Interesting popular press article on remitted/misdiagnosed (?) bipolar disorder

[futureapppsy2]

I Built My Identity Around Being Bipolar. Then My Doctor Said I’m Not Bipolar

What happens when what’s wrong with you isn’t what’s wrong with you?

www.phillymag.com

Thoughts?

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[wolfvgang22]

I Built My Identity Around Being Bipolar. Then My Doctor Said I’m Not Bipolar

What happens when what’s wrong with you isn’t what’s wrong with you?

www.phillymag.com

Thoughts?

I think it's a good article, good food for thought. I've had many such patients I've inherited from other psychiatrists who were diagnosed in the 1990s through 2010 when Bipolar was a very popular diagnosis. It has caused me to take my time as an outpatient psychiatrist in diagnosis and keep an open mind, knowing sometimes patients don't fit into our nice little DSM check box diagnoses all the time, and sometimes both the treatment team and the patient need time to gather all the information that may not be immediately obvious to any party.

I recently received a patient diagnosed with bipolar who experienced mania after consuming large quantities of energy drinks and having associated mania and psychosis and subsequent hospitalization. I don't completely blame the psychiatrist at the time for diagnosing bipolar mania, given the information he had, and the difficulty level of trying to diagnoses this patient in just a couple of brief meetings. Now, several months later, I believe the patient has severe MDD and complex comorbid personality issues, and mania has not returned in the absence of stimulants and depression has improved some with rTms. I am still in the process of investigating what precisely has been going on with this patient since childhood, and treating sympotomatically. I suspect an eating disorder as well, but getting the information from the patient and family has been slow and challenging due to family and patient dynamics. The pace of our overloaded and short staffed clinic is unfortunately a barrier to untangling this complex case.

As a result of such experiences, I am increasingly open and honest with my patients about my confidence level in their diagnosis and emphasize the collaborative nature of mental health evaluation and treatment. I advise them our science is still quite young and investigational, and make sure to get full informed consent with any treatment. I recognize that many patients don't deal well with uncertainty, but this is life. Some people are tragically not ready to receive certain aspects of treatment. This is nobody's "fault." We are still learning.

 

[Neuro111]

Roses are red,
Violets are blue,
You're schizoaffective,
And so am i.

 

[wolfvgang22]

Roses are red,
Violets are blue,
You're schizoaffective,
And so am i.

Are you schizoaffective if you do not experience mood instability or psychosis without medication for months or years? Conventional wisdom says patients who have experienced severe symptoms of serious mental illness like bipolar, schizophrenia, or schizoaffective need to be on medication for the rest of their lives to prevent recurring symptoms. In such cases is the initial diagnosis always wrong, or is it a little more complex than that?

 

[splik]

In such cases is the initial diagnosis always wrong, or is it a little more complex than that?

I hate this kind of circular reasoning where people claim someone couldn't have had schizophrenia or bipolar disorder if they have done well off meds. Even in the days of Kraepelin when there werent medications that helped, many patients did fine for 20+ years without recurrence of illness. There is a certain confirmation bias at play - the patients who get well, stay the hell away from psychiatry and so its the people who keep coming back when they stop their meds that we see that plays into this nonsense. As many on this forum know, I hold the minority opinion that most people with severe mental illness do not need long-term medications, and also believe we are doing tremendous harm to patients by exposing them long-term to toxic drugs they don't need. As I have a specialized practice now, I don't treat these patients but I have treated pts with bipolar disorder and schizophrenia with intermittent medications (i.e. during acute episodes) or without meds in the past. I also think psychotherapy, lifestyle modifications, nutrition, physical activity etc are woefully underutilized in treating patients with serious mental illness.

Obviously, I am not discounting that some pts do need lifelong/long-term medications (for instance, I would not advocate that insanity acquittees go off their meds) but the flawed paradigm of condemning people to a lifetime of medication due to risk aversion is dangerous and there is no good data to support the use of long-term meds for the majority of patients.

 

[When is graduation again?]

I hate this kind of circular reasoning where people claim someone couldn't have had schizophrenia or bipolar disorder if they have done well off meds. Even in the days of Kraepelin when there werent medications that helped, many patients did fine for 20+ years without recurrence of illness. There is a certain confirmation bias at play - the patients who get well, stay the hell away from psychiatry and so its the people who keep coming back when they stop their meds that we see that plays into this nonsense. As many on this forum know, I hold the minority opinion that most people with severe mental illness do not need long-term medications, and also believe we are doing tremendous harm to patients by exposing them long-term to toxic drugs they don't need. As I have a specialized practice now, I don't treat these patients but I have treated pts with bipolar disorder and schizophrenia with intermittent medications (i.e. during acute episodes) or without meds in the past. I also think psychotherapy, lifestyle modifications, nutrition, physical activity etc are woefully underutilized in treating patients with serious mental illness.

Obviously, I am not discounting that some pts do need lifelong/long-term medications (for instance, I would not advocate that insanity acquittees go off their meds) but the flawed paradigm of condemning people to a lifetime of medication due to risk aversion is dangerous and there is no good data to support the use of long-term meds for the majority of patients.

This is something I've been curious about actually because the literature I've read on first break psychosis states that it is more likely that people who discontinue treatment will relapse. But the number referenced was 50%, which would indicate that the other 50% of patients did fine with interrupting antipsychotic medication after they were in recovery. I've also seen it mentioned that, while continuing antipsychotics is associated with decreased release in the short-term (<3 y), in the long-term (7 years+) the relapse rates between the groups are equivalent. However, function and recovery rates were improved in the groups that had reduction/discontinuation of antipsychotics.

I've had a hard time rectifying how this conflicts with standard practice, but I guess that's just something I'll have to explore further during my outpatient years and post residency.

 

[downwithDTB]

This is something I've been curious about actually because the literature I've read on first break psychosis states that it is more likely that people who discontinue treatment will relapse. But the number referenced was 50%, which would indicate that the other 50% of patients did fine with interrupting antipsychotic medication after they were in recovery. I've also seen it mentioned that, while continuing antipsychotics is associated with decreased release in the short-term (<3 y), in the long-term (7 years+) the relapse rates between the groups are equivalent. However, function and recovery rates were improved in the groups that had reduction/discontinuation of antipsychotics.

I've had a hard time rectifying how this conflicts with standard practice, but I guess that's just something I'll have to explore further during my outpatient years and post residency.

Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy: long-term follow-up of a 2-year randomized clinical trial - PubMed

isrctn.org Identifier: ISRCTN16228411.

www.ncbi.nlm.nih.gov

Your memory of the above study is way off... They randomized first breakers treated to remission for 6 months (highly selected group) to maintain dose or try a taper strategy for 18 months... after that it was doctor's discretion. The taper would stop if the patient got worse. After 3 years, the taper group relapsed more but the overall relapse rate after 7 years was equal, with around 2/3 relapsing at least once. < 10% were able to discontinue antipsychotics.

The taper group, however, did show higher (but less than 50%) rates of 6 month remission at 7 years and were on lower doses.

Take homes: A very small number of people might come off antipsychotics after a first break successfully. Many of these drugs have wicked long half lives and maintaince dose can be way lower than hospital doses (2-3 mg of haldol). Trying to taper down antipsychotics is worth it if someone achieves remission for 6 months but they will probably not come off completely.

Remember, each relapse comes with a risk of job loss, family loss and prison time, never mind the literature on duration of untreated illness.

The author above likely had an identity disturbance if she had so little sense of self that she identified primarily as a disease. She also reported significant trauma and truly disabling symptoms. I find it interesting that there is so much criticism with acknowledging the possibility that perhaps she was actually treated into a sustained remission and that without that level of treatment, perhaps she would have ended up in jail or dead. Or maybe she didn't actually have a psychotic or bipolar disorder... who knows.

 

[clausewitz2]

The author above likely had an identity disturbance if she had so little sense of self that she identified primarily as a disease.

This seems like a totally unwarranted swipe at her character, given this is sort of the result that the mental health system pushes for generally, especially for people classified as SMI. Do all peer support specialists have identity disturbances? The system tries to socialize people into the role of "mental patient who takes their meds like a good girl/boy" and then we try to say they are the problem when they allow a major part of their self-definition to be based on their diagnosis?

Would you say this about people who identify largely as cancer "survivors", and spend huge amounts of time on advocacy work related to that?

That's...kind of breathtaking, I have to say.

 

[birchswing]

This is tangentially related, what happens to people who survive to old age with schizophrenia? Do they improve? I know the morbidity is higher, but assuming they do well enough to survive. I've heard some disorders like BPD for example improve with older age. Schizophrenia made me curious because I always hear it associated with youth (in terms of the onset), and I was curious if it would also taper as a person ages assuming they can get through the pitfalls of having it. I know they're not the same disease but the way in which schizophrenia tends to emerge in youth and Alzheimer's in old age and the way some of the symptoms overlap has always made me associate the two with each other.

 

[clausewitz2]

Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy: long-term follow-up of a 2-year randomized clinical trial - PubMed

isrctn.org Identifier: ISRCTN16228411.

www.ncbi.nlm.nih.gov

Your memory of the above study is way off... They randomized first breakers treated to remission for 6 months (highly selected group) to maintain dose or try a taper strategy for 18 months... after that it was doctor's discretion. The taper would stop if the patient got worse. After 3 years, the taper group relapsed more but the overall relapse rate after 7 years was equal, with around 2/3 relapsing at least once. < 10% were able to discontinue antipsychotics.

The taper group, however, did show higher (but less than 50%) rates of 6 month remission at 7 years and were on lower doses.

Take homes: A very small number of people might come off antipsychotics after a first break successfully. Many of these drugs have wicked long half lives and maintaince dose can be way lower than hospital doses (2-3 mg of haldol). Trying to taper down antipsychotics is worth it if someone achieves remission for 6 months but they will probably not come off completely.

Remember, each relapse comes with a risk of job loss, family loss and prison time, never mind the literature on duration of untreated illness.

So I agree with you that you have to be careful in interpreting this study. It is also true that many of the people in the discontinuation group did have at least some use of neuroleptics in the last two years of the follow-up. I would emphasize however that a) it was definitely more than 10% (17/103) and b) even more people ended up using less than the equivalent of 1 mg of haldol per day. It is not clear to me from the write-up how many of the people in that category were also using neuroleptics in an episodic, as-needed fashion, i.e. "take some when warning signs X Y and Z we have identified crop up and then we'll stop when those go away."

The taper group also ended up having functional remission and recovery rates that were twice as high as the medication group. Much less difference in terms of symptomatic remission, but then I think it is safe to say that for the vast majority of people who experience psychosis they are motivated much less by the idea of eradicating every potential symptom than by, you know, living their lives and not winding up hospitalized all the time.

The duration of untreated illness literature has a serious confound that no one has really worked out how to reckon with, namely that the people who end up with high DUP are also people who overwhelmingly have a very paranoid style and engage minimally if at all with treatment. It may be much less about being treated v. not than it is about whether or not you can sustain human relationships over time.

I don't go around telling everyone to stop neuroleptics straight away or anything, but especially early on, everyone deserves at least a chance to try tapering. Given the extent to which functional outcomes are also mediated by engagement with treatment of some kind (not necessarily neuroleptic medication) I rather think it is easier to get people to keep showing up and maybe accessing therapeutic/vocational type services if they aren't under the often entirely accurate impression that the cost of this is being badgered into chronic use of medications that they detest and, as @splik pointed out, are probably actively harmful along some dimensions in the long run.

 

[downwithDTB]

This seems like a totally unwarranted swipe at her character, given this is sort of the result that the mental health system pushes for generally, especially for people classified as SMI. Do all peer support specialists have identity disturbances? The system tries to socialize people into the role of "mental patient who takes their meds like a good girl/boy" and then we try to say they are the problem when they allow a major part of their self-definition to be based on their diagnosis?

Would you say this about people who identify largely as cancer "survivors", and spend huge amounts of time on advocacy work related to that?

That's...kind of breathtaking, I have to say.

I didn't mean this statement to be breathtaking or controversial, but over investment in a single component of your person is exactly what I would call a degree of identity disturbance, and I said likely. I also didn't mean it as an insult, but as a characterization that may be secondary as you say to socialization. I would say the same thing about someone who overinvests *their sense of self* in anything, be it surviving cancer, being a CEO, being a parent, being a psychiatist, ect. If your sense of self is so simple that you can define it in one word, as the author claimed, you have a deficiency that can likely be worked on to help with a more rounded and fulfilled life resistent to insult. If she was exaggerating, then I am wrong. I know plenty of folks who have schizophrenia and are ___. You can be a cancer survivor, an advocate, a compassionate and sensitive person and love poetry. It's the if I'm not x then the rest of me falls apart that worries me.
----

Regarding your other comments, you're correct, I should have said <20% of first episode psychosis who achieved remission went on to be med free at that time point. I don't know how I passed 6th grade. I also agree that everyone deserves a chance to taper down after their first episode, but with great caution and that function is much much important than symptoms (as long as the pt can handle the sx). I also think that we should remember that 2 mg of haldol daily at steady state is actually pretty strong... and likely enough for the average person who achieves remission.

 

[clausewitz2]

Regarding your other comments, you're correct, I should have said <20% of first episode psychosis who achieved remission went on to be med free at that time point. I don't know how I passed 6th grade. I also agree that everyone deserves a chance to taper down after their first episode, but with great caution and that function is much much important than symptoms (as long as the pt can handle the sx). I also think that we should remember that 2 mg of haldol daily at steady state is actually pretty strong... and likely enough for the average person who achieves remission.

I agree with you that function is much more important than symptoms. I also read this study as suggesting it is way more likely that you will have functional recovery if you ended up in the taper condition. I think also there is a very big difference between people who are taking haldol or whatever from time to time when things get bad for circumscribed periods versus people who take it daily for years and years. The structure of the data presented in this paper collapses that difference between the two but I would be very surprised if there were not more of the former in the taper group than in the later. So while the paper doesn't speak directly to that point, it is equally not fair to say that it demonstrates that 80% of people at 7 years end up on chronic daily neuroleptics.

Definitely agree with you about dosing, I have trouble remaining rational when I encounter other psychiatrists who just unthinkingly continue whatever massive doses someone ended up on inpatient without having spent a single blessed second thinking about why they are doing this indefinitely.

 

[cara susanna]

I'm wondering what diagnosis the psychiatrist posits instead. It sounds like the author was actively psychotic at one point, which I don't think can be explained by anxiety. Unless he's saying she remitted and she isn't really understanding that.

 

[Mass Effect]

This is tangentially related, what happens to people who survive to old age with schizophrenia? Do they improve? I know the morbidity is higher, but assuming they do well enough to survive. I've heard some disorders like BPD for example improve with older age. Schizophrenia made me curious because I always hear it associated with youth (in terms of the onset), and I was curious if it would also taper as a person ages assuming they can get through the pitfalls of having it. I know they're not the same disease but the way in which schizophrenia tends to emerge in youth and Alzheimer's in old age and the way some of the symptoms overlap has always made me associate the two with each other.

I've never seen someone with schizophrenia improve with age. Some are compliant with meds and do fine with regard to their mental illness and some are non-compliant and don't do well, just like the younger generation. The major difference in an older schizophrenia patient is the medical co-morbidities. As @splik pointed out, the medications are toxic and it's not uncommon to see an older patient with heart disease, diabetes, movement disorders, and/or the consequences of many years of substance use.

Borderline personality disorder (which is what I assume you mean by BPD, not bipolar disorder) is an entirely different beast. This is a trauma reaction that is typically treated in a completely different way. The most helpful thing is therapy (specifically DBT). Even with BPD, the patients who don't do therapy and/or don't fully engage in it can be just as borderliney as a 70 yo as they were as a 20 yo.

I didn't mean this statement to be breathtaking or controversial, but over investment in a single component of your person is exactly what I would call a degree of identity disturbance, and I said likely. I also didn't mean it as an insult, but as a characterization that may be secondary as you say to socialization. I would say the same thing about someone who overinvests *their sense of self* in anything, be it surviving cancer, being a CEO, being a parent, being a psychiatist, ect. If your sense of self is so simple that you can define it in one word, as the author claimed, you have a deficiency that can likely be worked on to help with a more rounded and fulfilled life resistant to insult

I think this is an overly simplistic and even insensitive way of viewing it, honestly. People with chronic illness identify the illness as a part of who they are and if you dig deep into that, you learn how traumatic the illness/diagnosis was for them and how it may have even changed the course of their lives. This is true of both physical and mental illnesses. Ask an MS patient about the diagnostic process and months or years of symptoms preceding it. Ask a cancer patient about learning the diagnosis or enduring treatment. It becomes a part of who they are just as much as being a CEO does.

In the author's case, she was diagnosed with a serious mental illness, requiring multiple psych admissions, 10 medications, and ECT. Even when stable, the emotional burden of knowing you have a mental illness, the course of which is unpredictable, and may require lifelong toxic medications and more admissions and more ECT is traumatic. Of course it's a huge part of who she is. It's likely been a part of every decision she's made since she got her diagnosis. Then to learn all that may have been for nothing is a huge blow.

Also, while I agree regarding the fact that being off meds without relapse isn't proof that you don't have the illness, I also have to say that in my experience, a lot of patients are diagnosed with bipolar disorder when actually, the appropriate diagnosis is borderline personality disorder. This is also true in child psych (though most aren't borderlines, just rebellious kids). So I do tend to approach a bipolar diagnosis with skepticism if a patient is stable without meds. I screen very carefully and very thoroughly for history of mania in these patients and if the patient is unreliable, I get a release for collateral before I continue the diagnosis.

 

[hamstergang]

Borderline personality disorder (which is what I assume you mean by BPD, not bipolar disorder) is an entirely different beast. This is a trauma reaction

It's not necessarily a trauma reaction.

 

[pediatric_psydoc]

It's not necessarily a trauma reaction.

Agreed, and individuals with borderline personality disorder often have a history of trauma in childhood. At the point the “trauma reaction” has evolved into a pattern of unstable behavior, mood, and self-image that is pervasive and ingrained in the personality once the personality has been formed, it goes beyond “trauma reaction” regardless of whether the pattern’s pathogensis may be based in trauma.

 

[Mass Effect]

It's not necessarily a trauma reaction.

While that's technically true, every single case I've seen has evolved from childhood trauma.

Agreed, and individuals with borderline personality disorder often have a history of trauma in childhood. At the point the “trauma reaction” has evolved into a pattern of unstable behavior, mood, and self-image that is pervasive and ingrained in the personality once the personality has been formed, it goes beyond “trauma reaction” regardless of whether the pattern’s pathogensis may be based in trauma.

What is the trigger for the pattern of unstable behavior, mood, and self image? I stand by what I said.

 

[downwithDTB]

I think this is an overly simplistic and even insensitive way of viewing it, honestly. People with chronic illness identify the illness as a part of who they are...

I said that if a diagnosis, or anything else, is a part of who you are, that's healthy. If anything is so central that it alone defines you, that is a deficit. As psychiatrists we should be able to point out elements of character pathology when discussing a diagnosis and not view that as an assault on the person. Over investing your identity in one thing doesn't make you a bad person nor does having minimal capacity for empathy. Having borderline pd or NPD doesn't make you bad. Having had no close relationships doesn't make you bad, but I'll have to discuss that when making a formulation. Who am I without cancer is very different from I felt a sense of purpose from using my experience to help others with cancer and now I'll have to replace that.

 

[cara susanna]

While that's technically true, every single case I've seen has evolved from childhood trauma.



What is the trigger for the pattern of unstable behavior, mood, and self image? I stand by what I said.

The "BPD and trauma" link is over-exaggerated and not as strong as we'd like to think it is (although it is strong, the field acts like it's a given when that's not necessarily true). I also think that PTSD is often misdiagnosed as BPD. PTSD can be accompanied by emotional and interpersonal dysregulation.

I met a prominent BPD researcher who does a lot of longitudinal studies and she told me her work suggested a lot of times it's just a really emotional kid and the parents don't know what to do with said kid. Which results in reinforcing problematic behavioral patterns and invalidation. Even DBT's biosocial model says that it's repeated invalidation and doesn't specify trauma, although of course trauma is extremely invalidating.

 

[Mass Effect]

The "BPD and trauma" link is over-exaggerated and not as strong as we'd like to think it is (although it is strong, the field acts like it's a given when that's not necessarily true). I also think that PTSD is often misdiagnosed as BPD. PTSD can be accompanied by emotional and interpersonal dysregulation.

I met a prominent BPD researcher who does a lot of longitudinal studies and she told me her work suggested a lot of times it's just a really emotional kid and the parents don't know what to do with said kid. Which results in reinforcing problematic behavioral patterns and invalidation. Even DBT's biosocial model says that it's repeated invalidation and doesn't specify trauma, although of course trauma is extremely invalidating.

How many patients have you seen with BPD and no trauma? Legit asking because my tally is 0. While I have no doubt invalidation is a star player, it's difficult to make a case for repeated invalidation so severe that it shapes such a pathologic view of the world and relationships without there being some type of psychologic mistreatment and/or emotional abuse attached to the invalidation.

 

[clausewitz2]

While that's technically true, every single case I've seen has evolved from childhood trauma.



What is the trigger for the pattern of unstable behavior, mood, and self image? I stand by what I said.

@cara susanna is right on the money - depending on the study something around 20-30% of people with BPD don't have any identifiable history of trauma. The biosocial DBT model, of only requires a mismatch between emotional needs/reactivity of the child and sensitive responsiveness of the parent. Worth noting the very psychodynamic, attachment-centered MBT model comes to more or less the same conclusion.

 

[Mass Effect]

@cara susanna is right on the money - depending on the study something around 20-30% of people with BPD don't have any identifiable history of trauma. The biosocial DBT model, of only requires a mismatch between emotional needs/reactivity of the child and sensitive responsiveness of the parent. Worth noting the very psychodynamic, attachment-centered MBT model comes to more or less the same conclusion.

How many legit cases of BPD have you seen with no trauma history? And keep in mind, I'm not identifying trauma only as childhood abuse. Relationships with others that are experienced as traumatic by the patient (emotional abuse, severe bullying by peers) can be just as traumatizing as a child who's suffered physical or sexual violence and in some cases, a more prominent trigger for the dysfunctional relationships we see with BPD. YMMV.

 

[splik]

How many legit cases of BPD have you seen with no trauma history?

I have seen many. Only about 1/2 of BPD pts have significant childhood trauma history. However those pts are the ones who have a worse course, are more severely impaired, more greatly utilize health services, and more likely to have other psychiatric comorbidities (e.g. depression, bipolar, PTSD, substance abuse).

 

[clausewitz2]

How many legit cases of BPD have you seen with no trauma history? And keep in mind, I'm not identifying trauma only as childhood abuse. Relationships with others that are experienced as traumatic by the patient (emotional abuse, severe bullying by peers) can be just as traumatizing as a child who's suffered physical or sexual violence and in some cases, a more prominent trigger for the dysfunctional relationships we see with BPD. YMMV.

I have spent a lot of this year working in an IOP focused on people diagnosed with BPD, so....lots? I am sure if you stretch the definition of trauma enough you can account for all of them, but the term begins to lose meaning and much explanatory power. After all, if one is traumatized by an event that happens in most people's lives without great incident, it is hard to say the event caused the dysfunction.

 

[Mass Effect]

I have seen many. Only about 1/2 of BPD pts have significant childhood trauma history. However those pts are the ones who have a worse course, are more severely impaired, more greatly utilize health services, and more likely to have other psychiatric comorbidities (e.g. depression, bipolar, PTSD, substance abuse).

Perhaps I'm too early in my career to have seen the ones with no trauma history. Or maybe I'm not catching the more subtle cases. I'm also very careful about the diagnosis as I think it's ridiculously overdiagnosed.

I have spent a lot of this year working in an IOP focused on people diagnosed with BPD, so....lots? I am sure if you stretch the definition of trauma enough you can account for all of them, but the term begins to lose meaning and much explanatory power. After all, if one is traumatized by an event that happens in most people's lives without great incident, it is hard to say the event caused the dysfunction.

I mean, that's true, but I'm not the one extending the definition. We know that the definition goes beyond just physical or sexual violence and that one event experienced without pathologic difficulty by one patient can be severely traumatic to another.

Nevertheless, at this stage of my career, I will respectfully agree to disagree. Perhaps I'll change my mind in a few years.

 

[calvnandhobbs68]

How many legit cases of BPD have you seen with no trauma history? And keep in mind, I'm not identifying trauma only as childhood abuse. Relationships with others that are experienced as traumatic by the patient (emotional abuse, severe bullying by peers) can be just as traumatizing as a child who's suffered physical or sexual violence and in some cases, a more prominent trigger for the dysfunctional relationships we see with BPD. YMMV.

I mean, that's true, but I'm not the one extending the definition. We know that the definition goes beyond just physical or sexual violence and that one event experienced without pathologic difficulty by one patient can be severely traumatic to another.

Nevertheless, at this stage of my career, I will respectfully agree to disagree. Perhaps I'll change my mind in a few years.

To throw my interpretation of it in there...I would agree that one event experienced without pathologic difficulty by one patient can be severely traumatic to another. However, I would venture to say that instead of stretching the definition of trauma to whatever the patient says it is, perhaps it is the patient's personality disorder that is causing them to misinterpret events that the majority of the population can cope with as particularly traumatic. This view would seem to get to the core of borderline personality disorder itself: poorly developed self image (so will misinterpret even fairly benign negative social interactions with as severely disorienting), preoccupation with abandonment, emotional lability, separation insecurity, etc. So depending on how far one is willing to stretch the definition of "trauma", it could certainly seem like many of these patients are experiencing "trauma" in their childhood (especially with vague things like "emotionally abusive") when in fact it is their personality disorder which is causing them to interpret and react to these stimuli in a different and maladaptive way vs the rest of the general population.

This may explain some of the disconnect between what the research shows (which is that there are a significant portion of patients with BPD who experience no true childhood trauma or abuse) and what these patients end up reporting as vague "trauma". Kind of a chicken or the egg thing.

 

[clausewitz2]

To throw my interpretation of it in there...I would agree that one event experienced without pathologic difficulty by one patient can be severely traumatic to another. However, I would venture to say that instead of stretching the definition of trauma to whatever the patient says it is, perhaps it is the patient's personality disorder that is causing them to misinterpret events that the majority of the population can cope with as particularly traumatic. This view would seem to get to the core of borderline personality disorder itself: poorly developed self image (so will misinterpret even fairly benign negative social interactions with as severely disorienting), preoccupation with abandonment, emotional lability, separation insecurity, etc. So depending on how far one is willing to stretch the definition of "trauma", it could certainly seem like many of these patients are experiencing "trauma" in their childhood (especially with vague things like "emotionally abusive") when in fact it is their personality disorder which is causing them to interpret and react to these stimuli in a different and maladaptive way vs the rest of the general population.

This may explain some of the disconnect between what the research shows (which is that there are a significant portion of patients with BPD who experience no true childhood trauma or abuse) and what these patients end up reporting as vague "trauma". Kind of a chicken or the egg thing.

Yes, precisely, well said. This also fits with the known heritability of BPD - there is a temperamental core that sets people up for experiencing a learning history that is much more likely to lead to development of the personality structure.

Imagine getting half a dozen donuts and immediately stuffing your face with them. If I do that, I'm going to feel a bit nauseous for a while and hate myself a bit, but a month from now it will not be affecting my life in the slightest. Meanwhile, someone with T1DM has been hospitalized. The donuts are obviously involved in some way but conceptualizing it as "post-bakery syndrome" is probably a category mistake.

 

[cara susanna]

How many legit cases of BPD have you seen with no trauma history? And keep in mind, I'm not identifying trauma only as childhood abuse. Relationships with others that are experienced as traumatic by the patient (emotional abuse, severe bullying by peers) can be just as traumatizing as a child who's suffered physical or sexual violence and in some cases, a more prominent trigger for the dysfunctional relationships we see with BPD. YMMV.

With all due respect, we conduct research with large samples because our anecdotal evidence as clinicians is not as reliable. As mentioned above, most studies have found some percentage of individuals with BPD who did not have trauma histories. I believe that the Wagner and Linehan study, which is often cited, had a rate of 66% with, so that'd be 33% without.

You also would want to keep in mind the selection bias that may result in more of your BPD cases having trauma histories--for instance, if you work in a VA, you're probably likely to see patients with trauma histories in general.

 

[bashir]

Yesterday I diagnosed a patient without any trauma history with BPD. Between the lack of any trauma history and lack of suicidality and self-harm, I almost missed it. At the point in the interview that I realized the patient seemed to meet the criteria for 5 different disorders I had the "aha" moment.

I'm curious about the assertion that BPD is overdiagnosed. I feel like I see it all tgg time and am generally not shy about diagnosing it. If it truly is overdiagnosed I'm sure I'm one of the worst offenders, but it's usually pretty clear in my view.

 

[deleted736562]

Very interesting article. Thanks for sharing. There was en entity called "pseudoneurotic schizophrenia" at one point but then went out of use. The boundaries between schizoaffective/bipolar, borderline personality disorder aren't always so clear. I did have a couple of female patients on the inpatient unit where I struggled between the three dx. The severity of the mood/psychosis seemed the deciding factor. And the idea that patients with a chronic psychotic illness uniformly get worse in functioning with age isn't a universal rule either. There are a lot of exceptions that do not fit with our neat DSM boxes and this woman could be one of those.

For a lot of patients I try to minimize what the diagnosis label means and I make it explicit that in psychiatry we're prone to changes. And let's face it; most of the time we aren't treating disease categories but managing symptoms.

One thing that irked me is her psychiatrist saying she doesn't have a "biological illness". We are doing the field a big disservice if we keep propagating this false dichotomy. Heck, even Borderline PD has more than 40% genetic heritability. I would also question revisiting the diagnosis now based on her current functioning/ongoing sx.

 

[Mass Effect]

I'm curious about the assertion that BPD is overdiagnosed. I feel like I see it all tgg time and am generally not shy about diagnosing it. If it truly is overdiagnosed I'm sure I'm one of the worst offenders, but it's usually pretty clear in my view.

If it's pretty clear, you're either seeing insanely personality disordered people or you're overdiagnosing in my opinion. I could tell horror stories about how I've witnessed people obtain that diagnosis (Saw a resident make the dx once in the medical service in someone who I didn't believe carried the dx. I asked why the dx was made and the resident said it was because the patient was tearful, yelling at nurses, irritable with her roommate, constantly pushing her call button, endorsing passive suicidality, overstating her pain (resident said "faking"), and seeking attention...in the context of cancer diagnosis made 2 days prior).

In my experience, people think it's a slam dunk dx because many of the symptoms are similar to common pathologic human behavior in times of crisis and usually by the time we see these patients, they are in crisis. They're dysregulated, possibly suicidal, their life is in shambles, they've lost loved ones, and they just can't get it together. But what's key is their life story, not how they look/what they share when we evaluate them. I never make the diagnosis on the inpatient unit (either medical or psychiatric) unless the patient is someone who has been closely tied to the mental health system for years and we have evidence of the disorder or unless I get a ton of collateral from family members who've known the patient his/her entire life.

 

[clausewitz2]

Very interesting article. Thanks for sharing. There was en entity called "pseudoneurotic schizophrenia" at one point but then went out of use. The boundaries between schizoaffective/bipolar, borderline personality disorder aren't always so clear. I did have a couple of female patients on the inpatient unit where I struggled between the three dx. The severity of the mood/psychosis seemed the deciding factor. And the idea that patients with a chronic psychotic illness uniformly get worse in functioning with age isn't a universal rule either. There are a lot of exceptions that do not fit with our neat DSM boxes and this woman could be one of those.

For a lot of patients I try to minimize what the diagnosis label means and I make it explicit that in psychiatry we're prone to changes. And let's face it; most of the time we aren't treating disease categories but managing symptoms.

One thing that irked me is her psychiatrist saying she doesn't have a "biological illness". We are doing the field a big disservice if we keep propagating this false dichotomy. Heck, even Borderline PD has more than 40% genetic heritability. I would also question revisiting the diagnosis now based on her current functioning/ongoing sx.

Pseudoneurotic schizophrenia or "Hoch-Palatin syndrome" is the old term for what is now BPD (although sometimes it was used for what some people call schizo-obsessive now, not a strict 1:1 mapping). Maybe that's your point, though, in which case I apologize.

If you had to pick a way to end up with an unstable sense of self and frequent suicidality, never knowing from month to month what your overall mood and level of functioning will be is a good way to do it.

One of our attendings who disappeared from our institution for years because he was in and out of state hospitals for fairly severe manic episodes always maintains that you are not necessarily going to see classic psychopathological features in people who are on the many meds typical of psychopharm for bipolar disorder. It is also the case that marked mood reactivity is pretty common between acute episodes in undisputed bipolar I, to say nothing of bipolar II. It is not rigorous at all but I find Akiskal's idea of bipolar "2 1/2" clinically useful sometimes for people who have a clear affective illness but more often have challenges related to how the dysfunctional ways of relating to people and the world they have fallen into as a result.

All that said saying someone is suffering from "paranoia" because they think everyone is judging them does not inspire confidence in the acumen of whoever said this person was psychotic.

The DSM is a kludge designed to keep our field's theological disputes to a dull roar but it was never trying to be a catalogue of all possible dysfunction.

 

[clausewitz2]

If it's pretty clear, you're either seeing insanely personality disordered people or you're overdiagnosing in my opinion. I could tell horror stories about how I've witnessed people obtain that diagnosis (Saw a resident make the dx once in the medical service in someone who I didn't believe carried the dx. I asked why the dx was made and the resident said it was because the patient was tearful, yelling at nurses, irritable with her roommate, constantly pushing her call button, endorsing passive suicidality, overstating her pain (resident said "faking"), and seeking attention...in the context of cancer diagnosis made 2 days prior).

In my experience, people think it's a slam dunk dx because many of the symptoms are similar to common pathologic human behavior in times of crisis and usually by the time we see these patients, they are in crisis. They're dysregulated, possibly suicidal, their life is in shambles, they've lost loved ones, and they just can't get it together. But what's key is their life story, not how they look/what they share when we evaluate them. I never make the diagnosis on the inpatient unit (either medical or psychiatric) unless the patient is someone who has been closely tied to the mental health system for years and we have evidence of the disorder or unless I get a ton of collateral from family members who've known the patient his/her entire life.

Well said. I only differ from this in that if the patient reacts to being told about the criteria/phenomenology of BPD by saying some variant of "oh my God, I didn't know there was a name for that!/you're describing my life/how did you know?" then maybe overwhelming collateral is less necessary.

 

[Mass Effect]

Well said. I only differ from this in that if the patient reacts to being told about the criteria/phenomenology of BPD by saying some variant of "oh my God, I didn't know there was a name for that!/you're describing my life/how did you know?" then maybe overwhelming collateral is less necessary.

Agree with this.

 

[bashir]

I don't diagnose BPD based solely on how someone is presenting in crisis. I agree that's a bad idea. But a careful interview (in any setting, I'd argue) can uncover patterns of symptoms and behavior across the patient's lifespan that are very suggestive of BPD. When that occurs I will typically go over the criteria with the patient and when they endorse all but one or two, I tell them more about borderline personality disorder. More often than not they have a response along the lines of "oh my God, why didn't anyone tell me before?" I often don't formally diagnose at that first meeting but hedge a bit with "you seem to be struggling with a lot of symptoms seen in this disorder. Let's progress with a treatment approach indicated for BPD and see how things go." I'm not totally sure why, honestly. I was trained not to but for the wrong reasons (people argue it's stigmatizing, and you can't know after one meeting with a person). I guess I'm ok with waiting even when I'm confident because waiting to formally diagnose decreases the emphasis on the diagnostic label, which in general is a good thing IMO. The idea of someone wrapping up so much of their identity in a psychiatric diagnosis troubles me.

 

[VA Hopeful Dr]

Well said. I only differ from this in that if the patient reacts to being told about the criteria/phenomenology of BPD by saying some variant of "oh my God, I didn't know there was a name for that!/you're describing my life/how did you know?" then maybe overwhelming collateral is less necessary.

Ha. I love this.

I'm FM but have the "you don't have bipolar" talk at least weekly. When I describe the symptoms of BPD they all react just like that.

 

[cara susanna]

As I mentioned above, I constantly see PTSD misdiagnosed as BPD. I mean, if you have an adult woman who is perfectly fine until she's sexually assaulted in the military, is that really a personality disorder?

Also, sometimes BPD becomes code for "difficult patient" and therefore gets diagnosed even if the person doesn't really fit the diagnostic pattern.

 

[MLT2MT2DO]

As I mentioned above, I constantly see PTSD misdiagnosed as BPD. I mean, if you have an adult woman who is perfectly fine until she's sexually assaulted in the military, is that really a personality disorder?

It certainly could be. I think this is where the BPD vs Complex PTSD arguments stem from.

 

[cara susanna]

It certainly could be. I think this is where the BPD vs Complex PTSD arguments stem from.

Personality develops by age 18. Diagnostic validity for BPD has even been found as early as age 12. If someone is completely fine until a traumatic event happens, that suggests it is more of a trauma reaction and not so much a pervasive style of coping and relating to the world. Emotional and interpersonal dysregulation are criteria of BPD but certainly not unique to that disorder. Sometimes I wonder if all personality disorders should have developmental trajectory requirements for diagnosis like Antisocial does.

Complex PTSD is a whole other can of worms, but long story short: there isn't much research evidence to support it as a separate diagnostic entity or subtype of PTSD.

 

[Mass Effect]

Personality develops by age 18. Diagnostic validity for BPD has even been found as early as age 12. If someone is completely fine until a traumatic event happens, that suggests it is more of a trauma reaction and not so much a pervasive style of coping and relating to the world. Emotional and interpersonal dysregulation are criteria of BPD but certainly not unique to that disorder. Sometimes I wonder if all personality disorders should have developmental trajectory requirements for diagnosis like Antisocial does.

Complex PTSD is a whole other can of worms, but long story short: there isn't much research evidence to support it as a separate diagnostic entity or subtype of PTSD.

While personality develops by age 18, a personality disorder does not have to develop by age 18. If that was the case, then no one would be diagnosed with any personality disorder if they didn't have traits of it in childhood or before the age of 18. In fact, I think it's dangerous to diagnose personality disorders before the personality is fully formed in the first place. I think personality disorders diagnosed in childhood are often questionable as troublesome adolescent behavior is overly pathologized to fit criteria for a personality disorder (like BPD). When I see a 10 yo diagnosed as a "budding borderline," I have to question that clinician.

As to your other point, it's entirely possible for someone having a trauma reaction to show symptoms of BPD. It could mean she had BPD that was well-controlled and stable until the traumatic event. Or it could mean she had BPD traits all along and the traumatic event triggered her vulnerabilities. Or it could just be a reaction to the traumatic event. In fact, the symptoms of BPD are quite similar to the response some people have to a trauma in general. That's the problem with the diagnosis, criteria, and the need to fit everyone into specific disorders.

 

[adaptation1]

Bipolar Disorder...perhaps misdiagnosed, overdiagnosed, and underdiagnosed all at the same time. The fault usually lies not in the diagnostician, rather the conceptualization of our disorders, which is based on phenomenology and description rather than biology. What we term "bipolar disorder" and "borderline disorder" may as well as represent 1000s of different disorders. Many borderline patients, even while on engaging in DBT, often require and benefit from mood stabilizers, their affective lability almost similar to "cyclothymia." In the future -- even as we spend millions dollars trying to unlock the secret of the brain and yielding little clinical application -- we still need to treat each patient as an individual and seeing what works, often through trial and error.

 

[MLT2MT2DO]

Personality develops by age 18. Diagnostic validity for BPD has even been found as early as age 12. If someone is completely fine until a traumatic event happens, that suggests it is more of a trauma reaction and not so much a pervasive style of coping and relating to the world. Emotional and interpersonal dysregulation are criteria of BPD but certainly not unique to that disorder. Sometimes I wonder if all personality disorders should have developmental trajectory requirements for diagnosis like Antisocial does.

Complex PTSD is a whole other can of worms, but long story short: there isn't much research evidence to support it as a separate diagnostic entity or subtype of PTSD.

So in this instance if trauma occurs you're saying BPD can not occur? Or only if it happens after 18? I'm curious why the cognitive schema of abandonment changes from age 17 years and 355 days to 18 years old...


Ive never been a fan of the "by 18 rule"

 

[cara susanna]

So in this instance if trauma occurs you're saying BPD can not occur? Or only if it happens after 18? I'm curious why the cognitive schema of abandonment changes from age 17 years and 355 days to 18 years old...


Ive never been a fan of the "by 18 rule"

No, but if there are absolutely no behaviors or symptoms suggestive of BPD in adolescence and it suddenly develops in adulthood after a trauma, I think that suggests it's more likely a trauma reaction than a personality disorder. Personality disorders are supposed to be lifelong, pervasive patterns of behavior.

 

[Mass Effect]

No, but if there are absolutely no behaviors or symptoms suggestive of BPD in adolescence and it suddenly develops in adulthood after a trauma, I think that suggests it's more likely a trauma reaction than a personality disorder. Personality disorders are supposed to be lifelong, pervasive patterns of behavior.

This is true, which is why I question the diagnosis being made in most cases on an inpatient psych unit when the patient has no history in the chart, though I often see it done.

However, if I'm treating someone at the age of 50 and they meet criteria for BPD and I know this from my longterm relationship as the treating psychiatrist, I don't really care whether they had traits in adolescence or not. That isn't part of the diagnostic criteria and for good reason. Likewise, if I treat a 25 yo with no BPD traits, but in learning about her hx, she tells me about her teen years, full of BPD-type stuff, didn't receive any treatment (no DBT), but with no current symptoms (no interpersonal conflicts, maintaining long-term relationships, doing well at work/school, etc), I don't make the diagnosis just because she had traits as a teen.

 

[cara susanna]

This is true, which is why I question the diagnosis being made in most cases on an inpatient psych unit when the patient has no history in the chart, though I often see it done.

However, if I'm treating someone at the age of 50 and they meet criteria for BPD and I know this from my longterm relationship as the treating psychiatrist, I don't really care whether they had traits in adolescence or not. That isn't part of the diagnostic criteria and for good reason. Likewise, if I treat a 25 yo with no BPD traits, but in learning about her hx, she tells me about her teen years, full of BPD-type stuff, didn't receive any treatment (no DBT), but with no current symptoms (no interpersonal conflicts, maintaining long-term relationships, doing well at work/school, etc), I don't make the diagnosis just because she had traits as a teen.

That's fair, and certainly a practical approach.

 

[whopper]

I don't know what to make of her specific experience because I don't know how good her psychiatrist was, how extensive and in-depth his approach was on diagnosing her, and his alternate methods.

I can say that Bipolar Disorder among other disorders such as ADHD are highly misdiagnosed and most of the people on this forum have seen several causes of it being misdiagnosed. So I am not surprised by the article.

 

[splik]

Personality disorders are supposed to be lifelong, pervasive patterns of behavior.

They are supposed to be but in reality they are not. 80% of patients with borderline personality disorder do not meet criteria at 5-10 year follow up. This is one reason why the personality disorder construct lacks validity. The test-retest reliability of these diagnoses is also low. This is why the field has moved away from the personality disorder diagnosis to assessment of personality functioning. I find this a much more useful and valid construct for what we're talking about.

 

[cara susanna]

They are supposed to be but in reality they are not. 80% of patients with borderline personality disorder do not meet criteria at 5-10 year follow up. This is one reason why the personality disorder construct lacks validity. The test-retest reliability of these diagnoses is also low. This is why the field has moved away from the personality disorder diagnosis to assessment of personality functioning. I find this a much more useful and valid construct for what we're talking about.

Definitely agree with you there.

 

[downwithDTB]

This is true, which is why I question the diagnosis being made in most cases on an inpatient psych unit when the patient has no history in the chart, though I often see it done.

However, if I'm treating someone at the age of 50 and they meet criteria for BPD and I know this from my longterm relationship as the treating psychiatrist, I don't really care whether they had traits in adolescence or not. That isn't part of the diagnostic criteria and for good reason. Likewise, if I treat a 25 yo with no BPD traits, but in learning about her hx, she tells me about her teen years, full of BPD-type stuff, didn't receive any treatment (no DBT), but with no current symptoms (no interpersonal conflicts, maintaining long-term relationships, doing well at work/school, etc), I don't make the diagnosis just because she had traits as a teen.

You can make the diagnosis on the inpatient unit when the patient tells you that they have been cutting for the last 16 years, have no friends except a tumultuous relationship, say that they have always been depressed except when their boyfriend does something awesome which is like never, describe their depression as feeling "empty" and their last psychiatist was much better than you... they are underperforming at work relative to IQ/education, they don't meet criteria for MDD, and nothing else seems to clearly explain their life long multidomain dysfunction and you have adequate collateral and a fairly reliable. You don't make it because they are splitting, acting out and have SI.

They are supposed to be but in reality they are not. 80% of patients with borderline personality disorder do not meet criteria at 5-10 year follow up. This is one reason why the personality disorder construct lacks validity. The test-retest reliability of these diagnoses is also low. This is why the field has moved away from the personality disorder diagnosis to assessment of personality functioning. I find this a much more useful and valid construct for what we're talking about.

That's somewhat fair; however, resolution of a disorder without professional treatment doesn't negate it's existence. Most MDEs resolve spontaneously as well. I would be shocked if the right supportive environment isn't just as good or better than DBT, TFP, GPM, ect.

I still think of this as a decent prognosis with the right environment developmental/genetic disorder. Yes, the DSM sx can wax and wane a bit into and out of meeting criteria and a person can recover. In the end, however, the treatments are mostly ways of dealing with a defined set of behaviors and they seem to work pretty generally... so...

 

[clausewitz2]

This is true, which is why I question the diagnosis being made in most cases on an inpatient psych unit when the patient has no history in the chart, though I often see it done.

However, if I'm treating someone at the age of 50 and they meet criteria for BPD and I know this from my longterm relationship as the treating psychiatrist, I don't really care whether they had traits in adolescence or not. That isn't part of the diagnostic criteria and for good reason. Likewise, if I treat a 25 yo with no BPD traits, but in learning about her hx, she tells me about her teen years, full of BPD-type stuff, didn't receive any treatment (no DBT), but with no current symptoms (no interpersonal conflicts, maintaining long-term relationships, doing well at work/school, etc), I don't make the diagnosis just because she had traits as a teen.

Makes sense to do this as a clinician, but I take @cara susanna to be saying in part that if you were to really get into what your 35 yo was like as a child, especially if you talked to someone who knew them as a teen, as a matter of fact it is overwhelmingly likely that those traits were there robustly.