Dissociation as a concept

[DrGachet]

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Do you find it useful? I am not talking about DID in particular but dissociation in general, such as dissociation of feelings from thoughts; or dissociative ego states intruding (no complete amnesia like in DID) or something even more pathological like fugue. By labeling these things as dissociation, are we really explaining them or simply reframing them?

In other words, to say patient X who has BPD is suddenly acting like a two year old (emotionally) because of an ego state intrusion, what have we really explained and how confidently? And how does this help with the treatment? Could the supposedly superficial behavioral modification be sufficient? Or can we do better with a trauma/abuse type theory situating the source of maladaptive behavior in dissociation of thoughts from emotions many years ago?

I am not suggesting that it has to be one or the other and it is true that regardless of the source of dysfunction, a safe and predictable environment, a caring and interested attitude, and an atmosphere of trust can do wonder. But hedging our bets, as useful as it may be, leaves me dissatisfied.

 

[Ibid]

a safe and predictable environment

Where is this Shangri-La?

 

[PETRAN]

Dissociation is a very controversial concept. I personally don't completely agree with the idea of dissociation strictly as an "ego defence mechanism". It does occur though, but probably for other reasons than the ones proposed by psychoanalysts. From a modern (scientific) point of view, it seems that some people are "inherently" more "dissociative" than others but not necessarily because of child abuse and such (it could be a contributing factor though). An excellent scientific researcher on controversial topics such as dissociation, hypnosis and the unconscious is Kihlstrom. Read this interview (if you haven't already).


http://www.sevencounties.org/poc/view_doc.php?type=doc&id=27004

and the summary


http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=29046&cn=41


I'm training in psychology, but i always take the purely psychoanalytic ideas with a grain of salt. I personally don't find it very useful in my clinical work because i simply don't believe in unconscious "repressions" and "conflicts" and stuff. There is no evidence for that whatsoever. Especially in regard to various mental health disorders. But if someone uses a psychoanalytic formulation and intervention and the patient likes it, it could be useful i guess? For drug consultations or CBT i don't think it has a strong significance to one's clinical work.

 

[whopper]

A problem with dissociation is that while I believe all of us would agree it exists (heck I dissociate if I get into an argument with my wife), it's hard to quantify and verify.

 

[nitemagi]

A problem with dissociation is that while I believe all of us would agree it exists (heck I dissociate if I get into an argument with my wife), it's hard to quantify and verify.

Especially with instruments like the DES, which are controversial.

Charles Scott seems to always do fun presentations at AAPL on dissociation related topics. Mostly blasting them because there's a lot of very dramatic [possibly ludicrous] stories that have emerged.

 

[393656]

I personally am not a psychotherapy fan and am purely biological with some CBT 🙂

I do believe in it and have seen it once or twice in a legitimate fashion. However it really has no clinical utility to identify it. The underlying pathology is almost always trauma/abuse and the damage it does creates far broader range of problems in someone than simply dissociation (which for some of these folks is actually the least problematic thing they do). No medications help and no specific approaches in dynamic therapy/analysis help. You still target the same thing with or without dissociation.

I guess when something has no clinical benefit to diagnosing it as it does not effect outcome good or bad, treatment or co-morbid disorders, I dont really give a rats about it.

 

[Suedehead]

dissociating is something we all do, from daydreaming to flashing back. I didn't really get the concept till I had kids. There I saw how it's a very normal part of how we deal until like age 4 or so - I can still see my kid's eyes totally glazing over as I tell a story or hear him talking to himself alone in his room replaying a part of the day like he's really there.

Dig some of what Wallstreet said. Dissociate disorders are RARE city. 99% chance your patient that is dissociating into multiple personalities is actually hysterical (there's an old term) - meaning they are engaging in a behavior that was somehow suggested to them while they were highly suggestible.

For more on this, chew on former Johns Hopkins psych dept chair Paul McHugh's book, "Try to Remember." Sweet.

 

[whopper]

It's rare but I've had a few cases where someone was severely dissociating and was misdiagnosed as psychotic. She was put on large amounts of antipsychotic medications. I was a resident at the time, and the attending was clueless.

The patient lay in bed all day, staring off into space, blurting syllables that did not form any coherent words.

I became convinced she was dissociating because her husband that left her told he he was thinking of changing his mind. Within minutes she was better as if nothing happened. One day later, the husband changed his mind again, and she was back where she was.

Now that couldn't have been psychosis.

 

[PETRAN]

It's rare but I've had a few cases where someone was severely dissociating and was misdiagnosed as psychotic. She was put on large amounts of antipsychotic medications. I was a resident at the time, and the attending was clueless.

The patient lay in bed all day, staring off into space, blurting syllables that did not form any coherent words.

I became convinced she was dissociating because her husband that left her told he he was thinking of changing his mind. Within minutes she was better as if nothing happened. One day later, the husband changed his mind again, and she was back where she was.

Now that couldn't have been psychosis.

Interesting. Why not psychosis? It sounds like one, dissociation does not include thought disorganization no? It could be some transient psychotic state induced by increased stress. Well, i guess that you can't really say for sure because even "psychosis" is a weird mental state that we don't know enough about 😛

 

[nitemagi]

I think whopper touches on an important topic often neglected - that of dissociative psychosis. I think it's especially important because we shouldn't be chasing it with neuroleptics, contrary to common practice. The patient with borderline PD, for example, presuming they aren't just malingering, usually has AH in the dissociative spectrum. AP's may work more as an "ego-glue" to use old school lingo, than really treating a schizophrenia-like psychosis.

A couple of other useful reasons to know about dissociation -
1. Conversion disorder. This is often considered to be somewhat in the dissociative spectrum, with the individual dissociating off a part of their own body. Another conceptualization is "self-hypnosis" to have their deficit, which I'll get to in a minute. If you go to the DSM Handbook of differential diagnosis, and check the algorithm for Hallucinations - the first step is Delirium/Dementia/due to a GMC? If no, is it substance induced? If no, is it multi-sensory (auditory and visual, for example), with insight that it's not real, and fantasy-like in nature? If YES, then it's considered pseudohallucinations, part of a conversion disorder.

Yes, a conversion disorder for psychiatric not motor symptoms. If anyone can't get ahold of the manual PM me and I'll send you the file for that tree.

2. Hypnosis. Yeah, it's a pet area of study for me. Current research describes it as a state with a combination of increased relaxation, concentration, and dissociation. Especially useful as a possible intervention for those who're already dissociating (though I don't know any prospective data showing it's better in patients who dissociate), but good to understand their phenomenology. High hypnotizability is considered to rule-out authentic schizophrenia.

In connection to the above, Herbert Spiegel (former Columbia Psychiatrist and a pioneer of much of modern hypnosis research) talked about a phenomenon he described as Grade 5 syndrome.
http://www.ncbi.nlm.nih.gov/pubmed/4416284
Namely highly hypnotizable people that can often languish on inpt units (state hospitals at the time), highly suggestible, can manifest a variety of conversion disorders, etc. He also wrote about it in his book Trance and Treatment.

I had a patient long-term diagnosed with schizophrenia, she was refractory to meds, kept getting worse, eventually noted to start develop loss of muscle tone, initially thought to be narcolepsy. Sleep specialists (multiple) consulted, ruled it out. Not seizures. I happened upon her and noted she was very hypnotizable. Very suggestible. Manifests good response to whatever for 2-3 days (even placebo, SSRI) then gets worse. Going through hundreds of pages of records, all seems to be conversion/dissociative/grade 5. Much improved with therapy. Gonna write a Case report and review one of these days.

 

[whopper]

Why not psychosis?

Well of course it could've been psychosis, but I was thinking that psychosis, as we typically understand it in the context of schizophrenia/schizoaffective/MDD w/ psychotic features/bipolar disorder w/ psychotic features is not going to go away based on a bit of good news, then come back with bad news.

A thing IMHO that separates a good psychiatrist vs a bad one is the good one is on a quest to figure out what's really going on. Not just throwing a pill at the situation. In the case I mentioned, the patient was given large doses of antipsychotics, and if she was dissociating, if anything, I think it would've made the situation worse. Most of the time, IMHO, its simply to easy to chalk up everything to something that'll be fixed by a medication. In fact,
I think it's a hallmark of a good psychiatrist to basically tell at least a few patients a month in most clinical settings that there's no need for medication.

I mean after all, if the person was dissociating, it was likely that her reality was too hard to deal with. To make that reality one of oversedation and all the other side effects of someone on an antipsychotic that doesn't need to be on one.......you can figure that out.

 

[PETRAN]

I think whopper touches on an important topic often neglected - that of dissociative psychosis. I think it's especially important because we shouldn't be chasing it with neuroleptics, contrary to common practice. The patient with borderline PD, for example, presuming they aren't just malingering, usually has AH in the dissociative spectrum. AP's may work more as an "ego-glue" to use old school lingo, than really treating a schizophrenia-like psychosis.

A couple of other useful reasons to know about dissociation -
1. Conversion disorder. This is often considered to be somewhat in the dissociative spectrum, with the individual dissociating off a part of their own body. Another conceptualization is "self-hypnosis" to have their deficit, which I'll get to in a minute. If you go to the DSM Handbook of differential diagnosis, and check the algorithm for Hallucinations - the first step is Delirium/Dementia/due to a GMC? If no, is it substance induced? If no, is it multi-sensory (auditory and visual, for example), with insight that it's not real, and fantasy-like in nature? If YES, then it's considered pseudohallucinations, part of a conversion disorder.

Yes, a conversion disorder for psychiatric not motor symptoms. If anyone can't get ahold of the manual PM me and I'll send you the file for that tree.

2. Hypnosis. Yeah, it's a pet area of study for me. Current research describes it as a state with a combination of increased relaxation, concentration, and dissociation. Especially useful as a possible intervention for those who're already dissociating (though I don't know any prospective data showing it's better in patients who dissociate), but good to understand their phenomenology. High hypnotizability is considered to rule-out authentic schizophrenia.

In connection to the above, Herbert Spiegel (former Columbia Psychiatrist and a pioneer of much of modern hypnosis research) talked about a phenomenon he described as Grade 5 syndrome.
http://www.ncbi.nlm.nih.gov/pubmed/4416284
Namely highly hypnotizable people that can often languish on inpt units (state hospitals at the time), highly suggestible, can manifest a variety of conversion disorders, etc. He also wrote about it in his book Trance and Treatment.

I had a patient long-term diagnosed with schizophrenia, she was refractory to meds, kept getting worse, eventually noted to start develop loss of muscle tone, initially thought to be narcolepsy. Sleep specialists (multiple) consulted, ruled it out. Not seizures. I happened upon her and noted she was very hypnotizable. Very suggestible. Manifests good response to whatever for 2-3 days (even placebo, SSRI) then gets worse. Going through hundreds of pages of records, all seems to be conversion/dissociative/grade 5. Much improved with therapy. Gonna write a Case report and review one of these days.

This looks like a fascinating case nitemagi. I always like these weird unexplained-symptom cases, they can be very stimulating if you like detective-type clinical work. These blurry "mind-body" cases are lovely. I'm always wondering though if it is some kind of a neurological manifestation happening at the cellular level/micro-stucture of the brain (and hence with no chance of detecting it with MRI and such e.g. like cryptogenic epilepsy). Loss of muscle-tone sounds a bit over the top to purely result from "unconscious ego-defences". I don't know. maybe i'm not that of a believer in traditional psychoanalytic formulations of problems. 😛

My take on the issue is that the so-called dissociative individuals have some unknown organic problem at the micro-structure of the brain. Maybe abberant wiring of primary sensorymotor areas for conversion and association areas for dissociation (although it is the same process). This problem could be exaggerated/induced with things that increase cortical excitability like psychological (or physical) stressors (Maybe a bit like migraine (?). This is what modern research is pointing to as well (read Kihstrom's interview in my previous post). Reasearch has shown that people with dissociative symptoms have a similar chance of trauma/abuse with the normal population. So, the traiditonal cocneptualization of dissociation as trauma-induced maybe is just wrong. Still, psychotherapy (together with some psychopharm-type intervention-i don't know maybe SNRI or SSRI?) could still improve the condition (since it would decrease stress and improve mood). The thing you said is very interesting though. That people who dissociate are very suggestible and that dissociation and hypnosis are related. I performed a search and stumbled upon this very interesting article


http://www.hypnosisandsuggestion.or...ssociation-or-imaginative-suggestibility.html

The article says that suggestibility and dissociation are maybe not related. I don't know. Since i'm also training as a neuropsychologist, i wonder if dissociation is related to some kind of subtle dysexecutive control. It could be studyworthy. Very interesting esoteric stuff. Nice conversation guys.

 

[393656]

I personally think what people call "psychosis" in borderline's should be labeled as a completely different phenomonon. I think it suffices to label it as most as an set of overvalued ideas or intrusive thoughts.

I simply do not believe any Borderline has true psychotic features-just do not buy it.

Unfortunately it has been accepted as such and neuroleptics are so commonly used (however that is neither here nor there since they are used for everything now aday!)

I definetly hope a re-classification of borderline may address this partly

 

[DrGachet]

All these theories...I don't really know. I still think a behavioral approach would be as useful at the end of the day. If somebody is regressing or has BPD organization and is dissociating, or if he has conversion disorder, what we have really is simply people who are dealing in ways that are at least partly dysfunctional in the current environment but are/were useful and adaptive, given the resources/intelligent/emotional maturity in different time/place. I don't need a strictly biological explanation of needing to locate some pathology in the brain, nor one that relies on trauma theory exclusively, labeling them as PTSD or something.

Sure, the person may need to grieve the various losses or come to terms with trauma(s) in their own way, but at the end of the day, what do I gain by labeling some maladaptive behavior as dissociation?

The real problem is not the limitation of behavioral explanation/treatment, at least in this debate, but the difficulties of changing the person's environment. Which is why meds are sometimes helpful. And I don't mean environment just in the sense of four walls, but so much more, including hangouts, the books he typically reads or websites he typically visits, family, circle of friends, etc.

Don't get me wrong, I'm not a strict behaviorist. In fact, I hated behaviorism because I found it shallow and inhumane, and constantly worried about symptom substitution. And I love psychodynamic theories because deep down I am a lover of complex theories.

But I'm trying to go with the simplest and mostly likely explanation, without having to resort to ideas that do not explain as much as they claim to.

And don't even get me started on dissociative psychosis. I still have difficulty grasping what psychosis really is.

 

[Suedehead]

All these theories...I don't really know. I still think a behavioral approach would be as useful at the end of the day. If somebody is regressing or has BPD organization and is dissociating, or if he has conversion disorder, what we have really is simply people who are dealing in ways that are at least partly dysfunctional in the current environment but are/were useful and adaptive, given the resources/intelligent/emotional maturity in different time/place. I don't need a strictly biological explanation of needing to locate some pathology in the brain, nor one that relies on trauma theory exclusively, labeling them as PTSD or something.

couldn't agree more. makes me think of the Perspectives of Psychiatry by McHugh. he puts dissociative jazz in the behavioral realm as well.

 

[PETRAN]

I personally think what people call "psychosis" in borderline's should be labeled as a completely different phenomonon. I think it suffices to label it as most as an set of overvalued ideas or intrusive thoughts.

I simply do not believe any Borderline has true psychotic features-just do not buy it.

Unfortunately it has been accepted as such and neuroleptics are so commonly used (however that is neither here nor there since they are used for everything now aday!)

I definetly hope a re-classification of borderline may address this partly

Absolutely. BPD has nothing to do with psychosis (on its own, unless a psychotic spectrum co-exists). I prefer the ICD label "Emotionally Unstable Personality Disorder". Other proposed names are aslo good e.g. emotional regulation disorder, emotion-impulse dysregulation disorder and such. Although a bit vague (i mean, what mental health issue doesn't involve some kind of emotional dysregulation?) i think they catch the essence of the disorder better in comparison to the neutral, irrelevant and possibly plain wrong "borderline personality".

What about borderline and bipolar type 2? I think that it is one and the same (with the more severe bipolar type 1 being a combination of higher levels of emotional dysregulation spectrum with psychotic spectrum. In even more severe cases it possibly makes "schizoaffective".) Complicated stuff

 

[nitemagi]

My take on the issue is that the so-called dissociative individuals have some unknown organic problem at the micro-structure of the brain. Maybe abberant wiring of primary sensorymotor areas for conversion and association areas for dissociation (although it is the same process). This problem could be exaggerated/induced with things that increase cortical excitability like psychological (or physical) stressors (Maybe a bit like migraine (?). This is what modern research is pointing to as well (read Kihstrom's interview in my previous post). Reasearch has shown that people with dissociative symptoms have a similar chance of trauma/abuse with the normal population. So, the traiditonal cocneptualization of dissociation as trauma-induced maybe is just wrong. Still, psychotherapy (together with some psychopharm-type intervention-i don't know maybe SNRI or SSRI?) could still improve the condition (since it would decrease stress and improve mood). The thing you said is very interesting though. That people who dissociate are very suggestible and that dissociation and hypnosis are related. I performed a search and stumbled upon this very interesting article


http://www.hypnosisandsuggestion.or...ssociation-or-imaginative-suggestibility.html

The article says that suggestibility and dissociation are maybe not related. I don't know. Since i'm also training as a neuropsychologist, i wonder if dissociation is related to some kind of subtle dysexecutive control. It could be studyworthy. Very interesting esoteric stuff. Nice conversation guys.

I would consider the micro-lesion hypothesis if I hadn't seen conversion pt's (including this one) be able to turn symptoms on and off on command with hypnosis.

The article you sent touches on a much larger "state vs. trait" debate in the scientific hypnosis literature. I would say that those who're hypnotized dissociate when in a trance state, but those that dissociate may not easily enter hypnosis per se.

 

[393656]

Sorry I do not buy this microlesion theory at all. Is clearly not organic IMO.

Also I agree with liking emotional dysregulation as a better term as its more uptodate. Borderline is completely not relevent to what the name means. Its no longer a medium between psychosis and neurosis and yet we keep the name.

However we just had the privelage of our group of residents meeting with the guy heading up the personality disorder chapter in DSM 5 and he confirmed they considered changing the name and had a majority of input from people to change the name, however they rationalized to keep it how it was for several reasons. Largely because no single name describes accurately the symptomology of BPD and thus changing it to another name would simply replace one meaningless term with another. That was the general point. So borderline it is. I am hoping they clarify something specifically about the non-sense psychosis they apparently expereince.

And sorry man my agreement stops with thinking BPD is even in the same realm of BPAD. Akiskal would agree with you but the personality disorder guy leading up DSM (cant think of his name right now) also addressed this and was very emphatic that they were a completely seperate disease. He is the worlds borderline expert too so I had to agree! But I personally do not believe there is absolutely anything related other than yes, emotions are tough to regulate when you are manic and bordeerlines have the same problem, but the underlying reason is a totally different animal.

 

[Suedehead]

Absolutely. BPD has nothing to do with psychosis (on its own, unless a psychotic spectrum co-exists). I prefer the ICD label "Emotionally Unstable Personality Disorder". Other proposed names are aslo good e.g. emotional regulation disorder, emotion-impulse dysregulation disorder and such. Although a bit vague (i mean, what mental health issue doesn't involve some kind of emotional dysregulation?) i think they catch the essence of the disorder better in comparison to the neutral, irrelevant and possibly plain wrong "borderline personality".

psychosis is hard to define. Most (but not all) of the severe borderline pts I treat will endorse 'stress related' psychosis - you know, whispers or the sense that they're not alone or a negative voice that tells them they're 'no good.'

And sorry man my agreement stops with thinking BPD is even in the same realm of BPAD. Akiskal would agree with you but the personality disorder guy leading up DSM (cant think of his name right now) also addressed this and was very emphatic that they were a completely seperate disease. He is the worlds borderline expert too so I had to agree! But I personally do not believe there is absolutely anything related other than yes, emotions are tough to regulate when you are manic and bordeerlines have the same problem, but the underlying reason is a totally different animal.

gorgeously said. Akiskal... sigh... the bipolar spectrum diagnostic vagueness drives me bonkers - a bipolar spectrum may very well exist, it's just that borderlines and IED kids are CONSTANTLY being told they have bipolar disorder. makes me embarrassed for our field that we're misconstruing our own constructs. But we're prone to fads.... it'll pass.

 

[393656]

psychosis is hard to define. Most (but not all) of the severe borderline pts I treat will endorse 'stress related' psychosis - you know, whispers or the sense that they're not alone or a negative voice that tells them they're 'no good.'



gorgeously said. Akiskal... sigh... the bipolar spectrum diagnostic vagueness drives me bonkers - a bipolar spectrum may very well exist, it's just that borderlines and IED kids are CONSTANTLY being told they have bipolar disorder. makes me embarrassed for our field that we're misconstruing our own constructs. But we're prone to fads.... it'll pass.

The nature that BPD are "hearing whispers telling them they are no good" and the way they describe it is always that they understand the "voices" are not real. This is exactly the opposite of what the definition of psychosis is. They have insight into the nature of the whispers and that is definitionly not psychosis.

I firmly believe these "whispers" you hear people talking about are simply negative thoughts that are intrusive and not in the psychotic realm.

 

[nitemagi]

The most amazing thing is seeing all these ADHD and bipolar (read conduct d/o) kids that grow up and end up in jail/prison. When I see them in that setting, it's like seriously? You think I'm going to prescribe stimulants to you? I think some nice epidemiological studies could be done about how we overdiagnose these in low SES families. Though a colleague is doing some systems of delivery research in child and found that it's more commonly white parents that want to medicate their unruly children.

 

[Manicsleep]

The micro lesion stuff is just arbitrary made up junk science. Same with trying to rename everything every 6 months (emotionally unstable personality disorder is no better and probably worse). The fact is we don't know what is going on a lot of the time so focus on solving that instead of this made up nonsense.

RE: the dissociative psychosis. I think it is real but its not like schizophrenia although to me the difference isn't insight. I have seen plenty of schizophrenics with insight into their hallucinations, especially higher educated ones who are well treated. At the same time, I can't prove it so perhaps it is like WS is saying and the waters get muddied with all the malingering, exaggerating, manipulation etc that goes on with this group.

 

[whopper]

I personally think what people call "psychosis" in borderline's should be labeled as a completely different phenomonon. I think it suffices to label it as most as an set of overvalued ideas or intrusive thoughts.

I'm there too. I've only rarely encountered psychosis in borderlines, and in most of the episodes where it could've been psychosis, when borderlines mention things such as believing everyone's against them, that could be more on the order of cognitive distortion and defense mechanisms vs. psychosis.

The only time I've seen someone with borderline PD mention something that was not arguably a defense mechanism or a cognitive distortion was one who had hallucinations, but that particular person, I had strong reason to believe, had bipolar disorder as well, and on top of that was already on a medication gumbo prescribed by another doctor, so who knows what the blazes was going on there. (She was not my patient but actually a fellow resident at the time).

 

[billypilgrim37]

I think it's helpful to remember that psychosis was once a more general term than a specific one, and that even the psychoses we would agree upon, that in mood disorder, delusional disorder, and schizophrenia, are somewhat distinct in their presentation (though of course much overlap and heterogenous within themselves). The 20 minute "micropsychosis" in borderline is clearly a very distinct phenomenon, but in strict traditional senses, it's appropriate. It's just a very different ballgame with different treatment. It's not a "psychotic disorder" or a "mood disorder," and I think that's the labelling we rail against, because we don't want to necessarily overmedicalize borderline. And that's pretty reasonable.

Interestingly, I believe for the purposes of my state's mental health and involuntary commitment codes, bpd is included as a mood disorder because it is a disorder involving so many changes in mood. The law is so concrete.

 

[393656]

"loss of touch with reality" is the past and current meaning of true psychosis. While bipolar folks and schizophrenia folks often have insight into their hallucinations or delusions, it more often than not is a transient time that progresses to true loss of touch with reality and losing insight, especially in all schizophrenics.

BPD never get to that point so their insight into these "voices" never reach the point of being out of touch with reality and therefore are not even in the same realm as psychosis.

I think you have to stick with the true defintions of things and not make up your own variations since wording and semantics and definitions is what our diagnostic structure is made of.

 

[billypilgrim37]

You're right. Me and Otto Kernberg shouldn't make stuff up.

 

[393656]

I dont care who you site. There is a definition and meaning of the term psychosis and it relates to someone who is losing or lost touch with reality testing and perception. You cant expand it to cover any wierd symptom you want such as a borderlines crazy ideas

 

[Manicsleep]

"loss of touch with reality" is the past and current meaning of true psychosis. While bipolar folks and schizophrenia folks often have insight into their hallucinations or delusions, it more often than not is a transient time that progresses to true loss of touch with reality and losing insight, especially in all schizophrenics.

BPD never get to that point so their insight into these "voices" never reach the point of being out of touch with reality and therefore are not even in the same realm as psychosis.

I think you have to stick with the true defintions of things and not make up your own variations since wording and semantics and definitions is what our diagnostic structure is made of.

Wallstreet, are you saying all schizophrenics have no insight into any aspect of reality testing or will eventually lose all insight? You are also saying that borderlines never lose touch with reality? 100% is a pretty solid number. You may want to reconsider.
Seeing things in black and white, all or never. I am not sure you realize who is the one 'making up' stuff here.

I think most of understand how psychosis destroys insight. That doesn't mean schizophrenics can't retain some insight or get it back with treatment and education. Perhaps, your mostly biologic approach is your downfall. You need to empower your patients and a psychotherapeutic intervention or biopsychosocial understanding can really be helpful. Be their physician not their pharmacist.

 

[whopper]

I believe for the purposes of my state's mental health and involuntary commitment codes, bpd is included as a mood disorder because it is a disorder involving so many changes in mood. The law is so concrete.

It all depends on the wording.

In Ohio, the wording is to the effect of..

Does the person have a disorder of thought, mood, perception, or memory, to the degree where it would cause the person to be a danger to self, others, not be able to care for oneself in the community, or significantly would step on the rights of him/herself or others, and is the hospital the least restrictive treatment environment.

Mind you the above is in regular English, not the psychiatric definition of a DSM "mood" disorder. So in most people's books, borderline PD is a disorder of mood because the person would suffer from siginifcant disturbances of mood.

Before I started fellowship, I thought the wording wouldn't allow borderline PD because in the DSM it's a personality disorder and not a DSM mood disorder, but it is a disorder where mood's involved.

Lots of doctors forget that laws are written in layman's English, not medical terminology.

 

[Suedehead]

I dont care who you site. There is a definition and meaning of the term psychosis and it relates to someone who is losing or lost touch with reality testing and perception. You cant expand it to cover any wierd symptom you want such as a borderlines crazy ideas

you're also presupposing general consensus... and there is none.

 

[Manicsleep]

you're also presupposing general consensus... and there is none.

Good point.

 

[393656]

Good point.

Psychosis has a definition-no room for arguement here. From the first day it was used way back when it meant not being in touch with reality. Plain and simple and if you or anyone else wants to modify the meaning at this point that is fine but that is not what the term means as it relates to diagnostics in our field.

 

[nitemagi]

I would agree with the psychosis definition, but that doesn't speak to etiology or the various subtypes Only 1 major type (related to schizophrenia or mood disorders) seems to warrant treatment with an antipsychotic. The subtypes associated with dissociation or BPD don't.

 

[DrGachet]

While we're on the subject, would somebody mind telling me what this definition for psychosis actually is? In operational terms?

 

[Suedehead]

Psychosis has a definition-no room for arguement here. From the first day it was used way back when it meant not being in touch with reality. Plain and simple and if you or anyone else wants to modify the meaning at this point that is fine but that is not what the term means as it relates to diagnostics in our field.

and what does that mean, 'not being in touch with reality?'

 

[393656]

and what does that mean, 'not being in touch with reality?'

Give me a break. Now don't try to play mr intellectual

Second someone commented that the definition of psychosis is different for schizophrenia/BPAD and borderline/dissociation. The entire point of this is to say the phenomonon in borderline is NOT consistent with what psychosis is by definition. They are not at all impaired in reality testing in regards to their "voices" etc. By definition as I mentioned when you have conistently full inisght into your voices being produced by your mind and you recognize they are not coming from another entity (are not real) that is not psychosis.

You can have insight as I mentioned in shizophrenia and bpad however it is largely associated with the subtle symptoms before a full blown psychotic episode or residual after treatment with anti-psychotics. However left untreated all true schizophrenics or truly psychotic bpad will not have insight or severely limited insight into their psychosis.

Just because people mis-label it, that does not mean it should/is an accepted definition or meaning. That is how mis-information gets spread and dilutes are ability to accurately diagnosis disorders properly. it is EXACTLy what has happened with borderline. because people call this "psychosis" they throw anti-psychotics at these people which have absolutely no efficacy in their intrusive "psychotic symptoms". It has some data to help impulse control but that is not even what people are throwing the meds at. Mis labeling symptoms leads to mis-utilizing medications.

 

[billypilgrim37]

Second someone commented that the definition of psychosis is different for schizophrenia/BPAD and borderline/dissociation.

I imagine you're referencing my comment, but that's not what I said. Never was there a definition of psychosis posited other than yours. The argument was that psychosis presents differently in a few different diagnoses where psychosis exists. It's not limited to the Kraeppelinian psychotic disorders, i.e. schizophrenia versus manic depression. This is a very mainstream idea, given that none of us would challenge the validity of psychotic depression or delusional disorder.

The argument has been whether borderlines have psychotic symptoms. Most others on the thread except you seem to think they do. Kernberg does. John Oldham does. You might not care who I "site," (sic) but that's on you.

The point is that this symptom can be accounted for as a symptom of bpd. Your example of borderlines who hear voices that have insight is a bit of a straw man argument, because that's not what we're talking about. We're talking about when we see borderlines go ravingly psychotic. It doesn't last for weeks or even days, and prognostically we don't expect them to have courses that run similar to other psychotic disorders. We have no data to justify whether antipsychotics are of benefit or not in these cases. Most of us think they're inappropriate, but many prescribe them anyway, usually when giving diagnoses of bipolar or schizoaffective to justify their use (or because these doctors think that psychotic symptoms do not appear in bpd).

If you haven't seen borderlines with true, brief psychotic symptoms, then that's fine. The rest of us apparently have. Go to state hospitals, and they're there. Come to my hospital, and they're there. Hang out with the ACT team, and you'll probably hear the stories. Many of these folks are given other diagnoses, usually bipolar, with or without real evidence for bipolar disorder. These are extremely impaired folks. Not every borderline has brief psychotic periods, but it's a well described feature.

 

[Manicsleep]

What is making you decide that borderlines are reality tested when they are not having symptoms but schizophrenics are tested when they are psychotic and not getting treated?

 

[Suedehead]

Give me a break. Now don't try to play mr intellectual

sigh

my question was sincere. I have NO idea what YOU mean by 'not being in touch with reality.' Unscientifically nonspecific and most certainly not agreed upon.

They are not at all impaired in reality testing in regards to their "voices" etc. By definition as I mentioned when you have conistently full inisght into your voices being produced by your mind and you recognize they are not coming from another entity (are not real) that is not psychosis.

You can have insight as I mentioned in shizophrenia and bpad however it is largely associated with the subtle symptoms before a full blown psychotic episode or residual after treatment with anti-psychotics. However left untreated all true schizophrenics or truly psychotic bpad will not have insight or severely limited insight into their psychosis.

so which is key for your definition of psychosis? 'not being in touch with reality' or lack of insight? or are those one in the same? to you?

I know of no known hard and true definition of psychosis. I dig this 'working definition,' though, by Oliver Freudenreich in his gem of a book 'Psychotic disorders' (emphasis added):

"In its most narrow conceptualization, psychosis is defined as the presence of delusions or clear-cut hallucinations, punctum. In broader definitions, formal thought disorder, behavioral disorganization, and catatonia are included in its definition. Psychotic symptoms are neither specific for any disorder nor even necessarily pathologic.

"Conceptually speaking, psychosis is 'impaired reality testing,' the famous 'break from reality.' Clinically, this is not terribly useful: how do you know when it is present? Attempts have been made to identify clinical signs and symptoms suggestive of psychosis, giving rise to the above operationalized definition of (narrowly defined) psychosis as delusions or hallucinations."

Just because people mis-label it, that does not mean it should/is an accepted definition or meaning. That is how mis-information gets spread and dilutes are ability to accurately diagnosis disorders properly. it is EXACTLy what has happened with borderline. because people call this "psychosis" they throw anti-psychotics at these people which have absolutely no efficacy in their intrusive "psychotic symptoms". It has some data to help impulse control but that is not even what people are throwing the meds at. Mis labeling symptoms leads to mis-utilizing medications.

Your concern that we throw around the wrong words and therefore throw around the wrong meds is totally legit. Even with our revered DSM, we are diverse in how we conceptualize and treat various disorders. We call something 'psychosis' and think an 'antipsychotic' is indicated. Lots of problems there, not the least of which is the assumption that antipsychotics are in any way specific for psychosis.

Like I said before, lots of very poorly functioning borderlines I treat endorse symptoms of psychosis. These patients do NOT meet the criteria for nor fit the picture of a psychotic disorder or a classical understanding of a bipolar disorder. They are personality impaired. When they tell me they hear voices telling them that they are no good, for example (whether or not these voices are inside or outside of their heads, or whether or not they have insight into it's reality), I call it psychosis because it is delusional or hallucinatory. This is my current working model, a provisional heuristic while we make sense of the nonsense of the human psyche. I'm very happy to accept a newer and more accurate paradigm if any of you all's got one.

Now, will this non-schizophrenic, non-bipolar 'psychosis' respond to an antipsychotic? that depends on how I'm conceptualizing it's clinical utility. I do NOT think that the antipsychotic will block D2 receptors and therefore decrease psychosis. But I just might think 'maybe this neuroleptic will chemically induce a clinically useful emotional dulling (like a very mild parkinson's syndrome) and help this person obtain some functionality.' This is a drug-centered approach that is also a heuristic while we make sense of the nonsense of our psychopharmacological armamentarium.

Here's the APA guidelines for treating BPD (thanks, Kugel). http://www.psychiatryonline.com/pracGuide/pracGuideTopic_13.aspx. see what you think. clearly THEY think borderlines have psychosis and may benefit from neuroleptics.

this was long. sorry.

For now, I work from Freudenreich's premise that "Psychotic symptoms are neither specific for any disorder nor even necessarily pathologic." Some of you good folks may disagree. I await the great consilience of psychiatry.