Understanding BPD vs. Bipolar: Key Differences Explained

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BPD, which stands for Borderline Personality Disorder, has significant areas of overlap with bipolar disorder. Both disorders implicate a breakdown in the emotion regulation areas of the brain. But what are the differences? Cross-sectionally, they’re sometimes quite difficult to tell apart. More differences emerge when looking longitudinally across time.

  1. Bipolar is episodic and predictable in the short term: episodes of mania and depression (and mixed episodes) come and go in a fairly predictable fashion. Some people have depression first and then fly into mania, while others start out with a manic episode and then crash into the depression. It’s roughly 50-50 between these patterns, but within individuals the pattern stays consistent. Which is to say, if you’re a mania first bipolar, you’ll most likely always be mania first.
  2. BPD breakdowns tend to be triggered by some situation the person has found themselves in. Their responses may be over-exaggerated but there is some kind of trigger. Bipolar episodes can also be triggered sometimes, but classically, bipolar episodes can occur with no trigger at all. They’re related to a sort of internal thermostat which is broken. Thus, time of year — and changes in sunlight, which affects this internal thermostat — can be triggers for bipolar disorder, and less likely for BPD.
  3. Psychosis is much more pronounced in bipolar disorder than in BPD. The classic euphoric mania with grandiose delusions come to mind; in bipolar disorder, psychosis is limited to mood episodes and is almost always mood-congruent. (Meaning, someone with classic euphoric mania might have grandiose delusions that they are a very important person or have special powers or abilities; meanwhile, someone in a mixed episode might hear muffled voices that make them feel very paranoid about who might be watching, and they see bugs crawling all over the walls. Okay, the mixed episode examples are psychotic features I have experienced myself.) BPD people may experience transient, stress-related psychosis, but they don’t hold onto it as strongly as bipolar people.
  4. Sleep and changes in sleep are arguably the most important symptoms for bipolar people. Not sleeping enough feeds into mania, while sleeping too much feeds into depression. The relationship between BPD and sleep is less clear. Lack of sleep may worsen emotion regulation challenges. People with BPD who don’t get enough sleep are likely to be irritable during the day.

Bipolar Disorder vs. Manic Depression: Importance of Lived Experience

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You may have heard that Bipolar Disorder used to be known as Manic Depression. This was the case until 1980, with the advent of the DSM-III. The committee over at the APA who decides these things had three goals in mind when they changed the name:

  1. Reduce stigma — The APA saw that the term “manic depression” had become highly stigmatizing.
  2. Provide a more accurate and clinical description of the condition
  3. Reflect the alternating periods of mania and depression that characterize the disorder — more on these in a minute.

I want to clarify that while the APA laid out the missions above, they did not consult the community members who live with the condition. Many people, some of them high profile (like Kay Redfield Jamison) still prefer the term manic depression still today. To change the name of a disorder without extensive community feedback feels like a violation of autonomy for those of us who live with a severe mental illness.

But let’s address the three goals laid out by the APA with the publication of the DSM-III…

  1. Although it’s very likely true that the term “manic depression” had become highly stigmatized, it seems a bit odd to assume that the stigmatization of the disorder came from what we choose to call it, rather than stemming from the people who live with the condition. Case in point, today “bipolar” is highly stigmatized and used inappropriately for a number of reasons — to refer to indecisive weather patterns, people we don’t like, and a host of other things. It’s just as bad as manic depression ever was. Why? Well, maybe the problem wasn’t the term manic depression. The stigma was never attached to the term. The stigma is attached to those of us who live with the condition, regardless of what you choose to call it. No matter how many times you change the name of the disorder, that truth would never change.
  2. Many of us in the bipolar disorder/manic depression sphere actually feel that “manic depression” is much more descriptive of our lived experiences. “Bipolar” exemplifies a particular phenotype, one which is at least somewhat common among bipolar folks (and considered by some to be an archetypal presentation) but to the exclusion of others with more uncommon manifestations of the disorder. If we are to take “bipolar disorder” at face value, I am left to assume that there are two “poles” (opposites) which people oscillate between. However, this ignores the very real and unfortunately common experience of mixed episodes — when the two opposing states of “bipolar” are somehow happening both at the same time. How can they be opposite, when in fact they coexist so frequently?
  3. I don’t think most people who know little about “bipolar disorder” are thinking about its longitudinal dynamics. Many people still believe that bipolar disorder is about quick shifts in mood lasting only a few hours (although these types of episodes do happen in classic bipolar disorder, they are much more rare and occur in the context of other well-known symptoms) or that bipolar disorder is the same as “multiple personality disorder”.

As it turns out, I think manic depression is both more accurate (instead of positing that mania and depression are opposing forces, when in reality, they seem to be linked and can even occur simultaneously) and, in the end, probably less stigmatizing than “bipolar disorder”. This just highlights the importance of including community input (for example, from “bipolar” patients) when making decisions like this.

What do you think? Leave a comment and let us know!

The Impact of Bipolar Disorder on Physical Health

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Those of us with bipolar disorder can bear a heavy burden when it comes to co-occurring conditions, medication side effects, and we are at higher risk for many diseases. Some of these effects are ameliorated by efforts at early screening and detection. We hope (perhaps naively) to catch tardive dyskinesia before it becomes permanent and Stevens-Johnson Syndrome before it becomes fatal. Likewise, in the US we have a federal registry for clozapine patients that aims to detect agranulocytosis (destruction of white blood cells, which disables the immune system) with rigorous blood testing.

Other medications may take a more nefarious route to affecting our health. Lithium is able to cross membranes and take up residence inside your body’s cells, where it stubbornly resists removal by hemodialysis. Years down the road, it can lead to kidney failure, not to mention destroying your thyroid gland.

But there’s more than meets the eye to the interface of bipolar disorder in medical care.

Bipolar disorder is widely stigmatized by medical professionals

I once presented at the ER for an abscess the size of a tennis ball erupting from my thigh (a consequence of my then-undiagnosed hidradenitis). I showed the triage nurse; she documented it. Then she asked for my phone and my shoes.

“The psychiatrist is going to see you,” an aide informed me.

“What? Why? I have an abscess!”

They didn’t care to listen to me. Two hours later, a psychiatry resident showed up at my bedside. He took a look at my abscess.

“I don’t know why they sent you over here,” he said, sighing. Another two hours passed before a “medical” MD came to take a look and determine (within minutes) that we were going to drain my abscess. It was extremely painful. Surely, anyone would be a touch irritable or agitated in such circumstances. But I’ve been told that having bipolar disorder in my history was good enough reason to detain me, independent of any other facts. You know what that’s called: discrimination. I hadn’t complained of any suicidal planning or expressed a desire to be admitted. In my place, someone without those two words in their file — “bipolar disorder” — would have been seen by a medicine doctor hours earlier.

But, to be fair, it’s not just bipolar disorder that is stigmatized. I was once being detained in the psych area of the ER, when an aide mentioned to another aide that she had PTSD. I was in a fairly good mood, and I joked, “You’re one of us!”

“I’m nothing like you,” she said, frowning coldly. “PTSD is not a mental illness.”

I was taken aback by her confidence and we started to argue when the charge nurse walked in. We both told our side of the story and the charge nurse decided to move the aide to a different part of the ER. She did not look happy, let me tell you.

Bipolar disorder can affect how drugs work in your body

Whether from drug-drug interactions or simply unusual metabolism of certain medications, prescribing medicine for physical health reasons is a tricky business when you have bipolar disorder. The most commonplace medications can be problematic: antibiotics (can cause mania), ibuprofen or most other NSAIDs (interacts with lithium and can raise lithium levels to toxic, resulting in profuse vomiting — try telling that to an overworked nurse who thinks you’re seeking pain meds!), prednisone or other steroids (can cause mania), Sudafed (stimulant — may cause mania)… the list goes on.

This is what I’ve found with alternatives. This only represents my own experience and should not be taken as an endorsement of research in this area (probably because there isn’t much).

Antibiotics: Doxycycline should be avoided, but amoxicillin is okay.
Ibuprofen/NSAIDs: The exception to this rule is old-fashioned aspirin, which is safe if you’re on lithium!
Prednisone/steroids: Unfortunately I haven’t found an effective alternative. You just gotta play the odds. Being manic is better than being dead.
Sudafed: I recommend diphenhydramine (Benadryl) which is effective, safe for bipolar disorder, and cheap.

Having bipolar disorder can increase your odds of having another disease

Some diseases and risk factors for diseases, including metabolic syndrome, obesity, diabetes mellitus (type 2), and diabetes inspidus (if you’re on lithium) appear to clearly be linked to certain medications people might take to treat their bipolar disorder. But others are less clear. Headaches are associated with bipolar disorder, especially migraines and cluster headaches (less commonly chronic tension headaches). Genetic evidence has aligned to connect epilepsy and bipolar disorder (such as the SP4 gene, which was published about in September 2024) and this is concordant with the longstanding clinical observation that bipolar disorder often responds to cocktails including anticonvulsant medications such as Lamictal (lamotrigine), Depakote (valproate), even Topamax (topiramate). Large studies have also shown that people with bipolar disorder are more likely to develop Parkinson’s Disease, independently of cases that are likely drug-induced.

Surprisingly, when COVID-19 first swept the world, some research suggested that people with bipolar disorder were more likely to have a severe or life-threatening COVID-19 disease course even when controlling for factors such as obesity. Taken together with available evidence, this may lend support to the idea that alterations in the body’s inflammatory pathways may be causal to bipolar disorder. It has long been recognized that influenza infection can precipitate manic or psychotic episodes. In January 2018 I had the flu and I became preoccupied with the fact that I (definitely) had AIDS and I began writing long goodbye letters to my friends. Luckily, the flu was better in about 3 days.

Drugs (use, abuse, and misuse) cause problems

As I mentioned, certain medications can have severe side effects…
Neuroleptics (such as Haldol/haloperidol): Neuroleptic Malignant Syndrome, Tardive Dyskinesia, Movement Disorder
Atypical Antipsychotics (such as Zyprexa/olanzapine, Risperdal/risperidone, Abilify/aripiprazole, and clozapine): Agranulocytosis (Clozapine specifically); Akathisia and movement disorder (particularly Abilify and Vraylar)
Anticonvulsants: Stevens-Johnson Syndrome (especially lamotrigine — and keep in mind that risk for SJS increases whenever you start or stop taking the medication suddenly, and if you do this multiple times your risk climbs higher and higher)
Antidepressants and other serotonergic drugs, such as stimulants and street drugs like MDMA: Serotonin Syndrome

Bipolar people are famous for resisting taking medications that could help them, which can make the above side effects more likely. Not taking your meds can also make bipolar disorder worse, and make you more at risk for accidental deaths such as a car crash, while also making you more at risk for intentional death (suicide). Lithium has uniquely shown a capacity to lower the risk of suicide.

Not only that, but it will always be assumed that you are “drug seeking” especially when you try to explain the bit about why you’re too good for the ibuprofen that everyone else takes. But no fear, the nurse has your back and will get you some IV lorazepam (Ativan) while they process your discharge.

Pediatric-onset bipolar disorder

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Traditionally, it has been thought that bipolar disorder emerges most typically in the early to mid 20s of a person’s life. It has been known since the time of Emil Kraepelin (circa 1921), however, that children can be affected by this illness. While adolescent onset (mid-to-late teens) is now recognized as common and similar to the presentation of adult bipolar disorder, pediatric onset bipolar disorder remains the subject of debate, and its presentation is somewhat different than adult bipolar disorder.

Why do some children get bipolar disorder?

We do have some idea why some people get bipolar disorder as adults, and others get it much younger. The effect is known as genetic anticipation, which occurs when certain genes accumulate in later generations. We know that bipolar youth are highly likely to have members of their family belonging to previous generations (parents, grandparents, aunts, uncles) with bipolar disorder. When those genes add up over successive generations, and the person has a LOT of the polymorphisms that cause bipolar disorder, they tend to get it a) younger and b) more severely. This also helps to explain why pediatric onset bipolar tends to be a clinically severe manifestation.

While adolescent-onset bipolar is not uncommon, bipolar disorder in children under the age of 12 remains rare. Nonetheless, it is important to diagnose. Studies have found that for every year of untreated illness, a child is 10% less likely to experience a resolution of symptoms for 2 months or longer — yet, an average of 10 years passes between symptom onset and treatment.

There is often a long delay between onset of symptoms and treatment. For me, it was 8 years (possibly more).

How does pediatric-onset differ from adult bipolar disorder?

Pediatric onset bipolar is commonly characterized by very rapid cycling. This is an uncommon phenotype (what the disorder “looks like”) in adults, but the majority of children with bipolar disorder are rapid cyclers. Chronic irritability is also common and is part of the reason pediatric bipolar disorder is so controversial. An episodic pattern of moods — whether the manias are dysphoric or euphoric — is arguably the hallmark of bipolar disorder; chronic irritability doesn’t seem to fit the bill, and in children who do not experience depression, an alternative diagnosis may be more appropriate. Nonetheless, irritability is a common symptom even among those children who seem to clearly meet the criteria for bipolar disorder.

Rapid cycling is the rule rather than the exception in children.

What happens to children with bipolar disorder?

Barring tragedy, children with bipolar disorder grow up to be adults with bipolar disorder. They need to be maintained on medication for the rest of their lives, or they are prone to relapse, just like any bipolar patient.

In my anecdotal experience (my symptoms started before the age of 10) I still have rapid cycling and dysphoric mixed manias as an adult. I urge those who are doubtful that rapid cycling bipolar is “real” or that it is somehow less valid to consider that many adults with this phenotype first experienced bipolar symptoms as children.

Recommended reading about bipolar in children

If you want to learn more about bipolar disorder in kids, I recommend the book The Bipolar Child by Demitri Papolos. It is really informative and helped me to better understand myself, as someone who had pediatric onset. I sat down in a library and read it all within a couple of hours.

After a suicide attempt

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Caution: this post contains explicit discussion of suicide

Two days ago (on September 10th) was World Suicide Prevention Day. Although it is important to address prevention of suicide attempts, the strongest predictor of a fatal (or “completed”) suicide is a history of previous, non-fatal suicide attempts. The risk factors for suicide attempts are more diverse and include: family history of suicide, early onset of bipolar disorder, extent of depressive symptoms, increasing severity of affective [mood] episodes, the presence of mixed affective [mood] states, rapid cycling, comorbid Axis I disorders, and abuse of alcohol or drugs1

Most suicide prevention effort focuses on people who are naive to psychiatric treatment and have reached a crisis point: people who don’t already have a psychiatric point of contact, and usually people who have never been treated in an inpatient setting before. In my experience, most people do not continue using crisis lines or similar services after they have been hospitalized once. Surmounting the fear and stigma around hospitalization itself is a primary reason crisis lines exist. Crisis lines are staffed by severely underqualified volunteers, who are usually following a script, and only have two action moves: call an ambulance, or tell you to go talk to someone else (sometimes your health insurance company). Yet, people find calling a crisis hotline less formidable than simply admitting themselves voluntarily.

But what about those of us with chronic illnesses, with volumes of psychiatric history, who have been admitted many times? This service is clearly not meant for me. If I spoke to a crisis line on what to me is an an average day, I might find myself being dragged to the ER and with an $800 ambulance fee to boot. There is no exception for chronicity. The stakes of a mistake are high, and the crisis line operator is equipped with a high school diploma.

There’s a gap between services for first-episode patients and services for profoundly disabled people who live in an institutional setting. After my close-to-fatal suicide attempt about two and a half years ago, I had to navigate what exactly life looks like after a serious suicide attempt. I consumed an amount of lithium equal to the 50% lethal dose in rats, and an antidepressant that is also a potent anti-emetic (anti-vomiting) drug. I knew I would absorb more of the lithium if I delayed the onset of (inevitable) severe vomiting.

I was hospitalized for only 16 days. The attending physician treating me thought I should go to a residential treatment program, but I was supposed to be at an academic conference and I begged to be realized in time to go. The head of the clinic evaluated the situation and decided to release me. I was discharged within hours of my flight to Europe. After the conference, I was enrolled in a partial hospitalization day program. The official length of the program was 8 weeks; I was probably enrolled for 4 months. My psychiatrist met with me nearly every day.

We tried a lot of medications, but for quite some time I was not permitted to take lithium. This was unfortunate, because lithium is probably the single most effective drug I take. I have cycled through almost every atypical antipsychotic: Seroquel, Abilify, Vraylar, Zyprexa, Saphris, Geodon… I’m sure I’ve forgotten something, it’s more than I can keep track of. I tried Depakote and Lamictal. Nothing has the same effect as lithium. Ironically, lithium also has a specific anti-suicide effect.

I continued to be suicidal throughout and beyond the partial program. I am lucky that my psychiatrist works well with me.

Chronic suicidality is probably more common than people realize. It doesn’t appear in the media. It’s taboo. You fear to acknowledge it exists somewhere. When we talk about improving mental health services, let’s give a little more attention to the people for whom posting a status update with the s-word in it is reason to panic and report it to Facebook headquarters.

References

  1. Hawton, K., Sutton, L., Haw, C., Sinclair, J., & Harriss, L. (2005). Suicide and Attempted Suicide in Bipolar Disorder: A Systematic Review of Risk Factors. The Journal of Clinical Psychiatry, 66(6), 693–704. https://doi.org/10.4088/JCP.v66n0604

Psychiatric disorders and discrimination by medical professionals

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There is much that could be written about the damage done by bad psychiatrists, but this post will specifically focus on non-psychiatric medical professionals: doctors, nurses, everyone involved with it.

Once I presented to the ER with a large abscess from a skin infection, and in great pain. I told the triage nurse that I had this abscess, and showed it to her (it was not subtle). She proceeded to look through my chart and started asking me about my bipolar disorder. I told her what she asked, and of course we got to “Are you planning to hurt yourself?” and I said no, because I wasn’t, I just really needed my abscess to be drained by a doctor.

Naturally, then, she put me in psychiatry and had a psychiatrist come speak to me. I told the psychiatrist what I told the nurse and showed him the abscess. He was horrified by it, and said he’d call my psychiatrist. After he spoke to her, he moved me to the medical area and gave his psychiatric stamp of approval. Finally, a medical doctor arrived and drained my abscess.

In retrospect, is it a big problem? I think it is. What if my condition were even more time-sensitive? They wasted significant time getting me a psych eval when I was not presenting with any major psychiatric symptoms, I just happen to have a chronic mental illness that I will have in my chart forever. What if I was having a heart attack? Would I have to get a psych eval because I’m bipolar?

If you have a label like “bipolar disorder type 1” they will always look for a psychiatric cause for your symptoms, even when the evidence doesn’t suggest it’s psychiatric (like, the huge abscess). They assume you are professionally crazy and anything you say is cause for suspicion, instead of an honest report of symptoms. Putting patients presenting with tangible physical illness in the psych area just because they have a diagnosis, but are not presenting with symptoms, is discrimination.

Anxiety and mania

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Recently, The Mighty published an article about the differences between anxiety and hypomania. However, I wanted to complicate the discussion by bringing up something that breaks the juxtaposition of anxiety and mania: primarily anxious mania, which is most likely a mixed episode associated with bipolar type 1.

The author describes how her anxiety leaves her “immobilized”. This can actually happen in mania, too — but usually not in hypomania. Hypomania is often very productive. Full mania is no longer productive — it’s frantic, potentially confused, and may be characterized by manic stupor. Emil Kraepelin used this term to describe a flight of ideas and elevated mood (not necessarily happy, but revved-up) combined with psychomotor slowness or immobility. I’ve been in this state, and I experienced it subjectively as intense feelings of anxiety paralyzing my every move. This might also be referred to nowadays as catatonia, and something similar can occur in severe depressive states; however, the catatonia that coincides with mania is likely excited catatonia (characterized by purposeless movements rather than being completely still).

Hypomania isn’t rare, exotic, or exciting to me. It’s just part of my life, and I take advantage of it when it comes around — which it will, no matter what. But, to me, full mania is to be avoided. Anxiety is also a daily part of my life, but the anxiety and paranoia I experience during a manic episode is even more excruciating than it usually is. Juxtaposing them as discrete, separate states can only take you so far in understanding what mania is and how it affects people.

One bipolar person’s drug regimen

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Currently, I take 8 medications for psychiatric reasons. I’ve also been on many others — including most of the atypical antipsychotics, several anticonvulsants, antidepressants, and more. These are my current drugs ranked in terms of how essential they are (if, for example, I could only get some of them, perhaps due to a catastrophe):

  1. Lithium — Big Pharma has yet to come up with something better. It could never be patented, it wasn’t paid for by anybody. It actually works. And it’s all-natural. But also, it sucks. Nature is brutal.
  2. Haldol — Indispensable, though I might be switching to Thorazine in the near future. I don’t picture myself living without an antipsychotic again. Typicals seem to work better for me than atypicals did, though I’ve notably NOT tried Risperdal (even though it’s a good fit for my symptoms) or clozapine. Both were considered, though.
  3. Ativan (lorazepam) — My symptoms tend to cluster around anxiety, insomnia, and irritability — maybe paranoia — all things helped by benzodiazepines. If it were not so problematic, I might have ranked it #2. It’s the best immediate symptom relief I can get aside from maybe sublingual Zyprexa (olanzapine).
  4. Adderall — I would never actually achieve anything in life without Adderall. That said, my need to do something with my life is inherently superseded by my need to be alive, which is why it ranks #4.
  5. Lamotrigine (Lamictal) — An anticonvulsant medication. It seems to be doing something, because I become depressed without it. Though I’m not exactly sure what it’s doing.
  6. Gabapentin — I’m supposed to be using it for anxiety to offset my lorazepam use. It’s also useful for severe headaches. I still feel the pain, but I kind of don’t care, like the pain just doesn’t command my attention.
  7. Clonidine — It’s a blood pressure med, but I’m using it for insomnia. I cycle through medications for insomnia because they all lose their effectiveness eventually. I haven’t been on clonidine before so I don’t know how long it will be useful for. Other drugs I’ve used for sleep: Trazodone, Remeron, Ativan, Seroquel (and other atypical antipsychotics)…
  8. Diphenhydramine (Benadryl) — An OTC drug! The original antihistamine. I take it as 50mg softgels (two of them, which is slightly more than the bottle indicates — consult your doctor). Sometimes works for sleep, not super reliable and fades quickly. Useful if I have a cold or flu because Sudafed is not the best choice for my wiring. Also potentially protective against Haldol-induced side effects. So overall, something I take regularly, but not every day.

Anyone want to share their regimen?