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Section 5
Bipolar, HIV, Cyclothymic, and Borderline Personality Disorder

Question 5 | Test | Table of Contents

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In the last section, we discussed techniques to predict manic and depressive states and to aid clients through the cycles of Listing Symptoms According to Category, Preventative Maintenance Plan, and Three-Part Breathing Exercise.

In this section, we will examine conditions that may co-occur with bipolar disorder:  autoimmune disorders, borderline personality disorder, and cyclothymic disorder.  We will also present ways to diagnose these comorbid conditions along with ways to treat clients with comorbid conditions.

3 Comorbid Conditions

♦ 1. Autoimmune Disorders
The first type of conditions that can co-occur with or may be mistaken for bipolar disorder is autoimmune disorders.  Many of these diseases, which include AIDS and lupus, affect the nervous system and produce severe and rapid behavioral changes.  Those clients that have been infected with the HIV virus exhibit moodiness, irritability, memory loss, and confusion. As you know, those clients suffering from the early stages of lupus may display symptoms ranging from mild anxiety to severe psychosis. 

Generally, an inquiry into the client’s medical history will reveal a potential for any co-morbid autoimmune disorders.  If a client is experiencing symptoms ranging outside of a bipolar diagnosis and the cause is suspected to be an autoimmune disorder, I schedule an interview session with the client. 

4 Questions for Autoimmune Disorders
Some of the questions I ask the client, include the following:
1. Have you ever experienced swelling or pain of the joints?
2. Has this swelling or pain ever caused you to walk with a cane or other assistance?
3. Have you ever noticed a red or purplish rash on your face or lesions on any part of your body?
4. Have you ever experienced a mild to severe seizure?

Kelly was 42 years old and a bipolar client of mine.  Kelly reported to me that during an outing with her friends, she noticed that her ankle swelled up without explanation.  Later, her knee on the other leg also swelled, but again without any noticeable injury.  The swelling caused Kelly to walk around with the assistance of a cane.  Kelly stated that these attacks have happened before in the past.  I referred her to a rheumatologist who diagnosed her with lupus.  Although Kelly did indeed have bipolar disorder, the mood swings that occur in early lupus were masked by her manic-depressive cycles and therefore, the lupus remained undiagnosed.

♦ 2. Borderline Personality Disorder
A second type of condition that can be comorbid with bipolar disorder is borderline personality disorder.  Diagnosing this disorder when a client might also be suffering from bipolar disorder is extremely difficult because the two conditions share much in common, particularly the rapid cycling periods.  However, a client suffering from borderline personality disorder has shorter periods of depressive states and do not experience the manic state of a strictly bipolar client. 

To effectively discern BPD from bipolar, I find it is helpful to look at a client’s relationships.  Often, a client with BPD will idealize the person they become close to and then quickly devalue them.  A BPD client will also go to great lengths to avoid being "abandoned" by their partner.  Also, BPD clients’ mood swings are impulsive and unpredictable, whereas bipolar cycles are somewhat easier to predict with the right symptom chart. 

Laura, age 27, called her boyfriend up to 10 times a day.  When she did, she often raged at him for "not being there for her" and, if she couldn’t reach him, accused him of being with another woman.  When alone, she would feel like disappearing and feel intolerable cravings to eat, smoke, drink alcohol, or cut herself with glass.  These problems had continued for several years, despite the fat that she was in psychotherapy and had tried various forms of antidepressant medication. 

♦ BPD Questionnaire
I suspected that Laura was suffering from BPD along with bipolar disorder and put this questionnaire to her:
1. Do you have difficulty defining for yourself who you are or who you want to be?
2. Do you have a history of very intense and unstable relationships?
3. Do you have a history of making great efforts to keep people from abandoning or leaving you?
4. Do you have difficulty controlling angry outbursts?
5. Do you have a history of impulsive or reckless behavior in sex, spending money, or eating?
6. Do you have a history of self-destructive acts?

Because Laura responded yes to all of these questions, I diagnosed her with BPD comorbid with bipolar disorder. Because BPD clients are treatment refractory, I recommend cognitive-behavioral psychotherapy. You may learn more about treating clients with BPD in the Healthcare Training Institute’s course "Diagnosis and Treatment:  Borderline Personality Impulse Control with Schema Therapy".

♦ 3. Cyclothymic Disorder
In addition to autoimmune disorders and borderline personality disorder, as you may know a third condition that may be comorbid with bipolar disorder is cyclothymic disorder.  Cyclothymic disorder is characterized by short periods of feeling active, irritable and excited; short periods of feeling mildly depressed; and a tendency to alternate back and forth between the two.

Often, cyclothymic disorder may be a precursor to bipolar disorder and even shares many characteristics with bipolar II disorder.  As a result of this, many psychiatrists, including myself, treat cyclothymic disorder with the same medications as bipolar II.  However, cyclothymic disorder clients can often function without the medication as their symptoms are shorter and less debilitating. 

Stephen was a 30-year-old client of mine who, since adolescence, had experienced a pattern of alternating between three day periods in which he cried considerably and lost interest in things.  This was followed by another three day period in which he would feel irritable, energetic, and talkative.  Stephen had never been hospitalized for either his depressive or hypomanic symptoms, nor had he been suicidal, unable to concentrate, or lost significant amounts of weight.  His girlfriend sometimes complained about his moodiness and raging.  Although it was more difficult to work when he was depressed, Stephen had never lost a job because of it.  As a result of this behavior, I diagnosed Stephen with cyclothymic disorder.

In this section, we discussed conditions that may co-occur with bipolar disorder:  autoimmune disorders, borderline personality disorder, and cyclothymic disorder.  We also presented ways to diagnose these comorbid conditions along with ways to treat clients with comorbid conditions.

In the next section, we will examine the traits of the sleep-wake cycle and how it affects bipolar clients:  social Zeistorers; social Zeitgebers; and a regulated sleep pattern.
Reviewed 2023

Peer-Reviewed Journal Article References:
Iverson, G. L. (1995). The need for psychological services for persons with systemic lupus erythematosus. Rehabilitation Psychology, 40(1), 39–49.

Lee, J. Y., & Harvey, A. G. (2015). Memory for therapy in bipolar disorder and comorbid insomnia. Journal of Consulting and Clinical Psychology, 83(1), 92–102.

Menninger, K. A. (1919). Cyclothymic Fugues: Fugues associated with manic-depressive psychosis: A case report. The Journal of Abnormal Psychology, 14(1-2), 54–63. 

Mneimne, M., Fleeson, W., Arnold, E. M., & Furr, R. M. (2018). Differentiating the everyday emotion dynamics of borderline personality disorder from major depressive disorder and bipolar disorder. Personality Disorders: Theory, Research, and Treatment, 9(2), 192–196.

Penner, F., Wall, K., Jardin, C., Brown, J. L., Sales, J. M., & Sharp, C. (2019). A study of risky sexual behavior, beliefs about sexual behavior, and sexual self-efficacy in adolescent inpatients with and without borderline personality disorder. Personality Disorders: Theory, Research, and Treatment, 10(6), 524–535.

Sauer-Zavala, S., Cassiello-Robbins, C., Woods, B. K., Curreri, A., Wilner Tirpak, J., & Rassaby, M. (2020). Countering emotional behaviors in the treatment of borderline personality disorder. Personality Disorders: Theory, Research, and Treatment. Advance online publication.

Smith, L. A. (1995). "Acute psychiatric illness: Effects on HIV-risk behavior": Comment. Psychosocial Rehabilitation Journal, 18(3), 5–6.

QUESTION 5
What are three conditions that may co-occur with bipolar disorder? To select and enter your answer, go to Test.

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