Managing Care for Persons with Borderline Personality Disorders

1. Managing Care for Persons withBorderline Personality Disorders Phyllis M. Connolly PhD, APRN, BC, CS Professor of Nursing San Jose State University connollydr@son.sjsu.edu 408-924-3144

2. Questions to Consider • How does the stigma of the label of Borderline Personality impact your care? • 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 are some effective interventions to deal with self-harm, and manipulative behaviors? • What are your self-care behaviors? • How might collaboration create newness and facilitate hope?

3. Qualities of Healthy Personality • Positive & accurate body image • Realistic self-ideal • Positive self-concept • High self-esteem • Satisfying role performance • Clear sense of identity

4. 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

5. Why Do We Behave the Way We Do? Behavioral (actions) Affective (feelings) Cognitive (thoughts) Interacting System’s Human Behavior

6. Stress: A person-environment interaction • Sources • Biophysical • Chemical • Psychosocial • Cultural • Heat-cold • noise • radiation • exhaustion • physical inactivity • alcohol • nicotine • caffeine

7. 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

8. Responses to Stress • Demanding situation--stressor • Internal state • Tension • Anxiety • Strains

9. 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

10. 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

11. 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)

12. 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

13. 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

14. 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

15. 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 

16. 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

17. 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)

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. Self-Injury • Body piercing • Eye brow tweezing • Hair removal • Nail biting • Hair twisting • tattos

25. Nursing Roles: BPD • Provide structured environment • Serve as an emotional sounding board • Clarify and diagnose conflicts • Assess for other health problems

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

27. You should have an emergency plan for handling a suicide gesture or ideation.

28. Risk Management: Suicide • Monitor & document risk assessment • Actively treat comorbid axis I disorders eg. major depression, bipolar disorder, substance abuse/dependence • Consultations

29. Someone needs to stay with the person at all times The person is experiencing strong feelings of abandonment, loneliness, guilt and hopelessness

30. Adaptive Problem Solving • Assist with basics • Living arrangements • Food availability • Identify past coping mechanisms • Identify person(s) available in the support system

31. Competency & Efficacy • Set achievable short term goals • Encourage & give positive feedback • Family & support persons are critical in providing positive feedback

32. Facilitating Hope • Provide a supportive climate • Facilitate a hopeful perception • Help the person to restructure the situation • Assist the person in making plans • Assist the person in taking action, and establishing goals for living

33. Concept of Newness Discovery • Creativity Resources Insight Plans Outcomes Facilitating Hope

34. 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

35. 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

36. 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

37. 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

38. 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 Stress Management

39. 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

40. 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

41. Interventions Cont. • 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

42. Calm unhurried approach Do not touch Respect personal space Use active listening Be aware of personal feelings Offer time-out/one-one in quiet area Initially ignore derogatory statements Protect other people 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 Interventions: Anger Non Verbal Verbal

43. 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

44. 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 Safety Guidelines: Violence

45. 3R’s Conflict Management • Relax • Reflect • Respond

46. Your Choice Response Stimulus

47. 3 R’S EMOTIONAL RESPONSE RED: STOP & RELAX Yellow: Wait & Reflect GREEN: GO & RESPOND

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

49. SELF-TALK • “I CAN MANAGE MY RESPONSE” • “I HAVE BEEN SUCCESSFUL BEFORE” • “WE CAN COME TO AN AGREEMENT”

50. VISUALIZE REFLECT