How effective is ECT for those with borderline personality disorder? What can help improve the quality of care for patients with borderline personality disorder and major depression? Two nurses who specialise in this field examine the use of electroconvulsive therapy, in terms of patient care and cost savings.

Use of electroconvulsive therapy (ECT) for patients with borderline personality disorder (BPD) has a poor outcome, some reported findings and anecdotal clinical experience suggest. (1) Patients with a rear or assumed co-morbid BPD are less likely to receive adequate treatment of any kind. (2) BPD is a significant health problem affecting one to four percent of the general population, 11-15 percent of psychiatric out-patients and 19-22 percent of psychiatric in-patients. (4-6) Seventy-five percent of these are female. (3)

There is very little documented research on the use of ECT for those with BPD and a comorbid depressive disorder. (2) Is this due to a Lack of understanding of BPD, or due to ongoing prejudice around this diagnosis? Our aim was to investigate a controversial topic in order to improve the quality of care and outcomes for this particular patient group.

This study aimed to review the efficacy, and the cost benefits for the hearth service, of the use of ECT with patients with a diagnosis of BPD and a major depressive disorder (MDD) within the mental health and addictions services (MHAS) of the Waikato District Hearth Board (WDHB). Our study used a case history, diagnostic material from the Diagnostic and Statistical Manual (of Mental Disorders) (DSM IV), (3) a literature review, a review of WDHB MHAS ECT statistics, and a questionnaire sent to 30 clinicians. The questionnaire was to get the views of clinicians working in mental hearth services on the use of ECT for those with BPD and MDD. Twenty out of 30 responded--13 psychiatrists, six psychiatric nurses and one dialectic behaviour therapy (DBT) specialist.

DSM IV diagnostic criteria for BPD are: "A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: .." There follows a list of nine symptoms of BPD (see table right).

"Their cost in terms of hospital days and staff hours is phenomenal. They ore recognised to be one of the most difficult groups to treat or even manage successfully and, they are a group for which few effective or empirically tested treatments exist". (6)

"The main tenet of the biosocial theory is that the core disorder in borderline personality disorder is emotional dysregulation. Emotional dysregulation is viewed as a joint outcome of biological disposition, environmental context, and the transaction between the two during development. The theory asserts that borderline individuals have difficulties in regulating several if not all emotions. This systemic dysregulation is produced by emotional vulnerability and maladaptive and inadequate emotional modulation strategies." (7)

Deliberate self harm (DSH) is frequent in patients with BPD; at least 75 percent attempt suicide and approximately 10 percent complete suicide. Clinicians must avoid the error of assessing frequent DSH as being mere gestures rather than a genuine wish to die; it is imperative that risk factors are understood and comprehensive plans of care are put in place. (5)

We examined, and hypothesised about, the negative and sometimes dismissive attitude of some clinicians toward those with a diagnosis of BPD. Is this due to a lack of job satisfaction since, no matter how much time and effort is devoted to this patient group, there is a continuing and relentless pathway toward self-destruction? Is it due to a sense of frustration when people with BPD are admitted to the inpatient service so frequently and it is felt they are no longer worth the effort?

In a recent study, it was intimated that only 22.2 percent of those treated with ECT for MDD and with an Axis II diagnosis of BPD had a poor result. (1) One response to the study pointed out that: "First of all there was an acute improvement in over 20 percent of depressed borderline disorder patients, most of whom would have been non-responsive to antidepressant medication. If this were generalizable, then it would amount to a large absolute number of potentially treatable individuals." (8) The same commentator goes on to say that many people with BPD have been tried on numerous medications over many years, to no avail, and continue to suffer. In selected cases, it "may well be worth the effort and expense of ECT". (8)

We conducted an informal survey of 30 clinicians at WDHB to gauge attitudes towards ECT for those diagnosed with BPD. The results showed that the majority of the 20 who responded were in favour of ECT for those with BPD who had a definitive diagnosis of a co-morbid major depressive disorder.

A CASE STUDY: Marcia's story

'I let my skin cry for me instead, the only difference is the drops are red. When I look in the mirror I have what I see A useless, worthless person looking back at me'

Marcia's perception of herself--in her own drawing and poetry.

Marcia (not her real name) is a 44-year-old woman with a diagnosis of BPD with recurrent MDD. She came to the attention of mental health services at the age of 22 following a drug overdose, and at this time was diagnosed with post-traumatic stress disorder with an underlying depression. She had experienced significant stressors in her life, including childhood sexual abuse, emigration with her family at the age of 16, and a divorce after a short marriage left her to cope with two young children as a solo parent. When her daughter was two years old, the child suffered a serious accident that left her scarred for life. Following this incident, Marcia moved away from all her support people to start a new life, and thought she had found a rewarding relationship with another man. However, he was abusive and attempted to murder her during a violent assault.

For more than 20 years, Marcia was prescribed a range of anti-depressant and anti-psychotic medications, none of which were of any benefit. In 2001 she started a course of dialectical behaviour therapy but did not follow this through, abandoning the treatment shortly after starting. During this 20-year period there were numerous incidents of deliberate self harm that resulted in scarring of Marcia's face and arms.

In 2005 Marcia was admitted to a mental health unit following a drug overdose; she was deeply depressed. Since medications had been ineffective, it was suggested Marcia have a course of ECT, to which she consented. In order to gauge the severity of Marcia's depression and to record a pre-treatment baseline, the ECT nurse conducted an assessment, using the Montgomery and Asberg Depression Rating Scale (MADRS). Marcia scored 43/59: this score is indicative of a major depressive episode. Her responses and presentation at interview identified seven of nine criteria for MDD as outlined in DSM IV. (2) Reflecting on Marcia's history, it was evident she had experienced, or was experiencing, at least seven of the nine identified behaviours in DSM IV used for diagnosing BPD.

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The ECT nurse was concerned for the patient's safety since, during the interview, Marcia had expressed a pervasive death wish; those findings were duly reported to the ward staff responsible for her care. The staff indicated they felt Marcia had deliberately scored herself as being more deeply depressed than she really was.

"While BPD does not appear to be associated with increased depression symptom severity when evaluated by clinicians, the subjective experience of depression, as indicated by patient self-reports, seems to be intensified." (9) And in Marcia's own words in a letter to her clinician: "I find it impossible to show any kind of emotion to anyone, be they close friend or stranger and always try to be in total control of my thoughts and actions, showing only what people want to see, happy, happy, joy, joy."

Marcia completed a course of eight ECTs as an inpatient and appeared greatly improved in mood. However, her MADRS score at this time was 29/59, indicative of a continuing depression, but without the all-consuming wish to die. She was discharged into community care with an objectively unresolved depressive episode. During 2005 Marcia continued to deliberately self harm and was admitted to hospital following each incident, ten times in all.

In March 2006 Marcia overdosed and was again admitted to the inpatient service under the care of a different mental health team. Marcia had indicated that ECT was the only effective treatment for her to combat the severe depressive episodes and consequent impulsivity to self-harm. Her consultant psychiatrist suggested she have a further, but more prolonged course of ECT, followed by continuation and maintenance treatment. Strong scepticism was expressed by some clinicians regarding the efficacy of the proposed treatment plan, and being a patient advocate at this time was like swimming against a powerful tide of disapproval.

Marcia embarked on a course of 12 ECTs, five as an inpatient and the remainder as an outpatient. Incidents of deliberate self harm continued during this period. Marcia came to the ward with enormous burn blisters on her arms and the ECT nurse thought that maybe the sceptics were right, and that ECT was not an effective treatment for Marcia. Her community nurse had warned the ECT nurse that Marcia confessed to having razor blades in her wallet, so the patient was subjected to a property search on each outpatient appointment, in accordance with the WDHB search policy. (10) Nothing potentially harmful was ever found.

However, treatment was abruptly discontinued when Marcia presented with a fresh facial laceration in the ward after recovery from ECT. On this day a clothing search revealed she had secreted a penknife and cigarette Lighter in her pocket. (10) In view of this safety risk, not only for herself, but also for other patients, a decision was made by the ECT team and ward clinicians that she should not return to the ward. However, the one positive outcome during the maintenance course was a 50 percent reduction in hospital admissions during 2006.

Marcia asks for another chance

In May 2007 Marcia again became extremely depressed and suicidal. She asked for another chance with ECT since medications were not effective. Senior clinicians agreed, on the understanding she submitted to a personal and property search every time she came to the ward as an outpatient. (10) Before being admitted to hospital, Marcia signed a contract to this effect, also agreeing to cover with a dressing any self-inflicted wounds. She proceeded to have four twice-weekly ECTs, the first treatment as an inpatient, and thereafter as an outpatient. Maintenance ECTs continued throughout that year: there were two mild incidents of self harm and only one further admission to hospital for respite, due to family problems considered potentially detrimental to Marcia's mental health.

Some clinicians argue that ECT is used by the patient as a "placebo" for deliberate self harm, as a form of self-punishment, with the secondary gain of being an ECT patient. According to to two American clinicians: "It is important in ELF practice to discriminate those patients who may benefit from ECT versus those who will not. As such, precise definition at 'benefit' needs to be clarified. Classically, the benefit from ECT is considered to be relief from the core symptoms and signs of melancholia, mania, catatonia or non-affective psychosis". (11)

Marcia has been closely involved with the formulation of this case study, and she was invited to share her thoughts on the subject. Her view of ECT is that it is painless and administered by another person, but deliberate self harm must be self-inflicted and "has to hurt like hell, otherwise there's no point in doing it". Marcia claims ECT helps lift her mood so she is able to combat her self-loathing and the eternal burden of guilt over the accident to her daughter.

It would be presumptious to claim ECT is, and has been, the sole catalyst for Marcia's improved mood and behaviours. This positive result is no doubt a combination of a number of therapeutic approaches and stronger family support, but there does appear to be a correlation between the use of ECT and the reduction in incidents of deliberate self harm and hospital admissions over the last three years. In 2005 Marcia had 10 admissions, in 2006 five admissions and in 2007 she was admitted once only for treatment and once for respite. From this one patient the benefits for the DHB in terms of cost savings are quite significant, and if we took at the overall statistics from WDHB, these financial advantages would be multiplied.

At the DHB, in 2005, 34 patients diagnosed with MDD were treated with ECT. Of these 34 patients, eight (23 percent) were diagnosed with BPD and co-morbid MDD. Two were outpatients, six were inpatients.

In 2006, 30 patients with MDD had ECT. Eight of those patients (26 percent) were diagnosed with BPD and MDD. Two were outpatients and six inpatients (four were the same patients from 2005). Four patients with BPD were discharged; two have not been re-admitted to hospital; one has moved to another district and is studying for a degree at university, and the fourth holds a responsible position in a public service. Four patients with BPD and recurrent MDD continued to have maintenance ECT.

These statistics show that approximately 50 percent of patients with MDD and concurrent BPD, continued to have maintenance ECT as outpatients, while 50 percent had not returned to hospital following a completed ECT course. We believe this is a positive outcome.

Conclusion

In this study we investigated the symptoms and behaviours of BPD and concurrent MDD and how, in selected cases, ECT can benefit those with depression and BPD and improve their quality of Life. Some negative attitudes and prejudice towards those with BPD has been identified among some clinicians.

There is evidence of real risk of death for this particular patient group that we, as clinicians, need to recognise and manage safety. The WDHB statistics reveal an acceptable positive outcome for this patient group when ECT is used as a treatment, and there is some financial benefit for the health service by reducing costs of inpatient care.

References (1) Feske, U. et al. (2004) Clinical outcome of ECT in patients with major depression and comorbid borderline personality disorder. The American Journal of Psychiatry; 161, 2073-2080.

(2) De Battista, C. & Mueller, K. (2001) Is electroconvulsive therapy effective for the depressed patient with co-morbid borderline personality disorder? The Journal of ECT; 17: 2.

(3) American Psychiatric Association (1995) Diagnostic and Statistical Manual of Mental Disorders; p650-654.

(4) Samuels, 3. et al. (2002) Prevalance and correlates of personality disorders in a community sample. British Journal of Psychiatry; 180, 536-542

(5) Black, D. W. et al. (2004) Suicidal behaviour in borderline personality disorder: prevalence, risk factors, prediction, and prevention. Journal of Personality Disorders; 18: 3, 226-39.

(6) Farrell, J. M. (2003) Borderline personality disorder treatment. Spectrum, Indiana Psychiatric Society.

(7) Linehan, M. M. (1993) Skills Training Manual for Treating Borderline Personality Disorder; 40: 2.

(8) Ness, D. E. (2005) ECT in patients with borderline personality disorder--letter to the editor. American Journal of Psychiatry; 162, 1762.

(9) Stanley, B. & Wilson, S. T. (2006) Heightened subjective experience of depression in borderline personality disorder. Journal of Personality Disorders; 20: 4.

(10) Waikato District Health Board. (2008) Policy: Searching of Mental Health Consumer in relation to Illicit Substances/Dangerous Articles. Clause 3.3.

(11) Rasmussen, K. G. & Lineberry, T. W. (2007) Patients who inappropriately demand electroconvulsive therapy. Journal of ECT; 23: 2, 109-113.,

(12) Flint, V. (2005-6) Waikato District Health Board ECT Statistics.

Diagnostic criteria for borderline personality disorder

A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1) Frantic efforts to avoid rear or imagined abandonment. (NOTE: do not include suicidal or self-mutilating behaviour covered in no5.)

2) A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation.

3) Identity disturbance: markedly and persistently unstable self-image or sense of self.

4) Impulsivity in at least two areas that are potentially self-damaging (eg spending, sex, substance abuse, reckless driving, binge eating).(Note: do not include suicidal or self-mutilating behaviour covered in no5)

5) Recurrent suicidal behaviour, gestures or threats, or self-mutilating behaviour.

6) Affective instability clue to a marked reactivity of mood (eg intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarefy more than a few days).

7) Chronic feelings of emptiness.

8) Inappropriate intense anger or difficulty controlling anger (eg frequent displays of temper, constant anger, recurrent physical fights).

9) Transient, stress-related paranoid ideation or severe dissociative symptoms.

Sue Hills-Johnes, RN, MHCert, Dip Ed, is clinical nurse specialist, and Val Flint, RN, is ECT nurse co-ordinator for the mental health and addictions service at the Waikato District Health Board.