Bipolar Disorder vs. Borderline Personality Disorder: What are the Differences

By  Jamie N. Sedgwick, LCPC, NCC

EMDRIA Consultant & Basic Trainer

“What is the difference between Bipolar Disorder and Borderline Personality Disorder?” I have had many clients and clinicians pose this question when exploring possible diagnoses and treatment planning. It has taken over 10 years of experience as a clinician specializing in trauma and working in several different treatment settings for me to feel confident in answering this question.

 Let’s start by taking a look at the technical, “on paper” diagnostic criteria for each.

Let’s Take a Look at Diagnostic Criteria

The Fifth Edition of the Diagnostic and Statistical Manual (DSM-5) indicates that there are different categories of Bipolar Disorder including Bipolar Disorder I, Bipolar Disorder II, and Cyclothymic Disorder (Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition. 2013. Pg 123). To understand the diagnostic differences between Bipolar Disorder and Borderline Personality Disorder, we will focus on Bipolar Disorder I.

 Diagnostic criteria for Bipolar Disorder I indicates that individuals must have experienced at least one Manic episode and Major Depressive episodes lasting at least 2 weeks (Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition. 2013. Page 124). A Manic episode is described as a period of mood disturbance and increased energy during which 3 of the following criteria are met resulting in a significant shift from usual behavior:

1. Inflated self-esteem or grandiosity
2. Decreased need for sleep (may feel rested after only 3 hours of sleep)
3. More talkative than usual or pressured to keep talking
4. Flight or idea or subjective experience that thoughts are racing
5. Distractibility
6. Increase in goal-directed activity or psychomotor agitation
7. Excessive involvement in activities that have a high potential for painful consequences

 Major Depressive episodes are characterized by at least 5 or more of the following symptoms being present during the same 2-week period with a noticeable change from usual behavior. Each symptom must be present nearly every day. At least one of the symptoms is either depressed mood or loss of interest or pleasure.

1. Depressed mood most of the day
2. Markedly diminished interest or pleasure in all, or almost all, activities
3. Significant weight loss when not dieting or weight gain, or a decrease or increase in appetite
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Diminished ability to think or concentrate
9. Recurrent thoughts about death, or suicide without a specific plan, or suicide attempt, or a specific suicide plan.

 In summary, a diagnosis of Bipolar Disorder I is indicative of major mood disturbances with periods of mood disturbances that may appear to be at “opposite ends of a spectrum.”

 Now, let’s take a look at the DSM-5’s diagnostic criteria for Borderline Personality Disorder. According to the DSM-5, an individual must experience patterns of instability of interpersonal relationships, self-image affect, and impulsivity beginning in early adulthood and present across many contexts as indicated by 5 or more of the following criteria (Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition. 2013. Page 663):

1. Frantic efforts to avoid real or imagined abandonment
2. A pattern of unstable and intense interpersonal relationships alternating between extremes of idealization and devaluation.
3. Identity disturbance or a lack of sense of self
4. Impulsivity in two areas that are potentially self-damaging (Do not include Criterion 5 behaviors)
5. Recurrent suicidal behaviors, gestures, or threats of self-mutilating behaviors
6. Affective instability due to reactivity of mood
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

In summary, the focus of this diagnostic material is interpersonal relationships, intrapersonal relationships, and the presence of maladaptive behaviors and coping mechanisms.

On paper, these diagnoses can seem very different. However, it is not uncommon for Borderline Personality Disorder to get misdiagnosed as Bipolar Disorder due to similarities in presentation.

Why Does Bipolar Get Confused and Misdiagnosed?

Are Bipolar Disorder and Borderline Personality Disorder similar?

While these two diagnoses seem distinctly different, their presentations often are not. This is especially true if a practitioner or clinician is only interacting with an individual for a short period of time. This could be the case in a variety of different settings including in-patient and crisis services.

 In my experience, individuals have most often been misdiagnosed with one of the previously mentioned Bipolar Disorders when, in fact, their symptoms are more in line with Borderline Personality Disorder. Often, these individuals are admitted to an inpatient facility and diagnosed with Bipolar Disorder after reporting symptoms of Mania during admission. These symptoms often include many of the criteria included for Borderline Personality Disorder.

 For example, the individual may report a period of time where they experienced an increase in confidence and energy during which they engaged in behaviors such as reckless driving, overspending, shoplifting, and substance abuse. The individual may present as having difficulty sitting still and talking very quickly. The individual also identifies periods of time when they have experienced significant depressive symptoms. A diagnosing provider may interpret this as the individual identifying current symptoms of Mania with a history of Depressive episodes and end up diagnosing the individual with Bipolar Disorder.

 However, the same symptoms could be indicative of Borderline Personality Disorder. The “severe dissociative symptoms” mentioned in the criteria for Borderline Personality Disorder can result in sudden and extreme shifts in presentation including an increase in confidence and energy. The reckless behavior described (reckless driving, overspending, shoplifting, and substance use) could also be indicators of Borderline Personality symptoms such as “Frantic efforts to avoid real or imagined abandonment,” “impulsivity in two areas that are potentially self-damaging,” or “inappropriate, intense anger or difficulty controlling anger.” For example, I have often had clients explain that reckless driving is caused by sudden and intense anger. The individual presenting as having difficulty sitting still and talking very quickly could be caused by “affective instability due to reactivity of mood,” another diagnostic criterion for Borderline Personality Disorder. Finally, symptoms of Borderline Personality Disorder such as identity disturbance or a lack of sense of self, recurrent suicidal behaviors, gestures, or threats of self-mutilating behaviors, and chronic feelings of emptiness can also be symptoms of a Depressive episode.

 You can begin to see how these diagnoses may get confused and misdiagnosed.

How Can We Tell the Difference?

A misdiagnosis can drastically shift the types of referrals provided and how a therapist creates a treatment plan so getting it right feels important.

 How can we tell the difference between Bipolar Disorder and Borderline Personality Disorder?

 First of all, if you are in a setting where you have some time to gather information and notice patterns in symptoms, take some time before choosing either diagnosis.

Secondly, start to take notice of patterns in symptoms. Borderline Personality Disorder is the result of attachment trauma which is why see so many symptoms related to interpersonal relationships and fears of abandonment. You can read more about Borderline Personality Disorder as attachment trauma here. More often than not, if symptoms increase following some kind of interpersonal stressor or conflict, then symptoms may be better explained by Borderline Personality Disorder instead of Bipolar Disorder. In fact, I first began to wonder about individuals being misdiagnosed with Bipolar Disorder when they would describe “triggers” for their Manic episodes. Bipolar symptoms are not influenced by triggers, or external stressors, but are related to brain structure and chemicals.

Slowing down and taking time to notice patterns in symptoms can help avoid a misdiagnosis and ineffective treatment plan.

The Good News

Eye Movement Desensitization and Reprocessing (EMDR) Therapy is an Evidence-based treatment modality that can effectively treat both Bipolar Disorder and Borderline Personality Disorder. EMDR is an 8 phase treatment approach that has been shown to be effective in treating a variety of diagnoses such as PTSD, C-PTSD, Personality Disorders, Depression, Anxiety, Bipolar Disorder, Eating Disorders, and more (Shapiro, 2016). EMDR is a treatment modality that works by using the brain’s own healing capacity to resolve symptoms instead of simply teaching skills to manage symptoms.

 If you are a therapist that works with diagnoses such as Bipolar Disorder, Borderline Personality Disorder, or any of the diagnoses mentioned above, it may be worth your time to consider getting trained in EMDR. Just be sure the training you choose is EMDRIA-approved. You can find these trainings by going to emdria.org. Trauma Specialists Training Institute (TSTI) is an EMDRIA-approved training provider offering EMDR Basic Training, Advanced Training, and ongoing consultation options.

 If you are an individual seeking treatment for Bipolar Disorder or Borderline Personality Disorder, be sure to ask potential therapists if they received EMDR Basic Training through an EMDRIA Approved provider and inquire about their experience with advanced EMDR trainings and ongoing consultation with an EMDRIA Consultant.

About the Author

Jamie Sedgwick, LCPC completed an EMDRIA Approved EMDR Basic Training in 2017. She credits this training with completely changing her therapy practice. Jamie is now an EMDR Consultant and Director of Training and Consultation at Trauma Specialist Training Institute.

Bibliography

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition. c. 2013.

 Shapiro, Francine. Eye Movement Desensitization and Reprocessing (EMDR)Therapy: Basic Principles, Protocols and Procedures. Third Edition. c. 2018