Personality Disorders Chapter 24

1. Know all of the 'Key Terms' in the front of the chapter. Antisocial personality disorder

A syndrome in which a person lacks the capacity to relate to others, does not experience discomfort in inflicting or observing pain in others, and may manipulate others for personal gain.

Avoidant personality disorder

A personality disorder in which the central characteristics are an extreme sensitivity to rejection and robust avoidance of interpersonal situations.

Borderline personality disorder

A disorder characterized by disordered images of self. Impulsive and unpredictable

Dependent personality disorder

A disorder in which people have a high need to be taken care of; this can lead to patterns of submissiveness with fears of separation and abandonment by others.

Diathesis-stress model A general theory that explains psychopathology using a multi-causational systems approach

Dialectical behavior therapy (DBT)

An evidenced-based cognitive behavioral therapy developed by Dr. Marsha Linehan. It has been shown to successfully treat chronically suicidal persons with borderline personality disorder, and it focuses on impulse control.

Emotional dysregulation A poorly modulated mood characterized by mood swings. Individuals with emotion regulation problems have ongoing difficulty managing painful emotions in ways that are healthy and effective.

Emotional lability

Rapidly moving from one emotional extreme to another. Typically, these emotional shifts include responding to situations with emotions that are out of proportion to the circumstances, pathological fear of separation, and intense sensitivity to perceived personal rejection.

Histrionic personality disorder

This disorder is characterized by attention-seeking behaviors, self-centeredness, low tolerance of frustration, and excessive emotionality. The person is often impulsive and melodramatic and may be flirtatious or provocative

Narcissistic personality disorder

A disorder characterized by a pervasive pattern of grandiosity, need for admiration, and lack of empathy for others.

Obsessive-compulsive personality disorder

Associated with excessive parental criticism, control, and shame. The child in this atmosphere responds to this negativity by trying to control his environment through perfectionism and orderliness. Heritable traits such as compulsivity, oppositionality, lack of emotional expressiveness, and perfectionism have all been implicated in this disorder.

Paranoid personality disorder

A longstanding distrust and suspiciousness of others based on the belief (unsupported by evidence) that others want to exploit, harm, or deceive the person. These individuals are hypervigilant, anticipate hostility, and may provoke hostile responses by initiating a "counterattack." They demonstrate jealousy, controlling behaviors, and unwillingness to forgive.

Personality Deeply ingrained personal patterns of behavior, traits, and thoughts that evolve, both consciously and unconsciously, as a person's style and way of adapting to the environment.

Personality Disorder An enduring pattern of experience and behavior that deviates significantly from the expectations within the individual’s culture.

Schizoid personality disorder

A disorder characterized by extreme emotional detachment and lack of relationships. Depersonalization, or feelings of detachment from oneself and the world, may be present.

Schizotypal personality A disorder characterized by lack of warmth, aloofness, and indifference to the

disorder feelings of others. Contributions to conversations tend to ramble and are lengthy, unclear, and overly detailed. Paranoia and mild, transient hallucinations and delusions distinguish this disorder from schizoid personality disorder.

Separation-individuation A psychological process in which a child separates from the mother (or significant parent) into a physically and psychologically differentiated person. This process may be disrupted and result in a disturbance in maintaining a reliable feeling of individual identity.

Splitting

A primitive defense mechanism in which the person sees self or others as all good or all bad, failing to integrate the positive and negative qualities of the self and others into a cohesive whole.

2. Compare and contrast the ten personality disorders given in the text, and be able to give a general description of each. (See Table 24-2)

Paranoid Personality Disorder Distrust/suspiciousness of others. Hostile and Violent. Cognitive and perceptual distortions. Blames others.

Tx: Psychotherapy, later CBT. Group therapy can help Rx: antidepressants, anxiolytics (antipsychotics may be of use, esp. if acutely psychotic)

Schizoid Personality Disorder: Reclusive. Avoidant. Uncooperative.

Tx: Supportive psychotherapy, Group therapy Rx: Antipsychotics, Antidepressants (anxiolytics as needed)

Schizotypal Personality Disorder:

Severe social deficits, extreme anxiety, paranoid, thinks everyone is out to get them, conversations ramble and are unclear, blames others; genetic link: altered dopamine transmission

Tx: Supportive psychotherapy, CBT, Group therapy for social skills Rx: Lower dose Antipsychotics and antidepressants

Histrionic Personality Disorder Attention seeking, self-centered, wants the best of everything, others feel smothered, impulsive, flirtatious & provocative

Tx: Group therapy, tx of comorbid disorders Rx: Antidepressants as needed

Narcissistic Personality Disorder

Antagonism via grandiosity & attention seeking, arrogant, inflated view of self, needs constant admiration, R/T childhood neglect

Tx: Psychotherapy only works after pt acknowledges narcissism. Group therapy may help pt learn empathy Rx: Lithium for mood swings, antidepressants also used

Avoidant Personality Disorder Low self-esteem, feeling or inferiority, reluctance to engage; R/T rejection/criticism

Tx: Psychotherapy focused on trust. Group therapy, Assertiveness training. Rx: Antidepressants, anxiolytics Beta blocker (atenolol)

Dependent Personality Need to be cared for, fear of Tx: Insight oriented psychotherapy,

Disorder separation & abandonment;

behavioral therapy, assertiveness training. Family and group therapy Rx: Anxiolytics, antidepressants for specific sx. Panic attacks can be helped w/ imipramine

Obsessive Compulsive Personality Disorder Rigidity

strives for perfectionism, inflexible, genuine affection for others, rehearse over and over again; R/T excessive parental criticism, control & shame

Tx: Supportive or insight oriented psychotherapy. Rx: Clomipramine and SSRIs, decrease obsessions)

Antisocial Personality Disorder .

sociopath, antagonistic behaviors (manipulative for personal gain, lack empathy), Disinhibited behaviors (high risk taking, disregard responsibility), criminal misconduct common; genetically linked to altered serotonin transmission

Tx: Psychotherapy (best when inpatient and not in jail) Rx: Pharmacotherapy for anxiety, rage, and depression. Benzodiazepines (careful use), Ritalin for ADHD, anticonvulsants my help impulsive behavior

Borderline Personality Disorder

High mortality rate; impairment in emotional control, fear of separation, self-image distortions, impulsivity, antagonism (anger, aggressive), splitting (unable to view + and - in one person)

Tx: Psychotherapy, DBT, Group therapy Rx: Antipsychotics may help anger and brief psychosis, SSRIs and MAOIs, Benzos ( anxiety)

3. Describe general guidelines/nursing interventions for working with clients with personality disorders:

Use a multidisciplinary approach as a main means of networking, communicating and reviewing plans with staff and services.

Have a clear treatment alliance between staff & patient (staff are “all on the same page”) Set clear, realistic limits with clearly defined consequences for desired and undesired

behaviors. Remain neutral. Avoid rejecting or rescuing Monitor personal reaction to patients Use simple and easy to understand language.

4) How should the inpatient milieu be managed for a patient with borderline personality

disorder (BPD)? How should the inpatient milieu be managed for a patient with antisocial personality disorder (APD)? They are managed similarly: BPD

Set realistic goals: use clear action words Be aware of manipulative behaviors ( flattery, seductiveness, instilling of guilt) Provide clear and consistent boundaries and limits Use clear and straightforward communication When behavior inappropriate/undesired, calmly review therapeutic goals & tx limits. Avoid rejecting or rescuing Asses for suicidal or self-mutilating behaviors, esp. during times of stress.

APD

Try to prevent/reduce effects of manipulation (flattery, seductiveness, instilling of guilt) Set clear and realistic limits on specific behaviors Ensure limits are adhered to by all staff Document sign of manipulation or aggression Provide clear boundaries and consequences Substance abuse is best handled through a well-organized tx program before other

forms of counseling are begun. 5) Which NANDAs are most commonly used for patients with BPD? For APD? BPD: Self-mutilation, Risk for self-mutilation, Risk for suicide, Risk for self-directed violence, Risk for other directed violence, Social isolation, Impaired social interaction, Disturbed personal identity, Ineffective coping. APD: Risk for other-directed violence, Defensive coping, Impaired social interaction, Ineffective health maintenance. 9. Describe appropriate nursing interventions for dealing with manipulative behavior (Box 24-2), aggressive behavior (Box 24-3) and impulse control (Box 24-4). Which of the personality disorders is most likely to need each type of interventions? Why? Manipulative behavior: Antisocial, Borderline, (Narcissistic, Dependent, Histrionic)

Limit setting : (Use easily understood, nonpunitive and clear language) o Discuss behavior concerns with pt o Identify desirable and undesirable pt behavior o Establish consequences for occurrence and non-occurrence of desired behaviors o Don’t argue or bargain w/ pt regarding establishment of consequences for behaviors

o Modify as needed to accommodate changes in pt situation Aggressive behavior (Box 24-3) Antisocial, Narcissistic, Paranoid

Anger control assistance o Limit access to frustrating situations o Encourage to seek assistance during tense situations o Monitor for inappropriate aggressiveness o Assist patient to identify source of anger o Identify consequences of inappropriate expression of anger

Impulse control (Box 24-4). Antisocial, Borderline

Impulse control training o Determine appropriate behavior for expressing anger given pt’s cognitive and

physical functioning o Limit pt access to frustrating situations until pt able to express anger adaptively o Encourage pt to seek help from staff when tension mounting o Monitor potential for inappropriate aggression, and intervene before it occurs. o Prevent physical harm if DTO or DTS (restraints, removal of potential weapons) o Provide physical outlets for anger or tension ( sports, art, journaling) o Provide reassurance to pt that staff will intervene to help pt maintain control o Assist pt in identifying source of anger o Identify what pt gets out of expressing anger (what function does it serve?) o Identify consequences of inappropriate expressions of anger.

11. How does DBT differ from CBT? (See Linehan article) DBT differs from CBT in that it also incorporates mindfulness (being aware of one’s thoughts and actively shaping them). 12. How should staff deal with a patient who is splitting staff? Present a calm, unified approach to patient. Clear boundaries specific to that pt should be clarified with all staff as well as consequences for desired and undesired pt behavior. Staff should self-monitor and check in with supervisor.if undue stress or countertransference takes place. 13. How should staff deal with a patient who is self-injurious? Prevent physical harm when DTS (by removal of potential weapons, restraints if necessary) Monitor pt with level determined by assessment and evaluation ( 1:1, q15min, q30min, etc.) Assist pt in identifying situations and/or feelings which may prompt self injury. Instruct pt in coping strategies.