Dear Editor:
The high prevalence of comorbid borderline personality disorder (BPD) and bipolar disorder, along with overlapping diagnostic criteria, can present a diagnostic and therapeutic dilemma in the clinic.[1–3] We describe a complex case of a patient with BPD who was subsequently also diagnosed with bipolar disorder. Partial disclosure of the bipolar diagnosis, a focus on developing a strong therapeutic alliance, and initiation of complementary psychoeducation were key components of treatment in this case.
Case report. A 27-year-old woman, previously diagnosed with BPD, was brought to the emergency unit of our clinic by her mother after cutting her wrists. Following the emergency treatment of her injuries, the patient was required to see our team for psychotherapeutic intervention.
When the patient presented to us, she was accompanied by her mother. Historically, the patient’s BPD behavior included self mutilation and parasuicidal behavior (e.g., wrist cutting and overdosing on prescription medication), which required hospitalization on numerous occasions. The patient had one child, and her employment history following college graduation was brief due to instability in affect regulation and interpersonal troubles. Upon presentation, the patient exhibited low self image and thought of herself as a “failed working mother.”
We initiated once-weekly visits for psychotherapy with the patient. The patient’s mother often accompanied her to therapy. During therapy, the patient’s mother was outwardly irritated by the patient’s history of erratic behavior, and continually criticized the patient’s “personality problems” and her incompetence as a mother. Almost immediately, the treatment team suspected the patient had co-occurring bipolar disorder, but did not feel it was in the patient’s best interest to reveal this diagnosis at this time.
During the first year and a half of therapy, the treatment team was often forced to focus on this turbulent relationship between the mother and the daughter due to their repeated conflicts during therapy. This focus provoked complex emotional feelings in the patient and greatly complicated the doctor-patient relationship, preventing the initation of a clear and effective treatment strategy.[4]
After a year and a half of this turbulent outpatient treatment, we decided to shift the focus of treatment. As a first step, we decided to partially disclose the co-diagnosis of bipolar disorder to the patient while she was experiencing a stable mood period. The patient was surprised by the unexpected disclosure. Gradually, over the ensuing weeks of therapy, we worked on developing the patient’s insight into her mood swings and we steered the therapy away from what the patient perceived as a focus on her “personality problems.” The patient successfully developed greater insight into her mood swings and was receptive to our proposed initiation of lithium and aripiprazole for mood stabilization. Her mother likewise responded positively to the partial disclosure of bipolar disorder and participated in psychoeducational sessions taught by the clinic’s psychologist that focused on bipolar disorder.
The patient and her mother revealed to us that previous doctors had always given her a diagnosis of BPD after a series of unsuccessful trials of medication. At this time in therapy, we chose to emphasize the importance of the patient maintaining the combined regimen of the mood-stabilizing drugs and the therapy sessions in order to build a stronger clinical alliance with the patient.
After four years of therapy, our patient still experienced interpersonal problems and continued to express feelings of emptiness, but she regularly attended therapy, was adherent with her medication, and behaved in a more stable way than she did before we initiated treatment for her bipolar symptoms.4 With a strong therapeutic alliance now in place and with the mood swings better controlled, we felt we could then begin to therapeutically address the BPD symptoms more effectively.
Discussion. Very few studies have reported on when it is most appropriate to disclose a diagnosis of BPD.[4] The diagnosis of BPD is often made after several repetitive parasuicidal behaviors. Since female BPD cases may best be conceptualized as a chronic shame response,[5] it seems clinicians are reluctant to give a diagnosis of BPD out of fear of provoking self-harm behavior in their patients.[4] We believe our patient had been given an inappropriately timed diagnosis of BPD by previous doctors, but additionally was suffering from undiagnosed and unexplained mood instability for many years. By partially disclosing a diagnosis of bipolar disorder, we were able to shift the focus of therapy away from the negatively perceived “personality problems” and instead focus on developing the patient’s insight into the mood swings and building a strong therapeutic alliance. We believe this contributed to the patient’s willingness to try the mood-stabilizing drugs. Next, we stressed the importance of maintaining medication adherence for her bipolar symptoms. We believe, in this case, it was very important to show our patient a clear treatment strategy. We believe this aided in developing a healthy therapeutic alliance, which itself had a mood-stabilizing effect.[6]
In cases of bipolar disorder, complementary psychoeducation that focuses mainly on hypomania might be helpful.[3] We suggest the education be based on a current theoretical model, such as “anastrophic thinking.”[7] In our patient’s case, explaining and addressing the hypomania symptoms to her rather than focusing on the symptoms of the personality disorder seemed to have nonspecific but positive psychotherapeutic effects for both her and her family, eventually clearing the way for initiating therapeutic intervention for her BPD symptoms.
References
1. Johnson AB, Gentile JP, Correll TL. Accurately diagnosing and treating borderline personality disorder: a psychotherapeutic case. Psychiatry (Edgmont). 2010;7:21–30.
2. Bolton S, Gunderson JG. Distinguishing borderline personality disorder from bipolar disorder: differential diagnosis and implications. Am J Psychiatry. 1996;153:1202-1207.
3. Stone MH. Relationship of borderline personality disorder and bipolar disorder. Am J Psychiatry. 2006;163;7:1126–1128.
4. Lequesne ER, Hersh RG. Disclosure of a diagnosis of borderline personality disorder. J Psychia Pract. 2004;10:170–176.
5. Rüsch N, Lieb K. Shame and implicit self-concept in women with borderline personality disorder. Am J Psychiaty. 2007;164:500–508.
6. Havens LL, Ghaemi SN. Existential despair and bipolar disorder: the therapeutic alliance as a mood stabilizer. Am J Psychother. 2005;59:137–147.
7. Colom F, Vieta E. Sudden glory revisited: cognitive contents of hypomania. Psychother Psychosom. 2007;76:278–288.
With regards,
Yuichiro Abe, MD, PhD; Nathalie de Kernier, PhD; and Kazunari Oshima, MD, PhD
Dr. Abe is from the Department of Psychophysiology, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan; Dr. de Kernier is from the Department of Clinical Psychology and Psychopathology, University of Paris Descartes, Paris, France; and Dr. Oshima is from the Department of Psychiatry, Tokyo Medical and Dental University, Tokyo, Japan.
Funding and disclosures: There was no funding received for the development of this letter. The authors have no conflicts of interest relative to the content of this letter.
