Background

Borderline personality disorder is referred to as a disorder that occurs with a pervasive pattern mainly affecting the instability of the following four areas including the affect regulation, control of impulse, interpersonal relationships and self-image (Ng, Bourke, &Grenyer, 2016). With the implementation of proper education along with clinical supervision, recovery focused care outcomes can be attained for the consumer (Cailhol et al., 2015). This case study aims to critically analyse the management of thehealth condition of the consumer suffering for BPD, emphasizing on the long term recovery of the consumer. Additionally discussion will involve care plans in collaboration with the consumer along with the selection of the appropriate nursing intervention.

The case presents the condition of a 23 years old female consumer named Lisa who presented to the local mental health centre with overlapping symptoms of borderline personality disorder.The main complaint of the consumer had been anxiety which had led to persistent insomnia for 5 years. She did not have any past history of psychological illness for which she required psychotherapeutic assistance. However, due to the recent developments, she had to take assistance of psychotherapy from an experienced psychiatrist. The appearance of the consumer had been very intense and she exhibited signs of panic and extreme anxiety, which had been evident from the lack of eye contact, and fidgeting. She also showed a very unusual pattern of mostly well healed, generally superficial scars that were present on herforearms, which indicates that she had been associated with self-harming tendencies.On further assessment, Lisa revealed that she had been participating in self-harming activities from the age of 13. Lisa had been hospitalized for about a period of three months for deteriorating suicidal tendencies, while she also tried to cut herself with a razor; and she was diagnosed with Borderline Personality Disorder leading to extreme anxiety.

For the purpose of diagnosis of borderline personality disorder (BPD), the Diagnostic and Statistical Manual of Mental Disorders V (2013) has been established in Australia. Considering the symptoms like emotional dysregulation and enduring instability of affect along with marked impulsivity and self-image and interpersonal relationships which are in accordance to the above mentioned manual, helps to characterise the BPD diagnosis. The DSM-V helps to stipulate the citerias which including the nine criterias that incidcates the diagnosis which include the minimum five characterics to be diagosised. The patient Lisa shows to meet all the mentioned criterias (Elwyn et al., 2014).

As per the DSM-V criteria, five fundamental symptoms including emotional dysregulation, enduring instability of affect, self-image and interpersonal relationships, and marked impulsivity are most vital signs of borderline personality disorders (DSM V criteria, 2018). In this case, Lisa had been suffering from depression and suicidality since her teenage, and her insomnia also had been due to negative thoughts. Along with that, Lisa had mentioned in the interview that even though she makes friends spontaneously, but these relationships do not last and help her in the recovery. This indicates that she has acute instability in life and meets criteria 2, enduring instability of affect. When questioned about her self esteem issues, Lisa stated she feels unworthy and unloved, and she believes her identity is only causing more stress and trouble to her family. This indicates that she suffers from extreme self esteem issues, matching criteria of self image and identity issues. The emotional dysregulation orf mood instability is exhibited by her swift change of topics in the interview and randomly becoming tearful. And lastly, she had been enganing is self harming and suivcvidal tendencies from a very young age proving the criteria for self harming tendencies. Hence, Lisa matches with 5 crietria of BPD successfully, proving the diagnosis correct (American Psychiatric Association, 2013). 

Diagnosis criteria

While involving in the recovery plan presented to Lisa, the intense relationships established only makes her more stressed out. This makes the patient attain the second c riteria. When it was discussed with Lisa that why she opted to be with good people and who provide stability, she thinks that she is not worthy of being with people to have their life together. While meeting the fourth criteria, it was seen that Lisa had been involved in interpersonal which ae been harmful to her therefore this made her impulsive regarding her drug-taking behaviour. In response to criteria 5, she has not been engaged in self-harm on the ward. While meeting criteria 8, it was seen that Lisa had mood swing with intense self-deprecation along with tearful engamgement which meets the criteria 6. While Lisa was admitted to the hospital, it was reported that she behaved in a paranoid manner since se was suffering from dissociative disorder that met criteria 9 (Psi.uba.ar. 2018).

The goal of the nursing intervention is to retrieve her from social isolation that will further enhance the recovery process.

The diagnosis of Lisa which can be concluded from her case deduces that she is having BPD. Therefore in reference to the current phychological therapies , certain guideliens have been suggested. For the psychotherapeutic approach for BPD, the dialectical behavioural therapy (DBT) is considered to be the gold standard. Dialectical behaviour therapy has been reported to be extremely supportive to the person in therapy and except in maladaptive ways of thinking and behaving along with assisting them to change and improve the ways so that they can cope with stress anxiety and stress resulting from the borderline personality disorder (Goldstein et al., 2015).  Consumers living with borderline personality disorders when attending dialectical behaviour therapy have been discovered to identify and construct their own problem solving and identity validation strategies which has help them to focus on the recovery and discover their own Unique Identity. Similarly for borderline personality disorder consumers with anxiety issues, mindfulness based therapy has been discovered to be extremely effective in building resilience and patience, which in turn lead to better emotional Regulation and impulsivity control (Cotton et al., 2016).

In order to focus on dialectical behaviour therapy and mindfulness space skills in the treatment planning for Lisa, I initiated engaging conversations and therapeutic relationship with her to build rapport (Cotton et al., 2016).  I invested considerable time on building rapport with her and helping her trust me before commencing with a intervention to facilitate therapeutic engagement and patient centred care. As soon as Lisa was comfortable with me I began developing her personal recovery plan to implement dialectical behaviour therapy and mindfulness based skills. As Lisa enjoyed being outdoors be arranged her dialectical behaviour therapy to be contacted in an outdoor environment with the consent and collaboration from the therapist (Eisner et al., 2017).  In terms of mindfulness skills, I attempted to train her in relaxation skills such as yoga, meditation, and mundane activities such as drawing and cutting vegetables which she enjoyed immensely. I also trained her the skills of reverse counting when she experienced any extreme emotional dysregulation  to calm her nerves and divert her attention (Murray et al., 2015). The training activities carried out for two months parallely with her DBT sessions which helps Liza overcome her  impulsive urges and anxiety attacks, and she verbalised the yoga and reverse counting helped her calm herself during her episodes of emotional dysregulation and anxiety.

Nursing interventions

It was also quite important to develop a therapeutic relationship with Lisa in order to effectively implement the nursing interventions. According to studies, the parameters of care are expected to help build a therapeutic relationship. In order to establish I tried to spend time with her during my shift hours. Lisa also reciprocated by practicing her skills of mindfulness which was moving towards the direction of recovery therefore I made sure to establish that I will work along with her to improve her skills (Cailhol et al., 2015).  When she was emotionally unravelled I made sure to remind her that she needs to practice mindfulness.

Next I took steps to steps to explore the personal safety in order to make sure that Lisa practiced her mindfulness. She liked being outsdoors therefore I also made sure to help her out where we together got involved in small tasks outdoors like in the balcony and garden. I tried playing small games with her so that she is reminded of her senses and what she is expeirncing so that it helps her to bring back mind in case it was wondering. The patient Lisa also enjoyed the little mindful activities like washing her hand when she enjyed the scented handwash and the feeling of cold water touching her hands.

In this case scenario, it is seen the interventions that were used to target the social functioning of Lisa were helpful in improving her overall mental health status. However, challenges were encountered during the start of the session because of the lack of skills in building rapport with the client. Her distrustful nature and easy to be irritated nature had been a considerable challenge in collaboration with her to make the initial planning. However, with continued and sustainable efforts compassionate therapeutic engagement, Lisa began to trust the care team and the care planning was smoother and easy to carry out or implement.I also faced challenges inopening up and engaging in small talk with the patient due to her volatile nature, irritability and mood swings which can be due to my lack of confidence, non-verbal communication skills and rapport building ability.Although, I quickly overcome this challenge my supervisor andLisa’s motherencouraged and helped me to gain her attention and encouraged her to take part in the sessions. Hence, in case optimal verbal and nonverbal interpersonal communication skills, therapeutic engagement and distraction techniques were used in this treatment from the beginning, Lisa’s recovery could have been faster (Dawson & MacMillan, 2013).

In another way I tried helping Lisa by making hrer take choices which had positive risks like the times her parents wanted to visit her. Lisa did not want them to visit her and which often led to the deterioration of her mental health. However ideally there was a role of her parents in her recovery process, therefore when they visited I tried to engage Lisa in mindful activities. This also made her take the risk of becoming dysregulated since it was made evident that this was worth the act since her parents could act as a support in the present environment. Additionally it was also speculated her Lisa could use the mindful activities after she was discharded from the hospital (Alvarez-Tomás et al., 2017).

In order to maintain the balance between the recovery of the patient along with maintenance of the safety of the patient suffering from borderline personality disorder, being a health professional it was required to follow certain guidelines which involved following the evidence-based and the planned care for the patients. There was requirement of practise redesign including in the appointments, the roles and the follow-up. This was followed by patient education involving self management, behavioural change, psychological support and the participation of the patient (Nathan & Gorman, 2015). There was also an implementation of an expert system that required the provision of education and decision support along with consultation. Finally there was requirement of proper information that included the reminders, the outcomes, the feedbacks and the care planning. All these would help in the improvement of the overall functions and the clinical outcomes. There is also a necessity to focus on the collaborative management that is the collaboration between the patient and the physician, which represents a model in which the health care providers are able to strengthen and support the patients in a better way and promote self-care by patients suffering from such behavioural issues (Larivière et al., 2015). In order to maintain he balance between this model, it is required to address the four aspects of the collaborative care that includes acknowledging the collaborative definition of problems, the goal setting in a joint manner, the provision of training and support services for every individual patient that includes the educational materials, in addition to the emotional support and structured programs and finally the sustained follow-up to monitor and reinforce progress, identify potential complications, or make needed modifications to the patient’s health care plan (O’connell & Dowling, 2014).

The health care professionals who bear the responsibility of taking care of the patients who are suffering from borderline personality disorder needs to be highly updated with the skills and the knowledge regarding the current skills of BPD treatment in order to be able to provide the nest possible care to these patients and not suffer burn out. However the splitting reputation of an individual having BPD was not quite understood which exists amongst most of the clinicians (Storebø et al., 2018). Although to be me it occurred that this occurred since the condition was manipulative in nature. This believe mostly came because of the information received from the other nurses and also because of the fact that I did not try to look up for much information and evidence regarding this. In case a thorough management plan coud be established, the cncern of splitting repulation could be managed along with coping up completely with the critical nature of the health professioals (Wetzelaer et al., 2014). Another intervention that could be helpful to reduce this was the initiation of good communication amongst the staff members where handover is seen to be a big opportunity to initiate conversation. It was also difficult to understand the actual core of splitting. It is often thought that health personnel who can provide whatever is required and can meet the needs of the patient immediately is soughtbe good and if the reverse occurs then the personnel is regarded as bad. Sometime incidences alos occur that the same clinician might be thought to be good at one point and the next moment the clinician might be seen as ecxtremly bad, which totally depends on the fact that what the patient requires and how the clician is able to meet the needs (Cramer, 2015). This is completely a immature and quite a primitive defence mechanism which is often found among the patients suffering from borderline personality disorder.  

Conclusion

Therefore, in conclusion it can be stated that the report gave an insight into thebehavioural and mental health issues faced by Lisa, a client with BPD. The discussion of her assessment activities revealed that the risk of suicide and impulsive behaviourhad been her main concerns.As she adaptedcoping skills to deal with depression, CBT was regarded as a suitable counselling modality to replace her negative thought pattern with positive coping skills. By taking a recovery-oriented approach to care for Lisa, the report gave an indication that that recovery led care can promote empowerment, patient safety and recovery from illness. Additionally the use of models like the collaborative care which were integrated into thehealth care of plan of the patient was able to show improvements in the clinical outcomes of the patient. I have learned a varied range of applicative practice skills in dealing with patients suffering from personality disorders, and I will be applying these skills and expertise in the future to avoid committing similar errors and ensuring to provide safe and effective patient centred recovery focussed care successfully.

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