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Psychiatrists often have to hospitalise those who don’t want admission, while striving to keep out many who do. More than 70 per cent of acute admissions are detentions under the Mental Health Act. The rest admit themselves voluntarily, via agreed plans – or despite attempts to keep them out. Many of these are impulsive souls with chaotic relationships and difficult lives, often complicated by drink and/or drugs, who take overdoses and cut themselves. Whether seen as victims of abuse, as sufferers of “an illness” or as an organisational nuisance, they are hard to treat.
Many such patients have the “borderline” type of “emotionally unstable personality disorder”, and are well known to crisis and community teams (and A&E). But is “personality disorder” an illness? Illness means a change in your state (physical or mental) but personality is something you have always had, like red hair. (Arguments abound about its definition: is one’s personality stable or changeable, and can it be measured?) The phrase “deeply ingrained maladaptive patterns of behaviour” begins most textbook definitions, and typical features include a fluctuating emotional world, a sense of emptiness and anger. Relationships deteriorate, thus the pervasive sense of abandonment. Impulse control is often childlike and patients may hear an inner “voice” saying unpleasant things like “kill yourself, stupid”, often in much harsher terms.
Julie was typical. Her arms laddered with old scars, haunted by childhood memories, she could be sullen, smiling, tense and chatty in one interview. Overdoses (sometimes real, sometimes not), jumping in the canal, cuttings galore and intrusive suicidality meant numerous admissions, monthly or more, for years. Crisis intervention, extra therapy, a support worker, a telephone hotline, and out-of-hours consultations repeatedly failed. A national specialist unit, designed for severe cases, rejected her as being “too suicidal”.
Although the prevalence of borderline states is probably 1 per cent or less among the general population, they are over-represented in A&E and hospital attendances. They do not do well on the wards. Medications don’t help the core persona, but impulsiveness and inner tension tend to get them put on large doses of tranquillisers and even antidepressants. These compound the overdose potential, so therapy is now accepted as the best option, with some evidence that group approaches, for two to three days a week, over two to three years, can really change behaviours … if you can get the patients to join in.
Many “borderlines” want to be defined as bipolar, preferring an illness that can go away to a state of being. It used to be unfashionable to tell people their diagnoses, because of the stigma attached. Now it is very much the thing: recognising yourself in the standard descriptions can generate enlightenment. Within the notion of “personality disorder” lies the assumption that your emotional age will, in time, catch up with your real age: you will, so to speak, “grow out of it”. But for most patients the major task of therapy is damage limitation.
Julie found that having two cats at home stopped her sense of abandonment, giving her living beings to relate to. This wasn’t really a cure, but did reduce her admission rate. Keep them at home, out of hospital and out of jail, and you’re doing fine, as an old colleague once said. Julie retired to the countryside, for a quieter life. She has been better since, scarred but alive.
Trevor Turner is a consultant psychiatrist working in east London. Some details have been changed to protect identity