Cyclothymia as a personality disorder; hormones and moods

I have had a partial response at least to the bupropion. Because of the anxiety it causes, I haven’t been overly eager to up the dose so I am still on half a normal dose. I can’t get anything done and feel bad a lot of the time, but I am not wallowing in my misery nonstop. I suspect I need a little serotonin, but as I have been told many times, it is not my job to be my doctor. I don’t even want to suggest anything anymore.

* * *

Things That Make Me Sad

I have done a few calculations that make me sad; these are calculations that probably should not be done.

For two weeks of every month, I am nearly symptom free.

Then ovulation hits and I have 2-3 days of misery, which slightly abate, but then I have two weeks of slowly mounting depression, darkening of the world.

That means that half my life or so is erased.

Add to that my twice yearly or so major episodes – usually one in September-October (depressive) and one in late March-April (manic).  Each lasts about 2 months.

Where exactly am I supposed to live in between all of this? How much time of being normal can I enjoy? Most of it gets eaten up trying to compensate for the things I ignored during the episodes, cleaning up messes I’ve made, trying to forgive myself.

Then, just as I think I might be alright, it begins all over again.

Is it any wonder they accuse me of having a personality disorder? I think the shrink is sort of right about that, but none of them fit because it’s one that has been taken off the books. I checked. I’m not borderline, I’m sure. Maybe some narcissistic traits, but I don’t lack empathy completely. Histrionic, well, no, I’m too shy for that.

When I was doing the reading on borderline to see if it could be, I was quickly relieved that it wasn’t. I read everything in the medical library, including pulling the original Krapelin and Kernberg out of the archives. There was a book from the 1950s or so that described borderline as something slightly different than today (more in psychodynamic terms and with more of an emphasis on the “psychosis” parts), and I was greatly relieved all around by my reading that the shrink was wrong.

(Please, if you are carrying a BPD diagnosis, don’t get offended, I mostly was happy that he was wrong, not that it’s the end of the world to have it. Also, after a horrible year getting used to the idea of being manic depressive, I didn’t think I could take having to go through that again to something else.)

The relief I felt was visceral – the descriptions just didn’t “click” with me the way that the bipolar ones did when I first read them.

When I first realized what was happening to me, that I was in the midst of a terrifying full manic episode, and steeled myself and went and read all night about manic depression (for about 36 hours straight, mania anyone?), something I didn’t know much about. After a few articles, every time, I was nearly physically ill, had to remove myself from the library to just breathe before passing out.

I saw myself described in such perfectly accurate, pathological terms. Shock – someone who had never seen or met me could so clearly describe my life – I knew in my gut that it was right, that as much as I wanted to, I couldn’t argue with it.

When I went to investigate borderline, I started in the big Kaplan and Saddock (I own only the small one) and then went backwards in time. I did some paper in med school on a psych topic and at that time, I’d read a lot of Krapelin and Bleuler and all of the older psychiatric writings, and I remembered that they were far better observationists of phenomena than we are today. Much of what they realized is forgotten in neurotransmission and the pharmaceutical industry, colored by what we are just starting to know about biology, and often gets bogged down in details while missing the big picture of a disease. They had far better intuitive understandings of various mental states and illnesses than anyone living today because they were scientists, observers, not trying to fit a dopamine theory or a serotonin theory or any other theory to what they saw.

So I had found some old, old book, probably translated from German, on borderline states. Hunched over that dusty volume, I turned page after page on borderline, interested out of curiousity, but after hours losing interest because it didn’t speak to me, wasn’t grabbing me by the heart and shaking me around like first reading about the bipolar syndromes did.

And then I turned a page, and the thing facing me was a chart, this: “Cyclothymic Personality” and I don’t remember  if they called it “disorder,” I don’t think so. I think then they were calling it “Personality Structure.” And I read it. And I got that sick feeling again.

The new thinking in psychiatry separates personality from mood, and cyclothymia has been popped over to mood (from what I can tell, this happened in DSM-III), and you can no longer have a cyclothymic temperament and full-blown mood episodes; having a major mood episode bumps you into the realm of “bipolar” somewhere and “erases” the cyclothymia diagnosis, at least as far as I can tell.

But that seems fairly arbitrary; because listen to this description (which supposedly is validated, see Akiskal’s writings in the late 1990s, and also, for BPDers who are reading along, his writings on BPD as an extension of a mood disorder with bad coping features are also very good, and a thank you to that psychiatrist I met once in New York who gave me Akiskal’s name to read up on).

The Cyclothymic Personality:

  • Lethargy alternating with eutonia
  • Shaky self-esteem alternating between low self-confidence and overconfidence
  • Decreased verbal output alternating with talkativeness
  • Mental confusion alternating with sharpened and creative thinking
  • Unexplained tearfulness alternating with excessive punning and jocularity
  • Introverted self-absorption alternating with uninhibited people-seeking

Then, the non-validated but often cited ones, in Akiskal’s rules of thumb for identifying BP in a depressed patient:

  • frequent shifts in line of work, study, interest, or future plans
  • irritable-angry-explosive outbursts that alienate loved ones
  • extravagant, colorful, unusual dress
  • frequent changes in residence or geographical location

Is it any wonder I look like a personality disorder? I am all over the place, this is what he sees, that sometimes I never shut up and can’t stop joking (and believe me, I grossly overestimate how funny I am), yet other times can barely speak for shyness. Or “I know every single thing in medicine better than anyone else,” versus “I’m terrified and can’t handle anything.” Or, the astounding self-centeredness of something like this blog versus my feelings sometimes of a vast and shattered love and compassion for everyone and everything in the universe.

What about on an existential level? My alternating nihilistic atheism with my sense of magic and wonder and unity and ultimate gratitude and worship at the universe?

No wonder one would think something is inherently unsettled in my self-concept. I always try to explain that it is the mood that is the problem, not me, but no one hears. I don’t feel like I change at my core, rather that the core is filtered through the mood. The mood grabs me and shakes me and twists me around, building me up, tearing me down, over and over again. It is exhausting. But it doesn’t erase who I am, though over time, I’m sure it has changed it some.

I don’t have identity issues. But I think that might be kind of hard for someone on the outside to see, especially someone who trained in the times of DSM.

If I remember correctly, that same book said that most of the way to distinguish between borderline and cyclothymic is that borderline has additional sine-quo-non attributes:

  • the abandonment issues and fear of such, the behaviors that go with that
  • disturbances of self-image: the sense of not knowing who they are/emptiness/fear of disappearing
  • splitting and the black/white worldview

The rest of the criteria can be or not be in either disorder. There are some that tend to be more common in one or the other (big ones: seasonality and sleep changes, more in cyclothymia; rejection sensitivity and unrelenting suicidality in borderline). Mood lability, interpersonal conflict, impulsivity, seductiveness, bisexuality, rages…any of these can appear in either disorder, maybe in slightly different forms, but they aren’t distinguishing characteristics.

* * *

I don’t know where I’m going with this post. I started this post wanting to update on how things are going before I go work another all-nighter, but also wanted to add some content. I doubt it is that informative for anyone – if you’re a shrink you probably already knew it, and if you are a patient, not sure what it could possibly do for you. Maybe I just wanted to point out that who we are is a tricky subject. Or that in psychiatry things need to go back to science and observation, not have theory dictating. Maybe that a system that catalogues pathology without normal workings is problematic in medicine.

I have been on a light schedule since January 1, and it has been both good and bad. Physically, I’ve been able to catch up on sleep, eat a little more healthily, but in a way, the sleep deprivation, while making me terribly unstabile and volatile, kept me out of the worst of the lows. I wanted to ask other women out there what to do about the mood stuff – I’ve tried every hormonal birth control type thing available, and all of them just made things worse. I’d do an oopherectomy in a second if I knew it would make this stop.

So that is the current state – floating, not really sick, not really well. Faith isn’t quite back, worry is still hanging around. Trying to rally some of that enthusiastic energy that has been gone or in rage form for so long to enjoy patients tonight. Not sure I’ll get there by tonight. Sending love to the universe as best I can, hoping some of it will come around to you, and maybe back to me. Until next time…

* * *

* Note: I used the term “borderline” without any qualifiers for several reasons. I find the whole “diagnosis” terribly subjective (and I think it has been shown to be fairly nonreliable though I don’t have a reference on hand), often a result of dislike for a patient, offensive as a woman, and unfair to the patient, who is pathologized, while the person who raped/beat/molested her is left with no stigma. I see patients with the patterns described, but once I let myself see them as “borderline,” I become free to ignore or brush off what they say, to shirk my duty to them. While the syndrome described exists, it is also perpetuated by treating physicians who treat patients as less than responsible adults.

Other reasons: One, in my opinion, “personality disorder” is a perjorative phrase. Two, it looks like the disorder is going to push over to the affective disorders. Three, I didn’t use “emotional dysregulation disorder” or any of these newer terms because they are not yet widely used enough to be easily recognized. Four, I am also discussing historical uses, which did use that phrase in a very different way than it is used now but nonetheless used it for similar phenomena.

I think the suggestion I like best for a new term will never catch on: Mercurial disorder. It’s catchy, one-word, poetic, and descriptive while not proposing a root cause, which we really and truly don’t know. (Emotional dysregulation disorder sounds nice, but do we know that that is the disorder and not an effect of it? Is that the central defining feature? Far from certain.) I used the word myself in a previous post without knowing it had been proposed as a replacement name.

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10 Comments

  1. Hello Sara,
    how long does it take you to write these posts?
    There is one heck of a lot in it.
    Also I like how you discuss the borderline PD and then when making a comment I am writing white letters onto a black surface!

    I find myself going back to your question of some time ago. How long does one keep seeking a solution to their emotional distress.

    Graffiti

  2. Interesting, but I wonder how useful it all is.

    I once had a professor who said of significance, “there are only two questions that matter: So what? and ‘”Who cares?”

    My questions for you would be:

    Of what use and significance are the description and labeling/diagnosis to you?

    How do you envision wellness for you? How do/would you feel, act, think, emote, relate, adapt, live your life when well?

    Are there any experiences in kairos that you can hold onto as exemplars or mileposts?

    Are there points along that perilous journey from unwell to well that have been oases? Can you build bridges from each of these to the next?

    Sometimes I muse that our western society is pathological, and that perhaps, living closer to agrarian habits in communities of about 150 people or so is where we maintain our evolutionary, cultural and societal balances.

    Do you get a dose of “green” every day? Outside, experiencing fresh air, raw weather, natural landscape, birdsong and local wildlife?

    Do you have the opportunity to be exposed to humor every day? Do you have at least one heartfelt laugh every day?

    How about human contact? Do you get and offer hugs, handclasps, etc. with someone with whom you have a relationship other than a brief patient encounter on a daily basis?

    Those types of things seem to me to be part of the fundamental aspects of humanness that I wonder if we have shoved aside.

  3. mercurial. i like it. and maybe the specifiers could be temperate and volatile? 😉

  4. I applaud your ability to really look at yourself as a whole and compare notes with what you’re trying to discover about yourself.

    One thing I’ve heard a lot in my psychology degree is that we have the innate tendency to search for things that we identify with when learning about the various diagnoses throughout the spectrum. I’m not saying you’re doing this, but it is always wise to acknowledge the tendency and take our similarities with the “disorder” with a grain of salt.

    Something you said really tugged at my guts… about how you often feel “normal” two weeks out of a month, aside from the whole yearly cycles.

    I, too, have a potentially terrible two weeks every month, and it’s always relieved when I begin my cycle.

    I don’t know that one can necessarily consider that anything that falls into a category like that as defined as a diagnosis, unless they begin to talk about putting PMS into the DSM. While it would be empowering, somewhat, it might also be debilitating to us as women.

    During those two weeks, I am a mad woman. I am clingy, irritated, hateful, and need validation that I am worthy. I am fearful and tearful and bloated. It’s horrible. Really, really horrible.

    The things I’ve done that mostly help most of the time are to very carefully watch my diet, get off of birth control, and give myself as much sleep as I can. I know that’s next to impossible while you’re working right now, but it might make those bad times a little easier to deal with.

    Also, I’ve noticed that during those bad times, I am exhausted, which means I want to consume more caffeine, which increases all of my crazy-makings, like irritation, irrationality, and anxiety.

    Ah, what a wicked world we live in where the female person is expected to maintain composure throughout a cycle of raging hormones!

    What it comes down to for me is that I often find it terribly difficult to live in a woman’s body.

    I guess what I’m saying is that while I acknowledge what you know to ring true, I also believe that sometimes there is no sense to our monthly cycle, and it is absolutely easy to get caught up in feeling like there is something wrong when it is natural for estrogen to make those of us otherwise rational into irrational crazy-makers. It’s easy to construe the hell women go through every month to any number of diagnoses.

    Hopefully you’ll know that you’re not alone in this struggle. Many of us go there, and often.

  5. Ok, a few quick responses before BED.

    Ash – PMS is in the DSM as Premenstrual (or sometimes “late luteal phase”) dysphoric disorder, or PMDD – mostly because Lilly sponsored lots of trials to get Prozac approved for it, under the name Sarafem.

    About seeing myself in a diagnosis – I know what you mean about how you can read ANY diagnosis and see yourself – like I always get a little chill when I read about narcissism or whatever. But I am referring to something that actually isn’t a diagnosis, and papers in which they describe the average life of someone like that. It was truly sickening. Not just the “Am I paranoid/obsessive-compulsive/dependent?” feeling that you get when you read any of the descriptions, but frightening…almost supernatural.

    Annie – I absolutely agree. When I lived in a close to the equator zone with no car (ie exposed to weather, days of even length), I was much more stable. I really want to get to a more agrarian lifestyle. I don’t write much about it here but I’m a super hippie and want to move more rural than I am now. I am also big on touch. I touch everyone as much as possible, because the person I knew who was the best “people person” I ever met did that.

    As to the thing about what does the diagnosis matter? Well, it is sometimes frightening and sometimes comforting to know that you are “a type.” It is nice to know that, if not MY DOCTOR, than at least some doctor or scientist somewhere has observed this shit and has some ideas about what is going on.

    Tony – these posts take me usually from one hour to three or so, that’s the limit of my attention span and why I have never written anything other than a medium length essay or short-short story. I think I’m a little bit hypomanic now, not that, quite, but a bit of a buzz from after being so down and have been more prolific lately. When I write well (not here, which is just stream-of-thought shit) usually the sentences and ideas come to me, unbidden, and I have to catch them, make notes really fast, before I forget. Then I sit down and write it all out in order. When I write something real, it is an automatic process that can strike at any time and feels rather as if it comes from outside me. I haven’t had that in a while.

  6. Oh – and Tony, the comment form is black and white, but it all comes out on the site in shades of gray 🙂

    And about when to stop pushing to feel better – I was fairly resigned to being always sort of crazy and miserable, until I hit that wonder drug (apparently totally by accident) and had 4 good years. In those 4 years, I managed to live like a normal person, and build a normal life. All the crazy just melted away. This taught me a lot about what goes into a normal life, and hopefully some of the healthier habits stuck.

    The point is, if I hadn’t had that experience, I wouldn’t seek improvement. I would assume that this is “as good as it gets.” But when I know what can be, I can’t help but want it again. I often wonder if it would have been better never to have known what it was like to feel well, seeing how cruel it has been to have had that taken away.

  7. Loving the Mercurial. I assume you’ve tried all the natural PMS things? Evening primrose oil, fish oil (all of course sources of omega 3 and omega 9s). And ditto for the “bionic women” types of birth control? The Mirenas and depos and so on.

  8. I did try the omegas…never noticed a difference. (They are supposed to work as a mood stabilizer all around.) But in the trials, they used doses of like 9 grams a day, and I was taking maybe 3. Evening primrose I didn’t. And unfortunately, I tried EVERY one of those birth control hormones on the market, the low estrogen, all the kinds of fake estrogen, the progestin only, etc (a self experiment a few years ago) and they all made it worse. That was disappointing.

  9. Yes, the doses are quite large. And most of them have directions like “take 2 pills, 3 times a day”. Which makes me wonder why on earth they don’t double hte pill strength (or just make massive, suppository types) if the standard dosage is 2. Duh. Small things, small minds…. Excuse my massive ignorance, but do the fake oestrogens include the various botanicals that menopausal women use?

  10. WOW! You’re right. Our posts are eerily similar. I know you’ve been reading me lately, so you know that Depo-Provera is poison, particularly for those women with mood disorders. I’ve been having problems with my uterus and last year the docs HAD to put me on progesterone for a week to kick-start a period so they could run some tests. I warned them what would happen and I was right, after a week of the progesterone I was hallucinating and seeing ghosts in the bottom of my coffee cup. I kid you not.

    IF you don’t need your ovaries anymore, I would consider an oopherectomy if I were you. I’m having a total hysterectomy in a few weeks and I’m very excited. My tubes have been tied for three and a half years (since the birth of my youngest), because my bipolar WILL NOT tolerate any hormonal therapy. Brutal. I have talked to other bipolar women who’ve had their ovaries removed and then went on low doses of estrogen and been just fine. Happy even. Don’t know if this would be a possibility for you, but it would alleviate your cyclical problems. Give you back almost half of your month.

    Good luck with this. You’ll be in my thoughts.
    -Sophie


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