• Doc, I think I am bipolar!

    by Matthew Goldenberg, D.O.
    on Oct 11th, 2016

Many patients come to my office because their mood has been “off” or they are worried they might be “bipolar.” Some of these patients are worried because their family or friends have told them that they might be “bipolar” and others are concerned because they have a relative with the diagnosis and similar symptoms. In some cases patients or their family and friends are correct in believing they have Bipolar Disorder, however, this is not always true.

I believe there is a major misconception in the public regarding what symptoms are consistent with Bipolar Disorder and which are not. This is especially important because treatments for several diagnoses, which can all present with similar “bipolar” symptoms, require very unique treatments.

Before I can make a diagnosis, as a Psychiatrist, I need to take a full history and perform a full psychiatric evaluation of my patient. Otherwise it is easy to confuse unipolar-depression, Bipolar Disorder and many of the Personality Disorders that can all present with seemingly similar symptoms. These Disorders can significantly impact a patient's mood, however, with proper evaluation and treatment, their prognoses are all much improved.

The major misconception that I consistently come across is that patients, and the general public, often believe that Bipolar Disorder causes dramatic mood changes over the course of a single day. This is absolutely not true and causes many people to unnecessarily believe they are “bipolar”.   In contrast, Bipolar Disorder classically causes mood swings that last days if not weeks at a time. For example, patients with Bipolar Disorder will be irritable or have an elevated mood consistently for several days in a row or longer. These periods are then followed with distinct periods of normal mood or depressed mood.

Therefore, if your mood switches, and is reactive to external stressors, multiple times throughout a single day, this is likely not Bipolar Disorder. [My upcoming Huffington Post article is going to be about Bipolar Disorder and how a Psychiatrist makes a diagnosis and formulates a treatment plan. I will post the link here when it is available. Please check back later this week!] Patients who come to my office and report that their mood always seems to be “up and down,” it is always reactive to the things happening around them and is always unstable, are often surprised when I inform them that this does not make them “bipolar.”

Do you or someone you know suffer from severe shifts in a single day and/or extreme mood reactivity to external stressors, that impairs relationships, ability to work and quality of life? Did you think this was a sign of being ''bipolar?"

What causes mood swings that occur several times in a single day?

If it is not Bipolar Disorder, you might be wondering what causes these type of mood swings that occur everyday and throughout the day? Let's start with defining the symptoms were are talking about. For example, patients will frequently report that their mood can be fine in the morning and something will set them off and they become angry, irritable or sad the rest of the day. (i.e. they are doing fine until someone says something mean, cuts them off while driving, cancels plans etc.).  Or, conversely, they will often wake up upset or sad and then something good happens (i.e. they get a promotion at work, their spouse/significant other surprises with a gift, they get paid etc) and their mood quickly improves. They feel like their mood is a "yo-yo" and they are "just along for the ride". A highly reactive and unstable mood can have a large negative impact on all facets of a patient’s life because the swings are unpredictable and uncontrollable.

An “up and down” and highly reactive mood, which has been consistently this way throughout the majority of a patient’s lifetime, is consistent with the symptomatology of a Personality Disorder. If this is the first time you have heard of Personality Disorders, you are probably scratching your head… let me explain.

In brief, our personality is a cluster of unique attributes, traits and patterns behavior, that defines how we interact with the world and those around us. I often explain to patients that we learn a set pattern of behavior so that we can quickly react and respond to stresses and situations that arise. These are important characteristics that everyone has and utilizes to solve problems and interact with peers.

However, a personality disorder is diagnosed when these traits and patterns of behavior negatively impact many or all facets of a patient’s life. Personality Disorders can negatively impact a patient's mood, anxiety, quality of life, ability to perform activities of daily living (at both home and work) and their ability to maintain relationships. There are several distinct personality disorders, each with their own cluster of symptoms and maladaptive behaviors. However, the one that I see most often get confused with Bipolar Disorder is called Borderline Personality Disorder.

Those with Borderline Personality Disorder report the extreme mood reactivity and mood lability that was described above. Additionally, a diagnosis is officially made when patients have met a total of (at least) five of the nine possible criteria.

These symptoms/criteria include:
1) “Fear of Abandonment”:  Frantic efforts are made to avoid real or imagined abandonment or patients may worry excessively that friends, family or intimate partners will leave them.

2) “A lot of Drama in Relationships”: A history of intense interpersonal relationships, alternating between extremes of idealization and devaluation.

3) “Unstable Self-Image”: Identity disturbance and/or an unstable self-image or sense of self.

4) “Impulsivity”: A consistent pattern of engaging in potentially self-damaging behavior.

5) “Recurrent Suicidal Behavior”: A history of making many suicidal gestures, threats and/or self-mutilating or suicidal behavior.

6) “Mood Lability and Reactivity”: (Discussed Above) Mood instability due to high mood reactivity, lasting a few hours and rarely more than a few days.

7) “Emptiness”: Chronic feelings of emptiness.

8) “Anger Issues”: Recurrent inappropriate episodes of intense anger or difficulty controlling anger.

9) “Stress Related Experiences”: Short-term stress-related paranoia or severe dissociative symptoms. Patient will report that when they are under stress things seem to “change strangely around them” or that they suddenly cannot trust those people that they normally would (family, friends romantic partners).

When patients present with the majority of these symptoms, I provide them with information regarding Borderline Personality Disorder for them to review. Patients will fall into three categories: 1) The information and diagnosis fits them nearly perfectly, 2) Parts of it ring true but others do not seem to fit, 3) The symptoms do not sound like them at all. I work with my patients to establish if a Personality Disorder, such as Borderline Personality Disorder, can explain some or all of the symptoms they are suffering from. The reason to establish if Borderline Personality Disorder is present is that the treatment is distinct from that of Bipolar Disorder.

Psychotherapy is often the first treatment modality employed for Borderline Personality Disorder. Dialectical Behavioral Therapy (DBT) is evidence based and highly effective in helping to change the pattern of behavior and personality characteristics of Borderline Personality Disorder. Patients learn how to change their thoughts and actions that have negatively impacted their quality of life.

DBT teaches patients how to differentiate “emotional” decisions and reactions from “wise” decisions and reactions. Every interaction with the people around us has a delicate balance of achieving our goals, maintaining the relationship (with the people we are interacting with) and keeping our self-respect. However, for those suffering from Borderline Personality disorder, these factors often get out of balance and one or two are emphasized while the others are neglected. When this happens it can have a severe negative impact on our relationships or on our self-image.

                                                          

While therapy is often the first-line treatment, medications can also be helpful, especially if there are other co-morbid diagnoses. It is possible to have both a Personality Disorder and a Mood Disorder, such as Bipolar Disorder. When this occurs both diagnoses must be treated to have a successful outcome. That is why getting the correct diagnosis, or diagnoses, is so important.

If you, or someone you know, might be suffering from Borderline Personality Disorder, I would encourage you to seek help from a Psychiatrist or a trained Therapist right away. You can speak to your primary care doctor or call your insurance company for referrals. The symptoms of Borderline Personality disorder can be terribly disruptive to a patient’s quality of life. However, with proper evaluation and treatment I have seen patients turn their lives around and thrive.


Best,

Dr. Goldenberg

docgoldenberg@gmail.com
docgoldenberg.com
Twitter: @docgoldenberg

Author Matthew Goldenberg, D.O. Matthew Goldenberg D.O. is double Board Certified in Psychiatry and Addiction Psychiatry and is a certified Medical Review Officer (MRO). He is an expert in the evaluation and treatment of mental health disorders and is an addiction specialist for adults in his private practice in Santa Monica, California. Dr. Goldenberg also provides addiction psychiatry consultations to some of the nation’s top residential and outpatient treatment programs in the Los Angeles area and is experienced in the evaluation and treatment of professionals working in safety-sensitive positions. In addition to his clinical work, Dr. Goldenberg is an active author, researcher and invited speaker at local and national conferences. He also volunteers his time as a Clinical Instructor in the Department of Psychiatry at UCLA and is an Assistant Professor of Psychiatry at Cedars Sinai Medical Center.

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