Decision-making capacity in psychiatric patients has been the topic of past research [1]. However, psychiatric disorders considered in such research are most often the psychotic and cognitive disorders [2]. This makes sense, as informed consent is traditionally thought to hinge upon comprehension [3].
However, such a viewpoint presupposes a subject that, understanding
relative risks and benefits of a proposed action, will usually act in a
way that maximizes benefit and minimizes harm to the self. Any
deviation from this self-preserving pattern of behavior in the
potential research subject is usually thought to result from altruism
or such obviously coercive circumstances as financial reward, lack of
other access to care, the perception that health care will be withdrawn
without participation, etc.
However, what about people that persistently and intentionally harm
themselves? A large subpopulation of psychiatric patients suffer
pathology which centers around a lifelong tendency to make what appear
to others to be bad decisions. They may persistently seek out victim
roles and manipulate others to harm them. They may make repeated
suicide attempts, or compulsively cut themselves. Can it be considered
ethical to draw blood from someone who consented because she has a
psychological need to see herself bleed? Borderline personality
disorder (BPD) is a prevalent, chronic, disabling, and
treatment-resistant condition. It affects approximately 2% of community
dwellers and 20% of psychiatric inpatients [4].
Although randomized clinical trials of both psychotherapeutic and
psychopharmacologic treatments for BPD are relatively common [4,5],
a literature search on consent issues with BPD subjects reveals little
research. Borderlines also likely have poorer general health (a 6.4%
rate of BPD has been measured in a primary care population [6])
than the general population and will likely be recruited into
non-psychiatric studies, in which the investigators may be unaware of
their psychiatric pathology and the issues involved. Although little
has been written on issues of research informed consent in borderline
personality disorder, I would argue that caution must be exercised in
assessing a borderline subject's ability to consent based solely on
comprehension of a study.
DSM-IV-TR diagnostic criteria for borderline personality disorder
stipulates that a patient display five of the following nine features [7]:
1) frantic efforts to avoid real or imagined abandonment
2) a pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization 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 (e.g., spending, sex, substance abuse, reckless driving,
binge eating)
5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
6) affective instability due to a marked reactivity of mood
7) chronic feelings of emptiness
8) inappropriate, intense anger or difficulty controlling anger
9) transient, stress-related paranoid ideation or severe dissociative symptoms
Common clinical features include frequent intense mood swings, the
inability to be alone nor to tolerate intimacy, extreme dependency on
others alternating with sudden hostility, perceiving others as all good
or all bad ("splitting"), chronic self-mutilation (often described as
relieving emotional pain), and chronic suicidality. BPD is frequently
comorbid with substance abuse, depression, anxiety, and eating
disorders [8]. Any of these symptoms could have implications for the informed consent process.
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