TABLE OF CONTENTS
2 The borderline personality disorder
2.2 Causes and clinicalcourse
2.3 Symptoms, care diagnoses, measures and goals
3 Principles of treatment
Over the course of my practical training, I got to know at several wards female as well as male borderline patients, and maybe got to understand a little bit as well.
This thesis shall be dedicated to a female friend from Germany. Back then, I was not aware that this young woman was suffering from a personality disorder called borderline.
The borderline disorder itself is a manifestation which has been diagnosed relatively recent and thus shows a considerable riddle character. Very specific manifestations of this disorder and the strains for the environment connected with them are eminently apparent. The strength of the appearance of the disorder and the ailment connected with it differ individually from person to person. Not least the fact that a cure is currently impossible should be a motivation for increased research. The named facts have strengthened me in my decision to dedicate the presented subject area thesis to the clinical picture borderline disorder.
The prevailing majority of books with a content relating to the borderline personality disorder are usually useful rather for therapists and physicians. The presented subject area thesis, however, shall have the goal to make a couple steps more towards nursing care, and dealing with borderline patients. The thesis shall make a contribution so that affected persons, their relatives and the nursing staff have a better understanding of dealing with BPS. People not directly affected by it shall be helped to get a feeling for this disorder, get rid of maybe existing prejudices about mentally ill persons, and to build up understanding and intuition.
The presented work describes the borderline syndrome, the diagnostic symptoms as well as nursing measures and goals, and explains them in more detail. Drug and psychological therapies were left out on purpose, because they are not directly connected with the tasks of the psychiatric nursing staff. To the lay person, the interplay between the symptoms and diagnostics of BPS and the steps relevant for care shall get conveyed in an transparent fashion, so that the “border land” does not get lost.
For the content-related practice framework, a case study was chosen which is based on an event from the acute area of the admission ward of a hospital in Vienna. The case of woman, age 22, who was hospitalized because of massive, self-injuring symptoms shows which nursing measures have to be taken first in the acute case so that a possible stabilization of the patient can get accomplished.
Finally, it shall get mentioned that the presented work has been written in the spirit of gender neutrality. Even in the case that male words get used shall, by no means, a gender preference be expressed.
2 The borderline personality disorder
Borderlines disorders get nowadays so often diagnosed in young adults that one can in some cases call it a diagnosis for a fashion diagnose, and can declare the diagnosis to be a fashion illness, respectively. One should forget at this point, however, that it is a mental disorder which unlike any other one seems to reflect the disunity and lack of orientation and limits of our age (Niklewski/Riecke-Niklewski 2006: 17).
The term “borderline” was first introduced in the 1930ies, but applied at that time as a collective term for border cases between the two other big categories of disorders: neurosis and psychosis. It was determined back then that many patients have deeper, and most of all longer lasting mental problems that neurotics, but were, on the other hand, not so much disturbed like people suffering e.g. from schizophrenia. Borderline was thus considered for many years as not investigated, an in-between category essentially only defined by what it is not: not a neurosis any more, not a psychosis yet (Möhlenkamp 2006: 9). This illness is characterized by an instability of feeling, behavior and the self-relation as well as the relation to other people. Affected persons experience themselves and others as strange. In the following, the most important borderline problems are presented in an overview:
A typical borderline trait is the difficulty to come to terms with positive and negative perceptions of oneself and of other people as well. It is very hard for a borderline patient to be angry at a beloved person while not losing the positive attitude towards this person. There are, so to say, only either-or attitudes. Emotions, but also opinions get polarized in a striking way, following a pattern that a borderline patient either likes or cannot stand a person. There is nothing in between: friend or foe, good or evil - the world is always perceived in black and white only (Möhlenkamp 2006: 59). The knowledge that someone can have good but also bad parts and still can be perceived as a complete person is not at the disposal of a borderline patient. Based on this fact - not to know a person can have different shades of colour - devastating relationship problems then originate. These people lack the ability to put themselves into the situation of someone else, and to realistically assess other people. In addition, they lack the possibility to develop real empathy and also feelings of guilt. This circumstance leads then to a situation where relationships are one-sidedly focused on the needs of the borderline patient. Other people, so to say, get exploited and manipulated for the satisfaction of the one needs (Röhr 2006: 148 ff.).
A borderline patient is characterized by inconsistent and also unpredictable emotions. This leads to the smallest of all events being able to trigger a bout of fierce, emotional reactions. Borderline patients hence experience a “rollercoaster of emotions” (Möhlenkamp 2006: 59).
These people show a remarkable tendency to act out impulses without considering the consequences, and a changing and capricious mood. Temper tantrums thus occur often when actions are criticized by other people (Schäfer 2003: 10).
Difficulties in tension regulation and self control
“Lasting states of high tension, experienced physically and psychically, impair the every-day functioning and lead to the most various psychosomatic and psychic symptoms (pains, sleep disorders, and psychosomatic function disorders). There are impulsive relief tries (bouts, addictive behavior, self-injury, and compulsions) which are only hard to control.” (Translation of the original German quote in: Möhlenkamp 2006: 59).
Low frustration tolerance
The slightest disappointments, most of all criticism and rejections, trigger strong affects - primarily anger - in borderline patients. The consequences are low persistence, break-ups of personal and job relations and constant conflicts (ibid.).
Fear to get abandoned and to be alone
“In borderline patients, it is the fear to get abandoned which makes any self-assertion seemingly impossible. The person comes into an unsolvable inner conflict which takes place between the urge for autonomy and the fear to get abandoned. This fear of abandonment blocks the tries to gain independence and makes it harder to develop an own personality (Niklewski/Riecke-Niklewski 2006: 66). “The absolute catastrophe is the separation of an important reference person: separation gets experienced as a loss of something belonging elementarily to oneself, as if something would break in the deepest inside, as if one would not be able to live without the other person.” (Translation of the original German quote in: Möhlenkamp 2006: 14 f.).
Negative self image
Self-confidence is characterized by self-depreciating and destructive thinking and fluctuates between idea of greatness and feelings of inferiority (ibid.: 60). Almost every borderline patient is deeply unsettled and suffers from a so-called “indentify diffusion”, that is the lack of security about who he really is. This insecurity can lead to considerable changes in the attitudes as well as set goals and wishes. This negative self-image often also leads then to the rejection of the own body (Sieber 2004: 24).
In the following, patterns of behavior and mechanisms, respectively, are listed, based on Kernberg (2000), about the way a person with borderline acts. These were augmented by example from practice.
Identity diffusion (identity without a defined border): As the borderline patient exhibits only deficient integration with respect to the own person, or to other person, he has a chronic inner void as a consequence.
This can lead to conflicting appearance of the self-perception (“How do I see myself, how do I feel myself?”) and behavioral patterns.
Is the patient e.g. in a state of chronic void (“I do not feel myself”), he makes a self- injuring act (cutting, burning) in order to feel himself again. Even the optical perception of the own blood is proof to be still alive.
The patient experiences again emotions he knows from before.
Example: While talking with his female psychologist, the borderlines experiences feelings of safety, warmth and devotion. He remembers times before the illness, when this feeling occurred. His mother was back then, in these situations, a “good”
mother. This means that the patient views the female psychiatrist as a “mother substitute”.
A possible reaction of the female psychiatrist to the behavior of the borderlines is explained here in more detail. She presumably would (because of the presumed counter transference) care attentively and lovingly for the patient.
Reaction and counter reaction go “hand in hand” in this example. This applies for positive as well as negative transferences. Working with borderline patients, it can sometimes happen that one does not behave as one would usually know from oneself (Example: the feeling to get manipulated can occur). Transference and counter transference can already a form of rejection from the side of the patient.
Rejection operations (= rejection mechanisms): Rejection mechanisms are necessary processes for the protection of the soul and the chance for psychic survival, with the functioning mode mostly presenting itself in a primitive way (thus, in attempts to explain this, one does talk about early rejection mechanisms).
Dissociation is in the centre of the rejection mechanisms. By dissociation, the own self as well as fellow human beings (relatives, intimate partners, nursing personnel etc.) are divided into “god” and “bad”. This means for the borderline patient to view the world in mainly black and white!
The affected persons and/or other persons experience an emotional confusion. The borderlines and his counterpart become insecure. One emotion drowns the other, and relations finally suffer from that. Example case: A female patient gives her male therapist a chocolate bar as a birthday present. He is very happy about it but is surprised how his client could find out this day. The patient asks: “Do you trust me?” Thereupon the therapist: “Yes, of course.” The patient says: “Close your eyes and stretch out your hand towards me.” As this happens, the borderline woman takes out a razor blade and cuts the therapist. Subsequently, she asks him: “Do you still trust me?” A relation had just been built up, but immediately suffocated in its origin. The reason is that the borderline patient has immense fear to get abandoned. In order to pre-empt this, this person destroys the relation by various actions and statements, not always being aware of it. Now, this person has the proof again to be worth nothing, otherwise there would be trust and a maintained relationship.
A person which gets idealized carries the expectation of total perfection. As this, of course, shows itself to be impossible, this person gets sooner or later totally devaluated. Example: a nursing person attentively cares for the patient, and has a daily relief talk with him. One day, the nurse herself is absent herself for a week because she is sick, and cannot carry out her duty to the patient as usual. If she shows up again afterwards and takes up the talks with the patient as usual, she gets assessed to be “evil” by the patient, and ignored. The high expectations borderline persons have cannot be fulfilled and end in a break-up of the relation.
Serves the borderline patient to maintain his inner world view. He lies to himself in order to escape from reality. Herein, the lie can really be believed in, as it gets internalized in the patient.
Omnipotent (divine, almighty) control and devaluation:
The borderline patient tries to gain control over other persons by actions or statements. He wants to achieve thereby that the whole world cares about him. Example: a patient tells in the therapeutic session that he recently bought a set of knives with the intention to cut up his wrists. Although suicide can never be excluded, this special case demonstrates that the patient has obtained a feeling of power and ability to act by owning the knives.
Limited ability to check reality: Reality is sometimes experienced as something strange. Inappropriate behavior and a malfunction of the relationship to reality happen in the process. Example: a female patient has an eating disorder. She is already extremely emaciated but still wants to lose weight because she thinks to be too thick. This woman sees herself in the mirror but experiences the reality differently. This is not a case of psychosis. The borderline patient only moves at the border to psychosis. (Langer 2004: 152 f.)
2.2 Causes and clinical course
“The cause for the tendency towards extreme affects was first seen in a disorder of the normal development of the personality in the first years of one's life, which is the reason one talks about an early disorder. What is normal at the age of a small child, so, in the first two to three years of one's life, namely a tilting of the affect from one pole to the other, e.g. from a full smile to unnerving crying is maintained as an adaptive responsiveness” (Translation of the original German quote in: Möhlenkamp 2006: 13).
Röhr (2006) as well describes that the developmental phase of a child is decisive whether a BPS will develop or not. If a mother can satisfy the needs of the own child not or only insufficiently, then this has implications for every subsequent relationship in the life of a human being. The ego ofthe early child is not or only insufficiently able to integrate good and bad attitudes of the mother at the same time. Therefore, the baby dissociates every part to mother which endanger a positive relationship. This dissociation is an early rejection mechanism it has to eliminate these unpleasant emotions. If borderline patient were thus not able in early childhood to identify themselves with the mother, they likewise do not manage to build up a wholesome perception over the course of the further development. (Röhr 2006: 148 f.).
In psychiatry, the common enduring between mother and child is called “containing”. Example: a baby gets the first teeth, has pains and cries. Crying is a call for help at the mother. The mother cannot really take away the pain from the baby, but take child into the arm, caress and console it, therefore simply convey a feeling of security and common enduring.
Another factor for the development of BPS can for instance be ]abuse and/or mistreatment at an early age. Experiences with sexual abuse in the family can trigger in the affected child or adolescent a state of shock, trauma, great fears, insecurity, anger, and the like. A family situation which does not work well can also conducive for BPS. Example: the father is an alcoholic and beats his wife or even the child. Up to the a person of trust, the father now deeply disappoints the child (Pflegenetz, online).