The Role of the Orbital Pre-frontal Cortex in Moderating Impulsivity Associated with Borderline Personality Disorder: A Literature Review

Rebecca M. DeMoor
March 2008

Abstract
   
Borderline Personality Disorder (BPD) is often associated with impulsive behavior including substance abuse and suicide. There is little research, however, investigating the neurological mechanisms which define the behavior. The functioning of the Orbital Pre-frontal Cortex (OFC) has been shown to play a role in regulating impulsive behavior. This literature review looks in depth into the role that the OFC could possibly play in regulating impulsivity within BPD.


Of the many symptoms that accompany people afflicted with Borderline Personality Disorder (BPD), impulsive behavior is often thought to have to most serious implications. Behaviors such as binge spending, reckless driving, suicide, self-injuries, and substance abuse are often seen in people diagnosed with the disorder and can lead to severe consequences such as societal punitive restrictions or even death. Impulsivity in general, however, has not been widely researched in relation to its underlying neurological mechanisms. The Orbital Pre-frontal Cortex (OFC) has been shown to be linked to impulsive behavior and there is evidence which suggests that the OFC plays a vital role in moderating impulsive behavior in the context of BPD.

In a study done by Grafman, Schwab, Warden, & Pridegen (1996), 279 Vietnam War veterans who had suffered only frontal lobe damage were compared to a control group of men with no brain damage on measures of aggression and violence. The results reported that men with damage to the frontal lobe were much more likely to engage in aggression and/or violence than men who had suffered no brain damage. Men who scored higher on aggression and violence also had a high correlation of family problems which indicates the presence of interpersonal dysfunction and could be a consequence of their reactive aggression, or impulsivity, as seen in BPD. This would suggest that the pre-frontal cortex might be singularly responsible for moderating impulsive behavior.

Another study was conducted in 2007 also emphasized the singular role of the prefrontal cortex in regulating impulsive behavior but within the context of BPD (Chanen, Velakoulis, Carison, Gaunson, Wood, Pan Yuen, Yucel, Jackson, McGorry, & Pantelis). Twenty Australian teenagers who had been recently diagnosed with BPD were brought into a hospital and scanned with Magnetic Resonance Imaging (MRI). All the BPD patients were clinically diagnosed and eleven were also were diagnosed with conduct disorder or some sort of drug dependence. The volumetric size of the OFC, hippocampus, and amygdala were then analyzed using tracing techniques. It was found that, when compared to a group of normal controls, the size of the hippocampus and the amygdala were relatively the same. The size of the OFC, however, varied greatly. The borderline patients had much less gray matter in the left hemisphere than the normal controls. It is suggested that due to this finding, the disorder originates in the prefrontal cortex and therefore is mainly manipulated by the OFC and not the amygdala or the hippocampus. The dysfunction of the latter, the authors suggest, could possibly occur as a result of prolonged malfunction of the OFC. These results suggest that the OFC is the primary moderator of impulsivity in people with BPD.

In fact, there is also medicinal evidence to support the claim that the OFC could be singularly regulating impulsive behavior in BPD patients. In a study conducted by New, Buchsbaum, Hazlett, Goodman, Koenigsberg, Lo, Iskander, Newmark, Brand, O’Flynn, & Siever (2004), Fluoxetine was administered to patients diagnosed with impulsive aggressive BPD. The patients were then given anatomical MRIs and PET scans to analyze metabolic rate. Since frontal cortex hypometabolism had been shown in impulsive aggressive BPD patients, Fluoxetine, which blocks reuptake of serotonin and creates a higher metabolism rate, was administered to see if raising the metabolic rate would have an effect on the level of impulsive aggression. Results showed that areas in the OFC showed significant increases in their metabolic rate and resulted in reduced aggression in the participants. These findings suggest that, along with the effectiveness of Fluoxetine in reducing impulsive aggression, the orbital pre-frontal cortex primarily moderates BPD impulsive behavior.

Some evidence suggests, however, that the amygdala, along with the OFC, is responsible for impulsive behavior. Baxter, Parker, Lindner, Izquierdo, & Murray (2000) conducted a study of Rhesus monkeys which investigated the possible relationship between the OFC and the amygdala. The monkeys had the contralesional connection between the amygdala and the OFC disconnected. They then trained the monkeys on a food selection device which required the monkeys to choose between cues for two foods; one of which had been intrinsically devalued by prior satiation. Results indicated that monkeys who had had their amygdala-OFC connections fully cut were not able to avoid cues for foods which no longer had intrinsic value. They still selected cues for foods at random as opposed to the control monkeys who actively avoided the cues for food which had been devalued. This argues a perspective that states that it was not the OFC or the amygdala by itself which regulates impulsivity but the connection between the two that determines informed decision-making.

In a 2007 article New, Hazlett, Buchsbaum, Goodman, Mitelman, Newmark, Trisdorfer, Haznedar, Koenigsberg, Flory, & Siever conducted another study examining the neurological functioning of impulsive aggressive BPD patients. Results from MRIs and PET scans suggested that there is a high rate of metabolic activity between the OFC and the amygdala in normal patients. However, patients with BPD showed weak connections between the amygdala and the OFC. This would suggest that the disconnection is responsible for the alterations in impulsive behavior in those with BPD and provide evidence toward the amygdala-OFC connection as its ultimate moderator.

To conclude, given the results of these studies, it would be safe to assume that the OFC plays a major part in moderating impulsive behavior which remains an area of big concern to those afflicted with BPD. It remains unclear, however, whether or not the OFC is working by itself or in conjunction with other areas of the brain, specifically the amygdala. Further research could examine the relation between the OFC and the amygdala and possibly the role of the amygdala on its own with regards to impulsivity and possibly compare BPD patients to people with brain damage causing impulsivity. In addition, while some form of long term treatment for BPD may be preferential to reduce impulsive behavior, a short term medication arising from a further neurological understanding of impulsivity within BPD might be a great help in alleviating the immediate consequences. 


References

Baxter, M.G., Parker, A., Lindner, C.C.C., Izquierdo, A.D., & Murray, E.A., (2000). Control of response selection by reinforcer value requires interaction of amygdala and orbital frontal cortex. The Journal of Neuroscience, 20(11), 4311-4319.

Chanen, A.M., Velakoulis, D., Carison, K., Gaunson, K., Wood, S.J., Pan Yuen, H., Yucel, M., Jackson, H.J., McGorry, P.D., & Pantelis, C., (2008). Orbitofrontal, amygdala and hippocampal volumes in teenagers with first-presentation borderline personality disorder. Psychiatry Research: Neuroimaging, 163, 116-125.

Grafman, J., Schwab, K., Warden, D., & Pridgen, A. (1996). Frontal lobe injuries, violence, and aggression: A report on the Vietnam head injury study. Neurology, 46(5), 1231-1238.

New, A. S., Hazlett, E. A., Buchsbaum, M. S., Goodman, M., Mitelman, S. A., Newmark, R., Trisdorfer, R., Haznedar, M. M., Koenigsberg, H. W., Flory, J., & Siever, L. J. (2007). Amygdala-prefrontal disconnection in borderline personality disorder. Neuropsychopharmacology, 32(7), 1629-1640.

New, A. S., Buchsbaum, M. S., Hazlett, E. A., Goodman, M., Koenigsberg, H. W., Lo, J., Iskander, L., Newmark, R., Brand, J., O’Flynn, K., & Siever, L. J. (2004). Fluoxetine increases relative metabolic rate in prefrontal cortex in impulsive aggression. Psychopharmacology, 176(3-4), 451-451.

Contact Info:
Rebecca DeMoor
Villanova University
Rebecca.demoor@villanova.edu

 

Families of Borderline Patients: The Psychological Environment Revisited
via Psychiatry MMC

The empirical literature in the area of families and borderline personality disorder (BPD) is growing. A large segment of this literature relates to studies of abuse propagated by family members during childhood (i.e., physical, sexual, emotional abuses; witnessing violence) as well as the genetic influences relating to the temperamental characteristics of affected individuals. However, in this edition of The Interface, we have elected to limit our focus to the accumulating literature on the psychopathology within the families of BPD individuals as well as the current focus of family treatment. (As a caveat, we advise the reader that not all families necessarily harbor significant psychopathology or overtly contribute to their member’s Axis II disorder.)

Psychopathology in the extended families of BPD patients. A number of studies have examined various psychopathological characteristics in the extended families of BPD probands in comparison with the extended families of a control proband. For example, Silverman and colleagues compared the first-degree relatives of three proband subsamples: (1) individuals with BPD; (2) individuals with other personality disorders; and (3) individuals with schizophrenia.[1] Compared with the other two subsamples, the relatives of BPD probands demonstrated independently greater risks for affective and impulse disorders.

In a study by Goldman, D’Angelo, and DeMaso,[2] investigators compared the family members of borderline versus non-borderline psychiatric probands. The families of individuals with BPD had significantly greater rates of depression, substance abuse, and antisocial characteristics.

Riso et al[3] compared the families of BPD probands with those probands of individuals with mood disorder or who were never-psychiatrically ill. Compared with these two control groups, investigators found increased rates of mood and Axis II disorders among the relatives of the BPD probands.

In a large study by Zanarini et al,[4] investigators compared family members of 341 BPD probands to 104 probands with another type of Axis II disorder. Over 1500 relatives of the BPD probands were interviewed. Compared with the nonBPD Axis II probands, the families of BPD probands were more likely to have BPD psychopathology, particularly subsyndromal symptoms.

Finally, in a 2003 review article, White et al[5] presented their analysis of the literature on the psychopathology among the relatives of individuals with BPD. This author group concluded that there do not appear to be familial associations with schizophrenia or major depression, but rather with impulse spectrum disorders and BPD, itself.

—February 18, 2009

 

Improving the Management of Women
with Borderline Personality Disorder
via NursingTimes.net

An inpatient service for women with borderline personality disorder adapted a therapeutic approach developed for use with outpatients. Mentalisation-based therapy helps clients to understand the meaning of their own behaviour and that of others, and allows positive risk-taking. It has led to real improvements in clients' progress towards more independent life.

Introduction

New Dawn is a unique specialist service providing intensive, long-term treatment for women with borderline personality disorder (BPD). Operating from Cygnet Hospital Bierley, outside Bradford, the ward treats complex cases with multiple difficulties such as eating disorders, substance misuse, attention-deficit hyperactivity disorder (ADHD) and short-lived psychosis.

The service was established in 2006 due to concerns that traditional approaches for this client group were unsuccessful. These concerns were echoed by changes in government thinking (National Institute for Mental Health in England, 2003a; 2003b). Both described areas of good practice and marked a change in approaches and responsibilities for mental health services regarding personality disorders.

Clients with BPD can evoke strong and often negative responses from nurses and other professionals, many of whom perceive this group as difficult and demanding. In the past, a diagnosis of personality disorder was equivalent to being deemed untreatable and exclusion from services was common. The result was a national deficit in services, resulting in inappropriate treatment and placement of clients, often through A&E, the prison service or high-security environments.

Mentalisation-based therapy

Cygnet Heath Care operates three New Dawn services. The unit in Bierley has adopted a structured psychotherapeutic programme, underpinned by mentalisation-based therapy (MBT) (Bateman and Fonagy, 2006). This was initially developed for use on an outpatient basis (Bateman and Fonagy, 1999), and Bierley has been unique in adapting MBT to an inpatient setting.

Bateman and Fonagy (1999) showed that MBT could reduce frequency and severity of self-harm behaviours and help with global functioning, depressive symptoms and relationships, all with sustained benefits. The impressive results on New Dawn reinforce this (see Fig 1).

Mentalisation is a normal ability: it involves how people see themselves and those around them, and is central to communication and relationships. In essence, it highlights the fact that how people behave is linked to their feelings, beliefs, desires and needs. So, when people interact with the world around them, they use understanding of themselves and others to make sense of this.

People with BPD often misinterpret their own thoughts, feelings and behaviours as well as those of other people. MBT focuses on looking at these in the present, through both individual and group work. It adapts a form of interview/questioning style derived from both reflexive and relational questions of the systemic model, in particular the Milan/post-Milan schools of systemic theory.

Developing the capacity to mentalise helps people to regulate emotions and build and maintain healthy relationships. Emotional arousal reduces the capacity to mentalise, while feeling calm and safe in a therapeutic relationship enables clients to explore their mind and those of people around them, to better understand the meaning of behaviour.

Other therapies

While New Dawn focuses on MBT, other therapies are provided to help develop clients' skills and address traumas they may have endured. This approach involves a variety of techniques such as: eye movement desensitisation and reprocessing (EMDR); meditation; occupational therapy; guided imagery; body psychotherapy; art psychotherapy; and music therapy. It also includes yoga, physical exercise, healthy eating and smoking-cessation programmes. There are opportunities to pursue further education, voluntary work and hobbies, with emphasis on improved quality of life and a gradual move towards independence.

Positive risk-taking

The team appreciates the need for positive risk-taking. Most notably, they generally avoid implementing special observations as a response to self-harm, and instead use harm-minimisation interventions, engaging clients in intensive therapy.

Clients are not required to sign 'no-harm contracts', which rarely work in BPD. Practitioners believe enforced agreements tend to make clients feel vulnerable and can, therefore, be perceived as setting them up to fail, prompting feelings of rejection and abandonment. This instigates cyclical self-harm behaviour. 

While self-harm is never encouraged or assisted, it is tolerated and recognised as an expression of acute psychological distress clients undertake with the intention of helping rather than killing themselves (Sutton, 2007). Staff believe completely preventing self-harm can be counterproductive and even dangerous. Instead they address this over an extended period of time.

Practitioners focus on clients' strengths, giving them choices and enabling them to work towards greater autonomy. Clients are taught about wound care and risk of accidental death due to self-harm, as well as the need to alert staff either during or immediately after self-harm to facilitate prompt interventions.

It is essential that clients are not judged or rejected due to such challenging behaviours, but are engaged by knowledgeable, calm, non-judgemental and non-punitive staff. At a time of crisis, which may result in self-harm and aggressive behaviour, practitioners try to use verbal de-escalation as much as possible, avoiding the need for seclusion or rapid tranquilisation where possible.

Client involvement

Particular importance is placed on clients participating in regularly reviewing and planning their care, giving them ownership of it. Staff help them make decisions and engage them in positive therapeutic work. For example, clients do not lose section 17 leave, nor would they be prohibited from participating in therapeutic activities simply because they have self-harmed or been aggressive, unless there is major concern of escalating risk. The multidisciplinary team work closely together and nurses are empowered to make decisions and discuss matters with the medical team. Family members and carers are also involved.

Client progress

When clients have developed sufficient emotional skills through MBT, practitioners gradually begin to use trauma-focused therapies to probe the root cause of their difficulties. This is often the most challenging and difficult part of treatment but arguably the most important. As they move through the programme, many move towards our step-down unit, an open environment suitable for clients who have made significant progress. This provides an ideal stepping-stone between a secure ward and an eventual return to independent living. Women on this ward have more freedom and autonomy, while continuing to participate in the New Dawn programme.

Staff challenges

BPD presents conceptual and therapeutic challenges for healthcare professionals. Staff are supported through regular supervision by an external clinical psychologist who is experienced in BPD but does not become involved with clients on New Dawn, to ensure objectivity.

As a team, practitioners encourage mentalising relationships with each other, similar to the way in which they do with clients. This helps maintain a sense of cohesion and support, whereby they are less critical of each other, especially when incidents occur. They do, however, acknowledge they are only human and aim to learn from incidents rather than allowing them to divide the team.

Risk assessments, care plans and management plans are discussed. Staff talk openly about their feelings in supervision and handovers. They aim to lead by example, coping better with difficult emotions by remaining calm when a client loses control, demonstrating empathy, setting clear boundaries and not responding in paternalistic ways. 

Like any service, practitioners have faced their own challenges and it was difficult to change people's attitudes to working in a new way. Many staff are initially anxious about positive risk-taking, for fear of litigation. Staff from other wards sometimes struggle with this approach due to poor understanding of self-harm, BPD and the rationale behind our methods. This can be overcome through education, supervision and rotating staff between wards so they see how we work and appreciate the positive results.

Conclusion

Many women have moved through the care pathway and are able to participate more readily in the community, in preparation for discharge. Renewed interest in activities, starting voluntary/paid work and training are maintained beyond discharge and promote greater confidence and self-esteem, and improved quality of life. The net result is reduced likelihood of a relapse and subsequent return to care.

—January 19, 2009

 

NEA-BPD's Survey for Families

Parents of people living with borderline personality disorder (BPD) have unique information about the early symptoms of the disorder and about the consequences of BPD for families of affected individuals. NEA-BPD is working with researchers on a new study looking at these important and underexplored areas. Please help us by completing an anonymous on-line survey about the childhoods and adolescences of your sons and daughters (both those with and without BPD), and about the impact BPD has had on your life.

To take part in this important survey, please click here.

—October 2008

 

What is Schema-Focused Therapy?
Amanda L. Smith

A lot of people believe that Dialectical Behavior Therapy is the only therapy designed for those clients or patients diagnosed with borderline personality disorder. However, other therapies do exist that have proven to be significantly effective.

Schema-Focused Therapy (SFT) was developed by Jeffery Young, PhD specifically to treat BPD. In an article published in the Archives of General Psychiatry in 2006, the concept of the "schema" was defined as patterns "of thinking, feeling, and behaving. The distinguished modes in BPD are detached protector, punitive parent, abandoned/abused child, and angry/impulsive child. In addition, some presence of the healthy adult is assumed. Change is achieved through a range of behavioral, cognitive, and experiential techniques that focus on (1) the therapeutic relationship, (2) daily life outside therapy (also through homework assignments), and (3) past (traumatic)
experiences. Recovery in SFT is achieved when dysfunctional schemas no longer control or rule the patient’s life."

In the Archives article it was concluded that when SFT was compared with Transference-Focused Psychotherapy (TFP)—a psychoanalytic approach in the treatment of BPD—that "Three years of SFT or TFP proved to bring about a significant change in patients' personality, shown by reductions in all BPD symptoms and general psychopathologic dysfunction, increases in quality of life, and changes in associated personality features. Using intention-to-treat analysis with adjustments for baseline assessments, SFT and TFP effectiveness became apparent at 12 months of treatment and was further extended at 3 years of treatment. Schema-focused therapy was superior to TFP with respect to reduction in BPD manifestations, general psychopathologic dysfunction, and change in SFT/TFP personality concepts."

Although SFT may not be appropriate for all persons diagnosed with BPD, it is important for anyone interested in effective treatment for BPD to learn more about this evidence-based treatment.

—June 2008

 

My Friend Has BPD: Our Journey Together
Catee Baugh, Eckerd College, ’10

My best friend Annabelle.* and I met at acting camp right before sixth grade. We talked casually then, but when we saw each other on the first day of middle school, we screamed. We were so glad to have one person we knew. And that’s how our friendship began.

It was rocky, to say the least. Annabelle would often say things that crushed my self esteem to pieces, like calling me fat or crybaby. One small, stupid thing I said could get her mad at me for weeks. Sometimes I just wanted to get away from her.

When we went to separate high schools, our friendship grew. We talked weekly, sharing the details of our lives. I didn’t approve of what Annabelle was doing at the time. She went from boy to boy to see what each of them could give her. She cheated on them, then acted like it was no big deal. She was drinking and taking medicine she didn’t need, like Vicodin. At the time I didn’t really know what to make of it all. It wasn’t until our junior year that I found out what was happening.

Annabelle and I were on the phone, and she consoling me after my first breakup. I was complaining about things my boyfriend had done and his excuses for how he treated me. He had depression and schizophrenia and when he went off his meds, he would stop being kind to me.

“What a crock,” Annabelle said. “I have BPD and I still don’t act that way.”

“Wait, what? BPD? What’s that?”

Annabelle told me about her symptoms—how she had trouble with stable relationships, how she always looked over her shoulder to see if there was someone better for her or someone better than her, how she cut herself to deal with pain and to punish herself. When one thing went wrong, it felt like the world would end. Annabelle got worse in the next couple of years. She called me several times, having cut or feeling worthless because of one small failure. Then I remember her turning point. Right before college, she met a guy, and for the first time, she opened up and told him what she needed. She’s been with him now for over a year and a half. She hasn’t cut herself in months. Her self-loathing episodes are less frequent, mostly when she’s exhausted or not feeling well. In all, she’s more stable.

It can be hard to be friends with Annabelle. She can be explosive and even hostile, and my temper’s not so great either. If I have a criticism or an issue with something, I have to find an extremely delicate way to put it. But it’s worth it. I can tell her about anything and everything, and even if I might not like her advice, I know it’s what she thinks is best for me. She has the classic fear of abandonment common in BPD, but it’s made our friendship stronger. Annabelle deeply appreciates everyone who stood by her. She’s incredibly loyal, and sometimes she’s been the only person to really stand up for me. Annabelle has never used her illness as an excuse for her behavior. She consistently strives to be a better friend, girlfriend, daughter, and person. She constantly pushes through her diagnosis to get to who she wants to be.

If you have a friend with BPD, you might wonder, “Where do I go from here?” Here’s my answer. Stick by your friend, even when it’s hard. People with BPD are afraid of losing you; if you want to be a good friend, don’t justify that fear. Remind your friend that she is a good person. That everyone makes mistakes, and one small error doesn’t ruin your life. Tell them how you feel—a gentle, objective opinion might help their viewpoint.

And get them help if they’re being self-destructive; they may hate you for it at the moment, but they need it more than you realize.

Finally, just listen to them. It’s the most important thing. You don’t need a psychology degree or a big guidebook. Try to understand where they’re coming from and what’s happening to them. Listening, with your mind and your heart, can get your friend to open up and tell you what they need. They don’t need therapy from you; they need love.

Don’t treat BPD like a character flaw. Treat it like the illness it is. Some may see Annabelle as a head case, a tramp, or a bitch. But she’s just a person who needs a little help sometimes. And she’s more than that. My best friend. My sister.

*Name has been changed

—April 2008

 

A Clinician’s Guide to BPD vs. BAD
Emily E. Lazarou, MD, MS, RD, LD

When I was invited to write a clinical article for FBPDA, I was excited. Then my mind starting working feverishly. Borderline Personality Disorder (BPD) and its treatment is a vastly complex venture and should be approached as such. To open the “Pandora’s Box” of such complexity must be done with care, in order to get the most out of it. A recurring clinical section in this newsletter is a positive step that helps educate everyone about BPD. I’m proud to start the discussion.

Personality disorders fascinated me even before I knew what they were. Not surprisingly, I use my knowledge of personality disorders to empathize with patients. When you start to look at a patient’s world through his or her eyes, it’s easier to determine the etiology of the situation and hence the direction of treatment.

Borderline Personality Disorder is the most commonly diagnosed of all personality disorders and one that evokes a lot of counter-transference on the part of the clinician. As a result, not all physicians are open to treating clients with BPD. Additionally, insurance companies tend to discriminate against Axis II Disorders and so, to add insult to injury, clinicians don’t get paid to treat patients with such conditions. Put these facts together and the situation is clear: When you as a clinician witness a distraught Borderline patient and his or her family enter your office, you are usually already starting at a disadvantage, one emphasized by misinformation and an unaccommodating health care system.

The term “Borderline” was employed to characterize BPD’s multifaceted nature. When the multiple symptoms inherent in BPD manifest, they can mimic the symptoms of many other disorders. In turn, this becomes a diagnostic conundrum for the busy, time-strapped physician. With this in mind, I’d like to examine Borderline Personality Disorder (BPD) vs. Bipolar Affective Disorder (BAD) and suggest how professionals can distinguish the two clinically. First, when I look at a patient, I take into account my counter-transference. Since counter-transference reflects the same feelings that the patient evokes in others in their environment, initially it’s your only gauge of how your client interacts with others. This is an important clinical finding that physicians need to pay attention to. Listen to your counter-transference. Is it positive? Negative? Generally speaking, BPD tends to produce negative vibes whereas BAD gives positive vibes. Briefly imagine a patient in a manic state rambling, giggling, and telling you about all the things they did during that short day. I smile just thinking about it.

Next, get down to basics. It is essential to actually know the criteria for each disorder. I find when I see one of these “diagnostic dilemmas” come into my office saying “I’m bipolar, schizophrenic, ADD, and PTSD” I pretty much know where it’s going. So sit down and look at the criteria. One person does not fit the diagnostic criteria for all of these disorders! I am all for getting a feeling for a patient and going with it initially until you can clarify the diagnosis. But when you take it to the next level and actually start treating a patient unsystematically based upon a hunch, that’s taking it too far. It doesn’t help the patient and both medically and legally, it doesn’t help you in the long run. You must take the time to check the criteria in order to diagnose and treat accordingly.

Since mood swings can be exhibited by patients with BPD and patients with BAD, this can be a source of misdiagnosis. BPD patients do have mood swings, but their duration and intensity are different than those experienced by persons with BAD. As I see it, this is really the only connection between BAD and BPD. In BAD, mood swings are circumscribed. In BPD, they can be happy, then sad, then back again—appointment to appointment or even within one appointment. Other differences are evident. Bipolar patients tend to not have the abusive history that is regularly seen in those with BPD (BPD patients often have sexual trauma in their past). Further, those with BPD exhibit a fear of abandonment, splitting, lack of sense of self, and self-harm behaviors that are not inherent in BAD. BPD patients also tend to have explosive relationships, while those who are bipolar typically have good relationships (with the exception of hypersexuality in manic episodes). And while bipolar patients do have suicidal thoughts, these appear during depressive states. In contrast, BPD patients have a chronic feeling of suicidality.

Clearly there are significant differences between BPD and BAD, yet misdiagnoses are not uncommon. Both conditions are treatable, but it is essential to know the criteria for both and the differences between these personality disorders in order to better serve patients.

Bottom line: Get back to basics. Listen to your gut. Empathize. Look through the eyes of your patients; they will tell you the diagnosis.

—March 2008