How Do You Distinquish between Those Who Are Sick and Those Who are Jerks?
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Q:  How Do You Distinquish between Those Who Are Sick and Those Who are Jerks?

My question is complex and hard to describe. Very basic info: my spouse isn't diagnosed, but being treated for bipolar.  Hospital test was inconclusive but other pointed to possibly borderline personality disorder and there was mention of enmeshing.  How do you distinguish between those who are sick and those who are just either jerks, drama queens, covert aggressive, etc.?  If there are huge spectrums and overlapping disorders ,etc, where is the accountability?  This is a huge moral dilema for the victimized family.

Dear Ms. P. --

Indeed, the diagnostic distinction between jerks and "sick" bothers a lot of people, including courts of law and psychiatric skeptics., Most of all, as you point out, it causes big problems for loved ones. 

This makes everyone want a lab test, something objective, a clear yes or no.  Unfortunately, as you point out, in my business there is no clear dividing line between "normal" and sick (aka "mentally ill").   

On the other hand, sometimes getting a clear answer is not necessary.  As you also suggest, sometimes people simply have to be held accountable for their behavior.  If someone loses their temper and ends up hurting others, he or she is still responsible for dealing with that event: taking steps to make sure that it doesn't happen again.  If the diagnosis is "jerk", then he needs to learn how to behave differently, getting some help (e.g. a psychotherapist, "anger management") if necessary.  If the diagnosis is "bipolar", then he needs to get a different kind of help perhaps, but it is still his responsibility to get it. 

As you will also learn, borderline personality disorder and bipolar disorder are not mutually exclusive.  A person can have both.  Indeed, the circumstances which cause borderline personality disorder can also make a genetic tendency toward having bipolar disorder more likely to express itself. 

So as you will see on my essay about borderline versus bipolar, I think there is more mileage to be had from focusing on treatment options than from focusing on trying to get the diagnosis straight.  You could compare the recommendations into helpful books, as well: Walking on Eggshells, about living with someone with borderline personality disorder; and Loving Someone with Bipolar Disorder, by Julie Fast.  

Good luck with the process --

Dr. Phelps

Published August, 2008


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