Transcript Borderline Personality Disorder

Personality
Disorders
Overview
Lifelong, inflexible, and dysfunctional
patterns of relating and behaving
 Patterns interfere with daily life
 Client often does not recognize own
dysfunction
 Interpersonal and occupational problems
result
Overview
 Diagnosis is on Axis II
 If admitted to an inpatient facility must have an Axis I
diagnosis also (e.g. alcoholism, depression)
 Difficult to treat
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Most are treated outpatient in individual or
group therapy
Often seen in drug treatment centers
Overview:
Interpersonal Characteristics
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Relationships
 Often experience conflict with others
 May have difficulty initiating or sustaining
relationships
 Cause distress to others
 only become distressed when others
react to them negatively
Affective/Cognitive
Characteristics
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Anxiety: Varies in the different clusters.
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Behavior is way of coping with anxiety and the
individual does not consider how their behavior
will affect others.
Cognitive issues:
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Rigidity of responses--difficulty in adapting to the
new or unexpected
Mistakes in judgment
Lack of insight
Gender and Personality
Disorder Diagnoses
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Female: greater percentage of Borderline
or Histrionic diagnoses
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Male: greater Percentage of Paranoid,
Schizoid, Antisocial, and Narcissistic dx.
Grouped by the
Three Clusters of Behavior
in the DSM IV-TR
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Cluster A
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Cluster B
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Exhibit odd and eccentric behaviors
Exhibit dramatic, emotional and erratic
behaviors.
Cluster C
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Exhibit anxious, fearful behaviors
Cluster A (Odd-Eccentric)
Characteristics: odd, eccentric behavior,
suspicious ideations, and social isolation.
Know this cluster as a group (do not have
to recognize each individually)
 Schizoid P.D.
 Schizotypal P.D.
 Paranoid P.D.
Cluster A Overview
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Similarities to schizophrenia
But no fixed delusions or hallucinations
May have transient psychotic symptoms
when under acute stress
May have biological family member with
schizophrenia
Cluster A, cont’d
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Schizoid
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Lacks desire to be close
to others
Lacks close friends
Solitary activities
Little interest in sexual
activity
Appears cold and
detached
Appears indifferent to
praise or criticism
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Schizotypal
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Ideas of reference
Magical thinking or odd
beliefs
Unusual perceptual
experiences including
bodily illusions
Odd thinking and speech
Odd or eccentric
appearance or behavior
Suspicious, social anxiety
Few close relationships
Cluster A, cont’d
Paranoid P.D.
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Secretive, fearful and distrustful.
Reads hidden meaning into benign statements or
events
Reluctant to confide in others; fears information
will be used against him/her
Suspicious about fidelity of spouse or S.O. without
justification
Perceived attacks on character or reputation
Bears grudges; responds to threats with anger
Photo from film: “Meet the Parents” with Ben Stiller and Robert De Niro
Cluster A: Nurse-client
Relationship
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Building trust is most important
Be honest; keep it simple
Do not intrude on privacy, if possible
Do not challenge odd beliefs or appearance
Cluster A: Milieu
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Do not push into social or group activities,
but give gentle encouragement
Choose groups that are non-threatening
What Should the Nurse Say/Do?
A recently admitted client is refusing to eat
in the cafeteria with others, stating,
“The cafeteria food is different. And those
people don’t want me. Why can’t I eat on
the unit?”
Cont’d
A)
B)
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C)
D)
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E)
(Choose all that apply)
“There is nothing wrong with the
cafeteria food.”
“You need to go over to the cafeteria if
you want to eat.”
“I’ll walk with you to the cafeteria.”
“Why do you think they don’t want you?”
“It can be hard to get comfortable when
you are new.”
Cluster B
(Dramatic, Emotional, Erratic)
Characteristics: Impulsive, dramatic behavior,
intolerance of frustration, and exploitative
interpersonal relationships. (Know Antisocial,
Borderline and Narcissistic)
 Histrionic P.D.
 Narcissistic P.D.
 Antisocial P.D.
 Borderline P.D.
 Is
most commonly dx’d. P.D.
Cluster B
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Histrionic
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Needs to be center of
attention
Dramatic and
provocative
Overreacts to minor
events
Easily influenced by
others
Superficial
relationships
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Narcissistic
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Grandiose
Fantasies of
unlimited power,
success or brilliance
Needs to be
admired
Sense of entitlement
(deserves special
treatment)
Lacks empathy
Takes advantage of
others to meet own
needs
Interventions for Histrionic or
Narcissistic P.D.
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Set appropriate limits
Be consistent in approach
Be matter-of-fact
Focus on here-and-now
Use supportive confrontation for
discrepancies and contradictions
Support self-esteem (does this seem like a
contradiction?)
What Should the Nurse Do/Say?
1) Client (stomps foot and makes faces while
talking): “I need the day room for my
exercise routine. You people have to
realize that I am in modeling and this is
important to my career.”
(Nurse uses a matter-of-fact
approach)
What Should the Nurse Do/Say?
2) Client: “I am depressed because I have
no true friends in my life. And even my
roommate here is so rude to me. What a fat
slob! I want to room with someone else.”
(Use supportive confrontation)
Cluster B, cont’d
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Antisocial Personality Disorder
Diagnosis is based on disordered behavior:
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Pattern of disregard of the rights of others
Non-conforming to rules
Often found in criminal justice system rather
than in mental health services
May seek hospitalization to avoid the law
Antisocial Personality Disorder:
Cognitive and Affective Aspects
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Low tolerance for frustration; cannot delay
gratification of impulses
Unable to make long-range plans
Deny and rationalize behavior
Little guilt or remorse
May be aggressive or abusive
Antisocial Personality:
Interpersonal Aspects
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May appear charming and confident, but with
little personal involvement
Self-interest comes before needs of others
Unable to sustain close personal relationships.
Sex life is impersonal and impulsive.
Antisocial Personality: Etiology
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Genetic: inherited trait or predisposition
CNS
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ANS under-responds to stress
Low activity in frontal lobe
Unable to learn from rewards and punishment
History of disordered life functioning
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Parent-child relationship often is unstable
Childhood characteristics of lying, stealing and being
truant.
Client Scenario
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A 24 year old unemployed male was admitted
from jail to the mental health unit after a suicide
attempt in his cell. In jail, was awaiting
sentencing for burglary: stole from the apt. of his
former girlfriend; also was abusing cocaine.
States to the nurse that his problems started
after she broke up with him: “She owed me, and
so I took some cash and stuff.” The client has a
distressed affect when discussing current
situation: “Now they’re putting a label of ‘crazy,’
on me.”
Antisocial Personality Disorder:
Interventions
 Essential for staff to agree on rules and stick
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with them
Will try to play one staff or shift against another
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Set firm limits
Point out effect of behavior on others
Point out consequences of behavior
Best form of treatment: Peer counseling and
self-help groups like AA, where peers can
confront and offer feedback
What Should the Nurse Say/Do?
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A client who is involuntarily in treatment on
the inpatient unit was found smoking in the
bathroom. A few days later the client’s
visitor smuggles in some alcohol, which he
and roommate consume.
A hospitalized client is verbally abusive and
uncooperative with select staff members,
but is friendly and cooperative with others.
Complains to you about the “nasty staff.”
Cluster B, cont’d:
Borderline Personality Disorder
Most commonly diagnosed Personality Disorder
Borderline Personality Disorder:
Overview
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Characterized by:
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Extremely intense and variable moods
Disturbed sense of self; often self-negative
Impulsivity, often with self-destructive behavior
Use of “splitting” (also called “black or white
thinking”) as defense mechanism
Borderline Personality
Disorder DSM IV-TR Criteria
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Fear of abandonment and frantic efforts to
avoid it
Unstable, intense relationships
Marked identity disturbance
Chronic feelings of emptiness
Impulsivity that may be self-damaging
 These behaviors help them to feel better
for a short period of time
Borderline Personality Disorder
DSM-IV TR Criteria
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When under stress may experience
transient, paranoid thoughts or delusions,
or dissociative symptoms
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These will resolve when the stress is relieved
DSM IV-TR Criteria, cont’d.
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Recurrent Self-Destructive
Behavior
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Affective instability
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Suicidal threats & gestures
Self-Injurious Behavior (SIB)
Rapid mood shifts
Low frustration tolerance
Problems with anger
Borderline PD: Etiology
A predisposition, plus childhood experiences,
is current accepted theory
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Childhood Environment: often chaotic or neglectful
Strong evidence for abuse, trauma history
Neurobiological: (cause or result of stress?)
 Serotonin dysregulation
 cholinergic and adrenergic abnormalities
 lack of integration of right and left hemispheres
 smaller hippocampal volume
 decreased volume of prefrontal cortex
Issues for Borderline Personality:
Splitting Phenomenon
Low tolerance for ambivalence
 Inability to cope with conflict
 Sense of identity is obtained from others
Result in this perspective:
I Either you are good or you are bad (no inbetweens)
 When you are not perfect, you have failed me
and you are bad (that means I’m no good, either)
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Issues for Borderline, cont’d
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Interpersonal Relationships
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Unstable and intense
Characterized by over-idealizing or
devaluation of others
Cannot resolve feelings that others are not
perfect and cannot meet all of their needs
Fear being abandoned; may be needy and
dependent
Issues for Borderline PD, cont’d
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Functions of Self-injury:
 Is self-punishment
 Relieves tension
 Improves mood
 Is evidence that they are real, and can feel
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Suicide risk is high due to:
 Self-injuring behaviors
 Severe emotional pain
 Impulsivity
BPD: Nurse-client Relationship
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Consistency, trust, honesty
Explain and then Enforce unit rules
Team approach: Minimize splitting of staff
Be accepting, Be matter of fact, Do not
show anger or irritation. (Transference
phenomenon is common in these clients)
Convey empathy
Nurse-client Relationship, cont’d
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Discuss how to express and handle feelings
Encourage self-responsibility and appropriate
behaviors
Offer choices, when possible
Give positive feedback for accomplishments and
progress
Don’t get discouraged by opposite behaviors
Do not minimize or ignore SIB; assess for suicide
Borderline Personality: Milieu
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Provide safe environment based on ongoing
assessment; suicide precautions if necessary
Groups: Coping skills, Expressive Arts
Journaling: Promotes safe identification of own
thoughts, feelings and actions
Issues for Therapy
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Frequently have long-term issues of abuse,
trauma, neglect
An advanced practice Health Care Provider can
assist the client in talking about these events in
individual or group therapy on long-term basis
BPD: Group Therapy
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Clients make good group members; can be
very insightful for others
Decreases transference issues. Feedback
from group can be helpful in dealing with
unrealistic expectations.
Attention-seeking behavior and entitlement
issues are dealt with better in group.
What Should the Nurse Say/Do?
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A client with a history of self-injury visited
this evening with family. She is later found
in her room, having cut her abdomen with a
plastic fork she had taken from her meal
tray. She says to the nurse, “My parents
told me I can’t come back home because
they can’t handle me.”
What Should the Nurse Say/Do?
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The client is placed on Close Observation
status for SIB and has a sitter. At midnight,
she expresses anger to the night shift
nurse that she can’t sleep due to staff
having to watch her. “I am being treated like
a criminal. If the evening shift nurses really
cared about me they would not have done
this to me. ”
Legal-Ethical Critical Thinking
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If a client who self-injures
has a history of abuse or
trauma, what are the
implications for use of
restraints and emergency
management?
BPD: Community Resources
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AA, ACOA
Family education and support groups, too
Cluster C:
(Anxious-Fearful)
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Dependent Personality Disorder
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Pervasive, excessive need to be taken care of
 Feels unable to care for self, little selfconfidence
 Fears being alone and helpless
 Unable to make decisions without much
support
 Fears loss of approval; will agree or will
perform tasks to avoid rejection
Cluster C, cont’d
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Avoidant Personality
Disorder
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Fears making mistakes
Fears disapproval and
rejection
Severe shyness and
feelings of inadequacy
and being disliked
Socially uncomfortable
and withdrawn
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Obsessive Compulsive
Personality Disorder
 Perfectionistic and
inflexible
 Preoccupied with
details
 Too busy to have fun
or friends
 Hoards objects and
money
Nursing Interventions for Cluster C
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Assist in setting small, achievable goals
Discuss fears and feelings prior to meeting a
goal
Assist to explore feelings
Assist to try new activities
Assist to decrease anxiety and need for
perfection
Cluster C: Milieu Management
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Groups: Assertiveness training, Stress
management, Leisure skills
Most clients seen as outpatients
What Should the Nurse Say/Do?
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A client with Cluster C traits is trying to learn how to be
more confident and assertive and has a list of goals he
wrote after attending a group on the unit. He asks the
nurse what goal he should choose to work on first. Here
is the client’s list:
1) improve my life
2) eat breakfast with other people every other day
3) identify one good thing about myself
5) find a woman who really cares
What Should the Nurse Do/Say?
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A) “Oops, you missed putting a # 4 on the
list.”
B) “#3 is a good goal. Try that one first.”
C) “What other ways can you work on your
issues than writing a list?”
(Can you identify a more helpful response?
What is the rationale for the response?)
Personality Disorders
Pharmacological Interventions
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Medications address severe, disabling symptoms.
Medications do not cure P.D.s
Primarily used when client in emergency or crisis
(PRN or short-term)
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Examples: Suicidal behavior
Transient psychosis
Assaultive behavior
Severe anxiety episode
Personality Disorders
Psychopharmacology, cont’d
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Low doses of some medications may be
indicated e.g. antipsychotic agents for
paranoia; mood stabilizers or SSRIs for
Borderline Personality Disorder, etc.
Treat co-morbid Axis I diagnoses:
Depression, Anxiety Disorders, Bipolar
Disorder, etc.
Evaluation of Interventions
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How can the nurse evaluate effectiveness
of interventions for the person who has a
personality disorder?
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Expectations (i.e. your goals) should be
realistic
What behaviors can change within a shortterm hospital stay?
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