Unfortunately, though, receiving a diagnosis for BPD — which can be effectively treated through psychotherapy — isn’t always easy. For one thing, popular attitudes about the disorder can reduce your chances of receiving a BPD diagnosis. “BPD in general has a fair amount of stigma attached to it, and so there can be reluctance on the part of clinicians to diagnose it,” says John Santopietro, MD, a board-certified psychiatrist and the senior vice president of Hartford HealthCare in Hartford, Connecticut. In a 2015 study, researchers observed that adolescents seeking treatment for a personality disorder (BPD is one type) faced more stigma than peers who sought treatment for other psychiatric disorders. Among all those adolescents seeking treatment for personality disorders, those with BPD faced the most stigma, according to the study. (2) But also tricky is the fact that several of the common symptoms of BPD mimic those of other psychiatric diagnoses — and, as is the case with any diagnosis, those with BPD may even be suffering from more than one related condition. As of 2007, the National Institute of Mental Health (NIMH) estimates that 1.4 percent of those in the United States experience BPD, and 84.7 percent of those with BPD also had one or more other mental health disorders. (3) Without the right diagnosis, people with BPD continue to struggle with their symptoms. “What people can often miss is just how much that person is suffering on the inside,” Dr. Santopietro says. “In fact, that’s why the behavior happens.” But by knowing the common comorbidities of BPD and how to request a diagnostic test, you can increase the chances of getting yourself or a loved one the right diagnosis and treatment. Another factor is that many of the same symptoms can overlap in several disorders. For example, people who have depression or an anxiety disorder can have problems concentrating. Just as fever, for instance, can be a symptom of many diagnoses, a lack of interest can be one symptom of several psychiatric disorders. The key is to understand the context in which the symptom occurs and identify the other symptoms as well, experts say. Symptoms can also vary between individuals. For example, to be diagnosed with BPD, someone must have five out of nine total symptoms listed in the DSM-5, the standard classification and tool clinicians use to diagnose mental illness. “Depending on how many symptoms, which symptoms, and the severity and duration of symptoms that an individual person has, the diagnosis can look very different across unique individuals,” Dr. Cullen says. Comorbidities are common for any mental illness, but they are particularly high for people with BPD. The NIMH estimates that 60.5 percent of people with BPD also have an anxiety disorder and 34.3 percent also have a mood disorder. (3) It’s unclear why comorbidities exist for people with BPD. “Part of it may be that in terms of the neurobiology or genetics, there’s some overlap across different disorders and then there’s some overlap in the symptoms that are experienced,” Cullen says. BPD can also often be misdiagnosed because it can be difficult for practitioners to differentiate BPD from mood disorders, such as major depressive disorder and bipolar disorder. “At the heart of borderline personality disorder, you’re talking about really significant dysregulation in a number of different areas and the core is around emotion dysregulation,” Cullen says. With BPD, there can also be a lot of “affective instability” or repeated, rapid, and abrupt shifts in mood — which may be explained by BPD, another mental illness, or both, she says. (6)
1. Bipolar Disorder
Bipolar disorder is marked by drastic fluctuations of depressive lows and manic highs, with affected individuals having trouble regulating their emotions and being prone to risky or impulsive behavior. Sound familiar? That’s because those are also common symptoms associated with BPD, meaning individuals with either of these conditions may have a hard time receiving the right diagnosis. Research suggests that about 3 percent of Americans a year have bipolar disorder, while up to 20 percent of people with bipolar also have BPD. (9,10) “[Bipolar disorder] is the most complicated and the one that often can be the most complex to tease out the differences,” Cullen says. While both those with bipolar disorder and BPD often experience interpersonal difficulties, a PBD diagnosis is characterized by specific obstacles like unstable relationships, fear of abandonment, and trust issues. Indeed, people affected by BPD often swing from idealizing a person to devaluing them in a very short period of time. To make an accurate diagnosis, it’s important for a clinician to understand the person’s thought processes, their relationships, and how they view themselves. “Looking at those [factors] closely I think can help understand: Is it one versus the other, or is it both?” Cullen says. It’s unclear how many people have PTSD and BPD together, but a 2015 study found more than 53 percent of people with BPD also met the criteria for PTSD at some point in their lifetime. (11) What’s more, people who were sexually abused as children, which is another risk factor for PTSD, have a higher risk for developing BPD than the general population, Santopietro says. Experts say genetics may be the cause of these conditions existing together, Cullen says. “We also believe that adverse events in people’s lives can interact with their biological vulnerability to make them more likely to develop borderline personality disorder,” she says, speculating on how the event that triggered PTSD may in turn increase someone’s risk for BPD. A 2017 study suggests early childhood trauma (a risk factor for PTSD) may alter the brain and make someone more likely to develop BPD. (12) Although someone with BPD may have experienced trauma, if they don’t have symptoms of PTSD — such as intrusive symptoms, emotional numbness, and increased arousal or hypervigilance — they would not meet the criteria for a PTSD diagnosis.
3. Major Depressive Disorder
Major depressive disorder (MDD) is a mood disorder and common comorbidity of BPD. Studies show between about 38 and 71 percent of people with one of the disorders also have the other. (4,13) Common symptoms of MDD include prolonged periods (defined as two weeks or more) of low mood, lack of interest, fatigue, and sleep problems — all symptoms of BPD, too. “Individuals with BPD may have low mood at times, but it generally lasts only a few hours or a few days and is only one of nine symptoms that a person may or may not have,” Cullen says. Unlike those with MDD, people with BPD have problems with emotional regulation and instability both in their mood and in many areas not directly related to mood like interpersonal relationships. Because impulsivity is one of the symptoms of BPD, substance use disorder is often a comorbidity of the condition. Up to 72 percent of people with BPD will also have a substance use disorder at some point in their lifetime. (14) “You can see where they’re at [a] higher risk for substance use because that can be a way of — in the short term — regulating their emotional state,” Cullen says. The distinguishing factor from a substance use disorder, however, is that people with BPD must demonstrate impulsivity in at least one other area, such as spending, sex, reckless driving, or binge eating. “Furthermore, an individual with BPD may not have any issues with substance use or could engage in impulsive substance use at times, but possibly not meet criteria for a substance use disorder if their problematic substance use does not rise to that level,” Cullen says.
5. Eating Disorders
Much like substance use disorder, in an effort to help regulate their emotions, people with BPD may also develop an eating disorder. A 2010 study found 90 percent of people with BPD also met the criteria for anorexia, bulimia, and eating disorder not otherwise specified (EDNOS), an eating disorder that doesn’t fit into a specific category. (15) Although people with BPD may have impulsivity related to eating, those who do not have symptoms that are pervasive, persistent, or as severe, would not meet the criteria for an eating disorder diagnosis, Cullen says. Panic disorder is a condition in which a person experiences episodes of panic attacks that seem to come out of nowhere and cause the person to be fearful that they will recur or will cause something terrible to happen, like a heart attack. (17) “When you’re thinking about BPD, a lot of times people often get to these crisis states where they feel very much overwhelmed by their emotions and oftentimes are not really sure what to do to regulate themselves,” Cullen says. As a result, they can experience anxiety and panic. Although one of the symptoms of BPD is anxiety, research estimates suggest between 61 to nearly 75 percent of people with BPD also meet the criteria for at least one type of anxiety disorder at some point in their lifetime, such as social anxiety disorder and panic disorder. (3,18) The difference between BPD and anxiety or panic disorders is the latter cause symptoms more frequently and for a greater period of time, for at least six months. “Their anxiety is more pervasive and chronic than the anxiety that is related to BPD,” Cullen says. Sometimes, people may have traits of personality disorders without meeting the full criteria for the disorders. For example, someone may have traits of borderline personality disorder as well as traits for antisocial personality disorder without having the full-blown forms of both illnesses. If you find yourself in this bucket, you may find yourself seeking help to deal with these symptoms. That said, although people can be diagnosed with more than one personality disorder, it’s rare, Santopietro says. Other personality disorders include: Paranoid Personality Disorder This personality disorder is marked by a pervasive distrust and suspiciousness of other people. (20) Schizoid Personality Disorder People avoid social activities and interactions with others and do not tend to show emotion. (21) Schizotypal Personality Disorder People with this disorder are often described as odd or eccentric; they have few, if any, close relationships; and they have unusual or unrealistic thoughts. (22) Antisocial Personality Disorder People have a pervasive disregard for the rights of other people — a sentiment that presents as hostility or aggression. It’s also common for people to be deceitful and manipulative. (23) Histrionic Personality Disorder People are consistently seeking attention and have excessive emotions. (23) Narcissistic Personality Disorder People have an inflated sense of self, a deep need for excessive attention and admiration, troubled relationships, and a lack of empathy for others. (24) Avoidant Personality Disorder People have feelings of inadequacy and are constantly afraid that others will criticize them, so they avoid situations and interactions with others. (25) Dependent Personality Disorder People have a strong need to be taken care of and have a fear of losing support from others. (25) Obsessive-Compulsive Personality Disorder People are preoccupied with control and perfectionism and often neglect relationships in favor of orderliness. (25) A psychiatrist, a psychologist, a clinical social worker, or a psychiatric nurse can help diagnose BPD correctly. (26)
