BPD Question

[clement]

How do you reconcile an attachment to mood disorder diagnoses in borderlines whose actual consolidating diagnosis is that of borderline PD? What strategies do you incorporate to manage these patients? I find it to be a nightmare in the outpatient setting when inheriting such patients.

I have many colleagues who offer an alleged unspecified mood disorder or bipolar spectrum illness diagnosis to borderlines. Sometimes they want it on paper to substantiate use of atypicals (liability)...or else to appease patients who might ask for records and find borderline PD as pejorative. Another reason is if they are a borderline with a hx of distant SA's or parasuicidal behavior, some colleagues get incentivized to pile on 10 meds and call it a mood disorder.

In the long run it harms those borderlines who indulge in the sick role, some of whom end up treated with LAI's. I think of it as an intersecting area between two circles, borderline PD and factitious disorder. I'm not dismissing the view that bipolar d/o and borderline PD can exist on a spectrum. How do you manage such patients when they are maxed out on a billion meds, want a med change at the first and every subsequent visit, claim nothing works for their bipolar d/o, and get offended when you tell them they have borderline PD? I tell them at this point I can more reliably diagnose borderline PD. Sometimes they want to go back to their previous psychiatrist who dumped them, but sometimes they want to stick around.

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[forchinet121]

Refer them to DBT and use medications judiciously that’s all you can do

 

[PikminOC]

How do you reconcile an attachment to mood disorder diagnoses in borderlines whose actual consolidating diagnosis is that of borderline PD? What strategies do you incorporate to manage these patients? I find it to be a nightmare in the outpatient setting when inheriting such patients.

I have many colleagues who offer an alleged unspecified mood disorder or bipolar spectrum illness diagnosis to borderlines. Sometimes they want it on paper to substantiate use of atypicals (liability)...or else to appease patients who might ask for records and find borderline PD as pejorative. Another reason is if they are a borderline with a hx of distant SA's or parasuicidal behavior, some colleagues get incentivized to pile on 10 meds and call it a mood disorder.

In the long run it harms those borderlines who indulge in the sick role, some of whom end up treated with LAI's. I think of it as an intersecting area between two circles, borderline PD and factitious disorder. I'm not dismissing the view that bipolar d/o and borderline PD can exist on a spectrum. How do you manage such patients when they are maxed out on a billion meds, want a med change at the first and every subsequent visit, claim nothing works for their bipolar d/o, and get offended when you tell them they have borderline PD? I tell them at this point I can more reliably diagnose borderline PD. Sometimes they want to go back to their previous psychiatrist who dumped them, but sometimes they want to stick around.

How are you reliably diagnosing BPD?

 

[wolfvgang22]

Sounds like you may be struggling and working harder than the patient in some of these cases. I have done that myself many times. Like forchinet said, use medications judiciously and refer for DBT. Often DBT is not available, which is sad, but not your fault. If the patient has DBT available and will not seriously commit to therapy, that is on them. You can lead a horse to water but you can't make them drink.

Don't let anyone, including yourself, make you feel responsible for that. I tell patients what is most likely to help them, empathize if they don't like it, and move on.

 

[Celexa]

When you say mood disorder, do you specifically mean they are holding on to a diagnosis of bipolar disorder, or mood disorder generally and/or depression?

After my diagnostic interview, I educate around the difference between true mania and mood swings and reactivity due to borderline and it's usually received fairly well. I don't try and argue the patient away from *all* mood disorder diagnosis due to a combination of factors--that they often have been genuinely depressed, that I cannot reliably sort out what is mood, trauma, and personality for a very long time, and that they need their misery acknowledged and saying "you [are or have been] depressed" is meaningful to them. I educate about bipolar 1 vs 2 particularly if I am fairly confident they don't have a bipolar 1 diagnosis but I can't exclude bipolar 2.

A patient who feels heard will usually listen.

Then I go about simplifying their medication regimen since almost always they're on too many meds and continue to assess and consider my diagnoses at every visit.

 

[splik]

Refer them to DBT and use medications judiciously that’s all you can do

DBT is not the only treatment for BPD, it does not deal with the underlying character issues, is not as widely available as it should be, and a lot of patients won't do it or don't like groups. GPM may be just as good as DBT in terms of outcomes and much easier to do in general psychiatric settings. Even BPD patients in DBT programs tend to be on a ton of meds. Obviously we want to avoid iatrogenic harm, but it seems it's not so terrible and there may even be some utility to patients being on several different medications for different symptom clusters, or as transitional objects. MBT and schema therapy are also very good treatments but they are even less available than DBT unfortunately.

P.S. I love me some DBT and often incorporate DBT skills into my work with pts across diagnoses but it is not the be all and end all of BPD treatment and truly DBT adherent programs are not as available as they should be.

In the long run it harms those borderlines who indulge in the sick role, some of whom end up treated with LAI's. I think of it as an intersecting area between two circles, borderline PD and factitious disorder. I'm not dismissing the view that bipolar d/o and borderline PD can exist on a spectrum. How do you manage such patients when they are maxed out on a billion meds, want a med change at the first and every subsequent visit, claim nothing works for their bipolar d/o, and get offended when you tell them they have borderline PD? I tell them at this point I can more reliably diagnose borderline PD. Sometimes they want to go back to their previous psychiatrist who dumped them, but sometimes they want to stick around.

BPD is becoming a more fashionable diagnosis nowadays than even bipolar. #BPD has more than twice the number of views on TikTok than #bipolar! Bipolar is so 2006!

 

[clement]

How are you reliably diagnosing BPD?

I get them at the end of the line. Like essentially terminal BPD w/ no pun intended.

 

[clement]

Sounds like you may be struggling and working harder than the patient in some of these cases. I have done that myself many times. Like forchinet said, use medications judiciously and refer for DBT. Often DBT is not available, which is sad, but not your fault. If the patient has DBT available and will not seriously commit to therapy, that is on them. You can lead a horse to water but you can't make them drink.

Don't let anyone, including yourself, make you feel responsible for that. I tell patients what is most likely to help them, empathize if they don't like it, and move on.

The challenge with using meds judiciously when these pts have been "inherited from others" is that they're more or less psychologically habituated to "needing" gallons of psychotropics (i.e. the meds are their teddy bear, as noted)...and a proposal to go down on or eliminate meds becomes dismissal akin to abandonment.

 

[romanticscience]

The challenge with using meds judiciously when these pts have been "inherited from others" is that they're more or less psychologically habituated to "needing" gallons of psychotropics (i.e. the meds are their teddy bear, as noted)...and a proposal to go down on or eliminate meds becomes dismissal akin to abandonment.

I'm a big fan of GPM. Honestly, these patients just need more time and the frustration of a system that disallows that. For instance, in the cases where patients have inherited these meds, it's often when they've had med management for emotional crises, which creates so much polypharmacy. If you see them weekly and say, let's see where we're at next time, or if you find it useful, schedule yourself another session, things resolve and preclude a med change.

I, too, loathe the inherited cocktails that the patients have developed psychological dependency/placebo responses toward. I've sometimes found it useful to make a deal with the patient that you'll see them more if they are willing to make little changes week to week ("I care more about you than just throwing meds at your problem). Again, I can do this because I'm in private practice.

 

[wolfvgang22]

I'm a big fan of GPM. Honestly, these patients just need more time and the frustration of a system that disallows that. For instance, in the cases where patients have inherited these meds, it's often when they've had med management for emotional crises, which creates so much polypharmacy. If you see them weekly and say, let's see where we're at next time, or if you find it useful, schedule yourself another session, things resolve and preclude a med change.

I, too, loathe the inherited cocktails that the patients have developed psychological dependency/placebo responses toward. I've sometimes found it useful to make a deal with the patient that you'll see them more if they are willing to make little changes week to week ("I care more about you than just throwing meds at your problem). Again, I can do this because I'm in private practice.

What's GPM?

 

[TheRightMedication]

What's so bad about continuing the meds empirically while you build a relationship and talk about it over time?

 

[romanticscience]

What's GPM?

Good Psychiatric Management of BPD.

A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder - PubMed

These results suggest that individuals with borderline personality disorder benefited equally from dialectical behavior therapy and a well-specified treatment delivered by psychiatrists with expertise in the treatment of borderline personality disorder.

pubmed.ncbi.nlm.nih.gov

Amazon product

General Psychiatric Management for BPD | Harvard University

This 8-hour course offers training in an empirically validated treatment approach to borderline personality disorder (BPD) known as Good or General Psychiatric Management (GPM).

pll.harvard.edu

 

[annoyedpsychiatrist]

some of my bpd patients are tiring but tbh 3/4 of them are good people who cant control their emotions and just mess up consistently in life. some of my bpd patients are fairly certain are bipolar 2 as well. Sometimes its hard to tell the difference in the messy cases.

 

[romanticscience]

This is also interesting. I remember getting frustrated trying "to figure out" BPD v. Bipolar 2 until I realized it's probably more a battle of theory (Akiskal v. Kernberg) on what to call it.

https://onlinelibrary.wiley.com/doi/full/10.1111/j.1600-0447.2004.00461.x

Deltito et al. (27), based on the conservative formal definition (1) of bipolar disorder (types I and II), reported a rate of 44% among BPD at Westchester-Cornell; taking the most liberal definition of bipolarity (including bipolar I, bipolar II, pharmacologic-hypomania, cyclothymic temperament, and family history for bipolar disorder), 81% of BPD patients could be considered lying within the bipolar spectrum.

 

[G Sheb]

When BPD patients are fixating on medication changes, my first thought is that they are looking for another teddy bear: you. Once successfully engaged in a relationship, the fixation on medications will wind down. My first advice is don't take these requests at face value, and don't respond to them at face value through rejection, as they will see it as a rejection of their emotional needs. Instead validate emotions as much as you can, try to look for the role they want the medication to play and see how you could address that. The first step would be to resist changing the dose if they request it (without framing it as a rejection of the request).
Instead, get to the nitty gritty of what they are experiencing and they would like to address. The process of doing that is sort of the 'dose change' they are looking for. Feeling heard and validated is kind of what they want. You do not have to go crazy on changing the whole regimen from the first couple of visits. It's a step by step process, and time is on your side. Paradoxically, borderline patients can be the easiest to engage once you have a relationship going because they make strong emotional bonds, even if unstable.

Some battles are also not worth fighting. If they've been on the medication for a long time, they are not abusing it, stopping it would risk a significant destabilization, then you know, just continue it. Until the right time to address this issue.

 

[smalltownpsych]

It takes the really skilled docs to work with Borderline PD. These patients are often in a high amount of distress aka emotional pain and want relief. Medications can provide some hope of that. Much of the pain they are experiencing is interpersonal so the fix is to help them begin to trust, allow, experience relief from healthy relationships as opposed to self harm, substances, medications, and toxic relationships, but that takes a long long long time and in the meantime if they are suffering too much and daddy/mommy doc is not helping and doesn’t really understand what they need and how to provide it, then it’s just one more experience of that negative pattern of relationships.

Also, wanted to add that most of the posts above reflect that understanding a good psychiatrist needs with these types of patients. I was just sharing my related and collaborators perspective and kind of sad I don’t get to collaborate with people with this level of understanding in the real world.

 

[clement]

I'm a big fan of GPM. Honestly, these patients just need more time and the frustration of a system that disallows that. For instance, in the cases where patients have inherited these meds, it's often when they've had med management for emotional crises, which creates so much polypharmacy. If you see them weekly and say, let's see where we're at next time, or if you find it useful, schedule yourself another session, things resolve and preclude a med change.

I, too, loathe the inherited cocktails that the patients have developed psychological dependency/placebo responses toward. I've sometimes found it useful to make a deal with the patient that you'll see them more if they are willing to make little changes week to week ("I care more about you than just throwing meds at your problem). Again, I can do this because I'm in private practice.

Beautiful. Exactly. I look back a the charts of half of these BPD cases on Seroquel with 100mg dose escalations every time the pt came in and said they were feeling emotional. Perhaps the best advice I received was, "Build rapport. They'll eventually share your concerns about ADRs. Get them off what they don't need to be on."

 

[clement]

When BPD patients are fixating on medication changes, my first thought is that they are looking for another teddy bear: you. Once successfully engaged in a relationship, the fixation on medications will wind down. My first advice is don't take these requests at face value, and don't respond to them at face value through rejection, as they will see it as a rejection of their emotional needs. Instead validate emotions as much as you can, try to look for the role they want the medication to play and see how you could address that. The first step would be to resist changing the dose if they request it (without framing it as a rejection of the request).
Instead, get to the nitty gritty of what they are experiencing and they would like to address. The process of doing that is sort of the 'dose change' they are looking for. Feeling heard and validated is kind of what they want. You do not have to go crazy on changing the whole regimen from the first couple of visits. It's a step by step process, and time is on your side. Paradoxically, borderline patients can be the easiest to engage once you have a relationship going because they make strong emotional bonds, even if unstable.

Some battles are also not worth fighting. If they've been on the medication for a long time, they are not abusing it, stopping it would risk a significant destabilization, then you know, just continue it. Until the right time to address this issue.

Exactly...As was mentioned to me by a colleague to whom I lamented.

 

[comp1]

Refer these patients to an intensive outpatient program or even a partial hospitalization program. Any time you are feeling overwhelmed, it probably isn't you. It's probably the patient and their issues are just too complex to be managed in a 20 med visit monthly or even a weekly psychotherapy visit. If the patient declines, that's really on them, particularly since so many now offer evening or virtual programs. Actual DBT is pretty darn rare, but you can find IOPs and PHPs in the vast majority of cities and private insurance generally loves them as the other option is inpatient care.

 

[Sushirolls]

What's GPM?

Gallons Per Minute
Higher the number, the better your water well.
Higher the number, the wider option of tractor implements your tractor can handle with the hydraulics.
/jk

 

[Stagg737]

Beautiful. Exactly. I look back a the charts of half of these BPD cases on Seroquel with 100mg dose escalations every time the pt came in and said they were feeling emotional. Perhaps the best advice I received was, "Build rapport. They'll eventually share your concerns about ADRs. Get them off what they don't need to be on."

I've had the "I'm not an anesthesiologist" talk with many a patient and I've found it to be extremely common with more severe or chronic BPD patients that they are reliant on meds because that's what helps severely blunt or ideally (in their minds) completely numb their emotional response. Having the conversation that you're there to help them understand and work through their uncomfortable emotions and lability and not just make them numb can be extremely helpful with your discussions about why you're trying to decrease their meds or at least not increase further. Meds are only a small part of their treatment, and if they're expecting a magic pill or to just fix everything or just want to be numb then they need to seek care elsewhere.

 

[Ceke2002]

some of my bpd patients are tiring but tbh 3/4 of them are good people who cant control their emotions and just mess up consistently in life. some of my bpd patients are fairly certain are bipolar 2 as well. Sometimes its hard to tell the difference in the messy cases.

Can't answer for the bipolar 2 bit, but I have a prior diagnosis of BPD. I say prior, because I haven't met diagnostic criteria for some time, and after several years worth of therapy whatever remnants were left have also pretty much been cleared up as well. I don't know if this is true for other BPD patients, but there was always a part of me who knew, deep down, that I really was being ridiculous with how I behaved at times, but I just couldn't stop myself. Like there was this teensy part of my brain that would be going, "Oh FFS, just calm down, you've only been dating this guy for 2 weeks, he literally left you to go to work 15 minutes ago, why are you having a meltdown because he didn't say he missed you when you've phoned him just as he's walking into work". Unfortunately the BPD side of my brain would have none of it, so whatever smidgen of rationality I had ended up getting drowned out with the usual, "WAAAAHHHH, but I thought he loved me, we were supposed to be together forever, now he doesn't even want to see me anymore, I'm so unlovable (as she does something to push people away thereby proving theory of unlovableness), I'm a bad horrid person and everybody leaaaaves meeeeee!!!!!111 (cue the excessive drinking and drugging, cue the self harm, etc). Oy Vey, so not fun.

I actually did have therapy pretty soon after I was diagnosed when I was about 19-20 years old, and I was lucky to find a psychologist who kinda specialised in personality disorders. Mostly CBT type stuff, from memory, but what I found the most helpful with that initial therapy was having someone who set clear boundaries, and who gave me a sense of stability in that it didn't matter what buttons I tried to push with my usual, "I'm a horrible, unlovable person, therefore I will act out and get the response I expect to get, which will prove said unlovableness", I still got the same calm, measured, but also boundaried response no matter what. That was vital to me being able to really connect with therapy in the early stages, and when therapy ended due to lack of funds on my part, I'd already learnt enough that I was able to then start applying that to my everyday life and manage my BPD symptoms a lot better (so much so that by the time I hit 30 I no longer met diagnostic criteria).

And echoing what others have said, there is no magic pill for BPD. Obviously if there are other issues that do need medication, then that's a judgement call that has to be made, but in terms of BPD the only thing that ever worked for me was a: Therapy and b: A willingness to actually commit to and participate wholly in said therapy.

(Usual disclaimer: I'm talking from my own former patient experience, I am no a healthcare professional of any description and you should not consider this professional advice in any way shape or form.)

 

[smalltownpsych]

Can't answer for the bipolar 2 bit, but I have a prior diagnosis of BPD. I say prior, because I haven't met diagnostic criteria for some time, and after several years worth of therapy whatever remnants were left have also pretty much been cleared up as well. I don't know if this is true for other BPD patients, but there was always a part of me who knew, deep down, that I really was being ridiculous with how I behaved at times, but I just couldn't stop myself. Like there was this teensy part of my brain that would be going, "Oh FFS, just calm down, you've only been dating this guy for 2 weeks, he literally left you to go to work 15 minutes ago, why are you having a meltdown because he didn't say he missed you when you've phoned him just as he's walking into work". Unfortunately the BPD side of my brain would have none of it, so whatever smidgen of rationality I had ended up getting drowned out with the usual, "WAAAAHHHH, but I thought he loved me, we were supposed to be together forever, now he doesn't even want to see me anymore, I'm so unlovable (as she does something to push people away thereby proving theory of unlovableness), I'm a bad horrid person and everybody leaaaaves meeeeee!!!!!111 (cue the excessive drinking and drugging, cue the self harm, etc). Oy Vey, so not fun.

I actually did have therapy pretty soon after I was diagnosed when I was about 19-20 years old, and I was lucky to find a psychologist who kinda specialised in personality disorders. Mostly CBT type stuff, from memory, but what I found the most helpful with that initial therapy was having someone who set clear boundaries, and who gave me a sense of stability in that it didn't matter what buttons I tried to push with my usual, "I'm a horrible, unlovable person, therefore I will act out and get the response I expect to get, which will prove said unlovableness", I still got the same calm, measured, but also boundaried response no matter what. That was vital to me being able to really connect with therapy in the early stages, and when therapy ended due to lack of funds on my part, I'd already learnt enough that I was able to then start applying that to my everyday life and manage my BPD symptoms a lot better (so much so that by the time I hit 30 I no longer met diagnostic criteria).

And echoing what others have said, there is no magic pill for BPD. Obviously if there are other issues that do need medication, then that's a judgement call that has to be made, but in terms of BPD the only thing that ever worked for me was a: Therapy and b: A willingness to actually commit to and participate wholly in said therapy.

(Usual disclaimer: I'm talking from my own former patient experience, I am no a healthcare professional of any description and you should not consider this professional advice in any way shape or form.)

As a psychologist on this end of it, I would say that my experience mirrors yours. It is important to emphasize that in order to be effective, the psychologist had to have a degree of stability themselves to be that secure object and have the expertise to communicate and hold clear boundaries in a healthy and non-judgemental way and yet maintain flexibility. I think of the difference between authoritative parenting vs authoritarian or permissive.

 

[G Sheb]

Can't answer for the bipolar 2 bit, but I have a prior diagnosis of BPD. I say prior, because I haven't met diagnostic criteria for some time, and after several years worth of therapy whatever remnants were left have also pretty much been cleared up as well. I don't know if this is true for other BPD patients, but there was always a part of me who knew, deep down, that I really was being ridiculous with how I behaved at times, but I just couldn't stop myself. Like there was this teensy part of my brain that would be going, "Oh FFS, just calm down, you've only been dating this guy for 2 weeks, he literally left you to go to work 15 minutes ago, why are you having a meltdown because he didn't say he missed you when you've phoned him just as he's walking into work". Unfortunately the BPD side of my brain would have none of it, so whatever smidgen of rationality I had ended up getting drowned out with the usual, "WAAAAHHHH, but I thought he loved me, we were supposed to be together forever, now he doesn't even want to see me anymore, I'm so unlovable (as she does something to push people away thereby proving theory of unlovableness), I'm a bad horrid person and everybody leaaaaves meeeeee!!!!!111 (cue the excessive drinking and drugging, cue the self harm, etc). Oy Vey, so not fun.

I actually did have therapy pretty soon after I was diagnosed when I was about 19-20 years old, and I was lucky to find a psychologist who kinda specialised in personality disorders. Mostly CBT type stuff, from memory, but what I found the most helpful with that initial therapy was having someone who set clear boundaries, and who gave me a sense of stability in that it didn't matter what buttons I tried to push with my usual, "I'm a horrible, unlovable person, therefore I will act out and get the response I expect to get, which will prove said unlovableness", I still got the same calm, measured, but also boundaried response no matter what. That was vital to me being able to really connect with therapy in the early stages, and when therapy ended due to lack of funds on my part, I'd already learnt enough that I was able to then start applying that to my everyday life and manage my BPD symptoms a lot better (so much so that by the time I hit 30 I no longer met diagnostic criteria).

And echoing what others have said, there is no magic pill for BPD. Obviously if there are other issues that do need medication, then that's a judgement call that has to be made, but in terms of BPD the only thing that ever worked for me was a: Therapy and b: A willingness to actually commit to and participate wholly in said therapy.

(Usual disclaimer: I'm talking from my own former patient experience, I am no a healthcare professional of any description and you should not consider this professional advice in any way shape or form.)

As a psychologist on this end of it, I would say that my experience mirrors yours. It is important to emphasize that in order to be effective, the psychologist had to have a degree of stability themselves to be that secure object and have the expertise to communicate and hold clear boundaries in a healthy and non-judgemental way and yet maintain flexibility. I think of the difference between authoritative parenting vs authoritarian or permissive.

I think you hit the nail on the head there. Object constancy is one of the most useful psychodynamic principles in dealing with cluster B patients, especially those with BPD. The idea is that patients have difficulty seeing other people as separate and distinct objects. As a therapist, you try to maintain constancy even when the patients are doing their best to destroy it, by maintaining being caring, there for them but also separate, and not reacting to every whim they display. It works like magic especially for the therapist when the inevitable devaluation comes in. In a way, it's a replication of a healthier parent/child relationship. At some point, you of course hope to get beyond that, when you are finally seen as a separate object with their own emotions, needs and motivations.