I recently saw a patient who nicely illustrated some of the diagnostic issues discussed in my blog titled Misdiagnosis of Bipolar Disorder. The case helps to present several of the issues that often lead to misdiagnosis or even mistreatment – enough so, that I thought it would be useful to do a case presentation with a discussion of the diagnostic issues. The patient recently completed an initial two-and-a-half hour clinical assessment. Some case facts have been altered to protect the individual’s identity. It may also be helpful to take a look at my blog posted two blogs ago.
Background of Mood Instability:
Katarina is a 28-year-old Russian female that lives with her fiancé and is employed as a paralegal.
Katarina presents with mood instability that commenced in her early 20s following graduation from college. She recalls that in her teens she had periods of time where she exhibited an exuberance – “a zest for life” – that she found to be intensely pleasurable, but noticeably bigger than what was present for most of her peers. She also reported that she intermittently “heard a voice in her head” of a woman named Paulina. Katarina stated, “The voice was always positive – more like a super-being or an angel that was guiding me.” The auditory hallucination ceased after a few years and has not returned in any other form. While Katarina did conclude her experience was unique, at the time she did not perceive anything to be wrong. Her positive intensity and her identification with a super-being was something she simply identified as a quintessential part of her identity.
In the few years following college graduation Katarina was fortunate to find employment in a Chicago-based law firm. The position paid well and allowed her to become self-supporting for the first time in her life while also providing her a lifestyle where she relished the experience of being out from under the academic pressure of an elite Northeastern university. Partying with friends was a frequent experience and Katarina increasingly found that her alcohol and cocaine-fueled clubbing would continue until the early AM hours and she would be able to attend work the next day with little or no fatigue. Katarina also found that her early 20s was a time of increasing sexual energy. Her nighttime partying would result in her hooking up with a male only to recognize that she had little emotional interest in continuing the relation beyond the next morning. She stated that she sometimes felt she was driven by her intense sexual energy and men were like objects to be used to help her discharge what she experienced as excessive and distracting energy.
Katarina’s bursts of intensity would last for two or three days at most. She’d usually find they were followed by a depressive crash where all the energetic intensity was gone. She would feel depleted, empty, and emotionally flattened. Perceptions of self shifted towards inadequacy and worthlessness. Sometimes she would have to call in sick for work because she barely had enough energy to get out of bed and face the day.
At her lowest points, suicide felt like a viable option. She had two experiences where she overdosed on opiate pain-killers. Both episodes were impulsive and without clear intent to kill herself. One required emergency room treatment when a friend found her passed out and unresponsive upon arriving at Katarina’s apartment to pick her up for a morning work-out date. Katarina reports these depressive episodes could last up to a week. They often cleared without any apparent reason. One day she would just awaken and recognize that she was feeling better. She’d do her best to resume her daytime responsibilities, clean up whatever mess was created by her mood instability and reestablish some semblance of normalcy. This could last for several weeks, even sometimes through a spring or summer season (fall and winter were more difficult), until things became ignited again and her energetic intensity would begin to take her back up.
An interesting part of Katarina’s story is her description of the presence vs. the absence of triggers that would activate her energetic cycling. Sometimes her mood would go up because she received some good news – usually something like her boss telling her she did a good job, or her making plans to do something new and exciting with friends. She states “it’s like everything would become wonderful and I’d think I had the best life in the world.”
The same kind of elevation could occur without good reason. “It would just kind of arrive but it would also seem to come out of nowhere.” In other words, there were no identifiable situational precipitants. The energy and behavior would look similar but there was one notable exception. When Katarina’s mood elevation was responsive to esteem-bolstering events or anticipatory pleasure, she would feel flirtatious and desirous of men’s attention, but she was definitely interested in “having someone show interest in her.” She would fantasize about having an ongoing boyfriend. But during those times when her energy would spike without any clear precipitant, it was much more physical and sexual in nature. She definitely wanted sex and the specific individual with whom she had it was not all that important, which was quite different than wanting a boyfriend! Katarina had not really reflected upon this distinction between her energetic states until the assessment questions that were posed to her during our initial meetings.
A similar kind of distinction was present with Katarina’s depressed states. When her elevations were tied to something specific occurring in her life then her subsequent depressions took on a tone of loneliness, sadness, loss and unfulfilled need. She hated this experience and would sometimes even cut or burn herself in order to interrupt her awareness of her pain. However, when her depressed mood seemed to come out of nowhere, the ensuing several-day mood decline had more the feeling of depletion, flatness and emptiness. It was not that Katarina would long for fulfillment that was absent, but more that she didn’t care about anything.
Katarina’s cutting and/or burning was an intervention strategy that temporarily worked for her and she reports that she still sometimes resorts to self-harm when her other efforts to manage depressive emotions are unsuccessful.
By Katarina’s mid-20s she had begun dating a male systems analyst who was a few years older than she. They moved in together after about one year and they plan to marry in the spring of 2016. The first few years of the relationship were good. They enjoyed socializing with friends and Katarina generally found that her mood was smoother. She did notice some brief one or two-day spikes but just chalked them up to ‘being her quirky self.” By about the 3rd year, Katarina noticed that along with some diminishing excitement about the relationship, she began to feel unreasonably jealous towards other female friends or acquaintances of her fiancé. She was convinced her fiancé was bored with her. Additionally, when he had to travel as part of his employment, she found herself to be “missing him desperately” and obsessing about what he might be doing with other women while he was away from her.
When Katarina was age 25 she and her fiancé moved to Charlottesville, VA due to a change of fiancé’s employment setting. She was also able to obtain a new position as a paralegal. Katarina liked the smaller town atmosphere of Charlottesville, but it also represented a strong loss of her community of Chicago-based friends. She found that new friendships were slower to develop than what she experienced during her early 20s in a more urban setting.
Katarina began drinking again – more than just casually. She also developed increasing frequency of sleep difficulties as her insecure anxious thoughts often interfered with her ability to fall asleep. She returned to the broad pattern of instability that was more characteristic of her early 20s, only now her awareness of feeling out of control was not as readily masked by the partying lifestyle of her younger years.
Katarina’s elevated energy and her heightened libido (sexual desire/sexual energy) continued to occur intermittently, only now she would direct her sexual energy towards her fiancé. While he enjoyed their sexuality, he also struggled with the inconsistency of Katarina’s mood and the intense anger she’d feel whenever he had to leave her or when she perceived he was attracted to other women.
Sometimes when Katarina was “up” she’d excessively and impulsively spend – often on revealing clothing and sparkly accessories. She said the impulsivity tended to accompany those times when her libido was elevated. She reports that both the sexuality and spending were brought about by her need to discharge the energy in order to diminish her experience of internal pressure. If she was elevated and her fiancé was away on business, then spending became her substitute gratification. She also admits that on several occasions she came close to being sexual with casual acquaintances or even strangers. She stated, “Sometimes when I’m up, I feel possessed by a kind of force that’s very physical, hedonistic and kind of frightening.”
There were also times when Katarina’s elevations were so apparent that her behavior became concerning to those in her workplace. One day her manager at the law firm where she worked gave her feedback that she seemed inappropriately agitated and loud with her co-workers. He suggested she take a few days off to get herself back together. Two weeks after that incident she missed three days of work due to an episode of sustained depression. Overall she perceives her depression was present for about 10 days to two weeks.
During the last several months Katarina has become aware of increased mood cycling. Prior to the last two months she’s probably had 7 or 8 mood elevations over the past two years. She now perceives her mood is shifting on a weekly basis, sometimes even more rapidly. She also now reports more frequent episodes where she will awaken at 2:00 or 3:00 AM and not be able to get back to sleep. When this occurs she is often not fatigued the next day.
Prior to seeking treatment Katarina had done some reading about symptoms of bipolar disorder. She was now seeking to determine if her symptoms might fit the diagnosis. She also did not understand her intense jealousy as well as the difficulties she had when her fiancée was away on business. She stated she was concerned she was ruining the relationship and she was fearful as to what might be wrong with her.
Attention Deficit Issues:
When Katarina was age 10 she was diagnosed by a school psychologist as having attention deficit disorder, non-hyperactive type. Her parents did not want her placed on medication. In class she had difficulty staying on topic. She would drift off, daydream and not get her schoolwork done. This was usually the source of conflict between her and her father. She was a slow learner despite strong performance on standardized tests. Katarina began to develop a sense of herself as an “underachiever who did not try hard enough.”
By her sophomore year in HS she convinced father to allow her to try a prescription of medication to see if it made a difference in her academic performance. Father agreed and her pediatrician prescribed Adderall 10 mg, morning and mid-afternoon. By the middle of Katarina’s sophomore year she was placed in AP classes where she was achieving As. Katarina no longer uses Adderall on a regular basis. The frequency of her psychostimulant use declined significantly following her graduation from college and her progression into her current career track. She does take the medication occasionally when her work-load is high. She also has some concerns, based on material she has read, that her Adderall use may be contributing to her mood instability.
Katarina was born in the USSR and moved to the US with parents when she was four. She is the oldest of two with one brother, two years younger. She spent her elementary school years in the Midwest where her father was completing his graduate degree in chemistry..
Katarina’s family struggled economically during their first five years in the US as the family’s income was derived solely from her father’s graduate research stipend. She perceives it took her family a while to adjust to US cultural norms. The school district for Katarina’s elementary school drew from a higher socioeconomic population base and throughout elementary school, Katarina felt like she didn’t fit in. As Katarina was about to enter Jr. High, her father secured a position as an assistant professor and the family moved to a university town in the Northeast. While Katarina had become more acculturated and comfortable with US norms, she was still related to as “the new kid” with a somewhat exotic background. She perceives it was not until high school that she found a peer group where she felt like she finally belonged.
Katarina’s father was unpredictably angry. She father is “hot and cold – doesn’t have a grey area.” He experiences a lot of ongoing mood variability and can become volatile with little warning. He was often physically abusive to Katarina during childhood up through early adolescence. She reports it was not uncommon that she would be slapped in the face, several times weekly. He continually pressured Katarina and her sister about their academic performance and couldn’t accept anything less than “A” performance without becoming angry.
Katarina perceives that mother did not provide adequate protection from father. She stated “my mother seemed just as afraid of him as we were.” She perceives her mother as generally anxious - “She’s afraid of life, doesn’t like to leave the house and is very dependent on my father.” Katarina does not recall many times as a child when she simply felt happy and secure. Experiencing infrequent contact with her extended family in Russia, she reports that the families on both sides are not very open about personal issues and there is not much understanding or cultural acceptance of mental health diagnoses. Most of the extended family has not received treatment for identified mental health difficulties, but she does get the sense from family stories that depression, anxiety and substance abuse are strong aspects of her family history. She does not report any specific family history involving bipolar disorder though her descriptions of father raise the question of whether he may have an undiagnosed mood disorder.
Substance Use Background:
Katarina did not socialize much in high school. When she went away to college she began to drink occasionally with peers on weekends but did not drink excessively until her first year out of school when she began binge drinking on weekends and sometimes on weeknights as well. She also used cocaine with peers. She’s not returned to this drug since her mid20s.
Katarina’s alcohol use subsided when she began her committed relationship with her now fiancée. However, she reports an increase of alcohol use over the last few months, commensurate with her increasing mood instability. She estimates that she’s been intoxicated about three to four times per month over the last half-year’s time.
Katarina reports very occasional cannabis use, typically when she is around peers who are getting high. She states the drug often makes her feel mildly paranoid and uncomfortable.
Discussion of Diagnostic Issues:
Katrina presents an interesting mix of developmental influences, current symptoms and the course of their progression. The salient diagnostic question is how do we understand the causes of her mood instability? Might her symptoms be indicative of a neuropsychiatric illness such as bipolar disorder? Are her symptoms more developmental and psychological in nature – possibly something along the lines of borderline personality disorder? What role do situational and substance use factors have in Katarina’s current struggles? Also, what weight should the ADD diagnosis be given in her current presentation?
When trying to sort out these kinds of questions, it is important to look at developmental history and to ask is there sufficient evidence to support the possibility of a personality disturbance such as borderline disorder. The answer here is affirmative. She grew up in a home where her father was unstable with volatile anger and mother was quite fearful and anxious. She has little recall of positive experience during her early years. Additionally, Katarina was four years old when her parents came to the US for father’s graduate studies. This means she was born when parents were in their late teens. Given Katarina’s description of parents during her childhood years, it is reasonable to wonder whether she received adequate emotional attunement and consistency of positive attachment during her early developmental years. Such areas of deficit are common for someone with borderline disorder, making it difficult for the individual to develop stable internal representations of self and others.
What are the other elements of this case that support a borderline personality disorder diagnosis? Katrina struggles with affect regulation. Within her depressive experience her emotion is sometimes intolerable to the extent that she resorts to cutting or burning as a means of lessening her internal pain. Essentially she substitutes somatic pain for psychic pain. The somatic pain is more tolerable and her self-destructive actions help to return her to a sense of being in control. These methods of coping with painful emotion reflect that during periods of strong emotional distress, she decompensates and resorts to more primitive defensive processes.
We also see that Katarina is frequently plagued by feelings of loss and emptiness, which are hallmark features of the depressive aspects of borderline disorder. She has a very insecure attachment to her fiancée and she finds that her negative perceptions of self activate fears of loss and intense jealousy or suspicion about his interest in other women. If fiancé needs to travel on business his actions rapidly evoke Katarina’s anger as if his employment related choices are interpreted as evidence of his rejection and abandonment. The intensity of her attachment needs and her fears of loss precipitate powerful affects which she cannot successfully modulate through more reality based thinking. These kinds of difficulties are commonly seen in individuals with borderline personality organization.
So what about the bipolar mood instability question? Is there enough to support the personality disorder diagnosis and set aside concerns about bipolar disorder? No - I couldn’t comfortably support that conclusion.
In addition to insecure attachment, rapidly shifting perceptions of self and other, and difficulties with affect regulation, Katarina displays the following symptoms: episodes of mood elevation and/or depression that have no clear situational precipitant. When her mood is elevated she experiences elevated energy, elevated libido, interpersonal gregariousness, impulsive spending and intense feelings of optimism all of which occur in tandem with lessened need for sleep. In her early 20s, along with her mood elevations, she also experienced auditory hallucinations and a grandiose delusion involving a super-being, (an aspect of her own self-representation) that guided her through life.
There are three aspects of the above symptoms that would indicate they cannot be easily ascribed to borderline personality issues:
1) Katrina describes a subset of her mood episodes as “coming out of nowhere.” Borderline psychopathology is rooted in relational paradigms. Experiences of intense positive and/or negative emotion are almost always based within interpersonal contexts and when we observe mood destabilization without identifiable precipitants, then we are left to understand these as primarily neurochemical events.
2) Elevated energy is almost always observed along with bipolar mood elevation. Such can also occur along with more intense emotions within the borderline realm. But with borderline mood elevation, it’s uncommon to see lessened need for sleep. One may be up late due to his/her emotional intensity but the next day the individual is usually fatigued. Katarina clearly experiences lessened need for sleep during her elevated mood episodes, particularly those without external precipitants.
3) Along with bipolar mood elevation we often see increased sexual energy. Again we have an overlap with borderline issues in that sexuality for the borderline individual may be used in the service of emotional need fulfillment. Katarina identifies two different kinds of sexual desire. The first occurs in relation to her needs for love and attention. It is a way of drawing attention to her in order to affirm her desirability and to temporarily sooth her painful feelings of loneliness. In contrast to this, Katarina sometimes finds that her sexual energy can be elevated almost to the point of discomfort. It’s not necessarily accompanied by strong emotional needs but is much more tied to sexual aspects of physical energy. Essentially when Katarina experiences elevated libido in tandem with other hallmark bipolar symptoms, we’re seeing that her connection with the male (fiancé or other) is more in the service of energetic discharge as opposed to emotional need fulfillment.
The other remaining evidence that informs us about the likely presence of bipolar disorder entails the course of her evolving symptoms. Bipolar disorder typically emerges between the mid-teenage years up through the mid-20s. Additionally, when left untreated, the course of bipolar disorder often reveals a trajectory of worsening symptoms entailing more acute highs and lows as well as more frequent mood shifting. This pattern closely fits Katarina’s presentation. Her mood shift frequency has progressed from seven or eight episodes in a two year period to current rapid cycling mood with changes occurring on a weekly basis.
Rather than being able to identify borderline or bipolar disorder as the primary reasons for Katarina’s struggles, it’s really more a matter of both diagnoses contributing to the current clinical picture. Each uniquely affects her at different times though there are also times where she may be in the midst of turmoil because both are co-occurring and potentially even exacerbating each other.
The last piece not yet addressed is Katarina’s ADD. The first important question to ask is whether it actually exists. It was first diagnosed by a psychologist at age 10. We don’t now have access to the initial diagnostic work up and with things such as ADD that usually involve soft symptoms (less acute), we should always be asking – was the previous diagnosis correct? The evidence that lends towards affirmation of the diagnosis is that Katarina does struggle with being able to sustain focused attention. So functionally she does experience deficit. Her academic performance also markedly improved when she began being treated with a psychostimulant in her sophomore year of high school. Sometimes such can be seen as de facto evidence of an underlying ADD condition.
But … the truth is that many people learn better if they use psychostimulants. When someone is not attention deficit and they take a drug like Adderall, they may experience side effects of jitteriness/restlessness, lessened appetite and difficulty sleeping. Katarina does not experience these side effects in a strongly noticeable way. Nevertheless, we acknowledge that aspects of what may appear to be psychostimulant side effects can also be part of the bipolar symptom set. Is Katarina definitely ADD? Things are not clear enough at this point to be definitive about the diagnosis. I think the answer is “probably,” but further assessment is warranted.