![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 18 of 18. This is the beginning of the thread.
Posted by Quintal on August 27, 2007, at 18:09:17
I find this interesting; I was diagnosed with Bipolar II Disorder and Social Anxiety Disorder, and later discharged with a diagnosis of 'Personality Disorder NOS' after a disagreement over my dose of Parnate, though the original diagnoses were not annulled as far as I know. I think I have BPD, or strong traits at least, and I've noticed for a while that I'm on a similar wavelength to the schizophrenics I know. It's hard to put into words exactly, more of an empathy thing - an understanding of their worldview and thought processes, yet I'm sure I'm quite sane. So I was intrigued to find that the original diagnostic label for BPD was 'Pseudo-neurotic Schizophrenia'. I wrote more on my experiences with my Schizophrenic friend in a previous post over on the main board, but I'd like to share them with an audience more experienced in these matters because I think it's an interesting connection.
http://www.dr-bob.org/babble/20070815/msgs/777248.html__________________________________________________
Background: In 1975, Kernberg conceptualized borderline personality disorder (BPD) as a diagnosis in a group of patients with particular primitive defense mechanisms and pathologic internalized object relations. Before this time, many different terms were used to describe the condition in patients with similar traits. In 1938, Stern referred to the borderline between neuroses and psychoses. In 1941, Zilboorg described a disorder that he considered to be a mild version of schizophrenia; patients with this disorder had disturbances of reality testing, associative thinking, shallowness of affect, and pervasive anger. In 1942, Deutsch described a group of patients who lacked a consistent sense of identity and source of inner direction. She created the term as-if personalities because the patients completely identified with those upon whom they were dependent. Later, Hoch and Polatin created the term pseudoneurotic schizophrenia to describe a disorder characterized by panphobias, pananxiety, and pansexuality.
In 1959, Schmideberg first described borderline disorder as a disorder of character. Grinker and associates made the first efforts to describe borderline personality through systematic empirical investigation. According to the original Diagnostic and Statistical Manual of Mental Disorders (DSM-I), many patients with borderline pathology would have been given the diagnosis of emotionally unstable personality.
The Diagnostic and Statistical Manual of Mental Disorders, Second Edition, (DSM-II) contained nothing that adequately described borderline personality. With the publication of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, (DSM-III), BPD became a diagnosis based on a systematic description of observable clinical characteristics. This description was carried over to the Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised, (DSM-III-R) in 1987 and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) in 1994.
Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself, and they are exhibited in a wide range of important social and personal contexts. When these traits are significantly maladaptive and cause serious functional impairment or subjective distress, they constitute a personality disorder. The manifestations of personality disorders are often recognized by adolescence and continue throughout most of adult life.
Personality disorders are not formally diagnosed in patients younger than 18 years because of the ongoing developmental changes in areas that become more defined personality traits in adulthood. However, if the disturbance is pervasive and if the criteria are fully and persistently met, diagnosing BPD in children and adolescents is appropriate. Furthermore, the disturbance must not be limited to a developmental stage.
Although the literature on BPD in the adult patient is vast, the continuity between the adult disorder and the childhood disorder, which is often referred to as borderline disorder or borderline syndrome, remains unclear. In a review of the literature in 1991, Block et al concluded that the diagnosis of BPD can be appropriate in the adolescent population. They noted that adolescents with BPD are indistinguishable from adult patients in terms of the early history, current behaviors, and coexisting axis-I disorders.
http://www.emedicine.com/ped/byname/personality-disorder--borderline.htm
__________________________________________________Why Psychiatrists Are Reluctant to Diagnose Borderline Personality Disorder
- by Joel Paris, MDAbstract: Clinicians can be reluctant to make a diagnosis of borderline personality disorder (BPD). One reason is that BPD is a complex syndrome with symptoms that overlap many Axis I disorders. This paper will examine interfaces between BPD and depression, between BPD and bipolar disorder, and between BPD and psychoses. It will suggest that making a BPD diagnosis does more justice to patients than avoiding it.
Key Words: borderline personality disorder, psychiatric diagnosis
What is Borderline Personality Disorder?
Borderline personality disorder (BPD) is a diagnosis with an unusual history. The idea that patients might fall on some sort of �borderline� between psychosis and neurosis dates back to 1937, at which time the syndrome was first described.[1] BPD patients do have quasipsychotic or micropsychotic symptoms, such as voices telling them to kill themselves, paranoid feelings, and depersonalization.[2] However these cognitive symptoms are not essential features of BPD. The core of the syndrome is a striking instability of mood, accompanied by a wide range of impulsive behaviors, particularly self-cutting and overdoses, and with intimate relationships that are impulsive, stormy, and chaotic.[3]
Since BPD begins early in life and can continue over many years, it is classified as a personality disorder. However, BPD differs from other categories on Axis II in that it is associated with a wide range of active symptoms.[4] Moreover, BPD is one of the most common clinical problems psychiatrists see in practice. One study found that half of all patients with repetitive suicide attempts in emergency rooms meet criteria for this diagnosis.[5] Due to suicidal threats and actions, BPD patients are often admitted to hospital.[6] BPD cases are also common in out-patient settings,[7] where the pathology is often serious enough to use a large amount of clinical resources.
Why Clinicians Are Reluctant to Diagnose BPD
Structured interviews pick up many cases of BPD missed in ordinary practice.[7] This finding shows that practitioners are not consistently making this diagnosis. There are a number of reasons why clinicians may be reluctant to recognize BPD.
First, Axis I diagnoses are more familiar to most professionals. Making an accurate Axis II diagnosis requires experience. Personality disorders often seem to lack precise symptomatic criteria, since many of their features describe problems in interpersonal functioning that require clinical judgment for accurate assessment.
Second, resistance to diagnosing patients with a personality disorder may be based on the idea that these conditions are untreatable,[8] or at least not treatable using the pharmacological tools that have come to dominate the treatment of so many other disorders. While there is good evidence for the efficacy of psychotherapy in BPD,[9] not every clinical setting has the resources to provide that form of treatment. Simpler constructs such as major depression lead to more familiar treatment options, particularly pharmacotherapy.
Third, clinicians may wish to avoid making diagnoses associated with stigma. It is an unfortunate reality that a diagnosis of BPD can indeed lead to rejection by the mental health system. If BPD were to be reclassified as, for example, a mood disorder, patients would tend to be seen as having a biological illness instead of having a problematical personality. However, stigma cannot be removed by reclassification. Patients who are chronically suicidal and who do not form strong treatment alliances will continue to be just as difficult, even under a different diagnostic label.
Comorbidity and Diagnostic Problems
Patients with BPD frequently meet criteria for multiple Axis I diagnoses.[10] Considering that the disorder is associated with so many symptoms, this level of comorbidty should not be surprising. Changing the diagnosis of a patient with BPD, however, to one of these comorbid disorders focuses on only one aspect the syndrome and fails to account for BPD�s broad range of clinical phenomena (affective, impulsive, interpersonal, and cognitive).
While it is tempting to conclude that diagnoses such as major depression are the �real� problems in BPD, similar symptoms can derive from entirely different causes. Clinical phenomena, such as low mood or unstable mood, are no more specific than fever or inflammation. All that �comorbidity� says is that there are enough symptoms in one patient to meet criteria for more than one DSM category.[11] Moreover, overlap is common in the DSM system�major depression has at least as much comorbidity as any Axis II disorder.[12]
Another source of confusion is that the description of BPD in DSM-IV-TR is not specific.[4] The definition introduced in DSM-III was an advance because it operationalized diagnosis using observable criteria. As with other disorders, DSM instructs the clinician to make a diagnosis when five out of nine criteria are met. The result is that many permutations lead to the same category, producing a heterogeneous group.
It would be better to identify crucial features without which the diagnosis should not be made. One can group the current DSM criteria into affective, impulsive, interpersonal, and cognitive components. Patients should have most or all of these features to merit the diagnosis. That approach has been used in a research measure, the Diagnostic Interview for Borderlines (DIB),[13] later revised as the DIB-R.[14] This semistructured interview scores each of four areas of pathology on four sub-scales (0�2 for affective and cognitive symptoms and 0�3 for impulsive and interpersonal symptoms), using an overall cutoff point of eight out of 10 for positive diagnosis. Patients who meet DIB-R criteria are much more homogeneous, as shown by studies demonstrating that this instrument distinguishes them from patients with other Axis II disorders, and diagnosis achieves similar specificity if one requires six or seven criteria rather than five.[15]
BPD and Psychosis
The original concept of BPD as lying on a border between neurosis and psychosis found a parallel in the diagnostic term pseudoneurotic schizophrenia.[16] The concept was that patients with such a wide variety of neurotic symptoms could be latently psychotic. However, this diagnosis confused personality disorders primarily affecting mood and impulsivity (like BPD) with categories that primarily affect cognition, such as schizotypal personality.[17] Neither family history studies nor biological markers support a link between BPD and schizophrenia.[18] Nonetheless, some cases are challenging for differential diagnosis, since the cognitive symptoms of BPD can occasionally be florid. However, these phenomena are transient and stress-related, while insight is retained, as the following case example illustrates.
Case example�Patient 1. Bill was a 25-year-old man under treatment for chronic suicidality, unstable relationships, and mood instability. He also had paranoid ideas, sometimes thinking that neighbors were plotting against him. All these thoughts, however, were exaggerations of real situations and never had the bizarre quality of delusions. Bill also heard critical voices in his head when stressed, but knew that such experiences were imaginary. Bill received a DIB-R score of 9/10.
Nonetheless, Bill was initially diagnosed with schizophrenia and treated for psychosis for over five years with injectable antipsychotic medication. Bill actually liked attending this clinic and getting the injections, since it gave him a reason to come in every two weeks and to talk with a nurse. However, as his life stabilized, Bill�s micropsychotic symptoms eventually remitted, along with his impulsive and affective symptoms. By age 30, Bill stopped taking neuroleptics and never had a relapse of paranoid ideas or hallucinations.
BPD, Depression, and Dysthymia
Depression is a common reason for clinical presentation in patients with BPD. It has been suggested that the BPD is an atypical form of unipolar depression.[19] BPD is associated with chronic lowering of mood, particularly dysthymia with an early onset.20 One argument in favor of BPD as a form of major depression was based on the frequency of family history of depression in BPD patients. However, impulsive disorders, such as substance abuse and antisocial personality, are actually more common in families than mood disorders.[18] Another argument was based on commonalities in biological markers, such as REM latency.[19] However, it has never been shown that these markers are specific to DSM categories.
There is an important phenomenological distinction between temporal patterns of depressive symptoms in depression and BPD.[21] In classical depression, mood is stable over weeks and is relatively unresponsive to the environment. In contrast, mood in BPD is highly mercurial. Moreover, mood can be strikingly unstable in the course of a single day, depending on life events. Patients have a mixture of affects�not only sadness or anxiety, but also anger, brief periods of elation, and feelings of numbness. On a more practical note, depression in BPD does not respond in the same way as classical depression to antidepressant drugs, as the following case illustrates.[9]
Case example�Patient 2. Susan was a 24-year-old woman under treatment for chronic depression, with rapid shifts of mood, usually to anger and rageful outbursts. She also had a history of self-cutting and repetitive overdoses. Susan received a DIB-R score of 10/10.
Nonetheless, Susan was diagnosed with major depression and treated with a variety of antidepressants from several classes, none of which had any lasting effect. Each medication change led to short-term improvement for a few weeks followed by relapse to her previous state. Once Susan became engaged in psychotherapy, however, she improved to the point that antidepressants were no longer considered necessary.
BPD and the Bipolar Spectrum
It has been proposed that borderline pathology falls within the spectrum of bipolar illness,[22] based on a wish to expand the narrower diagnostic construct of bipolar disorder into a much broader range of conditions termed the bipolar spectrum. In this model, the range of bipolar spectrum disorders would be extended to include bipolar III (antidepressant-induced hypomania), as well as bipolar IV (ultra-rapid-cycling bipolar disorder). The last category, bipolar IV, describes mood swings typical of BPD (i.e., rapid shifts over hours). This expanded definition might include many, if not most, patients with BPD.
The issue is whether the lability of mood seen in BPD is identical to phenomena observed in mood disorders, such as bipolar II.[23] Hypomanic episodes have to last for at least four days, and this consistency of mood is rarely seen in BPD. Instead, affective instability (AI) is a characteristic feature that distinguishes BPD from classical bipolar disorder (as well as from other personality disorders). Emotion dysregulation is a similar concept.[24]
Other lines of evidence have also failed to support the idea that BPD and bipolar disorder reflect the same underlying psychopathology.[25,26] To summarize, there is no evidence for a common etiology, family prevalence data shows that impulsive disorders are more common than mood disorders in the first-degree relatives of patients with BPD, the longitudinal course of BPD rarely shows evolution into bipolar disorder, and treatment studies have failed to show that mood stabilizers have anywhere near the same efficacy in BPD as they do in bipolar disorder.
The following case demonstrates some of the problems in differential diagnosis between BPD and bipolar disorder.
Case example�Patient 3. Lisa had been self-cutting since age 16 and presented to a clinic with chronic suicidal ideation, irritability, and rages. Lisa received a DIB-R score of 9/10.
Nonetheless, bipolar II disorder was diagnosed on the basis of Lisa�s mood swings, as well as repeated episodes in which she impulsively became involved with men�flying thousands of miles to meet them after an initial internet contact. At certain points of her illness, Lisa also showed quasipsychotic symptoms, such as an intense fantasy that she was Jesus�s sister who had been sent to earth with a mission. Yet lithium, prescribed for a full year in adequate doses, had no affect on her symptoms. Instead, all of these problems came under control within weeks once Lisa entered psychotherapy and formed a solid therapeutic alliance.
BPD and Posttraumatic Stress Disorder
The concept that BPD might be a �complex� form of posttraumatic stress disorder (PTSD) has been suggested by frequency of childhood abuse histories in these patients.[27] The problem is the assumption that trauma is the primary cause of BPD, rather than one among many risk factors. Research shows that biological, psychological, and social factors are all involved in the etiology of BPD, that severe trauma histories are only found in about a third of cases, and that most people exposed to child abuse in community samples have neither BPD nor any other diagnosable psychiatric disorder.[28]
Case example�Patient 4. Lisa came for treatment of chronic suicidal ideation, multiple overdoses, and unstable intimate relationships. She also had transient episodes of depersonalization. Lisa�s DIB-R score was 8/10.
A previous therapist had diagnosed Lisa with PTSD, and Lisa did have serious problems resulting from having been sexually abused by her stepfather between ages of 7 and 12. It was interesting, nonetheless, to note that her older sister, who was abused in precisely the same way, never experienced psychological problems to the extent that she ever sought treatment. While the issue of child abuse played an important role in her psychotherapy, Lisa�s symptoms resolved gradually over time as she was able to find regular employment and become involved in more stable, less demanding relationships.
Positive Reasons for Diagnosing BPD
What are the advantages in making the diagnosis of BPD? The first concerns the recognition of complex forms of psychopathology with symptoms that do not occur in isolation. BPD is a construct that can account for the co-occurrence of a wide range of affective, impulsive, and cognitive symptoms in the same patient.[4]
The second advantage concerns prediction of outcome. BPD has a characteristic course over time, beginning in adolescence, with symptoms peaking in early adulthood, followed by gradual recovery in middle age.[29] This outcome pattern provides a useful frame for therapy.
The third value of diagnosing BPD lies in predicting response to treatment. Pharmacotherapy for depression is less effective in the presence of any personality disorder, and patients with BPD respond inconsistently to antidepressants.[9] The problem is that drugs are not as effective in BPD as they are in the disorders for which they were originally developed. In several of the case examples presented above, the patients were treated with pharmacotherapy based on an Axis I diagnoses, without obvious benefit. Unfortunately, such results do not always lead physicians to reconsider diagnosis and therapy�all too often, patients are tried on a variety of medications or given nonevidence-based polypharmacy.
The fourth advantage, closely related to the last point, is the strong evidence that psychotherapy can be an effective form of treatment for BPD.[9] We now know that several forms of cognitive and dynamic therapy are at least as effective, if not more effective, than drugs in relieving the symptoms of BPD. If one does not make the diagnosis, patients may not be referred for these forms of psychotherapy.
The BPD diagnosis has its problems, but so do most of the disorders listed in DSM. Professionals treating patients meeting criteria for this disorder can benefit from the large empirical literature bearing on this complex clinical problem. The cases presented above are examples of how Axis I pathology can lead to mistaken expectations about course and treatment response. Finally, the the proper diagnosis of BPD can help us to inform and educate patients and their families.
http://www.psychiatrymmc.com/displayArticle.cfm?articleID=article295
__________________________________________________Q
Posted by RealMe on August 27, 2007, at 22:16:18
In reply to Pseudo-neurotic Schizophrenia, posted by Quintal on August 27, 2007, at 18:09:17
I am not sure what your question is, but you gave a nice summary of the diagnosis though others in Great Britain and France have also weighed in amongst others. When I first went to Menningers as a patient, that was my diagnosis, BPD plus MDD but not my diagnosis when I left treatment. Then it was only that I had avoidant traits and no depression. Now it is only MDD. I also trained at Menninger's, and Kernberg was there as director of the hospital when he wrote most of his works on BPD (in the 70's and before my times there). That was the specialty area at Menninger's back in the 50's through the 90's. Lots of people went there for long term treatment for BPD. Research showed it worked for some people to have long terms intensive treatment, that they could actually be "cured" so to speak of the personality disorder. Yes there is overlap with Axis I diagnoses. The fad popular diagnosis right now is Bipolar, and lots of people are being diagnosed as Bipolar who actually might be BPD. Funny thing is that the meds for Bipolar also work well with people who are BPD. Also, lots of people diagnosed with BPD have a history of trauma of some sort. Some dissoicate; some have mini-psychotic episodes, and sometimes the two are confused. The DSM is a guide but not always the best guide. I tend to view people as more than some symptoms mentioned in DSM. Yes, the itemization of BPD includes what is often found with folks who have BPD. The people at Menninger's who did not do well and were diagnosed with BPD were people who were also heavily into illegal drugs. Why those who weren't fared better with treatment, IDK. I haven't looked at the study in awhile.
I am missing a lot here, but I have read so many books on BPD and narcissism. I really enjoyed working with people with personality disorders when I did therapy. It was a challenge I enjoyed. I think it would be easier for my therapist if I still had a personality disorder. In the end it really doesn't matter the disorder if you have a therapist who knows how to work with you, and you are on the right meds.
RealMe
(Oz)
Posted by Quintal on August 27, 2007, at 23:36:54
In reply to Re: Pseudo-neurotic Schizophrenia » Quintal, posted by RealMe on August 27, 2007, at 22:16:18
I wasn't asking a question as such, just wanted to open it up for discussion. I didn't know about your past diagnosis, and it's very encouraging to hear that people make a recovery from these things. You were not one of the people I 'had down' as having a PD, and I'm usually pretty sensitive about things like that, so I suppose that shows how much progress you've made.
Yeah, I agree about the bipolar fad thing, and Lamictal did work for me, although that article says that bipolar meds don't typically work for people with BPD. The problem is that my diagnosis seemed to be more of an accusation than a diagnosis as such, almost as though they said there - we've outed you as having a personality disorder, and people like you don't deserve to have treatment. Well that's how I interpreted anyway, considering that the personality disorder thing made its debut in my discharge letter. My GP has treated me like dirt ever since. I had a stomach ulcer recently and..... good God I wish I could have taken a video camera with me to show you the viscousness of the woman. Lets just say it was clear she thought there was nothing wrong with me, and as I was trying to describe my symptoms she would nod her head sardonically and shoot me one of her nasty smiles from time to time. I got the medication I needed, but I found the whole thing harrowing and it left me quite shaken.
Needless to say, I feel uncomfortable about going back to ask for psych meds. Another borderline told me Parnate was one of the few meds that had shown good efficacy in BPD, and I responded well to it. I still have some in my cupboard and I was thinking about going back on it. My stomach ulcer also seems to be coming back so I was thinking about killing two birds with one stone and mentioning them both in the same appointment, but I can guess how it will be interpreted "Oh, he just invented the whole ulcer thing to come here and get more meds" or something like that. This just isn't good because I find that sort of behavior very 'triggering' rage-wise.
So... I was thinking of meeting it head on and bringing along some studies that show Parnate's efficacy in BPD. I wonder if that would work? I was wondering about Nardil because of the anxiety component, and there are some interesting studies of Nardil in BPD, but most of them show that while it helps anxiety and irritability, it exacerbates emotional dysregulation and reactivity. That would be in acordance with my experiences with benzos and a few other GABAergic drugs, so I think I'll steer clear of that. I'm wondering whether to take Parnate for a week to see if I can tolerate it without a benzo sleep-aid, otherwise it will just be another bad mark in my notes if I were to go back asking for that type of drug. She's not going to give a sleep aid so if I can't tolerate it there's no point in raising the issue with her because I can't tolerate the alternatives such as Seroquel etc.
There are no good therapists in my area, and I once waited two years to get an appointment for CBT. I was rejected at the assessment stage for being too unstable, and well... I was sorta hoping therapy would help with that, you know? So that's a no-no too. I'm on my own. I've read that many borderlines can't use therapy effectively anyway, and that self-study is the best option. I have "The Angry Heart: Overcoming Borderline and Addictive Disorders" and "Surviving a Borderline Parent". I find the first one quite helpful, but irritating. It makes me angry for some reason. I liked 'Surviving a Borderline Parent' one better though. Do you know of any good material on BPD?
Q
Posted by Quintal on August 28, 2007, at 6:09:47
In reply to Re: Pseudo-neurotic Schizophrenia » Quintal, posted by RealMe on August 27, 2007, at 22:16:18
>I also trained at Menninger's, and Kernberg was there as director of the hospital when he wrote most of his works on BPD (in the 70's and before my times there). That was the specialty area at Menninger's back in the 50's through the 90's.
I've just spotted that Kernberg was mentioned at the beginning of the first article I posted. I don't read psychology journals or anything like that so I'm not familiar with the key figures here. I don't even know what Menninger's is to be honest - a specialist psychiatric unit/hospital/research center? I will look and see.
Q
Posted by arora on August 28, 2007, at 7:04:50
In reply to Re: Pseudo-neurotic Schizophrenia » RealMe, posted by Quintal on August 27, 2007, at 23:36:54
Quintal-
it sounds like your knowledge of BPD is very thorough- so you've probably read these two already, but I thought I'd mention them for anyone else who is interested..."Lost in the Mirror: an Inside Look at Borderline Personality Disorder" by Richard Moskovitz M.D.
and the one I think is the best, because it's written by someone who actually experienced it, rather than by a doctor or therapist-
"Get me Out of Here: My Recovery from Borderline Personality Disorder" by Rachel Reiland.
Rachel is an exceptional author, and I found her book very helpful... I couldn't put it down. All the way through it I kept thinking- "that's just like how I am!" It was my first introduction to BPD, and it was certainly an eye-opener- now I understand a lot of my own reactions and behaviours, (not that I'm any closer to knowing how to handle it- but I've got a few glimmers of insight now... at least that's something, I suppose. :-)
arora
PS. Sorry, I don't know how to make those titles into links like you did.
Posted by RealMe on August 28, 2007, at 20:52:30
In reply to Re: Pseudo-neurotic Schizophrenia » RealMe, posted by Quintal on August 28, 2007, at 6:09:47
Well first of all Menninger's is not what it used to be. It was located in Topeka, Kansas for years back to it's beginnings when a father and two sons opened the clinic, Drs. C.F. and sons Karl and Will Menninger. They became famous over time as an excellent private psychiatric hospital, and movie stars and the rich used to go there for extended treatment. By the 60's it was still pretty much the same people who could afford to go there for long term treatment, but some with insurance were also going there as patients. This continued into the 1970's and 1980's. I was there as a patient in the early 80's and no I am not rich; I had a million dollar policy for mental health treatent. When I was there as a postdoc in the 90's, Menninger's was ranked as the number one psychiatric program in the country. I think after they moved to Houston, they fell pretty far in the rankings, and they are now around #6 in the country, I think. It's not the same hospital though. No more long term inpatient treatment.
I am really sorry to hear there is no one in your area to see for therapy. How far would you have to travel to get to see a good therapist? As far as meds and all are concerned, can you go to separate doctors for the psych meds and the physical meds? That way maybe the doctor doesn't have to know about the psych meds right away. Of course that means the person prescribing the psych meds would need to know about the other meds so that you weren't mixing things that should not be mixed.
As far as my therapy went, yes I made huge strides there. I became more neurotic ha, ha. Well that has been better than the way I was. So now neither my therapist at Menninger's when I left, my last therapist, or my current therapist--none of them think I have a personality disorder now. I guess that is a plus. Funny you should mention Parnate, though, as that is what worked for me at Menninger's as a med. I was also on Lithium. Now I am on Parnate, and my last therapist wanted me to try Nardil and Lithium as Parnate wasn't working for me this time. However, since the ECT, I am again using Parnate, and I think it is working. Who knows. I wonder what would happen if I d/c's it. I don't think I will, though as my therapist says we have some hard times ahead when it will be true for a time that what happens in therapy will bleed out into my life after I leave.
If I were you I don't know if I would try to diagnose myself from the books. I used to try to do that when I just did not know what was wrong with me. This is when I was in my later teens and early 20's. I decided I was schizophrenic, and I got a big laugh from my doctor at Menninger's about that one as apparently some doctor prior to Menningers said just that. So, you can always find some doctor to give you a diagnosis of some sort.
If you really want to know your diagnosis, then I recommend going to some place like Menninger's for an outpatient evaluation. When I was working there, these evaluations took around one week and involved a complete work up including medical, psychiatric, psych testing, meetings with a social worker and family,etc. And then a consultant works with the team to come up with an understanding of the patient and what that person needs in terms of treatment. If you have insurance, I would say go for it and get the stupid doctor you refered to to make a referral.
RealMe
(OzLand)
Posted by RealMe on August 28, 2007, at 20:58:51
In reply to Re: Pseudo-neurotic Schizophrenia, posted by arora on August 28, 2007, at 7:04:50
> (not that I'm any closer to knowing how to handle it- but I've got a few glimmers of insight now... at least that's something, I suppose. :-)
>
> arora
>
>
AroraThat is a lot right there, to have a glimmer of insight as most people with BPD do not have a clue in the world why they are the way they are much less what to do about it. That is where a good therapist means the world.
RealMe
(OzLand)
Posted by Quintal on August 29, 2007, at 5:16:04
In reply to Re: Pseudo-neurotic Schizophrenia » Quintal, posted by RealMe on August 28, 2007, at 20:52:30
The only person I could/would realistically approach for therapy is my old counselor from college. I live in the UK and the NHS psychology services are pretty poor, and the waiting lists are often several years long, and treatment times short. I once had an hour of what I think was Psychodynamic therapy of some kind, but the most she could offer me was four one hour sessions, and we both agreed that just wasn't going to do anything useful, so we terminated therapy at the first session and 'donated' my allotted time to someone else. I'd waited about eight months for that appointment, and I've already told you about the CBT. There may well be some private therapists in my area but I can't afford them.
I'm on the 'Notification of Registration' register, so all doctors have to notify my GP and a central monitoring agency if I attempt to register at their practice. I think it's a way of limiting drug-seeking behavior (I once forged a Klonopin prescription). So going to another GP for different meds isn't an option. I think it would be a pretty borderline thing to do anyway :-)
The borderline diagnosis was one I'd always tried to avoid, substituting it with more 'innocent' ones such as Social Anxiety Disorder and Bipolar II. I feel almost a sense of relief at acknowledging that yeah, that's my problem, and I'm getting better. I see a lot of borderline traits around me, and it's clear there are some in recovery, some working towards recovery, some are unaware, and some doing their level best to avoid recovery. I hope that by at least acknowledging I have these traits and attempting to overcome them I'm on the path to recovery.
Q
Posted by Quintal on August 29, 2007, at 5:40:33
In reply to Re: Pseudo-neurotic Schizophrenia, posted by arora on August 28, 2007, at 7:04:50
Thanks for the suggestions arora. I'm a bit of a novice when it comes to Psychology, so I always welcome new information. I've been looking at Rachel Reiland's book for a while. I've tended to concentrate more on self-help manuals so far. It would be interesting to read a story from a sufferer's perspective.
I've looked at "Lost in the mirror: an inside look at borderline personality disorder" and it was next on my 'to buy' list! I guess now is a good time to get it? You can link to Amazon by putting the title between double, double quotes "". It took me a few attempts to figure it out too:
http://www.dr-bob.org/babble/books/20061001/msgs/709116.htmlQ
Posted by RealMe on August 29, 2007, at 10:49:21
In reply to Re: Pseudo-neurotic Schizophrenia » RealMe, posted by Quintal on August 29, 2007, at 5:16:04
I was thinking if there was a psychiatrist around who could prescribe the psychiatric meds, and then your GP could prescribe the other meds.
Can you not change doctors and go to a different GP altogether?
RealMe
Posted by Quintal on August 29, 2007, at 18:12:30
In reply to Re: Pseudo-neurotic Schizophrenia, posted by RealMe on August 29, 2007, at 10:49:21
I live in a rural area and there's only one psychiatrist to serve a huge catchment area, so the services are heavily overloaded as it is, and many of those cases are emergencies and serious illness like Schizophrenia. My friend was discharged during her second pregnancy - a time of high stress for any woman surely, more so considering that her first psychotic break was triggered by the death of her first child. Hardly the time to discontinue care then eh? But that's what he did (it was the same man). So frankly it's mostly crisis management, and they have no time for treating *relatively* stable people with BPD unless there's serious suicidal ideation, and there isn't in my case.
I think I'm doing pretty well actually. I seem to have improved a great deal since being discharged, though I don't know what role quitting benzos has played in this new relative stability. Unfortunately I've been self-medicating with small doses of codeine in OTC painkillers, and though they've worked very well I've now built up tolerance, and an ulcer (from the ibuprofen contained in Nurofen Plus). So....I'll have to quit. And I'm hoping Parnate will help take up the slack in my dopamine system.
Yeah, I could change GPs but I'm sure there'd be questions asked and both parties would be suspicious of my intentions, so on the whole I don't think it would do me much good. Better the devil I know, or something like that.
Q
Posted by RealMe on August 29, 2007, at 21:03:16
In reply to Re: Pseudo-neurotic Schizophrenia » RealMe, posted by Quintal on August 29, 2007, at 18:12:30
So you mean you can't go to this psychiatrist for just medicaition management??? I wasn't meaning for therapy.
And is there no one, a psychologist, for example that you could see for therapy if you wanted that??
RealMe
Posted by Quintal on August 30, 2007, at 10:04:22
In reply to Re: Pseudo-neurotic Schizophrenia » Quintal, posted by RealMe on August 29, 2007, at 21:03:16
The only person I can go to for medication management is my GP. Even if I were referred back to the psychiatrist I would have to wait at least six months for an assessment interview, never mind an appointment, and that would all depend on whether I 'passed' the assessment. I have a feeling they're designed to get rid of people with my (long-term/hard to treat)problems. They mostly want simple cases that will respond quickly to medication, because makes their department look more efficient on the official statistics that way. So basically it's a crap shoot, and that isn't just me being negative. Ask any of the posters from the UK - and my area is particularly bad. Also, the psychiatrist said in his discharge letter that he didn't want to see me again "unless things change significantly". So I think that would be a definite minus at the assessment interview.
As I've already explained, the psychology services are even more dire than the psychiatric. That's why I the only person I think I could go to for real, genuine help is my ex-counselor. I'm sure she would be willing to make some arrangement if I asked, because of the ethical responsibility thing. I don't think she takes private patients, just college students, because she's paid by the college. I don't want to put her out and ask her to do anything she doesn't really want to do, so basically I'm on my own.
Q
Posted by Wittgenstein on August 30, 2007, at 15:21:17
In reply to Re: Pseudo-neurotic Schizophrenia » RealMe, posted by Quintal on August 30, 2007, at 10:04:22
Quintal,
I'm sorry you can't get the help you need. I am also from the UK (although live in the Netherlands now).
I was hospitalised after a suicide attempt earlier this year, while still in England (I was at university at the time). I was discharged, and told that an urgent appointment with one of the hospital's psychiatrists would be made within the next day or so - nothihng ever materialised. I later went back to my home down - visited my GP who refused to refer me for NHS mental health care - not even to a counselor let alone a psychiatric assessment and told me to come back again in 2 weeks! This was despite telling her I was suicidal - and I didn't have any prior diagnoses hanging over me.
In the end I had to see a private psychiatrist (I had private insurance but otherwise it was £270 for an initial assessment and £190 for a 50 minute follow-up). My insurance had a £1000 limit on mental health costs so there was no way I would have been able to get therapy or regular psychiatric consultations in the UK without digging deep into my pockets.
I'm glad I'm in the Netherlands now, where I can get the treatment I need - I pay for my T but that's a personal choice. I don't know what would have happened if I'd had to stay in the UK. The waiting lists and lack of support for those not in immediate crisis (and those who are) is appalling in my opinion.
I can't remember if it was you or another poster on this topic but the reference to the 'Surviving a Borderline Parent' book looks interesting - I may well order the book as it bears a lot of relevance to my childhood experiences. I'm not myself BPD.
Good luck. Does 'Mind' have any help on offer? I have the feeling they offer support groups - perhaps counseling too?
Witti
Posted by RealMe on August 30, 2007, at 22:26:33
In reply to Re: Pseudo-neurotic Schizophrenia » RealMe, posted by Quintal on August 30, 2007, at 10:04:22
Are there not groups up in arms making a big row about the pathetic conditions of mh care in the UK. Is London better because it is a big city?? Things are not good for most people here either. I guess I should count my lucky stars that I have two insurances that typically pay for everything However, this is not the case with my T. He is not a preferred provider. In other words, he won't just take what the insurance companies will pay him. He is $245 for 45 minutes, and I see him twice per week. My 2 insurances together pay around 47% of his bill. I have to pay the rest out of pocket. When I run out of my 60 sesssions per year, then I have to pay for probably 90% out of pocket. My T suggested I contact a nother psychologist we both know and pick up some private family court evaluations in Chicago as I could probably make around $4000 for one evaluation. And, that would pay for a couple of months. I am so exhausted right now, I would rather dip into my savings. I also got $20,000 from when my brother died. So, I can use that too. I think he thinks I will need around two to two and one-half years of therapy to work through my "unfinished business." My resistance, however, is getting in the way, and so I should start seeing $$$ when I go to his office. Maybe that would give me the stimulus to get off my darf and get into things.
I am sorry there is no one near by and that a psychiatrist won't even see someone for med's. Again; why aren't people throwing a fit about this? In my state, our Govenor signed a bill last year that raised what insurance companies should pay for mh outpatient treatment. It was 30 sessions per year, and it is now 60. There must be some organization that is fighting for rights of the mentally ill??? no???
RealMe
(OzLand)
Posted by Quintal on August 31, 2007, at 14:52:48
In reply to Re: Pseudo-neurotic Schizophrenia, posted by Wittgenstein on August 30, 2007, at 15:21:17
That's terrible Wiitgenstein. I'd say it borders on neglect, and that's not uncommon here is it? I saw a story in the paper today about a woman who was turned away from the hospital maternity unit and had to give birth at home due to staff shortages: http://www.thesun.co.uk/article/0,,2-2007400576,00.html
I'd highly recommend "Surviving a Borderline Parent" if you feel one of your parents had borderline traits. I liked the review by 'Battle-Scarred BPD Survivor', because it's so true.
There is a MIND group close to here, but I think it would be unwise for me to join it, for a variety of reasons. There's the social anxiety thing too, and I really don't think anybody else can help me do what I need to do, which is learn self-control. I suspect I'm one of those people that gets more neurotic the more attention I'm paid. I've honestly never been better since I was discharged, it's a bit of a paradox, but there you are.
I'm exploring other options though. I've been invited to an Ayahuasca healing ceremony in the UK with real, live, Peruvian Shaman.... but I'm not sure whether to go. I find the idea very interesting and I'd like to do something like that at some point in my life, I'm just not sure the time is right, but I suppose the time may never be 'right'.
I'm pleased to hear you're finally getting the treatment you need. There's no way I could afford a private psychiatrist either. I think there's another Brit here who had similar experiences on moving to another country, just goes to show that free public health care is realistic if it's managed efficiently.
Q
Posted by Quintal on August 31, 2007, at 15:55:27
In reply to Re: Pseudo-neurotic Schizophrenia » Quintal, posted by RealMe on August 30, 2007, at 22:26:33
Yeah, there are some pressure groups pushing for better mental health care. I think MIND is one of them, and there are others, but the standard of health care can be pretty poor in areas of heavy demand/low funding. Most people do get the care they need though, just not always in the most convenient time frame.
I think what happened to me was more a personal feud between me and this particular pdoc. I thought he was extremely Narcissistic and arrogant, and that this was influencing the decisions he made regarding my medication [he once tried to get me to take Zyprexa by telling me it was just a regular antidepressant like Prozac, and I got very angry and corrected him.... he discharged me from that particular unit to one closer to my home, but unfortunately two years later he later took up the vacancy left by one of the locum pdocs that was covering the post, and became my pdoc once again, much to our mutual delight].
Anyway, I wrote all this in my CBT journal, and next session my T asked if she could show him some of my comments (it ran into ~40 pages A4) because they worked in the same unit. At the time I agreed because I'd forgotten that I wrote anything about him, but of course he must have seen my comments. He told me he took my journal home to read at night. That creeped me out.
The next time I saw him, it was a review of my Parnate. I'd raised the dose because 20-30mg was making me feel suicidal, but I found doses above 40mg worked really well. When I first asked to try Parnate he asked me how much people were taking on the net, and I said 40mg+, and he said, well let's start at 30mg and go from there. I really didn't think he'd have a problem with me raising the dose to 40mg, considering it was making me feel suicidal and all, and I still don't think that was the problem. Anyway, he said 30mg was the most he was wiling to prescribe, even though I was doing well on a higher dose. I suggested Nardil as an alternative, but he claimed all MAOIs were more or less the same, then concluded the session with "well, there nothing more I can do for you Quintal, so I'm going to discharge you today".
So it's my interpretation that he was pissed off by the comments in my journal, and the discharge was 'revenge' for dissing him in front of a colleague. I should point out that I've not had this problem with other pdocs, there was just something about him. I really do think he had some sort of borderline/narcissistic thing going on, and that isn't just my perception either. My Schizophrenic friend had a disagreement over medication during her pregnancy - she didn't want to take any. So he responded by cutting off her supply and discharging her. I think he's a nasty piece of work, putting it politely, and I really don't want to go back under the 'care' of a man like that. I think it would make me ill.
Q
Posted by RealMe on August 31, 2007, at 21:17:58
In reply to Re: Pseudo-neurotic Schizophrenia » RealMe, posted by Quintal on August 31, 2007, at 15:55:27
Well I certainly don't blame you about the pdoc. I would not go back to him either. I always thought things were better in the UK. I guess not. Here in the US they keep saying we don't want to have the Canadian system, but what people I know in Canada tell me is that the main place where it is difficult to get into a doctor is Toronto. Otherwise, it is fine elsewhere. And my friend from Ontario Province who is living here for the time being but plans to go back says that a big problem is that a huge number of doctors are leaving to go to the US because they can make more money in the US. So, they also have a brain train. If the US adopted a Canadian plan, then I suppose the Canadian doctors would stay home, and the US doc's, well they would be stuck as there really would not be any place else to go.
RealMe
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