Borderline Personality Disorder was so named in the middle of the 20th century to describe a psychiatric disorder thought to be bordering psychosis and neuroses. It’s also been called “borderline schizophrenia.” It was given a spot in the first Diagnostic and Statistical Manual of Mental Disorders (we’re now on #5) under the diagnosis “emotionally unstable personality.” The term “borderline” has been the one to stick, even though research since that time has shown that it is not the borderline of a disorder. It is a disorder in its own right. However, it is also commonly associated or confused with another disorder: bipolar disorder.
Borderline Personality Disorder is characterized by unstable relationships, problems regulating moods and thoughts, struggles with a sense of self and possible paranoia or psychosis. Some of these characteristics do show up in bipolar disorder, so it is possible to mistake one for the other. With bipolar disorder you do have shifting moods, though typically in a cyclical manner, not the erratic manner often seen in BPD. Another shared characteristic is risky behavior. This is seen in BD’s manic or hypomanic phases whereas it can occur at any point in BPD.
It is especially challenging to distinguish between the two when they co-occur. It’s not uncommon for a patient to have multiple psychological disorders simultaneously. About 50% of people do, and it can come in many combinations including anxiety disorders, substance abuse disorders, mood disorders and affective disorders. About 20% have a combination of BPD and BD, usually BDII.
It’s up for debate whether the two simply co-occur within the same body and mind or if they amalgamate into basically a super-disorder. The outcome for having both disorders is worse than having either alone. The likelihood of suicide attempt is higher. The more symptoms of BPD that are present, the worse the bipolar disorder is thought to be.
It’s because of this complex relationship between the two disorders that researchers Joanna McDermid and Robert McDermid suggest in the January 2016 issue of the journal Current Opinion in Psychiatry that it be considered under the term “emotional frailty.”
The term “medical frailty” is used when discussing care for elderly or disabled patients require care that comes out to more than simply treating each problem individually. McDermid & McDermid propose that, similarly, the instance of comorbidity of bipolar disorder and borderline personality disorder require more than treating one with one treatment and one with another.
Bipolar disorder is primarily treated with medication. Mood stabilizers are used to help stave off depression and atypical antipsychotics are used to treat mania. There are other medications available and, most of the time, a combination of medications is needed to achieve the desired outcome.
There are currently no medicines approved by the FDA to treat borderline personality disorder. The primary treatment is therapy. There are different types of therapy used that focus on different outcomes: cognitive behavioral therapy, dialectical behavioral therapy and schema-focused therapy.
Since the outcomes for patients with both BD and BPD tend to be worse than each alone, there may indeed be a need for more than treating the disorders individually. “Emotional frailty” would give a name to the missing element that could be used to better the lives of those who live with both disorders comorbidly. It’s certainly worth a try.
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Photo credit: David Blackwell.