managing care for persons with personality disorders phyllis m. connolly phd, aprn, bc, cs professor...
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Managing Care for Persons with Personality Disorders
Phyllis M. Connolly PhD, APRN, BC, CSProfessor of Nursing
San Jose State [email protected]
408-924-3144
Questions to Consider How does the stigma of the label of Borderline
Personality impact care? What is the relationship between ego affects, ego
defenses and ego defects for persons with personality disorders
What are you views concerning suicide and self-harm? How do stress & anxiety impact your patient and you? What strategies are useful when dealing with anger? How do you respond when you feel as if you are being
manipulated? What is splitting? What are some effective interventions to deal with
self-harm, and manipulative behaviors? What are your self-care behaviors?
Qualities of Healthy Personality Positive & accurate
body image Realistic self-ideal Positive self-concept High self-esteem Satisfying role
performance Clear sense of
identity
Personality “persona” Complex pattern psychological
characteristics Not easily eradicated Expressed automatically in every
facet of functioning Biological dispositions &
experiential learning Distinctive pattern of perceiving,
feeling, thinking & coping
Why Do We Behave the Way We Do?
Affective (feelings)
Cognitive (thoughts)
Behavioral (actions)
Interacting System’s Human Behavior
Stress: A person-A person-environment interactionenvironment interaction
Sources Biophysical Chemical Psychosocial Cultural
Heat-cold noise radiation exhaustion physical
inactivity alcohol nicotine caffeine
External stimuli
Emotional feelings
Peripheral physiological
changes
Central nervous system arousal
Internal stimuli
Genetic equip
Past experience
StressIndividual perception of stressor-conscious
or unconscious
Stress Model
Responses to Stress
Demanding situation--stressor
Internal state Tension Anxiety Strains
Anxiety
Normal—feeling response to a threat to one’s safety, well-being, or self-concept
Characteristics Appropriate to the threat Anxiety can be relieved Can cope either alone or with some
support Problem solving slow but still usable
Abnormal Anxiety
Occurs more frequently, longer and more intense
Interferes with one’s life Function is more impaired Disproportionate to threat Blocks learning from the
experience Pervasive feeling in all
mental health problems
Psychosis
Brief Reactive Psychosis
Panic
Dread
Loneliness
Rituals
Avoidance
Psychosomatic
Heartpound
Palpitations
Shakiness
Butterflies
All senses alert
Calm
Daydreaming
Sleep
Panic
Acute and Chronic
Normal
RELATIVE SEVERITY OF ANXIETY(Haber p.437)
Definition: Personality Disorders Lasting enduring patterns of
behavior Significant social and occupational
impairment Beyond usual personality traits Pervasive in 2 areas of: cognition,
affect, interpersonal relationships, & impulse control
Usually begins in adolescence or early adulthood
Personality Disorders Common Characteristics
Not distressed by their behaviors
Become distressed because of the reactions of others or behaviors towards them by others
Not due to drug or alcohol Not due to medical condition Disorder of emotion
regulation
Prevalence Personality Disorders
Approximately 10 - 13% of general population
70 - 85% Criminals have a personality disorder
60 - 70% Alcoholics
70 - 90% Drug abusers
40 - 45% Persons with psychiatric disorder also have a personality disorder
Frequently referred to as “treatment-resistant”
Videbeck, 2001, p. 416
Prevalence Personality Disorders
Paranoid .5 - 2.5% Schizotypal 3% Schizoid Unknown Antisocial 3% (males) Borderline 2% Histrionic 2-3% Narcissitic <1% Dependent Unknown Avoidant 1% Obsessive Compulsive 1%
Etiology: Personality Disorders
Combination of biological, psychological, and social risk factors
Genetics (50% of personality) Life experiences Environment Schizotypical:
^ homovanillic acid (HVA) metabolite of dopamine
neuropsychological abnormalities, ^attention and information processing impairment, & eye movement abnormalities
Personality Disorders DSM-IV : Clusters: A, B, C
Cluster A, Odd, Eccentric
Paranoid Schizoid SchizotypalCluster B, Dramatic,
Emotional, Erratic Antisocial Borderline Histrionic Narcissistic
Cluster C, Anxious Fearful
Avoidant Dependent Obsessive-
Compulsive
Cluster A Personality Disorders: Odd or Eccentric
Paranoid distrustful, suspicious, lacks
trust in others, bears grudges, accuses others of harm or plots
Schizoid detached from others, “loner”
little to no sexual intimacy, little involvement in activities, lacks close friends, cold or aloof
Schizotypal Ideas of reference, odd beliefs,
behaviors, & speech, suspicious, inappropriate affect, lacks close friends
Cluster B Personality DisordersDramatic, Emotional Erratic
Histrionic seeks attention, provocative behavior,
easily suggestible, dramatic, flamboyant
Narcissistic Arrogant, needs admiration, entitled,
exploitative, grandiose, lacks empathy, preoccupied with power, beauty,or love
Antisocial lies, disregards the rights of others
Borderline Intense anger, suicidal, sees all good or
all bad, impulsive
Cluster C Personality Disorder: Anxious, Fearful Avoidant
Avoids others and activities, fears rejection, feels inhibited and inept
Dependent Passive, indecisive, fears loss of
approval, difficulty doing things alone, fails to assume responsibility
Obsessive-Compulsive Perfectionist, controlling,
inflexible, overconscientious, stubborn, miserly
Obsessive Compulsive Personality Disorder DSM-IV 301.4
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and
interpersonal control, at the expense of flexibility, openness,
and efficiency, beginning by early adulthood and present in a
variety of contexts
Obsessive Compulsive Personality Disorder: Criteria Preoccupied with
details, rules, lists, organization
Perfectionism interferes with task completion
Too busy working for friends or leisure activities
Unable to discard worthless objects
Others must do things their way in work
Reluctant to spend and hoards money
Rigid and stubborn
Nursing Interventions: OC Personality Disorder
Establish trusting relationship Develop high degree of self-
awareness (nurse) Avoid interpreting behavior Introduce and encourage leisure
activities Present behavioral change as a
possibility rather than a demand
Borderline Personality DSM-IV-TR, 301.83
Impulsive & self-damaging behaviors unsafe sex, reckless driving, substance
abuse, ↑ ED vists
Recurrent suicidal or self-mutilating behaviors; ↑ death rates
Transient quasi-psychotic symptoms during stress
Chronic feelings of emptiness or boredom, absence of self-satisfaction
Intense affect--anger, hostility, depression and/or anxiety
Borderline Personality: Etiology
Reduced serotonergic activity impulse and aggressive behaviors
Cholinergic dysfunction & increased norepinephrine associated with irritability & hostility
Smaller hippocampal volume Genetic
5 times more common in 1st degree biological relatives
75% women & victims of childhood sexual abuse, PTS Vulnerability to environmental stress, neglect or
abuse
Prevalence Borderline Personality Disorders
Approximately 2% of general population, 6 million Americans (NIMH, 2001)
High rate of self-injury without suicide intent
8% - 10% will commit suicide
Need extensive mental health services, account for 20% of psychiatric hospitalizations
69% are also substances abusers
With help, many improve over time & lead productive lives
Frequently referred to as “treatment-resistant”
Videbeck, 2001, p. 416
Borderline Personality DSM-IV, 301.83Splitting Primitive idealization Seeing external objects all good or all
bad Impaired object constancy Integral part of separation-individuationManipulation and dependency commonDifficulty being alone--seek intense brief
relationships (Fatal Attraction)
HEALTH PROBLEMS May have an infection Respiratory illness Diabetes Thyroid problems Nutritional imbalances Appendicitis Other disease processes May trigger other
symptoms
Nursing: BPD Therapeutic use of self, primary nursing
helpful (consistent clinical supervision critical)
Focus on strengths Maintain Safety Facilitate participation in care Select least restrictive environment Facilitate behavior change Help to assume responsibility for
behaviors
Borderline Personality: Ego Defense Mechanisms
Splitting Seeing external objects all good or all bad A form of manipulation Rapid idealization-devaluation
Dissociation Separation of mental or behavioral processes from the
rest of the person’s consciousness or identity Idealization
Viewing others as perfect, exalting others Projective identification
Placement of feelings on another to justify own expression of feelings
PSYCHIATRIC DISORDERS: ILLNESSES OF MENTAL
FUNCTION
FIVE MENTAL FUNCTIONS THINKING (COGNITION) FIVE SENSES (PERCEPTION) FEELINGS, HAPPY, SAD, ANGRY
(EMOTIONS) BEHAVIOR (RESPONSES TO COGNITION,
PERCEPTION, & EMOTIONS SOCIALIZATION
Ego Functions
Control & regulate instinctual drives Relation to reality
Sense of reality Reality testing Adaptation to reality
Object relationships Defensive functions
Reality Testing
Ego’s capacity for objective evaluation and judgment of the external world
Dependent on primary autonomous functions--memory & perception
Negotiating with the outside world Progression from pleasure to reality
Object Constancy
Holding on to internalized image of the mother
Results from a secure maternal-infant attachment
Infant incorporates aspects of significant other as part of self
Manipulation Mode of interaction which controls
others Self-defeating negatively affects IPR Using flattery, aggressive touching,
playing one person against another Deliberate “forgetting” Power struggles Tearfulness Demanding Seductive behaviors
Manipulation: Nursing Interventions Establish therapeutic relationship
Set limits and enforce consistently Offer constructive opportunities for
control, contracting Teach how to approach others in order
to meet needs Seek regular times to interact Use behavioral rehearsal to try out
alternative behaviors
Interventions Cont.Manipulation
Be honest, respectful, non-retaliatory Avoid labeling Avoid ultimatums Encourage putting feelings into words rather than
action Offer empathic statements Monitor your own reactions Use supervision and consultation with other staff Encourage use of exercise, journal writing, & activity
groups
Nursing Roles: BPD
Provide structured environment Serve as an emotional sounding
board Clarify and diagnose conflicts Assess for other health problems
Treatment BPD:Dilectical Behavioral Therapy
Once-weekly psychotherapy session focused on problematic behavior or event from past week; emphasis is on teaching management emotional trauma; TCs to therapists between sessions (Linehan, 1991)
Targets ↓ high-risk suicidal behaviors ↓ responses or behaviors that interfere with therapy ↓ behaviors that interfere with quality of life ↓ dealing with PTS responses enhancing respect for self acquisition of behavioral skills taught in group additional goals set by patient
DBT Continued Weekly 2.5 hr group therapy focused on
Interpersonal effectiveness Distress tolerance/reality acceptance skills Emotion regulation Mindfulness skills
Group therapist is not available TCs; referred to individual therapists
Results in decreased hospitalizations because of decrease in suicidal drive and higher level of interpersonal functioning
Evidence-Based Practice: Remission BPD
10 yr study 275 participants New England inpatient unit Several tools used for diagnosis Interviewed q 2 years 242 reached remisssion
Younger No hospitalizations before diagnosis No history of sexual abuse Less severe childhood abuse or neglect Negative family hx for mood and substance abuse No PTSD and symptoms of Cluster C Low neuroticism High extroversion, high agreeableness,
conscientiousness and good vocational record Zanarini, Frankenburg, Hennen, et al. (2006)
Targeted to symptoms Some helped with Zyprexa, Seroquel & Risperdal Effexor, Serzone, Prozac, Zoloft, Celexa, Luvox,
Paxil Anticonvulsants: Lamictal, Topamax, Depakote,
Trileptal, Zonegan, Neurontin & Gabitril Naltrexone Omega-3 Fatty Acid
Psychopharmacology
Important to monitor for side effects: sedation; diabetes; weight gain
Risk Management Issues (APA) General
Good collaboration & communication with all health care workers
Careful & adequate documentation, assessment of risk, communication with other clinicians, decision-making process & rationale for treatment
Attention to transference & countertransference problems; splitting
Consultation with colleague when suicide risk is high, patient not improving, unclear about best treatment
Termination of treatment must be handled with care, follow standard guidelines
Psychoeducation often helpful; include family members if appropriate
You should have an emergency plan for handling a suicide gesture or ideation.
Someone needs to stay with the person at all times
The person is experiencing strong feelings of abandonment, loneliness, guilt and hopelessness
Self-Harm Way of coping with deep distressing
emotions and feelings Cutting Burning Non-lethal overdoes Ingesting or inserting harmful objects Eating disorders Excessive drinking and drug abuse
Suicide not always the intent
Self-Care Deficit
Ego functioning which does not handle painful affects or maximize protective activity
Interventions Provide alternative ways to handle or tolerate
painful emotions--stress management Furnish structured supportive environment Increase awareness of unsatisfactory protective
behaviors Teach skills to recognize & respond to health-
threatening situationsCompton, 1989
Self-Injury
Body piercing Eye brow tweezing Hair removal Nail biting Hair twisting tattos
Risk Management: Suicide Monitor & document
risk assessment Actively treat
comorbid axis I disorders eg. major depression, bipolar disorder, substance abuse/dependence
Consultations
Antisocial Personality DSM IV 301.7
Pervasive pattern of disregard for and violation of the rights of others since age 15
failure to conform to social norms, repeating acts--grounds for arrest
deceitfulness, repeated lying, uses aliases, or conning others for personal profit or pleasure
Comparisons Personality Disorders & Mental Symptoms & Treatments
Disorder Hallucinations Delusions Drug RX
Therapy
Antisocial Only if substance abuse
Only if substance abuse
0 Behavioral
Borderline Only if psychotic May X Behavioral
DBT
Obsessive No May X Insight, cog. Behav.
Nursing Interventions: Parasuicide No harm contract—not a promise to
nurse, an agreement with oneself to be safe
Journaling Cognitive restructing: thought stoppage,
positive self-talk, decatastrophizing Teach communication skills, eye
contact, active listening, taking turns, validating meaning of other’s communication, use of “I” statements
Identifying Triggers
Alcohol and/or drugs Stopping psychotropic medications Lack of sleep Increased stress: losses, changes,
interpersonal relationships Increased anxiety Reactions to prescription /over the
counter drugs Nutritional imbalances Medical conditions
Stress Management Crisis Intervention
Deep breathing Self talk Time out Visualization Leaving the
situation Talking to
someone Music
Prevention Diet & nutrition Exercise & physical
activity Self-help groups Having fun Playing Massage Progressive
relaxation Assertiveness training
Interventions Dealing With Anger
Calm unhurried approach
Do not touch Protect other
people Respect personal
space Use active
listening Be aware of
personal feelings Use time-out/one-
one in quiet area
Initially ignore derogatory statements
State desire to assist person to maintain/regain control
DO NOT ARGUE OR CRITICIZE
DO NOT THREATEN PUNITIVE ACTION
Postpone discussion of anger & consequences until in control
Non Verbal Verbal
Communication Techniques
Be honest, respectful, non-retaliatory
Listen to understand Avoid labeling Avoid ultimatums Avoid power struggles Focus on person’s behaviors Offer empathic statements Assist person to think rationally Convey your interest in a successful
outcome
Safety Guidelines: Violence
Position self outside of person’s personal space
Stand on non-dominant side (wristwatch side)
Keep client in visual range
Make sure door of room is readily accessible
Avoid letting client come between you & door
Remove yourself from situation & summon help if violence
Avoid dealing with violent person alone
Your Choice
RELAX SPEAK SOFTLY AND SLOWLY KEEP YOUR LEGS AND ARMS
UNCROSSED DO NOT CLENCH YOUR FISTS DO NOT PRESS YOUR LIPS
TOGETHER TIGHTLY
“I CAN MANAGE MY RESPONSE” “I HAVE BEEN SUCCESSFUL
BEFORE” “WE CAN COME TO AN
AGREEMENT”
“I DON’T UNDERSTAND” LISTEN REPEAT SOMETHING THAT HAS
AGREEMENT TAKE A BREAK USE: “Perhaps,” “maybe,”
“sometimes,” “what if,” “it seems like,” “I wonder,” “I feel,” “I think”
Situation & Date Behavior, body cues, affect,
physical reactions, feelings Behavioral Response
What I did or said What I would like to have done or said
What prevented you from doing what you wanted?
SELF-EVALUATION: KEEP A LOG
Self-Care Staff Healthy diet and nutrition Exercise and physical activity Adequate sleep patterns Recreation & leisure Balanced lifestyle Meditation Tai Chi Clinical supervision Support groups Critical incident stress
debriefing
“Your care makes a difference in people’s lives”
Thank you