Fun Female Patient

[Zenman1]

I'm not sure "well I also see male patients" addresses the question or, indeed, betrays any meaningful consideration of it whatsoever.

There is no question, or any consideration, unless you make it one.

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[Zenman1]

From my biased perspective, I think the psychological component is missing from the conceptualization of this case. That is what makes for a fun case in my mind. Especially with an interesting and intelligent person with a significant trauma history, I want to have her as a regular psychotherapy patient. She actually sounds like a couple of my current more successful and enjoyable cases. BTW I am one of those rare clinicians who actually enjoys working with Borderline PD and experiences good outcomes. Maybe cause I come at it with a combo of Kernberg, Linehan, and some Kohut for good measure.

Also, wanted to add no patient ever reaches optimal functioning by adjusting medications alone and in fact it can be guide the opposite. Even in my patients with Schizophrenia or Bipolar Disorder, the medication is just one piece of the picture, albeit a vital one in those cases.

She's been seeing a marriage and family therapist for quite a while. One of our psychologists has agreed to spend a block of time interviewing her and then do psych testing, vs me spending 30 minutes at a time.

 

[Crayola227]

I don't know what anyone here thinks of this, it's just an idea I came across once in a handful of papers.

It was something along the lines that they may be some comorbidity seen with BPAD and BPD. The theory put forth IIRC, was that the mood instabilities inherent in BPAD may generate coping mechanisms or behaviors often seen in BPD.

I think it was put that for this reason in addition to others, DBT might be useful in cases where the diagnosis is unclear between the two, or heck, even for patients with clear BPAD that maybe aren't all that BPD-y, but might have some issues that seem like they might be helped with it.

I've seen psychiatrists take this approach with confirmed or suspected BPAD more than once.

Just food for thought.

 

[aim-agm]

It was something along the lines that they may be some comorbidity seen with BPAD and BPD. The theory put forth IIRC, was that the mood instabilities inherent in BPAD may generate coping mechanisms or behaviors often seen in BPD.

Can you elaborate on what coping mechanisms you are describing?

Also, if DBT helps both that is suggestive but not at all reliably indicative of meaningfully shared pathology/pathophysiology. You could frame both BPAD and BPD as, among other things, involving symptoms secondary to unstable mood state. DBT could help with dealing with the unstable mood state and reduce those symptoms without any implication as to what created those states in the first place. To draw an anology, water will help with a lot of diseases that involve being volume down (e.g. Central DI, Peripheral DI, dehydration, DKA, HHC, etc.) but that doesn't say anything about why the patient is volume down.

 

[Crayola227]

Can you elaborate on what coping mechanisms you are describing?

Also, if DBT helps both that is suggestive but not at all reliably indicative of meaningfully shared pathology/pathophysiology. You could frame both BPAD and BPD as, among other things, involving symptoms secondary to unstable mood state. DBT could help with dealing with the unstable mood state and reduce those symptoms without any implication as to what created those states in the first place. To draw an anology, water will help with a lot of diseases that involve being volume down (e.g. Central DI, Peripheral DI, dehydration, DKA, HHC, etc.) but that doesn't say anything about why the patient is volume down.

Yeah, like I said, it was just a theory I ran across. Emphasis on theory. I agree that frequently we give water, cause clinical improvement, with little to no knowledge of what was the etiology of what we treated.

I thought it was an interesting theory that I thought conceptually might have merit, and might be worth review. That is all.

You make an excellent point.

 

[Salpingo]

There is no question, or any consideration, unless you make it one.

I think the question is, would you ever entitle a post “fun male patient?”

Of course you could then say that’s an irrelevant question, or simply one you don’t want to answer, but for some people it’s pertinent clinical data (and not necessarily an accusation!). I appreciate your posts/shared cases enlivening the conversation on this board (and I’m impressed this one has gone a whole 3 paged with no questions about income or post-interview communication). But just prepare yourself for us Freudian wannabes (we don’t do fun! just sex and aggression)

 

[Crayola227]

Let's face it, you wouldn't entitle it that way because we all know women are more fun than men.

 

[Zenman1]

I think the question is, would you ever entitle a post “fun male patient?”

Sure, want one? Perhaps after we run this one into the ground. Had one today but diagnosis of PTSD is not in question. He's a FBBG who I accused of being a turtle dragging along some baby turtles that need to be let go.

Of course you could then say that’s an irrelevant question, or simply one you don’t want to answer, but for some people it’s pertinent clinical data (and not necessarily an accusation!). I appreciate your posts/shared cases enlivening the conversation on this board (and I’m impressed this one has gone a whole 3 paged with no questions about income or post-interview communication). But just prepare yourself for us Freudian wannabes (we don’t do fun! just sex and aggression)

Yep, there's a reason we write, "18-year-old twice divorced Hispanic female comes in for initial interview," vs one guy (not fun but nice) just writes, "18-year-old female." Maybe that's why he finishes his notes before me!

 

[Zenman1]

Let's face it, you wouldn't entitle it that way because we all know women are more fun than men.

Oh, heck no...cough, cough.

 

[Crayola227]

I think it was enough to say "interesting patient"

The formulation of the rest of the case, when you put in identifiers such as age, ethnicity, race, marital status... starts to sound a lot less sexist and a lot more clinical.

Or am I off there? I didn't take too much offense but if we want to go there... that's my thought.

 

[Jules A]

I think it was enough to say "interesting patient"

The formulation of the rest of the case, when you put in identifiers such as age, ethnicity, race, marital status... starts to sound a lot less sexist and a lot more clinical.

Or am I off there? I didn't take too much offense but if we want to go there... that's my thought.

How about "attractive, well dressed, 30 year old cauc female". True story. In my opinion the commentary on their appeal totally unnecessary.

 

[Prometheus123]

I agree that if you try reasonable pharmacological interventions for bipolar spectrum disorders (and the Phelps site gives some good evidence-based approaches) and don't get a good amount of response, then bipolar doesn't really fit. Because most bipolar will respond to meds, but you might have to try more than one thing.

Or perhaps, more controversially, you have hit on BPD that might have some medication-responsiveness. I know this is controversial but I know there have been some studies in this area.

Rheum frequently deals with this ambiguity in dx. Sometimes you don't know exactly what it is, you try meds, and what sticks sticks. If it doesn't than and move on to something else.

Just a layman chiming in from the peanut gallery here, but I vaguely remember seeing a study that found a correlation between polymorphisms in patients with one of the bipolar spectrum disorders (I don't remember which) and patients with BPP.

 

[Crayola227]

How about "attractive, well dressed, 30 year old cauc female". True story. In my opinion the commentary on their appeal totally unnecessary.

Well dressed is of course relevant, as is hygeine. Attractive... dunno. I appreciate how mentioning if they are dressed "provocatively" etc... it makes sense to mention the choices made by patient in appearance... but the fact they were born looking good? I'm sure it has some bearing on them clinically, but... I dunno.

I wouldn't put in the "general" or the initial opening, but I think there might be clinical symptoms where it would be pertinent to mention it, but I think it's more in terms of how the patient relates to their own appearance.