4% have a structured assessment approach when diagnosing BPD
Next month I’ve got a first appointment with the consultant psychiatrist in my mental health trust’s personality disorder pathway. I’m trying to decide whether to go and if I do go what I would like out of it.
A proper assessment of my difficulties is the obvious want.
I had asked the lady on the phone when setting the appointment (this was an appointment, the time and date of which they wished to set without any reference to my pre-existing obligations – I am like really, am I that powerless in this whole process?) what would happen at this meeting.
She said, ‘oh the psychiatrist will talk to you, see what support you need and so on’. I replied, ‘oh, ok thanks, and what about the assessment process, when and how does that take place?’. A pregnant pause ensued. She said, ‘your appointment is with the personality disorder team.’
There was another pause, presumably for me to fill in the gap with the unsaid, ‘you’re on the PD pathway ergo you’ve got BPD so what are you talking about an assessment?’ and say thanks for the appointment and put the phone down.
Instead I said, ‘oh yes I know but as far as I’m aware I’ve not had an assessment or a diagnosis so I was wondering how and when that occurred.’ Another pause. She then repeated, ‘oh the psychiatrist will talk to you, see what support you need and then take it from there.’ I gave up. Said thanks for the appointment and put the phone down.
Not because I was satisfied with her equivocation but because I didn’t want a record of ‘patient argumentative on phone’ – she must have BPD.
I’m aware of the debate around the PD as a valid construct, a label, a gateway to stigma and service exclusion. There are many good reasons for keeping well away from a (possibility of) diagnosis.
However, my GP notes already record the dreaded ‘traits of BPD’ so that ship has sailed.
Further, I’m in the fortunate position to be able to pay for treatment but I don’t want to piss away £10,000 per year and a few years of my life pursuing the wrong type of treatment.
I also already have a diagnosis of DID and would like consistency across treatment providers. I may need access to NHS crisis care at any time, or I may never get back to work, run out of savings and be dependent on NHS MH care and welfare benefits – for this I will need a proper diagnosis.
Overall I just want a holistic, professional considered and reasoned opinion on what is wrong and how best to try and fix it.
4% have a structured assessment approach when diagnosing BPD
I heard this at a BPD conference I attended. I didn’t take down the citation/source but it was said by a man who ought to know the truth of it. 4%!? Really? I’m horrified.
I personally would not rail against a diagnosis of BPD due to stigma/lack of services. Not least because when I told a few close friends there has been a judicious silence due to my ostensible fit with some of the criteria especially over the last 18 months. It’s a possibility. I can accept that.
Also, I’ve got a diagnosis of DID and that surely rivals if not surpasses BPD in terms of stigma/lack of services. It’s taking me time to get to grips with it sure, I’d rather it was not an issue at all, but I trust the assessment process and I see results (tiny yet but there) in the treatment recommended. I can accept it.
But I can’t accept the assessment of traits of or a diagnosis of BPD without a similar rigorous assessment process. The criteria, the manifestations, are common to many other diagnoses. I want to be sure that a diagnosis of BPD is not just an easy fall back option because the psychiatrist has no idea what DID is, or because CPTSD (from developmental trauma) is not in the diagnostic manuals or simply because I’m a woman who has tried to kill herself.
The NICE Quality Standard QS88 Personality Disorders: borderline and antisocial June 2015 provides as Quality Statement 1: Structured Clinical Assessment that ‘Mental health professionals use a structured clinical assessment to diagnose borderline or antisocial personality disorder.’
This is because, ‘Borderline and antisocial personality disorders are complex and difficult to diagnose. Even when borderline or antisocial personality disorder is identified, significant comorbidities are frequently not detected. People often need support that goes beyond healthcare and this makes care planning complex. Carrying out a structured assessment using recognised tools is essential to identify a range of symptoms, make an accurate diagnosis and recognise comorbidities.’
At the very least I’ve got a significant co-morbidity (of DID) and quite frankly I would like a consideration of how that diagnosis fits into the NHS’ putative diagnosis. Or why my traits – which appear to be recurrent suicidal behaviour, abandonment fears, marked reactivity of mood and dissociation – aren’t attributable to the DID or something else (CPTSD perhaps?). Or how my life story which does not fit the characterisation of ‘a pervasive pattern of instability of interpersonal relationships, self image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts’ (DSM-5) fits in.
NICE tells us that a structured clinical assessment should be undertaken using a standardised and validated tool such as the Diagnostic Interview for DSM–IV Personality Disorders (DIPD–IV), Structured Clinical Interview for DSM–IV Personality Disorders (SCID–II), Structured Interview for DSM–IV Personality (SIDP–IV), International Personality Disorder Examination (IPDE), Personality Assessment Schedule (PAS) or the Standardised Assessment of Personality (SAP).
I’m sure I wasn’t taken through one of the above with the psychiatrist I met at the CHTT whose opinion it is that I have traits of BPD. To be fair I spent some of that meeting flying above and to the side of myself (dissociation/depersonalisation) and some not there at all (me the writer) so who knows I may indeed have been and just can’t remember it.
I recognise that I may not get my wish for a professional, considered and reasoned opinion as a result of a structed assessment. Even NICE accepts that there is no gold standard test and ‘the level of agreement between interview schedules remains at best moderate (Zimmerman, 1994).’ But it would be a start.
What I do not want is what I’ve got and what NICE recorded back in 2009 as the problem of, ‘outside specialist treatment settings, there is still a heavy reliance on the diagnosis of borderline personality disorder being made following an unstructured clinical assessment…[T]here are potential pitfalls in this approach. First, agreement among clinicians’ diagnoses of personality disorder has been shown to be poor (Mellsop et al., 1982). Second, the presence of acute mental or physical illness can influence the assessment of personality. The presence of affective and anxiety disorders, psychosis, or substance use disorder, or the occurrence of an acute medical or surgical condition can all mimic symptoms of borderline personality disorder; a primary diagnosis of borderline personality disorder should only be made in the absence of mental or physical illness. It is also preferable for clinicians to obtain an informant account of the individual’s personality before definitively arriving at a diagnosis of borderline personality disorder.’
So to go or not to go?
At the moment I’m going. I don’t think it’s productive to shut down the potential for a collaborative formulation and diagnosis of my difficulties and how best to meet them.
I’ll ask for (or at least try as I’m deathly afraid of the meeting but that is for another blog) a structured assessment hopefully over a number of appointments, information of the effect of the DID (assuming they accept it, the other psychiatrist just dismissed it and said dissociation is part of BPD), the relevance of being acutely unwell when I saw that psychiatrist, the relevance of my life story.
We’ll see if I make that 4%.
DID Law & Practice 