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Differential diagnosis of borderline personality disorder from bipolar disorder.

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.

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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 et al., 2006), less familiarity with Axis II disorders (Paris, 2007), and the introduction of newer mood stabilizers and atypical antipsychotics (Moreno et al., 2007), to fears of decreased insurance reimbursement for treatment of an Axis II disorder (Gunderson et al., 2006). Whatever the reason, this trend may prevent clients who are better diagnosed as having a BPD from receiving optimal treatment (e.g., Paris, 2004).

Bipolar disorder and BPD represent distinct diagnostic constructs, and differential diagnosis is essential for helping clients obtain the best possible services. A BPD diagnosis, when appropriate, has heuristic value in directing counselors to interventions that are more likely to be effective than what is typically recommended for clients diagnosed with bipolar disorder. The purpose of this article is to explore the expansion of bipolar disorder in the psychiatric literature, present evidence for the validity of BPD, discuss strategies for differential diagnosis of the two types of disorder, review proposed changes in DSM-V, and integrate the research literature into a mental health counseling framework.

CHANGES IN DIAGNOSTIC PRACTICE

Both anecdotal reports and systematic research suggest a dramatic increase in the number of bipolar disorder diagnoses in both children and adults. For example, Blader and Carlson (2007) reviewed the records of children and adolescents in the National Hospital Discharge Survey from 1996 to 2004. The number discharged with bipolar disorder from participating hospitals increased from 1.4 per 10,000 in 1996 to 7.3 per 10,000 just six years later; the corresponding increase for adult discharges was from 10.4 per 10,000 to 16.2. Moreno et al. (2007) evaluated the increase in office-based visits for bipolar disorder in the National Ambulatory Care Survey between 1995-1996 and 2002-2003. The number of visits by children and adolescents increased nearly 4,000%, and the diagnoses for bipolar disorder in adults increased 186%. These numbers are surprising given the conservative estimates of bipolar disorder typical in epidemiological studies, which suggest that the disorder is relatively rare. For example, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000) reports the lifetime prevalence of bipolar I disorder to be between 0.4% and 1.6%, a rate comparable to what it reports for schizophrenia. Though more recent studies have found lifetime prevalence rates as high as 4% for bipolar I and II combined (Kessler et al., 2005), the discrepancy between the findings from epidemiological research and current diagnostic practices has yet to be explained.

Several explanations have been advanced for the increased prevalence, or at least diagnosis, of bipolar disorder. Moreno et al. (2007) hypothesized that the increase in diagnoses may be attributable to the availability of second-generation antipsychotics and newer mood stabilizers. Perhaps some physicians believe a diagnosis of bipolar disorder is necessary to justify use of these medications with clients who are emotionally unstable, aggressive, or impulsive. Another viewpoint attributes the increase to a paradigm shift in the literature. Carlson (1998) noted that the conceptualization of bipolar disorder has "expanded from being a disorder in which discrete episodes of mania, depression and euthymia with mood-congruent psychotic symptoms prevail, to a disorder where mixed states of affective dysregulation, mood-incongruent psychotic symptoms, and considerable comorbidity occur" (p. 178). This formulation has changed how many view not only bipolar disorder but also BPD.

MOOD OR PERSONALITY DISORDER

Hypothesized Bipolar Spectrum Several psychiatric researchers (Akiskal et al., 1989; Akiskal & Pinto, 1999; Ghaemi, Ko, & Goodwin, 2002; Perugi, Toni, Travierso, & Akiskal, 2003) have posited the existence of a bipolar spectrum that reaches well beyond the narrow descriptions of bipolar disorder in the most recent edition of the DSM-IV-TR (2000). In one of the more elaborate models, Akiskal and Pinto (1999) described a bipolar spectrum that incorporates seven subtypes: bipolar I (classic mania); bipolar I 1/2 (depression with persistent hypomania); bipolar II (depression interspersed with hypomania); bipolar II 1/2 (depression with briefer periods of hypomania); bipolar III (antidepressant-induced hypomania); bipolar III 1/2 (bipolarity associated with substance misuse); and bipolar IV (depression superimposed on a hyperthymic temperament). Perugi and Akiskal (2002) have also described a soft bipolar spectrum, or bipolar II spectrum, that includes not only disorders with strong affective components (e.g., atypical depression) but also some anxiety disorders (e.g., panic disorder), impulse control disorders, and personality disorders. The common denominator for this softer bipolar spectrum is an unstable temperament (cyclothymic-anxious-sensitive disposition) characterized by emotional instability, interpersonal sensitivity, anxiety, and impulsivity (Perugi & Akiskal, 2002). Though these researchers highlight personality factors in the etiology of bipolar spectrum disorders, they still emphasize the affective domain in both diagnosis and treatment.

More pertinent here, BPD has been identified as a candidate for this hypothesized bipolar spectrum (Akiskal et al., 1989; Smith, Muir, & Blackwood, 2004). Delito et al. (2001) described this position well when they wrote that "BPD is fundamentally an ultra-rapid cycling disorder" (p. 225). Spectrum proponents contend that a diagnosis of BPD is not only derogatory, it also prevents clients from receiving effective treatment. Perugi and Akiskal (2002) go so far as to assert that a BPD diagnosis is a "tragedy, because such a conceptualization robs 'borderline' patients from being considered as affectively ill" (p. 719). Their concern is that individuals so diagnosed will receive ineffective interventions, most commonly SSRIs, which will actually make their symptoms worse. Instead, they urge the use of newer mood stabilizers and atypical antipsychotics (Perugi & Akiskal, 2002; Perugi et al., 2003). Spectrum proponents rarely, if ever, recommend psychosocial interventions, whether case management or counseling. Consequently, clients who have been diagnosed with bipolar disorder rather than BPD may be relegated to a treatment plan that involves only brief contact with a physician for medication management (e.g., Paris, 2004).

Criticisms of the Bipolar Spectrum

Many mental health professionals reject this vast expansion of bipolar disorder. Not only is there no accepted definition of a bipolar spectrum, Patten (2006) pointed out, but its advocates "seem to imply that a large proportion of the population, including currently untreated people or people currently treated with antidepressants, should be managed instead with mood stabilizers" (p. 7).

Broadening bipolar disorder to cover a variety of mood, impulse-control, and personality disorders also creates serious psychometric problems. Vazquez and Tondo (2007) observe that "Excessive broadening of clinically popular concepts can weaken diagnostic precision, induce low levels of inter-rater reliability, and make difficult the construction of suitable diagnostic tools" (p. 174). For example, in addition to seven potential subtypes of bipolar disorder (Akiskal & Pinto, 1999), it is hypothesized that several anxiety, impulse control, and personality disorders also belong under the bipolar umbrella (Perugi & Akiskal, 2002). How will putting so many divergent clinical conditions on the bipolar spectrum improve research and treatment? One could just as easily argue that many of the disorders outlined in the DSM-IV-TR exist on a general psychopathology spectrum; researchers have consistently uncovered a high level of comorbidity among many DSM-IV-TR (2000) disorders as well as high covariance among the scales that comprise broadband personality tests, such as the MMPI-2 (e.g., Blaha, Merydith, Wallbrown, & Dowd, 2001).

For example, several studies have found that two general factors, anxiety and repression, underlie the validity and clinical scales of the MMPI/MMPI-2 (Graham, 2006). Yet, despite the tremendous overlap among symptoms and disorders, a solid case can be made for the value of recognizing related clinical conditions as separate diagnostic entities. Not only does specificity enhance communication among clinicians, it also benefits the treatment planning process. Many disorders currently listed in the DSM-IV-TR have been found to respond best to disorder-specific treatment (see Barlow, 2007).

Developmental Counseling Perspective

Although many work daily with clients who have been diagnosed with bipolar disorder and BPD, mental health counselors have not played a major role in this debate. One exception was a feminist critique of BPD by Hodges (2003), whose criticisms of the BPD diagnosis range from sexist applications, use of divergent polythetic criteria, and poor psychometric properties to use of the diagnosis to name-call difficult clients. She argued that many clients diagnosed with BPD would be better described as experiencing PTSD. However, her viewpoint suggests the awkward position of many counselors who work in the DSM-oriented mental health care system. To compete, they must adopt the DSM-IV-TR for diagnosis and treatment planning, though many disagree, to varying degrees, about the legitimacy of the medical model implicit in the DSM.

Compounding this problem, the counseling profession has no viable alternative to the DSM-IV-TR for categorizing clients who exhibit severe intrapersonal and interpersonal problems. Consider Hodges's recommendation (2003) for rebranding BPD as a variant of PTSD. She explicitly rejected the medical model of psychopathology and advocated instead a developmental view of client problems. Yet, lacking an alternative taxonomy, she ended up recommending that counselors replace one medically oriented mental disorder (BPD) with another, though less stigmatizing, one (PTSD).

While several developmental counseling models (e.g., Guterman, 1994; Ivey, 1989; Ivey & Ivey, 1998; Ivey & Rigazio-GiGillo, 1991) have been offered to guide practice and better differentiate counseling from other mental health disciplines, these models tend to be long on theorizing and short on scientific validation. The Ivey and Ivey Developmental Counseling and Therapy Model (1998) is the most comprehensive; it gives counselors a framework for client conceptualization and treatment planning. This model conceptualizes a client's problems, framed as developmental blocks, as the expected outcome of developmental history, personality style, and various systemic forces.

A major tenet in their model is the delineation of personality styles, which are positively framed analogues to the DSM-IV-TR's personality disorders. Ivey and Ivey (1998) described the borderline personality style as one in which an individual desires intensity in interpersonal relationships. Their recommendations for working with such clients are to "Confront engulfment and support individuation--that is, do the opposite; group/systems approaches are useful" (p. 338).

Neither their conceptualizations of these personality styles nor their recommendations for counseling have been validated through systematic research. In fact, the evidence for their model appears to be limited to theoretical deductions and the personal anecdotes from clinical practice (Ivey & Ivey, 1999). The Ivey and Ivey model is still at the conceptual stage of development; it does not connect counselors to empirically supported interventions that would likely be effective in working with clients with more severe mental health problems.

CONSTRUCT VALIDITY OF BORDERLINE PERSONALITY DISORDER

In contrast to the experimental bipolar spectrum or developmental conceptualizations, numerous studies have provided solid evidence for BPD as a valid diagnostic construct. As Bradley, Conklin, and Westen (2007) observed, "BPD is now the most highly researched PD and has the strongest evidence regarding its phenomenology, etiology, and treatment" (p. 171). Several studies support its multifaceted nature, arguing against its reclassification as a mood disorder. For example, Sanislow et al. (2002) conducted two factor analyses of the diagnostic criteria for BPD. The first evaluated a one-factor model that combined all nine symptoms. The second evaluated the fit of a three-factor model that has often emerged in the literature: (1) disturbed relatedness (unstable relationships, identity confusion, emptiness, stress-related paranoia); (2) behavioral dysregulation (impulsiveness, suicidality, self-mutilation); and (3) affective dysregulation (affective instability, inappropriate anger, avoidance of abandonment). They found the three-factor model to better fit the data.

Benazzi (2006) found that the diagnostic criteria for BPD had two orthogohal components. Component 1, affective instability, was characterized by high loadings on the symptoms of unstable mood, unstable interpersonal relationships, unstable self-image, feelings of emptiness, and anger. Component 2, impulsivity, was characterized by high loadings on impulsive behavior, suicidal behavior, fears of abandonment, and paranoid ideation. He suggested there might be two subtypes for BPD, one defined by affective instability, which may be associated with bipolar disorder, and the other characterized by impulsivity.

Researchers have also uncovered systematic differences between individuals with BPD and with bipolar I or II disorder, differences consistent with DSM-IV-TR criteria. Henry et al. (2001) found that the mood swings that those with bipolar II disorder experienced varied between euthymia, elation, and depression, whereas the mood changes experienced by those with BPD rotated between euthymia, anger, and anxiety. They found further that participants with BPD reported higher levels of impulsivity and aggression than those with bipolar II disorder. Similarly, Koenigsberg et al. (2002) found that the mood swings experienced by those with BPD involved changes between anxiety, depression, and anger, not switches from depression to mania, as in bipolar disorder. Wilson et al. (2007) found that individuals with BPD exhibited higher levels of impulsivity and hostility than those with bipolar II disorder. Finally, compared to those with bipolar disorder, individuals with BPD are also more likely to report problems with rage and parasuicidal behaviors (Gunderson et al., 2006).

Evidence for the validity of discriminating BPD from bipolar disorder can also be inferred from comorbidity and treatment studies. Paris et al. (2007) found that the median comorbidity between bipolar disorder and BPD in published studies was only 9%, and that bipolar disorder is no more likely to co-occur with BPD than with any other personality disorder. With regard to differential treatment responses, lithium has been found to be effective in treating bipolar I and II but not BPD. Furthermore, individuals with bipolar disorder have dissimilar responses from those with BPD to mood stabilizers and atypical antipsychotics. These medications help reduce impulsivity for individuals with BPD, whereas for those with bipolar disorder they reduce symptoms of mania and hypomania (e.g., Paris et al.). In another literature review, Dimeff, McDavid, and Linehan (1999) concluded that individuals with BPD respond inconsistently to pharmacotherapy, which makes it difficult to formulate medication recommendations or algorithms. In general, the literature provides evidence that BPD is more than just an episodic mood disorder, and that treatments that work well for bipolar disorder are not very effective in helping clients with BPD.

STRATEGIES FOR DIFFERENTIAL DIAGNOSIS

In the DSM-IV-TR, a diagnosis of BPD rather than bipolar disorder seems to boil down to how the emotional and behavioral instability exhibited by a client is conceptualized (Paris et al., 2007). Basically, a counselor must decide whether symptoms are best attributed to an acute mood disorder or they are just the latest manifestation of a more chronic problem. After ruling out a medical or pharmacological explanation, counselors should first evaluate the possibility that the emotional instability a new client exhibits occurs as part of a manic, hypomanic, or mixed episode (Magill, 2004). Because temporary personality changes may occur in the midst of a severe Axis I disorder, counselors should be very cautious about diagnosing BPD when clients are experiencing an acute mood disorder (Smith et al., 2004). A diagnosis of BPD, or for that matter any personality disorder, should be deferred until the counselor has completed a comprehensive assessment that will ideally include a diagnostic interview, psychosocial history, personality assessment, review of prior treatment records, and interviews with informants, if available.

In deciding whether a client's instability is more representative of a mood or a personality disorder, it is important to understand the fundamental differences between mood episodes and the personality construct of affective instability. The DSM-IV-TR (2000) defines a manic episode as an "abnormally and persistently elevated, expansive or irritable mood" present for at least one week, unless hospitalization is required, together with three additional symptoms, such as "inflated self-esteem or grandiosity, decreased need for sleep, pressure of speech, flight of ideas, distractibility, increased involvement in goal-directed activities or psychomotor agitation, and excessive involvement in pleasurable activities with a high potential for painful consequences" (p. 357). In ruling out a manic episode, a counselor should carefully evaluate both the nature and duration of the symptoms: Has the client experienced a demarcated episode of accelerated mood, almost resembling amphetamine intoxication, with such symptoms as decreased need for sleep, pressured speech, or grandiosity? Equally important, do the symptoms persist for at least a week, or does the client return to a normal emotional state within a few days, or even hours?

Ruling out an acute episode of mania should be relatively easy for the astute counselor. However, differential diagnosis becomes much more challenging when evaluating the possibility of rapid-cycling bipolar disorder or a mixed episode. The rapid-cycling specifier in the DSM-IV-TR has a very specific meaning that is often misunderstood. Rapid cycling does not refer to the phenomenon of emotional reactivity or the occurrence of many mood swings during a single day. Instead, this specifier is reserved to a diagnosis of bipolar disorder when an individual experiences at least four separate mood episodes in a calendar year. Technically, to count as a separate episode, symptoms of depression must persist for at least two weeks, symptoms of mania or mixed features for at least one week (unless hospitalization is required), and symptoms of hypomania for at least four days. Furthermore, mood changes "must be demarcated by either a period of full remission or by a switch to an episode of the opposite polarity" (DSM-IV-TR, 2000, p. 427). Technically, individuals who experience highly reactive moods or whose moods change often throughout the day are not experiencing rapid cycling bipolar disorder.

Ruling out a mixed episode poses the greatest challenge in differentiating BPD from bipolar disorder. Mixed episodes occur when an individual meets the diagnostic criteria for both manic and depressive episodes for at least one week. According to the DSM-IV-TR (2000), "The individual experiences rapidly alternating moods (sadness, irritability, euphoria) accompanied by symptoms of a Manic Episode... and a Major Depressive Episode" (p. 362). If there is no accurate historical record, it is nearly impossible to differentiate a mixed episode from the chronic anger and dysphoria common to those with BPD (Benazzi, 2008). For example, mixed episodes tend to be characterized by severe mood lability, agitation, irritability, increased psychomotor activity, cognitive impairment, and comorbid substance use (Gonzalez-Pinto, Aldama, Mosquera, & Gomez, 2007), symptoms that are also common in BPD. Mixed episodes are quite common, experienced by some 30-40% of those diagnosed with bipolar disorder (McElroy et al., 1992). Delito et al. (2001) hypothesized that many diagnosed with BPD may actually be experiencing chronic mixed episodes.

Before settling on a diagnosis of bipolar disorder, a counselor should evaluate whether a client's problems with emotional instability are better explained by the personality construct of affective instability than by references to manic, hypomanic, or mixed episodes. In contrast to an acute mood episode, affective instability describes a propensity to become irritable, depressed, aggressive, or anxious in response to environmental events. Siever and Davis (1991) defined affective instability as "a predisposition to marked rapidly reversible shifts in affective state that are extremely sensitive to meaningful environmental events which might induce more modest emotional responses in other people, such as separation, frustration of expectations, or criticism" (p. 1651). As explained by Bradley et al. (2007), the emotional instability those with BPD experience "comprises a tendency for emotions to spiral out of control, a tendency to become irrational under stress, and a dependence on others to regulate emotions" (p. 174). Unlike mood episodes, these emotional outbursts typically last less than a day (DSM-IV-TR, 2000). Of course, during a manic or mixed episode, individuals may also have extreme reactions to events, but by definition their mood difficulties must persist for a sustained period.

The differential diagnostic process should include careful consideration of the differences between an acute mood disorder and a more chronic and pervasive personality disorder. A mood disorder is differentiated by discrete episodes of mania, hypomania, or depression that persist for specified periods. Though individuals in the midst of a mood episode may experience problems beyond the affective domain, these problems may be secondary to the mood disorder and are not required for a diagnosis. In contrast, a personality disorder is characterized by persistent and inflexible patterns of maladaptive behavior and intrapersonal experience that impact multiple areas of functioning. Emotional instability, in isolation, is not sufficient to support a BPD diagnosis; to qualify, an individual must exhibit four additional symptoms from the following list: abandonment fears, chaotic interpersonal relationships, feelings of emptiness, identity disturbance, impulsivity, parasuicidal behavior, anger control problems, and transient cognitive impairment, such as brief psychosis or dissociation (DSM-IV-TR, 2000). Additional personality features common among those with BPD are sensation-seeking, splitting, rejection sensitivity, superficial psychological health, self-defeating behavior, and high levels of neuroticism (DSM-IV-TR, 2000; Maxmen & Ward, 1995). Just as important is an awareness of the consistency and longitudinal nature of personality disorders. Though remission does often occur, symptoms of personality impairment typically begin in adolescence or early adulthood, and personality disorders, or at least subthreshold symptoms, may persist for years or even decades (DSM-IV-TR, 2000; Fowler, O'Donohue, & Lilienfeld, 2007; McGlashan et al., 2005).

Besides understanding the fundamental differences between BPD and bipolar disorder, counselors must also work through the stigma that has become attached to the borderline label. This stigma is one factor behind the arguments for placing BPD on a bipolar spectrum (Akiskal et al., 1989) or PTSD (Hodges, 2003). Yet, as Linehan pointed out (1993), giving clients with BPD a different diagnosis will not magically make negative attitudes and prejudices go away. In fact, if the current diagnostic trend continues, bipolar disorder may eventually acquire all the prejudices currently associated with BPD. According to Linehan, what will really benefit these clients is not a name change but increased empathy for their pain and a better understanding of how to treat BPD.

IMPLICATIONS OF DIFFERENTIAL DIAGNOSIS FOR TREATMENT

Distinguishing between BPD and bipolar disorder is not just an esoteric issue for psychopathology researchers; it is of great consequence for front-line counselors who must for devise and implement treatment plans. While both sides of the debate agree that accurate diagnosis is essential for effective treatment, they disagree as to how symptoms of emotional and behavioral instability should be formally diagnosed and then treated. Those who consider BPD to be a variant of bipolar disorder contend that treatment should proceed with mood stabilizers and atypical antipsychotics (Perugi & Akiskal, 2002); those (e.g., Paris, 2004) on the other side of the debate recommend an intensive psychotherapy model, such as dialectical behavior therapy (Linehan, 1993).

All too often, a diagnosis of bipolar disorder limits treatment options to psychoactive medications, which as mentioned tend to be minimally effective in helping clients with BPD (Dimeff et al., 1999). An appropriate diagnosis of BPD has heuristic value in directing counselors to intervention strategies that are more likely to be effective than what is typically recommended for bipolar disorder. There is now evidence that both intensive psychoanalytic therapy (Bateman & Fonagy, 1991, 2001, 2008) and dialectical behavior therapy (DBT; Linehan, 1993) are effective in helping clients with BPD. The latter, which has stronger empirical support, is a creative mixture of cognitive-behavioral therapy, Zen Buddhism, and dialectical philosophy. The formal program for DBT lasts about a year and includes both individual and group therapy.

Numerous studies have found DBT to be effective in treating BPD symptoms (Ben-Porath, Peterson, & Smee, 2004; Brassington & Krawitz, 2006; Harley, Baity, Blais, & Jacob, 2007; Kroger et al., 2006; Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Turner, 2000) as well as such comorbid problems as substance use disorders (Harned et al., 2008; Linehan et al., 1999) and eating disorders (Chen, Matthews, Allen, Kuo, & Linehan, 2008; Palmer et al., 2003). Studies have also documented the enduring benefits of DBT after formal treatment ends (Linehan et al., 2006). Though most of this research evaluated the effectiveness of DBT with adult females, there is evidence that it is also effective with adolescents (Goldstein, Axelson, Birmaher, & Brent, 2007; Miller, Wyman, Huppert, Glassman, & Rathus, 2000; Rathus & Miller, 2002) and men (Evershed et al., 2003). In 1998, Division 12 of the American Psychological Association recognized DBT as a probably efficacious treatment for BPD (Chambless et al., 1998), and the American Psychiatric Association recommended DBT in its practice guidelines for BPD (American Psychiatric Association, 2004).

Furthermore, the theoretical tenets underlying DBT are compatible with a developmental counseling perspective. According to Linehan (1993), BPD represents a fundamental impairment in an individual's capacity for emotional regulation that results from the reciprocal influence of a genetic vulnerability to emotional dysregulation coupled with an invalidating environment. In other words, this model contends that BPD emerges when an emotionally vulnerable individual encounters repeated invalidation from caregivers, peers, and systemic forces. Furthermore, the goals of DBT are not limited to remediation of psychopathology; they include helping clients achieve normal emotional experiencing, accept what cannot be changed, increase autonomy and self-reliance, improve behavioral skills, and enhance spiritual growth, as well as helping clients achieve what Linehan calls a "life worth living." Besides being an effective treatment for borderline personality disorder, DBT also gives counselors a conceptual bridge for integrating a developmental counseling perspective with an empirically supported model for treating BPD.

POTENTIAL CHANGES IN DSM-V

The BPD debate is actually a microcosm of what is occurring generally in psychiatry about the nature of Axis I and Axis II disorders. Though Axis II was developed to encourage clinicians to consider more enduring personality characteristics that may impact treatment, as Fowler et al. (2007) pointed out, some Axis I disorders are actually more chronic than many Axis II disorders, which are more likely to remit than is commonly believed. For the DSM-V now being drafted, proposals have been made to either eliminate personality disorders altogether or integrate theme into Axis I. In that scenario BDP might be reclassified as a mood or impulse control disorder (Widiger, 2007).

Even those who accept BPD as a valid diagnosis have criticized how it has been defined in the latest editions of the DSM. Several proposals have been made to change the diagnostic criteria for BPD to better emphasize the disorder's most salient features. For example, McGlashan et al. (2005) evaluated the stability of personality disorder symptoms over a two-year period in 474 participants involved in the Collaborative Longitudinal Personality Disorders Study. Among participants with BPD, the authors found that affective instability, anger, and impulsivity were most likely to persist, and abandonment fears, identity confusion, and self-harm were most likely to decline. They suggested that the former set of symptoms be retained and emphasized in the DSM-V. Conklin and Westen (2005) asked psychiatrists and psychologists to rate patients recently diagnosed with BPD. Based on the results, they recommended that the criterion set for BPD in the DSM-V focus more on severe dysphoria, anxiety, emotional dysregulation, and poor coping skills.

Others have argued that tweaking the diagnostic criteria is not enough; what is really needed is a major overhaul of how personality disorders are classified. The DSM-V work groups are seriously contemplating an approach that would classify personality disorders in four or five general domains or factors (Widiger, Simonsen, Krueger, Livesley, & Verheul, 2005). Like the five-factor model of personality, a dimensional system that recurs in the literature consists of four domains/factors: neuroticism, extraversion/positive emotionality, agreeableness, and conscientiousness (Trull, Tragesser, Solhan, & Schwartz-Mette, 2007). As an alternative, Westen and Shedler (2000) have proposed a prototype matching model for the DSM-V based on their analyses of the SWAP-200, a 200-item Q-sort inventory that measures personality dysfunction. They suggest seven Q-factors: dysphoric, antisocial-psychopathic, schizoid, paranoid, obsessional, histrionic, and narcissistic. In their proposed model, a client would be rated on each factor or prototype, and then the factor scores could be treated dimensionally or formulated into a categorical assessment.

Though there may be major changes in how personality disorders are organized in the DSM-V, it is unlikely that BPD will disappear as a diagnostic entity. The concept of a borderline personality existed for decades before it was formally recognized in the DSM-III, the first edition of the DSM to officially recognize personality disorders (Bradley et al., 2007), and it will likely continue, in one form or another, in the fifth edition.

IMPLICATIONS FOR MENTAL HEALTH COUNSELORS

Unfortunately, the counseling profession has not had much impact on either the development or the revisions of the DSM. One reason is the lack of counselor-generated research on conditions covered by the DSM. DSM revisions are heavily influenced by published research and field trials, and if the counseling profession hopes to have more impact, this is where it needs to direct its efforts.

Another impediment to counselor participation in the DSM system is more philosophical: Some counselors, like Ivey and Ivey (1998), have argued that the DSM's medical model is unsuitable for the counseling profession's more positive developmental framework. Yet even Ivey and Ivey (1999) have conceded that counselors should be trained in the DSM and competent in its use. The counseling profession would be well served by avoiding a false dichotomy between use of the DSM-IV-TR and a developmental counseling perspective. As Hinkle (1999) pointed out, counselors can use the DSM for diagnosis and treatment planning without subscribing to any medical model:
 The DSM does follow a medical model--if you are a medical
 practitioner. If you are a counselor, the DSM may not be a manual
 of diseases, but simply a description of harmful behaviors,
 dysfunctions, mental disorders, developmental roadblocks, or
 whatever one chooses to call them. (p. 477)


Even some who drafted DSM-IV-TR acknowledged that the conceptualization of mental disorders was arbitrary: "Most, if not all, mental disorders are better conceived as no more than (but also no less than) valuable heuristic constructs" (Frist, Frances, & Pincus, 2004; p. 12). A diagnosis of BPD, or any other mental disorder, is just a short-hand way to summarize a client's problems, communicate with other professionals and third-party payers, and identify interventions likely to be effective for clients with similar problems.

One of the defining features of counselor education is training students to work effectively with clients experiencing both developmental challenges and mental disorders. Because of the plethora of clients with whom counselors work, Hinkle (1999) argued that they should not be limited to a single developmental perspective: "Development is one of the distinguishing emphases of our profession, but it cannot stand alone after a century of applying and modifying psychological, counseling, and medical knowledge and techniques that are known to be effective" (p. 481). Many conditions listed in DSM-IV-TR (2000), such as schizophrenia and dementia, have strong biological correlates, and are probably best understood using a medical model. Yet that should in no way prevent counselors from considering these clients' strengths, developmental histories, or systemic forces that affect how their problems are manifested and treated. In contrast, other conditions (e.g., adjustment disorders and V-codes) are probably best conceptualized from a developmental point of view. For example, a sibling relational problem (V61.8) certainly does not represent a biological dysfunction. Outside these two extremes, many of the disorders in the DSM (e.g., major depressive disorder, personality disorders, or conduct disorder) do not fit neatly into either a developmental or medical-model perspective. Rather than forcing clients into a particular theoretical model, we should adjust our models to fit their uniqueness.

Just as important, our counseling models and intervention strategies should be informed by the best available research, whether published in counseling journals or other outlets. There is evidence for the validity of BPD as a condition distinct from bipolar disorder (e.g., Paris, 2004). Consequently, counselors should make this diagnosis confidently after a conscientious process of assessment. The outcome of this process has important implications for our clients and for treatment planning. Bipolar disorder is thought to be best treated with medication, principally mood stabilizers and atypical antipsychotics; counseling or psychotherapy is thought of as an adjunct treatment (e.g., American Psychiatric Association, 2004). For clients diagnosed with BPD, however, therapy is considered to be the primary and pharmacotherapy the adjunct treatment (American Psychiatric Association; Dimeff et al., 1999). Two therapy models have been shown to be effective in helping clients diagnosed with BPD, the psychodynamic model (Bateman & Fonagy, 1991) and DBT (Linehan, 1993). Of the two, DBT has the strongest empirical support and should be the intervention of choice for counselors willing to work with these challenging clients.

REFERENCES

Akiskal, H. S., Cassano, G. B., Musetti, L., Perugi, G., Tundo, A., & Mignani, V. (1989). Psychopathology, temperament, and past course in primary major depressions: Review of evidence for a bipolar spectrum. Psychopathology, 22, 268-277.

Akiskal, H. S., & Pinto, O. (1999). The evolving bipolar spectrum: Prototypes I, II, III, and IV. The Psychiatric Clinics of North America, 22, 517-534.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.

American Psychiatric Association. (2004). Practice guidelines for the treatment of psychiatric disorders (2004 Compendium). Washington, DC: Author.

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Gregory T. Hatchett is affiliated with Northern Kentucky University. Correspondence concerning this article should be addressed to Gregory Hatchett, Department of Counseling, Social Work, & Leadership, BEP 203E, Northern Kentucky University, Highland Heights, Ky 41099. E-mail: hatchettg@nku.edu.
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Title Annotation:PROFESSIONAL EXCHANGE
Author:Hatchett, Gregory T.
Publication:Journal of Mental Health Counseling
Date:Jul 1, 2010
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