Borderline, Bipolar, or Both?

Abstract

Of all of the diagnostic dilemmas that confront psychiatry today, the resolution of the controversy surrounding the interrelationship of borderline personality disorder (BPD) and bipolar disorder is an especially vehement one. The controversy goes, indeed, to the heart of modern psychiatry, reflecting its quest to find diagnostic schema that have clinical utility and that also map correctly, and with some real precision, to brain function. With recent advances in the cognitive neurosciences, functional neuroimaging, and molecular neurogenetics, we are finally poised to identify and elaborate such diagnostic schema. 1‐4 And as noted in the articles on both sides of this Clinical Controversy—one by Joel Paris and the other by Daniel Smith and his colleagues—doing so is vitally important with regard to BPD and bipolar disorder because of their prevalence and high morbidity. In order to savor fully the challenge that these authors face, it is necessary to understand the historical context in which the relevant issues arise. Traditionally in personality research, there have been deep, systematic divisions between the psychodynamically and somatically oriented theoretical camps. Some psychodynamically oriented practitioners view the encroaching observations of the neurosciences as a kind of Trojan horse. The pleasing offering, the promise of an etiological explanation and efficacious somatic intervention, belies the true agenda of the neurosciences: to purge the field of personal narrative. Some somatically oriented practitioners belittle efforts to identify systematically the environmental antecedents and catalysts that shape behavior, characterizing those efforts as a hollow pursuit that places an arbitrary, post hoc meaning upon deterministic,