There's a lot in the literature about bipolar/borderline PD diagnostic issues (some arguing that they're on the same spectrum), but I find just as many patients who straddle the line between narcissistic PD and bipolar, type II.
The typical case is the relatively successful executive who suffers from bouts of "depression," often with irritability and lability, some alcohol use thats minimized, that often coincides with problems in their business or relationships. During this period, mistakes are made, with the patient screaming at his family or employees, which is then marked up to "impulsivity," raising the question of a "mixed episode." Of course, when things are going well and the patient is being validated for their brilliance and success, there's grandiosity and elevated self-esteem, even a little euphoria and increased goal-directed activity with diminished sleep requirement. For the sake of argument, a totally random example would be sending out messages on social media at 4am. Nothing crazy enough to really qualify as impairment, but enough to raise an eyebrow.
Medication doesn't seem to work, although there's some marginal benefit from mood stabilizers (which the patient seems to have mixed adherence to). Per the patient, benzodiazepines helps with their mania, and stimulants get them through their depression (interestingly, there isn't any adherence issues here).
I'm curious to get other peoples experiences with these cases, since I could be getting a little cynical with some of these cases. Is it essential to challenge the diagnosis? Do you feel that there is a "true" bipolar II or are we medicalizing bad behavior? Or is it the best way of getting patients to engage in help until they're ready to address interpersonal issues?
The typical case is the relatively successful executive who suffers from bouts of "depression," often with irritability and lability, some alcohol use thats minimized, that often coincides with problems in their business or relationships. During this period, mistakes are made, with the patient screaming at his family or employees, which is then marked up to "impulsivity," raising the question of a "mixed episode." Of course, when things are going well and the patient is being validated for their brilliance and success, there's grandiosity and elevated self-esteem, even a little euphoria and increased goal-directed activity with diminished sleep requirement. For the sake of argument, a totally random example would be sending out messages on social media at 4am. Nothing crazy enough to really qualify as impairment, but enough to raise an eyebrow.
Medication doesn't seem to work, although there's some marginal benefit from mood stabilizers (which the patient seems to have mixed adherence to). Per the patient, benzodiazepines helps with their mania, and stimulants get them through their depression (interestingly, there isn't any adherence issues here).
I'm curious to get other peoples experiences with these cases, since I could be getting a little cynical with some of these cases. Is it essential to challenge the diagnosis? Do you feel that there is a "true" bipolar II or are we medicalizing bad behavior? Or is it the best way of getting patients to engage in help until they're ready to address interpersonal issues?
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