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Many psychiatrists have reconceptualized borderline personality disorder (BPD) as a variant of bipolar disorder and, consistent with the treatment of bipolar disorder, emphasize the use of mood stabilizers and atypical antipsychotics in treatment. This change in diagnostic practice is unfortunate. BPD is a distinct diagnostic construct, and clients who fit this pattern require a fundamentally different treatment approach than what is typically recommended for bipolar disorder. The purpose of this article is to update counselors on the expansion of bipolar disorder in the psychiatric literature, present evidence for the validity of BPD, discuss strategies for the differential diagnosis of it from bipolar disorder, review proposed changes in DSM-V, and integrate the literature into a mental health counseling framework.
One of the most challenging diagnostic dilemmas facing mental health counselors is the differential diagnosis of borderline personality disorder (BPD) from bipolar disorder. Not only do the two disorders share several symptoms and associated impairments (e.g., Wilson et al., 2007), there is also continuing debate in the psychiatric literature about whether the two disorders actually represent different conditions (Akiskal & Pinto, 1999; Gunderson et al., 2006; MacKinnon & Pies, 2006; Paris, Gunderson, & Weinberg, 2007). In recent years some psychiatric researchers have claimed that is actually a mood disorder on a hypothesized bipolar spectrum and because it is biologically based should be treated with mood stabilizers and newer antipsychotics (e.g., Perugi & Akiskal, 2002). Others (e.g., Paris, 2007) have maintained that BPD is a valid diagnostic entity that demands a different treatment approach from that typically provided to clients with bipolar disorder. MacKinnon and Pies (2006) summed up the controversy well:
The question is whether it is more useful to lump all affectively unstable patients, including a subset of those with borderline personality disorder, under the same general category of bipolar spectrum disorders or to split them into fine categories based not only on symptom intensity and quality, but also factors of behavior and circumstance (p. 5).
In recent years many mental health providers, especially physicians, have decided to err on the side of bipolar disorder in resolving the differential diagnosis question (e.g., MacKinnon & Pies, 2006). Various explanations have been offered for this, ranging from the desire to protect clients from the borderline stigma (Gunderson...