Hi,

I haven't posted on here for a couple of years now. I was initially diagnosed as bipolar and then that was changed to borderline personality disorder. I have been prescribed anti depressants which did nothing and also quetiapine which I stopped taking cos of the side effects. I have had psychotherapy for 3 years now which is helping to some degree.

I am not sure if the diagnosis is correct. I do have black and white thinking, feelings of emptiness and unstable relationships but also I have a kinda leaden paralysis depressive feeling, agitation, distractability, periods of heightened creativity as well as lethargy. I also can sleep a few hours a night or for about 10 or 12. I think I am self medicating at weekends especially through alchohol. I often have blissful periods which don't last long but can last a few hours. I have lots of paranoia and anxiety. I get bored of people, projects and things very easily and my concentration is shocking. I have impulsive feelings and have crashed a number of motorcylces, cars etc in my time been quite promiscuous and then avoided sex for ages and had feelings like I was with God or merging with some wider universal consciousness.

The psychiatrist who changed me from bipolar to borderline did say it was marginal between that and bipolar with most others likely to diagnose the latter. My current psychothapist says it is a wide spectrum of experience. I sometimes wonder whether I should take meds because I am still only half functioning but really don't want to be arguing the toss about a rediagnosis.

I also had some quite severe social anxiety when I was younger and there seems to be a lot of crossover between the conditions. My shrink mentions the word temperament a lot and so do my friends. The latest letter to my doctor refers to unstable fluctuations of mood, reactive mood, difficulty developing stable relationships and sense of self.

Could I be cyclothymic or maybe atypical depressive or bipolar 2? Do you think I should try meds? I have moved on but would no way consider myself to be cured or able to function the way I would like?

[Trippin2.0]

I'm wondering why your pdoc hasn't considered a dual dx... Its not uncommon to have both. I do anyway

To answer your question, idk if you should try meds, maybe the reason therapy isn't very effective is because you're not dealing with everything, just the bpd? Idk just speculation on my part...

Meds can be helpful to alot of people, for me it did help during a crisis, but I can't fathom using them as daily management.

I really think you should speak to your pdoc about a dual dx, if you do have both disorders, it doesn't help to only address the one, no matter how many symptoms overlap. You need different coping skills as they are quite different at the core no matter how alike they look on the surface.

Sorry if I was unhelpful, weekends are hell

Thank you that is very helpful indeed.

It is difficult knowing precisely what you have when you are in a roller coaster ride which you cannot properly understand what it is. There is an interesting article saying how BPD, Bipolar 2 and Atypical Depression are all part of some mider soft bipolar spectrum. However, other schools think BPD and Bipolar are totally different conditions.

I am worried about being misdiagnosed because if I have both I may need medication. Another thing I also do is put on loads of weight then lose it. I lost 3 stone in 4 months and put it back on again. Another sign of bipolar. Also, thoughts in my head or often like a machine gun.

[ultramar]

I do have black and white thinking, feelings of emptiness and unstable relationships

I think as you mentioned, the above is one way pdocs/T's distinguish between the two conditions. Another way is 'reactivity' to environmental issues (I think mentioned by your pdoc), in other words moods being the result of reacting to something in the environment in the moment, rather than a protracted episode per se. And finally, I think another distinction is how long moods last, and you say the blissful feelings will last only for hours. My understanding is that anxiety can exist co-morbidly with both BPD and bipolar (and I guess anything else, really).

That said, of course you're only giving us a piece of the puzzle (none of us can explain everything in a post, or even to ourselves oftentimes!), so there may be other things going on pointing to bipolar 2.

It sounds like you've already discussed this with both pdoc and T, but you're still unsure, so maybe you can ask them how specifically they are distinguishing between the two? Also, as far as meds, my understanding is that mood stabilizers help some people with BPD, so if you feel that the antidepressants and therapy aren't working and you really need a different medication, then you could discuss the possibility of a mood stabilizer with your pdoc.

Thanks Ultramar,

I am confused because I do have a highly sensitive temperament at times and am extremely situationally sensitive to the extent it really affects my functioning especially in relationships which end up really life and death, up and down and all over the place.

But on top of that I sometimes have mood states which also seem to come from nowhere overlapping the above. As for moods lasting a few days or more I have definately been irratable and agitated for at least a few days but within that it also turns to brief periods of heavenly type bliss but with some kind of edge to it also! Very difficult to explain.

I wouldn't say I have normal periods but there are times when it doesn't seem to be as bad. I also do have period I talk fast people can't understand what I say, get distracted, become totally obsessed with sex and have some fantastic ideas (one of my friends said you have periods of genius followed by complete lethargy). I usually wake up tearful and depressed but when in work become much happier and I often take the mickey out of people. I am often up till 3am working on new projects and ideas or can't be bothered with my career. I have 3 jobs at present and my hours of work are very unconventional.

I just don't fit the typical depressed for a month, elated for a week and two months OK in between stereotype. I may go back to the Psychiarist again but after being diagnosed BPD by the second I have been referred for psychotherapy which I have been having for over 3 years. It is helping but I am scared I will never recover and may indeed be Bipolar as initially diagnosed or perhaps BPD and Bipolar.

[Happy Camper]

My psychiatrist said there is "almost always some overlap with personality traits." Going just on what you've said, it sounds like you have traits of both.

Meds are helpful to some people and not at all to others. You just don't know until you've given them a chance. In my case they've never done me any good; they only caused really nasty side effects.

I relate a lot to what you've said in that you have had short periods of bliss, have felt connected to a greater consciousness, bouts of creativity, paranoia/anxiety, agitation, emptiness, etc..
A bipolar 1 diagnosis was bootstrapped to me after a stay in inpatient where the hospital pdoc thought I was having a mixed episode, but I was just reacting to very intense and internalized stress stemming from long unaddressed psychological problems, which has also caused a lot of problems with my mood. I'm hoping to get the diagnosis looked at since I don't meet the criteria very well. Borderline describes me much better, though I'm not confident that they will see it.

As long as you're getting the right treatment for your symptoms, try not to worry too much about the actual term they use.

Not sure if anyone has read this very interesting article explaining the relationship. My depressive periods are definately ''atypical'' i.e. leaden type paralysis, rejection sensitivity and mood improving once getting into work or mingling with folk.

The analysis here is that those diagnosed Borderline generally have atypical features to their depression and according to the study here 70% of them would meet the criteria for Bipolar II with an even higher number considered to be on the bipolar spectrum.

It is a bit of a nightmare I think for someone to be told by two different pdocs that you have two conditions which both involve extremes of thinking and mood. I suppose I must just have faith in trusting them to have got it right. It would really affect me having to be arguing the toss again about diagnosis/treatment when I spent 5 years or more putting off seeing a psychiatrist when my doctor suggested I could be bipolar.

http://www.medscape.org/viewarticle/457151

[NuckingFutz]

Sounds like there are symptoms in every camp. If I were a mental health professional, I would recommend not drinking any alcohol and then I would be able to do a diagnosis. If you read the DSM manual, it states that alcohol and drug abuse must be excluded before a valid diagnosis is made.

[ultramar]

Originally Posted by sgthowie

Not sure if anyone has read this very interesting article explaining the relationship. My depressive periods are definately ''atypical'' i.e. leaden type paralysis, rejection sensitivity and mood improving once getting into work or mingling with folk.

The analysis here is that those diagnosed Borderline generally have atypical features to their depression and according to the study here 70% of them would meet the criteria for Bipolar II with an even higher number considered to be on the bipolar spectrum.

It is a bit of a nightmare I think for someone to be told by two different pdocs that you have two conditions which both involve extremes of thinking and mood. I suppose I must just have faith in trusting them to have got it right. It would really affect me having to be arguing the toss again about diagnosis/treatment when I spent 5 years or more putting off seeing a psychiatrist when my doctor suggested I could be bipolar.

http://www.medscape.org/viewarticle/457151

Just earlier today I did a ton of research on the relationship between bipolar and BPD looking for something to post, and I think it's possible you misread the part about 70% of people diagnosed with BPD would meet the criteria for Bipolar II. I read tons of articles and nothing even close to that. I can't read the article because you have to be a member of Medscape, is there any way you can post the whole article on here?

[ultramar]

I'm not saying you're one or the other or both, but something you wrote jumped out at me I'd like to comment on:

rejection sensitivity and mood improving once getting into work or mingling with folk.

Keep in mind that 'rejection sensitivity' is actually a hallmark of BPD and I have read that some people with BPD do feel better when around others, as there can be an intolerance of aloneness.

I'm wondering if you're questioning your diagnosis in part because you still haven't felt a great deal of improvement in therapy (I think you mentioned this) and you're getting frustrated with your treatment? If this is in part the reason, maybe you can talk to your therapist about feeling like you're not moving forward, maybe you and he/she can try some new approaches, or you could consider a different therapist who might help you more. Good luck!

[The_little_didgee]

Here is the first half of the Medscape article:

Demystifying Borderline Personality: The Cyclothymic-Bipolar II Connection

Introduction

Despite considerable overlap between borderline personality disorder and affective disorders based on methodologically sound studies, as prominent a borderline expert as Gunderson[1] has downplayed such a relationship. Such denial is all the more surprising given the fact that his research team[2] reported that borderline patients at some point in their life met criteria for dysthymia (80%) and/or major depressive disorders (100%). For this reason, it is generally conceded that the nature of affective illness in borderline patients is best described as "atypical." The question of the relationship between borderline and affective disorders then is one of characterizing the nature of "atypicality." The thrust of my argument in this report[3] is that the atypicality of the affective dysregulation of patients given borderline diagnoses can be more precisely delineated in terms of cyclothymic and bipolar II disorders.

Defining the Borderline Terrain

In the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), borderline refers to a discrete operationally defined construct within the "dramatic cluster" of personality disorders. This definition largely derives from the work of Gunderson and Singer.[4] Among its chief merits is the stimulation of a plethora of data-based investigations of borderline conditions since 1980 as well as the development of the Diagnostic Interview for Borderline (DIB) as its structured measurement. Among the limitations of this operationalized approach is that the concept has been oversimplified, even banalized: it has an unwieldy heterogeneity and overlaps significantly, not only with personality disorders within its own cluster, but also with the schizotypal-paranoid and anxious clusters. Of related concern is the fact that DSM-IV criteria, rather than restricting themselves to defining personality attributes, mix traits, symptoms and behaviors -- particularly of an affective nature (Table 1).

Table 1. Core Characteristics of DSM-IV Borderline Personality Rearranged to Highlight Affective Loading

Unstable intense relationships: splitting, object hunger, abandonment depression
Affective instability: mercurial moods, reactive dysphoria, angry outbursts
Behavioral dyscontrol: impulsivity, substance abuse, binge eating, suicidality
Chronic emptiness: boredom
Unstable sense of self: identity disturbances
Micropsychosis: paranoid sensitivity, dissociation

Of even greater concern is that the operational construct may not coincide with what psychoanalysts mean when they make the clinical diagnosis of borderline personality organization. The latter refers to Kernberg's pioneering contributions[5] in delineating a vulnerable psychic structure, rather than a specific nosologic entity. It refers to a class of personality dysfunctions with common defensive operations, reflecting a vulnerable psychic structure that functions at a "stably unstable" level between the classic neuroses and psychoses. Unlike Gunderson's concept of borderline as a specific personality disorder -- which does not lie on the border of any specific mental disorder -- Kernberg's conceptualization maps a large terrain of psychopathology with affective, neurotic, and paraphiliac disturbances. Kernberg's position appears to be more compatible with psychobiologic formulations of borderline, which place this personality disorder on the borders of such disorders as schizophrenic, manic-depressive, and epileptic psychoses. In this framework,[6] borderline refers to formes frustes of the major endogenous psychoses (ie, subschizophrenic, subaffective, or subictal disorders). This paper updates previous contributions by the present author,[6-10] and integrates them with other emerging trends that emphasize the central role of the cyclothymic constitution in the genesis of borderline, atypical, and bipolar II disorders.

Delineating the Affective Border

Initially, the borderline concept developed as a dilute form of psychosis, and its main usefulness was to exclude such patients from the couch. Working in New York, Stone[11] -- who reported that these patients often came from families with manic-depressive and alcoholic members -- can be credited for having been the first to make a persuasive argument about the need to shift from borderline as a subschizophrenic to a subaffective disorder.

Independently, the present author too arrived at the same conclusion: curiously, our work at the University of Tennessee[6,7] had started off with the hypothesis that many patients with borderline personality had affinity to schizophrenic disorders as defined in the framework of the Danish adoption study of schizophrenia. We studied 100 consecutive outpatients -- in a Memphis mental health center -- meeting the Gunderson and Singer criteria[4] for borderline personality. They were clinically evaluated using a semistructured interview based on a modified version of the Washington University approach to psychiatric diagnosis.[12]

Contradicting our starting hypothesis, only 16% were schizotypal.[6] As for other psychopathology, borderline embraced a broader spectrum than we had anticipated. At index evaluation, 66 met the criteria for recurrent depressive, dysthymic, cyclothymic, or bipolar II disorders; other patients met criteria for sociopathic, panic-agoraphobic, attention-deficit/hyperactivity and epileptic disorders. During prospective observation of up to 3 years, and compared with nonborderline personality subjects, borderline probands had a significantly higher risk for developing major affective disorders than schizophrenia spectrum disorders; furthermore, there were 4 completed suicides. Prominent substance abuse history, stormy biographies, and unstable developmental history marked by repeated object loss were common to all borderline subgroups. From a familial standpoint, borderline probands were closest to the affective, especially the bipolar, comparison group. This familial-genetic bipolar link was reinforced by antidepressant associated switches into irritable-angry hypomanic and mixed states in 20% of our sample during prospective observation. (Of note, "paradoxical" disinhibition on antidepressants in borderline patients has also been observed by others.[13,14])

To summarize, the recurrent nature of affective disorder, coupled with familial bipolarity and spontaneous and pharmacologic excursions into brief periods of elation, places the affective pathology of borderline patients in the soft bipolar realm (that can be broadly defined as bipolar II).

The Nature of "Atypicality"

It is often assumed that micropsychotic and dissociative episodes in patients given borderline diagnoses emanate from psychotic processes. This is a misconception. Grandiose or irritable forms of hypomania occurred in a third of our borderline probands with affective diagnoses.[6] Transient drug-induced psychoses secondary to alcohol, sedative hypnotic, psychedelic or stimulant drug use, or withdrawal were reported in nearly half of all borderline cases. Finally, depersonalization-derealization, as well as brief reactive psychoses, were not uncommon in the borderline probands with concurrent panic-agoraphobic diagnoses. Such data provide a useful beginning framework for understanding the "atypicality" of the affective disorder in borderline patients.

To explain the atypicality of the affective state of borderline patients, Gunderson and Phillips[1] contrasted "empty" depression in this personality with the more classical "guilt" depressions in "classical" affective disorder. Thus, their unstable, hostile, and labile moods -- the unrelenting tension and irritability with superimposed paroxysms of rage -- are relegated by these authors back into the characterologic realm. The thrust of this argument is based on a misconception that only classical affective disorder is a "true" affective disorder. In a forensic population, Coid[15] recently provided a compelling description of the affective storms of borderline patients (restlessness, irritability, explosive anger, tension, psychotic anxiety), which lead to -- and alternate with -- the deceptive "calm" and "emptiness" following self-mutilation. Whatever one ends up calling such patients, one cannot but respect their affectively driven temperamental excesses (lest one becomes victimized by them!). Since 1981, the present author[7] has defended the position that a significant proportion of these patients suffer -- and make their loved ones suffer -- as a result of temperamental dysregulation along dysthymic-irritable-cyclothymic lines. Mood lability and hostile emotional avalanches, which characterize borderline patients, seem to derive from such temperamental dysregulation, which is quintessentially affective in nature.

[The_little_didgee]

Here is the second half (without the references):

The Atypical-Bipolar II Connection

Major depressive states with reverse vegetative signs (so-called "atypical features") are commonly encountered in this unstable temperamental terrain. Three recent studies have provided greater clarification about this complex interface of volatile affective temperament and atypical affective states.

In collaboration with clinical researchers in Pisa,[16] we demonstrated that 72% of 80 depressive patients with DSM-IV atypical features simultaneously met the criteria for bipolar II; 60% had antecedent cyclothymic temperament. In addition, 94% were rated as interpersonally sensitive. As expected, using the DSM-IV axis II schema, both cluster B (borderline-histrionic) and cluster C (avoidant) personality disorders were prevalent.

Deltito and colleagues[17] studied 20 consecutive patients diagnosed borderline by experienced clinicians at Westchester-Cornell, "validated" independently by Gunderson's DIB. They then rated them by descending order of certainty of bipolarity: in light of what the current literature indicates as established bipolarity ( bipolar I + bipolar II), the conservative rate for bipolarity in this well-characterized, though small. sample of borderlines was 44%; taking the most liberal definition of bipolarity (including pharmacologic-hypomania, cyclothymic temperament, and family history for bipolar disorder), 81% of borderline patients could be considered lying on the border of within the bipolar spectrum. This provocative work, though preliminary, represents the first head-to-head comparison of borderline personality and bipolarity[11] (and obviously is in need of replication).

The author's research as part of the National Institute of Mental Health Collaborative Study of Depression[18] has shown that clinical features reminiscent of borderline features (SADS Item 12) were strongly predictive of which major depressives would, over a prospective observation period of 11 years, switch to bipolar II (Table 2). The temperament of these patients was a mélange of interpersonal sensitivity and mood lability. This study underscores the importance of temperamental factors in borderline psychopathology, as well as their value in predicting bipolar outcome. Stated more tersely, borderline personality, interpersonal sensitivity, mood labile temperamental traits, and bipolar II seem to represent overlapping expressions of the same diathesis. (That mood lability is not pathognomonic for borderline personality, and occurs in bipolar II as well, has been replicated by Henry and colleagues.[19])

Table 2. Prospective Prediction of Bipolar II Outcome in 8.6% of 559 Patients With Major Depressive Disorder*

- Younger age at onset
- High depressive recurrence
- Greater marital disruption
- Higher score on phobic anxiety
- More "borderline" clinical features
- Higher score on interpersonal sensitivity
- High on trait energy-activity and daydreaming
- High on trait mood lability
- 42% sensitivity
- 86% specificity

Borderline as a Casualty of the Axis I-Axis II Distinction

One of the inadequacies of our current nosologic schema of personality disorders is that the long-term functioning of patients suffering from major mood disorders is described primarily in "characterologic" language (Axis II in DSM-IV), which is conceptually removed from the "temperamental" language that had been used in classical European psychiatry during the first part of this century. For instance, today bipolar patients are often described as "dramatic," "erratic," "unstable," impulsive," "passive-aggressive," "histrionic," "narcissistic," or "borderline," as if affective temperaments had little to contribute to our understanding of these personality disorders. O'Connell and colleagues[20] appropriately pointed out that structured interviews tend to misclassify subthreshold affective disturbances as dramatic personality disorders. The author's work[21] and subsequent research by Levitt and colleagues[22] have actually shown significant overlap between the cyclothymic temperament and borderline personality disorder.

There are advantages to returning to the more natural affective temperamental language of describing the premorbid, intermorbid, and postmorbid phases of major affective disorders. In this framework,[7,21,23] affective temperaments represent the substrate from which the more florid episodes develop. Using the analogy of earthquakes, I have elsewhere[9] compared the predisposing terrain and affective instability in 2 types of depression. In many affective ill patients, the temperamental terrain is not visibly pathologic but refers to a vulnerable fault that can be destabilized periodically, erupting into extreme pathology that could lead to self-destruction. In this more classical affective type, the patient has relatively normal -- or even supernormal or hyperthymic -- functioning between episodes. In other patients, the temperamental terrain is characterized by greater instability and intermittent or nearly continuous emotional "mini-earthquakes"; these patients seem "protected," though not entirely, from major melancholic episodes. The patient with this second type of temperamental dysregulation suffers from protracted intermittent emotional disequilibrium and restlessness without necessarily having full-blown syndromal affective episodes. These are then considered to be "atypical" or "borderline" cases where the terrain is so pathologically unstable that it may be difficult to discern the superimposed episodes that are an accentuation of the basic pathology.

Borderline as the "Darker Side" of Cyclothymia

Our work has actually demonstrated that the temperamental terrain between depression and manic-depression is bridged by a spectrum of subtle bipolar disorders with an extremely variable course.[7,21,23] Mood switches are recurrent, biphasic and abrupt, and may be seasonal and sometimes exacerbated by antidepressants. The term "explosive" captures the abruptness of the affective switches, each phase lasting for hours, days, and, sometimes, weeks. These patients are rarely euthymic. Their mood shifts often follow a circadian pattern (ie, waking up convinced of the futility of existence), but can also be reactive to interpersonal altercations, often rather trivial in nature, but emotionally charged for the patient. Even when provoked by such situations, the resultant emotional outbursts are more like avalanches than understandable reactions proportional to the proximate provoking situation.[23] One must infer an endogenous propensity to extreme emotional reactivity to these patients. Given such emotional tempests, it is no wonder that most clyclothymes accumulate an extreme array of social disturbances by their mid-20s[21]: repeated romantic failure, episodic promiscuity, financial extravagance, uneven work or school record, dilettantism, geographic instability, polysubstance abuse, and joining various eschatologic cults. Such instability appeared to be secondary to lifelong biphasic mood swings below the threshold for full-blown bipolar disorder. Subsequent studies in a community sample[24] have reported similar interpersonal havoc and social disruptions.

The instability in the biography of cyclothymics is especially accentuated in those with predominantly irritable traits.[23] These individuals are habitually dysphoric, prone to anger, hypercritical and complaining, with a penchant for ill-humored joking. They would thus easily offend their loved ones, often leading to verbally abusive behavior when only minutes or hours earlier they had vowed "eternal" love. At other times, interpersonal crises escalate because of their pouting and obtrusive behavior. In brief, the morose temperamentality of the irritable cyclothymic provides the unstable base from which interpersonal tempests arise.

Recent data[25] from a French national collaborative study has shown that the notion of cyclothymia and hypomania as positive "sunny" traits and behaviors represents just one facet of soft bipolarity. This driven-euphoric facet should be contrasted with the irritable-tempestuous or "darker" side of bipolarity. The correlation of cyclothymia reaches significance (.37) only with the latter facet. In brief, depressions arising from a cyclothymic baseline are often characterized by dysphoric hypomanic periods, and are likely to be misdiagnosed as erratic personality disorders. Their high familial load for affective (including bipolar) disorder support their inclusion as a more unstable variant of bipolar II that can be best be characterized as "cyclothymic depressions."

Another study[26] relevant to the "darker" side of bipolarity, which is still unpublished, derives from the author's collaboration with the University of Pisa. In 107 atypical major depressive patients, logistic regression revealed that cyclothymic temperament accounted for much of the relationship between atypicality and borderline personality. The cyclothymic-sensitive disposition seems to represent the common denominator in the complex syndromic pattern of anxiety, mood, and impulse disorders. We explained these findings and considerations as support for the contention that atypical depression, borderline personality, cyclothymia, and bipolar II represent overlapping manifestations of a common underlying psychobiologic diathesis.

Unless their temperamental vulnerabilities are understood properly, the comorbidity and erratic clinical presentations of these borderline patients can baffle clinicians. As a result, some researchers prefer to characterize these vulnerabilities along the lines of sociopathy and related personality disorders.[27] Such characterization, in my opinion, misses the core emotionality of borderline patients that can be observed in both patients and in their biologic kin.[28] I submit that interpersonal sensitivity, mood reactivity, and lability are more germane to the origin of borderline psychopathology and its comorbidities. It is their innate -- and, to some extent, developmentally acquired -- intense reactivity to others that creates their turbulent relationships, and indeed their entire biography.

As discussed elsewhere,[10] the tragedy of borderline patients is that their impulsive drive, which thrusts them into the theater of human interactions -- coupled with their negative affectivity -- accentuates and thereby validates their sense of being rejected emotionally, maltreated, and abused; the more unfortunate among them do get actually abused by psychopathic family members (usually a step-parent).

Concluding Remarks

Discussion of psychopharmacologic and formal psychotherapeutic interventions in borderline personality conceived as a soft bipolar variant are beyond the scope of this paper. Suffice it to say that the affective framework for borderline personality described in this paper has major implications for clinical management. Foremost among them is that affective reconceptualization of borderline pathology may substantially reduce the therapists' countertransference[29] because now the patient is viewed as affectively ill, rather than "character flawed." Treatment should be undertaken with the requisite competence and confidence for a serious mental disorder. The suicide risk -- a potentially fatal consequence of the intense affective dysregulation -- should be conceptualized and clinically managed as rigorously as in any patient with serious mood disorder. The affective dysregulation and the impulsivity that underlies such risk may, in principle, be preventable with mood stabilizers, including carbamazepine and divalproex. This is a vital public health priority.

These patients often come from disturbed families and appear at risk for emotional instability due to both genetic factors (eg, bipolarity, alcoholism) and developmental factors (eg, disruption in early attachment bonds and other traumatic experiences). The neuroendocrine and sleep neurophysiologic correlates of their exquisite affective vulnerabilities have been documented elsewhere.[10] Since borderline patients -- in view of their negative affectivity -- often develop malevolent object representations of significant others in their lives,[30] clinicians must not assume that the parents of borderline patients are or were "monsters." Parents' guidance is often crucial to these patients' mastery of maturational tasks. On the other hand, Kurt Schneider's[31] wise admonition should not be forgotten: "On their bad days, keep out of their way as far as possible."

[ultramar]

I'm sorry but this guy is all over the place, it's confusing and in places outright bizarre.

As far as the statistic you mention:

taking the most liberal definition of bipolarity (including pharmacologic-hypomania, cyclothymic temperament, and family history for bipolar disorder), 81% of borderline patients could be considered lying on the border of within the bipolar spectrum.

First of all, what on earth does lying on the border of within the bipolar spectrum mean??

This just isn't a scientific study and it's frankly really out there. 20 patients studied. He says 80% qualify for bipolar spectrum because they're basing the diagnosis on/including 1) if the elevated mood was exclusively a reaction to medication, 2) if the person has cyclothymic temperament (this just means someone's mood changes frequently, could not be more non-specific), and 3) family history --in other words, one or more of these 20 pts were diagnosed on the bipolar spectrum only because they had a relative who has bipolar. There's not one iota of science here.

His conclusion is this: The strongest argument for reclassifying BPD as an affective disorder is so that their pdocs/T's won't dislike them (countertransference). Seriously, that's what the last paragraph says. He goes on to say that since it will be considered a valid disorder/to be taken seriously, it will/should be treated with bipolar meds. But no mention on why the meds will help these people, only that it's good for them to take them b/c it legitimizes their suffering. And no mention of therapy.

But really, if this weren't enough, this is his last sentence (referring to people with BPD):

On the other hand, Kurt Schneider's[31] wise admonition should not be forgotten: "On their bad days, keep out of their way as far as possible."

He's a wacko.

There's some good information out there on the similarities of BPD and BP, the differences, co-morbidity, etc. I suggest you keep looking, you'll find some helpful (and legitimate) information.

Damn. Forgot computer was running on battery, and just lost whole post. Will try to recoup the gist of it...

Originally Posted by ultramar

I'm not saying you're one or the other or both, but something you wrote jumped out at me I'd like to comment on:
rejection sensitivity and mood improving once getting into work or mingling with folk.
Keep in mind that 'rejection sensitivity' is actually a hallmark of BPD and I have read that some people with BPD do feel better when around others, as there can be an intolerance of aloneness.

I learned this differently. Two terms that at first glance seem the same, but really aren't: "rejection sensitivity" and "fear of abandonment". Fear of abandonment is, of course, a big component of BPD.

Personal observation... Folks with BPD seem to perceive negative intent/message a lot more often. They can see it as "reading between the lines". Even when there's no "between the lines" reading material, let alone negative meaning or ill intent intended on the part of the other. It's like an overly heightened vigilance for anything that might indicate abandonment. Often followed by frantic efforts to avoid it. A classic example is a text or message that doesn't get answered right away being taken as "not caring" or that they are cutting off contact, which is followed by a barrage of texts/calls seeking assurances. Those without BPD would most likely figure they were busy, no biggie, it's not personal. And believe it.
Then there is the pre-emptive abandonment reaction. Perceive imminent abandonment then dump them before they can dump you. Even if they never intended to.

One can be sensitive to rejection without extrapolating it into abandonment. Plain old hurt feelings. No fear of abandonment. No frantic efforts.

I've got BP. BF has BPD and I've been living with the day in/day out compare and contrast for almost 4 years now. Till it was figured out what was going on, his behavior often confused the hell out of me. Mood swings are common ground, but so many of the other parts are foreign to me. For instance...

Situational/interpersonal dynamics being key in mood shifts. Depressive mood wouldn't come out of nowhere(!), it would be tied to something situational/interpersonal, and could change on a dime. (For me, they do come out of nowhere. Situations can trigger or exacerbate, but just as likely I'll be fine while all hell is breaking loose or be thrown down the elevator shaft when everything's situationally fine.)

The roller coaster (along with chaos and drama) being a constant.

There is a big BPD indicator which is: extremes of idealization/devaluation of others. There is no corresponding BP symptom.
(No one has to wonder where they stand with me from day to day. They may not know how I'll be, but they don't need to worry about my view of them. It's consistent.)

The changing on a dime thing...I "get" rapid shifts, but struggle with understanding them in BPD because I don't "interpret" situational things through that lens. So, it's not unusual that I won't have a clue what tripped him off.

The suicidal threats and gestures. Do I get suicidal? Oooooh yeah. Been there. Lots. But I would never threaten it and have no use for gestures.

(And in case you're wondering, yeah, being in a couple with one of each is hard. But I love him dearly.)

Maybe someone already gave this link, but it's late, so forgive me for not re-reading to check. A concise overview right here on PC:
http://psychcentral.com/disorders/borderline-personality-disorder-symptoms/ (And wow can I ever relate to being on the other side of the intense relationships paragraph!)

Heh. And while re-writing, your most recent post came through, ultramar. Yup, the article struck me the same way. A WTH roundup.

Hello again,

Thanks to little digdee for posting the piece and further comments.

I personally was only diagnosed about 3 years ago so I am not used to reading in depth psychiatric journals. Ultramar doesn't appear impressed with the piece. However, there is similar thought processes on wikipedia about the similarities in affective instability in both BPD and Bipolar II.

The difficulty I have is that my depressions definitely manifest themselves in atypical forms. I also have unexplained pains and paralysis in my body and I am really reactive to sounds, noises etc. Sometimes I have intrusive thoughts in my head.

I definately have BPD traits around abandonment and rejection but I also have distractability, fatigue, either oversleeping or sleeping to little etc. I also often taken on to many tasks at once etc and am high achieving in my career having better ideas and projects than everyone else.

From my own research on the issue BPD does result in sleep disturbance, high functioning behaviour, distractability etc though the borderline is often a highly charismatic individual for instance. Bipolar 2 says the manic episodes are often negative that it cannot be often separated from regular depression with irritability, fatigue, anxiety, paranoid ideation etc. I definately have periods of those which can last a long time.

From my own perspective I found the above article very helpful. The BPD diagnosis I got was because I didn't have many periods when I felt ok inbetween episodes. The Pdoc said most others would diagnose me Bipolar and it was still marginal. He was also of a lower grade than the first pdoc (not sure if that means anything though).

My real concern is that I have been had on and off (more off than on) bouts of therapy for 20 years and often thought I was improving only to crash into depressions again and not feeling I have recovered because what is inside me continues to remain. I am scared of that happening again and even refuse to get my hopes up for fear of disappointment.

[ultramar]

This is pretty brief/general, but it's the paragraph from the PC description of BPD that relates most to mood issues in BPD (the types of things that can either be confused with -or- overlap with bipolar:

Individuals with Borderline Personality Disorder may display affective instability that is due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). The basic dysphoric mood of those with Borderline Personality Disorder is often disrupted by periods of anger, panic, or despair and is rarely relieved by periods of well-being or satisfaction. These episodes may reflect the individual’s extreme reactivity to interpersonal stresses.

I can see how the irritability and anxiety cited above could be confused with a form of hypomania or mixed episode. It must be hard for pdocs to make these distinctions, but I guess they have their ways. I think there are a lot of different things (perhaps not encompassed in any one article) that are taken into account. But along with distinguishing between the two, obviously both can exist simultaneously, where as someone here wrote once, the one just feels completely different than the other -in other words, the day to day stuff feels completely different, is a completely different experience, than an episode.

[The_little_didgee]

taking the most liberal definition of bipolarity (including pharmacologic-hypomania, cyclothymic temperament, and family history for bipolar disorder), 81% of borderline patients could be considered lying on the border of within the bipolar spectrum.

A conservative definition would be a firm boundary that separates Bipolar Disorder from similar illnesses.

First of all, what on earth does lying on the border of within the bipolar spectrum

This refers to BPD being on the threshold of the bipolar spectrum. Think bipolar lite.

On the other hand, Kurt Schneider's[31] wise admonition should not be forgotten: "On their bad days, keep out of their way as far as possible."

Unfortunately, this attitude is common.

He's a wacko.

He may be a wacko, but he makes some good points on the similarities between BPD and bipolar disorder. I did not find the paper offensive, except for the inane comment, at the end.

Remember it is one perspective.

Ultramar,

Thanks again for the response. I do agree the article I quoted may be a little on the overdiagnosing bipolar side of the coin but it did resonate. On wikipedia the following is mentioned:

''Both diagnoses involve symptoms commonly known as "mood swings". In bipolar disorder, the term refers to the marked lability and reactivity of mood defined as emotional dysregulation. The behavior is typically in response to external psychosocial and intrapsychic stressors, and may arise or subside, or both, suddenly and dramatically and last for seconds, minutes, hours or days.

Bipolar depression is generally more pervasive with sleep and appetite disturbances, as well as a marked nonreactivity of mood, whereas mood with respect to borderline personality and co-occurring dysthymia remains markedly reactive and sleep disturbance not acute.

The relationship between bipolar disorder and borderline personality disorder has been debated. Some hold that the latter represents a subthreshold form of affective disorder,while others maintain the distinctness between the disorders, noting they often co-occur.''

It is reading information like that which got me thinking. At first I accepted the BPD diagnosis but then after doing some of my own research on the issue (which I believe is a good thing) I realised that I do have huge levels of sleep and appetite disturbance also as well as periods of lethargy and heightened creative thinking along with distractability.

If these things were part of the diagnostic criteria for BPD I would be OK with it but they don't appear to be.

I think I probably have both. It is which is more predominant. That question I have yet to answer because I am often confused by my mood states and tend to run away from the way I am.

Thanks again for comments though.

[The_little_didgee]

Originally Posted by sgthowie

Thanks to little digdee for posting the piece and further comments.

Note: The concluding remarks are from the paper, not me. I just posted the paper, because I have a Medscape account and it was requested. None of the writing is mine.

Little Diageem

Be careful of Ultramar if it was you! (only kidding lol).

Yes, I knew it was available free on the internet somewhere. Think it is available also via a google search of Borderline and Bipolar.

[The_little_didgee]

The correct diagnosis makes a big difference on treatment and response to it.

Have you read about conditions like substance abuse/addiction, AD/HD and autism spectrum disorder? These conditions can resemble Bipolar and Borderline, at least on the superficial level.

DSM-IV-TR Diagnostic criteria for BPD and Bipolar Disorder:

[ultramar]

I'm not arguing your point (there are similarities, maybe you have one instead of the other, etc.), but the following is misquoted, this is just a point of fact:

In bipolar disorder, the term refers to the marked lability and reactivity of mood defined as emotional dysregulation. The behavior is typically in response to external psychosocial and intrapsychic stressors, and may arise or subside, or both, suddenly and dramatically and last for seconds, minutes, hours or days.

This refers to BPD, not bipolar. Trust me on this -I think you need to re-read that article.

I have no problem with the premise of similarities, co-morbidity, etc. I only have a problem with the way the article is written and researched. If you read it through very carefully, there are some really bizarre things there. This is my only bone of contention --the article, not you personally. One of many examples from the article:

The instability in the biography of cyclothymics [his re-definition of BPD] is especially accentuated in those with predominantly irritable traits. These individuals are habitually dysphoric, prone to anger, hypercritical and complaining, with a penchant for ill-humored joking.

Hypocritical, complaining, ill-humored joking?? This is hardly a scientific description of any disorder. If I were BPD I'd be really offended by this, and on behalf of those with BPD, I am offended.

It's a matter of reading through this carefully (and it is very hard to get through), I think you'll find that much of it doesn't add up.

This doesn't mean that there might be a couple of things in this long harangue that makes some sense, but as a whole, I'm just flabbergasted that this was published anywhere.

I do get riled up by such things getting published. Because published often carries the implication of 'truth' or 'authoritative' and when they're not, as in this case, I think they can really mislead people, and this bothers me.

[ultramar]

Originally Posted by The_little_didgee

The correct diagnosis makes a big difference on treatment and response to it.

Have you read about conditions like substance abuse/addiction, AD/HD and autism spectrum disorder? These conditions can resemble Bipolar and Borderline, at least on the superficial level.

DSM-IV-TR Diagnostic criteria for BPD and Bipolar Disorder:

Can you blow this up somehow? I clicked on it and couldn't find a way to make the text larger.

[The_little_didgee]

Originally Posted by ultramar

Can you blow this up somehow? I clicked on it and couldn't find a way to make the text larger.

Visit this site: http://www.psychiatrictimes.com/schi...-diagnosis-and

[joe50000]

I thought for a long time that I might have borderline personality disorder but in reality it was simply bipolar II. After finally being diagnosed and receiving treatment and therapy, it became quite clear to me. I would describe episodes from my past to my therapist, and while I do have a general fear of abandonment it doesn't have a pervasive and expansive impact on my personal relationships. I don't fear abandonment constantly or without cause.

The instability in the biography of cyclothymics is especially accentuated in those with predominantly irritable traits.[23] These individuals are habitually dysphoric, prone to anger, hypercritical and complaining, with a penchant for ill-humored joking. They would thus easily offend their loved ones, often leading to verbally abusive behavior when only minutes or hours earlier they had vowed "eternal" love. At other times, interpersonal crises escalate because of their pouting and obtrusive behavior. In brief, the morose temperamentality of the irritable cyclothymic provides the unstable base from which interpersonal tempests arise.

This is the kind of thing I would have read years ago and have self-diagnosed myself as being BPD, but it's too quick of a self-assessment. I have a lot of interpersonal conflict issues but most of those have stemmed from my emotional vulnerability when I was depressed (and therefore wanted to retreat from people, which they didn't understand), or my hypomania (where I became easily irritated or became unbearably grandiose with my behaviors.) Generally a lot of that kind of behavior was also due to my emotional immaturity at the time (who hasn't had a series of stormy relationships or acted like a complete jerk in their 20s?).

I also don't have the explosive and volatile temperament of people with BPD. I don't lash out in rages and then suddenly engage people in a loving manner. it's quite the opposite actually, most people accuse me of being emotionally cold, distant, and unreachable. I don't have anger at people without cause or over immaterial things. I do have intrusive thoughts that occur over minor slights, but that's a symptom of my episodes.

After several sessions with my therapist, who is actually quite experienced in treating BPD patients, he said that I might exhibit some of the traits, but that I do not have BPD. He said that most patients who receive treatment do not understand or perceive their own disorder - and often misdiagnose themselves. They also tend to be extremely evasive during therapy, and are often difficult to work with because they perceive their therapist as an enemy and are often quite hostile. It is a large spectrum to be sure, as bipolar disorder is as well, but he said that most likely I would not have engaged my therapist in the manner that I have, and that the responsive treatment for my depression and hypomania have been mostly pharmacological (as well as lifestyle changes). I responded very well to medication (after a few snags here and there) and most of my lifestyle changes were in accordance with typical changes most bipolar patients undergo, such as maintaining a regular sleep schedule, eating right, avoiding caffeine/nicotine/alcohol/drugs, finding a good support network, and learning to monitor my own moods.

More evidence that I don't have BPD is that my sister has BPD, and it's quite clear that our personalities are wildly different - she fits the diagnosis to a tee and she's been in therapy where they have diagnosed her as such - but only after months of evasive interactions. She was nearly shattered with her diagnosis and completely rejected treatment. She has a two-faced personality, where she has these explosive outbursts of anger that she hides behind of a facade of charm. It would be shocking to her friends and associates how incredibly angry she can get over a dirty bowl.

I say this because I don't think anyone here should read this and then suddenly jump to the conclusion that they have BPD. It takes an experienced clinician to do that.