Inpatient Management of Borderline PD

[BobA]

Does anyone have reading suggestions for management of Borderline PD on an inpatient psychiatric unit?

It seems like most of the literature I come across is for outpatient treatment - DBT, Mentalization, etc.

I would like to read something that would discuss how to work with patients who are help-seeking/help-rejecting, self-harming on the unit, not participating in treatment, etc. Of course, I encountered this time and time again in my training, but what I learned was mostly just by watching attendings do their work. I'm hoping to find some written material by an expert.

Thanks!

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[zenman]

Does anyone have reading suggestions for management of Borderline PD on an inpatient psychiatric unit?

It seems like most of the literature I come across is for outpatient treatment - DBT, Mentalization, etc.

I would like to read something that would discuss how to work with patients who are help-seeking/help-rejecting, self-harming on the unit, not participating in treatment, etc. Of course, I encountered this time and time again in my training, but what I learned was mostly just by watching attendings do their work. I'm hoping to find some written material by an expert.

Thanks!

I think most of the readings say discharge them fast and get them into outpatient treatment, lol!

 

[Therapist4Chnge]

You can take a DBT-informed approach by applying some of the concepts and interventions from a DBT program model....though most seem to take Option A....which is to expedite the d/c.

 

[PistolPete]

One of my attending's puts all of them on an ssri, mood stabilizer and anti psychotic. When stable and if insurance covers it, dc's to partial.

 

[SmallBird]

One of my attending's puts all of them on an ssri, mood stabilizer and anti psychotic. When stable and if insurance covers it, dc's to partial.

That's terrible!

 

[Bartelby]

That's terrible!

I know, right? Everybody knows it's an SSRI, a mood stabilizer, an antipsychotic, and klonopin that does the trick!

 

[SmallBird]

I know, right? Everybody knows it's an SSRI, a mood stabilizer, an antipsychotic, and klonopin that does the trick!

Still wrong. Yes, all of the above, plus vyvanse!

 

[PistolPete]

He's an old school attending, although quite smart. I still don't quite understand his justification for all 3 meds, but my gist is that most of the borderlines are depressed and have SI and often actual SA, so an SSRI I can understand. Mood stabilizer/lithium also. But the antipsychotic not so sure about. He once explained it to me as trying to harness the few neurons in the frontal lobe that are left to help them with impulse control, executive functioning, etc. Still not quite sure how I feel about it, but he has 20+ years more of experience than I, so that's that.

 

[splik]

He's an old school attending, although quite smart. I still don't quite understand his justification for all 3 meds, but my gist is that most of the borderlines are depressed and have SI and often actual SA, so an SSRI I can understand. Mood stabilizer/lithium also. But the antipsychotic not so sure about. He once explained it to me as trying to harness the few neurons in the frontal lobe that are left to help them with impulse control, executive functioning, etc. Still not quite sure how I feel about it, but he has 20+ years more of experience than I, so that's that.

well most borderlines are not depressed, being unable to regulate your emotions is a different thing altogether. there is no good evidence supporting the use of SRIs to treat borderline personality disorder, even less to support the use of anticonvulsants and lithium. the NICE guidelines for BPD which are quite sensible, suggest that in view of the evidence no psychiatric medications should be used in the treatment of BPD. any comorbid disorders should of course be treated as you would. whether you treat BPD with DBT, MBT, schema focussed cognitive therapy, cognitive analytic therapy, or psychoanalytic therapy seems to vary with local practice but it is not good practice! also antidepressants have no evidence in preventing suicide or suicide attempts, in fact there is more evidence for antidepressants precipitating suicidal ideation (but no evidence for increased suicides) than there is for suicide prevention!

 

[splik]

for the OP if you are more dynamically inclined:

Wishnie H. Inpatient Therapy with Borderline Patients. In: Mack JE, ed. Borderline States in Psychiatry. New York City, NY: Grune & Stratton, Inc.; 1975:41-62.

(if you pm me your email address i can send it to you)

also Adler, G. Hospital treatment of borderline patients. Am J Psychiatry 1973;130:32-36.

I also like George Vaillant's 'the beginning of wisdom is never calling a patient borderline' or something.

here we just DBT them to death.

 

[whopper]

With borderlines you lay out strict ground rules. Validate the patients but at the same time you don't give in to anything they want unless it's therapeutic.

Try to get them out of the hospital quickly unless there's a real danger to them based on an Axis I.

No benzos, no controlled substances. I've broken that rule only a few times, like maybe 10 out of thousands I've treated, so don't think the "exception to the rule" applies to 49%.

The only med I'm open to giving them is an SSRI but when I do it, I flat out tell them I'm not expecting the med to do much and that the real thing that'll get them better is DBT and taking responsibility for their lives.

My wife, who specializes in DBT pointed this out. Never ever ever tell the patient they have bipolar if they really don't. You're just making them think they need meds instead of psychotherapy. Don't ever tell them that meds are the mainstay treatment for borderline P.D. and cooperate with the DBT therapist.

The experience thing, no I wouldn't put much faith in that. DBT was not around decades ago and some docs are still under a false notion that it can be treated effectively with meds. If any case of borderline gets better with meds, it's likely not borderline and more along the lines of cyclothymia, or a real borderline who is in a honeymoon phase because the idiot psychiatrist gave the borderline a benzo, but as we all know in doing so, the borderline will then develop a tolerance to it, need/want more, and if the psychiatrist does so they're shooting the patient in the foot, if they don't do so the patient will flip out on them. This honeymoon phase will only last a few weeks.

 

[birchswing]

With borderlines you lay out strict ground rules. Validate the patients but at the same time you don't give in to anything they want unless it's therapeutic.

Try to get them out of the hospital quickly unless there's a real danger to them based on an Axis I.

No benzos, no controlled substances. I've broken that rule only a few times, like maybe 10 out of thousands I've treated, so don't think the "exception to the rule" applies to 49%.

The only med I'm open to giving them is an SSRI but when I do it, I flat out tell them I'm not expecting the med to do much and that the real thing that'll get them better is DBT and taking responsibility for their lives.

My wife, who specializes in DBT pointed this out. Never ever ever tell the patient they have bipolar if they really don't. You're just making them think they need meds instead of psychotherapy. Don't ever tell them that meds are the mainstay treatment for borderline P.D. and cooperate with the DBT therapist.

The experience thing, no I wouldn't put much faith in that. DBT was not around decades ago and some docs are still under a false notion that it can be treated effectively with meds. If any case of borderline gets better with meds, it's likely not borderline and more along the lines of cyclothymia, or a real borderline who is in a honeymoon phase because the idiot psychiatrist gave the borderline a benzo, but as we all know in doing so, the borderline will then develop a tolerance to it, need/want more, and if the psychiatrist does so they're shooting the patient in the foot, if they don't do so the patient will flip out on them. This honeymoon phase will only last a few weeks.

This is interesting advice. I had come to believe the standard was to not tell patients they had BPD. My aunt apparently now has had it for some time. She was being treated by a psychiatrist who diagnosed her with it but never told her. And they were doing DBT but didn't tell her they were. She had no idea what she had. I think she assumed bipolar since he was giving her Depakote. He eventually kicked her out of "therapy" (I am loathe to call it that because I think he had no idea what he was doing—she had romantic feelings toward him and he freaked out). She requested her medical transcripts and he refused them. Her new doctor eventually got them and that's how she found out she had been treated for BPD for a year. She was extremely open to the diagnosis and read up on it right away. One of the most self-aware people I know, so who knows how accurate the diagnosis was.

She was extremely frustrated with the situation, which I understand. Anyhow, at the time I was researching it, the information I came across online said that it was normal for psychiatrists to withhold that diagnosis. I thought it was unethical to do something like that, but I was still under the impression it was the standard of care.

 

[whopper]

Telling someone they have borderline P.D. could be good or bad. Labeling someone either has a neutral effect, a positive one because then the person understands their problem is not unique and there is treatment for it, or they feel as if they're just another number.

Should we tell someone with borderline P.D. IMHO yes, based on the western model of medical ethics. We are supposed to inform our patients. That said, if you do it, do it in the most beneficial way possible. If presented appropriately, a large amount of those that would've reacted negatively likely would not. I've noticed when I explain what the disorder is and why I believe the person has it, and I listen to the person's responses if they don't believe they have it, it helps them to accept it.

IMHO, anytime we come to an opinion on a patient that is negative upon them, I tell them my opinion as if it's an opinion and allow the patient to tell me why I might be wrong. Often I've noticed psychiatrists say something to the effect of "you have this problem," when in fact the person did not.

E.g. there was a case of Freud calling a patient homosexual when in fact he was not. When the patient protested, Freud simply told him it was resistance because he couldn't accept the truth, and the more he protested the more it proved to Freud the patient was homosexual. This in effect traps the patient into having to accept anything the provider says, and providers could be wrong. I've also noticed some psychiatrists coming to rather judgmental opinions based on counter-transference or cutting corners.

E.g. a patient that was raped 3x. While it's unlikely for a woman to raped that many times, it does happen and sometimes because of nothing the victim did. A psychiatrist could say something to the effect of "well if you've been raped 3x, that shows to me that you're doing something that's asking for this."

While no psychiatrist I've seen have said the above, I've seen psychiatrists (in fact one here did that to me years ago) accuse someone of doing something without even understanding the context of what was going on, and I used the rape example because it clarifies how this could cause damage in making assumptions that are wrong.

 

[CounselortoMD]

I know, right? Everybody knows it's an SSRI, a mood stabilizer, an antipsychotic, and klonopin that does the trick!

Where I worked for six years, we typically gave our BPD patients a huge script for Adderall IR, as well--just to complement their never-ending TID Klonopin Rx (or Xanax, naturally, if the patient preferred). Apparently, certain members of our medical staff found that this provision of copious amounts of speed throughout the day, when combined with their standing order for around-the-clock tranquilizers, was especially helpful in regulating the labile moods and emotional instabilities of our BPD patients.

Among such patients--whose mental conditions were constantly fluctuating between severe and unpredictable extremes--clearly, it made perfect sense to prescribe whopping dosages of uppers/downers all day long. Especially when you considered that the patients were also completely nonfunctional in all normal tasks of human life, and they exhibited highly erratic judgment coupled with frequent/impulsive/dangerous behavioral outbursts.

Beyond these obvious benefits, there was another very obvious perk associated with our standardized treatment approach: Once our BPD patients were successfully "maintained" on their Adderall and Xanax (with the addition, of course, of however much Ambien and MS Contin the patients demanded), we then often realized that the majority of them were actually misdiagnosed Bipolar NOS cases anyway. Problem solved, I suppose...

Finally, I might add that our patients were always quite satisfied with the medley of pills they received. Indeed, most of the time, they came back to us regularly for more.

 

[whopper]

This just goes to show you how the psychiatric adage of treat the symptoms is tenuous at best. Patients could present with a myriad of symptoms for very different reasons. Borderline can look like ADHD and or/bipolar. ADHD can look like bipolar disorder. So if I can't tell what it is, should we give the possibly bipolar disordered patient a stimulant? Using the treat the symptoms mentality yes.

This philosophy has led to a unnecessary polypharmacy.

Have I done a treat the symptoms approach? Yes, but only as a last resort, such as in TBI patients that were extremely disinhibited. When doing so, I tell the patient (or guardian) the reason why I'm doing this. e,g, "there is not much evidenced based data on exactly how to treat this," and when I use this approach I document the effect each med caused, stopping the med if there is no benefit and then not trying them on it again to prevent the polypharmacy.

I've had a few successes with this. E.g, I have a guy with a TBI who was disinhibited to the degree where he was leaving his nursing home and getting into fights with locals and then abusing opioids. Lamictal at about 400 mg got his behavior completely under control and he even told me he felt better on it. This, however, was about the 6th med I tried him on with absolutely no success on several antipsychotics and 3 seizure meds. Took about 4 months of trying several meds to get there. With each med that didn't work, I took him off and tried the next one. In the end I got him off of 3 meds that a previous psychiatrist started him on, completely off of opioids and benzos that he had been on for years.

 

[F0nzie]

I've had a few successes with this. E.g, I have a guy with a TBI who was disinhibited to the degree where he was leaving his nursing home and getting into fights with locals and then abusing opioids. Lamictal at about 400 mg got his behavior completely under control and he even told me he felt better on it. This, however, was about the 6th med I tried him on with absolutely no success on several antipsychotics and 3 seizure meds. Took about 4 months of trying several meds to get there. With each med that didn't work, I took him off and tried the next one. In the end I got him off of 3 meds that a previous psychiatrist started him on, completely off of opioids and benzos that he had been on for years.

I really like your methodical and practical approach with some of these complex patients. When there are too many drugs in the mix it's impossible to know what's working and what's not working.

 

[whopper]

Just an addendum though I think I got the point across.

I don't recommend the treat the symptoms pharmacological approach with borderlines. I do think there is some ground where a doc will have a hard time teasing it apart from cyclothymia, so I can understand some desire there to see if a med will work, but if it doesn't get them off of it after you've given it a reasonable attempt. E.g. an antipsychotic or mood stabilizer for about 1-2 months. No benefit? Get them off of it. Document it didn't work. Be upfront and don't make any promises that your pharmacological approach will definitely get them better, as this is pretty much the case with even easily diagnosable/treatable conditions.

But I've had so few cases where I couldn't tell if it was cyclothymia vs borderline.

I do think it's a reasonable approach if it's a weird case without much evidenced based data to give a direction. E.g. TBIs, extreme fetal alcohol syndrome, cases where nothing seems to be working and all the conventional meds have been tried....

I've actually, only from experience of having several patients that failed treatment on SSRIs/SNRIs, and TCAs for an anxiety disorder discover that gabapentin actually works quite well for anxiety. I wrote about it on the forum a few years ago as I was discovering this and then did several lit-searches to see if there was documentation to back it up and discovered there was. Then this got further reinforced because I've worked with some top doctors in the field and they too will use it for anxiety.

I had a guy with PTSD from being hit by lightening, all SSRIs, SNRIs, 3 TCAs, buspirone, vistaril, benadryl, 3 beta blockers, all failed, all at either maximum dosages or in the case of the BP meds at reasonable dosages for at least one month on each for the antidepressants and one week for the BP meds or antihistamines. The previous psychiatrist got this guy on mega doses of Xanax and Klonopin that he now developed a tolerance and dependence towards, and then the psychiatrist terminated him because he wasn't going to raise those meds that were already on terribly high dosages.

I gave the guy gabapentin out of desperation, the guy not only got better, we got him off all the benzos, and the nerve pain he had from the lightening was almost completely gone too. The entire process took about 2-3 months. Then on top of that his marriage, that already failed, recuperated, he remarried, and then one day he brought his son in, the kid being about ten years old, and the kid asked me"what the hell did you do to him? He's so much better!"

When I left private practice, I told the guy that he absolutely must stay on this medication regimen unless the next doctor could improve upon it and specifically gave him directions and documentation that he was tried on all the conventional meds and none of them worked. I feared the next doctor would just think "hey he needs to be on an SSRI" and the guy would have to go through that hell again.

 

[masterofmonkeys]

I've had really good results with lamictal in my patients with borderline who are also high insight. The kind of patient who gets that their PD isn't their fault, but ultimately only their hard work will overcome it, and that meds are a sort of psychiatric ibuprofen.

http://journals.lww.com/intclinpsyc...reliminary_study_of_lamotrigine_in_the.6.aspx

Also, I'm back. Smooches.

 

[Fermata]

Consistency with boundaries and limit-setting.

Honestly, I also believe it depends on your familiarity with the patient as they will appear in crisis often enough.

If they are in the community with consistent follow-up, involved in DBT, have a crisis plan, and a relatively reasonable medication regimen then sometimes an inpatient hospitalization for them becomes little more than respite.

Sometimes it seems like they wake up one day and decide that it is time for discharge (in which case I would urge you to move quickly 😀 ).

 

[notdeadyet]

Also, I'm back. Smooches.

Holy cow, there's a voice from the past. Welcome back, MoM...

 

[vistaril]

I think most of the readings say discharge them fast and get them into outpatient treatment, lol!

bingo.

 

[nitemagi]

I think there's different perceptions on what's happening when a borderline gets hospitalized.

1. Outpatient treatment is failing. Whatever's being done on the outside isn't working. So that needs to be changed. Discharging to the same isn't really seeing the big picture, but instead a turfing process - i.e. "let someone else deal with it." In this way I think we shirk our responsibilities to actually do something.

2. Obviously desperate people think the hospital is salvation and being too nice to them can reinforce the desire to be in the hospital. This perpetuates the use of the hospital as an avoidance mechanism to not have to deal with difficult emotions or situations. In that context putting them back into their life asap is an exposure mechanism.

3. Our bias towards these patients (it's not countertransference, since it's not based on our own family/historical relationship issues) colors our interest in treatment. This, combined with the refractoriness to common treatment approaches (tweak the meds), provocative nature of how they get what they want (ultimately burning relationship bridges), and financial pressures to keep in the hospital the shortest amount of time possible puts us in the position to want to do as little as possible.

And yet, if every interaction is viewed as a treatment opportunity, then perhaps we could be doing something else if we work outside the normal inpatient paradigm. I started a mini-DBT program during my old chief days at the VA (which suffers from the same revolving door as other inpatient hospitals). It was helpful.

Ultimately we should examine are WE feeding the cycle by repeatedly hospitalizing them and discharging them (giving them false hope, perhaps, or an out they always know they have). If so, then the obligation is on US to do something different. Pairing the reward of hospitalization with real work for them. Breaking the mold of our apathy and applauding actual successes and further independence.

I absolutely think the system has a flipped reinforcement system by rewarding dysfunction through attention, cutting with a holding environment, telling people to "Not" do things rather than encouraging alternatives. WE are a part of the problem. They're not fitting our contemporary psychiatric hammer-nail interventional system, so we get frustrated.

Time to broaden our toolbox and rethink the inpatient system.

 

[notdeadyet]

I find it interesting that these threads discussing hospitalization rarely mention the fact that most folks with BPD have co-morbid axis I diagnoses. Oftentimes it's manifestations of the axis I diagnosis that is actually bringing them in, but we can lose sight of that from the noise of the axis II. The boy who cries wolf every now and then sees a real wolf.

Borderline patients run the risk of getting overtreated during admission and undertreated during hospitalization.

 

[nitemagi]

I find it interesting that these threads discussing hospitalization rarely mention the fact that most folks with BPD have co-morbid axis I diagnoses. Oftentimes it's manifestations of the axis I diagnosis that is actually bringing them in, but we can lose sight of that from the noise of the axis II. The boy who cries wolf every now and then sees a real wolf.

Borderline patients run the risk of getting overtreated during admission and undertreated during hospitalization.

Which makes the most noise?

 

[BobA]

I agree with much of what's been said - treat the Axis I disorder, and keep hospitalization short. Also, I totally think we need to re-shape how we practice with these people. However, without expansion of outpatient treatment options to allow outpatient treatment and remove the rewards of inpatient treatment, , and changes in the medical liability system, there's only so much one inpatient doc can do.

In the system I'm currently practicing in, the most useful thing I've found is straight-forward skinneristic behavior plans. Cut while on the unit? Your room gets stripped and you loose all privileges, etc. Don't like these rules? you can leave (I try very very hard to keep these patients voluntary and not involuntary).

However, even here I'm sometimes over-matched. . .

Sometimes I just have to be patient and allow the longer hospitalization.

Interestingly, the commonly asserted claim that hospitalizations worsen the course of BPD is not evidence-based (as far as I can tell). It's based on (probably well-founded) expert opinion.

 

[vistaril]

I agree with much of what's been said - treat the Axis I disorder, and keep hospitalization short. Also, I totally think we need to re-shape how we practice with these people. However, without expansion of outpatient treatment options to allow outpatient treatment and remove the rewards of inpatient treatment, , and changes in the medical liability system, there's only so much one inpatient doc can do.

In the system I'm currently practicing in, the most useful thing I've found is straight-forward skinneristic behavior plans. Cut while on the unit? Your room gets stripped and you loose all privileges, etc. Don't like these rules? you can leave (I try very very hard to keep these patients voluntary and not involuntary).

However, even here I'm sometimes over-matched. . .

Sometimes I just have to be patient and allow the longer hospitalization.

Interestingly, the commonly asserted claim that hospitalizations worsen the course of BPD is not evidence-based (as far as I can tell). It's based on (probably well-founded) expert opinion.

I think you are overthinking this.....and being overly critical of yourself while also believing you can do more than you can in your role.

The reality is that you aren't going to help most of these patients. And you aren't going to hurt them either. You're just there. That's not a criticism and that's not a compliment. Inpatient psychiatrists aren't going to make any difference in the course of a borderline in almost all cases.

 

[whopper]

Where I did residency, we kicked the borderlines out--that I thought was the right thing and still do.

But the problem there was there was pretty much no DBT services in the area and despite that everyone in that system was frustrated with borderlines, no one was doing anything about it.

IMHO it was the result of intellectual incest with the department being run by attendings that all graduated from the same program where little DBT was taught and no one on the staff knew how to do it. Psychiatrists in general are terrible at DBT, yet the hospitals and local systems throw them all at us.

In effect, they kicked people out having done nothing for them except possibly even causing harm because now the borderline only had a negative experience with no DBT offered.

Where I'm at now, there are decent DBT services out there. A problem is that they're not everywhere and not everyone can get them but in this area there is actually a decent chance people could get a DBT therapist and one of the local hospitals has very good DBT therapy available. I've seen borderlines get significantly better with it. Doesn't happen overnight but typically, if a patient has a good DBT therapist, their visits to the ER/hospital go from once a month to once every 2-3 months, then every 6 months to eventually every few years, with the patient showing much better emotional regulation.

I'm not expecting psychiatrists to get trained in DBT but to at least refer borderlines out to DBT therapists.

 

[vistaril]

Where I did residency, we kicked the borderlines out--that I thought was the right thing and still do.

But the problem there was there was pretty much no DBT services in the area and despite that everyone in that system was frustrated with borderlines, no one was doing anything about it.

IMHO it was the result of intellectual incest with the department being run by attendings that all graduated from the same program where little DBT was taught and no one on the staff knew how to do it. Psychiatrists in general are terrible at DBT, yet the hospitals and local systems throw them all at us.

In effect, they kicked people out having done nothing for them except possibly even causing harm because now the borderline only had a negative experience with no DBT offered.

Where I'm at now, there are decent DBT services out there. A problem is that they're not everywhere and not everyone can get them but in this area there is actually a decent chance people could get a DBT therapist and one of the local hospitals has very good DBT therapy available. I've seen borderlines get significantly better with it. Doesn't happen overnight but typically, if a patient has a good DBT therapist, their visits to the ER/hospital go from once a month to once every 2-3 months, then every 6 months to eventually every few years, with the patient showing much better emotional regulation.

I'm not expecting psychiatrists to get trained in DBT but to at least refer borderlines out to DBT therapists.

well many people in the field(meaning dbt) will argue that individual dbt is not practical and it really needs to be a positive group setting. God knows there are a lot of therapists and psychologists marketing themselves as 'dbt therapists'(for individual therapy) but I don't know that it is really based in dbt or if it can really be as effective on an individual basis.....

 

[Psychobabbling]

I just ran into a potential snag. I'm on ECT this month, and the attending I was working with took an impromptu vacation. He stressed he wanted a thorough evaluation of every pt because even the wards are sometimes to brief with their interview. He left, and I ended up seeing one or two patients that were eventually discharged and my note was never signed by an attending lol. Anyways....

I saw one patient that is clearly borderline. He hits points 1-7 in DSM 5, doesn't self mutilate or have transient paranoia/psychosis. He has attempted suicide or made a gesture 1-2x/year. He was admitted for "major depressive disorder" and "cluster b traits." He was in DBT for nearly 2 years in the past. No one ever explained to him why he continued to feel the way he felt, why he idealized and devalued people seemingly on the flip of a dime, etc. the attending covering him ordered an ect consult for "depression." I saw him - he denied depressive symptoms, denied lethality, and was looking forward to being discharged to a group home so he could be around people.

I believe his Axis I diagnosis is (dsm 5) Persistent Depressive Disorder with Intermittent Major Depressive Episodes. Axis II is borderline. ECT has been shown to reduce depressive symptoms minimally in borderline pts, even in a MDE, and the benefits, if present, are short lasting. He has been admitted numerous times, referred for ECT by this same attending, and denied ECT each time.

Now, even after discussing with the attending that I spoke to this pt about BPD, she wants a re-consult because the PATIENT is asking for ECT. I don't know what I'm supposed to do with that. He's been on another antidepressant for.....3 days now but it's not working....so re-consult.... I spent almost 2 hours with this pt and discussed my line of thought, the likelihood of both BPD and depression playing a role with him, and the unlikelihood that ECT would be of lasting benefit. He wasn't even sure if ECT was worth it to begin with. Not sure if I'm "in the wrong" for talking about, but isn't our job to diagnose and treat? Shouldn't I be allowed to justify why ECT is NOT the treatment of choice for this guy?

(This same attending consulted us for ECT on a guy who 'claimed' he was chronically depressed, but took an "OD" because he didnt want to go back to jail and gets "depressed" for 2 days when he gets into an argument with family, and when they make up his depression "lifts")

 

[billypilgrim37]

well many people in the field(meaning dbt) will argue that individual dbt is not practical and it really needs to be a positive group setting. God knows there are a lot of therapists and psychologists marketing themselves as 'dbt therapists'(for individual therapy) but I don't know that it is really based in dbt or if it can really be as effective on an individual basis.....

This doesn't make any sense at all. Maybe you don't have good dbt therapists following the actual model, but the group participation is only one component of dbt, and by itself has never been shown to make any difference. The individual sessions with diary cards, skills practice, and a leveraged relationship are absolutely necessary. And all that requires a team for skills group, individual, live coaching, and treatment team meetings. Individual treatment without this context isn't worth a ton either. There's no evidence that individual aspects of dbt are helpful in a vacuum.

 

[whopper]

From what I've seen with patients, the difference between group and individual is tremendous, though I don't know what the evidenced based studies say. I should ask my wife since she specializes in this area.

 

[OldPsychDoc]

I just ran into a potential snag. I'm on ECT this month, and the attending I was working with took an impromptu vacation. He stressed he wanted a thorough evaluation of every pt because even the wards are sometimes to brief with their interview. He left, and I ended up seeing one or two patients that were eventually discharged and my note was never signed by an attending lol. Anyways....

I saw one patient that is clearly borderline. He hits points 1-7 in DSM 5, doesn't self mutilate or have transient paranoia/psychosis. He has attempted suicide or made a gesture 1-2x/year. He was admitted for "major depressive disorder" and "cluster b traits." He was in DBT for nearly 2 years in the past. No one ever explained to him why he continued to feel the way he felt, why he idealized and devalued people seemingly on the flip of a dime, etc. the attending covering him ordered an ect consult for "depression." I saw him - he denied depressive symptoms, denied lethality, and was looking forward to being discharged to a group home so he could be around people.

I believe his Axis I diagnosis is (dsm 5) Persistent Depressive Disorder with Intermittent Major Depressive Episodes. Axis II is borderline. ECT has been shown to reduce depressive symptoms minimally in borderline pts, even in a MDE, and the benefits, if present, are short lasting. He has been admitted numerous times, referred for ECT by this same attending, and denied ECT each time.

Now, even after discussing with the attending that I spoke to this pt about BPD, she wants a re-consult because the PATIENT is asking for ECT. I don't know what I'm supposed to do with that. He's been on another antidepressant for.....3 days now but it's not working....so re-consult.... I spent almost 2 hours with this pt and discussed my line of thought, the likelihood of both BPD and depression playing a role with him, and the unlikelihood that ECT would be of lasting benefit. He wasn't even sure if ECT was worth it to begin with. Not sure if I'm "in the wrong" for talking about, but isn't our job to diagnose and treat? Shouldn't I be allowed to justify why ECT is NOT the treatment of choice for this guy?

This, imho, is really good care on your part, and a good model of what CAN be done on an inpatient setting for BPD: safety , psychoeducation, and referral to appropriate treatment*. So many of the patients I see are coming in with "bipolar 2, cluster B traits", on three meds as "mood stabilizers", and as you say, still can't figure out why they feel the way they feel (and worse, why no one seems to really want to help them get better)--and yet they've never been told about borderline personality disorder: what it is, how they got it, how to treat it, how it can go into remission in 80% of properly treated patients without making them fat and diabetic....

*[and yes, vistaril, this really can and does help patients. The attitude that "reality is that you aren't going to help most of these patients" only perpetuates the kind of crap community care that psychobabbling describes.]

 

[whopper]

While a psychology major, I recall taking Abnormal Psychology from a professor rated as one of the best teaching profs in a very large college.

He spent the entire class talking about a patient that only said "hit me" constantly over the course of years. It turned out she had a severe dissociative disorder with borderline P.D. Her psychiatrists diagnosed her with schizophrenia, drugged her up on various meds like Thorazine, and not surprisingly she didn't get better.

The professor (a psychologist) didn't believe she had schizophrenia and engaged in psychotherapy and after about 3 months of only hearing "hit me" she finally started giving him more content. After several months he got her to the point where he was able to she was able to have coherent conversations with him and he was able to dig out of her that she was severely abused as a child.

During that entire time, the psychiatrist on the case kept chiding this psychologist, telling him he was a fool for pursuing his line of therapy.

This burned into my brain the often-times proven mental model that so many doctors employ that an illness is simply something to be diagnosed and treated with a pill as if it's a fast food production line.

Your post reminded me of the above case.

 

[vistaril]

And all that requires a team for skills group, individual, live coaching, and treatment team meetings. .

yeah I don't do dbt(or have any interest in doing so) so I'll take your word for it.....but where are all these resources(for most patients) supposed to be coming from? How is the treatment team billed? Bundled i guess? There is one person in private practice in this area who fancies herself a borderline specialist and does individual work, but she charges cash, doesn't take insurance, and is about as likely to participate in bundled billing as I would be to buy a smartcar.

 

[vistaril]

This, imho, is really good care on your part, and a good model of what CAN be done on an inpatient setting for BPD: safety , psychoeducation, and referral to appropriate treatment*. So many of the patients I see are coming in with "bipolar 2, cluster B traits", on three meds as "mood stabilizers", and as you say, still can't figure out why they feel the way they feel (and worse, why no one seems to really want to help them get better)--and yet they've never been told about borderline personality disorder: what it is, how they got it, how to treat it, how it can go into remission in 80% of properly treated patients without making them fat and diabetic....

*[and yes, vistaril, this really can and does help patients. The attitude that "reality is that you aren't going to help most of these patients" only perpetuates the kind of crap community care that psychobabbling describes.]

I can only speak for the borderlines I have seen as inpatients, but every single one has been told they have borderline personality disorder(of the ones who obviously do) by the time they are discharged(and most several times on previous hospitalizations). Additionally, they are told(and usually have been told multiple times in the past) that tweaking their mood stabilizers or antipsychotics aren't going to 'make them better'. I haven't seen a shortage of education on the matter on inpatient units.

 

[nitemagi]

I can only speak for the borderlines I have seen as inpatients, but every single one has been told they have borderline personality disorder(of the ones who obviously do) by the time they are discharged(and most several times on previous hospitalizations). Additionally, they are told(and usually have been told multiple times in the past) that tweaking their mood stabilizers or antipsychotics aren't going to 'make them better'. I haven't seen a shortage of education on the matter on inpatient units.

And therein lies a bit of the problem. If we imagine ourselves as someone with Borderline PD, and we tell them "we don't have anything that will help" without giving any other leads on a direction to go, we're essentially telling them "you're doomed." The data on people with Borderline PD is quite the contrary. Longitudinally, they get better. They learn more adaptive coping mechanisms over years or decades. Turfing them means they have to figure it out on their own.

I'm not saying every psychiatrist needs to know DBT, but I am saying if all you have is psychopharm, and even you don't believe that's helpful to these patients, then you either need more training or get out of the way [ie send them somewhere that might help].

If a surgeon in a community hospital has no experience in trauma surgery, and a group moves in that drives up the shootings, he'd best figure out some way to help. Because he's going to be facing it one way or another. He can't just throw up his hands and say "I don't know how to deal with that." Bring in outside expertise, or get more training.

The argument that "WE [psychiatrists]" shouldn't be treating personality disorders is misguided, IMHO. We're supposed to be the experts in the severely mentally ill. They tried passing the buck in the UK for a while, and the government ended up mandating them to treat, because there's no one else. I'd just as soon not be on the front lines with suicide evaluations or anything else, but that's part of the job, to meet society's need in that area.

Just some thoughts on the devil's advocate side.

 

[vistaril]

And therein lies a bit of the problem. If we imagine ourselves as someone with Borderline PD, and we tell them "we don't have anything that will help" without giving any other leads on a direction to go, we're essentially telling them "you're doomed." The data on people with Borderline PD is quite the contrary. Longitudinally, they get better. They learn more adaptive coping mechanisms over years or decades. Turfing them means they have to figure it out on their own.

I'm not saying every psychiatrist needs to know DBT, but I am saying if all you have is psychopharm, and even you don't believe that's helpful to these patients, then you either need more training or get out of the way [ie send them somewhere that might help].
.

I'm more than happy to 'get out of the way'.....the problem is, depending on their resources, there isn't anyone who really knows what they are doing either. And there certainly isn't some large network of integrated care that is going to make it all happen. I refer them to therapists and groups, It's not they are seeing Marcia Linehan here. And yeah it's not like my cbt patients are seeing aaron beck, but it seems that the people in the community who can do competent cbt(or something vaguely based in cbt) are about 100 times more common than people in the community who can do dbt for a non self pay population.

And yes I do know that some borderlines have their symptoms blunted over time.... But it's a huge mistake to assume that all(or even many) of them got excellent mental health services in treating their illness. Some did, but over decades a lot of stuff is bound to change....that doesn't necessarily mean they had great care at some point to 'fix' them.

And getting more training to get learn dbt is just not something I'm interested in or willing to do. And even if I did, I'm not sure how it would help many of the patients I try setting up outpt care as they wouldn't be able to pay for my services anyway.

 

[whopper]

And getting more training to get learn dbt is just not something I'm interested in or willing to do. And even if I did, I'm not sure how it would help many of the patients I try setting up outpt care as they wouldn't be able to pay for my services anyway.

IMHO it's not cost-effective for psychiatrists to do DBT themselves. I do believe psychiatrists need to be good in psychotherapy because at the very least we need to work with psychotherapists if not do it ourselves.

But the fact of the matter is one psychotherapist gets a borderline patient better over the course of several several months. If a psychiatrist treated only borderline patients, I'm talking on the order of maybe around a few dozen tops could that doctor carry due to the fact that these patients are extremely high maintenance, and that same doc could've otherwise seen and effectively treated hundreds to thousands of other patients and gotten them better in a manner of days to weeks. Further, that doc would hardly be using any of the skills learned in medschool and residency. DBT doesn't require medical training. It is a waste of over 10 years of training for a psychiatrist to simply do DBT.

So should a psychiatrist know DBT? Yes because if we want borderlines to get better and have some, we need to be able to work work with DBT therapists, requiring we have at least a fundamental knowledge of it.

And now pointing the finger at our own profession, even a fundamental framework of DBT isn't being taught in most residencies, and most psychiatric programs of any sort (residency, community mental health programs, etc) don't do any DBT or their DBT providers are nowhere near enough. Like I've said, psychiatrist shouldn't expect to do DBT, but we should at least be able to refer the patient to a DBT therapist and in most cases psychiatrists can't even do that.

 

[vistaril]

Like I've said, psychiatrist shouldn't expect to do DBT, but we should at least be able to refer the patient to a DBT therapist and in most cases psychiatrists can't even do that.

why(assuming the resources were there in terms of providers and pt access to them) couldn't we? I don't know how to do dbt, but I know how to pick up on borderlines. So why do I need to have some great foundation in understanding dbt to know to refer to dbt?

 

[whopper]

You didn't get my point but it could be because I didn't explain it well enough.

Many psychiatrists don't refer out to DBT therapists because...
1) There are no DBT therapists in the area
2) The DBT therapist is there but doesn't accept the form of payment the patient has
3) the psychiatrist, for whatever reason, knows the patient has borderline, but won't refer out.

And as asinine #3 is, there's plenty of docs that don't refer out. Why I don't know. I'm the only doc I know if in the PES I work in that actually tells the residents to refer borderlines to a DBT therapist. My theory is psychiatrists have this unofficiated idea that they're not supposed to treat it, so therefore end of story despite that it is a psychiatric disorder.

Where I did residency, no one was referred to a DBT therapist. No one. Complaints of borderlines were a dime a dozen but no one ever referred one of them during my four years there. NOT EVEN ONE.

Where I'm at, reason #1 and 2 aren't excuses cause the DBT therapists in this area accept a wide-array of payments from medicare/medicaid, private insurance, and out of pocket.