Diagnosing mental illness is an imperfect science. The DSM (Diagnostic and Statistical Manual) describes bipolar, borderline personality disorder (BPD) and post-traumatic stress disorder (PTSD) as distinct problems, but they share a lot of the same symptoms and can be very hard to distinguish. They also can occur together, which makes it even tougher to sort out.
Some common symptoms of these illnesses are trouble sleeping, thoughts of suicide, not being able to maintain relationships, feeling worthless, racing thoughts, inability to focus, low energy, and feeling heightened emotions. Bipolar, BPD and PTSD can all cause these problems, but for different reasons. For example, someone with bipolar may have trouble sleeping because they are in a manic episode, but someone with PTSD may not be able to sleep because of nightmares or flashbacks. Someone with BPD may have frequent mood swings because of their emotional sensitivity, which can be mistaken for bipolar disorder. A person can have racing thoughts because of bipolar disorder, or because they are triggered by the memory of abuse (PTSD), or because they fear being abandoned (BPD).
So why does the DSM distinguish between these problems? Because although they look alike, they are in fact different. They have different etiologies – they are caused by different things – and need to be treated through different approaches.
Bipolar Disorder
Bipolar disorder is a disease and genetics play an important role in whether or not you have bipolar disorder. Research shows that brains of people with bipolar disorder look different than brains of people without the disorder. Treating bipolar disorder often includes use of medication in order to prevent manic or depressive episodes. This is important because these episodes can cause damage to the brain. In addition to medication there are a number of other approaches to treating bipolar disorder, including psychotherapy, taking supplements, exercise and light therapy.
Borderline Personality Disorder (BPD)
The causes of BPD aren’t completely known, though we do know that approximately 75% of people with BPD have a history of childhood abuse. There may also be a genetic component, but that’s not quite clear yet. Once upon a time BPD was considered an intractable diagnosis. Research over the last several decades, mainly by Dr. Marsha Linehan (founder of Dialectical Behavior Therapy or DBT), has shown that BPD is NOT a lifelong sentence but in fact you can get better. DBT has been studied over the last 30 years and has been shown to be incredibly effective at treating BPD. BPD is a learned response, and therefore it can be unlearned and you can “build a life worth living”. What’s really fantastic about DBT, though, is it can help anyone live better, happier lives. You can “building a life worth LOVING”. I teach DBT to other therapists and use it in my own life, but that’s a topic for another day.
Post-Traumatic Stress Disorder (PTSD)
PTSD is caused when you experience a traumatic event – either feeling that your life is threatened or that someone else’s life is threatened. PTSD is not caused by the event itself, but rather by the perception of the event. Not everyone who experiences a traumatic event will get PTSD. For example, not everyone in 9-11 has PTSD. Traumatic events can include war, natural disaster, car accidents, invasive medical procedures, physical abuse, childhood abuse or neglect, sexual abuse, domestic violence and so on. Note that both BPD and PTSD have a relationship with childhood abuse and neglect. That’s one of the reasons it’s hard to separate out these two different diagnoses, and why it’s not uncommon for someone to have both. PTSD and trauma aren’t treated very effectively by medication, although some medications can put a band-aid on the symptoms. The most effective treatment is therapy, and specifically, therapy targeted at trauma (no, not all therapy is the same).
Even though these diagnoses are caused by different things and should be treated differently, I see them as a spectrum of problems. Therapists and psychiatrists are required to come up with a diagnosis after meeting with someone for one time (if they are going to bill insurance), but it’s difficult to be sure. Sometimes it takes months of assessment and re-assessment to make sure you understand what’s going on and how to treat it. Make sure you’re getting the right treatment for the right problem.
Remember that diagnoses are just a tool. They should never be used to label or limit people, but rather to explain and help people understand. Never confuse the person with the diagnosis. Treat the person.
Wow, my son has been diagnosed with bipolar and ptsd but after reading this it seems more like BPD. He has been in therapy since 3rd grade and now is 15, he suffers from ambodment by biological father, and death of his sister mood swings and anger . I don’t know if you respond to messages but I have a lot more info for you and don’t want to put on this message.
Mom who will never give up.
Hi Rosie. I’d be happy to talk further with you about this. Please call me at 650-209-0206 or email me at linnea@bayareamh.com
I suffer from
All 3 of these. And I agree 100%. Bipolar came about purely genetically for me. Borderline from childhood drama. And PTSD from adulthood trauma.
That’s a touch combination Mercedes. I hope my blog helped you. Childhood trauma is often correlated with BPD.
Excuse me, I meant "tough" combination
Worked as an LMHT2. In a institution for the criminally insanea for 23 yrs . I worked on an all-female unit that gave psychiatric evaluation for felonies charges. Meaning do they understand the proceedings in a courtroom are they able to help in their own defense and do they understand the charges at that time they cannot be forced medicated and the evaluation could last 60 days. They may be sent back for treatment which things could last 90 days and are given classes to help understand what goes on in a courtroom and could then have forced medications.. in all the diagnosis above do they consider antisocial personality disorder in the Axis 2. ?
Hi Cindy,
Thank you for your response. You’re a hero for doing such difficult work for so many years. Antisocial personality disorder is considered an Axis II disorder, or at least it was when we were using the DSM VI. At the end of last year the DSM V was released and it no longer uses the 5 axis system. Antisocial personality disorder is distinct from bipolar, borderline and PTSD but can co-occur. I’m not sure of this answers your question, but I hope it helps. Let me know if you have more questions. Linnea
I’ve been diagnosed rapid cycling bipolar one with psychotic features and ptsd and a severe anxiety disorder (which seems redundant). I like the theory that all mental illness stems from complexPTSD. It makes the most sense to me. And it gives me hope that things can get easier with healing. Reading this does make me want to get a brain scan… How is the bipolar brain different?
Hi Rebecca.
Mental illness comes from a variety of things, including but not limited to complex PTSD. Other factors include genetics, biological vulnerability, in utero stress, and early life experiences. With what you are describing I’d recommend seeking treatment from someone who has experience in these areas. Bipolar is diagnosed based on behaviors not a brain scan. There is some evidence that there is a different ratio of grey matter to white matter in bipolar, but I am not an expert on that area so I can’t comment further.
Wishing you the best,
Linnea
Linnea, I was under the impression that current thinking in the trauma treatment community was that Borderline Personality Disorder is not a distinct thing in and of itself and certainly not a personality disorder. Rather, what is called "BPD" is really a subset of the range of symptoms that can result when one has a trauma history. So its components are really part of complex PTSD / Developmental Trauma. Yet I see you here discussing it as if it were a valid diagnosis. Would you please speak to that? Thank you.
Hi Priscilla. Great question, thanks for asking it. Borderline personality disorder is a distinct diagnosis in the Diagnostic and Statistical Manual (DSM) which is what we use to define diagnoses. At the end of last year a new version of the DSM came out that has a different structure which impacts the borderline diagnosis. It is still considered a personality disorder but is no longer categorized as "axis 2", which used to meant that an illness is inborn and lifelong. Research has shown that in fact you can recover from borderline personality disorder with therapy so it is not lifelong. Even though borderline no longer fits with the traditional classification of personality disorder (axis 2, lifelong), it is still considered one of the forms of personality disorder. The reason for this is that people experience personality disorders such as borderline as central to their sense of who they are. BPD is often (though not always) correlated with having a trauma history – 75% of people with a BPD diagnosis do have trauma. That’s part of why it’s difficult to determine which diagnosis is most appropriate. So borderline personality disorder, bipolar and PTSD are all valid diagnoses in the DSM. Interestingly complex PTSD (C-PTSD) or developmental trauma is not a valid diagnosis in the DSM, even though a core component of the trauma research community fought to have it included. I still discuss PTSD in terms of shock trauma versus developmental trauma because they present very differently. In the blog I was referring to developmental trauma or complex PTSD which is a useful description even though not an official diagnosis. I hope this helps clarify things.
Best regards,
Linnea
I’ve many questions, Linnea, but I’ll do my best to be succinct, and choose the best few of the ones I’m thinking of. As I said on Twitter, I’ve been diagnosed with bipolar and PTSD, but I have little faith in local mental health professionals.
First, I was diagnosed with bipolar type II (major depressive episodes with short hypomanic spikes), although I do recall many chart notes listing bipolar I. I was told that this was a combination of changes with medication, and changes in the DSM– although, I’m not inclined to believe that. I am much more prone to believe that too many professionals in my area are simply incompetent.
That said, I must note I live in a small town area. I’m sure you’ve noticed that community mental health in such areas is miserable, and more on-point, has led to poor treatment. I was medicated for seasonal affective depression for years until a med nurse intuitively ordered a vitamin D lab test- and I was deficient. I had to take many backdoors to get proper treatment. This included connections by way of my 3rd nutritionist, the local mental health ombudsman office, our local RAINN contact (i.e., the local sexual assault organization) and a lot of work with the then director of counseling at my current agency. (I was placed with a Bosnian therapist who had been a neurologist, before coming to my DBT-focused therapist, who is now letting me go for case management, as I’m doing well by her estimation.) I went to see my current nutritionist for prediabetes, but, as she is the lone specialist for eating disorders in our region, she eventually got me to open up about binge eating.
I have been relatively stable on a low dose of lithium- it took many years to cut out a lot of other unnecessary drugs. The psychiatrist that diagnosed me with PTSD (but not complex PTSD) used psych drugs heavily to tweak things- which meant he usually overmedicated his patients. (Can you imagine my shock when other pros told me, "Gee, you’re on fewer drugs than Dr. D normally prescribes his patients"?) I take other drugs for nerve pain- you’re probably familiar with Cymbalta’s original application for mood stabilization.
I live in southcentral Washington state. Does this make sense? I have a family history for bipolar, and Bobbi Parish has noted that there’s definitely a history of intergenerational abuse, so that might as well be a family history for vulnerability to PTSD as well. But local resources to distinguish between the two are woefully inadequate. Is there anything more besides "do the best you can with the hand you’re dealt"? And yes, Athena Moberg is very happy that I have a copy of the DBT workbook you recommended.
(Sorry this comment is so long. I have great trouble keeping it as short as everyone else!)
Hi Jonathan,
Sorry it took me so long to respond! Let me start by saying congratulations again on getting into DBT. I am so happy that it’s helping. It changed my life and I love helping other people make those changes too. Diagnosis is a tricky matter, especially when trying to differentiate between bipolar I/II, PTSD, BPD, which all have similar symptoms. If you see a MH professional who isn’t trained in trauma then it is likely that they will overlook the trauma and lean toward other diagnoses. This is very common. If medication is giving you relief that’s great. Don’t worry so much about the diagnosis – it’s just a label. Good job on finding the link with vit D – deficiency can cause depression. You might also want to check out your vit B and folate levels. In a rural area you will have limited resources, but it is so clear to me that you are a self-advocate and using those resources to their fullest. <virtual hug>, Linnea