BPD and bipolar disorder, similarities and differences

Connection between borderline personality and bipolarity. On the face of it, there a lot of similarities between both of them. Could it be the same trouble, is it possible to confuse them. You will find on the last part of this document our vision which we hope comprehensive and listening to the suffering

The bipolar disorder
To make simple, a person who have a bipolar disorder have up and down
The mood swings are higher than "normal" people and also independent of lived events

• The "up"
Mania or Hypomania
- A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week
- Hypomanie is a  "manic light". That's mean that it is a mania in which we are less disrupted, lasting throughout at least 4 days
• The "down"
Depressive mood
- Depressive mood. Not a lot to say, the person is depressive, insomnia, appetite, desire, morbid thinking, ...
Symptoms have been present during the same 2-week period
• "mixed" episodes
The criteria are met both for a Manic Episode and for a Major Depressive Episode nearly every day during at least a 1-week period.

The bipolar disorders
There are several kind of bipolar disorder (like in diabetes)

• The type 1
In the type 1, the person has primarily and regularly manic episodes
• The type 2
In the type 2, the person alternates depressive episodes with hypomanic episodes

The "options"

The bipolat disorder could be with rapid cycling
At least four episodes of a mood disturbance in the previous 12 months
DSM IV requires that 2 mood episodes in the same direction be interrupted by 8 weeks of euthymia (ok), or substantial improvement, to qualify toward rapid cycling.

* Zanarini MC, Frankenburg FR, Hennen J,... - McLean Hospital, Belmont, USA.
Am J Psychiatry. 2OO4 - Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission.
OBJECTIVE: The purpose of this study was to assess the prevalence of axis I disorders among patients with borderline personality disorder over 6 years of prospective follow-up.
METHOD: A semistructured interview of demonstrated reliability was used to assess presence or absence of comorbid axis I disorders in 290 patients who met Revised Diagnostic Interview for Borderlines criteria
Follow-Up 2 years: 6.9% of Bipolar II disorder experienced by Patients With Borderline Personality Disorder

* Rossi A, Marinangeli MG, Butti G, Scinto A... - Department of Experimental Medicine, University of L'Aquila, Italy
2001 J Affect Disord - 29.6% of patients with Bipolar disorder have a Borderline personnality disorder DSM III, 19,6% an avoidant personality disorder.

* Benazzi F - Department of Psychiatry, Public Hospital Morgagni, Forli, Italy
2000 - Compr Psychiatry - Bipolar II disorder (BDII) may be confused with borderline personality disorder (BPD) when it is cyclothymic between episodes. The prevalence of BPD was 12% of BPII patients. The study underscore the unstability of cyclothymics episodes in BPD and the easiness to distingish them with the DSM IV

* Skodol AE, Stout RL, McGlashan TH,... - Dept of Psychiatry and Human Behavior, Brown University, Providence, Rhode Island, USA
1999 Depress Anxiety - Co-occurrence of mood and personality disorders
571 PD cases, 240 had diagnoses of BPD. Of the BPD cases, 13.3% were diagnosed with Bipolar disorder (9.2% with bipolar I, and 4.1% with bipolar II)

* Henry C, Mitropoulou V, New AS, Koenigsberg HW, Silverman J, ... - Service de Psychiatrie, Centre Hospitalier Charles Perrens - Bordeaux, France.
2001 J Psychiatr Res. - Affective instability and impulsivity in borderline personality and bipolar II disorders: similarities and differences.
Objectives: Many studies have reported a high degree of comorbidity between mood disorders, among which are bipolar disorders, and borderline personality disorder.
The aim of this study was to compare impulsivity, affective lability and intensity in patients with borderline personality and bipolar II disorder.
Borderline personality patients had significantly higher affective lability.
A significant interaction between borderline personality and bipolar II disorder was observed for lability between anxiety and depression.
The borderline patients displayed significant higher affective lability between euthymia and anger.
Whereas patients with bipolar II disorder displayed affective lability between euthymia and depression or euthymia and elation or between depression and elation
High scores for impulsiveness and hostility were obtained for borderline personality patients only.
Only borderline personality patients tended to have higher affective intensity
Conclusions :Our results suggest that borderline personality disorder cannot be viewed as an attenuated group of affective (mood) disorders. (depressive and bipolar disorders)

* Angst J, Gamma A, Sellaro R, Lavori PW,... - Zurich University Psychiatric Hospital, Switzerland.
2OO3 Eur Arch Psychiatry Clin Neurosci. - Recurrence of bipolar disorders and major depression. A life-long perspective.
OBJECTIVE: It is not known whether the risk of recurrence declines with time in bipolar disorders and in major depression. This study describes the life-long recurrence risk of bipolar I, bipolar II and major depressive disorders. METHOD: 160 bipolar-I, 60 bipolar-II and 186 depressive patients hospitalised between 1959 and 1963 were followed up every five years from 1965 to 1985. The course prior to the index hospitalisation was assessed in retrospect.
Results: The cumulative intensity curves for the transition from states of remission to new episodes remained linear over 30 to 40 years after onset, indicating a constant risk of recurrence over the life-span up to the age of 70 or more. The recurrence risk of bipolar disorders (0.40 episodes per year) was about twice that of depression (0.20 episodes per year); BP-II disorders had only a slightly higher recurrence risk than BP-I disorders. There were no significant gender differences in the course of either bipolar or depressive disorders. CONCLUSION: If long-term trials confirm its efficacy, these results support lifelong prophylactic treatment of severe types of mood disorders.

* Judd LL, Schettler PJ, Akiskal HS, Maser J - National Institute of Mental Health Collaborative Program on the Psychobiology of Depression Clinical Studies, San Diego
2OO3 Int J Neuropsychopharmacol. - Long-term symptomatic status of bipolar I vs. bipolar II disorders.
Weekly affective symptom severity and polarity were compared in 135 bipolar I (BP I) and 71 bipolar II (BP II) patients during up to 20 yr of prospective symptomatic follow-up. The course of BP I and BP II was chronic; patients were symptomatic approximately half of all follow-up weeks (BP I 46.6% and BP II 55.8% of weeks). ... Weeks with depressive symptoms predominated over manichypomanic symptoms in both disorders (31) in BP I and BP II at 371 in a largely depressive course (depressive symptoms=59.1% of weeks vs. hypomanic=1.9% of weeks). BP I patients had more weeks of cyclingmixed polarity, hypomanic and subsyndromal hypomanic symptoms. Weekly symptom severity and polarity fluctuated frequently within the same bipolar patient, in which the longitudinal symptomatic expression of BP I and BP II is dimensional in nature involving all levels of affective symptom severity of mania and depression. Although BP I is more severe, BP II with its intensely chronic depressive features is not simply the lesser of the bipolar disorders; it is also a serious illness, more so than previously thought...

"Bipolar disorder is essentially a mood fluctuation disorder, characterized most often by depression.  Bipolar people can abuse substances, but otherwise they do not typically show the range of different symptoms BPD people manifest.
BPD individuals can be depressed, but BPD is essentially a hyperreactive/impulsiveness disorder with mood features, but also other symptoms affecting thinking and perception, self-concept, relationships, etc.BPD involves instability not only of mood, but of perception of self, perception of others, relationships, behavioral consistency, self-control, etc.
The mood disturbances in Bipolar Disorder typically are along a depression--mania dimension; (mania, hypomania)
with BPD, however, mood disturbances typically involve the dimensions of anger and anxiety.
MostBPD patients do not have mania (sustained hyperactivity and elation), though they can often act impulsively." (Daniel C. Claiborn Atlanta)

"In bi-polar the self-destructive behaviors are because the individual feels all powerful and invincible, whereas in the BPD the self-destructive behaviors are an attempt to stop pain. It's a huge difference.
In bipolar disorder mania or hypomania must be present for the diagnoses to be made. Many individuals with the BPD have been erroneously diagnosed with bipolar because of the mood swings, even though they've never had mania or hypomania.
Bipolar I is the classic mania alternating with depression. Bipolar II is depression alternating with hypomania. Bipolar III is when the hypomania or mania occur only with antidepressant medication. Mixed bipolar is also called rapidly cycling bipolar where the person alternates between severe depression and severe mania in a very short period of time - sometimes minutes or hours. Cyclothymia is likely a form of bipolar with mini highs and mini lows in a cyclical manner." (Leland M. Heller, M.D.)

"Bipolar disorder is an episodic, long-term illness with a variable course. The first episode of bipolar disorder may be manic, hypomanic, mixed, or depressive and may be followed by several years during which the patient is symptom-free... The diagnosis of bipolar disorder must be carefully differentiated from substance-related disorders, antisocial behavior, or personality disorders... Untreated patients with bipolar disorder may have more than 10 total episodes of mania and depression during their lifetime..." (American Psychiatric Association)

Here is our feeling.

Are BPD and bipolar disorder 2 entities ?
Obviously yes

Is it possible to have both borderline and bipolar disorder ?
Probably yes

Bpd / Bipolar diagnosis made with working medication ?
It seems to be not possible to say "this medication is working, it is then the evidence that my diagnosis is...".
As the study are saying, bipolar medication like lithium, anticonvulsivant are also well responding with BPD so we can't use such result for diagnosis . Please read the medication page

Can we confuse bipolar and borderline ?
Well, in theory, not !

• Cycles in bipolar disorder are theoretically of rather long duration, sometimes a few months what is not the case in the borderline disorder.
• The Bipolar has long periods of remission during which he is well, we cannot say the same with bpd peoples
• The bipolar will suffer its cycles, basically no matter what it does, and independently of external factors, whereas in the borderline disorder cycles are the fruit of its emotions and its impulses, in short of lived moment what explains the speed of mood swing and the misleading feeling that he has several personalities
• Borderline people is unstable almost in all domains like self-image, relationships, black and white thinking, emotions , ... what is not the case with bipolar

Why some bpd peoples are misdiagnosed with bipolar disorder ?
The main reasons seems to be
- Insurance coverage
- Stigma: In the collective imagination, bpd is a personality disorder then it is not curable
- Training: A lot of therapits are not trained to diagnose and treat bpd
Here is what they say on the subject:

• "Bipolar is Axis I, BPD is Axis II. Insurance companies usually DO NOT cover Axis II diagnosis... An official diagnosis of bipolar disorder 'with' borderline personality traits is better then a single diagnosis of bpd, because bpd is NOT covered by most insurance companies" (Kathi's Mental Heath Review)
• "BPD is frequently called bipolar in a hospital because BPD is not covered by insurance companies since it is viewed as a "personality disorder" and not amenable to change" (bpd sanctuary)
• "The statistic of 2% cannot be accurate for the following reasons: clinicians are actively discouraged from putting BPD on a patient's chart because of the stigma and insurance denials and because most clinicians do not have the training to make a diagnosis" (bpdcentral)

What about the cure ?
If we refer to long-term studies, we can see that bipolar disorder (BP I and BPII) are life long disorder. There are treatment to better live BP disorders but it seems that we can't talk about "cure".
For bpd, the problem is different, there are treatments but we also have the possibilit to speak about "cure". Several studies show that most Bpd people can't no more be diagnosed with a bpd disorder after some years of treatment.
The "funny" thing is that a lot of therapists don't hesitate to diagnose a person as "bipolar" but are afraid to diagnose a people as "bpd"... it seems that it is because they have in mind that there is no hope for bpd people. It is totally false !

Please read page bpd a cure ?