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Dialectical Behavior Therapy and Old-Fashioned, Good Communication
Sarah Ritter, MA, MSN, RN, APN, PMHNP-BC;
and Lois M. Platt, MS, PMHNP-BC, LCPC
N
ABSTRACT urses working on psychiatric
Psychiatric unit inpatients often have serious mental illnesses with comorbid inpatient units must manage
difficult patient behaviors.
personality disorders. Mental illnesses usually respond favorably to medication
Some of the most challenging behav-
and psychotherapy, but personality disorders do not. Two personality disorders iors are exhibited by patients with
are commonly seen on inpatient units: borderline and antisocial. These person- comorbid personality disorders, espe-
ality disorders may destabilize the milieu with disruptive behaviors and present cially borderline and antisocial per-
sonality disorders. In addition to pro-
a challenge to nurses. Difficult patient behaviors and therapeutic responses by tecting other patients and the milieu,
nurses are examined. Dialectical behavior therapy techniques and good com- nurses must interact therapeutically
munication skills may be used by nurses to (a) interact therapeutically with pa- with patients with personality disor-
ders, who may be disruptive. Good
tients with personality disorders and (b) protect other patients and the milieu.
communication skills in combina-
[Journal of Psychosocial Nursing and Mental Health Services, 54(1), 38-45.] tion with dialectical behavior therapy
(DBT) give nurses the tools to manage Manual of Mental Disorders Cluster B staff to disagree about patient carea
some of the more destabilizing inpa- personality disorders: antisocial person- maneuver related to the ego defense
tient behaviors. ality disorder (ASPD) and borderline mechanism called splitting (Zanarini,
Personality disorders are character- personality disorder (BPD) (American Frankenburg, & Fitzmaurice, 2013).
ized by longstanding patterns of impair- Psychiatric Association [APA], 2013; Self-harm behaviors, such as cutting,
ment apparent in multiple domains, Langton, Hogue, Daffern, Mannion, burning, or scratching, are common
including cognition (e.g., perceptual & Howells, 2011). ASPD and BPD are among patients with BPD (Roth &
abnormalities, disruptions in the expe- characterized by impulsivity, manipu- Press, 2003). These behaviors neces-
rience of self), emotion (e.g., excessive lative behavior, irritability, and some- sitate watching the patient closely and
reactivity or intensity), interpersonal times aggression. may tax staffing resources. The hall-
behavior (e.g., social isolation, high- mark of BPD is avoidance of abandon-
conflict relationships), and impulse con- Antisocial Personality Disorder ment, either real or imagined. Patients
trol (Matusiewicz, Hopwood, Banducci, In forensic samples, the incidence with BPD may lie to gain admiration or
& Lejuez, 2010). Managing any of these of ASPD is estimated to be as high as nurturance from staff and often engage
behaviors on an inpatient psychiatric 70% (APA, 2013); the percentage is in power struggles.
unit is challenging, but violence (to less on general psychiatric units. Black,
self or others), aggression, and manipu- Gunter, Loveless, Allen, and Sieleni DISRUPTIVE BEHAVIOR
lation are usually the most problematic. (2010) note significant comorbidity On inpatient units it is common to
Often psychiatric unit inpatients are with BPD, substance use, and high see several types of disruptive behavior
treated for serious mental illnesses, such suicide risk. ASPD is characterized by exhibited by patients with ASPD and
as schizophrenia, bipolar disorder, and a pervasive pattern of disregard for, BPD. Each behavior is briefly examined.
major depression. These illnesses gen- and violation of, the rights of others.
erally respond to psychotropic medica- Patients with ASPD may demonstrate Aggression and Violence
tion with symptom stabilization. How- deception, criminality, lack of remorse, Aggressive and violent behaviors
ever, approximately one half of patients and a sense of entitlement (APA, 2013). may be the most distressing for staff
on an inpatient unit have comorbid Individuals with ASPD have also been and other patients. Although patients
personality disorders (Adshead & characterized by a tendency to malinger with serious mental illness, such as
McGauley, 2010). Although medi- and manipulate others for their own schizophrenia, psychosis, and bipolar
cation may help decrease distressing gain (Byrne, Cherniack, & Petry, disorder, may behave violently, the
symptoms, such as impulsive aggres- 2013; Kucharski, Falkenbach, Egan, & combination of psychotherapy and
sion and suicidal behavior (Howland, Duncan, 2006). Suicidal threats may medication may help these patients
2007), patients with severe personality be manipulative or genuine and must control behavior, given enough time.
disorders may continue to behave in be carefully assessed. Often irritable However, patients with personality
ways that are disruptive or destructive and violent, these patients may blame disorders may continue to have violent
because of their personality structure. the victim and experience frequent outbursts as a result of their personality
Currently, no U.S. Food and Drug arrests. Lying and stealing are typical structure rather than acute mental ill-
Administrationapproved drug treat- behaviors, as well as impulsivity, lack ness. Abracen et al. (2014) noted that
ment exists for aggression; prescribers of insight, and bad judgment. Patients BPD and ASPD are among the person-
often use a trial-and-error method, with ASPD may also be charming and ality disorders most likely to commit
which may complicate the clinical superficially likable, which allows them two or more instances of violence.
picture. Mauri et al. (2011) note that to manipulate others more effectively. Another distressing behavior
the effects of psychotropic drugs on present on psychiatric inpatient units
aggression and violence are unclear and Borderline Personality Disorder is pre-meditated versus impulsive vio-
undifferentiated. The occurrence of BPD on psychi- lence. In patients with ASPD, manipu-
atric inpatient units is estimated to be lative behavior may take the form of
OVERVIEW OF THE TERRIBLE TWO between 20% and 40% (Aguirre, 2012; calculated (or instrumental) violence
PERSONALITY DISORDERS APA, 2013; van den Bosch, Sinnaeve, for a perceived gain (Walsh, Swogger,
The two personality disorders most Hakkaart-van Roijen, & van Furth, & Kosson, 2009). In this case, the
likely to be seen on psychiatric inpa- 2014). Patients with BPD tend to dis- nurse must be aware of the patients
tient units are among those in the fifth rupt the milieu and interfere with other history and intervene by keeping other
edition of the Diagnostic and Statistical patients treatment. They often cause patients safe.