Impulsiveness and mood swings are common to both bipolar disorder and borderline personality disorder. And, you have to rely on symptoms to make a diagnosis since there is no lab test that can establish the diagnosis. Hence the two disorders are often confused with each other. But, it is important to distinguish between the two because the treatment varies for both.
Both these disorders affect millions of Americans. According to the National Institute of Mental Health, bipolar disorder affects 2.8 percent, or nearly 6.5 million adults. Borderline personality disorder affects anywhere from 1.6 to 5.9 percent of the American adult population.
Up to 70 percent of bipolar disorder patients are misdiagnosed initially, and up to 1/3rd remain misdiagnosed for a long time afterward. Often they are first diagnosed with depression and treated with antidepressants — this can be dangerous to bipolar patients, since the antidepressants can overcompensate for the low mood and induce hypomania and trigger the mood swings over and over again. Bipolar disorder is also often confused with borderline personality disorder, so here are the things you should look out for to make the correct diagnosis.
Diagnosis of Bipolar Disorder
Bipolar disorder is characterized by episodes of mood swings between mania (or hypomania – a milder mania) and depressed mood.
A manic episode is one of abnormally and persistently expansive, elevated, or irritable mood and goal-directed activity or energy that lasts at least 1 week. These symptoms are present most of the day, nearly every day. Mood in a manic episode is often described as euphoric, excessively cheerful, high, or “feeling on top of the world.” In some cases, there can be unlimited and haphazard enthusiasm for interpersonal, sexual, or occupational interactions. For example, the individual may spontaneously start extensive conversations with strangers in public. Sometimes the predominant mood is irritable rather than elevated, particularly when the individual’s wishes are not fulfilled. Mood may be labile with rapid shifts in mood occurring over brief periods of time.
During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present:
- Inflated self-esteem or grandiosity. Despite lack of any particular experience or talent, the individual may embark on complex tasks such as writing a novel or seeking publicity for some impractical invention. Grandiose delusions (e.g., of having a special relationship to a famous person) are common.
- Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). One may sleep little or may awaken several hours earlier than usual, feeling rested and full of energy. If severe, the individual may go for days without sleep, yet not feel tired. Often a decreased need for sleep heralds the onset of a manic episode.
- More talkative than usual or pressure to keep talking. Speech can be rapid, pressured, loud, and difficult to interrupt. They may talk continuously and without regard for others’ interest in it, often intrusively or without concern for the relevance of what is said. Speech is sometimes characterized by jokes, puns, amusing irrelevancies, and theatricality, with dramatic mannerisms, singing, and excessive gesturing.
- Flight of ideas or racing thoughts. There is a nearly continuous flow of accelerated speech, with abrupt shifts from one topic to another. When flight of ideas is severe, speech may become disorganized, incoherent, and distressful to the individual. Sometimes thoughts are so crowded that it is very difficult to speak.
- Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli). There is an inability to censor immaterial external stimuli (e.g., the interviewer’s dress, background noises, furnishings in the room) and often prevents one from holding a rational conversation or attending to instructions.
- Increased goal-directed activity (either socially, at work or school, or sexually) or purposeless activity (agitated mood and behavior). This often consists of excessive planning and participation in multiple activities. Increased sexual drive, fantasies, and behavior are often present. They show increased sociability (e.g., renewing old acquaintances or calling or contacting friends or even strangers). They often display restlessness (i.e., purposeless activity) by pacing or by holding multiple conversations simultaneously. Some individuals write excessive e-mails, text messages, on many different topics to friends, public figures, or the media.
- Excessive and impulsive involvement in risky activities (e.g., spending sprees, giving away possessions, reckless driving, foolish business investments, and sexual promiscuity that is unusual for the individual, even though these activities are likely to have drastic consequences).
Furthermore, the manic episode should be sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features, such as delusions or hallucinations. Also, the episode should not be on account of substance abuse or a medication, or another medical condition.
The depressive episode is one where five (or more) of the following symptoms have been present during the same 2-week period and at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure:
- Feels sad, empty, or hopeless, or seen to be tearful, most of the day, nearly every day.
- Markedly diminished interest in almost all activities that were once pleasurable, most of the day, nearly every day.
- Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.
- Sleeplessness or excessive sleep nearly every day.
- Restlessness or being slowed down nearly every day.
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
- Diminished ability to think or concentrate, or indecisiveness, nearly every day.
- Recurrent thoughts of death, recurrent suicidal ideation or a suicide attempt or a specific plan for committing suicide.
Furthermore, the above symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. And, the episode is not attributable to substance abuse or another medical condition.
Diagnosis of Borderline Personality Disorder
The essential feature of borderline personality disorder is a pattern of instability of interpersonal relationships, self-image, and moods, and marked impulsivity that begins by early adulthood and is present in a variety of contexts, as indicated by five (or more) of the following:
- Frantic efforts to avoid real or imagined abandonment.
- Interpersonal relationships alternating between extremes of idealization and devaluation. They may idealize potential caregivers or lovers at the first or second meeting, demand to spend a lot of time together, and share the most intimate details early in a relationship. However, they may switch quickly from idealizing other people to devaluing them, feeling that the other person does not care enough, does not give enough, or is not “there” enough.
- Marked and persistent unstable self-image or sense of self. It is characterized by shifting goals, values, and vocational aspirations. There may be sudden changes in opinions and plans about career, sexual identity, values, and types of friends.
- Impulsivity in at least two areas that are potentially self-damaging (e.g., gamble, spend money irresponsibly, binge eat, abuse substances, engage in unsafe sex, or drive recklessly).
- Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. Completed suicide occurs in 8%-10% of such individuals, and self-mutilative acts (e.g., cutting or burning) and suicide threats and attempts are very common.
- Unstable mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). These episodes may reflect the individual’s extreme reactivity to interpersonal stresses.
- Chronic feelings of emptiness. Easily bored, they may constantly seek something to do.
- Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). They may display extreme sarcasm, enduring bitterness, or verbal outbursts. The anger is often elicited when a caregiver or lover is seen as neglectful, withholding, uncaring, or abandoning. This is often followed by shame and guilt, leading to the feeling they have of being evil.
- Transient, stress-related paranoid ideation or severe dissociative symptoms (e.g., depersonalization).
Bipolar Disorder vs. Borderline Personality Disorder
Firstly, one of the main differentiating factors between bipolar disorder and borderline personality disorder is that symptoms of personality disorder are pretty consistent and ongoing, while people with bipolar disorder appear to have “breaks” between their extreme mood swings, in which they experience a symptom-free period.
Secondly, borderline personality disorder (BPD) issues manifest in relation to interpersonal relationships, while bipolar symptoms usually appear out of nowhere, with no obvious trigger or precipitant for their mood destabilization.
Thirdly, it also helps to focus on the following specific symptoms and risk factors:
- Impulsiveness: The impulsive behavior in bipolar disorder occurs when they are experiencing a period of mania. But in people with BPD the impulsive behavior is unrelated to mania.
- Sleep: People with bipolar disorder tend to have extremely disturbed sleep cycles, but people with BPD can have a regular sleep cycle.
- Mood cycles: Mood cycles tend to last for weeks to months in people with bipolar disorder. Mood shifts tend to last only for a few hours or days in people with BPD.
- Self-harm: Self-harm is less common in people with bipolar disorder than those with BPD (almost 75%), but the suicide attempt rate is higher.
- Unstable relationships: Many people with BPD have very intense, conflict-riddled relationships. People with bipolar disorder may have difficulty maintaining relationships because of the severity of their symptoms.
- History of trauma: Many people with BPD would have experienced trauma in their childhood or adolescence, such as abuse, abandonment, extreme adversity, unstable relationships in family life, and exposure to conflict.