Sometimes I Act Crazy: Is it Borderline or Bipolar?

Borderline Personality Disorder is often both overdiagnosed (sometimes by practitioners who don’t like their patient) and underdiagnosed (sometimes by clinicians who “don’t believe in” the BPD diagnosis). It is usually associated with other illnesses, mostly depression, and is especially often mistaken for bipolar disorder. The confusion is understandable. Both illnesses are characterized by mood swings, irritability, and erratic behavior. As we learn more about the associated neurobiology of these diseases, we may indeed find that there are physiological similarities. However, the third, fourth, and fifth editions of the DSM, over the last 30 years, make specific distinctions in the respective diagnoses.

Recent, more definitive studies have also established discriminating characteristics between borderline patients with depression and bipolar patients with primary depression. Bipolar patients have twice the number of first-degree relatives with the bipolar diagnosis (assuming, of course, that the relatives were accurately diagnosed). Borderline patients have more accompanying diagnoses, including post-traumatic stress disorder, eating disorders, and attention deficit disorder. Borderline patients also endorse more severe depressive symptoms and have experienced more suicide attempts and self-mutilating behavior. They exhibit increased anger, anxiety, paranoid thoughts, and hypochondria. Social functioning is also statistically more impaired in borderline than in bipolar individuals.

Unstable attachments and intense fear of abandonment are primary characteristics of BPD, but less often seen in bipolar illness. Mood changes in BPD are usually more reactive to situational stresses and more rapidly shift and dissipate, whereas bipolar swings may be spontaneous, and must persist, by formal DSM definition, for at least several days.

Although some patients satisfy criteria for both diagnoses, BPD occurs more commonly in the general population. Recommended treatment for these two illnesses is different. Pharmacotherapy is important in treating bipolar disorder, most often with mood stabilizers, antidepressants, and antipsychotics. Psychotherapy is the primary treatment for BPD, yet medications may be useful for accompanying symptoms. When medicines are employed, they are primarily the same drugs used in treating bipolar disorder.

In our society, stigma appears to hover over the diagnosis of BPD, more than with other labels. When celebrities are cited for outrageous behaviors, it seems more acceptable for them to embrace bipolar illness and race to rehab, rather than acknowledge what, for many, is more likely borderline conduct.

Despite similarities between bipolar disorder and BPD, distinguishing the diagnoses is paramount in devising optimal treatment.