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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 51. This is the beginning of the thread.
Posted by Racer on March 7, 2004, at 13:10:24
I've been wondering about this diagnosis, and all diagnoses really, for a while now. For all of you who have studied all this more than I, especially those students who are getting in depth knowledge about personality disorders, can you tell me what you think about it? What the current teaching is?
My new therapist -- with whom things are going rapidly from bad to worse -- keeps talking about people having diagnoses. Not having problems, but having diagnoses. She saw I was reading a compliation of the late Peter Cook's works, and said, all excited, "I wouldn't be surprised if he had a diagnosis!" As if that explained anything at all! Of course a diagnosis could have been made for him, but does it change the fact that a very brilliant man had to balance survival against success? That he died far too young, that he spent so many years at the bottom of a bottle? How about saying something more useful, like, "He was brilliant, it's too bad we'll never know what he could have produced had he lived."
Then we come to Borderline. A number of years ago, a pdoc told me to cooperate with treatment, or she would diagnose me with BPD and then I'd never be taken seriously again. In a new support group my therapist is running and has me in, she brought up BPD, as a sort of catch all diagnosis which she preferred not to mention by name. Not, you understand, that she didn't believe in it, just that she didn't like to use the name because it was so stigmatized. Hm, I mentioned that I thought it was partly stigmatized by the doctors having the attitude that any patient who did not "cooperate" with the prescribed treatment could be dropped into a drawer called "Borderline" and safely ignored. "Oh, well, there's nothing you can do for a borderline, anyway, so I don't have to worry about her anymore..." Even the DSM says it's mostly a dx of women. Not that it's mostly a disorder of women, but it's mostly diagnosed in women. Since I am a woman, and I have had the term brought up, I tend to see it as a way for doctors to abdicate any responsibility for the patient's recovery. Then again, I don't know much about it. I'd like to hear other people's opinions about all this.
So, if you have either been diagnosed BPD, or are going through psychology training, I'd like very much to hear what you think. Or, for that matter, if you just have anything to add, I'd like to read that, too.
Thanks!
Posted by gardenergirl on March 7, 2004, at 13:43:10
In reply to ???s about Borderline dx, posted by Racer on March 7, 2004, at 13:10:24
Racer,
I think the pdoc who threatened you with a diagnosis was totally out of line and contributes to the stigma of the borderline dx. I feel angry every time I read that. How dare him or her? I'm sorry that happened to you.I think, in a way, your T's refusal to name it also contributes to the stigma, but I can relate. I have a couple of clients who meet the DSM criteria for the dx, but I have not officially given it to them or told them. I think it is more important to work with the person, not the dx. Only occasionally do I wonder if someone would have a sense of relief at hearing that the troubles they are having are related to a cluster of symtoms that has a name and that others have the same group of problems and issues, too.
I go back and forth on this. I think for someone more stable, and with whom I have a good working relationship, and IF they ask, I might hand them my DSM pocket guide and have them look over Axis II disorders, PTSD, and mood disorders and see what they come up with.
I am lucky that I don't have to worry about reimbursement at the placement where I am training. Thus, I do not HAVE to give anyone a diagnosis. Although putting something that is definitely there on paper is helpful for other practioners, it does not give the complete picture of the client. And there is always the chance that another helping profession may request the records. If the client agrees, and I release them, then the dx is out there for others to see and react to and who may respond less sensitively.
The stigma in general makes me angry, because I love working with clients with borderline traits or diagnoses. I guess I have not experienced a long-term relationship with a client in which I became the object of devaluation (if I did, I did not know it.) That is one of the reasons some professionals don't like to work with clients with borderline. But I like to think that I would use that therapeutically and would have access to good supervision to cope with my countertransference.
Regarding your T, I'm sorry things aren't going well. She does seem like she thinks in terms of diagnoses. I'm not sure what she intended with her statement about Peter Cook. Have you shared your concerns with her?
I feel like I am rambling here, but I hope this helps!
gg
Posted by Racer on March 7, 2004, at 14:03:00
In reply to Re: ???s about Borderline dx, posted by gardenergirl on March 7, 2004, at 13:43:10
Thank you. You know that I'm still reeling from the other day. I'm not sure what to say when I go in there. (Beyond the basic, "How've you been sleeping lately?") I like your attitude about not adding to the stigma, and especially your sensitivity to the issues surrounding the dx getting into a paper record of you that may be used for less than positive purposes. And I especially like your attitude about working with a client, rather than a dx.
I guess I wonder what you believe about the validity of the diagnosis? If you think it's over or under reported? If it really is being used inappropriately by doctors as a way of avoiding difficult patients? And can you tell me more about it in general? (I guess I'm looking for reassurance here, like "that doctor was not right, because a) you don't fit the dx, and/or b) BPD means [x], it does not mean that there's no hope for patients who fit the diagnostic criteria." Yes, I do fret over things like this, which doesn't help. By the time I get to the doctor's office, I'm already so damned defensive it's a wonder I manage to squeak out "hello...")
Thanks GG! Them's part of my initials, did you know that? My husband's initials, too! Must be why we 'click', huh? Just the initials, nothing else needed...
Posted by shortelise on March 7, 2004, at 14:33:42
In reply to It does help, but brings up another ?? » gardenergirl, posted by Racer on March 7, 2004, at 14:03:00
BPD used to sometimes be called hysterical personality. Nice, huh?
My T said that dx's mean nothing for the most part, esp. for BPD. He said he does not use these labels for me, that he's never diagnosed me as such, other than having an anxiety disorder. More importantly, he said that there are a limited number of dx's and that no one fits any one of them exactly, that we are multifaceted.
And I have to disagree that "there is nothing that can help" a BPD. I recognize many of the characterstics in myself, and I am so much better than I used to be.
Racer, I do wish you well.
ShortE
Posted by Apperceptor on March 7, 2004, at 14:43:49
In reply to It does help, but brings up another ?? » gardenergirl, posted by Racer on March 7, 2004, at 14:03:00
Racer-
I must defer to gardnergirl, as she is further along in her clinical training than I am and I feel she knows her stuff.
In my experience/training, BPD is overdiagnosed, particularly in women (and especially in female schoolteachers, for some reason). Very few clinicians have a solid idea of what BPD is. The term "borderline" began because from an object relations / psychodynamic point of view, the tendencies experienced in BPD are equated with a level of functioning that is on the "borderline" between "neurotic" and "psychotic." What do you think of that? Many people disagree with the notion. I think it has SOME merit, but very limited. We all get a little questionable at times :-)
I feel the same way as gardnergirl...sickened by the people who have the bizarre nerve to "threaten" you with a diagnosis. Have you considered reporting the psychologist/psychiatrist who used the diagnosis as a threat to a state (or provincial) ethics board? If you need help locating the contact information I'd be happy to help. That is absolutely horrible.
As someone who has a few diagnoses of my own, as well as someone training in psychology, I do not think diagnosis in mental health is valid outside of insurance and referral purposes. I do not support the medical model. I do believe that mental illness is partially due to biological factors...HOWEVER, I do not believe they can be pigeonholed into a diagnostic category. For example, find me two people with "depression" who have anything resembling the same problem.....?
Take care-
Posted by Apperceptor on March 7, 2004, at 14:45:04
In reply to Re: It does help, but brings up another ??, posted by Apperceptor on March 7, 2004, at 14:43:49
Must also mention though...there are many therapists with a healthy understanding of borderline issues, who do an excellent job. Didn't mean to leave those out.
Posted by Racer on March 7, 2004, at 15:05:36
In reply to Re: It does help, but brings up another ??, posted by Apperceptor on March 7, 2004, at 14:45:04
You said a lot I agree with. Was it Tolstoy who wrote, "All happy families are alike, all unhappy families are unhappy in their own unique way?" I think that fits well here, don't you?
Thank you.
Posted by Racer on March 7, 2004, at 15:08:44
In reply to hysterical personality, posted by shortelise on March 7, 2004, at 14:33:42
Thank you very much. Your dr sounds very good, and very sensitive. I'll add those qualities to my general standard of adequate medical care, in hopes of finding a dr who can provide it by having a better way of recognizing what AMC consists of. Right now, my definition is pretty simple: treat me as well as my vet treats my cats. Doesn't sound so hard, does it? They don't even have to pet me under the chin or kiss my forehead, either. I'm not a stickler for those details, although I'm glad my vet does it.
Thanks again.
Posted by terrics on March 7, 2004, at 15:20:08
In reply to Re: It does help, but brings up another ??, posted by Apperceptor on March 7, 2004, at 14:45:04
I was given that dx. with one obvious criteria. I cried for hrs and hrs. after. I am in the medical field and knew what it meant. Up to that point I was always dxd as depressed. It is not a kind thing to tell someone. It is like saying,
you are the dregs of the psychologically ill.So here it is. The one criteria, and probably the most defining of BPD. I cut. Along with this I am running into a severe problem where I want to cut down to organs. This is something new. I used to just run the razor over my skin to cause bleeding. Now I keep running the blade over the same incision to make it straight and deep. It has become a driving urge. My abdomen looks like a mess right now from all the practice. This unfortunately is gory, but I would like to hold the slimy sticky insides in my hands. I think something has gotten out of control. I would like to understand why someone would do this. Just a little side note; I cut when I was nine after my father died. I had NO idea about cutting then and often wonder how such a thing can start without a prompt. terrics p.s. I keep this secret well. So it is good to be able to share it anonymously.
Posted by Dinah on March 7, 2004, at 15:28:30
In reply to Re: It does help, but brings up another ??, posted by Apperceptor on March 7, 2004, at 14:45:04
There is a somewhat positive side to understanding yourself, if you have a sensitive therapist, in thinking in terms of BPD. My manner of presenting myself is such that no one ever had seriously considered I might be borderline. And I really don't have enough of the criteria to meet the diagnosis. But when I read Linehan's "Cognitive-Behavioral Treatment of Borderline Personality Disorder" I grabbed a highlighter and started highlighting. It did so much to help me understand why I did the things I did. And find words to use to describe my feelings. It was such an "ah-hah" experience.
Since then, my therapist has come to the conclusion that I have borderline traits, but I'm the one that brought the idea to him. Since so much of borderline personality disorder is defined in terms of behavior, he might not have understood what drove me nearly as well if I hadn't brought up the possibility of the diagnosis to him.
So he now thinks I've got schizotypal traits on the outside, wrapped around an inside with borderline traits. :))
But then, I'm firmly convinced that Axis II should be done away with and the underlying biological sensitivies and resulting clusters of coping mechanisms should be seggregated. So more like splitting borderline into an Axis I disorder that consists of poor affect regulation and slow return to baseline. Possibly due to a poorly regulated cholinergic system. http://www.biopsychiatry.com/acetph.htm
And then something similar to Axis II, but not called "personality disorders" but rather more like "defense structure" where the clinician can have a mutually agreed upon way to classify symptom clusters that often occur together, but that are (IMHO) responses to biological vulnerabilities.
I'm tired and I'm not sure I explained it well. But wouldn't it be great to be on the DSM committee?
Posted by pegasus on March 7, 2004, at 15:57:48
In reply to ???s about Borderline dx, posted by Racer on March 7, 2004, at 13:10:24
I think diagnoses are so tricky, because they can be helpful, as Dinah described, but also very destructive, as in the way your old pdoc used them. The way I understand it, the most compelling reasons for using diagnoses are to communicate with other clinicians - especially for the purposes of research. For example, if someone is going to study the effects of some drug on depression, there has to be an agreement about what constitutes depression.
But I think we also get hung up on diagnoses, because we're so used to medical diagnoses. Medical disorders are a very imperfect analogy for mental disorders. Because different people can arrive at similar mental symptoms through such different pathways (life experiences, biological issues, etc.). And the diagnosis of mental disorders is completely dependent on the presence of certain symptoms. I mean, the diagnoses are defined by the symptoms. Which isn't the case for physical illnesses. A doctor can misdiagnose you even if they understand all of your phyisical symptoms. Because there is usually a real physical "right answer" about the cause.
But for mental disorders, the symptoms define the disorder, whatever the cause. Which a lot of people think means that the diagnoses are kind of arbitrary or meaningless.
I've been taught not to use diagnoses unless I have to (for insurance purposes, say). But on the other hand, sometimes different people have a lot in common in terms of their mental experiences, and it seems useful to me to consider what we can learn from one person that extends to another.
Sorry for the rambling, but that's my 2 cents.
- p
Posted by fallsfall on March 7, 2004, at 16:21:08
In reply to ???s about Borderline dx, posted by Racer on March 7, 2004, at 13:10:24
I have been diagnosed Borderline, but I don't fit the typical model - I'm not impulsive, and I don't get angry (maybe NOT getting angry is my problem...). Terrics, I disagree that SI is the hallmark of Borderlines - I think that splitting is - black and white thinking. I do a lot of splitting.
When I was interviewing new therapists, I would walk into their office and say "I have depression and BPD - but I'm not really a typical BPD...". One reason I did this was because if a therapist was going to have problems dealing with someone who was "BPD", then I knew they couldn't handle me. I wanted to know right off the bat.
Racer, if you ever read Psych books that are written for therapists, I would highly recommend Linehan's book "Cognitive-Behavioral Treatment of Borderline Personality Disorder". There is also a skills training manual, "Skills Training Manual for Treating Borderline Personality Disorder". The skills training manual has a few chapters at the beginning that summarize what is in the book - so if you only want to read a little, you could start there. These books describe how Linehan believes BPD is often triggered by the environment, and really capture (at least for me) what it feels like to be borderline.
Like Dinah, I had an "ah-ha" moment reading Linehan's books. The therapy that she describes is called DBT - it is a variant of CBT. I think that DBT could be helpful to lots of people who aren't Borderline (though many DBT programs are limited to patients with BPD). I did 6 months of DBT skills training, and my CBT therapist was very interested in reading Linehan's books.
For me, however, DBT and CBT did not go far enough. They were helpful in getting me to a place where I had enough coping skills to stay out of the hospital most of the time (I've been in twice, once before the DBT, once five years after). But they left me frustrated that the *cause* of my anguish wasn't being addressed - I was just learning to live better in spite of it. I'm now in Psychodynamic therapy, which does seem more able to get to the causes. I don't know if I could have survived my current therapy if I didn't have the DBT/CBT stuff first.
I have heard that with patients who have similar behaviors, that women are diagnosed with BPD, while men are given Anti-Social Personality Disorder diagnoses. My understanding is that Anti-Social PD is as rare amoung women as BPD is among men.
My take is that a diagnosis is helpful only if it helps you or your therapist understand you better, and create a more effective treatment plan. I think that there are a significant number of experienced therapists who aren't scared by the BPD diagnosis, and those of us who have even some tendencies in that direction will do ourselves and the therapists of the world a favor if we find out who they are, and stay away from the "unenlightened".
Posted by Apperceptor on March 7, 2004, at 17:00:46
In reply to Re: ???s about Borderline dx » Racer, posted by fallsfall on March 7, 2004, at 16:21:08
DBT is currently being systematically evaluated for use with depression and anxiety, with encouraging preliminary results. I also am very close to some psychologists who use it for these and other concerns in their own practices. I've used it once, in a DBT group for people with Bipolar I. It seemed to help, particularly "wise mind." It is my sincere hope that the word gets out that DBT, the supposedly "Borderline Therapy" is effective for other concerns, and perhaps this will help destigmatize.
I've had the pleasure of seeing Dr. Linehan speak, and her manner and approach is utterly engaging. She's a very "no bulls***" type person and her genuineness and lack of "clinical distance" is beautiful.
I hate the term "personality disorders." In my program, we are being told not to use it. The term we're using is "Characterological Disorders" (or "Characterological Maladjustments" among the more dynamically oriented faculty). Same thing, but I think taking it a little out of the vernacular might help a bit. Still a long ways to go, unfortunately.
Posted by Dinah on March 7, 2004, at 17:31:19
In reply to Re: It does help, but /MAY TRIGGER***, posted by terrics on March 7, 2004, at 15:20:08
Terrics?
I hate to sound like a mom here, but I can't help it. I am a mom. Are you making sure you're getting proper wound care? Embarassment isn't fun, but neither are a host of nasty bugs that you can get from an untended wound.
What does your therapist think of your increasing urges? Have you changed medications recently? I found that I had a lot more trouble on Luvox than off. It must have been disinhibiting for me somehow.
Posted by Apperceptor on March 7, 2004, at 18:18:20
In reply to Re: It does help, but /MAY TRIGGER*** » terrics, posted by Dinah on March 7, 2004, at 17:31:19
Please excuse my ignorance, I feel like I should know this, but could somebody tell me what "trigger" means? I've seen it in various places and I'm wondering.
I'm guessing it's got something to do with exacerbating urges or feelings...if this is the case and an answer to my question would be a trigger in itself, please don't hesitate to say so and I will figure it out some other way :-).
Posted by Dinah on March 7, 2004, at 18:26:33
In reply to Re: It does help, but /MAY TRIGGER***, posted by Apperceptor on March 7, 2004, at 18:18:20
It just means that people who are prone to self injury, or have issues with sexuality, or have suicidal ideation may find a post disturbing or it might exacerbate their problems
I suppose it maybe should be more specific? SI trigger? or suicidal ideation trigger? or abuse trigger?
Posted by Apperceptor on March 7, 2004, at 18:40:20
In reply to Re: It does help, but /MAY TRIGGER*** » Apperceptor, posted by Dinah on March 7, 2004, at 18:26:33
Thank you!
I think it can be applied to an even wider range of issues...I know that I've been "triggered" in the past (both online and in real life) with my obsessive-compulsive (primarily rumination) issues.
Wouldn't it be nice if we had "trigger warnings" in real life?
Posted by Apperceptor on March 7, 2004, at 18:58:13
In reply to ???s about Borderline dx, posted by Racer on March 7, 2004, at 13:10:24
Racer-
I'd like to suggest the book _Imbroglio: Rising to the Challenges of Borderline Personality Disorder_ by Janice M. Cauwels (ISBN: 0-393-03349-X). It addresses a lot of the issues you're confronting, and includes a great deal of feedback and contribution from individuals who carry a diagnosis of BPD themselves.
Posted by noa on March 7, 2004, at 19:47:40
In reply to Re: ???s about Borderline dx, posted by gardenergirl on March 7, 2004, at 13:43:10
My philosophy has come to be that diagnoses are not real things in and of themselves. They are man-made constructs to help organize symptoms into clusters to try to make sense of them in order to provide treatment.
Sometimes, new biological research comes along to support the idea that there is an underlying biological basis for validating one construct or another. But I think for the most part, the psychiatric diagnoses are all still waiting on that.
Take for example whether my depressive illness is unipolar or in the bipolar family. Who knows? At one point, my previous pdoc hypothesized that it might be, I think in part to explain the recurrences, but also in part to point to a new strategy to try---augmenting with lithium. But at the same time, he also said that lithium could help with depressive symptoms whether I had bipolar II or not. So in the end what difference did it make for me how to conceptualize my diagnosis? Most of psychopharm is trial and error anyway!
And therapy? I think they did studies that show that different kinds of therapy are actually more alike than different and that the healing aspects of therapy were those that are shared across the methods.
But sometimes I guess having a diagnosis could lead to a particular approach to treatment and that is when the diagnosis is the most relevant and useful.
Some of these diagnoses are based on concepts organized at an earlier time in the history of psychiatry, and therefore influenced by one school of thought or another, and that needs to be taken into consideration, as well.
OK, so all these different people, a rather diverse group, are clustered together because they share some symptoms. Perhaps this is a valid way to group them, perhaps not.
The biggest question for me is whether grouping them this way is helpful. Is the particular diagnosis helpful? Will it lead to a treatment plan that will work to help the person with their symptoms and problems?
Otherwise, diagnoses are rather useless at best, and can be used harmfully, as you related to us from your experience.
Some people find comfort in having a diagnosis and they feel better understood. But others feel shamed by it. So I say, if it helps, it is useful. If not, it is just an idea dreamed up by a bunch of psychiatrists sitting around a conference table decades ago. That is all it is. There is no evidence that conceptualizing things in this way is biologically valid.
I think sometimes MH people like to use the Borderline dx when they are working with challenging patients--it helps them distance themselves from the patients and helps them explain away their anxiety about being challenged.
But other times, it seems from what I've read here, the dx can be used with genuine care and professionalism, and with empathy for the patient's diagnosis.
If it is used as a weapon, obviously it isn't useful. If it helps someone feel understood and hopeful about finding relief--then to me, it is a valid and useful diagnosis.
BTW, there are some researchers who see BPD as falling into the bipolar spectrum, with rapid cycling explaining some of the emotional ups and downs. And some see hormones as a factor, too.
Posted by noa on March 7, 2004, at 19:58:21
In reply to Re: It does help, but /MAY TRIGGER***, posted by terrics on March 7, 2004, at 15:20:08
Terrics,
I appreciate your bravery in disclosing this. I know it must be hard to break the secret.
I think when I read Levenkron's book "Cutting", if I remember correctly, he doesn't necessarily equate cutting with borderline. But it's been a while since I read it. Anyone else know?
Cutting is a serious problem in itself. Do you find that the diagnosis of Borderline PD helps you and your therapist to understand your cutting behavior better?
Thanks.
Posted by noa on March 7, 2004, at 20:01:23
In reply to Re: ???s about Borderline dx, posted by pegasus on March 7, 2004, at 15:57:48
Pegasus--that was a very helpful explanation. You sound like a very compassionate therapist. Thank you.
> I think diagnoses are so tricky, because they can be helpful, as Dinah described, but also very destructive, as in the way your old pdoc used them. The way I understand it, the most compelling reasons for using diagnoses are to communicate with other clinicians - especially for the purposes of research. For example, if someone is going to study the effects of some drug on depression, there has to be an agreement about what constitutes depression.
>
> But I think we also get hung up on diagnoses, because we're so used to medical diagnoses. Medical disorders are a very imperfect analogy for mental disorders. Because different people can arrive at similar mental symptoms through such different pathways (life experiences, biological issues, etc.). And the diagnosis of mental disorders is completely dependent on the presence of certain symptoms. I mean, the diagnoses are defined by the symptoms. Which isn't the case for physical illnesses. A doctor can misdiagnose you even if they understand all of your phyisical symptoms. Because there is usually a real physical "right answer" about the cause.
>
> But for mental disorders, the symptoms define the disorder, whatever the cause. Which a lot of people think means that the diagnoses are kind of arbitrary or meaningless.
>
> I've been taught not to use diagnoses unless I have to (for insurance purposes, say). But on the other hand, sometimes different people have a lot in common in terms of their mental experiences, and it seems useful to me to consider what we can learn from one person that extends to another.
>
> Sorry for the rambling, but that's my 2 cents.
>
> - p
Posted by terrics on March 7, 2004, at 20:26:26
In reply to Re: ???s about Borderline dx, posted by gardenergirl on March 7, 2004, at 13:43:10
gg, you are kind not to mention the diagnosis to your clients. terrics
Posted by Racer on March 7, 2004, at 20:37:22
In reply to Re: It does help, but /MAY TRIGGER***, posted by Apperceptor on March 7, 2004, at 18:40:20
Posted by Apperceptor on March 7, 2004, at 21:05:28
In reply to Re: ???s about Borderline dx, posted by noa on March 7, 2004, at 19:47:40
!!!!!!
Noa has said everything I'd like to say on the topic of diagnoses, but more eloquently and comprehensively.
Thank you, Noa! Your type of thinking is a great asset to mental health.
Posted by Apperceptor on March 7, 2004, at 21:47:34
In reply to Re: ???s about Borderline dx » Racer, posted by Apperceptor on March 7, 2004, at 18:58:13
I saw a suggestion from Dr. Bob Up There ^ about giving people easy access to books. I suggested "Imbroglio" in this thread, so let's give it a try.
Dr. Bob, you owe me :-)
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