Rapid Cycling/BPD

[LadyHalcyon]

Have very impulsive, destructive 16 yr old patient with history of early sexual molestation. Mom recently died, father in prison. She meets all criteria for BPD diagnosis. First met patient when she was extremely suicidal, although I suspect it was more a cry for help. Either way, very depressed. She was placed inpatient 6 mo ago due to plan and intent; they initiated Lexapro to treat depression. Lexapro seemed to help with depression, but I was still seeing very impulsive behaviors, substance abuse, eating disorder, and rapid Cycling between rage and depression. She is on a wait list for a child/adolescent psychiatrist but wait is 6 mo. After researching pharmacological interventions , I spoke with her PCP and we agreed to add Lamictal and wean off Lexapro. A week or so after the addition of Lamictal, I started to see hypomanic traits (wearing lots of makeup, not sleeping, increased risky behavior like shoplifting-patient even reported she had been feeling "reckless".) I did not observe rapid speech or grandiosity; patient still exhibited feelings of worthlessness.

Spoke with PCP and she was taken off Lexapro. Patient's hypomanic symptoms disappeared but her depression returned with a vengeance. Her relationship also just ended so that is likely a contributing factor. She is currently inpatient again due to suicidal threats. Although I am not a prescriber, I have a good relationship with her PCP and her guardians. After reviewing several studies, my inclination is to add Abilify to the Lamictal as a way to treat the depression. The combo of lexapro and Lamictal seemed to trigger a hypomanic response, but it did help symptoms of depression. I was thinking the abilify would be able to alleviate the depression and anxiety (heightened arousal levels due to trauma). Thoughts?

Also, it seems Omega-3 has been shown to have some success if taken daily. Has anyone had any experience utilizing omega-3 as a way to reduce emotional liability?

---

Members don't see this ad.

 

[Armadillos]

If you feel she genuinely has bipolar disorder, abilify doesn’t have good evidence for treating the depressed phase. (How a med can treat depression in MDD and mania in bipolar, but not depression in bipolar is beyond me but thus is life as a psychiatrist).

As an aside med management in a potentially bipolar 16yo F is not a trivial situation, so would do whatever needed to have patient seen by a child/adolescent psychiatrist as opposed to PCP.

 

[FlowRate]

Abilify would be more appropriate if you were convinced/strongly suspected she was BorderlinePD and not BPAffectiveD. Latuda might be a good choice for treating BPAD mixed state if that's what you think is going on (and can get ins approval.)

Also, I suspect that activation side-effects of SSRI's, which are much more common in children/adolescents than adults, lead to a disproportionate number of later-in-life BPAD diagnoses (end up being called "mania" or "hypomania", potentially incorrectly) in BPD individuals.

 

[LadyHalcyon]

Definitely agree. Unfortunately there are a shortage of providers in the area so we are doing the best we can. I may call them and see if they have had any cancelations. I actually don't think she has bipolar, but I'm not ruling it out completely. Is it possible for hypomanic symptoms to be caused by an ssri and mood stabilizer if the person isn't bipolar? I also wonder how much of the hypomania could be attributed to her new relationship. I have never seen her manic, but I did see more rapid elevations in her mood after the Lamictal was added.

If you feel she genuinely has bipolar disorder, abilify doesn’t have good evidence for treating the depressed phase. (How a med can treat depression in MDD and mania in bipolar, but not depression in bipolar is beyond me but thus is life as a psychiatrist).

As an aside med management in a potentially bipolar 16yo F is not a trivial situation, so would do whatever needed to have patient seen by a child/adolescent psychiatrist as opposed to PCP.

 

[LadyHalcyon]

Abilify would be more appropriate if you were convinced/strongly suspected she was BorderlinePD and not BPAffectiveD. Latuda might be a good choice for treating BPAD mixed state if that's what you think is going on (and can get ins approval.)

Also, I suspect that activation side-effects of SSRI's, which are much more common in children/adolescents than adults, lead to a disproportionate number of later-in-life BPAD diagnoses in BPD individuals.

That is a good point. The lexapro (even without the Lamictal) made her jittery and gave her insomnia.

 

[LadyHalcyon]

Abilify would be more appropriate if you were convinced/strongly suspected she was BorderlinePD and not BPAffectiveD. Latuda might be a good choice for treating BPAD mixed state if that's what you think is going on (and can get ins approval.)

Also, I suspect that activation side-effects of SSRI's, which are much more common in children/adolescents than adults, lead to a disproportionate number of later-in-life BPAD diagnoses in BPD individuals.

How bad is the weight gain with Latuda? She has recently lost a lot of weight and I suspect she is restricting, although she claims the weight loss is due to depression.

 

[SourceOfDenial]

Have very impulsive, destructive 16 yr old patient with history of early sexual molestation. Mom recently died, father in prison. She meets all criteria for BPD diagnosis. First met patient when she was extremely suicidal, although I suspect it was more a cry for help. Either way, very depressed. She was placed inpatient 6 mo ago due to plan and intent; they initiated Lexapro to treat depression. Lexapro seemed to help with depression, but I was still seeing very impulsive behaviors, substance abuse, eating disorder, and rapid Cycling between rage and depression. She is on a wait list for a child/adolescent psychiatrist but wait is 6 mo. After researching pharmacological interventions , I spoke with her PCP and we agreed to add Lamictal and wean off Lexapro. A week or so after the addition of Lamictal, I started to see hypomanic traits (wearing lots of makeup, not sleeping, increased risky behavior like shoplifting-patient even reported she had been feeling "reckless".) I did not observe rapid speech or grandiosity; patient still exhibited feelings of worthlessness.

Spoke with PCP and she was taken off Lexapro. Patient's hypomanic symptoms disappeared but her depression returned with a vengeance. Her relationship also just ended so that is likely a contributing factor. She is currently inpatient again due to suicidal threats. Although I am not a prescriber, I have a good relationship with her PCP and her guardians. After reviewing several studies, my inclination is to add Abilify to the Lamictal as a way to treat the depression. The combo of lexapro and Lamictal seemed to trigger a hypomanic response, but it did help symptoms of depression. I was thinking the abilify would be able to alleviate the depression and anxiety (heightened arousal levels due to trauma). Thoughts?

Also, it seems Omega-3 has been shown to have some success if taken daily. Has anyone had any experience utilizing omega-3 as a way to reduce emotional liability?

I would be very uncomfortable diagnosing her with either bipolar or borderline personality disorder based on what you describe. Maybe keeping it in the differential. What you describe is a young person with significant developmental trauma, grief and loss, affective dysregulation and what I imagine would be significant issues surrounding healthy attachment.

I think anchoring on a diagnosis has shaped the thinking and treatment approach too much. I would argue that medication management at this point should be to reduce symptoms in order to help accomplish a sense of safety and semblance of stability, but based on your description this isn't going to be a case of finding a medication fix.

I think the most important thing you can do for this young person is to get them in with a therapist who works with developmental trauma. At this point I think that is as important than seeing a C&A psychiatrist, and likely to get you more bang for your buck.

 

[Desired Member]

I would be very uncomfortable diagnosing her with either bipolar or borderline personality disorder based on what you describe. Maybe keeping it in the differential. What you describe is a young person with significant developmental trauma, grief and loss, affective dysregulation and what I imagine would be significant issues surrounding healthy attachment.

I think anchoring on a diagnosis has shaped the thinking and treatment approach too much. I would argue that medication management at this point should be to reduce symptoms in order to help accomplish a sense of safety and semblance of stability, but based on your description this isn't going to be a case of finding a medication fix.

I think the most important thing you can do for this young person is to get them in with a therapist who works with developmental trauma. At this point I think that is as important than seeing a C&A psychiatrist, and likely to get you more bang for your buck.

Completely agree.

 

[Mass Effect]

I agree with the above. Right now, your main concern should be stabilization and safety until she is evaluated by a C&A psychiatrist (or really, any psychiatrist at this point). It concerns me that as a non-prescriber, you're influencing her PCP (when you're not quite sure what's going on with her) and starting a 16-year-old on an antipsychotic. I would hold off on med recommendations until she meets with a psychiatrist.

 

[Stagg737]

Have very impulsive, destructive 16 yr old patient with history of early sexual molestation. Mom recently died, father in prison. She meets all criteria for BPD diagnosis. First met patient when she was extremely suicidal, although I suspect it was more a cry for help. Either way, very depressed. She was placed inpatient 6 mo ago due to plan and intent; they initiated Lexapro to treat depression. Lexapro seemed to help with depression, but I was still seeing very impulsive behaviors, substance abuse, eating disorder, and rapid Cycling between rage and depression. She is on a wait list for a child/adolescent psychiatrist but wait is 6 mo. After researching pharmacological interventions , I spoke with her PCP and we agreed to add Lamictal and wean off Lexapro. A week or so after the addition of Lamictal, I started to see hypomanic traits (wearing lots of makeup, not sleeping, increased risky behavior like shoplifting-patient even reported she had been feeling "reckless".) I did not observe rapid speech or grandiosity; patient still exhibited feelings of worthlessness.

Spoke with PCP and she was taken off Lexapro. Patient's hypomanic symptoms disappeared but her depression returned with a vengeance. Her relationship also just ended so that is likely a contributing factor. She is currently inpatient AGAIN due to suicidal threats. Although I am not a prescriber, I have a good relationship with her PCP and her guardians. After reviewing several studies, my inclination is to add Abilify to the Lamictal as a way to treat the depression. The combo of lexapro and Lamictal seemed to trigger a hypomanic response, but it did help symptoms of depression. I was thinking the abilify would be able to alleviate the depression and anxiety (heightened arousal levels due to trauma). Thoughts?

Also, it seems Omega-3 has been shown to have some success if taken daily. Has anyone had any experience utilizing omega-3 as a way to reduce emotional liability?

Let's set aside the hypomania for a second (lots of things can look like hypomania) and read just the bolded for a second. I don't have the experience that many other members here have, but this screams early cluster B disorder to me. She had early childhood trauma and seems to have recent trauma, has anyone ruled out PTSD or acute stress disorder? Has she been worked up for a stress disorder now or in the past? How much actual therapy has she had? Any therapy aimed directly at coping with her traumas? How "rapid" are these mood swings and how long do they last? Daily? Weekly? Monthly? Are the depression, mood swings, or "hypomania" related to events/triggers or do they seem to occur regardless of triggers and stability of her social situation?

I feel like there's a lot of questions that need to be answered here (which probably and hopefully have been irl) before dropping a Bipolar diagnosis on a 16 yo with a significant history of distant and recent traumas. Sure, bipolar can be on the differential, but I'd drop it down the differential in this kid before ruling out some of the other diagnoses, as starting mood stabilizers or antipsychotics can do as much harm as help in someone who doesn't actually carry a diagnosis which these are useful for. I'm assuming since she's seeing you she's receiving therapy and has been worked up before, but I've seen some very obvious things missed which completely changed the treatment course for a patient. Interesting situation though, thanks for sharing (and hope the patient starts doing better).

 

[LadyHalcyon]

I do not believe she has bipolar. A diagnosis of ptsd could be warranted, but BPD is a better fit diagnostically speaking. She has a severe trauma history beginning at a very young age (neglect, physical, sexual). Not to mention the numerous attachment disruptions as a result of her parent's drug use. The mood swings occur in the same day, sometimes in the same minute. She uses cutting, food restriction, sex, and drugs in an attempt to regulate her emotions.

She has a pervasive fear of abandonment and engages in the typical push/pull pattern. She has horrible boundaries and exhibits extreme black and white thinking patterns. Her mood swings vascillate from fits of rage to extreme depression. Otherwise, she describes feeling numb most of the time. She has spoken of "wearing a mask" around others due to self-loathing and disgust. She literally hates herself so much to the point she doesn't look in the mirror when changing and/or turns the lights off. When caregivers attempt to set boundaries, she either acts aggressively or threatens suicide. The hypomania I witnessed is likely a result of SSRI activation, although I'm not completely ruling out bipolar. Even during the two weeks where she was more elevated, she still had extremely negative thoughts about herself. Additionally, she reported insomnia; not a decreased need for sleep. I actually think it can be harmful to avoid diagnostic labels due to fears related to stigma. However, I recognize the implication a Bipolar diagnosis can have, especially if it isn't accurate. I work with cluster B personality disorders and complex trauma frequently and I know therapy is the gold standard. However, her impulsivity, aggression, and depression are interfering with treatment. Therefore, I think med management is important. As mentioned previously, I am trying very hard to connect her with a child/adolescent psychiatrist but there is a very long wait list. Many of the articles I read said Abilify was effective at treating depression and anxiety in BPD and Bipolar. I am 90% sure she does not have Bipolar, but she seemed to experience high arousal levels as a result of the Lexapro, even though it reduced her symptoms of depression. I did give her the PCL-5 a week ago and she is also experiencing heightened arousal levels around crowds, loud noises etc.

Let's set aside the hypomania for a second (lots of things can look like hypomania) and read just the bolded for a second. I don't have the experience that many other members here have, but this screams early cluster B disorder to me. She had early childhood trauma and seems to have recent trauma, has anyone ruled out PTSD or acute stress disorder? Has she been worked up for a stress disorder now or in the past? How much actual therapy has she had? Any therapy aimed directly at coping with her traumas? How "rapid" are these mood swings and how long do they last? Daily? Weekly? Monthly? Are the depression, mood swings, or "hypomania" related to events/triggers or do they seem to occur regardless of triggers and stability of her social situation?

I feel like there's a lot of questions that need to be answered here (which probably and hopefully have been irl) before dropping a Bipolar diagnosis on a 16 yo with a significant history of distant and recent traumas. Sure, bipolar can be on the differential, but I'd drop it down the differential in this kid before ruling out some of the other diagnoses, as starting mood stabilizers or antipsychotics can do as much harm as help in someone who doesn't actually carry a diagnosis which these are useful for. I'm assuming since she's seeing you she's receiving therapy and has been worked up before, but I've seen some very obvious things missed which completely changed the treatment course for a patient. Interesting situation though, thanks for sharing (and hope the patient starts doing better).

 

[Stagg737]

I actually think it can be harmful to avoid diagnostic labels due to fears related to stigma. However, I recognize the implication a Bipolar diagnosis can have, especially if it isn't accurate.

Not trying to discourage placing a diagnosis on a patient. I was just pointing out that in this field we need to be prudent about it seeing as many providers, especially non-psychiatry/psychology people, will just read a diagnosis in a chart and treat based on that without even thinking if it could be wrong. For some diagnoses it's not as big of an issue, but for ones in which we commonly treat patients with some pretty powerful medications (bipolar and schizophrenia) an incorrect label can be life-altering in multiple ways and not just because of the stigma.

 

[LadyHalcyon]

I agree with the above. Right now, your main concern should be stabilization and safety until she is evaluated by a C&A psychiatrist (or really, any psychiatrist at this point). It concerns me that as a non-prescriber, you're influencing her PCP (when you're not quite sure what's going on with her) and starting a 16-year-old on an antipsychotic. I would hold off on med recommendations until she meets with a psychiatrist.

I understand your concerns. My main concern is her safety and I have no intention of demanding she be placed on medications as I am not a prescriber. I do want to alert her PCP of the change in behavior I observed while on the Lexapro. I also would like to discuss some research I reviewed and get his opinion, but perhaps that is outside my bounds.

The more I am discussing this case the more I am thinking about inpatient hospitalization/residential treatment. Her guardians already refused any IOP programs.

 

[LadyHalcyon]

Not trying to discourage placing a diagnosis on a patient. I was just pointing out that in this field we need to be prudent about it seeing as many providers, especially non-psychiatry/psychology people, will just read a diagnosis in a chart and treat based on that without even thinking if it could be wrong. For some diagnoses it's not as big of an issue, but for ones in which we commonly treat patients with some pretty powerful medications (bipolar and schizophrenia) an incorrect label can be life-altering in multiple ways and not just because of the stigma.

I completely agree with this. A 16 yr old with a Bipolar diagnosis will likely be on meds for life, which can cause diabetes, metabolic syndrome, obesity... You know the drill.

 

[SourceOfDenial]

Let's set aside the hypomania for a second (lots of things can look like hypomania) and read just the bolded for a second. I don't have the experience that many other members here have, but this screams early cluster B disorder to me. She had early childhood trauma and seems to have recent trauma, has anyone ruled out PTSD or acute stress disorder? Has she been worked up for a stress disorder now or in the past? How much actual therapy has she had? Any therapy aimed directly at coping with her traumas? How "rapid" are these mood swings and how long do they last? Daily? Weekly? Monthly? Are the depression, mood swings, or "hypomania" related to events/triggers or do they seem to occur regardless of triggers and stability of her social situation?

I feel like there's a lot of questions that need to be answered here (which probably and hopefully have been irl) before dropping a Bipolar diagnosis on a 16 yo with a significant history of distant and recent traumas. Sure, bipolar can be on the differential, but I'd drop it down the differential in this kid before ruling out some of the other diagnoses, as starting mood stabilizers or antipsychotics can do as much harm as help in someone who doesn't actually carry a diagnosis which these are useful for. I'm assuming since she's seeing you she's receiving therapy and has been worked up before, but I've seen some very obvious things missed which completely changed the treatment course for a patient. Interesting situation though, thanks for sharing (and hope the patient starts doing better).

I would also say you shouldn't drop a borderline personality disorder diagnosis on a 16 year old either. I appreciate that you highlighted all the traumas this person has been subjected to, but would argue the frame to understanding(through Borderline PD) is wrong. Consider this--PTSD is not the only way trauma presents. These are not discrete disorders, but are overlapping and on a spectrum of the impact of trauma. While there is much I dislike about the DSM, I particularly hate the placement of BPD in Axis II only served to create the illusion that it wasn't a trauma and stressor disorder.

To the original author, pick up a copy of Judith Herman's 'Trauma and Recovery'. I'm greatly influenced by her and her peers writings, but I think your approach would be different with that frame.

 

[LadyHalcyon]

Yes. I have read it. I also really likes the "The Body Keeps The Score" by Van Der Kolk. I see complex/developmental trauma and BPD as two sides of the same coin. The ICD 11 is on board, but the DSM has yet to create a complex/developmental trauma diagnosis. Therapeutically speaking, she needs BPD treatments, not Prolonged Exposure or Cognitive Processing Therapy. I don't throw around diagnoses recklessly, but i don't avoid socially stigmatizing diagnoses if I am confident. An accurate diagnosis helps inform future providers in regard to effective treatment approaches.

I would also say you shouldn't drop a borderline personality disorder diagnosis on a 16 year old either. I appreciate that you highlighted all the traumas this person has been subjected to, but would argue the frame to understanding(through Borderline PD) is wrong. Consider this--PTSD is not the only way trauma presents. These are not discrete disorders, but are overlapping and on a spectrum of the impact of trauma. While there is much I dislike about the DSM, I particularly hate the placement of BPD in Axis II only served to create the illusion that it wasn't a trauma and stressor disorder.

To the original author, pick up a copy of Judith Herman's 'Trauma and Recovery'. I'm greatly influenced by her and her peers writings, but I think your approach would be different with that frame.

 

[Stagg737]

I would also say you shouldn't drop a borderline personality disorder diagnosis on a 16 year old either. I appreciate that you highlighted all the traumas this person has been subjected to, but would argue the frame to understanding(through Borderline PD) is wrong. Consider this--PTSD is not the only way trauma presents. These are not discrete disorders, but are overlapping and on a spectrum of the impact of trauma. While there is much I dislike about the DSM, I particularly hate the placement of BPD in Axis II only served to create the illusion that it wasn't a trauma and stressor disorder.

To the original author, pick up a copy of Judith Herman's 'Trauma and Recovery'. I'm greatly influenced by her and her peers writings, but I think your approach would be different with that frame.

Tbf, I should have clarified that I was not trying to separate a diagnosis of PTSD or other stress-related disorder from borderline at this point nor do I think trauma and personality disorders are entirely separate entities (though they obviously can be). I was only attempting to convey that the history given seems to be more consistent with a personality/trauma-related disorder (or both, as you point out) than bipolar. I do understand that attempting to create a differential with largely independent diagnoses is taking a somewhat shallow view of what is actually going on, but it can help guide us in the appropriate direction for treatment and what we should be prioritizing for optimal outcomes.

I always find personality disorders and trauma-related disorders to be interesting, even though they do tend to have tragic histories. Any other recommendations for further reading is also appreciated, as I feel like my irl experience and common sense understanding of these disorders with these patients far exceeds my academic understanding of them and how they develop. @LadyHalcyon , any further readings you'd suggest are appreciated as well!

 

[LadyHalcyon]

Tbf, I should have clarified that I was not trying to separate a diagnosis of PTSD or other stress-related disorder from borderline at this point nor do I think trauma and personality disorders are entirely separate entities (though they obviously can be). I was only attempting to convey that the history given seems to be more consistent with a personality/trauma-related disorder (or both, as you point out) than bipolar. I do understand that attempting to create a differential with largely independent diagnoses is taking a somewhat shallow view of what is actually going on, but it can help guide us in the appropriate direction for treatment and what we should be prioritizing for optimal outcomes.

I always find personality disorders and trauma-related disorders to be interesting, even though they do tend to have tragic histories. Any other recommendations for further reading is also appreciated, as I feel like my irl experience and common sense understanding of these disorders with these patients far exceeds my academic understanding of them and how they develop. @LadyHalcyon , any further readings you'd suggest are appreciated as well!

Borderline personality disorder in adolescents: the He-who-must-not-be-named of psychiatry

This is a great one about adolescent and BPD but I have 5 to 10 articles focused specifically on medication management of BPD. PM me if you are interested. The above article says this:

"If two different persons are involved as the psychotherapist and the prescribing doctor, communication is very important. The pharmacological treatment will be symptom-oriented and will address impulsivity, affective instability, suicidal behaviors, and non-suicidal self-injury. No medication has received an official indication in the treatment of BPD, and long-term use of pharmacotherapy has not been studied in BPD. A good strategy could be to maintain a medication that works until psychotherapy has led to the development of new strategies."

That is what I am attempting to do here. Not overstep boundaries. I'm very concerned about this girl and she doesn't have the treatment team she really needs. The best I can do right now is communicate with her PCP. I really wish she had an amazing psychiatrist but it's a somewhat rural area and there is a serious lack of competent providers. And the providers available don't value communication. It's is very frustrating. It's representative of an overall problem in our health system today. Everything is so separate and specialized. Plus, communication takes time and there is so much pressure to meet certain demands. I work with the Medicaid population and I'm trying my best in a broken system.

 

[Mass Effect]

I think giving a 16-year-old a diagnosis of borderline personality disorder is likely do as much harm as good with providers outside mental health. I'm more old school and don't think it's an appropriate diagnosis in adolescence, though I know much of the thinking has changed.

 

[hamstergang]

I feel like I remember someone, probably @splik , posting that a history of sexual abuse had very low specificity and sensitivity for borderline personality disorder. But I'm about to get on a plane so can't really check. Not that this changes too much, but several in this thread have been implying otherwise.

 

[LadyHalcyon]

I feel like I remember someone, probably @splik , posting that a history of sexual abuse had very low specificity and sensitivity for borderline personality disorder. But I'm about to get on a plane so can't really check. Not that this changes too much, but several in this thread have been implying otherwise.

BPD is associated with nconsistent, rejecting, neglectful, and invalidating environment. Often times there has been sexual abuse, but not always. Basically an insecure attachment style, which impacts one's ability to self-soothe.

 

[clausewitz2]

Let's set aside the hypomania for a second (lots of things can look like hypomania) and read just the bolded for a second. I don't have the experience that many other members here have, but this screams early cluster B disorder to me. She had early childhood trauma and seems to have recent trauma, has anyone ruled out PTSD or acute stress disorder? Has she been worked up for a stress disorder now or in the past? How much actual therapy has she had? Any therapy aimed directly at coping with her traumas? How "rapid" are these mood swings and how long do they last? Daily? Weekly? Monthly? Are the depression, mood swings, or "hypomania" related to events/triggers or do they seem to occur regardless of triggers and stability of her social situation?

I feel like there's a lot of questions that need to be answered here (which probably and hopefully have been irl) before dropping a Bipolar diagnosis on a 16 yo with a significant history of distant and recent traumas. Sure, bipolar can be on the differential, but I'd drop it down the differential in this kid before ruling out some of the other diagnoses, as starting mood stabilizers or antipsychotics can do as much harm as help in someone who doesn't actually carry a diagnosis which these are useful for. I'm assuming since she's seeing you she's receiving therapy and has been worked up before, but I've seen some very obvious things missed which completely changed the treatment course for a patient. Interesting situation though, thanks for sharing (and hope the patient starts doing better).

Even if BPD is the "right" diagnosis, if you are going to be using medications mood stabilizers and neuroleptics have better evidence behind them than antidepressants for this population. On the older side now but a good place to start :Drug treatment for borderline personality disorder

Basically anything to introduce a space between impulse and action is going to be helpful to the extent anything will be. I think the activating effects of antidepressants are not considered often enough for these folks and I don't think there is compelling reason to think they likely to be useful for the kind of dysphoria that often gets mistaken for depression.

 

[clausewitz2]

How bad is the weight gain with Latuda? She has recently lost a lot of weight and I suspect she is restricting, although she claims the weight loss is due to depression.

The manufacturer will tell you that Latuda is weight neutral and will hint that it possibly even promotes a bit of weight loss. The later may be true of people switching to it from other, more obesogenic antipsychotics. It would be unusual for the weight gain to be tremendous.

 

[clausewitz2]

I am going to disagree slightly with the people saying you should never give an adolescent a BPD diagnosis. We know that adults who qualify for this diagnosis tend to have very clear histories of having very similar symptomatologies and experiences as adolescents. Turning 18 is not actually magic and is an arbitrary cut-off if we are talking about how human development actually works. If a BPD diagnosis in your neck of the woods means no one will work with her, fine, I can understand holding off. But the pattern I see around here more is that providers, particularly C&A providers, tend to make every mention of suicidality into an enormous crisis requiring inpatient admission in a repetitive and unhelpful fashion. This makes it very difficult for young people who experience chronic suicidality to maintain treatment relationships or feel safe disclosing anything.

If nothing else, the BPD label can alert people "hey, if this person talks about wanting to kill themselves, it doesn't mean you need to immediately call 911 every single f*ing time." I am very much on board with being super cautious with this label (the tendency apparent upthread to slap someone with a PD label because of an extensive trauma history is, ugh, far too common) but if the phenomenology fits I think you are doing a disservice to people to keep this from them. People who really merit the diagnosis generally report a sense of relief that there is a name for what they have experienced, or at least that is true of 90% of the people I have had this conversation with; the one exception was someone who was a social worker working in mental health, so probably unsurprising. I have seen some young people who were very high utilizers of our system while they were still on the child side of things do -much- better when they transitioned to the adult side because their treatment teams freaked out a whole lot less and were way more comfortable treating someone who was suicidal most days.

 

[hamstergang]

BPD is associated with nconsistent, rejecting, neglectful, and invalidating environment. Often times there has been sexual abuse, but not always. Basically an insecure attachment style, which impacts one's ability to self-soothe.

That really doesn't address the specific question brought up in my post. I'm otherwise very much aware of what BPD is as I am a psychiatrist.

 

[LadyHalcyon]

Thank you for the resource. It is very much appreciated!

Even if BPD is the "right" diagnosis, if you are going to be using medications mood stabilizers and neuroleptics have better evidence behind them than antidepressants for this population. On the older side now but a good place to start :Drug treatment for borderline personality disorder

Basically anything to introduce a space between impulse and action is going to be helpful to the extent anything will be. I think the activating effects of antidepressants are not considered often enough for these folks and I don't think there is compelling reason to think they likely to be useful for the kind of dysphoria that often gets mistaken for depression.

 

[LadyHalcyon]

That really doesn't address the specific question brought up in my post. I'm otherwise very much aware of what BPD is as I am a psychiatrist.

I'm sorry, I guess I misunderstood the question in your post. Could you please clarify?

 

[clausewitz2]

That really doesn't address the specific question brought up in my post. I'm otherwise very much aware of what BPD is as I am a psychiatrist.

Here's a good overview:
Google Scholar

TL;DR Somewhere between 20-45% or people diagnosed with BPD don't have a clear trauma history and about 80% of people with significant childhood trauma don't meet criteria for BPD.

 

[LadyHalcyon]

I completely agree. Adolescent inpatient facilities around here diagnose every kid like this with Bipolar, which I think is actually more harmful if it is not an accurate diagnosis. If anything, a diagnoses of BPD "should" reduce complete reliance on psychopharm interventions, as research clearly supports therapy (mainly DBT) is the gold standard of treatment.

I am going to disagree slightly with the people saying you should never give an adolescent a BPD diagnosis. We know that adults who qualify for this diagnosis tend to have very clear histories of having very similar symptomatologies and experiences as adolescents. Turning 18 is not actually magic and is an arbitrary cut-off if we are talking about how human development actually works. If a BPD diagnosis in your neck of the woods means no one will work with her, fine, I can understand holding off. But the pattern I see around here more is that providers, particularly C&A providers, tend to make every mention of suicidality into an enormous crisis requiring inpatient admission in a repetitive and unhelpful fashion. This makes it very difficult for young people who experience chronic suicidality to maintain treatment relationships or feel safe disclosing anything.

If nothing else, the BPD label can alert people "hey, if this person talks about wanting to kill themselves, it doesn't mean you need to immediately call 911 every single f*ing time." I am very much on board with being super cautious with this label (the tendency apparent upthread to slap someone with a PD label because of an extensive trauma history is, ugh, far too common) but if the phenomenology fits I think you are doing a disservice to people to keep this from them. People who really merit the diagnosis generally report a sense of relief that there is a name for what they have experienced, or at least that is true of 90% of the people I have had this conversation with; the one exception was someone who was a social worker working in mental health, so probably unsurprising. I have seen some young people who were very high utilizers of our system while they were still on the child side of things do -much- better when they transitioned to the adult side because their treatment teams freaked out a whole lot less and were way more comfortable treating someone who was suicidal most days.

 

[splik]

I feel like I remember someone, probably @splik , posting that a history of sexual abuse had very low specificity and sensitivity for borderline personality disorder. But I'm about to get on a plane so can't really check. Not that this changes too much, but several in this thread have been implying otherwise.

Indeed. Contrary to popular belief, the best study did not find a significant different in rates of sexual abuse during childhood and adolescence in those with BPD vs those without, and most individuals with BPD do not have a history of sexual abuse. They do have modestly elevated rates of physical/sexual abuse when collapsed compared to those without BPD. Per Linehan's biosocial model, BPD develops in those with a particular reactive temperament when exposed to a chronically invalidating environment. For some of our patients, that will include interpersonal violence, neglect, physical and sexual abuse and other atrocities, but for many it might just involve put downs, slights, digs, or a rejection of the child as a person. The key to creating a borderline child is variable reinforcement. The environment has to be unpredictable enough that the child doesn't know whether they are going to receive praise or scorn from their caregivers. Sexual abuse is elevated across diagnostic categories of mental disorder, including bipolar disorder. Some studies have found childhood sexual abuse to be as high as 50% in patients with rapid cycling bipolar disorder (though they were of lower quality).

 

[LadyHalcyon]

Here's a good overview:
Google Scholar

TL;DR Somewhere between 20-45% or people diagnosed with BPD don't have a clear trauma history and about 80% of people with significant childhood trauma don't meet criteria for BPD.

Right. Although I conceptualize trauma a bit differently in regard to BPD. I think of it more as an attachment trauma/insecure attachment style. Often their childhood does include more typical definitions of trauma, but not always. I do think early childhood sexual abuse is a moderator for BPD. No not everyone who experiences BPD has been sexually abused, but the more severe cases of BPD I have seen often include childhood sexual abuse.

I like the attached article because it breaks down the different constructs between PTSD, BPD, and complex trauma. View attachment Distinguishing PTSD, Complex PTSD, and Borderline.pdf

 

[cara susanna]

I want to point out a few things from the research relevant to this thread:
- Diagnostic validity and reliability for BPD has been found before age 18, even as as young as 12 years old
- As mentioned above, the link between trauma and BPD isn't as well established as conventional wisdom in the field would have you believe
- There is no predictive relationship between complex symptoms of PTSD and "complex" trauma exposure (i.e., there is no predictive relationship between these symptoms and trauma exposure frequency, chronicity, and subtype). Similarly, there is currently not enough evidence that what we think of as complex PTSD is distinct from PTSD or even warrants a subcategory of PTSD. It should also be noted that complex PTSD definitions vary across studies, and this has muddied the research as well. Finally, there is no evidence that traditional PTSD evidence-based therapies can't work just as well for individuals with more complex PTSD symptoms. See this article - SAGE Journals: Your gateway to world-class journal research

 

[Neuro111]

PGY3 here. I haven't had these many cases to deal with yet. But I want to throw in some considerations. The choice of Lamictal, I wonder, is a good idea in this patient especially if you are looking for rapid symptom control. As you already know, Lamictal takes too long to titrate up - 6 or 7 weeks or so to get up to 200 mg or a therapeutic dose. Second issue that I see with her is compliance. Do you have a sense of how reliable she or her family will be in terms of taking Lamictal and would they be able to follow through instructions on how to restart the medication if there is a gap? In the interim where she doesn't have a therapist or would not have anyone to teach her coping skills, I guess the goal would be to create as much gap between heightened emotions and self injurious or impulsive behavior. For that part, I wonder what your guys' thoughts are on a low dose + time limited use of standing klonopin?

 

[splik]

PGY3 here. I haven't had these many cases to deal with yet. But I want to throw in some considerations. The choice of Lamictal, I wonder, is a good idea in this patient especially if you are looking for rapid symptom control. As you already know, Lamictal takes too long to titrate up - 6 or 7 weeks or so to get up to 200 mg or a therapeutic dose. Second issue that I see with her is compliance. Do you have a sense of how reliable she or her family will be in terms of taking Lamictal and would they be able to follow through instructions on how to restart the medication if there is a gap? In the interim where she doesn't have a therapist or would not have anyone to teach her coping skills, I guess the goal would be to create as much gap between heightened emotions and self injurious or impulsive behavior. For that part, I wonder what your guys' thoughts are on a low dose + time limited use of standing klonopin?

Giving benzos to a drug abusing borderline teen is like throwing gasoline on a fire

 

[whopper]

In regards to Omega 3s
Rant: Use of supplements and diet is very much under-utilized.
Despite this, however, I don't usually see any improvement with mental health and diet unless the person's diet is very very bad. e.g. everything is frozen food and heated/fast food/chips/soda.

I still do make dietary recommendations but hardly ever see results from it.

Also while the data with omega 3s and mental health can be strong if the person takes mega-dosages of it (e.g. 15 g a day) that's a heck of a lot of fish oil, can leave the person stinky, plus there's potential bleeding risk.

In regards to rapid-cycling and Borderline PD: the 2 can be hard to distinguish and lots of people, erroneously, think along the lines of only one thing is going on with a patient. Many patients are onions and you can fix one thing but there's plenty of other layers of problems going on. It's inspiring to see people above treat it as the complex subject(s) it is and not oversimplifying everything to Bipolar Disorder.

 

[SourceOfDenial]

I want to point out a few things from the research relevant to this thread:
- Diagnostic validity and reliability for BPD has been found before age 18, even as as young as 12 years old
- As mentioned above, the link between trauma and BPD isn't as well established as conventional wisdom in the field would have you believe
- There is no predictive relationship between complex symptoms of PTSD and "complex" trauma exposure (i.e., there is no predictive relationship between these symptoms and trauma exposure frequency, chronicity, and subtype). Similarly, there is currently not enough evidence that what we think of as complex PTSD is distinct from PTSD or even warrants a subcategory of PTSD. It should also be noted that complex PTSD definitions vary across studies, and this has muddied the research as well. Finally, there is no evidence that traditional PTSD evidence-based therapies can't work just as well for individuals with more complex PTSD symptoms. See this article - SAGE Journals: Your gateway to world-class journal research

I’m curious how you would conceptualize the impact of childhood neglect(as a form of trauma) and what about traumatic events that don’t meet criterion A but nonetheless cause significant symptoms. What I see clinically differs from what I see in research. (I.e. I’m not going to withhold a trauma focused therapy for a person who has symptoms but doesn’t necessarily meet DSM criteria for ptsd). If it walks like a duck, quacks like a duck...

 

[cara susanna]

I’m curious how you would conceptualize the impact of childhood neglect(as a form of trauma) and what about traumatic events that don’t meet criterion A but nonetheless cause significant symptoms. What I see clinically differs from what I see in research. (I.e. I’m not going to withhold a trauma focused therapy for a person who has symptoms but doesn’t necessarily meet DSM criteria for ptsd). If it walks like a duck, quacks like a duck...

Depends on what it is and how well it fits into the "mold" of traditional PTSD evidence-based therapy. Sorry, wish I could elaborate more but it just varies so much from case to case! But, like, for example, I might be able to do CPT with someone for sexual harassment that doesn't fall into criterion A if it results in similar symptoms to PTSD and there are clear beliefs that are getting in the way.

 

[Mass Effect]

I am going to disagree slightly with the people saying you should never give an adolescent a BPD diagnosis. We know that adults who qualify for this diagnosis tend to have very clear histories of having very similar symptomatologies and experiences as adolescents

And we also know that many teens who exhibit BPD symptoms in adolescence do not grow up to be borderlines. How many teen girls have you seen at age 15 who get dumped by their boyfriend who become "suicidal" or split between their peer group or are raging drama queens? Then they get to college, become focused on academics or get involved in a serious relationship that their symptoms remit and they grow up and out of that mindset where they have to rely on such coping skills. It's important to consider the possibility, certainly, but slapping that diagnosis on a teen who could very well be caught up in the emotion dysregulation of adolescence, often driven by hormones, coupled with the psychosocial impacts of middle school or high school, does more of a disservice because that diagnosis will likely always be part of his/her medical record.

 

[LadyHalcyon]

And we also know that many teens who exhibit BPD symptoms in adolescence do not grow up to be borderlines. How many teen girls have you seen at age 15 who get dumped by their boyfriend who become "suicidal" or split between their peer group or are raging drama queens? Then they get to college, become focused on academics or get involved in a serious relationship that their symptoms remit and they grow up and out of that mindset where they have to rely on such coping skills. It's important to consider the possibility, certainly, but slapping that diagnosis on a teen who could very well be caught up in the emotion dysregulation of adolescence, often driven by hormones, coupled with the psychosocial impacts of middle school or high school, does more of a disservice because that diagnosis will likely always be part of his/her medical record.

Very true. Her behavior far exceeds normal emotional liability in teens. In fact, right now she is inpatient because she is threatening suicide if she is sent home.

 

[LadyHalcyon]

I want to point out a few things from the research relevant to this thread:
- Diagnostic validity and reliability for BPD has been found before age 18, even as as young as 12 years old
- As mentioned above, the link between trauma and BPD isn't as well established as conventional wisdom in the field would have you believe
- There is no predictive relationship between complex symptoms of PTSD and "complex" trauma exposure (i.e., there is no predictive relationship between these symptoms and trauma exposure frequency, chronicity, and subtype). Similarly, there is currently not enough evidence that what we think of as complex PTSD is distinct from PTSD or even warrants a subcategory of PTSD. It should also be noted that complex PTSD definitions vary across studies, and this has muddied the research as well. Finally, there is no evidence that traditional PTSD evidence-based therapies can't work just as well for individuals with more complex PTSD symptoms. See this article - SAGE Journals: Your gateway to world-class journal research

What are your thoughts on the research article I posted about complex ptsd?

 

[clausewitz2]

And we also know that many teens who exhibit BPD symptoms in adolescence do not grow up to be borderlines. How many teen girls have you seen at age 15 who get dumped by their boyfriend who become "suicidal" or split between their peer group or are raging drama queens? Then they get to college, become focused on academics or get involved in a serious relationship that their symptoms remit and they grow up and out of that mindset where they have to rely on such coping skills. It's important to consider the possibility, certainly, but slapping that diagnosis on a teen who could very well be caught up in the emotion dysregulation of adolescence, often driven by hormones, coupled with the psychosocial impacts of middle school or high school, does more of a disservice because that diagnosis will likely always be part of his/her medical record.

I think if someone is diagnosing someone as BPD just because they are a teenager feeling suicidal after a breakup the problem lies in the treater's understanding of the diagnosis. The research cited upthread supports the stability of this diagnosis for people meeting criteria and not for vague "BPD traits". I recognize that adults get slapped with PD labels all the time based on vague ideas of "Cluster B traits" and what not but I hope we can all agree that doing this is bordering on diagnostic malpractice. If you don't have the time, inclination, or familiarity with the literature to systematically evaluate for one of these constructs, don't give people one of these labels. They are really not meant to be acceptable ways of expressing your annoyance with the patient or suggesting they are a bad person.

I am with you entirely on being extra careful with doing this in young people. Making sure the patterns of dysfunction and core phenomenology have been consistently present for at least a year (as currently formally required) helps a lot with that. I think if you as the treater are very careful with your evaluation, are not using the label to enact your countertransference, and this is evident in your interactions with the patient, sharing your honest clinical opinion is likely to do far more good than harm.

 

[cara susanna]

What are your thoughts on the research article I posted about complex ptsd?

I've read Cloitre's work on the subject, that article included. Although her research suggests that what she proposes as C-PTSD is distinct from BPD, I haven't seen enough evidence that it is a distinct entity from PTSD. In that particular study, she only looks at individuals with childhood abuse histories and does not compare them to people with non-complex trauma as the article that I linked does.

I also have read all of her research on STAIR, adverse reactions to prolonged exposure, and the step-based approach with "complex" trauma. I do not find a sufficient argument that these individuals react poorly to PE and that a different treatment approach is necessary for them. In fact, the studies that have been done examining building skills prior to engaging in a trauma EBP has so far not found any improved outcomes in either symptom reduction, treatment engagement, or treatment retention.

I want to add that I read these studies hoping to find evidence for C-PTSD and the step-based approach because it makes so much sense intuitively (in fact, I read all of this research because I was hoping to submit a grant proposal related to the step-based approach for trauma treatment). But the evidence just isn't there IMO and, as critics of the C-PTSD construct have pointed out, as a result we're often delaying care.

 

[birchswing]

I think either the BPD diagnosis is becoming more common or people talk about it more, and among young people it seems to maybe be having a moment of acceptance. I think young people are a bit more unassuming in general these days. I won't mention names even though they're celebrities because that might complicate things for you all in terms of being able to talk about it, but there's a young 20s celebrity who has popularity with young people who shared publicly a diagnosis of BPD and it does not seem to have cast him as a pariah. In fact he talks about it quite frequently as part of his entertainment. At first I thought he was confused and meant bipolar, but it's become apparent it is BPD. Well at least the trappings of it. I think if the diagnosis were more ubiquitous it might lessen the stigma, which isn't even to say that more people would be diagnosed but just that the diagnosis comes out of the closet, even to the patient.

There was another instance of a celebrity talking very openly about her daughter's BPD diagnosis given at a young age, and it seemed cruel and bizarre the extent to which she talked about how ill the daughter was. It was in the context of the daughter coming of age, and the celebrity mother trying to exert influence over the daughter's life/decisions by announcing her mental illness in an attempt for broadcasters not to interview her and also seemingly to enact some of her own poor coping. I was very angry on behalf of the child at the time thinking that this mother had ruined the daughter's life by airing this dirty laundry, and in particular the BPD diagnosis. And while the daughter in her own right is not a celebrity, the reaction I've seen to this celebrity (with regard to her fans tweeting her) hasn't been the type of stuff you sometimes see where people come to regard someone identified as having BPD as an untouchable.

I've never personally been given a PD diagnosis. But when I've read the descriptions, I've always wondered: Why would a person not want to know this? If you have a roadmap of how you're likely to react to situations based on an ingrained pattern of behavior, it would give you comfort to know that there is an identified pattern governing you that you've now been made aware of rather than just chaos and that you can do something about it with interventions you enact when you see the pattern emerging. In some ways, the diagnosis seems like a type of treatment in and of itself.

 

[FlowRate]

I've read Cloitre's work on the subject, that article included. Although her research suggests that what she proposes as C-PTSD is distinct from BPD, I haven't seen enough evidence that it is a distinct entity from PTSD. In that particular study, she only looks at individuals with childhood abuse histories and does not compare them to people with non-complex trauma as the article that I linked does.

I also have read all of her research on STAIR, adverse reactions to prolonged exposure, and the step-based approach with "complex" trauma. I do not find a sufficient argument that these individuals react poorly to PE and that a different treatment approach is necessary for them. In fact, the studies that have been done examining building skills prior to engaging in a trauma EBP has so far not found any improved outcomes in either symptom reduction, treatment engagement, or treatment retention.

I want to add that I read these studies hoping to find evidence for C-PTSD and the step-based approach because it makes so much sense intuitively (in fact, I read all of this research because I was hoping to submit a grant proposal related to the step-based approach for trauma treatment). But the evidence just isn't there IMO and, as critics of the C-PTSD construct have pointed out, as a result we're often delaying care.

I'd love to read the review article that would follow this elevator-pitch thesis. Too bad negative reviews are also not particularly popular.

 

[cara susanna]

I'd love to read the review article that would follow this elevator-pitch thesis. Too bad negative reviews are also not particularly popular.

Here's one that covers some of the issues. Keep in mind that it's now older and most of the studies I mentioned above that haven't found improved outcomes with the step-based approach (i.e., skills building prior to trauma EBP engagement) are newer.

CRITICAL ANALYSIS OF THE CURRENT TREATMENT GUIDELINES FOR COMPLEX PTSD IN ADULTS. - PubMed - NCBI

 

[LadyHalcyon]

I've read Cloitre's work on the subject, that article included. Although her research suggests that what she proposes as C-PTSD is distinct from BPD, I haven't seen enough evidence that it is a distinct entity from PTSD. In that particular study, she only looks at individuals with childhood abuse histories and does not compare them to people with non-complex trauma as the article that I linked does.

I also have read all of her research on STAIR, adverse reactions to prolonged exposure, and the step-based approach with "complex" trauma. I do not find a sufficient argument that these individuals react poorly to PE and that a different treatment approach is necessary for them. In fact, the studies that have been done examining building skills prior to engaging in a trauma EBP has so far not found any improved outcomes in either symptom reduction, treatment engagement, or treatment retention.

I want to add that I read these studies hoping to find evidence for C-PTSD and the step-based approach because it makes so much sense intuitively (in fact, I read all of this research because I was hoping to submit a grant proposal related to the step-based approach for trauma treatment). But the evidence just isn't there IMO and, as critics of the C-PTSD construct have pointed out, as a result we're often delaying care.

Thank you for the response. It's interesting because there does seem to be differences between presentations, although perhaps it isn't an entirely different construct. It isn't unusual for the severity of hyperarousal and re-experiencing symptoms to subside with the passage of time. However, there does seem to be interpersonal elements associated with trauma the DSM does not fully capture. I have found exposure-based therapies to help reduce re-experiencing, exposure, and hypervigilance symptoms, but not as helpful when addressing interpersonal deficits.

 

[DisorderedDoc417]

I think giving a 16-year-old a diagnosis of borderline personality disorder is likely do as much harm as good with providers outside mental health. I'm more old school and don't think it's an appropriate diagnosis in adolescence, though I know much of the thinking has changed.

Everyone seems to forget that chronic and enduring with time are an important part of the BLPD diagnosis as well. She’s only 16. If she learns to better regulate mood later in life, perhaps there was an alternative diagnosis. Definitely sounds more cluster b though, from the arm chair.

 

[clausewitz2]

Everyone seems to forget that chronic and enduring with time are an important part of the BLPD diagnosis as well. She’s only 16. If she learns to better regulate mood later in life, it was a wrongful diagnosis. Definitely sounds more cluster b though, from the arm chair.

The empirical literature says this is absolutely false; something like 70% of adults who meet criteria at Time A don't anymore at Time B 10 years later. One of the major takeaways if you read the specialist literature on this is that BPD usually gets better. It is crucial you discuss prognosis realistically if you are making this diagnosis. If you think this is so something that will always be true about them then no wonder you're leery of the diagnosis.

There are many reasons why DSM conception of personality "disorders" is steaming garbage but that is a big one.

 

[DisorderedDoc417]

So you’re telling me you expect most with a dx of BLPD at age 21 to be “cured” by 31? You must see a “different” population.

 

[Mass Effect]

The empirical literature says this is absolutely false; something like 70% of adults who meet criteria at Time A don't anymore at Time B 10 years later. One of the major takeaways if you read the specialist literature on this is that BPD usually gets better. It is crucial you discuss prognosis realistically if you are making this diagnosis. If you think this is so something that will always be true about them then no wonder you're leery of the diagnosis.

There are many reasons why DSM conception of personality "disorders" is steaming garbage but that is a big one.

The issue from my perspective is, that it never disappears from the chart. A teenager with raging hormones can very well demonstrate "traits" of cluster B personality, but only within the arena of mental health is giving the diagnosis doing more good than harm.