Borderline personality disorder—An overview for emergency clinicians

Australasian Emergency Nursing Journal (2008) 11, 173—177

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CLINICAL PRACTICE UPDATE — MENTAL HEALTH

Borderline personality disorder—–An overview for emergency clinicians Kristy Koehne, RPN, RN ∗, Natisha Sands, RPN, RN, PhD University of Melbourne, School of Nursing and Social Work, Level 5, 234 Queensberry St, Carlton, Vic. 3010, Australia Received 13 May 2008; received in revised form 12 June 2008; accepted 23 July 2008

KEYWORDS Borderline personality disorder; Emergency nursing; Crisis intervention

Summary The diagnosis of borderline personality disorder frequently underlies self-harm and suicidal presentations to the emergency department. Borderline pathology combined with high levels of comorbidity, stigma, and treatment uncertainty, increase the challenges of caring for someone with this diagnosis in an emergency setting. Attributes such as black-and-white thinking and splitting may compromise an already precarious situation. The maintenance of safety requires prioritisation and necessitates a practical and respectful approach, which avoids notions of attention-seeking behaviour. Clinical assessment should distinguish between selfharm and suicide attempts where possible and take into account acute on chronic risk. The emergency clinician will need to consider the degree of containment required in the emergency department and is encouraged to maintain transparency and honesty with the client regarding treatment decisions. If hospitalisation needs to be considered, clinicians should take into account immediate therapeutic benefit versus the counter-therapeutic risk of dependency and regression. Overall, it is reasonable for clinicians to aim for clients to return to their pre-crisis level of functioning, and beneficial for clinicians to approach this client group with therapeutic optimism. © 2008 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.

Introduction Borderline personality disorder (BPD) is the most common personality disorder seen in the clinical setting,1 occurring in approximately 2% of the general population, 10% of men-

∗ Corresponding author. Tel.: +61 3 8344 9400; fax: +61 3 9347 4375. E-mail address: [email protected] (K. Koehne).

tal health outpatients, and 20% of psychiatric inpatients.2 Crises constitute an inevitable part of the clinical presentation of BPD3 and clients frequently present to the emergency department because of self-harm, suicidal ideation, or attempted suicide.4,5 When a client with BPD presents in crisis, it is likely that they will be distressed and vulnerable to impulsivity, rapidly changing emotions, and angry outbursts.6 In an environment already characterised by pressure and unpredictability7 this can present a highly challenging situation. This paper aims to equip clinicians with basic clinical information about

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174 Table 1 DSM-IV-TR1(p. 710) criteria for borderline personality disorder (1) Frantic efforts to avoid real or imagined abandonment (2) A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation. (3) Identity disturbance: markedly and persistently unstable self-image of sense of self (4) Impulsivity in at least two areas that are potentially self-damaging (5) Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour (6) Affective instability due to a marked reactivity of mood (7) Chronic feelings of emptiness (8) Inappropriate, intense anger or difficulty controlling anger (9) Transient, stress related paranoid ideation or severe dissociative symptoms

BPD and provide some straightforward suggestions that have been informed by both clinician and consumer expertise. The authors acknowledge the complexity of this diagnosis and the potential for significant variations in clinical presentations, and this discussion does not claim to provide exhaustive assessment or treatment recommendations. BPD is categorised as a Cluster B personality disorder within the Diagnostic and Statistical Manual of Mental Disorders.2 It is defined as ‘‘a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts.’’2(p. 706) The diagnosis is made when an individual meets five of a possible nine criteria (see Table 1). This clinical definition provides minimal insight into the experience of those with the diagnosis. Alternatively, a consumer likens the experience of BPD to ‘‘having been born without an emotional skin, with no barrier to ward off real or perceived emotional assaults.’’8(p. 173) The degree to which clients experience despair and desperation is unlikely to be fully appreciated by clinicians.9 It is a disorder which causes substantial turmoil to the individual, their family and society.10 In comparison with the diagnosis of major depressive disorder, which constitutes the leading cause worldwide of years lived with disability,11 the BPD diagnosis results in significantly more impairment in functioning,12 greater use of psychosocial treatments,13,14 and an increase in medication use.14

K. Koehne, N. Sands the nurse feeling illegitimated, with therapeutic aspirations unmet.21 This diagnosis is highly stigmatised22 and in extreme cases the diagnosis of personality disorder has been used to justify the exclusion of people from care.23 This may originate from the belief that personality disorders do not fit under the category of mental illness24 and the view that they are less amenable to treatment, or even untreatable.25 BPD is frequently accompanied by comorbidities, including ‘axis one’ disorders such as major depressive disorder, social phobia, post-traumatic stress disorder, substance use disorders and eating disorders.26 There is also significant variability within the BPD diagnosis, with 151 possible different combinations of the 9 criteria.27 This means that clients may present to the emergency department with numerous psychiatric diagnoses and high levels of complexity. It is recommended that clinicians approach this complexity with pragmatism. As each presentation may be vastly different, clinicians should simply respond to the priorities which present. During a crisis, or period of emotional arousal, the ability of the client to mentalise, or make sense of their own and others thoughts and feelings, is compromised,28 therefore a complex response is likely to compound difficulties.

Fundamental knowledge for the emergency clinician Black-and-white thinking A common characteristic of BPD is difficulty making sense of alternative or opposing perceptions or feelings within the self or others. This can result in the perception of people or situations in ‘black or white,’ ‘all or nothing,’ ‘good or bad’ terms.1 This tendency for rigidity in thinking creates a vulnerability to powerful emotional storms and impulsive actions.29 This phenomenon may also be referred to as splitting and can translate to the clinician who may quickly be perceived as good or bad. For example, within the DSMIV-TR2 criteria clients may alternate between extremes of idealisation and devaluation in their relationships. The clinician should view splitting as symptomatic of the disorder, rather than interpreting this behaviour personally. Splitting may also occur within treatment teams, necessitating transparency and honesty amongst clinicians and in communications with the client. Sincerity is also important, both in disagreement and agreement.30 Consumers have identified the importance of people being ‘straight’ with them, and tend to trust clinicians who set clear boundaries without being punitive or judgemental.31

Safety Barriers to care Providing care to clients with BPD is commonly perceived as challenging.15—17 The client often presents with a complexity of issues including suicidality, unrelenting crises,18 and intense emotionality.19 The professional identity of clinicians may be challenged by parasuicidal behaviour,20 potential non-compliance with treatment,21 and the inability to neatly fix or assuage suffering. This can result in

While this paper does not seek to discuss issues of risk in great detail, it must be acknowledged that recurrent suicidality is central to the borderline construct. Suicidality is often a focal point for treatment decisions and dilemmas, and predominates as a source of conflict and anguish for all involved.32 Clients with BPD are typically at a chronically elevated risk of suicide, with 8—10% of people with this

BPD in the emergency department diagnosis committing suicide.1,2,33,34 Risk factors include; prior suicide attempts, comorbid mood disorder, high levels of hopelessness, family history of completed suicide or suicidal behaviour, comorbid substance abuse, history of sexual abuse and high levels of impulsivity and/or antisocial traits. Ongoing chronic risk may be ‘‘periodically intensified by situational factors, producing acute suicide risk.’’35(p. 23) Clinicians should try to establish the reasoning behind the occurrence of self-harm, particularly whether there was suicidal intent.36 Self-harm may occur without suicidal ideation, and in this context it is often described by consumers as a ‘survival mechanism’ or a way of managing internal distress, or despair.37 Asking and listening are essential components of a self-harm assessment, requiring the clinician to resist the often instinctive temptation to either avoid this subject, or proceed immediately to the provision of advice. In addition to a thorough risk assessment,38,39 close observation or specialling may be required in the emergency department, particularly when self-harm co-exists with acute suicidal ideation.38 Where a client is considered to be acutely suicidal, it may be necessary to involve the family or a significant other to assist in protecting the patient from harm.1 Overall, emergency clinicians should aim to provide containment, which consists primarily of maintaining safety, providing prompt attention and reducing the duration and impact of the presenting problem. Self-harm should be managed respectfully and without judgement.37 If the client presents frequently to the emergency department, staff should seek to collaborate with mental health professionals involved in the client’s care to develop a comprehensive treatment plan. A treatment plan should involve the client and incorporate guidelines for ED clinicians, treatment pathways and the client’s individualised coping strategies.40 In addition to providing a clear and coherent plan which minimises fragmentation of service delivery,36 the absence of a treatment plan represents a potential marker for suicide prediction.41

175 cerned about the use of hospitalisation for the management of self-injurious behaviour and the potential for admissions to be counter-therapeutic.45 For example, custodial interventions may encourage further regression, helplessness and remove the client’s sense of competence and selfcapacity.40 An alternative though equally debated approach is client-controlled hospitalisation, whereby brief hospitalisation is proactively negotiated by client and their treating clinician.3

Attention-seeking? It is common for clinicians to perceive clients with BPD to be in control of their challenging behaviour, thus evoking less sympathy amongst staff.17 Self-injurious behaviour may be ‘‘mistakenly thought of as wilful, deliberate and under the patient’s control.’’35(p. 21) In Victoria, a recent study found that 89% of a sample of 65 registered nurses working in psychiatric settings agreed with the statement that people with this diagnosis are manipulative.15 Consumers identified that being told that they were attention-seeking was the most distressing response they received from health care providers.46 To perceive and label clients as attention-seeking promotes misunderstanding on several levels. This perspective locates blame with the client and fails to acknowledge the role of the health care system in promoting dependence (as previously discussed). Consumers encourage clinicians to alter terminology and comprehension, by considering the term ‘attachment-seeking’ rather than ‘attention-seeking.’46 In attachment terms, the individual is trying to maintain proximity to someone perceived as being better able to cope with the world, and able to provide care, comfort and security.47 Understanding behaviour in this sense aligns with the DSM-IV-TR criteria of ‘‘frantic attempts to avoid real or imagined abandonment.’’2(p. 710) The threat of abandonment fuels frantic attempts to connect,48 which may explain frequent contact with health services. Repeated presentations to the ED may reinforce the clinician’s and client’s sense of helplessness and frustration, and increase the client’s vulnerability to rejection, from people and services.

Crises and hospitalisation Therapeutic optimism A key clinical feature of the borderline diagnosis is a marked reactivity to situational stress. This makes sense when considering the client who presents to the ED as highly suicidal and emotionally unstable, and upon admission to hospital, with the provision of a supportive environment and dissipation of situational stress, becomes calm and cooperative.42 The decision whether or not to hospitalise clients with BPD often arises during a crisis, and is rarely a straightforward one. Overall clinical consensus suggests that where possible, inpatient care should be minimised.35 If necessary, inpatient stays should be ‘‘brief and goal-focused on reducing symptoms related to the current crisis.’’36(p. 35) While an inpatient admission may be indicated when a client is demonstrating an acute-on-chronic risk,43 this may be very difficult to delineate, and as Paris44 points out, no sharp line exists between chronic and acute suicidality. Experts who caution against hospitalisation are particularly con-

Historically there has been a tendency for therapeutic pessimism in the care of people with BPD,31 as identified in the previous discussion on barriers to care. However, there have been significant overall treatment advances in the field29,49,50 and current views suggest that clinicians should maintain and express optimism in the care of clients with BPD. While functional impairment may persist,51 research which has followed the course of the disorder over substantial periods of time, found that around 50% of BPD patients no longer met diagnostic criteria after 2 years, and were unlikely to relapse.42 Symptoms of BPD that tend to resolve relatively quickly over time include impulsivity (including self-mutilation and suicide attempts) and treatment regressions.52 With the knowledge that consumers identify the importance of maintaining hope53,54 and optimism for change,53 ED clinicians should endeavour

176 Table 2

K. Koehne, N. Sands Tips for emergency clinicians

• Avoid judgement and labelling as manipulative or attention-seeking • Expect a heightened vulnerability to rejection and situational stress • Maintain transparency and honesty • Do not take interactions too personally • Maintain therapeutic optimism • Identify acute and chronic risks in risk assessment • Is there a need for a collaborative treatment plan?

to maintain hopefulness in their communications with this client group.

Summary A client with BPD is likely to present frequently to the emergency department in crisis, and exhibiting high levels of distress. Despite improvements in prognosis and clinician attitudes3 BPD continues to be a stigmatising and debilitating diagnosis. The discussion in this article has sought to inform and advise emergency clinicians on the clinical management of a disorder that challenges clients and clinicians alike (see Table 2). While BPD will not be cured during a visit to the emergency department, it is reasonable for clinicians to aim to assist the person to return to their pre-crisis level of functioning and provide supportive care delivered with therapeutic optimism.36

Competing interests None declared.

Funding None declared.

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