The Complex Interplay of Bipolar Disorder and Borderline Personality Disorder: Understanding 'Borderpolar' and Integrated Treatment

This podcast episode, hosted by psychiatrist Dr. Tracey Marks, addresses the frequently asked question of whether an individual can have both Bipolar Disorder (BD) and Borderline Personality Disorder (BPD) simultaneously. The answer is a definitive yes, with professionals coining the unofficial term "borderpolar" to describe this dual diagnosis. Dr. Marks distinguishes BPD as akin to one's "hardwiring" or climate, representing long-standing personality traits, while BD is compared to a "storm" that comes and goes, signifying episodic mood disturbances. While both disorders involve mood instability, a key distinction lies in the duration: BPD mood shifts last hours to a day, whereas BD episodes (hypomania, depression) last a minimum of four days or two weeks, respectively. Despite past debates on whether BPD belongs to the bipolar spectrum, current research confirms they are distinct entities, yet a significant 20% of individuals with one disorder also have the other.

The co-occurrence of BD and BPD leads to a more severe and complex clinical picture. Individuals with "borderpolar" experience more frequent mood episodes, reduced periods of stability, an earlier age of bipolar onset, and significantly higher rates of suicidality (thoughts and attempts), aggression, hostility, and substance misuse. They also tend to have more comorbid diagnoses like PTSD and OCD, leading to increased unemployment and hospitalizations. Clinically, this manifests as persistent distress and dissatisfaction even when bipolar episodes remit, fears of abandonment that sabotage relationships, and heightened impulsivity and poor judgment, especially during hypomanic phases. Self-harm, while not a primary feature of pure bipolar disorder, becomes a significant and dangerous coping mechanism in "borderpolar" individuals, particularly during depressive or manic states, making the interplay of symptoms challenging for clinicians to disentangle.

Accurate diagnosis relies on a "longitudinal history," observing long-standing patterns of behavior that persist regardless of episodic mood states, rather than just a "slice in time" view of symptoms during an episode. This distinction is crucial because treatment approaches differ significantly. For bipolar disorder, medication is the primary treatment, supplemented by therapies like social rhythm, interpersonal, cognitive behavioral (CBT), psychodynamic, and dialectical behavior therapy (DBT). In contrast, BPD's primary treatment is therapy, with DBT being the gold standard, and medication used only for co-occurring symptoms like depression or anxiety.

For individuals with "borderpolar," an integrated approach is essential: medication for bipolar disorder combined with DBT or a comparable therapy for BPD. Dr. Marks emphasizes that medication alone is insufficient to address the core BPD features, such as an unstable view of self and relationship instability. Neglecting the BPD component can lead to poor treatment outcomes, perpetuating emotional instability, emptiness, hopelessness, suicidal thoughts, and maladaptive coping mechanisms like self-harm. The episode concludes by noting that while "borderpolar" has earned its own name due to symptom similarities, comorbidity is common, and any personality disorder can co-occur with other mental health conditions like unipolar depression or schizophrenia, highlighting the broader complexity of psychiatric diagnosis and treatment.

"Can you have bipolar disorder and borderline personality disorder at the same time I've been asked this question several times and the answer is yes"

"some people will refer to this as border polar and this isn't an official term but it's one coined by professionals in the field psychiatrists and therapists"

"I considered borderline personality disorder as your hardwiring similar to the climate of the area where you live I compared bipolar disorder to a storm that comes in and lasts for a period of time and then goes away"

"what the latest research has shown is that 20% of people have both disorders"

"people who have both of these things going on at the same time tend to have more severe illness"

"with BPD you get the fears of being rejected or abandoned by people that you care about and this wreaks havoc on your relationships"

"using self-harm as a coping mechanism is not really a feature of bipolar disorder but this can really get out of control in a border polar person who's either depressed or manic"

"The primary treatment for bipolar disorder is medication first in therapy second... for borderline personality disorder the primary treatment is therapy first and maybe medication if there's something else to treat"

"if you have both disorders you really need medication and DBT or some other comparable therapy for your borderline personality disorder medication alone is probably not going to be enough"

"if you try and address the unstable view of self and the relationship instability with medication you're not going to get far"