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European Psychiatry
journal homepage: http://www.europsy-journal.com
Original article
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 16 July 2015
Received in revised form 1st September 2015
Accepted 5 September 2015
Available online 21 October 2015
Background: Diagnosing mental illness is a central role for psychiatrists. Correct diagnosis informs both
treatment and prognosis, and facilitates accurate communication. We sought to explore how
psychiatrists distinguished two common psychiatric diagnoses: bipolar disorder (BD) and borderline
personality disorder (BPD).
Methods: We conducted a qualitative study of psychiatrists to explore their practical experience. We then
sought to validate these results by conducting a questionnaire study testing the theoretical knowledge
and practical experience of a large number of UK psychiatrists. Finally we studied the assessment process
in NHS psychiatric teams by analysing GP letters, assessments by psychiatrists, and assessment letters.
Results: There was broad agreement in both the qualitative and questionnaire studies that the two
diagnoses can be difcult to distinguish. The majority of psychiatrists demonstrated in survey responses
a comprehensive understanding DSM-IV-TR criteria although many felt that these criteria did not
necessarily assist diagnostic differentiation. This scepticism about diagnostic criteria appeared to
strongly inuence clinical practice in the sample of clinicians we observed. In only a minority of
assessments were symptoms of mania or BPD sufciently assessed to establish the presence or absence
of each diagnosis.
Conclusion: Clinical diagnostic practice was not adequate to differentiate reliably BD and BPD. The
absence of reliable diagnostic practice has widespread implications for patient care, service provision
and the reliability of clinical case registries.
2015 Elsevier Masson SAS. All rights reserved.
Keywords:
Mania and bipolar disorder
Borderline personality disorder
Psychiatry in Europe
Psychiatric assessments
1. Introduction
Both borderline personality disorder and broadly dened
bipolar disorder are common psychiatric diagnoses in the adult
population with similar prevalences of 16% [4,13,17,21,23]. The
two are commonly comorbid [9,11,19] with comorbidity as high as
50.1% of those with bipolar-1 [17], indicating an association well
beyond chance. However, patients with BPD are deemed to require
psychological treatments where medication plays a minor role
[25], whereas those with BD generally require complex medication
and didactic help with self-management [26]. Prognosis is also
very different: 73% of BPD may have remitted in 6 years [45] whilst
BD is usually a life-long relapsing condition [3].
Therefore, psychiatric diagnosis matters as a pragmatic tool for
informing treatment, communicating about patterns in psychiatric
illness, development of appropriate services, and allocation of
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Table 1
Clinician characteristics of 32 clinicians who participated in qualitative interviews.
Male
Female
Total
16
16
32
39.1
39.4
39.3
Medical qualication
16
10
26 (81%)
MRCPsych
15
23 (72%)
CMHT
13
20 (63%)
5 (16%)
Self-harm team
2 (6%)
Psychotherapy/therapeutic community
5 (16%)
Specialist training
Bipolar
Borderline
Both
1
1
0
1
3
3
2 (6%)
4 (13%)
3 (9%)
cases (n = 24), assessments with patients referred for the assessment of mood instability were observed and/or audio-recorded.
2.1.3. Interviews
Clinician interviews were conducted using a topic schedule and
were audio-recorded (for full topic schedule and more information
about qualitative interviews see Supplementary material). Interviews varied in length from 20 to 100 minutes. Some clinicians
completed multiple interviews when patients had multiple
assessments or when clinicians assessed more than one patient
meeting the inclusion criteria, resulting in a total of 38 clinician
interviews of 32 unique clinicians who had assessed 32 patients.
2.1.4. Data analysis
Quantitative data were summarized using standard statistical
approaches; qualitative data coding, management and analysis
were conducted using NVivo software [29]. Semi-structured
interviews were conducted as part of an on-going and iterative
process of data collection and analysis. Audiotaped interviews
were transcribed, reviewed, and uploaded to NVivo. Qualitative
analysis used a framework technique [32]. Data gathering ceased
when understanding of the experience of clinicians in assessing
and diagnosing in patients with mood instability was no longer
being advanced. To reduce researcher bias, we discussed and
maintained an awareness of preconceptions (facilitated by
interviewer note-keeping and memos) and constantly linked the
emerging thematic framework to clinician-derived data.
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focus for treatment (Box 2). A few clinicians suggested that BD and
BPD were on a continuum.
2.2.3. Use of the diagnostic criteria
While most clinicians stated that the diagnostic features were
helpful in distinguishing the two diagnoses, many of the
presenting features were felt to lack specicity to BD or BPD
(Box 3). Most clinicians felt that limiting assessment to the
diagnostic checklists would lead to incorrect diagnoses being
made, and they emphasized the importance of clinical judgement
and impressionistic approaches.
2.2.4. Other features distinguishing the diagnoses
Many clinicians felt that the nature of the clinician-patient
relationship during the clinical assessment was an important
inuence on their diagnostic decision-making (Box 4). This was
particularly the case with BPD, where hostility and assuming a
childlike relational position were felt to be indicative. Early abusive
experiences and attachment difculties were frequently reported
as more relevant to BPD.
2.2.5. Other non-clinical factors inuencing diagnosis
Several factors unrelated to the clinical presentation or
management were cited as inuencing diagnostic decisions (Box
5). These included systemic factors relating to healthcare targets
and funding. Other clinicians viewed BPD as a diagnosis which was
used when patients difculties did not conform to any specic
mood disorder. The time constraints placed upon clinicians and the
increasing use of diagnosis to manage costs and access to care were
viewed as important external pressures.
2.2.6. Stigma
The perceived stigma associated with BPD was often cited by
clinicians as a reason to avoid giving patients this diagnosis (Box 6).
By contrast, BD was seen by clinicians as a more acceptable
diagnosis for patients.
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969
970
Fig. 1. Proportion of diagnostic criteria for depression addressed in GP referral letters, assessment, and psychiatrist letters.
Fig. 2. Proportion of diagnostic criteria for mania addressed in GP referral letters, assessment, and psychiatrist letters.
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Fig. 3. Proportion of diagnostic criteria for borderline personality disorder addressed in GP referral letters, assessment, and psychiatrist letters.
5. Discussion
To our knowledge, this is the rst study to explore the views,
experience and clinical practice of clinicians attempting to
distinguish BD and BPD. There was broad agreement in both the
qualitative and questionnaire studies that the two diagnoses can
be difcult to distinguish from one another, and that this
differential diagnosis can be a source of disagreement amongst
clinical staff. The majority of psychiatrists demonstrated a
comprehensive understanding of the criteria recommended in
Table 2
Proportion of depressive symptoms recorded when all sources (n = 30 referrals)
examined.
Depression
Depressed mood
93
Anhedonia
67
70
27
33
27
Insomnia or hypersomnia
Initial insomnia
Middle insomnia
Early morning wakening
Hypersomnia
47
33
20
70
7
3
77
73
Table 3
Proportion of manic symptoms recorded when all sources examined.
Mania/hypomania
57
53
87
43
20
23
Distractibility
Diminished ability to think or concentrate, or indecisiveness
50
90
27
30
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Table 4
Diagnoses given by psychiatrists together with the number of symptoms explored in assessments and described in GP letters.
Diagnosis given
Bipolar disorder
Borderline personality disorder
Bipolar disorder and borderline
personality disorder
Major depressive disorder
Cyclothymia
PTSD
No diagnosis given
No assessment letter written
a
b
Depression
Mania
BPD
Depression
Mania
BPD
5
4
1
5.5 (2)
3.0 (1)
N/Ab
6.0 (1)
3.5 (0)
N/Ab
3.0 (1)
5.5 (1)
N/Ab
4.4
3.4
4
2.80
2.6
7
0.0
2.8
5
10
1
1
6
2
4.5 (2)
3.0 (0)
N/Ab
5.5 (3)
7.0 (2)
3.0 (2)
5.0 (1)
N/Ab
4 (1)
7.0 (2)
2.5 (1)
4.0 (0)
N/Ab
1.5 (0)
4.0 (1)
5.2
3.0
6.0
3.67
N/A
4.7
4.0
6.0
3.0
N/A
1.8
1.0
2.0
0.83
N/A
This is the number of assessments where adequate symptoms were explored to make a diagnosis.
This assessment was not recorded.
Table 5
ICD-10 diagnoses generated by OPCRIT.
ICD-10 diagnosis
Bipolar disordera
Major depressive disorder
Non-organic psychotic syndrome
PTSD
Agoraphobia
Social phobia
Harmful use of alcohol
Alcohol dependence
Harmful use of cannabis
Cannabis dependence
Substance misuse disorder
Other personality disorders
No diagnosis
a
Clinical diagnosis
Bipolar
disorder
Borderline
personality
disorder
Major
depressive
disorder
Cyclothymia
PTSD
Number of
diagnosis
given
Number of
assessment
letter
3
1
1
0
0
0
0
0
0
0
0
1
1
1
2
2
0
0
0
0
2
0
0
1
2
0
0
1
3
2
1
1
0
3
1
1
0
1
2
0
0
1
0
0
0
0
0
0
0
0
0
0
1
1
1
0
0
0
1
0
1
0
0
0
1
0
0
2
0
0
0
0
0
0
0
0
0
0
1
0
0
1
0
0
0
0
0
0
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