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Art &science
The synthesis of art and science is lived by the nurse in the nursing act
JOSEPHINE G PATERSON

Raising awareness of borderline personality disorder and self-injury


Lamph G (2011) Raising awareness of borderline personality disorder and self-injury. Nursing Standard. 26, 5, 35-40. Date of acceptance: June 21 2011.

Abstract
People with personality disorders frequently present to general health services. A large proportion of people with borderline personality disorder will self-injure and seek physical clinical interventions from adult or practice nurses. These patients are often excluded from services and are highly stigmatised both in mental health services and the wider society. This article aims to increase the awareness of borderline personality disorder and self-injury among non-mental health nurses to assist them to work more effectively with patients who present with these difficulties.

Author
Gary Lamph Advanced practitioner in personality disorder, 5 Boroughs Partnership NHS Foundation Trust, Warrington. Correspondence to: gary.lamph@5bp.nhs.uk

Keywords
Borderline personality disorder, mental health, personality disorders, self-injury These keywords are based on subject headings from the British Nursing Index.

Review
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Online
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PEOPLE WITH A DIAGNOSIS of personality disorder are one of the most socially excluded and stigmatised groups of patients in health services and society (Sampson et al 2006). Government policy and evidence-based literature have challenged the historical assumption that people who present with personality disorder are untreatable (Department of Health (DH) 1999, National Institute for Mental Health in England (NIMHE) 2003a, 2003b, National Institute for Health and Clinical Excellence (NICE) 2009). Personality disorder has been defined as any disorder in which an individuals personal characteristics cause regular and long-term problems in the way they cope with life and interact with other people and in their ability to respond emotionally (HM Government 2011a, 2011b). The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defined personality disorder as an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment (American Psychiatric Association (APA) 1994). People with personality disorder do not present exclusively to specialist mental health services during crisis situations or relapse. They can present to a multitude of services, but will frequently encounter non-specialist health services, including emergency departments, general wards and GP surgeries. In the UK there are 150,000 self-injury attendances at emergency departments each year and self-injury ranks in the top five most common causes of acute medical admissions (NICE 2004). Half of all people who self-injure will attend a primary care setting one month before or two october 5 :: vol 26 no 5 :: 2011 35

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months after emergency department attendance (NICE 2004). Healthcare staff have minimal awareness of personality disorder or how to work effectively with people with the condition (Sampson et al 2006, DH 2009). Borderline personality disorder (BPD) is one of the most stigmatised of all the personality disorder types (Huband and Duggan 2007). There is a high incidence of repeated self-injurious behaviour in people with BPD (Lieb et al 2004) and these patients are likely to attend general health services for medical interventions after self-injury. People who present to health services with self-injury often describe their experience of treatment negatively, with poor staff awareness, a lack of understanding of self-injury and punitive responses being reported (NICE 2004). Hopkins (2002) described how non-mental health nurses found it difficult to understand why people self-injure and felt they lacked skills to work with these patients effectively. This in turn leads to feelings of frustration and negativity in staff. It is desirable that non-mental health nurses who are likely to encounter people with these difficulties have an increased awareness and understanding of BPD and self-injury in an attempt to support and work with them more effectively (Wilstrand et al 2007). By increasing awareness of BPD and self-injury, non-mental health nurses who encounter these patients will become more understanding and better equipped to work with the difficulties that present, thereby improving the patient experience (NIHME 2003b). which specifically targets non-specialist mental health services/multi-agency partners, was commenced in Wigan Metropolitan Borough. The aim of the training is to create more responsive systems and non-stigmatising services, which in turn will increase social inclusion and improve outcomes for people with personality disorder (NIHME 2003b). In 2009, the DH produced commissioning guidance on personality disorder; the key message is that personality disorder is not only the concern of mental health services but also the wider health community as people with personality disorder rely on many different agencies for support, including general health care, housing and criminal justice. The need for staff from all sectors, including specialist mental health services, primary care, non-mental health trusts and other multi-agency third sector partners, to address gaps in knowledge, skills and attitudes towards mental health was outlined by HM Government (2009). They are directed to deliver interventions that challenge stigma, improve outcomes and aid the recovery of people with mental health difficulties. NICE (2009) guidance clearly stated that people with BPD should not be excluded from any health or social care service based on their diagnosis or self-injuring behaviours. Personality disorder is a key feature in documents such as No Health Without Mental Health (HM Government 2011a, 2011b) and is discussed in the context of non-mental health care. Specific reference is made to the frequent use of non-mental health services by people with personality disorder in primary care and at emergency departments. Personality disorder is high on the governments agenda for an improved and more responsive service and is no longer a diagnosis for exclusion.

Personality disorder guidance


The DH (1999) described standards for mental health services and discussed the need to provide evidence-based interventions for all people presenting with severe mental illness, including personality disorders. NIHME (2003a) published Personality Disorder: no Longer a Diagnosis for Exclusion, which provides policy implementation guidance for developing personality disorder services. It explores the need to raise awareness, reduce staff burnout and challenge the reluctance to work with people with personality disorder. NIHME (2003b) also published Breaking the Cycle of Rejection, which raises awareness of the wider system and other key agencies that encounter people with personality disorder. This guidance specifically mentions general health services, including emergency departments and primary care organisations. The need to equip non-mental health agencies with improved knowledge, understanding and awareness is described, and as a result training initiatives are being introduced across the UK. An example of this nationally recognised training, 36 october 5 :: vol 26 no 5 :: 2011

Borderline personality disorder


BPD is one of ten personality disorder types that are divided into three different clusters. BPD falls into cluster B (dramatic, emotional or erratic behaviour) of the diagnostic criteria most commonly used, which includes antisocial, histrionic and narcissistic personality disorders (APA 1994). Key traits or patterns of behaviour commonly associated with BPD include difficulty in maintaining stable relationships, poor self-image, difficulty in controlling emotions, marked impulsivity often resulting in self-injurious behaviour and transient psychotic symptoms. Women with BPD are more likely to come into contact with services (NICE 2009). BPD is more prevalent in deprived urban areas, and it decreases in prevalence with age (Coid et al 2006). As many as 75% of people with BPD also

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self-injure (Kerr et al 2010). People are rarely diagnosed as having BPD before the age of 18 years as their personalities are not fully developed until adulthood (APA 1994). Causal factors for BPD continue to be discussed in the literature, however there is a common consensus that both genetic and early developmental experiences, including physical, sexual and emotional abuse, have an important role in the development of BPD (Lieb et al 2004, Suyemoto 1998). There are reports that up to 71% of people with a diagnosis of BPD have experienced childhood sexual abuse; however, many people who have not experienced this form of abuse can also develop BPD (Lieb et al 2004). Lack of secure and stable attachments with others during childhood is often seen in patients with BPD (Lieb et al 2004).

Hopkins (2002) suggested that the perspectives and experiences of people who self-injure should be explored to educate staff and improve understanding of these patients. This is further supported by the NICE (2004) guidance on self-injury. For the purpose of this article people with experiential viewpoints are defined as

BOX 1
Criteria for formal diagnosis of borderline personality disorder
Four of the following criteria need to be identified for a formal diagnosis of borderline personality disorder: Affective difficulties such as: 4Intense anger. 4Chronic feelings of emptiness. 4Marked emotional disturbance. Cognitive difficulties such as: 4Transient stress-related paranoia, or severe dissociative experiences. 4Persistent or unstable self-image. Impulsive behavioural disturbance such as: 4Recurrent suicide attempts, gestures, threats and self-injury. 4Impulsivity in other self-damaging behaviours. Interpersonal difficulties such as: 4Effort to avoid abandonment in relationships. 4A pattern of unstable interpersonal relationships.
(Lieb et al 2004)

Self-injury
NICE (2004) define self-injury as intentional self poisoning or injury, irrespective of the apparent purpose of the act. Self-injury can present in many forms including overdosing, ingestion of foreign objects, head banging, lacerations, burning, hair pulling and ligaturing (National Self Harm Network 2008). Patients who self-injure have a risk of suicide 100 times greater than the general population (NHS Centre for Reviews and Dissemination 1998). Self-injury is described in different ways, many of which hold negative and stigmatising connotations, such as self-mutilation and deliberate self-harm. These labels imply that self-injury is chosen and deliberate. The majority of people who self-injure are aware of their actions during self-injury and can give a clear account of why they have self-injured. However, NICE (2004) also explained how some people, especially those with a history of child abuse, may unintentionally self-injure during dissociation or trancelike states, hence describing this as being a non-deliberate or uncontrolled act. Low et al (2000) supported this notion and described childhood sexual abuse as being a key developmental factor that can result in later self-injurious behaviours. A high prevalence of self-injury has been established in patients with BPD. Self-injury alone, however, does not constitute a definite diagnosis of BPD. A further four of nine possible criteria need to be identified for a formal diagnosis of BPD to be reached (Box 1). Not everyone who self-injures will have a diagnosis of BPD, however similar evidence-based interpersonal responses that are used in BPD are likely to have transferable benefits when working with patients who self-injure (APA 1994).

BOX 2
Experts by experience narratives: why people self-injure

4I self-harm as a form of self-punishment as sometimes I feel I am a bad


person and hate myself, this occurs during bouts of depression when nothing seems positive and my life appears worthless.

4Self-injury can stop you feeling numb, the physical pain from self-injury
makes you feel human again, physical pain can be seen and is easier to understand than the emotional pain that is not visible.

4I started self-injury by cutting my forearms to release pent-up tension,


anxiety and stress, by seeing blood it made me feel like the badness was running out of me.

4I have used self-injury to cope with my emotions as I had previously


been trained to hide emotions (by an abuser).

4When people self-harm they do it to hurt themselves, they dont see the
hurt it causes to others. Bad things have happened to me that I had no control over. Self-harming allows all that badness that was inserted into me to leave me in the same way, but with self-harm I am now in full control.

4Self-injury releases pressure and relief from stressors and worries


that build up, however it is often something minor that acts as my breaking point.

4I self-harm as I dont have other coping mechanisms such as talking


things over with someone.
The narratives were provided by the following expert by experience groups: 5 Boroughs Partnership NHS Foundation Trust Personality Disorder Hub, Wigan Multi-Agency Experts by experience representatives and No Secrets Self-Injury Support Group.

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experts by experience. The viewpoints of experts by experience have therefore been included in this article in line with these recommendations. People who self-injure describe many functions of self-injury. There is an increased risk of suicide in people who self-injure, however self-injury is rarely a suicide attempt but is more often used as a coping mechanism for dealing with emotions and past traumas (National Self Harm Network 2008). Some people who self-injure describe self-injuring in response to suicidal thoughts, however the function of self-injury is often not to cause death but to reduce and cope with the suicidal thoughts (National Self Harm Network 2008). Some people do, however, self-injure in an attempt to end their lives. Crawford et al (2003) described self-poisoning as the most common form of self-injury and claim that 41% of non-accidental self-poisoners overdose with the intent to die. This type of self-injury therefore indicates an increased risk of suicide, which would need to be risk assessed further by a mental health professional and the necessary support put in place to manage this risk and offer the patient appropriate levels of support and treatment. Many staff describe feeling uncomfortable with the management of risk when working with people who self-injure. Although people who self-injure may be at increased risk of suicide because of the nature of their self-injury, many who self-injure would oppose this view. When managing risk it is vital to spend time with the patient in an attempt to understand the function of his or her self-injury. Self-injury may serve numerous functions for an individual. A person who frequently attends a healthcare facility following self-injury may on each attendance have different reasons or functions for self-injury. It is therefore important to try to discover the reason or function of the self-injury on each presentation. A new psychosocial assessment and risk assessment is therefore required each time a patient presents even if the nurse has frequent clinical contact with the patient, the nurse should not assume that he or she knows what the function of self-injury is on this occasion (Horrocks et al 2003). Box 2 provides narratives from people who self-injure. The narratives were individually provided in a written format using an information-gathering form, which was developed by the author. These narratives were included because experts by experience are best placed to inform the reader why they self-injure and to describe unique and individual functions of, and reasons for, self-injury.

TABLE 1
Experiences of experts by experience in non-mental health settings
Positive experiences Nurse at A&E treated my injuries as if they had been caused accidentally and was respectful. Made me relax and feel respected. Nurse listened and took time to try and understand my difficulties. Felt listened to and understood. Nurse in a walk-in centre was not afraid to ask me more about why I had self-injured, made me feel relaxed. Nurse in walk-in centre made sure I had support from mental health services, she clearly cared and made me feel valued. Doctor offered me pain relief while stitching my wounds, he explained everything he was doing and helped put me at ease. Referred to secondary mental health service for assessment, made me feel deserving of help and listened to. Negative experiences Nurse in a walk-in centre asked me if she should bother with anaesthetic before stitching my wound, I felt humiliated. Nurse at A&E made me wait until everyone else had been seen in the waiting room, made to feel like the other people were more deserving of treatment and that I shouldnt be seeking treatment. A nurse told me I was stupid for scarring myself and that everyone gets depressed but that most dont self-injure, left me feeling belittled and ashamed. Told by a nurse to stop wasting their time, that they should be treating real injuries, felt hurt. Overheard staff laughing that I would have a big hangover the next morning after overdosing, made me feel belittled and reluctant to go back for other injuries.

Improving the therapeutic relationship


In order to improve the therapeutic relationship when working with people who self-injure, it is important to find out what their expectations of services are and how they would like to be treated. The question how do people who self-harm want to be treated? is best addressed by exploring the experiences of patients in relation to staff responses to self-injury in a non-mental health setting. Table 1 provides some examples of positive and negative experiences and the emotional effects on people with BPD who have self-injured. The narratives are useful when reflecting on our own practice. It is important to challenge our assumptions about self-injury and to emphasise and adopt non-judgemental interpersonal responses. The positive narratives are as important as the negative narratives. This article aims to encourage nurses to reflect on their practice when working with people who self-injure. It is important that nurses increase their awareness of their prejudices in an attempt to work more effectively with people who present with BPD and/or self-injury. Rayner et al (2005) suggested that working with people who self-injure will always evoke an emotional response and that feelings of helplessness, despair and the associated anxiety that the patient presents with can be transferred to the nurse. This process is often

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referred to as countertransference (Rayner et al 2005). These emotional responses can trigger a negative interaction between the nurse and the patient. Having an awareness of countertransference may help the nurse to reduce his or her negative thoughts and can assist nurses in altering their own reactions and behaviours, resulting in a more effective interpersonal treatment response (Rayner et al 2005). Working with self-injury and people with a diagnosis of BPD can be challenging, as staff may lack awareness or knowledge of dealing with patients who present with these difficulties, or feel ill-equipped to support their needs. Some practitioners will have preconceived ideas and opinions about self-injury and BPD, however raising awareness helps to challenge these opinions. Working with people with these difficulties can be emotionally demanding and it is important to recognise the emotional impact this can have on the staff providing care. When this is combined with stigmatisation and resentment from within organisations, it is even more difficult to provide positive treatment experiences. Effective interpersonal responses are paramount when working with people with BPD and self-injury. Although non-mental health nurses will most commonly have a clinical role to provide physical interventions to these patients, the interpersonal interventions and delivery of treatment can have a powerful psychological

effect on the individual. The nurses interpersonal responses can start a process of healing and stabilise emotions. Box 3 provides a list of helpful strategies for nurses working with people with BPD and self-injury. All staff working with people with BPD and self-injury require increased awareness and understanding of the presenting issues, skills to treat these patients more effectively and a consistent team approach that supports best practice and empathetic treatment responses.

Implementing the NICE guidance


NICE (2004) provided best practice guidance for working with people who have self-injured. This guidance is of great importance and relevance to mental health and non-mental health nurses. It outlines the physical treatment of self-injury as well as psychological treatment. The key physical recommendations include: 4Effective engagement achieved through understanding and empathy. 4Rapid assessment of physical and psychological needs. 4Self-injury should prompt staff to commence a psychosocial assessment and risk assessment. 4A timely treatment response to minimise pain and discomfort. 4Adequate anaesthetic or analgesia should be offered during painful treatments.

BOX 3
Strategies for working effectively with people who have borderline personality disorder and self-injure

4Increase awareness of borderline personality disorder (BPD) and self-injury to improve understanding and increase empathy. 4Provide a consistent team approach all members need to have improved awareness and understanding of the approaches discussed
in this box (Sampson et al 2006).

4Listen to the patient using listening skills can be a valuable intervention. Listen to the persons story, consider how you might feel in
his or her situation and listen as if this is the first time you have heard these problems.

4Validate and display an understanding of the patients emotions validation is an interpersonal technique that shows the patient that
the nurse understands his or her problems and actions even when the nurse does not necessarily agree these are the best responses.

4Display hope and optimism people with BPD can and do get better (NICE 2009). Suggesting peer support groups can be beneficial
to people who self-injure (NICE 2009). Ask your local mental health services about any local support groups. It may also be helpful to suggest using the internet for online support and information.

4Increase self-awareness to be aware of the effects that interpersonal and physical interventions can have on a person with BPD or
self-injury. When treating self-injury try to treat the injury with the same empathy and understanding as if it had been caused accidentally.

4Engage with patients with BPD and self-injury breaking the cycle of rejection for people with BPD is every health professionals
responsibility, not just that of mental health services (NIHME 2003b).

4Debrief and seek support or supervision, have supportive team approaches in place to support team members to deal with their own
emotional responses (Bland and Rossen 2005).

4Employ collaborative working approaches. Hopkins (2002) suggested that closer relationships between non-mental health nurses and
mental health nurses should be forged in an attempt to bridge any gaps in knowledge.

4Recognise countertransference when working with people who self-injure. This can reduce nurses negative thoughts, which in turn
can enhance treatment and interpersonal responses and improve the patient experience (Rayner et al 2005).

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4Sedation should be offered when treatment of self-injury is likely to trigger distressing memories of previous abuse. 4Prompt and effective psychological and psychiatric treatment. 4Collaboration with the other agencies supporting the patient. Hughes and Kosky (2007) tested a simple screening tool that covers the key recommendations set out by NICE (2004). They stated that this can be an effective method to ensure that the NICE (2004) guidelines for self-injury are adhered to. Three months after the screening tool was implemented, improvements were noted in the quality of risk assessments and the information recorded. This assessment tool includes prompts to ensure that mental health is considered within the assessment framework, that relevant professionals involved are identified, and a risk assessment and a flow chart outline potential care pathways.

Conclusion
People who present with BPD or self-injurious behaviours are often stigmatised by healthcare providers and society, excluded from services and misunderstood. This can lead to ineffective interpersonal responses and negative treatment experiences for the individual. If awareness of BPD and self-injury can be raised and the presenting individuals better understood, treatment experiences and responses will also improve. This will not only provide a better service to people with BPD but will also have positive effects on the nursing staff working with them NS Acknowledgement The author would like to acknowledge and express special thanks to the expert by experience representatives who supported and offered their valuable contributions to this article.

References
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