of the article, and others like it,
hence this commentary.)
This commentary provides a rationale for the
above conclusion.
The Course and Outcome of Bipolar Youth
(COBY) study is an important contribution to
our knowledge about childhood mood conditions.
In this report, DSM-IV personality disorder denitions were assessed as predictors of outcome.
This approach has been taken in many analyses,
with well-characterized and prospectively followed samples. In general, it is found that DSM
denitions of personality disorders, for example
borderline, predict poor outcomes in DSMdened mood syndromes (whether major depressive disorder, MDD, or bipolar illness) (2). A
similar result is found in this paper for childhood
bipolar illness.
The usual conclusion is that BPD is a harmful
comorbidity, predicting poor outcomes. Propo-

nents of the BPD concept then advocate for more

attention to its diagnosis and treatment (especially
with psychotherapies, often psychoanalytically
derived) (3).
The authors here make the same claim, presented as straightforward interpretation of the
data: The number of BPD symptoms signicantly
predicted poor clinical course of BP, above and
beyond BP characteristics. . ...BPD severity adds
signicantly to the burden of BP illness and prospectively predicts a more chronic and severe
course and outcome beyond BP characteristics.
This interpretation would have made sense in
1985, but stated baldly as it is in 2015, it fails to
convince.
The key assumption by the authors is that the
concept of comorbidity validly applies to this
paper. The idea of comorbidity was proposed originally by the physician and epidemiologist Alvan
Feinstein about 40 years ago to mean the simultaneous occurrence of two independent and separate
diseases (4). Yet the DSM approach to BPD is
such that it negates a valid concept of comorbidity.
The diagnostic criteria given for BPD were developed by the DSM-III committee headed by Gunderson in the 1970s and have changed little under
his leadership for the next 40 years in the 4th and
5th revisions (5).
What does it mean to say that borderline symptoms predictor poor course above and beyond
bipolar symptoms? Readers should look at both
DSM criteria sets. For borderline personality, it is
perfectly feasible to meet diagnostic criteria simply
based on standard, long-proven, well-accepted
characteristics of the symptoms or consequences of
bipolar illness. All you need is ve of nine criteria,
including: aective instability, unstable interpersonal relationships, anger, impulsivity (especially
around sex and spending) and suicidal behaviour.
The majority of patients with bipolar illness
(whether type I or type II) will meet the above ve
criteria based on the symptoms or consequences of
repeated manic/hypomanic and depressive episodes, not to mention the impact of mood temperaments of cyclothymia or hyperthymia in up to
one-half of persons with bipolar illness.
1

Commentary
As we have argued previously (6), the most eective way to distinguish borderline personality from
bipolar illness is on the four borderline criteria that
are not included above: dissociative symptoms,
chronic (not episodic) emptiness, identity disturbance and abandonment feelings. We would add
the key importance of childhood sexual trauma,
which the DSM framers continue to refuse to
include in borderline criteria, despite a strong causal association. Further, we have reviewed data
showing that recurrent parasuicidal behaviour,
such as self-cutting, is more common in borderline
personality than bipolar illness (6).
This non-DSM manner of dening borderline
personality and dierentiating it from bipolar illness would present an opportunity for some useful
data analyses that actually answer the question
raised by the researchers: Does borderline personality worsen the course of bipolar illness?
What could be said against the view-point presented in this commentary? One approach would
be to say that it is not the role of researchers to
either endorse or criticize DSM; rather researchers should take an agnostic approach, employing
DSM criteria because they are the most widely
used psychiatric nosological system. The problem
with this approach is that it is unscientic: A scientic attitude is not agnostic; not all approaches
are equally valid in science; some are proven
more valid than others; and whatever is accepted
by the majority is not thereby rendered more
valid. This attitude is part of the problem in psychiatric research for the past two generations.
We have simply refused to critique the DSM system in our research; instead, researchers claim it
is not up to them to critique DSM. If not them,
who will do it?
Another response to this commentary could be
that there is disagreement as to what constitutes
core criteria for BPD. Some argue for aective
instability or interpersonal sensitivity as core criteria (7, 8). These perspectives conveniently ignore
the history of BPD. As proposed by psychoanalytic thinkers like Kernberg and others (9, 10),
although there were always diering views about
the condition, borderline personality always
involved patients who were not seen in any way as
having manic-depressive illness. The original view
of borderline personality had to do with people
who had childhood traumatic experiences, usually
of the sexual variety, and who had adult symptoms
that involved either prepsychotic symptoms or dissociative-type symptoms of hysteria (9, 10).
Manic and severe depressive episodes genetically
determined, severe, and unrelated to sexual trauma
were something entirely dierent and were not
2

related to the borderline concept before DSM-III

(9, 10).
To a great extent, it is an empirical question as to
what represents the core of BPD. How is it most
specically dierentiated from other valid diagnoses, such as bipolar illness? Sophistic interpretations
often aim at proving a point, rather than seeking
the truth. It is not valid to say that sexual trauma is
not central to borderline personality because some
purportedly borderline patients do not have sexual
trauma (5). Some patients also have lung cancer
who do not smoke cigarettes. It is not legitimate to
say that parasuicidal self-injury is not central to
borderline personality because parasuicidal behaviours occur with similar prevalence in persons with
and without BPD in some studies (11). Other studies show the opposite, as we have cited, with high
rates of parasuicidal behaviour in borderline personality and quite low rates in bipolar illness (6).
It is unavoidable that many researchers, especially of the generation that has created and
enforced DSM revisions, are attached to thinking
about research only within the context of DSM criteria. But, current and future generations of psychiatrists would not be doing justice to their
profession if they allowed time to stand still with
criteria that were essentially set in 1980. The world
has changed, science demands change, and
researchers should be at the forefront of change.
We have not learned from this data analysis
what the authors claim about the relationship
between borderline personality and bipolar illness.
We have learned that to obtain new knowledge
about that relationship, we need to learn to think
and work outside of DSM denitions.
S. N. Ghaemi1,2 and S. Barroilhet1,2
1

Mood Disorders Program, Tufts Medical Center, Boston, MA,

USA, and
2
School of Psychology, University of Los Andes, Santiago, Chile
E-mail: nghaemi@tuftsmedicalcenter.org

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Commentary
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