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Glenn Yank, MD is a Psychiatrist located in Tennessee.


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Question:
My questions is in regard to my boyfriend. I’ve known him for a long time. However, three months ago he moved in. During this time he confessed to me that he’d been diagnosed with rapid cycling bipolar in 1996. He has mutulation scars on his left arm during the time he was suicidal. Since he has been with me, he has suddenly become extremely domonic during certain episodes, later to hardly recall the drama… He refers to his life and family in two distinct concepts, one with hate, one with love and compassion. During the times of his episodes, he has broken pictures on my wall, degraded me for hours on hours, paced and pouted and ranted, gotten “lost” in my house not knowing what to do with himself, and kept me up at night in rages. His good self is totally opposite. Wonderful, polite, loving, kind and generous. Because he has a bad history of childhood trauma where his father beat his mother and his mother beat him, I am concerned that indeed his diagnosis might not be bipoar at all, but rather DID. One reason is because he once said, “how did i get here??” regarding moving in with me. Even his expressions and voice change. Yet he still denies that he could have multiples. He believes he is bipolar. One side of him hates me passionately, one side loves me. I cannot get him to understand this. Could it be possible he was diagnosed wrong? Thanks, Amy

Answer:

Your question raises several important questions. One question is what is the place of borderline personality disorder in the differential diagnoses of mood swings and episodic aggressive behavior. Another question is what is the role of personality disorders in understanding the rapid and profound changes some people experience in their sense of self and their way of interacting with others. A related question is what is the difference between the psychological defenses of dissociation, which is the hallmark of dissociative identity disorder, and splitting, which is a key feature in the psychological makeup of borderline personality disorder.

Before proceeding with a discussion, let me state that I cannot make an accurate diagnosis of your boyfriend (or anyone) on the basis of correspondence, and that accurate diagnosis would require more information than is available in your letter and a formal, face to face diagnostic interview with an appropriately trained mental health professional. That being said, let’s proceed.

You describe several important phenomena related to understanding your boyfriend’s problems and to this discussion:

  • He experiences sudden changes in mood.

  • He refers to his family and his life in two distinct ways, one of which is positive and loving and one of which is negative and characterized by hate.

  • You describe two distinct “sides” to his personality.

  • He has what you termed “episodes,” which sound like sudden rages with aggressive behavior.

  • He has what you termed “mutilation scars.”

  • He experiences the likely dissociative phenomena of poor recall for periods of intense emotion and “getting lost” in your house.

Let us compare these phenomena to some of the symptoms that are criteria for the diagnosis of borderline personality disorder, taken from the DSM IV (rearranged and re-numbered to match the foregoing statements for purposes of this discussion). Borderline Personality Disorder is defined as “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:”

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

  2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

  3. identity disturbance: markedly and persistently unstable self-image or sense of self

  4. inappropriate intense anger or difficulty controlling anger

  5. recurrent suicidal behavior, gestures, or threats or self-mutilating behavior

  6. transient, stress-related paranoid ideation or severe dissociative symptoms

For completeness, the other criteria are:

  1. impulsivity in at least two areas that are potentially self-damaging

  2. frantic efforts to avoid real or imagined abandonment

  3. chronic feelings of emptiness

Although it is not clear from your letter (or more extensive history) whether your boyfriend has “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts,” it appears that several of the problems that you describe match up well with criteria for the diagnosis of Borderline Personality Disorder. Further, significant histories of childhood trauma and/or neglect are seen in the majority of patients with Borderline Personality Disorder. Thus, it is not necessary to invoke diagnoses of either Bipolar Affective Disorder, rapid cycling type, or Dissociative Identity Disorder to account for the problems and history that you describe.

Distinguishing Borderline Personality Disorder from Bipolar Disorders, particularly rapid and ultra-rapid cycling ones, is not easy, and these disorders can co-exist. Rapid cycling Bipolar Disorder is defined as the occurrence of 4 distinct mood disorder episodes with a year, and occurs in about 20% of Bipolar patients. Ultra-rapid or ultradian (cycling within 24 hours) is much less common. In ultra-rapid cycling, the mood swings are not reactions to interpersonal events, triumphs, or failures, and occur on their own. The mood swings encompass the full range of manic and depressive symptoms, including changes in energy level and the speed at which the person thinks and talks. In contrast, the rapid mood swings in patients with Borderline Personality Disorder are reactive to changes in the person’s life, particularly in their relationships, and also to events that affect their self-esteem. For example, criticism in the workplace can trigger depression or rage, but a success can trigger feelings of elation with decreased need for sleep. Although Borderline Personality Disorder can co-exist with Bipolar Disorder (most commonly Bipolar II Disorder, in women), in my experience of running a mood disorder inpatient unit for several years, the vast majority of patients who said they were diagnosed as “rapid cyclers” turned out to have co-morbid severe personality disorders (Borderline, or Personality Disorder not otherwise specified with borderline features).

Ultra-rapid cycling Bipolar Disorder without a co-morbid personality disorder does not include the confusion about self-concept or the conflicts in relationships seen in personality disorders (other than the difficulties in living with a person whose mood is unstable). However, the oscillations between loving and hating, valuing and devaluing in relationships that you describe is much more characteristic of Borderline Personality Disorder. People with both Bipolar and Borderline Personality Disorders experience profound changes in their sense of themselves over time, but a patient who is primarily Bipolar usually experiences these changes as coming from inside themselves or as mysterious phases of their illness, whereas a patient with Borderline Personality Disorder usually experiences their changes as responses to what is going on in their life, particularly in their relationships. It is as if their self esteem is tied to what they perceive others feel about them, which leads to the phenomena of frantic efforts to avoid rejection (because rejection means that they have no self worth) and feeling empty when alone (they only feel that they have a complete self when someone else is present).

The presence of dissociative phenomena such as poor recall of conversations, “getting lost,” and asking “how did I get here?” do not, by themselves, indicate a diagnosis of Dissociative Identity Disorder (DID), because DID is not the only form of psychiatric disorder in which dissociative phenomena are prominent. For example, dissociative symptoms are also seen in other dissociative disorders, Post Traumatic Stress Disorder (PTSD), Complex PTSD (see: http://www.ncptsd.va.gov/facts/specific/fs_complex_ptsd.html), Borderline Personality Disorder, and other severe personality disorders.

The last question I would like to address is the difference between splitting and dissociation. I have discussed these defenses in a previous Shrinktime column. “Splitting” was defined as the unconscious “keeping apart of inner representations (of self and other) that are experienced as ‘good’ and ‘bad’ in order to preserve the “good” and prevent it from being contaminated or destroyed.” What are kept separate in splitting are experiences of the self and other that have distinctly different emotional feelings associated with them. The person who uses splitting alternates between loving and hating, but cannot feel both of these feelings at the same time. However, these feelings are linked by memory and are both felt by the same personality. The person can remember that their feelings have gone back and forth – they just cannot hold them both in consciousness at the same time. Splitting is most consistent with a person having different “sides” between which they go back and forth, but these are different sides of the same person.

Dissociation was defined as the “splitting-off or separating a group of thoughts, memories, feelings, and activities from the main portion of consciousness; compartmentalization.” Thus, there is some similarity in that both defenses involve keeping different portions of the mind’s content away from each other. However, in dissociation there is more of a disturbance in consciousness so that memory of whatever has been dissociated cannot be accessed. Dissociation exists on a range from everyday “tuning out” to the extreme form of dissociating entire, separate identities.

In contrast to splitting, in dissociation that has progressed to DID, each personality has a range of emotions (although they may “specialize” in one), but does not have access by memory to the other personalities. In splitting, there are separate “ego-states” which each have a predominant emotion and are contained within one personality.

To return to the question, yes it is possible that your boyfriend was diagnosed incorrectly, although this is not certain from the limited information available. However, the information that you have shared is most consistent with Borderline Personality Disorder, which would account for or “cover” all of the important problems that you described. Bipolar Disorder, even an ultra-rapid cycling type, does not account for the alternation between idealizing and devaluation, the self-mutilation, or the dissociative phenomena that you describe. Thus, if your boyfriend has Bipolar Disorder, it is not all that he has. Further, there is no information that you provided that points specifically to DID, although it also cannot be excluded without a lot more intensive assessment. I hope that you and he will be able to get the help that you need.

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Disclaimer: The information contained here is not intended nor implied to be a substitute for professional advice relative to your specific medical or mental health condition or question. ALWAYS seek the advice of your physician or other health provider for any questions you may have regarding your medical or mental health condition. Information provided here DOES NOT constitute a doctor-patient relationship between you and the column author.

© Copyright 2003-2005. All rights reserved. Contact: ShrinkTime Last edited: 12/06/04.