Expert answer:Literature Review


Solved by verified expert:write a one page literature review about BORDERLINE PERSONALITY DISORDER using the research article link below. state the reason of the study, how the study can be related to a patient that is suffering from the disease. also write about what the study is all about (describe briefly how the study was conducted ) and give the outcomes of the study. again, explain how the result of the study can be utilize to treat patient suffering from BORDERLINE PERSONALITY DISORDERAPA FORMAT with 2 references

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ANP46410.1177/0004867411435289BassettANZJP Articles
Borderline personality disorder and
bipolar affective disorder. Spectra or
spectre? A review
Australian & New Zealand Journal of Psychiatry
46(4) 327­–339
DOI: 10.1177/0004867411435289
© The Royal Australian and
New Zealand College of Psychiatrists 2012
Reprints and permission:
Darryl Bassett1,2
Objective: Bipolar affective disorder and borderline personality disorder have long been considered to have significant
similarities and comorbidity. This review endeavours to clarify the similarities and differences between these disorders,
with an effort to determine whether they reflect different forms of the same illness or separate illness clusters.
Method: The published literature relating to bipolar affective disorders, borderline personality disorders, and related
areas of knowledge was reviewed using searches of several electronic databases (AMED, CINHAL, Embase, Ovid,
ProQuest, MEDLINE, Web of Science, ScienceDirect) and published texts. These findings were combined with the
personal clinical experience of the author, and information gathered from colleagues, to create a review of this topic.
Results: Bipolar affective disorders and borderline personality disorders differ with respect to sense of self, disruption
of relationships, family history of bipolar disorders, the benefits of medications, the extent of cognitive deficits, the form
of affective dysregulation and mood cycling, the incidence of suicide and suicide attempts, the form of psychotic episodes,
the incidence of early sexual abuse but not early trauma in general, the loss of brain substance, alterations in cortical
activity, glucocorticoid receptor sensitivity, and mitochondrial dysfunction. They are similar with respect to non-specific
features of affective dysregulation, the incidence of atypical depressive features, the incidence of self-mutilation, the incidence of transporter polymorphisms, possible genetic linkages, overall reduction in limbic modulation, reduction in the
size of hippocampi and amygdala, and the incidence of sleep disruption.
Conclusions: This review concludes that bipolar affective disorders and borderline personality disorder are separate
disorders, but have significant elements in common.
Atypical depressive disorder, bipolar disorder, bipolar spectrum, borderline personality disorder, cyclothymia
The relationship between borderline personality disorder
and bipolar affective disorder has been a topic of debate
since at least 1979 (Boyce and Wilson, 2011; Siever and
Gunderson, 1979; Stone, 1979). The presumed associations
have been multiplied by increasing interest in patients
who suffer less severe forms of mania but still suffer significant affective instability (the bipolar spectrum disorders) (Benazzi, 2009; Howland and Thase, 1993; Kwapil
et al., 2011; Perugi et al., 2011; Thomas, 2004; Tiller and
Schweitzer, 2010; Van Meter et al., 2011; Youngstrom
et al., 2010). While such interest has captured recent attention, the concept of bipolar disorder with relatively mild
forms of mania is not a recent development (Baethge et al.,
2003; Brieger and Marneros, 1997; Slater and Roth, 1969).
Our current major diagnostic systems have added to the
confusion with long lists of criteria for each of these diagnostic groups, which permit the inclusion of a wide range
of clinical presentations (Meares et al., 2011a). While bipolar disorder has been recognised as a diagnostic entity for a
very long time (at least since Aretaeus of Cappadocia, circa
AD 150–200) (Adams, 1972; Hornblower and Spawforth,
of Medicine, University of Notre Dame, Fremantle Australia
of Psychiatry and Clinical Neurosciences, University of Western
Australia, Nedlands, Australia
Corresponding author:
Darryl Bassett, Suite 25, Hollywood Specialist Centre, 95 Monash
Avenue, Nedlands, WA 6009, Australia.
Australian & New Zealand Journal of Psychiatry, 46(4)
1996), borderline personality disorder as currently defined
is a relatively more recent construct (Stern, 1938).
The problem of misdiagnosis of bipolar disorder has
been well recognised and is the subject of considerable
comment (Benazzi, 2000, 2006, 2008; Boyce and Wilson,
2011; Chilakamarri et al., 2011; George et al., 2003; Little
and Richardson, 2010; Paris, 2010; Paris et al., 2007;
Patfield, 2011; Ruggero et al., 2010a, 2010b; Smith et al.,
2004; Tiller and Schweitzer, 2010; Yatham et al., 2009).
One can readily appreciate that, among patients, a diagnosis of bipolar disorder gives a sense of optimism that treatment for their distressing illness is available. Conversely, in
the context of our current service structure, a diagnosis of
borderline personality disorder carries greater stigma and
the implication that treatment may be unavailable (Aviram
et al., 2006). A more biological diagnosis also externalises
the locus of control, which is of appeal to some patients and
Nevertheless, bipolar disorder is both frequently overdiagnosed and frequently missed (Hadjipavlou and Yatham,
2009; Leboyer and Kupfer, 2010). Evidence is steadily
accumulating that bipolar disorder is associated with significant risks to brain structure and function, making early
and effective treatment particularly important (Berk et al.,
2009, 2010a, 2010b, 2011; Macneil et al., 2011). On the
other hand, the positive misdiagnosis of bipolar disorder
brings significant potential adverse consequences, including inappropriate medication exposure, insurance complications, employment implications, stigma and a distorted
perception of health status.
The failure to diagnose borderline personality disorder
also has significant potential adverse consequences, as targeted psychotherapy and psychosocial management have
proven efficacy. In the context of several shared elements,
the complex phenomenological differences between the
two disorders will emerge with greater clarity as they are
examined in this paper (Berk et al., 2004).
It would seem helpful to begin by reflecting upon what
might be considered the ‘core’ elements of each group of
disorders. Meares et al. (2011a) used factor analysis to
define four core elements for borderline personality disorder: ‘painful incoherence’ (highly intense emotional pain
reflecting a fragmented sense of self; the most significant
factor); ‘role absorption’ (loss of identity); ‘inconsistency’;
and ‘lack of commitment’ (the least significant factor)
(Meares et al., 2011a). Although other significant features of
borderline personality disorder such as a fear of abandonment, impulsivity, recurrent self-injurious behaviour, affective instability (rapidly fluctuating moods provoked by life
events), episodic explosive rage and episodic psychotic
phenomena were clearly significant, they were not regarded
as ‘core’ features. Previous factor analyses identified disturbed relatedness (identity disturbance, chronic perceptions
of internal emptiness, unstable relationships), behavioural
dysregulation (self-injurious behaviour, impulsivity) and
Australian & New Zealand Journal of Psychiatry, 46(4)
ANZJP Articles
affective dysregulation (inappropriate anger, efforts to avoid
abandonment, affective instability) as the three prime features of borderline personality disorder (Clifton and
Pilkonis, 2007). Significantly, Clifton and Pilkonis (2007)
established that these latter factors correlated so highly
together that they statistically reflected one comprehensive
construct. It would be helpful to identify that construct in a
clinically meaningful way.
Like Meares et al. (2011a), I suggest that an ‘emotionally
noxious sense of self” (an emotionally painful disruption of
self-identity, a recurring fear of abandonment and chronic
emptiness) is that core entity. Zanarini et al. (2007) argue for
a similar concept, and also suggest that the interaction of
this core element with a ‘kindling’ life event converts this
predisposition into a clinical syndrome. However, Trull et
al. (2011), in their discussion of the proposed diagnostic criteria for DSM-V, maintain that there is no single ‘latent’
group identity for borderline personality disorder and therefore a categorical diagnostic structure is unsatisfactory.
Instead, they argue for a combination of the dimensions of
clinical signs and symptoms derived from factor analyses,
combined with the core features of affective dysregulation,
impulsivity, and interpersonal hypersensitivity. This seems
consistent with the notion of a fundamental core element of
a noxious sense of self.
Young et al. (2003), and Kellogg and Young (2006),
have formulated the core elements of borderline personality
disorder using a schema-based model. They describe these
core schema elements as five modes which reflect the
impact of childhood traumatic experiences: (1) ‘the abandoned and abused child’: fear of isolation and abandonment; (2) ‘the angry and impulsive child’: rage over
perceived abuse, deprivation, rejection, subjugation and
punishment; (3) ‘the detached protector’: emotional withdrawal, disconnection, isolation and behavioural avoidance; (4) ‘the punitive parent’: identification with a
devaluing and rejecting parent; and (5) ‘the healthy adult
mode’: the least common mode which allows the patient to
meet essential needs and to seek containment of the recurring emotional pain. Their formulation is largely consistent
with those described above, although they do not place
emphasis upon self-observation and evaluation. However,
their model has the added value of constructing a framework for a cognitive approach to psychotherapy.
Bipolar disorder would seem to have a very different
nature when the fundamental features of this disorder are
considered. These consist of elements of depressive disorder (dysphoric mood, anhedonia, psychomotor disorder)
and elements of mania (unusually and significantly
increased energy evident in several forms, impaired judgement with disinhibition, unusually elevated or irritable
mood), with subjective experiences linked to these elements (emotional emptiness, irrational guilt, suicidal
thoughts, grandiose thoughts, elevated or depressed mood,
increased creativity or impaired cognitive function, and a
number of other features) (Hosokawa et al., 2009; Parker,
2000, 2009; Parker et al., 2006). Importantly, disruption of
a sense of self and an incapacity to maintain mutually satisfying relationships with others are not core features of
bipolar disorder. As a consequence, the approach to effective psychotherapy for bipolar disorder is different to that
for borderline personality disorder (Basco and Rush, 2005;
Goodwin and Jamison, 2007d; Kellogg and Young, 2006;
Linehan, 1993).
Matters of difference
Mania and hypomania in various ways define bipolarity,
but some uncertainty arises when the milder forms of
mania, such as those seen in cyclothymia, are considered
(Akiskal and Benazzi, 2006; Alloy et al., 2011; Diagnostic
and Statistical Manual of Mental Disorders, 2000;
Goodwin and Jamison, 2007e; International Classification
of Mental and Behaviour Disorders, 1994; Phelps, 2009;
Smith et al., 2005).
Perugi et al. (2011) report evidence of cyclothymic temperament in patients diagnosed with bipolar disorder, borderline personality disorder and atypical major depressive
disorder, although their criteria for cyclothymia were not
clearly defined (Perugi et al., 2011). Further, they did not
separate cyclothymia as a syndrome from cyclothymic temperament as an element of personality. Ghaemi et al. (2004)
maintain that cyclical patterns of mood shifts are a common
element of bipolar disorder, recurrent major depressive disorder and atypical major depressive disorder, but that atypical depressive features and early onset are more common
in bipolar disorder. The absence of mania in major depressive disorder and atypical major depressive disorder would
seem critically important, despite the cyclical nature of
their symptom profiles. As noted previously, a family history of major mood disorders helps to reinforce the diagnosis of a bipolar disorder (Galione and Zimmerman, 2010;
Ghaemi et al., 2004; Mitchell et al., 2008; Souery et al.,
2012), and the life trajectories of disabling symptoms of
bipolar disorder tend to be more prolonged than with borderline personality disorder (Paris, 2004; Paris et al., 2007).
However, both disorders are associated with a significant
incidence of childhood trauma (approximately 50% in
bipolar disorder and 60–80% in borderline personality disorder) (Alvarez et al., 2011; Ball and Links, 2009; Conus
et al., 2010; Etain et al., 2008; Fowke et al., 2011; Garno
et al., 2005; Herman et al., 1989; Hyun et al., 2000), and
early life trauma may play an aetiological role in both
(Holmes, 2003; Joyce et al., 2003; Watson et al., 2006).
Patients with bipolar disorders and borderline personality
disorders may differ in the form of childhood trauma, or
their vulnerability to such trauma, but the possible
details of such differences remain uncertain.
Mackinnon and Pies (2006) offer support for the notion
that rapid cycling of mood states is a common element of
both bipolar and borderline states. The suggestion has some
clinical support but appears inconsistent with the nonaffective components, as well as the details of affective
disruptions discussed later, observed in both disorders.
Self-mutilation has been observed with similar frequency in both bipolar disorder, particularly mixed states
(Joyce et al., 2010), and borderline personality disorder.
Therefore, such self-injury does not distinguish these disorders diagnostically. The separation of bipolar disorder and
borderline personality disorder must then be achieved with
criteria other than the presence of affective dysregulation
and cyclicity of symptoms and signs alone. Importantly,
however, the time course of the cyclicity is helpful: the
presence of discrete, prolonged periods of affective symptoms, as opposed to rapidly shifting states, does suggest a
bipolar diagnosis.
Differences have also been identified in thinking styles
between bipolar and borderline patients, with implications for their emotional health and relationship quality.
Wupperman et al. (2009) identified significant deficiencies
in mindfulness (attention, awareness and acceptance of the
moment) in patients with borderline personality disorder.
These included reduced interpersonal effectiveness, as well
as passive and impulsive emotion regulation, even when
they controlled for neuroticism. Nilsson et al. (2010), using
the Temperament Evaluation of Memphis, Pisa, Paris and
San Diego Autoquestionnaire, and the Young Schema
Questionnaire, found that bipolar patients exhibited a
higher level of maladaptive schemas and affective temperaments compared with controls. In contrast, borderline
patients exhibited a higher level of cyclothymic temperament and reduced self-control.
Quantitative clinical studies
There have been numerous attempts to quantify the similarities and differences between bipolar disorder and borderline
personality disorder, as well as their comorbidity (Paris et al.,
2007). Perugi et al. (2011) studied a population of patients
diagnosed with atypical major depressive disorder, 32% of
whom they subsequently found could be diagnosed with
bipolar disorder (24% without antidepressant-induced bipolarity and increased to 78% if hyperthymia or cyclothymic
temperaments were considered indicative of bipolarity).
When these atypically depressed patients were divided into
those who also suffered from borderline personality disorder
(42%), the only significant differences in demographic and a
range of clinical features were shorter durations of the current illness and a higher rate of suicide attempts. The presence of bipolar features, however, defined in their study, did
not identify comorbid borderline personality disorder in
these atypical major depressive disorder patients.
Galione and Zimmerman (2010) examined the clinical
features of patients suffering depressive disorders (unipolar
and bipolar), both with and without comorbid borderline
Australian & New Zealand Journal of Psychiatry, 46(4)
ANZJP Articles
Table 1. Significant differences between borderline personality disorder and bipolar disorder.
Borderline personality disorder
Bipolar disorder
Altered sense of self
No altered sense of self
Relationships severely disrupted
Relationships not as severely disrupted
No family history of bipolar disorder
Family history of bipolar disorder
Increased glucocorticoid receptor sensitivity
Reduced glucocorticoid receptor sensitivity
Mood stabilizers modestly effective
Mood stabilizers very effective
Atypical antipsychotics modestly effective
Atypical antipsychotics very effective
Cognitive deficits less severe
Cognitive deficits more severe
Affective dysregulation between anger and depression
Affective dysregulation between euphoria and depression
Higher incidence of suicide attempts
Higher incidence of completed suicide
Very rapid mood cycling
Less rapid mood cycling
Early sexual abuse prominent
Early sexual abuse not prominent
Limited loss of gray matter
More loss of gray matter
Limited loss of white matter
More loss of white matter
Alterations of insula activity
Uncertain changes in insula activity
No changes in dorsolateral or dorsomedial prefrontal
Reduced activity of dorsolateral and dorsomedial prefrontal
No changes in cuneus and lingual
Reduced activity of cuneus and lingual gyri
No mitochondrial dysfunction
Mitochondrial dysfunction
Psychosis – non-specific features and sometimes persistent
Psychosis – most often linked to affective state and not
persistent long-term
personality disorder. They found the following differences
when depressive disorders were comorbid with borderline
personality disorder: earlier age of onset of depressive
symptoms, greater frequency of depressive episodes, greater
frequency of ‘atypical’ depressive symptoms, higher prevalence of comorbid anxiety disorders and substance abuse,
and a greater number of suicide attempts. They also found
that a history of bipolar disorder in first-degree relatives was
not significantly associated with the presence of borderline
personality disorder. They concluded that overall their data
did not support the inclusion of borderline personality disorder as a component of the bipolar spectrum.
On the other hand, it is interesting that Mitchell et al.
(2008) found that the probability of a depressive disorder
being part of a bipolar disorder was increased by the presence of features of atypical major depressive disorder, an
earlier age of onset of first depressive episode, a history of
multiple and shorter depressive episodes, and/or a family
history of bipolar disorder. While there is overlap in their
findings with the probability of borderline personality
Australian & New Zealand Journal of Psychiatry, 46(4)
disorder being present, the family history of bipolar disorder is again a prominent distinguishing feature.
Paris et al. (2007), in their review of the bipolar disorder/borderline personality disorder interface, also concluded that bipolar disorder and borderline personality
disorder were most likely separate disorders. Specifically,
they found that while episodes of mania in bipolar disorder
contrasted with more affective instability in borderline personality disorder, there was a significantly higher frequency
of bipolar disorder in first-degree relatives of bipolar disorder patients, the benefits of mood stabilizers were more
predictable in bipolar disorder than borderline personality
disorder, and the prognosis for borderline personality disorder was generally better t …
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