Borderline Personality D/o and Countertransference

[BobA]

It could just be my intern year counter-transference, but does anyone else feel that we as psychiatrists and members of the mental health establishment are enablers of the childish actions of patient's with Borderline Personality Disorder?

When we "rescue" these patient's in distress by providing them inpatient respite from their chaotic lives, are we preventing them from the experiencing the pain they must experience in order to have the motivation to change and grow?

When we give them medications for their symptoms, are we implicitly sending the message that they don't have to do the psychological work to change their mindset?

discuss.

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[strangeglove]

That's why brief hospitalizations are usually recommended for these patients.

And if allowing these patients to experience pain is therapeutic, then they would pretty much cure themselves.

 

[beezley]

They need to be given the responsibility to change things for themselves.

I totally put up (figurative) barriers when I interact with borderlines because I feel like they just want to suck out my life-blood. But I guess we will learn to deal with that the further we go along (I too am an intern)

Tonight I feel like all my life-blood has been sucked out. DC'd a tough borderline today. I feel bad because this person's life is such a mess, but at the same time I find myself thinking, 'just get your **** together already'. Us putting the life together for them is not going to solve the problem.

I know I have a lot to learn in this department.

 

[whopper]

That's why brief hospitalizations are usually recommended for these patients.

Agree, and several experts such as Linehan have pointed this out.

My own counter-transference on Borderlines has diminished greatly after PGY-1. It went down even further after I started forensic fellowship due to a very significant reason: I actually saw Borderlines get DBT, and actually get dramatically better after a few months of DBT treatment.

During residency, the typical revolving door was Borderline holds the crisis ER doctor hostage with a suicidal threat--> patient gets admitted to inpatient, inpatient psychiatrist is upset that the person was admitted and discharges with a referral ---> outpatient throws an SSRI or atypical at the Borderline (AND NO DBT TREATMENT) --> Borderline gets no improvement from medication ---> ends up in ER with the same problem--week after week, month after month, year after year.

Where I'm doing fellowship, the forensic center has psychologists who actively do DBT. My wife has some extensive DBT training and she's made tremendous progress with several Borderlines, getting several of them to break the frequent trips to the hospital.

I think my frustration with Borderlines would've dropped tremendously had our system been able to provide DBT because there would've been something we could've done for them that actually worked instead of the revolving door.

Another frustration factor was to see the large number of psychiatrists get referred a Borderline patient, dx them with Bipolar, throw a mood stabilizer or atypical, and further continue them through the revolving door of ineffective treatment.

I just got a Borderline today who was diagnosed with Bipolar. We went through all the DSM criteria, and the only sx of Bipolar she had was impulsivity (which is also a criteria for borderline). She had all 9 out of 9 criteria for Borderline, was sexually abused by her father, her only good father figure-her grandfather died when she was 13, and has lead the stereotype borderline life ever since. Despite that, 5 previous psychaitrists diagnosed her with Bipolar and put her on the usual bogus slew of meds that provided no benefit for her. Every single atypical and mood stabilizer you could name she's been on it.

Its a real shame because borderlines are a plenty, psychiatrists usually aren't trained in DBT, and market forces propel us to give a dx that only pays us to treat people with an Axis I, not an Axis II. This creates the perfect storm situation where these people who need the right and appropriate help won't get it.

Thankfully, where I work I was able to refer her to a DBT therapist and DBT groups.

 

[OldPsychDoc]

Borderlines will suck the life out of you as a resident, but when you get some taste of how their lives have been to get them to that...

One night at 2 AM, a social worker in our psych ED called me for that night's borderline-in-distress call. I'll always remember what she said on the phone: "Yeah, she's a Borderline, but she comes by it honestly." The young lady had an unstable mother, was raped by her step-father and step-brother at 12, was using drugs since 14...you get the picture. How the heck does someone learn to deal "normally" with distress with that kind of background? When you can adopt the perspective that you're trying to help these folks take some small step today toward managing life more effectively tomorrow, your interactions with them can be a lot more rewarding for both of you.

So just roll your eyes privately, roll up your sleeves, and try to point them in the right direction to work their way out of their current crisis.

 

[sunlioness]

Agree with you, OPD. I read somewhere (I don't remember where. Colin Ross maybe) that Borderline PD is a perfectly normal response to childhood abuse, neglect, and/or chaos. People can't be expected to learn to regulate themselves or develop healthy attachment patterns when those were never modeled or provided for them as children. And the stigma against them in the mental health field, while understandable, does nothing to help. Nor does the culture of defensive medicine in which attention-seeking suicidal threats actually "work" --because it's too dangerous for the provider legally not to act on them with hospitalization, just in case.

You're really fortunate, Whopper, to work in an environment with an integrated approach that gets people to proper treatment. I think a huge part of the problem (and provider frustration and burnout) is that these patients are just too draining for any one person to manage effectively. And not too many places are set up to have that team approach, so the revolving door and the turfing continues, benefiting no one --least of all the patients themselves.

 

[kugel]

market forces propel us to give a dx that only pays us to treat people with an Axis I, not an Axis II.

Please explain.
Who doesn't pay for admission for Axis II disorders if there is evidence of imminent danger to self/others?

 

[masterofmonkeys]

No one will pay for an Axis II. Which is why half the time they leave the hospital with a (inappropriate much of the time) axis I diagnosis of bipolar or depression or ptsd or somesuch. Not that many borderlines don't fit these criteria and wouldn't benefit from medication, but that their PD really does explain the context of the crisis a lot better.

I find borderlines pretty easy to deal with. I've worked with abused animals for a while. Adopted two dogs from that kind of environment. Worked in a monkey sanctuary that mostly had either lab monkeys or abused pets. Most of us understand why abused and neglected animals behave like they have borderline PD. Which is why so many people volunteer for these kinds of organizations.

I guess it's a little harder for us to swallow that a human exposed to the same kinds of stimuli will turn out exactly the same. We demand more of them. Unfortunately, we aren't often willing to provide them the structure that will allow them to demand more of themselves.

I don't get upset when my ******ed dog bites me. Or a monkey I was feeding flung poop at me. It's a response to their chaotic rearing environment. Once I learned to approach borderlines with the same mindset, the countertransference was eliminated.

But I'm not perfect, I will struggle until I retire (or die, more likely) with countertransference to 'chronic pain' patients.

 

[kugel]

No one will pay for an Axis II.

I've never had that problem. Medicare, Medicaid (Calif.), Other insur... never (that I know of) been denied if the documentation was clear as to why the pt cannot be safe outside the hospital today. It's always been about the documentation - not the dx.

A borderline pt I know with 47 volumes (hundreds of admits) has never had an admit denied when
A) she's hurt herself seriously (needed surgery several times) or
B) hurt herself less seriously but still stating she will hurt herself further if released today AND has signif affect change from her known baseline documented.

When docs have admitted her b/c of "SI statement earlier today (though denying SI now) and many previous serious suicide attempts," but don't bother to document clearly what's happening now to differentiate today from yesterday and the day before (when she had same sx's as today) - I believe some of those were denied reimbursement. My impression is that reviewers view that kind of admit as CYA.

I've been TOLD lots of times that insur won't pay for Personality Disorder, but never had it happen. And when I look up the reimbursement criteria, I can't find any such exclusion. Except that Antisocial is excluded for Medicaid here.

California Medicaid ("Med-Cal") will reimburse for the following diagnoses (according to their own written regulations) as long as the other criteria for admission are met:
Pervasive Dev’t Disorders
Disruptive Behaviors and Attn Deficit Disorders
Feeding and Eating Disorders of Infancy and Early Childhood
Tic Disorders
Elimination Disorders
Other Disorders of Infancy, Childhood or Adolescence
Dementias with Delusions or Depressed Mood
Substance-induced psychotic, mood, or anxiety disorders
Schizophrenia and Other Psychotic Disorders

Mood Disorders
Anxiety Disorders
Somatoform Disorders
Dissociative Disorders
Eating Disorders
Intermittent Explosive Disorder
Pyromania
Adjustment Disorders
Personality Disorders (except Antisocial)

 

[Anasazi23]

I've never had that problem. Medicare, Medicaid (Calif.), Other insur... never (that I know of) been denied if the documentation was clear as to why the pt cannot be safe outside the hospital today. It's always been about the documentation - not the dx.

A borderline pt I know with 47 volumes (hundreds of admits) has never had an admit denied when
A) she's hurt herself seriously (needed surgery several times) or
B) hurt herself less seriously but still stating she will hurt herself further if released today AND has signif affect change from her known baseline documented.

When docs have admitted her b/c of "SI statement earlier today (though denying SI now) and many previous serious suicide attempts," but don't bother to document clearly what's happening now to differentiate today from yesterday and the day before (when she had same sx's as today) - I believe some of those were denied reimbursement. My impression is that reviewers view that kind of admit as CYA.

I've been TOLD lots of times that insur won't pay for Personality Disorder, but never had it happen. And when I look up the reimbursement criteria, I can't find any such exclusion. Except that Antisocial is excluded for Medicaid here.

California Medicaid ("Med-Cal") will reimburse for the following diagnoses (according to their own written regulations) as long as the other criteria for admission are met:
Pervasive Dev’t Disorders
Disruptive Behaviors and Attn Deficit Disorders
Feeding and Eating Disorders of Infancy and Early Childhood
Tic Disorders
Elimination Disorders
Other Disorders of Infancy, Childhood or Adolescence
Dementias with Delusions or Depressed Mood
Substance-induced psychotic, mood, or anxiety disorders
Schizophrenia and Other Psychotic Disorders

Mood Disorders
Anxiety Disorders
Somatoform Disorders
Dissociative Disorders
Eating Disorders
Intermittent Explosive Disorder
Pyromania
Adjustment Disorders
Personality Disorders (except Antisocial)

Interesting if true. I'm always intrigued by perpetuated wives' tales. However, this is Medi-cal. I wonder if it's different by state. Also, I'll agree that it had been drilled into me in the hospitals (all of them) and even in group practice, that you cannot diagnose a primary substance use disorder
or PD and get paid.

So what are you writing on Axis I to get paid if you admit a borderline with SI?

 

[strangeglove]

No one will pay for an Axis II. Which is why half the time they leave the hospital with a (inappropriate much of the time) axis I diagnosis of bipolar or depression or ptsd or somesuch. Not that many borderlines don't fit these criteria and wouldn't benefit from medication, but that their PD really does explain the context of the crisis a lot better.

I find borderlines pretty easy to deal with. I've worked with abused animals for a while. Adopted two dogs from that kind of environment. Worked in a monkey sanctuary that mostly had either lab monkeys or abused pets. Most of us understand why abused and neglected animals behave like they have borderline PD. Which is why so many people volunteer for these kinds of organizations.

I guess it's a little harder for us to swallow that a human exposed to the same kinds of stimuli will turn out exactly the same. We demand more of them. Unfortunately, we aren't often willing to provide them the structure that will allow them to demand more of themselves.

I don't get upset when my ******ed dog bites me. Or a monkey I was feeding flung poop at me. It's a response to their chaotic rearing environment. Once I learned to approach borderlines with the same mindset, the countertransference was eliminated.

But I'm not perfect, I will struggle until I retire (or die, more likely) with countertransference to 'chronic pain' patients.

At the risk of sounding like your psychodynamic supervisor, it sounds like you have quite a bit of unresolved countertransference about Borderlines that manifests in your thinking about them like animals.

It's perfectly reasonable and healthy to have negative countertransference reactions to Borderlines. I think that what's important is to be able to manage this countertransference in ways that don't result in enactments, e.g. kicking them out of an inpatient unit because they anger your, or dosing them with inappropriate meds. Being aware of your countertransference, as opposed to believing it to be "eliminated", will make this less likely to occur, IMHO.

 

[whopper]

Where I did hospital work in NJ, there were issues with admitting a patient for an Axis II. We were told not to do that. The Medicare/Medicaid laws may have been different. Yeah the borderlines did get admitted, but the doctor wrote down Mood DO NOS or Bipolar or MDD, hence the problem I mentioned.

Another problem was while psychotherapy for borderlines was covered in outpatient, no one I knew did DBT. No one. At best it was a thing mentioned in the psychiatry book, and all the professors mentioned you should get borderlines DBT treatment, but no one did it themselves or even taught how to give DBT. Yeah they'd do some type of talk therapy, but it wasn't DBT.

The best DBT programs are structured to cover the borderline people in a 24/7 manner like an ACT team, with the entire team trained in DBT. The person on call is supposed to act as a line of defense to prevent the person from going to the hospital. A good person on the team will know how to prevent the person from getting back into the hospital, while at the same time setting boundaries to prevent the borderline from manipulating the team members for attention.

 

[beezley]

From OPD: 'So just roll your eyes privately, roll up your sleeves, and try to point them in the right direction to work their way out of their current crisis.'

Thanks OPD, I'll remember that when I am on call tomorrow. Maybe it is just intern year in general that is sucking the life out of me, but my countertransference towards borderlines doesn't help.

 

[kugel]

So what are you writing on Axis I to get paid if you admit a borderline with SI?

v71.09 No diagnosis
or
799.9 Diagnosis deferred

 

[masterofmonkeys]

At the risk of sounding like your psychodynamic supervisor, it sounds like you have quite a bit of unresolved countertransference about Borderlines that manifests in your thinking about them like animals.

Well, a psychodynamic supervisor would probably know me a little better
I'm an evolutionary biologist and a Hindu. I think of everyone as animals, myself included. To paraphrase a verse from the vedas. "What, after all, is the difference between a dog or a monkey and a young child?"

The limbic system is actually quite an old part of the brain, and there are very few differences therein amongst the more intelligent social mammals. And a dog's prefrontal and orbitofrontal cortices are actually remarkably similar to our own.

I find it quite maddening that westerners often delineate such sharp boundaries between man and animals. It limits our understanding of the world and ourselves.

edit: I'll admit though, that 'eliminated' was poor word choice.

 

[strangeglove]

Well, a psychodynamic supervisor would probably know me a little better
I'm an evolutionary biologist and a Hindu. I think of everyone as animals, myself included. To paraphrase a verse from the vedas. "What, after all, is the difference between a dog or a monkey and a young child?"

That sounds like countertransference to me

I never said it was a bad thing to think of your patients (or yourself) like animals - just that it is good to be mindful of how this stance affects your treatment. Sounds like you've given it quite a bit of thought.

 

[whopper]

that you cannot diagnose a primary substance use disorder

I was also told in residency you couldn't admit someone based on a substance disorder or a substance induced disorder.

The reality though was if you had someone psychotic from PCP, and that person was dangerous you still admitted, them, you just put down Psychosis NOS and a substance abuse or dependence disorder along with it.

Messed up...yeah I know, but I was a resident, and if the attending wasn't going to do anything about it, even when you're scratching your head and asking him what's going on with it, the resident sure as heck will not either.

 

[nancysinatra]

I actually find working with Axis II patients interesting and, when it goes well, rewarding. In fact, I think I would prefer an Axis II patient over a predictable Axis I most days, honestly--but maybe this is because as an intern I find a lot of the Axis I admissions and discharges I am churning out at a dizzying rate to be very similar at this point.

However I will admit when I'm in a hurry to get work done, borderline patients and antisocial patients can bring out a great deal of frustration. Borderlines scare me with their threats and antisocials irk me with their malingering, which they are very good at, far better than I seem to be good at preventing it. But when I have time and can be patient, I find the psychological aspects of these patients fascinating. Do they need inpatient admission? It depends. I think it is OUR shortcoming that for borderlines, we don't offer the proper treatment at the proper time so as to avoid inappropriate hospitalizations. For antisocial "patients" I wish the place where I do call would take a stronger stand against malingering.

Now schizotypal, OCPD, paranoid, histrionic... those are really interesting patients! And narcissists can be incredibly entertaining.

I think the thing that makes me enjoy working with these patients is the challenge of finding something in each patient that is human and recognizable even when their personalities are in shambles. It's also a challenge because so often the Axis II patients have me pegged before I have the slightest clue about them. (Antisocial malingerers especially!) Anyway it's different from trying to empathize with an Axis I patient, where you're really dealing with illness head on. I find it rewarding quite often. But frustrating too!

 

[whopper]

I actually find working with Axis II patients interesting and, when it goes well, rewarding

I'm actually having a similar experience now that I'm in a situation where I actually have some resources for people with these disorders. Its a very rewarding experience to have a Borderline, see DBT have beneficial effect, and then see the person lead a much more satisfying and productive life.

 

[VMSmith]

It's also a challenge because so often the Axis II patients have me pegged before I have the slightest clue about them.

So so true.

 

[toothless rufus]

I often wonder how borderlines view the behaviors of other borderlines, and how they would react to them.

 

[kazza27]

if everyone with BPD is like my ex friend,lock them up and throw away the key.
though i suspect that my ex friend used her bpd as an excuse for her behaviour,if i was in america id be under 10 yrs of trauma therapy lol

 

[whopper]

I often wonder how borderlines view the behaviors of other borderlines, and how they would react to them.

From my own experience its either hate-hate, or a love-fest that eventually becomes a hate-hate experience, or its a love-hate relationship.

I've seen it a hundred times throughout my life, but what really simplified it to that equation was seeing 2 psychiatry residents, one with combined borderline and histrionic disorder get transferred to another site at my program, and see the love-fest that started between her and someone with several criteria of borderline (though she truly didn't have borderline, but had several traits of that and histrionic disorder--hey I guess you could say she had personality DO NOS).

Then within a few weeks-the relationship became hate-hate.

When I say these people had these disorders, I'm not joking. They really did. False accusations of rape, staff splitting, coming to work in a see through shirt where the person's breasts were exposed etc...

 

[spemat31]

It isn't always severe abuse either. My mom and aunt are the severe cases and they were not abused. They "felt unheard" and un-American. Well, I actually learned German and was called a "Russian" for it in school too. So it is something about how she is as a person. My brother too.

 

[Ceke2002]

So in this thread you say:

It isn't always severe abuse either. My mom and aunt are the severe cases and they were not abused. They "felt unheard" and un-American. Well, I actually learned German and was called a "Russian" for it in school too. So it is something about how she is as a person. My brother too.

But in another thread you mention the following:

My mom had been diagnosed with borderline PD. She said it was "life experience depression". My aunt was just the same too and they both had normal lives. My grandparents were fresh off the boat from Germany so that may have been it but I remember just going all robotlike and cold when I was 6 after she lured me into her vortex and I ended up getting beat and told I shouldn't have been born. Lucky for me, I later developed a full on manic episode and mine go for almost a year when they are bad. I bet manic patients aren't your forté. I know I irritate all the nurses. But I quit addiction psychology to be a mediator just to get out of that life. My mom passed, I don't deserve to relive that misery.

So your Mother and Auntie both felt "Unheard" and "Unamerican", were potentially affected by having to deal with life in a new country alongside parents who were 'fresh off the boat' and probably struggling with their own issues of integration into a foreign society - oh, but wait, your Mother and Auntie did in fact have normal lives, which kind of negates your previous statements. Granted I agree that the abuse associated with the development of BPD doesn't necessarily have to be severe in order for the disorder to manifest itself, especially if you're talking about a particularly sensitive child being exposed to situations they may subjectively perceive as being traumatic or abusive, but the way your statements are reading here it sounds like a case of "methinks this person doth protest too much". I mean of course *you* experienced some taunting at school pertaining to learning a particular language, but the insinuation is that unlike your Mother's experiences you were just fine, and you switched career paths from addiction psychology to mediation because you wanted to get away from "that life". What life are you talking about? The one where your involvement in Psychology is bringing up the type of "misery you don't wish to relive"? How lucky for you as well that after growing up with an abusive, borderline Mother, and experiencing your own bullying/ostracisation at school, you've developed the type of "Manic" symptoms you can point to with the insinuation that it's something outside of your control. Sounds like it's far easier for you to just change jobs when things get too close to home, or put forth symptoms you can distance yourself from rather than accepting that perhaps those bootstraps you keep trying to pull yourself up by aren't perhaps working as well as you think.

Sounds to me like your own time working in addiction psychology may have bought up more than a little countertransference for you, unsuprisingly seeing as I expect some of the patients you were treating may have had stories that were just a little too close to home.

 

[ahmedqman]

I'm bumping this thread. I think medicating people with severe cluster B traits/borderline personality disorder is ridiculous, and my attendings keep telling me to do it, e.g. "affective instability" using lamictal, depakote, atypicals, etc. etc. It's such a load of bull**** and these people don't get better. Unfortunately, there's only 1 DBT therapist in my city.

 

[splik]

Few thoughts:

- DBT is a valuable therapy but most patients are not at the point where they can engage in this. much work is about getting patients to engage in therapy
- contrary to popular belief DBT is not really a treatment "for" borderline personality disorder. it does not really alter character structure. it was developed to treatment chronically parasuicidal individuals and focuses largely on crisis management. Even Linehan has said it was really the first phase of treatment for these patients so they could engage in more enduring therapeutic work. It is certainly helpful at reducing suicidal and self-injurious behavior and hospitalizations but it doesn't focus on broken character structure
- DBT is not the only therapy for borderline personality disorder - mentalization-based treatment, transference focused psychotherapy and schema focused cognitive therapy all have their place
- a motivational interviewing approached focused on rolling with resistance and provided lots of praise and validation is important when working with these patients
- actually the APA's own guidelines "Good Psychiatric Management" recommends using pharmacotherapy to target particular symptom clusters. In fact general psychiatric management has been shown to be just as good as DBT at reducing suicidal behavior, health care utilization, ER visits, and psychiatric hospital stays. Read more here and here
I was very suspicious about this at first, and still question the received wisdom of loading patients up on various pharmaceuticals but this approach can and does work. Also patients in fidelity DBT programs often remain on shedloads of drugs as well. Call them transitional objects, "gifts" from the doctor, or placebos if you will - but the outcomes speak for themselves
- there is even some "evidence" for using seroquel - the first and last author of the paper are known to be ethically questionable, the numbers are small, the duration is short and could represent a "flight to health" we see in these patients - and you can't really do a fair comparison between inert placebo and quetiapine because the latter is so sedating you would need to give a sedating comparator to control for the active placebo effect, but the point is, these patients do respond (transiently as it might be) to pharmacotherapy. This may be more for psychological reasons but that is a large part of many of our drug and somatic treatments anyway. my point is, there has been a resurgence of interest and data suggesting that though not perhaps ideal, if part of a sensible team-based approach may have its place.
- also remember that depression, anxiety disorders, and even bipolar disorder are highly comorbid with borderline personality disorder and drug treatment may be indicated in that case. Curiously enough, good psychiatric management suggests starting borderline patients on an SSRI "to establish therapeutic alliance" haha. The fact is we use crude tools with most of our patients and we need to meet them where they are. the system is broken and evidence based treatments are not as widely available. Where I am we have more DBT programs than probably anywhere else and there are still major issues with engagement and getting people to agree to participate. You obviously have to weigh up risks and benefits and I certainly felt very frustrated with all these poor patients on multiple psychotropics but I am learning that they may have their place. At the same time we need to balance benefits against the potential for iatrogenic harm and use the fewest most benign medications at the lowest doses for the shortest duration, evaluating for changes and not falling prey to the psychotropic merry go round and paying attention to the countertransference enactments that can occur in your prescribing
- good supervision/process group/consultation/personal therapy is often essential in working with these challenging patients and maintaining your own sanity

 

[OldPsychDoc]

And let me just add to that fine post by splik: as you're carefully choosing targeted meds, use the visit(s) as an opportunity to do some good psychoeducation. Tell them what their diagnosis is, and what it means. Tell them and remind them and tell them again that the meds are just part of the process of recovery, and that for as long as you will be treating them, your emphasis will be on "Skills, not Pills". Help them raise their expectations for what they can learn to manage. Demonstrate empathy and understanding while maintaining strong boundaries. It can be done.

 

[hamstergang]

I think medicating people with severe cluster B traits/borderline personality disorder is ridiculous... It's such a load of bull**** and these people don't get better.

What are you basing this on?

 

[notdeadyet]

What are you basing this on?

Agreed. There is data that indicates that with time, many folks with BPD have sufficient improvement to the point of no longer meeting criteria.

The problem is that for folks who don't like BPD, they tend to avoid taking these folks on as long-term clients, so the only time they see BPD is in acute settings or for short term care, in which case here isn't time to see significant improvement.

 

[ahmedqman]

Thanks Dr. splik for the input. so psychotropics have their use... but it may not be in the way one might think. I've just seen borderlines tried on so many strange cocktails... thorazine for thevoices... stelazine you name it.... that I sometimes throw my hands up at the med merry go round. I continue to be supportive with these pts and have gotten one of my cluster b's to talk with a therapist who does supportive and cbt work and I do a lot of validation with her.


I will refer to your post for the future in order to keep my head straight.

 

[ahmedqman]

I take what I said back. One of my cluster Bs got better on lamictal today. Just when I thought things are hopeless...

It's the bias of the 18 months of inpatient that got me.

 

[Shikima]

I take what I said back. One of my cluster Bs got better on lamictal today. Just when I thought things are hopeless...

It's the bias of the 18 months of inpatient that got me.

outpt is better.

 

[Attending1985]

I like the NICE guidelines for treating BPD with recommendation to use drugs for co-morbid conditions but not the core symptoms. I question the ethics of using antipsychotics in those with BPD. Especially if we're considering effects due to psychological reasons when the cardiac risk is very real.

 

[PistolPete]

Agree, and several experts such as Linehan have pointed this out.

My own counter-transference on Borderlines has diminished greatly after PGY-1. It went down even further after I started forensic fellowship due to a very significant reason: I actually saw Borderlines get DBT, and actually get dramatically better after a few months of DBT treatment.

During residency, the typical revolving door was Borderline holds the crisis ER doctor hostage with a suicidal threat--> patient gets admitted to inpatient, inpatient psychiatrist is upset that the person was admitted and discharges with a referral ---> outpatient throws an SSRI or atypical at the Borderline (AND NO DBT TREATMENT) --> Borderline gets no improvement from medication ---> ends up in ER with the same problem--week after week, month after month, year after year.

Where I'm doing fellowship, the forensic center has psychologists who actively do DBT. My wife has some extensive DBT training and she's made tremendous progress with several Borderlines, getting several of them to break the frequent trips to the hospital.

I think my frustration with Borderlines would've dropped tremendously had our system been able to provide DBT because there would've been something we could've done for them that actually worked instead of the revolving door.

Another frustration factor was to see the large number of psychiatrists get referred a Borderline patient, dx them with Bipolar, throw a mood stabilizer or atypical, and further continue them through the revolving door of ineffective treatment.

I just got a Borderline today who was diagnosed with Bipolar. We went through all the DSM criteria, and the only sx of Bipolar she had was impulsivity (which is also a criteria for borderline). She had all 9 out of 9 criteria for Borderline, was sexually abused by her father, her only good father figure-her grandfather died when she was 13, and has lead the stereotype borderline life ever since. Despite that, 5 previous psychaitrists diagnosed her with Bipolar and put her on the usual bogus slew of meds that provided no benefit for her. Every single atypical and mood stabilizer you could name she's been on it.

Its a real shame because borderlines are a plenty, psychiatrists usually aren't trained in DBT, and market forces propel us to give a dx that only pays us to treat people with an Axis I, not an Axis II. This creates the perfect storm situation where these people who need the right and appropriate help won't get it.

Thankfully, where I work I was able to refer her to a DBT therapist and DBT groups.

So you don't start meds... and there's no pressure from insurance companies and you get paid the same? Just making sure, because this is exactly what I plan to do in private practice. As soon as I hear "I'm Bipolar" I immediately assume they're borderline until proven otherwise.

 

[Shikima]

So you don't start meds... and there's no pressure from insurance companies and you get paid the same? Just making sure, because this is exactly what I plan to do in private practice. As soon as I hear "I'm Bipolar" I immediately assume they're borderline until proven otherwise.

About 10% are. Assume all have Cluster B until proven otherwise.

 

[ahmedqman]

This reminds me of a lady who threatened our clinic manager after she was angry at staff because she thought her appointment was at 10:30 AM (but showed up 5 hours early, and our staff left and confirmed a voice mail stating that her appt was at 3:30 PM the day before), she screamed "I'm bipolar, *****" and stormed out. Didn't know that was such a tough gal diagnosis. "Watch out, I'm bipolar!" *shakes finger*

Cluster B, through and through.

When they behave this way with staff, part of me just lets it go and states "it's the illness". Part of me wants to just say "you are accountable for your behavior, your diagnosis does not excuse you. " After all, there are nice borderlines out there. Our clinic manager nearly laid the smack down on this patient and was about to discharge her, but she gave her one more shot. She was bearable during her visit with me though, so I'll continue to see her if she shows up to her appts.

 

[sunlioness]

Understanding the illness allows you to have compassion. It's never an excuse for bad behavior. That would be enabling, not treatment.

 

[Salpingo]

Few thoughts:

- DBT is a valuable therapy but most patients are not at the point where they can engage in this. much work is about getting patients to engage in therapy
- contrary to popular belief DBT is not really a treatment "for" borderline personality disorder. it does not really alter character structure. it was developed to treatment chronically parasuicidal individuals and focuses largely on crisis management. Even Linehan has said it was really the first phase of treatment for these patients so they could engage in more enduring therapeutic work. It is certainly helpful at reducing suicidal and self-injurious behavior and hospitalizations but it doesn't focus on broken character structure
- DBT is not the only therapy for borderline personality disorder - mentalization-based treatment, transference focused psychotherapy and schema focused cognitive therapy all have their place
- a motivational interviewing approached focused on rolling with resistance and provided lots of praise and validation is important when working with these patients
- actually the APA's own guidelines "Good Psychiatric Management" recommends using pharmacotherapy to target particular symptom clusters. In fact general psychiatric management has been shown to be just as good as DBT at reducing suicidal behavior, health care utilization, ER visits, and psychiatric hospital stays. Read more here and here
I was very suspicious about this at first, and still question the received wisdom of loading patients up on various pharmaceuticals but this approach can and does work. Also patients in fidelity DBT programs often remain on shedloads of drugs as well. Call them transitional objects, "gifts" from the doctor, or placebos if you will - but the outcomes speak for themselves
- there is even some "evidence" for using seroquel - the first and last author of the paper are known to be ethically questionable, the numbers are small, the duration is short and could represent a "flight to health" we see in these patients - and you can't really do a fair comparison between inert placebo and quetiapine because the latter is so sedating you would need to give a sedating comparator to control for the active placebo effect, but the point is, these patients do respond (transiently as it might be) to pharmacotherapy. This may be more for psychological reasons but that is a large part of many of our drug and somatic treatments anyway. my point is, there has been a resurgence of interest and data suggesting that though not perhaps ideal, if part of a sensible team-based approach may have its place.
- also remember that depression, anxiety disorders, and even bipolar disorder are highly comorbid with borderline personality disorder and drug treatment may be indicated in that case. Curiously enough, good psychiatric management suggests starting borderline patients on an SSRI "to establish therapeutic alliance" haha. The fact is we use crude tools with most of our patients and we need to meet them where they are. the system is broken and evidence based treatments are not as widely available. Where I am we have more DBT programs than probably anywhere else and there are still major issues with engagement and getting people to agree to participate. You obviously have to weigh up risks and benefits and I certainly felt very frustrated with all these poor patients on multiple psychotropics but I am learning that they may have their place. At the same time we need to balance benefits against the potential for iatrogenic harm and use the fewest most benign medications at the lowest doses for the shortest duration, evaluating for changes and not falling prey to the psychotropic merry go round and paying attention to the countertransference enactments that can occur in your prescribing
- good supervision/process group/consultation/personal therapy is often essential in working with these challenging patients and maintaining your own sanity

All good points, just wanted to add that I think one of the unfortunate, unintended consequences of DBT's success has been the assumption that it is the only effective treatment for borderline PD. As a result, so many psychiatrists will throw up there hands, assume they have nothing to offer and write them off with the plan "refer to DBT". This is exacerbated by our training on inpatient units where borderlines DO typically regress. Like Splik mentioned, DBT is technically not a treatment for PERSONALITY disorder but targets maladaptive BEHAVIORS. All psychiatrists should have the training to treat borderline PD, with the caveat that there has to be some patient buy-in (the same way we treat patients with substance abuse). That means using medication safely, understanding the pathology and having some awareness of the major psychotherapies for BPD (TFP, MBT, DBT, schema therapy).

 

[hamstergang]

I take what I said back. One of my cluster Bs got better on lamictal today. Just when I thought things are hopeless...

Why do you think the Lamictal is the reason the patient got better?

 

[ahmedqman]

Well, she actually didn't in the long term. She discontinued the medication due to "side effects." I'm just managing her intermittent SI with coping strategies. She finds the bible and listening to music helpful which treats her intermittent SI. She is in therapy currently, receiving a lot of CBT and supportive therapy from the therapist. I haven't gotten a phone call from her in 2 months, so I assume she's doing well.

Also, a DBT therapist just joined our university though, so I may take advantage of her expertise and try to learn from her.

 

[smalltownpsych]

Well, she actually didn't in the long term. She discontinued the medication due to "side effects." I'm just managing her intermittent SI with coping strategies. She finds the bible and listening to music helpful which treats her intermittent SI. She is in therapy currently, receiving a lot of CBT and supportive therapy from the therapist. I haven't gotten a phone call from her in 2 months, so I assume she's doing well.

Also, a DBT therapist just joined our university though, so I may take advantage of her expertise and try to learn from her.

Patients with Borderline PD tend to have a greater placebo response so they always have a new med that is working, then stops working for whatever reason. They also can have a new relationship that is working or a new therapist that is working. Psychoeducation is extremely important so that they know that they have to make an effort to stop the chronic pattern of instability. Utilizing a healthy paternalizing transference can be useful initially to get them to commit to a stable course of treatment that will work, but you have to be solid in your information becuase people with Borderline PD have also been demonstrated to be better than average at reading people. Wanted to second what someone else said about DBT not treating the underlying disorder as opposed to be an initial framework to deal with treatment interfering behaviors. Skills building is an adjunct to therapy and Marsha Linehan does the therapy with her own patients and let's others teach the skills. I have to juggle both in my own practice. What I wouldn't give for a good skills trainer that we could actually bill for.

Also, speaking of treatment interfering behaviors, if they have a comorbid substance abuse problem, they really need to stop that too which is often the hardest part. Much of my own success with those patients comes about when they are in a chemical dependency monitoring situation because of some kind of legal problems.

 

[Crayola227]

So you don't start meds... and there's no pressure from insurance companies and you get paid the same? Just making sure, because this is exactly what I plan to do in private practice. As soon as I hear "I'm Bipolar" I immediately assume they're borderline until proven otherwise.

ugh I hate this we've ruined the diagnosis and made so much stigma for real BPAD sufferers as a result