Diagnosing borderline personality disorder

[nexus73]

Any tips for diagnosing borderline personality disorder (or potentially other personality disorders as well...e.g. narcissistic) in patients who are not forthcoming? I think I've got a fair grasp on this. I sometimes use the McLean screener for borderline personality symptoms. But do struggle at times with patients who have a previous diagnosis of BPD, know what it is, and don't want to be diagnosed with it. So any questions related to borderline are met with a "no" from the patient. Sometimes the clinical interaction and social history provide enough indirect evidence that the diagnosis is present. But, I recently heard of a patient suing his PCP for diagnosing him with borderline personality disorder and I started thinking whether I'm following strict DSM-5 criteria for BPD diagnosis, and suspect I am usually not doing this fully. I've taken to hedging with: cluster b traits, rule out BPD, or unspecified personality d/o with borderline traits.

In my experience giving a BPD diagnosis naive patient the symptoms to review themselves often leads to a wholehearted acceptance of the diagnosis. I haven't found the same with narcissistic or antisocial, as the criteria tend to be pretty unflattering and most patients with these disorders are quick to resist they have these symptoms. Given this difficulty, you end up having to ask questions in a subtle way to not raise suspicion, and almost have to deceive patients into conveying the reality to you. With this, I do find it challenging, and somewhat worrisome if a patient with borderline PD or narcissistic PD can then sue me if they disagree with the diagnosis and somehow feel that has damaged them in some way.

---

Members don't see this ad.

 

[robellis]

Any tips for diagnosing borderline personality disorder (or potentially other personality disorders as well...e.g. narcissistic) in patients who are not forthcoming? I think I've got a fair grasp on this. I sometimes use the McLean screener for borderline personality symptoms. But do struggle at times with patients who have a previous diagnosis of BPD, know what it is, and don't want to be diagnosed with it. So any questions related to borderline are met with a "no" from the patient. Sometimes the clinical interaction and social history provide enough indirect evidence that the diagnosis is present. But, I recently heard of a patient suing his PCP for diagnosing him with borderline personality disorder and I started thinking whether I'm following strict DSM-5 criteria for BPD diagnosis, and suspect I am usually not doing this fully. I've taken to hedging with: cluster b traits, rule out BPD, or unspecified personality d/o with borderline traits.

In my experience giving a BPD diagnosis naive patient the symptoms to review themselves often leads to a wholehearted acceptance of the diagnosis. I haven't found the same with narcissistic or antisocial, as the criteria tend to be pretty unflattering and most patients with these disorders are quick to resist they have these symptoms. Given this difficulty, you end up having to ask questions in a subtle way to not raise suspicion, and almost have to deceive patients into conveying the reality to you. With this, I do find it challenging, and somewhat worrisome if a patient with borderline PD or narcissistic PD can then sue me if they disagree with the diagnosis and somehow feel that has damaged them in some way.

Stop being paranoid about being sued..you’re not going to lose a lawsuit or have any meaningfully negative outcome for diagnosing a patient with BPD

 

[Attending1985]

When you diagnose BPD there has to be buy in from the patient. If there isn’t don’t diagnose it it’s not going to be helpful to them. I wouldn’t recommend diagnosing them with bipolar disorder but finding another way to frame their experience would be useful that is helpful to them.

 

[Psychresy]

When you diagnose BPD there has to be buy in from the patient. If there isn’t don’t diagnose it it’s not going to be helpful to them. I wouldn’t recommend diagnosing them with bipolar disorder but finding another way to frame their experience would be useful that is helpful to them.

But might it be useful to a future provider who may have otherwise diagnosed them with bipolar disorder or another mood disorder and unnecessarily started them on a medication?

 

[Attending1985]

But might it be useful to a future provider who may have otherwise diagnosed them with bipolar disorder or another mood disorder and unnecessarily started them on a medication?

Yes that’s true. If you’re inpatient or doing a one time consult your relationship with the patients isn’t as consequential. It’s a much different story if you’re working with them on a long term basis. If the former is your situation you can document and contact other providers regarding your inclination towards BPD without trying to persuade the patient to agree with the diagnosis while being clear you don’t believe the explanation for their distress is bipolar disorder.

 

[splik]

Actually narcissistic patients typically readily and enthusiastically accept they are narcissists. (E.g. Development and Validation of the Single Item Narcissism Scale (SINS) and You Probably Think this Paper’s About You: Narcissists’ Perceptions of their Personality and Reputation)

I’m not that much into diagnoses so if a pt won’t accept diagnosis and I don’t think I need to document it I will put something else (eg “mood reactivity 2/2 comple developmental trauma”). Also if pt requests removal of personality disorder diagnosis from their problem list I will usually just remove it. This very rarely happens maybe twice in the past 7 yrs but who needs the drama. If the patient is not ready to accept such a diagnosis and is upset about it I don't see the point of arguing about it.

 

[allantois]

Inpatient facility near me loves to slap kids with PD. Then the parents come all upset saying they won’t go there ever again. There’s also an opposite problem of patients clinging on to PD diagnosis and blaming all their ills on it.

 

[clausewitz2]

Actually narcissistic patients typically readily and enthusiastically accept they are narcissists. (E.g. Development and Validation of the Single Item Narcissism Scale (SINS) and You Probably Think this Paper’s About You: Narcissists’ Perceptions of their Personality and Reputation)

I’m not that much into diagnoses so if a pt won’t accept diagnosis and I don’t think I need to document it I will put something else (eg “mood reactivity 2/2 comple developmental trauma”). Also if pt requests removal of personality disorder diagnosis from their problem list I will usually just remove it. This very rarely happens maybe twice in the past 7 yrs but who needs the drama. If the patient is not ready to accept such a diagnosis and is upset about it I don't see the point of arguing about it.

N of like 3 but the three people I have diagnosed with ASPD to date (all very much textbook fulfillment of all the criteria without other identifiable symptoms of anything) have been quite ready to accept the diagnosis when I explain the criteria. One of them actually said, "yeah, that's pretty much my life story" after having been previously diagnosed with schizophrenia because one time he injected meth and heard voices for a couple weeks. Again, these were all very classic, right down to the experiencing of all emotions other than anger as a kind of vague headache/stomachache, total lack of interest in experiencing any aversive sensations, and hyperbolic discounting of potential negative consequences of actions. Still, every time I assumed I'd get a pretty negative reaction and it was never that. These may be a special case where it was something of a relief to them to have an explanation for why meds never seemed to help with anything. They had also uniformly reached that mid-30's/early-40's age range where they realize they can't rip and run like they used to and start maybe thinking about doing things differently.

 

[splik]

N of like 3 but the three people I have diagnosed with ASPD to date (all very much textbook fulfillment of all the criteria without other identifiable symptoms of anything) have been quite ready to accept the diagnosis when I explain the criteria. One of them actually said, "yeah, that's pretty much my life story" after having been previously diagnosed with schizophrenia because one time he injected meth and heard voices for a couple weeks. Again, these were all very classic, right down to the experiencing of all emotions other than anger as a kind of vague headache/stomachache, total lack of interest in experiencing any aversive sensations, and hyperbolic discounting of potential negative consequences of actions. Still, every time I assumed I'd get a pretty negative reaction and it was never that. These may be a special case where it was something of a relief to them to have an explanation for why meds never seemed to help with anything. They had also uniformly reached that mid-30's/early-40's age range where they realize they can't rip and run like they used to and start maybe thinking about doing things differently.

I think your experience matches what we know. I don’t treat antisocials in my practice for obvious reasons but when I come across patients with such traits in the ED or acute settings it is not uncommon for them to tell me they think they are “sociopaths” and when eliciting a history of conduct disorder for pts to say something like “man, it’s like you know my life!” Such patients will not reject such diagnoses out of shame or narcissistic injury but because it doesn’t suit their purposes (for example if seen as a barrier to inpatient admission or a disability claim)

 

[comp1]

PLEASE don't avoid the diagnosis! You could be saving the patient a life time of antipsychotic/mood stabilizer merry go rounds. Buy in from the patient is important and obviously helpful, but remember to first do no harm. You can get your checklist documentation/diagnosis done without actually asking the questions so bluntly. What have their relationships been like? What was the best? What was the worst? Let the patient tell their story or review remote records and you should get enough information from that to support a diagnosis without the direct questioning. You rightly surmise that direct questions, particularly yes/no, are only going to tell you how the patient wants to present to you. Also, I'm sure that I'm not the first here to recognize that threatening or going through with a lawsuit over a mental health diagnosis alone is quite a devaluation....

 

[Stagg737]

I've taken to hedging with: cluster b traits, rule out BPD, or unspecified personality d/o with borderline traits.

I typically do this with either "Borderline features" if they're presenting with symptoms but may just as likely be d/t some other MH problem (usually PTSD) or "Borderline traits"/rule out BPD if I feel strongly that they likely have the disorder but I don't have the hx or reliability to solidly diagnose. Additionally, when I use the "borderline features" I discuss in my assessment paragraph what symptoms I'm seeing and what other explanation they could have that's not a PD (PTSD, PDD, anxiety with perseveration, etc). I think it gives others a heads up of what I'm seeing in the moment that they should be watching for without forcing a diagnosis.

Given this difficulty, you end up having to ask questions in a subtle way to not raise suspicion, and almost have to deceive patients into conveying the reality to you. With this, I do find it challenging, and somewhat worrisome if a patient with borderline PD or narcissistic PD can then sue me if they disagree with the diagnosis and somehow feel that has damaged them in some way.

It really shouldn't be that hard though. Most symptoms of BPD have significant overlap with other disorders and require further follow-up to distinguish between the two. Impulsive? Does this only occur during periods consistent with (hypo)mania/intoxication or is this their baseline? Lability, difficulty with relationships, or derealization/paranoia? Were these present only after a trauma or have they always been there? If the trauma was in childhood, do these symptoms only come up when PTSD symptoms are exacerbated or with certain triggers or can any increase in significant stress contribute? I think the only criteria that's tough to ask without being direct is fear of abandonment, and even that can be framed in a less obvious way.

Also, why do you feel you're deceiving them? Unless you're just using a symptom checklist for everything other than BPD symptoms I'm not sure why you feel that way.

I recently heard of a patient suing his PCP for diagnosing him with borderline personality disorder

Well, you're a psychiatrist, not a PCP. Seems like BPD is well within your domain so I wouldn't worry about it. Also, context would matter a lot here. I'm guessing the doc wasn't sued just for making a diagnosis, there must have been some kind of effect on treatment or some form of harm that led to the lawsuit. If it was literally just a diagnosis, then the patient's lawyer seems pretty stupid as that's not a winnable case. This is all assuming that BPD is even the correct diagnosis...

I think it's weird that a PCP made that diagnosis anyway instead of just referring to psych unless there was an ulterior motive (withholding meds, discharging from ED, etc). Idk any PCP who would want to be the one addressing this anyway.

 

[hallowmann]

I typically do this with either "Borderline features" if they're presenting with symptoms but may just as likely be d/t some other MH problem (usually PTSD) or "Borderline traits"/rule out BPD if I feel strongly that they likely have the disorder but I don't have the hx or reliability to solidly diagnose. Additionally, when I use the "borderline features" I discuss in my assessment paragraph what symptoms I'm seeing and what other explanation they could have that's not a PD (PTSD, PDD, anxiety with perseveration, etc). I think it gives others a heads up of what I'm seeing in the moment that they should be watching for without forcing a diagnosis...

"Cluster B traits" is my garbage can statement, or I'll just call it Emotional Intensity Disorder, which virtually everyone feels OK with because it "sounds like me", and leave it at that. That said, more often than not, they are OK with the BPD diagnosis, unless they are on disability for Bipolar disorder or Schizoaffective/Schizophrenia and you don't think they have those things. If I write Cluster B traits, rule out BPD, or emotional intensity, I expect psychiatrists to know what I mean.

 

[FlowRate]

"Cluster B traits" is my garbage can statement, or I'll just call it Emotional Intensity Disorder, which virtually everyone feels OK with because it "sounds like me", and leave it at that. That said, more often than not, they are OK with the BPD diagnosis, unless they are on disability for Bipolar disorder or Schizoaffective/Schizophrenia and you don't think they have those things. If I write Cluster B traits, rule out BPD, or emotional intensity, I expect psychiatrists to know what I mean.

"Mood Lability"/Emotional Lability is the ICD code I put for most of these pts in the billing section of the chart, even when I might more explicitly mention BPD/Cluster B in my note itself.

 

[Stagg737]

"Cluster B traits" is my garbage can statement, or I'll just call it Emotional Intensity Disorder, which virtually everyone feels OK with because it "sounds like me", and leave it at that. That said, more often than not, they are OK with the BPD diagnosis, unless they are on disability for Bipolar disorder or Schizoaffective/Schizophrenia and you don't think they have those things. If I write Cluster B traits, rule out BPD, or emotional intensity, I expect psychiatrists to know what I mean.

Lol at emotional intensity disorder, I kind of like that. "Cluster B traits/features", for me, is something I just use when there is clearly some sort of antisocial/borderline/histrionic situation occurring but the patient is either so dysregulated or such a poor historian that I just don't have the time to untangle it at that time. I prefer to be as specific as possible, but I do think it's at least a valid way to signal other docs "hey, you should be aware of this" when they go to see the patient.

 

[psychacad]

If patients don't want the diagnosis, I think it's fair to drop it. This isn't like a broken leg or pneumonia diagnosis. It's almost like an identity label, especially for 'personality disorders', cause it's sort of like saying the core is disordered. There are other ways to formulate the issue that is more patient-centric and in line with their experience. I usually try to empathize with their concern and run the spiel that it's just a label we use in our system and they don't have to define themselves by this label.

I've had a couple of patients who also had issues with labels like 'schizophrenia' where it gets more dicey, but who am I to argue with it? I'd love to sit with the DSM gods just to see how they discuss the 'diagnosis' labels and what it might do to the therapeutic alliance.

 

[Stagg737]

If patients don't want the diagnosis, I think it's fair to drop it. This isn't like a broken leg or pneumonia diagnosis. It's almost like an identity label, especially for 'personality disorders', cause it's sort of like saying the core is disordered. There are other ways to formulate the issue that is more patient-centric and in line with their experience. I usually try to empathize with their concern and run the spiel that it's just a label we use in our system and they don't have to define themselves by this label.

I've had a couple of patients who also had issues with labels like 'schizophrenia' where it gets more dicey, but who am I to argue with it? I'd love to sit with the DSM gods just to see how they discuss the 'diagnosis' labels and what it might do to the therapeutic alliance.

Out of curiosity, say you have a patient who is clearly borderline but without obvious anxiety or depression whose main problem is emotional lability and problems with relationships. How do you bill for those individuals? Just use an "other specified xyz" that would fit closest with their symptoms?

 

[nexus73]

Out of curiosity, say you have a patient who is clearly borderline but without obvious anxiety or depression whose main problem is emotional lability and problems with relationships. How do you bill for those individuals? Just use an "other specified xyz" that would fit closest with their symptoms?

adjustment disorder NOS

 

[Attending1985]

PLEASE don't avoid the diagnosis! You could be saving the patient a life time of antipsychotic/mood stabilizer merry go rounds. Buy in from the patient is important and obviously helpful, but remember to first do no harm. You can get your checklist documentation/diagnosis done without actually asking the questions so bluntly. What have their relationships been like? What was the best? What was the worst? Let the patient tell their story or review remote records and you should get enough information from that to support a diagnosis without the direct questioning. You rightly surmise that direct questions, particularly yes/no, are only going to tell you how the patient wants to present to you. Also, I'm sure that I'm not the first here to recognize that threatening or going through with a lawsuit over a mental health diagnosis alone is quite a devaluation....

You could also easily do as splik
said and write something like depression secondary to developmental trauma. First do no harm also includes diagnosing someone with someone that causes more trauma. Let’s face it our diagnoses are pretty meaningless. We can deprescribe or not prescribe without diagnosing with BPD.

 

[Candidate2017]

Patients are generally happy to realize there is a diagnosis that explains why they are always having interpersonal problems. As I ask/discuss each successive criteria for borderline personality, I feel like I'm doing an astrology reading because the usual reaction is increasing levels of "OMG, OMG that exactly describes me!!! How did you know???"

Patients are also happy for a more insidious reason: it appears to give them permission to externalize and avoid responsibility for their actions. That is something I address at the next session.

As also pointed out above, if in a consult or other short relationship, it's best to word the assessment as rule out emotional reactivity or rule out personality.

 

[Stagg737]

adjustment disorder NOS

Does this work? I've always been told that NOS or unspecified disorders typically won't be reimbursed.

Patients are generally happy to realize there is a diagnosis that explains why they are always having interpersonal problems. As I ask/discuss each successive criteria for borderline personality, I feel like I'm doing an astrology reading because the usual reaction is increasing levels of "OMG, OMG that exactly describes me!!! How did you know???"

Patients are also happy for a more insidious reason: it appears to give them permission to externalize and avoid responsibility for their actions. That is something I address at the next session.

As also pointed out above, if in a consult or other short relationship, it's best to word the assessment as rule out emotional reactivity or rule out personality.

I've had the same response a number of times where patients are either amazed or creeped out that I described them so well. I've even had a few patients break down because they could finally put a title to what's wrong with them after being misdiagnosed over and over. I don't worry too much about the initial externalization. I just make sure to be upfront with them that medications aren't going to help and that if they actually want to get better they need to commit to therapy. I've had a few patients who started DBT programs and were doing really well on follow-up a few months later. I feel like just telling a lot of BPD that there's an actual treatment that works is enough to get them to buy in.