J Pers Disord. Lahey T. A proposed medical school curriculum to help students recognize and resolve ethical issues of global health outreach work. Federal government websites often end in .gov or .mil. Some participants stated that moral distress, while unpleasant, may actually assist the trainees in their personal development of obtaining a moral compass, as well as humility and self-awareness: If you consistently have moral distress even though you are doing the things that all the principles tell you [] part of what happens in ethical practice is figuring out what resonates with who you are as a human being. The above article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. Although the evidence for drug therapy is less conclusive than for the psychosocial interventions, US data indicate that prescribing rates for borderline personality disorder are paradoxically high. Comorbidity with other personality disorders and with mental state disorders is the norm. Examining the Construct Validity of Borderline Personality Traits Using Familial Aggregation and Other External Validators. Further, this study did not obtain the perspectives of trainees. Revised NESARC personality disorder diagnoses: gender, prevalence, and comorbidity with substance dependence disorders, The prevalence of personality disorders in a community sample. Nurs Clin North Am. Articulate the most current research on identification, prevalence, comorbidity, course, and treatment of BPD to guide clinical decision-making processes and enhance research, administration, consultation, and policy work. government site. Gunderson JG, Stout RL, McGlashan TH, Shea MT, Morey LC, Grilo CM, et al. The site is secure. The fourth theme, moral development, refers to the development of a moral compass and the exercise of humility and self-awareness. We also acknowledge that the results of our study are based on the perspectives of U.S.-based health professionals, whose interpretation of ethical issues will likely be different to those local providers living and working in the resource-constrained setting. 2000 Apr;157(4):601-8. doi: 10.1176/appi.ajp.157.4.601. What's wrong with being "borderline ethical"? Clipboard, Search History, and several other advanced features are temporarily unavailable. In addition to problems in relationships, work, and physical health, many people with BPD also suffer from legal issues. Participants provided 11 examples of ethical dilemmas associated with global-health outreach work that they had experienced and that they suggested trainees could also potentially encounter. Burrin C, Daniels NF, Cardinal RN, Hayhurst C, Christmas D, Zimbron J. All authors contributed to the design, implementation, analysis and preparation of the manuscript. Three of these themes (cultural differences, professional issues, limited resources) are categorized under the core category of external issues. 2022 Apr-Jun;VII(2):93-102. doi: 10.20529/IJME.2021.096. In addition, this figure also highlights potential indirect relationships between some ethical issues and other themes that could be considered when developing curriculum content. We knew that likely this patient would die without a pericardiocentesis. Scope of practice issues place visiting trainees in extremely difficult ethical dilemmas, where the norms they have been taught in school challenged their ethical intuitions in unfamiliar situations. 1994 Sep;151(9):1316-23. doi: 10.1176/ajp.151.9.1316. Would you like email updates of new search results? Family members knowledge about borderline personality disorder: correspondence with their levels of depression, burden, distress, and expressed emotion, Comorbidity and associated severity of borderline personality disorder and physical health conditions in a nationally representative sample. Federal government websites often end in .gov or .mil. Korecki JR, Schwebel FJ, Votaw VR, Witkiewitz K. Subst Abuse Treat Prev Policy. Clinical Practice Guideline for the Management of Borderline Personality Disorder. New York: Nova Publisher; 2016. Another professional issue that many participants discussed was their perception of direct or indirect exposure to corruption. Crawford TN, Cohen P, First MB, Skodol AE, Johnson JG, Kasen S. Comorbid Axis I and Axis II disorders in early adolescence: outcomes 20 years later. Abdul-Quader A.S., Heckathorn D.D., McKnight C., Bramson H., Nemeth C., Sabin K., Gallagher K., Des Jarlais D.C. official website and that any information you provide is encrypted For example, participants reported cases that compelled them to reconsider their duty to inform the patients of the true nature of their affliction and the circumstances of the proposed treatment. However, this can present an ethical dilemma for nursing and medical staff, with these clinician responses shifting between the moral principles of beneficence . Please enable it to take advantage of the complete set of features! Effectiveness of a responder driven sampling for recruiting drug users in New York City: Findings from a pilot study. The authors observed a regular escalation of self-harming behaviours and increased suicidal ideation in these patients just before discharge, possibly indicating their underlying anxiety in going back to the home environment. Collaborative goal setting is fundamental to successful prescribing. The inability to self-soothe can lead to . This discussion highlights the ethical components of these questions. At least two reviewers independently analyzed the data and participated in all coding. Opening our hearts and minds: The meaning of international clinical nursing electives in the personal and professional lives of nurses. We audio-recorded all focus groups and the interview. This need not be a deterrent to becoming involved in their care, but it does require a degree of self-reflection and self-monitoring. Disclaimer. The results of this study have identified two core overarching educational goals of a pre-departure global-health curricula. Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study. Some participants voiced concerns regarding the troubling power dynamics at some destinations. Copyright 2018 Elsevier Inc. All rights reserved. Future work should include the perspectives of both these stakeholders. We transcribed each of the focus groups and interview verbatim. Conflict of interest: Andrew Chanen was a member of the development group for the National Health and Medical Research Councils Clinical Practice Guideline for the Management of Borderline Personality Disorder. Int J Med Res Pharm Sci, 2017; 4(3): 3844. Andrea Rosenhaft. J Pers Disord. Patient personality characteristics and therapeutic integration: treating borderline personality and emotionally dysregulated-dysphoric personality features. However, access to these treatments is limited in the Australian healthcare system. Relevant ethical issues and challenges are considered, and both seminal treatment studies and often neglected findings are highlighted. Psychiatry Research, 2018; 259: 323329. Am I doing all the work? Drugs are prescribed for 78% of patients for more than 75% of the time over a sixyear period and polypharmacy occurs in 37% of patients,32 perhaps reflecting clinical needs and pressures. Healthcare management. Careers. Optimal ethical and clinical interventions, in most cases, overlap. government site. Borderline personality disorder in primary care, Borderline personality disorder among primary care depressive patients: a five-year study, The frequency of personality disorders in psychiatric patients. One participant proposed that in such a case one might argue: [] that the beneficent thing to do is to withhold that information if the family is saying, No, he cant handle this. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). frequent displays of temper, constant anger, recurrent physical fights), Transient, stress-related paranoid ideation or severe dissociative symptoms. National Collaborating Centre for Mental Health. Vignettes and role plays are used to bring EBP to life. To ensure multi-professional input, we initially identified participants from the UCSF Schools of Medicine, Nursing and Pharmacy who were known to have professional experience working, or teaching, as providers in resource-limited settings. The .gov means its official. Another repeated concern involved the expectation that trainees perform outside of their scope of practice due to insufficient workforce at local sites. However, this takes on particular significance when the condition being treated is fundamentally a relational disorder. This site needs JavaScript to work properly. Ethical Issues in Assessing and Treating Borderline Personality Disorder - DocShare.tips A review and discussion of ethical issues which commonly arise in the treatment of individuals with (features of) Borderline Personality Disorder, including boundaries, suicide, self-harm, assessment & diagnosis, treatment, and more. Stress caused by difficulties encountered in ensuring that BPD patients comply with the therapy regularly places doctors and nurses at crisis point. In light of the clinical needs and pressures, and the harm associated with prescribing for these patients, the NHMRC16 and UK National Institute for Health and Care Excellence (NICE)28 have considered the controlled trial evidence. Investigation of a larger group of participants could contribute additional experiences that would affect our categorization of ethical topics and themes. What distinguishes borderline personality from these other disorders is that the features are present most of the time and comprise part of the patients usual self. A model of integrated care comes from Max Weber who differentiated between formal rationality, the endorsement by healthcare managers of the most efficient ways of achieving organisational goals (e.g., ensuring more hospital beds by quick discharges of bed blockers), and substantive rationality, the expectation by healthcare professionals that values and morals should instead be based on tradition, compassion and dedication13;pertinent to the care of BPD patients in our case. Hence, in the authors experience, any attempt to establish a long-term therapeutic relationship with BPD patients might have limited outcomes. There are no supplies. Borderline personality disorder is a severe mental disorder that has its onset during adolescence and emerging adulthood.1 It affects up to 3% of the population2,3 and occurs almost equally among males and females.4. The DSM-5 criteria for borderline personality disorder are listed in Box 1.18 Although the DSM-5 requires any five of these nine criteria in order to make a diagnosis, even low levels of borderline pathology (e.g. Careers. The trainees that I work with are mainly integrated in the programs and theyre getting certain skills, and they know they are going to work in the field long term. Patients with borderline personality disorder are frequent users of inpatient mental health units, with inpatient crisis intervention often used based on the risk of suicide. The use of drugs can be considered in acute crisis situations where psychological approaches are not sufficient. Disclaimer. Treatment of Patients With Borderline Personality Disorder 7 INTRODUCTION This practice guideline summarizes data regarding the care of patients with borderline person-ality disorder. We had a similar situation there where we were going to collaborate with the department of public health to do the initial survey. 2009 Mar 15;104(3):264-70. doi: 10.1007/s00063-009-1041-7. 8600 Rockville Pike "Primum non nocere" and the principle of non-maleficence. Also, the skills needed by healthcare personnel to reduce chronic self-harming and suicidal ideation in this vulnerable population are complex and need to be updated on an on-going basis also due to the tendency of these patients to raise allegations towards their healthcarers3. Eleven of the participants were female and seven male. An official website of the United States government. Elansary M., Graber L.K., Provenzano A.M., Barry M., Khoshnood K., Rastegar A. Unable to load your collection due to an error, Unable to load your delegates due to an error. Price J. Coding: Open coding. Attempts by patients with BPD to self-harm or commit suicide intensify over weekends or public holidays as their sense of solitude increases during these periods, especially when there is also a shortage of healthcare professionals available for immediate support. Epub 2008 Feb 20. Careers. sharing sensitive information, make sure youre on a federal Once each phase of coding had been completed, coders met and discussed the various codes and coding decisions, to determine agreement and disagreement. 2003 Jun;48(5):301-10. doi: 10.1177/070674370304800505. The .gov means its official. The collaboration of all those involved parties is also important to reduce the risk of silo management where confined and regional policies do not embrace a wider perspective for the management of specific problems while responding only within the confines of the own guidelines and procedures14.In these cases, integrated care in communities can halt self-harming and suicidal attempts of patients with BPD. Butteris S.M., Gladding S.P., Eppich W., Hagen S.A., Pitt M.B., Sugar Investigators Simulation use for global away rotations (SUGAR): Preparing residents for emotional challenges abroadA multicenter study. Unauthorized use of these marks is strictly prohibited. It is associated with adverse long-term outcomes that include severe and persistent functional disability,9 high family and carer burden,10 physical ill health,11 and premature mortality,12 including a suicide rate of 8%.13 People with the disorder use mental health services continuously for long periods of time.14 After schizophrenia, borderline personality disorder is the most costly psychiatric disorder to treat in Australia on a per case basis.15. The authors would like to thank Dr Louise McCutcheon for comments on an earlier version of this manuscript. The .gov means its official. [(accessed on 23 June 2016)]. Evidence-Based Treatment of Borderline Last chance to save on APA 2023 registration! I didnt even know how to practice in that setting. Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study. Some strategies to assist in this task can be drawn from the common characteristics of evidence-based treatments in Box 2, e.g. As observed by the authors of the current editorial, increased suicidal ideation in persons with BPD also occurs during minor crises in life, when experiencing intensified flashbacks about past abuses, during minor losses, after significant conflicts with others and after the separation from influential people in their social network. An official website of the United States government. This site needs JavaScript to work properly. Available online: Stanford Center for Innovation in Global Health Ethical challenges in short-term global health training. MeSH terms Economic Competition . Accessibility 5 It affects around one-quarter of primary care . A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: Despite the evidence of the reliability and validity of the diagnosis, and the treatability of the condition,20 many people with borderline personality disorder remain undiagnosed in clinical practice. This relates to external environmental and/or situational issues that trainees are confronted with. The site is secure. As a reaction, the authors observed that BPD patients demand endless and unconditional attention from their primary carers. Drug treatment might be warranted for patients who have a co-occurring mental disorder such as major depression. HHS Vulnerability Disclosure, Help 1 - 3 The https:// ensures that you are connecting to the 2014 Jan;5(1):108-16. doi: 10.1037/per0000055. 1 It affects up to 3% of the population 2, 3 and occurs almost equally among males and females. Available online: Addo-Atuah J., Dutta A., Kovera C. A global health elective course for PharmD Curriculum. This article examines the use of crisis intervention through moral duties, intentions and consequences, culminating in an action/consequence model of risk management, used to explore potential outcomes. 2020 Jul 29;15(1):51. doi: 10.1186/s13011-020-00293-3. Borderline personality disorder and the ethics of risk management: The action/consequence model Patients with borderline personality disorder are frequent users of inpatient mental health units, with inpatient crisis intervention often used based on the risk of suicide. This scenario has created discrepancies in health care policies about treatments and hospital (re)admissions of patients with BPD reaching an epidemic magnitude in many healthcare trusts. Borderline personality disorder (BPD): prevalence, management, options and challenges. But, it is difficult to be both. For example, Stanford and John Hopkins online global health ethics training currently present a case study under the topic shifting resources that describes how local resources can inappropriately be diverted to support trainees on their placement [25]. Since the 1990s there has been growing optimism and enthusiasm for the treatment of borderline personality disorder. Borderline Personality Disorder (BPD): Prevalence, management options and challenges (1st ed.). The authors declare no conflict of interest. [] So I said I wonder if [the traditional vaccinations] would also facilitate HIV transmission. And somebody at the table said, Okay, were going to make a policy that nobody can give traditional vaccinations!. HHS Vulnerability Disclosure, Help So many of the countries Ive worked in have so few actual pharmacists, but they still have to have people to provide medicine. Callister L.C., Cox A.H. In: Anderson R (Ed.) Bethesda, MD 20894, Web Policies Omega-3 polyunsaturated fatty acids might reduce the overall severity of borderline personality disorder.27. Please enable it to take advantage of the complete set of features! Occasionally, even local professionals who were more experienced than the participants themselves would defer to their opinions. In this comment, the author says that BPD-Compass is described as comprehensive and short term. Global health electives have been shown to be valuable, beneficial and highly relevant for those trainees and health professionals who participate [3,4,5]. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days), Inappropriate, intense anger or difficulty controlling anger (e.g. [] these were mostly physicians, and I was the only nurse there. It may not be sustainable once we walk out the door, so do we save the persons life at that moment or do we just continue to try and train people there about how to care for people? Would you like email updates of new search results? In general, both groups recommend against prescribing psychotropic drugs for treating borderline personality disorder. Accessibility Data was analyzed in NVivo 9 (QSR International Pty Ltd., Doncaster, Australia). We then sent the same email invitations to those potential participants until representation from each multi-professional group was confirmed. For example, a person with borderline personality disorder also may be more likely to experience symptoms of major depression, PTSD, bipolar disorder, anxiety disorders . Letkiewicz AM, Spring JD, Carrillo VL, Shankman SA. Participants agreed that the important thing in all morally distressing situations is that global health trainees have a reliable moral and personal guidance that they can rely on. Referral for one of these first-line treatments is recommended.16,24 No single treatment is recommended over another and they have common core features (Box 2).25 Treatment guidelines include one published by the Australian National Health and Medical Research Council (NHMRC).16, Systems training for emotional predictability and problem solving, Approaches to prototypic borderline personality disorder problems are structured (manual-directed), Patients are encouraged to adopt self-control (i.e. In some areas, health workers were expected to refrain from delivering diagnoses that would cause too much emotional distress to a patient. Thus, clinicians are justified in using any of these efficacious treatments. I dealt with anorexia, major depressive disorder, and borderline personality disorder. Getty Images. describe this phenomenon as clinical limits in their series of case studies highlighting ethical dilemmas in global health electives [24]. Trull TJ, Jahng S, Tomko RL, Wood PK, Sher KJ. and transmitted securely. TREATING BORDERLINE PERSONALITY DISORDER Quick Reference Guide Based on Practice Guideline for the Treatment of Patients With Borderline Personality Disorder,originally published in October 2001. 2006 Jan;19(1):95-101. doi: 10.1097/01.yco.0000191498.69281.5e. Consequently, community teams, general practitioners and hospital staff feel hopeless due to recurrent readmissions of people with BPD and the lack of definitive treatment for such pathology. A different study, involving Canadian resident psychiatrists self-reflecting on their work in Ethiopia, found that they had entered their placement with a number of pre-existing biases towards their host institutions and communities [5]. Imagine struggling to manage stress, rejection or conflict. Pompili M, Girardi P, Ruberto A, Tatarelli R. Suicide in borderline personality disorder: a meta-analysis. Izadnegahdar R., Correia S., Ohata B., Kuile S., Vaillancourt S., Saba N., Brewer T.F. Elansary M., Kallem S., Peluso M., Thomas J., Rabin T. Global health clinical ethics. Radstone S.J.J. PMC De Zutter AWEA, Horselenberg, Peter J. van Koppen PJ. This is what it's like to live with Borderline Personality Disorder : a mental health condition characterized by a pattern of ongoing instability in moods, behavior, self-image and functioning. Healthcare workers beliefs about the role of medical students during their electives. People with borderline personality disorder typically present to health services during times of crisis, following self-harm, because of the consequences of impulsive and self-damaging behaviour, or because of poor physical, sexual and reproductive health. According to Page Six, "Meet Cute" actor Pete Davison is presently in rehab and is being treated for borderline personality disorder and PTSD.He's reportedly in the same Pennsylvania facility as . [Should hospitalization be required after the emergency discharge of patients with borderline personality disorder who have attempted suicide (FRENCH CRISIS cohort)?]. Keywords: One point of difficulty is the tendency of patients with BPD to split their teams and to create niches of protectors and opposers within staff with possible conflicts within the team that is treating them. We conducted a qualitative study involving focus groups and an interview at the University of California San Francisco. [(accessed on 23 June 2016)]. Honest and open discussion about whether a trial of a drug is warranted or has been effective is fundamental. PMC Eighteen participants provided examples of ethical dilemmas associated with global-health outreach work. official website and that any information you provide is encrypted Borderline personality disorder is a leading cause of disability and mortality and is common in clinical practice. mood, anxiety, eating and substance use disorders) can overwhelm the clinical picture, but this does not indicate that the underlying personality pathology is unimportant or should be a secondary concern.21 Rather, there is evidence to suggest that personality disorder might be a key vulnerability factor for recurrent mental state disorders.22,23 Patients with borderline personality disorder who have these co-occurring conditions should be treated for these conditions in accordance with best practice. These additional participants are then also asked to identify more participants who are then invited.