Breaking new ground

Mental Health Nursing,  Mar/Apr 2002  by Osborne, Sarah

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As beginners, my fellow students and I generally found people with the socalled personality disorders perplexing, challenging and difficult. The few skills we had, along with the passage of time, did not seem to make a discernible difference to the experiences and behaviour of this group of people. They were to remain unpopular and as a consequence did not receive the necessary help.

To the general public, people with personality disorders are inherently dangerous. The recent conviction in Germany of two self-styled 'vampires', both with personality disorder, for ritual murder, all too readily sustains the popular prejudices.

As trainee professionals, I and my fellow students watched as the patient careers of those with PD moved them on to prison, Broadmoor (in extreme cases), just drifting on or little improvement.

It is refreshing to see, therefore, Alan Jones's and Amanda Whitehouse's discussions of interventions for people diagnosed as having Borderline Personality Disorder(BPD) in this edition of Mental Health Nursing.

The Diagnostic and Statistical Manual of Mental Disorders (2000) discusses BPD thus: `The essential feature.. is a pervasive pattern of instability of interpersonal relationships, self-image and affect plus a marked impulsivity that begins by early adulthood and is present in a variety of contexts. People with BPD make frantic efforts to avoid real or imagined abandonment.'

The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in self-image, affect, cognition and behaviour.

It is suggested that abandonment fears are related to an intolerance of being alone and a need to have other people with them. The BPD person, for example, may suddenly despair at a clinician announcing the end of a session. They may express panic or fury when someone important to them is late or cancels an appointment. Frantic efforts to avoid abandonment may include impulsive reactions such as self-mutilation or suicidal behaviours.

A pattern of unstable and intense relationships is common. Potential caregivers or lovers may be idealised at a first or second meeting, with demands to spend a lot of time together and share the most intimate details early on in a relationship. This idealisation may quickly turn to devaluation, however, associated with the feeling that the other person does not care enough, does not give enough, or is not there enough.

Sudden and dramatic shifts in selfimage characterised by shifting goals, values and vocational aspirations are common. There may be sudden changes in opinions, career plans, sexual identity, values and types of friends. Impulsivity is common gambling, spending irresponsibly, binge eating, substance abuse, unsafe sex and reckless driving, for example. Self-mutilation and para-suicide are common.

This list of characteristics can be daunting and, as Alan Jones points out, the challenges these clients present are often not seen as welcome ones by the team to whom they are referred. Despite my usual antipathy towards behaviour therapy, it is pleasing to see pieces of work that offer some practical guidelines for those working with this diverse and often demanding group. I am sure these papers will prove useful to clinicians.

Copyright Community Psychiatric Nurses Association Mar/Apr 2002
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