ethical issues in treating borderline personality disorder

8600 Rockville Pike Webinars are converted to video on-demand programs with closed captioning after the live air date. They basically demanded a bribe, which was not small. Non-response to psychotherapy for borderline personality disorder: A systematic review. Letkiewicz AM, Spring JD, Carrillo VL, Shankman SA. In critically understaffed locations, participants had to make difficult decisions between performing procedures they were not qualified for or else leave the patient to die. Family members knowledge about borderline personality disorder: correspondence with their levels of depression, burden, distress, and expressed emotion, Comorbidity and associated severity of borderline personality disorder and physical health conditions in a nationally representative sample. Borderline personality disorder is a leading contributor to the burden of disease in our community. Hence, a new culture is required for the management and treatment of patients with BPD in the community. Thus, clinicians are justified in using any of these efficacious treatments. Please enable it to take advantage of the complete set of features! Opening our hearts and minds: The meaning of international clinical nursing electives in the personal and professional lives of nurses. The authors of the current editorial propose possible strategies of intervention both on the psychopharmacological and managerial side. Honest and open discussion about whether a trial of a drug is warranted or has been effective is fundamental. Elit L., Hunt M., Redwood-Campbell L., Ranford J., Adelson N., Schwartz L. Ethical issues encountered by medical students during international health electives. The scope of practice is constantly changing in the global setting. 1985 Jul 13;291(6488):130-1. doi: 10.1136/bmj.291.6488.130. In: Anderson R, editor. Inclusion in an NLM database does not imply endorsement of, or agreement with, It is likely that considerable national health service resources will have to be allocated to these patients in the future. Advance registration ends June 30. Given the limited number of interviews and focus groups, we were not able to determine if thematic saturation was achieved. When categorizing the ethical issues into four themes, we recognized that they further align into two overarching core categories: those themes that referred to external factors faced by trainees (cultural issues, professional issues, and limited resources) and the theme which referred to internal factors faced by trainees on a personal level (personal moral development). These 11 ethical dilemmas (codes) fell into four major themes relating to: cultural differences, professional issues, limited resources, and personal moral development. Articulate the most current research on identification, prevalence, comorbidity, course, and treatment of BPD to guide clinical decision-making processes and enhance research, administration, consultation, and policy work. These findings are important because, although ethical themes in global-health work have been described in the past, for example the broader issues of social justice, solidarity, humility, and introspection , the specific ethical issues described can further inform existing, or future, in-person, online or simulation-based global health ethics . The first level of coding involved open coding where we took raw segments of data and systematically reviewed them line-by-line, attributing specific descriptive labels or codes to the data [20]. Accessibility describe this phenomenon as clinical limits in their series of case studies highlighting ethical dilemmas in global health electives [24]. The organigram sees inter-professional actions, targeted psychopharmacological policies and psychiatric crisis teams in A&E that can reduce the need to hospitalise patients with BPD at any ensuing crisis. An official website of the United States government. Hence, the authors recommend the use of long-lasting depot antipsychotic injections (e.g., Zuclopenthixol Decanoate) to stabilise their mood and reduce impulsivity, the risk of overdoses, pseudo-psychotic symptoms and command hallucinations leading to deliberate self-harm. There is now a variety of effective evidence-based psychosocial treatments (Box 2). 1994 Sep;151(9):1316-23. doi: 10.1176/ajp.151.9.1316. The authors would like to thank Dr Louise McCutcheon for comments on an earlier version of this manuscript. Global health competencies and approaches in medical education: A literature review. Psychiatr Clin North Am. Bach B, Farrell JM. Our findings resonate with other work investigating the same topic. Relevant ethical issues and challenges are considered, and both seminal treatment studies and often neglected findings are highlighted. An ethics curriculum for short-term global health trainees. Participants discussed other cases where material shortages brought up additional dilemmas and caused distress to the participants. However, access to these treatments is limited in the Australian healthcare system. There are many high-quality reviews16,27,28 including a Cochrane review.27,29 The Cochrane group found 33 randomised controlled trials in adults with borderline personality disorder,27,29 but commented that the overall evidence base for prescribing is unsatisfactory. [Should hospitalization be required after the emergency discharge of patients with borderline personality disorder who have attempted suicide (FRENCH CRISIS cohort)?]. Burrin C, Daniels NF, Cardinal RN, Hayhurst C, Christmas D, Zimbron J. In: Mills A., Durepos G., Wiebe E., editors. This relates to external environmental and/or situational issues that trainees are confronted with. Lazzari C, Shoka A, Masiello I. 2022 Jun 30;25(2):611. doi: 10.4081/ripppo.2022.611. Diagnostic and statistical manual of mental disorders. It therefore provides some guidance for those who wish to try empirical treatment (Box 3). Also, the current definition of depression incorporates non-specific forms of dysphoria that overlap with borderline personality disorder. FOIA Curr Opin Psychiatry. Theres just no word for it!. These questions include whether psychiatrists should tell patients their diagnosis, what they should tell them about their suicide risk, whether they should be "always" available by phone, when they should hospitalize these patients involuntarily, and how they should respond after these patients have attempted suicide and return for further care. HHS Vulnerability Disclosure, Help Borderline personality disorder is a severe mental disorder that has its onset during adolescence and emerging adulthood. There should be clear and collaborative goals that are regularly reviewed with the patient. The fourth theme, moral development, reflects internal issues faced by each trainee, in a unique and individual manner, and refers more to the development of a moral compass and the exercise of humility and self-awareness than any environmental or situational issues a trainee might be facing. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC-BY) license (, global health education, global health training, ethics, global health electives, healthcare education. Price J. Coding: Open coding. Some patients will invite clinicians to behave differently with them and we can be aware of these invitations without automatically feeling cheated or manipulated and becoming more rigid and inflexible. I didnt even know how to practice in that setting. Bookshelf These patients will tell you that this is how they usually are. Battat R., Seidman G., Chadi N., Chanda M.Y., Nehme J., Hulme J., Li A., Faridi N., Brewer T.F. And the patient died overnight. At the same time, healthcare professionals are discouraged by the complex management of patients with BPD, which, in combination with their tendency to challenge or make unwarranted allegations against their health carers, results in feelings of sadness, rejection and alarm in the latter. Bethesda, MD 20894, Web Policies Similarly, there is a parallel increase in the human and medical resources needed to manage this disorder efficiently. Conflict of interest: Andrew Chanen was a member of the development group for the National Health and Medical Research Councils Clinical Practice Guideline for the Management of Borderline Personality Disorder. Our study has certain limitations; this is a single center study with a small number of participants. Bethesda, MD 20894, Web Policies The .gov means its official. Callister L.C., Cox A.H. This approach continues until an adequate number of participants are recruited into the study [18]. Further, the multi-professional sample in our study suggests that the material can be used to help educate trainees in different health sciences. Gunderson JG, Stout RL, McGlashan TH, Shea MT, Morey LC, Grilo CM, et al. [] The idea is that you eventually develop this compass of practice.. The above article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. Available online: DeCamp M., Rodriguez J., Hecht S., Barry M., Sugarman J. At least two reviewers independently analyzed the data and participated in all coding. and transmitted securely. Can J Psychiatry. Mood stabilisers (topiramate, sodium valproate, lamotrigine) have shown some effect in reducing affective dysregulation and impulsive aggression. To date, there has been no study of Australian prescribing practices, but clinical experience suggests that the situation might be similar. Ethical dilemmas in global clinical electives. In light of the clinical needs and pressures, and the harm associated with prescribing for these patients, the NHMRC16 and UK National Institute for Health and Care Excellence (NICE)28 have considered the controlled trial evidence. Eighteen participants provided examples of ethical dilemmas associated with global-health outreach work. In: Mills A., Durepos G., Wiebe E., editors. Borderline Personality Disorder (BPD): Prevalence, management options and challenges (1st ed.). National Library of Medicine Indian J Med Res Pharm Sci, 2018; 5(4): 6168. Soloff PH, Lis JA, Kelly T, Cornelius J, Ulrich R. Am J Psychiatry. APA Office of Continuing Education in Psychology. MeSH Evidence-based principles (EBP) are derived and emphasized throughout, with specific attention to differential diagnoses and treatment decision making. Drugs should not be used as primary therapy for borderline personality disorder, because they have only modest and inconsistent effects, and do not change the nature and course of the disorder. The https:// ensures that you are connecting to the Stress caused by difficulties encountered in ensuring that BPD patients comply with the therapy regularly places doctors and nurses at crisis point. Drug treatment might be warranted for patients who have a co-occurring mental disorder such as major depression. Healthc Financ Manage. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). government site. Participants also discussed the impact of differences in training between trainees and local staff. Gross R, Olfson M, Gameroff M, Shea S, Feder A, Fuentes M, et al. Soloff PH, Lynch KG, Kelly TM, Malone KM, Mann JJ. [(accessed on 23 June 2016)]. A model of integrated care comes from Max Weber who differentiated between formal rationality, the endorsement by healthcare managers of the most efficient ways of achieving organisational goals (e.g., ensuring more hospital beds by quick discharges of bed blockers), and substantive rationality, the expectation by healthcare professionals that values and morals should instead be based on tradition, compassion and dedication13;pertinent to the care of BPD patients in our case. 2022 Jul;56(7):771-787. doi: 10.1177/00048674211046893. Some strategies to assist in this task can be drawn from the common characteristics of evidence-based treatments in Box 2, e.g. Schemas and modes in borderline personality disorder: The mistrustful, shameful, angry, impulsive, and unhappy child. An official website of the United States government. Abedini N.C., Gruppen L.D., Kolars J.C., Kumagai A.K. Beneficence; borderline personality disorder; ethics; non-maleficence; risk management. Referral for one of these first-line treatments is recommended.16,24 No single treatment is recommended over another and they have common core features (Box 2).25 Treatment guidelines include one published by the Australian National Health and Medical Research Council (NHMRC).16, Systems training for emotional predictability and problem solving, Approaches to prototypic borderline personality disorder problems are structured (manual-directed), Patients are encouraged to adopt self-control (i.e. Articulate and describe the specific components and evidence for the five main empirically supported treatment options for BPD. Following this, we conducted axial coding, which involved the organization of codes identified during open coding into broader themes and categories based on observed relationships or common characteristics [21]. The Haile T. Debas Academy of Medical Educators in collaboration with the UCSF Center for Innovation in Interprofessional Education funded this study. Indian J Med Ethics. These themes can be used to inform existing and proposed global-health training and perhaps more broadly health professional curriculum design, regardless of the approach utilized. Borderline personality disorder; diagnosis; ethics; involuntary hospitalization; patient-psychiatrist relationship; suicide; telephone contact; terminating treatment. Wicks D. Coding: Axial coding. Eleven of the participants were female and seven male. Washington (DC): American Psychiatric Association; 2013. The site is secure. This site needs JavaScript to work properly. one criterion) are associated with substantial increases in psychosocial impairment.19. Borderline personality disorder and the ethics of risk management: The action/consequence model Patients with borderline personality disorder are frequent users of inpatient mental health units, with inpatient crisis intervention often used based on the risk of suicide. Identify and describe at least four clinical and ethical issues that arise in the diagnosis and treatment of BPD. Bradley E.H., Curry L.A., Devers K.J. Before Caution should be used if prescribing medicines associated with substance dependence. Nurs Clin North Am. Such diagnoses are often unreliable because they do not assess each of the DSM-5 borderline personality disorder criteria and do not take into account other reasons for such presentations, such as temporary aberrations in mental state, depression or other disorders. Three of these themes (cultural differences, professional issues, limited resources) are categorized under the core category of external issues. Kane-Urrabazo C. Managements role in shaping organizational culture. Historically pre-departure training for global health electives has been highly varied [8] but more recently, in recognition of ethical conflicts facing trainees, there have been increasing efforts to introduce more substantive pre-departure training in global-health ethics [9,10,11]. J Pers Disord. This scenario has mostly affected female patients with BPD who seek admission to psychiatric hospitals often for respite from chronic suicidal ideation4.Moments of amplified suicidal ideas become evident when internal voices, perceived as auditory hallucinations commanding to self-harm or to commit suicide, become more intense5. Once each phase of coding had been completed, coders met and discussed the various codes and coding decisions, to determine agreement and disagreement. Pharmacotherapy for borderline personality disorder--current evidence and recent trends. For example, participants reported cases that compelled them to reconsider their duty to inform the patients of the true nature of their affliction and the circumstances of the proposed treatment. In caring for patients with borderline personality disorder, strong thoughts or feelings on the part of the doctor can be used as a reminder to reflect on what is happening in the doctorpatient relationship: Am I feeling pulled or pushed to respond in particular ways? Borderline personality disorder is a leading cause of disability and mortality and is common in clinical practice. Before Stoffers JM, Vllm BA, Rcker G, Timmer A, Huband N, Lieb K. Psychological therapies for people with borderline personality disorder. sharing sensitive information, make sure youre on a federal [(accessed on 23 June 2016)]. In: Anderson R (Ed.) An integrative perspective on psychotherapeutic treatments for borderline personality disorder. National Library of Medicine These issues also facilitated their personal moral development, as well as prompted them to start building a theoretical approach regarding global moral issues. Federal government websites often end in .gov or .mil. [] Nurses in [resource limited country] now, are doing Cesarean sections, are the prescribers of anti-retroviral therapy []. The discussion was unstructured allowing participants to address the question in-depth. DBT includes group and individual therapy designed specifically to treat borderline personality disorder. 2022 Oct;78(10):2041-2053. doi: 10.1002/jclp.23426. Would you like email updates of new search results? Trainees who complete such electives are also more likely to focus their clinical career working with disadvantaged communities and often display increased levels of volunteerism and humanitarianism [3]. Another cause of diagnostic confusion is the high rate of comorbid conditions. Anupama V, Bhola P, Thirthalli J, Mehta UM. Corporate management of patients with borderline personality disorder through integrated care (pp 1762). These interventions may maximize the autonomy patients with borderline personality disorder and at the same time be clinically optimal, increasing a sense of self-efficacy and patient-psychiatrist trust in the patients. 1 - 3 Attempts to treat and to reduce suicidal ideation and self-harm in this group of patients are often thwarted as they challenge medical decisions and endeavour to sabotage the proposed care plans. MeSH Author Bernard Liebowitz 1 Affiliation 1 Liebowitz & Associates, Chicago, USA. The research on borderline personality disorder (BPD) is complex, confusing, and replete with contradictory findings from heterogeneous, convenient, small, and/or selected samples. This discussion highlights the ethical components of these questions. Healthcare management. Motives for filing a false allegation of rape. 2022 Dec;36(6):641-661. doi: 10.1521/pedi.2022.36.6.641. establish likely risks of prescribing, including interactions with alcohol and other substances. and transmitted securely. Implications for dimensional ratings of personality disorders, Classification, assessment, prevalence, and effect of personality disorder. The time-limited use of drugs can be considered as an adjunct to psychological therapy, to manage specific symptoms. Standardized approaches to individual psychotherapy of patients with borderline personality disorder. Clipboard, Search History, and several other advanced features are temporarily unavailable. This increase is a reflection of the presence of global health electives and training programs within many health sciences curricula [2]. All authors have read and approved the submission of the manuscript. If drugs have been prescribed to manage a crisis, they should be withdrawn once the crisis is resolved. Data were analyzed using constant comparative methodology [19]. 1986 Feb 15;292(6518):466-9. doi: 10.1136/bmj.292.6518.466. A narrative approach to aid socio-psychopharmacological assessment and treatment. A key role for the clinician is to keep ones eye on these goals, assisting the patient to persist with the chosen strategy, without becoming too rigid. [] these were mostly physicians, and I was the only nurse there. Revised NESARC personality disorder diagnoses: gender, prevalence, and comorbidity with substance dependence disorders, The prevalence of personality disorders in a community sample. But, it is difficult to be both. Some participants stated that moral distress, while unpleasant, may actually assist the trainees in their personal development of obtaining a moral compass, as well as humility and self-awareness: If you consistently have moral distress even though you are doing the things that all the principles tell you [] part of what happens in ethical practice is figuring out what resonates with who you are as a human being. We conducted a qualitative study at the University of California San Francisco (UCSF) between November 2013 and January 2014. 3Orygen Youth Health, Northwestern Mental Health, Melbourne, 1Orygen The National Centre of Excellence in Youth Mental Health, 2Centre for Youth Mental Health, University of Melbourne. impulsive substance use, unsafe sex), chronic dysphoria and anxiety, severe mood instability and reactive aggression. Interpersonal difficulties and challenges, particularly maladaptive help-seeking, are part of the everyday work of caring for people with borderline personality disorder. encouraging patients to develop a sense of self-control, and helping patients to connect feelings to events and actions. FOIA Federal government websites often end in .gov or .mil. For example, challenges with informed consent, truth telling, scope of practice and local staff training have been described elsewhere [6,3,24]. Bookshelf The trainees that I work with are mainly integrated in the programs and theyre getting certain skills, and they know they are going to work in the field long term. Although various tools are available to aid the diagnosis of borderline personality disorder, clinical application of the DSM-5 criteria is sufficient in a busy clinical practice. These findings are important because, although ethical themes in global-health work have been described in the past, for example the broader issues of social justice, solidarity, humility, and introspection [11], the specific ethical issues described can further inform existing, or future, in-person, online or simulation-based global health ethics training. government site. However, this can present an ethical dilemma for nursing and medical staff, with these clinician responses shifting between the moral principles of beneficence and non-maleficence, dependent on the outcomes of the actions of containing or tolerating risk. The https:// ensures that you are connecting to the Sugar and Crump add that host institutions often have inflated ideas about the skill level of trainees on short-term placements adding to this difficult situation [9]. Global health electives have been shown to be valuable, beneficial and highly relevant for those trainees and health professionals who participate [3,4,5]. While our framework (Figure 1) generalizes many potential ethical global health scenarios and we support trainees maintaining a nuanced approach to each situation they encounter, our findings are of importance for future global health-ethics training development, and we propose that the categorization represented in our framework (Figure 1) should be consulted when preparing global health trainees for their fieldwork. Int J Med Res Pharm Sci, 2017; 4(3): 3844. the contents by NLM or the National Institutes of Health. 2006 Jan;19(1):95-101. doi: 10.1097/01.yco.0000191498.69281.5e. doi: 10.1016/s0193-953x(05)70151-9. HHS Vulnerability Disclosure, Help A different study, involving Canadian resident psychiatrists self-reflecting on their work in Ethiopia, found that they had entered their placement with a number of pre-existing biases towards their host institutions and communities [5]. 2022 Apr-Jun;VII(2):93-102. doi: 10.20529/IJME.2021.096. Careers. We transcribed each of the focus groups and interview verbatim. Scope of practice issues place visiting trainees in extremely difficult ethical dilemmas, where the norms they have been taught in school challenged their ethical intuitions in unfamiliar situations. Fujita J, Takahashi Y, Nishida A, Okumura Y, Ando S, Kawano M, et al. Hooke GR, Savani P, Stewart B, Araujo S, Page AC. 1991 Oct;42(10):1034-8. doi: 10.1176/ps.42.10.1034. Suicide and deliberate self-harm in personality disorders. Therefore, social interactions with primary carers result in dissatisfaction of people with BPD about any medical or psychiatric plan is set up for them. This study seeks to add to the number and variety of vignettes that are available to include in global health ethics curricula and training. BPD is a highly-misunderstood conditioneven within the mental health field. Hopwood CJ, Swenson C, Bateman A, Yeomans FE, Gunderson JG. Advancing psychology to benefit society and improve lives. It may not be sustainable once we walk out the door, so do we save the persons life at that moment or do we just continue to try and train people there about how to care for people?

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ethical issues in treating borderline personality disorder

ethical issues in treating borderline personality disorder

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