Idiot Premed Question About Lithium

[tetaoh]

---

Members don't see this ad.

During a recent shadowing experience I observed a longtime patient of the psychiatrist who was on high dose of lithium (1200 mg, is that high, I don’t really know?), synthroid and vistaril as needed. Official diagnosis was borderline personality disorder. The patient was one of the psychiatrist’s favorites because she had been in such good shape for a long time (after first hospitalization due to suicide attempt, after starting antidepressant) and was such a likable character. The patient was in CBT therapy but did not sound like she ever participated in DBT.

I’m a bit confused why someone with borderline personality disorder would show treatment response to lithium and get better without DBT. My limited understanding on the subject was that lithium was a mood stabilizer that was not well tolerated by people without bipolar disorder especially at those dosages. I thought that if you were to give a dose of lithium like that they would either feel ill (sluggish, tired) if they did not have the disorder, or better if they did have bipolar disorder. Have I learned a totally oversimplified version of how lithium works for bipolar and borderline personality disorder?

Please forgive the naïve premed question!

 

[vistaril]

During a recent shadowing experience I observed a longtime patient of the psychiatrist who was on high dose of lithium (1200 mg, is that high, I don’t really know?), synthroid and vistaril as needed. Official diagnosis was borderline personality disorder. The patient was one of the psychiatrist’s favorites because she had been in such good shape for a long time (after first hospitalization due to suicide attempt, after starting antidepressant) and was such a likable character. The patient was in CBT therapy but did not sound like she ever participated in DBT.

I’m a bit confused why someone with borderline personality disorder would show treatment response to lithium and get better without DBT. My limited understanding on the subject was that lithium was a mood stabilizer that was not well tolerated by people without bipolar disorder especially at those dosages. I thought that if you were to give a dose of lithium like that they would either feel ill (sluggish, tired) if they did not have the disorder, or better if they did have bipolar disorder. Have I learned a totally oversimplified version of how lithium works for bipolar and borderline personality disorder?

Please forgive the naïve premed question!

1200mg is not a very high daily dose of lithium. It's pretty typical.

Also, there are studies showing that Lithium decreases suicidality, suicide completion, and many think it decreases impulsive behavior in general(independent of mood stabilization). Im guessing thats why the patient was put on Lithium.

As for how someone out there in many practices gets labeled borderline and not bipolar(or vice versa)....you got me. Reliability of dx between different psychiatrists for such presentations is very very poor.

 

[tetaoh]

That's interesting about the other effects of lithium, besides mood stabilization.

Given that lithium decreases those behaviors commonly associated with bpd, why isn't it more of a first line treatment for borderline? I thought it was either therapy and/or SSRI in treatment of bpd, not lithium.

 

[nitemagi]

That's interesting about the other effects of lithium, besides mood stabilization.

Given that lithium decreases those behaviors commonly associated with bpd, why isn't it more of a first line treatment for borderline? I thought it was either therapy and/or SSRI in treatment of bpd, not lithium.

The risk:benefit ratio may be higher with lithium, depending on the level of impairment. Some BPD pt's do just fine with an SSRI.

 

[vistaril]

That's interesting about the other effects of lithium, besides mood stabilization.

Given that lithium decreases those behaviors commonly associated with bpd, why isn't it more of a first line treatment for borderline? I thought it was either therapy and/or SSRI in treatment of bpd, not lithium.

Lithium is a drug with more side effects than ssris overall. It can can cause weight gain, drowsiness and sometimes a feeling of cognitive dulling, hypothryoidism, and renal dysfunction(both acute and chronic). There is also the problem of lithium sometimes becoming supratherapeutic/toxic. If I had to pick one thing from lithium I would like to eliminate in a fantasy world I would pick the chronic renal issues that pop up in a non-trivial number of patients.

There are a lot of different lines of thought on bpd....you'll see other mood stabilizers like tegretol used a lot as well. Lamictal too. There is a well known paper out that argues you should target pharmacotherapy in BPD depending on where the heaviest symptom burdens are(which could mean antipsychpotic, antidepressent, or mood stabilizers).

The fact that there is so much different stuff out there and so many different drug arguments tells me one thing- none of it is much good.

 

[michaelrack]

I thought that if you were to give a dose of lithium like that they would either feel ill (sluggish, tired) if they did not have the disorder, or better if they did have bipolar disorder.

Please forgive the naïve premed question!

The side effects of a medication (feeling sluggish, tired in the case of Li) have little to do with the disorder you are treating with it.

 

[Salpingo]

During a recent shadowing experience I observed a longtime patient of the psychiatrist who was on high dose of lithium (1200 mg, is that high, I don't really know?), synthroid and vistaril as needed. Official diagnosis was borderline personality disorder. The patient was one of the psychiatrist's favorites because she had been in such good shape for a long time (after first hospitalization due to suicide attempt, after starting antidepressant) and was such a likable character. The patient was in CBT therapy but did not sound like she ever participated in DBT.

I'm a bit confused why someone with borderline personality disorder would show treatment response to lithium and get better without DBT. My limited understanding on the subject was that lithium was a mood stabilizer that was not well tolerated by people without bipolar disorder especially at those dosages. I thought that if you were to give a dose of lithium like that they would either feel ill (sluggish, tired) if they did not have the disorder, or better if they did have bipolar disorder. Have I learned a totally oversimplified version of how lithium works for bipolar and borderline personality disorder?

Please forgive the naïve premed question!

With regards to DBT vs. CBT, there are a couple of issues at play.

The fact that your preceptor has such positive regard for the patient is fairly telling. For all you know, the patient is a total mess at home, but adores the positive reception she gets for being the model patient, and may be underreporting her symptoms significantly. Not saying this is the case, but if you're interested in psychiatry, this is the type of countertransference you should always be aware of, especially with BPD, and its the easiest way to get split.

Second, when really studied in-depth (i.e. randomized control trials), the modality of therapy doesn't seem to be much of a factor in outcome. While borderline --> DBT is usually the right answer on an exam, the most important element is a strong therapeutic rapport/relationship. That being said, DBT was originally developed as a treatment for a symptom of some borderlines: self-destructive acts, typically cutting. That's what much of the literature uses as an endpoint, although it also has some benefit in reducing rehospitalizations. There's a lot of self-soothing and mindfulness to replace those self-destructive urges, but that doesn't mean a CBT therapist can't target these symptoms as well.

 

[notdeadyet]

It's also worth noting that DBT is not the panacea it's sometimes made out to be. While it's invaluable with the right patient, it bears repeating that it requires WORK to be effective. Many BPD patients, on a particular admission, are not going to be good candidates for it.

 

[tetaoh]

Thanks for all the great explanations about lithium and DBT vs CBT. Really interesting stuff and seemingly very complex.

The other thing that threw me for a loop (again, because I don't know anything about anything at this point) is the hospitalization soon after she started an SSRI. I thought that sort of thing was associated more with bipolar - start someone with undiagnosed bipolar on an SSRI and they more often then not go into a mixed or manic state. And this particular patient seemed to fit that model though I'm sure I'm just over analyzing it.

I guess my question would be, is it true that if a patient gets suicidal and/or has a mixed episode soon after starting an antidepressant, that they are likely bipolar? Or could it happen to anyone, just a lot more likely in the case of a mood disorder? Or is the mixed state post-antidepressant thing just a myth I mis-absorbed from SSRI black box warnings?

 

[tetaoh]

With regards to DBT vs. CBT, there are a couple of issues at play.

The fact that your preceptor has such positive regard for the patient is fairly telling. For all you know, the patient is a total mess at home, but adores the positive reception she gets for being the model patient, and may be underreporting her symptoms significantly. Not saying this is the case, but if you're interested in psychiatry, this is the type of countertransference you should always be aware of, especially with BPD, and its the easiest way to get split.

Second, when really studied in-depth (i.e. randomized control trials), the modality of therapy doesn't seem to be much of a factor in outcome. While borderline --> DBT is usually the right answer on an exam, the most important element is a strong therapeutic rapport/relationship. That being said, DBT was originally developed as a treatment for a symptom of some borderlines: self-destructive acts, typically cutting. That's what much of the literature uses as an endpoint, although it also has some benefit in reducing rehospitalizations. There's a lot of self-soothing and mindfulness to replace those self-destructive urges, but that doesn't mean a CBT therapist can't target these symptoms as well.

So is cutting pretty much always associated with BPD and not bipolar? Thinking back the patient had been a cutter prior to going on lithium. So maybe that's why the BPD diagnosis was so cut and dry?

 

[OldPsychDoc]

I don't think it's that difficult to make a diagnosis of Borderline PD--the DSM makes it pretty clear, and frankly the only things it has in common with Bipolar Affective Disorder is the instability of mood, which if you take a careful history and have seen a few solid cases of each, is pretty easy to distinguish in quality and pattern from a true mood disorder, and the impulsive actions--which are also generally quite different in quality.

What is difficult is caring enough to TELL the patient what their diagnosis is--and phrase it as a good thing. So which would you rather have--a difficulty regulating your emotions that you can learn to control, with time and effort, and which will be in remission in 10 years for 80% of people with that diagnosis, or an incurable disorder that will recur throughout your lifetime and which can only be treated with toxic chemicals?

 

[michaelrack]

I guess my question would be, is it true that if a patient gets suicidal and/or has a mixed episode soon after starting an antidepressant, that they are likely bipolar? ?

no, yes

 

[billypilgrim37]

So is cutting pretty much always associated with BPD and not bipolar? Thinking back the patient had been a cutter prior to going on lithium. So maybe that's why the BPD diagnosis was so cut and dry?

Cutting can be associated with many diagnoses. It's common in BPD.

 

[strangeglove]

While lithium has anti-suicide effects, it can also be quite lethal in overdose, so it should not be an automatic suicidal=lithium choice, especially in highly impulsive patients.

 

[shan564]

OP - I think you've stumbled across a general concept that most of us don't learn until med school.

There's a reason why computers can't be doctors. The reason is because signs, symptoms, and management plans are not objective. You can't say "if this patient does X, then the best treatment is Y"... and that's especially true in psychiatry. Usually, these decisions (such as your lithium question and your SSRI/hospitalization question) are made based on extensive knowledge of that particular patient, a strong understanding of how people usually respond to these drugs, etc. So if you really want to know why your supervisor followed those particular management plans, you have to ask your supervisor... and if he/she is a good doctor, then there will likely be specific reasons why this patient has been treated in a way that's not necessarily consistent with the textbooks.

And that's the purpose of clinical rotations in med school. When I first started 3rd year, I was just trying to learn all of the basics of management. Then I realized that I can learn that stuff from textbooks, and I should use my clinical rotations to learn about how different doctors approach different problems and make decisions. It's not about knowing the right answers, but rather about asking the right questions. Rather than "why is lithium used in some patients with BPD?", the right question is "why did you choose to use lithium in this patient?"

Patient gets suicidal and/or has a mixed episode soon after starting an antidepressant, that they are likely bipolar? Or could it happen to anyone, just a lot more likely in the case of a mood disorder? Or is the mixed state post-antidepressant thing just a myth I mis-absorbed from SSRI black box warnings?

The SSRI black box warnings are a bit confusing. Yes, patients are at increased risk of suicide after taking the SSRI. The nature of this risk isn't too well-understood, but many experts think that a large part of it is the fact that the SSRI gives you your motivation back, and lack of motivation is a big thing that stops depressed patients from completing suicide. Then after a few weeks, their mood improves, so they're no longer at risk of suicide due to the increased motivation.

So in other words, suicidality after starting an SSRI is not related to bipolar disorder. It can happen to anybody.

That said, triggering a manic/mixed state IS suggestive of bipolar disorder. Although I don't know if I'd say that it's "more likely than not." But I've only been a doctor for a few weeks... maybe a real expert can correct me.

 

[vistaril]

OP - I think you've stumbled across a general concept that most of us don't learn until med school.

There's a reason why computers can't be doctors. The reason is because signs, symptoms, and management plans are not objective. You can't say "if this patient does X, then the best treatment is Y"... and that's especially true in psychiatry. Usually, these decisions (such as your lithium question and your SSRI/hospitalization question) are made based on extensive knowledge of that particular patient, a strong understanding of how people usually respond to these drugs, etc. So if you really want to know why your supervisor followed those particular management plans, you have to ask your supervisor... and if he/she is a good doctor, then there will likely be specific reasons why this patient has been treated in a way that's not necessarily consistent with the textbooks.

And that's the purpose of clinical rotations in med school. When I first started 3rd year, I was just trying to learn all of the basics of management. Then I realized that I can learn that stuff from textbooks, and I should use my clinical rotations to learn about how different doctors approach different problems and make decisions. It's not about knowing the right answers, but rather about asking the right questions. Rather than "why is lithium used in some patients with BPD?", the right question is "why did you choose to use lithium in this patient?"
QUOTE]

this is the kind of rationalization that can always be used to justify sloppy lazy practices.....that's not to say that individualizing treatment isn't important in psychiatry, but far too often this is given as justification for lazy sloppy psychiatry.

 

[shan564]

this is the kind of rationalization that can always be used to justify sloppy lazy practices.....that's not to say that individualizing treatment isn't important in psychiatry, but far too often this is given as justification for lazy sloppy psychiatry.

I was actually thinking about that too, but I didn't want to accuse the OP's supervisor of being lazy/sloppy...

 

[tetaoh]

I was actually thinking about that too, but I didn't want to accuse the OP's supervisor of being lazy/sloppy...

Don't worry, she Isn't my supervisor. It was just a one day shadowing experience - which is partly why I wasn't able to ask all of the follow up questions I would like. Henceforth me bugging you guys.

Thanks for all the great replies, they were really helpful.