Differential Diagnosis - bipolar - borderline

[Vasa Lisa]

Greetings -
This is my first foray over here to the "big boards" - I tend to hang out with the MA level folks. If this isn't the place to ask - let me know - but I sure would appreciate either some personal reflections, literature referrals, or just plain mentoring. I am still working toward my 4000 hours for my LPC - (licensed professional counselor) and at times feel pretty green. I feel pretty nervous and intimidated to be asking for help here because I am not sure I can articulate my question properly.

So here is something that has come up over the last few months. I work primarily with women in small agency and private practice type settings. I am seeing several clients who have been referred for therapy who see a psychiatrist for medication management. Often they come with a dx of Bipolar II and are on various combinations of medications.

As I work with these clients, I get the sense that they meet criteria for borderline personality disorder. Many of them are keenly sensitive, emotionally disregulated, have difficult forming secure attachments, struggle in interpersonal relationships - especially with men, and suffer from a chronic emptiness and lack of sense of self. And they seem to be powerless in the face of their impulses.

We start with the relationship between therapist and client and then I weave in DBT skills work even if the dx is bipolar. The fundamental skills training of DBT seems to be effective in helping them stabilize enough to do talk therapy.

With Bipolar II - the 4 day period of hypomania - is something I don't see and they don't self-report. I can imagine that they meet the criteria for an episode - but not necessarily for a solid 4 days. So that's what makes me wonder how they come in with that dx. I see the volatility - but it seems more Axis II than Axis I. I can imagine that in the future these criteria will be more of a continuum instead of a specific cut off.

I know this is complex and there is no "answer" yet I would appreciate some additional direction or your experiences with dx clients with one or the other or both of these conditions.

The differential dx seems a lot easier when considered in the abstract. Working with real clients over the last few years has been challenging, exciting, and really stretched me to think in new ways. Guidance would be welcome and appreciated.

Thank you,

Vasa Lisa

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[erg923]

Greetings -
This is my first foray over here to the "big boards" - I tend to hang out with the MA level folks. If this isn't the place to ask - let me know - but I sure would appreciate either some personal reflections, literature referrals, or just plain mentoring. I am still working toward my 4000 hours for my LPC - (licensed professional counselor) and at times feel pretty green. I feel pretty nervous and intimidated to be asking for help here because I am not sure I can articulate my question properly.

So here is something that has come up over the last few months. I work primarily with women in small agency and private practice type settings. I am seeing several clients who have been referred for therapy who see a psychiatrist for medication management. Often they come with a dx of Bipolar II and are on various combinations of medications.

As I work with these clients, I get the sense that they meet criteria for borderline personality disorder. Many of them are keenly sensitive, emotionally disregulated, have difficult forming secure attachments, struggle in interpersonal relationships - especially with men, and suffer from a chronic emptiness and lack of sense of self. And they seem to be powerless in the face of their impulses.

We start with the relationship between therapist and client and then I weave in DBT skills work even if the dx is bipolar. The fundamental skills training of DBT seems to be effective in helping them stabilize enough to do talk therapy.

With Bipolar II - the 4 day period of hypomania - is something I don't see and they don't self-report. I can imagine that they meet the criteria for an episode - but not necessarily for a solid 4 days. So that's what makes me wonder how they come in with that dx. I see the volatility - but it seems more Axis II than Axis I. I can imagine that in the future these criteria will be more of a continuum instead of a specific cut off.

I know this is complex and there is no "answer" yet I would appreciate some additional direction or your experiences with dx clients with one or the other or both of these conditions.

The differential dx seems a lot easier when considered in the abstract. Working with real clients over the last few years has been challenging, exciting, and really stretched me to think in new ways. Guidance would be welcome and appreciated.

Thank you,

Vasa Lisa

Although a structured diagnostic interview is really only as good as the clinical judgment of the clinician using it, when starting out, they are a good way to learn how to word the inquiries.

First, I would make sure you know the disorders themselves inside and out. Not only the DSM criteria, but also how they present. Next, I would look into using structured interviews such as the SADs should i suspect manic symptoms.

 

[IAmAUser]

.

 

[toothless rufus]

you are wise beyond your years
the number of bull**** bipolar diagnoses for borderline patients is staggering
keep doing what you're doing
(imho)

I understand that this is may be a trend related billing. For example not being able to bill for inpatient admission with a Dx of borderline PD when they would in fact benefit from inpatient stay, or the physician is reluctant to just DC and follow outpt 2/2 worries about impulsivity and a SA, so slaps on bipolar to keep them there. Or that for the unscrupulous you can just in general bill at a higher level for an Axis I.

Also, there seems to be a component of applying criteria laxly within the concept of a "bipolar spectrum." It makes perfect sense to me that there is indeed a spectrum, but c'mon: a lot of these people are decidedly not bipolar.

In any case it seems to me that the Dx is most definitely being applied too easily in many cases.

 

[nitemagi]

It's overdiagnosed. Most definitely.

I trained under Akiskal, a well known psychiatrist and researcher who pushed the idea that there are many subtypes of bipolar (such as bipolar III, hyperthymic temperament), and that borderline PD is also a subtype of bipolar. His argument is that borderline pt's feel some improvement on mood stabalizers. Which I think is flawed logic.

Love Akiskal though. One of the more fun lecturers/mentors I've had.

 

[BobA]

I think another reason Bipolar is over diagnosed is that patients often reject the Borderline Diagnosis whereas they accept the Bipolar Diagnosis.

Many psychiatrists shy away from the fight that can ensue after a Borderline Diagnosis.

This is a real shame as many patients whose BPD is misdiagnosed as BPAD don't focus their treatment on psychotherapy as they should and place a relative overemphasis on medications.

 

[xthine]

^I've been seeing this frequently in the outpatient clinic... BPD patients who would seem to rather hang their hats on a Bipolar Disorder diagnosis and ony choose to take medications versus an Axis II and DBT. The hand out on BPD that I hand to them often goes unnoticed. Of course by the time they see us more often than not they already carry the BD diagnosis from another provider and are already on a slew of meds...mood stabilizers, SSRIs, benzodiazepines, atypical antipsychotics etc.

 

[Chrismander]

I understand that this is may be a trend related billing. For example not being able to bill for inpatient admission with a Dx of borderline PD when they would in fact benefit from inpatient stay, or the physician is reluctant to just DC and follow outpt 2/2 worries about impulsivity and a SA, so slaps on bipolar to keep them there. Or that for the unscrupulous you can just in general bill at a higher level for an Axis I.
.

Can you provide any evidence to back this up? This claim is batted around a lot, sounded plausible (and outrageous) to me as a wet-behind the ears intern, but this is really patently unture.

I'll be joining a large multispeciality group when i graduate in June and am compensated on an RVU model. I get 0.95 RVU per 90862 med check regardless of diagnosis. If I choose to do psychotherapy (discouraged) with any patients I'd be compensated at the corresponding RVU for the psychotherapy code. The psychotherapy code would pay the same whether I performed psychotherapy on someone I coded as bipolar or someone I coded as borderline. Yeah you make less doing psychotherapy on someone than doing more med checks in the same time frame, but it has nothing to do with which code you choose to assign to them.

So please find me evidence that people code bipolar to make more money. I'd love to hear it.

 

[OldPsychDoc]

To the OP--THANK YOU for noticing. As with all of my esteemed colleagues above, we see the label of Bipolar applied sloppily, often to justify provision of inappropriate care, or to mitigate stigma for the patient. (I might cynically suggest that pharmaceutical marketing and direct-to-consumer advertising has also played a part since the major second-generation antipsychotics have indications for bipolar disorder.) It is often easier to "medicalize" mood swings, emotional distress, and impulsivity than it is to educate about a chronic and difficult diagnosis. (Kind of like calling obesity a "glandular problem" instead of addressing it as a complex and chronic behavioral issue.)

So when that patient comes in complaining about "my bipolar" of which the main symptom is "I can love you one minute and want to kill you the next", it is definitely time to do some psychoeducation and start talking about DBT and stress management, not reviewing a list of medications and side effects.

 

[OldPsychDoc]

Can you provide any evidence to back this up? This claim is batted around a lot, sounded plausible (and outrageous) to me as a wet-behind the ears intern, but this is really patently unture.

I'll be joining a large multispeciality group when i graduate in June and am compensated on an RVU model. I get 0.95 RVU per 90862 med check regardless of diagnosis. If I choose to do psychotherapy (discouraged) with any patients I'd be compensated at the corresponding RVU for the psychotherapy code. The psychotherapy code would pay the same whether I performed psychotherapy on someone I coded as bipolar or someone I coded as borderline. Yeah you make less doing psychotherapy on someone than doing more med checks in the same time frame, but it has nothing to do with which code you choose to assign to them.

So please find me evidence that people code bipolar to make more money. I'd love to hear it.

Agree with you, this is primarily accepted mythology. We've had no problems (well excepting possibly a few Byzantine private insurers) getting admissions approved for suicidal ideation whether or not the primary dx is 296.xx, 296.5x, 296.89, 311, or the infamous 301.83. And as you say, outpatient billing is the same. And I'll add, at least in our state, Borderline PD qualifies one as having Severe and Persistent Mental Illness, qualifying one for case management services, etc, just as for Schizophrenia, "real" Bipolar, and MDD.

 

[Vasa Lisa]

erg923 - Thanks for the reply and yes - structured interviews can be a way in - but I haven't found my mix yet of establishing rapport while also sticking to a structured or semi-structured interview - working on it though! I have used something called the HCL-32. Are you familiar with it?

Wasn't familiar with SADs - but it looks like a robust resource - thanks. And yes - definitely in that stage of learning the DSM inside and out and also the reality of clinical presentation inside and out. Thankfully I have exceptional supervision and we still audio and video tape for supervision which is invaluable.

IAmAUser - I appreciate the validation and support... but in my sixth decade being wise for my years takes on a whole new meaning

toothless rufus - What you say about billing makes a lot of sense. Some of my clients have had hospitilzations while still on their parent's health insurance - and did benefit from being in patient for stabilization. I suspect many of these clients would benefit from a more intensive partial hospitilazation program - but alas - the economics of mental health care means that level of care isn't economically viable - which is why god created LPC residents. We need the direct hours and 50 minutes a week, once a week with me isn't enough but it is better than no tx.

nitemagi - Thanks for chiming in - and reminding me of the research on temperment. Sometimes I get lost in the 50 minute hour and lose the forest for the trees. Some of my trees can be prickly at times.

BobA - yes! I have begun to suspect the same thing. And I find myself the one doing some psychoeducation about PD as a logical response to the "there and then" of childhood and then appealing to the part of the client who is an adult in the "here and now" who can collaborate in tx to gain skills to improve their relationships with others. Some of my clients are relieved when I "name" their experience and tell them there is tx and hope for what they are experiencing. And I can bet you can imagine how other clients respond

I love this work! Endlessly fascinating.

Vasa Lisa

 

[toothless rufus]

Can you provide any evidence to back this up? This claim is batted around a lot, sounded plausible (and outrageous) to me as a wet-behind the ears intern, but this is really patently unture.

I'll be joining a large multispeciality group when i graduate in June and am compensated on an RVU model. I get 0.95 RVU per 90862 med check regardless of diagnosis. If I choose to do psychotherapy (discouraged) with any patients I'd be compensated at the corresponding RVU for the psychotherapy code. The psychotherapy code would pay the same whether I performed psychotherapy on someone I coded as bipolar or someone I coded as borderline. Yeah you make less doing psychotherapy on someone than doing more med checks in the same time frame, but it has nothing to do with which code you choose to assign to them.

So please find me evidence that people code bipolar to make more money. I'd love to hear it.

Just what I've heard. Glad to know from someone with experience that its not true.

 

[dl2dp2]

I think when you have a difficult differential dx, the safest way to do it is go back to measurement based care/evidence based medicine and just go with DSM/psychometric instruments. Go to the differential diagnosis table in the DSM. Does the patient satisfy criteria for bipolar. Does the patient satisfy BPD criteria. Does she satisfy both? Remember all the medication trials for bipolar and all the DBT/CBT trials for BPD are based one measurements and DSM criteria. Not only do you get some traction using existing criteria in terms of diagnosis, you also get some estimate of the effect of your chosen therapeutics based on literature. i.e. what's the percentage of patients improving on lithium who meet the criteria for bipolar i? what's the percentage on 1 year of DBT? There are answers all in the literature based on DSM (or some other psychometric instrument.)

When clinicians cling to a diagnosis without the precise metric of psychometrics, that's where people get "overdiagnosed". Most of the existing commonly used criteria have high interrater reliability. How to do ensure that your way of understanding what BPD phenomenology is the same as the DBT clinical trialists'? No other way except through psychometric instruments.

The problem of DSM isn't that it's wrong. It's that it's too much of a lumper--it's imprecise. Of course, supposedly DSM V is attempting to address some of that.

 

[splik]

Previous posts have addressed the overdiagnosis of bipolar disorder. there has been a big push from bipolar experts to diagnose bipolar over borderline based either on the belief they are one a continuum (akiskal) or that missing a diagnosis of borderline is inconsequential, missing a diagnosis of bipolar fatal (goodwin). Both are flawed.

I will make the point that there is also a strong comorbidity between the two - approaching 50%. It is not an either/or, frequently patients struggle with characterological problems and a significant mood disorder.

Diagnoses have some utility and if we take them too seriously can guide treatment (e.g. antidepressant monotherapy for major depression, mood stabilizers for bipolar, DBT/mentalization based treatment for borderline), but in reality the best psychiatrists don't let a diagnosis overshadow the problems and symptoms that patients have. People don't come to us with borderline or bipolar - they come with depressed mood, suicidal ideation, irritability, relationship crises, hallucinations, disorganized behavior etc. And we work with those.

I think there is a lot of scepticism about bipolar diagnoses. I certainly follow the maxim 'never believe a diagnosis of bipolar disorder you haven't made yourself'. That said, it is important to remember that mood disorders are cyclical in nature - the number of times I have heard attendings say 'that patient doesn't have a bipolar bone in her body' and be completely wrong is countless. Just because a patient isn't floridly manic, severly depressed or whatever when you see them, just because the primary problem when you see them is fear of abandoment or alexithyma, just because everything about them screams borderline, doesn't mean that they don't have bipolar.

 

[nitemagi]

Previous posts have addressed the overdiagnosis of bipolar disorder. there has been a big push from bipolar experts to diagnose bipolar over borderline based either on the belief they are one a continuum (akiskal) or that missing a diagnosis of borderline is inconsequential, missing a diagnosis of bipolar fatal (goodwin). Both are flawed.

I will make the point that there is also a strong comorbidity between the two - approaching 50%. It is not an either/or, frequently patients struggle with characterological problems and a significant mood disorder.

Diagnoses have some utility and if we take them too seriously can guide treatment (e.g. antidepressant monotherapy for major depression, mood stabilizers for bipolar, DBT/mentalization based treatment for borderline), but in reality the best psychiatrists don't let a diagnosis overshadow the problems and symptoms that patients have. People don't come to us with borderline or bipolar - they come with depressed mood, suicidal ideation, irritability, relationship crises, hallucinations, disorganized behavior etc. And we work with those.

I think there is a lot of scepticism about bipolar diagnoses. I certainly follow the maxim 'never believe a diagnosis of bipolar disorder you haven't made yourself'. That said, it is important to remember that mood disorders are cyclical in nature - the number of times I have heard attendings say 'that patient doesn't have a bipolar bone in her body' and be completely wrong is countless. Just because a patient isn't floridly manic, severly depressed or whatever when you see them, just because the primary problem when you see them is fear of abandoment or alexithyma, just because everything about them screams borderline, doesn't mean that they don't have bipolar.

Nice post, Splik. I would add to be mindful of the slippery slope of symptom focused management. I do it plenty myself, but with an eye that there can easily reach a point with polypharmacy where we're chasing transient sx's, and ultimately doing more harm than good. Have to keep the big picture in mind, and recognize that if there is a personality d/o in the picture (or just poor coping strategies or hypersensitivity to any mild pertubation) that absolute elimination of sx's isn't going to be realistic, and skills training/therapy/mindfulness and acceptance needs to part of the picture.

 

[Suedehead]

I will make the point that there is also a strong comorbidity between the two - approaching 50%. It is not an either/or, frequently patients struggle with characterological problems and a significant mood disorder.

Cormorbidity is a tough subject for me. You mention comorbidity above. Are we a talking about a comorbidity between a personality disorder and a PRIMARY mood disorder? By 'primary,' I mean a dysfunction in the brain's natural ability to regulate mood, suggesting something is truly haywire, a disease? Or are we talking about a SECONDARY mood disorder that manifests similarly but suggests an external insult (drugs, life stressor, chronic abuse, etc, etc).

If you're talking about a secondary mood disorder then the 'comorbidity' is rather better explained by the external insults (and better addressed by addressing the external insults, ie therapy and maybe a med for support, etc.). I wonder if it's misleading to suggest there are two problems here...

Our field trips me out, really. How to name these grand complexities is hard enough.... and then we have to come up with treatment plans.....

 

[BobA]

Cormorbidity is a tough subject for me. You mention comorbidity above. Are we a talking about a comorbidity between a personality disorder and a PRIMARY mood disorder? By 'primary,' I mean a dysfunction in the brain's natural ability to regulate mood, suggesting something is truly haywire, a disease? Or are we talking about a SECONDARY mood disorder that manifests similarly but suggests an external insult (drugs, life stressor, chronic abuse, etc, etc).

If you're talking about a secondary mood disorder then the 'comorbidity' is rather better explained by the external insults (and better addressed by addressing the external insults, ie therapy and maybe a med for support, etc.). I wonder if it's misleading to suggest there are two problems here...

Our field trips me out, really. How to name these grand complexities is hard enough.... and then we have to come up with treatment plans.....

One of the problems I encounter in assessing co morbidity of PD and a mood disorder is recall bias. If I ask someone with a symptomatic PD how their mood has been for the past two weeks of course everything has been terrible, etc. Recall bias makes assessing mood disorders in folks with a known PD very tricky business. Collateral is necessary and often it's difficult/impossible to obtain. Ideally we'd get to know our patients over time, but this doesn't happen too often these days (esp in the inpatient setting).

On the other hand, many with a primary mood disorder can have borderline personality organization that shows only when the mood disorder is symptomatic.

 

[PETRAN]

Cormorbidity is a tough subject for me. You mention comorbidity above. Are we a talking about a comorbidity between a personality disorder and a PRIMARY mood disorder? By 'primary,' I mean a dysfunction in the brain's natural ability to regulate mood, suggesting something is truly haywire, a disease? Or are we talking about a SECONDARY mood disorder that manifests similarly but suggests an external insult (drugs, life stressor, chronic abuse, etc, etc).

If you're talking about a secondary mood disorder then the 'comorbidity' is rather better explained by the external insults (and better addressed by addressing the external insults, ie therapy and maybe a med for support, etc.). I wonder if it's misleading to suggest there are two problems here...

Our field trips me out, really. How to name these grand complexities is hard enough.... and then we have to come up with treatment plans.....

How can you differentiate between the two? I think that some people used to differentiate between a more "endogenous" and a more "reactive" depression but how can you tell if there is trully a difference? In the end of the day, both endogenous biological factors (genetic influences) and/or severe life stressors (or even childhood stress or attachment issues which could be accompanied by epigenetic changes or abnormal synaptic plasticity) can lead to a "last common pathway" mainfesting in the same abnormal brain patterns (e.g. amygdala/HPA overactivation and frontal hypo-activation). So, in any case, both pharma- and psycho- therapy would be the optimal thing to do. Huh?

As for co-morbidity, i think the whole DSM "discrete-diagnosis" is misleading. Some manifestations can get associated and connected by similar/common underlying dys-functions IMO. I mean, if you view "depression" as a kind of an emotional chronic pain or chronic fever it explains why it is so common as a co-morbidity to so many conditions and circumstances.

 

[Suedehead]

How can you differentiate between the two? I think that some people used to differentiate between a more "endogenous" and a more "reactive" depression but how can you tell if there is trully a difference? In the end of the day, both endogenous biological factors (genetic influences) and/or severe life stressors (or even childhood stress or attachment issues which could be accompanied by epigenetic changes or abnormal synaptic plasticity) can lead to a "last common pathway" mainfesting in the same abnormal brain patterns (e.g. amygdala/HPA overactivation and frontal hypo-activation). So, in any case, both pharma- and psycho- therapy would be the optimal thing to do.

that's a little like saying "whether or not this fever is caused by a bacteria or a virus it still needs to be treated." and i'm ok with that because fevers (here translated as 'mood disorders') can be deadly, right?

But this analogy fits my initial concern... we need to treat mood disorders, regardless of their origin, but to TRULY treat them we need to be aware of their etiology or essence. We cannot be satisfied with treating a fever if haven't addressed the infection.

My original concern, again, was this.... sure there are primary mood disorders, just like there are idiopathic/primary fevers. I'd put bipolar type I here, a nasty scary disease. but MOST mood disorders will be seocndary and better conceptualized and addressed (and named) from their likely etiology/essence. Treat the borderline personality and the fever should get better. I think it's wrong to suggest a true comorbidty - that would be like saying 'this patient has a bacterial infection AND an idiopathic fever." I'm sure that happens, but come on, right?

I know I'm parsing words here, but this sort of understanding is important to me.

 

[PETRAN]

that's a little like saying "whether or not this fever is caused by a bacteria or a virus it still needs to be treated." and i'm ok with that because fevers (here translated as 'mood disorders') can be deadly, right?

But this analogy fits my initial concern... we need to treat mood disorders, regardless of their origin, but to TRULY treat them we need to be aware of their etiology or essence. We cannot be satisfied with treating a fever if haven't addressed the infection.

My original concern, again, was this.... sure there are primary mood disorders, just like there are idiopathic/primary fevers. I'd put bipolar type I here, a nasty scary disease. but MOST mood disorders will be seocndary and better conceptualized and addressed (and named) from their likely etiology/essence. Treat the borderline personality and the fever should get better. I think it's wrong to suggest a true comorbidty - that would be like saying 'this patient has a bacterial infection AND an idiopathic fever." I'm sure that happens, but come on, right?

I know I'm parsing words here, but this sort of understanding is important to me.

Yes, i'am with you that the concern (depression, fever) must be addressed, but in contrast to fever (i guess?), in most cases the precise aetiology of depression is still unkown (unless it is secondary to some clear-cut endocrine condition or medical proble etc.-and even then you have to consider if the medical problem is still the only cause).

The fundamental problem comes when you consider depression in terms of a seperate "disease" when exactly it would be silly to think of fever as a "seperate disease" from the factors that cause it. I mean "primary depression" (if it exists-in a pure-form) still has some unknown biological aetiology which can be a combination of factors and muptiple aetiologies such as combinations of various genetic expressions, events in the uterus etc. So, it would be better to have a "theoretical form" of the underlying factors of the disorder, such us "amygdala/HPA overactivity/OFC-underactivity caused by genes x, y, z and possible uterine exposure to x substance. Currently reinforced by y psychological mechanisms and expressed with chronic depressed mood, generalized anhedonia,generalized anxiety when socializing with others and sometimes suicidal ideation".

When early life events and critical periods come to the picture with synaptic plasticity and epigenetics, it poses a question if such a "pure primary endogenous depression"exists, and if it is of any practical meaning to search for the hypothetical biological "factors" that could have led to its' chronicity.

In any case, i think that most depression could be (at least partly) sustained by some-kind of dysfunctional way of dealing with things and most depression would probably get better if those ways of dealing with things get addressed. It could be bordeline social sensitivity, it could be ways of dealing with failure, it could be interpersonal stress regulation, it coule be a lot of things.

 

[dl2dp2]

In any case, i think that most depression could be (at least partly) sustained by some-kind of dysfunctional way of dealing with things and most depression would probably get better if those ways of dealing with things get addressed. It could be bordeline social sensitivity, it could be ways of dealing with failure, it could be interpersonal stress regulation, it coule be a lot of things.

While in theory the way you think is useful, in practice it isn't. I'll tell you why. The most obvious notable examples are substance induced mood disorders. In large-ish VA samples, they noted that people who are heavy drinkers are also often depressed, and simply stop them from drinking dramatically improved depression. A couple of other trials then studied if adding antidepressants make any difference in terms of alcoholics who are also depressed. There's no consistent effect.

In terms of what you said, is there any evidence that in large psychotherapy trials, the actual stressor (as you said in the previously paragraph) of the depressed patient affect outcome? Or consistent effect of the modality per se affecting outcome? The answer is no.

The reality is, the efficacy of a particular therapy is not demonstrated UNTIL it's clearly delineated in clinical trials. Inferring efficacy based on putative mechanism or historical data--or your clinical judgement--is very dangerous. Things don't often make sense, and the only right way to do things is let the evidence speak for itself. This is why when things get confusing it's especially important to go back to literature, consult experts and rely on existing DSM/guidelines as much as possible.

 

[whopper]

I'm experiencing an interesting forensic phenomenon. In lower income, crime-ridden neighborhoods, a number of children are being diagnosed with bipolar disorder due to well-meaning (but perhaps damaging) social workers, asking that the kid be seen by a psychiatrist who misdiagnoses bipolar disorder. By getting that diagnosis, this kid, who often times has a single parent (usually not doing anything close to real parenting), a bad behavioral record in school, and may need some type of help is offered more of it.

Okay fine, so what's the problem other than that this is medical fraud, here's how it's damaging...now the kid gets a round of meds that likely will not do anything other than cause side effects, the kid thinks his problem is due to something that can only be controlled with meds and he doesn't see his own conduct disorder problems as something he has responsibility over, he gets a disability check further rewarding his desire to be diagnosed, and then as an adult commits a crime thinking he is not at fault because of mental illness.

Then as an adult, they come over to my forensic unit because they refused to cooperate with the court and a doctor recommends they be found incompetent to stand trial due to the failure to cooperate and the history of mental illness. The problem here is that doctors asked to do evaluations in these types of situations only have about 1 hour to see the defendant and operate on an notion that if the person is malingering, the hospital forensic people need to figure it out because they cannot in one hour. The kid, now an adult, is determined to get a not guilty by reason of insanity defense when he's not really mentally ill at all in an Axis I sense other than drug abuse, and is determined to stay misdiagnosed. I of course will not further that diagnosis after taking them off of meds, seeing no signs of psychosis or mania for months, and malingering testing highly suggests they are exaggerating or faking mental illness.

This phenomenon is actually more common than most people think. Mental health providers need to drop this notion that they need to diagnose even if they do not believe in the diagnosis because of some misguided attempt to give the person help that in reality will not help them and stick to a real diagnosis. If a kid is problematic, the doctor may be doing more damage to the kid by misdiagnosing them.

 

[Vasa Lisa]

Lots for me to digest here -

OldPsychDoc – Not sure if you are “old” but your comments echo the experience I have collaborating with older psychiatrists – ones who were steeped in psychotherapy training before there were the meds to manage everything. There is a wisdom in this non rx approach to client’s difficulties that gets buried under the advertising blitz that assaults our clients. Sometimes life hurts and sometimes we have to advocate for ourselves and sometimes we feel bad because we are behaving badly and honestly therapy is work with no quick resolution.

I am grateful for medication and have seen the dramatic awakening that clients experience when they are on an effective medication. And I have seen clients so medicated that they are up or down depending on if they just took their Adderall that helps them “focus” because of their ADHD (who are also dx with Bipolar II) or if they just took their Xanax to manage their panic attack. And this is on top of various mood stabilizers, antipsychotics, and anti-depressants. Because I am new to this work – I am still in the naïve phase at times with the imperfection of the process of providing mental health services – and also determined to be an effective therapist.

sluox - I get what you say about psychometrics - and going back to basics - and that the DSM is imprecise.

splik – Yes – that makes sense – both/and not either/or. Axis I and Axis II but the dx that comes to me is Axis I only –hence my wondering. And you are absolutely right – people come when they are overwhelmed by life stressors and in pain and that is what we work with – and why I chose to become a counselor instead of some other type of mental health care provider. I will keep in mind the time frame also – that just because I am not seeing the mania/hypomania in the several months of tx doesn’t mean it isn’t there.

suedehead – I am right there with you on the treatment plans! I have a love/hate relationship with them – they keep the scientific side of me engaged in the process of where we have been and where we are going – and that is helpful. I always write a hypothesis/wondering at the end of my progress notes to remind me of that aspect of therapy. And as a new clinician treatment plans require a rigor that helps me articulate myself.

On the other hand, many with a primary mood disorder can have borderline personality organization that shows only when the mood disorder is symptomatic.

I need to ponder this.

whopper – yes – I see this same thing in the schools – children who receive a dx get additional services – increase the severity – increase the services – and then they graduate and the world offers them a different set of rules and chaos and mayhem ensues.

I appreciate all the responses – and it has helped me articulate my question. Why would a psychiatrist dx a client with bipolar II, see the client 1 - 4 times per year for 15 minutes to tweak meds and then the client comes to me (usually on her own - sometimes as a referral) for talk therapy and during these weekly sessions I get the a distinct impression that the client has axis II issues that have never been addressed to her. And then I am the one to begin to open that conversation with her and wonder with her about the rx and talking to her doctor about what exactly they are prescribed to treat.
I have a disturbing number of clients who are dependent on various benzodiazepine and I have read a lot here on the pros and cons of prescribing this medication. I can see it as being essential for some clients for stabilization and then I wonder if it doesn't become a crutch to protect people from the existential vicissitudes of life.

As an LPC resident - at first I thought - yikes! who am I to question the diagnosing and prescribing dr/psychiatrist? Yet when I have been involved in collaborative care and been able to consult with the psychiatrist - it is much better for the client and for me the clinician who will be the one sitting with her hour after hour, week after week, year after year providing the "corrective emotional experience." It is slow, patient work, and perhaps one day I will get burned out or tire of it - but for me for now - I am still in that eager, excited learning phase of wanting to both understand on a rational/intellectual/thinking level while also trusting my feeling/sensing/intuition.

Vasa Lisa

 

[PETRAN]

While in theory the way you think is useful, in practice it isn't. I'll tell you why. The most obvious notable examples are substance induced mood disorders. In large-ish VA samples, they noted that people who are heavy drinkers are also often depressed, and simply stop them from drinking dramatically improved depression. A couple of other trials then studied if adding antidepressants make any difference in terms of alcoholics who are also depressed. There's no consistent effect.

In terms of what you said, is there any evidence that in large psychotherapy trials, the actual stressor (as you said in the previously paragraph) of the depressed patient affect outcome? Or consistent effect of the modality per se affecting outcome? The answer is no.

The reality is, the efficacy of a particular therapy is not demonstrated UNTIL it's clearly delineated in clinical trials. Inferring efficacy based on putative mechanism or historical data--or your clinical judgement--is very dangerous. Things don't often make sense, and the only right way to do things is let the evidence speak for itself. This is why when things get confusing it's especially important to go back to literature, consult experts and rely on existing DSM/guidelines as much as possible.

So, what do you suggest with the depressed alcoholics? (sorry, i didn't got the argument ) That depression can only result by alcohol or any other biological factor? If thats the case i don't disagree with that. As with "chronic pain", it could be the end result of many things, it is like a normal emotional response that goes awry and this can happen by many things.

I agree with learning the DSM, since thats the strandard guideline for now, but this doens't mean that it is right. IMO yes, all mental health professionals should learn it and use it in their clinical practice (well, there is no other way even if you want to...), but at the same time it needs to be heavily challenged. Someone must tell these people to abandon "generating" new disorders on the basis of whetever phenotype is considered problematic and even "trendy" among clinicians at a given time (or...drug companies...no im not with the conspiracy fellows but it is true a bit...) and start adopting a more scientific basis. Start with the the actual psychological and neuroscientific data and then suggest some possible phenotypic expressions.


I mean, It is somehow ridiculous to get diagnosed with...panic disorder, social anxiety, hypochondriasis, generalized anxiety and depression as well as a "bit" of OCD (or OCPD) at the same time (!) like the person really has 5-6 different "diseases". Isn't that a bit silly? For all these there would probably be common underlying mechanisms that interact and sustain all these different "diseases". I mean, if you think about it, all these "different" diseases will probably get better with just one drug (or two) e.g. an SSRI/SNRI. From a psychotherapeutic point of view, exposing the person to what avoids (facing his/her fears) and teaching him/her to adopt better and more efficient strategies to perceive, interpret and deal with the stressors will also "decrease" all these diseases at the same time. It probably suggests that all these "labels" are not real "diseases", more like possible "symptoms" of an underlying disordered process (or two ).

As for psychotherapy, it is true, we don't know exactly which part of therapy affects outcome. No need to be so precise here (well this is not rocket science-for better or worse) what i mean is, giving some insight to the patient and then interacting with-or learning-the patient how to perceive/interpret/deal with the stressors surely works, in a big way. I mean, do you think that it would be clinically "complete" to have a neurotic patient-such as the example i mentioned above- with "5-6 different anxiety disorders" and just give him/her an SSRI, augmented by an SNRI and a Benzo and then "bb"? It would surely calm him/her on the short-term, but this patient doesn't really habituate to the stressors, neither does he/she learn how to cope with the situations that provoke his/her maladaptive responses. Maybe the patient had a disproportional-or dysregulated- amygdala response and the SSRI would help "blunt" or "regulate" the degree of response, but the patient would really need to also work in changing the ways of perceiving/interpreting things, alter existing stressful associations and also stop forming new problematic ones (and maybe in this way change some problematic synaptic plasticity?). So yes, it surely helps, sorry if i misinterpreted your post. (By the way there are many other factors that seem to have a substantial effect on the therapeutic outcome, the experience of the therapist, the quality of the patient-therapist relationship etc.)

 

[nitemagi]

So, what do you suggest with the depressed alcoholics? (sorry, i didn't got the argument ) That depression can only result by alcohol or any other biological factor? If thats the case i don't disagree with that. As with "chronic pain", it could be the end result of many things, it is like a normal emotional response that goes awry and this can happen by many things.

I agree with learning the DSM, since thats the strandard guideline for now, but this doens't mean that it is right. IMO yes, all mental health professionals should learn it and use it in their clinical practice (well, there is no other way even if you want to...), but at the same time it needs to be heavily challenged. Someone must tell these people to abandon "generating" new disorders on the basis of whetever phenotype is considered problematic and even "trendy" among clinicians at a given time (or...drug companies...no im not with the conspiracy fellows but it is true a bit...) and start adopting a more scientific basis. Start with the the actual psychological and neuroscientific data and then suggest some possible phenotypic expressions.


I mean, It is somehow ridiculous to get diagnosed with...panic disorder, social anxiety, hypochondriasis, generalized anxiety and depression as well as a "bit" of OCD (or OCPD) at the same time (!) like the person really has 5-6 different "diseases". Isn't that a bit silly? For all these there would probably be common underlying mechanisms that interact and sustain all these different "diseases". I mean, if you think about it, all these "different" diseases will probably get better with just one drug (or two) e.g. an SSRI/SNRI. From a psychotherapeutic point of view, exposing the person to what avoids (facing his/her fears) and teaching him/her to adopt better and more efficient strategies to perceive, interpret and deal with the stressors will also "decrease" all these diseases at the same time. It probably suggests that all these "labels" are not real "diseases", more like possible "symptoms" of an underlying disordered process (or two ).

As for psychotherapy, it is true, we don't know exactly which part of therapy affects outcome. No need to be so precise here (well this is not rocket science-for better or worse) what i mean is, giving some insight to the patient and then interacting with-or learning-the patient how to perceive/interpret/deal with the stressors surely works, in a big way. I mean, do you think that it would be clinically "complete" to have a neurotic patient-such as the example i mentioned above- with "5-6 different anxiety disorders" and just give him/her an SSRI, augmented by an SNRI and a Benzo and then "bb"? It would surely calm him/her on the short-term, but this patient doesn't really habituate to the stressors, neither does he/she learn how to cope with the situations that provoke his/her maladaptive responses. Maybe the patient had a disproportional-or dysregulated- amygdala response and the SSRI would help "blunt" or "regulate" the degree of response, but the patient would really need to also work in changing the ways of perceiving/interpreting things, alter existing stressful associations and also stop forming new problematic ones (and maybe in this way change some problematic synaptic plasticity?). So yes, it surely helps, sorry if i misinterpreted your post. (By the way there are many other factors that seem to have a substantial effect on the therapeutic outcome, the experience of the therapist, the quality of the patient-therapist relationship etc.)

I think if you read the green journal (AJP) with even irregularity you'll see there's a lot of active debate in the literature on the current DSM and DSM-V, including active challenges to the proposed DSM-V criteria by prominent psychiatrists and researchers.

 

[dl2dp2]

I agree with learning the DSM, since thats the strandard guideline for now, but this doens't mean that it is right. IMO yes, all mental health professionals should learn it and use it in their clinical practice (well, there is no other way even if you want to...), but at the same time it needs to be heavily challenged...start adopting a more scientific basis. Start with the the actual psychological and neuroscientific data and then suggest some possible phenotypic expressions.

We might be talking past each other, but this particularly point is exactly wrong. There is a time and a place to challenge the DSM and the guidelines, but it's not in the clinic or your private office. It's not in the inpatient unit. It's at the laboratories and clinical trial nodes and at the consensus committees. Haphazardly practice based on what you think may or may not deserve "challenging" is extremely problematic and really is why a lot of community psychiatry is so poorly practiced. Psychiatry is a branch of medicine. Medicine is about evidence. Practicing psychiatry without evidence is akin to dillydally of mixing psychotropic alchemy with psychobabble. Obviously in many instances existing evidence is incomplete, and a certain amount of clinical judgement is required, but in every case, looking for evidence should be the FIRST concern, not an afterthought.

In fact, contrary to what you believe, people in the DSM/guidelines world (i.e. "mainstream" psychiatry) are overlapping with the basic/translational neuroscience researchers quite substantially. Some of the leading neuroscience researchers are/have been also practicing psychiatrists. The modern scientific foundation of psychiatry is, in Tom Insel's words, "clinical neuroscience." I don't really want to drop any more names, but I'm not really sure what new way of thinking that you are proposing that they haven't already thought of twice over. Echoing the above post, perhaps it's time to do a cursory read of the green journal.

And the idea that psychotherapy is not, or cannot, or need not be quantitative and scientifically rigorous because it's "not rocket science" is, quite frankly, insulting to both psychotherapy research and rocket science.

 

[Fastball32]

I'm on the side where the DSM in it's present state is far from perfect (common, it's about 18 years old), however it's what we have right now.
During the 90's we have seen a 40x increase in the Bipolar diagnosis among children/adolescents in outpatient settings, and a 7x increase in inpatient settings. These CDC numbers have led to a lot of recent research into Bipolar Disorder and whether we can predict whether certain children will develop Bipolar. This is what is spurring the Severe Mood Dysregulation Disorder --> Temper Dysregulation Disorder with Dysphoria --> and now, Disruptive Mood Dysregulation Disorder diagnosis for DSM-5.
Without going into too much details, it seems that the Disruptive Mood Dysregulation Disorder child is actually Depressed, and NOT Bipolar.
The APA recognizes that some of the Bipolar Diagnosis confusion is related to the wording. The wording is open to interpretation, so in DSM-5, they will have wording more similar to a MDD. If you want more details, the rationale is on the APA website.

There have been several proposed reasons why the diagnosis of Bipolar has increased, but an important fact is that insurance companies stopped paying for Conduct/Oppositional Defiant Disorder treatment, thus leading many clinicians to diagnose Mood or Bipolar Disorder for reimbursement.

The problem is, we started believing it...

 

[cara susanna]

According to Linehan, BPD is in part biological, so to me it makes sense that it's often confused for bipolar disorder. I see patients with bipolar disorder diagnoses when they should have BPD diagnoses and it's very frustrating. It's also sad because usually these patients tend to get their identity from this diagnosis.

To me the best indicator is that interpersonal pattern. I learned in one of my classes that bipolar d/o corresponds with mood swings that are unrelated to the environment, whereas BPD you only get mood swings with environmental triggers. However, that idea is a lot murkier in the real world.

 

[nitemagi]

According to Linehan, BPD is in part biological, so to me it makes sense that it's often confused for bipolar disorder. I see patients with bipolar disorder diagnoses when they should have BPD diagnoses and it's very frustrating. It's also sad because usually these patients tend to get their identity from this diagnosis.

To me the best indicator is that interpersonal pattern. I learned in one of my classes that bipolar d/o corresponds with mood swings that are unrelated to the environment, whereas BPD you only get mood swings with environmental triggers. However, that idea is a lot murkier in the real world.

That's an artificial distinction. Sleep deprive a bipolar pt. and that can switch them into a manic episode.

 

[AcronymAllergy]

That's an artificial distinction. Sleep deprive a bipolar pt. and that can switch them into a manic episode.

I believe there's also evidence to suggest that significant life events (even, or particularly, major positive life events/goal attainment) are associated with increased incidence of manic episodes. That, and "schedule disruption" in general.

In my personal experience, the bipolar/borderline issue becomes particularly salient with male clients, who can often be diagnosed with the former when the latter might be more accurate. When I hear mention of "hyper-rapid cycling bipolar" on the order of three or four "manic episodes" per week, a little red flag pops up in the back of my head regarding distress tolerance and emotional dysregulation.

Although that's not to say the individual couldn't have both.

 

[BobA]

According to Linehan, BPD is in part biological, so to me it makes sense that it's often confused for bipolar disorder. I see patients with bipolar disorder diagnoses when they should have BPD diagnoses and it's very frustrating. It's also sad because usually these patients tend to get their identity from this diagnosis.

To me the best indicator is that interpersonal pattern. I learned in one of my classes that bipolar d/o corresponds with mood swings that are unrelated to the environment, whereas BPD you only get mood swings with environmental triggers. However, that idea is a lot murkier in the real world.

Interpersonal pattern is definitely the key here.

However, I don't think the environment vs. endogenous trigger carries much weight. Much more important is the duration of mood episode.

Interpersonal difficulties (esp pronounced cognitive distortions) + brief intense mood fluctuations = BPD

I frankly think that rapid cycling is rare and tends to occur in severely ill patients rather than ambulatory pts. But a clue that it might be rapid cycling rather than PD might be the absence of interpersonal difficulties/cognitive distortions.

 

[Iwillheal]

Came across this thread today... Just wanted to say that rapid-cycling bipolar does present with cognitive distortions so I don't think that in itself differentiates the two. Unless you're speaking about specific distortions or relative usage. This description from Psychology Today seems right on:

"According to Dr. Friedel, director of the BPD program at Virginia Commonwealth University...

1. People with BPD cycle much more quickly, often several times a day.

2. The moods in people with BPD are more dependent, either positively or negatively, on what's going on in their life at the moment. Anything that might smack of abandonment (however far fetched) is a major trigger.

3. In people with BPD, the mood swings are more distinct. Marsha M. Linehan, professor of psychology at the University of Washington, says that while people with bipolar disorder swing between all-¬encompassing periods of mania and major depression, the mood swings typical in BPD are more specific. She says, 'You have fear going up and down, sadness going up and down, anger up and down, disgust up and down, and love up and down.'"

In short it's all about emotion dysregulation and relationship difficulties.

 

[firedoor]

...I would add to be mindful of the slippery slope of symptom focused management. I do it plenty myself, but with an eye that there can easily reach a point with polypharmacy where we're chasing transient sx's, and ultimately doing more harm than good. Have to keep the big picture in mind, and recognize that if there is a personality d/o in the picture (or just poor coping strategies or hypersensitivity to any mild pertubation) that absolute elimination of sx's isn't going to be realistic, and skills training/therapy/mindfulness and acceptance needs to part of the picture.

Hell...yeah