clinical focus
Personalities
in pain
People with borderline personality disorder
needing aged care can suffer greatly; meeting
their needs requires training and empathy.
Josephine Beatson interviewed by Dallas Bastian
E
xperts shine light on the importance
of timely identification of older
people with borderline personality
disorder in a recent study.
Associate professor Josephine Beatson,
senior clinical adviser at Spectrum
Personality Disorder Service for Victoria,
and her team, warn that clinical experience
suggests a growing prevalence of borderline
personality disorder (BPD) in residential
aged-care and psychiatric facilities.
Their study, published in the Australian &
New Zealand Journal of Psychiatry, reports
that timely identification of the disorder
is needed so sufferers can receive skilled
help, understanding and treatment.
In the article titled “Missed diagnosis: The
emerging crisis of borderline personality
disorder in older people”, the authors write
that no diagnostic or rating instruments
have been developed for BPD in older
people, and add: “Escalations of symptoms
32 agedcareinsite.com.au
and maladaptive behaviours usually
occur when the diagnosis of borderline
personality disorder is either not made
or delayed.”
Staff education surrounding the disorder
is urgently needed, they say.
Beatson, who is also with the Department
of Psychiatry at the University of Melbourne,
sits down with Aged Care Insite to discuss
BPD, its prevalence among older age groups,
and what health professionals should know
about this disorder.
ACI: What is borderline personality
disorder, and how common is it in
residential aged-care settings?
JB: It’s a complex, severe mental illness
that is characterised by unstable states
of emotion. In younger people, unstable
impulses often manifest in self-harm
and suicidal behaviours, but that’s much
less the case in the older age group. It is
marked by poor functioning in many areas,
particularly interpersonal relationships.
People do sometimes – often even –
struggle to hold jobs and things when they
suffer the effects of this disorder.
As for its prevalence in aged care
… there is some data from good
research suggesting that 60 per cent
of the in-patient psychiatric population
suffers from one of the several different
personality disorders. Not all of those are
borderline, and what we have no idea of is
what percentage of those have BPD.
In the community at large, including in
the aged community, rather than the aged
care community, we think between 1 per
cent and 3 per cent of the population would
suffer from borderline personality disorder.
But even that has not been well researched.
Did you decide to look into the diagnosis
of the disorder in older age groups due
to a paucity of research?
Partly, but mainly because I was talking to
aged-care psychiatrists and people who
were training as aged-care psychiatrists,
and it was clear that this illness causes a
great deal of trouble in aged-care facilities.
I had some extremely telling experiences of
just how much difficulty can arise around
patients with this problem in aged care [for
the patients as well as the staff].
We need to get some education out there
for staff in aged-care facilities and psychiatric
aged care about how patients with this
particular illness can best be managed and
the [potential problems] averted.
In what other ways does borderline
personality disorder differ in aged and
younger individuals?
The unstable and intense emotions
remain in elderly patients with borderline
personality disorder, [so they’re] unstable,
intense, and have up and down emotional
states. [They also have] intense and
unstable interpersonal relationships. Sadly,
many of these people will have alienated
members of their family and their friends.
They may have few friends or relatives
still involved with them, which is a sad
situation, especially for the elderly.
They develop unstable and intense
interpersonal relationships with in-patient
staff also, whether it’s aged-care staff or
psychiatric in-patient staff.
The patient often expresses a lot
of hostility. They tend to have poorly
controlled anger and that intense anger
persists in elderly patients. [There’s often]
an enormous fear of aloneness and
abandonment, so things may happen