A View from the NHS Working with People with Borderline Personality Disorder

As a trainee psychiatrist (2000) Personality Disorder- ‘ a persistent pattern of maladaptive behaviour’ Axis 2- separate from Axis 1 – ‘major mental illness’ Disorder vs Illness- is it an illness that needs to be treated BPD- ‘lies on the borderline’.

As a trainee psychiatrist (2004) Quickly learn that this is a risk prone population in whom risk is difficult to manage therefore giving you sleepless nights Watch senior colleagues and the mental health team struggle to manage BPD patients- overly involved or avoidant First hand experience of working with people who seem to elicit strong personal reactions in a junior- mainly fear, helplessness and impotency

As a Consultant now Not much has changed around me First hand experience of my senior colleagues strife- - wondering when the next FAI is waiting to happen - trying to resolve crisis in short outpatient appointments on a busy day - lone soldier- trying to carry the load of all the risk prone patients; trying to persuade the team members to participate in care- manage their fear of working with BPD - support others/ answer to other organisation who are dealing with a mental health patient, maintain a semblence of control

Facts and Figures Prevalence in General population – 0.7 % 6% of primary care attendees, frequent attendance 50% of non Forensic mental health patients Usually have co-existing mental health conditions- alcohol use, eating disorder, self harm. Only BPD in 3-10% of patients

Facts and Figures Average length of stay in acute mental health wards days, can be frequent or longer 66-99% of Tertiary care users- specialist centres and Psychotherapy Comorbid psychosis and BPD patients are the heaviest users Can lead to over prescription of medication High utilisation of emergency services Cost implications

Facts and Figures General Adult service struggles to provide an adequate service for people with BPD No uniform approach survey in England- - 17% had dedicated service - 40% some level of service - 28% no service at all No dedicated funding/ commissioning

The Real Price Ripple effect- starting from the person, family, service and the society Relationship difficulties, parenting, work and financial loss, demands of complicated presentation of unmanaged mental health to service, substance misuse and forensic involvement

What is going on within the service? The key barrier is our understanding? Illness vs disorder- is personality disorder an illness. Diagnosis or description of behaviour? Stereotypical view of personality disorder- unpredicatble, responsible for their behaviour, chronic, resistant to treatment Prejudice leads to barriers in treatment True for all mental illness at one point history, still true for BPD even within the mental health service

What is going on within the service No dedicated funding or service- leads to ‘gate keeping’; priorotising Lack of explicit training to equip existing and new staff No common language within the service or how the service communicates with patients Usually single model of psychological treatment available within the service

Doing things differently..... Reserach and experience have shed more light- BPD is a societal and a biological illness It is a significant part of our practice BPD is chronic and takes time to respond Training and support is needed to develop confidence within services to work with BPD patients Ultimately a step forward in understanding and belief about BPD