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Borderline or Bipolar: Can 3 Questions Differentiate Them?

The Prisoner’s Dilemma paradigm separates the two, but that’s not practical as a clinical tool.

Borderline or Bipolar: Can 3 Questions Differentiate Them?

January 10, 2017 | Bipolar Disorder, Mood Disorders
By James Phelps, MD

Treatments for borderlinity and bipolarity are quite different. Which approach should you consider for a patient with impulsive risk-taking, episodes of irritability and hostility, fractured relationships, substance use problems, and severe depressions with brief phases of remission (maybe too good?) in between?

The Prisoner’s Dilemma paradigm separates the two,1 but that’s not practical as a clinical tool. What if you could pluck just 3 items from a standard bipolar screening questionnaire and increase your diagnostic certainty by 30% when faced with this common differential? That may be possible, based on a new study from Nassir Ghaemi and colleagues, led by Paul Vöhringer.2

Of course, replication studies will be needed before we can declare a new diagnostic approach is at hand. But in the meantime, I hope you might be curious: what 3 items from the good old Mood Disorders Questionnaire (MDQ)3 were so discriminating?

Vöhringer et al2 obtained an MDQ from 260 patients whose diagnosis was then established by structured interview (the usual gold standard in this kind of study). Then they analyzed the individual MDQ items looking for those that discriminate well between bipolar disorders and borderline personality disorder. They found 3, a “clinical triad,” that had remarkable statistical power:

1. Elevated mood: “You felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?”

2. Increased goal-directed activities: “You were much more active or did many more things than usual?”

3. Episodicity of mood symptoms: “If you checked YES to more than one of the above, have several of these ever happened during the same period of time?”

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Healing with paint: How the pioneer of art therapy helped millions of mental health patients

Lisa Buttery, a 25-year-old artist who works at Brighton University, shares Molloy’s experiences. She has been dealing with borderline personality disorder since her teens, and has used art in therapy and as a creative outlet.

Healing with paint: How the pioneer of art therapy helped millions of mental health patients

Edward Adamson was the first artist to be employed in a UK hospital. Kashmira Gander explores how his studio was an oasis of calm in a harsh twentieth century mental hospital, and how his legacy lives on.

Kashmira Gander @kashmiragander Wednesday 7 September 2016

It is the late 1990s and once again Gary Molloy’s severe bipolar disorder has hospitalised him. Unbeknown to Molloy, though, this stint will be the one to transform his life. “I saw these wonderful paintings on the ward. They were quite abstract. I was mystified and inspired, ” recalls Molloy, now 47, of his stay in a hospital in east London where he was born and raised.

Gripped, he needed to find out more, and discovered the works were created at Core Arts, a nearby centre for people with mental health illnesses. This is how Molloy, who was deterred from creativity by his teachers because of his gift for maths, says he discovered art.

“I found something magical in painting, writing and poetry. It eased the symptoms,” says the civil servant turned artist who is now a trustee and volunteer at the centre. “Ever since, I’ve been managing my condition by being creative, and building my self-esteem. It was a catalyst.” The impact on Molloy is undeniable: he hasn’t been hospitalised for 17 years.

Art as therapy was first used in the early and mid-20th century. Patients were often forced to deal with archaic and brutal practices, but they were also first to experience pioneering treatments. This duality, as well as how mental health has been approached over the centuries, and what the future might hold, is being explored at the Wellcome Collection’s latest exhibition: Bedlam: the asylum and beyond.

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A Spectrum Approach to Mood Disorders

The author deftly explores the overlapping symptoms of mixed bipolar symptoms, anxiety disorders, borderline personality disorders, ADHD, and major depression.

A Spectrum Approach to Mood Disorders

September 06, 2016 | Film And Book Reviews, Bipolar Disorder, Depression, Major Depressive Disorder, Mood Disorders
By Tammas Kelly, MD

A Spectrum Approach to Mood Disorders: Not Fully Bipolar but Not Unipolar—Practical Management

by James Phelps, MD; New York: WW Norton and Company, 2016
255 pages • $32.00 (hardcover)

In A Spectrum Approach to Mood Disorders, Dr Jim Phelps bravely enters territory that academia has largely neglected—the nebulous region between full bipolar disorder and major depression. This is where so many of our patients live. The book is a must-read for any health professional involved in the treatment of affective illnesses, including psychiatrists, psychiatric nurse practitioners, psychologists, and therapists.

His previous book, Why Am I Still Depressed?,1 is still a great source of information about bipolar II for professionals who wish to learn more and for patients who are suffering from bipolar II and soft bipolar. In A Spectrum Approach, he once again leads us to a greater understanding of the complexity of the bipolar disorders.

The author’s website, Psycheducation.org, averages around 40,000 unique visitors each month. It is safe to assume that at one time or another, the majority of our patients with bipolar disorder have read Dr Phelps’ work. He is perhaps one of the most widely read experts on bipolar disorder of our time.

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Borderline or Bipolar: Objective Data Support a Difference

When euthymic bipolar patients played (ostensibly with another person, though the actual partner was a computer), they made choices very like control patients, choosing to cooperate almost 75% of the time. But patients with BPD cooperated only about 50% of the time (ANOVA difference, P = .03).

Borderline or Bipolar: Objective Data Support a Difference

News | April 12, 2016 | Bipolar Disorder, Borderline Personality, DSM-5
By James Phelps, MD

When a patient presents with episodes of depression, irritability, and emotional lability (especially tears and anger, with rapid changes), might he or she have borderline personality disorder (BPD)? Or could it be rapid cycling bipolar disorder (BD)?

Although there are other possibilities, such as substance use, differentiating these 2 common conditions can be extremely difficult. DSM criteria have a roughly 90% overlap: only 2 DSM criteria features are clearly present in one and absent in the other: namely, abandonment fear and chronic emptiness.1

Indeed, Deltito and colleagues,2 as well as others, have argued that borderlinity is just another version of bipolarity or at least that the “broadening of the bipolar diagnosis to include a spectrum of poorly defined conditions has added to the plausibility of this idea.”3 In refutation of this notion, data that demonstrate a clear difference between the 2 conditions, involving interpersonal trust, have recently been published.3

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From hellish cycles to stability: A mental health story

“One in four people will have mental illness,” she said, in their lifetime. That’s a lot of people.

From hellish cycles to stability: A mental health story
Stephanie Dickrell

Eventually, she was diagnosed with borderline personality disorder, bipolar disorder, post-traumatic stress disorder and depression.

“People think of you for (your diagnosis). You shouldn’t live your diagnosis. That’s what I’m trying to get out to people,” she said.

But it didn’t start there. Hagfors had a hard time making and keeping friends as a child. Borderline personality disorder isn’t something that just happens. It develops over time via the environment, usually in childhood.

“I was very emotional growing up. Like every little thing bothered me,” she said. “In school, I’d maybe have one friend. I tried to be in things like band. But I would come home from school and just cry all night long.”

Because of stress, Hagfors has been grinding her teeth since she was a year old.

She was really good at basketball, but anxiety won.

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Study Will Evaluate Bipolar Medication in Treating Borderline Personality Disorder

The secondary outcomes are depressive symptoms, deliberate self-harm, social functioning, health-related quality of life, resource use and costs, side effects of treatment, adverse events, and withdrawal of trial medication due to adverse effects.

Study Will Evaluate Bipolar Medication in Treating Borderline Personality Disorder
Aug 12, 2015 | Bill Schu

Borderline personality disorder (BPD) is challenging to diagnose and treat. As yet, there are no drugs currently licensed for BPD treatment. In fact, guidance from England’s National Institute for Health and Care Excellence recommends that pharmacologic therapy not be used for patients with BPD at all. This is potentially troubling, because those patients typically experience rapid and extreme changes in mood, poor social functioning and have high rates of suicidal behavior.

Some smaller-scale research has suggested that mood stabilizers may produce short-term reductions in symptoms of BPD, but few controlled, randomized clinical trials have been undertaken in this area. A new study announced in Trials will compare the effectiveness of the bipolar disorder and anti-seizure medication lamotrigine, which has been shown to be effective at preventing or delaying some depressive effects in patients with bipolar disorder, versus placebo in patients with BPD.

The lamotrigine and borderline personality disorder: Investigating Long-term Effectiveness trial (LABILE) is a multi-center, two-arm, parallel group, double-blind, placebo-controlled randomized trial with three-, six-, and 12-month follow-up assessment. It will be the first study to examine the long-term clinical effectiveness and cost-effectiveness of lamotrigine for people with BPD.

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