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Dual Diagnosis: Bipolar and Borderline Personality Disorder

Is a dual diagnosis possible?

Bipolar disorder covers a spectrum of mood disorders characterized by major mood swings. The mood swings can range from manic or hypomanic high moods to depressed low moods. Borderline personality disorder (BPD), on the other hand, is a personality disorder marked by instability in behaviors, functioning, mood, and self-image.

Many of the symptoms of bipolar disorder and borderline personality disorder overlap. This is particularly the case with type 1 bipolar disorder, which involves intense manic episodes. Some symptoms shared between bipolar disorder and BPD include:

  • extreme emotional reactions
  • impulsive actions
  • suicidal behaviors

Some argue that BPD is part of the bipolar spectrum. However, most experts agree that the two disorders are separate.

According to a review on the relationship between BPD and bipolar disorder, about of people with type 2 bipolar disorder receive a BPD diagnosis. For people with type 1 bipolar disorder, about receive a BPD diagnosis.

The key to differentiating the disorders is looking at them on the whole. This can help determine if you have one disorder with tendencies of the other disorder, or if you have both disorders.

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Symptoms

What symptoms occur when a person has both conditions?

When a person has both bipolar disorder and BPD, they’ll display symptoms unique to each condition.

Symptoms unique to bipolar disorder include:

  • manic episodes causing extremely high feelings
  • symptoms of depression within manic episodes (sometimes known as a “mixed episode”)
  • changes in quantity and quality of sleep

Symptoms unique to BPD include:

  • day-to-day emotional changes related to factors such as family and work stress
  • intense relationships with difficulty regulating emotions
  • signs of self-harm, such as cutting, burning, hitting, or injuring themselves
  • ongoing feelings of boredom or emptiness
  • outbursts of intense, sometimes uncontrollable anger, most of the time followed by feelings of shame or guilt
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Diagnosis

How can you receive a diagnosis with both conditions?

Most people who have a dual diagnosis of bipolar disorder and BPD receive one diagnosis before the other. That’s because the symptoms of one disorder can overlap and sometimes mask the other.

Bipolar disorder is often diagnosed first because symptoms can change. This makes it more difficult to detect BPD symptoms. With time and treatment for one disorder, the other may become clearer.

Pay a visit to your doctor and explain your symptoms if you think you’re showing signs of bipolar disorder and BPD. They’ll likely conduct an assessment to determine the nature and extent of your symptoms.

Your doctor will use the newest edition of the Diagnostic and Statistical Manual (DSM-5) to help them make a diagnosis. They’ll review each of your symptoms with you to see if they align with the other disorder.

Your doctor will also consider your mental health history. Often, this can provide insight that can help distinguish one disorder from the other. For example, both bipolar and BPD tend to run in families. This means if you have a close relative with one or both of the disorders, you’re more likely to have them.

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Treatment

How are bipolar disorder and BPD treated together?

The treatments of bipolar disorder and BPD are different because each disorder causes different symptoms.

Bipolar disorder requires several types of treatment, including:

  • Medication. Medication can include mood stabilizers, antipsychotics, antidepressants, and anti-anxiety medications.
  • Psychotherapy. Examples include talk, family, or group therapy.
  • Alternative treatments. This may include electroconvulsive therapy (ECT).
  • Sleep medications. If insomnia is a symptom, your doctor may prescribe sleep medications.

BPD is primarily treated with talk therapy — the same type of therapy that can help treat bipolar disorder. But your doctor may also suggest:

  • cognitive behavioral therapy
  • dialectic behavior therapy
  • schema-focused therapy
  • Systems Training for Emotional Predictability and Problem Solving (STEPPS)

Experts don’t recommend that people with BPD use medications as their primary treatment. Sometimes medication can worsen symptoms, especially suicidal tendencies. But sometimes a doctor might recommend medications to treat specific symptoms, such as mood swings or depression.

Hospitalization may be necessary in treating people with both disorders. The manic episodes that go along with bipolar disorder combined with the suicidal tendencies sparked by BPD may cause a person to attempt to take their life.

If you have both disorders, you should avoid drinking alcohol and doing illicit drugs. These disorders increase a person’s risk for substance abuse, which can worsen your symptoms.

Suicide prevention

If you think someone is at immediate risk of self-harm or hurting another person:

  • Call 911 or your local emergency number.
  • Stay with the person until help arrives.
  • Remove any guns, knives, medications, or other things that may cause harm.
  • Listen, but don’t judge, argue, threaten, or yell.

If you think someone is considering suicide, get help from a crisis or suicide prevention hotline. Try the National Suicide Prevention Lifeline at 800-273-8255.

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Outlook

What’s the outlook for someone with a dual diagnosis?

A dual diagnosis of bipolar disorder and BPD can sometimes cause severe symptoms. The person may need intense inpatient care in a hospital setting. In other cases, people with both disorders may need outpatient care, but not hospitalization. It all depends on the severity and intensity of both disorders. One of the disorders may be causing more extreme symptoms than the other.

Both bipolar disorder and BPD are long-term conditions. With both of these disorders, it’s very important to work with your doctor to develop a treatment plan that works for you. This will ensure that your symptoms improve rather than worsen. If you feel your treatment isn’t working as well as it should, talk to your doctor right away. 

Article resources
  • Bipolar disorder. (2015).
  • Borderline personality disorder. (2016).
  • Duckworth K. (2017). Borderline personality disorder and bipolar disorder: What’s the difference?
  • Mayo Clinic Staff. (2017). Bipolar disorder: Treatment.
  • Zimmerman M, et al. (2013). The relationship between borderline personality disorder and bipolar disorder.
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