The Care and Management of Individuals with Personality Disorders - Research Paper Example

The Care and Management of Individuals with Personality Disorders Introduction Martina is an 18 year old woman, who is actually my first cousin and lives in my neighborhood. Though younger to me by few years, we actually played and grew up together. But now, we have drifted apart after having some differences in our relationship a few months ago. After I joined this course, I began to look back into our relationship remembering our childhood and teenage days. It has suddenly dawned upon me that Martina is actually suffering from borderline personality disorder and the reason for her behavior is the disorder which she is stricken with. Suddenly feelings of sympathy and guilt have shaken me so much that I write this essay with heart felt apologies to my dearest cousin for not having identified her situation and for not having guided her to proper treatment and counseling. In the process of writing this article, I have studied current literature pertaining to borderline personality disorders, its psychopathology and treatment strategies. Through this knowledge, I wish to help Martina seek proper guidance and treatment from my professor who is a renowned psychiatrist. In the following paragraphs to follow, I will elaborate various clinical features and circumstances in the life of Martina which have prompted me to diagnose the disorder. I will also elaborate on various aspects of BPD after giving a brief introduction about many other personality disorders. Case Scenario I remember our early years when Martina was just an infant. My aunt, who happens to be Martina's mother, used to constantly complain that Martina is an intense baby who is cranky and gets upset for no reason. Martina was hard to comfort and could not get adjusted easily to new people and environment. She would cry on and on and her mother would get fed up with her give her a good spanking. Even as days went by, Martina continued to be the same. She would cry intensely and angrily whenever her mother left her. Her mother started to work when Martina was 18 months old and we would hear constant complaints from the baby-care center about Martina’s crankiness. Despite this problem, my aunt continued to work for long hours. Martina's father was in the army and seldom got in touch with his family. This was probably one of the reasons why my aunt worked. She wanted to out beat loneliness, little realizing that she made her daughter suffer the same way. In school years, when we played together, there are many occasions when I felt that Martina is a sweet and loving girl. However, in early teenage years, her behavior and personality began to change towards worse. Martina used to become angry intensely and suddenly. She would express intense emotions and yell at friends, teachers, relatives and parents. She developed impulsive behavior. Most of the times, she had very few friends. With any friend or relative, she would develop some conflict within no span of time and end the relationship. Then she would complain of boredom and search for another friend. For the past 2 years, Martina has been in the book of bad girls. She displayed severe emotional instability. She would fight with her parents and teachers every day. Her mom would get calls from the school atleast twice a week complaining about Martina's rude behavior and conflicts. Though she always wanted her mother to be beside her, she would sometimes leave the house and not return home for several days. Nobody could understand her. Last year, Martina came to my house to spend some time. During that time, I noticed some scars on her hands. When enquired, she told me that she tried a lot to die by cutting her veins but in vain. From what she told me, I mustered that she attempted suicidal acts many times; many were to just scare her mom. After this, I called my aunt and questioned her if she knew all this. She knew! Martina got terribly upset with me for discussing these aspects and threw intense fits of anger. She went back home and never called again. When I tried to get in touch, she was rude and extremely emotional. My mom has asked me not to get in touch with her because "she is a bad girl." Just like her parents, even I was under the impression that she is arrogant and has problems of teenage, until now, when I have begun to view her problem from a psychoanalytic perspective. An overview of personality disorders Disorders pertaining to certain personality types which are unlike contemporary personality types of the society are known as personality disorders. These disorders are a result of long-standing maladaption in the perception and response to certain situations in life and also to other people (Bienenfeld, 2008). According to the Diagnostic and Statistical Manual of the American Psychiatric Association, Fourth Edition, Text Revision (DSM-IV-TR), "a personality disorder is an enduring pattern of inner experience and behavior that differs markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment" (APA, 2000). The International Classification of Mental and Behavioral Disorders (ICD-10) (cited in NHS, 2003) defines this disorder as ‘a severe disturbance in the characterological condition and behavioral tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption.’ Most of the data pertaining to epidemiology of personality disorders is available from the United States. These disorders affect about 10-15% of US population (Bienenfeld, 2008). Individuals affected with personality disorders are at risk for development of Axis-I psychiatric disorders like mood disorders (Bienenfeld, 2008). The ICD-10 describes 9 categories of personality disorders and according to DSM-IV-TR (APA, 2000), there are 10 categories of personality disorders spread across in 3 clusters namely, cluster A, cluster B and cluster C. Most patients with personality disorders have overlapping symptoms making it difficult to allocate a single diagnosis to them. The DSM clustering system helps in solving this problem and hence this method of classification has been employed in this essay. Cluster A includes personality disorders which involve odd and eccentric behaviour. The disorders which fall into this category are paranoid personality disorder, schizoid personality disorder and schizotypal personality disorder. In paranoid personality disorder, the persons are always distrustful and suspicious of other persons and can blame them for being deceitful or exploiting in nature. Friends and partners may be assumed to be untrustworthy and unfaithful. These patients are at risk of development of other psychiatric conditions like obsessive compulsive neurosis, substance abuse, major depression and agoraphobia (Bienenfeld, 2008). Persons with schizoid personality disorder are aloof from others, they don't seem to enjoy anything in life; they are indifferent to both praise and criticism and remain markedly detached from others. They are risk of development of major depression (Bienenfeld, 2008). Those with schizotypal personality disorder exhibit eccentric thoughts, behavior and perceptions. They may have off-beliefs and exhibit magical thinking. They may have ideas of reference and believe that statements made in public by others are actually directed at them. They may have vague stereotyped speech, exaggerated social anxiety and idiosyncratic perceptions. They are at risk of developing delusional disorder, brief psychotic disorder or schizophreniform disorder (Bienenfeld, 2008). Individuals with cluster B personality disorders are basically dramatic and emotional in nature. Antisocial personality disorder, borderline personality disorder, histrionic personality disorder and narcissistic personality disorder fall into this category. Individuals with this disorder have no regard for rules of society do not care for others. They lie and deceive others many times, violate various rules, laws and regulations, exhibit physical aggressiveness, lack remorse, do not care for safety of one self and others and have irresponsible work culture. They are likely to resort to substance abuse and pathological gambling and can land up in anxiety disorders and somatization disorder (Bienenfeld, 2008). Those with borderline personality disorder are frequently mistaken to be having psychotic disorder. They have intense but unstable interpersonal relationships. They are very impulsive and exhibit intense moods and self-perception. Persons with borderline personality disorder are at risk of developing bulimia, posttraumatic stress disorder and substance abuse (Bienenfeld, 2008). Persons with histrionic personality disorder exhibit attention seeking behavior and display inappropriate intense emotions which are actually labile. Their behavior is many a times seductive and appears dramatic. They have the ability to give impressionistic speeches, although the topics they discuss are vague. Histrionic people are likely to develop substance abuse and anorexia nervosa. Patients with narcissistic personality are actually grandiose and expect to be admired by others. For this purpose, they exaggerate their accomplishments and talents and behave in an arrogant manner. However, they exploit others, are jealous towards those who have true accomplishments, lack empathic heart and lack sense of entitlement. They are at risk for depression, substance abuse and anorexia (Bienenfeld, 2008). Cluster C involves personality disorders with anxious and fearful theme. The 3 personality disorders which fall into this category are avoidant personality behavior, dependent personality behavior and obsessive compulsive personality disorder. Patients with avoidant personality behavior are shy in nature. They have inhibition towards social mingling, exhibit feelings of inadequacy and are hypersensitive to rejection. Though they have positive desire in establishing relationships, they are unable to do so due to social isolation. They frequently develop social phobia (Bienenfeld, 2008). People with dependent personality behavior display submissive and dependent behavior. Diagnosis of this condition is established by the presence of 5 of the following: decision-making difficulty in the absence of reassurance or guidance, inability to assume responsible posts, inability to openly express disagreement with others, difficulty in initiating activities, takes extra effort to get nurturance and support, helplessness in situations when alone, seeks another relationship urgently when one has ended and worries unnecessarily about being left behind. They are likely to develop anxiety disorders and adjustment disorder (Bienenfeld, 2008). On the other hand, people with obsessive-compulsive neurosis are persistently involved with perfectionism and orderliness. Due to this, they are unable to be flexible or open, especially in ethical, moral and cultural aspects. They are also stubborn and stingy and despite projecting a perfectionist picture, fail to be efficient. Most of these people are type-A personalities and are risk of development of myocardial infarction (Bienenfeld, 2008). After going through various personality disorders, I have diagnosed Martina to be having borderline personality disorder which I will be discussing in the further paragraphs. Borderline Personality Disorder or BPD Borderline personality disorder or BPD is a mental illness which is characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior that often disrupts family and work life, long-term planning, and the individual's sense of self-identity (Borderline Personality Disorder, NIMH). Historically, this disorder has been given a clinical picture between psychosis and neurosis. This term is seldom used for adolescents because; those under 18 years have ongoing developmental changes. However, it is appropriate to diagnose this condition in those under the age of 18 if the nature of symptoms is pervasive and persistent and not related to developmental changes (Lubit, 2008). In children, BPD is diagnosed based on the presence of a combination of externalizing symptoms and internalizing symptoms. The externalizing symptoms include disruptive behavioral problems and the internalizing symptoms include those of mood and anxiety (Lubit, 2008). According to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), BPD in adolescents is diagnosed when "maladaptive traits have been present for at least 1 year, are persistent and all-encompassing, and are not likely to be limited to a developmental stage or an episode of an Axis I disorder" (Muscari, 2005). To diagnose a person to have borderline personality disorder, atleast 5 of these characteristics must be present: marked instability of self-image which is persistent, intense and also unstable interpersonal relationships, dangerous impulse behavior, efforts to escape expected abandonment, recurrent suicidal thoughts, attempts or threats, instability of affect, persistent empty feelings, unnecessary exhibition of intense anger and transient dissociation (APA, 2000). Features which were pervasive and pointed to BPD in Martina were unstable interpersonal relationships, dangerous impulse behavior, recurrent suicidal attempts and threats, unnecessary exhibition of intense anger and efforts to escape expected abandonment. Pathophysiology The exact pathophysiology is not known. But it has been noted that those with BPD also may have other mental and neurologic problems like learning disorders, attention deficit hyperactivity disorder, soft neurologic signs, features of frontal lobe dysfunction and abnormal EEG findings (Lubit, 2008). It has been proposed that several factors contribute to the development of BPD and these include organic, psychosocial and environmental. These patients have constitutional incapacity to tolerate stress and inability to regulate their affect (Lubit, 2008). Family environmental factors which can predispose to BPD are trauma, child neglect, parent separation, sexual abuse, physical abuse and presence of serious parental psychopathology, such as substance abuse and antisocial personality disorder (Lubit, 2008). To the best of my knowledge, Martina does not have any learning disorders or attention deficit hyperactivity disorder. However, she did suffer from child neglect and parent separation in early childhood years and probably that is what triggered the development of the disorder. Morbidity and mortality Suicidal tendencies are more in this group of people, leading to premature death. Martina has attempted suicide many times. BPD is associated with many comorbid conditions like dysthymia, major depression, psychoactive substance abuse, psychotic disorders, mood disorders, anxiety, eating disorders, and somatoform disorders (Lubit, 2008). Demographics The incidence of BPD in general population is about 1-2% (Lubit, and Finley-Belgrad, 2008). BPD is four times more common in females. It usually presents in late adolescence. No predilection to any race has been noted (Lubit, 2008). Psychological theories of BPD Many psychological theories have been proposed for the development of BPD, most of which believe that the origins of this disorder are in problematic family experiences in childhood. According to psychodynamic theories, BPD in adulthood is due to adverse experiences in childhood. The theories propose that the intensity of psychopathology in adulthood is dependent on the age at which the traumatic experiences occurred. Earlier the age when the experiences occurred, greater the adult psychopathology (Paris, 2008). These theories are unscientific and are based on armchair speculation, theory and on the behavior of BPD patients with small children. Also, these theories are based on studies on a small proportion of patients and hence cannot be fully given importance (Paris, 2008). However, currently, there are many other theories which are in vogue. According to Kerberg (1975; cited in Lubit, and Finley-Belgrad, 2008), BPD occurs due to a constitutional inability to control affect. This inability makes the individual more vulnerable to adverse conditions in early childhood like deprivement of maternal love and abandonment by mother, leading to dependency, anxiousness and hypersensitivity to rejection. Masterson and Rinsley (1975; cited in Paris, 2008) proposed that BPD is caused by failure to master separation-individuation in the toddler phase of childhood. These theorists criticized over-protective mothers who did not facilitate separation. However, there are no data to support this proposal. However, Alder (1985; cited in Paris, 2008) was of the opinion that emotional neglect during early years of life by mothers contributed to the development of BPD. Alder argued that such neglect aroused intense feelings of loneliness contributing to BPD. This theory was further developed by Fonagy, Target and Gergely (2000), Ley (2005) and Bradley and Westen (2005) who hypothesized that aberrations in attachment in childhood are the causes for interpersonal relationship difficulties in BPD (cited in Paris, 2008). This aspect demands further research. Current researchers like Linehan et al (cited in Lubit, and Finley-Belgrad, 2008) consider BPD as a complex and multifactorial condition involving emotional vulnerability and invalidating environment. Freud developed psychoanalytic theory to understand the psychopathogenesis of various personality disorders like BPD. According to this theory, every person has a personality which is formed by 3 structures, namely, the id, the ego, and the superego (Boeree, 2009). Id represents one's reservoir of psychic energy which manifests as instincts. This aspect has no contact with reality and the person is not conscious about it. Ego is that aspect of personality which handles demands of reality. Through ego, one makes decisions by reasoning. Both id and ego do not have morality. This function is taken care of by superego which is often called as 'conscience'. According to Freud, most of the personality processes occur below the level of awareness. Freud proposed that conflicts arising in these personality structures can lead to anxiety. When such conflicts arise due to childhood traumatic experiences, especially sexual, resolution of conflict is attempted by ego by certain defense mechanisms like repression, denial, acetism, isolation, displacement, turning against self, projection, altruistic surrender, reaction formation, undoing, introjection, sublimation and rationalization (Boeree, 2009). Failure of such defense mechanisms contributes to development of personality disorder. Freud also proposed various stages of psychosexual development and hypothesized that specific trauma or life experiences in specific stages can lead to certain personality-related problems in adulthood. The psychosexual stages are oral stage (birth to 18 months), anal stage (18 months to 3-4 years), phallic stage (from anal stage to 5,6, or 7 years), latent stage (from phallic stage to puberty) and finally genital stage (through puberty) (Boeree, 2009). Clinical features In children, BPD may present as fluctuations in ego states, primitive regressions of deep levels, disturbed interpersonal relationships, and severe anxiety (Lubit, 2008). (Martina was an intense baby who would cry all the time and would find it difficult to get adjusted to new situations). The children are not able to receive comfort from others (martina could not be comforted easily). They exhibit withdrawal of libido from the object world (Lubit, 2008). Adolescents with BPD may have major ego function problems or problems with central aspects of object relationships (Martina always had problems with interpersonal relationships). They have disturbed thinking patterns and always seem to be in crisis (Muscari, 2005). Adults are not able to adequately soothe themselves. They are over-emotional and adapt maladaptive attempts at self-soothing (Lubit, 2008). They attempt to fulfill their needs by means of suicide threats, self-harm, and angry behavior (Just like Martina!). The patient may also symptoms such as overwhelming anger when in a state of crisis (Again, just like Martina!). Psychotic symptoms may also be present. Due to these behaviors, these persons have marked social impairment, disturbed personal relationships and poor performance at work and academics. Physically and appearance-wise, these patients appear normal. Investigation There are no laboratory tests or imaging studies to diagnose this condition. The diagnosis is made on the basis of clinical picture. Routine tests involve fasting glucose and thyroid function studies. EEG may not be useful, although in many cases abnormal EEG can be noted, of course with no diagnostic value (Lubit, 2008). Tests Structured tests with tools such as the Wechsler Adult Intelligence Scale (WAIS) cannot demonstrate BPD because; the patients show ordinary reasoning abilities. Unstructured projective tests, such as the Rorschach test demonstrate abnormal processes (Lubit, 2008). Treatment BPD is a difficult condition to treat because of the nature of the disease and also issues arising during the course of treatment. Relapse is a common problem. Another important problem is difficult relationships between the patients and the counselors or therapists which make treatment very difficult. While many individuals are relieved of destructive symptoms during the first year of proper treatment, 50% of the treated patients have no symptoms at all after 10 years of treatment. Long term consistent treatment is essential for prevention of relapse in BPD. This recovery is partly due to self-reflection and greater maturity as age progresses. Abuse in childhood, symptoms in early life, continuous symptoms over long period of time and comorbid conditions are some factors which contribute to difficult treatment (WebMD, 2007). The following are the various treatments for BPD. Psychotherapeutic treatment: The first treatment which must be initiated in BPD is professional counseling with a goal to control destructive behaviors (WebMD, 2007). Thereafter control of emotions can be aimed at. Psychotherapy is difficult because of the impulsive nature of the condition (Lubit, 2008). The patient needs to be hospitalized for a prolonged period. Kernberg's modified psychoanalytic approach aims at resolution of pathologic internalized representations of interpersonal relationships. The goal of any psychotherapeutic treatment would be to gradually make the patient adjust socially, in the framework of a realistic therapeutic relationship. 'Experience rather than explanations benefit the patient' approach makes the patient learn to tolerate the hateful and destructive feelings that arise because of transference, thereby replacing them with more constructive and positive reactions (Lubit, 2008). There are many forms of counseling as discussed below. 1. Cognitive-behavioral therapy (CBT): This form of psychotherapy mainly influences dysfunctional and problematic cognitions, emotions and behaviors through a 'goal- oriented' systematic approach. The main objective of the treatment is to identify thoughts, beliefs, assumptions and behaviors that are related to debilitating, dysfunctional, inaccurate and unhelpful negative emotions and monitor them (WebMD, 2007). The result expected out of such forms of therapy is to replace or transcend these emotions with more realistic and useful emotions. 2. Dialectic behavior therapy (DBT): This is a modified version of standard cognitive-behavioral techniques. This treatment is specifically developed for BPD (NICE, 2009). It focuses on 4 skills: mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance without impulsivity. DBT reduces suicidal and self-injurious behaviors and self-reports of anger and anxious ruminations. The incidences of treatment drop-outs are less when compared to psycho-therapeutic treatment. Also, the duration of hospitalization and thus the cost to health care is less when compared to the other treatments (Lubit, 2008). 4. Cognitive analytic therapy (CAT): This treatment addresses interpersonal difficulties through theoretical and practical attention (NICE, 2009). 5. Psychodynamic therapy: This treatment uncovers the understanding of past experiences and relates it to current behavior (WebMD, 2009). Thus, unconscious internal conflicts are brought to light and realization of these conflicts helps one come to terms with reality. 6. Family-oriented treatment for children: These interventions diminish the risk of further undermining parental self-esteem. When treated appropriately, the child may have good developmental outcome (Lubit, 2008). In family therapy, which is part of this therapy, family members are also educated about the condition of the patient so that proper support and cooperation is delivered from them (WebMD, 2009). 7. Support groups: People with similar problems and interests can meet together to discuss about various challenges and treatment aspects and receive support, guidance and advice from other’s experiences (WebMD, 2009). Pharmacotherapy: BPD as such may not need any pharmacological intervention. However, those with severe impulses, instability of the affect and psychosis may be benefited with medication. The drugs mainly used are selective serotonin reuptake inhibitors like fluoxetine and sertraline, antipsychotics like risperidone and opiate receptor antagonists like naltrexone (Lubit, 2008). Since comorbid illness like bipolar disease, depression, substance misuse and post-traumatic stress disorder are common in those with BPD, initiation of antidepressants, antipsychotics and mood stabilizers may be necessary to gain control of comorbid conditions. Most of the times, combination drugs are used in the treatment (NICE, 2009). Treatment of comorbid conditions is a must to gain success. Other therapies: Group analytic psychotherapy employs non-directive groups with relationship between members as a therapeutic tool. This form of treatment prevents hazards of individual therapy like relationship problems which are commonly seen in severe personality disorders. Other treatment modalities are humanistic and integrative psychotherapies, systemic therapy and nidus therapy which work on the family and environment to treat BPD (NICE, 2009). Issues pertaining to staff splitting Patients with BPD see the world with a different perspective and need to be dealt with in a different manner for effective outcome of treatment. Thus, issues like staff splitting are common to arise. Splitting of staff means playing one member of the therapy staff off against another. This is due to black andwhite thinking that BPD patients possess. It is important to resolve issues pertaining to splitting because splitting introduces conflict and introduces two ideas of treatment making treatment very difficult. Clinicians can solve splitting by identifying it as soon as possible and mentioning it to the patient that they have identified it (Bland, Tudor and Whitehouse, 2007). Other advice Patients with BPD must be advised to sleep well and go to bed at the same time every night. They must eat a well balanced diet and perform regular exercise. They must be advised to avoid alcohol and consumption of illicit drugs and not take unprescribed medications. These patients must be strictly told to avoid taking major life decisions in times of disturbance and emotional surge. They must be helped to build a strong social support system involving parents, relatives, health professionals and family members who understand the nature of the disease and have positive relations with the patient. Prognosis The long-term outcome is generally unknown. Actually, BPD patients change little overtime. Children with BPD are likely to develop other personality disorders also (Lubit, 2008). Conclusion Personality disorders are common psychiatric conditions which are disabling in nature. Though majority of personality disorder patients are able to get on with daily living with minimal distress and difficulty, some of them have severe disabilities crippling regular day-to-day activities and pose a burden to their families, friends and associates. According to the DSM-IV TR, there are 10 types of personality disorders grouped into 3 clusters. BPD is a common condition that affects about 1-2% of population. It is mostly multifactorial in origin with psychopathology roots in early childhood traumatic experiences. Treatment is difficult and long term in nature with many challenges cropping up in between. There is hope for resolution of symptoms if treatment is taken consistently for many years. References American Psychiatric Association or APA. (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association. Bland, A., Tudor, G., and Whitehouse, M. (2007). Nursing Care of Inpatients with Borderline Personality Disorder. Perspectives in Psychiatric care, 43(4), 204- 212. National Institute of Mental Health (NIMH) (2008). Borderline Personality Disorder. Retrieved on 21st August, 2009 from http://www.nimh.nih.gov/health/publications/borderline-personality-disorder.shtml Bienenfeld, D. (2008). Personality Disorders. Emedicine from WebMD. Retrieved on 22nd August, 2009 from http://emedicine.medscape.com/article/294307-overview Boeree, C.G. (2009). Sigmund Freud. Personality Theories. Retrieved on 21st August, 2009 from http://webspace.ship.edu/cgboer/freud.html Lubit, R.H., and Finley-Belgrad, E.A. (2008). Borderline Personality Disorder. Emedicine from WebMD. Retrieved on 21st August, 2009 from http://emedicine.medscape.com/article/913575-overview Lubit, R.H. (2008). Personality Disorder: Borderline. Emedicine from WebMD. Retrieved on 21st August, 2009 from 2008 http://www.emedicine.com/ped/TOPIC270.HTM Muscari, M.E. (2005). What Therapy Is Recommended for Borderline Personality Disorder in Adolescents? Medscape Pediatrics. Retrieved on 21st August, 2009 from http://www.medscape.com/viewarticle/508832 National Institute for Mental Health in England or NHS. (2003). Personality disorder: No longer a diagnosis of exclusion. Retrieved on 21st August, 2009 from http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4054230.pdf NICE Guidelines (2009). Borderline Personality Disorder : treatment and management. Retrieved on 21st August, 2009 from http://www.nice.org.uk/nicemedia/pdf/CG78FullGuideline.pdf Paris, J. (2008). Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice. London: Guildford Press WebMD. (2007). Borderline Personality Disorder - Treatment Overview. Retrieved on 21st August, 2009 from http://www.webmd.com/mental-health/tc/borderline-personality-disorder-treatment-overview Read More