The Moody Blues: Differentiating Bipolar Disorder from Borderline Personality Disorder

Transcription

1 The Moody Blues: Differentiating Bipolar Disorder from Borderline Personality Disorder Jose Herrera, MD Assistant Professor Department of Psychiatry Michigan State University

2 Objectives: Gain greater knowledge of the epidemiological and diagnostic similarities and differences between Bipolar Affective Disorder (BAD) and Borderline Personality Disorder (BPD). Achieve knowledge of the types of treatments available for these disorders, and the differences between them. Gain a greater appreciation for the treatment challenges that these patient populations face in accessing mental health care. Participants will gain a better understanding of how to help these patient populations, including when to refer to a specialist.

3 What this is not: Intended to be a complete discussion on diagnosis or treatment Intended to place the burden of diagnosis or treatment solely on the primary provider, nor replace referral to a specialist (when available) Imply a one or the other mindset about BPD and BAD, nor label patients Supposed to make you feel bad about the important and difficult work you are doing!

4 Why do we care? Psychiatric complaints including depression are common in the primary care and private practice therapy settings as are psychosocial problems These also provide a setting for longitudinal surveillance which is critical in diagnosis of MDD, BAD, and BPD MDD, BAD, and BPD as singular illnesses are frequently misdiagnosed, can co occur, and the treatments are different Borderline Personality Disorder is frequently misdiagnosed as Bipolar Disorder and vice versa

5 What is the Diagnosis? A. Bipolar Disorder, Type 1 (BAD 1) B. Bipolar Disorder, Type 2 (BAD 2) C. Major Depressive Disorder (MDD) D. Borderline Personality Disorder (BPD) E. None of the Above

6 Case #1 A 50 yr old WM, recently divorced, presents with a 2 month history of gradual onset of depressed mood, entry and middle insomnia, and feelings of worthlessness, with worsening in the last 2 weeks. This includes loss of self esteem (despite running a successful startup business that allowed him to retire early, and fathering 3 adult college educated children), loss of enjoyment in travel and exercise, lack of motivation, and recent weight loss. He had started some old Prozac I found about 1 week after his divorce was finalized, which he described as a casualty of my drive to succeed, but ran out.

7 Case #1 He denied any history of alcohol or drug use, and PMH was positive for mild HTN and hyperlipidemia. He exercises regularly but had not done so in the last 4 weeks. Although maintaining a good relationship with his children, coworkers, and his ex wife, he proclaims that my life has been a failure, and reluctantly admits that he has recently been contemplating suicide, although he denies active intent or access to means including firearms.

8 Case #2 Cecily is a 42 yr old MWF who presents for evaluation of recurrent depressive episodes, starting in her late teens. These episodes (including the current one) tend to develop over the span of about 1 2 weeks, with precipitous decline into anergia, depressed mood, amotivation, profound guilt, hypersomnia, and hyperphagia, and mild suicidal ideation without attempt or plan. With or without treatment, these episodes seem to also resolve rather rapidly, but have recently tended to progress to periods of spontaneous increased energy, irritability, accelerated speech and thoughts, although the depressed mood would not improve; these periods could last for several hours, days, or even a few weeks, often ending when her other symptoms, including depressed mood, would resolve.

9 Case #2 On review of history, Cecily (and her husband who was available by phone) recall occasional periods when she would feel extremely happy, selfconfident, energetic, and needing less sleep than usual, although given the repeated episodes of depression she stated these periods felt normal to her. Her husband contested this assertion somewhat, noting that people noticed this seemed out of character for her despite normally being a pleasant, optimistic person when not depressed.

10 Case #2 During these periods, she would talk more, start numerous home projects without completion, and occasionally distractible although still functional. He also commented with a laugh that their sex life was great during these periods, which typically lasted about 2 3 days (neither is sure exactly how long.) They both agreed that the longest such period lasted about 1 week (but has not been that long since) during her senior year of college when she was graduating and they were preparing to get married. She also reports that one of her biological aunts and one grandparent were hospitalized when she was young for schizophrenia or something but is adamant that I am nothing like them.

11 Case #3 Sara is a 29 yo SWF who presents to her PCP for treatment of depressed mood and chronic suicidal thoughts. She had recently moved from another town to work in retail and to try something new. She reports a history of previous psychiatric treatment since the age of 17 with 3 4 previous psychiatric hospitalizations for overdose, typically with antidepressants. Her treatment has consisted of primarily medication, including antidepressants, neuroleptics, and mood stabilizers. She can t afford therapy.

12 Case #3 (Cont.) Sara also reports a history of frequent superficial cutting, along with persistent thoughts of death. She notes chronic depressed mood with frequent mania consisting of 1 2 days of increased energy and volitional sleep deprivation and irritability, followed by a hypersomnia the following day. During the exam, she appears generally dysphoric, but otherwise with intact grooming.

13 Case #3 (Cont.) She described nothing working to treat her depression, which are often prompted by difficult interactions with family, boyfriends, and coworkers who treat me awful although she describes herself as having lots of really close friends. She reflected on numerous traumas which she didn t want to talk about. She reports her mood as all over the place, but also comments to the PCP that you seem amazing, I am sure that you can help me.

14 Case #4: A 32 yo AA male presents to your office on referral from his PCP for treatment of depression for which he was started on sertraline approximately 3 weeks ago. To your surprise, he presents in the waiting room with a broad, almost inappropriate smile and can be heard laughing in the waiting room from your office. He appears mildly diaphoretic on approach. He leaps up from his chair in the waiting room and firmly shakes your hand, stating that he just walked 10 miles from a political protest in town, although he didn t mind because he couldn t wait to meet you.

15 Case #4: (cont) The PCP had called prior to his appt to discuss the case with you, noting that his PMH was negative, and labs were WNL including UDS; however, he wanted to make sure that care was coordinated as he had concerns about SI (although not requiring hospitalization at the time) and the profound, rapid onset of his depression. Interestingly, during your interview the man replies No way! when you inquire about suicidal ideation, stating that his recent political activism brought him to the realization that he was put on this earth to do amazing things, just like Jesus and that he recently found out from a search on Ancestry.com that may be related to Moses and Martin Luther King. Although able to engage in the interview,

16 Case #4: (cont) He frequently appears to be distracted, glancing around the room, out the window, at the clock, and comments that your hair looks great, I am going to get mine cut just like that. He is unable to spell the word WORLD backwards, stopping after several tries and proclaiming with a laugh, Whatever, the world s all love anyway When asked about his treatment goals, he states I am here to spread God s love, like it says in the bible, although he quickly diverts to asking you if you do STD testing here, noting that he has had unprotected sex with numerous male and female peers in the last 2 3 days during the protest rally, adding that I am not a homosexual but the moment just felt right. Towards the end of your session, he spontaneously reclines on the couch, stating do you mind if I take a nap? I haven t been able to sleep for a week, I have been so excited about the political season and meeting you, this is a real blessing.

17 Case #5 Victoria is a 29 year old, recently graduated attorney at a prominent law firm who presents for evaluation of difficulty in mood, superficial cutting since her teens, and anxiety since she was young. She states that my mood swings are getting out of hand and that they are ruining things with my boyfriend, and starting to affect my work. She noted that she and her boyfriend had been discussing marriage but that they had broken up again for the 100 th time which seems to happen on a monthly basis, prompted by some minor slight or argument which she admits she usually instigated; she had contemplated seeking help in the past but things had always patched themselves up after I sulked about it for a few weeks, I was busy finishing law school and we weren t serious anyway; However, recently since the talk of marriage, he has become fed up with me, even though I am always sorry and we make up, and told me if I don t get help he doesn t know if we can move forward because it s like living with a split personality.

18 Case #5 She relates that she has become more tearful, sad, anxious, and argumentative at home, and irritable with lack of focus at work which only adds to her stress. During these times, she was less social, avoided sex and socializing with friends and family, but was able to work although during these times she would questions why I worked so hard to get a job at such a malignant place. She recognized that this was not her normal disposition and that always felt guilty, self critical, and regretful afterwards, but that during these times I just feel like I can t control it. I feel like I am going crazy, and I get mega pissed when my boyfriend says I am just PMS ing!

19 Case #5 On careful history, she reveals that these changes in mood happen very rapidly, usually unprompted by external events, about 5 7 days prior to the onset of her menses and resolve with the start of her period after about 2 days. At this point, she notices a lifting of her mood. She denies drug or alcohol use. PMH is negative. She only takes an OCP. Family history is positive for depression in her mother.

20 Epidemiology Prevalence of : Major Depression (MDD): 5 15 % (up to 2x more common in women; may be skewed) Bipolar Disorder (BAD): 1 3 % (May also be underdiagnosed, Men = women) Borderline Personality Disorder (BPD): 1 3 % (11% outpatient pop., 20% inpt pop., Women 3x > Men)

21 Comorbidity Between 30 and 70% of depressed patients receive a concurrent diagnosis of a personality disorder (Usually Cluster B), often in hospital and CMH settings Not ideal! Up to 75% of people with Borderline Personality Disorder (BPD) will meet criteria for a mood disorder at some point in their lifetime, with MDD (32%) and BAD 1 (31%) most common.

22 Diagnostic Overlap/Comparison The Moody patient Frequent, vague complaint The Treatment Resistant patient Both disorders are difficult to treat, and time intensive! The Noncompliant patient Comorbid PD decreases already low compliance The I can t stand this person patient High utilizers of health care and MH services, provider burnout

23 The Challenge: How do we approach differentiating between difficult presentations of mood disorders and mood symptoms in a fast paced setting? How do we avoid labeling, misunderstanding, and over/under treatment, or inappropriate treatment? How do we better collaborate on and integrate better care for patients with serious psychiatric disorders?

24 Bipolar Hong Kong (bipolarhk.com)

25 DSM V Criteria for Manic Episode A distinct period of abnormally and persistently elevated, expansive, or irritable mood, AND persistently increased goaldirected activity or energy Lasting at least 1 week (or any duration if hospitalization is necessary).

26 DSM V Criteria for Manic Episode During the period of mood disturbance and increase energy or activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree AND represent a noticeable change from usual behavior

27 Manic Episode 1. Inflated self esteem or grandiosity 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) 3. More talkative than usual or pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing

28 Manic Episode 5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) 6. increase in goal directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

29 Manic Episode The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

30 Manic Episode Note: A full manic episode that emerges during antidepressant treatment (eg medication, ECT) but persists at a fully syndromal level beyond the physiological effects of that treatment is sufficient evidence for a manic episode, and, therefore a Bipolar I diagnosis.

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34 Hypomanic Episode Distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days and present for most of the day nearly every day. This hypomanic mood is clearly different from the person s usual mood. During the period of mood disturbance, 3 or more of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree:

35 Hypomanic Episode Inflated self esteem or grandiosity Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) More talkative than usual or pressure to keep talking Flight of ideas or subjective experience that thoughts are racing

36 Hypomanic Episode Distractibility (e.g., attention too easily drawn to unimportant or irrelevant external stimuli) Increase in goal directed activity (either socially, at work or school, or sexually) or psychomotor agitation Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments

37 Hypomanic Episode Associated with a change in functioning that is uncharacteristic of the person. For example, the individual may be far more productive or outgoing and social than they usually are. Not subtle the change is directly noticeable by others (usually friends or family members) during a hypomanic episode.

38 Hypomanic Episode Usually not severe enough to cause serious impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features. The observable symptoms of a hypomanic episode must not be due to substance use or abuse (e.g., alcohol, drugs, medications) or caused by a general medical condition (e.g., hyperthyroidism or diabetes).

39 Bipolar Disorder Difficult Diagnosis! Some estimates suggest that patients see an average of 3 5 providers over spans of up to 5 7 years before an accurate diagnosis is made Approximately 10 15% of Unipolar Depression will be revised to Bipolar Disorder, although may be up to 30% meeting criteria in some studies. About % of the time, bipolar disorder may present as depression, especially Bipolar Type II, and hypomania may not be recognized or cause significant dysfunction

40 Major Depressive Episode A. Five (or more) of the following symptoms have been present during the same two week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure (anhedonia)

41 Major Depressive Episode 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. feels sad or empty) or observation made by others (e.g. appears tearful) 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly ever day (as indicated by either subjective account or observation made by others) 3. Significant weight loss when not dieting or weight gain (e.g. a change of more than 5% of body weight in a month), or decrease or increase in the appetite nearly every day

42 Major Depressive Episode 4. Insomnia or hypersomnia nearly every day 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) 6. Fatigue or loss of energy nearly every day

43 Major Depressive Episode 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self reproach or guilt about being sick) 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

44 Major Depressive Episode B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g. hypothyroidism)

45 Unipolar (MDD) vs Bipolar Depression Unipolar Depression Later Onset Fewer Episodes More gradual onset Female > male Bipolar Depression Earlier Onset More episodes Acute, rapid onset Female = male

46 Unipolar (MDD) vs Bipolar Depression Unipolar Depression More psychomotor agitation Typical Symptoms Insomnia Lower risk of suicide Bipolar Depression More psychomotor retardation and lethargy Atypical symptoms Hypersomnia Greater risk of suicide (especially mixed states, impulsivity, grandiosity)

47 Unipolar (MDD) vs Bipolar Depression Unipolar Depression Antidepressants more effective Lithium LESS effective Family history of depression Bipolar Depression Antidepressants LESS effective (and may destabilize Lithium more effective Family history of mania and depression

48 They love without measure those whom they will soon hate without reason. -Thomas Sydenham Girl, Interrupted

49 Borderline Personality Disorder A pervasive pattern of instability of: Interpersonal relationships Self image Affects

50 Borderline Personality Disorder Marked impulsivity, beginning in early adulthood and present in a variety of contexts, as indicated by five (or more) of the following : 1. Frantic efforts to avoid real or imagined abandonment* 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

51 Borderline Personality Disorder 3. Identity disturbance: markedly and persistently unstable self image or sense of self 4. Impulsivity in at least two areas that are potentially self damaging (e.g., substance abuse, binge eating, and reckless driving)

52 Borderline Personality Disorder 5. Recurrent suicidal behavior, gestures, or threats, or self mutilating behavior 6. 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)

53 Borderline Personality Disorder 7. Chronic feelings of emptiness 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) 9. Transient, stress related paranoid ideation or severe dissociative symptoms

54 Proposed DSM V (2013) diagnostic criteria for Borderline Personality Disorder: The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose borderline personality disorder, the following criteria must be met: A. Significant impairments in personality functioning manifest by: 1. Impairments in self functioning (a or b): a. Identity: Markedly impoverished, poorly developed, or unstable self image, often associated with excessive self criticism; chronic feelings of emptiness; dissociative states under stress. b. Self direction: Instability in goals, aspirations, values, or career plans. AND 2. Impairments in interpersonal functioning (a or b): a. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities. b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.

55 Comparison Bipolar Affective Disorder (BAD) Episodic mood shifts (usually depressive) with periods of stability Mood periods days to weeks (median 2 months) Depression turned inward, less outward (loss of esteem) Tendency to start earlier than MDD, but later than BPD Often mood shifts are independent of stressors or at least more delayed in onset Episodes/shifts in mood/behavior tend to be noticeable, out of character Borderline Personality Disorder (BPD) Highly Variable mood shifts Instability is the rule, not the exception Mood periods minutes to hours, rarely more than a few days (often reactive) Depression often turned outward (anger, resentment), although there may be both History starting in late teens/early adulthood ( Always been like this ) Often reactive to external stressors, displaced locus of control Episodes/shifts in mood/behavior tend to be trait state /inflexible/ the way they are

56 Treatments Bipolar Affective Disorder (BAD) Mood Stabilizers Borderline Personality Disorder (BPD) PSYCHOTHERAPY (DBT, CBT, Sub Abuse) Antipsychotic/neuroleptics Psychotherapy (CBT) Substance abuse tx SSRIs best evidence for depressive, anxiety symptoms Low dose antipsychotics/neuroleptics for transient/recurrent psychotic symptoms/mood stabilization Mood Stabilizers?? (caution with Lithium)???SSRIs/antidepressants??? Caution with Benzodiazepines

57 Summary Clinical diagnosis is difficult, but accurate history, collaboration of providers/family, and longitudinal care is helpful Diagnosis (not labeling) can be therapeutic These disorders (including BPD) can be very challenging and frustrating for patients and providers alike, but can get better

58 Useful Tools/Resources (Borderline Personality Disorder Resource Ctr) lity disorders institute professionals.php (Personality Disorders Institute of Weill Medical College of Cornell University) Young Mania Rating Scale (YMRS)

59 "Perilous highs and desperate lows and extravagant flurries of mood are not always symptoms of a broken mind, but signs of a beating heart -Terri Cheney, Manic: A Memoir

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61 Questions?

62 References Diagnostic and Statistical Manual (DSM 5), American Psychiatric Association APP Board Review Guide for Psychiatry (Bourgeois, M.D. et al) Comprehensive Textbook of Psychiatry, Kaplan and Sadock, M.D., 9 th Edition DSM 5 Clinical Cases, John W. Barnhill M.D. Ed., various contributors Essentials of Clinical Psychiatry, Hales and Yudovsky, M.D.

63 Thank You and Go Green!!