Managing Care for Persons with Personality Disorders

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Managing Care for Persons with Personality
Disorders

• Phyllis M. Connolly PhD, APRN, BC, CS
• Professor of Nursing
• San Jose State University
• connollydr_at_son.sjsu.edu
• 408-924-3144

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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 your 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?

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Qualities of Healthy Personality

• Positive accurate body image
• Realistic self-ideal
• Positive self-concept
• High self-esteem
• Satisfying role performance
• Clear sense of identity

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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

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Why Do We Behave the Way We Do?
Behavioral (actions)
Affective (feelings)
Cognitive (thoughts)
Interacting Systems Human Behavior
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Stress A person-environment interaction

• Sources
• Biophysical
• Chemical
• Psychosocial
• Cultural

• Heat-cold
• noise
• radiation
• exhaustion
• physical inactivity
• alcohol
• nicotine
• caffeine

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Stress Model
External stimuli
Emotional feelings
Central nervous system arousal
Genetic equip
Individual perception of stressor-conscious or
unconscious
Stress
Internal stimuli
Past experience
Peripheral physiological changes
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Responses to Stress

• Demanding situation--stressor
• Internal state
• Tension
• Anxiety
• Strains

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Anxiety

• Normalfeeling response to a threat to ones
  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

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Abnormal Anxiety

• Occurs more frequently, longer and more intense
• Interferes with ones life
• Function is more impaired
• Disproportionate to threat
• Blocks learning from the experience
• Pervasive feeling in all mental health problems

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Psychosis Brief Reactive Psychosis Panic Dread Lon
eliness 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)
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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

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Stress Management

• Prevention
• Diet nutrition
• Exercise physical activity
• Self-help groups
• Having fun
• Playing
• Massage
• Progressive relaxation
• Assertiveness training

• Crisis Intervention
• Deep breathing
• Self talk
• Time out
• Visualization
• Leaving the situation
• Talking to someone
• Music

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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

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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

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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

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Prevalence Personality Disorders

• Paranoid .5 - 2.5
• Schizotypal 3
• Schizoid Unknown
• Antisocial 3 (males)
• Borderline 2
• Histrionic 2-3
• Narcissitic lt1
• Dependent Unknown
• Avoidant 1
• Obsessive Compulsive 1

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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

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Personality Disorders DSM-IV Clusters A, B, C

• Cluster A, Odd, Eccentric
• Paranoid Schizoid
• Schizotypal
• Cluster B, Dramatic, Emotional, Erratic
• Antisocial
• Borderline
• Histrionic
• Narcissistic

• Cluster C, Anxious Fearful
• Avoidant
• Dependent
• Obsessive-Compulsive

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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

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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

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Antisocial Personality DSM IV 301.7 (cluster B)

• 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

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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

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Obsessive Compulsive Personality Disorder DSM-IV
301.4 (cluster C)

• 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

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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

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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

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Borderline Personality DSM-IV, 301.83

• Splitting
• Primitive idealization
• Seeing external objects all good or all bad
• Impaired object constancy
• Integral part of separation-individuation
• Manipulation and dependency common
• Difficulty being alone--seek intense brief
  relationships (Fatal Attraction)

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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

?
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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

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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

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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 persons consciousness or
  identity
• Idealization
• Viewing others as perfect, exalting others
• Projective identification
• Placement of feelings on another to justify own
  expression of feelings

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Ego Functions

• Control regulate instinctual drives
• Relation to reality
• Sense of reality
• Reality testing
• Adaptation to reality
• Object relationships
• Defensive functions

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Reality Testing

• Egos 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

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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

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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 situations

Compton, 1989
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Interventions Dealing With Anger
Verbal
Non Verbal

• 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

• 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

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Your Choice
Response
Stimulus
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3 RS EMOTIONAL RESPONSE
RED STOP RELAX
Yellow Wait Reflect
GREEN GO RESPOND
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BREATHE

• RELAX
• SPEAK SOFTLY AND SLOWLY
• KEEP YOUR LEGS AND ARMS UNCROSSED
• DO NOT CLENCH YOUR FISTS
• DO NOT PRESS YOUR LIPS TOGETHER TIGHTLY

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SELF-TALK

• I CAN MANAGE MY RESPONSE
• I HAVE BEEN SUCCESSFUL BEFORE
• WE CAN COME TO AN AGREEMENT

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VISUALIZE
REFLECT
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RESPOND

• I DONT 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

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Communication Techniques

• Be honest, respectful, non-retaliatory
• Listen to understand
• Avoid labeling
• Avoid ultimatums
• Avoid power struggles
• Focus on persons behaviors
• Offer empathic statements
• Assist person to think rationally
• Convey your interest in a successful outcome

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Safety Guidelines Violence

• Position self outside of persons 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
  potential for violence
• Avoid dealing with violent person alone

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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

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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

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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

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Nursing BPD

• Therapeutic use of self, primary nursing helpful
  (consistent clinical supervision critical)
• Focus on patients strengths
• Maintain Safety
• Facilitate participation in care
• Select least restrictive environment
• Facilitate behavior change
• Help to assume responsibility for behaviors

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Nursing Roles BPD

• Provide structured environment
• Serve as an emotional sounding board
• Clarify and diagnose conflicts
• Assess for other health problems

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HEALTH PROBLEMS

• May have an infection
• Respiratory illness
• Diabetes
• Thyroid problems
• Nutritional imbalances
• Appendicitis
• Other disease processes
• May trigger other symptoms

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Psychopharmacology

• 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

Important to monitor for side effects sedation
diabetes weight gain
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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.
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You should have an emergency plan for handling a
suicide gesture or ideation.
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Risk Management Suicide

• Monitor document risk assessment
• Actively treat comorbid axis I disorders eg.
  major depression, bipolar disorder, substance
  abuse/dependence
• Consultations

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Someone needs to stay with the person at all times

• The person is experiencing strong feelings of
  abandonment, loneliness, guilt and hopelessness

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Nursing Interventions Parasuicide

• No harm contractnot 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
  others communication, use of I statements

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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

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Self-Injury

• Body piercing
• Eye brow tweezing
• Hair removal
• Nail biting
• Hair twisting
• tattos

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Treatment BPDDilectical 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

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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

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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)

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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

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SELF-EVALUATION KEEP A LOG

• 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?

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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

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Thank you

• Your care makes a difference in peoples lives