Borderline Personality Disorder Evaluation

Introduction

Forensic mental health assessment is referred to a nature of evaluation that is executed to deliver relevant scientific and clinical information to the legal decision-maker or litigants who are included in criminal or civil proceedings. In forensic presentations, personality disorder is regarded as a mental disorder in which a person showcases the unhealthy and rigid pattern of thinking, behaviour and functioning. In this assignment, the easy is going to inform about the aetiology of borderline personality disorder. Later, evidence-based holistic care for patients with similar condition is to be discussed along with critically discussing gaps in legal protocol regarding the disease. The specialist services required to be designed for meeting the needs and demands of patients with the disease, including healthcare dissertation help, is to be evaluated. Lastly, current provision to deliver specialists services and the gaps affected by political and economic agenda regarding the disease is to be critically examined.

Part A

Aetiology of Borderline personality disorder

Borderline personality disorder (BPD) is referred to the mental disorder which effects in the way a person thinks and feel about them resulting to create problems in everyday functioning. The BPD creates difficulty to manage behaviour and emotions, self-image problems and develop pattern of unstable relationship (Linehan et al. 2015). In borderline personality disorder, the people feel an intense fear of being abandoned as well as experience difficulty to tolerate being alone. The presence of inappropriate anger and frustration along with frequent mood swings makes people with BPD face hindrance in maintaining long-lasting relationships even though they want to be in a relationship (Costa et al. 2016). The NHS, UK informs that genes inherited from the parental generation who had incidence of BPD make individuals more vulnerable to develop BPD. However, no specific results are available which indicates the nature of gene responsible for causing BPD (NHS, 2019). The NHS also mentioned that if 1 identical twin has Borderline personality disorder then the second identical twin has 2/3rd chances of having BPD (NSH, 2019). In the study by Witt et al. (2017), the researchers studied 998 patients who are suffering from BPD and 1545 patients were selected as control for the study. They found that two significant genes which are dihydropyrimidine dehydrogenase present on chromosome 1 (DPYD) and Plakophilin-4 present on chromosome 2 (PKP4) are responsible to cause BPD in most of the individuals they studied. This was the first report in which control genome-wide association was examined.

In the study of Coccaro et al. (2015), it is mentioned that low level of serotonin in individuals is associated with rise of borderline personality disorder. This is because lower level of the chemical leads the person to show aggression and act in a hindered manner out of severe anger or depression. The serotonin is a neurotransmitter which is regarded as the happy chemical in the body as to contributes to the happiness and well-being of individual (Perroud et al. 2016). Thus, the lack of proper amount of serotonin leads the body unable to cope with negative emotion making the person show hindered behaviour. The MRI studies of the brain of individuals suffering from BPD revealed that three parts of their brain were smaller than usual or expressed unusual level of activity. The three brain parts are the amygdale that has the role to control and regulation emotional mainly the negative emotions of the individuals; hippocampus that has the task to regulate and control behaviour and orbitofrontal cortex that is involved in helping the person make proper planning and decisions (Silvers et al. 2016). These abnormal developments of the brain parts are regarded to be influenced by the way the person is brought up from their early childhood as it is the phase when the brain gets developed based on the impact of environmental factors.

Assessing reason behind the cause of Borderline personality disorder

The environmental factors which cause development of BPD in a person include emotional and sexual abuse along with physical torture during childhood. This is because the relationship of a person with their family and parents has a strong impact on the way the individuals are going to perceive the world to showcase behaviour and emotion in certain situations. Thus, negative impact on the minds of the child due to abusive nature of parents makes them develop distorted thinking orienting them to develop BPD in adult stage (Dittrich et al. 2018). In the study by Infurna et al. (2016), it is informed that children who are neglected by their parents in early childhood are seen to show BPD in the adult stage. This is because of their unresolved anger and emotions along with lack of care influence their mentality to act in a hindered manner. The children who grow up with individuals that have a family member with mental disorder or drug misuse problem are prone to get influenced by BPD (Westbrook and Berenbaum, 2017).

Diagnosis of Borderline personality disorder

The diagnosis of Borderline personality disorder (BPD) is made through psychological evaluation by making the individual complete certain questionnaires. The ICD-10 that is the International Classification of Diseases and Related Health Problems developed by WHO and DSM-5 which is the Statistical Manual of Mental Disorder is used for diagnosis of BPD. According to DSM-5, the presence of any at least five symptoms out of the identified symptoms regarding BPD indicates the person is suffering from the psychological condition The identified symptoms of BPD according to DSM-5 are frantic efforts for avoiding real abandonment, unstable and intense relationship with individuals characterised by alternation of idealisation and devaluation, unstable self-image, impulsivity, suicidal thoughts or behaviour, unstable moods, intense anger, stress-related paranoid and chronic feeling of being alone (Morey et al. 2016; Fossati et al. 2016). The ICD-10 indicates that presence of symptoms such as unstable self-image, unstable interpersonal relationships, impulsive behaviour, sudden mood swings, aggressive impulse and others in individuals can be diagnosed with BPD (who.int, 2019).

Evidence-based Holistic care for Patient with Borderline personality disorder

Therapeutic approaches and communication:

The patients suffering from Borderline personality disorder (BPD) are provided psychotherapy as the fundamental therapeutic approach. There is no specific medication that is approved by Food and Drug Administration for treatment of BPD but certain medications are provided to patients with BPD to help them cope with co-occurring health problems such as aggression, impulsiveness, depression and others (Ripoll, 2013). The Dialectical Behaviour Therapy (DBT) is a nature of cognitive behaviour therapy that is specifically developed to treat people with borderline personality disorder. In this therapy, the people with BPD are made to learn to regulate their emotions and distress so that they can develop better interpersonal relationship (Bedics et al. 2015). This informs that DBT teaches the individuals with BPD regarding the way to live in the moment and cope with their stress and emotion healthily so that no negative effects are created on their thinking and behaviour, in turn, helping them to improve their relationship with others (Kramer et al. 2016). The DBT is beneficial for patients suffering from BPD as it takes a proactive approach are resolving raised problems. This is because through DBT patients are informed the way they are to react so that their self-destructive behaviour and intense emotions are controlled before their intention to execute negative actions takes over them. In DBT, the patients with BPD are taught coping skills and mindfulness techniques such as meditation, self-soothing and regulated breathing for helping people with BPD combat counterproductive urges and show controlled behaviour (Barnicot et al. 2016). As argued by Rudge et al. (2017), DBT includes a long-term process in helping individuals to cope with BPD. It means that effective commitment from the patients with BPD is required to ensure the success of the therapy. This indicates that patients with BPD if leave the DBT in the half-way due to lack of commitment their psychological condition cannot be improved.

The Metallisation-based therapy (MBT) is a nature of talk therapy which has the key aim to ensure recovery of mental state and avoids developing insight. The therapy examines the current moments and uses the information to help the person with BPD identify their personal thoughts and feelings at the moment, in turn, making them develop an alternative perspective regarding the situation (Aggarwal and Patton, 2018). This indicates that MBT makes patients with BPD think differently before reacting to a certain situation helping them to control their negative behaviour. In MBT, the therapist uses different techniques for lowering or raising the emotional arousal as required in a moment, interrupt non-metalizing and encourage flexibility in regarding talking about perspective (Aggarwal and Patton, 2018). The MBT is beneficial for patients with BPD because it teaches the individuals to become conscious of their internal state and way to develop empathy for other's experiences so that negative interactions can be avoided (Aggarwal and Patton, 2018). In forensic presentations, the risk assessment of individuals suffering from Borderline personality disorder (BPD) is essentially required. This is because it is going to help the forensic to inform about the immediate risks to be faced from the person such as showcase of violence towards others, intent to create suicidal attacks, aggressiveness towards individuals, lack of self-control and others during their presentation before the law (NICE, 2018). The information is required so that effective steps can be taken to minimise the risk factors to be experienced from the person (NICE, 2018). In addition, risk assessment of the patients with BPD is required before care so that their immediate needs and long-term demands can be identified and accordingly care services can be managed and provided to ensure their well-being (NICE, 2018). Thus, the information would help to provide care services which are more urgently required followed by other approaches ensuring avoidance of any risk from the patient. The NICE guidelines mention that individuals within the prison population who express symptoms of BPD have equal ability to access care services provided in the community as needed for the condition (NICE, 2018). This informs that the people who are forensically presented as individuals suffering from BPD have equal rights in regarding population in the community to access care services needed to improve their condition. The NICE guidelines mention that individuals with Borderline personality disorder (BPD) have the right to choose their treatment frequency, length of therapy session and frequency of the services (NICE, 2018). Thus, it indicates that in forensic presentations the individuals with BPD are to be provided the right to choose the term and frequency of their psychotherapy session. The Care Quality Commission informs that criminal justice system, police and the mental health services are required to work so that people with BPD can be identified as well as proper services can be offered to them at the right time to avoid risk from them in the society (NICE, 2018).

Legal, Ethical and Safeguarding Approaches:

The forensic mental health services are provided to individuals who show the incidence of mental disorder or neurodevelopmental disorder and have a history of criminal offence. This is because such individuals are vulnerable to others in society and thus require effective care services so that they can cope with the psychological issues to become better individuals (Karsten et al. 2016). In forensic mental health services, the care provision for individuals with borderline personality disorder (BPD) and other issues is to keep the patient in the middle of the care plan so that the care is provided in the best interest of the person (Chanen, 2015). This is because such care would help the individual control their negative emotions and behaviour making them act positively in society. The importance of promotion of care for individuals suffering from mental disorder such as BPD is that it helps to ensure public safety. The forensic services are required to be flexible so that needs of the individuals are fulfilled to make them become better people in the society (Karsten et al. 2016). The Mental Health Act 1983 informs that patients suffering from any nature of mental illness if identified can be detained and provided care with or without their will. This is required so that the individual’s health can be improved to make them less vulnerable to the society, in turn, helping them to leave a better life without creating any risk (legislation.gov.uk, 1983). According to the law, in forensic presentation, the individual who has been detected with borderline personality disorder (BPD) are to be treated in proper care facility under the law. Thus, the individuals are to be detailed for care so that the individual's health can be improved as otherwise they are regarded as vulnerable to society. The section 117 of Mental Health Act informs that people with mental illness have the ability to access services after completion of care (legislation.gov.uk, 1983). Thus, the section of Act safeguards the people who are regarded to be suffering from BPD by the forensic presentation after their recovery. This is evident as they would have the opportunity to get services to ensure their behaviour and emotions remain in control to showcase positive actions in the society as well as towards family members after discharge from the prison. The formation of Criminal Justice Mental Health Team is referred to a multi-agency team that was developed for working in criminal justice settings for supporting and addressing the needs of people with complex and multiple vulnerabilities including needs for health and social care. The team executes screening assessment in different criminal justice settings and work together from point the individual is arrested to the end of sentence by offering screening examination, referrals, signposting and supporting needs, supporting communication with criminal agencies and aid engagement with proper services (NICE, 2018). Therefore, the teams are effective to offer care services for people with mental health issues such as BPD while at prison. Thus, they are effective to safeguard individuals with mental problems like BPD from executing self-harm and negative activities as well as safeguard the society from negative behaviour and attitudes of people with mental health issues by providing them support to improve through proper aid.

Current guidelines do not consider complexity of treatment and the way complexity is changed

The recent guidelines regarding borderline personality disorder (BPD) are seen not to always consider the complexity of treatment related to individual cases regarding the disease. This is because in framing the current guidelines for treatment the different complex elements and co-morbid factors which can also give rise to BPD among individuals are not identified. Moreover, the current guidelines lack information for the staffs regarding the way they are to work together to provide complex care to individual patients by assessing their individual background (NHS, 2018; NHS, 2019). Thus, the lack of detailed information makes the staffs lack scope to determine the way complex care is to be offered for each person. This indicates that the current guidelines are required to be reframed so that they inform about the complex elements to be determined for individuals suffering from mental health issues such as BPD and different approaches to be considered by staffs in supporting each individual according to their background and complex features. Moreover, the staffs are to be provided proper training regarding the way they are to work together in analysing health cases of individuals to offer complex treatment to each person.

Part B

Discussing ways in which specialist services are required to be designed for meeting the needs and demands of patients with the disease

The effective working of the clinical team helps to meet the needs and demands of service users to be fulfilled ensuring satisfactory care support. In challenging environment where borderline personality disorder (BPD) is identified, the clinical team to provide seamless care to the service users is required to follow proper leadership models and styles. The Leadership Framework Model is developed by the NHS that is be used for explaining the way challenges in providing services in forensic presentation of BPD can be resolved to deliver seamless care. The model is to be used because it is the most effective and consistent approach for establishing leadership among the healthcare staffs irrespective of their role, disciple as well as function (leadershipacademy.nhs.uk, 2012). The Leadership Framework Model by NHS informs that shared responsibility between staffs and management is one of the ways for achieving success to offer seamless care. According to the model, the leaders are to develop a proper vision and communicate it to the staffs along with inform strategy to the staffs so that the vision framed can be accomplished by them (leadershipacademy.nhs.uk, 2012). This is because properly framed strategy would indicate the staffs regarding the way they are work in accomplishing the mentioned vision. Thus, in this scenario of forensic presentation of Borderline personality disorder (BPD), the leaders require to mention the vision to the staffs which are to develop improved behaviour and attitude of the individuals with BPD so that they are successful to show positive emotions and actions in the society as well as in interpersonal relationships. The strategy that is to use different types of psychotherapy and effective care services is to be communicated to the staffs by the leaders so that they understand the way the mentioned vision is to be accomplished. However, if the vision and strategy are not effectively communicated by the leader to its staffs then the service providers would be unable to work systematically due to confusion making them fail to accomplish the vision (Pihlainen et al. 2016).

In Leadership Framework Model developed by the NHS, the next stages that are to be followed by the leader in health and social care context are setting direction, improvising services, managing services, demonstrating personal qualities and working with others (leadershipacademy.nhs.uk, 2012). As asserted by Aij and Rapsaniotis (2017), indicating the proper direction to work in a team by the leader within a challenging environment makes them help the staffs cope with issues faced in accomplishing their work. This is because leaders have effectively proficiency and expertise from previous experiences regarding the way the clinical team are to be directed in challenging situation so that they can overcome difficulties and troubles at work. For instance, in challenging environment where the patients with forensic presentation of BPD refuses to return to hospital or care centre after leave policy or absconds the leaders require to inform the clinical team regarding the way they are to bring them back. The leaders require directing the team that they are to use assistance from an Approved Mental Health Practitioners or use the law under section 135(2) which needed involvement of the magistrate court to bring the service users back to the care centre or hospital. This is because the care centre or hospitals are the legally approved areas referred to the patient with forensic presentation of BPD to be treated for their disorder by the law (rethink.org, 2017). As argued by Merrill (2015), failure of the leaders to direct the staffs in challenging situation makes them fail to overcome difficulty at work. This result the staffs unable to meet the vision as well as fail to overcome the trouble experienced at work.

According to the Leadership Framework Model, leaders are to encourage and coordinate improvement of services as well as inform clinical team regarding the way they are to manage the services to effectively provide seamless care in a challenging situation (leadershipacademy.nhs.uk, 2012). This is means in challenging environment where forensic presentation of BPD is done the leaders are to inform clinical team regarding the way they are to improve and manage their services. It is required so that any probable troubles such as aggressiveness, physical harm and others from the patients towards the clinical team who are involved in care or self-harm, the accomplishment of suicides and others by the patients towards them can be avoided. Thus, the effective management and improvement of services by the leaders ensure better protection of the clinical team while at work as well as ensure improved well-being of the patients. The working with others is to be promoted by leaders for the clinical team in challenging situation (leadershipacademy.nhs.uk, 2012; Alilyyani et al. 2018). This is because it would make the leaders direct the members of the clinical team to work collaboratively by sharing ideas in successfully providing care for the patient with BPD. The showcasing of personal qualities by each individual in the clinical team is to be set by the leaders by allocating each member specific roles as per their quality (leadershipacademy.nhs.uk, 2012). This is because it would make the leaders provide opportunity to each member in the team to demonstrate their ability in accomplishing the vision of ensuring better well-being and relationship development by the patient with BPD. The transformational leadership style is also to be followed by leaders in allowing the clinical team to provide seamless care. The transformation leadership informs that leaders are to encourage, motivate as well as inspire their subordinates for creating change and innovation in services so that growth can be achieved (Olvera et al. 2017). In forensic presentation of patient with BPD, the clinical team often experiences challenge of providing satisfactory individual care to the patients with BPD (de Vogel et al. 2016). The transformation leadership style is required in this case as it would make the leaders inspire and motivate the clinical team to identify innovative way of offering care to service users to overcome the issue. This is evident as effective motivation leads the clinical team with the help of their leader think and develop new ways of delivering care to provide better satisfaction to the patients.

Evaluation of current provision to deliver specialists services and the gaps affected by political and economic agenda

The political condition of the country has a creative influence on the management and administration of services. As a result of Brexit, it is seen that increased turmoil has been created in the health and social care field. This is evident as 5000 nurses are reported to have left the NHS, UK within the last 2 years as they were migrants and Brexit has made them unable to have permission to work in the country. Moreover, in the NHS, UK the number of EU-trained midwives and nurses feel from 38,024 in 2017 to 33,035 in 2019 calculating to a drop of 4,989 nurses (theguardian.com, 2019). This condition has led the vacancy rate of nurses to be raised to 11.8% in the first quarter 2018-19 from 10.2% in the first quarter of 2017-18 (nursingtimes.net, 2018). The figures indicate that there is increased staff shortage in the UK as result of restricted work policy made by Brexit which is making migrant and EU-trained nurses unable to work in the country. The staff shortage created as a result of Brexit is hindering proper management of care for patients with Borderline personality disorder (BPD). This is because without presence of qualified workforce in the health and social care field there is lack of availability of nurses who have the ability to determine and deliver proper individualised therapeutic care for the patients with BPD (kingsfund.org.uk 2019). In 2018/19, the NHS England has planned to spend £12.2 billion on providing and improving services regarding mental health. This is roughly 1 in 10 pounds that are spent by the UK Department of Health and Social Care for health and social care services (fullfact.org 2018). In between 2013 to 2015, the mental health trusts operating in the UK who are involved with providing services regarding BPD, schizophrenia and others are seen to experience reduction in the allocation of budget by 40-50% (mentalhealth.org.uk 2019). In addition, only 5.5% rise in the expenditure by the government towards mental health services is mentioned compared to the 16.8% rise in budget for spending on physical health services (theguardian.com, 2018). The economic statistics inform the UK administration and government are more focussed on spending increased finances to uplift physical health servicers compared to mental health services. Thus, it indicates that there is lower availability of budget by the trusts and hospital involved in developing care services for mental health issues such as borderline personality disorder, depression, dementia and others. Therefore, it is creating lower economic support for people with mental health issues to avail care service to improve their health in the UK.

Conclusion

The discussion regarding forensic presentation of borderline personality disorder (BPD) informs that individuals who have been exposed to abuse, neglect, maltreatment and others in childhood are more inclined to develop the disorder. However, the effective implication of psychotherapy such as Metallization-Based therapy and Dialectical-Based Therapy are effective for its treatment. The Mental Health Act is to be followed in providing legally approved services to patients with BPD. The leaders need to follow Leadership Framework Model developed by NHS and transformation leadership style in providing seamless carte ion challenging situation for patients with BPD. In the UK, it is seen that political and economic agenda is both creating gaps in offering effective mental health services to patients who are suffering from any nature of mental health issues such as BPD and others.

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