• Subject Name : Nursing

Treatment of Personality Disorder

Borderline personality disorder (BPD) is a severe psychiatric problem which is characterized by patterns of instability among the patient. The patients generally have disturbances in their self-image and have unbalanced interpersonal relationships. The patient behaves in an impulsive manner and thus exhibits suicidal conduct by thinking about suicide or by attempting it, which causes a significant amount of distress and impairment in the patient life (Kulacaoglu & Kose, 2018). Patients suffering from this disorder have high rates of morbidity and that complicates their medical care in comparison to others. People who are suffering from borderline personality disorder are very much vulnerable to emotional hyperarousal which creates abnormalities in their neurological systems. Because of that, they cannot control their emotion and feel stressed most of the times. With that, they are also vulnerable towards interpersonal and social stressors because of abnormalities in neurobiological systems. Thus, it is important for them to seek clinical attention (Kulacaoglu & Kose, 2018).

In the episode of care for Shanae who is a female and is of 22 years old, it is necessary to look at her psychological issues. She was admitted to the hospital’s emergency department because of the overdose of paracetamol, which she has taken intentionally. With that, she had self-inflicted cuts on her both wrists. While talking to her, it was known that she was most of the time depressed and that she often thinks about committing suicide. She also cut herself whenever she feels overwhelmed. She also perceives herself as a fat person and often hears a voice which criticizes her. Therefore, it can be said that one of the psychological issues that she might be facing is depression. It is evident that most of the patient with borderline personality disorder have depression and in this case study also, Shanae self-explained that she is feeling depressive from a very long period of time. Features of depression that can be seen in people are hopelessness, worthlessness, suicidal behaviour, self-criticality, significant anxiety, poor sleep and guilt feeling. The emotional crisis experienced by people is also the main reason for depression in them (Rao & Broadbear, 2019). Patient with depression also deficits in cognitive fluency or flexibility and generally exhibits impairment in their cognitive domain (Beblo et al., 2014). Hence, being depressed from long time may have contributed towards Shanae current presentation.

The social health issues that need to be outlined to address the episode of care is that she did not have proper social support from the community or from anyone. She did not have any person who can uphold her social needs so that her social well-being is maintained. She has been fired from her job 2 weeks ago because she missing her duties and her boyfriend also mentioned that he did not want to continue his relationship with her as he is moving elsewhere. With that, she lives with other people and did not have a proper relationship with them. She had friends who also intake MDMA and methamphetamine. People who are suffering from a borderline personality disorder and have social difficulties generally have a high level of conflict which is marked by fears of being abandon and dependency on others. These individuals are mostly unstable and struggle to keep close relationships with other people. Borderline personality disorder patients in addition to that have fewer numbers of social contacts and have problems in managing their emotions, thoughts and behaviours (Beeney et al., 2018). Thus, it can be said that being socially distant and not having proper support might have contributed towards Shanae current presentation.

The biological issue that needs to be highlighted to address the episode of care is taking of care by Shanae. She has mentioned in her assessment that she takes drug such as MDMA and methamphetamine with her friends and because of that she also missed her job. Consumption of drugs and other substances can cause excessive problems in people and can also be one of the indicators of borderline personality disorder. Because of drug intake the person can have troubles in emotional dysregulation, and could also have affective instability. Drugs could also enhance some emotions of the persons which are underlying for example depression and rage. With the help of drugs, borderline personality disorder patients try to numb their feelings which came from other issues that they have in their life (Trull et al., 2018). Thus it can be stated that doings drugs by Shanae could have contributed towards her current presentation in the emergency ward. 

The plan of care which could be provided to Shanae should include features which could help her deal with her depression, lack of social support and intake of drugs. With that, it is also important for the healthcare provider to reduce the self-harm tendency in her. It is important to decrease the number of suicidal threats or attempts that are committed by her. The care which should be given to Shanae should involve management of the crisis and short-term admission in the healthcare system for her own safety and distress de-escalation. She should also be given help from mental health services and should be offered with private services that could help her with the treatment of the depression. She could also be given a wide range of psychological therapies and could attend them in multiple sessions over a period of time. With the help of therapies, crisis-prone or risky behaviour could be eliminated. Therapies could also help her in the reduction of consumption of drugs and other substances which causes enhancement in the negative emotions (Grenyer, Lewis, Fanaian & Kotze, 2018). One of the therapies which could be used is dialectical-behaviour therapy (DBT). This therapy highlights the psychosocial aspects while treating a patient. It helps in curing the tendency of suicide in patients and mood disorders. In DBT, the process involves the client and therapist to work with strategies which will balance the cognitive and emotional regulations. By this, the patient could cope with his thoughts and feelings in addition to the behaviour and events which are happening (Choi-Kain, Finch, Masland, Jenkins & Unruh, 2017). Another therapy which could also be used is mentalization-based therapy (MBT). This therapy combines psychodynamic, systemic, cognitive-behavioural and ecological approaches. Patient of the borderline personality disorder have disorganized attachment and this therapy could help with better control on behaviour. The goal of this therapy is to increase the affect regulation. Thus, it can help patients suffering from a borderline personality disorder (Vogt & Norman, 2019). These therapies can help with borderline personality disorder and problems associated with substance abuse. They can also facilitate in fixing the eating disorder that is found in most of the borderline personality disorder patients. In addition to that, they also aid with managing the post-traumatic stress disorder (PTSD) (Choi-Kain, Finch, Masland, Jenkins & Unruh, 2017).

It is also significant that she gets involved in community-based services for a brief period of time so that she can bond with multiple people of the community and society. By doing this, this would find support and encouragement from community members and hence would not be socially secluded. The care should also be developed that she can have fast access to it in case of crisis. She should also be provided with adequate resources that could help her with her condition. In addition to that, interventions should be introduced to her so that risk of suicide will be reduced (Grenyer, Lewis, Fanaian & Kotze, 2018). Nursing staff who are working with borderline personality disorder patient should also take care that patient is away from all the sharp objects so that she cannot make use of those objects to cut herself or do any other injuries. The main goal of the care plan in the emergency department is to prevent future harm to the patient and to stabilize and address her psychiatric and emotional need (Agnol et al., 2019). Nurses should express concern and should communicate in an effective manner. Pharmacological interventions should also be provided to the patient so that. With that, appropriate referrals should be provided to the patient. There should also be the follow-up to check whether the patient is following the intervention or not. The nurse could also educate the patient so that she did not take any critical step which could harm her and would decrease her quality of life. For a better plan of care, it is very important that the healthcare provider exhibits empathetic behaviour and should perform active listening (Agnol et al., 2019).

Referrals could be made to healthcare service providers so that Shanae could get proper care and treatment that will resolve her health issues. The first healthcare professional that can help people with a borderline personality disorder is a physician. A physician could do a physical assessment of the patient as a borderline personality disorder patient generally shows signs and symptoms of self-harm. In this case study also, Shanae exhibits multiple cuts on her both of the wrists and on her thighs. By doing a physical examination, the current health status of the patient could be known. It could further assist in diagnosing the condition (Dubovsky & Kiefer, 2014). The physician could also recognize the underlying problems that are affecting the patient. The physician might also build rapport and could make the patient feel less raged and frustrated. A physician could also educate the patient and could perform follow-ups. By regularly checking on the patient, the physician could also make sure suicide attempts are not made by the patient. The physician could also look at patients physical and as well as mental wellbeing and could also suggest some interventions that could ultimately help the patient in managing her borderline personality disorder. By doing all this, the physician could lessen the rates of self-injuries and life-threatening behaviour which is showcased by the patient (Dubovsky & Kiefer, 2014).

Another referral which should be made should be for a psychologist. A psychologist has a very important role in treating borderline personality disorder. A borderline personality disorder is a serious condition which requires support from psychological treatments. A psychologist can help a borderline personality disorder patient by the use of therapies. For example, a psychologist can make use of DBT and MBT. With that, there are various other therapies that could be put in place so that the patient did not harm herself or try to commit suicide. These therapies are transference focused psychotherapy, schema-focused therapy, transference focused psychotherapy and general psychiatric management. Each one of the therapies could help in the treatment of borderline personality disorder (Storebø et al., 2018). With that, a psychologist could help with dealing with emotional and social problems. They can also aid in unwinding the patient intense emotions and could help in reconnecting to people. In addition to that, a psychologist can also help in dealing with post-traumatic stress disorders. They can help the patient to feel more comfortable and safe and could also provide a protective environment for them. They can also help the patients in dealings with interpersonal challenges. The therapies facilitate patients in solving problems and building stress tolerance. They also help in aiding the patients in acquiring the needs that they have (Storebø et al., 2018). Thus, the psychologist role is a very crucial role in helping the borderline personality disorder patients.

Borderline personality disorder and major depressive episodes are most likely to link with the dysregulated immune system which contributes towards more of the depression that is experienced by the patient. With that, these patients have low nutrition level too (Grudet, Malm, Westrin & Brundin, 2014). Many of the patients generally suffer from bulimia nervosa and anorexia nervosa. Therefore, it is important to support patients with their nutritional needs. For that, a nutritionist could help to manage the patient needs and requirements. A nutritionist could help the patient by telling her about the important things that should be involved in her diet (Marino, Hardin, Gasbarro, Dansereau & Fischer, 2020). Moreover, nutritionist could also check which essential component is missing from the diet of the borderline personality disorder patient and for that supplements could be provided to the patients. Those supplements could be Vitamins, antioxidants, omega-3 fatty acids, zinc and so on. This would improve the patient's diet and would also keep her fit and healthy. A nutritionist could also prepare a diet plan for the patient and could help her to maintain suitable body weight. Nutritionist thus could also help with marinating a positive body image (Marino, Hardin, Gasbarro, Dansereau & Fischer, 2020). Therefore, nutritionist could assist the borderline personality disorder patient and her condition.

A support group could also help in managing the borderline personality disorder in people. Borderline personality disorder patients generally have less number of relationships to the community. They are often being secluded socially and this worsens their situation. They develop depression and other mental problems because they are not socially accepted. So, for treating a patient with a borderline personality disorder, people have to support her. Studies have also proven that having a support group could improve the borderline personality disorder patient condition and relationships with others (Barr, Townsend & Grenyer, 2020). Support from a peer could help with managing the mental condition and thus can create a better environment for the patient. The support group can provide with emotional help and can help them to understand their emotions and feelings. They could also enhance the mental well-being of a person. In the support group, people could share their experiences and their feelings and thoughts and thus can form safe relationships which are therapeutic for them. They can also help empower the individuals and could promote positive behaviour. The support group can also impart the knowledge about the disorder and thus can make the patient aware of the condition. Therefore, a support group can help in empowering the patient and would also support her in times of need (Barr, Townsend & Grenyer, 2020). By joining a support group, the patient would feel that she is being understood and she will become more comfortable in sharing her thoughts and feelings. Also, it will help the patient in managing her borderline personality disorder condition and would provide her with extra information for self-management. It will also enhance the self-esteem of the person which will in turn maintain the mental well-being of the person (Barr, Townsend & Grenyer, 2020).

One of the community resources which could be accessed by borderline personality disorder patient to improve her health is Australian Borderline Personality Disorder Foundation. This foundation is created in association with volunteers, passionate clinicians and carers who want to encourage and help the patients who are suffering from a borderline personality disorder. Their aim is to reduce the stigma and help people to access the services that are made for them. They target every individual in the Australian population such as aboriginal and Torres Strait Islanders, Adults, Families, People with an increased danger of suicide and people who bereaved by suicide. They also target young peoples and children in addition to patients of mental illnesses. With that, they also take care of farming communities and remote and regional communities (Australian Borderline Personality Disorder Foundation Limited, 2020). They are a charitable organization. Its mission is to form a positive culture around borderline personality disorder. The other aims of this foundation are to provide timely, high quality and responsive treatment service to the borderline personality disorder patients and to their family and carer. It also focuses on educating and family member and the carer so that they can provide better care to the patients. With that, they also give education to the clinicians as well about the borderline personality disorder condition. They basically want to improve the patient’s wellbeing in the community and it also provides the best quality research about every aspect of borderline personality disorder (Australian Borderline Personality Disorder Foundation Limited, 2020).

Another community resource that could be accessed by the patient is Project Air Strategy for Personality Disorders. They have partnered with Medical research institute of the University of Wollongong and Illawarra Health in addition to NSW Health Districts and NSW Ministry for Health and Local. It seeks to communicate with families, consumers, community and carers so as to provide better treatment and support to the personality disorder patients (Project Air Strategy for Personality Disorders, 2020). Their mission is to improve treatment options for the patients of personality disorders and their carers and family. They have provided the patient with suicide prevention helplines. They also help with borderline support by providing relevant information about the illness and supporting its diagnosis in patients. They also give details about support groups for the patient and their families and carers. In addition to that, they have given multiple numbers for multiple support group so that the borderline personality disorder patient or her family could connect to them and can acquire their help (Project Air Strategy for Personality Disorders, 2020).

In conclusion, it can be said that Borderline personality disorder is a chronic mental problem which affects patient mental well-being. The patients act in impulsive behaviour and often try to commit suicide and try to self-harm themselves. They also have to face episodes of depression and anxiety. In this case study also, the patient, Shanae was diagnosed with borderline personality disorder and she was found to be self-harming herself by cutting her wrists. She was admitted due to overdose of paracetamol which she did knowingly. She also stated that she will try to harm herself again. Therefore, she needs help with various issues that she was struggling with. One of the main issues was depression. She stated that she was depressed for a very long time. Other issues were that she did not receive proper support from the community or the society and that she has a tendency to consume drugs. Plan of care for her involves showing social support and giving her help via multiple therapies such as CBT and MBT. She could also be provided help from clinicians, psychologists, nutritionists and support group. In addition to that, she could also gain support from community group programmes such as Australian Borderline Personality Disorder Foundation and Project Air Strategy for Personality Disorders. Therefore, by considering these steps and programs, Shanae could be helped.

References for Borderline Personality Disorder

Agnol, E. C. D., Meazza, S. G., Guimarães, A. N., Vendruscolo, C., & Testoni, A. K. (2019). Nursing care for people with borderline personality disorder in the Freirean perspective. Revista Gaucha de Enfermagem40. https://doi.org/10.1590/1983-1447.2019.20180084 

Australian BPD foundation limited. (2020). Mission & values. Available at https://bpdfoundation.org.au/mission.php

Barr, K. R., Townsend, M. L., & Grenyer, B. F. (2020). Using peer workers with lived experience to support the treatment of borderline personality disorder: A qualitative study of consumer, carer and clinician perspectives. Borderline Personality Disorder and Emotion Dysregulation, 7(1), 1-14. https://doi.org/10.1186/s40479-020-00135-5

Beblo, T., Mensebach, C., Wingenfeld, K., Rullkoetter, N., Schlosser, N., Diplpsych, & Driessen, M. (2011). Patients with borderline personality disorder and major depressive disorder are not distinguishable by their neuropsychological performance: A case-control study. The Primary Care Companion for CNS Disorders13(1), PCC.10m00982. https://doi.org/10.4088/PCC.10m00982blu

Beeney, J. E., Hallquist, M. N., Clifton, A. D., Lazarus, S. A., & Pilkonis, P. A. (2018). Social disadvantage and borderline personality disorder: A study of social networks. Personality Disorders9(1), 62–72. https://doi.org/10.1037/per0000234

Choi-Kain, L. W., Finch, E. F., Masland, S. R., Jenkins, J. A., & Unruh, B. T. (2017). What works in the treatment of borderline personality disorder. Current Behavioral Neuroscience Reports4(1), 21–30. https://doi.org/10.1007/s40473-017-0103-z

Dubovsky, A. N., & Kiefer, M. M. (2014). Borderline personality disorder in the primary care setting. Medical Clinics98(5), 1049-1064.

Grenyer, B. F., Lewis, K. L., Fanaian, M., & Kotze, B. (2018). Treatment of personality disorder using a whole of service stepped care approach: A cluster randomized controlled trial. PloS One13(11), e0206472. https://doi.org/10.1371/journal.pone.0206472

Grudet, C., Malm, J., Westrin, Å., & Brundin, L. (2014). Suicidal patients are deficient in vitamin D, associated with a pro-inflammatory status in the blood. Psychoneuroendocrinology50, 210-219.

Kulacaoglu, F., & Kose, S. (2018). Borderline Personality Disorder (BPD): In the Midst of vulnerability, chaos, and awe. Brain Sciences8(11), 201. https://doi.org/10.3390/brainsci8110201

Marino, J., Hardin, R., Gasbarro, A., Dansereau, V. A., & Fischer, S. (2020). Outpatient treatment for adults with complex eating disorders and co-morbid conditions: A decision making model and case example. Eating Disorders28(2), 171-183. https://doi.org/10.1080/10640266.2020.1723372

Project Air Strategy for Personality Disorders. (2020). Available at https://www.projectairstrategy.org/mpalinks/index.html

Rao, S., & Broadbear, J. (2019). Borderline personality disorder and depressive disorder. Australasian Psychiatry: Bulletin of Royal Australian and New Zealand College of Psychiatrists27(6), 573–577. https://doi.org/10.1177/1039856219878643

Storebø, O. J., Stoffers‐Winterling, J. M., Völlm, B. A., Kongerslev, M. T., Mattivi, J. T., Kielsholm, M. L., Nielsen, S. S., Jørgensen, M. P., Faltinsen, E. G., Lieb, K., & Simonsen, E. (2018). Psychological therapies for people with borderline personality disorder. The Cochrane Database of Systematic Reviews2018(2), CD012955. https://doi.org/10.1002/14651858.CD012955

Trull, T. J., Freeman, L. K., Vebares, T. J., Choate, A. M., Helle, A. C., & Wycoff, A. M. (2018). Borderline personality disorder and substance use disorders: an updated review. Borderline Personality Disorder and Emotion Dysregulation5(1), 15. https://doi.org/10.1186/s40479-018-0093-9

Vogt, K. S., & Norman, P. (2019). Is mentalization-based therapy effective in treating the symptoms of borderline personality disorder? A systematic review. Psychology and Psychotherapy92(4), 441–464. https://doi.org/10.1111/papt.12194

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