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Caution should be exercised in obtaining informed consent for research from subjects …

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- Informed consent for research in Borderline Personality Disorder

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coercive circumstances as financial reward, lack of other access to care, the perception that health care will be withdrawn without participation, etc.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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