Borderline adolescents

Meerkat · Feb 24, 2006

Well, perhaps they are using the initial dx to meet criteria for admission. Although you're right, technically 'Borderline' is over 18. But it seems to be the flavour of the month is mental health.

Meerkat · Feb 24, 2006

By the way, I come across the same thing constantly...nurses labeling any (female) pt whom they deem as 'needy, irritating, self-martyring' to be borderline. 'She so borderline!' is an everyday echo on the unit. And they DO treat them differently, totally forgetting that it is an illness, not a willful decision to be difficult.

mebeafrn · Feb 24, 2006

so true!!!!I see charting that says pt. "likes"(quotes are mine) to_____fill in the blank w/ such as ,staff split,manipulate,have negative attention,have males do physical holds,be gamey etc... as if this is a conscious choice and these pt. really like to have this be the way they get their needs met. Even more frustrating is trying to gently get the the nurses to look at what type of environment and life experience create the use of this type of behaviors just for survival as a child and get the attitude of "well, it's not that way now so they should just quit it" Sometimes I do ask if diabetics/asthmatics etc.. can "just quit it" sometimes I see the light come on,other times they look at me as if I've maybe taken the keys and nametag from someone:chuckle

I'm so glad our techs all have at least a BS in a human service related field and most are psychology majors on their way to a MS. They provide a buffer while we get the nurses up to snuff who haven't had a solid psych backround.

And yes,Borderline as a solid Axis II before age 18 is not our norm either.

CharlieRN · Feb 27, 2006

Nice to find someone else who likes borderlines. I share the belief that this is an improper dx for an adolescent. I know my facility will not accept it. I can't recall just what the DSM says about it but I'm sure it says something. The office copy seems to have gone for a walk, but I found the psychiatry handbook from the "house officer series". It says that, "personality disorders, except sociopathic, can be diagnosed in adolescents... if the pattern is stable clear and incompatable with Axis I childhood disorder.

The sub text I am detecting is that you feel the clients are being harmed by being given the dx. That's a serious matter. Giving a diagnosis is justified by it being helpful toward the effective tx of the patient. If infact calling a patient "borderline" is itself a harmful act then it is a violation of the primary injunction to "do no harm".

rn/writer, RN · Feb 27, 2006

There is a good reason that adolescents should not be diagnosed as BPD. So much of "typical adolescent behavior" is self-centered, non-empathetic, and erratic, that at some point, just about every kid would qualify. Stir in some anger, angst, and hormones and you can have a real party.

Truly, some psych kids are BPDs in the making. Otherwise we wouldn't have any BPD folks later on. But to slap this label on so easily does no one any favors.

Many of these kids come from choaticand abusive homes and/or disturbed families. Their behavior is an attempt to make sense out of the senseless or send out an alarm that all is not well in their world.

BPD is a developmental delay in the psycho-social-emotional world. Any doubts? Compare a BPD adult with a two year old. Little empathy or impulse control. Single-minded determination to get what they want. Constant need for attention and approval. Reflexive lying to cover their misdeeds and avoid responsibility. Huge deficiency in the area of communication and social skills. Tendency to have tantums when appetites are denied and goals are frustrated.

Environmentally-induced (non-organic) mental delays can be somewhat mitigated, even if not not totally erased, when they are caught in adolescents. Perhaps the BPD-type delays can be affected as well. This would take a huge committment of time and effort on the part of someone in such a kid's life to basically reparent the toddler self and cultivate the empathy, integrity, and social skills that the normal kid would have aquired in the previous 10+ years. In some kids, it may simply be too late.

For those who still stand a chance, it's sad that most of the treatment they get is punitive and judgmental. Certainly, they need to learn boundaries and get appropriate feedback regarding negative behaviors. But without the positives that help a child develop successfully, all the limits do are contain a kid in pain.

I doubt there is much that can be done for a true budding sociopath, but there has been some wonderful work done with attachment disorder kids that seems like it would have some application with "BPD" kids.

Sigh. I finally had to get out of adolescent psych, not because of the kids, but because I felt we had so little to offer some of them.

docpsychrn · Mar 14, 2006

i am a psychiatric nurse who has been in this field for almost 20 years now. sadly, i have a 14 yr old son that is having serious mental health issues. he was diagnosed with adhd as a small child but most recently he was diagnosed with bipolar disorder and completely taken off his adderol for hyperactivity. first of all, i don't agree with the diagnosis and second of all my son is suffering worse without his adderol and his school work is suffering because of it as well. i have noticed during the past year while dealing with my son, they are very quick to label the teens as "bipolar" sort of like a catch all to include all their behaviors. why can't they just allow the teens to be teens and deal with the actual behavioral disorder versus giving them a diagnosis that really can't be determined until they are 18 or older??? i am so afraid that this will affect my son in the next few years when it comes to jobs or entering the military. he is a super kid, he is just having some adjustment problems along with anger issues with his father. i feel that bpdo is being used way too much and way too easily in the mental health field. by the way, i also work as the mental health nurse at a prison with 2000 offenders and i see the same diagnosis being used over and over for them as well. i am not a doctor but i have been in the business long enough that i know that my son is not bipolar....any thoughts?

Thunderwolf, MSN, RN · Mar 15, 2006

Thread clarification....Borderline Personality Disorder is totally different from Bipolar Mood Disorder. Let us not confuse the two.

The discussion moves onward.

Mudfiend · Mar 18, 2006

Wow, I was gone for a while and so many responses....

To clarify, this isn't an initial diagnosis to get a pt admitted, admission criteria for our unit is Axis I, if there is no Axis I diagnosis, they do not meet criteria, this is diagnosed primarily by one MD after the initial assessment.

I'm glad to find out I'm not the only one feeling this way. On my unit now I'm an in the minority.

I do feel that some of our patients do meet criteria. But I also agree rn/writer that a lot of the behaviors that is causing the MD to diagnose borderline is pretty "normal" behavior for teenagers.

I also get upset when we have to provide educational material to the patient on borderline disorder and they are given an assignment by the MD to read through the information and write down how they fit with each part of the criteria. I don't know about you but in nursing school after reading the symptoms of something everyone in my class "developed" that disease/disorder.

It really upsets me because it seems like a diservice to these kids who may not be borderline because in our area there isn't treatment. And to the people in my area, borderline = "they can't be helped" even though things such as DBT have shown to be helpful.

This wouldn't bother me if it were one or two patients once in a while. We have a fairly new MD and of his patients he will diagnose borderline 9 out of 10 times. Our other MD who has been with us 6 years could get those same patients on a next admission and not see the diagnosis.

I'm starting to not make sense...but I do want to thank everyone for making me feel a little less alone in how I'm feeling about this.

docpsychrn · Mar 19, 2006

correction: i accidently wrote a response to bipolar disorder instead of borderline personality disorder! my mistake! i have worked with borderlines for years and i too believe it's an overused diagnosis for many of our mentally ill patients. i would say that over half of the women on my forensic psych ward were diagnosed with borderline personalities. of course they had to have an axis i to keep them in the hospital so they were always able to find something else to put in that area...

mebeafrn · Mar 19, 2006

I looked at the DSM IV while I was wrestling old charts out of med records today and it talks about behaviors"experienced in adolscence and early adulthood" when going thru the dx. criteria so it's not something established in adol. I agree too with the poster who talked about typical adol behavior/borderline being so similar,consistently inconsisent as one of our MD's used to say,but not about the kids,they hadn't had time to develop or not develop consistent behaviors.

The thing that bothers me the most about over or misuse of that dx. is the instant rxn. staff often have,without ever seeing or interacting with the pt.

I've often wondered what it would be like if the Axis II was unknown. To me bottom line,if not for my good fortune in the people that raised me,it could be me on the other side of the glass.

leslie :-D · Mar 19, 2006

i am a psychiatric nurse who has been in this field for almost 20 years now. sadly, i have a 14 yr old son that is having serious mental health issues. he was diagnosed with adhd as a small child but most recently he was diagnosed with bipolar disorder and completely taken off his adderol for hyperactivity. first of all, i don't agree with the diagnosis and second of all my son is suffering worse without his adderol and his school work is suffering because of it as well. i have noticed during the past year while dealing with my son, they are very quick to label the teens as "bipolar" sort of like a catch all to include all their behaviors. why can't they just allow the teens to be teens and deal with the actual behavioral disorder versus giving them a diagnosis that really can't be determined until they are 18 or older??? i am so afraid that this will affect my son in the next few years when it comes to jobs or entering the military. he is a super kid, he is just having some adjustment problems along with anger issues with his father. i feel that bpdo is being used way too much and way too easily in the mental health field. by the way, i also work as the mental health nurse at a prison with 2000 offenders and i see the same diagnosis being used over and over for them as well. i am not a doctor but i have been in the business long enough that i know that my son is not bipolar....any thoughts?

hi doc,

my dtr has so many similarities with your son. she is now 16 yo. at 4yo she was dx'd with add by a team of pediatric specialists.

when she was 15 yo, she had her 1st of 6 inpt hospitalizations in a dual dx unit. on her 1st hospitalization, the psychiatrist spoke with her for 10 min and gave her a dx of bipolar. all subsequent hospitalizations, the psychiatrists just followed suit of the initial dx. on her last hospitalization (12/05), the psychiatrist immediately dc'd her ssri antidepressant and her add meds, stating both were likely to induce mania. they upped her lithium and started her on zyprexa 15mg qd.

since she's been home, i decided to wean her off the zyprexa. i studied bipolar and was not convinced that she has it. taking her off the zyprexa had no effect on her. she's also been clean since discharge and has been doing phenominally well. i would like to get her reevaluated to see if another psychiatrist would dx her w/bipolar. how can anyone make a dx when the pt is doing drugs and/or drinking, like my dtr had been. i discussed my concerns with my own psychiatrist. he told me that bipolar is quite overused in the adolescent population; and that borderline is extremely overused in gen'l. he also resists from dx'ing one w/borderline, knowing the stigma it carries and wouldn't want anyone being treated negatively because of the borderline dx.

i don't know what meds your son is on, but i would suggest getting him reevaluated by a reputable psychiatrist. oh. at my dtr's last hospitalization, the psychiatrist also dx'd her w/mild schizo-affective disorder.:uhoh21: only god knows where that one came from.

best of luck to you and yours.

leslie