The Elephant in the Room: How to care for those with Emotional Dysregulation Disorders

1. The Elephant in the Room: How to care for those with Emotional Dysregulation Disorders RMHC Discharge Liaison Team Carrie Howard, RN Pauline Barton, RN Hideko Saito-Dufton RN, CPMHN(c)

2. Learning Objectives • To further define what constitutes Emotional Regulation disorders • To identify common responsive behaviors and challenges associated with providing care to this population. • To discuss care approaches related to responsive behaviours and communication: do’s and don’ts • To apply these principles to a case study using P.I.E.C.E.S framework.

3. Case Mrs. J Mrs. J refused her BG monitoring this am. She came late for her meal again, and staff went to her room three times to remind her. After the meal had been cleared, Mrs. J approached a PSW to complain that she “did not get anything to eat” and she will be telling the doctor that the “nurses are trying to starve me”. Mrs. J is offered toast and cereal for breakfast. She also continues to refuse her medications. Shortly after, she requested a prn for her anxiety and reported that “that girl that gets me up doesn’t know anything, she shouldn’t work here, she got me all upset”. Staff try and encourage her to take her regular medications, as she is to receive her antidepressant and staff know that missing a dose can make her feel awful. Staff were not able to re-direct her to take her meds “you don’t really care if I take them or not”. Mrs. J was given a prn of Ativan for her anxiety.

4. Case Mrs. J (cont’d) After breakfast, Mrs. J was asked to go to group exercise. During the activity, Mrs. J displayed several disruptive and attention seeking behaviours. She raised her voice over that of others, made rude comments to the other ladies in the class about their weight and elicited several responsive behaviours from her peers. When this happened, staff had to stop the group and diffuse the altercations. Mrs. J was asked to leave the group early, which often occurs. Others in the home often comment on how awful Mrs. J can be and so they avoid speaking with her. Later in the day, Mrs. J is found to be weepy in the hallway. Several staff walk by Mrs. J, as they often see this behaviour. It is usually unfounded complaints, or complaints of other staff and they would rather not enter into those types of conversations.

5. Case Mrs. J cont’d Mrs. J yells out “I wish I was dead” and begins to wail loudly. The RN asks Mrs. J “what is the problem?”. “ I’m going to die and no-one cares!!” . Mrs. J then asks staff for a prn for her bowels. Staff know that this is a frequent request and that often Mrs. J will overuse the laxatives, resulting in episodes of loose stools. The RN told Mrs. J “no you can’t have anything for your bowels right now”. Re-direction from these requests were often ineffective, as Mrs. J responds to staff loudly that “my cousin died of constipation, you don’t know anything, get me the pill”. After about 30 minutes, staff received a call from Mrs. J’s daughter. She was critical of staff not giving her mother a laxative as requested. She demanded that staff give her mother what she asks for. She called back after an hour to check that staff had followed through with the request. She visited that night and spoke with her mother. Mrs. J is now reporting that her daughter is in the process of lodging a formal compliant to the DOC.

6. Emotional DysregulationDefined Associated with ways of thinking and feeling about oneself and others that significantly and adversely affect how an individual functions in many aspects of life.

7. Definition Cont’d • Long-term, unchanging patterns of dysfunction. • Patterns forms and develop over long period of time. • Evident by early adulthood and usually persists throughout the person’s lifetime.

8. Patterns are reinforced and then becomes fixed and unrelenting. • Influenced by: physical and emotional abuse. • Family interactions of neglect, emotional over or under-involvement or invalidation. • Biological or genetics • Difficulty regulating emotions

9. Emotional regulation is a process by which individuals influence their emotions, specifically when they have them and how they experience and express these emotions

10. Expression ofEmotional Dysregulation Vulnerability to negative emotion • Highly sensitive to their thoughts; causes emotional arousal. • Highly reactive with a slow return to baseline.* • Recurrent suicidal behaviour: gestures/threats, self mutilation. • Chronic feelings of boredom • Excessive fear of abandonment (real/imagined) • In periods of extreme stress can present with transient psychotic symptoms*

11. Expression of Emotional Dysregulation Poor coping skills • Inability to manage social interactions. • Inability to identify and label emotional experiences. • Poor arousalmanagement* • Excessive need state • Constant state of crisis • Impulsivity with regards to spending, sex, drug/alcohol abuse

12. Expression of Emotional Dysregulation Poor coping cont’d • Disturbances in identity, sexual orientation, value-belief system • Poor choices in career goals, friends and romantic partners • Make unattainable goals.

13. Expression of emotional Dysregulation Maladaptive responses to other’s emotions • Others responses often trigger emotional arousal. • Manipulate environment to satisfy needs/soothe fears. • View things/people as all good or all bad. • Utilize passive aggressive behaviours* • Black and white thinking can cause a defense mechanism called “splitting”

14. Types • Paranoid • Schizoid Cluster A • Schizotypal * • Antisocial * • Borderline * Cluster B • Histrionic • Narcissistic * • Avoidant * • Dependent Cluster C • OCD *

15. Behaviors and Challenges • The client will often test the limits of the treatment team. • They will have angry or agitated periods. • They will attempt to deviate from the treatment plan: late for care or meals, will only let a certain staff do care. * • They will attempt to split staff: good nurse/ bad nurse. • They often make caregivers feel helpless/incompetent or less effective than other peers. “Splitting”

16. Approaches:Communication Prior To Approach: • Consider what is your agenda, multiple options and how much time you have. • Know strengths and limitations of yourself and your resident • Focus on the person, not the disease During The Approach: • Be an active listener by being physically and mentally present and showing interest • Validate underlying emotions • Avoid listening to stack or repetitive complaints • Focus on his/her feelings

17. Approaches (cont’d) During the Approach: • Change vague complaints into specific problem statement • Problematic situations • Uncomfortable emotions (feelings/symptoms) • Dysfunctional behaviour • Troubling, re-current thoughts • Focus on assisting the process of problem solving, NOT “recue” or “cure” • Direct to distraction of negative thoughts • Keep the time!!

18. Approaches (cont’d) The Plan: • Create a plan of care with specific goals and routines, with client involvement. • Consistency is the key: All staff should be familiar with routines and directives. • Client should be assigned a consistent staff member for continuity, if at all possible, to establish a trust relationship. • Inform client of their assigned staff, whom they can go to for requests and care. Other staff to re-direct to this staff when approached. • Care conference on a scheduled or as needed basis to stay consistent and to see behaviour based on current situations • Keep yourself in mind!!

19. Pro-attention Plan • This is an efficient and objective way to provide the person with needed attention at a more convenient time for the care providers and other team members. • It gives attention to the individual before they seek it out in negative ways • It is important that this attention is separate from providing care, administering medications and meals

20. Back to Case Study… Mrs. J is 81 years old, and has resided in LTCH for 10 years. Dx: Emotional Dysregulation disorder, Major Depression, anxiety disorder, somatization disorder, CHF, HTN, hypothyroid, hyponatremia, pain, OA knees, recurrent UTI’s, Hx hip #. Mrs. J often presents as lethargic and disinterested. She has multiple somatic complaints with regards to her GI system, pain, as well as subjective sleeplessness. She refuses care at times from certain staff, so hygiene is often poor. She seeks out medications to “help her”(has difficulty identifying her needs), is hyper-vigilant of other residents in the home and how care is provided to them, often citing that they get “preferred treatment”. MMSE done by new graduate, first time 29/30.

21. Back to Case Study Medications: Cymbalta 60mg po once a day Gabapentin 200mg po tid Mirtazapine 45mg qhs Trazodone 50mg tid Hydromorph contin ER 6mg bid Fentanyl patch 50 mcg/72hrs. Clonazepam 0.5 mg bid Seroquel XR 50mg once a day Metformin 100 mg tid Lasix 40 mg once a day Coversyl 4 mg once a day Ramipril 2.5 mg po once a day HCTZ 25 mg po once a day Synthroid 0.05 po once a day PRN: Trazodone 25 mg po q 6h for anxiety/sleeplessness Ativan 0.5 mg po q 6h Seroquel 25mg po for agitation Hydromorphone 2 mg po q4h Tylenol 650 mg po q4h Maalox 30 ml q2h Ventolin 2 puffs q4h

22. Back to Case Study History of trauma Spent time in foster care as a young child. Remote report of physical and sexual abuse, Mrs. J does not talk about this. Mood is euthymic and often she c/o depression and wanting to die. Mrs. J lost her husband 11 years ago(hx alcohol abuse), # of hip 10 years ago prompted the admission to LTCH. Has few relationships in the home, as she can be critical and demanding of her peers. Mrs. J is estranged from two of her children. Her oldest daughter is overly involved with her mother’s care (co-dependent relationship).

23. Back to Case Study • Mrs. J loves to read, she attend programs of interest if asked and encouraged to go (BINGO, exercise). She is very mobile and can easily get around the home. • Lives in a ward room with three other ladies. 2 of the women have severe dementia and are full care. The third is a well liked lady in the home, who is very active with resident’s council. • Daughter visits every other day for 4 hours, participates in assisting with her mothers care, requests meetings with the ADOC at each visit to talk about her mother. Daughter can be very critical of the staff, as can her mother. Recreation staff have a good idea of Mrs. J likes and dislikes but find it hard when she is disruptive in programs, so they often wait until the last minute to invite her. She attends church.

24. Take Home!!! • Do not take behaviour personally • Don’t get sucked in • Do NOT take behaviour personally

25. Questions ???

26. References • health.discovery.com/encyclopedias/ 2871.html • www.intelihealth.com • mentalhelp.net • www.surgeongeneral.gov/library/mentalhealth/chapter4/sec2_1.htmal • Sort, N.P., Kitchiner, N.J., & Curran, J. (2004). Unreliable Evidence, Journal of Psychiatric and Mental Health Nursing, 11; 106-111.

27. References (cont.) • Dada, F., Sethi, S., & Grossberg, G. (2001). Generalized anxiety disorder in the elderly. The Psychiatric Clinics of North America 24(1); 155-162. • Antai-Otang, D. (2003). Current treatment of generalized anxiety disorder. Journal of Psychosocial Nursing 41(12); 20-29.

28. References • Mosby,2007,Psychiatric Nursing Care Plans • References—Gentle Persuasive Approaches in Dementia Care • Strategies to enhance communication, CME program, Dr. Orange UWO Nov. 2010.

29. References • 2008, DSM-IV • 2006, Borderline Personality Disorder, Dr. Anne Dietrich, PhD, Adler Clinic, Vancouver, B.C. • 2007, Psychiatric Nursing Care Plans, Mosby