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Acres K, Loughhead M, Procter N. Carer perspectives of people diagnosed with borderline personality disorder: A scoping review of emergency care responses. Australas Emerg Care 2019; 22:34-41. [PMID: 30998870 DOI: 10.1016/j.auec.2018.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 12/05/2018] [Accepted: 12/05/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Caring for a person with borderline personality disorder remains largely stigmatised and misunderstood. When a crisis arises, carers often seek help with the person they care for in emergency care settings such as the emergency department. The aim of this review was to explore, locate and compile the literature regarding the perspectives of family carers for a person with borderline personality disorder in an emergency care setting with a focus on nursing practices. This review advances understandings of carer perspectives in emergency care settings. METHODS The Joanna Briggs Institute (2015) [1], methodology for scoping reviews guided this review. A search of Emcare, Medline and Ovid Nursing was performed during April 2018, to identify literature where carer views and perspectives on engaging with emergency care services were reported. A grey literature search was also conducted. A total of ten articles and reports were included in this review. Consultation with a carer support group precipitated this review, which assisted in the formulation of the research questions. RESULTS Papers found via the study focused on health professional responses, rather than on nursing practice. Findings indicate that carers often perceive emergency departments as the only option for emergency care in a crisis. Carers require information about how to effectively manage a crisis with their loved one more effectively. CONCLUSION This scoping review identified that carers are often not consulted or engaged with by health professionals. Carers often perceive that nurses and health professionals have a lack understanding about the consumer's conceptualisation of distress and the nature of BPD, which becomes a barrier to effective crisis support and management. The literature often reported that a trusting and collaborative relationship between carers, nurses and health professionals demonstrated improved outcomes for the carer and consumer.
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Affiliation(s)
- Kristy Acres
- School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Adelaide SA 5000, Australia.
| | - Mark Loughhead
- School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Adelaide SA 5000, Australia.
| | - Nicholas Procter
- School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Adelaide SA 5000, Australia.
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Ring D, Lawn S. Stigma perpetuation at the interface of mental health care: a review to compare patient and clinician perspectives of stigma and borderline personality disorder. J Ment Health 2019:1-21. [PMID: 30862201 DOI: 10.1080/09638237.2019.1581337] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 08/28/2018] [Accepted: 09/25/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND People with borderline personality disorder (BPD) experience significant stigma, particularly at the interface of care delivery. AIMS To compare and contrast what stigma looks like within mental health care contexts, from the perspective of patients and mental health professionals (MHPs) and how it is perpetuated at the interface of care. METHOD A review of the literature was undertaken to compare the experiences of stigma towards BPD from the patient and MHP perspective by thematically analysing the results from empirical studies exploring their experiences. RESULTS Thirty studies were found; 12 on patients perspectives and 18 on clinicians perspectives. Six themes arose from the thematic synthesis: (1) stigma related to diagnosis and disclosure; (2) perceived un-treatability; (3) stigma as a response to feeling powerless; (4) stigma due to preconceptions of patients; (5) low BPD health literacy and (6) overcoming stigma through enhanced empathy. A conceptual framework for explaining the perpetuation of stigma and BPD is proposed. CONCLUSION Stigma towards people with BPD is perpetuated through poor BPD health literacy by patients and MHPs that stalls effective treatment and engagement, and disempowers all concerned, deferring responsibility to others. Addressing this stigma requires multiple strategies that include more targeted education, advocacy and leadership.
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Affiliation(s)
- Daniel Ring
- a College of Medicine and Public Health , Flinders University , Adelaide , Australia
- b Department of Psychiatry , Margaret Tobin Centre Flinders University , Adelaide , Australia
| | - Sharon Lawn
- a College of Medicine and Public Health , Flinders University , Adelaide , Australia
- b Department of Psychiatry , Margaret Tobin Centre Flinders University , Adelaide , Australia
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Thomas N, Gurvich C, Kulkarni J. Borderline personality disorder, trauma, and the hypothalamus-pituitary-adrenal axis. Neuropsychiatr Dis Treat 2019; 15:2601-2612. [PMID: 31564884 PMCID: PMC6743631 DOI: 10.2147/ndt.s198804] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/26/2019] [Indexed: 12/14/2022] Open
Abstract
Borderline personality disorder (BPD) is a complex psychiatric illness for which treatment poses a significant challenge due to limited effective pharmacologic treatments, and under-resourced psychological interventions. BPD is one of the most stigmatized conditions in psychiatry today, but can be understood as a modifiable, neurodevelopmental disorder that arises from maladaptive responses to trauma and stress. Stress susceptibility and reactivity in BPD is thought to mediate both the development and maintenance of BPD symptomatology, with trauma exposure considered an early life risk factor of development, and acute stress moderating symptom trajectory. An altered stress response has been characterized in BPD at the structural, neural, and neurobiological level, and is believed to underlie the maladaptive behavioral and cognitive symptomatology presented in BPD. The endocrine hypothalamus-pituitary-adrenal (HPA) axis represents a key stress response system, and growing evidence suggests it is dysfunctional in the BPD patient population. This theoretical review examines BPD in the context of a neurodevelopmental stress-related disorder, providing an overview of measurements of stress with a focus on HPA-axis measurement. Potential confounding factors associated with measurement of the HPA system are discussed, including sex and sex hormones, genetic factors, and the influence of sample collection methods. HPA-axis dysfunction in BPD largely mirrors findings demonstrated in post-traumatic stress disorder and may represent a valuable neuroendocrine target for diagnostic or treatment response biomarkers, or for which novel treatments can be investigated.
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Affiliation(s)
- Natalie Thomas
- Central Clinical School , Monash Alfred Psychiatry Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Caroline Gurvich
- Central Clinical School , Monash Alfred Psychiatry Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Jayashri Kulkarni
- Central Clinical School , Monash Alfred Psychiatry Research Centre, Monash University, Melbourne, Victoria, Australia
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Schess J, Diminic S, Hielscher E, Harris MG, Lee YY, Kealton J, Whiteford HA. Investment in Australian mental health carer services: how much and does it reflect evidence of effectiveness? AUST HEALTH REV 2018; 44:104-113. [PMID: 30558709 DOI: 10.1071/ah18065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 10/05/2018] [Indexed: 11/23/2022]
Abstract
Objective The aims of this study were to quantify Australian federal and state government expenditure on mental health carer services for 2014-15, map the types of services being provided and explore how funded service types compare with the evidence base for the outcomes of these carer services. Methods Web searches were conducted to identify in-scope mental health carer services in Australia funded by federal and state and territory governments. Funding estimates were confirmed where possible with available government and carer organisation contacts. A literature search was conducted for reviews of studies investigating mental health carer service outcomes. Results In 2014-15, the estimated Australian national, state and territory government expenditure on mental health carer services was approximately A$90.6million. This comprised A$65.6million in federal expenditure and A$25.0million in state and territory expenditure. Most funding streams provided respite and psychoeducation. The literature showed positive carer outcomes for psychoeducation and intensive family interventions. Evidence was lacking for the effectiveness of respite services. Conclusions These findings suggest a mismatch between what is known about the extent to which different service types deliver positive carer outcomes and the current allocation of funds across Australia's mental health system. This study also highlights the fragmentation of the mental health carer services system, supporting the need to streamline access. What is known about this topic? Informal carers of people with mental disorders provide a critical role to the significant number of individuals with mental illness in Australia, and provide an unpaid workforce to the Australian mental health system. This role comes with significant physical, emotional and financial burden, which government-funded services can assist with to allow mental health carers to continue to serve in their caring role while improving their quality of life. What does this paper add? Using both published data and communication with health and non-government officials, we have estimated federal and state expenditure on mental health carer services at A$90.6million in 2014-15 fiscal year and have provided a mapping of the services this expenditure funds. In addition, through analysis of the literature on outcomes of carer services provided, we have seen a mismatch of expenditure and the evidence base. What are the implications for practitioners? There is a necessity for both more research into service outcomes aimed particularly at mental health carers and thinking critically about whether the current prioritisation of funds can be increased and/or reallocated to create better outcomes for mental health carers.
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Affiliation(s)
- Jaclyn Schess
- Department of Economics, Yale University, New Haven, Connecticut, USA. Email
| | - Sandra Diminic
- Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Qld 4076, Australia. Email
| | - Emily Hielscher
- Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Qld 4076, Australia. Email
| | - Meredith G Harris
- Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Qld 4076, Australia. Email
| | - Yong Yi Lee
- Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Qld 4076, Australia. Email
| | | | - Harvey A Whiteford
- Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Qld 4076, Australia. Email
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55
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Wlodarczyk J, Lawn S, Powell K, Crawford GB, McMahon J, Burke J, Woodforde L, Kent M, Howell C, Litt J. Exploring General Practitioners' Views and Experiences of Providing Care to People with Borderline Personality Disorder in Primary Care: A Qualitative Study in Australia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E2763. [PMID: 30563256 PMCID: PMC6313450 DOI: 10.3390/ijerph15122763] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 12/04/2018] [Accepted: 12/05/2018] [Indexed: 11/17/2022]
Abstract
The prevalence of people seeking care for Borderline Personality Disorder (BPD) in primary care is four to five times higher than in the general population. Therefore, general practitioners (GPs) are important sources of assessment, diagnosis, treatment, and care for these patients, as well as important providers of early intervention and long-term management for mental health and associated comorbidities. A thematic analysis of two focus groups with 12 GPs in South Australia (in discussion with 10 academic, clinical, and lived experience stakeholders) highlighted many challenges faced by GPs providing care to patients with BPD. Major themes were: (1) Challenges Surrounding Diagnosis of BPD; (2) Comorbidities and Clinical Complexity; (3) Difficulties with Patient Behaviour and the GP⁻Patient Relationship; and (4) Finding and Navigating Systems for Support. Health service pathways for this high-risk/high-need patient group are dependent on the quality of care that GPs provide, which is dependent on GPs' capacity to identify and understand BPD. GPs also need to be supported sufficiently in order to develop the skills that are necessary to provide effective care for BPD patients. Systemic barriers and healthcare policy, to the extent that they dictate the organisation of primary care, are prominent structural factors obstructing GPs' attempts to address multiple comorbidities for patients with BPD. Several strategies are suggested to support GPs supporting patients with BPD.
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Affiliation(s)
- Julian Wlodarczyk
- College of Medicine and Public Health, Flinders University, GPO Box 2100, Adelaide 5001, Australia.
| | - Sharon Lawn
- College of Medicine and Public Health, Flinders University, GPO Box 2100, Adelaide 5001, Australia.
- Flinders Human Behaviour and Health Research Unit, Flinders University, GPO Box 2100, Adelaide 5001, Australia.
| | - Kathryn Powell
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide 5000, Australia.
| | - Gregory B Crawford
- North Adelaide Palliative Care Service, Discipline of Medicine, University of Adelaide, Adelaide 5000, Australia.
| | - Janne McMahon
- Private Mental Health Consumer Carer Network (Australia) Ltd., PO Box 542, Marden 5070, Australia.
| | - Judy Burke
- Sanctuary BPD Carer Support, Adelaide 5001, Australia.
| | - Lyn Woodforde
- Carers SA, 338 Tapleys Hill Rd, Seaton 5023, Australia.
| | - Martha Kent
- Borderline Personality Disorder Centre of Excellence, Country Health SA Mental Health Services, 22 King William St, Adelaide 5000, Australia.
| | - Cate Howell
- Cate Howell, Cate Howell and Colleagues, 14 Hay St, Goolwa 5214, Australia.
| | - John Litt
- Department of General Practice, College of Medicine and Public Health, Flinders University, GPO Box 2100, Adelaide 5001, Australia.
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Borderline Personality Disorder: Barriers to Borderline Personality Disorder Treatment and Opportunities for Advocacy. Psychiatr Clin North Am 2018; 41:695-709. [PMID: 30447733 DOI: 10.1016/j.psc.2018.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patients experience difficulty in accessing the evidence-based treatments that exist for borderline personality disorder. This article identifies barriers to treatment within the US structural, economic, and political landscape and how families have created an advocacy movement to address this problem. It explores how the United States has addressed such barriers, in comparison to other countries. Finally, it offers recommendations for future advocacy to increase access to treatment for borderline personality disorder.
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Baker C. Virtual issue-supporting people who self-harm or are suicidal-Editorial. J Psychiatr Ment Health Nurs 2018; 25:143-144. [PMID: 29485244 DOI: 10.1111/jpm.12457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- C Baker
- University of Nottingham, Nottingham, UK
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58
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Abstract
Personality disorders have received limited recognition as a public health priority, despite the publication of treatment guidelines and reviews showing effective treatments are available. Inclusive approaches to understanding and servicing personality disorder are required that integrate different service providers. This viewpoint paper identifies pertinent issues surrounding early intervention, treatment needs, consumer and carer experiences, and the need for accurate and representative data collection in personality disorder as starting points in mental health care reform.
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Affiliation(s)
- Brin Fs Grenyer
- 1 School of Psychology, Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW, Australia
| | - Fiona Yy Ng
- 1 School of Psychology, Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW, Australia
| | - Michelle L Townsend
- 1 School of Psychology, Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW, Australia
| | - Sathya Rao
- 2 Spectrum, The Personality Disorder Service for Victoria, Eastern Health, East Ringwood, VIC, Australia
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Grimholt TK, Jacobsen D, Haavet OR, Ekeberg Ø. Lower suicide intention in patients with personality disorders admitted for deliberate self-poisoning than in patients with other diagnoses. Ann Gen Psychiatry 2017; 16:21. [PMID: 28435437 PMCID: PMC5397795 DOI: 10.1186/s12991-017-0145-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 04/11/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND People with deliberate self-poisoning and personality disorders are in increased risk for suicide. Intention and psychiatric features are important factors in a psychiatric evaluation and for planning aftercare. METHODS Patients admitted to medical departments after deliberate self-poisoning were studied (n = 117). Patients with personality disorder according to (ICD-10, F.60-69) were compared to patients with affective disorders, substance use disorders, and unknown psychiatric diagnosis on Beck Suicide Intention Scale (SIS), Beck Suicide Ideation Scale (BSI), Beck Hopelessness Scale (BHS), and Beck Depression Inventory (BDI). RESULTS The mean suicide intention score (SIS) was significantly lower among patients with personality disorders compared with patients with other psychiatric diagnoses 10.2 (95% CI 8.1-12.4) vs. 14.6 (95% CI 12.7-16.4) (p = 0.040). The hopelessness scores (BHS) were significantly higher among patients with personality disorders 13.0 (95% CI 10.9-15.2) compared with patients with affective disorders 8.2 (95% CI 6.1-10.3) and substance use disorders 9.9 (95% CI 5.2-14.6) (p = 0.0014) and unknown psychiatric diagnoses 10.6 (95% CI 9.1-12.2). There were no significant differences between the groups on suicide ideation (BSI) and depression (BDI). CONCLUSIONS Although patients with personality disorders had lower suicide intention compared to patients with other psychiatric diagnoses, they reported significantly more hopelessness. This distinction is an important implication in the clinical assessment and planning of further treatment of DSP patients.
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Affiliation(s)
- T K Grimholt
- Department of Acute Medicine, Oslo University Hospital, Nydalen, Pb 4950, Oslo, Norway
| | - D Jacobsen
- Department of Acute Medicine, Oslo University Hospital, Nydalen, Pb 4950, Oslo, Norway
| | - O R Haavet
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Ø Ekeberg
- Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway.,Department of Behavioural Sciences in Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
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Penfold S, Groll D, Mauer-Vakil D, Pikard J, Yang M, Mazhar MN. A retrospective analysis of personality disorder presentations in a Canadian university-affiliated hospital's emergency department. BJPsych Open 2016; 2:394-399. [PMID: 27990295 PMCID: PMC5156851 DOI: 10.1192/bjpo.bp.116.003871] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 11/21/2016] [Accepted: 11/23/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Individuals with personality disorders often have extensive involvement with healthcare services including frequent utilisation of emergency departments. AIMS The aim of this study was to identify factors associated with emergency department presentations by individuals with personality disorders. METHOD A 12-month retrospective data analysis of all mental-health-related emergency department visits was performed. Age, gender, time and season of presentation, length of stay, mode of arrival and discharge arrangements for individuals with personality disorders were compared to individuals with other psychiatric diagnoses. RESULTS There were 336 visits by individuals with personality disorders and 5290 visits by individuals with other psychiatric diagnoses. Individuals with personality disorders were significantly more likely to be female, young adults, brought in by police, arrive in the evening, discharged home and have a longer median length of stay. CONCLUSION Knowing what factors are associated with emergency department presentations by individuals with personality disorders can help ensure that appropriately trained support staff are available. DECLARATION OF INTEREST None. COPYRIGHT AND USAGE © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.
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Affiliation(s)
- Sarah Penfold
- , MD, Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Dianne Groll
- , PhD, Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Dane Mauer-Vakil
- , BKin, Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Jennifer Pikard
- , MD, Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Megan Yang
- , MD, Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Mir Nadeem Mazhar
- , FRCPsych, FRCPC, DABPN, Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
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Abstract
This article reviews the recent literature on the stigma of personality disorders, including an overview of general mental illness stigma and an examination of the personality-specific stigma. Overall, public knowledge of personality disorders is low, and people with personality disorders may be perceived as purposefully misbehaving rather than experiencing an illness. Health provider stigma seems particularly pernicious for those with borderline personality disorder. Most stigma research on personality disorders has been completed outside the USA, and few stigma-change interventions specific to personality disorder have been scientifically tested. Limited evidence suggests that health provider training can improve stigmatizing attitudes and that interventions combining positive messages of recovery potential with biological etiology will be most impactful to reduce stigma. Anti-stigma interventions designed specifically for health providers, family members, criminal justice personnel, and law enforcement seem particularly beneficial, given these sources of stigma.
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Affiliation(s)
- Lindsay Sheehan
- Illinois Institute of Technology, 3424 S. State Street, Chicago, IL, 60616, USA.
| | | | - Patrick Corrigan
- Illinois Institute of Technology, 3424 S. State Street, Chicago, IL, 60616, USA.
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