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Dr. Bob is Robert Hsiung, MD,
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Posted by Apperceptor on March 7, 2004, at 17:00:46
In reply to Re: ???s about Borderline dx » Racer, posted by fallsfall on March 7, 2004, at 16:21:08
DBT is currently being systematically evaluated for use with depression and anxiety, with encouraging preliminary results. I also am very close to some psychologists who use it for these and other concerns in their own practices. I've used it once, in a DBT group for people with Bipolar I. It seemed to help, particularly "wise mind." It is my sincere hope that the word gets out that DBT, the supposedly "Borderline Therapy" is effective for other concerns, and perhaps this will help destigmatize.
I've had the pleasure of seeing Dr. Linehan speak, and her manner and approach is utterly engaging. She's a very "no bulls***" type person and her genuineness and lack of "clinical distance" is beautiful.
I hate the term "personality disorders." In my program, we are being told not to use it. The term we're using is "Characterological Disorders" (or "Characterological Maladjustments" among the more dynamically oriented faculty). Same thing, but I think taking it a little out of the vernacular might help a bit. Still a long ways to go, unfortunately.
Posted by Dinah on March 7, 2004, at 17:31:19
In reply to Re: It does help, but /MAY TRIGGER***, posted by terrics on March 7, 2004, at 15:20:08
Terrics?
I hate to sound like a mom here, but I can't help it. I am a mom. Are you making sure you're getting proper wound care? Embarassment isn't fun, but neither are a host of nasty bugs that you can get from an untended wound.
What does your therapist think of your increasing urges? Have you changed medications recently? I found that I had a lot more trouble on Luvox than off. It must have been disinhibiting for me somehow.
Posted by Apperceptor on March 7, 2004, at 18:18:20
In reply to Re: It does help, but /MAY TRIGGER*** » terrics, posted by Dinah on March 7, 2004, at 17:31:19
Please excuse my ignorance, I feel like I should know this, but could somebody tell me what "trigger" means? I've seen it in various places and I'm wondering.
I'm guessing it's got something to do with exacerbating urges or feelings...if this is the case and an answer to my question would be a trigger in itself, please don't hesitate to say so and I will figure it out some other way :-).
Posted by Dinah on March 7, 2004, at 18:26:33
In reply to Re: It does help, but /MAY TRIGGER***, posted by Apperceptor on March 7, 2004, at 18:18:20
It just means that people who are prone to self injury, or have issues with sexuality, or have suicidal ideation may find a post disturbing or it might exacerbate their problems
I suppose it maybe should be more specific? SI trigger? or suicidal ideation trigger? or abuse trigger?
Posted by Apperceptor on March 7, 2004, at 18:40:20
In reply to Re: It does help, but /MAY TRIGGER*** » Apperceptor, posted by Dinah on March 7, 2004, at 18:26:33
Thank you!
I think it can be applied to an even wider range of issues...I know that I've been "triggered" in the past (both online and in real life) with my obsessive-compulsive (primarily rumination) issues.
Wouldn't it be nice if we had "trigger warnings" in real life?
Posted by Apperceptor on March 7, 2004, at 18:58:13
In reply to ???s about Borderline dx, posted by Racer on March 7, 2004, at 13:10:24
Racer-
I'd like to suggest the book _Imbroglio: Rising to the Challenges of Borderline Personality Disorder_ by Janice M. Cauwels (ISBN: 0-393-03349-X). It addresses a lot of the issues you're confronting, and includes a great deal of feedback and contribution from individuals who carry a diagnosis of BPD themselves.
Posted by noa on March 7, 2004, at 19:47:40
In reply to Re: ???s about Borderline dx, posted by gardenergirl on March 7, 2004, at 13:43:10
My philosophy has come to be that diagnoses are not real things in and of themselves. They are man-made constructs to help organize symptoms into clusters to try to make sense of them in order to provide treatment.
Sometimes, new biological research comes along to support the idea that there is an underlying biological basis for validating one construct or another. But I think for the most part, the psychiatric diagnoses are all still waiting on that.
Take for example whether my depressive illness is unipolar or in the bipolar family. Who knows? At one point, my previous pdoc hypothesized that it might be, I think in part to explain the recurrences, but also in part to point to a new strategy to try---augmenting with lithium. But at the same time, he also said that lithium could help with depressive symptoms whether I had bipolar II or not. So in the end what difference did it make for me how to conceptualize my diagnosis? Most of psychopharm is trial and error anyway!
And therapy? I think they did studies that show that different kinds of therapy are actually more alike than different and that the healing aspects of therapy were those that are shared across the methods.
But sometimes I guess having a diagnosis could lead to a particular approach to treatment and that is when the diagnosis is the most relevant and useful.
Some of these diagnoses are based on concepts organized at an earlier time in the history of psychiatry, and therefore influenced by one school of thought or another, and that needs to be taken into consideration, as well.
OK, so all these different people, a rather diverse group, are clustered together because they share some symptoms. Perhaps this is a valid way to group them, perhaps not.
The biggest question for me is whether grouping them this way is helpful. Is the particular diagnosis helpful? Will it lead to a treatment plan that will work to help the person with their symptoms and problems?
Otherwise, diagnoses are rather useless at best, and can be used harmfully, as you related to us from your experience.
Some people find comfort in having a diagnosis and they feel better understood. But others feel shamed by it. So I say, if it helps, it is useful. If not, it is just an idea dreamed up by a bunch of psychiatrists sitting around a conference table decades ago. That is all it is. There is no evidence that conceptualizing things in this way is biologically valid.
I think sometimes MH people like to use the Borderline dx when they are working with challenging patients--it helps them distance themselves from the patients and helps them explain away their anxiety about being challenged.
But other times, it seems from what I've read here, the dx can be used with genuine care and professionalism, and with empathy for the patient's diagnosis.
If it is used as a weapon, obviously it isn't useful. If it helps someone feel understood and hopeful about finding relief--then to me, it is a valid and useful diagnosis.
BTW, there are some researchers who see BPD as falling into the bipolar spectrum, with rapid cycling explaining some of the emotional ups and downs. And some see hormones as a factor, too.
Posted by noa on March 7, 2004, at 19:58:21
In reply to Re: It does help, but /MAY TRIGGER***, posted by terrics on March 7, 2004, at 15:20:08
Terrics,
I appreciate your bravery in disclosing this. I know it must be hard to break the secret.
I think when I read Levenkron's book "Cutting", if I remember correctly, he doesn't necessarily equate cutting with borderline. But it's been a while since I read it. Anyone else know?
Cutting is a serious problem in itself. Do you find that the diagnosis of Borderline PD helps you and your therapist to understand your cutting behavior better?
Thanks.
Posted by noa on March 7, 2004, at 20:01:23
In reply to Re: ???s about Borderline dx, posted by pegasus on March 7, 2004, at 15:57:48
Pegasus--that was a very helpful explanation. You sound like a very compassionate therapist. Thank you.
> I think diagnoses are so tricky, because they can be helpful, as Dinah described, but also very destructive, as in the way your old pdoc used them. The way I understand it, the most compelling reasons for using diagnoses are to communicate with other clinicians - especially for the purposes of research. For example, if someone is going to study the effects of some drug on depression, there has to be an agreement about what constitutes depression.
>
> But I think we also get hung up on diagnoses, because we're so used to medical diagnoses. Medical disorders are a very imperfect analogy for mental disorders. Because different people can arrive at similar mental symptoms through such different pathways (life experiences, biological issues, etc.). And the diagnosis of mental disorders is completely dependent on the presence of certain symptoms. I mean, the diagnoses are defined by the symptoms. Which isn't the case for physical illnesses. A doctor can misdiagnose you even if they understand all of your phyisical symptoms. Because there is usually a real physical "right answer" about the cause.
>
> But for mental disorders, the symptoms define the disorder, whatever the cause. Which a lot of people think means that the diagnoses are kind of arbitrary or meaningless.
>
> I've been taught not to use diagnoses unless I have to (for insurance purposes, say). But on the other hand, sometimes different people have a lot in common in terms of their mental experiences, and it seems useful to me to consider what we can learn from one person that extends to another.
>
> Sorry for the rambling, but that's my 2 cents.
>
> - p
Posted by terrics on March 7, 2004, at 20:26:26
In reply to Re: ???s about Borderline dx, posted by gardenergirl on March 7, 2004, at 13:43:10
gg, you are kind not to mention the diagnosis to your clients. terrics
Posted by Racer on March 7, 2004, at 20:37:22
In reply to Re: It does help, but /MAY TRIGGER***, posted by Apperceptor on March 7, 2004, at 18:40:20
Posted by Apperceptor on March 7, 2004, at 21:05:28
In reply to Re: ???s about Borderline dx, posted by noa on March 7, 2004, at 19:47:40
!!!!!!
Noa has said everything I'd like to say on the topic of diagnoses, but more eloquently and comprehensively.
Thank you, Noa! Your type of thinking is a great asset to mental health.
Posted by Apperceptor on March 7, 2004, at 21:47:34
In reply to Re: ???s about Borderline dx » Racer, posted by Apperceptor on March 7, 2004, at 18:58:13
I saw a suggestion from Dr. Bob Up There ^ about giving people easy access to books. I suggested "Imbroglio" in this thread, so let's give it a try.
Dr. Bob, you owe me :-)
Posted by emmaley on March 8, 2004, at 2:41:48
In reply to ???s about Borderline dx, posted by Racer on March 7, 2004, at 13:10:24
I react strongly when I hear about instances such as what you described with your pdoc. No one deserves to be coerced, not even when it's "deemed" in their best interest.
I am so sorry you were put in that position, and I agree wholeheartedly with what gardengirl posted, and many others. So glad that you posted this to check it out. Awesome.
Posted by Racer on March 8, 2004, at 2:47:15
In reply to Re: It does help, but /MAY TRIGGER***, posted by terrics on March 7, 2004, at 15:20:08
Have you talked to your therapist or pdoc about this? I hate to sound like a Mom here, especially since I'm not one, but that does sound pretty dangerous to me. Wound care, if nothing else. I hate to think of how bad that must feel for you, and how frightening that must be for you.
Have you told your T about the new aspects of it? The first rule in veterinary medicine is that, when confronted by new behaviors, rule out any physical cause for them before assuming it's behavioral. That sounds pretty reasonable for human care, too, as far as I'm concerned. Rule out something like hormonal changes, or a subclinical infection, or something weird like maybe an inflammatory syndrome starting up.
You don't have to give any details at all, but are you aware of anything new in your life that might have triggered this change? More stress than usual? I guess what I'm asking is this: are you aware of what changed, whether you are ready to talk to your T about it yet or not?
Last, and this is one of those personal questions I can ask and you have no reason to answer if you don't want to, does your T ever talk about this as a behavior, rather than a dx? You know, talking about finding other outlets for the pain? I'm really just curious about what the current treatment is like, not asking for any details about you that you might not want to get into.
Best good luck to you.
Posted by emmaley on March 8, 2004, at 3:08:44
In reply to ???s about Borderline dx, posted by Racer on March 7, 2004, at 13:10:24
Somehow, this thread brings back memories of watching the film, "The Hours," when Virginia Woolf (Nicole Kidman) said the following lines in a scene where her husband Leonard was so desperate for her to follow the doctors' prescriptions of staying in the countryside when she wished to return to London:
Leonard Woolf: If I didn't know you better I'd call this ingratitude.
Virginia Woolf: I am ungrateful? You call ME ungrateful? My life has been stolen from me. I'm living in a town I have no wish to live in... I'm living a life I have no wish to live... How did this happen? I'm dying in this town.
Leonard Woolf: If you were thinking clearly, Virginia, you would recall it was London that brought you low.
Virginia Woolf: If I were thinking clearly? If I were thinking clearly?
Leonard Woolf: We brought you to Richmond to give you peace.
Virginia Woolf: "If I were thinking clearly, Leonard, I would tell you that I wrestle alone in the dark, in the deep dark, and that only I can know. Only I can understand my condition. You live with the threat, you tell me you live with the threat of my extinction. Leonard, I live with it too. "
"This is my right; it is the right of every human being. I choose not the suffocating anesthetic of the suburbs, but the violent jolt of the Capital, that is my choice. The meanest patient, yes, even the very lowest is allowed some say in the matter of her own prescription. Thereby she defines her humanity."This scene at the train station always gets me. I always weep uncontrollably for it is so beautifully said, and with such courage. For some reason, it always pulls at my deepest core.
Should the client not have some say in the matter of their own prescription?
I am not great at diagnosing. I see the necessity for its existence and the potential benefits and harms. It's something that I struggle with still.
Posted by emmaley on March 8, 2004, at 3:28:12
In reply to Re: It does help, but /MAY TRIGGER***, posted by terrics on March 7, 2004, at 15:20:08
I want to really support what Racer, Dinah, and noa posted, terrics, and I want to support you. Like Racer asked, have you discussed this new development with your therapist? I so wish that you travel this path with loving companions that can support you, instead of feeling alone.
Take gentle care,
Posted by fallsfall on March 8, 2004, at 7:10:36
In reply to Re: ???s about Borderline dx, posted by emmaley on March 8, 2004, at 3:08:44
I just saw "The Hours" for the first time this week. Unfortunately, I couldn't watch it straight through as the phone kept ringing and I ended up needing to finish it the next day.
I also liked that scene. Mental Illness does not mean that we have no valid thoughts; it does not mean that we have no preferences.
Posted by gardenergirl on March 8, 2004, at 10:18:52
In reply to It does help, but brings up another ?? » gardenergirl, posted by Racer on March 7, 2004, at 14:03:00
>
> I guess I wonder what you believe about the validity of the diagnosis? If you think it's over or under reported? If it really is being used inappropriately by doctors as a way of avoiding difficult patients?I think there are some who use the term as a derogative name for people, like your pdoc threatened. I do think it's a valid diagnosis, although like Dinah, I think it seems to fit better under mood disorders than personality or characterological disorders. I'm not really sure if it is under or over reported. No data to go on in my head.
And can you tell me more about it in general? (I guess I'm looking for reassurance here, like "that doctor was not right, because a) you don't fit the dx, and/or b) BPD means [x], it does not mean that there's no hope for patients who fit the diagnostic criteria."
Here is a site that gives info about BPD. http://www.bpd.net.nz/dsm.html
It lists the DSM-IV criteria among other things. I would not presume to try to affirm or deny such a difficult to make dx for someone here, but you might be able to do that for yourself when you read the criteria.The reassuring thing is that even if you do fit the criteria, that does not mean there is no hope for you. Haven't you made progress already in therapy? Besides DBT and psychodynamic therapies have shown to be effective with people with BPD.
Someone earlier posted about feeling like DBT only went so far, and that psychodynamic is better now. I wonder if the program she was in takes DBT through all four stages? The first stage is very crisis and problem solving oriented. This is usually when skills training happens. Once the person is stronger and is utilizing skills effectively to prevent the more troubling symptoms, stage two then focuses on trauma and emotional processing. I'm guessing a lot of programs just provide stage one stuff. Three and four move towards actual happiness and self-esteem. A lot of therapies do not go that far.
> Thanks GG! Them's part of my initials, did you know that? My husband's initials, too! Must be why we 'click', huh? Just the initials, nothing else needed...Cool!
gg
Posted by Crooked Heart on March 8, 2004, at 11:12:33
In reply to Re: It does help, but /MAY TRIGGER***, posted by terrics on March 7, 2004, at 15:20:08
Hi terrics
When you start DBT at the end of March, will you be stopping seeing your present therapist? I know from what you've said in other threads that she has crossed boundaries, she has dumped her stuff on you, but also last week she gave you some very practical and helpful advice. I just wonder whether the prospect of finishing with a therapist, even one who has forgotten that it's her job 'to mind the store', not the patient's, well I wonder if that has something to do with the desire to cut deeper?
Would it help to see a pdoc or even a family doctor if it feels as though things are getting out of control?
Just suggestions, I don't know if they're any help.
Please take care and keep posting. Thinking of you. ((((terrics))))
Posted by fallsfall on March 8, 2004, at 15:38:38
In reply to Re: It does help, but brings up another ?? » Racer, posted by gardenergirl on March 8, 2004, at 10:18:52
I'm the one who switched from DBT/CBT to Psychodynamic therapy.
I was in CBT for a year before I went into one 6 month DBT skills training class. My CBT therapist went to the therapist's meetings during those 6 months, but she is not trained in DBT (she bought and read Linehan's books). I am atypically borderline, so during the class I was able to attend to most of the sessions and complete most of the homework. So, I would say that I was mostly out of the crisis phase during skills training.
I stayed with the same CBT therapist for an additional 7 years. I had neglect, but not trauma, in my childhood. So the work I have to do is more related to general views and feelings, rather than processing specific traumatic events. I became frustrated with CBT because it felt like we were skimming the surface - learning how to deal with symptoms and collecting more coping skills, but that those things only covered up the pain. I asked my therapist at least twice to help me go deeper. The first time she said that she really wasn't trained to do that, nor did she "believe" in it. The second time she did try - but it was very clear that she was completely uncomfortable with the whole thing. So I dropped it quickly.
I guess that my assessment of the 4 stages in DBT is that I couldn't get past stage 2. I was able to return to work for 2 years (after a 5 year disability), but I still considered myself to be depressed, and after the two years I crashed again and have been disabled for an additional 2 years.
I did agree with the diagnosis when I received it (8 years ago). Since then I have made some progress and there are times when I think that I don't quite meet the requirements any more (but there are also times when I do...).
Posted by terrics on March 8, 2004, at 21:10:44
In reply to Re: It does help, but /MAY TRIGGER*** » terrics, posted by Racer on March 8, 2004, at 2:47:15
T completely ignores anything to do with SI. I think she thinks ignoring it will diminish the behavior. She does not think I am a true borderline, that was someone else who dxd bpd, a very cruel human being. My current T. did ask if SI was esculating. I will talk to her about it Wed.
Yes there is a big stress in my life. I will tell it soon. It is nothing horrible, just difficult for me. Thanks for your concern. terrics
Posted by terrics on March 8, 2004, at 21:13:45
In reply to Re: It does help, but /MAY TRIGGER*** » terrics, posted by Crooked Heart on March 8, 2004, at 11:12:33
Posted by terrics on March 8, 2004, at 21:15:02
In reply to Re: It does help, but /MAY TRIGGER*** » terrics, posted by emmaley on March 8, 2004, at 3:28:12
Posted by gardenergirl on March 9, 2004, at 15:34:38
In reply to Re: It does help, but brings up another ?? » gardenergirl, posted by fallsfall on March 8, 2004, at 15:38:38
Thanks for sharing more of your experience. Actually, my experiences with DBT also come from reading the book and my Behavior Therapy class. I am not formally trained in DBT. But I use many of the principles with a number of clients as I really like the approach. I agree with how CBT only seems to skim the surface. Very helpful for developing skills, but not at getting at pain. Glad you are working with someone who is trained in this and obviously more comfortable with it.
Also, thanks for clarifying about trauma. My post seems to suggest that all people with BPD have had trauma, and I know that's not true. I guess I was being sloppy. Certainly many have inner pain, as do those without the dx. Again, glad that your T is a good fit for you.
Take care!
gg
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