Bpd

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SaraPharm

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Why is there such a stigma against individuals suffering from borderline personality disorder. Are they difficult patients to work with? I always hear that they are the "worst" to deal with by mental health professionals.
I'm curious to know what psychiatrists, psych residents, and psychologists think on this matter.
 
Fortunately bpd has not realized stigma in mainstream society because nobody even knows what it is.

I think within the field you may hear frustration with bpd for various reasons but I think the real reason is because it can't be remedied in a 15 min med check.
 
F0nzie said:
I think within the field you may hear frustration with bpd for various reasons but I think the real reason is because it can't be remedied in a 15 min med check.
Meh, what CAN be remedied with a 15 minute med check?

The reason BPD is often unpopular with clinicians is the nature of the symptoms can at times make the patients unpleasant to deal with and the most effective treatment modalities are fairly labor intensive.
 
Meh, what CAN be remedied with a 15 minute med check?
.

which, considering the number of people out there doing 15 minute(and much less in many cases!) med checks, is a problem.
 
which, considering the number of people out there doing 15 minute(and much less in many cases!) med checks, is a problem.
Yeah, we've been through this. I've yet to see the "much less" than 15 minute appointments, especially not in "many cases," but it may be more common in your neck of the woods. And the 15 minute checks out my way are typically in stable patients getting meds refilled and periodic check-ins. I've never seen a 15 minute eval or a 15 minute management appointment for a complicated case.
 
Yeah, we've been through this. I've yet to see the "much less" than 15 minute appointments, especially not in "many cases," but it may be more common in your neck of the woods. And the 15 minute checks out my way are typically in stable patients getting meds refilled and periodic check-ins. I've never seen a 15 minute eval or a 15 minute management appointment for a complicated case.

how plugged in to all the private practices in your region(and by region I don't mean 15 mile radius...I mean 3 hr radius) are you? I think if you branched out a bit and really went office to office, the results would surprise you. Especially those that operate under an insurance based model(which according to surveys is still the clear majority of psychiatry)
 
A psychiatrist, if treating someone with borderline P.D., should flat out tell them that medications don't do much for this disorder and the real treatment is psychotherapy. The psychiatrist should then either do the psychotherapy or refer them to someone who can do it.

Medicating this disorder is almost pointless. If the person has a real comorbid problem such as depression, yes you could treat that with medication but it likely won't do much if anything for the borderline P.D.

What several docs usually do is see borderlines as someone not to be helped. This is a wrong attitude becuase there are interventions that work. The problem is most psychiatrists don't know how to do the psychotherapy that improves it. Like I said, refer out but most won't.

Another problem is some docs have developed an erroneous philosphy that anything can be medicated. Studies show only limited benefits with meds in this disorder, and some psychiatrists resort to extremely toxic and side-effect prone meds that only offer little improvement at best to treat it. Most experienced psychiatrists have encountered the borderline patient on a 4+ psychotropic medication regimen, all of which are providing no benefit but the person has gained 100+ pounds from it, and then the treating doctor that put them on it giving the completely lame explanation of "I was trying to treat the symptoms."

Let me tell you something. If a med hasn't worked, you stop it. Doesn't take a rocket scientist to know that. Tried an antidepressant for a month at the maximum dose and it did nothing? No point in continuing it. Same goes with pretty much all the other meds. There is no point in keeping someone on something that doesn't work, especially if the person gained 100 lbs from it and it costs $500 a month.
 
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I think if you branched out a bit and really went office to office, the results would surprise you. Especially those that operate under an insurance based model(which according to surveys is still the clear majority of psychiatry)
I'm not sure what you're arguing here. Yes, I believe there are psychiatrists doing 7 minute visits. Many would argue that this doesn't do much therapeutically. Just because a bunch of docs practice this way doesn't mean it's good care. You more than anyone are aware that there are a lot of bad psychiatrists practicing bad psychiatry out there.
 
...Let me tell you something. If a med hasn't worked, you stop it. Doesn't take a rocket scientist to know that. Tried an antidepressant for a month at the maximum dose and it did nothing? No point in continuing it. Same goes with pretty much all the other meds. There is no point in keeping someone on something that doesn't work, especially if the person gained 100 lbs from it and it costs $500 a month.

On that topic---
 
A psychiatrist, if treating someone with borderline P.D., should flat out tell them that medications don't do much for this disorder and the real treatment is psychotherapy. The psychiatrist should then either do the psychotherapy or refer them to someone who can do it.

Medicating this disorder is almost pointless. If the person has a real comorbid problem such as depression, yes you could treat that with medication but it likely won't do much if anything for the borderline P.D.

What several docs usually do is see borderlines as someone not to be helped. This is a wrong attitude becuase there are interventions that work. The problem is most psychiatrists don't know how to do the psychotherapy that improves it. Like I said, refer out but most won't.

Another problem is some docs have developed an erroneous philosphy that anything can be medicated. Studies show only limited benefits with meds in this disorder, and some psychiatrists resort to extremely toxic and side-effect prone meds that only offer little improvement at best to treat it. Most experienced psychiatrists have encountered the borderline patient on a 4+ psychotropic medication regimen, all of which are providing no benefit but the person has gained 100+ pounds from it, and then the treating doctor that put them on it giving the completely lame explanation of "I was trying to treat the symptoms."

Let me tell you something. If a med hasn't worked, you stop it. Doesn't take a rocket scientist to know that. Tried an antidepressant for a month at the maximum dose and it did nothing? No point in continuing it. Same goes with pretty much all the other meds. There is no point in keeping someone on something that doesn't work, especially if the person gained 100 lbs from it and it costs $500 a month.


I really don't understand how my ex-husband's psychiatrist, who has treated him for years, doesn't see this. I even went to him a couple times and told him about all the behaviors that are just bizarre (in fact the doctor couldn't even think of a word to describe them and was stumped and finally just said "bizarre). The same doctor also treats my ex's ex, who is bipolar. So he knows a lot about him. What does he do? He just doubles his Klonopin dosages and increases his Zoloft and keeps giving him Ambien every night, even after I tell him how much the guy drinks with all of it, that he takes nyquil with it almost daily, that my ex would disassociate and wake up with knives under his pillow and not remember how they got there, fall asleep with a knife in his hand, flip out with a loaded gun, been taken by the police to the psych ward for being suicidal. Shoot, the guy even pooped his pants a couple times in his sleep because he was damn near comatose from all the meds. I'm no doctor but how can his doctor not see this stuff is NOT working!!!!! All the doctor kept telling me is how klonopin and ambien are safe long-term. I 'm like yeah, maybe so, as long as he doesn't accidentally stab himself in his sleep. At least the doctor wrote in my records that he adivsed me not to live with him, that it's unsafe. Guess he had to cover his butt in case my ex offed me.
 
I really don't understand how my ex-husband's psychiatrist, who has treated him for years, doesn't see this. I even went to him a couple times and told him about all the behaviors that are just bizarre (in fact the doctor couldn't even think of a word to describe them and was stumped and finally just said "bizarre). The same doctor also treats my ex's ex, who is bipolar. So he knows a lot about him. What does he do? He just doubles his Klonopin dosages and increases his Zoloft and keeps giving him Ambien every night, even after I tell him how much the guy drinks with all of it, that he takes nyquil with it almost daily, that my ex would disassociate and wake up with knives under his pillow and not remember how they got there, fall asleep with a knife in his hand, flip out with a loaded gun, been taken by the police to the psych ward for being suicidal. Shoot, the guy even pooped his pants a couple times in his sleep because he was damn near comatose from all the meds. I'm no doctor but how can his doctor not see this stuff is NOT working!!!!! All the doctor kept telling me is how klonopin and ambien are safe long-term. I 'm like yeah, maybe so, as long as he doesn't accidentally stab himself in his sleep. At least the doctor wrote in my records that he adivsed me not to live with him, that it's unsafe. Guess he had to cover his butt in case my ex offed me.

Just to pre-empt any potential violations here, I have to point out that we have a fairly strict policy to avoid providing medical advice on this forum. Commenting on this story would put us at risk of violating that. The reason for that rule is that it would be unethical to make a clinical judgement without personally seeing the patient, even if the story sounds completely egregious. It would also be inappropriate for us to criticize another clinician's judgement without thoroughly analyzing the case.
 
I really don't understand how my ex-husband's psychiatrist, who has treated him for years, doesn't see this.

Some psychiatrists, especially the most biologically oriented ones do not believe in the borderline personality disorder diagnosis, or do not believe in making the diagnosis in someone who is currently experiencing a major mental illness. The argument goes that people with depression, bipolar, severe anxiety, psychosis etc can look "borderline" but this will dissipate with treatment with drugs. It is certainly true that patients with mood disorders can look personality disordered during acute episodes, but that doesn't preclude a developmental history and thorough assessment of the patient's behaviors, emotional reactivity, interpersonal relations and core beliefs which may reveal an underlying personality disorder. It is this thinking that kind of led to an explosion of people being diagnosed with bipolar disorder instead of borderline and certain bipolar "experts" argued that a dx of bipolar should be made over borderline where dx was in doubt based on the erroneous beliefs that missing a personality disorder was "inconsequential" or was untreatable anyway.
 
Some psychiatrists, especially the most biologically oriented ones do not believe in the borderline personality disorder diagnosis,

I guess these psychiatrists don't have good social skills or dated much, at least from my own life experiences. You meet enough people, you will meet a borderline PD person sooner or later. When you meet such a person, learn enough about them how can you not identify it? And yet I know these people exist.

Another problem with PDs is that the doctor is usually supposed to hold the person responsible for their own behaviors. In disorders like schizophrenia there is an identifiable physiological phenomenon, almost neurological (if not completely so) going on that fits a medical model very well, so psychiatrists are often willing to give such patients more leeway for their inappropriate behaviors. So when you do that with a borderline PD, and the doc is already ticked off with them-the two don't mix well. It often leads to the doctor's actions just adding fuel because he/she can make themselves out to be the person's enemy.

The other problem is borderlines cannot even engage in outpatient DBT unless their GAF (yeah I know it's not in DSM V) is relatively well. I'm talking 50+. Ones with a GAF below that usually are too impulsive to maintain the treatment unless there's a proverbial gun to their head (e.g. court-ordered, on a forensic unit). We live in a free country where we cannot mandate this treatment and even if we put a 72 hold on such patients, it'd take several months (at best), not days, to get them better with DBT.
 
IMHO (based on what I see from real-life experiences, not what I see in studies), most people have at least a few traits of borderline PD up until their mid-20s. Again, my point is how could one not see that this disorder is real unless they're just so completely out of touch with human emotions.
 
Just to pre-empt any potential violations here, I have to point out that we have a fairly strict policy to avoid providing medical advice on this forum. Commenting on this story would put us at risk of violating that. The reason for that rule is that it would be unethical to make a clinical judgement without personally seeing the patient, even if the story sounds completely egregious. It would also be inappropriate for us to criticize another clinician's judgement without thoroughly analyzing the case.

Makes perfect sense to me. Please don't violate your rules!

I would imagine it's frustrating to be his physician. I could see it in his expressions when I went to him and he'd just roll his eyes and say "He's pouting, I know..." or he'd go, "yep, he's disassocitating," etc. I could tell he'd heard it all before and I doubt he would have told me it's unsafe to live with him after meeting with him a total of an hour and a half or maybe two hours if he didn't know a lot. Can you take what another patient tells you about your patient and use that in your treatment? Don't answer that if it's a violation. I just wonder how one would deal with that. You have a patient who comes in and "acts" for you and doesn't tell you he threatens people over parking spots with guns, wakes up with knives under his pillow, basically acts like a really dangerous and scary human being (or more like a non-human sometimes) and you know this but yet don't see it directly from the patient.

I guess these psychiatrists don't have good social skills or dated much, at least from my own life experiences. You meet enough people, you will meet a borderline PD person sooner or later. When you meet such a person, learn enough about them how can you not identify it? And yet I know these people exist.

Another problem with PDs is that the doctor is usually supposed to hold the person responsible for their own behaviors. In disorders like schizophrenia there is an identifiable physiological phenomenon, almost neurological (if not completely so) going on that fits a medical model very well, so psychiatrists are often willing to give such patients more leeway for their inappropriate behaviors. So when you do that with a borderline PD, and the doc is already ticked off with them-the two don't mix well. It often leads to the doctor's actions just adding fuel because he/she can make themselves out to be the person's enemy.

The other problem is borderlines cannot even engage in outpatient DBT unless their GAF (yeah I know it's not in DSM V) is relatively well. I'm talking 50+. Ones with a GAF below that usually are too impulsive to maintain the treatment unless there's a proverbial gun to their head (e.g. court-ordered, on a forensic unit). We live in a free country where we cannot mandate this treatment and even if we put a 72 hold on such patients, it'd take several months (at best), not days, to get them better with DBT.

Now that I think about it, I had a friend who is a very difficult person, to say the least. She has a great job and is good at what she does. EVERYONE knows she needs psychiatric help. It's obvious to the whole world...except her. If you try to tell her she gets mad and goes "I'm not f'ing crazy! Why does everyone tell me that!" And all anyone says is to try to help her because it's obvious she needs it. She is paranoid, thinks people at work are tapping her phone and laptop (and no, she doesn't work for the CIA...) and I've watched her flip out on people and even ask my ex-husband to come with his gun to get a guy to move his 18-wheeler, throwing a complete tantrum. She very well could have been arrested or had the truck driver hurt her if he hadn't been so laid back. It was downright scary. Maybe she's BPD? I dunno, never really thought about it. I just always thought of her as my difficult friend. But I do know that when physicians have suggested she needs psychiatric care she becomes furious.

IMHO (based on what I see from real-life experiences, not what I see in studies), most people have at least a few traits of borderline PD up until their mid-20s. Again, my point is how could one not see that this disorder is real unless they're just so completely out of touch with human emotions.

When I've read about it, I can relate to having had some similar behaviors....when I was 14 or so.

I think that what we have learned about the neurobiology of chronic severe stress is eminiently helpful in the understanding of Borderline PD, and argues convincingly toward it being a very "real" biologically predisposed condition.

I don't even remotely understand all the intricacies of the brain, but when I was under severe stress before I left my husband I had vertigo and my toes went numb. Never had it before in my life. My doctor even said it wasn't stress causing it but was inner ear. After I separated...it went away, never has come back. I was literally falling over like a drunk person, and that's only from a short time period being under that type of stress (little over a year with him). And that's just the more physical aspects of it, not the psychological. So it makes sense that someone who was raised by a parent with a similar condition would be affected.
 
Is there any reason a psychiatrist would not tell a concerned immediate family member their loved one's diagnosis?

I am 110% certain that my mother has BPD (mainly because other medical professionals in the family have told me so and know her 40 year psychiatric history) and when she became completely non-functional last year, her psychiatrist called me and said my mother was "splitting" and sees things in "black and white." So I asked if she has BPD. The psychiatrist said that I am asking an inappropriate question. I found this interesting. Since when do Drs not tell family members the diagnosis? Perhaps my mom told her not to tell anyone, but I just want to know if there is some code that psychiatrists follow about telling people psychiatric diagnoses?

I would expect a release to be signed before any doctor would release medical information. On the issue of diagnosis, it may be less a with holding issue, and more that the doctor avoids focusing on the diagnosis. A diagnosis is a cluster of symptoms, and discussing the actual symptoms is arguably more useful.
 
As a former BPD sufferer I would have to say that yes, we are an exceedingly difficult population to deal with. But I don't think the majority of us really mean to be. Having BPD is kind of like hitting yourself in the face with a hammer and saying 'ouch that hurts', but you still keep on hitting yourself because a hammer is the only tool you've been given and shown how to use.

I do remember, when my symptoms were full blown, experiencing a lot of what I guess might be called circular logic and self fulfilling prophecy type thinking. My thought process at the time tended to go something like this -

"I start with the premise that I am the most worthless and horrible person in the history of ever, I meet someone I'd like to have a long term, positive engagement with, I really want to make friends but deep down I know that eventually they'll see the ugliness that is me and I'll be abandoned and alone. What do I do? Do I just not bother to try at all, or do I go in with a back up plan to keep hold of the friendship when the inevitable happens. I desperately want to be normal and have normal relationships with people, so I pick option 2. On some conscious or subconscious level I remember growing up and watching my mentally unstable Mother kicking off and going into hysterics in order to elicit some sort of reassuring or attention seeking response - there were the tantrums, the screaming, the foot stomping, tears on cue, threats of suicide, etc etc - that's how I know how to relate to people, that was the behaviour that was modeled for me. So inevitably the day comes when my new found friendship under goes it's first challenge. In my black and white borderline world there's not really too many shades of grey so things tend to either be categorised into 'it has to be 100% perfect all the time', or 'behold the approaching apocalypse is upon us'. So I think to myself, okay I was prepared for this and I respond accordingly - I scream, I yell, I cry, I throw tantrums, I cut myself, I threaten to commit suicide, and so on. After all this is what I know to do, this is what I've seen in the past, it's not like someone's come along and tapped me on the shoulder and gone 'Psst, there's actually a much better way to relate to people than what you're doing. Now maybe my friend does what I want them to do at first, maybe do the rush in with reassuring words, and attentive gestures, but more often than not there comes a point where my volatile behaviour is just too much for them and they end up walking away. Aha, I think to myself, I am the most worthless and horrible person in the history of ever, and I will forever be abandoned and alone, this experience has just proven that point, next time I will be prepared (to do exactly the same thing, and come to exactly the same conclusion)"

It was the same with romantic relationships - 'OMG, holy shizzballs, hideous and worthless me has actually found someone who wants to be my boyfriend/girlfriend. Quick, I must turn into the world's biggest limpet and cling for dear life'. Invariably my behaviour would end up driving them away, but instead of being able to stop and think 'okay, maybe the way I'm approaching things isn't working, let's try something else', my mind would go straight to 'Clinging didn't work, clearly I wasn't clinging hard enough, must cling more'.

Again, the hammer analogy, instead of us thinking 'Okay, clearly continuing to smack myself in the face with this hammer isn't working, maybe I should put this hammer down and try to find a better alternative', we tend to go '*whack' Ouch that hurt, let me hit myself again, *whack* Okay that still hurt, let me try hitting myself faster this time *whack-whack-whack*, Hmm, nope still in pain'. That's when we need someone to come along and go 'Here, this is a pillow, try this instead, I'll show you how to use it'.
 
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