Linehan article

[OldPsychDoc]

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Linehan--recovering borderline

 

[Doctor Bagel]

I just read that and think it's pretty fantastic. Good for her for speaking out! Unfortunately, there's so much stigma (and so many consequences) associated with going public about mental health problems, it's hard for our patients to identify inspiring stories.

It does make you wonder about the whole idea that having personal experience with something makes you better able to understand it and help treat it. I know that's a long standing idea in the addiction world with many people expressing a belief that the best addiction therapists are recovering addicts.

And of course it makes you question the whole attitude in psychiatry that we don't want mental health professionals who have ever had mental health problems. In fact, I think we discriminate a little more than other specialties.

 

[Ibid]

I just read that and think it's pretty fantastic. it's hard for patients to identify inspiring stories.

It does make you wonder about the whole idea that having personal experience with something makes you better able to understand it and help treat it.

And of course it makes you question the whole attitude in psychiatry that we don't want mental health professionals who have ever had mental health problems. In fact, I think we discriminate a little more than other specialties.

Not just a little more, much much more. Senior people with a severe and enduring diagnosis are thin on the ground for more reasons than one.

I enjoyed the article as well. Told it like it is and said something hopeful at the same time.

 

[loveoforganic]

Discussed on ology boards as well

http://forums.studentdoctor.net/showthread.php?t=832975

 

[Manicsleep]

Her work should be judged on how effective it is...and its pretty effective. The fact that she gives hope to others is good but should be taken with a grain of salt. I was asked today "how long before I can be cured" by a patient who read that article.

There needs to be balance with hope for the best while preparing to cope for the worst. I spent the whole hour on that because as we all know, borderlines can be rather black and white. I am not looking forward to more of these talks yet at the same time, I am glad linehan came forward.

There is a part of me that is skeptical that she has/had true BPD because she was discharged in 63 with no real effective treatments (per the article) and she was able to hold a job and get a psychology PhD by 1971. I think there is more to the story than borderline personality disorder, which is a pervasive egosyntonic disorder. Cluster B traits with a mood disorder or something along the lines strikes me as more plausible although who knows what the reality was (I doubt even linehan really knows at this point).

 

[Ibid]

Her work should be judged on how effective it is...and its pretty effective. The fact that she gives hope to others is good but should be taken with a grain of salt.

Why can't you just take it at face value? Or why are you unable to?

There needs to be balance with hope for the best while preparing to cope for the worst. I spent the whole hour on that because as we all know, borderlines can be rather black and white. I am not looking forward to more of these talks

I believe you.

There is a part of me that is skeptical that she has/had true BPD because she was discharged in 63 with no real effective treatments (per the article) and she was able to hold a job and get a psychology PhD by 1971. I think there is more to the story than borderline personality disorder, which is a pervasive egosyntonic disorder. Cluster B traits with a mood disorder or something along the lines strikes me as more plausible although who knows what the reality was (I doubt even linehan really knows at this point).

Oh the irony. This whole post is a classic example of why people don't come forward. They are belittled, their story doubted, motivations questioned and generally derided. God forbid they claim any sort of recovery as this is always met with "well they were not really ill in the first place."

 

[whopper]

There, doctors gave her a diagnosis of schizophrenia; dosed her with Thorazine, Librium and other powerful drugs, as well as hours of Freudian analysis; and strapped her down for electroshock treatments, 14 shocks the first time through and 16 the second, according to her medical records. Nothing changed, and soon enough the patient was back in seclusion on the locked ward.

A classic example of the borderline that even these days gets misdiagnosed and sent through a round of treatments that are very unlikely to cause benefit for a borderline patient authorized by a psychiatrist who knows hardly anything of DBT other than it's the answer to the board exam question as the treatment for borderline PD.

Glad she came up with DBT. Wish more people utilized it and stopped viewing any sort of problematic behavior as something solvable by medications.

There is a part of me that is skeptical that she has/had true BPD because she was discharged in 63 with no real effective treatments (per the article) and she was able to hold a job and get a psychology PhD by 1971

Well, we can only take her word on it, but IMHO, I believe she did have borderline PD because the development of DBT is something that IMHO could've only been developed by someone who had borderline PD, got to some degree a milder form of it, if not completely over it, and then self-analyzed why they got better and made a therapy out of it. IMHO one could only come up with concepts such as radical acceptance if they can phenomenologically understand borderline PD. It's something that most people don't understand even after dealing with borderline patients for years.

I've also noticed that several people with a mental illness situation choose to study it either in a psychology or psychiatry curriculum. Further, borderline PD often-times mellows out with time. She came from money. It's realistically possible that her family provided her a cushion where she could still go to school, and get second and third chances despite past problems. Most of the borderlines I know without money are the ones that fall to the point where they are picked up by community services. Usually the ones from money I've seen are picked up by parents over and over. Thankfully some of them do get better.

Even if she didn't have borderline PD, the more important thing is that she developed something that does actually work to treat it quite well.

But IMHO, her story is certainly out of the ordinary.

 

[Technotronic]

🙂

 

[whopper]

Why can't a brother doubt, especially when it affects so many other people and the story doesn't add up.

Possibly a problem with simply communicating via text. I got no problem with doubts, and my response was merely a retort meant on a friendly level. When we talk via text, people could interpret a friendly post as oppositional, and vice versa.

I have seen people with borderline PD get better without therapy, but with good therapy, the duration of the disorder should be much less. In the situations where I've seen the person get better, the person does learn over time, via making several mistakes, to not engage in similar behaviors. After years of it, and probably due to other factors (such as the hormones mellowing out, a sex drive doesn't mix well with borderline PD, having a positive loving relationship with someone of extreme patience who can accept the person's disruptive tendencies), it's not out of the ordinary for someone to get better.

Other things, which may act as therapy, such as adopting zen meditation could help, in fact Linehan did adopt some principles of eastern philosophy into DBT.

As for being high-functioning, I know someone with borderline PD that got into Columbia (not the medical school or residency), in fact had some highly successful ventures (if you look at it from a C.V. sense) in her life, if anything, possibly helped by her borderline PD. Let's just say that her family's money, coupled with her being attractive, and sleeping with the right people got her places. She's one of the people I mentioned that did get better on her own over time. Eventually this person did go to Cornell for graduate school, based on real merit, though she spent about 8 years "finding herself" after undergrad. The borderline in this case wasn't severe enough for hospitalization, but it was there.

I know someone who got into another prestigious institution for residency, was histrionic but in a manner that was let's say "ticklish" to men, and it got her places as well. I can only say that I hope her manipulative tendencies have gotten better.

People are complicated and so is borderline PD. I've seen several rotten kids get into highly prestigious programs, didn't even do well at the program, but thanks to some good old buttkissing and family connections, then continue to still get places. Yeah, no one liked them, they weren't good workers, but still happened.

(Not that Linehan was like that, but I don't find it impossible or close to it that with borderline PD, if she had it, that she got to where she is).

 

[futureapppsy2]

She probably had super-mild personality disorder

JMHO, but I really don't see how people can call multiple suicide attempts, extensive self-harm, three years of isolated psychiatric hospitalization, and years of suicidal ideation "mild." Granted, she did much improve/recover (completely?), but still, that's a pretty extensive, serious history there. Good for Linehan for "coming out"--I do wonder if she'll feel any professional backlash from this, even as prominent and well-respected as she is. Psychology/mental health in general can have a lot of stigma with regards mental health problems, even a history thereof.

 

[whopper]

Granted, she did much improve/recover (completely?)

Linehan has, at DBT workshops she teaches at, told the audience that she regularly meditates to the degree where she's attended temples, Catholic contemplative prayer, and has mentioned she's had borderline PD traits to some degree, though never to what I've seen in the NY Times article.

A buddy of mine (who is now one of my bosses) did some work at U. Washington, and while he did not know her well or even interact with her. He told me the local rep was that she was incredibly talented, but also had a hot-button for psychiatrists that were quick to medicate and didn't listen to patients, and some people said that she told them DBT was a product of her own experiences.

At first I didn't give it much thought, and simply thought it was a rumor, but the more I did think about it, the more I came to an opinion that one could not have established DBT unless they had borderline PD themself because it's highly based on dealing with internal thought processes that are difficult on the outside to assess, not based on external regulation. As I said above, I've seen some therapists deal with borderline patients for several years and still have no idea on understanding or treating them who have not taken the time to study DBT.

As for the other elements of the rumor, the NY Times article seems to support it. Still don't know how true it is but I find it believable.

 

[Manicsleep]

@futureapppsy I think the super-mild thing was sarcasm. Notice the question mark at the end of the sentence.

I see a lot of borderlines. I do DBTish therapy and used to follow the linehan model completely until I realized there were other models that were just as effective. I agree that medications are not the end all but they do work if used with therapy.

One thing I don't see is patients with borderline personality disorder get better spontaneously. It doesn't happen. Many people are given this label when it is just some borderline/cluster B traits and often its not even just borderline. They have narcissism as well as histrionic aspects but they all get called borderline especially if they are young women with a depressed mood and have life stressors as well as self injurious behavior.

Like I said in my previous post, we don't know what the reality was, it happened 50 years ago. Even Linehan's memory of that has to be distorted from the actual truth. But based on the few facts, a 17 yo gets hospitalized for SIB, is released at 19 and by 27 has a PhD in psychology without any treatment for BPD, its unlikely that she had the disorder but more likely had strong traits which allowed her to have some insight.

 

[cara susanna]

What struck me about Linehan's description of herself as a teenager/young adult is that she describes affective instability and self-harm behaviors, but she doesn't seem to talk about that interpersonal component that is so essential to BPD. It's hard to know if she'd meet criteria for the disorder without hearing about those other features. I don't think you can argue that she didn't demonstrate actual Borderline pathology simply because she was able to get her PhD. Remember the idea of "apparent competence"--when things are going well, an individual's functioning is better to the point where you may not even realize he/she has BPD.

 

[kugel]

For me, Linehan's personal history with mental health problems sort of evens itself out. It gives her a credibility, but it also affects my trust of her objectivity. For me, its a wash.

As for DBT being "state of the art"

Borderline personality disorder.
Leichsenring F - Lancet - 1-JAN-2011; 377(9759): 74-84
Recent research findings have contributed to an improved understanding and treatment of borderline personality disorder. This disorder is characterised by severe functional impairments, a high risk of suicide, a negative effect on the course of depressive disorders, extensive use of treatment, and high costs to society. The course of this disorder is less stable than expected for personality disorders. The causes are not yet clear, but genetic factors and adverse life events seem to interact to lead to the disorder. Neurobiological research suggests that abnormalities in the frontolimbic networks are associated with many of the symptoms. Data for the effectiveness of pharmacotherapy vary and evidence is not yet robust. Specific forms of psychotherapy seem to be beneficial for at least some of the problems frequently reported in patients with borderline personality disorder. At present, there is no evidence to suggest that one specific form of psychotherapy is more effective than another. Further research is needed on the diagnosis, neurobiology, and treatment of borderline personality disorder.Copyright © 2011 Elsevier Ltd. All rights reserved.

 

[cara susanna]

DBT efficacy is hard to determine because it has 24/7 therapist availability, which most comparison treatments do not offer.

 

[billypilgrim37]

Like 12 step programs, DBT is a bit like a religion. When I review DBT skills w/ pts, go over their diary cards, etc., I feel like a bit of a cult leader.

But it's such a well-developed system, if you can get a pt to buy into it, they may have just bought themselves a much better life. That's not such a bad thing. DBT has remarkable face validity, in that the affective reactivity is what gets our patients into so much trouble, and that's exactly what folks work on.

The "cult" effects are typically what make it hard to craft research methodologies that really capture how helpful a treatment is. DBT for all borderlines is probably not as helpful as DBT for the borderlines who think DBT is made of magic and rainbows, of which there are lots. And I'm pretty sure there are lots of nonspecifics that go into whether an addict engages in AA or NA, some of which have probably been measured, and some of which probably haven't been. But like an estrogen receptor positive breast tumor responds well to certain pharmacotherapy, a "DBT-receptor positive borderline" can have a pretty miraculous recovery compared to other treatments.

 

[Technotronic]

🙂

 

[whopper]

One thing I don't see is patients with borderline personality disorder get better spontaneously. It doesn't happen.

I've seen borderlines get better without professional therapy, but these people had things in their life that highly emulated therapy such as a desire to get better, a positive and close relationship with someone with extreme patience, etc. It's rare. I've also seen several symptoms dampen in intensity, though I don't think it's because the disorder necessarily got better. It's more likely, IMHO, that the person was just getting older, and some things that lead to the impulsivity criteria, such as a strong sex drive, just happen to weaken.

I know a psychiatrist with borderline PD. She never had it to the point of hospitalization, nor did she do any of the parasuicidal behaviors. Her homelife was excessive chaotic, in fact on one occasion, one of her kids called the police on her because she was verbally abusing him excessively, then slapped him. The police officer took it to just be "discipline." In any case, no one at her job knew about it because at work, she put on a good face, but at home, she was borderline to the point of dysfunctional family, GAF of low 60s.

At the wedding of her daughter, I saw an episode where she was screaming at her daughter during a photoshoot, claiming something to the effect of the daughter was "jealous" of her and that the wedding was a nightmare (which by the way was beautiful except for the above) and it must've been the daughter's "revenge" for the years of torment the mother gave her. The daughter was in tears.

But like I said, this psychiatrist, when she showed up to work, never showed any traits. I guess she had enough insight to know to keep that aspect of herself quiet in that setting.

She had the following criteria

A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
Identity disturbance: markedly and persistently unstable self-image or sense of self.
Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days).
Chronic feelings of emptiness
Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms

I knew about this person because they lived next-door to me while growing up. I was close with their kids, and I knew what was going on behind closed doors. I did some work at the hospital she worked at.

The disorder comes in various degrees. We psychiatrists often see the worst parts of the spectrum. Lots of people have it, but to a degree where they don't have to be hospitalized, and can function in society, though with problems.

This person I mentioned, also worked in a setting where psychiatric patients were often medicated, the patients had a severe mental disorder (e.g. psychosis to a bad extreme) and psychotherapy wasn't often utilized. I speculate that her own lack of psychotherapy knowledge did not give her nudge to introspect herself and her own issues.

Point being that someone with a high level of education and achievement can still suffer from a personality disorder.

 

[digitlnoize]

I don't see how this is any different than the cardiologist who has a hx of heart disease, or the doc who went into heme-onc because he survived a childhood cancer. Given the prevalence of mental illness, I'm not surprised that there are a ton of docs with depression, personality disorders, etc. I mean, how many narcissistic surgeons do we all know? 🙂

 

[cara susanna]

The difference is that most personality disorders are actually in some way adaptive in some situations. Narcissists for instance could do very well in a surgical career because they're independent, confident, the career affords them high respect, and they don't really have to interact with patients. Borderline PD is considered so severe and inherently maladaptive in that there are really no circumstances in which it can be considered adaptive.

As for 8 years of apparent competence... I dunno, really. I think that there's a missing piece in the puzzle, for sure. I just don't think we can say that she for sure didn't have Borderline PD simply because she was able to achieve so much. I think either she maybe did just have certain features of the disorder and not other, or if she did have them, she practiced DBT-ish techniques on herself (before DBT was even formed). DBT's #1 strength is that it decreases problematic behaviors, even if it doesn't decrease the thoughts/emotions that are fueling them.

 

[digitlnoize]

The difference is that most personality disorders are actually in some way adaptive in some situations. Narcissists for instance could do very well in a surgical career because they're independent, confident, the career affords them high respect, and they don't really have to interact with patients. Borderline PD is considered so severe and inherently maladaptive in that there are really no circumstances in which it can be considered adaptive.

I know...hence the smiley face. That being said, people overcome disabling conditions all the time.

How about the blind MD: http://www.msnbc.msn.com/id/7318398/ns/health-health_care/t/blind-medical-student-earns-md/

Or the wheelchair-bound DO: http://www.seattlepi.com/default/article/Meet-David-Card-the-doctor-in-a-wheelchair-892535.php

Another good article about disabled medical students: http://nfb.org/legacy/bm/bm04/bm0401/bm040106.htm

Or the Quadriplegic Doctor: http://medicaleconomics.modernmedic...uld-you/ArticleStandard/Article/detail/124144 (about half way down the page).

Or, the one-handed medical student (now a graduate): http://www.do-online.org/TheDO/?p=1096&page=2

I know Borderline PD is a serious illness, and can drastically affect the real-world performance of many people. Still, I can see someone overcoming even this, in light of the obstacles others have overcome. Is it normal? Obviously not. Can it be done? Anything is possible...

 

[cara susanna]

Yes, I definitely agree with you there.