Borderline personality disorder and bipolar disorder are often confused – even by clinicians. However, although some of their symptoms are similar, the two disorders are very different. They have different symptoms, causes, and courses of illness – and require different treatments.
Distinguishing between the two disorders is very important. Misdiagnosis can prevent a young person from accessing suitable treatment, whether it’s a type of psychotherapy or medication. On the other hand, accurate diagnoses pave the way for effective treatment and lasting recovery.
This blog offers some information on the differences between BPD and bipolar disorder – and how clinicians can differentiate between the two.
What Is Borderline Personality Disorder?
Borderline personality disorder (BPD) is a type of personality disorder that usually develops during adolescence. Having borderline personality disorder doesn’t mean there is something wrong with someone’s personality. Instead, it means that the way they relate to themselves and the world around them makes some aspects of daily life difficult to manage. Some experts understand BPD traits as a normal response to – or coping mechanism for – difficult life experiences that become unhelpful or harmful in everyday life.
BPD traits and symptoms can look very different from one person to another. But there are some common characteristics. Young people with BPD may:
- have patterns of intense and unstable relationships
- have an incoherent and quickly changing sense of self
- make frantic attempts to avoid (imagined or actual) abandonment
- experience chronic feelings of emptiness
- engage in impulsive behaviours, self-harm, or suicidal behaviours
There is a lot of stigma and misconceptions surrounding BPD. Some people still believe and say that BPD is untreatable or that recovery is unlikely. But in reality, with effective support, many people recover from BPD and live fulfilling independent lives.
What Is Bipolar Disorder?
Bipolar disorder is a type of depression that involves big changes in mood. These mood swings are much more extreme than those without bipolar experience. Mood episodes can be short or long, sometimes lasting for months.
During depressive episodes, young people with bipolar disorder may have recurring suicidal thoughts and feelings of despair and hopelessness. During manic or hypomanic episodes, they may experience extreme excitement, invisibility, delusions and hallucinations. Some people also experience mixed episodes, where they experience aspects of mania and depression at the same time.
Bipolar usually develops during adolescence or early adulthood, but it can onset at any time.
Living with bipolar disorder can seriously affect a young person’s life. But with effective treatment and support, young people can manage symptoms and build fulfilling futures.
Understanding Mood Changes in BPD and Bipolar Disorder
People sometimes confuse BPD and bipolar because they both involve mood changes. It’s true that extreme mood shifts – moving between a very high and a very low mood – are a core feature of both conditions. However, the causes and patterns of these mood changes are very different in each disorder.
In BPD, mood shifts are transient and usually happen in response to interpersonal events. They may be triggered by feelings of rejection or fears of abandonment. The events that cause mood shifts in BPD may seem insignificant to people without the disorder but often trigger intense psychological distress. For example, a close friend or partner not responding to a call can cause suicidal feelings or impulses to self-harm.
These responses don’t come out of nowhere. They’re rooted in BPD traits like sensitivity to rejection or fear of abandonment that may have developed over years. These traits may have formed because of traumatic childhood experiences involving perceived abandonment by caregivers, emotional unavailability, and unmet needs.
People with BPD often also struggle to manage their emotions and to self-soothe in times of distress. This can intensify their feelings and cause more extreme mood changes.
On the other hand, bipolar disorder is characterised by longer-lasting mood changes. While they can be triggered by certain events or mental states, they tend to be less related to events than BPD mood shifts. The triggers for bipolar episodes are more likely to be internal and biological, such as stress or lack of sleep.
Unlike those with BPD, young people with bipolar often experience prolonged periods of stability when they are not having a depressive or manic episode. When they are experiencing an episode, their thoughts and feelings tend to be relatively unaffected by events. For example, during a depressive episode, they’re unlikely to feel better even when something good happens to them. On the other hand, interpersonal events can usually cause the mood of someone with BPD to suddenly switch, even when they have been experiencing intense distress.
Symptoms of Bipolar Disorder and BPD
Although there can be some overlap in the symptoms of BPD and bipolar disorder, the overall pattern of symptoms is very different.
In bipolar disorder, the main symptom is extreme changes in mood that usually last a few days or a few weeks at a time. Symptoms of high moods may include feeling very happy and agitated, having a lot of energy, needing little sleep, and elevated self-confidence. They can also include delusions, paranoia, and hallucinations.
Symptoms of low moods include feeling sad or upset, social withdrawal, difficulties concentrating, and despair or hopelessness.
On the other hand, BPD symptoms include mood changes, but alongside several other core traits and symptoms that span different dimensions of emotions and behaviours. These include patterns of unstable relationships, an incoherent sense of self, and experiences of paranoid ideation and dissociation.
When Do BPD and Bipolar Symptoms Overlap?
Despite their core differences, there are still times when BPD and bipolar symptoms can overlap. Aside from mood changes, young people with both disorders may experience hallucinations and delusions, paranoia, and feelings of emptiness. Both disorders are linked to a high risk of self-harm and suicide attempts.
However, the causes and context of these symptoms are different in each disorder.
Paranoia, hallucinations, and delusions
Paranoia, hallucinations, and delusions are symptoms of both bipolar and BPD.
In bipolar disorder, these symptoms usually only appear when someone is experiencing a manic episode. Both high and low episodes in bipolar disorder are associated with imbalances in neurotransmitters (chemical messengers in the brain) like serotonin and dopamine. These imbalances can cause mood dysregulation, but also hallucinations, delusions, and paranoia.
Among people with borderline personality disorder, hallucinations, delusions, and other psychotic symptoms are relatively common. Research suggests they’re experienced by 26-54% of people with the disorder and are often connected to traumatic experiences. Transient, paranoid ideation (and dissociation) is also a core symptom of BPD.
However, unlike in bipolar disorder, hallucinations and delusions in BPD don’t only occur alongside a high mood. Instead, the frequency and triggers of these experiences can look very different from one person to the next, and experts still aren’t sure exactly why they happen. Some theories suggest that psychotic experiences in BPD may be a reaction to stress and/or associated with loneliness.
Feelings of emptiness
One common symptom of BPD is chronic feelings of emptiness. Feelings of emptiness can be difficult to articulate in words. They’ve been described as a kind of nothingness or a void that excludes all kinds of inner experiences, that prevents someone from experiencing themselves and the world around them.
Among people with BPD, feelings of emptiness might be linked to an unstable and incoherent sense of self. This may prevent young people from building a clear sense of who they are, through which they can internalise their experiences. Children who experienced inconsistent behaviours from their caregivers may have never developed a cohesive narrative of their own self and experiences, causing feelings of emptiness.
Young people with bipolar disorder may also experience feelings of emptiness. However, these feelings are typically only experienced during depressive episodes, subsiding during stable periods or high episodes. As with other bipolar symptoms, these feelings are likely connected to imbalances in neurotransmitters that regulate mood and emotions.
Self-harm and suicidality
Self-harm and suicidality are common among young people with bipolar and BPD. Research has found that 37% of adolescents with bipolar disorder have a history of self-harm. Among people with BPD, the prevalence of self-harm may be around 50 to 80% and 40 to 85% may have made suicide attempts.
In both disorders, suicide attempts and self-harm usually happen at times of low mood or intense psychological distress, whether during a low bipolar episode or after, among those with BPD, after a triggering interpersonal event.
The prevalence of self-harm and suicide highlights the urgency of effective support, treatment, and care for young people with both disorders.
Suicide Prevention
If you are feeling suicidal, there are people who can help. You could talk to a friend, family member, or someone else you trust about your feelings. You can also call a phone line for confidential support:
- Samaritans – call 116 123
- Papyrus (for people under 35) – call 0800 068 4141
The Aetiology of Borderline Personality Disorder and Bipolar Disorder
Aetiology (or etiology) refers to the cause or set of causes of a disease or condition. Researchers still don’t know the precise aetiology of either BPD or bipolar disorder. However, they have some ideas about how and why the conditions develop.
Genetic Factors
It’s established that the development of most mental disorders is influenced by inheritable, genetic vulnerabilities. This means that a person’s genes – affecting their biology and character traits – can make them more or less likely to develop the disorder. However, researchers haven’t identified precise biological vulnerabilities for either BPD or bipolar disorder.
Environmental Factors
Environmental factors can also play an important role in the development of mental health disorders. A young person’s experiences, particularly childhood adversity and trauma, can shape the way they develop emotionally, cognitively, and socially. They can also affect their brain development.
Comparing the Causes of BPD and Bipolar
The development of BPD and bipolar disorder may involve both genetic and environmental factors. But while research suggests that bipolar disorder has a very strong heritability, BPD seems to be much more influenced by environmental factors.
Numerous studies have documented high rates of childhood adversity among people with BPD, including insecure attachments, abuse, and neglect. The pathway to BPD seems to fit a biopsychosocial model where genetic predispositions, adverse life events, and social stressors combine in the development of the disorder. While there is evidence for childhood adversity among those with bipolar disorder, it is much less frequent.
Treating BPD and Bipolar Disorder
Borderline personality disorder and bipolar disorder are very different conditions. So, it’s not surprising that they require different kinds of treatment. BPD treatments are unlikely to be effective for bipolar disorder, and vice versa.
This means that receiving an accurate diagnosis is important. Misdiagnoses can lead to the wrong kind of treatment provision, preventing young people from recovering.
Treating Bipolar Disorder
Treatment for bipolar disorder often involves medication. Medications like lithium can help young people maintain a more stable mood, with less intense highs and lows. Doctors may also prescribe specific medications for manic or depressive episodes, such as antipsychotics and antidepressants.
Alongside medication, young people with bipolar disorder should also receive psychological support to help them manage their condition. This might involve learning how to track their mood and identify triggers of episodes. During depressive episodes, talking therapies like cognitive-behavioural therapy can help to manage and improve symptoms.
Treating Borderline Personality Disorder
Unlike with bipolar disorder, medication is not consistently effective in treating BPD symptoms. While research shows that some medications are very effective in treating bipolar symptoms, studies have never found the pharmaceutical treatment to cause the core symptoms of BPD to remit.
Instead, treatment for BPD typically centres around psychotherapy. This might include dialectical-behavioural therapy (a talk therapy specially designed for BPD), adolescent identity treatment, or mentalisation-based treatment.
Treatment for BPD often involves a broader support team, including social workers, psychologists, and occupational therapists.
Differential Diagnosis: Distinguishing Bipolar Disorder and BPD
Despite the clear differences between BPD and bipolar, misdiagnoses are common. Misdiagnoses of BPD are especially likely because clinicians often still have misconceptions about the disorder. For example, they may falsely believe that BPD is poorly defined or that it doesn’t respond to treatment.
Young people with BPD who are misdiagnosed with bipolar may not be referred to or recommended effective treatments like DBT. This can be detrimental to their well-being.
In most cases, it should be easy for clinicians to differentiate between BPD and bipolar disorder. But for a minority of young people, it may be more difficult. In these instances, it may help clinicians to look for certain features of BPD, such as sensitivity to stressors and triggers, difficulties managing emotions, and the absence of hypomania.
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