Why are therapists hesitant to give a BPD diagnosis?

[Mollyd]

BPD is "incurable" so they won't reimburse?

I'm not so sure that is exactly it.  From my perspective a personality disorder is perceived as a developmental disorder, noting that it is included in the same category as borderline intelligence.  It's a developmental disorder in that key components of the personality development were missing/not completed/don't exist. (E.G. in npd what is missing is empathy and a sense that they are equivalent to those around them ... in bpd what is missing is the development of proportionality and consistent sense of self.  These things are not there -they are missing or not developed fully). It is not seen as "curable", but more a condition that just is.  Treating it would be adding to the development of the person - which is different that Axis I treatment -where the person is seen as normally developed with a condition on top of that.

The reason it's not reimbursable isn't so much that it isn't curable, but more that it's a different axis/construct all together.  Reimbursement can occur (on axis I) if a therapist is using CBT/DBT etc. to mediate anxiety or mood disregulation - or other related symptom sets that also carry diagnoses.  A provider can diagnose/treat and include the axis II disorder. It's just that to diagnose ONLY the axis II disorder ... it's kind of like saying one is going to give therapy for the condition of borderline intellegence.  That's not therapy.  That's something else.

Aix II is for reporting personality disorders and mental retardation - and noting "prominent maladaptive personality disorder features". 

Axis III is for reporting General Medical Conditions.  We don't expect that therapists would be paid for treating medical conditions, right?

There is no cure for mental retardation and therapy isn't done for that specifically.  But, that's not to say that some services, therapy and otherwise aren't appropriate for those with this condition. 

I continue to think providers need to include the axis II diagnosis, or at least features if they are recognized.

My thoughts, anyway.

Molly

[Randi Kreger]

1. Ignorance, especially if the person is under 18
2. Belief that people shouldn't be "labeled"
3. So the person won't get stigmatized or refused treatment by other professionals who look in the chart
4. To get insurance coverage, especially when there is an Axis 1 disorder
5. So the person with BPD won't have their feelings hurt, see themselves as unloveable, use the illness as an excuse, etc.

Those are the main ones.

Randi Kreger
www.BPDCentral.com
The Essential Family Guide to BPD

[MagentaOrchid]

My T said she does give the dx.  She told me she gets one of two reactions.  One, they get upset and storm out and dont come back.  She says these type pwBPD are not able to be helped.  The other ones go ahead, read about it.  Admit that it is like them.  She says these ones can be helped somewhat. 

She has been in practice many years and I liked her explanation.  It helped me realize, my mom will not accept her diagnosis (she has been told).  And it helped me trust her further that she is not going to be keeping secrets from me about my own mental health. 

[GENERAL ANNOUNCEMENT]

GENERAL ANNOUNCEMENT This board is intended for general questions about BPD and other personality disorders, trait definitions, and related therapies and diagnostics. Topics should be formatted as a question. Please do not host topics related to the specific pwBPD in your life - those discussions should be hosted on an appropraite [L1] - [L4] board. You will find indepth information provided by our senior members in our workshop board discussions (click here).

[dados76]

insurance.. can have something to do w/it.. my partners primary dx is OCD/PTSD bc those are covered by insurance for treatment.. 'secondary' dx are bpd/ppd.. even tho thats probably backwards to how he actually is.. his first dx was done in a correctional facility.. so they didnt care too much abt insurance and just ran down a checklist of whatever he 'probably' had.. his current doc explained that.. w/OCD as a primary dx.. he qualifies for a little more flexibility at work and is more likely to get his therapy covered by insurance.. which means he gets to stay in treatment.. and cant get fired from his job for having a panic attack and needing a break or something.. so.. depends on a lot of factors.. R tho.. also aint never had a doctor tell him he doesnt have bpd

[harmony1]

our marriage counselor told me that a therapist is not supposed to hurt the patient that is in denial..even tho a diagnosis would be helpful..if they are in deep denial it can do more harm than good

[nonhere]

"Why is a BPD diagnosis not given out more often?"  It's at the root of a great insecurity many have... is the person in my life "ill" or is it me?   What does it all mean when a person in our life fits many of the criteria of BPD or BPD traits (but not the obvious tangible criteria sch as cutting, suicide)and have seen a therapists and not been diagnosed or treated.

I very much liked reading what Skip wrote here: It's at the root of a great insecurity many have.  It certainly is for me.

Someone upthread suggested that therapists may be reluctant to diagnose because "you can't do with therapy with an empty chair".  I think that's an excellent point; and it parallels (horribly) how a non (e.g. me) in a relationship with a pwBPD can behave.  Is the other person "ill" or is it me?  I was never able to bring myself to say, clearly and definitely: "YOU are ill" or "YOU are impossible to deal with" or "YOU are behaving in a way I can't put up with - I'm out of here".  Precisely because, like a therapist, I knew that any chance to engage with the person depended on not saying that.  I think that with many kinds of therapy, there's a very good reason NOT to give an early diagnosis, if that'll prevent therapy from proceeding.  (I'd feel terrible if I went into therapy and the therapist simply pronounced "You are suffering from mental disorder X" - I'd say "so what?  It's a label.  How about helping me with it?").

The big difference, of course, is that I'm not a therapist.  It was wrong of me to hold back my "diagnosis", for the sake of continued engagement, because I wasn't competent (or in the right kind of relationship - therapeutic - with the person) to do any good.  But IMHO there are lots of good reasons why someone who is a professional, qualified therapist, and could do some good, to avoid making a clear "diagnosis".

Makes it hard as hell for us recovering nons. I'm back to the point from Skip I started with: wouldn't it be great if there was some undeniable, authoritative rubber-stamp from on high that told us (definitely, in the face of every doubt, and in the face of every protestation from the BPDex that they were behaving totally reasonably) no: this person is definitely ill?

[Dera]

My therapist told me that psychologists are moving away from giving patients a label and toward describing them as having a collection of traits. He is a bpd and I am a non... what does that mean anyway? It makes a lot of sense to me to describe that he has these 6 traits and I have those 2 traits rather than just apply a label. I can't explain this well enough, and if someone can elaborate the point better than me I'd be interested to read it.

[GreenMango]

Dera

From my understanding there are a couple of reasons one of which the label is very stigmatizing.  Addressing behaviors, while isn't always easy, can be a more functional and less alienating approach to working with someone.  Not every person that displays traits qualifies for a clinical diagnosis, but the behavior is still dysfunctional or distressing and can be addressed.

GM

[Dera]

It seems to me that labels are useful in some contexts... how would we have all found each other here if we did not apply the bpd label to our loved ones?

However, on an individual basis it may be counterproductive to oversimplify someone has "a bpd". They have traits of bpd, and no doubt other issues as well, that do need treatment of course. Our brains like things to be black and white, and we want to interpret everything they've ever done as being bpd, which is an unhelpful oversimplification. Therapists are human too. Maybe it's better for them to move away from slapping a label on someone and treating them as "a bpd" instead of a complex human being.

[RUkidding]

I believe that it is. From what I have read the only way to be diagnosed with BPD is by a mental health professional. Thru a series of tests , sessions ect. I do know that there are MRIs and brain scans that can show abnormalities li the brain but they cannot give a specific diagnosis. PTSD and other mental illnesses show up also but to the best of my knowledge the diagnosis of a specific mental illness is done by a mental health professional and not a neurologist and therefore it in my opinion have to be subjective. The skill level of that person , the patient ect all would factor in . I believe this is true with most if not all mental illnesses. I also believe BPD would be one of the more subjective ones because of the wide varying of traits and the range of criteria needed for a diagnosis of BPD. This is just my opinion  ur I have not seen anything to make me think differently. If anyone does have anything I would be very interested to know. My r/s with my exbpdgf affected me in many ways. One thing it did was made me educate myself on BPD which is something I had never heard of . It gave me empathy for those who suffer from it and all mental illnesses. It made me grow as a person and appreciate my life even more. This women touched me in ways that I can't even explain. I have felt emotions with a deepness that I never have before. Those emotions include anger ,frustration , despair , but also joy and especially love . She was the cutest thing ever with cute lil soft feet so also lust :P she def rocked my world and despite all the crazyness I have no regrets !

[RUkidding]

Unfortunately but true it seems is the stigma that goes with mental illness. People are I believe very afraid to be diagnosed with a mental illness. I believe of they are smart enough they may be able to downplay some things when seeing a doctor. Or totally deceive them. I know the dr is trained to see through that ect bit the patient may be quite good at that also. As a society we do treat those with mental illness like lepers in some ways and most know that so they avoid any kind of diagnosis and this treatment. The compassion for them and others with disabilities that I have as a result of my r/s is something I am greatful I learned. I was a compassionate person I believe before but much moreso now . Breathelife I would advise u to just know u did ur best and nothing would of been right. You will in my opinion never get the answers to the questions u have. Let them go . Your ex doesn't know them no one does. I love her like I've never loved before and I now realize it wasn't what  I believed it was. She wasn't who I thought she was and I may not be to her what I thought I was. But my love was real that I do know and that's good enough for me.  I do hope that helps u and u find peace in it. I believe u will

[Want2know]

I think this is a good topic to discuss, perhaps using the term "inter-subjectivity" as a basis for what it seems you are trying to understand and relay to the group here.

Inter-subjectivity is how we can express ideas in a way that is necessary for communicating with one another.  Take for example the word "blue".  We all know what blue looks like, but do you really know what someone else's perception of the color blue is?

Inter-subjectivity allows us to agree upon a term so we can use it in a meaningful way.  Relating this concept to what I think you are saying about being subjective with psychological diagnoses, it is a way we can have some common discussion of our observations and express them in a way that promotes understanding and progression of thought, and can help with behavioral assessments and a courses of action.

[RUkidding]

Maybe I'm using the subjective incorrectly. I'm meaning that the diagnosis of mental illness and especially BPD is not an exact science. Two mental health professionals examining the same patient could both come to different diagnosis and neither would be wrong. What they consider meets the def of intense, risky, chronic ect would have determine their determination if the DSM criteria is being met. The reason I brought up this topic was in expressing my views how to help us best get thru our recovery from this r/s. which is that we should not look for the answers that many of us have and that we shouldn't play back this r/s in our mind and start to wellif I would of done this maybe things would have been dif ect. That by trying to do those things we are just wasting our time. Those answers will found. I also believe that if one wanted to we could actually shape those answers to put us in a better light. Many here seem to see a T to help us thru this period and possibly figure our role in it. I believe that many will do almost anything to have an excuse or proof that it wasn't simply that we're stupid , naive , stubborn ect and they we just got played or fooled which I believe is a possibility .  That's where the subjectivity comes in. Whether our SO is technically BPD really doesn't matter. They did things or said things that made it almost impossible to have a healthy r/s with them. Leave it at that. I've read many threads asking that ?(did they have BPD?). We will never know because there is no definitive way to know. Judge them by how they treated u and others. It is extremely tough to accept that you'll  ever really know it was mental illness, u got played , or a lil of both , or even something diff. If u dont accept that I believe the u will ended up in a sorta circular search for answers. Your doing the same things ie reading books on it or the posts here , seeing a T) and expecting to get a diff result then one you always seem to get which is u don't know. It's like our circular discussion with them. At some point u have to get off that merry go round and accept that will truely never now. So I say  get off it
now or you'll be doing those things forever. U have to totally stop. Because every lil tidbit u find leads to more questions we need to answer. Like a crack addict that more hit could get them back in it fully but with us that one lil tidbit gets us back in fully too . Just how I see it.

[Want2know]

"Why is a BPD diagnosis not given out more often?"  It's at the root of a great insecurity many have... is the person in my life "ill" or is it me?   What does it all mean when a person in our life fits many of the criteria of BPD or BPD traits (but not the obvious tangible criteria sch as cutting, suicide)and have seen a therapists and not been diagnosed or treated.

lasagna points out insurer issues. Lincoln points out that at certain types care providers do not have the education and background to diagnose these disorders.   lasagna points out the potential negative impact on the therapy... that patients often don't return (as a dx is telling an insecure, hypersensitive person that they are their own problem. geroldmodel point out that the "diagnosis" can't be made by a social worker, or non-MD therapist. All good points.

But it is also important to consider that even in the case of skilled, specialized psychiatrists, they don't have the equivalent of the low cost technical tools like blood tests and x-rays to diagnose patients like other doctors have.  

1. Clinical Process Psychiatrists are limited to what the patient tells them.  This communication is a function of time (appointments are under an hour), communication skills of the patient (remember, people often see a therapists when they are in crisis), patient self awareness and honesty, and patient follow up (coming in for additional appointments, reporting progress).

My understanding is that many clinicians work through a hierarchy of diagnosis and treatment - treating the more episodic, pharmaceutical responsive, and lower cost conditions first - they go after the "low hanging fruit".  Many of the Axis I disorders fall into this category. If this does not resolve the problems, they dig deeper.  The process is a little like peeling back an onion and dealing with each new layer.  If the patients heals or stop coming in, the pealing process stops. Insurance company reimbursement policies tend to encourage this approach.

Axis II disorders are far more expensive, complex treatments.  And they are often obscured by other comorbid conditions.

In a hospital setting, there is more time to analyze and diagnose a patient.  Outpatient treatment, however, is often very time limited.

Right now with the current medications and therapies that are available, a diagnosis of BPD (except in cases of suicidal ideation, or cutting) is likely to come later (rather than earlier)... the diagnosis of "high functioning" BPD is not obvious and straight forward.  

2. Subclinical The discussion also raises an obvious suggestion that many of the partners, parents, children here aren't  "BPD" by the clinical definition... they have some traits, or many traits, but not enough, or severe enough to be diagnosed.  They are extremely difficult people, nonetheless.  In many ways, the same tools, options, and thought processes are valid in subclinical situations... maybe even being more effective.

Anyway... "General BPD Topics and Questions" is an information exchange board... for me, this was a good exchange of information we have gathered.  Thanks.

Skippy

If you look at the diagnostic process, in practice , it's pretty clear that in the absence of a serious tramatic event (e.g., attempted suicide) that a personality disorder is diagnosed over time and based on non-response to therapy -- it's not a first line diagnosis.

[Oldsoldier2411]

Here's the therapeutic view as I understand it. BPD need a connection to a T that is accepting, not rejecting.  Labeling a pt as BPD certainly can be perceived as very rejecting.   Instead, the therapist acknowledges the very real emotions (fear, sadness) that drive BPD behavior and validates those feelings.  Alternative, healthier reactive  behaviors are discussed in a non-judgemental tone. You cannot do therapy with an empty chair.

A very valid point. Over here in the UK organisations, such as "NICE" use the DSM and ICD 10. That does NOT mean ALL will use these tools. Some may decide to consult them when THEY consider it appropriate. This can be a serious delay in therapy. Some may miss the tell tale signs. Some may even be unaware of what they are looking at due to inexperience in that disorder. Sometimes it is only when the sufferer is in crisis that they come forward. Quite often a delay can lead the sufferer not getting the help they need at that time and doing so puts the sufferer at risk, even children if the sufferer has them. I know from my paperwork that when a therapist comes to the home of the suffer then the sufferer became confrontational. This makes the therapist become defensive in some cases. However, then when the sufferer becomes calmer the they consider the crisis is over BUT not resolved. So the cycle will reappear at some time later. With the sufferers moving locations at times can lead therapists/councellors going through the same processes again. This can lead to numbers of sufferers being low.

"NICE" maintains that treatment should be carried out in a positive manner so in doing so hiding the negatives from the paperwork and dodging a referral or even a comment that could point to an accurate diagnosis.

Ian

[Abigail]

I think a therapist could hand the patient a print out of symptoms/traits that the patient frequently exhibits and discuss those (without the words Borderline PD on top).  If the client can see that, yes, he is explosive, yes he does engage in black or white thinking, etc. then you could later move on with the label once the person accepts that he has those traits. 

For instance, if you have a client who engages in splitting, then tell them that a particular behavior is splitting.  And, gently tell your client that his/her personality or responses are difficult to live with.  The delusion of victimhood needs to be peeled away.  There's really no hope for improvement if the PD person has never been clued in that he's not the victim that he purports himself to be, and instead, is actually victimizing others!

After my husband had been released from the psych ward of a hospital for suicidal plans and without any diagnosis aside from depression, we went to see a new doctor that someone had recommended.  The doctor was a general practitioner but he dealt with a lot of mental health issues.  I accompanied my husband and while we were waiting for the doctor to come in the room, my husband was reading various things that the doctor had on the wall.  One of the papers gave a list of different symptoms and feelings that described (unbeknownst to us at the time) what it felt like to suffer from BPD.  When the doctor arrived, my husband, pointed to the list and told the doctor that it was exactly how he felt.  He didn't know what it was describing but he knew that was how he felt and acted. 

And to think he'd been to at least 4 psychiatrists prior to this and had been Baker acted to a psych hospital, yet no one ever made the diagnosis before.

[lbjnltx]

Clinical Practice Guideline for the Management Of Borderline Personality Disorder:

Communicating the diagnosis

The diagnosis should be communicated to the person (and their family, partner or carer, if appropriate). Health professionals should only do this when they are reasonably confident that the diagnosis is correct.

Discussion of the diagnosis provides the opportunity for the person to understand their illness, request treatment and become involved in their own recovery. Effective intervention may be less likely if the diagnosis is not made or recorded. Health professionals should take care to maintain a balance between validating the person’s problems and experiences (placing these
within the BPD framework), and promoting a view that change is possible, through a shared effort.

At the time of diagnosis, and after a thorough assessment process, the clinician should:

• explain which main symptoms of BPD the person has reported
• tell the person they have BPD, and explain what this condition means
• assure the person that this disorder can be treated
• give the person information about it (e.g. fact sheets, video, reliable website), and advise the person that some of the information about BPD that they may find on the internet is misleading
• invite the person to ask any questions about the diagnosis
• discuss whether the person would like to inform their family, partner or carers of their diagnosis.

If so, discuss how you can best support them to do this (e.g. a consultation, providing fact sheets for families and carers).

Some people may experience distress if they are told the diagnosis at an inappropriate time or context. The diagnosis must be explained carefully, using non-technical language. The term ‘borderline’ is not meaningful to people with BPD and their families and friends and, for some people, it may have associations with blame and stigma. Therefore, the clinician should explain the condition in a sensitive, non-judgemental way that conveys that it is not the person’s own fault, but a condition of the brain and mind that is associated with both genetic and environmental risk factors.

Reasons to disclose the diagnosis of BPD to the person

• Disclosure respects the person’s autonomy.
• People with BPD may be relieved to learn that their distress is due to a known illness.
• Information about the diagnosis is necessary for psychoeducation.
• Accurate diagnosis can guide treatment.
• Many people will self-diagnose using information on the internet.

The diagnosis can provide optimism, because:

• it is a known condition shared by other people
• effective treatments for BPD are available
• people with BPD can recover from their symptoms.

It is the place of the well informed, established therapist to disclose a diagnoses to their patient...   not a family member, friend, or observer.

From the Australian Government National Health and Medical Research Council
http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/mh25_borderline_personality_guideline.pdf

[MCC503764]

It's the stigma that's associated with it... think about it, BPD essentially means "crazy" in the therapy world.  If you were labeled with that, could you imagine the challenges that would be faced with therapy?

[SadWifeofBPD]

It's the stigma that's associated with it... think about it, BPD essentially means "crazy" in the therapy world.  If you were labeled with that, could you imagine the challenges that would be faced with therapy?

True.

My sister, a T, says that amongst her partners, they don't even bother much with identifying which Axis II PD a person has because the treatment is about the same.  They just refer to these folks as: Axis II.

BTW... I was surprised when she told me how much T's hate to treat pwPDs and how much they hate to treat anyone who is suicidal.  The pwPDs are so demanding, fill up their message machines, etc.  And, no one wants to have on their record that a patient committed suicide "on their watch."