Bipolar versus Borderline: Disease Mongering Pill Pushers Stack the Deck

In my Psychology Today blogpost of 12/11/11, Bipolar or Borderline, I described how disease mongering, pill-pushing psychiatrists have done their utmost best to blur the distinction between the mood (affective) instability seen in borderline personality disorder (BPD) with the mood episodes characteristic of true bipolar disorder. 

This distinction is important because BPD is clearly a disorder of interpersonal relationships and behavior mixed in with a history of trauma and family dysfunction, while true bipolar disorder is a serious biogenic brain disease. BPD, while some of its symptoms do respond quite well to the right medications, should be treated primarily with psychotherapy, while bipolar disorder should be treated primarily with medication.

In the prior post I discussed the use of invalid symptom checklists in studies to exaggerate the incidence of bipolar disorder. They are also used by some incompetent psychiatrists to make diagnoses that justify snowing every patient who walks in the door with potentially toxic antipsychotic medication. In the June 2016 issue of the Journal of Personality Disorders, researcher Mark Zimmerman goes into some detail about exactly how corrupt researchers use slight of hand to distort their data (Improving the Recognition of Borderline Personality Disorder in a Bipolar World, pp. 320-335).

They are very good at it. And it matters. Zimmerman states: "Although BPD is as frequent as (if not more frequent than) bipolar disorder, as impairing as (if not more impairing than), and as lethal as (if not more lethal than) bipolar disorder, it has received less than one tenth [emphasis mine] the level of funding from the NIH [the National Institutes of Health] and has been the focus of many fewer publications in the most prestigious psychiatric journals."

And, Zimmerman points out, the difference is not due to just the fact that there were more drug studies for bipolar disorder. In fact, the amount of funding for the drug treatment of bipolar disorder was just a little more than 10% of the total.

As I have mentioned several times in this blog, self-report symptom checklists are meant to be screening devises. This means that if you are positive for bipolar disorder on the screen, it does not mean you have bipolar disorder. It means you should be evaluated further! Screening tests are designed to have a lot of false positives - people who come out as positive on the test but who do not actually have the disorder. In fact, the majority of people who screen positively do not have bipolar disorder.

Zimmerman specifically brings up the Mood Disorders Questionnaire (MDQ) that I discussed in the previous post. Get this: in one study by Frye and others in the journal Psychiatric Services in 2005, the authors found that one half of the patients who were positive for bipolar disorder on the MDQ were not diagnosed with bipolar disorder by the treating clinician.  

Their conclusion? They said the clinicians "failed to detect" or "misdiagnosed" bipolar disorder in these patients! Actually, the exact opposite is far more likely: it sounds like the clinicians' judgments tended to be correct.

Frye and others then went on to state that these patients were "inappropriately treated because they were given antidepressants instead of mood stabilizers." Again, exactly the wrong conclusion to draw from the authors' own data. Yet they went on to say that this completely false conclusion was "worrisome." Some of us would call this real chutzpah.

Bipolar, my ass researchers love to talk about the bipolar "spectrum," based on the crazy logic that if a given symptom appears slightly similarly in two people, they must both have a version of the same syndromic psychiatric disorder. Zimmerman asks why no one talks of a borderline spectrum, when clinically, many patients are diagnosed as having borderline traits. This means that out of the nine criteria, of which you are required to meet any 5,6,7, 8, or all nine to qualify for the diagnosis, the patients may only have three or four. 

In fact, as reported in the July issue of the American Journal of Psychiatry (Vol. 173, pp. 688-694), Zanarini and others followed 290 patients with BPD closely over 2 years. They found that "...the symptoms of borderline personality disorder are quite fluid..." This means that they come and go over time. This was particularly true for acute symptoms like self-mutilation. Therefore, people with the disorder may frequently go from 5 symptoms to 4, and suddenly they don't "have" it anymore - unless and until the 5th symptom recurs!

In actual reality, he said redundantly, those people who exhibit three or four of the nine symptoms look a lot more like those folks who have five or more than they do like those folks who have none of them. Now that sounds like a "spectrum" to me.

Borderline or Bipolar?

As psychiatrists have gone from doing both psychotherapy and prescribing psychiatric drugs to doing basically nothing but writing prescriptions, many of them have fallen into some very bad habits. When all you have is a hammer, everything starts to look like a nail. In this case, when all you have are drugs, everything starts to look like a brain disease.

Personality problems, anxiety, agitation, and reactions to problematic family and other interpersonal interactions have been widely mis-labeled as biological/genetic brain diseases. Quite a change from when real brain diseases like autism and schizophrenia were thought to be behavioral disorders!

One of the worst trends in this regard is the use by psychiatrists of “symptom checklists” to save time in making a psychiatric diagnosis on their patients. Frankly, the doctor’s secretary could make a diagnosis just as easily as the doctor could using this shortcut. Patients are quizzed about specific symptoms without even seeing if they understand what the symptom must be like in order to be clinically significant.

The evaluation of psychiatric symptoms must take into account their psychosocial context, their pervasiveness, and their time course in order to distinguish them from everyday mood reactivity due to life experiences. Additionally, some symptoms are seen in a wide variety of different psychiatric conditions, and an understanding of these three factors, as well as the taking into account of the presence of other symptoms necessary in order to qualify for a given diagnosis, is essential in differentiating the different disorders.

For example, symptoms seen in a variety of psychiatric disorders as well as in normal people under stress include:

• Impulsivity
• Irritability
• Aggression
• Hostility and Rage
• Moodiness and sudden mood changes
• Agitation
• Poor Concentration
• Disorganization

Irritability can be seen in anxiety, major depressive disorder, dysthymia, mania, personality disorders, and in someone who’s just having a bad day.

Nowhere is this problem more problematic than in the differentiation between a major mood disorder called bipolar disorder (which used to be more accurately called manic-depression), and a personality disorder spawned by dysfunctional families called borderline personality disorder (BPD). Psychiatric drugs only help with anxiety and reactivity in the latter disorder – psychotherapy is by far its most important treatment. True bipolar disorder, on the other hand, does not really respond to psychotherapy at all, but is treatable and preventable with certain medications.

In my 35 years experience of taking complete psychiatric histories, and in my 18 years of experience watching psychiatric residents (trainees) taking psychiatric histories, I know that asking patients about prior episodes of mania is one of the more difficult things to do in psychiatry. Almost everybody has been euphoric, partied all night, and felt on top of the world at one time or another. Patients almost invariably answer yes if asked about theses symptoms. The patient has to be made to understand that in mania, these symptoms are really extreme, have to last several days, be relatively unresponsive to anything that is going on in the environment, and be completely different from the patient’s normal functioning. It literally has to be a Jeckyl and Hyde situation.

You also have to rule out other potential factors that may account for a patient’s “yes” answer. For example, it may seem absurd when you think about it, but many psychiatrists stop after asking a patient about whether they have ever had a period in which they stayed up all night for several days while remaining energetic. They don’t ask obvious follow-up questions like, “Did you nap in the daytime?” “Were you using methamphetamines or cocaine at that time?” or even, “How much coffee were you drinking then?”

Furthermore, despite objections from the people who wrote the diagnostic manual in psychiatry, some psychiatrists believe that a “manic” period can last just an hour or two, or even a few minutes. They say that folks who have brief mood swings or go into a rage are “rapid cyclers” or have “sub-threshold bipolar disorder.” There is absolutely not one bit of credible scientific evidence that short-duration “mood swings” are in any way related to bipolar disorder. The docs pushing this idea literally made this up in order to justify selling and prescribing more drugs. They pulled it out of their you-know-whats.

Ironically, a patient who is actively manic and one who is acting out from borderline personality disorder look nothing alike if seen when symptoms are present. The difference is not subtle at all! Furthermore, if psychiatrists know the tricks of the trade (and most do not), they can get a patient with BPD to turn off and on most of their symptoms like a faucet. Manic patients stay manic no matter what the doctor does in the short term short of knocking them out with sedatives.

Nonetheless, the purveyors of bipolar disorder (my ass), tout a screening symptom checklist called the Mood Disorder Questionnaire (MDQ). They claim it is almost as accurate as a full psychiatric interview in diagnosing bipolar disorder. Sure it is – a really, really BAD psychiatric interview. Actually, patients who score positively are just as likely to have borderline personality disorder as bipolar disorder, according to a study published online March 23 in the Journal of Clinical Psychiatry by Mark Zimmerman and colleagues. They found that of the 98 patients who screened positive on the MDQ, 23.5% were ultimately diagnosed as having bipolar disorder and 27.6% as having borderline personality disorder.

My colleague in the Association for Research in Personality Disorders, Joel Paris, MD, of McGill University in Montreal agreed with Dr. Zimmerman et.al, saying that the MDQ scale is "completely invalid." As he told Medscape Psychiatry, "The scale lists all the symptoms of bipolar disorder, but it does not attach any time scale."

Another study in the Journal of Clinical Psychiatry by the same group (Reggero, Zimmerman et. Al. V,71:1, January 2010, pp.26-31) showed that 40% of patients in their sample who met clear DSM criteria for borderline personality and not for bipolar had been misdiagnosed as bipolar by a prior mental health professional, as well as 10% of all of the other patients.

These patients are getting potentially toxic medications while not receiving the psychotherapy they need. IMHO, this situation borders on criminality.