Exploring General Practitioners’ Views and Experiences of Providing Care to People with Borderline Personality Disorder in Primary Care: A Qualitative Study in Australia
Abstract
:1. Introduction
2. Materials and Methods
3. Results
3.1. Challenges Surrounding Diagnosis of BPD
“They come in with some sort of behavioural problem, or depression, or anxiety, or a mood swing, and then you’ve got to try and work out whether they might fit into a broader category.”(GP, FG2)
“…the things that alert me are some of the textbook criteria of people who talk about a lot of empty feelings, a lot of “what if somebody abandons me”, the rapid change—one minute thinking someone’s wonderful and the next minute saying how awful they are, which sometimes I discover applies to me as well.”(GP, FG1)
“But it’s complicated too, because not all ‘cutters’ are necessarily BPD. So, it’s not straightforward…”(GP, FG1)
[When asked how they recognize BPD] “You get sort of an instinct for it and the nature of the interaction I think gives you the clues…and I guess you get that gut feeling.”(GP, FG1)
[On encountering a complex presentation possibly involving BPD] “… I’m seeing the presenting things and not actually looking underneath.”(GP, FG1)
“I feel so bogged down sometimes with the physical symptoms that they’ve presented with that I never feel like I get to the psychological.”(GP, FG1)
“… meeting these people for the first time, you’re usually dealing with the crisis that they come in with rather than the diagnosis.”(GP, FG2)
“I think the difference with less experience is that the physical things that present are so front and central that they [junior doctors] find it difficult to even look to something else before they’ve gone through each and every one of the physical things…”(GP, FG1)
“I reckon a lot of people sort of deny it… Not that many patients come in and say they’ve got a personality disorder, because I think there is a bit of a stigma there.”(GP, FG2)
“We must have a consensus statement on what the evidence-based interventions are that you can use in these conditions. Most diseases have a manual plan, but it doesn’t seem to be working for many psychological and psychiatric conditions. Yeah, it would be very difficult to do, but at least something that says ‘these five therapies work’.”(GP, FG2)
3.2. Comorbidities and Clinical Complexity
“Comorbidity seems to be huge. I mean they present with so many physical symptoms as well as mental health symptoms... it’s not unusual to have six, seven, eight, nine, separate problems, and the last one will be, ‘oh, I’ve been having chest pains’.”(GP, FG1)
[Of treating comorbidities] “… you’re committed to investigating and I try to prioritise them, what the potential life-threatening things are, and then work my way through it.”(GP, FG2)
“I’ve made an hour-long appointment for a patient because she has so many problems; then she didn’t turn up.”(GP, FG1)
“Why the short appointments? Why is Medicare loaded towards the short appointments?”(GP, FG2)
[Of time constraints while addressing multiple issues] “… can we just clarify, the therapy has 15 minutes to gauge this, and you probably have half an hour to 45 minutes just to sort of make sure you’re in the right playing field.”(GP, FG1)
[Concerning the nature of patient presentations] “… the way they present with physical symptoms can be very compelling… Someone’s feeling whatever symptoms they’re presenting with can be very engaging for us.”(GP, FG1)
[Concerning mental health comorbidities] “… there’s often a different diagnosis, like an eating disorder. So, all the focus gets put on that rather than maybe the underlying thing that could very well be BPD…”(GP, FG1)
“… the majority of the physical symptoms are psychosomatic, but you can’t assume that. You have to look into it… So, every consultation is a long consultation.”(GP, FG1)
“There’s a lot that I think are given the label bipolar disorder and complex post-traumatic stress disorder, and for some of my patients, there’s been a reluctance to actually use the label personality disorder.”(GP, FG1)
3.3. Difficulties with Patients’ Behaviour and the GP–Patient Relationship
[When describing their work with patients with BPD] “Sometimes I’ve got a patient that I think is a bottomless pool of need…”(GP, FG1)
[When discussing the idea of “heart sink patients”] “I’ve got to balance that… now I wonder if there such a thing as a ‘heart sink doctor’. Could there be doctors that patients think, ‘oh, no, I’m not going to see that doctor’.”(GP, FG1)
[When describing their reluctance to take on patients with BPD] “… I think a lot of GPs in their practice, they don’t refuse to see these patients… The problem is that they miss appointments frequently… A couple of patients of mine would easily miss 50% of their appointments, and a lot of doctors will just say, ‘no, two missed appointments, that’s it. I’m never going to see them again’.”(GP, FG1)
“… in the practice that I work in, a lot of the patients come and go… one of our problems is the patient group tend[s] to be a bit mobile. Sometimes they go down to the university clinic and sometimes they come to us and sometimes they go abroad… one of our problems is that we don’t get to know a lot of our patients really well.”(GP, FG2)
“I think it’s the boundaries, I think, when you feel like someone’s encroaching on your boundaries, your alarm bells go off… someone that makes you uncomfortable.”(GP, FG1)
“People are people, they’re not diagnoses. So, you’ll keep on seeing them… and you know that, yep, she’s going to be needy and you hope that one day she’ll say, ‘yeah, today’s a good day’.”(GP, FG1)
“So, it’s interesting because when you can see the clients and you sort of have more flexibility, then it can pose some different issues where you have to kind of be very mindful they don’t just come drop in all the time expecting you to sort of be there and be at their beck and call.”(GP, FG1)
3.4. Finding and Navigating Systems for Support
“In my counselling, I very much take a person at face value and listen and try to understand their reality… why are they behaving like this and responding to their reality like this. Why do they not have more emotional resilience? I’m not very good at taking that step back, which is why I love getting letters from psychologists and psychiatrists…”(GP, FG1)
“… My challenge in General Practice is that psychiatrists are one of the most tricky people to access, and I think that is one of the challenges that will need to be overcome… you need to have a sense that there is a pathway or there’s somewhere to go…”(GP, FG1)
4. Discussion
4.1. Challenges Surrounding Diagnosis of BPD
4.2. Comorbidities and Clinical Complexity
4.2.1. Mental Health Comorbidities
4.2.2. Medical Comorbidities
4.3. Difficulties with Patient Behaviour and the GP–Patient Relationship
4.4. Systems Issues
4.5. Limitations
5. Conclusions
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
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Degree of interaction with patients with BPD
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Wlodarczyk, J.; Lawn, S.; Powell, K.; Crawford, G.B.; McMahon, J.; Burke, J.; Woodforde, L.; Kent, M.; Howell, C.; Litt, J. Exploring General Practitioners’ Views and Experiences of Providing Care to People with Borderline Personality Disorder in Primary Care: A Qualitative Study in Australia. Int. J. Environ. Res. Public Health 2018, 15, 2763. https://doi.org/10.3390/ijerph15122763
Wlodarczyk J, Lawn S, Powell K, Crawford GB, McMahon J, Burke J, Woodforde L, Kent M, Howell C, Litt J. Exploring General Practitioners’ Views and Experiences of Providing Care to People with Borderline Personality Disorder in Primary Care: A Qualitative Study in Australia. International Journal of Environmental Research and Public Health. 2018; 15(12):2763. https://doi.org/10.3390/ijerph15122763
Chicago/Turabian StyleWlodarczyk, Julian, Sharon Lawn, Kathryn Powell, Gregory B. Crawford, Janne McMahon, Judy Burke, Lyn Woodforde, Martha Kent, Cate Howell, and John Litt. 2018. "Exploring General Practitioners’ Views and Experiences of Providing Care to People with Borderline Personality Disorder in Primary Care: A Qualitative Study in Australia" International Journal of Environmental Research and Public Health 15, no. 12: 2763. https://doi.org/10.3390/ijerph15122763