Clinical difference borderline bipolar

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Abstract and Introduction

Abstract

Purpose of review: Differentiating bipolar II disorder (BP II) from borderline personality disorder (BPD) is a

common diagnostic dilemma. The purpose of this review is to focus on recent studies that have considered

clinical differences between the conditions including family history, phenomenology, longitudinal course,

comorbidity and treatment response, and which might advance their clinical distinction.

Recent findings: Findings suggest key differentiating parameters to include family history, onset pattern, clinical

course, phenomenological profile of depressive and elevated mood states, and symptoms of emotional

dysregulation. Less specific differentiation is provided by childhood trauma history, deliberate self-harm,

comorbidity rates, neurocognitive features, treatment response and impulsivity parameters.

Summary: This review refines candidate variables for differentiating BP II from BPD, and should assist the design

of studies seeking to advance their phenomenological and clinical distinction.

Introduction

Clinical differentiation of bipolar disorder from borderline personality disorder (BPD) is reported as a common

diagnostic dilemma.[1–4,5] This may reflect BPD being an ultrarapid cycling (i.e. rapid mood switches over 48 h or

less) bipolar spectrum disorder.[6] Alternatively, BPD and bipolar disorders are, as positioned in Diagnostic and

Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)[7] and ICD-10,[8] separate conditions requiring more

refined diagnostic differentiation, as positioned in this review.

Differentiating BPD from bipolar I disorder (BP I) appears relatively straightforward, reflecting the common

presence of characteristic psychotic manic symptoms. By contrast, nonpsychotic bipolar II (BP II) disorders are

frequently incorrectly diagnosed as BPD due to shared features including impulsivity and emotional dysregulation.

Cross-sectionally, such 'affect storms' in BPD can resemble hypomania[9] and lead to misdiagnosis.[10,11]

Longitudinally, the high frequency of interepisode residual symptoms in BP II, including chronic dysphoria[12,13]

may compromise diagnosis.

Although the present review seeks to focus on BPD differentiation from BP II as against bipolar in general, few

studies have considered separate bipolar subtypes in comparative analyses. Thus, BPD versus BP II distinctions

are detailed where available, but in the absence of BP II being specifically compared, we include relevant studies

considering bipolar disorders in general. We now overview candidate differentiating parameters.

Family History

Several studies suggest a general 'breeding true' phenomenon, with a greater probability of first-degree relatives

with bipolar or a major mood disorder in bipolar probands,[5,14] and an increased likelihood of impulse control

disorders (antisocial personality and substance abuse disorders) or a unipolar mood condition in family members

of those with BPD.[15] Additionally, borderline 'features' (e.g. deliberate self-harm, identity problems) are over-

represented in family members of those with BPD,[16] with Perugi et al. [17] reporting that patients with a major

depressive disorder and a comorbid BPD had a higher rate of hypomania/mania in first-degree relatives. This could

reflect a common genetic contribution to two independent or interdependent conditions, or be artefactual because

of the failure to diagnose truly separate conditions. Overall, a family history of bipolar disorder is likely to support a

BP II as against BPD diagnosis.

Clinical Differentiation of Bipolar IIDisorder From Borderline PersonalityDisorderAdam Bayes, Gordon Parker, Kathryn Fletcher

Curr Opin Psychiatry. 2014;27(1):14-20.

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Age of Onset

Bipolar disorder in childhood is rare, with late adolescence or young adulthood being the highest onset risk

period[18–20] and with onset generally representing a distinct change.[21] By contrast, a distinct onset period is

lacking for BPD, with 'negative affectivity' instead established at an early age[22] and many BPD patients reporting

being depressed their whole lives.[9] Thus, a clear onset period favours a BP II condition.

Illness Course

There is some suggestion of differing illness courses. Bipolar tends not to remit with age and can worsen over

time,[23] whereas BPD has a more favourable prognosis, with many individuals no longer meeting criteria in middle

age.[24] For example, Paris and Zweig-Frank[25] reported that only 8% met criteria for BPD at a 27-year follow up.

Thus, failure to remit may be suggestive of a BP II condition versus attenuation over time characterising BPD.

Depressive Symptoms

Phenomenological differences in depressive states have been reported. Melancholic features of depression are

over-represented in BP II,[26] as are agitated and mixed symptoms,[27] whereas BPD is more characterized by

nonmelancholic reactive depressive episodes.[9] Atypical features of depression (e.g. hypersomnia, hyperphagia)

are over-represented in both BP II[28] and BPD, offering little diagnostic discriminatory value.[29,30]

In contrast to 'typical' depressive features (e.g. decreased self-esteem, self-criticism) frequently associated with

BP II, BPD depressive states are often more characterized by emptiness, shame and 'painful incoherence'.[31]

Other differences include higher levels of self-reported cognitive depressive symptoms in BPD relative to BP II –

pointing to a more severe subjective experience in the former group.[32] Those with BPD tend to project

responsibility onto others,[33] be accusatory, blaming, hostile and more angry than depressed[9] compared to

those with a BP II condition.[32,34] In contrast, those with bipolar tend to be more likely to feel guilty about

annoying others with any irritable mood[33] and be self-demeaning/self-accusatory.[9]

Suicidality and Deliberate Self-harm

Suicidality, a common BPD feature, is also common in BP II disorder.[35–37] Similarly, self-mutilation (e.g. wrist

cutting) occurs in both BP II (especially during mixed states)[38] and BPD with a similar frequency.[5] Such

features therefore offer limited differentiation.[5]

Hypomanic Symptoms and Correlates

Individuals with a BP II disorder generally report elated mood, increased energy, creativity, connectedness,

grandiosity and productivity, contrasting with the emotional dysregulation commonly reported by those with a BPD

condition. Furthermore, hypomania is viewed by BP II patients as uncharacteristic.[39] Some BP II individuals

experience hypomanic episodes characterized by irritability, akin to the irritability and anger occurring in BPD.

However, in contrast to BPD, the irritability/anger is episodic and present only during elevated mood states in BP

II, assisting differential diagnosis.[10] Mixed mood states, commonly observed in females with BP II,[40] as well as

ultrarapid cycling may also be mistaken for borderline phenomena. In those with BPD, elation is rarely present

and brief (less than 48 h).[2] In contrast to the grandiose sense of self, experienced in BP II hypomania, there

remains an ongoing poor self-image in those with BPD.[33] Clinically, assessing anxiety levels during 'highs' can

be central, with anxiety disappearing or attenuating in those with a BP II condition and increasing in those with

BPD.[41]

Mood State Context

Individuals with BP II are more likely than those with BPD to have autonomous mood episodes and lacking an

interpersonal context,[33] although reactive moods (e.g. secondary to substance use or psychological stressors)

can be experienced. By contrast, symptoms of BPD are usually reactive,[2] generally triggered by a



psychologically salient interpersonal event such as frustration, rejection or a sense of abandonment.[9,39]

Emotional Dysregulation

Emotional dysregulation, also referred to as affective instability, is defined as brief mood changes characterized

by temporal instability, high intensity and delayed recovery from the actual dysphoria.[42] Emotional dysregulation

is not pathognomonic of BPD as it can occur in BP II,[2,34,43] but analysis of the valence, frequency and intensity

of affective shifts may assist differentiation. For example, in contrast to the affect shifts from euthymia to anger or

anxiety observed in BPD, individuals with BP II display more affective lability from euthymia to depression or to

elation, and from elation to depression.[34] More recently, Reich et al. [44] compared a combined BP II and

cyclothymic group with BPD participants and reported the former as experiencing more frequent and intense shifts

between euthymia and elation, and between depression and elation. By contrast, BPD participants experienced

more frequent and intense lability between anxiety and depression, and between euthymia and anger.

Neurobiological studies suggest that emotional dysregulation in bipolar may be internally driven, in contrast to the

reactivity to social cues observed in BPD.[42] Thus, if emotional dysregulation is present, shifts between

depression, euthymia and elation could suggest a BP II condition, whereas shifts between anger and anxiety may

characterize BPD.

Impulsivity

Impulsivity is defined as a tendency for rapid, unplanned behaviours,[45] and to act on urges without regard to

consequences.[46] It may be a partially heritable trait[2] and can occur periodically as a state phenomenon.

Although impulsivity may represent a shared phenotype of bipolar and BPD,[2] nuances in its differential

expression have been suggested.

Impulsivity may represent both a trait and state feature of bipolar disorder.[47] Benazzi[48] quantified a trait

impulsivity rate of 41% in remitted BP II outpatients, indicating that it is not specific to BPD. In BP II, however,

episode-based impulsivity is more commonly associated with hypomanic as against depressive BP II mood

states.[32] Impulsivity during hypomania has also been modelled as lying on a continuum with inter-episode trait

impulsivity.[48–51]

Impulsivity is a core diagnostic feature of BPD and may represent a way of managing negative emotions by

distraction or relief from intense negative affect[52] rather than relate to any mood-related disinhibition

characterizing bipolar. In BPD, impulsivity tends to be more enduring,[53] although Zanarini et al. [54] reported it as

the feature most likely to remit.

Several studies have directly compared impulsivity in BP II and BPD, revealing differing features. Higher scores on

the Barratt Impulsiveness Scale[55] were quantified in BPD relative to BP II patients.[34] In another study, those

with BP II tended towards the 'attentional impulsiveness' associated with cognitive disturbances (including

impaired concentration, distractibility and racing thoughts), in contrast with motor and 'nonplanning impulsiveness'

characterized by difficulty planning actions and thinking about consequences observed in those with BPD.[32]

More recently, differing phenomenological impulsivity profiles were reported in BPD and BP II patients, with a trend

towards higher scores on the Urgency and (lack of) Perseverance subscales of the Urgency, Premeditation,

Perseverance and Sensation Seeking Impulsive Behavior Scale[56] in the former group.[57]

Neuropsychological Deficits

Although many neuropsychological studies contrasting bipolar and BPD have been undertaken (see Coulston et

al. [4]), few have directly compared BP II with BPD and most separately compared BP II with controls and BPD

with controls. Executive function deficits (measured by the Wisconsin Card Sorting Test) have been reported in

BPD,[58] whereas in BP II, executive function deficits were more broad.[4] However, deficits of this nature have

been reported as dependent on mood state and episode type in bipolar.[59] Deficits in sustained attention are

typically seen in bipolar[60] but not BPD.[58] Deficits in working memory and verbal memory were found in a

systematic review of 14 neuropsychological studies of BP II compared with controls,[61] whereas spatial working



memory was intact in BPD relative to controls.[58]

Neuroimaging Findings

Structural and functional neuroimaging studies investigating bipolar and BPD have been reviewed by Coulston et

al. [4] and Mauchnik and Schmahl[62]; however, none analyzed sufficient numbers of BP II patients. Frontolimbic

network dysfunction is apparent in both BPD and bipolar disorder (as reviewed in).[4] However, Malhi et al. [63]

reported differential engagement of frontolimbic emotion processing distinguishing bipolar from BPD, with

increased dorsomedial prefrontal cortex activity in bipolar patients and diminished amygdala activity in BPD. Such

differing neural processing may underpin the emotional dysregulation observed in the two diagnostic conditions.

Social Cognition

Social cognition refers to mental operations underlying social interactions,[64] with one being the ability to infer

mental states of others, termed 'mentalization' or Theory of Mind (ToM).[65] There is an expanding literature on

social cognition deficits in BPD, albeit with no BP II and BPD comparison studies. Failure of mentalization is a

central deficit in BPD,[66,67] characterized by difficulty using the cognitive strategies of reappraisal and

suppression to regulate intense emotions.[68] Martino et al. [65] reported lower ToM performance in euthymic BP II

individuals relative to controls; however, potential confounders included medication exposure and attention-

executive function impairments.

Psychotic Symptoms

According to DSM-5, psychotic manic episodes assign an individual to BP I status, whereas hypomanic states

(intrinsic to BP II) lack psychotic features. In BP II depressive episodes, psychotic features are uncommon, albeit

with lifetime prevalence estimates ranging considerably – from 3 to 45%.[69] When present, they tend to be mood

congruent (e.g. guilt, nihilism) and more enduring. By contrast, some 75% of BPD patients experience transient

dissociative and paranoid symptoms[70] but rarely having a depressive theme.

Childhood Trauma

A history of childhood trauma (emotional, physical or sexual abuse) is not a distinctly differentiating feature as

high rates are associated with both disorders – approximately 50% in bipolar disorders and 60–80% in BPD.[5]

Bassett[5] suggests that those with BPD and bipolar may differ in terms of the form of childhood trauma

experienced or their vulnerability to such trauma, but formal studies are lacking.

Self-identity and Relationships

Differences in self-identity are observed in both conditions. Those with BPD generally experience a disruption to

their sense of self[5] with core elements including 'painful incoherence' (i.e. emotional pain related to a fragmented

sense of self) and 'role absorption' (i.e. loss of identity).[31] By contrast, those with BP II tend to experience self-

deficits only when depressed and a grandiose self when hypomanic, with stability of self-identity when euthymic.[33]

Assessment of the individual's capacity to have meaningful relationships can assist diagnostic clarification.[9] A

tendency towards idealization and devaluation, as well as severe abandonment fears is suggestive of BPD.[71,72]

Those with BPD experience severe and ongoing discrepancies in their assessment of self and others, have

ongoing interpersonal conflicts and evidence immaturity in their views of others.[9] By contrast, when euthymic,

those with bipolar are unlikely to show pathological relationships and tend to maintain stable relationships.[9]

Treatment Response

As overviewed by Bassett,[5] antidepressants, anticonvulsant mood stabilizers and atypical antipsychotics appear

more beneficial for bipolar conditions[73] relative to BPD. Lithium, in particular, appears to show no clear utility for

personality disorders,[74] whereas those with BPD rarely remit on mood stabilizers[75] or report improvement only



for secondary reasons (e.g. sedation).[39]

In relation to psychotherapy, different fundamental features of bipolar and BPD argue for differing

psychotherapeutic approaches, with the latter arguing for a therapeutic focus on the disrupted sense of self and

improving mutually satisfying relationships.[5] However, shared features of both conditions and the nonspecific

benefits of psychological treatments limit the capacity for psychotherapeutic response to offer diagnostic

differentiation. For example, Dialectical Behaviour Therapy (DBT) and mentalization-based therapies are effective

for BPD,[72] yet preliminary evidence (from a combined BP I and II sample) suggests DBT is also effective in

reducing bipolar depressive symptoms.[76] Further, Cognitive Behaviour Therapy is effective for BP (I and II),[73]

with benefits also observed for BPD including reduction of suicidal acts, anxiety and of dysfunctional beliefs.[77]

Personality Factors

Personality factors, including affective temperament, have been assessed closely in both bipolar and BPD. Perugi

et al. [30] suggest that mood liability and interpersonal sensitivity traits are related to a shared cyclothymic

temperament linking BP II, BPD and atypical depression. The affective temperament characterizing BPD (when

compared with BP I, not BP II) consists of a pattern of dysregulation involving depressive, cyclothymic, irritable

and anxious features but without hyperthymic features (e.g. exuberance and self-confidence).[78] A shared irritable

affective temperament has been associated with both bipolar disorder and BPD (as reviewed in),[79] with Fletcher

et al. [79] reporting a BP II (compared with UP depression) profile characterized by elevated irritability (in addition

to anxious worrying, self-criticism and interpersonal sensitivity). However, the presence of a cyclothymic

temperament in those with BP II often leads to incorrectly diagnosing BPD.[80] Akiskal et al. [80] terms this 'dark',

unstable variant of the 'sunny' BP II disorder – 'BP II 1/2' – and more highly associated with irritable risk taking

compared with 'classic' euphoria-driven hypomanic symptoms.[80]

Comorbidity

Both conditions are associated with an increased risk of anxiety and substance abuse disorders in particular,[2,44,81] although varying study methodologies make comparative analyses difficult to interpret. In a sample of

those with BP II, the lifetime over-representation of anxiety disorders was quantified,[82] with an odds ratio of 9.1

for any anxiety disorder. Comorbid attention deficit hyperactivity disorder (ADHD) appears to also be an over-

represented feature of bipolar,[23] with an OR of 9.2 quantified in those with BP II,[82] but without a comorbidity

rate formally quantified for BPD. It is unclear whether comorbidity is greater between bipolar and BPD relative to

other personality disorders, with mixed results reported.[37,41,83–85] The majority of people diagnosed with one

disorder (i.e. bipolar or BPD) do not have the other,[11] supporting differentiation of the two conditions.

Conclusion

We review a wide range of potential parameters differentiating BP II disorder from BPD, while accepting that a

small percentage of individuals may have both conditions. The literature is limited by most studies considering

bipolar in general (i.e. both BP I and BP II subtypes) and any extrapolation of findings from studies of bipolar

groups to BP II alone risks false conclusions.

No clear distinctive neuroimaging differences have been identified. Although some neurocognitive differences have

been suggested, their discrimination is too limited for application. Personality testing might be expected to show

commonalities (reflecting shared emotional dysregulation and impulsiveness) and not particularly discriminating

unless assessed as to whether present as a trait or only during mood states. Other parameters (e.g. family

history and a 'breeding true' phenomenon, childhood trauma, self-harm, impulsivity) may be of some discriminating

use but again require consideration of context rather than simply considering prevalence.

The seemingly most useful discriminating domains would appear to be phenomenological differences in terms of

mood and age of onset. The majority of BP II hypomanic episodes are euphoric anxiety-free states and in sharp

contrast with the hostility, irritability and anxiety-weighted periods experienced by those with BPD. The majority of

depressive episodes in those with a BP II condition are melancholic in nature and contrast with the



nonmelancholic reactive depressive episodes experienced by those with a BPD. BPD (being based in personality

style) would appear to evolve from childhood and adolescence, whereas BP II is most likely to have a sharp onset

period (i.e. the individual reporting episodes of hypomania and of depression emerging when no such distinct

episodes were previously present).

Sharpening differentiation would benefit from more specific studies focussing on BP II and not bipolar in general,

with multivariate analyses considering multiple potentially discriminating domains and refining the most distinctive.

These are likely to weight clinical nuances that might then be expected to lead to follow-up studies pursuing

underlying differentiating contributions from more precisely defined subsets of those with a BPD or BP II disorder,

evaluating the likely relevance of differing drug and nondrug treatments. Misdiagnosis of BP II as a BPD can risk

extensive periods on nondrug treatments when the individual might benefit from a mood stabilizer, whereas

misdiagnosis of BPD as a bipolar disorder can conversely risk inappropriate pharmacological treatment.

Sidebar

Key Points

The literature is limited by most studies considering bipolar disorder in general rather than contrasting BP II

only with BPD.

Although differences have been identified or are suggested across a number of parameters, few appear

substantive.

Phenomenological distinction appears currently the most differentiating domain, and involves consideration

of both poles and the type of depression (i.e. melancholic versus nonmelancholic), the extent to which

anxiety is decreased or increased during episodes, and the differing 'onset' periods for each condition.

Although clinical differentiation might be expected to be reasonably clear-cut, in the majority of instances

the coterminous presence of both a BP II and a BPD needs to be conceded in a percentage of individuals.

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