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Personality Disorders. Overview. Lifelong, inflexible, and dysfunctional patterns of relating and behaving Patterns interfere with daily life Client often does not recognize own dysfunction Interpersonal and occupational problems result. Overview. - PowerPoint PPT Presentation
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Personality Disorders
OverviewLifelong, inflexible, and dysfunctional
patterns of relating and behaving Patterns interfere with daily life Client often does not recognize own
dysfunction Interpersonal and occupational problems
result
Overview
Diagnosis is on Axis II If admitted to an inpatient facility must have an Axis I
diagnosis also (e.g. alcoholism, depression)
Difficult to treat Most are treated outpatient in individual or
group therapy Often seen in drug treatment centers
Overview: Interpersonal Characteristics Relationships
Often experience conflict with others
May have difficulty initiating or sustaining relationships
Cause distress to others only become distressed when
others react to them negatively
Affective/Cognitive Characteristics
Anxiety: Varies in the different clusters. Behavior is way of coping with anxiety and the
individual does not consider how their behavior will affect others.
Cognitive issues: Rigidity of responses--difficulty in adapting to the
new or unexpected Mistakes in judgment Lack of insight
Gender and Personality Disorder Diagnoses
Female: greater percentage of Borderline or Histrionic diagnoses
Male: greater Percentage of Paranoid, Schizoid, Antisocial, and Narcissistic dx.
Grouped by the Three Clusters of Behavior in the DSM IV-TR
Cluster A Exhibit odd and eccentric behaviors
Cluster B Exhibit dramatic, emotional and erratic
behaviors. Cluster C
Exhibit anxious, fearful behaviors
Cluster A (Odd-Eccentric)
Characteristics: odd, eccentric behavior, suspicious ideations, and social isolation. Know this cluster as a group (do not have to recognize each individually) Schizoid P.D. Schizotypal P.D. Paranoid P.D.
Cluster A Overview Similarities to schizophrenia But no fixed delusions or hallucinations May have transient psychotic symptoms
when under acute stress May have biological family member with
schizophrenia
Cluster A, cont’d Schizoid
Lacks desire to be close to others
Lacks close friends Solitary activities Little interest in sexual
activity Appears cold and
detached Appears indifferent to
praise or criticism
Schizotypal Ideas of reference Magical thinking or odd
beliefs Unusual perceptual
experiences including bodily illusions
Odd thinking and speech Odd or eccentric
appearance or behavior Suspicious, social
anxiety Few close relationships
Cluster A, cont’d
Secretive, fearful and distrustful. Reads hidden meaning into benign statements or
events Reluctant to confide in others; fears information will
be used against him/her Suspicious about fidelity of spouse or S.O. without
justification Perceived attacks on character or reputation Bears grudges; responds to threats with anger
Paranoid P.D.
Photo from film: “Meet the Parents” with Ben Stiller and Robert De Niro
Cluster A: Nurse-client Relationship Building trust is most important Be honest; keep it simple Do not intrude on privacy, if possible Do not challenge odd beliefs or appearance
Cluster A: Milieu Do not push into social or group activities,
but give gentle encouragement Choose groups that are non-threatening
What Should the Nurse Say/Do?
A recently admitted client is refusing to eat in the cafeteria with others, stating,
“The cafeteria food is different. And those people don’t want me. Why can’t I eat here?”
Cont’d (Choose all that apply)A) “There is nothing wrong with the cafeteria
food.”B) “You need to go over to the cafeteria if
you want to eat.”C) “I’ll walk with you to the cafeteria.” D) “Why do you think they don’t want you?”E) “It can be hard to get comfortable when
you are new.”
Cluster B (Dramatic, Emotional, Erratic)
Characteristics: Impulsive, dramatic behavior, intolerance of frustration, and exploitative interpersonal relationships. (Know Antisocial, Borderline and Narcissistic) Histrionic P.D. Narcissistic P.D. Antisocial P.D. Borderline P.D.
Is most commonly dx’d. P.D.
Cluster B Histrionic
Needs to be center of attention
Dramatic and provocative
Overreacts to minor events
Easily influenced by others
Superficial relationships
Narcissistic Grandiose Fantasies of
unlimited power, success or brilliance
Needs to be admired Sense of entitlement
(deserves special treatment)
Lacks empathy Takes advantage of
others to meet own needs
Interventions for Histrionic or Narcissistic P.D. Set appropriate limits Be consistent in approach Be matter-of-fact Focus on here-and-now Use supportive confrontation for
discrepancies and contradictions Support self-esteem (does this seem like a
contradiction?)
What Should the Nurse Do/Say?1) Client (stomps foot and makes faces while
talking): “I need the day room for my exercise routine. You people have to realize that I am in modeling and this is important to my career.”
(Use matter-of-fact approach)
What Should the Nurse Do/Say?
2) Client: “I am depressed because I have no true friends in my life. And even my roommate here is so rude to me. What a fat slob! I want to room with someone else.”
(Use supportive confrontation)
Cluster B, cont’d Antisocial Personality Disorder
Diagnosis is based on disordered behavior: Pattern of disregard of the rights of others Non-conforming to rules Often found in criminal justice system rather
than in mental health services May seek hospitalization to avoid the law
Antisocial Personality Disorder: Cognitive and Affective Aspects
Low tolerance for frustration; cannot delay gratification of impulses
Unable to make long-range plans Deny and rationalize behavior Little guilt or remorse May be aggressive or abusive
Antisocial Personality: Interpersonal Aspects
May appear charming and confident, but with little personal involvement
Self-interest comes before needs of others Unable to sustain close personal relationships. Sex life is impersonal and impulsive.
Antisocial Personality: Etiology Genetic: inherited trait or predisposition CNS
ANS under-responds to stress Low activity in frontal lobe
Unable to learn from rewards and punishment History of disordered life functioning
Parent-child relationship often is unstable Childhood characteristics of lying, stealing and being
truant.
Client Scenario A 24 year old unemployed male was admitted
from jail to the mental health unit after a suicide attempt in his cell. Was awaiting sentencing for burglary: stole from the apt. of his former girlfriend. States to the nurse that his problems started after she broke up with him. Client was using alcohol and cocaine heavily. Explains, “She owed me and so I took some cash and stuff.” The client has a distressed affect when discussing current situation. He states, “Now they’re putting a label of ‘crazy,’ on me.”
Antisocial Personality Disorder: Interventions
Essential for staff to agree on rules and stick with them
Will try to play one staff or shift against another Set firm limits Point out effect of behavior on others Point out consequences of behavior
Best form of treatment: Peer counseling and self-help groups like AA, where peers can confront and offer feedback
What Should the Nurse Say/Do? A client who is involuntarily in treatment on
the inpatient unit was found smoking in the bathroom. A few days later the client’s visitor smuggles in some alcohol, which he and roommate consume.
A hospitalized client is verbally abusive and uncooperative with select staff members but is friendly and cooperative with others. Complains to you about the “nasty” staff.
Cluster B, cont’d: Borderline Personality
Disorder
Most commonly diagnosed Personality Disorder
Borderline Personality Disorder: Overview
Characterized by: Extremely intense and variable moods Disturbed sense of self; often self-negative Impulsivity, often with self-destructive behavior Use of “splitting” (also called “black or white
thinking”) as defense mechanism
Borderline Personality Disorder DSM IV-TR
Criteria Fear of abandonment and frantic efforts
to avoid it Unstable, intense relationships Marked identity disturbance Chronic feelings of emptiness Impulsivity that may be self-damaging
These behaviors help them to feel better for a short period of time
Borderline Personality Disorder DSM-IV TR Criteria
When under stress may experience transient, paranoid thoughts or delusions, or dissociative symptoms These will resolve when the stress is relieved
DSM IV-TR Criteria, cont’d. Recurrent Self-Destructive
Behavior Suicidal threats & gestures Self-Injurious Behavior (SIB)
Affective instability Rapid mood shifts Low frustration tolerance
Problems with anger
Borderline PD: Etiology A predisposition plus childhood experiences is
current accepted theory Childhood Environment: often chaotic or
neglectful Strong evidence for abuse, trauma history Neurobiological: (cause or result of stress?)
Serotonin dysregulation cholinergic and adrenergic abnormalities lack of integration of right and left hemispheres smaller hippocampal volume
Issues for Borderline Personality: Splitting Phenomenon
Low tolerance for ambivalence Inability to cope with conflict Get a sense of identity from the other Result in this perspective:I Either you are good or you are bad (no in-
betweens) When you are not perfect, you have failed me
and you are bad (that means I’m no good, either)
Issues for Borderline, cont’d Interpersonal Relationships
Unstable and intense Characterized by over-idealizing or
devaluation of others Cannot resolve feelings that others are not
perfect and cannot meet all of their needs Fear being abandoned; may be needy and
dependent
Issues for Borderline PD, cont’d Functions of Self-injury:
Is self-punishment Relieves tension Improves mood Is evidence that they are real, and can feel
Suicide risk is high due to: Self-injuring behaviors Severe emotional pain Impulsivity
BPD: Nurse-client Relationship Consistency, trust, honesty Explain and then Enforce unit rules Team approach: Minimize splitting of staff Be accepting, Be matter of fact, Do not
show anger or irritation. (Transference phenomenon is common in these clients)
Convey empathy
Nurse-client Relationship, cont’d
Discuss how to express and handle feelings Encourage self-responsibility and appropriate
behaviors Offer choices, when possible Give positive feedback for accomplishments and
progress Don’t get discouraged by opposite behaviors Do not minimize or ignore SIB; assess for suicide
Borderline Personality: Milieu Provide safe environment based on ongoing
assessment; suicide precautions if necessary Groups: Coping skills, Expressive Arts Journaling: Promotes safe identification of own
thoughts, feelings and actions
Issues for Therapy Frequently have long-term issues of abuse,
trauma, neglect An advanced practice Health Care Provider can
assist the client in talking about these events in individual or group therapy on long-term basis
BPD: Group Therapy Clients make good group members; can be
very insightful for others Decreases transference issues. Feedback
from group can be helpful in dealing with unrealistic expectations.
Attention-seeking behavior and entitlement issues are dealt with better in group.
What Should the Nurse Say/Do? A client with a history of self-injuring
behavior visited earlier this evening with family. She is later found in her room, having cut her abdomen with the broken end of a plastic fork she had taken from her meal tray. She says to the nurse, “They told me I can’t come back home because they can’t handle me.”
What Should the Nurse Say/Do? The client is placed on Close Observation
status for SIB. At midnight, she expresses anger to the night shift nurse that she can’t sleep due to staff having to watch her. “I am being treated like a criminal. If the evening shift nurses really cared about me they would not have done this to me. ”
Legal-Ethical Critical Thinking
If a client who self injures has a history of abuse or trauma, what are the implications for use of restraints and emergency management?
BPD: Community Resources AA, ACOA Family education and support groups, too
Cluster C: (Anxious-Fearful)
Dependent Personality Disorder Pervasive, excessive need to be taken care of
Feels unable to care for self, little self-confidence
Fears being alone and helpless Unable to make decisions without much
support Fears loss of approval; will agree or will
perform tasks to avoid rejection
Cluster C, cont’d Avoidant Personality
Disorder Fears making
mistakes Fears disapproval and
rejection Severe shyness and
feelings of inadequacy and being disliked
Socially uncomfortable and withdrawn
Obsessive Compulsive Personality Disorder Perfectionistic and
inflexible Preoccupied with
details Too busy to have fun
or friends Hoards objects and
money
Nursing Interventions for Cluster C
Assist in setting small, achievable goals Discuss fears and feelings prior to meeting a
goal Assist to explore feelings Assist to try new activities Assist to decrease anxiety and need for
perfection
Cluster C: Milieu Management Groups: Assertiveness training, Stress
management, Leisure skills Most clients seen as outpatients
What Should the Nurse Say/Do? A client with Cluster C traits is trying to learn how to be
more confident and assertive and has a list of goals he wrote after attending a group on the unit. He asks the nurse what goal he should choose to work on first. Here is the list:
1) improve my life 2) eat breakfast with other people every other
day 3) identify one good thing about myself 5) find a woman who really cares
What Should the Nurse Do/Say?
A) “Oops, you missed putting a # 4 on the list.”
B) “#3 is a good goal. Try that one first.” C) “What other ways can you work on your
issues than writing a list?”
Personality DisordersPharmacological
Interventions Medications address severe, disabling symptoms. Medications do not cure P.D.s Primarily used when client in emergency or crisis
(PRN or short-term) Examples: Suicidal behavior
Transient psychosis
Assaultive behavior
Severe anxiety episode
Personality Disorders Psychopharmacology,
cont’d Low doses of some medications may be
indicated e.g. antipsychotic agents for paranoia; mood stabilizers or SSRIs for Borderline Personality Disorder, etc.
Treat co-morbid Axis I diagnoses: Depression, Anxiety Disorders, Bipolar Disorder, etc.
Evaluation of Interventions How can the nurse evaluate effectiveness
of interventions for the person who has a personality disorder?
Expectations (i.e. your goals) should be realistic
What behaviors can change within a short-term hospital stay?