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It seems to me that many psychiatrists cannot tell the difference between Bipolar Disorder, and Borderline Personality Disorder (BPD). From your description your daughter has BPD which should be treated with therapy rather than with heavy duty psychotropic medications.
Let me give you the "official" diagnostic criteria for both mania (part of bipolar) and BPD. You can see the similarities. Violent and aggressive outburst and cutting and purging are characteristic of BPD and not of bipolar disorder.
A) A distinct period of abnormally and persistently elevated, expansive or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)
B) During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
1) inflated self-esteem or grandiosity
2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3) more talkative than usual or pressure to keep talking
4) flight of ideas or subjective experience that thoughts are racing
5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6) increase in goal-directed activity (at work, at school, or sexually) or psychomotor agitation
7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C) The symptoms do not meet criteria for a Mixed Episode
D) The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
E) The symptoms are not due to the direct physiological effects of a substance or a general medical condition.
BPD – DSM-IV
1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterised by alternation between extremes of idealization and devaluation.
3. Identity disturbance - markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging, e.g. spending, sex, substance abuse, reckless driving or binge-eating.
5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.
6. Affective instability due to a marked reactivity of mood, e.g. intense episodic dysphoria, irritability or anxiety, which usually lasts for between a few hours and several days.
7. Chronic feelings of emptiness
8. Inappropriate, intense anger, or difficulty controlling anger, e.g. frequent displays of temper, constant anger or recurrent physical fights.
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
Anyone with six or more of the above traits and symptoms may be diagnosed with Borderline Personality Disorder. However, the traits must be long-standing (pervasive), and there must be no better explanation for them, e.g. physical illness, a different mental illness or substance misuse.
There are many side effects to the Abilify.
However, it is not really effective for BPD. Dialectical Behavior Therapy is the treatment of choice.
Let me recommend some books for you that will give you clarity and understanding.
And here is a book about the treatment I mentioned. This is actually a self-help book, but therapy is the best option.
Psychiatrists do not usually do therapy. They do not find underlying solutions. They usually suppress symptoms with medications.
Thank you for your information. Re: mania - She meets the irritable mood criteria, has had what appear to be "mixed" episodes and has definitely had disturbance of mood which has required hospitalization. She also has psychotic features during these elevated episodes (asymmetrical pupil dilation, completely unreachable). Re: BPD, she definitely has some of those features as well (not so much the idealization extreme, though).
What are your thoughts on lamictal? I feel we do have do help her to manage her moods - it's like a switch goes off and she's a different kid. She has well periods, and then definitely not so well periods.
Being unreachable could be the severe dissociative symptoms of BPD.
If the Lamictal is acting as a circuit breaker and allowing her to be more functional then it is a good idea. She may have bipolar and BPD as well, thus showing symptoms of both.
If she was at first being given only antidepressants (Wellbutrin and Prozac) they may have been causing the mania symptoms, particularly the mixed state.
Antidepressants without antipsychotics or mood stabilizers or antiepileptics will often increase mania and induce the dangerous "mixed" state.
AND?? You can have both? I am concerned to get her off the Abilify as it has really curbed the outward violence (really extreme and unsafe behaviors) and has helped her to stay reachable. Can you recommend something else to help her maintain control and stay reachable? I feel like every time she dissociates, the more likely it will happen again. The mania/mixed state started well before the antidepressants. They just made the Sx worse - more agitation/aggressive behavior.
The abilify helped the mania and mixed state, but in return the Sx have gone inward toward herself. She did not have this before ability, or maybe it was underneath the whole time?
Her psychiatrist is using the only method available which is trial and error, since different people react differently.
It was probably all there before. The psychiatrists must prescribe according to the best results that they get.
Has she been (or will she) talk to therapist as well?
You can have both. One is a personality disorder and the other is a mood disorder.
I can't stand the trial and error method - I wish there was a better way. AND, what makes therapy challenging is that my daughter doesn't want to be there so isn't getting much out of it. She doesn't experience the magnitude of these episodes & has a hard time reflecting on them. She'll say "it wasn't that bad" - when it is a SIGNIFICANTLY dangerous situation. Her personality when out of episodes is sweet and sensitive and kind. Jeckyll and Hyde...
That is typical. I have worked with many with BPD and they can be the sweetest people imaginable, until they imagine rejection or abandonment, and then become frighteningly angry.
You need a therapist who works exclusively with Dialectical Behavior Therapy. She may or may not respond, but it is worth a try.
Get the books and it will help you understand that aspect of her problem.
Unfortunately, trial and error is the only method, though in the hands of a skilled psychiatrist, finding the best drug combination is more certain because of their experience and practice.
A lot of issues around trust. And, yes - it's as if she misinterprets our house rules as rejection & becomes frigtheningly angry. Can DBT cure this? Background history: at age 3.5 she had 105-106degree fever x 1 week - Dx encephalitis. Biological great-grandmother bipolar (committed suicide at age 30). Prior to illness, no issues with behavior. VERY easy & happy baby. In survival (hands over ears, couldn't touch, wouldn't keep clothing on) for about 5 months after hospitalization - post-viral, post-traumatic stress..
Why the posttraumatic stress?
From the hospital experience - they had to do spinal tap, lots of needle pokes, etc.
She was very scared
And isolated from family?
No - I stayed with her the entire time
Is this curable? It has been long-standing and chronic and I'm sure has created identity issues. She also has social anxiety.
Traumatic experiences have various potential outcomes that often overlap.
PTSD and Borderline can also be "comorbid".
It seems that she has anxiety issues as well (and PTSD is an anxiety disorder).
We have tried so many things to keep her in the home, but are wondering if an intensive residential program (with DBT focus) would be the right course of action while she is still young. Thoughts?
Have the psychiatrists given her any antianxiety medication to use ONLY on an AS NEEDED BASIS? I am talking about benzodiazepines which are very effective but can be addictive if used too often..
If she was willing to try it and not feel abandoned if would be a wonderful idea. Trying the therapy first might be a more realistic way since she does had abandonment/rejection feelings.
There is hope for her to learn to temper her anger, and begin to feel safer and more assured. It is a learning process that no medication can teach her.
Medication might calm her enough to be able to participate, but only therapy can change her life for the better.
No anxiety meds. Clonopin was recommended at one time, but my daughter did not want to take it (and doesn't want to take medicine, in general). We have fought having her take medicine for a very long time, but things got to such an unsafe point that we succumbed. I was hoping the vitamins - Truehope - would work, and although helpful they weren't 100%. I totally agree about the therapy - but she's got to be able to/hopefully want to participate.
Is paranoia and suspciousness also a sign of BPD?
Traumatized people with PTSD can be easily startled; they are also hypervigilant (looking over their shoulder); I mention PTSD because she seems to have a number of symptoms that overlap. Although mental health uses neat category boxes, real life doesn't work that way, and if you consider it without the frameworks then people who experience trauma have various reactions some of which overlap when you try to put a framework over them.
AND, frequent irritation and poor frustration tolerance with BPD? Well periods, too?
The only reason I care about a label is I want to go down the right path to help her...
She is naturally suspicious because of all the pokes and other trauma, and hospitalizations. Frequent irritation and being easily frustrated are symptoms of depression, which is something that she sometimes experiences whether from bipolar, borderline, or PTSD. Depression is depression.
You want to go in the right direction but you must find someone who can see the whole picture and say that this young woman has been traumatized and needs to learn to trust and feel safe again.
To use a crude analogy, if your car is having lots of problems and the mechanic only works on the fuel system, but not the electrical, or the transmission, then you will not have the best repair.
Agreed. I do think we have found that in her current therapist. She is not DBT specialized, but does incorporate DBT into her sessions. Have you heard of Dr. Leland Heller from Florida? He specializes in treatment for BPD/dysregulation of the limbic system. I was wondering if you are in agreement with his approach.
Let me have a quick look.
Absolutely the man to be helping you.
He has written two books about BPD and is someone who works outside the box. You might have to travel far and wide to find someone as suitable to help your daughter.
I am impressed.
If he can help her by lowering the activity of her limbic system then that would be most amazing.
Great! I will continue to read his book "Biological Unhappiness" and guide the path in this direction. Any recommendations to keep her safe when she is in a "manic" state - we do not want to hospitalize her for obvious reasons (but have had to twice in the past year). We do our best to manage at home, but it is a challenge when she is looking for anything to harm us/herself. We have locked up pills, sharp knives, etc., but she manages to find other ways. She becomes very impulsive (in contrast to her main personality which isn't impulsive at all).
What makes this even more challenging is that she doesn't appear to want help. All of her problems are because of "someone else" & she struggles to take responsibility/accountability for her actions.
Impulsivity is a characteristic of BPD and mania. If she has favorite music that calms her then you should turn it on. If she has a beloved pet (dog, cat) then bring it to her. If she responds to hugs or closeness or soothing talk, then give her all that you can.
Underneath all of this she is an amazing person - kind, sensitive and thoughtful. She doesn't like when other people argue and wants to do the right thing. BUT, when it comes to this, she does everything in stark contrast to who she is. At those times it seems as though her moral compass is broken.
Don't use logic on her. Just gentle soothing words.
When in these modes she becomes ODD - if we bring a pet to her, she won't want it. If she, however, goes to it then it's ok (as long as we don't compliment her on using a good strategy). She doesn't want hugs/closeness/talking - it is very hard to help her.
It is not her moral compass, but just her ability to self-regulate. It is not spiritual or intellectual but simply behavioral and emotional. She needs the maximum love whether or not she outwardly responds.
Thank you. :)
Can you recommend calming words? So many things aggravate her while in this mode.
Can you sing? An old family favorite?
"Side by side". "Oh what a beautiful morning" "Amazing grace" if you are church-goers.
She wouldn't like that at all. It's as if talking/sounds overwhelm her senses & she shuts down even more.
Then say nothing. Just be there (if she wants you to be there).
What about when she is attacking me? When I try to separate, she follows or blocks my way. She is now bigger than I am.
Does she hit you and physically hurt you?
Yes. Mostly it's my husband, though. He is much bigger than I am. The Abilify has helped a lot with that.
If you can go safely and passively "limp" and offer no resistance, will she stop?
Sometimes. What I do is look away from her (so she can't lock in to my eyes- trying to bring her out of fight/flight), and keep my voice really calm. It does seem to help, but then she may take off to go harm herself. My husband does his best to stay calm, but it is really easy to get drawn in emotionally. He naturally has a louder voice and is more stern than I am. SO, he sometimes kindles her flame & then she really gets out-of-control.
for a long time he thought this was behavioral - he sees now it is more
So it seems that your husband's reactions are sometimes countertherapeutic. He is making the situation worse and needs to learn to respond differently. Your reactions, on the other hand seem very appropriate and effective.
What is behavioral? What does he see now?
We have worked very hard on his approach - what comes natural and seems right is not effective with our daughter. He is working on it and I think is handling things better. Behavioral meaning how she is acting is within her control and she is manipulating and a "bad" kid. He sees now that a lot of her actions are beyond her control & therefore he has more compassion for her. It does wear you down, though, when she is calling you names and is acting down-right nasty and disrespectful and rude (not to mention the mania-states). Her depression is hard too, because we so want to help her but she will not open up and talk to us. She is very internal, but doesn't have the processing to handle all these overwhelming feelings inside. I wish she would let us help her.
Thanks. I understand. Let me mention that a violent storm is hitting us right now and if I get disconnected from you as a result I will get back to you when the power is restored, if we lose it.
Bio-behavioral is how I see it
I now understand the tremendous scope of your situation. If you cannot work with her at home, and other medications cannot keep her from self-injury, she may need some inpatient care at the appropriate facility.
No worries. I have to head out to pick up the kids soon. Can we resume our chat later? I really do appreciate your insight & professional opinion. Thank you!!
If we ultimately decide that is what is best (which I am concerned about the separation/anxiety/attachment piece), can you recommend a facility that seems a good fit from your understanding from our conversation?
Sure. I shall save the chat and you can pick up later. I will get to you as soon as I can (will have to continue with current client of the moment).
No - Midwest
OR anywhere that has an excellent reputation
So we are not so far away. I am in south central KY.
I will have a look.
Thanks. I'm heading out to get the kids.
Talk later. :)