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Flashcards in Borderline Personality Disorder Deck (41):
1

What is personality?

• Complex pattern of characteristics (largely outside of awareness)

• Distinctive patterns of perceiving, feeling, thinking, coping, and behaving

• Personality traits
– Prominent, exhibited in a wide range of social and personal contexts

• No sharp division between normal and abnormal personality
– Viewed on a continuum
–> Intrinsic, pervasive, biopsychosocial

2

Personality Disorder

• An enduring pattern of deviant inner experiences and behavior differing from cultural expectations
– Pervasive and inflexible –> Leading to distress or impairment

• DSM 5-focus (Dx strategy) on disturbances in:
1. Self functioning: self-identity and self direction
2. Interpersonal functioning: ability to relate to others with empathy or intimacy (scary)
3. Schema- a person’s view of the world that filters information and only lets in what is compatible with his/her personal beliefs

• Prevalence=4.4-13.4% (9.6% median)

3

Personality Disorder Clusters

Odd or Eccentric Behavior: paranoid, schizoid, schizotypal

Dramatic, Emotional, or Erratic Behavior: antisocial, borderline, histrionic, narcissistic

Anxious or Fearful: avoidant, dependent, obsessive-compulsive

4

BPD: criteria

-unstable interpersonal relationships
-scared of abandonment
-identity disturbance
-impulsivity
-recurrent suicidal behavior
-instability of mood
-chronic feelings of emptiness
-innappropriate/intense anger
-stressed
--> usually early adulthood

5

BPD

The person has acquired few strategies for relating, and his/her approach to relationships & the environment is INFLEXIBLE and MALADAPTIVE.

Behavior provokes negative reactions from others.

Remissions common & relapse rates relatively low, sx decrease but psychosocial functioning may not improve

6

BPD: Cognitive Dysfunction

–Dichotomous thinking: evaluating people, objects & experiences in mutually exclusive ways (good OR bad, trustworthy OR deceitful, success OR failure)

–Catastrophizing: ex. "I didn't pass this test...I'm never going to be anything"

–Self-attribution errors: inappropriate self-blame

7

BPD: Dissociation

–>disruption in the normally occurring linkages among subjective awareness, feelings, thoughts behavior & memories.

Examples are:
1. Derealization & depersonalization - feeling the self or environment is strange or UNREAL
– Out of body experiences
– Emotional numbing
– Amnesia for painful experiences (often abuse)
– Not being present during stress “spacing out”
– Alterations in body perceptions

8

BPD seeking help

• May not seek professional help unless extreme stress/internal distress (ex. self harm or suicide attempt)
• Do not want to burden others

9

Risk factors

–Childhood physical or sexual abuse
–Lack of stable home, nurturing

10

BPD adaptation/expectations

• Adaptation skills are characterized by tenuous stability, fragility, and lack of resilience when faced with stressful situations.
• When their unrealistic expectations of self are not met they feel shame, self hate & self directed anger.

11

Clinical Course

• Diagnosed in young adulthood --> but symptoms start in childhood or adolescence - assess family, tx child/adol

• Appear more competent than they actually are

• Life is one crisis after another, remissions and recurrences

• Emotional reactivity with minimal coping

• Avoidance by others because of intensity of emotions

12

Epidemiology

• 0.5 to 2.7% (1.6 median) prevalence in general populations

• In clinical populations, BPD is the MOST FREQUENTLY diagnosed personality disorder --> due to self harm and emergent care

• Mostly women

• Mean age of diagnosis is mid-20s

• Coexistence with other disorders (mood, substance abuse, eating, dissociative and anxiety disorders)

• Estimated suicide rate up to 10%
--continually pay attention to this; VERY HIGH suicide rate for BPD

13

Etiology: Biologic Theories

1. CNS dysfunction and possible structural changes (LIMBIC system and FRONTAL LOBE)
• associated with affective instability, transient psychosis, impulsive, aggressive, & suicidal behavior

2. Possible INCREASED DOPAMINE as reason for transient psychotic states including derealization, paranoid thinking, dissociation & depersonalization

14

Etiology: Psychoanalytic Theory

-Does NOT achieve separation-individuation: when a child develops a sense of self & a permanent sense of significant others

-Failure to achieve OBJECT CONSTANCY, integration of good and bad in the same person, thus relating to others as a series of disconnected parts leads to SPLITTING (ex. friends, treatment team, etc)

-Projective identification: falsely attributes their own unacceptable feelings to others.

15

Etiology: Psychological

– Maladaptive cognitive processes (cognitive schema)

– Abandonment depression

16

Etiology: Biosocial Theory

(Marsha Linehan PhD.)

– Emotional dysregulation (unable to control)

– Emotional vulnerability (innate)

– Invalidating environment

17

Nursing Assessment

• Physical indicators of self-injurious behaviors
– Cutting, scratching, or swallowing
– Ask specific questions about types of behaviors, antecedents, consequences

• Pharmacologic assessment, including over the counter, prescription and illicit drugs

• Inhibited grieving

• Eating disorders

• Mood disorders

• Anxiety disorders

• Cognitive disturbance
– Dichotomous thinking
– Dissociation and transient psychotic episodes

• Social support systems

• Interpersonal skills

• Self-esteem and coping skills

• Family assessment-relationships, support

18

Assessing Behavioral Pattern

• Emotional vulnerability
• Self invalidation
• Unrelenting crisis
• Inhibited grieving
• Active passivity
• Apparent competence

19

Assessing Response Patterns

• Labile moods
• Anger problems
• Interpersonal issues
• Chaotic relationships
• Fears of abandonment
• Self-dysregulation
• Identity disturbance
• Emptiness
• Affective/ Behavioral/ Cognitive dysregulation
• Impulsivity
• Dissociative responses
• Paranoid ideation
• Parasuicidal behavior or threats

20

Parasuicidal Behavior

• Creates frequent hospitalizations, very frustrating for others

• Seems manipulative, but can end in death, so careful assessment and treatment must be done

21

Nursing Diagnosis

• Risk for self-mutilation
• Disturbed thought process
• Ineffective coping
• Personal identity disturbance
• Low self-esteem
• Powerlessness
• Post-trauma response
• Sleep disturbance
• Inadequate nutrition
• Spiritual distress
• Anxiety
• Grieving

22

Interdisciplinary Treatment

• Inpatient requires the WHOLE mental health team
– Discharge, transfer or staff vacation may
activate abandonment depression

• Dialectic Behavior Therapy (DBT) & Skills Training

23

DBT Therapists

• On call for patients but stay on the phone just FIVE minutes to assist and coach patients through skills rather than dependency

24

Dialectic Behavior Therapy

• Form of Cognitive Behavior Therapy

• Requires monitoring and commitment by patient

• Core interventions include:
– problem solving
– exposure techniques (gradual/relaxed
– skill training
– contingency management ("if this happens, what are you going to do?")
– cognitive modification

25

Evidence-Based Treatment for Borderline Personality Disorder

DBT produces lower attrition, fewer and less severe episodes of parasuicidal behavior, and fewer hospital days.

18 months partial hospitalization with group & individual psychotherapy reduced:
• suicide attempts
• acts of self-harm
• psychiatric symptoms
• inpatient days.
--> It increased the quality of social and interpersonal functioning.

26

DBT Goals of Skills Training: Mindfulness Skills

• Mindfulness skills: (paying attention for a purpose) to decrease identity confusion, emptiness, cognitive dysregulation

27

DBT Goals of Skills Training: Interpersonal Skills

to decrease interpersonal chaos, fear of abandonment

DEARMAN

28

DBT Goals of Skills Training: Emotional Regulation Skills

to decrease labile affect and excessive anger

29

DBT Goals of Skills Training: Distress tolerance skills

to decrease impulsive behaviors and suicide threats

30

DEARMAN

• Describe the circumstances

• Express your feelings about it

• Assert what you want

• Reward the person in advance

• Mindful-don’t be distracted, focus

• Appear confident. Don’t be aggressive

• Negotiate. Be willing to “give to get”

31

emotion regulation skills

Opposite to emotion action
• Fear (urge to hide)- go forward
• Sadness (retreat)- get active
• Shame (hide, fix)- apologize or do it again
• Anger (strike out)- gently avoid, be decent

32

Mindfulness

• This is the intersection of the rational mind and emotions. Based on Eastern philosophy.

• Put all your attention on just one thing, describe it, just the facts, participate in it

• Ex. rubbing the arm of a wooden chair

33

Distress Tolerance Skill --> Self Soothe with the 5 senses

• Vision: look at a flower, watch a candle burn, look at nature

• Hearing: soothing music, sounds of nature, sing your favorite song

• Smell: bake bread, boil cinnamon, wear your favorite perfume, smell flowers

• Taste: soothing drink, favorite food, savor the taste slowly

• Touch: bubble bath, sit in a comfortable chair, put on lotion

34

Nursing Interventions: Nurse-Patient Relationship

– Establish trust
– Recognize abandonment vs intimacy
– Plan any terminations carefully
– Establish personal boundaries and limitations
– Remain neutral to client’s comments, being neither flattered nor offended

35

Nursing Interventions: Model Self-Respect by...

– Observing personal limits
– Being assertive
– Clearly communicating expectations

36

Other Nursing Interventions

• Develop self & staff awareness to avoid counter- transference

• Validate positives; avoid confrontation if possible

• Management of dissociative states, transient psychosis
– Determine triggers & cues, manage stress, safety, meds

• Teach distress tolerance skills when not psychotic

• Abdominal breathing

37

Preventing Transient Psychosis

Teach Wise mind ACCEPTS

A-activities
C-contributing to others
C-compare with less fortunate
E-emotions that are opposite
P-push away from situation
T-thoughts other than current ones
S-sensations that are intense (ex. ice)

38

Pharmacologic Interventions

• Reinforce that the meds will assist the biological portion of the illness but the patient needs to work on the social & psychological.

• Controlling emotional dysregulation
– Antidepressants- minimal help

• Reducing impulsivity
– Anticonvulsants (& sometimes Lithium)

• Managing transient psychotic episodes
– Antipsychotics

• Decreasing anxiety-Buspirone (Buspar) (benzodiazepines may worsen & cause agitation)

39

Managing Self Injurious and Suicidal Behavior

Prevention and treatment of self-injury
– Figure out what leads up to injury
– Help develop strategies to prevent destructive behavior
– Avoid touching or restraining those who have been physically, sexually abused

The current professional trend is to focus on supportive plans rather than contracting not to kill oneself.

Commitment to treatment

Contingency plans

Treat injury avoid excess attention to it

Pay more attention to pt during stable times, teach skills

40

Nursing Interventions

Cognitive interventions:

-Assist with emotion regulation-tolerate feelings without acting out

-Communication triad
1. “I” statement to identify feelings
2. Nonjudgmental statement of the emotional trigger
3. What the patient would like done differently to restore comfort to the situation

-Thought stopping
• Deep breath
• Visualize stop sign or say stop
• Replace with a positive alternative (self affirmation)

-Challenge dysfunctional thinking (schema)

41

Name 2 people who suffered from BPD.

Princess Diana and Marilyn Monroe