Borderline Personality Disorder as a "dumping ground" diagnosis for chronic suicidality?

[futureapppsy2]

Has anyone else noticed that clinicians seem to be assuming that chronic suicidality equals a definitive diagnosis of BPD more and more, without doing a good differential? I mean, with chronic suicidality, BPD should definitely be on the differential list, but it's not the only disorder that can lead to this (MDD, Persistent Depressive Disorder, PTSD, etc), nor is it sufficient to diagnosis BPD in and of itself. It remains me of the old (and still somewhat prevalent) idea that non-suicidal self-injury automatically equaled BPD, even when research strongly shows that that's not the case.

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[hebel]

Has anyone else noticed that clinicians seem to be assuming that chronic suicidality equals a definitive diagnosis of BPD more and more, without doing a good differential? I mean, with chronic suicidality, BPD should definitely be on the differential list, but it's not the only disorder that can lead to this (MDD, Persistent Depressive Disorder, PTSD, etc), nor is it sufficient to diagnosis BPD in and of itself. It remains me of the old (and still somewhat prevalent) idea that non-suicidal self-injury automatically equaled BPD, even when research strongly shows that that's not the case.

I've seen the self-injury = borderline personality disorder happen a lot, but not as much with recurrent suicidality. I also don't see borderline diagnosed very often (at least formally), but see plenty of people with "bipolar."

 

[Merovinge]

Where I trained and where I practice now I see BPD dramatically under-diagnosed, likely due to the gravity of the diagnosis and in some cases the lack of available treatment (DBT, residential/php/iop options limited). I'd be interested to practice in an environment where this was over-called, since the discussion of the diagnosis and treatment options is such a pain for the psychiatrist.

 

[kopftonmd]

Where I trained and where I practice now I see BPD dramatically under-diagnosed, likely due to the gravity of the diagnosis and in some cases the lack of available treatment (DBT, residential/php/iop options limited). I'd be interested to practice in an environment where this was over-called, since the discussion of the diagnosis and treatment options is such a pain for the psychiatrist.

On my CPEP rotation, another med student and I got into a long discussion about BPD overdiagnosis vs. correct diagnosis in that setting that we were seeing. A lot of patients ended up with "Cluster B traits" in their charts (with the final diagnosis typically being acute adjustment d/o), primarily because no one wanted to either a) label them or b) go through the process of going over the criteria with a comb to see if they actually qualify per the DSM. This would happen even with classic presentations where that was clearly their problem, but no one wanted to handle that in the CPEP setting.

My peer still felt we were far too liberal with cluster B pathologizing, arguing that it was just labeling a normal response to difficult life circumstances. I was fairly liberal with including BPD in my differentials but I still was definitely not tagging everyone who probably had it. I guess it's hard to get past that stigma.

 

[Old&InTheWay]

My peer still felt we were far too liberal with cluster B pathologizing, arguing that it was just labeling a normal response to difficult life circumstances.

It’s like refusing to diagnose diabetes because it is a normal physiological response to donuts.

 

[Bartelby]

I agree with the general sentiment here, I typically see BPD underdiagnosed (even when it is a textbook presentation) and misdiagnosed rather than overdiagnosed. Typically that appears as a diagnosis of MDD, Bipolar Disorder, PTSD, etc. without comment on personality.

 

[WisNeuro]

I agree with the general sentiment here, I typically see BPD underdiagnosed (even when it is a textbook presentation) and misdiagnosed rather than overdiagnosed. Typically that appears as a diagnosis of MDD, Bipolar Disorder, PTSD, etc. without comment on personality.

My experience as well. MH providers, in general, seem reluctant or scared to actually diagnose and discuss a Cluster B diagnosis with their patients. It's unfortunate in our area as we actually have pretty good DBT programs, both in and outpatient.

 

[nexus73]

I think it can be hard to tease out the BPD diagnosis, ensuring you've got 5 of 9 criteria unless you go through the specific symptoms with patients, which takes time you don't necessarily have in a 60 minutes intake when you have many other questions to ask. And if you have a patient who has been diagnosed with BPD before and understands the negative connotation it brings, how they might be treated different by doctors just for having the diagnosis, they can be pretty resistant to endorsing symptoms they absolutely do have, so that can make it tricky. I also think some doctors are afraid to "label" someone as BPD for some reason...I don't know if there is liability risk for "misdiagnosis" or just accurately making a diagnosis the patient doesn't like. I really prefer the term "emotionally unstable" personality disorder over borderline personality disorder as it's more descriptive. Plus I think it's clearly right in the name, the patient isn't choosing to be this way, it's their emotionally unstable personality disorder.

I like using the MacLean BPD screener and if it looks positive, I give the patient a handout about BPD and have them read it to see if they think it fits. Most of the time they come back to the next appointment amazed there is something that explains what they've been dealing with their entire lives and wonder why it wasn't diagnosed sooner. Then you try to refer the to someone who does DBT, but nobody really does, so they find another therapist and you hope for the best.

 

[Candidate2017]

On my CPEP rotation, another med student and I got into a long discussion about BPD overdiagnosis vs. correct diagnosis in that setting that we were seeing. A lot of patients ended up with "Cluster B traits" in their charts (with the final diagnosis typically being acute adjustment d/o), primarily because no one wanted to either a) label them or b) go through the process of going over the criteria with a comb to see if they actually qualify per the DSM. This would happen even with classic presentations where that was clearly their problem, but no one wanted to handle that in the CPEP setting.

My peer still felt we were far too liberal with cluster B pathologizing, arguing that it was just labeling a normal response to difficult life circumstances. I was fairly liberal with including BPD in my differentials but I still was definitely not tagging everyone who probably had it. I guess it's hard to get past that stigma.

Personality disorders are better diagnosed in a long term setting where you get to know the patient and can observe or elicit those 5 of 9 criteria, rather than in a CPEP. Inpatient clinicians may be hesitant to dx it because nurses, staff and other physicians have a habit of writing off patients when they are labeled "borderline".

I don't have a problem telling patients I've observed for a while that I believe they are borderline. It seems to be an "aha" moment for them when I discuss criteria and developmental theories of borderline personality.

 

[kopftonmd]

Personality disorders are better diagnosed in a long term setting where you get to know the patient and can observe or elicit those 5 of 9 criteria, rather than in a CPEP. Inpatient clinicians may be hesitant to dx it because nurses, staff and other physicians have a habit of writing off patients when they are labeled "borderline".

I don't have a problem telling patients I've observed for a while that I believe they are borderline. It seems to be an "aha" moment for them when I discuss criteria and developmental theories of borderline personality.

Totally get that. However, it seems to me that there are some patients/populations who really should get the diagnosis in CPEP. I'm thinking of the folks who are in and out often, typically for the same thing: aggression or HI or SI after a stressor (breakup, fight with parents, etc.), with classic features of BPD (predisposing factors like history of trauma, long history of conflictual relationships, clear splitting, lack of sense of self, etc.). They keep coming in and out because their underlying issue isn't being treated. Or if they have a diagnosis (bipolar?!) and are meds, they aren't helping because... they need a correct diagnosis and DBT, not lithium. Granted, it's hard to arrange for correct f/u and tx from the CPEP, but the ball needs to get rolling somewhere.

Granted, I am a neophyte and if this isn't right, please correct me.

 

[Sushirolls]

Has anyone else noticed that clinicians seem to be assuming that chronic suicidality equals a definitive diagnosis of BPD more and more, without doing a good differential? I mean, with chronic suicidality, BPD should definitely be on the differential list, but it's not the only disorder that can lead to this (MDD, Persistent Depressive Disorder, PTSD, etc), nor is it sufficient to diagnosis BPD in and of itself. It remains me of the old (and still somewhat prevalent) idea that non-suicidal self-injury automatically equaled BPD, even when research strongly shows that that's not the case.

Quacks like a duck, walk like a duck, it is duck.

The vast majority of chronic SI I have encountered are not better explained by MDD, PTSD, or PDD. Axis II, Cluster B Traits, or possibly the full Borderline PD diagnosis is most appropriate. Do you get overlap of Borderline/Axis II/Cluster B with the MDD/PTSD/PDD, yes.

But chronic suicidality is definitely a 'screen' to trigger a more in depth cluster B, personality disorder review.

As for your self-injury = BPD being not proven in literature please drop some pub med IDs. It's more the exception that I've seen chronic self harm to not be reflective of BPD. I've seen a few OCD, or delusional disorders, or substance use, etc but the vast majority are better accounted for by Cluster B/BPD/Axis II with the various other comorbid Axis I PTSD/MDD etc.

There is a reason why DSM versions continue to reflect self harm and injury as a criteria of Borderline Personality disorder, but it is not in PTSD, MDD, PDD...

 

[futureapppsy2]

Quacks like a duck, walk like a duck, it is duck.

The vast majority of chronic SI I have encountered are not better explained by MDD, PTSD, or PDD. Axis II, Cluster B Traits, or possibly the full Borderline PD diagnosis is most appropriate. Do you get overlap of Borderline/Axis II/Cluster B with the MDD/PTSD/PDD, yes.

But chronic suicidality is definitely a 'screen' to trigger a more in depth cluster B, personality disorder review.

As for your self-injury = BPD being not proven in literature please drop some pub med IDs. It's more the exception that I've seen chronic self harm to not be reflective of BPD. I've seen a few OCD, or delusional disorders, or substance use, etc but the vast majority are better accounted for by Cluster B/BPD/Axis II with the various other comorbid Axis I PTSD/MDD etc.

There is a reason why DSM versions continue to reflect self harm and injury as a criteria of Borderline Personality disorder, but it is not in PTSD, MDD, PDD...

I’ll provide more studies tomorrow but here’s a couple to get you started:

Non-suicidal self-injury with and without borderline personality disorder: Differences in self-injury and diagnostic comorbidity

Although non-suicidal self-injury (NSSI) occurs in people with and without borderline personality disorder (BPD), few studies have compared the clinic…

www.sciencedirect.com

https://www.scopus.com/record/display.uri?eid=2-s2.0-0032901636&origin=inward&txGid=ad53698a45c669a68b0a713ee4177d20

https://www.tandfonline.com/doi/abs/10.1080/13811118.2013.809040

Again, not arguing that NSSI or chronic suicidality doesn’t occur at high rates in people with BPD, it’s just not exclusive to or diagnostic of it.

 

[clausewitz2]

I’ll provide more studies tomorrow but here’s a couple to get you started:

Non-suicidal self-injury with and without borderline personality disorder: Differences in self-injury and diagnostic comorbidity

Although non-suicidal self-injury (NSSI) occurs in people with and without borderline personality disorder (BPD), few studies have compared the clinic…

www.sciencedirect.com

https://www.scopus.com/record/display.uri?eid=2-s2.0-0032901636&origin=inward&txGid=ad53698a45c669a68b0a713ee4177d20

https://www.tandfonline.com/doi/abs/10.1080/13811118.2013.809040

Again, not arguing that NSSI or chronic suicidality doesn’t occur at high rates in people with BPD, it’s just not exclusive to or diagnostic of it.

We see self-harming behaviors under stress in a wide range of mammals, it is pretty well conserved across species. This is a very old and non-specific phenomenon unlikely to be confined to a single DSM diagnosis that we have had in its modern form since the early 80s.

 

[tr]

I’ll provide more studies tomorrow but here’s a couple to get you started:

Non-suicidal self-injury with and without borderline personality disorder: Differences in self-injury and diagnostic comorbidity

Although non-suicidal self-injury (NSSI) occurs in people with and without borderline personality disorder (BPD), few studies have compared the clinic…

www.sciencedirect.com

https://www.scopus.com/record/display.uri?eid=2-s2.0-0032901636&origin=inward&txGid=ad53698a45c669a68b0a713ee4177d20

https://www.tandfonline.com/doi/abs/10.1080/13811118.2013.809040

Again, not arguing that NSSI or chronic suicidality doesn’t occur at high rates in people with BPD, it’s just not exclusive to or diagnostic of it.

Non suicidal self injury (really really common, esp among adolescents) and chronic SI (quite uncommon) are very different. I agree with @Sushirolls that chronic SI is almost always personality related - it would almost have to be, since mood disorders are by definition episodic, not chronic. Chronicity is the defining feature of a personality disorder.

I don't think these pubs about NSSI are at all relevant to chronic SI.

 

[psych_0]

I've seen much more over-diagnosing of "bipolar disorder" than any other diagnosis. Anecdotally, when patients say things like "it's just my bipolar" (to describe their reasons for admission) or "my whole family has bipolar disorder," I often find their "bipolar" diagnosis is just their previous provider not wanting to have the "you actually have borderline personality disorder" talk. If I had a dollar for every time I've heard a patient say "you just described my whole life" or "no one has ever understood me like that" after I sat with them and explained what BPD means (often by going over criteria by criteria after the diagnosis is made)...I'd have at least $15. Some said there's "not enough time" to tease out the difference between bipolar & BPD during intake? How much time do you need? I strongly disagree that you need months or years of assessment to diagnose BPD unless a patient is being purposefully vague with responses. A lot of times when I mention a BPD criteria with a true borderline, I'm met with a "OMG yes! That is so me! How did you know that!" Very rarely do I get a BPD who denies most of the criteria and then collateral tells a different story.

Just my anecdotal 2 cents.

 

[cara susanna]

I see it over-diagnosed, IMO, but I also work with a lot of women who have a history of sexual trauma.

 

[clausewitz2]

I don't think these pubs about NSSI are at all relevant to chronic SI.

They're not. However, @Sushirolls specifically asked for pubs about self-harm, not SI. He then went on to say self-injury overwhelmingly tended to mean BPD in his experience. This was explicitly what was being responded to.

 

[futureapppsy2]

We see self-harming behaviors under stress in a wide range of mammals, it is pretty well conserved across species. This is a very old and non-specific phenomenon unlikely to be confined to a single DSM diagnosis that we have had in its modern form since the early 80s.

You mean feather-picking parrots don't all have BPD? 😉

 

[futureapppsy2]

I see it over-diagnosed, IMO, but I also work with a lot of women who have a history of sexual trauma.

Yep. It's also important to remember that BPD is, well, a personality disorder. If emotional dysregulation and suicidality symptoms suddenly show up in someone's mid to late 20s after trauma, it's imprudent to diagnose BPD without first assessing for--and treating, if applicable--PTSD.

 

[tr]

Yep. It's also important to remember that BPD is, well, a personality disorder. If emotional dysregulation and suicidality symptoms suddenly show up in someone's mid to late 20s after trauma, it's imprudent to diagnose BPD without first assessing for--and treating, if applicable--PTSD.

I don't think too many people are confused about symptoms that show up in previously healthy adults after a defined time point that includes a trauma.
It would take a pretty oblivious clinician to diagnose that as BPD.

It's much stickier when you're looking at someone who had chronic childhood trauma. I really do not think the DSM offers anything like an adequate label for this. BPD is the closest fit in most cases IMO. If we had better descriptors we'd be using them.

 

[futureapppsy2]

I don't think too many people are confused about symptoms that show up in previously healthy adults after a defined time point that includes a trauma.
It would take a pretty oblivious clinician to diagnose that as BPD.

It's much stickier when you're looking at someone who had chronic childhood trauma. I really do not think the DSM offers anything like an adequate label for this. BPD is the closest fit in most cases IMO. If we had better descriptors we'd be using them.

Trust me, there are a lot of clinicians (psychiatrists, psychologists, and masters-level clinicians alike) who look at any patient with NSSI, suicidality, and emotional dysregulation (or even one of the above) and go “must be BPD” without assessing for chronicity, onset after adult trauma, the actual diagnostic criteria for BPD, etc. Should BPD be in the differential here? Of course. Is it an automatic diagnosis? No.

 

[cara susanna]

I don't think too many people are confused about symptoms that show up in previously healthy adults after a defined time point that includes a trauma.
It would take a pretty oblivious clinician to diagnose that as BPD.

It's much stickier when you're looking at someone who had chronic childhood trauma. I really do not think the DSM offers anything like an adequate label for this. BPD is the closest fit in most cases IMO. If we had better descriptors we'd be using them.

A good percentage of people with BPD have no trauma history whatsoever. The link between the two has been vastly overstated in the field, when compared to what the research actually shows.

I feel like people get stuck on the emotion dysregulation piece and ignore the other critical clusters of the disorder that characterize it. Like, emotion dysregulation alone doesn't mean it's BPD.

 

[watto]

A good percentage of people with BPD have no trauma history whatsoever. The link between the two has been vastly overstated in the field, when compared to what the research actually shows.

I feel like people get stuck on the emotion dysregulation piece and ignore the other critical clusters of the disorder that characterize it. Like, emotion dysregulation alone doesn't mean it's BPD.

I have read that affective instability has been used as gate criterion, with sensitivity of 92.8% and negative predictive value of 99% (the MIDAS project, 3674 psychiatric outpatients evaluated with semi-structured interview, looking for exact reference but can't find it for some reason).

 

[Stagg737]

Interesting topic, and I'll agree with some of the earlier posters that I see it underdiagnosed far more than overdiagnosed. I've had to tell more than a few "bipolar" patients that they weren't actually bipolar but had BPD (or ADHD a few times). I also agree that in patients with BPD severe enough to warrant seeking out psychiatric treatment, it's not particularly hard to diagnose. My screening and interview involves the following:

Anyone who tells me that have NSSI, chronic SI, or affective instability warrants further investigation for BPD. I usually then have several questions related to ongoing difficulties with maintaining relationships (especially close ones) and if they have a significant fear of being abandoned/have done or said anything to prevent relationships from ending. If they say no to those two questions, I drop the line of questioning and just make a mental note of it. If they say yes to either (especially if they've physically done something or threatened suicide to maintain a relationship), I'm asking them the full criteria as well as what other people have said about them or how others view them.

I'm pretty thorough with my screen for BPD and it's helped me to parse out BPD from bipolar, PTSD, ADHD, etc or find co-morbidities many times. Even with a more thorough screen, it rarely takes more than 5 minutes if the patient isn't overly circumstantial and can make a huge difference in treatment course. I've had more than a couple patients with the same reaction that Psych_0 mentioned above of "Omg, you're describing my whole life" who were very grateful to finally have a reason for why they think and act the way they do. I do agree that for more mild BPD traits or cagey patients that it's much harder to diagnose without developing a longer therapeutic relationship. But I think even if they don't have BPD and just have some suggestive characteristics, they'd probably still benefit from shifting a heavier focus to psychotherapy and CBT/DBT.

I see it over-diagnosed, IMO, but I also work with a lot of women who have a history of sexual trauma.

I agree that most of the time when I've seen BPD inappropriately diagnosed, it's in someone who has PTSD or an "other specified trauma disorder" but was never fully screened appropriately. I've found it somewhat disappointing how many times relatively obvious diagnoses have been missed because the patient was just never asked the right questions.

You mean feather-picking parrots don't all have BPD? 😉

I think the proper term is Plumatillomania 😉

 

[tr]

The thing about diagnosing personality disorders is that they cannot be accurately diagnosed in the presence of an active Axis I.
It's too easy for an active Axis I to mimic an Axis II. This plus potential issues of stigma within health care makes me hesitant to throw an Axis II diagnosis out there the first time I meet someone.

I think the stigma is less prominent now than when I was in training, maybe because DBT is more widely available than it used to be, but I feel like it used to be pretty common for people to roll their eyes and throw up their hands at personality disordered patients, which made me reluctant to chart a diagnosis that could result in second-class treatment.

I think a lot of other clinicians may have a similar approach because I rarely see BPD written out in the chart, except by the people running the DBT program. I'm not sure I would call this underdiagnosis, because the plan still reflects the suspected diagnosis. It's more like cautious charting.

 

[clausewitz2]

The thing about diagnosing personality disorders is that they cannot be accurately diagnosed in the presence of an active Axis I.
It's too easy for an active Axis I to mimic an Axis II. This plus potential issues of stigma within health care makes me hesitant to throw an Axis II diagnosis out there the first time I meet someone.

This came very close to biting me in the a** once. Got an intake for a patient who had been repetitively presenting to an ED for a couple months s/p intentional med overdoses. Constantly dysphorically "depressed," rageful, stormy relationships, interpersonally sensitive, the whole stereotypical presentation. Had a bipolar diagnosis in the chart with zero explanation of why. Definitely probably would have ended up going down the BPD pathway but I happened to find onnnnnne inpatient note that seemed to be describing catatonia, although they didn't call it that.

Probably did meet criteria for BPD, but apparently the very special kind of BPD that goes from living in the ED suicidal to working full time, living on their own, and only seeing me Q3 months after 1200 mg of lithium and telling me that they had forgotten what feeling okay was like.

I'm more cautious and deliberate about deleting bipolar diagnoses now, though obviously i still do at times.

 

[cara susanna]

I have read that affective instability has been used as gate criterion, with sensitivity of 92.8% and negative predictive value of 99% (the MIDAS project, 3674 psychiatric outpatients evaluated with semi-structured interview, looking for exact reference but can't find it for some reason).

That's really interesting and I've love to see the exact reference. One thing, though, is I'm sure the study had a more rigorous definition of affective instability than what I see used in the "real world."

 

[FatherPsychiatry]

We see self-harming behaviors under stress in a wide range of mammals, it is pretty well conserved across specie.

this explains the behaviors of my border(line) collie

 

[watto]

That's really interesting and I've love to see the exact reference. One thing, though, is I'm sure the study had a more rigorous definition of affective instability than what I see used in the "real world."

There is a recent (free text) review of the MIDAS project by Zimmerman, et al, that references their data for the overdiagnosis of bipolar disorder, as well as some BPD data:

A Review of 20 Years of Research on Overdiagnosis and Underdiagnosis in the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) Project - PMC

The Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project represents an integration of research methodology into a community-based outpatient practice affiliated with an academic medical centre. The MIDAS project is the ...

www.ncbi.nlm.nih.gov

Edit: I think I found the BPD reference:
Zimmerman M, Balling C, Dalrymple K, Chelminski I. Screening for borderline personality disorder in psychiatric outpatients with major depressive disorder and bipolar disorder. J Clin Psychiatry. 2019;80(1):18m12257.

 

[whopper]

Unfortunately vast swaths of our entire field are prone to misdiagnosing. I've seen every single patient go to a VA and get a PTSD diagnosis whether they had it or not. There's a place in town (and I've seen this happen in NJ, Ohio, Pennsylvania, Kentucky, Illinois) that diagnoses everyone with Bipolar Disorder no matter what is going on with that patient.

So while I haven't seen a place overdiagnosing Borderline PD, I wouldn't be surprised. It's not a good idea to diagnose someone with a personality disorder unless you've really gotten to know them. At most I would put "Cluster B traits." I would only put borderline PD in the diagnosis if something very outside the norm happened such as the patient was already seen by a clinician with a good rep that I trusted, diagnosed with it, that other clinician went the extra mile to diagnose it, the patient underwent DBT for months and was having significant improvement.

 

[PikminOC]

Unfortunately vast swaths of our entire field are prone to misdiagnosing. I've seen every single patient go to a VA and get a PTSD diagnosis whether they had it or not. There's a place in town (and I've seen this happen in NJ, Ohio, Pennsylvania, Kentucky, Illinois) that diagnoses everyone with Bipolar Disorder no matter what is going on with that patient.

So while I haven't seen a place overdiagnosing Borderline PD, I wouldn't be surprised. It's not a good idea to diagnose someone with a personality disorder unless you've really gotten to know them. At most I would put "Cluster B traits." I would only put borderline PD in the diagnosis if something very outside the norm happened such as the patient was already seen by a clinician with a good rep that I trusted, diagnosed with it, that other clinician went the extra mile to diagnose it, the patient underwent DBT for months and was having significant improvement.

I thought VA tried not to dx PTSD as it then increased service connection benefit to veterans

 

[WisNeuro]

I thought VA tried not to dx PTSD as it then increased service connection benefit to veterans

At least back when I was in the VA, the C&P examiners for MH were essentially diploma mill rubber stamps for PTSD. Essentially asking some yes/no questions, give em a PCL and tell them to collect their checks. There is little quality control to this process. And now, at least in my area, they are farming these evals out to private contractor companies, paying so low that they will only be able to get people who cannot find work anywhere else to complete these exams.

 

[psych_0]

I thought VA tried not to dx PTSD

What? When I was a resident, I had to check out to this one clinic attending that would stop me mid-sentence and say "Oh they had (X-Y-Z-) position in the military? I'm sure they have PTSD. You don't even need to tell me anymore. What else is going on?" Yea that attending was awful at her job and all the residents hated working with her, but in my experience that was more the norm than an exception. In a different VA clinic, I've had patients tell me "Oh you don't think I have PTSD?!? I knew I should have gone to the VA in ___. They diagnose everyone with PTSD. This was a waste of my time." Veterans know where they can go for easy PTSD diagnoses that come with service connection dollars. It's a sad reality in my area (midwest).

 

[WisNeuro]

What? When I was a resident, I had to check out to this one clinic attending that would stop me mid-sentence and say "Oh they had (X-Y-Z-) position in the military? I'm sure they have PTSD. You don't even need to tell me anymore. What else is going on?" Yea that attending was awful at her job and all the residents hated working with her, but in my experience that was more the norm than an exception. In a different VA clinic, I've had patients tell me "Oh you don't think I have PTSD?!? I knew I should have gone to the VA in ___. They diagnose everyone with PTSD. This was a waste of my time." Veterans know where they can go for easy PTSD diagnoses that come with service connection dollars. It's a sad reality in my area (midwest).

It's also a sad reality in the southwest and northwest from my personal experience.

 

[PsyDr]

What? When I was a resident, I had to check out to this one clinic attending that would stop me mid-sentence and say "Oh they had (X-Y-Z-) position in the military? I'm sure they have PTSD. You don't even need to tell me anymore. What else is going on?" Yea that attending was awful at her job and all the residents hated working with her, but in my experience that was more the norm than an exception. In a different VA clinic, I've had patients tell me "Oh you don't think I have PTSD?!? I knew I should have gone to the VA in ___. They diagnose everyone with PTSD. This was a waste of my time." Veterans know where they can go for easy PTSD diagnoses that come with service connection dollars. It's a sad reality in my area (midwest).

These are the idiots that are unaware of the odds ratio for developing PTSD after exposure, the negative outcomes of being on disability, the post traumatic growth research, among others.

 

[futureapppsy2]

It's also a sad reality in the southwest and northwest from my personal experience.

The pervasive idea in the general population, including a lot of healthcare providers, that PTSD is the only—and universal—mental health issue in veterans doesn’t help with this at all, either, in my experience.

 

[Stagg737]

The pervasive idea in the general population, including a lot of healthcare providers, that PTSD is the only—and universal—mental health issue in veterans doesn’t help with this at all, either, in my experience.

If I see a VA patient that doesn't carry a diagnosis of either PTSD, a substance use disorder, or a cluster B personality disorder in their chart, I consider them a unicorn.

 

[WisNeuro]

If I see a VA patient that doesn't carry a diagnosis of either PTSD, a substance use disorder, or a cluster B personality disorder in their chart, I consider them a unicorn.

Or a VA patient over the age of 30 without at least a handful of medications.

 

[futureapppsy2]

If I see a VA patient that doesn't carry a diagnosis of either PTSD, a substance use disorder, or a cluster B personality disorder in their chart, I consider them a unicorn.

Also, a single mild TBI listed as a cause for a whole plethora of symptoms.

 

[Stagg737]

The thing about diagnosing personality disorders is that they cannot be accurately diagnosed in the presence of an active Axis I.
It's too easy for an active Axis I to mimic an Axis II. This plus potential issues of stigma within health care makes me hesitant to throw an Axis II diagnosis out there the first time I meet someone.

I think the stigma is less prominent now than when I was in training, maybe because DBT is more widely available than it used to be, but I feel like it used to be pretty common for people to roll their eyes and throw up their hands at personality disordered patients, which made me reluctant to chart a diagnosis that could result in second-class treatment.

I think a lot of other clinicians may have a similar approach because I rarely see BPD written out in the chart, except by the people running the DBT program. I'm not sure I would call this underdiagnosis, because the plan still reflects the suspected diagnosis. It's more like cautious charting.

Agree with the first part, but when they have a supposed Axis I disorder that's treatment resistant to everything that's persisted for years, at some point we have to start looking harder at Axis II. Even if it's just traits and not a full-blown disorder, I think it can have enough significance to make meds minimally effective without some form of therapy to address the malignant thought processes. I'd also add to my previous post about BPD, that I don't typically make a BPD diagnosis on first encounter unless I can see a long history of notes in the chart (have had some patients with years of notes to parse through) or the patient straight up says their borderline and they've previously been treated for it with decent success. Otherwise I just put Cluster B traits or if it's way up on my differential r/o BPD.

To the bolded, I've seen that quite a bit too. My biggest problem with that is that there are so many bad docs or NPs out there treating patients that they may not pick up on the obvious treatment plan. I've had a couple patients who were clearly borderline and previous treatment plans made this seem obvious, but didn't have a BPD diagnosis who were subsequently inappropriately prescribed meds to treat their "Bipolar disorder", oftentimes by an NP. I actually have a patient I saw this week who has been on at least 5 antipsychotics, Lithium, Depakote, Lamictal, and numerous antidepressants who is so obviously borderline that an M3 could make the diagnosis, but has never had CBT/DBT. The first doc he saw seemed to know what they were doing and mentioned therapy to him, but he couldn't at the time. Subsequently, he saw 2 other prescribers who just ran with the "Bipolar" diagnosis and threw meds at him before coming to our clinic. Poor kid has had so many med side effects that it's taken a literal physical and mental toll on him (EPS, eating/metabolic problems, increased anxiety, etc).

While I understand the idea of keeping BPD off their chart to minimize stigma, I feel like it backfires enough that it's better to just give the BPD diagnosis when appropriate or just put "Cluster B traits". I wouldn't even mention a bipolar disorder unless you legitimately suspect it since not everyone is able to read between the lines properly.

 

[Basis]

Borderline personality disorder is extremely under-diagnosed at least in terms of chart documentation. Borderlines rack up a long list of medications and a long list of incorrect diagnoses. I generally feel that in 99% of cases they do not actually have any axis 1 disorder at all.

Also, I don't really think there is much role at all in these patients for medications. I may not be the biggest fan of the FDA, but as far as I know there are still to this day exactly zero FDA approved medications for borderline personality disorder. Don't you think if a single pharma company could have gotten enough studies together that shows that some drug in the last 70 years was better than placebo for these patients in any sort of outcome they would have gotten it approved by now? Imagine having the only drug approved for such a common diagnosis (meaning the only one insurance companies will basically want to cover from then on). I'm sure they've tried over the years without luck.

These patients also use medications as an excuse for not engaging in appropriate psychotherapy. They just constantly chase medication adjustments and titrations.

 

[whopper]

Included in the MOC is this article on treating personality disorders.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61394-5/fulltext

By the way, this is one of the several articles that are used in the ABPN MOC program. Almost all of the articles are highly relevant to practice which is a reason why so far I'm a fan of the ABPN MOC.

In short meds don't really help much if at all, and the data that does support meds shows they only help short term. The tide has somewhat turned but I remember when I was a resident about 10 years ago I kept seeing borderline after borderline overmedicated and the psychiatrist even acknowledged the meds didn't help yet kept giving them making me wonder WTF was wrong with the doctor.

Pharmacotherapy of borderline personality disorder
The present American Psychiatric Association guideline
59
states that symptom targeted pharmacotherapy is an important adjunctive treatment. This therapy is based on Siever and Davis'
23
dimensions of affective instability (treated with selective serotonin reuptake inhibitor [SSRIs] or monoamine oxidase inhibitors), impulsive aggression (treated with SSRIs or mood stabilisers), and cognitive–perceptive disturbances (treated with low dose antipsychotics). By contrast the UK's NICE guidelines
15
state that drug treatment should generally be avoided, except in a crisis, and then given for no longer than 1 week. The World Federation of Societies of Biological Psychiatry guidelines
60
stated that moderate evidence exists for antipsychotic drugs being effective for cognitive–perceptual and impulsive–aggressive symptoms, that some evidence exists for SSRIs being effective for emotional dysregulation, and that some evidence exists for mood stabilisers being effective for emotional dysregulation and impulsive–aggressive symptoms. The second Cochrane review
61
saw no evidence for the efficacy of SSRIs, but reported that mood stabilisers could diminish affective dysregulation and impulsive–aggressive symptoms in patients with borderline personality disorder, and that antipsychotic drugs could improve cognitive–perceptual symptoms and affective dysregulation. Some concern exists that several of the trials showing positive outcomes provide unreliable data.
25
The most recent guidelines for treatment of borderline personality disorder from Australia's National Health and Medical Research Council (NHMRC)
62
again reviewed the scientific literature and included a series of meta-analyses. They concluded that “overall pharmacotherapy did not appear to be effective in altering the nature and course of the disorder. Evidence does not support the use of pharmacotherapy as first line or sole treatment for BPD [borderline personality disorder]”.
The NICE and NHMRC guideline committees agreed with the Cochrane review
61
and other reviews
63
and meta-analyses
64
that evidence existed that some second generation antipsychotics (notably aripiprazole and olanzapine) and mood stabilisers (notably topiramate, lamotrigine, and valproate) could slightly reduce borderline personality disorder symptoms over the short term. However, as guideline groups they needed to consider the risks and possible benefits of evidence-based treatments. The fact that most of the recommended drugs have substantial long-term risks whereas other treatments such as psychosocial interventions do not have these risks affected their recommendations
65
The situation is complicated by the fact that drugs are used very frequently in the treatment of borderline personality disorder despite the scarcity of evidence for their use. Zanarini and colleagues
4
reported that 78% of patients with borderline personality disorder were on drugs for more than 75% of the time during a 6 year period. Additionally, 37% of these patients were on three or more drugs. In view of this situation clinicians should be guided towards the drugs with at least some evidence (ie, major tranquillisers and mood stabilisers) and away from those with less evidence (ie, SSRIs, tricyclic antidepressants, and benzodiazepines). NICE
66
have argued that the assumption that drug treatment is justified at all is without evidence and their prescription should not be encouraged. The NICE guidelines
15
explicitly state that if patients have no comorbid illness, efforts should be made to reduce or stop pharmacotherapy (panel 3).

 

[biomom]

Just a therapist here. Browsing anyway.

My psychopathology professor in grad school taught us that every woman has BPD. You just have to look for it. He also said that the nicer a patient is, the more BPD symptoms they have. They’re just good at hiding symptoms. My guess is the guy just couldn’t get laid.

After grad school and licensure training, I worked with a doctor who diagnosed nearly everyone with BPD. That and autism, which she really saw as cluster c. I had done an assessment heavy internship as well as prelicensure training. I questioned the over reliance on BPD and felt there were other issues at play for many, but my questions were rebuffed. And hey. Who am I? I’m just a therapist. It isn’t for me to question a psychiatrist. Things were weird though. One day she would love me and praise me. The next day she would scream at me and threaten to fire me. Then she would hug me. She screamed at patients and drank booze at work. I eventually quit, realizing she was the true borderline. She eventually lost her license.

So there are all kinds of BPD stories.

 

[Mass Effect]

Trust me, there are a lot of clinicians (psychiatrists, psychologists, and masters-level clinicians alike) who look at any patient with NSSI, suicidality, and emotional dysregulation (or even one of the above) and go “must be BPD” without assessing for chronicity, onset after adult trauma, the actual diagnostic criteria for BPD, etc. Should BPD be in the differential here? Of course. Is it an automatic diagnosis? No.

The other thing that bugs me is seeing children with this diagnosis. I recently met an 13-year-old with the diagnosis. It was total crap.

I also agree that this should never be diagnosed at a first visit or even a second one. You need time to accurately tease out the "personality" before diagnosing a personality disorder, regardless of checklists.

 

[hallowmann]

I'm in the camp of often finding it underdiagnosed than over. That said, I do more often than I would expect find that those with the diagnosis rarely get diagnosed with another appropriate condition, because their symptoms are just brushed off at borderline/cluster B traits even when they're not. Seen a few that really met true criteria for other conditions. Isn't that the point of a differential in a formulation? Our diagnoses are far from ideal and complete, and it's not like they're all mutually exclusive, even if some are.

 

[dl2dp2]

In clinical practice, BPD is generally not that difficult to diagnose. And in many ways it's much more of a benign diagnosis than say bipolar disorder. I can usually do a differential at the extend of an extended evaluation, and usually I go over the criteria with the patient and discuss the nuances. Typically there is very little in terms of nuance.

If you have BPD, in general this means that in 3-5 years if you are consistent with therapy you'll get better. Several large longitudinal studies support this, and this is also usually what I tell the patients. And this is in fact what I see when I do the therapy myself. They get better.

People with genuine bipolar disorder have unpredictable episodes that are very hard to manage and their behavior tend not progressively improve. It's more similar conceptually to something like episodic/progressive MS, autoimmune disorders, etc. This is what I tell patients/family as well. You need to stay on meds, very careful monitoring, high suicide risk, etc.

 

[Lexanoob]

Somewhat of a tangent, but related in regards to discussion on appropriate settings to diagnose personality disorder: what about patients that are very chronically decompensated such that they often present to ED/hospital/acute setting very frequently (sometimes multiple times a day) for many, many years with a similar presentation, with no history of outpatient care at least in the past 10 years, due to suspected characterological traits with an absence of fulfilling criteria for an axis I illness and absence of substance use. With this chart history, would you feel comfortable with diagnosing a personality disorder?

 

[dl2dp2]

Somewhat of a tangent, but related in regards to discussion on appropriate settings to diagnose personality disorder: what about patients that are very chronically decompensated such that they often present to ED/hospital/acute setting very frequently (sometimes multiple times a day) for many, many years with a similar presentation, with no history of outpatient care at least in the past 10 years, due to suspected characterological traits with an absence of fulfilling criteria for an axis I illness and absence of substance use. With this chart history, would you feel comfortable with diagnosing a personality disorder?

What's the point of this diagnosis? What setting are you in? You can always diagnose personality disorder NOS, or you can take out your DSM and go over the criteria and check them off.

Why would any MD not feel "comfortable" making a purely clinical diagnosis based on history? Which aspect of this is confusing or stigmatizing? Is BPD really more stigmatizing than schizoaffective or bipolar I or even chronic depression or opioid use disorder? Which of the psych diagnoses is not stigmatizing???

 

[Lexanoob]

What's the point of this diagnosis? What setting are you in? You can always diagnose personality disorder NOS, or you can take out your DSM and go over the criteria and check them off.

Why would any MD not feel "comfortable" making a purely clinical diagnosis based on history? Which aspect of this is confusing or stigmatizing? Is BPD really more stigmatizing than schizoaffective or bipolar I or even chronic depression or opioid use disorder? Which of the psych diagnoses is not stigmatizing???

Thanks for the input! This setting was in the C/L setting for a patient with a well documented chart history of malingering with poor coping mechanisms, that would escalate while hospitalized around the time of discharge, which would end up being pursued for administrative reasons due to abuse of staff. The diagnosis in question was of antisocial personality disorder. I’m a resident, and assigned this diagnosis based on dsm-5 criteria, but my attending, while supportive felt that they would never feel comfortable assigning personality pathology in an acute setting when patients could be expected to be using less mature defense mechanisms, which made sense to me, but also is confusing for patients who seem to be only seen and evaluated in acute settings. Despite this pattern of behavior for many years with the exact same presentation (concerning for borderline intellectual functioning)c only one other provider diagnosed this patient with this diagnosis, and multiple other providers assigned diagnoses of adjustment disorder or malingering. Appreciate any thoughts on this! Thanks in advance.

 

[dl2dp2]

Thanks for the input! This setting was in the C/L setting for a patient with a well documented chart history of malingering with poor coping mechanisms, that would escalate while hospitalized around the time of discharge, which would end up being pursued for administrative reasons due to abuse of staff. The diagnosis in question was of antisocial personality disorder. I’m a resident, and assigned this diagnosis based on dsm-5 criteria, but my attending, while supportive felt that they would never feel comfortable assigning personality pathology in an acute setting when patients could be expected to be using less mature defense mechanisms, which made sense to me, but also is confusing for patients who seem to be only seen and evaluated in acute settings. Despite this pattern of behavior for many years with the exact same presentation (concerning for borderline intellectual functioning)c only one other provider diagnosed this patient with this diagnosis, and multiple other providers assigned diagnoses of adjustment disorder or malingering. Appreciate any thoughts on this! Thanks in advance.

If he meets criteria he meets criteria.

The criteria already have wording on "pervasive" and "pattern", and if you think he meets these criteria, then it's fine to diagnose. If you think you suspect the diagnosis but can't be fully sure, you can say r/o, symptoms consistent with, and spell out which part is not ascertained yet in your assessment. This is all standard stuff. People in the ER get r/o BPD all the time.

All the psychobabble nonsense should be thrown into the wastebin. Frankly people with borderline intellectual functioning don't really have enough ego function to sustain psychoanalytic formulation (see I can do psychobabble myself), so to categorize their defenses makes no sense and was not the intended original purpose of this body of knowledge. At ALL.

Of course, you wouldn't want to run afoul of your attending on the rotation, just because you might get a bad eval. But just because he's an attending doesn't mean he's always right.

Finally, people like this get seen in CL all the time. Ideally, they should be absorbed into a long-term residential program, but usually, there's no money for that. Which is fine for the hopsital, as every hospitalization triggers massive $$ from Medicare to pay for them (as they are typically on SSI), but frustrating for the providers as they feel that they aren't doing anything productive and are subject to abuse. This aspect is why I had much hate for CL. Also--from the patient's perspective malingering is much more stigmatizing, IMO, as you are basically implying the patient he's making things up for a secondary gain. What IS the secondary gain? It sounds more like there's a primary gain.