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

[clausewitz2]

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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.



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...

GPM is basically a supportive therapy, just with some structure. If you are dealing with a lot of folks with real BPD, though, given the feelings and reactions they tend to evoke in clinicians, your supportive treatment better have some defined structure and a clear framework or you run a very high risk of getting sucked into problematic rescuing/caretaking behavior and/or angry rejecting.

Unstructured supportive approaches really don't work out that well with BPD.

 

[clausewitz2]

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.

Schizotypal PD holds up pretty well longitudinally and test-retest wise, but then it also doesn't clearly or consistently separate from schizoid PD, so that distinction probably isn't meaningful. The phenomenology of many people meeting criteria for schizoid on any event actually involves extreme loneliness a lot of the time coupled with finding people overwhelming and terrifying.

 

[clausewitz2]

Indeed, but is schizotypy a personality disorder? It's little different from some of the other personality types which were heavily influenced by psychoanalytic thinking (including schizoid PD). schizotypal disorder was invented by those doing heritability studies of schizophrenia, having a hard time making a case as strong as the liked, noticing alot of schizophrenics had odd probands who didn't really meet criteria for schizophrenia, and lumping it in assuming this was some muted phenotypic expression or indicating variable penetrance of whatever genes they thought might be causing this.

Oh, I think a personality disorder per se is absolutely the wrong way to think about it (positive schizotypal traits actually predict subjective well-being and social success in the right cultural contexts, e.g. neo-pagan communities). More trying to point out that the entity labelled that way is picking out -something-. It also seems to be relatively heritable, certainly can cause a lot of distress, and is associated with UHR/CHR states so falls under the remit of mental health in some way. It seems to hang together better in terms of decomposability than most things labelled PD but as you point out that is not a high bar.

I've had a number of chronic putative PDD folks who were probably depressed but kind of secondarily to impairments stemming from these traits and who also described at least one parent who was either a very, very odd duck or had a history that suggested SMI. No one had ever documented anything about this and unsurprisingly SSRIs didn't fix it. A bit like OCD and eating disorders, most of the time if you don't specifically look for it it's just never going to come up.

 

[cara susanna]

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.

Yes, that's what I meant. I should add that I do a lot of diagnostic assessments in our clinic and BPD vs. PTSD is a common referral question. So I have a little more time to dig into things like childhood history etc. than other providers.

 

[clausewitz2]

Yes, that's what I meant. I should add that I do a lot of diagnostic assessments in our clinic and BPD vs. PTSD is a common referral question. So I have a little more time to dig into things like childhood history etc. than other providers.

As someone who does this work a lot, do you think there's any utility in asking some of the structural interview questions the TFP people are enamored with? Their contention is that emotional reactivity, chronic dysphoria, suicidality and rage aside, when you ask someone with PTSD qua PTSD a question like "how could I describe you to someone else as a person such that they would know what you're like?" , they will be able to give you a relatively detailed and nuanced description of themselves as people. Whereas someone with BPD qua BPD will say something like "I guess I'm mean sometimes" or give a very concrete label/psychiatric diagnosis or just fail to understand how it is even possible for anyone to answer this question. By useful I mean "helpful to guide pragmatic treatment in practice" and not "would be acceptable to peer reviewers."

I am guessing you do not have an especially dynamic orientation but sometimes I feel like those folks can get at meaningful distinctions in situations where purely behavioral observations at the level of resolution available in clinic are not very helpful. I guess it helps be good at detecting a category when you're the ones who invented it, though...

 

[cara susanna]

As someone who does this work a lot, do you think there's any utility in asking some of the structural interview questions the TFP people are enamored with? Their contention is that emotional reactivity, chronic dysphoria, suicidality and rage aside, when you ask someone with PTSD qua PTSD a question like "how could I describe you to someone else as a person such that they would know what you're like?" , they will be able to give you a relatively detailed and nuanced description of themselves as people. Whereas someone with BPD qua BPD will say something like "I guess I'm mean sometimes" or give a very concrete label/psychiatric diagnosis or just fail to understand how it is even possible for anyone to answer this question. By useful I mean "helpful to guide pragmatic treatment in practice" and not "would be acceptable to peer reviewers."

I am guessing you do not have an especially dynamic orientation but sometimes I feel like those folks can get at meaningful distinctions in situations where purely behavioral observations at the level of resolution available in clinic are not very helpful. I guess it helps be good at detecting a category when you're the ones who invented it, though...

I do use structured interview questions but I do generally find their utility limited. In the end, it's still self-report. I'm fortunate that there is an excellent measure of BPD in the Personality Assessment Inventory, which I always give for these testing cases. I also look for the pattern of devaluation and idealization and fear of abandonment. Someone with PTSD may have relationship issues, but that doesn't mean they have the same pattern you'd see in someone with BPD. I also look for symptom severity and functional impairment being related to relationships and environment as opposed to PTSD triggers. And, again, I do think historical trajectory of the symptoms is important to consider. You are right in that I'm not dynamically oriented: I'm trained in DBT, and that does inform my case conceptualization and diagnosis of BPD.

Honestly, though, sometimes the cases I get the person doesn't meet any criteria for BPD (aside from maybe, like, emotion dysregulation and suicidal behavior) and I'm not even sure why it was a diagnostic rule-out in the first place. Which is why above I said that sometimes BPD seems to be code for "difficult patient."

Edit: I should add that I also give the CAPS to assess PTSD, and I do find that structured interview very helpful.

 

[clausewitz2]

I do use structured interview questions but I do generally find their utility limited. In the end, it's still self-report. I'm fortunate that there is an excellent measure of BPD in the Personality Assessment Inventory, which I always give for these testing cases. I also look for the pattern of devaluation and idealization and fear of abandonment. Someone with PTSD may have relationship issues, but that doesn't mean they have the same pattern you'd see in someone with BPD. I also look for symptom severity and functional impairment being related to relationships and environment as opposed to PTSD triggers. And, again, I do think historical trajectory of the symptoms is important to consider. You are right in that I'm not dynamically oriented: I'm trained in DBT, and that does inform my case conceptualization and diagnosis of BPD.

Honestly, though, sometimes the cases I get the person doesn't meet any criteria for BPD (aside from maybe, like, emotion dysregulation and suicidal behavior) and I'm not even sure why it was a diagnostic rule-out in the first place. Which is why above I said that sometimes BPD seems to be code for "difficult patient."

Edit: I should add that I also give the CAPS to assess PTSD, and I do find that structured interview very helpful.

Ah, sorry, structural, not structured, as in personality structure a la Kernberg. It is quite irritating that they chose to use easily confused terminology.

Still a super helpful response! In addition to "difficult patient" it sometimes also means "upset and the medications/therapies I know how to use didn't make it all better."

 

[downwithDTB]

GPM is basically a supportive therapy, just with some structure. If you are dealing with a lot of folks with real BPD, though, given the feelings and reactions they tend to evoke in clinicians, your supportive treatment better have some defined structure and a clear framework or you run a very high risk of getting sucked into problematic rescuing/caretaking behavior and/or angry rejecting.

Unstructured supportive approaches really don't work out that well with BPD.

I assume you're not convinced by mcmain 2009 that the GPM version of supportive psychotherapy isn't as good as DBT on average? Saying it "doesn't work" seems a bit over the top given the number of BoPD specialists that use it AND the results of study above.

Also, if inspire of above you say GPM-ish supportive "get a god d@mn job, Al" doesn't work, and it doesn't sound like you're in camp DBT, that leaves team TFP, which nobody can afford and even kernberg doesn't think will work for the sickest patients and doesn't have enough providers to refer to. So?

 

[clausewitz2]

I assume you're not convinced by mcmain 2009 that the GPM version of supportive psychotherapy isn't as good as DBT on average? Saying it "doesn't work" seems a bit over the top given the number of BoPD specialists that use it AND the results of study above.

Also, if inspire of above you say GPM-ish supportive "get a god d@mn job, Al" doesn't work, and it doesn't sound like you're in camp DBT, that leaves team TFP, which nobody can afford and even kernberg doesn't think will work for the sickest patients and doesn't have enough providers to refer to. So?

...no, not at all what I meant. I am very pro-GPM as it is easily the most feasible treatment option available for real-deal BPD in our current healthcare system and works well enough. You were contrasting it with supportive therapies, but it sort of is that with a number of caveats and clear structure. I was saying that unstructured, unguided, supportive psychotherapy of the kind that someone who goes to a random community therapist because they are having a tough breakup might get for a few months and then move on with their lives is not an approach that is likely to bear any fruit. Equally true of the "supportive psychotherapy" that some psychiatrists believe they are doing when they tell people it's okay to feel sad sometimes, don't drink alcohol, take your meds. GPM does those things but first establishes a very clear and explicit treatment frame for it to occur in. That's why it's somewhat specialized.

Not sure where you got the impression I am anti-DBT, I am spending a significant chunk of my week at this point as a DBT therapist. I think it gets increasingly hand-wavy once you get past Stage I and am much more convinced of its utility for reducing suicide attempts and self-injurious behaviors but it meshes well with other third wave approaches that were designed with higher-functioning people in mind so it's all good.

Know what you're doing, know why you're doing it, and get consultation/supervision on a regular basis. Be deliberate and thoughtful without being a robot. Be authentic and accepting but don't validate the invalid. Be boringly predictable and consistent in your response to behaviors that tempt you to significantly change the terms of treatment. If you actually do those things consistently congratulations, you are now among the top quarter of all therapists in dealing with BPD, everything else is icing on the cake for most clients.

GPM's take-home above all is that the common sense basics are surprisingly rare in actual practice.

 

[cara susanna]

Ah, sorry, structural, not structured, as in personality structure a la Kernberg. It is quite irritating that they chose to use easily confused terminology.

Still a super helpful response! In addition to "difficult patient" it sometimes also means "upset and the medications/therapies I know how to use didn't make it all better."

Oh, whoops! I'm not steeped enough in Kernberg's theory to say, but I do love Millon's conceputalization of BPD as having structural deficits. That being said, that doesn't really help me when I assess for BPD.

The problem with DBT is that the patient has to be committed. A psychiatrist telling them to do DBT, without their wanting to do it, will not work and just be frustrating for the therapist because DBT without commitment is, well, not DBT. It also can be REALLY hard to access full model in certain places.

I also run into issues providing even DBT-informed therapy and treating BPD in the VA specifically due to policies, but that's probably a whole other thread.

 

[whopper]

A problem with Bipolar Disorder, and misdiagnosis, and I've mentioned this before. Psychiatry, unfortunately, is filled with bad psychiatrists. I don't say that to attack psychiatry just like a bad police officer doesn't further the argument that all police officers are bad,

But due to bad psychiatrists, Bipolar Disorder being a non-lab diagnosis, insurance incentives to spend less and less time with patients, and that Bipolar Disorder happens to be the most defensible misdiagnosis diagnosis.....
Add up the equation.

I have seen several psychiatrists in assembly-line fashion diagnose people with Bipolar Disorder. I've seen it in NJ, NY, PA, KY, OH, MO. Almost every city tends to have a place where they only spend 5-10 minutes with a new patient and diagnose Bipolar Disorder.

Practice like this gives the rest of us a bad name.

 

[MLT2MT2DO]

A problem with Bipolar Disorder, and misdiagnosis, and I've mentioned this before. Psychiatry, unfortunately, is filled with bad psychiatrists. I don't say that to attack psychiatry just like a bad police officer doesn't further the argument that all police officers are bad,

But due to bad psychiatrists, Bipolar Disorder being a non-lab diagnosis, insurance incentives to spend less and less time with patients, and that Bipolar Disorder happens to be the most defensible misdiagnosis diagnosis.....
Add up the equation.

I have seen several psychiatrists in assembly-line fashion diagnose people with Bipolar Disorder. I've seen it in NJ, NY, PA, KY, OH, MO. Almost every city tends to have a place where they only spend 5-10 minutes with a new patient and diagnose Bipolar Disorder.

Practice like this gives the rest of us a bad name.

I don't think it's fair to only focus on psychiatry having bad psychiatrists. Healthcare in general has lazy/poor providers, just like any other job. You'd think all the hoops we have to jump through as physicians would have weeded these people out but it's not the case.

I see whackado PCP prescription/diagnosing roughly as often as whackado psych providers.

 

[VA Hopeful Dr]

I don't think it's fair to only focus on psychiatry having bad psychiatrists. Healthcare in general has lazy/poor providers, just like any other job. You'd think all the hoops we have to jump through as physicians would have weeded these people out but it's not the case.

I see whackado PCP prescription/diagnosing roughly as often as whackado psych providers.

Is that PCP's screwing up psych diagnosis or PCP screwing up everything diagnosis?

I ask because if the former, we're way more susceptible to that than the average psychiatrist (less psych training and shorter visits where more has to get done). If the latter, it goes back to the old "doctors are people too, and lots of people suck at their jobs".

 

[MLT2MT2DO]

Is that PCP's screwing up psych diagnosis or PCP screwing up everything diagnosis?

I ask because if the former, we're way more susceptible to that than the average psychiatrist (less psych training and shorter visits where more has to get done). If the latter, it goes back to the old "doctors are people too, and lots of people suck at their jobs".

When it comes to PCPs its the psychotropic med regimens usually due to a misdiagnosis that make me question competency. At a certain point it's OK to tell your patient "no" because I'm sure if 6mg of Xanax doest fix anxiety 8mg is the move. Or actually say "I don't know you should see a psychiatrist" instead of adding a 3rd low dose SGA.

Again I was just trying to point out, it's not fair to just point out to "there are bad psychiatrists", when "there's poor practitioners in all fields" that seem to lack common sense

 

[watto]

I assume you're not convinced by mcmain 2009 that the GPM version of supportive psychotherapy isn't as good as DBT on average? Saying it "doesn't work" seems a bit over the top given the number of BoPD specialists that use it AND the results of study above.

Also, if inspire of above you say GPM-ish supportive "get a god d@mn job, Al" doesn't work, and it doesn't sound like you're in camp DBT, that leaves team TFP, which nobody can afford and even kernberg doesn't think will work for the sickest patients and doesn't have enough providers to refer to. So?

Don't forget mentalization-based! [Step into my shoes for a moment. Can you think of any other therapies I might suggest for BPD?]

 

[Mass Effect]

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.

I get that, but I guess I question whether or not it matters? It won't affect my diagnosis nor my treatment recommendation (I don't do therapy). It won't lead me toward the diagnosis nor would it lead me away from the diagnosis.

 

[VA Hopeful Dr]

When it comes to PCPs its the psychotropic med regimens usually due to a misdiagnosis that make me question competency. At a certain point it's OK to tell your patient "no" because I'm sure if 6mg of Xanax doest fix anxiety 8mg is the move. Or actually say "I don't know you should see a psychiatrist" instead of adding a 3rd low dose SGA.

Again I was just trying to point out, it's not fair to just point out to "there are bad psychiatrists", when "there's poor practitioners in all fields" that seem to lack common sense

All true, but psychiatrists are the experts in mental health. You should be held to a higher standard than I am in this area.

If a psychiatrist treats diabetes with a regimen that doesn't really make sense that's much different than if an endocrinologist does it. Neither are good but only one of those people is the expert.

 

[clausewitz2]

I get that, but I guess I question whether or not it matters? It won't affect my diagnosis nor my treatment recommendation (I don't do therapy). It won't lead me toward the diagnosis nor would it lead me away from the diagnosis.

Hmm, I suppose if you are not engaging with therapy even to the extent of structuring your interactions along GPM lines then it doesn't matter, but I think in situations where the picture is somewhat murky a long history of very similar experiences, I think it should lead you toward the diagnosis. At the very least it tells you that whatever the role of trauma in producing the symptoms it is not the only major causal factor. For me at least it would make me much more interested in intense and detailed monitoring of specific changes and benefits associated with medication at various doses and make me much faster to stop or taper down anything where between the two of us we can't identify a concrete benefit. Also keeping focus more firmly on social and occupational functioning and less on symptom reports per se. Perhaps also using some DBT principles like titrating affect based on how they are behaving in the appointment, being very wary of apparent competence/active passivity phenomena, being explicitly dialectical etc.

You're right though that it is more relevant to whether they are ontologically similar diagnoses and less for how to guide management, which is the conversation I thought we were having. But then Thread Derailment is my middle name so I'm not one to talk.

 

[MLT2MT2DO]

All true, but psychiatrists are the experts in mental health. You should be held to a higher standard than I am in this area.

If a psychiatrist treats diabetes with a regimen that doesn't really make sense that's much different than if an endocrinologist does it. Neither are good but only one of those people is the expert.

Of course we should be held to a higher standard in regards to mental health. What does that have to do with my comment?

My comment was directed towards "there's many bad psychiatrists"

In your example not only would you not expect the psychiatrist to treat those correctly you'd likely not want the psychiatrist to not treat them at all. If you don't know what you're treating why are you treating it, sure try one or two things but then ask for help if it's going nowhere.

 

[whopper]

I don't think it's fair to only focus on psychiatry having bad psychiatrists. Healthcare in general has lazy/poor providers, just like any other job. You'd think all the hoops we have to jump through as physicians would have weeded these people out but it's not the case.

Agree but the context of this thread is a psychiatric diagnosis, hence why I'm limiting it to psychiatry.

Also other fields have more objective measures of diagnosing making misdiagnosis less of mystery. Psychiatrists need to hold themselves to higher standards in diagnosing through interview, history, signs and symptoms because we don't utilize lab tests in most of our cases.

But despite that this should be obvious our field in (edit: is) filled with clinicians that spend minimal time and as a result are known to do poor work but continue doing it. In this regard the onus should be somewhat more in psychiatry in those diagnoses areas that require very good clinical judgment. This is not a simple black and white thing. In other fields the above creates another dilemma where clinicians only then rely on labs without utilizing good clinical acumen and through (edit: throw) the latter out the window when they shouldn't do so.

 

[VA Hopeful Dr]

Of course we should be held to a higher standard in regards to mental health. What does that have to do with my comment?

My comment was directed towards "there's many bad psychiatrists"

In your example not only would you not expect the psychiatrist to treat those correctly you'd likely not want the psychiatrist to not treat them at all. If you don't know what you're treating why are you treating it, sure try one or two things but then ask for help if it's going nowhere.

Why bring up non-psychiatrists in a psychiatry forum when someone is complaining about the poor care that some psychiatrists provide then? Do PCPs doing a bad job mean that a psychiatrist doing a bad job doesn't matter anymore?

I actually would expect most psychiatrists to be able to manage basic diabetes care - y'all are physicians last I looked. I don't expect you to titrate insulin or manage some of the newer meds, but metformin is well within your wheelhouse.

Same way I can manage uncomplicated psych issues but ideally shouldn't really be managing complex bipolar, for example.

 

[whopper]

Agree VA.
It's a whataboutism.

"So what that I raped that woman? There's a murdered over there! Murder is worse than rape." --> then everyone ignores the rapist.
This is a psych forum. We're talking about psychiatry. We're talking about a psychiatric misdiagnosis.

Also in my case I specifically wrote that we have to bear in mind that pointing out problems in our field doesn't mean our field as a whole is bad. I used the 1 bad police officer doesn't mean all police officers are bad argument.

But if you want to fix that problem, you need to focus on addressing the issue. Throwing in a whataboutism prevents this.

 

[deleted736562]

Agree VA.
It's a whataboutism.

"So what that I raped that woman? There's a murdered over there! Murder is worse than rape." --> then everyone ignores the rapist.
This is a psych forum. We're talking about psychiatry. We're talking about a psychiatric misdiagnosis.

Also in my case I specifically wrote that we have to bear in mind that pointing out problems in our field doesn't mean our field as a whole is bad. I used the 1 bad police officer doesn't mean all police officers are bad argument.

But if you want to fix that problem, you need to focus on addressing the issue. Throwing in a whataboutism prevents this.

Part of the reason why psychiatrists are constantly talking **** about each other has also a lot to do with the lack of clear practice standards, good empirical evidence and diagnostic procedures...etc. That also creates a fertile ground for lazy/poor practice.

 

[cara susanna]

I get that, but I guess I question whether or not it matters? It won't affect my diagnosis nor my treatment recommendation (I don't do therapy). It won't lead me toward the diagnosis nor would it lead me away from the diagnosis.

For me it's because BPD is a stigmatizing diagnosis and this patient's providers will more likely than not treat them differently because of it. Also, if someone is diagnosed with BPD when it's actually PTSD they may be asked to delay trauma treatment that would actually be effective because providers think they need DBT first (not saying anyone in this thread would do that, but I've seen it in my own practice). For that reason, I try to use the diagnosis judiciously. Like I said, though, as a psychologist I generally am in a position where I am asked to provide more comprehensive assessments. I completely understand why you wouldn't be able to go that in depth in your role.

 

[MLT2MT2DO]

Agree VA.
It's a whataboutism.

"So what that I raped that woman? There's a murdered over there! Murder is worse than rape." --> then everyone ignores the rapist.
This is a psych forum. We're talking about psychiatry. We're talking about a psychiatric misdiagnosis.

Also in my case I specifically wrote that we have to bear in mind that pointing out problems in our field doesn't mean our field as a whole is bad. I used the 1 bad police officer doesn't mean all police officers are bad argument.

But if you want to fix that problem, you need to focus on addressing the issue. Throwing in a whataboutism prevents this.

This was a post about misdiagnosing, you took it as an opportunity to jump on "bad psychiatrists" as you have a history of doing. PCPs also misdiagnosis psych illnesses, bipolar no less, (subject of the topic). As a whole this is an issue in medicine

But if you want to use a political buzzword to attempt to villianize my post, go ahead. Also great job on using the rape metaphor that really dramatized it to another level.

 

[VA Hopeful Dr]

This was a post about misdiagnosing, you took it as an opportunity to jump on "bad psychiatrists" as you have a history of doing. PCPs also misdiagnosis psych illnesses, bipolar no less, (subject of the topic). As a whole this is an issue in medicine

But if you want to use a political buzzword to attempt to villianize my post, go ahead. Also great job on using the rape metaphor that really dramatized it to another level.

everyone at some point or another is going to misdiagnose something, we're all human after all. But as the experts in the area under discussion, y'all should be doing it less than the rest of us and trying to figure out ways to make it happen less.

it also matters more if a psychiatrist misdiagnoses something than if a family doctor like me does. If I misdiagnosed someone with bipolar and you as a psychiatrist see that patient it's very easy to dismiss my diagnosis by claiming that I am not a mental health expert. that is harder to do if the person who got it wrong in the first place is in the same field as you are.

Also, the wiser approach to take to this is to fix the area of medicine where you have experienced. I'm not sure you can make much of a difference when it comes to misdiagnosing hypertension or diabetes. But as a psychiatrist, you can have significant influence on improving the diagnostic accuracy for mental health conditions

 

[whopper]

you took it as an opportunity to jump on "bad psychiatrists" as you have a history of doing.

Like I said this is a common phenomenon made worse by the shortage cause patients are trapped into keeping their bad psychiatrists or have no treatment at all even if they can get a psychiatrist.

Rape, I get it, it really puts it to a very extreme level. So I get that you think it's a bad example. Agree with you.

Villianize? I get too given the above.

But if you parse out the emotional comments I wrote (that I agree can be unfair and I see that given what you've written), and take the emotionally neutral comments I stick by what I said.

 

[Mass Effect]

Hmm, I suppose if you are not engaging with therapy even to the extent of structuring your interactions along GPM lines then it doesn't matter, but I think in situations where the picture is somewhat murky a long history of very similar experiences, I think it should lead you toward the diagnosis

Of course. A long history of these symptoms/experiences is diagnostic, so of course it matters. I'm saying that childhood history of the same behavior isn't crucial to the diagnosis. Example: 50 yo has hx of symptoms at least since college. She denies any similar behavior in childhood. Would you not give the diagnosis? I would. Alternatively, 50 yo has hx of childhood/teenage borderline traits, but since college, has had stable relationships and no symptoms of it. I wouldn't give the diagnosis.

My point in saying all this is just to make the point that you don't need symptoms in childhood to make the diagnosis in most patients (unless the patient is very young). Likewise, symptoms in childhood do not automatically identify the disorder.

For me at least it would make me much more interested in intense and detailed monitoring of specific changes and benefits associated with medication at various doses and make me much faster to stop or taper down anything where between the two of us we can't identify a concrete benefit.

Yes, I agree. But again, I'm not saying this is bad to do. I do a thorough medication history and symptom history with everyone. And I go through all the questions we all do -- what's worked, at what doses, what duration, what side effects, why was it stopped, etc. I'm just saying that in terms of borderline personality, childhood history of symptoms (while important to document) does not affect my diagnosis most of the time in middle-aged adults, unless symptom stabilization is due to medication.

 

[cara susanna]

Of course. A long history of these symptoms/experiences is diagnostic, so of course it matters. I'm saying that childhood history of the same behavior isn't crucial to the diagnosis. Example: 50 yo has hx of symptoms at least since college. She denies any similar behavior in childhood. Would you not give the diagnosis? I would. Alternatively, 50 yo has hx of childhood/teenage borderline traits, but since college, has had stable relationships and no symptoms of it. I wouldn't give the diagnosis.

My point in saying all this is just to make the point that you don't need symptoms in childhood to make the diagnosis in most patients (unless the patient is very young). Likewise, symptoms in childhood do not automatically identify the disorder.



Yes, I agree. But again, I'm not saying this is bad to do. I do a thorough medication history and symptom history with everyone. And I go through all the questions we all do -- what's worked, at what doses, what duration, what side effects, why was it stopped, etc. I'm just saying that in terms of borderline personality, childhood history of symptoms (while important to document) does not affect my diagnosis most of the time in middle-aged adults, unless symptom stabilization is due to medication.

For me it'd be adolescence. Childhood I could see where there'd be no active symptoms of BPD, but I can't imagine someone developing those behaviors in adulthood if they didn't have them in adolescence unless it's reactive to something else (like a trauma). I see your point, though, and that's why it's probably inherently flawed to conceptualize BPD as a personality disorder.

 

[hallowmann]

Like I said this is a common phenomenon made worse by the shortage cause patients are trapped into keeping their bad psychiatrists or have no treatment at all even if they can get a psychiatrist.

Rape, I get it, it really puts it to a very extreme level. So I get that you think it's a bad example. Agree with you.

Villianize? I get too given the above.

But if you parse out the emotional comments I wrote (that I agree can be unfair and I see that given what you've written), and take the emotionally neutral comments I stick by what I said.

I'm sorry, I had to chuckle at the bolded a bit. Can we just all agree to always look at the emotionally neutral comments only? Or better yet only make those statements to begin with. Online forums would be a way better place for it.

Plus, I might steal that line to tack onto posts when I get a little to "enthusiastic".

For me it'd be adolescence. Childhood I could see where there'd be no active symptoms of BPD, but I can't imagine someone developing those behaviors in adulthood if they didn't have them in adolescence unless it's reactive to something else (like a trauma). I see your point, though, and that's why it's probably inherently flawed to conceptualize BPD as a personality disorder.

Sometimes its impossible to get a clear picture of someone in adolescence depending on your resources, informants, etc. at the time, or to even have an effective method of identifying BPD symptoms in adolescence for some individuals. Your adolescent experience varies heavily depending on your cultural background, your household, in short your environment. A very structured place with say clear limits on your relationships, interpersonal interactions, expressions of emotion, etc. could simply mask BPD symptoms and behaviors, until say you are released to essentially your own devices in college.

I'm going to stop there, because I agree with a great deal of what you've said in theory, but I think we should be careful not to make it seem like the only people with BPD are people that we can identify as having those behaviors in adolescence, and all others are reactive possibly to trauma. I know that's not necessarily what you're saying, but it could easily come across that way to others reading this.

 

[Mass Effect]

For me it'd be adolescence. Childhood I could see where there'd be no active symptoms of BPD, but I can't imagine someone developing those behaviors in adulthood if they didn't have them in adolescence unless it's reactive to something else (like a trauma). I see your point, though, and that's why it's probably inherently flawed to conceptualize BPD as a personality disorder.

So if someone has a clear case of BPD, you would assume it was there in adolescence. But what about those who have symptoms in adolescence, but don't have any symptoms of BPD once they're in college?

 

[clausewitz2]

So if someone has a clear case of BPD, you would assume it was there in adolescence. But what about those who have symptoms in adolescence, but don't have any symptoms of BPD once they're in college?

Then they've substantially remitted, like the majority of cases of BPD do. I think I'd have a low threshold for maybe thinking this was an appropriate diagnosis again if in the future relevant symptoms returned, but getting better is the norm, not the exception. The countervailing idea is entirely the result of how vividly we can all recall our encounters with the small minority who tend to have the most severe behaviors and also don't experience a lot of improvement.

I think we are all agreed that personality disorders per se (fixed, unchanging, trait-like) are problematic conceptually.

 

[cara susanna]

I'm going to stop there, because I agree with a great deal of what you've said in theory, but I think we should be careful not to make it seem like the only people with BPD are people that we can identify as having those behaviors in adolescence, and all others are reactive possibly to trauma. I know that's not necessarily what you're saying, but it could easily come across that way to others reading this.

Yes, I agree with you there. I do think it's fair to say that I'm not sure we should definitively diagnose BPD in the type of case I mentioned above. If the behaviors/symptoms persist following trauma treatment or appear independent of trauma cues, then I think BPD is more likely.

Also, I would definitely not diagnose someone who displayed behaviors in only adolescence with BPD. First, let's face it, a lot of BPD symptoms overlap with the emotional and behavioral dysregulation you often see in adolescence developmentally. Second, it's possible it was BPD but remitted, and I wouldn't be able to see the utility of diagnosing BPD if symptoms aren't active. Like I said, it's a stigmatizing diagnosis and I try to use it judiciously.

 

[whopper]

Bipolar Disorder is more difficult to diagnose, in a manner that makes misdiagnosis understandable, if it's weaker Bipolar II Disorder or Cyclothymia If the patient comes in only reporting depression and is given an antidepressant and goes manic despite that the physician asked of prior mania (you could get a young person who never did go manic and this is how you discover they have Bipolar Disorder or the patient doesn't state their mania cause they like mania).

Cyclothymia IMHO isn't given enough emphasis. I've met even highly acclaimed psychiatrists who seemed to forget what it was. It's subtle to the degree where it's difficult to tell if the person has it for real vs a personality disorder (or enough traits of one to be a problem) vs both.

Add to the problem assuming the patient has Cyclothymia that companies don't pursue FDA indications for it. So let's assume you've correctly diagnosed them with it. Now you might've harmed the patient's odds of getting their insurance to pay for meds.

 

[Mass Effect]

Then they've substantially remitted, like the majority of cases of BPD do. I think I'd have a low threshold for maybe thinking this was an appropriate diagnosis again if in the future relevant symptoms returned, but getting better is the norm, not the exception. The countervailing idea is entirely the result of how vividly we can all recall our encounters with the small minority who tend to have the most severe behaviors and also don't experience a lot of improvement.

Sorry, I disagree. I wouldn't diagnose anyone with BPD if they only had symptoms in adolescence and those symptoms were no longer prevalent by adulthood. Rather than thinking it was in remission, I would be more inclined to believe that their behavior in adolesence was a mix of hormonal, behavioral, and emotional dysregulation, likely in response to their peer group or chaotic home life or both. I actually think it's bad practice to diagnose BPD until adulthood. You can look to symptoms in adolescence to justify the diagnosis, but diagnoses in adolescence are always questionable in my book.

Yes, I agree with you there. I do think it's fair to say that I'm not sure we should definitively diagnose BPD in the type of case I mentioned above. If the behaviors/symptoms persist following trauma treatment or appear independent of trauma cues, then I think BPD is more likely.

Also, I would definitely not diagnose someone who displayed behaviors in only adolescence with BPD. First, let's face it, a lot of BPD symptoms overlap with the emotional and behavioral dysregulation you often see in adolescence developmentally. Second, it's possible it was BPD but remitted, and I wouldn't be able to see the utility of diagnosing BPD if symptoms aren't active. Like I said, it's a stigmatizing diagnosis and I try to use it judiciously.

This exactly.

 

[clausewitz2]

Sorry, I disagree. I wouldn't diagnose anyone with BPD if they only had symptoms in adolescence and those symptoms were no longer prevalent by adulthood. Rather than thinking it was in remission, I would be more inclined to believe that their behavior in adolesence was a mix of hormonal, behavioral, and emotional dysregulation, likely in response to their peer group or chaotic home life or both. I actually think it's bad practice to diagnose BPD until adulthood. You can look to symptoms in adolescence to justify the diagnosis, but diagnoses in adolescence are always questionable in my book.



This exactly.

Perhaps I was unclear. BPD in remission = no diagnosis of BPD.