borderline personality disorder

[chaos]

Do you think borderline personality disorder is seen as less of a 'valid' disorder than other personality disorders, or other disorders in general such as schizophrenia, or depression? I've been on several psych forums and I've heard patients diagnosed with borderline complain that their therapists don't take them as seriously as someone with say, schizophrenia. This nature of complaining could be endemic to the disorder, but do you think it's true? If so, why? It can be dangerous to the patient, especially if they engage in self-harm, and their limited self-awareness into their aberrant behaviors could be equated to the lack of insight seen in people with schizophrenia, yet no one would ever think to become exasperated with someone with sz for 'not seeing' their problems (well, my psychiatrist might beg to differ, but I'm talking about the general population). Basically, my question is, why is there a tendency to see attention seeking behaviors and borderline personality disorder as sort of a nuisance when it is far less socially and physically dangerous than many other disorders? (or am I wrong about this phenomenon?) Just a random thought to provoke some conversation.

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[JatPenn]

BPD patients may indicate that their therapists do not "take them seriously" because this is actually a critical component to a common treatment; dialectical behavior therapy.

The therapist is to refrain from reinforcing erratic/dramatic behavior that characterizes the disorder, such as sympathizing with patients when they call with one of their daily "crises" or otherwise giving them the attention they seek. It's actually a very effective behavioral treatment, I'm a fan.

 

[chaos]

hmmm I didn't know that, since I know very little about the disorder outside the DSM criteria. Do you think there is a trend where the therapist actually takes them less seriously as a client in their own mind, though?

 

[Psyclops]

The issues about the relation to BPD patients and their treaters are very interesting. They do have very serious pathology and it is not taken lightly. But there is a common misconception that they are not very treatable. Additionally, the attention seeking behaviors can manifest themselves in very socially and physically dangerous ways (e.g., promiscuity, cutting, etc.).

 

[JatPenn]

hmmm I didn't know that, since I know very little about the disorder outside the DSM criteria. Do you think there is a trend where the therapist actually takes them less seriously as a client in their own mind, though?

Possibly, but frankly I'm not aware of any data to support this as anything other than speculation.

There are many psychologists who specialize in BPD and a growing literature base concerning etiology and treatment.

 

[Psyclops]

If you have worked on an inpatient unit, the staff do tend to have a dismissive attitude towards BPD clients. They can be extremely disruptive to the millieu. They can interfere with otehr pts treatment quite a bit. Although this tends to be part of their pathology, it is can be seen as controllable, unlike hallucinations for example. This attitude makes it more frustrating for the staff, since they see BPD patients as not willing to behave. So they can be dismissive.

 

[pingouin]

"taking a patient's concerns seriously" and "taking a patient's concerns as seriously as the patient is taking them" are two different things. the latter quickly leads to therapist burnout.

 

[Psyclops]

Good point jlw. IN reference to my previous post, I wasn't condoning the behavior merely reporting on it.

 

[pingouin]

Good point jlw. IN reference to my previous post, I wasn't condoning the behavior merely reporting on it.

I know. And you're absolutely right. I'm guilty of it on occasion. (I had actually been responding to chaos but didn't use quotes.)

I suppose my take-home point for the OP and others is that it really is a matter of perception, or in some cases, misperception. Consider that transient paranoia and unstable self-image are just 2 of the criteria currently used as diagnostic indicators of BPD. Both can be forms of cognitive distortion or- misperception. Take a patient who is actively in the midst of a "borderline episode" with these symptoms- is it plausible that the therapist or hospital staff aren't taking them seriously? Absolutely. It's also plausible that the therapist or staff are taking them very seriously and their symptoms are interfering with their ability to understand that.

 

[Anuwolf]

Do you think borderline personality disorder is seen as less of a 'valid' disorder than other personality disorders, or other disorders in general such as schizophrenia, or depression? I've been on several psych forums and I've heard patients diagnosed with borderline complain that their therapists don't take them as seriously as someone with say, schizophrenia. This nature of complaining could be endemic to the disorder, but do you think it's true? If so, why? It can be dangerous to the patient, especially if they engage in self-harm, and their limited self-awareness into their aberrant behaviors could be equated to the lack of insight seen in people with schizophrenia, yet no one would ever think to become exasperated with someone with sz for 'not seeing' their problems (well, my psychiatrist might beg to differ, but I'm talking about the general population). Basically, my question is, why is there a tendency to see attention seeking behaviors and borderline personality disorder as sort of a nuisance when it is far less socially and physically dangerous than many other disorders? (or am I wrong about this phenomenon?) Just a random thought to provoke some conversation.

I thought I’d take a hit off of this one.

I’ve been diagnose of having Borderline Personality Disorder. I often get accused of being attention seeker or ***** because I self harm. I don’t think I’m trying to seek attention by self harming, I self harm because I want to see if I’m still alive. In my episodes I sometimes feel numb, both physically and mentally. I also self harm simply so I can see my blood dripping. It also causes me to be sexually aroused; I have to masturbate when I see my blood drip.

The question quote is

I've heard patients diagnosed with borderline complain that their therapists don't take them as seriously as someone with say, schizophrenia. This nature of complaining could be endemic to the disorder, but do you think it's true? If so, why?

I can think of 1 particular therapist that I’ve went to see for a couple of years before I was diagnosed of having BPD. It seemed like the therapists that I had been with was interested in one thing and one thing only, which was my insurance money. She would talk about how great her New York trips were and such on. I would tell her if only if I had the money to go on vacations that I would not have the kind of problems that I had at the time, she would brag and made me feel WORSE. I would sometimes walk out of the office crying because I would have loved that trip. Out of 1-10 of being the worse.. That therapist would have gotten a big fat 10 from me for being the worse therapist in South Florida.

I personally do not believe that is part of the symptom, theirs simply a lot of therapists that shouldn’t be treating people with BPD that they don’t know a whole lot about. Some shouldn’t even be in the field in the first place.

Also I feel that psych isn’t treating BPD as serious as they are with schizophrenia people.

Anyhow feel free to ask me any questions.

 

[Psyclops]

Take a patient who is actively in the midst of a "borderline episode" with these symptoms- is it plausible that the therapist or hospital staff aren't taking them seriously? Absolutely. It's also plausible that the therapist or staff are taking them very seriously and their symptoms are interfering with their ability to understand that.

That pretty much sums it up in my experience. Another thing to consider is that sometimes (oftentimes?) their attention seeking behaviors manifest themselves as cutting, suicidal beh., pseudoseizures, etc. Its not hard to see how this quickly exhausts the provider's patientce. For a scholarly reference see, The Boy Who Cried Wolf (Author Unkown, 1218).

 

[Psyclops]

When it comes to PDs BPD is the most studied, by far. I assure you that many are studying it, and many are very good at treating it. It's a shame that you had a bad experience with a therapist. Perhaps in the future, now that you ahve a diagnosis, you can ask the provider if the specialize in its treatment.

 

[Anuwolf]

That pretty much sums it up in my experience. Another thing to consider is that sometimes (oftentimes?) their attention seeking behaviors manifest themselves as cutting, suicidal beh., pseudoseizures, etc. Its not hard to see how this quickly exhausts the provider's patientce. For a scholarly reference see, The Boy Who Cried Wolf (Author Unkown, 1218).

Why is it that you people think that the reason why we self harm is to seek some attention. Since you’re the expert, why do we wear long sleeves after we cut on our arms? To seek some attention? Absolutely WRONG! We just can’t help it if people become brown nose into our business. This is the reason why we complain that you guys aren’t listening to us. You listen more on what some book of what Joe schmoe tells you rather then the patients.

You never told me who you are Psyclops… are you a nurse or a psychiatrists.

 

[pingouin]

Please keep in mind that this is a clinical discussion about general trends within BPD. No diagnosis is "one size fits all", so I could interview 100 people with BPD and each would have a unique experience. Because we are speaking generally, an individual situation may not exactly mirror what we say. I wouldn't expect it to.

 

[Psyclops]

Look, I wasn't talking about you per se. I posted my thread at the same time you did, so it wasn't in response to yours (although it would seem so otherwise). But one thing about BPD and many other disorders is that there is a substantial amount of herterogeneity of symptoms. What that means is that two people who meet the diagnosis for the disorder do not necessarily have the same symptoms. There are 9 symptoms and you must have 5 of them. You can figure out the permutations. I'm not an expert on BPD. And although you are presumably very familiar with your own symptomology, there are many others who do not exactly mirror your symtomology.

 

[pingouin]

Look, I wasn't talking about you per se. I posted my thread at the same time you did, so it wasn't in response to yours (although it would seem so otherwise). But one thing about BPD and many other disorders is that there is a substantial amount of herterogeneity of symptoms. What that means is that two people who meet the diagnosis for the disorder do not necessarily have the same symptoms. There are 9 symptoms and you must have 5 of them. You can figure out the permutations. I'm not an expert on BPD. And although you are presumably very familiar with your own symptomology, there are many others who do not exactly mirror your symtomology.

JINX!!



(clearly I'm the faster typer )

 

[Psyclops]

You certainly are. You would have survived longer in the wild west. That made me laugh out loud.

 

[pingouin]

You certainly are. You would have survived longer in the wild west. That made me laugh out loud.

You just used bigger words like "heterogeneity" and "permutations".

Pffft... psychologists

 

[Craig39OKC]

I have been diagnosed (sp) with : ADHD,OCD,PTSD,Manic bi-polar (with mixed poles),Anxiety disorder,personality disorder am a recovering alcoholic. But the damage I insued during a robbery was too much. HELP!!!!!!!!

 

[50960]

I am not going to close this thread YET, because it has some good discourse. However, personal stories invite advice giving and that is line we cannot cross here on SDN. Certain members will be personally contacted regarding this, and hopefully we can keep this thread open.

Mod

 

[pingouin]

I am not going to close this thread YET, because it has some good discourse. However, personal stories invite advice giving and that is line we cannot cross here on SDN. Certain members will be personally contacted regarding this, and hopefully we can keep this thread open.

Mod

^^^

 

[worriedwell]

To the OP...

keep in mind, BPD is an AXIS II diagnosis, which is very different than an AXIS I diagnosis, and therefore needs to be treated accordingly from a therapeutic philosophy.

the example of schizophrenia is probably the prime example of an axis I diagnosis with very strong biological evidence for dysfunction and treatment is predominantly pharmacologic before anything else.

Axis II disorders, BPD being the most famous/infamous, requires a particular skillset of therapy (and pharmacology, which is very often helpful for these folks from a harm reduction/stability point of view). In addition, by definition, it is character "pathology" or if you don't like that term character traits that are pervasive and often not ego-dystonic. Thus, the treating therapist (and staffs) response to a BPD patients provocative behavior is in some ways a part of the diagnostic process. If someone is really getting a rise out of you as a therapist and making you feel a gamut of emotions through manipulation, provocation, and splitting, it helps you consider the diagnosis of BPD. The thought is that this reflects on how individuals who live with BPD interact with their peers and in can be inferred that their character traits are a contributor to the rocky relationships that they have.

Of course, each individual is unique, but generally speaking, its a two way street, of course the people treating BPD should have empathy, but the client themselves influences how people think of them through their behavior and this may be why you see what seems to be an overabundance of people seeming to not take BPD as "seriously".

best,
worriedwell

 

[Psyclops]

To the OP...

keep in mind, BPD is an AXIS II diagnosis, which is very different than an AXIS I diagnosis, and therefore needs to be treated accordingly from a therapeutic philosophy.

This could be argued.

http://www.bpdresources.com/otherdisorders.html#Bipolar

Are the axis qualitatively different? They are certainly artificial distinctions in my boodk.

 

[worriedwell]

agreed, could be argued, and my use of the phrase "very different" should probably be toned down.

nonetheless, DBT is a great example of what seems to be the trend for axis II/borderline stuff that is quite different than most of the treatment for axis I. (at least from what I hear, as I don't have experience with DBT)

 

[pingouin]

I just spent the morning at a DBT seminar. The thinking of BPD as an affective DO rather than characterological (sp?) disorder came up... let me weed through some of the materials and links they gave us and I'll post more later.

 

[Psyclops]

I'm interested in seeing evidence supporting that. From what I understand, although there is affective lability, much of thier issues are interpersonal, which wouldn't point to a purely affective pathology.

 

[50960]

Recent research shows that 75% of women diagnosed with borderline PD do not meet Dx criteria for the disorder 10 years later. This is not even close to the same for any heavily genetic loaded disorder like mood disorders or schizophrenia.

 

[Psyclops]

That's interesting, but are you suggesting anything by that comment? It sounds like you are questioning the validity, am I wrong?

 

[Psyclops]

Something that might be of interest.

http://www.apa.org/monitor/mar04/axis.html

 

[Poety]

Recent research shows that 75% of women diagnosed with borderline PD do not meet Dx criteria for the disorder 10 years later. This is not even close to the same for any heavily genetic loaded disorder like mood disorders or schizophrenia.

From what I"ve learned, it runs along the parallel with antisocial in men

ETA:


clearly I didn't finish my post, what I meant by that was that research has shown that men dx with antisocial also don't meet criteria by the time they're in their 50's or something like that. So, I've spoken with some PD specialists and they've suggested that BPD is common for women, and antisocial for men, but they may stem from the same maladjusted coping mechanism and manifest differently in men vs. women. This ofcourse was theory, but one I found interesting.

Perhaps its learning better coping skills as they age, or perhaps running out of energy to maintain that level of dysfucntion?

 

[Psyclops]

Recent research shows that 75% of women diagnosed with borderline PD do not meet Dx criteria for the disorder 10 years later. This is not even close to the same for any heavily genetic loaded disorder like mood disorders or schizophrenia.

I've done a little thinking about this, and PDs (BPD in particular) tend to be unstable in terms of specific symptomology (i.e., the 5 out of 9) but not in the overarching personality patholgy (i.e., maladaptive interpesonal functioning).

 

[psychanon]

I've done a little thinking about this, and PDs (BPD in particular) tend to be unstable in terms of specific symptomology (i.e., the 5 out of 9) but not in the overarching personality patholgy (i.e., maladaptive interpesonal functioning).

Some symptoms may be more state-like, and others more trait-like. In BPD, impulsivity tends to be the first symptom to go, whereas affective symtpoms are more stable. Most symptoms are gone by the late 30's/ early 40's, which is why the goal of DBT is to keep them alive until then. Anyway, this lack of stability really speaks to the artificiality of the Axis I/II distinction, since by definition Axis II disorders are supposed to be stable, and many are less so than Axis I disorders. Of course, if the axis distinction has clinical utility, then maybe the artificiality is worthwhile.

From what I"ve learned, it runs along the parallel with antisocial in men

I think BPD and ASPD run in families together also, so there may be a shared genetic component. Of course, it could be the shared underlying dimension of impulsivity.

 

[pingouin]

OK, summing up the info from my seminar yesterday..
It was made very clear (as has been done in other DBT seminars and readings I've done) that the purpose of DBT is to teach people how to effectively manage their symptoms, not to cure. Also clear is that DBT is still a relatively new concept, therefore it's still a work in progress, very dynamic, and no one has "perfected" it. And yet, it still appears to work in reducing self-injurious behaviors and treatment costs. The focus yesterday was not on the diagnosis of BPD, rather on understanding how DBT is utilized.

I mentioned the connection with bipolar in my earlier post- what was touched on (and sorry, she didn't give us references for this) is that BPD was historically considered an "excess of aggression" disorder, now viewed as an affective continuum disorder similar to bipolar with strong anxiety/shame components. Current lethality stats are that 70-75% of those diagnosed BPD have a history of at least one self-injurious act, suicide rates for BPD are 9% and double to triple that for those persons with a history of self-injurious behavior.

Validation (why it's critical and how to provide it) was a hot topic, especially the principle of "radical genuineness". Emphasis was placed on how therapist use of self is utilized MUCH more than in other therapy types, and that this can be a pretty drastic change for some clinicians, and uncomfortable for some. Of course, she also focused on dialectics and finding synthesis and balance in what may appear to the patient to be opposing ideas- ie, "I made a poor choice, and I'm still a good person anyway." vs. "poor choice= bad person". She didn't get into the specific emotions-management skills due to lack of time, although I've been through some of that before..

What she didn't bring up that I've heard in another presentation is the use of "but" vs. "and" when doing the dialectics. Thought being that "but" invalidates everything that went before it (and again, validation is key to DBT), whereas "and" is an additive statement. I've been working on this in my practice and have had some success, and have coached a few of my patients to do this when dealing with family conflict at home. They're reporting that it seems to help in de-escalating some situations. I'm still working on dropping "but" out of my vocabulary- but that's hard!

For a lot of really good info on DBT, www.behavioraltech.org is Marsha Linehan's website, and it's got lots of resources on there, including training schedules and assessment instruments developed by Linehan et al.

 

[Psyclops]

Some symptoms may be more state-like, and others more trait-like. In BPD, impulsivity tends to be the first symptom to go, whereas affective symtpoms are more stable. Most symptoms are gone by the late 30's/ early 40's, which is why the goal of DBT is to keep them alive until then. Anyway, this lack of stability really speaks to the artificiality of the Axis I/II distinction, since by definition Axis II disorders are supposed to be stable, and many are less so than Axis I disorders. Of course, if the axis distinction has clinical utility, then maybe the artificiality is worthwhile.



I think BPD and ASPD run in families together also, so there may be a shared genetic component. Of course, it could be the shared underlying dimension of impulsivity.

I hate using these emoticons, but I though this was such a great post. I agree wholeheartedly with both points. The artificial distinction has helped the treatment and research of PDs but has exhausted it's utility. And one doesn't have to think hard to come up with chronic Axis I d/os.

 

[MeghanHF]

A Case in Point for the Maxim 'Do No Harm'
By RICHARD A. FRIEDMAN, M.D.
Published: May 30, 2006 in the NY Times

http://www.nytimes.com/2006/05/30/h...49825600&en=f42855219f552969&ei=5070&emc=eta1

 

[Psyclops]

Interesting, I don't know if I like the tone so much though. It seems that they should have put more emphasis on the fact that it isn't a therapists fault that this happens per se.

 

[MeghanHF]

Interesting, I don't know if I like the tone so much though. It seems that they should have put more emphasis on the fact that it isn't a therapists fault that this happens per se.

Hmmm...but don't we have a responsibility, particularly when working with complex cases, to keep an eye out for worsening symptoms and try to figure out why?

 

[Psyclops]

Absoolutely, it was very interesting, and I believe the writier's heart was in the right place, it's just that, I don't know, I tend to be very weary of out-of field criticism. I'm a fan of within field criticism though....

 

[Demosthenes]

Recent research shows that 75% of women diagnosed with borderline PD do not meet Dx criteria for the disorder 10 years later. This is not even close to the same for any heavily genetic loaded disorder like mood disorders or schizophrenia.

That assumes the dx was correct in the first place...

A friend of mine works at a service for PDs, and she complains a lot about the number of pts who are referred to their service who have received a dx of BPD, without meeting the criteria in the first place. They're seeing BPD used as a dumping ground, which is diminishing its usefulness as a dx.

Someone posted a few comments about pts with BPD being treated for bipolar, which also happens, but the numbers of women who receive the dx inappropriately is maddening. These DOs are only useful tools if they are applied appropriately, and some psychiatrists use shortcuts -- "The pt got upset with me when I was half an hour late for an appt -- she must be BPD." "Pt didn't respond to 20mg Paxil, must not be MDD, must be BPD." It's appalling. (I've got a chick in one of my groups who's almost classic Cluster C -- Avoidant, Obsessive-Compulsive, maybe a bit Dependent -- and her psychopharmacologist insists she's BPD! Maybe in another universe, but in this one she doesn't meet a single criteria for the dx.)

 

[MeghanHF]

The new issue of *Harvard Mental Health Letter* (June) includes an
article: "Borderline personality disorder: Origins and symptoms." It's fairly comprehensive and talks about borderline and temperament, environment, sexual abuse hx, bipolar, etc. If anyone is interested in a copy, please pm me - it's too long to post here.