Non-response to psychotherapy for borderline personality disorder: A systematic review. Med Klin (Munich). However, this can present an ethical dilemma for nursing and medical staff, with these clinician responses shifting between the moral principles of beneficence . Borderline personality disorder is a leading cause of disability and mortality and is common in clinical practice. De Panfilis C, Marchesi C, Cabrino C, Monici A, Politi V, Rossi M, et al. Bethesda, MD 20894, Web Policies Accessibility government site. The use of drugs can be considered in acute crisis situations where psychological approaches are not sufficient. We held separate focus groups for medicine, nursing, and pharmacy professionals to enable exploration of each professions unique perspective. Elansary M., Graber L.K., Provenzano A.M., Barry M., Khoshnood K., Rastegar A. Borderline personality disorder: Understanding causes, symptoms and These questions include whether psychiatrists should tell patients their diagnosis, what they should tell them about their suicide risk, whether they should be "always" available by phone, when they should hospitalize these patients involuntarily, and how they should respond after these patients have attempted suicide and return for further care. Three of these themes (cultural differences, professional issues, limited resources) are categorized under the core category of external issues. 1989 Dec;24(4):955-65. It may not be sustainable once we walk out the door, so do we save the persons life at that moment or do we just continue to try and train people there about how to care for people? J Nurs Manag, 2006; 14(3): 188-94. Webinars are converted to video on-demand programs with closed captioning after the live air date. Federal government websites often end in .gov or .mil. Am J Psychiatry. Diagnostic and statistical manual of mental disorders. This was an interesting findingthe divide between external and internal factors has not been identified before to our knowledge and has educational implications since external factors are much easier to present as case vignettes or to simulate, whereas internal factors are more subjective and harder to elicit for each trainee, especially in the short period of time during which most ethics training transpire. A model of integrated care comes from Max Weber who differentiated between formal rationality, the endorsement by healthcare managers of the most efficient ways of achieving organisational goals (e.g., ensuring more hospital beds by quick discharges of bed blockers), and substantive rationality, the expectation by healthcare professionals that values and morals should instead be based on tradition, compassion and dedication13;pertinent to the care of BPD patients in our case. Attempts by patients with BPD to self-harm or commit suicide intensify over weekends or public holidays as their sense of solitude increases during these periods, especially when there is also a shortage of healthcare professionals available for immediate support. Res Psychother. We would like to thank all health professionals who participated in this study. 8600 Rockville Pike In some areas, health workers were expected to refrain from delivering diagnoses that would cause too much emotional distress to a patient. Recent findings: The diagnostic currency of personality disorder as a psychiatric/medical disorder has a longstanding history of ethical and social challenges through critiques of the medicalization of deviance. Our study has certain limitations; this is a single center study with a small number of participants. Illustrating routine outcomes monitoring at different points in a patient's journey: Inpatient then daypatienttreatment of a patient with depressive and borderline symptoms. In critically understaffed locations, participants had to make difficult decisions between performing procedures they were not qualified for or else leave the patient to die. New York: Nova Science Publishers, 2016; p. 6797. Participants agreed that the important thing in all morally distressing situations is that global health trainees have a reliable moral and personal guidance that they can rely on. Drugs should not be used as primary therapy for borderline personality disorder, because they have only modest and inconsistent effects, and do not change the nature and course of the disorder. [Borderline personality disorder, self-mutilation and suicide: literature review]. Some strategies to assist in this task can be drawn from the common characteristics of evidence-based treatments in Box 2, e.g. Culture is defined as the character of an institution that affects employee gratification and organisational accomplishments12.What is needed is a frank and constructive dialogue between healthcare managers, leaders and medical staff in the hospital and in the community. The recent increase in the number of patients accessing healthcare services with a diagnosis of borderline personality disorder continues to put unprecedented pressure on healthcare professionals. You are telling me theres a risk in the procedure? New York: Palgrave Macmillan, 2015; p. 124141. Schizophr Res, 2015; 168: 209212. Unauthorized use of these marks is strictly prohibited. Although it was once considered untreatable, the outlook for patients with borderline personality disorder is much improved, with a range of effective psychosocial treatments available for the disorder. Teaching modalities for this training can be either in-person didactic sessions, online or simulation [12,13,14,15,16]. 2007 Jun;164(6):922-8. doi: 10.1176/ajp.2007.164.6.922. Borderline Personality Disorder (BPD): Prevalence, management options and challenges (1st ed.). Global health ethics for students. For example, participants reported cases that compelled them to reconsider their duty to inform the patients of the true nature of their affliction and the circumstances of the proposed treatment. Try to have humility and awareness. Borderline personality disorder; diagnosis; ethics; involuntary hospitalization; patient-psychiatrist relationship; suicide; telephone contact; terminating treatment. Treatment of Borderline Personality Disorder - PubMed Evidence-Based Treatment of Borderline Personality Disorder: Clinical At the same time, healthcare professionals are discouraged by the complex management of patients with BPD, which, in combination with their tendency to challenge or make unwarranted allegations against their health carers, results in feelings of sadness, rejection and alarm in the latter. Download PDF Abstract The recent increase in the number of patients accessing healthcare services with a diagnosis of borderline personality disorder continues to put unprecedented pressure on healthcare professionals. Please enable it to take advantage of the complete set of features! We conducted a qualitative study involving focus groups and an interview at the University of California San Francisco. Frantic efforts to avoid real or imagined abandonment (do not include suicidal or self-mutilating behaviour covered in criterion 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. 8600 Rockville Pike The challenge is that patients with BPD often use overdoses of oral medication in a suicide attempt10. Before Cohen P, Crawford TN, Johnson JG, Kasen S. The children in the community study of developmental course of personality disorder. Pete Davidson Is Reportedly In Rehab After Struggling With Borderline These issues also facilitated their personal moral development, as well as prompted them to start building a theoretical approach regarding global moral issues. Patients with borderline personality disorder are frequent users of inpatient mental health units, with inpatient crisis intervention often used based on the risk of suicide. Here's how I recovered. In caring for patients with borderline personality disorder, strong thoughts or feelings on the part of the doctor can be used as a reminder to reflect on what is happening in the doctorpatient relationship: Am I feeling pulled or pushed to respond in particular ways? These patients may, for example, react intensely in negative ways and these responses may be easily triggered. 2008 Oct;34(5):452-8. doi: 10.1016/j.encep.2007.10.007. The final part of analysis involved selective coding whereby the discrete categories and themes we had identified were further refined into two overarching categories that integrated all of the other categories identified [19]. Unable to load your collection due to an error, Unable to load your delegates due to an error. The site is secure. Bethesda, MD 20894, Web Policies Max Weber: bureaucracy, formal rationality and the modern hospital. FOIA Ethical Issues in Assessing and Treating Borderline Personality Disorder Borderline personality disorder is characterised by a pervasive pattern of instability in emotional regulation, interpersonal relationships and self-image, along with marked impulsivity.17 Clinically, this often manifests as recurrent self-harm and suicide attempts. The discussion was unstructured allowing participants to address the question in-depth. This intermediate workshop focuses on current research findings on BPD, with particular focus on prevalence, phenomenology, comorbidity, course, and treatment outcomes. Relevant ethical issues and challenges are considered, and both seminal treatment studies and often neglected findings are highlighted. Inclusion in an NLM database does not imply endorsement of, or agreement with, 2014 Sep;40(4):289-94. doi: 10.1016/j.encep.2013.09.003. government site. Accessibility frequent displays of temper, constant anger, recurrent physical fights), Transient, stress-related paranoid ideation or severe dissociative symptoms. Carlo Lazzari, Ahmed Shoka, Basavaraja Papanna & Kapil Kulkarni. In accordance with grounded theory, we did not propose any a priori hypotheses prior to data collection and we analyzed data inductively without reference to any predetermined theory [19]. Anupama V, Bhola P, Thirthalli J, Mehta UM. The disorder has a fourfold higher prevalence among primary care patients than among the general population.5 It affects around one-quarter of primary care patients with depression6 and one in five psychiatric outpatients.7,8 In these settings females outnumber males by a ratio of up to 4:1. [] So I said I wonder if [the traditional vaccinations] would also facilitate HIV transmission. And somebody at the table said, Okay, were going to make a policy that nobody can give traditional vaccinations!. The fourth theme, moral development, reflects internal issues faced by each trainee, in a unique and individual manner, and refers more to the development of a moral compass and the exercise of humility and self-awareness than any environmental or situational issues a trainee might be facing. informed consent is a big issue it goes back to what the cultural practice has dictated for so many years. J Clin Psychol. [(accessed on 23 June 2016)]. Benefits include a better understanding of other cultures, an appreciation of global socio-political health issues and the development of cultural competence [4]. The first-line management for borderline personality disorder is psychosocial treatment, not drugs. [] The idea is that you eventually develop this compass of practice.. FOIA It is often much easier to start prescribing than to stop it. We identify four questions that arise within this population: (1) when should patients be restrained and secluded; (2) what ethical justifications can be employed to analyze the use of restraint and seclusion in these populations; (3) what special considerations need to be taken into account in the use of restraint and seclusion; and (4) what me. Pattern of social cognition decits in individuals with borderline personality disorder. Callister L.C., Cox A.H. Since the 1990s there has been growing optimism and enthusiasm for the treatment of borderline personality disorder. Also, the current definition of depression incorporates non-specific forms of dysphoria that overlap with borderline personality disorder. HHS Vulnerability Disclosure, Help We transcribed each of the focus groups and interview verbatim. Consequently, patients with BPD require a constant and unlimited allocation of medical and psychiatric resources, together with targeted care plans. Consequently, a chronic feeling of inadequacy in patients with BPD translates itself in enduring dissatisfaction with any therapy and healthcare professionals. The .gov means its official. Personal Disord. Evidence-based principles (EBP) are derived and emphasized throughout, with specific attention to differential diagnoses and treatment decision making. Use single drugs prescribed in limited quantities for a limited time. Even returning trainees who have been exposed to these dilemmas on their previous missions would likely benefit from discussion and counseling on how to address ethical challenges. Careers. Healthc Financ Manage. 1991 Oct;42(10):1034-8. doi: 10.1176/ps.42.10.1034. Please enable it to take advantage of the complete set of features! eCollection 2021. At the beginning of the focus group and interview, we informed participants that the aim of the session was to identify ethical issues that global health trainees may face when placed overseas that then could be used to inform the content of curriculum for global-health ethics pre-departure training. There are no gloves. National Health and Medical Research Council. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days), Inappropriate, intense anger or difficulty controlling anger (e.g. In fact, many of the ethical issues identified are not limited to practicing abroad and may also reflect challenges trainees face in pluralistic communities in their home countries. This places them at risk of being given treatments that are ineffective or even harmful.21 The central task for diagnosing personality disorder is to separate state (transient aberrations in mental state) from trait (long-standing patterns of thinking, feeling, behaving, perceiving and relating). The site is secure. This includes exposing trainees to external environmental and/or situational ethical dilemmas related to cultural differences, professional differences, and limited resources, as well as providing them with skills necessary to develop an internal moral compass and exercise of humility and self-awareness. In: Mills A., Durepos G., Wiebe E., editors. They need to know how and where to seek help when faced with difficult moral and ethical dilemmas. An integrative perspective on psychotherapeutic treatments for borderline personality disorder. [] these were mostly physicians, and I was the only nurse there. Examining the Construct Validity of Borderline Personality Traits Using Familial Aggregation and Other External Validators. Faculty noted that many trainees on placements could struggle with ethical dilemmas on both professional and personal levels, and that training in this area prior to embarking on their global-health missions would be beneficial. Zimmerman M, Chelminski I, Young D, Dalrymple K, Martinez J. Furthermore, as these patients have an intense vulnerability to social rejection, they rarely feel adequate during social interactions thus developing an enduring sense of solitude9. Revised NESARC personality disorder diagnoses: gender, prevalence, and comorbidity with substance dependence disorders, The prevalence of personality disorders in a community sample. Updated on August 15, 2021 Fact checked by Adah Chung Print Robert Daly If you have borderline personality disorder (BPD), you are already well-acquainted with the serious impact symptoms can have on your life. Federal government websites often end in .gov or .mil. Zanarini MC, Frankenburg FR, Hennen J, Silk KR. Attempts to treat and to reduce suicidal ideation and self-harm in this group of patients are often thwarted as they challenge medical decisions and endeavour to sabotage the proposed care plans. Drugs are prescribed for 78% of patients for more than 75% of the time over a sixyear period and polypharmacy occurs in 37% of patients,32 perhaps reflecting clinical needs and pressures. Healthcare workers beliefs about the role of medical students during their electives. Soloff PH, Lis JA, Kelly T, Cornelius J, Ulrich R. Am J Psychiatry. Our findings resonate with other work investigating the same topic. It is concluded randomized controlled trials and meta-analyses suggest little to no difference between any active specialty treatments for borderline personality disorder; there are no differences between dialectical behavior therapy and non-dialectical behavior therapy treatments or between cognitive behavior-based and psychodynamic theory-based treatments. Before FOIA And I was standing there with two medical students from somewhere else and thinking to ourselves, what should we do? Wicks D. Coding: Axial coding. Many BPD patients suggest that they would rather stay in the hospital instead of returning to the community that is considered by them as unsafe or unstructured. Antipsychotics such as aripiprazole, olanzapine and quetiapine have shown some effect in reducing cognitiveperceptual symptoms and affective dysregulation. A narrative approach to aid socio-psychopharmacological assessment and treatment. Patient factors predicting early dropout from psychiatric outpatient care for borderline personality disorder. Bach B, Farrell JM. Before Another repeated concern involved the expectation that trainees perform outside of their scope of practice due to insufficient workforce at local sites. This model may be useful in measuring adherence and violation of the principles of beneficence and non-maleficence and therefore an aid to clinical decision making. An official website of the United States government. and transmitted securely. Psychosocial treatment is the primary therapy but access to this is poor. These treatments and the corresponding evidence associated with each are described. [(accessed on 23 June 2016)]. This scenario has created discrepancies in health care policies about treatments and hospital (re)admissions of patients with BPD reaching an epidemic magnitude in many healthcare trusts. Hooke GR, Savani P, Stewart B, Araujo S, Page AC. Before 2022 Oct;78(10):2041-2053. doi: 10.1002/jclp.23426. Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder. Milton Keynes: Open University Press, 2006; p. 5373. In fact, some participants argued that the idea of autonomy as a paramount value in the health professions should in fact be abandoned in cultures where it carries no such importance. More broadly, despite some of the topics identified during our qualitative study being reported elsewhere, the specific scenarios we describe are largely new and can be utilized as case studies or vignettes during global health ethics training. But, it is difficult to be both. Br Med J (Clin Res Ed). Despite advances in psychosocial treatment for borderline personality disorder, improvements remain suboptimal.24,25 Access to treatment is limited, and dropout rates are high (1577%).26 The NHMRC guidelines provide advice that can be implemented when referral to specialist services for borderline personality disorder is unavailable. What Works in the Treatment of Borderline Personality Disorder Legal Issues and Borderline Personality Disorder - Verywell Mind Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. and transmitted securely. In this case, inter-professional coordination, integrated care and constant information sharing are required11. Most ethical issues and dilemmas described so far caused significant moral distress, especially in inexperienced trainees. Borderline personality disorder is a severe mental disorder that has its onset during adolescence and emerging adulthood. Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study. While our framework (Figure 1) generalizes many potential ethical global health scenarios and we support trainees maintaining a nuanced approach to each situation they encounter, our findings are of importance for future global health-ethics training development, and we propose that the categorization represented in our framework (Figure 1) should be consulted when preparing global health trainees for their fieldwork. Vignettes and role plays are used to bring EBP to life. Identify and describe at least four clinical and ethical issues that arise in the diagnosis and treatment of BPD. At times, these other disorders (e.g. This site needs JavaScript to work properly. The first level of coding involved open coding where we took raw segments of data and systematically reviewed them line-by-line, attributing specific descriptive labels or codes to the data [20]. Healthcare management is another way of intervention. NIMH Borderline Personality Disorder bernie@liebowitzassoc.com; PMID: 14503151 No abstract available. Others noted that informed consent was often related to cultural differences. Evaluating three treatments for borderline personality disorder: a multiwave study. mood, anxiety, eating and substance use disorders) can overwhelm the clinical picture, but this does not indicate that the underlying personality pathology is unimportant or should be a secondary concern.21 Rather, there is evidence to suggest that personality disorder might be a key vulnerability factor for recurrent mental state disorders.22,23 Patients with borderline personality disorder who have these co-occurring conditions should be treated for these conditions in accordance with best practice.