Question:
Can anyone please refer me to information about this condition? For years I was thought not to be manic/depressive because I don't experience mania. Apparently, they have a relatively new diagnosis for people like me, Bipolar 2. I've been in a major depressive episode for15 months, and off work for one year yesterday. They have me on effexor, but it's no silver bullet.
Answer:
Effexor uis an antidepressant. You need a mood stabilzer if you do have
Bipolar Affective Disorder. Biploar disorder (Manic - Depressive illness) is classified into Biploar
I disorder and Bipolar II disorder. Bipolar I disorder is diagnosed
based on the presence of atleast one manic episode with or without the
presence of major depressive episode. Bipolar II disorder is diagnosed
by the presence of at least one Hypomanic episode and one or more major
depressive episodes. Manic episode differs from hypomanic episode by the
presence of more sever symptoms for longer duration of time. In Biploar
I disorder, a person can have significant impairment in social,
occupational or other important areas of functioning where as in Bipolar
II disorder, it is unlikely. What is the true definition of bipolar 2? What are its symptoms and
treatments? What other types of bipolar disorder are there, and what are
the distinctions?
A. Bipolar 2 disorder involves the cyclical alternation of major
depressive periods with periods of so-called hypomania. Hypomania is a
state of elevated energy and/or mood that falls short of outright mania.
Hypomanic individuals do not become frankly delusional or require
hospitalization.
Typical symptoms during the depressive phase of type 2 bipolar disorder
(or type 1, which involves alternating major depression and mania)
include persistently depressed mood (nearly every day), hopelessness,
poor concentration, increased or decreased appetite, increased or
decreased weight, loss of pleasure in most activities, and poor
concentration. (Bipolar depression more often presents with excessive
eating and sleeping than does unipolar depression.)
The hypomanic individual typically presents with heightened energy,
elevated or irritable mood, increased talkativeness, decreased need for
sleep, increased social or sexual activity, and increased spending or
work-related activities. Some bipolar type 2 individuals get most of
their creative work done in their hypomanic periods, knowing that they
have only so much time before they "crash." Bipolar type 2 disorder is
associated with significant social and vocational disability and an
increased risk of suicide. In addition to type 1 (classical) and type 2
bipolar disorder, some clinicians speak of "type 3" bipolar in relation
to drug- or medication-induced bipolar mood swings. Many such
individuals have a family history of type 1 or 2 bipolar disorder. The
mainstay of treatment for both type 1 and 2 bipolar disorder is the use
of mood stabilizers, such as lithium, valproate and carbamazepine.
Recently, two new agents--lamotrigine and gabapentin--have been used
with some success in bipolar patients. Educative and supportive
counseling is also an integral part of treatment. Now let's take the "paint" approach to "borderline vs. bipolar", a
common diagnostic disagreement. You may have already
seen my essay on this, which notes the almost complete overlap of
symptoms between the two diagnoses. With that much
overlap, these people must have basically the same "pigments". One
person might have gotten them from genes, the other from
experience -- we can't tell the difference yet.
However, one pigment seems to differ in each.
They both have red for hot emotions, and blue for depressive symptoms,
and a sparkly pigment that makes them impulsive. But
the "bipolar" person has a magic ingredient that makes her pigments
vary cyclically over time. There is some consistency to
the way this magic pigment works: she tends to be either one way, or
another, all symptoms varying together. Remember, this
magic stuff is another "pigment". She could get a big dose of it, and
be bipolar I: extreme swings separated by years, looking
much the same each time they reappear. If she got a small dose of the
"vary" pigment instead, her symptoms might be less
clearly "cyclic", more mixed and muddled.
On the other hand, the "borderline" person has a green ingredient that
makes her feel empty, and feel much worse in this way
when she is alone. Plenty of people who wouldn't be called
"borderline" have quite a bit of green in them, but if you get a lot
of
this green pigment, you're more likely to have trouble in
relationships. When two very green people get together, each will
feel
badly when the other goes away somehow (including emotionally; if one
gets mad at the other, for example). Imagine what
happens in a relationship if one person is very green, and the other
is not; this can be as troublesome as when both are green.
You've heard these matches described as problems of "co-dependency".
How much "green" a person has seems to depend on
both genetics and experience: some kids just turn green no matter how
good an upbringing they get; others can develop
emptiness from experiences that they had growing up (lots of real or
perceived abandonment may do it; certainly sexual abuse
seems to do it).
Just to make it clear that this is not "always somebody's fault": the
"match" between a child's temperament and the parenting
they receive can be the problem, not the child's temperament or the
parenting either. Some kids can handle a pretty distant
parent okay; others can be devastated by this. Some kids will feel
"smothered" by an involved parent; others will thrive with
such attention. Children can show these differences right from birth.
You can read more about this "match" in the superb
scholarship of Marsha Linehan, Ph.D. Warning: her book "Cognitive
Behavioral Therapy of Borderline Personality
Disorder"Linehan prompted a psychiatrist friend to say: "never have I
read so important a book that was so boring". Dr.
Linehan repeats the same themes over and over, but for good reason:
they're crucial themes to understanding this personality.
You could go to a bookstore that has it and just read the section on
"Emotionally Invalidating Environments": it's in the first
chapters just after the definition of the disorder.
So, to summarize: diagnoses are not based on known chemical
differences. They are conveniences for researchers, and are
also supposed to help you find the right treatment. But because
symptoms are spread over spectra, from a little to a lot, labels
can often be misleading. Finally, borderline patients have most of
the features of bipolar, plus an emptiness streak; and may
have less clear "cycling" of their symptoms.
What's the difference between bipolar disorder and "Borderline
Personality Disorder"?
Dr. Akiskal, often states that he does not believe "borderline"
exists.
You would be amazed at all the discussion within psychiatry about
"borderline versus bipolar". For example, look at this
woman's question to a borderline site:
http://www.mhsanctuary.com/BPDr/226.HTM
she gives a pretty textbook description of a manic phase, in my
opinion. But neither her psychiatrist nor the website doc' go for
"bipolar". This kind of disagreement goes on all the time.
There is tremendous overlap in the symptom patterns of bipolar and
borderline personality disorder (Borderline PD). The
overlap reflects a basic problem with the concept of a "diagnosis" in
the first place; for a brief essay on this topic, click here.
Notice in the table below that almost every symptom is found in each
column:
Some doctors believe self-harm is "diagnostic" of borderline PD, or
worse yet, synonymous: all borderlines cut, and anybody
who cuts is borderline. It's hard, let me tell you, to convince them
it isn't that simple. Read one of the very helpful websites on
self-harm if you need more information on this common behavior.
However, I think there is indeed one symptom that differentiates the
two (to the extent there's any point in doing so; more on
that in a moment). You noticed the big yellow blank in the table,
yes? People with profound fear of abandonment, and a feeling
of chronic emptiness, have a different struggle in life from those who
don't have these problems. Recently one of the most
prominent borderline specialists, Dr. Glen Gabbard, emphasized these
symptoms as the core of "borderline"
experience.Gabbard
"Rejection hypersensitivity" is highlighted because although this is a
well-described symptom of "atypical depression", which
closely resembles some bipolar depressive features, Dr. Gabbard also
advocates seeing such interpersonal sensitivity as a
borderline pattern.
However, here's the crucial question: what difference does it make
whether you're "borderline" or "bipolar", as far as treatment
you might benefit from? That's the point of "diagnosis" anyway,
right? -- to help match patients to treatments that have worked
well for others before them. (Diagnoses also help predict how things
are likely to go in the future -- "prognosis"; but that's a lot
less crucial). And the answer is: it doesn't make that much
difference.
There are good treatments for both conditions. Borderline PD is
usually treated with psychotherapy as the main tool, with
medications as needed or to the extent that they are helpful. Bipolar
disorder is treated just the other way around: start with
medications as the core ingredients in treatment, but using
psychotherapy wherever it might be helpful. All of the medications
we routinely use in treating bipolar disorder have been shown in
published studies to have some value in borderline PDSoloff:
antidepressants, mood stabilizers, and (to a lesser extent, and much
more so with the new ones) antipsychotics. .
So imagine there really is a difference between these two conditions.
We don't really know that now. But imagine there is one,
some difference in the structure of the limbic system, the emotion
system of the brain, perhaps. And imagine that we had some
great lab test that could tell the two apart perfectly (that's rarely
the case even with an excellent lab test, by the way, so don't
hold your breath). Now, suppose you really have "borderline", but you
get called "bipolar ". What happens? You get treated
primarily with medications. These might help, as those studies I
mentioned a moment ago indicate. But you would still need
some help with feelings of abandonment and emptiness (and the problems
with relationships that come up when you have those
feelings). Unless you had a really rigid psychiatrist or mental
health system, you could then try to get the psychotherapy which
might help (either Linehan's approach, or a more traditional
psychodynamic psychotherapy. Both have good evidence of
benefit.Linehan, Meares).
What about the other way around? Suppose by our magic test you
"really" have bipolar, but get diagnosed borderline PD.
Well, until recently, this was the big problem. You'd get labeled as
"personality disorder" and often your medical care, from
primary care as well as mental health providers, would change
accordingly. You'd get shunted to the bottom of the list of
patients someone might want to take into a practice. You'd be told
that your situation was basically unchangeable except with
years of psychotherapy, and then discharged from the hospital no
matter what your symptoms were, as was one of my patients
only several months ago. (Even if you "really" have borderline PD you
shouldn't be treated this way anymore: if our mental
health system were perfect (right), you would be found in some
deliberate screening program to have borderline PD and placed
in a treatment program designed for your condition. Hmm, sounds like
how they treat diabetes, doesn't it?).
But back to our example: you're "really" bipolar, but you get
diagnosed "borderline. Even if you were initially treated with
psychotherapy, ideally it would be noticed that you were not improving
fully, and might need medication treatment as well. And
hopefully, since mood instability is your primary problem (not plain
depression, nor psychosis), you would then be treated with
mood stabilizers.
The point here is that you would not necessarily be lead into a
treatment that can harm you with the "wrong" diagnosis, either
way. You might well get a treatment that could be helpful, even if it
is not the "core treatment" you will eventually need (and
hopefully get). For a further discussion of how "diagnosis" is being
re-worked in mental health, and what that means for the
distinction between bipolar and borderline, click here.
As you can see, overall my recommendation is that you avoid getting
too stuck on a diagnostic label. Which one you get
depends a great deal on the orientation of the therapist or doctor!
Psychiatrists might be better diagnosticians, in theory,
because the they have pliers as well as hammers ("when all you have is
a hammer, everything looks like a nail"). But finding a
psychiatrist who really does use her/his pliers just as much as
his/her hammer can be difficult. Finding a psychiatrist at all can be
difficult. In that case, a therapist who feels comfortable treating
borderline personality disorder is a good starting place; you can
use websites like this one to learn more about the two diagnoses and
help guide your treatment from there.
