Primary Care PAs: Diagnosing Borderline Personality Disorder vs. Bipolar Disorder

Primary Care PAs are at an intersection between shorter, problem-focused appointments and caring for complex mental health needs. Psychiatric providers and psychological/therapy-based providers are at a premium. These specialized providers often have waitlists, only accept cash pay or any number of other factors that are barriers to accessing care. I have yet to meet a primary care PA who has enough mental health providers they can easily refer to.  

When a patient presents, and you see instability in personal life or employment, changes from prior appointments, or generally get a “red flag” feeling, you should add borderline personality disorder or bipolar disorder to the differential. Of course, it might be a change in the thyroid, leading to insomnia, but it could also be bipolar.  

One main takeaway from this article is how to do the initial screening. Primary care should not have the burden of diagnosing complex mental health conditions. Diagnosing these conditions and teasing out nuances of personality disorders…. often takes multiple hour-long meetings. This isn’t an insult to the ability of primary care providers but more to the nature of shorter appointments.  

So let’s discuss how you can screen and how you might speak with a patient who you feel needs workup. Also of note: BPD is the abbreviation for Borderline Personality Disorder. BPAD is an affective mood disorder. They are very close abbreviations, but note the difference; BPD (borderline) vs. BPAD (affect/mood).

Borderline Personality Disorder

We all know these patients. Patients that are just changing, unstable, and present with many somatic concerns, yet no medication or treatment presents a solution. When I was a correctional social worker, I had a client who made me want to pull my hair out. He never followed through with plans, complained about not making progress, and had so many problems in his personal life it was no wonder mental health treatment wasn’t helping. My supervisor then candidly told me, “Clients that make you feel like you’re crazy, make you second guess your ability to treat, and generally drive you batty…you should always think about the possibility of borderline.” And I keep that unofficial screening in my pocket….but of course, that isn’t really how we describe the disorder or make a diagnosis.  

Exploring the Diagnosis of BPD  

Borderline Personality Disorder (BPD) is a complex and challenging mental health condition that is characterized by a pervasive pattern of instability in relationships, self-image, emotions, and behavior. The disorder typically manifests in early adulthood and can cause significant distress and impairment in social, occupational, and other areas of functioning.

There are several key traits or symptoms associated with BPD. One of the primary features of BPD is emotional dysregulation, which can manifest as intense and unstable emotions, rapid mood swings, and difficulty managing stress. Individuals with BPD may also experience chronic emptiness and have a distorted sense of self-identity.

Diagnosing Borderline Personality in PC

Borderline personality disorder (BPD) can be challenging to diagnose. As a medical professional, it’s essential to understand the criteria for diagnosing BPD and the challenges that can arise in the diagnostic process. 

The diagnosis of BPD is based on a comprehensive clinical evaluation that includes a detailed history and a mental status examination. The DSM-5 criteria for BPD include the following:

1. Frantic efforts to avoid real or imagined abandonment
2. A pattern of unstable and intense interpersonal relationships
3. Impulsivity in at least two areas that are potentially self-damaging
4. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior
5. Emotional instability is the reactivity of mood
6. Chronic feelings of emptiness
7. Inappropriate, intense anger or difficulty controlling anger
8. Transient, stress-related paranoid ideation or severe dissociative symptoms.

The diagnostic process can be complicated because many individuals with BPD also have co-occurring conditions, such as depression or substance abuse, which can mask or mimic the symptoms of BPD. Additionally, individuals with BPD may have difficulty accurately recognizing and reporting their symptoms. I have found that some patients are very open to the diagnosis of BPD; “Oh, that explains so much.” or “Ok, I have a diagnosis finally…Now I can work on treatment.” There is a flip side to that coin, “You don’t believe me that something is wrong, you don’t want to deal with me.” or “So you’re saying I’m crazy.” I hear many patients say, “My mom had borderline, and I’m nothing like her.” As a primary care provider, you can explain that it’s a possible diagnosis and it should be explored with a mental health specialist. So don’t discount the role the patient takes in the diagnostic process.  

To accurately diagnose BPD, it’s essential to have a thorough understanding of the criteria and to take a comprehensive and patient-centered approach to evaluation. A multidisciplinary team that includes mental health professionals, primary care physicians, and social workers may help make an accurate diagnosis and develop a comprehensive treatment plan. By understanding the criteria for BPD and taking a patient-centered approach, medical professionals can improve the accuracy of diagnosis and provide appropriate and effective treatment for individuals with this challenging condition.

Screening Tools for Borderline Personality Disorder

There is no single screening tool that can definitively diagnose BPD. That being said, several screening tools can help identify individuals who may be at risk for BPD or who may benefit from further evaluation by a mental health professional. These screening tools include:

1. Personality Assessment Inventory – Borderline Features (PAI-BOR): This is a self-report questionnaire that assesses for features commonly associated with BPD, such as emotional instability, impulsive behavior, and self-harm.
2. McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD): This is a brief self-report questionnaire that assesses for symptoms of BPD, including emotional instability, impulsivity, and identity disturbance.
3. Borderline Symptom List-23 (BSL-23): This is a self-report questionnaire that assesses for a range of BPD symptoms, including emotional dysregulation, self-harm, and disturbed interpersonal relationships.

These can be given by the nurse/MA prior to the appointment and then discussed while providing the referral.  

Keep in mind one difficulty in screening for BPD is the possibility of an underlying mood disorder. So let’s think about how this might play out. Pt might have:

1. Borderline Personality DO 
2. Borderline PD AND Bipolar Disorder
3. Bipolar disorder type I or type II.
4. Any of the above WITH a somatic concern.  

That is a lot…amiright?  

BPAD In Contrast to BPAD; and How To Screen For BPAD

I love the Mood Disorder Questionnaire (MDQ) for screening for bipolar disorder. This easy-to-fill-out questionnaire helps you to know, “Should I continue to explore the possibility of Bipolar.” It can also screen unipolar depression from possible bipolar depressive episodes.  

Using MDQ in Primary Care

The MDQ is a self-administered questionnaire that can be completed by the patient in the waiting room or during an appointment. It consists of a series of questions addressing symptoms of mania and depression. The MDQ is a quick and easy-to-use tool that can provide valuable information for doctors. Using the MDQ can improve patient outcomes by providing a more accurate diagnosis and tailored treatment plan. If a patient scores positively on the MDQ, following up with a thorough diagnostic evaluation is essential.  

By googling MDQ, you can easily find a pdf copy of this evaluation; it is tested, validated, and available for free for general use. I encourage you to add it to your practice!

Patients presenting with instability

We don’t always know the underlying reason for instability…but as medical providers, we often get a sense of the red flags. Our “spidey sense” can tell us if this issue needs to be explored. I encourage you to refer these patients to mental health professionals..its absolutely necessary in providing thorough primary care!