Differentiating Between BPD and Bipolar Disorder in Clinical Practice Transcript

Saundra Jain, PsyD: Welcome back, everyone. Hey, Dr Chepke, Dr Jain. It's great to be here with both of you this afternoon. Thanks for joining us. We have a ton of questions. So I say, let's jump in. Craig, I'm gonna start with you if you would allow me to. This is the most popular question. And I think it's something that all of us as clinicians have had to deal with. And here it is. Any tips on how to tease out bipolar 2 with borderline personality disorder?

Craig Chepke, MD: That is a great question. I'm not surprised that's the most important one because that's something that we really have to dig in and figure out. And it can be difficult. So bipolar 2 disorder is a tough diagnosis to make in and of itself. We talked about that during the presentation and borderline personality can be as well.

There is mood instability with both of them. The thing is that with borderline personality disorder—I mean there's a number of things, I'm going to try and keep it a little bit short—that with borderline personality disorder it's more stable. There's not the discrete episodic mood episodes like we see in hypomania in bipolar 2 disorder that it is relatively discrete. There can be some soft ons and off, but it's not persistent. It's not consistent across the entire lifespan of the person, whereas borderline personality disorder, those traits tend to be more specific. And then that would be probably the number one thing that I would tease out, it would be trying to find out when did it exist or exactly start. Now that is difficult for bipolar II disorder because with hypomania, patients don't realize that it's problematic. And by DSM criteria, by definition, it's not functionally impairing. So the times for bipolar disorder, when they have those flare-ups in the moods that go above and beyond what they generally experience, that usually does cause some functional impairment.

And there are a lot of them. Lashing out at some of their loved ones, doing some things that they probably shouldn't, and it escalates to a point where it wouldn't be mania, but it's more than what hypomania would be. So those would be a couple of the things that I'll look at first, and I'll kind of leave it there and let Rakesh weigh in. What do you think? 

Rakesh Jain, MD: Yeah, Craig, you nailed it. It's a common confusing differential, but I think it will also be important to remember they can often be comorbid. So sometimes it's not a matter of this or that, sometimes it's both. And perhaps one tip you and I could share with our listeners is borderline personality disorder or mood changes are predominantly triggered by interpersonal conflict, rejection sensitivity, and a sense of emptiness.

There is a very significant psychological trigger to mood instability. That's not always the case with bipolar type 2. So keeping in mind that the core features of borderline personality are rejection sensitivity, sense of emptiness, the core feature of bipolar type 2 is mood instability, followed by interpersonal difficulties but not preceding it, sometimes helps with the differential diagnosis. 

Dr Chepke: Don't you have a saying about that in Texas? Something about dogs? 

Dr Rakesh Jain: Yes, I think to our Psych Congress family members, what Craig is referring to is a saying in Texas, which is a dog can have ticks and fleas. And I think it's an important adage to remember. Very often we appropriately try and decide it's this or that. And in this situation, if the patient has both, medications won't help. Psychotherapy won't help. But psychotherapy plus appropriate medication intervention will help. That's why, Craig, your point is spot on.

The goal is to get to the right diagnosis or the right diagnoses. 

Dr Saundra Jain: Well, to follow up to the whole tick and fleas thing being present at the same time. One of the really popular questions is how often are either of you seeing these 2 disorders as co-morbid? Rakesh? Craig?

Dr Rakesh Jain: Maybe I'll get the ball rolling. The answer is often. Often.

And the reason why it's often is because there's shared genetic pathology that seems to pop up with what we call personality disorders, but they actually are highly stable familial genetic traits. And I use the phrase familial genetic on purpose because it's both the family of origin, but even adoption studies show very stable presence of borderline personality disorder and bipolar disorder. So Saundra, they actually travel often. The error not to make is if you see someone with prominent borderline personality symptoms, there is a very strong transference and counter-transference issues that often stops us.

Us, the caring clinicians from going a little bit deeper. And that's why what Craig and I talked about in the formal presentation is when in doubt: screen. When not in doubt: screen. What we're saying is screen. You don't just wait for the signals, don't just confirm what you already know but screen. Even when you're 100% sure it's not bipolar? Screen. Because you're double confirming it. So Craig would you like to add anything further?

Dr Chepke: So, I think you did a great job, and there's not a whole lot to add. I was trying to figure out the numbers in my head when you first asked Saundra, and I think the correct answer is also often I can't give an exact percentage. But, you know, I think one thing that I wanted to point out is that, I love what Rakesh said about the shared familial and genetic components of what we call personality disorders. I really dislike that term. It's very pejorative. It makes it feel like it's a judgment on the person. ‘Oh, that's their personality,’ like they're stained with it. And there is significant evidence scientifically that there is a biological component of it, we just haven't yet delineated it, like we have not in all of our disorders. 

I mean, multiple sclerosis was believed to be psychosomatic until the MRI was invented. And then, ‘oh, wow, there's plaques all up and down your spinal cord and in your brain. My bad. I said you were making it up all these years.’

So I don't like anytime that we use victim shaming terminology in medicine, which is very, very often, unfortunately. So diagnosis, diagnoses, that are called personality disorders, being that a person has failed antidepressants or mood stabilizers or what have you implying that they failed, not that the medications failed the patient.

I think we need to be very careful with the way that we use our language in mental health and think about that. And there's the DSM criteria and the names are the names, but we need to be sensitive about that. And that transference that Rakesh mentioned, be careful not to let that lead into our interactions and cause us to give substandard care to patients who either have confirmed or suspected personality disorders.