Depression? Borderline? PTSD?

[randomdoc1]

I know these disorders can all be comorbid with each other and of course, I know the DSM-V criteria for them. But my question is this, what are findings you've come across that were helpful in teasing out if someone has say, predominantly borderline personality disorder or PTSD as opposed to MDD (especially treatment resistant cases) and persistent depressive disorder (or vice versa)? They have many overlapping findings such as the mood disturbances, effects on behavior, concentration, course of illness, etc. Many histories are not the most straightforward. Some findings I felt helpful (of course they are not the final determinants of my assessment) are things like:
-numerous failed adequate medication trials (although admittedly I rarely see a person who was trialed on an MAOI...I remember 1 person who had a dramatic response when people were starting to suspect a personality disorder too!)
-timing of initial onset of symptoms (such as in association with a major trauma)
-if symptoms are chronic and consistent versus a clearly episodic nature
Also, many patients have comorbid substance use disorders too, making the diagnosis even more challenging. It just seems like so many people get labeled with "depression." However, if some of these cases are truly primarily borderline personality disorder or PTSD instead, that would certainly change my treatment approach. Thoughts?

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[smalltownpsych]

If they have recurring nightmares or intrusive meories and have symptoms of hyperarousal due to a significant life threatening or sexual trauma they have experienced, then they have PTSD. If the trauma happened when they are a kid and they have chaotic interpersonal relationships and self-harm, then they have BPD. If they don't have trauma and are really, really depressed (physiological signs are good for this differential IMO), then they have MDD. If they have a problem with substance abuse, then you have to treat that too. The problem you are running into is that depressed mood is merely a symptom and medications do little or nothing to alleviate that symptom. So we end up with the majority of our patients who are taking medications that don't help.

 

[randomdoc1]

If they have recurring nightmares or intrusive meories and have symptoms of hyperarousal due to a significant life threatening or sexual trauma they have experienced, then they have PTSD. If the trauma happened when they are a kid and they have chaotic interpersonal relationships and self-harm, then they have BPD. If they don't have trauma and are really, really depressed (physiological signs are good for this differential IMO), then they have MDD. If they have a problem with substance abuse, then you have to treat that too. The problem you are running into is that depressed mood is merely a symptom and medications do little or nothing to alleviate that symptom. So we end up with the majority of our patients who are taking medications that don't help.

Interesting point about considering physiologic complaints. I agree that depressed mood is just a symptom and feel like people often jump too quickly to label it as MDD. For example, someone with BPD can chronically feel empty, have unstable self image, transient psychosis, and suicidal thoughts. It has also been my observation that people with BPD as opposed to another disorder, the chaotic intense interpersonal relationships seems to prop up more. Although, not everyone with BPD necessarily has this. Looking at the DSM-V, there are 9 symptoms listed, you need 5 to meet criteria. So you can have two people with BPD who only have one symptom in common. Anyways, a person with MDD can also present as angry, depressed, emotionally act out, have SI, and of course that's not good for interpersonal relationships...

Likewise, someone with PTSD can easily complain of impaired concentration, depressed mood, anhedonia, irritability, and impulsivity. I've come across many who were labeled as having MDD to have symptoms which can be seen in MDD but they all seemed to be somehow tied to a prior trauma.

Thanks for your post! Just thought it would be fun to discuss because as I got to know some patients longer term in my career what I originally thought as MDD too in some cases started to pan out looking more like PTSD, BPD, or vice versa.

 

[PistolPete]

Good points. Some consider BPD to be a variant of PTSD. But the above points by smalltownpsych are good at trying to tease out the difference. For BPD you can also ask if they ever had a transitional object and if they did, how long did it take them to give it up? This is also called the "teddy bear sign" since if you see a patient on an inpatient unit with 2 or 3 teddy bears, odds are they have BPD.

 

[PsyDr]

Get psych testing to clarify.

 

[WisNeuro]

The Teddy Bear sign lacks specificity.

 

[randomdoc1]

The Teddy Bear sign lacks specificity.

How about the luggage sign?

 

[WisNeuro]

How about the luggage sign?

Depends, I've seen some generational differences on that one.

 

[SeniorWrangler]

The patient gets to have as many diagnoses as they like, and the DSM is silent about etiology. The combination of PTSD+BLPD+Depression/Bipolar is extremely common in my experience and probably represents some underlying process.

 

[smalltownpsych]

Interesting point about considering physiologic complaints. I agree that depressed mood is just a symptom and feel like people often jump too quickly to label it as MDD. For example, someone with BPD can chronically feel empty, have unstable self image, transient psychosis, and suicidal thoughts. It has also been my observation that people with BPD as opposed to another disorder, the chaotic intense interpersonal relationships seems to prop up more. Although, not everyone with BPD necessarily has this. Looking at the DSM-V, there are 9 symptoms listed, you need 5 to meet criteria. So you can have two people with BPD who only have one symptom in common. Anyways, a person with MDD can also present as angry, depressed, emotionally act out, have SI, and of course that's not good for interpersonal relationships...

Likewise, someone with PTSD can easily complain of impaired concentration, depressed mood, anhedonia, irritability, and impulsivity. I've come across many who were labeled as having MDD to have symptoms which can be seen in MDD but they all seemed to be somehow tied to a prior trauma.

Thanks for your post! Just thought it would be fun to discuss because as I got to know some patients longer term in my career what I originally thought as MDD too in some cases started to pan out looking more like PTSD, BPD, or vice versa.

Yup. Both the patients with chronic PTSD and BPD will have significant amount of depression and at times medication can be helpful. Probably more so in an uncomplicated PTSD case than in BPD. Especially since the medication can become part of the unstable object world that these patients have. Hence the increased placebo effect that tails off rapidly after about two weeks that is found with BPD and the resultant polypharmacy that this can engender.

The Teddy Bear sign lacks specificity.

Of course, with a base rate of about 20%, it usually isn't that hard to pick out the patients with BPD from the rest of the milieu. I think the scars on their arms and thighs and good interpersonal skills (relative to the others on the unit) are a pretty reliable indicator. No need for teddy bears.

 

[smalltownpsych]

The patient gets to have as many diagnoses as they like, and the DSM is silent about etiology. The combination of PTSD+BLPD+Depression/Bipolar is extremely common in my experience and probably represents some underlying process.

Yup. CLS. Crummy Life Syndrome. That's when the debate between genes vs. environment is moot cause they got dealt a crummy hand from both.

 

[Jules A]

Of course, with a base rate of about 20%, it usually isn't that hard to pick out the patients with BPD from the rest of the milieu. I think the scars on their arms and thighs and good interpersonal skills (relative to the others on the unit) are a pretty reliable indicator. No need for teddy bears.

Throw in recompensation immediately upon arrival to the inpatient unit and I don't even need to see the sutureless scars to figure its a BPD slam dunk.

 

[deleted314290]

The patient gets to have as many diagnoses as they like, and the DSM is silent about etiology. The combination of PTSD+BLPD+Depression/Bipolar is extremely common in my experience and probably represents some underlying process.

Or that you can bill for high complexity medical decision making...

 

[AcronymAllergy]

Yup. CLS. Crummy Life Syndrome. That's when the debate between genes vs. environment is moot cause they got dealt a crummy hand from both.

I always liked Inadequate Personality Disorder (although not always the same as what you're discussing), and feel like we might've really lost something when that was tossed after DSM-2.

 

[tr]

The patient gets to have as many diagnoses as they like, and the DSM is silent about etiology. The combination of PTSD+BLPD+Depression/Bipolar is extremely common in my experience and probably represents some underlying process.

Ok but every DSM diagnosis carries the disclaimer that the symptoms are not better accounted for by another condition. So if the pt meets criteria for PTSD and MDD but all symptoms are traceable to the trauma, they only get one diagnosis.

No purpose is served by creating DSM jambalaya.

 

[randomdoc1]

Ok but every DSM diagnosis carries the disclaimer that the symptoms are not better accounted for by another condition. So if the pt meets criteria for PTSD and MDD but all symptoms are traceable to the trauma, they only get one diagnosis.

No purpose is served by creating DSM jambalaya.

lol. This doesn't directly pertain to my original questions but I get annoyed whenever I see notes about a single patient reportedly having ADHD, OCD, anorexia nervosa, bipolar disorder, PTSD....etc. etc. Whenever I see that, it makes me think personality disorder and/or crummy life syndrome.

 

[splik]

I know these disorders can all be comorbid with each other and of course, I know the DSM-V criteria for them.

not sure why you say of course, i'd be impressed if you did, I would say at least 95% of psychiatrists would not know the diagnostic criteria for both BPD and PTSD. I did a straw poll a few years ago challenging various psychiatrists and not one of them could tell all the criteria for BPD, and the PTSD criteria are so complicated unless you are doing the CAPS all the time you probably don't know it (I certainly do not know the criteria and I consider myself to have a pretty good knowledge base!)

 

[randomdoc1]

not sure why you say of course, i'd be impressed if you did, I would say at least 95% of psychiatrists would not know the diagnostic criteria for both BPD and PTSD. I did a straw poll a few years ago challenging various psychiatrists and not one of them could tell all the criteria for BPD, and the PTSD criteria are so complicated unless you are doing the CAPS all the time you probably don't know it (I certainly do not know the criteria and I consider myself to have a pretty good knowledge base!)

I guess I just assumed as psychiatrists we'd be expected to know the criteria by heart for at least some of these more commonly encountered diagnoses? But I agree, I wouldn't be surprised if I were to find many do not know the criteria by heart. It's still kind of fresh in my mind since I'm just out of residency and the clinical skills exams were not that long ago. So, in the last part of my residency, a fair amount of time was spent repeating the criteria in my thoughts in preparation to do well on the exam. I'm sure they'll slowly fade in and out of my memory too if I don't regularly visit the DSM-V and quiz myself. Especially the criteria for PTSD. It's kind of a bear. Now if you ask me to recite the criteria for avoidant personality disorder, schizotypal, various impulse control disorders, etc...I will not know the exact criteria for a lot of them.

 

[PistolPete]

lol. This doesn't directly pertain to my original questions but I get annoyed whenever I see notes about a single patient reportedly having ADHD, OCD, anorexia nervosa, bipolar disorder, PTSD....etc. etc. Whenever I see that, it makes me think personality disorder and/or crummy life syndrome.

I understand what you're getting at, but it's also true that co-morbidity is the rule, and not the exception. The patient can have as many diagnoses as they want.

 

[splik]

I guess I just assumed as psychiatrists we'd be expected to know the criteria by heart for at least some of these more commonly encountered diagnoses? But I agree, I wouldn't be surprised if I were to find many do not know the criteria by heart. It's still kind of fresh in my mind since I'm just out of residency and the clinical skills exams were not that long ago. So, in the last part of my residency, a fair amount of time was spent repeating the criteria in my thoughts in preparation to do well on the exam. I'm sure they'll slowly fade in and out of my memory too if I don't regularly visit the DSM-V and quiz myself. Especially the criteria for PTSD. It's kind of a bear. Now if you ask me to recite the criteria for avoidant personality disorder, schizotypal, various impulse control disorders, etc...I will not know the exact criteria for a lot of them.

I think a lot of people think "I know it if I see it" and the overwhelming majority of psychiatrists do not stringently apply the criteria (which might explain all the bs diagnoses). I know the dx criteria by heart for mood disorders, anxiety disorders, psychotic disorders, and functional neurological symptom disorder - that is about it! But then I don't use DSM diagnoses (or criteria) in my clinical work and for forensic work I look it up!

 

[tr]

I think a lot of people think "I know it if I see it" and the overwhelming majority of psychiatrists do not stringently apply the criteria (which might explain all the bs diagnoses). I know the dx criteria by heart for mood disorders, anxiety disorders, psychotic disorders, and functional neurological symptom disorder - that is about it! But then I don't use DSM diagnoses (or criteria) in my clinical work and for forensic work I look it up!

Yeah I only know mood and anxiety criteria well. PTSD is a bear but in practice if you recall the categories it isn't terrible. If I uncover a trauma history (criterion A) I ask about whatever symptoms I can remember from each of the B categories ( re-experiencing, avoidance, cognition/mood, arousal/reactivity). Often a lot of information on the latter two will have come from other parts of the interview. I may not be able to conclusively rule out but I can often rule in this way.

For people with chronic childhood trauma who don't fit BPD criteria I often designate them complex PTSD. It's not in the DSM yet but I feel we need a way to acknowledge the categorical differences between people who had ongoing adversity in early life vs those who experienced trauma as adults with formed personalities.