managing care for persons with borderline personality disorders phyllis m. connolly phd, aprn, bc,...
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Managing Care for Persons withBorderline Personality Disorders
Phyllis M. Connolly PhD, APRN, BC, CSProfessor of Nursing
San Jose State [email protected]
408-924-3144
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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?
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Qualities of Healthy Personality Positive & accurate
body image Realistic self-ideal Positive self-concept High self-esteem Satisfying role
performance Clear sense of
identity
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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
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Why Do We Behave the Way We Do?
Affective (feelings)
Cognitive (thoughts)
Behavioral (actions)
Interacting System’s Human Behavior
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Stress: A person-A person-environment interactionenvironment interaction
Sources Biophysical Chemical Psychosocial Cultural
Heat-cold noise radiation exhaustion physical
inactivity alcohol nicotine caffeine
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External stimuli
Emotional feelings
Peripheral physiological
changes
Central nervous system arousal
Internal stimuli
Genetic equip
Past experience
StressIndividual perception of stressor-conscious
or unconscious
Stress Model
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Responses to Stress
Demanding situation--stressor
Internal state Tension Anxiety Strains
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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
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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
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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)
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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
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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
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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
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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
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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
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Borderline Personality DSM-IV, 301.83Splitting Primitive idealization Seeing external objects all good or all
bad Impaired object constancy Integral part of separation-individuationManipulation and dependency commonDifficulty being alone--seek intense brief
relationships (Fatal Attraction)
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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
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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
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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
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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
Psychopharmacology
Important to monitor for side effects: sedation; diabetes; weight gain
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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
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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
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Self-Injury
Body piercing Eye brow tweezing Hair removal Nail biting Hair twisting tattos
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Nursing Roles: BPD
Provide structured environment Serve as an emotional sounding
board Clarify and diagnose conflicts Assess for other health problems
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HEALTH PROBLEMS May have an infection Respiratory illness Diabetes Thyroid problems Nutritional imbalances Appendicitis Other disease processes May trigger other
symptoms
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You should have an emergency plan for handling a suicide gesture or ideation.
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Risk Management: Suicide Monitor & document
risk assessment Actively treat
comorbid axis I disorders eg. major depression, bipolar disorder, substance abuse/dependence
Consultations
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Someone needs to stay with the person at all times
The person is experiencing strong feelings of abandonment, loneliness, guilt and hopelessness
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Adaptive Problem Solving Assist with basics
Living arrangements
Food availability Identify past
coping mechanisms
Identify person(s) available in the support system
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Competency & Efficacy Set achievable
short term goals Encourage & give
positive feedback Family & support
persons are critical in providing positive feedback
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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
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DiscoveryDiscovery CreativityCreativity
Concept of NewnessConcept of Newness
ResourcesResources InsightInsight PlansPlans OutcomesOutcomes
Facilitating HopeFacilitating Hope
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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
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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 situationsCompton, 1989
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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
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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
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Stress Management 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
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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
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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
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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
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Interventions: Anger
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
Non Verbal Verbal
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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
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Safety Guidelines: Violence
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
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3R’s Conflict Management
Relax
Reflect
Respond
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Your Choice
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RELAX SPEAK SOFTLY AND SLOWLY KEEP YOUR LEGS AND ARMS
UNCROSSED DO NOT CLENCH YOUR FISTS DO NOT PRESS YOUR LIPS
TOGETHER TIGHTLY
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“I CAN MANAGE MY RESPONSE” “I HAVE BEEN SUCCESSFUL
BEFORE” “WE CAN COME TO AN
AGREEMENT”
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“I DON’T UNDERSTAND” LISTEN REPEAT SOMETHING THAT HAS
AGREEMENT TAKE A BREAK USE: “Perhaps,” “maybe,”
“sometimes,” “what if,” “it seems like,” “I wonder,” “I feel,” “I think”
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Situation & Date Behavior, body cues, affect,
physical reactions, feelings Behavioral Response
What I did or said What I would like to have done or said
What prevented you from doing what you wanted?
SELF-EVALUATION: KEEP A LOG
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Self-Care Staff Healthy diet and nutrition Exercise and physical activity Adequate sleep patterns Recreation & leisure Balanced lifestyle Meditation Tai Chi Clinical supervision Support groups Critical incident stress
debriefing
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Newness: Collaboration A dynamic transforming process of
creating a power sharing partnership for pervasive application in health care practice, education, research, & organizational settings for the purposeful attention to needs and problems in order to achieve likely successful outcomes (Sullivan, 1998, p. 6)
Explore options for internal & external resources for collaboration
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Transdisciplinary Collaboration Wheel
Rehab GoalsFeedback
Services Budget
CommunityResources
DailyLiving
Voc Rehab
RecreationalActivities
Speech,Language,
CommunicationHealthMeds
CM= Case Manager
AS = Agency Staff
SW = Social Work
SP = Speech Pathology
N/M = Nursing/Medicine
RT = Recreational Therapy
OT = Occupational Therapy
CLIENT
AS/CM
SWOT
RTSP
N/MJ. NovakP. Connolly1997
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“Your care makes a difference in people’s lives”
Thank you