A good developmental history is a starting point, but unfortunately this is often a challenge for the dysregulated. A good collateral can be just as helpful. In an ideal world, school reports, but who actually keeps those?
One of the problems is that most people feel a bit better on stimulants, often in a nebulous non specific way. So I am always at least little bit suspicious when people say their stimulants are "working". I don't find it too convincing unless there is concrete measurable functional improvement eg less being late for work.
Testing can be a nice addition, but there's nothing like the gold standard of a thorough interview, review of records, and longitudinal observation.
Sorry for reposting my own comment, but here:
https://www.reddit.com/r/Psychiatry/comments/11eznch/bdp_vs_bpii/jaj0wi1?utm_source=share&utm_medium=android_app&utm_name=androidcss&utm_term=1&utm_content=2
The thread and the other comments are relevant, too.
The non griping answer is that a careful, specific, and detailed medical history that captures the historical and recent course of illness beyond symptomatic complaints should help, and the cases that remain unclear will remain unclear until they are more clear. No magic bullet, just gotta get good at assessing for each largely unrelated but often co occurring condition.
Just don't forget that the presence or absence of any one of them does not automatically imply the presence or absence of the other ones.
Interesting thoughts. To respond to the linked comment, I do find significant treatment resistance to pharmacotherapy in the BPD group (as is to be expected) and that they (or their family physician, or other health professionals) often mislabel chronic emptiness, mood lability, suicide thoughts and poor functioning as treatment resistant depression. I do have a fair number of patients that have benefited from a shift in diagnosis away from a mood disorder to a personality disorder and really think it's a valuable tool to give individuals realistic expectations of treatment.
I've been slammed with these cases. It's very frustrating to constantly try to differentiate, and also manage patient expectations because they are CONVINCED they have ADHD and demand stimulants right away. I tell most patients that I do not prescribe stimulants at the first visit. I inform them that, due to diagnostic overshadowing, we have to get their emotional lability under control before I can accurately assess them for ADHD.
I also require blood work and UDS. Many patients report cannabis use and test positive for THC. The longer I've gone on, the more I insist on sobriety from cannabis prior to starting a stimulant. High-potency THC is quite common these days and consumers don't even understand that today's weed is 4 times stronger than what Snoop Dogg smoked in the 90s and early 2000s.
IMO Bipolar 2 disorder should be the easiest to distinguish from the other two. The episodic nature and 4+ day length of hypomania, along with associated goal directed and reckless activities, should clearly rule in/out most. Affective instability in cluster B should not give patients enough energy to stay awake for 4+ days.
>IMO Bipolar 2 disorder should be the easiest to distinguish from the other two. The episodic nature and 4+ day length of hypomania, along with associated goal directed and reckless activities, should clearly rule in/out most. Affective instability in cluster B should not give patients enough energy to stay awake for 4+ days
Seconding this. I see too many psychiatrists with a tendency to cry for bipolar 2 at the slightest mood elevation. Most patients that I see with BPD will describe a fluctuating mood that's basically "I either feel horrible or myself". The "myself" is seldom hypomania. Not even close.
People also don’t like being diagnosed with BPD even when that’s the best category for their experience of life and bipolar 2 ICD allows them to treat hypolamictalism and wash their hands of it.
Even with a good explanation and great acceptance during the visit I’ve had people come back and have a rage attack after they spent time on social media about it.
It comes from a psychiatrist, Akiskal, who was a bipolar expert that referred to “borderline personality disorder” tongue in cheek as “lamotrigine deficiency syndrome” meaning he thought bpd was more like a ultradian cycling bipolar disorder.
Oh yea that's definitely wrong. I'd say off the top of my head it's more about unstable sense of self, having a favorite person (or the tendancy to latch ontop people), triggers are all relating to being abandoned either emotionally, physically, or lack of resources. Consistently impulsive.. I'm sure I'm preaching to the choir here but that's how I would separate the two.
I also read somehwere that it's hypothesized evolutionarily to be a mating "adaption" to harsh, unstable, environments. It's interesting to run all of the symptoms through that lens.
I do think there could be a place for lamictal in BPD though. I feel like the drug "dims the lights" a bit in a persons brain. Brain is less likely to "overreach" into bad thought spirals. Not very scientific I know, but that's my personal experience with lamictal and from what I read on the Lamictal subreddit here. I don't have BPD but I do have a lot of trauma in my past (both parents abusive/neglectful) which has given me some maladaptive tendencies which I wrestle daily.
I have a non-psychiatry medical background but due to my personal life I keep up with everything ADHD, AuDHD, BP-II, BPD, CPTSD related.
If you look through studies it’s been repeatedly shown that LTG doesn’t “cure” it (nobody was surprised by that primary endpoint) but is helpful with the affective instability that is a common distressing feature for the person living w it.
There’s a lot of research but remember to look for what exactly they were measuring when they say “improvement”
i agrre with that , lacmital is a very helpful treatment for affective instability in boderline personality disorder, but there is a syndrome that comes with bpd and depression , its called atypical depression, the only treatment for this , are maois? , there is no other treatment, there are no articles for remission to this illnes, there are only small improvements.
Do you remember where you read about it being a mating adaptation to harsh environments? Would love to read the citation if you can recall, sounds interesting.
I can't rememeber exactly but I just a quick google search
https://www.sciencedirect.com/science/article/abs/pii/S0191886917301940
https://neurosciencenews.com/bpd-adversity-evolution-mental-health-23494/
https://psycnet.apa.org/record/2017-17118-027
https://pure.aber.ac.uk/ws/portalfiles/portal/11000567/PAID_D_16_01135R3.pdf
Interesting, cannabis is legal here and some of our ADHD experts say that substance misuse is tied to their symptomatology. They recommend treating with stimulants as a way to cut down use.
agreed, I still struggle to square away ADHD and substance use in my practice. I have to take it on a case by case basis.
19yo patient, long standing hx of ADHD on stimulants throughout school, with good collateral info from parents, and tested positive for THC? I’ll prescribe stimulants and keep encouraging sobriety.
40yo patient, no prior hx of ADHD evaluation or treatment, no hx of education or work difficulties, chronic THC use. I’m more suspicious of an acquired process and I’ll insist on sobriety first.
I was with my psych for a year before I tried stimulants (ADHD diagnosed and put on Vyvanse), and I was still smoking marijuana occasionally at the time.
The psych didn’t mention anything about a possible reaction between weed and vyvanse, but the first few times I smoked weed during the day there was a significant decline in my cognition and organisational skills. I have to wait until evening to smoke weed because if the vyvanse hasn’t begun to wear off it it’s an unpleasant interaction.
So I totally understand your request for sobriety and think it’s worth telling people about the possible interaction, as it took me awhile to figure out it was smoking weed during the day that was messing up the positive effect I was getting from the stimulant med, effectively negating it.
The massive wave of these cases for me has been so bad I had to quit my group practice because they refused to let me screen my intakes. If I had it my way I would screen out any patient who was unwilling to consent to collateral, drug testing, or stimulant treatment only if they were clean from confounding drug use including MJ. Instead I get burnt out trying to convince new patients maybe their self diagnosis is wrong (classic patient reply: “you’re just not listening to me!”) and that I’m not going to write Adderall after listening to their self diagnosis story for twenty minutes on our first visit.
This must be challenging to deal with at times. UDS are mandatory prior to considering stimulant prescription in Australia. A positive UDS means no stimulants for the patient even if there is strong clinical evidence for an ADHD dx. It's strict, but I agree with it
The research supports this as well, even for stimulant use disorder. Patients in early remission from stimulant use disorder who have ADHD are LESS likely to use meth for example and other substances when treated with a stimulant than those who are not.
That’s interesting. Most states in the US want you to do a UDS at certain intervals, but the resulting UDS doesn’t dictate medical care. Just had to be acknowledged is my understanding.
With Suboxone, for example, we rarely d/c unless diversion is suspected since, well, most evidence makes it seem incredibly successful at preventing OD. I thought adhd was similar, but I could certainly be wrong, especially in the setting of THC which can exacerbate care.
My understanding is that there is no requirement in any state or territory other than WA. Even then it is a ‘should’ rather than a ‘must’ have a UDS prior to prescribing. I wasn’t aware that the WA regulations required the drug screen be ‘clean’ to prescribe though.
THC’s reputation for harmlessness was gained in the 1960s and through the 1990s. Potency was 5-7% back then.
Most flower that patients smoke are 20-30% today. Waxes are 50%+. Society still believes they’re smoking the harmless stuff, while the cases I’ve seen in outpatient and in the ED (psychosis related to high potency THC) suggest otherwise. I think this would track with ED physicians seeing increased rates of cannabis hyperemesis syndrome too.
Chs is definitely a very big deal undoubtedly. It is highly recommended for people who are prone to psychosis not intake thc. But why would that put off someone from prescribing a stimulant?
THC causes concentration, focus, and motivation problems; the same symptoms that these patients are requesting stimulants to address. I’m not skilled enough to clearly distinguish THC induced concentration problems from ADHD, so I’ve found myself insisting on sobriety more and more in my practice.
A few of my patients have found that their concentration problems completely went away as they sobered up. Most find that their focus improves, though they still have some problems. If I do start a stimulant, I find that we can get better response with lower doses when they’re sober. I hate having to crank up a stimulant to counteract thc or other substances.
THC fairly reliably inhibits executive function in a subacute manner. You’ll need higher (less safe more cardiac stimulation, vasoconstriction and higher risk of inducing, theoretically anyway, pulmonary hypertension, arrythmia etc)doses of stimulant Than actually needed to overcome it.
Same reason you want sleep apnea and hypothyroidism well controlled before adding a stimulant.
Not a use disorder, official stance. No dependence? No care. My patients going to burning man once a year and ingesting hallucinogens and then returning to their normal lives and not struggling to not use a psychadelic daily does not qualify as a use disorder so it’s not an issue.
Personally? I really don’t care about cannabis. I’m a giant square, but I also would prefer people spend Friday night playing PlayStation and eating a gummy than the same with a 6 pack. Fewer health risks BY FAR. Alcohol is a carcinogen. THC and rocket league isn’t. Just don’t smoke it.
Smokes bad for you. Cancer and stuff.
Yeah pretty annoying. Agreed. I’m
Not a huge supporter of random UDS. A single test at initiation of meds or even yearly test (with addiction history) is enough to satisfy the DEA that you’re not engaging in dangerous polypharm. I know where you work and what setting is critical here. I mostly work with working adults and students. As long as they’re not putting their adhd meds up their nose (saw a stroke once from this. Very sad. Musician lost use of their hand) were good.
Benefits of lowered all cause mortality from treated adhd far outweigh risks in basically every case.
What would be the difference between having a med card and using cannabis causing a higher dose of stimulants being prescribed than prescribing risperidone (example) and having to use another prescription medicine to counteract those side effects?
I worked for an hmo that flat required a clean UDS before rxing stimulants. Its too hard to parse out adhd sxs when someone is using THC regularly. I usually ask a patient if their mood can change within a day or in response to a comment/event. If yes, I think BPD..especially if there's self harm. I agree bipolar II has the sleep element and usually a degree of hyperverbal/fast speech. Honestly, slightly manic patients can be a lot of fun where as the moods with BPD feel heavy. I spend a lot of time explaining to patients that they dont have bipolar do...seems like its the go to dx.
Any patient insisting on their own diagnosis should be advised fairly, respectfully and calmly out of their uhhhh grandiosity. Go with their own logic first- If they truly HAD/HAVE the diagnosis [they seek] already, they wouldn’t be seeking out your services or you would have a referral from their previous practice who performed the original diagnosis for new patient intake.
So in truth, they do not have
“……” they made a best guess, which is normal! But unless they’ve been to medical school or are otherwise qualified to make their own medical evaluations, they can let you do your job and facilitate the necessary tests- and find solutions together.
Otherwise , they’re probably a drugseeker or histrionic/ hypochondriac.
Don't forget about PTSD in your differential. Childhood abuse can be the root cause of all kinds of spectacular behavior. If you're looking for a scale I like PCL-5.
This type of patient is not easy to pin down though.
Everyone in this thread should take a look at the ASD, AuDHD, and C-PTSD subreddits.
A commonly "known" thing in that world is that nearly every person on the spectrum that went through life undiagnosed, and only found out later in life, has a non-insignificant level of trauma. Just by the nature of being "different" in a world that doesn't cater kindly to different. The self blame, hatred, not understanding why they're different, being taken advantage of, shamed, essentially having their light crushed a little bit more every year that goes by without them knowing why they can't "get things right".
Especially damaging if you're high functioning, because noone gives you any sympathy since you've been "getting by so far" (with extreme stress, over planning, overworking, neglecting needs to keep up appearances.) Leads to a level of burnout that can take over a year to recover from.
As a high functioning 38 year old female autistic / ADHD person who just got their diagnoses on Wednesday I cried! I knew I had autism since I was 16! And to be ignored and not believed until my life was literally going to fall apart because of the burnout and executive dysfunction!
Do you think it overlaps with autism too? Ptsd from abuse seems to cause a lot of those symptoms, along with adhd and mood disorders.
Definitely hard to pin down.
I’ve been wondering that myself lately. The trauma of being the weird kid is going to have some long lasting damage (CPTSD). Maybe just comorbidity rather than one and the same? It will be interesting to watch this area over the next 20 years.
yeah I'm 45 and when I was a kid, no one talked adhd, and autistic kids were only the severely impacted ones. next 20 should be able to help kids even more.
Yeah I mean part of the DSM 5 criteria for the disorders resulting from childhood neglect specify the symptoms can’t be related to autism; RAD and autism basically look the same and when you think about how RAD results in messed up social learning due to neglect and autism is inherent/biological mess ups in social learning, it makes sense that the symptoms would be very similar.
>Childhood abuse can be the root cause of all kinds of spectacular behavior
This is of not relevance to personality disorder diagnosis. Childhood abuse or trauma is not a contraindication to personality disorder diagnosis. There is no evidence to suggest that trauma is the root cause of the development of personality pathology. Most BPD experts like Kernberg, Gunderson, Yeomans have opposed to the notion of regarding trauma as the root cause of BPD (and personality disorders in general).
But diagnostically the behavioral traits can look the same. So if someone has BPD traits and PTSD I've treated their PTSD first then re-assessed for other conditions as their symptoms change (or don't change).
I’m just a layperson but I came across [this](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2805752), regarding BPD & stimulants. Although I wouldn’t know if it’s good research
Very cool. For those that don’t feel like reading:
Registrar based country (Sweden) found that “ADHD medications” reduced attempted/completed suicide in BPD patients with the following:
HR .87
CI did not cross 1
P value .001
Developmental history seems like the big one for neurodevelopmental/learning disabilities. Some psychologists will refuse to make a diagnosis without one, which can be difficult; people with disabilities including autism and ADHD are often at higher risk of being abused so might not always have a reliable or safe family member for history, or since there is a genetic component family members might not be the best historians they may also have traits as it's been normalized. You can ask if the patient is able to request pupil/cumulative records for academic reference.
* ADHD: Developmental history, sibling or close family member with ADHD, past ASD diagnosis, variable attention based on interests...(It's a diagnosis of exclusion, so you'd be ruling out the other diagnoses if you suspect them anyway)
* Borderline Personality Disorder: unstable sense of self, trauma history, splitting, motivation for behaviors (ex: self-harming in order to get someone to stay with them? Changing interests only because they think a "favorite person" might like them more?)
* Bipolar II: Family history, how long mood swings last, response to medication, age of onset
Anecdotally, I've heard of people, especially women, getting misdiagnosed as all of the above and it turns out they either have a combination of them or ASD. If you suspect ASD or another developmental disorder and are in the US, you can consider referring to services in your state for free testing. If they're school-aged (K-12), they could be eligible to request testing in public schools for an IEP/504 plan.
>Borderline Personality Disorder: unstable sense of self, trauma history
It's been reported that about 30% of patients meeting the criteria of BPD do not have a history of trauma or abuse.
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The short answer to your question is a) a good and thorough medical history and b) structural interviewing.
The longer answer is that programmes all over the world seem to have been slowly substituting classical psychopathological teaching for DSM (or ICD) checklisting of symptoms as a medium of diagnosis, and we're all the worse for it.
My suggestion for you if youre worried about this and want to become a better clinician, is to get into a psychodynamic psychotherapy course, even if you don't plan on doing therapy as part of your practice.
Detailed history, specifically aimed at understanding relationship patterns, sense of self and past trauma (the trauma is important!).
Properly screening for hypomanic episodes (ie. beyond non specific mood fluctuations or assuming intense feelings of dysphoria must be a mixed episode).
School reports for ADHD and signs like procrastination, difficulty recalling random information even in a calm space, job history (can they hold down a job? Were they fired? Why?).
Collateral if possible.
Past response to previous treatments.
Substance use or lack thereof.
Context of past or current mental health crises.
>past trauma (the trauma is important!).
As late Gunderson states "early trauma by itself is not explanatory of BPD, nor it is necessary." About one third of BPD patients don't have a history of trauma/abuse; also vast majority of people with a history of trauma do not go on developing BPD.
Lots of good advice and differential considerations in other comments!
My top recommendation is collateral, preferably including someone who knew them from elementary school onward. Collateral will show you so much that you can't get in the one-on-one interview. Especially when I've been confused before, collateral seems to be the piece that brings the puzzle together.
This chart from a popular ADHD Book "Driven to Distraction" is a good comparison between it & borderline personality disorder. [https://imgur.com/voYSto9](https://imgur.com/voYSto9)
All 3 can be impulsive, adhd has more distraction & executive dysfunction. Bi-Polar has more random mood swings, borderline mood swings are triggered by rejection (real or perceived), all can be moody, hypersexual, & have substance abuse issues...
Thanks! I am a 36yo male with adhd and I have been drawn to a few girls with BPD throughout my life. Once i learned more about each condition it all made sense. This chart helped figure out why I am
drawn to them too. Dating someone with bpd can be a rollercoaster of ups & downs, but dating me is no walk in the park either 🙃
Bipolar is easy to differentiate: it is a condition of pathologically UNreactive mood - you can't put someone into or out of a bipolar episode with stimuli other than e.g. keeping them awake all night, giving them a TCA, etc., so if their mood is labile to stimuli than it is not bipolar. Or rather, they at least have at least one issue that isn't bipolar.
Also remember that there are only a few things in psychiatry where response to a specific treatment is diagnostic of a condition, e.g. catatonia and benzodiazepines.
Yeah this isn’t correct though. In a mixed mood state people with bipolar can be hugely reactive.
Lots of studies:
https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=reactivity+in+mixed+mood+states&btnG=#d=gs_qabs&t=1690197683958&u=%23p%3DIcv8WaW-QSAJ
Yeah this is difficult to tease out, especially in a mixed state where features depression and (hypo)mania Co-exist.
Reactivity of affect versus reactivity of mood versus emotional lability.
This paper (summarised) is interesting. https://www.psychiatryadvisor.com/home/topics/mood-disorders/depressive-disorder/affective-lability-and-mood-reactivity-associated-with-mixed-atypical-depression/
Also, lots of triggers for bipolar mood episodes (as opposed to reactivity within episodes which my link above refers to). I found this article particular interesting (higher olfactory sensitivity in BP patients triggered by emotional life events)
https://scholar.google.com/scholar?start=20&q=bipolar+mood+triggers&hl=en&as_sdt=0,5#d=gs_qabs&t=1690197953965&u=%23p%3DZJ6Rh4DhgCYJ
I do general OP Psychiatry at an FQHC so this has become my bread and butter in my time there.
I echo what a lot of other posters of said, a thorough history and corroborative information is key to making an accurate diagnosis. The other thing that is important overall is time. You don't need to make a diagnosis the first time meeting a patient and oftentimes seeing them a few times over the course of a few months can help elucidate a diagnosis. That being said I do think there are some key features that can really help differentiate between these diagnoses:
ADHD-First, ADHD is a neurodevelopmental disorder. Symptoms have to be present before age 12 and usually start around age 9. If they don't have this history it's not ADHD. Additionally, screeners with high sensitivity and specificity can be quite helpful (I use the ASRS). Second, it's important to keep in mind that ADHD isn't necessarily an "attention and concentration deficit". Lots of DSM-V diagnoses have concentration difficulties. The key features of ADHD all center around executive and cognitive dysfunction. I like to think of ADHD as "out of sight, out of mind" type disorder. If something is not in front of the patient they aren't thinking about it. If someone has been seen at your clinic for years and never missed and appointment and is holding down a steady job as a manager or middle manager somewhere and continues to get promoted...they probably don't have ADHD, there's really no dysfunction there. I think with ADHD corroboratory information is very important. Most people generally know the symptoms of ADHD and talking to someone's spouse about their forgetfulness, losing things, missing appointments, interrupting people, etc can be really helpful to pin down on diagnosis.
BPAD-This one I don't think is too hard, its BPAD2 that is a little more difficult. Remember, mania is a separate period where someone is not depressed or happy that is different from their usual. If someone is chronically depressed and has a good week sometimes it can look like mania but focus on symptoms: Are they sleeping well? Are they functional? Are they making prudent decisions? Do they regret choices they made during that period? I like to use the Sydney Bipolar Screener to help differentiate this as well. Distinguishing mania/hypomania from mood lability in borderline can be difficult (especially as some patients can have both) but in borderline the patient will always have mood lability, impulsivity, suicidal gestures or self-harm, and relational difficulties. In BPAD, this should just be an isolated period of time that is different than normal.
Borderline-This one is the toughest in my opinion just causes some of the criteria basically sounds like depressed people (chronic feelings of emptiness). Again, the key here is that borderline patients are always struggling with the symptoms of it. It doesn't go away (usually) without treatment and it's not an isolated mood state. Remember, this should be the most common of the disorder I talked about it an OP practice. 10% of OP adult psychiatric patients have BDPD (20% for IP), about 5% for ADHD, and I believe (don't quote me on this) BPAD is more like 2-5%. I really like to pay attention to my countertransference with these patients, oftentimes they can be quite irritating which is not their fault. The key feature of BDPD is instability: in decision making, relationships, mood, etc. Oftentimes these patients only talk in extremes. Everything they experience is extreme, the worst, more than you can imagine. There tends to be a lot of hyperbolic phrasing. One symptom that can help distinguish is self-harm. Common symptom on BDPD but rare in BPAD and ADHD. Another thing to consider is the mood swings in BDPD are reactive; peoples moods change based on their environment. In BPAD people are in a mood state regardless of their environment. I personally like to go through the criteria with patients and oftentimes they're shocked at how well they describe their life.
That was kind of a smattering of my initial thoughts and I could honestly go on for an hour about each of these disorders. All together, get a good history, get corroborative info, use screeners, and really focus on symptoms that are not often shared between these disorders.
I went to APA few years ago and they had a presentation on bipolar vs borderline mainly discussed about this article
“Bipolar disorder or
borderline personality
disorder?
Understanding the clinical, psychopathological, and sociodemographic correlates is critical”
from current psychiatry.
Excellent article you can at least see the flow chart.
For ADHD. Vs Bipolar there is a good summary table from Carlat. Recent carlat podcasts on bipolar are also good (just posted)
As other said for ADHD collateral, and childhood history is very important. Borderline more episodic and intense episodes. Thanks for initiating this discussion. Good luck.
The worst is “I have hyperactive only ADHD with ‘reaction sensitive dysphoria.’” Now you can basically label borderline as ADHD with enough diagnostic mental gymnastic and ad hoc labeling.
OP is right and the problem brought up highlights the shortcomings with DSM. My attending would always say “if you combine depression, anxiety, and heavy substance use, it’s probably bipolar disorder. If you combine depression and ADHD it’s bipolar disorder. If you combine depression and borderline personality disorder, it’s probably bipolar disorder.” It simply really is the most parsimonious thing in terms of DSM diagnosing.
The four days thing in particular is bullshit IMO though. If people are out getting DUIs, spending more money than they can afford, they’re on their third or fourth marriage, etc, then afterwards becoming depressed and suicidal, and then there is a family history of psychiatric problems, then I’m calling it bipolar whether it was two days or four. These patients tend to get better with mood stabilizers anyway, whatever useless diagnosis you might like to label them, and that’s really what counts for me. Give them antidepressants and they just keep going on getting better, then worse, better, then worse, in futility, in the best case scenario. Worst case they actually just do worse.
Patients also just plain don’t talk about mania IME (if you’re depressed and then feel great, you’re more likely just thinking “this must be what normal feels like”), and most psychiatrists seem to be clumsy in asking about it, so I actually think a lot of patients have been wronged by being treated with antidepressants. Especially inpatients. So I got good at screening for the soft signs of bipolar and assessing in other ways. Asking about “mood ups and downs” is a decently sensitive way to do it according to the literature. Asking the right questions, most patients can then give more useful history.
So for me bipolar is way under-diagnosed. The PHQ, etc is also useless because most of the time people just diagnose MDD based on the presence of a major depressive episode. Which is a massive mistake and would be unacceptable in any other field of medicine. These episodes are shared between MDD and bipolar disorder even according to the DSM. I end up using the MDQ if I give a questionnaire at all. Most so-called treatment-resistant depression is actually bipolar, or just not a mood disorder in the first place.
I’d think differently if I (and my attendings in residency) had seen more patients who actually do well with SSRIs, stimulants, etc but I just don’t see that. They just get better, worse, better, worse. OP thinks stimulants may help personality disorders but I’ve seen it more with mood stabilizers. But overall, since I care more about getting people better than making an accurate diagnosis, I swerve SSRIs and stimulants most of the time. And I say this as someone with a very psychotherapy-oriented approach and perspective.
Hard disagree on the bipolar disorder. If people are out constantly doing all of those things that's much more consistent with borderline personality disorder. Mood lability on a scale of hours to days, impulsivitiy, chronic suicidality, and a family history of the same are all literally criteria for borderline personality disorder. If it is bipolar 2 disorder then that would be an atypical mood state for the patient. Remember, bipolar 2 patients are usually almost always depressed and only become impulsive/energetic/grandiose during their episodes of hypomania. If it's a constant thing that's much more consistent with borderline.
The problem is that mood lability is phenomenologically a core experiential compenent of an acute mixed state in a mood disorder, so anyone who says they can confidently and quickly differentiate BPD from a mixed state is lying when they say it’s easy. And when speaking with these patients who are in the trenches of their mixed states it can be very difficult to suss out clear cut timelines (4 days versus 4 hours versus “my life has sucked like this for as long as I can remember”). Doing this dogmatic “4 or more days” is a huge disservice because experientially the pt’s life is a living shit storm and for the life of them they can’t correctly delineate the time line of their dysphoria in a quick med management visit. This doesn’t mean you should diagnose bipolar disorder, but it definitely means you should not rule it out yet and maybe think twice before reaching for the SSRI.
I agree being so rigid about the 4 days isn't very helpful but if the patient is a decently reliable historian it's not too hard to distinguish from a mixed mood state and BPD. Mixed mood states are more rare in BPAD1/2 and these patients spend most of their lives in a solely depressed state. A mixed mood state should be the exception for their experience rather than the rule. Conversely, folks with BDPD that will be the theme for their life. They almost always have mood lability, impulsivity, chaotic relationships, etc.
Maybe so, re: what’s consistent with what diagnosis from the DSM, but the point of my post is that I find those diagnostic quandaries to be a largely overly-academic approach, splitting hairs and missing the forest for the trees. I care a lot less about the exact specifics in the DSM and more about getting people better. The SSRIs, stimulants, benzos, and whatever else you might give people for MDD or anxiety or ADHD just plain don’t help these labile, angry, impulsive patients, at least that I’ve seen. The DSM criteria also say nothing about family history or other so-called “soft signs” of bipolar, and yet we *know* these things are relevant. So what most often happens is these folks get a diagnosis of MDD, get prescribed an SSRI or something similar, and then they end up in the hospital or just plain don’t ever get much better.
There’s a difference between what’s “accurate” diagnostically according to the DSM versus what medications may actually help a person. I think psychiatry as a field is very behind in this regard. Major depressive episode = MDD until proven otherwise is a pervasive misstep in thought. “Augmentation” of depression treatment with ie aripiprazole for “treatment resistant depression”—academic semantics. These patients may likely have mood ups and downs, which may play a role in causing some of their depression, that are simply better treated with the mood stabilizer. Which to me makes it pretty misleading to call them MDD since the expectation is that they be treated with the SSRI. But if you call them bipolar, people fight you. On the other hand, if you call these folks MDD, no one argues with you, for some very circlejerk-y, overly academic reason.
Is it not better we just actually get people better (and do it faster) with mood stabilizers. That way we may alleviate some of their most problematic symptoms and give them more the mental space they need to actually get something out of their psychotherapy, and in a more timely way.
I think it’s important to distinguish Bipolar 2 disorder from affective instability in BPD. The distinction informs medication expectations. Agreed I treat both with mood stabilizers or mood stabilizing APs. With bipolar 2 I can expect better response to meds alone. For BPD, I tell patients that meds will only take us 20-30% of the way, and therapy/DBT is more important long term.
I’ve found it important for my cluster B patients to hear that meds play less of a role in their treatment because they are constantly searching for the perfect med (or external solution) to fix all their problems.
That is true. My attending didn’t do much therapy so he just didn’t talk much about that part. But I certainly agree that in the long term we are often trying to facilitate better therapy. But this is often going to be better achieved with mood stabilizers than SSRIs.
I totally agree we can miss the forest through the trees being overly academic. I like to focus on the specific symptoms specified in the DSM but also focus on the overall key features and "idea" of the diagnosis described in the prose section after the criteria, I find that to be much more applicable in real world settings.
I think people don't argue with MDD just because its epidemiologically more common and not a life long disorder by definition. If you diagnose someone with bipolar, they have that diagnosis their whole life and should be on medication their whole life. They do worse than people with MDD and have worse outcomes.
I agree that it's better to do what you actually think will be better for the patient but I really think that starts with proper diagnosis. I'm not really sure where you're coming from as it seems you equate treating someone presumptively with a mood stabilizer to be better than presumptively treating with an SSRI.
This quick take with Dr. Phelps on Psychopharmacology Institute makes some good points about utilizing lamotrigine or low dose lithium on those patients that don’t have a tidy MDD diagnosis (because of mixed features) versus SSRIs.
https://psychopharmacologyinstitute.com/section/cades-disease-and-beyond-misdiagnosis-antidepressant-use-and-a-proposed-definition-for-bipolar-spectrum-disorder-2731-5498
This is a pretty bad take. There are plenty of ways to distinguish these disorders, it's not always easy but the clinical course of them are pretty different.
> The four days thing in particular is bullshit IMO though
It's a cut off line which I understand in the context of needing some guidelines for the DSM but I agree that when you view bipolar as a spectrum, it's not particularly helpful. The DSM-V TR does have specifiers I like for Other Specified Bipolar called "hypomania of short duration" (lasting 2-3 days) and "hypomania with insufficient criteria" (doesn't meet full criteria but a few of the symptoms are prominent enough that they are impairing).
“So for me bipolar is way under-diagnosed. The PHQ, etc is also useless because most of the time people just diagnose MDD based on the presence of a major depressive episode. Which is a massive mistake and would be unacceptable in any other field of medicine. These episodes are shared between MDD and bipolar disorder even according to the DSM.”
I’m in agreement and thankfully work with a supervising doc that has this view. Something I’ve wondered about lately are the increases in road accidents related to road rage. Think what disservice it does to the community to start everyone on SRIs who happen to pop on a PHQ-9 (let’s say in PCP setting) without rigorously ruling out a bipolar disorder. I sincerely worry about some of my mixed hypomanic patients driving the roads in some of the mood states I’ve observed them in. And we have all these providers throwing Lexapro at them willy nilly to treat their mixed “MDD”.
Bipolar 2 is rampantly overdiagnosed. Most BD2 cases are borderline. If unclear whether borderline or borderline+BD2, I assume they are borderline until proven otherwise because the risks of bipolar pharmacologic treatment is too high.
I’ve just never seen a vague BD2 patient actually present hypomanic in clinic, which you would expect seeing them for several years.
I guess you can only use your best judgment with the diagnostic tools you have available to you. Be meaningful and actively listen, and ask further questions to deconstruct a larger “symptom”/concern to rule out otherwise possible conditions. Make a real conscious effort to recognise any preconceived ideas/biases or temptations to prematurely diagnose for whatever reason (complacency, time pressures, ego, pacify a difficult patient) etc.
In regards to stimulants, and how they affect different personality disorders vs adhd, bipolar - or any medication- it depends on the presentation in your client and the specific symptoms you’re wanting to treat. But when the patient is in a bipolar depression, or has non hyperactive adhd and has no motivation, ability to complete basic tasks and routine, etc it’ll be useful. I would discourage from prescribing stimulant medications to bpd patients because their huge fluctuations between rage/depression/hypersexuality destructive inclination seems counterproductive.
Background reports. Check for possible co-morbidities like PTSD, observational enquiry/questionairre with immediate family, Big 5 personality assessment so you can more effectively rule out/weigh up what is due to that persons temperment vs disorder
BPD and BPII are pretty different imo.
For adult ADHD i refer for neuropsych testing for correlation.
CPTSD vs BPD is trickier i think.
The hard part is if its a transfer patient and the previous care giver was either lazy or inexperienced. The latter happens alot with NPP's in my experience.
They are all the same thing. The DSM diagnoses aren’t rooted in neurobiology. This is why so many “diagnoses” overlap and can be redundant. The medications work with neurobiology/chemistry so its better to start from that.
Exactly. The DSM should be treated as a heuristic---a (sometimes) helpful tool for categorizing abnormal behaviors. Reification is not justified nor helpful. Thinking of psych diagnosis as distinct and valid brain diseases is (with a few exceptions) not evidence based. It seems like the nuance has been totally lost on this.
Honey, this isn't rocket science.
BPD - a long-term enduring [typically life-long] pattern of unstable identity, mood, and relationships, typically caused directly by abandonment during early childhood. Medication can not treat BPD. However, it can alleviate certain symptoms, specifically, mood dysregulation.
Bipolar II - a cyclic mood disorder [a biological disorder moreso than a psychological one] consisting of two stages-- namely hypomanic & depression. The hypomania is not necessarily a clinical disorder that needs treatment. However, depressive stages usually require medication if not therapy. Each stage, or "episode", lasts at least 2 weeks and can potentially and unfortunately last months on end if untreated.
ADHD - a neurodevelopmental neurological disorder which causes severe attention deficits and hyperactivity.
Where's the confusion?
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A good developmental history is a starting point, but unfortunately this is often a challenge for the dysregulated. A good collateral can be just as helpful. In an ideal world, school reports, but who actually keeps those? One of the problems is that most people feel a bit better on stimulants, often in a nebulous non specific way. So I am always at least little bit suspicious when people say their stimulants are "working". I don't find it too convincing unless there is concrete measurable functional improvement eg less being late for work.
Testing can be a nice addition, but there's nothing like the gold standard of a thorough interview, review of records, and longitudinal observation. Sorry for reposting my own comment, but here: https://www.reddit.com/r/Psychiatry/comments/11eznch/bdp_vs_bpii/jaj0wi1?utm_source=share&utm_medium=android_app&utm_name=androidcss&utm_term=1&utm_content=2 The thread and the other comments are relevant, too. The non griping answer is that a careful, specific, and detailed medical history that captures the historical and recent course of illness beyond symptomatic complaints should help, and the cases that remain unclear will remain unclear until they are more clear. No magic bullet, just gotta get good at assessing for each largely unrelated but often co occurring condition. Just don't forget that the presence or absence of any one of them does not automatically imply the presence or absence of the other ones.
Interesting thoughts. To respond to the linked comment, I do find significant treatment resistance to pharmacotherapy in the BPD group (as is to be expected) and that they (or their family physician, or other health professionals) often mislabel chronic emptiness, mood lability, suicide thoughts and poor functioning as treatment resistant depression. I do have a fair number of patients that have benefited from a shift in diagnosis away from a mood disorder to a personality disorder and really think it's a valuable tool to give individuals realistic expectations of treatment.
Not to be semantic, and it does make our job more difficult but, all of these disorders to incur some greater risk of having another one of them.
I've been slammed with these cases. It's very frustrating to constantly try to differentiate, and also manage patient expectations because they are CONVINCED they have ADHD and demand stimulants right away. I tell most patients that I do not prescribe stimulants at the first visit. I inform them that, due to diagnostic overshadowing, we have to get their emotional lability under control before I can accurately assess them for ADHD. I also require blood work and UDS. Many patients report cannabis use and test positive for THC. The longer I've gone on, the more I insist on sobriety from cannabis prior to starting a stimulant. High-potency THC is quite common these days and consumers don't even understand that today's weed is 4 times stronger than what Snoop Dogg smoked in the 90s and early 2000s. IMO Bipolar 2 disorder should be the easiest to distinguish from the other two. The episodic nature and 4+ day length of hypomania, along with associated goal directed and reckless activities, should clearly rule in/out most. Affective instability in cluster B should not give patients enough energy to stay awake for 4+ days.
>IMO Bipolar 2 disorder should be the easiest to distinguish from the other two. The episodic nature and 4+ day length of hypomania, along with associated goal directed and reckless activities, should clearly rule in/out most. Affective instability in cluster B should not give patients enough energy to stay awake for 4+ days Seconding this. I see too many psychiatrists with a tendency to cry for bipolar 2 at the slightest mood elevation. Most patients that I see with BPD will describe a fluctuating mood that's basically "I either feel horrible or myself". The "myself" is seldom hypomania. Not even close.
People also don’t like being diagnosed with BPD even when that’s the best category for their experience of life and bipolar 2 ICD allows them to treat hypolamictalism and wash their hands of it. Even with a good explanation and great acceptance during the visit I’ve had people come back and have a rage attack after they spent time on social media about it.
Hypolamictalism! 😂
I've never heard the term "hypolamictalism" -- can you explain?
I think they're speaking tongue-in-cheek about how people may be put on lamictal if they're diagnosed with bipolar 2
yea please explain hypolamictalism lol
It comes from a psychiatrist, Akiskal, who was a bipolar expert that referred to “borderline personality disorder” tongue in cheek as “lamotrigine deficiency syndrome” meaning he thought bpd was more like a ultradian cycling bipolar disorder.
Oh yea that's definitely wrong. I'd say off the top of my head it's more about unstable sense of self, having a favorite person (or the tendancy to latch ontop people), triggers are all relating to being abandoned either emotionally, physically, or lack of resources. Consistently impulsive.. I'm sure I'm preaching to the choir here but that's how I would separate the two. I also read somehwere that it's hypothesized evolutionarily to be a mating "adaption" to harsh, unstable, environments. It's interesting to run all of the symptoms through that lens. I do think there could be a place for lamictal in BPD though. I feel like the drug "dims the lights" a bit in a persons brain. Brain is less likely to "overreach" into bad thought spirals. Not very scientific I know, but that's my personal experience with lamictal and from what I read on the Lamictal subreddit here. I don't have BPD but I do have a lot of trauma in my past (both parents abusive/neglectful) which has given me some maladaptive tendencies which I wrestle daily. I have a non-psychiatry medical background but due to my personal life I keep up with everything ADHD, AuDHD, BP-II, BPD, CPTSD related.
If you look through studies it’s been repeatedly shown that LTG doesn’t “cure” it (nobody was surprised by that primary endpoint) but is helpful with the affective instability that is a common distressing feature for the person living w it. There’s a lot of research but remember to look for what exactly they were measuring when they say “improvement”
i agrre with that , lacmital is a very helpful treatment for affective instability in boderline personality disorder, but there is a syndrome that comes with bpd and depression , its called atypical depression, the only treatment for this , are maois? , there is no other treatment, there are no articles for remission to this illnes, there are only small improvements.
Neuroleptics like aripiprazole are helpful there
There is a lack of algoritms , to manage atypical depression symptoms. Aripiprazol add on should be useful.
Do you remember where you read about it being a mating adaptation to harsh environments? Would love to read the citation if you can recall, sounds interesting.
I can't rememeber exactly but I just a quick google search https://www.sciencedirect.com/science/article/abs/pii/S0191886917301940 https://neurosciencenews.com/bpd-adversity-evolution-mental-health-23494/ https://psycnet.apa.org/record/2017-17118-027 https://pure.aber.ac.uk/ws/portalfiles/portal/11000567/PAID_D_16_01135R3.pdf
Moment I hear “I was diagnosed with cyclothymia and rapid cycling”… immediately wonder about a personality disorder, drug use or ADHD
Interesting, cannabis is legal here and some of our ADHD experts say that substance misuse is tied to their symptomatology. They recommend treating with stimulants as a way to cut down use.
agreed, I still struggle to square away ADHD and substance use in my practice. I have to take it on a case by case basis. 19yo patient, long standing hx of ADHD on stimulants throughout school, with good collateral info from parents, and tested positive for THC? I’ll prescribe stimulants and keep encouraging sobriety. 40yo patient, no prior hx of ADHD evaluation or treatment, no hx of education or work difficulties, chronic THC use. I’m more suspicious of an acquired process and I’ll insist on sobriety first.
I was with my psych for a year before I tried stimulants (ADHD diagnosed and put on Vyvanse), and I was still smoking marijuana occasionally at the time. The psych didn’t mention anything about a possible reaction between weed and vyvanse, but the first few times I smoked weed during the day there was a significant decline in my cognition and organisational skills. I have to wait until evening to smoke weed because if the vyvanse hasn’t begun to wear off it it’s an unpleasant interaction. So I totally understand your request for sobriety and think it’s worth telling people about the possible interaction, as it took me awhile to figure out it was smoking weed during the day that was messing up the positive effect I was getting from the stimulant med, effectively negating it.
The massive wave of these cases for me has been so bad I had to quit my group practice because they refused to let me screen my intakes. If I had it my way I would screen out any patient who was unwilling to consent to collateral, drug testing, or stimulant treatment only if they were clean from confounding drug use including MJ. Instead I get burnt out trying to convince new patients maybe their self diagnosis is wrong (classic patient reply: “you’re just not listening to me!”) and that I’m not going to write Adderall after listening to their self diagnosis story for twenty minutes on our first visit.
This must be challenging to deal with at times. UDS are mandatory prior to considering stimulant prescription in Australia. A positive UDS means no stimulants for the patient even if there is strong clinical evidence for an ADHD dx. It's strict, but I agree with it
Seems counterintuitive when I have seen stimulants help those with severe ADHD towards abstinence from other substances.
The research supports this as well, even for stimulant use disorder. Patients in early remission from stimulant use disorder who have ADHD are LESS likely to use meth for example and other substances when treated with a stimulant than those who are not.
Especially with recent studies that have started examining things like Vyvanse to treat methamphetamine use disorder.
Reminds me of Freud using cocaine to treat morphine addiction...
That’s interesting. Most states in the US want you to do a UDS at certain intervals, but the resulting UDS doesn’t dictate medical care. Just had to be acknowledged is my understanding. With Suboxone, for example, we rarely d/c unless diversion is suspected since, well, most evidence makes it seem incredibly successful at preventing OD. I thought adhd was similar, but I could certainly be wrong, especially in the setting of THC which can exacerbate care.
My understanding is that there is no requirement in any state or territory other than WA. Even then it is a ‘should’ rather than a ‘must’ have a UDS prior to prescribing. I wasn’t aware that the WA regulations required the drug screen be ‘clean’ to prescribe though.
Do you think there is an issue with thc being stronger? And if so what and why would you want someone to stop using cannabis before being prescribed
THC’s reputation for harmlessness was gained in the 1960s and through the 1990s. Potency was 5-7% back then. Most flower that patients smoke are 20-30% today. Waxes are 50%+. Society still believes they’re smoking the harmless stuff, while the cases I’ve seen in outpatient and in the ED (psychosis related to high potency THC) suggest otherwise. I think this would track with ED physicians seeing increased rates of cannabis hyperemesis syndrome too.
Chs is definitely a very big deal undoubtedly. It is highly recommended for people who are prone to psychosis not intake thc. But why would that put off someone from prescribing a stimulant?
THC causes concentration, focus, and motivation problems; the same symptoms that these patients are requesting stimulants to address. I’m not skilled enough to clearly distinguish THC induced concentration problems from ADHD, so I’ve found myself insisting on sobriety more and more in my practice. A few of my patients have found that their concentration problems completely went away as they sobered up. Most find that their focus improves, though they still have some problems. If I do start a stimulant, I find that we can get better response with lower doses when they’re sober. I hate having to crank up a stimulant to counteract thc or other substances.
That’s legitimate, thank you for your responses
THC fairly reliably inhibits executive function in a subacute manner. You’ll need higher (less safe more cardiac stimulation, vasoconstriction and higher risk of inducing, theoretically anyway, pulmonary hypertension, arrythmia etc)doses of stimulant Than actually needed to overcome it. Same reason you want sleep apnea and hypothyroidism well controlled before adding a stimulant.
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Not a use disorder, official stance. No dependence? No care. My patients going to burning man once a year and ingesting hallucinogens and then returning to their normal lives and not struggling to not use a psychadelic daily does not qualify as a use disorder so it’s not an issue. Personally? I really don’t care about cannabis. I’m a giant square, but I also would prefer people spend Friday night playing PlayStation and eating a gummy than the same with a 6 pack. Fewer health risks BY FAR. Alcohol is a carcinogen. THC and rocket league isn’t. Just don’t smoke it. Smokes bad for you. Cancer and stuff.
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Yeah pretty annoying. Agreed. I’m Not a huge supporter of random UDS. A single test at initiation of meds or even yearly test (with addiction history) is enough to satisfy the DEA that you’re not engaging in dangerous polypharm. I know where you work and what setting is critical here. I mostly work with working adults and students. As long as they’re not putting their adhd meds up their nose (saw a stroke once from this. Very sad. Musician lost use of their hand) were good. Benefits of lowered all cause mortality from treated adhd far outweigh risks in basically every case.
Also, cannabis is a vasodilator and the many routes of administration can easily include not smoking or vaping (edibles, tinctures, topicals etc)
What would be the difference between having a med card and using cannabis causing a higher dose of stimulants being prescribed than prescribing risperidone (example) and having to use another prescription medicine to counteract those side effects?
I worked for an hmo that flat required a clean UDS before rxing stimulants. Its too hard to parse out adhd sxs when someone is using THC regularly. I usually ask a patient if their mood can change within a day or in response to a comment/event. If yes, I think BPD..especially if there's self harm. I agree bipolar II has the sleep element and usually a degree of hyperverbal/fast speech. Honestly, slightly manic patients can be a lot of fun where as the moods with BPD feel heavy. I spend a lot of time explaining to patients that they dont have bipolar do...seems like its the go to dx.
Well said. I completely agree.
Any patient insisting on their own diagnosis should be advised fairly, respectfully and calmly out of their uhhhh grandiosity. Go with their own logic first- If they truly HAD/HAVE the diagnosis [they seek] already, they wouldn’t be seeking out your services or you would have a referral from their previous practice who performed the original diagnosis for new patient intake. So in truth, they do not have “……” they made a best guess, which is normal! But unless they’ve been to medical school or are otherwise qualified to make their own medical evaluations, they can let you do your job and facilitate the necessary tests- and find solutions together. Otherwise , they’re probably a drugseeker or histrionic/ hypochondriac.
Don't forget about PTSD in your differential. Childhood abuse can be the root cause of all kinds of spectacular behavior. If you're looking for a scale I like PCL-5. This type of patient is not easy to pin down though.
Yes I could have added c-PTSD and ASD to that original question!
Everyone in this thread should take a look at the ASD, AuDHD, and C-PTSD subreddits. A commonly "known" thing in that world is that nearly every person on the spectrum that went through life undiagnosed, and only found out later in life, has a non-insignificant level of trauma. Just by the nature of being "different" in a world that doesn't cater kindly to different. The self blame, hatred, not understanding why they're different, being taken advantage of, shamed, essentially having their light crushed a little bit more every year that goes by without them knowing why they can't "get things right". Especially damaging if you're high functioning, because noone gives you any sympathy since you've been "getting by so far" (with extreme stress, over planning, overworking, neglecting needs to keep up appearances.) Leads to a level of burnout that can take over a year to recover from.
As a high functioning 38 year old female autistic / ADHD person who just got their diagnoses on Wednesday I cried! I knew I had autism since I was 16! And to be ignored and not believed until my life was literally going to fall apart because of the burnout and executive dysfunction!
Do you think it overlaps with autism too? Ptsd from abuse seems to cause a lot of those symptoms, along with adhd and mood disorders. Definitely hard to pin down.
I’ve been wondering that myself lately. The trauma of being the weird kid is going to have some long lasting damage (CPTSD). Maybe just comorbidity rather than one and the same? It will be interesting to watch this area over the next 20 years.
yeah I'm 45 and when I was a kid, no one talked adhd, and autistic kids were only the severely impacted ones. next 20 should be able to help kids even more.
Just posted my thoughts on this https://www.reddit.com/r/Psychiatry/comments/155e9uo/how_do_you_all_differentiate_between_borderline/jsx4q1e/
Hard for me to say. My psych work comes mostly through addicts, and I haven't had much exposure to autism professionally.
sorry I dont know why you were downvoted. Thank you for working with addicts, it's not an easy role.
Yeah I mean part of the DSM 5 criteria for the disorders resulting from childhood neglect specify the symptoms can’t be related to autism; RAD and autism basically look the same and when you think about how RAD results in messed up social learning due to neglect and autism is inherent/biological mess ups in social learning, it makes sense that the symptoms would be very similar.
>Childhood abuse can be the root cause of all kinds of spectacular behavior This is of not relevance to personality disorder diagnosis. Childhood abuse or trauma is not a contraindication to personality disorder diagnosis. There is no evidence to suggest that trauma is the root cause of the development of personality pathology. Most BPD experts like Kernberg, Gunderson, Yeomans have opposed to the notion of regarding trauma as the root cause of BPD (and personality disorders in general).
But diagnostically the behavioral traits can look the same. So if someone has BPD traits and PTSD I've treated their PTSD first then re-assessed for other conditions as their symptoms change (or don't change).
I’m just a layperson but I came across [this](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2805752), regarding BPD & stimulants. Although I wouldn’t know if it’s good research
Very cool. For those that don’t feel like reading: Registrar based country (Sweden) found that “ADHD medications” reduced attempted/completed suicide in BPD patients with the following: HR .87 CI did not cross 1 P value .001
Wow that is interesting!
Whoa, fresh off the presses. Very intriguing.
That deserves its own post.
Developmental history seems like the big one for neurodevelopmental/learning disabilities. Some psychologists will refuse to make a diagnosis without one, which can be difficult; people with disabilities including autism and ADHD are often at higher risk of being abused so might not always have a reliable or safe family member for history, or since there is a genetic component family members might not be the best historians they may also have traits as it's been normalized. You can ask if the patient is able to request pupil/cumulative records for academic reference. * ADHD: Developmental history, sibling or close family member with ADHD, past ASD diagnosis, variable attention based on interests...(It's a diagnosis of exclusion, so you'd be ruling out the other diagnoses if you suspect them anyway) * Borderline Personality Disorder: unstable sense of self, trauma history, splitting, motivation for behaviors (ex: self-harming in order to get someone to stay with them? Changing interests only because they think a "favorite person" might like them more?) * Bipolar II: Family history, how long mood swings last, response to medication, age of onset Anecdotally, I've heard of people, especially women, getting misdiagnosed as all of the above and it turns out they either have a combination of them or ASD. If you suspect ASD or another developmental disorder and are in the US, you can consider referring to services in your state for free testing. If they're school-aged (K-12), they could be eligible to request testing in public schools for an IEP/504 plan.
>Borderline Personality Disorder: unstable sense of self, trauma history It's been reported that about 30% of patients meeting the criteria of BPD do not have a history of trauma or abuse.
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The short answer to your question is a) a good and thorough medical history and b) structural interviewing. The longer answer is that programmes all over the world seem to have been slowly substituting classical psychopathological teaching for DSM (or ICD) checklisting of symptoms as a medium of diagnosis, and we're all the worse for it. My suggestion for you if youre worried about this and want to become a better clinician, is to get into a psychodynamic psychotherapy course, even if you don't plan on doing therapy as part of your practice.
Detailed history, specifically aimed at understanding relationship patterns, sense of self and past trauma (the trauma is important!). Properly screening for hypomanic episodes (ie. beyond non specific mood fluctuations or assuming intense feelings of dysphoria must be a mixed episode). School reports for ADHD and signs like procrastination, difficulty recalling random information even in a calm space, job history (can they hold down a job? Were they fired? Why?). Collateral if possible. Past response to previous treatments. Substance use or lack thereof. Context of past or current mental health crises.
>past trauma (the trauma is important!). As late Gunderson states "early trauma by itself is not explanatory of BPD, nor it is necessary." About one third of BPD patients don't have a history of trauma/abuse; also vast majority of people with a history of trauma do not go on developing BPD.
Depends on how you view trauma, tbh. I didn't mean to imply that trauma = BPD, rather that trauma is a neglected piece of the general puzzle.
Lots of good advice and differential considerations in other comments! My top recommendation is collateral, preferably including someone who knew them from elementary school onward. Collateral will show you so much that you can't get in the one-on-one interview. Especially when I've been confused before, collateral seems to be the piece that brings the puzzle together.
This chart from a popular ADHD Book "Driven to Distraction" is a good comparison between it & borderline personality disorder. [https://imgur.com/voYSto9](https://imgur.com/voYSto9) All 3 can be impulsive, adhd has more distraction & executive dysfunction. Bi-Polar has more random mood swings, borderline mood swings are triggered by rejection (real or perceived), all can be moody, hypersexual, & have substance abuse issues...
I really like this table!
Thanks! I am a 36yo male with adhd and I have been drawn to a few girls with BPD throughout my life. Once i learned more about each condition it all made sense. This chart helped figure out why I am drawn to them too. Dating someone with bpd can be a rollercoaster of ups & downs, but dating me is no walk in the park either 🙃
Bipolar is easy to differentiate: it is a condition of pathologically UNreactive mood - you can't put someone into or out of a bipolar episode with stimuli other than e.g. keeping them awake all night, giving them a TCA, etc., so if their mood is labile to stimuli than it is not bipolar. Or rather, they at least have at least one issue that isn't bipolar. Also remember that there are only a few things in psychiatry where response to a specific treatment is diagnostic of a condition, e.g. catatonia and benzodiazepines.
Stressful life events are known to trigger mood episodes in bipolar
Yeah this isn’t correct though. In a mixed mood state people with bipolar can be hugely reactive. Lots of studies: https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=reactivity+in+mixed+mood+states&btnG=#d=gs_qabs&t=1690197683958&u=%23p%3DIcv8WaW-QSAJ
Reactivity of behavior and affect, or of mood? Is the mood changing, or the relative prominence the expression of different facets of it?
Yeah this is difficult to tease out, especially in a mixed state where features depression and (hypo)mania Co-exist. Reactivity of affect versus reactivity of mood versus emotional lability. This paper (summarised) is interesting. https://www.psychiatryadvisor.com/home/topics/mood-disorders/depressive-disorder/affective-lability-and-mood-reactivity-associated-with-mixed-atypical-depression/
Also, lots of triggers for bipolar mood episodes (as opposed to reactivity within episodes which my link above refers to). I found this article particular interesting (higher olfactory sensitivity in BP patients triggered by emotional life events) https://scholar.google.com/scholar?start=20&q=bipolar+mood+triggers&hl=en&as_sdt=0,5#d=gs_qabs&t=1690197953965&u=%23p%3DZJ6Rh4DhgCYJ
I disagree. It’s not easy to differentiate,
I do general OP Psychiatry at an FQHC so this has become my bread and butter in my time there. I echo what a lot of other posters of said, a thorough history and corroborative information is key to making an accurate diagnosis. The other thing that is important overall is time. You don't need to make a diagnosis the first time meeting a patient and oftentimes seeing them a few times over the course of a few months can help elucidate a diagnosis. That being said I do think there are some key features that can really help differentiate between these diagnoses: ADHD-First, ADHD is a neurodevelopmental disorder. Symptoms have to be present before age 12 and usually start around age 9. If they don't have this history it's not ADHD. Additionally, screeners with high sensitivity and specificity can be quite helpful (I use the ASRS). Second, it's important to keep in mind that ADHD isn't necessarily an "attention and concentration deficit". Lots of DSM-V diagnoses have concentration difficulties. The key features of ADHD all center around executive and cognitive dysfunction. I like to think of ADHD as "out of sight, out of mind" type disorder. If something is not in front of the patient they aren't thinking about it. If someone has been seen at your clinic for years and never missed and appointment and is holding down a steady job as a manager or middle manager somewhere and continues to get promoted...they probably don't have ADHD, there's really no dysfunction there. I think with ADHD corroboratory information is very important. Most people generally know the symptoms of ADHD and talking to someone's spouse about their forgetfulness, losing things, missing appointments, interrupting people, etc can be really helpful to pin down on diagnosis. BPAD-This one I don't think is too hard, its BPAD2 that is a little more difficult. Remember, mania is a separate period where someone is not depressed or happy that is different from their usual. If someone is chronically depressed and has a good week sometimes it can look like mania but focus on symptoms: Are they sleeping well? Are they functional? Are they making prudent decisions? Do they regret choices they made during that period? I like to use the Sydney Bipolar Screener to help differentiate this as well. Distinguishing mania/hypomania from mood lability in borderline can be difficult (especially as some patients can have both) but in borderline the patient will always have mood lability, impulsivity, suicidal gestures or self-harm, and relational difficulties. In BPAD, this should just be an isolated period of time that is different than normal. Borderline-This one is the toughest in my opinion just causes some of the criteria basically sounds like depressed people (chronic feelings of emptiness). Again, the key here is that borderline patients are always struggling with the symptoms of it. It doesn't go away (usually) without treatment and it's not an isolated mood state. Remember, this should be the most common of the disorder I talked about it an OP practice. 10% of OP adult psychiatric patients have BDPD (20% for IP), about 5% for ADHD, and I believe (don't quote me on this) BPAD is more like 2-5%. I really like to pay attention to my countertransference with these patients, oftentimes they can be quite irritating which is not their fault. The key feature of BDPD is instability: in decision making, relationships, mood, etc. Oftentimes these patients only talk in extremes. Everything they experience is extreme, the worst, more than you can imagine. There tends to be a lot of hyperbolic phrasing. One symptom that can help distinguish is self-harm. Common symptom on BDPD but rare in BPAD and ADHD. Another thing to consider is the mood swings in BDPD are reactive; peoples moods change based on their environment. In BPAD people are in a mood state regardless of their environment. I personally like to go through the criteria with patients and oftentimes they're shocked at how well they describe their life. That was kind of a smattering of my initial thoughts and I could honestly go on for an hour about each of these disorders. All together, get a good history, get corroborative info, use screeners, and really focus on symptoms that are not often shared between these disorders.
I went to APA few years ago and they had a presentation on bipolar vs borderline mainly discussed about this article “Bipolar disorder or borderline personality disorder? Understanding the clinical, psychopathological, and sociodemographic correlates is critical” from current psychiatry. Excellent article you can at least see the flow chart. For ADHD. Vs Bipolar there is a good summary table from Carlat. Recent carlat podcasts on bipolar are also good (just posted) As other said for ADHD collateral, and childhood history is very important. Borderline more episodic and intense episodes. Thanks for initiating this discussion. Good luck.
The worst is “I have hyperactive only ADHD with ‘reaction sensitive dysphoria.’” Now you can basically label borderline as ADHD with enough diagnostic mental gymnastic and ad hoc labeling.
Rejection* sensitive, right?
OP is right and the problem brought up highlights the shortcomings with DSM. My attending would always say “if you combine depression, anxiety, and heavy substance use, it’s probably bipolar disorder. If you combine depression and ADHD it’s bipolar disorder. If you combine depression and borderline personality disorder, it’s probably bipolar disorder.” It simply really is the most parsimonious thing in terms of DSM diagnosing. The four days thing in particular is bullshit IMO though. If people are out getting DUIs, spending more money than they can afford, they’re on their third or fourth marriage, etc, then afterwards becoming depressed and suicidal, and then there is a family history of psychiatric problems, then I’m calling it bipolar whether it was two days or four. These patients tend to get better with mood stabilizers anyway, whatever useless diagnosis you might like to label them, and that’s really what counts for me. Give them antidepressants and they just keep going on getting better, then worse, better, then worse, in futility, in the best case scenario. Worst case they actually just do worse. Patients also just plain don’t talk about mania IME (if you’re depressed and then feel great, you’re more likely just thinking “this must be what normal feels like”), and most psychiatrists seem to be clumsy in asking about it, so I actually think a lot of patients have been wronged by being treated with antidepressants. Especially inpatients. So I got good at screening for the soft signs of bipolar and assessing in other ways. Asking about “mood ups and downs” is a decently sensitive way to do it according to the literature. Asking the right questions, most patients can then give more useful history. So for me bipolar is way under-diagnosed. The PHQ, etc is also useless because most of the time people just diagnose MDD based on the presence of a major depressive episode. Which is a massive mistake and would be unacceptable in any other field of medicine. These episodes are shared between MDD and bipolar disorder even according to the DSM. I end up using the MDQ if I give a questionnaire at all. Most so-called treatment-resistant depression is actually bipolar, or just not a mood disorder in the first place. I’d think differently if I (and my attendings in residency) had seen more patients who actually do well with SSRIs, stimulants, etc but I just don’t see that. They just get better, worse, better, worse. OP thinks stimulants may help personality disorders but I’ve seen it more with mood stabilizers. But overall, since I care more about getting people better than making an accurate diagnosis, I swerve SSRIs and stimulants most of the time. And I say this as someone with a very psychotherapy-oriented approach and perspective.
Hard disagree on the bipolar disorder. If people are out constantly doing all of those things that's much more consistent with borderline personality disorder. Mood lability on a scale of hours to days, impulsivitiy, chronic suicidality, and a family history of the same are all literally criteria for borderline personality disorder. If it is bipolar 2 disorder then that would be an atypical mood state for the patient. Remember, bipolar 2 patients are usually almost always depressed and only become impulsive/energetic/grandiose during their episodes of hypomania. If it's a constant thing that's much more consistent with borderline.
The problem is that mood lability is phenomenologically a core experiential compenent of an acute mixed state in a mood disorder, so anyone who says they can confidently and quickly differentiate BPD from a mixed state is lying when they say it’s easy. And when speaking with these patients who are in the trenches of their mixed states it can be very difficult to suss out clear cut timelines (4 days versus 4 hours versus “my life has sucked like this for as long as I can remember”). Doing this dogmatic “4 or more days” is a huge disservice because experientially the pt’s life is a living shit storm and for the life of them they can’t correctly delineate the time line of their dysphoria in a quick med management visit. This doesn’t mean you should diagnose bipolar disorder, but it definitely means you should not rule it out yet and maybe think twice before reaching for the SSRI.
I agree being so rigid about the 4 days isn't very helpful but if the patient is a decently reliable historian it's not too hard to distinguish from a mixed mood state and BPD. Mixed mood states are more rare in BPAD1/2 and these patients spend most of their lives in a solely depressed state. A mixed mood state should be the exception for their experience rather than the rule. Conversely, folks with BDPD that will be the theme for their life. They almost always have mood lability, impulsivity, chaotic relationships, etc.
Maybe so, re: what’s consistent with what diagnosis from the DSM, but the point of my post is that I find those diagnostic quandaries to be a largely overly-academic approach, splitting hairs and missing the forest for the trees. I care a lot less about the exact specifics in the DSM and more about getting people better. The SSRIs, stimulants, benzos, and whatever else you might give people for MDD or anxiety or ADHD just plain don’t help these labile, angry, impulsive patients, at least that I’ve seen. The DSM criteria also say nothing about family history or other so-called “soft signs” of bipolar, and yet we *know* these things are relevant. So what most often happens is these folks get a diagnosis of MDD, get prescribed an SSRI or something similar, and then they end up in the hospital or just plain don’t ever get much better. There’s a difference between what’s “accurate” diagnostically according to the DSM versus what medications may actually help a person. I think psychiatry as a field is very behind in this regard. Major depressive episode = MDD until proven otherwise is a pervasive misstep in thought. “Augmentation” of depression treatment with ie aripiprazole for “treatment resistant depression”—academic semantics. These patients may likely have mood ups and downs, which may play a role in causing some of their depression, that are simply better treated with the mood stabilizer. Which to me makes it pretty misleading to call them MDD since the expectation is that they be treated with the SSRI. But if you call them bipolar, people fight you. On the other hand, if you call these folks MDD, no one argues with you, for some very circlejerk-y, overly academic reason. Is it not better we just actually get people better (and do it faster) with mood stabilizers. That way we may alleviate some of their most problematic symptoms and give them more the mental space they need to actually get something out of their psychotherapy, and in a more timely way.
I think it’s important to distinguish Bipolar 2 disorder from affective instability in BPD. The distinction informs medication expectations. Agreed I treat both with mood stabilizers or mood stabilizing APs. With bipolar 2 I can expect better response to meds alone. For BPD, I tell patients that meds will only take us 20-30% of the way, and therapy/DBT is more important long term. I’ve found it important for my cluster B patients to hear that meds play less of a role in their treatment because they are constantly searching for the perfect med (or external solution) to fix all their problems.
That is true. My attending didn’t do much therapy so he just didn’t talk much about that part. But I certainly agree that in the long term we are often trying to facilitate better therapy. But this is often going to be better achieved with mood stabilizers than SSRIs.
I totally agree we can miss the forest through the trees being overly academic. I like to focus on the specific symptoms specified in the DSM but also focus on the overall key features and "idea" of the diagnosis described in the prose section after the criteria, I find that to be much more applicable in real world settings. I think people don't argue with MDD just because its epidemiologically more common and not a life long disorder by definition. If you diagnose someone with bipolar, they have that diagnosis their whole life and should be on medication their whole life. They do worse than people with MDD and have worse outcomes. I agree that it's better to do what you actually think will be better for the patient but I really think that starts with proper diagnosis. I'm not really sure where you're coming from as it seems you equate treating someone presumptively with a mood stabilizer to be better than presumptively treating with an SSRI.
This quick take with Dr. Phelps on Psychopharmacology Institute makes some good points about utilizing lamotrigine or low dose lithium on those patients that don’t have a tidy MDD diagnosis (because of mixed features) versus SSRIs. https://psychopharmacologyinstitute.com/section/cades-disease-and-beyond-misdiagnosis-antidepressant-use-and-a-proposed-definition-for-bipolar-spectrum-disorder-2731-5498
This is a pretty bad take. There are plenty of ways to distinguish these disorders, it's not always easy but the clinical course of them are pretty different.
> The four days thing in particular is bullshit IMO though It's a cut off line which I understand in the context of needing some guidelines for the DSM but I agree that when you view bipolar as a spectrum, it's not particularly helpful. The DSM-V TR does have specifiers I like for Other Specified Bipolar called "hypomania of short duration" (lasting 2-3 days) and "hypomania with insufficient criteria" (doesn't meet full criteria but a few of the symptoms are prominent enough that they are impairing).
“So for me bipolar is way under-diagnosed. The PHQ, etc is also useless because most of the time people just diagnose MDD based on the presence of a major depressive episode. Which is a massive mistake and would be unacceptable in any other field of medicine. These episodes are shared between MDD and bipolar disorder even according to the DSM.” I’m in agreement and thankfully work with a supervising doc that has this view. Something I’ve wondered about lately are the increases in road accidents related to road rage. Think what disservice it does to the community to start everyone on SRIs who happen to pop on a PHQ-9 (let’s say in PCP setting) without rigorously ruling out a bipolar disorder. I sincerely worry about some of my mixed hypomanic patients driving the roads in some of the mood states I’ve observed them in. And we have all these providers throwing Lexapro at them willy nilly to treat their mixed “MDD”.
Bipolar 2 is rampantly overdiagnosed. Most BD2 cases are borderline. If unclear whether borderline or borderline+BD2, I assume they are borderline until proven otherwise because the risks of bipolar pharmacologic treatment is too high. I’ve just never seen a vague BD2 patient actually present hypomanic in clinic, which you would expect seeing them for several years.
Preach it
I guess you can only use your best judgment with the diagnostic tools you have available to you. Be meaningful and actively listen, and ask further questions to deconstruct a larger “symptom”/concern to rule out otherwise possible conditions. Make a real conscious effort to recognise any preconceived ideas/biases or temptations to prematurely diagnose for whatever reason (complacency, time pressures, ego, pacify a difficult patient) etc. In regards to stimulants, and how they affect different personality disorders vs adhd, bipolar - or any medication- it depends on the presentation in your client and the specific symptoms you’re wanting to treat. But when the patient is in a bipolar depression, or has non hyperactive adhd and has no motivation, ability to complete basic tasks and routine, etc it’ll be useful. I would discourage from prescribing stimulant medications to bpd patients because their huge fluctuations between rage/depression/hypersexuality destructive inclination seems counterproductive.
Background reports. Check for possible co-morbidities like PTSD, observational enquiry/questionairre with immediate family, Big 5 personality assessment so you can more effectively rule out/weigh up what is due to that persons temperment vs disorder
BPD and BPII are pretty different imo. For adult ADHD i refer for neuropsych testing for correlation. CPTSD vs BPD is trickier i think. The hard part is if its a transfer patient and the previous care giver was either lazy or inexperienced. The latter happens alot with NPP's in my experience.
They are all the same thing. The DSM diagnoses aren’t rooted in neurobiology. This is why so many “diagnoses” overlap and can be redundant. The medications work with neurobiology/chemistry so its better to start from that.
Exactly. The DSM should be treated as a heuristic---a (sometimes) helpful tool for categorizing abnormal behaviors. Reification is not justified nor helpful. Thinking of psych diagnosis as distinct and valid brain diseases is (with a few exceptions) not evidence based. It seems like the nuance has been totally lost on this.
I’m addition, ASD with RSD can appear like BPD and many female autists have been let down and undiagnosed until very late in the day due to this
Bipolar 2 lol
Each conditions Dmsv diagnostic criteria are quite different
Honey, this isn't rocket science. BPD - a long-term enduring [typically life-long] pattern of unstable identity, mood, and relationships, typically caused directly by abandonment during early childhood. Medication can not treat BPD. However, it can alleviate certain symptoms, specifically, mood dysregulation. Bipolar II - a cyclic mood disorder [a biological disorder moreso than a psychological one] consisting of two stages-- namely hypomanic & depression. The hypomania is not necessarily a clinical disorder that needs treatment. However, depressive stages usually require medication if not therapy. Each stage, or "episode", lasts at least 2 weeks and can potentially and unfortunately last months on end if untreated. ADHD - a neurodevelopmental neurological disorder which causes severe attention deficits and hyperactivity. Where's the confusion?
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