Differentiating Borderline Personality Disorder from Bipolar Disorder
By BERNADETTE GROSJEAN, MD

Borderline personality disorder (BPD) and bipolar disorder frequently co-occur (numbers range from 8% to 18%), although they are distinct clinical entities (Paris J et al, Compr Psychiatry2007;48(2):145–154). A proper diagnosis guides the most effective treatment, but you’ve probably faced the difficult challenge of diagnosing these conditions, which share several clinical features.

BPD can be described by four types of psychopathology: affective disturbance, impulsivity, cognitive problems, and intense, unstable relationships. What’s most important—in addition to seeing that your patient meets DSM-IV criteria for BPD—is to establish that patterns of affective instability, impulsivity, and unstable relationships have been consistent over time. Thus, obtaining a detailed history is crucial. Also, the key features we see in BPD, such as dissociation, paranoia, and cognitive problems, are often affected by the patient’s environment and, particularly, his or her relationships. A patient might have a history of rapid and sudden deterioration when relationships change—such as threatening suicide after a breakup or severe mood swings when separated from her family. Generally, the more intense or significant the relationship is, the greater the risk of chronic stress and mood dysregulation.

Many of the same features are seen in patients with bipolar disorder, such as dysphoria, hyperactivity, impulsivity, suicidality, and psychotic symptoms. As a result, borderline patients with this cluster of symptoms are often misdiagnosed with bipolar disorder, possibly because of the effectiveness of psychopharmacological treatments for such symptoms. In fact, a more thorough assessment might show that these patients actually suffer from a personality disorder. In one study, more than one third of those misdiagnosed with bipolar disorder met DSM-IV criteria for BPD (Zimmerman M et al, Compr Psychiatry2010;51(2):99–105).

In BPD, mood changes are generally short-lived, lasting only for a few hours at a time. In contrast, mood changes in bipolar disorder tend to last for days or even weeks or months. Mood shifts in BPD are usually in reaction to an environmental stressor (such as an argument with a loved one or a frustration in the waiting room), whereas mood shifts in bipolar disorder may occur out of the blue. Some clinicians consider BPD an “ultrarapid-cycling” form of bipolar disorder, but there’s little evidence to support this link (Gunderson JG et al, Am J Psychiatry 2006;163(7):1173–1178). Patients with BPD might rapidly cycle through depression, anxiety, and anger, but these mood shifts rarely involve elation; more often, the mood shifts are from feeling upset to feeling just “OK.” Likewise, the anxiety or irritability of BPD should not be mistaken for the mania or hypomania of bipolar disorder, which usually involve expansive or elevated mood.

At a more existential level, patients with BPD—particularly younger patients— often struggle with feelings of emptiness and worthlessness, difficulties with self-image, and fears of abandonment. These are less common in bipolar disorder, where grandiosity and inflated self-esteem are common, especially during mood episodes. And while both conditions may include a history of chaotic relationships, a patient with BPD may describe relationship difficulties as the primary—or sole—source of her/his suffering, while the bipolar patient may see them as an unfortunate consequence of his behavior.

A pattern of self-harm and suicidality often serves as a cue for diagnosing BPD (but are not necessarily required). But both can be seen in bipolar disorder, too. In BPD, suicide threats and attempts may occur along with anger at perceived abandonment and disappointment. Patients often explain these impulses as a way to be relieved of pain, or to “stop their thinking,” more so than to end their lives, per se. Patients with BPD may experience “micropsychotic” phenomena of short duration (lasting hours or at most a few days), including auditory hallucinations, paranoia, and episodes of depersonalization. However, patients generally retain insight, and can acknowledge that “something strange is happening” without strong delusional thought. When psychotic symptoms occur in bipolar disorder, they happen in the context of a mood episode, they tend to last longer, and patients may be unable to reflect on their behavior.

Accurate diagnosis of BPD and bipolar disorder can be difficult, but it’s essential for proper treatment and optimal outcome. Remission rates in BPD can be as high as 85% in 10 years (Gunderson et al, Arch Gen Psychiatry 2011;68(8):827–837), particularly with effective psychotherapeutic treatments (Zanarini MC, Acta Psychiatr Scand 2009;120(5):373– 377). Unfortunately, such treatment is not always available. Some medications can be used in BPD, such as an SSRI for impulsivity, severe and persistent depression and/or suicidality, or an atypical antipsychotic for recurrent dissociative symptoms or disinhibition. However the only consensus seems to be that medications should be used as adjuncts to psychotherapy (Silk KR, J Psychiatric Practice 2011;17(5):311–319). The long-term use of a mood stabilizer or atypical should be reserved for known cases of bipolar disorder.

TCPR’s VERDICT: Clinicians sometimes think of a BPD diagnosis as pejorative (chronic and untreatable) and may be reluctant to disclose it, but patients and their families often find it helpful to be informed of the diagnosis. Similarly with bipolar disorder, accurate diagnosis often determines prognosis and effective treatment. For the clinician, however, it’s imperative that you make the proper diagnosis in these two often overlapping, but fundamentally quite distinct, conditions in order to optimize your patients’ outcomes.

Mental health issues topic of presentations

By Linda Braden Albert | [email protected] | Posted 14 hours ago

A series of presentations on mental health issues will begin Thursday at the Blount County Public Library. The first presentation is by Sita Diehl, past executive director of the National Alliance on Mental Illness (NAMI) Tennessee and currently national director of state advocacy for NAMI National.

Larry Drain, recently named president of NAMI Maryville, said, “When they asked me to take the job, I really wanted to figure out a way not only to help NAMI but to help the community. Every day, nowadays, when you read the paper or watch TV or whatever, in one way or another, mental health issues are there. There’s a lot of bad information, misinformation, so the idea I had was that if we could bring a series of people to Maryville to talk about mental health issues, that would be a real, real positive thing for this community.”

Diehl’s current position entails her traveling from state to state, organizing efforts to make outcomes for mental health possible in each state, Drain said. “I’ve known her for years, and she was the very first person I asked. Her topic will be about finding support, whether you’re a family member, whether you’re somebody with a mental illness. She will talk a lot about NAMI, some about the mental health system in Tennessee. There will be a question and answer period after she gets through talking. Anybody who comes will be enriched by her.”

On April 24, Doug Varney, commissioner of mental health and substance abuse services for the state of Tennessee, will speak on mental health and drug addiction. Drain said, “I think he will talk some about prescription drugs and meth, what the state is trying to do to deal with some of these things. Especially in Blount County, it is such a live issue. ... He knows the topic inside out.”

Additional speakers in upcoming months include Ben Harrington, executive director, East Tennessee Mental Health Association; Scott Ridgeway, director, Tennessee Suicide Prevention Network; Allen Doderlain, national president, Depression and Bipolar Support Alliance; Pam Binkley, recovery coordinator, Optum Health, who will talk about emotional first aid; Lisa Ragan, director, Office of Consumer Affairs, Tennessee Department of Mental Health, who will speak on peer support, recovery, etc.; and Elizabeth Power, a nationally known expert on post-traumatic stress disorder. Mental health professionals from Blount Memorial Hospital have also been invited to speak.

Drain said, “I think this will be a quality addition to the Maryville community and I hope lots of folks will come. ... For a lot of folks here, the whole area of mental health, mental health treatment, the resources involved and things like that are so confusing. My hope is that all these speakers can shed some light, bring some facts and really help people in the Blount County area.”

Larry Drain, hopeworkscommunity

                                   Alternative to Meds Center                                                
                                          Success Story   
By: Ericka G.
                The script for my success journey had already played out in the optimistic stage of my mind prior to this life-changing breakthrough. Before this perceived notion of accomplishing the most profound discovery, there lied a mental environment of opposing views. The pivotal dynamic contrast that lied dormant was the hopelessness marked by my former psychiatrist’s repetitive voice relaying that psychotic medication intake would be for a lifetime. But something deep within surpassed this voice and rang out louder representing hopefulness with the confidence to know that holistic alternatives existed with healthier ways to manage my symptoms.  Therefore, I launched a mission in search for this non-conventional approach through a few browse searches on Google and suddenly a vision was birthed to one day attend the “Alternative to Meds Center”. As anticipation rose to meet the eager embrace of new found hope, the circling theme that dominated my thoughts involved the declaration of healing that stood me right in the face the night before my arrival. This arrival of recovery victory existed prior to packing my bags and stepping on the soil of Sedona, Arizona to embark upon this outstanding program here at ATMC. With the proper mindset and motivated perception, the stabilizing tone was set for past frustration to become whole manifestation.


Though healing had already taken place, I forged a goal to become totally medication free to avoid the pulsating cardiac distress fueled by the side effects of Geodon. In addition, I didn’t want to play a prolonged game of Russia Roulette by taking a risk on a harmful medication that could cause future health issues. Stable and highly productive the last 8 years, through the collective effort of remaining true to my faith in God as I properly managed my symptoms, I gained the blessing of being hospital-free during this duration. This all-inclusive, holistic approach in addressing every angle of total well-being produced excitement coupled with enlightenment and elevation.  With a willing and open receptiveness, I became a thriving “sponge” with the drive to advance my knowledge of the program’s teachings, tools, and training. From the moment I started the program, the enlightening mode of taking advantage of every nugget of information to better equip myself for mental health and physical wellness became the focal point of my positive interaction. Every aspect of the program especially the counseling has propelled me to new levels of understanding the greater need for self-care through diligence and improvement all in making me a more polished individual. The beneficial knowledge I received concerning the importance of supplementation to the health-conscious meals to the intensive detoxification process worked hand and hand to cohesively promote total restoration, mental clarity, and longevity. With these practices, the collaborative effort of the staff’s supportive attitude and expert awareness of the best solutions to all of my needs made this an exceptional experience. My gratitude continues to deepen, most importantly, to Mr. Lyle Murphy for making his vision a staple reality that would be successfully influential in making a difference for so many of us.

7 Things a Child with Depression Should Know

By Deborah Serani, Psy.D. on February 2, 2014 - 8:42am I know depression.

I lived with it as a child, watched it almost destroy me as a teen, and learned to manage it as an adult.

As a clinician who specializes in mood disorders, I like to teach kids and teenagers how to live with their depression. These tips offer children ways to understand their own unique self, become aware of their thoughts and feelings, and build resiliency as they manage the chronic illness of depression. 

1) Understanding the texture of feelings: Many children in this era of super technology aren’t skilled at reading facial cues, understanding eye contact and complex emotions. Studies show that children with depression struggle further, however, having difficulty differentiating the differences between different kinds of emotions. Sad is different than lonely. Lonely is different disappointed. Often, depressed children need help understanding the textures of emotions. When they become confident identifying their feelings, they can set into motion the best plan of action to improve their mood.

2) How to spot negative thinking: I like to teach children about the quality of their thoughts by using a thumbs up and thumbs down technique. Is what you’re thinking a good thought….one that would get a thumbs up from other people? I studied for my test. But if I get a bad grade, it’s okay because I know I tried my best. Or is it a hurtful or negative? One that really is untrue and realistic. It doesn’t matter if I studied. I’m stupid and I’ll fail the test anyway. Teaching children to catch the negative talk helps them approach every issue in life from a place of positivity.

3) How to use positive self-care: Learning to live with depression requires a child to be clever and ever-ready to use soothing ways to address sad moods. Teaching kids and teens to use their 5 senses – sight, touch, hearing, taste and smell – really helps. Things like cozying up to a stuffed animal, hugging loved ones, snacking on healthy, flavorful foods, taking in the fresh air, listening to upbeat music and making time to see colors, nature and sunshine. All of these raise dopamine and serotonin levels improving mood, and teach children how to self-soothe.

4) Why exercise is important: The fatigue that comes with depression leaves kids tired and irritable. Physical complaints like aches and pains also knock them out for the count too. When we take the time to teach children about the importance of physical exercise, it will become part of a lifelong skill-set. Be it playing tag with friends or catch with the dog, swimming or riding a bike, kick-boxing or yoga, or a simple walk, the shift in neurochemistry boosts mood.

5) When too much of something isn’t good: It’s also vital for kids to learn how too much of anything can upset the apple cart. For example, the fatigue of depression can leave children tired, with many prone to sleeping all day. Instead, children should learn that a nap is better than a full-on sleepfest. Some depressed children eat in excess, while others lose their appetite altogether. Both of these extremes are unhealthy. Too much crying, too much avoidance or too much irritability raises the stress hormone cortisol, which heightens anxiety and alertness. When we teach children to monitor their experiences with healthy limits, we give them the ability to balance and self-manage their well-being. Daily stickers for young ones and journaling for the older set can teach children how to better monitor symptoms and moods.

6) Know the difference between a bad day and a sad mood: When depressed kids learn how to measure the moment, they learn that a sad mood doesn’t have to ruin a day. However, if they can’t shake off the sad mood – and the rest of the day feels like an epic fail, it’s great for kids to know that a bad day doesn’t equal a bad life. Tomorrow is a new day. One to be measured for its own value.

7) How to let others know you need help: When children are depressed, they often don’t know how to reach out for support. Their fatigue and irritability dulls problem solving skills. Others might not feel they deserve help or would rather isolate themselves from family or friends. Depressed children need to know that everyone needs help now and then – and that no one can …or should… handle everything alone. I like to teach children to communicate their needs verbally and non-verbally. With words, through crying, by touch – it’s okay to show you others that you’re having a tough time.

The Depression and Bipolar Support Alliance (DBSA) is the leading patient-directed national organization focusing on depression and bipolar disorder. The organization fosters an environment of understanding about the impact and management of these life-threatening illnesses by providing up-to-date,
scientifically-based tools and information. DBSA supports research to promote more timely diagnosis, develop more effective and tolerable treatments and discover a cure. The organization works to ensure that people living with mood disorders are treated equitably. Assisted by a scientific advisory board comprised of the leading researchers and clinicians in the field of mood disorders, DBSA has more than 1,000 peer-run support groups across the country. Nearly five million people request and receive information and assistance each year. DBSA’s mission is to improve the lives of people living with mood disorders. For more information about DBSA or depression and bipolar disorder, please visit www.DBSAlliance.org or call (800) 826-3632.