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Possible Borderline?

Question:

As of right now I am a twenty-year old female. I was diagnosed with depression when I was 14 and originally put on Zoloft for treatment combined with therapy. I had started cutting myself when I was twelve however and I’ve had suicidal thoughts beginning at seven. I tend to have quickly shifting moods from being extremely hyper to suicidal to intensely angry. When suicidal or angry, I seek release through cutting because I have an intense need to hurt someone or something so I turn to myself. I also tend to self-sabotage any relationships that I have. When my mood switches again to being happy for a day or two, I reform those relationships only to sabotage them again. Does it sound like I have BPD as well as depression or could these all just be symptoms of what I’ve already been diagnosed with.

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Answer:

Making a diagnosis is a process of understanding diagnostic patterns (e.g., the constellations of symptoms that make up the universe of disorders) and then figuring out which constellations are best fitting the observed symptoms. You’re describing the following symptoms:

  • depressed mood
  • manic (e.g., hyper) mood
  • angry mood
  • rapid fluctuations between mood states (what is called "lability" or being "labile")
  • difficulty maintaining intimate relationships (your sabotage)
  • suicidal impulses
  • self-harming behavior (your cutting)

If we compare this set of symptoms against the criteria for a standard "unipolar" depression diagnosis, such as you are suggesting was made for you years ago, we’d find that while some of it fits, there is some of it that maybe doesn’t fit so well. The depressed and angry moods fit, as do the suicidal impulses and to some extent the lability and the relationship problems. The hyper moods you describe don’t fit very well, and neither does the idea that you are fluctuating between mood states. When hyper moods and rapidly fluctuating mood states are described, we typically start thinking about a bipolar disorder sort of condition (although not necessarily bipolar disorder itself), and/or a "dramatic/erratic" personality condition such as borderline personality disorder. The self-harming behavior and relationship difficulties can be consistent with a borderline personality disorder sort of diagnosis, but then again, they can fit perfectly well into a bipolar-spectrum diagnosis too (an aside: The very first bipolar patient I ever saw had bandages on his wrists. He had been hospitalized in the midst of a depressive episode during which he thought it was a good idea to end his life. Luckily, he did not succeed, but he did manage to wound himself pretty good). The long and short of it is that there isn’t enough information present here in your letter to really narrow things down very well.

Let’s consider the idea of a bipolar spectrum problem for a moment. Diagnosing standard depression is fairly easy; all you need is some persistent depressed mood and associated symptoms and you’re good. Diagnosing bipolar disorder is more subtle than diagnosing standard depression. A diagnosis of bipolar disorder requires a doctor who is able to document your mood going up and down in between depressive and manic (or at least hypomanic) energized and indeed, hyper, states. It is common enough that depression is diagnosed early on in a patient’s life, but later that patient’s diagnosis is refined (as more history has accumulated) into bipolar disorder. I can’t help wondering if this has happened for you but you don’t know it yet. Talk to your psychiatrist and mention your hyper moods to him or her and the fact that you are shifting between hyper and angry/depressed and ask if your depression could possibly be something more complicated than simple depression. Your doctor will be in the best position to ask the rest of the questions needed to figure that distinction out. It is important to know if you’re bipolar because the medications for bipolar disorder aren’t quite the same as those for standard depression, and it is important to have the right medications in order to get the best results.

Classically, the mood cycles involved in bipolar disorder were thought to occur slowly over the course of months. As time has gone on and more has been learned about the subtleties of the disorder, more rapid cycling forms have been identified (or at least described – they remain controversial in some professional circles). Mood shifts in the fastest proposed rapid cycling forms of bipolar disorder are said to happen as frequently as several times in a day.

It is very difficult to distinguish between ultra-rapid cycling forms of bipolar disorder and personality disorders like borderline personality disorder. As I’ve pointed out in my essay on the subject which I recommend you read, the distinction between these two is theoretical in nature, with bipolar disorder being thought to be a biological condition, while borderline personality disorder being thought to be a developmental and psychological disorder. In practice, at the superficial level at least, they can appear to be identical twins. Again, your local doctor is in the best position to help tease apart these distinctions.

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