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Personality Variances: BORDERLINE PERSONALITY DISORDER

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Claire Sogocio

on 28 February 2014

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Transcript of Personality Variances: BORDERLINE PERSONALITY DISORDER

Personality Variances:
BORDERLINE PERSONALITY DISORDER

Personality disorders are characterized by changes in behaviour, social interactions, mood, and impulsivity that affect the individuals ability to function in daily living. Personality disorders are separated into clusters according to specific characteristics:
Implications of the
Mental Health Act
By: Claire S., Maricel D., Aklil B., Maggie F., Melissa V.
Personality Disorders
A
B
C
CLUSTER
A
Social avoidance or low sociability issues (i.e. Paranoid PD, Schizoid PD, and Schizotypal PD)

CLUSTER
B
Highly emotional and dramatic in social situations, and react to feelings with impulsivity (i.e. Antisocial PD, Borderline PD, Histrionic PD, and Narcissistic PD)
CLUSTER
C
Very cautious and fearful (i.e. Avoidant PD, Dependent PD, Obsessive-Compulsive PD)

SYMPTOMOLOGY
- Instability in interpersonal relationship, self-image, and emotions
- Impulsivity
- Frantic efforts to avoid real or imagined abandonment
- Recurrent suicidal behaviours
- Identity disturbance
- Chronic feelings of emptiness
- Transient, stress-related paranoid thoughts
- Inappropriate anger
(CMHA, 2004)
EPIDEMIOLOGY
- Onset is early adulthood, but the symptoms have usually been present for many years prior to diagnosis
- Diagnosis is made after the individual is 18
- 75% of individuals diagnosed are female
- Affects roughly 2% of the general population
- Symptoms usually decrease as the individual gets older


PREDISPOSING FACTORS
DSM-5 CRITERIA
A. Significant impairments in personality functioning manifested by:
B: Pathological personality traits in the following domains:
- Negative Affectivity, characterized by:
a. Emotional Liability
b. Anxiousness
c. Separation Insecurity
d. Depressivity
- Disinhibition, characterized by:
a. Impulsivity
b. Risk-taking
- Antagonism, characterized by:
a. Hostility

C: The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
D: The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.
- Impairments in self-functioning (a or b)
a) Identity
b) Self-direction
- Impairements in interpersonal functioning
(a or b)
a) Empathy
b) Intimacy
(APA, 2012)
(CMHA, 2004).
(Grohol, 2007).
(APA, 2012)
E: The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (i.e. a drug of abuse, or medication) or a general medical condition (i.e. severe head trauma).

- American Psychiatric Association, 2012. DSM-IV and DSM-5 Criteria for the Personality Disorders. [online] Retrieved from: http://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/610_clinica_cuadrosfront_psicosis/material/dsm.pdf [Accessed February 15, 2014].
- Austin, W., & Boyd, M. (2010) Psychiatric & Mental Health Nursing for Canadian Practice.
(2nd Ed.). Philadephia, PA: Lippincott Williams & Wilkins.
- Canadian Mental Health Association, 2004. Personality Disorders. [online] Retrieved from: http://www.cmha.bc.ca/get-informed/mental-health-information/personality-disorders
- Davidson, G., Blankstein, K., Flett, G., Neale, J., (2010) Abnormal Psychology. Mississauga, Ontario: John Wiley & Sons Canada Ltd
- DBT Centre of Vancouver (2011). Fees. In Therapy Services. Retrieved from http://www.dbtvancouver.com/services/ [Accessed February 18, 2014]
- Grohol, J.M., (2007). Borderline Personality Disorder. Psych Central. [online] Retrieved from: http://psychcentral.com/lib/symptoms-of-borderline-personality-disorder/0001063 [Accessed February 15, 2014].
- Dryden-Edwards, R. (n.d.). Borderline Personality Disorder. MedicineNet.com. [online] Retrieved from: http://www.medicinenet.com/borderline_personality_disorder/article.htm
- Grant, B.F., Chou, S.P., et al (2008). Prevalence, Correlates, Disability, and Comorbidity of DSM-IV Borderline Personality Disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2008 April; 69(4): 533–545. [online] Retreived from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2676679/?_escaped_fragment_=po=27.7778
- National Institute of Mental Health .(n.d.). Borderline Personality Disorder. Retrieved from http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml
- Nauert, R. (2009). Brain Scans Clarify Borderline Personality Disorder. Psych Central. Retrieved on February 28, 2014, from http://psychcentral.com/news/2009/09/04/brain-scans-clarify-borderline-personality-disorder/8184.htm
- Shea, C. (1998). Psychiatric Interviewing: The Art of Understanding. (2nd Ed.). Philadelphia,
PA: W.B. Saunders Company.

References
THE
5
VARIABLES
Physiological
- Multiple lacerations due to cutting
- Alcohol and marijuana use
- Overdose on prescription medication
- Risk for STI
Psychological
- Low self esteem
- Borderline personality disorder
- Frequent mood swings
- Severe emotional reactions
- Dependent personality traits
- Para-suicidal behaviours
- Poor coping
Sociocultural
- Low socio-economic class
- Unstable job
- No social support
- Societal stigma towards mental illness
Developmental
- Childhood trauma
- Estranged 16-year-old daughter
- Divorced
- No stable job
- 34-year-old
- Diagnosis at age 19
Spiritual
- Grew up in a Catholic household
- Daughter brings meaning to her life
- Finds joy in music and art
Professional, Ethical & Legal Issues
- Required frequent mental health services
- Borderline Personality Disorder characteristics can often lead to the patient being labelled as "difficult"
- Countertransference can occur
- Nurses may find themseves in conflict with each other/multidisciplinary team from manipulation & splitting by the patient
- Often sexually active & have multiple sexual partners
Shirley is a 34 year-old female that has been connected to your mental health team for the past 10 years; she was diagnosed with borderline personality disorder at the age of 19. Throughout your time spent with her, you have developed a vast collateral regarding her history and experiences. She was sexually abused as a young girl, and was witness to a volatile relationship between her parents who refused to separate due to their highly Catholic background. The client has had multiple sexual partners over the past 20 years, yet finds difficulty holding close relationships (intimate or platonic) and believes this is because she is unlovable and that nobody likes or understands her – she does have an estranged 16 year old daughter (who is in the custody of the father). She has a long history of abusing alcohol and marijuana to cope with distress, and has recently overdosed on her prescription medications (resulting in her most recent hospitalization). Over the past 15 years, your client has been hospitalized 23 times for major depression, anxiety, and parasuicidal behaviours. In a rountine appoinment with you, you notice that she has multiple superficial lacerations on her forearms and legs - when inquired about what happened she stated that she was "feeling angry, and it made [her] feel better". She then further expressed that her boyfriend had left her and that she was contemplating leaving her job as a stocker- this is a reoccuring situation for the client. In past experiences you know that she acts impulsively in times of stress, and you're worried about her safety. She states that she is feeling safe at this time, and confides in her music and art as a form of release.
CASE STUDY
Universal Experiences
“An apprehension or dread in response to internal or external stimuli that can be experienced in physical, emotional, cognitive and/or behavioral ways”
Environmental
Determinants
Stressors
- Mental illness diagnosis (borderline personality disorder)
- Self-invalidation
- Poor coping
- Substance use
- Anxiety
Stressors
- Divorce
- Strained relationship with family
- Estranged daughter
- Multiple failed relationship
- Lacking positive feedback from significant others
- Low Socio-economic class
- Not having stable job

Universal Experiences
,

Environmental Determinants
, &

Stressors
ANXIETY
(Austin & Boyd, 2010, p.432)
- Shirley grew up in an invalidating environment and this has caused an emotional dysregulation.
- She experiences anxiety frequently due to high sensitivity and inability to cope with negative stimuli

Anxiety
Internal
- Anxiety & Fear of Abandonment
External
- Social stigma
- Relationships with parents
- Community mental health team
- Economic status
Interpreted
- Believes that others will abandon her
- Does not believe that she is good enough for others
Stressors
Intrapersonal
Interpersonal
Extrapersonal
Social
Determinants of Health
Social
Determinants of Health
Employment
- Currently employed as a stocker where interactions with other co-workers are limited
- Has problems maintaining position stability and frequently leaves a job, citing stress reasons
- Struggles to gain senior employment
Income
- Limited financial means
- Receives monthly assistance from PWD Act
- Majority of funds goes towards living costs and DBT therapy
Food Insecurity
Diet fluctuates between TV dinners and fresh produce
Housing
- Lives in 1-bedroom apartment
- Unable to access subsidized satellite apartments
Early Childhood Development
- Grew up in highly volatile home
- Sexually abused as young girl
- Sexuality was scrutinized and condemned by Catholic parents
Education
- Completed High School
- Enrolled in post-secondary but found them too stressful and dropped out
Healthcare
- Accesses short-term hospitalizations and crisis counseling
- Goes to DBT therapy
Social Exclusion
Social Supports
- Mental Health Team
- Friends met at DBT therapy
- Sociable but problems maintaining close, stable relationships
- Demands attention; fears rejection and abandonment
Resources
* http://www.heretohelp.bc.ca/sites/default/files/images/visions-bpd.pdf
* http://www.raminader.com/PDFs%20Uploaded/Wellness%20-%20VancouverCoastalMentalHealthGuide.pdf
* http://heartjunky.wordpress.com/2011/12/21/government-funded-mental-health-care-for-bpd-in-bc-canada/

Nursing Diagnosis #1:

Variance in self-esteem (poor self-esteem) related to Borderline Personality Disorder as evidenced by self-loathing, self-mutilation, inability to maintain close relationships (platonic & intimate), multiple sexual partners, dependency on others, and fear of rejection
Nursing Diagnosis #2:

Variance in coping (self-mutilation) related to inability to handle stress as evidenced by lacerations on arms and thighs, visible scarring, and history of hospitalizations for self-mutilation
Goal:
Patient will identify triggers that result in self-mutilation
* Nurse will encourage client to keep a diary to record her feelings before and after self-mutilation & events leading up to self-mutilation. This will help identify patterns of behaviors and identify triggers and feelings that lead to self-mutilation.
* Nurse will educate client on alternative adaptive coping mechanisms. By doing so, the client will learn how to handle stressful situations and feelings effectively, rather than being self-destructive
* Nurse will help client identify 5 strengths about herself. Doing so will increase the client’s self-esteem and she will learn to love/respect herself, thereby decreasing self-mutilating behaviors
* Nurse will provide client with local resources, such as support groups. This will allow the client to have additional supports in the community
* Nurse will develop a safety plan together with the client. This will provide the client with a plan during times of stress and decrease the chances of impulsive behaviors
* Nurse will discuss risk management with client. By doing so, the client will be informed of the risks and this may decrease her self-mutilating behavior
- Would apply to patients who have
been admitted
involuntarily
(Austin & Boyd, 2010, Shea, 1998)
DBT therapy is not covered by MSP. Individual sessions range from $120-170 per hour and group sessions cost $95 per two-hour group (DBT Centre of Vancouver, 2011)
Approximately
50%
of patients with BPD are unemployed at follow-up, and of those who are employed only a portion are self-sufficient
(Sansone, R., Sansone, L. (2012)
A dietary pattern comprised of processed and “unhealthy” is associated with a higher likelihood of psychological symptoms, anxiety and depression
(Jacka, F. et al. 2010)
BPD develops when people with a biological diathesis for having difficulty controlling their emotions are raised in a family environment that is invalidating
(Linehan, M. 1993)
Gender
Shirley is a female who directs her insecurities and anger issues inwards, towards herself
Men more often display ‘intensive anger’ and end up in the justice system and jail, whereas women more frequently showed ‘affective instability
(Tadic, A. et al, 2009)
(APA, 2012)
COMORBIDITY
Neurological Changes
(Department of Psychiatric Nursing ,2011)
(Department of Psychiatric Nursing ,2011)
(Department of Psychiatric Nursing ,2011)
(Department of Psychiatric Nursing ,2011)
(Department of Psychiatric Nursing ,2011)
RPN ROLES
- Establish Rapport
- MSE
- Safety Risk Assessment
*Assess need for hospitalization
- Communicate with team
- Educate on alternative coping mechanisms
(CMHA, 2004).
(CMHA, 2004).
(CMHA, 2004).
MRI's can detect how the brain of an individual with BPD functions - this helps to explain why these individuals have difficulty regulating their emotions and behaviours.
Certain parts of the brain remain inactive when the individual is faced with a situation that requires them to control their reactions (Nauert, 2009).

Another study elaborates that some individuals have parts of the brain that become overactive when reacting to perceived negativity (NIMH, n.d.).
Comorbidity exists largely in mood and anxiety disorders, substance abuse, and other personality disorders such as narcissistic PD – there is also a high correlation to those with BPD and those that attempt and/or commit suicide.
(Grant, Chou, et al, 2008)
- childhood trauma
-- neglect
-- divorced family
-- sexual abuse
- learning difficulties
- substance abuse
CAUSATION
- causation is still unknown, however it is ofter looked at through a biopsychosocial model.
(Dryden-Edwards, n.d.)
TREATMENTS
1) Assistance from
multidisciplinary team
2)
Multi-modular
approach to medication
3) Various forms of
Psychotherapy
MULTIDISCIPLINARY TEAM
- Psychology
- Social Work
- Psychiatric Nursing
MEDICATIONS
-
Anxiolytics
: buspirone (Buspar)
-
Antidepressants
(SSRI): fluoxetine (Prozac)
-
Mood Stabilizers
: Divalproex Sodium (Depakote)
-
Antipsychotic
:
PSYCHOTHERAPY
- Cognitive-Behavioral Therapy


- Dialectival-Behavioral Therapy

(National Institute of Mental Health, 20**)
Your TURN! -->
(National Institute of Mental Health, 20**)
Multi-modular approach to reduce anxiety, depression, agression, sensitivity, impulsivity, and other emotional dysregulation
(Austin & Boyd, 2010)
Identify/change core beliefs that contribute to false perception of themselves and others
Clients and coaches work together
Focus on interconnected behaviors, not single diagnosis
Clients understanding of dx and active participation
(Austin & Boyd, 2010)
- Work as a multidisciplinary team
- Consistency in care
- Limit Setting
- Assess for withdrawal symptoms
- Direct to resources
ANY QUESTIONS?
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