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Managing Care for Persons with
Personality Disorders
Phyllis M. Connolly PhD, APRN, BC, CS
Professor of Nursing
San Jose State University
[email protected]
408-924-3144
Questions to Consider
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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?
Qualities of Healthy
Personality
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Positive & accurate
body image
Realistic self-ideal
Positive self-concept
High self-esteem
Satisfying role
performance
Clear sense of identity
Personality “persona”
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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
Why Do We Behave the Way We Do?
Affective
(feelings)
Behavioral
(actions)
Cognitive
(thoughts)
Interacting System’s Human
Behavior
Stress: A person-environment
interaction
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Sources
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Biophysical
Chemical
Psychosocial
Cultural
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Heat-cold
noise
radiation
exhaustion
physical inactivity
alcohol
nicotine
caffeine
Stress Model
External
stimuli
Emotional
feelings
Genetic
equip
Past
experience
Internal
stimuli
Individual
perception
of stressorconscious or
unconscious
Central
nervous
system
arousal
Peripheral
physiological
changes
Stress
Responses to Stress
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Demanding
situation--stressor
Internal state
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Tension
Anxiety
Strains
Anxiety
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Normal—feeling response to a threat to
one’s safety, well-being, or self-concept
Characteristics
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Appropriate to the threat
Anxiety can be relieved
Can cope either alone or with some
support
Problem solving slow but still usable
Abnormal Anxiety
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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
Psychosis
Brief Reactive
Psychosis
Panic
Panic
Dread
Loneliness
Rituals
Avoidance
Psychosomatic
Heartpound
Acute and Chronic
Palpitations
Shakiness
Butterflies
All senses alert
Calm
Daydreaming
Normal
Sleep
RELATIVE SEVERITY OF ANXIETY
(Haber p.437)
Definition: Personality
Disorders
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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
Personality Disorders
Common Characteristics
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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
Prevalence Personality
Disorders
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Approximately 10 - 13% of general population
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70 - 85% Criminals have a personality disorder
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60 - 70% Alcoholics
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70 - 90% Drug abusers
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40 - 45% Persons with psychiatric disorder also
have a personality disorder
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Frequently referred to as “treatment-resistant”
Videbeck, 2001, p. 416
Prevalence Personality
Disorders
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Paranoid
Schizotypal
Schizoid
Antisocial
Borderline
Histrionic
Narcissitic
Dependent
Avoidant
Obsessive Compulsive
.5 - 2.5%
3%
Unknown
3% (males)
2%
2-3%
<1%
Unknown
1%
1%
Etiology: Personality Disorders
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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
Personality Disorders DSM-IV :
Clusters: A, B, C
Cluster A, Odd,
Eccentric
 Paranoid Schizoid
 Schizotypal
Cluster B, Dramatic,
Emotional, Erratic
 Antisocial
 Borderline
 Histrionic
 Narcissistic
Cluster C, Anxious
Fearful
 Avoidant
 Dependent
 ObsessiveCompulsive
Cluster A Personality Disorders: Odd or
Eccentric
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Paranoid
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Schizoid
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distrustful, suspicious, lacks trust
in others, bears grudges,
accuses others of harm or plots
detached from others, “loner”
little to no sexual intimacy, little
involvement in activities, lacks
close friends, cold or aloof
Schizotypal
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Ideas of reference, odd beliefs,
behaviors, & speech, suspicious,
inappropriate affect, lacks close
friends
Cluster B Personality Disorders
Dramatic, Emotional Erratic
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Histrionic
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Narcissistic
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Arrogant, needs admiration, entitled,
exploitative, grandiose, lacks empathy,
preoccupied with power, beauty,or love
Antisocial
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seeks attention, provocative behavior, easily
suggestible, dramatic, flamboyant
lies, disregards the rights of others
Borderline
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Intense anger, suicidal, sees all good or all
bad, impulsive
Cluster C Personality Disorder:
Anxious, Fearful
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Avoidant
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Dependent
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Avoids others and activities, fears
rejection, feels inhibited and
inept
Passive, indecisive, fears loss of
approval, difficulty doing things
alone, fails to assume
responsibility
Obsessive-Compulsive
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Perfectionist, controlling,
inflexible, overconscientious,
stubborn, miserly
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
Obsessive Compulsive
Personality Disorder: Criteria
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Preoccupied with
details, rules, lists,
organization
Perfectionism
interferes with task
completion
Too busy working
for friends or leisure
activities
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Unable to discard
worthless objects
Others must do
things their way in
work
Reluctant to spend
and hoards money
Rigid and stubborn
Nursing Interventions: OC
Personality Disorder
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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
Borderline Personality DSM-IVTR, 301.83
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Impulsive & self-damaging behaviors
 unsafe sex, reckless driving, substance abuse,
 ￪ ED vists
Recurrent suicidal or self-mutilating behaviors;
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￪ death rates
Transient quasi-psychotic symptoms during stress
Chronic feelings of emptiness
or boredom, absence of
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self-satisfaction
Intense affect--anger, hostility, depression and/or
anxiety
Borderline Personality:
Etiology
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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
Prevalence Borderline
Personality Disorders
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Approximately 2% of general population, 6 million
Americans (NIMH, 2001)
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High rate of self-injury without suicide intent
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8% - 10% will commit suicide
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Need extensive mental health services, account for 20% of
psychiatric hospitalizations
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69% are also substances abusers
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With help, many improve over time & lead productive lives
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Frequently referred to as “treatment-resistant”
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)
HEALTH PROBLEMS
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May have an infection
Respiratory illness
Diabetes
Thyroid problems
Nutritional imbalances
Appendicitis
Other disease processes
May trigger other symptoms
Nursing: BPD
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Therapeutic use of self, primary nursing
helpful (consistent clinical supervision
critical)
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Focus on strengths
Maintain Safety
Facilitate participation in care
Select least restrictive environment
Facilitate behavior change
Help to assume responsibility for behaviors
Borderline Personality: Ego
Defense Mechanisms
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Splitting
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Dissociation
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Separation of mental or behavioral processes from the rest of
the person’s consciousness or identity
Idealization
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Seeing external objects all good or all bad
A form of manipulation
Rapid idealization-devaluation
Viewing others as perfect, exalting others
Projective identification
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Placement of feelings on another to justify own expression of
feelings
PSYCHIATRIC DISORDERS:
ILLNESSES OF MENTAL FUNCTION
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FIVE MENTAL FUNCTIONS
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THINKING (COGNITION)
FIVE SENSES (PERCEPTION)
FEELINGS, HAPPY, SAD, ANGRY
(EMOTIONS)
BEHAVIOR (RESPONSES TO COGNITION,
PERCEPTION, & EMOTIONS
SOCIALIZATION
Ego Functions
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Control & regulate instinctual drives
Relation to reality
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Sense of reality
Reality testing
Adaptation to reality
Object relationships
Defensive functions
Reality Testing
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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
Object Constancy
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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
Manipulation
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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
Manipulation: Nursing
Interventions
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Establish therapeutic relationship
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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
Interventions Cont.Manipulation
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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
Nursing Roles: BPD
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Provide structured environment
Serve as an emotional sounding board
Clarify and diagnose conflicts
Assess for other health problems
Treatment BPD:
Dilectical Behavioral Therapy
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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)
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Targets
 ￬ high-risk suicidal behaviors
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￬ 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
DBT Continued
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Weekly 2.5 hr group therapy focused on
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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
Evidence-Based Practice:
Remission BPD
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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)
Psychopharmacology
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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
Important to monitor for side effects:
sedation; diabetes; weight gain
Risk Management Issues
(APA) General
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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
You should have an
emergency plan for handling a
suicide gesture or ideation.
Someone needs to stay with
the person at all times
The person is
experiencing strong
feelings of
abandonment,
loneliness, guilt and
hopelessness
Self-Harm
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Way of coping with deep distressing emotions
and feelings
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Cutting
Burning
Non-lethal overdoes
Ingesting or inserting harmful objects
Eating disorders
Excessive drinking and drug abuse
Suicide not always the intent
Self-Care Deficit
Ego functioning which does not handle painful
affects or maximize protective activity
 Interventions
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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 healththreatening situations
Compton, 1989
Self-Injury
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Body piercing
Eye brow tweezing
Hair removal
Nail biting
Hair twisting
tattos
Risk Management: Suicide
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Monitor & document risk
assessment
Actively treat comorbid
axis I disorders eg.
major depression, bipolar
disorder, substance
abuse/dependence
Consultations
Antisocial Personality
DSM IV 301.7
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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
Comparisons Personality Disorders &
Mental Symptoms & Treatments
Disorder
Hallucinations
Delusions
Drug
RX
0
Therapy
Antisocial
Only if substance Only if
abuse
substance
abuse
Borderline
Only if psychotic
May
X
Behavioral
DBT
Obsessive
No
May
X
Insight,
cog. Behav.
Behavioral
Nursing Interventions:
Parasuicide
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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
Identifying Triggers
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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
Stress Management
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Crisis Intervention
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Deep breathing
Self talk
Time out
Visualization
Leaving the situation
Talking to someone
Music
Prevention
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Diet & nutrition
Exercise & physical
activity
Self-help groups
Having fun
Playing
Massage
Progressive relaxation
Assertiveness training
Interventions Dealing With
Anger
Verbal
Non Verbal
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Calm unhurried
approach
Do not touch
Protect other
people
Respect personal
space
Use active listening
Be aware of
personal feelings
Use time-out/oneone in quiet area
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Initially ignore derogatory
statements
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
Communication Techniques
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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
Safety Guidelines: Violence
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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
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Avoid letting client
come between you &
door
Remove yourself
from situation &
summon help if
violence
Avoid dealing with
violent person alone
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”
SELF-EVALUATION: KEEP A
LOG
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Situation & Date
Behavior, body cues, affect, physical
reactions, feelings
Behavioral Response
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What I did or said
What I would like to have done or said
What prevented you from doing what
you wanted?
Self-Care Staff
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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
Thank you
“Your care makes a difference in
people’s lives”