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The Neuropsychotherapist
Bipolar disorders are in the differential for nearly every psychiatric presentation, from psychosis to depression to obsessive thinking to substance use. Three conditions present the most difficult differential diagnostic challenges relative to bipolar disorders because of the extensive overlap
in diagnostic criteria and overall phenomenology: borderline personality disorder, post-traumatic
stress disorder (PTSD), and attention deficit disorder (ADD). Worse, these conditions are commonly comorbid with bipolar disorders. Thus the diagnostic question is often not this, or that? but
this, that, or both?
The bottom lines of this article are:
admit the tremendous overlap in diagnostic criteria (resistance is futile)
focus on treatment options; it takes the pressure off of difficult diagnostic distinctions
think iterativelystart with low-risk options and adjust treatment as you go, keeping an
open mind about diagnoses that might be escaping you.
These principles will emerge in consideration of the three diagnoses, relative to bipolarity.
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Borderlinity,
not Borderline Personality Disorder
Borderline personality disorder (BPD)what an unfortunate choice of terms. We in psychiatry who are so
normal (ahem) shall deem a patient to have a personality disorder. Great public relations.
Nevertheless, there is a real phenomenon this label
is intended to describe. Contrary to Akiskal and others,
who suggested incorporating borderlinity into the bipolar spectrum (Akiskal et al., 2006), most recent data
suggest that borderlinity is a different phenomenon
than bipolarity (Ghaemi et al., 2014). The classic presentations of BPD (e.g., behaviors reflecting attachment
problems, from overvaluation/devaluation to abandonment distress) are clearly different from the classic forms
of Bipolar I (e.g., sustained euphoric mood, with pressured speech after two nights with no need for sleep).
But as clinicians well know, there are many variations of
borderlinity, often hesitatingly referred to in a diagnostic assessment as borderline traits.
Many authors have written about differentiating BPD
and bipolar disorders. For example, Joel Paris and Donald Black (2015) emphasize getting the right treatment
to the right patient, particularly psychotherapy for BPD
instead of medications. Even though I disagree with
their emphasis on DSM criteria to differentiate BPD
from bipolar disorders, I completely agree with their
emphasis on psychotherapy and avoidance of atypical
antipsychotics.
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for the patients misdiagnosed as bipolar was BPD (Zimmerman et al., 2010a). The Brown University team found that
positives on the Mood Disorders Questionnairea tool designed to detect bipolaritywere actually more likely to
warrant a borderline diagnosis than a bipolar diagnosis when the SCID was used as the gold standard.
Using the SCID as the arbiter of what illness the patient really carries is of course problematic: we lack lab
tests and other objective means of establishing the true diagnosis, and resort to the SCID instead. (Colleagues
in surgery and internal medicine sometimes offer sympathy over this, sometimes derision.) Think of how a SCID
is performed: a research assistantin this case two well-trained graduate studentsasks the patient a series of
questions, following a strict written guide. For this kind of work, some standard is required and the SCID is accepted in research circles as the best for this purpose. Indeed, this convention is so routine that it might appear, if
we do not pause to think about it, as though our field has accepted the idea that a graduate student following a
question guide is somehow closer to truth, whatever that is in this case, than clinicians who may have seen the
patient over many visits.
Nevertheless, the Brown University reports underscore what clinicians encounter all the time: BPD and bipolarity
swirl around one another. As one thoughtful review concluded, bipolar and borderline disorders are often indistinguishable given the core characteristics of emotional dysregulation and impulsivity that feature in both (Coulston
et al., 2012).
Table 4.1 lists DSM criteria for the two conditions, emphasizing this overlap. The borderline criteria are straight
from the DSM. The bipolar column lists well-accepted clinical features of bipolar disorders.
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The Neuropsychotherapist
Borderline
Bipolar
Stable/ unstable
Anger
Intense anger
Intense anger
Relationships
Unstable relationships
Suicidality
Impulsivity
Attachment
Symptom duration
Hours to a day
Because of the extensive overlap, differentiating these conditions by DSM criteria places tremendous weight on
the last two domains. But symptom duration for hypomanic symptoms is strongly debated. For example, Parker
and colleagues found that the four-day requirement excluded 315 of 501 patients (63 percent) who otherwise met
Bipolar II criteria (Parker et al., 2014).Those with briefer hypomanic symptoms did not differ from those with standard hypomania duration in age of onset of symptoms or family history of bipolar disorder (suggesting that the two
groups did not differ biologically, despite one meeting DSM criteria for Bipolar II and the other not).
If one discards the duration criterion as unsupported by research data, differentiating bipolar from borderline
comes down to the attachment criteria alone. Experienced clinicians can recognize the attachment disturbance
within minutes in a first interview: the transference energy is often intense, early, and trends toward rapidly
overvaluing or devaluing providers. I would not expect structured interviews by graduate students to capture this
phenomenon, and thus do not find the studies by Zimmerman et al. compelling, regarding their emphasis on borderlinity over bipolarity, given the overlap between all the remaining criteria (Zimmerman, 2015).
The point here is not to declare the two conditions indistinguishable but to emphasize that DSM criteria alone do
not discriminate them well. Fortunately, however, other features not found in the DSM (nor the SCID) do differentiate the two conditions somewhat (see Table 4.2).
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Domain
Borderline
Bipolar
Age of onset
Childhood; disturbances should be noted even before puberty and strongly shortly thereafter
Family history
Episode precipitants
Recognize the Bipolarity Index elements here? (They are italicized in the table.) Their ability to help differentiate borderlinity from bipolarity underscores their importance in initial histories. None of these three factors are
as powerful as the attachment factor, in my opinion, but they can be useful, particularly when findings align, for
example, childhood onset, family history negative for bipolar disorder, and episodes commonly associated with
interpersonal events are all found together. Unfortunately, trauma is so prevalent in both borderline and bipolar
conditions, PTSD is often a given. The diagnostic question is whether there is bipolarity underneath that often more
obvious trauma. Lets look at PTSD in the same way, comparing diagnostic criteria with bipolar disorder. Then will
come an examination of the impact of all this overlap on treatment choices.
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PTSD
Bipolar
Borderline
Stable/ unstable
Anger
Intense anger
Intense anger
Intense anger
Relationships
Unstable relationships
Unstable relationships
Suicidality
Suicide risk
Impulsivity
Attachment
Onset
After trauma
Interpersonal
Symptom
duration
Hours to a day
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The Neuropsychotherapist
a given childs temperament create the myriad combinations we see clinically, where establishing a cutoff
for the presence or absence of BPD is difficult. Just how
much avoidance of abandonment constitutes frantic,
for example?
So we have three continua, when the mood spectrum
is added to the borderline spectrum and the trauma
spectrum. Not only do their criteria overlap, these three
conditions can cause or adversely affect the others.
Indeed, by their nature, they are likely to do so. For example, in a family with a parent with poorly controlled
Bipolar I, the children carry genetic risk for bipolar disorder but are more likely than peers to experience physical and sexual trauma and more likely to experience an
invalidating emotional environment. No wonder people
are struggling to distinguish these conditions. They can
be so woven together that teasing them apart is clinically impossible. What to do?
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Again, the point is to illustrate the overlap between these conditions. If there is an obvious trauma with an obvious date of occurrence, that helps; but of course, the trauma is often an entire childhoods experience, and then
there is no specific trauma date nor easy pre/post comparison possible.
Hopefully these tables have made clear the problem with which clinicians are all too familiar: these three conditions are sometimes extremely difficult to differentiate. Moreover, each is itself a spectrum.
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The Neuropsychotherapist
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having bipolar disorder. If the emphasis is therefore on mood stabilizers and avoiding antidepressants, this will not lead pharmacotherapy
in a wrong direction. It may not help much. Too
vigorous an attempt to control symptoms with
medications could expose the patient to undue
side effects and risks. Hopefully the clinician will
remember the medical school dictum: when
your treatment is not working, question your diagnosis. Dont cling to a presumption of bipolar disorder; keep thinking and reevaluating. As
treatment proceeds, the patient should be understanding more about bipolarity and become
progressively more able to assist with the differential diagnosis (including contradicting an
inaccurate bipolar interpretation).
An inaccurate bipolar diagnosis, where borderlinity would have been more accurate, will
not lead to wrong medicines, although it can
lead to many medication trials with little
benefit and toward medications with more
risks than antidepressants.
Again, I emphasize: if the patient
has tempestuous interpersonal relationships, impulsive self-harm, and
dramatic mood swings, a good clinician will keep borderlinity high in
the differential, including in ongoing diagnostic revisions. Perhaps
even more important, if chronic
emptiness and abandonment fear
are prominent in the history, regardless of how much bipolarity
was detected, a borderline-focused psychotherapy should be
strongly considered, independent of medication strategy. Thus
a spectrum approach to bipolarity does not preclude good clinical
approaches to borderlinity of any
degree (assuming psychotherapy re-
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The Neuropsychotherapist
Antidepressants. Here we come to the single element in treatment that goes in two opposite directions
depending on the diagnosis. With BPD, antidepressants
may be tried and may help somewhat. But in bipolar disorders, antidepressants can cause a worsening in several
ways (discussed in Chapter 12): not just inducing a manic
episode but more perniciously by inducing mixed states
with agitation, irritability, and suicidal ideation. Perhaps
even worse, as described in Chapter 12, antidepressants
canaccording to someinduce a long course of subtle worsening that can take years to detect and many
months to reverse. In a patient with significant borderlinity, a persistent dysphoria is likely to be attributed to
the illness (or should I say to the patient?) rather than
to an antidepressant. When the system of care shuffles
patients from one provider to another, the opportunity
to detect that antidepressants might be contributing to
(rather than relieving) suffering is often lost. There is no
alternative but to keep wondering if the antidepressant
might be part of the problem. This is difficult when the
patient is significantly depressedhow can one consider removing a medication whose very name suggests it
is the solution? On the other hand, when the patient has
been experiencing severe depressive symptoms, often
for years, while taking an antidepressant, one can consider the possibility that it is ineffective at a minimum.
At that point, strong consideration should be given to
a trial of antidepressant discontinuation (guidelines for
the process in Chapter 12).
Likewise, before an antidepressant is used, it is crucialprimum non nocereto make sure the patient does
not have significant bipolarity, perhaps underneath BPD
(knowing that the two are frequent co-travelers). If the
patient is already on an antidepressant and experiencing agitation, irritability, and suicidal ideation, one must
consider the possibility that the antidepressant is the
culprit (to some degree), not just the borderlinity.
All the arguments above apply in PTSD as well:
The differential is difficult, it is frequently hard to
be certain.
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