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Clinical differentiation of bipolar II disorder from borderline personality

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 REVIEW

CURRENT
OPINION Clinical differentiation of bipolar II disorder from
borderline personality disorder
Adam Bayes, Gordon Parker, and Kathryn Fletcher

Purpose of review
Differentiating bipolar II disorder (BP II) from borderline personality disorder (BPD) is a common diagnostic
dilemma. The purpose of this review is to focus on recent studies that have considered clinical differences
between the conditions including family history, phenomenology, longitudinal course, comorbidity and
treatment response, and which might advance their clinical distinction.
Recent findings
Findings suggest key differentiating parameters to include family history, onset pattern, clinical course,
phenomenological profile of depressive and elevated mood states, and symptoms of emotional
dysregulation. Less specific differentiation is provided by childhood trauma history, deliberate self-harm,
comorbidity rates, neurocognitive features, treatment response and impulsivity parameters.
Summary
This review refines candidate variables for differentiating BP II from BPD, and should assist the design of
studies seeking to advance their phenomenological and clinical distinction.
Keywords
affective instability, bipolar II disorder, borderline personality disorder, emotional dysregulation

INTRODUCTION general, few studies have considered separate bipo-

Clinical differentiation of bipolar disorder from bor-
derline personality disorder (BPD) is reported as a
&&
common diagnostic dilemma [1–4,5 ]. This may
reflect BPD being an ultrarapid cycling (i.e. rapid
mood switches over 48 h or less) bipolar spectrum
disorder [6]. Alternatively, BPD and bipolar dis-
orders are, as positioned in Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5)
[7] and ICD-10 [8], separate conditions requiring
more refined diagnostic differentiation, as posi-
tioned in this review.
Differentiating BPD from bipolar I disorder (BP
lar subtypes in comparative analyses. Thus, BPD
versus BP II distinctions are detailed where available,
but in the absence of BP II being specifically com-
pared, we include relevant studies considering
bipolar disorders in general. We now overview can-
didate differentiating parameters.
FAMILY HISTORY
Several studies suggest a general ‘breeding true’
phenomenon, with a greater probability of first-
degree relatives with bipolar or a major mood dis-
&&

I) appears relatively straightforward, reflecting the
common presence of characteristic psychotic manic
symptoms. By contrast, nonpsychotic bipolar II (BP
II) disorders are frequently incorrectly diagnosed as
BPD due to shared features including impulsivity
and emotional dysregulation. Cross-sectionally,
such ‘affect storms’ in BPD can resemble hypomania
&
[9 ] and lead to misdiagnosis [10,11]. Longitudi-
nally, the high frequency of interepisode residual
symptoms in BP II, including chronic dysphoria
[12,13] may compromise diagnosis.
Although the present review seeks to focus on
BPD differentiation from BP II as against bipolar in
order in bipolar probands [5 ,14], and an increased
likelihood of impulse control disorders (antisocial
personality and substance abuse disorders) or a
unipolar mood condition in family members of those
with BPD [15]. Additionally, borderline ‘features’
School of Psychiatry, University of NSW, Sydney, Australia
Correspondence to Adam Bayes, Kiloh Unit, Prince of Wales Hospital,
Randwick NSW 2031, Sydney, Australia. Tel: +61 2 9382 4352; fax:
+61 2 9382 4399; e-mail: Adam.Bayes@SESIAHS.HEALTH.NSW.
GOV.AU
Curr Opin Psychiatry 2014, 27:14–20
DOI:10.1097/YCO.0000000000000021

www.co-psychiatry.com Volume 27  Number 1  January 2014

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

KEY POINTS
 The literature is limited by most studies considering
bipolar disorder in general rather than contrasting BP II
only with BPD.
 Although differences have been identified or are
suggested across a number of parameters, few
appear substantive.
 Phenomenological distinction appears currently the
most differentiating domain, and involves consideration
of both poles and the type of depression (i.e.
melancholic versus nonmelancholic), the extent to which
anxiety is decreased or increased during episodes, and
the differing ‘onset’ periods for each condition.
 Although clinical differentiation might be expected to
be reasonably clear-cut, in the majority of instances the
coterminous presence of both a BP II and a BPD needs
to be conceded in a percentage of individuals.
(e.g. deliberate self-harm, identity problems) are
over-represented in family members of those with
BPD [16], with Perugi et al. [17] reporting that patients
with a major depressive disorder and a comorbid BPD
had a higher rate of hypomania/mania in first-degree
relatives. This could reflect a common genetic con-
tribution to two independent or interdependent con-
ditions, or be artefactual because of the failure to
diagnose truly separate conditions. Overall, a family
history of bipolar disorder is likely to support a BP II as
against BPD diagnosis.
AGE OF ONSET
Bipolar disorder in childhood is rare, with late
adolescence or young adulthood being the highest
onset risk period [18–20] and with onset generally
representing a distinct change [21]. By contrast, a
distinct onset period is lacking for BPD, with ‘nega-
tive affectivity’ instead established at an early age
[22] and many BPD patients reporting being depres-
&
sed their whole lives [9 ]. Thus, a clear onset period
favours a BP II condition.
ILLNESS COURSE
There is some suggestion of differing illness courses.
Bipolar tends not to remit with age and can worsen
over time [23], whereas BPD has a more favourable
prognosis, with many individuals no longer meet-
ing criteria in middle age [24]. For example, Paris
and Zweig-Frank [25] reported that only 8% met
criteria for BPD at a 27-year follow up. Thus, failure
to remit may be suggestive of a BP II condition
versus attenuation over time characterising BPD.
0951-7367 ß 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Differentiation of BP II disorder from BPD Bayes et al.
DEPRESSIVE SYMPTOMS
Phenomenological differences in depressive states
have been reported. Melancholic features of depres-
sion are over-represented in BP II [26], as are agitated
and mixed symptoms [27], whereas BPD is more
characterized by nonmelancholic reactive depress-
&
ive episodes [9 ]. Atypical features of depression (e.g.
hypersomnia, hyperphagia) are over-represented in
both BP II [28] and BPD, offering little diagnostic
discriminatory value [29,30].
In contrast to ‘typical’ depressive features
(e.g. decreased self-esteem, self-criticism) frequently
associated with BP II, BPD depressive states are often
more characterized by emptiness, shame and ‘pain-
ful incoherence’ [31]. Other differences include
higher levels of self-reported cognitive depressive
symptoms in BPD relative to BP II – pointing to a
more severe subjective experience in the former
group [32]. Those with BPD tend to project respon-
&&
sibility onto others [33 ], be accusatory, blaming,
&
hostile and more angry than depressed [9 ] com-
pared to those with a BP II condition [32,34]. In
contrast, those with bipolar tend to be more likely to
feel guilty about annoying others with any irritable
&&
mood [33 ] and be self-demeaning/self-accusatory
[9 ].
&
SUICIDALITY AND DELIBERATE SELF-
HARM
Suicidality, a common BPD feature, is also common
in BP II disorder [35–37]. Similarly, self-mutilation
(e.g. wrist cutting) occurs in both BP II (especially
during mixed states) [38] and BPD with a similar
&&
frequency [5 ]. Such features therefore offer limited
differentiation [5 ].
&&
HYPOMANIC SYMPTOMS AND
CORRELATES
Individuals with a BP II disorder generally report
elated mood, increased energy, creativity, connect-
edness, grandiosity and productivity, contrasting
with the emotional dysregulation commonly
reported by those with a BPD condition. Further-
more, hypomania is viewed by BP II patients as
uncharacteristic [39]. Some BP II individuals experi-
ence hypomanic episodes characterized by irritabil-
ity, akin to the irritability and anger occurring in
BPD. However, in contrast to BPD, the irritability/
anger is episodic and present only during elevated
mood states in BP II, assisting differential diagnosis
[10]. Mixed mood states, commonly observed in
females with BP II [40], as well as ultrarapid cycling
may also be mistaken for borderline phenomena. In
those with BPD, elation is rarely present and brief
www.co-psychiatry.com 15
 Mood and anxiety disorders
(less than 48 h) [2]. In contrast to the grandiose sense
of self, experienced in BP II hypomania, there
remains an ongoing poor self-image in those with
&&
BPD [33 ]. Clinically, assessing anxiety levels
during ‘highs’ can be central, with anxiety dis-
appearing or attenuating in those with a BP II con-
dition and increasing in those with BPD [41].
MOOD STATE CONTEXT
Individuals with BP II are more likely than those
with BPD to have autonomous mood episodes and
&&
lacking an interpersonal context [33 ], although
reactive moods (e.g. secondary to substance use or
psychological stressors) can be experienced. By con-
trast, symptoms of BPD are usually reactive [2],
generally triggered by a psychologically salient
interpersonal event such as frustration, rejection
&
or a sense of abandonment [9 ,39].
EMOTIONAL DYSREGULATION
Emotional dysregulation, also referred to as affective
instability, is defined as brief mood changes charac-
terized by temporal instability, high intensity and
delayed recovery from the actual dysphoria [42].
Emotional dysregulation is not pathognomonic of
BPD as it can occur in BP II [2,34,43], but analysis of
the valence, frequency and intensity of affective
shifts may assist differentiation. For example, in
contrast to the affect shifts from euthymia to anger
or anxiety observed in BPD, individuals with BP II
display more affective lability from euthymia to
depression or to elation, and from elation to depres-
&&
sion [34]. More recently, Reich et al. [44 ] compared
a combined BP II and cyclothymic group with BPD
participants and reported the former as experienc-
ing more frequent and intense shifts between euthy-
mia and elation, and between depression and
elation. By contrast, BPD participants experienced
more frequent and intense lability between anxiety
and depression, and between euthymia and anger.
Neurobiological studies suggest that emotional dys-
regulation in bipolar may be internally driven, in
contrast to the reactivity to social cues observed
in BPD [42]. Thus, if emotional dysregulation is
present, shifts between depression, euthymia and
elation could suggest a BP II condition, whereas
shifts between anger and anxiety may characterize
BPD.
IMPULSIVITY
Impulsivity is defined as a tendency for rapid,
unplanned behaviours [45], and to act on urges
without regard to consequences [46]. It may be a
16 www.co-psychiatry.com
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partially heritable trait [2] and can occur period-
ically as a state phenomenon. Although impulsivity
may represent a shared phenotype of bipolar and
BPD [2], nuances in its differential expression have
been suggested.
Impulsivity may represent both a trait and state
feature of bipolar disorder [47]. Benazzi [48] quanti-
fied a trait impulsivity rate of 41% in remitted BP II
outpatients, indicating that it is not specific to BPD.
In BP II, however, episode-based impulsivity is more
commonly associated with hypomanic as against
depressive BP II mood states [32]. Impulsivity during
hypomania has also been modelled as lying on
a continuum with inter-episode trait impulsivity
[48–51].
Impulsivity is a core diagnostic feature of BPD
and may represent a way of managing negative
emotions by distraction or relief from intense nega-
tive affect [52] rather than relate to any mood-
related disinhibition characterizing bipolar. In
BPD, impulsivity tends to be more enduring [53],
although Zanarini et al. [54] reported it as the feature
most likely to remit.
Several studies have directly compared impul-
sivity in BP II and BPD, revealing differing features.
Higher scores on the Barratt Impulsiveness Scale [55]
were quantified in BPD relative to BP II patients [34].
In another study, those with BP II tended towards
the ‘attentional impulsiveness’ associated with cog-
nitive disturbances (including impaired concen-
tration, distractibility and racing thoughts), in
contrast with motor and ‘nonplanning impulsive-
ness’ characterized by difficulty planning actions
and thinking about consequences observed in those
with BPD [32]. More recently, differing phenomeno-
logical impulsivity profiles were reported in BPD and
BP II patients, with a trend towards higher scores on
the Urgency and (lack of) Perseverance subscales
of the Urgency, Premeditation, Perseverance and
Sensation Seeking Impulsive Behavior Scale [56] in
the former group [57].
NEUROPSYCHOLOGICAL DEFICITS
Although many neuropsychological studies con-
trasting bipolar and BPD have been undertaken
(see Coulston et al. [4]), few have directly compared
BP II with BPD and most separately compared BP II
with controls and BPD with controls. Executive
function deficits (measured by the Wisconsin Card
Sorting Test) have been reported in BPD [58],
whereas in BP II, executive function deficits were
more broad [4]. However, deficits of this nature have
been reported as dependent on mood state and
episode type in bipolar [59]. Deficits in sustained
attention are typically seen in bipolar [60] but not
Volume 27  Number 1  January 2014

BPD [58]. Deficits in working memory and verbal
memory were found in a systematic review of 14
neuropsychological studies of BP II compared with
controls [61], whereas spatial working memory was
intact in BPD relative to controls [58].
NEUROIMAGING FINDINGS
Structural and functional neuroimaging studies
investigating bipolar and BPD have been reviewed
by Coulston et al. [4] and Mauchnik and Schmahl
[62]; however, none analyzed sufficient numbers of
BP II patients. Frontolimbic network dysfunction is
apparent in both BPD and bipolar disorder (as
reviewed in [4]). However, Malhi et al. [63] reported
differential engagement of frontolimbic emotion
processing distinguishing bipolar from BPD, with
increased dorsomedial prefrontal cortex activity in
bipolar patients and diminished amygdala activity
in BPD. Such differing neural processing may under-
pin the emotional dysregulation observed in the two
diagnostic conditions.
SOCIAL COGNITION
Social cognition refers to mental operations under-
lying social interactions [64], with one being the
ability to infer mental states of others, termed ‘men-
talization’ or Theory of Mind (ToM) [65]. There is an
expanding literature on social cognition deficits in
BPD, albeit with no BP II and BPD comparison
studies. Failure of mentalization is a central deficit
in BPD [66,67], characterized by difficulty using the
cognitive strategies of reappraisal and suppression to
regulate intense emotions [68]. Martino et al. [65]
reported lower ToM performance in euthymic BP II
individuals relative to controls; however, potential
confounders included medication exposure and
attention-executive function impairments.
PSYCHOTIC SYMPTOMS
According to DSM-5, psychotic manic episodes
assign an individual to BP I status, whereas hypo-
manic states (intrinsic to BP II) lack psychotic fea-
tures. In BP II depressive episodes, psychotic features
are uncommon, albeit with lifetime prevalence esti-
mates ranging considerably – from 3 to 45% [69].
When present, they tend to be mood congruent (e.g.
guilt, nihilism) and more enduring. By contrast,
some 75% of BPD patients experience transient dis-
sociative and paranoid symptoms [70] but rarely
having a depressive theme.
CHILDHOOD TRAUMA
A history of childhood trauma (emotional, physical
or sexual abuse) is not a distinctly differentiating
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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Differentiation of BP II disorder from BPD Bayes et al.
feature as high rates are associated with both dis-
orders – approximately 50% in bipolar disorders
&& &&
and 60–80% in BPD [5 ]. Bassett [5 ] suggests that
those with BPD and bipolar may differ in terms of the
form of childhood trauma experienced or their
vulnerability to such trauma, but formal studies are
lacking.
SELF-IDENTITY AND RELATIONSHIPS
Differences in self-identity are observed in both
conditions. Those with BPD generally experience
&&
a disruption to their sense of self [5 ] with core
elements including ‘painful incoherence’ (i.e.
emotional pain related to a fragmented sense of self)
and ‘role absorption’ (i.e. loss of identity) [31]. By
contrast, those with BP II tend to experience self-
deficits only when depressed and a grandiose self
when hypomanic, with stability of self-identity
&&
when euthymic [33 ].
Assessment of the individual’s capacity to have
meaningful relationships can assist diagnostic
&
clarification [9 ]. A tendency towards idealization
and devaluation, as well as severe abandonment
fears is suggestive of BPD [71,72]. Those with BPD
experience severe and ongoing discrepancies in
their assessment of self and others, have ongoing
interpersonal conflicts and evidence immaturity in
&
their views of others [9 ]. By contrast, when euthy-
mic, those with bipolar are unlikely to show patho-
logical relationships and tend to maintain stable
&
relationships [9 ].
TREATMENT RESPONSE
&&
As overviewed by Bassett [5 ], antidepressants,
anticonvulsant mood stabilizers and atypical anti-
psychotics appear more beneficial for bipolar con-
ditions [73] relative to BPD. Lithium, in particular,
appears to show no clear utility for personality
disorders [74], whereas those with BPD rarely remit
on mood stabilizers [75] or report improvement
only for secondary reasons (e.g. sedation) [39].
In relation to psychotherapy, different funda-
mental features of bipolar and BPD argue for differ-
ing psychotherapeutic approaches, with the latter
arguing for a therapeutic focus on the disrupted
sense of self and improving mutually satisfying
&&
relationships [5 ]. However, shared features of both
conditions and the nonspecific benefits of psycho-
logical treatments limit the capacity for psychother-
apeutic response to offer diagnostic differentiation.
For example, Dialectical Behaviour Therapy (DBT)
and mentalization-based therapies are effective for
BPD [72], yet preliminary evidence (from a com-
bined BP I and II sample) suggests DBT is also
effective in reducing bipolar depressive symptoms
www.co-psychiatry.com 17
 Mood and anxiety disorders
[76]. Further, Cognitive Behaviour Therapy is effec-
tive for BP (I and II) [73], with benefits also observed
for BPD including reduction of suicidal acts, anxiety
and of dysfunctional beliefs [77].
PERSONALITY FACTORS
Personality factors, including affective tempera-
ment, have been assessed closely in both bipolar
and BPD. Perugi et al. [30] suggest that mood liability
and interpersonal sensitivity traits are related to a
shared cyclothymic temperament linking BP II, BPD
and atypical depression. The affective temperament
characterizing BPD (when compared with BP I, not
BP II) consists of a pattern of dysregulation involv-
ing depressive, cyclothymic, irritable and anxious
features but without hyperthymic features (e.g.
exuberance and self-confidence) [78]. A shared irri-
table affective temperament has been associated
with both bipolar disorder and BPD (as reviewed
in [79]), with Fletcher et al. [79] reporting a BP II
(compared with UP depression) profile character-
ized by elevated irritability (in addition to anxious
worrying, self-criticism and interpersonal sensi-
tivity). However, the presence of a cyclothymic
temperament in those with BP II often leads to
incorrectly diagnosing BPD [80]. Akiskal et al. [80]
terms this ‘dark’, unstable variant of the ‘sunny’ BP
II disorder – ‘BP II 1/2’ – and more highly associated
with irritable risk taking compared with ‘classic’
euphoria-driven hypomanic symptoms [80].
COMORBIDITY
Both conditions are associated with an increased risk
of anxiety and substance abuse disorders in particu-
&&
lar [2,44 ,81], although varying study method-
ologies make comparative analyses difficult to
interpret. In a sample of those with BP II, the lifetime
over-representation of anxiety disorders was quan-
tified [82], with an odds ratio of 9.1 for any anxiety
disorder. Comorbid attention deficit hyperactivity
disorder (ADHD) appears to also be an over-
represented feature of bipolar [23], with an OR of
9.2 quantified in those with BP II [82], but without a
comorbidity rate formally quantified for BPD. It is
unclear whether comorbidity is greater between
bipolar and BPD relative to other personality dis-
orders, with mixed results reported [37,41,83–85].
The majority of people diagnosed with one disorder
(i.e. bipolar or BPD) do not have the other [11],
supporting differentiation of the two conditions.
CONCLUSION
We review a wide range of potential para-
meters differentiating BP II disorder from BPD, while
18 www.co-psychiatry.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
accepting that a small percentage of individuals may
have both conditions. The literature is limited by
most studies considering bipolar in general (i.e. both
BP I and BP II subtypes) and any extrapolation of
findings from studies of bipolar groups to BP II alone
risks false conclusions.
No clear distinctive neuroimaging differences
have been identified. Although some neurocognitive
differences have been suggested, their discrimination
is too limited for application. Personality testing
might be expected to show commonalities (reflecting
shared emotional dysregulation and impulsiveness)
and not particularly discriminating unless assessed as
to whether present as a trait or only during mood
states. Other parameters (e.g. family history and a
‘breeding true’ phenomenon, childhood trauma,
self-harm, impulsivity) may be of some discriminat-
ing use but again require consideration of context
rather than simply considering prevalence.
The seemingly most useful discriminating
domains would appear to be phenomenological
differences in terms of mood and age of onset.
The majority of BP II hypomanic episodes are
euphoric anxiety-free states and in sharp contrast
with the hostility, irritability and anxiety-weighted
periods experienced by those with BPD. The
majority of depressive episodes in those with a BP
II condition are melancholic in nature and contrast
with the nonmelancholic reactive depressive epi-
sodes experienced by those with a BPD. BPD (being
based in personality style) would appear to evolve
from childhood and adolescence, whereas BP II is
most likely to have a sharp onset period (i.e. the
individual reporting episodes of hypomania and of
depression emerging when no such distinct episodes
were previously present).
Sharpening differentiation would benefit from
more specific studies focussing on BP II and not
bipolar in general, with multivariate analyses
considering multiple potentially discriminating
domains and refining the most distinctive. These
are likely to weight clinical nuances that might then
be expected to lead to follow-up studies pursuing
underlying differentiating contributions from more
precisely defined subsets of those with a BPD or BP II
disorder, evaluating the likely relevance of differing
drug and nondrug treatments. Misdiagnosis of BP II
as a BPD can risk extensive periods on nondrug
treatments when the individual might benefit from
a mood stabilizer, whereas misdiagnosis of BPD as a
bipolar disorder can conversely risk inappropriate
pharmacological treatment.
Acknowledgements
None.
Volume 27  Number 1  January 2014

Conflicts of interest
This review was supported by NHMRC Program Grant
(1037196) funding.
The authors have no conflicts of interest to declare.
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