u/formulation_pending

I've recently passed a few of these patients off to my attending for full reformulation.

It seems that they got a schizophrenia diagnosis while under the influence of drugs or a cognitive impairment, and antipsychotics thrown at them. The antipsychotics didn't work (or worse, work 'a little bit' because their behaviours 'improve' from being sedated all the time), so they got more antipsychotics thrown at them, and some of them go on clozapine.

These people end up on bizarre combinations of 3+ oral + depot antipsychotics +/- clozapine, 'residual psychotic symptoms' and a high burden of side effects which inevitably get more medications thrown at them.

Of the patients I've had reformulated so far, one was pseudopsychotic secondary to severe BPD with erratic behaviour and impulsivity labelled as 'disorganisation', one had previous episodes of drug-induced psychosis (but no primary psychotic illness) + aripiprazole-induced impulsivity + had ongoing perceptual disturbances from HPPD, and one had ASD + a cognitive impairment + a prolonged grief reaction which could not be distinguished from actually perceiving dead loved ones due to the impairment.

All improved markedly once delabelled, deprescribed, and put through intensive psychotherapy (though behaviours initially worsened as sedating medications were removed).

How frequently do you see this kind of presentation in your practice and what are your thoughts? Leaving this question quite vague as I'm keen to hear an open discussion with whatever clinical gems people feel inclined to drop.

Recurrently consulted lately for patients with known ASPD "responding to internal stimuli" and acting in inappropriate and erratic ways.

I go to assess them and they've got to get a pen and paper out of their bag first. Or they spend 5 minutes profusely thanking their nurse nearby. Or try to grab a chair for me, despite my explicit wish not do this. These are quite transparently attempts to assert control over the situation by making me wait to review, and the evident air of performed civility does not help my impression of this.

If I actually get to assessment it usually consists of theatrical tales and little to no answer of important questions re: risk, rather stringing me along their narrative.

My approach has been to try a little bit, but I've got other things to do, so if they're going to spend 10 minutes performatively finding a chair and picking the right pen to write notes about my review on, I'm going to leave. This is 100% my countertransference talking, but I don't like being fucked with and I'm not going to reinforce that they can do that to people and have it work.

My assessment is then based on collateral, chart review (which usually shows inconsistent psychotic symptoms and documentation of previous malingering), and my brief observation that they are linear, not responding to internal stimuli, and clearly trying to control the situation. On the off chance I'm convinced something real was actually happening, I order a UDS, which so far has shown 100% hit rate for meth.

The usual conclusion is that they are inappropriate and erratic because of their ASPD and their "psychotic symptoms" are malingered. I note risks and then note it is squarely not a psych issue and to call the police or security if they start doing it again.

Is there anything I am missing with my approach or something I could be doing better?

Don't get me wrong I think the concept is valid. Person with BPD scared of being abandoned, either abandons you first to make you feel abandoned or acts in a way that makes you abandon them, both recruiting you into their system. Cool, fine.

But I see a lot of people talking about projective identification recently in a way that really just sounds like not taking responsibility of their own thoughts. Of note

• A therapist who saw a patient who was not responding emotionally while describing past trauma, while they themselves were getting upset about it - which they labelled projective identification.

Yes I'm sure there's a defense mechanism there but I would argue it's isolation of affect from the patient, and the therapist's own feelings about what seemed to be quite a horrific trauma coming through - not projective identification. I don't know if it's reasonable to assume the patient somehow induced these feelings in the therapist because they were unable to handle them themselves.

• A therapist who was attracted to a patient and labelled this projective identification of her sexual urges.

We share this patient - she has no PD diagnoses, does not seem to act or dress in a provocative way, and frankly speaking is just an objectively attractive full-figured woman. I feel the much more compelling explanation is that the therapist is simply attracted to the patient and would not like to be.

It sometimes feels to me that projective identification, while a valid concept, is something people use to avoid taking responsibility for their own thoughts by claiming they belong to or were induced by someone else.

Thoughts?

Won't make this post too long.

I like teaching and mentorship. Public psychiatry is probably not where I want to spend most of my long-term career once I'm a consultant.

I could give med students lectures, which is fine. But I do enjoy clinical supervision.

What are my options to do this in private practice?

I'm excellent at treating OCD. Mostly because (controversial take) most people are pretty bad, so I benefit from the bar for excellence being very low. The research on diagnostic delays and the iatrogenic harms caused by misapplied therapies meant for other disorders supports this.

However I feel this success is making me overgeneralise OCD treatment to other anxiety disorders.

For example in social anxiety I may use iCBT to identify that their fears are imaginary, ACT and the Choice Point to demonstrate the idea of "sure you're anxious, but your life is better if you go do it anyway", and ERP with avoidance and rumination about previous awkward encounters framed as the response we are preventing. I do various other forms of this with other anxiety spectrum disorders, abandonment sensitivity in BPD, some trauma.

I suppose what I am attempting to target here is the fairly transdiagnostic idea of faulty threat appraisal leading to maladaptive behaviours which are maintained because they are perceived as protective against the threat, and the patient will not realise the threat was never as great as they thought unless they drop the behaviours and realise they are still fine.

Don't get me wrong, this works right now, and often really well. But I can see that there's little holes in what I'm doing - the fears from anxiety are not ego-dystonic and are experienced as quite real and not just intrusive thoughts to let go, the fear in social anxiety and BPD of judgment and abandonment are not quite as easily marked as "safe" by ERP because judgement and abandonment really do happen.

What I don't want to do is become someone who bluntly applies the same tools to everything. We all know someone like that, a trauma-informed therapist who digs through a flatly atraumatic history until deciding that the person's problems must have come from the trauma of being born, or an ADHD specialist who decides that every disorder is just executive dysfunction applied to the control of different emotions and circuits.

I have a hammer. So far it has proven to be quite a good hammer, and everything that I have used it on seems to have been reasonably nail-shaped. My fear is I will go too far with this.

What does everyone here think?

Resident - have brought this up in supervision but curious about your opinions. Also a follow on from my ASD post. Details a little fudged for confidentiality but general gist is very much there.

Essentially have a patient in his 50s who as far as I can tell did perfectly fine until a few years ago. I have asked developmental history as sensitively and open-endedly as I can and his mental health literacy is quite poor so I doubt he is sensing a BPD screen and avoiding it, if he was doing that I would expect him to be misleading me on the MSI-BPD too.

As far as I can tell, extremely stable friendships, relationships, sense of self for decades of his life - maintained the same friends throughout, long-term marriage to one person not marred by repeated fights etc.. Real happy guy previously, and I don't have a reason to suspect otherwise. Collateral supports this.

However a few years ago had significant physical trauma leading to loss of job which previously provided both income and social standing, as well as a "provider" role within his family. Since then endorses 8 of 9 BPD symptoms (besides dissociation), also has what I feel to be pseudohallucinations.

My trouble is that

1. The features do not emerge in early adulthood as per the required criteria
2. There is (sort of) an explanation for why he hits the criteria e.g. identity disturbance / chronic self-harm / suicidality / sense of emptiness are because he's lost what he considers to be his purpose and clearly has not coped with this, issues with relationships / irritability / abandonment are because his old circle seems to have left him after this event and evidently he has ongoing suffering due to both physical trauma itself and loss of purpose and identity. In some sense I feel I would react quite similarly and be quite irritable if I lost it all one day like that. Bluntly I think he might just hit criteria because his life is not pleasant.

And yet he presents as quite borderline in front of me, clear splitting, chronic SI, meeting most criteria currently etc.. It feels too long to be an adjustment disorder.

Am I able to diagnose BPD here, and am I missing something on his past history even with what I feel was a reasonable way of taking it? Do you need to already have had BPD or previous personality vulnerabilities to deteriorate into this particular state after a stressor in late adulthood, or can symptoms truly start this late? Is this simply the nebulously defined "BPD traits"? Or perhaps an adjustment disorder, if we consider the stressor to be ongoing because his life is still quite difficult?

Not that it changes anything since I think he'll benefit from DBT anyway, but just curious.

Cheers all.

I don't do ASD assessments specifically but for the purpose of general assessment I do note when there are ASD traits I can see in front of me that may be contributing to the presentation.

I have had a few people (mostly male but some female) who clearly present as autistic to me on MSE / cross-sectionally, e.g.

• Sitting upright in formal-looking unmoving postures
• Fleeting poor eye contact that evidently causes them some discomfort
• Non-spontaneous speech of short length which only directly answers your question with little to no tonal variation or bizarre ways of using it, e.g. using mid-sentence tonality when ending a sentence which leads to confusion as I wait for further elaboration that does not arrive
• Generally impaired turn taking in conversation, a lot of "no sorry, you go"
• Very restricted affect which they will report is long-standing (and collateral will agree) in contrast to a newly restricted affect you may see in depression
• Difficulty getting ideas across that are not already part of their explanatory framework due to what I feel is concrete thinking, e.g. I had a patient who had excellent insight into the fact that their non-compliance with medication had led to previous relapses into psychosis, but was also extremely insistent that 2 standards of alcohol every weekend since the age of 18 (non-American) was binge-drinking of extremely early onset and had also been a large driver of their relapses - and could not be convinced otherwise

And yet when I take a more targeted history about autism, nothing of note shows up. At most they seem a little introverted, but they deny all the main things including stereotyped interests, sensory issues, social difficulties, fascinations that others might consider odd (e.g. dates, number plates), rigid routines etc.. And the developmental history might show a mild delay, but otherwise very normal there as well and certainly these people are reasonably functional now and have completed tertiary education.

I get that if I am asking these questions bluntly e.g. "do you have troubles with routines" I may not get the best answers as they may only be able to reference their own experience and tell me no, unaware that compared to someone else they in fact are quite rigid. I am also aware that they may also sniff out that I am screening them for ASD and try to obfuscate, but I am aware of that risk from many BPD screenings and do try and ask the questions discreetly and open-endedly. I do feel like my actual process of taking the history is reasonable.

Essentially - the MSE and my entire conversation with them shows strong ASD traits, and yet what they tell me on history does not show this at all.

What am I missing here?