A Biopsychosocial Approach to Bipolar-boderline Debate - Psychological Effect of a Biological...
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Letters to the editor A biopsychosocial approach to bipolar-borderline debate: psychological effect of a biological temperament DOI: 10.1111/acps.12298 Akiskal was the first to suggest borderline personality as an Axis I disorder within the bipolar affective spectrum about two decades ago. His idea has been derived mostly from the simi- larities of affective instability, inappropriate anger, impulsivity, and unstable relationship proposed as some borderline criteria with what is seen in bipolar II disorder. Four lines of evidence can be considered as sup por ts for Aki ska l’s the ory . Fir st, cyclothymic temperament has been found to be highly sensitive (88%) in identifying bipolar II disorder and has been the most common affective temperame nt amo ng pat ients wit h this disorder. Second, there has been a high comorbidity between bord erline personal ity and bipo lar (part icular ly the broa d definition of bipolarity). Third, there has been strong associa- tion between atypica l depr essio n and bipolarit y (i.e. in one study 72% of atypical depressives met criteria of bipolar spec- trum) and atypicality of depression has been assumed to be related to an affective tempe ramental dysre gulati on. Fourt h, cyclothymic temperament has been associated with borderline personal it y amon g 107 atypical depressi ves ( P = 0.001). Hence, Akiskal has explained all these findings as support for the conclusion that atypical depression, borderline personality, cyclot hymia, and bipol ar II disor der repre sent overlappi ng man ife sta tio ns of cyc lot hymic temperame nt as a common underlying diathesis (1). On the othe r hand, emphas izing more on the differenc es than similarities, Ghaemi has stated that these two disorders are different. He has argued that the assumed ‘core’ presenta- tions of mood lability and impulsivity are not pivotal to either illness (2). In contrast to bipolar disorder, affective instability in borderline personality is not episodic and includes mostly shifts from euthymia to anger and rarely from depression to elation (3). Furthermore, the greater importance of genetic vul- nerability in the etiology of bipolar disorder than that of bor- derline personality, the four borderline features that are not pred ictive of bipo larity (aban donment, ident ity distu rban ce, recurrent suicidal or self-mutilating behavior, and dissociative symptoms), and the importance of psychoanalytic theories in the development of borderline personality as a psychological structure are the main differences on which Ghaemi’s opinion has been based (2). It seems that these two opinions are not necessarily contra- dictory. Having the same diathesis needs neither the similarity of the two disorders nor the overlapping within one spectrum. A third model can be proposed in which the psychoanalytic effect of cyclothymic temperament on the development of bor- der line per son alit y migh t be notewo rth y. As pro pos ed by Kernb erg, borderlin e perso nality evolves from the failure to integrate representations of good and bad aspects of self and othe rs. From this view-po int, a cyclot hymic child might be assumed as develo ping two compl etely opposite repre senta- tions of self and others – depending on high and low levels of mood – that cannot be integrated. Furthermore, a prolonged emotional dysregulation, which can be aggravated by cyclothy- mi c te mperament, mi ght re nder self -soothing capaci ty impaired. With out developing the capaci ty for self- soot hing, borderline patients may have to depend on the actual presence of an object to manage and tolerate their intense emotions (4). Therefore, in the proposed third model, cyclothymic tem- perament through the biological pathway can lead to bipolar II disorder, and through the psychological pathway might con- tribu te to bord erlin e pers onalit y. On the other hand, some studies have found associations between temperamental profile of borderline personality (high novelty seeking and high harm avoidance) and cyclothymic temperament (5). This might indi- cate that people with cyclothymic temp eramen t are biolo gi- cally vulnerable to borderline personality as well. Affect ive tempe ramen ts as indivi dual differences in emo- tional reactivity and regulation are expected to be evident from early childhood. The available data on cyclothymic disorder or temperament in youth are limited. However, a study by Gold- berg showed that early onset bipolar disor der increases the probability of borderline personality disorder (3). One study of cyclot hymia patients foun d 62% with borderlin e perso nality (3). A future direction of research will be the association of cyclothymic temperament and bipolar II disorder in borderline perso nalit y sampl e. A pros pecti ve stud y is requi red to inves ti- gate cyclothy mic temperame nt in yout h as a pred ictor of later borderline personality. Applying the third model in clinical practice, it can be pro- posed that all bord erline patients need psych othe rapy even though they have bipolar or cyclothymia comorbidity, because borderline personality in this situation is seen not as a symp- tom of the affective spectrum, but it is its psychological compli- cation that needs a distinct approach. On the other hand, the bipolar or cyclothymic comorbidity of borderline personality requires separate biological treatment as it might have some predi sposi ng or even perpetuating effects on the borderlin e personality. N. Khalili Department of Psychiatry, Shahid Beheshti Hospital, Kerman University of Medical Sciences, Kerman, Iran E-mail: [email protected] References 1. Perugi G, Fornaro M, Akiskal HS. Are atypical depression, bor der line per son alit y dis ord er and bip olar II dis ord er ove rlappi ng man ife sta tio ns of a common cycl oth ymi c diathesis? World Psychiatry 2011;10:45 – 51. 2. Barroilhet S, V€ ohringer PA, Ghaemi SN. Borderline versus Bipolar: difference matter. Acta Psychiatr Scand 2013;128: 385 – 386. 3. Paris J, Gunderson J, Weinberg I. The interface between bor- derline personality disorder and bipolar spectrum disorders. Compr Psychiatry 2007;48:145 – 154. 4. Bradley R, Westen D. The psychodynamics of borderline personality disorder: a view from developmental psychopa- thology. Dev Psychopathol 2005;17:927 – 957. 158 Letters to the editor
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Transcript of A Biopsychosocial Approach to Bipolar-boderline Debate - Psychological Effect of a Biological...
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Letters to the editor
A biopsychosocial approach to bipolar-borderlinedebate: psychological eect of a biologicaltemperament
DOI: 10.1111/acps.12298
Akiskal was the rst to suggest borderline personality as anAxis I disorder within the bipolar aective spectrum about twodecades ago. His idea has been derived mostly from the simi-larities of aective instability, inappropriate anger, impulsivity,and unstable relationship proposed as some borderline criteriawith what is seen in bipolar II disorder. Four lines of evidencecan be considered as supports for Akiskals theory. First,cyclothymic temperament has been found to be highly sensitive(88%) in identifying bipolar II disorder and has been the mostcommon aective temperament among patients with thisdisorder. Second, there has been a high comorbidity betweenborderline personality and bipolar (particularly the broaddenition of bipolarity). Third, there has been strong associa-tion between atypical depression and bipolarity (i.e. in onestudy 72% of atypical depressives met criteria of bipolar spec-trum) and atypicality of depression has been assumed to berelated to an aective temperamental dysregulation. Fourth,cyclothymic temperament has been associated with borderlinepersonality among 107 atypical depressives (P = 0.001).Hence, Akiskal has explained all these ndings as support forthe conclusion that atypical depression, borderline personality,cyclothymia, and bipolar II disorder represent overlappingmanifestations of cyclothymic temperament as a commonunderlying diathesis (1).
On the other hand, emphasizing more on the dierencesthan similarities, Ghaemi has stated that these two disordersare dierent. He has argued that the assumed core presenta-tions of mood lability and impulsivity are not pivotal to eitherillness (2). In contrast to bipolar disorder, aective instabilityin borderline personality is not episodic and includes mostlyshifts from euthymia to anger and rarely from depression toelation (3). Furthermore, the greater importance of genetic vul-nerability in the etiology of bipolar disorder than that of bor-derline personality, the four borderline features that are notpredictive of bipolarity (abandonment, identity disturbance,recurrent suicidal or self-mutilating behavior, and dissociativesymptoms), and the importance of psychoanalytic theories inthe development of borderline personality as a psychologicalstructure are the main dierences on which Ghaemis opinionhas been based (2).
It seems that these two opinions are not necessarily contra-dictory. Having the same diathesis needs neither the similarityof the two disorders nor the overlapping within one spectrum.A third model can be proposed in which the psychoanalyticeect of cyclothymic temperament on the development of bor-derline personality might be noteworthy. As proposed byKernberg, borderline personality evolves from the failure tointegrate representations of good and bad aspects of self andothers. From this view-point, a cyclothymic child might beassumed as developing two completely opposite representa-tions of self and others depending on high and low levels ofmood that cannot be integrated. Furthermore, a prolongedemotional dysregulation, which can be aggravated by cyclothy-mic temperament, might render self-soothing capacity
impaired. Without developing the capacity for self-soothing,borderline patients may have to depend on the actual presenceof an object to manage and tolerate their intense emotions (4).
Therefore, in the proposed third model, cyclothymic tem-perament through the biological pathway can lead to bipolarII disorder, and through the psychological pathway might con-tribute to borderline personality. On the other hand, somestudies have found associations between temperamental proleof borderline personality (high novelty seeking and high harmavoidance) and cyclothymic temperament (5). This might indi-cate that people with cyclothymic temperament are biologi-cally vulnerable to borderline personality as well.
Aective temperaments as individual dierences in emo-tional reactivity and regulation are expected to be evident fromearly childhood. The available data on cyclothymic disorder ortemperament in youth are limited. However, a study by Gold-berg showed that early onset bipolar disorder increases theprobability of borderline personality disorder (3). One study ofcyclothymia patients found 62% with borderline personality(3). A future direction of research will be the association ofcyclothymic temperament and bipolar II disorder in borderlinepersonality sample. A prospective study is required to investi-gate cyclothymic temperament in youth as a predictor of laterborderline personality.
Applying the third model in clinical practice, it can be pro-posed that all borderline patients need psychotherapy eventhough they have bipolar or cyclothymia comorbidity, becauseborderline personality in this situation is seen not as a symp-tom of the aective spectrum, but it is its psychological compli-cation that needs a distinct approach. On the other hand, thebipolar or cyclothymic comorbidity of borderline personalityrequires separate biological treatment as it might have somepredisposing or even perpetuating eects on the borderlinepersonality.
N. KhaliliDepartment of Psychiatry, Shahid Beheshti Hospital, Kerman
University of Medical Sciences, Kerman, IranE-mail: [email protected]
References
1. Perugi G, Fornaro M, Akiskal HS. Are atypical depression,borderline personality disorder and bipolar II disorderoverlapping manifestations of a common cyclothymicdiathesis? World Psychiatry 2011;10:4551.
2. Barroilhet S, Vohringer PA, Ghaemi SN. Borderline versusBipolar: dierence matter. Acta Psychiatr Scand 2013;128:385386.
3. Paris J, Gunderson J,Weinberg I. The interface between bor-derline personality disorder and bipolar spectrum disorders.Compr Psychiatry 2007;48:145154.
4. Bradley R, Westen D. The psychodynamics of borderlinepersonality disorder: a view from developmental psychopa-thology. Dev Psychopathol 2005;17:927957.
158
Letters to the editor
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5. Maremmani I, Akiskal HS, Signoretta S, Liguori A, Perugi G,Cloninger R. The relationship of Kraepelian aective tem-peraments (as measured by TEMPS-I) to the tridimensional
personality questionnaire (TPQ). J Aect Disord2005;85:1727.
DOI: 10.1111/acps.12299
Reply
With thanks to my colleagues for their insightful comments,I would suggest that the interpretation presented assumes thescientic validity of the DSM-5 (and prior) criteria for border-line personality. Elsewhere (1), I have presented my rationalefor the present claim; here, I can only present my conclusionsand refer readers there for my premises and evidence. Border-line personality evolved as a clinical picture that referred towomen (mostly) who had experienced childhood (mostly) sex-ual abuse, and who tended to engage in repetitive self-injury(usually cutting), had dissociative experiences (includingsomatic symptoms in the past, such as paralysis), and had verycomplex emotional experiences with their psychotherapists(usually characterized by notable anger and even rage, even onthe part of the clinician, referred to as countertransferencehate). This summary picture of borderline personality has rea-sonably strong historical and scientic support (1). But withDSM denitions, the sexual abuse etiology was excluded, theexperiences of the clinician were ignored, and self-injury anddissociative experiences are listed as only two of nine criteria,ve of which are sucient to make the diagnosis.
In other words, in the extremely broad DSM-based deni-tion, borderline personality can be diagnosed in any person
who is moody and has unstable interpersonal relationships,without any sexual abuse or self-harm or dissociative symp-toms. Of course, this denition is so broad that it includesmany persons with bipolar and unipolar mood illnesses.
I think DSM-based borderline personality disorder doesnot do justice to the scientic and clinical evidence about thatclinical picture. If I am correct, then there would be no need tohypothesize dierent biological versus psychological pathwaysto explain the comorbidity of a more or less validly describedcondition (cyclothymia) and a more or less invalidly describedcondition (DSM-dened borderline personality).
S. N. GhaemiDepartment of Psychiatry, Tufts Medical Center, Boston, MA,
USAE-mail: [email protected]
Reference
1. Ghaemi SN, Dalley S, Catania C, Barroilhet S. Bipolar orborderline: a clinical overview. Acta Psychiatr Scand 2014;130:2529.
159
Letters to the editor
