Bipolar Syndrome versus Borderline Personality Disorder
How do you distinguish between bipolar syndrome and borderline personality disorder?The American psychiatric Association defines borderline personality as (quoting from the DSM five page 663):
“A pervasive pattern of instability interpersonal relationships, self-image, and affects, and marked impulsivity, beginning in early adulthood and present in a variety of contexts as indicated by five (or more) of the following:
1/ Frantic efforts to avoid real or imagined abandonment.
2/ A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation.
3/ Identity disturbance: markedly and persistently unstable self image or sense of self.
4/ Impulsivity in at least two areas that are potentially self damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating).
5/ Recurrent suicidal behaviour, gestures, or threats, or self mutilating behaviour.
6/ Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and or rarely more than a few days).
7/ Chronic feelings of emptiness.
8/ Inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper, consistent anger, recurrent physical fights).
9/ transient, stress-related paranoia ideation or severe dissociative symptoms.”
You can see how many of the symptoms overlap with bipolar syndrome, everything in 4, 5 and 6 above are also classic bipolar characteristics and 7, 8 and 9 are also common features of bipolar syndrome. The main difference I can see is that with borderline personality disorder (BPD) the behaviours are in response to and triggered by events whether real or imagined in the persons interpersonal relationship i.e. when a person with BPD feels loved/attractive they feel great, excessively or idealistically great but then that the threat of real or even imagined abandonment, criticism or devaluation produces an enormous and horrible response crashing them down into destructive depression and anger, in the sense it’s all about rejection. I’m sure that in today’s world with Facebook and other social media the possibility of triggers for BPD worse than they’ve ever been.
A characteristic of BPD is that the changes in mood are highly reactive or responsive to the outside world (specifically relationships) and usually only last a few hours or rarely a few days, there are types of bipolar syndrome however that do not have a rapid cycling feature and this can help you to distinguish between the two. So if for example you have a sustained elevated manic/hypomanic mood or persistent depressive mood regularly lasting days, weeks, months or years then that’s bipolar disorder and not BPD. If however you have bipolar syndrome with ultra-rapid cycling (i.e. you switch from manic/hypomanic to depressed several times in a day) then it may be very difficult to distinguish between bipolar syndrome and BPD, also bipolar mixed states now called mixed effective disorder can be complex to understand.
Generally speaking however the volatile reactivity to the outside world is pervasive and continuously present compared to bipolar disorder which may be episodic with periods of remission; unfortunately however sometimes bipolar disorder at least when untreated is also continuous.
It may be useful to look at the triggers for the two conditions: in BPD the triggers are always to do with interpersonal relationships conversely in bipolar syndrome there can be other triggers or no apparent triggers at all, for example I have a trigger for my bipolar mania which is nothing to do with interpersonal relationships, I’ve often become manic dancing to house music even when alone in my own home let alone with the added excitement of being in a club (which is apparently what you kids call the disco these days). Unfortunately however using triggers as a means of differentiating between bipolar syndrome and BPD may not work because it’s quite possible to have bipolar syndrome and one of your triggers could be the feeling of rejection in your relationships, I’ve definitely been triggered by my interpersonal relationships, becoming high when I felt popular and rapidly swinging into depression when I felt rejected, so sometimes this can make distinguishing between the two conditions difficult.
Furthermore paranoia is a common feature of bipolar syndrome, I lived with horrible paranoia myself most of my life and it can wreak havoc in your interpersonal relationships, feeling paranoid or rejected can overlap so much that in practice it’s hard to distinguish them. Incidentally something I’ve done in my treatment over the last five years has completely eliminated the paranoid thoughts and feelings that were part of my bipolar syndrome which is nice.
Other characteristics of bipolar disorder that are not part of BPD are the grandiosity/super confidence, speeded up rapid talking, incredible energy and flow of ideas characteristic of bipolar mania.
Although the DSM-5 makes reference to BPD starting in adolescent hood, so can bipolar syndrome so I don’t think age of onset helps us differentiate.
A very common feature of bipolar syndrome is sleep disturbances i.e. having periods where you need very little sleep but is periods where you need lots of sleep and also having the timing of your sleep cycles go out of whack.
Another distinguishing feature between bipolar syndrome and BPD is that in BPD the condition is considered to be always present, it’s basically the person’s personality, it’s their baseline whereas in bipolar syndrome when the condition is in remission or properly managed with treatment the mood swings go away. Over time this may be a useful way of distinguishing the two, so if you successfully treat bipolar syndrome gradually over time you should experience periods of balance without any mood swings because that’s your baseline when you’re well, however if you’ve got mixed states with ultra rapid cycling and paranoia and one of your triggers that can set off a mood swing is being told your great being told your rubbish and rejected then in the beginning you quite possibly can’t distinguish between the two conditions with absolute certainty.
So how do you distinguish between bipolar syndrome with ultra rapid cycling when social paranoia/rejection is a trigger and borderline personality disorder?
The honest answer is with great difficulty, but there is a solution…
Let’s be practical here the point to a diagnosis is to help lead you to practical solutions see someone with what could be bipolar syndrome I’ll start to apply my bipolar treatments which involves self-monitoring changes in your speed/mood and then self-medicating to adjust the levels of the neurotransmitter dopamine, regulating sleep and sleep cycles, applying total darkness to the brain while sleeping, dampening down overactive stress responses and other things which you can find described elsewhere on my site. When these treatments work well that’s that however when the treatments work very poorly or not at all and the primary emotional trigger for the mood changes is coming from interpersonal relationships then I’m thinking more along the lines of BPD and would recommend that the person have psychotherapy to change psychology and improve coping strategies, as far as I know a therapy particularly developed for BPD is called Schema therapy. If the treatment I was applying for bipolar syndrome was working quite well and yet there were still clearly defined triggers whether in interpersonal relationships or not I would still also recommend appropriate psychotherapy to look at changing one psychology around as triggers.
What matters more than fitting yourself into one diagnostic box versus another diagnostic box is you getting well so try the treatment for both and see which one or combination you feel helps you the most; diagnostic labels in psychiatry are not perfect and your individual condition may not perfectly fit into one of the boxes. Use diagnostic labels just as helpful tools to suggest which therapies may help you the most and try the therapies.
You may also be wondering is it possible to have both bipolar syndrome and BPD to which the answer is absolutely yes, sorry there’s nothing fair in health or medicine so maybe if you have a lot of overlapping symptoms you might not get a definitive diagnosis, one psychiatrist may suggest you have bipolar syndrome and another BPD but there is a really simple and effective way to sort this out and cut through the confusion which is to try the treatments for both and see which one or combination you feel helps you the most. My approach would be do everything you can to improve the fundamental health of your brain, try up and down regulating the production of dopamine when you’re depressed or manic, try mood stabilising remedies, apply darkness therapy et cetera et cetera for the bipolar side and engage in appropriate psychotherapy to address the psychology of your triggers.
Mental health conditions can respond fantastically well to treatment, remember even when it feels like getting well is impossible it probably isn’t, mental health problems are very treatable. When you feel really terrible you can lose sight of what it would feel like to be well; the but know this the feeling and belief that nothing you can do will make any difference is the illness talking, that’s the illness messing with your mind, actually it’s the illness messing with your brain our brain constructs what we think is reality; with the right treatments your brain literally constructs a completely different reality. So keep working on the improving your health and solving the problem, try thinking outside the box but do keep safe and always consult with your Dr and or appropriate health care provider before making any changes that cause your condition to put you in harm’s way.