Disentangling Rapid-Cycling Bipolar From Borderline

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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