Mental Health, Misdiagnosed
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Mental health can be murky. How do you know the difference between depression and just feeling sad? What happens when you’re diagnosed with depression and anxiety, but it’s actually something else? On today’s show, we find out. Nzinga’s answers questions about the relationship between mental health, addiction, and medication from two listeners, one with bipolar and the other with borderline personality.
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[00:28] Dr. Nzinga Harrison: Hello, everybody. This is in Nzinga, and you’re listening to In Recovery with Dr. Nzinga Harrison. This is a show about all things addiction. So when I say addiction, I don’t just mean alcohol and drugs. I mean other things you might not think of: exercise, porn, chaos. We’ve talked about quite a bit of it. So if you’d like to have your question answered on the show, please send them to us. And once we have your questions, I answer them from my expertise as a physician, doctor, addiction expert, psychiatrist, chief medical officer and co-founder of Eleanor Health. Mom, wife, friend, human. Basically, we get into all of it to break down this idea that there are those people that have addiction and the rest of us when really all of us have some kind of addiction of some sort. So with that, Claire, should we jump in to this week’s show?
[01:46] Claire Jones: So this week, we’re going to talk about mental illness, focusing specifically on the misdiagnosis and medication around personality disorders and how those relate to addiction. And the two personality disorders we’re going to focus on are borderline personality disorder and bipolar disorder. So Nzinga, can you start off by sort of defining what those are in layman’s terms? And like, what do they look like on the outside maybe, and what do they feel like? Also acknowledging that that’s going to look very different person to person, but sort of generally speaking. Can you talk about both of those?
[02:21] Dr. Nzinga Harrison: I definitely can. So the first thing is that actually borderline personality disorder is a personality disorder. Bipolar disorder is a mood disorder. I understand why you made the mistake that you did, calling them both personality disorders, because the symptoms can really overlap. And we run into this in psychiatry quite a bit because the symptoms of all of the illnesses we’re taking care of are thinking, feeling behaviors, and they can overlap a lot. And so people commonly mistake bipolar disorder for borderline personality disorder. And the other direction and I want to specifically say, I recognize for somebody to say to you that your personality disorder is hurtful. Totally. And so I actually when I talk to people about borderline personality, I usually will just say “borderline personality.” So with all of that, to answer your question, the difference between borderline personality and bipolar disorder are numerous. The problem is that the symptoms are also very similar.
[03:37] Dr. Nzinga Harrison: So when we think about how a personality disorder develops, there’s this idea that there are coping skills that are psychotic. And psychotic means losing your grip on reality. So for some people, when you get pushed to the extremes of your stress tolerance and coping skills, you’ll start to lose your grip on reality. So you might get paranoid under a lot of stress. You might have out of body experiences. You might feel detached. Like things are happening around you or you’re not really a part of it. You might actually have hallucinations. That is like losing your grip on reality as a result of stress. And then on the other side, there are what we call neurotic. And so you’ve heard people say like, oh, that person is neurotic or, oh, you’re being neurotic. And that’s really like when you’re pushed to the bounds of your coping, then the symptoms that you develop are anxiety symptoms or compulsive or obsessive, very cognitive type of neurotic type of symptoms. The idea of the borderline personality is that it splits. It’s on the borderline between psychotic and neurotic coping, OK?
[05:01] Dr. Nzinga Harrison: And so under stress, what we see for people that have borderline personality disorder is that sometimes under stress they can lose their grip on reality and sometimes under stress they can become very neurotic and obsessive and anxious. And most of the time, under stress, it’s a combination of all of that. Sitting like really in the watershed area between these two different big buckets of coping, and of course, it’s a spectrum in between. And so none of us is born with coping skills. And none of us is born knowing how to have effective interpersonal interactions and effective relationships. We learn all of that from our experiences and from the adults around us. You can think of personality disorders as kind of like development of coping skills and relationship strategies that are desperately trying to protect you from an evolutionary standpoint. Everything we do as humans is about survival and keeping ourselves safe physically and emotionally. And so the borderline personality is really, like, stress tolerance is very low. And so the feeling of emotional danger is high at almost all times. And so the coping is to be reaching into this psychotic bucket, reaching into this neurotic bucket, constantly trying to protect myself. But the tools are making things worse.
[06:53] Dr. Nzinga Harrison: The tricky part is because the symptoms of borderline personality disorder and bipolar disorder, whether it’s type one or type two, are for the most part the same symptoms — it’s mood instability, mood swings, anxiety, paranoia and stress. All of those are symptoms of all three of these illnesses. So when a person comes into me and I say, you know, what brought you in? What do you hope that I can help you with? And they say these mood swings are out of control. So the way you can think about that is like shortness of breath is a symptom. And so when you come to the doctor and you say, I can’t breathe, I’m short of breath, that opens up a whole set of possible diagnoses. I’m like, can she not breathe because it’s an asthma attack? Or it’s a heart attack or pneumonia? Can she not breathe because it’s a pulmonary embolism or a blood clot in her lung? So as soon as you give me that first complaint, I build an entire list, top to bottom, of what it could be. And then I ask you questions to say, OK. So it’s not that, it’s not that, it’s probably not this, it’s probably this. Then the way I have to answer that question is chronology, timing of the symptoms, and what else is associated with that mood swing when it comes. And so for bipolar disorder, type one and type two, those are episodic. That means the depression is an episode. It has a beginning. It has an end.
[08:26] Dr. Nzinga Harrison: It is different from how you usually feel. The mania or the hypomania, which is not needing to sleep, feeling on top of the world, very talkative, can get psychotic with it, definitely. There’s like a whole set of criteria. It’s an episode. It has a beginning and an end. And it is different from your usual emotional and relationship functioning. So when I have a person come in to me and say these mood swings are out of control, then I say, when did the mood swings start and they’re like, I’ve been having mood swings since I was eight, all day every day. That’s not episodic. That’s a continuous thread, right? Ah, I say, tell me about the depression. And a person says, I was doing perfectly fine and then like it was around October, I just started to like feel myself thinking so negatively and started getting disheartened. And I mean, I felt that way probably for like three or four months before I got myself back. And then I had myself back for like a year. And here it is again. That’s episodic. It has a beginning and it had an end. It had a period in the middle where you felt like your regular self and then it had a beginning. When I talk to a person with borderline personality disorder, it’s like almost every day my mood can swing five times in a day. If your mood can swing five times in a day, this is not an episode. I can’t remember a day when I didn’t feel depressed. I don’t know what their triggers were. No, it’s not over time. Now I’m thinking borderline personality. And I’m going down the rest of my diagnostic criteria to confirm that. Where a lot of psychiatrists, psychologists, mental health professionals, therapists miss that first clue is the person comes in and says it’s mood swings and their first thought is bipolar disorder, and they’re not diligent about lining up that chronology. And part of it is because I don’t want it to be borderline personality disorder because of the inherent stigma that we’ve built into the mental health system that says those patients are hard to take care of and don’t get better.
[10:43] Dr. Nzinga Harrison: What I’ll say is that the other problem is this idea that you can just walk into the psychiatrist’s office or a therapist’s office and have a one-hour appointment and know what the diagnosis is. People have been diagnosed with every other diagnosis in the DSM 90 percent of the time because their previous treatment providers have either been not longitudinal — so like a couple of visits — or have been staying away from the diagnosis because of stigma. And they look at this and they say, oh my gosh, this is what I’ve been going through. What can we do? And it’s important because the treatment of borderline personality disorder is different from the treatment of bipolar disorder, whether that’s type one or type two.
[11:31] Claire Jones: So that’s actually a perfect transition for our first question. I’m going to add an element to this, which is like also the misdiagnosis of bipolar for anxiety and depression, because let’s say somebody is going through an episode that is a three or four month period, but they go and they see their psychiatrist at the two month mark. Is that sort of why this misdiagnosis happens?
[11:58] Dr. Nzinga Harrison: Yes, that’s exactly it. And so the most powerful diagnostic consideration that I have as your psychiatrist is how your symptoms have changed over time. And so I always say of our illnesses, everything can look like everything, depending on what point in time. And so you can come to me and I can say, no diagnosis. And it’s because you’re between episodes. And then I can see you two months from now and you can have a severe mania with psychosis and look just like you have schizophrenia. And then you get diagnosed with schizophrenia when it was actually an episode of psychotic mania, and the diagnosis is bipolar disorder. And so keeping track of those symptoms over time is excruciatingly important. This is like my point of empowerment for all of our listeners. When a mental health professional or a medical professional gives you a diagnosis, literally insist on having the conversation. Let’s pull up the diagnostic criteria and make sure that those diagnostic criteria meet the symptoms you’ve been experiencing on the timeline that you have been experiencing them. Because I can say anxiety disorder, that’s not a diagnosis. What anxiety disorder? Is it a social anxiety disorder, a generalized anxiety disorder? Is it panic disorder? I can say mood disorder. Is a major depressive disorder? Is it dysthymic disorder? Is it bipolar disorder type one? Because the interventions are different.
[18:39] Claire Jones: So, as I mentioned, the first question we have is from a listener who was misdiagnosed with depression and anxiety. Let’s take a quick listen.
[18:50] Caller: Hi, Nzinga. I’m being treated for depression and anxiety, and during the past year, medications led me to heavy cannabis and alcohol use, and the subsequent loss of a relationship. Now I have a preliminary diagnosis for bipolar two disorder along with new medications. I’ve cut down on my use by a lot, but I still can’t seem to quit or stop thinking about substances, even though I can tell that they’re hurting my mental health and relationships. Can substance abuse trigger mental health disorders? Is there a particular link between certain abused substances and certain diagnoses? And how can I go about repairing relationships broken by the confusing mix of mental health and substance abuse disorders when lying has been an issue due to the substance abuse? Thank you for your time.
[19:40] Claire Jones: So what is the connection? Now that we sort of established like there can be a big mixed diagnosis here? I have personal experience from someone in my life who experienced a very similar thing. They were diagnosed with anxiety and depression, started taking an SSRI, started drinking more, and then just like that, unraveled like a whole different chain of events kind of that were really negative. And then once they were diagnosed, once they were diagnosed with bipolar, it was really different. So what is the connection between — it’s such a complicated question, it’s like, what is the connection between SSRIs or the wrong medication and addiction for different mental health disorder?
[20:40] Dr. Nzinga Harrison: So the question is like, what is the relationship between depression, anxiety other mental health disorders, the medications that we use for them, substance use disorders? Can one make one better? Can one make one worse? Like, how are they all interconnected? So the answer to the question is always the brain. The brain is the common denominator between a mental health diagnosis and addiction diagnosis and medication. So medication alone is never the answer. You already know what I’m gonna say, get a therapist and somebody to help you with your stress. But anyway, so we’re talking about the SSRI. We do know there is a small chance — and different anti-depressants have different risk of this — but there is a small chance if I do my whole diligence and I come up with the diagnosis of major depressive episode. Uni-polar. I do not think you have a bipolar disorder based on the information I have available to me right now, and I give you an antidepressant, that can, for some people, drive that push into hypomania or mania. And then it’s like, oh, what I’m actually dealing with here is a bipolar disorder, whether that’s type two or type one. As much as humanly possible, if you can try to keep the same psychiatrist and the same therapist over time. Because sometimes we just need time to be able to tell us the answers. And so sometimes it’s a bipolar disorder and we just didn’t have the information to know that. So we thought it was a major depressive disorder and we started the SSRI. Even when it’s bipolar disorder, if you’re in the depressed episode, I’m still going to start an antidepressant to get you out of it. But I will also start a mood stabilizer. So that I can put the cap, so that I don’t push you into mania or hypomania with that antidepressant. And what’s critically important there is for most of the time, we try to use one medication at the lowest effective dose. That’s how it should be. A lot of my colleagues are not practicing that way. This is another thing: we use all the same medications, but the chronology tells us when to use that medication, what doses we might use, how long we want you on that medication. And within anti-depressants, there are some anti-depressants that I would use for a major depression that I wouldn’t use for bipolar depression. In terms of adding in addiction, substance use disorders. Substance use disorders, mood disorders, personality disorders, psychotic disorders.
[23:37] My people, we have two parts of the brain: the deep brain, which is where our emotions and our impulses are, that are constantly responding to the environment. Our cortex, which is where our decision making and our behaviors are. These two parts of the brain is what is driving mental diagnosis, addiction diagnosis, what is responding to the medications we put in. And so the relationship is bi-directional, tri-directional, omni-directional. All of these things are affecting each other. So if you have a substance use disorder, I actually cannot diagnose bipolar disorder while you’re using. Because substances can make your brain chemistry — remember, I said anything can look like anything. Substance use disorder, intoxication and withdrawal cycles literally can look like schizophrenia. So methamphetamine intoxication, you come in with paranoia and psychosis. You look like you have schizophrenia. When actually what you have is methamphetamine-induced psychosis. Cannabis psychosis, you look like you have schizophrenia. Opioid withdrawal, you look like you have anxiety disorder. Now, some other physical symptoms there that can help me, but the psychological withdrawal from marijuana, from alcohol, from opioids, from amphetamines, all of these can look exactly like a depressive disorder and anxiety disorder, a personality disorder. Because personality disorder is how you’re interacting with the world and drugs change that. And so anything that happens within a month of intoxication or withdrawal is considered substance-induced. Period.
[25:30] From the other direction, though, we thought it was anxiety and I would need to know which one of the anxiety disorders were, but let’s just say we thought it was one of the anxiety disorders. We put on the SSRI, which is totally evidence-based, I hope you also got some therapy and some stress reduction, because the real evidence is for everything all at once. That SSRI sounds like it started to drive some irritability and mood instability, which then said, oh, this might be a bipolar type two disorder. You look further back and you’re like, yep, I have the diagnostic criteria for bipolar type two disorder. So let me take this SSRI off and put on a mood stabilizer. When that SSRI was driving that mood instability and driving the impulsivity that characterizes mania and hypomania, then substance use started going up. And this is why we say the relationship is inextricable, and bi-directional because anxiety can drive people to drink. Drinking can drive, anxiety, can drive people to drink. A medication on a unipolar depression that drives mania, can drive impulsivity, can lead people to using whatever — methamphetamine, alcohol, marijuana. And then methamphetamine further reduces impulse control, which can drive the mania up a notch, which can drive the drug use up a notch. So you see the picture that I’m painting.
[31:39] Claire Jones: OK, so then how does substance use disorder relate to borderline personality? Because we had a listener call in who had a really similar story. So here’s a little bit from that voicemail.
[31:54] Caller: The difficulty with the diagnostic criteria for BPD, they’re all kind of issues that people have all the time. It’s just that the difference is the intensity and the frequency. So, for example, instead of maybe just feeling a tiny bit embarrassed about something, it’s just this overwhelming sense of deep shame and humiliation that I then will ruminate on and off forever, it seems. And the other some of the other criteria that I have, which I think definitely feeds into my alcohol issues, are the inability to self-soothe some feelings of chronic emptiness, worry about abandonment, really unstable self-image and so on and so forth.
[32:45] Claire Jones: So is the relationship to alcohol and drugs the same in BPD as it is with bipolar?
[32:51] Dr. Nzinga Harrison: So having borderline personality disorder increases your risk for developing a substance use disorder. Part of that is because, like I said, the brain is the brain. And those two big parts of the brain that we talk about are those two big parts of the brain. And the symptoms come out in different ways, but it’s coming from those two big parts of the brain. The other part of it, though, is that borderline personality disorder and substance use disorders have a shared risk pathway. So, you know, how I always talk about every illness has biological or genetically inherited risk, but also has environmental risks? So the same is true for borderline personality disorder and for alcohol use disorder and substance use disorders. Part of it is coded in your DNA. So that’s like 40 to 60 percent of your risk of developing the borderline personality disorder, the substance use disorder. That’s going to be coded in your DNA. High blood pressure, diabetes, asthma. The remaining 60 to 40 percent is environmental. And we know that the more early negative experiences, so adverse childhood experiences that a person has, whether that’s poverty, whether that’s abuse, whether that’s neglect, whether that’s trauma, food insecurity, housing insecurity, gender identity.
[34:12] Dr. Nzinga Harrison: Marginalized, oppressed for other reasons, like the more of those things, the more at risk you are for developing a personality disorder because it’s about coping. And it’s about being nurtured and accepted and valued and poured into. Those are the things that protect our children from developing mental health conditions in later life. Borderline personality and addictive disorders included. And so that same risk pathway that leads people to a diagnosis of borderline personality disorder is the pathway that leads people to substance use disorders. And then your genetics kind of inform, which, if not more than one of those pathways, you go down. And that’s kind of like high level. Yes. The risk pathway is the same. But we look at the specific symptoms of the borderline personality disorder, frantic efforts to avoid abandonment. Whether that’s physical abandonment or emotional abandonment. A lot of times in adolescence that can come from getting with a crowd that accepts me no matter what. And a lot of times adolescents that have had these early childhood experiences that are putting them at risk are taking more risks around drug use and using. So, yes, increased risk absolutely has no value. And usually that comes with the messages that this person has been given about themselves as they were coming up. So any kind of persistent negative depression, anxiety, low self-esteem, unstable self-image, all of those increase the risk for substance use disorders because remember, your brain will find a way to protect you from those dangerous feelings and substances can numb it for right now. And then the substances become their own issue.
[36:10] Dr. Nzinga Harrison: And then the last thing, the borderline personality disorder really is characterized by impulsivity. And that’s because the deep brain where the impulses and the emotions, in a person with borderline personality disorder, that part of the brain is like on steroids. It is so strong that the prefrontal cortex is trying to speak up and say, hey, wait a minute, let’s think about this. Hey, wait a minute. Is that actually dangerous? Hey, wait a minute. Maybe we would make a different decision. But that deep brain, that dopamine pathway that is so strong that the prefrontal cortex doesn’t always have a voice. And so the risk of trying self-damaging behaviors like drugs, like sex, like prostitution, that risk is higher just because of the relative strength of that deep brain.
[37:03] Claire Jones: When she first left us a message, she said, “I know it’s still ongoing and my borderline personality disorder will never be cured.” What does that mean? Is that true?
[37:15] Dr. Nzinga Harrison: Yes. So it is true. But I think when people hear, like, I’ll never be cured, that kind of takes hope away a little bit, like I’m going to be dealing with this forever. And so what the way I like folks to think about it is like also your high blood pressure is never cured. Also, your diabetes is never cured. But what you do is figure out what are those things you can do that keep your high blood pressure in remission or that keep your diabetes in remission. And what are the clues that you can see that your blood pressure is going up or that your blood sugar is going up? And then what’s your strategy for getting those back into remission? Because your blood pressure is always responding to life. Your blood sugar is always responding to life. Your borderline personality disorder is always responding to life. Your alcohol use disorder is always responding to life. And so, no, it will never be cured, but that doesn’t mean you have to always be suffering from it. It just means you have to know — the same way you know what triggers your alcohol use disorder, you have to know what triggers your borderline personality disorder. The same way, you know when your alcohol use disorder is getting “out of control,” or falling out of sobriety into active illness, then you need to know what are the signs that your borderline personality disorder is “falling out of control.” And then just like, you know, your strategy for getting that alcohol use disorder back in remission, walking back to path of sobriety as you’ve defined it, that you have that same knowledge set for your borderline personality disorder. And that comes from therapy. And so there may be mood stabilizing medications that you’re on. There may be medications that you’re on for cravings for your alcohol use disorder. That’s just like your blood pressure medication. That’s just like your insulin for your diabetes. But you can take all the insulin in the world, and if your stress is out of control and your food eating is out of control, your blood sugar is going to be out of control. And so I want you to have the exact same concept. So I don’t want this idea of never cured to be like a hope sap because it doesn’t have to be a hope sap.
[39:37] Dr. Nzinga Harrison: What it says is I need to have an intimate understanding of this illness that I have, and how I keep this illness in remission and how I recognize when this illness is trying to peep his head from under the bed. So that I can push that illness’ head right back under the bed.
[40:03] Claire Jones: So I’m going to try and guess what sort of treatment and approach there is to this. So, first things first, therapy as always. If you don’t know how to find a therapist, listen to our therapy 101 episode. But I think more importantly than just going to therapy is knowing the right questions to ask and knowing the right patterns to look out for. Like you said, this is very dependent on chronology. And so paying attention, asking your doctor to pay attention to that. And then knowing what the relationship is between different substances and these different mental health and personality — what is a general word for all of this stuff?
[40:48] Dr. Nzinga Harrison: I say mental health diagnoses.
[40:53] Claire Jones: Knowing what the risk is for substance use and all of these different mental health diagnoses. Because it changes from each one to each one across the board.
[41:05] Dr. Nzinga Harrison: Yeah. So, Claire, your guess was spot on. Very well done. I will drop it into our same construct just because I want to make sure that I repeat this construct 32 times in every episode, which is biological, psychological, social, cultural, political. And so for every single illness that we talked about today, bipolar one disorder, bipolar type two disorder, borderline personality disorder, alcoholism, other substance use disorders, the very first thing is to remember that you are not bipolar. You have bipolar disorder. You are not borderline. You have borderline personality disorder. The importance is because you want your identity as a human being to not be the symptoms of the illness that you have. And so looking biologically, there are biological interventions for every single one of these illnesses we talked about. But when your professional gives you a diagnosis, the first thing I want you to do is ask them to pull out the DSM-5 diagnostic criteria and go through those symptoms and that chronology and make sure you agree, yes, this makes sense.
[42:28] Dr. Nzinga Harrison: Then number two, together you can look up the biological, psychological, social, cultural, political, evidence-based interventions because, for example, bipolar disorder, just like I will choose a different medication than I would choose for borderline personality disorder, I would choose a different therapy. The evidence-based therapy for borderline personality disorder is DBT, dialectical behavioral therapy. It really focuses on emotional management and impulse control and reducing self-harm behaviors. And so that’s why it’s important for me to know that I’m dealing with borderline personality disorder as opposed to bipolar disorder, so that together we can make the right evidence-based choices that give us the best chance of getting these illnesses in remission. Same thing if I’m dealing with alcohol-induced depressive disorder, that is different than dealing with major depressive disorder, because my plan needs to include something for that alcohol, if that’s what’s inducing the disorder. Social-politically, people’s stress is off the charts right now. Her prefrontal cortex is under a barrage of all the stressful things that are going on. And her deep brain, her limbic system and her dopamine system are like, listen, sister, we know what can help with this. And her prefrontal cortex is like, anyone, please just take some of the stress down so I can get some of my strength back. And so you have to be dipping into every single one of those buckets to make sure we’re increasing the chance. But then this is the last thing that I’ll say, which is like grace.
[44:19] Dr. Nzinga Harrison: It is knee-Jerk to say you gave me a bad diagnosis. So then you prescribe that medication. So then I got worse and that’s your fault. And what I want you all to understand is that practicing psychiatry, doing therapy is a long game. And so I can be a better doctor to you if our relationship is happening over time, we can only do that together if we’re willing to learn together and be in the evidence base together as much as we can. That was my words of wisdom.
[44:54] Claire Jones: OK, great. I think that concludes our episode for this week.
[45:09] Dr. Nzinga Harrison: In Recovery is a Lemonada Media original. The show is produced by Claire Jones and edited by Ivan Kuraev. Music is by Dan Molad. Jessica Cordova Kramer and Stephanie Wittels Wachs are our executive producers. Rate and review us and say nice things. And follow us @LemonadaMedia across all social platforms, or find me on Twitter @naharrisonmd. If you’ve learned from us, share the show with your others. Let’s help destigmatize addiction together.