Can Borderline Personality Disorder Be Misdiagnosed?
Borderline personality disorder (BPD) is, unfortunately, frequently misdiagnosed. This is because it shares symptoms with a variety of other conditions, such as attention-deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), and bipolar disorder.
BPD misdiagnosis creates frustration, delays recovery, and causes distrust in the mental health industry. However, with the right assessment approach, many people achieve a correct diagnosis, receive effective treatment, and can start the route to recovery.
To help you understand BPD misdiagnosis and your options, this page explores:
- Why BPD can be misdiagnosed and why getting the right diagnosis matters.
- BPD misdiagnosis in men vs women.
- The conditions BPD can be misdiagnosed as.
- The steps involved in BPD assessments.
- Where to find professional support.
Why Getting the Right Diagnosis Matters
A borderline personality disorder (BPD) diagnosis is not intended to “label” but is instead a helpful map for self-awareness and for how best to move forward with help, treatment, and support for your condition. A wrong diagnosis can lead to:
- Medication that doesn’t address the main problem.
- Shallow therapy that is too surface-level.
- Increased shame and confusion.
- Continued crisis moments with no explanation.
- Feeling like treatment “doesn’t work.”
Why Is BPD Sometimes Misdiagnosed?
In 2024, a review found the rates of BPD among adults to be between 0.7% and 2.7%.[1] But in mental health settings, numbers are a lot higher. In fact, about 12% of outpatients (people receiving mental health care without staying in hospitals or clinics) and 22% of inpatients (people receiving care while staying in a hospital or clinic) have BPD.[1]
We see even more discrepancies in the number of people with BPD as we look further into research. Earlier research suggests higher rates of people living with BPD (almost 6%).[2]
The gap in these numbers is relevant as it suggests that a lot of people’s BPD might only become “visible” once distress levels are serious enough to drive them into care.
Plus, if one study finds less than 3% of adults have BPD and another finds nearly 6%, there may be differences in assessments and in whether symptoms are understood as BPD or thought to be something else.
BPD Misdiagnosis in Men vs Women
BPD used to be described as more common in women than in men. However, large population research recently suggests that it is more balanced between the genders. Lifetime rates are 5.6% in men and 6.2% in women.[2]
This raises a question about the diagnosis of BPD in the past. If men are now known to have BPD at similar rates, were symptoms previously being missed, misdiagnosed, or given different labels?
A 2022 review found that men with BPD more often showed external symptoms. For example, men may be more likely to present with:
- Anger.
- Impulsivity.
- Substance use.
- Risk-taking.
This may lead clinicians to diagnose substance use, anger problems, or bipolar disorder instead of BPD.[3]
In contrast, women may be more likely to enter care for:
- Depression.
- Anxiety.
- Eating difficulties.
- Self-harm.
These conditions may be more easily aligned with BPD symptoms.
BPD Misdiagnosis as Bipolar Disorder
One of the most common misdiagnoses of BPD is bipolar disorder. The two have a lot of shared symptoms; however, the pattern is significantly different.
Similarities Between BPD and Bipolar Disorder
BPD and bipolar disorder can look similar due to the emotional highs and lows both share. In both conditions, someone may appear:
- Reactive.
- Impulsive.
- Angry.
- Distressed.
- Difficult to calm.
Both can also involve:
- Risky behavior.
- Relationship strain.
- Emotional intensity that feels bigger than the situation itself.
This overlap can help explain why misdiagnosis happens. In one outpatient study of over 600 people, patients who met criteria for BPD were much more likely to report that they had previously been misdiagnosed with bipolar disorder. This was the case even when they did not meet the criteria.[4]
Key Differences Between Bipolar Disorder and BPD
Differences between bipolar disorder and BPD include:
- Timing: With bipolar disorder, mood episodes usually last longer. Mania, hypomania, or depression may last days, weeks, or months. With BPD, emotions often shift faster, sometimes within hours.
- Triggers: Bipolar mood episodes can be affected by substances, life events, and more, but are not always tied to a specific relationship trigger. BPD mood shifts are often more closely linked to relationship stress.
- Body and behavior changes: Bipolar mania or hypomania often involves wider changes, such as reduced need for sleep, faster speech, inflated confidence, and more. In BPD, impulsive behavior may happen, but it’s often driven by panic, shame, or a fear of being left. Research comparing affective instability in BPD and bipolar disorder found that BPD-related mood shifts were more frequent and more interpersonal than those in bipolar.[5]
Other Conditions BPD Can Be Mistaken For
As well as bipolar disorder, there are a few other diagnoses worth mentioning that BPD can also be mistaken for. A 2024 review noted that BPD is often associated with:[1]
- Depression.
- Anxiety-related difficulties.
- Post-traumatic stress disorder (PTSD).
- Attention-deficit hyperactivity disorder (ADHD).
- Substance use.
- Eating disorders.
- Bipolar disorder.
This may be because these conditions all have many visible symptoms that overlap with BPD.
ADHD and BPD both involve impulsive choices and difficulty pausing before reacting; both can manifest as issues at work, school, or in relationships. However, the reason behind the behavior is different. In ADHD, impulsivity is often linked to attention and stimulation. In BPD, impulsivity is more likely a result of emotional pain or panic in relationships.
One review found that ADHD and BPD overlap mainly in impulsivity and emotional dysregulation, but BPD involves frantic efforts to avoid abandonment and stress-related paranoia.[6]
Trauma can also complicate diagnosis. PTSD, complex PTSD, and BPD can all involve:
- Emotional pain.
- Shame.
- Anger.
- Dissociation.
- Relationship difficulties.
- Feeling unsafe.
Despite the similarities, PTSD is centered on trauma symptoms such as flashbacks and a feeling of being constantly on edge. BPD, on the other hand, involves a wider pattern of:[7]
- Identity disturbance.
- Abandonment fears.
- Unstable relationships.
- Emotional storms.
Depression and anxiety can also mask BPD. This is mainly because the time when people seek help is often when they feel low or unable to cope.
Can You Have BPD and Another Diagnosis?
Yes, this is very common. You can have BPD and other mental health conditions alongside it. For example, a person may have ADHD-related impulsivity and BPD-related fear of abandonment. Or they may have trauma symptoms and BPD symptoms.
This is why a proper personality disorder assessment needs context and depth. Treatment then needs to be thoughtful and layered, rather than one-size-fits-all.
Mission Connection is here to help you or your loved one take the next steps towards an improved mental well-being.
What Is Involved in BPD Assessments?
BPD assessments can be a little tricky because a thorough BPD diagnosis ideally looks at a person’s patterns over time. By “patterns” we mean their:
- Habits within relationships.
- Emotional reactions.
- Understanding/view of their identity.
- Levels of impulsivity and distress.
The most common starting point is a clinical interview that uses DSM criteria. “DSM” stands for Diagnostic and Statistical Manual of Mental Disorders. In simple terms, the clinician asks about the main BPD symptoms.
A 2024 review explained that BPD is diagnosed when a pattern of symptoms begins in early adulthood and shows up across multiple areas of life.[1] The only shortfall here is that the method depends on the clinician’s skills, interview style, and manner.
There’s a chance, if the assessment focuses only on the current crisis, that BPD might be missed or mistaken for depression, anxiety, trauma, ADHD, or bipolar disorder. The pattern over time is the crucial differentiator for BPD.
If you’re considering a BPD assessment, you will likely encounter the following techniques:
Structured or Semi-Structured Interviews
Structured interviews, like the SCID personality disorder interview, are often used used in research and specialist clinics. But what is the SCID? It stands for “Structured Clinical Interview for DSM Disorders” and is an interview that guides the clinician through a set of questions. This assessment helps to make findings more consistent.
Semi-structured interviews for BPD are reasonably reliable; different interviewers are likely to reach similar conclusions when they use the assessment properly. However, research also notes that dimensional ratings, which measure symptom severity, are often more reliable than a simple “yes/no” BPD diagnosis.[8]
A factor that can lead to misdiagnosis is that someone could have serious BPD traits but fall just below the diagnostic threshold. In contrast, another may meet criteria during a crisis but look different once stabilized.
Self-Reporting Questionnaires
The obvious problem with self-reporting questionnaires is that we answer them ourselves. But why is this a problem? Because it can be difficult to answer questions about your own patterns or ways of being objectively. Plus, on a bad day, you might answer one way; on a good day, another.
Research has also found that people living with BPD may experience shame about the disorder, and this could lead to answering more “shyly” when it comes to signs and symptoms. Supporting this is a 2016 study that compared people with:
- BPD.
- Schizophrenia-spectrum disorders.
- Major depressive disorder.
- Bipolar disorder.
- Anxiety disorders.
Those with BPD showed the highest levels of self-stigma across reporting groups. Sadly, this suggests the label can become internalized, leaving people feeling defective, judged, or less worthy of care.[9]
Further, a questionnaire can also over-identify BPD if someone is in acute distress, depressed, traumatized, or very anxious when answering. For these reasons, results on self-assessment tools are best looked at as “this needs more assessment,” not “this proves BPD.”
The McLean Screening can be helpful as a first step reporting tool. The screening asks direct questions about common symptoms and can show whether someone may need a fuller personality disorder assessment. Further, the MSI-BPD could be useful for identifying people who may have BPD.[10]
Symptom Severity Scales and Follow-Up Over Time
Some tools assess how severe BPD symptoms are, rather than only asking whether BPD is present or absent. The Borderline Personality Disorder Severity Index, for example, has been found to be reliable and valid for measuring BPD severity and separate symptom areas.
This can be useful because BPD symptoms often change depending on the day, relationship events, substance use, and so on.[11] The critique, therefore, is that a single assessment can still capture only one window of time.
What BPD Treatments Can Help?
The good news is that BPD treatment has come a long way. Some evidence-based approaches that are used to treat borderline personality disorder (BPD) include:
- Dialectical behavior therapy, or DBT, was originally created to target BPD symptoms. It teaches emotional regulation, distress tolerance, mindfulness, and relationship skills.
- Mentalization-based therapy helps you slow down and better understand your own mind and other people’s minds.
- Schema therapy looks at belief systems and where they came from.
- Cognitive behavioral therapy (CBT)-based support helps with harsh thoughts and black-and-white thinking.
The right diagnosis should:
- Help you feel more understood.
- Explain things that previously felt random.
- Help you and your care team choose the right support.
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Get Professional Support for Accurate BPD Diagnoses With Mission Connection
If you recognize BPD symptoms in yourself, or if you feel unsure about a past diagnosis, Mission Connection can help you explore what is really going on. Our team offers compassionate, evidence-based care for people dealing with emotional dysregulation, relationship distress, trauma, and personality disorder symptoms. We go beyond traditional treatment and provide life-changing care.
We offer personalized outpatient treatment with psychotherapy as a first-line treatment for BPD, including approaches such as DBT, mentalization-based therapy, schema therapy, and other options that support emotional regulation and relationships.
In addition to standard outpatient care at our locations in California, Virginia, and Washington, we also offer more intensive levels of care, such as a partial hospitalization program (PHP) or an intensive outpatient program (IOP). We are in-network with most major insurance providers.
To find out more about our in-person, virtual telehealth, or hybrid program that combines in-person and virtual care, call us at 866-833-1822. You can also find out how we can support you in diagnosis and treatment by getting started online.
With the right assessment and the right treatment, life can become easier, and our team of experts would love to help you in your journey.
