The first diagnosis I received from a psychiatrist, in my early twenties, was of bipolar mood disorder. As I have described elsewhere on this blog, I rejected the diagnosis and the treatment plan, and then avoided psychiatric intervention for around 8 or 9 years. The next time I saw a psychiatrist, I was asked different questions and came away with a diagnosis of clinical depression, clinical anxiety and borderline personality traits. I was surprised by this, but after reading around I had to admit that I displayed many characteristics or behaviours which could point to borderline personality disorder. I struggled to spend time alone; I had had a recent period of intense relationship instability; I had difficulties knowing who I really was; I had taken an overdose a couple of years before; I felt that I tended to repeat a lot of the same mistakes over and over again in my social interactions, especially at work. Overall, the diagnosis seemed a reasonable fit, and was useful for explaining some of the ways I behaved.
More recently, however, I began to question how appropriate that diagnosis was. Between 2004 and 2010, my life was very stable. I began and sustained a very good, secure, long-term relationship; I worked for the same organisation continuously and progressed steadily in my career without any disasters. I coped with my partner being away without any of the panic I would have experienced in my twenties. When I presented myself to a psychiatrist earlier this year, I gave him my full history, including both prior diagnoses, and came away with the diagnosis of bipolar restored.
Trying to make sense of the change of diagnosis, I came home and did some Googling. Among the many articles I read, one by Dr Jim Phelps on his informative site, Psycheducation, really stood out. Moving from “your diagnosis” to “your position on a spectrum” introduces what Phelps calls a “paint” approach to the question of why someone receives a diagnosis of borderline or bipolar. He points out that there is “an almost complete overlap of symptoms” between the markers for the two conditions. Both involve an unstable sense of self, an unstable pattern of mood (possibly with paranoid or other psychotic features), and changes in mood states and energy levels which can lead behaviours such as impulsive spending, poor sexual and relationship choices, substance misuse, self-harm, suicidal behaviours, etc.
Phelps suggests that if conditions were colours, with this much diagnostic overlap, both Borderline Personality Disorder and Bipolar Disorder would share a lot of the same pigments – they are on the same spectrum. In this model, both can be seen as having a “red” pigment that represents hot emotions (like anger and elation), a “blue” pigment for depressive symptoms, and what Phelps thinks of as a “sparkly” pigment (isn’t that nice?) which stands for impulsive traits.
Here’s where the difference comes: the bipolar person has a “magic” pigment which makes the other pigments vary in a cyclical way over time. Get a big dose of the magic, and you’ll end up unequivocally Bipolar I; get less, and you may be Bipolar II or cyclothymic. (A criticism I would insert here is that the theory assumes bipolar people “tend to be either one way, or another, all symptoms together” i.e. all red or all blue, which doesn’t account for mixed states). Borderline people don’t have this magic pigment, but they have what Phelps suggests is a “green ingredient” causing feelings of emptiness and loneliness, which can cause problems in their interpersonal relationships, and lead them to struggle to cope if they are alone.
Phelps summarises this “pigment” or “spectrum” idea like this. Diagnoses are not objective realities; “they are conveniences for researchers, and are also supposed to help you find the right treatment. But because symptoms are spread over spectra, from a little to a lot, labels can often be misleading. Finally, borderline patients have most of the features of bipolar, plus an emptiness streak; and may have less clear “cycling” of their symptoms.”
What does this mean in practice? Well, for a start, your diagnosis will depend on how good a sense of colour vision your doctor has, and maybe what glasses she or he is wearing that day. Some pigments may leap out at one doctor, but if you ask for a second opinion, another doctor may think a different pigment seems more obvious. Also, I think your level of pigmentation can change; I’m not the same person I was at 15, or 20, or 30, and people develop and grow.
Put this way, a diagnosis of bipolar when I was in my early twenties makes sense. The psychiatrist didn’t see so much of my undeniable greenness because we didn’t talk about those issues much, so for him the magic of my mercurial mood changes outweighed the green. In my late twenties, after disclosing an overdose, with relationship problems and job problems, and having failed to recognise some hypomanic phases, I got a diagnosis with more green, less magic. After developing some emotional coping skills, relationship and job stability and functioning well for years, but then having very distinct blues and reds, I was at my most “magic” and got re-diagnosed as bipolar.
The major difference between whether you are seen as “green” or “magic” is the type of treatment plan you are offered. Viewed as having borderline issues, I received no drug options other than anti-depressants, but I was offered NHS therapy; viewed as bipolar, I have had in-depth discussions of drug treatment options, but no offer of talking therapies. Phelps has some interesting things to say about potential risks of treating people who are actually borderline as if they are bipolar, but his over-riding message is that we should avoid getting “too hung up on a diagnostic label” – if the doctor and the treatment plan are helpful for you, that’s what counts, more than whether you are “really, truly” borderline or bipolar. Neither diagnosis is an unreasonable interpretation of the symptoms bipolar and borderline people tend to display. For people who have had different diagnoses at different times, the pigment model helps to understand how this can happen, and perhaps begin to let go of any anger about being “wrongly” diagnosed or treated.
The best thing about the pigment model, in my view, is that we’re all purple together.