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Disentangling Rapid-Cycling Bipolar From Borderline

Mark Dombeck, Ph.D.

A while back I wrote an essay titled "Blurring The Boundary Between Mental And Physical" in which I suggested that the scientific research establishment concerned with health care has produced pretty convincing evidence over the last several decades that many of the so-called mental illnesses have strong physical component causes and that many physical illnesses have strong mental or behavioral component causes. Mass consciousness of this realization (which breaks down the old ideas about the mind and the body being different things) is seeping into cultural awareness, but not fast enough to have yet substantially influenced public policy. Insurance parity for mental illnesses (vs. physical illnesses) isn't yet a mandate, and disease prevention programs for maintaining people's health throughout the lifespan are underfunded when they are present at all. If the nation was really serious about improving people's mental and physical health status, these reforms would be no-brainers for policy wonks to enact.

Even thought the government doesn't (want to) 'get it' (make the structural changes necessary to respect reality), the health care establishment increasingly does. For example, more and more physicians recognize the role bad lifestyle choices (such as poor diet, lack of exercise, smoking and obesity) play in promoting serious diseases such as diabetes, heart disease and cancer, and numerous research studies document linkages between depression and mood disorders and serious illness. The mental health establishment has helped lead this charge by institutionalizing the view that both biological and psychological perspectives are important in conceptualizing illness into their method of diagnosis, and by utilizing multidisciplinary treatment teams composed of diverse professionals, each attuned to particular aspects of patients' experience (e.g., biological, psychological, social, spiritual), who each can contribute treatment recommendations. In short, the "BioPsychoSocial" diagnostic approach pushes clinicians to think outside the blinders of their own professional disciplines to consider how medical, developmental, psychological, and social conditions and symptoms come together to produce a particular patient's illness.

While for the most part biopsychosocial diagnosis processes work out well and create a more holistic picture of patients than would otherwise be possible, sometimes such approaches can create confusion as well as illumination. When there are multiple possible causes of troublesome symptoms to pay attention to, how does one know which causes to treat? Nowhere is this sort of confusion illustrated so well as when DSM axis I (one) and axis II (two) diagnoses conflict.

The next few paragraphs are intended for people who don't know about how DSM diagnosis works. If you know this stuff already, feel free to skip them.

Some words of explanation are in order. DSM stands for "diagnostic and statistical manual." The DSM is the bible of psychiatric and mental health diagnosis; All providers who would like to get paid for their work must subscribe to the categories and procedures described therein. A DSM diagnosis is divided into five axes, each of which asks the diagnosing clinician to pay attention to a different aspect of patients' biological, psychological or social reality. Axis I is the place where primary mental illness diagnoses are made like depression - these diagnoses are thought to occur as discrete events and to not be related to developmental trends. Axis II is the place where developmental trends and associated symptoms - many of which manifest as personality and social skill problems - are noted. Axis III is where physical disorders like cancer and heart disease are noted. Axis IV is where social problems like not having a stable place to live or a poorly developed social network are noted. Axis V, finally, is reserved for a sort of global "how well is this person functioning" rating.

That developmentally-influenced illnesses are recorded separately from non-developmentally influenced illnesses is the result of a political compromise of sorts. The DSM started out life as a psychoanalytic document - before tools and research-based approaches were commonplace in psychiatry. It stayed that way until DSM III (three) was published in 1980 or so. At that time (so I am to understand), the psychoanalytic viewpoint, with its emphasis on how past events influence present behavior, was banished from the mainstream and relegated to Axis II. Thus was born the personality disorders, which are after all a family of diagnoses that deal specifically with ways that developmental history influences people to have maladjusted personalities in the present. With this division of diagnosis into Axis I and Axis II components, both 'empirical' diagnoses and psycho analytically informed diagnoses could take place side by side and cross-illuminate one another. It usually does work out that way too - except in cases where the two diagnostic perspectives appear to compete to describe the same thing.

I can think of two cases to illustrate the point. First, there is considerable diagnostic overlap between social phobia and avoidant personality disorder diagnoses, and second there is considerably overlap between rapid-cycling or cyclothymic forms of bipolar spectrum disorder and borderline personality disorder. We'll use the latter case as our example.

Bipolar disorder - sometimes known as manic-depressive disorder - is a form of mood disorder characterized by periodic cycling between depressive-like (sad, irritable, agitated) and manic-like (energetic, impulsive, happy) states. Bipolar disorder is thought of as a spectrum disorder in that there are extreme forms and mild forms and everything in between. The classic bipolar presentation (e.g., Bipolar type 1) involves mood alternation between pronounced depressive and manic episodes, possibly involving actual psychotic states, several times per year, with each episode lasting months in duration. But there are milder forms of bipolar where patients complain of pronounced depressions only, depressions with mild manic symptoms (bipolar type 2), mild depression and manic symptoms, etc. There are also individual differences in the periodicity of bipolar cycling, with rapid-cycling (more than four times per year), ultra-rapid cycling (more than once per month) and ultridian cycling (more than once per day) now discussed in the literature. Ultra-rapid and ultridian cycling patterns were not accepted as existing when I was in graduate school in the 1990's. If a patient was cycling faster than four times per year, we were taught to think strongly that there must be some underlying personality disorder accounting for that. Things have changed a little in ten years.

Bipolar disorders are considered to be disorders of brain chemistry. The dominant view is that the disorder is 'hardware' driven - with mood swings being caused by disregulated ratios of various brain chemicals and/or neural sensitivities to brain chemicals in a manner similar to how some forms of Diabetes are conceptualized as being disorders of blood chemistry and insulin sensitivity. The chemicals go out of whack and that causes the disorder. Not surprisingly, the common treatments used with bipolar conditions are almost exclusively pharmacological; Lithium, Valproic Acid (Depakote) and more recently, anti-psychotic agents like Olanzipine (Zyprexa) and Seroquel. There is little room in this causal conceptualization for the possibility that higher level brain functions such as thought or social representation might play a causal role in producing the mood swings.

In contrast to bipolar disorder which is diagnosed on Axis I, borderline personality disorder is diagnosed on Axis II. Borderline personality disorder is understood to be a disorder of fragile self-concept and disregulated emotional coping in which sensitive people (generally who were abused in some form as children) show a rigid pattern of intense interpersonally-directed emotionality and unstable intimate relationships. Borderline people also show pronounced mood variation, but this is thought to occur not due to underlying brain chemistry problems, but rather to fragile relationship coping skills and a tendancy to view relationship partners in very high contrast “good or evil but not a mixture of the two” manner any pole of which proves to be difficult to sustain. Mood swings in the context of borderline are thought of as 'software' problems brought on by changes in the patient's perception and appraisal of their social situation. If bipolar patients' rigid and unstable thought process have been in place for some time (which in most cases it has been as the disorder is thought to have it's genesis as an attempt to cope with early abuse), then their personality (and even their evolving nervous system tuning) grows up with unstable mood as a central feature. After a while it becomes hard to say what is the product of the unstable and rigid black and white thinking and what is the product of having lived that way so long that it becomes normal for that patient to be that way. In any event, a diagnosis of borderline disorder does usually imply that underlying brain hardware is assumed to be more or less okay. Not surprisingly, borderline personality disorder is more likely to be treated with psychotherapy than are bipolar conditions. Of course, this being America in the 21st century, lots of medications are used for bipolar treatment too, and, as they often prove helpful, this is a good thing.

Rapid cycling bipolar and borderline disorders are not intended to be describing the same thing. It is quite possible (and indeed is most often the case) that they are each diagnosed in the absence of reference to the other. However, there are these patients who seem to have both things happening at the same time, and that is where things get interesting. Exactly what does it mean if both disorders are diagnosed to be present at the same time: Does it mean that one diagnosis is more right than the other? Can a patient's mood cycling be caused by more than one thing at the same time? The answer to the first question sort of boils down to how much weight doctors making diagnoses give to either chemical or interpersonal causal explanations for why patient's moods are swinging (which in turn is strongly influenced by their professional training). The answer to the second question is most likely "yes."

Lest you think that moods can only be caused by chemicals, you'd be quite wrong. The success of cognitive behavioral psychotherapy approaches has established pretty much beyond any doubt that thoughts are capable of influencing mood, and that if a patient can be taught to think differently about his or her depressive (or anxious) thoughts, his or her mood will lift. Knowing this makes it perfectly plausible that instabilities in someone's ability to feel secure in relationships and someone's lack of knowledge with regard to how to sooth themselves when they get agitated can translate into mood swings as pronounced as anything chemically induced. Both chemicals and thoughts are legitimate potential causes of mood swings. It's a reasonable thing to disregard the influence that thought and perception has on mood instability when dealing with clear and pronounced 'hardware' problems (such as bipolar I), but in more mild forms of bipolar disorder it is possible that chemicals and thoughts - hardware and software - play a role in determining patients' mood.

Fortunately, it is not really all that important to get the diagnosis perfect - to disentangle the possibilities of whether rapid-cycling bipolar or borderline diagnoses are more appropriate. It so happens that the treatment approaches used for one disorder are highly similar to those used to treat the other disorder -at least in terms of medicines. This may not be an accident, in that both disordered chemistry and disordered thought may be pushing the same levers to move mood up and down – the same levers that are manipulated by medications. It's hard to determine if this is the case, but as per usual, more research will ultimately settle the question.

To the extent that disentangling rapid-cycling bipolar disorder from borderline disorder becomes important, it make take creative assessment techniques to make it happen. You'd perhaps expect some regularity to mood cycling if it were truly uniquely caused by some underlying chemical disturbance. In contrast, you'd expect more random mood cycling, or mood cycling that is closely tied to events in patients' emotional lives if it were caused uniquely by some interpersonal problem. Right now mood cycling is basically assessed using self-reports and it is easy for patients to just not know how frequently or regularly their mood fluctuates in a given period. If some future advance made it feasible to measure the proper chemicals on an ongoing basis so as to establish cycling in a more objective way, we might get somewhere. But that too will have to wait for the future.

The purpose of my essay this month is hopefully clear now: I am writing to show how the diversity of causes that DSM diagnoses acknowledge can lead to situations that are sometimes diagnostically confusing even as they better reflect the complexities inherent in patients' presentations. Reducing the diagnostic task to either biology or psychology alone would make it simpler to accomplish, but would potentially harm patients seeking help in cases where their disorder's causes were not recognized or properly acknowledged. The present example suggests in miniature both the progress that has been made and the progress that still needs to occur before this type of diagnostic differentiation issue can be cleanly resolved.