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Is borderline personality disorder a mood disorder?

  • Gordon Parker (a1)
Summary

Borderline personality disorder is by its very naming positioned as an Axis II personality disorder and thus seemingly distinct from an Axis I mood state. Clinical differentiation of those with a borderline condition and those with a bipolar disorder is commonly held to be difficult, so raising the question as to whether they may be independent or interdependent conditions, and allowing several possible answers.

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References
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1 Tyrer, P. Why borderline personality disorder is neither borderline nor a personality disorder. Personal Ment Health 2009; 3: 8695.
2 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th edn) (DSM-5). APA, 2013.
3 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (3rd edn) (DSM–IIII). APA, 1980.
4 Paris, J Gunderson, J Weinberg, I The interface between borderline personality disorder and bipolar spectrum disorder. Compr Psychiatry 2007; 48: 145–54.
5 Parker, G. Clinical differentiation of bipolar II disorder from personality-based “emotional dysregulation” conditions. J Affect Disord 2011; 133: 1621.
6 Livesley, J. Toward a genetically-informed model of borderline personality disorder. J Pers Disord 2008; 22: 4271.
7 Bassett, D. Borderline personality disorder and bipolar affective disorder. Spectra or spectre? A review. Aust NZ J Psychiatry 2012; 46: 327–39.
8 Parker, G Manicavasagar, V. Modelling and Managing the Depressive Disorders: A Clinical Guide. Cambridge University Press, 2008.
9 Parker, G Roy, K Mitchell, P Wilhelm, K Malhi, G Hadzi-Pavlovic, D Atypical depression: a reappraisal. Am J Psychiatry 2002; 159: 1470–9.
10 Klein, DF Davis, JM. Diagnosis and Drug Treatment of Psychiatric Disorders. William and Wilkins, 1969.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Is borderline personality disorder a mood disorder?

  • Gordon Parker (a1)
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eLetters

Borderline Personality Disorder: Thinking outside the box

Temi Metseagharun, ST- 7
13 June 2014

This editorial by Gordon Parker asking the question "Is borderline personality disorder a mood disorder?" (1) caught my attention because it raises the debate surrounding the long-standing issue of the scientific validity of psychiatric diagnoses, comorbidity, psychopathology and general philosophy of mind. Talking about "mood disorders," and indeed any symptom-based diagnosis is reminiscent of talking about "fevers" without addressing the aetiology of the fever in question. In a previous e-letter on the question "Should our major classifications of mental disorders be revised? (2) I proposed "no pathology without physiology" which means that the truly disordered mind can only be understood when the normal functioning brain mechanisms (explaining mind-brain interrelationships) are sufficiently well understood. It is fair to categorise, by convention, a group of disorderswhere "the fundamental disturbance is a change in mood or affect"(ICD-10) and call them "mood disorders," but how fundamental is mood disturbance onits own? There are likely to be more fundamental or deeper processes, suchas biochemical mechanisms and even the more relevant but unknown processesby which life events or personal history affect mood and personality development. An individual's mood is the metaphorical barometer, scaling and psychological feedback of the worthiness and value of life at a point in time. It is by nature unstable (or reactive) and reflective of events at aspecific point in time. It is therefore not surprising that basic consciousness and virtually all psychiatric conditions could present with a mood component. If the reactivity is extremely deviant, hyper-intense orout-of-context, then it should be regarded as disordered, but this will beby convention or social norms and nothing strictly scientific, unless we have a minimally reasonable brain mechanism, such as in delirium, that explains a malfunctioning brain/mind.

Thinking outside the box, I would agree with other arguments against positioning BPD as a mood disorder, not because of the validity of the diagnostic categories involved, but because of the implications for treatment if BPD is reclassified as a mood disorder - likely to engender unnecessary and inappropriate medical treatments, when the core problems were and will almost certainly remain psychosocial.

1. Parker G. Is borderline personality disorder a mood disorder? Br JPsychiatry 2014; 204: 252-3.

2. Goldberg D. Should our major classifications of mental disorders be revised? Br J Psychiatry. 2010 Apr;196:255-6.

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Conflict of interest: None declared

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Borderline Personality Disorder: a mood disorder but not bipolar or unipolar variant

Steven Marwaha, Associate Clinical Professor of Psychiatry and Consultant Psychiatrist
16 May 2014

I would like to thank Professor Parker for his erudite editorial on whether borderline personality disorder (BPD) is a mood disorder. Professor Parker examines this question by asking if BPD is a bipolar or unipolar mood condition and concludes by suggesting that it is probably neither. I would like to offer a supplementary interpretation of the literature; that is BPD is in large part a mood disorder but isn't necessarily a bipolar or unipolar mood variant.

BPD is highly comorbid with bipolar disorder1 and depression2 and those who develop bipolar disorder have early temperamental markers of emotional dysregulation3. Support that BPD is a mood disorder is also aligned with the fact that affective instability is a core feature of the syndrome. Whilst under investigated there is emerging evidence that affector mood instability as opposed to mood episodes may be the core feature ofbipolar disorders4. The majority of patients with established bipolar, even after symptomatic control continue to experience daily or weekly moodswings5. Further, the prevalence of mood instability and cyclothymic temperament is increased in unaffected bipolar probands6 and it predicts functioning in those with bipolar4. Mood instability is highly prevalent in unipolar depression7 and independently links to suicidality and health service use. Furthermore in BPD, affective instability is the least stableof the "trait like" features of the syndrome over two years8. Thus all three disorders share mood instability as a clinical component and this all points to BPD, at least in part, being a disorder of mood.

However BPD doesn't exactly fit into the bipolar or depressive affectrubric given the affective shifts don't last long enough for either mood disorder diagnosis. Detailed studies of the nature of affective instability in mood disorders and BPD using the same measurement methods are limited. However as Professor Parker states there are differences. Those with bipolar disorder have greater levels of euthymia-elation and affect intensity. In BPD there are more shifts between anxiety, depressionand euthymia-anger9. Negative emotionality is a critical feature of BPD but it is changeable, as is obvious to clinicians who have been charged with the care of people with BPD on inpatient wards.

Affect can be studied on the basis of intensity, frequency of shift, rapidity of rise-times and return to baseline, reactivity to psychosocial cues or whether endogenously driven and the extent to which there is overdramatic expression10. To this could be added valence. Using this framework BPD could be conceptualised as a disorder of mood in which affect changes are intense, frequent, rapid to occur and slow to dissipateand in which the valence of the mood state is typically negative incorporating depression, anxiety and anger. This pattern of difficulties whilst related to mood, do not appear to overlap to a significant extent with how depression or bipolar disorder might be described using the same affective framework. Though it is clear terms such as intensity, frequency, rapidity of rise etc need to be better specified, experience sampling methods analyzing affective patterns in the three disorders may further illuminate this area and indeed the debate.

1. Mantere, O., Melartin, T. K., Suominen, K., Ryts?l?, H. J., Valtonen, H. M., Arvilommi, P., ... & Isomets?, E. T. (2006). Differences in Axis I and II comorbidity between bipolar I and II disorders and major depressive disorder. The Journal of clinical psychiatry, 67(4), 584-593.

2. Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., ... & Ruan, W. J. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. The Journal of clinical psychiatry, 69(4), 533.

3. Luby, J. L., & Navsaria, N. (2010). Pediatric bipolar disorder: evidence for prodromal states and early markers. Journal of Child Psychology and Psychiatry, 51(4), 459-471.

4. Strejilevich, S., Martino, D., Murru, A., Teitelbaum, J., Fassi, G., Marengo, E., Igoa, A. & Colom, F. (2013). Mood instability and functional recovery in bipolar disorders. Acta Psychiatrica Scandinavica.

5. Bonsall, M. B., Wallace-Hadrill, S. M., Geddes, J. R., Goodwin, G.M. & Holmes, E. A. (2012). Nonlinear time-series approaches in characterizing mood stability and mood instability in bipolar disorder. Proceedings of the Royal Society B: Biological Sciences 279, 916-924.

6. Diler, R. S., Birmaher, B., Axelson, D., Obreja, M., Monk, K., Hickey, M. B., Goldstein, B., Goldstein, T., Sakolsky, D. & Iyengar, S. (2011). Dimensional psychopathology in offspring of parents with bipolar disorder. Bipolar disorders 13, 670-678.

7. Marwaha, S., Parsons, N., Flanagan, S., & Broome, M. (2013). The prevalence and clinical associations of mood instability in adults living in England: results from the Adult Psychiatric Morbidity Survey 2007. Psychiatry research, 205(3), 262-268.

8. Chanen, A. M., Jackson, H. J., McGorry, P. D., Allot, K. A., Clarkson, V. & Yuen, H. P. (2004). Two-year stability of personality disorder in older adolescent outpatients. Journal of Personality Disorders18, 526-541

9. Reich, D. B., Zanarini, M. C., & Fitzmaurice, G. (2012). Affective lability in bipolar disorder and borderline personality disorder. Comprehensive psychiatry, 53(3), 230-237.

10. Koenigsberg, H. W. (2010). Affective instability: toward an integration of neuroscience and psychological perspectives. Journal of personality disorders, 24(1), 60-82.

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Conflict of interest: None declared

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The diagnostic status of borderline personality disorder

Peter Tyrer, Professor of Community Psychiatry
16 May 2014

Gordon Parker1 makes a powerful case against the hypothesis that borderline personality disorder is really a form of bipolar or unipolar disorder. In so doing he is tilting at a windmill in whose construction Ihad absolutely no part. In my article2 and in other critiques3-4 I do not claim any connection between bipolar, unipolar and borderline, I only state that borderline personality disorder owes much greater affinity to mood than to personality. Its core is not a disorder of depression or mania, but one of emotional dysregulation associated with many other mood states5 but nothing about it is driven by personality. The very name of borderline personality disorder betrays an abrogation of diagnosis; it overlaps with post-traumatic stress, other personality disorders, anxiety,depression, dissociative and adjustment disorders yet does not belong to any of them. By adding layer upon layer of diagnostic requirements that allow it to become grossly heterogeneous it has confused everybody and satisfied none. Personality disorder is trait based and these traits are persistent over time and linked to normal personality variation. There is good evidence that borderline personality characteristics are linked closely to affective instability, not normal personality variation6, and its natural history is one of remission rather than persistence7. The task of nosology is now to separate the essential core of emotional dysregulation from personality disorders, where its infiltration has been most damaging8, and from the many disorders that give the term 'comorbidity' such a bad press. A start has been made in the reclassification of personality disorder in ICD-11, where borderline and the other current categories of personality disorder have all been removed9,10 but much more needs to be done.

1.Parker G. Is borderline personality disorder a mood disorder? Br JPsychiatry 2014; 204: 252-3.2.Tyrer P. Why borderline personality disorder is neither borderline nor a personality disorder. Personal Mental Health 2009; 3: 86-953.Tyrer P . Flamboyant, erratic, dramatic, borderline, antisocial, sadistic, narcissistic , histrionic and impulsive personality disorders: who cares which? Criminal Behaviour and Mental Health 1992; 2: 95-104.4.Tyrer P. Borderline personality disorder: a motley diagnosis in need ofreform. Lancet 1999; 354, 2095-6.5.Reisch T, Ebner-Priemer UW, Tschacher W, Bohus M, Linehan MM. Sequences of emotions in patients with borderline personality disorder. Acta Psychiatr Scand 2008; 118: 42-8. 6.Kendler KS, Myers J, Reichborn-Kjennerud T. Borderline personality disorder traits and their relationship with dimensions of normative personality: a web-based cohort and twin study. Acta Psychiatr Scand 2011;123: 349-59.7.Zanarini MC, Frankenburg FR, Hennen J, Silk KR. The longitudinal courseof borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. Am J Psychiatry 2003; 160: 274-83.8.Mulder R, Crawford M, Tyrer P (2011). Classifying personality pathologyin psychiatric patients. J Pers Disord 2011; 25, 364-77.9.Tyrer P, Crawford M, Mulder R; on behalf of the ICD-11 Working Group for the Revision of Classification of Personality Disorders . Reclassifying personality disorders. Lancet 2011; 377: 1814-5.10.Tyrer P, Crawford M, Mulder R, Blashfield R, Farnam A, Fossati A, et al. The rationale for the reclassification of personality disorder in the 11th Revision of the International Classification of Diseases. Personal Mental Health 2011; 5 : 246-59.

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Conflict of interest: The author is Chair of the ICD-11 Working Group for the Revision of Classification of Personality Disorders.

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