Is spontaneous recovery from Borderline Personality Disorder a thing?
December 6, 2016 6:24 PM   Subscribe

For 5-6 months last year, my daughter was falling apart. Symptoms included extreme hostility, depression, inability to focus on simple tasks, insomnia. She was virtually incapable of caring for herself, so I moved in with her. She was taken to the ER 6 times between July and Oct and hospitalized for 3-7 days each time (4 different university affiliated Chicago hospitals). Diagnoses included PTSD, anxiety disorder(s), Bipolar, and Borderline Personality Disorder. (I first wrote about these issues here.) Then the crisis passed and within a matter of weeks, these labels no longer seemed applicable. So, what happened?

As always, I will apply all common sense caveats re “you are not my doctor/lawyer/whatever”.

Prior to this crisis period:

1. she had been in a serious car accident in CA, but did not receive medical attention (she walked away from an accident that the police officer who later found her car described as "not survivable"), so we (her father, friends, and I) suspected a possible brain injury. Unfortunately, by the time we learned the facts of the accident, it was too late to do relevant tests to determine if this might be causing the problems.

2. she had been taking Adderall for ADD off-and-on for several years and the same doctor had been prescribing Xanax for anxiety issues for at least the last year. At first, her friends suspected she was abusing her prescriptions, but it turned out that she actually had pills left over at the end of the month. (The prescribed doses were above average, but well within the normal range.)

From the beginning (before the first hospitalization) she said she had anxiety disorder, PTSD (sometimes she said the underlying trauma was a sexual assault that occurred last year, other times—notably, when she was pissed at her dad about something—she blamed her "childhood"), and also, Bipolar, which, frankly, I didn't see, i.e., her supposed manic episodes seemed Adderall-related to me. BPD was added by three different psychiatrists during hospital stays. As far as I know, she self-diagnosed PTSD, anxiety disorder, and Bipolar.

Fwiw, she never accepted the BPD diagnosis because, as she said, "BPD is seriously fucked up". To my untrained (but not completely uniformed) eyes, BPD seemed to fit. However, I recognize that this disorder is difficult to diagnosis and/or overlaps Bipolar. Note: between hospitalizations, she occasionally saw the doctor who wrote the Adderall and Xanax prescriptions, but that was the extent of her therapy.

Over the course of this crisis period, she was prescribed 4 different anti-psychotics, 4 different benzodiazepines, an SSRI antidepressant, an antihypertensive that is sometimes used off-label for PTSD symptoms, and Adderall, even though every single doctor (at one time, even the doctor who wrote the original prescription) said it was contraindicated. And amazingly, there were no duplicates among the doctors. As a result, she amassed quite a collection of meds and ended up experimenting to try to determine what might work. Btw, this wasn't about seeking a "high", she was trying to find "normal".

In October, she moved into an apartment that was supposed to add stability to her life, but her landlord turned out to be a jackass who made her life miserable and she ended up in the hospital in mid-October. Fortunately, she left the hospital in the best shape she had been since the crisis began. There were still some very difficult days in November, but the crisis seemed to have passed. She somewhat reluctantly tossed her collection of meds at the end of the month (though she did end up taking Effexor for several months over the winter).

Unfortunately, just as she seemed to be getting her life back, she was arrested for possession of marijuana and due to an assortment of complications, she was totally preoccupied with legal issues until July. Despite the previous mental health issues, she handled the mess as well as could be expected of anyone.

These days she's still struggling to put her life back together. Between the mental health issues and the legal issues, she's lost most of her former friends (and she's arguably better off without that crowd, but it still hurts) as well as her source of work/income (poverty-level wages). She's recently moved in with me, which she doesn't think is ideal, i.e., it means that she's about 3 hours from a couple of remaining friends. But she is no longer homeless/couch surfing and trying to get by with ad hoc day jobs. I'm trying to give her space and support—whatever she needs to come up with some goals/plans.

I am grateful, of course, that she does not seem to be suffering from PTSD, Bipolar, an anxiety disorder, and/or BPD, but I can't help but wonder what was going on last year. Each disorder was diagnosed by at least 2-3 other doctors, who prescribed similar (but not identical) medications, which seems to indicate that these were valid diagnoses. But does PTSD, Bipolar, and/or BPD ever manifest as a short term disorder and then disappear without therapy?

Final note: assume that calling her doctors is not an option. Although I have permission to speak with them, I don't want to call anyone without first talking to Daughter and this isn't the time to bring up my questions with her.
posted by zombies puppet to Health & Fitness (21 answers total) 4 users marked this as a favorite
In my experience, with my loved one who has bipolar/BPD, yes, it is entirely possible that this can manifest in the short term and then disappear without therapy (which my loved one has generally refused) and medications (which they have taken from time to time, but not steadily over the long term) because the person's brain chemistry may level out on its own. My loved one had 10+ years of general good mental health before a crash took them down to the bottom again.

In my experience, the hardest part is when this person's brain chemistry is in the normal range -- because it makes them believe they are cured and have no further need for meds or therapy. Then when things go off the rails again, they are quite hard to corral/convince for meds & therapy/hold in a health care center.

I'm sorry you're going through this. It's very difficult for family members and friends.
posted by BlahLaLa at 6:53 PM on December 6, 2016 [1 favorite]

Borderline personality disorder -- like all personality disorders (or "nondisordered" personalities) -- is a set of enduring, ingrained traits and behaviors. By definition, it is not temporary.

Bipolar disorder is in fact an episodic disease.
posted by i_am_a_fiesta at 7:16 PM on December 6, 2016 [11 favorites]

No, people do not spontaneously recover from those types of issues. If you are talking about this past October, it is to soon to tell whether she is moving on from all of this. If in a year she is working, supporting herself, and getting along with others then you can say whatever that all was seems to be gone. Enjoy the passing of those big bumps in the road on her way to adulthood. Time will tell.
posted by cairnoflore at 7:35 PM on December 6, 2016 [2 favorites]

Anecdata: When I was finishing up my Master's and doing my internship in an inpatient psychiatric unit, we had a high functioning (yet older) woman come in for several repeat admissions over the course of a month-6 weeks. My supervisor was her outpatient therapist, so he knew her lengthy history and she had been diagnosed with Borderline Personality Disorder. On her last inpatient visit, we put her in a group of patients who were seriously struggling with things like schizophrenia and bipolar disorder (this was at the recommendation of her outpatient therapist...I was just watching and learning). Her behaviors improved quite rapidly while she was on the unit and that stay was much shorter than her other ones. At her followup visit with her outpatient therapist (who also had privileges at the inpatient unit, so he had supervised her treatment throughout), she explained that the group experience "opened her eyes" and made her realize that she had been wallowing in her own form of self pity, probably exacerbated by her husband being gone for some lengthy business trips around that time. She was never readmitted while I was involved with that facility (although I do not know how she did in the long run).

That's just one very small example, but it's possible she's making some different choices that is allowing her to manage her symptoms better at the moment. Also, Borderline Personality Disorder is about how one interacts and manages relationships with others. If she has lost most of her "original" friends, it could be that those relationships were highly triggering for her in ways she couldn't understand nor explain. Therefore, she could simply be responding to more positive interactions with others (or could be feeling more secure, which can lead to her lashing out less?). I think you make a good distinction that "the crisis passed". That may have been an ongoing crisis for her, and it has resolved itself for the time being. Something else may trigger those symptoms again in the future without warning (resulting in another crisis episode). Some patients have longer periods of symptom relief punctuated by "crises".

Was she diagnosed with actual Borderline Personality Disorder, or Borderline traits? That could be a difference.

I also think there was a head injury with the accident. People who have concussions or frontal lobe damage will exhibit mood instability and irritability, along with impulsivity. It's hard for us to really know without knowing her for a longer time.

(This is just my opinion, not based on a full assessment of anyone, etc. etc.)
posted by MultiFaceted at 7:50 PM on December 6, 2016 [3 favorites]

Also...that outpatient therapist who specialized in Borderline Personality Disorders did tell me that women who reach their 40s could see a rapid reduction in symptoms and have more stable relationships. I don't remember exactly why though...I'd have to go back and look it up.
posted by MultiFaceted at 7:52 PM on December 6, 2016 [1 favorite]

I have had several (3-4) friends get serious TBIs (one had a brain tumor, others were sports related) and yes, if you didn't know them before you'd think they had a major mental illness: binge drinking, drug abuse, lack of inhibition, combativeness, emotional lability, promiscuity, run ins with the law, loss of executive function, spending sprees etc. All but one have largely recovered the ability to cope with the passage of time, at least two to three years seems to be the key. Some personality changes remain but they are stable in their new personality, if that makes sense. The one who hasn't recovered had a really bad accident and has some major deficits.

So I am not a doctor obviously and have no idea what is going on with your daughter but I'd say that, in my experience, the timeframe fits for a TBI. I had one friend who had vertigo for 2 and a half years then one day it just stopped. If she had none of these issues before the car accident it seems insane that she was diagnosed and treated as if she did. Having said that there may be long term consequences for her mental health anyway and I have no idea if they treat organic injury differently or not.
posted by fshgrl at 8:00 PM on December 6, 2016 [10 favorites]

I'm under the impression that complex PTSD can cause symptoms similar to BPD. Theoretically, could the recent assault have brought "childhood"-related trauma to the surface?
posted by salvia at 8:16 PM on December 6, 2016 [8 favorites]

Borderline personality disorder -- like all personality disorders (or "nondisordered" personalities) -- is a set of enduring, ingrained traits and behaviors. By definition, it is not temporary.

There's been a lot of research that has contradicted this, although it was at once the standard assumption. (This only pertains to BPD; I can't speak to other personality disorders.) I don't have the time to track down the articles, but they're relatively recent. You should look for articles published by Mary Zanarini and John Gunderson, to start. You may also wish to check out The National Education Alliance for BPD.

My impression is that Bipolar Disorder and ADHD tend to be more long term, but I'm not up on the latest research.

Of course, then there's also the head injury to contend with, and I'm not sure to what extent that could be affecting these potential diagnoses and symptoms.

She somewhat reluctantly tossed her collection of meds at the end of the month (though she did end up taking Effexor for several months over the winter).

FWIW, medications are usually prescribed for co-morbid disorders, but I don't think there are any BPD specific meds that have been approved for that purpose.

Whether or not BPD is the correct diagnosis, you may want to look into DBT (Dialectical Behavior Therapy) if your daughter would be open to that.

Of course, IANAD/IANYD. In fact, I'm not any kind of professional. I've just done lots of readings on my own and picked up some things from various places.
posted by litera scripta manet at 8:42 PM on December 6, 2016 [2 favorites]

This is longer than I thought it was going to be, sorry. (I copypasted big chunks of text because I think they're worth reading closely.)

Some points for consideration.

There is a strong gender bias in the diagnosis of borderline personality disorder. Whether that's to do with sociocultural factors, biological factors, or diagnostic bias has been a huge question for a long time.

This study found that in a population of Italian women and men with diagnosed personality disorders, "Moderation analyses revealed a significant association between ADHD and BPD symptoms among only female (vs. male) outpatients. Furthermore, in the female subsample, mediation analyses revealed that both impulsivity and emotion dysregulation fully mediated the relationship between retrospectively assessed ADHD symptoms and current BPD features." Which I think is interesting, and at least suggestive of the possibility that when impulsivity and emotion dysregulation are present, ADHD in women might get called BPD, if other indicators suggest it to clinicians.

(Like mention of sexual abuse. It's worth noting that the history of people with BPD often involves multiple experiences of abuse, from multiple perpetrators. Some conceive of BPD as a complex pattern of responses to trauma - even as "delayed PTSD" [see this]. It seems at least possible that if someone's diagnosed not long after a single assault, an acute traumatic reaction, in someone who has ADHD, might look like BPD. Even to an experienced clinician. It also seems at least possible that diagnoses after an initial diagnosis piggybacked the first, if they saw her chart [which I assume they must have]. I mean, this happened.)

From the review linked above:

Currently, outside specialist treatment settings, there is still a heavy reliance on the diagnosis of borderline personality disorder being made following an unstructured clinical assessment. However, there 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.

Diagnosis of BPD in young people is controversial. In this paper, it was suggested that BPD can be reliably diagnosed in young people... (There is also mention of a need for caution. I think the validity of this diagnosis in your daughter's case depends a lot on how cautious the first psychiatrist was, especially.) The authors also found that BPD can follow a few courses: "... there appears to be a legitimate subgroup of adolescents for whom the diagnosis remains stable over time as well as a less severe subgroup that moves in and out of the diagnosis."

It could end up a few ways, according to that review:

... until recently, there was a paucity of longitudinal research into personality disorders to support the notion of borderline personality disorder as a stable construct. Reviews of the subject published over the past 10 years hinted at considerable variation in stability estimates (Grilo et al., 2000). Recent prospective studies have shown that a significant number of individuals initially diagnosed with borderline personality disorder will not consistently remain at diagnostic threshold, even over comparatively short periods of time (Shea et al., 2002). It seems that while individual differences in personality disorder features appear to be relatively stable (Lenzenweger, 1999), the number of criteria present can fluctuate considerably over time. Given the many problems associated with the diagnosis of borderline personality disorder, it seems clear that reclassification is urgently needed and this is likely to happen with the publication of DSM-V (Tyrer, 1999).

With a head injury that wasn't assessed in a timely way, and that cocktail of drugs, and your daughter's young age, I think... there's room for caution. And if the diagnosis does turn out to be valid, room for hope. There's treatment (see the review, again), and there are a lot of ways things could go.
posted by cotton dress sock at 8:43 PM on December 6, 2016 [13 favorites]

Can you explain a little more as to why you don't think bipolar disorder fits? I suffer from bipolar disorder and a lot of what you've described resonates with me as possibly being a mixed state triggered by the car crash. I'm surprised to read that she was prescribed multiple antipsychotics and benzodiazepines but wasn't tried on mood stabilizers.

Also, has she seen a neurologist regarding residual effects of the car accident? I understand that it's too late for some tests to assess brain damage, but if she hasn't already done so, it could be useful to at least assess her overall cognitive functioning.
posted by Pizzarina Sbarro at 8:48 PM on December 6, 2016 [2 favorites]

Psychiatric diagnoses are generally just a label for the symptoms a person is displaying or reporting. They generally require that medical issues or substance-induced issues be ruled out as the cause for those symptoms, but a lot of times the work isn't done to actually rule out those issues, or the issue is a subtle medical issue for which diagnosis is difficult. The psychiatric conditions you've listed don't tend to spontaneously resolve themselves that quickly (though I'd echo litera scripta manet in saying that BPD does actually resolve itself in many cases without treatment, but that generally takes eight-ish years), which likely means the initial diagnoses were incorrect.
posted by lazuli at 8:50 PM on December 6, 2016 [5 favorites]

Oh, wait, on seeing Pizzarina Sbarro's response: Yes, bipolar disorder, especially manic episodes, can be extremely episodic, and could likely explain a lot of what's happened. I also agree that TBI could be complicating things.
posted by lazuli at 8:53 PM on December 6, 2016

Sorry - your daughter is 26; for some reason I registered her age as younger. Still, I think there are plenty of reasons to at least consider the possibility that they'd gotten it wrong.
posted by cotton dress sock at 11:42 PM on December 6, 2016

What was going on last year is that she was dealing with a whole bunch of crises.

sometimes she said the underlying trauma was a sexual assault that occurred last year, other times—notably, when she was pissed at her dad about something—she blamed her "childhood"

Why are you putting it in scare quotes?

Has anyone in the family taken her seriously about her complaints of sexual assault and genuinely listened to her without judgement? Withholding judgement would mean things like not minimizing her anger at her father or her childhood, for instance. We women get the totally wonderful treat of having to digest every goddamned fucking thing that happens to us for everyone else, while people roll their eyes at it (i.e. no one or very few help us do the digesting OR we get sent to a psychiatrist), and then being told we're crazy when we act out in ways like, say, taking marijuana to dull the pain.
posted by fraula at 1:53 AM on December 7, 2016 [16 favorites]

A lot of good information above. I just wanted to add that taking psychiatric medications inconsistently and playing with dosages/combinations can cause erratic behavior, mood swings, anxiety, suicidal ideation, etc so all the medication changes (both made by her doctors and herself) could definitely have played a role.
posted by Waiting for Pierce Inverarity at 4:03 AM on December 7, 2016 [7 favorites]

You received plenty of good responses above. I just wanted to say that, while it can be very helpful to think of mental illness as actual illness, it's not something that can be diagnosed with a lab test nor even by a brain scan. When we talk about Borderline Personality Disorder, we are talking about a diagnosis that is built on a set of behaviours and self-reported introspections.

There is room to ask if there is a difference between having BPD and acting like someone who has BPD. And, while it is true that many people who have BPD will find it to be persistent throughout their lives, it is also true that all kinds of factors could also cause someone to behave as though they have BPD just until those factors clear up.

Your daughter was diagnosed with BPD, but the doctor who made that diagnosis did not have any magical ability to read your daughter's underlying personality. The doctor could only make the diagnosis based on how your daughter was behaving, and what she was reporting about her own thoughts at the time. It is certainly possible that immediate trauma was causing your daughter to check all the diagnostic boxes for BPD and then, once that trauma passed, to stop meeting the threshold for BPD diagnosis. Whether that means the diagnosis was wrong or whether it means she had BPD and then got better is, to a degree, an academic question.
posted by 256 at 5:34 AM on December 7, 2016 [3 favorites]

I remember this question from last year, and I remember thinking then that the car accident and potential brain injury wasn't investigated well enough. I still think that... and perhaps even more so now because unlike BPD, brain injuries CAN heal and that could explain the improvement.
posted by rabbitrabbit at 5:44 AM on December 7, 2016 [2 favorites]

I'm on the brain injury from the car accident bus.

I was surprised not to see any reference to a brain scan in the previous questions of yours about this, and if she indeed did not have a scan, I would guess she might have had a subdural hematoma, because those can resolve themselves without surgery over a period of months, apparently, and there are some kinds of MRIs that might be able to detect remaining signs of a hematoma that has completely resorbed, in case a belated claim on her insurance is possible.
posted by jamjam at 12:46 PM on December 7, 2016 [1 favorite]

There are some issues with the diagnostic process for BPD. For one, as people have pointed out, the symptoms overlap heavily with a number of other mental illnesses, including, bipolar, depression, ptsd, etc. There are also indications that there's a certain amount of sexist bias at work in borderline diagnosis, as in, traits that are either normal (eg. emotional immaturity in teenage or young adult women) or symptoms of other disorders that appear more commonly in women are pathologized into a borderline diagnosis.

I know this because I was diagnosed with BPD as a teenager, and then had that diagnosis rescinded/corrected by several later psychiatric professionals, who told me that this happens a lot with the bpd diagnosis. I stopped having the symptoms most associated with bpd, and my therapist told me that at the time I was diagnosed, I was most likely just emotionally immature (I was 16 at the time) and the rest of my symptoms were explained by my PTSD and depression. BPD is a personality disorder, so even with treatment, the person will typically always have the disorder, even if it's well managed by therapy or medication. That's pretty much how they tell if someone has been wrongly diagnosed with the disorder; people that truly have it will always have it, and people that don't, the symptoms will disappear or align more strongly with some other diagnosis.

tl;dr Basically, I'd bet that she was erroneously diagnosed with bpd, because it happens a lot. However, the bipolar is another issue. It's normal for that disorder to include episodes of relatively normal function, even extended periods. But the key to extending those periods is constant monitoring and medication, so I'm somewhat alarmed that she threw away her meds.
posted by katyggls at 1:14 PM on December 7, 2016

sometimes she said the underlying trauma was a sexual assault that occurred last year

It really does seem like between this and the horrifying car accident (crawled back up a 300 foot mountain, jesus) your daughter's breakdown was a reaction to both a traumatic rape and a TBI that sound like they happened in a very short time span. Either one of those things would be enough, imo, to account for her crisis state last year, but it looks like she was dealing with both, and neither were taken seriously by the medical personnel treating her.

As for the multiple misdiagnoses-- I know many young women who were misdiagnosed with all of these things, including Bipolar, in periods of extreme emotional duress. Everything you're hearing about BPD as a trash diagnosis is right-- BPD is real, it describes a very real pattern of thoughts and behaviors that people can and do recover from, but it's also hugely misdiagnosed due to sexism and a general inability of the system to deal with women's trauma experiences. Looking at your daughter's various diagnoses, some seem like an incomplete description of her symptoms without addressing the underlying cause. There's been a big push to re-classify BPD as Complex PTSD, so I think the BPD, PTSD, and anxiety diagnoses seem to have been accurate descriptions of her emotional state at the time-- one where she was experiencing extreme emotional disturbance in reaction to multiple traumas-- but not of persistent, lifetime issues of purely psychological origin. Reading your other post, it seems like none of her doctors took the possibility that she'd sustained a TBI seriously, and that seems like the root cause of all of these misdiagnoses, and a major compounding factor in the trauma of her sexual assault.

I am so glad to hear that your daughter is safe and recovering.
posted by moonlight on vermont at 2:05 PM on December 7, 2016 [1 favorite]

My dad had a TBI that resulted in a lot of BPD + ADHD behavior but because he was 65 and male, they called it loss in executive function. (Well it helped that he was scanned after his massive aneurysm.)

I am actually leaning towards PTSD here with a side of brain injury, or brain injury with a side of PTSD. Whatever it is, it sounds like she might be getting to a place to explore it in a non-crisis-oriented way. This might be a great time to find an excellent therapist who is skilled or has a amspevislost network for the whol alphabet soup and see what happens. In my experience PTSD can wax and wane like this.
posted by warriorqueen at 5:05 PM on December 7, 2016

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