Personality Disorders (PD) West Coast University Psychiatric / Mental Health Nursing NURS 204.

Personality Personality Disorders (PD)Disorders (PD)

West Coast UniversityWest Coast University

Psychiatric / Mental Psychiatric / Mental Health NursingHealth Nursing

NURS 204NURS 204

PersonalityPersonality

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

Personality traits is a persistent Personality traits is a persistent behavioral patterns that do not behavioral patterns that do not significantly interfere with one’s significantly interfere with one’s life, even though the behaviors life, even though the behaviors may be annoying or frustrating to may be annoying or frustrating to othersothers

Definition of Definition of Personality DisorderPersonality Disorder

Traits and habits that comprise the personality Traits and habits that comprise the personality are inflexible (rigid) and damagingare inflexible (rigid) and damaging

Pathology/impairment will affect the individual Pathology/impairment will affect the individual and those who interact with the individualand those who interact with the individual

Enduring pattern of inner experience and Enduring pattern of inner experience and behavior that deviates from the expectations of behavior that deviates from the expectations of the person’s culture, that is pervasive and the person’s culture, that is pervasive and inflexible. Manifested in two or more of the inflexible. Manifested in two or more of the following areas:following areas: CognitionCognition Affect Affect Interpersonal functioningInterpersonal functioning Impulse controlImpulse control Social or occupationalSocial or occupational RelationshipRelationship

PD: Common PD: Common CharacteristicsCharacteristics

Onset in adolescence or early adulthood.Onset in adolescence or early adulthood. Tendency to foster vicious cycles (crisis Tendency to foster vicious cycles (crisis orientation)orientation)

Persists throughout the person’s life Persists throughout the person’s life (chronicity)(chronicity)

Lack insight: not aware of their pathologyLack insight: not aware of their pathology Intense transference/counter-transference Intense transference/counter-transference reactionreaction

Failure to accept the consequences of Failure to accept the consequences of behaviorbehavior

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

PD: Common PD: Common CharacteristicsCharacteristics

ManipulationManipulation NarcissismNarcissism ImpulsivenessImpulsiveness

Biologic FactorsBiologic Factors

Alterations in hormone & platelet Alterations in hormone & platelet monoamine oxidase (MAO) levelsmonoamine oxidase (MAO) levels

Neurotransmitter changesNeurotransmitter changes Electroencephalographic (EEG) changesElectroencephalographic (EEG) changes Structural brain changesStructural brain changes Diminished blood flow and Diminished blood flow and inflammationinflammation

Chronic inflammation, as evidenced by Chronic inflammation, as evidenced by the presence of elevated levels of C-the presence of elevated levels of C-reactive proteinreactive protein

Genetic FactorsGenetic Factors

Familial tendenciesFamilial tendencies Cluster B correlated with mood Cluster B correlated with mood disorders, alcoholism, & disorders, alcoholism, & somatizationsomatization

Genetic variationGenetic variation

Psychosocial FactorsPsychosocial Factors

ParentParent––child interactionschild interactions Intrapsychic theoryIntrapsychic theory EnmeshmentEnmeshment AbandonmentAbandonment Identity diffusionIdentity diffusion

Cluster A Personality Cluster A Personality DisorderDisorder

Odd or EccentricOdd or Eccentric Paranoid personality disorderParanoid personality disorder Schizoid personality disorderSchizoid personality disorder Schizotypal personality disorderSchizotypal personality disorder

Paranoid Personality Paranoid Personality DisorderDisorder

A pervasive distrust and A pervasive distrust and suspiciousness of others such suspiciousness of others such that their motives are that their motives are interpreted as malevolent, interpreted as malevolent, beginning by early adulthood beginning by early adulthood and present in a variety of and present in a variety of contexts. contexts. E.g. Richard NixonE.g. Richard Nixon Film: “The Caine Mutiny” (1953)Film: “The Caine Mutiny” (1953)

Paranoid PD Paranoid PD CharacteristicsCharacteristics

Suspiciousness and MistrustSuspiciousness and Mistrust RigidityRigidity HypervigilanceHypervigilance Distortions of realityDistortions of reality Restricted affectRestricted affect Exclusion Exclusion

Schema for Paranoid PDSchema for Paranoid PD People will eventually try to hurt mePeople will eventually try to hurt me People can’t be trusted. They will People can’t be trusted. They will always take advantage of mealways take advantage of me

People will try to bother or annoy mePeople will try to bother or annoy me Don’t get mad, get evenDon’t get mad, get even Any insult, no matter how slight, Any insult, no matter how slight, directed at me should be punisheddirected at me should be punished

Always be prepared for the worstAlways be prepared for the worst If I get close to people they can If I get close to people they can find out my weaknesses find out my weaknesses

Nursing GuidelinesNursing Guidelines Avoid being to nice or friendlyAvoid being to nice or friendly Give clear and straight forward Give clear and straight forward explanations of tests and procedures explanations of tests and procedures beforehandbeforehand

Use simple, clear language; avoid Use simple, clear language; avoid ambiguityambiguity

Respect personal space and client’s Respect personal space and client’s preferencepreference

Provide client with a daily schedule Provide client with a daily schedule of activities and inform client of of activities and inform client of changes or reasons for delayschanges or reasons for delays

Schizoid Personality Schizoid Personality DisorderDisorder

A pervasive pattern of detachment A pervasive pattern of detachment from social relationships and a from social relationships and a restricted range of expression restricted range of expression interpersonal settings, beginning interpersonal settings, beginning by early adulthood and present in by early adulthood and present in a variety of contexts:a variety of contexts: Mr. Spock in the original Star Trek Mr. Spock in the original Star Trek seriesseries

Schizoid PD Schizoid PD CharacteristicsCharacteristics

DetachedDetached Aloof social styleAloof social style Experience transient psychotic Experience transient psychotic episodesepisodes

Experience anxiety, depression, Experience anxiety, depression, and dysphoric affectand dysphoric affect

Isolative Isolative Deny interest in relationshipsDeny interest in relationships Humorless Humorless

Schema for Schizoid PDSchema for Schizoid PD

There are few reasons to be There are few reasons to be close to peopleclose to people

I am my own best friendI am my own best friend Stay calmStay calm Displays of emotions are Displays of emotions are unnecessary and embarrassingunnecessary and embarrassing

What others say is of little What others say is of little interest or importance to meinterest or importance to me

Nursing GuidelinesNursing Guidelines

Avoid being too nice or friendlyAvoid being too nice or friendly Do not try to increase Do not try to increase socializationsocialization

Perform thorough diagnostic Perform thorough diagnostic assessment as needed to identify assessment as needed to identify symptoms of disorders that the symptoms of disorders that the patient is reluctant to discusspatient is reluctant to discuss

Schizotypal Personality Schizotypal Personality DisorderDisorder

A pervasive pattern of social and A pervasive pattern of social and interpersonal deficits marked by acute interpersonal deficits marked by acute discomfort with, and reduced capacity discomfort with, and reduced capacity for, close relationships as well as by for, close relationships as well as by cognitive or perceptual distortions cognitive or perceptual distortions and eccentricities of behavior, and eccentricities of behavior, beginning by early adulthood and beginning by early adulthood and present in a variety of context:present in a variety of context: ““Kramer” on “Seinfeld”Kramer” on “Seinfeld” ““Phoebe” on “Friends”Phoebe” on “Friends” Film: “Psycho” (1960)Film: “Psycho” (1960)

Schizotypal PD Schizotypal PD CharacteristicsCharacteristics

Ideas of referenceIdeas of reference Odd beliefs or magical thinking Odd beliefs or magical thinking (clairvoyance, telepathy, or “sixth (clairvoyance, telepathy, or “sixth sense”)sense”)

Vague, circumstantial, metaphorical, Vague, circumstantial, metaphorical, overelaborate, or stereotypedoverelaborate, or stereotyped

Suspiciousness or paranoid ideationSuspiciousness or paranoid ideation Odd appearance, eccentric or peculiarOdd appearance, eccentric or peculiar Lack close friends or confidantsLack close friends or confidants Social anxietySocial anxiety

Nursing GuidelinesNursing Guidelines

Respect patient’s need for Respect patient’s need for social isolationsocial isolation

Be aware of patient’s Be aware of patient’s suspiciousness and employ suspiciousness and employ appropriate interventionsappropriate interventions

Nursing ProcessNursing Process

Nursing DiagnosisNursing Diagnosis Ineffective CopingIneffective Coping Impaired social interactionImpaired social interaction

Outcome identificationOutcome identification Participate in activity groupsParticipate in activity groups Copes effectively with stressful Copes effectively with stressful situationsituation

Approaches staff and other clients Approaches staff and other clients without encouragementwithout encouragement

Verbalizes thoughts and feelings that Verbalizes thoughts and feelings that interfere with socializationinterfere with socialization

Cluster BCluster B

Dramatic, emotional, or erraticDramatic, emotional, or erratic AntisocialAntisocial BorderlineBorderline Narcissistic Narcissistic HistrionicHistrionic

Antisocial Personality Antisocial Personality DisorderDisorder

A pervasive pattern of A pervasive pattern of disregard for and violation of disregard for and violation of the rights of others occurring the rights of others occurring since age 15, as indicated by since age 15, as indicated by the following:the following: Career CriminalsCareer Criminals Film: “The God Father”Film: “The God Father”

Antisocial PD Antisocial PD CharacteristicsCharacteristics

Failure to conform to social Failure to conform to social norms norms

DeceitfulnessDeceitfulness ImpulsiveImpulsive Irritability and aggressivenessIrritability and aggressiveness Reckless Reckless IrresponsibleIrresponsible Lack of remorseLack of remorse

Schema for Antisocial Schema for Antisocial PDPD

Rules are meant for othersRules are meant for others Only fools follow all of the rulesOnly fools follow all of the rules Rules are meant to be brokenRules are meant to be broken My pleasure comes firstMy pleasure comes first I will not allow myself to be I will not allow myself to be frustratedfrustrated

I will do whatever I must to get I will do whatever I must to get whatever I wantwhatever I want

I am really smarter than most I am really smarter than most everybody elseeverybody else

Nursing GuidelinesNursing Guidelines Be alert to manipulation such as flattery, Be alert to manipulation such as flattery, seductiveness, instilling of guilt or seductiveness, instilling of guilt or verbal attacksverbal attacks

Set clear and realistic limits of specific Set clear and realistic limits of specific behaviorbehavior

Ensure that all limits are adhered to by Ensure that all limits are adhered to by all staff involvedall staff involved

Do not seek approval or coax, provide Do not seek approval or coax, provide clear boundaries and consequencesclear boundaries and consequences

Do not argue, bargain, or rationalizeDo not argue, bargain, or rationalize Confront inappropriate behaviorsConfront inappropriate behaviors

Borderline Personality Borderline Personality DisorderDisorder

A pervasive pattern of A pervasive pattern of instability of interpersonal instability of interpersonal relationship, self-image, and relationship, self-image, and affects, and marked impulsivity affects, and marked impulsivity beginning in early adulthood beginning in early adulthood and present in a variety of and present in a variety of contexts:contexts:

Borderline PDBorderline PD Frantic efforts to avoid real or imagined Frantic efforts to avoid real or imagined abandonmentabandonment

Unstable and intense interpersonal Unstable and intense interpersonal relationshipsrelationships

Identity disturbanceIdentity disturbance ImpulsivityImpulsivity Recurrent suicidal behavior, gestures, or Recurrent suicidal behavior, gestures, or threats, or self mutilationthreats, or self mutilation

Chronic feeling of emptinessChronic feeling of emptiness Intense anger or difficulty controlling Intense anger or difficulty controlling angeranger

Schema for Borderline Schema for Borderline PDPD

I am not sure who I amI am not sure who I am I will eventually be abandonedI will eventually be abandoned My pain is so intense that I can’t My pain is so intense that I can’t bear itbear it

My anger controls me. I can’t My anger controls me. I can’t modulate my feelingsmodulate my feelings

When I am overwhelmed I must When I am overwhelmed I must escape (by flight or suicideescape (by flight or suicide

Nursing GuidelinesNursing Guidelines Set realistic goals, use clear action wordsSet realistic goals, use clear action words Be aware of manipulative behaviors, such as Be aware of manipulative behaviors, such as flattery, seductiveness, instilling of guiltflattery, seductiveness, instilling of guilt

Provide a clear and consistent boundaries and Provide a clear and consistent boundaries and limitslimits

Avoid rejecting or rescuingAvoid rejecting or rescuing Assess for suicidal and self-mutilating Assess for suicidal and self-mutilating behaviors, especially during times of stressbehaviors, especially during times of stress

Use a nonjudgmental attitude when client Use a nonjudgmental attitude when client discusses suicidal/self-destructive thoughtsdiscusses suicidal/self-destructive thoughts

Implement safety precautionsImplement safety precautions

Narcissistic Narcissistic Personality DisorderPersonality Disorder

A pervasive pattern of A pervasive pattern of grandiosity (in fantasy and grandiosity (in fantasy and behavior), need for admiration, behavior), need for admiration, and lack of empathy, beginning and lack of empathy, beginning in early adulthood and present in early adulthood and present in a variety of contexts:in a variety of contexts: ““Frazier Crane” on “Frazier”Frazier Crane” on “Frazier” ““Jerry Seinfeld” on “Seinfeld”Jerry Seinfeld” on “Seinfeld”

Narcissistic PDNarcissistic PD Grandiose sense of self-importanceGrandiose sense of self-importance Preoccupied with fantasies or unlimited Preoccupied with fantasies or unlimited success, power, brilliance, beauty, or ideal success, power, brilliance, beauty, or ideal lovelove

Believes that he or she is special and Believes that he or she is special and importantimportant

Require excessive admirationRequire excessive admiration Sense of entitlementSense of entitlement ExploitativeExploitative Lack empathyLack empathy Envious of othersEnvious of others Shows arrogant, haughty behavior or attitudesShows arrogant, haughty behavior or attitudes

Schema for Narcissistic Schema for Narcissistic PDPD

I must have my way in every I must have my way in every interactioninteraction

I am more special than anyone I am more special than anyone elseelse

I should only have to relate to I should only have to relate to people like mepeople like me

I must be admiredI must be admired No one should have more of No one should have more of anything that I haveanything that I have

Nursing GuidelinesNursing Guidelines

Remain neutral; avoid engaging Remain neutral; avoid engaging in power struggles or becoming in power struggles or becoming defensive in response to the defensive in response to the patient’s disparaging remarks, patient’s disparaging remarks, no matter how provocative the no matter how provocative the situation may be.situation may be.

Histrionic Personality Histrionic Personality DisorderDisorder

A pervasive pattern of A pervasive pattern of excessive emotionality and excessive emotionality and attention seeking, beginning in attention seeking, beginning in early adulthood and present in early adulthood and present in a variety of contexts:a variety of contexts: Judy Garland, Liza Minnelli, Robin Judy Garland, Liza Minnelli, Robin WilliamsWilliams

““Jack” and “Karen” on “Will” and Jack” and “Karen” on “Will” and “Grace”“Grace”

Histrionic PDHistrionic PD Uncomfortable in situations in which he or Uncomfortable in situations in which he or she is not the center of attentionshe is not the center of attention

Interaction are characterized by Interaction are characterized by inappropriate sexually seductive or inappropriate sexually seductive or provocative behaviorprovocative behavior

Rapid shifting and shallow expressions of Rapid shifting and shallow expressions of emotionsemotions

Use physical appearance to draw attentionUse physical appearance to draw attention Shows dramatization, exaggerated Shows dramatization, exaggerated expressionsexpressions

Easily influenced by othersEasily influenced by others

Schema for Histrionic Schema for Histrionic PDPD

Appearances are importantAppearances are important People are judged on external People are judged on external appearanceappearance

I must be noticedI must be noticed I must never be frustrated in lifeI must never be frustrated in life I must get everything I think that I must get everything I think that I wantI want

Beauty is the most important Beauty is the most important consideration in judging someoneconsideration in judging someone

Nursing GuidelinesNursing Guidelines

Understand seductive behavior Understand seductive behavior as a response to distressas a response to distress

Keep communication and Keep communication and interactions professional, interactions professional, despite temptation to conspire despite temptation to conspire with the patient in a with the patient in a flirtatious and misleading flirtatious and misleading mannermanner

Cluster CCluster C

Anxious and fearfulAnxious and fearful DependentDependent Obsessive-compulsiveObsessive-compulsive Avoidant Avoidant

DependentDependent

A pervasive and excessive need A pervasive and excessive need to be taken care of that leads to be taken care of that leads to submissive and clinging to submissive and clinging behavior and fear of behavior and fear of separation, beginning by early separation, beginning by early adulthood and present in a adulthood and present in a variety of contextvariety of context

Dependent PDDependent PD Difficulty making everyday decisionsDifficulty making everyday decisions Needs others to assume responsibilityNeeds others to assume responsibility Difficulty expressing disagreement with Difficulty expressing disagreement with othersothers

Difficulty initiating projectsDifficulty initiating projects Goes to excessive lengths to obtain support Goes to excessive lengths to obtain support from othersfrom others

Feels helpless and uncomfortable when aloneFeels helpless and uncomfortable when alone Unrealistically preoccupied with fears or Unrealistically preoccupied with fears or being left to take care of him/herselfbeing left to take care of him/herself

Urgently seeks another relationship as a Urgently seeks another relationship as a source of care and supportsource of care and support

Schema of Dependent PDSchema of Dependent PD

I can’t function without the support I can’t function without the support of othersof others

Without the advice and reassurance of Without the advice and reassurance of others I can’t existothers I can’t exist

In any situation, I am probably wrongIn any situation, I am probably wrong Anger expression, people will abandon Anger expression, people will abandon meme

If I am abandoned, I will be destroyedIf I am abandoned, I will be destroyed I must keep people near meI must keep people near me If I am alone, I may be hurtIf I am alone, I may be hurt

Nursing GuidelinesNursing Guidelines

Identify and help address current stressorsIdentify and help address current stressors Be aware that strong counter-transference Be aware that strong counter-transference often develops in clinicians because of often develops in clinicians because of client’s excessive clinging.client’s excessive clinging.

Evaluate client’s ability for self-care.Evaluate client’s ability for self-care. Avoid doing things the client is capable of Avoid doing things the client is capable of doingdoing

Help client identify assets and liabilitiesHelp client identify assets and liabilities Emphasize strengths and potential.Emphasize strengths and potential. Point out when client negates own feelings Point out when client negates own feelings or opinionsor opinions

Obsessive-compulsiveObsessive-compulsive

A pervasive pattern of A pervasive pattern of preoccupation with orderliness, preoccupation with orderliness, perfectionism, and mental and perfectionism, and mental and interpersonal control, at the interpersonal control, at the expense of flexibility, openness, expense of flexibility, openness, and efficiency, beginning by early and efficiency, beginning by early adulthood and present in a variety adulthood and present in a variety of context:of context: ““Niles” on “Frasier”Niles” on “Frasier” Martha StewartMartha Stewart

Obsessive-Compulsive PDObsessive-Compulsive PD Preoccupied with details, rules, lists, Preoccupied with details, rules, lists, order, organization, or schedulesorder, organization, or schedules

Shows perfectionism that interferes with Shows perfectionism that interferes with task completiontask completion

Excessively devoted to work and productivityExcessively devoted to work and productivity Overconscientious, scrupulous, inflexibleOverconscientious, scrupulous, inflexible Unable to discard worn-out or worthless Unable to discard worn-out or worthless objectsobjects

Reluctant to delegate tasks or work with Reluctant to delegate tasks or work with othersothers

Adopts a miserly spending styleAdopts a miserly spending style Rigid and stubbornRigid and stubborn

Schema for OCPDSchema for OCPD

There are strict rules in lifeThere are strict rules in life By focusing on details of a By focusing on details of a situation, one will reduce the situation, one will reduce the chances of making errorschances of making errors

A person is defined by what they doA person is defined by what they do The better the job you do the better The better the job you do the better person you areperson you are

Rules must be adhered to without Rules must be adhered to without alterationalteration

Emotions must be controlledEmotions must be controlled

Nursing GuidelinesNursing Guidelines

Guard against engaging in power Guard against engaging in power struggles with client. Need for struggles with client. Need for control is very high in these control is very high in these clientsclients

Intellectualization, Intellectualization, rationalization, and reaction rationalization, and reaction formation are the most common formation are the most common defense mechanismsdefense mechanisms

AvoidantAvoidant

A pervasive pattern of social A pervasive pattern of social inhibition, feelings of inhibition, feelings of inadequacy, and inadequacy, and hypersensitivity to negative hypersensitivity to negative evaluation, beginning by early evaluation, beginning by early adulthood and present in a adulthood and present in a variety of context:variety of context:

Avoidant PDAvoidant PD

Avoids occupational activityAvoids occupational activity Unwilling to get involve with peopleUnwilling to get involve with people Avoids intimate relationshipAvoids intimate relationship Afraid of being criticized or Afraid of being criticized or rejected in social situationrejected in social situation

Views self as socially inept, Views self as socially inept, personally unappealing, or inferior personally unappealing, or inferior to othersto others

Reluctant to take personal risks or Reluctant to take personal risks or to engage in any new activitiesto engage in any new activities

Schema for Avoidant PDSchema for Avoidant PD

I must be likedI must be liked I must not look foolish to I must not look foolish to myself or others at any timemyself or others at any time

The world is a dangerous placeThe world is a dangerous place I must depend on others to take I must depend on others to take care of mecare of me

Isolation is preferable to Isolation is preferable to being put at risk of being hurtbeing put at risk of being hurt

Nursing GuidelinesNursing Guidelines

A friendly, gentle reassuring A friendly, gentle reassuring approach is the best way to approach is the best way to treat clientstreat clients

Being pushed into social Being pushed into social situations can cause extreme situations can cause extreme and severe anxietyand severe anxiety

Application of the Application of the Nursing ProcessNursing Process

SafetySafety ConsistencyConsistency Boundary settingBoundary setting Appropriate self-disclosureAppropriate self-disclosure

The Nurse’s ResponseThe Nurse’s Response

Self-awarenessSelf-awareness CountertransferenceCountertransference Labels and stigmaLabels and stigma SupervisionSupervision

ResourcesResources http://www.bpdcentral.com

Borderline Personality Disorder Central is an Borderline Personality Disorder Central is an organization with information and resources for organization with information and resources for people who care about someone who may have people who care about someone who may have borderline personality disorder (BPD). borderline personality disorder (BPD).

http://www.bpdresourcecenter.orgThe Borderline Personality Disorder Resource The Borderline Personality Disorder Resource Center (BPDRC) at New York–Presbyterian Hospital Center (BPDRC) at New York–Presbyterian Hospital has been set up to help those impacted by the has been set up to help those impacted by the disorder find the most current, accurate disorder find the most current, accurate information on the nature of BPD and on sources of information on the nature of BPD and on sources of treatment.treatment.

http://www.mentalhelp.net/poc/center_index.php?id=8This Mental Help Net link contains information This Mental Help Net link contains information about personality disorders: types, treatment, about personality disorders: types, treatment, research, literature, and resources.research, literature, and resources.