The difficult patient: Understanding and working with people with personality disorders
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1 The difficult patient: Understanding and working with people with personality disorders Dr. Jacquie Cohen, Registered Psychologist Borderline Personality Disorder Treatment Program Capital Health Addictions and Mental Health Program Overview Brief review What is a personality disorder (PD)? Types of PDs Borderline Personality Disorder (BPD) BPD in the medical & mental health settings Beliefs about BPD Understanding BPD What can we use from BPD treatments? Working with people with BPD on a day-today basis in clinical settings What is a personality disorder? Personality is your typical way of acting, feeling, thinking, and relating to the world 1
2 What is a personality disorder? Personality disorder Enduring pattern of relating to the world that does not work very well Affects two or more of: cognition; affectivity; interpersonal functioning; and impulse control 9% of the U.S. population (1 in 11) meet criteria for a PD (Lenzenweger et al., 2007) Types of personality disorders CLUSTER A Odd or eccentric Paranoid; Schizoid; Schizotypal CLUSTER B Dramatic, emotional, or erratic Antisocial; Borderline; Histrionic; Narcissistic CLUSTER C Anxious Avoidant; Dependent; Obsessive-Compulsive Types of personality disorders CLUSTER A ( odd ) Paranoid distrustful; suspicious Schizoid detached; emotionally restricted Schizotypal discomfort with close relationships; cognitive and perceptual distortions 2
3 Types of personality disorders CLUSTER C ( anxious ) Avoidant socially inhibited; feel inadequate; hypersensitive to negative evaluation Dependent submissive, clinging; need to be taken care of Obsessive-Compulsive preoccupied with orderliness, perfectionism, control Types of personality disorders CLUSTER B ( dramatic ) Antisocial disregard for and violation of rights of others Borderline instability across relationships and affect; impulsive Histrionic excessive emotionality Narcissistic grandiose; need admiration; lack empathy Prevalence of specific personality disorders Data from U.S. National Epidemiological Survey (Grant et al., 2008, 2012; Stinson et al., 2008) Obsessive-compulsive (7.8%) most common Narcissistic (6.2%) Borderline (5.9%) 3
4 Borderline Personality Disorder (BPD) The most studied of the PDs in the general population and in mental health and medical settings Represents 76% of all PD hospital admissions (UK National Health Service, 2010); another 15% are antisocial or unspecified BPD in medical settings Likely higher prevalence than other PDs 6% of internal medicine outpatients (Gross et al., 2002) 18 25% in a primary care setting with a high indigent population (Sansone, 2000) 9% of patients undergoing cardiac testing (Sansone et al., 2011) BPD in medical settings Traits may intensify medical symptoms Associated with heightened risk of chronic medical illness (Keuroghlian, 2013) Self-sabotage Associated with greater likelihood of disruptive behaviours but not actual physical threat (Sansone et al., 2011) 4
5 BPD in mental health settings 10% of outpatients & 20% of inpatients (Torgersen et al., 2001) Consume disproportionate amount of mental health resources (up to 40%) Clinician burnout Beliefs about BPD BPD is untreatable Highly suicidal Difficult patients We tend to believe people with BPD are manipulative and attention-seeking, and that they cause splitting among health care providers How do we help these patients? The problem with multi-problem patients 5
6 Comorbid mental health problems Current Axis I diagnoses (Linehan et al., 2004) Major depression 75% Post-traumatic stress disorder 51% Panic disorder +/- agoraphobia 40% Eating disorders 24% Obsessive-compulsive disorder 20% Social phobia 16% Substance-use disorders 21 67% How do we treat multi-problem clients in the context of unrelenting crises & suicidal behaviour? Dialectical Behaviour Therapy (DBT) Comprehensive treatment program developed by Marsha Linehan in the 1980s Focus is on reducing suicidal behaviour by helping clients build a life worth living Developed for women with BPD; reformulated for multidiagnostic treatmentresistant populations 6
7 Dialectical Behaviour Therapy (DBT) Rooted in Behaviour therapy, Zen practices, and Dialectical philosophy (the tension between polar opposites between acceptance and change) Dialectical Behaviour Therapy (DBT) Standard DBT includes individual treatment, group treatment, between-session skills coaching, and consultation team for therapists (clinicians working with people with BPD need support) Adapted for inpatient, forensic, and adolescent populations Evidence supporting DBT Recognized by the Cochrane Review (Stoffer et al., 2012) as the treatment of choice for characteristics associated with BPD Efficacy indicated by 18 RCT s (Linehan et al., 2014) Better outcomes than TAU & CTBE across multiple domains, including suicidal and selfinjurious behaviour, emergency/inpatient treatment, anger, depression, and social and global adjustment, (Bedics et al., 2012; Kliem et al., 2010; Linehan et al., 2006) 7
8 Other EBT s for BPD Mentalization-based therapy Schema-focused therapy Cognitive analytic therapy STEPPS (Systems training for emotional predictability and problem solving) What is the basis of DBT? Why does it work when so many other treatments failed? Problem with standard treatments Focus on CHANGE Invalidate Self-Construct AROUSAL Impaired Processing No New Learning; No Collaboration Focus on ACCEPTANCE Invalidate Suffering 8
9 Solution Apply a dialectical approach Validate uncontrollable, helpless experience of intense emotional arousal (ACCEPTANCE STRATEGIES) AND Teach emotion modulation (CHANGE STRATEGIES) Teach two new sets of behaviour: Acceptance Skills Change Skills Core treatment strategies: Problem Solving Validation 9
10 Core treatment strategies: Validation, Acceptance, Mindfulness Cognitive-Behaviour Therapy Understanding BPD: Biosocial model BPD is the result of mutual interactions over time between: Biologically based emotional dysregulation (Nature) AND Invalidating environments (Nurture) Understanding BPD: Biosocial model Biological vulnerability contributes to difficulties regulating emotions (Ebner-Priemer et al., 2005; Juengling et al., 2003) Compared to people without BPD, people with BPD experience more frequent (more easily triggered; Lynch et al., 2005), more intense (become more distressed; Donegan et al., 2003), longer lasting aversive states (slower to return to baseline; Stiglmayr et al., 2005) 10
11 Understanding BPD: Biosocial model Invalidating environments Communicate that a person s emotional responses are incorrect, pathological, or not to be taken seriously Fail to understand person s vulnerability oversimplify problem solving & fail to teach distress tolerance Punish communication of negative experiences & only respond to emotional displays when they are escalated person learns to oscillate between emotional inhibition & extreme emotional communication Understanding BPD: Biosocial model Inability to regulate emotion is considered the core dysfunction of BPD Understanding BPD: Biosocial model Symptoms are seen as a combination of biologically based emotional dysregulation & maladaptive emotion regulation strategies Self-harm behaviours have important affectregulating properties distract from, numb, or relieve emotional pain are a way to feel something convey extent of pain & elicit help 11
12 BPD Criteria Reorganized Emotional dysregulation Affective instability Problems with anger Behavioural dysregulation Impulsivity Recurrent suicidal or self-mutilating behaviour Interpersonal dysregulation Fears of abandonment Unstable & intense relationships Self dysregulation Identity disturbance Sense of emptiness Cognitive dysregulation Transient paranoid ideation or severe dissociative sx EMOTIONAL DYSREGULATION SELF DYSREGULATION INTERPERSONAL DYSREGULATION BEHAVIOURAL DYSREGULATION COGNITIVE DYSREGULATION Teach two new sets of behaviour: Change Skills Acceptance Skills 12
13 Core treatment strategies: Validation, Acceptance, Mindfulness Cognitive-Behaviour Therapy Balancing treatment strategies ACCEPTANCE Validation CHANGE Problem Solving Environmental Intervention Reciprocity Consultationto-the-Client Irreverence Dialectics Means to retain flexibility & balance We often simultaneously hold two opposing positions (suicidal clients often simultaneously want to live & want to die) Dialectical progress comes from the synthesis of two opposing positions A better solution can be found (the best alternative to suicide is to build a life worth living) 13
14 Behaviour therapy (CHANGE strategies) Self-monitoring (diary cards) Behaviour chain analyses (BCAs) for problem behaviour Contingency management Skills training Cognitive restructuring Exposure Skills Training EMOTION REGULATION (emotion dysregulation) Increase positive emotions; stop avoiding negative emotions; reduce impulsivity DISTRESS TOLERANCE (behaviour dysregulation) Impulse control; self-soothing strategies INTERPERSONAL EFFECTIVENESS (interpersonal dysregulation) To achieve one s objective while maintaining self-respect & relationships CORE MINDFULNESS (cognitive & self dysregulation) Focusing attention; observing immediate context; non-judgmental stance; developing effectiveness States of mind Reasonable Mind Wise Mind Emotional Mind 14
15 What aspects of DBT can we apply in our day-to-day interactions with patients with BPD? Balancing treatment strategies ACCEPTANCE Validation CHANGE Problem Solving Validation (ACCEPTANCE strategies) To promote self-acceptance and selfcompassion Acceptance is not the same as approval 15
16 Levels of Validation 1. Listening & observing 2. Accurate reflection 3. Articulating the unverbalized 4. Validating in terms of past experiences or biological vulnerability 5. Validating in terms of current circumstances 6. Radical genuineness Levels of Validation LEVEL 4. VALIDATING BEHAVIOUR IN TERMS OF PAST EXPERIENCES OR BIOLOGICAL VULNERABILITY Especially helpful when a person is highly judgmental of their own reactions It makes sense to me that your reaction was so extreme. Given your history with your father, I can imagine how sensitive you are to people trying to exert authority over you. Levels of Validation LEVEL 5. VALIDATING BEHAVIOUR IN TERMS OF CURRENT CIRCUMSTANCES Validate the valid and do not validate the invalid; especially helpful when a client has difficulty trusting their reactions I can completely understand why you felt so angry. It sounds like your worker really misunderstood your situation. It seems as though you got pretty extreme though and she is no longer willing to work with you because of it. We should work on how to manage those feelings so you can respond in ways that don t make your situation worse. 16
17 Levels of Validation LEVEL 6. RADICAL GENUINENESS Be typical of how you act in other relationships: neither overly sweet nor aloof. Have accurate expectations (not treating patients as fragile and also not ignoring true limitations); being willing to be vulnerable (self-disclose reactions) when this would be helpful Communicates that patients are equal, capable, and valid What about change strategies? How can I use any of these interventions when our interactions are so brief? In-the-moment skills coaching - developed for use on acute mental health units 17
18 AVIS-R (skills coaching; Swenson, 2006) A ATTEND A ASSESS V VALIDATE V VALIDATE I INVITE I INSTRUCT S SHOW S SEE R REINFORCE R REVIEW AVIS-R (Skills coaching; Swenson, 2006) A ATTEND to the client in a genuine & focused manner. Get their attention. A ASSESS the situation. I understand you are really upset. Would you be willing to tell me what s going on? AVIS-R (Skills coaching; Swenson, 2006) V VALIDATE the emotional suffering and pain that motivated the problem behaviour. You must have been really upset when the physician wasn t available to talk to you this morning. That must have been really tough. 18
19 AVIS-R (Skills coaching; Swenson, 2006) V VALIDATE the difficulty of trying to do things differently. It must be really hard to do something else in this situation and it s especially difficult to change when you feel so upset. AVIS-R (Skills coaching; Swenson, 2006) I INVITE. You can now attempt to gently push for change by inviting the person to use a coping skill in the moment. Provide a clear rationale. The goal is to open the door to for new skill development. If we could get you to spend some time soothing yourself, it may reduce some of those painful feelings that lead you to want to selfharm. Would you be interested in learning a skill that might work for you in this situation? AVIS-R (Skills coaching; Swenson, 2006) I INSTRUCT. Once you have a willingness to try a skill, instruct the patient how to use it in the moment. You can also nonjudgmentally describe what may have been a more skillful response. When we use imagery, we find a safe place in our minds and make it as real as possible. I wonder if next time, you could ask for an icepack to reduce some of those intense urges to hurt yourself. 19
20 AVIS-R (Skills coaching; Swenson, 2006) S SHOW. Show them how to use the skill in the moment (e.g., deep breathing, selfsoothing, listing pros and cons of a behaviour). You can also suggest what you might do in a similar situation. If I were using this sill in this situaiton and my mind was really spinning over something, I might distract myself by listening to some really powerful music. AVIS-R (Skills coaching; Swenson, 2006) S SEE. Actually observe the person using the skill. This might involve doing a one-minute deep breathing exercise with the person and then talking about how it went. Or you might help your patient get out of bed and go for a walk when they feel depressed and withdrawn. AVIS-R (Skills coaching; Swenson, 2006) R REINFORCE. Once the patient has tried or fully used a skill, it is essential to reinforce their attempt or success to encourage the use of more sklllful behaviour in the future. Reinforce even small steps toward change. I really appreciate that you were open to trying this. You really stuck with this even though it was hard. 20
21 AVIS-R (Skills coaching; Swenson, 2006) R REVIEW the entire exercise with the patient to elicit feedback and let them know you are willing to be flexible and open to their experience. How did this go? The next time we do something like this, is there anything I can do to make it go better? Stages of Treatment Stage 4 Incompleteness joy & meaning Stage 3 Problems in living ordinary happiness Stage 2 Quiet desperation emotional experiencing (PTSD TREATMENT; OTHER EXPOSURE THERAPIES) Stage 1 Severe behavioural dyscontrol behavioural control (SAFETY; SKILL DEVELOPMENT) In summary Individuals with BPD are well-represented in medical and mental health settings The disruptive behaviour of people with BPD is how they learned to cope with intense emotional suffering There are effective treatments for BPD; people with BPD do get better Validation goes a LONG way! Be genuine Make sure you have support 21
22 Resources For mental health clinicians Dimeff, L. A., & Koerner, K. (Eds.). (2007). DBT in Clinical Practice: Applications Across Disorders and Settings. (Behavioral Tech) For patients and family members Chapman, A. L., & Gratz, K. L (2007). The BPD Survival Guide. Manning, S. (2011). Loving Someone with BPD. Resources BPD Treatment Program Currently only able to accept referrals from within CHAMHP TELEPHONE
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