Goals of Patient Assessment and Management
1. Identify the borderline patient as early in the medical hospitalization as possible and prevent costly regressive behaviors of the patient and staff.
2. Prevent staff "splitting" (see definition later).
3. Set limits on patient's unrealistic expectations and inappropriate behaviors as a nonpunitive therapeutic care intervention.
4. Support the patient's healthier defenses and strengths.
5. Manage staff anger, frustration, guilt, and hopelessness while preserving professional caregiving through the use of appropriate staff boundaries.
MANAGEMENT CHALLENGES
Staff splitting
Patient will try to play one staff member against another and confuse care by telling different versions of a story to different people. This often results in staff members taking sides against each other.
Separation anxiety
Patient will demonstrate fear and increased acting out at change of shift with frequent changes in personnel, or when significant caregivers go on vacation.
Entitlement/narcissism
Patient has an offensive sense of deservedness that is difficult for others to manage. This is a necessary defense against an overwhelming fear of the physical illness.
Demanding/acting out
Patient has demanding behavior and acting out when demands are not met. May threaten suicide.
INTERVENTIONS
Conduct brief daily conferences to plan treatment and reach consensus about what to tell the patient. Make no changes in the plan unless the entire team is involved and informed. Patient needs to be told simply and truthfully what is being done.
Use consistent personnel whenever possible.
Introduce yourself at the start of the shift and say how long you will be there.
Anticipate vacations/time off and prepare patient well in advance.
Be alert for signs of entitlement/narcissism.
Be aware of your own anger.
Do not confront or imply that the patient does not deserve the impossible things asked for.
Say, "I understand what you are asking for and because you deserve the best possible care, I am going to continue to pursue the plan dictated by the team's experience/judgment."
Do not try to argue.
Quietly/firmly/repeatedly/calmly set the agreed-upon limits.
Use physical restraints according to hospital policy if the patient acts out violently toward self or others.
Understanding and Managing Patients With Borderline Personality Disorder in Medical/Surgical Units
Common Behaviors
Hostility or other intense affect
Manipulation
Impulsivity
Self-destructive behaviors, suicide
Views of the world as black/white, good/bad
Clinging, demanding style
Dependency, neediness
Poor treatment adherence
Hypochondriacal concerns
An offensive sense of deservedness
Normal Staff Reactions To Borderline Personality Disorder
* Strongest emotion is anger and even hate (well documented in the literature).
* Staff "splitting" is common, as seen in staff disagreement about the care plan and nurses siding against the doctors (or vice versa) or against each other.
* Exhaustion occurs because these patients use up an inordinate amount of time and resources.
* Guilt occurs when staff realize the intensity of their negative reactions and/or that they cannot "cure" the patient.
Causes and Treatment
The patient with a borderline personality has suffered a defect in psychosocial development that is most likely associated with early childhood trauma involving physical, sexual, or emotional abuse; abandonment by a parent; or death of a parent. It is a disorder of character with a neurological component. Because it is a chronic illness with periodic acute exacerbations, symptoms may worsen with life stressors to the point of psychosis. Treatment involves years of psychotherapy and pharmacologic intervention. During medical hospitalization, interventions focus on preventing worsening of borderline behaviors.
Common Primitive Defense Mechanisms
Primitive denial Patient is able to deny to the point of obliterating reality.
Entitlement: This is to the BPD individual person what hope and faith are to the average person.
Primitive idealization: The staff may be viewed as all powerful. Rage occurs when the staff makes human errors. Then the staff seems all bad.
Intrapsychic splitting: Active process of keeping perceptions and feelings of opposite quality separate from each other.
Projective identification: If I'm bad, then you must be bad if you care for me.
Situations Triggering Borderline Decompensation and Acting Out
* Unstructured, unclear situations.
* Lack of continuity of caretakers. Separation from important caretakers or family.
* Expressed intense negative or positive affect toward the patient by others including staff.
* Team disagreement about treatment plan (nurse-to-nurse or nurse-to-doctor disagreement).
* Forced regression such as being admitted to a hospital.
* Fear of personal disintegration related to undergoing invasive bodily procedures.