According to a report presented at the American Psychiatric Association meeting, borderline personality disorder may be underdiagnosed — at least initially.
In the presentation, David Meyerson of DePaul University in Chicago reported on an evaluation of lifetime diagnostic and treatment histories in patients eventually found to have the disorder.
The substantial lag in correct diagnosis frequently results in polypharmacy with medications that are not the most effective for the disorder.
“Diagnosing borderline personality disorder can be complicated and difficult because its symptoms overlap with other disorders,” Meyerson said.
In the study, done at Mount Sinai School of Medicine in New York, Dr. Meyerson and his colleagues found that 34 percent of patients given a psychiatric diagnosis before entry into the study had been given the wrong one or sometimes more than one.
- Explain to interested patients that borderline personality disorder can be a challenging diagnosis to make because of its close resemblance to or overlap with other psychiatric disorders.
- Note that this study was published as an abstract and presented orally at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
- The most common false-positive diagnoses were bipolar disorder (17%) and depression (13%), followed by anxiety disorders (10%) and eating disorders (1%).
Another challenge for diagnosis is that “in theory, two individuals could present with only one overlapping symptom and both meet criteria for borderline personality disorder,” he noted.
These criteria include at least five of the following:
- Efforts to avoid abandonment
- Unstable, intense interpersonal relationships
- Identity disturbance
- Mood instability
- Chronic emptiness
- Inappropriate, intense anger
- Paranoid ideation or dissociation
The study included 70 adults who met the criteria.
All had been given a diagnosis from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) in the past and had also seen a mental health professional in adulthood or been prescribed a psychotropic medication.
Yet, 74 percent of the patients who met the criteria for the condition had never been diagnosed with borderline personality disorder in the past, despite an average of 10.44 years since their first “psychiatric encounter.”
By comparison, an average 4.68 years had elapsed since the first mental health contact for the 26 percent who had been diagnosed with the disorder prior to study entry.
Meyerson noted that the study might have underestimated the rate of false-positive psychiatric diagnoses among borderline personality disorder patients, because it did not diagnose premenstrual dysphoric disorder or attention deficit hyperactivity disorder.
Other limitations included the retrospective design that relied on participants’ memories of diagnoses and treatment, lack of interviewer blinding, and small sample size.
But regardless of the exact rate, there were clear implications for treatment, Meyerson said.
The gold standard treatment for borderline personality disorder is behavioral therapy; medication only alleviates specific symptoms, Meyerson noted.
In the study, though, 69 percent of patients whose borderline personality disorder was not identified before had previously been treated with medications for other diagnoses. And 78 percent of those given an earlier diagnosis of the disorder were given medication, although that is “not the most effective treatment for borderline personality disorder,” he said.
A prior false-positive diagnosis was associated with even higher medication rates (P<0.05 for mean number of prescribed psychotropic drugs).
A correct diagnosis — vital for successful treatment — is more likely when psychiatrists use at least a semistructured clinical interview, Meyerson emphasized.
Another clue in making the differential diagnosis is the qualitative difference in impulsivity in borderline personality disorder (difficulty planning and thinking about consequences) compared with that in bipolar disorder (racing thoughts), he said.
Suicidality also shows differences in borderline personality disorder, such as more job- or health-related triggers than seen in major depressive disorder alone, Myerson added.
One important contributor to misdiagnosis is financial compensation, he noted.
Often patients will be officially diagnosed with another disorder, such as bipolar disorder, if the patient’s insurance company doesn’t reimburse for borderline personality disorder, he noted.
However, the study was unable to determine this or any other reason for misdiagnosis.
Source: American Psychiatric Association