Maladaptive Behavior Patterns personality disorders and abuse

What sort of future is coming up from behind, I really don t know. But the past, spread out ahead, dominates everything in sight. R.M Pirsig from Zen and the Art of Motorcycle Maintenance

People with Personality Disorders have long term: 

Low frustration tolerance Pain intolerance Over reaction to life events Lack of impulse control Immature coping strategies (over use of defense mechanisms) Impaired personal relationships

Nursing Issues with all PD:  


Balance in your expectations for change hope, but not a quick fix Be authentic, patient, trustworthy Have good limit setting skills Have good ego boundaries Have good team communication, to decrease splitting

The Odd/Eccentric Group: Schizoid, Paranoid, Schizotypal 

Some nursing issues include: ineffective individual coping social isolation defensive coping

Paranoid Personality D/O 

Fear others will harm or exploit Hypervigilant and tend to be hostile (as a response to perceived threat) Can become psychotic if stressed Nursing be consistent, truthful, out in the open. Approach with care and tell what is happening, what you are doing

Schizoid Personality D/O 

Doesn t want relationships Flat affect, little emotion seen, not aware there is a problem with this Few relationships, can become delusional if stressed Nursing-build trust slowly, consistent, not overly emotional or smothering

Schizotypal PD   

Has social anxiety. Wants relationships but not skilled at getting them. Often has eccentric thinking and/or behavior Nursing-be consistent, trustworthy, keep clear boundaries, help ct. with very gradual change in social bx.

Dramatic/ Emotional PDs   

Includes Antisocial, Borderline, Histrionic, and Narcissistic Focus more study energy on Antisocial and Borderline Sample nursing diagnoses include: Altered family process, ineffective individual coping, self mutilation, risk for violence, low self esteem

Antisocial PD (more men) 

Feels entitled, acts charming to get way Deceitful, manipulative, vengeful Seeks risks, stimulation (drugs, sex, crime, gambling) Has no conscience or empathy Irresponsible and unsafe

Borderline PD (more women)   


Overwhelmingly emotionally needy, despairing. Angry, dysphoric, labile Lives in a crisis and creates a crisis if too calm Abandonment issues are key Self destructive behavior and mutilation occur Splitting, dichotomous thinking

Histrionic PD 

Dramatic, flambouyant Charming, intense, but shallow in relationships Center of attention, if not gets upset and creates stir May have dramatic ups and downs.

Narcissistic PD 

Self absorbed and self centered Overestimates own self worth as a defense to cover self doubt Grandiose. Wants attention, praise, admiration. If this doesn t happen, becomes upset/angry/vengeful Very critical. Little tolerance for imperfection

Anxious and Fearful PD: avoidant, dependent, and obsessive compulsive 

Of all three, dependent is most common Nursing diagnosis can include:
Self esteem disturbance Anxiety Hopelessness powerlessness

Avoidant PD 

Often co-occurs with social phobias See social isolation Very sensitive to criticism and afraid of being judged negatively Feels rejected a lot, fears being rejected Low self esteem

Dependent Personality D/O 

Passive, submissive, self sacrificing Few self initiated behaviors Little decisionmaking Tolerates maltreatment, being bossed Urgent need to be in relationship in which someone else is in control

Obsessive Compulsive PD 

R/t OCD Thrifty, saving, verbose, organized Critical of self and others Rigid emotionally; taskmasters, have a hard time expressing emotion

Abuse: Incidence is high   

1.8-2.9 million battered women each yr in US. Battering is single most common cause of injury to women. 8% women are battered before or during pregnancy. 2 million reported cases of child abuse each yr in US (2000-5000 die) 0.5-1 million cases of elder abuse in US yearly.

Why abuse continues ( a few reasons) 

Society legitimizes violence and privacy Intergenerational acting like we have seen growing up Structural inequality of abused persons Stockholm syndrome (discuss)

Power and Control Issuesways abusers act 

Threats and coercion Economic restriction Intimidation(pets, weapons, breaking) Emotional abuse Isolate the abused person Denial Threaten loved ones (esp. children)

Cycle of Violence   

Tension building tension, blaming, aggression in abuser Abuse (battering) episode acute episode of abuse Calm/honeymoon acts calmer, nicer, may apologize/gifts/promises. In severe abuse this may be minimal

Myths that create problems in stopping abuse  


If the abuse was that bad the victim would tell or get out Victim deserves it Abuse only occurs among the poor and uneducated Families should be kept together at all costs    

If it weren t for drugs and alcohol, the abuse wouldn t have occurred Victims are lying or exaggerating to get attention Batterers are uneducated men who can be spotted easily Families should always be kept together

Abusers typically:   


Victims of abuse in youth Lack empathy, and minimize seriousness of abuse Controlling Jealous Impulsive    

Low frustration tolerance Angry, violence focused Attribute failure to others behavior Traditional views Often alcohol/drug abuse

Some Assessment findings that hint at abuse: 

Frequent ER visits Withdrawn/depresd Inconsistent physical findings Multiple suicide attempts Overprotective family member  


Alcohol or other drug abuse One car accident Delay in seeking medical care Injury to head, sexual organs Injuries in various stages of healing

Some assessment questions 

What happened? Have you been in a fight? Tell me about it. The injuries you have look like the kind I have seen when___. Have you been hurt in this way? 

Are you involved in an abusive relationship? Tell me about it.

Some nursing interventions 

Make time and privacy to talk Listen and validate, not judge Document impartially and completely Ask. Don t assume info will be offered   

If abuse is suspected but denied, give info anyway (privately) Assist with practical needs Remember the legal issues involved with children and elders

Educational Interventions 

Cycle of violence Community resources Danger of homicide, esp re leaving the abuser Safety planning Self esteem issues redefine self as the survivor

Safety Plans-a few basics   

Cash, checks, keys, credit card, essentials bag, hidden out of home Copies of all vital docs hidden out of home Code system, older kids involved Route of escape, tell trusted people

Security Plan if you leave  


Bring kids with you or go back for them with police Lock everything, all the time Private mail/phone Picture of abuser to people who may see Don t keep it a secret, it is not your fault

Some other Intervention Issues   

Be wary of marriage counseling, people who advise to stay with abuser, abusive parent at all costs Note, there are mandatory reporting laws for children and elders. Can t heal trauma well when still under future risk. Safety is paramount.

Post-traumatic Stress Disorder 

Exposure to trauma Re-experiencing traumatic event Numbing Avoidance of reminders of event Anxiety/arousal responses Distress in important areas of functioning

Re-experiencing the event  


Intruding reminders/memories/flashbacks Nightmares Acting or feeling like the event(s) reoccurring Leads to anxiety and acute distress

Types of Avoidance   

Thought/feelings/conversations about the event Stays away from people and places associated with event Repression Lack of participation with others, detachment, short sense of future

Treatment of PTSD 

Antianxiety agents for short term relief Antidepressants, particularly SSRI s At risk for developing substance abuse due to self-medication for distress


Blitz rape out of the blue, fast Confidence rape more of a set up involved, may know victim and repeat, use threats Inability to consent issue Aggression or Sexual Expression?

Rape Intervention-a few points   

Collecting Evidence while maintaining dignity, respect in initial response Privacy, time to talk, one to one contact, rape counselor, follow up Anticipatory Guidance Community Resources