Acta Psychiatr Scand 2013: 1–2
Published by Blackwell Publishing Ltd
All rights reserved
DOI: 10.1111/acps.12107
Invited comment
Borderline versus bipolar: differences matter
If you want to distinguish between two conditions, look for
their differences, not their similarities. This is a simple idea,
ignored by combatants in the bipolar-borderline wars.
Let’s begin with mistaken similarities.
The most common mistake is to see ‘mood swings’, or mood
lability, as central to both conditions. ‘Mood’ is not central to
mood disorders. During mania, one can be sad, happy, irrita-
ble, or anxious. The core psychopathology of bipolar illness
appears to be psychomotor activation (1). In contrast, most
patients with borderline personality do not have such psycho-
motor activation (decreased need for sleep with increased
energy, increased goal-directed activities, pressured speech) –
especially episodically. Some claim that impulsivity is central
to both conditions. But most manic, and all hypomanic, epi-
sodes, do not involve notable impulsive behavior [the minority
of manic episodes involve sexual indiscretions or impulsive
spending (2)].
Similarly, although borderline personality can have mood
lability, this feature is variable; borderline patients sometimes
are impulsive in behavior, but they are not always so.
This clinical debate about overlap is scientifically false. The
‘core’ features of mood lability and impulsivity are not central
to either illness.
The concept of mood temperaments further complicates
matters. Bipolar illness is episodic, whereas personality disor-
ders are constant. This is one key distinction. But mood tem-
peraments, like cyclothymia or hyperthymia (constant mild
manic features), are also constant (3). If mood lability is seen
as central, little distinction exists on that feature between
cyclothymic or hyperthymic temperaments vs. borderline
personality.
Let’s turn to the useful differences between these conditions.
Self-destructive cutting behavior is highly uncommon in
bipolar illness, but common in borderline personality
(50–80%). Bipolar disorder is almost completely genetic, about
80–90% heritable, similar to physical height (4). Borderline
personality is much less genetic, with about half the genetic
loading, similar to anxiety conditions. If bipolar illness is pres-
ent in the family, based on the above data, then bipolar illness
is highly probable in a proband. Finally, borderline personality
is highly associated with sexual trauma (40–70%); the preva-
lence of sexual trauma in bipolar illness (20–40%), although
higher than the general population (13–17% in women and 2.5
–5% in men), is half that in borderline personality.
These differences help us better appreciate this analysis from
the BRIDGE study. The BRIDGE data are reported mostly in
terms of overlap between these two conditions. What matters
more is how they differ.
In terms of overlap, 4/9 borderline criteria predicted bipolar
illness. Critics might cite the inherent overlap of mood lability
in the broad bipolarity specifier definition of the BRIDGE
study, but this broad definition does not mean that those
patients have borderline personality either, because mood
lability is neither central nor specific to borderline personality,
happening also in bipolar illness and other conditions.
© 2013 John Wiley & Sons A/S.
ACTA PSYCHIATRICA SCANDINAVICA
The more striking finding is that four borderline features
were not predictive of bipolarity even using the broad bipo-
larity specifier: abandonment, identity disturbance, recurrent
suicidal or self-mutilating behavior, and dissociative symp-
toms. These borderline features are all the more impressive
when one appreciates that this is a sample of patients with
clinical depression in which the prior probability of bipolar
illness, simply based on presence of depression and the clini-
cal/demographic features of the sample, is about 50%.
As DSM ignores possible causes, and childhood sexual
abuse is not listed among DSM criteria, these data do not
assess that important predictor of borderline personality. We
think it likely would differ as well.
In sum, these data are quite useful, if viewed from the per-
spective of how these conditions differ, not how they appear
similar.
Look for the differences: if patients have sexual trauma
and/or self-mutilation and/or dissociation, borderline person-
ality is probable and bipolar illness unlikely. If patients have a
family history of bipolar illness and marked episodic psycho-
motor activation, in the absence of sexual trauma and self-
mutilation, it would seem indefensible to diagnose borderline
personality.
Still, there will be differences of opinion, which leads us to
offer a final comment.
Unfortunately, it is a truism of sociology that political
and economic factors influence professional debates. One
proponent of borderline personality has even decried ‘bipo-
lar imperialism’ (5), as if certain ‘territory’ is being invaded
by a foreign group. Such rhetoric can easily be turned
around: it can be claimed that borderline ‘imperialism’ led
to marked bipolar underdiagnosis from the 1960s through
the 1990s, and even today. Furthermore, manic depression
has been described in the scientific literature for almost
two centuries, with literally thousands of nosologic validity
studies (symptoms, genetics, course, treatment effects, and
biology); borderline personality, in contrast, is a psychoan-
alytic construct of about 50 years vintage, with a few
dozen, at most, studies of nosologic validity. These are not
nosologic equals: A clearly valid disease is being compared
with a psychological construct.
In that comparison, instead of political rhetoric, this kind
of scientific research can help clarify the controversy.
S. Barroilhet1,3, P. A. V€
ohringer3,4 and S. N. Ghaemi2
1
Escuela de Psicologıa, Universidad de los Andes, Santiago,
Chile, 2Director, Mood Disorders Program, Tufts Medical
Center, Professor of Psychiatry and Pharmacology, Tufts
University Medical School, Boston, MA, USA,
3
Mood Disorders Program, Tufts Medical Center, Professor of
Psychiatry and Pharmacology, Tufts University Medical
School, Boston, MA, USA and 4Department of Psychiatry,
Hospital Clinico Universidad de Chile, Facultad Medicina
Universidad de Chile, Santiago, Chile
E-mail: nghaemi@tuftsmedicalcenter.org
1
Invited comment
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