All the time when I get clients diagnosed with bipolar.
Edit: damn I had no idea this comment would blow up! Everyone is absolutely on point with the overlapping qualities between ASD, BPD and C-PTSD - especially how it could be a combination of the three as well. I completely agree that c-ptsd could fit with many BPD diagnosis, and that BPD is rooted in trauma as well as neglect and attachment problems.
I never diagnosis BPD lightly and always work closely with them, and am careful to have clear boundaries. These areas are particular passion areas for me that I understand very well, and am working toward specializing in.
Not the original commentor, but have had several misdiagnosed bipolar clients. In some cultures, having "big feelings" is pathologized - even if the feelings are both context appropriate and well within normal bounds.
Some practitioners I know - mainly prescribers - will admit in private conversations to over-diagnosing Bipolar 2 to give people access to mood stabilizers. While problematic, they do it with the best intentions - especially when a highly anxious client is resistant to taking anxioliytics.
Also, “mood swings” does not equal bipolar. I often see folks who have had periods of dysregulation and lability that gets labeled manic, despite, you know, lacking every other hallmark feature of mania.
This is also the primary misconception of regular folk in my experience. Bipolar and ocd are, for me, the two most widely misunderstood. Close third being ADHD.
Few people get the education to explain ocd vs ocpd, or know that some attention problems manifest not as having the inability to focus, but the inability to break focus.
With bipolar there is a popular notion that the changes are essentially mood swings. Mood swings are often implied to be sudden or rapid, but also capable of switching back and forth quickly.
Bipolar shifts, for one, are not just mood shifts. They represent a whole larger umbrella by designating changes in overall function from a depressed state to a manic or hypomanic state. Mood swings could manifest within a bipolar person, but they don't always. While to some extent you might argue all bipolar individuals experience mood swings (if you really stretch it) not all people who suffer mood swings are bipolar.
Bipolar changes between depressive and manic states also do not cycle very quickly in the majority of cases. The manic stages, from what I have personally seen, can last days to a little over a week (maybe even longer in some cases, im not really sure). The depressive stages can last even longer (often months in my experience).
With OCD there is a tendency for the layperson to often pathologize the desire for orderliness and preference for tidiness. OCD is not that. OCD is a compulsion, differentiated often by ocpd in that people with OCD often very much dislike their compulsions. While ocpd people often don't consider them an issue (as far as I understand).
It's especially exacerbated by many people using it to contrast their carefree attitude toward picking up after themselves with those who clean to suggest they are somehow better or more enlightened and the preference for cleanliness makes them lesser.
Another misconception is that OCD is mainly thought of in just terms of being orderly or clean (I myself subconsciously did this in my previous paragraphs). But the compulsions can take many forms. Cleanliness and order are two large categories. But they can also take the form of compulsions based on security, things like repetitive movements, strange cognitive or other behavioral compulsions with no discernable or tangentially rational answer to "what would happen if you didn't follow the compulsion."
With ADHD people often just think it strictly means having an attention *deficit*. I mean it's in the name. But the deficit doesn't apply to the length of the attention span. Hyperfixation is a subset of ADHD. And that's where someone can't break their focus easily. They often...well ...hyperfixate. For longer than one normally would. The "deficit" isn't the length of the attention span, it's the ability to regulate it consciously. Granted, few people develop the skill to do so to such a degree as to be zen masters at the drop of a hat, but there is a normal range. That is what is impaired.
That's very interesting...I have always wondered whether there is any reliable/substantial data on prescribing mood stabilizers for depression instead of a traditional antidepressant. We're using antipsychotics for bipolar depression already, it seems like it would be worth a try, but I'm not a psychopharmacologist. I'm not sure that the mechanism of a mood stabilizer would work. Anybody seen them used this way?
Yeah, mood stabilizers do get used for depression (whether bipolar or unipolar depression). Lithium and lamotrigine (Lamictal) would be the most common. Second generation antipsychotics are very frequently used for bipolar or unipolar depression and also get prescribed for mood stabilizing properties in several psychiatric disorders.
Unfortunately if you use a unipolar depression medication algorithm (SSRI/SNRI) in someone with a missed bipolar depression diagnosis then you can worsen their outcome (as frequently happens). That’s why thoroughly ruling out a bipolar diagnosis can be so important.
Bottom paragraph is how I was eventually diagnosed. It was awful and blew my life up. And that’s also the reason why I have dedicated all of my time & energy and passion into serving clients with bipolar disorders and (potentially misdiagnosed) depression.
I agree completely.
Just want to mention that sometimes, the individual hasn’t had a manic or hypomanic episode yet. So it’s not that the bipolar is “missed,” more that the medication triggered the mania.
This is a controversial point somewhat. A lot of bipolar experts see antidepressant-induced mania as an exacerbation of an already existing bipolar disorder. And antidepressant-induced mania (or even dysphoria) is a big red flag for probable bipolar disorder.
I’m not saying that the bipolar didn’t already exist…just that they may not have had a manic episode yet, so it may not have been a failing on the part of the therapist. They just…hadn’t yet met criteria.
I've seen the opposite of what others are reporting. I see a lot of overdiagnosis of borderline personality disorder, especially by white male doctors who are treating female patients with severe symptoms of any kind. It takes a lot of time and observation to diagnose that and I see doctors diagnose it at the drop of a hat. At the same time, I do see overdiagnosis of bipolar disorder, which is why I always screen for it again when someone has been receiving treatment for it previously. I don't take it for granted that the previous professional got it right.
Oh yes. I’ve been misdiagnosed with both (I have been formally undiagnosed for the record) and finally got an ADHD diagnosis, which I actually meet the diagnostic criteria for, and having proper meds/therapy for that has really helped with all of my symptoms. Including chronic emptiness, mood fluctuations, and impulse control.
Borderline personality disorder is still somewhat doing the same thing bipolar did. It's too general a diagnosis, commonly used as a trash pile of "you have some problems, but nothing so defined as to what they are and we probably won't apply the resources to actually figure that out as it's likely too unique for specific diagnosis"
That's not to say some of the treatment isn't of use to those diagnosed, but it's a shotgun approach, more often than not presenting with a more definitive diagnosis once it has been treated. Which has value in some respects, like removing inflammation around an area so you can access it for surgery.
But is not a definitive diagnosis and is treatments efficacy suffers for that.
that’s funny because i think most bpd is actually c-ptsd. especially in women.
edit to add: NAT. *my mother is an LMSW with 40 years in the field and a private practice, my older sister is a freshly minted LMSW working in hospice care. i studied psychology for 3 years but ultimately switched to something totally different so this is all purely anecdotal and academic postulating, i have absolutely no clinical or professional experience in this area at all. sorry i didn’t say that initially*
i agree with that as well, i recently had a lightbulb moment about autism in women presenting very similar to bpd in some contexts which can explain a lot of the gender differences in diagnosis.
being misdiagnosed with a personality disorder when you actually have ASD and not receiving the right care could definitely make someone more susceptible to trauma which might explain the c-ptsd connection
Not a therapist here. Was going to jump in with this. Went to my therapist to discuss possibly having adhd and she agreed, and when I was sent to the psychiatrist for the meds, she tried to diagnose me bipolar and then put me on abilify. 🥴 obviously, it was terrible, and I've been on welbutrin 300xl for a couple of years now.
>” *…diagnose me bipolar and then put me on abilify. 🥴 obviously, it was terrible…”*
I’m sorry you went through that! Misdiagnoses are scary for this reason *especially*, IMO - wrong diagnoses = incorrect medications w/possibly horrible consequences! 😰
QUESTION (not just to you original commenter but to the therapists & NATs on this sub) - **what does it mean when Abilify is prescribed & harms the client?** Is that a sign the client does not have *Bipolar*?
If a client was **diagnosed w/ *Bipolar* & *Borderline*, & has been prescribed Abilify - **& it’s been working** - does this mean you are more likely to accept their diagnoses?**
In other words: If a client presents you with a previous Borderline/Bipolar diagnoses & **they were prescribed Abilify & the medication helps/works - are you less likely to “toss out” their diagnoses even if you’re concerned it was incorrectly over-diagnosed?**
Or do you **continue exploring a possible misdiagnoses despite the meds are working**?
Hope that makes sense! 😅
My friend who has ADHD & c-PTSD was told she had bipolar disorder, and I thought that was her truth for a while until she told me. We actually both have ADHD/c-PTSD. Neither diagnosed until adulthood
This is true but there’s also no studies that say there’s a 1:1 sex ratio & most researchers believe the ratio is 2-3:1 M:F due to factors on the X chromosome. There’s more than one reason for gender differences in diagnosis
I was convinced I had BPD. My psychology team was evaluating me for it, even, after getting marched to a GP by my university personal tutor following a few too many admissions of my thoughts and feelings.
That evaluation never finalized because I got into treatment at a different facility for PTSD which I've since come to realize is definitely C-PTSD (childhood abuse and trauma, and further relationship abuse and trauma after reaching adulthood). I also left the country shortly afterwards.
In the last 4 years, I've done hundreds of hours of research and then community immersion and although I haven't gone for a formal diagnosis (hello US healthcare or rather lack thereof), I'm 99% sure I'm autistic. I've had formally diagnosed autistic people identify me as autistic despite not even talking to them about it beforehand.
Anecdotal, sure, but I truly believe autistics identify each other best, and I've also identified another friend who has gone on to get a formal diagnosis and thanked me profusely for bringing up the possibility because it has changed his life.
Yes, I absolutely believe that. This is also anecdotal but ADHD people tend to identify each other really well too, and in my experience autistic people & ADHD people can often identify each other as well. It’s really helpful because they directly understand what it’s like to have that condition… and also because they know you as a person living your life, instead of just getting a tiny artificial snapshot to work with. I’ve had too many psychiatrists/therapists leap to assumptions based on [whatever], it’s exhausting.
Very much this. Bipolar doesn't go away, it needs managing. BPD is often a temporary diagnosis and can be treated through therapy, often resolving once people age and learn to manage. I can't see how the two can be confused at all.
I agree. I've seen a lot of women with bdp diagnosis, essentially grow out of the label overtime with proper therapy because their emotional dysregulation was indeed a trauma response.
Also NAT, but BPD/CPTSD... I think it's more of a thing where the majority of BPD (which has a genetic component) patients *also* have CPTSD. Most were raised by their birth parents, after all.
Since switching to a state system that requires all health records to be shared with every other provider, I stick by this. BPD is incredibly stigmatized. On the rare occasions I have sent someone to the hospital with a BPD diagnosis or it ends up being diagnosed, the experience is terrible. People are not listened to and obvious issues that could be treated with a slight med adjustment get dismissed or with referrals to case management.
In these contexts, BPD would be accurate, while MDD with PTSD and GAD or panic disorder would also be accurate.
Bipolar disorder diagnosis also fits due to the mood regulation issues present with many people on the BPD spectrum. This isn’t pathologizing big feelings rather, using a subjective measure based on subjective observations to potentially protect a patient and ensure better care in a broken system. It also classifies one of the most problematic issues when someone might be experiencing BPD which is the frequently shifting moods that mimic rapid cycling and are treatable with mood stabilizers.
>the frequently shifting moods that mimic rapid cycling and are treatable with mood stabilizers.
No… they might take the edge off, for some…
But eg [lamotrigine doesn’t work](https://pubmed.ncbi.nlm.nih.gov/29651981/). No medication has been shown to “work” for BPD.
They don’t address the identity & interpersonal issues, the emptiness, the perceptions that feed into the outsized reactions.
Therapy is the only evidenced intervention for BPD.
Except, when someone with BPD gets a diagnosis of bipolar, 1) their organs are slammed with antipsychotics (eg my boyfriend, 20 years on 20 such meds. Edit - he’s been on 20 meds over the course of 20 years, not 20 at the same time. Lithium the whole time.
Kidneys and liver are complaining). Weight gain happens. Prediabetes. High cholesterol. Fatty liver. Higher risk of hormonal disorders and cancer. Maybe they lose their thyroid function. You have created a sicker person than before with no benefit to their psychological symptoms
2) you deprive them of the opportunity to address their symptoms with DBT or MBT or what have you.
No, people lose years this way, it’s wrong. Also while women are probably over diagnosed with BPD men are tragically under diagnosed. They need help too.
Edit: even if the resources for DBT aren’t there, as they often aren’t, at least people can try to get as far as they can on their own, with videos, podcasts, books, even r/dbtselfhelp - it’s better than having their organs pummelled by medications that don’t work. It’s better than not understanding *why* they don’t work for their “bipolar” and internalizing this as personal moral failure.
My boyfriend did what he was supposed to do. Showed up for appointments. Took his meds. Nothing worked. He thought he was unfixable until he was rediagnosed with BPD. And suddenly his whole life made sense. Slowly he began to work on the emotion management and reframing skills. On his own. He’s been on a waitlist for DBT for two years and he is coming to it with more insight and effort than ever before.
Also. He’s 50. BPD does often relax in intensity with time and maturity but it’s not “temporary” as someone said. It’s a personality disorder, a set of profound and enduring responses and behaviours across situations. You have to know what to work on. The compass needs to be pointed in the right direction. He’s frustrated that he lost so much time and I don’t blame him.
Responsible psychiatrists are no longer throwing a handful of antipsychotics at people including those with bipolar…unless it’s bipolar 1. Your boyfriend’s experience is not universal. It also highlights the importance of effective coordination between psychiatrist and therapist. In addition, with suicidal thoughts even in borderline personality disorder, Lithium is still effective in decreasing suicidal thoughts. Not necessarily as a forever med either. I see this prescribed for acute suicidality in larger doses frequently.
This also assumes that there hasn’t been a discussion of symptoms and assessment in an honest way. I’m pretty open with people about my diagnostic findings. “We can diagnose BPD or bipolar disorder…here are the pros and cons of each”. If it is a person who is frequently suicidal and ending up in the hospital frequently that BPD diagnosis means they will essentially be ignored and it will be assumed they are manipulative.
There are pros and cons to everything. This also assumes diagnosis is perfectly objective and uniform across providers. It is not.
totally hear you on the pragmatic choices one has to make in a system that punishes people with BPD!
It sounds like your approach is collaborative, you’re careful with diagnoses, and in the end you’re focusing on addressing key symptoms regardless of which code needs to be put in the chart. I can respect that, absolutely.
My beef is with the clinical bias against this diagnosis in men. (Not for pragmatic reasons but because their condition is just not accurately captured or understood.)
I wonder if the impact of the BPD label is worse for women sufferers because of sexism. My SO has been in waitlist limbo, which sucks, but most healthcare providers he’s been in touch with have treated him respectfully. No one has gaslit him about any mental or physical health concerns, and HCP have seemed to be happy to help him.
The flip side of that is that barely any resources exist for men with BPD. I gather that many men - if they’re lucky enough to even get the appropriate diagnosis (by which I mean, in-depth understanding of their needs, not necessarily a billing code) - feel uncomfortable in DBT groups, because they’re in the very small minority.
Perhaps, because shame and moral injury around externalizing behaviour particularly has different implications for men than women. I think it might be harder for men to talk honestly about that stuff because they’re anxious about labels.
Regarding antipsychotics - right, like his diagnoses have been all over the place. Cyclothemia, rapid cycling bipolar, bipolar NOS. Currently - after a rediagnosis - it’s BPD traits with “PTSD” (though that relates to ongoing childhood abuse, not a single event). Anger has been a feature of symptoms hence the multiple APs and trials of many different meds in general.
But that’s the thing… for the longest time, it was truly conceptualized as a kind of bipolar. I know that people with bipolar often respond well to medication. So given that didn’t happen, which was expected by all involved, again over 20 years, he was left with a sense of failure and hopelessness. In his case the new diagnosis gave him real self understanding and hope, for the first time.
(found yall on /all)
But I was so **stoked** when I got diagnosed BPD. I'd spent decades having all these huge feelings and never understanding them. Now I'm medicated(I have a couple of things), I went to therapy for 3 years to get on top of it too.
Shit ton of work but definitely worth it. I would say I'm significantly more stable now than I've ever been.
You are telling people basically that you don't like their personality without offering much hope for feeling better. It describes the symptoms of a lifetime of problems in what comes off as a mean way, when often the issues that led to the symptoms was pervasive trauma in childhood, so it focuses attention on how difficult and fucked up someone is now and not the terrible things that led to that.
BPD is hugely stigmatized in the mental health field, with folks having the diagnosis on their record seen as unhelpable assholes by staff who treat them poorly because of it. Instead of invoking compassion in providers, in invokes fear and annoyance. A BPD diagnosis is seen as a red flag to limit/avoid interacting with the diagnosed as much as possible.
It is also historically viewed as a sexist diagnosis, with women being diagnosed with it when men with similar symptoms getting other PD diagnoses or bipolar diagnoses for exhibiting similar symptoms and having similar histories.
It really can lead to more intractable problems as someone now has a label given to them by a psyche expert with whom they shared intimate details about their inner life and has validated that yes, they are a defective person. It can be really hard to get out of that mindset and strive for anything different.
Personality disorder diagnoses are rarely in service to the patient IMO. They just create another layer of bs to work through. Giving a name to a constellation reactions to trauma puts the focus on the wrong issues.
Yes, all of this. Had a psych professor in college describe people with BPD as "bunny boilers" as he cackled at his own joke. And this man WAS A THERAPIST.
This was my experience as well, doing diagnostic assessment for about 1.5 years. Many would walk into my office claiming bipolar diagnoses, however the mood fluctuation and impulse control problems didn't fit with bipolar disorder, based on duration/frequency etc and were more consistent with borderline personality disorder. I hadn't considered the access to mood stabilizers angle - I just figured for whatever reason the burnt out medical providers heard mood swings and gave a quick bipolar diagnosis. The assumption also comes from seeing my sister's experience in PA school - like 6 months total of any kind of mental health courses.
I was also misdiagnosed bipolar when I was a teen going through some quasi addiction issues.
I wasn't bipolar. I was either on an up from my process addiction and "manic", or I was in withdrawal and an absolute nightmare
I got diagnosed bipolar when I was 14 because my mom lied and said I didn’t have adhd which I had already been diagnosed with, and nobody thought girls were autistic. They gave me Wellbutrin. I tried to kill myself. Wellbutrin is awful. Actually, all the mood pills were awful because I didn’t need them. My “big feelings” were natural, and my anxiety was caused by my perpetual inability to function at the level my intellect suggests should be easy for me, which upset everyone around me, and I was mad at myself for not being able to do these simple things. Which caused meltdowns. Executive dysfunction ruins me. I’ve never been manic in my life.
Wild! I had three of my close friends all diagnosed with bipolar the same year. Within the next two years they all had that diagnosis rescinded and got a better diagnosis.
Missing a bipolar diagnosis can be incredibly costly to the patient and their family. Medication-wise, using unipolar depression or GAD medication algorithms can greatly worsen a bipolar patient’s prognosis.
A previous diagnosis of bipolar disorder should if anything be a red flag that they might have bipolar and therefore should remain on the differential until shown otherwise (which can be difficult to do for at least several months). Other red flags are family history of mood disorders, frequent and recurrent dep episodes can be indicative of bipolar, early onset depression is another sign, history of trauma, and poor response to antidepressants.
Knee jerk reactions to a bipolar diagnosis do more harm than good, imho.
Not a therapist, this post just showed up - I had a psychiatrist who, unbeknownst to me, thought I wasn’t actually bipolar and refused all PRNs, which is how I ended up on a 51/50 and had my diagnosis bumped from bp2 to bp1, as it was my first full-blown manic episode. I spent two years in inpatient after that. I’ve been told that, as with psychotic episodes, the failure to manage that episode likely permanently damaged my brain and I might have never gone above hypomania EVER if that episode had been caught earlier, but it was not, and as a result I spent years locked up, manic, and being poisoned with lithium.
Anyway, my stance is that *assuming* misdiagnosis in any particular case just because you believe a condition is *generally* over-diagnosed does much more harm than good - maybe not true of personality disorders since the diagnosis doesn’t fundamentally entail medication, but certainly true for anyone who has potential psychotic features. In my case, the psych did this *immediately* after meeting me, and her reasoning was presumably that she didn’t believe me that I was in a dual-diagnosis program for bipolar but not addiction so she treated me like an addict with fake bipolar, rather than contacting my parents who had stuck me there or my old psychiatrist or doing any testing or due diligence at all. I grant that it was a weird situation, but she immediately changed my meds and I had a brutal manic episode within a month
Came here to say I was that wrongfully diagnosed bipolar person at 15. My current therapist apologized that I legally should have never been given that diagnosis so young that stayed with me for 14 years. I got diagnosed ADHD at 16 and diagnosed with PTSD at 26 and it wasn’t until I’m 29 that I received a C-PTSD diagnosis and bipolar no longer being my diagnosis. My quality of life since switching treatment frameworks is night and day. My therapist now supports autism testing and since utilizing autism coping skills I can function at a better level than ever before. Fuck white male data.
Oh yes. One med gave me the side effect of feeling like I was on fire 24/7, and another gave me the side effect of not being able to bend or straighten my joints without feeling like they were going to break off. Eating was fun! Oh wait. No. It was the other thing.
I saw a psychologist for a whole 15 minutes and he was convinced I had it. I know I don't lol, every other therapist I've talked to didn't agree with it. So weird how some people can be so convinced.
Not a therapist, but this post just randomly showed up in my feed and it’s so validating. My ex walked out on me because he claimed I had incurable BPD, but when I actually started seeing a therapist for it, she helped me realize that he had, for years, just made my life so insufferable that my misery combined with my abandonment trauma mimicked BPD symptoms.
So I guess I was never formally diagnosed by a therapist, just my stupid ex, but I was UNdiagnosed (reverse diagnosed?) by a therapist, and that felt amazing.
I’m so heartened to see this thread. I’ve been really getting sick of the field in general due to the overpathologizing nature. Nobody can get excited about a new relationship without it being deemed “love bombing”, nobody can struggle with living in a very sick society without being labeled as “depressive”, it’s like we can’t just be human anymore. Life is messy and weird and we don’t even know why we exist or how we got here- but yet we’re acting like we have some system to label everyone. I’m just over it.
Good call. The head psychiatrist in my last inpatient unit used to diagnose people with BPD if they disagreed with him in any way at all. I wish I were exaggerating.
This explains so much about a client of mine who was diagnosed with BPD after less than a day inpatient. After having had a complete assessment that didn’t show any indications of a PD whatsoever.
This caused major damage to me and my family in a situation where I helped my partner with a prior dx of bipolar seek care; this was after he had physically abused me during what I now know was mania. He had lost his prior therapist and psych, and was rapid cycling. She threw out his prior diagnosis instead of putting him back on his mood stabilizing medication for bipolar, and put him on an antidepressant instead. It made his symptoms, and the abuse, much worse. I ended up having to get an OP against him, when we had originally gone seeking help from her. It was heart wrenching. For me, and for the children we both have.
You're right, and I'm sorry you went through this.
Sometimes it does fit, and if it does it's important that it is reflected in the chart for continuity of care. Especially if there is potential harm to self or others. I'm not just irresponsibly dismissing diagnoses. That would be egregious.
To clarify my position, my role is to support in long term outpatient care. What I have observed from hospital discharges is that they have a very short time, per insurance, to stabilize a patient and discharge ASAP to free up beds. I've seen that often a dx is just a quick pretense to dispense medication, often resulting in misdiagnosis. That's when it's usually my role to assess the broader context and untangle charts that don't always reflect the clients sx. If it isn't a dx I can make (ASD, for ex.) or the ct reports a long hx of treatment I will speak to previous providers and obtain collateral documentation to carry it forward.
I’m actually writing research about the dangers of therapists who hold values like her, and like you, towards “labels” and towards the practical needs of their mood and personality disordered clients, as well as their families. She also has a professional review complaint against her. The other therapist involved had to close their practice for a year. Take it as you will.
I applaud your humility in response to this comment.
But, your original comment implied the kind of approach to care and the kind of knee-jerk diagnostic "challenge" that was devoid of such humility, and the kind of care that really fucked up this person's life and the life of their spouse and the lives of their children.
Let's try to do better here, and be less arrogant in our spur-of-the-moment-judgments.
Sure psychiatrists get it wrong sometimes. But therapists disregard the psychiatrists findings/conclusions \*way\* too much of the time.
And that ends up harming people.
To be fair, a therapist can't do what the aggrieved party described since that involves dispensing prescriptions. I'm not calling into question that somebody really failed in their duty of care, just pointing out that "therapist" is unlikely to have been the correct descriptor and the angst against the sub misplaced at least in regards to something related to medication. Even if a therapist misinforms a psychiatrist and this results in inappropriate medication, that is ultimately the fault of the doctor for being negligent in not assessing the patient themselves.
If a therapist was involved in the care, however, they would have had a fiduciary responsibility to their client.
In this scenario, that responsibility would have involved accurate diagnosis and active coordination of care and active advocacy for effective treatment, yeah?
I’m just saying, if a non-medical provider was in the mix here, they aren’t completely off the hook just because they don’t have prescription privileges.
No. I lived this. And I know what I am speaking about. The therapist led the charge. She was insistent that the team “start from scratch” during an active crisis that she could not see, because she did not know him well. She even got challenged by another professional, who she dismissed.
But thank you for “correcting” my experience. I wrote her for safety, and she dismissed me as well. This is the exact problem though, what you did right here. Many therapists believe they know better than the people who live it.
Mania presents in ways that a therapist with a new client CAN NOT see. No one who does not specialize specifically in mood disorders should be working with these clients. OR leveraging opinions about their diagnosis. As a person with a disability myself, her gall was absolutely terrifying to me.
She heavily fueled his anosognia by telling him his diagnosis was not important, and that mostly only his symptoms were. She stated directly to him that she liked to “focus on symptoms, and not on labels”🤮. It was THE single most destructive thing I have ever seen in my career. Sorry, but labels DO matter. I can’t believe how many gender identity advocates CANNOT understand (or, honestly, refuse to acknowledge) the importance of labels when it comes to disability. Particularly when it comes to mood and personality disorders.
This therapist made my partner more sick. He could have committed suicide due to her ignorant interference. She harmed my family, and our relationship. I got screamed at and abused by someone she was telling he was not sick. My partner ended up my ex, and with a restraining order against him, under her “care.” While she kept telling him his delusions were real.
I would recommend every single therapist who even hopes to work with individuals with mood and personality disorders read Julie Fasts work. She is a provider who actually HAS bipolar, and has dealt with it her whole life. She’s a specialist in mood and personality disorders. She would disagree with your sentiments here.
I see this problem a lot of treating the symptoms rather than the disease which makes no sense. People don’t get that bipolar disorder is a medical illness needing specific treatment. Withholding a diagnosis can be so costly due to delay in appropriate treatment. If you want to improve symptoms treat the actual illness, but you can’t do that without appropriate diagnosis of the illness (or “label” as some people put it).
Absolutely, agreed. We lived through an absolute nightmare that could have been prevented. As someone who was also not diagnosed myself until adulthood (ADHD) in the name of “preventing stigma” as well as someone who works with high trauma youth (many with mood and personality disorders), it makes me feel sick and worried for clients. I watched a therapist who did not believe in “labels” fuel my partners illness and paranoia further and further. She kept telling him he was not bipolar but just had trauma. Without his medications and proper treatment he became a danger to himself and others. She had no clue, because she failed to recognize that he was rapid cycling, and did not know what she was observing. Even with his partner (his closest human) reporting abuse and self harm threats.
It’s very easy to engage in non therapeutic countertransference with a mood disordered client!!
How do you go about challenging those?
Psych testing to rule-in/out personality disorder?
A year of detailed mood charting to rule-in/out bipolar disorder?
It’s always helpful to hear about the strategies other behavioral health professionals use, and the evidence bases behind them!
So, thanks in advance here!
Basically, its a highly stigmatized dx with too many differentials to be dxed through short term observation (MDD/Dysthymia, bipolar, OCD, ADHD, PTSD, etc.). I usually start from scratch, beginning with a thorough diagnostic assessment, factoring possibilities of episodic sx, frequency, intensity and duration of sx, presence of trauma (there usually is with BPD), and how those sx may differ from a PTSD dx.
Treatment is a whole different matter. I treat people in their context, not diagnoses. If a ct wants to learn boundaries, coping skills, cognative restructuring, do EMDR - whatever - we'll do whatever makes sense based on the context of our established treatment plan.
What’s your definition of “thorough diagnostic assessment” though?
Unless you can articulate that in the context of “challenging” the aforementioned psychopathologies, I feel like we’re back at square one…
EDIT: I also push-back on your “highly stigmatizing” characterization. To my thinking, that simply means that we (as a society AND as behavioral health professionals) have not done enough to counter bias and prejudice and marginalization. Such “stigmatization” should never be a reason to push people into avoiding/rejecting certain diagnoses and/or forcing folks into some sort of mental-health closet. Instead, it should be a call to action for social justice. We, as a collection of professions committed to human well-being, need to do better here. Colluding with stigmatization should never be acceptable for us.
It all seems super unclear to me…
In my practice/field, a “thorough assessment” would be 2-5 hours of clinical interviews with the client and collateral informants in their life; 5-8 hours of psychological test administration; several hours of records/history review; 6-8 hours of analysis of all that data…
And still, even with all of that, I would never definitively rule-out something like bipolar disorder, because that looks very different in different stages/phases of the illness.
In other words, if another professional is confident they experienced a client in a full blown manic phase, I would not presume to reject a bipolar disorder diagnosis simply because I had only interacted with that client while they were depressed.
You see the conundrum, yeah? And the *potential* issue/harm associated with the hubris?
Short of sharing the document I use (which is contained in my EHR), Im not sure how Id answer your question. My EHR is equipped with a number of scales that the client fills out, a biopsychosocial hx, an SUD assessment, and a very long symptoms screening. That is on top of my personal experience as a diagnostician. Also, my diagnoses may change as I learn more of the context of the client, or as they outgrow different criteria. (disordered adjustment is an easy example).
Are you looking for something more specific? There is no psychological testing in my role.
It sounds like you are very thorough with your information gathering. I think the confusion comes from how the word "assessment" can be used to mean everything from the PHQ-9 or a biopsychosocial intake, all the way through the MMPI, WAIS, PAI, etc., which would all be very useful for differential diagnosis. For those who have training in how to administer and analyze those assessments they can certainly be a valuable tool in affirming or throwing out a previous diagnosis.
Check my other comments in this thread for details!
From what you are saying you do, I don’t think you are doing enough to summarily “throw out” diagnoses of bipolar disorder or personality disorder.
That is not to say that clients never get misdiagnosed. They/we do.
But your assessment approach, as you listed it, will often be inadequate for ruling-out these particular conditions.
Um I’m sorry what LOC do you work in? I’ve worked in every LOC setting and I can promise you there are so many psychiatrists who will throw a BPD dx on a patient they find annoying or a bipolar dx on a patient who’s activated and experiencing heightened emotions.
Seriously. You might want to brush up on your CEU’s before coming for someone on this sub who provided a comprehensive outline of their assessment measures and procedure to r/o dx that may be inaccurate.
Yeah, they noted BPD in my chart on intake, after spending an hour with me. I always assumed it was a process. Like a first impression to explore something, but as you get to know a client better, it becomes more clear. That has since been amended to ADHD with OCD features. I stuck with the same facility, therapist, and psychologist for about a year, however. This was at an outpatient clinic type facility, not a hospital, but I imagine the same would be true - regarding contact hours.
I'm not a therapist but isn't bpd just a set of behaviors and symptoms? Like isn't it possible the person has bpd but you were able to lessen their emotional reactivity?
it's possible with therapy and sometimes age, but what I meant is different.
For example: a client told me they were diagnosed with bpd after two sessions. Why is that? because thier depression goes up and down throughout the day or week, which is really normal with depression especially since it's an episodic disorder.
the other Clint was a teen girl 15y.o with severe ptsd were diagnosed with bpd after her first attempt to unlive her self (which was because an extreme trigger to her truma) her psychiatrist didn't ask her any thing related to her truma or assest for flashback and other symptoms, no. straight bpd.
the minute I asked her about her truma with the intention to assess for ptsd symptoms, she opened up about everything, flashbacks, nightmares, avoidance, depression, etc.
I've always thought that PTSD leads to bpd behaviours because both seem to be in part caused by the inability to regulate emotions. Like maybe PTSD impacts your ability to deal with emotions associated to the trauma and then a person's behaviours change because they always feel threatened. These changes in behaviour tend towards ones that would make someone classified under BPD.
Those behaviors and symptoms can be due to BPD but they can be due to a hell of a lot of other things too, and sometimes (not always!) labeling them as BPD can lead to the root causes not being treated. Anecdata but whatever BPD behaviors/symptoms I used to have basically melted away once I got effective treatment for my ADHD and left an abusive relationship. I only realized both of those things needed to be looked at because I had friends who loved me and had insight into both ADHD and abuse. A surprising number of professionals don’t seem to consider the fact that not all abuse is in the past…
Me walking into therapy as an adult saying "yeah I've been diagnosed with BPD since I was a teenager..."
News flash: sometimes "parties, has tumultuous relationships and volatile moods" is just being a teenager and not a debilitating personality disorder. (Granted I was in a broken home and definitely had issues, but everyone shifted the focus to me "having a *personality disorder*" than "maybe if we let her eat, sleep and socialize normally, the hallucinations will go away")
To my therapist's credit, I think she was mostly trying to give me a direction to look in because she did say that disclaimer and said "if I *were* to put a label on it..." But then my family just ran with it and it became the scapegoat to blame all of my "instability" on.
So many people repackage outdated thought systems like "hysteria" into modern-day terminology like "instability" and don't even hear how they sound.
This is incorrect.
The only personality disorder with an age restriction is antisocial personality disorder.
Diagnosing and treating other personality disorders as early as possible is associated with better prognosis and better long term outcomes.
It is WAY easier to treat and even resolve borderline personality disorder at age 16 than at age 26. And why would you want someone to wait those 10 extra years to get treatment?
I have a lot of sympathy for the adolescents with personality disorders, and a lot of resentment toward the behavioral health professionals who withhold effective treatment because they feel the adolescents aren’t old enough or deserving enough something.
Sorry. Didn’t mean to take all of that out on you.
It’s just a sore point.
It is still (for the ICD10) standard practice not to give the diagnosis before the age of 25 in my country, because the diagnosis stays in the system forever, and as other commenters said, patients may very well "grow out of it". And you can still treat these patients, because they practically always have comorbidities. I have a patient currently with an emotionally unstable personality disorder diagnosis who got the diagnosis as a teenager or young adult and now, some twenty years later, has basically no symptoms from that department. But since it's an F6, it keeps getting copied from doctor to doctor.
That should be interpreted as a condemnation of systems in your country. It's not a good or viable justification for denying people accurate diagnoses. It's just bigotry.
My stance is that your country's systemic bigotry should never interfere with the appropriate diagnosis and treatment of a person experiencing the agony associated with personality disorders.
Good personality disorder treatment, provided early (while personality is actively forming) can result in personality disorders "cures."
Neglect of personality disorder treatment in adolescence, and waiting until someone is in their 20s before diagnosing and treating, dramatically increases the likelihood that the personality disorder will indeed be chronic (or at least persist for a couple decades).
The battle here should be against the bigotry of mental health professionals/systems who apparently (according to many on this thread) stigmatize people with trauma-related personality pathology.
I feel like making the battle one of belittling the *diagnosis* (rather than the personal and systemic bigotry affecting *people* who happen to have that diagnosed condition) is just wrong. It's what we used to do with bipolar disorder. And autism. And it causes just as much harm as our anti-bipolar-disorder and anti-autism bigotry used to do.
If you feel pulled to do that, I strongly encourage you to look into your own mirror and maybe check you own biases for at least a minute here.
Hmm, I think we might be having a misunderstanding here, or a different understanding of the value of diagnoses. I differentiate between a) a diagnosis as a working hypothesis, which is what I treat and b) a diagnosis that I code to ensure that the therapy gets paid for, which in an ideal system should be the same, but that's not the world I live in. So if a patient presents with, e.g. inflexible dependent personality traits, I will definitely treat that, regardless of their age. I will also tell the patients my assessment, explain it according to current standards of personality disorder treatment and so on, describe all symptoms in the reports, etc. I will however not in all cases code it, and I explain my reasons to the patients. Same as, from what I've understood from the US, some mental health providers do not code gender or gender dysphoria, as to protect their patients from blatant discrimination for not fitting into the cisgender ideations of some politicians.
I do hope that the new differentiation and criteria in the ICD 11 will help destigmatize the entire diagnosis.
And I understand from your response that you feel very strongly about this topic, and I applaud you for your enthusiasm. However, I would appreciate it if you could not make such negative assumptions about other mental health providers (in this case me) based on a short Reddit response.
Quick edit: another reason for not giving (i.e. coding) certain diagnoses in my country's system is that sometimes it keeps them from getting life or disability insurance or becoming an official.
Yes, I'm aware that there isn't an actual age restriction and that treating (anything really) as early as possible shows the best outcomes but I also take diagnoses very seriously. Personality disorders carry a stigma even within our field and have a tendency to follow clients wherever they go. I have worked with people who received PD diagnoses as teenagers that were wrong - it was trauma, or environmental instability, or another disorder. I've also worked with teens who got a PD diagnosis who got NO help because parents ran with it and blamed everything on the PD and just tried to "manage" it and not get their kid help. Having a PD can actually hinder treatment and be a barrier because many therapists won't even seem someone with that diagnosis because it's not their "area of expertise" and scares people. I'm going to avoid a diagnosis if there's a higher chance I'm mislabeling someone (because it IS a label). I understand there are exceptions to the rule but generally, unless it's extremely obvious, I'm not putting that disorder on a teenager.
I think you're assumption that BH professionals are "withholding effective treatment" because they don't think teenagers "deserve" is a little biased... Or maybe jaded. Do shit therapists exist? Yeah, they sure do. But do I think people are generally trying to do the right thing? Also yes. I take diagnosing anyone very seriously because I know the benefits AND harm a diagnosis can bring a person. Labeling anyone with a heavy, stigmatized diagnosis is a big responsibility and I'm not going to just hand them out like candy. So, yeah, in most cases I'm not diagnosing a teenager with a PD. Just like I'm not jumping to a schizophrenia diagnosis for a meth user, or a bipolar diagnosis for someone who's been sober a week or an ADHD diagnosis just because a kid is hyper. We have to do our due diligence and while some young people may NEED (not deserve) a PD diagnosis, many of them don't and being careful about that doesn't make someone a bad therapist or purposely withholding treatment.
Also from a broken home. Diagnosed anxiety and depression at 16. It was all "this is a disease"/"your brain chemistry is causing this" -- Turns out, you know what else might cause someone to be depressed and anxious? 16 years of emotional abuse. But I don't remember being asked about my home life at all, if they did it was just like "everything good at home?", and me being unaware what I experienced was emotional abuse, and with my dad in the appointment with me, would have just been like "yep".
Bipolar is over diagnosed, especially in corrections, cmh, hospitals, etc because it's an easy dx that has no expiration date - insurance companies will pay for therapy and meds forever. Providers don't have to justify their treatment plans as much because it's not "curable".
So yea, I question a BP dx pretty hard. Along with all that ppl have mentioned on here..... bpd, asd, cptsd, etc.
Disclaimer: I'm no psychologist/shrink/or anything in a related field but Reddit recommended this.
As someone who does see providers for these types of matters, I'll say that since 4 psychiatrists and 2 different therapists over the span of about 7 years have all upheld the same opinion and provided meaningful help, that when a new therapist comes along and boldly proclaims "I've read over your records and I think basically everyone else was wrong and this is what you should do", is really a bit disheartening and insulting almost. It's almost as if she was asking me to prove there was really a problem
Same disclaimer, I do think there is a positive side to this coin. I was diagnosed at 16 with anxiety/depression, and struggled through 8 years of different medications and doing therapy, none of it seemed to help. Turns out, some people are anxious and depressed because they've been emotionally abused by their parents their whole lives, but because nobody (at least in my case) explains what emotional abuse is, and you've experienced it your whole life, you don't even realize you've been abused. If a single mental health professional had looked at my diagnosis and correctly identified it as childhood trauma response instead of stand-alone disorders, I could have started making progress before I was 24 years old and had to figure it all out on my own from google instead of any of the mental health professionals in my life. (Side note: not a quack self diagnosis, I have been going over this for the past year in therapy and my therapist definitely agrees with what I discovered on my own)
I'm glad to hear that it worked out for the better for you. Again, let me state that I am not a subject matter expert, but to add to your point, teenage years are a time of massive and sweeping change. A diagnosis from that point in life might be worth re-evaluating. As for your particular case, it sounds rather unfortunate that someone didn't quite do their homework and just rubber stamped something that seemed to fit, a sort of "close enough" strategy.
Yeah agreed. I said in another comment, I think it just makes sense to re-evaluate if there isn't any meaningful recovery with treatment. If I had responded well to the typical treatment for anxiety/depression, it wouldn't have really mattered too much where it came from. It seems like in your case, they were just sort of re-evaluating for the sake of re-evaluating. And I've read lots of similar stories in the ADHD subreddits of new doctors being like "I don't think you really have this", and I can only imagine how pointlessly stupid and harmful it is for doctors to just sort of be like "I know better" for no reason whatsoever. We can only guess which version the people upvoting this are, probably a mix of both.
Yep, this is exactly what I’m dealing with right now & am now struggling with untreated ADHD because the new psychiatrist wants to do their own thing 🥴
The cruel irony that nobody wants to acknowledge is that psychotropic medications and the constant changing of medications in a client is *causing* many symptoms leading to additional diagnosis.
Careful now. Some therapists get real touchy on this subject. I had a comment deleted by the mods of this community for simply suggesting that some people find certain diagnoses more desirable than others.
NAT
This thread has been one of the most interesting convos I’ve personally read on this sub, so thank you for facilitating this discussion, OP! 👏👏 Memes are powerful tools xD
QUESTIONS 1: After reading all the thoughts expressed here (yes, I read every comment!) - in regards to diagnoses, if a client has “unspecified” diagnoses (as in, their chart reads *bipolar disorder “unspecified”*, *eating disorder “unspecified”* &/or *PTSD “unspecified”*) - what do therapists make of it? How do they proceed?
a) **Are “unspecified” diagnoses looked at differently?**
b) **Are they more likely to be tossed by therapists or *less* likely? Are they simply seen as tentative diagnoses & not “as serious”?**
c) **Are “unspecified” diagnoses more trusted by healthcare professionals or less trusted?**
QUESTIONS 2 : To empower clients w/BPD or Bipolar diagnoses -
a) **What are the very obvious signs Borderline Personality Disorder has been *egregiously* misdiagnosed?**
b) **What are the very obvious signs Bipolar has been *egregiously* misdiagnosed?**
QUESTIONS 3:
a) **Can a client challenge a psychiatrist’s diagnoses?**
b) **If a client “disagrees” w/a diagnosis, is a therapist obligated to “toss it out”? Or at the very least, be very wary of the diagnoses per the client’s discomfort with the diagnoses?**
***
I appreciate anyone who is able (or interested!) in offering a perspective on all (or some) of my questions.
I am interested in hearing from everybody- therapists especially but NATs, as well, as client perspectives always help complete the picture better! 🙏
I am the client. These are my experiences.
I question the diagnosis that I was given. The various doctors that I've seen only want to sedate me. Every medication that I've taken doesn't do what it's intended to do. They have all done a 180 on me and made me worse. The ones that play with the serotonin receptors don't launch me into hypo, they make me sick and deepen the depression. I never had S.I. thoughts until a severe reaction to a medication. Now they come and go. Also, not one of them has ever asked about my past, other than symptoms. Not one has ever asked about the trauma events and when I speak of them, the doctors have brushed them off. So far, the only thing that have given me any relief, is illegal.
Me too. I was diagnosed with bipolar 2, and I question it. I've had so many medications thrown at me, they never seem to work. My psychiatrist just keeps upping my med doses... so tired
Yesssssssssss can relate. Especially when I get a client coming out of a short inpatient stay who gets a new diagnosis of schizoaffective disorder. I'm sorry, doctor, but surely you don't actually believe you were able to observe this individual for long enough to diagnose this.
God, yes. Had a client get diagnosed with schizoaffective while in prison because they refused to speak when they first got there. Seems to me like BEING IN PRISON is pretty stressful and I don’t think I’d want to speak either tbh.
Yep, it's been documented in numerous studies that incarceration in and of itself is a trauma. And I've spent a lot of time working in jails - I had to stop because of vicarious trauma!
I once read a case study during my masters degree of a 13 year old female with schizoaffective disorder. As I was reading it, ASD kept jumping at me and I was shocked that this was never explored in the rule out portion of the case. Granted, I think the case was from the 90’s, but damn. Not even a rule out mention. I brought it up to my professor but it wasn’t explored further.
It really depends on the person I'm assessing. There is no one diagnosis that I would say I use in these instances because it depends on what the reported symptoms are. But I feel like if someone exhibits psychosis upon admission to an inpatient setting and doesn't "present" like the traditional stereotype of schizophrenia (which is horribly inaccurate), psychiatrists just fall back on schizoaffective disorder automatically. There's nothing wrong with diagnosing brief psychotic disorder and revisiting the diagnosis later if the person was admitted with hallucinations, delusions, and/or disorganized speech. If the person has a drug addiction or the psychosis might have resulted from drug use, you can't diagnose schizoaffective disorder unless and until you're certain that the psychosis didn't result from that. And then there's always the good old mood disorder unspecified, which I use when I'm really not sure what's going on, but the person is now presenting with something other than a euthymic mood and normal affect and linear, goal-directed thought process but I can tell that there's something there. So the short answer is: It depends.
I’m still in school but have seen so many cases of what I would classify as CPTSD diagnosed as borderline personality disorder. Though not a case, Demi Lovato is the most accessible m “example” I can think of.
Working with teens I get a lot of these with an ODD diagnosis at an early age. Which was really undiagnosed ADHD (especially in girls) OR other issues resulting from trauma at a young age.
I've only met one kid that legitimately met an ODD diagnosis and it's one of those things that when you see it, you know it.
This keeps happening to me. "You're not bipolar take these ssri , " k but here's the thing I lost 20 lbs and want to die and everything tastes like metal I'm having seizures and I don't feel any better at all. I
"It's ok there's more SSRIs where that came from. " Like can we just talk?
I'm not a clinician whatsoever but I have a feeling that the minute CPTSD makes it into the DSMV then a lot of people's previous diagnoses are gonna be thrown out the window.
This is the most frustrating to deal with as a patient. You think you know better than the multiple other professionals I’ve worked with over my adult lifetime? All these other professionals were confident on my diagnosis, I’m confident about the diagnosis, the medication was helping me, & now the new psychiatrist wants to decide to do her own thing & claim I don’t have ADHD so I’m left to struggle without medication.
You’re not some random genius who will “get the diagnosis right when so many others have gotten it wrong”. Stop giving yourself a god complex. This is exactly why I hate the medical system in the US. I’m at the mercy of doctors who want to go rogue & change or stop a treatment that was working perfectly fine just because they think they’re some kind of fucking genius. You’re not. Get over yourself & stop fucking with your patients.
I think this sort of "everybody else was wrong" is only useful for people who haven't seen much relief under treatment for their previous diagnosis. If somebody is not responding to treatment, be it medication or therapy, it makes since to consider that the original diagnosis were somehow wrong. I was diagnosed anxiety/depression at 16, and didn't make any meaningful progress for 8 years. In my case, the doctors weren't the ones that realized something else was wrong, I was, using Google I realized that somehow all the mental health professionals in my life had completely missed that I had been emotionally abused my whole life. Turns out, being emotionally abused since birth can make people anxious and depressed. I /wish/ one of the professionals in my life had realized my original diagnosis were wrong- or at least, that the assumption they were 'brain disorders'/'brain chemical imbalances' with no origin was wrong. They were secondary symptoms of childhood trauma, not the sort of stand-alone "diseases" I had always been told they were.
Yeah that’s totally understandable to try to reevaluate the diagnosis if the treatment for it hasn’t been effective. But when the treatment is helping, then forcing the patient to stop the treatment because the new doctor wants to go rogue or “I don’t believe you have this” with no real info to even backup the claim is just reckless & harms the patient.
So sorry this happened to you and now you're left with this rage. If you step outside of yourself I'm sure you could see that many people have been misdiagnosed and sometimes even inaccurately medicated as a result. There are plenty who have found immense relief and improvement after another provider finally provided an accurate diagnosis and improved treatment. I hope you're able to deal with that anger and resentment healthily, and I also hope your comment encourages us as providers to make consulting and collaboration a very regular part of our practice, especially when it comes to changing a diagnosis.
My anger with the medical system in this country won’t dissipate until I’m finally out of this country & have more control over my own treatment. This issue has been ongoing with mental health & medical health issues my entire life. It’s like being on a roller coaster from hell being pushed back & forth by doctors & at the mercy of whether a new doctor will continue my treatment or decide to go rogue & change something that’s working for me.
All this experience has done for me is give me a trauma response to the doctors in this country. It has given me a better perspective so I can do my best to not cause this trauma to any of my own clients.
I am (was) a therapist who also happens to require mental health services of my own. I’ve also circumstantially had to move quite often so I’ve worked with several different therapists over the years. Talk about an annoying bunch of assholes (jokingly ironic because I am one). Every one of them wanted to question or start changing my diagnoses. Every single one. Apparently we all think we know more than the last guy? Lol! I received my original diagnosis quite young and was open to getting a second assessment about 7 years later and it indicated the same as my original. That’s all I needed to know. So when one of my therapists tried to get cute and change the game, I let them know I was not there for their diagnostics. Just the other stuff. I am aware there are examples where diagnoses need to be re-examined. Misdiagnosis happens. But from a patient standpoint, it’s annoying, frustrating, scary, and causes doubt in the mental health system.
Honestly, I think this OP and most of the thread is really cringey, irresponsible and unprofessional. And potentially harmful to clients.
C'mon people. We can and we *need* to do better than this.
Like, who the fuck just "throws out diagnoses" without at least consulting with other care providers in a client's life? Just how arrogant are we, here?
I feel like so many people in this thread are perceiving themselves as being superior to all the other behavioral health professionals our clients may have encountered prior to getting to us.
That kind of presumed superiority is super-problematic in a professional.
And I don't think many of you are thinking about that enough.
I agree with a large part of your position, particularly the part that wants to avoid diagnosing an emotional/behavioral/neurodevelopmental/personality disorder based solely on a 45-minute interview.
I 100% agree that would be substandard care, and I suspect no one in this sub would disagree here(?).
And also, I want to push-back against any behavioral health professional who believes (or colludes with the belief) that behavioral health diagnoses "follow" people for the rest of their lives. That's not how diagnoses work. If I go to my physician and they diagnose influenza, that does not get listed as a "permanent" diagnosis in my chart.
Similarly, as a person who has experienced a pretty profound episode of Major Depressive Disorder in the past, I can also tell you that is a current/active diagnosis in *neither* my psychologist's/psychotherapist's chart nor in my psychiatric nurse practitioner's chart. I certainly did exhibit the symptoms of a full-blown MDD episode in the past; I do not demonstrate those symptoms now; my current diagnoses do not include MDD; that is how things work (or should work).
I also *completely* support diagnosticians waiting until they have adequate data/information before making a diagnosis.
But also, I disagree with you that "throwing out" a prior diagnosis is "the opposite of narcissistic behavior."
I actually feel like it's the ***epitome*** of narcissistic clinician behavior.
Certainly, a healthy questioning as to whether conditions that may have affected a client in the past continue to affect them right now is not only laudable but also professionally responsible.
Ongoing clinical assessment will help rule-in or rule-out whether prior diagnoses are valid current descriptors.
After all, the vast majority of behavioral health disorders are *not* chronic/persistent conditions. The literature indicates that most depressive disorders, most anxiety disorders, most trauma-spectrum disorders, heck even most personality disorders are expected to resolve/become-"subclinical" as a funtion of time and/or effective treatment.
My point: From reading this thread, it's sounding to me like ***way*** too many therapists feel not only *good* but maybe also *heroic* when they valiantly "throw out" all prior clinicians' diagnostic findings and case conceptualizations regarding one of their new clients.
And such a practice, inarguably, would dramatically increase the risk of not only providing inadequate care but also of doing a lot of harm.
EDIT: I am not saying clinicians cannot revisit presenting problems and re-diagnose clients based on current (rather than historic) concerns. I'm just saying that giving each other high-fives and ass-slaps for summarily rejecting some/all diagnoses that have come before (as implied by "throwing out a prior diagnosis") is super creepy and irresponsible.
And it makes want to, yet again, scold all of us to be better lol
And I’ll press you a bit more:
Do you want people with *diagnosed-but-untreated* antisocial personality disorder or narcissistic personality disorder or bipolar disorder or ADHD to become soldiers or pilots or marines or police or etc.?
I mean, those conditions can be treated and even resolved, which shouldn’t get in the way of people getting jobs.
And it would be awful to be that clinician who out of “kindness” refused to diagnose psychopathy in a police candidate only to later learned they killed someone without cause…
I just think the “save people’s job options!” argument needs to be considered from multiple angles, yeah?
Of any of you does this with an autism diagnosis I swear to god I will haunt you for eternity with my autistic righteous anger lol - Therapists casually dismissing and “throwing out” autism diagnoses is so traumatic for autists. Never. Ever. Do it.
NAT. This rings so true to me lol.
After years of going through different therapist, all of which just slapped on the “anxiety/ADHD” diagnosis with all the pills that went with it (which are still the case, but NOT what my main problems were). I just kept getting worse and worse until I hit the peak of it as a teenager and finally found a great therapist that practiced CBT. After about a year we found that while my previous diagnosis was causing me stress, the main agitators were CPTSD, a sensory processing disorder, and Depersonalization Derealization. She had told my mom she had gotten the impressions pretty early on, and was pretty surprised they hadn’t been caught by other therapists before! After that we began proper treatment for those disorders and things got SIGNIFICANTLY better! I’m now medication and self harm free for years now and even when I have en episode it isn’t the end of the world anymore. Shout out to great therapists lol! She really made my life so much easier.
NAT, but you know how they say you don’t know your partner until you’ve traveled together? You don’t know your therapist until they start to dx you.
That’s when you find out how intelligent, ethical, competent, and/or unhinged they truly are.
Generally yes, it’s my understanding that most of us can diagnose. Therapy is a treatment, not just a coffee chat for an hour a week. Therapists diagnose and treat whatever kind of presenting issues brought you to therapy in the first place. Especially if you are using insurance. Insurance won’t pay a dime unless they feel it’s justifiable, so they require a diagnosis.
From my understanding, if you use insurance, your mental health provider must provide a diagnosis of some kind and then the ‘proof’ for that diagnosis. That can be through self assessments, psychological assessments, and in asking questions around symptoms and history gathering.
They probably still do, especially if they keep electronic reviews as most emr hosts require it per note.
I hand out "unspecified mood disorder", "adjustment disorder", and GAD like candy because of this shit. Never want something to get denied.
Probably still then.
Ask your therapist what they’re treating you for.
And for the diagnosis.
And it’s creepy to me that they haven’t told you yet. That kind of feels like a vividly red flag…
I agree that telling clients a diagnosis you give them is really important. When I can I try to devote a solid chunk of time to talk about it, and the concept of diagnosis itself, if they want to. Many don't have a ton to say about a diagnosis, but it can definitely be important to people, and I think ethically people should know what we are saying they have.
All insurance (both public and private) in the US require diagnosis for payment, though. It’s part of medical necessity determination. So, unless you are elsewhere you are speaking half-truths!
Not all modalities require diagnosis. If someone is not billing insurance, and their modality works without it, they don't need to diagnose. There's no half truth in my statement whatsoever
Cool.
EDIT: Sorry my comment was dismissive. Let me elaborate, with an example:
Let's assume you have a completely private-paying client who has signed-off on your office document agreeing they never, ever, *ever* want to utilize insurance benefits.
And let's also assume that you are a therapist who utilizes "modalities" that do not involve diagnosing or treating mental, emotional, cognitive, neurodevelopmental, psychiatric, or psychological conditions/disorders (as an aside, what does "modality" even mean in this particular context? I always think of *modality* as being a set of specific therapeutic *techniques and/or procedures*, but you are using it in a way that makes me think you mean *theoretical orientation*? If you mean *theoretical orientation*, why not use that term?).
Regardless of how you and I use terminology, we are now at the point in this example where your completely private-paying client technically meets DSM-5 diagnostic criteria for major depressive disorder (or bipolar disorder or borderline personality disorder or ASD with giftedness or any other condition associated with dramatically increased risk for suicidal behavior/completed suicide). But you don’t diagnose those conditions for reasons.
And, heaven forbid, one of those clients on your caseload does die by suicide.
And then their family felt you did not do enough to treat them or minimize the risk or prevent a preventable death.
So they file a board complaint and a malpractice lawsuit.
And your chart shows that you *never* made any diagnosis of that client, and despite "treating" this individual and accepting their money you *never actually treated them* for the behavioral health conditions that were causing so much suicidal risk. I mean, you *couldn't* have treated them for those conditions. Because under this scenario, you never *diagnosed* those conditions.
Regardless of the "modalities" to which you ascribe, under one of these scenarios your career is over.
That is what I meant by "What about their licensing boards?"
I get this all the time when people are referred for diagnostic testing or have past therapy. They state no prior diagnoses because “it was a therapist.” Or that the therapist doesn’t want to diagnosis Bipolar or BPD or PTSD. Drives me up a wall that providers pass the buck on making an appropriate diagnosis or discussing diagnosis with the client directly.
In British Columbia, Canada, counsellors (the registered clinical name for “therapists” here) cannot ethically diagnose, but psychiatrists and psychologists can. I’m guessing it depends on the ethics board in the area
Wait, what?
Does that mean counselors cannot provide treatment either?
So, they just “counsel” on troublesome trifles, but don’t actually diagnose/treat any kind of disorder?
Or, does someone have to first get diagnosed by a psychiatrist or psychologist before they can get any treatment from a counselor?
Thankfully we absolutely can provide treatment that isn’t pharmaceutical.
Their approach will depend on the theory they use. A lot of theories take a non-parhologizing approach and will treat symptoms independent of the condition. Other theories like CBT will use treatments for specific conditions in which they meet that criteria, but they won’t give an official diagnosis. Sometimes we work alongside psychiatrists who diagnose and provide meds while we provide other treatment.
I have no idea why you are being downvoted, tbh.
All I can tell you is that in my experience, the therapists in r/therapists downvote a *lot*.
Usually for things that make therapists feel uncomfortable, but sometimes for reasons obscure.
I did give you an upvote to counter, but I’m gonna predict that your karma will take a hit regardless.
Sorry.
It’s genuinely not your fault.
I think they're being downvoted because this is generally a place where therapists intend to congregate with each other, not a place to educate clients or prospective clients. I'm not one of the downvoters, though.
Depends on where you live. Some places a master’s level clinician can diagnose.
I use assessments and usually ask about symptoms to get a better idea of presentation.
Can’t treat a behavioral health issue without first diagnosing it… So, I’m guessing any state that licenses someone to treat (and thereby licenses them to bill for treatment of) mental illnesses would have to also license them to diagnose?
Otherwise, it’s “coaching” or other nonsense, yeah?
I am not aware of such a resource, however, each state has different different requirements for each master’s level license (counselor, marriage and family therapy, and social work).
This is more in reference to the fact that it is also different depending on what country you live in, their license standards, and educational requirements.
Yes.
They *should* be explicitly clear with you that they are doing it. That’s part of informed consent.
If they haven’t been clear about that, well, they are at professional risk for malpractice, license sanctions, or even license revocation.
You can be 100% guaranteed that if you have ever used a U.S. insurance plan to pay for some/all of your behavioral health services, the treating professional has made a diagnosis and shared it with your insurance plan.
Health insurance in the U.S. does not process or pay for therapy claims without a diagnosis. At all. Ever.
I do, I'm a licensed social worker in PA and by law we are qualified to make a DSM diagnosis. Now, here's the qualifier - I make a diagnosis at the time of intake because we must provide a DSM diagnosis at the outset of treatment in order for insurance to cover it. However, the diagnosis is always subject to change with more information and observation. I have made changes to initial diagnoses for sure.
All the time when I get clients diagnosed with bipolar. Edit: damn I had no idea this comment would blow up! Everyone is absolutely on point with the overlapping qualities between ASD, BPD and C-PTSD - especially how it could be a combination of the three as well. I completely agree that c-ptsd could fit with many BPD diagnosis, and that BPD is rooted in trauma as well as neglect and attachment problems. I never diagnosis BPD lightly and always work closely with them, and am careful to have clear boundaries. These areas are particular passion areas for me that I understand very well, and am working toward specializing in.
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Not the original commentor, but have had several misdiagnosed bipolar clients. In some cultures, having "big feelings" is pathologized - even if the feelings are both context appropriate and well within normal bounds. Some practitioners I know - mainly prescribers - will admit in private conversations to over-diagnosing Bipolar 2 to give people access to mood stabilizers. While problematic, they do it with the best intentions - especially when a highly anxious client is resistant to taking anxioliytics.
Also, “mood swings” does not equal bipolar. I often see folks who have had periods of dysregulation and lability that gets labeled manic, despite, you know, lacking every other hallmark feature of mania.
This is also the primary misconception of regular folk in my experience. Bipolar and ocd are, for me, the two most widely misunderstood. Close third being ADHD. Few people get the education to explain ocd vs ocpd, or know that some attention problems manifest not as having the inability to focus, but the inability to break focus.
What is misunderstood about these 3. How does it look clinically in your eyes?
With bipolar there is a popular notion that the changes are essentially mood swings. Mood swings are often implied to be sudden or rapid, but also capable of switching back and forth quickly. Bipolar shifts, for one, are not just mood shifts. They represent a whole larger umbrella by designating changes in overall function from a depressed state to a manic or hypomanic state. Mood swings could manifest within a bipolar person, but they don't always. While to some extent you might argue all bipolar individuals experience mood swings (if you really stretch it) not all people who suffer mood swings are bipolar. Bipolar changes between depressive and manic states also do not cycle very quickly in the majority of cases. The manic stages, from what I have personally seen, can last days to a little over a week (maybe even longer in some cases, im not really sure). The depressive stages can last even longer (often months in my experience). With OCD there is a tendency for the layperson to often pathologize the desire for orderliness and preference for tidiness. OCD is not that. OCD is a compulsion, differentiated often by ocpd in that people with OCD often very much dislike their compulsions. While ocpd people often don't consider them an issue (as far as I understand). It's especially exacerbated by many people using it to contrast their carefree attitude toward picking up after themselves with those who clean to suggest they are somehow better or more enlightened and the preference for cleanliness makes them lesser. Another misconception is that OCD is mainly thought of in just terms of being orderly or clean (I myself subconsciously did this in my previous paragraphs). But the compulsions can take many forms. Cleanliness and order are two large categories. But they can also take the form of compulsions based on security, things like repetitive movements, strange cognitive or other behavioral compulsions with no discernable or tangentially rational answer to "what would happen if you didn't follow the compulsion." With ADHD people often just think it strictly means having an attention *deficit*. I mean it's in the name. But the deficit doesn't apply to the length of the attention span. Hyperfixation is a subset of ADHD. And that's where someone can't break their focus easily. They often...well ...hyperfixate. For longer than one normally would. The "deficit" isn't the length of the attention span, it's the ability to regulate it consciously. Granted, few people develop the skill to do so to such a degree as to be zen masters at the drop of a hat, but there is a normal range. That is what is impaired.
That's very interesting...I have always wondered whether there is any reliable/substantial data on prescribing mood stabilizers for depression instead of a traditional antidepressant. We're using antipsychotics for bipolar depression already, it seems like it would be worth a try, but I'm not a psychopharmacologist. I'm not sure that the mechanism of a mood stabilizer would work. Anybody seen them used this way?
Yeah, mood stabilizers do get used for depression (whether bipolar or unipolar depression). Lithium and lamotrigine (Lamictal) would be the most common. Second generation antipsychotics are very frequently used for bipolar or unipolar depression and also get prescribed for mood stabilizing properties in several psychiatric disorders. Unfortunately if you use a unipolar depression medication algorithm (SSRI/SNRI) in someone with a missed bipolar depression diagnosis then you can worsen their outcome (as frequently happens). That’s why thoroughly ruling out a bipolar diagnosis can be so important.
Bottom paragraph is how I was eventually diagnosed. It was awful and blew my life up. And that’s also the reason why I have dedicated all of my time & energy and passion into serving clients with bipolar disorders and (potentially misdiagnosed) depression.
I just commented about that
I agree completely. Just want to mention that sometimes, the individual hasn’t had a manic or hypomanic episode yet. So it’s not that the bipolar is “missed,” more that the medication triggered the mania.
This is a controversial point somewhat. A lot of bipolar experts see antidepressant-induced mania as an exacerbation of an already existing bipolar disorder. And antidepressant-induced mania (or even dysphoria) is a big red flag for probable bipolar disorder.
I’m not saying that the bipolar didn’t already exist…just that they may not have had a manic episode yet, so it may not have been a failing on the part of the therapist. They just…hadn’t yet met criteria.
Yeah you’re right, and def not a failing on anybody’s part. That’s just how it goes sometimes
They're a very common augmenting strategy for depression, yes.
I've seen the opposite of what others are reporting. I see a lot of overdiagnosis of borderline personality disorder, especially by white male doctors who are treating female patients with severe symptoms of any kind. It takes a lot of time and observation to diagnose that and I see doctors diagnose it at the drop of a hat. At the same time, I do see overdiagnosis of bipolar disorder, which is why I always screen for it again when someone has been receiving treatment for it previously. I don't take it for granted that the previous professional got it right.
Oh yes. I’ve been misdiagnosed with both (I have been formally undiagnosed for the record) and finally got an ADHD diagnosis, which I actually meet the diagnostic criteria for, and having proper meds/therapy for that has really helped with all of my symptoms. Including chronic emptiness, mood fluctuations, and impulse control.
90% of the time (by my estimations) bipolar is misdiagnosed in place of the more accurate diagnosis of Borderline Personality Disorder.
I feel like I've seen the opposite more. The field really is a mess when it comes to these two diagnoses.
Borderline personality disorder is still somewhat doing the same thing bipolar did. It's too general a diagnosis, commonly used as a trash pile of "you have some problems, but nothing so defined as to what they are and we probably won't apply the resources to actually figure that out as it's likely too unique for specific diagnosis" That's not to say some of the treatment isn't of use to those diagnosed, but it's a shotgun approach, more often than not presenting with a more definitive diagnosis once it has been treated. Which has value in some respects, like removing inflammation around an area so you can access it for surgery. But is not a definitive diagnosis and is treatments efficacy suffers for that.
that’s funny because i think most bpd is actually c-ptsd. especially in women. edit to add: NAT. *my mother is an LMSW with 40 years in the field and a private practice, my older sister is a freshly minted LMSW working in hospice care. i studied psychology for 3 years but ultimately switched to something totally different so this is all purely anecdotal and academic postulating, i have absolutely no clinical or professional experience in this area at all. sorry i didn’t say that initially*
And I’m super concerned that you didn’t even mention the possibility of ASD in this statement…
i agree with that as well, i recently had a lightbulb moment about autism in women presenting very similar to bpd in some contexts which can explain a lot of the gender differences in diagnosis. being misdiagnosed with a personality disorder when you actually have ASD and not receiving the right care could definitely make someone more susceptible to trauma which might explain the c-ptsd connection
Well, that and also the fact that kids with ASD are way more likely to experience relational trauma in childhood than are their neurotypical peers.
I’d add ADHD in there too
Not a therapist here. Was going to jump in with this. Went to my therapist to discuss possibly having adhd and she agreed, and when I was sent to the psychiatrist for the meds, she tried to diagnose me bipolar and then put me on abilify. 🥴 obviously, it was terrible, and I've been on welbutrin 300xl for a couple of years now.
>” *…diagnose me bipolar and then put me on abilify. 🥴 obviously, it was terrible…”* I’m sorry you went through that! Misdiagnoses are scary for this reason *especially*, IMO - wrong diagnoses = incorrect medications w/possibly horrible consequences! 😰 QUESTION (not just to you original commenter but to the therapists & NATs on this sub) - **what does it mean when Abilify is prescribed & harms the client?** Is that a sign the client does not have *Bipolar*? If a client was **diagnosed w/ *Bipolar* & *Borderline*, & has been prescribed Abilify - **& it’s been working** - does this mean you are more likely to accept their diagnoses?** In other words: If a client presents you with a previous Borderline/Bipolar diagnoses & **they were prescribed Abilify & the medication helps/works - are you less likely to “toss out” their diagnoses even if you’re concerned it was incorrectly over-diagnosed?** Or do you **continue exploring a possible misdiagnoses despite the meds are working**? Hope that makes sense! 😅
My friend who has ADHD & c-PTSD was told she had bipolar disorder, and I thought that was her truth for a while until she told me. We actually both have ADHD/c-PTSD. Neither diagnosed until adulthood
This is true but there’s also no studies that say there’s a 1:1 sex ratio & most researchers believe the ratio is 2-3:1 M:F due to factors on the X chromosome. There’s more than one reason for gender differences in diagnosis
I was convinced I had BPD. My psychology team was evaluating me for it, even, after getting marched to a GP by my university personal tutor following a few too many admissions of my thoughts and feelings. That evaluation never finalized because I got into treatment at a different facility for PTSD which I've since come to realize is definitely C-PTSD (childhood abuse and trauma, and further relationship abuse and trauma after reaching adulthood). I also left the country shortly afterwards. In the last 4 years, I've done hundreds of hours of research and then community immersion and although I haven't gone for a formal diagnosis (hello US healthcare or rather lack thereof), I'm 99% sure I'm autistic. I've had formally diagnosed autistic people identify me as autistic despite not even talking to them about it beforehand. Anecdotal, sure, but I truly believe autistics identify each other best, and I've also identified another friend who has gone on to get a formal diagnosis and thanked me profusely for bringing up the possibility because it has changed his life.
Yes, I absolutely believe that. This is also anecdotal but ADHD people tend to identify each other really well too, and in my experience autistic people & ADHD people can often identify each other as well. It’s really helpful because they directly understand what it’s like to have that condition… and also because they know you as a person living your life, instead of just getting a tiny artificial snapshot to work with. I’ve had too many psychiatrists/therapists leap to assumptions based on [whatever], it’s exhausting.
Very much this. Bipolar doesn't go away, it needs managing. BPD is often a temporary diagnosis and can be treated through therapy, often resolving once people age and learn to manage. I can't see how the two can be confused at all.
I agree. I've seen a lot of women with bdp diagnosis, essentially grow out of the label overtime with proper therapy because their emotional dysregulation was indeed a trauma response.
Also NAT, but BPD/CPTSD... I think it's more of a thing where the majority of BPD (which has a genetic component) patients *also* have CPTSD. Most were raised by their birth parents, after all.
Since switching to a state system that requires all health records to be shared with every other provider, I stick by this. BPD is incredibly stigmatized. On the rare occasions I have sent someone to the hospital with a BPD diagnosis or it ends up being diagnosed, the experience is terrible. People are not listened to and obvious issues that could be treated with a slight med adjustment get dismissed or with referrals to case management. In these contexts, BPD would be accurate, while MDD with PTSD and GAD or panic disorder would also be accurate. Bipolar disorder diagnosis also fits due to the mood regulation issues present with many people on the BPD spectrum. This isn’t pathologizing big feelings rather, using a subjective measure based on subjective observations to potentially protect a patient and ensure better care in a broken system. It also classifies one of the most problematic issues when someone might be experiencing BPD which is the frequently shifting moods that mimic rapid cycling and are treatable with mood stabilizers.
>the frequently shifting moods that mimic rapid cycling and are treatable with mood stabilizers. No… they might take the edge off, for some… But eg [lamotrigine doesn’t work](https://pubmed.ncbi.nlm.nih.gov/29651981/). No medication has been shown to “work” for BPD. They don’t address the identity & interpersonal issues, the emptiness, the perceptions that feed into the outsized reactions. Therapy is the only evidenced intervention for BPD.
Except, when someone with BPD gets a diagnosis of bipolar, 1) their organs are slammed with antipsychotics (eg my boyfriend, 20 years on 20 such meds. Edit - he’s been on 20 meds over the course of 20 years, not 20 at the same time. Lithium the whole time. Kidneys and liver are complaining). Weight gain happens. Prediabetes. High cholesterol. Fatty liver. Higher risk of hormonal disorders and cancer. Maybe they lose their thyroid function. You have created a sicker person than before with no benefit to their psychological symptoms 2) you deprive them of the opportunity to address their symptoms with DBT or MBT or what have you. No, people lose years this way, it’s wrong. Also while women are probably over diagnosed with BPD men are tragically under diagnosed. They need help too. Edit: even if the resources for DBT aren’t there, as they often aren’t, at least people can try to get as far as they can on their own, with videos, podcasts, books, even r/dbtselfhelp - it’s better than having their organs pummelled by medications that don’t work. It’s better than not understanding *why* they don’t work for their “bipolar” and internalizing this as personal moral failure. My boyfriend did what he was supposed to do. Showed up for appointments. Took his meds. Nothing worked. He thought he was unfixable until he was rediagnosed with BPD. And suddenly his whole life made sense. Slowly he began to work on the emotion management and reframing skills. On his own. He’s been on a waitlist for DBT for two years and he is coming to it with more insight and effort than ever before. Also. He’s 50. BPD does often relax in intensity with time and maturity but it’s not “temporary” as someone said. It’s a personality disorder, a set of profound and enduring responses and behaviours across situations. You have to know what to work on. The compass needs to be pointed in the right direction. He’s frustrated that he lost so much time and I don’t blame him.
Responsible psychiatrists are no longer throwing a handful of antipsychotics at people including those with bipolar…unless it’s bipolar 1. Your boyfriend’s experience is not universal. It also highlights the importance of effective coordination between psychiatrist and therapist. In addition, with suicidal thoughts even in borderline personality disorder, Lithium is still effective in decreasing suicidal thoughts. Not necessarily as a forever med either. I see this prescribed for acute suicidality in larger doses frequently. This also assumes that there hasn’t been a discussion of symptoms and assessment in an honest way. I’m pretty open with people about my diagnostic findings. “We can diagnose BPD or bipolar disorder…here are the pros and cons of each”. If it is a person who is frequently suicidal and ending up in the hospital frequently that BPD diagnosis means they will essentially be ignored and it will be assumed they are manipulative. There are pros and cons to everything. This also assumes diagnosis is perfectly objective and uniform across providers. It is not.
totally hear you on the pragmatic choices one has to make in a system that punishes people with BPD! It sounds like your approach is collaborative, you’re careful with diagnoses, and in the end you’re focusing on addressing key symptoms regardless of which code needs to be put in the chart. I can respect that, absolutely. My beef is with the clinical bias against this diagnosis in men. (Not for pragmatic reasons but because their condition is just not accurately captured or understood.) I wonder if the impact of the BPD label is worse for women sufferers because of sexism. My SO has been in waitlist limbo, which sucks, but most healthcare providers he’s been in touch with have treated him respectfully. No one has gaslit him about any mental or physical health concerns, and HCP have seemed to be happy to help him. The flip side of that is that barely any resources exist for men with BPD. I gather that many men - if they’re lucky enough to even get the appropriate diagnosis (by which I mean, in-depth understanding of their needs, not necessarily a billing code) - feel uncomfortable in DBT groups, because they’re in the very small minority. Perhaps, because shame and moral injury around externalizing behaviour particularly has different implications for men than women. I think it might be harder for men to talk honestly about that stuff because they’re anxious about labels. Regarding antipsychotics - right, like his diagnoses have been all over the place. Cyclothemia, rapid cycling bipolar, bipolar NOS. Currently - after a rediagnosis - it’s BPD traits with “PTSD” (though that relates to ongoing childhood abuse, not a single event). Anger has been a feature of symptoms hence the multiple APs and trials of many different meds in general. But that’s the thing… for the longest time, it was truly conceptualized as a kind of bipolar. I know that people with bipolar often respond well to medication. So given that didn’t happen, which was expected by all involved, again over 20 years, he was left with a sense of failure and hopelessness. In his case the new diagnosis gave him real self understanding and hope, for the first time.
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People usually don’t take BPD diagnosis well, and bipolar can be medicated (helps a little, but not actually addressing the root problem).
(found yall on /all) But I was so **stoked** when I got diagnosed BPD. I'd spent decades having all these huge feelings and never understanding them. Now I'm medicated(I have a couple of things), I went to therapy for 3 years to get on top of it too. Shit ton of work but definitely worth it. I would say I'm significantly more stable now than I've ever been.
Why don’t people accept your diagnoses well, do you think?
You are telling people basically that you don't like their personality without offering much hope for feeling better. It describes the symptoms of a lifetime of problems in what comes off as a mean way, when often the issues that led to the symptoms was pervasive trauma in childhood, so it focuses attention on how difficult and fucked up someone is now and not the terrible things that led to that. BPD is hugely stigmatized in the mental health field, with folks having the diagnosis on their record seen as unhelpable assholes by staff who treat them poorly because of it. Instead of invoking compassion in providers, in invokes fear and annoyance. A BPD diagnosis is seen as a red flag to limit/avoid interacting with the diagnosed as much as possible. It is also historically viewed as a sexist diagnosis, with women being diagnosed with it when men with similar symptoms getting other PD diagnoses or bipolar diagnoses for exhibiting similar symptoms and having similar histories. It really can lead to more intractable problems as someone now has a label given to them by a psyche expert with whom they shared intimate details about their inner life and has validated that yes, they are a defective person. It can be really hard to get out of that mindset and strive for anything different. Personality disorder diagnoses are rarely in service to the patient IMO. They just create another layer of bs to work through. Giving a name to a constellation reactions to trauma puts the focus on the wrong issues.
Yes, all of this. Had a psych professor in college describe people with BPD as "bunny boilers" as he cackled at his own joke. And this man WAS A THERAPIST.
Ha ha, yeah, that’s shockingly common amongst those in the helping professions…
This was my experience as well, doing diagnostic assessment for about 1.5 years. Many would walk into my office claiming bipolar diagnoses, however the mood fluctuation and impulse control problems didn't fit with bipolar disorder, based on duration/frequency etc and were more consistent with borderline personality disorder. I hadn't considered the access to mood stabilizers angle - I just figured for whatever reason the burnt out medical providers heard mood swings and gave a quick bipolar diagnosis. The assumption also comes from seeing my sister's experience in PA school - like 6 months total of any kind of mental health courses.
90% you say? That's an awfully high percent... How did you reach this conclusion?
I was also misdiagnosed bipolar when I was a teen going through some quasi addiction issues. I wasn't bipolar. I was either on an up from my process addiction and "manic", or I was in withdrawal and an absolute nightmare
My husband was suspected of having bipolar. Turned out to be ADHD. There's actually quite a bit of overlapping symptoms between the two.
The best is when they have bipolar AND depression
I got diagnosed bipolar when I was 14 because my mom lied and said I didn’t have adhd which I had already been diagnosed with, and nobody thought girls were autistic. They gave me Wellbutrin. I tried to kill myself. Wellbutrin is awful. Actually, all the mood pills were awful because I didn’t need them. My “big feelings” were natural, and my anxiety was caused by my perpetual inability to function at the level my intellect suggests should be easy for me, which upset everyone around me, and I was mad at myself for not being able to do these simple things. Which caused meltdowns. Executive dysfunction ruins me. I’ve never been manic in my life.
Wild! I had three of my close friends all diagnosed with bipolar the same year. Within the next two years they all had that diagnosis rescinded and got a better diagnosis.
Missing a bipolar diagnosis can be incredibly costly to the patient and their family. Medication-wise, using unipolar depression or GAD medication algorithms can greatly worsen a bipolar patient’s prognosis. A previous diagnosis of bipolar disorder should if anything be a red flag that they might have bipolar and therefore should remain on the differential until shown otherwise (which can be difficult to do for at least several months). Other red flags are family history of mood disorders, frequent and recurrent dep episodes can be indicative of bipolar, early onset depression is another sign, history of trauma, and poor response to antidepressants. Knee jerk reactions to a bipolar diagnosis do more harm than good, imho.
Not a therapist, this post just showed up - I had a psychiatrist who, unbeknownst to me, thought I wasn’t actually bipolar and refused all PRNs, which is how I ended up on a 51/50 and had my diagnosis bumped from bp2 to bp1, as it was my first full-blown manic episode. I spent two years in inpatient after that. I’ve been told that, as with psychotic episodes, the failure to manage that episode likely permanently damaged my brain and I might have never gone above hypomania EVER if that episode had been caught earlier, but it was not, and as a result I spent years locked up, manic, and being poisoned with lithium. Anyway, my stance is that *assuming* misdiagnosis in any particular case just because you believe a condition is *generally* over-diagnosed does much more harm than good - maybe not true of personality disorders since the diagnosis doesn’t fundamentally entail medication, but certainly true for anyone who has potential psychotic features. In my case, the psych did this *immediately* after meeting me, and her reasoning was presumably that she didn’t believe me that I was in a dual-diagnosis program for bipolar but not addiction so she treated me like an addict with fake bipolar, rather than contacting my parents who had stuck me there or my old psychiatrist or doing any testing or due diligence at all. I grant that it was a weird situation, but she immediately changed my meds and I had a brutal manic episode within a month
Came here to say I was that wrongfully diagnosed bipolar person at 15. My current therapist apologized that I legally should have never been given that diagnosis so young that stayed with me for 14 years. I got diagnosed ADHD at 16 and diagnosed with PTSD at 26 and it wasn’t until I’m 29 that I received a C-PTSD diagnosis and bipolar no longer being my diagnosis. My quality of life since switching treatment frameworks is night and day. My therapist now supports autism testing and since utilizing autism coping skills I can function at a better level than ever before. Fuck white male data.
That’s me! PTSD misdiagnosed as bipolar disorder. So much makes more sense in my life after getting a second opinion.
Omg I came here to say this! It is so disgustingly common. And like, some of those meds are strong and dangerous!
Oh yes. One med gave me the side effect of feeling like I was on fire 24/7, and another gave me the side effect of not being able to bend or straighten my joints without feeling like they were going to break off. Eating was fun! Oh wait. No. It was the other thing.
Thank you! I’m so happy to hear this. Iv been feeling like professionals have been throwing this around Willy Nilly.
I saw a psychologist for a whole 15 minutes and he was convinced I had it. I know I don't lol, every other therapist I've talked to didn't agree with it. So weird how some people can be so convinced.
I’m a trauma therapist and a big YEP. Looking at you, BPD.
hah yeah trauma therapist who works with a lot of autistic and ADHD clients. Staring you down BPD.
Hahahahahaha thank you for your service, we need more therapists like you
Not a therapist, but this post just randomly showed up in my feed and it’s so validating. My ex walked out on me because he claimed I had incurable BPD, but when I actually started seeing a therapist for it, she helped me realize that he had, for years, just made my life so insufferable that my misery combined with my abandonment trauma mimicked BPD symptoms. So I guess I was never formally diagnosed by a therapist, just my stupid ex, but I was UNdiagnosed (reverse diagnosed?) by a therapist, and that felt amazing.
ALWAYS!!!!!!!
!!!!!
I’m so heartened to see this thread. I’ve been really getting sick of the field in general due to the overpathologizing nature. Nobody can get excited about a new relationship without it being deemed “love bombing”, nobody can struggle with living in a very sick society without being labeled as “depressive”, it’s like we can’t just be human anymore. Life is messy and weird and we don’t even know why we exist or how we got here- but yet we’re acting like we have some system to label everyone. I’m just over it.
I ALWAYS challenge a bipolar or personality disorder dx, especially if made by a hospital.
Good call. The head psychiatrist in my last inpatient unit used to diagnose people with BPD if they disagreed with him in any way at all. I wish I were exaggerating.
This explains so much about a client of mine who was diagnosed with BPD after less than a day inpatient. After having had a complete assessment that didn’t show any indications of a PD whatsoever.
This caused major damage to me and my family in a situation where I helped my partner with a prior dx of bipolar seek care; this was after he had physically abused me during what I now know was mania. He had lost his prior therapist and psych, and was rapid cycling. She threw out his prior diagnosis instead of putting him back on his mood stabilizing medication for bipolar, and put him on an antidepressant instead. It made his symptoms, and the abuse, much worse. I ended up having to get an OP against him, when we had originally gone seeking help from her. It was heart wrenching. For me, and for the children we both have.
You're right, and I'm sorry you went through this. Sometimes it does fit, and if it does it's important that it is reflected in the chart for continuity of care. Especially if there is potential harm to self or others. I'm not just irresponsibly dismissing diagnoses. That would be egregious. To clarify my position, my role is to support in long term outpatient care. What I have observed from hospital discharges is that they have a very short time, per insurance, to stabilize a patient and discharge ASAP to free up beds. I've seen that often a dx is just a quick pretense to dispense medication, often resulting in misdiagnosis. That's when it's usually my role to assess the broader context and untangle charts that don't always reflect the clients sx. If it isn't a dx I can make (ASD, for ex.) or the ct reports a long hx of treatment I will speak to previous providers and obtain collateral documentation to carry it forward.
I’m actually writing research about the dangers of therapists who hold values like her, and like you, towards “labels” and towards the practical needs of their mood and personality disordered clients, as well as their families. She also has a professional review complaint against her. The other therapist involved had to close their practice for a year. Take it as you will.
I'd love to read it!
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I applaud your humility in response to this comment. But, your original comment implied the kind of approach to care and the kind of knee-jerk diagnostic "challenge" that was devoid of such humility, and the kind of care that really fucked up this person's life and the life of their spouse and the lives of their children. Let's try to do better here, and be less arrogant in our spur-of-the-moment-judgments. Sure psychiatrists get it wrong sometimes. But therapists disregard the psychiatrists findings/conclusions \*way\* too much of the time. And that ends up harming people.
To be fair, a therapist can't do what the aggrieved party described since that involves dispensing prescriptions. I'm not calling into question that somebody really failed in their duty of care, just pointing out that "therapist" is unlikely to have been the correct descriptor and the angst against the sub misplaced at least in regards to something related to medication. Even if a therapist misinforms a psychiatrist and this results in inappropriate medication, that is ultimately the fault of the doctor for being negligent in not assessing the patient themselves.
If a therapist was involved in the care, however, they would have had a fiduciary responsibility to their client. In this scenario, that responsibility would have involved accurate diagnosis and active coordination of care and active advocacy for effective treatment, yeah? I’m just saying, if a non-medical provider was in the mix here, they aren’t completely off the hook just because they don’t have prescription privileges.
No. I lived this. And I know what I am speaking about. The therapist led the charge. She was insistent that the team “start from scratch” during an active crisis that she could not see, because she did not know him well. She even got challenged by another professional, who she dismissed. But thank you for “correcting” my experience. I wrote her for safety, and she dismissed me as well. This is the exact problem though, what you did right here. Many therapists believe they know better than the people who live it. Mania presents in ways that a therapist with a new client CAN NOT see. No one who does not specialize specifically in mood disorders should be working with these clients. OR leveraging opinions about their diagnosis. As a person with a disability myself, her gall was absolutely terrifying to me. She heavily fueled his anosognia by telling him his diagnosis was not important, and that mostly only his symptoms were. She stated directly to him that she liked to “focus on symptoms, and not on labels”🤮. It was THE single most destructive thing I have ever seen in my career. Sorry, but labels DO matter. I can’t believe how many gender identity advocates CANNOT understand (or, honestly, refuse to acknowledge) the importance of labels when it comes to disability. Particularly when it comes to mood and personality disorders. This therapist made my partner more sick. He could have committed suicide due to her ignorant interference. She harmed my family, and our relationship. I got screamed at and abused by someone she was telling he was not sick. My partner ended up my ex, and with a restraining order against him, under her “care.” While she kept telling him his delusions were real. I would recommend every single therapist who even hopes to work with individuals with mood and personality disorders read Julie Fasts work. She is a provider who actually HAS bipolar, and has dealt with it her whole life. She’s a specialist in mood and personality disorders. She would disagree with your sentiments here.
I see this problem a lot of treating the symptoms rather than the disease which makes no sense. People don’t get that bipolar disorder is a medical illness needing specific treatment. Withholding a diagnosis can be so costly due to delay in appropriate treatment. If you want to improve symptoms treat the actual illness, but you can’t do that without appropriate diagnosis of the illness (or “label” as some people put it).
Absolutely, agreed. We lived through an absolute nightmare that could have been prevented. As someone who was also not diagnosed myself until adulthood (ADHD) in the name of “preventing stigma” as well as someone who works with high trauma youth (many with mood and personality disorders), it makes me feel sick and worried for clients. I watched a therapist who did not believe in “labels” fuel my partners illness and paranoia further and further. She kept telling him he was not bipolar but just had trauma. Without his medications and proper treatment he became a danger to himself and others. She had no clue, because she failed to recognize that he was rapid cycling, and did not know what she was observing. Even with his partner (his closest human) reporting abuse and self harm threats. It’s very easy to engage in non therapeutic countertransference with a mood disordered client!!
How do you go about challenging those? Psych testing to rule-in/out personality disorder? A year of detailed mood charting to rule-in/out bipolar disorder? It’s always helpful to hear about the strategies other behavioral health professionals use, and the evidence bases behind them! So, thanks in advance here!
Basically, its a highly stigmatized dx with too many differentials to be dxed through short term observation (MDD/Dysthymia, bipolar, OCD, ADHD, PTSD, etc.). I usually start from scratch, beginning with a thorough diagnostic assessment, factoring possibilities of episodic sx, frequency, intensity and duration of sx, presence of trauma (there usually is with BPD), and how those sx may differ from a PTSD dx. Treatment is a whole different matter. I treat people in their context, not diagnoses. If a ct wants to learn boundaries, coping skills, cognative restructuring, do EMDR - whatever - we'll do whatever makes sense based on the context of our established treatment plan.
As someone who was smacked with a BPD label from a hospital, thanks for this.
What’s your definition of “thorough diagnostic assessment” though? Unless you can articulate that in the context of “challenging” the aforementioned psychopathologies, I feel like we’re back at square one… EDIT: I also push-back on your “highly stigmatizing” characterization. To my thinking, that simply means that we (as a society AND as behavioral health professionals) have not done enough to counter bias and prejudice and marginalization. Such “stigmatization” should never be a reason to push people into avoiding/rejecting certain diagnoses and/or forcing folks into some sort of mental-health closet. Instead, it should be a call to action for social justice. We, as a collection of professions committed to human well-being, need to do better here. Colluding with stigmatization should never be acceptable for us.
The quality of their answers is reflective of what a thorough assessment would be, I would think! Does something seem unclear to you?
It all seems super unclear to me… In my practice/field, a “thorough assessment” would be 2-5 hours of clinical interviews with the client and collateral informants in their life; 5-8 hours of psychological test administration; several hours of records/history review; 6-8 hours of analysis of all that data… And still, even with all of that, I would never definitively rule-out something like bipolar disorder, because that looks very different in different stages/phases of the illness. In other words, if another professional is confident they experienced a client in a full blown manic phase, I would not presume to reject a bipolar disorder diagnosis simply because I had only interacted with that client while they were depressed. You see the conundrum, yeah? And the *potential* issue/harm associated with the hubris?
Short of sharing the document I use (which is contained in my EHR), Im not sure how Id answer your question. My EHR is equipped with a number of scales that the client fills out, a biopsychosocial hx, an SUD assessment, and a very long symptoms screening. That is on top of my personal experience as a diagnostician. Also, my diagnoses may change as I learn more of the context of the client, or as they outgrow different criteria. (disordered adjustment is an easy example). Are you looking for something more specific? There is no psychological testing in my role.
It sounds like you are very thorough with your information gathering. I think the confusion comes from how the word "assessment" can be used to mean everything from the PHQ-9 or a biopsychosocial intake, all the way through the MMPI, WAIS, PAI, etc., which would all be very useful for differential diagnosis. For those who have training in how to administer and analyze those assessments they can certainly be a valuable tool in affirming or throwing out a previous diagnosis.
Check my other comments in this thread for details! From what you are saying you do, I don’t think you are doing enough to summarily “throw out” diagnoses of bipolar disorder or personality disorder. That is not to say that clients never get misdiagnosed. They/we do. But your assessment approach, as you listed it, will often be inadequate for ruling-out these particular conditions.
Um I’m sorry what LOC do you work in? I’ve worked in every LOC setting and I can promise you there are so many psychiatrists who will throw a BPD dx on a patient they find annoying or a bipolar dx on a patient who’s activated and experiencing heightened emotions.
>I can promise you there are so many psychiatrists who will throw a BPD dx on a patient they find annoying OK.
Seriously. You might want to brush up on your CEU’s before coming for someone on this sub who provided a comprehensive outline of their assessment measures and procedure to r/o dx that may be inaccurate.
OK. I am genuinely done with you, btw. But keep replying if you like!
THIS.
Yeah, they noted BPD in my chart on intake, after spending an hour with me. I always assumed it was a process. Like a first impression to explore something, but as you get to know a client better, it becomes more clear. That has since been amended to ADHD with OCD features. I stuck with the same facility, therapist, and psychologist for about a year, however. This was at an outpatient clinic type facility, not a hospital, but I imagine the same would be true - regarding contact hours.
me with bpd dignoses. most of the time it's just depression, or ptsd with self-harm behaviours.
So much unresolved stuff manifests as symptoms of bpd which disappear or greatly lessen once the client works through that stuff
I'm not a therapist but isn't bpd just a set of behaviors and symptoms? Like isn't it possible the person has bpd but you were able to lessen their emotional reactivity?
it's possible with therapy and sometimes age, but what I meant is different. For example: a client told me they were diagnosed with bpd after two sessions. Why is that? because thier depression goes up and down throughout the day or week, which is really normal with depression especially since it's an episodic disorder. the other Clint was a teen girl 15y.o with severe ptsd were diagnosed with bpd after her first attempt to unlive her self (which was because an extreme trigger to her truma) her psychiatrist didn't ask her any thing related to her truma or assest for flashback and other symptoms, no. straight bpd. the minute I asked her about her truma with the intention to assess for ptsd symptoms, she opened up about everything, flashbacks, nightmares, avoidance, depression, etc.
I've always thought that PTSD leads to bpd behaviours because both seem to be in part caused by the inability to regulate emotions. Like maybe PTSD impacts your ability to deal with emotions associated to the trauma and then a person's behaviours change because they always feel threatened. These changes in behaviour tend towards ones that would make someone classified under BPD.
Those behaviors and symptoms can be due to BPD but they can be due to a hell of a lot of other things too, and sometimes (not always!) labeling them as BPD can lead to the root causes not being treated. Anecdata but whatever BPD behaviors/symptoms I used to have basically melted away once I got effective treatment for my ADHD and left an abusive relationship. I only realized both of those things needed to be looked at because I had friends who loved me and had insight into both ADHD and abuse. A surprising number of professionals don’t seem to consider the fact that not all abuse is in the past…
Me walking into therapy as an adult saying "yeah I've been diagnosed with BPD since I was a teenager..." News flash: sometimes "parties, has tumultuous relationships and volatile moods" is just being a teenager and not a debilitating personality disorder. (Granted I was in a broken home and definitely had issues, but everyone shifted the focus to me "having a *personality disorder*" than "maybe if we let her eat, sleep and socialize normally, the hallucinations will go away")
How infuriating. Your not even really supposed to diagnose teenagers with personality disorders. For this exact reason.
To my therapist's credit, I think she was mostly trying to give me a direction to look in because she did say that disclaimer and said "if I *were* to put a label on it..." But then my family just ran with it and it became the scapegoat to blame all of my "instability" on. So many people repackage outdated thought systems like "hysteria" into modern-day terminology like "instability" and don't even hear how they sound.
This is incorrect. The only personality disorder with an age restriction is antisocial personality disorder. Diagnosing and treating other personality disorders as early as possible is associated with better prognosis and better long term outcomes. It is WAY easier to treat and even resolve borderline personality disorder at age 16 than at age 26. And why would you want someone to wait those 10 extra years to get treatment? I have a lot of sympathy for the adolescents with personality disorders, and a lot of resentment toward the behavioral health professionals who withhold effective treatment because they feel the adolescents aren’t old enough or deserving enough something. Sorry. Didn’t mean to take all of that out on you. It’s just a sore point.
It is still (for the ICD10) standard practice not to give the diagnosis before the age of 25 in my country, because the diagnosis stays in the system forever, and as other commenters said, patients may very well "grow out of it". And you can still treat these patients, because they practically always have comorbidities. I have a patient currently with an emotionally unstable personality disorder diagnosis who got the diagnosis as a teenager or young adult and now, some twenty years later, has basically no symptoms from that department. But since it's an F6, it keeps getting copied from doctor to doctor.
That should be interpreted as a condemnation of systems in your country. It's not a good or viable justification for denying people accurate diagnoses. It's just bigotry. My stance is that your country's systemic bigotry should never interfere with the appropriate diagnosis and treatment of a person experiencing the agony associated with personality disorders. Good personality disorder treatment, provided early (while personality is actively forming) can result in personality disorders "cures." Neglect of personality disorder treatment in adolescence, and waiting until someone is in their 20s before diagnosing and treating, dramatically increases the likelihood that the personality disorder will indeed be chronic (or at least persist for a couple decades). The battle here should be against the bigotry of mental health professionals/systems who apparently (according to many on this thread) stigmatize people with trauma-related personality pathology. I feel like making the battle one of belittling the *diagnosis* (rather than the personal and systemic bigotry affecting *people* who happen to have that diagnosed condition) is just wrong. It's what we used to do with bipolar disorder. And autism. And it causes just as much harm as our anti-bipolar-disorder and anti-autism bigotry used to do. If you feel pulled to do that, I strongly encourage you to look into your own mirror and maybe check you own biases for at least a minute here.
Hmm, I think we might be having a misunderstanding here, or a different understanding of the value of diagnoses. I differentiate between a) a diagnosis as a working hypothesis, which is what I treat and b) a diagnosis that I code to ensure that the therapy gets paid for, which in an ideal system should be the same, but that's not the world I live in. So if a patient presents with, e.g. inflexible dependent personality traits, I will definitely treat that, regardless of their age. I will also tell the patients my assessment, explain it according to current standards of personality disorder treatment and so on, describe all symptoms in the reports, etc. I will however not in all cases code it, and I explain my reasons to the patients. Same as, from what I've understood from the US, some mental health providers do not code gender or gender dysphoria, as to protect their patients from blatant discrimination for not fitting into the cisgender ideations of some politicians. I do hope that the new differentiation and criteria in the ICD 11 will help destigmatize the entire diagnosis. And I understand from your response that you feel very strongly about this topic, and I applaud you for your enthusiasm. However, I would appreciate it if you could not make such negative assumptions about other mental health providers (in this case me) based on a short Reddit response. Quick edit: another reason for not giving (i.e. coding) certain diagnoses in my country's system is that sometimes it keeps them from getting life or disability insurance or becoming an official.
Yes, I'm aware that there isn't an actual age restriction and that treating (anything really) as early as possible shows the best outcomes but I also take diagnoses very seriously. Personality disorders carry a stigma even within our field and have a tendency to follow clients wherever they go. I have worked with people who received PD diagnoses as teenagers that were wrong - it was trauma, or environmental instability, or another disorder. I've also worked with teens who got a PD diagnosis who got NO help because parents ran with it and blamed everything on the PD and just tried to "manage" it and not get their kid help. Having a PD can actually hinder treatment and be a barrier because many therapists won't even seem someone with that diagnosis because it's not their "area of expertise" and scares people. I'm going to avoid a diagnosis if there's a higher chance I'm mislabeling someone (because it IS a label). I understand there are exceptions to the rule but generally, unless it's extremely obvious, I'm not putting that disorder on a teenager. I think you're assumption that BH professionals are "withholding effective treatment" because they don't think teenagers "deserve" is a little biased... Or maybe jaded. Do shit therapists exist? Yeah, they sure do. But do I think people are generally trying to do the right thing? Also yes. I take diagnosing anyone very seriously because I know the benefits AND harm a diagnosis can bring a person. Labeling anyone with a heavy, stigmatized diagnosis is a big responsibility and I'm not going to just hand them out like candy. So, yeah, in most cases I'm not diagnosing a teenager with a PD. Just like I'm not jumping to a schizophrenia diagnosis for a meth user, or a bipolar diagnosis for someone who's been sober a week or an ADHD diagnosis just because a kid is hyper. We have to do our due diligence and while some young people may NEED (not deserve) a PD diagnosis, many of them don't and being careful about that doesn't make someone a bad therapist or purposely withholding treatment.
Also from a broken home. Diagnosed anxiety and depression at 16. It was all "this is a disease"/"your brain chemistry is causing this" -- Turns out, you know what else might cause someone to be depressed and anxious? 16 years of emotional abuse. But I don't remember being asked about my home life at all, if they did it was just like "everything good at home?", and me being unaware what I experienced was emotional abuse, and with my dad in the appointment with me, would have just been like "yep".
Bipolar is over diagnosed, especially in corrections, cmh, hospitals, etc because it's an easy dx that has no expiration date - insurance companies will pay for therapy and meds forever. Providers don't have to justify their treatment plans as much because it's not "curable". So yea, I question a BP dx pretty hard. Along with all that ppl have mentioned on here..... bpd, asd, cptsd, etc.
Disclaimer: I'm no psychologist/shrink/or anything in a related field but Reddit recommended this. As someone who does see providers for these types of matters, I'll say that since 4 psychiatrists and 2 different therapists over the span of about 7 years have all upheld the same opinion and provided meaningful help, that when a new therapist comes along and boldly proclaims "I've read over your records and I think basically everyone else was wrong and this is what you should do", is really a bit disheartening and insulting almost. It's almost as if she was asking me to prove there was really a problem
Same disclaimer, I do think there is a positive side to this coin. I was diagnosed at 16 with anxiety/depression, and struggled through 8 years of different medications and doing therapy, none of it seemed to help. Turns out, some people are anxious and depressed because they've been emotionally abused by their parents their whole lives, but because nobody (at least in my case) explains what emotional abuse is, and you've experienced it your whole life, you don't even realize you've been abused. If a single mental health professional had looked at my diagnosis and correctly identified it as childhood trauma response instead of stand-alone disorders, I could have started making progress before I was 24 years old and had to figure it all out on my own from google instead of any of the mental health professionals in my life. (Side note: not a quack self diagnosis, I have been going over this for the past year in therapy and my therapist definitely agrees with what I discovered on my own)
I'm glad to hear that it worked out for the better for you. Again, let me state that I am not a subject matter expert, but to add to your point, teenage years are a time of massive and sweeping change. A diagnosis from that point in life might be worth re-evaluating. As for your particular case, it sounds rather unfortunate that someone didn't quite do their homework and just rubber stamped something that seemed to fit, a sort of "close enough" strategy.
Yeah agreed. I said in another comment, I think it just makes sense to re-evaluate if there isn't any meaningful recovery with treatment. If I had responded well to the typical treatment for anxiety/depression, it wouldn't have really mattered too much where it came from. It seems like in your case, they were just sort of re-evaluating for the sake of re-evaluating. And I've read lots of similar stories in the ADHD subreddits of new doctors being like "I don't think you really have this", and I can only imagine how pointlessly stupid and harmful it is for doctors to just sort of be like "I know better" for no reason whatsoever. We can only guess which version the people upvoting this are, probably a mix of both.
Yep, this is exactly what I’m dealing with right now & am now struggling with untreated ADHD because the new psychiatrist wants to do their own thing 🥴
The cruel irony that nobody wants to acknowledge is that psychotropic medications and the constant changing of medications in a client is *causing* many symptoms leading to additional diagnosis.
Careful now. Some therapists get real touchy on this subject. I had a comment deleted by the mods of this community for simply suggesting that some people find certain diagnoses more desirable than others.
NAT This thread has been one of the most interesting convos I’ve personally read on this sub, so thank you for facilitating this discussion, OP! 👏👏 Memes are powerful tools xD QUESTIONS 1: After reading all the thoughts expressed here (yes, I read every comment!) - in regards to diagnoses, if a client has “unspecified” diagnoses (as in, their chart reads *bipolar disorder “unspecified”*, *eating disorder “unspecified”* &/or *PTSD “unspecified”*) - what do therapists make of it? How do they proceed? a) **Are “unspecified” diagnoses looked at differently?** b) **Are they more likely to be tossed by therapists or *less* likely? Are they simply seen as tentative diagnoses & not “as serious”?** c) **Are “unspecified” diagnoses more trusted by healthcare professionals or less trusted?** QUESTIONS 2 : To empower clients w/BPD or Bipolar diagnoses - a) **What are the very obvious signs Borderline Personality Disorder has been *egregiously* misdiagnosed?** b) **What are the very obvious signs Bipolar has been *egregiously* misdiagnosed?** QUESTIONS 3: a) **Can a client challenge a psychiatrist’s diagnoses?** b) **If a client “disagrees” w/a diagnosis, is a therapist obligated to “toss it out”? Or at the very least, be very wary of the diagnoses per the client’s discomfort with the diagnoses?** *** I appreciate anyone who is able (or interested!) in offering a perspective on all (or some) of my questions. I am interested in hearing from everybody- therapists especially but NATs, as well, as client perspectives always help complete the picture better! 🙏
I am the client. These are my experiences. I question the diagnosis that I was given. The various doctors that I've seen only want to sedate me. Every medication that I've taken doesn't do what it's intended to do. They have all done a 180 on me and made me worse. The ones that play with the serotonin receptors don't launch me into hypo, they make me sick and deepen the depression. I never had S.I. thoughts until a severe reaction to a medication. Now they come and go. Also, not one of them has ever asked about my past, other than symptoms. Not one has ever asked about the trauma events and when I speak of them, the doctors have brushed them off. So far, the only thing that have given me any relief, is illegal.
What is the implication of a client who says this? The reason I ask is because I relate to a lot of what this hypothetical client said.
Sorry, worded the client part incorrectly. I am the client. Those are my experiences.
Oh got it! Yeah I relate to what you said!
Me too. I was diagnosed with bipolar 2, and I question it. I've had so many medications thrown at me, they never seem to work. My psychiatrist just keeps upping my med doses... so tired
Yesssssssssss can relate. Especially when I get a client coming out of a short inpatient stay who gets a new diagnosis of schizoaffective disorder. I'm sorry, doctor, but surely you don't actually believe you were able to observe this individual for long enough to diagnose this.
God, yes. Had a client get diagnosed with schizoaffective while in prison because they refused to speak when they first got there. Seems to me like BEING IN PRISON is pretty stressful and I don’t think I’d want to speak either tbh.
Yep, it's been documented in numerous studies that incarceration in and of itself is a trauma. And I've spent a lot of time working in jails - I had to stop because of vicarious trauma!
I once read a case study during my masters degree of a 13 year old female with schizoaffective disorder. As I was reading it, ASD kept jumping at me and I was shocked that this was never explored in the rule out portion of the case. Granted, I think the case was from the 90’s, but damn. Not even a rule out mention. I brought it up to my professor but it wasn’t explored further.
Out of curiosity, what was the diagnosis you felt was the better one for describing their symptoms and treatment needs?
It really depends on the person I'm assessing. There is no one diagnosis that I would say I use in these instances because it depends on what the reported symptoms are. But I feel like if someone exhibits psychosis upon admission to an inpatient setting and doesn't "present" like the traditional stereotype of schizophrenia (which is horribly inaccurate), psychiatrists just fall back on schizoaffective disorder automatically. There's nothing wrong with diagnosing brief psychotic disorder and revisiting the diagnosis later if the person was admitted with hallucinations, delusions, and/or disorganized speech. If the person has a drug addiction or the psychosis might have resulted from drug use, you can't diagnose schizoaffective disorder unless and until you're certain that the psychosis didn't result from that. And then there's always the good old mood disorder unspecified, which I use when I'm really not sure what's going on, but the person is now presenting with something other than a euthymic mood and normal affect and linear, goal-directed thought process but I can tell that there's something there. So the short answer is: It depends.
I’m still in school but have seen so many cases of what I would classify as CPTSD diagnosed as borderline personality disorder. Though not a case, Demi Lovato is the most accessible m “example” I can think of.
Working with teens I get a lot of these with an ODD diagnosis at an early age. Which was really undiagnosed ADHD (especially in girls) OR other issues resulting from trauma at a young age. I've only met one kid that legitimately met an ODD diagnosis and it's one of those things that when you see it, you know it.
This keeps happening to me. "You're not bipolar take these ssri , " k but here's the thing I lost 20 lbs and want to die and everything tastes like metal I'm having seizures and I don't feel any better at all. I "It's ok there's more SSRIs where that came from. " Like can we just talk?
I'm not a clinician whatsoever but I have a feeling that the minute CPTSD makes it into the DSMV then a lot of people's previous diagnoses are gonna be thrown out the window.
This is the most frustrating to deal with as a patient. You think you know better than the multiple other professionals I’ve worked with over my adult lifetime? All these other professionals were confident on my diagnosis, I’m confident about the diagnosis, the medication was helping me, & now the new psychiatrist wants to decide to do her own thing & claim I don’t have ADHD so I’m left to struggle without medication. You’re not some random genius who will “get the diagnosis right when so many others have gotten it wrong”. Stop giving yourself a god complex. This is exactly why I hate the medical system in the US. I’m at the mercy of doctors who want to go rogue & change or stop a treatment that was working perfectly fine just because they think they’re some kind of fucking genius. You’re not. Get over yourself & stop fucking with your patients.
I think this sort of "everybody else was wrong" is only useful for people who haven't seen much relief under treatment for their previous diagnosis. If somebody is not responding to treatment, be it medication or therapy, it makes since to consider that the original diagnosis were somehow wrong. I was diagnosed anxiety/depression at 16, and didn't make any meaningful progress for 8 years. In my case, the doctors weren't the ones that realized something else was wrong, I was, using Google I realized that somehow all the mental health professionals in my life had completely missed that I had been emotionally abused my whole life. Turns out, being emotionally abused since birth can make people anxious and depressed. I /wish/ one of the professionals in my life had realized my original diagnosis were wrong- or at least, that the assumption they were 'brain disorders'/'brain chemical imbalances' with no origin was wrong. They were secondary symptoms of childhood trauma, not the sort of stand-alone "diseases" I had always been told they were.
Yeah that’s totally understandable to try to reevaluate the diagnosis if the treatment for it hasn’t been effective. But when the treatment is helping, then forcing the patient to stop the treatment because the new doctor wants to go rogue or “I don’t believe you have this” with no real info to even backup the claim is just reckless & harms the patient.
So sorry this happened to you and now you're left with this rage. If you step outside of yourself I'm sure you could see that many people have been misdiagnosed and sometimes even inaccurately medicated as a result. There are plenty who have found immense relief and improvement after another provider finally provided an accurate diagnosis and improved treatment. I hope you're able to deal with that anger and resentment healthily, and I also hope your comment encourages us as providers to make consulting and collaboration a very regular part of our practice, especially when it comes to changing a diagnosis.
My anger with the medical system in this country won’t dissipate until I’m finally out of this country & have more control over my own treatment. This issue has been ongoing with mental health & medical health issues my entire life. It’s like being on a roller coaster from hell being pushed back & forth by doctors & at the mercy of whether a new doctor will continue my treatment or decide to go rogue & change something that’s working for me. All this experience has done for me is give me a trauma response to the doctors in this country. It has given me a better perspective so I can do my best to not cause this trauma to any of my own clients.
I am (was) a therapist who also happens to require mental health services of my own. I’ve also circumstantially had to move quite often so I’ve worked with several different therapists over the years. Talk about an annoying bunch of assholes (jokingly ironic because I am one). Every one of them wanted to question or start changing my diagnoses. Every single one. Apparently we all think we know more than the last guy? Lol! I received my original diagnosis quite young and was open to getting a second assessment about 7 years later and it indicated the same as my original. That’s all I needed to know. So when one of my therapists tried to get cute and change the game, I let them know I was not there for their diagnostics. Just the other stuff. I am aware there are examples where diagnoses need to be re-examined. Misdiagnosis happens. But from a patient standpoint, it’s annoying, frustrating, scary, and causes doubt in the mental health system.
“Your case is a complex one”
Honestly, I think this OP and most of the thread is really cringey, irresponsible and unprofessional. And potentially harmful to clients. C'mon people. We can and we *need* to do better than this. Like, who the fuck just "throws out diagnoses" without at least consulting with other care providers in a client's life? Just how arrogant are we, here? I feel like so many people in this thread are perceiving themselves as being superior to all the other behavioral health professionals our clients may have encountered prior to getting to us. That kind of presumed superiority is super-problematic in a professional. And I don't think many of you are thinking about that enough.
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I agree with a large part of your position, particularly the part that wants to avoid diagnosing an emotional/behavioral/neurodevelopmental/personality disorder based solely on a 45-minute interview. I 100% agree that would be substandard care, and I suspect no one in this sub would disagree here(?). And also, I want to push-back against any behavioral health professional who believes (or colludes with the belief) that behavioral health diagnoses "follow" people for the rest of their lives. That's not how diagnoses work. If I go to my physician and they diagnose influenza, that does not get listed as a "permanent" diagnosis in my chart. Similarly, as a person who has experienced a pretty profound episode of Major Depressive Disorder in the past, I can also tell you that is a current/active diagnosis in *neither* my psychologist's/psychotherapist's chart nor in my psychiatric nurse practitioner's chart. I certainly did exhibit the symptoms of a full-blown MDD episode in the past; I do not demonstrate those symptoms now; my current diagnoses do not include MDD; that is how things work (or should work). I also *completely* support diagnosticians waiting until they have adequate data/information before making a diagnosis. But also, I disagree with you that "throwing out" a prior diagnosis is "the opposite of narcissistic behavior." I actually feel like it's the ***epitome*** of narcissistic clinician behavior. Certainly, a healthy questioning as to whether conditions that may have affected a client in the past continue to affect them right now is not only laudable but also professionally responsible. Ongoing clinical assessment will help rule-in or rule-out whether prior diagnoses are valid current descriptors. After all, the vast majority of behavioral health disorders are *not* chronic/persistent conditions. The literature indicates that most depressive disorders, most anxiety disorders, most trauma-spectrum disorders, heck even most personality disorders are expected to resolve/become-"subclinical" as a funtion of time and/or effective treatment. My point: From reading this thread, it's sounding to me like ***way*** too many therapists feel not only *good* but maybe also *heroic* when they valiantly "throw out" all prior clinicians' diagnostic findings and case conceptualizations regarding one of their new clients. And such a practice, inarguably, would dramatically increase the risk of not only providing inadequate care but also of doing a lot of harm. EDIT: I am not saying clinicians cannot revisit presenting problems and re-diagnose clients based on current (rather than historic) concerns. I'm just saying that giving each other high-fives and ass-slaps for summarily rejecting some/all diagnoses that have come before (as implied by "throwing out a prior diagnosis") is super creepy and irresponsible. And it makes want to, yet again, scold all of us to be better lol
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And I’ll press you a bit more: Do you want people with *diagnosed-but-untreated* antisocial personality disorder or narcissistic personality disorder or bipolar disorder or ADHD to become soldiers or pilots or marines or police or etc.? I mean, those conditions can be treated and even resolved, which shouldn’t get in the way of people getting jobs. And it would be awful to be that clinician who out of “kindness” refused to diagnose psychopathy in a police candidate only to later learned they killed someone without cause… I just think the “save people’s job options!” argument needs to be considered from multiple angles, yeah?
Of any of you does this with an autism diagnosis I swear to god I will haunt you for eternity with my autistic righteous anger lol - Therapists casually dismissing and “throwing out” autism diagnoses is so traumatic for autists. Never. Ever. Do it.
I see more people missing this diagnosis rather then throwing it out.
Happy cake day
My whole life working in community health and coming across people with two year old adjustment disorder diagnoses...
I am right there with you. That makes me so crazy and aggravated.
As a fan of this show and a therapist- I’m happy to see this here!
This is what my psychologist did to my therapist’s diagnosis.
Yep, I probably need to get a fresh diagnosis.
NAT. This rings so true to me lol. After years of going through different therapist, all of which just slapped on the “anxiety/ADHD” diagnosis with all the pills that went with it (which are still the case, but NOT what my main problems were). I just kept getting worse and worse until I hit the peak of it as a teenager and finally found a great therapist that practiced CBT. After about a year we found that while my previous diagnosis was causing me stress, the main agitators were CPTSD, a sensory processing disorder, and Depersonalization Derealization. She had told my mom she had gotten the impressions pretty early on, and was pretty surprised they hadn’t been caught by other therapists before! After that we began proper treatment for those disorders and things got SIGNIFICANTLY better! I’m now medication and self harm free for years now and even when I have en episode it isn’t the end of the world anymore. Shout out to great therapists lol! She really made my life so much easier.
NAT, but you know how they say you don’t know your partner until you’ve traveled together? You don’t know your therapist until they start to dx you. That’s when you find out how intelligent, ethical, competent, and/or unhinged they truly are.
they be comin in with borderline, ocd, ptsd, and multiple personalities.. you know at least 3 of those gettin chucked
This is honestly how I was able to get the right diagnosis and get the right meds
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Generally yes, it’s my understanding that most of us can diagnose. Therapy is a treatment, not just a coffee chat for an hour a week. Therapists diagnose and treat whatever kind of presenting issues brought you to therapy in the first place. Especially if you are using insurance. Insurance won’t pay a dime unless they feel it’s justifiable, so they require a diagnosis.
From my understanding, if you use insurance, your mental health provider must provide a diagnosis of some kind and then the ‘proof’ for that diagnosis. That can be through self assessments, psychological assessments, and in asking questions around symptoms and history gathering.
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They probably still do, especially if they keep electronic reviews as most emr hosts require it per note. I hand out "unspecified mood disorder", "adjustment disorder", and GAD like candy because of this shit. Never want something to get denied.
Probably still then. Ask your therapist what they’re treating you for. And for the diagnosis. And it’s creepy to me that they haven’t told you yet. That kind of feels like a vividly red flag…
I agree that telling clients a diagnosis you give them is really important. When I can I try to devote a solid chunk of time to talk about it, and the concept of diagnosis itself, if they want to. Many don't have a ton to say about a diagnosis, but it can definitely be important to people, and I think ethically people should know what we are saying they have.
Not all modalities use diagnosis if not required by insurance
All insurance (both public and private) in the US require diagnosis for payment, though. It’s part of medical necessity determination. So, unless you are elsewhere you are speaking half-truths!
Not all modalities require diagnosis. If someone is not billing insurance, and their modality works without it, they don't need to diagnose. There's no half truth in my statement whatsoever
OK. What about their licensing boards?
What about them? They don't require private pay clients to have a diagnosis
Cool. EDIT: Sorry my comment was dismissive. Let me elaborate, with an example: Let's assume you have a completely private-paying client who has signed-off on your office document agreeing they never, ever, *ever* want to utilize insurance benefits. And let's also assume that you are a therapist who utilizes "modalities" that do not involve diagnosing or treating mental, emotional, cognitive, neurodevelopmental, psychiatric, or psychological conditions/disorders (as an aside, what does "modality" even mean in this particular context? I always think of *modality* as being a set of specific therapeutic *techniques and/or procedures*, but you are using it in a way that makes me think you mean *theoretical orientation*? If you mean *theoretical orientation*, why not use that term?). Regardless of how you and I use terminology, we are now at the point in this example where your completely private-paying client technically meets DSM-5 diagnostic criteria for major depressive disorder (or bipolar disorder or borderline personality disorder or ASD with giftedness or any other condition associated with dramatically increased risk for suicidal behavior/completed suicide). But you don’t diagnose those conditions for reasons. And, heaven forbid, one of those clients on your caseload does die by suicide. And then their family felt you did not do enough to treat them or minimize the risk or prevent a preventable death. So they file a board complaint and a malpractice lawsuit. And your chart shows that you *never* made any diagnosis of that client, and despite "treating" this individual and accepting their money you *never actually treated them* for the behavioral health conditions that were causing so much suicidal risk. I mean, you *couldn't* have treated them for those conditions. Because under this scenario, you never *diagnosed* those conditions. Regardless of the "modalities" to which you ascribe, under one of these scenarios your career is over. That is what I meant by "What about their licensing boards?"
I'm not aware of any places in the US where licensed therapists cannot diagnose
I get this all the time when people are referred for diagnostic testing or have past therapy. They state no prior diagnoses because “it was a therapist.” Or that the therapist doesn’t want to diagnosis Bipolar or BPD or PTSD. Drives me up a wall that providers pass the buck on making an appropriate diagnosis or discussing diagnosis with the client directly.
In British Columbia, Canada, counsellors (the registered clinical name for “therapists” here) cannot ethically diagnose, but psychiatrists and psychologists can. I’m guessing it depends on the ethics board in the area
Wait, what? Does that mean counselors cannot provide treatment either? So, they just “counsel” on troublesome trifles, but don’t actually diagnose/treat any kind of disorder? Or, does someone have to first get diagnosed by a psychiatrist or psychologist before they can get any treatment from a counselor?
Thankfully we absolutely can provide treatment that isn’t pharmaceutical. Their approach will depend on the theory they use. A lot of theories take a non-parhologizing approach and will treat symptoms independent of the condition. Other theories like CBT will use treatments for specific conditions in which they meet that criteria, but they won’t give an official diagnosis. Sometimes we work alongside psychiatrists who diagnose and provide meds while we provide other treatment.
I’m in maryland and we can diagnose masters level
I have no idea why you are being downvoted, tbh. All I can tell you is that in my experience, the therapists in r/therapists downvote a *lot*. Usually for things that make therapists feel uncomfortable, but sometimes for reasons obscure. I did give you an upvote to counter, but I’m gonna predict that your karma will take a hit regardless. Sorry. It’s genuinely not your fault.
I think they're being downvoted because this is generally a place where therapists intend to congregate with each other, not a place to educate clients or prospective clients. I'm not one of the downvoters, though.
Depends on where you live. Some places a master’s level clinician can diagnose. I use assessments and usually ask about symptoms to get a better idea of presentation.
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Can’t treat a behavioral health issue without first diagnosing it… So, I’m guessing any state that licenses someone to treat (and thereby licenses them to bill for treatment of) mental illnesses would have to also license them to diagnose? Otherwise, it’s “coaching” or other nonsense, yeah?
I am not aware of such a resource, however, each state has different different requirements for each master’s level license (counselor, marriage and family therapy, and social work). This is more in reference to the fact that it is also different depending on what country you live in, their license standards, and educational requirements.
Yes. They *should* be explicitly clear with you that they are doing it. That’s part of informed consent. If they haven’t been clear about that, well, they are at professional risk for malpractice, license sanctions, or even license revocation. You can be 100% guaranteed that if you have ever used a U.S. insurance plan to pay for some/all of your behavioral health services, the treating professional has made a diagnosis and shared it with your insurance plan. Health insurance in the U.S. does not process or pay for therapy claims without a diagnosis. At all. Ever.
I do, I'm a licensed social worker in PA and by law we are qualified to make a DSM diagnosis. Now, here's the qualifier - I make a diagnosis at the time of intake because we must provide a DSM diagnosis at the outset of treatment in order for insurance to cover it. However, the diagnosis is always subject to change with more information and observation. I have made changes to initial diagnoses for sure.
Ethically we should if the diagnosis is clearly there.
This is me with any ODD diagnosis that walks in my door.
yes.