ID1998 Martin Dunitz Ltd

InternationalJournal of Psychiatry in Clinical Practice I998 Volume 2 Pages 67 - 68

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A patient who changed my practice: Personality disorder or bipolar disorder? MALCOLM LADER

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Professor of Clinical Psychopharmucology, institute of Psychiatry, London

Correspondence Address Prof. MH Lader, OBE, DSc, PhD, MD, FRCPsych, Institute of Psychiatry, Section of Clinical Psychopharmacology [MRC), De Crespigny Park, Denmark Hill, London SE5 8AF, UK Tel: +44 (0)171 919 3372 Fax: +44 (0) I 71 252 5437

The case of a man originally diagnosed as having a personality disorder is presented Follow-up over many years revealed that he was really sufferingfrom a bipolar manic-depressive disorder which responded well to lithium His later life was characterired by stability. ( h t J Psych Clin Prac 1998 2: 67-68) Keywords lnpolar disorder lithium

Received 19 November 1997; accepted for publication 21 November 1997

first encountered Mr JD when I was a psychiatrist-intraining. I saw him in an outpatient clinic with the provisional diagnosis by my supervising psychiatrist of borderline personality disorder. I was expected to provide regular (every 2 - 3 weeks) supportive psychotherapy. He was then followed up by me for many years. The reason for the initial referral was that he had been caught stealing from his employers by a very clever manipulation of the accounts. This embezzlement had gone undetected for some years, but was episodic in nature, with intervals of several months when no irregularities had occurred. Mr JD had pleaded that he was not in control of his actions and his employers had been generous and agreed not to press legal proceedings providing he sought psychiatric help.

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BACKGROUND HISTORY Mr JD was the son of a clergyman in the west of England. Apparently his family had no history of definite mental illness, although there was some question about an aunt who had apparently had a reputation as an eccentric paranoid recluse. Mr JDs birth and early development were normal and he was a precocious child, being able to read quite fluently by the age of 5 . He also showed great mathematical ability, and was junior chess champion of his county at the age of 8. He first went to local schools and then to a minor public (known as ‘private’ in the UK) school, where he excelled both academically and at sport. However, at the age of 18 when he had obtained very good exam results, he told his father that he had no intention of going to university, and set off on a round-the-world trip. Nothing was heard from him for months at a time, but

eventually he returned, at the age of 25, and appeared to be quite affluent. He refused to give an explanation for his new-found wealth. In the ensuing years he lost all his money, some of it gambling and some of it in speculative investments. He drifted through a long series of jobs, of which he quickly tired, at varying levels of capability; they were mostly clerical, occasionally with financial responsibility. Then he took the job in which he had been caught embezzling money. He had been with that company for 12 years and had had numerous promotions. He had many girlfriends and was attractive to women. His relationships with them were usually stormy, and almost always ended with his breaking off the relationship for no apparent reason. He never resorted to violence, nor did he have any forensic history other than embezzlement. At the initial interview he was accompanied by his current girlfriend, a member of the English aristocracy who was quite bedazzled by him. She described him as extremely intelligent, very good company, extrovert and very popular among the rather idle set with which he mixed. He had used the money that he had embezzled in order to keep up with this well-heeled group. He drank sporadically but could hold his drink, and had a reputation amongst his clique of being a wine expert. He was knowledgeable on many matters and this was a genuine understanding of the topics and not just familiarity with a few catchwords.

ON EXAMINATION The referring psychiatrist had made a diagnosis of abnormal personality (borderline type), and in my junior capacity I saw no reason to change that diagnosis. My role

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M HLader

was to support Mr JD through the various vicissitudes of life, trying to keep him on an even keel. At interview he was in normal mood, somewhat contrite and with some insight into his condition. He believed that he could not really control his irregular behaviour.

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TREATMENT AND PROGRESS I saw him every 2-3 weeks for the next 4 years. There were again episodes when he became unstable. He rented an expensive car and crashed it when drunk, and he had at least two more girlfriends during this time. Then an interview with me proved the turning point. He came in full of grandiose plans, speaking volubly and under some pressure, and with ideas that there were people ganging up against him. The whole clinical picture was typical of mania, which in his case presented very much like his personality-disordered hehaviour but to an extreme. I then reviewed his history and wondered whether the episodes of instability were in fact subclinical mania, and that his irresponsibility and promiscuity reflected a hypomanic type of response rather than a personality disorder.' I put my theory to the therapeutic test. After the usual precautions I established him on lithium and luckily he was compliant with the regimen. His behaviour altered markedly after about 6 months. He became much more stable, but did confess that he missed the 'highs' which had been so much part of his life, and which lent it sparkle and variety. However, he accepted that any chance of stability was worth taking, and stayed on the lithium for the ensuing 12 years. However, he developed heart disease, of which there

REFERENCE 1. Goodwin FK,Jamison KR (1990) Manic-depressive illness 108110. Oxford University Press,New York.

was a strong family history. One day I was phoned up by his partner of 10 years' standing, to be informed that he was in a hospital and dying. I asked what the problem was and was told he had gone into heart failure and been put on a diuretic. Unfortunately the lithium had been continued. I immediately rang up the doctor treating him at the general hospital and asked what the lithium level was.There was a puzzled silence at the end of the line and I had to explain to the newly qualified doctor the dangers of combining lithium and a diuretic. His lithium level then turned out to be nearly 2 mmoV1. His lithium was stopped temporarily and he recovered. About 5 years later he died, having enjoyed something like 15 years of stability in a loving relationship with a parmer and a record of useful work.

COMMENT Since I met that patient I have refrained, as much as possible, from making the facile diagnosis of personality disorder. Whenever 1 encounter a patient whose erratic behaviour is episodic, or in whom there is evidence of depression, I consider the possibility that this is a manicdepressive bipolar type 11 illness, 'in which the hypomanic episodes are subclinical for almost all the time. I believe that this has enabled me to help several patients who had been 'written off as hopeless cases, because the maturation processes which usually help personality-disordered patients had not taken place in them. Instead, the use of a mood-stabilizing medication has put them on an even keel, enabling them to pursue an occupation and establish lasting and satisfactory relationships.

A patient who changed my practice: Personality disorder or bipolar disorder?

The case of a man originally diagnosed as having a personality disorder is presented. Follow-up over many years revealed that he was really suffering ...
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