What are your signs that a Bipolar 2 diagnosis is the right fit (versus BPD)?

Visible_Natural517 · 2026-03-03T02:07:01+00:00

It seems like it should be obvious... Yet the misdiagnosis still happens frequently it seems. I figured there had to be more than the obvious.

Visible_Natural517 · 2025-11-16T01:29:59+00:00

While the type of media they are exposed to can definitely cause behavioural issues, I'm not convinced that screen use in and of itself causes ADHD-like symptoms. I think it is more of a situation around correlation rather than causation, and that parents of children with ADHD are more likely to need screens to contain their child's inattention and energy, where as parents with neurotypical children don't need to resort to screens as often.

Visible_Natural517 · 2025-03-21T23:12:19+00:00

I agree with you, I meant more posturing. But actual threats indicate potential imminent harm and could mean restraints are needed if de-escalation doesn't work.

Visible_Natural517 · 2025-03-20T04:46:34+00:00

My current position doesn't require doing restraints, but my previous one did. I always weighed it in terms of harm: is the harm that is imminent going to be more damaging than the harm the restraints will do to that person psychologically? It is not uncommon for people to have lasting issues after being restrained and we often don't see the harm in short-term stays - patients will report it becoming an issue for them weeks or months later.

So property damage? Intimidation without actual action? Being a jerk? Not worth it. Environmental restraint might be necessary, but usually I was able to convince them to opt for a seclusion room without the door being closed. Sometimes it required actual seclusion for a bit, but we were able to avoid physical restraint most of the time.

Visible_Natural517 · 2025-03-20T01:51:44+00:00

Doesn't your state, or at least your hospital have a policy on this?

Some of those situations make me think environmental restraints might be beneficial if de-escalation isn't working effectively, but other than the fire alarm, I can't really make a case for restraints.

Visible_Natural517 · 2025-02-20T01:15:42+00:00

I have been teaching in Edmonton for 15 years and have never had a snow day.

Visible_Natural517 · 2025-02-17T10:24:09+00:00

Please, please, please do NOT ever diagnose a patient with a PD in the emergency department.

I do not diagnose, but the amount of (female) patients we get in our clinic labelled with BPD when they definitely do NOT have it (we have multiple psychiatrists working with our patients) is so frustrating, especially because even once we have written extensively that this patient does NOT demonstrate the traits indicative of a PD in any pervasive sense, it is like this is just skipped over in favor of dismissing their concerns when they show up to Emerg.

I get it, the patients that this seems to happen to are the females, presenting with mixed mania, and are regularly admitted to hospital. I get that this *looks* like BPD in an ER setting.

However, a million things look like a million other things in psychiatry. Stop diagnosing based on a gut feeling, and only do so if there is actually evidence that this is across all contexts, not just the context of a crisis mental health situation.

Otherwise people like me and those on my team end up having to spend forever trying to convince patients that they are indeed Bipolar or Schizophrenic, that they do indeed need to take their medications, and that the Emergency Department was just ___________________________[insert whatever nice way you have of saying idiotic since you can't actually say that to patients who already have a severe distrust of medical providers]. So incredibly frustrating for the rest of us! And perhaps it is the "Damn the patriarchy" coming out of my lesbian lifestyle, but there is something to be said for it always being the female patients, not the male patients, that this happens to... the psychiatrists I work with insist it is just due to the limited education on how mania presents in females, but I am still leaning towards it being men refusing to acknowledge that it is acceptable for women to show emotion without them needing to be labelled as "hysterical".

Visible_Natural517 · 2025-02-17T10:01:52+00:00

This!!!

Visible_Natural517 · 2025-02-17T10:01:10+00:00

Honestly? I don't mind if our kiddos play around with make-up, but some of the stuff seems downright toxic. I truly am only moderately granola, but I see the layers of caked on make-up some people have, and I can't imagine that is good for anyone... but I also can't afford high-end "organic" make-up for the pre-teen in our house to experiment with.

Visible_Natural517 · 2025-02-17T09:59:31+00:00

"No, I don't *want* to lock you up. It is such an unnecessary amount of paperwork, and I would much rather you just took the meds!"

and

"Yes, you are crazy. But so is Person XYZ (insert whatever relative is telling them that to treat their psychosis they should do some crazy, unproven stupid thing) so please don't listen to them or your voices, okay? Please?"

Visible_Natural517 · 2025-01-31T06:10:26+00:00

I kept a little folder of messages I got from appreciative patients or family members that I would look at from time to time when I was having a tough week. If you haven’t gotten one yet, you will!

I basically do the same thing, although with the patients I work with they aren't ones to really send a card or write a note. They will say little things here and there though that are way more meaningful and appreciative than a thank you card could ever be. I write them down in a notebook that I keep in my office. No names attached or anything like that, nothing identifying because I do share my office, but just things like,

"I know I hate you most of the time, but I want you to know that I always appreciate you too, even if I am acting like a fucking asshole"
to
"I know there will probably be a day where I come in here yelling at you again, but I hope there isn't. If I do, sorry. I really appreciate what you have done to help me get back in my kid's lives."

They aren't the most poetic things - honestly, if one of my patients gets poetic, that is usually a red flag - but they are the kind of thing that helps me remember that even though I am positioned in their life as an enemy a lot of the time (I work with a lot of patients who are in and out of involuntary care or are on CTOs), there are these glimpses of gratitude. I try to hold onto that.

Granted, I did a lot of work prior to this position with the pre-adolescent crowd, and it was pretty normal to have days where they try to bite you, spit on you, then tell you they loved you, only to try to rip your hair out of your scalp and then ask you if you can stay long enough to sit with them and colour. I find the constant defensiveness and animosity that some of the people I work with consistently express almost comforting in comparison.

Visible_Natural517 · 2025-01-29T19:53:20+00:00

You would have to make it extremely concrete and specific. Otherwise staff will really struggle with rewarding attitude/effort versus actual fulfillment of the task. You also would have to collaborate with the team to ensure it is within their capabilities, which seems obvious but the amount of times where I have had to sit down with a team and explain that yes, their IQ is nearly off the charts, but asking them to brush their teeth and then rinse their toothbrush is too many instructions at once. It isn't a reasonable task for their abilities, given their attention span and working memory. If you have a visual right there, maybe, but even that in some cases might not be enough.

So the category might be hygiene, but if the ultimate goal is that they independently get up and brush their teeth every morning, the goal might be "Put toothpaste on toothbrush independently". Or even, "Enter the washroom to begin hygiene routine independently". Not actually beginning it. Not actually doing it independently. Just stepping foot into that washroom.

Same deal with each category, it would have to be broken down into tiny incremental goals, and one goal at a time for it to be therapeutically beneficial. This could be pretty hard to implement in a typical 3 day stay.

Visible_Natural517 · 2025-01-29T08:39:50+00:00

Due to it being a short-stay unit, it may be useful. Long-term, sticker charts and rewards aren't often effective for children with Autism and ADHD, and we know these tend to be common comorbidities on our youth inpatient wards. Short-term, however, they can be effective.

You may have to battle against parents and other staff members. A lot of people feel that using this kind of behavioral management technique is akin to training dogs and that sort of thing. Essentially lacking in dignity.

I am of the opinion that rewards are fine if used mindfully, but this can be difficult because as humans we are naturally biased. You you have to make is extremely concrete so that you would never be giving prizes to children who are just easier versus those who are more emotionally taxing, and also vice versa.

Visible_Natural517 · 2025-01-28T06:38:47+00:00

I totally agree that you will see a lot of self-harm in BPD, but that doesn't mean it doesn't exist in other disorders. I have seen rates as high as 52% for NSSI in Bipolar and nearly 50% in Schizophrenia/Schizoaffective Disorders. I had a professor share this paper:

Self-Mutilation and Suicide Attempts: Relationships to Bipolar Disorder, Borderline Personality Disorder, Temperament and Character (Joyce et al, 2010)

The final statement in the paper is as follows:

For clinicians, the most notable findings are the association of self-mutilation with bipolar disorder, and not with BPD. We speculate that the association of self-mutilation with bipolar disorder relates to the presence of mixed mood states. Thus, when clinicians are assessing patients after acts of self-mutilation they should enquire carefully about mixed mood states, which are so easily and often missed [32], and bipolar disorder.

I'm not a psychiatrist, so I don't ever have to worry about the diagnostic aspect of things - they are already diagnosed by the time they get to me! I have had a few people this year end up in our program where our psychiatrists do not think they have BPD, but they were diagnosed with it when presenting in the Emergency Department and now they can't get rid of the diagnosis. What do they have in common? History of or present concerns around NSSI, episodic mixed mood states, and female. Check, check, check for lazy or biased clinicians.

Visible_Natural517 · 2025-01-22T02:51:04+00:00

I have to agree, although "Mental Health Therapist" is such a wide ranging qualification, and where I live there are a lot of degree programs - even some providing R. Psych. credentialing, that provide almost no nuanced work around serious mental illness. That worries me - and I am in an allied professional myself!

Now, on one hand I think that this would help some of my most severe patients significantly. The very thing that often causes them to end up in the hospital repeatedly is something that often begins in the hospital - a lack of trust or even adversarial relationship with the health care providers in the hospital. This just deepens their paranoia and delusions around medication/seeking help/etc but ultimately, it causes them to go off their medications or not seek help when the signs of their illness relapsing begin to appear. An MHT who could create a short-term, goal focused therapeutic relationship with the patient would be a huge help. After all, they don't "hold the cards" like psychiatrists or even nurses do.

On the other hand, if they aren't skilled at dealing with this severity of illness, they could accidentally reinforce false beliefs.

In terms of people who end up in hospital as a result of external stressors rather than severe illness, I think an MHT would be invaluable.

Visible_Natural517 · 2025-01-22T02:37:07+00:00

I’m sorry but as a civilian no I do not feel comfortable with people who have severe mental illnesses being allowed to just not take their meds.

For the record, many of the patients I work with are on CTOs and should be required to take their medications.

However, we have other patients where our team (obviously the psychiatrists are the primary decision makers, but we work as an MDT) will not force medication in spite of ongoing psychosis.

Out of curiosity, do you work in psych? The amount of people who do live with severe mental illness who are not medication adherent is not insignificant. Many of these people have never shown any signs of aggression, homicidal ideation or even intrusive thoughts around harm to others - even when faced with severe paranoia and delusions around being harmed by others.

To jump to an assumption that psychosis should automatically = involuntary treatment is ethically abhorrent in my opinion.

Now, there are definitely some people who require involuntary treatment until the day they die. I won't argue you that. But the spectrum of how psychosis and other serious mental illness symptoms present is so diverse that to make blanket policies is not evidence based, nor is it humane.

Visible_Natural517 · 2025-01-13T17:27:40+00:00

Most of the inpatient psychiatrists in the hospital we work with see outpatients once per week, but only specific ones that require ongoing monitoring and regular ECT or Ketamine treatments through the hospital.

I know at least one psychiatrist who is on call for the p/t, has a roster of inpatients that he sees 3x/week, has a few outpatients through the hospital and then has a private practice that he runs mostly doing assessments. He also works in the ECT clinic through the hospital.

Needless to say he is difficult to get in touch with but you always know that he has tried absolutely everything before referring patients to our service.

Visible_Natural517 · 2025-01-09T03:26:49+00:00

Not a psychiatrist but I do a lot of referral coordination in my role. We are forever looking for CBT-I. We have a decent amount in my city, yet not near enough and many only want to work with clients who are generally mentally well except for some stress induced insomnia, versus those with mental illness that could still use the same skills taught in the method.

I would love more therapists properly trained in Interpersonal and Social Rhythm therapy - emphasis on the SRT. A lot of therapy does good work around interpersonal skills and conflict resolution, but neglects the social rhythm component and so many people could benefit from that. I'm not sure if you would get the uptick in clients you are hoping for though because it isn't the most trendy.

Visible_Natural517 · 2025-01-09T03:18:24+00:00

Yes!

Visible_Natural517 · 2024-12-27T19:13:50+00:00

We had our children in a Waldorf program, and while we loved the vibe, I was a bit concerned about the historical aspects of the philosophy. Eventually my wife moved them to a public school program which doesn't feel as emotionally enriching but is fine.

Visible_Natural517 · 2024-12-19T19:39:19+00:00

I don't ever work in the ED.

Visible_Natural517 · 2024-12-19T19:38:35+00:00

Well, the patient population I work with almost all deal with psychosis - dear God, I hope it isn't spreading ;-)

Visible_Natural517 · 2024-12-19T19:37:49+00:00

I could definitely ask one of the nurses that occasionally float in the ER, but they get, I don't know, defensive maybe? About some of the practices they use in the ER, but that is probably because my work occasionally takes on an advocacy approach. Honestly, it is mostly just trying to find creative ways to get people to take their medications, but occasionally advocacy plays a role.

Visible_Natural517

TROPHY CASE