Friday, March 29, 2013

Lucid Analysis – Trials in Therapy : Definitely Getting Better


Happy Faces Everyone. I feel so much better. So, so much better. I feel really bad about posting when I feel so down. I feel like I’m letting people down somehow, or that I’m in some way I failure. I know those are faulty, negative thoughts though. It’s important that I’m honest about my feelings with myself and with you. Especially when, as predicted, they do absolutely get better. This whole week has been wonderful.


It got worse there for a bit. I tried pulling it together and went out with Tech Boy last Friday night. Or was it Saturday? Who can remember? We were going to go for Hibachi then to a movie. I had thought maybe 7:30. He wanted to come over around 6. I think someone missed me ::wink::. He brought a bottle of wine. We had a glass, watched Archer, and hung out for a while. Turns out we couldn’t go to the Hibachi place I wanted to go to because the wait was so damn long. ::frustrated, but okay, deep breath:: I knew another place. So we went there. Found parking eventually. Walked in. They’re not doing walk-in Hibachi until an hour and a half later. Starving! Fuck in. Let’s just go to the place down the street that we know. Whatever. What, there’s a 45 minute wait there too? Fine. Just fine. I’ll put down our name. Tech Boy went off to get me a glass of wine. I was so irritable, angry, and instantly sad. At one point I was trying so hard not to cry… because our restaurant didn’t work out? I ended up drinking like 5 glasses of wine that night. We chatted with the couple next to us and went to a music club with them for a little while after. By the time he got me back to my place, I was pretty vomitty. 5 glasses of wine on my frame with not so much food is way too much. I hate having him see me like that. He told me he doesn’t care, he just wants me to be okay. He took care of me, and snuggled up with me. 

The next day I mostly snuggled with my cats, read my book, and something important. Idk.

Then due to a lot of scheduling conflicts our crew was short this week so I actually got out on site and helped out on the construction floor with our technicians and worked alongside Tech Boy most of the week (as opposed to him doing work for me). It was pretty awesome. Frustrating and aggravating as hell considering all of the OTHER men not in my crew that aren’t used to me and who every single time passed me had to stare, look inquisitive, say something, turn their head, drop their jaw, or in some way make it obvious that they’ve never in their life seen a women ever holding a wrench. ::headdesk:: until I politely told them to move their ass because they were inhibiting my productivity… but other than that it was actually a ton of fun. I usually get to work on my prototypes, but field installation is for the techs and shop workers. It’s fun working with my guys. I really love the noise out there too.

Therapist notices that when I’m working as part of team, as a part of an actual team, not just an individual unit (engineer) in a group of engineers, that I feel much more connected and happier with my job, not just like I’m putting on a new personality to be paid for.  So I’ve been doing that all week, and I’ve felt incredibly productive and really appreciated. It’s been pretty wonderful.

My energy and my mood has been really, really high. It’s been great.

I’m not going to say that my meds haven’t been helping though. I’m now up from 25 mg of the Topamax to 50mg. I’ve seen no discernible side effects so far, except oddly, I can’t taste carbonation as well anymore. This makes me terribly sad (not really, but you know). One of my biggest addictions ever, ever, is to seltzer water. I LOVE carbonated water haha.

But yeah, things have been going really well. Things with Tech Boy especially have been going really well. I still can’t say he’s my one true love or anything, but I adore him. And you know what. He’s trying. I was really concerned about his inability to accept me for who I am, all my problems and my hard life… because how he’s experienced the world is so different from my experience of it. I was concerned about his need to avoid, when I’m working so hard to face my problems and fix things, to communicate and work through. And of course, his drinking. But from what I’ve seen so far, all of these things seem to be things he’s been really working on. It’s just, sweet. And I can see that he cares about me. I can definitely tell. I missed him. I’m glad he’s in my life. Right now I’m just taking it one day at a time, and for now, that’s good enough. I like where my day is.

I’m a little sad this week though. Because while I’m not going back home to see my family for Easter. Every year it’s usually one of 3 times that I go home to see them, but because I just dropped $2500.00 to have my car repaired I simply can’t afford it. Plus my brother is graduating in May and I’d rather go home for that. Super proud!  

So since I’m finally feeling better I’m going to have friends over tomorrow. It’s K’s birthday so I’m going to make Hawaiian Sweet Bread and Honey-Lavender Cupcakes. Then a bunch of us will gather at my place and we’ll probably just gather and geek out all night. We’re kind of dorks like that. Then Sunday Tech Boy said he’d come over and spend Easter with me because his family isn’t doing anything either. So that’ll be pretty awesome.

It’s funny. I feel so boring when I’m happy. No problems to get in my way or obsess over. My ankle is finally healing. It’s been almost 4 weeks since I’ve run though so I’m going to have to recondition myself. Bleh. It’s been so long since I’ve had an injury like this. I’m going to start retraining today. I’m so anxious to start running again.

Therapist really didn’t have much to talk with me about either. She doesn’t like to push me when I’m up this up. I’m not sure if that’s a good therapeutic philosophy or not, but yanno what, I don’t mind not having my mood trashed with thoughts of sadness of depression.

So yeah, that’s that. What’s been up with you? How’s this spring season treating you? 

Article: Some conditions misdiagnosed as bipolar disorder


Hello Dear Readers. Before I get to my Lucid Analysis later today I thought I’d drop off this quick article for you to read. It’s more recent than the one I posted yesterday. Bipolar is apparently quite often misdiagnosed.


Some conditions misdiagnosed as bipolar disorder

By Amy Norton

NEW YORK | Thu Aug 13, 2009 3:26pm EDT

(Reuters Health) - A study published last year suggested that bipolar disorder may be over diagnosed in people seeking mental health care. Now new findings shed light on which disorders many of these patients actually have.

Bipolar disorder, also known as manic depression, involves dramatic swings in mood -- ranging from debilitating depression to euphoric recklessness.

In the original 2008 study, researchers at Brown University School of Medicine found that of 145 adults who said they had been diagnosed with bipolar disorder, 82 (57 percent) turned out not to have the condition when given a comprehensive diagnostic interview.

In this latest study, published in the Journal of Clinical Psychiatry, the researchers used similar standardized interviews to find out which disorders those 82 patients might have.

Overall, they found, nearly half had major depression, while borderline personality disorder, post-traumatic stress disorder (PTSD), generalized anxiety and social phobia were each diagnosed in roughly one-quarter to one-third.

When the researchers then compared the patients with 528 other psychiatric patients who had never been diagnosed with bipolar disorder, they found that those in the former group were nearly four times more likely to have borderline personality disorder.

They were also 70 percent more likely to have major depression and twice as likely to have PTSD.
Some of other diagnoses were less common but still seen at elevated rates among the patients previously diagnosed with bipolar disorder. These included antisocial personality disorder and impulse-control disorder.

Over diagnosis of bipolar disorder is concerning, in part, because it is typically treated with mood-stabilizing drugs that can have side effects -- including effects on the kidneys, liver, and metabolic and immune systems, explained lead researcher Dr. Mark Zimmerman, an associate professor at Brown and director of outpatient psychiatry at Rhode Island Hospital.

In addition, he told Reuters Health in an email, over diagnosis means some patients are likely not getting the appropriate care for the problems they do have.

Bipolar disorder shares certain characteristics with some other psychiatric conditions. Borderline personality disorder, for instance, is marked by unstable mood, impulsive behavior and problems maintaining relationships with other people.

But Zimmerman and his colleagues suspect that some doctors are over diagnosing bipolar disorder because -- unlike certain other causes of mood disturbance -- it does have effective drug therapies.

There are no medications approved specifically for treating borderline personality disorder, for instance, but research suggests that some forms of "talk therapy" are effective.

"We believe that clinicians are inclined to diagnose disorders what they feel more comfortable treating," Zimmerman explained.

"The increased availability of medications that have been approved for the treatment of bipolar disorder might be influencing clinicians who are unsure whether or not a patient has bipolar disorder or borderline personality disorder to err on the side of diagnosing the disorder that is medication-responsive," he added.

This "bias," Zimmerman said, is reinforced by drug company marketing, which highlights certain studies that have suggested that bipolar disorder goes unrecognized in many people.

SOURCE: Journal of Clinical Psychiatry, online July 28, 2009.


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Things like this make me really angry. Making a diagnosis based on what you feel comfortable treating? Or based on the increased availability of drugs for one disorder versus the availability of drugs for another? Even worse… catering to drug companies that push their medications for profit!?!

Do you have any idea how dangerous that is? Bipolar may be “easier” to treat medically, but anyone diagnosed as bipolar will tell you that the struggle to find the right combination of medications to treat their disorder was not an easy process. And that’s WITH a proper diagnosis. My psychiatrist tried to treat me with mood stabilizing drugs meant for bipolar disorder and they really screwed me up. Badly. Made me worse. Providing the wrong diagnosis because another disorder is seems more medically treatable is just as reckless and dangerous as they claim we are at our most impulsive. Except they’re not the ones that have to pay the long term health consequences to our health when the medications don’t work. 

Thursday, March 28, 2013

Comorbid - Relationship Between Borderline Personality Disorder And Bipolar Disorder, Long-Term Study


Comorbid - Relationship Between Borderline Personality Disorder And Bipolar Disorder, Long-Term Study

Article Date: 02 Jul 2006

Results from a long-term study indicate that borderline personality disorder (BPD) and bipolar disorder do not commonly coexist, a finding which has important implications for treatment. The findings are reported in the July 2006 issue of The American Journal of Psychiatry (AJP), the official journal of the American Psychiatric Association (APA). 

BPD is a long-term, pervasive pattern of impulsive behavior, instability and changeable mood. Whether it is a variant of bipolar disorder is the focus of the AJP article, "Descriptive and Longitudinal Observations on the Relationship of Borderline Personality Disorder and Bipolar Disorder" by John G. Gunderson, M.D., medical director for the Borderline Personality Disorder Treatment Center at McLean Hospital. 

The study found only modest connections to bipolar disorder among 196 patients with BPD. The rate of co-occurring bipolar disorder in these patients was 19 percent. In patients with other personality disorders, the rate was eight percent. Among the patients who did not have bipolar disorder at the beginning of the study, eight percent of the BPD patients developed bipolar disorder over the next four years, compared to three percent of the patients with other personality disorders. 

Despite these differences, the rates of bipolar disorder in the BPD patients remained under 20 percent. This low frequency has important implications for treatment, as many BPD patients receive only a diagnosis of bipolar disorder and the two diagnoses generally are treated with different approaches. Psychosocial interventions are important in the treatment of BPD, whereas medication is generally the first choice for bipolar disorder. 

"The diagnosis of borderline personality disorder arose from psychoanalytic psychotherapy practice, whereas bipolar disorder is the subject of intensive neurobiological research and psychopharmacological treatment," stated Robert Freedman, M.D., AJP editor-in-chief. "This study is an important step in examining the extent of overlap between the two disorders." 

The co-occurrence of bipolar disorder did not worsen the course of BPD over four years. Remission occurred in two-thirds of both the BPD patients with and without bipolar disorder. 

In an accompanying editorial, Michael H. Stone, M.D., of Columbia University notes the article's "more balanced position on the controversy" about the relationship of borderline personality to bipolar disorder. He suggests that the moderately higher rates of bipolar disorder in patients with BPD disorder may indicate a subgroup of BPD patients with higher genetic risk for bipolar disorder. 

Why people with BPD are often misdiagnosed with Bipolar: Part – Even more


Aside from obvious symptoms there are also some other common reasons that people with BPD are often misdiagnosed with Bipolar disorder.


#1. Insurance companies often won’t cover treatment or therapy for Borderline Personality Disorder because while a lot of progress has been made and there is still some stigma and treatment isn’t as straightforward as with other Axis-I Disorders. Bipolar Disorder however is an Axis-I disorder and is considered to be highly treatable. With both disorders having the ear mark of affective instability, mood swings, etc. It’s an easy enough switch to pull off.  


#2. Many psychiatrists and therapists simply don’t like to diagnose Borderline Personality Disorder. I’ve talked about this before. With the stigma surrounding BPD, professionals and clinicians often don’t want to work with people that have BPD and psychiatrists don’t want to “leave a mark” on their patients that will medically trail them for the rest of their lives.  Diagnosing with Bipolar instead of Borderline is done because they’re “basically” similar and “some treatment is better than no treatment”… which is lazy.. It may be well intentioned but it’s basically well intentioned bullshit. 


#3. Many psychiatrists make diagnosis within the first meeting or two of seeing a new patient. Often times this diagnosis is based off of answers filled out on a couple questionnaires. Unless you have a lot of experience with both Bipolar and Borderline it can be very difficult to tell the difference between the two. And if you haven’t spent a lot of time with someone that is Borderline in general you not going to have a clear picture of how they cycle between moods and the length of time that it takes for them to cycle. It’s very important that a clinician be familiar enough to distinguish between Bipolar and Borderline Personality Disorder, to be familiar with BOTH disorders to properly diagnose either I would imagine. This is probably the biggest problem.


#4. I’ve been searching and searching and searching for material to talk about the comorbidity of Bipolar and Borderline PD. In fact it’s probably MIS-diagnosed as co-morbid more often than it actually occurs as comorbid.  However, I did find one intriguing little article that I shall follow up with shortly and then try to follow that one up with even more information….


BTW, in case you’re curious, I’ve been feeling better lately. I’ve been keeping myself as busy as humanly possible, and maybe the meds are helping? Idk. 

Tuesday, March 26, 2013

Borderline personality disorder and the misdiagnosis of bipolar disorder


Really the whole point here is understanding that misdiagnosis is a big deal and a big problem. Without proper diagnosis not only is the disorder more difficult to treat, but it can actually be made worse, or at the least, not be helped. This paper from the Journal of Psychiatric Research discusses the topic specifically. I’ll include the relevant aspects and link to the full article: HERE.



Borderline personality disorder and the misdiagnosis of bipolar disorder

Abstract

Recent reports suggest bipolar disorder is not only under-diagnosed but may at times be over-diagnosed. Little is known about factors that increase the odds of such mistakes. The present work explores whether symptoms of borderline personality disorder increase the odds of a bipolar misdiagnosis. Psychiatric outpatients (n = 610) presenting for treatment were administered the Structured Clinical Interview for DSM-IV (SCID) and the Structured Interview for DSM-IV Personality for DSM-IV axis II disorders (SIDP-IV), as well as a questionnaire asking if they had ever been diagnosed with bipolar disorder by a mental health care professional. Eighty-two patients who reported having been previously diagnosed with bipolar disorder but who did not have it according to the SCID were compared to 528 patients who had never been diagnosed with bipolar disorder. Patients with borderline personality disorder had significantly greater odds of a previous bipolar misdiagnosis, but no specific borderline criterion was unique in predicting this outcome. Patients with borderline personality disorder, regardless of how they meet criteria, may be at increased risk of being misdiagnosed with bipolar disorder.

1. Introduction

For years, a consensus had emerged that bipolar disorder was being under-diagnosed. A recent report, however, showed a dramatic shift in this trend, with the rate of bipolar diagnosis among outpatient office-based visits doubling in the last decade among adults and rising nearly 40-fold among children and adolescents. A subsequent study from our group provided evidence of potential misdiagnosis of bipolar disorder.

Little work has considered factors associated with the possible over-diagnosis of bipolar disorder. One source of error may involve confusing symptoms of borderline personality disorder with bipolar disorder. Although the disorders are clearly distinct as defined by the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 2000), a number of shared phenomenological features make the latter hypothesis plausible. Affective instability is a core feature of both disorders, albeit the nature and course of this instability may differ. The difficulty controlling anger often seen in patients with borderline personality disorder might be confused with the irritability of a manic episode (American Psychiatric Association, 2000). Impulsivity is a hallmark of borderline personality disorder, but is also common in patients with bipolar disorder even outside of episodes ( Links et al., 1999Swann et al., 2003 and Zanarini, 1993). Both disorders are also often characterized by recurrent suicide attempts ( Fyer et al., 1988Ruggero et al., 2007 and Zanarini et al., 2008) and problematic social functioning ( American Psychiatric Association, 2000Bauwens et al., 1991Dion et al., 1988,Fagiolini et al., 2005 and Weinstock and Miller, 2008). Similarities between the two disorders have even prompted some to question whether they belong to the same spectrum, although evidence for this hypothesis remains mixed ( Akiskal et al., 1985Akiskal, 2002Benazzi, 2008Deltito et al., 2001,Gunderson et al., 2006Koenigsberg et al., 2002Mackinnon and Pies, 2006Magill, 2004Paris et al., 2007,Smith et al., 2004 and Wilson et al., 2007).

In this report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project (Zimmerman, 2003) we assess the extent to which specific features of borderline personality disorder may put a patient at risk of being misdiagnosed with bipolar disorder. Based on the similar phenomenological features discussed above, we hypothesized that the borderline criteria reflecting affective instability, anger, impulsivity, recurrent suicidal behavior, and interpersonal instability would be most associated with bipolar misdiagnosis.

2. Methods

The present report compares these two groups (i.e., those reporting a previous misdiagnosis to those who had never been misdiagnosed, n = 610) to determine if specific borderline criteria increase the odds of having had a misdiagnosis. We began by assessing whether having borderline personality disorder in general increased the odds of reporting a previous misdiagnosis. We then assessed whether this outcome was more likely depending on the total number of borderline criteria endorsed. Analyses shifted to considering each of the nine borderline criteria, with the odds of reporting a previous diagnosis calculated for each of them. The significance of these odds was tested using the chi-square statistic.

3. Results

Demographic characteristics of the patients who report having been previously diagnosed with bipolar disorder did not significantly differ from the patients who had not been previously diagnosed with bipolar disorder (Zimmerman et al., 2008). Close to 9% of the sample (n = 52) met DSM-IV criteria for borderline personality disorder. As hypothesized, patients who reported previous misdiagnosis were significantly more likely to have borderline personality disorder than patients who were not misdiagnosed (24.4% vs. 6.1%). Looking at this another way, nearly 40% (20/52) of the patients diagnosed with DSM-IV borderline personality disorder report having been misdiagnosed with bipolar disorder compared to slightly more than 10% (62/558) of the patients without borderline personality disorder.

With respect to borderline personality disorder criteria, the average number of criteria met was significantly higher in the patients reporting a previous bipolar diagnosis (M = 2.4, SD = 2.5) compared to patients not reporting they had been given this diagnosis (M = 1.0, SD = 1.7; t = 6.4, p < .001). The data in Table 1 shows that the likelihood of being misdiagnosed with bipolar disorder increased with the number of borderline personality disorder criteria a patient met. Regarding specific symptoms, Table 2 shows that with the exception of transient dissociation, each borderline criterion was associated with a history of a bipolar misdiagnosis, though the strength of association varied.

       In short, the more Borderline traits displayed, the higher the likelihood of a Bipolar           misdiagnosis. Until you get just too many Borderline traits say 7+ and it becomes blatantly obvious but even then, there can still be some confusion.


4. Discussion

The present report is the first study that we are aware of to consider whether borderline criteria place patients at risk for being misdiagnosed with bipolar disorder. Patients reporting they had been previously diagnosed with bipolar disorder but who did not have it according to a SCID were compared to those who had never been diagnosed with bipolar disorder.

Patients with borderline personality faced significantly higher odds of having been misdiagnosed, with almost 40% of them reporting a previous misdiagnosis compared to only 10% of patients with other disorders. As hypothesized, borderline criteria reflecting affective instability, anger, impulsivity, recurrent suicidal behavior, and interpersonal instability all increased the odds of this outcome. These criteria, however, were not unique in doing so, since almost all the borderline criteria (with the exception of transient dissociation) were associated with increased odds of a previous misdiagnosis. Chronic emptiness was independently associated with the outcome, but the association was not particularly strong, with the odds being statistically but not meaningfully different from other criteria. Interestingly, the link between the number of borderline criteria and misdiagnosis was not linear (see Table 1). Participants endorsing six criteria had higher odds of reporting a misdiagnosis compared to those endorsing seven or more criteria. This may indicate that as patients endorse more symptoms of borderline personality disorder they become less diagnostically ambiguous, and hence less likely to have been misdiagnosed.





Overall, results suggest that having borderline personality disorder, as opposed to any particular set of criteria, increases the odds that a person may at one time or another be misdiagnosed with bipolar disorder.

Misdiagnosis of borderline personality disorder as bipolar disorder has serious clinical implications. A wave of effective new therapies has been developed for the treatment of borderline personality disorder that is distinct from those that would be used to treat bipolar disorder. These include long and short versions of dialectal behavior therapy, short and long term cognitive behavioral therapy tailored for borderline personality disorder, mentalization-based and transference-focused therapy, schema-focused therapy, and adjunctive group psychoeducation. Misdiagnosis would presumably delay the use of these more appropriate psychotherapies. Furthermore, there is mixed evidence that medications used to treat bipolar disorder are effective for borderline personality disorder, with a Cochrane review (Binks et al., 2006) of available randomized controlled trials concluding that pharmacological treatment of BPD in general is not based on good evidence. Given promising new data showing that borderline personality disorder often remits with appropriate treatment (Gunderson et al., 2000 and Zanarini et al., 2003), the need to accurately diagnose the condition becomes even more critical.

Findings in the present study are robust, but they must be interpreted in light of the study’s limitations. Among them, we were limited in our ability to collect information about previous clinical care. So while current diagnoses were based on semi-structured, reliable assessments administered by highly trained, mostly Ph.D. clinicians and were validated by family psychiatric history, the history of previous diagnoses was based on patients’ self-report. This raises the possibility of reporting errors. In other words, a certain proportion of patients reporting a previous diagnosis may have been mistaken, either by errors in recollection or because they misinterpreted past consultations. It is difficult to know the extent of this problem, but its effects on the current findings will be mitigated if such reporting errors occur equally across groups (there is no evidence to suggest this is not the case). Moreover, even if some of these self-reports are in error, it is unlikely that this is true for all or even most cases. Nevertheless, findings must be replicated using studies that better document diagnostic histories.

A second potential limitation is that we cannot rule out the possibility that some patients we deemed as not having bipolar disorder according to the SCID may in fact have had the disorder, despite the SCID diagnosis. This may be particularly true if one widens the concept of bipolar disorder to include softer forms of the spectrum (e.g., Akiskal, 2002). As a result, some past clinicians may have made the diagnosis based on this wider, non-DSM-IV concept of bipolar disorder. It is important to note, however, that the concept of the spectrum remains uncertain and that the SCID diagnoses in the present study were validated by family psychiatric history data (Zimmerman et al., 2008).

In summary, results from the present report highlight that patients with borderline personality disorder, regardless of how they meet criteria, may be at risk of being misdiagnosed with bipolar disorder. This finding suggests the need for clinicians to carefully attend to differential diagnoses between these disorders (Bolton and Gunderson, 1996) and for future research to identify markers that better differentiate patients with bipolar disorder from those with borderline personality disorder.

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For me I wouldn’t say I was entirely misdiagnosed when I first begun therapy. I was originally diagnosed Major Depressed and General Anxiety Disorder (though I knew I was Borderline), which I do have, however that isn’t all I have. I would say I wasn’t completely diagnosed. However I would say I was mis-medicated at first. Fortunately when I found my current Therapist she knew just what to do with me and at least in that I was quite lucky.

I’ve spent a significant amount of time here talking about Bipolar and Borderline, the difference between the two, and the potential for misdiagnosis. There is one more thing that I do want to talk about that can make diagnosis especially tricky… and that’s what happens when you have BPD and Bipolar comorbidly. I’m guessing explodey. We’ll get there. 

Monday, March 25, 2013

Quotes from the Borderline: Duality



“If we never experience the chill of a dark winter, it is very unlikely that we will ever cherish the warmth of a bright summer’s day. Nothing stimulates our appetite for the simple joys of life more than the starvation caused by sadness or desperation. In order to complete our amazing life journey successfully, it is vital that we turn each and every dark tear into a pearl of wisdom, and find the blessing in every curse.”


― Anthon St. Maarten, Divine Living: The Essential Guide To Your True Destiny





Bipolar or Borderline one thing we share is an appreciation for living in the extremes. Life is a duality. Learning to embrace the in-betweens; to live in the greys; to find the mediums in life is our goal. We live in the blackest of spaces, but if we can find even the smallest of life’s lightest lessons, we’ve achieved something great for ourselves. 




Sunday, March 24, 2013

Solitary





To be solitary does not mean to be abandoned. When we can work this out, I think we have have put a foot on the right path. 






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