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Challenging behaviour is often a symptom, not a personal attack

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Throughout university we’d been taught that patients with this diagnosis can exhibit “challenging” behaviour, that they can divide teams and we should reflect on how we feel to avoid burnout.

Although we spent a great deal of time analysing how best to nurse patients with a personality disorder (PD), this was approached in a clinical manner.  We barely covered the reasons why someone might choose to behave in these ways and want to spend their time in hospital.

So, what is it about this diagnosis that worries nurses before they’ve even met the patient?

Although those with PD can often put a strain on nurse time, I don’t believe reluctance to engage is the result of laziness.

Nurses join the profession wanting to help people. But trying to care for someone who appears to be thwarting attempts to be helped can leave health professionals feeling hopeless. It can be difficult to empathise with someone whose behaviour doesn’t always appear to fit with what they are saying. And even harder to put yourself in someone’s shoes when they are doing everything they can to avoid discharge, a situation that can often come up when nursing this patient group.

Let’s face it, mental health wards are a far cry from the Hilton so why do they want to stay?

It can be easy to forget thatBPD is an illness in itself and the challenging behaviour that can come with it is a symptom, not a personal attack. Understanding this behaviour makes it easier to get a grip on what is actually happening.

In my experience, this is where compassion can often fall down.

And, in these situations, maintaining unconditional positive regard can be difficult.

I agree with the Willis Commission that nurse education is of a high standard, but I feel that training is focused solely on helping and supporting people who want to get better. Little time is spent exploring the reasons why someone might rely heavily on services, often without any apparent reason.

Learning why someone may want to stay in hospital and go to extremes to resist discharge may help nurses, particularly those newly qualified, to remain compassionate when faced with challenging behaviour.

For this reason, it is essential that education on personality disorders centres on the reasons behind the presentation, rather than simply how to manage challenging behaviour.

After all, not everyone can learn compassion, but everyone can learn understanding.

  • Comments (2)

Readers' comments (2)

  • Anonymous

    Yes I agree. Sometimes we can get too focused on how diifficult we find a patient and forget the reason for that behaviour.

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  • Anonymous

    Very good article and highly relevant comment above.

    From the current understanding of PDs and especially BPD and according to the ICD-10 and DSM-V (in press), they have mixed complex pathologies which make their symptoms and explanations of challenging behaviour difficult to discuss in such a short space and with limited time but awareness among all HC personnel, including those who are not mental health specialists, is vital and especially at the first point of contact for the patient across all of the medical services. This indicates the importance of specialist training in interacting with different types of individuals with different, complex and challenging needs as well as the needs and protection of the staff.

    Another point in these groups of patients, and especially those suffering from BPD, is that theyoften have hypersensitive and overactive autonomic nervous systems (‘fight or flight mechanism’ and the HPA axis) and can be perceived as 'drama queens'. This type of behaviour should never be ignored as it can be a sign of far deeper and more serious problems such as deliberate self harm, severely damaged relationships, manipulation of others in a desperate attempt to get the acknowledgement (we all crave after if we feel we do not get it), attention, help and the support they need as they may not have adequately learned during their development because of their particular socio-environmental circumstances the more healthy coping mechanisms seen in a majority of other adults. Feelings of helplessness and hoplessness and attempted and completed suicide are also commonly associated with BPD. Known as 'black white thinking or dichotomous thinking' their world view and perception of others is often perceived as all good or all bad and this can change according to the situation and behaviour of the other at any time. Somebody can be seen wonderful one moment and wicked the next making the necessity to build a relationship of trust and confidence very important. They are also subject to rapid mood swings similar to the bipolar group of disorders but unlike these can go from high to low in a matter of minutes or hours and fall into the depths of despair which may trigger extreme apathy and other negative and fearful behaviours.

    Impulsive behaviour and difficulties of emotional control are symptomatic of BPD which can explain their difficulties at times of interacting with others, such as displaying signs of frustration, anger and aggression, etc., although they may have the intelligence, charm and social intelligence of any other individual and are often described as ‘the life and soul of the party’, especially when their condition is stable.

    There are individuals with BPD successfully working in the helping professions such as medicine and nursing although a ‘wounded helper syndrome’ has pushed some, with a lesser degree of success, into their career choice.

    The causes of BPD are largely unknown but its development is thought, in some but by no means all cases, to be associated with childhood trauma. Crises, which occur most frequently in younger adults until around mid-life and more females than males (possibly because more females tend to seek medical help) may be triggered by situations of extreme stress and severe personal crises such as those which occur commonly in midlife with the loss of a significant other and other major upheavals such as moving location, etc.

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