Hey, I want to be a public health nurse. I am great at prevention and promoting healthy lifestyles, med surg type stuff, but I am not that great at psych. So, I am trying to really go through and learn about the psych illnesses more than what I learned in class (I don't feel like my instructor was effective at all). I am having an okay time learning most of them. But, personality disorders baffled me; especially, borderline.
I don't understand it. What are they like? I have read they are manipulative, but I don't understand what kind of stuff they do that is manipulative. I understand the black and white stuff like a person is all good or all bad. Are they cheery people or are they depressed? Do they really lie a lot; have you ever met an honest one? Does that mean I should take what they tell me as being true? Have all of them been abused or are some of them just like that without abuse? Are they able to hold down jobs and what kind of services would I need to refer them to (I know it's on a case by case basis but generally what kind of advocacy/ case management do they need?) How does this differ from Bipolar?
Any info is appreciated. I had considered joining a psych organization along with the couple other ones I have selected to join just so I can get info and journal articles about psych illnesses, homelessness, etc. in order to learn about and advocate for my future patients. Like I said, I understand med surg slightly better but I am not close minded or think psych patients are crazy or anything.
Apr 23, '12
What are they like?
I have read they are manipulative, but I don't understand what kind of stuff they do that is manipulative. I understand the black and white stuff like a person is all good or all bad. Are they cheery people or are they depressed?
They are cheery if they get what they want. However, they use whatever emotion they need to in order to manipulate their media and reach their desired goal.
Do they really lie a lot; have you ever met an honest one? Does that mean I should take what they tell me as being true?
Taking in the Concept that Reality is merely a Consensual Perspective, so is a Truth or a Lie. As George Costanza said, "Remember- it's not a lie if you believe it." Diane Ackerman wrote an entire book on the perceptions of the mind, called An Alchemy of Mind.
Have all of them been abused or are some of them just like that without abuse?
I tend to lean toward the Predisposed Genetic Template of the Personality Theory. But it is possible that the Borderline Personality is a result of Coping Mechanisms.
Are they able to hold down jobs and what kind of services would I need to refer them to (I know it's on a case by case basis but generally what kind of advocacy/ case management do they need?)
Allow the Individual to attain the Highest Level of Functioning they can. Like most of us, they'll follow the Peter Principle and will ascend to the Level of Their Incompetence.
How does this differ from Bipolar?
Bipolar is a Mood Disorder. Borderline is a Personality Disorder.
These answers are merely my perspective and are subject to interpretation and argument, but you asked some very good questions, wish_me_luck!
I wish you luck!
Apr 25, '12
They are usually manipulative in the way where they will try and tell you what to do and and in a hospital setting try and tell you they are allowed to do certain things even if they are not. It is never wise to take their word on things and to talk to the nurse in charge or a nurse who knows their care plan. They may also claim to be very sick even when they are not to try and get you to feel sorry for them or other tactics to try and get you to feel sorry for them. In many cases they will act like the nicest person to you but will turn on you as soon as you do not do what they want. Once that happens they can me quite mean. You just have to not take anything personally.
Apr 26, '12
so far you've gotten some good info.
i wanted to add that not every difficult patient you encounter is a borderline personality disorder patient.
there tends to be a bad habit, especially in non-psych nurses or nurses who don't understand personality disorders, to immediately slap the "borderline" label on any patient who is demanding or difficult, changes their mind a lot, is seeking sympathy, and/or tells staff different stories.
patient changes their mind about something? must be borderline. not happy with dinner or a medication and wants something else? must be borderline. minimizes pain to the nurse but tells the doctor they are in agony? must be borderline.
yes, most of these "difficult" patients probably have borderline pd to some degree. but not all do.
some patients are just indecisive. some are just entitled. some indeed just want a shoulder to cry on. some may tell varying stories, not to split or manipulate staff, but for other reasons: maybe they don't want the doc/nurse know how bad off they really are, maybe they forgot to mention something, maybe they didn't want to bother a busy nurse for pain meds, maybe they are stressed or in crisis and not thinking clearly, maybe they relate better to one staff over another, etc.
just something to keep in mind.
that being said, regardless of whether the patient has borderline pd, remember to be consistent with boundaries and unit rules. take what the patient tells you with a grain of salt, and do not let them split staff whether they do it intentionally or accidentally. and definitely learn not to take things they say or do personally.
the best way to learn about personality disorders (borderline pd is only one of several you will encounter--antisocial pd, narcissistic pd and obsessive-compulsive pd are also common ones). there are lots of good reference books out there. if you want to learn about borderline pd from the patient pov, look for "get me out of here" by rachel reiland.
Last edit by Meriwhen on Apr 26, '12
Apr 27, '12
Okay, thanks. I don't think I will be on a unit with them as I want public health. But, in public health, we see a lot of vulnerable populations cases (psych, homelessness, addicts) and I want to know how to deal with them/understand them in order to get an idea how to help them. That's why I was curious also about case management, advocacy, and whether they typically can hold a job...The other psych illnesses seem to be as long as they stay on their medication regimen, they do okay; but when they come off, that's where the problem starts. PDs, from what I know, usually don't benefit from meds.
Apr 28, '12
In a nutshell, I would describe borderlines as having the ability to conjure up the emotion necessary to get the results they want. When they do not get the results they want, this leads to the labeling of the person/situation as "bad" for the time being. However, they are often sweet when they feel that you take a personal interest in who they are as a person. At their core, I think they also split themselves into good and bad parts and are extremely tough on themselves when they screw up, and likewise sing their own praises loudest of all when they succeed.
I have a friend with BPD and she's extremely attention-seeking. She will make up stories, either to brag or for sympathy, and has often come to me with random illnesses (and even a pregnancy once). She goes between loving and hating people...there is rarely an in-between and often if there is, it doesn't stay there long.
I would say that many patients with BPD traits have a history of abuse, neglect, and/or abandonment in their past, but I do not think that this is what causes the disorder. I believe that it makes it much more obvious to the public though due to an unhealthy environment and learning poor coping skills.
Remember that each individual is different. You should *always* take what your patients say with a grain of salt, but I would advise against getting into the mindset that because Patient A has Disorder X, she must do Action Y. Therefore, do not assume a BPD is lying until there is clear evidence. In documentation, it is important to use the power of quotation marks and refrain from putting your opinion into it. A phrase that drives me crazy in the psych world is "not interested in treatment" without any supporting evidence. Make sure that you do not pigeonhole your psych patients. They are capable of change and worthy of love just as much as anyone else.
Apr 30, '12
some empathy, clear boudaries and a litle Zen...the how to engage with those borderline very nice people
May 1, '12
This very website has a great entry on BPD. Borderline Personality Disorder on the Behavioral Unit
. Most of what I saw here would agree with my own experience with the disorder.
May 2, '12
When thinking of personality disorders in general (vs an Axis I disorder), think of the personality being "stunted": a lot of borderline (and other personality-disordered people) behave like a child, throwing "tantrums" (quite literally, or other types of tantrums like self-injurious behavior) in order to get their own way.
Still, there's another school of thought that isn't even convinced of the existence of BPD: it is, after all, overdiagnosed in females (men with similar behaviors tend to get the Bipolar label). This website is very useful: borderline
May 6, '12
angelalala... just wanted to follow up one your post by saying that not all who self-injure do it to seek attention/ to get their own way.
May 14, '12
Borderlines alternate back and forth between valuing and devaluing others. If you do what they want, you're the greatest nurse ever. If you don't, you are worthless and against them. There is little, if any, middle ground. True borderlines are among the most diffcult patients to work with. They often have hair-trigger tempers, and you are never quite sure what will set them off. The worst, IMO, are Axis I Bipolar disorder, Axis II borderline personality disorder. Nasty disposition and lots of energy to fuel it.
As others have said, some are quick to slap the borderline label on any difficult patient. Some may have borderline traits, but they aren't true borderlines. Reviewing the DSM IV can be very useful in giving you insight.
May 18, '12
Please, please DO NOT start off thinking they are all negative, manipulative, narcissistic, whatever other words people might throw at you.
Basically, the mind set of a borderline patient is: no-one likes me, I am negative, I want attention because that way I can be helped and will feel better. They want the attention to get...attention! Because they feel that they are not worthy of much, they feel they have to use negative ways, such as manipulation and not honesty, to get what they need. They are often frequent flyers of hospitals because they feel stuck and don't realise that they have a way to get out of their own problems. They feel someone else must fix them, when with psychiatry often the turning point is when they realise it is up to THEM to turn around and get help. They act narcissistic because they want attention, and often can't understand that others need attention too. It is very easy to feel negative of them after a while because they are so demanding and hard to understand.
Personality disorders are very complex and for most people are life-long. There isn't an easy fix, which is frustrating for us nurses. With health care for them I think what is the common practice is for them to have a psychologist to give them the attention and care they require, and to try and encourage them to stay out of hospitals. Often with BPD they can be prone to bouts of self injury and suicidiality, and feel the need to be "Rescued" so end up in hospital. They need to have someone to call before this occurs, so a psychologist or 24/7 mental health team they need upon discharge.
Jun 4, '12
Borderlines- attempt to split staff, highly attention seeking, manipulate people into getting what they want I think because that is how they have learned to survive and get their needs met in the world, have a hard time regulating their emotions. Basically everything everyone already said. However I will add the comment that you should be careful in not believing a borderline. I learned early on that sometimes even the most psychotic patient may be telling you something that actually happened to them, just like when some of the stories you hear seem like they might not possibly be true they actually might be, even if they sound crazy. We tend to approach borderlines with strict boundaries, hold them to the rules of the units, do not allow them to split staff. It might sound mean (that's what I first thought when I saw staff approaching BPD's like that) but I've found that they actually respond pretty well to it and if they are mean to you they 9/10 times will come apologize later. You can't take anything in this business personal. Remember through all their attempts at getting attention, all the things people dislike about the patient that makes them borderline, they are sick. Keep compassion and sympathy in your heart and forgive.
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