Diagnosed Bipolar. Now what?

[Bee Girl]

Hello,

My bf has been seeing a therapist for a brief time and she referred him to a psychiatrist, who diagnosed him with mild bipolar and started him on lithium.

I think he's being honest with them about his anger outbursts, and starting therapy and even admitting that he has an issue is huge progress, but I'm guessing he's not seeing and communicating what triggers him, and it's taken me almost three years to figure that out and get here.

I certainly realize I'm no professional, and I understand that lithium can help with mood stabilization, so this all may help... . but something about this misdiagnosis troubles me, and I think it's the missed opportunity for the right psychotherapy. I think his T is helping him a cognitive therapy but I wonder how focused it is.

My bf mentioned last week that his T wanted to speak to me (he's nervous about it but willing) and I wonder how it might go over if I ask to speak to her alone? I wouldn't intend to force the BPD issue, but give her my perspective on the triggers and pattern of dysregulation.

One thing that breaks my heart is that the psychiatrist reportedly said "the good news is that you don't have a personality disorder" and my boyfriend seemed really relieved (he understands the difficulty with treatment for PD). Perhaps it is bipolar, or bipolar and BPD. He's very high functioning.

Confused.

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[waverider]

What do YOU believe are the defining differences between a mood disorder and a personality disorder?

Ask the T what he/she believes the difference is in regards to your partner.

Can you explain to the the T what you perceive are the triggers, and how long the episodes last.

[Bee Girl]

My sense of the difference between a mood disorder and a personality disorder is about what has influence on or drives the change in behavior. For my bf, I can see how much he is affected by how others "treat" him, and the degree to which he is sensitive to it is marked. He can be boosted by someone treating him with regard and triggered into rage by someone disrespecting him. I'm not sure if I'm articulating it, but it feels like the externals ("good" and "bad" completely feed and inform his outlook, while a mood disorder might change the perspective from the inside out.

It would be helpful to hear the T's distinctions.

His triggers revolve around feeling betrayed, disrespected, disagreed with, confronted, dismissed. Nothing that's pleasant for anyone, but it took a while for me to figure out the common denominator in even the very small (and baffling) ways those feelings get triggered for him, especially when involving me. One minute I'm the love of his life and the next I'm the worst thing that ever happened to him, and it took many, many repeats and hearing myself say "but I didn't do anything wrong" before I could detect the trigger in something as innocuous-seeming as saying hello to the cat before greeting him when I came home from work.

The episodes, when they are full blown (less often lately due to my tools and his willingness to admit and work on his anger) usually last a day.

[Bee Girl]

Another thought is that at the bottom of it I can sense he's hurting from very low self esteem and a feeling of shame that probably feels "outed" when people seem to disrespect or abandon/betray him. I'd hope that his T can get to that and help him with it more than anything. He's the most insecure person I've ever met and it must be painful. That's not so much about the diagnosis but about what needs healing. If that was addressed supportively and actively I wouldn't care so much what the dx was.

[waverider]

Yes mood swings in Personality Disorders are quickly triggered by situational (external) events. They escalate rapidly like an eruption and then can die down just as quickly. Mood Disorders are internally driven, like a chemical imbalance, and may seem to have no real reason. Hence they are more treatable with medications. The mood swings normally have much longer cycles than a personality disorder.

The inherent denial that comes with a personality disorder often hides the causes from outside observers and hence makes diagnosis difficult especially if the episodes are not witnessed first hand.The suffer is often unaware of the quick cycling, and so they may complain they are feeling depressed and will act like it has been like this for a while, even if they were perfectly fine half an hour ago, as now is forever, and always will be. That is THEIR perception. Half an hour later they will feel the opposite and block their previous stance.

The real danger of a misdiagnosis is that the suffer can come to believe that medications can fix whatever it is rather than for them to learn new management tools themselves, leading to avoidance of the correct treatment.

It would be best if you hear the T first hand before you conclude what the T thinks, as your partners reporting of the Ts opinions could be highly skewed.

The problem with therapy is that it doesn't do much good unless the patient is ready for it, as opposed to just using it for support and empathy, then switching to denial once the the truths about what THEY can change to improve their lives.

Denial is an ingrained survival tools, and it is often masked by a false, or shallow, insights, which shows as mirroring of what they have heard before. Just like they can mirror the interests of others they can do likewise with therapy talk. Playing the part without it becoming part of how they really see themselves, and without owning it. This is lack of self identity at work.

[waverider]

If that was addressed supportively and actively I wouldn't care so much what the dx was.

The danger a T faces is if they press an unwanted diagnosis on someone, they simply quit therapy, hence they often appear to skirt around the real issue, until such time as a client is ready for it.

[bpbreakout]

Not sure whether this helps but my BPDw was diagnosed with BP2 8 years ago and changed psychiatrist about 6 months ago and was "re-diagnosed" with BP2, PTSD, emotional disregulation, borderline and possible ADHD.

BPDw never felt right with the BP2 diagnosis though I think a lot of this was denial. However in BP2 terms she was ultra-rapid cycling and can change moods quite rapidly within a day. Her triggers are almost identical to the ones you described and generally short lived.

Personally I find the "cocktail" diagnosis far more realistic as it also took into account what was going on in her life and a lot of very difficult FOM issues (ie considered the whole person). The old psychiatrist I think suspected personality disorder of some kind but did little to encourage therapy just medications so I think saw it as a biological issue. BPDw is still taking meds for bipolar (seroquel and tegretol) on the basis that they still help with mood swings whatever their source so has left the BP2 diagnosis open.

In my case BPDw is highly sensitive about me seeing her psychiatrist which I have accepted though to be honest I think she is afraid that I will divulge things about her that she is holding back on. In your case may be best to have joint session and build up some trust rather than have a one on one.

I think there is a 20% crossover between BP and BPD so a dual diagnosis isn't at all unusual.

Whatever the case I believe you are rigt about the self esteem issue being more important than the diagnosis.

Good luck

[Bee Girl]

This does help, and whether the diagnosis is accurate at this point (a "cocktail" makes sense) is less important than the step away from complete denial. As long as he's acknowledging it and addressing it with a T and a psychiatrist it's a good start. I don't feel like I'm alone in this. The tools, advice and support available here are applicable and most valuable to me. Thank you.

[hergestridge]

My wife has also had a bipolar diagnosis. However, she lied her face blue about the triggers because she's so embarrased about it. Of course she said that she just gets ups and downs "for no particular reason", when actually her menstrual cycle, an upsetting conversation or her getting psyched up before a party are things that affect her mood.

She's been on lithium since november and nothing has happened so far. Absolutely nothing. And when she's having a good day she can pretend that the lithium is working and has been working all the time, and when she's on a real down she will admit that it's had no effect whatsoever. Ever the revisionist mind.

The doctor said it will take 1-2 to years to eveluate the effect (!) which basically means no f**ing treatmeant at all for a couple of years.

Actually, I know the doctor who gave my wife the BPII diagnosis. He thinks the borderline diagnosis is psychobabble and that he can tell a who's got a "real" personality disorder from four control questions. He's on a mission to set BPII diagnosis to all the "undiagnosed"/"misdiagnosed" people out there.

There's so much ideology and stuff in the psychiatric field, you'd be surprised.

Still, I think there may be a BP streak to my wive's condition no doubt. She seems to have periods of heightened sensitivity when she's having trouble sleeping and her sense of taste is altered (she craves spicy food all of a sudden), which seems a bit odd. But the main problem is borderline. I sat beside her when she lied her way through the interview with the psychiatrists.

[bpbreakout]

Hergest, the person who diagnosed BPDw with BP2 was very good in a crisis and helped BPDw through a major family crisis over several years which caused a major depression for BPDw. I had a lot of respect for the psychiatrist. However is/was approaching retirement and very straight down the line & quite inflexible on the BP2 diagnosis. She didn't really encourage BPDw to do any therapy and her attitude towards me was there was very little anyone could do about it apart from take medications and I found her very dismissive whenever I approached her. BPDw took around 3 years of lithium, epilem and finally tegratol/seroquel to get the medications "right" which I understand is quite normal. The main problem with this approach (which may be similar to your situation) is that I found myself making excuses for BPDw's behaviour on the basis that she had a chemical imbalance in her brain and couldn't help it so have wasted a lot of years with this. BPDw eventually didn't feel right with the diagnosis and after a mjaor crisis got a second opinion. Per my post above, the new (and much younger) psychiatrist has diagnosed attachment issues, borderline, bipolar, adhd, anxiety, complex PTSD and so on. BPDw has done some therapy since then to help with some FOO issues but this hasn't gone as far as her exploring how these issues might be affecting how she behaves towards me.  . New psychiatrist has also diagnosed 12 months weekly DBT which BPDw doesn't have the time for , need I say more