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

[comp1]

Where are these places that overdiagnose borderline PD? I've worked in several locations and never seen it. It must be so odd to be jumping right to recommending long term evidence based talk therapy instead of switching to a new medication every other week for a bipolar disorder that just never seems to respond.

---

Members don't see this ad.

 

[hebel]

Where are these places that overdiagnose borderline PD? I've worked in several locations and never seen it. It must be so odd to be jumping right to recommending long term evidence based talk therapy instead of switching to a new medication every other week for a bipolar disorder that just never seems to respond.

Agree. Much much more common in my experience to see bpd underdiagnosed while bipolar and/or schizoaffective (bipolar type) overdiagnosed. The latter is much more egregious and harmful in my opinion.

 

[psychacad]

Agree. Much much more common in my experience to see bpd underdiagnosed while bipolar and/or schizoaffective (bipolar type) overdiagnosed. The latter is much more egregious and harmful in my opinion.

It's insane. What are the scores of psychiatrists learning in residency? In some settings almost every other patient gets a schizoaffective dx. Schizoaffective is very hard to diagnose going by the DSM. and deliberately so, made even more stringent in DSM V. My biggest pet peeve in this field. I don't know how we could get away with this level of incompetence.

 

[Mass Effect]

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.

Your attending is correct. The only way you should make a personality disorder diagnosis in an acute setting is if the patient him or herself agrees the criteria is met based on history or collateral and even then, I would be extremely cautious. This is not a diagnosis to be made just because someone is unpleasant when in the hospital.

And yes, I do think personality disorders are more stigmatizing than other psych diagnoses. They're the only group of diagnoses in which the patient is usually blamed for the illness.

I also believe BPD is over-diagnosed and generally includes any difficult patient.

Personality Disorders

Overview of statistics for personality disorders. Personality disorders represent “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture” per the Diagnostic and Statistical Manual on Mental Disorders, fifth edition (DSM-5)...

www.nimh.nih.gov

 

[Stagg737]

It's insane. What are the scores of psychiatrists learning in residency? In some settings almost every other patient gets a schizoaffective dx. Schizoaffective is very hard to diagnose going by the DSM. and deliberately so, made even more stringent in DSM V. My biggest pet peeve in this field. I don't know how we could get away with this level of incompetence.

I see schizoaffective diagnoses fairly frequently with patients in our area and will admit I'm most likely guilty of over-diagnosing this. When I see a schizoaffective diagnosis I interpret it as this patient has a primary psychotic disorder but has also had either severe depressive episodes that meet MDD criteria or true manic episodes. I essentially just treat it as schizophrenia/other primary psychotic disorder with a h/o severe affective component. Is this the most appropriate or accurate way to interpret a schizoaffective disorder? No. But I have found it to be the most practical as the vast majority of "schizoaffective" patients I've seen do have a primary psychotic component which needs to be addressed.

The most problematic issues I've seen with this diagnosis are when patients end up on antipsychotics long term when they actually just have MDD w/ psychotic features or even sometimes PTSD

And yes, I do think personality disorders are more stigmatizing than other psych diagnoses. They're the only group of diagnoses in which the patient is usually blamed for the illness.

I also believe BPD is over-diagnosed and generally includes any difficult patient.

Disagree with the first statement and somewhat with the second. Substance use disorders are almost uniformly pinned on the patients and I'd even argue that there are a significant number of depressed patients who are blamed for their poor functioning because they "aren't trying hard enough".

The latter I semi-agree with. I do think difficult patients are often inappropriately diagnosed with BPD, but I do think there is probably a large percent of "BPD" patients who may have significant traits or features but don't meet full criteria. Which is still inappropriate, but reasonable to include something like R/o Borderline traits or R/o BPD in a note. Where I'm at, it's far more common for me to see any patient with mood swings or impulsivity get diagnosed as bipolar than patients labeled with BPD. I think there's probably a lot of variation in from area to area or even doc to doc in terms of what they see misdiagnosed and there is probably some level of confirmation bias involved as well.