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Letters to the Editor
OB/GYN December 2001
To the Editor:
Your November article on borderline personality disorder (BPD) is
greatly appreciated (2001;26[11]:32-41). However, I am concerned
that the authors did not refer to the recent concept that BPD may
be, at least in some cases, a form of rapid-cycling bipolar disorder
and, thus, amenable to treatment with mood stabilizers such as lithium.
B.J. McFadden, MD
Greenville, SC
Dr Lyon responds:
Dr McFadden highlights a diagnostic dilemma appreciated by many
psychiatrists, that of distinguishing an Axis I disorder from an
Axis II disorder when a patient presents with atypical features
of either one. Nonetheless, his assertion that rapid-cycling bipolar
disorder is often misdiagnosed as BPD is not well supported in the
literature. Bolton and Gunderson highlight the danger of this approach
by pointing out that patients can become so single-minded in their
pursuit of a pharmacologic respite that they refuse to accept the
need for a strong personal intervention program in dealing with
underlying personality issues.1
In general, these distinctions are outside the scope of busy OB/GYNs,
who often have only 15 minutes to assess each patient's chief medical
complaint, as well as all underlying confounders. The problem is
magnified by a lack of adequate referral re-sources, even when a
psychiatric problem is appropriately identified. And when you factor
in BPD patients' characteristic resistance to therapy, it seems
clear that it will be a relatively rare phenomenon for an OB/GYN
to correctly distinguish a rapid-cycling bipolar disorder from a
possibly coexisting borderline personality; to promptly and effectively
generate a referral to the appropriate specialist; and to see an
appreciable improvement in the patient's functionality based on
use of appropriate pharmacotherapy.
Our article is an attempt to keep the vexing diagnosis of BPD in
the forefront of physicians' minds. It is well beyond our intent
to explore nuances of further evaluation and therapy. I agree with
Dr McFadden's implied assertion that patients with any Axis I or
II disorder will benefit if a mental health professional is an integral
part of the care team.
Reference
- Bolton S, Gunderson JG. Distinguishing borderline personality
disorder from bipolar disorder: differential diagnosis and implications.
Am J Psychiatry. 1996;153(9):1202-1207.
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