That’s the question that begat this article, but it mushroomed into more than that. You see, to talk about how borderline and bipolar are different, we also need to talk about how they’re similar. And to talk about how they’re similar, we need to talk about how they’re both diagnoses in the Diagnostic and Statistical Manual, or DSM. And to talk about the DSM, we need to talk about how language shapes our understanding of a thing.
On Language and the DSM
If you’re unfamiliar with the DSM, it’s the manual that contains all the current psychiatric presentations. A new one is published roughly every 10 years or so; the fifth one has been out for about 5 years. Everything in the DSM – from anxiety to adjustment to tobacco use – is classified as a disorder.
Classifications and definitions change: for example, the DSM listed homosexuality as a mental disorder until 1987. One can see how this paralleled our cultural treatment of homosexuality as somehow ‘unnatural’. Gender dysphoria is still a classification in the DSM-V, parceled out with goal posts such as “a marked incongruence between one’s experienced…and assigned gender, of at least 6 months’ duration, as manifested by at least six of the following symptoms”. The medicalized language, with its precise delineation of symptoms, suggests that gender – already a cultural construct – can be quantified in this way. It also implies, in what is perhaps the oddest feature of all, that the American Psychiatric Association is the premiere authority on this matter.
The point I’m trying to make here is that what we collectively decide is a disorder – and what the parameters of that ’disorder’ are – is a human construct, not necessarily fact. It would be dishonest, however, to say that certain presentations do not share recurring constellations of symptoms, because they do. What we call bipolar has existed for as long as humans have recorded symptoms. The Traditional Chinese Medical text the Spiritual Axis, which dates back to 475 BCE, describes it thusly:
When Dian [Depression] first appears, there is lack of joy, heavy and painful head, red eyes, eyes looking up. When Kuang [Mania] first appears, there is little sleep, no hunger, glorification of the self as if one were the most knowledgeable person, shouting at people, no rest in day or night.
I will say two problematic things about the DSM. First, the language we use shapes our experience. Whether we use strengths- or deficit-based language is a choice that will influence how we connect with another, and whether that person feels safe with us. When we use the word disorder it de facto becomes pathology, and sometimes by extension we pathologize the individual. I personally avoid using the word disorder when I can, and try to honour how a person defines themselves. For some, a label puts them in a box; for others, it sets them free.
The second thing I want to highlight is that the DSM carries a great deal of power: for better or worse, it shapes the dominant discourse around mental health. You know the saying, “If all you have is a hammer, everything looks like a nail?” Well, if all you have is the DSM, everything looks like a disorder. Boiled down to its simplest element, what I’m trying to say is this: think critically about all information, including this article. No one has an absolute window on the truth.
Back to the Original Question
An important distinction between borderline and bipolar is that bipolar has a strong physiological/genetic component. One of the screening questions for bipolar is whether any family members have had it. Borderline can also run in families, but that tends to be more a product of environment than genetics. Moreover, people often outgrow a borderline presentation with maturity, treatment, and time, whereas for most people, bipolar is a sidekick for life.
Impulsivity and extreme highs and lows can make the two look similar, though in borderline the behaviours can shift many times within the same day and are usually caused by external factors. With bipolar, on the other hand, the factors generally have a physiological basis and episodes last longer. There are some hallmarks of mania that you wouldn’t find with borderline, such as not sleeping yet not being tired; a rapid rate of speech; an elevated expression of righteousness. Bipolar depression is unique, as well. In the absence of mania it can look like regular depression; however, with bipolar antidepressants often trigger mania.
Also, there are some things that make borderline unique. Some people experience an inconsistent sense of themselves. Suicidal or self-harming behaviours are quite common. Intense relationships can form quickly but then fall apart, intensifying a person’s feelings of unworthiness. Sometimes because of boundary violations in the past, a person has difficulty making or honoring boundaries in the present. The good news is: sense of self, effective ways of expressing distress, and boundaries are all teachable skills. With time and effort, a person doesn’t need to feel dominated by their emotions.
Treatments for Bipolar and Borderline
For both borderline and bipolar, stress can make things worse, so skills in this area are very helpful. The ‘usual suspects’ apply here: how is the person sleeping? Eating? Moving? What substances are they putting in the body? Tending to sleep is particularly important with bipolar, as lack of sleep often precipitates an episode of mania or depression, and is itself a symptom of mania. Food is our original medicine. Having awareness of the effects sugar and caffeine, for example, can take a person a long way in regulating their own mood naturally. Ditto with exercise: move your body and chances are you’ll feel better. Even the act of getting outside and feeling the air on your skin is a powerful step in the direction of mental health.
Because borderline is influenced so much by environment, it’s helpful for individuals to gain skills that allow them respond to the events and people in their lives. Dialectical Behaviour Therapy, or DBT, is a go-to treatment for borderline. Based on acceptance and change, DBT teaches mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. As someone who has taught DBT groups for years, I can say that it teaches great life skills for anyone – you don’t have to have any sort of ‘diagnosis’ to reap the benefits. And also, people in DBT groups are always changing their hair colour, their piercings, their style. There’s never a dull moment and I love it!
On Social Justice and Mental Health
I’m including here some of the excellent work done by the Icarus Project, which is a “media and activist endeavour broadly aligned to a Recovery approach, arguing that mental illness should be understood as an issue of social justice”. For those of you who don’t know, Icarus is the figure from Greek mythology who was warned by his father but nevertheless flew too close to the sun with wings made from feathers and wax. The wax melted and he plummeted into what is now known as the Icarian Sea. The myth is often used as a metaphor for bipolar.
However, as a person whose own namesake from Irish mythology, Deirdre, suffers a similarly tragic ending, I’d like to offer a different interpretation. What if Icarus did touch the sun, and made it, and everything was okay? John Lennon asked, “Who in the world do you think you are: a superstar? Well, right you are!” What if, as he wrote, we all shine on, like the moon and the stars and the sun?
The Icarus Project goes on to state that “a person’s mental state can improve through greater social support and collective liberation.” That is my stance as a counsellor as well:
The more we attend to social justice as an aspect of mental health, and hold one another in community rather than isolation, the closer we all are to liberation.
Just because you have a mental health diagnosis doesn’t mean it defines you, but it doesn’t mean you need to ignore it either. Know yourself and the terrain of your symptoms, and create a care plan that works for you. Reach out if you have any questions and, as always, in health and wellness, Deirdre.