BPD and morbid obesity

[psychma]

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I have a client that was diagnosed with bipolar disorder that clearly meets the criteria for bpd instead. I have held off on changing the diagnosis because she wants to have bariatric surgery this year and because her psychiatrist diagnosed her with bipolar 2 and I feel I’d have to talk to him. How would my diagnosis affect her eligibility for surgery? She has no substance abuse history. I hate to take this away from her but at the same time feel her diagnosis should be updated.

 

[MCParent]

Hot take: diagnose ppl with what they have not what is convenient for them.

 

[psychma]

That’s my take too. Thanks.

 

[PsyDr]

So doctor, are you telling the jury that you purposely withheld a diagnosis? Are you aware that the diagnosis of borderline personality disorder is associated with poor surgical outcomes? And instead of telling the surgeon that the patient had a diagnosis associated with poor surgical outcomes, you purposely mislead the surgeon? And your patient had a bad surgical outcome? Is withholding a diagnosis a regular part of your profession? So you are deviating from the standard of care, which resulted in harm to your patient? And your actions caused the surgeon to be sued?


Boom: you’ve now admitted to malpractice and are liable for the patient’s surgical outcomes/pain+suffering AND the surgeons legal expenses.

 

[BuckeyeLove]

You're the treating clinician, correct? You won't be doing any sort of objective psycho-legal-medical eval (or you shouldn't be). What are you seeing that makes you think this is more a characterological syndrome as opposed to a mood-spectrum illness? Lay it all out in whatever you use to document, provide justification for the dx, but honestly if you're seeing BPD (or cluster b stuff), call it on your end, especially if it's providing justification for your informed treatment course (obviously). Hell, make mention that they've also been diagnosed with bipolar by their prescribing doc "Per history" (i would bet half of the legit bpd I've seen in the last 10 years has also carried a bipolar spectrum illness dx as well because of bad psychiatrists). The more i think about it, the more i would be concerned about not making that call but then doing therapy that is essentially to treat that condition. Fostering cognitive insight into med management of bipolar is a hell of a lot different than DBT. Is this an insurance patient or private pay, because if the former then I'd be big worried about my last point. Why worry about "changing" the diagnosis? You're not prescribing meds to justify said dx correct? I guess what I'm saying is...if it is what it is...it is what it is. Also, these diagnoses aren't always mutually exclusive.

 

[cara susanna]

I do bariatric pre-surgical evals and MH diagnosis in itself doesn't really matter provided the symptoms are well managed. Also, in my clinic we never really give an outright "no," it's more just fulfilling certain requirements before they can get approved.

But, yeah, even if it did matter for approval I would not recommend withholding a diagnosis that is clinically indicated.

 

[smalltownpsych]

These conversations are really for the patient to have with psychiatrist and surgeon. Also, does patient concur with diagnosis and your treatment plan or are they wanting to “hide” the diagnosis. Working with boundaries and empowering patient is central to working with patients with Borderline personality stuff.

 

[LM02]

Also, be prepared for the psychiatrist to simply disagree with you. I've had similar conversations in the past, with thoughtful justification for my diagnosis, only to be "told" by the psychiatrist that I'm incorrect and that they will continue with their treatment plan based on their diagnosis. So if that happens, at least you have it on record that you communicated your assessment and tried?

 

[psychma]

Also, be prepared for the psychiatrist to simply disagree with you. I've had similar conversations in the past, with thoughtful justification for my diagnosis, only to be "told" by the psychiatrist that I'm incorrect and that they will continue with their treatment plan based on their diagnosis. So if that happens, at least you have it on record that you communicated your assessment and tried?

That is exactly what happened. The client is not onboard with the diagnosis and sees it as a big negative. She yelled at me for 15 minutes then disconnected from the session.

 

[BuckeyeLove]

That is exactly what happened. The client is not onboard with the diagnosis and sees it as a big negative. She yelled at me for 15 minutes then disconnected from the session.

Well I'd say that seals the deal on your end regarding the validity of the diagnosis lol.

 

[Egg122]

I have a client that was diagnosed with bipolar disorder that clearly meets the criteria for bpd instead. I have held off on changing the diagnosis because she wants to have bariatric surgery this year and because her psychiatrist diagnosed her with bipolar 2 and I feel I’d have to talk to him. How would my diagnosis affect her eligibility for surgery? She has no substance abuse history. I hate to take this away from her but at the same time feel her diagnosis should be updated.

It shouldn't affect her eligibility for surgery if she is psychiatrically stable.

 

[PsyDr]

It shouldn't affect her eligibility for surgery if she is psychiatrically stable.

That opinion would contradict the European guidelines, and the general definition of a personality disorder.

 

[smalltownpsych]

I would also look at this through the lens of what diagnostic criteria for the disorder are being met and how that is relevant to the patients life and health more so than the label itself. I work with patients who have a hx of Borderline PD who are in a relatively stable place after much treatment. Makes me question the whole conceptualization of “personality” disorder. I tend to think of it as developmental dysfunction and maladaptive patterns of behavior that can be treated. Just because most clinicians get pulled into enacting aka reinforcing the same maladaptive behavior patterns doesn’t mean that they can’t be shifted. If I were treating the patient, I would be looking at how to help them get a potentially lifesaving surgery by engaging them in therapy. If they are a hot mess and or unstable for surgery, then a course of intensive DBT needs to be utilized. If they are in a more stable place, then continuing the building of skills and better interpersonal patterns should be ongoing and we would have a dialogue about what makes sense for them in their life.

 

[cara susanna]

That opinion would contradict the European guidelines, and the general definition of a personality disorder.

The guidelines I've been given to use don't say anything about personality disorders being disqualifying. Really, no diagnosis is in itself disqualifying (with the exception of eating disorders and substance use), it all depends on how well symptoms are managed.