bipolar or borderline (or ptsd or adhd)?

7/25/2019 Bipolar or Borderline (or PTSD or ADHD)?

1/10The Neuropsychotherapist Vol 4 Issue 6,June201616

Bipolar or Borderline

(or PTSD or ADHD)?Managing Dicult Distinctions

and Comorbidities

James Phelps


2/10www.neuropsychotherapist.com 17The Neuropsychotherapist

Borderlinity,

not Borderline Personality Disorder

Borderline personality disorder (BPD)what an un-fortunate choice of terms. We in psychiatry who are sonormal (ahem) shall deem a patient to have a personal-ity disorder. Great public relations.

Nevertheless, there is a real phenomenon this labelis intended to describe. Contrary to Akiskal and others,who suggested incorporating borderlinity into the bi-polar spectrum (Akiskal et al., 2006), most recent datasuggest that borderlinity is a dierent phenomenonthan bipolarity (Ghaemi et al., 2014). The classic pres-entations of BPD (e.g., behaviors reecting attachmentproblems, from overvaluation/devaluation to abandon-ment distress) are clearly dierent from the classic formsof Bipolar I (e.g., sustained euphoric mood, with pres-

sured speech after two nights with no need for sleep).But as clinicians well know, there are many variations ofborderlinity, often hesitatingly referred to in a diagnos-tic assessment as borderline traits.

Many authors have written about dierentiating BPDand bipolar disorders. For example, Joel Paris and Don-ald Black (2015) emphasize getting the right treatmentto the right patient, particularly psychotherapy for BPDinstead of medications. Even though I disagree withtheir emphasis on DSM criteria to dierentiate BPDfrom bipolar disorders, I completely agree with their

emphasis on psychotherapy and avoidance of atypicalantipsychotics.

In any case, controversy reigns in this area. Shouldyou need an example, see the recent exchange betweenthe BRIDGE team (Perugi et al., 2013) and Joel Paris(2013). Therefore, lest it be misunderstood: in the fol-lowing analysis, I am not saying that some phenomenonwhich the borderline term attempts to capture does

not exist. I am not saying it is a version of bipolar disor-der. As the very controversy here attests, there is over-lap and uncertainty about the boundaries of these twoconditions. So while some research teams continue towork on distinguishing them (e.g., Coulston et al., 2012),we need some means of coping with the middle ground,where borderline traits overlap with bipolar traits.

The Overlap Problem:

Borderline and Bipolar

In Brown University reports of bipolar overdiagno-sis, the most common diagnosis from the StructuredClinical Interview for DSM Disorders (SCID) for patientsmisdiagnosed as bipolar was Major Depression (Zim-merman et al., 2010b). This makes sense: clinicians haddetected depression but also found something suggest-ing bipolarity, perhaps a nding from the wedge of hy-pomania that they thought sucient to invoke bipolardisorder. During the SCID, however, that nding did notreach the DSM threshold, whereas depression was con-rmed: voila, unipolar.

But in their data, the other common SCID diagnosis

Bipolar disorders are in the dierential for nearly every psychiatric presentation, from psycho-

sis to depression to obsessive thinking to substance use. Three conditions present the most di-

cult dierential diagnostic challenges relative to bipolar disorders because of the extensive overlap

in diagnostic criteria and overall phenomenology: borderline personality disorder, post-traumatic

stress disorder (PTSD), and attention decit disorder (ADD). Worse, these conditions are common-

ly comorbid with bipolar disorders. Thus the diagnostic question is often not this, or that? but

this, that, or both?

The bottom lines of this article are:

admit the tremendous overlap in diagnostic criteria (resistance is futile)

focus on treatment options; it takes the pressure o of dicult diagnostic distinctions

think iterativelystart with low-risk options and adjust treatment as you go, keeping an

open mind about diagnoses that might be escaping you.

These principles will emerge in consideration of the three diagnoses, relative to bipolarity.



for the patients misdiagnosed as bipolar was BPD (Zimmerman et al., 2010a). The Brown University team found thatpositives on the Mood Disorders Questionnairea tool designed to detect bipolaritywere actually more likely towarrant a borderline diagnosis than a bipolar diagnosis when the SCID was used as the gold standard.

Using the SCID as the arbiter of what illness the patient really carries is of course problematic: we lack labtests and other objective means of establishing the true diagnosis, and resort to the SCID instead. (Colleaguesin surgery and internal medicine sometimes oer sympathy over this, sometimes derision.) Think of how a SCIDis performed: a research assistantin this case two well-trained graduate studentsasks the patient a series ofquestions, following a strict written guide. For this kind of work, some standard is required and the SCID is ac-

cepted in research circles as the best for this purpose. Indeed, this convention is so routine that it might appear, ifwe do not pause to think about it, as though our eld has accepted the idea that a graduate student following aquestion guide is somehow closer to truth, whatever that is in this case, than clinicians who may have seen thepatient over many visits.

Nevertheless, the Brown University reports underscore what clinicians encounter all the time: BPD and bipolarityswirl around one another. As one thoughtful review concluded, bipolar and borderline disorders are often indistin-guishable given the core characteristics of emotional dysregulation and impulsivity that feature in both (Coulstonet al., 2012).

Table 4.1 lists DSM criteria for the two conditions, emphasizing this overlap. The borderline criteria are straight

from the DSM. The bipolar column lists well-accepted clinical features of bipolar disorders.



Table 4.1. Criteria for borderline and bipolar disorders

Domain Borderline Bipolar

Stable/ unstable Unstable sense of self Transient paranoia ordissociation

Affective instability

Unstable mood Transient paranoia Affectiveinstability

Anger Intense anger Intense anger

Relationships Unstable intense relationships Unstable relationships

Suicidality Recurrent suicidal behavior Suicidal ideation or attempts

Impulsivity Impulsive spending, sex, drug use, risky behaviors Impulsive spending, sex, drug use, risky behaviors

Attachment Abandonment fear Chronic emptiness Normal attachment range, at least prior to onset

Symptom duration Hours to a day Technically >4 days

Because of the extensive overlap, dierentiating these conditions by DSM criteria places tremendous weight onthe last two domains. But symptom duration for hypomanic symptoms is strongly debated. For example, Parkerand colleagues found that the four-day requirement excluded 315 of 501 patients (63 percent) who otherwise metBipolar II criteria (Parker et al., 2014). Those with briefer hypomanic symptoms did not dier from those with stand-

ard hypomania duration in age of onset of symptoms or family history of bipolar disorder (suggesting that the twogroups did not dier biologically, despite one meeting DSM criteria for Bipolar II and the other not).

If one discards the duration criterion as unsupported by research data, dierentiating bipolar from borderlinecomes down to the attachment criteria alone. Experienced clinicians can recognize the attachment disturbancewithin minutes in a rst interview: the transference energy is often intense, early, and trends toward rapidlyovervaluing or devaluing providers. I would not expect structured interviews by graduate students to capture thisphenomenon, and thus do not nd the studies by Zimmerman et al. compelling, regarding their emphasis on bor-derlinity over bipolarity, given the overlap between all the remaining criteria (Zimmerman, 2015).

The point here is not to declare the two conditions indistinguishable but to emphasize that DSM criteria alone donot discriminate them well. Fortunately, however, other features not found in the DSM (nor the SCID) do dierenti -ate the two conditions somewhat (see Table 4.2).

Table 4.2. Other features of borderline and bipolar disorders

Domain Borderline Bipolar

Age of onset Childhood; disturbances should be noted even be-fore puberty and strongly shortly thereafter

1824 with relatively normal premorbid mood, rela-tionships, function

Family history Substance use and trauma Bipolar or very high-functioning relatives

Episode precipitants Common, usually interpersonal, with rapid symptomonset thereafter

Largely independent of psychosocial events

Recognize the Bipolarity Index elements here? (They are italicized in the table.) Their ability to help dierenti-ate borderlinity from bipolarity underscores their importance in initial histories. None of these three factors areas powerful as the attachment factor, in my opinion, but they can be useful, particularly when ndings align, forexample, childhood onset, family history negative for bipolar disorder, and episodes commonly associated withinterpersonal events are all found together. Unfortunately, trauma is so prevalent in both borderline and bipolarconditions, PTSD is often a given. The diagnostic question is whether there is bipolarityunderneath that often moreobvious trauma. Lets look at PTSD in the same way, comparing diagnostic criteria with bipolar disorder. Then willcome an examination of the impact of all this overlap on treatment choices.



The Overlap Problem: PTSD and Bipolar

Table 4.3 is constructed in the same fashion as the earlier one, with DSM criteria for PTSD (not all of them)compared with common bipolar symptoms. The borderline column is copied from the previous table for three-waycomparison.

Table 4.3. Comparison of PTSD, bipolar disorder, and borderline disorder

Domain PTSD Bipolar Borderline

Stable/ unstable Unstable experience Transientparanoia or dissociation


Unstable mood Transient parnoiaAffective instability

Unstable sense of self Transient paranoiaor dissociation


Anger Intense anger Intense anger Intense anger

Relationships Unstable relationships Unstable relationships Unstable intense relationships

Suicidality Suicide risk Suicidal ideation or attempts Recurrent suicidal behavior

Impulsivity Substance use, impulsive avoidance Impulsive spending, sex, drug use,risk behaviors

Impulsive spending, sex, drug use,risky behaviors

Attachment Normal attachment range, at leastprior to trauma

Normal attachment range, atleast prior to onset

Abandonment fear Chronic empti-ness

Onset After trauma After mood changes Interpersonal

Symptomduration

Hours to a day with each intrusiverecall

Technically >4 days Hours to a day

Again, the point is to illustrate the overlap between these conditions. If there is an obvious trauma with an obvi-ous date of occurrence, that helps; but of course, the trauma is often an entire childhoods experience, and thenthere is no specic trauma date nor easy pre/post comparison possible.

Hopefully these tables have made clear the problem with which clinicians are all too familiar: these three condi-

tions are sometimes extremely dicult to dierentiate. Moreover, each is itself a spectrum.

A Spectrum View of Trauma

and Borderlinity

Trauma is obviously a continuum from extremeevents involving life ordeath to moderate events of mis-fortune. Moreover, there is a spectrumof responses tothe same event: some people have experienced terribletrauma and yet seem relatively unaected (bottle that);whereas othersare debilitated by much more minor butto them very trying experiences.

Likewise, borderlinity also makes more sense as acontinuum than as a yes/no phenomenon. Consider:Borderline specialist Marsha Linehan characterizes BPDas arising from an emotionally invalidating environ-ment in childhood (Linehan, 1993). Family environ-ments surely sort into a continuum from highly emo-tionally attuned to utter empathetic failure; childrenrange from emotionally thick-skinned and unperturb-

able to easily injured and extremely sensitive. Interac-tions among these varying emotional environments and

a given childs temperament create the myriad com-binations we see clinically, where establishing a cutofor the presence or absence of BPD is dicult. Just howmuch avoidance of abandonment constitutes frantic,for example?

So we have three continua, when the mood spectrumis added to the borderline spectrum and the trauma

spectrum. Not only do their criteria overlap, these threeconditions can cause or adversely aect the others.Indeed, by their nature, they are likely to do so. For ex-ample, in a family with a parent with poorly controlledBipolar I, the children carry genetic risk for bipolar disor-der but are more likely than peers to experience physi-cal and sexual trauma and more likely to experience aninvalidating emotional environment. No wonder peopleare struggling to distinguish these conditions. They canbe so woven together that teasing them apart is clini-cally impossible. What to do?



Getting out of the Woods:

Focus on Treatment

Treatment options for these three problems (border-linity, trauma, and bipolarity) dier in only a few crucialrespects. So why not focus on the treatment implica-tions of those dierences (or lack thereof), instead ofgnashing teeth about diagnoses with broadly overlap-ping criteria and frequent comorbidity? Look at whatone must consider to decide between psychotherapy,mood stabilizers, and antidepressants.

Dialectic Behavioral Therapy (DBT). At present, DBTis the most widely accepted treatment for BPD, thoughother therapies have randomized trial evidence for ef-cacy, notably the STEPPS program from Iowa (Blumet al., 2008) and the Mentalization approach from Bate-man and Fonagy (2009). What if the patient really hasbipolar disorder, not BPD, and mistakenly gets DBT?

This is not much of a problem (except perhaps for inef-cient use of a limited resource): most patients with amood or anxiety disorder would benet from the skillscomponent of this treatment, or the support, and per-haps even the safety focus. At least DBT is not likely todo harm in a patient with bipolar disorder. Indeed, mul-

tiple studies have tried mindfulness as a treatment forbipolar disorders, including an online approach (Murrayet al., 2015).

Mood stabilizers. Diagnosticians fret about distin-guishing unipolar from bipolar disorder because theyfear the latter will lead to use of atypical antipsychot-ics, and many fear that calling BPD bipolar will run

the same risk. But what about lithium and lamotrigine?What do they do in BPD? What medications are most ef-fective for BPD?

In a thoughtful commentary, Kenneth Silk outlinesthe medication approaches for BPD (2015). His bot-tom line: nothing is great, all might help some, antide-pressants are not clearly better than mood stabilizers(indeed, the latter may be somewhat better for somesymptoms), and psychotherapy is the mainstay instead.A Cochrane review places similar slight emphasis on

mood stabilizers while concluding that none are particu-larly eective overall (Stoers, 2010).

At minimum it seems fair to say that antidepressantshave not been shown to be clearly superior to any othermedication class. Therefore, consider the scenario inwhich a patient with BPD is mistakenly diagnosed as



having bipolar disorder. If the emphasis is there-fore on mood stabilizers and avoiding antide-pressants, this will not lead pharmacotherapyin a wrong direction. It may not help much. Toovigorous an attempt to control symptoms withmedications could expose the patient to undueside eects and risks. Hopefully the clinician willremember the medical school dictum: when

your treatment is not working, question your di-agnosis. Dont cling to a presumption of bipo-lar disorder; keep thinking and reevaluating. Astreatment proceeds, the patient should be un-derstanding more about bipolarity and becomeprogressively more able to assist with the dif-ferential diagnosis (including contradicting aninaccurate bipolar interpretation).

An inaccurate bipolar diagnosis, where bor-derlinity would have been more accurate, willnot lead to wrong medicines, although it can

lead to many medication trials with littlebenet and toward medications with morerisks than antidepressants.

Again, I emphasize: if the patienthas tempestuous interpersonal rela-tionships, impulsive self-harm, anddramatic mood swings, a good clini-cian will keep borderlinity high inthe dierential, including in ongo-ing diagnostic revisions. Perhapseven more important, if chronicemptiness and abandonment fearare prominent in the history, re-gardless of how much bipolaritywas detected, a borderline-fo-cused psychotherapy should bestrongly considered, independ-ent of medication strategy. Thusa spectrum approach to bipolar-ity does not preclude good clinicalapproaches to borderlinity of anydegree (assuming psychotherapy re-



sources such as DBT are locally available, a separate andsometimes signicant problem).

Antidepressants. Here we come to the single ele-ment in treatment that goes in two opposite directionsdepending on the diagnosis. With BPD, antidepressantsmay be tried and may help somewhat. But in bipolar dis-orders, antidepressants can cause a worsening in several

ways (discussed in Chapter 12): not just inducing a manicepisode but more perniciously by inducing mixed stateswith agitation, irritability, and suicidal ideation. Perhapseven worse, as described in Chapter 12, antidepressantscanaccording to someinduce a long course of sub-tle worsening that can take years to detect and manymonths to reverse. In a patient with signicant border-linity, a persistent dysphoria is likely to be attributed tothe illness (or should I say to the patient?) rather thanto an antidepressant. When the system of care shuespatients from one provider to another, the opportunityto detect that antidepressants might be contributing to(rather than relieving) suering is often lost. There is noalternative but to keep wondering if the antidepressantmight be part of the problem. This is dicult when thepatient is signicantly depressedhow can one consid-er removing a medication whose very name suggests itis the solution? On the other hand, when the patient hasbeen experiencing severe depressive symptoms, oftenfor years, while taking an antidepressant, one can con-sider the possibility that it is ineective at a minimum.At that point, strong consideration should be given toa trial of antidepressant discontinuation (guidelines forthe process in Chapter 12).

Likewise, before an antidepressant is used, it is cru-cialprimum non nocereto make sure the patient doesnot have signicant bipolarity, perhaps underneath BPD(knowing that the two are frequent co-travelers). If thepatient is already on an antidepressant and experienc-ing agitation, irritability, and suicidal ideation, one mustconsider the possibility that the antidepressant is theculprit (to some degree), not just the borderlinity.

All the arguments above apply in PTSD as well:

The dierential is dicult, it is frequently hard tobe certain.

One is often looking for bipolarity underneathtrauma (complicating the search).

Psychotherapy is the preferred approach.

Medications help, but none particularly well.

Antidepressants are commonly used.

Before antidepressants are used, make sure thata thorough search for bipolarity has been con-

ducted. If the patient is on an antidepressant and experi-

encing agitation, irritability, and suicidal ideation,consider antidepressant-induced mixed statesfrom undetected bipolarity.

Attention Decit Disorders

Here again there is overlap in diagnostic criteria, andagain the way out of the woods is to focus on treatmentoptions and maintain vigilance for being inaccurate with

ones rst diagnosis. As a psychiatrist for adults, Ive notoften had to face the dicult dierential diagnosis of ayoungster who presents with distractibility, irritability,and hyperactivity. ADD is included in this chapter pri-marily to draw a parallel with the foregoing disorders:the criteria overlap and so do the conditions. I found thefollowing a useful guide, from a childrens bipolar spe-cialist and his team (Sala et al., 2014). They encouragethinking about bipolarity when ADHD symptoms:

appear for the rst time later in life. appear abruptly in an otherwise healthy child.

were responding to stimulants and now are not.

come and go and tend to occur with mood chang-es.

Other markers that should prompt consideration ofbipolarity from the outset, regardless of ADHD symp-toms, include when a child:

begins to have mood symptoms, less sleep, or hy-persexuality.

has recurrent severe mood swings, temper, rage.

has hallucinations or delusions.

has strong family history of bipolar disorder andis not medication-responsive.



Stimulants appear surprisingly unlikely to exacerbatebipolar disorder when added to an optimized moodstabilizer, although data for this assertion are limited.Three randomized trials in adolescents on adequatemood stabilizers showed no increase in mood instabil-ity when stimulants were added to prior adequate bipo-lar treatment (reviewed in Peruzzolo et al., 2013). Nev-ertheless, before considering stimulant medications,

the same cautions reviewed above for borderlinity andPTSD apply here:

1. The dierential is dicult; it is frequently hard tobe certain.

2. One is often looking for bipolarity underneathADD, complicating the search.

3. Psychotherapy is the preferred approach, at leastinitially.

4. Make sure before medications are used that a

thorough search for bipolarity has been conduct-ed.

5. If the patient is on a stimulant or antidepressant,and experiencing agitation, irritability, and sui-cidal ideation, consider medication exacerbationof undetected bipolarity.

These general cautions apply for all of the difcult dif-

ferential diagnoses relative to bipolarity.

References

Akiskal HS, Akiskal KK, Perugi G, et al. Bipolar II and anx-ious reactive comorbidity: toward better pheno-typic characterization suitable for genotyping. J Af-fect Disord. 2006 Dec;96(3):23947.

Bateman A, Fonagy P. Randomized controlled trial of out-patient mentalization-based treatment versus struc-tured clinical management for borderline personalitydisorder. Am J Psychiatry. 2009 Dec;166(12):135564.

Blum N, St John D, Pfohl B, et al. Systems training for emo-tional predictability and problem solving (STEPPS)for outpatients with borderline personality disorder:a randomized controlled trial and 1-year followup.Am J Psychiatry. 2008 Apr;165(4):46878.

Coulston CM, Tanious M, Mulder RT, Porter RJ, Malhi GS.Bordering on bipolar: the overlap between borderlinepersonality and bipolarity. Aust N Z J Psychiatry. 2012Jun;46(6):50621.

Ghaemi SN, Dalley S, Catania C, Barroilhet S. Bipolar orborderline: a clinical overview. Acta Psychiatr Scand.2014 Aug;130(2):99108.

Linehan M. Cognitive Behavioral Therapy for Borderline Per-

sonality Disorder. Guilford Publications, 1993.

Murray G, Leitan ND, Berk M, et al. Online mindfulness-based intervention for late-stage bipolar disorder: pi-lot evidence for feasibility and eectiveness. J AectDisord. 2015 Jun 1;178:4651.

Paris J. Borderline personality and bipolar disorder: thelimits of phenomenology. Acta Psychiatr Scand. 2013Nov;128(5):384.

Paris J, Black DW. Borderline personality disorder andbipolar disorder: what is the dierence and why doesit matter? J Nerv Ment Dis. 2015 Jan;203(1):37.

Parker G, Graham R, Synnott H, Anderson J. Is the DSM-5 duration criterion valid for the denition of hypo-mania? J Aect Disord. 2014;156:8791.

Perugi G, Angst J, Azorin JM, Bowden C, Vieta E, YoungAH; BRIDGE Study Group. The bipolar-borderline per-sonality disorders connection in major depressive pa-tients. Acta Psychiatr Scand. 2013 Nov; 128(5):376-83.

Peruzzolo TL, Tramontina S, Rohde LA, Zeni CP. Phar-

macotherapy of bipolar disorder in children and ad-olescents: an update. Rev Bras Psiquiatr. 2013 OctDec;35(4):393405.

Sala R, Gill MK, Birmaher B. Dierentiating pediatricbipolar spectrum disorders from attention-decit/hyperactivity disorder. Psychiatric Annals. 2014;44:410415.

Silk KR. Management and eectiveness of psychop-harmacology in emotionally unstable and border-line personality disorder. J Clin Psychiatry. 2015Apr;76(4):e5245.

Stoers J, Vllm BA, Rcker G, et al. Pharmaco-logical interventions for borderline personal-ity disorder. Cochrane Database Syst Rev. 2010 Jun16;(6):CD005653.

Zimmerman M. Improving the recognition of borderlinepersonality disorder in a bipolar world. J Pers Disord.2015 Apr 20;116.

Zimmerman M, Galione JN, Ruggero CJ, et al. Screeningfor bipolar disorder and nding borderline personal-ity disorder. J Clin Psychiatry. 2010a;71(9):12127.

Zimmerman M, Ruggero CJ, Chelminski I, Young D.

Psychiatric diagnoses in patients previously over-diagnosed with bipolar disorder. J Clin Psychiatry.2010b;71(1):2631.

This article is an excerpt from A Spectrum Approachto Mood Disorders: Not Fully Bipolar But Not Unipolar -

Practical Management, by James Phelps. Reprinted withpermission of the publisher W. W. Norton & Co.

James Phelps, MD, is director of the Mood Disordersprogram at Samaritan Mental Health in Corvallis, Ore-gon, which serves a ve-hospital system.


10/1025

James Phelps provides an invaluable resource for understanding andaddressing complex or intractable mood disorders. Frustrating for clini-cians and patients alike, the traditional rst line of defenseantidepres-santsregularly fails to help and often worsens symptoms. Here is help.Lucidly written and comprehensively researched, this guidebook up-ends rigid notions about bipolarity versus depression and provides cleardirection and evidence for eective treatment options. It belongs on

every practitioners bookshelf. Jana Svoboda, LCSW, Clinical SocialWorker, Samaritan Family Medicine Resident Clinic

Engaging, wise, and superbly practical, this book addresses thecomplexity of the subject matter while providing an accessible guidefor a range of health professionals to improve the treatment of mooddisorders. The author integrates research and decades of clinical experi-ence with a refreshing candor, inspiring you to think. The value of thisbook lies not only in the empowerment of the treating provider, but alsoin emphasizing the empowerment of the individualseeking treatment. Lea Burns, PsyD, Primary Care

Psychologist, Samaritan Family Medicine ResidentClinic

A Spectrum Approach to Mood DisordersNot Fully Bipolar but Not Unipolar

Practical Management

How to understand your clients true illnesses, not just their DSM checklists. Though the DSM discusses thecriteria for mood disorders in absolute termseither present or absentprofessionals are aware that while suchdichotomies are useful for teaching, they are not always true in practice. Recent genetic data support clinicianslongstanding recognition that a continuum of mood disorders between unipolar and bipolar better matches real-ity than a yes/no, bipolar-or-not approach. If we acknowledge that continuum, how does this aect our approachto diagnosis and treatment?

In A Spectrum Approach to Mood Disorders, nationally recognized expert James Phelps provides an in-depthexploration of the signs, symptoms, and nuanced presentations of the mood disorder spectrum, focusing on thebroad gray area between Major Depression and Bipolar I. Combining theoretical understanding and real-worldscenarios, Phelps oers practical treatment guidelines for clinicians to better understand the subtle ways mooddisorders can show up, and how to nd the most benecial path for treatment based on the patients individual

pattern of symptoms.Is it trauma, or is it bipolar? Borderline? Both? Phelpss expertise and wealth of personal experience provides

readers with unparalleled insight into a subject that is by nature challenging to dene. His emphasis on non-medi-cation approaches, as well as chapters on all the major pill-based treatments (from sh oil to lithium to the avoid-ance of atypical antipsychotics and antidepressants), creates a comprehensive resource for any clinician workingwith patients on the mood spectrum. Appendices on the relationship between bipolar diagnosis, politics, andreligion; and a plain-English approach to the statistical perils of bipolar screening, oer further value.

Phelps has written an invaluable guide of the critical information professionals need to treat patients on themood disorder spectrum, as well as a useful tool for highly motivated families and patients to better understandthe mood disorder that eects their lives. This book seeks to alter the black and white language surroundingthese mood disorders to inuence a shift in how patients are diagnosedto insure that treatment matches their

specic needs.

bipolar or borderline (or ptsd or adhd)?

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