Bipolar 2.

[annoyedpsychiatrist]

I was just curious how confident you guys feel with the bipolar 2 diagnosis in the outpatient setting. I ask, but usually when they present the history is unclear and often fairly vague with some BPD sx thrown in the mix. The challenge behind it is that patients rarely present to me in hypomania, its typically a depressive episode, and patients often have a remote/vague psychiatric hx and arent the best at remembering details. For some patients when i have a lot of information about them its easier, but on initial eval there are times where I find my differential as bipolar 2 vs BPD vs bipolar 2 w/ bpd traits, etc. There are obvious differences between the diagnosis of BPD/bipolar 2 but sometimes getting the patient to hammer down their symptoms/timeline of sx can be challenging. A lot of the bipolar 2 patients also have had sx at a young age/trauma history that may point in the direction of BPD, then kind of endorse these hypomanic sx which could suggest multiple diagnosis.

I dunno, ive always found bipolar 2 to be a fascinating disorder, perhaps one of the most over diagnosed and underdiagnosed disorders.

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[wolfvgang22]

In outpatient psychiatry there is no need to be in a huge hurry if you suspect Bipolar II despite a high index of suspicion for Bipolar I. In these cases, see the patient monthly, establish a good rapport and observe them over time while considering the differential. If they have supportive close friends or family invite the patient to have them participate in the patient's care with consent and get collateral information. Often a patients history then becomes more and more clear as you get to know them.

Treat symptomatically and be sensitive to symptoms of mania or hypomania. I have several such patients. Sometimes I find they do not have Bipolar, but had situational factors and have depression and have no one to talk to, so when they see me they enjoy the interaction and talk a lot. Sometimes it is undiagnosed ADHD. Sometimes they really do have Bipolar II and benefit from a mild mood stabilizer and lithium, divalproex, or antipsychotics are not needed, but gabapentin or lamotrigine manage their symptoms well. Bipolar I will reveal itself with a mixed or manic episode that you can often catch quickly if you are following up frequently.

 

[annoyedpsychiatrist]

In outpatient psychiatry there is no need to be in a huge hurry if you suspect Bipolar II despite a high index of suspicion for Bipolar I. In these cases, see the patient monthly, establish a good rapport and observe them over time while considering the differential. If they have supportive close friends or family invite the patient to have them participate in the patient's care with consent and get collateral information. Often a patients history then becomes more and more clear as you get to know them.

Treat symptomatically and be sensitive to symptoms of mania or hypomania. I have several such patients. Sometimes I find they do not have Bipolar, but had situational factors and have depression and have no one to talk to, so when they see me they enjoy the interaction and talk a lot. Sometimes it is undiagnosed ADHD. Sometimes they really do have Bipolar II and benefit from a mild mood stabilizer and lithium, divalproex, or antipsychotics are not needed, but gabapentin or lamotrigine manage their symptoms well. Bipolar I will reveal itself with a mixed or manic episode that you can often catch quickly if you are following up frequently.

Good perspective, that is how ive been looking at it primarily, focusing on a differential and narrowing in the long run with subsequent follow ups while looking closely at the symptoms.

 

[nexus73]

collateral is crucial but should not be treated as gospel

people with B2D can have BPD too, which further complicates diagnosis

 

[Sushirolls]

I have a bunch of people that I and patient can't delineate between. Bipolar II / BPD; or the third circle in this ven diagram, PTSD.

PTSD vs bipolar II vs BPD

I've gotten more comfortable over time with these grey zone overlaps, not knowing, and instead having open dialogues with the patient and letting them shape which direction to go for treatment.

 

[Stagg737]

I've had 2 or 3 patients where I was convinced they had true bipolar II per DSM criteria and the key factor is nailing down their "hypomania". I tend to focus on periods of high productivity and try and get the best picture of what those times look like, it can definitely take several appointments to really get a good picture of what their "hypomania" is though. Anecdotally, those 2 or 3 patients all seemed to do very well with moderate doses of Abilify (7.5-10mg).

I have a bunch of people that I and patient can't delineate between. Bipolar II / BPD; or the third circle in this ven diagram, PTSD.

PTSD vs bipolar II vs BPD

I've gotten more comfortable over time with these grey zone overlaps, not knowing, and instead having open dialogues with the patient and letting them shape which direction to go for treatment.

My venn diagram is bipolar, BPD and ADHD, as I see the 3 conflated all the time and there really is a lot of overlap there. I don't include PTSD because it really can look like almost anything and I've seen it misdiagnosed as a psychotic disorder or panic disorder frequently as well. Imo, PTSD as currently described and classified is psych's 'great imitator'.

 

[romanticscience]

Some things that have helped me differentiate:

1. Considering the symptom of energy or "expansiveness" as the primary manic symptom versus irritability or just a high mood. Many of the patients which could carry a label of bipolar 2 have high levels of dissociation, which create these spells where they are super impulsive and have little self-awareness, usually in the context of interpersonal stress (argument) or crisis (breakup); as opposed to the BPD anger/aggression, they develop this sort of La Belle Indifférence and fly to Australia.

[4] The manic characteristics are not fulfilled in many cases clinically diagnosed with “mania.” The expansivity is missing in the next two examples of inventiveness only superficially resembling mania:

One patient reports good periods during which he is making inventions alternating with
gloomy periods with inactivity. A closer examination reveals periods dominated by negative
symptoms and better periods with fewer such symptoms. For several years he has been
working on a project to develop an improved laundry basket. In the good periods he spends much of his time on this task, taking out books from the library to solve technical problems and drawing sketches. In both types of period his affective mood is neutral.
Another patient in good mood brags a lot of creativity and inventiveness. As an example
of this he mentions that the moment his girlfriend told him she needed a coffee table at the sofa by the window he got a splendid idea of how to design it.

Laundry baskets and coffee tables are miserable expressions of expansive manic projects! We expect manic patients to have expansive plans agreeing with their manic mood. These are also missing in the following example:

A woman displaying pressure of speech and having certain grandiose ideas explains when
questioned about her plans for the future that she wants to apply for disablement pension so she can devote herself full-time to cooking for her friends.

2. Hypnotizability: The higher someone scores, the less confident I am in some of their subjective reports.
3. Conceptual development of diagnoses develops in parallel. More psychiatry's problem and less mine lol For instance, the borderline personality construct from Kernberg [1] s very different, theoretically, but overlapping symptomatically with the bipolar constructs from Akiskal [2]. I remember a study where they went and used something like the TEMPS scale or other bipolar measure on all the borderlines at Cornell Westchester and found that something like 40-60% met the criteria [too lazy to find reference]. So, is this comparing red skies or red apples [3]?

[1] Kernberg, O. F., & Yeomans, F. E. (2013). Borderline personality disorder, bipolar disorder, depression, attention deficit/hyperactivity disorder, and narcissistic personality disorder: practical differential diagnosis. Bull Menninger Clin, 77(1), 1-22.
[2] Akiskal, H. S., Hantouche, E. G., & Allilaire, J. F. (2003). Bipolar II with and without cyclothymic temperament:“dark” and “sunny” expressions of soft bipolarity. Journal of affective disorders, 73(1-2), 49-57.
[3] Ghaemi, S. N., & Barroilhet, S. (2015). Bipolar illness versus borderline personality: red skies versus red apples. Borderline Personality and Mood Disorders, 97-115.
[4] Jansson, L., & Nordgaard, J. (2016). The psychiatric interview for differential diagnosis (Vol. 270). Switzerland: Springer.

 

[clausewitz2]

collateral is crucial but should not be treated as gospel

people with B2D can have BPD too, which further complicates diagnosis

Ahh, Akiskal's famous "Bipolar 2 and 1/2"

 

[annoyedpsychiatrist]

Glad to see there is an overall agreement on it and people are open minded with the treatment plan. Seems like we all kind of agree that its a differential but overall looking at the distressing symptoms the best route to manage those. I had a patient today that fit the description of my original post, where she showed traits of BPD/Bipolar 2 (but no clear manic period besides impulsive periods of spending money/risk sex that were isolated/short lived) but also clear signs of adhd (fidgting, talking really fast, disorganized at home to the point of borderline hoarding, impulsive life choices, etc). Definitely some gray areas sometimes.

 

[annoyedpsychiatrist]

Some things that have helped me differentiate:

1. Considering the symptom of energy or "expansiveness" as the primary manic symptom versus irritability or just a high mood. Many of the patients which could carry a label of bipolar 2 have high levels of dissociation, which create these spells where they are super impulsive and have little self-awareness, usually in the context of interpersonal stress (argument) or crisis (breakup); as opposed to the BPD anger/aggression, they develop this sort of La Belle Indifférence and fly to Australia.

[4] The manic characteristics are not fulfilled in many cases clinically diagnosed with “mania.” The expansivity is missing in the next two examples of inventiveness only superficially resembling mania:

One patient reports good periods during which he is making inventions alternating with
gloomy periods with inactivity. A closer examination reveals periods dominated by negative
symptoms and better periods with fewer such symptoms. For several years he has been
working on a project to develop an improved laundry basket. In the good periods he spends much of his time on this task, taking out books from the library to solve technical problems and drawing sketches. In both types of period his affective mood is neutral.
Another patient in good mood brags a lot of creativity and inventiveness. As an example
of this he mentions that the moment his girlfriend told him she needed a coffee table at the sofa by the window he got a splendid idea of how to design it.

Laundry baskets and coffee tables are miserable expressions of expansive manic projects! We expect manic patients to have expansive plans agreeing with their manic mood. These are also missing in the following example:

A woman displaying pressure of speech and having certain grandiose ideas explains when
questioned about her plans for the future that she wants to apply for disablement pension so she can devote herself full-time to cooking for her friends.

2. Hypnotizability: The higher someone scores, the less confident I am in some of their subjective reports.
3. Conceptual development of diagnoses develops in parallel. More psychiatry's problem and less mine lol For instance, the borderline personality construct from Kernberg [1] s very different, theoretically, but overlapping symptomatically with the bipolar constructs from Akiskal [2]. I remember a study where they went and used something like the TEMPS scale or other bipolar measure on all the borderlines at Cornell Westchester and found that something like 40-60% met the criteria [too lazy to find reference]. So, is this comparing red skies or red apples [3]?

[1] Kernberg, O. F., & Yeomans, F. E. (2013). Borderline personality disorder, bipolar disorder, depression, attention deficit/hyperactivity disorder, and narcissistic personality disorder: practical differential diagnosis. Bull Menninger Clin, 77(1), 1-22.
[2] Akiskal, H. S., Hantouche, E. G., & Allilaire, J. F. (2003). Bipolar II with and without cyclothymic temperament:“dark” and “sunny” expressions of soft bipolarity. Journal of affective disorders, 73(1-2), 49-57.
[3] Ghaemi, S. N., & Barroilhet, S. (2015). Bipolar illness versus borderline personality: red skies versus red apples. Borderline Personality and Mood Disorders, 97-115.
[4] Jansson, L., & Nordgaard, J. (2016). The psychiatric interview for differential diagnosis (Vol. 270). Switzerland: Springer.

Well the interesting part is my intake today also has a comorbid sleep disorder. Seeing a sleep doctor and they labeled her with idiopathic hypersomnia so the patient has low energy most of the time.

 

[clausewitz2]

For those with access, a fascinating and relevant article in the most recent Journal of Philosophy, Psychiatry and Psychology :

Project MUSE - Bipolar Disorder and Self-Determination: Predicating Self-Determination at Scope

muse.jhu.edu

Explores the implications for identity formation of unpredictable shifts in value structure and the options available for someone with a bipolar disorder for retaining some autonomous sense of self while also retaining a sense of agency-in-the-moment.

 

[comp1]

Practically from a pure med management perspective...is there a huge problem? The person is almost certainly on some sort of mood stabilizer, whether it's borderline PD or bipolar II. If you're debating whether they have borderline PD, they should probably be in at least some sort of therapy.

 

[ObsequiousAplomb]

Practically from a pure med management perspective...is there a huge problem? The person is almost certainly on some sort of mood stabilizer, whether it's borderline PD or bipolar II. If you're debating whether they have borderline PD, they should probably be in at least some sort of therapy.

Most mood stabilizers have been shown to exacerbate BPD symptoms and have minimal to no positive impact potential.

 

[comp1]

I don't think the standard of care is to avoid mood stabilizers in borderline PD. They certainly aren't as effective as they are in bipolar disorder, but all of literature I have seen say SGAs at least do a little something. They can even often be used to help clarify the diagnosis through success or failure.

 

[clozareal]

This is the tough part about not having objective biomarkers.

It makes sense that they wouldn't present to you in hypomania as they spend only 10% of their time in mania, 40% of their time in depression, and 50% of their time euthymic (see attached). I often get prospective mood charting over months up to a year in these cases and try to look for clear cut episode between mania, depression, and euthymia. The tough part is that borderline symptoms can also be episodic.

I was told that the most specific symptom criteria of hypomania/mania is decreased need for sleep. Those with borderline or not-bipolar will be more tired when they get less sleep over the 4+ days but not so much with bipolar I/II. But those with borderline may have 2 days of hypomania which is why they extended it to 4 days to decrease the false positives from borderline personality disorder. Apparently this temporal cutoff is not mirrored by a clear cutpoint in reported data so some researchers actually think it should be shortened to 2 days so that those with unipolar can be categorized as bipolar and have access to more appropriate treatment options.

I agree with wolfvgang in treating symptomatically. I think regardless of bipolar II or borderline, psychotherapy often helps and actually gives you objective information when you observe them longitudinally.

https://onlinelibrary.wiley.com/doi/10.1111/j.1399-5618.2007.00467.x

 

[Desired Member]

I like to give patients the Mclean screening for bpd. Then at least i have a good idea if they may have bpd and should discuss further with them, educate them about bpd and possibly refer to dbt. This is not official , or evidence based at all but here goes: ive found that bipolar patients tend to also meet criteria for generalized anxiety and sometimes adhd, not always, but very often. The one (?) patient i believe I truly saw with bpad2 recounted a hypomanic epsiode while taking prozac (for severe anxiety) and acted completely uncharacteristic to their usual behaviors and then it went away and they were very sad.
With bpd it seems there is typically (not always) a lot of angst around romantic relationships/possibility of partner leaving, frequent self harm, attention seeking. As far as bpad2 and bpd coexisting that sounds like a nightmare

 

[Liquid8]

Always tricky, and generally need longitudinal observation to clarify things. Initially I look mostly at the duration of mood episodes - Bipolar episodes tends to be longer, and rapid/day to day changes are more suggestive of BPD, and treatment history, especially lack of response to antidepressants, or increased irritability are probably the key issues for me. Screening for dissociation, self-harm, manipulative behaviour, black/white thinking towards other clinicians also leans towards borderline.

I find my bipolar patients have specific signatures for their mood changes.

Eg. one starts to feel like a bad person, such as when she can’t get things done at work or experiences failures outside her control and it has that internally driven, depressive flavour as she’s well regarded with her colleagues. When I explore further there has usually been a sleep disturbance, or period of brief elevation prior usually characterised by heightened sensations – “colours look brighter or more vivid” type stuff, sometimes with a missed few days of medication but not always. In the past she was diagnosed as BPD, due to having angry outbursts towards her mother, against a background of severe trauma. But her relationship with everyone else is actually very good and she responded well to lithium.

One of the ones I’m dealing with currently is a good example of why it’s necessary to get that additional history from multiple sources and maintain communication channels. This one has a mix of bipolar II, BPD and ADHD although I’m doubtful of the latter. A month ago she quietly decided she wanted to see someone else after I set some firm limits on inappropriate stimulant use for weight loss, which was interesting as here wasn’t any opposition to this in the session. But in the interim, she cancelled a number of regular appointments that were booked in advance.

Earlier this week I get a weird call about wanting to know if she should be admitted – tells me her psychologist thinks it should happen, but the patient is ambivalent and isn’t voicing any risks. On my previous face to face assessment there wasn’t anything that screamed high risk behaviour, and as she is involved with a lot of services none of them have contacted me which would generally be the case if a patient is deteriorating. She also tells me she’s been physically unwell over this time which at face value may explain things.

The next day her psychologist calls in a state of concern – the patient has been in crisis for the last month, and at their session a week ago she had to call an ambulance last week due to suicidal ideation, and the patient was discharged from Emergency. Then I find out that she’s been in ED overnight due to overdosing on pills and alcohol. The ED psychiatrist who sees her thinks she’s being manipulative and inconsistent, but there’s a question about lithium dosage and compliance so would like to discharge her with some acute crisis followup and a planned admission. Apparently the complaint is that I’m not listening to her, which I assume is relating to the stimulant misuse and cancelled appointments. Reluctantly I tee up an admission, but with 2 recent ED presentations the offer has to be put forth. On the next day this option is declined by the patient, and I inform the psychologist of this development.

Another day passes, and another call comes through. She’s back in the ED, and tells them she has turned down an admission and gets sent home with crisis followup. She’s telling others I’m not hearing her about the lithium dose. I review my notes, and I can see that she was on a higher dose last year but after stopping it, overdosing on other meds and having a brief hospitalisation she was restarted back on a lower dose and hasn’t brought it up at all in the past year. Objectively she has also made a lot of gains this year, with the dose remaining stable throughout. The ED sends me their letter, and the note states that she’s stopped her lithium for a few weeks, which also doesn’t fit with someone supposedly wanting to increase it.

For now, I think I have managed to get all treating providers on the same page to stop the split. In one sense we’re in a holding pattern - she still has her psychology sessions, a bit of short term crisis support, but has to decide what she wants to do regarding an admission. The ball is in her court, and she knows how to access services if she wants to. In the back of my mind I suspect that she probably would accept an admission under a different doctor, but would likely not get accepted due to her level of complexity.

 

[whopper]

One should always screen for Bipolar Disorder when a patient complains only of depression. You give an antidepressant and it turned out they had Bipolar II you could push that person into their first full blown mania.

Despite this, and it's rare, I've had a few patients who I believe really only had MDD, put them on a successful antidepressant and the person developed Bipolar Disorder later on and were full blown manic in part because of the antidepressant. I know they didn't have Bipolar Disorder cause these people aside from never having been manic or hypomanic beforehand, were on an antidepressant well over a year and the antidepressant did it's rightful thing and then later on (these patients were in the 18 to 25 age zone) they became manic.

I got a patient right now, prior depression and anxiety, successfully treated with an antidepressant for 3 years, age 22, becomes full blown manic but had COVID at the same time. His father, not a medical professional, but a highly educated man asked, "doc, could it be my son doesn't have Bipolar Disorder but the COVID caused him to be manic?"

The problem here is yes it could be the COVID induced mania. There are several reports of COVID-related psych issues. The problem and I told the patient and his father this is we don't have a good study where 1000 people were studied and followed. I gave him the old "holding the wolf by the ears" statement. If I stop the Bipolar medication he could go manic. If we keep it going he might not really have Bipolar Disorder and keep an unneeded medication.

In cases like this I spell out the risks and benefits and let the patient decide. What I usually recommended when asked "what would you do?" is keep on the same regimen if things are going well, and during a hopefully near future period, where we don't expect any significant stress, slowly wean off of meds that might not be needed. This way if the patient becomes worse they won't be much worse and we can reverse course while they're still under stability.

 

[mistafab]

I don't think the standard of care is to avoid mood stabilizers in borderline PD. They certainly aren't as effective as they are in bipolar disorder, but all of literature I have seen say SGAs at least do a little something. They can even often be used to help clarify the diagnosis through success or failure.

The NICE guidelines for BPD are accessible freely. They go through all commonly used therapeutics in BPD and review the evidence. In summary, mood stabilizers in borderline personality disorder do not work.

But yes, border-poles exist.

 

[clausewitz2]

But yes, border-poles exist.

Something like 30-40% of people with bipolar I also qualify for a diagnosis of a personality disorder, often narcissistic. How exactly are you going to have a stable or healthy sense of yourself if you can't predict with any certainty what you're going to care about or what is going to matter to you or how you will react to the world month to month?

 

[annoyedpsychiatrist]

So i try to approach prescribing from a logical point of view. My issue with mood stabilizers in borderline is that, quite frequently they're female (although I get some males occasionally) so that makes me not use VPA right off the bat. Second thing is, quite a few of them have prior OD attempts or jump to suicidal guestures as an answer and even though they dont mean to try to end their life, the attempt sometimes does more damage than intended, so i stray away from lithium in borderline. Ive noticed BPD patients are prone to side effects and again, quite a few are female so i dont use third line tegretol.

I do really like SGAs for borderline. I have a lot of good success with low dose zyprexa to help with severe mood dysregulation+ prozac in a sort of symbyax combo. If they have a lot of metabolic issues i tend to stray away from this, but either way if i use it i monitor weight carefully but also consider quality of life, as the more severe ones have a pretty bad quality of life because they have burned so many bridges at work, home, etc. Sometimes ill use zoloft+abilify combo. Either way I frequently use SGAs in borderline because ssris may help alleviate some sx but the mood dysregulation is usually still pretty bad which SGAs seem to help some. Insight is the biggest thing, the ones that have insight obviously do significantly better than the ones with poor insight. Theres no exact algorithm for BPD that works extremely well for most patients, so I think a lot of it is simply building trust, recognizing that there may be times when they see you as the enemy and dont take it personal, being transparent and explaining the goals of the medication. Some of my BPD patients are doing pretty well though a few others with comorbid substance issues who were xanax/adderall fishing south out other providers when i didnt hand it out like candy. Of note ive been seeing one patient with BPD, she used to be on 4-5mg total daily klonopin (before I started seeing her) and shes down to .25mg every other day, sometimes less.

 

[mistafab]

Something like 30-40% of people with bipolar I also qualify for a diagnosis of a personality disorder, often narcissistic. How exactly are you going to have a stable or healthy sense of yourself if you can't predict with any certainty what you're going to care about or what is going to matter to you or how you will react to the world month to month?

This is definitely the core. Well put.

 

[mistafab]

So i try to approach prescribing from a logical point of view. My issue with mood stabilizers in borderline is that, quite frequently they're female (although I get some males occasionally) so that makes me not use VPA right off the bat. Second thing is, quite a few of them have prior OD attempts or jump to suicidal guestures as an answer and even though they dont mean to try to end their life, the attempt sometimes does more damage than intended, so i stray away from lithium in borderline. Ive noticed BPD patients are prone to side effects and again, quite a few are female so i dont use third line tegretol.

I do really like SGAs for borderline. I have a lot of good success with low dose zyprexa to help with severe mood dysregulation+ prozac in a sort of symbyax combo. If they have a lot of metabolic issues i tend to stray away from this, but either way if i use it i monitor weight carefully but also consider quality of life, as the more severe ones have a pretty bad quality of life because they have burned so many bridges at work, home, etc. Sometimes ill use zoloft+abilify combo. Either way I frequently use SGAs in borderline because ssris may help alleviate some sx but the mood dysregulation is usually still pretty bad which SGAs seem to help some. Insight is the biggest thing, the ones that have insight obviously do significantly better than the ones with poor insight. Theres no exact algorithm for BPD that works extremely well for most patients, so I think a lot of it is simply building trust, recognizing that there may be times when they see you as the enemy and dont take it personal, being transparent and explaining the goals of the medication. Some of my BPD patients are doing pretty well though a few others with comorbid substance issues who were xanax/adderall fishing south out other providers when i didnt hand it out like candy. Of note ive been seeing one patient with BPD, she used to be on 4-5mg total daily klonopin (before I started seeing her) and shes down to .25mg every other day, sometimes less.

The Maudsley book brings up olanzapine as potentially useful, citing open label studies that found some effect. Poor quality evidence yes, yet the often clawing desire by the patient to have you "do something" can make it difficult to say "no" to something that could be potentially useful.

I've also noticed that in the different settings we've worked in during residency - the proportion of Borderline plus patients (MDD, GAD, Bipolar) is much higher in certain settings compared to others given differences in referral streams.

Maudsley refers to lithium as useful in BPD for antisuicidal properties. I had a patient with chronic, distressing SI in BPD+MDD where we used lithium with success, but the caveat is this person never tended to OD as means of self harm, so this was reducing distress without really increasing odds of morbidity/mortality from overdose.

 

[smalltownpsych]

Something like 30-40% of people with bipolar I also qualify for a diagnosis of a personality disorder, often narcissistic. How exactly are you going to have a stable or healthy sense of yourself if you can't predict with any certainty what you're going to care about or what is going to matter to you or how you will react to the world month to month?

When supervising therapists, I started to use the phrase, “growing up Bipolar” to describe some of the maladaptive personality traits that persist after patient stabilizes on medication. Typically a different flavor of personality disorder than one that develops in response to significant early childhood trauma. Also, points to why case formulation to guide treatment is often more important than just checking symptom boxes for a diagnosis.

 

[shoomer]

When supervising therapists, I started to use the phrase, “growing up Bipolar” to describe some of the maladaptive personality traits that persist after patient stabilizes on medication. Typically a different flavor of personality disorder than one that develops in response to significant early childhood trauma. Also, points to why case formulation to guide treatment is often more important than just checking symptom boxes for a diagnosis.

Would you mind going into more depth or pointing me to a resource on this? I have a vague sense of what you're describing but I can't say I understand it well.

 

[smalltownpsych]

Would you mind going into more depth or pointing me to a resource on this? I have a vague sense of what you're describing but I can't say I understand it well.

I don’t know if there are resources on it although someone could write a book with that title.

Some of my thinking on this first originated when I was in my internship and worked with an 8 year old with Bipolar Disorder. When I first met the kid, she was literally scary. Mom had hid the knives, wrote in the intake document twice just to be clear “she scares me”. She scared other kids in waiting room because of her intense glare. This kid had a degree of emotional lability and intensity that was incredible.

While waiting a month or so for the psychiatrist apppointment, I began psychotherapy with the young lady.Initially it was hard to connect because any words or interactions led to intense emotions that she tried vainly to suppress. That is what gave her that intense death stare. She was a bright girl though and as I gently worked with her, I began helping her to connect and emotionally regulate. We were actually making some slow progress and I began to clearly see how her emotional dysregulation was interfering with her social development. In other words, how could this kid learn to develop normally with this type of over the top reactivity and intensity.

Psychiatrist concurred with my diagnosis and prescribed risperidone which had just been approved for pediatric use by the fda. I was blown away at the results. It was one of those dramatic shifts that we occasionally get to see with medications. The girl appeared to be in the normal range of emotional response and could now communicate freely with others including peers. She literally came out of her shell and they were no longer afraid of her.

The family had to move right at this point and the mom wanted to know the plan to continue supporting her and what the little girls prognosis would be. The mom said that she didn’t want to see her daughter experience the life that her brother, the little girls uncle had. Untreated Bipolar for much of his life, major behavioral problems during childhood and adolescence and a decrease in functioning that even with appropriate medications was just not the same person he was. I stated that with understanding of her condition and how to support it with therapy and medications the hope would be that she could function and experience life in a more normative fashion so that she would experience the key social-developmental milestones and not have the same types of experiences that she saw her brother go through that led to the worse outcome.

Since then I have worked with a few more people who have had some intense emotional difficulties from an early age and seen that they have some patterns that seem typical. Not seeking or being able to receive support for emotional regulation from others. Instead, they blow up on the people that care about them. Also, very fixed on trying to stay in the positive mood state because that is the one that gets them in the least trouble also because it feels a little better…sort of. Hating on themselves because of hyper sexuality from a young age. When in a more normal state due to medications, their sense of self is minimal at best. Their identity is mainly encapsulated by their symptoms and experiences of battling with the system. Sort of similar to a Borderline PD and could meet that criteria, but I think of the Borderline patient either defining self in relationships or in terms of their trauma and abuse/vicrime/perpetrator narrative.

I do better thinking this stuff out when discussing cases verbally so hope the written version helps. Also, one girl that I am thinking of as I was writing some of this that I didn’t see when she was first getting treatment at age 8 and I only got to meet when she was 20 died of an overdose not too long ago. Very sad young lady. One of the last interactions I had with her was in a group where I was able to connect with her and she was moved to tears and asked for a hug at the end of the group. I wish I could have helped her more. A reason why I share these things is to help other professionals to help other kids who are growing up confused and thinking there is something wrong with them and it’s their fault and often getting the negative messages reinforced by professionals because they don’t understand it well enough yet either.
Thank you for asking.

 

[forchinet121]

I don’t know if there are resources on it although someone could write a book with that title.

Some of my thinking on this first originated when I was in my internship and worked with an 8 year old with Bipolar Disorder. When I first met the kid, she was literally scary. Mom had hid the knives, wrote in the intake document twice just to be clear “she scares me”. She scared other kids in waiting room because of her intense glare. This kid had a degree of emotional lability and intensity that was incredible.

While waiting a month or so for the psychiatrist apppointment, I began psychotherapy with the young lady.Initially it was hard to connect because any words or interactions led to intense emotions that she tried vainly to suppress. That is what gave her that intense death stare. She was a bright girl though and as I gently worked with her, I began helping her to connect and emotionally regulate. We were actually making some slow progress and I began to clearly see how her emotional dysregulation was interfering with her social development. In other words, how could this kid learn to develop normally with this type of over the top reactivity and intensity.

Psychiatrist concurred with my diagnosis and prescribed risperidone which had just been approved for pediatric use by the fda. I was blown away at the results. It was one of those dramatic shifts that we occasionally get to see with medications. The girl appeared to be in the normal range of emotional response and could now communicate freely with others including peers. She literally came out of her shell and they were no longer afraid of her.

The family had to move right at this point and the mom wanted to know the plan to continue supporting her and what the little girls prognosis would be. The mom said that she didn’t want to see her daughter experience the life that her brother, the little girls uncle had. Untreated Bipolar for much of his life, major behavioral problems during childhood and adolescence and a decrease in functioning that even with appropriate medications was just not the same person he was. I stated that with understanding of her condition and how to support it with therapy and medications the hope would be that she could function and experience life in a more normative fashion so that she would experience the key social-developmental milestones and not have the same types of experiences that she saw her brother go through that led to the worse outcome.

Since then I have worked with a few more people who have had some intense emotional difficulties from an early age and seen that they have some patterns that seem typical. Not seeking or being able to receive support for emotional regulation from others. Instead, they blow up on the people that care about them. Also, very fixed on trying to stay in the positive mood state because that is the one that gets them in the least trouble also because it feels a little better…sort of. Hating on themselves because of hyper sexuality from a young age. When in a more normal state due to medications, their sense of self is minimal at best. Their identity is mainly encapsulated by their symptoms and experiences of battling with the system. Sort of similar to a Borderline PD and could meet that criteria, but I think of the Borderline patient either defining self in relationships or in terms of their trauma and abuse/vicrime/perpetrator narrative.

I do better thinking this stuff out when discussing cases verbally so hope the written version helps. Also, one girl that I am thinking of as I was writing some of this that I didn’t see when she was first getting treatment at age 8 and I only got to meet when she was 20 died of an overdose not too long ago. Very sad young lady. One of the last interactions I had with her was in a group where I was able to connect with her and she was moved to tears and asked for a hug at the end of the group. I wish I could have helped her more. A reason why I share these things is to help other professionals to help other kids who are growing up confused and thinking there is something wrong with them and it’s their fault and often getting the negative messages reinforced by professionals because they don’t understand it well enough yet either.
Thank you for asking.

What you’re describing (emotional lability, trying to maintain highs, impulsivity) that makes me think of a personality disorder, why did you diagnose this 8 year old with bipolar disorder? Im not a child psychiatrist so maybe it presents differently in children and mania is not as pronounced? It doesn’t seem she met the criteria based on your description

 

[PsyDr]

I was just curious how confident you guys feel with the bipolar 2 diagnosis in the outpatient setting.

There is some lay understanding that bipolar translates to irritability (e.g., "They're so bipolar, they're one way and then another."

Something like 30-40% of people with bipolar I also qualify for a diagnosis of a personality disorder, often narcissistic. How exactly are you going to have a stable or healthy sense of yourself if you can't predict with any certainty what you're going to care about or what is going to matter to you or how you will react to the world month to month?

That doesn't make sense. Personality is an enduring pattern of behavior. Mania is supposed to be a "noticeable change from usual behavior".

Also: "Grandiosity may emerge as part of manic or hypomanic episodes, but the association with mood change or functional impairments helps distinguish these episodes from narcissistic personality disorder."

 

[clausewitz2]

There is some lay understanding that bipolar translates to irritability (e.g., "They're so bipolar, they're one way and then another."





That doesn't make sense. Personality is an enduring pattern of behavior. Mania is supposed to be a "noticeable change from usual behavior".

Also: "Grandiosity may emerge as part of manic or hypomanic episodes, but the association with mood change or functional impairments helps distinguish these episodes from narcissistic personality disorder."

I am saying that studies that take samples of people who have been diagnosed with bipolar I and give them a SCID when euthymic find that a substantial proportion meet criteria for a personality disorder. This is not talking about people who are that moment manic or hypomanic.

 

[smalltownpsych]

What you’re describing (emotional lability, trying to maintain highs, impulsivity) that makes me think of a personality disorder, why did you diagnose this 8 year old with bipolar disorder? Im not a child psychiatrist so maybe it presents differently in children and mania is not as pronounced? It doesn’t seem she met the criteria based on your description

Decreased need for sleep, hypersexuality, extreme emotional lability. That extreme part is probably what mania looks like in a kid. Also, family hx of clear Bipolar I added some confidence. Child psychiatrist concurred with diagnosis and it was definitely not something I would just slap on the average emotionally labile or impulsive kid or even kid with trauma or attachment disruptions and budding PD.
Actually my bigger question later down the road is how imipramine which was prescribed for bed wetting could have played a role in either causing or triggering the mania.

 

[smalltownpsych]

There is some lay understanding that bipolar translates to irritability (e.g., "They're so bipolar, they're one way and then another."





That doesn't make sense. Personality is an enduring pattern of behavior. Mania is supposed to be a "noticeable change from usual behavior".

Also: "Grandiosity may emerge as part of manic or hypomanic episodes, but the association with mood change or functional impairments helps distinguish these episodes from narcissistic personality disorder."

It makes sense when you consider that a portion of our personality development is based on our biological predispositions or temperaments. In other words, if you experience extreme shifts in mood then you could develop patterns of relating to the world and others that is reflective of that. in theory, this pattern of relating would be more stable than the mood fluctuations. In other words, they would still be grandiose even when not in the elevated mood state. I think I’ve also seen clinical evidence of this.

 

[PsyDr]

It makes sense when you consider that a portion of our personality development is based on our biological predispositions or temperaments. In other words, if you experience extreme shifts in mood then you could develop patterns of relating to the world and others that is reflective of that. in theory, this pattern of relating would be more stable than the mood fluctuations. In other words, they would still be grandiose even when not in the elevated mood state. I think I’ve also seen clinical evidence of this.

Not really. Temperament is present 3hrs after birth, according to Chess. And I’m guessing it’s a separate set of transmitters in Cloningers model, or the kindling theory.

Why would they be grandiose after a manic episode? The obvious exception would be high achievers who are more productive when manic.

 

[smalltownpsych]

Not really. Temperament is present 3hrs after birth, according to Chess. And I’m guessing it’s a separate set of transmitters in Cloningers model, or the kindling theory.

Why would they be grandiose after a manic episode? The obvious exception would be high achievers who are more productive when manic.

I think you are completely missing my point. I wasn’t saying that temperament relates to Bipolar, I was saying that it relates to personality development.
To the other point, perhaps in learning to interact with people in a grandiose way when fueled by mania, they might continue to act and or think the same way. Also, the grandiosity, especially when coupled with elevated mood, could be reinforcing of certain behaviors that would persist when not in the manic state.
Regardless, the point that I am making is that our emotional makeup shapes who we are. To be clear, I am not saying that this shaping means Bipolar or any other mental illness would cause a personality disorder, but it could be one factor that gives rise to certain traits characteristic of those disorders.

 

[hamstergang]

Decreased need for sleep, hypersexuality, extreme emotional lability. That extreme part is probably what mania looks like in a kid. Also, family hx of clear Bipolar I added some confidence. Child psychiatrist concurred with diagnosis

But isn't one of the hallmarks of bipolar disorder that such issues occur in discrete episodes, and outside those episodes that should be a lack of such symptoms? The way I too frequently see bipolar disorder diagnosed is when the kids are consistently labile, and that just doesn't make sense to me. You didn't quite say in your post, but I didn't get the sense you were describing episodic issues.

 

[clausewitz2]

But isn't one of the hallmarks of bipolar disorder that such issues occur in discrete episodes, and outside those episodes that should be a lack of such symptoms?

That's obviously the classical description, but even Kraeplin didn't think most people with MDI usually returned to some baseline free of symptoms in between episodes. Those episodes should be clear and notable departures from the norm but it doesn't mean the norm has to be fine and dandy.

 

[smalltownpsych]

But isn't one of the hallmarks of bipolar disorder that such issues occur in discrete episodes, and outside those episodes that should be a lack of such symptoms? The way I too frequently see bipolar disorder diagnosed is when the kids are consistently labile, and that just doesn't make sense to me. You didn't quite say in your post, but I didn't get the sense you were describing episodic issues.

I have worked with a lot of emotionally labile kids and the vast majority I didn’t even consider Bipolar as the diagnosis. So I generally agree with you. However, the one kid who I did diagnoses had a degree of intensity that set it apart and made me think that they were just in a manic episode that magnified whatever emotion she felt at any given moment. in other words, the episode had been going on for a period of time and was a deviation from baseline and it also occurred after taking imipramine for bedwetting. Not sure if imipramine is one of those known for triggering mania, but that’s a piece of the puzzle too,

I would agree that it is probably pretty rare as I have only seen 2 younger kids who probably had Bipolar out of a clinical sample size of well over a hundred. Both had times when they were awake all night and one heard voices and both had thoughts of using knives to kill people. One responded immediately and dramatically to medication, the other had a more subtle response. Even in adolescent inpatient it is not very common to see “real” Bipolar that meets diagnostic criteria for having a manic episode and I approach most patients with that dx from others with a high degree of skepticism.

In short, I do think it’s more of a zebra and so when I hear the hoofbeats of emotional lability, I’m going to look at the more common horses such as trauma, unstable environmental factors, learning difficulties, etc. To get back to original post, I don’t know if I would really feel comfortable at all slapping a Bipolar 2 label on a younger kid given how challenging it would be to parse that out.

 

[Merovinge]

That's obviously the classical description, but even Kraeplin didn't think most people with MDI usually returned to some baseline free of symptoms in between episodes. Those episodes should be clear and notable departures from the norm but it doesn't mean the norm has to be fine and dandy.

There's peer reviewed evidence that kids with bipolar disorder do have symptoms between episodes and this should be the expectation, completely agree.

People get very skittish to diagnosis bipolar disorder across all of CAP, but there are very few times you are going to make a mistake on this if you can get good collateral around diminished need for sleep, particularly with several goal-directed/possibly unfinished activities in the evening while everyone else is asleep. A 13 year old who is planning a new gadget, painting their nails, cleaning their room, and getting ahead on homework in the same night is a lot different than a 13 year old watching Youtube all night. I have inherited patients where there is very clear signal about hypomanic or even frankly manic concerns and people punt the diagnosis even on an IP unit (which I presume is related to a hesitancy to make the diagnosis in a child). I had a patient this last year who needed a second manic episode with psychosis before having someone even bring up bipolar disorder, let alone take them off an antidepressant.

 

[clausewitz2]

Not sure if imipramine is one of those known for triggering mania, but that’s a piece of the puzzle too,

TCAs are actually the class of antidepressants were we genuinely have the best evidence for the idea of manic-switching, so absolutely could be a piece of that puzzle.

 

[PsyDr]

I think you are completely missing my point.

1) The data does not support that your formulation of the etiology of personality disorders (e.g., Johnson, 2013; Raine's body of work; Cloningers body of work).

2) I think you are missing my point: Induce mania in two people. The outcomes are going to be very different depending on personality, ability, and social setting. The mania is not going to change the makeup of your 5 factors, or we would common personality characteristics in that population (e.g., epilepsy and personality).

 

[FlowRate]

I don't see patients where this differential is challenging nearly as often as I find patients who are just clearly misdiagnosed as bipolar who, when you really get them to stop using bipolar words they've been told previously and nail them down on baseline characteristics vs episodes, no longer report any experiences at all consistent with episodic mania or hypomania. (And clearly endorse most/all the other features of borderline.) Baseline, life-long severe mood reactivity does not look to me much like specific mood episodes.

Something new I learned from this thread and subsequent literature review is that I somehow missed the more recent literature on the negative study for lamotrigine vs placebo and with regard to basically recommending against med treatment for BPD. I hear dramatically reduced mood lability with lamotrigine from my patients so regularly that it's hard to chalk it up to just placebo.

 

[clausewitz2]

I don't see patients where this differential is challenging nearly as often as I find patients who are just clearly misdiagnosed as bipolar who, when you really get them to stop using bipolar words they've been told previously and nail them down on baseline characteristics vs episodes, no longer report any experiences at all consistent with episodic mania or hypomania. (And clearly endorse most/all the other features of borderline.) Baseline, life-long severe mood reactivity does not look to me much like specific mood episodes.

Something new I learned from this thread and subsequent literature review is that I somehow missed the more recent literature on the negative study for lamotrigine vs placebo and with regard to basically recommending against med treatment for BPD. I hear dramatically reduced mood lability with lamotrigine from my patients so regularly that it's hard to chock it up to just placebo.

The study in question for whatever reason was not able to have lamotrigine dispensed at regular pharmacies or mailed to the participants so every single refill, placebo or non, was brought to the participant's homes by people associated with the research team every month and they took the opportunity to do assessments. Given how sensitive this population is to interpersonal contact I tend to think there is a floor effect here.

 

[clausewitz2]

1) The data does not support that your formulation of the etiology of personality disorders (e.g., Johnson, 2013; Raine's body of work; Cloningers body of work).

2) I think you are missing my point: Induce mania in two people. The outcomes are going to be very different depending on personality, ability, and social setting. The mania is not going to change the makeup of your 5 factors, or we would common personality characteristics in that population (e.g., epilepsy and personality).

I don't think propensity to mania and personality traits are as independent as you seem to be asserting:

APA PsycNet

psycnet.apa.org

 

[smalltownpsych]

1) The data does not support that your formulation of the etiology of personality disorders (e.g., Johnson, 2013; Raine's body of work; Cloningers body of work).

2) I think you are missing my point: Induce mania in two people. The outcomes are going to be very different depending on personality, ability, and social setting. The mania is not going to change the makeup of your 5 factors, or we would common personality characteristics in that population (e.g., epilepsy and personality).

First, I wasn’t formulating the etiology of personality disorders. Second, I wasn’t referring to big five personality dimensions and I agree that experiences aren’t likely to change those dimensions or traits. I was referring more to patterns of interpersonal and intrapersonal relating. Merely saying that who we are, which includes personality traits such as the big five and what I am positing in addition are experiences with mental illness, can affect how we view ourselves and others and interact with the world. Not sure why that is a controversial hypothesis. The converse would be to say that one’s experiences with mental illness don’t affect who they are which seems a bit odd to me. I don’t have the time or inclination to devote to researching this, but I do believe that the more we understand our patients experience and how that affects them, then the more effective our treatment is.

 

[clausewitz2]

First, I wasn’t formulating the etiology of personality disorders. Second, I wasn’t referring to big five personality dimensions and I agree that experiences aren’t likely to change those dimensions or traits. I was referring more to patterns of interpersonal and intrapersonal relating. Merely saying that who we are, which includes personality traits such as the big five and what I am positing in addition are experiences with mental illness, can affect how we view ourselves and others and interact with the world. Not sure why that is a controversial hypothesis. The converse would be to say that one’s experiences with mental illness don’t affect who they are which seems a bit odd to me. I don’t have the time or inclination to devote to researching this, but I do believe that the more we understand our patients experience and how that affects them, then the more effective our treatment is.

I think the day psychology concludes that the Big Five specify the entirety of personality and interpersonal functioning for any given individual is the day psychology basically gives up on caring about accurately describing the behavior and mental processes of actually existing human beings.

 

[smalltownpsych]

I think the day psychology concludes that the Big Five specify the entirety of personality and interpersonal functioning for any given individual is the day psychology basically gives up on caring about accurately describing the behavior and mental processes of actually existing human beings.

Thank you. I was thinking along those lines that last night but couldn’t quite articulate it.

 

[FlowRate]

The study in question for whatever reason was not able to have lamotrigine dispensed at regular pharmacies or mailed to the participants so every single refill, placebo or non, was brought to the participant's homes by people associated with the research team every month and they took the opportunity to do assessments. Given how sensitive this population is to interpersonal contact I tend to think there is a floor effect here.

Thanks, now that I read the study itself, there are also other issues. The biggest one is that, aside from the drug randomization, patients continued to receive care as usual, meaning medication management with options for any drug (other than lamotrigine and other AED's) and ongoing psychotherapy throughout the study. They neglect to give any further analysis on what other medications patients were taking during the trial.

As an aside, also interesting (sad) that other authors have cited the cost figures when referring to the study but the cost figures were not at all statistically significant.

 

[clausewitz2]

Thanks, now that I read the study itself, there are also other issues. The biggest one is that, aside from the drug randomization, patients continued to receive care as usual, meaning medication management with options for any drug (other than lamotrigine and other AED's) and ongoing psychotherapy throughout the study. They neglect to give any further analysis on what other medications patients were taking during the trial.

As an aside, also interesting (sad) that other authors have cited the cost figures when referring to the study but the cost figures were not at all statistically significant.

My takeaway overall from the study is that lamotrigine does not have an enormous effect size for most people with diagnosis, but this study licenses the conclusion 'some proportion of people with the diagnosis may notice improvements' just as strongly as 'this does nothing if it says BPD in your chart.'

 

[FlowRate]

I had a couple of cases recently that brought up this BPAD/BPD/CPTSD issue and I had also run into some reasonable clinicians (a psychologist at work, the Ghaemi book that several people had recommended in another thread recently) that advocated an approach different than the relatively prevailing take in this thread.

I'm curious about peoples' thoughts regarding patients who largely meet BPD criteria but specifically do not report intense/unstable relationships and frantic efforts to avoid abandonment? Are those necessary defining features (rule out) of BPD for you or do we just lack a good alternative diagnostic label for patients where chronic baseline/non-episodic mood lability/impulsivity/anger/identity challenges are an issue?

And apologies for the necrobump. Felt like this thread was good context for my question.

 

[wolfvgang22]

I had a couple of cases recently that brought up this BPAD/BPD/CPTSD issue and I had also run into some reasonable clinicians (a psychologist at work, the Ghaemi book that several people had recommended in another thread recently) that advocated an approach different than the relatively prevailing take in this thread.

I'm curious about peoples' thoughts regarding patients who largely meet BPD criteria but specifically do not report intense/unstable relationships and frantic efforts to avoid abandonment? Are those necessary defining features (rule out) of BPD for you or do we just lack a good alternative diagnostic label for patients where chronic baseline/non-episodic mood lability/impulsivity/anger/identity challenges are an issue?

And apologies for the necrobump. Felt like this thread was good context for my question.

I think if the patient doesn't have Borderline symptoms that are causing significant impairment I don't agonize over it much and focus on the symptoms that are causing the most impairment. I might write "Borderline traits" or "cluster B traits" if the patient doesn't meet DSM criteria for a personality disorder. Meaning - is it a disorder if it's not the cause of poor functioning or causing distress? Is it even something the patient wants to work on?

Now, please excuse me, my spouse hasn't responded to my text in over 3 minutes and I'm worried they'll never come back. How inconsiderate! Boy are they gonna get an earful! (I am joking)

 

[clozareal]

I think you're talking about a factor analysis of the diagnostic criteria, which ones are essential, which ones are more sensitive/specific in BPD. Gunderson likes to say that an intolerance of aloneness is one of the defining criteria for the diagnosis of BPD. It's tough to see because it's an interpersonal phenomenon rather than an individual symptom.

This is a good paper on this, which says there are three domains/components to BPD diagnosis: disturbed relatedness, affect dysregulation, and behavioral dysregulation. The symptoms that scored the highest were affective instability, inapprorpiate anger, and impulsivity. Avoidance of abandonment was the 2nd lowest symptom that came up clinically, 1st being suicidal or self-injurious behaviors.

Confirmatory factor analysis of DSM-IV criteria for borderline personality disorder: findings from the collaborative longitudinal personality disorders study - PubMed

The diagnostic criteria for borderline personality disorder appear to reflect a statistically coherent construct. Three homogeneous components were supported empirically, lending conceptual clarity to different classes of the criteria for borderline personality disorder.

pubmed.ncbi.nlm.nih.gov