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THE PSYCHOLOGY OF PERSONALITY DISORDERS
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Author Topic: Why are therapists hesitant to give a BPD diagnosis?  (Read 58490 times)
karategrrl
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« on: January 08, 2008, 07:25:43 PM »

This took me a while to figure out, but based on what my ex's therapist has told me, here it goes... My ex is high functioning...She can hold down a job, pay her bills, etc. She meets 7 out of the 10 criteria...So it bothered me when her therapist refused to give a BPD stamp...going as far as saying "If I was to diagnose, it would be BPD...I won't do that, but I'll treat you for BPD"... So here's the thing...If a therapist or Dr. gives the actual stamp of BPD, the person is now qualified for SS benifits, or other compensation...This really bothered me because Ex would use her lack of diagnosis as a fighting tool, "see, even my therapist doesn't agree that I have BPD"...So now I'm more accepting of this descision...
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« Reply #1 on: January 08, 2008, 07:51:41 PM »

To my knowledge, insurance companies don't cover treatment for BPD because they are not convinced that any tools work. so most therapists stick with diagnoses more in the anxiety/depressed realm.       Also, it might show up during a custody investigation I am speaking in the broadest parameters here. I have no knowledge of your particulat situation.

I'm surprised the therapist broached the subject of BPD at all. That causes a lot of patients to never return, so it is gingerly discussed way into treatment.       I am unaware that BPD automatically qualifies one for SSI.  Perhaps you have some specialized knowledge in that field. Many BPDs are able to have successful careers.        I wish you the best. 
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karategrrl
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« Reply #2 on: January 09, 2008, 08:28:44 AM »

My friends brother got SS benifits because of his personality disorder...
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Abigail
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« Reply #3 on: January 09, 2008, 12:39:32 PM »

 In my opinion, that is unethical.  Imagine saying to someone, "If I were to diagnose him or her, I would say diabetes, but I'm not going to say that.  However, I will treat him or her for diabetes."  I believe we have a right to know the truth even if it isn't what we want to hear.  I may not be very happy if I were diagnosed with diabetes but I would rather know so I can educate myself and learn what I need to do.  I might make the choice to be in denial, but that would be my choice.

  I do understand that there is still a stigma with the BPD label and that many individuals do not want to hear it.  But you can never get any better if you deny the truth.

  Abigail
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« Reply #4 on: January 10, 2008, 10:24:24 AM »

I don't know for sure, but it may also be that most therapists simply aren't qualified to offer a diagnosis of BPD.

It's kind of like getting diagnosed with diabetes by a podiatrist. 

But then again, if the therapist suspects it, they should refer you.
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« Reply #5 on: January 10, 2008, 02:30:15 PM »

Diagnosis and classification of personality disorders or even health in general,

differs all around the globe.

In USA the DSM-IV-TR is used to diagnose.

In Europe the ICD-10 is used.

But THEY ARE ONLY TOOLS to diagnose.

Other factors -such as a job- has to be taken into consideration.

In Europe most countries have universal healthcare.

When BPD is diagnosed treatment, therapy and a possible loss of income because of the inablility to work,

will be repayed by the social security system.

In the US it seems that insurance companies do not cover anything when diagnosed.

In my country psychiatrists, forensic psychologists and general practitioners can diagnose a personality disorder officialy. Only psychiatrists and general practitioners can prescribe drugs.

Therapists, Councerlors or even standard psychologists cannot officialy diagnose. They can only refer.

Quote
"If I was to diagnose, it would be BPD...I won't do that, but I'll treat you for BPD"...



So imo this is a very reasonable statement.

She has all the emotional issues of a BPD, but she can hold a job and is high-functioning.

He will deal with the emotional issues in the same way as if she was low-functioning.

What does it matter to you karategrrl ?
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Skip
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« Reply #6 on: January 11, 2008, 11:46:03 AM »

"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
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« Reply #7 on: January 12, 2008, 12:38:28 AM »

My ex's therapist coddled her to no end.  I remember asking her therapist about BPD and she said to me, "I can see how you'd think that but I'm not ready to go there."  I think her therapist simply knew that she couldn't push her too hard and so she seemed to never push her.  I mean, come on, after meeting every week for over a year you gotta push the client at some point!
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karategrrl
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« Reply #8 on: January 12, 2008, 11:06:12 AM »

My ex's therapist coddled her to no end.  I remember asking her therapist about BPD and she said to me, "I can see how you'd think that but I'm not ready to go there."  I think her therapist simply knew that she couldn't push her too hard and so she seemed to never push her.  I mean, come on, after meeting every week for over a year you gotta push the client at some point!

Not if you want to get paid...You have to ask yourself, are T's really there to help, or are they there to make a living? If they push too hard, the BPD will leave...If they treat them for something and it seams to be making a difference, why lable it? Not that I'm saying their unethical, I'm just sayng, they want to keep their clients...
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lasagna
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« Reply #9 on: January 15, 2008, 12:02:14 PM »

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.

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« Reply #10 on: January 15, 2008, 01:58:32 PM »

A couple of things I have learned from T in the past few weeks:

1) Most T's will only treat a few BPD's at a time because they are VERY high maintenance.

2) Making a formal diagnosis usually occurs when law enforcement or civil authorities are involved. This ties back to what was said earlier, a BPD will likely feel threatened and leave if they are faced with a diagnosis. Unless they are compelled to stay by the system.
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« Reply #11 on: January 20, 2008, 11:26:53 PM »

I asked a T who specializes in treating BPD's exactly this question. Her response was kind of scary to me. One: all therapists worth the paper their degrees are printed on *recognize* BPD when they see it (which can occur YEARS before any formal Dx happens, if it does at all). and Two: they also have a healthy fear of diagnosing it, due to it being counter productive in whatever modality of treatment they are applying. Three: only a psychiatrist can diagnose.   The other things were a compilation of other poster's replies: but seemed to boil down to fear on the part of the therapist.
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« Reply #12 on: January 21, 2008, 09:32:44 AM »

I asked a T who specializes in treating BPD's exactly this question. Her response was kind of scary to me. One: all therapists worth the paper their degrees are printed on *recognize* BPD when they see it (which can occur YEARS before any formal Dx happens, if it does at all). and Two: they also have a healthy fear of diagnosing it, due to it being counter productive in whatever modality of treatment they are applying. Three: only a psychiatrist can diagnose.   The other things were a compilation of other poster's replies: but seemed to boil down to fear on the part of the therapist.

Your third statement is incorrect. Any certified psychologist can render a diagnosis. Only a Psychiatrist (MD) can prescribe psychotropic drugs. However, since there are not many Psychiatrists in some areas, a psychologist will make a recommendation to you Family Doctor, who will write the script.
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Mollyd
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« Reply #13 on: January 21, 2008, 01:47:41 PM »

FWIW -

Many are making a huge assumption - that most therapists who know of a dx of BPD chooses to either not document it officially, or not tell the client of their findings.  I don't know if either of those scenarios is true, though it may be the experience of people on this board.

This, to my mind, is a multifaceted issue.  There is the issue of therapist training, ethics and diagnositic consistency.  There is also the issue, mentioned previously, of insurance reimbursement (It is true that an axis II disorder cannot be the primary dx - for many insurance companies to reimburse). And there are the good points that Skip makes.

I believe it is unethical for therapists to determine a dx and not disclose it to their client.  Clients have the right to choose the treatment of their choice.  To not disclose a dx, in essence, prevents a client from considering the different choices in front of them.  For example, if a doc didn't disclose a patient had cancer, that would obviously be unethical, as the patient has the right to know what they are dealing with, and then, make appropriate choices. 

I think a therapist who "knows" of a dx and withholds it, has to have some darn good reasons, past personal discomfort ...  and I can't really imagine any reason that justifies withholding.

That said, therapists, like all of us, are people.  Some are smarter than others, some more ethical, some are embedded with issues that interfere with their ability to do their jobs - just like everyone else.  There are crappy cops, crappy politicians and religious leaders, etc.  Therapists are certainly not immune from their own barriers.

Are therapists adequately trained to appropriately diagnose pd's out of grad school?  Based on my knowledge of master's level psych programs - generally, I'd say no. I believe the training is inadequate in that area.  And, I don't know if that particular thing can be trained, really.  I believe what can be trained is to know what one doesn't know - new grads can be taught when they are over their head - outside their scope of expertise, what to do then.

Another aspect of the problem, in my opinion, is that the broader field of mental health does not agree about pd's.  As has been mentioned in other threads, there are groups of folks in the "field" who don't like the organizational criteria of PD's altogether.  There are folks who "view" BPD as linked to bipolar and ptsd, and others who don't at all, but see pd's as a distinct category - much like it's presented in DSM verbage.  There are folks who find the pd criteria as needing much, much, revamping in terms of diagnostic criteria and dimensionality.  And so on. 

I understand why there is the perception that "most therapists don't ... ", but, I think the reason is complex, and the perception is generalized.

There two final thoughts.  First, therapists may well discuss a diagnosis of BPD with someone who has it - and the person with the pd may deny the dx was discussed, distort what was said, or refuse to acknowledge the conversation ever occured.  What happens in real life also happens in the therapy room.  Second, also as in real life - many people on this board hold the position that "telling" the person with BPD that they have it is ill advised - because ... it makes things worse.  The same can be true in the therapy room, I'd imagine.  If a therapist documents their dx (which they are obligated to do) and does all the things they would do (treatment interventions, referrals) what difference does it make?

Now, personally I don't advocate not telling - not from family members or therapists - but, it is the actions and behaviors that really are what it's all about.  If a person is willing to do all the treatment interventions and healing - what they call themselves, really doesn't matter - or does it?  And, to whom does it really matter, and why?

Always, fwiw

Molly

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« Reply #14 on: January 21, 2008, 07:41:54 PM »

Your third statement is incorrect. Any certified psychologist can render a diagnosis. Only a Psychiatrist (MD) can prescribe psychotropic drugs. However, since there are not many Psychiatrists in some areas, a psychologist will make a recommendation to you Family Doctor, who will write the script.

Yes, except that in the States or at least this one, any MD or DO (MD and DO are equivalent regarding scope of practice in the USA) can write an Rx without a recommendation/referral from anyone. My family practice doc writes for all of mine as well as Dxed me. Doc's Dx concurred w/ T perhaps a year or more after the fact -- doc was first and already writing for me.
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« Reply #15 on: January 23, 2008, 05:38:52 AM »

It seems to me that different countries probably have different regulatory procedures as to who is legally entitled to make an official diagnosis of BPD.

I am in Australia. My psychologist recently told me that only psychiatrists here can make a formal diagnosis. I imagine that if a psychologist's client wanted to be tested the psychologist would write a referral to a psychiatrist.

In Australia psychologists can't prescribe medication, psychiatrists and GPs (our term for medical doctor - it stands for 'General Practitioner') can.

Our health insurance system is very different to the US model. It has changed somewhat in recent years, but is largely still based on the 'universal health care' model, with an optional private insurance system alongside. The choice of private insurer is the individual's, not associated with their place of employment.

I don't know how a person diagnosed with BPD would fare. I know the government funded Medicare system would be obliged to treat such a person, regardless of their income. How appropriate or frequent the therapy would be I don't know. I'm not sure how things would go with the private insurers. It might depend on the insurer and type of cover.

Soar
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« Reply #16 on: September 18, 2008, 12:14:09 PM »

I am a therapist. The ONLY reasons why I even bother to diagnose is so my clients can get reimbursed from insurance. My thoughts are that the DSM IV is a tool. I also don't see mental health the same as physical health but interconnected. So I see a Dx of diabetes to be much different from a diagnosis of a mental issue. Also, a person can present one mental issue at age 20 and a different one in their 40s. I see psychology as a combination of craft and science, intuition and relationship. A medical doctor doesn't need to be particularly empathetic while performing open heart surgery.

The whole Dx of BPD is also variable...some would say women have BPD and men NPD more often than not...I see them as very much the same, splitting, rage, fear of engulfment/emeshment, control...etc...childhood abuse/neglect/trauma.

I just assume that if anyone has severe neglect, alcoholism in the family, abuse, trauma, etc...I have to RULE OUT BPD first. Since I adopted that approach, I have much better results and happier clients.

I am not afraid to discuss BPD characteristics with my clients. I have to model honesty, trust, integrity. I have to be careful how and when I do this, sometimes its years into therapy. I start by saying that if I were them, I'd feel ______ in a given situation. When they are amazed that I know how they must feel, I start introducing the BPD concepts to them. When they do the push=pull dance in Tx, I ask them where else this has happened to THEM in their lives. I actually enjoy working with BPDs, the high functioning ones at least.

Also a lot of therapists hate working with them because they tend to call all the time. I cured that. I MAKE them call me nightly on a special line I don't pick up. Being oppositional to control, they rarely call then...smiley

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« Reply #17 on: September 18, 2008, 02:33:48 PM »

Job Application

Have you ever been diagnosed with a mental illness?

The T may recognise that there may be severe ramifications to the diagnosee, if he/she checked the dotted line. No job, no entrance into certain things...and you can get caught if you lie.

This is the reason why I spent thousands of dollars on T's, as opposed to hundreds, and never declared seeing a mental health expert on my insurance. My uBPD mother 'diagnosed' me with NPD. 2T's have said that I am not. What an expensive relief. But I did get better clarity on what she probably is.
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« Reply #18 on: September 19, 2008, 08:10:58 AM »

Quote
My psychologist recently told me that only psychiatrists here can make a formal diagnosis. I imagine that if a psychologist's client wanted to be tested the psychologist would write a referral to a psychiatrist

This was mentioned in the context of Australia I believe.  I think we need to be careful as psychology and medical training vary greatly in different countries.  In some countries,  medical students go directly to med school out of high school.  In the US, to be called a "psychologist" one must have a doctorate degree.  Psychology, in the US, started as an assessment/diagnostic discipline.  It remains a strength.  I am a psychologist. . . all I do is diagnose/assess (clinically).  I don't do treatment. 


Quote
Not if you want to get paid...You have to ask yourself, are T's really there to help, or are they there to make a living? If they push too hard, the BPD will leave...If they treat them for something and it seams to be making a difference, why lable it? Not that I'm saying their unethical, I'm just sayng, they want to keep their clients...

       Doctors purposely mis-diagnonse...SO THEY GET PAID!

Insurance companies are in the business of accepting risk, they and thier actuaries know that the chances of REAL RECOVERY are slim, none and slim just left town...So mant doc's will just label it something else because they don't want to work for free.

This is a complex issue.  To the former, thinking that way is unethical (if that were the motivation).  Diagnosis, and its impact, must be considered in the overall picture of helping the patient.   Regarding pay, it's not purposeful mis-diagnosis, but it is a delicate dance.  This is a major pet peeve of mine with the way the insurance industry/medicare/medicaid is currently setup.  Even for assessment, there are a lot of diagnoses that I will not get paid for.  Think about that.  I get a referral from an MD/DO (whatever) because they suspect a problem, or want to rule out a problem.  I work for 6-12 hours on assessing this person, analyzing the data, researching the results, and writing the report.  If I say there is nothing wrong (with respect to billling code, which is based on diagnosis), I don't get paid.  This is true for the MD crowd as well.  That's stupid.  So, we have to hire billing experts to navigate the system to figure out what we have to say to ethically get paid for our work. 

Quote
  I believe it is unethical for therapists to determine a dx and not disclose it to their client.

I think it depends.  If I believe the outcome to telling a patient they have BPD is suicide, it would be unethical to tell them. Also, as others have mentioned, there is a controversy with the Axis II system.  Many consider it to be an unhelpful diagnostic approach and don't use it.  There are plenty of other ways to describe a similar constellation of symptoms that have validity. 

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« Reply #19 on: September 19, 2008, 01:32:25 PM »

This is a great thread... a very complicated subject matter...arguments can be made for so many variations of opinions and perspectives

My background...I am a board certified family practice doc...

Insurance Game:

As unreal mentioned above we get stuck with bills that go unpaid because insurance companies dictate to us what they will pay. Healthcare, I think, is the only system where the provider of a service can't demand their own fees. There are daily situations where I code things intentionally in an effort to receive payment...I don't lie...but I document things carefully

Client/patient perspective:

If a person enters into a therapists office to seek treatment the therapist is obligated to treat them in the best possible way to meet that client's needs. They should do so ethically and by professional community standards.

If they are following a therapy model the general direction of therapy may be the same for multiple diagnosis...thereby making a diagnosis not as important...the focus is on the client...and their  best interest..regardless of outside influences...not to mention these diagnosis are complicated, pervasive, branding, and take a realtionship between the provider and the client to make...the building of the relationship takes time and trust...they also tend to focus on a paticular behavior and modification of that behavior...so it's a one step at a time deal

Thereapist...those with midlevel professional credentials...are not really there to diagnose anyway... Hope that's not offensive to anyone...just my opinion

Docs outside of psychiatry:

A large percentage of my practice deals with mental health. Primary care providers (internists, OB/GYNS, FPs, pediatricians) see a dissproportionate amout of mental health. Usaully the patients needs don't require subspecialty attention. Often mental health patients carry multiple psychiatric diagnosis. There are multiple diagnosis I don't feel qualified to make or treat. The PDs are certianly in that spectrum. That's not to say I don't see them and recognize them it's just not a label I'd be willing to code...or even a possible diagnosis I'd mention to the patient... If they see me for their mental health I would code and treat their depression (a co-morbid condition)...or whatever co-diagnosis I could make and refer them out for diagnosis/treatment...

Psychologists (Phd training) and Psychiatrist...

Even here there are nuances that will be client specific. If a client wanders in off the street the obligation of the provider is strictly to help...doesn't necessarily require exact diagnosis...

However where referrals ore concerned...Diagnosis here should be as exact as possilbe because they are being asked for an expert opinion to help guide a team approach to therapy. Still would take time. The psychologists are going to be the professionals that do the testing and psychotherapy. The psychiatrists will be the people to guide pharmacologic therapy...


In General :

Any provider is ethically bound to help their patients and protect them. That is the nature of how we are trained. We should be very careful when we label someone with a diagnosis that can impact their lives whether its getting insurance, finding employment, or custody issues.

My own personal situation:

My X was diagnosed with Personality Disorder, NOS characterized as severe by her psychiatrist. That diagnosis was confirmed recently by a forensic psychologist who ultimately was an expert witness on her behalf. My litigation with my X has been helped by the diagnosis. Fair or not, I got her psychiatric records and used them for my gain in an effort to protect my children. Me nor my attorneys have argued that because of her mental illness she should be restricted from contact. Rather we have argued because of her behavior she shouldn't. The diagnosis has been used to strenthen that argument and argue potential future behavior...It's been something we have discussed to try and force her into theray...which has not worked...

I've been very thankful that her psychiatrist labeled her. The diagnosis gave me some peace...The paradox is the diagnosis was rendered for her and not intended for my use.

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Mollyd
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« Reply #20 on: September 19, 2008, 02:26:40 PM »

Quote
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
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« Reply #21 on: June 24, 2010, 12:35:18 PM »

1. Ignorance, especially if the person is under 182. 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 chart4. To get insurance coverage, especially when there is an Axis 1 disorder5. 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 KregerThe Essential Family Guide to BPD
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« Reply #22 on: January 29, 2011, 09:25:39 AM »

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. 
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« Reply #23 on: January 29, 2011, 01:34:43 PM »

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 wink
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« Reply #24 on: April 13, 2011, 01:36:41 PM »

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
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« Reply #25 on: May 17, 2012, 02:21:42 PM »

"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?
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« Reply #26 on: June 16, 2012, 10:18:42 PM »

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.
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« Reply #27 on: June 17, 2012, 10:11:05 PM »

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.

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« Reply #28 on: June 18, 2012, 06:56:27 AM »

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.
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« Reply #29 on: November 02, 2012, 02:47:00 PM »

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 !
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« Reply #30 on: November 02, 2012, 05:42:33 PM »

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 smiley
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« Reply #31 on: November 02, 2012, 06:16:38 PM »

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.
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« Reply #32 on: November 03, 2012, 08:40:14 AM »

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.
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« Reply #33 on: November 03, 2012, 07:01:08 PM »

"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.
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« Reply #34 on: March 20, 2013, 04:18:30 AM »

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

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« Reply #35 on: March 26, 2013, 07:37:15 PM »

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.
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« Reply #36 on: May 09, 2013, 12:28:06 PM »

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

www.nhmrc.gov.au/_files_nhmrc/publications/attachments/mh25_borderline_personality_guideline.pdf


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« Reply #37 on: May 25, 2013, 10:02:07 AM »

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?
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« Reply #38 on: May 25, 2013, 04:54:16 PM »

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."
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« Reply #39 on: October 20, 2013, 01:01:58 PM »

In the case of my wife, the doctors only hint at the borderline situation. She's sought help for what the thought of as bipolar symptoms last year and was treated with antipsychotics. She still had 3-4 "black" days every now and then - usually triggered by a fight or something that had upset her. Whenever this happende she called her doctor or went to the emergerncy ward. Everywhere doctors said that her behaviour was not neceserily bipolar but rather "related to personality". She did not understand this, and it took some time until I got it too (even though I work with health care issues).

Recently my wife had an evaluation with her psych doctor and I was invited to come along. The doctor then explained that since the antipsychotics had not affected the mood shifts, the mood shifts that my wife had been experiencing was definately personality-related and not related to bipolarity. She also asked me how long these mood shifts had been going on, and I confirmed that they had been going on for the last 20 years. She also said that my wife was going to quit the Seroquel and try Lamictal instead. Then the doctor wanted to speak to me in private, without my wife. Then she told not to expect any great changes ahead (!). I was completely overwhelmed by the situation (which was rather emotional to be honest) and did not ask any further questions.

Where I live (Sweden), Lamictal is indicated for treament of emotionally unstable personality disorder. That's what I know.

The doctor has not used the term borderline, or "personality disorder" in coversation to either me or my wife. My wife is partially absent from her work because of her illness. She's in counselling because of she has trouble taking care of our three year old daughter. She has a 20 year record of seeking psychiatric help. Our family life is hell. She can't stand other people and she can't stand being alone.

I've been telling her that the doctor propably mean that she's "borderline", and that's the way she's perceived it too. But you can't build a future on "hints", can you?

She is also waiting for an ADHD evaluation. The very first suspicion of that and it went into the medial records and everyone got to know. Same thing with the bipolarity. As a husband I was offered to join supports groups and stuff. But when this "personality" stuff came up, I feel they're throwing the lid on the casket.

My wife doesn't cut herself and doesn't hit her baby. She only abuses her child and her husband verbally and makes her little daughter cry far too often). Are they saving up the diagnosis for the people they're putting in DBT (i e the people who cut themselves?).
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« Reply #40 on: November 16, 2014, 01:46:45 PM »

I have seen this question asked several times on the boards and found the following description helpful, and likely quite accurate, as it’s that of a Therapist who has BPD.  This was copied from a site that’s recommended ‘by us’ for BPD sufferers:

I'm a Therapist and the truth is, BPD is the diagnosis most people in the field absolutely detest. I came into this field to work with pwBPD, people like myself, so I was very taken aback by the way others in the field reacted.  

BPD does not respond quickly to medication like acute Schizophrenia or Bipolar. BPD takes extended time in therapy (YEARS) which in today's managed care system, is time that therapists just really aren't given (8-15 sessions). BPD isn't covered by many insurance companies (this is why many have a difficult time getting the diagnosis in the first place). If a doctor can't bill for it, then they won't give you the disgnosis or they just won't treat you altogether.

Above all, many have experienced splitting from a pwBPD and it's something that drives therapists/psychiatrists insane. One minute you're bff's, the next minute you're Satan. Many just simply don't have the patience, empathy or sympathy to have to walk on eggshells with their client and never know who they're going to get from session to session. From talking to colleagues about it, the disconnect seems to be in misunderstanding the motives of pwBPD.


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« Reply #41 on: January 30, 2015, 05:57:22 AM »

I have looked but nowhere can i find figures for the proclivity of patients to be misdiagnosed with BPD ( e.g. % of complex PTSD mistaken for BPD ) there are plenty of figures for BPD being mistaken for something else but not vice versa.
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« Reply #42 on: January 30, 2015, 01:45:34 PM »

This could be very hard to find, because it is not in the researchers' interests to track mistakes in diagnosing people. This could be for several reasons; for example, admitting that patients were misdiagnosed would undermine the validity of the researchers' own studies; it wouldn't support their view of themselves as competent professionals, and so on. Even if they don't mind admitting the mistakes, they may not feel it benefits them to expend extra time and/or money searching for who was misdiagnosed. There are probably not many government grants for this type of thing!

What you could search for might be "reliability of diagnoses"; that is I believe a close term related to mistakes in diagnosis. The reliability for BPD is often questionable in studies; I remember reading that about 30-40% of the time, doctors in certain studies cannot agree on who has the same diagnosis. This is discussed further in the book Mad Science by Stuart Kirk. Also, the British Psychological Society did a study of the reliability of diagnoses that was interesting; it showed that often, patients were diagnosed with contrary diagnoses by different doctors. They said that one could even make an argument that, given the subjective/descriptive nature of psychiatric diagnoses, that the symptoms of each do not cluster together nearly as closely into distinct syndromes as psychiatrists assert that they do. This is not at all to say that the symptoms of any person's condition are not real and painful; of course they are. But it could suggest that BPD and ptsd are less distinct than is commonly thought. If I remember right, I read about this BPS study in Paris Williams' book, Rethinking Madness.
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« Reply #43 on: February 20, 2015, 06:37:53 AM »

thanks BPD there is an interesting post on epigenetics you might be interested in gist is mistreatment / trauma as a young child may trigers genetic switching on of certain BPD relavent genes as a defense mechanism to protect child
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« Reply #44 on: February 28, 2015, 12:00:02 PM »

thanks BPD there is an interesting post on epigenetics you might be interested in gist is mistreatment / trauma as a young child may trigers genetic switching on of certain BPD relavent genes as a defense mechanism to protect child

Or, those genes are fully active, thus the child is prone to seek or create trauma and chaos…  My conclusion is this ‘behavior’ begins far earlier than is discernible and has far less to do with nurture than nature. 

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