When there's a fine line between BPD and Bipolar?

[Ceke2002]

Just curious as to how you tell the difference if someone is displaying possible signs of both? I recently caught up on an old talk show episode (not going to say which one, because I don't want anybody commenting on a specific case) and one of the guests they had on I found really interesting to watch, because on the way hand I was getting major BPD vibes from her, but then on the other hand there was also a lot of stuff that might have been observed as being part of a Bipolar disorder diagnosis.

So if you had a patient displaying the following the behaviours/symptoms, purely out of academic interest/curiosity here, how would you formulate their diagnosis - BPD, Bipolar Disorder, dual diagnosis of both, or something else entirely?

- Pressure of speech
- Flights of ideas
- Inappropriate emotional responses (cracks up laughing at serious stuff, then just as quickly bursts into tears for no apparent reason)
- Emotional Dysregulation (flies off the handle at the drop of a hat, 'drama queen' type behaviour)
- Family members report manipulative behaviours
- Attention seeking
- Grandiosity
- Hypersexuality
- Drug and Alcohol abuse
- Persistent pattern of unstable relationships
- Self harm
- Impulsivity (gets up and drives over a hundred kilometres in the middle of the night to break into a private cabin because they suddenly decided they wanted to see a pretty view)
- Little to no insight into the effects of their behaviours on others (children have been removed by CPS due to parental instability, kids left unattended for long periods, signs of neglect, doesn't seem to understand why the kids have been removed, flips from saying how much they miss their children, and want them back, to making wild statements about their destiny as an A list actress and how they really can't care about the kids because they have to fulfill their dreams first, and they're going to be famous because hundreds of thousands of people are going to DVR the show and they're about to be discovered by a major hollywood producer)
- Doesn't believe there's anything wrong with them, but regularly checks into private mental health facilities for what they describe as 'Spa weeks'
- Family also reports episodes of severe depressive illness, which the person in question also seems to be in denial about (while attempting to give a rambling explanation of what was really going on at the time, replete with almost hysterical laughter through out, I lost audio before they actually got to any sort of point).

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[Shikima]

If you hear "It's my bipolar acting up" or hear mood swings being described as "bipolar symptoms", then you have met diagnostic criteria.

 

[hamstergang]

Bipolar Disorder should be characterized by episodes of mania/hypomania with or without depressive episodes. If the manic type symptoms don't occur together in somewhat discrete episodes, then I'd hesitate to call it Bipolar.

- Drug and Alcohol abuse

Drugs make people do crazy things. Be sure not to attribute behaviors to other disorders if they're explainable by substance use.

 

[Ceke2002]

If you hear "It's my bipolar acting up" or hear mood swings being described as "bipolar symptoms", then you have met diagnostic criteria.

Yeah that's one of the things that actually made me question if I was seeing Bipolar disorder as opposed to BPD (the show itself never gave a diagnosis, but they did get her to agree to go in for a proper assessment somewhere). It's not like she kept going on about 'it's not my fault, it's my Bipolar disorder', or 'You know I can't help it when I get moody and angry with you, I have Bipolar disorder'. There was none of that, just a complete denial that anything was wrong, while talking ten to the dozen, jumping from one topic to the next with no connection between anything, cracking up laughing at inappropriate times and making wildly grandiose claims.

 

[Ceke2002]

Bipolar Disorder should be characterized by episodes of mania/hypomania with or without depressive episodes. If the manic type symptoms don't occur together in somewhat discrete episodes, then I'd hesitate to call it Bipolar.

Drugs make people do crazy things. Be sure not to attribute behaviors to other disorders if they're explainable by substance use.

Drug induced behaviour would definitely be a possibility as well. I take it in order to diagnose Bipolar disorder, or something like Schizophrenia as opposed to drug induced Psychosis, that a person has to be clear of substances for a certain period of time to rule out that as a main cause?

 

[nexus73]

People can have both bpd and bipolar.

 

[MLT2MT2DO]

If you hear "It's my bipolar acting up" or hear mood swings being described as "bipolar symptoms", then you have met diagnostic criteria.

"The only medication that works for my Bipolar is that Gabapentin"

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[Ceke2002]

People can have both bpd and bipolar.

Yes, I have some international friends with a dual diagnosis of BPD and Bipolar, just never really seen what that might look like before, t'was interesting and made me wonder how you would tease out symptoms of one from the other.

 

[Shikima]

Yeah that's one of the things that actually made me question if I was seeing Bipolar disorder as opposed to BPD (the show itself never gave a diagnosis, but they did get her to agree to go in for a proper assessment somewhere). It's not like she kept going on about 'it's not my fault, it's my Bipolar disorder', or 'You know I can't help it when I get moody and angry with you, I have Bipolar disorder'. There was none of that, just a complete denial that anything was wrong, while talking ten to the dozen, jumping from one topic to the next with no connection between anything, cracking up laughing at inappropriate times and making wildly grandiose claims.

You've met criteria for A2

 

[splik]

Yes, I have some international friends with a dual diagnosis of BPD and Bipolar, just never really seen what that might look like before, t'was interesting and made me wonder how you would tease out symptoms of one from the other.

technically dual diagnosis refers to co-occurring substance use disorder and a major mental illness. PD + major mental illness would either be referred to as comorbid or co-occurring. 20% of BPD pts meet criteria for bipolar I or II

 

[Ceke2002]

technically dual diagnosis refers to co-occurring substance use disorder and a major mental illness. PD + major mental illness would either be referred to as comorbid or co-occurring. 20% of BPD pts meet criteria for bipolar I or II

Oh yeah, of course, sorry, thanks for the correction.

Kind of fascinating to potentially see both diagnoses at the same time - I've seen what just BPD looks like (and experienced it myself, obviously), and I've seen what just Bipolar Disorder looks like, but not the two diagnoses together. So how is treatment formulated when there's a co-morbid diagnosis of BPD and Bipolar?

I wish I could link to what I'm actually talking about, but that would probably contravene that Goldwater rule (or whatever the correct name for it is).

 

[Ceke2002]

You've met criteria for A2

So A2, Axis II? Personality disorder then. So how does BPD seem to so often get misdiagnosed or mistaken for Bipolar Disorder? I can understand a lay person like myself seeing someone possibly displaying signs of both, and not being sure what's what, but in professional practice shouldn't the diagnostic rate be a bit more, I don't know, realistic?

 

[smalltownpsych]

Some of the differential questions I would have would be regarding sleep pattern, suicidality, substances used. The vignette does seem to provide a lot of behavior consistent with manic episodes, but a patient with Borderline PD who is running wild on substance use can look about the same. I would like to see what they looked like in an inpatient facility after a period of time that is a bit longer than the "spa week". The main problem with that is typically she would be immediately administered numerous medications before even having a chance to stabilize at all from both the lifestyle and the substance use.

 

[Ceke2002]

Some of the differential questions I would have would be regarding sleep pattern, suicidality, substances used. The vignette does seem to provide a lot of behavior consistent with manic episodes, but a patient with Borderline PD who is running wild on substance use can look about the same. I would like to see what they looked like in an inpatient facility after a period of time that is a bit longer than the "spa week". The main problem with that is typically she would be immediately administered numerous medications before even having a chance to stabilize at all from both the lifestyle and the substance use.

Yes a patient with BPD running amok on substances, always a fun time for everyone around them.

I think at that end of the show that is why they managed to convince her to go in somewhere for an actual assessment, not just pop along to the local mental health ward for a 'spa week'. And seriously, private enterprise or not, who in their right mind allows anyone to just drop in and out of a hospital situation for a bit of RnR whenever they like? Isn't that like a ridiculously huge waste of resources if nothing is actually being done to treat or assess the patient properly, and the patient themselves fully admits they are using the admissions to have some time off?

 

[PistolPete]

There is a lot of overlap, as several have pointed out, as many psychiatric diagnoses are "dirty diagnoses." You have to look at the whole picture.

I personally think bipolar disorder is overdiagnosed and personality disorders, such as borderline personality disorder, are underdiagnosed.

So someone who has intense affect that changes by the minute/hour and a history of unstable relationships and cuts probably has BPD.

Someone who hasn't slept for days and who believes he can fly is probably bipolar.

The problem is when you don't ask enough questions. Someone who has unstable affect could have either diagnosis. Someone who is sexually indiscriminate could have either diagnosis. Someone who has short periods of psychosis could have either diagnosis.

Having both is possible but not common.

 

[Ceke2002]

There is a lot of overlap, as several have pointed out, as many psychiatric diagnoses are "dirty diagnoses." You have to look at the whole picture.

I personally think bipolar disorder is overdiagnosed and personality disorders, such as borderline personality disorder, are underdiagnosed.

So someone who has intense affect that changes by the minute/hour and a history of unstable relationships and cuts probably has BPD.

Someone who hasn't slept for days and who believes he can fly is probably bipolar.

The problem is when you don't ask enough questions. Someone who has unstable affect could have either diagnosis. Someone who is sexually indiscriminate could have either diagnosis. Someone who has short periods of psychosis could have either diagnosis.

Having both is possible but not common.

Yes, this makes sense, thank you. I know I've had lay people with some knowledge, because they work in a Psychiatric setting in a non healthcare provider scenario, try and insist that I should be assessed for Bipolar disorder when they've seen me in an emotionally disregulated state, and lacking sleep - but I don't have Bipolar disorder, I fit absolutely none of the criteria to make that diagnosis. But on the other hand I can sort of see how, to someone who isn't adequately trained in complex or overlapping diagnoses, that some of the residual issues I have with formerly meeting diagnostic criteria for BPD, could look like Bipolar disorder.

 

[splik]

Kind of fascinating to potentially see both diagnoses at the same time - I've seen what just BPD looks like (and experienced it myself, obviously), and I've seen what just Bipolar Disorder looks like, but not the two diagnoses together. So how is treatment formulated when there's a co-morbid diagnosis of BPD and Bipolar?

depends on whether it is bipolar I or II. If it is bipolar II I would treat as borderline personality disorder and then work on that basis. If bipolar I, I would treat as bipolar I and once that was better stabilized work on treating the BPD.

It's not that fascinating, our diagnoses are all made up so comorbidity is the rule rather than exception. also even where there isn't frank personality disorder taking into count personality features and temperament should really be part of the formulation of all patients and their treatment

 

[Ceke2002]

depends on whether it is bipolar I or II. If it is bipolar II I would treat as borderline personality disorder and then work on that basis. If bipolar I, I would treat as bipolar I and once that was better stabilized work on treating the BPD.

It's not that fascinating, our diagnoses are all made up so comorbidity is the rule rather than exception. also even where there isn't frank personality disorder taking into count personality features and temperament should really be part of the formulation of all patients and their treatment

This is very true, and highly indicative of a good Psychiatrist in my opinion. Maybe I should have said 'this is fascinating to a lay person'.