do you tell your Borderline pts about their diagnosis?

[fiatslug]

I find there is a disturbing "conspiracy of silence" among mental health professionals about the diagnosis of borderline PD. I work in a Partial Hospitalization program, and will often see pts who are in outside therapy (sometimes for years) and while their borderline characteristics are clearly evident, their therapists never talk about it with them. I get why we all do this, on one level: there's a huge prejudice in mental health against borderlines, and having that label come up when you pull up a person's record could facilitate dismissive treatment of the pt. But really, I think that argument rings hollow--it's not like, without that diagnosis in the chart, their character pathologies are magically hidden from other providers...

In my experience, having the conversation about borderline PD is an important part of treatment. Mind you, I do get motivated borderlines (my fav patients, actually, so my countertransference is positive and hopefully helps to shape how they hear this) in my program. Certainly there are borderlines of the more impaired variety (who help create some of the negative countertransference against borderlines in our field). People are coming in b/c they are recognizing, hey, something in the way I conduct my life ain't working, and I find them to be receptive to the diagnosis. Of course I preface it by telling them not to Google borderline PD, b/c it'll make you feel bad about yourself, and also often give them the Marsha Linehan article from the NYT last summer where she outed herself as someone who suffered from borderline PD.

I get frustrated with the long term outpt therapists who seem to collude in the silence around the borderline diagnosis. I mean, I've had patients who have gone through DBT in the past who have never heard of borderline PD --WTH? Honestly, some patients who have made the biggest leaps seem to do it in the context of understanding so much more about themselves because of the context the diagnosis (and discussions about etilogy and antecedents) gives their own hx.

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[whopper]

To some, giving the patient a specific diagnosis labels them. One patient I met told me it freed her because upon realizing she had the exact DSM criteria of it, and knowing there was a treatment for it, it gave her hope that this wasn't happening to her alone and she just didn't have something where no one kenw what to do with it.

Not every patient will act in this manner. First you got to be confident in the diagnosis though often times diagnosing it is not the hardest thing in the world.

Don't present it as a type of shameful diagnosis. Many healthcare professionals, and I include myself in this at least years ago before I knew more about it (and the people in my residency weren't training me much on it), see people with borderline as troublemakers. This is not the type of disorder where the person wants to be dysfunctional by choice and they don't have as much control over their emotions that tend to blow up far worse than most of us experience. They are not supposed to be enabled either and seen as victims to the degree where their bad behavior is excusable. We are supposed to start in teaching them the tools of getting better while not allowing them to get away with further ineffective behavior.

It's like being a parent with a problematic kid. We're not supposed to hate the kid for the problem, but we're not supposed to give in to them either. We're supposed to do the right thing-that is get them to understand why it's wrong and try to stop the bad behavior without causing harm.

In an emergency or inpatient setting this is pretty much on the order of next to impossible which is why it doesn't really help to hospitalize most borderline patients. It's not going to solve the problem.

When I present it, in general, I mention they have the signs and symptoms of the disorder and that I speculate the person may have it. I ask them what they think and if they believe me. I try not to make it the type of thing where it's their fault but do tell them they have a responsibility to fix it. I also mention that there is treatment for it, but it can take months, even years, for the person to get significantly better and they have to work on it diligently. Usually from there, I sedge-way that I'm not a DBT therapist but I'll refer them to one since I believe there's better people that can treat this than I.

The most I've ever gotten with a borderline patient in one session was I got the patient from yelling at me and acting as the typical terrible borderline patient to crying, breaking down, and say she believes she has the disorder and wanted help. I was working in a local private facility, and I gave this patient about 3 hours of treatment when most people get 1/2 an hour. I realized we made a huge advancement and I just couldn't walk out on it. I got a bunch of material for her including the NY Times Linehan article on her self-disclosure of having it and did an extended psychotherapy session. I ended up calling my wife who had dinner ready telling her I had one of those miracle sessions with a borderline patient where she's actually understanding what it is, what she needs to do, and why she's been hating herself for years and I needed to take it as far as it would go. I ended up getting home 8PM when I should've been home about 5:30. She went from having to be injected quite a few times, to after having that conversation, for the rest of the weekend was fine.

Man, that was one of the only times in my life I was seeing a patient that finally saw the light while I had them right there in front of me. I just couldn't leave in the middle of it without trying to see if I could help further it along and made sure it stuck.

Several borderlines, if treated like a troublemaker will just further act in that manner. No, you can't tolerate their bad behavior. You may have to inject them, but when doing so, try to make them understand why it's happening. E.g. if a borderline patient is throwing items, and will not calm down and you end up having to inject her and put her in restraints, a thing I've started doing is when they wake up, I talk to them and tell them we had to do it for safety reasons and that I hope they don't feel traumatized by it. I also tell them that we don't want that to happen again and ask them if there's anything we can do together to prevent it, but I never let them feel they can ever get away with acting like that again while under my watch.

 

[OldPsychDoc]

Tell them. It gets them on the road to an actual, effective treatment program. I'm tired of them thinking they have "bipolar".

 

[fiatslug]

Tell them. It gets them on the road to an actual, effective treatment program. I'm tired of them thinking they have "bipolar".

Exactly my thoughts!

 

[Slingshot]

I think you have to look at it by a case by case basis. Of course I never withhold information about the diagnosis but I do not necessarily get into details of the diagnosis with every borderline. Thankfully now that I do my own cash practice I can choose to simply not take this people if it is clear upfront but they will surely sneak in down the line.

Sometimes it is good and sometimes not.

If someone is the type who you know or anticipate really buying into the diagnosis then having an actual "diagnosis" can help them start to take steps to move forward and be more invested in treatment.

On the other hand, if you get the feel a person will not buy into the diagnosis, then you risk labeling them with "only" a personality disorder and they feel their symptoms are discounted.

So depends on if you can guage the willingness of the patient to accept and buy the diagnosis wholeheartedly. I hate treating them and hope to never see one again as they are sure difficult to manage!

 

[fiatslug]

I hate treating them and hope to never see one again as they are sure difficult to manage!

Hmmm, I feel entirely the opposite. I find the patients who get the best traction, who make the biggest leaps in treatment are motivated borderlines. I find it extremely gratifying to work with them. Which is not to say every borderline is a delight to treat, certainly... but I'd take a schedule full of borderline pts over somatically preoccupied help-rejecting complainer types any day!

 

[OldPsychDoc]

I think you have to look at it by a case by case basis. Of course I never withhold information about the diagnosis but I do not necessarily get into details of the diagnosis with every borderline. Thankfully now that I do my own cash practice I can choose to simply not take this people if it is clear upfront but they will surely sneak in down the line.

Sometimes it is good and sometimes not.

If someone is the type who you know or anticipate really buying into the diagnosis then having an actual "diagnosis" can help them start to take steps to move forward and be more invested in treatment.

On the other hand, if you get the feel a person will not buy into the diagnosis, then you risk labeling them with "only" a personality disorder and they feel their symptoms are discounted.

So depends on if you can guage the willingness of the patient to accept and buy the diagnosis wholeheartedly. I hate treating them and hope to never see one again as they are sure difficult to manage!

So does that conversation go?

"My frank assessment is that you have depression, frequent mood swings, difficulty managing your emotions and relationships, and impulsive feelings of self harm. These might be somehow related to your chaotic upbringing and history of early life traumas, but I find it too difficult to manage such problems and I would rather not discuss with you the details of your probable diagnosis or an effective treatment approach, because you might not like it. So either show up with some problem I want to treat, or get out of my office."
???

 

[BobA]

We recently had grand rounds by John Gunderson, MD, one of the world's foremost expert on BPD, and he was adamant that you should tell patients about their diagnosis.

Furthermore, not telling them violates the basic medical ethics principle of autonomy. It's unethical not to tell someone their diagnosis.

With the rare exception, it's gone well for me each time I've told patients about it. I usually give them a handout and recommend some websites for them to research it further on their own.

However, I think therapists who are not MD's are trained in a different model. They often don't use the DSM so it seems.

 

[whopper]

I hate treating them and hope to never see one again as they are sure difficult to manage!

I used to feel the same way. I attribute it to lack of appropriate training since no one in my general residency program knew anything about DBT other than it was the appropriate treatment for borderline PD. There was no one in the hospital's system trained in it. Borderlines were treated on the same order as antisocial PD patients and given meds to treat symptoms while not really accomplishing much if at all on that front.

The drama from a borderline patient could be draining before you don't know how to manage these patients.

Furthermore, not telling them violates the basic medical ethics principle of autonomy. It's unethical not to tell someone their diagnosis.

True in fact that's one of the foundations of western medical ethics. In some other cultures the ethics are different and it's considered appropriate to not tell the patient, but that's there and not here. We are bound to give our patients honest assessments and opinions.

 

[Slingshot]

That is why I speak to all potential patients on the phone first and then make it clear the initial meeting is to evaluate whether working together is a good fit. Than if I find evidence of the diagnosis I refer to a colleage who does DBT. So yes, I simply have the luxury of not seeing them and am glad for that.

Many folks do not care to know a ton of details about their diagnosis. Sometimes they just want the treatment and to move forward.

 

[whopper]

When you talk to someone about medical treatment, with some exceptions, that establishes a doctor patient relationship. Be careful how you do this. I know a Suboxone prescribing doctor that does this to weed out troublemakers. The problem here is one could argue he is now their doctor.

Although I doubt if you told a someone during this screening process of yours that you didn't think there was a good fit, they'd pursue action against you for not further treating you---though if they knew the law and wanted to be troublesome they could. Be careful.

 

[NJWxMan]

In my psychotherapy clinic, you have three sessions to determine whether the pt will be a reasonable dynamic candidate. I suspect that as long as you keep the details pertaining to ONLY history and no discussion about treatment, that you can refer the pt elsewhere. A perfect example of this is in neurosurgery in which someone presents for back pain. If the neurosurgeon rules out surgery as an option, they then refer to a pain management specialist.

When you talk to someone about medical treatment, with some exceptions, that establishes a doctor patient relationship. Be careful how you do this. I know a Suboxone prescribing doctor that does this to weed out troublemakers. The problem here is one could argue he is now their doctor.

Although I doubt if you told a someone during this screening process of yours that you didn't think there was a good fit, they'd pursue action against you for not further treating you---though if they knew the law and wanted to be troublesome they could. Be careful.

 

[zenman]

With new patients (ones that don't already know they are BPD and that I suspect might be) I have them look the diagnosis up online, (and/or BPD forums) and see if anything fits for them. So far it's worked well.

 

[vistaril]

my policy with most borderlines is to not admit them, which means there is less opportunity to talk about their dx.....

I know some people have a different strategy, but there is nothing accomplished by most borderline admissions. admitting a borderline for safety is about like washng your truck before you go mud-bogging....

 

[OldPsychDoc]

my policy with most borderlines is to not admit them, which means there is less opportunity to talk about their dx.....

I know some people have a different strategy, but there is nothing accomplished by most borderline admissions. admitting a borderline for safety is about like washng your truck before you go mud-bogging....

What about instead of thinking to yourself "OMG--another stupid borderline that doesn't have to be admitted", you were taking the attitude that you're evaluating a person who is in distress and doesn't know what to do about it? You have the wealth of training and experience to recognize what is going on in his/her frequent crises and requests for admission, and just maybe if you'll call it what it really is, provide some compassionate psychoeducation, and point them in the direction of recovery you will make a difference. And sometimes it may take an admission to get them three days away from the boyfriend, to stop the self medicating for a minute, etc... Of course, this assumes that your hospital is a semi-compassionate environment -- if every one has the "OMG another 301.83" attitude going, then it pretty much is a futile exercise of counter-transference.

These folks didn't ask to be borderline--and believe it or not, they're not doing this stuff to punish you.

 

[strangeglove]

This thread is yet another proof of the importance of psychodynamic training. It has as much to do with managing your own reactions to patients as it does with managing the patients themselves. More useful than DBT training, IMO. You can't teach skills if you are yourself unskilled.

 

[vistaril]

What about instead of thinking to yourself "OMG--another stupid borderline that doesn't have to be admitted", you were taking the attitude that you're evaluating a person who is in distress and doesn't know what to do about it? You have the wealth of training and experience to recognize what is going on in his/her frequent crises and requests for admission, and just maybe if you'll call it what it really is, provide some compassionate psychoeducation, and point them in the direction of recovery you will make a difference. And sometimes it may take an admission to get them three days away from the boyfriend, to stop the self medicating for a minute, etc... Of course, this assumes that your hospital is a semi-compassionate environment -- if every one has the "OMG another 301.83" attitude going, then it pretty much is a futile exercise of counter-transference.

These folks didn't ask to be borderline--and believe it or not, they're not doing this stuff to punish you.

been done before with almost all of these pts, at least the ones coming through here. It's not like they haven't been hospitalized before....in most cases multiple times. Hopefully(and Im sure it was), at some point in those previous hospitalizations some psychoeducation and follow up is provided. As one of my favorite attendings says "maam, we're not going to reinvent the wheel here"......

And yes, an admission would get them away from their boyfriend for a few days, but they're going to go back right to him anyways when I discharge them. Or find someone even more antisocial. Or go back to the self medicating when they leave the hospital.....

whether we like to admit it or not, our resources are not finite. A bed and inpatient treatment we give someone who has likely reached maximum therapeutic benefit from hospitalizations is resources we are removing from the pt population that may benefit more. Of course given the choice between admitting a BIC and an obvious frequent flyer malingerer, I'd prefer the former, but that doesn't have to be the choice.

and yes, it's *easier* for the people on a service to have a bunch of malingerers and BICs on the service. Maybe that's why it happens so much. But I didn't go into psychiatry to just do the "easy" thing.

 

[whopper]

I know some people have a different strategy, but there is nothing accomplished by most borderline admissions. admitting a borderline for safety is about like washng your truck before you go mud-bogging....

Hmm, I'm actually agreeing with Vistarl OPD!

I do think there are a few borderline patients that need hospitalization. These are very few, but the majority no. I do, however, believe that very severe borderline pts need very good case management or 24-hour DBT services, and most places don't offer it creating a very bad situation--> the patient wouldn't benefit from hospitalization but is too difficult to handle for the outpatient providers.

And I was in that situation in residency with no supervision or real training on DBT or other effective treatments for it. This in turn created an opinion by many in the system I was in that borderline patients were just troublemakers, kick them out, too bad, or medicate them with meds that really don't cause benefit, the patient now gains tremendous weight and it only costs society hundreds to thousands a month to keep that revolving door going. What an unfortunate situation and I believe this is going on in more places than not.

 

[Apollyon]

I have a question about pts with BPD - does feeling guilty about having done or said anything fit with the disorder? Does that go in favor of the disorder, or against it? I am not sure if I am being clear; an example would be the pt that says to an SO "If you leave me, I'll kill myself", which they don't actually intend to do. Afterwards, do any BPD pts verbalize something like "I said that, and I feel really bad about it", or is it a hallmark of sorts of the disorder to NOT feel that way?

As I think about it, also, some (most?) BPD patients won't even realize that they said or did something outrageous. Thus, if there is realization something happened, that has to occur before any sorrow, and, even then, awareness =/= caring.

 

[F0nzie]

I have a question about pts with BPD - does feeling guilty about having done or said anything fit with the disorder? Does that go in favor of the disorder, or against it? I am not sure if I am being clear; an example would be the pt that says to an SO "If you leave me, I'll kill myself", which they don't actually intend to do. Afterwards, do any BPD pts verbalize something like "I said that, and I feel really bad about it", or is it a hallmark of sorts of the disorder to NOT feel that way?

As I think about it, also, some (most?) BPD patients won't even realize that they said or did something outrageous. Thus, if there is realization something happened, that has to occur before any sorrow, and, even then, awareness =/= caring.

I would say that it can be seen as a hallmark as most borderline's I've worked with have not had the insight to be able to reflect back and have any sort of understanding or awareness of what is objectively seen as a dramatic behavioral response to the experience of unconscious and deep rooted emotional issues related to abandonment, neglect, feelings of rejection or dismissal. Some of these patients need years of psychodynamic work to get to the point where they can make room for their emotional experience, feel safe, and trust themselves to be able to articulate it. A lot of these patients did not receive validation, empathic attunement in their lives, and their emotional experiences may have been met with hostility by early caregivers. They will need a very caring, empathic, and infinitely patient therapist to help them facilitate this process.

I have seen substance abuse patients detoxing that will act out and apologize after their sober.

 

[whopper]

Afterwards, do any BPD pts verbalize something like "I said that, and I feel really bad about it", or is it a hallmark of sorts of the disorder to NOT feel that way?

Everyone is different, and don't look at it as type of pure ideal thing where everyone fits the same mold. Borderlines, after experiencing an acute inflammatory emotional episode, when calmed down may be able to make better sense of what happened. Will that person apologize or acknowledge fault? Not everyone will. If they do, it is a sign they're in a better state than not.

 

[Apollyon]

Thank you. I can tell you, as a non-psychiatrist in the ED, as expected, these pts drive me crazy!

 

[nitemagi]

I have a question about pts with BPD - does feeling guilty about having done or said anything fit with the disorder? Does that go in favor of the disorder, or against it? I am not sure if I am being clear; an example would be the pt that says to an SO "If you leave me, I'll kill myself", which they don't actually intend to do. Afterwards, do any BPD pts verbalize something like "I said that, and I feel really bad about it", or is it a hallmark of sorts of the disorder to NOT feel that way?

As I think about it, also, some (most?) BPD patients won't even realize that they said or did something outrageous. Thus, if there is realization something happened, that has to occur before any sorrow, and, even then, awareness =/= caring.

I think there's a lot in this thread worth talking about more.
In my experience, how you say it is as important as what you say.
BPD are on a spectrum. The better fxning ones recognize they're out of control and have some insight that their behaviors are maladaptive and hurt relationships with others. But they can still be impulsive, just regretful later and not know how to stop it the next time.
The lesser fxning ones would cut their own throat to get what they want, not even thinking that they'd be dead in the process.

Maybe someone has mentioned the dx to them before, maybe not. I think the conspiracy of silence is real, and connected to the mindset of "what do I have to do to finish THIS clinical encounter and get them out of my ER/Clinic/Hospital." Maybe there's thoughts about the larger picture, maybe not. There's a mass consensus in some clinics that leads to labeling anyone difficult as borderline, which becomes an excuse to write off making an effort, or maybe an excuse for our dislike for the person. Take your pick.

 

[whopper]

I think the biggest problems are lack of places that offer the right therapy for people with this disorder, that and the person with it has to want to have enough insight to realize they got a problem that could get better. Seeing them in an acute care setting could hopefully have us guiding them and leading them to the water, but it's not much more we can do in that setting.

These patients do get frustrating, especially in the ER, psych ER setting. IMHO, addressing the potential frustration should be something done in training because if residents (and other providers) don't understand this disorder well, it can lead to counter-transference that's destructive to the provider and the patient. Going through 4 years of training where no one in the program appeared to have a good understanding of the disorder certainly was frustrating for me.

 

[nitemagi]

These patients do get frustrating, especially in the ER, psych ER setting. IMHO, addressing the potential frustration should be something done in training because if residents (and other providers) don't understand this disorder well, it can lead to counter-transference that's destructive to the provider and the patient. Going through 4 years of training where no one in the program appeared to have a good understanding of the disorder certainly was frustrating for me.

 

[billypilgrim37]

The psych ER is such a terrible place to give any sort of care to these folks. They need consistency and validation, and the ER is set up as basically a triage. And folks with BPD simply defy triage! They basically obey the Heisenberg Uncertainty Principle. Evaluating them can itself change their dangerousness.

Brief hospiitalizations are generally the approach around here, but we have a whole floor dedicated to trauma-informed care where some of these folks can get some actual treatment, and there's actual fair coordination with outpatient teams.

Discharging them from the ED can be incentive to up the ante. It's not ideal, but brief inpatient stays can be a reasonable part of a DBT crisis plan.

 

[OldPsychDoc]

Maybe someone has mentioned the dx to them before, maybe not. I think the conspiracy of silence is real, and connected to the mindset of "what do I have to do to finish THIS clinical encounter and get them out of my ER/Clinic/Hospital." Maybe there's thoughts about the larger picture, maybe not. There's a mass consensus in some clinics that leads to labeling anyone difficult as borderline, which becomes an excuse to write off making an effort, or maybe an excuse for our dislike for the person. Take your pick.

The day I "got it" was 2 AM on a night float weeknight. I'd cleared off the board early and headed off to the other end of the hospital to tuck in the psych floor and maybe get some sleep. SW paged me--"I've got someone you have to see..." The usual...female, 20s, superficial scratches, thoughts of doing worse to herself, sad, nothing going right, some ex-boyfriend had been seen with someone new, etc., etc... Probably didn't need an admission, but doesn't have anyplace else to go. What got it into my head though, was what what the social worker said as she presented it on the phone:

"Yeah, she's a Borderline, but she comes by it honestly..."​

Had been repeatedly sexually abused by uncle and male cousins, mother totally non-supportive when the allegations came to light, got started early in her succession of "unstable and intense interpersonal relationships".... The gal was bleeding interpersonal pain from every orifice. So I sucked it up and went downstairs, the SW and I spent some time with her, elicited enough of a contract for safety that we could get her to a female friend's couch for the rest of the night. We talked a bit about the diagnosis, how long it had been going on, how long it might take to get better if she availed herself of the resources we were suggesting, etc. Believe me, it feels a whole lot facing sleep deprivation at 4 am after that than if I'd spent the time rolling my eyes at how much I hated dealing with her kind and resenting that she was bothering me with her problems in "my" emergency room. I don't know if we made a difference, but I do know that that social worker made a difference for me. "...she comes by it honestly..." I'll never forget it.

 

[roubs]

I mean, I've had patients who have gone through DBT in the past who have never heard of borderline PD --WTH?

DBT does emphasize the similarity between BPD and individuals who regularly engage in non-suicidal self-injury, it's possible someone who frequently engaged in NSSI received DBT and in someone's judgement did not meet enough criteria for BPD at that time.

It's also quite possible that a DBT practitioner didn't place frequent emphasis on the patient's diagnosis. They were still targeting affective disturbance, fraught interpersonal relationships, frequent NSSI/impulsivity and other problems associated with this dx. I don't think it's consistent with DBT to withhold informing a patient of their diagnosis or refusing to discuss diagnosis.

This thread is yet another proof of the importance of psychodynamic training. It has as much to do with managing your own reactions to patients as it does with managing the patients themselves. More useful than DBT training, IMO. You can't teach skills if you are yourself unskilled.

Just want to point out that there is a huge focus on (counter)transference in DBT training and practice. I'm not in a dynamic program so perhaps dynamic folks frown on lifting/incorporating their principles into other therapies, but regardless it is done in DBT probably more than any other form of CBT.

Btw, is it emphasized in psychiatry that DBT reduces days of hospitalization? And yeah I realize it's often difficult/near impossible to get them into a program.

"...she comes by it honestly..."

In a review by Linehan, 76% of women with a borderline dx were victims of sexual abuse in childhood.

 

[nitemagi]

Btw, is it emphasized in psychiatry that DBT reduces days of hospitalization? And yeah I realize it's often difficult/near impossible to get them into a program.

Depends on the program. I co-ran a DBT group for a year during residency, and I think it's useful for a much broader spectrum than just BPD. BPD is simply the group it was studied on. The data is mostly on SIB and hospitalizations. Less impressed that it's benefitting long term outcomes any better than other therapies or even treatment as usual. Mentalization, so many others seem good as well but underutilized.

 

[vistaril]

We talked a bit about the diagnosis

most borderlines have had this talk a million times......

If a borderline who has been in contact with MH multiple times(as almost all borderlines have after a certain point) hasn't been educated about their dx before, I really question what the heck is going on at that hospital, outpt health center, training program, etc.....

 

[whopper]

True.

Also several don't want to undergo psychotherapy.

Then there's the group that may not be appropriate for psychotherapy in an outpatient setting. E.g. someone with borderline PD with moderate or or worse MR, a severe antisocial PD patient with borderline PD, etc. I'm talking severe to the point where the person may be a repeat rapist. Yes even then psychotherapy can help but usually the person won't show up to the office and if so the people in the office may not feel safe and justifiably so. Those cases are very difficult.

Still, it's our job at least to lead them to water and hope they take the drink even if it's their 15th time in the ER in the last 6 months without judgment. We should, however, not enable any problems these patients have. No benzos, no inpatient hospitalizations unless you think it's going to actually do something beneficial for real, and things to that effect unless there's a serious exception to the rule going on.

 

[OldPsychDoc]

most borderlines have had this talk a million times......

If a borderline who has been in contact with MH multiple times(as almost all borderlines have after a certain point) hasn't been educated about their dx before, I really question what the heck is going on at that hospital, outpt health center, training program, etc.....

I beg to disagree--and I believe that was question raised by our OP here. What IS happening in the community is that providers are shying away from the diagnosis and NOT educating these folks, ERs are rolling their eyes at them and pushing them out the door without discussion, and their primaries are calling it "bipolar" and giving them F---ing Xanax.

I just admitted a patient TODAY who is 36, has the classic history, suicidal ideation, soft psychosis, MULTIPLE outpatient "diagnoses" (including schizophrenia--for <bleep>'s sake!) and med trials, and had NEVER even heard the word. (Only 2 hospitalizations though--is afraid of hospitals. Her new GF talked her into giving us a try...) How much LESS misery, how much more productivity in this young woman's life if someone had "had the talk" 10 years ago?

 

[fiatslug]

I beg to disagree--and I believe that was question raised by our OP here. What IS happening in the community is that providers are shying away from the diagnosis and NOT educating these folks, ERs are rolling their eyes at them and pushing them out the door without discussion, and their primaries are calling it "bipolar" and giving them F---ing Xanax.

I just admitted a patient TODAY who is 36, has the classic history, suicidal ideation, soft psychosis, MULTIPLE outpatient "diagnoses" (including schizophrenia--for <bleep>'s sake!) and med trials, and had NEVER even heard the word. (Only 2 hospitalizations though--is afraid of hospitals. Her new GF talked her into giving us a try...) How much LESS misery, how much more productivity in this young woman's life if someone had "had the talk" 10 years ago?

*Exactly* what I was talking about, thank you OPD. Seriously, I do believe that cowardice about discussing this diagnosis with patients sets back their recovery.

 

[pingouin]

I beg to disagree--and I believe that was question raised by our OP here. What IS happening in the community is that providers are shying away from the diagnosis and NOT educating these folks, ERs are rolling their eyes at them and pushing them out the door without discussion, and their primaries are calling it "bipolar" and giving them F---ing Xanax.

I just admitted a patient TODAY who is 36, has the classic history, suicidal ideation, soft psychosis, MULTIPLE outpatient "diagnoses" (including schizophrenia--for <bleep>'s sake!) and med trials, and had NEVER even heard the word. (Only 2 hospitalizations though--is afraid of hospitals. Her new GF talked her into giving us a try...) How much LESS misery, how much more productivity in this young woman's life if someone had "had the talk" 10 years ago?

I think, too, that there can be significant qualitative differences in "the talk" between providers.

Attitudes toward BPD can range from empathic and encouraging to dismissive of these patients as hopeless cases. Clinicians who use the latter method are essentially engaging in anti-motivational interviewing.

Patients may be getting "the talk", but it may very well be shutting out non-constructive feedback. Shocking.

 

[vistaril]

I beg to disagree--and I believe that was question raised by our OP here. What IS happening in the community is that providers are shying away from the diagnosis and NOT educating these folks, ERs are rolling their eyes at them and pushing them out the door without discussion, and their primaries are calling it "bipolar" and giving them F---ing Xanax.

I just admitted a patient TODAY who is 36, has the classic history, suicidal ideation, soft psychosis, MULTIPLE outpatient "diagnoses" (including schizophrenia--for <bleep>'s sake!) and med trials, and had NEVER even heard the word. (Only 2 hospitalizations though--is afraid of hospitals. Her new GF talked her into giving us a try...) How much LESS misery, how much more productivity in this young woman's life if someone had "had the talk" 10 years ago?

curious- how do you know that at some point many different mh professionals havent been very clear with her?

as for primary care physicians, they don't have time to educate the pt. Extensive education on personality disorders is not the role of a primary medical doctors appointment. Obviously, appropriate referral would be nice, but as I think many whopper said many patients dont want this........

oh, and then there is the resource issue. resources, as we all know, just don't appear out of thin air......

 

[nitemagi]

curious- how do you know that at some point many different mh professionals havent been very clear with her?

as for primary care physicians, they don't have time to educate the pt. Extensive education on personality disorders is not the role of a primary medical doctors appointment. Obviously, appropriate referral would be nice, but as I think many whopper said many patients dont want this........

oh, and then there is the resource issue. resources, as we all know, just don't appear out of thin air......

No one knows. Sure they could be lying when they say no one has talked to them before. The resources are getting used up one way or another, whether that's by repeated ER visits and hospitalizations (the revolving door), or putting in the time to try education and to intervene to break the cycle. Why not put resources towards changing patterns rather than only crisis management.

We have a presumption that the system is broken, that someone else should do it but they don't. That time you spend with a patient is an opportunity to intervene, to treat. It may not be full DBT, but it's better than apathy and quick discharges with crossed fingers.

Educating difficult patients (essentially confronting our own anxiety and annoyance) is hard to do, so most fall into the free rider position (basic economics), assuming someone else will do it. Often no one does. Have I done longitudinal tracking of multiple providers to prove that? No. I rely on that pesky piece of data called self-report.

 

[vistaril]

No one knows. Sure they could be lying when they say no one has talked to them before. The resources are getting used up one way or another, whether that's by repeated ER visits and hospitalizations (the revolving door), or putting in the time to try education and to intervene to break the cycle. Why not put resources towards changing patterns rather than only crisis management.

We have a presumption that the system is broken, that someone else should do it but they don't. That time you spend with a patient is an opportunity to intervene, to treat. It may not be full DBT, but it's better than apathy and quick discharges with crossed fingers.

Educating difficult patients (essentially confronting our own anxiety and annoyance) is hard to do, so most fall into the free rider position (basic economics), assuming someone else will do it. Often no one does. Have I done longitudinal tracking of multiple providers to prove that? No. I rely on that pesky piece of data called self-report.

I think the problem is that "the revolving door" and "putting in the time to educate and to intervene" are very compatible.

we have emr so when I see a borderline pull in I will pull up their last discharge summary(if they got admitted). In many cases the discharge summary made it very clear that the pt was properly educated and given proper f/u with outpt dbt(again if possible).

And when I was in the er, these pts we are discussing would not get admitted. Simple as that. they were given some of my time depending on pt flow. I'm not deluded enough to think anything I said alters long term outcomes, but it may provide some degree of distress relief transiently. Resources are finite....sorry, they are.

And there is really no end to applying a similar policy to other pathologies......seemingly every pt pulling into the er out of cash in early opiate withdrawl is anxious and hopeless and someone in a mental health field at some point in time probably mentioned a possible depressive or anxiety d/o. Why don't we just admit them too and use the resources of an inpt admission to educate them on how they need substance treatment/sobriety instead of meds......

I've come on for residents who admitted an obvious borderline into the ER and they try to "explain" the admission. I understand the explanation. I just don't agree with it and I believe that 2 months later some other psychiatrist 20 minutes away at another hospital may admit the pt again for the point of educating the pt on their dx, setting up f/u, and "getting it right" finally........

 

[nitemagi]

Why don't we just admit them too and use the resources of an inpt admission to educate them on how they need substance treatment/sobriety instead of meds......

I've come on for residents who admitted an obvious borderline into the ER and they try to "explain" the admission. I understand the explanation. I just don't agree with it and I believe that 2 months later some other psychiatrist 20 minutes away at another hospital may admit the pt again for the point of educating the pt on their dx, setting up f/u, and "getting it right" finally........

More straw man arguments. No one said to admit them. We said to educate them about their diagnosis.

 

[OldPsychDoc]

I think the problem is that "the revolving door" and "putting in the time to educate and to intervene" are very compatible.

we have emr so when I see a borderline pull in I will pull up their last discharge summary(if they got admitted). In many cases the discharge summary made it very clear that the pt was properly educated and given proper f/u with outpt dbt(again if possible).

And when I was in the er, these pts we are discussing would not get admitted. Simple as that. they were given some of my time depending on pt flow. I'm not deluded enough to think anything I said alters long term outcomes, but it may provide some degree of distress relief transiently. Resources are finite....sorry, they are.

And there is really no end to applying a similar policy to other pathologies......seemingly every pt pulling into the er out of cash in early opiate withdrawl is anxious and hopeless and someone in a mental health field at some point in time probably mentioned a possible depressive or anxiety d/o. Why don't we just admit them too and use the resources of an inpt admission to educate them on how they need substance treatment/sobriety instead of meds......

I've come on for residents who admitted an obvious borderline into the ER and they try to "explain" the admission. I understand the explanation. I just don't agree with it and I believe that 2 months later some other psychiatrist 20 minutes away at another hospital may admit the pt again for the point of educating the pt on their dx, setting up f/u, and "getting it right" finally........

But the question is not "Should you admit borderlines?" but "Should you tell them their diagnosis?"
I'm happy that you have access to a convenient EMR (which no doubt logs each patient's full and proper diagnosis accurately) so that you can "see them pulling in" and choose whether or not to bestow your time on them (or upon your benighted juniors, who lack your wisdom and understanding of how to manage things properly). However, in most ERs in the land, this is not the case, and even if a community provider has documented "Axis II: Borderline traits likely, evaluate further" on their chart, you won't have access to that chart at 2 AM, and the patient has quite possibly not received even a rudimentary explanation that their depression and anxiety is not necessarily a matter of inadequate pharmacology ("the meds stopped working"), and they aren't going to know how to manage crises, because (excuse me while I refer to the OP again) NO ONE TOLD THEM WHAT THEIR PROBLEM IS! And the sad thing is, one reason providers fail in this, as Pingouin implies, is that the provider's attitude is that it is "hopeless", or "too hard to manage"--when if anything, doing this right brings a hell of a lot more hope for recovery* than sentencing them to a lifetime of toxic mood stabilizers for their non-existent "bipolar" or (god-forbid) "schizoaffective" disorders.

*Remission rates in BPD can be as high as 85% in 10 years (Gunderson et
al, Arch Gen Psychiatry 2011;68(8):827– 837). (shamelessly cut and pasted from Carlat Psychiatry Report, March 2012)

 

[vistaril]

More straw man arguments. No one said to admit them. We said to educate them about their diagnosis.

well I was partly referring to the pt OPD mentioned that he admitted....additionally, you were against "quick discharge".....It's possible to educate a pt in the ed and still do "quick discharge", so that's a little vague.

also, the er is just that....the EMERGENCY room. that doesn't mean I won't do anything in terms of patient education, but I do think one should remember at all times it is an EMERGENCY room. With the education angle of things, in many cases(depending on specially what the presentation was) the pt isn't going to be stable enough to greatly benefit from the education anyways.

if a borderline shows up at a community mental health center where they are a semi-established pt in crisis then that changes the discussion somewhat.

 

[Iwillheal]

I wish we did not have to use the bpd label, given the stigma. It's to the point I would even prefer something as simpleminded as "fragile" personality, though ultimately I'd prefer something like "Complex post-traumatic stress disorder" (had the research supported a stronger correlation between childhood trauma and bpd.)

Or use "borderline personality organization" from the psychodynamic lit accompanied by the personality label (e.g. histrionic). Not because it creates less stigma but because I think it's more accurate.

Another point: I think there is more tolerance for treating people who have suffered war trauma, or purely physical trauma (terrible accident), than bpd patients. They're all needy in a way, but there are differences. I think bpd pts need a lot of help but they often reject it. I think it's also quite painful for me personally to provide that help because often I feel like...I feel like I'm cleaning the wound of an injured animal that switches back and forth between a wolf and a lamb, so if I'm not completely grounded, I can lose touch with reality (of the situation) myself and buy into what I'm presented with. Yes, I'm new to the field but I can't help feeling the need to be hypervigilant around these patients lest I say something or do something or use a certain body language that they can reveal a certain "hook" on which they can hang their ****. I genuinely care for these people but it's emotionally draining for me to deal with them. Not all of them of course but a large portion of them. I feel like only a stronger mind can dance their dance. Maybe in due time I can too but right now I rather not.

 

[vistaril]

But the question is not "Should you admit borderlines?" but "Should you tell them their diagnosis?"
I'm happy that you have access to a convenient EMR (which no doubt logs each patient's full and proper diagnosis accurately) so that you can "see them pulling in" and choose whether or not to bestow your time on them (or upon your benighted juniors, who lack your wisdom and understanding of how to manage things properly). However, in most ERs in the land, this is not the case, and even if a community provider has documented "Axis II: Borderline traits likely, evaluate further" on their chart, you won't have access to that chart at 2 AM, and the patient has quite possibly not received even a rudimentary explanation that their depression and anxiety is not necessarily a matter of inadequate pharmacology ("the meds stopped working"), and they aren't going to know how to manage crises, because (excuse me while I refer to the OP again) NO ONE TOLD THEM WHAT THEIR PROBLEM IS! And the sad thing is, one reason providers fail in this, as Pingouin implies, is that the provider's attitude is that it is "hopeless", or "too hard to manage"--when if anything, doing this right brings a hell of a lot more hope for recovery* than sentencing them to a lifetime of toxic mood stabilizers for their non-existent "bipolar" or (god-forbid) "schizoaffective" disorders.

*Remission rates in BPD can be as high as 85% in 10 years (Gunderson et
al, Arch Gen Psychiatry 2011;68(8):827– 837). (shamelessly cut and pasted from Carlat Psychiatry Report, March 2012)

this is what doesn't add up: If they've been given a dx of schizoaffective d/o or even bipolar d/o and started on mood stabilizers +/- antipsychotics for that d/o, they probably have been involved with mental health at some point. And if a psychiatrist/psychologist whatever hasn't been honest with them and given them the right dx and educated them, well that's unfortunate.....I prefer giving pts the right dx, but I don't view it as my responsibility to correct every single previous incorrect dx from less competent psychs.

what I will do when I see a borderline in the er is go in, assess that they are borderline....tell them so, briefly explain what this means and treatment recs, and discharge them. If I have time I may even hang around long enough talking with the pt for the worst of the crisis to dissipate and that may actually be a better opportunity to throw in the education stuff then.

but again I think it's important not to lose sight of the fact that I am not running a day treatment program or a 24/7 dbt group here......

but going back to the original question.....sure...of course tell them their dx.

 

[vistaril]

Another point: I think there is more tolerance for treating people who have suffered war trauma, or purely physical trauma (terrible accident), than bpd patients. They're all needy in a way, but there are differences. I think bpd pts need a lot of help but they often reject it. I think it's also quite painful for me personally to provide that help because often I feel like...I feel like I'm cleaning the wound of an injured animal that switches back and forth between a wolf and a lamb, so if I'm not completely grounded, I can lose touch with reality (of the situation) myself and buy into what I'm presented with. Yes, I'm new to the field but I can't help feeling the need to be hypervigilant around these patients lest I say something or do something or use a certain body language that they can reveal a certain "hook" on which they can hang their ****. I genuinely care for these people but it's emotionally draining for me to deal with them. Not all of them of course but a large portion of them. I feel like only a stronger mind can dance their dance. Maybe in due time I can too but right now I rather not.

i think it all comes back to the setting you're in........I actually like some borderlines as therapy pts in some ways. I dislike therapy overall and have no interest in doing it, and actually after 8 more days will never do therapy another day in my life(fingers crossed), but again.....consider the setting. If I'm in working the psych er, they are not going to get admitted. It won't benefit them. Try overthinking it and rationalizing it and you may come to a different conclusion.......

Also, regarding borderlines......some people like treating them and some people don't. And after residency, just treat the pts you feel best treating. Other specialties limit there pt base in similar ways.....some neurologists refuse to see movement disorder pts for example.

 

[vistaril]

The psych ER is such a terrible place to give any sort of care to these folks. They need consistency and validation, and the ER is set up as basically a triage. And folks with BPD simply defy triage! They basically obey the Heisenberg Uncertainty Principle. Evaluating them can itself change their dangerousness.

Brief hospiitalizations are generally the approach around here, but we have a whole floor dedicated to trauma-informed care where some of these folks can get some actual treatment, and there's actual fair coordination with outpatient teams.

Discharging them from the ED can be incentive to up the ante. It's not ideal, but brief inpatient stays can be a reasonable part of a DBT crisis plan.

1) Agreed, the psych ER is a terrible place to care for borderlines in crisis. The best place to handle their crisis is at the.......oh wait, they never went to their followup appt, counselor, or group so they don't have any access to those things
2) it's always easier to admit pts than to discharge pts. My 3 yo nephew can admit admit admit.........whenever I hear a psychiatrist use the phrase "can be reasonable" regarding an admission, it always makes me think they know it's weak themselves....nobody says the good admissions "can be reasonable........"

 

[billypilgrim37]

whenever I hear a psychiatrist use the phrase "can be reasonable" regarding an admission, it always makes me think they know it's weak themselves....nobody says the good admissions "can be reasonable........"

You've made it quite clear that your clinical judgment vastly exceeds the rest of ours. It is only because you are such a great psychiatrist that you can make such judgments without any real information upon which to base your supremely wise proclamations.

 

[zenman]

http://www.youtube.com/watch?v=ZLShoKfXakg&feature=plcp

 

[fiatslug]

http://www.youtube.com/watch?v=ZLShoKfXakg&feature=plcp

He kind of sounds like a cross b/w Jack Nicholson and Woody Allen

 

[vistaril]

You've made it quite clear that your clinical judgment vastly exceeds the rest of ours. It is only because you are such a great psychiatrist that you can make such judgments without any real information upon which to base your supremely wise proclamations.

I don't neccessarily know that my clinical judgement exceeds everyone here.....I think my clinical judgement is pretty darn good, but there are many psychiatrists here who have a heck of a lot more experience than me. Now experience doesn't always equate with clinical judgement, but it plays into it with some presentations.

That said, part of clinical judgement is being able to step back and see the picture within the whole system. Sometimes psychiatrists, oftentimes experienced ones, lose sight of this. I think experienced psychiatrists who occasionally admit borderlines probably fall into this category.

 

[OldPsychDoc]

I don't neccessarily know that my clinical judgement exceeds everyone here.....I think my clinical judgement is pretty darn good, but there are many psychiatrists here who have a heck of a lot more experience than me. Now experience doesn't always equate with clinical judgement, but it plays into it with some presentations.

That said, part of clinical judgement is being able to step back and see the picture within the whole system. Sometimes psychiatrists, oftentimes experienced ones, lose sight of this. I think experienced psychiatrists who occasionally admit borderlines probably fall into this category.

Ahh yes, along with the pulmonologists who "occasionally admit" COPDers who haven't been compliant with smoking cessation and cardiologists who keep stenting arteries in those pesky folks who keep eating saturated fats. And don't even get me started on those silly diabetics!

Thank god you're here to set us straight, Dr. V.

 

[BobA]

Dr. V are you sure your management of borderlines isn't influenced by counter-transference?

It seems odd to have such a hard and fast rule about anything in medicine.

Psychiatrist who are open to evaluating their own emotional reactions to patients, who are open to the idea that they can be vulnerable human beings too, are going to be much better psychiatrists.