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psychiatric patients

Borderline Personality Disorder or Traumatic Stress Disorder

Borderline Personality Disorder – What if it is a traumatic stress disorder?

When most people think of Borderline Personality Disorder – they think of bad behavior.  It is someone that is very difficult to deal with, someone that you have to be on guard against, Borderline Disordersomeone who will try their best to manipulate you.
But, while that may be the outcome, just like most psychiatric disorders, it isn’t exactly their fault.

One of the problems with BPD is that since it is a “personality disorder“, there is often no recognized medical treatment.

We simply expect that the patient should self-monitor and control their behavior.  Therapy may help this, but how many of us (psychiatric patients, in general) really want to go to therapy.

Many of us have already spent hundreds of hours with a therapist – who may or may not help.  In addition, the best therapists are likely people who can “see through the bullshit” and refuse to be manipulated.  This obviously goes against the nature of someone with Borderline Personality Disorder.

In fact, the stigma is so bad that some therapists won’t even work with Borderline patients.

Co Morbid DisordersOne theory may help.  Some therapists have developed an automatic assumption that a Borderline patient is also a trauma victim.  While this co-morbid condition may not always be true, it can help some therapists feel more comfortable treating the patient.

Due to many soldiers returning from impossible battlefields in the Middle East, Post Traumatic Stress Disorder is fairly well recognized.  Remember; I am not saying that it is easily treatable, but to some extent, the stigma is less.

When therapists look at Borderline patients as truly a PTSD patient, they may be more willing to treat the disorder. And they will attempt to get to the underlying causes of abandonment, impulsive and destructive issues, loss of control and poor self-image.

While PTSD is well defined by the professional psychiatric community, a longer-term disorder currently known as complex traumatic disorder is not.  Most examples of CTSD still involve soldiers, or they may involve women who had difficult pregnancies or who were violently sexually abused, repeatedly.

However, what if you don’t fit any of those recognized categories?

There are more ways to treat traumatic stress disorders such as Cognitive Behavioral Therapy or a newer one, Dialectical Behavior TherapyDBT focuses on four major areas:

•    Regulation of emotionsPost-Traumatic Stress Disorder
•    Tolerance for distress
•    Interpersonal effectiveness
•    Mindfulness

Unlike CBT, there is no “processing” component – making it work well as an initial treatment, starting before the patient has developed coping skills.  It builds up the feeling of emotional safety so that coping skills may develop.

Differentiating between “plain” Borderline patients – and those whose behavior is brought on by traumatic experience may help to eliminate some of the stigma still associated with BPD.  It may also offer actual, more effective treatment than CBT or other approaches.

Melissa Lind

Why do Bipolar Patients Quit Taking Their Meds?

Why do bipolar and schizophrenic persons quit taking medicine?

Talk to any medical professional about the trials and tribulations of dealing with bipolar patients and they will tell you that the single most bothersome thing is the frequency with which manic-depressives quit taking their meds.

This problem isn’t unique to bipolar patients, but it is more insidious and often more surprising.  Schizophrenics, who quit taking their meds, are identified fairly quickly.  Those with depression who quit taking their meds stay in their houses – this is troublesome but not a public nuisance.

People with bipolar disorder are usually quite memorable both at the best of times and the worst of times.  They are vivacious; they are shining; they are exasperating; they are amazing, and they are irritating.  Generally in order to be diagnosed, a bipolar patient will present one of two ways – either severely depressed or psychotic but their illness has gone unnoticed or unaddressed for a long time.

To be fair, psychiatric patients of any type may quit taking their meds for a number of legitimate reasons.  Well, semi-legitimate.

Mood DisordersLegitimately, a psychiatric patient of any type will have consulted with his or her physician before quitting can be medically supervised while doing so.  Even with medical supervision, the only really legitimate reason for a psychiatric patient to quit taking their meds completely is a person who has been taking anti-depressants for a short period of time (less than one year) who has only had one episode of clinical depression.  In this case, a psychiatrist would agree that a patient who does not have a long term history of depression can taper off the medication because they may not need it forever.  This patient is rare. Once another episode of depression or mood disorder occurs, virtually everyone will agree that it is a chronic problem that should be addressed with medication.  Permanently.

One legitimate reason for temporarily discontinuing use would be pregnancy, to avoid potential harm to the fetus.  In most cases, the medication would be re-started as soon as the patient is able.

Patients may also approach their physician about discontinuing a specific medication to switch to another.  Reasons for this might be ineffectiveness, intolerable side effects or cost.

Unfortunately, for most psychiatric patients there is no legitimate reason to discontinue medication altogether.  The physician will suggest or even prescribe an alternative medication.  The patient may feel that they have been unheard by their physician and while this may be the case, for most patients who “quit”, it is actually more likely that they have not talked to the physician at all.

Bipolar patients and those with other psychiatric conditions most often quit taking their medication without medical supervision or intervention in secret.  Oddly, this is because the brain is a tricky thing – most often they quit when they are doing well.  When the medication is working, they begin to believe that they do not need the medication – that they are “OK”.

Most psychiatric patients don’t want to have a mental disorder – or more likely they don’t want to be told that they have a mental disorder.  This may be in part due to the social stigma, but it may also be because they really like the way they are.  Medication often takes away the “spark” that has made them vivacious, memorable, brilliant and even irritating or dangerous.

It is very difficult to go from “outstanding” – whether it is good or bad to normal.  Bipolar patients in particular also quit taking their medication because their brains are bored.  The brain is used to go up and down, backwards and forwards, in and out.  When medication is working, the roller coaster goes away.

This may be good for a while, after the crisis because life has gotten way out of whack, they need time to recover, rest, and breathe.  But when the fires are put out, and the dust clears, the brain begins to crave the excitement.

Again, this really means the medication is working, and they will quit, yet again, starting the cycle all over again.

So, what can a caretaker, a parent, a spouse, or a friend do?  Likely any attempt at supervision or intervention will be met with anger, avoidance or outright denial.

Bipolar CaosAs bipolar disorder, and schizophrenia most often emerges in the late teens or early adulthood, is should be predictable that they do not want supervision.  They do not want to be told that someone else knows best.

When confronted or even questioned, the bipolar will almost always say that everything is OK – even if it is far from OK.  In short, they will lie.

Again, what can a caretaker, a parent, a spouse, or a friend do?  In short, especially in the newly diagnosed (and for a bipolar or schizophrenic the definition of newly would be likely less than 10 years), there will be no opportunity for supervision.  They will be secretive and untruthful.  You must wait for the crash and be there to assist with the crisis and recovery – only to repeat it again in a few months or years.

The good news is that eventually, the periods between “the crashes” will likely lengthen. When they are thinking clearly, when the medication is working – ask them why they do it.  Encourage them to participate in therapy, join a bipolar or mental disorder group. Realize they may not always go.

Over a period of years, perhaps decades – the patient may eventually become to accept that they truly do need the medication.  Likely they will never be completely compliant but one can always hope.

A caregiver, a parent, a spouse, a friend can look for signs – if you are close, you may be able to keep track of their medication, physician visits, refills but you may not be able to.  You should prepare yourself when you see signs: a developing increase in communication, vivacity, anger – likely followed by erratic behavior and hiding.

Intervene as much as you can but know that your may not be able to stop them.  They quit medication when it is working because it makes them….normal.

Melissa Lind