Do overlapping diagnoses hold up? In episode 270, I received a question from an individual who asked just that, wanting to know whether it’s possible for bipolar and borderline personality disorder to coexist. In this post, I dive into more detail and talk about overlapping diagnoses, their validity, as well as certain issues which can arise.
Long time listener, love the pod. Got a brief question for ya!My friend and I were talking about overlapping diagnoses today—namely, whether it’s possible to have both bipolar and borderline personality disorder, or BPD and NPD. This got us into a broader discussion about whether overlapping diagnoses hold up. Namely, when someone says they have anxiety, depression, PTSD, BPD, bipolar, and ASD—by default, that list of diagnoses actually just fall into one diagnosis with symptoms (i.e. ASD has anxiety and depression as symptoms).
Good question! So let me answer your first question first. Can bipolar and a personality disorder like borderline personality disorder coexist? The answer is yes.
I actually have a funny case example of this where I saw someone for neuropsych testing and the previous psychologist that assessed them said that they could not have borderline because they had bipolar or vice versa. In my report, I was pretty bold and basically wrote that the previous psychologist was unfortunately incorrect, cited some research, and indicated that it’s actually somewhat common for the two disorders to coexist. Mood swings are 100% a common part of borderline. People with this personality disorder often have intense emotional reactions to things, especially when it involves interpersonal interaction. This can cause rapid mood swings and variability from moment to moment. This is different than what happens in bipolar.
In bipolar, you get depressed and manic phases that are more enduring. You have depression and then you have phases of being elevated for two weeks or more, not sleeping, feeling fired up, making poor decisions, etc. It’s easy to mistake the two because in borderline, you do often have sensation-seeking and risk-taking behaviors. The difference is in the timeline and the changes from their baseline functioning. You basically have micro and macro shifts in mood and functioning. Let’s say you have someone with borderline. Maybe they have very volatile relationships and find themselves being frequently sexual in ways that are not very safe or demonstrated good judgement. They dive headfirst into new experiences and relationships, but also quickly shift to feeling depressed and hopeless when it feels like something has gone wrong.
You might think that this person has bipolar because of how elevated they are and the fact that they have mood swings. But if this is the way the person always is, this wouldn’t be bipolar. This same person can go through a period of mania where they sell their car to get a bus ticket to another state where a new lover lives that they are going to start a life with. That would be out of character for them since their variability is usually a bit more small-scale. During this period of time, they feel a decreased need for sleep, have pressured speech, way more ideas than they usually have, and overall seem to be different from their typical level of functioning. This is what it might look like to have both.
The validity of overlapping diagnoses
Now your second question is also very interesting. Do overlapping diagnoses hold up. That’s pretty complicated. One big issue in general is that a lot of people aren’t actually diagnosed or they are diagnosed poorly. If you run into someone that says they are on the spectrum, have ADHD, have depression, anxiety, PTSD, and OCD. Do they actually have those? Or is that mainly based on their experience and what they have learned from the internet? Alternatively, you also run into a problematic situation where someone’s doctor will add diagnoses onto their problem list based on a vague sense of the disorder rather than a qualified assessment of it. So, you can get a list of diagnoses that just increases over time. But doctors often don’t want to mess with someone else’s conclusions or diagnoses, so they won’t take diagnoses OFF the problem list. They will just add to it.
In reality, a lot of times diagnoses should be revised. If someone goes through the process of being assessed and it’s revealed that they have an autism spectrum disorder, they probably shouldn’t be diagnosed with social phobia. In the DSM, at the bottom of every diagnosis, it basically says that the diagnosis is only valid if it isn’t better accounted for by another disorder, the effects of medication, or drugs.
In terms of the usefulness of having more than one diagnosis, it really depends on which combination we are talking about. The example I just gave would be pretty unnecessary to have both diagnoses, as the social anxiety would likely better be accounted for by the autism. However, if bipolar disorder, but their difficulties with inattention and executive functioning are present regardless of whether they are manic or depressed, it might be useful to have both diagnoses. You also want to look at the person’s history. Are these things persistent or did they, for instance, have an existing diagnosis for a long time, and then due to other circumstances in their life, they began showing other symptoms and now it makes sense to revise and add a co-morbid diagnosis?
There are a variety of reasons a diagnosis might matter in the first place. It could be that insurance requires a diagnosis for reimbursement. It also might guide treatment or how to approach the situation. For the latter, I think the most important thing is to actually assess the person and help them understand themselves. There are treatments that often apply for a given symptom regardless of why it’s there. For example, you could have someone who is schizophrenic, someone who has Lewy Body Disease, and someone who has a severe urinary tract infection that all have visual hallucinations and would benefit from antipsychotic medication. These are obviously different diagnoses and that matters in terms of long-term prognosis and the trajectory of their life, but in the moment, it’s really the symptom that required treatment.
If there is someone that seems to be accumulating a lot of diagnoses like this, I think that it would be best to work with a specialist who can help tease them apart. For no reason other than to help the person understand themselves. For instance, someone might get down on themselves because they are embarrassed about having “agoraphobia” and not being able to go into public places. This person also has OCD and it turns out that they are not afraid of people, it’s actually that they have a hard time coping with the intrusive thoughts that their OCD causes when they are around other people. This would give them a better understanding and more of a target to work on improving.
This is something that could be talked about for hours and I think a lot of it depends on the particular situation. There are cases where one specific diagnosis is much better than a collection of other diagnoses. There are other situations where the separate diagnoses are totally valid. Whether it matters really depends on the situation.
You can listen to this on Episode 270 of the podcast!
Thank you for the great question!
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