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Ask the Mental Health Expert Archives 2001-2004

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Antisocial Bipolar Patients

Q. Bipolar patients without psychotic symptoms seem to be just like antisocial patients. When the bipolar patient is on lithium or a mood stabilizer they often become the person you knew was in there.

I realize there is a lot to it, but it seems so many adolescent patients who are ADD (attention deficti disorder) or ADHD (attention deficit hyperactivity disorder) are now also bipolar. By the time they are 18, they now are borderline or antisocial. I am a nurse and I am not sure how to differentiate the lot of them. Can you help?

A. You are raising some interesting and complicated questions. I agree that some bipolar patients may show antisocial features, but this is usually true during manic or hypomanic phases of the illness. A classic paper entitled, "Playing the Manic Game." [Janowsky et al, Arch Gen Psychiatry 1970; 22:252-6] noted that manic patients may often behave in a manipulative, "gamey", or antisocial manner--but again, these are usually not in evidence when the patient has regained their normal (euthymic) mood state.

In fact, the euthymic bipolar patient often looks back with considerable guilt at his or her antisocial behavior during the manic phase--a feature that clearly distinguishes the bipolar patient from the truly antisocial personality disordered patient.

On the other hand, Faraone et al (Am J Med Genet 1998; 81:108-16) have found evidence of a three-way association among attention deficit hyperactivity disorder (ADHD), antisocial traits, and bipolar disorder-suggesting, perhaps, some common genetic factor underlying these conditions. (Perhaps a generalized impulsivity is common to all three?)

In general, though, I believe that aggression and impulsivity in bipolar patients are linked with states of hyperarousal rather than with antisocial personality traits (Swann AC, J Clin Psychiatry 1999; 60(suppl 15):25-28].

I agree, however, that in younger patients, it's sometimes hard to tease out Axis II pathology (borderline or Antisocial PD) from normal adolescent turmoil; from ADHD; from bipolar disorder! One clue is family history: if this is heavily loaded with bipolar disorder, it raises my level of suspicion in the identified patient.

In theory, ADHD and personality disorders are not phasic conditions; i.e., they are always expressed, to some degree, with minor variation depending on the psychosocial environment. In contrast (again, theoretically) bipolar disorder is phasic, with discernible cycles and periods of normal mood. However, in reality, this distinction doesn't always hold up in younger bipolar patients, who may show ongoing mood instability that does not always fit into neat periods of mania, hypomania, or depression (J. Wozniak MD, Bipolar Options conference, 5/9/03).

Recently, my colleagues and I (notably Dr. Nassir Ghaemi) have developed a screening instrument called the Bipolar Spectrum Diagnostic Scale (BSDS) that we believe is helpful in screening for the softer end of the bipolar spectrum; however, we have not yet tested this in ADHD or Axis II diagnosis populations. You may find a copy of this scale at the website http://www.mdf.org.uk/about/BSD.pdf.

October 2003

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