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Treatment

There are good treatments for both conditions. Borderline PD is usually treated with psychotherapy as the main tool, with medications as needed or to the extent that they are helpful. Bipolar disorder is treated just the other way around: start with medications as the core ingredients in treatment, but using psychotherapy wherever it might be helpful.

Medications
All of the medications we routinely use in treating bipolar disorder have been shown in published studies to have some value in borderline PDSoloff: antidepressants, mood stabilizers, and antipsychotics. (The mood stabilizers and modern antipsychotics are all presented, each with a page of details on benefits and risks, on my mood stabilizer list page). Here are some of the studies:

At least two studies have been published both showing that "borderline personality disorder" patients respond to DepakoteHollander ,Frankenburg. A pair of recent studies showed response to Zyprexa was greater than to placebo.Bogenshutz,Zanarini A small randomized trial showed lamotrigine was better than placebo in patients with borderline diagnoses.Reich Similarly, a research team looked back at "borderline" symptoms in the pair of large lamotrigine studies for bipolar patients, and found that "borderline" symptoms appeared to improve along with the bipolar symptoms.Preston

Most recently, aripiprazole has also been shown to be better than placebo for patients with borderline personality disorder.Nickel Lithium has not been studied in a controlled trial in borderline personality disorder, but is advocated for "targeting specific symptom domains" such as mood instability; I did not find anything newer about lithium than the old review by Soloff in 1994, which also includes a review of the use of carbamazepine in borderline.

Therefore it seems even safer now than several years ago (when I first wrote this essay) to say that "mood stabilizer" medications typically thought of for bipolar disorder are also worth thinking of in borderline PD.

Psychotherapy
The best studied technique for borderline personality disorder is "dialectic behavior therapy", designed and studied initially by Dr. Marsha Linehan. Here is a brief and moderately technical overview; and a remarkable site that describes DBT from the user's perspective, with lots of useful details including how to make your own flash cards, and links to Linehan's lectures (some have even been transcribed). This technique is distinguished from the approaches which proceeded it in (at least) three ways:

It has randomized-trial evidence for effectiveness;
It has an understandable, logical, research-oriented rationale behind it.
It focuses on behaviors, and may not be sufficient treatment for feelings.
A group in Europe used the Linehan treatment approach, and got the same results as in Dr. Linehan's original researchLinehan et al, namely a dramatic decrease in suicidal and self-harm behaviors, although they point out that the big improvements came for the patients with the most severe symptoms.Verheul They suggest that the Linehan DBT approach may be best suited for patient with severe self-harm and suicidal behavior, and that other therapies might be more appropriate for patients without these behaviors -- because DBT does not seem to affect mood symptoms very much. Thus, there may be even more reason, supported by the Verheul study, to think about medications for mood, as well as psychotherapies for mood (after DBT for self-harm and suicidality, if present). \=

Update 9/2009: other therapies which have emerged as effective for borderline in randomized clnical trials (RCTd):



Let's Ask Directly: Does Diagnosis Affect Treatment?

Imagine there really is a difference between these two conditions. We don't really know that now. But imagine there is one, some difference in the structure of the limbic system, the emotion system of the brain, perhaps. And imagine that we had some great lab test that could tell the two apart perfectly (that's rarely the case even with an excellent lab test, by the way, so don't hold your breath). Now, suppose you really have "borderline", but you get called "bipolar ". What happens? You get treated primarily with medications. These might help, as those studies I mentioned a moment ago indicate. But you would still need some help with feelings of abandonment and emptiness (and the problems with relationships that come up when you have those feelings). Unless you had a really rigid psychiatrist or mental health system, you could then try to get a psychotherapy to address these.

What about the other way around? Suppose by our magic test you "really" have bipolar, but get diagnosed borderline PD. Well, until recently, this was the big problem. You'd get labeled as "personality disorder" and often your medical care, from primary care as well as mental health providers, would change accordingly. You'd get shunted to the bottom of the list of patients someone might want to take into a practice. You'd be told that your situation was basically unchangeable except with years of psychotherapy, and then discharged from the hospital no matter what your symptoms were, as was one of my patients only several months ago. (Even if you "really" have borderline PD you shouldn't be treated this way anymore: if our mental health system were perfect (right), you would be found in some deliberate screening program to have borderline PD and placed in a treatment program designed for your condition. Hmm, sounds like how they treat diabetes, doesn't it?).

But back to our example: you're "really" bipolar, but you get diagnosed "borderline". Even if you were initially treated with psychotherapy, ideally it would be noticed that you were not improving fully, and might need medication treatment as well. And hopefully, since mood instability is your primary problem (not plain depression, nor psychosis), you would then be treated with mood stabilizers.

The point here is that you would not necessarily be lead into a treatment that can harm you with the "wrong" diagnosis, either way. You might well get a treatment that could be helpful, even if it is not the "core treatment" you will eventually need (and hopefully get). For a further discussion of how "diagnosis" is being re-worked in mental health, and what that means for the distinction between bipolar and borderline, click here.

However, diagnoses also help predict how things are likely to go in the future -- "prognosis". For borderline personality disorder, the prognosis is not as good: responding to a medication so well that symptoms disappear completely, which is frequent in bipolar disorder (at least one person in 4 gets that kind of response; and only about 1 in 5 shows no improvement, with the rest of the group in the middle somewhere). So one of the risks in labeling a person bipolar, who "really" is borderline (as if we knew that there really is a "real" difference at some biological level, which we don't), is that it might raise too much hope of a good outcome.

Worse yet, people with borderline-ness are prone to idealizing their doctors and therapists. So raising hope (for example, by emphasizing "bipolar" and the possibility of a great response) plays right into that idealizing, with increased potential for great disappointment later when treatment does not work as hoped (as emphasized by Gunderson in his 2006 interview). That great disappointment can likewise be magnified by people with borderline-ness, sort of a mirror image of the initial idealization and hopefulness. This overidealization and later strong devaluation are well-recognized phenomena in borderline-ness. Since suicide attempts are also very common in people who meet the DSM diagnostic rules for "borderline personality disorder", you can see the problem here: raising hopes that get dashed later can lead to an intense hopelessness to which the person is already prone, and hopelessness is a well-known risk factor for suicide.

Therefore may I caution: assuming that a person is not "really" borderline, and is instead "really" bipolar, can add risk. We should all watch out for that. At the same time, assuming that a patient is "really" borderline when he/she might have bipolar disorder also clearly adds risk: it lowers the hope that an excellent treatment response is possible, which is a very terrible thing for a doctor to do to a patient and her/his family. It also lowers the determination to keep trying for a better outcome ("she's a borderline" has historically been a reason not to admit people to hospital, or discharge them more quickly than others, for example). Finally, missing bipolarity because of a diagnosis of "borderline" may lead to an emphasis on using antidepressant medications, which are not thought to make borderline worse; indeed, they can help quite a bit -- but they can definitely make bipolar disorder worse, as you've seen or will see discussed repeatedly elsewhere on this website.

Bottom line: one cannot simply assume that everything which looks like borderline personality disorder "really" is bipolar disorder. In particular, one must be careful not to raise hopes of possible symptom-free life if there is some diagnostic uncertainty about bipolarity versus borderline-ness. At the same time, lowering expectations and treatment effort because a person appears to have borderline traits is a similar pitfall on the opposite side of a presumed best "middle ground" approach.

As you can see, overall my recommendation is that you avoid getting too stuck on a diagnostic label. Which one you get depends a great deal on the orientation of the therapist or doctor! Psychiatrists might be better diagnosticians, in theory, because the they have pliers as well as hammers ("when all you have is a hammer, everything looks like a nail"). But finding a psychiatrist who really does use her/his pliers just as much as his/her hammer can be difficult. Finding a psychiatrist at all can be difficult. In that case, a therapist who feels comfortable treating borderline personality disorder is a good starting place; you can use websites like this one to learn more about the two diagnoses and help guide your treatment from there.

Finally, if you're wondering about what causes borderline personality disorder in the first place, here's a brief essay introducing some new research in that area, about how attachment to parents, particularly moms, is mediated by particular brain chemicals.