Agenda. Treating the Suffering of Mood and Behavioral Dysregulation

Transcription

1 Treating the Suffering of Mood and Behavioral Dysregulation Barbara J. Limandri, DNSc, APRN, BC Linfield College School of Nursing Agenda Behavioral and biological processes of mood dysregulation Similarities & differences in mood dysregulation of borderline and bipolar disorders Behavioral strategies to modify mood dysregulation Biological strategies to modify mood dysregulation Barbara Limandri, DNSc, APRN, BC 1

2 Suffering Four Noble Truths of Buddhism Suffering exists. There is a cause for suffering. There is an end to suffering. In order to end suffering, you must follow the Eightfold Path The Eightfold Path Discernment, wisdom Right understanding of the Four Noble Truths Right thinking, following the right path Virtue, morality Right speech Right conduct Right livelihood Concentration, meditation Right effort Right mindfulness Right concentration Barbara Limandri, DNSc, APRN, BC 2

3 Suffering and Dysregulation One of the deepest forms of suffering in our culture is the pain of feeling that "something is wrong with me." Radical acceptance is the capacity to see clearly what is happening in the moment, and to accept what we see with love. (Lotus in the Mud) Suffer from invalidation of self React with intensity & sensitivity The BPDs According to DSM Borderline Personality Frantic efforts to avoid abandonment Unstable & intense IPR Identity disturbance Impulsivity Recurrent suicidality/selfharm Affective instability Chronic emptiness Intense anger Bipolar Disorder Abnormally elevated, expansive mood Inflated self-esteem Decreased need for sleep More talkative & pressured Distractibility Increased goal-directed activity Excessive involvement in risky activities Barbara Limandri, DNSc, APRN, BC 3

4 Dialectical Behavior Therapy CBT with emphasis on behavior Additional Buddhist principles of mindfulness and balance (dialectic) Focus on behavior dysregulation Emotional Behavioral Interpersonal Cognitive Self Research Synthesis on DBT NIMH and NIDA randomized clinical trials indicate is more effective than treatment as usual for clients with borderline personality disorder and with comorbid substance abuse RCT study in Netherlands produced similar results independent of Linehan s group Treatment based on established protocols to assure fidelity of treatment. Barbara Limandri, DNSc, APRN, BC 4

5 Treatment Structure Occurs in three phases Phase I: Stabilization Phase II: Expansion of emotional experience Phase III: Addressing problems of living Target Behaviors With Skills Mindfulness Distress Tolerance Emotional Regulation Interpersonal Effectiveness Problem Solving Barbara Limandri, DNSc, APRN, BC 5

6 Tools of DBT Individual therapy Group skills training Telephone consultation/coaching Consultation to team Consultation to family Behavioral Chain Analysis Describe the problem behavior Describe specific precipitating event Describe vulnerability factors Describe in detail what led up to the behavior What are the consequences? What are different solutions How to prevent reoccurrence What to do to repair the relationship Barbara Limandri, DNSc, APRN, BC 6

7 Biological Strategies Client assessment and consultation Medication evaluation & follow up Client education Consultation to the client Consultation to the team Consultation to the family Prescribing Principles Medications treat the brain, not the diagnosis Symptom focused Targeting behaviors with medications Eliciting client motivation Addressing hypersensitivities Collaboration, not coercion Barbara Limandri, DNSc, APRN, BC 7

8 Prescribing Relationship Therapy & prescribing Establishing trust Repairing the relationship Radical irreverence Radical acceptance Ending the relationship Complex Client Presentations Aryel: PTSD, MDD, BPD Susan: BPD x 2, Substance abuse, Anorexia Daryl: Substance abuse, MDD Karem: Conduct D/O, PTSD, Substance abuse Barbara Limandri, DNSc, APRN, BC 8

9 Process of Case Analysis Assessment: what else needs to be known? Describe behaviors Validation Target behavior with problem solving & use of skills Establish a commitment Aryel 42 yo, Eastern European, married lesbian, with a 14 yo son and 16 yo daughter, lawyer (failed bar x 3) Multiple diagnoses: MDD, BPD, PTSD Childhood sexual abuse by brother, raped in high school, disowned by parents Symptom presentation: agitated, irritable, depressed, chronic insomnia, tearful amotivational, anhedonia, emotional eating, hypervigilance, exaggerated startle, difficulty concentrating, hypersensitive, panic attacks Barbara Limandri, DNSc, APRN, BC 9

10 Aryel s Medications Previous: all the SRI s (they don t work), Wellbutrin, Ambien, Lunesta, Restoril, Xanax, Ativan, Klonopin, Adderall, diet pills Susan 28 yo Anglo divorced mother of 8 year old daughter Multiple diagnoses: Bipolar, ADD, Borderline PD, Anorexia, substance abuse During 8 th grade (14 yo) used meth consistently x 1 yr Married at 18 yo and divorced at 21 yo Sx presentation: very anxious, tearful, angry, easily frustrated, difficulty listening, sensitive to criticism, chronic pain Barbara Limandri, DNSc, APRN, BC 10

11 Susan s Medications Previous: Concerta, Adderall, Strattera, Guanfacine, Clonidine, Zoloft, Prozac, Paxil, Celexa, Lexapro, Wellbutrin, Effexor, Cymbalta, Xanax, Ativan, Klonopin, Seroquel, Zyprexa, Abilify, Geodon, Haldol, Lithium, Depakote, Lamictal, Neurontin, Oxycodone, Percocet, Fentynl Daryl 32 yo single, Anglo man, 2 yrs college, sommelier, cohabitating with girlfriend Multiple diagnoses: MDD, substance abuse, Domestic violence Many relationships but none for longer than 2 years, estranged from family Has been drinking since 11 yo, used meth x 1 ½ yrs (18-19 yo), cocaine intermittently, pot daily, neither pot nor alcohol are problems. Symptom presentation: angry, sad, externalizes feelings, sensitive to criticism, poor concentration, hypersexual, poor appetite, chronic pain from back injury Barbara Limandri, DNSc, APRN, BC 11

12 Daryl s Medications Previous: Zoloft and Prozac (inhibited sexual response), Oxycodone, Hydrocodone Karem 16 yo African American, ward of the court, school refusal Diagnoses: Conduct D/O, PTSD, substance abuse (pot, meth, alcohol) Multiple assault charges of teachers, foster parents, peers Unknown father, mother in prison for child abuse, 4 siblings in different foster care, multiple physical & sexual abuse Symptoms: angry, excess sleep, poor appetite, amotivation, anhedonia, poor impulse control, cognitive difficulties Barbara Limandri, DNSc, APRN, BC 12

13 Karem s Medication Prozac, Zoloft, Lithium, clonidine Barbara Limandri, DNSc, APRN, BC 13