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

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

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

http://orcid.org/0000-0002-3274-9724

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

http://orcid.org/0000-0003-2498-692X

Giselle Pianowski

analysis

data interpretation

discussion of results

review

final approval

http://orcid.org/0000-0003-4400-7151

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.

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Figures | Tables

Figures (1)
Tables (2)

Thumbnail

Figure 1.
Borderline Personality Disorder Dimensional profile of Anakin Skywalker

Thumbnail

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

Thumbnail

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

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
Biomarkers, early events, symptoms, and traits	BPD vs. BD	Childhood (8 years old)	Youth (18 to 22 years old)	Adulthood (46 years old)	Disorder recommendation
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-chlorians^a			None
Early life stress^b (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?
Diagnostic criteria	Youth	Adulthood	Is the criterion present?
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 8^th 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).

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Programa de Pós-Graduação em Psicologia, Pontifícia Universidade Católica de Campinas Núcleo de Editoração SBI - Campus II, Av. John Boyd Dunlop, s/n. Prédio de Odontologia, 13060-900 Campinas - São Paulo Brasil, Tel./Fax: +55 19 3343-7223 - Campinas - SP - Brazil
E-mail: psychologicalstudies@puc-campinas.edu.br

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

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[1] Correspondence to: L. F. CARVALHO. E-mail: <lucas@labape.com.br>.