Exploring stigmatisation among people diagnosed with either bipolar disorder or borderline personality disorder: A critical realist analysis

Talking about borderline personality disorder, shaping care: The multiple doings of narratives

This article focuses on the narratives that circulate about borderline personality disorder (BPD) in health-care settings in Australia and the effects such narratives can have on how people practice and seek out care. People with a BPD diagnosis frequently access health-care services, often encountering stigma and discrimination. Drawing on narrative theory, we critically unpack the circulation and capacities of BPD narratives and the ways they can often contribute to poor and troubling experiences. This article is based on qualitative interviews with people living with a BPD diagnosis, as well as health practitioners who work with people with a BPD diagnosis. Our findings identified insidious and powerful BPD narratives that circulate in health-care settings, particularly in short-term, acute, or non-specialist contexts, such as emergency departments and in-patient units. These narratives influenced the ways that participants both practiced and sought out care. To improve health service quality for people with a BPD diagnosis, or those experiencing mental distress, it is important to challenge the sociocultural-political norms and relations that can influence approaches to care and practice. Disrupting and reframing negative BPD narratives and raising awareness about the impact of stories that are told about BPD have the potential to generate social change.

Stigma power in practice: Exploring the contribution of Bourdieu's theory to stigma, discrimination and health research

Stigma and discrimination are increasingly understood as shaping health, and in turn conceptualised as social processes shaped by power and structural inequities. A challenge to analysis and implementing interventions is developing theory that can integrate analysis of structure, agency and power. One theoretical framework already promoted by prominent scholars as supporting this need is Bourdieu's social practice theory. This paper explores the application to date of Bourdieu's theory on stigma, discrimination and health. The paper describes how existing health literature has used concepts of symbolic violence, fields, capitals and habitus to develop insight into stigma power. The discussion explores how this theoretical framework is though underutilised and there has been little consideration of new programmatic approaches based on this theory. Directions for future research include the need for integrated approaches to analysis, especially using habitus to explore stigma power, and addressing processes of change. Directions for conceptualising interventions address how a mismatch of field and habitus could foster change and then the role for prophets in fostering symbolic revolutions. All these potential directions must in turn be integrated within the vast scholarship on stigma. In conclusion, further application and development of Bourdieu's social practice theory could help address the theoretical challenges facing the field of stigma, discrimination and health research.

Clarifying and extending our understanding of problematic pornography use through descriptions of the lived experience

Problematic pornography use (PPU) is a complex and growing area of research. However, knowledge of the PPU lived experience is limited. To address this gap, we conducted an online qualitative study with 67 individuals who self-identified as having problematic pornography use (76% male; Mage = 24.70 years, SD = 8.54). Results indicated several dimensions that have not been fully explored in the literature. These included various mental and physical complaints following periods of heavy pornography use, sexual functioning deficits with real partners, and a subjectively altered state of sexual arousal while using pornography. Moreover, we expanded on current knowledge regarding the inner conflict associated with PPU and clarified the ways that users can progress to increasingly intensified patterns of pornography use, such as tolerance/escalation and pornographic binges. Our study highlights the complex and nuanced nature of PPU and provides suggestions for future research and clinical practice.

Prejudice toward people with borderline personality disorder: Application of the prejudice toward people with mental illness framework

BACKGROUND

People living with borderline personality disorder (BPD) face high levels of prejudice and discrimination from both the community and medical professionals, but no measure of prejudice toward people living with BPD exists.

AIMS

The current study aimed to adapt an existing Prejudice toward People with Mental Illness (PPMI) scale and investigate the structure and nomological network of prejudice toward people with BPD.

METHODS

The original 28-item PPMI scale was adapted to create the Prejudice toward People with Borderline Personality Disorder (PPBPD) scale. The scale and related measures were completed by three samples: 217 medical or clinical psychology students, 303 psychology undergraduate students, and 314 adults from the general population.

RESULTS

The original four-factor structure of the PPMI was supported in the PPBPD scale. Reported prejudice toward people with BPD was more negative than prejudice toward people with mental illness in general. The association of the PPBPD scale with antecedents and consequences was assessed, including social dominance orientation, right-wing authoritarianism, ethnocentrism, personality traits, empathy, prior contact, and feelings toward other stigmatized groups and mental illnesses.

CONCLUSIONS

This study provided evidence for the validity and psychometric properties of the PPBPD scale across three samples and investigated anticipated relationships with theoretically related antecedents and consequences. This research will help improve understanding of the expressions underlying prejudice toward people with BPD.

Glass half full: A diary and interview qualitative investigation of flourishing among adolescents living with chronic pain

BACKGROUND

Counter to paediatric pain literature that typically highlights the deleterious impacts associated with adolescent chronic pain, evidence suggests that some adolescents flourish in their experience of pain. This study sought to explore how adolescents experience, understand and perceive flourishing while living with chronic pain.

METHODS

Twenty-four adolescents aged 11-24 years were recruited via clinical and online settings. All adolescents were asked to complete daily diary entries, with a subset of 10 participants asked to complete follow-up interviews.

RESULTS

Inductive reflexive thematic analysis generated two themes: 'Appreciating the moment' and 'Becoming a better version of myself'. Themes addressed how self and other comparisons facilitated a renewed appreciation for achievements and pleasures in life due to living with chronic pain. Adolescents further demonstrated a perception of continued personal and social growth in their experience of chronic pain, including increased emotional maturity, resilience, positivity, kindness and improved communication skills.

CONCLUSIONS

We conclude that adolescents can experience positive changes in functioning and flourish in some domains of life despite, or resulting from, chronic pain. Further research with an exclusive focus on flourishing is needed to build on this work and address this important gap in knowledge.

SIGNIFICANCE

We present evidence that adolescents can flourish when living with chronic pain. Such knowledge may inform the development of positive psychological treatment strategies that are focused on reinforcing adolescents' existing strengths, to expand on current treatment options for adolescents living with chronic pain.

Experiences of Stigma and Discrimination in Borderline Personality Disorder: A Systematic Review and Qualitative Meta-Synthesis

Individuals with a diagnosis of borderline personality disorder (BPD) typically experience discrimination and stigma, resulting in poor identification and delayed care. We conducted a review to examine and synthesize qualitative studies exploring experiences of stigma and discrimination among individuals with BPD. In August 2021, we systematically searched the following databases: Embase, Medline, Cochrane Library, PsycINFO, and Cinhal. We also hand searched reference lists and Google Scholar. We then synthesized studies using meta-ethnography. We included seven articles in the study, all of high or moderate quality. Five themes were identified: (1) resistance from clinicians (withholding information), (2) othering, (3) negative impact on self-image/esteem, (4) hopelessness surrounding the perceived permanency of BPD, and (5) feeling like a burden. This review highlights the need for improved understanding of BPD across health care services. We also discussed the need to introduce a standardized pathway of care across health services following a BPD diagnosis.

Experiences of familial stigma among individuals living with mental illnesses: A meta-synthesis of qualitative literature from high-income countries

WHAT IS KNOWN ON THE SUBJECT?: Mental illness stigma has been long acknowledged as a social problem that continues to persist and contribute to social exclusion of affected persons globally. Researchers have explored mental illness stigma in the general public and among health professionals, with little focus on stigma from family members and close relatives of persons with mental illnesses. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study appears to be the first meta-synthesis of familial mental illness stigma in high-income countries. Family members or close relatives of persons with mental illnesses may be perpetrators of stigma. That is, the family may enact stigma of mental illness against their relative to "save face" or by avoiding or narrowing their social contacts. Familial stigma is harmful due to the likely disaffection it brings within one's home environment. Familial mental stigma from the existing literature seems to be a by-product of public stigma and stigma by association WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Further research is necessary to look at the existence of familial mental illness stigma as well as available policies to reduce its impact on affected individuals in high-income countries. Researchers in high-income countries should endeavour to examine the relationship between familial, public and associative stigma to establish baseline metrics to inform future anti-stigma programs seeking to reduce familial mental illness stigma.

ABSTRACT

INTRODUCTION: Familial mental illness stigma is a pervasive issue but very subtle in high-income countries. Familial mental illness stigma implies persons living with mental illnesses are discriminated against by their family members or close relatives.

AIM/QUESTION

This meta-synthesis explored the experiences of familial stigma among individuals living with mental illnesses in high-income countries, focusing on empirical literature, to understand the breadth of current literature and ways to reduce this form of stigma.

METHOD

We conducted a meta-synthesis through a structured search of qualitative data from six electronic databases (Sociological Abstract, CINAHL, Medline, PsycINFO, Google Scholar and Embase). Inclusion criteria comprised: empirical primary research, primary technique for data collection is qualitative, studies published in a peer-reviewed journal in the English language between 2000 and 2020, studies reported on experiences of familial mental illness stigma, and studies conducted in high-income countries. The exclusion criteria were as follows: all grey literature, studies not written in English and non-peer-reviewed, studies not focused on familial mental illness stigma, quantitative peer-reviewed articles on the related concept and peer-reviewed articles on the related topic before the year 2000.

RESULTS

The study identified only 28 peer-reviewed articles on the topic within two decades. Concealment of familial stigma was found to be detrimental due to the potential for alienation within one's home environment. Disclosure and social contact within the family system were considered as critical interventions to provide some safety nets for individuals with mental illnesses.

DISCUSSION AND IMPLICATIONS FOR PRACTICE

The paucity of studies over the review period highlights the need for further attention to support optimal environments for persons living with mental illnesses. Families' understanding of the difficulties of mental illness stigma is vital to supporting the development of policies and interventions towards the avoidance of social exclusion within societies. Families should make concerted efforts to reduce stigma, and this includes within the family system. Education and training approaches around mental illness-related stigma should involve individuals with lived experience and their families, as well as service providers and the general public.

Personality Pathology in Winter Depression: Prevalence and Treatment Trajectories in Cognitive-Behavioral Therapy and Light Therapy

Personality disorders are highly comorbid with major depression; however, findings are mixed regarding their impact on depression treatment outcomes and trajectories. Limited research has studied personality pathology in winter depression, specifically. This study (1) explored the prevalence of personality pathology in winter depression and (2) examined its effects on winter depression treatment trajectories. Participants were 174 adults with Major Depression, Recurrent with Seasonal Pattern from a randomized clinical trial comparing group cognitive-behavioral therapy for seasonal affective disorder (CBT-SAD) and light therapy. Participants completed the Millon Clinical Multiaxial Inventory-III (MCMI-III; Millon et al., 1994) at baseline. The prevalence of MCMI-III-defined pathological personality traits and personality disorders in this sample was 98/174 (56.3%) with any trait and 65/174 (37.4%) with any disorder. Dependent was the most common elevation (65/174, 37.4%), trait (43/174, 24.7%), and disorder (22/174, 12.6%). Most participants with pathological personality elevations had only one personality disorder (58/174, 33.3%) and one pathological personality trait (82/174, 47.1%). Growth curve analysis revealed personality pathology predicted higher baseline depression scores, but the number of MCMI-III pathological personality elevations (i.e., traits and disorders) and personality disorders did not predict change in depression over the timeframe of pretreatment, weekly during treatment, posttreatment, and follow-ups one and two winters later in CBT-SAD or light therapy. Results suggest that personality pathology is not a negative prognostic indicator or prescriptive factor for winter depression treatment with CBT-SAD or light therapy, which may inform treatment algorithms and decision-making in practice.

Stigma in people living with bipolar disorder and their families: a systematic review

BACKGROUND

Stigma affects different life aspects in people living with bipolar disorder and their families. This study aimed to examining the experience of stigma and evaluating predictors, consequences and strategies to combat stigma in people with bipolar disorder and their families.

METHODS

We conducted a systematic review according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) in 2022. We extensively reviewed six online databases (PubMed, Scopus, Medline, EMBASE, Web of Science and Google Scholar). Articles published in the English language about stigma in people living with bipolar disorders and their families were included.

RESULTS

A total of 42,763 articles were retrieved, of which 40 articles from 14 countries were included in this study (n = 7417 participants). Of the 40 articles, 29 adopted quantitative methods (72.5%), two used mixed-methods (5%), eight used qualitative (20%) methods, and one was a case series (2.5%). The results of the studies were categorized into four themes: 1. Stigma experienced by people living with bipolar disorders and their families, 2. Predictors of stigma in people living with bipolar disorders and their families, 3. Consequences of stigma in people living with bipolar disorders and their families, 4. Effective interventions and strategies to reduce stigma in people living with bipolar disorders and their families.

CONCLUSION

The results of this study might be useful to design psychiatric cognitive interventions to reduce stigma in people living with bipolar disorders and their families and designing community-based interventions to normalize bipolar disorder at the community level.

Personality Disorder Diagnoses in ICD-11: Transforming Conceptualisations and Practice

Background

Until the advent of the ICD-11, classification of personality disorders was based on categorical prototypes with a long history. These prototypes, whilst familiar, were not based in the science of personality. Prototypical classifications were also complex to administer in non-specialist settings requiring knowledge of many signs and symptoms.

Method

This article introduces the new structure of ICD-11 for personality disorders, describing the different severity levels and trait domain specifiers. Case studies illustrate the main aspects of the classification.

Results

The new ICD-11 system acknowledges the fundamentally dimensional nature of personality and its disturbances whilst requiring clinicians to make categorical decisions on the presence or absence of personality disorder and severity (mild, moderate or severe). The connection between normal personality functioning and personality disorder is established by identifying five trait domain specifiers to describe the pattern of a person's personality disturbance (negative affectivity, detachment, dissociality, disinhibition, and anankastia) that connect to the Big 5 personality traits established in the broader study of personality.

Conclusions

Whilst new assessment measures have been and are in development, the success of the new system will rely on clinicians and researchers embracing the new system to conceptualise and describe personality disturbances and to utilise the classification in the investigation of treatment outcome.

Lived Experiences of Mental Health Recovery in Persons of Culturally and Linguistically Diverse (CALD) Backgrounds within the Australian Context

Lived experience research related to mental health recovery is advancing, but there remains a lack of narrative material from the perspectives of people from under-represented, non-dominant cultural backgrounds in this domain. This study aimed to explore the lived experiences of mental health recovery in people of culturally and linguistically diverse (CALD) backgrounds in the Australian context. The current study involved a secondary analysis of audio and visual data collected during the digital storytelling project Finding our way in Melbourne, Australia. Thematic analysis was used to understand the lived experience narratives of nine participants in relation to mental health recovery. Five themes were identified through an iterative process of analysis, including Newfound opportunities and care, Family as key motivators and facilitators, Coping and generativity, Cultivating self-understanding and resilience, and Empowerment through social engagement. First person lived experience narratives offer deep insight into understanding the ways in which individuals of marginalised communities conceptualise and embody recovery. These findings further the literature and understanding on how to better serve the needs of people with mental health challenges from CALD communities through informed knowledge of what may be helpful to, and meaningful in, individuals' recoveries.

Structural stigma and its impact on healthcare for borderline personality disorder: a scoping review

BACKGROUND

People with Borderline Personality Disorder (BPD) and their carers/families continue to experience structural stigma when accessing health services. Structural stigma involves societal-level conditions, cultural norms, and organizational policies that inhibit the opportunities, resources, and wellbeing of people living with attributes that are the object of stigma. BPD is a serious mental illness characterized by pervasive psychosocial dysfunction including, problems regulating emotions and suicidality. This scoping review aimed to identify, map, and explore the international literature on structural stigma associated with BPD and its impact on healthcare for consumers with BPD, their carers/families, and health practitioners.

METHODS

A comprehensive search of the literature encompassed MEDLINE, CINAHL, PsycINFO, Scopus, Cochrane Library, and JBI Evidence-Based databases (from inception to February 28th 2022). The search strategy also included grey literature searches and handsearching the references of included studies. Eligibility criteria included citations relevant to structural stigma associated with BPD and health and crisis care services. Quality appraisal of included citations were completed using the Mixed Methods Appraisal Tool 2018 version (MMAT v.18), the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Research Syntheses Tool, and the AGREE II: advancing guideline development, reporting, and evaluation in health care tool. Thematic Analysis was used to inform data extraction, analysis, interpretation, and synthesis of the data.

RESULTS

A total of 57 citations were included in the review comprising empirical peer-reviewed articles (n = 55), and reports (n = 2). Studies included quantitative, qualitative, mixed methods, and systematic review designs. Review findings identified several extant macro- and micro-level structural mechanisms, challenges, and barriers contributing to BPD-related stigma in health systems. These structural factors have a substantial impact on health service access and care for BPD. Key themes that emerged from the data comprised: structural stigma and the BPD diagnosis and BPD-related stigma surrounding health and crisis care services.

CONCLUSION

Narrative synthesis of the findings provide evidence about the impact of structural stigma on healthcare for BPD. It is anticipated that results of this review will inform future research, policy, and practice to address BPD-related stigma in health systems, as well as approaches for improving the delivery of responsive health services and care for consumers with BPD and their carers/families.

REVIEW REGISTRATION

Open Science Framework ( https://osf.io/bhpg4 ).

Stigma in bipolar disorder: A current review of the literature

Stigma has been found to have an impact on those living with bipolar disorder, with many experiencing negative consequences of stereotypes, prejudice and discrimination as a result of their condition. The aim of this review was to assess the current literature in bipolar disorder to determine the impact of stigma on people living with this condition and caregivers. Public stigma was associated with greater functional impairment, anxiety and poorer work-related outcomes, while self-stigma was also found to be associated with lower levels of functioning across a range of domains and greater depressive and anxiety symptoms. For those with bipolar disorder, public stigma was reported at similar rates to those with schizophrenia and depression in some studies, with other studies noting mixed results. Qualitative studies noted that public stigma and discrimination were experienced from family, friends and healthcare providers. Self-stigma was found to be higher for those who were younger in several studies and associated with worse medication adherence. It was generally found to be higher in bipolar disorder participants than in those with anxiety disorders and lower than those with personality disorders. Limitations of the current research include the following: few studies have used a longitudinal design, few have assessed the impact of stigma on medication adherence and few have explored these issues in younger populations. More research is needed to explore the experiences of self-stigma for those in the younger age group specifically, given the relationship between younger age and greater self-stigma noted in several studies and the relationship between this and lower treatment adherence.

Is it time to change the approach of mental health stigma campaigns? An experimental investigation of the effect of campaign wording on stigma and help-seeking intentions

Introduction

Mental health stigma causes a range of diverse and serious negative sequelae. Anti-stigma campaigns have largely aligned with medical theories and categorical approaches. Such campaigns have produced some improvements, but mental health stigma is still prevalent. The effect of alternative theoretical perspectives on mental health within anti-stigma campaigns has not been tested. Moreover, we do not know their effect on help-seeking intentions.

Methods

We conducted an online experimental pre-post study comparing the effects of two anti-stigma campaign posters on mental health stigma and help-seeking intentions. One poster adhered to the medical, categorical approach to mental health, whereas the other poster portrayed mental health problems in line with a non-categorical, continuous perspective.

Results

After controlling for familiarity with the campaign poster, country of residence and pre-test scores, we found no significant between-group differences in terms of help-seeking intentions and all stigma attitudes except for danger-related beliefs. That is, those who viewed the non-categorical poster reported an increased perception that people with mental health problems are dangerous.

Discussion

Our largely null findings may suggest the equivalence of these posters on stigma and help-seeking intentions but may also reflect the brevity of the intervention. Our findings concerning danger beliefs may reflect a Type I error, the complexities of stigma models, or the adverse effects of increased perceived contact. Further research is needed to test the effects of differing mental health paradigms on stigma and help-seeking intentions over a longer duration.

Experiences of Compassion in Adults With a Diagnosis of Borderline Personality Disorder: An Interpretative Phenomenological Analysis

The study explored experiences of compassion in adults with a diagnosis of Borderline Personality Disorder (BPD) to further the development of the construct of compassion in relation to BPD. Interpretative Phenomenological Analysis was used to develop themes from the narratives of six adults with a diagnosis of BPD. Five themes emerged: Emotional Connection to Suffering, Empathic Understanding, Prioritisation of Needs, A Model of Genuine Compassion and Developing Acceptance and Worth. Participants described the role of compassion in their difficulties, including the adverse impact of experiences of incompassion upon their sense of self. The themes were integrated into a model that highlighted a process of recovery through therapeutic encounters with others in which genuine compassion was modelled. In addition, barriers to compassion and factors facilitating the development of compassion emerged from the analysis and have implications for clinical practice.

Mental Health Workers' Attitudes Towards Individuals With a Diagnosis of Borderline Personality Disorder: A Systematic Literature Review

The attitudes of mental health workers toward individuals with mental health conditions can impact the quality of care they provide. Negative attitudes among mental health workers seem particularly common in response to people diagnosed with borderline personality disorder (BPD). The current review aimed to identify and review the literature regarding mental health workers' attitudes toward individuals diagnosed with BPD, specifically focusing on studies comparing workers' attitudes toward BPD with attitudes toward other mental health diagnoses. The findings suggest that mental health workers have more negative attitudes toward individuals labeled as having BPD than toward individuals with other diagnoses, such as depression. This is likely due to factors associated with the label itself, in addition to workers' perceptions of BPD symptoms and previous experiences of delivering treatment. The implications of these findings are considered, with a particular focus on how mental health services can effectively address negative attitudes toward BPD.

Sexuality in people living with a serious mental illness: A meta-synthesis of qualitative evidence

WHAT IS KNOWN ON THE SUBJECT

A serious mental illness influences sexual life and people affected have worries about their sexual health. People living with a serious mental illness can and want to participate in interventions related to sexual health.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

People who suffer a serious mental illness are interested in maintaining an active sex life. People who suffer a serious mental illness experience rejection when they open up and they lose intimate relationships or possibilities of meeting other people because of ignorance and prejudices surrounding mental health.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Mental health services must respond to this need, that is including sexual needs assessment among routine standard practices or training nurses on sexual education to allow them to advise patients and their families and friends. Health systems should promote awareness programmes and reduce the stigma surrounding mental health and sexuality.

ABSTRACT

INTRODUCTION: Sexuality-related nursing care is scarce and mainly focuses on biological issues. There is also a lack of knowledge about how serious mental illnesses affect sexuality.

AIM

To explain how people with a serious mental illness perceive and experience their sexuality.

METHOD

A meta-synthesis was conducted to integrate qualitative studies. Four databases were used to perform the search, focused in the last ten years. Nine articles were included, and their results analysed thematically.

RESULTS

Four categories were identified: "Pathologized sexuality," which explains how the disorder and treatment affect sexuality; "Not my sexuality anymore," which describes feelings emerging from the perceived limitations and the role of self-acceptance; "Learning to manage intimate relationships," which explains the desire to establish intimate personal relationships and define their meaning; and "Reconstructing my sexuality," which elucidates the influence of the environment on sexuality.

DISCUSSION

Sexuality is influenced by several factors, the main ones being: the clinical complications, the side effects of drug treatment, the social support, the relationship with the health sector and stigma.

IMPLICATIONS FOR PRACTICE

Having a serious mental illness affects sexuality and can provoke suffering and social isolation. Mental health services should address this issue and carry out community interventions to reduce stigma.

Evaluation of an anti-stigma intervention for Mexican psychiatric trainees

BACKGROUND

There is research evidence regarding the presence of stigmatising attitudes in psychiatrists towards people with mental illness, but a lack of studies and interventions focused on this issue in low and middle-income countries.

AIMS

To assess the feasibility of implementing an anti-stigma intervention for Mexican psychiatric trainees, and its potential effects.

METHODS

This study comprised a pre-post design with outcome measures compared between baseline and 3-month follow-up. Quantitative outcome measures were used to evaluate the potential effects of the intervention, whilst the process evaluation required the collection and analysis of both quantitative and qualitative data.

RESULTS

Twenty-nine trainees (25% of those invited) participated in the intervention, of whom 18 also participated in the follow-up assessment. Outcome measures showed the intervention had moderately large effects on reducing stereotypes and the influence of other co-workers on trainees' own attitudes. The main mechanisms of impact identified were recognition of negative attitudes in oneself and colleagues, self-reflection about the impact of stigma, one's own negative attitudes and recognition of one's ability to make change. Participants accepted and were satisfied with the intervention, which many considered should be part of their routine training. However, trainees' work overload and lack of support from the host organisation were identified as barriers to implement the intervention.

CONCLUSIONS

A brief anti-stigma intervention for Mexican psychiatric trainees is feasible, potentially effective, well accepted and was considered necessary by participants. This study also suggests mechanisms of impact and mediators should be considered for developing further interventions, contributing to reducing the damaging effects that mental health-related stigma has on people's lives.

Utilization of Health Care Services by Patients With Cluster B Personality Disorders or Schizophrenia

OBJECTIVE

The comparable severities of cluster B personality disorders and schizophrenia are increasingly recognized. The authors sought to compare the general medical and psychiatric comorbid conditions and use of medical services among individuals with one or both of these disorders.

METHODS

Data were collected from the linked health administrative databases of Quebec's universal health plan in the Quebec Integrated Chronic Disease Surveillance System, which covers 99% of Quebec's population. The study cohort of 2016-2017 included almost 7.05 million people, and the study covered the 1996-2017 period.

RESULTS

Comorbid conditions were extremely prevalent in the three groups studied-persons with cluster B personality disorders, schizophrenia, or both-compared with the general population. People having both disorders had the highest prevalence of comorbid conditions. Psychiatric services were used more frequently by individuals in all three groups than among those in the general population, and use was especially high among people with both disorders. Medical care service use was heterogeneous, with patients with cluster B personality disorders using more medical care services but fewer specialized outpatient treatments and psychotherapy than those with schizophrenia or with both disorders.

CONCLUSIONS

The three cohorts had higher rates of comorbid conditions and health care service use than individuals in the general population. Patients with cluster B personality disorders used fewer psychiatric services than patients with schizophrenia or with both disorders. One explanation for this difference may be that people with cluster B personality disorders encounter more obstacles in accessing mental health care services.

Is Mental Illness like Any Other Medical Illness? Causal Attributions, Supportive Communication and the Social Withdrawal Inclination of People with Chronic Mental Illnesses in China

The saying "mental illness is like any other illness" has increasingly become pervasive in promoting mental health literacy among the public in China. This discourse is based on the fact that mental illness is attributed to primarily biogenetic causes. This study comprises an investigation of the impact of causal attributions of mental illness on the social withdrawal inclination of people with chronic mental illnesses (PCMIs) in China. Drawing on attribution theory and a sample of PCMIs, the current authors further question the effectiveness of biogenetic discourse to combat social stigma and to integrate PCMIs into society. In addition, in response to the proliferation of discussion on the digital inclusion of those with mental disabilities, this study constructs a structural model in which the varied effects of supportive communication are used as bridging factors, including face-to-face, telephonic and social media communication. The results indicate a stronger social withdrawal inclination when the PCMIs attributed their illnesses to biogenetic causes. In addition, biogenetic attribution was also found to potentially hinder the PCMIs from using the telephone and social media to seek supportive communication, while psychosocial attribution was found to have potential to combat PCMIs' social withdrawal inclination. In this vein, this study calls for further investigation on the conditional factors upon which digital inclusion might work for PCMIs in China.

Mental Health Support in the Perinatal Period for Women With a Personality Disorder Diagnosis: A Qualitative Study of Women's Experiences

Women who receive a diagnosis of personality disorder may face particular challenges in the context of having a baby. However, this area has received little attention. This study aimed to qualitatively explore experiences of mental health support during the perinatal period in a group of mothers who self-reported having a personality disorder diagnosis. Semistructured interviews were conducted with 12 women who received mental health support during the perinatal period. These data were analyzed thematically. Key themes related to women feeling judged to be unfit mothers; not feeling heard or understood by services; feeling that services struggled with the complexity of their needs; valuing specialist support to cope with their struggles in motherhood; and valuing professional relationships that resembled real-life friendships. Our findings raise questions about how best to provide support to this group of women and about the use and consequences of the diagnosis of personality disorder among new mothers.

Mental Health Service Users' Perceptions of Stigma, From the General Population and From Mental Health Professionals in Mexico: A Qualitative Study

Negative attitudes towards people with mental health disorders have been widely studied and identified in the general population, and even within health care professionals. Moreover, studies focused on service users have also identified mental health professionals, including psychiatrists, as a source of stigma. However, in Mexico and Latin America few studies have been conducted addressing this issue. To explore mental health service users' perceptions of stigma by members of the general population and by psychiatrists in Mexico, service users at a psychiatric hospital in Mexico were invited to participate in either focus groups or individual interviews, which were audio recorded, transcribed and analysed using thematic analysis. A total of 47 service users participated in this study. The results suggested that participants were not only aware of the possible consequences of mental health related stigma, but they have also experienced stigmatisation for having a mental illness. Participants also considered psychiatrists can hold negative attitudes towards people with mental illness, something that can represent a barrier for them to have optimal quality of care. Therefore, participants agreed that these attitudes should be addressed to improve the care they received from these professionals. This study suggests that, like members of the general population, psychiatrists are also considered as a source of stigma by people with mental illness in Mexico. These findings not only add to previous work conducted in Mexico and other countries, they also confirm the importance of addressing negative attitudes in this group of health professionals.

Structural stigma and its impact on healthcare for consumers with borderline personality disorder: protocol for a scoping review

BACKGROUND

Structural stigma in health systems experienced by consumers diagnosed with Borderline Personality Disorder (BPD) is a widespread phenomenon that causes major health inequities and harm for this population. Structural stigma in this context relates to institutional policies, cultural norms, and organizational practices that limit consumers' access to health services, quality of care, and capacity to achieve optimal health and well-being. BPD is a serious mental illness with high morbidity and mortality, characterized by instability in interpersonal relationships, self-image, and emotional and behavioral deregulation, which stem from significant traumatic childhood/life events, and/or biological etiologies. The objectives of this scoping review are to explore the international literature on structural stigma in healthcare systems specific to BPD, and to provide an overview of the impact of structural stigma on health services for BPD consumers and their carers/families.

METHODS

This scoping review will follow the Joanna Briggs Institute (JBI) scoping review guidelines. We will search the following electronic databases (from inception onwards): MEDLINE, CINAHL, PsycINFO, Scopus, Cochrane Library, and JBI-Evidence databases. Grey literature will be identified through the Google search engine. We will include all types of literature in English, published and unpublished, including any study design, reviews, clinical practice guidelines, policy reports, and other documents. No restrictions on publication date of sources of evidence will be applied. International literature should examine structural stigma associated with BPD in any healthcare setting such as, outpatients, inpatients, primary health care, or community-based facilities. Two reviewers will independently screen all titles, abstracts, and full-text citations. Quality appraisal of the included sources of evidence will be assessed using the Mixed Methods Appraisal Tool (MMAT) 2018 version. Data analysis will involve quantitative (e.g., frequencies) and qualitative (e.g., thematic analysis) methods.

DISCUSSION

This review is anticipated to enhance both identification and understanding of those structures in health systems (i.e., institutional policies, cultural norms, and practices) that manifest and perpetuate stigma experienced by consumers with BPD and their carers/families. The findings can be used to inform future research, policy, and practice relating to stigma reduction strategies that can be adopted to improve the provision of BPD-responsive services and care for this population.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework ( https://osf.io/bhpg4 ).

Service users' experiences of receiving a diagnosis of borderline personality disorder: A systematic review

There is ongoing controversy regarding the borderline personality disorder (BPD) diagnosis. Whilst the experiences of people living with BPD have been widely acknowledged, the process of receiving the diagnosis is poorly described. This systematic review aimed to synthesize the existing research exploring people's experiences of receiving a diagnosis of BPD, as well as examining what is considered best practice in the diagnostic delivery process. The findings from 12 qualitative studies were synthesized using thematic analysis, generating two overarching themes: negative and positive experiences of receiving a diagnosis of BPD. These themes were described using the following sub-themes: the communication of diagnosis and meaning made of it, validity around diagnosis and attitudes of others. Results indicate that there is a substantial difference between a well-delivered and poorly delivered diagnosis. The diagnostic delivery process is fundamental to how people understand and interpret the BPD diagnosis. The way in which the BPD diagnosis is shared with people can ultimately shape their views about hope for recovery and their subsequent engagement with services. © 2020 John Wiley & Sons, Ltd.

Expanding boundaries in psychiatry: uncertainty in the context of diagnosis-seeking and negotiation

Psychiatric diagnosis has become pervasive in modern culture, exerting an increasing influence on notions of personhood, identity practices and forms of self-governing. The broadening of diagnostic categories and increasing awareness regarding popular diagnostic categories has led to an increased demand for formal diagnosis within clinical encounters. However, there is continuing 'epistemological uncertainty' (Fox 2000) surrounding these entities, in part due to their lack of associated clinical biomarkers and their 'fuzzy boundaries'. Meanwhile, this diagnostic expansion has encountered resistance from those concerned with the alleged 'over-pathologisation' of emotional distress. Drawing upon the concepts of 'diagnostic cultures' (Brinkmann 2016) and the 'looping effects of human kinds' (Hacking 1995), this article considers some of the competing forces acting upon the contested boundaries of diagnostic categories as they play out within diagnostic interactions. The study involved ethnographic observations of diagnostic encounters within several UK-based mental health clinics. By focusing on interactions where diagnosis is negotiated, findings illustrate the role played by different kinds of diagnostic uncertainty in shaping these negotiations. It is argued that diagnostic reification plays a key role in the moral categorisation of patients, particularly where there is uncertainty regarding individual diagnostic status.

Lived experiences of adults with borderline personality disorder: a qualitative systematic review protocol

OBJECTIVE

The objectives of this review are: to explore the lived experiences of individuals with a diagnosis of borderline personality disorder (BPD) and to present recommendations for policy, practice, education and research.

INTRODUCTION

Borderline personality disorder is a mental disorder characterized by poor capacity to engage in effective relationships, intense and sudden mood changes, poor self-image and emotion regulation, significant impulsivity and severe functional impairment. Studies estimate the prevalence of BPD at 15% to 22% and identify a predominantly negative attitude among health professionals towards individuals with BPD. This review will examine the lived experiences of people with a diagnosis of BPD in order to better understand this condition.

INCLUSION CRITERIA

This review will include peer-reviewed qualitative studies on adults with a diagnosis of BPD in all settings and from any geographical location.

METHODS

A three-step search strategy will be used. A search strategy has been developed for MEDLINE. A second search using all identified keywords and index terms will be conducted across MEDLINE, CINAHL, PsycINFO and Embase. Studies will be screened by title and abstract by two independent reviewers against the review inclusion criteria. The full text of selected citations will be assessed against the inclusion criteria and for methodological quality. Qualitative data will be extracted from included papers using a standardized data extraction tool. Qualitative research findings will be pooled using the meta-aggregation approach. The final synthesized findings will be graded according to the ConQual approach and presented in a Summary of Findings.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019141098.

Internalized stigmatization in borderline personality disorder and attention deficit hyperactivity disorder in comparison to bipolar disorder

INTRODUCTION

Internalized stigma constitutes a major concern in mental health illness. It has numerous repercussions on patients, including poor self-esteem, higher illness severity, poor adherence to care and reduced global functioning. The goal of this study was to compare internalized stigma between three diagnoses frequently seen in psychiatric practice: Borderline personality disorder (BPD), Attention deficit-hyperactivity disorder (ADHD) and Bipolar disorder (BD).

METHODS

A total of 244 French-speaking patients were recruited in a specialized psychiatric center at University Hospitals of Geneva, Switzerland. 39 patients had a diagnosis of BPD, 136 had ADHD and 69 had BD. Every subjects completed the Internalized Stigma of Mental Illness (ISMI) scale, which is the most widely used scale employed to measure of internalized stigma. One way ANOVA analysis with adjustment on age and gender was done to compare the three groups (BPD, ADHD, BD).

RESULTS

Participants with BPD reported higher ISMI score than subjects with ADHD and BD. BD experienced more internalized-stigma than ADHD. Higher ISMI score was also associated with higher severity of the respective disorder, poorer quality of life and unemployment.

LIMITATIONS

Limitations of this research include the small sample, especially in BPD group. A disequilibrium between male and female subjects can also impact our results. Observational nature of our study mean that we can only make correlation between variables and not infer causality. Finally, other confounding factors not taken into account in this study may have had influence on stigma.

CONCLUSIONS

Our findings are coherent with recent literature on BPD reporting high level of distress and of stigmatization. This has serious consequences on provided care and need to be address by mental health professionals to assure the optimal service to this population.

Features of YouTube™ videos produced by individuals who self-identify with borderline personality disorder

Objectives

Many individuals use YouTube™ to seek out information and share first-hand experiences about mental illnesses, as well as to gain a sense of community. YouTube™ use may be especially appealing when offline supports are lacking or difficult to access, and when there is a fear of stigmatisation. Borderline personality disorder (BPD), also referred to as emotionally unstable personality disorder (EUPD), is a complex and often stigmatised mental-health disorder. The primary objective of this study was to describe the dominant messages that individuals who self-identify with the diagnosis of BPD present through YouTube™ videos.

Methods

The content analysis method was used to review 349 first-person YouTube™ uploads. Videos were coded for information regarding video and vlogger characteristics, video type, vlogger motivation and video content. Associations between video features including upload date and style and vlogger experience and motivation were examined.

Results

Findings indicate that more people who self-identify as being diagnosed with BPD are creating YouTube™ videos about their experiences, and these videos have shifted over time from being mostly anonymous multimedia productions to being monologues where the vlogger speaks directly to their audience. Discussions related to DSM-5 symptoms, treatment, effective coping and hope for the future are elements found in the uploads.

Conclusion

The nature and content of BPD first-person YouTube™ uploads has increased and changed over time. Increased awareness of these changes may assist mental-health practitioners to support clients and direct them to explore uploads that offer hope and promote engagement in help-seeking and effective coping behaviours.

Living with personality disorder and seeking mental health treatment: patients and family members reflect on their experiences

BACKGROUND

Despite effective treatments for personality disorders being developed, consumers and carers often report negative experiences of mental health services, including challenges accessing these treatments.

METHODS

This qualitative study used separate focus groups to compare the unique perspectives of consumer and carers, and to investigate how to improve services for individuals with personality disorders. Reflexive thematic analysis was used to analyze the data.

RESULTS

Both consumers and carers (N = 15) discussed the value of providing appropriate information to consumers when they are diagnosed with personality disorder. Consumers and carers described the importance of creating a safe environment for consumers when they present to the emergency department. Both groups discussed experiencing positive and negative treatment from mental health professionals, and suggested that professionals should be trained to understand personality disorder. Limited accessibility and quality of services, and offering peer support to consumers were also described by consumers and carers. Consumers and carers also had perspectives which were unique to their group. Consumers identified the importance of psychological treatment, having a strong therapeutic relationship with a mental health professional, and the benefit of long term psychotherapy with the same professional. Broadening the scope of psychotherapies including creative, animal-assisted, and physical therapies was recommended by consumers. Carers described the importance of assessing for personality disorder and intervening early. Involvement in the assessment, diagnosis, and intervention process was important to carers. The desire to be recognized and supported by mental health professionals was discussed by carers.

CONCLUSIONS

This research contributes to the concern that consumers with personality disorder and their carers experience stigma and low quality care within mental health services. In line with these findings, we recommend guidelines for health professionals who work with consumers with personality disorder.

Does weight-related stigmatisation and discrimination depend on educational attainment and level of income? A systematic review

OBJECTIVES

Obesity is considered a global health issue, because of its health-related consequences and also because of its impact on social status as a result of stigma. This study aims to review the quantitative state of research regarding socioeconomic characteristics' influence on weight-related stigmatisation and discrimination. Based on Bourdieu's Theory of Class and his concept of 'habitus', it is assumed that people with a higher level of education and income show stronger negative attitudes towards people with obesity.

METHOD

A narrative systematic literature review was conducted in 2017 using PubMed, PsychINFO, Web of Science and the Cochrane Library. Seventeen studies that measured weight bias and either educational attainment or level of income were included in the analysis.

RESULTS

The results of the studies included were inconsistent: six of these studies were found to support the hypothesis, whereas two of the studies contradicted it. The remaining seven studies did not show any significant correlation between weight bias and either education or income.

CONCLUSION

In light of the inconsistent and heterogeneous results of the studies that report a significant association between weight bias and socioeconomic variables, the findings must be discussed concerning their cultural context, that is, cultural and governmental differences. Furthermore, educational attainment seems to be more likely to predict weight bias than income. The review revealed a lack of research when it came to examining the impact of socioeconomic capital on weight bias.

Mental illness and bipolar disorder on Twitter: implications for stigma and social support

Background: Mental illness (MI), and particularly, bipolar disorder (BD), are highly stigmatized. However, it is unknown if this stigma is also represented on social media.Aims: Characterize Twitter-based stigma and social support messaging ("tweets") about mental health/illness (MH)/MI and BD and determine which tweets garnered retweets.Methods: We collected tweets about MH/MI and BD during a three-month period and analyzed tweets from dates with the most tweets ("spikes"), an indicator of topic interest. A sample was manually content analyzed, and the remainder were classified using machine learning (logistic regression) by topic, stigma, and social support messaging. We compared stigma and support toward MH/MI versus BD and used logistic regression to quantify tweet features associated with retweets, to assess tweet reach.Results: Of the 1,270,902 tweets analyzed, 94.7% discussed MH/MI and 5.3% discussed BD. Spikes coincided with a celebrity's death and a MH awareness campaign. Although the sample contained more support than stigma messaging, BD tweets contained more stigma and less support than MH/MI tweets. However, stigma messaging was infrequently retweeted, and users often retweeted personal MH experiences.Conclusions: These findings demonstrate opportunities for social media advocacy to reduce stigma and increase displays of social support towards people living with BD.

Identifying the Complexity of Diagnosing Bipolar Disorder: A Focused Ethnography

Purpose: To identify and describe the complexity of diagnosing bipolar disorder, including the diagnostic process and patient experiences of being newly diagnosed with bipolar disorder. Design: A mixed-methods focused ethnography was conducted, grounded in a post-positivist foundation. Methods: Medical records (n = 100) of patients whose diagnosis had been switched to bipolar disorder were examined. Six weeks post-hospitalization, ten outpatients with the diagnosis of bipolar disorder underwent an in-depth interview. Findings: Four diagnostic processes were identified during the retrospective record review. Two patterns and five themes were identified from the interviews. The first pattern, living with undiagnosed bipolar disorder, demonstrated common experiences of distinguishing impulsive moods and behavior, suffering life challenges, and seeking relief. The second pattern, acclimating to a new diagnosis of bipolar disorder, demonstrated participants' ways of understanding the diagnosis and reconciling the diagnosis. Patterns in the interviews corroborated data from the record review. Conclusions: The rendering of an appropriate diagnosis is key. Many participants' lives were significantly improved when diagnosis was made, and treatment recommendations for bipolar disorder (BPD) were initiated. These findings offer clinicians and researchers new ways to think about the complexity of the diagnosis of BPD including contrasting decision-making outcomes along a screening, diagnosis, and treatment continuum, as well as using the diagnostic event to instigate meaningful life change in the patient.

Perspectives on ICD-11 to understand and improve mental health diagnosis using expertise by experience (INCLUDE Study): an international qualitative study

Developed in collaboration with WHO Department of Mental Health and Substance Abuse, this study (conducted in India, the UK, and the USA) integrated feedback from mental health service users into the development of the chapter on mental, behavioural, and neurodevelopmental disorders for ICD-11. The ICD-11 will be used for health reporting from January, 2022. As a reporting standard and diagnostic classification system, ICD-11 will be highly influential by informing policy, clinical practice, and research that affect mental health service users. We report here the first study to systematically seek and collate service user perspectives on a major classification and diagnostic guideline. Focus groups were used to collect feedback on five diagnoses: depressive episode, generalised anxiety disorder, schizophrenia, bipolar type 1 disorder, and personality disorder. Participants were given the official draft diagnostic guidelines and a parallel lay translation. Data were then thematically analysed, forming the basis of co-produced recommendations for WHO, which included features that could be added or revised to better reflect lived experience and changes to language that was confusing or objectionable to service users. The findings indicated that an accessible lay language version of the ICD-11 could be beneficial for service users and their supporters.

Stigma: A linguistic analysis of personality disorder in the UK popular press, 2008-2017

WHAT IS KNOWN ON THE SUBJECT?: People with a diagnosis of personality disorder often experience stigma both outside of, and within, mental health services. The media contribute to people's understanding of mental health issues, and negative portrayals appear to lead to increased negative attitudes in readers. Relatively little is known about how the press represent personality disorder, and the types of messages that people with this disorder may be receiving, which may impact on their understanding of themselves and emotional well-being. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The key findings indicate that in a 10-year period, the representation of personality disorder in the popular tabloid press in the UK was characterized by the frequent use of language of violence. The research approach enabled the study to identify significant patterns in the language used, rather than only using a checklist of words that the press are directed to avoid. This adds to our understanding about the images repeatedly presented that may affect how readers treat people with a diagnosis of personality disorder and affect the self-esteem of those with the diagnosis. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses are well placed to address issues of stigma both in terms of the general public's beliefs and the impact it has on those who use mental health services. A greater understanding of the messages in the press can help nurses to support service users who are vulnerable to believing that their lives will start to reflect the negative messages they have read. ABSTRACT: Introduction Many people with a diagnosis of personality disorder experience stigma, and the press' representations may contribute to those processes. To date, little is known about how the press write about people with personality disorder and analysis of language used is often limited to checklists of words to avoid. Aim The aim of the study was to explore the linguistic characteristics of press articles about personality disorder in popular tabloids in the UK and consider the implications for stigmatization. Method Corpus linguistics was used to examine a 50% sample of all articles published by the popular press in the UK, from 2008 to 2017, that referred to personality disorder (n = 260). Results The findings identified a range of words that constructed narratives of violence. Discussion The method enabled the findings to expand the current level of knowledge in the field, identifying patterns in the use of the language of violence, which may contribute to the processes of self-stigma. Implications for practice Greater understanding of the messages in the press can sensitize nurses to common misconceptions about the disorder, how these may have become internalised and the need for psycho-social interventions to address the impact of self-stigma on self-esteem.

The personality disorder patient pathway: Service user and clinical perspectives

AIMS

There have been recent policy developments and research into care provision for service users with personality disorder. However, few studies have focused on service user and staff perspectives on how services could be improved.

METHODS

A qualitative study was undertaken in the UK between 2016 and 2017. We conducted six focus groups with clinicians in mental health services with experience of working with people with personality disorder. Using an online survey, we asked current and past service users with personality disorder to describe their experiences of mental health services and make recommendations for improvements. A thematic analysis was conducted.

RESULTS

Forty-five clinicians participated in the focus group and 131 service users contributed to the online survey. The main areas of concern identified by both staff and patients were the diagnosis of personality disorder, the absence of a coherent care pathway, access to psychological treatment and staff training.

CONCLUSIONS

The care pathway for individuals with personality disorder is unclear to clinicians and service users, and elements of the pathway are disjointed and not working as effectively as they could. Guidelines recommended by National Institute for Health and Care Excellence are not being followed. Specialist psychological interventions should be available to ensure consistent and stable care provision. © 2019 John Wiley & Sons, Ltd.

Collaborative diagnosis between clinician and patient: why to do it and what to consider

This article discusses findings from the literature and our own research related to the experience of the diagnostic process in mental healthcare, primarily from the perspective of patients, and it focuses on the benefits of collaboration. A common finding throughout our research is that, if a diagnostic process is undertaken, the majority of patients want to be actively involved and feel valued in it. This helps ensure that they find the process and the resulting diagnosis to be meaningful, informative and useful. We believe that collaboration could also mitigate some of the reported negative unintended consequences of diagnosis, including feeling stigmatised, labelled and disempowered. Our work has led us to conceive of diagnosis as having two overarching elements: the diagnostic process and the resulting diagnostic label. This article focuses specifically on the diagnostic process; we do not consider here the debate surrounding the evidence base for the validity of psychiatric classification.

LEARNING OBJECTIVES

After reading this article you will be able to: •

DECLARATION OF INTEREST

None.

The double hazard in recovery journey: The experiences of UK Chinese users of mental health services

BACKGROUND

The recent interest in recovery from mental health problems has not meaningfully addressed the perspectives of ethnic minorities.

AIM

To contribute to the discussion of recovery-oriented service with a study on the experience of Chinese people using UK mental health services.

METHODS

In-depth life history interviews were carried out with the users. The qualitative data were analysed using thematic analysis.

RESULTS

Four themes emerged as hindrances to personal recovery: (1) language difficulty creates hurdles, (2) diagnostic label is experienced as a double-edged sword, (3) treatment-related stigma and (dis)empowerment are identified, and (4) grievances are found in hospitalisation.

DISCUSSION

Having mental illness and being an ethnic minority in the UK experienced double hazard in their recovery journey. While the deprivation of agency and the stigma process in the health care system hinders their recovery, they are further disadvantaged by their ethnic minority status. Four pointers for service improvement, that apply to Chinese users in the United Kingdom and have general implications for users beyond this group, are proposed.

A hidden activism and its changing contemporary forms: Mental health service users / survivors mobilising

This commentary concerns how the organisation of State welfare benefits in the UK have changed over the last 20 years, arguing that this has had harmful, even fatal, consequences for people with disabilities and particularly those with mental distress of psychosocial disabilities. This current situation may be called that of austerity. The paper describes how a ‘hidden activism’ has emerged to contest this situation and explains why it is, and to a degree, must be hidden. I then focus on the discourse of responsibilisation where every citizen must take responsibility for embodying the virtues of the good, working person. To ensure this, unemployment has been framed as a psychological problem and psychologists are now employed to ‘treat’ this problem in order that everybody might enter the world of work. I argue that in current conditions this is not possible for all with mental distress. Engaging then with community psychology, I address the issue of allies and how the absence of attention to mental distress might be remedied by this form of work. I draw on the emerging field of user / survivor-led research in mental health and argue that collaboration with community psychology will not be without problems.

Subgroups of Adolescent Girls With Borderline Personality Disorder Symptoms

The aim of this study was to determine whether borderline personality disorder (BPD) can be differentiated from other disorders in a clinical sample of adolescent girls. Participants (N = 75) were grouped based on the pattern of BPD symptom endorsement using a latent class analysis. Four latent classes were identified. The most impaired class endorsed seven BPD symptoms and an average of three comorbid disorders. An intermediate class endorsed three BPD symptoms and had the highest prevalence of PTSD (41.7%). A third class reported two BPD symptoms and had a high prevalence of anxiety disorders (62%). The fourth class had no BPD symptoms and, on average, one comorbid disorder. Only a small subset of these teenage girls met criteria for BPD, and they had distinct and severe impairment. The results suggest the modest likelihood of a BPD diagnosis in clinical samples of teenage girls, and to also be vigilant for PTSD.

A qualitative study: experiences of stigma by people with mental health problems

OBJECTIVES

Prior research has examined various components involved in the impact of public and internalized stigma on people with mental health problems. However, studies have not previously investigated the subjective experiences of mental health stigma by those affected in a non-statutory treatment-seeking population.

DESIGN

An in-depth qualitative study was conducted using thematic analysis to investigate the experiences of stigma in people with mental health problems.

METHODS

Eligible participants were recruited through a local mental health charity in the North West of England. The topic of stigma was examined using two focus groups of thirteen people with experience of mental health problems and stigma.

RESULTS

Two main themes and five subthemes were identified. Participants believed that (1) the 'hierarchy of labels' has a profound cyclical impact on several levels of society: people who experience mental health problems, their friends and family, and institutional stigma. Furthermore, participants suggested (2) ways in which they have developed psychological resilience towards mental health stigma.

CONCLUSIONS

It is essential to utilize the views and experiences gained in this study to aid understanding and, therefore, develop ways to reduce the negative impact of public and internal stigma.

PRACTITIONER POINTS

People referred to their mental health diagnosis as a label and associated that label with stigmatizing views. Promote awareness and develop improved strategies (e.g., training) to tackle the cyclical impact of the 'hierarchy of labels' on people with mental health problems, their friends and family, and institutional stigma. Ensure the implementation of clinical guidelines in providing peer support to help people to combat feeling stigmatized. Talking about mental health in psychological therapy or health care professional training helped people to take control and develop psychological resilience.

Experiencing mental health diagnosis: a systematic review of service user, clinician, and carer perspectives across clinical settings

Receiving a mental health diagnosis can be pivotal for service users, and it has been described in both positive and negative terms. What influences service-user experience of the diagnostic process is unclear; consequently, clinicians report uncertainty regarding best practice. This Review aims to understand and inform diagnostic practice through a comprehensive synthesis of qualitative data on views and experiences from key stakeholders (service users, clinicians, carers, and family). We searched five databases and identified 78 papers for inclusion, originating from 13 countries and including 2228 participants. Eligible papers were assessed for quality, and data were coded and then developed into themes, which generated a model representing factors to consider for clinicians conveying, and individuals receiving, mental health diagnoses. Themes included disclosure, information provision, collaboration, timing, stigma, and functional value of diagnosis for recovery. Variations between different stakeholders and clinical contexts are explored. Findings support an individualised, collaborative, and holistic approach to mental health diagnosis.

"This is not a Life Anyone would want"-A Qualitative Study of Norwegian ACT Service users' Experience with Mental Health Treatment

We discuss Norwegian service users' experiences with community mental health treatment in general, and the interprofessional Assertive Community Treatment (ACT) model in particular. To gain the right to treatment, service users have to accept certain limitations, such as medication and community treatment orders (CTOs). Seventy participants responded to five open-ended questions. In addition, eight of them participated in either focus group or interviews. A collaborative approach, using Stepwise-Deductive Induction (SDI) method was used to analyze the participants' experiences. The results showed that the treatment contributes to an experience of autonomy but also one of restriction. It provides service users with enhanced normalcy, but simultaneously a feeling of deviance. There needs to be an ongoing reflection and discussion about those paradoxes in treatment, and service users have to be involved.

The Compelling and Persistent Problem of Bipolar Disorder Disguised as Major Depression Disorder: An Integrative Review [Formula: see text]

BACKGROUND

Up to 40% of patients with bipolar disorder are misdiagnosed, usually with major depression disorder.

OBJECTIVE

The purpose was to describe the current state of the science of the misdiagnosis of bipolar disorder, with the ultimate goal of improving psychiatric diagnostic workups including screening.

DESIGN

An integrative review was conducted using standard criteria for evaluating research articles.

RESULTS

Forty-nine articles met the eligibility criteria. Articles explored patient-related and health care provider-related factors contributing to the misdiagnosis of bipolar disorder as well as consequences of misdiagnosis. Clinically oriented, reliable, and valid screening tools for bipolar disorder also were reviewed.

CONCLUSIONS

Awareness of multiple, challenging patient-related factors and more comprehensive assessment and screening by health care providers may reduce misdiagnosis.

How Is a Label of Borderline Personality Disorder Constructed on Twitter: A Critical Discourse Analysis

This research took a social constructionist stance and explored how Borderline Personality Disorder (BPD) is constructed by Twitter users who identify with this diagnostic label. Consistent with this position, a critical discourse analysis (CDA) methodology was employed. The data comprised two-hundred and twenty-five tweets. Tweets from professionals, or links to blogs, were excluded, in an attempt to ensure only personal tweets were used. Two interpretative repertoires were produced from the analysis: BPD as an existence of tension and BPD as a different existence. The findings indicated that authors were involved in a negotiation between themselves and BPD, which had an impact upon their felt sense of agency/control over BPD. Likewise, authors constructed themselves in opposition to individuals who did not identify with the diagnosis of BPD. Whilst this provided more favourable positions, it potentially limited access to healthcare professionals and services. The research highlights the importance of the terminology and language clinicians employ when working with clients and other professionals, as they may inadvertently disempower or stigmatise. As CDA does not assume equivalence between individuals' accounts and their internal experiences, future research may need to explore the experience of stigmatisation through social networking sites.

Protocol for a qualitative study exploring perspectives on the INternational CLassification of Diseases (11th revision); Using lived experience to improve mental health Diagnosis in NHS England: INCLUDE study

INTRODUCTION

Developed in dialogue with WHO, this research aims to incorporate lived experience and views in the refinement of the International Classification of Diseases Mental and Behavioural Disorders 11th Revision (ICD-11). The validity and clinical utility of psychiatric diagnostic systems has been questioned by both service users and clinicians, as not all aspects reflect their lived experience or are user friendly. This is critical as evidence suggests that diagnosis can impact service user experience, identity, service use and outcomes. Feedback and recommendations from service users and clinicians should help minimise the potential for unintended negative consequences and improve the accuracy, validity and clinical utility of the ICD-11.

METHODS AND ANALYSIS

The name INCLUDE reflects the value of expertise by experience as all aspects of the proposed study are co-produced. Feedback on the planned criteria for the ICD-11 will be sought through focus groups with service users and clinicians. The data from these groups will be coded and inductively analysed using a thematic analysis approach. Findings from this will be used to form the basis of co-produced recommendations for the ICD-11. Two service user focus groups will be conducted for each of these diagnoses: Personality Disorder, Bipolar I Disorder, Schizophrenia, Depressive Disorder and Generalised Anxiety Disorder. There will be four focus groups with clinicians (psychiatrists, general practitioners and clinical psychologists).

ETHICS AND DISSEMINATION

This study has received ethical approval from the Coventry and Warwickshire HRA Research Ethics Committee (16/WM/0479). The output for the project will be recommendations that reflect the views and experiences of experts by experience (service users and clinicians). The findings will be disseminated via conferences and peer-reviewed publications. As the ICD is an international tool, the aim is for the methodology to be internationally disseminated for replication by other groups.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT03131505.

Seeking to understand lived experiences of personal recovery in personality disorder in community and forensic settings - a qualitative methods investigation

BACKGROUND

Understandings of personal recovery have emerged as an alternative framework to traditional ideas of clinical progression, or symptom remission, in clinical practice. Most research in this field has focussed on the experience of individuals suffering with psychotic disorders and little research has been conducted to explore the experience of individuals with a personality disorder diagnosis, despite the high prevalence of such difficulties. The nature of the personality disorder diagnosis, together with high prevalence rates in forensic settings, renders the understanding of recovery in these contexts particularly problematic. The current study seeks to map out pertinent themes relating to the recovery process in personality disorder as described by individuals accessing care in either community or forensic settings.

METHODS

Individual qualitative interviews were utilised to explore the lived experience of those receiving a personality disorder diagnosis and accessing mental health care in either community or forensic settings. A thematic analysis was conducted to identify shared concepts and understanding between participants.

RESULTS

Fourty-one individual participant interviews were conducted across forensic and community settings. Recovery was presented by participants as a developing negotiated understanding of the self, together with looked for change and hope in the future. Four specific themes emerged in relation to this process: 1. Understanding early lived experience as informing sense of self 2. Developing emotional control 3. Diagnosis as linking understanding and hope for change 4. The role of mental health services.

CONCLUSIONS

Through considering personal recovery in personality disorder as a negotiated understanding between the individual, their social networks and professionals this study illustrates the complexity of working through such a process. Clarity of understanding in this area is essential to avoid developing resistance in the recovery process. Understanding of recovery in a variety of diagnostic categories and social settings is essential if a truly recovery orientated mental health service is to be developed.