Authors: Shalome Kanagaratnam, Hugh Grant-Peterkin / Editor: Swagat Mishra / Codes: CAP30, MHC4, SLO7 / Published: 26/04/2022
Your personality is your relationship with yourself and the world – a complex constellation of behaviours and responses to one’s inner world that make you the person you are. It’s a combination of your genes and your environment. In its basic form – it is the ‘self’ that perceives others and is also perceived by others. But what happens if your personality is disordered or disrupted by psychiatric illness? How can your ‘self’ then be accurately discerned from your personality disorder? Where does the condition end and you begin?
The 3 P’s
A UK study in 2006 suggested that, at any given time, about 1 in 20 people will have a personality disorder (PD). This term encompasses 10 different conditions, as described by the ICD-10 classification, all of which exhibit the 3 P’s: pervasive, persistent and pathological. The disorder therefore has to cross over multiple domains in your life, persist over a long period of time and cause significant disturbance to your working life, family life and health. Diagnosis must exclude other causes such as developmental stages, substance misuse and organic pathology.
Assessment in the ED
Patients with a PD often live chaotic lives characterised by interpersonal conflict and maladaptive behaviours. Reasons for presenting to the Emergency Department are varied and include a desire for human interaction, failure of community resources and safety concerns following suicidal ideation, self-harm or substance misuse. The mainstay of emergency assessment, as with any other patient, is knowing your environment and the resources at your disposal. Patients with emotionally unstable personality disorder (EUPD) in particular, tend to draw in a lot of attention and concern. Clinical care often requires support from security and, possibly, also the police. So you can expect a sense of chaos and disturbance. This can pose a risk to clinical staff, distract from productivity and impact upon the safety of other patients so think about the safety of yourself, the team and other patients when approaching any potentially challenging patient. You can do this by considering your department’s physical layout, the skills mix of your team and maintaining clear communication regarding who is doing what and when.
Introduce yourself – at the start of your shift, seek out the psychiatry liaison team and introduce yourself. Building that relationship supports both in treating these patients and you can also enquire about any expected patients – often psychiatry know if someone’s having a crisis in the community and likely to pitch up in ED. Do the same with the security team.
Psychological PPE – being on the receiving end of a patient’s vulnerability and frustration can feel personal and unpleasant. Remind yourself that its not actually about you personally but about what you represent as a caregiver in their life.
Compassion – these patients almost invariably have had disturbed and difficult early lives involving abandonment and neglect. Their experience of care from parents and others is therefore often deficient and abusive. So when they need help, they enter the hospital with distress they can’t articulate and expect to be cared for – much like any other patient. But this triggers vulnerability which they also can’t articulate and the combination can lead to what is often inaccurately perceived as ‘acting out.’
Connect to their emotional state – this is an intervention in psychiatry just as taking blood might be in other aspects of medicine. Hear the emotion through active listening, validate it and then reflect it back. This can de-escalate the crisis so that you and the patient can start to form a therapeutic alliance to move forward e.g. ‘that must be really frustrating for you – what can we do about it?’
Recognise splitting – PD patients polarise their relationships with other people into either ‘you’re amazing’ or ‘I hate you.’ They will either idealise or devalue. So they might pick on one of the clinical team and say: ‘they understand me and you don’t.’ Recognise when it’s happening and its impact upon you and the team.
Preconceptions – avoid making judgments before entering the room or with the difficult headspace from your last encounter or assuming you know the end-result of the consultation. Try to maintain compassion throughout – if we can’t do this, its not just the patient who misses out. We lose a way of being with our patients and this can eventually lead to burnout.
Lack of team approach – before entering the patient’s room, step out with the whole team (doctors, nurses, security) and ask: what is our approach as a team? Don’t just think ‘I’ve got the answer because the last time they were here, we had a great rapport and I fixed everything.’
Go in blind – know the context by reading through the patient’s psychiatric notes so that you know when there is a departure from their usual patterns of behaviour and the presence of any high-risk features.
Decisions regarding self-discharge – in the Mental Health Act (MHA), it doesn’t matter whether a patient has capacity or not. If a patient needs to come in for treatment for their mental health problem but refuses, a psychiatrist can still fill out that first recommendation of a Section 2. The problem arises however when a patient wants to self-discharge in the ED in the no-man’s land between identifying risk and completing the Section 2. In such an event, you are often looking to common law to hold that person for a short interval in their best interests.
Caring for patients with PD can be complex and demanding. By adopting a systematic plan for ensuring the physical and psychological safety of staff, establishing boundaries, minimising splitting and conducting a comprehensive risk assessment with admission under the MHA where necessary, we can ensure high quality care for these patients.
However, the need for collaboration and compassion cannot be underestimated as this patient group have invariably experienced abandonment, abuse and neglect early on in life. Remember – its not necessarily about you specifically as a person. You represent something for them – you are a caregiver that’s let them down. You are a system that’s blocking their attempts at getting care. Its worth remembering that in the moment to aid decompression and enable you to better care for the patient.
- Camden and Islington NHS Foundation Trust, Meeting the challenge, Making a Difference
- MIND, Personality Disorders
- RCEM Learning, Dick T. Mental Health in the ED. 2018.
- NETRAG+ Episode 3: Night shift anxiety and patients with personality disorders