Case 25.1 – Borderline Personality Disorder

Need to build rapport and therapeutic alliance with Katie – introduce yourself, explain confidentiality and its limits, be open to hearing Kate's concerns but be careful not to 'take sides' with her against the other medical and nursing staff: just listen.

Take a history:

Presenting symptoms

• Circumstances surrounding overdose:
  • Planning or impulsive overdose?
  • Triggers / stressors for this overdose – similar or different to past overdoses?
  • Wish to be dead
  • Expectation about outcome of self-harming behaviour or suicide attempt/threat
  • Length of time suicidal feelings have been present
  • Regret/remorse over current/previous attempt
  • Mental state at time of self-harm or suicide attempt or threat (alcohol or drug intake, social situation, relationship changes, bereavements)
  • Plans for others after death: suicide notes, changes to will, consequences
• Specific plans to end life now
• Lethality and frequency of plans or attempts
• Other self-harming behaviour
• Feelings of hopelessness / worthlessness / guilt
• Assess current suicidal intent/wishes
• Assess for current symptoms to suggest a mood disorder
• Ask Kate about recent emotional experiences – has her mood been fluctuating
• What are usual coping strategies when feeling suicidal?

Other history

• Past psychiatric history – Diagnoses / treatments / treatment providers / admissions / pattern of past overdoses
• Medical history: How does Kate usually manage her diabetes? Does she have any complications to suggest poorly managed diabetes, concerning HBA1C levels
• Social support or problems
• Relationship issues
• Skills, strengths and assets
• Psychosocial and occupational functioning
• Personal and financial difficulties
• Timeline / developmental history

Complete a mental state exam

• Can Kate be engaged in the review? Are you able to build rapport?
• Is Kate able to give a good / clear account of what happened?
• What are Kate's mood and affect?
• Are there any psychotic symptoms present?
• Is Kate's cognition clear?

Differentiating suicide attempt from non-suicidal self-harm:

• Self-harm means any behaviour that involves the deliberate causing of pain or injury to oneself. This includes cutting, burning or hitting oneself, overdosing on prescription or illegal drugs, among others
• Non-suicidal self-harm is usually a response to distress—often the distress is associated with mental illness or interpersonal problems. In the short-term, some people report that cutting, burning or hitting oneself provides temporary relief from the psychological distress they are experiencing. In other cases, self-harm is a way of seeking care or of getting out of intolerable situations or emotional conflicts
• People who self-harm repeatedly have episodes in which the self-harm is not suicidal (e.g., it is performed to release stress, to feel the pain, to feel 'real') and episodes in which the self-harm is suicidal. In all cases, repeated self-harm suggests that the patient requires careful professional help

Questions to assess suicidal intent:

• Start with general questions:
  • "Have you ever felt that life is not worth living?"
  • "Sometimes people who feel that way try to kill themselves. Have you ever felt that way?"
  • Describing things in the third person ("Many people who feel upset often think of killing themselves. Have you ever felt like that?") is often more effective and perceived by patients as less threatening or critical
• Move to concrete questions about what happened:
  • "Diabetic patients who go through a difficult patch might overdose in insulin. Is that what happened?"
  • "When you took the overdose, did you think you might die?"
  • "Did you make a plan to take the overdose, or was it a spur of the moment decision?"
  • "Are you still thinking of ending your life?"
• If the intent was suicidal, clarify seriousness and likelihood of repetition:
  • "How do you feel about being alive now?"
  • "Have you been thinking about trying to harm yourself again?"
  • "Have you made a plan to end your life?"

Immediate management plan:

• Ensure safety – Kate is not currently suicidal but may have increased suicidality at times of stress / interpersonal conflict e.g. conflict with nurses or mother if she comes to visit
• Make sure there are no easily accessible ways to harm herself at the bedside – scissors / insulin pens etc.
• Does not need a special 1:1 nurse at present, but something to consider if she becomes very distressed / suicidal
• Build a therapeutic alliance – in this case this does not mean siding with Kate again the nursing staff, but rather listening to her concerns and acknowledging her emotions, while also reinforcing the role the nurses have in caring for her
• Make sure diabetic management is optimised
• Review Kate's past notes – what has happened in hospital before, who else has been involved, what has helped previously
• Make a referral to Consultation Liaison psychiatry
• Think about if the Mental Health Act is needed - in discussion with mental health team, where it seems there is high risk – hopefully it can be avoided in Kate's case and she can be engaged in treatment

Short term management plan:

• Arrange a meeting with endocrinologist / nursing staff / CL psychiatry to discuss a consistent approach to Kate's management in the ward setting
  • Aim to avoid splitting
  • Make a clear plan for when blood sugars will be taken and what the margin of error will be
• Communicate the management plan to Kate, offer her support to understand the plan
• Discuss emotional regulation techniques Kate can use in the ward setting
• Unlikely to benefit for an admission to a psychiatric ward – need to plan for Kate's discharge home
• Planning for discharge:
  • Engage Kate in the planning – ask her about her thoughts on why has presenting to hospital and how she could be better supported at home
  • Teach Kate some distress tolerance skills to help in the short term

Who needs to be involved in the plan:

• Mother
• Nursing staff
• Medical team – endocrinologist/ DM educator
• Mental health providers in the community – psychologist / GP / community mental health team

Think about options for who can help prevent further presentations.

Nurses concerns:

This is a good example of negative countertransference. The negative nursing staff responses can lead to an unplanned discharge, therapeutic nihilism, and an early recurrence of the same behaviour. Often patients like Kate, who feel rejected by a hospital or clinician, re-present quickly elsewhere with the same problem.

Negative comments by nursing staff (or medical staff for that matter) are opportunities to discuss and educate them about the needs and best way to manage patients with emotional instability and splitting. It needs to be acknowledged that patients like Kate can feel difficult to care for and may consume a lot of medical resources.

However, although the motivation for these patients' behaviour varies from case to case, rejection or punitive responses make the situation worse. Nursing staff should be informed of Kate's problems (e.g., a description of the mental disorder) what is the overall management plan –not just of the medical problems associated with the treatment of her diabetes but also the management plan to deal with the psychological problems—follow up after discharge and strategies to minimise further overdoses and readmission.

Background information:

BPD belongs in Cluster B of the personality disorders (together with antisocial, narcissistic and histrionic) in the DSM 5 classification. The name "borderline" derives from originally believing to be at the "borderline" of psychosis. The disorder can lead to pervasive instability which often disrupts family and work life, long-term planning, and a person's sense of self-identity.

DSM 5 Diagnostic Criteria:

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, as indicated by five (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment
2. A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealization and devaluation
3. Identity disturbance: markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)
5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour
6. 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)
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
9. Transient, stress-related paranoid ideation or severe dissociative symptoms

The NHMRC Guideline suggests Australia has a population prevalence of 1-4%. Females have higher rates than males, and it is more common in younger people.

Explaining Borderline Personality Disorder diagnosis to Kate:

Principles:

• Chose the right time and setting to explain the diagnosis – make sure Kate is calm and able to engage in a discussion, allow enough time for a good discussion
• Be open to questions
• Be empathetic
• Be honest about the diagnosis
• Use clear and patient centred language
• Allow for a hopeful stance – BPD is a serious mental disorder but is treatable
• Offer to resources for Kate to read more about BPD – Your Health in Mind from RANZCP, Project Air, Headspace etc.

Key things to discuss with Kate:

• Borderline personality disorder (BPD) is a mental illness that makes it hard for a person to feel comfortable in themselves, causes problems controlling emotions and impulses and causes problems relating to other people
• People with BPD experience high levels of distress and anger
• People with BPD can find everyday situations very upsetting
• Things that other people do or say can feel very hurtful
• BPD is a condition of the brain and mind. It is not the person's fault and they did not cause it
• BPD is a treatable condition and most people with BPD can recover
• Overcoming emotional problems, finding more purpose in life, and building better relationships are many people's main goals for their treatment
• BPD is treated with psychological treatments (talking therapies). These usually involve talking with a health professional one-to-one, or sometimes attending special groups
• Psychological treatment for BPD should be well-organised and pre-planned (structured), designed for people with BPD, and given by a health professional who is properly trained and supervised
• Medication not recommended as a person's main treatment for BPD, but may be helpful to manage particular symptoms

As you talk about the features of the disorder with Kate, you can ask her if this fits with her experience or if she can this of examples from her own life.

Create a Management Plan for diabetic care and readmission to hospital:

Because these patients present frequently while staff (e.g., residents, nursing) change regularly, it is also helpful to agree on a multidisciplinary management plan (involving endocrinologists, emergency dept. staff, consultant psychiatrist etc) to deal with re-admissions. This plan is kept in the medical file and gives clear guidelines, enhancing consistent management. When a plan is not available, problems arise, staff become inconsistent and negative responses are more likely.

Discuss aims of treatment with Kate which might include:

• To overcome emotional problems (such as depression, anxiety and anger)
• To find more purpose in life (e.g. by making a positive contribution to her community)
• To build better relationship with her mother
• To learn how to understand and live with herself
• To improve physical health and have better control her diabetes
• To learn how to reduce self-harming behaviours

Engage Kate's GP and family in her care and ensure they have access to resources and support.

Treatments for BPD are psychologically based, medication is usually not recommended but is sometimes used to manage symptoms.

Discuss with Kate that all treatments have some things in common:

• Designed to solve typical problems for people with BPD and focus on helping them change
• Structured: they are pre-planned, well-organised and have regular sessions (often based on a written manual that treatment provider follows)
• Ideas behind the treatment are clearly set out and explained
• Relationship between patient and the person providing the treatment is an important part of the treatment
• Patients are encouraged to take control of their life, and are involved in making plans for treatment
• Treatment provider helps patient to understand how the things that happen to them are linked to their feelings
• The treatment provider doesn't just listen, but responds to the patient's ideas and helps guide them to solve their problems
• The treatment provider pays attention to the patient's emotions and accepts the experiences and feelings are real

Evidenced based treatments in Australia / New Zealand:

• Dialectical behaviour therapy (DBT)
• Cognitive behavioural therapy (CBT) designed especially for people with BPD
• Mentalisation-based treatment (or 'mentalisation')

Dialectical behaviour therapy (DBT):

Dialectical behaviour therapy (DBT) is a modified version of cognitive-behavioural therapy (CBT) designed to treat borderline personality disorder (BPD). It can also be used to treat other conditions, like suicidal behaviour, self-harm, substance use, post-traumatic stress disorder (PTSD), depression and eating disorders.

How DBT works:

The term 'dialectical' means 'working with opposites'. DBT uses seemingly opposing strategies of 'acceptance' and 'change'. The therapist accepts you just as you are, but acknowledges the need for change in order for you to recover, move forward and reach your personal goals.

During a course of DBT, the therapist works with you to help you move away from a chaotic life and towards a life that you find personally meaningful and fulfilling.

DBT involves developing two sets of acceptance-oriented skills and two sets of change-oriented skills.

Acceptance-oriented skills:

• Mindfulness: Learning how to focus your awareness on the present moment, and to acknowledge and accept your thoughts, feelings, behaviours and bodily sensations as they occur, without the need to control or manipulate them
• Distress tolerance: Learning how to manage and cope during a crisis, and to tolerate distress when it is difficult or impossible to change a situation. Learning to accept any given situation just as it is, rather than how you think it should be, or want it to be. Learning new skills like distraction and self-soothing, for both coping with and improving distressing moments

Change-oriented skills:

• Emotional regulation: Learning how to effectively manage your emotional experience, and not allow your emotions to manage you
• Interpersonal effectiveness: Learning assertiveness strategies to appropriately ask for what you want or need. Learning how to say no, and how to manage interpersonal conflict in a way that maintains respect for yourself and others

A typical course of DBT:

DBT is typically run as a 24-week program, often taken twice to create a one-year program. In its standard form, there are three ways you receive DBT during the program. There are also shorter versions of DBT such as 12 week courses depending on the setting, and some versions do not include telephone coaching. DBT has been adapted for different needs.

• DBT skills training group: A group facilitator teaches specific skills in a classroom setting, and sets tasks for the group members to practise between sessions. The skills training group typically meets once weekly, usually for around 2½ hours, across the 24-week program
• Individual therapy: Running at the same time as the group, individual therapy typically occurs weekly to enhance your motivation and commitment to the program. It's also an opportunity to discuss and apply specific DBT skills to your current everyday life
• Between-sessions telephone coaching: On-the-spot telephone coaching from your therapist can be available at times during the week when you're struggling. Your therapist guides you and encourages you to apply your new DBT skills to address and manage your issues