Transcript Borderline Personality Disorder

Personality Disorder
Personality Disorders
 Client suffers from lifelong, inflexible and
dysfunctional patterns of relating and behaving
 Patterns are excessive and interfere with daily
life
 Relationships
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Dysfunctional patterns and behaviors of the client
 Cause distress to others
 Client does not recognize dysfunction and only
becomes distressed when others react to them
negatively
Behavioral Characteristics
 Personality Disorder is a way of relating
to the world. An enduring pattern of
acting and responding,
 Narcissism- speak and act as if their own
needs are paramount. Normal in
Adolescents.
 Annoying: Tend to “Get under your skin.”
 Problems in interpersonal situations.
Personality Disorder
 Personality Disorders are difficult to treat
Most are not in Psychiatric Hospitals
 May be admitted to an inpatient facility but must have an
Axis I diagnosis also (alcoholism, depression and anxiety)
 The most common personality disorder inpatient is
Borderline Personality Disorder
 Most are treated outpatient in individual or group therapy
 May be in drug treatment center
 Axis II Diagnosis
 Used to designate
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Personality disorders or traits
Developmental Disorders
Habitual use of Particular defense Mechanism
Affective/Cognitive
Characteristics
 Anxiety: Varies in the different clusters.
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Behavior is their way of coping with anxiety
and the individual does not consider how
their behavior will effect others.
 Cognitive issues:
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Rigidity of responses often causes
individual to not reach their potential.
Inflexibility leads to mistakes in judgment
making them prone to job problems.
Socioculturally
 Believe problems in their lives are other
people’s fault or the rest of the world.
 History of broken relationships, family
and marital problems.
 Alcoholism and drugs
 Age of onset; Adolescence, tend to
decrease in middle age. What is normal
in adolescence is not later.
Grouped by the Three Clusters
of Behavior in the DSM IV TR
 Cluster A
 Exhibit odd and eccentric behaviors; includes
schizoid, schizotypal, and paranoid disorders.
 Cluster B
 Exhibit dramatic emotional and erratic behaviors;
includes Narcissistic, histrionic, antisocial, and
borderline disorders.
 Cluster C
 Exhibit anxious fearful behaviors; includes
dependant, avoidant and obsessive-compulsive
disorders.
Gender and Personality
Disorders
 Female: greater percentage of
Borderline or Histrionic
 Male: Greater Percentage of Paranoid,
Schizoid, Antisocial, and Narcissistic
This Presentation
1. Cluster A will be reviewed first
2. Cluster C will be reviewed second
3. Cluster B will be the most
comprehensive review
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Borderline Personality Disorder will be
reviewed last in this presentation. This
disorder is the most common Axis II
disorder encountered by the Mental Health
Nurse.
Cluster A
 Characteristics: odd, eccentric behavior,
suspicious ideations, and social
isolation. Know this cluster as a group
(do not have to recognize each
individually)
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Paranoid
Schizoid
Schizotypal
Cluster A
 Schizoid
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Lacks desire to be
close to others
Lacks close friends
Solitary activities
Little interest in sexual
activity
Avoids activities
Appears cold and
detached
Appears indifferent to
praise or criticism
 Schizotypical
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Ideas of reference
Magical thinking or odd
beliefs
Unusual perceptual
experiences including
bodily illusions
Odd thinking and
speech
Suspicious; social
anxiety
Few close
relationships
Paranoid
 Behaviorally; often alcoholic, secretive,
argumentative and fearful of people.
Hyper-alert to danger and rarely seek
help.
 Angry, Controlling, and judgmental.
 Cognitively; very guarded “none of your
Business.”
 Difficulty in intimate relationships. Cold
aloof manner, Often litigious.
 Holds grudges; lacks trust in others
Cluster C
 Dependent Personality Disorder
 Pervasive, excessive need to be taken care of
 Submissive and clinging
 Fears of separation
 Avoids responsibility
 Expresses helplessness
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Interventions
 Nurse assists client to increase responsibility in
daily living
 Needs assistance with anxiety
 Teach assertiveness and verbalization of feelings
Cluster C
 Avoidant Personality
Disorder
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Severe shyness and
avoidant behavior
Socially uncomfortable
and withdrawn
Nurse helps by assisting
the client in setting small
goals
Discusses fears and
feelings prior to meeting a
goal
 Obsessive Compulsive
Personality Disorder
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Perfectionist and
inflexible
Preoccupied with trivial
details and procedures
Difficulty expressing
warmth and kindness
Having fun is difficult
Nurse helps by assisting
the client to explore
feelings and try new
activities
Teach that making
mistakes is normal to
decrease need for
perfection
Cluster B
 Characteristics are; impulsive, dramatic
behavior, intolerance of frustration, and
exploitative interpersonal relationships. (Know
Antisocial Borderline and Narcissistic)
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Histrionic
Narcissistic
 Also occasionally seen in inpatient treatment)
Antisocial
Borderline
 (most often Personality Disorder seen in
inpatient treatment)
Cluster B
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Histrionic
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Dramatizes and draws
attention to self
Feels helpless and needs
reassurance
Extroverted and thrives on
attention
Lacks insight
Temper tantrums, outbursts
of anger over minor events
The nurse gives positive
reinforcement for acts that
are focused on others
The nurse facilitates
independence in problem
solving and daily functioning
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Narcisistic
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Grandiosity and exageration
about accomplishments
Needs to be admired
Indifferent to criticism
A sense of entitlement
(should be rewarded despite
the lack of effort or work)
Lack of empathy for others
The nurse uses supportive
confrontation of
discrepancies; limit setting
and a consistent approach
Antisocial Personality Disorder
 Pattern of disregard of the rights of others
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Poor boundaries
 Does not have a good understanding of where
they stop and the next person begins.
 History of disordered life functioning
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Parent child relationship is unstable
 Vacillates between permissiveness and severe
punishment
 Poor understanding of limits on there behavior
because limits are very inconsistent
 Genetic predisposition
Antisocial
 Predominant childhood characteristic of lying, stealing and
being truant.
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High correlation between this disorder and substance abuse.
Conform to rules when it suits their purpose.
 Express themselves easily, but with little personal involvement.
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Professes undying love one moment rejection the next.
Irritating , aggressive, low guilt.
Often in the criminal justice system and NOT the Mental Health
system.
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Example of lack of guilt or remorse:
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Client will state they needed to rob a store with a gun because of
their low income and inability to support themselves.
The reason why the are in jail is because they were caught. It is
the mistakes they made that led them to be caught that is the
problem; NOT the crime.
Antisocial/ Cognitive & Socially
 Initially appear to be charming and intellectual
 Smooth talker
 Deny and rationalize their behavior
 Egocentric and grandiose
 Confident everything will work out
 Ego-syntonic; Cannot delay gratification and
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make no long range plans
Unable to sustain close relationship.
Sex life is impersonal and impulsive.
Quick anger, lack of guilt, abusive
Hospitalized to avoid the law
Treatment of Anti-social Personality
Disorder
 Drug Treatment center, jails and prisons
 Essential for staff to agree on rules and
stick with them.
 Will try to play one staff or shift against
another.
 Best form of Treatment; Peer counseling
and self-help groups, like AA.
Borderline Personality
Disorder
Borderline Personality
Disorder DSM IV TR Criteria
 Unstable, intense relationships characterized by
over-idealizing and devaluation others
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Intense ambiguous feelings.
This is when two feelings such as love and hate are
present at the same time
Client with BPD cannot resolve feelings that others
are not perfect and cannot meet all of their needs
 Impulsiveness and self-destructive
 Substance abuse
 Sexual promiscuity
 These behaviors help them to feel better for a
short period of time
DSM IV TR Criteria Cont.
 Recurrent suicidal threats & gestures
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Self-Injurious Behavior (SIB)
 Affective instability
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anxiety to depression
 Inappropriate displays of anger
DSM IV TR Criteria Cont.
 Marked persistent identity disturbance in
two areas: career, friends, values
 Chronic feelings of emptiness and
boredom.
 Frantic efforts to avoid abandonment
 Transient, stress related, psychotic
symptoms or sense dissociative.
Etiology of Borderline
Personality Disorder
 Masterson’s theory: Child tries to separate and
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mom withdraws love. Child clings and mom
rewards. Child unsure of affection. Fathers may
be distant, alcoholic or unavailable.
Neglect of the child
Split occurs: Good me-Bad me
Invalidating, chaotic environment
No object constancy (consistency in care giving
of the child). Develops a low tolerance of
ambivalence.
75% of clients with BPD are women and victims
of childhood sexual abuse
Issues for Borderline
 Identity
 No sense of who
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 Intimacy
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they are
Feel very empty
See themselves as
all good or all bad
Very needy
fearful
abandonment fear
Symptoms
 Self-mutilation
Clients discuss feelings of depersonalization
 To prove they are alive, they cut until they feel pain
 May also state that the physical pain alleviates the
emotional pain
 Anhedonia
 Cannot enjoy life in conventional way
 Impulsiveness
 Cannot soothe self; very intense emotions
 Try to teach coping skills.
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Borderline Personality Disorder
and Countertransference
 Positive Countertransference
 Lack of a sense of identity and inability to meet
their own needs
 Look to others as being “all good” and seek to get
others to meet their needs
 Negative Countertransference
 Other people will eventually fail in attempting to
meet all the needs of an individual with BPD
 Results in malice/rage
 Aversion: More serious problem
 Working with these problems is the responsibility of
an advanced practice Health Care Provider
Therapy
 Clients have long-term issues of abuse and
neglect
 An advanced practice Health Care Provider can
assist the client in talking about these events in
individual or group therapy
 The nurse stays in the “here and now”
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This is very therapeutic
Can assist the client in identifying how their
behavior results in unwanted responses from
others
Helps the client to identify coping strategies and
understand the disorder through teaching
Group Therapy
 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.
 AA, ACOA, groups are very useful.
Nursing Interventions
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Safety
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Limit Setting
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Acknowledge emotional pain
Offer support and empower to understand and change dysfunctional behavior
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Review: What happened? How did you react (behave)? How did that work for you? What can you do
next time?
Prevent Splitting
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Maintain clear boundaries
Therapeutic Relationship
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Clients in the acute care setting are in crisis
Keep environment free of contraband
Assess for suicidal thoughts frequently
Observe closely
Be consistent
Follow all rules of the unit
Follow the client’s treatment plan
Prevent Triangulation
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Clients will try to get the nurse to engage in complaints about another staff (a third person)
Refer the client back to the staff they have a problem with
Offer to talk about the client
Treatment and Individual Therapy
Working with the client to change behaviors can
be like a roller coaster for the health care provider.
 Client trusts is improving, then panics fearing
separation
 Experiences abandonment depression, clings to
others and then distances.
 Clinging: the therapist is all good
 Distancing: anger; the therapist is all bad
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BPD: Ups and Downs
 Example:
Client appears better
 Ready for discharge
 Fears abandonment
 Makes suicide gesture
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This is not personal (it is not the nurse’s responsibility;
this behavior is generated by a fear of abandonment
Client believes they are getting worse and needs
reassurance and reminder of progress…regression can
be temporary
The nurse needs to be OBJECTIVE not emotional…
MATTER of FACT in the approach to the client
Interventions and Milieu
 Contracts with specific goals and
responsibilities are important.
 Never discuss another staff member with
these client
 Goal is “reintegrate the split”
 Can remind client of the other side (all
people have both good and bad
qualities)
Treatment and Milieu
 Hold Client responsible for actions while
maintaining positive expectations. Have
consequences identified on plan and
stay with them.
 Remain CALM and MATTER-OF-FACT
 Realize this is client’s illness, behavior
are not personal.
 Role is with day to day activities. One
person process issues with client
National Education Alliance for
Borderline Personality Disorder
 New group that has begun
 Had a national conference in Houston,
Feb. 2006.
 Latest research on pathophysiology
 Uses an educational approach, family
support
 Believes trauma is important in the
development of BPD
The End