BMJ 2014;349:g6798 doi: 10.1136/bmj.
g6798 (Published 13 November 2014)
Letters
MOOD STABILISERS AND BORDERLINE PERSONALITY DISORDER
Bipolar disorder comorbid with borderline personality
disorder and treatment with mood stabilisers
Mark Agius associate specialist, department of psychiatry, University of Cambridge , Norma Verdolini
2
registrar
1
Weller Wing, Bedford Hospital, Bedford MK42 9DJ, UK; 2School of Specialisation in Psychiatry, University of Perugia, Perugia, Italy
Crawford and colleagues discuss the difficulty in deciding
whether patients with borderline personality disorder (BPD)
should be treated with mood stabilisers.1
This decision is affected by the fact that patients can have two
comorbid but distinct conditionsbipolar disorder and BPD.
Bipolar disorder has an important genetic component, often
with a family history of the disease, whereas BPD is mostly
related to environmental factors, often including exposure to
abuse.
Mood stabilisers are an essential treatment for bipolar disorder
because they stabilise mood and reduce suicidality. Patients
with BPD who dont have comorbid bipolar disorder show mood
lability but not hypomanic or manic episodes, as defined by the
Diagnostic and Statistical Manual of Mental Disorders, fifth
edition (at least four days of clearly high mood).2
If the bipolar component is ignored in patients with BPD and
bipolar disorder, they will not receive the mood stabilising
treatment they need. This will affect prognosis, because patients
with bipolar II disorder have a relatively high risk of suicidality
that can be exacerbated by the impulsivity and self harming
behaviour caused by comorbid borderline traits.3
We therefore propose that patients with possible BPD should
be carefully assessed for hypomanic episodes,4 and only if these
patients are shown to have bipolar disorder should mood
stabilisers be prescribed.
ma393@cam.ac.uk
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Page 1 of 1
LETTERS
1
We have recently shown that bipolar disorder is still often
underdiagnosed by community mental health teams,5 partly
because bipolar disorder is often comorbid with borderline traits.
In our published audit, when a policy of identifying hypomanic
episodes was adopted, 14.66% of patients were found to have
bipolar disorder comorbid with BPD. This figure was within
the proportion of patients (12-23%) predicted in the international
literature to have both borderline and bipolar conditions.4
Competing interests: None declared.
Full response at: www.bmj.com/content/349/bmj.g5378/rr/777783.
1 Crawford MJ, MacLaren T, Reilly JG. Are mood stabilisers helpful in treatment of borderline
personality disorder? BMJ 2014:349:g5378. (16 September.)
2 Elisei S, Anastasi S, Verdolini N. The continuum between bipolar disorder and borderline
3
personality disorder. Psychiatr Danub 2012;24(suppl 1):S143-6.
Costa LD, Alencar AP, Neto PJ, Santos MD, da Silva CG, Pinheiro SD, et al. Risk factors
for suicide in bipolar disorder: a systematic review. J Affect Disord 2014;170C:237-54.
4 Agius M, Lee J, Gardner J, Wotherspoon D. Bipolar II disorder and borderline personality
disorderco-morbidity or spectrum? Psychiatr Danub 2012;24(suppl 1):S197-201.
5 Bongards EN, Zaman R, Agius M. Can we prevent under-diagnosis and misdiagnosis of
bipolar affective disorder? Repeat audits to assess the epidemiological change in the
caseload of a community mental health team when bipolar disorder is accurately assessed
and diagnosed. Psychiatr Danub 2013;25(suppl 2):S129-34.
Cite this as: BMJ 2014;349:g6798
BMJ Publishing Group Ltd 2014
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