Differentiating Bipolar Disorder from Borderline Personality Disorder in Pediatric Patients

Educational Objectives

The goal of this program is to improve the differentiation of bipolar disorder from borderline personality disorder (BPD) in pediatric patients. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize common features of mood and personality disorders.
2. List the diagnostic criteria for BPD.
3. Identify the causes and triggers of bipolar disorder and BPD.

Summary

Introduction: bipolar disorder (BD) and borderline personality disorder (BPD) have similar and overlapping diagnostic criteria; one study suggested ≤40% of patients with BPD might be misdiagnosed with BD; such misdiagnoses can lead to delayed treatment, which is linked to worse outcomes; there are biases in diagnosis, noting disparities based on race and ethnicity, with White individuals more likely to be diagnosed with BD and Black individuals more likely to be diagnosed with schizophrenia; despite no actual differences in illness rates, people from racial and ethnic minority groups often receive less specialized mental health treatment; there is a need to recognize and address biases in diagnosis and treatment, as well as the differences in treatment approaches for BD and BPD; mood lability, a common complaint, overlaps with various conditions, eg, major depression, attention-deficit/hyperactivity disorder (ADHD), autism, anxiety, and learning disorders

Mood disorders vs personality disorders: mood disorders — characterized by episodic and recurrent mood disturbances with symptom-free intervals; personality disorders — one’s way of thinking, feeling, and behaving persistently deviates from cultural norms, leading to distress and functional impairments; lasts over time and usually manifests in ≥2 different areas (eg, cognition, affectivity, interpersonal functioning, impulse control)

Bipolar disorder: BD, a type of mood disorder, includes episodes of mania and depression, while unipolar disorder typically involves recurring depressive episodes; bipolar 2 disorder includes repeated depressions and occasional hypomanic episodes; BD typically evolves from an asymptomatic at-risk stage, with emergence of prodromal symptoms in late adolescence and early adulthood, which usually lead to the initial mood episode; ≥80% of individuals who experience a manic episode have ≥1 recurrence

Mania: defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting ≥1 wk (can be shorter if hospitalized); activity and energy are increased most of the day, nearly every day; irritability can be the predominant mood state in mania; impairment, hospitalization, or psychotic features are often present, and the episode cannot be attributed to substance use or medical issues; diagnosis requires the presence of ≥3 symptoms (≥4 if mood is irritable), ie, decreased need for sleep, increased self-esteem or grandiosity, more talkativeness or pressured speech, racing thoughts or flight of ideas, distractibility, increased energy, and engaging in high-risk activities

Hypomania: similar to mania but less severe, with symptoms lasting ≥4 consecutive days instead of 1 wk; the noticeable change from baseline does not necessarily lead to impairment in functioning; in a major depressive episode, symptoms must persist for ≥2 wk, with ≥1 of various symptoms, ie, sadness, loss of interest, feelings of worthlessness or guilt, fatigue, sleep or appetite changes, restlessness or slowed movements, difficulty concentrating, suicidal thoughts

Distinguishing between BD types: a core feature of bipolar 1 is a manic episode, which may be preceded or followed by hypomania or depression; bipolar 2 requires ≥1 depressive episode and ≥1 hypomanic episode, with individuals returning to their usual functioning between episodes; individuals with bipolar 2 often initially seek treatment for depression, as hypomania can be difficult to distinguish because of its pleasurable aspects and potential enhancement of performance; bipolar 2 diagnosis can be tricky and may be overused, particularly in youth, and often describes other conditions

Borderline personality disorder: characterized by persistent day-to-day emotional issues that significantly impact daily life; manifests as a pervasive pattern of instability in interpersonal relationships, self-image, affect, and marked impulsivity, typically starting in early adulthood; diagnosis — requires the presence of ≥5 criteria, ie, fear of abandonment, unstable relationships, fluctuating between idealization and devaluation of others, impulsivity in ≥2 potentially self-damaging areas (eg, sex, spending, substance use, reckless driving), recurrent suicidal behaviors or self-harm, moodiness lasting hours to days, chronic feelings of emptiness, anger problems, and paranoia or dissociation during stress; intensity often escalates with conflicts, traumatic events, or stressors; splitting (a key feature) involves seeing oneself or others as all good or all bad, lacking integration of positive and negative attributes; usually arises from an attempt to mitigate fear of abandonment

Bipolar disorder vs BPD: BD is characterized by sleep issues, distinct mood episodes lasting days to weeks, mood stability between episodes, possible psychosis, and strong family history; BPD features fear of abandonment, unstable self-image, unstable relationships, feelings of emptiness, interpersonal conflict, short-lived mood shifts lasting hours to days, dissociation, and self-harm; both disorders share moodiness, anger, suicidality, risk-taking behaviors, and impulsivity, but the duration of affective issues differ; BD often involves longer episodes, while BPD presents with shorter, intense mood swings; BD more commonly has a family history, but there can be family history of BPD; sleep changes are a hallmark of BD; self-harm is more common with BPD; BD is more responsive to treatment

Triggers: BD often has a strong family history, chemical imbalances, and environmental factors, eg, hormonal and seasonal changes, stress; triggers can include hormonal fluctuations, stress, nutritional deficiencies, poor sleep, substance use, and negative life events; BPD is often associated with trauma, parental substance use, and genetics, with triggers including criticism, fear of abandonment, conflicts in relationships, job loss, and romantic rejection

Treatment approaches: in treating BD, medications, eg, mood stabilizers, antipsychotics, and antidepressants, are essential for managing symptoms, though their use can be complex, especially in bipolar depression; therapy options include cognitive behavioral therapy, dialectical behavioral therapy (DBT), interpersonal and social rhythm therapy, and family-focused therapy, along with psychoeducation for patients and families; in BPD, medications primarily target comorbid conditions (eg, anxiety, depression, ADHD) to facilitate engagement in therapy, which may include DBT and other interventions

Dialectical behavioral therapy: components include mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness; targets core areas of impairment in BPD and is typically recommended; medications are rarely offered without therapy

Mentalization-based therapy: focuses on understanding one's mental states and their impact on others; this helps individuals with BPD manage their behaviors, feelings, and interpersonal relationships more effectively, reducing impulsivity and addressing the fear of abandonment

Overlap between BD and BPD: staying true to the defining characteristics of BD (ie, episodic and recurrent nature, symptom-free intervals) while also considering how comorbid conditions may manifest is crucial; trauma disorders can further complicate diagnoses in this context, contributing to diagnostic controversy

Controversy surrounding pediatric BD: involves concerns about overdiagnosis and the potential misidentification of other conditions, eg, posttraumatic stress disorder, autism, ADHD; disruptive mood dysregulation disorder (DMDD) emerged as a diagnostic category to address severe irritability and emotional instability in children; many children initially diagnosed with pediatric BD actually have ADHD or other conditions; DMDD criteria include manifestation at <10 yr of age, persistent irritability, severe temper outbursts, and impairment in daily functioning; caution is advised because of overlap with trauma and neurodevelopmental disorders; severe trauma can manifest similarly to BD

Controversy surrounding BPD: involves doubts about BPD diagnosis in youth, with some arguing that children are too young to have a personality disorder; however, research has shown that the diagnostic criteria for BPD are as reliable, valid, and stable in adolescence as they are in adulthood; failure to diagnose BPD in youth can lead to a delay in appropriate treatment; engaging youth in discussions about the criteria for BPD allows them to recognize and articulate their experiences, providing validation and a sense of community; diagnosing BPD expands the understanding of the individual's suffering beyond labels, eg, generalized anxiety disorder and major depression

Assessing mood disorders: particularly in BD, assessment requires establishing the child's baseline behavior to identify noticeable changes indicative of episodic symptoms; focus on identifying the child’s symptoms during a specific episode; differentiate between episodic and chronic symptoms is crucial; consider normative behavior for the child's age group; explore potential non-DSM diagnoses, eg, language disorders or cultural factors; avoid assigning diagnoses solely based on the severity of symptoms; avoid leading questions; open-ended questions facilitate gathering relevant information without leading the patient into a specific diagnosis; additionally, internet-savvy youth may self-diagnose or be familiar with diagnostic criteria, emphasizing the importance of thorough exploration and clarification of symptoms during assessment

Challenges: parents may focus on the most severe behavior, while clinicians need to discern between chronic and episodic symptoms; guide questioning towards understanding mood states during specific episodes rather than solely focusing on reported behaviors; self-reports of acting out behaviors from youth may be unreliable, often requiring collateral information from parents, siblings, or teachers; assessing mood in youth can be aided by structured interviews and questionnaires, eg, the Parent General Behavior Inventory, Young Mania Rating Scale, and Parent Mood Disorder Questionnaire; mood diagrams depicting peaks and valleys in mood episodes are helpful visual aids; mood diaries allow for tracking mood fluctuations, significant events, substance use, sleep patterns, and stressors; psychoeducation and collaborative problem-solving techniques are valuable for empowering families and addressing behavioral challenges

Readings

Campos A, Ferreira AR, Gonçalves-Pinho M, et al. Bipolar Disorder in pediatric patients: A nationwide retrospective study from 2000 to 2015. J Affect Disord. 2022;298(Pt A):277-283. Doi:10.1016/j.jad.2021.10.113; Chapman J, Jamil RT, Fleisher C. Borderline Personality Disorder. StatPearls Publishing. June 2, 2023; Cichoń L, Janas-Kozik M, Siwiec A, et al. Clinical picture and treatment of bipolar affective disorder in children and adolescents. Obraz kliniczny i leczenie choroby afektywnej dwubiegunowej u dzieci i młodzieży. Psychiatr Pol. 2020;54(1):35-50. doi:10.12740/PP/OnlineFirst/92740; Fahrendorff AM, Pagsberg AK, Kessing LV, et al. Psychiatric comorbidity in patients with pediatric bipolar disorder - A systematic review. Acta Psychiatr Scand. 2023;148(2):110-132. doi:10.1111/acps.13548; Khafif TC, Rotenberg LS, Nascimento C, et al. Emotion regulation in pediatric bipolar disorder: A meta-analysis of published studies. J Affect Disord. 2021;285:86-96. doi:10.1016/j.jad.2021.02.010; Preyde M, DiCroce M, Parekh S, et al. Exploring screening for borderline personality disorder in pediatric inpatients with psychiatric Illness. Psychiatry Res. 2022;309:114397. doi:10.1016/j.psychres.2022.114397; Sanchez M, Lytle S, Neudecker M, et al. Medication Adherence in Pediatric Patients with Bipolar Disorder: A Systematic Review. J Child Adolesc Psychopharmacol. 2021;31(2):86-94. doi:10.1089/cap.2020.0098; Skodol AE, Shea MT, Yen S, et al. Personality disorders and mood disorders: perspectives on diagnosis and classification from studies of longitudinal course and familial associations. J Pers Disord. 2010 Feb;24(1):83-108. doi: 10.1521/pedi.2010.24.1.83. PMID: 20205500; PMCID: PMC6540749.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Espana was recorded at the 7th Annual Pediatric Mental Health Update, held March 8, 2024, in Lake Oswego, OR, and presented by Oregon Health and Science University School of Medicine. For information about upcoming CME activities from this presenter, please visit https://www.ohsu.edu/school-of-medicine/cpd. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.75 CE contact hours.

Lecture ID:

PD702701

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.