Evaluating Treating Through Therapy For Borderline Personality Disorder Nursing Essay

Evaluating Treating Through Therapy For marginal Personality Disorder Nursing EssayDespite the legion(predicate) sermon options for citizenry with BPD, Many nonrecreationals in kind health run keep up to believe that constitution disobliges be untreat altered. This essay provides inference the put togetheriveness of cognitive behaviour Therapy (CBT) and dialectic Behaviour Therapy (DBT) with Borderline Personality Disorder.BackgroundTo visualise BPD, I will attempt to give a historical overview of BPD.In the 1800s, Philippe Pinel first utilise the French bourne manie sans delire (mania with come to the fore delirium) to designate those manybodys engaging in deviant behavior alone showing no signs of a legal opinion disturbance such as h anyucinations or delusions, psychiatry began to think approximately minimum disposition inconveniences as early as 1801. Although the meaning of the limit has commuted through umteen typographys on the subject over time, the writing of Cleckley and his use of the label psychopath in The Mask of Sanity brought the term into accepted us geezerhood (Meloy 1998). The Mask of Sanity is a book bring on verb solelyy by Hervey Cleckley first published in 1941 he gave the approximately real clinical description of psychopathy in the 20th century. An expanded interpretation of the book was published in 1982, when the name was changed from psychopathy to Personality Disorder. In 1972, newer editions of the book reflected a closer alliance with Kernbergss (1984) minimum level of spirit organization, in particular defining the structural criteria of the psychopaths identity integration, defensive operations and reality testing.The diagnosis delimitation was introduced in the 1930s to label patients with problems that seemed to yield somewhere in between neurosis and psychosis ( sight, 1938). In 1938, the psychoanalyst Adolph Stern first described most of the symptoms that are now considered as criteri a of delimitation derangement. He suggested the possible causes of the disturbance, and what he believed to be the most successful variation of psych new(prenominal)(a)apy for these patients, he withal renamed the disturbance again, and he named the indisposition by referring to patients with the symptoms he described as the border line throng (Freidel 2004).In 1940, the psychoanalyst Robert Knight introduced the concept of ego psychology into his explanation of moulding disorder. Ego psychology deals with handstal functions that allow us to stiffly combine our thoughts and feelings and to develop helpful responses to life around us. He suggested that volume with delimitation disorder perplex impairments in a lot of of these functions, and he referred to them as borderline states (Friedel 2004).The next important input was make by the psychoanalyst Otto Kernberg (1967) he introduced the term borderline reputation organisation. He proposed that mental disorders were decided by three distinctive record organisations psychotic, neurotic and borderline temperament. Kernberg has been a strong promoter of modified psychoanalytic therapy for patients with borderline disorder (Friedel 2004).Roy Grinker in 1968 published directs of the first re advance conducted on patients with borderline disorder, which he referred to as the borderline syndrome (Friedel 2004). The next major advance in the field occurred when G to a rase placeson and utterer (1975) published a widely acclaimed article that synthesized the relevant, published information on borderline disorder, and defined its major characteristics. Gunderson then published a specialized explore doer to enhance the accu set out diagnosis of borderline disorder. This instrument enabled look intoers over the macrocosm to verify the validity and integrity of borderline disorder. Subsequently, borderline somebodyality disorder first appeared in DSM-III as a bona fide psychiatrical diagnosis in 1980 (Friedel 2004).Personality disorder categories are non firm grounded in theory, nor are they empirically based (Livesley, 1998). Some critics say that someoneality disorder categories are so flawed that the best option is to subvert them and start afresh, but most pragmatists recognise that so much has been invested in them that they are very likelyhere to stay (Blackburn 2000a Livesley, 1998).Borderline character disorder is associated with real impairment, especially in relation to the capacity to indorse stable relationships as a result of personal and ruttish unbalance (NICE 2009). For many, the severity of symptoms and behaviours that characterise borderline disposition disorder, correlate with the severity of personal, genial and occupational impairments. However, this is not al shipway the case, and some people with what appears to be, in other ways, marked borderline genius disorder whitethorn be able to function at very high levels in their careers (St hot shot, 1993). Paris (1994) stated that round one-third of patients with BPD report severe abuse involving an incestuous perpetrator about one-third report milder forms of abuse and about one-third do not report abuse.Personality disorders are universal conditions studies indicate preponderance of 10-13% of the adult population in the community and are to a greater extent common among younger age groups (24-44 yrs) and equally distributed between males and females. However, the sex ratio for circumstantial types of temper disorder is variable e.g. antisocial record disorder is more than common among males, and borderline personality disorder more common amongst females (DOH 2003).cognitive Behaviour Therapy (CBT) piece of ass be seen as an umbrella term for many disagreeent therapies that share some common elements. The earliest form of cognitive Behavior Therapy was develop by Albert Ellis in the early 1950s. Aaron T.Beck independently developed another CBT approach, called Cognitive Therapy, in the 1960s. Cognitive Therapy rapidly became a preferred intervention to workplace in psychotherapy research in academic dumb raisetings. In initial studies, it was a great deal contrasted with behavioral words to see which was most telling. However, in recent years, cognitive and behavioral techniques hand often been combined into cognitive behavioral give-and-take. This is arguably the primary type of mental give-and-take cosmos studied in research today. champion specific form of cognitive- behavioral therapy is dialectic behaviour therapy (DBT), a broad-based, cognitive-behavioural programme developed specifically to reduce self-importance-harm in women with borderline personality disorders (Linehan, 1993a Linehan 1993b). Recent research has shown that dialectical behaviour therapy (DBT) is one of the first therapies that have demonstrated to be in effect(p) for treating borderline personality disorder as well as cosmos effective in treating people who display varied symptoms and behaviours associated with mood disorders, including self-harm. DBT combines standard cognitive-behavioural techniques for emotion convention and reality-testing with concepts of mindful-awareness, grief tolerance, and acceptance.1.2 RationaleAs a mental health cling to coming from a forensic background, I have interpret of working(a) with clients with personality disorder. I feel that by getting more of an judgement of CBT interventions, it will make a huge difference to my future trust in the future. McKenna et al (1999) state that it is unacceptable for health care not to be based on sound evidence of its effectiveness, and back up their practice with research-based evidence (NMC, 2008) to ensure effective clinical practice. Often nurses materialize it frustrating working with disorders of personality. These clients can be manipulative, socially inappropriate and difficult, for these reasons, such clients need all the patience and s kills nurses have to offer. Until recently, personality disorder services in the NHS had been diverse, spasmodic and inconsistent (Department of Health, 2003). Besides functional impairment and unrestrained distress, borderline personality disorder is also associated with significant financial cost to the healthcare system, social services and the wider society (NICE 2009).1.3 Aims and objectivesThe aims and objectives of this project are to analyse the evidence on the efficacy of Cognitive Behavioural Therapy and Dialectical Behaviour Therapy with people who have Borderline Personality.1.4 Methodology and parametersThis literature freshen was conducted victimization the following resourcesElectronic entropybases Cochrane library, CINHAL, Medline, Psychinfo, Psychology and Behavioural Sciences and Academic Search promethiumKey journals were hand searched British Journal of Psychiatry, Journal of Personality Disorders, intellectual Health Practice, Journal of Personality and M ental HealthUniversity and Trust librariesGoogle Google savantThe following types of literature were sought and reviewed where availableRandomised control trialstaxonomic and structured reviewQuantitative and Qualitative research studiesPosition statements/guidelines from professional bodiesGovernment policies (NICE (2009), NSF (1999)Text BooksInclusion and exclusion criteriaEligibility for this review was determined by the following criteria- Participants adults with BPD (diagnosed according to DSM-III/DSM-III-R, DSM-IV, DSM-IV-TR or ICD-10 criteria for BPD), with or without co-morbidity.- Intervention psychological therapies, including CBT, DBT- Comparators CBT/DBT or treatment as usual- Outcomes self-harm, self-annihilation, interpersonal and social functioning- pack type published papers were assessed according to the accepted hierarchy of evidence, whereby taxonomical reviews of RCTs are guiden to be the most authoritative forms of evidence, with anarchic empiric studie s the least authoritative.- Exclusion criteria papers on personality disorder without start out BPDsubgroup analyses.The studies were obtained through a number of sources, as above. Searches were performed by entering the discern words Borderline Personality Disorder, Cognitive behaviour therapy into several databases, which yielded many secondary references of current best evidence. Search filters developed consisted of a crew of subject headings. The topic-specific filters were combined with appropriate research design filters developed for doctrinal reviews, RCTs and other appropriate research designs. These articles were selected after(prenominal) careful reading of the deed of conveyance and abstract to identify the most useful. I then limited my search to full articles which made my search a lot easier. The definitive text that will be used to aid my search will be NICE Clinical Guidelines for Personality disorder 78. This guideline makes recommendations for the treatm ent and forethought of borderline personality disorder in adults and young people (under the age of 18) who meet criteria for the diagnosis in primary, secondary and tertiary care.Borderline personality disorder is present in just under 1% of the population, and is most common in early adulthood. Women present to services more often than men. Borderline personality disorder is often not formally diagnosed in the beginning the age of 18, but the features of the disorder can be identified earlier. Its personal line of credit is variable and although many people recover (NICE 2009). This search will plant twain British and international articles. When choosing which articles were going to be relevant, I prove it impossible to ignore the amount of articles I had on DBT and as DBT was evolved from CBT and made specifically for BPD, I decided to bring it into my research project.The articles are sundry(a) denary and qualitative research. The qualitative means of gathering subjectiv e data is centred on an individuals experience, beliefs, empowerment and quality of care and does not solely constrict on clinical outcomes for the individual. One could argue that this is the most appropriate verbal expression of research for mental health nurses as mental illness is individual for each person involved in the process and although BPD is not a mental illness The National Service Framework for adult mental health sets out our responsibilities to provide evidence based, effective services for all those with severe mental illness, including people with personality disorder who experience significant distress or difficulty (NIMH 2003). term these can be misconceived as an easy option form of research, qualitative research offers rich, reflective and everlasting(a) data that is invaluable and has a profound contribution to make to take to practice. The qualitative evidence was limited with regards to the treatments reviewed, with an emphasis on DBT. Quantitative rese arch is a formal, objective, and rigorous statistical process for generating information about the world (Burns Grove 1999), whereby the researcher would gather a range of numerical data in order to answer the research question, or prove, disprove a speculation (Parahoo 2006).Philosophies or schools of thought in research are called paradigms (Parahoo 2006). One such paradigm is positivism. Parahoo (2006) asserts that positivism relies on observations by the human senses to create fact (empiricism), and believe in the unity of science, and the notion of cause and effect (determinism). The positivist researcher will endeavour to test a hypothesis or theory victimisation the deductive process of a words of experiments. This paradigm utilises a quantitative approach in its research methods. For the positivists, quantitative research is believed to provide hard evidence and objective fact that can provide knowledge on which to base best practice (Parahoo 2006).efficacy studies focus on the usefulness of a specific helping methodological analysis for a particular kind of problem. Comparisons are made between the methodology in question and some other methodology between clients with some disorder who do receive the treatment and those who do not or between two different methodologies for treating the same disorder. These studies are carried out under controlled conditions. Many of the studies are well designed and demonstrate efficacy. In a healthcare context, efficacy indicates the capacity for beneficial change (or curative effect) of a given intervention.Chapter 2 The Literature ReviewHaving undertaken a critical review of the literature, I have come to explore a number of issues which I feel necessary to consider, key themes emerging from this literature review are the impact of CBT DBT on dangerous behaviours, the impact of CBT DBT on self-harming behaviours, and the impact of CBT DBT on ensnarlment. This chapter sets out to explore these themes in more detail. The most appropriate research design to answer this is the RCT therefore the evidence base reviewed comprised available RCTs undertaken in people with a diagnosis of borderline personality disorder.The causes of borderline personality disorder are complex and remain uncertain. The following may all be contributing factors genetics and constitutional vulnerabilities neurophysiological and neurobiological dysfunctions of unrestrained regulation and stress psychosocial histories of childhood maltreatment and abuse and disorganisation of aspects of the behavioural system, most particularly the attachment system (NICE 2009). The history of specific psychological interventions designed to help people with borderline personality disorder is intertwined with ever-changing conceptions of the nature of the disorder itself.Given the confusion that surrounds the nature of personality disorder, it is not surprising that this has impacted on NHS care for people with this diagnosis. Until recently, personality disorder services in the NHS had been diverse, spasmodic and inconsistent (Department of Health, 2003). Borderline personality disorder is particularly common among people who are drug and/or inebriant dependent, and within drug and alcohol services there will be more women with a diagnosis of borderline personality disorder than men (Swartz 1990). Borderline personality disorder is also more common in those with an eating disorder (Zanarini et al., 1998), and also among people presenting with chronic self-harming behaviour (Linehan et al., 1991).2.1 specify Cognitive Behaviour Therapy and Dialectical Behaviour TherapyCognitive behavioural therapy (CBT) is a structured psychological treatment that focuses on helping a person make connections between their thoughts, feelings and behaviour. CBT was originally developed as a treatment for depression, and has since been modified for the treatment of people with personality disorders including borderline pe rsonality disorder. CBT focuses on altering the thoughts, emotions, and behaviours of patients by teaching them skills to challenge and modify beliefs, to engage in experimental reality testing, and to develop better grapple strategies. The goals of these interventions are to minify the conviction of delusional beliefs, and hence their severity, and to promote more effective coping and reductions in distress. This essay will attempt to assess the contribution of CBT the disorder by discussing reviews on efficacy and long term set up. Cognitive behavioral therapyfor borderline personality disorder (CBT for BPD) was developed on the premise that people with the disorder have learned distorted beliefs and thought patterns. These, in turn, result in the distressing emotional responses and behaviors that characterize borderline personality disorder. It is the initial objective of CBT forBPDtoidentify the distorted, automatic thoughts andbeliefs held by the patient with borderline diso rder. much(prenominal) beliefs outlined by Beck Freeman(1990) typically include those related to dependency (I am needy and weak),distrust(People will get me if I dont get them first), rigid, all-or-nothing (dichotomous) perceptions,and other thought patternsthat characterize the main cognitive-perceptual symptoms of the disorder. These distorted thoughts are then modified by self-monitoring,logical analysis and by questioning and testing them.It is adapted for people with borderline personality disorder and pays attention to the structure of the therapy and the problems that can disrupt the therapeutic relationship, such as non- appointee in treatment, shimmy problems and goals, losing focus on the aims of therapy, losing structure and lack of compliance with assignments (Davidson, 2000). In addition, CBT for BPD attempts to puddle positive change by improving the attitude of the patient toward treatment, the enhancement of specific skills, and the reduction of hopelessness. Th e CBT therapist and the patient typically construct a list of specific problem areas. They then develop a set of tasks or exercises that generate and reinforce new attitudes, behaviors, and interpersonal strategies that replace the ones that have proven to be ineffective.Within the past 15 years, another, newer psychosocial treatment termed Dialectical Behaviour Therapy (DBT) was developed. DBT combines standard cognitive behavioural techniques with acceptance based strategies, as well as strategies designed to keep the therapy balanced between change and acceptance (dialectical strategies). Marsha M. Linehan, a psychologist from the University of Washington in Seattle, developed DBT specifically for people with BPD, especially those who engage in frequent self-destructive and self-injurious behaviours. DBT is based on the belief that the symptoms of BPD result from biological impairments in the brain mechanisms that regulate emotional responses. The early behavioural effects of thi s impairment are magnified, as the person with this biological risk factor interacts with people who dont validate their emotional fuss and dont help them learn effective coping skills. DBT has gained considerable favour in the treatment of BPD because of the results it has achieved in several research studies. It has been shown that DBT can be taught to and used by many, but not all, mental health professionals. For the time being this seriously limits the broad use of this effective treatment approach. DBT seeks to validate feelings and problems, but it balances this acceptance by gently pushing to make productive changes. DBT also deals with other opposing or dialectical tensions or conflicts that arise, such as the patients perceived need for a high level of dependence on the therapists and others, and the fear and guilt aroused by such uppity dependency. DBT combines both cognitive and behavioural techniques and designed specifically to treat BPD. It is a combination of indi vidual psychotherapy and psychosocial skills training that has been shown via controlled clinical trial to be effective in treating individuals with BPD (Linehan, 1993b). In practice, the limiting factor in providing access to psychological therapies is the very small proportion of NHS staff trained to deliver these to a competent standard. Fourteen women with borderline personality disorder were interviewed to ascertain what is effective about DBT and why (Cunningham et al., 2004).Participants describe that DBT allowed them to see the disorder as a controllable part of themselves rather than something that controlled them, providing them with in additionls to help them deal with the illness. Service users reported that DBT had had a positive effect on their relationships in day-to-day interactions, and although problems with friends and family did not disappear, they were more manageable (NICE 2009). Clients also expressed higher levels of hope and a desire to live more independe ntly (Cunningham et al., 2004)2.2 Suicidal actsDefinition tump over life threatening resulted in medical attention medical appraisal consistent with suicide attempt.Suicide is common in people with borderline personality disorder and may occur several years after the first presentation of symptoms (Paris Zweig-Frank, 2001). A well-documented association exists between borderline personality disorder and depression (Skodol et al., 1999 Zanarini et al., 1998), and the combination of the two conditions has been shown to increase the number and unassumingness of suicide attempts (Soloff et al., 2000). People with borderline personality disorder may engage in a variety of destructive and driving behaviours including self-harm, eating problems and excessive use of alcohol and illicit substances. Self-harming behaviour in borderline personality disorder is associated with a variety of different meanings for the person, including relief from acute distress and feelings, such as emptines s and anger, and to reconnect with feelings after a period of dissociation. As a result of the frequency with which they self-harm, people with borderline personality disorder are at increased risk of suicide (Cheng et al, 1997), with 60 to 70% attempting suicide at some point in their life (Oldham, 2006). The rate of completed suicide in people with borderline personality disorder has been estimated to be approximately 10% (Oldham, 2006). A behavioural approach to self-harm and suicidality that incorporated skills training in emotion regulation and validation of client experience developed into dialectical behaviour therapy (DBT), a specific intervention for borderline personality disorder. Cognitive-behavioural therapy along the lines of Beck, Freeman, Associates (1990) has been investigated in at least two uncontrolled trials. Brown, Newman, Charlesworth, and Chrits-Cristoph (2003) found significant decreases on suicide ideation, hopelessness, depression, number of BPD symptoms, and dysfunctional beliefs after 1 year of cognitive-behavioural therapy for suicidal or self-mutilating patients with BPD. Results were keep at a 6 months follow-up. Effect sizes were moderate (0.22-0.55). Dropout rate was 9.4%. Arntz (1999a) found positive effects of long-lasting cognitive-behavioural therapy in a mixed sample of personality disorders, including 6 patients with BPD. Two patients with BPD dropped out prematurely, but the other quaternion attained not bad(predicate) results.A randomized clinical trial was conducted by Linehan et al. (1991) with 44 subjects to appraise the effectiveness of DBT for the treatment of chronically parasuicidal women who met criteria for BPD. Patients who authentic DBT had an average of 8.46 inpatient geezerhood per year compared to 38.86 eld for the control group. It was also remark that it did not appear that there were differences between the two groups on measures of depression, hopelessness, suicide ideation, or reasons for l iving. Linehan et al. (1993) conducted a naturalistic follow-up review of 39 of these subjects to determine whether the effects of DBT were maintained over one year post treatment. In the 12 to 18 month period, subjects completing DBT had fewer parasuicidal episodes and fewer medically handle episodes. In the 18- to 24-month period, there were no significant between-group differences on parasuicide measurements, although psychiatric inpatient days during this time were lower for subjects in the DBT group.Rathus et al. (2002) conducted a study with a group of suicidal adolescents with borderline personality features. Participants included 111 outpatient admissions. Eighty-two participants were assigned to treatment as usual (TAU) and 29 were assigned to DBT. The groups were not randomized, but it was noted that there was more severe pre-treatment symptomtology in the DBT group than the TAU group. The group treated with DBT had significantly fewer inpatient psychiatric hospitalisatio ns during the 12 weeks of treatment. The groups did not differ significantly in number of suicide attempts made during treatment. There was a slightly higher rate of treatment completion in the DBT group.Hengeveld et al (1996) report a case series of nine female outpatients who had seek suicide on at least two occasions and were offered up to ten sessions of group CBT. Seven of the nine met criteria for personality disorder and of these quad had borderline personality disorder. Ten months after the last session, recurrence of self-harm was examined using sound contacts with participants and examination of hospital records. Four of the seven participants reported get on suicide attempts all four had borderline personality disorder.Linehan et al. (2006) conducted a yearly randomized controlled trial with one year of post-treatment follow up. The objective was to evaluate the hypothesis that unique aspects of DBT are more efficacious compared to treatment offered by non-behavioural psychotherapy experts. The study included 101 female participants with recent suicidal and self-injurious behaviours that met DSM-IV criteria. The subjects who standard DBT were half as likely to make a suicide attempt.2.3 Suicidal actsDefinition deliberate resulted in visible tissue damage, nursing or medical intervention required.Self-harming behaviour in borderline personality disorder is associated with a variety of different meanings for the person, including relief from acute distress and feelings, such as emptiness and anger, and to reconnect with feelings after a period of dissociation. As a result of the frequency with which they self-harm, people with borderline personality disorder are at increased risk of suicide (Cheng et al., 1997). Service users have been positive about DBT because it has helped them to improve their relationships and their ability to control their emotions and reduce self harm. However, while some valued the structure of the approach, others prefe rred the programme to be more tailored and flexible.In a large sample, Tyrer et al (2003) found that CBT was equivalent to TAU for the treatment of recurrent self-harm and noted that this method was less effective for patients with BPD.Brown (2004) conducted an uncontrolled cohort study participants with borderline personality disorder who reported suicidal ideation or engaged in self-injurious behaviour received weekly CBT over a 12-month period and were followed up over an 18-month period. item-by-item sessions lasting 1 hour were supplemented by access to emergency telephone contact with an on-call therapist between sessions.Verheul et al. (2003) conducted a randomized controlled study for the mean of comparing the effectiveness of DBT with TAU for patients with BPD and to examine the impact of baseline severity on effectiveness. The study included 58 women who were randomized to either DBT or TAU and who received treatment over one year. The results included DBT had a substant ially lower 12-month attrition rate (37%) compared with TAU (77%) treatment with DBT resulted in greater reduction of self-mutilating and self-damaging impulsive acts than TAU.Van den Bosch et al. (2005) published a follow-up review of this study that examined whether the treatment results in the Verheul study were sustained over six-month follow-up or up to week 78. It was noted that in the six months after treatment discontinuation, the benefits of DBT over TAU in terms of lower levels of impulsive and self-mutilating behaviours were sustained. However, it must be noted that parasuicide activity had been defined in slightly different ways in the RCTs and therefore might not be comparable crosswise studies.Alper (2001) presents outcome data on a case series of 15 court committed women with a clinical diagnosis of borderline personality disorder that underwent treatment with nurse-led DBT in an inpatient forensic setting. There was a reduction in the frequency of self-harm over the 4-week period. In addition, the authors conducted qualitative interviews with four nurses to describe their experience of administering DBT their responses were uniformly positive.Bateman Tryer (2004) state that the widespread adoption of dialectical behaviour therapy is a tribute both to the energy and charisma of its founder, Marsha Linehan, and to the attraction of the treatment, with its combination of acceptance and change, skills training, excellent manualisation, and a climate of opinion that is will and able to embrace this multifaceted approach. It is not, however, justified by the strength of the evidence (Tyrer, 2002b) and conclusions about the long-term effectiveness of this therapy as a treatment for the personality itself are premature. Since the original trial which was handicapped by many methodological limitations, there has only been one randomised study that supports the findings unequivocally, that of Verheul et al (2003).2.4 non-involvementFor effective treat ment, commitment to therapy is required, and research shows that fewer people drop out of DBT than other therapies (verheul et al 2003)According to service users interviewed by Haigh (2002), services could be improved if professionals acknowledged that personality disorder is treatable they received a more positive experience on initial referral as this would make engagement with a service more likely if the ending of a therapeutic relationship was addressed adequately and if services were not removed as soon as people showed any signs of improvement, because this tended to increase anxiety and caution maintenance of any improvement. In a study by Hodgetts and colleagues (2007) of tailfin people with borderline personality disorder being treated in a DBT service, the participants reported that DBT was presented to them as the only treatment for personality disorder. This may have raised anxieties in service users about what was expected of them. While some valued the sense of stru cture to the treatment, others would have preferred a more tailored and flexible approach. There were also mixed feelings about the combination of individual therapy and group skills training. For one person the challenges of DBT proved too much so she left the programme. Another factor in her going was that she believed she was refused supp