Multidisciplinary team care and the challenges of borderline personality disorder

Abstract

Objective

There are relatively few papers addressing the challenges faced in the care of people with Borderline Personality Disorder in healthcare systems. We therefore present a clinical perspective on multidisciplinary team management of Borderline Personality Disorder.

Conclusions

Borderline Personality Disorder has historically attracted significant stigma, partly due to negative, inaccurate beliefs regarding prognosis. Unique challenges may be encountered treating this condition, which, if not appropriately recognised and managed, contribute to and perpetuate stigma and poor outcomes. Potential challenges that may arise for multidisciplinary team care include splitting of teams, negative emotional contagion, fragmentation of care, patient re-traumatisation, frequent admissions, medicalisation, and de-medicalisation of Borderline Personality Disorder. We describe these challenges to facilitate multidisciplinary team discussions that promote greater awareness and better management for the benefit of patients and clinicians.

Absence is a house so vast that inside you will pass through its walls and hang pictures on the air.

― Pablo Neruda

Borderline Personality Disorder (BPD) is a contentious diagnosis that has historically attracted stigma and therapeutic nihilism due to beliefs that the diagnosis is not amenable to treatment, despite evidence to the contrary. ¹ Controversy remains about the conceptualisation of BPD as either a specific personality disorder or a high level of general impairment on a continuum of personality functioning. ² When BPD symptoms are examined in factor analytic studies, they are scattered over a range of both personality and other disturbances, and lack specificity. ³ For the purposes of this clinical perspective, we define BPD as a moderate to severe personality disorder with a wide range of associated symptoms and reduced social, psychological, and occupational functioning. ⁴

The complexity of BPD requires skill in planning effective multidisciplinary care. ⁵ Psychotherapy is the mainstay of treatment for BPD, and, when used appropriately, patients with a diagnosis of BPD may improve more substantively and rapidly than historically expected, and maintain improvements for longer than other psychiatric disorders. ⁶ However, care for patients with a diagnosis of BPD may be inconsistent and potentially harmful, through the negative influence of individual, cultural, and healthcare systemic issues.^5,7 Marcus Evans wrote about ‘Problems in the Management of Borderline Patients’ in the late 20^th century, highlighting the ways in which inaccurate negative beliefs about people with a diagnosis of BPD precipitate and perpetuate interpersonal conflict between patients and clinical staff. ⁸ Since this time, people with severe personality disorders have continued to experience discrimination in healthcare settings, and negative attitudes persist to degrade care. ⁹ Paradoxically, a lack of training and lack of confidence may arise from collective team negative countertransference and clinicians’ avoidance of care for those with personality disorders. ⁵ Additionally, unwarranted fear of litigation for adverse outcomes may contribute to high-intensity, unstructured treatments, which can cause complications for patients. ⁷

Whilst there is considerable research into the psychopathology, diagnosis, and psychotherapy of BPD, relatively little attention has been given to multidisciplinary team treatment challenges. Building on research around the complications associated with psychotherapy for BPD, we aim to provide a clinical update regarding potential challenges and complications of BPD management more broadly, within healthcare systems and outside of psychotherapy.

Challenges and complications of BPD management

Team splitting

‘Splitting’, a psychological phenomenon common in BPD, refers to experiencing shifts of emotional perception of others and the self, resulting in fluctuations between idealisation and devaluation. ¹⁰ Failure to recognise and manage splitting is a significant problem in healthcare services. Patients may idealise one part of a multidisciplinary treating team while devaluing another or may shift through idealisation to devaluation of any clinician. Splitting can contribute to fractures in therapeutic alliances, both between a patient and their primary clinicians and amongst teams. Splitting within the treatment team may perpetuate a disorganised attachment style for patients. If not adequately recognised, splitting may inadvertently evoke rivalries between staff and frustration with patients; subsequent disharmony may be distressing for both patients and staff. ⁸ Failure to recognise the impact of splitting on team dynamics can also result in disjointed care for patients, leading to perceived rejection and, at its worst, regression. If splitting is anticipated, and open communication occurs within treating teams, the impacts of splitting may be greatly reduced through team members becoming aware of the effects of idealisation and devaluation on them. Team members should be united and work to create an atmosphere that is conducive to allowing the patient to simultaneously experience positive and negative aspects of important relationships, including relationships with staff, to help reduce the salience of splitting. ⁸

Negative emotional and behavioural contagion

Social contagion theory states that behaviour may be learned by observing others and modelling behaviour. ¹¹ Contagion is a risk in groups where self-harming behaviours may be present. ¹² In addition, the spread of ideas, behaviours, and affect may result in the contagion of mood states, such as depression. ¹³ People with a diagnosis of BPD report higher levels of emotional contagion, compared with healthy controls. ¹⁴ It is therefore important that special consideration be given to how topics such as self-harm are discussed in healthcare settings. Dialectical Behaviour Therapy (DBT) usefully recommends participants to not discuss problem behaviours (including self-harm and suicidal behaviours) in groups. ¹⁵ It is important to note however that DBT and other therapeutic modalities do maintain a specific focus on discussing these behaviours in the individual therapy context so that they are addressed and patients do not feel limited in what they discuss. In this way, there is a focus on helping patients understand and change these behaviours in a manner that is both validating and safe for the others and systems that surround them.

Fragmentation of care/lack of care coordination

Due to the interactions of people with a diagnosis of BPD with multiple levels of healthcare systems (from primary through to acute tertiary care), there are substantial risks of fragmentation of care. As symptoms and the attachment disturbance of BPD may exist across the lifespan, continuity of care is essential. Coherent treatment strategy, role clarity, and continuity of care are therefore important recommendations for managing BPD, according to the American Psychiatric Association. ¹⁶ Unfortunately, clinical roles within treating teams are not always explicitly defined to patients, nor are these always practically demarcated due to exigencies of team functioning, and a dynamic environment is common. This can be confusing for patients, and may encourage and perpetuate splitting. Treating teams are also likely to be multi-disciplinary, and each clinician may offer different advice or management strategies according to their specific healthcare discipline and expertise. Teams need specified united strategies that all agree on. Clinical pathways have been suggested to help coordinate care and encourage consistency in BPD management. ⁷ For people with a diagnosis of BPD who struggle with metacognitive organisation (i.e. knowledge and understanding of one’s own thinking), consistency of approach is fundamental and stabilising.

Re-traumatisation

Amongst those with a diagnosis of BPD, there are high rates of childhood trauma, so the social climate of clinical settings may be potentially re-traumatising. Clinical settings, through environmental and interpersonal risks, may elicit emotional dysregulation, regression, and behavioural expressions of distress. ¹⁷ In public hospital settings, lack of privacy, high levels of auditory and other stimuli, and exposure to other patients and their histories are environmental factors that may provide reminders of a patient’s past trauma. Clinicians may fail to recognise triggers of trauma, and instead respond to distress in ways that induce further trauma, such as using coercive measures like restraint and seclusion in emergency departments or inpatient units, which can provide reminders of past trauma. Disregarding patients’ views or other forms of emotional invalidation may also be experienced as traumatising. ¹⁷ Therefore, implementing trauma-informed practices has potential to evoke positive shifts in treatment settings, thus reducing the risk of re-traumatisation and improving clinical and team outcomes.

Long hospital stays/frequent admissions

Risk management for people with a diagnosis of BPD is a challenging concept that can trigger over- or under-emphasis of risk. For example, recurrent risk of suicide may incur medico-legal liability, which may then result in patients being admitted for fear of litigation, rather than for therapeutic benefit. Consequently, many people with a diagnosis of BPD experience frequent or lengthy hospital admissions, which may cause harm. ⁷ Long hospital stays prevent patients from adaptive coping in the community and may encourage over-dependence and institutionalisation, alongside escalation of non-suicidal self-injury. Higher rates of crisis presentations are linked with higher rates of suicide attempts. ¹⁸ Further, frequent and lengthy admissions can be costly for healthcare systems and may perpetuate stigma regarding BPD through labelling patients as ‘frequent presenters’. Hospitals need robust clinical pathways for the patients with a diagnosis of BPD who present to Emergency Departments to guide teams and prevent iatrogenic risks. ⁷

Medicalisation: Over- and mis-diagnosis and medical investigation

For those who have a diagnosis of BPD, mis- and over-diagnosis are common. There are over 200 combinations of symptoms, so presentation is highly heterogenous. ¹⁹ BPD is often seen as a ‘diagnosis of exclusion’, leading many people who have a diagnosis of BPD to experience many changes in diagnosis over time. ²⁰ Additionally, the overlap of borderline features with most other severe psychiatric disorders is confusing and potentially counterproductive. ⁴ The symptom overlap of BPD with other disorders may be considered to manifest non-genetic behavioural phenocopies of other psychiatric diagnoses. Bipolar affective disorder is one diagnosis often attracted by people with a diagnosis of BPD, and mood stabilisers may be commenced as a result. Transient dissociative symptoms or psychotic-like features contribute significantly to over-diagnosis of psychotic disorders in this population, resulting in inappropriate treatment with antipsychotic medication and lengthy hospital admissions. Prominence of low mood can result in the treatment of depressive symptoms being prioritised over the diagnosis and treatment of BPD. ²¹ Emotional dysregulation and irritability may represent a behavioural phenocopy of Attention-Deficit Hyperactivity-Disorder (ADHD), leading to people being prescribed stimulant medication. Heterogeneity of presentation, non-genetic behavioural phenocopies, multiple comorbidities, and frequent physical concerns may lead people with a diagnosis of BPD to have medical over-investigation of both psychological and physiological symptoms. Conflict within the treating team can arise when diagnoses are contested, which can affect the intra-team dynamics. It is therefore important in these scenarios for teams to work together for the sake of the client, ensuring that their needs remain paramount, and interpersonal dynamics do not cloud the clinical picture and affect patient care. Further to this, we would recommend team structures that facilitate multidisciplinary case conferencing where difference of opinion can be discussed in a non-threatening way. The use of secondary consultation from an external agency/person can aid in this process. Alternatively, utilising clinical guidelines may aid in these scenarios. ²²

Medicalisation: Polypharmacy/ECT

Systematic reviews report no difference from placebo for any psychotropic medication with BPD. ²³ Despite this, polypharmacy is common; people with a diagnosis of BPD often receive several drugs at a time, for sustained periods, increasing the risk of adverse effects such as metabolic syndrome, weight gain, and sleep disturbance. ²³ Similarly, people with a diagnosis of BPD may also receive Electroconvulsive Therapy (ECT) for serious emotional difficulties, despite minimal evidence that ECT improves the core features of BPD. ²⁴ In fact, presence of BPD symptoms is associated with a less robust response to ECT in those with comorbid Major Depressive Disorder and can cause harm such as increased likelihood of depressive relapse and poorer social functioning after ECT. ²⁴

‘De-medicalisation’

Interestingly, whilst over-medicalisation of people with a diagnosis of BPD occurs, so does, ‘de-medicalisation’. De-medicalisation occurs when a patient is labelled as ‘difficult’ and is denied basic medical care. ²⁵ Stigma for people with a diagnosis of BPD is persistent and pervasive, and may result in iatrogenesis due to failures in accessing, or the provision of, effective care. ⁷ Patients that clinicians reject are more likely to slip through the cracks of the system, less likely to receive the personal investment of their providers, and receive worse care. ²⁵ People with a diagnosis of BPD are regarded as difficult to manage even if their behaviour is the same as other patients without the label. ³ The label of BPD potentially devalues all other symptoms, including physical concerns, so that they may be disregarded. ³ People with a diagnosis of BPD may also experience psychological distress as physical symptoms and not have physical concerns taken seriously, despite high rates of somatic comorbidities among those with a diagnosis of BPD, such as chronic pain, endocrine, or metabolic conditions. ² It is therefore important for clinicians to recognise the interpersonal component of care provision to reduce any risk of de-medicalisation.

Conclusions

BPD has positive outcomes if given the right care. We have discussed the challenges of working with BPD to facilitate united and well-coordinated team care and clinical pathways that promote better treatment and outcomes. Clinicians need to recognise the potential for challenges and complications in caring for those with a diagnosis of BPD, in order to provide effective intervention. Better recognition and management of potential challenges may challenge clinical pessimism regarding prognosis and improve functional outcomes.

Much more research on multidisciplinary team care is needed. Whilst there have been significant developments in the management of BPD, there are individual, social, and healthcare contexts and environmental factors that present ongoing challenges and complications for treatment. Such factors have little been investigated, may require parallel cultural, sociological psychological, and medical research, and there is limited understanding of the frequency in which these challenges and complications are encountered in clinical practice. Furthermore, specific, widely distributed, evidence-based recommendations are needed on how to address challenges and complications of BPD treatment.