Diagnosis Keeps Changing: BP II, BPD, IED
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Q:  Diagnosis Keeps Changing: BP II, BPD, IED

My diagnosis with my Dr. keeps changing like I am a puzzle to her. first BP2, then borderline, then IED.

Is it possible to have the mini psychotic episodes and still be BP2?

I have read up on all three and BP2 still describes me best but I have to admit I can relate to both the borderline and IED in parts but not fully.

She has me on paxil 30mg lithum 300 twice a day and clonazapam when needed.

I believe I shouldn't be on the paxil but I am not the doctor.

I also read your book never has anything hit home like that was like you knew me. my mother read it too and is very impressed.

thanks in advance for your time

Dear Ms. M' -- 
You may have read my little essay on Borderline "versus" Bipolar, the bottom line of which is that the two conditions are so close in terms of symptoms (not a perfect overlap, but almost); and the treatments one might consider are so close; that spending a lot of energy trying to figure out which one you have (or both) is not a productive use of time and energy, in my opinion. The psychotherapies for Borderline PD are potentially quite useful for bipolar disorder, and very unlikely to make bipolar disorder worse (perhaps the time and money and energy could be spent working on some skills that would be more bipolar-specific, that would be about the only downside). So even a wrong emphasis is not likely to make things worse -- with one major exception. We'll come to that in a minute. 

Meanwhile, IED ("Intermittent Explosive Disorder") has been shown to respond pretty well to one of the main treatments for bipolar disorder, valproate (Depakote). And a cognitive-behavioral therapy would be pretty helpful there too, most likely -- just like the CBT that's now regarded as an important part of the psychotherapy for bipolar disorder. So the same story applies here as well as with Borderline: similar symptoms, so similar diagnosis (IED and bipolar); and the treatment options are nearly identical, so again, why spend much energy trying to figure out "which one? or both?"  Just get on with treatment, which means examining all the treatment options with their pro's and con's, and making a plan for which you'll try first, then second, then third (hopefully finding one before you get to "ninth" or so). 

But, there's that one major exception: antidepressants.  You've heard me go on about my views regarding the role of antidepressants in the treatment of bipolar depression (in my book, and to a lesser extent on my website), where the bottom line is to recognize that -- in the view of nearly all mood experts -- antidepressants can make bipolar disorder worse, in some people. So, you say "I believe I shouldn't be on the Paxil".  Well, there could be some very good reasons to be on and stay on the Paxil, and I hope that by working at it, you'll be able to help your doctor explain to your satisfaction what those reasons are; or bring her around to considering a trial of tapering the Paxil to see where that leaves you (in which case you'll remember my quoting the recommendation of Gary Sachs, the Harvard bipolar specialist, about taking as much as 4 months to taper). You have also read the chapter on talking with doctors; the website has a brief page which summarizes that section. Good luck working that out -- 

Dr. Phelps

Published October, 2006


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