http://esciencenews.com/articles/2010/03/25/is.it.really.bipolar.disorder

Is it really bipolar disorder?
Published: Thursday, March 25, 2010 – 13:00 in Health & Medicine

A study from Rhode Island Hospital has shown that a widely-used screening tool for bipolar disorder may incorrectly indicate borderline personality disorder rather than bipolar disorder. In the article that appears online ahead of print in the Journal of Clinical Psychiatry, the researchers question the effectiveness of the Mood Disorder Questionnaire (MDQ). The MDQ is the most widely-used and studied screening tool for bipolar disorder. It is a brief questionnaire that assesses whether a patient displays some of the characteristic behaviors of bipolar disorder. It can be administered by clinicians or taken by patients on their own to determine if they screen positively for bipolar disorder. For the purposes of this study, the MDQ was scored by researchers.

Bipolar and borderline personality disorders share some clinical features, including fluctuations in mood and impulsive actions. The treatments, however, will vary depending on the individual and the diagnosis. Principal investigator Mark Zimmerman, MD, director of outpatient psychiatry at Rhode Island Hospital, conducted a study to test the accuracy of the MDQ.

The research team interviewed nearly 500 patients using the Structured Clinical Interview for Diagnostic Statistical Manual IV (DSM-IV) and the Structured Interview for DSM-IV for personality disorders. The patients were also asked to complete the MDQ. The research team then scored the questionnaires and found that patients with a positive indication for bipolar disorder using the MDQ were as likely to be diagnosed with borderline personality disorder as bipolar disorder when using the structured clinical interview. Further, their findings indicate that borderline personality disorder was four times more frequently diagnosed in the group who screened positive on the MDQ.

Zimmerman says that these findings raise caution for using the MDQ in clinical practice because of how differently the disorders are treated. “An incorrect diagnosis of bipolar disorder will usually lead to a treatment involving medications. If a patient truly has bipolar disorder, that treatment may work. However, at this time there are no approved medications to treat borderline personality disorder.

“Without an accurate diagnosis of borderline personality disorder, we may have many people in treatment who are taking medications that will not work to alleviate the characteristics of the condition from which they really suffer.” Zimmerman, who is also an associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, continues, “In addition, patients with unrecognized borderline personality disorder will not be treated with one of the effective psychotherapies for this condition. It is therefore vital that we develop or identify a more accurate method to distinguish between these two conditions, and adopt it into clinical practice.”

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If Bipolar Disorder Is Over-diagnosed, What Are The Actual Diagnoses?

ScienceDaily (July 29, 2009) — A year ago, a study by Rhode Island Hospital and Brown University researchers reported that fewer than half the patients previously diagnosed with bipolar disorder received an actual diagnosis of bipolar disorder after using a comprehensive, psychiatric diagnostic interview tool –the Structured Clinical Interview for DSM-IV (SCID). In this follow-up study, the researchers have determined the actual diagnoses of those patients.

Their study is published in the July 28 ahead of print online edition of The Journal of Clinical Psychiatry.

Under the direction of lead author Mark Zimmerman, MD, director of outpatient psychiatry at Rhode Island Hospital, the researchers’ findings indicate that patients who received a previous diagnosis of bipolar disorder that was not confirmed by a SCID, they were significantly more likely to be diagnosed with borderline personality disorder as well as impulse control disorders.

Their research involved the study of 82 psychiatric outpatients who reported that they received a previous diagnosis of bipolar disorder that was not later confirmed through the use of the SCID. The diagnoses in these patients were compared to 528 patients who were not previously diagnosed with bipolar disorder. The study was conducted between May 2001 and March 2005.

Zimmerman, who is also an associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, says, “In our study, one quarter of the patients over-diagnosed with bipolar disorder met DSM-IV criteria for borderline personality disorder. Looking at these results another way, nearly 40 percent (20 of 52) of patients diagnosed with DSM-IV borderline personality disorder had been over-diagnosed with bipolar disorder.”

The results of the study also indicate that patients who had been over-diagnosed with bipolar disorder were more frequently diagnosed with major depressive disorder, antisocial personality disorder, posttraumatic stress disorder and eating and impulse disorders.

Zimmerman and colleagues note that “we hypothesize that in patients with mood instability, physicians are inclined to diagnose a potentially medication-responsive disorder such as bipolar disorder rather than a disorder such as borderline personality disorder that is less medication-responsive.”

In their previously published study that concluded bipolar disorder was over-diagnosed, they studied 700 patients. Of the 700 patients, 145 reported they had been previously diagnosed as having bipolar disorder; however, fewer than half of the 145 patients (43.4 percent) were diagnosed with bipolar disorder based on the SCID. The authors state that the over-diagnosis of bipolar disorder can have serious consequences, because while bipolar disorder is treated with mood stabilizers, no medications have been approved for the treatment of borderline personality disorder. As a result, over-diagnosing bipolar disorder can unnecessarily expose patients to serious medication side effects, including possible impact to renal, endocrine, hepatic, immunologic and metabolic functions.

Zimmerman concludes, “Because evidence continues to emerge establishing the efficacy of certain forms of psychotherapy for borderline personality disorder, over-diagnosing bipolar disorder in patients with borderline personality disorder can result in the failure to recommend the most appropriate forms of treatment.”

Along with Zimmerman, other researchers involved in the study include Camile Ruggero, PhD; Iwona Chelminski, PhD and Diane Young, PhD, all of Rhode Island Hospital and Brown University.

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Wednesday, Mar. 11, 2009

Redefining Crazy: Researchers Revise the DSM

By John Cloud

If you wanted to make a list of important books you should read, what would you choose? Anna Karenina, maybe? The Bible? How about the Diagnostic and Statistical Manual of Mental Disorders?

It may not be at the top of your list, but the DSM, as it’s usually called, is one of the most important books in the world. It attempts to categorize, describe and give a code number to literally every problem that can occur in your mind, from schizophrenia to borderline personality disorder to something called mathematics disorder, which is essentially being so bad at math that it amounts to a mental problem.

The DSM is important not only because it is wildly ambitious but also because mental-health professionals around the world have adopted its classification system. In the U.S., it is virtually impossible to get reimbursed by an insurance company for treatment unless a mental-health professional identifies your condition by a DSM code number. (The number for mathematics disorder, if you were wondering, is 315.1. The code for Tourette’s syndrome is 307.23; the code for sexual sadism is 302.84. As I said, the DSM tries to cover everything.) (See the top 10 medical breakthroughs of 2008.)

The American Psychiatric Association (APA), which owns the DSM, is in the process of rewriting the book, which was first published in 1952. The DSM-V, as the fifth edition will be called, is set to be published in 2012. But the process of researching it began way back in 1999 — five years after the publication of the last major revision, the DSM-IV — meaning the new book’s production will take 13 years overall. (Read about how we get labeled by the DSM.)

Why so long? Last week, a research organization called the American Psychopathological Association (which goes by the acronym APPA, to distinguish it from the APA) brought many of the key players in the development of the DSM-V to a conference in New York City to discuss some of the reasons the writing of the book is so complicated.

One obvious reason is that so many people have a stake in what the world defines as crazy and what it calls normal. Famously, homosexuality was listed as a DSM condition until a 1974 vote among APA members removed it. Other groups of mental-health professionals and patients want certain disorders to be added (and covered by insurance): sexual compulsivity, for instance, is not in the DSM, even though “sexual aversion disorder” (302.79) — the persistent and distressing avoidance of genital contact not explained by another disorder like depression — is included. (Read an interview with an author who has bipolar disorder.)

Debates about what should and shouldn’t be in the DSM are fascinating and often bitter, and as I have pointed out before, the book makes at least one fundamental error in the way it conceives of mental problems: it ignores causes almost entirely. If you feel sad and tired for a couple of months, have trouble sleeping and making decisions, and gain weight, you can be given a DSM diagnosis of depression (296.31 or 296.32, mild or moderate, recurrent) and prescribed drugs for it — even if the reason for your funk is that you just lost your job. Such physiological responses as insomnia are evolutionarily natural (and sometimes helpful, in a jump-starting sort of way) when you suffer a trauma like losing your job. But according to the DSM, only perfect is considered normal. Another basic problem with the DSM: it tries to reduce the vastly complex experiences of your mind to a single number.

At last week’s conference, there were tantalizing hints that the DSM-V might fix some of these problems. Dr. Steven Hyman, provost of Harvard, a former psychiatry professor at its medical school and a former director of the National Institute of Mental Health, agitated at the meeting for a new DSM framework that would stop trying to divide mental problems into discrete all-or-nothing categories. That method is appropriate for some medical problems — you either have leukemia or you don’t — but depression, for instance, doesn’t work like that. (Read “Why Do the Mentally Ill Die Younger?”)

Rather, Hyman argued that many mental illnesses are problems that lie along a continuum from normal and functioning to disordered and tragic. To the annoyance of some old-fashioned DSM defenders, he made the case that the DSM should regard mental illness as “continuous with normal”: less like leukemia and more like hypertension. You don’t get diagnosed with hypertension until you meet a cutoff point for high blood pressure that takes into account other extenuating factors: your age, for instance, or the conditions under which the blood-pressure reading is taken. Depression should be the same: if you are sad because you just got divorced, the DSM shouldn’t necessarily consider you to have an illness.

Such a diagnostic model wouldn’t be simple, though, which is one reason the DSM is taking 13 years to rewrite. And in the meantime, the book still has to be useful to everyday clinicians seeing patients who need a code number for insurance companies. “It’s like wondering how you repair the airport while the planes are still flying,” Hyman said at the conference.

Hyman noted that medical problems, whether in the mind or in the body or both, are usually caused by some combination of genes, environment, behavior and chance. Despite the comforting modern notion that severe psychological illnesses are simply due to an unfortunate genetic inheritance, it is the exceedingly rare mental condition that is caused only by genes. (Rett syndrome is one example.) Rather, if you take something like generalized anxiety disorder (300.02), there may be a variety of causes that set it off: genes that cause excessive activity in the fear-producing part of the brain called the amygdala, a stressful job that stimulates that activity, engaging in dumb behavior like having an affair that exacerbates your anxiety, then randomly getting into an anxiety-heightening situation like a car accident. The DSM has to try to account for all of that complexity — causes, effects, unintended consequences — and still be definitive.

Hyman said in an interview that one way the DSM currently handles this complexity is to have what he described as a “wastebasket” diagnosis — called “not otherwise specified” (NOS) — that captures just about anything that doesn’t easily fit the categorical model. One major problem with the NOS diagnosis: pretty much anyone can qualify for a diagnosis that, by definition, is not specified. A 2005 American Journal of Psychiatry paper found that nearly half of a group of 859 people who sought psychological help in Rhode Island could be considered to have a DSM personality disorder if diagnosticians were allowed to include the NOS option. Another problem: how do you adequately treat patients whose illness is unspecified?

A continuum model like the one Hyman proposes could help solve this problem by recognizing that people aren’t always one thing or another. They’re sometimes just a little depressed or a little anxious. To avoid medicalizing normal stress, the DSM-V would set a cutoff point within the spectrum. Of course, determining the right cutoff point for the DSM’s 350 illnesses would take an enormous research effort, one that has begun for some disorders like depression but probably hasn’t even been thought about for rare problems like sexual sadism.

Other attendees at the APPA conference indicated that the new DSM will almost certainly adopt a continuum model for mental illnesses. But don’t be surprised if the book doesn’t come out as scheduled in 2012. If the three-day conference came to any solid conclusion, it was that toting up all the ways our minds can fail is a lot harder than, say, explaining why your appendix might burst.

Read “Tallying Mental Illness’s Costs.”

Read “I’m O.K. You’re O.K. We’re Not O.K.”

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A 2008 study of nearly 35,000 adults in the Journal of Clinical Psychiatry found that 5.9%–which would translate into 18 million Americans–had been given a BPD diagnosis. As recently as 2000, the American Psychiatric Association believed that only 2% had BPD. (In contrast, clinicians diagnose bipolar disorder and schizophrenia in about 1% of the population.) BPD has long been regarded as an illness disproportionately affecting women, but the latest research shows no difference in prevalence rates for men and women. Regardless of gender, people in their 20s are at higher risk for BPD than those older or younger.

Because generally, it has been acknowledged that BPD occurs in about 2% of the population (which is already equal to the level of bipolar and schizophrenia combined, yet the condition gets much less attention or funding); however, this article states that research has shown that BPD is more than twice as prevalent than previously thought (at 5.9%, which would be almost three times as much as bipolar and schizophrenia combined). Also, the article states that, against the previously published data, there is no difference in prevalence rates between men and women. Typically, the research has shown that BPD patients are 75% female. So, I decided to track down this study and did so. Here is an abstract of the study:

Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions.

Grant BF, Chou SP, Goldstein RB, Huang B, Stinson FS, Saha TD, Smith SM, Dawson DA, Pulay AJ, Pickering RP, Ruan WJ.

Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD 20892-9304, USA. bgrant@willco.niaaa.nih.gov

OBJECTIVES: To present nationally representative findings on prevalence, sociodemographic correlates, disability, and comorbidity of borderline personality disorder (BPD) among men and women. METHOD: Face-to-face interviews were conducted with 34,653 adults participating in the 2004-2005 Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Personality disorder diagnoses were made using the Wave 2 Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version. RESULTS: Prevalence of lifetime BPD was 5.9% (99% CI = 5.4 to 6.4). There were no differences in the rates of BPD among men (5.6%, 99% CI = 5.0 to 6.2) and women (6.2%, 99% CI = 5.6 to 6.9). BPD was more prevalent among Native American men, younger and separated/divorced/widowed adults, and those with lower incomes and education and was less prevalent among Hispanic men and women and Asian women. BPD was associated with substantial mental and physical disability, especially among women. High co-occurrence rates of mood and anxiety disorders with BPD were similar. With additional comorbidity controlled for, associations with bipolar disorder and schizotypal and narcissistic personality disorders remained strong and significant (odds ratios > or = 4.3). Associations of BPD with other specific disorders were no longer significant or were considerably weakened. CONCLUSIONS: BPD is much more prevalent in the general population than previously recognized, is equally prevalent among men and women, and is associated with considerable mental and physical disability, especially among women. Unique and common factors may differentially contribute to disorder-specific comorbidity with BPD, and some of these associations appear to be sex-specific. There is a need for future epidemiologic, clinical, and genetically informed studies to identify unique and common factors that underlie disorder-specific comorbidity with BPD. Important sex differences observed in rates of BPD and associations with BPD can inform more focused, hypothesis-driven investigations of these factors.

I suppose that the idea that BPD “is associated with considerable mental and physical disability, especially among women” points to the fact that more women seek treatment for the disorder because of the “disability” aspect of its presentation among women. Perhaps that can explain the previously acknowledged statistics of 75% occurrence in women.

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Possible Genetic Causes Of Borderline Personality Disorder Identified

ScienceDaily (Dec. 20, 2008) — According to the National Institute of Mental Health, borderline personality disorder (BPD) is more common than schizophrenia or bipolar disorder and is estimated to affect 2 percent of the population. In a new study, a University of Missouri researcher and Dutch team of research collaborators found that genetic material on chromosome nine was linked to BPD features, a disorder characterized by pervasive instability in moods, interpersonal relationships, self-image and behavior, and can lead to suicidal behavior, substance abuse and failed relationships.

“The results of this study hopefully will bring researchers closer to determining the genetic causes of BPD and may have important implications for treatment programs in the future,” said Timothy Trull, professor of psychology in the MU College of Arts and Science. “Localizing and identifying the genes that influence the development of BPD will not only be important for scientific purposes, but will also have clinical implications.”

In an ongoing study of the health and lifestyles of families with twins in the Netherlands, Trull and colleagues examined 711 pairs of siblings and 561 parents to identify the location of genetic traits that influences the manifestation of BPD. The researchers conducted a genetic linkage analysis of the families and identified chromosomal regions that could contain genes that influence the development of BPD. Trull found the strongest evidence for a genetic influence on BPD features on chromosome nine.

In a previous study, Trull and research colleagues examined data from 5,496 twins in the Netherlands, Belgium and Australia to assess the extent of genetic influence on the manifestation of BPD features. The research team found that 42 percent of variation in BPD features was attributable to genetic influences and 58 percent was attributable to environmental influences, and this was consistent across the three countries. In addition, Trull and colleagues found that there was no significant difference in heritability rates between men and women, and that young adults displayed more BPD features then older adults.

“We were able to provide precise estimates of the genetic influence on BPD features, test for differences between the sexes, and determine if our estimates were consistent across three different countries,” Trull said. “Our results suggest that genetic factors play a major role in individual differences of borderline personality disorder features in Western society.”

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October 21, 2008

Mind

When All Else Fails, Blaming the Patient Often Comes Next

By RICHARD A. FRIEDMAN, M.D

Doctors and psychotherapists generally don’t like it when their patients don’t get better. But the fact is that lots of patients elude our clinical skill and therapeutic cleverness. That’s often when the trouble starts.

I met one such patient not long ago, a man in his early 30s, who had suffered from depression since his teenage years. In six years of psychotherapy, he had been given nearly every antidepressant under the sun, but his mood hadn’t budged.

Weeping in my office one day, he explained that he was depressed because he was a failure and a whiner. “Even my therapist agreed with me,” he said. “She said that maybe I don’t want to get better.”

I could well imagine his therapist’s frustration. She had been working with him for nearly three years without significant progress, and she was now doing what many clinicians do when the chips are down: blame the patient for failing to improve.

“I think he has an unconscious desire to remain sick,” she told me.

About a month later, I saw this patient respond remarkably well to a novel treatment. Free of depression at last, he was joyful and relieved — an odd reaction, you must admit, from someone who secretly wished to be ill.

Not just that, but he no longer felt like a failure and was much more upbeat about his future prospects.

I decided to challenge him. “How come you’re feeling so much better despite the fact that nothing in your life has really changed in the past few weeks?”

“Well, I guess I just think like that when I’m down.”

Exactly. His sense of worthlessness was a result of his depression, not a cause of it. It’s easy to understand why the patient couldn’t see this: depression itself distorts thinking and lowers self-esteem. But why did his therapist collude with the patient’s depressive symptoms and tell him, in effect, that he didn’t want to get better?

For an all too human reason, I think. Chronically ill, treatment-resistant patients can challenge the confidence of therapists themselves, who may be reluctant to question their treatment; it’s easier — and less painful — to view the patient as intentionally or unconsciously resistant.

I recall an elderly woman who was referred by a colleague for intractable depression, in which I have a special interest. I was eager to help her.several months and many treatments later, I began to get frustrated that she was no better and noticed that my thinking about her shifted. I wondered whether there was something about the sick role that she found rewarding.

After all, she had constant visits from friends and family members, not to mention an army of medical experts who were all trying, in vain, to cure her. If she got better, she might lose all that care and attention.

Then one morning, shortly after starting a new combination of antidepressants, she called. I did not recognize the cheerful voice. “I’m feeling really good,” she told me. “Not depressed at all.”

My delight aside, I felt chagrined that I had begun to write her off as a help-rejecting crank.

Of course, it makes good medical sense for therapists to rethink the diagnosis and treatment of any patient who fails to improve. But this is a double-edged sword.

Another patient, a young woman with unstable moods, was recently hospitalized with a diagnosis of bipolar disorder. When she failed to respond to two mood stabilizers, the staff began to entertain a diagnosis of borderline personality disorder, which involves emotionally chaotic relationships and impaired ability to function in the world.

“She’s pretty aggressive and demeaning, and we think she has some serious character pathology,” one of the residents told me.

But partly treated bipolar disorder can mimic borderline personality disorder, and after she received a third mood stabilizer, her “personality disorder” melted away, along with her provocative behavior.

This patient had frustrated her clinicians with her lack of response to treatment. In turn, her doctors reacted by changing her diagnosis to a personality disorder. The change in thinking shifted the blame from the clinicians to the patient herself, who was now viewed more as bad than sick.

To be sure, some patients really do want to be sick. People with Munchausen syndrome, for example, deliberately produce physical or psychological symptoms for the express purpose of assuming the sick role. And they will go to extraordinary means to defeat doctors who try to “treat” them.

But a vast majority of patients want to feel better, and for them the burden of illness is painful enough. Let’s keep the blame on the disease, not the patient.

Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College.

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When Hope is Not Enough
Get the Non-BPD book that is designed for
staying and working on the relationship

Substance Abuse

I don’t think I have to cite any references on this one. The bio I read makes it clear that Cobain was a junkie and used consistently. Also, despite his slim frame (5’7″, 130 pounds), he used far more heroin than others in his final days and his body was, for the most part, able to take it. He did overdose numerous times. Abuse of pain killers (of which heroin is one), is not uncommon with BPD (sometimes called “Bellman’s Syndrome”).

His heroin use eventually began affecting the band’s support of Nevermind, with Cobain passing out during photo shoots. One memorable example came the day of the band’s 1992 performance on Saturday Night Live, where Nirvana had a shoot with photographer Michael Levine. Having shot up beforehand, Cobain nodded off several times during the shoot. Regarding the shoot, Cobain related to biographer Michael Azerrad, “I mean, what are they supposed to do? They’re not going to be able to tell me to stop. So I really didn’t care. Obviously to them it was like practicing witchcraft or something. They didn’t know anything about it so they thought that any second, I was going to die.”

Eating Disorder (or chronic pain leading to one)

Kurt Cobain had a chronic, undiagnosed stomach disorder from which he developed an eating disorder, being unable to keep down food.

Throughout most of his life, Cobain battled chronic bronchitis and intense physical pain due to an undiagnosed chronic stomach condition. This last condition was especially debilitating to him emotionally, and he spent years trying to find its cause. However, none of the doctors he consulted were able to pinpoint the specific cause, guessing that it was either a result of Cobain’s childhood scoliosis or related to the stresses of performing.

Volatile Relationships

His relationship with Courtney Love was volatile. He also had volatile relationships with others in his band and with managers and ex-girlfriends.

Love arranged an intervention concerning Cobain’s drug use that took place on March 25. The ten people involved included musician friends, record company executives, and one of Cobain’s closest friends, Dylan Carlson. But Bassist Krist Novoselic tipped him off as he considered the idea to be “stupid”. However, by the end of the day, Cobain had agreed to undergo a detox program. Krist Novoselic drove him to the airport to catch his flight, but Cobain was far from wanting to go, in a fit of panic, Cobain drew violence and the two fought at the airport, eventually Cobain freed himself and ran through the airport lobby screaming “fuck you”, this would be the last time Krist would see Kurt alive.

Shame and Unstable Self Image

His lyrics probably do the best for this…

All Apologies:
I wish I was like you
Easily amused
Find my nest of salt
Everything is my fault
I’ll take all the blame
Aqua seafoam shame
Sunburn, freezeburn
Choking on the ashes of her enemy

Dumb:
I’m not like them
But I can pretend
The sun is gone
But I have a light
The day is done
But I’m having funI think I’m dumb
Or maybe just happy

Radio Friendly Unit Shifter:
What is wrong with me?
What is what I need
What do I think I think?

This had nothing to do with what you think
If you ever think at all
Bi-polar opposites attract
All of a sudden my water broke
I love you for what I am not
Did not want what I have got
Blanket acne’d with cigarette burns
Speak at once while taking turns

And of course, there are probably twenty more examples in his various lyrics. The only other musician that I can think of off the top of my head who consistently used the words “shame” and “I’ll take the blame” is Ian Curtis (Joy Division’s lead singer who also committed suicide).

Suicide Attempts

I think these go without saying, considering his eventual actual suicide. But we know of at least one other:

Following a tour stop at Terminal Eins in Munich, Germany, on March 1, 1994, Cobain was diagnosed with bronchitis and severe laryngitis. He flew to Rome the next day for medical treatment, and was joined there by his wife on March 3. The next morning, Love awoke to find that Cobain had overdosed on a combination of champagne and Rohypnol (Love had a prescription for Rohypnol filled after arriving in Rome). Cobain was immediately rushed to the hospital, and spent the rest of the day unconscious. After five days in the hospital, Cobain was released and returned to Seattle. Love later stated that the incident was Cobain’s first suicide attempt.

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Attorney: Spears not fit enough to take part in probate case

* Story Highlights
* Britney Spears’ attorney says the pop star is not ready to participate in court
* Lawyer told court Thursday that Spears’ medical condition is “fluid”
* Spears’ probate case scheduled to go to trial July 31

LOS ANGELES, California (AP) — Britney Spears is not yet fit to participate in court proceedings in her conservatorship case, her lawyer told a Los Angeles Superior Court commissioner Thursday.

Samuel Ingham, Spears’ court-appointed attorney, and attorneys for the pop star’s father and conservator, James Spears, spent 90 minutes in Commissioner Reva Goetz’ chambers.

Ingham told the court afterward that Spears’ medical condition is “fluid” because her treatment is changing.

Spears’ probate case is scheduled to go to trial July 31, but Ingham said it could be “harmful” for her to participate. Goetz agreed and said Spears’ diagnosis is not complete.

The 26-year-old singer and her estate have been under the conservatorship of her father for four months.

I’d say that’s code for “she’s acting nutty again.” They probably don’t want to release that she’s got BPD. “Some form of bipolar” is likely to come up again. I mean, come on… she started this whole thing in January. How long does it take a team of doctors to diagnose her? Hmm?

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No celebrity has come out and announced that they have the disorder. While several celebrities have said they have bipolar disorder (just search on the Internet and you’ll see), no celebrity has announced they have BPD. Why? Probably because of the stigma (see below). There are certainly candidates for the disorder, but no poster child yet.

Many people believe that BPD is just a case of the person behaving badly. Non-BPs are definitely guilty of this in spades. The behaviors associated with the disorder – including drug abuse, lying and manipulation – lead many people, including family members and therapists, to believe that the disorder begins and ends with behavior. While behavioral therapies seem to be the most effective in treating the disorder, emotional dysregulation and cognitive disortions play a big role and shouldn’t be ignored. A person with BPD is not just someone behaving badly. They are trying to adapt to the large amount of emotional pain that they feel. Sometimes these adpatations will take the form of dangerous and distructive behavior, but that behavior is not about anyone other than themselves – in other words the behavior is not about you (the Non-BP).

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Bipolar is an Axis I disorder and BPD is an Axis II disorder. This really must change. Historically, BPD has been considered a “personality” disorder. People see it as a character flaw (even some of the sufferers). It is not a character flaw – it is a serious emotional and mental illness that should be treated as such. There are biological components to BPD just as there are biological components to bipolar disorder. It’s time to get rid of the Axis II classification of BPD and treat it like bipolar disorder.

There is a huge stigma surrounding BPD. If you do a search on the Internet and read Non-BP stories, most are in the vein of “I’m glad I got rid of my borderline wife.” There are several Non-BP books that are also in this vein. There is little worse in the mind of the public than someone having BPD. It’s time to remove the stigma. I hope that deeming May as BPD awareness month will help to increase awareness and remove the stigma.

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TMZ reported that Spears’ friends “have known for a while that Britney has a very serious mental condition — likely a bipolar disorder that is now in the red zone.”

I think the language here is quite important. Borderline Personality Disorder is so maligned that not a single celebrity has come out and stated that they have the disorder. Bipolar disorder, on the other hand, is not considered just the result of “bad behavior” – it is considered biological in nature – and therefore many celebrities have come out and admitted they have bipolar disorder. Bipolar is an Axis I disorder, BPD an Axis II.

Unfortunately, this distinction is a fallacy. Experts are considering changing the name of BPD to Emotional Regulation Disorder (or emotional dysregulation disorder) and making it Axis I. Why? Because clearly a large part of BPD is biological.

One of the main differences between bipolar and BPD is the length of the mood swings. In the case of Bipolar Disorder the length of the manic and depressive episodes (and mixed episodes) usually lasts days or weeks, if not longer. There is the case of Bipolar II in which a person may experience hypomania – which is possibly why the media has reported Britney to  have “a” bipolar disorder, rather than just “bipolar disorder” (although some of the media has removed the “a” from in front of the reported disorder). Substance abuse and suicide are both common with Bipolar Disorder and it effects about one half to 1 and one half of a percent of the population.

Borderline Personality Disorder is actually more common than bipolar disorder – some estimates say that it is up to 5% of women and about 2% of the population at large. It is characterized by wildly swinging emotions – not moods. Although many want to classify it as a subclass of mood disorders (like Cyclothymia), it is more a dysregulation of the emotional system. Emotions are immediate and the behaviors, impulsiveness, rage, “moods”, etc. only last for HOURS, not days or weeks. The DSM-IV says this about BPD:

Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

Substance abuse is so common with BPD sufferers that most estimates say it is co-morbid in over 75%. Also, self-destructive impulses are common (like cutting, over-eating, eating disorders, shopping, shoplifting, sexual deviance or inappropriateness) with BPD. As are suicidal gestures and thoughts, but these are usually impulsive. Impulsivity is a major problem with BPD and here is what the DSM-IV says about that:

Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).

While I am not a doctor and not knowledgeable enough to diagnose Britney, I suspect that she may have BPD (or bipolar II) and, if she does have BPD, I would hope that she could be the first celebrity to come out and say so. It’s not her fault. It’s not just “bad behavior”. It is a serious mental illness and should be taken care of immediately. What I don’t understand is why she doesn’t get herself a “helper” to aid her in the regulation of her obviously dysregulated and impulsive behavior.

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Related posts:

1. Celebrities with Borderline Personality Disorder (possibly, not for sure)
2. Charlie Sheen and Borderline Personality Disorder
3. Britney Spears and Mel Gibson

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