Teaching differential diagnosis with Anakin Skywalker: the duel between borderline personality disorder and bipolar disorder (2024)

Theoretical article – Health PsychologyEstud. psicol. (Campinas) 40 2023https://doi.org/10.1590/1982-0275202340e210047 copy

Ensinando diagnóstico diferencial com Anakin Skywalker: o duelo entre transtorno da personalidade borderline e transtorno bipolar

    Objective:

    Previous publications have focused on a leading pop culture phenomenon, Star Wars, to teach several issues in psychiatry, which can make understanding challenging themes easier. This article delves into matters of differential diagnoses regarding two psychiatric disorders.

    Methods:

    We examine and compare the symptoms and specificities of borderline personality disorder and bipolar disorder in the light of the fictional villain of the films, Darth Vader/Anakin Skywalker.

    Results and Conclusion:

    Our considerations of his diagnosis should be interpreted as an academic exercise with two main goals: to discuss the differential diagnosis between borderline personality disorder and bipolar disorder in an illustrative, soft, and ludic way; and to teach how to connect one’s behaviors with diagnostic criteria - in this case, those related to borderline personality disorder.

    Keywords:
    Diagnosis; Film; Personality disorders; Teaching method

    Objetivo:

    Publicações de outrora utilizaram um dos principais fenômenos da cultura pop, Star Wars, para ensinar diversas questões sobre psiquiatria, demonstrando que usar os filmes da série para ensinar tais assuntos pode facilitar a compreensão de temas desafiadores. O objetivo deste artigo é aprofundar as questões do diagnóstico diferencial de dois transtornos psiquiátricos.

    Métodos:

    Nós examinamos e comparamos as especificidades do transtorno de personalidade borderline e transtorno bipolar à luz do personagem fictício dos filmes Star Wars, o vilão Darth Vader/Anakin Skywalker.

    Resultados e Conclusão:

    As considerações sobre o diagnóstico de Darth Vader devem ser interpretadas como um exercício acadêmico com dois objetivos principais: discutir o diagnóstico diferencial entre transtorno de personalidade borderline e transtorno bipolar de forma ilustrativa, suave e lúdica; e ensinar como relacionar os comportamentos com critérios diagnósticos, neste caso, especificamente relacionados ao transtorno de personalidade borderline.

    Palavras-chave:
    Diagnóstico; Filme; Transtornos de personalidade; Método de ensino

    Fictional universes may facilitate the exploration of challenging themes and complex definitions. In this paper, we discuss how a popular character from Star Wars can be used in psychiatric discussions with trainees/students to address real-world issues on differential diagnoses between Borderline Personality Disorder (BPD) and Bipolar Disorder (BD). Specifically, we focus on the franchise’s most famous fictional character, the villain Darth Vader/Anakin Skywalker. This paper is tongue specific in some places and assumes that the reader has a general knowledge of Star Wars. Finally, when discussing issues related to differential diagnoses between BPD and bipolar disorder BD, the current (categorical) diagnostic system and the main alternative (dimensional) diagnostic system for psychiatric conditions are brought into focus, since they directly impact diagnostic decision-making in the clinic.

    Research from several scientific disciplines has taken advantage of Star Wars analogies for teaching (e.g., hematology/oncology; ergonomics methods) (Springer, 2014Springer, T. A. (2014). von Willebrand factor, Jedi knight of the bloodstream. Blood, The Journal of the American Society of Hematology, 124(9), 1412-1425. https://doi.org/10.1182/blood-2014-05-378638
    https://doi.org/https://doi.org/10.1182/...
    ; Walker et al., 2016Walker, G., Salmon, P., Bedinger, M., & Stanton, N. (2016). What the Death Star can tell us about ergonomics methods. Theoretical Issues in Ergonomics Science, 17(4), 402-422. https://doi.org/10.1080/1463922X.2015.1130879
    https://doi.org/https://doi.org/10.1080/...
    ). Accordingly, Star Wars scenes and characters have been used to teach psychiatric disorders (Friedman & Hall, 2015aFriedman, S. H., & Hall, R. C. (2015a). Teaching psychopathology in a galaxy far, far away: the light side of the force. Academic Psychiatry, 39(6), 719-725. https://doi.org/10.1007/s40596-015-0340-y
    https://doi.org/https://doi.org/10.1007/...
    , 2015bFriedman, S. H., & Hall, R. C. (2015b). Using Star Wars’ supporting characters to teach about psychopathology. Australasian Psychiatry, 23(4), 432-434. https://doi.org/10.1177/1039856215590032
    https://doi.org/https://doi.org/10.1177/...
    ; Hall & Friedman, 2015Hall, R. C., & Friedman, S. H. (2015). Psychopathology in a galaxy far, far away: the use of Star Wars’ dark side in teaching. Academic Psychiatry, 39(6), 726-732. https://doi.org/10.1007/s40596-015-0337-6
    https://doi.org/https://doi.org/10.1007/...
    ).

    The Star Wars saga is considered amenable to various complex analyses, maybe as a result of the mythological and religious themes within the storyline (Lyden, 2003Lyden, J. (2003). Film as religion: myths, morals, and rituals. New York University Press.). Star Wars presents the requirements to be used as a teaching tool (Hall & Friedman, 2015Hall, R. C., & Friedman, S. H. (2015). Psychopathology in a galaxy far, far away: the use of Star Wars’ dark side in teaching. Academic Psychiatry, 39(6), 726-732. https://doi.org/10.1007/s40596-015-0337-6
    https://doi.org/https://doi.org/10.1007/...
    ), described as follows: (a) it is timeless, (b) universal in the scope of themes addressed, (c) well-known, and (d) sufficiently culturally incorporated to become a shorthand for a broader concept.

    The main recurrent character in the six episodes is Anakin Skywalker. Anakin later develops into the villain Darth Vader. Some claim this character, probably one of the most well-known villains in the history of cinema, is among the main factors explaining Star Wars’ success (Bui et al., 2011Bui, E., Rodgers, R., Chabrol, H., Birmes, P., & Schmitt, L. (2011). Is Anakin Skywalker suffering from borderline personality disorder? Psychiatry Research, 185(1-2), 299. https://doi.org/10.1016/j.psychres.2009.03.031
    https://doi.org/https://doi.org/10.1016/...
    ). Anakin Skywalker is a Force-sensitive human male, considered the Chosen One by some, and was a Jedi Knight of the Galactic Republic. Details on Anakin Skywalker’s traits and history can be found in specific publications (Bray et al., 2017Bray, A., Dougherty, K., Horton, C., & Kogge, M. (2017). Star Wars: absolutely everything you need to know: updated and Expanded. Dorling Kindersley Limited.).

    From the categorical diagnosis perspective, the literature tends to agree that Anakin Skywalker had BPD (Bui et al., 2011Bui, E., Rodgers, R., Chabrol, H., Birmes, P., & Schmitt, L. (2011). Is Anakin Skywalker suffering from borderline personality disorder? Psychiatry Research, 185(1-2), 299. https://doi.org/10.1016/j.psychres.2009.03.031
    https://doi.org/https://doi.org/10.1016/...
    ; Carvalho, 2017Carvalho, L. F. (2017). From Anakin Skywalker to Darth Vader: understanding Star Wars based on Theodore Millon’s theory of personality pathology. Revista de Medicina y Cine, 13(3), 121.; Friedman & Hall, 2015aFriedman, S. H., & Hall, R. C. (2015a). Teaching psychopathology in a galaxy far, far away: the light side of the force. Academic Psychiatry, 39(6), 719-725. https://doi.org/10.1007/s40596-015-0340-y
    https://doi.org/https://doi.org/10.1007/...
    , 2015bFriedman, S. H., & Hall, R. C. (2015b). Using Star Wars’ supporting characters to teach about psychopathology. Australasian Psychiatry, 23(4), 432-434. https://doi.org/10.1177/1039856215590032
    https://doi.org/https://doi.org/10.1177/...
    ; Hall & Friedman, 2015Hall, R. C., & Friedman, S. H. (2015). Psychopathology in a galaxy far, far away: the use of Star Wars’ dark side in teaching. Academic Psychiatry, 39(6), 726-732. https://doi.org/10.1007/s40596-015-0337-6
    https://doi.org/https://doi.org/10.1007/...
    ; Tobia et al., 2015Tobia, A., Draschil, T., Zimmerman, A., Breig, J., Peters, S., Rudge, D., & Velez, D. (2015). Darth Vulcan? In support of Anakin Skywalker suffering from borderline personality disorder. Psychiatry Research, 1(229), 625-626. https://doi.org/10.1016/j.psychres.2015.07.039.
    https://doi.org/https://doi.org/10.1016/...
    ), although there are controversies (Rocha et al., 2012Rocha, F. F., Malloy-Diniz, L., & Corrêa, H. (2012). Revisiting the Anakin Skywalker diagnostic: transcending the diagnostic criteria. Psychiatry Research, 198(1), e179. https://doi.org/10.1016/j.psychres.2011.07.024
    https://doi.org/https://doi.org/10.1016/...
    ). The BPD can be difficult to diagnose because of the symptoms it shares with other conditions, mainly mood disorders (Biskin & Paris, 2012Biskin, R. S., & Paris, J. (2012). Diagnosing borderline personality disorder. CMAJ, 184(16), 1789-1794. https://doi.org/10.1503/cmaj.090618
    https://doi.org/https://doi.org/10.1503/...
    ). Specifically, BPD can be misdiagnosed as BD (American Psychiatric Association, 2013American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5.).

    One meta-analysis (Fornaro et al., 2016Fornaro, M., Orsolini, L., Marini, S., Berardis, D., Perna, G., Valchera, A., Ganança, L., Solmi, M., Veronese, N., & Stubbs, B. (2016). The prevalence and predictors of bipolar and borderline personality disorders comorbidity: systematic review and meta-analysis. Journal of Affective Disorders, 195, 105-118. https://doi.org/10.1016/j.jad.2016.01.040
    https://doi.org/https://doi.org/10.1016/...
    ) reported that comorbidity between BPD and BD is frequent, with about one in five people presenting a BPD-BD comorbid diagnosis. Although comorbidity is typical and several commonalities are present (Bøen et al., 2015Bøen, E., Hummelen, B., Elvsåshagen, T., Boye, B., Andersson, S., Karterud, S., & Malt, U. F. (2015). Different impulsivity profiles in borderline personality disorder and bipolar II disorder. Journal of Affective Disorders, 170, 104-111. https://doi.org/10.1016/j.jad.2014.08.033
    https://doi.org/https://doi.org/10.1016/...
    ), studies comparing BPD and BD suggest that they are separate and unique (De la Rosa et al., 2017De la Rosa, I., Oquendo, M. A., García, G., Stanley, B., González-Pinto, A., Liu, S. M., & Blanco, C. (2017). Determining if borderline personality disorder and bipolar disorder are alternative expressions of the same disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. The Journal of Clinical Psychiatry, 78(8), 994-999. https://doi.org/10.4088/JCP.16m11190
    https://doi.org/https://doi.org/10.4088/...
    ). Our focus is on this premise, i.e., that BPD and BD have separate identities. Therefore, according to this paper’s teaching purposes, we are more dedicated to identifying Anakin’s primary disorder than discussing the possibility of comorbidity.

    Misdiagnosing BPD as BD can occur with both BD-I and BD-II types, although researchers have argued that the similarities with BPD are more typical for the BD-II type and less for BD-I (Bayes et al., 2016Bayes, A. J., McClure, G., Fletcher, K., Roman Ruiz Del Moral, Y. E., Hadzi-Pavlovic, D., Stevenson, J. L., Manicavasagar, V. L., & Parker, G. B. (2016). Differentiating the bipolar disorders from borderline personality disorder. Acta Psychiatrica Scandinavica, 133(3), 187-195. https://doi.org/10.1111/acps.12509
    https://doi.org/https://doi.org/10.1111/...
    ). The manic episodes expected in BD-I patients (American Psychiatric Association, 2013American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5.) may facilitate its distinction from BPD. These are periods of atypical and persistently high levels of irritable mood, which may include grandiosity, a reduced need for sleep, distraction, racing thoughts, psychom*otor agitation, and excessive involvement in activities with potentially painful consequences. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic criteria, from the categorical perspective, patients with BD-II are not expected to present manic episodes but hypomanic episodes, which are less intense than manic episodes (for instance, hypomania does not usually lead to hospitalization). However, the differences between BD-I and BD-II are subtler than anticipated by diagnostic manuals (Novick et al., 2010Novick, D. M., Swartz, H. A., & Frank, E. (2010). Suicide attempts in bipolar I and bipolar II disorder: a review and meta-analysis of the evidence. Bipolar Disorders, 12(1), 1-9. https://doi.org/10.1111/j.1399-5618.2009.00786.x
    https://doi.org/https://doi.org/10.1111/...
    ; Kupka et al., 2007Kupka, R. W., Altshuler, L. L., Nolen, W. A., Suppes, T., Luckenbaugh, D. A., Leverich, G. S., Frye, M. A., Keck Jr., P. E., McElroy, S. L., Grunze, H., & Post, R. M. (2007). Three times more days depressed than manic or hypomanic in both bipolar I and bipolar II disorder 1. Bipolar Disorders, 9(5), 531-535. https://doi.org/10.1111/j.1399-5618.2007.00467.x
    https://doi.org/https://doi.org/10.1111/...
    ). Therefore, we will distinguish the BD types only when strictly necessary.

    Emotional lability, impulsiveness, aggressiveness, depression, and anxiety are shared traits and symptoms between BPD and BD (Bøen et al., 2015Bøen, E., Hummelen, B., Elvsåshagen, T., Boye, B., Andersson, S., Karterud, S., & Malt, U. F. (2015). Different impulsivity profiles in borderline personality disorder and bipolar II disorder. Journal of Affective Disorders, 170, 104-111. https://doi.org/10.1016/j.jad.2014.08.033
    https://doi.org/https://doi.org/10.1016/...
    ; Wilson et al., 2007Wilson, S. T., Stanley, B., Oquendo, M. A., Goldberg, P., Zalsman, G., & Mann, J. J. (2007). Comparing impulsiveness, hostility, and depression in borderline personality disorder and bipolar II disorder. The Journal of Clinical Psychiatry, 68(10), 1533. https://doi.org/10.4088/JCP.v68n1010
    https://doi.org/https://doi.org/10.4088/...
    ). Although similar, BPD and BD are distinctly described and categorized by psychiatric manuals as DSM-5 (American Psychiatric Association, 2013American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5.). The literature describes BPD as a pattern of impulsivity and general instability, including impairments in interpersonal relationships, self-image, and affects, and characterizes BD-I and BD-II types as having oscillating periods of depression and of abnormally elevated mood, called manic episodes.

    Table 1 presents the symptoms and traits typically shared between BPD and BD, compares symptoms and traits in terms of frequency and intensity in each disorder, and informs some specificities on genetics and early events (see the first column). It also presents information regarding Anakin Skywalker (see columns three to five), discussed later in this paper. The last column concludes with a disorder recommendation.

    Table 1.
    Shared features between Borderline Personality Disorder and Bipolar Disorder in Anakin Skywalker’s behaviors

    The first step into a differential diagnosis for Anakin Skywalker may proceed from the severity of his pathological functioning. Considering that (a) his behaviors’ representative traits are always very extreme (e.g., killing all Tusken Raiders represents the aggressiveness trait), and (b) previous literature suggests BPD as more severe than BD (although similar on Emotional lability) (Bøen et al., 2015Bøen, E., Hummelen, B., Elvsåshagen, T., Boye, B., Andersson, S., Karterud, S., & Malt, U. F. (2015). Different impulsivity profiles in borderline personality disorder and bipolar II disorder. Journal of Affective Disorders, 170, 104-111. https://doi.org/10.1016/j.jad.2014.08.033
    https://doi.org/https://doi.org/10.1016/...
    ; Mazer et al., 2019Mazer, A. K., Cleare, A. J., Young, A. H., & Juruena, M. F. (2019). Bipolar affective disorder and borderline personality disorder: differentiation based on the history of early life stress and psychoneuroendocrine measures. Behavioural Brain Research, 357, 48-56. https://doi.org/10.1016/j.bbr.2018.04.015
    https://doi.org/https://doi.org/10.1016/...
    ; Wilson et al., 2007Wilson, S. T., Stanley, B., Oquendo, M. A., Goldberg, P., Zalsman, G., & Mann, J. J. (2007). Comparing impulsiveness, hostility, and depression in borderline personality disorder and bipolar II disorder. The Journal of Clinical Psychiatry, 68(10), 1533. https://doi.org/10.4088/JCP.v68n1010
    https://doi.org/https://doi.org/10.4088/...
    ), the most appropriate choice to interpret the traits and symptoms manifested by Anakin seems to be the BPD composition.

    The typical symptoms from BD-I (i.e., manic episodes) are not clearly present in Anakin. He manifests signs of grandiosity solidly and recurrently, from his childhood to his adult years. However, as grandiosity is the sole sign related to manic episodes and its manifestation is not episodic, we can conclude that Anakin’s grandiosity is an expression of a pathological trait, as previously stated (Carvalho, 2017Carvalho, L. F. (2017). From Anakin Skywalker to Darth Vader: understanding Star Wars based on Theodore Millon’s theory of personality pathology. Revista de Medicina y Cine, 13(3), 121.; Hall & Friedman, 2015Hall, R. C., & Friedman, S. H. (2015). Psychopathology in a galaxy far, far away: the use of Star Wars’ dark side in teaching. Academic Psychiatry, 39(6), 726-732. https://doi.org/10.1007/s40596-015-0337-6
    https://doi.org/https://doi.org/10.1007/...
    ; Rocha et al., 2012Rocha, F. F., Malloy-Diniz, L., & Corrêa, H. (2012). Revisiting the Anakin Skywalker diagnostic: transcending the diagnostic criteria. Psychiatry Research, 198(1), e179. https://doi.org/10.1016/j.psychres.2011.07.024
    https://doi.org/https://doi.org/10.1016/...
    ).

    Table 1 reveals that Anakin’s pattern resembles a BPD diagnosis more than a BD diagnosis. Nevertheless, this table does not show whether Anakin presents sufficient criteria for a BPD diagnosis. Table 2 presents the nine BPD criteria, examples representing each (when applicable), and our conclusion regarding their presence in Anakin.

    Table 2.
    Anakin Skywalker´s Borderline Personality Disorder diagnostic criteria (at least 6 criteria) (APA, 2013)

    Anakin presents six of the nine diagnostic criteria composing BPD (Fornaro et al., 2016Fornaro, M., Orsolini, L., Marini, S., Berardis, D., Perna, G., Valchera, A., Ganança, L., Solmi, M., Veronese, N., & Stubbs, B. (2016). The prevalence and predictors of bipolar and borderline personality disorders comorbidity: systematic review and meta-analysis. Journal of Affective Disorders, 195, 105-118. https://doi.org/10.1016/j.jad.2016.01.040
    https://doi.org/https://doi.org/10.1016/...
    ). Table 1 helps connect Anakin’s behaviors and the diagnostic criteria. However, we showed substantial BPD specifications in Table 2 (e.g., abandonment avoidance, identity disturbance, and intense anger). For instance, we can observe self-related impairments as a form of identity disturbance (Anakin sometimes believes he should agree with the Jedi and sometimes goes against them). We can also see interpersonal impairments, such as the unstable and intense relationship with his wife, Padmé, which drives him to kill her, or with his mother, Shmi, which leads him to extinguish an entire Tusken Raiders village. The presence of self and interpersonal impairments is a reliable indicator of PD (American Psychiatric Association, 2013American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5.). As observed, the specificities of the pattern exhibited by Anakin resemble a BPD pattern.

    According to our observations on Star Wars, Anakin presents a BPD pattern mainly related to emotional instability, impulsivity, and aggressiveness traits. Although DSM-5 does not provide BPD subtypes, Anakin’s trait profile reflects the BPD impulsive type presented in the 10th revision of the International Classification of Diseases (World Health Organization, 1992World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines.). Anakin’s BPD pattern is also compatible with the impulsive borderline traits described by Millon (2011Millon, T. (2011). Disorders of personality: introducing a DSM/ICD spectrum from normal to abnormal. John Wiley & Sons.), even though Anakin presents restlessness, irritability, and impatience, which is consistent with Millon’s petulant borderline personality style. According to Millon (2011)Millon, T. (2011). Disorders of personality: introducing a DSM/ICD spectrum from normal to abnormal. John Wiley & Sons., petulant borderlines may be best characterized by extreme unpredictability and restless, irritable, impatient, and complaining behaviors. Nonetheless, Millon (2011)Millon, T. (2011). Disorders of personality: introducing a DSM/ICD spectrum from normal to abnormal. John Wiley & Sons. presents the impulsive borderline as seductive, shallow, erratic, intolerant to boredom and routine, and prone to losing control.

    Although it is possible to reach a conclusion about a probable diagnosis for Anakin, the decision between the diagnosis of BPD or BD is a difficult one (Phelps, 2014Phelps, J. (2014, September 15). Bipolar disorder and borderline personality disorder: what’s the difference? PsychEducation.org.https://psycheducation.org/diagnosis/bipolar-disorder-and-borderline-personality-disorder/#Overlap_between_diagnostic_criteria
    https://psycheducation.org/diagnosis/bip...
    ; Phillips & Kupfer, 2013Phillips, M. L., & Kupfer, D. J. (2013). Bipolar disorder diagnosis: challenges and future directions. Lancet, 381(9878), 1663-1671. https://doi.org/10.1016/S0140-6736(13)60989-7
    https://doi.org/https://doi.org/10.1016/...
    ), even when considering the diagnostic system that these nosological entities are inserted in (Leibenluft, 2014Leibenluft, E. (2014). Categories and dimensions, brain and behavior: the yins and yangs of psychopathology. JAMA Psychiatry, 71(1), 15-17. https://doi.org/10.1001/jamapsychiatry.2013.2810
    https://doi.org/https://doi.org/10.1001/...
    ). In other words, the categorical diagnostic system tends to create artificial differences between functions that are less distinct in real life (Haslam et al., 2012Haslam, N., Holland, E., & Kuppens, P. (2012). Categories versus dimensions in personality and psychopathology: a quantitative review of taxometric research. Psychological Medicine, 42(5), 903. https://doi.org/10.1017/S0033291711001966
    https://doi.org/https://doi.org/10.1017/...
    ; Leibenluft, 2014Leibenluft, E. (2014). Categories and dimensions, brain and behavior: the yins and yangs of psychopathology. JAMA Psychiatry, 71(1), 15-17. https://doi.org/10.1001/jamapsychiatry.2013.2810
    https://doi.org/https://doi.org/10.1001/...
    ). Despite this attempt to differentiate psychopathological categories, for example, BPD and BD share several diagnostic criteria, and, in fact, they look nearly identical in the DSM-5, with the crucial exception of two criteria of BPD, that is, chronic emptiness and fear of abandonment.

    Unlike the categorical system, a dimensional diagnostic system allows the identification of profiles in which the symptoms and typical characteristics of two theoretically distinct psychiatric disorders are present. The greater flexibility of the dimensional model seems to reflect more adequately the complex human functioning regarding mental conditions and, therefore, several authors assert that a dimensional system has more validity and utility over the categorical model (Widiger & Trull, 2007Widiger, T. A., & Trull, T. J. (2007). Plate tectonics in the classification of personality disorder: shifting to a dimensional model. American Psychologist, 62(2), 71. https://doi.org/10.1037/0003-066X.62.2.71
    https://doi.org/https://doi.org/10.1037/...
    ).

    From a dimensional perspective, Anakin possibly would not receive an exclusively BPD or BD diagnosis, but his pathological profile would be set up reflecting his major impairments. Figure 1 illustrates a possible profile for Anakin. The figure was created to reflect the diagnostic criteria presented in Table 2. In addition, the score from 0 to 3 was based on the alternative Model for Personality Disorders (American Psychiatric Association, 2013American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5.), where 2 and 3 are indicators of personality pathology.

    From a dimensional perspective, Anakin’s score indicates functioning impairment for six criteria. Efforts to avoid abandonment, identity disturbance, affective instability, and intense anger are the characteristics with the most significant damage in the pathological pattern exhibited by Anakin. In addition, he does not reach the cutoff point for three criteria. As previously pointed out by the literature, the dimensional diagnostic model is more informative compared to the categorical model because, more than just fitting the patient into a category, it informs the clinician about the intensity of the damage in the evaluated pathological characteristics, establishing a clinically relevant profile for decision-making (Haslam et al., 2012Haslam, N., Holland, E., & Kuppens, P. (2012). Categories versus dimensions in personality and psychopathology: a quantitative review of taxometric research. Psychological Medicine, 42(5), 903. https://doi.org/10.1017/S0033291711001966
    https://doi.org/https://doi.org/10.1017/...
    ; Leibenluft, 2014Leibenluft, E. (2014). Categories and dimensions, brain and behavior: the yins and yangs of psychopathology. JAMA Psychiatry, 71(1), 15-17. https://doi.org/10.1001/jamapsychiatry.2013.2810
    https://doi.org/https://doi.org/10.1001/...
    ; Widiger & Trull, 2007Widiger, T. A., & Trull, T. J. (2007). Plate tectonics in the classification of personality disorder: shifting to a dimensional model. American Psychologist, 62(2), 71. https://doi.org/10.1037/0003-066X.62.2.71
    https://doi.org/https://doi.org/10.1037/...
    ).

    In conclusion, we present our final word on Anakin Skywalker’s diagnosis. However, we forked Anakin’s diagnostic judgement both for the categorical perspective, which is the current model, and for the dimensional system, the main alternative model proposed.

    Our conclusion was weighted considering previous publications in which psychiatric diagnosis for Anakin included a post-traumatic stress disorder hypothesis, a BPD hypothesis, or even the impossibility of closing in a specific diagnosis. Regarding the title of our paper, from a categorical perspective, the duel between BPD and BD comes to an end, and BPD prevails. In other words, evidence from the Star Wars films (Table 1) and the detailed look at BPD diagnostic criteria (including literature besides DSM) indicate that Anakin Skywalker’s pathological pattern resembles the BPD pattern. Therefore, from a categorical perspective, our psychiatric diagnosis of Anakin Skywalker is BPD.

    On the other hand, from a dimensional perspective, the diagnosis is more complex, encompassing symptoms and characteristics of both BPD and BD. It is possibly a more detailed diagnosis that truly reflects Anakin’s daily pathological functioning since the dimensional model allows the construction of complex profiles composed of symptoms from various disorders. Specifically, from a dimensional perspective, Anakin exhibits a pattern of impairment mainly associated with exaggerated efforts to avoid abandonment, identity disturbance, affective instability, and intense anger. Based solely on a categorical model, Anakin could present a BPD diagnosis, which would imply that he shows, for example, dissociative symptoms and suicidal behavior, not reflecting the precise pathological profile presented by the character. The informative and detailed capacity of the dimensional diagnosis indicates the dangers of believing that we can make the distinction accurately (i.e., decide between one mental diagnosis or another), which can negatively impact clinical interventions.

    Although we present a final word regarding Anakin Skywalker’s mental disorder diagnosis, these considerations should be interpreted as an academic exercise with two main aims. First, to discuss the differential diagnosis between BPD and BD in an illustrative, soft, and ludic way. Second, to teach how to connect one’s behaviors with diagnostic criteria, in this case, specifically related to BPD. We hope our effort with this paper in contributing to the ways to teach using Star Wars may help students and professionals in the mental health field discuss BPD (in contrast to BD). Moreover, we expect our paper to assist professionals in creatively elaborating presentations and lessons on psychiatric disorders and, of course, knowing a little more about the Star Wars universe. Furthermore, we emphasize the need to constantly question our conclusions and adopt a humble, scientific attitude toward our theoretical convictions - as Obi-Wan Kenobi would say, “Only a Sith deals in absolutes.”

    Raquel Souza Lobo Guzzo
    Editor

    • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5

    • Bayes, A. J., McClure, G., Fletcher, K., Roman Ruiz Del Moral, Y. E., Hadzi-Pavlovic, D., Stevenson, J. L., Manicavasagar, V. L., & Parker, G. B. (2016). Differentiating the bipolar disorders from borderline personality disorder. Acta Psychiatrica Scandinavica, 133(3), 187-195. https://doi.org/10.1111/acps.12509
      » https://doi.org/https://doi.org/10.1111/acps.12509

    • Biskin, R. S., & Paris, J. (2012). Diagnosing borderline personality disorder. CMAJ, 184(16), 1789-1794. https://doi.org/10.1503/cmaj.090618
      » https://doi.org/https://doi.org/10.1503/cmaj.090618

    • Bøen, E., Hummelen, B., Elvsåshagen, T., Boye, B., Andersson, S., Karterud, S., & Malt, U. F. (2015). Different impulsivity profiles in borderline personality disorder and bipolar II disorder. Journal of Affective Disorders, 170, 104-111. https://doi.org/10.1016/j.jad.2014.08.033
      » https://doi.org/https://doi.org/10.1016/j.jad.2014.08.033

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    • World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines

    • 2

      How to cite this article: Carvalho, L. F., Miguel, F. K., & Pianowski, G. (2023). Teaching differential diagnosis with Anakin Skywalker: the duel between borderline personality disorder and bipolar disorder. Estudos de Psicologia (Campinas), 40, e210047. https://doi.org/10.1590/1982-0275202340e210047

    • Publication in this collection
      01May2023
    • Date of issue
      2023
    • Received
      16Mar2021
    • Reviewed
      29Mar2022
    • Accepted
      19Apr2022

    Authorship

    Lucas de Francisco Carvalho

    conception

    design

    data interpretation

    discussion of results

    review

    final approval

    Universidade São Francisco, Programa de Pós-Graduação em Psicologia. Campinas, SP, Brasil.

    Fabiano Koich Miguel

    analysis

    data interpretation

    discussion of results

    review

    final approval

    Universidade Federal de São Carlos, Centro de Educação e Ciências Humanas, Departamento de Psicologia. São Carlos, SP, Brasil.

    Giselle Pianowski

    analysis

    data interpretation

    discussion of results

    review

    final approval

    Universidade São Francisco, Programa de Pós-Graduação em Psicologia. Campinas, SP, Brasil.

    • Correspondence to: L. F. CARVALHO. E-mail: <lucas@labape.com.br>.
    • The authors declare they have no conflict of interests.

    • L. F. CARVALHO was responsible for the conception and design, analysis, data interpretation, discussion of results and review and approval of the final version of the article. F. K. MIGUEL and G. PIANOWSKI contributed to the analysis, data interpretation, discussion of results, review and approval of the final version of the article.

    SCIMAGO INSTITUTIONS RANKINGS

    Universidade São Francisco, Programa de Pós-Graduação em Psicologia. Campinas, SP, Brasil.

    Universidade Federal de São Carlos, Centro de Educação e Ciências Humanas, Departamento de Psicologia. São Carlos, SP, Brasil.

    Figures | Tables

    • Figures (1)
    • Tables (2)

    Figure 1.
    Borderline Personality Disorder Dimensional profile of Anakin Skywalker

    Table 1.
    Shared features between Borderline Personality Disorder and Bipolar Disorder in Anakin Skywalker’s behaviors

    Table 2.
    Anakin Skywalker´s Borderline Personality Disorder diagnostic criteria (at least 6 criteria) (APA, 2013)

    Figure 1. Borderline Personality Disorder Dimensional profile of Anakin Skywalker

    Teaching differential diagnosis with Anakin Skywalker: the duel between borderline personality disorder and bipolar disorder (4)Note: We use the 3-points metric (0-3) from the alternative Model for Personality Disorders (APA, 2013), where 2 and 3 are indicators of personality pathology.

    Table 1. Shared features between Borderline Personality Disorder and Bipolar Disorder in Anakin Skywalker’s behaviors

    Biomarkers, early events, symptoms, and traits BPD vs. BD Anakin Skywalker Disorder recommendation
    Childhood
    (8 years old)
    Youth
    (18 to 22 years old)
    Adulthood
    (46 years old)
    Biomarkers (Phelps, 2014Phelps, J. (2014, September 15). Bipolar disorder and borderline personality disorder: what’s the difference? PsychEducation.org.https://psycheducation.org/diagnosis/bipolar-disorder-and-borderline-personality-disorder/#Overlap_between_diagnostic_criteria
    https://psycheducation.org/diagnosis/bip...
    )
    None High levels of Midi-chloriansa None
    Early life stressb (Leibenluft, 2014Leibenluft, E. (2014). Categories and dimensions, brain and behavior: the yins and yangs of psychopathology. JAMA Psychiatry, 71(1), 15-17. https://doi.org/10.1001/jamapsychiatry.2013.2810
    https://doi.org/https://doi.org/10.1001/...
    )
    BPD > BD Slave; abandons his mother; orphaned of a father BPD
    Emotional lability BPD ~ BD Love-hate relationship with his wife and with his mentor (epi. III) Love-hate relationship with his son and with the Emperor (epi. VI) BPD/BD
    Impulsiveness BPD > BD Hidden and hasty marriage (epi. II) Tells his son that he is his father and attacks him (supposedly, killing him) (epi. V) BPD
    Aggressiveness/hostility BPD > BD Kills all Tusken Raiders (epi. II) and all the Jedi placed in the Jedi library (epi. III) Kills those who are under his command when expectations are not met (epi. IV, V) BPD
    Harm avoidance (De la Rosa et al., 2017De la Rosa, I., Oquendo, M. A., García, G., Stanley, B., González-Pinto, A., Liu, S. M., & Blanco, C. (2017). Determining if borderline personality disorder and bipolar disorder are alternative expressions of the same disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. The Journal of Clinical Psychiatry, 78(8), 994-999. https://doi.org/10.4088/JCP.16m11190
    https://doi.org/https://doi.org/10.4088/...
    ; Phillips & Kupfer, 2013Phillips, M. L., & Kupfer, D. J. (2013). Bipolar disorder diagnosis: challenges and future directions. Lancet, 381(9878), 1663-1671. https://doi.org/10.1016/S0140-6736(13)60989-7
    https://doi.org/https://doi.org/10.1016/...
    )
    BPD > BD None None None
    Depression BPD > BD None None None
    Anxiety (Leibenluft, 2014Leibenluft, E. (2014). Categories and dimensions, brain and behavior: the yins and yangs of psychopathology. JAMA Psychiatry, 71(1), 15-17. https://doi.org/10.1001/jamapsychiatry.2013.2810
    https://doi.org/https://doi.org/10.1001/...
    )
    BPD > BD Unable to stop worrying about his mother (epi. II, III) Constantly worried about the future of the Empire (epi. V, VI) BPD
    Manic episodes (Fornaro et al., 2016Fornaro, M., Orsolini, L., Marini, S., Berardis, D., Perna, G., Valchera, A., Ganança, L., Solmi, M., Veronese, N., & Stubbs, B. (2016). The prevalence and predictors of bipolar and borderline personality disorders comorbidity: systematic review and meta-analysis. Journal of Affective Disorders, 195, 105-118. https://doi.org/10.1016/j.jad.2016.01.040
    https://doi.org/https://doi.org/10.1016/...
    ; World Health Organization, 1992World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines.)
    BD-I > BPD None None None
    • Note: a: Midi-chlorians are microscopic, intelligent life forms, and reside within the cells of all living organisms, allowing the Force to speak through them, making some beings sensitive to the Force (Carvalho, 2017Carvalho, L. F. (2017). From Anakin Skywalker to Darth Vader: understanding Star Wars based on Theodore Millon’s theory of personality pathology. Revista de Medicina y Cine, 13(3), 121.); b: e.g., emotional abuse, emotional neglect, and physical neglect. Row cells regarding symptoms or traits are in grey for childhood, as the diagnostic of Borderline Personality Disorder (BPD) and Bipolar Disorder (BD) are based on symptoms and traits presented in adulthood (i.e., ≥ 18 years old).

    Table 2. Anakin Skywalker´s Borderline Personality Disorder diagnostic criteria (at least 6 criteria) (APA, 2013)

    Diagnostic criteria Anakin Skywalker Is the criterion present?
    Youth Adulthood
    1. Efforts to avoid real or imagined abandonment Cannot bear the thought of losing his mother and wife (epi II, III) None* Yes
    2. Unstable and intense interpersonal relationships, including idealization and devaluation Love-hate relationship with his wife and with his mentor (epi. III) Love-hate relationship with his son and with the Emperor (epi. VI) Yes
    3. Identity disturbance “I’m not the Jedi I should be.” (epi. III)b Oscillates between defending the empire and destroying his son (epi. VI) Yes
    4. Impulsivity with self-damaging Hidden and hasty marriage (epi. II) He tells his son that he is his father and attacks him (supposedly, killing him) (epi. V) Yes
    5. Suicidal behavior, threats, or self-mutilating behavior None None No
    6. Affective instability (e.g., irritability, anxiety)a Unable to stop worrying about his mother (epi. II, III) Constantly worried about the future of the Empire (epi. V, VI) Yes
    7. Chronic feelings of emptiness None None No
    8. Intense anger Kills all the Tusken Raiders (epi. II) and all the Jedi that were in the Jedi library (epi. III) Kills those who are under his command when expectations are not met (epi. IV, V) Yes
    9. Stress-related paranoid ideation or severe dissociative symptoms None None No
    • Note: a: focus was given to anxiety, as irritability is also contemplated within the 8th criterion; b: quote from Anakin; *: the reader must note that when episodes IV, V, and VI were released, Shmy Skywalker (Anakin’s mother) and Padmé Amidala (Anakin’s wife) had not yet been created. Therefore, in these episodes, there is no explicit evidence of Anakin’s abandonment avoidance, although the Star Wars canon clearly suggests this trait in Vader (e.g., Fortress Vader saga in Star Wars Darth Vader comics 19 to 25).

    How to cite

    Teaching differential diagnosis with Anakin Skywalker: the duel between borderline personality disorder and bipolar disorder (2024)
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