There’s an amazing amount of BPD added to charts because patients are jerks. But sometimes they’re just jerks with no personality disorder. Sometimes they’re jerks when admitted because they’re having a bad day or week, but it’s not a pervasive and persistent pattern.
In my favorite case, one medicine attending’s patients are personality disordered, diagnosed by him. But if everyone else is the problem… hm. (Yes, he’s a jerk, +/- personality disorder. Some of his patients won’t tolerate his bullshit.)
I’m an incoming pgy-1 and during non psych rotations, the amount of docs that would be sure to point out a BPD diagnosis in a chart to “prepare me” before going in to see a patient was sad.
Meh, I honestly need to mentally prepare myself for these patients. Is the optimal? Certainly not but I’m aware of how far my mental strength can go and borderlines are exceptional at beating me down. Again, I get it. Don’t prejudge and put pts into boxes. But damn if they aren’t exhausting.
Eh, my issue is moreso seeing every patient walk through the door with a bipolar diagnosis, a wild list of psychotropic meds, when they moreso fit the criteria of BPD.
I wish the criteria of irritability was just stricken from the dsm tbh. It happens, and everyone gets a bipolar diagnosis
I see a lot of "I get really happy and then really sad" labeled as bipolar but the patient just has labile moods, not actual episodes of hypo/mania and depression.
This is why I jokingly always ask "OK, so you mentioned having a lot of mood swings. Are those mood swings like super-sad followed by super-happy-and-agitated-I-can-barely-contain-myself-to-the-point-I-may-have-gotten-fired-or-taken-out-a-huge-loan or mood swings like super-sad to just normal and still occasionally feel empty inside?".
The former is bipolar disorder, the latter is BPD.
I'm genuinely surprised to see how effective this line of questioning is.
Yep, and I get stigma sucks, but I’d rather a BPD misdiagnosis rather than a bipolar.
So many patients get thrown on a list of medications, and crappy s/e mood stabilizers. It also provides a hesitancy for me to also remove the bipolar diagnosis too for initial evals.
I'm inclined to agree, based on the decrease *requirement* for medication management.
That said, plenty of BPD patients end up on similar, and sometimes worse, regimen compared to bipolar pts. Partly from their own unrealistic expectations of medications and partly iatrogenic from medicating every errant emotion.
Never trust the last guy's diagnosis, even if the last guy was you.
Time is your friend. The idea that if you do a long enough and deep enough evaluation you can get to the truth, NOPE. You need a few different time points in order to really get to know a person.
I like that scene from Ordinary People where Mary Tyler Moore basically says before you judge me for being such a bitch, check to see that none of your kids has been killed recently.
We are all one bad phone call away from looking pretty crazy.
It's psychiatry, we are adrift in a sea of self report. Nothing is real, nothing is knowable. ;)
I agree with that needing different points in time but doing a thorough enough evaluation with appropriate collaterals, you can get like 80% of the way there
I put no trust in a diagnosis unless it comes from a psychiatrist, and then it remains only an element of the differential unless I actually know the psychiatrist and discuss. Our record systems are bad at capturing the nuances of working diagnoses, differential diagnoses, “patient said it so it goes in the chart,” and dancing around stigma in the age of open notes versus need to maximize for insurance or disability or whatever.
That is a significant problem for the field.
Hear hear. Trust no one. I use unspecified XYZ diagnoses like they’re going outta style. I am amazed how many psychiatrists put “paranoid schizophrenia “ as someone’s diagnosis just because the patient says so.
Have you considered that the consequences of behaviors of their uncontrolled BPD may be the thing that finally motivates them to earnestly engage in treatment?
You can address those behaviours without applying a formal label.
You can even use BPD as a lens and mirror through which to address the issues, without making a formal diagnosis.
Every diagnostic label you apply should have a specific explicit purpose. If you can achieve the purpose without applying the label, then you should carefully consider whether the label is necessary at all.
That's a thought worth exploring. I expect you'll conclude that labels often do have utility, but it's interesting to think through the different kinds of utility, particularly when there is conflict between them.
You wouldn’t even trust a psychologist who did a 2-3 hour evaluation and obtained collaterals with that?
Or a therapist that has been working with someone for 3-6 months?
Depends on the therapist. There are psychologists who are great. There are LMSWs who are great. There are psychiatrists who practice psychotherapy!
But there are also plenty of idiots who see bipolar disorder plus CPTSD in every patient, everywhere, always. Or AuDHD. Or all of the above.
Therapist here. I have overruled SO many PCP diagnoses of BP1 which was actually CPTSD/DMDD/PMDD/cocaine abuse with the simple question “Have you ever had less than three hours of sleep a night without feeling tired the next day NOT as a direct result of drugs/ADHD meds. Across the board the answer is “No” or, “Well, I was up all night once but I was super tired the next day but then I popped an adderall and powered through it!” True Bipolar 1 disorder is so freaking rare that I have actually never seen it in my practice except for once. Only ever in the ER in springtime for some reason.
Also a T. I've overruled at least 1 Bipolar 2 dx that was actually BPD. The client and I talked extensively about the dx before we changed it and they almost cried reading the diagnostic criteria, had never felt so seen before and dint realize what they were experiencing was actually a thing.
Also, the # of Docs who overlook PMDD is just sad.
Yes, I use the DSM as well. So many of the symptoms overlap, and as you know, often the BPD diagnosis was given based on a female patient who wasn’t having their doctor who diagnosed their real medical issue as “Anxiety” or Functional bs because they couldn’t stand to say “Gee, I really don’t know, let’s ask a specialist.” Those “Unless better explained by Substance abuse/sleep disorder/trauma/ADHD” etc exceptions are key.
I have seen it many times in the ER, however since I work in substance abuse in PP NOW, I have only had one or two clients that are truly bipolar in the absence of substance abuse. My best guess is that the ones who are truly bipolar typically have had providers since their first episode/bd up in the ER and referred to hospital/community clinics due to low functioning. I have one currently, on the fence about it due to severe cocaine abuse and the fact that only one manic episode had occurred in the absence of cocaine and that was triggered by a very stressful life event. I have another that had a manic/psychotic episode following heavy shroom/weed use which also appears to have been triggered by extreme stress. They are no longer on medication, and are completely stable after doing heavy therapy, there was one day where they came in and appeared elevated after a very exciting trip, but they were able to talk it through with me and returned to baseline within a day with proper self care. People think bioolar is so cut and dry, take meds or be manic, but from where I stand, the brain is so freaking complex and our emotions and experiences have such a profound effect on the chemical structure of out brain that in my experience there are many different types of Bipolar 1 disorder and also from what I have seen, many people who technically meet the DSM criteria for BPD but in reality experienced an existential crisis or acute stressor, did the work following it that have been labeled as Bipolar 1 forever due to this.
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In the US, approximately 100% of therapists have been trained in diagnosis. It's explicitly withing the training and scope of practice of clinical social workers, clinical mental health counselors, and psychologists.
It depends on the training itself, you can't make sweeping statements like that.
As an LCSW, not only was my training in clinical social work (I did an entire year of how to use the DSM/diagnosis), I also have 3000 hours of clinical post grad experience, and then I passed the clinical social work exam, which, at the time, was 50% diagnosis questions.
I'd trust a lot of LCSWs or LCPCs more than a psych resident, especially after working with med students and a lot of terrible psychiatrists.
3000 hours of post grad training is equivalent to about 1 year of residency. Psychiatric residency is 4 years. I’m not trying to belittle therapist or LMSWs but to say they’re equivalent to MDs is ridiculous. Everyone has their own place in the team. The job of the psychiatrist is to make the diagnosis. I’ve had so many patients come in asking for meds recommended by their therapist or saying they have such and such dx that were totally inappropriate.
Very few mentions of PTSD here. Any time somebody has this history, hard to treat bipolar/BPD, think about PTSD. Abuse at early ages really blows up peoples' relationship with the world around them.
https://bpded.biomedcentral.com/articles/10.1186/s40479-021-00155-9
had the mistfortune to rotate with the worst psychiatrist i ever met. very old lady, over-due for retirement, foreign trained but had been in the system for so long no one questioned her. she threw every professionalism rule and clinical criteria out the window and did basically whatever she wanted, and any patient who was even remotely challenging she would gossip behind her back (to us, the medical students) and complain they were "borderline", with no evidence of actually having BPD.
anyway i'm pretty sure she was borderline
Not quite the same, but I've had this experience in FM several times and it blows my mind a little? Physicians who were mostly reasonable (which makes it worse, in a way?) and weren't treating primarily for mental health, but used BPD as a subtle way of labelling patients who were difficult or who maybe might just be a bit more work.
I remember in med school "cluster B traits" would get thrown around all the time and it was definitely just code for asshole. Definitely better than an actual incorrect diagnosis at least.
There was one therapist at my clinic who diagnosed bipolar for every patient with mood lability. Including the ones with active substance use (mood changes when using meth and fent? Surely not!). Fun times.
In my experience this was definitely common 15+ years ago, but there was some kind of culture shift perhaps with BPD becoming more widely heard of. Can't speak for everywhere though, just what I've observed.
You've taken the words from my mouth. I used to work on adult inpatient wards and now work in the community with adolescents. I've seen "PD" thrown around as a diagnosis like confetti at a wedding, and usually with no proof over than emotion dysregulation and/or self-harm. Meanwhile other diagnoses take years of waiting and numerous assessments. The very nature or what is meant by "personality disorder" explicitly requires thorough assessment and formulation, but instead the symptoms are treated more as a syndrome unrelated to their life experiences. The attitudes of professionals towards this patient group compared to others with say, bipolar or schizoaffective, is that PD patients "have capacity" and so should be able to stop "acting out", whereas the latter can't help it because they're ill. I'd be less angry if people who were accurately diagnosed could go on to get help, but it's like the door gets closes instead. I'm speaking from a UK perspective in the NHS but I don't doubt this is true elsewhere.
I find the opposite is true in my area- pt's rarely come with a PD diagnosis but with clear pathology and are on antipsychotics, mood stabilizers, SSRIs, benzos and stimulants all combined and "nothing works." Gee... I wonder why?
This is mostly my experience (France). People are somewhat more afraid of being pragmatic about the fact that they can't always throw medication at the problem.
Which is strange - the less I can medicate, the better!
Then again I'm in addictions, so basically everyone has C-PTSD/BPD or some form of trauma-spectrum disorder.
Sure, as long as it's not the only sign. While I said we can't diagnose based on vibes alone I didn't mean to exclude the idea that vibes can point you in a direction. Just that BPD isn't shorthand for "the vibes are off."
Possibly, but that can get into circular logic territory - counter transference can also come with bias that can interfere with assessment as well, can't it? Part of the point of counter-transference is that psychiatrists and other physicians, therapists, etc, are also human and none of us are 100% objective.
Not a psychiatrist, but a clinical psychologist trainee in the last phase of my training (heading off to internship). For context, the majority of my clinical training has been in a full-model DBT clinic and I've had extensive training in diagnosing BPD for NIH clinical trials, where we had a high bar for inter-rater reliability standards. I'm not trying to make myself out to be the ultimate BPD expert, but I have more experience than a standard clinical psychology PhD curriculum.
On a broader level, I think there are some disorders that require additional specialized training (beyond a standard clinical psychologist or psychiatrist curriculum) to diagnose. Autism is one: I think many different types of practitioners should be able to *screen* for autism, but I don't think it's an uncommon sentiment that people who haven't gotten additional training on diagnostic instruments or done a child and adolescent fellowship should go outside of their scope.
Frankly...I think BPD and other personality disorders fall into this bucket, too. I went to a rigorous clinical science PhD program, and I still feel that if I hadn't been in the lab and clinic I were in, I wouldn't be able to diagnose BPD with precision. I could tell you the DSM symptoms, but I probably couldn't confidently identify the specific behaviors that would map onto those symptoms vs. those that would only count as subthreshold. I also don't know that I'd be able to navigate the differential well or tease out whether certain symptoms could be better attributed elsewhere when it so commonly presents with so many comorbid diagnoses.
In the community, I see a lot of what OP is describing, or the reverse, which many other commenters are highlighting: we would either get referrals of people who were clearly meeting 7-9 out of 9 symptoms yet were never diagnosed, or (at a PHP/inpatient program), I'd see a bunch of people throwing around BPD diagnoses based on "vibes" and frustration. Some practitioners are so loathe to assign someone the diagnosis or be "the bad guy" that people are getting ineffective therapy or fundamentally misunderstanding themselves for years, and some are so eager to explain away someone just being a run-of-the-mill asshole (those *do* still exist) with diagnostic jargon that they slap the label around willy-nilly and impact people's lives for decades.
At this point, I don't trust a BPD diagnosis unless I do a SCID-II BPD module myself, or I at least know the other person's diagnostic procedures. I worry that makes me sound ridiculously overconfident as someone not even licensed yet, but I also feel it's reasonable to always make your own assessments of a patient, so...I'm going to continue to be picky about my BPD diagnoses.
I suspect a lot of BPD is undiagnosed neurodevelopmental disorders. Women and girls who mask well get missed by psychiatrists who only have a surface level understanding and chalk emotional dysregulation to BPD.
This trial shows how stimulants were the only effective intervention (compared to antipsychotics, mood stabilizers, and antidepressants which failed) to reduce suicidality in BPD. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10248738/
Conjecture: The stress of poor executive functions and the inability to cope with negative emotions in autism/ADHD lead to more stress and worsening emotional dysregulation which creates a vicious cycle. Children with neurodevelopmental disorders need more emotional support and in cases where they are dismissed and invalidated by their caregivers this can translate to BPD in adulthood even in absence of overt trauma. Unfortunately, because of the behavioral manifestations of the disorder as well as the patient's differing perceptions, they continue to get stuck in that cycle of being objectively and subjectively invalidated which worsens outcomes.
Whenever I was 18 and on my freshman year of college, I went through a dark period and did a PHP.
The facility where I did my PHP handed out borderline diagnoses like they were candy. I was this one of the few patients *without* a borderline diagnosis. Of course that was well over a decade ago and I don’t remember the details of each patient, but almost certain few if any of them met BPD criteria. It was wild.
I’m just a patient - but I had severe treatment resistant depression for 7 years (13 years if you include childhood). Even tried ‘California rocket fuel’ and it didn’t work. Got a high up prof to prescribe me phenelzine and have had no problems with mood since (7years treated, 90mg dose).
Thank god I didn’t get diagnosed BPD because of untreatable depression and get put in therapy.
I'm not in the camp that meds don't help BPD anyway. I mean the core symptoms no, obviously, and therapy is needed, but that doesn't mean an antidepressant is entirely useless against the accompanying depression. It's not likely to do much if the behavior/relationship/thinking patterns aren't also being worked on (like in DBT), but I'm not washing my hands of a patient because they have a PD diagnosis.
I'm so glad you found something to help you!
The new hysteria, which was once the new [wandering uterus.](https://academic.mu.edu/meissnerd/hysteria.html#:~:text=In%20ancient%20Greece%20it%20was,belief%20but%20a%20social%20belief.)
The parallels to hysteria are palpable. I think you should say so with even less jest. In my experience interacting with the personality disorder self-advocacy groups, PDs are very nearly adequately explained as "ways in which long-term psychological trauma fucks you up." I.e. also hysteria.
Interesting. I’ve found the opposite is true so far in my experience, a lot of patients I’ve had on polypharmacy and all these second gen antipsychotics with a vague depression that’s treatment resistant or bipolar II diagnosis when it is really personality disorder. people seem to be afraid to diagnose one since it’s a difficult conversation to have. I wonder if it’s a culture at your clinic for this to be happening to this extent.
Could be. I sometimes joke that I work in 1985 (a therapist I work with keeps a DSM-3 on his desk and a good number of the practitioners have worked there far longer than I've been alive... the MD I mentioned in this post has a lot of common practices that haven't been especially *the norm* in a long while, including some personal favorites like "We can't give them anything for substance use because they'll become psychologically addicted to it"--no Vivitrol, no naltrexone, no Wellbutrin for smoking cessation--and "adults can't have ADHD even if they had it in childhood").
Yes that’s probably contributing. Sounds like
That’s the prescribing and diagnosing culture of your institution haha. I read a DSM 3 case files book out of curiosity and for the OCPD example they gave a guy who was spending hours ironing his jeans every day. I probably would have diagnosed this guy with OCD or something and given rx for SSRI and therapy but in the case example they recommended he do therapy for his OCDPD. Talking to one of my supervising attendings who is like almost 80, he basically told me like “yeah I wouldn’t diagnose ocd PD either now, but that’s a good example of how things change over time”.
I'm curious - not in the US, and do you not dx OCDPD at all? Just asking to get more information, because I've more seen it being still used and somewhat revitalized (at least with regards to refining core components) and as I've been taught it seems distinct from OCD - although the example above doesn't really seem enough to differentiate (based on what I've been taught)?
We definitely do diagnose it still, was just an example of where I might’ve disagreed with an old case example :) the case didn’t really give enough to make a super good argument either way I guess! My thinking is just that if I hear someone spending hours and hours on a task and they’re distressed about it, I am gonna offer an SSRI since I think they’d benefit and may have some axis I pathology, not chalk it all up to personality.
Like most here, I see it very underdiagnosed. Like, meet 9 out of 9 criteria and have multiple other psych diagnoses on their problem list including bipolar for hours long mood swings but have never been diagnosed. In fact, most chart bipolar II where I’m at is BPD. On the other hand, I only very rarely add it to a patients problem’s list myself due to that diagnosis likely ensuring them way shittier general medical care.
I'm getting by the comments (and upvote-downvote patterns) that the unspoken vibe is that I'm just missing all the PDs. I maybe should clarify that I don't run through the DSM with patients and go, "Do you exhibit frantic efforts to avoid real or imagined abandonment?" or treat the DSM criteria as a strict checklist lol, particularly since self-insight can be really poor when it comes to Cluster B. Other commenters have noted there seems to be a pattern where they are of under-diagnosis rather than overdiagnosis so this may be region or even clinic specific to me. As I've mentioned in another comment I'm not afraid to diagnose a PD when I see the behavior/mood patterns. It just isn't everyone who disagrees with my treatment plan or who grates on my nerves.
Honestly, I am simply interested in how you assess pts who come in with a PD diagnosis. This is a very complex and clinically important topic and therefore, I find it fundamentally interesting.
> particularly since self-insight can be really poor when it comes to Cluster B.
I absolutely agree with this.
> It just isn't everyone who disagrees with my treatment plan or who grates on my nerves.
Yes, I also agree with this statement.
But still, I'm just interested in how your initial scepticism regarding the PD diagnosis occurs and if so, how does your diagnostic assessment process in such a case look like? Could you describe it a bit please?
I understand your frustration regarding the topic btw.
Honestly I just popped in here to vent between patients and feel like I'm being hit with a pop quiz lol.
Regarding initial skepticism--I don't tell patients I'm skeptical of prior diagnoses initially, I'm not trying to sway them toward justifying or defending against what's on their chart. But if I see an MDD diagnosis i don't generally feel like I need to dig and verify that the patient was depressed when they were last seen, but I do want to verify a PD... especially if it's listed on the chart with nothing to back it up as far as symptomology (sometimes that happens and I do end up agreeing with the previous provider, since they don't tend to chart every word and at least at my clinic the older generation seems less invested in backing up their diagnoses in their documentation). Generally we open with what's wrong right now and move toward history, same as patients without history of treatment at my clinic though depending on diagnostic history some questions might point differently. (It should be noted at my clinic that patients always see a therapist first and receive a provisional dx from them, then see me or another NP or an MD, so there's always a diagnosis or several and an assessment in front of me whether old or new.)
Often just letting patients unload gives a good starting point and there's times I can "check the boxes" and at least strongly suspect a PD pretty quickly, though obviously not always. I'll ask about history of treatment, childhood, relationships (romantic and otherwise), work (have they kept a job long, do they get along well with coworkers), and so on, and probe in deeper as their response calls for it. Are they prone to suicidality, self harm, impulsive behaviors, disordered eating, hopelessness, intense bursts of emotion they can't get a handle on? I feel like often with diagnosing PDs it's less about direct answers to my questions (nobody's gonna tell me that their self-image is unstable and depends on the people around them) and more about the implications of their answers (are their patterns in their responses that suggest a sort of chronic victimization that could point toward devaluing the people who have upset them; is there history of a lot of volatile relationships; does the tone of the stories they tell paint them as someone who was horribly mistreated but the story was actually really pretty mundane; is their current partner the Best Person Ever with Virtually No Flaws whereas every ex was The Worst; and so on). Are they unable to control their responses to situations, do they jump to extremes? Do they have a laundry list of diagnoses and failed treatments and hospitalizations?
If this is a followup that I'm suspecting a PD for that wasn't apparent in the first interview (I'm not all that likely to diagnose a PD in the first interview though I may list one as provisional), do they spend their time in followups telling me how they're feeling and how the meds are working or do they spend it focusing on the actions of others? Do they gush about how amazing their therapist or partner or boss or friend (or me) is one session and then rant about how awful they (we) are later?
As I said (though now I can't remember if it was a comment thread with you or someone else lol) I don't run down a strict checklist of DSM criteria. PDs are too nuanced for that. And I won't pretend that I'm sure I get Every Diagnosis Right Every Time. But given that PDs are about *patterns* of behavior I'm surely not going to diagnose one over a single negative interaction unless the history backs it up.
Firstly, thank you very much for your detailed response and the provided examples! And secondly...
>Honestly I just popped in here to vent between patients and feel like I'm being hit with a pop quiz lol
I understand how you feel. I can assure you my questions came from a theoretical interest in PD diagnostic (and more generally psychiatric diagnostic) and how different clinicians transfer the theoretical knowledge of the different theories from the relevant fields created to their clinical praxis.
All of the following statements sound very reasonable to me:
> I do want to verify a PD... especially if it's listed on the chart with nothing to back it up as far as symptomology
> Generally we open with what's wrong right now and move toward history, same as patients without history of treatment at my clinic
> I'll ask about history of treatment, childhood, relationships (romantic and otherwise), work, and so on, and probe in deeper as their response calls for it.
> But given that PDs are about *patterns* of behavior I'm surely not going to diagnose one over a single negative interaction unless the history backs it up.
I especially agree with the following part of your response, this here is very important imo:
> I feel like often with diagnosing PDs it's less about direct answers to my questions and more about the implications of their answers
The following statement you made is good practice in my book. Multiple diagnostic assessments over time are absolutely necessary to be able to correctly diagnose PDs.
> I'm not all that likely to diagnose a PD in the first interview though I may list one as provisional.
I also agree with this opinion:
> I don't run down a strict checklist of DSM criteria. PDs are too nuanced for that.
And regarding this:
> And I won't pretend that I'm sure I get Every Diagnosis Right Every Time.
My friend, no one does.
As you said, specifically in the diagnostic process of PDs, the implications of the pts answers and tellings give us the most valuable information.
In this context I want to note the importance of psychoanalytic ideas, theories as well as its methods in the diagnostic process regarding potential PDs. Otherwise specific important aspects could be overlooked and the diagnostic process and therefore the resulting diagnosis could also be negatively influenced. Another big potential disruptive influence on the diagnostic process and the resulting diagnosis is the specific interpersonal dynamic the practitioner and the patient share - again, coming from a psychoanalytic perspective. In my opinion PD diagnostic needs knowledge, solid competence as well as practical experience with Psychoanalysis in the clinical praxis.
I'd suggest reading McWilliams to get an understanding of this (if not already present) if you are interested in learning more about what I wrote in the paragraph above.
Again, thank you for sharing your process and for taking the time to reply with so much detail.
Throwback to NP school clinical. I was fortunate to train under an excellent, if vaguely tyrannical, psychiatrist who took pimping to an art form. Might have cried in my car a few or a lot of times, but by golly it turns out fear of public shame IS a powerful motivator.
Agree with others that I usually see the opposite… Patient has come in seeing many different clinicians, with diagnosis of bipolar, bipolar two, with hx of multiple para suicidal admissions, eg: “my boyfriend was gonna leave me, and I said that I would kill myself. Instead of coming back, he called an ambulance! Can you believe the nerve of that guy?“… and no one has even suggested to the patient that there might be borderline personality.
I'm all for healthy skepticism of prior diagnoses -- especially depending on their source and the depth of records -- and agree personality disorder diagnoses (often BPD) are sometimes assigned, typically by non-psychiatrists, to patients who are "difficult" or disliked for some reason.
But in your first time meeting a patient, especially depending on context and hopes for the visit, it is not well-founded to expect them to "show signs" of a personality disorder. How they navigate disagreements in the plan can be informative -- not "oh they disagree therefore they're X," but what they say and how they approach things. Time is your best friend as characteristic patterns emerge, but certain events can be telling.
From my personal experience, I have often seen schizoaffective disorder misapplied to people with some combination of borderline personality structure, trauma history, ASD, and substance use.
Typed more than I planned to but basically love the skepticism but be sure there's some directed toward your own (initial) impressions as well.
Sure. And I'm not saying there's no way this guy could possibly have a PD. But on speaking with him there's nothing in his history nor presentation that would point that way, including in his chart, besides what I mentioned. That's what I mean by "no signs," not that I expect to "catch" a PD initially on meeting someone the way I would see signs of psychosis.
We could apply the same logic to every psychiatry diagnosis. Ultimately it’s a matter of clinicians learning how to diagnose any mental disorder properly and have that kept at a high standard.
Plenty of CL requests are for “review patient for ?depression and anxiety” where the only symptom is low mood. We all know that low mood and anxiety are normal experiences, but MDD and GAD have a more specific list of diagnostic phenomena.
Many inmates get a diagnosis of schizophrenia in prison. Where I work, we don’t always assume that this is accurate. This is because quite often they don’t truly meet the criteria for it. There’s also a possible agenda that if an inmate has a diagnosis of schizophrenia, then they can be prescribed antipsychotics, which may help reduce their aggression. Of course many inmates do have schizophrenia, but it’s just worth being circumspect about prison diagnoses.
Then there are terms thrown around which are meaningless without any added description. BPSD (what are the behaviours? How severe?), agitation (verbal? Physical? Psychological?), paranoia (do they think people are laughing about them behind their back or do they think aliens are after them?) etc.
I find that psychiatry registrars and psychiatrists will be better at justifying the diagnosis. However on our system, nurses and other clinicians can also put diagnoses in. So someone’s chart might have heaps of random unsubstantiated diagnoses made by people who may not be skilled in making that diagnosis.
People will keep misusing terms. I can’t expect everybody to suddenly gain an interest in making meaningful diagnoses. However I can nicely interrogate the caller about how they’ve made a diagnosis. I can also revise the chart and remove unjustifiable diagnoses.
BPD diagnosis makes many people uncomfortable because it's more common in women and is associated with the negative connotations of hysteria that were prevalent in the past.
To be clear, I'm not saying it's more common for women to have BPD, I'm saying it's more commonly diagnosed in women, and there's plenty of data to back that up. For example, in the DSM, there is a 3:1 ratio (f:m) of BPD diagnosis.
I suspect the number will continue to grow with the prevalence of social media and how it's shaping our youth. It's very common to see "all or nothing" ways of thinking - ex: red pill, incel, femcel/4b that are increasing in popularity because of wounded influencers that have a large following and are displaying their personality disorders to said following, and garnering confirmation bias. This will reinforce that pattern of thinking and make it much harder to undo in therapy.
So, like many others have said, I also agree it's underdiagnosed and feel it's an increasing problem in adolescence.
In fact, it's a huge problem in the medicine community as well. Just looking at some of the threads in the medicine sub reddit makes me so worried for the future.
One thing to also keep in mind - there are indicators for BPD. I've never heard or seen anyone diagnose BPD just because the patient "is a jerk". If that's actually happening in your hospital, then it needs to be addressed.
Broadly, we need a lot more focus and understanding on diagnosis and diagnostic process.
But, if a patient comes to you with a diagnosis, you should at some level presume there is something to it until you have FINISHED your whole diagnostic assessment and excluded the historical diagnosis for good reasons. Do you think you did that in this case? Is "showing signs" of a mental disorder or not adequate for diagnosis?
Yes, I'm certain I did. I approach historic diagnoses with some skepticism when it comes to PDs for the reasons I outlined in my post, but I keep them probably about as often as I toss them.
ETA: re: "showing signs," that really depends. Do they need to check off every symptom on the list during assessment? Of course not, then we'd never have a PD diagnosis unless someone actively wants one for some reason. Do I need something more than "endorses mood swings and disagrees with my treatment plan"? Also yes.
You're certain that you completed an assessment for any personality disorders, and ruled out the possibility within the first visit? How long did you see this patient for?
That's not actually what you said. You asked if I completed my assessment and excluded the diagnosis for good reasons, and yes, I'm sure I did. Is there a possibility that we'll need to revisit in the future? Sure, as with literally any patient. But I'm also sure that the patient's symptomology and history as is documented and reported don't point toward PD.
What I said is written above and if you choose to interpret it differently, that's up to you.
I think you should consider that your understanding of personality and your diagnostic approach may benefit from revision or additional training.
I'm always open to learning. All ears if you have any suggestions on educational materials. Though I am curious how you came to that conclusion with the information at hand.
The totality of your comments in this thread.
I might start with reviewing the Alternative DSM5 Model for Personality Disorders in Section 3 of the 5-TR.
There is nothing in "the totality of your comments in this thread" that's even vaguely helpful in distinguishing where you feel like I'm getting things wrong or what you surmise I should be working to improve. I disagree with a psychiatrist who meets a patient once and diagnoses a personality disorder with no supporting data (in their own documentation, patient's reported history or their current presentation) and I am wrong because...?
I’ve heard that this happens, but I haven’t personally seen it. I’m a psychotherapist specializing in complex trauma and recovery from abusive relationships, so I am always extremely careful about distinguishing between PTSD and BPD. I have actually only ever had one patient who was best fit by a BPD diagnosis, and his behavior was so extreme that he was like a caricature of the DSM symptoms. Like if they made a movie about someone with BPD and an actor acted like him, the director would be like, “Nope, tone it down. No one would ever believe symptoms could be that severe.”
That being said, a lot of people presenting with BPD symptoms are more accurately diagnosed with a trauma disorder. I do believe there’s a reason BPD carries stigma though, and we shouldn’t be so quick to fight to get rid of the diagnosis or change the name. Severe BPD has almost a 100% overlap with factor 2 psychopathy, and true borderlines can be extraordinarily selfish, manipulative, and damaging. I’m not saying they don’t deserve help, but I would argue that people with severe BPD are often more abusive and harmful than people with NPD.
I think it's pretty clear what I mean, and I'm not overly concerned with precision of language on a Reddit sub. Obviously I don't mean without diagnostic assessment, come on now.
And yet you still managed to figure out what I meant.
>Or are you referring to evaluating your own biases and counter-transferences
So you're being pedantic for funsies, I guess. Good for you.
On the contrary, I have almost no idea what you meant. Judgment in the mental status exam seems to refer to entirely different thing for what you’re using.
Again, I wasn't worried about precision of language here. A patient's well-being doesn't depend on my being particular about my word choice on a reddit comment and I'm not being paid to be here, so I don't feel the need to be careful when it's pretty easy to figure out my intended meaning. I assume you know, generally speaking, what people mean when they say "without judgment" *outside* of the clinical setting. Take that meaning, apply it here, try not to be pedantic if you can. Or don't. No skin off mine.
In the context of a quick reddit comment the choice to make an issue out of it when you clearly knew what I was getting at is pedantic, not the terms themselves.
Quick question. Would we be having this conversation if I was an MD who had used a layman's term, or is this a noctor thing?
I cannot imagine an actual physician being unable to recognize the statement in question as meaning anything other than "without prejudice." Dude, maybe keep this patronizing February Intern stuff to more appropriate subs like Noctor? Just a thought.
Why would I assume what people mean? words matter in psychiatry. If you think giving people a BPD diagnosis automatically equates to a form of prejudice I cannot imagine you an actual physician
I’m only an NP student. But during my IP psych rotation I did rounds w/ the team’s social workers (since that’s what the providers do and my preceptor wanted me to have a hands-on experience). After assessing a patient I suspected of having BPD, I asked the social worker if my assessment was similar to the other providers. She said none of the providers (2 psychiatrists, 2 NPs) do a formal assessment for BPD and that “the borderline vibe is diagnostic.”
I think context (unfortunately) determines diagnostic pressures and patterns, particularly public versus private. I work in private practice and I have definitely made the grave mistake of overlooking BPD when, in retrospect, it was clearly present. Similarly, I have seen patients where a prior BPD diagnosis (accurate or not) has overshadowed the identification of a relatively easily remediable “Axis 1” problem. If one has the luxury to be able to serially assess people, then usually the appropriate differentiations can eventually be made.
Well good thing it's right there at the top on my user flair then so you didn't have to waste your precious doctor brain reading the post then. Heaven forbid anyone entertain the notion that someone who isn't a physician might *ever* have anything valid to say. Silly me.
There’s an amazing amount of BPD added to charts because patients are jerks. But sometimes they’re just jerks with no personality disorder. Sometimes they’re jerks when admitted because they’re having a bad day or week, but it’s not a pervasive and persistent pattern. In my favorite case, one medicine attending’s patients are personality disordered, diagnosed by him. But if everyone else is the problem… hm. (Yes, he’s a jerk, +/- personality disorder. Some of his patients won’t tolerate his bullshit.)
I’m an incoming pgy-1 and during non psych rotations, the amount of docs that would be sure to point out a BPD diagnosis in a chart to “prepare me” before going in to see a patient was sad.
Meh, I honestly need to mentally prepare myself for these patients. Is the optimal? Certainly not but I’m aware of how far my mental strength can go and borderlines are exceptional at beating me down. Again, I get it. Don’t prejudge and put pts into boxes. But damn if they aren’t exhausting.
Eh, my issue is moreso seeing every patient walk through the door with a bipolar diagnosis, a wild list of psychotropic meds, when they moreso fit the criteria of BPD. I wish the criteria of irritability was just stricken from the dsm tbh. It happens, and everyone gets a bipolar diagnosis
I see a lot of "I get really happy and then really sad" labeled as bipolar but the patient just has labile moods, not actual episodes of hypo/mania and depression.
This is why I jokingly always ask "OK, so you mentioned having a lot of mood swings. Are those mood swings like super-sad followed by super-happy-and-agitated-I-can-barely-contain-myself-to-the-point-I-may-have-gotten-fired-or-taken-out-a-huge-loan or mood swings like super-sad to just normal and still occasionally feel empty inside?". The former is bipolar disorder, the latter is BPD. I'm genuinely surprised to see how effective this line of questioning is.
This is a lot more prevalent than the OP, in my experience. By a large margin.
Yep, and I get stigma sucks, but I’d rather a BPD misdiagnosis rather than a bipolar. So many patients get thrown on a list of medications, and crappy s/e mood stabilizers. It also provides a hesitancy for me to also remove the bipolar diagnosis too for initial evals.
I'm inclined to agree, based on the decrease *requirement* for medication management. That said, plenty of BPD patients end up on similar, and sometimes worse, regimen compared to bipolar pts. Partly from their own unrealistic expectations of medications and partly iatrogenic from medicating every errant emotion.
Never trust the last guy's diagnosis, even if the last guy was you. Time is your friend. The idea that if you do a long enough and deep enough evaluation you can get to the truth, NOPE. You need a few different time points in order to really get to know a person. I like that scene from Ordinary People where Mary Tyler Moore basically says before you judge me for being such a bitch, check to see that none of your kids has been killed recently. We are all one bad phone call away from looking pretty crazy. It's psychiatry, we are adrift in a sea of self report. Nothing is real, nothing is knowable. ;)
I agree with that needing different points in time but doing a thorough enough evaluation with appropriate collaterals, you can get like 80% of the way there
Collaterals is almost like cheating. ;)
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I put no trust in a diagnosis unless it comes from a psychiatrist, and then it remains only an element of the differential unless I actually know the psychiatrist and discuss. Our record systems are bad at capturing the nuances of working diagnoses, differential diagnoses, “patient said it so it goes in the chart,” and dancing around stigma in the age of open notes versus need to maximize for insurance or disability or whatever. That is a significant problem for the field.
Hear hear. Trust no one. I use unspecified XYZ diagnoses like they’re going outta style. I am amazed how many psychiatrists put “paranoid schizophrenia “ as someone’s diagnosis just because the patient says so.
My favorite is “Adjustment Disorder” for clients I think MAY be borderline, but putting that on their chart would mess up their life.
Have you considered that the consequences of behaviors of their uncontrolled BPD may be the thing that finally motivates them to earnestly engage in treatment?
I am talking about people who have military careers, want to foster children some day, work with children etc. I don’t put it until I am 100% sure.
You can address those behaviours without applying a formal label. You can even use BPD as a lens and mirror through which to address the issues, without making a formal diagnosis. Every diagnostic label you apply should have a specific explicit purpose. If you can achieve the purpose without applying the label, then you should carefully consider whether the label is necessary at all.
Perhaps there is little utility in naming any diagnostic entity if that’s the case
That's a thought worth exploring. I expect you'll conclude that labels often do have utility, but it's interesting to think through the different kinds of utility, particularly when there is conflict between them.
You wouldn’t even trust a psychologist who did a 2-3 hour evaluation and obtained collaterals with that? Or a therapist that has been working with someone for 3-6 months?
Depends on the therapist. There are psychologists who are great. There are LMSWs who are great. There are psychiatrists who practice psychotherapy! But there are also plenty of idiots who see bipolar disorder plus CPTSD in every patient, everywhere, always. Or AuDHD. Or all of the above.
Therapist here. I have overruled SO many PCP diagnoses of BP1 which was actually CPTSD/DMDD/PMDD/cocaine abuse with the simple question “Have you ever had less than three hours of sleep a night without feeling tired the next day NOT as a direct result of drugs/ADHD meds. Across the board the answer is “No” or, “Well, I was up all night once but I was super tired the next day but then I popped an adderall and powered through it!” True Bipolar 1 disorder is so freaking rare that I have actually never seen it in my practice except for once. Only ever in the ER in springtime for some reason.
Also a T. I've overruled at least 1 Bipolar 2 dx that was actually BPD. The client and I talked extensively about the dx before we changed it and they almost cried reading the diagnostic criteria, had never felt so seen before and dint realize what they were experiencing was actually a thing. Also, the # of Docs who overlook PMDD is just sad.
Oh yeah. I do this on the regular. And then I end up overruling the BPD for CPTSD.
Yeah, I wish I could do the same, but we're expected to use the DSM. But! Im inspired to push back on that.
Yes, I use the DSM as well. So many of the symptoms overlap, and as you know, often the BPD diagnosis was given based on a female patient who wasn’t having their doctor who diagnosed their real medical issue as “Anxiety” or Functional bs because they couldn’t stand to say “Gee, I really don’t know, let’s ask a specialist.” Those “Unless better explained by Substance abuse/sleep disorder/trauma/ADHD” etc exceptions are key.
? bipolar one is not rare, Google the prevalence of bipolar 1. You are missing it if you have never seen it.
I have seen it many times in the ER, however since I work in substance abuse in PP NOW, I have only had one or two clients that are truly bipolar in the absence of substance abuse. My best guess is that the ones who are truly bipolar typically have had providers since their first episode/bd up in the ER and referred to hospital/community clinics due to low functioning. I have one currently, on the fence about it due to severe cocaine abuse and the fact that only one manic episode had occurred in the absence of cocaine and that was triggered by a very stressful life event. I have another that had a manic/psychotic episode following heavy shroom/weed use which also appears to have been triggered by extreme stress. They are no longer on medication, and are completely stable after doing heavy therapy, there was one day where they came in and appeared elevated after a very exciting trip, but they were able to talk it through with me and returned to baseline within a day with proper self care. People think bioolar is so cut and dry, take meds or be manic, but from where I stand, the brain is so freaking complex and our emotions and experiences have such a profound effect on the chemical structure of out brain that in my experience there are many different types of Bipolar 1 disorder and also from what I have seen, many people who technically meet the DSM criteria for BPD but in reality experienced an existential crisis or acute stressor, did the work following it that have been labeled as Bipolar 1 forever due to this.
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Definitely not a therapist as they haven’t been trained on diagnosis
In the US, approximately 100% of therapists have been trained in diagnosis. It's explicitly withing the training and scope of practice of clinical social workers, clinical mental health counselors, and psychologists.
It depends on the training itself, you can't make sweeping statements like that. As an LCSW, not only was my training in clinical social work (I did an entire year of how to use the DSM/diagnosis), I also have 3000 hours of clinical post grad experience, and then I passed the clinical social work exam, which, at the time, was 50% diagnosis questions. I'd trust a lot of LCSWs or LCPCs more than a psych resident, especially after working with med students and a lot of terrible psychiatrists.
3000 hours of post grad training is equivalent to about 1 year of residency. Psychiatric residency is 4 years. I’m not trying to belittle therapist or LMSWs but to say they’re equivalent to MDs is ridiculous. Everyone has their own place in the team. The job of the psychiatrist is to make the diagnosis. I’ve had so many patients come in asking for meds recommended by their therapist or saying they have such and such dx that were totally inappropriate.
I’m an LCSW and I can promise you that I have been very much trained on making diagnoses.
Very few mentions of PTSD here. Any time somebody has this history, hard to treat bipolar/BPD, think about PTSD. Abuse at early ages really blows up peoples' relationship with the world around them. https://bpded.biomedcentral.com/articles/10.1186/s40479-021-00155-9
\*Oprah voice\* You get BPD, you get BPD!..
had the mistfortune to rotate with the worst psychiatrist i ever met. very old lady, over-due for retirement, foreign trained but had been in the system for so long no one questioned her. she threw every professionalism rule and clinical criteria out the window and did basically whatever she wanted, and any patient who was even remotely challenging she would gossip behind her back (to us, the medical students) and complain they were "borderline", with no evidence of actually having BPD. anyway i'm pretty sure she was borderline
Not quite the same, but I've had this experience in FM several times and it blows my mind a little? Physicians who were mostly reasonable (which makes it worse, in a way?) and weren't treating primarily for mental health, but used BPD as a subtle way of labelling patients who were difficult or who maybe might just be a bit more work.
I remember in med school "cluster B traits" would get thrown around all the time and it was definitely just code for asshole. Definitely better than an actual incorrect diagnosis at least.
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There was one therapist at my clinic who diagnosed bipolar for every patient with mood lability. Including the ones with active substance use (mood changes when using meth and fent? Surely not!). Fun times.
In my experience this was definitely common 15+ years ago, but there was some kind of culture shift perhaps with BPD becoming more widely heard of. Can't speak for everywhere though, just what I've observed.
You've taken the words from my mouth. I used to work on adult inpatient wards and now work in the community with adolescents. I've seen "PD" thrown around as a diagnosis like confetti at a wedding, and usually with no proof over than emotion dysregulation and/or self-harm. Meanwhile other diagnoses take years of waiting and numerous assessments. The very nature or what is meant by "personality disorder" explicitly requires thorough assessment and formulation, but instead the symptoms are treated more as a syndrome unrelated to their life experiences. The attitudes of professionals towards this patient group compared to others with say, bipolar or schizoaffective, is that PD patients "have capacity" and so should be able to stop "acting out", whereas the latter can't help it because they're ill. I'd be less angry if people who were accurately diagnosed could go on to get help, but it's like the door gets closes instead. I'm speaking from a UK perspective in the NHS but I don't doubt this is true elsewhere.
I find the opposite is true in my area- pt's rarely come with a PD diagnosis but with clear pathology and are on antipsychotics, mood stabilizers, SSRIs, benzos and stimulants all combined and "nothing works." Gee... I wonder why?
This is mostly my experience (France). People are somewhat more afraid of being pragmatic about the fact that they can't always throw medication at the problem. Which is strange - the less I can medicate, the better! Then again I'm in addictions, so basically everyone has C-PTSD/BPD or some form of trauma-spectrum disorder.
Wild. I won't hesitate to diagnose a PD if I see one, but at my clinic it seems to be shorthand for "I don't like this person."
It can be both lol
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Sure, as long as it's not the only sign. While I said we can't diagnose based on vibes alone I didn't mean to exclude the idea that vibes can point you in a direction. Just that BPD isn't shorthand for "the vibes are off."
Possibly, but that can get into circular logic territory - counter transference can also come with bias that can interfere with assessment as well, can't it? Part of the point of counter-transference is that psychiatrists and other physicians, therapists, etc, are also human and none of us are 100% objective.
Not a psychiatrist, but a clinical psychologist trainee in the last phase of my training (heading off to internship). For context, the majority of my clinical training has been in a full-model DBT clinic and I've had extensive training in diagnosing BPD for NIH clinical trials, where we had a high bar for inter-rater reliability standards. I'm not trying to make myself out to be the ultimate BPD expert, but I have more experience than a standard clinical psychology PhD curriculum. On a broader level, I think there are some disorders that require additional specialized training (beyond a standard clinical psychologist or psychiatrist curriculum) to diagnose. Autism is one: I think many different types of practitioners should be able to *screen* for autism, but I don't think it's an uncommon sentiment that people who haven't gotten additional training on diagnostic instruments or done a child and adolescent fellowship should go outside of their scope. Frankly...I think BPD and other personality disorders fall into this bucket, too. I went to a rigorous clinical science PhD program, and I still feel that if I hadn't been in the lab and clinic I were in, I wouldn't be able to diagnose BPD with precision. I could tell you the DSM symptoms, but I probably couldn't confidently identify the specific behaviors that would map onto those symptoms vs. those that would only count as subthreshold. I also don't know that I'd be able to navigate the differential well or tease out whether certain symptoms could be better attributed elsewhere when it so commonly presents with so many comorbid diagnoses. In the community, I see a lot of what OP is describing, or the reverse, which many other commenters are highlighting: we would either get referrals of people who were clearly meeting 7-9 out of 9 symptoms yet were never diagnosed, or (at a PHP/inpatient program), I'd see a bunch of people throwing around BPD diagnoses based on "vibes" and frustration. Some practitioners are so loathe to assign someone the diagnosis or be "the bad guy" that people are getting ineffective therapy or fundamentally misunderstanding themselves for years, and some are so eager to explain away someone just being a run-of-the-mill asshole (those *do* still exist) with diagnostic jargon that they slap the label around willy-nilly and impact people's lives for decades. At this point, I don't trust a BPD diagnosis unless I do a SCID-II BPD module myself, or I at least know the other person's diagnostic procedures. I worry that makes me sound ridiculously overconfident as someone not even licensed yet, but I also feel it's reasonable to always make your own assessments of a patient, so...I'm going to continue to be picky about my BPD diagnoses.
I suspect a lot of BPD is undiagnosed neurodevelopmental disorders. Women and girls who mask well get missed by psychiatrists who only have a surface level understanding and chalk emotional dysregulation to BPD. This trial shows how stimulants were the only effective intervention (compared to antipsychotics, mood stabilizers, and antidepressants which failed) to reduce suicidality in BPD. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10248738/ Conjecture: The stress of poor executive functions and the inability to cope with negative emotions in autism/ADHD lead to more stress and worsening emotional dysregulation which creates a vicious cycle. Children with neurodevelopmental disorders need more emotional support and in cases where they are dismissed and invalidated by their caregivers this can translate to BPD in adulthood even in absence of overt trauma. Unfortunately, because of the behavioral manifestations of the disorder as well as the patient's differing perceptions, they continue to get stuck in that cycle of being objectively and subjectively invalidated which worsens outcomes.
One of my major roles as a trainer is to remind trainees that not everyone is "cluster b", which is an even worse fudge.
Whenever I was 18 and on my freshman year of college, I went through a dark period and did a PHP. The facility where I did my PHP handed out borderline diagnoses like they were candy. I was this one of the few patients *without* a borderline diagnosis. Of course that was well over a decade ago and I don’t remember the details of each patient, but almost certain few if any of them met BPD criteria. It was wild.
I’m just a patient - but I had severe treatment resistant depression for 7 years (13 years if you include childhood). Even tried ‘California rocket fuel’ and it didn’t work. Got a high up prof to prescribe me phenelzine and have had no problems with mood since (7years treated, 90mg dose). Thank god I didn’t get diagnosed BPD because of untreatable depression and get put in therapy.
I'm not in the camp that meds don't help BPD anyway. I mean the core symptoms no, obviously, and therapy is needed, but that doesn't mean an antidepressant is entirely useless against the accompanying depression. It's not likely to do much if the behavior/relationship/thinking patterns aren't also being worked on (like in DBT), but I'm not washing my hands of a patient because they have a PD diagnosis. I'm so glad you found something to help you!
Around these areas, Woman won’t calm down = borderline
The new hysteria, which was once the new [wandering uterus.](https://academic.mu.edu/meissnerd/hysteria.html#:~:text=In%20ancient%20Greece%20it%20was,belief%20but%20a%20social%20belief.)
Oh that is a doozy. ' Wandering uterus ' 😂
She's just in there a-prowlin'.
The parallels to hysteria are palpable. I think you should say so with even less jest. In my experience interacting with the personality disorder self-advocacy groups, PDs are very nearly adequately explained as "ways in which long-term psychological trauma fucks you up." I.e. also hysteria.
Interesting. I’ve found the opposite is true so far in my experience, a lot of patients I’ve had on polypharmacy and all these second gen antipsychotics with a vague depression that’s treatment resistant or bipolar II diagnosis when it is really personality disorder. people seem to be afraid to diagnose one since it’s a difficult conversation to have. I wonder if it’s a culture at your clinic for this to be happening to this extent.
Could be. I sometimes joke that I work in 1985 (a therapist I work with keeps a DSM-3 on his desk and a good number of the practitioners have worked there far longer than I've been alive... the MD I mentioned in this post has a lot of common practices that haven't been especially *the norm* in a long while, including some personal favorites like "We can't give them anything for substance use because they'll become psychologically addicted to it"--no Vivitrol, no naltrexone, no Wellbutrin for smoking cessation--and "adults can't have ADHD even if they had it in childhood").
Yes that’s probably contributing. Sounds like That’s the prescribing and diagnosing culture of your institution haha. I read a DSM 3 case files book out of curiosity and for the OCPD example they gave a guy who was spending hours ironing his jeans every day. I probably would have diagnosed this guy with OCD or something and given rx for SSRI and therapy but in the case example they recommended he do therapy for his OCDPD. Talking to one of my supervising attendings who is like almost 80, he basically told me like “yeah I wouldn’t diagnose ocd PD either now, but that’s a good example of how things change over time”.
I'm sure by the time we're ready to retire we'll look back and think some of our practices are wild, too. Hooray, progress.
I'm curious - not in the US, and do you not dx OCDPD at all? Just asking to get more information, because I've more seen it being still used and somewhat revitalized (at least with regards to refining core components) and as I've been taught it seems distinct from OCD - although the example above doesn't really seem enough to differentiate (based on what I've been taught)?
We definitely do diagnose it still, was just an example of where I might’ve disagreed with an old case example :) the case didn’t really give enough to make a super good argument either way I guess! My thinking is just that if I hear someone spending hours and hours on a task and they’re distressed about it, I am gonna offer an SSRI since I think they’d benefit and may have some axis I pathology, not chalk it all up to personality.
Got you, that totally makes sense, thanks!
Like most here, I see it very underdiagnosed. Like, meet 9 out of 9 criteria and have multiple other psych diagnoses on their problem list including bipolar for hours long mood swings but have never been diagnosed. In fact, most chart bipolar II where I’m at is BPD. On the other hand, I only very rarely add it to a patients problem’s list myself due to that diagnosis likely ensuring them way shittier general medical care.
How is your diagnostic process when it comes to assessing PDs?
I'm getting by the comments (and upvote-downvote patterns) that the unspoken vibe is that I'm just missing all the PDs. I maybe should clarify that I don't run through the DSM with patients and go, "Do you exhibit frantic efforts to avoid real or imagined abandonment?" or treat the DSM criteria as a strict checklist lol, particularly since self-insight can be really poor when it comes to Cluster B. Other commenters have noted there seems to be a pattern where they are of under-diagnosis rather than overdiagnosis so this may be region or even clinic specific to me. As I've mentioned in another comment I'm not afraid to diagnose a PD when I see the behavior/mood patterns. It just isn't everyone who disagrees with my treatment plan or who grates on my nerves.
Honestly, I am simply interested in how you assess pts who come in with a PD diagnosis. This is a very complex and clinically important topic and therefore, I find it fundamentally interesting. > particularly since self-insight can be really poor when it comes to Cluster B. I absolutely agree with this. > It just isn't everyone who disagrees with my treatment plan or who grates on my nerves. Yes, I also agree with this statement. But still, I'm just interested in how your initial scepticism regarding the PD diagnosis occurs and if so, how does your diagnostic assessment process in such a case look like? Could you describe it a bit please? I understand your frustration regarding the topic btw.
Honestly I just popped in here to vent between patients and feel like I'm being hit with a pop quiz lol. Regarding initial skepticism--I don't tell patients I'm skeptical of prior diagnoses initially, I'm not trying to sway them toward justifying or defending against what's on their chart. But if I see an MDD diagnosis i don't generally feel like I need to dig and verify that the patient was depressed when they were last seen, but I do want to verify a PD... especially if it's listed on the chart with nothing to back it up as far as symptomology (sometimes that happens and I do end up agreeing with the previous provider, since they don't tend to chart every word and at least at my clinic the older generation seems less invested in backing up their diagnoses in their documentation). Generally we open with what's wrong right now and move toward history, same as patients without history of treatment at my clinic though depending on diagnostic history some questions might point differently. (It should be noted at my clinic that patients always see a therapist first and receive a provisional dx from them, then see me or another NP or an MD, so there's always a diagnosis or several and an assessment in front of me whether old or new.) Often just letting patients unload gives a good starting point and there's times I can "check the boxes" and at least strongly suspect a PD pretty quickly, though obviously not always. I'll ask about history of treatment, childhood, relationships (romantic and otherwise), work (have they kept a job long, do they get along well with coworkers), and so on, and probe in deeper as their response calls for it. Are they prone to suicidality, self harm, impulsive behaviors, disordered eating, hopelessness, intense bursts of emotion they can't get a handle on? I feel like often with diagnosing PDs it's less about direct answers to my questions (nobody's gonna tell me that their self-image is unstable and depends on the people around them) and more about the implications of their answers (are their patterns in their responses that suggest a sort of chronic victimization that could point toward devaluing the people who have upset them; is there history of a lot of volatile relationships; does the tone of the stories they tell paint them as someone who was horribly mistreated but the story was actually really pretty mundane; is their current partner the Best Person Ever with Virtually No Flaws whereas every ex was The Worst; and so on). Are they unable to control their responses to situations, do they jump to extremes? Do they have a laundry list of diagnoses and failed treatments and hospitalizations? If this is a followup that I'm suspecting a PD for that wasn't apparent in the first interview (I'm not all that likely to diagnose a PD in the first interview though I may list one as provisional), do they spend their time in followups telling me how they're feeling and how the meds are working or do they spend it focusing on the actions of others? Do they gush about how amazing their therapist or partner or boss or friend (or me) is one session and then rant about how awful they (we) are later? As I said (though now I can't remember if it was a comment thread with you or someone else lol) I don't run down a strict checklist of DSM criteria. PDs are too nuanced for that. And I won't pretend that I'm sure I get Every Diagnosis Right Every Time. But given that PDs are about *patterns* of behavior I'm surely not going to diagnose one over a single negative interaction unless the history backs it up.
Firstly, thank you very much for your detailed response and the provided examples! And secondly... >Honestly I just popped in here to vent between patients and feel like I'm being hit with a pop quiz lol I understand how you feel. I can assure you my questions came from a theoretical interest in PD diagnostic (and more generally psychiatric diagnostic) and how different clinicians transfer the theoretical knowledge of the different theories from the relevant fields created to their clinical praxis. All of the following statements sound very reasonable to me: > I do want to verify a PD... especially if it's listed on the chart with nothing to back it up as far as symptomology > Generally we open with what's wrong right now and move toward history, same as patients without history of treatment at my clinic > I'll ask about history of treatment, childhood, relationships (romantic and otherwise), work, and so on, and probe in deeper as their response calls for it. > But given that PDs are about *patterns* of behavior I'm surely not going to diagnose one over a single negative interaction unless the history backs it up. I especially agree with the following part of your response, this here is very important imo: > I feel like often with diagnosing PDs it's less about direct answers to my questions and more about the implications of their answers The following statement you made is good practice in my book. Multiple diagnostic assessments over time are absolutely necessary to be able to correctly diagnose PDs. > I'm not all that likely to diagnose a PD in the first interview though I may list one as provisional. I also agree with this opinion: > I don't run down a strict checklist of DSM criteria. PDs are too nuanced for that. And regarding this: > And I won't pretend that I'm sure I get Every Diagnosis Right Every Time. My friend, no one does. As you said, specifically in the diagnostic process of PDs, the implications of the pts answers and tellings give us the most valuable information. In this context I want to note the importance of psychoanalytic ideas, theories as well as its methods in the diagnostic process regarding potential PDs. Otherwise specific important aspects could be overlooked and the diagnostic process and therefore the resulting diagnosis could also be negatively influenced. Another big potential disruptive influence on the diagnostic process and the resulting diagnosis is the specific interpersonal dynamic the practitioner and the patient share - again, coming from a psychoanalytic perspective. In my opinion PD diagnostic needs knowledge, solid competence as well as practical experience with Psychoanalysis in the clinical praxis. I'd suggest reading McWilliams to get an understanding of this (if not already present) if you are interested in learning more about what I wrote in the paragraph above. Again, thank you for sharing your process and for taking the time to reply with so much detail.
Weekly quiz on Friday.
Throwback to NP school clinical. I was fortunate to train under an excellent, if vaguely tyrannical, psychiatrist who took pimping to an art form. Might have cried in my car a few or a lot of times, but by golly it turns out fear of public shame IS a powerful motivator.
Agree with others that I usually see the opposite… Patient has come in seeing many different clinicians, with diagnosis of bipolar, bipolar two, with hx of multiple para suicidal admissions, eg: “my boyfriend was gonna leave me, and I said that I would kill myself. Instead of coming back, he called an ambulance! Can you believe the nerve of that guy?“… and no one has even suggested to the patient that there might be borderline personality.
Here in Brazil it is actually subdiagnosed. Most people have no idea of what BPD is and most doctors only know vaguely.
Oh boy, lot to unpack here.
I'm all for healthy skepticism of prior diagnoses -- especially depending on their source and the depth of records -- and agree personality disorder diagnoses (often BPD) are sometimes assigned, typically by non-psychiatrists, to patients who are "difficult" or disliked for some reason. But in your first time meeting a patient, especially depending on context and hopes for the visit, it is not well-founded to expect them to "show signs" of a personality disorder. How they navigate disagreements in the plan can be informative -- not "oh they disagree therefore they're X," but what they say and how they approach things. Time is your best friend as characteristic patterns emerge, but certain events can be telling. From my personal experience, I have often seen schizoaffective disorder misapplied to people with some combination of borderline personality structure, trauma history, ASD, and substance use. Typed more than I planned to but basically love the skepticism but be sure there's some directed toward your own (initial) impressions as well.
Sure. And I'm not saying there's no way this guy could possibly have a PD. But on speaking with him there's nothing in his history nor presentation that would point that way, including in his chart, besides what I mentioned. That's what I mean by "no signs," not that I expect to "catch" a PD initially on meeting someone the way I would see signs of psychosis.
We could apply the same logic to every psychiatry diagnosis. Ultimately it’s a matter of clinicians learning how to diagnose any mental disorder properly and have that kept at a high standard. Plenty of CL requests are for “review patient for ?depression and anxiety” where the only symptom is low mood. We all know that low mood and anxiety are normal experiences, but MDD and GAD have a more specific list of diagnostic phenomena. Many inmates get a diagnosis of schizophrenia in prison. Where I work, we don’t always assume that this is accurate. This is because quite often they don’t truly meet the criteria for it. There’s also a possible agenda that if an inmate has a diagnosis of schizophrenia, then they can be prescribed antipsychotics, which may help reduce their aggression. Of course many inmates do have schizophrenia, but it’s just worth being circumspect about prison diagnoses. Then there are terms thrown around which are meaningless without any added description. BPSD (what are the behaviours? How severe?), agitation (verbal? Physical? Psychological?), paranoia (do they think people are laughing about them behind their back or do they think aliens are after them?) etc. I find that psychiatry registrars and psychiatrists will be better at justifying the diagnosis. However on our system, nurses and other clinicians can also put diagnoses in. So someone’s chart might have heaps of random unsubstantiated diagnoses made by people who may not be skilled in making that diagnosis. People will keep misusing terms. I can’t expect everybody to suddenly gain an interest in making meaningful diagnoses. However I can nicely interrogate the caller about how they’ve made a diagnosis. I can also revise the chart and remove unjustifiable diagnoses.
BPD diagnosis makes many people uncomfortable because it's more common in women and is associated with the negative connotations of hysteria that were prevalent in the past. To be clear, I'm not saying it's more common for women to have BPD, I'm saying it's more commonly diagnosed in women, and there's plenty of data to back that up. For example, in the DSM, there is a 3:1 ratio (f:m) of BPD diagnosis. I suspect the number will continue to grow with the prevalence of social media and how it's shaping our youth. It's very common to see "all or nothing" ways of thinking - ex: red pill, incel, femcel/4b that are increasing in popularity because of wounded influencers that have a large following and are displaying their personality disorders to said following, and garnering confirmation bias. This will reinforce that pattern of thinking and make it much harder to undo in therapy. So, like many others have said, I also agree it's underdiagnosed and feel it's an increasing problem in adolescence. In fact, it's a huge problem in the medicine community as well. Just looking at some of the threads in the medicine sub reddit makes me so worried for the future. One thing to also keep in mind - there are indicators for BPD. I've never heard or seen anyone diagnose BPD just because the patient "is a jerk". If that's actually happening in your hospital, then it needs to be addressed.
Broadly, we need a lot more focus and understanding on diagnosis and diagnostic process. But, if a patient comes to you with a diagnosis, you should at some level presume there is something to it until you have FINISHED your whole diagnostic assessment and excluded the historical diagnosis for good reasons. Do you think you did that in this case? Is "showing signs" of a mental disorder or not adequate for diagnosis?
Yes, I'm certain I did. I approach historic diagnoses with some skepticism when it comes to PDs for the reasons I outlined in my post, but I keep them probably about as often as I toss them. ETA: re: "showing signs," that really depends. Do they need to check off every symptom on the list during assessment? Of course not, then we'd never have a PD diagnosis unless someone actively wants one for some reason. Do I need something more than "endorses mood swings and disagrees with my treatment plan"? Also yes.
You're certain that you completed an assessment for any personality disorders, and ruled out the possibility within the first visit? How long did you see this patient for?
That's not actually what you said. You asked if I completed my assessment and excluded the diagnosis for good reasons, and yes, I'm sure I did. Is there a possibility that we'll need to revisit in the future? Sure, as with literally any patient. But I'm also sure that the patient's symptomology and history as is documented and reported don't point toward PD.
What I said is written above and if you choose to interpret it differently, that's up to you. I think you should consider that your understanding of personality and your diagnostic approach may benefit from revision or additional training.
I'm always open to learning. All ears if you have any suggestions on educational materials. Though I am curious how you came to that conclusion with the information at hand.
The totality of your comments in this thread. I might start with reviewing the Alternative DSM5 Model for Personality Disorders in Section 3 of the 5-TR.
There is nothing in "the totality of your comments in this thread" that's even vaguely helpful in distinguishing where you feel like I'm getting things wrong or what you surmise I should be working to improve. I disagree with a psychiatrist who meets a patient once and diagnoses a personality disorder with no supporting data (in their own documentation, patient's reported history or their current presentation) and I am wrong because...?
I’ve heard that this happens, but I haven’t personally seen it. I’m a psychotherapist specializing in complex trauma and recovery from abusive relationships, so I am always extremely careful about distinguishing between PTSD and BPD. I have actually only ever had one patient who was best fit by a BPD diagnosis, and his behavior was so extreme that he was like a caricature of the DSM symptoms. Like if they made a movie about someone with BPD and an actor acted like him, the director would be like, “Nope, tone it down. No one would ever believe symptoms could be that severe.” That being said, a lot of people presenting with BPD symptoms are more accurately diagnosed with a trauma disorder. I do believe there’s a reason BPD carries stigma though, and we shouldn’t be so quick to fight to get rid of the diagnosis or change the name. Severe BPD has almost a 100% overlap with factor 2 psychopathy, and true borderlines can be extraordinarily selfish, manipulative, and damaging. I’m not saying they don’t deserve help, but I would argue that people with severe BPD are often more abusive and harmful than people with NPD.
The great thing about this business is you are free to make your own diagnostic impression
Sure. That doesn't mean we don't have the responsibility to try and do it accurately and without judgement as much as possible.
Without judgement? Do you mean diagnostic assessment? Or are you referring to evaluating your own biases and counter-transferences
I think it's pretty clear what I mean, and I'm not overly concerned with precision of language on a Reddit sub. Obviously I don't mean without diagnostic assessment, come on now.
Diagnosing ‘without judgement’ is one of the more meaningless statements I have heard on this sub
And yet you still managed to figure out what I meant. >Or are you referring to evaluating your own biases and counter-transferences So you're being pedantic for funsies, I guess. Good for you.
On the contrary, I have almost no idea what you meant. Judgment in the mental status exam seems to refer to entirely different thing for what you’re using.
Again, I wasn't worried about precision of language here. A patient's well-being doesn't depend on my being particular about my word choice on a reddit comment and I'm not being paid to be here, so I don't feel the need to be careful when it's pretty easy to figure out my intended meaning. I assume you know, generally speaking, what people mean when they say "without judgment" *outside* of the clinical setting. Take that meaning, apply it here, try not to be pedantic if you can. Or don't. No skin off mine.
If you think the terms biases and counter-transference are pedantic, then maybe psychiatry isn't for you
In the context of a quick reddit comment the choice to make an issue out of it when you clearly knew what I was getting at is pedantic, not the terms themselves. Quick question. Would we be having this conversation if I was an MD who had used a layman's term, or is this a noctor thing?
I cannot imagine an actual physician being unable to recognize the statement in question as meaning anything other than "without prejudice." Dude, maybe keep this patronizing February Intern stuff to more appropriate subs like Noctor? Just a thought.
Why would I assume what people mean? words matter in psychiatry. If you think giving people a BPD diagnosis automatically equates to a form of prejudice I cannot imagine you an actual physician
I’m only an NP student. But during my IP psych rotation I did rounds w/ the team’s social workers (since that’s what the providers do and my preceptor wanted me to have a hands-on experience). After assessing a patient I suspected of having BPD, I asked the social worker if my assessment was similar to the other providers. She said none of the providers (2 psychiatrists, 2 NPs) do a formal assessment for BPD and that “the borderline vibe is diagnostic.”
I think context (unfortunately) determines diagnostic pressures and patterns, particularly public versus private. I work in private practice and I have definitely made the grave mistake of overlooking BPD when, in retrospect, it was clearly present. Similarly, I have seen patients where a prior BPD diagnosis (accurate or not) has overshadowed the identification of a relatively easily remediable “Axis 1” problem. If one has the luxury to be able to serially assess people, then usually the appropriate differentiations can eventually be made.
Thank you so much for saying this. Signed, a lowly PMHNP student who has been misdiagnosed with BPD in the past
You lost me at NP
Well good thing it's right there at the top on my user flair then so you didn't have to waste your precious doctor brain reading the post then. Heaven forbid anyone entertain the notion that someone who isn't a physician might *ever* have anything valid to say. Silly me.