Bipolar Disorder Often Diagnosed Without Evidence in Patients With NPD and BPD

(Part 1 of 3)

James A. Jenkins, MD, staff psychiatrist, Emerson Hospital, Concord, Massachusetts, talks with Psych Congress Network's Senior Digital Managing Editor, Heather Flint, about the differences between narcissistic personality disorders and borderline personality disorder and how these 2 disorders often get misdiagnosed as bipolar disorder despite a lack of evidence to support the diagnosis.

In the upcoming parts 2 and 3, Dr Jenkins, who recently gave a session titled "Narcissistic personality disorder: where we are and where we are going" at Psych Congress 2021 in San Antonio, Texas, explores comorbid mood disorders, the impact of substance use disorders, and tips for clinicians who are diagnosing these disorders.

Read the transcript:

Flint:  Hello, Psych Congress Network. We are sitting here with Dr James Jenkins. We're going to discuss some topics about narcissistic personality disorder today. Dr Jenkins, if you'd like to introduce yourself to our audience.

Dr James Jenkins:  Hi, I'm Dr Jenkins. I'm a psychiatrist in the Boston area. I do primarily inpatient psychiatry work right now. I've also worked in a number of programs for the treatment of severe personality disorders and complex psychopathology, including at Mass General Hospital and McLean Hospital.

Flint:  Thank you. I want to start off today with talking about the differences between narcissistic personality disorder (NPD) and borderline personality disorder (BPD).

Dr Jenkins:  This is a really good question. It's also a really hard one to answer because the reality is that there's a lot of comorbidity and overlap, not just between those two personality disorders, but between all personality disorders.

We think of personality disorders as if the people who are narcissistic or have NPD only have NPD, and the people who have BPD only have BPD. The reality is about 80% of people who are diagnosed with one disorder will have the other disorder as well. That being said, there are some differences between the two diagnoses.

People who have borderline personality disorder tend to be more, what we would call, affiliative. They have more of a desire for closeness, intimacy, and relationships with other people.

The problem is that that ends up being very painful for them. They have this really high sensitivity to pre-perceiving rejection and abandonment. They're, what we would call, interpersonally hypersensitive. People who are narcissistic, on the other hand, they tend to not have as much of a drive or motivation to be connected to other people.

In fact, when we look at the specific traits of a personality, because we have tons and tons and years of experience during research studies of breaking personalities down into specific traits, we find that people who have NPD are a little bit more antagonistic than some of the other personality disorders.

For people with NPD, the difficulties that they have, have more to do with regulating their self-esteem. A healthy person can regulate their self-esteem without having to completely rely on the environment around them or completely rely on validation, praise, admiration, or things coming externally.

For people who have NPD, they just can't seem to do that. They have these wild fluctuations in self-esteem that end up resulting. There's some similarities between them, but there are also many differences.

Flint:  Do you find that people often misdiagnose and confuse the two disorders?

Dr Jenkins:  Yes. Men are much more likely to be diagnosed with narcissistic personality disorder, and women are much more likely to be diagnosed with borderline personality disorder. The reality is that at least with NPD, we know that there's probably not a gender difference. With BPD, with borderline personality disorder, the gender difference is much, much smaller than what people tend to believe.

The other problem is that some of the impulsive aggression that people with BPD exhibit, for men, gets interpreted in a different way. They're more likely, even if they have BPD, to be diagnosed with something like narcissistic personality disorder, or antisocial personality disorder. I would say, you definitely see a lot of misdiagnoses.

The bigger problem is not even giving a personality disorder diagnosis. A lot of times these people are called bipolar, and there's not good evidence to support a bipolar diagnosis.

Flint:  It seems like these diagnoses are, what we would say, maybe like orphan diagnoses, right? There is not a lot of attention put on them.

Dr Jenkins:  Yeah.

Flint:  Do you feel the reason is that there's not a lot of focus, maybe there's not a lot of adequate training for clinicians, or is that a space where we really need to focus on?

Dr Jenkins:  We do. There's a lot of attention that's played to treatment-resistant depression, treatment-resistant mood disorders. When you look at the data, a lot of those people who are treatment-resistant, many of them will meet criteria for an underlying personality disorder.

We also know that at least on an inpatient unit, 50% of people who come on to an inpatient unit and are admitted, will probably meet criteria for personality disorder. In an outpatient clinic, it's 20-30%. It certainly we're seeing these patients, whether we're diagnosing them or not, they're there.

It complicates treatment greatly if you're not aware of it, and you don't understand how a diagnosis of a personality disorder affects the treatment. It also affects outcomes for things like psychopharmacology. Part of what makes it hard is that we don't have a clean evidence base.

With some of the other diagnoses that we have in psychiatry, we've gotten to the point where we have a robust evidence base. We know how to design clinical trials. I used the word clean, but it's tidied up. With narcissistic personality disorder, there's still even a lot of differences in how people would classify the diagnosis and what diagnostic criteria they might use.

If we can't even define what it is, how are we going to do good research studies? That's a huge challenge. One of my mentors, when I was in residency, was very excited about NPD. His name was John Gunderson. He was pivotal in the treatment and coming up with the diagnostic criteria of BPD.

He felt strongly that where we're at with understanding NPD, is where we were with BPD in the 1980s when people thought it was an untreatable disorder, and that these people who are suffering with this terrible disorder should just be thrown to the back of a psych ward to live out the rest of their lives.

Now we have multiple different evidence-based treatments, and the outcomes are actually really good. Hopefully, we'll get there with diagnoses like narcissistic personality disorder.

James A Jenkins, MD, spent his residency gaining expertise in a variety of psychotherapies and milieu treatments for people with complex psychiatric diagnoses and co-occurring personality disorder diagnoses. His advanced training includes certification and expert supervision in Dialectical Behavior Therapy, Mentalization-Based Therapy, and Good Psychiatric Management. Dr Jenkins is a former medical director of the McLean Hospital Cambridge Residence, a residential program for transitional age youths with emerging personality disorder diagnosis who are preparing to exit the mental health system. He was also a staff psychiatrist at the McLean Hospital Gunderson Residence, an intensive residential treatment program for adult women with complex personality disorder diagnoses and refractory psychiatric symptoms. Dr Jenkins is interested in the integration of medication management, milieu treatment, and evidence-based psychotherapies to provide the most comprehensive treatment for those whom prior treatments have failed. Additionally, he is interested in increasing accessibility of these treatments and their implementation in less resourced or traditional environments. Recently he joined the psychiatry department at MassGeneral Hospital and is working to help translate the principles of Dr John Gunderson's Good Psychiatric Management to the consultation-liason service and also in their psychiatric emergency room. Dr Jenkins is an active member of Alpha Omega Alpha and Gold Humanism Honor Society.