W 6: Personality disorders

Question 1

What is a personality disorder?

Answer 1

= psychological qualities that contribute to an individual’s enduring/consistent and distinctive patterns of feeling, thinking, and behaving

Question 2

Define personality disorder

Answer 2

An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s
culture. This pattern is manifested in two (or more) of the following areas:
- Cognition (i.e., ways of perceiving and interpreting self, other people, and events).
- Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response).
- Interpersonal functioning.
- Impulse control

Question 3

What are some key traits of personality disorders?

Answer 3

• The enduring pattern is inflexible and pervasive (all area of ones life) across a broad range of personal and social situations.
• The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
  The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
• The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).

Question 4

What are people with cluster A personality disorder described as and what disorders are included in each?

Answer 4

Odd/eccentric
- Paranoid
- Schizoid
- Schizotypal

*less likley to seek treatment

Question 5

What are people with cluster B personality disorder described as and what disorders are included in each?

Answer 5

Dramatic/erratic

• antisocial
• borderline (BPD)
• histrionic
• narcissistic

*more likley to come to the notice of health professionals

Question 6

What are people with cluster C personality disorder described as and what disorders are included in each?

Answer 6

Anxious/fearful

• avoidant
• dependant
• obsessive-compulsive

*May seek treatment

Question 7

What is the DSM V Criteria For BPD?

Answer 7

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts,
- as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment (e.g. doesn’t get an instant text back).
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. (e.g. black and white thinking. You can go from the best to the worst nurse)
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging
5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour (feel as they can only control their life or death)
6. Affective instability due to a marked reactivity of mood. (up and down mood and can be miss diagnosed as bipolar)
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

• these symptoms of episodical and can be changed by life events

Question 8

Why do those with BPD have high rates of interaction with the healthcare system?

Answer 8

• they have an increased risk of suicide
• they have an increased risk of suffering co-morbidities
• a lack of support for BPD so they just have to go to emergency

Question 9

Why is there a great stigma around BPD?

Answer 9

• those with BPM transfer/project their emotions which makes it hard to work with and challenges empathy.
• a lack of understanding in nurses

Question 10

What are the causes BPD?

Answer 10

• Not fully understood
• Likely to involve biological, social and/or environmental factors
• May relate to childhood experiences of trauma or neglect

Remember:
- The person may not have caused all of their problems, but they have to solve them anyway
- Having BPD is not deliberate; it is a disorder people do not choose to have. And, people can recover!

Question 11

What is emotional regulation?

Answer 11

The ability to:
- Inhibit impulsive and inappropriate behavior related to strong negative or positive emotions
- Organise oneself for coordinated action in the service of an external goal
- Self-soothe any physiological arousal that the strong emotion has induced
- Refocus attention in the presence of strong emotion

Question 12

What is dysemotional regulation?

Answer 12

• Difficulties regulating painful emotions

Characterised by;
- inability to regulate intense physiological arousal
- problems turning attention away from stimuli
- cognitive distortions and failures in information processing
- insufficient control of impulsive behaviours related to strong emotions

• This results in dysfunctional behaviours

Question 13

Why and what dysfunctional behaviours are used by people in BPD to cope?

Answer 13

= dysfunctional behaviour planning and thinking about distracts from the emotional pain

Coping straties
- suicide
- self harm (physical harm interrupts and distracts from emotional harm)

Question 14

What are some key nursing considerations/points to consider when helping someone with BPD ho has experienced crisis?

Answer 14

• Many people with BPD experience crisis, resulting in need for support from healthcare services
• Onset associated with a precipitating event (severe or seemingly trivial), sudden overwhelming emotional distress and psychosocial dysfunction that lasts for days to weeks
• Characterised by emotional distress
  - strong emotions ‘feels like they are going to explode
• Every person’s experience of crisis is different; coping strategies are different
  - ask what might have helped them in crisis before
• Difficulty articulating their experience
  - this is when they often go to self harm as it communication the notion of not being ok
• May feel unable to cope and may expect others to take responsibility for their needs
  - don’t mother them
  - we want to promote recovery
• Increase in risk of suicide and self-harm (not always)
• Crisis impacts carers and loved ones so look after them also. Could be in a parallel crisis because they hate seeing a loved on in distress

Question 15

What are some ways interventions for someone with BPD who is in crisis?

Answer 15

• Respond promptly, whether reported by the person or by a family member or carer.
• Listen to the person – validates the person’s experience and shows that you believe the person’s distress is real. Let the person ‘ventilate’ – this can relieve tension.
• Be supportive, non-judgemental, and show empathy and concern. Express concern if the person mentions suicidal thoughts or other risks to their safety.
• Assess the person’s risk. Check if there is any change in the pattern of self-harm and suicidality that could indicate high immediate risk. Check for repeated traumatic experiences or new adverse life events.
• Assess mental health status and rule out co-occurring mental illness.
• Stay calm and avoid expressing shock or anger.
• Focus on the here and now
• Take a problem-solving approach.
• Plan for the person’s safety in collaboration with them. Do not assume that you know best about how to help them during a crisis. Ask the person to say if they want help and to explain what kind of help they would like. Provide practical help.
• Clearly explain your role and the roles of other staff members.
• Communicate with and involve the person’s family, partner or carers, if appropriate.
• Offer support to the person’s family, partner or carers.
• Where possible, liaise with other clinicians/teams/hospitals involved in the person’s care.
• These should be identified in the person’s management plan and crisis plan (if available).

Question 16

What actions should you take If The Person Is At High Acute Risk Of Suicide?

Answer 16

• Do not leave the person alone. If necessary, use the powers of local mental health legislation.
• Prevent or reduce access to the means of suicide. (take meds if they plan to OD)
• Do not use threats or try to make the person feel guilty. “think of your family or kids”
• Consult senior staff.
• Contact all involved in the person’s care (e.g. medical practitioner, crisis team, mental health service, hospital, family, partner, carers, other supports).
• Find out what, or who, has helped in the past.
• Clearly explain your actions.
• Do not agree to keep the suicide plan a secret.
• Make a management plan

Question 17

What are some treatment goals for someone with BDP?

Answer 17

• Long term engagement is psychotherapy
• Suicide prevention
• Prevention of self-harm
• Avoiding the need for hospital admission
• Improving relationships
• Learning skills for coping
• Overcoming personal problems
• Personal employment and occupational goals
• Developing the ability to deal with situations that trigger emotional crises
• Learning self-soothing or distraction techniques
• Reducing or managing anger
• Reducing depression or anxiety
• Managing co-occurring conditions
• Reducing or controlling problem behaviours (problem for the person) such as impulsivity
• Discovering a personal reality and developing the ability to describe and represent this reality

Question 18

What are some Key Principles For Working With People With
Personality Disorder?

Answer 18

• Be compassionate
• Demonstrate empathy
• Listen to the person’s current experience
• Validate the person’s current emotional state
• Take the person’s experience seriously, noting verbal and non-verbal communications
• Maintain a non-judgemental approach
• Stay calm
• Remain respectful
• Remain caring
• Engage in open communication
• Be human and be prepared to acknowledge both the serious and funny side of life where appropriate
• Foster trust to allow strong emotions to be freely expressed
• Be clear, consistent, and reliable
• Remember aspects of challenging behaviours have
  survival value given past experiences
• Convey encouragement and hope about their capacity for change while validating their current emotional experience

Question 19

Define Transference reactions

Answer 19

Transference: transfers beliefs, feelings, thoughts or behaviours that occurred in one situation, usually in their past, to a situation that is happening in their present.

Question 20

Define countertransference reactions

Answer 20

= therapists/nurses emotional response to the patient that they can pick up on
= Typical countertransference emotions when working with people with BPD include helpless, inadequate, overwhelmed, disorganised, special, overinvolved

• Be aware of your own feelings towards the patient as this
  can influence your provision of care

Question 21

What are some EVP treatments for BPD?

Answer 21

*To date, no drug approved for treatment of BPD

= Evidence suggests psychotherapy is the most efficacious treatment for BPD
Effective structured therapies share the following characteristics:
- The therapy is based on an explicit and integrated theoretical approach, to which the therapist adheres
- The therapy is provided by a trained therapist.
- The therapist pays attention to the person’s emotions.
- Therapy is focussed on achieving change.
- There is a focus on the relationship between the person receiving treatment and the clinician.
- Therapy sessions occur regularly over the planned course of treatment.

Psychotherapies include DBT, CBT, ACT, MBT etc.
- cognitive behavioural therapy
- acceptance and commitment therapy

Question 22

Can BPD co-occur, if so what with?

Answer 22

Yes
- Major depressive disorder
- Dysthymic disorder
- Bipolar affective disorder
- Generalised anxiety disorder
- Panic disorder
- Agoraphobia
- Social phobia
- Post-traumatic stress disorder (PTSD)
- Obsessive-compulsive disorder
- Eating disorder
- Substance use disorder
- Attention deficit hyperactivity disorder

Question 23

What are some other non pharmacological treatments/interbentions for BPD?

Answer 23

• pets
• art
• peer support
• self soothing
• kindness

Question 24

Describe the cluster A disorder of: paranoid personality disorder

Answer 24

a. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.

Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.

Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.

Reads hidden demeaning or threatening meanings into benign remarks or events.

Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).

Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.

Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

b. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” i.e., “paranoid personality disorder (premorbid).”

Question 25

Describe the cluster A disorder of: schiziod personality disorder

Answer 25

a. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

Neither desires nor enjoys close relationships, including being part of a family.

Almost always chooses solitary activities.

Has little, if any, interest in having sexual experiences with another person.

Takes pleasure in few, if any, activities.

Lacks close friends or confidants other than first-degree relatives.

Appears indifferent to the praise or criticism of others.

Shows emotional coldness, detachment, or flattened affectivity.

b. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to the physiological effects of another medical condition.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” i.e., “schizoid personality disorder (premorbid).”

Question 26

Describe the cluster A disorder of: schizotypal personality disorder

Answer 26

a. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

Ideas of reference (excluding delusions of reference).

Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations).

Unusual perceptual experiences, including bodily illusions.

Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).

Suspiciousness or paranoid ideation.

Inappropriate or constricted affect.

Behavior or appearance that is odd, eccentric, or peculiar.

Lack of close friends or confidants other than first-degree relatives.

Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.

b. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” e.g., “schizotypal personality disorder (premorbid).”

Question 27

Describe the cluster B disorder of: antisocial personality disorder

Answer 27

a. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following:

Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.

Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.

Impulsivity or failure to plan ahead.

Irritability and aggressiveness, as indicated by repeated physical fights or assaults.

Reckless disregard for safety of self or others.

Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.

Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

b. The individual is at least age 18 years.

c. There is evidence of conduct disorder with onset before age 15 years.

d. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

Question 28

Describe the cluster B disorder of: borderline personality disorder

Answer 28

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)

A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

Identity disturbance: markedly and persistently unstable self-image or sense of self.

Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)

Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

Chronic feelings of emptiness.

Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

Transient, stress-related paranoid ideation or severe dissociative symptoms.

Question 29

Describe the cluster B disorder of: histrionic personality disorder

Answer 29

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

Is uncomfortable in situations in which he or she is not the center of attention.

Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.

Displays rapidly shifting and shallow expression of emotions.

Consistently uses physical appearance to draw attention to self.

Has a style of speech that is excessively impressionistic and lacking in detail.

Shows self-dramatization, theatricality, and exaggerated expression of emotion.

Is suggestible (i.e., easily influenced by others or circumstances).

Considers relationships to be more intimate than they actually are.

Question 30

Describe the cluster B disorder of: narcissistic personality disorder

Answer 30

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).

Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.

Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).

Requires excessive admiration.

Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).

Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).

Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.

Is often envious of others or believes that others are envious of him or her.

Shows arrogant, haughty behaviors or attitudes.

Question 31

Describe the cluster C disorder of: avoidant personality disorder

Answer 31

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.

Is unwilling to get involved with people unless certain of being liked.

Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.

Is preoccupied with being criticized or rejected in social situations.

Is inhibited in new interpersonal situations because of feelings of inadequacy.

Views self as socially inept, personally unappealing, or inferior to others.

Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

Question 32

Describe the cluster C disorder of: dependent personality disorder

Answer 32

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.

Needs others to assume responsibility for most major areas of his or her life.

Has difficulty expressing disagreement with others because of fear of loss of support or approval. (Note: Do not include realistic fears of retribution.)

Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).

Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.

Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself.

Urgently seeks another relationship as a source of care and support when a close relationship ends.

Is unrealistically preoccupied with fears of being left to take care of himself or herself.

Question 33

Describe the cluster C disorder of: obsessive complsive personality disorder

Answer 33

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, as indicated by four (or more) of the following:

Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.

Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met).

Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).

Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).

Is unable to discard worn-out or worthless objects even when they have no sentimental value.

Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.

Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.

Shows rigidity and stubbornness.

Question 34

When do symptoms of BPD typically occur? and what might these early symptoms be?

Answer 34

in adolescence

Include;
- impulsive behaviours
- identity issues
- affective instability
*these then turn into maladaptive and enduring functional impairments as adolescent transition to adulthood.

Yes these symptoms are typical in adolescents but the difference here as that over time these symptoms will decrease in healthy adolescents. In adolescents with BPD they will increase.

Question 35

Is BPD an indefinite diagnosis?

Answer 35

No,
An adult living with BPD will most likely experience periods of remission and relapse (characterised by meeting the threshold of at least five out of nine DSM-criteria for BPD)

Question 36

What medical conditions can BPD be associated with?

Answer 36

• higher rates of chronic disease such as diabetes and cardiovascular disease attributed to high rates of risk factors such as smoking
• sexually transmitted infections, particularly among women living with both BPD and substance use disorders (NHMRC, 2012)
• Polycystic ovarian syndrome, it has been hypothesised that trauma leads to an increase or dysregulation of cortisol
• Pain sensitivity
• Somatic complaints (Sansone & Sansone, 2015)

Question 37

What findings would be expected on an MSE?

Answer 37

Appearance
- Superficial lacerations, scarring visible

Behaviour
- Avoiding eye contact, guarded, dismissive, suspicious, distrustful, overfamiliar, giving excess praise to the nurse, rude and abrupt, overconfident, manipulative, pleasant and polite, impulsive, slowed psychomotor activity

Speech
- Speech will usually reflect mood. So for example, if the person is angry they may be yelling and displaying pressured speech.

Mood
- Labile, angry, anxious, sad, bored, empty, irritable, excitement, elation, tension. May say things like “I feel like shit” “I feel overwhelmed” “I feel numb” “I’m really sensitive” “my mood keeps changing”

Affect
- crying, tearful, restricted range, blunted (particularly if on psychiatric medication)

Thought content
- Hopeless and helpless themes “I can’t control my mood” “what is the point?”, Thoughts of suicide or self-harm. Themes of worthlessness, loneliness, guilt, shame, Somatic complaint, Feeling like they don’t belong, Wanting to be rescued

Thought form: Nill thought disorder

perception
- May experience auditory hallucinations or depersonalization

Cognition
- Orientated to time, place, person. May have poor memory, poor concentration and short attention span.

Judgement
- impaired

Insight
- Partial. May be aware that something is not right and they want things to be different, but may be reluctant to engage in treatment.

Question 38

What should you assess in a BPD risk assessment?

Answer 38

• suicide
• self-harm
• comorbid conditions (?diagnosis’, ?substance use)
• vulnerability (worried about your safety?)
• dependant children (cared for and safe?)
• coping strategies

Question 39

What is a key principle in a BPM management plan?

Answer 39

• involve the patient
• dont take over the responsibility of caring for their needs/rescue the person as this can undermine the person’s limited capacity to care for themselves.

Question 40

What are some recommendations surrounding medication use for BPD?

Answer 40

• Medicines should not be used as primary therapy for BPD, because they have only modest and inconsistent effects, and do not change the nature and course of the disorder
• The time-limited use of medicines can be considered as an adjunct to psychological therapy, to manage specific symptoms.
• Caution should be used if prescribing medicines that may be lethal in overdose, because of high suicide risk with prescribed medicines among people with BPD
• Caution should be used if prescribing medicines associated with substance dependence e.g. benzodiazepines.
• The use of medicines can be considered in acute crisis situations where psychological approaches are not sufficient; they should be withdrawn once the crisis has been resolved.

Question 41

What are some helpful coping strategies for people with BPD?

Answer 41

• distractions
• grounding/breathing check-ins
• focusing techniques
• establish boundary in relationships
• eating well
• reaching out if needing help
• sticking to medication regimen
• letting emotions occur and that’s ok e.g. crying
• kick cardboard boxes outside
• listening to music
• yoga and meditation
• cuddding a soft toy
• comfy clothes
• sing fav song
• distract with movie
• distract with puzzle
• punch pillow if angry
• find private place to scream e.g. car
• shake like a dog

Question 42

Explain trauma informed care

Answer 42

A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization”

Question 43

What are the 6 key principles of trauma informed care?

Answer 43

• safety
• trustworthiness and transparency
• peer support
• collaboration and mutuality
• Empowerment, voice and choice
• cultural, historical and gender issues

Question 44

How to effectively response to someone self harming

Answer 44

• Express concern and actively listen
• Give support and reassurance
• Remember self-harm has a clear function for the individual. - Identify this function and the event that lead to the harm.
• Validate the distress that lead to the harm
• Minimise attention to the injury itself
• Encourage patient to dress the wound themselves if it does not require nursing intervention.
• Assess suicide risk
• Encourage alternative coping strategies

Question 45

What are some Things to avoid when talking with someone about deliberate self-harm

Answer 45

• Minimise the person’s feelings or problems.
• Use statements that don’t take the person’s pain seriously (such as “but you’ve got a great life” or “things aren’t that bad”).
• Try to solve the person’s problems for them.
• Touch (e.g. Hug or hold hands with) the person without their permission.
• Use labels such as ‘self-mutilator’, ‘self-injurer’, or a ‘cutter’ to refer to the person.
• Accuse the person of attention seeking.
• Make the person feel guilty about the effect their self-injuring is having on others
• Set goals or pacts, such as “If you promise not to hurt yourself between now and next week, you’re doing really well”, unless the person asks you to do this.
• Try to make the person stop self-injuring (e.g. By removing self-injury tools) or giving them ultimatums. Remember for many people self-harm may be their only coping strategy. What do you think might happen if they no longer have this coping strategy to rely on?

Question 46

Explain dialectical behaviour therapy and whar are the areas?

Answer 46

• DBT is considered a form of of Cognitive Behavioural Therapy (CBT), as it uses principles of CBT, combined with mindfulness, acceptance and dialectics.
• DBT places less emphasis on using cognitive methods than CBT does and instead emphasises the learning and practice of new skills (O’ Connell & Dowling, 2014).
• BBT was created on the assumption that many of the problems people with BPD experience are the result of skills deficits. For example, people living with BPD will likely have deficits in emotion regulation skills and as a result they will use maladaptive behaviours to regulate their emotions. These behaviours may include suicide attempts, non-suicidal self-injury or substance abuse.

Dialectical Behavioural Therapy skills are arranged into four areas:
1. Mindfulness skills
2. Interpersonal effectiveness skills
3. Emotion regulation skills
4. Distress tolerance skills

If you work with a person who has experienced DBT in the past you might like to encourage them to draw on what they have learned. Here are some examples of the skills that are taught for each area (You may like to refer back to this while you are on placement). You may actually find some of the skills to be helpful for managing your own emotions.

Question 47

Explain the mindfull skill ‘loving kindness’

Answer 47

What is it?
- a mindfulness practice designed to increase love and compassion first for ourselves and then for our loved ones, for friends, for those we are angry with, for difficult people, for enemies, and then for all beings.
- Loving kindness can protect us from developing and holding on to judgmentalness, ill will, and hostile feelings toward ourselves and others.

Practising
- like saying a prayer for yourself or someone else. As when you are asking or praying for something for yourself or others, you actively send loving and kind wishes, and recite in your mind words and phrases that express good will toward yourself and others.

Instructions
1. Choose a person to send loving kindness toward. Do not select a person you do not want to relate to with kindness and compassion. Start with yourself, or, if this is too difficult, with a person you already love.

2. Sitting, standing, or lying down, begin by breathing slowly and deeply. Opening the palms of your hands, gently bring the person to mind.
3. Radiate loving kindness by reciting a set of warm wishes, such as “May I be happy,” “May I be at peace,” “May I be healthy,” “May I be safe,” or another set of positive wishes of your own. Repeat the script slowly, and focus on the meaning of each word as you say it in your mind. (If you have distracting thoughts, just notice them as they come and go and gently bring your mind back to your script.) Continue until you feel yourself immersed in loving kindness.
4. Gradually work yourself up through loved ones, friends, those you are angry with, difficult people, enemies, and finally all beings. For example, use a script such as “May John be happy,” “May John be at peace,” and so on (or “John, may you be happy,” “May you be at peace,” and so on), as you concentrate on radiating loving kindness to John.
5. Practice each day, starting with yourself and then moving to others.

Question 48

Explain the interpersonal effectiveness skills ‘ DEAR MAN’

Answer 48

The goal is for people to be able to get what they want from another person.
This includes
- Obtaining their legitimate rights.
- Getting another person to do something they want that person to do.
- Saying no to an unwanted or unreasonable request.
- Resolving an interpersonal conflict.
- Getting their opinion or point of view taken seriously.

Describe: Describe the current situation (if necessary). Stick to the facts. Tell the person exactly what you are reacting to. “You told me you would be home by dinner but you didn’t get here until 11.”

Express: Express your feelings and opinions about the situation. Don’t assume that the other person knows how you feel.

“When you come home so late, I start worrying about you.”

Use phrases such as “I want” instead of “You should,” “I don’t want” instead of “You shouldn’t.”

Assert: Assert yourself by asking for what you want or saying no clearly. Do not assume that others will figure out what you want. Remember that others cannot read your mind.

“I would really like it if you would call me when you are going to be late.”

Reinforce: Reinforce (reward) the person ahead of time (so to speak) by explaining positive effects of getting what you want or need. If necessary, also clarify the negative consequences of not getting what you want or need.

“I would be so relieved, and a lot easier to live with, if you do that.”

Remember also to reward desired behavior after the fact.

(stay) Mindful: Keep your focus on your goals. Maintain your position. Don’t be distracted. Don’t get off the topic.

Keep asking, saying no, or expressing your opinion over and over and over. Just keep replaying the same thing again and again.

If another person attacks, threatens, or tries to change the subject, ignore the threats, comments, or attempts to divert you. Do not respond to attacks. Ignore distractions. Just keep making your point.

Appear confident: Appear effective and competent. Use a confident voice tone and physical manner; make good eye contact. No stammering, whispering, staring at the floor, retreating. No saying, “I’m not sure,” etc.

Negotiate: Be willing to give to get. Offer and ask for other solutions to the problem. Reduce your request. Say no, but offer to do something else or to solve the problem another way. Focus on what will work. “How about if you text me when you think you might be late?” Turn the problem over to the other person. Ask for other solutions. “What do you think we should do? . . . I can’t just stop worrying about you [or I’m not willing to].”