Dealing with disclosure in patients with borderline personality traits

Perhaps this is because the decision to disclose the psychiatric opinion to the patient is arbitrary, owing to the fact that the diagnosis may be made in just one sitting and personality traits are arguably within the spectrum of normal. Often the patient is left in the dark and only sees light when a brave but irate psychiatrist decides that their current presentation warrants a revision of the existing diagnosis to the personality disorder.

Is it fair to the patient with borderline personality traits that we should, as colleagues in health care, collude in keeping the truth away from the unsuspecting person walking through the door?

One problem in disclosure is that the personality attributes of patients with borderline traits are often considered egosyntonic.1 This means that the patient’s inner mind agrees with the observable, externalised behaviour on his or her part. There is therefore little or no reason to question or challenge his or her own impulsive, polarised thoughts and behaviours. Telling a patient that what had seemed perfectly acceptable for years is now improper will probably raise doubts regarding the doctor. So the patient is not provided with that piece of information, in a tacit hope that the therapeutic alliance is preserved, but at the expense of further destructive behaviour on the part of the patient and labelling by health care professionals.

In these days of defensive medicine, registrars and consultants in psychiatry would most likely keep such information from the patient, to whom disclosure is not obligatory.

Further research investigating the therapeutic benefits and harms of disclosure will be an area of much interest in the future. For now, there seems to be a reasonable argument in picking either side of the fence.