Bipolar Illness Versus Borderline Personality: Red Skies Versus Red Apples

  • S. Nassir Ghaemi
  • Sergio Barroilhet


Major sexual trauma that derails personality development in early childhood has important consequences and can produce a clinical picture of complex PTSD symptoms that we call borderline personality. This is a truth, but it is a falsehood if this picture is allowed to deny and ignore our most treatable common psychiatric disease: bipolar illness. We demonstrate in this review that these conditions are two completely different entities: bipolar illness, in its entire spectrum ranging from severe mania to mild hypomania, is a medical disease almost completely genetic in etiology; borderline personality is a clinical picture with a primarily psychosocial etiology, based mainly on sexual trauma and pathogenesis. They share some clinical features—like mood lability and impulsivity and hypersexuality—which are nonspecific, and they differ in key specific ways: sexual abuse and parasuicidal self-harm are much more common in borderline personality, while psychomotor activation, without sexual abuse or parasuicidal self-harm, along with a strong genetic heritability, is basically diagnostic of bipolar illness. The similarities between these conditions are superficial—like red apples and red skies; the differences are profound. We also discuss mood temperaments and bipolar spectrum concepts and demonstrate their validity, how they are part of the overall disease of manic-depressive illness, and how they clearly differ from the clinical picture of borderline personality. Historical, conceptual, and empirical reviews of the literature are provided, along with case examples.


Bipolar Disorder Sexual Abuse Major Depressive Disorder Borderline Personality Disorder Sexual Trauma 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Paris J, Gunderson J, Weinberg I. The interface between borderline personality disorder and bipolar spectrum disorders. Compr Psychiatry. 2007;48(2):145–54.PubMedCrossRefGoogle Scholar
  2. 2.
    Akiskal HS. Demystifying borderline personality: critique of the concept and unorthodox reflections on its natural kinship with the bipolar spectrum. Acta Psychiatr Scand. 2004;110(6):401–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Paris J. Borderline or bipolar? Distinguishing borderline personality disorder from bipolar spectrum disorders. Harv Rev Psychiatry. 2004;12(3):140–5.PubMedCrossRefGoogle Scholar
  4. 4.
    Ghaemi S. The rise and fall of the biopsychosocial model: reconciling art and science in psychiatry. Baltimore: Johns Hopkins University Press; 2009.Google Scholar
  5. 5.
    Spitzer RL, Endicott J, Robins E. Research diagnostic criteria: rationale and reliability. Arch Gen Psychiatry. 1978;35:773.PubMedCrossRefGoogle Scholar
  6. 6.
    Shorter E. Before Prozac: the troubled history of mood disorders in psychiatry. New York: Oxford University Press; 2009.Google Scholar
  7. 7.
    Decker HS. The making of DSM-III®: a diagnostic manual’s conquest of American Psychiatry. New York: Oxford University Press; 2013.Google Scholar
  8. 8.
    Goldstein S. Console and classify: the French psychiatric profession in the 19th century. Chicago: University of Chicago Press; 2002.Google Scholar
  9. 9.
    Angst J, Marneros A. Bipolarity from ancient to modern times: conception, birth and rebirth. J Affect Disord. 2001;67(1–3):3–19.PubMedCrossRefGoogle Scholar
  10. 10.
    Kernberg O. Borderline personality organization. J Am Psychoanal Assoc. 1967;15(3):641–85.PubMedCrossRefGoogle Scholar
  11. 11.
    Boestrom A. Zustandbild und Krankheit in der psychiatrie. Klinische Wochenshcrift. 1923;2:1728–31.CrossRefGoogle Scholar
  12. 12.
    Gunderson J. Borderline personality disorder. Washington, DC: American Psychiatric Press; 1984.Google Scholar
  13. 13.
    Wakefield JC. The concept of mental disorder: diagnostic implications of the harmful dysfunction analysis. World Psychiatry. 2007;6(3):149–56.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Frances A. DSM in philosophyland: curioser and curioser. 2010. Cited 8 Nov 2010; Available from:
  15. 15.
    Frances A. A warning sign on the road to DSM-V: beware of its unintended consequences. Psychiatr Times. 2009;26(8):1–4.Google Scholar
  16. 16.
    Simpson SG, Folstein SE, Meyers DA, McMahon FJ, Brusco DM, DePaulo Jr JR. Bipolar II: the most common bipolar phenotype? Am J Psychiatry. 1993;150(6):901–3.PubMedGoogle Scholar
  17. 17.
    Sobczak S, Honig A, Nicolson NA, Riedel WJ. Effects of acute tryptophan depletion on mood and cortisol release in first-degree relatives of type I and type II bipolar patients and healthy matched controls. Neuropsychopharmacology. 2002;27(5):834–42.PubMedCrossRefGoogle Scholar
  18. 18.
    Sobczak S, Riedel WJ, Booij I, Aan Het Rot M, Deutz NE, Honig A. Cognition following acute tryptophan depletion: difference between first-degree relatives of bipolar disorder patients and matched healthy control volunteers. Psychol Med. 2002;32(3):503–15.PubMedCrossRefGoogle Scholar
  19. 19.
    Dickerson FB, Boronow JJ, Stallings C, Origoni AE, Cole S, Leister F, et al. The catechol O-methyltransferase Val158Met polymorphism and herpes simplex virus type 1 infection are risk factors for cognitive impairment in bipolar disorder: additive gene-environmental effects in a complex human psychiatric disorder. Bipolar Disord. 2006;8(2):124–32.PubMedCrossRefGoogle Scholar
  20. 20.
    Soderlund J, Olsson SK, Samuelsson M, Walther-Jallow L, Johansson C, Erhardt S, et al. Elevation of cerebrospinal fluid interleukin-1ss in bipolar disorder. J Psychiatry Neurosci. 2011;36(2):114–8.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Tondo L, Baldessarini R, Hennen J, Floris G. Lithium maintenance treatment: depression and mania in bipolar I and II disorders. Am J Psychiatry. 1998;155:638–45.PubMedGoogle Scholar
  22. 22.
    Berk M, Dodd S. Bipolar II disorder: a review. Bipolar Disord. 2005;7(1):11–21.PubMedCrossRefGoogle Scholar
  23. 23.
    Ghaemi S. Taking disease serious: against “pragmatic” nosology. In: Kendler KS, Parnas J, editors. Philosophical issues in psychiatry II: Nosology. Oxford: Oxford University Press; 2012. p. 42–52.CrossRefGoogle Scholar
  24. 24.
    Paris J. The bipolar spectrum: a critical perspective. Harv Rev Psychiatry. 2009;17(3):206–13.PubMedCrossRefGoogle Scholar
  25. 25.
    Cooper JE, Kendell RE, Gurland BJ, Sartorius N, Farkas T. Psychiatric diagnosis in New York and London. Oxford: Oxford University Press; 1972.Google Scholar
  26. 26.
    Ghaemi SN, Boiman EE, Goodwin FK. Diagnosing bipolar disorder and the effect of antidepressants: a naturalistic study. J Clin Psychiatry. 2000;61(10):804–8, quiz 9.PubMedCrossRefGoogle Scholar
  27. 27.
    Ghaemi SN, Sachs GS, Chiou AM, Pandurangi AK, Goodwin FK. Is bipolar disorder still underdiagnosed? Are antidepressants overutilized? J Affect Disord. 1999;52:135–44.PubMedCrossRefGoogle Scholar
  28. 28.
    Goodwin F, Jamison K. Manic depressive illness. 2nd ed. New York: Oxford University Press; 2007.Google Scholar
  29. 29.
    Ghaemi SN, Vohringer PA, Vergne DE. The varieties of depressive experience: diagnosing mood disorders. Psychiatr Clin North Am. 2012;35(1):73–86.PubMedCrossRefGoogle Scholar
  30. 30.
    Ghaemi S. On depression: diagnosis, drugs, and despair in the modern world. Baltimore: Johns Hopkins University Press; 2013.Google Scholar
  31. 31.
    Hammad TA, Laughren T, Racoosin J. Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry. 2006;63(3):332–9.PubMedCrossRefGoogle Scholar
  32. 32.
    Dilsaver SC, Chen YW, Swann AC, Shoaib AM, Krajewski KJ. Suicidality in patients with pure and depressive mania. Am J Psychiatry. 1994;151(9):1312–5.PubMedGoogle Scholar
  33. 33.
    Berk M, Dodd S. Are treatment emergent suicidality and decreased response to antidepressants in younger patients due to bipolar disorder being misdiagnosed as unipolar depression? Med Hypotheses. 2005;65(1):39–43.PubMedCrossRefGoogle Scholar
  34. 34.
    Mojtabai R, Olfson M. National trends in psychotropic medication polypharmacy in office-based psychiatry. Arch Gen Psychiatry. 2010;67(1):26–36.PubMedCrossRefGoogle Scholar
  35. 35.
    Zimmerman M, Ruggero CJ, Chelminski I, Young D. Is bipolar disorder overdiagnosed? J Clin Psychiatry. 2008;69(6):935–40.PubMedCrossRefGoogle Scholar
  36. 36.
    Anthony JC, Folstein M, Romanoski AJ. Comparison of lay DIS and a standardized psychiatric diagnosis. Arch Gen Psychiatry. 1985;42:667–75.PubMedCrossRefGoogle Scholar
  37. 37.
    Regier DA, Narrow WE, Clarke DE, Kraemer HC, Kuramoto SJ, Kuhl EA, et al. DSM-5 field trials in the United States and Canada, Part II: test-retest reliability of selected categorical diagnoses. Am J Psychiatry. 2013;170(1):59–70.PubMedCrossRefGoogle Scholar
  38. 38.
    Smith D, Ghaemi S. Is underdiagnosis the main pitfall when diagnosing bipolar disorder? Yes. BMJ. 2010;340:c854.PubMedCrossRefGoogle Scholar
  39. 39.
    Holtzman NS, Vohringer PA, Sullivan M, Lovdahl H, Correa E, Patkar A, et al., editors. Underdiagnosis of bipolar disorder: an international reality (abstract). In: American Psychiatric Association annual meeting, Philadelphia, 2012.Google Scholar
  40. 40.
    Bruchmuller K, Meyer TD. Diagnostically irrelevant information can affect the likelihood of a diagnosis of bipolar disorder. J Affect Disord. 2009;116(1–2):148–51.PubMedCrossRefGoogle Scholar
  41. 41.
    Healy D. Mania: a short history of bipolar disorder. Baltimore: Johns Hopkins University Press; 2008.Google Scholar
  42. 42.
    Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatry. 1970;126:983–7.PubMedGoogle Scholar
  43. 43.
    Ghaemi SN, Ko JY, Goodwin FK. “Cade’s disease” and beyond: misdiagnosis, antidepressant use, and a proposed definition for bipolar spectrum disorder. Can J Psychiatry. 2002;47(2):125–34.PubMedGoogle Scholar
  44. 44.
    Cassano GB, Rucci P, Benvenuti A, Miniati M, Calugi S, Maggi L, et al. The role of psychomotor activation in discriminating unipolar from bipolar disorders: a classification-tree analysis. J Clin Psychiatry. 2012;73(1):22–8.PubMedCrossRefGoogle Scholar
  45. 45.
    Koukopoulos A, Sani G, Koukopoulos AE, Manfredi G, Pacchiarotti I, Girardi P. Melancholia agitata and mixed depression. Acta Psychiatr Scand Suppl. 2007;433:50–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Angst J, Gamma A, Bowden CL, Azorin JM, Perugi G, Vieta E, et al. Diagnostic criteria for bipolarity based on an international sample of 5,635 patients with DSM-IV major depressive episodes. Eur Arch Psychiatry Clin Neurosci. 2012;262:3–11.PubMedCrossRefGoogle Scholar
  47. 47.
    Kraepelin E. Manic-depressive insanity and paranoia. Edinburgh: E & S Livingstone; 1921.Google Scholar
  48. 48.
    Bienvenu OJ, Davydow DS, Kendler KS. Psychiatric ‘diseases’ versus behavioral disorders and degree of genetic influence. Psychol Med. 2011;41(1):33–40.PubMedCrossRefGoogle Scholar
  49. 49.
    Perlis RH, Uher R, Ostacher M, Goldberg JF, Trivedi MH, Rush AJ, et al. Association between bipolar spectrum features and treatment outcomes in outpatients with major depressive disorder. Arch Gen Psychiatry. 2011;68:351–60.PubMedCrossRefPubMedCentralGoogle Scholar
  50. 50.
    Tondo L, Vazquez G, Baldessarini RJ. Mania associated with antidepressant treatment: comprehensive meta-analytic review. Acta Psychiatr Scand. 2010;121(6):404–14.PubMedCrossRefGoogle Scholar
  51. 51.
    Tondo L, Baldessarini RJ, Vazquez G, Lepri B, Visioli C. Clinical responses to antidepressants among 1036 acutely depressed patients with bipolar or unipolar major affective disorders. Acta Psychiatr Scand. 2013;127(5):355–64.PubMedCrossRefGoogle Scholar
  52. 52.
    Akiskal HS, Pinto O. The evolving bipolar spectrum. Prototypes I, II, III, and IV. Psychiatr Clin North Am. 1999;22(3):517–34, vii.PubMedCrossRefGoogle Scholar
  53. 53.
    Matthews G, Deary I, Whiteman M. Personality traits. 3rd ed. Cambridge: Cambridge University Press; 2009.CrossRefGoogle Scholar
  54. 54.
    Eysenck H. The scientific study of personality. London: Routledge Kegan and Paul; 1952.Google Scholar
  55. 55.
    Kretschmer E. Physique and character. New York: Cooper Square Publishers; 1921 (1970).Google Scholar
  56. 56.
    Kelsoe JR. The genetics of bipolar disorder. Psychiatr Ann. 1997;27:285–92.CrossRefGoogle Scholar
  57. 57.
    Serretti A, Mandelli L, Lorenzi C, Landoni S, Calati R, Insacco C, et al. Temperament and character in mood disorders: influence of DRD4, SERTPR, TPH and MAO-A polymorphisms. Neuropsychobiology. 2006;53(1):9–16.PubMedCrossRefGoogle Scholar
  58. 58.
    Vöhringer P, Whitham E, Thommi S, Holtzman N, Khrad H, Ghaemi S. Affective temperaments and clinical practice: a validation study in mood disorders. J Affect Disord. 2012;136(3):577–80.PubMedCrossRefGoogle Scholar
  59. 59.
    Hantouche EG, Akiskal HS. Toward a definition of a cyclothymic behavioral endophenotype: which traits tap the familial diathesis for bipolar II disorder? J Affect Disord. 2006;96(3):233–7.PubMedCrossRefGoogle Scholar
  60. 60.
    Akiskal H. Temperament and mood disorders. Harv Ment Health Lett. 2000;16(8):5–6.PubMedGoogle Scholar
  61. 61.
    Widiger TA, Simonsen E, Krueger R, Livesley WJ, Verheul R. Personality disorder research agenda for the DSM-V. J Pers Disord. 2005;19(3):315–38.PubMedCrossRefPubMedCentralGoogle Scholar
  62. 62.
    Koukopoulos A, Sani G. DSM-5 criteria for depression with mixed features: a farewell to mixed depression. Acta Psychiatr Scand. 2014;129(1):4–16.PubMedCrossRefGoogle Scholar
  63. 63.
    Salvatore P, Baldessarini RJ, Centorrino F, Egli S, Albert M, Gerhard A, et al. Weygandt’s On the Mixed States of Manic-Depressive Insanity: a translation and commentary on its significance in the evolution of the concept of bipolar disorder. Harv Rev Psychiatry. 2002;10(5):255–75.PubMedCrossRefGoogle Scholar
  64. 64.
    Angst J, Azorin JM, Bowden CL, Perugi G, Vieta E, Gamma A, et al. Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode: the BRIDGE study. Arch Gen Psychiatry. 2011;68(8):791–8.PubMedCrossRefGoogle Scholar
  65. 65.
    Phelps J, Ghaemi SN. The mistaken claim of bipolar ‘overdiagnosis’: solving the false positives problem for DSM-5/ICD-11. Acta Psychiatr Scand. 2012;126(6):395–401.PubMedCrossRefGoogle Scholar
  66. 66.
    Vöhringer P, Alvear K, Medina S, Espinosa C, Alexandrovic K, Ruimallo P, et al. Differentiating Borderline Personality Disorder from Bipolar Disorder. (abstract) American Psychiatric Association annual meeting, May 5–9 2012, Philadelphia PA.Google Scholar
  67. 67.
    Perugi G, Angst J, Azorin JM, Bowden C, Vieta E, Young AH. The bipolar-borderline personality disorders connection in major depressive patients. Acta Psychiatr Scand. 2013;128:376–83.PubMedCrossRefGoogle Scholar
  68. 68.
    Brodsky BS, Cloitre M, Dulit RA. Relationship of dissociation to self-mutilation and childhood abuse in borderline personality disorder. Am J Psychiatry. 1995;152(12):1788–92.PubMedGoogle Scholar
  69. 69.
    Oumaya M, Friedman S, Pham A, Abou Abdallah T, Guelfi JD, Rouillon F. Borderline personality disorder, self-mutilation and suicide: literature review. Encéphale. 2008;34(5):452–8. Personnalite borderline, automutilations et suicide : revue de la litterature.PubMedCrossRefGoogle Scholar
  70. 70.
    Boffetta P, Pershagen G, Jockel KH, Forastiere F, Gaborieau V, Heinrich J, et al. Cigar and pipe smoking and lung cancer risk: a multicenter study from Europe. J Natl Cancer Inst. 1999;91(8):697–701.PubMedCrossRefGoogle Scholar
  71. 71.
    Joyce PR, Light KJ, Rowe SL, Cloninger CR, Kennedy MA. Self-mutilation and suicide attempts: relationships to bipolar disorder, borderline personality disorder, temperament and character. Aust N Z J Psychiatry. 2010;44(3):250–7.PubMedCrossRefGoogle Scholar
  72. 72.
    Valtonen H, Suominen K, Mantere O, Leppamaki S, Arvilommi P, Isometsa ET. Suicidal ideation and attempts in bipolar I and II disorders. J Clin Psychiatry. 2005;66(11):1456–62.PubMedCrossRefGoogle Scholar
  73. 73.
    Kendler KS, Prescott C. Genes, environment, and psychopathology. New York: Guilford Press; 2006.Google Scholar
  74. 74.
    Fossati A, Madeddu F, Maffei C. Borderline Personality Disorder and childhood sexual abuse: a meta-analytic study. J Pers Disord. 1999;13(3):268–80.PubMedCrossRefGoogle Scholar
  75. 75.
    Maniglio R. Prevalence of child sexual abuse among adults and youths with bipolar disorder: a systematic review. Clin Psychol Rev. 2013;33(4):561–73.PubMedCrossRefGoogle Scholar
  76. 76.
    Conus P, Cotton S, Schimmelmann BG, Berk M, Daglas R, McGorry PD, et al. Pretreatment and outcome correlates of past sexual and physical trauma in 118 bipolar I disorder patients with a first episode of psychotic mania. Bipolar Disord. 2010;12(3):244–52.PubMedCrossRefGoogle Scholar
  77. 77.
    Strakowski SM, Delbello MP, Adler CM. The functional neuroanatomy of bipolar disorder: a review of neuroimaging findings. Mol Psychiatry. 2005;10(1):105–16.PubMedCrossRefGoogle Scholar
  78. 78.
    Shamay-Tsoory SG, Tomer R, Berger BD, Aharon-Peretz J. Characterization of empathy deficits following prefrontal brain damage: the role of the right ventromedial prefrontal cortex. J Cogn Neurosci. 2003;15(3):324–37.PubMedCrossRefGoogle Scholar
  79. 79.
    Ongur D, Lundy M, Greenhouse I, Shinn AK, Menon V, Cohen BM, et al. Default mode network abnormalities in bipolar disorder and schizophrenia. Psychiatry Res. 2010;183(1):59–68.PubMedCrossRefPubMedCentralGoogle Scholar
  80. 80.
    Soloff PH. Psychopharmacology of borderline personality disorder. Psychiatr Clin North Am. 2000;23(1):169–92, ix.PubMedCrossRefGoogle Scholar
  81. 81.
    Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M. Borderline personality disorder. Lancet. 2004;364(9432):453–61.PubMedCrossRefGoogle Scholar
  82. 82.
    Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, van Asselt T, et al. Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Arch Gen Psychiatry. 2006;63(6):649–58.PubMedCrossRefGoogle Scholar
  83. 83.
    Huxley TH. Aphorisms and reflections. London: Macmillan and Co.; 1907.Google Scholar

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© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of PsychiatryMood Disorders Program, Tufts Medical CenterBostonUSA
  2. 2.Tufts University School of MedicineBostonUSA
  3. 3.Escuela de PsicologíaUniversidad de los AndesSantiagoChile

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