2012

PERSONALITY DISORDERS

COMPETENCIES
Given relevant questions and case scenarios the students will be able to : 1. place the personality disorders within their respective clusters. 2. describe the most appropriate interventions in the treatment of individuals with personality disorders

Personality: an ingrained, enduring pattern of

behaving and relating to self, others, and the environment; behaviors and characteristics are consistent across a broad range of situations and do not change easily

Personality disorders: when personality traits

become inflexible and maladaptive and significantly interfere with how a person functions in society or cause the person emotional distress; usually not diagnosed until adulthood; maladaptive behavior can be traced to early childhood or adolescence

PERSONALITY DISORDERS OVERVIEW

Behavioral features are rigid and inflexible

Resulting

in distress and maladaptive coping with self, but others find distressing

Ego syntonic:
Comfortable

PERSONALITY DISORDERS OVERVIEW

Axis II diagnosis Ten identified disorders Eleventh Personality Disorder Not Otherwise Specified (NOS)

Passive-aggressive

personality disorder Self-defeating personality disorder

PERSONALITY DISORDERS

Prevalence of personality disorders

Often

difficult to discern due to frequent comorbidity of other diagnoses Most common comorbid diagnoses:
Mood

disorders Substance-related disorders Anxiety disorders Attention-deficit hyperactive disorders

DSM-IV-TR CATEGORIES

Cluster A: people whose behavior is odd or eccentric (paranoid, schizoid, schizotypal) Cluster B: people who appear dramatic, emotional, or erratic (antisocial, borderline, histrionic, narcissistic) Cluster C: people who are anxious or fearful (avoidant, dependent, obsessive-compulsive) Disorders being considered for inclusion are depressive and passive-aggressive

ONSET AND CLINICAL COURSE

Personality disorders occur in 10% to 13% of the general population Incidence is even higher in lower socioeconomic groups 40% to 45% of people with a primary diagnosis of major mental illness also have a coexisting personality disorder that significantly complicates treatment

Clients with personality disorders have:

Higher death rates, especially as a result of suicide Higher rates of suicide attempts, accidents, and emergency department visits Increased rates of separation, divorce, and involvement in legal proceedings regarding child custody Increased rates of criminal behavior, alcoholism, and drug abuse

ETIOLOGY

Genetics Temperament Psychosocial factors Character Self-directedness Cooperativeness Self-transcendence

CAUSATIVE FACTORS: THEORIES AND PERSPECTIVES

Psychodynamic theories
Personality
Oral Anal Genital

develops through orderly progression of psychosexual stages (Freud) :

(Oedipal)

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CAUSATIVE FACTORS: THEORIES AND PERSPECTIVES

Understanding ego development

Developmental
Personality

stages

originates in the prenatal period Oral stage (Freud)

Infant is totally dependent on primary caregiver

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CAUSATIVE FACTORS: THEORIES AND PERSPECTIVES

Understanding ego development

Developmental
Trust

stages

(Erikson)

Trust basic to healthy personality development and adaptive responses Healthy ego develops

If

child perceives world as loving and accepting

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CAUSATIVE FACTORS: THEORIES AND PERSPECTIVES

Neurobiological theories
Low

levels of serotonin implicated in:

Impulsivity Aggression Suicidal

gestures

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CAUSATIVE FACTORS: THEORIES AND PERSPECTIVES

Neurobiological theories
Low

levels of Monoamine oxidase resulting in elevated levels of dopamine Brain structure abnormalities EEG abnormalities

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CAUSATIVE FACTORS: THEORIES AND PERSPECTIVES

Genetic factors
Links

found for development of:

behavior Antisocial personality

Antisocial

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CAUSATIVE FACTORS: THEORIES AND PERSPECTIVES

Genetic factors
Studies

also indicate that the development of these can be modified by good parental care Genetic characteristics in combination with environmental forces are the most likely factor in PD

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CAUSATIVE FACTORS: THEORIES AND PERSPECTIVES

Temperament
Thought

to influence personality development Temperamental differences apparent within first months of life become more dramatic in second six months of life Studies associate temperament with a variance between child and environment

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CAUSATIVE FACTORS: THEORIES AND PERSPECTIVES

Child abuse
High

prevalence of child abuse in the histories of clients with maladaptive behaviors High prevalence of sexual abuse in clients with borderline PD

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PERSONALITY DISORDER ISSUES ACROSS THE LIFE SPAN

Infancy
Infants

have:

Preformed

organization Rhythmically organized behaviors Internal states associated with organization

Evidence

of happy expectation and satisfaction of self in well-nurtured infants

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PERSONALITY DISORDER ISSUES ACROSS THE LIFE SPAN

Childhood
Separateness
Child

evolves

needs reassurance Praise for steps taken toward independence

Language
Prime

develops

example of a rule-directed organization of the ego Miller (1979)

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PERSONALITY DISORDER ISSUES ACROSS THE LIFE SPAN

Childhood
Childhood
Conduct

personality disorders:

disorders Oppositional defiant disorder

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PERSONALITY DISORDER ISSUES ACROSS THE LIFE SPAN

Adolescence
Demonstrate

oppositional defiant and conduct

disorders Positive self-esteem is the core struggle with the search for identity

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PERSONALITY DISORDER ISSUES ACROSS THE LIFE SPAN

Adolescence
Impairments
Acting

in ego and superego development are considered major cause of maladaptive behavior
out Extreme hostility toward authority figures

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PERSONALITY DISORDER ISSUES ACROSS THE LIFE SPAN

Adulthood
Healthy

behavior depends on mastering early developmental tasks Ability to use adaptive coping skills depends on:
Emotional

repertoire Experience and perceptions of stressors Available support systems

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PERSONALITY DISORDER ISSUES ACROSS THE LIFE SPAN

Older adulthood
Older

adults reach greater stability in social and occupational function Clients are influenced by internal and external stimuli

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PERSONALITY DISORDER ISSUES ACROSS THE LIFE SPAN

Older adulthood
Challenged

to use previous life experiences to cope with aging process Antisocial behaviors present in earlier years generally become less of a problem

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A psychiatric technician mentions to the nurse, I think I heard the ED doctor say that the patient I just brought to the unit has a personality disorder. To follow up on this, the nurse could look at the diagnostic sheet under the DSM-IV-TR axis: A. I B.II. C.III. D.IV.

CULTURAL CONSIDERATIONS

Guarded or defensive behavior may be displayed as a result of language barriers or previous negative experiences and should not be confused with paranoid personality disorder People with religious or spiritual beliefs, such as clairvoyance, speaking in tongues, or evil spirits as a cause of disease, could be misinterpreted as having schizotypal personality disorder

CULTURAL CONSIDERATIONS (CONTD)

An emphasis on deference, passivity, and politeness should not be confused with a dependent personality disorder Cultures that value work and productivity may produce citizens with a strong emphasis in these areas; this should not be confused with obsessivecompulsive personality disorder Social stereotypes about gender roles and behaviors can influence diagnosis of certain personality disorders

TREATMENT Many people with personality disorders do not seek treatment because they dont believe they have a problem Individual and group therapy may be helpful to those desiring change, but any changes are slow Improvement in relationships, improved basic living skills, relief of anxiety may be goals of therapy Cognitive-behavioral techniques such as thoughtstopping, positive self-talk, and decatastrophizing can be effective

Pharmacologic treatment is based on the type and severity of symptoms rather than the particular personality disorder itself. Four symptom categories include:

Cognitive-perceptual distortions including psychotic symptoms Affective symptoms and mood dysregulation Aggression and behavioral dysfunction Anxiety

PHARMACOLOGIC TREATMENT FOR SYMPTOMS

Cognitive-perceptual disturbances (magical thinking, odd beliefs, illusions, suspiciousness, ideas of reference, and low-grade psychotic symptoms) Low-dose antipsychotic medications Mood dysregulation (emotional instability, emotional detachment, depression, and dysphoria) Lithium, carbamazepine (Tegretol), valproate (Depakote), low-dose neuroleptics, SSRIs, MAOIs, atypical antipsychotics Aggression (predatory or cruel behavior, impulsivity, poor social judgment, and emotional lability) Lithium, anticonvulsant mood stabilizers, benzodiazepines, and lowdose neuroleptics Anxiety SSRIs, MAOIs, or low-dose antipsychotics

INDIVIDUAL AND GROUP PSYCHOTHERAPY

Focus is on building trust, teaching basic living skills, providing support, decreasing distressing symptoms, and improving interpersonal relationships. Cognitive-behavioral therapy Basic living skills for people with cluster A personality disorders Inpatient hospitalization to provide safety for people with borderline personality disorder Assertiveness training groups for people with cluster C personality disorders Relaxation or meditation techniques for people with cluster C personality disorders

When planning education for the family of a patient with a personality disorder, the fact that can be included is that personality disorders: A.involve traits that are dysfunctional and inflexible. B.cause little subjective distress or impaired functioning. C.involve only one aspect of personality. D.result in symptoms that are simple to manage.

Patients with personality disorders suffer lifelong inflexible and dysfunctional patterns of relating and behaving. The patient experiences subjective distress, usually based on others reactions to him or her, and functioning is impaired. More than one aspect of personality is involved: personality disorders are described as pervasive. Behaviors are complex and difficult to manage

CLUSTER A PERSONALITY DISORDERS

Paranoid personality disorder Schizoid personality disorder Schizotypal personality disorder

PARANOID PERSONALITY DISORDER

Clinical Picture

Mistrust and suspiciousness, aloof and withdrawn, guarded or hypervigilant, restricted affect, use the defense mechanism of projection Approach in a formal, business-like manner, keep commitments, be straightforward, involve them in formulating their care plans, help them learn to validate ideas before taking action

Nursing Interventions

SCHIZOID PERSONALITY DISORDER

Clinical Picture

Detached from social relationships, restricted affect, aloof and indifferent, no leisure or pleasurable activities, do not report feeling distressed about lack of emotion, intellectual and accomplished with solitary interests, indifferent to praise or criticism, dissociate from or no bodily or sensory pleasures Improve functioning in the community, make referrals to social services, provide care that accommodates the desire for solitude

Nursing Interventions

SCHIZOTYPAL PERSONALITY DISORDER

Clinical Picture

Acute discomfort in relationships, cognitive or perceptual distortions, eccentric behavior, bizarre speech, affect flat and sometimes inappropriate

Nursing Interventions Promote self-care, social skills, and improved functioning in the community

A nursing diagnosis appropriate to consider for a patient with any of the personality disorders is: A.noncompliance. B.impaired social interaction. C.disturbed personal identity. D.disturbed sensory perception.

Without exception, individuals with personality disorders have problems with social interaction with othershence, the diagnosis of impaired social interaction. For example, some individuals are suspicious and lack trust, others are dependent, and still others are manipulative. None of the other diagnoses are universally applicable to patients with personality disorders; each might apply to selected clinical diagnoses, but not to others

CLUSTER B PERSONALITY DISORDERS

Antisocial Borderline Narcissistic Histrionic

ANTISOCIAL PERSONALITY DISORDER

Clinical Picture Pervasive pattern of disregard for and violation of rights of others, deceit and manipulation

APPLICATION OF THE NURSING PROCESS

Assessment

History: lying, truancy, vandalism, sexual promiscuity, and substance use in childhood and adolescence General appearance and motor behavior: appears normal, may be charming and engaging, trying to manipulate Mood and affect: shallow emotions, chooses emotions to work to their advantage, no genuine feelings of empathy, no guilt, only remorseful if caught

APPLICATION OF THE NURSING PROCESS (CONTD) Assessment (contd)

Thought processes and content: views the world as cold and hostile, thinks everyone else is as ruthless as he or she is, so trusts no one Sensorium and intellectual processes: intact Judgment and insight: lacks insight, poor judgment due to inability to delay gratification, impulsivity, or ethical/legal considerations of actions

APPLICATION OF THE NURSING PROCESS (CONTD) Assessment (contd)

Self-concept: superficially appears self-assured and confident, even arrogant, but this covers low self-esteem; poor relationships due to exploitation and using others Roles and relationships: has trouble keeping jobs, being a parent, staying married, and so forth

Application of the Nursing Process (contd)

Data Analysis Nursing diagnoses include: Ineffective Individual Coping Ineffective Role Performance Risk for Other-Directed Violence

APPLICATION OF THE NURSING PROCESS (CONTD) Outcomes The client will: Demonstrate nondestructive ways to express feelings and frustration Identify ways to meet own needs without infringing on rights of others Achieve satisfactory role performance

APPLICATION OF THE NURSING PROCESS (CONTD)

Intervention

Forming therapeutic relationship

Limit setting Confrontation

Promoting responsible behavior Helping client solve problems and control emotions Enhancing role performance

APPLICATION OF THE NURSING PROCESS (CONTD) Evaluation Can client maintain a job with acceptable performance? Can client meet basic family responsibilities? Can client avoid committing illegal or immoral acts?

BORDERLINE PERSONALITY DISORDER

Clinical Picture Pervasive pattern of unstable interpersonal relationships, self-image, affect, and marked impulsivity

APPLICATION OF THE NURSING PROCESS

Assessment

History: disturbed early relationships with parents; punitive responses from parents; family history of abuse and alcoholism General appearance and motor behavior: mildly dysfunctional clients appear normal; severely affected clients may be disheveled, unable to sit still, crying, out of control; very labile emotions Mood and affect: dysphoric mood; unhappy, restless, malaise; intense feeling of loneliness; boredom; frustration; abandonment by others; mood is labile and feelings are intense

APPLICATION OF THE NURSING PROCESS (CONTD) Assessment (contd)

Thought processes and content: polarized thinking/splitting; others are adored after a brief acquaintance, then despised if they dont meet clients expectations; obsessive and ruminative thoughts about abandonment, suicide, and selfharm; may have dissociative episodes Sensorium and intellectual processes: oriented; intellectual functions intact; may experience transient psychotic symptoms such as hallucinations under severe stress; may have flashbacks of abuse (consistent with PTSD diagnosis)

APPLICATION OF THE NURSING PROCESS (CONTD)

Assessment (contd)

Judgment and insight: judgment is poor; impulsive and reckless behaviors such as lying, shoplifting, gambling are common; limited insight: believes problems are due to others failing them Self-concept: unstable and shifts rapidly--needy one minute, hostile and rejecting the next; frequent selfinjury; lacks consistent view of self Roles and relationships: difficulty fulfilling roles, especially involving mundane tasks (school, work); relationships are stormy given clients behavior, but client blames others; clings to people, then rejects them angrily; desires relationships/friendships, but behavior drives others away

APPLICATION OF THE NURSING PROCESS (CONTD) Assessment (contd)

Roles and relationships: difficulty fulfilling roles, especially involving mundane tasks (school, work); relationships are stormy given clients behavior, but client blames others; clings to people, then rejects them angrily; desires relationships/friendships, but behavior drives others away Physiologic and self-care considerations: in addition to selfmutilation, bingeing and purging are common; abuse of alcohol or drugs, unprotected sex, reckless behavior; usually difficulty sleeping

APPLICATION OF THE NURSING PROCESS (CONTD) Data Analysis Nursing diagnoses include: Risk for Suicide Risk for Self-Mutilation Risk for Other-Directed Violence Ineffective Coping Social Isolation

APPLICATION OF THE NURSING PROCESS (CONTD) Outcomes The client will:

Be safe and free of significant injury Not harm others or destroy property Demonstrate increased control of impulsive behavior Take appropriate steps to meet his or her own needs Demonstrate problem-solving skills Verbalize greater satisfaction with relationships

APPLICATION OF THE NURSING PROCESS (CONTD) Intervention Long-term therapy to resolve family dysfunction and abuse Hospitalization when client is exhibiting selfharm behaviors or having intense symptoms Brief hospitalizations to stabilize condition

APPLICATION OF THE NURSING PROCESS (CONTD) Intervention (contd) Promoting the clients safety
No-self-harm

contract

Promoting the therapeutic relationship Establishing boundaries in relationships Teaching effective communication skills

Application of the Nursing Process (contd) Intervention (contd) Helping the client to cope and control emotions Reshaping thinking patterns

Cognitive restructuring Thought stopping Positive self-talk Decatastrophizing

Structuring daily activities

TREATMENT APPROACHES

Borderline Personality Disorder (BPD)

Dialectical

behavior therapy most effective Awareness of boundaries and splitting behaviors Self-mutilation common in BPD
Result

of impulse dyscontrol

Take

suicide threats seriously

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TREATMENT APPROACHES

Borderline Personality Disorder

Psychopharmacology
Limited

success in use of psychotropic medications Medications used to manage aggressiveness, impulsivity, psychoses, mood, and anxiety Antimanic medications and neuroleptics used to control impulsivity Antidepressants have helped some clients

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APPLICATION OF THE NURSING PROCESS (CONTD) Evaluation Is the client able to be safe and refrain from selfinjury? Can the client maintain employment? Can the client have fairly stable interpersonal relationships? Is the client experiencing fewer crises less frequently over time?

HISTRIONIC PERSONALITY DISORDER

Clinical Picture

Excessive emotionality and attention seeking; colorful and theatrical speech; overly concerned with impressing others; emotionally expressive, gregarious, and effusive; emotions are insincere and shallow; self-absorbed; uncomfortable when they are not the center of attention and go to great lengths to gain that status Give feedback about social interactions; teach social skills through role playing

Nursing Interventions

NARCISSISTIC PERSONALITY DISORDER

Clinical Picture

Grandiose; lack of empathy; need for admiration; arrogant or haughty attitude; disparage, belittle, or discount the feelings of others; view their problems as the fault of others; hypersensitive to criticism and need constant attention and admiration Use self-awareness skills to avoid anger and frustration; use matter-of-fact manner; set limits on rude or verbally abusive behavior

Nursing Interventions

A patient with a borderline personality disorder relates the following: When I met him, he was perfect. He gave me everything a girl could want. Then I found out how hateful he really is; he left me alone tonight to go to see his sisters family. Then I had to cut myself. Based on the patients description, the nurse should make the assessment that the patient: A.uses splitting. B.has paranoid tendencies. C.has problems with verbal communications. D.substitutes fantasy relationships for actual ones.

Splitting involves the inability to integrate the good and bad aspects of an object, so her boyfriend is seen as perfect or entirely bad, not as a person with some traits that she likes and some that she dislikes. Paranoid tendencies involve feelings of persecution. Verbal communication ability seems fluent, based on the scenario. There is no indication that the patient is fantasizing.

The characteristic of individuals with dramaticerratic personality disorders that makes it advisable for staff to have frequent patientcentered meetings is the individuals propensity for: A.behaving responsibly in the peer group. B.quickly and successfully adapting to stress. C.manipulating others to evade limits. D.coping successfully with a stressful environment.

The group of dramatic-erratic personality disorders includes antisocial and borderline personality disorders. These patients are particularly skillful at manipulating others to get their needs met. The other options list characteristics that would not require frequent meetings.

CLUSTER C PERSONALITY DISORDERS

Avoidant personality disorder Dependent personality disorder Obsessive-compulsive personality disorder

AVOIDANT PERSONALITY DISORDER

Clinical Picture

Social inhibitions; feelings of inadequacy; hypersensitivity to negative evaluation; avoid situations or

relationships that may result in rejection, criticism, shame, or disapproval; strongly desire closeness and intimacy but fear possible rejection and humiliation Nursing Interventions

Explore positive self-aspects and reasons for self-criticism; practice self-affirmations and positive self-talk; cognitive restructuring techniques, such as reframing and decatastrophizing; teach social skills

DEPENDENT PERSONALITY DISORDER

Clinical Picture

Submissive and clinging behavior; excessive need to be taken care of; pessimistic and self-critical; other people hurt their feelings easily; report feeling unhappy or depressed; difficulty making decisions; seek advice and repeated reassurances

Nursing Interventions

Help identify strengths and needs; use cognitive restructuring; assist in daily functioning; teach problem solving and decision making; refrain from giving advice

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER Clinical Picture

Preoccupation with orderliness, perfectionism, and control; formal and serious demeanor; constricted emotions; stubborn; preoccupied with details, rules, lists, and schedules; believe they are right; problems with judgment and decision making

Nursing Interventions

Help accept or tolerate less-than-perfect work; use cognitive restructuring techniques; encourage to take risks; practice negotiation

When caring for a patient with dependent personality disorder, the behavior that the nurse should positively reinforce is: A. choosing which outfit to wear. B.asking another patient for advice. C.sitting next to the nurse at community meeting. D.concealing anger with a member of the family.

Dependent patients find it difficult to make even simple decisions. They often ask advice; thus, independently choosing his or her own attire is a behavior to be reinforced. The other options are behaviors that reflect dependent needs and are not desirable.

Personality traits most likely to be documented that describe a patient with an obsessivecompulsive personality disorder are: A.affable, generous. B.perfectionist, inflexible. C.dramatic speech, impulsive. D.suspicious, holds grudges.

The individual with obsessive-compulsive personality disorder is perfectionist, rigid, preoccupied with rules and procedures, and afraid of making mistakes. The other options refer to behaviors or traits not usually associated with OCPD.

RELATED DISORDERS

Depressive personality disorder Passive-aggressive personality disorder

DEPRESSIVE PERSONALITY DISORDER

Clinical Picture

Sad, gloomy, or dejected affect; persistent unhappiness, cheerlessness, and hopelessness; inability to experience joy or pleasure in any activity; cannot relax; do not display a sense of humor; brood and worry over all aspects of daily life; thinking is negative and pessimistic Assess risk for self-harm; encourage to become involved in activities; give factual feedback; use cognitive restructuring techniques; teach effective social skills

Nursing Interventions

PASSIVE-AGGRESSIVE PERSONALITY DISORDER Clinical Picture

Negative attitudes; resent, oppose, and resist demands expected by others; express resistance through procrastination, forgetfulness, stubbornness, and intentional inefficiency Help examine the relationship between feelings and subsequent actions; teach appropriate ways to express feelings directly

Nursing Interventions

ELDER CONSIDERATIONS

Personality disorders from Clusters A and C are more prevalent in older age and are closely correlated with depression

COMMUNITY-BASED CARE

Caring for clients with personality disorders occurs primarily in community-based settings Acute psychiatric settings such as the hospital are useful for safety concerns for short periods Often the personality disorder is not the focus of attention; rather, the client may be seeking treatment for a physical condition Most people with personality disorders are treated in group or individual therapy settings, community support programs, or self-help groups

MENTAL HEALTH PROMOTION

Identify behaviors in children and adolescents that correlate with the development of personality disorders as adults

Adolescents exhibiting Cluster A and Cluster B traits are more likely to commit violent acts in adulthood Children at risk for Cluster B personality disorders demonstrate dramatic emotional responses to other people while paradoxically showing self-centeredness and utter disregard for the feelings of others Activities that are structured, met regularly, involve skill mastery, and led by one or more adults

Employ prevention strategies

SELF-AWARENESS ISSUES

Avoiding client attempts to manipulate Engaging in clear communication Setting limits and boundaries Dealing with frustration: clients change slowly yet look like they are capable of better behavior Working effectively as part of the team; consistency is essential

THE ROLE OF THE NURSE

The Generalist Nurse

Examines

personal responses prior to treatment Provides support with aid of a nurse therapist Provide honest confrontation and limit setting Utilize specific interventions as indicated by personality type

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ROLE OF THE NURSE

Nurses must recognize behaviors are representative of the personality disorder and not aimed at personal destruction of the nurse Nurses can model adaptive behaviors by mastering feelings and responses to the clients with PD

107

THE ROLE OF THE NURSE

The Advanced-Practice Psychiatric Nurse

Treats

in a variety of clinical settings

care Community mental health clinics

Acute

Maintains

constant and clear boundaries with the

client Commits to long periods of therapy

Many

clients are not suited to brief encounters

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THE NURSING PROCESS

Evaluation
Clients

likely to regress and need frequent reinforcement Reviewing interventions in relation to the goal and outcome criteria with client to foster partnership

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A patient has disrupted unit routine with his manipulation. He often plays one staff member against another. He tells the nurse that he can have a pass to leave the unit because another nurse allowed him a pass, even though his activity level does not permit this. The best approach would be for the nurse to: A.give him the pass, because a precedent has been set. B.call the physician to get permission for the pass. C.suspend all privileges because the patient was trying to manipulate. D.suggest that the matter be discussed by the patient and the two nurses.

When an attempt is made to play staff against one another, it is necessary to involve the two parties and the patient. Often, when this is suggested, the patient will back off and say he was just joking. The other options result in successful manipulation, buck passing to avoid making a decision, and retaliation.

Thank you. Take a 15 minute Break then Quiz