Misdiagnosis of borderline personality disorder

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Borderline personality disorder (BPD) is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, a distorted sense of self, and intense emotional responses, which can be misdiagnosed.[ citation needed ] Misdiagnosis may involve erroneously assigning a BPD diagnosis to individuals not meeting the specific criteria or attributing an incorrect alternate diagnosis in cases where BPD is the accurate condition.

Contents

Alternative diagnoses

Misdiagnosis of borderline personality disorder (BPD) can occur due to symptom overlap with other mental health conditions and the high rate of comorbidity in personality disorders. [1] Research has shown that having a personality disorder like BPD is a significant vulnerability factor for comorbidity with other mental health conditions. [2] [3] The mood instability characteristic of BPD often leads to confusion with bipolar disorder. [4] Furthermore, the significant role of trauma in BPD complicates its distinction from complex post-traumatic stress disorder (C-PTSD) or post-traumatic stress disorder (PTSD), adding to the challenges of accurate diagnosis. [5]

Complex post-traumatic stress disorder

Complex post-traumatic stress disorder (C-PTSD), recognized in the ICD-11 but not in the DSM-5, shares core features with BPD, such as emotional dysregulation, interpersonal difficulties, and a negative self-concept, complicating their differentiation. [5] Unique manifestations of these symptoms in C-PTSD and BPD can aid in distinguishing between them; for instance, C-PTSD often involves reactive anger or substance use, while BPD is more associated with self-injury or suicidality. [5] [6] Relationship instability in BPD typically involves rapid shifts between idealization and devaluation, whereas in C-PTSD, it stems from difficulty forming close connections. [7] Additionally, while individuals with BPD may experience fluctuating self-concepts, those with C-PTSD usually maintain a consistently negative self-image. [7] Understanding these differences is crucial for clinicians to accurately diagnose and differentiate between C-PTSD and BPD, especially when comorbid with PTSD, underscoring the importance of comprehensive evaluations.

Bipolar disorder (BD)

Bipolar disorder (BD), a mood disorder characterized by significant mood swings, is categorized into bipolar I, involving at least one manic episode, and bipolar II, characterized by at least one hypomanic and one depressive episode. [8] Both BD and BPD exhibit overlapping features, making differential diagnosis challenging. Affective instability and negative affectivity are core features of both disorders, albeit with variations in their nature and longevity. The difficulty in controlling anger in BPD and the presence of irritability in BD might not be easily differentiated. Impulsivity is a common trait in both conditions; however, in BD, impulsivity may diminish between mood episodes. Additionally, both disorders are characterized by high rates of suicidality and similarly impact social functioning. [9] A small study of 700 participants showed that diagnostic criteria for BPD put patients with BPD at risk of being misdiagnosed with BD, as it found that 40% of those diagnosed with BPD report having been misdiagnosed with BD. [9]

Consequences of misdiagnosis

Misdiagnosis of BPD can result in a number of negative consequences. The reasoning for diagnosis is that of debate within the mental health field. Still, it is primarily looked at as serving the function of providing health professionals of the patient's mental health state, to inform treatment approaches, and to aid in accurately reporting successful treatment approaches. [10] Therefore, misdiagnosis can result in outcomes such as not having access to appropriate psychiatric medications or not being provided evidence-based psychological treatment for their disorders. [11]

Medical

As diagnosis is an essential part of determining what medications to prescribe to a patient or if a patient would benefit from psychopharmacotherapy, being misdiagnosed can have a range of adverse outcomes. Current research has indicated while some prescription medications can help with specific symptoms of BPD, there is no medication proven to decrease BPD symptoms as a whole. [11] In contrast, disorders such as bipolar disorder (BD) have a range of psychiatric medications (e.g., Lithium, anticonvulsants, GABA analogs) being used as a first-line approach to treatment. [12] By providing people with BPD with misdiagnoses such as BD, people with BPD can be subject to receiving medications that will not impact their symptomology and may result in adverse side effects. [11] Alternatively, people who are diagnosed with BPD who may instead have BD or C-PTSD (complex post-traumatic stress disorder) may be deprived of psychopharmacological interventions that would decrease symptoms severity. [11]

Psychological

Misdiagnosis of BPD can also result in adverse psychological consequences as a diagnosis is used in determining evidence-based treatment approaches used in the therapeutic setting. Treatment approaches such as dialectical behavior therapy and cognitive behavioral therapy for borderline personality disorder are two evidence-based treatments shown to be effective in the treatment of BPD. [9] By providing a misdiagnosis, a person with BPD would likely not have access to these specific treatment approaches, and therefore, their access to evidence-based treatment for their BPD would be delayed until an accurate diagnosis is given. [9]

Related Research Articles

Bipolar I disorder is a type of bipolar spectrum disorder characterized by the occurrence of at least one manic episode, with or without mixed or psychotic features. Most people also, at other times, have one or more depressive episodes.

<span class="mw-page-title-main">Borderline personality disorder</span> Personality disorder of emotional instability

Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, a distorted sense of self, and intense emotional responses. Individuals diagnosed with BPD frequently exhibit self-harming behaviours and engage in risky activities, primarily due to challenges in regulating emotional states to a healthy, stable baseline. Symptoms such as dissociation—a feeling of detachment from reality, a pervasive sense of emptiness, and an acute fear of abandonment are prevalent among those affected.

Schizoaffective disorder is a mental disorder characterized by abnormal thought processes and an unstable mood. This diagnosis requires symptoms of both schizophrenia and a mood disorder: either bipolar disorder or depression. The main criterion is the presence of psychotic symptoms for at least two weeks without any mood symptoms. Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be psychotic depression, bipolar I disorder, schizophreniform disorder, or schizophrenia. This is a problem as treatment and prognosis differ greatly for most of these diagnoses.many people with schizoaffective disorder have other mental disorder such as anxiety disorder

<span class="mw-page-title-main">Mood swing</span> Extreme or rapid change in mood

A mood swing is an extreme or sudden change of mood. Such changes can play a positive part in promoting problem solving and in producing flexible forward planning, or be disruptive. When mood swings are severe, they may be categorized as part of a mental illness, such as bipolar disorder, where erratic and disruptive mood swings are a defining feature.

<span class="mw-page-title-main">Dialectical behavior therapy</span> Psychotherapy for emotional dysregulation

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders and interpersonal conflicts. Evidence suggests that DBT can be useful in treating mood disorders and suicidal ideation as well as for changing behavioral patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies and ultimately balance and synthesize them—comparable to the philosophical dialectical process of thesis and antithesis, followed by synthesis.

Dysphoria is a profound state of unease or dissatisfaction. It is the semantic opposite of euphoria. In a psychiatric context, dysphoria may accompany depression, anxiety, or agitation.

Child psychopathology refers to the scientific study of mental disorders in children and adolescents. Oppositional defiant disorder, attention-deficit hyperactivity disorder, and autism spectrum disorder are examples of psychopathology that are typically first diagnosed during childhood. Mental health providers who work with children and adolescents are informed by research in developmental psychology, clinical child psychology, and family systems. Lists of child and adult mental disorders can be found in the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10), published by the World Health Organization (WHO) and in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association (APA). In addition, the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood is used in assessing mental health and developmental disorders in children up to age five.

Complex post-traumatic stress disorder is a stress-related mental disorder generally occurring in response to complex traumas, i.e., commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive little or no chance to escape.

<span class="mw-page-title-main">Bipolar disorder in children</span>

Bipolar disorder in children, or pediatric bipolar disorder (PBD), is a rare mental disorder in children and adolescents. The diagnosis of bipolar disorder in children has been heavily debated for many reasons including the potential harmful effects of adult bipolar medication use for children. PBD is similar to bipolar disorder (BD) in adults, and has been proposed as an explanation for periods of extreme shifts in mood called mood episodes. These shifts alternate between periods of depressed or irritable moods and periods of abnormally elevated moods called manic or hypomanic episodes. Mixed mood episodes can occur when a child or adolescent with PBD experiences depressive and manic symptoms simultaneously. Mood episodes of children and adolescents with PBD are different from general shifts in mood experienced by children and adolescents because mood episodes last for long periods of time and cause severe disruptions to an individual's life. There are three known forms of PBD: Bipolar I, Bipolar II, and Bipolar Not Otherwise Specified (NOS). The average age of onset of PBD remains unclear, but reported age of onset ranges from 5 years of age to 19 years of age. PBD is typically more severe and has a poorer prognosis than bipolar disorder with onset in late-adolescence or adulthood.

<span class="mw-page-title-main">DSM-5</span> 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is the 2013 update to the Diagnostic and Statistical Manual of Mental Disorders, the taxonomic and diagnostic tool published by the American Psychiatric Association (APA). In 2022, a revised version (DSM-5-TR) was published. In the United States, the DSM serves as the principal authority for psychiatric diagnoses. Treatment recommendations, as well as payment by health care providers, are often determined by DSM classifications, so the appearance of a new version has practical importance. However, not all providers rely on the DSM-5 for planning treatment as the ICD's mental disorder diagnoses are used around the world and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions. The DSM-5 is the only DSM to use an Arabic numeral instead of a Roman numeral in its title, as well as the only living document version of a DSM.

Bipolar II disorder (BP-II) is a mood disorder on the bipolar spectrum, characterized by at least one episode of hypomania and at least one episode of major depression. Diagnosis for BP-II requires that the individual must never have experienced a full manic episode. Otherwise, one manic episode meets the criteria for bipolar I disorder (BP-I).

Personality disorders (PD) are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual's culture. These patterns develop early, are inflexible, and are associated with significant distress or disability. The definitions vary by source and remain a matter of controversy. Official criteria for diagnosing personality disorders are listed in the sixth chapter of the International Classification of Diseases (ICD) and in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).

The mainstay of management of borderline personality disorder is various forms of psychotherapy with medications being found to be of little use.

Cyclothymia, also known as cyclothymic disorder, psychothemia / psychothymia, bipolar III, affective personality disorder and cyclothymic personality disorder, is a mental and behavioural disorder that involves numerous periods of symptoms of depression and periods of symptoms of elevated mood. These symptoms, however, are not sufficient to indicate a major depressive episode or a manic episode. Symptoms must last for more than one year in children and two years in adults.

<span class="mw-page-title-main">Differential diagnoses of depression</span> Differential diagnoses

Depression, one of the most commonly diagnosed psychiatric disorders, is being diagnosed in increasing numbers in various segments of the population worldwide. Depression in the United States alone affects 17.6 million Americans each year or 1 in 6 people. Depressed patients are at increased risk of type 2 diabetes, cardiovascular disease and suicide. Within the next twenty years depression is expected to become the second leading cause of disability worldwide and the leading cause in high-income nations, including the United States. In approximately 75% of suicides, the individuals had seen a physician within the prior year before their death, 45–66% within the prior month. About a third of those who died by suicide had contact with mental health services in the prior year, a fifth within the preceding month.

Childhood schizophrenia is similar in characteristics of schizophrenia that develops at a later age, but has an onset before the age of 13 years, and is more difficult to diagnose. Schizophrenia is characterized by positive symptoms that can include hallucinations, delusions, and disorganized speech; negative symptoms, such as blunted affect and avolition and apathy, and a number of cognitive impairments. Differential diagnosis is problematic since several other neurodevelopmental disorders, including autism spectrum disorder, language disorder, and attention deficit hyperactivity disorder, also have signs and symptoms similar to childhood-onset schizophrenia.

The Bipolar Spectrum Diagnostic Scale (BSDS) is a psychiatric self-rating scale created by Ronald Pies in screening for bipolar disorder (BD). Its initial version consists of a descriptive narrative aimed to capture the nuances and milder variants of BD. Upon revision by Nassir Ghaemi and colleagues, the scale was developed into two sections for a total of 20 questions. The BSDS is widely accepted as an important measure of bipolar disorder alongside other diagnostic tools such as the Mood Disorder Questionnaire and the Bipolar Depression Rating Scale.

<span class="mw-page-title-main">Disruptive mood dysregulation disorder</span> Medical condition

Disruptive mood dysregulation disorder (DMDD) is a mental disorder in children and adolescents characterized by a persistently irritable or angry mood and frequent temper outbursts that are disproportionate to the situation and significantly more severe than the typical reaction of same-aged peers. DMDD was added to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) as a type of depressive disorder diagnosis for youths. The symptoms of DMDD resemble many other disorders, thus a differential includes attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), anxiety disorders, and childhood bipolar disorder, intermittent explosive disorder (IED), major depressive disorder (MDD), and conduct disorder.

<span class="mw-page-title-main">Post-traumatic stress disorder and substance use disorders</span> Association of PTSD and substance dependencies

Post-traumatic stress disorder (PTSD) can affect about 3.6% of the U.S. population each year, and 6.8% of the U.S. population over a lifetime. 8.4% of people in the U.S. are diagnosed with substance use disorders (SUD). Of those with a diagnosis of PTSD, a co-occurring, or comorbid diagnosis of a SUD is present in 20–35% of that clinical population.

References

  1. ↑ Chanen, Andrew M; Thompson, Katherine N (2016-04-01). "Prescribing and borderline personality disorder". Australian Prescriber. 39 (2): 49–53. doi:10.18773/austprescr.2016.019. ISSN   0312-8008. PMC   4917638 . PMID   27340322.
  2. ↑ Korelitz, B. I.; Sommers, S. C. (November 1975). "Responses to drug therapy in ulcerative colitis. Evaluation by rectal biopsy and histopathological changes". The American Journal of Gastroenterology. 64 (5): 365–370. ISSN   0002-9270. PMID   2008.
  3. ↑ Cohen, Patricia; Crawford, Thomas N.; Johnson, Jeffrey G.; Kasen, Stephanie (October 2005). "The Children in the Community Study of Developmental Course of Personality Disorder". Journal of Personality Disorders. 19 (5): 466–486. doi:10.1521/pedi.2005.19.5.466. ISSN   0885-579X.
  4. ↑ Kernberg, Otto F.; Yeomans, Frank E. (2013). "Borderline personality disorder, bipolar disorder, depression, attention deficit/hyperactivity disorder, and narcissistic personality disorder: Practical differential diagnosis". Bulletin of the Menninger Clinic. 77 (1): 1–22. doi:10.1521/bumc.2013.77.1.1. ISSN   0025-9284. PMID   23428169.
  5. 1 2 3 Jowett, Sally; Karatzias, Thanos; Shevlin, Mark; Albert, Idit (2019). "Differentiating symptom profiles of ICD-11 PTSD, complex PTSD, and borderline personality disorder: A latent class analysis in a multiply traumatized sample". Personality Disorders: Theory, Research, and Treatment. 11 (1): 36–45. doi:10.1037/per0000346. ISSN   1949-2723. PMID   31259603. S2CID   195757445.
  6. ↑ Cloitre, Marylène; Garvert, Donn W.; Weiss, Brandon; Carlson, Eve B.; Bryant, Richard A. (2014-09-15). "Distinguishing PTSD, Complex PTSD, and Borderline Personality Disorder: A latent class analysis". European Journal of Psychotraumatology. 5 (1): 25097. doi:10.3402/ejpt.v5.25097. ISSN   2000-8198. PMC   4165723 . PMID   25279111. S2CID   11984913.
  7. 1 2 Brewin, Chris R.; Cloitre, Marylène; Hyland, Philip; Shevlin, Mark; Maercker, Andreas; Bryant, Richard A.; Humayun, Asma; Jones, Lynne M.; Kagee, Ashraf; Rousseau, Cécile; Somasundaram, Daya (2017). "A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD". Clinical Psychology Review. 58: 1–15. doi:10.1016/j.cpr.2017.09.001. ISSN   0272-7358. PMID   29029837. S2CID   4874961.
  8. ↑ "Bipolar and Related Disorders", Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, American Psychiatric Publishing, Inc, 2013, doi:10.1176/appi.books.9780890425596.057204, ISBN   978-0-89042-559-6 , retrieved 2020-10-15
  9. 1 2 3 4 Ruggero, Camilo J.; Zimmerman, Mark; Chelminski, Iwona; Young, Diane (2010). "Borderline personality disorder and the misdiagnosis of bipolar disorder". Journal of Psychiatric Research. 44 (6): 405–408. doi:10.1016/j.jpsychires.2009.09.011. ISSN   0022-3956. PMC   2849890 . PMID   19889426.
  10. ↑ Sartorius, Norman (2015). "Why do we need a diagnosis? Maybe a syndrome is enough?". Dialogues in Clinical Neuroscience. 17 (1): 6–7. doi:10.31887/DCNS.2015.17.1/nsartorius. PMC   4421902 . PMID   25987858.
  11. 1 2 3 4 Paris, Joel; Black, Donald W. (2015). "Borderline Personality Disorder and Bipolar Disorder". The Journal of Nervous and Mental Disease. 203 (1): 3–7. doi:10.1097/nmd.0000000000000225. ISSN   0022-3018. PMID   25536097. S2CID   2825326.
  12. ↑ Thompson, Kevin. (2007). Medicines for mental health : the ultimate guide to psychiatric medication (2nd ed.). North Charleston, S.C.: BookSurge Pub. ISBN   978-1-4196-6954-5. OCLC   226095173.
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