Both borderline personality disorder and broadly defined bipolar disorder are common (prevalence: 1-6%). Comorbidity occurs in approximately 1 in 5 (Fornaro et al, 2016) with a high symptom overlap; impulsivity, suicidal behaviour and affective instability.
This commonly leads to misdiagnosis in outpatient settings:
- 25% of patients diagnosed with bipolar disorder were, in fact, borderline personality disorder patients
- 44% of borderline personality disorder patients had their diagnosis corrected to bipolar disorder.
The problem of misdiagnosis spans psychiatry as this occurs in other conditions (Vöhringer, et al 2016; OConghaile et al, 2015; Zbozinek et al, 2012).
Bipolar disorder and borderline personality disorder differ in treatment and prognosis:
- Borderline personality disorder is usually treated with psychological therapy and may be in remission after 6 years
- Bipolar disorder is usually treated with medication and is a lifelong relapsing condition.
A qualitative study of how psychiatrists and nurses distinguish bipolar disorder from borderline personality disorder
32 secondary care psychiatrists and nurses used semi-structured interviews mostly in a community-mental-teams setting. Clinicians found differential diagnosis difficult because of the symptom overlap in relation to the following:
- Mood instability
- The need to rely on self-reported mood symptoms
- Inaccurate retrospective recall
- Chaotic lifestyles
- Illicit drug use
- Conducting diagnostic assessments in crisis situations
Many clinicians felt that diagnosing bipolar disorder was more important. However, as one psychiatrist rightly pointed out:
If you go to someone who’s got borderline-type problems, and you just try to find out if they’ve got bipolar – have had a hypomanic episode, and you just ask your questions in that way, you’d be very likely to erroneously conclude that they have had a hypomanic episode.
Clinician survey of diagnostic knowledge and experience
A survey of 648 psychiatrists’ (70% consultants) knowledge and use of diagnostic criteria when distinguishing bipolar disorder and borderline personality disorder, found 76% of respondents felt confident in their ability to discriminate between the 2 conditions. However, 52% of respondents indicated this was a source of disagreement.
Even though respondents’ knowledge matched DSM-IV-TR, only half of respondents preferred using diagnostic criteria; but 84% and 75% of respondents thought diagnostic criteria matched the clinical presentation of bipolar disorder and borderline personality disorder, respectively. Only 6% endorsed borderline personality disorder occurring comorbidly with bipolar disorder as a fairly frequent occurrence in their practice, which is substantially different to published accounts, as mentioned above.
An observational study of the diagnostic assessment process in ordinary practice
When analysing audio recordings of 18 patient interviews in secondary care, depressive symptoms were adequately assessed in 61% of cases but in 20% of cases elevated mood was not addressed at all. Enough symptoms were explored to affirm borderline personality disorder in 22% of cases.
Experienced psychiatrists’ diagnoses were compared to OPCRIT (Operational CRITeria), a diagnostic system that automates the generation of diagnoses using a checklist constructed from the major psychiatric diagnostic classifications. The agreement between diagnoses and OPCRIT was 5 out of 18. Of the 7 patients given a diagnosis of bipolar disorder 3 had bipolar disorder according to OPCRIT. Of the 5 patients given a diagnosis of borderline personality disorder, OPCRIT suggested 1 had bipolar disorder and 4 had other conditions.
There may be previous studies that examine new diagnostic methods, but I am not aware of other research that examines common practice in this level of detail.
What is troubling is that not enough information was available to clinicians to establish anything other than depression. Even more so, they proceeded to diagnose without enough information.
When considering the survey and clinical practice data in tandem, clinicians’ views about how diagnostic criteria represent clinical practice manifest as a minority of assessments being sufficiently assessed for symptoms of mania or borderline personality disorder and largely conflict with OPCRIT diagnoses. Instead we see some factors as heavily influencing the differential diagnosis such as an abusive past or a family history of psychiatric disorders. Whilst these associations are supported by research (Distel et al, 2008; Kendler et al, 2008; Zanarini et al, 1989), they are not exclusive to either condition. This is in agreement with previous reports on clinical practice (Aboraya, 2009). If all psychiatrists use impressionistic approaches the utility of diagnostic labels to inform treatment and communication become fundamentally flawed, as do their medico legal defensibility.
The paper quotes one psychiatrist:
So I think if you’re someone who goes, what do I feel this patient is presenting to me with? Or you’re someone who goes well, what boxes am I ticking, I think that that then leads you down two different routes in terms of thinking about diagnosis.
Of course, he is absolutely correct, however, another psychiatrist is quoted:
I challenge anyone to be able to say what their mood’s like reliably over that period of time.
If you apply this to psychiatrists instead of patients you find that this eloquently describes the problem with impressionistic approaches; their inherent vulnerability to variation and inaccuracies. All medical and medical-affiliated professions are pushed towards evidence-based-practice for good reason, but this paper shows practice in direct opposition to this principal.
One problem may be that clinicians are aiming to manage the condition as a whole, hence, an overarching label is useful. However, both these conditions exist on a spectrum. It may aid standardisation or evidence based practice if the aim was to manage symptom clusters. At the very least, it may incentivise clinicians to elicit more information from their patients.
Where appropriate, this article largely satisfied the CASP checklist for qualitative studies (PDF). Of particular note was the 8.1% response rate for the survey, but it did cover a considerable portion of the UK, many different contexts and reached data saturation, but it may have suffered from self-selection bias and the number of clinicians included in the qualitative study was small.
Saunders KEA, et al. Distinguishing bipolar disorder from borderline personality disorder: A study of current clinical practice. European Psychiatry 2015:30(8):965-974. [Abstract]
Fornaro M, et al. (2016) The prevalence and predictors of bipolar and borderline personality disorders comorbidity: Systematic review and meta-analysis. J Affect Disord. 2016;195:105-18. [PubMed abstract]
Vöhringer PA, et al. (2016) Discriminating Between Bipolar Disorder and Major Depressive Disorder. Psychiatr Clin North Am. 2016;39(1):1-10. doi: 10.1016/j.psc.2015.10.001. [PubMed abstract]
OConghaile A, et al. (2015) Distinguishing schizophrenia from posttraumatic stress disorder with psychosis. Curr Opin Psychiatry. 2015;28(3):249-55. [PubMed abstract]
Zbozinek TD, et al. (2012) Diagnostic overlap of generalized anxiety disorder and major depressive disorder in a primary care sample. Depress Anxiety. 2012;29(12):1065-71.
Distel MA, et al. (2008) Heritability of borderline personality disorder features is similar across three countries. Psychol Med 2008;38(9):1219–29. [PubMed abstract]
Kendler KS, et al. (2008) The structure of genetic and environmental risk factors for DSM-IV personality disorders: a multivariate twin study. Arch Gen Psychiatry 2008;65(12):1438–46.
Zanarini MC, et al. (1989) Childhood experiences of borderline patients. Compr Psychiatry 1989;30(1):18–25. [PubMed abstract]
Aboraya A. (2009) Use of structured interviews by psychiatrists in real clinical settings: results of an open-question survey. Psychiatry 2009;6(6):24–8.
Is it bipolar disorder or borderline personality disorder? https://t.co/uOLhxtl9ne #MentalHealth https://t.co/ot4SNrPAcu
Is it bipolar disorder or borderline personality disorder? https://t.co/8vrNG83DEe
.@Mental_Elf interesting read. Sadly I have seen diagnosis be as much a source of professional conflict as consensus esp in complex cases
@nuwandiss @Mental_Elf And where do you think that leaves person on receiving end of diagnoses?
.@Mothermindful @Mental_Elf totally agree. Work in AOT where folk have usually had numerous diagnoses, unhelpful
I’ve also experienced mental health workers to interprete ’bpd’ to mean bipolar disorder when read in notes. So that also hasnt helped.
This should never happen anywhere, easily preventable mistake…
.@Mental_Elf diagnostic labels can make a big difference to the attitude of professionals towards the patient
@nuwandiss @Mental_Elf As the article also suggests-different diagnoses=different treatments+ outcomes!
@tadhg50 @Mental_Elf absolutely
Today @Doc_Murtada on distinguishing #BipolarDisorder from borderline personality disorder #BPD https://t.co/puTgHZeDQ6
@Mental_Elf @Doc_Murtada nice blog! thx for citing our MA of bipolar disorder and borderline PD comorbidity https://t.co/MgLpPE6DIm
@BrendonStubbs No problems :) it was very helpful
@Mental_Elf Mmm…..Does this say something about validity of any psychiatric diagnosis? Know many ppl who’ve had quite a few in their time
@Mothermindful yes, it does. But remember that these illness have a huge symptom overlap which is complicated by the face that the present on a spectrum; not all patients have all symptoms
Quite technical in parts but may be of interest in various ways: Lauren Stevens, Mark Stevens and Chad Andrew Lyon
Yes very interesting. I certainly know of one young woman who was re-diagnosed as borderline personality disorder after a misdiagnosis of bipolar. As for me, I am certain my diagnosis is correct. To quote the article, “Bipolar disorder is usually treated with medication and is a lifelong relapsing condition”… It also gets worse as one grows older, but this is offset by the ability to develop more effective coping strategies (in my case anyway). Happy days!
coping strategies should be something that all patients get taught/trained in from the very start!
thanks Melangell, will try to make the next blog simpler :)
Bipolar disorder and borderline personality disorder have high symptom overlap and are often misdiagnosed https://t.co/puTgHZeDQ6
@Mental_Elf interesting GP & ex CCO known 19 yrs r adamant don’t have BPD but psyc barely knows me & only 4 short period time says BPD!
Is it bipolar disorder or borderline personality disorder? https://t.co/E6VOIJvKTl
Is it bipolar disorder or borderline personality disorder? https://t.co/1pfaULDVhT via @sharethis
@Mental_Elf I have both DX one gets me drugs the other therapy .. two psychs two different opinions
@BPDFFS @Mental_Elf How ya doing Sue?
Thank-you for this blog, a very useful consideration of the diagnosis and the contributing factors that may sway a clinicians judgement. One comment that really struck me was: “An exclusive diagnosis of personality disorder is quite a good way of saying I don’t want anything to do with this patient.” Something we often suspect but shocking to see in print. Also with this paper it seems the nurses perspective has got a bit lost, or maybe I’m mis-reading it
you weren’t misreading, but dont forget that psychiatrists are not infallible, they are just as flawed as the rest of us, although we hold them to a higher standard
Is it bipolar disorder or borderline personality disorder? https://t.co/RJk09to3Uo via @sharethis
Are we missing the nursing perspective on bipolar & BPD diagnosis? Important comment from @LornaSaunder https://t.co/hya5I75CTT @Doc_Murtada
@Mental_Elf greater stigma re BPD and from my experience seems to be a “we can’t do anything for a PD so we needn’t bother” -needs 2 change.
this was a point raised by authors of the paper:PD diagnosed when patients cudnt be diagnosed with anything else
@Doc_Murtada @Mental_Elf still so far to go in field of psychiatry. Can it ever be an exact science?
Absolutely! I wrote 2 blogs on it. Patients need to push for this:
@Doc_Murtada @Mental_Elf I look forward to reading them
@BeccaBoo3011 @Mental_Elf Both true+worse -arse about face. REMISSION IS POSSIBLE WITH PD, bipolar= lifelong. Which one is more treatable?!
good point! the paper focused heavily on diagnosis by psychiatrists, cud you tell us more about nurse perspective?
@Doc_Murtada @Mental_Elf It says in the paper nurses were interviewed, but all responses were from psychs. Only lists medical qualification?
apologies4lack of clarity
they did 3 studies (mostly with psychiatrsts)
nurses’ views not explored by authors
@Doc_Murtada @Mental_Elf @CityMentHealth There are a variety of articles looking at MHNs attitudes to BPD (apols for acronym)
@Mental_Elf @LornaSaunder @Doc_Murtada Historically, MHNurses don’t ‘diagnose’, Psych’s do! MHNs usually ‘formulate’ +/-deliver ‘care plans’
@Mental_Elf I was misdiagnosed with BPD whilst inpatient for anorexia. Still to this day, I get asked about my non existent BPD ?
@Kowareta_Doll thats really unfortunate, I would hope that someone actually corrects your notes at some stage…
El 25% de los trastornos bipolares son TLP; el 44% de los TLP se acaban diagnosticando como trastornos bipolares https://t.co/m9GeYsBtvL
Is it bipolar disorder or borderline personality disorder? https://t.co/z5RKVsgBbR via @sharethis
Qualitative study of how psychiatrists & nurses distinguish bipolar disorder from borderline personality disorder https://t.co/puTgHZeDQ6
@Mental_Elf Something needs to change for people with BPD whose suffering is enormous with little or no help or understanding #BPD #TARA4BPD
Is it bipolar disorder or borderline personality disorder? https://t.co/rwgmKtlFpo via @sharethis
Really interesting , I question my son only had bpd . I’m sure it’s bipolar as well . It’s a hard struggle to get someone to see what I see
Thanks for sharing your experience, Bernadette
It could be both and both are manageable, sometimes it takes time to get the right balance, could you tell us more about your experience?
@Connect2Pharma heres that blog:
Bipolar & borderline personality both often over-diagnosed by rushed clinicians who don’t take a careful history
@AllenFrancesMD thanks for sharing
correct, if we educated patients to keep a symptom diary or a mood tracker, I wonder if it would improve diagnostic accuracy…?
[…] 1Is it bipolar disorder or borderline personality disorder? Mental Elf Blog post. […]
If you are a woman who self harms then you’re getting a diagnosis of bpd regardless of what other signs, symptoms and personality traits you have. Having specialist pd teams around has made people think a bit more about diagnosis and there is now a treatment pathway for pd. The national PD conference this month was fantastic but its full of people who have the faith already. Need to do more to keep hope and empathy with staff before its lost in toxic ward environments. @keirwales
Hi Kier, thank you for sharing.
Thankfully, there is better recognition and awareness for mental health in general. Conditions that are not as widely known as the stuff that gets air time will need more time to generate awareness. Having said all of that, I think society is heading in the right direction, now we, as mental health professionals, need to catch
‘Many clinicians felt that diagnosing bipolar disorder was more important’ Well that’s an interesting statement I’m assuming it’s because the psychiatrists first line of treatment is medication and therefore they can help with bipolar disorder. Unlike BPD as NICE recommended treatment is therapy. I wonder if this is a reason people get mis diagnosed …
My second point is that I got a diagnosis of BPD from a very kind psychiatrist in 40 minutes of meeting me. I also got a diagnosis of bipolar spectrum disorder from another kind psychiatrist within 40 minutes of meeting me. This for me seems too fast yes I was well kempt had appropriate eye contact but how can you put a diagnosis on someone which is life changing in that time. I think there should be more discussion and education for people using services before a diagnosis … If any … Is given …It should be mutually agreed .. I know time is something we don’t seem to have but my thoughts are it should be more carefully considered.
After reading about both disorders bipolar 2 and BPD there are crossovers . I could have BPD and suffer with depression well isn’t that bipolar 2? I could get manic act impulsively both symptoms of each disorder as are psychotic episodes. I’m confused what’s counted as a brief episode and what’s a not so brief one… Is there a time limit?
Anyway I stuck with my original diagnosis my therapy is helping but I use medication mainly as PRN on occasion. I do use the bipolar diagnosis when I think I might get treated with more respect because believe me the difference in how some HCP’s treat you is unbelievable. Some are wonderful however.
So my main message is take more time when diagnosing and if someone disagrees or doesn’t find it helpful listen to them …
Thanks for sharing your experience, Sue. This is never easy, most of all to you, the patient. Keeping mind that I know very little about your situation or symptoms, it could be that you have both. And the original publication did mention that diagnoses are influenced by non-clinical factors, which is sad but it is what we have to deal with.
I think you are right, more time is needed with better diagnostic tools. I think relying on one account in your first session with a psychiatrist could easily lead to misdiagnosis, but if you document which symptoms you feel in a diary or a mood tracker or something, it could lead to a more reliable diagnostic procedure.
Lastly, the need to diagnose immediately might be causing more harm than good, in the blog, I suggest trying to manage symptom clusters, instead of treating a condition, would this have made a difference for you?
Study suggests clinical diagnostic practice is not adequate to reliably distinguish btwn bipolar & BPD https://t.co/puTgHZeDQ6
@Mental_Elf Interesting paper.
1) loads of people meet criteria for both
2) the criteria for bipolar 2 are bizarrely easy to meet
3) diagnosis takes time
@PsychiatrySHO @Mental_Elf time getting know s/u r crucial my GP & exCCO known 19yrs don’t believe I have BPD but Psyc hardly knows me Dx it
@PsychiatrySHO @Mental_Elf Agreed, time is most important. BPD intrapsychic structure has to be looked for unless very low level defences.
@graemeinbelfast @PsychiatrySHO @Shirley747
This is complicated by diagnosis in psychiatry needs a complete overhaul
RT @Mental_Elf: Join our discussion about diagnosing bipolar disorder & borderline personality disorder https://t.co/puTgHZeDQ6 https://t.c…
Is it #bipolar disorder or #borderlinepersonalitydisorder? https://t.co/0b2iIHHkdk via @sharethis
RT @Mental_Elf: Does DSM help psychiatrists to distinguish bipolar disorder from borderline personality disorder? https://t.co/puTgHZeDQ6 @…
Yes, it should but some psych do not believe DSM reflects the actual disease
it is of course more complicated as these illnesses present on a spectrum; not all patients have all symptoms
RT @Mental_Elf: Don’t miss: Is it bipolar disorder or borderline personality disorder? https://t.co/puTgHZeDQ6 #EBP #WorldBipolarDay
Thanks for sharing, what did you like about the blog?
RT @Doc_Murtada: مقالي الجديد عن تمييز مرض اضطراب الشخصية الحدي من مرض ثنائي القطبية
Is it bipolar disorder or borderline personality disorder? https://t.co/rtG278Yl5E
@RKallemWhitman @IntlBipolar @GreggBeratan ‘we’ really don’t https://t.co/jFIg3bj1dx he’s gone, there’s life to live.
Is it bipolar disorder or borderline personality disorder?
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Bipolar disorder or borderline personality disorder?
Is it bipolar disorder or borderline personality disorder? https://t.co/l6vNDAnvtH via @sharethis
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This is just an example of why the diagnosis of mental distress is no good at all. DSM 5 has so many new ones that anyone could be labelled with a mental illness. Mental distress and looking at what happened to the person not what is wrong with them is the way forward to have a humanistic mental health system. Psychiatry needs a paradigm shift. It would be good to see The Mental Elf focusing more articles on this.
Hi, so are you essentially saying that the diagnoses of both have flaws, we should go by the symptom cluster to determine if we should prescribe medications? And your suggestions/if there is any further evidence on how do we go about to do so? Apologise if I missed these points in your article.
I got diagnosed as BPD but feel I’ve got Bipolar not BPD. Yes I had childhood trauma and substance abuse but I do not suffer from fear of abandonment, separation and rejection which seems to be a key factor. Also I do not need a hair-trigger response for my changes in moods, I’ll change moods for No reason and they will last for days or weeks at a time. Then followed by periods of feeling settled, I’ve read that BPD don’t really have settled days. Reading up on a persons life with bipolar sounds just like mine. Also the people closest to me feel the same and they are the ones who suffer through my episodes. Bipolar also runs in both sides of my family. I want my diagnose changed so I can get the correct help