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Borderline Personality Disorder


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									Personality Disorder
Personality Disorders

 Client suffers from lifelong, inflexible and
  dysfunctional patterns of relating and behaving
 Patterns are excessive and interfere with daily
 Relationships
      Dysfunctional patterns and behaviors of the client
         Cause distress to others

         Client does not recognize dysfunction and only
          becomes distressed when others react to them
   Behavioral Characteristics
 Personality Disorder is a way of relating
  to the world. An enduring pattern of
  acting and responding,
 Narcissism- speak and act as if their own
  needs are paramount. Normal in
 Annoying: Tend to “Get under your skin.”
 Problems in interpersonal situations.
             Personality Disorder

 Personality Disorders are difficult to treat
     Most are not in Psychiatric Hospitals
    May be admitted to an inpatient facility but must have an
      Axis I diagnosis also (alcoholism, depression and anxiety)
    The most common personality disorder inpatient is
      Borderline Personality Disorder
    Most are treated outpatient in individual or group therapy
 May be in drug treatment center
 Axis II Diagnosis
    Used to designate
            Personality disorders or traits
            Developmental Disorders
            Habitual use of Particular defense Mechanism
 Anxiety: Varies in the different clusters.
      Behavior is their way of coping with anxiety
       and the individual does not consider how
       their behavior will effect others.
 Cognitive issues:
      Rigidity of responses often causes
       individual to not reach their potential.
      Inflexibility leads to mistakes in judgment
       making them prone to job problems.
 Believe problems in their lives are other
  people’s fault or the rest of the world.
 History of broken relationships, family
  and marital problems.
 Alcoholism and drugs
 Age of onset; Adolescence, tend to
  decrease in middle age. What is normal
  in adolescence is not later.
Grouped by the Three Clusters
of Behavior in the DSM IV TR

 Cluster A
    Exhibit odd and eccentric behaviors; includes
     schizoid, schizotypal, and paranoid disorders.
 Cluster B
    Exhibit dramatic emotional and erratic behaviors;
     includes Narcissistic, histrionic, antisocial, and
     borderline disorders.
 Cluster C
    Exhibit anxious fearful behaviors; includes
     dependant, avoidant and obsessive-compulsive
     Gender and Personality
 Female: greater percentage of
  Borderline or Histrionic

 Male: Greater Percentage of Paranoid,
  Schizoid, Antisocial, and Narcissistic
This Presentation

1. Cluster A will be reviewed first
2. Cluster C will be reviewed second
3. Cluster B will be the most
   comprehensive review
         Borderline Personality Disorder will be
          reviewed last in this presentation. This
          disorder is the most common Axis II
          disorder encountered by the Mental Health
                    Cluster A
 Characteristics: odd, eccentric behavior,
  suspicious ideations, and social
  isolation. Know this cluster as a group
  (do not have to recognize each
     Paranoid
     Schizoid
     Schizotypal
                        Cluster A
 Schizoid                          Schizotypical
      Lacks desire to be                Ideas of reference
       close to others                   Magical thinking or odd
      Lacks close friends                beliefs
      Solitary activities               Unusual perceptual
      Little interest in sexual          experiences including
       activity                           bodily illusions
      Avoids activities                 Odd thinking and
      Appears cold and                   speech
       detached                          Suspicious; social
      Appears indifferent to             anxiety
       praise or criticism               Few close
 Behaviorally; often alcoholic, secretive,
  argumentative and fearful of people.
  Hyper-alert to danger and rarely seek
 Angry, Controlling, and judgmental.
 Cognitively; very guarded “none of your
 Difficulty in intimate relationships. Cold
  aloof manner, Often litigious.
 Holds grudges; lacks trust in others
                     Cluster C

 Dependent Personality Disorder
    Pervasive, excessive need to be taken care of
       Submissive and clinging
       Fears of separation
       Avoids responsibility
       Expresses helplessness

      Interventions
          Nurse assists client to increase responsibility in
           daily living
          Needs assistance with anxiety
          Teach assertiveness and verbalization of feelings
                         Cluster C
 Avoidant Personality                 Obsessive Compulsive
   Disorder                             Personality Disorder
       Severe shyness and                  Perfectionist and
        avoidant behavior                    inflexible
       Socially uncomfortable              Preoccupied with trivial
        and withdrawn                        details and procedures
       Nurse helps by assisting            Difficulty expressing
        the client in setting small          warmth and kindness
        goals                               Having fun is difficult
       Discusses fears and                 Nurse helps by assisting
        feelings prior to meeting a          the client to explore
        goal                                 feelings and try new
                                            Teach that making
                                             mistakes is normal to
                                             decrease need for
                    Cluster B
 Characteristics are; impulsive, dramatic
  behavior, intolerance of frustration, and
  exploitative interpersonal relationships. (Know
  Antisocial Borderline and Narcissistic)
      Histrionic
      Narcissistic
         Also occasionally seen in inpatient treatment)
      Antisocial
      Borderline
         (most often Personality Disorder seen in
          inpatient treatment)
Cluster B
   Histrionic                              Narcisistic
        Dramatizes and draws                    Grandiosity and exageration
         attention to self                        about accomplishments
        Feels helpless and needs                Needs to be admired
         reassurance                             Indifferent to criticism
        Extroverted and thrives on              A sense of entitlement
         attention                                (should be rewarded despite
        Lacks insight                            the lack of effort or work)
        Temper tantrums, outbursts              Lack of empathy for others
         of anger over minor events              The nurse uses supportive
        The nurse gives positive                 confrontation of
         reinforcement for acts that              discrepancies; limit setting
         are focused on others                    and a consistent approach
        The nurse facilitates
         independence in problem
         solving and daily functioning
Antisocial Personality Disorder

 Pattern of disregard of the rights of others
      Poor boundaries
         Does not have a good understanding of where
          they stop and the next person begins.
 History of disordered life functioning
      Parent child relationship is unstable
         Vacillates between permissiveness and severe
         Poor understanding of limits on there behavior
          because limits are very inconsistent
 Genetic predisposition
 Predominant childhood characteristic of lying, stealing and
   being truant.
       High correlation between this disorder and substance abuse.
       Conform to rules when it suits their purpose.
 Express themselves easily, but with little personal involvement.
       Professes undying love one moment rejection the next.
        Irritating , aggressive, low guilt.
       Often in the criminal justice system and NOT the Mental Health
            Example of lack of guilt or remorse:
                  Client will state they needed to rob a store with a gun because of
                   their low income and inability to support themselves.
                  The reason why the are in jail is because they were caught. It is
                   the mistakes they made that led them to be caught that is the
                   problem; NOT the crime.
Antisocial/ Cognitive & Socially
 Initially appear to be charming and intellectual
    Smooth talker
    Deny and rationalize their behavior
 Egocentric and grandiose
 Confident everything will work out
 Ego-syntonic; Cannot delay gratification and
    make no long range plans
   Unable to sustain close relationship.
   Sex life is impersonal and impulsive.
   Quick anger, lack of guilt, abusive
   Hospitalized to avoid the law
Treatment of Anti-social Personality

 Drug Treatment center, jails and prisons
 Essential for staff to agree on rules and
  stick with them.
 Will try to play one staff or shift against
 Best form of Treatment; Peer counseling
  and self-help groups, like AA.
Borderline Personality
     Borderline Personality
  Disorder DSM IV TR Criteria

 Unstable, intense relationships characterized by
  over-idealizing and devaluation others
      Intense ambiguous feelings.
      This is when two feelings such as love and hate are
       present at the same time
      Client with BPD cannot resolve feelings that others
       are not perfect and cannot meet all of their needs
 Impulsiveness and self-destructive
    Substance abuse
    Sexual promiscuity
       These behaviors help them to feel better for a
        short period of time
       DSM IV TR Criteria Cont.

 Recurrent suicidal threats & gestures
      Self-Injurious Behavior (SIB)
 Affective instability
      anxiety to depression
 Inappropriate displays of anger
   DSM IV TR Criteria Cont.
 Marked persistent identity disturbance in
  two areas: career, friends, values
 Chronic feelings of emptiness and
 Frantic efforts to avoid abandonment
 Transient, stress related, psychotic
  symptoms or sense dissociative.
         Etiology of Borderline
         Personality Disorder
 Masterson’s theory: Child tries to separate and
    mom withdraws love. Child clings and mom
    rewards. Child unsure of affection. Fathers may
    be distant, alcoholic or unavailable.
   Neglect of the child
   Split occurs: Good me-Bad me
   Invalidating, chaotic environment
   No object constancy (consistency in care giving
    of the child). Develops a low tolerance of
   75% of clients with BPD are women and victims
    of childhood sexual abuse
             Issues for Borderline
 Identity            No sense of who
                         they are
                        Feel very empty
                        See themselves as
 Intimacy
                         all good or all bad
                        Very needy
                        fearful
                        abandonment fear
 Self-mutilation
    Clients discuss feelings of depersonalization
    To prove they are alive, they cut until they feel pain
    May also state that the physical pain alleviates the
     emotional pain
 Anhedonia
    Cannot enjoy life in conventional way
 Impulsiveness
    Cannot soothe self; very intense emotions
    Try to teach coping skills.
  Borderline Personality Disorder
     and Countertransference
 Positive Countertransference
    Lack of a sense of identity and inability to meet
     their own needs
    Look to others as being “all good” and seek to get
     others to meet their needs
 Negative Countertransference
    Other people will eventually fail in attempting to
     meet all the needs of an individual with BPD
    Results in malice/rage
    Aversion: More serious problem
    Working with these problems is the responsibility of
     an advanced practice Health Care Provider
 Clients have long-term issues of abuse and
 An advanced practice Health Care Provider can
  assist the client in talking about these events in
  individual or group therapy
 The nurse stays in the “here and now”
      This is very therapeutic
      Can assist the client in identifying how their
       behavior results in unwanted responses from
      Helps the client to identify coping strategies and
       understand the disorder through teaching
           Group Therapy
 Clients make good group members; can
  be very insightful for others
 Decreases transference issues.
  Feedback from group can be helpful in
  dealing with unrealistic expectations.
 Attention seeking behavior and
  entitlement issues are dealt with better in
 AA, ACOA, groups are very useful.
Nursing Interventions
   Safety
         Clients in the acute care setting are in crisis
         Keep environment free of contraband
         Assess for suicidal thoughts frequently
         Observe closely
   Limit Setting
         Maintain clear boundaries
   Therapeutic Relationship
         Acknowledge emotional pain
         Offer support and empower to understand and change dysfunctional behavior
                Review: What happened? How did you react (behave)? How did that work for you? What can you do
                 next time?
   Prevent Splitting
         Be consistent
         Follow all rules of the unit
         Follow the client’s treatment plan
   Prevent Triangulation
         Clients will try to get the nurse to engage in complaints about another staff (a third person)
         Refer the client back to the staff they have a problem with
         Offer to talk about the client
Treatment and Individual Therapy
 Working with the client to change behaviors can
  be like a roller coaster for the health care provider.
 Client trusts is improving, then panics fearing
 Experiences abandonment depression, clings to
  others and then distances.
 Clinging: the therapist is all good

 Distancing: anger; the therapist is all bad
BPD: Ups and Downs

    Example:
             Client appears better
             Ready for discharge

             Fears abandonment

             Makes suicide gesture
         This is not personal (it is not the nurse’s responsibility;
          this behavior is generated by a fear of abandonment
         Client believes they are getting worse and needs
          reassurance and reminder of progress…regression can
          be temporary
         The nurse needs to be OBJECTIVE not emotional…
          MATTER of FACT in the approach to the client
Interventions and Milieu
 Contracts with specific goals and
  responsibilities are important.
 Never discuss another staff member with
  these client
 Goal is “reintegrate the split”
 Can remind client of the other side (all
  people have both good and bad
          Treatment and Milieu
 Hold Client responsible for actions while
  maintaining positive expectations. Have
  consequences identified on plan and
  stay with them.
 Realize this is client’s illness, behavior
  are not personal.
 Role is with day to day activities. One
  person process issues with client
National Education Alliance for
Borderline Personality Disorder
 New group that has begun
 Had a national conference in Houston,
  Feb. 2006.
 Latest research on pathophysiology
 Uses an educational approach, family
 Believes trauma is important in the
  development of BPD
The End

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