Inside Bipolar Podcast: Borderline Personality Disorder vs. Bipolar. Why the Confusion?

Meet Your Inside Bipolar Podcast Hosts

Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, “Mental Illness is an Asshole and other Observations,” available from Amazon; signed copies are also available directly from the author.

He is also the host of Healthline Media’s Inside Mental Health podcast available on your favorite podcast player. To learn more about Gabe, or book him for your next event, please visit his website, gabehoward.com.

Dr. Nicole Washington is a native of Baton Rouge, Louisiana, where she attended Southern University and A&M College. After receiving her BS degree, she moved to Tulsa, Oklahoma to enroll in the Oklahoma State University College of Osteopathic Medicine. She completed a residency in psychiatry at the University of Oklahoma in Tulsa. Since completing her residency training, Washington has spent most of her career caring for and being an advocate for those who are not typically consumers of mental health services, namely underserved communities, those with severe mental health conditions, and high performing professionals. Through her private practice, podcast, speaking, and writing, she seeks to provide education to decrease the stigma associated with psychiatric conditions.

Find out more at DrNicolePsych.com.

Episode Transcript:

Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.

Announcer: You’re listening to Inside Bipolar, a Healthline Media Podcast, where we tackle bipolar disorder using real-world examples and the latest research.

​​Gabe: Welcome everyone. My name is Gabe Howard and I live with bipolar disorder.

Dr. Nicole: And I’m Dr. Nicole Washington, a board-certified psychiatrist.

Gabe: Dr. Nicole, today we’re going to be talking about bipolar disorder and borderline personality disorder, specifically, how so many people in the mental health community get them confused. Now, from my perspective, all I can see is that it’s the letters. Borderline personality disorder is abbreviated BPD, and people think that stands for bipolar disorder. And I think this is where the confusion comes in.

Dr. Nicole: You know, you’re always saying how you are almost a doctor because you spend so much time with me. You are so far off on this one.

Gabe: Aww.

Dr. Nicole: So clearly you need to spend some more time studying. These two things are quite often confused for each other.

Gabe: And not because of the abbreviation?

Dr. Nicole: Not because of the abbreviation. I see people all the time who come to me and say, oh, I’ve been diagnosed with bipolar disorder. And as I start digging and trying to figure out, okay, what were these manic episodes like? I soon realized they did not have a manic episode at all. They didn’t have a hypomanic episode. What they are describing to me is a is a history consistent with borderline personality disorder. The misdiagnosis happened somewhere along the way and it just stuck.

Gabe: As you’re talking. One of the things that I think about is the diagnosis flip flop episode,

Dr. Nicole: Mm-hmm.

Gabe: Where people go in and they relate their symptoms and they get a diagnosis. But then as time moves on, as evaluation moves on, as more information becomes available, you realize that that initial diagnosis doesn’t fit and it moves over. It sounds like what you’re saying is that one of the initial diagnoses that sometimes people get for borderline personality disorder is bipolar disorder, is does it work in reverse, or are there people who are diagnosed with borderline personality disorder that actually have bipolar disorder?

Dr. Nicole: You know it could work in reverse. I don’t see that as often. What I see more often is someone who has borderline personality disorder, and for whatever reason, they are diagnosed with bipolar disorder and they sit with that diagnosis. It gets on the record. People just kind of pass it on from person to person. They tell people, oh, I have bipolar disorder. And maybe nobody takes the time to really try to. So, they kind of go with that. Unfortunately, or fortunately, I’m, uh, side eyeing everybody all the time. So, I am always like, oh, you have bipolar disorder. What kind of symptoms did you have? Like, I need to make sure if I say you have bipolar disorder that it gels, it tracks, it makes sense. And if it doesn’t make sense, then we got to figure this thing out.

Gabe: All right, Dr. Nicole, as you pointed out, hanging out with doctors does not make me a doctor. I want you to know that that hanging out with Gabe doesn’t make you bipolar.

Dr. Nicole: [Laughter]

Gabe: I know you’ve been telling people that. I’ve. I’ve heard it out there on the circuit. I just the circuit. I’m making air quotes. But let’s go ahead and define our terms medically. We everybody listening to the show is very well aware of bipolar disorder, but borderline personality disorder, something we’ve never talked about before. What is borderline personality disorder?

Dr. Nicole: It’s a personality disorder. Right. So that in and of itself tells you it’s more pervasive. It’s more consistent. You know, we talk all the time about bipolar disorder being an episodic illness. There are episodes you have who you are Gabe at baseline. Who is Gabe normally. How does Gabe respond to the world? How does Gabe think? How does Gabe feel? How does gate behave? That’s who you are. And then you have these episodes that you experience. You experience depression episodes. We know what depression looks like. No real confusion there. And then you have either hypomania or mania. So, you have these manic episodes or these hypomanic episodes, but they’re episodes, they’re distinct periods of time. They are different than who Gabe is. Normally they’re a change from your baseline. They’re different. Somebody who knows you and loves you and spends enough time around you. Your wife would be like, huh, okay, this is not normal. This is different because it’s different. It’s an episode. It’s distinct, it’s defined, it has edges. We can say, oh, that’s the perimeter of that episode. With a personality disorder, it’s more of a pattern of behavior. It’s more of kind of who you are at baseline. And if who you are at baseline is a little unstable, that’s where it gets to be a little bit tricky. So, a person who has borderline personality disorder, it really at the foundation of it, there’s a difficulty or an inability to control themselves, to manage their feelings, to manage their actions. You may see a lot of impulsive and reckless behavior. I like to describe it as your internal thermostat being off. So, a thermostat being that thing that allows you to maintain your temperature on the inside, it allows you to maintain your mood stability. For a person who has borderline personality disorder, that thermostat may not function well all the time. So, their internal temperature, their mood, the way they behave, the way they act is often affected by the things going on outside of them, not necessarily themselves being able to regulate that.

Gabe: Obviously, I know a lot about living with bipolar disorder as that’s my diagnosis. As I’m listening to you describe borderline personality disorder, I think that that’s not even close. That’s that’s how do people get these confused? You’ve I, I swear, it’s like getting the flu mixed up with a broken arm. I’m going to I’m going to accept your base premise that these two things get confused all the time, but they sound so different. They just sound so very different.

Dr. Nicole: I don’t know if it’s like the flu and a broken arm, but maybe it’s like the flu and a common cold or a flu and allergies. Right? So

Gabe: Okay, okay.

Dr. Nicole: For both, you might walk in and say, my nose is runny, I’m a little stuffy, right. But the flu comes with so much more then runny nose. You know, there’s fever. There’s there’s more severe things going on. The it’s similar but different. So, one of the places and really I think the biggest place where people get confused is because there are mood swings. With borderline personality disorder.

Gabe: Oh, okay.

Dr. Nicole: Their disorder there. Their their mood swings. They’re swings, though. People with bipolar disorder do not have mood swings as part of their bipolar disorder, they have mood episodes, they have mood shifts that we’re talking whole shifts, right? Swings happen with borderline personality disorder, but they’re usually in response to what’s going on around them. They’re in response to stress. They’re in response to relationship stuff. They’re in response to work stuff. They’re in response to things that internal thermostat not being regulated. There’s lots of swings because everything can affect them so deeply in a way that really doesn’t make sense to a lot of other people. So, remember when we talk about misdiagnosing bipolar disorder, there are so many people who just think, oh, a bipolar disorder, you just have a lot of mood swings. So how often have you not heard someone who has mood swings and somebody will say, oh, that person’s bipolar. Oh, that person’s bipolar. If they go off on somebody at the post office that, that, that may maybe they do have it, but that doesn’t give me the evidence that they have it.

Gabe: This does go back to the all the Gabes of the world are not actually doctors, right? Because even as you were talking and you said people with bipolar disorder don’t have mood swings, I was like, oh, you misquoted that. You meant to say borderline personality disorder. And then as you explained more, I was like, oh, I was wrong. And then of course, you finished up your analogy with that means we’re reporting this wrong to the people around us and to all of our Dr. Nicole’s. So, I can see how this would happen, where I would just walk in and say, I’m having mood swings all over the place. You know, sometimes I’m happy, sometimes I’m sad. And somebody would be like, oh, well, that that sounds like bipolar disorder, because in that little tiny chunk, it does. This is where, of course, the follow up questions become exceedingly important. And of course, that part is on the Dr. Nicole’s of the world.

Dr. Nicole: Yes.

Gabe: But this is where the answers to those follow up questions become exceedingly important. And that’s on the gables of the world. And I know a lot of times when my doctors ask me questions, I just give like real quick answers.

Dr. Nicole: Mm-hmm.

Gabe: Well, do you have mood episodes? Yeah, sure. I was happy in the morning. I was sad at night, and then I was mad at my uncle. So. Yeah. Yeah, that’s a but I’m not actually defining my terms. How do we come together? Because I, I see exactly how this misunderstanding occurs. And I got to tell you from my vantage point right now, it seems very 50, 50, like both sides are contributing to this misunderstanding. How do we how do we meet in the middle?

Dr. Nicole: Yeah, I agree it is definitely a both sides thing. Unfortunately, the questioning can be wow, it can be very frustrating. Uh, because the person who’s trying to explain to me what they’re experiencing, sometimes it’s hard for them to explain and I’m not frustrated with them. I’m frustrated that I can’t figure it out very quickly, that there are times when a person is telling me about their episodes and they are so descriptive and they’re so textbook that I automatically know, oh yeah, you have had bipolar, you, you’ve had a bipolar episode, you’ve had mania, you’ve had hypomania. There are times, honestly, a person has said to me, oh, I have bipolar disorder. And I’ve thought, hmm, I bet you haven’t. But tell me why you think you have. And then they give me the history and I think, oh my gosh, that sounds pretty classic. Like a manic or a hypomanic episode. Like, yeah, that, that that absolutely sounds like that. But then there are times when the person just isn’t great at explaining it. It’s hard because you if it was a manic or a hypomanic episode, you just may not have the memory to be able to explain it in a way that does it justice.

Dr. Nicole: You may minimize it. You may make it sound like mood swings, like, hey, I’ll be fine. And then, you know, all of a sudden I’m just kind of angry, and then all of a sudden I’m like in a really great mood. And then all of a sudden I’m. I’m sad. You may describe it that way, but it could actually be that it was a full episode and you just don’t have the memory to go with what you’re describing. So having a person there who was there for the episodes, that would be nice, because oftentimes if you’re having trouble really giving me the mania hypomania history, sometimes having a loved one there who’s kind of watched you through it all, they’re the ones who can answer some of these questions a little bit better. So maybe involving somebody in that initial evaluation, having someone explain to you so you can explain to the doctor what it is that they saw during those episodes. Maybe that can be a place to help the patient understand a little bit better.

Gabe: It’s always fascinating to me that it always comes back to this self-reporting. Bipolar disorder is so cruel, because the way that we can get the best help is to give our Dr Nicole’s the best information. But of course, we’re not in a position to deliver the best information. Our brains are compromised. Something’s going wrong. We’re living with a severe and persistent mental illness that changes our perspective, that impacts our ability to understand what’s going on. And it would be wonderful if there was always somebody who witnessed these things who could say, yes, I saw my loved one do this. But there’s a couple of problems with that. Some sometimes the worst symptoms are just not done around mom. They just aren’t right. You know, hypersexuality is often not experienced in full view of your mother. You’re hiding these things. You’re away. If there’s a mixture of drugs and alcohol. These just aren’t the kinds of things that you’re doing with family members or friends. And then we get into they have their own biases mixed in. Maybe the manic episode hurt them. So now they’re relating the story with

Dr. Nicole: Right.

Gabe: Their own trauma, with their own pain. So

Dr. Nicole: Right.

Gabe: It again, it I you know, there’s not a good ending here except

Dr. Nicole: Yeah.

Gabe: To say you can see how this keeps happening over and over and over again.

Dr. Nicole: I think even through emotionally charged information, I can still pull things out. Mom may not have been around for some of the more intense behaviors, but mom may be able to say, and he was calling me all night long and calling me. He was up all night. He was calling me saying ugly stuff, or he was calling me and cursing me out. And I might say, is that something he does frequently? And she’s like, no, he never does that. So, it

Gabe: That’s a really good point.

Dr. Nicole: It gives me glimpses into what is going on. Or if mom says, and I thought he was on drugs because he was talking super-fast and I’m like, is that how he is? Normally no, that’s not how he is normally or you know, we have our arguments. But like, he was calling me all kinds of bad names and he was cursing at me and he was accusing me of stuff that I, that I didn’t do. Is that normal for him? No, that’s not how he normally is. So those are the kind of things sometimes that I can pull out of the emotional stuff. So, it doesn’t matter a lot of times if the family members can be, uh, can be objective in what they’re telling me because I know they can’t, uh, their feelings were hurt. They’re scared. Um, sometimes they make things bigger than I think they probably really were because they’re scared. And they want to make sure I understand how important things are, uh, to them. And so, I but so I have to kind of tease out like, okay, that’s feeling that sounds like a fact. That’s feeling. Oh, that’s definitely feeling. Oh, these are facts. So, I can pull those things out and kind of still get that information. A lot of times we do say, well, it doesn’t really matter. You know, labels blah blah, blah, but this is the place where it absolutely matters, because the treatment for borderline personality disorder and the treatment for bipolar disorder are so complete opposite that it absolutely matters. This is not the argument of schizophrenia versus schizoaffective disorder or schizoaffective versus bipolar disorder with psychotic features. You know, those are ones that you can make the argument the treatments are largely the same. So, if we’re not right, we’re still probably going to see some benefit. That is not the case here.

Gabe: So that’s what I wanted to ask you about, Dr. Nicole, because I know that borderline personality disorder, to my understanding, does not respond to medication.

Dr. Nicole: Yes.

Gabe: And we know that bipolar disorder does respond to medication. And there’s this part of me that thinks, okay, then doesn’t this resolve itself quickly if you get the wrong diagnosis because you’re literally giving the person the wrong treatment. So, you should see zero benefit almost immediately and think, huh, I diagnosed them with this. I’m giving them this. It’s not working. Maybe I’m wrong, but I imagine that is just an incredible oversimplification.

Dr. Nicole: Well, I mean, if you are treating someone for what you think is bipolar disorder and they’re not seeing benefit, they’re still feeling a little all over the place. They’re still feeling like they’re swinging all over the place with their moods, their impulsiveness is there, the recklessness is there. That stuff is still there. At some point you do have to question, okay, now what is this like, what am I doing? So that is a question that we ask ourselves often. The complicated part is sometimes people who have well, a lot of times people who have borderline personality disorder also have these other disorders kind of going hand in hand. They have depression, they have anxiety, they have PTSD. A lot of people with borderline personality disorder have a trauma history. So sometimes the treatments can help a little bit. And then it gets even more confusing because they tell you, well, I have a partial response, or I, I felt better for a little bit and then it got worse again. So, it really, really is very complicated. But it’s super important to know what am I treating because we have to be able to get on the same page.

Gabe: All right. Since you called me out for not being a doctor, I want to learn a little more so that next time I get it right and I can be closer to being a doctor. You mentioned mood swings, and we’ve mentioned that the treatments are different, but are there any other similarities between borderline personality disorder and bipolar disorder?

Dr. Nicole: Yes. Uh, impulsiveness is one of them. Right. So, people who have borderline personality disorder have a pattern of impulsivity, spending, the risky sex act, substance use. But that impulsivity, again, it’s more of a constant of who they are. So, a person who has bipolar disorder, maybe they have risky sex and they’re promiscuous during a manic episode, but when their mood is normal, or maybe even when they’re depressed, these things aren’t happening. So that risky sex activity is isolated to that episode, that defined episode. But a person who has borderline personality disorder may have a pattern of just reckless kind of promiscuity that really exists regardless of mood, episode, good mood, angry, sad, whatever that looks like. So again, it’s that pervasive nature of those symptoms. Another place where we see, uh, similarities is that a person who has bipolar disorder can have psychosis, they can have hallucinations, they can have paranoia, they can have other delusions. But those things are limited by definition. They’re limited to either the severely depressed episode or they’re limited to the manic episode when that person is in a normal mood state my favorite word euthymia, uh, when they’re in that, in that normal mood state. That stuff isn’t there for a person who has borderline personality disorder. They can have these, uh, transient psychotic symptoms. So, they may report hearing voices or being paranoid or things like that.

Dr. Nicole: But those things are often related to moments of increased stress. Uh, they’re limited to stressful situations, strong emotions, not necessarily as constant or consistent as you see them in someone who has true psychosis. So those are two other kind of symptom sets that that could make it difficult to tell. Because if I’m the doctor and I’m asking you, so tell me, have you had episodes where you did things that were, you know, risky behavior, you know, out-of-character, risky things, you know, lots of spending, uh, risky sex acts. And they go, oh, gosh, yes. Sometimes I, you know, I go through these moments where I’m like, spending like, crazy. And I’m, you know, sometimes I’m promiscuous, and then afterwards I’m beating myself up because I’m thinking, what did I do that could sound like bipolar disorder on the surface? If I ask you if you’ve ever had, you know, psychosis during one of these episodes, you might say, yes, when I’m when I’m very angry, you know, I will hear voices or I will get really paranoid. And I may go, oh my gosh, that sounds like a manic episode for sure. But it’s the it’s the additional questions that I have to ask to tease that out.

Sponsor Break

Dr. Nicole: And we’re back discussing the complicated relationship of bipolar disorder with borderline personality disorder.

Gabe: As you were talking, I can really start to see how difficult this would be, because there’s some people that like, well, I have risky sex all the time, but I don’t have a problem with it. So, it’s just it’s their hobby and

Dr. Nicole: Right.

Gabe: That’s their choice that they’re allowed to make. But the reason that I bring that up is because often we lie about that. We’re in front of a doctor, our parents, our friends, the older generation, people who we know are judgmental

Dr. Nicole: Yeah.

Gabe: And we feign that it’s a problem. We’re like, oh yes, I feel bad about it when actually we don’t. We’re just we’re just 22 and talking to a 45-year-old doctor who looks like our mom. And yeah, we kind of feel like she’s judgmental, even if she’s not. We’ve just internalized society’s weird sex messages where we use sex to sell gum. But it’s also wrong to have sex except for procreation. So, I bring that up just because that’s another element to all of this. But I also bring it up because specifically, what you said about the difference between borderline personality disorder and bipolar disorder was this idea that you go back and forth. So, if I understand correctly and please remember not a doctor. So, you have to correct me in borderline personality disorder, this is just sort of your resting state. You’re doing something often that you often regret. We’ll just we’ll just go with that. So, you’re often having promiscuous sex and you’re often regretting it. Whereas with bipolar disorder you have large swaths of time where you’re not having promiscuous sex and you’re good with that. And then you have an episode where for a couple of weeks or a couple of months, you do it that ends, and you reflect back and think, why did I do that? That is so out of character for me. Am I describing those two differences accurately?

Dr. Nicole: It’s not quite that cut and dry, but you’re on the right path. It if you think about it, the manic episode where that’s a key part of the mania, there’s also going to be the other mania. Things like I didn’t need as much sleep, I had more energy during those times. I whatever those other mania symptoms are that you had during those times. So, it’s not just that one thing. It’s all the things together in a cluster that makes us go, oh, okay. That’s what that is. Remember the person who has borderline personality disorder, it’s impulsive. So, it may not be that they thought, I’m going to, but it may be that, oh, I met this guy tonight and, uh, that’s what happened. Or I met this girl tonight and it’s going down, and it wasn’t something I planned afterwards. I’m like, uh, do I feel bad about it? Maybe I do, maybe I don’t, but it’s the impulsivity of it. It’s the it’s the impulsive nature of what is happening. It’s the impulsive nature of the spending. It’s the I don’t have money for this. I’m buying it anyway because it makes me feel good. You know, I’m going to do it anyway. Uh, it’s the impulsiveness of it, and it’s the fact that it’s more pervasive and not limited to these episodes.

Gabe: I’m really starting to see how difficult this is from your perspective because, for example, your example of impulsivity and spending, well, you recognize that retail industry has made $1 billion profit every year on the impulse buy aisle. This is why candy bars are

Dr. Nicole: Yeah.

Gabe: Right next to the register. They’re trying to get you to make an impulse buy on the way out. Now, of course, what we need to be thinking about is there’s a vast amount of difference between an impulse buy of a snack or even the impulse buy of something that’s, you know, ten, 20, 30, $40 and impulse buying a car. Uh, impulse buying a vacation, impulse spending your rent money. Money that is earmarked for other things.

Dr. Nicole: Yes.

Gabe: But I can see where somebody might come in and think, well, do I have impulse spending? Sure. America has impulse spending. Why could why should I see this as anything more than just typical? I think it’s a problem of using the same words to mean different things. I am really curious, Dr. Nicole, can you have borderline personality disorder and bipolar disorder? We’ve always talked about them as being mutually exclusive up until now.

Dr. Nicole: Oh, Gabe. And there is a complicated, uh, situation there. Absolutely. A person can have borderline personality disorder and bipolar disorder, and that is so tricky to be able to tease out what’s causing what. So unfortunately, this is what happens. Person comes in, they give you history, you think, oh, you definitely have this thing. We’ve talked about how if we if we think first, the thing is bipolar disorder, we might give this person a bunch of medications. They might see some benefit but not full benefit. And sometimes we’re going just down way, way, way down the wrong road with these folks. And then they’re back and they’re like, ah, I don’t know. Remember, there are lots of mood swings related to outside things with borderline personality disorder. So, a person might come in one week and they say, I’m doing really great. My meds are working. This is fantastic. You know, life is going really well, but that’s because life is going really well. People who have borderline personality disorder are often very reactive to what’s going on around them. They really struggle with maintaining that internal consistent temp. So, the next month you see them, they may say, oh my gosh, life has been really terrible because maybe there’s been relationship issues, maybe there were issues at work, whatever it is that’s going on that’s stressing them out and they’re like, oh no, I’m horribly depressed. Like my meds aren’t working anymore. And there’s always the temptation to change the meds, change the meds, change the meds. When we figure out, oh, this is borderline personality disorder. Then we start having conversations about, you know, I don’t know that we need to change the meds every time you have a shift. We need to be more intentional about. Is this a mood episode? Have you been feeling this way consistently for you know, how long? What are the symptoms? And you start to learn the person, which is why I’m always harping on the importance of having one person manage your mental health for an extended period of time, if you can.

Dr. Nicole: If you have that luxury, do that because that’s where you get to see patterns. That’s where I start to notice, you know, when these things go on, your mood goes kind of out of control. And it doesn’t seem like those are medication things that we can affect. But it does seem like when you start to have trouble sleeping, that’s where we know maybe you’re inching into a mood episode, but I only see those patterns when I’ve seen a person for a while. In the same vein, someone who has both, they usually takes me a while to figure out like it. It really, really usually takes me an extended period of time to figure out that it’s both. So maybe we get the bipolar disorder under a little bit better control, and then all of a sudden I’m seeing these borderline personality disorder traits popping out at me, and I’m thinking, oh, I didn’t see these before. And maybe that’s because you were in such deep mood episodes. I couldn’t see it. And then all of a sudden I can see it and we can start having conversations, and even then we have to go through the every time we visit the conversation of, okay, is this an actual mood episode that we can affect with medication, or is this your borderline personality disorder? And are you just having difficulty kind of reacting to the world around you and interacting appropriately? It’s not it’s not easy by any means.

Gabe: And I don’t think anybody should expect serious and persistent mental illness to be easy. But the closer you get to what’s actually wrong and getting the correct treatments is, the closer you’re going to get to recovery. I’ve said it before, and I’m going to say it again. I’m dragging out the soapbox. I wish we did sound effects on this show.

Dr. Nicole: [Laughter]

Gabe: I so often people believe they’re just like, look, I went and saw Dr. Nicole. She gave me a diagnosis. I took the pills. Why am I not getting better? And I think this is the exact wrong mindset to have. You need to have the mindset of I am vigilant, I am on guard. I am going to dig deep and this is going to take a long time. People always write me back and like, well, what if it doesn’t take a long time? That’s fantastic. Are you kidding? That is awesome. You beat the curve. I, I don’t think there’s anything wrong with entrenching yourself into I am fighting a war. And hey, it might be the six Day War, and that would be fantastic. I, Dr. Nicole, I’m. There’s a lot swirling in my head. There’s a lot. And one of the things that kept coming up over and over and over again which which I’m not 100% sure what to do with, was the amount of stigma in the mental health community towards borderline personality disorder. So many people with bipolar disorder were like, well, they say that I had borderline personality disorder and I can’t believe they called me that. Can you believe that? I’m not one of those people. I have bipolar and that’s serious. And I think, oh, oh, could,

Dr. Nicole: Yeah.

Gabe: Could, could you imagine if somebody said they tried to diagnose me as one of those bipolar people, but I just have depression? Can you believe they did? Those same people would be up in arms with

Dr. Nicole: Yeah.

Gabe: Stigma. Discrimination. Can you believe this? I just, I

Dr. Nicole: Right.

Gabe: I’m not asking you to answer why there’s so much discrimination towards borderline personality disorder, but

Dr. Nicole: Well,

Gabe: You’ve got to have some thoughts on this because I know you’ve seen it as well.

Dr. Nicole: But. But just to be clear, these things happen at every level. There are people with depression. They said I had bipolar; I don’t have that. Like I don’t want to have bipolar disorder. There are people who have bipolar disorder with psychotic features who may have been told they had schizophrenia, and they’re all ticked off. How dare they say that I have schizophrenia? I mean, we see it in the substance world. My patients who, uh, are, are drug users will go to an AA meeting and will, depending on the culture of that meeting, will all but be told like, oh, no, we’re alcoholics here. We’re not drug addicts. You need to go to an AA meeting like we do it at every level. We do it at every every level. Uh, but I will tell you, back when I was in training, if I even tried to broach the subject of borderline personality disorder with a patient, I might get cussed out like the reality I just might have gotten cussed out, just to even bring it up.

Gabe: Wow. Just just like that? Of everything that happens, that’s the one?

Dr. Nicole: Yeah.

Gabe: [Laughter]

Dr. Nicole: like if I was to say, you know, I have been seeing some patterns, have you ever considered? And there’s a screen that you can do with patients to kind of show them like, oh, this is how you scored on this screen. But I’ve gotten cursed out before about mentioning it. I will say there’s been a shift in theory over the last several years, maybe the last decade. Because now when I bring it up, people aren’t as angry about it. They aren’t like, oh my God, you’re telling me I have a personality? So, you know, because I think that feels like, oh my God, you’re attacking who I am. Like, at least if I have bipolar disorder, it’s a disorder. You can treat it with medication and you know, it’s a thing and we recognize it. It’s an illness. But people hear personality disorder and they think, oh, like you’re attacking who I am. You’re attacking me as a person. This is not like some disorder. And I think we’ve shifted that thinking to, yeah, it’s a disorder. It’s a personality disorder. A lot of times these people have extensive trauma histories at the core of borderline personality disorder, there is this fear of abandonment. Whether it’s real or it may be real, it may be imaginary. And. That is at the core, and sometimes people just really struggle with how they interact with the world, and they don’t like how they keep showing up.

Dr. Nicole: People who have borderline personality disorder don’t like that. They can’t keep friends and don’t like that they don’t have a good sense of who they are. They don’t like that, that everything is always up and down and they feel out of control, but they feel like they have no control over it. So now people say, oh my gosh, like I have this thing, but there’s actual treatment for it. So, there is a type of therapy, dialectical behavioral therapy, that was an offshoot of cognitive behavioral therapy, which was initially designed for people who have borderline personality disorder. So now it’s like, oh, I have this thing. I don’t like how I’m showing up in the world. I don’t like how I treat people. I don’t like how I act. I’m not proud of that, and I want to change it. And there’s a therapy specifically targeting just that. So, I think it gives people a little bit more hope now that they didn’t have before. But yeah, back in the day, I used to I used to get cussed out for bringing up the fact that I even thought a person might have borderline personality disorder.

Gabe: I’m very glad that you brought up the reality check that, unfortunately, stigma happens at all levels and we all need to do better, and I believe that we’re all guilty of it. I have thought before, oh wow, at least I didn’t do that. I have had the fleeting thought of, well, I was never addicted to drugs, so at least I didn’t do that. And even though these are micro, they’re tiny, right? I’m not screaming at people, but I. Why did I think that? Like for some reason my illness is pristine and I’m just trying my best, but everybody else, they got a little fault. Uh, and in reality, I have a little fault too, right? I’ve done some things wrong that I need to take responsibility for, but I also don’t want to be constantly judged for it. And I need to extend that out. And I think that we all do. But thank you so much for, of course, bringing up that we all could do better. It’s not isolated in one area. Unfortunately. I, I’m, I’m trying to frame this as good news. It’s in all areas of patient advocacy.

Dr. Nicole: [Laughter]

Gabe: And mental health advocacy. We all can do better. Dr. Nicole, I first off, I’m sorry that you got I’m always sorry that you get cussed out. I but I got to tell you, I spend a lot of time on the internet reading what people think of their psychiatrist. And frankly, the in-person version is much better than the online forum version.

Dr. Nicole: [Laughter]

Gabe: So just don’t Google anything and you’ll be okay. We’ve touched on so much, we’ve touched on so much. And I kind of want to boil it down a little. Dr. Nicole, what advice do you have for somebody who believes that they’ve been misdiagnosed? Because it’s not as simple as they can just walk in and say, hi, my Dr. Nicole, I think you got it wrong. And I want you to reassess me because psychiatrists don’t like that.

Dr. Nicole: [Laughter]

Gabe: But if somebody genuinely feels that they have the wrong diagnosis,

Dr. Nicole: Mm-hmm.

Gabe: I got to tell you, as a patient, it’s not as simple as walking up to our Dr. Nicole and saying, hey, I think you got it wrong, or hey, I want you to reassess me.

Dr. Nicole: Yeah, I would say do some research on the front end before you show up to that appointment, do your due diligence at reputable sources. Don’t bring in Reddit thread comments as to why you think you were misdiagnosed. But if you have Psych Central articles or Healthline articles, or you have National Institutes of Mental Health or CDC articles or whatever it is that you have from reputable sources, and you can say, this is what I’ve been reading and I have some questions. The second thing is the way you approach it is everything, which in that true for most of life, if you walk into that visit and say, I think you got my diagnosis wrong, I don’t think you know what you’re talking about. I think I have this instead of this that is going to set the tone for a very awkward visit. But if you walk in and say, lately I’ve been questioning if I actually do have bipolar disorder, and I think I may have borderline personality disorder. And these are the reasons why that’s a whole different conversation that sets the tone for a totally different vibe in the room. And the third thing is, remember that discussion doesn’t have to be just that one time and it’s done. That can be a discussion of, can I maybe get on your schedule a little more frequent over the next few months while we figure this out? Because I really do have concerns that maybe the reason I’m not seeing benefit is because maybe there’s something else. Be open to the idea that maybe both things are present. Maybe it’s not one or the other, maybe it’s a combo. Maybe you’re one of those combination people. Uh, be open to the discussion. Be open to what your psychiatrist has to say, and just start the conversation.

Gabe: Dr. Nicole, you never cease to amaze me. It turns out that going to medical school really pays off. I honestly thought I could learn as much as, you know, just by being your podcast co-host. And it just it just turns out that that’s not true. I, I say that joking. I

Dr. Nicole: [Laughter]

Gabe: Honestly knew that I was not a doctor, but it’s easy to get in that mindset that

Dr. Nicole: Yeah,

Gabe: You’ve done a lot of research, you’ve done

Dr. Nicole: Yeah.

Gabe: A lot of reading, and I don’t mean reading on conspiracy theory websites. I mean, you’ve stuck to the National Institute of Mental Health, the Health Centrals, the Psych Central’s, you’ve done the right stuff, and you’re starting to think, hey, I think I’ve got this. And

Dr. Nicole: Mm-hmm.

Gabe: We have phrases like, I’m an expert in my own lived experience. I’m an expert in my, my bipolar disorder. And you are you can be an expert in your mental illness, in your bipolar disorder. But we’ve got a lot to learn. And that’s where that partnership really, really, really pays huge dividends. Dr. Nicole, any last words?

Dr. Nicole: Just be open. That’s all I can tell you is to be open. Because these are very complicated concepts. Misdiagnoses do happen. Be open.

Gabe: Thank you everybody for tuning in. My name is Gabe Howard, and I am an award-winning public speaker. And I could be available for your next event. And listen, I’ll bring Dr. Nicole if you ask me to. I also wrote the book “Mental Illness Is an Asshole and Other Observations,” which you can get on Amazon, but you can get a signed copy with free show swag. Or learn more about me by heading over to gabehoward.com.

Dr. Nicole: And I’m Dr. Nicole Washington. You can find me on all social media platforms @DrNicolePsych, or at my website, DrNicolePsych.com.

Gabe: Dr. Nicole and I need a huge favor. Wherever you downloaded this episode, please follow or subscribe to this show. It is absolutely free. And while you’re in the favor giving mood, we need another one. Recommend the show in those forums. In those support groups. Hell, send somebody a text message because sharing the show is how we’re going to grow. We will see everybody next time on Inside Bipolar.

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