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Tuesday, March 21, 2017

Praise for Families

Over the last few years, I've had the fortune of acquiring an extensive network of friends who have advocated and still advocate for the severely mentally ill population. The majority of these friends are family members of people with severe mental illnesses. Their horror stories about the barriers faced in accessing care for their sick loved ones are evidence of our broken system. I've seen them fight relentlessly for good mental health treatment.

I recall the many times as an inpatient psychiatric social worker when I couldn't think of anything to say to families besides "My hands are tied. There's nothing further I can do. The doctor is ordering the discharge, not me. I know you're angry." Some of them lashed out angrily at me. I didn't take it personally. I knew they were at a point beyond frustration. Others told me they understood it wasn't my fault that their ill loved ones were getting discharged prematurely again.

This network of new friends also includes Mary Barksdale and Robert "Joe" Bruce (Joe Bruce's story). Mary's son Farron (Farron's storykilled two police officers in Alabama while delusional, unaware of this, and unmedicated. Robert's son William killed his mother, Amy in Maine while delusional, unaware of this, and unmedicated. These and countless other stories inspire me to join their fight. They remind me to stand courageously when I authorize involuntary transfers to hospitals for patients whom I know will be discharged prematurely. In fact, when I think about my patients with psychosis and anosognosia who didn't want help during my inpatient years, I cannot identify one patient who was discharged at the appropriate time.

Tuesday, March 7, 2017

Borderline Personality Disorder

One of the aspects of my job that I like most is that each case closes very fast, that is, usually in about two to three hours. This means that there's not much opportunity to spend endless amounts of time with patients or family members who are particularly challenging to work with. Many patients among this group have borderline personality disorder.

What is borderline personality disorder? The most common and most outstanding characteristics I've noticed in those patients with this disorder, both as a social worker and in my current role as an emergency clinician are as follows. The following characteristics certainly are not apparent in all patients with borderline personality disorder.
  • Many of them make many suicidal gestures (falling between wanting to kill oneself and making a suicide attempt, these include holding a knife close to one's wrist) - the teen who frequently ties clothing around her neck just tight enough to not lose consciousness in the presence of residential staff members. 
  • Many of them make suicide attempts with a high chance of rescue, that is, in front of others - the man who hangs himself on a closely supervised inpatient unit. 
  • Many of them are not able to identify any new stressor or precipitant that could've contributed to their worsened mental functioning - the young adult who reports being in conflict with her loved ones again. 
  • Many of them feel the need to be patients on inpatient units inappropriately, thus can appear desperate to get there - the woman who overdoses on medications in front of me because I'm not willing to meet her demand of inpatient.
  • Many of them are passively suicidal without any suicidal plan on a daily basis - the man who reports praying to never wake up again every night at bedtime. 
  • Many of them superficially injure themselves intentionally - the woman who's arms are scarred beyond repair resulting in nerve damage. 
  • Many of them have no intention to die by suicide - the woman who overdoses on pills forty-five times while passively suicidal, and then dies in the forty-sixth time she does this. 
In Massachusetts, unless a patient is needing a forensic evaluation, such as in determining whether one is criminally responsible for a crime or innocent due to mental illness, a patient needing "long" term inpatient care funded by the state must typically go through a non-state inpatient unit first. A large percentage of the patients on my inpatient caseload (I only worked for non-state units) who were waiting for entry into state-funded inpatient units had borderline personality disorder. This was not a coincidence. Among those patients waiting for this entry, this disorder was the second most common behind illnesses involving psychosis.

As I increasingly realized how serious borderline personality disorder is, it struck me as odd that borderline personality disorder would be this common among those waiting for state-funded inpatient care. They often didn't present with severe signs of mood disorders. They often didn't present with mania. They often were not psychotic. So why were they getting admitted to expectedly the most intensive and most restrictive level of inpatient care possible?

It turns out that they are most dangerous when they've recently increased the potential lethality of their self-injurious behaviors. Their danger involves being most at risk for accidentally killing themselves. I usually do not grant inpatient admission to the patient who is desperately wanting this, but who hasn't engaged in serious self-injury recently and doesn't have a suicidal plan. On the other hand, I ensure that the patient who swallows an object besides food or medication, such as a pen cap, gets transferred to safe confinement.

They can be unpredictable. In emergency services, a patient with borderline personality disorder demands that she be granted an inpatient admission while she is not meeting the criteria for this. Although passively suicidal, she is functioning safely. I try redirecting her to use healthy coping strategies, to no avail. She continues to press for an inpatient admission. She presses for this again until she pours large handfuls of her pills into her mouth, gradually swallowing these in my view. I grant inpatient to her. Even though personality disorders are, by formal definition, less problematic than major mental illnesses, the only mental illness that this patient presents is borderline personality disorder.