Psychiatric Nursing Personality Disorders Chapter 22 1.

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Psychiatric NursingPersonality Disorders

Chapter 22

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Objectives

Define personality vs. personality disorders

Identify various types of personality disorders

Personality

The individual qualities, including habitual behavior patterns, that make a person unique.

It is an ingrained enduring pattern of behaving and relating to self, others, and the environment; it includes perceptions, attitudes, and emotions.

These behaviors and characteristics are consistent across a broad range of situations and do not change easily.

A person usually is not consciously aware of her or his personality

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Personality Disorders• Personality traits (features):• Is a set of characteristics possessed by a person

that uniquely influences his or her cognitions, emotions, interpersonal orientation, motivation, and behaviors in various situations).

•When does personality disorder happen? •When personality traits are inflexible and maladaptive and cause significant functional impairment or distress, they constitute as personality disorders. Set of characteristics that combine to negatively affect your life.

Personality Disorders

Rigid, stereotyped behavior pattern

Persists throughout the person’s life

Pattern of perceiving, thinking, and relating that impairs social or occupational functioning

Axis II diagnoses

Personality Traits

Persistent behavioral patterns that do not significantly interfere with one’s life, even though the behaviors may be annoying or frustrating to others

Common Characteristics

Failure to accept the consequences of behavior

Lack of insight

External response to stress

Essential Characteristics

Chronicity

Pervasiveness

Maladaptation

Biologic Factors

Personality develops through the interaction of hereditary dispositions and environmental influences.

Temperamentb refers to the biologic processes of sensation, association, and motivation that underlie the integration of skills and habits based on emotion.

The four temperament traits are harm avoidance, novelty seeking, reward dependence, and persistence.

Each of these four genetically influenced traits affects a person’s automatic responses to certain situations.

These response patterns are ingrained by 2 to 3 years of age

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Alterations in hormone & platelet monoamine oxidase (MAO) levels

Smooth-pursuit eye movements

Neurotransmitter changes

Biologic Factors (cont'd)

Electroencephalographic (EEG) changes

Structural brain changes

Diminished blood flow and inflammation

Genetic Factors

Familial tendencies

Cluster B correlated with mood disorders, alcoholism, and somatization

Genetic variation

Psychosocial Factors

Parent-child interactions

Intrapsychic theory

Enmeshment

Abandonment

Identity diffusion

Humanistic Theory

Personality disorders are a combination of multiple factors.

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Diagnosis is made when the person exhibits enduring behavioral patterns that deviate from cultural expectations in two or more of the following areas:

• Ways of perceiving and interpreting self, other people, and events (cognition)

• Range, intensity, lability, and appropriateness of emotional response (affect)

• Interpersonal functioning

• Ability to control impulses or express behavior at the appropriate time and place (impulse control)

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Some people with personality disorders believe their problems stem from others or the world in general; they do not recognize their own behavior as the source of difficulty.

For these reasons, people with personality disorders are difficult to treat, which may be frustrating for the nurse and other caregivers as well as for family and friends.

There are also difficulties in diagnosing and treating clients with personality disorders because of similarities and subtle differences between categories or types. Types often overlap, and many people with personality disorders also have coexisting mental illnesses.

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The nurse should understand normal personality development before learning what is considered dysfunctional (remember Freud, Sullivan, Erikson, etc.).

What are the factors affecting personality development?

Factors that affect personality development (heredity, experiential learning, social interaction).

Individual with personality disorders are not often treated in acute care setting for their personality disorder as their primary diagnosis.

DSM-IV-TR (APA) groups the personality disorders into three categories: Cluster A, Cluster B, & Cluster C.

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1. Cluster A: odd or eccentric behavior. • Paranoid personality disorder• Schizoid personality disorder• Schizotypal personality disorder

2. Cluster B: dramatic, emotional behavior• Antisocial personality disorder• Borderline personality disorder• Histrionic personality disorder• Narcissistic personality disorder


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Personality Disorder

3. Cluster C: anxious and fearful behavior• Avoidant personality disorder• Dependent personality disorder• Obsessive-compulsive personality

disorder• Passive-aggressive personality disorder

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1 (A). Paranoid personality disorders

Definition: Pervasive (spreading throughout) distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood.

Long-standing irrational suspiciousness and mistrust of people.

Prevalence is difficult to establish, because individual with the disorder seldom seek assistance for their problem or require hospitalization.

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Paranoid personality disorders

When they present for treatment at the insistence of others, they may be able to pull themselves together so their behavior does not appear maladaptive.

More common among men than women

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Clinical Picture Long-standing suspiciousness and mistrust of

people, consistently on guard (cautious), hyper-vigilant (very attentive), and ready for any threat.

They appear tense and irritable, (immune) insensitive to the feelings of others, oversensitive and misinterpret events, envious and hostile (unfriendly) to others who are successful.

They trust no one, therefore, they consistently testing the honesty of others. Always feel that others are there to take advantage of them. Perceive the world as harsh and unkind.

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Paranoid PD: clinical picture continue Hostile to others who are successful & believe

the only reason they are not successful is because they have been treated unfairly.

They are consistently in the defensive. They learned to attack first (aggression and violence).

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Causes:

Hereditary,

Parental antagonism (against the children) & harassment (persistent attack of criticism). Due to harsh parental treatment they learned to perceive the world as harsh and unkind.

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2 (A). Schizoid personality disorders

This disorder characterized by a profound (deep/strong) defect in the ability to perform personal relationships or to respond to others in any meaningful, emotional way.

Prevalence (3-7.5% of general population) and does not need primary hospitalization.

Clinical picture Social withdrawal, discomfort with human

interaction, cold and aloof (not emotional). Prefer to work in isolation, unsociable, little

need or desire for emotional ties.

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Schizoid PD: Clinical Picture continue In the presence of other they appear shy,

anxious, uneasy, inappropriately serious about everything and unable to experience pleasure sometimes.

They are cold and un-empathetic. Their behavior and conversation exhibit little or

no spontaneity (not free/not comfortable). They don’t display any sexual desire of others. They don’t like group therapy and they don’t

look for treatment.

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Cause: Hereditary characteristics. Early interactional patterns that the person

found to be cold and unsatisfying. The childhoods of these individuals have

often been characterized as bleak (offering no excitement), cold, & lacking empathy.

A child brought up with this type of parenting may become a schizoid adult.

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3 (A). Schizotypal personality disorders

Described as ‘’latent (potential) schizophrenics’’. Their behavior is odd and eccentric, but not to the level of schizophrenia. 3% of the population has this disorder. They need for social isolation.

Clinical Picture Aloof and isolated, have bland (flat) and apathetic

(no emotions) manner. They have magical thinking, idea of reference,

illusions, and depersonalizations are part of their everyday world.

They show disorders in speech pattern some times. When they are under stress, they may

decompensate and demonstrate psychotic symptoms such as delusional thoughts, hallucination for brief period of time.

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3 (A). Schizotypal personality disorders

Causes: Heredity: more common among the first

degree biological relatives of people with schizophrenia.

They were likely shunned (avoided), ignored, rejected, and humiliated by others resulting in feelings of low self- esteem and marked distrust of personal relations. Having failed to cope with these, they began to withdraw and reduce contact with individuals that evoke (produce) sadness and humiliation.

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4 (B). Antisocial personality disorders

A pattern of socially irresponsible and guiltless behavior that reflects a disregard for and violation of the rights of others.

Clinical Picture: The person use and manipulate others for

personal gain and have a general disregard for the law.

They have difficulty sustaining consistent employment and developing stable relationships.

The prevalence is 3% for men and 1% for women.

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5 (B). Borderline personality disorders (emotionally unstable PD)

Characterized by a pattern of intense & chaotic (unorganized) relationships, with affective instability & fluctuating (irregular) attitudes toward other people.

Clinical Picture: The individuals are impulsive (they don’t think

before they act) and self-destructive. The prevalence is 2-3% of the population. Common twice in women than men.

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6 (B). Histrionic personality disorders

This disorder characterized by colorful, dramatic, and extra emotionality and attention seeking. They have difficulty maintaining long-life relationships & need constant affirmation of approval and acceptance from others.

Clinical Picture Self-dramatizing, attention-seeking, overly and

inappropriately seductive. People with this disorder often demonstrate what our

society tend to admire: to be well liked, successful, popular, attractive, & sociable, however, beneath this is a driven quality, a consuming need for approval or attract attention at all costs.

Failure to evoke the attention results in anxiety.

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Clinical Picture continue Highly distractible and have difficulty in paying

attention to the details. Highly suggestible, strongly dependent, & easily

influenced by others. Interpersonal relationships are superficial They might have somatic complains and

episodes of psychosis may occur during periods of extreme stress.

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Causes: Neurobiological: low basal dopaminergic

activity, sympathetic arousal, adrenal hyperactivity, and neurochemical imbalance.

Hereditary. Learning experiences during childhood

(parents are likely to give positive or negative feedback).

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7 (B). Narcissistic personality disorders

Individual with this disorder have exaggerated sense of self-worth (vanity). They lack empathy and are hypersensitive to the evaluation of others. They believe that they have the right to receive special consideration & their desire is sufficient justification for possessing whatever they seek.

Men more than women

Clinical Picture Overly self-centered and exploiting others to fulfill

their own desires. Because they view themselves as ‘’superior’’, they

believe they are entitled to special rights & privileges.

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Clinical Picture continue Impaired interpersonal relationships, their

mood is usually optimistic, relaxed, cheerful. Mood easily change.

They seek persons who provide them with positive feedback that they require, and who will not ask much in return.

Cause: Hereditary-parents have narcissism Parents were demanding perfection and

placed unrealistic expectation on the child.

7 (B). Narcissistic personality disorders

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8 (C). Avoidant personality disorders

Those are extremely sensitive to rejection, and therefore have socially withdrawn life. Their extreme shyness & fear of rejection lead them to be socially withdrawn. They have feelings of inadequacy.

Equal in men and women

Clinical Picture Awkward & uncomfortable in social situations Their speech is usually slow & constrained, with

frequent hesitations, fragmentary thought sequences Often lonely and express feeling of being unwanted

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8 (C). Avoidant personality disorders

Clinical Picture continue May develop depression, anger, &

anxiety at oneself for failing to develop social relations.

They desire to have close relationships but avoid that because of their fear of being rejected.

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9 (C). Dependent personality disorders

Pervasive and excessive need to be taken care of that leads to fears of separation. Allow others to take decisions, feel helpless when they are alone. Depend on other people to meet their emotional and physical needs.

Clinical Picture Tolerate miss treatment by others Cannot be assertive Lack of self-confidence (posture, voice),

passive, they easily be hurt by criticism.

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Clinical Picture continue They are overly generous & thoughtful &

underplay their own attractiveness & achievement.

They may appear to others that they are happy and enjoying life but when they are alone they may feel pessimistic and discouraged

They let others make their important decisions. They have passive role in their relationships.

They feel incapable of caring for themselves. Avoid positions and responsibility & feel anxious

when forced into them.

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Causes: Hereditary The problem may o arise when parents

become over protective and discourage independent behavior on the part of the child.

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10 (C). Obsessive-compulsive personality disorders

Those are serious and formal individuals who have difficulty expressing emotions. They are overly disciplined, perfectionist, and preoccupied with rules. The intense fear of making mistakes leads to difficulty with decisions.

More common in men

Clinical Picture Inflexible and lack of spontaneity, they work

patiently at tasks that require accuracy and discipline.

Tend to be polite and formal.

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10 (C). Obsessive-compulsive personality disorders

Clinical Picture continueConcerned with organization & efficiency“company man”Commonly use the defense mechanism of reaction formation (presenting the opposite thought).

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Personality disorders test

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Borderline personality disorder: nursing care

Nursing Diagnoses:

1. Risk for self mutilation

2. Dysfunctional grieving

3. Impaired social interaction

4. Disturbed personal identity

5. Anxiety

6. Low self-esteem

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Antisocial personality disorder: nursing care

Nursing Diagnoses:

1. Risk for other-directed violence

2. Defensive coping

3. Low self-esteem

4. Impaired social interaction

5. Knowledge deficit

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Personality disorders: Treatment modalities

1. Interpersonal psychotherapy

2. Psychoanalytical psychotherapy

3. Milieu or group therapy

4. Cognitive and behavioral therapy

5. Psychopharmacology (antipsychotic medication can be helpful in the treatment of the paranoid, schizotypal and borderline personality disorders)

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11 (C). Passive-aggressive personality disorders

Pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance in social and occupational situations.

Some people passively expressing covert regression

Clinical Picture They feel cheated and unappreciated, life unkind

to them while others are having an easy life.

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11 (C). Passive-aggressive personality disorders

Clinical Picture continue They often switch among the roles of the

martyr, affronted, aggrieved, misunderstood, guilt-ridden, sickly, & overworked.

Causes: parental attitude.

Application of the Nursing Process

Safety

Consistency

Boundary setting

Appropriate self-disclosure

Difficult Behaviors

Manipulation

Narcissism

Impulsiveness

Interventions for Paranoid Personality Disorder

Respect personal space.

Respect client’s preference.

Give feedback based on nonverbal cues.

Provide client with a daily schedule of activities and inform client of changes.

Interventions for Paranoid Personality Disorder

(cont'd)

Help client identify adaptive diversionary activities.

Use role-playing.

Use an objective, matter-of-fact approach with client.

Use concrete, specific words rather than global abstractions.

Interventions for the Angry Client

Use a calm, unhurried approach.

Do not touch client indiscriminately.

Respect personal space.

Use active listening skills.

Remain aware of personal feelings.

Interventions for Antisocial Personality Disorder

Use a concerned, matter-of-fact approach.

Set, communicate, and maintain consistent rules and regulations.

Do not argue, bargain, or rationalize.

Interventions for the Antisocial Personality

Disorder (cont'd)

Confront inappropriate behaviors.

Do not seek approval or coax; use choices and consequences.

Be alert for flattery or verbal attacks.

Interventions for Manipulative Behavior

Assign one primary staff member.

Maintain realistic limits with enforceable consequences.

Give a rationale for limits and consequences.

Interventions for Manipulative Behavior

(cont'd)

Model respect, honesty, openness, and assertiveness.

Confront client each time manipulation occurs.

Interventions for Dependent Personality

Disorder

Evaluate client’s ability for self-care.

Avoid doing things the client is capable of doing.

Help client identify assets and liabilities.

Interventions for Dependent Personality

Disorder (cont'd)

Emphasize strengths and potential.

Encourage client to take responsibility for own opinions.

Point out when client negates own feelings or opinions.

The Nurse’s Response

Self-awareness

Countertransference

Labels and stigma

Supervision

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THANK YOU

Psychiatric Nursing Personality Disorders Chapter 22 1.

Documents

personality slide

inflammation slide

stress slide

personality disorders

biologic factors personality

years of age slide

mood disorders

response patterns