Borderline personality disorder: still a diagnosis of exclusion?

7/30/2019 Borderline personality disorder: still a diagnosis of exclusion?

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26 June 2009 mentalhealth today


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Borderline personality disorder:still a diagnosis of exclusion?

Reerring to people as PDs simply depersonalises them, andterms such as manipulative and attention seeking are oten

derisive, and usually inaccurate, says Christopher Raven

KEY WORDS

Personality disorder

Stigma

Community mentalhealth

Assertive outreach

A&E department

AUTHOR

Christopher Ravenhas worked inmental health since

1990. He qualifedas a social workerin 2000 and hasworked in manyroles (includingmanagementand tenantparticipation),and varioussettings, both inthe voluntary andstatutory sectors.These includeresidential care,inpatient settings,community mentalhealth teams andassertive outreach.He currently worksin Tower Hamletshome treatmentteam.

Contact: [email protected]

Take-home messages

Regardless of your setting, professional background or role, a more individualised and optimistic approach

to working with people with a borderline personality disorder should go a long way to relieving the distress

and discontent in both service user and practitioner alike.

Target audience

This article provides an alternative and optimistic approach to working with people who are diagnosed

with borderline personality disorder and should be of particular interest to care co-ordinators as well as

practitioners in acute care and crisis settings.

D

espite recent initiatives and positivegu idance rom the government ,borderline personality disorder remainsa diagnosis that seems to evoke extremes

o emotional response rom practitioners,such as annoyance, rustration, anxiety, helplessnessand sometimes apathy. As a result, people diagnosedwith borderline personality disorder oten receivelimited and inconsistent care, which can oten mimictheir own internal turmoil.

Service provision or people diagnosed withpersonality disorder is sparse, with exclusionarypractice still operating in many mental health services(Department o Health, 2006).

One reason or this could be the controversial natureo the diagnosis, in that many clinicians eel that it isimpossible to treat a persons personality, and thereorepeople with this personality type only really receive

treatment or their acute symptoms in times o crisis,rather then or the disorder as a whole (Flory, 2007).

As a crisis oten appears brie although it can berequent in times o particular stress the time spanin which proessionals intervene is oten short, so theopportunities or making any real dierence to theservice users lie is very limited. This reinorces theproessional view that the condition is untreatable, andstrengthens the stigma attached to it.

Many service users diagnosed with personalitydisorder do indeed eel stigmatised by services, andeel they are viewed as diicult, manipulative, andattention seeking. Many eel blamed by services or their

condition, when all they seek is legitimacy and basicacceptance (NIMHE, 2003).

Ater many years working in mental health, I havecome to the conclusion that, because o the stigma

attached to the diagnosis and how it is described in manyproessional texts, people diagnosed with borderlinepersonalities are not always adequately inormed abouttheir diagnosis. Practitioners can become cautiousabout giving inormation due to this stigma, and analternative diagnosis is oten applied. I believe that thestigma associated with personality disorder is actuallycreated by services eeling powerless to help, and weperpetuate this stigma when we avoid labelling peoplewith such a stigmatising diagnosis as this reduces theopportunities or individuals to learn about themselves,and receive appropriate treatment.

I have also ound that proessionals can also becomecautious about oering support in case it opens up cans

o worms, and many eel ill equipped to deal with theraw emotion that can sometimes maniest. Conversely,other practitioners oten seem unwilling to believethat the service user is eeling any real emotion at all,giving way to the view that they are attention seeking ormanipulating services in some way.

More oten then not, ineective support andinormation provision is due to practitioners notunderstanding the diagnosis particularly well.

I hope to challenge the view that people withborderline personalities are beyond help, or somehownot in need o support rom mental health servicesby exploring what the condition really means or the

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people who experience it. I also hope to oer positiveadvice, and argue that working with, or even having aborderline personality type, though at times distressingand diicult, can at other times be very positive andrewarding.

The diagnosisAccording to the ICD-10 Classication o Mental andBehavioural Disorders (WHO, 1994), emotionallyunstable personality disorder is a condition in whichthere is a marked tendency to act impulsively, andwithout consideration o the consequences, togetherwith aective instability. The ability to plan ahead maybe minimal, and outbursts o extreme anger may otenlead to violence, or behavioural explosions (p204).

The ICD-10 identies two variants o emotionallyunstable personality disorder, the impulsive personalitytype, and the borderline personality type. Peoplewith impulsive personalities are described as having

emotional instability and poor impulse control, whichcan oten result in outbursts o violence, or threateningbehaviour, especially when criticised.

People with borderline personalities are alsocharacterised with emotional instability, along withunclear or disturbed sel-image, aims and internalpreerences (including sexual), as well as chronic eelingso emptiness. The ICD-10 also describes a tendency tobecome involved in intense and unstable relationships,resulting in repeated emotional crisis, associated withexcessive eorts to avoid abandonment and a series osuicidal threats or acts o sel-harm (WHO, 1994).

The American Psychiatric Association (1994)denes borderline personality disorder in its DSM-IV

classiication o mental disorders. Here it is deinedas a pervasive pattern o instability o interpersonalrelationships, sel-image, and aects, and markedimpulsivity beginning in early adulthood and presentin a variety o contexts, and goes on to list a numbero diagnostic criteria, o which ve or more should bepresent or at least a year.

n Frantic eorts to avoid real, or imaginedabandonment

n A pattern o unstable and intense interpersonalrelationships characterised by alternating betweenextremes o idealisation and devaluation

n Identity disturbance: markedly and persistently

unstable sel-image or sense o seln Impulsivity in at least two areas that are potentiallysel-damaging (or example, spending, sex,substance abuse, reckless driving, binge eating)

n Recurrent suicidal behaviour, gestures, or threats,or sel-mutilating behaviour

n Aective instability due to marked reactivity omood, usually lasting a ew hours and only rarelymore then a ew days

n Chronic eelings o emptinessn Inappropriate intense anger or diculty controlling

angern Transient stress-related paranoid ideation or severe

dissociative symptoms.

Looking at these denitions, terms such as illness andsymptoms are airly obvious in their absence. This isquite correct, as I agree in principle that mental health

services should have no involvement in trying to curea person o their personality. Your personality is whatmakes you who you are, and like all personality types,the components that make up your personality can beboth positive and negative. However, this does seemto be the root o the diiculties that services have in

working with borderline personality disorder, in thatby its very nature, health services are in the business otreating illnesses, and health practitioners become veryrustrated when they eel unable to do this (Perkins etal, 1996).

Nevertheless, I would argue that mental healthservices have a clear and important role in supportingpeople with borderline personalities, and can makevery real and signiicant changes in how peopleperceive themselves and manage distress. Also,people with borderline personalities can also beprone to legitimate illnesses such as depression,post-traumatic stress disorder, and anxiety due to the

impact o their personality on their lives, and the lieevents that possibly contributed to the developmento the personality type in the rst place (Chapman &Gratz, 2007).

The ICD-10 and DSM-IV denitions describe twomain eatures o borderline personality, the rst beingimpulsivity and emotional instability, and the secondbeing eelings o emptiness and an undeined oruncertain sense o sel. Issues such as being unable toplan ahead, having emotional outbursts, sel-harm, anda ear o abandonment are, in my opinion, less to dowith symptoms, and more to do with how individualsreact to the two eatures o borderline personality.This is quite a useul point o view, as it opens up

opportunities to:n identiy the positives and negatives that the

personality eatures present, allowing service usersto ampliy the positives and manage the negatives

n identiy behaviours or habits that are adverselyaecting the service user, and support themto understand them within the concept otheir personality, thereby developing eectivecoping strategies to either remove, replace, orreconceptualise them, or at least minimise theirimpact.

This approach does, however, rely on open, optimistic,

and positive communication with the service user,which is diicult with existing deinitions. I haveound the Chapman and Gratz (2007) deinitiono borderline personality disorder clear and accessible,and have ound it useul when explaining the diagnosisto service users.

BPD (borderline personality disorder) is adisorder o instability and problems with emotions.People with BPD are unstable in their emotions, theirthinking, their relationships, their identity, and theirbehaviour. People with BPD have rocky relationshipsand are oten araid o being abandoned. Emotionally,people with BPD eel like they are on a roller coaster,with their emotions going up and down at the drop

o a hat. They may also have trouble with anger(either having anger outbursts or being so scared oanger that they avoid it entirely). People with BPDact impulsively (they act quickly without thinking)



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when they are upset, and they sometimes attemptsuicide and engage in sel-harm. Oten people withBPD have trouble guring out who they are, and theysometimes have trouble thinking clearly and stayinggrounded when they are stressed out. (Chapman &Gratz, 2007: 1617).

The causesThere are many theories as to why people developpersonal i ty d i sorders , inc luding b io log ica l ,psychological and social actors, which createin individuals a combination o diiculties withpersonal identity and with accurately interpretingthe behaviour o others (Alwin, 2006).

Chapman and Gratz (2007) suggest that people withborderline personality disorder are naturally sensitiveand emotional people, and in that respect it is to somedegree a physical condition, as emotionality is reliant onsuch actors as genes and brain unction.

For naturally emotional people to go on to developa borderline personality, they have usually experienceda sustained invalidating environment or signiicantlytraumatic events in their developmental years (usuallyin childhood). An invalidating environment is onein which people communicate that your thoughts oreelings are not valid, reasonable, understandable ortrue (Chapman & Gratz, 2007, 53).

Unortunately, service users with borderlinepersonalities have oten ound mental healthpractitioners assuming that what they say, eel or do issomehow invalid, unreasonable, or untrue (NIMHE,2003), which o course mirrors and perpetuates pastabuses.

The ofcial guidanceThe NICE clinical guidance or working with borderlinepersonality disorder sets out the ollowing advice.

n People with borderline personality disorder shouldnot be excluded rom any health or social careservices because o their diagnosis, gender, orbecause they have sel-harmed.

n Health and social care proessionals should work inpartnership with people with borderline personalitydisorder with the aim o developing their autonomyand promote choice.

n Health and social care proessionals working with

people with borderline personality disorder should:explore treatment options in an atmosphere ohope and optimism, explaining that recovery ispossible and attainable

build up a trusting relationship, work in an open,engaging and non-judgemental manner, and beconsistent and reliable

be aware o sensitive issues, including rejection,possible abuse and trauma, and the stigmaoten associated with sel-harm and borderlinepersonality disorder.

n Health and social care proessionals should ensurethat withdrawal and ending o treatments, andtransition rom one service to another, is discussed

careully and in advance with the person (and carersi appropriate) and anticipate that endings mayevoke strong emotions and reactions or the person(NICE, 2009).

The guidance in practiceThe irst stage in adequately supporting people withborderline personalities is to recognise the role mentalhealth services has had in perpetuating the stigmaassociated with the condition, and to develop a morepositive and hopeul attitude.

Being emotionally sensitive, with a ear oabandonment makes many people with borderlinepersonalities very skilled at reading body languageor signs o rejection. I you are a practitioner withnegative views o borderline personality disorder,and are unwilling to refect on this and change youropinion, the best way or you to support a person withborderline personality disorder is to keep away, as youmay only succeed in alienating them and reinorcingtheir eelings o inadequacy and o being out o control.You may in act, perpetuate and mirror the abusiverelationships that created the personality disorder inthe rst place.

I, on the other hand, you are willing to provide asupportive service, then try and understand the natureo the condition. People with borderline personalities,especially when in distress, are emotionally labile. Thisis actually a good thing i approached correctly, as theservice user can be very responsive to the practitionersemotional state. I approached incorrectly, it doesbecome a hindrance.

I have ound that two extremes o intervention areoten carried out. Services will either under-supportdue to ears o creating dependency, opening cans oworms which will be dicult to close, or under-valuingthe level o distress at the time. Under-supporting isproblematic, because it can ampliy the service users

eelings o rejection and low sel-worth. Alternatively,services can also over-react, with practitioners showingtoo much concern and entering into the crisis with theservice user. Over-reaction is also problematic, as itamplies the service users eelings o chaos and o beingout o control.

What people with borderline personalities need intimes o crisis is rm ground. Coming rom a strengthsperspective (Morgan, 1996), I have ound that oeringmeasured, but supported and optimistic interventionshas, in my experience, been very eective, and I haveound people to respond very strongly and positivelyto not only reassurance, but also to my genuine trust in

their ability to manage the situation.Be aware also that a single episode o distress can beshort lived, but the underlining crisis can be lengthyi its cause is not addressed. People with borderlinepersonalities manage their lives adequately most o thetime, despite the diculties their personalities presentthem. Occasionally, lies events undermine their usualcoping skills, and a crisis ollows. The very nature o thepersonality type means that crisis can take the ormo rapidly cycling periods o distress then calm. Avoidtreating each episode o distress as a new event, as it maynot be, it may be part o the current crisis still. Beoregetting rustrated and concerned about dependency,consider oering consistent support through each

episode o distress, taking every opportunity to assistthe service user in learning rom their experience, anddeveloping strategies, and the condence to deal withany uture distress.



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Take an interest when the service user is not in crisis,as this is the best time to educate, explore and developstrategies or coping with crisis, and adverse lie events.Develop a true understanding o the individual andwork together to orm plans. Help them avoid stressulsituations by recognising any issues they may have with

orward planning.In other words, ensure that individuals remain

actively involved in nding solutions to their problems,even during crisis, and encourage individuals to considerdierent treatment options and lie choices, withconsideration or any consequences these choices mayhave (NICE, 2009).

Also, be aware o the stigma associated with thediagnosis, but avoid letting it prevent you rom oeringinormation about the condition. Be mindul o thelanguage you use, not only with the service user, butalso in the oce, as the language you use, and whichis used around you will aect your attitude towards

your service users. Reerring to people as PDs simplydepersonalises them, and terms such as manipulativeand attention seeking are oten derisive, and usuallyinaccurate.

For example, i someone were attention seeking, thiswould suggest that they are in need o some attention. Itis not the service users responsibility to seek attentionin a way that services ind appropriate, but it is thepractitioners responsibility to respond proessionallyand skilully (Perkins & Repper, 1996).

Manipulative behaviour can be considered aprocess in which a service user has learnt rom yearso being under-supported by services, to exaggeratetheir symptoms to receive the support they eel they

need, however, I do not believe that this is always thecase. Remember that when in distress a person with aborderline personality may be overwhelmed by strongemotions, eel out o control, and may be impulsive.Is it not then understandable, when someoneapproaches more than one source o support, isinconsistent regarding the support they want andcan quickly become rustrated and reactive? Again,it is the services responsibility to respond to thisproessionally and skilully, and not judge the serviceuser or having the symptoms o their condition(Perkins & Repper, 1996).

Finally, be aware o the impact o endings and that

people with borderline personalities are particularlysensitive to eelings o abandonment and may havetrouble not taking a change o practitioner or servicepersonally.

Consider whether an ending o a service should bestructured and phased out over a period o time, andwhether working with other care providers might behelpul over such transitions, and ensure systems are inplace or managing any potential crisis over this time(NICE, 2009).

Managing riskAs a diagnosis, borderline personality disorder isoten associated with a number o sel-harming and

risk-taking behaviours, and may be a cause o anxietyand rustration in practitioners. Such behaviour caninclude repeated sel-harm, severe risk taking andattempts at suicide. These issues are o particular

concern due to the emotional liability and impulsivityassociated with the condition. Chapman et al(2007)cites one study that ound 75% o people diagnosedwith borderline personality disorder saying they havemade at least one attempt to end their lie, and it isalso estimated that between 5% and 10% o people

with this diagnosis are actually successul (Chapman& Gratz, 2007).

This risk o suicide, along with the associatedimpulsivity can raise serious concerns or mentalhealth services, and in view o these risk potentials, itis no wonder that both services and service users preeradmission to hospital when saety is in any doubt.

The National Institute or Health and ClinicalExcellence (2009) gives the ollowing advice inregards to ormulating risk assessment or people withborderline personality disorder.

n Undertake within the context o a needs assessments.n Dierentiate between acute and long-term risks.

n

Identiy risks to sel, and others (including thewelare o dependent children).n Formulate assessments with the person concerned.n Explicitly relate to long-term treatment strategies.n Take into account any changes in personal

relationships, including the therapeutic relationship.

One o the long-term risks to service users is repeatedadmission to hospital when in emotional distress.This is problematic because it erodes the serviceusers independence, sel-esteem, and any opportunityto develop uture, or try out exis t ing copingstrategies (Raven, 2007). It also increases thestigmatisation already present or that person due

to their diagnosis, as practitioners in acute caresettings become increasingly more rustrated at eachidentical presentation.

In summaryn Challenge your own assumptions, attitudes and

prejudices.n Work towards autonomy, and choice.n Be optimistic, supportive, encouraging and

consistent.

Messages or community mental health andassertive outreach teams

n

Care co-ordinators are the most consistent andimportant health care proessional in the serviceusers lie, so they should get to know the personbehind the diagnosis.

n Focus on recovery and on developing copingstrategies, rather than only being involved when itis a matter o risk management or crisis.

n C o n s i d e r t h e r i s k s o d e p e n d e n c y a n dinstitutionalisation when considering hospitaladmission or reerral to home treatment, as youmay well be the most eective person to supportsomeone through crisis, due to your ongoingrelationship.

n Formulate with the service user a user-led

comprehensive multidisciplinary care plan thatspeciies potential triggers or that person, andidentied the course o action to be taken when indistress (NICE, 2009).



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Mental Health Todaywelcomes reports and research papersthat can help inorm our readers practice.

Guidelines or authors are available atwww.pavpub.com/pavpub/mentalhealthtoday/contributor.pd


Messages or accident and emergencydepartments, psychiatric liaison andinpatient services

n Hospital admissions may eel the saest option attimes when a service user is expressing suicidalthoughts and belies, or is harming themselves, but

is not always helpul in the long run, especially ithere are repeated admissions.

n A&E can be a sae haven when needed, even i it isor a short while, as can short hospital admissions.

n You may need to spend some time reassuring theservice user that the crisis will pass and that theyhave the past experience, the skills and the abilityto get through what they are currently experiencing.

n Waiting time targets may make it dicult to devotethis amount o time in A&E.

n Make sure that their established diagnosis is notmasking another acute condition, such as depression.

n Home treatment is a less restrictive option than

admission to hospital.

Messages or crisis resolution and hometreatment teams

n Repeated reerrals to home treatment are not alwayshelpul, but there is denitely a role in supportingcare co-ordinators and inpatient services to breakthe cycle o revolving door admissions, and a lot ogood crisis management work can be achieved.

ConclusionBorderline personality disorder is caused by acombination o being born particularly emotional,and then having those emotions invalidated by

others. Mental health practitioners need to developcompassionate and non-judgemental attitudes i theywish to successully support people with borderlinepersonalities, and should ocus on helping people makepositive changes to their lives. This seems very simple,but o course the most eective interventions are. n

Alwin N (2006) The causes o personality disorder. In: M Sampson,R McCubbin & P Tyrer (Eds) Personality Disorder and CommunityMental Health Teams: A practitioners guide. Chichester: John Wileyand Sons Ltd.

American Psychiatric Association (1994) Diagnostic and StatisticalManual o Mental Health (4th ed). Arlington, VA: AmericanPsychiatric Association.

Chapman AL & Gratz KL (2007) The Borderline Personality DisorderSurvival Guide: Everything you need to know about living with BPD.Oakland, CA: New Harbinger Publications, Inc.

Department o Health (2006) Personality Disorder Capacity Plans2005 Summary. London: Department o Health.

Flory L (2007) Understanding Borderline Personality Disorder.

London: Mind.

Morgan S (1996) Helping Relationships in Mental Health. London:Chapman and Hall.

NICE (2009) Borderline Personality Disorder: Treatment andmanagement: The National Institute or Health and ClinicalExcellences clinical guideline 78. London: NICE.

NIMHE (2003) Personality Disorder: No longer a diagnosis oexclusion. London: National Institute or Mental Health in England.

Perkins E & Repper JM (1996) Working Alongside People withLong-term Mental Health Problems. Cheltenham: Nelson ThornesPublishers Ltd.

Raven C (2007) Breaking the cycle o risk. OpenMind146 July/August.

WHO (1994) The ICD-10 Classifcation o Mental and Behavioural

Disorders. Geneva: World Health Organization.


Borderline personality disorder: still a diagnosis of exclusion?

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