After the child is sick, his temperament changes greatly, he is impulsive and irritable, is it bipolar disorder, or borderline personality disorder?

Text | He Rihui

Publish | Sunny day psychology

01. Is it bipolar disorder when a child loses his temper and scolds his parents?

Some children originally have a gentle personality, very obedient and sensible, but after the appearance of mental and psychological symptoms, the temperament changes greatly, the mood is very unstable, impulsive, sensitive and irritable, and always lose their temper because of a little thing, and even smash things at home and scold their parents.

Some patients have difficulty controlling their emotions, frequent self-harm, self-injury, shocking wounds on the body, parents are both sad and worried.

For adolescent patients with the above conditions, what kind of mental and psychological disorders do they have? This is a question that many patients and families are confused about.

Many psychiatrists regard this part of the patient's irritability and emotional agitation as hypomanic/manic episodes, and they have had a major depressive episode, so many psychiatrists will diagnose these patients with bipolar disorder.

Many parents do not know about "bipolar disorder", but by asking a psychiatrist or searching on the Internet, they find that bipolar disorder is a "serious mental illness". Many doctors say that it is very difficult to cure this disease, and even "need to take drugs for life", "heritability is as high as 80%" and so on.

Parents are very anxious, fearful, and full of doubts: How can my child become a person with severe mental illness when he is not so serious?

Some parents also learn about "adolescent borderline personality disorder" in the process of seeking medical treatment, and find that their children also have many symptoms that meet the diagnostic criteria for this personality disorder.

Moreover, Brace, an associate professor at Harvard Medical School and a well-known expert on adolescent borderline personality disorder in the United States, also said that in the United States, many adolescents with borderline personality disorder are misdiagnosed as bipolar disorder, resulting in a lack of targeted treatment. If these adolescents can get a timely and correct diagnosis, combined with professional dialectical behavior therapy (DBT), their symptoms can be greatly reduced, and even gradually recovered.

After seeing this information, many parents are even more puzzled: Has my child been misdiagnosed? Could it not be bipolar disorder, but "adolescent borderline personality disorder"?

In fact, this part of the parents' doubts is not unreasonable. Because from the perspective of precision psychopsychology, it is inappropriate for many patients to be diagnosed with bipolar disorder, especially adolescent patients.

Many psychiatrists interpret tantrums and beatings as "irritability" as one of the symptoms of hypomanic/manic episodes, and then make a diagnosis of bipolar disorder.

But in fact, this is controversial clinically.

Professor Yan Wenwei, a former psychiatrist at the Shanghai Mental Health Center, once pointed out that the main symptoms of hypomanic/manic episodes are "happy" and "ecstatic", and this high mood can infect others. He said, "Some doctors, no matter what kind of disease, as long as the patient loses his temper and impulsiveness, he thinks it is mania, and adding lithium carbonate or debagin, saying that it is an emotional modifier that can adjust emotions, that is not right."

Professor Sun Xueli, former professor of the Mental Health Center of West China Hospital of Sichuan University, also elaborated on "agitation" and "agitation" in the book "Consensus on the Identification and Optimization of Treatment Options for Bipolar Disorder and Its Atypical Symptoms":

An attack for the purpose of defense is called "agitation", and an attack for the purpose of control can be called "agitation"; "Agitation" is similar to "dog attack", the patient's heart is actually depressed and anxious, and "agitation" is similar to "tiger attack", the patient is angry because he is arrogant and does not allow others to question.

And, if the patient is in a typical hypomanic/manic episode, although they sometimes get angry, when they are not angry, they usually act pleasant, happy, full of plans and hopes for the future, feel good about themselves, and appear positive and optimistic.

Obviously, many adolescent patients do not belong to this situation. Most of the time they are depressed, painful, silent, and sometimes become irritable and angry, because a large number of superimposed psychological trauma is activated, the inner pain, depression, despair to the extreme, a large number of strong negative emotions accumulate uncontrollably burst out.

Strictly speaking, this is a state of "agitation" under extreme pain and depression, not a state of "irritability".

They did not be happy or happy after the emotional outburst, but continued to be depressed, depressed, and did not like to talk like before the tantrums. Some children will even feel very inferior, guilty, self-denial because of their uncontrolled and aggressive behavior, and their depression is more serious, and if there is self-harm and self-injury, the frequency is more frequent.

So, from this point of view, if a patient is diagnosed with bipolar disorder just because of irritability and tantrums, it is likely to involve overdiagnosis. Or in other words, these patients do not belong to typical bipolar disorder, but belong to the "pan-bipolar" type.

02. It is not appropriate to give minors a diagnosis of "borderline personality disorder"

So if the child does not belong to typical bipolar disorder, will it be borderline personality disorder? This depends on whether the child has the core symptoms and features of borderline personality disorder.

The main characteristics of borderline personality disorder are that the patient's mood, interpersonal relationships, self-image, and behavior are unstable, accompanied by a variety of impulsive behaviors, which is a complex and serious mental disorder.

Diagnostic criteria for borderline personality disorder are as follows (refer to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, (DSM-5))

A common pattern of behavior marked by pronounced impulsivity in the form of interpersonal instability, self-image, and emotional instability, begins in early adulthood and appears in a variety of situations with the following 5 (or more) symptoms.

1. Frantic efforts to avoid real or imagined abandonment (note: suicide or self-injurious behavior in Criterion 5 is not included).

2. Unstable, tense patterns of interpersonal relationships characterized by oscillating between over-idealization and over-debasement.

3. Identity disorder: Patients have obvious and persistent, unstable self-image or self-feeling.

4. Impulsive behavior (e.g., cost, sex, substance abuse, driving spree, binge-eating) in at least two areas of potential self-harm (note: suicide and self-harm behaviors in Criterion 5 are not present)

5. Recurrent suicidal behavior, suicidal gestures or threats of suicide, or self-injurious behavior

6. Emotional instability due to a pronounced mood response (eg, intense intermittent irritability, irritability, or occasional anxiety that often lasts for hours or days)

7. Long-term feelings of emptiness

8. Inappropriate, intense anger, or difficulty controlling anger (e.g., frequent anger, anger, fighting)

9. Short, stress-related paranoid thoughts or severe dissociation symptoms

Among them, the core symptom of borderline personality disorder is that patients are very, very afraid of being abandoned by family, lovers, friends, and even favorite teachers. Once they feel abandoned, they are prone to violent mood swings and even extreme behavior. But in fact, objectively, others often do not abandon them.

For example, patients are prone to over-reliance on good friends, or even fawn over them, and even find ways to meet them when friends make some inappropriate requests.

When they give, their friends give praise and recognition, and they are very happy, excited, and think that someone cares and cares about them. But if friends seem to be slightly snubbed and ignore them for some reason, they will be very sensitive, produce strong negative emotions, and accuse friends of abandoning themselves, and even completely deny the good of their past friends.

If the friend makes an explanation and some compensatory behavior in time, and returns to the patient, the patient's mood will be greatly relieved, and then he feels that the friend is really good and continues to pour out his heart and lungs.

But if friends really don't interact with them, they are likely to have an emotional breakdown, be angry and resentful towards their friends, think that they are abandoned, and then behave out of control, frantically smash things, self-harm, and may even attempt suicide or retaliation.

Of course, the above is just an example of a friend. People with borderline personality disorder are likely to have similar feelings about closer family members, favorite teachers, and even netizens who can chat. Sometimes others just reduce their communication with patients for objective reasons, and patients feel uncontrollably abandoned.

Patients who meet the core symptoms mentioned above are most likely to have borderline personality disorder.

However, for adolescents under the age of 18, whether they can be diagnosed with personality disorders is also controversial in clinical practice.

According to the mainland "Advanced Course in Psychiatry", individuals under the age of 18 cannot be diagnosed with personality disorders. However, DSM-5 (5th edition of the Diagnostic and Statistical Manual of Mental Disorders compiled by the American Psychiatric Association) believes that if the patient's symptoms and characteristics have been present for at least one year, then a person under the age of 18 can also be diagnosed with a personality disorder (except antisocial personality disorder).

Although the above two opinions are not completely consistent, it can be seen that for adolescents under the age of 18, the diagnosis of personality disorders must be very cautious.

Some parents do not understand personality disorders, think that it is just "personality problems", feel as if it is much milder than the "serious mental illness" of bipolar disorder, and hope that their children can be diagnosed with adolescent borderline personality disorder. But in fact, in the clinical practice of mainstream psychiatry, the treatment of personality disorders is much more difficult than bipolar disorder, and doctors know much less about personality disorders.

At present, the "three-axis diagnosis" in psychiatric clinics has not been popularized, and most psychiatrists only look at axis one mental illness (such as depression, bipolar disorder, obsessive-compulsive disorder, anxiety, etc.), lack of awareness of understanding and recognition of axis two personality abnormalities, and rarely diagnose the personality aspects of patients.

Therefore, domestic psychiatrists are rarely able to identify borderline personality disorder, and even if they do, they often have no way to take personality disorder and cannot provide patients with efficient treatment options.

Although the above-mentioned dialectical behavior therapy (DBT) can alleviate the symptoms of borderline personality disorder to a certain extent, DBT is far from popular in mainland China, and there is a lack of truly professional, experienced DBT therapists who can combine mainland society and culture. The vast majority of psychological counseling/psychotherapy in China still stays in traditional CBT, humanism, family therapy and psychoanalytic therapy, which is still very ineffective for personality disorders.

In this case, if the psychiatrist diagnoses adolescent patients with "borderline personality disorder" and cannot provide them with effective treatment, they are likely to carry the label of "personality disorder" all the time and cannot get rid of it.

In addition, people with true borderline personality disorder meet 3 characteristics of personality disorders: severe lack of empathy, severe lack of self-reflection ability, and behavior far beyond social norms.

And the vast majority of adolescent patients I have interacted with have personality abnormalities that have not really reached the point of personality disorders. They still have some self-reflection and empathy, especially when they are relatively emotionally calm; And even when they are emotionally volatile, they don't behave far beyond social norms. Therefore, the diagnosis of personality disorders in adolescent patients is not appropriate.

03. The root cause of borderline personality abnormalities is pathological memory

In fact, whether it is diagnosed with bipolar disorder or diagnosed with adolescent borderline personality disorder, this is a symptomatic diagnosis, which is a diagnosis made by the doctor based on the patient's explicit symptoms and his own experience and knowledge system. If the doctor is more concerned about bipolar disorder, it is easy to put the patient's symptoms in the same position and diagnose bipolar disorder.

However, if we start from the main causes of mental and psychological disorders, from the perspective of precision psychiatric psychology, whether it is bipolar disorder, depression, or borderline personality disorder, this is in line with the etiological diagnosis we proposed - post-traumatic stress response disorder (PTSRD). These patients all suffered a great deal of superimposed psychological trauma during their growth.

For adolescent patients with symptoms of borderline personality disorder, they mainly suffered from superimposed psychological traumatic events related to "feeling abandoned" and insecurity.

For example, we once saw a senior in high school, Xiao Gan, who was diagnosed with bipolar disorder by other authoritative psychiatrists, was very emotionally unstable, was seriously ill, took a variety of psychiatric drugs, and received many modified electroconvulsive treatments, but suicidal thoughts were still strong.

During systematic deep psychological intervention, we found that she had symptoms of borderline personality disorder – a particular fear of being abandoned.

Gan had trusted a psychology teacher, but the teacher later referred her to a new psychology teacher due to job transfers. She soon had a nervous breakdown, believing that the psychology teacher had abandoned her. Of course, the psychological teacher did not inform the patient in advance, there were certain work mistakes, and he also bore certain responsibilities.

When she was a freshman in high school, Xiao Gan's Chinese teacher treated her very well. But when she changed her Chinese teacher in her third year of high school, she felt abandoned again, resented her original Chinese teacher, and became angry and sad as soon as she started Chinese class.

And the reason why she is so afraid of being abandoned and so sensitive to the departure of those around her is related to the long-term absence of her father in her childhood.

When Gan was young, his father worked in the power grid and traveled a lot. Every time Xiao Gan said that he wanted his father to accompany him more, his father always agreed, and described it very beautifully, saying that he would go home soon and would accompany Xiao Gan to play around.

Of course, Xiao Gan is looking forward to it very much, but his father is actually "painting a big cake", just verbally comforting Xiao Gan, in fact, he still can't go home for a long time. Even at home, he rarely accompanies his daughter, leaving his old promises behind.

Over time, Xiao Gan formed a very solid misunderstanding, she thought that she was abandoned by her father, forming a great psychological trauma.

Therefore, once Xiao Gan recognizes the person who feels that he can be trusted, he will take out his heart and lungs and very much hope to maintain a close relationship with the other party. But once others reduced contact with her for some reason, she immediately felt abandoned, became irritable and irritable, giving people a feeling of "great change in temperament". But in fact, this is also the "agitated" state that occurs after the superimposed psychological trauma is activated.

Some people with borderline personality disorder experience strong negative emotions when they feel abandoned. In order to vent this negative emotion, they may also abuse alcohol or prescription drugs, which eventually evolves into alcohol addiction, prescription drug addiction, and so on.

Some patients will also quickly release negative emotions through self-harm and self-injury, and it is not even ruled out that they will resort to suicidal behavior when they feel abandoned. Because they are likely to have catastrophic thinking, thinking that others abandon them because they are not worthy of love, and if they cannot have the love of others, what is the point of living?

In our clinical deep psychological intervention, we found that when the pathological memory repair technology (TPMIH) under deep hypnosis was used to repair their insecurity-related psychological trauma events such as "feeling abandoned", their emotions were greatly stabilized, they were no longer oversensitive to interpersonal relationships, suffering from gains and losses, and were able to get along with others more rationally.

In fact, whether it is depression, bipolar disorder, or borderline personality disorder, it is mainly caused by pathological memory. It's just that the nature and number of pathological memory events are different, resulting in patients showing different psychopsychological symptoms.

With the advent of the era of precision psychopsyche, if effective means are taken to efficiently repair the pathological memory behind their symptoms, patients are fully expected to move towards recovery efficiently and quickly.

As for the prevention of borderline personality disorder, how to get along with patients with borderline personality disorder, how parents can help patients with borderline personality disorder to speed up recovery, etc., we will write articles for detailed analysis later.