nursingforsocialjustice

I feel my spirit die a little when I hear a co-worker talk about the “PD in bed 35-B”. People living with personality disorders, especially (in my experience) people living with Borderline Personality Disorder (BPD). I have a special place in my heart for people living with the BPD label, because throughout my career I have witnessed first-hand how misunderstood they often are and also, in times of my own self-reflection I experienced my own frustration, anxieties and moral distress working with people living with BPD.

Psychiatry is an interesting discipline in comparison to other areas of health care because we cannot see a mental health disorder in the same way that we can see and diagnose something like coronary artery disease or a leg fracture. The diagnoses are based on a manual filled with disorder and diagnostic criteria that are somewhat connected to the historical context (sometimes the social mores) of the time when research was being produced. I mentioned this because there was a time when homosexuality was considered a mental health disorder, also hysteria. Understanding that,there is value in knowing what the diagnostic criteria are for people we providng me way that it is valuable knowing about the diagnosis of someone diagnosed with Diabetes Type I or Ovarian Cancer when we are participating in their treatment. The diagnostic criteria for Borderline Personality Disorder is as follows (according to the DSM-5 Criteria, which was revised June 2011):

The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose borderline personality disorder, the following criteria must be met:

A. Significant impairments in personality functioning manifest by:

1. Impairments in self functioning (a or b):

a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive selfcriticism; chronic feelings of emptiness; dissociative states under stress.

b. Self-direction: Instability in goals, aspirations, values, or career plans.

AND

2. Impairments in interpersonal functioning (a or b):

a. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.

b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.

B. Pathological personality traits in the following domains:

1. Negative Affectivity, characterized by:

a. Emotional liability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.

b. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.

c. Separation insecurity: Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy.

d. Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior.

2. Disinhibition, characterized by:

a. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.

b. Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one‟s limitations and denial of the reality of personal danger.

3. Antagonism, characterized by:

a. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.

C. The impairments in personality functioning and the individual‟s personality trait expression are relatively stable across time and consistent across situations.

D. The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or socio-cultural environment.

E. The impairments in personality functioning and the individual‟s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).

(American Psychiatric Association, 2013)

(If you are reading this and did not realize that the DSM was not in the 5th Edition, there may be benefit in reading more about the revisions made from the DSM-4TR, because they are based in peer-reviewed evidence published after the DSM 4-TR was published.)

When I was in my mental health rotation of my nursing undergraduate program in 2007 we were educated about the stereotypes and stigma that people living with Borderline Personality Disorder were subject to. When I took Abnormal Psychology in 2001 when I was working on my undergraduate psychology degree we learned about the stereotypes and stigma that people living with Borderline Personality Disorder were subject to. In 2017, I still hear a lot of stereotyped language used in mental health (inpatient and in the community). When I read the research now it seems like so much progress has been made in terms of understanding the disorder, and best practice guidelines to better work with people living with BPD. So my heart sinks (Titanic level sinking) when I hear phrases like, “she’s a PD” or “that’s that Axis II coming out” or “they’re attention seeking” or “their being manipulative” coupled with a major eye role (sometime also seemingly laden with contempt). I have experienced the “PDs” coupled with the major eye roll twice in the last year by people that are young enough in their career that they would have learned about the DSM 5 and Dialectical Behaviour Therapy/techniques in their nursing education.  In a landscape where there are fewer and fewer educators and clinical leadership, less and less specially trained staff and high staff attrition sometimes it can feel easier to see someone as the “diabetes in room 12” rather than the person who reminds us of ourselves or our mother/sister/brother/friend, the person living with chronic depression who survived a suicide attempt that we desperately want to fix, but are at a loss for how. In a landscape of disillusionment perhaps trying to change our frame, our outlook can be helpful in helping us put the human being back into the disorder being treated.

It is a special privilege that mental health nurses who work in inpatient care have. We are with people for 8 (often 12) hour shifts, for days, weeks, months. It is an opportunity. It can also be emotionally draining. It is hard to provide care to someone who is in acute behavioural crisis, someone that may have just self-harmed, someone that may be at high risk of self harming, it is hard to provide care to someone who lived through a suicide attempt and the feelings that remain are disappointment and failure. The people who require the care of inpatient mental health services are the most symptomatic, the ones who need the most help. Sometimes it is the same people over and over again. It can be easy to stop seeing the person and only see the symptoms, the illness, the label, the stereotypes that we have about the labels.

The concept of person-first language is not a new one (Jensen, Pease, Lambert, Hickman, Robinson…Ramirez, 2013), but perhaps the time is now to start deliberately changing how we talk about the people we provide care for to put the person first rather than the thing that we think is wrong with them.

Peace,

Michelle D.

References

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association.

Jensen, M. E., Pease, E. A., Lambert, K., Hickman, D. R., Robinson, O., McCoy, K. T., … & Ramirez, J. (2013). Championing person-first language: a call to psychiatric mental health nurses. Journal of the American Psychiatric Nurses Association, 19(3), 146-151.