How to approach teenage girls who are cutting?

[DisorderedDoc417]

I feel like whenever I see a teenage girl who is cutting to feel things or release tension, she always gets a diagnosis of Borderline Personality Disorder regardless of whether or not she actually meets criteria based on symptoms.

In teenagers, I generally don’t slap on the Dx in the first meeting given proving chronic and enduring is kind of a heavy burden to meet on someone who is so young. Better to note provisional with cluster b traits. Unfortunately around this area it is hard to get insurance to pay for dbt unless they have the dx.

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[clausewitz2]

I feel like whenever I see a teenage girl who is cutting to feel things or release tension, she always gets a diagnosis of Borderline Personality Disorder regardless of whether or not she actually meets criteria based on symptoms.

This is poor reasoning. Self-harm is in no sense pathognonmic for BPD. Of course it should raise your prior somewhat, but you are going to miss a lot and misclassify a lot of people. It is frankly sloppy in a way that is very hard to justify. Self-harm in response to stress is observed in a number of animals, including rats. This suggests that it is a fairly conserved behavior across mammals, most of who do not have BPD.

 

[Nasrudin]

This is poor reasoning. Self-harm is in no sense pathognonmic for BPD. Of course it should raise your prior somewhat, but you are going to miss a lot and misclassify a lot of people. It is frankly sloppy in a way that is very hard to justify. Self-harm in response to stress is observed in a number of animals, including rats. This suggests that it is a fairly conserved behavior across mammals, most of who do not have BPD.

Good point. And while I don't disagree. I think there's an aversion to calling a thing the quacks, walks on paddles, and lives in ponds.... a duck. But not in the classification clarity sense. More in the stop with the overmedicating a bunch of mood complaints when you're obviously dealing with more stable, unstable behaviors over time, that may appear dramatic at one particular presentation. But it's not like it's that difficult to obtain a relational and social/work functioning hx. Or a pattern of emotional experience interpretation that demonstrations externalization tendencies and so forth. So that identifying a provisional proximal phenomenon can direct care more effectively.

I think the problem with the training resident experiencing confusion about this coming up in a medical model for which nosology of classification as it pertains to psychiatric dx's is entirely f'd from it's first premises on up. No conceptual clarity comes from pursuing it, except by more pragmatic humility of knowing what something is not, so that treatment doesn't go from marginally helpful to shamelessly harmful.

That and there is an inherent cultural bias that care, empathy, and more of these, is what people need. When quite often they need boundaries of effective care seeking, feedback on what are effective relational strategies, a brief period of reflection on worse consequences of their behavior, i.e. getting admitted to a psychiatric ward, and some brief exercises in emotional regulation, while resonating calm and strength and stability in their proximal environment. DBT participation is a point along their way to self regulation that they may be at or not. MI regarding this was a good idea. And Linehan makes ample use of this type of strategy in her approach, so. Beginning that is always good even in an acute setting.

OP you could always just look pragmatically at what options for care you have to offer and try to think in a common sense manner about what would actually benefit the patient among these. Then, if you have time, try to determine how many times both yourself and the people around you are treating their own "guilt" or anxiety or sense of moral superiority by being an "empathetic" clinician, rather than helping anyone do anything better. including the poor emotionally laden person you saw.

 

[SeniorWrangler]

"Some psychologists have hypothesized that EMDR actually desensitizes people to the traumatic material and thus is related to exposure therapy. A more accurate description is that it integrates the traumatic material." (2015, Van der Kolk, "The Body Keeps the Score")



This is more a dogmatic underpinning of Western psychiatry than an actual scientific fact.

For one. one can directly observe in a PET or ffMRI scan that during a flashback or dissociative episode, the right amygdala + associated limbic regions are hyperactivated, but the left MPFC and the left hemispheric speech centers are hyperinhibited.

Patients with a history of trauma have an underactivated and underconnected default mode network. Traumatic experience and sympathetic hyperarousal not only inhibits many DMN structures required for cognitive processing of experience, such as the MPFC and anterior cingulate, but also the thalamus and hippocampus.

Retrieval of traumatic memory is thus often disorganized and involves fairly noncognitive regions and fragmented sensory information. CBT and talk therapy engage the DLPFC, which has no direct connection with the amygdala or even other limbic regions, while engaging the median prefrontal cortex rather poorly, which actually has a direct connection to the the amygdala. EMDR and other somatic forms of therapy work because they activate the MPFC, the amygdala and limbic regions simultaneously in ways that talk therapy and CBT do not. Furthermore, Van der Kolk, who leads the Trauma Center in Boston, argues that traumatic imprints are stored in noncognitive circuits poorly accessed by cognitive therapy but more easily accessed by somatic therapies.

Are you sure the core issues are always influenced by the cognitions?

citations

1. A.F. Arnsten, et al. "α-1 Noradrenergic receptor stimulation impairs prefrontal cortical cognitive function.," Biological Psychiatry 45, no. 1 (1999) 26-31.
2. Y.D. "Van der Werf et al." "Special Issue: Contributions of thalamic nuclei to declarative memory functioning," Cortex 39 (2003); 1047-62.
3. B.M. Elzinga and J.D. Bremner, "Are the neural substrates of memory the final common pathway in Post-traumatic Stress Disorder (PTSD)?" Journals of Affective Disorders 70 (2002) 1-17
34 L, M. Shin, et al., "A functional magnetic resonance imaging study of amygdala and medial prefrontal cortex responses to overtly presented fearful faces in Post-traumatic Stress Disorder," Archives of General Psychiatry 62 (2005) 273-81
5. L, M. Williams et al. "Trauma modulates amygdala and medial prefontal responses to consciously attended fear," NeuroImage 29 (2006) 347-57
6. R. A. Lanius, et al. "Brain activation during script-driven imagery-induced dissociative responses in PTSD: a functional magnetic resonance imaging investigation," Biological Psychiatry 52 (2002): 305-11
7. J.E. LeDoux, "Emotion Circuits in the Brain," Annual Review of Neuroscience 23, no. 1 (2000): 155-84.
8. J.E. LeDoux: "Extinction of Emotional Learning: Contribution of Medial Prefrontal Cortex," Neuroscience Letters 163, no. 1 (1993): 109-113

That's a whole lot of conjecture based on some connectivity studies and BOLD imaging studies. I've seen a lot of lovely theories germinate, bloom, and die based on this.

Here's a good article on the subject with no imaging but that I've found very helpful:

Vaillant, George E. "The beginning of wisdom is never calling a patient a borderline; or, the clinical management of immature defenses in the treatment of individuals with personality disorders." The Journal of psychotherapy practice and research 1.2 (1992): 117.