Borderline personality disorder and bipolar disorder are often confused.2 While they seem similar, bipolar disorder includes significant periods of depression and mania (a state of restless excitement that can lead to psychosis). Borderline personality disorder affects all aspects of someone’s ability to function due to extreme and rapid emotional, cognitive and behavioral instability.
Symptoms of Borderline Personality Disorder (BPD)
The traits associated with BPD fall into five categories of dysregulation: emotions, relationships with others, behaviors, thinking, and internal self.5 Dysregulation means being unable to effectively manage these symptoms and maintain stability. These areas of dysfunctions are relational and impact interactions with others, the environment, and someone’s own internal state.
Early research suggested higher rates of BPD in women; however, current research shows a comparable rate of BPD diagnosis in men and women. Women with BPD more often report feelings of emptiness and emotional instability, whereas men identify more with impulsivity.7
The depth of emotional misery experienced due to BPD increases the risk of death by suicide by nearly 50 times that of the general population.7Additionally, 75% of adults with BPD report at least one incident of self-harm during their lifetime.7 It is estimated that between 1 to 6% of the general population have BPD. Due to impulsive risk taking, self-harm, and suicidality, individuals with BPD are often hospitalized.7
Signs and symptoms of borderline personality disorder may include:
- Attaching easily to others and fearing abandonment
- Hating being alone
- Chronic patterns of emotional and behavioral instability
- Chaotic, intense relationships, which may include domestic violence
- Shifting between extreme opposites: love, hate; kind, cruel; strong, weak; capable, helpless; persecutor, victim
- Intense emotions with extreme highs and lows that seem uncontrollable and rapidly changing
- High emotional sensitivity; crying easily and being “thin skinned”
- Acting emotionless, aloof, or uncaring
- Exhibiting deep despair and emotional misery expressed as, “I can’t take it anymore.”
- Coming across to others as unstable or volatile
- Viewing the world as hurtful
- Appearing competent, but internally feeling incapable, useless, or worthless
- A good actor, but worrying they will be found out as a fraud
- Lying or exaggerating frequently
- Impulsivity with poor problem solving skills
- Risky behaviors, like gambling, spending, stealing, sexual promiscuity, reckless driving, extreme sports, drug or alcohol use, binge eating
- Often have a history of trauma
- Living in a state of unrelenting crisis and high drama
- Engaging in intentional self-harm, such as cutting, burning, skin picking, overdoses, or breaking bones
- Having frequent thoughts of suicide
- Using threats, such as suicide, or running away, to influence others
- Experiencing a sense of emptiness or numbness
- Not being able to identify who they really are
- Frequently feeling misunderstood, different, weird, or like they don’t fit in
- Lacking close friends
- Inappropriate and intense anger, enough to fight or throw things
- Being paranoid, or distrustful of others
- Dissociating from reality, losing track of time or staring off into space
Symptoms of Bipolar Disorder
Bipolar disorder is a severe psychiatric illness that affects about 2% of the population.1,4 Bipolar disorder causes extreme mood swings between highs (mania, which can become psychosis) and lows (depression). Mania may appear once in a lifetime, or a few times per year. There can also be stable periods with normal moods. It is estimated that depression accounts for about 75% of bipolar mood states over time.22 This may be why bipolar disorder has the highest rate of completed suicide of any psychiatric disorder.2
For a diagnosis of bipolar disorder, an individual must meet criteria for a manic or hypomanic episode. To be considered mania, an individual must have high energy or activity with an elevated, expansive, or irritable mood that lasts for at least one week and is present most of the day, nearly every day. To be considered hypomania, the mood must last at least four consecutive days and be present most of the day, almost every day.1
Signs of a manic episode for those with bipolar disorder may include:9
- A heightened sense of self-importance
- Sleeplessness, or feeling no need for sleep
- Taking on purposeless tasks without stopping
- Increased energy, activity, restlessness, agitation
- Euphoric mood
- Thinking up “great” ideas that may actually be implausible
- Being impatient and “on the move”
- Extreme irritability
- Poor concentration
- Poor decision-making
- Moving thoughtlessly from one activity to another
- Racing thoughts, fast talking, jumping between ideas
- Impulsive spending sprees or sexual behavior
- Provocative, intrusive, or aggressive behavior
- Misuse of drugs, alcohol, and prescription medications
- Denial that anything is wrong
Signs of a depressive episode may include:9
- Sad, anxious, or empty-feeling mood nearly every day
- Feelings of hopelessness and pessimism
- Loss of interest or pleasure in activities once enjoyed
- Changes in appetite, significant and unintended weight loss or gain
- Sleeplessness or sleeping too much
- Restlessness and irritability
- Decreased energy and fatigue nearly every day
- Feelings of guilt, worthlessness, and helplessness
- Difficulty concentrating, remembering, or making decisions nearly every day
- Bodily symptoms not caused by physical illness or injury
- Thoughts of death or suicide or making plans for suicide
Bipolar disorder can be diagnosed as mild, moderate or severe, or with psychosis. There are many other specifiers that can be added to the diagnosis: anxious distress, mixed features, rapid cycling, melancholic features, mood-congruent psychotic features, catatonia, peripartum onset, and seasonal pattern.1
BPD vs. Bipolar Disorder
The difference between BPD and bipolar disorder can seem subtle, but there are several symptoms that can help determine which disorder is present.
Key Differences Between BPD & Bipolar Disorder
| Borderline Personality Disorder | Bipolar Disorder |
| Chronic emotional instability with frequent, rapid changes | Mood instability over longer periods of time with periods of normal mood in between |
| Dichotomous thinking: thinking and behaving in extreme opposites | Poor cognitive ability during depressive or manic episodes |
| Unrelenting crisis | Crises appear during height of depressive or manic episodes |
| Poor problem solving | Poor decision making |
| More self-harm and suicide attempts | More completed suicides |
| Extreme fear of abandonment and fear of being alone | Likely to isolate during depressive episode and can be overly social during manic episode |
| Sleep disorders; chaotic, not enough, wrong hours | Sleeping too much or sleeping too little |
| Constantly feels something is wrong with them | Denies anything is wrong |
| Intentional self-harming behaviors | Impulsive behavior that can lead to self-harm |
| More likely to fear dying | More likely to have recurrent thoughts of death (not fear of dying) |
| Continuous and unchanging pattern of instability that impacts functioning | Uncharacteristic changes in functioning noticeable by others when moving from one episode to another |
| Intense emotions and high emotional sensitivity | Normal emotions with episodes of extreme highs and lows |
| BPD can be accompanied by depression and has more emotional reactivity and volatility | Bipolar can look a lot like major depressive disorder; estimates are that 75% of the time the mood is disabling depression |
| Singular personality trait is chronic instability | Three mood states: manic, normal, depressive |
| Suicidality is chronic | Suicidality is intermittent |
What Causes Bipolar vs. BPD?
There are a number of causes for both BPD and Bipolar disorder which at times overlap. These causes are environmental, genetic and can be hereditary.
Causes of BPD may include:
- History of physical, mental and sexual abuse
- Death of a caregiver
- Family history of BPD
- History of depression, anxiety or bipolar disorder
- Inconsistency in childhood
- Trauma
- Attachment style dysfunction
- Low self-esteem
Bipolar disorder can be caused by:
- Family history of Bipolar Disorder
- Death of a caregiver
- Trauma
- Drug and alcohol abuse
- Sleep disturbances
- Overwhelming stress
Can You Have Bipolar and BPD?
It is possible to have both BPD and bipolar disorder. Given the great overlap of the symptoms of both conditions, it’s common to misconstrue one diagnosis for the other; however, some people actually have both diagnoses. Currently, about 20% of individuals with BPD also have a diagnosis of bipolar disorder.10 Sorting through the symptoms of both can take time, but learning about both disorders can help in understanding which symptoms are that of bipolar disorder and which are related to BPD.
Diagnosis of Borderline Personality Disorder vs. Bipolar Disorder
Before treatment is determined, the most important step is getting the correct diagnosis. Due to the overlapping characteristics of BPD and bipolar disorder, these disorders can be confused and a misdiagnosis could mean ineffective treatment and poor outcomes.7 Diagnosis should be sought through a healthcare provider, either a primary care physician or mental health specialist, such as a psychiatrist or a psychologist, prior to beginning any treatment.
There are several factors that can help determine whether BPD or Bipolar disorder should be diagnosed, including:3
- What triggers the mood shift? BPD shifts are triggered by sensitivity to the environment. Bipolar swings are neurological and aren’t triggered by changes in the environment.
- How do they react when depressed? Individuals with BPD can still be impulsive and reactive when depressed. Bipolar depression is disabling.
- What are their thinking patterns? Individuals with BPD use severe dichotomous thinking and swing between extreme opposites, i.e., fantastic and horrible. Individuals with bipolar disorder do not display dichotomous thinking.
- What’s the emotional response to stressors? People with BPD show deep, intense emotional pain that evokes strong empathy. People with bipolar disorder often don’t express emotional pain, making it hard to empathize with them.
- What is their care seeking behavior? Individuals with BPD openly seek care, hoping for exclusivity, and are highly sensitive to rejection (even the smallest slight). Individuals with bipolar disorder initiate care impulsively on their own without considering others and leave them to “clean up” the mess.
- How do they handle conflict? People with BPD use splitting (everything is all good or all bad); if they are challenged, they become angry. People with bipolar ignore undesirable realities; if confronted, they deny the significance of it.
- What are the lengths of their mood states? People with BPD experience changing mood states that last minutes, a few hours, or a few days. People with bipolar disorder experience enduring mood states and may have one or more extreme mood states in a year.
- What is the nature of their shifting states? People with BPD shift their mood without shifting their level of energy. People with bipolar shift both mood and amount of energy.
Treatment for BPD vs. Bipolar Disorder
Treatments for BPD and bipolar disorder are different, though therapy is recommended for both. BPD is less frequently treated with medication, with the exception of medicating co-occurring disorders like anxiety or depression. Bipolar disorder is quickly and effectively treated with medication. Research on bipolar disorder has found that using medication and psychotherapy together provides the best outcome.
Treatment for BPD
BPD has been found to respond well to dialectical behavioral therapy (DBT) as well as cognitive behavioral therapy (CBT). DBT is currently the frontline approach for treating BPD. This includes both group and individual psychotherapy with a specific approach aimed at helping those with BPD learn how to navigate and handle their feelings. These skills help teach those with BPD how to better relate to others and handle challenges.
There may be times when a psychiatrist or other prescriber may recommend medication as well. There is some controversy about medication use for BPD because it is a personality disorder. Personality disorders have a biological aspect, but there is not enough solid research to identify a targeted, consistent, effective medication for personality disorders.
Most medications used for BPD are in these categories:7
- Antidepressants
- Anti-psychotics
- Mood stabilizers
- Anti-anxiety agents
- Nutraceuticals
Treatment for Bipolar Disorder
Cognitive behavioral therapy (CBT) is quite often used to treat bipolar disorder. CBT is the frontline treatment option for bipolar disorder as well as other mood disorders. CBT challenges those with bipolar disorder as it focuses on changing negative thought processes to more positive thoughts. It helps to identify triggers of a bipolar episode and understand why a mood swing can occur. Long term, CBT for bipolar disorder can help to give awareness of issues which otherwise would have gone unmanaged.
Medications are often an important part of treatment for those with bipolar disorder. Common medications include:
- Lithium
- Mood stabilizers
- Anti-psychotics
- Antidepressants
- Anti-anxiety agents
Lithium has been used for decades and is the most well-known bipolar medication; however, it can become toxic in high doses and must be monitored with blood tests.2
