The symptomatic overlap between borderline personality disorder (BPD) and bipolar disorder (BD) is a topic of scientific and academic debates. This presentation highlights the main distinguishing features between the two disorders.

1. Borderline Personality
DisorderVs. Bipolar Disorder:
Diagnostic Considerations
Mohamed Ibrahim
PHO
Mackay Base Hospital
March 2022

2. Overlap between BD and BPD
• The symptomatic overlap between borderline personality
disorder (BPD) and bipolar disorder (BD) is a topic of scientific
and academic debates.
• Misdiagnosis is a common phenomenon

3. Why are BD and BPD often conflated?
• Mood changes and affective lability
• Risky behavior
• Impulsivity
• Suicidality

4. Bipolar
Disorder

6. Symptoms of Depressive Episode

7. Borderline
Personality
Disorder

11. Mood Cycling
BD: mood cycles that last for weeks
to months.
BPD: sudden, short-lived mood shifts that
last for a few hours or days

12. Triggers For Mood Swings
• Mood shifts in BPD are usually in reaction to an environmental
stressor. Iinteractions with other people or expectations about
relationships are what drive the shifts
• Mood cycles in BD are more random and less related to events.

13. Quality Of Mood Swings
• People with BD tend to experience mania and depression while people with
BPD experience intense emotional pain and feelings of emptiness, desperation,
anger, hopelessness, and loneliness.
• The mood shifts typical of BPD rarely involve elation. Usually, the shift is from
feeling upset to feeling OK, not from feeling bad to feeling a high or elevated
mood, which is more typical of bipolar disorder.

14. Sleep
• People with BD tend to have extremely disturbed sleep cycles
during periods of mania and depression (decreased need for
sleep in mania and insomnia/hypersomnia in depression)
• People with BPD can have a regular sleep cycle.

15. Non-suicidal Self-harm
• General population: 4%
• BD: 27.9% (BD II > BD I)
• BPD: 65-80% (41 % of patients have more than 50 self-mutilation acts).
Self-injury in borderline personality is seen as a means of emotional regulation, with 96 percent
saying that their negative moods were relieved immediately following an act of self-harm.
Klonsky 2011

16. SUICIDE
Suicidal
attempts
Completed
suicide
Bipolar
disorder
20–60% 4–19%
Borderline
personality
60%–70% 9%
Plans et al 2019

17. Impulsivity
• BPD is characterized by impulsive and dangerous behaviours such as driving recklessly,
inappropriate sexual behaviour, binge eating, and substance abuse.
• BD patients, during a manic episode, is known for their impulsive and risk-taking
behaviour like hypersexuality, excessive spending, and substance abuse.
• Components of impulsivity:
• Acting without inhibitions and consideration
• Choosing immediate pleasure over long-term planning.

18. Interpersonal Relationships
• Many people with BPD have very intense, conflict-riddled
relationships.
• People with BD may have difficulty maintaining relationships
because of the severity of their symptoms.

19. Abandonment Fears
• Fear of abandonment is a characteristic feature in patients with
BPD.They are consistently anxious to be forsaken and left
behind from people they are attached to.
• Patients with BD can also have this fear, but it is not a
characteristic feature of the disorder.

20. Self-image
• Poor self-image is a core feature of BPD
• People with BD can experience low self-esteem while in the
depressive phase. However inflated self-esteem is a core feature
of the manic phase.

21. Feelings of Emptiness
• Chronic emptiness is experienced as a sense of nothingness and numbness
that reflects a feeling of disconnection from both self and others. It is
associated with feelings of unfulfillment and purposelessness.
• Chronic emptiness is a frequent experience that significantly limits the
functional capacity of people with BPD.
• Feelings of emptiness may occasionally be reported in the depressive phase
of BD-II, rare to be seen in depressive phase of BD-I

22. Psychotic Symptoms
• BD: mood congruent delusions
oManic phase: grandiosity delusions
oDepressive phase: delusions of guilt / somatic delusions
• BPD: hallucinations and/or paranoid ideation are usually
transient and stress-related. Auditory hallucinations are
perceived as critical, controlling, and distressing.

23. Dissociative Experiences
• Dissociative experiences are far more common in BPD than
BD.
• Around 75% to 80% of people with BDP report experiencing
stress-related dissociation.
• Linked to self-harm

24. History of Childhood Trauma
Childhood Sexual
trauma
childhood trauma
(all types)
General population 9.2% 28%
Bipolar Disorder 24-30% 49%
Borderline
Personality Disorder
50-76% 90%

25. Heritability
Bipolar
Disorder
Borderline
Personality
General population risk 1% 3%
Risk for 1st degree relatives 9% 4.7%
MZ twin concordance 45% 11.5%
Heritability 80% 40%

26. Treatment Response
• There is a strong consensus that psychotherapies alone are not effective in bipolar illness.
They may be elective adjunctively with medications, but not by themselves.
• In contrast, there is a similar strong clinical consensus that psychotherapies are central to
the treatment of borderline personality. Many experts in borderline personality see
medications as adjunctive treatments for that condition.
• Many RCTs of bipolar illness exist, and demonstrate good efficacy with various agents, like
lithium, in prophylaxis of that condition, sometimes with complete remission. In contrast,
fewer RCTs exist of treatment with medications for borderline PD, and they tend to
demonstrate modest symptomatic benefits with psychotropic medications.

27. Prognosis
• Features of BPD gradually wane with advancing age. During their 30s and 40s, the
majority of patients attain greater stability in their relationships and vocational
functioning. Follow-up studies indicate that after about 10 years, as many as half of the
individuals no longer have a pattern of behaviour that meets full criteria for borderline
personality disorder.
• The passage of decades in bipolar illness appears to bring an increase in the
predominance of depressive symptoms in individuals in their third, fourth and fifth
decades.The interval between mood episodes tends to decrease as the individual ages.

28. Comorbidity between BD and BPD
• A literature review (Paris et al.2007) reported a prevalence of bipolar I
disorder (BD-I) in patients with BPD is 9.2%) and a prevalence of bipolar II
disorder (BD-II) is 10.7%
• Zimmerman et al 2013:About 20% of bipolar II patients and 10% of bipolar I
patients have comorbid BPD, and there is a robust relationship between BPD
and bipolar disorder II.
• Patients with comorbid BPD and BD have higher rates of hostility, substance
abuse, impulsivity and suicide.

29. Take Home Messages
• Any patient presenting with symptoms suggestive of either bipolar or borderline should be
screened for both disorders.
• Borderline personality and bipolar illness are distinguishable clinically and diagnostically.
• BPD is often undiagnosed or misdiagnosed. Interpersonal features help with diagnostic
discrimination.
• The two illnesses should be treated distinctly, with appropriate medications emphasized for
bipolar illness, and psychotherapies emphasized in borderline personality.