BPD stigma is 'most common' crisis trigger

Stigma associated with borderline personality disorder (BPD) is "the most common" trigger for a mental health crisis among the one in 100 people living with a diagnosis of the condition, a report from the Mental Welfare Commission Scotland has found.

Borderline personality disorder is characterised by difficulty forming and maintaining a sense of self, high levels of distress and problems developing and sustaining relationships.

The MWC is an independent body monitoring mental health responses north of the border.

Over 70 people with the diagnosis were interviewed, with 19 GPs, 110 A&E staff, and 84 psychiatrists also surveyed. Family members/carers and people providing therapies were also asked for their views.

The majority of people living with BPD reported they had at least one episode of crisis in the month prior to answering the questionnaire.

The most commonly mentioned trigger for crisis was negative attitudes from other people, followed by trauma, family issues or lack of support from services.

People mentioned many ways of coping in crisis situations.

Some said they withdrew from family, friends and usual activities and would try to deal with the situation alone.

Others would seek help from services. People described the common symptoms of increased suicidal thoughts, urges and impulsivity during a crisis.

• See also: An introduction to BPD
• See also: I need urgent help, I'm feeling suicidal

Only a minority of those the MWC spoke with described having crisis plans, but the majority of those who did said they found them helpful.

Around a third of psychiatrists said their team always developed crisis plans with patients.

In Scotland, everyone has the right to participate in putting together a care plan and risk or safety plan under the
Patients’ Rights (Scotland) Act 2011.

Key findings

• People with BPD reported that they were often treated with less sympathy and understanding by professional staff than people with other mental health diagnoses.
• People's experience of being given the diagnosis was varied. While there were positive experiences, many spoke of feeling let down in this aspect of their care.
• Psychological therapies were highly valued, but access to those therapies, and waiting times, varied across the country.
• Many people with BPD reported a negative experience of using A&E services, and A&E staff shared their view that these departments were not well placed to meet their needs.
• What people with BPD told the Commission helps them stay well, and what services and professional staff thought about this, often differed.
• Families/carers said that at times the emotional impact of caring for individuals with BPD could be high, including feeling overwhelmed or powerless.

Response 

"We found that stigma is a reality in the lives of people with borderline personality disorder, and its effects can be dramatic," said Alison Thomson, Executive Director (Nursing) at the Mental Welfare Commission.

"It affects confidence and self-esteem, and it was the most commonly reported issue to trigger a crisis.

"We found many challenges - services in some areas are not good enough. Addressing our recommendations for change will need a concerted effort by organisations across Scotland.

"But the report also shows what can be achieved when people with BPD do have access to effective therapy, support and understanding. I hope that this fact will help drive all parties to make these changes, so they can improve the outcome for people with this diagnosis."

The report follows a recent BPD publication by the Royal College for Psychiatrists in Scotland.

The MWC have encouraged people to read the two reports to access a comprehensive view of BPD in Scotland today.

Insight

Psychological therapies were highly valued by people the MWC consulted with.

Mindfulness, cognitive behavioural therapy (CBT) and dialectical behavioural therapy (DBT) were among the most common that people received, with most reporting they had been helpful.

Access to therapies and waiting times varied across Scotland.

Psychiatrists and GPs said that better access to evidence-based psychological therapies for people with BPD would improve the care and treatment of their patients.

Although no drug is specifically licensed for the treatment of BPD, a high number of people reported that they found medication to be helpful, particularly in managing anxiety.

The majority said the diagnosis of BPD was made by a psychiatrist. A few were diagnosed by their GP, community psychiatric nurse or psychologist

Lived experience

People sought help in a crisis in a variety of ways: by contacting their mental health worker or local crisis response team, speaking with their GP, calling a helpline or attending A&E.

People also had experience of contact with the police due to concerns about their behaviour or safety during a crisis.

The MWC heard mixed experiences about the support people received from mental health services when in crisis. 

“Crisis services are awful, they don’t take you seriously, they just offer distraction techniques which are no good in crisis… they say go for a relaxing walk or take a bath,” one participant said.

“Saying things like 'this will pass' doesn't help," added another. "Neither does people thinking you are attention seeking."

"Even with a management plan, when I am in crisis it does not get followed even though I wrote it when I was in a good place."

A few people mentioned advance statements and liked the idea of using these, especially if they could state their wishes about what should happen to their children if they were in crisis.

As people become more able to manage their crises, the majority reported that they used skills they have learned in the past to assist in recovering from crisis.

People spoke of how important it was to have professionals who didn’t reject or discharge them at times of crisis, but instead persevered.

Being supported by professionals who know you well was highlighted as being beneficial.

What's happening south of the border?

Former health minister Norman Lamb this week raised the issue of widening support options for people diagnosed with Borderline Personality Disorder with his successor Matt Hancock, according to trainer and campaigner Keir Harding.

"We asked him to highlight the plight of those who are diagnosed with personality disorder and compelled to receive treatment they may not want miles from home," said Mr Harding.