Methods:
A total of 290 inpatients with BPD [Borderline Personality Disorder] were interviewed at baseline and 12 consecutive follow-up waves, each separated by two years, after index hospitalization. Included were also 72 inpatients with other personality disorders. Surviving patients were reinterviewed. A series of interviews and self-report measures were used to assess psychosocial functioning and treatment history, axis I and II disorders, and childhood/adult adversity.
Results:
Results show that rates of SSDI [Social Security Disability Insurance] utilization were relatively stable over 24 years of follow-up (on average, 47.2% of the patients with BPD were on SSDI). Patients with BPD were three times more likely to be on SSDI than patients with other PDs. Patients with BPD displayed flexibility in their usage of SSDI. By 24 years, 46% of patients remitted, out of which 85% experienced recurrence and 50% of the patients had a new onset over time. In multivariate analyses, four variables were found to predict SSDI status in patients with BPD over time. These variables were: age 26 or older, lower IQ, severity of non-sexual childhood abuse, and presence of PTSD. ...
There is one thing about this study that make me wonder. Hospitalization is uncommon for Borderline Disorder itself yet this study tracked patients who had been hospitalized. That would suggest that these patients either had unusually bad cases of Borderline Disorder or had other psychiatric diagnoses in addition to Borderline Disorder. I will say that sometimes those with Borderline Disorder are hospitalized by mistake because the behaviors of the patients involved suggested some other disorder such as Bipolar Disorder. There's certainly the intensity of symptoms with Borderline Disorder, just not that much risk of suicide or homicide, which, in general, is what gets you hospitalized for a psychiatric disorder these days.
The fact that patients with Borderline Disorder were much more likely to be on Social Security disability benefits than those with other personality disorders is not surprising. To begin with, Social Security approves almost no one based upon a personality disorder alone. However, Borderline is one of the worst personality disorders you can have. If anyone is going to be approved on a personality disorder, it's likely to be someone with Borderline Disorder. Also, those with other really severe personality, disorders such as Antisocial Personality Disorder, are likely to spend a lot of time in prison. That's not the case with Borderline Disorder.
Clients with Borderline Disorder are difficult for me to deal with but it's not just their relationships with lawyers. People with Borderline Disorder can't maintain relationships with anyone, including employers. That's the problem. The fact that less than 50% of those with Borderline Disorder are on Social Security disability benefits is proof of how hard it is to be approved for Social Security disability benefits. Very few of those with a Borderline Disorder diagnosis work more than intermittently. That's just a fact. If you have a disorder that prevents you from working on a regular basis, shouldn't you be approved for Social Security disability benefits?
8 comments:
The severity of BPD must be highly variable. Some people with BPD come out of rehab and are able host Saturday Night Live.
https://www.ndtv.com/feature/comedian-pete-davidson-checks-into-rehab-after-struggling-with-borderline-personality-disorder-4162340
I have bi-polar disorder and work for SSA. It’s difficult and I miss a lot of work.
Since Covid and the loss of staffing it’s gotten much worse and most days I have to force myself to go to work. Being able to work from home has helped but it’s still so stressful.
I can’t imagine filing for disability. Mostly because I can’t imagine relying on the government to take care of me. That’s a scary thought to have an agency like SSA play such a large roll in determining my income and my healthcare.
I don't blame SSA and DDS examiners. I fully understand the world turns on credible undeniable evidence. I have a low opinion of ALJ's at SSA.
@11:42am, Pete Davidson is an exception, largely due to the fact that he's wealthy and famous, and therefore has access to medical care and medicines that are out of reach for most people. Not to mention there are varying levels of BPD complications, and he seems to be on the "quieter" end of that scale.
BPD in general is one of the most difficult mental health problems a person can have, except for what gets you hospitalized or someone hurt. Insurance doesn't want to cover treatment, nobody is ever really "cured" of it, and they are condemned to a lifetime of misery for themselves and everyone around them.
Because most people with BPD lash out in all directions, society tends to take a "brought it on themselves" attitude towards their problems. Which, is true, but either we are going to take care of people with problems they didn't ask for, or we aren't. We shouldn't pick and choose based on how much a person irritates us. Nobody asks for schizophrenia either, but we try and help them where we can.
As a society we have a choice: either we can go Mad Max and "I got mine", or we can go Star Trek and just take care of people. The future we make is up to us.
So true. As with the Listings, diagnosis is not enough. You need functional limitations.
Most Claims Specialists hate taking claims with personality disorders- if they don't start the interview aggressive, it can still go from 0 to 100 with just the wrong word or phrase. I don't mind the BPD interviews as much as the severe bipolar ones (that usually have their overshare dial set to maximum), since most BPD people are capable of short, transactional relationships.
You're 100% right that SSA is unlikely to approve a claim without a secondary diagnosis involved.
If you talk to employers the types of symptoms that people with personality disorders exhibit are usually not tolerable. SSA recognizes that the basic mental demands of work include the ability to "respond appropriately to supervision, coworkers and work situations." People with a significant personality disorder just can't do that consistently. They may be intelligent and otherwise capable, which I think distracts many adjudicators into thinking they are able to work. Problem is they can't sustain it when their symptoms manifest around others.
People with BPD are hospitalized at a much higher rate, statistically, because of chronic suicidality, emotional instability, interpersonal conflict, and episodes of decompensation leading to crisis. IOP treatment for BPD is sort of gold standard, ideally DPT with groups and life skills training, and thus inpatient time is longer. McClean is considered the authority on BPD specifically in the field, and much of the research on this subject has been generated by their program.
McClean's program gets you psychotherapy, DBT, often IOP or PHP, family therapy, social work case management, psychiatry, psychopharmacologist, weekly group therapy, some other sort of therapist typically. I practiced with patients using these programs, and they are one of the most holistic and rigorous in this country. That doesn't necessarily make them geniuses because I have seen some wild statements and conclusions in their documentation (which are all over this study). Their writing style is dramatic with lots of flowery asides, long narrative, very comprehensive, and they lean diagnostically toward personality disorders since its their specialty.
The correlation here is unsurprising, as I see more undiagnosed PDs than actual BPD in this work. Clinicians actively avoid adding them to documentation for billing because insurance doesn't want to cover chronic treatment -- this is important for context.
In any event, they use a lot of healthcare and social services because their default internal stress management coping mechanism is set to "catastrophe." We treat BPD as a taboo, terminal illness and a PITA. If they generate a lot of treatment notes, or suicide attempts, you've got a better chance at a favorable decision. If you live in a state without those resources for treatment, there are few records to review to make an informed decision even with a CE for SSA.
More importantly: why BPD? Terrible childhood > brain development changes > nervous system development changes > chaotic environments > defensive coping skills > rigidness, etc. infinity = chronic anger and pain. Emotional pain like you "don't have skin," zero frustration tolerance, need for constant validation to provide stability and safety, maybe using self-harm as a coping tool. That's all before you're an adult. Hopefully you have resources.
If you don't get that together to be functional, adulting is a mountain of never-ending stressors, uncontrollable economic factors, and too little time to learn good coping skills while dragging through life. Imagine if that was you as a child and acknowledge pain and anger are understandable. They should be met with empathy even if they are unpredictable. Validate, acknowledge frustration, ask how you can help, provide compassionate service. This applies to industry experts, healthcare staff, claimants, patients.
All the other above comments are also valid. Stay strong.
Thanks for sharing this research with us!
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