regarding borderline patients

nightingale, RN · Jun 18, 2006

Thanks Wolfie

lovinghands · Jun 18, 2006

i read on the forums nurses resentments toward "borderline" patients. look at it like this. our country enables "borderline" behavior. if you scream suicide or self harm yourself we have built hospitals and paid health care prof to take care of them. we also have laws that say if you cry suicide or self harm we can "lock" you up. we also have laws if you cry suicide or self harm and a health prof doesn't "take care" of you you can sue them. i know many people from africa. they don't have "borderline personalty" disorders there. so next time you get "resentfull" of a "borderline" patient remember if we didn't live in a country that makes laws saying you have to "take care" of these people, or build hosp to house them, or pay health prof to take care of them, then we would not have this prob. so it's not the patient to blame but the "system". basically our "system" has invented "borderline" patients.

Just my 2 cents here.

Keep in mind that most patients suffering with borderline personality disorder are undiagnosed and never see the likes of therapy, let alone inpatient care. These ppl are in our communities, struggling and attempting to function in society to the best of the means. The pts with this disorder that I see on my unit are usuallly extreme cases. So I don't quite see the connection between the system inventing this disorder. I do see hospitals fostering dependency in borderline patients by enabling manipulative behaviors and offering inadequate resources of treatment.

Sheri257 · Jun 18, 2006

Borderline is no exception. These folks do exist. In the US, they may be dx'd more because the dx has...let's say...a more established acceptance and relevance to our culture....where other countries, it may not. I hear folks' arguments here back and forth, but it comes down to the cultural acceptance of the label/dx. Regardless of country or culture, the PD still exists....one country is more accepting and one is not; culturally it fits in one, in the other, it has little relevance...but, the diagnostic pattern/criteria still exists nevertheless.

But that doesn't mean there isn't flaws in the diagnostic criteria. Wasn't homosexuality once considered a disorder in the DSM? While different cultures may prevent certain conditions from being diagnosed, cultural influence can also lead to flawed diagnostic criteria as well.

I'm not saying that some of these people don't need or don't deserve help ... they do. But, I think the OP has a valid point in raising questions about it. You have to consider the possibility that our culture can also encourage and, almost, create some of these disorders, at least to some extent. Sometimes the criteria seems to be so broad and vague that it inevitably encourages abuse of the system.

The criminal justice system is a classic example. A child abuser can end up in a state psych facility just as easily as prison. When I've asked doctors why certain child abusers ended up in a psych facility and others don't, they really couldn't explain why except they had really good lawyers. From what I understand, nearly a third of patients in criminal psych facilities are fakers, not truly mentally ill. And, on the flip side, there are seriously mentally ill patients in prison who do belong in psych facilities but never get any help.

Maybe these problems can't be avoided, and every system will be inevitably flawed. But, at the same time, I think questioning the validity of some of these disorders is a good thing because, in many cases, some of these diagnoses can lead to a great deal of abuse, and create just as many problems as they may solve.

:typing

cardiacRN2006, ADN, RN · Jun 18, 2006

Wow! I'm suprised by some of these responses.

To all who disbelieve borderline personlality patients exist; you have obviously never known one. I know one. She was raped repeatedly by her father as a child and ignored by her mother. Her life now consists of no boundries, it always being about her, and manipulations (like driving to a random church and crying for money or spending all her money on a puppy when rent is due and then calling and crying to everybody about her kids being thrown out on the street). No amount of time or therpy or meds will fix her. She has been in therpy for 20 years. There is no fixing that trauma. She can only live day to day. We will buy food for her kids since she calls crying about not having any, and the same day we deliver the food, she will take the kids to the movies. There are literally countless ways that she fits the bill for this disease--and none of them are related to making money for the machine, or just looking for some extra "attention".

Listen, these diseases are just as real as diabetes. To think they are not, and be working in Psych is a dirty shame. If you doubt these diseases, get out of the psych field. You are doing a terrible inservice to these patients and an embarrassment to the nursing community.

Thunderwolf, MSN, RN · Jun 18, 2006

Again, some good responses. Interesting enough, most folks who do have a psych dx often have more than one or more than one undx'd....for this is more common than not...which just makes the dx picture more complex and explains much of the variance often seen from patient to the next. Yes, the system can be abused....not too difficult. Malingering is what is often underdx'd or if dx'd, not addressed. The dx system creating a dx simply in and of itself I really have some difficulty believing to some extent. I believe that some diagnoses often are in their infancy in our understanding, but once understood either fall to the way side and is no longer considered a dx (Passive Aggressive PD comes to mind) OR the dx becomes better understood over time and research and the dx criteria becomes better defined. This is a good debate, however. The discussion moves forward.

Sheri257 · Jun 18, 2006

Yes, the system can be abused....not too difficult. Malingering is what is often underdx'd or if dx'd, not addressed.

And therein lies the problem. As long as it's not too difficult to fake a disorder, and since the system doesn't do much about it then, the credibility of that disorder/diagnosis can always be called into question. You can't fake diabetes. You either have high blood sugar or you don't. But you can fake a mental disorder ... which makes the whole thing a dicey proposition.

I often have conflicting feelings about it. I see some of the situations these people grew up in and I think, who am I to judge? Who's to say I wouldn't have a psychotic break if something like that happened to me. I do feel a lot of empathy for those patients and I do think those people deserve help and treatment.

Then, on the other hand, you do see the malingerers who take advantage and sometimes you think the system is a little too forgiving. The diagnosis has basically allowed them to not be responsible for anything. At a certain point, are we really caring for these people or just enabling dependency and abuse of the system?

I do think that a lot of these disorders are probably valid. I just don't think the system does a good job of weeding out malingerers who deplete resources for those who really need it. And, as long as the system doesn't do much about it, the credibility of some of these diagnoses can be called into question.

:typing

Thunderwolf, MSN, RN · Jun 19, 2006

You make some valid points....however, WE are the system, not the DSM/ICD. It also emphasizees the point that clinicians are only as good as their own skills to assess and intervene appropriately. And yes, empathy (not co-dependency) with patients is very important to both patients and clinicians alike. Empathy engenders a supportive understanding for the patient. Empathy also gives back to the clinician a reminder that he/she is but a stone throw away from developing a disorder one day as well...helps keep us humble. In my years of practice, it doesn't matter how big, or bad, or healthy, or together one is as a clinician. Pack on enough stress without the structure and support, we all face the risk of being a patient one day ourselves. Seen it with other clinicians (nurses, psychologists, social workers, doctors). Experienced it for myself at one time. However, with regard to malingerers, if there is an external reward to be ill, THERE lies the problem. That is where intervention needs to be adressed from a SYSTEM standpoint. Take away the reward, malingering would become much less. Clinicians, therefore, need to be skillful in their detection and refer them out of OUR system...not keep them in. In this, we are to blame...not the DSM...for we keep them in. Again, excellent discussion.

Sheri257 · Jun 19, 2006

Clinicians, therefore, need to be skillful in their detection and refer them out of OUR system...not keep them in. In this, we are to blame...not the DSM...for we keep them in.

On the flip side ... if clinicians are having so much trouble identifying and referring malingerers out of the system (which they obviously are in many cases), does that not indicate that certain DSM disorders and the diagnostic criteria could also be the problem?

As you pointed out Passive Aggressive PD is no longer considered a diagnosis and, as I mentioned, neither is homosexuality. Obviously the DSM is not without it flaws so, it may not just be a question of clinical detection skills or the lack thereof.

:typing

hsieh · Jun 19, 2006

thanks thunderwolf. i didn't start this thread to slam borderline - i've just found on the forums and at work people have a negative attitude towards borderline and something in me tells me it's not right to tx or take money for services for a type of patient that is considered nothing more than a "drama king/queen". they have staff developement meetings where i work to talk about things like pd but none were like thunderwolf's. they do have a developmental prob but our system doesn't help them. should tx consist of putting them on a plan to go live in namibia for a few years - that would be better than putting them in a psych hop?

LydiaNN · Jun 19, 2006

thanks thunderwolf. i didn't start this thread to slam borderline - i've just found on the forums and at work people have a negative attitude towards borderline and something in me tells me it's not right to tx or take money for services for a type of patient that is considered nothing more than a "drama king/queen". they have staff developement meetings where i work to talk about things like pd but none were like thunderwolf's. they do have a developmental prob but our system doesn't help them. should tx consist of putting them on a plan to go live in namibia for a few years - that would be better than putting them in a psych hop?

You refer to Africa an awful lot, so much so that I just have to say that we're not sending anyone to Africa, nor are we adopting the way they do things in Africa, and as far as I'm concerned, that's a very good thing. Yes, it is right to treat people with this disorder. If patients have a credible dx from a reputable diagnostician, the providers who consider them ''drama queens or kings'' really ought to find another line of work. The solution isn't to disregard a clinical diagnosis in favor of the opinion of a burnt out provider who has just had it up to their teeth with the manifestations of the disorders they signed on to treat. The solution is to document any suspected incidents of malingering and bring these forward.

hsieh · Jun 19, 2006

if not africa, how about the center of the amazon rain forest? people laughed at the wright brothers when they wanted to invent a "flying machine". "borderline" are seriously developmentally disabled - they need drastic measures like a drastic change in enviroment. this way they will develope. africa and the amazon are just my ideas of drastic change of enviroment.

LydiaNN · Jun 19, 2006

if not africa, how about the center of the amazon rain forest? people laughed at the wright brothers when they wanted to invent a "flying machine". "borderline" are seriously developmentally disabled - they need drastic measures like a drastic change in enviroment. this way they will develope. africa and the amazon are just my ideas of drastic change of enviroment.

Um... no. I can't tell whether you are serious, but in case you are: not in a box, not with a fox, not in a house, not with a mouse, not in a boat, not with a goat... I do not believe we should be looking backwards for cutting edge research and treatment in BPD or other psychiatric conditions of which our understanding is still in its infancy. We need to move forward, not find out what's happening in a country where the average life expectancy is 40.2 yrs. Thanks for asking, though....