Do we discriminate against borderline patients?

Without having read the article yet, I would say, in general, we do.

But, the article's argument that we don't like that they don't respond to treatment is crap! We don't respond the same way to schizophrenic patients, which also tend to be treatment resistant. The notion that a celebrity would be required to make a diagnosis "acceptabe" although nt laughable in itself, the fact that they aren't doing it because of the stigma of the mental health field is. In fact, I would bet that many celebrities would meet the criteria for cluster B PDs.

Hurricane said:

This post on BrainBlogger says we (mental health professionals) do.

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Well if the brainblogger says it, it must be true.

Discriminate: to make a difference in treatment or favor on a basis other than individual merit

Therefore, if a borderline is treatment resistant, and is even dropped from treatment, there is no evidence that discrimination has occurred. In this scenario, the individual merit of the person, or in this case, patient, has been evaluated. The author of that article makes no objective case for this. The references are woefully inadequate.

If the purpose of the article is to rile up borderlines, to make them more upset than they already are...then I don't see the point.

Psychiatry is allowed to have difficult-to-treat patients. It is human nature to hesitate in taking on such cases, as they demand a large amount of the psychiatrist's time, energy, often results in disturbance of their own personal family, and even income...not to mention propensity for actual or threatened lawsuits (I have no objective evidence for the last portion of this statement).

Many of my most interesting cases have been of the borderline variety. They are tough to treat, and are extremely refractory.....having a dozen of them in your practice can make your life hell. That's just a fact.

I was going to make ana's point as well. There are only so many difficult cases you can take on at once. Regardless, I do think there is some truth to the fact that BPD patietns are treated with a certain ammount of hostility and even a condesending attitude.

We do and we don't.

We do if we disrepsect these patients, feed into their conflict, think less of them as human beings, etc.

Let's all admit it. Somewhere in our younger lives, we did things which could be considered "Borderline". However we probably also had better families, a more stable upbringing, etc.

We do not disprespect Borderlines if we do not treat patients with an Axis II disorder who are not a danger to themselves or others & do not want treatment. We can't unless we're willing to do charity work. Managed care won't pay for it. Further, the majority of the population has some personality d.o. of some form.

We do not disprespect borderlines if we set boundaries with them. Setting boundaries prevents us from adding fuel to their fires. It is even considered sound psychotherapy for patients with cluster B disorders in Kaplan & Sadock.

We do not disrespect these patients if we turn these patients away from inpatient treatment and they are not a danger to themselves or others. Managed care and state laws for the most part forbid you to accept a patient simply because they have an Axis II d/o. We are obligated to follow the law & not lie.

However that does not mean we should ignore these people & their needs completely, even if managed care does push us away from them. We can for example be open to seeing if they may have a true Axis I d/o, diagnosing them with an Axis I, with the additional Axis II d/o if we feel it is appropriate. We can also direct them to improve their own self esteem through introspection, self help, referall to psychological therapy etc with a concise explanation of the disorder and how they can about with self help.

Further, studies show that about 10-15% of borderlines can do dangerous behavior due to it (and I'm basing this off of memory, I might be wrong here), and that of one of the subtypes of the disorder-Affective Borderline PD (yes there are further subdivisions of this disorder) does respond to psychotropic treatment.

Like it or not, managed care will not pay for treatment of this disorder, even though it is a recognized disorder and there are proven treatments for it. Do the best you can under the circimstances.

Finally and this is something where I disagree with the blog: several people have Axis II d/o's. Just because someone has an Axis II doesn't mean they necessarily need treatment. Most teens & college aged people have some form of cluster B traits-does that mean I should treat them? Of course not. A heck of a lot of it is simply just growing up. A lot of us have issues. That doesn't necessarily mean that a doctor HAS to treat it. Some people pursue therapy through self help, religion, art etc.

whopper said:

We do not disprespect Borderlines if we do not treat patients with an Axis II disorder who are not a danger to themselves or others & do not want treatment. We can't unless we're willing to do charity work. Managed care won't pay for it. Further, the majority of the population has some personality d.o. of some form.

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Ok, I need to set a limit on the ammount of negatives you can use in one sentance.

I don't think the majority of the populations suffers from a PD.

Psyclops said:

Ok, I need to set a limit on the ammount of negatives you can use in one sentance.

I don't think the majority of the populations suffers from a PD.

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Actually I checked and you are correct. About 15% of the adult population suffers from a diagnostic DSM Axis II d/o. I was basing my information on a nurse who told me that--but ahem--as a doctor I should've based it on evidence based info vs. 2nd hand info.

I have to go to bed but is that what the DSM says? 15% sounds high, but I wll check it out in the morn. Peace out.

Here's my source...

http://www.emedicine.com/med/topic3472.htm

"Personality disorders affect 10-15% of the adult US population"

I checked other sources that had about 15%.

I often notice several staff where I work always use the Borderline label for any Cluster B d.o.

And unfortunately, several of our staff do disrespect Borderline pts, but at least have the sense to do so behind their backs. E.g. the patient is in the closed room and when the nurse walks out they'll say "just another borderline" in a condescending manner. One of them used to sing Madonna's borderline and make fun of them while we could see the pt through an observation camera.

Which makes me think--"a borderline condescending a borderline". Yeah I know sometimes you need to let off some steam, but trust me, where I work some of the staff aren't exactly professional.

For me, I can't help but harbor negative countertransference for a person that I formulate as borderline. My thoughts are much less negative when I think of such a person as 'regressed neurotic.' Having said that, I have worked with a woman, twice weekly therapy, for nearly two years now, and she is clearly borderline. I have grown to feel her pain due to her inability to relate to the objects in her life because of her PD, I actually really like her, as a person, too. Of course, it has helped that I am usually on her good split.

The cluster B that I have a much more difficult time with, are the antisocial ones. I only have negative countertransference for them.

I have serious negative countertransferance toward borderlines - Im going to have to work on that one.

I only get PO'd with borderlines if that person tries to manipulate the situation into something that'll cost the system a lot of money.

Reason why it gets me mad is because everyone ends up paying for it through higher taxes & bills. I sometimes wonder if there's some person who can't pay their bill because of borderline pt who's demanding inpatient treatment for nonlegitimate reasons.

Otherwise I just ignore the cluster B behavior, sometimes I even get a kick out of it but keep my outward appearance neutral.

whopper said:

I only get PO'd with borderlines if that person tries to manipulate the situation into something that'll cost the system a lot of money.

Reason why it gets me mad is because everyone ends up paying for it through higher taxes & bills. I sometimes wonder if there's some person who can't pay their bill because of borderline pt who's demanding inpatient treatment for nonlegitimate reasons.

Otherwise I just ignore the cluster B behavior, sometimes I even get a kick out of it but keep my outward appearance neutral.

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Whooper, May I ask if you’re a student or an actual psychiatrists? By judging your post you sure act like a student, you have a long journey a head of you son (or daughter). It always seems that it’s us Borderlines (Yes I’m diagnosed of having borderline personality disorder) that get blamed for everything. We get made fun of while trying to get treatment (you guys even admit to it) inside hospitals and we are to blame for higher taxes and bills (while more doctors demand to get higher salaries, make some sense eh?!) and that we the B.P.D demand and crave to go to inpatient, eh?

As to my knowledge with Borderline Personality Disorder, This is NOT the behavior of a Borderline rather then somebody suffering from a severe case of Munchausen’s syndrome (http://www.clevelandclinic.org/health/health-info/docs/2800/2821.asp?index=9833 ) or somebody who is simply homeless and do not have any other places but to spend the night inside the hospital and to get free food. I do not see in your statement that you’re not blaming the homeless people and the Munchausen’s syndrome folks for the higher taxes and bills other then to blame the borderline personality disorder folks. It truly makes me depressed (guess I need to take that antidepressant eh?) to see how uneducated *some* psychiatrists are, let a loan that the students are being trained by *some* theses psychiatrists.

Anuwolf said:

Whooper, May I ask if you’re a student or an actual psychiatrists? By judging your post you sure act like a student, you have a long journey a head of you son (or daughter). It always seems that it’s us Borderlines (Yes I’m diagnosed of having borderline personality disorder) that get blamed for everything. We get made fun of while trying to get treatment (you guys even admit to it) inside hospitals and we are to blame for higher taxes and bills (while more doctors demand to get higher salaries, make some sense eh?!) and that we the B.P.D demand and crave to go to inpatient, eh?

As to my knowledge with Borderline Personality Disorder, This is NOT the behavior of a Borderline rather then somebody suffering from a severe case of Munchausen’s syndrome (http://www.clevelandclinic.org/health/health-info/docs/2800/2821.asp?index=9833 ) or somebody who is simply homeless and do not have any other places but to spend the night inside the hospital and to get free food. I do not see in your statement that you’re not blaming the homeless people and the Munchausen’s syndrome folks for the higher taxes and bills other then to blame the borderline personality disorder folks. It truly makes me depressed (guess I need to take that antidepressant eh?) to see how uneducated *some* psychiatrists are, let a loan that the students are being trained by *some* theses psychiatrists.

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Anuwolf, if you don't mind, can you tell us how your psychiatrist told you of your diagnosis? What did s/he say, and how did you respond? What do you think about your diagnosis?

I have not told any of my patients that they have borderline pd, even though it is in their chart. I can't imagine telling someone, that s/he is fundamentally disordered. That seems so calloused. What I say is that 'it seems like you have very chaotic relationships...blah, blah, blah."

What helps me with the countertransference, aside from thinking of the pathology in terms of regressed neuroticism, is that I think about how BPD folks often have had chaotic and stressful childhoods that they themselves could not help... My BPD therapy patient's mom is quite a narcissist...

outofhere said:

I have not told any of my patients that they have borderline pd, even though it is in their chart. I can't imagine telling someone, that s/he is fundamentally disordered. That seems so calloused. What I say is that 'it seems like you have very chaotic relationships...blah, blah, blah."

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I can't help but think that this is unethical. Especially if it was you who made the diagnosis. Furthermore, behavior like this seems to perpetuate the bad stereotypes associated with MH diagnoses. This is a serious question: How do you expect to help someone if you don't have the constitution to tell them their diagnosis? In my opinion, this is bad form.

Maybe I'm missing something?

I see your point.

The clinic I work at serves the indigent. And to meet criteria for tx, you need to meet medical necessity: defined as nearly all parity diagnoses, but developmental d/o are excluded. Therefore, these BPD pts have Axis I dx that I am working on. So much of their PD sx are also part of their Axis I dx sx. Some of them actually know they have BPD, if they are in the DBT program.

I guess I am also trying to dodge a bullet by avoiding saying things like, 'you are fundamentally flawed.'

At the same time, does it help people to know their PD dx, or does it just make things worse? I don't know. Maybe I am too paternalistic, yet, at the setting I am in, it doesn't seem wrong.

Outofhere,
I liked the psychiatrists that was asking me the questions and was diagnosing me. I was at the hospital at the time when I was being diagnosed. I don’t exactly remembered what the psychiatrist had told me but I do remember her asking me if I self harm, I told her “Yes”. How’d I respond? I responded like a regular adult, not nasty, not sarcastic, not rude, etc. I was not at the hospital involuntary. I do however admit that during my discussion to the psychiatrists that I became overly stressed and had a panic attack, the psychiatrists checked my pressure and soon gave me something to relax; I believe it was an ativan. I soon realize that I suffer from white coat syndrome, where people become nervous and have high blood pressure when they enter in a hospital/ doctors office situation.

outofhere said:

I have not told any of my patients that they have borderline pd, even though it is in their chart. I can't imagine telling someone, that s/he is fundamentally disordered. That seems so calloused. What I say is that 'it seems like you have very chaotic relationships...blah, blah, blah."

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I support psychiatrists for not telling their patients (especially the ones with Obsessive compulsive disorder) that they have an illness, however if the patient wants to know then they should be let known. I think that by telling them the diagnoses that the treatment for their illness would be more difficult to treat as some people would obsess about it and would affect their treatment plan. I also think that some people would use their illness to do things like steal, murder, criminal, etc and to put the blame on the diagnoses and won’t accept the responsibility for their actions. Just think about it, you came to the doctor to get help.. You’ve answered to all of their questions and then they tell you “you’re crazy! You have “diagnosed name”. You come home with 1 or couple of labels over your head.

I am not of the camp to diagnose PD as an inpatient psychiatrist. I think that carrying a PD has tremendous implications- for instance, the fact that we are even discussing if we discriminate against BPD... Therefore, I was taught that as much as I think someone is BPD, to write on the Axis II as r/o borderline traits, and only if I am nearly certain. Otherwise, I always defer. Simply put, a BPD needs to be evaluated on the long term- we all have some of these traits to some degree, and under the stress of being involuntary, it is hard not sway a little bit more to the regressed side.

I guess I find it hard to believe that being told your personality is 'wrong' can make one more relieved that whatever is going on has a name. I would personally find it more useful, if a therapist said, "some people have relationship difficulties more than others, and seems like you have more than most...etc," and frame it in a psychotherapy way. Keep in mind, that Freud did not have a DSM to use, and many of his patients would qualify as borderlines...

Anuwolf, if you read the above posts, I feel that disrespecting borderline patients is wrong, and others mentioned anger w/ borderline patients.

I am a 2nd going on to 3rd year in a few days psychiatric resident.

E.g. a patient in the inpatient unit is screaming, barricading the communal dining room due to borderline behavior. This is emotionally stirring to the therapist.

getting a "kick" out of it may have been poor choice of words. It is however emotionally stirring, and sometimes those emotions can serve a positive tool-to act as a stimulus to try to figure out why the patient is doing an action and to then use the info to better help the patient.

Whether or not I'm a student or a doctor should make little difference. I've seen several attendings view their borderline patients as children in a very condescening manner. Students actually don't know how to interpret the situation and often do not have that view.

For clarification, when I meant "manipulate" for lots of "money" I'm talking about for invalid, nonlegitimate uses of health resources. E.g. a Cluster B patient demanding to be taken home by ambulance -which costs hundreds to even thousands of dollars because the patient reasons "you're a hospital", and the person lives about 3 miles away and can take a cab home, and then the hospital refuses and the patient has an emotional outburst, e.g. starts throwing things because that person will not be given their own ambulance.

This upsets me because depending on the person in charge at the time--well they might actually honor the request. I feel this is a disservice to those that cannot afford health care. Quite honestly, I try not to get upset at the patient, and this would be countertransference. I would though be upset at one of my colleagues for honoring such a request becaue they're just trying to take the easy way out, to get the patient out of the hospital...which is actually a disservice to the patient-it feeds into their borderline behavior and the patient may get stuck with a very expensive bill he/she might not be able to afford.

One of the CORE bases of medical ethics is what is called the JUSTICE model. A doctor by employing the justice model cannot frivolously throw medical resources at a patient. There has to be a fairness in approach, one of the reasons is to save the community its resources it has allotted for health reasons-which are limited.

Borderlines do of course in several cases need professional help. However that help must be given appropriately. Individuals with the diagnosis should not be blamed for the problems of all with the diagnosis, but as a demographic, borderlines do pose a diagnostic and therapeutic challenge to psychiatrists.

Presentation of a dx: there is an art to presenting a diagnosis. I believe that any doctor with the majority of Axis II patients can tell the patient the diagnosis in a manner where the the patient will understand the diagnosis in a positive manner.

I have several patients who come to me and have had a psychiatrist for years-and when I see them they don't know what their diagnosis is, don't know why the doc put them on the meds they're on. This if pushed to the extreme can be considered failure to practice the standard of care. On the medical floor I've had several patients who were given a "lacks capacity" label because they could not state the nature of their diagnosis but were not even explained the nature by their therapist. Further several studies show that the more the patient knows of their diagnosis, the more compliance the patient has and the better the treatment outcomes.

double post

outofhere said:

I am not of the camp to diagnose PD as an inpatient psychiatrist. I think that carrying a PD has tremendous implications- for instance, the fact that we are even discussing if we discriminate against BPD... Therefore, I was taught that as much as I think someone is BPD, to write on the Axis II as r/o borderline traits, and only if I am nearly certain. Otherwise, I always defer. Simply put, a BPD needs to be evaluated on the long term- we all have some of these traits to some degree, and under the stress of being involuntary, it is hard not sway a little bit more to the regressed side.

I guess I find it hard to believe that being told your personality is 'wrong' can make one more relieved that whatever is going on has a name. I would personally find it more useful, if a therapist said, "some people have relationship difficulties more than others, and seems like you have more than most...etc," and frame it in a psychotherapy way. Keep in mind, that Freud did not have a DSM to use, and many of his patients would qualify as borderlines...

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I think you make a very good point when you say that during a hospitalization might not be the best time to examine their true behavior. So taht shouldbe taken into account.

But I think that not diagnosisng them because you fell "it sounds bad" is a little on the lame side of things. Call a rose by any other name and it will smell as sweet. Call a PD by any other name and it will be as disordered. I'm not a huge fan of the categorical system used by the DSM, but given that we have it, and given that a diagnoses is useful to communicate information to other clinicians, I think it should be at least give a r/o, if not the full diagonsis.

Response to psyclops..

Unfortunately with Borderline patients, the only way you can tell if it is a borderline PD is by hospitalization. Remember, the name of the disorder has an "urban legend" attached to it because supposedly doctors often confuse borderline with psychosis, depression, anxiety or bipolar. Sometimes you need a day or 2 to properly observe the patient in a controlled manner.

Unfortunately, this leads to a problem I mentioned earlier. If that patient is in the hospital for too long, the doc under pressure from the hospital to make money may slap a diagnosis they might not even believe is correct for billing purposes. E.g. the patient is actually believed to be borderline, but the doc puts a "depressive do nos" dx.

So then when the patient shows up again to the hospital, and another doctor takes the case and reads the discharge summary and it says Depressive DO NOS--well I'm sure you get the point.

But I definitely agree that an honest diagnosis should be used, even if its one that's non-PC. As I mentioned above, several of my own borderline patients, if I take the time to explain the diagnosis with them actually take it in a positive manner, and it often serves as a stepping stone for them to understand the nature of their behavior.

E.g. I told a young female patient about the diagnosis, its causes and how it is often connected to low self esteem. After this, she started obtaining self help books on the disorder and on treating low self esteem and from there showed improvement. Had I just kept her in the dark about her diagnosis, I do not think she would've improved.

outofhere said:

I am not of the camp to diagnose PD as an inpatient psychiatrist. I think that carrying a PD has tremendous implications- for instance, the fact that we are even discussing if we discriminate against BPD... Therefore, I was taught that as much as I think someone is BPD, to write on the Axis II as r/o borderline traits, and only if I am nearly certain. Otherwise, I always defer. Simply put, a BPD needs to be evaluated on the long term- we all have some of these traits to some degree, and under the stress of being involuntary, it is hard not sway a little bit more to the regressed side.

I guess I find it hard to believe that being told your personality is 'wrong' can make one more relieved that whatever is going on has a name. I would personally find it more useful, if a therapist said, "some people have relationship difficulties more than others, and seems like you have more than most...etc," and frame it in a psychotherapy way. Keep in mind, that Freud did not have a DSM to use, and many of his patients would qualify as borderlines...

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Agreed that if you are at a facility which is set up for shorter hospital stays, disclosure of the BPD diagnosis should be done by the outpatient providers. State hospitals have the luxury of being able to keep the patients longer, therefore have more time to provide the appropriate treatment before discharging.

The idea of telling a patient s/he is "fundamentally flawed" is disturbing to me. I have three patients who I'm currently working with to whom I've disclosed their Axis II diagnosis (and this doesn't count the people I've already told or who came in already diagnosed). It's a process, not a one-time shot. Here's what I've found works pretty well for me-
Talk to them about their capacity for emotional regulation. My clients tell me that they've always been dysregulated. To paraphrase a client, "My meds are working, I know that. My moods are stable. But sometimes something sets me off and -BAM- I just go OFF."
Link that dysregulation to the unstable sense of self and interpersonal relationship conflicts that are characteristic of BPD. Have them give examples of when the dysregulation affected both of these.
Do a reading from a DBT skill-building workbook on one individual's experience with the disorder, leaving out the name of the diagnosis. EVERY client I've done this with has identified strongly with it.
Name the diagnosis for what it is. Several people I've worked with have expressed relief that there's a name, that others have been diagnosed, that they're not alone... the reading I use also refers to BPD as "emotional intensity disorder" which I like as a more descriptive diagnosis, so I will alternate between the two.
Homework assignment: give them a copy of the reading, give me your experience in your words.
Talk about the stigma associated with BPD, clinicians' attitudes, what they may or may not have heard about it in the past.
Psychoeducation by reviewing the diagnostic criteria and putting specific examples from their life on each of the criteria which they meet.
Start the DBT skill-building stuff. (Unfortunately I don't have the space to do the groups, so I work with people individually on this.)

I'd be interested to see how others disclose the diagnosis to their patients.

I'm also interested in hearing from the psychiatrists whether they do the disclosure themselves? For every patient I've disclosed to, I've always consulted the psychiatrist to confirm the diagnosis, and they've always been, uh... gracious?.. enough to tell me that they'll just step aside and let me do the disclosure.

If I got a patient who I believe is borderline...

I try to present it this way.

I'll ask them several things which are strongly correlated with the diagnosis.
1) Are your parents divorced?
2) Do you cut yourself?
3) -if the patient is a female: did your father leave the family structure before you hit puberty...

Usually after a few such questions, the patient has said yes to the overwhelming majority of them, and is now wondering if I am psychic.

I then ask them, without trying to feed them the DSM IV list about their personal relationships etc.

Then after I've heard enough to have enough DSM diagnostic criterion I tell them I believe they have that diagnosis.

At this point, often the patient believes I'm dead on correct in knowin their problem. E.g. when I ask them--did your parents divorce before you hit puberty (something which has been empirically been correlated with BPD in female pts) they're thinking -how the heck did you know that?

And this makes them very open into believing I understand their problem.

I then tell them to not view the diagnosis as a label. I reassure them that BPD is not seen as a biochemical imbalance but more of a personality disorder and I explain to them the difference, which often relieves the patient. I also tell them what options they have for therapy, and that psychotherapy, not medications are often the best way to treating it. I also try to motivate them to read up on the disorder and encourage self help books and if possible an outpatient psychotherapist.

I also reassure them that I'm not psychic. I've had some patients actually get creeped out but in a positive manner because they claim I got so many things with them correctly nailed down. I tell them that the human mind's circuitry despite being unique to each person has several commonalities. With BPD, studies show which landmark life events can trigger this disorder. Despite the oddness to this, it has been very positive. It makes the patient feel I really know who they are and what their problem is, and by reassuring them I'm just another guy, it also helps the doctor-patient relationship. I try to enforce the idea that if they understand the disorder, just as I've been educated in it, they'll be able to help themselves.

When possible, I also try to involve the family, since family issues have been correlated with this disorder.

A couple of things, Emotional disregulation disorder I don't think captures the interpersonal aspects fo the disorder, which I believe are paramount.

Also, paraental divorce, although correlated, I wouldn't think would be causal. Parents who have problems, like many of the parents of BPD patients do, will divorce at a much higher rate. So I think it is misleading to tell them that as if it were a cauasal factor. maybe I'm misunderstanding your post?

Well I don't tell them its a causal factor, though who knows? Maybe it is.

As a psychologist Psyclops, I'm sure you've been given the statistical correlation does not mean causation argument several times in statistics-which we MDs get, but not as often.

If a patient does feel creeped out by specific questions I ask them which seem to be directly related to them, I mention that I believe they have BPD because they're showing all the classic correlations.

Now are parental relationships causal? IMHO they are in at least several cases of BPD. The opinion is not scientific, but based on personal opinion and it has some basis in theory given the physiological-evolutionary makeup of child rearing, and given several psychoanalytic theories tie personality d/o's with parental rearing.

Which would lead to an interesting paper---an exact causal basis for BPD. To my knowledge, none exist.

My bad Whop, I meant to imply that the correlation was most likely not due to causation in this case. But I didn't clarify enough. And, I assure you we get the C no = C all the time, probably even more than the MD since we tend to be a more research related degree.

This is quite an interesting thread.

I have not had the experience working at State or long term inpatient facilities- but I can see how that would be a good place, in the midst of intense group work/individual sessions, to make the diagnosis.

I am not sure if cutting is so closely correlated, or at least, a history of cutting. Some teenagers just cut- and it seems to be quite a fad, right now anyway. Not all cutters have bpd, maybe traits, but not the pd dx.

In terms of parental influence, I think it is more related to inconsistent parenting: which may be more likely to happen in a divorced family, but not 100%.

I think of these patients as never able to get what they really want emotionally, a really sad state, of course.

I think the questions of "Do we discriminate against borderlines?" and "do we have negative countertransference to borderlines?" are getting confused here. Of course we have negative countertransference to borderlines... generating countertransference is the entire dynamic motivation of borderline behaviors. We have negative countertransference to borderlines almost by definition. BUT, managing the countertransference is part of what we do as psychiatrists. If you allow the countertransference to influence the treatment in a negative way, then yeah, you're discriminating against someone based on their diagnosis (in exactly the same way that's documented here in the multiple posts dealing with "annoying" addicts who haven't managed to stay sober after multiple detoxes).

The real sign of discriminating against borderlines is this whole idea of not wanting to make a diagnosis. By defering Axis II or using the ridiculous "r/o Cluster B Traits" as a euphemism for BPD, we only increase the stigma attached to that diagnosis. In much the same way that physicians in the 50s and 60s wouldn't use the word "Cancer", but said malignancy, growth, neoplasm, etc. instead, the diagnosis itself becomes something to avoid. The reason things changed with cancer is that it went from an untreatable certain death sentence, to a disease that you might have a fair shot of surviving. There IS treatment for BPD (DBT), so we should stop doing these pts a disservice by refusing to make the appropriate diagnosis and getting them the appropriate treatment.

Point well taken.

I have been thinking, maybe the way I think about borderline is very much shaped by the clinic I have been training at- in some ways, the system discriminates against BPD. Sure, we have DBT, but you must have a 'medical necessity' axis I dx to be in tx in the first place. DBT was started as a way to save $, since these pts kept showing up to the ED/hospital. So, to be in DBT, you also need to have used the hospital facilities at least 2 or more times...etc. The focus therefore, is on the axis I dx, and with this population, I have not had the experience of telling someone they have BPD.

That aside, though, I see how 'hiding' one's axis II dx is unethical. However, I think this is hardly on the level of not telling someone they have cancer. Because, the system does not view axis II d/o in the same way as it sees cancer, depression...etc. You can call up private practitioners and say, "I have cancer/depression..." and they will set up an appointment with you. My impression is, (since I am not in private practice), you call up a private psychiatrist and say, "I was recently dx with BPD, let me come see you, please." I would think the majority of these practitioners will say, "ummm, I am full," as it is highly demanding to meet the needs of a BPD in private practice. Is it more important to have the pt know what ultimately will hinder their path to wellness? I am going to ask my supervisors (the ones in private practice) when I see them, and update this thread on what they say.

"I am but a naive soon-to-be intern, but I don't get how it can be ethical and legal to keep a patient's diagnosis from him or her."

I totally agree with the last batch of posts.

If you keep a diagnosis hidden from your patient you are actually committing what could possibly be considered malpractice should the patient's lack of knowledge of their diagnosis cause them harm.

IT IS CONSIDERED A STANDARD OF CARE TO INFORM YOUR PATIENT OF THEIR DIAGNOSIS & TREATMENT.

To suggest otherwise violates the standard of care and you better have a good reason to do so and document if you choose to do so, and quite frankly I can't really think of anything offhand that justifies it though I'm sure there are few.

Now in defense of some of the above posts, there are times where you can greatly suspect borderline, but won't document it and that can be justified, because to do a real diagnosis, you have to properly justify true DSM diagnositic criterion. Several docs don't do that. They just see some borderline traits, consider the patient is borderline, but don't document it because the patient may be under their care for other reasons. However IMHO if the patient's borderline PD is of direct reason why they are being treated, you better document it and discuss it with the patient.

When I have a pt on the unit, and we're recommending DBT for BPD, I give them a couple of articles printed @ 2 yrs ago in the New York Times:

"With Toughness and Caring, a Novel Therapy Helps Tortured Souls":
(crap, these links don't work!)

and

"So Far, Holding Up Under Scrutiny": (about DBT, same author)
(Google "new york times article dialectical behavioral therapy"--these articles are the first things to come up)

A lot of pts seem to find the articles really resonate with them, and they are more open to DBT after reading the articles. I also try to let them know that a lot of what they might read on the internet about Borderline PD is very negative, but that this treatment has been helpful to a lot of pts with BPD.

Thank you for the links. This will be a welcome addition of materials to give to my patients with BPD.

Alright. I am back.

I discussed this topic with one of my supervisors. She asked me, "but what about 'first do no harm?'" She is of the opinion that some BPD will be ready to hear this dx, but some just are not, and to tell them will actually make them become unglued more, whereas to work on their axis I dx will be more useful, until they are ready to hear it. Secondly, this attending, who used to be an attending with UCSF (highly well read and respected), also thought that DBT is NOT definitely a cure, and so this issue is NOT completel black and white. I find it interesting that this discussion had become so polarized (split) that it is a similar process that happens within a BPD person! (Isn't that interesting?)

I have worked with patients who have been told they have BPD, but those BPD in general, are much more high functioning and actually were able to process the meaning and prognosis of BPD. I believe that the ones with the most pathology (the population at my training program) are much lessly to be able to find this label useful.

I will see a few more supervisors next week and will ask the same question. I will keep you folks posted.

outofhere said:

Alright. I am back.

I discussed this topic with one of my supervisors. She asked me, "but what about 'first do no harm?'" She is of the opinion that some BPD will be ready to hear this dx, but some just are not, and to tell them will actually make them become unglued more, whereas to work on their axis I dx will be more useful, until they are ready to hear it. Secondly, this attending, who used to be an attending with UCSF (highly well read and respected), also thought that DBT is NOT definitely a cure, and so this issue is NOT completel black and white. I find it interesting that this discussion had become so polarized (split) that it is a similar process that happens within a BPD person! (Isn't that interesting?)

I have worked with patients who have been told they have BPD, but those BPD in general, are much more high functioning and actually were able to process the meaning and prognosis of BPD. I believe that the ones with the most pathology (the population at my training program) are much lessly to be able to find this label useful.

I will see a few more supervisors next week and will ask the same question. I will keep you folks posted.

Click to expand...

Many of the borderlines I work with already know their diagnosis, and indeed, wear the dx as a sort of "badge of courage; constantly using it as an excuse for their inappropriate behavior, reminding you on the phone on call that they are borderline, and that's why they need to talk tonight, and so forth.

I'm not a big believer of witholding diagnoses from patients. While I understand the potential awkwardness of telling someone that their essential core being is misformed, the worse part of valor might be to withold a diagnosis with the belief (not based on any evidence) that somehow telling them would crush their soul. There are ways to put things...delivering bad news is what doctors do.

Often, newly formed borderlines are looking for some sort of answer or explanation to help them understand their behaviors and maladaptive patterns. I would argue that telling them might even make their burden that much lighter....."We all have some flaws in our character. Some people have have patterns in their personalities that make their lives harder than what others experience. Your pattern of personality is called 'borderline personality,' and explains a lot of the difficulties you're having. People with borderline personalities often exhibit x...y...and z..." This usually garners a "Hey, that's me! response" in my experience.

We've told patients they've had terminal cancers, Hepatitis C, stds from supposedly faithful partners. Bad news is just that - bad news. Borderline personality disorder is bad news, and you can't make the assumption that telling a patient they have this diagnosis will throw them into a life-threatening psychosis or have them run for the nearest railroad tracks to lay in front of. An open diagnosis makes it much easier to discuss treatment regimens, refer them to other specialists or facilities, and discuss new research that may be of benefit to them. This is in opposition to keeping them in the dark, and prescribing medicines for some amorphous condition. Just my thoughts.

outofhere said:

Secondly, this attending, who used to be an attending with UCSF (highly well read and respected), also thought that DBT is NOT definitely a cure, and so this issue is NOT completel black and white.

Click to expand...

This is very consistent with the research on DBT. Evidence suggests that the treatment results in a significant reduction in self-harm behaviors, but not much else.

But, interestingly, these data are somewhat consistent with the treatment model itself - the purpose of DBT isn't to "cure" patients but to help them recognize their symptoms and to use alternative coping strategies to deal with them. For example, the aim isn't to eviscerate affective dysregulation - in fact, we work with patients to help them "accept" the fact that they are going to continue have intense mood swings. But by accepting and labeling the symptoms (e.g., "a thought is just a thought"), the patients can be better prepared to use their new skills.

Very good post sazi, I agree entirely. I can't see a reason not to tell a patient their diagnosis indefinetly, maybe for a day if they were highly agitated, but not keeping it for "some later date". By your (or you supervisor's) logic, do no harm, we shouldn't tell anyone anything bad. It might cause them distress! It's like logic that goes into awarding the burglar a settlement who broke his leg breaking into your house.

LM02 said:

This is very consistent with the research on DBT. Evidence suggests that the treatment results in a significant reduction in self-harm behaviors, but not much else.

But, interestingly, these data are somewhat consistent with the treatment model itself - the purpose of DBT isn't to "cure" patients but to help them recognize their symptoms and to use alternative coping strategies to deal with them. For example, the aim isn't to eviscerate affective dysregulation - in fact, we work with patients to help them "accept" the fact that they are going to continue have intense mood swings. But by accepting and labeling the symptoms (e.g., "a thought is just a thought"), the patients can be better prepared to use their new skills.

Click to expand...

Great post, LM! Marsha Linehan is the first to admit that DBT is not a cure, rather a set of tools to help people manage their symptoms and increase their distress tolerance.

Her website has a lot of helpful info for patients, families, and clinicians, tools, and FAQs about DBT-
www.behavioraltech.org

OK kids, this is maybe only loosley related to this. But I think it captures the essance of the arguement as I see it.

http://www.cnn.com/2006/HEALTH/07/05/obese.kids.ap/index.html

I am of the calling a spade a spade camp. And when the public takes medical terms and uses them as pejoratives they can take on negative undertones. But I don't think that is a reason for us to stop using them.

On another note, LM02 = Linehan, Marsha '02?

Psyclops said:

On another note, LM02 = Linehan, Marsha '02?

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Haha - love it.

Nah, I just happened to have received somewhat extensive training in DBT over the years... But not in Seattle!

Though I have seen her speak at a conference or two.

Perhaps it would ben an interesting exercise, for those of us in residency, to ask our supervisors what they think and do. I suspect that the opinion will be quite mixed.

So far, I have yet to find an attending who absolutely discloses the BPD dx. These attendings trained at BIG name institutions in CA. Maybe it is regional thing? I will also ask my peers in process group when I get a chance.

whopper said:

Let's all admit it. Somewhere in our younger lives, we did things which could be considered "Borderline". However we probably also had better families, a more stable upbringing, etc.

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"Better families" ain't diagnostic, Dude. There are Borderlines in the very best families, after all. Even in intact families, for that matter. I think the attitude that only lousy families can create Borderlines is part of the stigma against it.

As for most of us doing things in our younger days which could be considered "Borderline," there's a phrase from the DSM I think you should remember: "Persistent and Pervasive." Having a fit because your high school steady breaks up with you doesn't mean you're Borderline; nor does sleeping around in college, nor driving too fast when you're upset. None of those things, as single incidents or even as a pattern that lasts a limited time, are diagnostic.

Hell, I check to make sure I have my car keys before I close the car door every time -- does that make me OCPD? Or just someone who had AAA on speed dial for years?

whopper said:

Finally and this is something where I disagree with the blog: several people have Axis II d/o's. Just because someone has an Axis II doesn't mean they necessarily need treatment. Most teens & college aged people have some form of cluster B traits-does that mean I should treat them? Of course not.

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Of course not, because having some traits is not having a disorder! It's simply having some traits. That's why the DSM includes minimum thresholds for those traits, and has that funny alliterative line in the PD section: Persistent and Pervasive. It also says that the traits must be long standing, apparent from adolescence in some cases, and isn't there a suggestion that PD traits are ego-syntonic?