Bipolar illness versus borderline personality: Red skies versus red apples

Abstract

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.