Dependent vs. Borderline PD

[Chrismander]

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Sorry if this has already been asked--I tried to search for this but got a few hundred posts, none of which had to do with either personality disorder.

Do you guys ever have difficulty differentiating borderline PD from dependent? I had a patient the other day who presented for worsening SI/anxiety/depression over a month. I got a strong "Cluster C" vibe from her because she just seemed so darn anxious, her problems were chronic (but worsened recently) and didn't meet Axis I criteria. But my attending was leaning much more towards Borderline. I've reviewed the criteria, and think she could probably meet both BPD and DPD. I think part of the problem is that she's relatively older (60ish) than most of the borderlines i've seen, so i think she may have "burnt out" to some extent--she stopped smoking crack and sleeping around a long time ago (like 25+ years ago), so if I'd seen her earlier I might have a different impression of her. Celibate now for many years, but definitely had a borderline flair to her earlier relationships with men.

No suicidal attempts in her life, no self-mutilation, just a low-level chronic passive SI without a formed plan, for several decades, that intensifies with stress (when morbid intrusive thoughts start to pop in, as in the last month, which is why she presented). This confuses me a bit, because obviously chronic SI is very Cluster B, but I'm used to seeing many attempts/gestures, some self-mutilation at least. And she doesn't seem to have ever told anyone about her SI--her sister and children were totally unaware of her daily SI when I talked to them. My vague, very un-scientific notion of borderlines is that they tell people when they have SI or act out in some other way (gestures, attempts) in order to express their discomfort and get people to come care for them. she seems to be chronically suicidal, and just covers it up, like she doesn't want to worry anyone or be a bother.

Very impulsive, and frequently "flees" under stress--just picks up, leaves her apartment and life behind (most recently leaving all her furniture and most of her belongings in her old apartment). So she's got impulsivity going for a Borderline diagnosis. Also very unable to manage on her own--goes from living with a sister, to a boyfriend, to her adult children's, back to the sister's, etc. But this fear of abandonment/being alone seems like it go both towards BPD and DPD. Her sister reports that the patient is completely helpless in her own life, can't even handle making doctor's appointments or getting around town without someone helping her, freezes over every decision and needs other people to make it for her. The patient gave me a good story of consistently doing what other people wanted even if she didn't want to, just to avoid argument. i'm used to borderlines being more directly angry/defiant/manipulative, she seemed too meek. Granted this was one interview and she was feeling pretty crappy, so maybe i just caught her on a low day.

Basically, have you guys ever found yourselves not being able to call BPD vs DPD, or am i just radically misreading the criteria? if so, can you give me any pointers to simplify the call, or correct some of my thinking on how i'm calling the criteria? I know that PD's in general have a pretty high comorbidity with other PD's, so could I just be seeing a Dependent Borderline? Also, what's the natural history/course of borderlines in the absence of treatment? Do older borderlines sort of "burn out" and look different than their younger counterparts?

Thanks!

 

[OldPsychDoc]

This is why God gave us the 301.9 code.

Seriously-- you do a nice job of enumerating the traits. It's hardly necessary to shoehorn them into a single DSM category.

 

[michaelrack]

It will become clearer after you spend more time with her. It's often difficult to diagnose personality disorders based on patient's report of symptoms. Pay attention to transference/countertransference issues.
It sounds like you are off to a good start.

 

[Anon15]

I think part of the problem is that she's relatively older (60ish) than most of the borderlines i've seen, so i think she may have "burnt out" to some extent--she stopped smoking crack and sleeping around a long time ago (like 25+ years ago), so if I'd seen her earlier I might have a different impression of her.

What you may be seeing are residual symptoms of BPD. At one point this patient may have met full criteria for BPD however what you describe does not seem to warrant 4/9 DSM criteria for BPD. Keep in mind (due to her age) that empirical research has demonstrated that the symptoms of BPD that remit the fastest are those more acute type symptoms (i.e. self injurious behavior, impulsivity, etc.) as opposed to the more stable or temperamental symptoms (i.e. chronic dysphonic feelingd, fears of abandonment, etc.)

Very impulsive, and frequently "flees" under stress--just picks up, leaves her apartment and life behind (most recently leaving all her furniture and most of her belongings in her old apartment). So she's got impulsivity going for a Borderline diagnosis.

Remember the patient needs to display impulsivity in at least 2 areas. Simply fleeing is not enough.

Basically, have you guys ever found yourselves not being able to call BPD vs. DPD, or am i just radically misreading the criteria?

No. They present very differently.

Also, what's the natural history/course of borderlines in the absence of treatment?

In a longitudinal study of the course of BPD 88% of individuals diagnosed with BPD at baseline had remitted by year 10.

 

[Therapist4Chnge]

It will become clearer after you spend more time with her. It's often difficult to diagnose personality disorders based on patient's report of symptoms. Pay attention to transference/countertransference issues.
It sounds like you are off to a good start.

Exactly what I was going to write. I am skeptical when I see BPD on a chart because it is often based on a quick self-report assessment during a clinical interview, which is not an effective way to assess for BPD. I think one of the most common issues is 'cutting', which seems to default to BPD....but that isn't always accurate. It seems to be a catch all Dx in certain settings, especially when there is 'something' there, but there isn't enough time to flush out the symptoms further.

-t

 

[nitemagi]

Correct me if I'm wrong, but TECHNICALLY you can be diagnosed with more than one personality disorder.

 

[Anon15]

TECHNICALLY you can be diagnosed with more than one personality disorder.

What do you mean by this? DSM-IV SCID-II?

 

[manwhoisthursdy]

What do you mean by this? DSM-IV SCID-II?

SCID-II?

Do the criteria for any one personality disorder say that you can't make the diagnosis if another personality d/o is already diagnosed? I don't think they do ... so I guess you can diagnose more than one personality disorders.

It does seem to me that at that point it would be better to give a psychodynamic assessment of the patient's defense mechanisms, ego strengths and weaknesses, coping styles, and all that good stuff. Wouldn't that be more useful than having a list of 2 or more DSM-IV axis II diagnoses and trying to have to figure out from that what the patient is really like?

 

[billypilgrim37]

Do the criteria for any one personality disorder say that you can't make the diagnosis if another personality d/o is already diagnosed? I don't think they do.

Which is why "Axis II: Cluster B traits" is the most commonly used line of documentation on our unit besides "Axis V: GAF = 20." Unless the person is throwing poop, which gives them "Axis V: GAF = 0."

Given how poorly the NIMH research agenda has addressed Axis II disorders since DSM-III, I haven't been convinced that these distinctions are consistently useful over simply listing traits and symptoms.

 

[Anon15]

SCID-II?

For assessment purposes

I guess you can diagnose more than one personality disorders.

I agree

It does seem to me that at that point it would be better to give a psychodynamic assessment of the patient's defense mechanisms, ego strengths and weaknesses, coping styles, and all that good stuff.

For BPD, no, not really. Empirically the most effective treatment for BPD is DBT which does not need nor require a psychodynamic assessment.

Wouldn't that be more useful than having a list of 2 or more DSM-IV axis II diagnoses and trying to have to figure out from that what the patient is really like?

Sure if can you prove it is helpful.

 

[Therapist4Chnge]

For BPD, no, not really. Empirically the most effective treatment for BPD is DBT which does not need nor require a psychodynamic assessment.

I've found an object relations approach can be quite effective for treating BPD (a modified psychodynamic approach that pays particular attention to a more supportive role can also be effective) . An O.R. approach is supported in the research, though DBT has more recent research and seems to be the preferred method of treatment.

-t

 

[Anon15]

I've found an object relations approach can be quite effective for treating BPD (a modified psychodynamic approach that pays particular attention to a more supportive role can also be effective) .
-t

Good point. However, in my experience this type of therapy is usually long term. It seems quite common now to reach across to the proverbially "other side" and supplement this with DBT.

 

[nitemagi]

Which is why "Axis II: Cluster B traits" is the most commonly used line of documentation on our unit besides "Axis V: GAF = 20." Unless the person is throwing poop, which gives them "Axis V: GAF = 0."

Given how poorly the NIMH research agenda has addressed Axis II disorders since DSM-III, I haven't been convinced that these distinctions are consistently useful over simply listing traits and symptoms.

And check the DSM. Officially People can be diagnosed with multiple personality disorders, especially from 2 clusters (such as BPD and dependent-- i.e. b+c). As you stated and we all know, the DSM is a work in progress.

 

[Atilla]

And check the DSM. Officially People can be diagnosed with multiple personality disorders, especially from 2 clusters (such as BPD and dependent-- i.e. b+c). As you stated and we all know, the DSM is a work in progress.

The current DSM criteria for diagnosis of personality disorder is notoriously unreliable, with upto 60 % of the patients don't meet the criteria after a period of six months.

I think the best way to diagnose is longitudnal course -atleast a few months of follow up.

 

[Therapist4Chnge]

Good point. However, in my experience this type of therapy is usually long term. It seems quite common now to reach across to the proverbially "other side" and supplement this with DBT.

Agreed. A psychodynamic approach tends to be longer-term, though a true Axis-II Dx will be persistent and requires longer-term follow-up anyway. I'm not as well versed in time-limited psychodynamic therapy in regard to BDP, but it could probably be modified to work.

DBT can be quite effective, both short and long term. My dealings with it are mostly in the group setting, and I've found it to be a nice adjunct to individual work done by patients. The groups tend to be more supportive and educational, providing reinforcement in-between individual sessions. There are a number of good texts and workbooks geared to education and maintenance type work.

-t

 

[manwhoisthursdy]

For BPD, no, not really. Empirically the most effective treatment for BPD is DBT which does not need nor require a psychodynamic assessment.

Aren't "need" and "require" the same thing? Anyway, I was suggesting a psychodynamic formulation *not* as a precursor to psychodynamically oriented psychotherapy, but simply as a better way to understand the patient.

When treating a pt with depression with medication, a psychodynamic formulation could be used to answer the question, "Why might this patient stop taking his meds?" Similarly for BPD, a psychodynamic formulation might help answer the question, "What types of stressors might lead this patient to decompensate and engage in parasuicidal behavior?"

No?

 

[michaelrack]

Aren't "need" and "require" the same thing? Anyway, I was suggesting a psychodynamic formulation *not* as a precursor to psychodynamically oriented psychotherapy, but simply as a better way to understand the patient.

When treating a pt with depression with medication, a psychodynamic formulation could be used to answer the question, "Why might this patient stop taking his meds?" Similarly for BPD, a psychodynamic formulation might help answer the question, "What types of stressors might lead this patient to decompensate and engage in parasuicidal behavior?"

No?

Initially I was going to say no- each school of psychotherapy has its own way of formulating a case, and you can do a cognitive-behavioral formulation (or dbt formulation). However, most of the other schools of psychotherapy borrow elements of psychodynamics when it comes to their methods of formulating a case; so I guess that you are ultimately right.

 

[Anon15]

Aren't "need" and "require" the same thing?

No. I might need a drink because I am thirsty, but I require water if I want to live.

Similarly for BPD, a psychodynamic formulation might help answer the question, "What types of stressors might lead this patient to decompensate and engage in parasuicidal behavior?"

Asking about stressors is psychodynamic? Maybe is the patients mother is the stressor...🙂


In all seriousness, in your previous post you mentioned patient's defense mechanisms, ego strengths and weaknesses, coping styles, etc--I don't think that is necessary.

 

[manwhoisthursdy]

Asking about stressors is psychodynamic? Maybe is the patients mother is the stressor...🙂


In all seriousness, in your previous post you mentioned patient's defense mechanisms, ego strengths and weaknesses, coping styles, etc--I don't think that is necessary.

To clarify -- what I was suggesting is that understanding a patient's ego strengths/weaknesses/defenses, etc., are how we can have a better understanding of what kinds of stressors this patient may be particularly vulnerable to. I guess I see a psychodynamically informed approach as fully integrated with, not "as opposed to" or "in addition to" a good psych history.

Also -- I suggested this psychodynamic approach not as opposed to any other theoretical model of how to view a patient's behavior, but simply as opposed to listing the DSM-IV Axis-II diagnoses the patient happens to meet -- my point was that two patients who meet criteria for the same personality disorders could be quite different depending upon why/how they meet those criteria. The "why/how" is what I'd call psychodynamic.

Finally, I think I have to agree with you that such an approach can't always be called "necessary". But is it helpful? At least more helpful than the alternative? I would think so.

 

[Anon15]

Also -- I suggested this psychodynamic approach not as opposed to any other theoretical model of how to view a patient's behavior, but simply as opposed to listing the DSM-IV Axis-II diagnoses the patient happens to meet -- my point was that two patients who meet criteria for the same personality disorders could be quite different depending upon why/how they meet those criteria. The "why/how" is what I'd call psychodynamic.

Although the "why/how" will be different for each and every patient, persons who share the DSM-IV Axis-II diagnoses of BPD are displaying similar behaviors. A behaviorist would argue that we need to know about the prodrome in order to treat the current maladaptive behaviors. Is it helpful, sure, but if it is BPD we are discussing, the literature on the psychodynamic approach as being the most helpful therapy in treating BPD is scant.

At least more helpful than the alternative? I would think so.

What is the alternative?

 

[Therapist4Chnge]

There are a number of quality resources that speak to psychodynamic treatment models for BPD. Kerberg, Masterson, and Gunderson have some great papers on the topic. They never did large studies, as that wasn't in favor then, but they did do smaller case study research that is still quite applicable. Knight, Stone, Oldham et al. also have some more recent writings on the subject.

Gunderson, J.G., Singer, M.T. (1986). Defining Borderline Patients: An Overview. Essential Papers on Borderline Disorders: One Hundred Years at the Border. New York University Press. 453-474.

Kernberg, O. (1967). Borderline personality organization. Journal of the American Psychoanalytic Association. 15, 641-685.

Knight, R.P. (1986). Borderline States. Essential Papers on Borderline Disorders: One Hundred Years at the Border. New YorkUniversity Press. 159-173.

Masterson, J. (1981). The Narcissistic and Borderline Disorders. Brunner/Mazel Publishing. New York, New York.

Oldham, J.M., Gabbard, G.O., Goin, M.K., John Gunderson, J., Soloff, P., Spiegel, D., Stone, M. Phillips, K.A. (2001). Treatment of Patients With Borderline Personality Disorder. American Psychiatric Association.

Stone, M. H. (1986). The Borderline Syndrome: Evolution of the Term, Genetic Aspects, and Prognosis. Essential Papers on Borderline Disorders: One Hundred Years at the Border. New York University Press. 475-497.

-t

 

[manwhoisthursdy]

What is the alternative?

The alternative discussed was to list, under axis II, something like "bpd, antisocial pd" or "cluster b traits" and leave it at that.

 

[Anon15]

There are a number of quality resources that speak to psychodynamic treatment models for BPD. Kerberg, Masterson, and Gunderson have some great papers on the topic. They never did large studies, as that wasn't in favor then, but they did do smaller case study research that is still quite applicable. Knight, Stone, Oldham et al. also have some more recent writings on the subject.

Gunderson, J.G., Singer, M.T. (1986). Defining Borderline Patients: An Overview. Essential Papers on Borderline Disorders: One Hundred Years at the Border. New York University Press. 453-474.

Kernberg, O. (1967). Borderline personality organization. Journal of the American Psychoanalytic Association. 15, 641-685.

Knight, R.P. (1986). Borderline States. Essential Papers on Borderline Disorders: One Hundred Years at the Border. New YorkUniversity Press. 159-173.

Masterson, J. (1981). The Narcissistic and Borderline Disorders. Brunner/Mazel Publishing. New York, New York.

Oldham, J.M., Gabbard, G.O., Goin, M.K., John Gunderson, J., Soloff, P., Spiegel, D., Stone, M. Phillips, K.A. (2001). Treatment of Patients With Borderline Personality Disorder. American Psychiatric Association.

Stone, M. H. (1986). The Borderline Syndrome: Evolution of the Term, Genetic Aspects, and Prognosis. Essential Papers on Borderline Disorders: One Hundred Years at the Border. New York University Press. 475-497.

-t

Thanks T4C, I am aware of these papers. What I find most interesting however, is when Gunderson was asked point blank by Linehan (Stanton Lecture, McLean Hospital 2006), "What empirical evidence do you have that demonstrates that your therapy is effective?" He had NO answer.

I am not doubting the helpfulness of psychodynamic therapy (can you tell it's not my orientation) however in treating BPD it is not the gold standard.

 

[Anon15]

The alternative discussed was to list, under axis II, something like "bpd, antisocial pd" or "cluster b traits" and leave it at that.

Agreed

 

[Therapist4Chnge]

Thanks T4C, I am aware of these papers. What I find most interesting however, is when Gunderson was asked point blank by Linehan (Stanton Lecture, McLean Hospital 2006), "What empirical evidence do you have that demonstrates that your therapy is effective?" He had NO answer.

I am not doubting the helpfulness of psychodynamic therapy (can you tell it's not my orientation) however in treating BPD it is not the gold standard.

Case history outcome can show effectiveness, however it is often hard to capture and quantify effectively for broader application, particularly for Axis-II Dx as they really can vary in manifestation.

I think it can be one way to approach this Dx, though it is far from the best answer for everyone. DBT has a stronger body of research, though I think one reason is that it lines up better with quantifiable methods. In general I believe it is a trickier animal to quantify improvement in Axis-II Dx, but as research goes, DBT would be my answer for the 'most' supported method, though I'm not sure if it is always the most effective.

-t

 

[Anon15]

DBT has a stronger body of research, though I think one reason is that it lines up better with quantifiable methods.

Isn't this what make psychology/psychiatry science? Quantifiable methods? Without these quantifiable methods aren't we often named the "soft" science, the people who are not "real" doctors.

 

[Therapist4Chnge]

Isn't this what make psychology/psychiatry science? Quantifiable methods? Without these quantifiable methods aren't we often named the "soft" science, the people who are not "real" doctors.

This is an issue of qualitative vs. quantitative methods. I would love if everything was quantifiable in numbers that translate to answers, but not everything can be captured that easily. I think there is a gap between properly quantifying different aspects of the field, particularly in therapeutic intervention. Research design and methodology are two areas that need to be better addressed, particularly in the area of outcome research. I'm hoping we can better capture some of this data in the near future, so we can parse out the contributing and non-contributing factors. I think there are effective interventions out there that suffer because we cannot yet properly quantify their contributions, outside of a case study model. I think Axis-II Dx is particularly problematic to capture, outside of more generic scoring that may or may not translate into a better standard of living. Things like self-reports and the like are measures, though I'm not sure how they translate in actual terms.

-t

 

[Anon15]

This is an issue of qualitative vs. quantitative methods. I would love if everything was quantifiable in numbers that translate to answers, but not everything can be captured that easily. I think there is a gap between properly quantifying different aspects of the field, particularly in therapeutic intervention. Research design and methodology are two areas that need to be better addressed, particularly in the area of outcome research. I'm hoping we can better capture some of this data in the near future, so we can parse out the contributing and non-contributing factors. I think there are effective interventions out there that suffer because we cannot yet properly quantify their contributions, outside of a case study model. I think Axis-II Dx is particularly problematic to capture, outside of more generic scoring that may or may not translate into a better standard of living. Things like self-reports and the like are measures, though I'm not sure how they translate in actual terms.

-t

I can appreciate your point, well stated. But haven't we already begun to parse out the contributing and non-contributing factors? For example, case studies. Are case studies valuable, sure, these days aren't they mainly presented for teaching purposes or appear in textbooks. What was effective 20 years ago may not be effective today.

For example, I have a VCR, it still works, still does what I need it to do, I like it. It's not broke so why fix it, right? But I could buy a DVD player that is just a little bit faster and a little bit better and will do the exact same thing.

Back to topic: Treating BPD with ONLY psychodynamic therapy to like using a VCR. So go to Target, buy that DVD player and add in a little DBT.

 

[Therapist4Chnge]

I can appreciate your point, well stated. But haven't we already begun to parse out the contributing and non-contributing factors? For example, case studies. Are case studies valuable, sure, these days aren't they mainly presented for teaching purposes or appear in textbooks. What was effective 20 years ago may not be effective today.

For example, I have a VCR, it still works, still does what I need it to do, I like it. It's not broke so why fix it, right? But I could buy a DVD player that is just a little bit faster and a little bit better and will do the exact same thing.

Back to topic: Treating BPD with ONLY psychodynamic therapy to like using a VCR. So go to Target, buy that DVD player and add in a little DBT.

I see where you are going with the VCR vs. DVD....but I think it is more like selecting a decent wine. You may have the choice between a newer but well regarded Napa Chardonnay that you can enjoy right out of the bottle. Your other choice is a classic Bordeaux Cabernet that needs decanting, but the process will allow for more of the nuances to come out, in addition to separating the sediment that may have gathered over time. Both methods generally work with dinner, though your choice may depend on the dish (person), and/or if they have the time to go through the decanting process. Some people just want their wine, while others want to make sure they choose the right wine.....whether it is red or white.

-t

 

[Anon15]

I see where you are going with the VCR vs. DVD....but I think it is more like selecting a decent wine. You may have the choice between a newer but well regarded Napa Chardonnay that you can enjoy right out of the bottle. Your other choice is a classic Bordeaux Cabernet that needs decanting, but the process will allow for more of the nuances to come out, in addition to separating the sediment that may have gathered over time. Both methods generally work with dinner, though your choice may depend on the dish (person), and/or if they have the time to go through the decanting process. Some people just want their wine, while others want to make sure they choose the right wine.....whether it is red or white.

-t

Light bulb just click on. Got it. Liked the description.