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JOSEPHINE G PATERSON
Abstract
People with personality disorders frequently present to general health services. A large proportion of people with borderline personality disorder will self-injure and seek physical clinical interventions from adult or practice nurses. These patients are often excluded from services and are highly stigmatised both in mental health services and the wider society. This article aims to increase the awareness of borderline personality disorder and self-injury among non-mental health nurses to assist them to work more effectively with patients who present with these difficulties.
Author
Gary Lamph Advanced practitioner in personality disorder, 5 Boroughs Partnership NHS Foundation Trust, Warrington. Correspondence to: gary.lamph@5bp.nhs.uk
Keywords
Borderline personality disorder, mental health, personality disorders, self-injury These keywords are based on subject headings from the British Nursing Index.
Review
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Online
Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
PEOPLE WITH A DIAGNOSIS of personality disorder are one of the most socially excluded and stigmatised groups of patients in health services and society (Sampson et al 2006). Government policy and evidence-based literature have challenged the historical assumption that people who present with personality disorder are untreatable (Department of Health (DH) 1999, National Institute for Mental Health in England (NIMHE) 2003a, 2003b, National Institute for Health and Clinical Excellence (NICE) 2009). Personality disorder has been defined as any disorder in which an individuals personal characteristics cause regular and long-term problems in the way they cope with life and interact with other people and in their ability to respond emotionally (HM Government 2011a, 2011b). The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defined personality disorder as an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment (American Psychiatric Association (APA) 1994). People with personality disorder do not present exclusively to specialist mental health services during crisis situations or relapse. They can present to a multitude of services, but will frequently encounter non-specialist health services, including emergency departments, general wards and GP surgeries. In the UK there are 150,000 self-injury attendances at emergency departments each year and self-injury ranks in the top five most common causes of acute medical admissions (NICE 2004). Half of all people who self-injure will attend a primary care setting one month before or two october 5 :: vol 26 no 5 :: 2011 35
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self-injure (Kerr et al 2010). People are rarely diagnosed as having BPD before the age of 18 years as their personalities are not fully developed until adulthood (APA 1994). Causal factors for BPD continue to be discussed in the literature, however there is a common consensus that both genetic and early developmental experiences, including physical, sexual and emotional abuse, have an important role in the development of BPD (Lieb et al 2004, Suyemoto 1998). There are reports that up to 71% of people with a diagnosis of BPD have experienced childhood sexual abuse; however, many people who have not experienced this form of abuse can also develop BPD (Lieb et al 2004). Lack of secure and stable attachments with others during childhood is often seen in patients with BPD (Lieb et al 2004).
Hopkins (2002) suggested that the perspectives and experiences of people who self-injure should be explored to educate staff and improve understanding of these patients. This is further supported by the NICE (2004) guidance on self-injury. For the purpose of this article people with experiential viewpoints are defined as
BOX 1
Criteria for formal diagnosis of borderline personality disorder
Four of the following criteria need to be identified for a formal diagnosis of borderline personality disorder: Affective difficulties such as: 4Intense anger. 4Chronic feelings of emptiness. 4Marked emotional disturbance. Cognitive difficulties such as: 4Transient stress-related paranoia, or severe dissociative experiences. 4Persistent or unstable self-image. Impulsive behavioural disturbance such as: 4Recurrent suicide attempts, gestures, threats and self-injury. 4Impulsivity in other self-damaging behaviours. Interpersonal difficulties such as: 4Effort to avoid abandonment in relationships. 4A pattern of unstable interpersonal relationships.
(Lieb et al 2004)
Self-injury
NICE (2004) define self-injury as intentional self poisoning or injury, irrespective of the apparent purpose of the act. Self-injury can present in many forms including overdosing, ingestion of foreign objects, head banging, lacerations, burning, hair pulling and ligaturing (National Self Harm Network 2008). Patients who self-injure have a risk of suicide 100 times greater than the general population (NHS Centre for Reviews and Dissemination 1998). Self-injury is described in different ways, many of which hold negative and stigmatising connotations, such as self-mutilation and deliberate self-harm. These labels imply that self-injury is chosen and deliberate. The majority of people who self-injure are aware of their actions during self-injury and can give a clear account of why they have self-injured. However, NICE (2004) also explained how some people, especially those with a history of child abuse, may unintentionally self-injure during dissociation or trancelike states, hence describing this as being a non-deliberate or uncontrolled act. Low et al (2000) supported this notion and described childhood sexual abuse as being a key developmental factor that can result in later self-injurious behaviours. A high prevalence of self-injury has been established in patients with BPD. Self-injury alone, however, does not constitute a definite diagnosis of BPD. A further four of nine possible criteria need to be identified for a formal diagnosis of BPD to be reached (Box 1). Not everyone who self-injures will have a diagnosis of BPD, however similar evidence-based interpersonal responses that are used in BPD are likely to have transferable benefits when working with patients who self-injure (APA 1994).
BOX 2
Experts by experience narratives: why people self-injure
4Self-injury can stop you feeling numb, the physical pain from self-injury
makes you feel human again, physical pain can be seen and is easier to understand than the emotional pain that is not visible.
4When people self-harm they do it to hurt themselves, they dont see the
hurt it causes to others. Bad things have happened to me that I had no control over. Self-harming allows all that badness that was inserted into me to leave me in the same way, but with self-harm I am now in full control.
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TABLE 1
Experiences of experts by experience in non-mental health settings
Positive experiences Nurse at A&E treated my injuries as if they had been caused accidentally and was respectful. Made me relax and feel respected. Nurse listened and took time to try and understand my difficulties. Felt listened to and understood. Nurse in a walk-in centre was not afraid to ask me more about why I had self-injured, made me feel relaxed. Nurse in walk-in centre made sure I had support from mental health services, she clearly cared and made me feel valued. Doctor offered me pain relief while stitching my wounds, he explained everything he was doing and helped put me at ease. Referred to secondary mental health service for assessment, made me feel deserving of help and listened to. Negative experiences Nurse in a walk-in centre asked me if she should bother with anaesthetic before stitching my wound, I felt humiliated. Nurse at A&E made me wait until everyone else had been seen in the waiting room, made to feel like the other people were more deserving of treatment and that I shouldnt be seeking treatment. A nurse told me I was stupid for scarring myself and that everyone gets depressed but that most dont self-injure, left me feeling belittled and ashamed. Told by a nurse to stop wasting their time, that they should be treating real injuries, felt hurt. Overheard staff laughing that I would have a big hangover the next morning after overdosing, made me feel belittled and reluctant to go back for other injuries.
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referred to as countertransference (Rayner et al 2005). These emotional responses can trigger a negative interaction between the nurse and the patient. Having an awareness of countertransference may help the nurse to reduce his or her negative thoughts and can assist nurses in altering their own reactions and behaviours, resulting in a more effective interpersonal treatment response (Rayner et al 2005). Working with self-injury and people with a diagnosis of BPD can be challenging, as staff may lack awareness or knowledge of dealing with patients who present with these difficulties, or feel ill-equipped to support their needs. Some practitioners will have preconceived ideas and opinions about self-injury and BPD, however raising awareness helps to challenge these opinions. Working with people with these difficulties can be emotionally demanding and it is important to recognise the emotional impact this can have on the staff providing care. When this is combined with stigmatisation and resentment from within organisations, it is even more difficult to provide positive treatment experiences. Effective interpersonal responses are paramount when working with people with BPD and self-injury. Although non-mental health nurses will most commonly have a clinical role to provide physical interventions to these patients, the interpersonal interventions and delivery of treatment can have a powerful psychological
effect on the individual. The nurses interpersonal responses can start a process of healing and stabilise emotions. Box 3 provides a list of helpful strategies for nurses working with people with BPD and self-injury. All staff working with people with BPD and self-injury require increased awareness and understanding of the presenting issues, skills to treat these patients more effectively and a consistent team approach that supports best practice and empathetic treatment responses.
BOX 3
Strategies for working effectively with people who have borderline personality disorder and self-injure
4Increase awareness of borderline personality disorder (BPD) and self-injury to improve understanding and increase empathy. 4Provide a consistent team approach all members need to have improved awareness and understanding of the approaches discussed
in this box (Sampson et al 2006).
4Listen to the patient using listening skills can be a valuable intervention. Listen to the persons story, consider how you might feel in
his or her situation and listen as if this is the first time you have heard these problems.
4Validate and display an understanding of the patients emotions validation is an interpersonal technique that shows the patient that
the nurse understands his or her problems and actions even when the nurse does not necessarily agree these are the best responses.
4Display hope and optimism people with BPD can and do get better (NICE 2009). Suggesting peer support groups can be beneficial
to people who self-injure (NICE 2009). Ask your local mental health services about any local support groups. It may also be helpful to suggest using the internet for online support and information.
4Increase self-awareness to be aware of the effects that interpersonal and physical interventions can have on a person with BPD or
self-injury. When treating self-injury try to treat the injury with the same empathy and understanding as if it had been caused accidentally.
4Engage with patients with BPD and self-injury breaking the cycle of rejection for people with BPD is every health professionals
responsibility, not just that of mental health services (NIHME 2003b).
4Debrief and seek support or supervision, have supportive team approaches in place to support team members to deal with their own
emotional responses (Bland and Rossen 2005).
4Employ collaborative working approaches. Hopkins (2002) suggested that closer relationships between non-mental health nurses and
mental health nurses should be forged in an attempt to bridge any gaps in knowledge.
4Recognise countertransference when working with people who self-injure. This can reduce nurses negative thoughts, which in turn
can enhance treatment and interpersonal responses and improve the patient experience (Rayner et al 2005).
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Conclusion
People who present with BPD or self-injurious behaviours are often stigmatised by healthcare providers and society, excluded from services and misunderstood. This can lead to ineffective interpersonal responses and negative treatment experiences for the individual. If awareness of BPD and self-injury can be raised and the presenting individuals better understood, treatment experiences and responses will also improve. This will not only provide a better service to people with BPD but will also have positive effects on the nursing staff working with them NS Acknowledgement The author would like to acknowledge and express special thanks to the expert by experience representatives who supported and offered their valuable contributions to this article.
References
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