submitted 1 month ago by peterfreed
I am happy to answer general questions about the diagnosis, prognosis, and treatment of personality disorders, particularly the “big two”: narcissistic and borderline personality disorders. I can’t give medical advice to individuals, comment on celebrity personalities, reveal information about patients, or participate in jokey exchanges. But if you have a practical question that is hard to find answered online (for example “how can you tell the difference between depression and a personality disorder?”) I will gladly give a serious answer or, if there isn’tan answer, try to frame the discussion in a useful way. For what it’s worth, I am well aware of the many flaws in modern psychiatric diagnosis, the problems of overdiagnosis and overmedication, and the large number of quack treatments out there (e.g., conversion therapy for homosexuality). I am also well aware that many people think psychiatry leads the pack in creating these problems! I am open to serious discussions about the flaws and over-reaching that sometime plague my field and if you are earnest in your question I will be non-defensive and earnest in my response. If you just rip on psychiatry ala Tom Cruise, I won’t answer the question. And finally I was on the academic faculty of an Ivy League psychiatry department for seven years, with an NIMH grant to study the neural basis of emotion using fMRI, so I can discuss the use of neuroscience (as well as the limitations of neuroscience) to diagnose and treat mental suffering.
I think three things. First, is that there is no clear biological distinction between psychiatric medications and illicit drugs. Molecules come into the body, molecules cross the blood-brain barrier, molecules attach to protein receptors on neurons, molecules alter neural activity, and the change in neural activity correlates with changes in subjective experience. But there is no way of looking at a molecules and saying “this should be illegal” or “this causes problems” or “this is a great molecule.” It all depends on context. Second, I think many people use marijuana recreationally, the way many people use alcohol recreationally. It doesn’t interfere in their functioning in any way; they don’t miss work, get into conflicts over it, have medical side effects, and use it just for occasional fun. They don’t meet criteria for any psychiatric disorder. And finally I think there are a largish group of people who use marijuana to manage a psychiatric symptom. Typical uses are to fall asleep and calm down. Frequently people get into an avoidance cycle where marijuana starts to play a role in them not engaging fully in life. That marijuana is illegal is kind of irrelevant to thinking about its role in someone’s life, and I don’t think its legalization will really change how psychiatrists think about it or analyze its effects in someone’s life. I have a ton of patients who smoke and drink and eat too much, and that tobacco, booze and sugar are legal doesn’t really alter my medical thinking.
Is there much hope for those clinically diagnosed with borderline personality disorder?
There is more than much. There is tons. There is oodles. People with BPD who are properly diagnosed and whowant treatment and collaborate with their treaters get better in droves. Getting better is the rule, not the exception. Moreover there is epidemiological evidence that many of them get better on their own, without treatment. I don’t know the exact stats, but of 100 borderline patients tested 7 years after diagnosis, something like 30% no longer meet criteria for BPD without treatment. Of course if you want to get better faster, or are worried you might be in the 70%, that’s a good reason to get treatment ASAP. Also if the patient has kids, getting fast treatment can save the kids tons of suffering. This is my expertise so I have a ton more to say on this; if you have follow up questions I’d be glad to answer.
30% no longer meet criteria for BPD without treatment.
What do you think the cause of this is? Is there external environmental factors that can cause BPD and symptoms disappear when they are removed?
My experience is that there is no magic in psychotherapy, the magic is in relationships. If the patient can find a person – shrink, lover, friend, mentor – who they can respect and admire and trust, and who sticks with them through thick and thin while demanding to be treated well – the person can get better. There is also some talk about how the aging process itself leads to a mellowing. The energy that makes people get mad very easily, or sad very easily, or anxiety very easily wanes as we age, and it’s just harder to produce that level of emotion when you’re 50 than when you’re 25.
Thanks for this! I have several more questions.
Is it true that BPD sufferers required weekly long term treatment in order to progress or is it possible for them to do intermittent treatment as long as they are focussed on recovery?
While DBT is the most commonly heard of treatment, what is your opinion on the type of therapy that uses replaying situations in your head to train your brain to use different pathways in order to stop the cycle of jumping to the most comfortable ( and usually most damaging) response to a stressor?
Do many BPD sufferers also suffer dermatillomania as a subconscious form of self harm? Could this go away once they begin to recover?
Do you think the parameters of BPD need to be reviewed in order to lessen the stigma that those with BPD face? I work in mental health and still those suffering BPD seem to face the most stigma as they are immediately labelled manipulative or criminal.
Do you think someone suffering BPD in their early twenties should consider not having children if they have suffered mental health problems for most of their life due to childhood trauma?
I know this may seem annoying of me, but could you just post one question at a time? I am happy to address them all but it gives me more time to look at other posts.
I’ll answer just your first. There is no hard-and-fast rule about treating BPD. I try to be flexible with my patients. Personally I do twice-a-week treatment, and will not do once-a-week treatment, because once-a-week treatment goes more than half the speed as twice-a-week treatment, and I am usually trying to get people better ASAP. The reason is that you don’t want your patients to miss their developmental milestones. If the patient is 20y old and still a freshman in college (bc they’ve dropped so many classes) giving them half-speed treatment could mean they won’t finish college until they are 26; full-speed might get them out at 23. That’s a huge difference, because a 26y old applying for her first job looks different to an employer than a 23y old. Extrapolate this out – imagine patients who are 35y old. Twice weekly treatment could get them functional enough to have a happy relationship and make their partner comfortable having a baby before they are 40, when rates of birth defects go way, way up. Once a week could mean they are only ready for a baby when they are 42. Some people might think these are sexist considerations, to which I can only say that I take biology seriously, and know how depressed patients get when they miss developmental milestones. But certainly a motivation for change is the single biggest predictor of success in treatment; trusting your shrink is the second; frequency must come somewhere after that. I don’t know the stats or the research, only my clinical experience.
I already understand that but thankyou
I really don’t think ADHD should hold anyone back from any job. I would be surprised if someone with ADHDwanted to be a librarian, but even then I don’t think it would be ruled out. People should focus on their life goals first, and then medicate and use behavioral strategies as needed to be functional. Sometimes people with adult ADD have underlying personality issues that prevent them from “finishing anything.” That’s a common complaint – that they start things with enthusiasm but don’t finish. These people can feel like they are casting about for a good career, but the cause in their case is not ADHD.
underlying personality issues that prevent them from “finishing anything.”
Can you elaborate on this?
Sure. Many people with PDs notice that their enthusiasm for projects wanes over time. For example, they may decide to start a photography hobby,buy a fancy camera, take lots of pictures all weekend…. and then never take the camera out again. Or they may switch colleges and think that the new college is going to be better than the first one, but after two semesters find lots of flaws with it and transfer to a third college. Or they may have brief intense relationships that die out after a few weeks. If this becomes a pattern – if they constantly get excited early, but lose interest fast and quit – that can be part of their condition. After improving, patients demonstrate a stick-to-itiveness that they didn’t have before. Since sticktoitiveness is a key to success in any field or relationship, developing this ability is a great accomplishment.
Yes definitely; they are both in the “differential diagnosis” – the term psychiatry uses to describe the importance of listing several competing explanations for a given set of symptoms. That said, if you do a personality diagnosis and find identity diffusion and splitting defenses, you have a personality disorder on your hands. Hypomania may be an additional problem, by hypomania does not cause identity diffusion or splitting.
Super complicated and wonderful question; I think about this a lot. I divide my thinking into three broad areas. First, how do we know our diagnostic categories are valid? In science we have these two categories for things like diagnoses – accuracy and precision. (http://en.wikipedia.org/wiki/Accuracy_and_precision). You could have a ridiculous disorder, like “santa claus belief disorder” that you could “diagnose” in children younger than 7 with incredible precision (that is, the interview is straightforward and no psychiatrist would screw it up). So then you could say something like “santa claus belief disorder is one of the most reliably diagnoses disorders in psychiatry.” But that’s kind of pointless, because it shouldn’t be a diagnosis in the first place. That’s where accuracy comes in – the question of whether the disorder is “really’ a disorder. I think that many psychiatric diagnoses are not “real” diseases. Typically this is because the patient has “something else” that is “deeper” than what they’ve been diagnosed with, and stopping at the diagnosis is kind of a false stopping point. It’s not accurate. A common example is diagnosing someone with borderline personality disorder with depression. Sure, they have depressionper se but that’s not really an accurate way of seeing them. Their depression is caused by their BPD. Second, assuming our diagnostic categories are valid, are we diagnosing all the problems someone has? Frequently people are under diagnosed. A super common one is when an alcoholic gets diagnosed with depression without telling the doctor how much they drink. Missing that alcoholism diagnosis is a misdiagnosis. Third, there is what most people think of when they think of misdiagnosis, which is wrong diagnosis. The psychiatrist simply screws up the interview and misses something. Because I tend to be a tertiary psychiatrist – people come to me after having seen several other shrinks – almost by definition I see many patients who’ve been misdiagnosed. I don’t know the stats on this but will try to look them up at some point. Happy to continue discussion, it’s a really big topic.
What’s your opinion on long-term SSRI use?
As a former young depressed teenager my initial recoveries were aided by the ending of SSRI treatment. I view long-term SSRI use as a form of crutch that while on one-hand can prevent worse things than depression like suicide, on the other hand doesn’t seem to solve the person’s real problems. I’ve formed this viewpoint from seeing people who while medicated don’t seem to be going anywhere past a barely getting by state. I’m not sure if there are any studies on this out there–but I’d love to see some research on the state of chronicly depressed individuals who have been taking SSRIs for many years.
I more or less agree with you. If someone was depressed once in their teens, got over the depression, and is functioning again, take them off and see what happens. At the other end of the spectrum, if I see a 35y old person with 4 lifetime depressions, I tend to recommend they “set it and forget it” eg, start an antidepressant and once it’s working, just stick with it. They are very, very likely to have another episode off of medication. Then there’s the whole middle ground between.
How does being diagnosed with a personality disorder usually affect the life of the patient, in comparison to a disorder that can seem more “legitimate” such as GAD or an eating disorder? (In how they are seen by other people, how it is handled by their workplace, etc.)
Is it true that a lot of companies don’t cover treatment for them and/or don’t recognize it as a legitimate mental health problem because they are seen largely as “uncurable”?
Well first of all nobody ever has to know what you’ve been diagnosed with. HR isn’t allowed to ask you. My experience is that people are getting reimbursed at much better rates for PDs than they used to. However most people with PDs have an Axis I disorder (depression, anxiety, GAD) in addition to the PD. So that can be their diagnosis code, and they can get reimbursed for that. With all that taken care of, there’s just the issue of how the person feels about the diagnosis. There, I’d just say that generally speaking people find it useful – after the initial shock – to be diagnosed. To the degree that the diagnosis is correct, they tend to have an “aha!” moment and say “so that’s what’s been going on.” But there can also be a mourning period when you realize that your problems have a name and therefore are real. It really depends on the individual and how they respond, and working it through is part of their change process.
Do you think that psychedelics will have any place in mainstream psychotherapy in the near future? Based on the current information we have on them: would you personally prescribe any of them if they were rescheduled? Have you seen any major change in a person who has used them, for better or worse?
We jump down a person’s throat for not visiting the dentist regularly.We roll our eyes at people who do not have regular checkups with their physician. In your opinion: why, as a culture, do we not give a rat’s ass that people aren’t regularly checking up on their mental health?
That is really interesting. Ketamine is looking like a winner for the very rapid treatment of depression (works on the order of minutes). But it needs to be administered intravenously. I don’t think anything’s going to happen in the near term but over time as the culture loosens up I think some boutique MDs will start finding uses for these meds.
The main downside is that they can trigger schizophrenia. In the lay public most people don’t see it. But for a psychiatrist in Manhattan – a city of 8 million – we frequently see those 1 in 10,000 dose cases in which a person becomes psychotic on a psychedelic and “stays there.” I see it a few times a year when I work regularly in the ER. And I have had 4 patients in the past 2 years who became psychotic on marijuana and never stopped; all ended up with psychotic diagnoses.
As far as mental health checkups, I really don’t think it’s a good idea. You are more likely to falsely diagnose someone than you are to catch a disorder nobody has noticed. Medicine in general seems to me to be moving slowly away from a belief in the usefulness of population-level screening towards a model in which people should be asked to identify problems (in themselves or others) and then seek treatment. The number of “false positives” introduced by many tests is a serious concern. Perhaps the #1 issue in mental health today is identifying suicidal and homicidal people. I am not convinced that screening can do this though. How do you think it would/should work?
That’s a myth. There is absolutely treatment for sociopathy. Many people who say there isn’t are secretly talking about very high-end sociopaths who are consciously and contentedly sadistic and criminal. But there is a very large group of sociopathic individuals who want to be part of normal society, but simply find they lack the normal guilt and empathy feelings that help neurotypicals automatically fit in. For them the treatment involves a long-term supportive treatment designed to help them work around their natural tendency to not really care how other people feel. It involves a lot of psychoeducation (at first), letting key family members or loved ones in on their diagnosis, and coming up with a game plan for avoiding legal trouble. Once these things are in place, they can start talking through specific incidents (eg shoplifting, lying, feeling empty when something bad happens to another person) in an effort to see whether there are little flickers of empathy and guilt. I have found that these “embers” of empathy and guilt can be slowly heated up. I have seen several patients go on to happy lives and happy relationships. Going into fields of work where sociopathy is an asset can be helpful. A review of famous world leaders, athletes, businessmen will reveal many personalities who sound, on close reading, as though they have sociopathic tendencies. Not all of them are “evil” by any means. Reconceptualizing sociopathy as “trouble feeling guilt or empathy” is a useful first step to helping them. That said, the treating MD and everyone else must remain ever vigilant for signs that they are being mistreated, and forthrightly and directly confront aggression. Staying silent, letting things pass, or telling yourself it must be your mistake never helps the patient.
Having me quite a few psychopaths I would like to remind people that this story is not true for everybody; some psychopaths are genuinely incapable of feeling guilt and will never have altruistic relationships with other people, ever…no matter what.
Exactly – there’s variation in the population. I wouldn’t say altruistic though; few people ever achieve that goal, but empathic? I prefer that concept to altruism – what do you think. PF
Send me a message and we can email each other. I know a female subcriminal psychopath with a PCL-R score of 23. She’s terrorizing her corporation to no end, and getting promoted as a result.
Yes, it exacerbates them. Getting 8h of sleep/night is key to symptom control.
So if someone only sees/hears things when they are tired, does that mean they should see someone about that?
Hey, M1 right here! You mention the limitations of neuroscience to diagnose/treat mental suffering. Can you explain a bit more about that? And are these limitations purely technical in that we just haven’t reached that point in science yet, or is there a fundamental limitation to applied neuro?
Edit: Also, any general advice to someone who’s just starting out?
How did you end up in the field? Was it life and wandering, or maybe an inspiring circumstance?
If it’s not out of bounds, what’s a rough estimate of the percent of your BPD patients that become able to sustain stable relationships? And with those that do succeed, was it mostly through dialectic behavioral therapy? Or have you found other therapies or medication to be useful in treatment?
Thanks for doing this AMA!
For me it was wanting to understand myself + loving people + finding neuroscience totally fascinating + wanting to understand and prescribe medications. It was between psychiatry and psychology for me, but I wanted to prescribe, so I had to go to med school.
Personally I am a huge optimist on BPD. I see all my patients improve. They are naturally relational people and so far they have all improved continuously in their ability to have relationships. Most get into them eventually.
NPD, on the other hand, is much harder to treat. These are the patients who age through their reproductive years. I feel much more guarded in NPD.
I have never seen DBT get someone “all the way better.” Those who stop treatment with DBT are “walking wounded” in my experience. They have learned a bag of (very useful!) tricks for controlling their emotions. They have learned some tricks for improving mentalization and empathy. But the reason I do transference focused psychotherapy (TFP) is because it focuses on the relationship between doctor and patient, and really homes in on the subtle dynamics – the devaluation, the idealization, the sadism, the masochism – that have the power to make or break relationships. The hype around DBT is disproportionate to its effectiveness. It provides a toolbox, but it doesn’t build the house.
That’s a myth. Medications are very useful in the treatment of BPD. The generation of clinicians who think medication is not useful for BPD was trained in the 80s and earlier. Those of us who came of age in the 90s and 00s prescribe for these patients routinely. It’s the rule, not the exception. The common meds are SSRIs, SNRIs, and low-dose atypical antipshychotics, with benzos used much more often than the literature would indicate (the party line, which most of us ignore, is to avoid benzos in BPD).
Just so as I understand – I don’t mean Bipolar Disorder (which I have) you mean Personality Disorder? I mean I have two AAPs an AEP and Benzo PRN and various Z drugs to help me sleep. I was originally diagnosed as BPD and was offered nothing but therapy. I truly hope that things have changed, that diagnosis (although wrong) brought me to my knees.
I just gave a lecture today at Cornell on psychopharmacology for BPD – borderline personality disorder – and NPD – narcissistic personality disorder. The idea that BPD = no meds is not cutting edge. It is possible it reflects the fact that many people who treat BPD cannot, by law, prescribe meds, nor do they have any training in medication, because they are PhDs or MSWs. But MDs routinely medicate personality disorders which – don’t forget! – have a neural basis just like the rest of the mind!
Personally I like the concept. I find histrionic patients are much healthier than borderline or narcissistic patients. Most don’t need treatment at all – they just need to find a partner who likes their hysteria. America as a country seems to have a burgeoning love affair with hysteria. Most of the reality shows on MTV seem to have casted histrionic personalities almost exclusively. I can’t see a future in which I stop thinking about hysteria, regardless of what happens in DSM-V. It’s a really useful concept.
Almost none. It’s not relevant unless the person is manifestly cognitively impaired. And at that point you don’t need an IQ test to tell you there’s a problem. But please note that I’m an MD, and MDs tend not to be focused much on testing in general – we go by our clinical exam. Psychologists might well give you a different answer.
Social worker here. Do you find that many clients referred to you after being diagnosed with borderline personality disorder don’t actually fit the diagnostic criteria, but rather haven’t shown rapid enough improvement in mood for their diagnosing clinician? I get the sense that many clients who seek treatment for depression or anxiety issues are diagnosed with bpd after a clinician deems their recovery to not be progressing quickly enough, resulting with the client being placed in the too-hard basket. Do you see this, and if so, how much do you think this comes down to the clinician’s mentality of “well, I haven’t been able to fix him/her, so it must be something wrong with their personality” rather than the clinician perhaps falling short in their efforts to help the client? While I’m not suggesting that BPD is just a word for people who take too long to recover from depression, I do wonder if sometimes this particular diagnosis absolves the clinician from any self-blame regarding their inability to help the client within the time available to them. I’m thinking of doing a phd investigating stigmatisation of those with bpd – it’s a fascinating and tricky area.
I love what you’re thinking about and how youre thinking, and the thesis idea sounds great. Personally I find bpd is under-diagnosed, because many people have been told they have bipolar II disorder when they really have bpd. I also find that since the key feature of bpd is rapid shifts in mood, typically in a triangle from “fine” to furious to despairing, they don’t tend to be diagnosed with depression, which is just a constant low mood. It’s really bipolar that they get misdiagnosed as.
It may sound funny to say this, but feeling frustrated, wanting to get rid of the patient, and noticing that medications just aren’t getting the depression better are all good ways of realizing that the patient may have a personality disorder. Working with countertransference – your feelings of frustration – can help the patient greatly. Just giving into it, or taking it seriously – can hurt them. That’s why it’s key to think about your hateful feelings from a diagnostic standpoint. BTW there’s a great old paper called “the hateful patient” you should check out if you haven’t already.
Thanks, that’s a great perspective for me to think about, and I’ll definitely look at that paper. Another question, if you don’t mind – I hear about quite a significant number of adolescents being “diagnosed” with bpd, which is ridiculous anyway since a diagnosis requires them to be 18+ as you’d know. It occurred to me then that some of the traits of bpd such as the shifts in mood you’ve described, the difficulties with interpersonal relationships, are similar to those of normal adolescents who just haven’t learnt effective coping mechanisms yet. Given the significant over-representation of young female survivors of sexual abuse in those diagnosed with bpd, how often do you think bpd in this population is some kind of pathology and how much do you believe is simply due to maladaptive coping mechanisms developed in periods of great stress and trauma? Being a social worker obviously I tend to look more at the social side of mental illness rather than the organic or cognitive side, but it seems to me that so often personality disorders are seen as some fundamental defect in an individual rather than a maladaptive way of coping developed under societal and environmental stress.
Why is there more focus and research into bpd, npd, aspd and less into schizoid and avoidant pd’s?
All the information i read into avpd and spd seem to lead back into the same sources.
Is it simply a case of your profession finding the conflict based pd’s more interesting or are there other reasons?
They present much, much less frequently for treatment! Of every 100 patients referred to me I’d guess I end up thinking maybe 5 are schizotypal and 5 are schizoid, while I find maybe 50 are narcissitic and 30 are borderline and maybe 10 are something else. Like I said, I don’t even think about avoidant pd, because I find those patients resolve into other conditions. I’d probably revise these numbers a bit if I really sat down for an hour to think about it, but it gives you a flavor for what it feels like on the shrink’s end of the business. Just from a numbers standpoint, bpd and npd are the common illnesses.
I never diagnose people with avoidant PD (here: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001936/). I find these patients are more usefully conceptualized as having either a social anxiety disorder, a narcissistic personality disorder (covert type – eg the “shy loner”), or both. It’s a good example of an official diagnostic category that is not very clinically useful – at least here in NYC.
My go-to drugs are the atypical antipsychotics. Lithium and depakote cause side effects that most people, particularly women, can’t stand. Meanwhile the new atypicals – eg abilify, geodon – have good side effect profiles and are quite effective. I dont ever use stimulants (if that’s what you mean) to treat BPD. In 10 years I’ve never done it. I can’t imagine what they’d help with. The big problem in BPD is affect dysregulation – mood going up and down quickly and intensely. Stimulants can’t help with that.
I was thinking more of drugs like Clonidine, Tenex, and Atarax. I also have acquaintances who are using Lamictal for what I think is BPD, which raises another point – to what degree do you think physicians in general are shying away from Axis II disorder diagnoses in favor of, say, Bipolar NOS or another Mood Disorder?
Oh, these are great points. Lamictal is very popular in the the treatment of BPD. It helps a great deal with reducing the affect dysregulation (ups and downs, from sad to mad to anxious). It can cause a rash and rarely a condition called SJS which can be very serious. It also takes a long time to get to therapeutic levels – sometimes several weeks – which is a downside. I personally avoid the boutique treatments you describe, but in particular cases it might be reasonable to experiment with them. In terms of your last question, I think many doctors are wary of treating Axis II, so following the logic of “if you don’t diagnose it they don’t have it,” they don’t diagnose it. Also they get subtle pressure from management, big pharma, and insurance companies to diagnose patients with Axis I disorders. You can bet that once some medication gets approved for the treatment of BPD, the pharma company that made it will make a big push to diagnose the condition more often, and doctors will slowly oblige. Diagnosis does “follow the money” to a degree. Finally, ideologically many doctors don’t like the concept of mental illness, and they want to biologize all of psychiatry. So they prefer to call BPD bipolar disorder. The problem is that the core problems in personality – identity diffusion and splitting defenses – are completely missed when one is treating bipolar disorder. This is why so many patient languish for years in treatments that go nowhere: they are misdiagnosed and don’t get the psychotherapy treatment they need.
My impression is that reducing sympathetic reactivity is a useful strategy when attempting to curb the retraumatization associated with triggering events (more commonly associated with PTSD, but certainly one can view the affective dysregulation experienced by people with BPD as serially traumatizing). But I’m not an MD, I only see what you’all are doing from a distance.
My views about personality structure seem to correspond with yours (I’m partial to Kohut, whose observations on the relationship between manic symptoms and personality structure have never seemed to be recognized, at least out here in the West). I was just curious about what you were doing/using, so thanks for indulging me.
I had a discussion with some colleagues a couple years ago about something I’d observed, and it turned out they had also observed, about an unexpected association between kids we were seeing who were PDD-spectrum having a parent who seemed very much to be a hard narcissist. Have you ever made, or heard of anyone making, that observation?
Hey – I love your thinking here. Wish we had more like you around. To the last first, it is more or less the common wisdom that the worst thing that can happen to a young child is to have a narcissistic mother. Her inability to empathize, her persistent misreading of his unformed but urgent social cues, her tendency to feel “criticized” by her child’s sadness and fear (eg, her urgent need to feel like a good mother, even if it comes at the expense of actually being one) all severely interfere with the child’s development. Prosody is interrupted or stilted, and the kid never learns how to manage his own intense affects. He tends to feel dysregulated and dangerous. Wouldn’t be surprised if it contributed to PDD. Sounds like a great research study for someone to do.
Kohut is big here in NYC, and I think a lot of self psychology has percolated into psychodynamic psychotherapy.
I like your idea about reducing sympathetic activity. I sometimes put people on propanolol, which is the opposite of a sympathomimetic, but it’s the same general idea. Certainly worth a shot and I will keep it in mind – thanks for the suggestion.
This is an awesome IAmA!Thank you for doing this. I have been diagnossed with major depression. I have an awesome shrink, but sometimes I do get the feeling he is more or less just a pill pusher, I would like to get to a point in my life where I dont need the meds, sometimes I feel like the only way I can be somewhat normal and happy is going to be a lifetime of pills and that in itself keeps me depressed. My Dr has explained it like this “if you had diabetes and had to take insulin everyday to stay alive, would that make you feel bad or depressed? Well, you have a chemical inbalance in your brain that prevents you from staying happy, you need to take medicine everyday to maintain a proper chemical balance, you shouldnt feel bad or guilty about that” (paraphrased, but it was really close to that). Is that really true? Is there no way to really ever get over having major depression?
In your opinion, what is the best way for someone who has chronic depression to deal with it long-term? Not in terms of specific drugs, but in terms of strategy. Should consulting with a Psychiatrist come first? Psychotherapy first? Concurrent? What frequency? Any other tools that individual should use that you have seen or read about being effective, ex. meditation?
if I had to say the one thing that best prevents depression, I would say love. If someone feels really loved, and if someone really loves someone else – even if it’s a pet, or a parent, or a sibling – that’s just a huge protection against depression. Number two in terms of effectiveness – but number one in terms of how quickly it can happen – is having a work/school/volunteer commitment. Having someone depend on you to show up, and someone who will get on your case when you let them down, is a big protector. It is very hard to get someone who isn’t working and doesn’t have friends out of depression. It is rather easy to get someone who is working and in love out of a depression.
That said, it really all depends. Depression is such a heterogenous term – there are so many different ways to be depressed – that there is no catchall strategy. For example a guy who sleeps all the time, eats too much, and feels numb and bored and a woman who can’t sleep, can’t eat, and cries and startles at the smallest thing are both called “depressed.” But they are really different. So you can’t really give generic advice. That’s why an individual shrink is so useful: they can tailor treatment to your particular case.
What do you think of the upcoming changes for the DSM-V? Also, I’ve read recently about the possibility of a new class of anti-psychotics targeting the glutamatergic system. What are your thoughts on this (if any)? And also, what are your thoughts on the recent decrease in funding for CNS-disorder drug discovery in many pharmaceutical companies?
Thanks (and sorry for a lot of questions)!
Can you just ask them one at a time? I will answer the first and if you want resubmit the others. More or less the new DSM will be like the old DSM. There’s a good article explaining this here:http://psychcentral.com/blog/archives/2009/05/26/update-dsm-v-major-changes/. I am not an expert on DSM-V, but I think the vibe in the field is that people aren’t feeling very anxious or worried about the changes, which is a sign they aren’t going to be that life-shattering. We’ll still be thinking about our patients in terms of mood, anxiety, thought and substance abuse disorders. Generally the thinking about the Axis II disorders is that DSM is “catching up” to how the experts in the field are thinking. But the DSM doesn’t lead the way in clinical practice, it follows.
I have asked my shrink that question before, he said the difference between someone who is chronically depressed (major depression) and bi polar is how fast you cycle through. Bi -polar is so fast, like minute by minute, hour by hour (one hour up, one down), durring those time you lack impulse control,take crazy risks,self harm, etc. Major depression or even chronic depression is more long term, you will be in the low for longer periods of time and you are mostly aware you are depressed (a lot of bi-polar people are oblivious to thier situation). I think that is correct, maybe the Dr can clarify.
Bi-polar is not minute to minute changes, as far as I know.
The closest thing to your description that I can think of is Cyclothymia (Spelling?) or BPD maybe?
I’ve only been studying a few years, though so I’m not claiming to be more knowledgeable than your therapist, but everything I have been taught has been contradictory to what you just said.
You are describing ultra rapid cycling form of bipolar 2. Classic bipolar can have cycles of years. The difference is that chronic depression does not have any episodes of mania. Your diagnosis can change upon a manic (or hypomanic or mixed episodes (my personal favorite :/).
Regular depression has varying levels of intensity. For instance, I feel depressed when I get up in the morning, but it’s gone as soon as I take my medication for it. I may feel depressed on Tuesday, but not on Wednesday.
Bipolar depression occurs when there are symptoms of mania along with depression.
On the flip side of NPD/BPD and other personality disorders is co-dependency. I’m a participant of a support network for people with PD’s in our lives and how to recover from those relationships, and so many of us worry that we are PD ourselves, because it seems that the symptoms or behaviors of PD and co-dependency can often be similar. Or there’s some dynamic that makes a co-dependent feel they are the ones with the destructive behavior.
Do you counsel those with co-dependency? If so, what do you see as the major differences between PDs and co-dependency?
Those with PDs can really mess up the people they are in personal relationships with. Children and spouses, in particular, can be tightly wrapped up into the dysfunctional behaviors and communication patterns themselves.
Can you “spot” the PD in the group and not be succumbed by their manipulative tactics to make everyone else in the family look bad?
One of the most common tactics we see in our support group are NPDs or BPDs choosing a therapist that will “prove” they are sane and that everyone else in the family is “just being difficult” or ganging up on the person. How do you, as a therapist, avoid being caught up in the manipulation, too, and do you see other therapists who do not understand PDs get manipulated?
Hi there! Thanks for doing this. As an Undergrad Psych student, I took a class in Personality Assessment that was truly fascinating.. and the curiosity that incited has stayed with me.
OK, question: In treating patients with BPD, what precautions must you, the psychiatrist take to ensure they don’t become totally enamored with you? A friend of mine who has struggled with BPD tends to idolize her therapists in a way that she has trouble separating her own personality from them, and from my own research it seems like this is a common problem. She has had several therapists who have had to stop treating her because she believed they were romantically involved.
How do you avoid this? Again, thanks!
Well, in my treatment you make their “erotic transference” a focus of the treatment. You obviously don’t act on it – the shrink doesn’t declare his love for the patient, and nobody touches anybody. But you help the patient explore her feelings. The reason for this is that she is almost always idealizing you, the shrink, the way she idealizes others in her life; and almost as inevitably, she is going to be disappointed in you later on and then devalue you. Getting used to seeing the idealization/devaluation cycle in action is crucial to getting better. Trying to get rid of the erotic transference, or ignore it, is bad medicine. Remember, you are treating the total person,and if the total person develops crushes on inappropriate and unavailable people – while, meanwhile, having terrible trouble in her real-world relationships – you need to talk about it.
Great question. Psychiatry divides patients into – more or less – two categories. The first know that they have problems, and describe them to the doctor, and the doctor agrees, and then they both work on the problem together. These are called ego-dystonic disorders, because the patient knows that they aren’t normal or right or healthy (or something like that). Ego-dystonic means something like “against the self.” Anxiety is the classic example of an ego-dystonic disorder: the patient can’t stand feeling anxious. The second don’t know that they have problems, and don’t think they need a doctor, or if they do see a doctor describe some other problem that is not their “actual” problem. These disorders are called ego-syntonic, because they are “with the self,” meaning the person thinks the problem is them, or they are the problem, and they like themselves, and therefore don’t think they have a problem. As you can imagine it is much harder for the doctor to help this patient, because the patient only dimly knows they have the problem. Sometimes people use addiction as an example of ego-syntonic disorders (eg, the alcoholic sahing “I don’t have a problem”) but I prefer the example of the person who complains about not having a boyfriend but then, when a man likes her, pushes him away. She doesn’t realize she is pushing him away, and in fact may defend herself when her mom tells her something like “don’t you think you should dress up for your date tonight?”; she may say it is her right to wear sweatpants and no makeup on a date, and she wants a man to like “me for me, not my mascara.” Thus her mom is left worrying her daughter is sabotaging her date, while the woman herself is indignant at this criticism. For this latter type of person, what is typically needed is to get what’s called “collateral history.” You (or sometimes the patient) interview friends, family members, lovers, children and ask them what the patient is like. If everyone identifies a certain theme – “she gets mad really easy,” or “I feel like I’m walking on eggshells around her” or “she’s not very reliable” or “she doesn’t follow through on her promises” – that’s a sign that there is an ego-syntonic problem.
Combining these two approaches – asking the patient (or yourself) what’s wrong, and asking important (and trusted) others in your life if they have any concerns – usually tells you if there are problems. If you are happy, and the people in your life are happy with you, it’s very doubtful there are problems.
How would I get my mom, who blames everyone else but herself for problems, to seek help? She claims she has seen a psychiatrist but I very much doubt it. She said the psychiatrist blamed all of us for the problems. I have a very hard time believing that.
I just can’t answer specific questions like that. It’s not ethical. If you ask it in a more generic way, in which no particular person is being inadvertently turned into my patient (and I am not being therefore inadvertently turned into their doctor) I can help answer it. But it has to be a generic question.
Great question. Toughest problem in all of personality disorder treatment. Same one faced in addiction: the denial is the hardest part.
The people who have done the best thinking on this are the motivational interviewing folks. Check out this site:http://www.motivationalinterview.org/
What is your opinion of Dr. Sam Vaknin, author of Malignant Love,
I came across his website! quite a few years ago and found it facinating that someone with NPD would have enough insight to put together the ways in which NPD types function/dysfunction.
hi there, i have a couple of questions which i can’t really find answers to anywhere else. psychiatrists don’t like to give me a straight answer because maybe it sounds like i’m questioning their field of study too much. anyway, hope you can help me clear this up: 1) how would you distinguish being depressed with having depression (like a “disease”)? 2) why are there so many claims of people successfully divorcing themselves from medication and never having to return to psychiatric care? if conditions such as bipolar, schizophrenia were really genetic diseases, shouldn’t their condition get worse, not better, in the absence of medication?
i have some follow up questions if you could take the time to address the ones above. many thanks.
I don’t think I totally get your meaning here: 1) how would you distinguish being depressed with having depression (like a “disease”)? Can you be more precise?
In terms of #2, each of us has a certain diathesis to expressing a disease. For example, let’s say there’s a way of scoring how severe a trauma is – from 1 for stubbing my toe to 100 for surviving a plane crash. I probably have some number – say 45 – that I can tolerate without developing depression. Anything that happens in my life between 1 and 45, I’m okay; I bounce back. But above 45, I get depressed. You, on the other hand, probably also have a number, but maybe yours is 65. Above 65, you get depressed; below it, no. Given this, you can easily imagine that if I go my whole life and the worst thing that ever happens to me is a 30, I will never get depressed. But you, alternately, go through 3 level 70 events, so you get depressed 3 times. Using this simple model we can imagine many scenarios in which people get depressed once in their lives and never again. Antidepressants do just one thing, more or less: they increase the minimum trauma score it takes to trigger depression. Let’s say I go on Prozac: it increases my number to 80. Now I become a much more resilient person than I was. Now I can handle anything up to 80 and not get depressed afterwards. So you can imagine that if I went off my Prozac after a few years, and never experienced a stressor above 45, I would never get depressed. Then I might walk around saying “I never needed Prozac; I went off it and I was fine.” Well, that’s true given that I never experienced a trauma. But let’s say a level-60 trauma comes along and hits me. Now it’s too bad I went off Prozac. On it I would have avoided the depressive episode. Off it, I get depressed. That’s the kind of reasoning we use in psychiatry. Medications change your chances of getting sick; they change the threshold at which you develop certain mood and anxiety and thought disorders in response to environmental stressors. But there is no exact science to this, because whether you get sick depends in the end on the interaction of your nervous system and life events.
thanks for your response! that was a very good analogy. to clarify my first question, i was trying to ask how you differentiate an episode of depression (ie. divorce or death in the family) to a psychiatric disease (ie major depressive disorder). My mom was going through a few rough patches when I was younger. The doctor said she has a psychiatric disease, and she’s been on SSRI’s for ~8 years. I honestly think that if she just gave herself some time to overcome those obstacles, she would be healthier and less numb to her environment. But, my opinion obviously holds no weight since I’m not a medical professional. So, based on scenarios like these, how can a psychiatrist determine whether these symptoms are temporary or are going to persist for the rest of their lives? ADD in children is another example. I think it’s a little much that we need to medicate children for being too hyper, when that’s usually how most kids are. Don’t you think that children have possibility to grow out of these phases?
edit: here is a good example of what i’m talking abouthttp://www.reddit.com/r/IAmA/comments/yb1z2/i_am_a_psychiatrist_specializing_in_psychotherapy/c5u294l
how was this guy diagnosed with a chemical imbalance? if i was going through a stressful phase in my life, i’m sure i could qualify for major depressive disorder also.
editedit: so just to link back to your example so you don’t need to repeat yourself. it’s plausible that if someone has a low tolerance for trauma that they have a condition. but, if trauma affects everyone differently, ie. some people are more passionate and get more upset over breakups than others; but maybe they wouldn’t be as upset as someone else when they lose their job because that’s not important to them. where do you draw the line and say that this person has a chemical imbalance?
Aha! The word I would use for what you are calling depression is “grief.” Freud has a wonderful book called “mourning and melancholia” where he asks exactly the question you are asking – what is the difference between grief and depression!
I sometimes have to take patients misdiagnosed with depression off meds and put them into therapy because what they actually have is normal grief – just happened 2 months ago, and it was a relief to the patient to hear her grief had been pathologized.
Your opinion holds lots of weight. A doctor should not be a sage on the stage, but a guide on the side. You are hiring her (or him) and you are ultimately the boss and therefore the judge of whether what is being said to you is useful.
Figuring out whose grief will lead to depression was my research focus at Columbia for 7 years, and part of why I left neuroscience was because I decided that clinical interviewing, not brain scans, were the most effective way of doing this. But it’s very tough. It takes a good deal of subtlety, but generally people without personality disorders get over grief fairly well; those with unstable senses of self get stuck in grief that turns to “complicated grief”.
The neuroscientist Jaak Panksepp has talked convincingly about the best thing we can do for “ADD” kids is make recess the first class of the day. Run around tons, burn off their energy, and then start school. If you look at any other mammal, the juveniles engage in tons and tons of rough and tumble play. America, with its strange fixation on teaching the ABCs and numbers, short-changes our kids out of many hours of play each year. As Panksepp points out, play builds far more skills – social, motor, conceptual – than any class we can put our kids in.
Finally, stress is not depression. The hallmark of depression is the loss of the ability to function. Stressed people can function. It’s a huge difference. Many people that the lay public call “depressed” do not meet psychiatric criteria for depression (a downside of medicine stealing a word from the common language). But in psychiatry, you have to be pretty dysfunctional to be labled with depressed. To name just one thing, it has to last 2 weeks! In common parlance, depression is used to describe 1 day episodes; that’s not a DSM-V depression though.
i’m very glad to see you’re much more open minded than some of the other psychiatrists i’ve talked with. i guess it just bother me that some people in this field are quite pedantic and keep going on about chemical imbalances. i know as patients we can choose to reject this advice, but there are people like my mom who just blindly trust what the guy in a white lab coat tells her. don’t get me wrong, i think there is definitely a place for medication and this treatment. you would know better than me how extreme some patients can be. but, i still think that at the end of the day the drug companies are still corporations with the intention of reporting high earnings to their shareholders. with this kind of mindset, it’s inevitable that medication will be pushed onto patients who don’t need it, and who would be better off without it. i understand that it’s by all means a grey area, but i appreciate you acknowledging the flaws, and doing your best to help your patients. thanks for the answering.
Hey, thanks for doing this, I’m very interested in this field of study.
First of all, how are you?
What is your opinion on the debated existence of Multiple Personality Disorder/Dissociative Identity Disorder, if I may ask?
Also, (I apologize for the multiple questions) what do you think is the best way to teach positive coping mechanisms in people with depressive disorders? If any of these are not what you’re looking for, my apologies, and feel free to say so/not answer.
Thanks! I figure I am privy to a lot of the common sense assumptions of modern psychiatry that don’t always leak out to the general public, so it’s kind of an attempt at public service for me to share it. Reddit makes that possible in an easier and more interactional and informal format than a blog or book would. Low effort, high informational exchange, win-win for all of us, right?
To your questions: first, I believe in what you might call the “planetary” model of personality. On the surface, it can seem like there are these distinct disorders in psychiatry – Multiple Personality Disorder and Borderline personality disorder in psychology – that are separated from one another the way it seems that Europe and Asia, for example, are separated on planet earth. But when you learn about how the earth is made, you realize that the oceans are what makes it seem as though the continents are separate things. Raise the sea level a thousand feet, or dry up all the water altogether, and all the apparent boundaries between continents disappear. The same process can continue, with tectonic plantes, as you go on down, until at the core “it’s all one thing.” Same with psychology in my view. On the surface, sure, there’s probably something worth calling multiple personality disorder or DID. If someone was really into that idea, I wouldn’t try to take it away from them. But if they thought that things stopped there, I wouldn’t agree with them. “Underneath” MPD/DID lies a more fundamental construct, which is personality organization. All MPD/DID patients have a more serious problem of which MPD/DID is just a specific manifestation. That problem is a borderline personality organization, or BPO. BPO isn’t in the DSM, and gets no attention outside of psychiatric circles, but in the crowd I run with you really can’t try to understand – let alone change – people if you don’t assume that people with MPD/DID and BPD (borderline personality disorder – not to be confused with BPO) and NPD (narcissistic personality disorder) all share a more fundamental unifying psychological problem. Thus to close out the analogy, when someone comes to my office and meets criteria for MPD (which I have never had cause to diagnose; I find it too specific a concept) I would not employ some specialized treatment for them. I would just suggest the same type of therapy I put a BPD or NPD patient through; the reason would be that I was trying to address their BPO. This is analogous to a geologist not having a particular theory about how Europe works; they focus on a theory of tectonic plates that is good for understanding the whole world.
Oh, whoops, second question: that one is so big I guess I need clarification. What is a positive coping mechanism? I think I need to know what mechanisms you mean before I can comment on how I would teach them. It is likely that they need to be taught in different orders, as one of the defining characteristics of depression is that it is very, very hard for the person to “learn” even the simplest things that – when non-depressed – they could do without difficulty. For a depressed person, getting dressed or making a phone call can be agony and seem almost impossibly complex, even if they could manage a clothing store when healthy.
Yes, thank you greatly for doing this. Reddit’s format is perfect for this, as I find learning is much easier in an informal setting. Maybe it’s just me, however.
As someone with MPD, I found your analogy perfect. I logically understand what you mean, and if I want treatment I’ll certainly keep it in mind, and I appreciate your approach. I find too many people tend to sensationalize this disorder (along with schizophrenia) as “extreme” and “dangerous”, which I think is a barrier towards treatment of those who want it.
Not personally. In a nutshell, schizoid PD is treated by developing one trusting relationship with the shrink over time, and learning how you are different from neurotypicals – eg, that you really don’t need the same amount of contact and emotional intensity that, to use a high-end example, every single person in a Nicholas Sparks novels seems to need. Schizotypal PD is best treated by honoring the fact that you are a more creative, quirky, sparkly, unusual soul than those around you, and that you should find a career and a community and a partner who loves that about you! If either of these drift into frank paranoia or delusionality, you may need some professional help. Of note, many shrinks don’t diagnose these conditions accurately, and misdiagnose patients leading to – sometimes – years of frustration as they bark up the wrong tree. For example, telling a schizoid person he is afraid to love is almost as tragic as telling a homosexual he is afraid of women. That’s a bit flip, but in a nutshell kind of way it captures the essence of issue.
Shoot – I wish I could answer this but I really can’t weigh in on particular cases for medicolegal reasons – it’s considered unethical (and would make you my patient – even over the internet!). If you write in with a generic question, I can answer that. Thanks very much for your interest, PF
The main thing to realize is that when diagnosing personality disorders the doctor does not try to diagnose particular disorders. Instead we try to see whether the person, generically, has a personality disorder. Only after this do we diagnose a particular disorder.
The diagnostic technique depends on figuring out two things. First, does the person have something called identity diffusion? Second, does the person rely on splitting defense mechanisms. If the answer to both these questions is “no” they do not have a personality disorder. If the answer to both these questions is “yes,” they do. Then you take more of a history to figure out which PD they have. In most PD circles, it doesn’t particularly matter which PD they have because in the end what you are trying to fix is the identity diffusion and the splitting defense mechanisms.
So what is identity diffusion? It’s a complex question and most textbooks spend hundreds of pages exploring its nuances. But in very broad strokes, people without identity diffusion “are comfortable in their own skin” and “know who they are” are “true to themselves” and are empathic towards others; they make other people “feel seen” and respected and appreciated. They don’t treat other people as interchangeable. They act and think the same from day to day; they don’t have major fluctuations in whether they like or don’t like themselves, like or don’t like other people, feel optimistic or pessimistic about their lives, and so forth. Identity diffusion is the opposite. I can say more about this if you like.
Splitting is easier to understand – in lay terminology its “black and white” or “all or nothing” thinking. People who use splitting defenses tend to love or hate people, and to describe them in either idealizing or devaluing terms. This applies to themselves also. They tend to either put themselves down, hate themselves, loathe themselves or to act arrogant, entitled, and so forth. Typically the splits wobble back and forth, so that sometimes they love and sometimes they hate the same person. Couples who keep breaking up and getting back together often have at least one member who is using splitting defenses.
We spend hours – in my practice I can spend ~4 sessions when first meeting someone – trying to figure this out, because you can’t ask someone straight-up “do you use splitting defenses?” You need to hear lots of anecdotes before you get a sense, and often you need to get collateral information from a family member. Over that time period it emerges that they are narcissistic, avoidant, borderline, histrionic and so forth. But as a shrink – at least in my field, which focuses on the psychodynamic treatment of personality disorders – you are more or less focused singlemindedly on their identity structure, their sense of self, and their defense mechanisms.
I can say more about this if you like.
I do love discussing theory but I think I’ve had enough psychology for one day! (Makes me very neurotic)
I may come back later today and ask a few questions about western/linear treatment. Thank you very much for answering my questions, I learned quite a bit!
That’s super cool! It’s a great field; I don’t know any psychiatrists who don’t like their work. Actually, I don’t know anyone who doesn’t love it. It’s great for anyone who loves neuroscience, science, psychology and people.
My main tips would be to take all the science you can, including lots of neuroscience, as well as psychology classes. Think about the connection between the two. You might check out my website neuroself.com for some good links.
A typical day in private practice really just consists of biking to work and seeing patients for 45 minutes at a time. Most are in psychotherapy with medication management. I take breaks to write notes in their chart and eat. It’s very rewarding if you really like people and like helping people learn and think about themselves. If you are someone who likes talking and gossip and are socially oriented, you will really enjoy your career. Good luck! PF
Usually some medication to reduce the intensity of emotions and “buy more time” for them to think before getting angry/sad/upset, then DBT for the first 6-12 months to learn emotion and relationship management skills, leading to mentalization based therapy (MBT) for 6-12 months to learn how to see things from other’s point of view in real time when emotions are high, ongoing psychoeducation concomitantly for the family to learn how to work with the patient, and after that a transition to transference-focused psychotherapy (TFP) for several years of 2x/week psychotherapy that focuses on relationships. The process should be complete on the order of 3-5 years, though many stay in treatment longer.
Thank you for taking the time to do this. My question is on BPD and sociopathy. What is the link there. Are BPDs sociopaths? What Im asking is, how does that all look. There seems to be a split where you see a lot of the typical BPD emotional dysregulation, cutting, etc. but others who are BPD but lie constantly, cheat, steal but dont cut or hirt themselves. What is your take on this?
Basically the dogma in psychiatry is that narcissism’s extreme end is sociopathy. It is not considered to be related to borderline PD. If a borderline is engaged in honest to goodness sociopathy, she likely needs a second opinion, as it is likely she has a narcissistic disorder in additoin to the borderline. The treatment is different, though related, because narcissism involves a grandiose sense of self, fear of humiliation, and a quest for power and perfection. Borderline doesn’t have a grandiose self, the fear is of rejection, and the quest is for perfect (idealized) love. Very different (though both involve poor identity and splitting).
Thank you very much. Also, is pathological lying a common symptom of BPD. As in lies, cheats and steals? I have seen a lot of borderlines engage in serial lying yet “manipulation” is given as the DSM, not lying. When you press if lying is a core symptom you will ge different answers. Wouldnt lack of empathy in BPD lead to lying? Would that fall more under narcissism as well? Thank you again.
No no no no no. No! If you are seeing that behavior, you are not seeing a “pure” borderline. You are almost certainly seeing a narcissistic/antisocial personality disorder. Lack of empathy does not lead to lying, in my clinical experience. Lack of empathy is a kind of requirement for lying – it is necessary – but it is not sufficient. I treat many, many borderlines, and lying, cheating and stealing are simply not characteristic of this group. They are pathomnemonic of antisocial PD, which is its own (albeit related) thing.
Well then that is a huge public relations problem for BPDs because they have a huge reputation for lying and the ones I have known lied maliciously an vindictively. I guess they were misdiagnosed or comorbidity with BPD/NPD or BPD/APD is a huge thing because I could ask any spouse or friend of a BPD that I have known and they would say that they were fantastic and persuasive liars.
Very much so, unfortunately. Thank you so much for takin the time to answer questions. Its a huge split with “victim sites” vs “bpd support sites” and confusion on this. “BPDs are lying, conniving triangulating monsters to avoid like the plague” vs “fragile, hurting people that are too sensitive and just emptionally dysregulated.” Big issue.
Thank you again, this is one of the most interesting and insightful ama I have seen.
Im on a phone and not quite sure how to post links on this app. My apologies. Not trying to tell you to “google it” but thats the best i can do. So with that said…
Google “BPD lying” You can search Reddit for “Borderline Personality Disorder, Sick or Crazy Asshole” Its an article with a lot of comments from people. Google The Last Psychiatrist for his writings on Borderline Personality. Shari Schreiber’s stuff. Shrink for Men (shrinkformen.com) is a website devoted to men involved with BPD and NPD women and advises men to avoid these people like the plague. These are all sites devoted to avoiding these people. Psychiatrists and Psychologists with tons of experience painting an entirely different picture of the disorder.
You have the BPD support sites though, (bpdfamily, for instance) with the typical Walking on Eggshells line of reasoning that BPDs need emotional support and love and structure and how to avoid their triggers.
It’s almost like the DSM is describing an entirely different disorder from what you encounter “in the wild.” Even searching reddit for “Borderline Personality Disorder” is nothing but horror stories. What its like to be a child or a partner and the abuse they suffered.
BPDs are notorious for triangulating and completely snowing therapists so I guess my concern is that maybe psychiatrists are getting a sanitized version of BPD. Since there is a lack of self, it sort of stands to reason that they might just be learning to become the “perfect patient” in the office and a more efficient terror at home.
Thank you again.
This is super! I think you are taking this discussing in a great direction. Somebody, someday, should put together a conference where this gets hashed out with all participants treated as equal members.
For what it is worth, I’d be willing to bet dollars to doughnuts (whatever that means) that people who have NPD are being misdiagnosed as BPD and then the BPD diagnosis is getting NPD’s bad name. I just taught a class this AM where I told the class that I think ~50% of all PD patients are NPD, and BPD makes up only 30%. But reading the popular press you’d think BPD >> NPD. As far as people saying to avoid relationships with BPD NPD, that’s ridiculous. It’s like saying “don’t try to climb Mt. Everest.” I mean, talk about splitting! People with personality disorders are people with a lot more to them than their condition, and people without personality disorders have tons of problems so far as I can tell. If you are in love with someone, you work with them, and who’s to say that the depth of the relationship you produce, having helped someone through BPD, isn’t worth everything? I don’t know, I am from the school of thought that says life is more complicated than “avoid people with BPD,” and would want the people saying it to take some serious time to explore their own thinking. It is likely they will emerge as engaging in pathological thinking and devaluating and projection and denial. We’re all just people. Thank you for the heads up, I will look into the horrible publicity, but I stick to my guns: it says more about the publicizers than the patients!
Okay posting my questions individually for you now.
While DBT is the most commonly heard of treatment, what is your opinion on the type of therapy that uses replaying situations in your head to train your brain to use different pathways in order to stop the cycle of jumping to the most comfortable ( and usually most damaging) response to a stressor?
That sounds reasonable. I don’t do that myself because it is a CBT based approach. I focus on my relationship with the patient, and if there’s nothing between us at the moment, on her relationships with others. But there’s nothing wrong with that approach a priori, though I doubt it can get anyone all the way better.
Do you think the parameters of BPD need to be reviewed in order to lessen the stigma that those with BPD face? I work in mental health and still those suffering BPD seem to face the most stigma as they are immediately labelled manipulative or criminal.
Jeeze, I’ve never seen the criminal label. You run with a rough crowd! Manipulative, sure, but not in an antisocial way. Borderlines are focused on rejection and love, not humiliation and power. I don’t think medicine should change diagnostic criteria to meet social goals. Pressure needs to be put on society to rethink its values, ala the sea change we’ve seen in our attitude towards homosexuals. It’s doable, but will probably take another generation or two.
Goodness no! With good treatment she would be easily in position by her 30s to have a healthy relationship and get pregnant in a timely manner. This is a treatable condition! She just needs to find someone who specializes in BPD and has really seen what it takes to get someone from bad to better!
Wow, never thought about it. I can say that clinically very few of my BPD patients have had abortions, and that of the sum total of all my female patients, most of the ones that have had abortions have not had BPD. Finally, I would say that most of the women I have known who have had abortions do not have any mental illness (that I know of). I really don’t think there is a connection between mental illness and abortion.
They tend to be intuitive and emotionally intelligent and socially gifted. Most seem to do something with lots of interaction with others, often something creative; art, writing, psychology, media, social work, public interest work. But it really depends on their talents and ideals.
Hi Dr. Peter Freed. I’m a student applying to medical school interested in Psychiatry as a possible field. Do you have any hind-sight/advice to share for someone of my generation? What do you see as the greatest challenge for Psychiatry in the coming years?
Also, schools of Osteopathic Medicine are growing in numbers in the country. What is your opinion on students applying the DO route in addition to MD? Is discrimination as true as the pre-med community touts?
Hi! I think psychiatry is a growing field, gaining in respect outside medicine, respected by other physicians (if only the first time they encounter a psychiatric patient on their service and need our help), and a great way to go. I don’t know abou the greatest challenge – maybe just the same challenge it’s been for a while now: synthesizing and integrating somatic treatment and psychotherapy. And continuing to figure out how to make treatment outcomes less a reflection of the particular shrink you see and his/her particular idiosyncracies. There is still way too much diversity in treatment approaches – especially because there are so many cooks in the psychiatric kitchen. I personally have a lot of respect for DOs. I think the degree could really help someone be a great psychiatrist and bring a great perspective. That said, if you care a lot about prestige and want to be the chairman of a department, etc, I can’t see DO ever equalling the prestige of the MD degree within medicine – they will always be seen as second bananas as a group. That’s just typical lame social dynamics having nothing to do with actual training and ability. Many MDs think, when they hear you have a DO, “oh, couldn’t get into medical school, eh?”. But as individuals they can be respected just as much as anyone, and as with everything, once you prove your mettle people forget about your degree and think about you. Over time you’ll find nobody you work with will even really remember what your degree is – it will be your work product they care about. And of course some patients will actively seek you out because of the DO.
It depends on their flexibility. Most therapists have 1-5 sessions/week that open up because of scheduling changes. So if you can say to the shrink “I’ll take the next available one – call me anytime” it will happen soon. I’ve never made someone wait more than 2 weeks, and usually it’s within 5 days for me. HMO shrinks may be less flexible.
I mean, there are people out there that think have mental issues but are not sure. How much time does it take a patient to go see a therapist for the first time, since they started thinking about it?
I am 22 and I’ve been wanting to go see a therapist for at least 4 years.
You should go as soon as you think it might be helpful. Go to someone who already has many patients, so that they will not just say you need a therapist when really what they mean is they need patients. Go to someone who has no motivation to say you need treatment save when it is true – at a university medical center, for example – and get what is called an “initial evaluation.” They will give you a diagnosis, a prognosis, and a plan. Make sure you understand their reasoning after they evaluate you. There’s no harm in going and you should learn a lot.
I have schizoid personality disorder. I also have an intense interest in psychology. Is there any chance I could become a clinical psychologist, or should I just stick to research? I’m horrible at interpersonal relationships, and I don’t experience emotions on a normal level, but I figure that being objective and not easily attached could be an asset to a clinical psychologist. What are your thoughts?
It’s hard to say; it depends a lot on you. It also depends on the type of treatment you’d do. For example, you might do well dispensing very structured, manualized CBT treatments; you might also be great at working with patients with schizoid PD. From what you say you would have less of a natural fit doing transference focused psychotherapy for borderline PD, where the rapid flux of emotion is both the focus and the tool you would be using (in the form of countertransference).
Well, they definitely need a way to connect! They also present with Axis I disorders. Improving screening for Cluster A would be a very worthy career, and one that many mental health professionals would appreciate. We all know it often gets missed.
People with borderline personality disorder experience rapid and unpredictable shifts in their self esteem; sometimes they like themselves, sometimes they can’t stand themselves; sometimes they feel they deserve better; sometimes they feel they don’t deserve anything. They can be consumed with shame and hopelessness, and can also feel intense anxiety, sadness, and anger. Sometimes they lash out at those they love most, thereby pushing them away, only to regret what they’ve done when the damage is done. They are exquisitely sensitive to rejection, and at their worst can do things that hurt themselves – cutting, binging, purging, acting out sexually. With help, and time, and love, they can get much, much better.
Yes: rejection sensitivity. Almost all borderline patients report feeling very sensitive to exclusion, mistakes, shame, humiliation as kids, and to having difficulty keeping their moods calm and even positive in the face of social stress. Often they misperceive rejection, thought they were being rejected when they weren’t, and so induced (in the form of a self-fulfilling prophecy) the very rejection they feared. Sometimes, in an effort to pre-empt rejection, the borderline patient will herself reject others. After puberty, this rejection sensitivity begins to severely affect love relationships in addition to friendships and family dynamics.
The single best sign of an unhealthy relationship is unhappiness. If one (or both) partners are feeling miserable, stuck, or wanting to get out, there’s something wrong. If both people are happy and feeling lucky – good relationship! Sometimes things get tricky when, as in codependency, someone is drawn “like a moth to the flame” to stay in a relationship that makes them unhappy. Other times things are tricky when the relationship fluctuates from very unhappy to happy – a “push-pull” cycle of breaking up and getting back together. In the simplest case, a borderline patient’s cycles of rejecting and then yearning for their partner get the partner on a yo-yo where they can’t leave and can’t stay. That’s a good time for the partner to get some psychoeducation to figure out what it means to them to be in this relationship, learn some skills for boundary setting and self-preservation, and decide how they’d like to handle things. In my experience, if the troubled person wants therapy, that’s a great sign. Staying in a relationship with a troubled person who denies that they have problems is more dicey; it’s rare for these people to suddenly change, and so the relationship can stay chronically unhappy. Obviously if there is physical or emotional abuse, the partner should be encouraged to separate and reassess, and if there are children involved they must be removed from the house if they are being endangered emotionally or physically. That requires assessment by an outside agency eg child protective services.
Would Adult ADD be classified as a personality disorder? My doctor gave me a prescription for Adderall but I hate the way it makes me feel and haven’t noticed any change in my thought processes or behavior when I take it. I’m at the end of my rope. I’m 23 years old and have always struggled with school. I just want to be like everyone else, I am sick of watching my friends move on with their lives and careers while I am stuck taking 1 step forward and 2 steps back. I got the prescription from my family physician, I’ve never been to a psychiatrist before. I’m just tired of feeling like a loser everyday.
This is a good example of the kind of post I can’t respond to after the first sentence; it’s all personal about your particular case, and I don’t want to trigger a doctor-patient relationship. Apologies in advance. Adult ADD is not considered a PD, because when that is all that someone has, a stimulant medication clears it up quickly. PDs are persistent, global patterns of social dysfunction that involve confusion about identity and difficulty managing a range of emotions. ADD isn’t that. That said, many patients with PD initially present with ADD, and only after a careful history does the MD realize there may be a PD as well.
Err? I have adult ADHD, I was diagnosed at 26 or so. I’ve tried every single type of medication they had, NONE of them worked. Ritalin actually made me MORE hyper and made my heart race. One made my penis stop functioning so that was a no go. I went to psychiatrists for 6 months testing everything they could, nothing worked. I’m still having issues with it and can’t really work.
The only recourse they’ve given me is: hit the gym and do a healthy diet with low sugar.
Sounds too close to an actual case. But I can say this: if someone walked into my office with that as their “chief complaint,” I’d have to take an hour and half long history, with tons of questions and answers and anecdotes along the way, before I would give a recommendation. Good treatment is based on really knowing your patient.
People with schizoid PD are often called “loners” in the popular press. Clinically there is no “cure” for schizoid PD. What that means is that people with this condition are not likely to change their underlying tendency to not “need” as much human contact as people without the condition (sometimes called “neurotypicals”). But the condition doesn’t change for the worse either; it’s a stable personality style. The treatment options tend to revolve around helping the person improve social functioning by learning to read social cues and understand how others may experience them. EG, the schizoid person may “just want to be alone” and not realize that this preference strikes others as a kind of rejection, and even offensive. Some of the same techniques as are used to treat Asperger’s can be useful. In my work, I try to help patients not slip into feeling paranoida about others, and also to work on building one or two really close relationships. In severe cases this can begin by getting a pet, which can be a wonderful introduction to social relations. Often I become the main relationship in their life, and by sharing my own feelings about them, and listening to theirs about me, the patient gets a chance to work through – in “slow motion” – interpersonal interactions that just go too fast in regular life.
Are there any genuine online tests you would recommend for (any) personality disorders?
Someone told me i was passive-aggressive and when I looked into it, the different theories confused me and I haven’t had a definite answer for diagnosis and treatment. Without seeing a psych, how would I know I am passive-aggressive? I almost feel like the denial of it might be a symptom.
How is passive-aggressive pd treated? I’m expecting you might say it’s different depending on the individual but just even the vaguest outline would help … thankyou in advance.
I really don’t know any good online tests.
I don’t diagnose people with that condition, because I don’t think it’s “fundamental.” Typically passive-aggressiveness turns out to resolve into other conditions which are more fundamental.
Also, you don’t have to have a diagnosis to be treated. Passive-aggressive dynamics are best treated with a psychodynamic psychotherapy that explores what scares you about being direct with people. And of course most of us are passive aggressive from time to time. Sarcasm, for example, is a form of passive aggression.
I can’t answer much more because the rest of your question is too specific to you. If you reframe it in a more general way I can try to take a stab at it!
Thankyou. I think you’ve answered it really – I need to get more specific professional help. I have a good idea of why I am the way I am, I think I’m just terrified of digging it all up. But that’s therapy all over isnt it? lol Thanks for replying.
Is psychiatry a form of social control? Are you paid to drug the problematic aspects of society? The main correlates of mental illness have long been proven to be poverty and disempowerment. Psychiatry seems to propel that injustice, placing the illness in the brain of the individual rather than the broken history/society they were shaped by. There are many women’s lib publications challenging the abusive use of the the diagnosis – BPD – with no evidence ever produced to support the diagnosis even exists beyond a normative adaptive response to serious trauma. I imagine it a tautology for a psychiatrist to be able to entertain these arguments beyond acknowledging that they exist.
Yes and yes. Psychiatry is a form of social control and we are paid to drug the problematic aspects of society. But that’s not all psychiatry is. For example, when someone gets laid off by Bain Capital and develops a major depression, comes to me, and gets put on Prozac, I am treating them for a problem caused by Mitt Romney, in a certain sense. But then again, I don’t really have the option of calling him up and talking him into buying back the company and re-hiring my patient. From a practical standpoint, I am left with the choice: to treat or not to treat this particular patient?
Now to make the scenario more interesting, let’s say this patient develops an atypical form of depression common in men in which his symptom isn’t sadness but anger. And let’s say his anger is leading him to want to start a protest movement to shut down Bain Capital. And let’s say his plan is to make Mitt Romney look like such a jerk that his political career gets shut down before he gets nominated for President by his party. And let’s say Ron Paul wins in his place. By medicating my patient I am throwing the nomination from Gingrich to Paul. So what should I do? Let’s say I like Ron Paul; should I now medicate in order to give Romney the nomination or not medicate to give Paul the medication? Or is the whole anecdote impossible to think about usefully? Most shrinks think it’s just impossible to think about the anecdote at a moral level, and assume the hippocratic oath requires them not to think about it morally. We’re taught that if the guy in front of us is depressed and we can help him, we should help him, and let history take care of. It doesn’t mean there’s no historical or moral or social context or implications – even dire, or wonderful implications – to our actions. It just means we avoid thinking about them, and then acting on these thoughts.
As far as your middle point about BPD being a normative adaptive response to trauma, I think that’s interesting, but few of my patients have had physical or sexual trauma. Most have had emotionally complex childhoods, with one or both parents having empathy deficits (for reasons of their own). But I fully agree that all psychiatric diagnoses are wrapped up in social norms. Famously there is no physical exam in psychiatry, and there are no physical or biological criteria for psychiatric diagnosis. That supports your contention, which I agree with, that psychiatric diagnoses are historically informed. In 20-30 years, when the research domain criteria (rdoc) (here:http://www.nimh.nih.gov/research-funding/rdoc/index.shtml) have replaced the DMS criteria, everyone reading this now will see how right you are: many current psychiatric diseases or criteria sets will have disappeared. Which will raise the question: did the people carrying the diagnoses have social diseases? I say, largely, yes. But some illnesses – schizophrenia, obsessive compulsive disorder, others – are likely to survive in a clearly recognizable form.
Therein lies the problem, in my view. They were sent to you for ‘treatment’, so that’s what they got. It seems counterintuitive on every level to join the dots between losing one’s job feeling depressed and receiving a drug for a hypothesised neurological illness (especially as emerging literature suggests antidepressants are ineffective beyond placebo in all cases except severe depression). If I lose my job, as a man in the Western world I would expect, at this point, to feel depressed, at that point. I would expect that being provided an equivalent job, with a hypothetical mechanism for triggering self respect, would be a very successful treatment. However, the systemic context of the feelings and behaviours are dismissed in favour of a model that suggests disease and the need for a pill – a social panacea. Does the individual then recover? The US statistics on long-term antidepressant dependence suggests not. Pills don’t equal income and status, it seems. Odd that.
Psychiatry treats symptoms, fails to cure and has created a system for supporting a disease model that justifies high salaries and huge profits for psychopharma.
The logic has no logic. Treat psychosomatic illness with drugs. Treat a childhood of poorly empathising parents with drugs. The list is endless.
All this being said, your light style of reply is refreshing for a psychiatrist. I’m pretty stubborn in my views, seeing a place for psychiatrists in supporting more holistic treatments involving community based psychological and social support. Unfortunately, they often lead teams and simply don’t have the training to see beyond the medical model. I’ve worked with too many psychiatrists, and taught a fair batch, to see this in reality – sadly.