Why is DD's therapist reluctant to diagnose?

[LittleThings]

Hi to All,

  I've posted here once before and am so grateful for the responses I received.

  My DD is 19 and was diagnosed in June with Bipolar disorder as well as anxiety and depression, and put on meds... .Lithium, Lexpro, and Klonapin for anxiety. She had to quit college and come home. She'd come out in the fall as bi, and more recently gay. Didn't get out of bed really until she found a girlfriend... and that seemed to boost her a bit. Didn't really "fix things" for her, as she may have hoped. GF and all her friends are at college. She's lonely for sure. Has never really been single... always had a BF... .always drama.

   Her psych explained that she wanted to treat her for the bipolar, while also recognizing that she had many symptoms of BPD. They would address that later. My DD has improved to the degree that she isn't cutting (was pretty severe) and is able to drive without crippling anxiety and is trying to hold down a part time job. There hasn't been suicidal ideation in a few months. She spends much of her free time in her room, in bed watching shows to "take her mind off things." in her words.

  Psychiatrist just switched DD to Cymbalta instead of the Lexapro this week. DD had told her she wasn't feeling better for the last 2 weeks, hence the switch.

  Tonight she lost it and lay on her bed unable to bring herself to go to work. She said " I feel violent, like I want to throw things. I don't know who I am anymore. I can't do this anymore. I can't remember anything. Even when I'm doing OK, I'm sad inside. I don't feel any better. I'm only good at being alone. I just want to be alone right now." She then went to sleep.

  I have asked if her therapy had been helping and she'd said in the past that the therapist knew her well and she didn't want to switch. Tonight I asked again because I knew this week was a "depressing session" in her words. She said she had asked the therapist if she thought she had BPD and the therapist hadn't given her an answer during their session, and that she never directly addressed it.

I have to wonder if my DD is getting what she needs at this point. There is a family history of bipolar (my mother), and her deep, fairly lengthy depression and mood swings (manic episode) do point to it. Again there has been some improvement, but not sure if medication is the reason. Psych said the meds would stop the cutting right away and it has.

I understand medication can help immensely in Bipolar, but not necessarily in BPD and that DBT therapy is crucial to BPD sufferers. When I asked my DD if therapist had been trying to introduce any coping techniques or particular methods, she said no.

  Do you think there is some reason my daughter's therapist avoiding the subject? My daughter also told me the therapist was surprised when the psychiatrist had diagnosed her with Bipolar. I am beginning to think the therapist is not the right fit, or that someone is missing something... .

  I feel clueless myself. We have had some forward progress, and my DD is trying hard. We have established boundaries and some understanding of ways to validate without enabling.

Thanks for reading.


 

Our objective is to better understand the struggles our child faces and to learn the skills to improve our relationship and provide a supportive environment and also improve on our own emotional responses, attitudes and effectiveness as a family leaders

[nomoreoptions]

While meds can't be the sole solution with BPD they can be extremely helpful.  People who have suffered from BPD have the scars, and need therapy to help overcome the pain and feelings, and to learn different coping mechanisms.  But there has been a lot of research in the last few years regarding the physical aspects of BPD, including physical differences in the brain, and neurotransmitter issues.  Interestingly, many of these are very similar to bipolar issues.  There are also clear correlations between certain executive function capabilities, such as working memory.  Our son's working memory scores range from the first percentile to a high of about the 16th.  He has been diagnosed as PTSD, ADHD, MDD and prior to being medicated easily could have been diagnosed as bipolar/rapid cycling and BPD.

But your daughter's therapist may feel that dwelling on the label makes it harder to feel good about herself, particularly if she is inquisitive and does her on-line research.  Also, therapists often aren't in the business of diagnosis.  They should be working with the pdoc.  If they haven't heard something directly from the pdoc they should NOT offer diagnostic opinions until they have consulted, because contradictory diagnoses can be extremely distressing to the patient, as can a lack of concrete info, or incomplete info, as is true in your daughter's case.  Coordinated care is SO important,

An interesting medication in cases like these is lamictal.  There is evidence in favor of it being prescribed, with an ssri, for ALL of these conditions (except ADHD, but I'd think with the proper ADHD med it would also likely decrease ADHD-related impulsivity, etc.).

Not to second guess your pdoc, but be careful with the benzos with a BPD sufferer.

[LittleThings]

Thank you for your reply.

There's definitely a lack of coordination b/w the psych and the therapist. I don't think they have been in touch at all. My DD is still in the beginning of treatment, if you consider that she had been feeling pretty bad/unstable for much of middle school and all of high school, and just seeing a psychiatrist this June, and no medication up to that point.

I do think the meds are key here, but so far haven't read that they were helpful to the BPD sufferer, and as you caution, perhaps the wrong one can be harmful, or at the very least, ineffective. I will mention Lamictal!

I know Lithium is some strong stuff and I am nervous that she is on this. However the psych said she wouldn't keep her on it too long (not sure what she's thinking the time frame is) because it is hard on the body/liver.

I will ask my DD, when the time is right, to elaborate on the anger and the memory issues... .as everyone here knows, communicating with someone with BPD (and/or other illness) can be a herculean task.

I should mention that she has been switched to Atarax (hydroxyzine)to take for anxiety as needed, and takes an antihistamine to help her sleep. No more Klonapin.

One thought I have regarding diagnoses is that for someone who has been struggling with out of control emotions and thoughts for a long time without relief, is that sometimes a "label" helps them feel as though it's not "just them", and that there is hope, and help... .and some light at the end of the tunnel. Does that make sense?

My daughter is struggling with many things (she has lost about 30% or her hair-testing hasn't shown a reason), and I understand the therapist wants her to feel good about herself, but at the same time wonder if a more focused approach would help. Hopefully we can get some interaction b/w the professionals.

[nomoreoptions]

I personally agree with you in terms of the label, but many don't.  My son's first pdoc didn't, but his current one is much more receptive.  He has felt a great deal of relief at knowing that this is not his "fault," but I fear it has given him some justification for his behaviors as well, and he needs to work on accepting his role in making things better.  He likes to blame others, and he finds it a bit easy to blame anyone but himself, although it is so sad to see how much he also tortures himself over his difficulties.

There is a section on this site regarding medications.  There is some disagreement as to whether or not the ssri's can help, but for some Prozac works wonders.  For my kid Prozac alleviated the anxiety and the disassociative elements (paranoia, seeing and hearing things), reduced the splitting, but was insufficient for the depression, irritability and rage.  Wellbutrin was added for the depression, and worked well.  He also has ADHD, and Ritalin has worked wonders for his schoolwork, but his rage/mood issues are still there, so we are now discussing adding abilify, risperdal or lamictal.  Lamictal has the fewest side effects.  BuSpar doesn't always work, but for some, particularly as an add-on to an ssri, it can be an amazing anti-anxiety drug with very few side affects and none of the addiction risks of the benzos.

It's NO substitute for therapy, and everyone's mileage is different on these meds, but for many it gets them to a state where they can tackle the enormous issues.  We are lucky in that our kids are seen at a major hospital clinic where all care is coordinated, and they are very receptive to family involvement.  Your daughter's mental health providers have, in my opinion, an obligation to consult with each other, particularly if requested to do so.

DBT is an extremely valuable tool, but it's not the only therapy option.  I feel your pain.  It's heartbreaking to observe crippling depression/self-harming in our teenagers.  Best of luck, remember that it can take some experimentation, and unfortunately it can take quite a bit of time, as pdocs make changes incrementally, and frequently one drug at a time with justifiably slow titration schedules.

[nomoreoptions]

BPDdemystified.com has a good overview of some of the treatment options, both for therapy and meds.

[modafinilguy]

FRIG lost my post.

STIGMA.

ARISTOCRACY.

":)octor, do you think I have BPD as a mental disorder?"

I'll translate that to word's that illustrate the emotional impact, the mental impact that to many psychiatrists, the above has:

":)octor, do you think I am cheap trashy worthless slut? CTWS Disorder? Is this my mental disorder, essentially a disorder of whores?"

BPD is like a swear word to many doctors.

[nomoreoptions]

True, but that is why it is so essential to get the pdoc on board.  Pdocs will, at the very least, if qualified, prescribe the meds that make it easier for the BPD patient to function at a level that allows for productive therapy.  Mentally ill patients tend to distort the truth, but BPD patients can be very good at it, and they can be very hard to treat, plus the stigma that it was possibly caused by environment makes it very hard for therapists to work productively with parents, because they have their primary duty to their patients.  This can hinder progress hugely.

A very good family therapist (we have one who pre-dates our taking in our BPD son) can be invaluable, because they have an obligation to EVERYONE in the family, you are all his/her clients, so you can tell him/her anything, so can your child.  You can meet as an entire family, or just the parents, or the mom and one kid, etc.  In our situation the family therapist, trauma therapist and psychiatrist are all at the same facility.  They work together.

There have been so many breakthroughs recently in terms of the origins of this disease.  I'm very hopeful that the health care field will grow more comfortable considering this as a possibility as early as puberty.  It's certainly not a death sentence for a child to be diagnosed with MDD or GAD, although in the past it was highly stigmatizing.  BPD is a more complex disorder, but approximately 6% of the population suffers from it, it often starts showing up in early teens, and it's time that the mental health professionals earn their exorbitant fees and treat it appropriately.

[LittleThings]

Moda, Are you saying it's a catch-all or a cop out diagnosis?

I know it's complex, but if the patient is willing to work, and the therapist and psych are both on board, it seems real progress could be made. Meds and the right, most effective therapy/treatment. DBT is effective is it not?

At this point we are not in therapy with her. We can contact both the therapist or psychiatrist to report anything, but our daughter hasn't signed a release for either. She is 19 and not obligated to share what goes on in either office, although she does to a tiny degree. I don't ask many questions. I know she has distorted some things, but as she keeps going in therapy these things I believe, fall away.

We offered a suggestion to switch to a different psych (current one sometimes cancels at the last minute, or is quite late), but when we contacted the new office, my dd was told she'd have to see one of their therapists as well, and that would mean leaving the current one, who saw her briefly in high school separately and with us. I think that makes tons of sense to have both at one practice for the sake of some continuity.

DH and I have seen our own therapist, but she moved last month and we've yet to find a new one.

Things are going downhill, and our DD didn't go to work today, hasn't called. Says she will.

She's unable to complete things, or follow through on obligations. Things are much different since she's an adult (technically), and yet with her living here we get to watch the "show". Very little we can control.

[nomoreoptions]

Family therapy is still an option, even though she is an "adult."  Our son is also.  I'm so sorry that the maze of finding the right combo of mental health care providers can be so difficult.

Can you try yet another pdoc office?  If you are relying on those who take insurance or sliding scale options I realize you may have few choices.  This truly sucks.  I agree with you that it makes sense to have both her therapist and pdoc at one office.  Maybe she would be willing to try at least one session with a new therapist, which can be SO scary but the current situation clearly isn't working.

BPD is anything BUT a catch-all, cop out diagnosis.  Compared to bipolar, ADHD, MDD, etc. there are fewer diagnostic criteria, and they are more specifically defined with fewer overlapping symptoms.  Even so, one of the major problems is the rate of comorbidity with other disorders.  I have read that the mean number of axis one disorder comorbidity occurrences is over 4, with the mean number of axis two comordity occurrences coming in at 1.  That's a whole lot of mental illness our BPD sufferers are confronting, a mean of six psychiatric disorders.

[nomoreoptions]

I know it sounds heartless, but you still support her.  She sounds like she is receptive to help.  Our son goes to therapy and takes his meds, but has the added complication of years of physical and sexual abuse by his birth mother.  His coping mechanisms/presentation are such that his therapist was astonished when he recently disregulated massively in the waiting room even though he has been seeing him for months.  He told me he had "no idea" but I had been telling him.  His previous therapist told me outright that she felt that he was being "straight" with her when she told me that "I" had a confrontational parenting style.  If your daughter truly is BPD you have no idea what is happening in therapy.  She may not want to switch because she feels comfortable.  While trusting a therapist is critical, it's not helpful if it allows one to not face reality.

Go to the website I posted, and find the section about treatment myths.  It discusses how wrong the decision to exclude family members and loved ones from the treatment process is.  It IS possible to be more included, as long as the care providers give very clear guidelines as to what will be shared and what will not to all involved and all agree.  And few providers will refuse to receive and read e-mail updates.

[LittleThings]

Thanks so much for your insight into this!

I feel as though my daughter has recently been confronting reality in therapy, and as it has been "depressing" as she says. The comfort level is there, but when the realization came that she has the main role in this, and must do the work, it seems to have proven to be too much. It seems like she just wants to be taken care of.

I do know she has blamed both my DH and me separately in past sessions, for her problems.

What that did in effect is make me realize that we have not been validating, but instead have tried to boost her by saying things like... ."You do too have friends." "Lots of people love you." "Maybe he didn't call you because he was really busy." "You are smart and beautiful and can do anything you set your mind to.", instead of "Those are difficult feelings to cope with", etc, etc. I explained that we never wanted to hurt her, but we didn't understand her intense feelings, or how to help, or what to do.

I have needed to detach from her at times to protect my own sanity, and have been seen by her as selfish for doing so. We do enjoy each other's company from time to time.

My DH has been accused of detaching as well. Unfortunately, he has admitted to being scared of her, and afraid to talk to her a times for fear she would "bite his head off", which she has repeatedly to all of us on a regular basis.

She told me her last boyfriend broke up with her because she was miserable. He treated her like a queen, and we thought they were going to be together for a long time. After they broke up she told me he was a "horrible" person.

We have a son who is younger and has a thicker skin, doesn't let things bother him, while she has virtually no emotional skin. We have parented them the same, essentially, same rules. They grew up in the same house.

She has agreed to go to therapy more than once per week. We'll see, but I really believe there is so much work to be done that she feels frustrated and defeated before she even starts the hard stuff.

She will be seeing the psych this week and hopefully things will start to come together, whether she switches or asks for a dialogue b/w both providers.

Our objective is to better understand the struggles our child faces and to learn the skills to improve our relationship and provide a supportive environment and also improve on our own emotional responses, attitudes and effectiveness as a family leaders

[LittleThings]

Thank you for the website. It's great... .some good info there.

I forgot to mention that she was rejected by one of her peers in middle school, and subsequently had to go to anger management after that child reported that my DD's reaction was to get a bit physical, pull her arm at recess.  She told us that after that happened, she used to cry in a corner of her room. Kept that a secret until recently.

Sorry, didn't mean to write a book! Just a little history there.

[nomoreoptions]

I think many of us could write a book, no problem.

When our son was in foster care with his aunt he started at a large ghetto NYC high school, where he was bullied.  He actually managed to order weapons on-line which he intended to use in retaliation.  Fortunately his aunt found them and his case worker took him for a psych eval.  But afterwards he received no psychiatric or therapeutic care.  Simply unbelievable.

Our daughter, who has MDD and GAD, was bullied in lower school.  Years later she told us that many nights she couldn't sleep more than a couple of hours.  She kept her anxiety hidden until she became fairly agoraphobic, at 15.  She was an only child and I am a stay-at-home mom who listens, and I didn't have a clue.

[LittleThings]

When she first told me about hiding and crying in her room, I really thought... .clueless parenting on my part. How did I miss this?

I guess she has more inner strength than she gives herself credit for. She was an honor student who got 2100 on her SAT's. Hardly missed a day of school. She had some really "up" times, mostly just before graduation, but things just got increasingly hard.