Letters to the editor

A biopsychosocial approach to bipolar-borderline

debate: psychological eect of a biological
temperament
DOI: 10.1111/acps.12298
Akiskal was the rst to suggest borderline personality as an
Axis I disorder within the bipolar aective spectrum about two
decades ago. His idea has been derived mostly from the simi-
larities of aective 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 supports for Akiskals theory. First,
cyclothymic temperament has been found to be highly sensitive
(88%) in identifying bipolar II disorder and has been the most
common aective temperament among patients with this
disorder. Second, there has been a high comorbidity between
borderline personality and bipolar (particularly the broad
denition of bipolarity). Third, there has been strong associa-
tion between atypical depression and bipolarity (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 aective temperamental dysregulation. Fourth,
cyclothymic temperament has been associated with borderline
personality among 107 atypical depressives (P = 0.001).
Hence, Akiskal has explained all these ndings as support for
the conclusion that atypical depression, borderline personality,
cyclothymia, and bipolar II disorder represent overlapping
manifestations of cyclothymic temperament as a common
underlying diathesis (1).
On the other hand, emphasizing more on the dierences
than similarities, Ghaemi has stated that these two disorders
are dierent. 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, aective 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
predictive of bipolarity (abandonment, identity disturbance,
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 dierences on which Ghaemis 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
eect of cyclothymic temperament on the development of bor-
derline personality might be noteworthy. As proposed by
Kernberg, borderline personality evolves from the failure to
integrate representations of good and bad aspects of self and
others. From this view-point, a cyclothymic child might be
assumed as developing two completely opposite representa-
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-
mic temperament, might render self-soothing capacity
impaired. Without developing the capacity for self-soothing,
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-
tribute to borderline personality. On the other hand, some
studies have found associations between temperamental prole
of borderline personality (high novelty seeking and high harm
avoidance) 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 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 disorder increases the
probability of borderline personality disorder (3). One study of
cyclothymia patients found 62% with borderline personality
(3). A future direction of research will be the association of
cyclothymic temperament and bipolar II disorder in borderline
personality sample. A prospective study is required to investi-
gate cyclothymic temperament in youth as a predictor of later
borderline personality.
Applying the third model in clinical practice, it can be pro-
posed that all borderline patients need psychotherapy even
though they have bipolar or cyclothymia comorbidity, because
borderline 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, the
bipolar or cyclothymic comorbidity of borderline personality
requires separate biological treatment as it might have some
predisposing or even perpetuating eects on the borderline
personality.
N. Khalili
Department of Psychiatry, Shahid Beheshti Hospital, Kerman
University of Medical Sciences, Kerman, Iran
E-mail: navidkhalili2000@yahoo.com
References
1. Perugi G, Fornaro M, Akiskal HS. Are atypical depression,
borderline personality disorder and bipolar II disorder
overlapping manifestations of a common cyclothymic
diathesis? World Psychiatry 2011;10:4551.
2. Barroilhet S, Vohringer PA, Ghaemi SN. Borderline versus
Bipolar: 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 borderline
personality disorder: a view from developmental psychopa-
thology. Dev Psychopathol 2005;17:927957.
158
Letters to the editor
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 Disord
2005;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 the
scientic validity of the DSM-5 (and prior) criteria for border-
line personality. Elsewhere (1), I have presented my rationale
for the present claim; here, I can only present my conclusions
and refer readers there for my premises and evidence. Border-
line personality evolved as a clinical picture that referred to
women (mostly) who had experienced childhood (mostly) sex-
ual abuse, and who tended to engage in repetitive self-injury
(usually cutting), had dissociative experiences (including
somatic symptoms in the past, such as paralysis), and had very
complex emotional experiences with their psychotherapists
(usually characterized by notable anger and even rage, even on
the part of the clinician, referred to as countertransference
hate). This summary picture of borderline personality has rea-
sonably strong historical and scientic support (1). But with
DSM denitions, the sexual abuse etiology was excluded, the
experiences of the clinician were ignored, and self-injury and
dissociative 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 includes
many persons with bipolar and unipolar mood illnesses.
I think DSM-based borderline personality disorder does
not do justice to the scientic and clinical evidence about that
clinical picture. If I am correct, then there would be no need to
hypothesize dierent biological versus psychological pathways
to explain the comorbidity of a more or less validly described
condition (cyclothymia) and a more or less invalidly described
condition (DSM-dened borderline personality).
S. N. Ghaemi
Department of Psychiatry, Tufts Medical Center, Boston, MA,
USA
E-mail: nghaemi@tuftsmedicalcenter.org
Reference
1. Ghaemi SN, Dalley S, Catania C, Barroilhet S. Bipolar or
borderline: a clinical overview. Acta Psychiatr Scand 2014;
130:2529.
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Letters to the editor