Borderline Personality Disorder Exam Questions and Answers

Borderline Personality Disorder Exam Questions and Answers Borderline personality disorder: characterized by disruptive pattern of instability related to self-identity, interpersonal relationships, and affects, combined with marked impulsivity and destructive behavior interpersonal relationships, self-identity, affect Unstable Interpersonal Relationships: (hallmark indicator of disorder) Extreme fear of abandonment History of unstable attachments Constantly seeking reassurance and validation Idealize others and establish intense relationships that violate others' interpersonal boundaries, which leads to rejection Intense shame and self-hate follow relationship failures and often result in self-injurious behaviors "Best friends" may be healthcare workers because other relationships don't last. Personality disorder enduring pattern of inner experience and behavior deviates from expectations of culture onset in adolescents or early adulthood Inability to relate with empathy or intimacy Social and occupational impairment Occurs in about 10% of the general population Does not perceive self as having a problem BPD Appear more competent than they actually are Set unrealistically high expectations for themselves and, when not met, feel intense shame, self-hate, and self-directed anger One crisis after another Minimal coping skills Intensity of emotions often frightens them and others Others limit their contact with them because of emotional intensity Feelings of intense anger and profound abandonment are long-term problems Unstable Self-Image: Identity Diffusion No sense of their own identity or their personality is poorly developed Commonly direct their actions in accord with the wishes of other people. Ex: "I am a singer because of my mother." Look for someone else to identify with or be like Unstable Affects Affective instability: rapid and extreme shift in mood Core characteristic of BPD Friends may describe as moody, irresponsible, or intense Limited ability to regulate anger, anxiety, sadness, and disgust Cognitive dysfunctions Dichotomous thinking: "black or white" Thinking can become disorganized: bizarre notions, sometimes delusions and hallucinations Dissociation is common ■ Dissociation: thinking, feeling, or behaviors occur outside a person's awareness. Occurs to a certain extent in all people and can often be adaptive. Ex: coping strategy to avoid disturbing events. Ex: forgetting part of a trip down a familiar road because you're so used to driving it that you don't pay attention. Might be present or appear present but mentally be in different place; used as a coping skill for BPD persons. Behavioral dysfunctions ○ Impaired problem solving: soliciting help from others in a helpless manner ○ Impulsivity: act in the moment and clean up the mess afterward ■ Ex: gambling, spending money, abusing substances ■ Can be physically or verbally aggressive Self-harm behaviors: ○ Present in half of patients with BPD ○ Suicide attempts ○ Parasuicidal behaviors: any nonfatal serious, deliberate self-harm with or without suicide intent ■ Ex: wrist cutting Risk factors for BPD: ● Physical abuse ● Sexual abuse ● Parental loss and separation ● Higher proportion of women ● High rate of comorbid mood disorders in BPD Etiology of BPD: ● Brain dysfunction in the limbic system and frontal lobe ● May be an increase in dopamine that may be responsible for transient psychotic states (delusions, hallucinations) ● May not have achieved the separation-individuation developmental stage Projective identification defensive way of interacting with the world; falsely attribute to others their own unacceptable feelings, impulses, or thoughts; they project these unwanted feelings onto others. Maladaptive cognitive schemas patterns of thoughts that determine how a person interprets events; ex: misinterpretation of other people's actions as wrong or not how a normal person would see things. Emotional dysregulation the inability to control emotions in social interactions; rejection sensitivity, intense outbursts of anger where others could control themselves. Invalidating environment most severe form occurs in situations of child sexual abuse Social situation negates private emotional responses and communication: when core emotional responses and communications are continuously dismissed, trivialized, devalued, punished, and discredited (invalidated) by respected or valued persons, the vulnerable individual becomes uncertain about his/her feelings. Sexual abuse: child told "special secret" -- fear, pain, sadness -- abusing (but trusted by child) adult dismisses child's true feelings Child grows up thinking that his feelings aren't the way they should be; child is told that his feelings are wrong and this can be very confusing. Family Response to BPD: ● BPD individuals often part of chaotic family, but their disorder contributes to the chaos ● Family members afraid to disagree with patient or refuse to meet their multiple needs because they are afraid destructive behavior will follow ● Family members often become "burnt out" and withdraw from the patient -- increases patient's fear of abandonment ● Families often feel captive to these patients Treatment Collaboration of treatment by whole mental health care team Patients see the world in absolutes (dichotomous thinking): treatment team members are categorized as all good or all bad. This is called splitting: used as a defense mechanism; can be challenging to clinicians. They split the members of the health care team into good or bad; prevents treatment. Medications: mood stabilizers, anti-depressants, anxiolytics Psychotherapy: helps manage dysfunctional moods, implusive/self-injurious behaviors Because it's a lifelong disorder, ongoing treatment is necessary. Interventions for BPD 1. Teach nutritional balance: may be on the go that they don't eat and sleep properly. 2. Teach sleep enhancement 3. Prevent self-harm a. Five Senses Exercise: (Linehan, 1993); teaches the patient to find more productive and enduring ways to find comfort. Get in tune with all five senses. i. Vision: go outside and look at the stars or flowers or autumn leaves ii. Hearing: listen to beautiful or invigorating music or the sounds of nature iii. Smells: light a scented candle, boil a cinnamon stick in water iv. Taste: drink a warm, soothing, nonalcoholic beverage v. Touch: take a hot bubble bath, pet your dog or cat, get a massage 4. Less medication is better; use only for target symptoms and for short time periods. assessments 5. Assess for inhibited grieving: unresolved grief that can last for years. What happened that wasn't resolved or that they never talked about? 6. Assess for impulsive behaviors 7. Assess for dichotomous thinking = how they view other people 8. Assess for dissociation and transient psychotic episodes 9. Assess for risk of suicide or self-injury other interventions 10. Model self-respect by observing personal limits, being assertive, and clearly communicating expectations 11. Use Dialectical Behavior Therapy (DBT): this combines cognitive and behavioral therapy strategies a. Core interventions: problem solving, exposure techniques, skill training, contingency management (reinforcement of positive behavior), cognitive modification Skills groups: a. Emotional regulation skills: taught to manage intense, labile moods b. Interpersonal effectiveness skills: development of assertiveness and problem solving skills within an interpersonal/group therapy context c. Mindfulness skills: help the person improve observation, description, and participation skills by learning to focus the mind and awareness on the current moment's activity. Want to focus on the here and now. d. Distress tolerance skills: help the patient tolerate and accept distress as a part of normal life e. Self-management skills: helping patients learn how to control, manage, or change behavior, thoughts, or emotional responses to events Address abandonment issues inform the patient of the length of the relationship with the therapist and remind patient how many sessions are left. i. Explore anticipated feelings about the end of the nurse-patient relationship Establish personal boundaries and limitations: i. State clearly the limits (written rules or contract) and the consequences of violating them. The limits must be consistently maintained. ii. State the day, time, and duration of each contact iii. Note the time during each shift the nurse will talk individually with the patient iv. Respond immediately to boundary violations without taking the behavior personally v. Know how the patient obtains social support; this is important to understanding the quality of interpersonal relationships. Are the person's "best friends" health care workers? vi. Assess ability to relate to others: friendships, frequency of contact vii. How the nurse responds to the patient is usually a clue to how others perceive and respond to the patient. How this client makes you feel is usually the feeling others have when they interact with patient. Patients feel rejected by their natural support system, so they create one within the healthcare system. i. During periods of crisis they call or visit various psychiatric units asking to speak to former caregivers. It may be the only contact, "friends," or people that will put up with them. ii. One of the treatment goals is to help the person establish a natural support network iii. Treatment and recovery involves long-term therapy and continued follow-up