Managing Care for Persons with Personality Disorders

Phyllis M. Connolly PhD, APRN, BC, CSProfessor of Nursing

San Jose State Universityconnollydr@son.sjsu.edu

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