Managing Care for Persons with Personality Disorders

1. Managing Care for Persons with 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 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?

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 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

15. 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%

16. 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

17. Cluster A, Odd, Eccentric Paranoid Schizoid Schizotypal Cluster B, Dramatic, Emotional, Erratic Antisocial Borderline Histrionic Narcissistic Cluster C, Anxious Fearful Avoidant Dependent Obsessive-Compulsive Personality Disorders DSM-IV : Clusters: A, B, C

18. 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

19. 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

20. 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

21. 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

22. 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 Obsessive Compulsive Personality Disorder: Criteria

23. 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

24. 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 

25. 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

26. 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

27. 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)

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

29. 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

30. 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

31. 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

32. Ego Functions • Control & regulate instinctual drives • Relation to reality • Sense of reality • Reality testing • Adaptation to reality • Object relationships • Defensive functions

33. 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

34. 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

35. 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

36. 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

37. 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

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

39. 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

40. 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

41. 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)

42. 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

43. 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

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

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

46. 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

47. 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

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

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

50. 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