Psychiatric Annals

CME Article 

Can We Differentiate Borderline Personality Disorder from Bipolar Disorder?

Benjamin Li, MD; Nizete-Ly Valles, PhD; John Saunders, MD; Amy Vyas, MD; Mohammad Naqvi, MD; Asim A. Shah, MD

Abstract

Distinguishing between borderline personality disorder and bipolar disorder is challenging due to symptom overlap. However, through careful screening and history-taking, collateral information from sources familiar with the patient, and the use of appropriate screening instruments, one may arrive at the correct diagnosis that will lead to optimal treatment planning. Clinicians must also recognize the possibility of the comorbidity of bipolar disorder and borderline personality disorder, and how such comorbidity may lead to poorer outcomes. This article reviews some of the key differences seen between borderline personality disorder and bipolar disorder in terms of neurobiology, heritability, longitudinal course, and subtle nuances in overlapping symptoms. [Psychiatr Ann. 2020;50(1):19–23.]

Abstract

Distinguishing between borderline personality disorder and bipolar disorder is challenging due to symptom overlap. However, through careful screening and history-taking, collateral information from sources familiar with the patient, and the use of appropriate screening instruments, one may arrive at the correct diagnosis that will lead to optimal treatment planning. Clinicians must also recognize the possibility of the comorbidity of bipolar disorder and borderline personality disorder, and how such comorbidity may lead to poorer outcomes. This article reviews some of the key differences seen between borderline personality disorder and bipolar disorder in terms of neurobiology, heritability, longitudinal course, and subtle nuances in overlapping symptoms. [Psychiatr Ann. 2020;50(1):19–23.]

Many diagnostic challenges exist in distinguishing borderline personality disorder (BPD) from bipolar disorder (BD). In fact, some conceptualize BPD as an atypical variant of a mood disorder.1 This may stem from several observations: both disorders share overlapping symptoms, particularly in the realm of impulsivity and affective instability.1 Thus, quite frequently, BD with inter-episodic symptoms may appear similar to BPD. It is also noted that patients with BPD appear to be at high risk of developing BD during longitudinal follow-up.1 Identifying the difference between BPD and BD may pose an even greater challenge when taking into account mood elevations of shorter durations seen in bipolar 2 disorder, as well as “subthreshold” BD (characterized by episodes that do not meet the 4-day criteria for a hypomanic episode),2 or even rapid-cycling BD.3

Inconsistency with diagnostic approach may also influence this diagnostic challenge. Although the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5)4 identifies BPD and BD as distinct and separate diagnoses, symptom-driven diagnoses have their limitations due to overlap between disorders. Another impressionistic approach supported by attachment theories, which was revealed in a survey to be preferred by one-quarter of responders, may base diagnosis off of interactions with patients as opposed to diagnostic criteria.5 However, this use of a more clinician-based diagnosis using long-term follow-up and the involvement of transference and countertransference may include subjective risk and clinical biases that may lead to inconsistency in diagnosis.6 Other studies suggest that looking into certain patient characteristics outside of the diagnostic criteria, such as sex, known family history, or history of sexual abuse or developmental trauma, may help distinguish between the diagnoses.2,7

Ultimately, failure to distinguish between BD and BPD may result in a poorer clinical course or suboptimal treatment. Both disorders require a different therapeutic approach, with more emphasis on psychotherapy in BPD and more on pharmacotherapy in BD.3 In addition, one must not ignore the possibility of the co-occurrence of BPD and BD. Prevalence estimates for BPD in patients with BD may be as high as 30%.1,3 Presence of comorbid BPD in BD is associated with a longer hospital length-of-stay, higher charges during hospitalization, increased risk of drug abuse, higher suicide risk, and greater use of electroconvulsive therapy.8 Compared to BD alone, comorbid BPD and BD may have more frequent and severe mood episodes, worse inter-episode functioning, reduced treatment adherence, and poorer outcomes with medication management.1 Given the above, it would be a disservice to minimize diagnoses at the expense of appropriate treatment.

Despite the similarities between BPD and BD, growing evidence exists on how differences in biology, clinical course, and symptom clusters may help delineate between the two disorders.

Differences in Symptom Quality

Personality disorders can be understood as sustained disturbances in areas of cognition, affectivity, interpersonal functioning, and impulse control. Specifically, BPD is described as “a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity” by the DSM-5.4 The affective symptoms in BPD include mood reactivity with dysphoric moods that are most commonly related to interpersonal stressors, which is less frequently seen in BD. Also, psychotic symptoms tend to be transient in BPD whereas more prolonged episodes may occur in BD.9 Recurrent suicidal thoughts and gestures, as well as nonsuicidal self-injury, may arise from anticipated abandonment or expectations of responsibility, or serve as a maladaptive form of relief-seeking.4 This may differ from long-meditated or even fantasized suicidal ideation that may be present in BD due to depressive episodes.

Impulsivity is a shared symptom between BPD and BD. In BPD, it may be considered as manifesting in the behavioral symptom cluster or as a core feature, which can be understood as a chronic and clinically significant lack of impulse control.10 Although it is not named specifically in the diagnostic criteria for BD, impulsivity is also a prominent feature of the behavioral symptoms.11 In fact, impulsivity has also been shown to persist in people with BD through periods of euthymia.12 However, impulsivity tends to be of a chronic nature throughout BPD, whereas it is more limited to the manic phases of BD.9

In describing manic or hypomanic episodes of BD, the essential features are “abnormally and persistently elevated, expansive, or irritable mood”4 and concurrent changes in behavior, which can be broadly understood as activated (including lack of need for sleep, pressured speech, or increased goal-directed activity) and disinhibited (distractibility and uncharacteristic involvement in risky behaviors). Presence of elevated mood, increased goal-directed activities, and episodicity has been shown to be the strongest means of distinguishing the presence of BD (as opposed to BPD) in an outpatient mood clinic setting.13

Biology of BPD and BD

The specific etiologies for BPD and BD have not been determined, although there are searches for genetic biomarkers for both disorders.14 There are reported distinctions in the family histories of those with BPD and BD. Previous work involving a twin study has suggested a strong level of heritability with BPD (0.69),15 which is higher than the reported heritability for BD (0.63).16 In the context of those with BPD, family studies have not shown a strong familial relationship between BPD and BD, although other work found a 4-fold to 20-fold increase of BPD in relatives of probands with BPD relative to the general public.17 This is in comparison to the evaluation of family histories of people with BD, where it is estimated that a relative of a proband with BD has a 10-fold increase in the risk for BD.11

Although not diagnostic itself, differences in neuroimaging may also provide some clues to help distinguish between the two disorders. A study from 2014 reviewing functional magnetic resonance imaging demonstrated a difference in functional network connectivity.18 When studying resting state networks involved in detecting social salience, affect regulation, and self-referential processing, it was found that connectivity between the ventromedial prefrontal cortex and precuneus was increased in patients with BD. On the other hand, connectivity between the precuneus and right fronto-parietal region was decreased in patients with BPD.18

Structural differences also exist. Another study noted differences in hippocampal volume, with patients with BD and BPD each having a decrease in hippocampal volume relative to healthy controls.19 However, this decrease was only noted in the right hippocampus for those with BD and was bilateral in those with BPD.19 Patients with BPD may have decreased amygdala volumes, whereas patients with BD have decreased volume in the bilateral medial orbital frontal cortex and increased volume in the right putamen.20

Onset and Progression

Although both BD and BPD involve elevations and depressions of mood, a closer examination of the duration of symptoms, as well as the age of onset of the disorder, can help clinicians determine the correct diagnosis.

The average age of onset, or more specifically, the first manic or depressive episode associated with BD, usually occurs in the early twenties. Some studies report an average age of onset of 25 years,21 whereas others report an age of 20 to 22 years,22 with few occurrences in teenage years and rarely in childhood. In contrast, the presentation of severe symptoms associated with BPD may present earlier than BD. An estimated one-third of patients with BPD first harmed themselves at age 12 years or younger.23 Because BPD is a personality disorder, diagnosis before age 18 years is difficult, as children and adolescents usually undergo mood changes without any underlying disease. However, DSM-5 allows clinical diagnosis of BPD in children if symptoms persist for at least 1 year.24

Similar to the age of onset, the duration of symptoms also varies greatly between the two disorders. Manic and depressive episodes associated with BD usually occur in intervals of weeks, with periods of stable mood that can last months to years before appearing again. On the other hand, BPD is associated with mood changes that occur on shorter intervals. A study conducted in 2010 sampled 219 participants and concluded that the average duration of bipolar I mood episodes was 13 weeks,25 and that the interval between cycles can be up to 6 months to a year. Patients who suffer from rapid cycling experience episodes more frequently, with four or more episodes in 1 year. Mood shifts resulting from BPD are typically short, lasting just a few minutes to hours, and occur much more frequently than those of BD.26

The clinical course of BD spans the life of the patient; it is a chronic, recurring disability, and episodes tend to occur closer and closer as the disease progresses.27 Although BPD is also considered to be a lifelong disease, a recent study shows that there is a consistent reduction in symptoms as time progresses, and prevalence of disease diagnosis and initial symptom presentation trends downward in the early to mid-twenties.28

Conclusion and Recommendations

Due to symptom overlap, differentiating BD from BPD poses a diagnostic challenge for mental health providers. However, given that the treatment for each of the disorders varies, with the most efficacious treatment for BD being pharmacological and for BPD being psychotherapeutic, accurate diagnosis is pivotal for optimal prognosis. Despite the challenge, research has elucidated possible methods to improve diagnostic specificity. When a patient presents with affective instability and impulsivity, which overlap between the two disorders, mental health providers can thoroughly assess the clinical course of the symptoms, examine symptom clusters, obtain a family history, and monitor treatment outcomes. Table 1 summarizes some of these differences.

A Comparison of Characteristics of Bipolar Disorder and Borderline Personality Disorder

Table 1.

A Comparison of Characteristics of Bipolar Disorder and Borderline Personality Disorder

To help aid in diagnosis, providers may begin with a brief screening. For BPD, the McLean Screening Instrument for Borderline Personality Disorder has been found to be specific and sensitive to identify BPD at a cut-off score of 7.29 BD can be adequately screened for by assessing for the co-occurrence of euphoric mood and hyper-productivity, implicating the possibility of using a 3-item screener.30 Notably, euphoric mood is not a common symptom of BPD, which is frequently characterized as mood that fluctuates between depression and irritability.31 BPD may also present as severe ratings of both depression and anxiety.32 Regarding symptom clusters, studies have found that an algorithm derived from the personality inventory for DSM-5 (PID-5) is a sensitive and specific measure to assess for BPD.33 The PID-5 algorithm is comprised of scales of emotional lability, anxiety, separation insecurity, hostility, depression, impulsivity, and risk-taking behaviors, with higher algorithmic scores predicting a BPD diagnosis but not BD.33

Considering the interplay of symptoms may also help guide diagnosis. Impulsivity in response to emotions such as anger and depression may reflect BPD, with behavioral hyperactivation increasing risk for mania but not BPD.34 Obtaining a thorough family history of psychiatric conditions is useful, with BPD being more heritable than BD.31 Collateral information can clarify symptom onset and establish duration of symptoms, meaning that family members or friends can help establish whether the behaviors noted are a pervasive pattern of emotional and behavioral reactivity, indicating a personality disorder, or a stark change in previous functioning, indicating a mood disorder. Additionally, mental health providers can note the psychopharmacological effects of the medication, as current pharmacological treatments have mild effects on the emotional instability of BPD but often help stabilize mood in BD.31 Significant reductions in impulsivity, with minimal impact to affect stabilization, may indicate BPD.31

Although research continues to provide possible methods for differentiating these disorders, limitations exist (eg, use of clinical samples, a dearth of longitudinal studies, differing methodology, and lack of studies differentiating the types of BD). As such, research can continue to help clinicians differentiate these disorders by further examining the commonalities and differences between BPD and bipolar type II or cyclothymia, as well as examining their comorbidity. Additionally, considering other factors beyond emotional and behavioral overlap, such as cognitive factors, may also help clinicians improve the diagnosis.

References

  1. McDermid J, Sareen J, El-Gabalawy R, Pagura J, Spiwak R, Enns MW. Co-morbidity of bipolar disorder and borderline personality disorder: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Compr Psychiatry. 2015;58:18–28. https://doi.org/10.1016/j.comppsych.2015.01.004 PMID: doi:10.1016/j.comppsych.2015.01.004 [CrossRef]25666748
  2. Bayes A, Graham RK, Parker GB, McCraw S. Is 'subthreshold' bipolar II disorder more difficult to differentiate from borderline personality disorder than formal bipolar II disorder?Psychiatry Res. 2018;264:416–420. https://doi.org/10.1016/j.psychres.2018.04.018 PMID: doi:10.1016/j.psychres.2018.04.018 [CrossRef]29689499
  3. Riemann G, Weisscher N, Post RM, et al. The relationship between self-reported borderline personality features and prospective illness course in bipolar disorder. Int J Bipolar Disord. 2017;5(1):31. https://doi.org/10.1186/s40345-017-0100-x PMID: doi:10.1186/s40345-017-0100-x [CrossRef]28944443
  4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
  5. Saunders KEA, Bilderbeck AC, Price J, Goodwin GM. Distinguishing bipolar disorder from borderline personality disorder: A study of current clinical practice. Eur Psychiatry. 2015;30(8):965–974. https://doi.org/10.1016/j.eurpsy.2015.09.007 PMID: doi:10.1016/j.eurpsy.2015.09.007 [CrossRef]26647873
  6. Bayes AJ, Parker GB. Clinical vs. DSM diagnosis of bipolar disorder, borderline personality disorder and their co-occurrence. Acta Psychiatr Scand. 2017;135(3):259–265. https://doi.org/10.1111/acps.12678 PMID: doi:10.1111/acps.12678 [CrossRef]
  7. Bayes AJ, McClure G, Fletcher K, et al. Differentiating the bipolar disorders from borderline personality disorder. Acta Psychiatr Scand. 2016;133(3):187–195. https://doi.org/10.1111/acps.12509 PMID: doi:10.1111/acps.12509 [CrossRef]
  8. Patel RS, Manikkara G, Chopra A. Bipolar Disorder and Comorbid Borderline Personality Disorder: Patient Characteristics and Outcomes in US Hospitals. Medicina (Kaunas). 2019;55(1):13. https://doi.org/10.3390/medicina55010013 PMID: doi:10.3390/medicina55010013 [CrossRef]
  9. Bassett D, Mulder R, Outhred T, et al. Defining disorders with permeable borders: you say bipolar, I say borderline!Bipolar Disord. 2017;19(5):320–323. https://doi.org/10.1111/bdi.12528 PMID: doi:10.1111/bdi.12528 [CrossRef]28833995
  10. Links PS, Heslegrave R, van Reekum R. Impulsivity: core aspect of borderline personality disorder. J Pers Disord. 1999;13(1):1–9. https://doi.org/10.1521/pedi.1999.13.1.1 PMID: doi:10.1521/pedi.1999.13.1.1 [CrossRef]10228922
  11. Henry C, Mitropoulou V, New AS, Koenigsberg HW, Silverman J, Siever LJ. Affective instability and impulsivity in borderline personality and bipolar II disorders: similarities and differences. J Psychiatr Res. 2001;35(6):307–312. https://doi.org/10.1016/S0022-3956(01)00038-3 PMID: doi:10.1016/S0022-3956(01)00038-3 [CrossRef]11684137
  12. Swann AC, Pazzaglia P, Nicholls A, Dougherty DM, Moeller FG. Impulsivity and phase of illness in bipolar disorder. J Affect Disord. 2003;73(1–2):105–111. https://doi.org/10.1016/S0165-0327(02)00328-2 PMID: doi:10.1016/S0165-0327(02)00328-2 [CrossRef]12507743
  13. Vöhringer PA, Barroilhet SA, Alvear K, et al. The International Mood Network (IMN) Nosology Project: differentiating borderline personality from bipolar illness. Acta Psychiatr Scand. 2016;134(6):504–510. https://doi.org/10.1111/acps.12643 PMID: doi:10.1111/acps.12643 [CrossRef]27611723
  14. Paris J, Black DW. Borderline personality disorder and bipolar disorder: what is the difference and why does it matter?J Nerv Ment Dis. 2015;203(1):3–7. https://doi.org/10.1097/NMD.0000000000000225 PMID: doi:10.1097/NMD.0000000000000225 [CrossRef]
  15. Torgersen S, Lygren S, Oien PA, et al. A twin study of personality disorders. Compr Psychiatry. 2000;41(6):416–425. https://doi.org/10.1053/comp.2000.16560 PMID: doi:10.1053/comp.2000.16560 [CrossRef]11086146
  16. Smoller JW, Finn CT. Family, twin, and adoption studies of bipolar disorder. Am J Med Genet C Semin Med Genet. 2003;123C(1):48–58. https://doi.org/10.1002/ajmg.c.20013 PMID:14601036
  17. White CN, Gunderson JG, Zanarini MC, Hudson JI. Family studies of borderline personality disorder: a review. Harv Rev Psychiatry. 2003;11(1):8–19. PMID:12866737
  18. Das P, Calhoun V, Malhi GS. Bipolar and borderline patients display differential patterns of functional connectivity among resting state networks. Neuroimage. 2014;98:73–81. https://doi.org/10.1016/j.neuroimage.2014.04.062 PMID: doi:10.1016/j.neuroimage.2014.04.062 [CrossRef]24793833
  19. Rossi R, Lanfredi M, Pievani M, et al. Volumetric and topographic differences in hippocampal subdivisions in borderline personality and bipolar disorders. Psychiatry Res. 2012;203(2–3):132–138. https://doi.org/10.1016/j.pscychresns.2011.12.004 PMID: doi:10.1016/j.pscychresns.2011.12.004 [CrossRef]22944368
  20. Yu H, Meng YJ, Li XJ, et al. Common and distinct patterns of grey matter alterations in borderline personality disorder and bipolar disorder: voxel-based meta-analysis. Br J Psychiatry. 2019;215(1):395–403. https://doi.org/10.1192/bjp.2019.44 PMID: doi:10.1192/bjp.2019.44 [CrossRef]30846010
  21. Duckworth K. Borderline personality disorder and bipolar disorder: what's the difference?. www.nami.org/Blogs/NAMI-Blog/June-2017/Borderline-Personality-Disorder-and-Bipolar-Disord. Accessed November 26, 2019.
  22. Kawa I, Carter JD, Joyce PR, et al. Gender differences in bipolar disorder: age of onset, course, comorbidity, and symptom presentation. Bipolar Disord. 2005;7(2):119–125. https://doi.org/10.1111/j.1399-5618.2004.00180.x PMID: doi:10.1111/j.1399-5618.2004.00180.x [CrossRef]15762852
  23. Zanarini MC, Frankenburg FR, Ridolfi ME, Jager-Hyman S, Hennen J, Gunderson JG. Reported childhood onset of self-mutilation among borderline patients. J Pers Disord. 2006;20(1):9–15. https://doi.org/10.1521/pedi.2006.20.1.9 PMID: doi:10.1521/pedi.2006.20.1.9 [CrossRef]16563075
  24. Biskin RS. The lifetime course of borderline personality disorder. Can J Psychiatry. 2015;60(7):303–308. https://doi.org/10.1177/070674371506000702 PMID: doi:10.1177/070674371506000702 [CrossRef]26175388
  25. Solomon DA, Leon AC, Coryell WH, et al. Longitudinal course of bipolar I disorder: duration of mood episodes. Arch Gen Psychiatry. 2010;67(4):339–347. https://doi.org/10.1001/archgenpsychiatry.2010.15 PMID: doi:10.1001/archgenpsychiatry.2010.15 [CrossRef]20368510
  26. Belli H, Ural C, Akbudak M. Borderline personality disorder: bipolarity, mood stabilizers and atypical antipsychotics in treatment. J Clin Med Res. 2012;4(5):301–308. https://doi.org/10.4021/jocmr1042w PMID:23024731
  27. Haldipur CV. Bipolar disorders: clinical course and outcome. Prim Care Companion J Clin Psychiatry. 1999;1(6):194. https://doi.org/10.4088/PCC.v01n0605a doi:10.4088/PCC.v01n0605a [CrossRef]
  28. Bornovalova MA, Hicks BM, Iacono WG, McGue M. Stability, change, and heritability of borderline personality disorder traits from adolescence to adulthood: a longitudinal twin study. Dev Psychopathol. 2009;21(4):1335–1353. https://doi.org/10.1017/S0954579409990186 PMID: doi:10.1017/S0954579409990186 [CrossRef]19825271
  29. Zanarini MC, Vujanovic AA, Parachini EA, Boulanger JL, Frankenburg FR, Hennen J. A screening measure for BPD: the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD). J Pers Disord.2003;17(6):568–573. https://doi.org/10.1521/pedi.17.6.568.25355 PMID: doi:10.1521/pedi.17.6.568.25355 [CrossRef]
  30. Balling C, Chelminski I, Dalrymple K, Zimmerman M. Differentiating borderline personality disorder from bipolar disorder with the Mood Disorder Questionnaire (MDQ): A replication and extension of the International Mood Network (IMN) nosology project. Compr Psychiatry. 2019;88:49–51. https://doi.org/10.1016/j.comppsych.2018.11.009 PMID: doi:10.1016/j.comppsych.2018.11.009 [CrossRef]
  31. Paris J. Differential diagnosis of bipolar and borderline personality disorders. Neuropsychiatry (London). 2011;1(3):251–257. https://doi.org/10.2217/npy.11.21 doi:10.2217/npy.11.21 [CrossRef]
  32. di Giacomo E, Aspesi F, Fotiadou M, et al. BRT Group. Unblending borderline personality and bipolar disorders. J Psychiatr Res. 2017;91:90–97. https://doi.org/10.1016/j.jpsychires.2017.03.006 PMID: doi:10.1016/j.jpsychires.2017.03.006 [CrossRef]28327444
  33. Fowler JC, Madan A, Allen JG, Oldham JM, Frueh BC. Differentiating bipolar disorder from borderline personality disorder: diagnostic accuracy of the difficulty in emotion regulation scale and personality inventory for DSM-5. J Affect Disord. 2019;245:856–860. https://doi.org/10.1016/j.jad.2018.11.079 PMID: doi:10.1016/j.jad.2018.11.079 [CrossRef]30699870
  34. Fulford D, Eisner LR, Johnson SL. Differentiating risk for mania and borderline personality disorder: the nature of goal regulation and impulsivity. Psychiatry Res. 2015;227(2–3):347–352. PMID: doi:10.1016/j.psychres.2015.02.001 [CrossRef]25892256

A Comparison of Characteristics of Bipolar Disorder and Borderline Personality Disorder

Characteristic Bipolar Disorder Borderline Personality Disorder
Heritability15–17 Strong May be higher than bipolar disorder
Neurologic structural differences19,20 Decreased volume in medial orbital frontal cortex and right hippocampus Decreased volume in bilateral hippocampus and amygdala
Age of onset21–23 First episode typically occurs in early 20s Earliest signs may present before age 12 years
Duration of mood episodes25,26 May last weeks Often occur at shorter intervals (minutes to hours)
Disease progression27,28 Episodes occur closer together as disease progresses Reduction in symptoms as time progresses
Cause of mood reactivity9 Sometimes there is no clear precipitant Often related to interpersonal stressor
Quality of mood shift31 Euphoria can be present Tends to shift from euthymia/depression to irritability
Psychotic symptoms9 More prolonged experiences Tend to be transient
Impulsivity9 More limited to manic episodes Tends to be chronic
Recurrent suicidal gestures4 Often from depression Often related to anticipated abandonment or maladaptive form of relief-seeking
Treatment emphasis3 Psychopharmacology Psychotherapy
Authors

Benjamin Li, MD, is Assistant Professor of Psychiatry, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine and Harris Health System. Nizete-Ly Valles, PhD, is an Assistant Professor of Psychology, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine and Harris Health System. John Saunders, MD, is an Assistant Professor of Psychiatry, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine and Harris Health System. Amy Vyas, MD, is an Assistant Professor of Psychiatry, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine and The Menninger Clinic. Mohammad Naqvi, MD, is the Clinical Studies Coordinator, The University of Texas MD Anderson Cancer Center. Asim A. Shah, MD, is a Professor and the Executive Vice Chair, Menninger Department of Psychiatry and Behavioral Sciences; and a Professor, Department of Community and Family Medicine, Baylor College of Medicine.

Address correspondence to Benjamin Li, MD, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, BCM350, Houston, TX 77030; email: btli@bcm.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20191126-01

Sign up to receive

Journal E-contents