Working With Bpd Ptsd

Working with Mental Illness in the Community Paula Mendenhall, LMHC, LPHA

Learning Objectives Identify behaviors and characteristics of individuals with BPD, PTSD and Schizo affective Disorder who present within community settings Discuss general approach and suggested intervention strategies for individuals with BPD, PTSD and Schizo affective Disorder Discuss keys to maintaining a safe and effective interaction Role play effective techniques with three different populations Discuss resources available for treatment.

How Understanding May Help Understanding of some of the basic characteristics and features of borderline personality disorder, PTSD and schizo affective disorder may assist you to increase public and personal safety, improve the outcome of an interaction, enhance cooperation and possibly reduce the stress of all individuals involved.

Mental Illness and Community Safety Frequently arrested for minor offenses, many times as a result of homelessness, They are incarcerated in jails where their mental health needs are not met The U.S. Department of Justice reported in 1999 that 16% of all inmates in state and federal jails have a severe mental illness. 283,000 people with serious mental illnesses were in jail or prison - more than four times the number in state mental hospitals. The average daily number of patients in state and county psychiatric hospitals has steadily dropped from 592,853 in 1950 to 71,619 in 1994. 40% of families of persons with mental illness reported that the individual had been arrested at some point in their lives. BPD Today Newsletter www.borderlinepersonalitydisordertoday.com

Mental Illness and Incarceration “ When incarcerated, offenders with mental illnesses may present problems, particularly when they arrive in a disoriented or psychotic state. Once in jail, they remain longer than others with similar convictions. Often their condition deteriorates without appropriate treatment and issues concerning behavioral management arise. They may leave jail without supplies of needed medications, public benefits to pay their living costs or Medicaid for community-based mental health services. As a result, many simply recycle back into the criminal justice system." BPD Today Newsletter www.borderlinepersonalitydisordertoday.com

Taking a closer look Borderline Personality Disorder

BPD in a nutshell “ Borderline individuals are the psychological equivalent of third-degree-burn patients. They simply have, so to speak, no emotional skin. Even the slightest touch or movement can create immense suffering.” Marsha Linehan “ The methods of self-harm that borderlines choose can be gruesomely creative. One psychologist related to me an incident of a woman who used fingernail clippers to pull off slivers of her skin.” “ BPD is a disorder that could be called the ‘I don’t fit in’ disorder”. “ Back from the Edge”, Borderline Personality Disorder Resource Center "Everyone talks about [BPD], but it usually seems that no one knows quite what to do about it.“ Duke University Psychiatrist

Emotional Chaos “ People with BPD seem to have no internal governor. They are powerfully connected to the people close to them and terrified by the possibility of losing them - yet they attack those people so unexpectedly that they often ensure the very abandonment they fear. When they want to hold, they claw instead! What defines BPD -and makes it so explosive - is the sufferers' inability to modulate their feelings and behavior. When faced with an event that makes them depressed or angry, they often become inconsolable or enraged”.

WHY I FEEL SO BAD GRAPH 10 5 0 TIME IN HOURS 1 2 3 4 5 I N T E N S I T Y NEW BASELINE

BPD ~ What to Look For History of hospitalizations, baker acts, house calls by police; Suicide attempts and other self destructive threats/acts; Demanding or aggressive and someone who idealizes or devalues your skills, law enforcement, etc.; It’s hard to get cohesive information from the individual; You are becoming uncommonly frustrated/angry at the individual; You become uncommonly close to the individual (wanting to rescue); The individual Is disruptive and provoking conflict between others; Disregards laws/rules and has little concern about any type of consequences; Is trying to get people on his/her side without regard to their position or relationship to others.

BPD Can Be Fatal Among Suicides, 40-65% have a Personality Disorder Among Personality Disorders, BPD is most associated with suicidal behavior Among BPD, 8-10% commit suicide up to 75% attempt suicide 69-80% self-mutilate

Facts of BPD Affects 1-2% of population; but is grossly under diagnosed; Mostly female 70%; Affects all cultures, levels of intelligence and social classes; An Illness and not a behavior; Can co-exist with other disorders (bipolar disorder, mood, anxiety, eating disorders, substance abuse,PTSD, dissociative, and psychotic); One of the most stigmatized, under treated, undiagnosed, misdiagnosed and difficult to treat disorders; Patients that are high end users of the MH system and the Legal system; Increased family history for Substance-Related Disorders (e.g., drug abuse), Antisocial Personality Disorder, and Mood Disorders, like depression or bipolar disorder; Quite often a history of abuse: sexual, emotional or physical; early abandonment or divorce.

How Does BPD Cause Problems Borderline personality disorder make it hard for the person to maintain relationships, sometimes jobs, and in general, stability. People with this disorder often cause a great amount of stress or conflict in relationships with others, especially significant others and close family members. It is not uncommon to see many unrelenting crises in the BPD’s life: divorce, physical, sexual or emotional abuse, substance abuse, additional emotional problems (such as an eating disorder or depression), self-harm, job instability, estrangement from one’s family, and much more.

You might be dealing with BPD IF: You can’t seem to get them to think differently about things – Black and White, “all or nothing” thinking. Their emotions seem to get the best of them and they are highly reactive and can’t seem to calm down. Their lives are in chaos, or they have many crises. You’ve been to their house before… They tell you there is nothing wrong with their behavior and attitude -- it’s the other person who doesn’t understand! They just don’t seem to be able to function in a consistent way. They tell you things have been bad for a long time and they are always misunderstood. They say they have been in therapy a long time. They are acting in self defeating, impulsive or emotionally extreme ways and they are NOT on drugs or alcohol. They try to play you against another person, getting you on their side not the other officer, or family member’s side. They are obviously trying to manipulate – they aren’t very good at it and don’t disguise it well. If they were skilled at it, you wouldn't know

Linehan, Marsha M. 1993. Skills Training Manual for Treating Borderline Personality Disorder . The Guilford Press, New York, NY.

Two levels of functioning: High Functioning-Acting Out Episodes of raging Holds a job – with responsibility Is capable of maintaining friendships Can act “normal” when necessary Primary emotion: ANGER Low functioning-Acting In Episodes of self harm Threats of suicide or attempts Unable to hold job or working below level Trouble with ADLs Risky behaviors Primary emotion: FEAR

4 Subtypes of Behavior Styles Ego centric, narcissistic type: Attention seeking; high expectations of others. Anti-social type: Self hatred, can be cruel to others without remorse. Jealous, critical, easily slighted. May try to intimidate others. Shame based type: Overwhelming feelings of worthlessness, helplessness, hopelessness and despair. Very fearful. Isolative type: Fearful, anxious, seek control, potential for disaster everywhere. Critical of others - reflects their inner shame.

BPD – their perspective “ We are not making a rational decision to act inappropriately as such to involve law enforcement. Our brains have betrayed us and we have become out of control needing law enforcement to keep ourselves/and or those around us safe.” BPD Today Newsletter www.borderlinepersonalitydisordertoday.com

Taking a Closer Look PTSD and Trauma

PTSD ~ TRAUMA VICTIMS The person has been exposed to a traumatic event Experienced, witnessed or confronted with an event(s) that involved actual or threatened death or serious injury, or threat to physical integrity of self or others AND the person experienced intense fear, helplessness or horror.

Symptoms of Trauma Reliving the Event Recurrent & intrusive memories, nightmares, flashbacks, hallucinations, reaction to triggers. In kids: repetitive play, re-enactment, frightening dreams. Persistent Avoidance Efforts to avoid anything related to the event, inability to recall important parts of the trauma; not interested in usual activities, feeling detached from others, numbness,sense of doom. Increased Arousal Sleep problems; anger; problems concentrating; hypervigilance; exaggerated startle response

Acute Stress Disorder vs. PTSD Acute Stress Disorder Occurs within 4 weeks of the event, and lasts for a minimum of 2 days – maximum of 4 weeks. Similar symptoms as PTSD: numbness detachment “ in a daze” things seem unreal amnesia reliving avoidance anxiety & increased arousal distress & social or occupational impairment. PTSD When acute stress is not resolved it can develop into PTSD. Acute – less than 3 months from the event Chronic – 3 months or more from the event Delayed onset – symptoms don’t occur until 6 months or more after the event.

Taking a Closer Look Schizoaffective Disorder

Symptoms of a psychosis Symptoms vary from person to person and may change over time. The major symptoms of psychotic disorders are hallucinations and delusions. Hallucinations are unusual sensory experiences or perceptions of things that aren't actually present, such as seeing things that aren't there, hearing voices, smelling odors, having a "funny" taste in your mouth and feeling sensations on your skin even though nothing is touching your body. Delusions are false beliefs that are persistent and organized, and that do not go away after receiving logical or accurate information. For example, a person who is certain his or her food is poisoned, even if it has been proven that the food is fine, is suffering from a delusion.

What are the symptoms of a psychotic disorder? Other possible symptoms of psychotic illnesses include: Disorganized or incoherent speech Confused thinking Strange, possibly dangerous behavior Slowed or unusual movements Loss of interest in personal hygiene Loss of interest in activities Problems at school or work and with relationships Cold, detached manner with the inability to express emotion Mood swings or other mood symptoms, such as depression or mania

Schizoaffective Disorder One of the most difficult to diagnose and treat disorders Most clinicians and researchesrs believe it is a form of schizophrenia Blend of symptoms of schizophrenia and a mood disorder 2 – 5 out of 1000 people 2 types: Depressive and Bipolar

Schizoaffective Disorder Mood symptoms may or may not be present. Delusions and hallucinations. Anti-social and shunned – may be loners or lonely. Cycle of severe symptoms, then improvement. Stress makes symptoms worse. Strange, unusual thoughts & perceptions Paranoid thoughts & ideas: People are out to get me! Delusions (False fixed beliefs)persecution and conspiracy theories. Depression, mania. Irritability, poor temper control. Suicidal or Homicidal thoughts and behaviors. May be intelligent, and/or high functioning.

Assumptions that will help with BPD They are doing the best they can. They may not have caused all of their own problems, but they have to solve them anyway They want to improve. They need to do better, try harder, and/or be more motivated to change They can try new behaviors especially if they realize that what they have tried isn’t working. The lives of suicidal, BPD individuals are unbearable as they are currently being lived Linehan, Marsha M. 1993. Cognitive-Behavioral Treatment of Borderline Personality Disorder , The Guilford Press, New York, NY.

Communicate Listen to what the individual is saying and what is being distorted. “Just the facts” Decide how to respond in a way that calms things down and keeps your integrity intact. If there are children present, model good behavior. In communicating with someone who may have BPD, balance being understanding with problem solving (change).

TIPS for Communicating Effectively Be genuine and use an easy manner Be gentle Recognize that they are survivors and treat them with respect If they try to change the subject, use “broken record”. Ignore biting or sarcastic comments – Don’t take the bait. When establishing a boundary or limit, don’t discuss whether it is right or wrong. That is a non-issue. i.e., “Physical threats may be okay to you, but they are not to me.” Use “foot in the door/door in the face” technique. Provide support.

Show Compassion Let them know that you are aware they are emotionally upset and that there is probably a reason for that. “ I can see that you are very upset.” “ This seems very hard for you, will you consider letting me help you so things don't get worse?”

Strategies that are NOT Helpful: Avoid saying: You shouldn’t feel this way! You need to get over it! It’s not that big of a deal. Grow up! Maybe you should just kill yourself if it’s that bad. I can’t believe I’m seeing you again! I don’t care about your problems. Avoid: Yielding to the idealization or take sides; Getting excessively close; Becoming overly emotional or acting emotional; Punishing individual; Engaging in power struggle.

Helping Trauma Victims If you encounter someone who has experienced trauma: Reassure in a calm voice – Use their name frequently If having flashbacks, gently ground them to reality Offer them comforts: water, blanket, place to sit,etc. Breathing deeply helps If possible, stand beside them and tell them, “I'm right here, you're going to be okay, it's not happening now. Never come up from behind or startle Don't touch them without asking – start slowly Get them to talk to someone Remember they are afraid and don't feel safe

Create a sense of safety PTSD FEAR is the dominant emotion FIGHT, FLIGHT or FREEZE are the typical responses If an individual seems belligerent, consider if they are actually having a flashback They don't feel safe – help them feel safe

Resources for Trauma Response Critical Incident Stress Management Team Can assist first responders in managing stress related to intense situations that may affect ability to function, personal life and job performance Can assist groups in managing traumatic events in the workplace

Concerns related to psychotic disorders Homelessness, poverty & lack of support system Premature death from poor self care and substance abuse May be confused, disoriented, mute, or make up words. Suicide – 10% completion Misconception that they are always dangerous. When properly treated and free of drugs/alcohol, they are no more dangerous than anyone else. May think you can read their mind. Stress makes symptoms worse – decompensation. During decompensation phase may be a danger to self or others.

Helping the Psychotic Reassure them you don't want to hurt them. Go along with their delusions and paranoia – don't confront or try to argue them into reality. Get them to accept help from someone – ask if there is anyone they trust – call them. Get the family involved if possible. Get them safely to treatment – Baker Act. Hospitalize preferred over jail.

Resources : There is Hope Research has shown treatment works! Medications and therapy have been proven to be effective. Critical Incident Stress Management

Contact Information Paula Mendenhall, LMHC, LPHA 3802 Erlich Rd., Tampa, FL -and- 4809 Trouble Creek Rd., New Port Richey, FL 727-534-6621 [email_address]

References American Psychiatric Association, 11994. Diagnostic and Statistical Manual IV, Washington, DC Back from the Edge , Borderline Personality Disorder Resource Center, New York, Presbyterian Hospital, Westchester Division, White Plains, NY. BPD Today Newsletter. Available on line: www.borderlinepersonalitydisordertoday.com Dorfman, W.I., Walker, L.E., 2007. FIRST Responder's Guide to Abnormal Psychology: Applications for Police, Firefighters and Rescue Personnel , Springer Linehan, Marsha M. 1993. Cognitive Behavioral Treatment of Borderline Personality Disorder . The Guilford Press, New York, NY. Kreger, R. & Shirley, J.P., 2002. Walking on Eggshells , New Harbinger Publications, Oakland, CA Psychotic Disorders , Available on line: http://www.medicinenet.com/psychotic_disorders/article.htm#symptoms

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