Rapid Cycling/BPD

[DisorderedDoc417]

Argue what you will. Inherent to the personality disorder diagnosis is the chronic and enduring and pervasive pattern. If you’re Willy nilly applying the diagnosis because they hit 5 of 9 criteria, you’re misusing the dsm.

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[DisorderedDoc417]

The issue from my perspective is, that it never disappears from the chart. A teenager with raging hormones can very well demonstrate "traits" of cluster B personality, but only within the arena of mental health is giving the diagnosis doing more good than harm.

And that diagnosis should be erased from the EMR with demonstrated improvement — I totally agree.

 

[cara susanna]

Thank you for the response. It's interesting because there does seem to be differences between presentations, although perhaps it isn't an entirely different construct. It isn't unusual for the severity of hyperarousal and re-experiencing symptoms to subside with the passage of time. However, there does seem to be interpersonal elements associated with trauma the DSM does not fully capture. I have found exposure-based therapies to help reduce re-experiencing, exposure, and hypervigilance symptoms, but not as helpful when addressing interpersonal deficits.

I agree... I do think that the PTSD diagnosis is very specific and won't always apply to everyone. If I saw someone who had trauma exposure and trauma-related interpersonal deficits but didn't have reexperiencing and hyperarousal, I'd probably give them Other specified.

I often use DBT skills with trauma survivors even if they don't have BPD just for that reason. Sometimes the skills-based approach makes sense, like in situations such as that.

 

[clausewitz2]

Argue what you will. Inherent to the personality disorder diagnosis is the chronic and enduring and pervasive pattern. If you’re Willy nilly applying the diagnosis because they hit 5 of 9 criteria, you’re misusing the dsm.

Pervasive and enduring are perfectly consistent with "amenable to improvement". The category mistake you seem to be making is holding "has been established for a long time" and "permanent" as equivalent.

They are not. I am not sure I can totally make sense of your objection without assuming that they are the same thing.

 

[DisorderedDoc417]

Pervasive and enduring are perfectly consistent with "amenable to improvement". The category mistake you seem to be making is holding "has been established for a long time" and "permanent" as equivalent.

They are not. I am not sure I can totally make sense of your objection without assuming that they are the same thing.

Who is saying things aren’t amenable to improvement? I wouldn’t get them established into DBT and spend hours in and outside of the hospital working with them if I didn’t think that getting better was an option. Let’s not be condescending, eh? We can let pervasive and enduring mean what they mean. If there is confusion, we can always reference a dictionary.

 

[clausewitz2]

Who is saying things aren’t amenable to improvement? I wouldn’t get them established into DBT and spend hours in and outside of the hospital working with them if I didn’t think that getting better was an option. Let’s not be condescending, eh? We can let pervasive and enduring mean what they mean. If there is confusion, we can always reference a dictionary.

So you said this:

If she learns to better regulate mood later in life, perhaps there was an alternative diagnosis.

Which I am genuinely having a difficult time reconciling with:

Who is saying things aren’t amenable to improvement?

You expressed skepticism about the idea of improvement in a ten year time span, which I can understand. I think you have to always keep in mind the overrepresentation in your clinical experience of the small subset of people with BPD who are hospitalized repeatedly and frequently; this is not actually the modal course. I would politely suggest you look at the relevant literature since this is not a controversial point.

If changing over a longish span of time fits just fine with your understanding of chronic and pervasive, what is your objection to making the disgndiag, precisely?

 

[Mass Effect]

So you said this:


You expressed skepticism about the idea of improvement in a ten year time span, which I can understand. I think you have to always keep in mind the overrepresentation in your clinical experience of the small subset of people with BPD who are hospitalized repeatedly and frequently; this is not actually the modal course. I would politely suggest you look at the relevant literature since this is not a controversial point.

If changing over a longish span of time fits just fine with your understanding of chronic and pervasive, what is your objection to making the disgndiag, precisely?

I'll only speak for myself, but my objection is that once it's in the chart, it stays in the chart. There is no such thing as BPD, in remission or BPD, by history or BPD, most recent episode...

I don't give the diagnosis unless I'm 100% certain, which is why I don't tend to give it to children. If the symptoms are a big enough deal that I feel other providers need to be aware, I describe them so as not to label a 14-year-old with a personality disorder when his/her personality is very realistically manipulated by their acute environment and affected by the hormones of adolescence.

 

[LadyHalcyon]

I'll only speak for myself, but my objection is that once it's in the chart, it stays in the chart. There is no such thing as BPD, in remission or BPD, by history or BPD, most recent episode...

I don't give the diagnosis unless I'm 100% certain, which is why I don't tend to give it to children. If the symptoms are a big enough deal that I feel other providers need to be aware, I describe them so as not to label a 14-year-old with a personality disorder when his/her personality is very realistically manipulated by their acute environment and affected by the hormones of adolescence.

Do you not ever remove diagnoses or mark them resolved? I'm not sure how it would be any different from someone not meeting criteria for PTSD after Prolonged Exposure/CPT

 

[clausewitz2]

I'll only speak for myself, but my objection is that once it's in the chart, it stays in the chart. There is no such thing as BPD, in remission or BPD, by history or BPD, most recent episode...

I don't give the diagnosis unless I'm 100% certain, which is why I don't tend to give it to children. If the symptoms are a big enough deal that I feel other providers need to be aware, I describe them so as not to label a 14-year-old with a personality disorder when his/her personality is very realistically manipulated by their acute environment and affected by the hormones of adolescence.

Hmm, our experiences may be influenced by EMR differences on some level. I can very easily delete something from someone's problem list.

Again on the acute point - we are talking about a consistent pattern for over a year. At what point do acute circumstances explain much of anything?

As a matter of practice I don't think I would pull the trigger at less than two years to be honest but at some point you have to pull back and wonder why the child is having a much harder time negotiating the developmental challenges of adolescence than the vast majority of their peers.

 

[LadyHalcyon]

Hmm, our experiences may be influenced by EMR differences on some level. I can very easily delete something from someone's problem list.

Again on the acute point - we are talking about a consistent pattern for over a year. At what point do acute circumstances explain much of anything?

As a matter of practice I don't think I would pull the trigger at less than two years to be honest but at some point you have to pull back and wonder why the child is having a much harder time negotiating the developmental challenges of adolescence than the vast majority of their peers.

I agree. I have regularly seen child and adolescent inpatient hospitals and, to some extent, CMHCs slap a bipolar diagnosis on something like 80% of all patients. To me, that is almost more problematic because the main focus of Bipolar treatment is medication management/medication adherence. These medications have serious negative consequences in regard to overall physical health.

I agree it is good practice to be conservative with diagnoses, especially with children. That being said, I think it's important to consider the harm associated with not including a personality disorder diagnosis. During my initial intake with this patient, I diagnosed her with MDD, recurrent. I updated her diagnoses after a couple months of regular sessions. The EMR I use also allows for diagnoses to be changed/removed.

In fact, many of my patients describe feeling a sense of relief when they finally have a label that helps them better understand themselves. For this specific patient, providing the her caregivers with psychoeducation about BPD helped them understand the patient, which helped them to respond differently to her behavior. It also validated their experiences, as it is very difficult to be on the receiving end of her rage.

Earlier this week the patient was refusing to go home because she "hated" her caregivers; she indicated she would kill herself if made to return. She also was refusing their visits, which hurt their feelings immensely. They reached out to me asking if they should stop trying to visit her. I reminded them about the pervasive fear of abadonemnt associated with BPD and the tendency to enage in a push/pull interpersonal pattern. I went to visit the patient Friday, and she admitted she was trying to push them away because she believes they will better "better off" without her. She also acknowledged, without my prompting, her tendency to "try to get attention" in maladaptive ways. During the session I reassured her they love her and validated her fears associated with intimacy. I received a message this morning from her caregivers stating they followed my advice and visited her; they played board games and had a really good visit.

I only mention those details in an attempt to highlight how accurate diagnoses and conceptualizations improve treatment outcomes. For this patient, she felt a sense of comfort when she received a diagnosis that explained her feelings and behaviors. Her caregivers also felt validated. Uderstanding her diagnosis helped them respond differently to her behaviors, which will ultimately impact the effectiveness of treatment.

 

[Mass Effect]

Do you not ever remove diagnoses or mark them resolved? I'm not sure how it would be any different from someone not meeting criteria for PTSD after Prolonged Exposure/CPT

It would be different for two reasons:
1. PTSD patients aren't as stigmatized, dismissed, dreaded, and avoided by our medicine colleagues.
2. Once it's in the chart, it's in the chart and in the notes of colleagues, so erasing it makes no difference as problems lists are routinely so long that people don't double-check every single psych diagnosis. Once someone in the ED writes a note that includes BPD, the next time the patient comes in, they carry that forward without even realizing that the patient may no longer meet criteria.

Hmm, our experiences may be influenced by EMR differences on some level. I can very easily delete something from someone's problem list.

As can I. See above.

Again on the acute point - we are talking about a consistent pattern for over a year. At what point do acute circumstances explain much of anything?

Acute circumstances can last much more than a year or two for a 13 or 14 or 15-year-old. We're talking peer bullying, childhood abuse at home, drama in the peer group, etc, magnified by normal adolescent stress intolerance and emotional dysregulation.

As a matter of practice I don't think I would pull the trigger at less than two years to be honest but at some point you have to pull back and wonder why the child is having a much harder time negotiating the developmental challenges of adolescence than the vast majority of their peers.

I'm not convinced it's the "vast majority" of their peers, honestly. Have you ever taught middle school students (primarily girls)? There are quite a lot who have anything but a peaceful co-existence with their peers. Add to that one or two who have had turbulent upbringings and they're already pre-disposed to maladaptive coping skills. Add in hormones and impulsivity that comes with that age group and you've got the makings of a personality that could meet criteria for BPD without the understanding that the situation is transient and the child's personality is likely to be as well (and yes, I've read the literature about personality being formed by the age of 6, with which I disagree).

 

[LadyHalcyon]

It would be different for two reasons:
1. PTSD patients aren't as stigmatized, dismissed, dreaded, and avoided by our medicine colleagues.
2. Once it's in the chart, it's in the chart and in the notes of colleagues, so erasing it makes no difference as problems lists are routinely so long that people don't double-check every single psych diagnosis. Once someone in the ED writes a note that includes BPD, the next time the patient comes in, they carry that forward without even realizing that the patient may no longer meet criteria.



As can I. See above.



Acute circumstances can last much more than a year or two for a 13 or 14 or 15-year-old. We're talking peer bullying, childhood abuse at home, drama in the peer group, etc, magnified by normal adolescent stress intolerance and emotional dysregulation.



I'm not convinced it's the "vast majority" of their peers, honestly. Have you ever taught middle school students (primarily girls)? There are quite a lot who have anything but a peaceful co-existence with their peers. Add to that one or two who have had turbulent upbringings and they're already pre-disposed to maladaptive coping skills. Add in hormones and impulsivity that comes with that age group and you've got the makings of a personality that could meet criteria for BPD without the understanding that the situation is transient and the child's personality is likely to be as well (and yes, I've read the literature about personality being formed by the age of 6, with which I disagree).

I'm not sure I would diagnose a 14 yr old with BPD. I have a 14yr old patient now who has borderline traits, but I don't think that is an appropriate diagnosis...... Yet. Hopefully with early intervention those traits will soften. His behavior seems more like an extreme version of normal adolescent egocentrism and emotional liability.

 

[DisorderedDoc417]

So you said this:


You expressed skepticism about the idea of improvement in a ten year time span, which I can understand. I think you have to always keep in mind the overrepresentation in your clinical experience of the small subset of people with BPD who are hospitalized repeatedly and frequently; this is not actually the modal course. I would politely suggest you look at the relevant literature since this is not a controversial point.

If changing over a longish span of time fits just fine with your understanding of chronic and pervasive, what is your objection to making the disgndiag, precisely?

The problem is with making the diagnosis in a child, which has been hashed our above and seemingly without the argument (that really isn’t) happening here.

Again, I don’t think any paternalistic or condescending comments or assumptions about my background, training, or knowledge base are necessary. You could perhaps consider a degree of misunderstanding on your part and seek clarification first before jumping to the former conclusions. That might be more “polite”. No hard feelings. I say we get back to discussing and learning from each other which is lots more fun.

 

[clausewitz2]

The problem is with making the diagnosis in a child, which has been hashed our above and seemingly without the argument (that really isn’t) happening here.

Again, I don’t think any paternalistic or condescending comments or assumptions about my background, training, or knowledge base are necessary. You could perhaps consider a degree of misunderstanding on your part and seek clarification first before jumping to the former conclusions. That might be more “polite”. No hard feelings. I say we get back to discussing and learning from each other which is lots more fun.

Maybe the issue is that I have mistakenly conveyed the impression that I want 12 and 13 year olds diagnosed with BPD or something like that. The kids I have in mind when we have been arguing about this have been for most part 16 or 17.

I am trying to be as transparent as possible when I lay out what I don't understand about what you are saying. I repeat the idea that change over a ten year period is the norm and this is well-supported. I can't tell if you accept this or not; if you think that is wrong I would genuinely love to see the work you have in mind indicating this. I am eager to stay abreast of these things. I also agree that learning from each other is far more fun.

Another issue that occurs to me is maybe about system resources. I have adolescent and transitional age DBT IOPs to refer people to, so making the diagnosis matters for resources available. If your system doesn't have that I imagine the urgency would be reduced somewhat.

My big concern is that the kids I have in mind often get slapped with a bipolar (or worse, psychosis) diagnosis and end up on meds that cause tremendous weight gain, give them diabetes, or exposes them to increased risk of CV-related death.

 

[clausewitz2]

It would be different for two reasons:
1. PTSD patients aren't as stigmatized, dismissed, dreaded, and avoided by our medicine colleagues.
2. Once it's in the chart, it's in the chart and in the notes of colleagues, so erasing it makes no difference as problems lists are routinely so long that people don't double-check every single psych diagnosis. Once someone in the ED writes a note that includes BPD, the next time the patient comes in, they carry that forward without even realizing that the patient may no longer meet criteria.



As can I. See above.



Acute circumstances can last much more than a year or two for a 13 or 14 or 15-year-old. We're talking peer bullying, childhood abuse at home, drama in the peer group, etc, magnified by normal adolescent stress intolerance and emotional dysregulation.



I'm not convinced it's the "vast majority" of their peers, honestly. Have you ever taught middle school students (primarily girls)? There are quite a lot who have anything but a peaceful co-existence with their peers. Add to that one or two who have had turbulent upbringings and they're already pre-disposed to maladaptive coping skills. Add in hormones and impulsivity that comes with that age group and you've got the makings of a personality that could meet criteria for BPD without the understanding that the situation is transient and the child's personality is likely to be as well (and yes, I've read the literature about personality being formed by the age of 6, with which I disagree).

So many people with BPD have pretty terrible life circumstances. I am curious as to what point in terms of age or persistence you are willing to pull the trigger on this in practice. Similarly, can you imagine any scenario in which you would?

We may also be working off of different mental models of the kids we are talking about. What diagnosis would you assign to a 17 year old who has thought about suicide daily for the past three years, has been hospitalized more than a dozen times following reported suicide attempts proximally triggered by arguments with friends or her sibling receiving something she did not, who has tied sheets around her neck while on an inpatient unit because the peer specialist she was talking to had to go down the hall to help with an emergency restraint for a few minutes, who finds incomprehensible the question of "what are you like as a person", feels she does not have any feelings that do not come from other people, disassociated at the drop of a hat, and tends to at least briefly endorse any psychiatric symptom her (differently challenged) sibling experiences?

Maybe I would understand better what diagnosis you use instead in a situation like that. Also, what medication do you reckon will be helpful?

Not snark, genuine curiosity.

 

[clausewitz2]

The problem is with making the diagnosis in a child, which has been hashed our above and seemingly without the argument (that really isn’t) happening here.

Again, I don’t think any paternalistic or condescending comments or assumptions about my background, training, or knowledge base are necessary. You could perhaps consider a degree of misunderstanding on your part and seek clarification first before jumping to the former conclusions. That might be more “polite”. No hard feelings. I say we get back to discussing and learning from each other which is lots more fun.

It also strikes me that you and @Mass Effect may be reacting to the unfortunate tendency of many people to assign BPD labels to any (usually female) person who self harms or has a trauma history and is emotionally labile and might be assuming that is what I am suggesting. That practice in fact enrages me and I think it is a disgusting example of the continued misogyny of psychiatry and medicine as a whole. I am really talking about someone with an extensive pattern of dysfunction relative to peers in their milieu and who also experience the core phenomenology. There are many different structured instruments and approaches for assessing this rigorously and what I feel like I am suggesting is the opposite of the dismissive sexism of "oh, she's just a big ol' borderline"

 

[Dharma]

Avoiding diagnosis in someone who definitively meets criteria because of pervasive stigma amongst providers (but not necessarily the general population) is erroneous and harmful. The answer- better education including information re favorable remission rates, modicums of treatment outside of DBT, etc of practitioners both within and outside the field- seems well past due.

The error lies in many providers' typical response to BPD (e.g. "that borderline," "she's so borderline," the eye-rolling that accompanies such, etc) and obvious inability of many to effectively manage countertransference (internal frustration in particular) which perpetuates the stigma.

Time to destroy the stigma amongst ourselves and our colleagues in other fields and approach with the objectivity we strive for in diagnosis and treatment of other mental health disorders.

 

[SourceOfDenial]

Time to destroy the stigma amongst ourselves and our colleagues in other fields and approach with the objectivity we strive for in diagnosis and treatment of other mental health disorders.

I think we are fooling ourselves if we expect objectivity in diagnosing psychiatric illnesses. If you mean we should strive to diagnose based on criteria, let's also be critical of the the criteria.

 

[Mass Effect]

So many people with BPD have pretty terrible life circumstances. I am curious as to what point in terms of age or persistence you are willing to pull the trigger on this in practice. Similarly, can you imagine any scenario in which you would?

We may also be working off of different mental models of the kids we are talking about. What diagnosis would you assign to a 17 year old who has thought about suicide daily for the past three years, has been hospitalized more than a dozen times following reported suicide attempts proximally triggered by arguments with friends or her sibling receiving something she did not, who has tied sheets around her neck while on an inpatient unit because the peer specialist she was talking to had to go down the hall to help with an emergency restraint for a few minutes, who finds incomprehensible the question of "what are you like as a person", feels she does not have any feelings that do not come from other people, disassociated at the drop of a hat, and tends to at least briefly endorse any psychiatric symptom her (differently challenged) sibling experiences?

Maybe I would understand better what diagnosis you use instead in a situation like that. Also, what medication do you reckon will be helpful?

Not snark, genuine curiosity.

I think I said at the beginning that i would assign the dx to very clear cut cases, where i am 100% certain it is much more than adolescence causing this, particularly in older folks. My beef is when i see 13 or 14 yr olds dx'd due to self harm or SI following a breakup.

It also strikes me that you and @Mass Effect may be reacting to the unfortunate tendency of many people to assign BPD labels to any (usually female) person who self harms or has a trauma history and is emotionally labile and might be assuming that is what I am suggesting. That practice in fact enrages me and I think it is a disgusting example of the continued misogyny of psychiatry and medicine as a whole. I am really talking about someone with an extensive pattern of dysfunction relative to peers in their milieu and who also experience the core phenomenology. There are many different structured instruments and approaches for assessing this rigorously and what I feel like I am suggesting is the opposite of the dismissive sexism of "oh, she's just a big ol' borderline"

I'm reacting to the belief that personality disorders should not be soft and dx in a person at a young age when there are other factors at play. Actually, many in our profession feel this way. It's not that cut and dried. Describe the sxs buy i personally don't give the label under 18, except in clear cut cases.

 

[Mass Effect]

Avoiding diagnosis in someone who definitively meets criteria because of pervasive stigma amongst providers (but not necessarily the general population) is erroneous and harmful. The answer- better education including information re favorable remission rates, modicums of treatment outside of DBT, etc of practitioners both within and outside the field- seems well past due.

The error lies in many providers' typical response to BPD (e.g. "that borderline," "she's so borderline," the eye-rolling that accompanies such, etc) and obvious inability of many to effectively manage countertransference (internal frustration in particular) which perpetuates the stigma.

Time to destroy the stigma amongst ourselves and our colleagues in other fields and approach with the objectivity we strive for in diagnosis and treatment of other mental health disorders.

Assigning a dx due to black and white thinking is wayyyyyyy more harmful. If i see the phrase "budding borderline" uttered about 12 yo, i usually call the clinician out on it because THAT'S what's erroneous and harmful.

 

[clausewitz2]

I think I said at the beginning that i would assign the dx to very clear cut cases, where i am 100% certain it is much more than adolescence causing this, particularly in older folks. My beef is when i see 13 or 14 yr olds dx'd due to self harm or SI following a breakup.



I'm reacting to the belief that personality disorders should not be soft and dx in a person at a young age when there are other factors at play. Actually, many in our profession feel this way. It's not that cut and dried. Describe the sxs buy i personally don't give the label under 18, except in clear cut cases.

Okay, I think this may be a situation where we are way more in agreement than disagreement. I am complaining about people who refuse to give the label in those clear cut cases, and you are complaining about those who give teenagers the label because they self-harm and were suicidal after a breakup. It sounds like both of us would refuse to do both of those things. My complaint came from interactions with child folks at my shop who just never even talk about the issue, and while I do not want to speak for your experiences I have encounter plenty of people doing what you describe. Does that seem fair?

I am generally of the opinion that all of our diagnoses are ontologically questionable so I generally hold them lightly or "soft" as it were. I take your point that some of our colleagues tend to be much more literal or at least essentialist when it comes to the label we write down.

 

[Dharma]

I think we are fooling ourselves if we expect objectivity in diagnosing psychiatric illnesses. If you mean we should strive to diagnose based on criteria, let's also be critical of the the criteria.

Agree. Striving for objectivity is a worthy ideal.

 

[Dharma]

Assigning a dx due to black and white thinking is wayyyyyyy more harmful. If i see the phrase "budding borderline" uttered about 12 yo, i usually call the clinician out on it because THAT'S what's erroneous and harmful.

Quite easy to get caught up in the realm of 0's and 1's... and yes, dangerous in a field that is mostly someplace in between. But let's not avoid calling a spade, a spade...

 

[Dharma]

Okay, I think this may be a situation where we are way more in agreement than disagreement. I am complaining about people who refuse to give the label in those clear cut cases, and you are complaining about those who give teenagers the label because they self-harm and were suicidal after a breakup. It sounds like both of us would refuse to do both of those things. My complaint came from interactions with child folks at my shop who just never even talk about the issue, and while I do not want to speak for your experiences I have encounter plenty of people doing what you describe. Does that seem fair?

I am generally of the opinion that all of our diagnoses are ontologically questionable so I generally hold them lightly or "soft" as it were. I take your point that some of our colleagues tend to be much more literal or at least essentialist when it comes to the label we write down.

 

[DisorderedDoc417]

It also strikes me that you and @Mass Effect may be reacting to the unfortunate tendency of many people to assign BPD labels to any (usually female) person who self harms or has a trauma history and is emotionally labile and might be assuming that is what I am suggesting. That practice in fact enrages me and I think it is a disgusting example of the continued misogyny of psychiatry and medicine as a whole. I am really talking about someone with an extensive pattern of dysfunction relative to peers in their milieu and who also experience the core phenomenology. There are many different structured instruments and approaches for assessing this rigorously and what I feel like I am suggesting is the opposite of the dismissive sexism of "oh, she's just a big ol'

It also strikes me that you and @Mass Effect may be reacting to the unfortunate tendency of many people to assign BPD labels to any (usually female) person who self harms or has a trauma history and is emotionally labile and might be assuming that is what I am suggesting. That practice in fact enrages me and I think it is a disgusting example of the continued misogyny of psychiatry and medicine as a whole. I am really talking about someone with an extensive pattern of dysfunction relative to peers in their milieu and who also experience the core phenomenology. There are many different structured instruments and approaches for assessing this rigorously and what I feel like I am suggesting is the opposite of the dismissive sexism of "oh, she's just a big ol' borderline"

It strikes me that you tend to over generalize others and make assumptions off of next to nothing. I would be careful with these tendencies.

 

[clausewitz2]

It strikes me that you tend to over generalize others and make assumptions off of next to nothing. I would be careful with these tendencies.

I think sharing my thought processes and intuitions about what might explain in a perfectly reasonable fashion points that seem puzzling or contradictory to me is in keeping with good principles of argumentative charity. If an otherwise smart person seems to just miss the point entirely, I think it is good practice to try and figure out where they and you differ in key assumptions that may be contributing. I did try to get your reasoning from you just like from other people in this thread who were willing to be explicit and explain themselves.

I'm still not sure where or what you are objecting to in what I've said, because apart from vaguely implying that someone having an improvement in BPD symptoms between 21 and 31 was highly unlikely, you've really not offered any substantive points or made any arguments.

I would love to hear your take on how and when BPD should be diagnosed beyond suggestions that I am unfamiliar with the criteria. I think that could be a really productive conversation. I love exchanging ideas and exploring disagreements of principle or fact so I am hopeful you will engage in that conversation, but I am afraid all I'm going to get from you is vague snark again. Hopefully I'm wrong.

 

[DisorderedDoc417]

I think sharing my thought processes and intuitions about what might explain in a perfectly reasonable fashion points that seem puzzling or contradictory to me is in keeping with good principles of argumentative charity. If an otherwise smart person seems to just miss the point entirely, I think it is good practice to try and figure out where they and you differ in key assumptions that may be contributing. I did try to get your reasoning from you just like from other people in this thread who were willing to be explicit and explain themselves.

I'm still not sure where or what you are objecting to in what I've said, because apart from vaguely implying that someone having an improvement in BPD symptoms between 21 and 31 was highly unlikely, you've really not offered any substantive points or made any arguments.

I would love to hear your take on how and when BPD should be diagnosed beyond suggestions that I am unfamiliar with the criteria. I think that could be a really productive conversation. I love exchanging ideas and exploring disagreements of principle or fact so I am hopeful you will engage in that conversation, but I am afraid all I'm going to get from you is vague snark again. Hopefully I'm wrong.

For the most part we agree. Which makes this charade rather futile. I don’t respect your philosophical approach, taking others’ arguments and reducing them to absurdity. First time goers who meet some of the criteria as a teenager are not an appropriate BLPD diagnosis. The ridiculous example you have on another post above would of course be BLPD until proven otherwise.

You’re not arguing with me because I’m choosing not not to engage with you, which I’m thankful you’ve picked up on. You’re on this diatribe that I can’t fully understand... it isn’t an effective means of drawing out someone into a discussion. The reason this exchange started was because you Can’t help but dig deeper into a long line of disrespectful and rather rash assumptions about others, and making accusations that others are not being educated or trained properly... having gone off of nothing more than a couple random posts. That’s annoying. Stop doing it. Engage rather in polite collegial discussion. I’m really not interested in drawing this conversation further off the rails so I’m going to refrain from doing so any further. When multiple people are trying to say they agree with you and you come back stirring up trouble... it’s time to ask the question.

 

[LadyHalcyon]

I gave a presentation once for our state psychological associations about ethics and rural populations (exciting, right)? I'm not even sure how this conversation came about, but during the Q & A portion of the didactic at least two psychologists (I think there were only about 15 in the room) said they will not treat anyone with a BPD diagnosis for fear of a malpractice claim (think Glenn Close in Fatal Attraction). Of course no child should carelessly be diagnosed with any diagnosis. Furthermore, many teens exhibit borderline traits that are, in many ways, developmentally appropriate and responses to life stressors. However, a diagnosis is needed for billing. These emotionally disregulated children and teens who are in and out of hospitals often get the following diagnoses: ODD, ADHD, and Bipolar. I'm not sure any of these diagnoses are less harmful than a borderline diagnosis. In fact, I have observed strong countertransferential reactions toward children diagnosed with ODD and Conduct Disorder, especially if the patient is male. I think this issue is multi-part, but a big piece of it is the stigma that exists amongst mental health providers toward Borderline Personality Disorder.

 

[clausewitz2]

For the most part we agree. Which makes this charade rather futile. I don’t respect your philosophical approach, taking others’ arguments and reducing them to absurdity. First time goers who meet some of the criteria as a teenager are not an appropriate BLPD diagnosis. The ridiculous example you have on another post above would of course be BLPD until proven otherwise.

You’re not arguing with me because I’m choosing not not to engage with you, which I’m thankful you’ve picked up on. You’re on this diatribe that I can’t fully understand... it isn’t an effective means of drawing out someone into a discussion. The reason this exchange started was because you Can’t help but dig deeper into a long line of disrespectful and rather rash assumptions about others, and making accusations that others are not being educated or trained properly... having gone off of nothing more than a couple random posts. That’s annoying. Stop doing it. Engage rather in polite collegial discussion. I’m really not interested in drawing this conversation further off the rails so I’m going to refrain from doing so any further. When multiple people are trying to say they agree with you and you come back stirring up trouble... it’s time to ask the question.

I certainly got to agreement with people upthread, but I guess we will have to differ on whether it was immediate. I do apologize if I communicated or conveyed any insinuations about your training - I did genuinely mean only to gently challenge the assertions you seemed to be making about remission != BLPD.

The example I gave may strike you as ridiculous but I felt comfortable posting it because even people working on the child side in our system would not be able to uniquely identify a specific individual because it describes more than a few known very well to our inpatient child units. That may be a genuine difference in populations, I don't know.

I try very hard not to make assumptions. I do try to be transparent in my guesses about what may be driving disagreement but I do try not to act as if they were true until I get confirmation. Looking back on the thread I do think I was pretty consistent in hedging or attributing my guesses explicitly to my own thought process, but I do apologize if that was unclear in any of those instances.

I regret that I came across as insulting or casting aspersions on your training, although I would gently challenge you to identify a specific place where I did this because I'm not having luck identifying one.

As for reductio ad absurdum my feeling is it is a very ancient method of reasoning in philosophy and time-honored for a reason but I would be interested in your objection to the form.

No charades here, I promise, but I do hope a truce is possible!

 

[clausewitz2]

I gave a presentation once for our state psychological associations about ethics and rural populations (exciting, right)? I'm not even sure how this conversation came about, but during the Q & A portion of the didactic at least two psychologists (I think there were only about 15 in the room) said they will not treat anyone with a BPD diagnosis for fear of a malpractice claim (think Glenn Close in Fatal Attraction). Of course no child should carelessly be diagnosed with any diagnosis. Furthermore, many teens exhibit borderline traits that are, in many ways, developmentally appropriate and responses to life stressors. However, a diagnosis is needed for billing. These emotionally disregulated children and teens who are in and out of hospitals often get the following diagnoses: ODD, ADHD, and Bipolar. I'm not sure any of these diagnoses are less harmful than a borderline diagnosis. In fact, I have observed strong countertransferential reactions toward children diagnosed with ODD and Conduct Disorder, especially if the patient is male. I think this issue is multi-part, but a big piece of it is the stigma that exists amongst mental health providers toward Borderline Personality Disorder.

When I first started residency I was really amazed by the discrepancy between how clinicians react to reading a borderline diagnosis and how people who fit the picture often react when it is explained to them. No joke, in my intern year on one of the inpatient units I overheard someone I had this conversation with on the phone saying "Mom, mom, I had to tell you, there's a name for what's been going on with me..."

I have started warning people when I have that conversation these days that if they Google it they might find people saying very hurtful things and reiterating what I mean when I say it and what our best evidence looks like.

Oddly it hasn't been a big issue that has come back to me yet (if the diagnosis is actually warranted I think often the person in question is pretty used to people reacting poorly to them and assuming the worst, label or no label) but I am preparing for the day when it gets thrown in my face.

 

[LadyHalcyon]

The only PD diagnoses that requires an age of 18 is ASPD. And I have major issues with that diagnosis.

 

[Mass Effect]

Quite easy to get caught up in the realm of 0's and 1's... and yes, dangerous in a field that is mostly someplace in between. But let's not avoid calling a spade, a spade...

No one suggested we should.

 

[thoffen]

Seems like we're getting thrown off by the labeling. Most prominent here is that the medical model doesn't seem to be helping the patient. Medication might have an important role in treatment here, but it's also clear that this is a person who needs as a priority a strongly boundaried treatment with a long-term stable attachment figure. A provider who is not attempting a psychotherapy relationship can very well be that person. But if they are not, they have to help establish who is and work through them how their role fits with the treatment. A manualized DBT treatment is obviously the one most would reach for and will make those things explicit if followed, but by no means is it the only treatment that can be effective. It's important to know what that really means, too, because it is quite often in the community advertised DBT therapy does not follow the manual, and someone with high risk who communicates therapeutic issues via acting out really needs that level of structure in their individual treatment.

 

[deleted736562]

When I first started residency I was really amazed by the discrepancy between how clinicians react to reading a borderline diagnosis and how people who fit the picture often react when it is explained to them. No joke, in my intern year on one of the inpatient units I overheard someone I had this conversation with on the phone saying "Mom, mom, I had to tell you, there's a name for what's been going on with me..."

That has been my experience too. A lot of BPD patients are confused by their symptoms and know that this is "not simply depression and anxiety". Putting a name to all of that is sometimes a relief.

I also think my countertransferance improved a lot when I started outpatient. Probably because of the space to develop an actual human connection. We put far too much emphasis on "limits and boundaries"; not that they aren't important, but sometimes we use them more to protect ourselves rather than help patients and they are meaningless outside the context of a connection.

 

[LadyHalcyon]

Happy to report my patient is out of acute inpatient and seems to be doing better. Her Lamictal was increased and she was taken off the lexapro, as it was causing hypomanic episodes. She was also recently placed on abilify, in the hopes it will help address her depression and anxiety. She has noticed the Lamictal increase has helped reduce her aggressive episodes and overall mood liability. Both me and her nurse practitioner agree she should be seen by a child and adolescent psychiatrist, but unfortunately there is a shortage in our area. The behaviors were interfering with treatment; my plan is continue a combination of DBT and trauma-focused therapy. We have also decided to add an adolescent substance abuse group. Hopefully, once she is more stable, she can begin to wean off the medication. I was also reviewing literature stating 1000mg of omega-3 per day was effective in reducing symptoms commonly associated with BPD.