Borderline personality disorder and bipolar disorder diagnoses are often confused.2 While they seem similar, bipolar disorder is a mood disorder, which includes significant periods of depression and mania (a state of restless excitement that can lead to psychosis). Borderline personality disorder is a personality disorder that affects all aspects of effective life function due to extreme and rapid emotional, cognitive and behavioral instability.
Traits & Characteristics 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 or maintain stability. These areas of dysfunctions are relational and depend on interactions with others, the environment and one’s 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 endorse 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 meet the diagnosis. In a clinical setting, 10% of outpatients and 20% of inpatients meet criteria for a BPD diagnosis. Due to impulsive risk taking, self-harm, and suicidality, individuals with BPD are high utilizers of health care and inpatient treatment.7
Characteristics of borderline personality disorder include some, or all, of the following:
- Attaches easily to others and fears being abandoned
- Hates being alone
- Chronic patterns of emotional and behavioral instability
- Chaotic, intense relationships, which may include domestic violence or assault
- Shifts 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; cries easily and is “thin skinned”
- Acts emotionless, aloof, or uncaring
- Exhibits deep despair and emotional misery expressed as, “I can’t take it anymore.”
- Comes across to others as unstable or volatile
- Views the world as hurtful
- Appears competent, but internally feels incapable, useless, or worthless
- A good actor, but worries he/she will be found out as a fraud
- Frequently lies or exaggerates
- Impulsive with poor problem solving skills
- Risky behaviors, like gambling, spending, stealing, sexual promiscuity, reckless driving, extreme sports, drug or alcohol use, binge eating
- History of trauma is prevalent
- Lives in a state of unrelenting crisis and high drama
- Engages in intentional self-harm, such as cutting, burning, skin picking, heroin overdoses or breaking bones
- Has frequent thoughts of suicide and may have multiple attempts over time
- Uses threats, such as suicide, or running away, to influence others
- A sense of emptiness or numbness
- Not being able to identify who he/she really is
- Frequently feels misunderstood, different, weird, or like he/she doesn’t fit in
- Lacks close friends
- Inappropriate and intense anger, enough to fight or throw things
- Paranoid, or distrustful of others
- Dissociates from reality, loses time or stares off as if he/she is not present
Traits & Characteristics of Bipolar Disorder (BD)
Bipolar disorder is a severe psychiatric illness ranked as one of the top twenty causes for disability and affects about 2% of the population.1,4 Bipolar disorder causes extreme mood swings between highs (mania, which can change to 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.2. This may be why bipolar disorder has the highest rate of completed suicide of any psychiatric disorder.2
Bipolar disorder manifests with both internalized and externalized symptoms: internalized are most commonly anxiety and depression, while externalized are risk-taking and impulsivity.2 A recent study has shown that bipolar disorder is 30 times greater in adults who were diagnosed with both attention deficit hyperactivity disorder (ADHD) and anxiety during childhood; however, there is controversy surrounding this finding.5 Bipolar disorder is one of the most inheritable mental health diseases.4
For a diagnosis of bipolar disorder, it is necessary for an individual to 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
Characteristics of bipolar disorder include the following:
Mania episode signs and symptoms include:9
- Heightened sense of self-importance
- Sleeplessness, or feeling no need for sleep
- Takes on purposeless tasks and doesn’t stop
- Increased energy, activity, restlessness, agitation
- Euphoric mood
- Thinks up “great” ideas that may be implausible
- On the move and can’t wait
- 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
- Abuse of drugs, such as cocaine, alcohol and sleeping medications
- Denial that anything is wrong
Depressive episode signs include:9
- Sad, anxious, or empty-feeling mood nearly every day
- Feelings of hopelessness and pessimism – giving up
- Loss of interest or pleasure in activities once enjoyed, including sex
- Change 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
Key Differences Between BPD & Bipolar Disorder
The table below outlines the differences between Borderline Personality Disorder and 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 |
| No specific medications for personality disorders | Effective treatment with medication |
| More parasuicide 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 |
Diagnosis of Borderline Personality Disorder vs. Bipolar Disorder
Dr. Gregory Lester suggests the following comparisons to differentiate the diagnosis of BPD from bipolar disorder.
These factors determine whether BPD or Bipolar disorder should be diagnosed:3
- What triggers the mood shift: BPD shifts are triggered by sensitivity to the environment. Bipolar swings are neurological and independent of 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 dichotomous thinking; swinging between extreme opposites, i.e., fantastic and horrible. Individuals with bipolar disorder do not display dichotomous thinking.
- The depth of emotional response: Individuals with BPD show deep, intense emotional pain that evokes strong empathy. Individuals with bipolar disorder lack depth of or 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: Individuals with BPD use splitting (it’s all good or all bad); if they are challenged, they become angry and conflictual. Individuals with bipolar ignore undesirable realities; if confronted they deny the significance of it.
- What are the lengths of their mood states: Individuals with BPD experience changing mood states that last, minutes, a few hours or a few days. Individuals with bipolar experience enduring mood states and may have one or more extreme mood states in a year.
- What is the nature of their shifting states: Individuals with BPD shift mood without shifting their level of energy. Individuals with bipolar shift both mood and psychic energy.
Diagnosis should be sought through a healthcare provider, either a primary care physician or mental health specialist such as a psychiatrist prior to beginning any treatment.
Treatment for BPD vs. Bipolar Disorder
Treatment for BPD and bipolar disorder are different. Since BPD is a personality disorder and bipolar is a mood disorder, effective treatments are specific to the nature of the illness. BPD is less frequently treated with medication, with the exception of medicating co-occurring disorders. 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.
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
Medications work for some people and not for others.
Medications for bipolar disorder are somewhat similar. The most common medications for treatment are: Lithium; Mood stabilizers; Anti-psychotics; Antidepressants; and 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
Psychotherapy is recommended for both disorders. BPD has been found to respond well to Dialectical Behavioral Therapy (DBT) and Acceptance and Commitment Therapy. Cognitive Behavioral Therapy is quite often used to treat bipolar disorder. Having the support and guidance of a qualified therapist makes a difference and should be considered an essential part of treatment for both disorders.
Outlook of BPD vs. Bipolar
There is no cure for mental illness. Luckily, both of these disorders can be managed with the right treatment. Before treatment is determined, the most important step is getting the correct diagnosis. Due to the overlapping characteristics of BPD and bipolar these disorders can be confused and a misdiagnosis could mean ineffective treatment and poor outcomes.7
Untreated borderline personality disorder leads to a lack of reliable, supportive relationships because most BPD friends or family members cannot tolerate emotional chaos long term. Social and family connections are fundamental to human beings. Without them physical and mental health outcomes are reduced and longevity is unlikely. Untreated BPD also leads to higher rates of eating disorders, addiction, incarceration and suicide. For individuals with BPD effective treatment and support systems are imperative.
Bipolar disorder is treatable with medication and therapy long-term. The correct diagnosis and education about the disease are essential. Individuals with bipolar disorder need to include their loved ones in their treatment.2 Their changes in mood and behaviors can be more easily identified by someone else, and that could mean quick action to reduce the potential damage (financial, physical, emotional, occupational, and in relationships). Depressive episodes must be taken seriously, even if it is the 100th episode, suicide is always a potential risk and can be prevented.
Like most illnesses, the key is recognition, accurate diagnosis and effective treatment. Millions of people have these diagnoses and live productive, satisfying lives. Those people who remain unaware and untreated can be disabled by mental illness. Asking questions and educating one’s self then seeking treatment is the key to having a life worth living.
Additional Resources for BPD and Bipolar Disorders
The following are helpful additional resources for anyone impacted by BPD or bipolar disorder:
