instability of mood and interpersonal relationships, and suicidal behaviour that can complicate medical care” (Canadian Medical Association, 2005). Borderline personality disorder (PBD) is one of the disorders that nurses may encounter frequently. The DSM-IV divides personality disorders into three different clusters depending on their similarity of their symptoms that they may present, BPD falls into cluster B. Cluster B “includes antisocial, histrionic, borderline, and narcissistic personality disorders. These disorders are characterised by dramatic, highly emotional, and unstable behaviours” (Nursing Made Incredibly Easy, 2006). Due to these specifics of a personality disorder, nurses and all health care provides must have an assessment tool to assist them in the process of diagnosis and implementation of care.
In a primary health setting, the person that may be suffering from Borderline Personality Disorder will have numerous assessments completed to allow and facilitate the health care provider with the person’s specifics of this condition and to facilitate with the treatment that the client will receive. Once a client has been admitted to hospital or mental health facility, one of the first assessment tool used is the Mental Status Examination. The Mental Status Examination, more commonly abbreviated to MSE, is “a semi-structured interview with a consumer to assess the person’s current neurological and psychological status using several dimensions, such as perception, affect, though content, form of thought and speech” (Elder, Evans & Nizette, 2009). The MSE is a standardised assessment tool which is applied in its own right to mental examination. This assessment is a screening tool which allows the examiner to evaluate the client’s appearance and behaviour, speech, moods, thoughts, thought processes, cognition, perception and their own insight to their own situation and their illness. This MSE takes place usually as an interview with a health care professional as it allows the examiner to develop a report with the client and build up trust. During the interview, the health care professional should take mental notes and pay close attention to the client’s presentation in regards to personal hygiene, grooming and clothing and also noting their behaviour towards the health care professional whether they are withdrawn from the conversation or hostile and unreceptive. These mental notes aid in later interviews and interventions by enabling the health care professional to formulate a care plan as a preliminary diagnosis. Speech is also an important factor of this assessment and should be looked at by rate or speech whether it is fast or slow paced, the tone and volume or the spoken words and the quantity of information. One of the most important things to look at in speech is whether the client is willing to participate in the conversation and if they are not, then try and find out the possible reasons to why this is such as any language barriers, physical difficulties or is it merely the progression of the mental illness. “Affect refers to the varying emotional response witnessed during the interview” (Commonwealth of Australia, 2003). Mood and affect together provide useful information for later diagnosis. Moods such as normal, blunt, flat, euthymic, angry or anxious all enable a concise and accurate diagnosis. Thought and thought processes indicate the reasons behind the behaviour and express the client’s beliefs and ideations which arise due to the condition. Cognition allows the health care professional to evaluate the level of consciousness, memory and orientation, as well as the ability to concentrate on a certain topic. This allows the health care professional to evaluate whether their client may have an inorganic or organic brain disorder which is crucial to their evaluation in regards to the treatment and diagnosis. Perception and insight is the last topic of the assessment tool, and is probably the most important in the sense that it allows the health care professional to assess the client’s own understanding and insight into their behaviour and illness and overall situation in which the client may be facing. Whilst undertaking the MSE, a risk assessment should be completed.
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“Psychiatric in-patient facilities have a central role in the care of patients presenting with suicide risk. Good therapeutic relationships with patients and their families are key components for the reduction of suicide risk in in-patient facilities” (NSW Department of Health, 2004). In a psychiatric milieu, risk is best referred to as the harm to the patient themself, others, exploitation by other people and even neglect of one’s self. It is essential that a risk assessment is conducted on admission to determine the overall risk of the patient to either harm or hurt themselves or other patients or staff members. It is vital to talk to the client about suicidal idealization and if they have attempted to commit suicide in the past. Asking open ended questions and not being afraid to ask the client these questions will allow the nurse to gain a better picture of where the client is currently at with their mental thinking and reasoning. By gaining a previous history of aggression, self harm and violence of a client, it give staff an idea of what kind of behaviour this person has formerly has and what triggered off the behaviour. “A failure to adopt an assertive outreach approach to the delivery of care, or respond to early warning signs of a relapse and, last but not least, a neglect of the rule that the best predictor of future behaviour is past behaviour. The result is the inadequate delivery of care to individuals involved with the inevitable tragic consequences” (Watkins, 2001). Acquiring a family history is a valuable source of information in regards to the client’s diagnosis as it is believed that some mental illnesses are based on genetics. In addition to the family history, gathering information about the clients relationships with family members and other relationships along with the client’s history of employment and education. a and or attemps The health care professional, while assessing their client’s mental health status, previous history and overall condition, they should also look at the stressors which precipitate the client’s behaviour and their illness.
Stressor pertains to the word stress, which means “any emotional, physical, social, economic or other factor that requires a response or change” (Harris, Nagy & Vardaxis, 2006). “While it would be impractical to eliminate all stress, it is important to be able to minimize stressors in your life and deal with the stress that you do experience-what’s known as stress management” (Scott, 2009). Stressors affect a person with Borderline Personality Disorder immensely. This is why understanding and assessing stressors in clients with this disorder is very important to help with developing the necessary nursing interventions and treatments. It is also important to help the client manage their own stressors in everyday life so that relapses do not occur. People with Borderline Personality Disorder experience a multitude or stressors, some of which are predisposed factors. It is the duty of the health care professional, especially the nurse who should evaluate all aspects during a nursing assessment. A predisposition to the illness may include biological, developmental and sociocultural factors. It is believed that biological factors play a major role in the development of a mental illness such as borderline personality disorder. Inherited biological factors, such as genetic susceptibility, are just one of the examples which can lead to a mental illness. Personality disorders have been linked to substance abuse. “Borderline personality disorder and antisocial personality disorder in particular are associated with a wide variety of substance use disorders” (Stuart & Laraia, 2005). Developmental factors are major life changes at an early age; these may include abandonment at a very young age by a significant other whether that is a mother, father or primary care giver. People that suffer from borderline personality disorder are fearful to get themselves into a close relationship and have poor or little social networks. This is due to their inability to form meaningful and emotional relationships and often cause problems in these relationships, as well as previous experiences and emotions when they were abandoned as a child. “Sociocultural factors also can influence the person’s ability to establish and maintain relatedness” (Stuart & Laraia, 2005). People who have a biological susceptibility to a personality disorder can be exacerbated by sociocultural influence. While relationship choice, choosing of friends, and family dynamic may not have total impact on borderline personality disorder, they certainly do some sort of impact on the client. Nurses gathering previous medical history should look back at their clients family structure to better understand their clients early childhood behaviour which may reflect their current mental status. However, the nurse should not only look at predisposing factors but also at precipitation stressors.
Precipitation stressors that affect a person can be categorised sociocultural and psychological stressors. Sociocultural and psychological stressors are like trigger points, which set off people with PBD, these stressor have a negative impact on the persons emotional growth. These stressors have an even greater impact if the person has a predisposition to the illness. Sociocultural stressors include divorce, death a close family or friend. Psychological stressors cause the person with BPD to experience anxiety, this may include relationship problems, going away from family and friends such as camps even job promotions. Nurses need to understand that these stressors cause anxiety, and are often the root of behaviours in people with BPD.
Although clients who are diagnosed with borderline personality disorder are prescribed medications, there are alternative therapies that do not involve the use of medications. These alternative therapies include cognitive behaviour therapy, interpersonal therapy and dialectal behavioural therapy. “Cognitive behaviour therapy (CBT) is a type of psychotherapy that helps people to change unhelpful or unhealthy thinking habits, feelings and behaviours. CBT may be used to treat problems including anxiety, depression, low self-esteem, uncontrollable anger, substance abuse, eating disorders and other problems” (State Government of Victoria, 2010). This intervention is a combination of cognitive therapy and behavioural therapy. The goal of cognitive therapy is to modify the way the person feels about the subject that is causing apprehension, such as blemished or hazy feelings that can lead to self-destructive feelings and behaviours. On the other hand, behavioural therapy intends to educate the person techniques and skills which can help them to alter their behaviour. “Interpersonal therapy (IPT) is a type of treatment for patients with depression which focuses on past and present social roles and interpersonal interactions. During treatment, the therapist generally chooses one or two problem areas in the patient’s current life to focus on” (Schimelpfening, 2008). “Dialectical behaviour therapy is a program which consists of four modules: mindfulness, interpersonal effectiveness, emotion regulation and distress tolerance. This therapy focuses on helping the patient develop skills which can help them to remain grounded and in control of their body and mind, cope with interpersonal conflict, tolerate stressful situations and help them regulate their emotions.” (Reach Out Australia, 2010). These alternative therapies work with the client to formulate personal techniques that will help the client to focus and control their behaviours and emotions.
“Registered nurses work with individuals, families, groups and communities, assessing mental health needs, and developing a nursing diagnosis and a plan of nursing care, implementing the plan, and finally evaluating the nursing care” (American Psychiatric Nurses Association, 2009). From this statement we are able to conclude that nurses must not only understand the processes of mental illnesses, but also implement and execute the specific care required by their clients. As one can see this would than not be well structured care as it is missing other health care providers. For a nurse to be able to provide holistic care to their clients, they must be able to work with psychologists, psychiatrists and allied health care workers such as social workers, cancellers and therapists. All this is required to evaluate, construct and implement the care required by a person with BPD.
