Patients with Borderline PD
Three words which can produce almost as much anxiety in staff as in the patients with the diagnosis. Borderline Personality Disorder is a tough one. Joy and I have co-written Brief Encounters but it seems relevant to specify here that it’s me, Marion, writing this as BPD is the very unwelcome mental illness I’ve wrestled with for the last 10 years. Indeed it’s because my BPD produces rather outlandish behaviour, that was met with nothing but patience and kindness by the staff at St Ann’s Hospital, Tottenham, that I set up Star Wards.
So what is this illness and how does it impact on patients and staff? BPD is fundamentally a condition making it very, very hard (often impossible!) to regulate our feelings, and those feelings are frequently intolerably painful. There’s a website called “Anything to stop the pain” and that’s a pretty accurate ‘strapline’ for living with BPD. The present moment can be so agonising that anything is preferable – which is one reason why self-harming is such a powerful, addictive coping mechanism for many of us. Most people with BPD have a history of trauma or abuse (not everyone – I don’t) and the more that staff can bear this in mind when working with patients who have BPD, the more effective the response from both staff and patient.
For me, the relevant features for hospital staff to be aware of are:
- Seemingly trivial things can trigger a sense of catastrophe. I recently failed to catch a dog gone AWOL and was convinced he would die, it was all my fault and that I’d never be able to cope with the guilt.
- That sense of catastrophe is closely followed by a self-destructive response. Self-harming (cutting or overdosing for me) is a way many of us with BPD cope with overwhelming emotions. It gives us a sense of self-agency – the outside world may be unmanageable but we create a little micro-world/experience around the self-harming which is divertingly absorbing, externalises the internal pain (eg blood being released) and allows for us to self-soothe by tending the wounds. I have a sort of ‘hierarchy’ of self-destructive responses. The lowest-key is cutting, but when life is overwhelming and feels completely out of control, I take an overdose. I completely, totally appreciate that this can appear childish, selfish, attention-seeking etc and is time-consuming and expensive for a grossly overstretched NHS. But for me it’s the only way I have at that stage for regaining my equilibrium and continuing the slog of being alive. By bringing myself to the point of death and then through my own actions (going to poor old A&E) getting that reversed, my emotional thermostat is sufficiently reset.
- Then there’s the suicidality! (It really isn’t an easy illness!) The emotional pain, guilt about being so ‘high maintenance’ and anxiety-provoking for friends and family and my restricted functioning make being alive unattractive. I am now pretty much programmed to look for ways out.
- I have attachment issues! One of the main factors resulting in BPD is attachment failure in infancy. This results in relationship difficulties for most of us such as a giant fear of abandonment.
- It took me years to really recognise how much of my severe depression is fuelled by anxiety. Anxiety sounds/feels rather a mild concept and can be submerged under all the considerations of distress, risk etc. But it’s a major factor in this mental illness, as indeed it often is with all mental illnesses.
What helps when in hospital
- Safety. The reality is that I’ve probably arrived at hospital equipped to self-harm, but even if unarmed, I’ll be searching (often successfully) for something to cut with. Mental health wards are very experienced at and geared up for minimising the availability of (potentially) sharp objects but it’s almost impossible on general wards. My view is firmly that it is usually better for someone to cut and that episode be over, rather than energetic, often fraught attempts by staff to prevent this, resulting in a ratcheting up of the compulsion to cut which can lead to much more serious injury. It’s impossible to remove ligature points and other potentially fatal elements of hospital design so a very suicidal patient may well need someone with them 24/7.
- Staff being understanding and non-judgmental. This can be very hard! The combination of extreme emotions producing what appears to be greatly unreasonable behaviour and all the risk from self-harming and suicidality can be overwhelming for staff. Yet again, mentalising is crucial – I completely stop mentalising when I’m in meltdown as the pain and confusion are so intense, and must rely on others to reintroduce perspective and calm. I suppose my main plea is that it’s not my fault! I didn’t go out and decide to acquire a mental illness and then choose BPD because it looks a good laugh. It’s hell to live with and I’m painfully aware how my behaviour can seem to others and the stress it creates.
- Trauma and abuse. For example, patients with BPD may need particular sensitivity to how intimate examinations are carried out.
- Attachment. Patients with BPD can feel an unusually strong dependence on hospital staff and small things can really help, like my named nurse coming to say goodbye before the end of their shift.
With all these complicated issues, ward staff will get invaluable help from the mental health liaison nurse and other specialist mental health colleagues
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