Pharmacological treatment of BPD

[LadyHalcyon]

While I know bpd is best treated through therapy, I was wondering if anyone has seen an improvement of emotional liability with certain drugs. For example, have you had more success with mood stabilizers like Lamictal vs an SSRI like Lexapro?

Sent from my SM-G950U using SDN mobile

---

Members don't see this ad.

 

[Drrrrrr. Celty]

I feel like most in-patient BPD pts end up on seroquel for mood stabilization after they inevitably fail to resolve symptoms with an SSRI.

 

[LadyHalcyon]

I feel like most in-patient BPD pts end up on seroquel for mood stabilization after they inevitably fail to resolve symptoms with an SSRI.

What about outpatient?

Sent from my SM-G950U using SDN mobile

 

[FlowRate]

I don't know if I can legally post the whole thing online, but here's the table summary of a nice related article:

 

[Armadillos]

I feel like most in-patient BPD pts end up on seroquel for mood stabilization after they inevitably fail to resolve symptoms with an SSRI.

Completely anecdotal but I’ve by far had the most luck with seroquel when it comes to helping BPD symptoms. And I feel like I can justify it due to the depression augmentation indication.

 

[clausewitz2]

Completely anecdotal but I’ve by far had the most luck with seroquel when it comes to helping BPD symptoms. And I feel like I can justify it due to the depression augmentation indication.

I think anything that is notably sedating and introduces some time between thought and action is going to be perceived as helpful by many BPD folks. Low dose Thorazine can play the same role. I saw one lady who once successfully got haldol prn q2 hours for almost 2 days while inpatient because she really liked how it made her not feel things.

Open question if this is a desirable outcome.

More generally, GPM principles all the way. Have specific target symptoms, figure out how you are going to measure them, if a drug is not having a measurable effect taper off. Lean hard into the medical model, sometimes a temporary identity as a patient with a condition that steadily gets better over time is not a bad thing.

 

[LadyHalcyon]

I don't know if I can legally post the whole thing online, but here's the table summary of a nice related article:

Thank you so much!

Sent from my SM-G950U using SDN mobile

 

[LadyHalcyon]

I think anything that is notably sedating and introduces some time between thought and action is going to be perceived as helpful by many BPD folks. Low dose Thorazine can play the same role. I saw one lady who once successfully got haldol prn q2 hours for almost 2 days while inpatient because she really liked how it made her not feel things.

Open question if this is a desirable outcome

She is young and so ideally I don't want her to be a zombie or have metabolic syndrome. That being said, her symptoms are worsening and her "coping" behaviors are escalating. Lexapro isn't cutting it for her at all.

Sent from my SM-G950U using SDN mobile

 

[st2205]

I get most traction with Lamictal, plus the whole dosing schedule gives you reason to persist.

 

[DisorderedDoc417]

After Antidepressant trials, Agree with lamictal above. The metabolic side effects of a seroquel are quite nasty. Lamictal is well tolerated if they can follow your instructions it seems to be one of the best tolerated of the mood stabilizers. With seroquel, If using low doses you’re not really getting the mood stabilizing effect. If just giving for insomnia —- smh.

Anecdotally seem to hear some luck with loxapine. Kind of get the antidepressant benefits in addition to mood. See Latuda, some of the newer players on the block of insurance can swing it.

Abilify at lower dose Is fairly common although I’m not a huge believer yet in my own patients.

There are definitely some options, but you’re chasing symptoms in a population that is both prone to catastrophizing and magnifying not only symptoms but also medication side effects as I’ve come to see more in the out pt setting. You’re trying to put out fire with a hose and they are quivk to call in and complain that they are now soaked. They also struggle to identify the incremental and gradual improvement you might expect to see, especially if trapped in all or nothing type patterns leading to likely inaquate trials that add up FAST. It is tough, there is no question about it. Id also love to see what other people think works. Benzos and stimulants don’t seem to be the answer in most cases unless addressing acute Comorbid dx.

*written on iPhone please forgive the errors.

 

[ryerica22]

After Antidepressant trials, Agree with lamictal above. The metabolic side effects of a seroquel are quite nasty. Lamictal is well tolerated if they can follow your instructions it seems to be one of the best tolerated of the mood stabilizers. With seroquel, If using low doses you’re not really getting the mood stabilizing effect. If just giving for insomnia —- smh.

Anecdotally seem to hear some luck with loxapine. Kind of get the antidepressant benefits in addition to mood. See Latuda, some of the newer players on the block of insurance can swing it.

Abilify at lower dose Is fairly common although I’m not a huge believer yet in my own patients.

There are definitely some options, but you’re chasing symptoms in a population that is both prone to catastrophizing and magnifying not only symptoms but also medication side effects as I’ve come to see more in the out pt setting. You’re trying to put out fire with a hose and they are quivk to call in and complain that they are now soaked. They also struggle to identify the incremental and gradual improvement you might expect to see, especially if trapped in all or nothing type patterns leading to likely inaquate trials that add up FAST. It is tough, there is no question about it. Id also love to see what other people think works. Benzos and stimulants don’t seem to be the answer in most cases unless addressing acute Comorbid dx.

*written on iPhone please forgive the errors.

OMG, how true. I get the weirdest complaints, that "25 mg of Lamictal is giving me amnesia" but its funny how the Xanax some of my BPD patient's take does the trick. I seriously just tell them that no amount of medication I will ever give them will be able to replace therapy.

 

[LadyHalcyon]

Definitely no benzos or stimulants as has a budding addiction problem (came to last session stoned). Mom also recently died of drug overdose. My thoughts were either adding abilify to the lexapro or switching to a mood stabilizer like Lamictal. But honestly this whole situation is a ticking time bomb and her guardians seem to think everything will be fine because they just bought a puppy for the household

Sent from my SM-G950U using SDN mobile

 

[Dharma]

Clear communication and education regarding the disorder is key. Hopefully at some point the diagnosis was thoroughly explained. I find that such a session can be empowering for the patient and the vast majority respond favorably. The earlier this occurs the better.

Setting expectations regarding the likelihood of successful pharmacological treatment of a personality disorder is paramount especially in these cases where the patient has a scroll of previous medications (and all of the "side effects"). The patients whom seem to be the most troublesome are those who have had providers who apparently gave into the endless (impossible?) pursuit of targeting poor coping skills with medications. When I see that, it's time to reset expectations, although it is not always the easiest conversation to have.

Personally I have found with these situations, it is often important to ask oneself: Whose distress am I treating? The patient's or my own?

All of that said, I like the idea of Lamictal but mostly in those "my bipolar" cases. (You know you have those). Other than that, I target the mood/anxiety/trauma disorder and push hard for therapy (again with that realistic expectation of Rx improvement talk).

Off topic: Is it just me or are resident clinics full to the brim with cluster B? Is it like this in the big kid world of outpatient psychiatry?

 

[splik]

Off topic: Is it just me or are resident clinics full to the brim with cluster B? Is it like this in the big kid world of outpatient psychiatry?

resident clinics are overrepresented by personality disordered patients. one of my psychoanalytic supervisors during residency would say it was diagnostic if a patient chose to seek care in a resident clinic. patients in the real world are more treatable.

 

[NickNaylor]

There is a relatively recent Cochrane review of pharmacological treatment of borderline personality disorder. That would probably be a good place to start: Drug treatment for borderline personality disorder

 

[Ironspy]

resident clinics are overrepresented by personality disordered patients. one of my psychoanalytic supervisors during residency would say it was diagnostic if a patient chose to seek care in a resident clinic. patients in the real world are more treatable.

This is the most hopeful thing I have ever read online

 

[st2205]

OMG, how true. I get the weirdest complaints, that "25 mg of Lamictal is giving me amnesia" but its funny how the Xanax some of my BPD patient's take does the trick. I seriously just tell them that no amount of medication I will ever give them will be able to replace therapy.

I would usually go this route but I find that I can’t absokutely insist therapy as a process of improvement because the dearth of therapists who would be able to engage in appropriate therapy without some level of collusion. While I find it to be the best option on paper, I find we achieve that in reality in a minority of cases.

 

[LadyHalcyon]

There is a relatively recent Cochrane review of pharmacological treatment of borderline personality disorder. That would probably be a good place to start: Drug treatment for borderline personality disorder

Thanks for the resource!

Sent from my SM-G950U using SDN mobile

 

[romanticscience]

Clear communication and education regarding the disorder is key. Hopefully at some point the diagnosis was thoroughly explained. I find that such a session can be empowering for the patient and the vast majority respond favorably. The earlier this occurs the better.

Setting expectations regarding the likelihood of successful pharmacological treatment of a personality disorder is paramount especially in these cases where the patient has a scroll of previous medications (and all of the "side effects"). The patients whom seem to be the most troublesome are those who have had providers who apparently gave into the endless (impossible?) pursuit of targeting poor coping skills with medications. When I see that, it's time to reset expectations, although it is not always the easiest conversation to have.

Personally I have found with these situations, it is often important to ask oneself: Whose distress am I treating? The patient's or my own?

All of that said, I like the idea of Lamictal but mostly in those "my bipolar" cases. (You know you have those). Other than that, I target the mood/anxiety/trauma disorder and push hard for therapy (again with that realistic expectation of Rx improvement talk).

Off topic: Is it just me or are resident clinics full to the brim with cluster B? Is it like this in the big kid world of outpatient psychiatry?

I'm someone who worked in one of these clinics who transitioned to private practice. Many of my patients end up in resident clinics because of the soft limits that are difficult to enforce in a system (eg, aversion to discharging from a community clinic). Unfortunately, patients can't adhere to the frame of my private practice and end up in the community resident clinic.

Related to this topic is the high level of drop-out both in evidence-based BPD psychotherapies and medication trials. I'm trained in TFP and I believe the drop out rate in the RCT was ~30%. I do more GPM (Gunderson, 2015) now; the supportive structure retains more patients.

 

[ryerica22]

Clear communication and education regarding the disorder is key. Hopefully at some point the diagnosis was thoroughly explained. I find that such a session can be empowering for the patient and the vast majority respond favorably. The earlier this occurs the better.

Setting expectations regarding the likelihood of successful pharmacological treatment of a personality disorder is paramount especially in these cases where the patient has a scroll of previous medications (and all of the "side effects"). The patients whom seem to be the most troublesome are those who have had providers who apparently gave into the endless (impossible?) pursuit of targeting poor coping skills with medications. When I see that, it's time to reset expectations, although it is not always the easiest conversation to have.

Personally I have found with these situations, it is often important to ask oneself: Whose distress am I treating? The patient's or my own?

All of that said, I like the idea of Lamictal but mostly in those "my bipolar" cases. (You know you have those). Other than that, I target the mood/anxiety/trauma disorder and push hard for therapy (again with that realistic expectation of Rx improvement talk).

Off topic: Is it just me or are resident clinics full to the brim with cluster B? Is it like this in the big kid world of outpatient psychiatry?

I tried this with some patients and they like to have their phone out with me during session, just argue with me and then fire me as their doctor.

Also, with BPD Patients, I oftentimes find that they don't want any medication to work or want to get better because their families/households have given them so many free passes to act however they want to, that it rewards them.

 

[ryerica22]

Definitely no benzos or stimulants as has a budding addiction problem (came to last session stoned). Mom also recently died of drug overdose. My thoughts were either adding abilify to the lexapro or switching to a mood stabilizer like Lamictal. But honestly this whole situation is a ticking time bomb and her guardians seem to think everything will be fine because they just bought a puppy for the household

Sent from my SM-G950U using SDN mobile

Wow I love how the guardians are giving them a puppy instead of going for DBT. Super guardians.

 

[LadyHalcyon]

Wow I love how the guardians are giving them a puppy instead of going for DBT. Super guardians.

We are meeting today to review her diagnosis and treatment recommendations. But yeah, they are a trip

Sent from my SM-G950U using SDN mobile

 

[DisorderedDoc417]

This is the most hopeful thing I have ever read online

I’m still going to end up inpatient. Partly for this exact reason.

 

[LadyHalcyon]

I tried this with some patients and they like to have their phone out with me during session, just argue with me and then fire me as their doctor.

Also, with BPD Patients, I oftentimes find that they don't want any medication to work or want to get better because their families/households have given them so many free passes to act however they want to, that it rewards them.

I see frequent ambivalence toward improvement because they believe certain behaviors are the only ones that allow them to get their emotional needs met by their family. Usually come from a very invalidating environment. As a result, they have learned to escalate their behavior/distress in order to get someone to pay attention. One of the most important pieces of therapeutic work is helping them understand they don't need to be in crisis to ask for what they need.

Sent from my SM-G950U using SDN mobile

 

[clausewitz2]

Clear communication and education regarding the disorder is key. Hopefully at some point the diagnosis was thoroughly explained. I find that such a session can be empowering for the patient and the vast majority respond favorably. The earlier this occurs the better.

Setting expectations regarding the likelihood of successful pharmacological treatment of a personality disorder is paramount especially in these cases where the patient has a scroll of previous medications (and all of the "side effects"). The patients whom seem to be the most troublesome are those who have had providers who apparently gave into the endless (impossible?) pursuit of targeting poor coping skills with medications. When I see that, it's time to reset expectations, although it is not always the easiest conversation to have.

Personally I have found with these situations, it is often important to ask oneself: Whose distress am I treating? The patient's or my own?

All of that said, I like the idea of Lamictal but mostly in those "my bipolar" cases. (You know you have those). Other than that, I target the mood/anxiety/trauma disorder and push hard for therapy (again with that realistic expectation of Rx improvement talk).

Off topic: Is it just me or are resident clinics full to the brim with cluster B? Is it like this in the big kid world of outpatient psychiatry?

University clinics tend

resident clinics are overrepresented by personality disordered patients. one of my psychoanalytic supervisors during residency would say it was diagnostic if a patient chose to seek care in a resident clinic. patients in the real world are more treatable.

I tried this with some patients and they like to have their phone out with me during session, just argue with me and then fire me as their doctor.

Also, with BPD Patients, I oftentimes find that they don't want any medication to work or want to get better because their families/households have given them so many free passes to act however they want to, that it rewards them.

Family psychoeducation is very important in situations like these with BPD. Do you have a release? Can a family member come to their appointment?

 

[LadyHalcyon]

University clinics tend



Family psychoeducation is very important in situations like these with BPD. Do you have a release? Can a family member come to their appointment?

Yup. Just had appointment with pt and parents. Trying to explain the criteria for bpd and emphasize the importance of emotional validation and about 30 seconds later they do exactly what I said not to do.

Sent from my SM-G950U using SDN mobile

 

[Dharma]

I tried this with some patients and they like to have their phone out with me during session, just argue with me and then fire me as their doctor.

Mission accomplished.

 

[Orgone]

Lexapro isn't cutting it for her at all.

I see what you did there . . .

patients in the real world are more treatable.

As a 4th year moonlighting in an outside clinic, I remember being shocked that the patients were actually . . . getting better. And on something like prozac.

As opposed to the resident clinic standard SSRI + Buspar/Wellbutrin + 2 Mood Stabilizers + Antipsychotic + Benzo +/- stimulant (if they were charming).

 

[st2205]

I see what you did there . . .



As a 4th year moonlighting in an outside clinic, I remember being shocked that the patients were actually . . . getting better. And on something like prozac.

As opposed to the resident clinic standard SSRI + Buspar/Wellbutrin + 2 Mood Stabilizers + Antipsychotic + Benzo +/- stimulant (if they were charming).

Resident clinic: where the attending has to do no work nor have to suffer through this misery, but is able to collect the massive RVU windfall that’s possible nowhere else in medicine.

*Cue “OMG you have no idea how much selfless sacrifice we make to educate [i.e. submit charges] residents.”

 

[FlowRate]

Resident clinic: where the attending has to do no work nor have to suffer through this misery, but is able to collect the massive RVU windfall that’s possible nowhere else in medicine.

*Cue “OMG you have no idea how much selfless sacrifice we make to educate [i.e. submit charges] residents.”

Interesting, we see patients individually, so the attendings don't bill.

Edit: except for intakes and one or two specific slots, if we want them to join, in which case they can bill.

 

[clausewitz2]

Interesting, we see patients individually, so the attendings don't bill.

Our clinics are not consistent on this, some attendings at some clinics do see every patient and some attendings at some clinics don't see any. have not noticed any huge difference in how our resident clinics operate that lines up with this.

 

[PikminOC]

This is an excellent thread. It is a ticking time bomb. I just discharged one of these. Her mom wrote me a letter about how horrid of a psychiatrist I am and that I have to take the patient (adult female) back or she will report me to the med board.

 

[NickNaylor]

This is an excellent thread. It is a ticking time bomb. I just discharged one of these. Her mom wrote me a letter about how horrid of a psychiatrist I am and that I have to take the patient (adult female) back or she will report me to the med board.

Sounds like you're getting a two-for-one in that situation.

 

[LadyHalcyon]

This is an excellent thread. It is a ticking time bomb. I just discharged one of these. Her mom wrote me a letter about how horrid of a psychiatrist I am and that I have to take the patient (adult female) back or she will report me to the med board.

Well the apple doesn't fall far from the tree now does it....

Sent from my SM-G950U using SDN mobile

 

[ryerica22]

Our clinics are not consistent on this, some attendings at some clinics do see every patient and some attendings at some clinics don't see any. have not noticed any huge difference in how our resident clinics operate that lines up with this.

The attending can just pop in and say hello/bye? That is enough for billing?

 

[clausewitz2]

The attending can just pop in and say hello/bye? That is enough for billing?

The clinics where they do not see our patients is just that, they do not see them at all under ordinary circumstances. We bill 99211 in those cases.

To be clear, we do get supervision regularly on our cases and the attendings are usually down the hall if emergency consultation is needed, but the autonomy is nice.

Other clinics in our system are more traditional and we have to budget the last 10 minutes or so of an appointment for staffing/attending to see them.

 

[ryerica22]

The clinics where they do not see our patients is just that, they do not see them at all under ordinary circumstances. We bill 99211 in those cases.

To be clear, we do get supervision regularly on our cases and the attendings are usually down the hall if emergency consultation is needed, but the autonomy is nice.

Other clinics in our system are more traditional and we have to budget the last 10 minutes or so of an appointment for staffing/attending to see them.

that's good to know that you have a nice mix. Other residency programs are not so lucky.

 

[ryerica22]

I hate to say it, but some Borderline patient's really do just belong in jail just as some Antisocial pts do. This is for the ones that refuse to try DBT, refuse to try any med besides Xanax and are so profane/vulgar I just have to walk away.

I may sound harsh, but unfortunately, I have had to encounter a lot of very resistant borderline patients in my time.

 

[splik]

I hate to say it, but some Borderline patient's really do just belong in jail just as some Antisocial pts do. This is for the ones that refuse to try DBT, refuse to try any med besides Xanax and are so profane/vulgar I just have to walk away.

I may sound harsh, but unfortunately, I have had to encounter a lot of very resistant borderline patients in my time.

you've obviously never worked in a women's jail or prison. women's correctional institutions are full of borderlines. they do exceptionally poorly in correctional settings. while it might be appropriate for some borderline patients to be incarcerated because of the crimes they have committed or are charged with, your post makes it sound like patients with mental illness should be jailed without cause. i hope that is not what you meant to say.

 

[LadyHalcyon]

I hate to say it, but some Borderline patient's really do just belong in jail just as some Antisocial pts do. This is for the ones that refuse to try DBT, refuse to try any med besides Xanax and are so profane/vulgar I just have to walk away.

I may sound harsh, but unfortunately, I have had to encounter a lot of very resistant borderline patients in my time.

From my work with that population, at least half of individuals in jails or prisons are cluster B. I'm sure that number is high, but it sure does FEEL like it's at least 50% when you are working in prisons etc.

Sent from my SM-G950U using SDN mobile

 

[clozareal]

The largest RCT (N=195) looking at Lamictal for patients with borderline personality disorder concluded that it wasn't clinically effective or cost-effective compared to placebo.

The Clinical Effectiveness and Cost-Effectiveness of Lamotrigine in Borderline Personality Disorder: A Randomized Placebo-Controlled Trial. - PubMed - NCBI

Another small RCT (N=27) looked at aggression in women with borderline personality disorder and found it to be effective.

Lamotrigine treatment of aggression in female borderline-patients: a randomized, double-blind, placebo-controlled study. - PubMed - NCBI

 

[ryerica22]

you've obviously never worked in a women's jail or prison. women's correctional institutions are full of borderlines. they do exceptionally poorly in correctional settings. while it might be appropriate for some borderline patients to be incarcerated because of the crimes they have committed or are charged with, your post makes it sound like patients with mental illness should be jailed without cause. i hope that is not what you meant to say.

No I have not worked in a women's jail. I also NEVER meant to say that patient's with Borderline Personality or Other Mental Illness deserve to be in jail without cause. I'm simply saying that we shouldn't give Borderline Personality Patient's a free pass to be physically assaultive or aggressive to other people. There are tons of borderline patient's who need to be incarcerated because of the crimes they get away with.

 

[birchswing]

From my work with that population, at least half of individuals in jails or prisons are cluster B. I'm sure that number is high, but it sure does FEEL like it's at least 50% when you are working in prisons etc.

Sent from my SM-G950U using SDN mobile

From my lay knowledge, a lot of the cluster b disorders stem from developmental issues (abuse, neglect).

I'm wondering in a prison population how many people could reasonably be expected to maintain a healthy personality. Prison features the abuses and neglect that mirror a bad childhood. The idea and philosophy of a prison itself is of inherent badness, and prisoners are in a way going through a reparenting process, which itself is controversial in the world of therapy but in the setting of a prison I don't think would be considered particularly healthy.

So I guess I'm saying if a person already had a personality disorder which caused a propensity to do things that landed them in prison, the prison might not be rehabilitative. But furthermore if you had someone on the edge of the propensity for maladaptive coping, then put them in the physical/mental stress of a prison, could you really argue that there is such a thing as a normal/healthy outcome? I feel like there are some situations in which the expected outcome of even the most hardy, emotionally balanced individual would be that the person would become messed up. I guess some don't, or at least they have the propensity to contain the pains internally. I mean Martha Stewart came out the other side OK from what we can see on the outside, but she was made of very stocky stuff before she went in and she had family support along with legions of fans supporting her.

As an analogy the military won't take people who have severe mental distress, but people who were mentally healthy enough to join will leave sometimes in a very mentally distressed way. Prisons are different in that they take people with a propensity for maladaptive coping and then expose them to more negative situations.

 

[ryerica22]

From my lay knowledge, a lot of the cluster b disorders stem from developmental issues (abuse, neglect).

I'm wondering in a prison population how many people could reasonably be expected to maintain a healthy personality. Prison features the abuses and neglect that mirror a bad childhood. The idea and philosophy of a prison itself is of inherent badness, and prisoners are in a way going through a reparenting process, which itself is controversial in the world of therapy but in the setting of a prison I don't think would be considered particularly healthy.

So I guess I'm saying if a person already had a personality disorder which caused a propensity to do things that landed them in prison, the prison might not be rehabilitative. But furthermore if you had someone on the edge of the propensity for maladaptive coping, then put them in the physical/mental stress of a prison, could you really argue that there is such a thing as a normal/healthy outcome? I feel like there are some situations in which the expected outcome of even the most hardy, emotionally balanced individual would be that the person would become messed up. I guess some don't, or at least they have the propensity to contain the pains internally. I mean Martha Stewart came out the other side OK from what we can see on the outside, but she was made of very stocky stuff before she went in and she had family support along with legions of fans supporting her.

As an analogy the military won't take people who have severe mental distress, but people who were mentally healthy enough to join will leave sometimes in a very mentally distressed way. Prisons are different in that they take people with a propensity for maladaptive coping and then expose them to more negative situations.

Don't do the crime, if you can't pay the time.

 

[birchswing]

Don't do the crime, if you can't pay the time.

Treat the criminal in a way such that you expect to live next door to them when they are released because you might, or at least want that for the people they do end up living next door to and enter the lives of.

 

[ryerica22]

It's totally unfair that some borderline patients get to slap people, use physical violence, create a scene in public places with their hysteria/panic and that they get their way. I've seen grown women create a tantrum about the fact that Nordstroms won't return their perfume and get their way. Security should have been called, but, no, they just get away with their behavior and get rewarded for it. On the other hand, when you are civil and polite, you get a stern "NO!".

Maybe I'm a bit jaded and cynical, but I feel we diagnose too many axis 1 disorders when the true disorder is just Borderline Personality Disorder. I tend to laugh to myself when I see interns coming up with strange diagnoses in DSM V when they completely ignore BPD. No doubt there is often co-occuring substance abuse, anxiety/depression, etc. but we are all very reluctant to diagnose BPD.

 

[Amygdarya]

I've seen grown women create a tantrum about the fact that Nordstroms won't return their perfume and get their way. Security should have been called, but, no, they just get away with their behavior and get rewarded for it. On the other hand, when you are civil and polite, you get a stern "NO!"

Mmm, Toto, we're not in Kansas anymore.
I agree with you that it's fairly common to see BPD misdiagnosed as BD (and it's been discussed on this forum ad nauseum), but by giving the quoted example you're committing another error: giving a psychiatric diagnosis based on obnoxious behavior. Borderline does not mean obnoxious; in fact, being obnoxious is nowhere near the core of what borderline means.

 

[Attending1985]

Mmm, Toto, we're not in Kansas anymore.
I agree with you that it's fairly common to see BPD misdiagnosed as BD (and it's been discussed on this forum ad nauseum), but by giving the quoted example you're committing another error: giving a psychiatric diagnosis based on obnoxious behavior. Borderline does not mean obnoxious; in fact, being obnoxious is nowhere near the core of what borderline means.

Extremes of affect in people with bpd can be obnoxious. I think this is a common experience, hence walking on eggshells to avoid the fallout.

 

[Amygdarya]

Extremes of affect in people with bpd can be obnoxious. I think this is a common experience, hence walking on eggshells to avoid the fallout.

Yes, people with BPD have extremes of affect. But having extremes of affect doesn't necessarily mean being borderline, which was my point.

 

[clausewitz2]

Mmm, Toto, we're not in Kansas anymore.
I agree with you that it's fairly common to see BPD misdiagnosed as BD (and it's been discussed on this forum ad nauseum), but by giving the quoted example you're committing another error: giving a psychiatric diagnosis based on obnoxious behavior. Borderline does not mean obnoxious; in fact, being obnoxious is nowhere near the core of what borderline means.

Yeah, fair to say that if a patient tells you that anecdote you are going to spend more time assessing cluster B traits but BPD wouldn't even be my first guess if you held a gun to my head.

Re: your later post, extremes of affect are like the fever of psychiatry. Something to investigate but totally nonspecific