Borderline personality disorder

Question 1

What characteristics are common in cluster B personality disorders?

Answer 1

Erratic and dramatic
Emotional

Question 2

Personality disorders in cluster B

Answer 2

• Borderline personality disorder
• Narcissistic personality disorder
• Antisocial personality disorder

Question 3

Characteristics of cluster A personality disorders

Answer 3

Odd and eccentric, such as paranoid personality disorder or schizoid personality disorder

Question 4

Cluster C personality disorders

Answer 4

Anxious and fearful
Such as: avoidant personality disorder, obsessive compulsive personality disorder

Question 5

Characteristics of BPD/BPD symptoms

Answer 5

• Inability to control emotions
• Impulsive
• Psychosis symptoms when highly stressed
• Dissociation when stressed
• Instability in relationships
• Frantic efforts to avoid being alone (sexually inappropriate behaviours, threats of suicide)
• Self-harm due to intense emotions
• Regressed behaviour (typically child-like regression)
• Derogatory own audible thoughts (often not hallucinations)
• Do anything to avoid going into a black hole when feeling intense emotions (self-harm, sexual inappropriate behaviours, alcohol and drugs, binge eating)
• Splitting

Question 6

What medications are often prescribed to people with BPD?

Answer 6

• Mood stabilisers
• Antidepressants
• Anxiolytics

Question 7

What are treatment modalities for BPD?

Answer 7

• DBT
• CBT
• Medication
• Limit setting
• Behaviour management plans (BMPs)

Question 8

Why do people with BPD “manipulate” those they love?

Answer 8

They have an intense fear of abandonment and rejection. They therefore use manipulation tools in order to retain close relationships

Question 9

What is splitting?

Answer 9

• Seeing someone as 100% good and then 100% bad
• A perceived act of rejection or abandonment can cause people with BPD to turn on someone close to them and only see them as bad resulting in the relationship to end

Question 10

Impact of splitting in nursing care

Answer 10

• Patients can see some nurses as good and others as bad
• Need to have a consistent message between all healthcare workers, especially all nurses, to reduce the risk of patients splitting and turning on nurses

Question 11

What are ways to reduce aggression or splitting while caring for a patient with BPD?

Answer 11

• Consistent message from all nursing staff
• Set limits with patient, so they are aware of how often they will be have nurses attention etc.
• Ensure documentation is non-judgemental, so don’t use words like “tantrum”, “childish” or “violent”
• Separate person from behaviour - when discussing expectations and their behaviours, ensure you only speak about their behaviours instead of saying that they are bad
• Use good anger management tools (let out anger then show you are in control) so they can express themselves in a healthy way without anger building up to explosive levels

Question 12

Anger management for BPD

Answer 12

1. Visual and constructive
   - Let out anger and then show you are in control (e.g. strip bed and beat up mattress but then make bed)
2. De-escalation
   - Appear confident and calm (display calmness, speak slowly, gently and clearly, lower voice, show you are listening, avoid arguing, avoid staring, create space, calm patient before trying to solve the problem)
   - Non-threatening body posture (Calm and open posture such as sitting or standing without crossing arms, reduce direct eye contact, allow the patient adequate personal space, keep both hands visible, avoid sudden movements, avoid audiences)

Question 13

What is DBT?

Answer 13

• Dialectical behaviour therapy
• First line approach for BPD
• Has the idea that people are likely to react in unhealthy ways when under stress, and assumes that all behaviours are learnt, so people need to learn healthy behaviours and reactions of emotional stress
• Mindfulness, emotional regulation, interpersonal effectiveness and distress tolerance

Question 14

How does mindfulness help people with BPD?

Answer 14

• Assists patients to develop skills to tolerate their behaviour which decreases self-damaging and sabotaging behaviours and increases self respect, goal achievements and healthy behavioural responses to stress
• E.g. helps patient understand that it is normal to feel angry and the feeling of anger does not make them terrible or bad. This results in the patient not overreacting to their feelings of anger when splitting or rejected, so are less likely to self-harm etc.

Question 15

How does interpersonal effectiveness help with BPD?

Answer 15

• Provides strategies to the patient to solve problems with others, and strategies to cope with interpersonal conflict
• E.g. teaching them it is okay to say no, they won’t be abandoned

Question 16

How does distress tolerance help with BPD?

Answer 16

• Emphasises the ability to manage emotional pain in a non-judgemental way
• Reduces unhealthy behaviours in response to intense emotions

Question 17

How does emotion regulation help with BPD?

Answer 17

• Teaches them how to regulate their emotions to prevent such intense emotional reactions and the subsequent unhealthy behaviours in response

Question 18

What are DBT skills for emotional regulation?

Answer 18

• Identifying and labelling emotions
• Identifying obstacles to changing emotions
• Reducing vulnerability to “emotion mind”
• Increasing positive emotional events
• Increasing mindfulness to current emotions
• Taking opposite action
• Applying distress tolerance techniques

Question 19

CBT in BPD treatment

Answer 19

• Aims to change unhealthy habits (self-harm, intense emotions) to healthy behaviours by changing the way patients react/think
• E.g. A friend cancelling plans because they were busy not because they don’t like you or are abandoning you

Question 20

Behavioural contracts in BPD

Answer 20

• A contract between patient and healthcare provider (MHN) usually regarding not being allowed to do certain behaviours if they are admitted
• These need to be enforced as patients will sign anything to be admitted without any intention to uphold the contract

Question 21

Limit setting in BPD

Answer 21

Placing limits on patients with BPD as they often have trouble establishing and maintaining healthy relationships and personal boundaries
1. Identify acceptable and unacceptable behaviour from the patient
2. Identify the consequences of the patient exceeding the limits
3. Identify the desired or expected behaviour from the patient

Question 22

Behaviour management plans (BMPs)

Answer 22

• Plan for how clinicians respond to the patient when in crisis
• All services have the BMP, so will respond in the same way (police, ED, ward)
• Makes sure that all treatment is consistent and gives the staff and patient structure
• Needs to be regularly reviewed by case manager or consultant psychiatrist or it will not be effective
• E.g. nurses need to take temporary control of decisions etc. until the patient is able to take personal responsibility for their safety

Question 23

Nursing care for patients with BPD

Answer 23

1. Physical assessment
   - Ensure they are medically stable
   - Monitor intake, sleep, ADLs
   - Monitor for signs of alcohol or substance use, and consider withdrawal regime
2. MSE
   - Document ensuring to use non-judgemental language like childish, tantrum or violent
   - Handover any changes
3. Nurse-patient relationship
   - TIC as trauma is often cause
   - Non-judgemental, non-confrontational
   - Consistent message between all staff to prevent splitting
   - Limit setting: agree to talk to them for 10 minutes every hour
   - Continuity of care
4. Education
   - Psychoeducation
   - Medication education
5. Risk assessment
   - Suicide
   - Self harm
   - Vulnerability
   - Harm from others
   - Harm to others
   - Compliance with care
   - Self neglect
6. Risk management
   - Identify risks
   - Identify strengths and plan to reduce these risks
   - Gauge suicidal thoughts, intent and plan and find out about history of attempts
   - Document risks and plan to reduce risks