Misdiagnosing Personality Disorders as Bipolar I Disorder

The signs and symptoms of bipolar mania mimic those of certain personality disorders,potentially leading to a misdiagnosis.

The manic phase of the Bipolar I Disorder is often misdiagnosed as a Personality Disorder.

In the manic phase of Bipolar Disorder, patients exhibit many of the signs and symptoms of certain personality disorders, such as the Narcissistic, Borderline, Histrionic, or even Schizotypal Personality Disorders: they are hyperactive, self-centered, lack empathy, and are control freaks. The manic patient is euphoric, delusional, has grandiose fantasies, spins unrealistic schemes, and has frequent rage attacks (is irritable) if her or his wishes and plans are (inevitably) frustrated.

Bipolar Disorder got its name because the mania is followed by - usually protracted - depressive attacks. A similar pattern of mood shifts and dysphorias occurs in many personality disorders such as the Borderline, Narcissistic, Paranoid, and Masochistic. But whereas the bipolar patient sinks into deep self-deprecation, self-devaluation, unbounded pessimism, all-pervasive guilt and anhedonia - patients with personality disorders, even when depressed, never lose the underlying and overarching structure of their primary mental health problem. The narcissist, for instance, never foregoes his narcissism, even when down and blue: his grandiosity, sense of entitlement, haughtiness, and lack of empathy remain intact.

From my book "Malignant Self Love - Narcissism Revisited":

"Narcissistic dysphorias are much shorter and reactive - they constitute a response to the Grandiosity Gap. In plain words, the narcissist is dejected when confronted with the abyss between his inflated self-image and grandiose fantasies - and the drab reality of his life: his failures, lack of accomplishments, disintegrating interpersonal relationships, and low status. Yet, one dose of Narcissistic Supply is enough to elevate the narcissists from the depth of misery to the heights of manic euphoria."

The etiologies (the causes) of the Bipolar Disorder and of personality disorders differ. These disparities explain the different manifestations of mood swings. The source of the Bipolar's mood shifts is assumed to be brain biochemistry. The source of the transitions from euphoric mania to depression and dysphorias in the Cluster B personality disorders (Narcissistic, Histrionic, Borderline) is the fluctuations in the availability of Narcissistic Supply. Whereas the narcissist is in full control of his faculties, even when maximally agitated, the bipolar often feels that s/he has lost control of his/her brain ("flight of ideas"), his/her speech, his/her attention span (distractibility), and his/her motor functions.

The bipolar is prone to reckless behaviors and substance abuse only during the manic phase. In contrast, people with personality disorders do drugs, drink, gamble, shop on credit, indulge in unsafe sex or in other compulsive behaviors both when elated and when deflated.

As a rule, the bipolar's manic phase interferes with his or her social and occupational functioning. Many patients with personality disorders, in contrast, reach the highest rungs of their community, church, firm, or voluntary organization and function reasonably well most of the time. The manic phase of Bipolar sometimes requires hospitalization and involves psychotic features. Patients with personality disorders are rarely if ever hospitalized. Moreover, psychotic microepisodes in certain personality disorders (e.g., the Borderline, Paranoid, Narcissistic, Schizotypal) are decompensatory in nature and appear only under unendurable stress (e.g., in intensive therapy).

The bipolar patient's nearest and dearest as well as perfect strangers react to his mania with marked discomfort. The constant, unwarranted cheer, the emphasized and compulsive insistence on interpersonal, sexual, and occupational, or professional interactions engenders unease and repulsion. The patient's lability of mood - rapid shifts between uncontrollable rage and unnatural good spirits - is downright intimidating.

Similarly, people with personality disorders also garner unease and hostility from their human environment - but their conduct is more often considered to be manipulative, cold, and calculating, rarely out of control. The narcissist's gregariousness, for example, is goal-orientated (the extraction of Narcissistic Supply). His cycles of mood and affect are far less pronounced and less rapid.

From my book "Malignant Self Love - Narcissism Revisited":

"The Bipolar's swollen self-esteem, overstated self-confidence, obvious grandiosity, and delusional fantasies are akin to the narcissist's and are the source of the diagnostic confusion. Both types of patients purport to give advice, carry out an assignment, accomplish a mission, or embark on an enterprise for which they are uniquely unqualified and lack the talents, skills, knowledge, or experience required.

But the bipolar's bombast is far more delusional than the narcissist's. Ideas of reference and magical thinking are common and, in this sense, the bipolar is closer to the schizotypal than to the narcissistic."

Sleep disorders - notably acute insomnia - are common in the manic phase of bipolar and uncommon among patients with personality disorders. So is "manic speech" which is pressured, uninterruptible, loud, rapid, dramatic (includes singing and humorous asides), sometimes incomprehensible, incoherent, chaotic, and lasts for hours. It reflects the bipolar's inner turmoil and his/her inability to control his/her racing and kaleidoscopic thoughts.

As opposed to subjects with personality disorders, bipolars in the manic phase are often distracted by the slightest stimuli, are unable to focus on relevant data, or to maintain the thread of conversation. They are "all over the place": simultaneously initiating numerous business ventures, joining a myriad organization, writing umpteen letters, contacting hundreds of friends and perfect strangers, acting in a domineering, demanding, and intrusive manner, totally disregarding the needs and emotions of the unfortunate recipients of their unwanted attentions. They rarely follow up on their projects.

The transformation is so marked that the bipolar is often described by his or her closest as "not being himself of herself". Indeed, some bipolars relocate, change name and appearance, and lose contact with their "former life". Like in psychopathy, antisocial or even criminal behavior is not uncommon and aggression is marked, directed at both others (assault) and oneself (suicide). Some biploars describe an acuteness of the senses, akin to experiences recounted by drug users: smells, sounds, and sights are accentuated and attain an unearthly quality.

People with personality disorders are mostly ego-syntonic (the patient feels good with himself, with his life in general, and with the way he acts). In contrast, bipolars regret their misdeeds following the manic phase and try to atone for their actions. They realize and accept that "something is wrong with them" and seek help. During the depressive phase they are ego-dystonic and their defenses are autoplastic (they blame themselves for their defeats, failures, and mishaps).

Finally, personality disorders are usually diagnosed in early adolescence. Full-fledged bipolar disorder rarely occurs before the age of 20. The pathology of the bipolar is inconsistent. The onset of the manic episode is fast and furious and results in a conspicuous metamorphosis of the patient. With the exception of the Borderline patient, this is not the case in personality disorders.

More about this topic here:

Roningstam, E. (1996), Pathological Narcissism and Narcissistic Personality Disorder in Axis I Disorders. Harvard Review of Psychiatry, 3, 326-340

Stormberg, D., Roningstam, E., Gunderson, J., & Tohen, M. (1998) Pathological Narcissism in Bipolar Disorder Patients. Journal of Personality Disorders, 12, 179-185

Vaknin, Sam - Malignant Self Love - Narcissism Revisited - Skopje and Prague, Narcissus Publications, 1999-2006

This article appears in my book, "Malignant Self Love - Narcissism Revisited"

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