A Brief Overview of Borderline Personality Disorder
The purpose of this article is to provide nurses with an update on Borderline Personality Disorder (BPD). This article aims to provide a succinct overview of the recent research and literature in order to make it accessible to all nurses, thereby promoting evidenced based practice. Areas covered include a defi nition, the prevalence as well as causal factors and treatment of the disorder. The author will also recommend some suitable articles and books for those who wish to read further into the topic.
A point of interest is that the Mental Health Act (2001) clearly states that Personality and Substance Abuse Disorders are not included in its defi nition of mental illness, (Government of Ireland, 2001). However, the more recently published Report of the Expert Group on Mental Health Policy (hereafter referred to as Expert Group) states that the care of those with a diagnosis of BPD is clearly within the remit of the psychiatric services. This document makes the topic of BPD relevant to all psychiatric nurses in Ireland, as they can therefore expect to see more energy and resources being directed towards this client group. Furthermore, as many acute psychiatric units are based in general hospitals, Accident and Emergency Departments have now become the first port off call for those seeking psychiatric services out of hours. Coupled with the tendency of clients with BPD to self-harm, be impulsive and to abuse drugs and alcohol, it is hard to imagine any nurses who will not have some contact with this client group.
Definition of BPD
Personality disorders are psychiatric diagnoses which are clearly defi ned in both the DSM-IV (APA, 2000) and the ICD-10, (World Health Organisation, 1989). Everyone has their own distinct personality traits which infl uence how they think, feel and behave in their lives. These personality traits tend to become evident in an individual by adolescence or early adulthood and remain relatively stable over time. However, sometimes these traits can become particularly maladaptive and result in signifi cant distress and impairment to social functioning for an individual. The DSMIV criteria for diagnosing BPD are presented in Box A, however a little time will be spent explaining how these symptoms might present in practice. Hurt et al’s. (1992) division of the DSM criteria into three areas (identity, affect and impulsivity) makes them more accessible and so will be used here.
Diagnostic Criteria for Borderline Personality Disorder
‘A pervasive pattern of interpersonal relationships, self-image, and affects, and marked impulsivity beginning in early childhood and present in a variety of contexts as indicated by five of the following:
- Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behaviour covered in Criteria 5.
- A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation.
- Identity disturbance: markedly and persistently unstable self-image or sense of self.
- Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behaviour covered in Criteria 5.
- Recurrent suicidal behaviour, gestures or threats, or self-mutilating behaviour.
- Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
- Chronic feelings of emptiness.
- Inappropriate, intense anger or diffi culty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights).
- Transient, stress-related paranoid ideation or severe dissociation symptoms.
Identity symptoms include intense fears of abandonment by others, feeling empty and without purpose, fluctuating self-image and lacking a sense of self. In practice these symptoms often present as the client being very anxious in relationships and frequently seeking reassurances from significant others, including staff. Clients with BPD can also appear to have little direction in their lives and often speak about not knowing what to do with life. Affective or mood symptoms are a major part of the borderline presentation. In particular, feelings of anger and hurt can present as very intense and often appear to the onlooker as inappropriate or as an over reaction. Due to the client’s fear of abandonment or mistreatment by others their anger is often directed at people who they perceive have betrayed their trust in some way. These feelings often result in relationships which appear very unstable with the client moving from hating someone to loving them (and often back again) in a very short space of time. As well as the feelings of anger, depressive feelings are very common among clients with BPD along with a poor self-concept. Finally, impulsive symptoms are most commonly associated with self-harm and suicidal behaviours but many other behaviours can also be extremely impulsive. For example, clients with BPD often engage in a variety of risky and impulsive behaviours, such as substance abuse, unprotected sex or drink driving. Impulsivity may also explain how the client approaches many important decisions in their lives such as ending or starting relationships, quitting a job or moving house. Incidence International research estimates that about 2% of the general population meet the diagnostic criteria for BPD. According to Irish statistics the admissions and treatments of clients with any personality disorder is relatively uncommon. For example, clients with a diagnosis of Personality Disorder account for about 4% of the admissions to psychiatric units and amount to 3% of inpatient days, (Daly and Walsh 2003a & 2003b). On the other hand, the American Psychiatric Association (2000) estimate that approximately 20% of all inpatients and 10% of all outpatients meet the diagnostic criteria for BPD. These fi gures suggest that many clients with BPD may be going undiagnosed in Irish services.
Females account for about 70% of those diagnosed with BPD, (Krawitz and Watson 2003) but things may not be this simple. Becker and Lamb (1994) asked professionals to assign a likely diagnosis to a client based on a written case history where the sex of the client (and no other details) was randomly changed. They found that professionals were more likely to attribute a diagnosis of BPD to women than men which the authors suggest questions the validity of the diagnosis. Simmons (1992) echoes this idea claiming that angry and promiscuous women are likely to be diagnosed with BPD while males exhibiting the same characteristics are more likely to draw a diagnosis of antisocial personality disorder. Becker (2000) has further argued that the current trend to see BPD as a “consequence of character” has led many professionals, concerned about blaming clients, to embrace diagnoses that are seen as a result of fate, such as post-traumatic stress disorder, instead. These studies may help to explain why the diagnosis of BPD is so rarely used in Ireland when compared to the international research on the incidence within psychiatric clients.
Like the majority of psychiatric disorders BPD has no single identified cause and is probably best viewed as the result of interplay between various factors. It is impossible to present a complete review of the literature on the aetiology of BPD in this article therefore those interested should consult the further reading section at the end of this article. Traditionally, many professionals have viewed personality disorders as simply a personality quirk but recent research is starting to suggest that some biological factors may also play a role. We will therefore view BPD from a biopsychosocial perspective in this section starting with biological factors. While the research is sparse to date, some research has suggested that genetics may play a role in the development of the disorder. Torgerson et al. (2000) report that twin studies demonstrate that in identical twins the concordance rate is 35% while in nonidentical twins the rate is only 7%. Krawitz and Watson (2003) cite numerous studies which point to a reduction in serotonin activity in clients with BPD and such reductions have been linked with increased anger, impulsivity, suicidal ideation and irritability as well as a lowering of mood. From a social perspective clients with a diagnosis of BPD are predominantly female and “adverse events” in childhood are evident in about 40% to 71% of cases depending on which studies are examined, (Lieb et al. 2004). The difficulties in childhood most frequently reported by client’s ranges from neglect to emotional, physical and sexual abuse. The literature has paid particular attention to the high levels of sexual abuse, including rape, reported by those with BPD with some studies suggesting up to 70% of clients have experienced some form of sexual abuse, (Krawitz & Watson 2003). However, Krawitz and Watson caution against the simplistic view that BPD is the result of sexual abuse as most clients who suffer sexual abuse do not develop the disorder and about 30% of those with the disorder were never abused.
While most schools of psychotherapy have a theory as to the cause and development of BPD, the cognitive behavioural therapies, particularly Dialectical Behaviour Therapy (DBT), have developed the most evidence for there effectiveness and therefore only this theory will be presented here. DBT views those with BPD as having a fundamental diffi culty or lack skills in tolerating frustration and unpleasant experiences or emotions. This inability to deal with frustration leads those with the disorder to go to great lengths, such as self-harm, to distract themselves from the unpleasant experience. DBT also postulates that clients often have a deficit in life skills and that these need to be taught to the client if they are to be able to deal with strenuous life events.
In order to make therapy work, in the face of frequent crisis and high levels of suicidality being experienced by the client, it is recommended that the therapist have a hierarchy of goals when working with the client, (Lenihan 1993). Typically, suicidal and self-harming behaviours are targeted at the beginning and once some reduction and control has been found in this area other behaviours which interfere with therapy are targeted. For example, a client with BPD may find it difficult to trust a therapist due to a fear of abandonment and as a result they may not attend for many appointments. The therapist may therefore help the client to control these fears and behaviours so that they do not interfere with the therapy. Finally, once, suicidal, and self-harm behaviours and other behaviours which interfere with therapy are causing fewer problems for the client, the therapy can focus on the clients other difficulties such as self-concept and anger.
It is important to note that the main form of treatment for BPD needs to be psychotherapy (American Psychiatric Association, 2000) and any attempts to treat them without the use of psychotherapy are likely to be inadequate. The Expert Group (2006) states that the treatment of BPD needs to be addressed and recommend the development of therapeutic teams to address their need and suggest that a DBT team is likely to be an effective means of providing this care. DBT is a form of cognitive behavioural therapy (CBT) specifically designed to treat BPD and was outlined in the previous section on causal factors. DBT differs from traditional psychotherapy in that that DBT is delivered by a team of therapists. Typically the client attends weekly “skills training” groups with other clients to learn new ways of coping with difficult situations and emotions. They also have an individual therapy session, usually on a weekly basis. Other therapies, particularly CBTs, have been found to be helpful and there are various articles and books available which outline their use in both individual and inpatient settings. Typically effective therapies help the client to examine their dysfunctional relationship patterns while teaching problem solving skills and providing acceptance and validation, (Expert Group 2006).
Medications may be of some help to clients but the benefits are likely to be modest which should be made clear to the client and their family, (Fagin 2004). Fagin (2004) provides a good overview of the use of medications with clients with BPD and his points will be summarised here.
Mood problems, such as low mood, anger and hypersensitivity, are common in those with BPD and antidepressants may be of use. High doses of fluoxetine (60mg) should be the first line treatment but venlafaxine and MAOI’s could also be considered if there is no response from the fluoxetine. In order to target impulsive behaviour numerous drugs may also be used such as mood stabilisers, antipsychotics and SSRI’s. Many clients with BPD experience psychotic symptoms resulting in antipsychotics, including clozapine being used. Benzodiazepines can be used to treat anxiety but caution is needed due to the tendency of such medications to create dependency which only complicates matters further. Fagin (2004) specifi cally mentions clonazepam as being useful and recommends against alprazolam which he states can provoke aggressiveness. With all medications the potential gains will need to be carefully weighed against the risks on a client to client basis. For example, placing a client on an MAOI may seem appropriate if they are depressed but the client will need to comply with a strict diet due to the “cheese effect” and MAOIs may be fatal in overdose, (Healy, 2005). If the client is impulsive or actively suicidal MAOIs may therefore need to be withheld or closely supervised.
Some nurses believe that patients with BPD should not be admitted to inpatient units as this is counterproductive (James, 2005). Research indicates that this is not the case and those with BPD can do well in longterm residential care where psychotherapy is provided, (Gabbard et al., 2000) or in therapeutic communities, (Kelly, et al. 2004).
Given that most units in Ireland will not be providing psychotherapy it would seem likely that long term admissions for clients with BPD are unlikely to be helpful. Maltsberger (1994) points out that chronically suicidal patients frequently evoke a strong counter-suicide response from staff, leading to prolonged admissions.
Short admissions, (a few hours to a few days) can be helpful in providing an opportunity for assessment, respite and crisis intervention if the risk of suicide or self-harm is particularly high, (Krawitz & Watson 2003, Fagin 2004). Nehls (1994a & 1994b) describes the use of brief hospital admissions for this client group where the client initiates admission for an agreed length of time (usually a few days) and this approach was positively viewed by staff and led to a decrease in time in hospital for clients. Working with clients with BPD can be challenging and staff need to be consistent in their approach as the client is often chaotic and chaotic staff will only aggravate this further. Box B contains some general principles for providing care to clients with BPD which are particularly important in inpatient settings.
Principles for providing care to clients with BPD
(adapted from Fagin 2004)
- Necessary limits should be clearly set and explained to the clients. Avoid power struggles and be willing to be fl exible when possible.
- Be prepared to tolerate intense feelings from the client such as anger and hate.
- Encourage the client to refl ect on their emotions, thoughts and actions and the relationships between these.
- Invest time in developing a strong therapeutic alliance. When possible allow the client choice and input on decisions.
- Avoid team inconsistencies and be careful not to reinforce the client’s view of good and bad staff, i.e. splitting. Care planning decisions should ideally be agreed as a team and then discussed with the client.
- Be conscious of the stress and strong emotions frequently provoked by these clients. Supervision and team support are vitally important.
As this article has shown, BPD is a common disorder that can be very debilitating for those affected. Recent Irish Government policy has firmly laid the responsibility for caring for these clients with the psychiatric services. The result of this is that knowledge of BPD and its treatment is likely to become more relevant to psychiatric nurses in Ireland. International research has indicated numerous approaches to working with these clients which can be helpful including medication, psychotherapy and the use of short term crisis admissions. As working with these clients can sometimes be challenging it is also worth bearing in mind that the disorder has a better prognosis than other mental illnesses such as Bipolar Affective Disorder, (Lieb 2004). In fact numerous studies have shown that at 6 year follow-up of previously hospitalised clients with BPD, over 75% of clients no longer met the criteria for BPD, (Lieb, 2004).
Further reading Some of the references used in writing this article may be of interest to various professionals working with clients with BPD. For an overall view of BPD I highly recommend the book by Krawitz and Watson (2003) which is very easy to read. It would be a good investment for any team or unit which works with these clients as it covers practically every area including the history of the disorder, treatments as well as legal issues. The article by Lieb et al. (2004) attempts to present a summary of all areas in a more condensed version so is well worth a look. For nurses working on inpatient units the article by Fagin (2004) provides some useful and practical advice. I would recommend that all staff familiarise themselves with the contents of the Expert Group’s Report (2006) as this will have a huge infl uence on the development of the mental health services and not just in relation to BPD. For those interested in learning more about the use of Brief Hospital Treatment Plans the articles by Nehls (1994a & 1994b) are reccomended. Finally, the anxiety and turmoil created by caring for clients who are chronically suicidal and self-harming is likely to be something all mental health staff are familiar with and the article by Maltsberger (1994) provides a very useful discussion on this topic.
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