Borderlines and Antisocials

Borderlines and Antisocials are the most common personality dissorders I have encountered in my prison employment experience. The term "Borderline" harks back to the early stages of Psychiatry when this patient population was thought to be borderline psychotic. The Bible of Psychiatry, the Diagnostic and Statistical Manual, defines Borderline Personality Disorder as the following: Rapid changes in mood, intense unstable interpersonal relationships, marked impulsively, instability in affect, and instability in self image as indicated by at least five of the following:

*Going to about any lengths to avoid real or imagined abandonment.
*Intense unstable interpersonal relationships characterized by changing between idealization and devaluation the relationship.
*Lack of ones own identity. A marked instability of self image or the sense of self.
*Impulsively in two or more areas that are self damaging. These may included abuse, sex, spending, eating, driving reckless, or etc.
*Recurrent gestures, self mutilation, suicidal behavior, or threats.
*Instability in affect.
*Marked feelings of emptiness.
*Frequent displays of anger due to a difficulty in control.
*Dissociative or paranoid

Borderlines are very difficult to work with. They can very quickly draw in the people around them either with charm or manipulation of sympathy. These are the ones that will tell you that you are their favorite nurse and nobody can take care of them the way you can. Whenever I hear these words it is chilling. You will be their favorite nurse for awhile, then when you displease them, they will often refuse treatment from you or stop speaking to you. After some time has passed, suddenly you are the best nurse in the world again. Borderlines are also the cutters. Yes, the inmates get razors in prison for shaving purposes, so there is plenty of opportunity without having to go to all the trouble to pull off a piece of the desk and sharpen it.

One of the interesting features of working in a prison is the high density of Antisocials, otherwise known as Sociopaths. The DSM defines Antisocial Personality Disorder as a disregard for and violation of the right's of others, those right's considered normal by the local culture, as indicated by at least three of the following:

A. Repeated acts that could lead to arrest.
B. Conning for pleasure or profit, repeated lying, or the use of aliases.
C. Failure to plan ahead or being impulsive.
D. Repeated assaults on others.
E. Reckless when it comes to their or others safety.
F. Poor work behavior or failure to honor financial obligations.
G. Rationalizing the pain they inflict on others.

The prison is full of Antisocials of varying intensities for obvious reasons. Borderlines manipulate your compassion, try to punish you, and try to hurt you. Antisocials try to control through intimidation. People often ask me if I ever feel afraid at work. I usually say "Rarely," but I don't say "never." Some Antisocials are charming, some are very abraisive. When you have to be near them to take vitals and examine them you feel a chill. I have one inmate, who is in for natural life, that I will not allow to walk behind me. I will not allow myself to be in a room with her where an officer cannot see me. This inmate happens to be the number one brittle diabetic of the facility, so I am frequently in contact with her.

It just so happens that the prison's diabetic problem child number two is a combination Borderline and Antisocial. Every since I led the code when she slit her wrists I have been subject to "favorite nurse" status. Picking someone up out of a pool of blood, bandaging them, cleaning them up, and sending them out is a very emotional experience. After she came back I got a call from the housing unit that her dressing was coming off and it was a few more hours till treatment line. The inmates aren't allowed to have medical supplies in their property, there is a twice daily treatment line for dressing changes, blood pressure checks, and weekly injections et cetera. So I called her over and changed the dressing. The wound was gaping so I applied some steri-strips, I thought it looked a bit infected so I refered her to the nurse practitioner. The treatment line does not have steri-strips, they only change the over-bandaging. Steri-strips can stay in place for a few days so at the end of my work week I called her back over to change the steri-strips. This was part of how I became "favorite nurse."

Her sugar control has made her an in-patient in the infirmary, and also a resident in the assisted living unit. She is currently in population but is the only inmate in the institution that has orders to come to the infirmary for a pre-bedtime fingerstick just before lockdown. She somehow also became my MS inmate's aide so she is around the infirmary all the time for that job.

So far I have described the Borderline traits. Her Antisocial traits reveal themselves more slowly. She lies very frequently. I think that her poor sugar control, as well as the sugar control of the chilling Antisocial mentioned above, results from their inability to follow the "rules" of diabetes. They both recklessly manipulate their own sugars by puposely over and under dosing themselves with insulin. They both have horrible crimes that involved harm to first degree family memebers.

Dealing with patients like these two over the long term is one of the major challenges of nursing in a prison. Every night when you come in, they will be there. They were both there before I came, and will remain after I've moved on.