Personality DisordersPersonality Disorders

Elisa A. Mancuso RNC, MS, FNSElisa A. Mancuso RNC, MS, FNS

ProfessorProfessor

PersonalityPersonality

Complex pattern of deeply embedded Complex pattern of deeply embedded emotional & behavioral characteristics.emotional & behavioral characteristics.

Traits are stable & predictable = Self IdentityTraits are stable & predictable = Self Identity

Personality Traits = Behavioral PatternsPersonality Traits = Behavioral Patterns– Thinking, perceiving & relating to environment & Thinking, perceiving & relating to environment &

self.self.– Demonstrated in social & personal contexts. Demonstrated in social & personal contexts. – Attitudes & EmotionsAttitudes & Emotions

Personality Disorders (Axis II)Personality Disorders (Axis II)

Rigid & maladaptive traits.Rigid & maladaptive traits.

““Disorder of Self”Disorder of Self” – Inner Distress & Self-centeredInner Distress & Self-centered

Cause social & functional impairment via:Cause social & functional impairment via:– Cognitive (Perceptual distortions)Cognitive (Perceptual distortions)– Affective (Mood deregulation)Affective (Mood deregulation)– Interpersonal Behavior (Aggression)Interpersonal Behavior (Aggression)– Impulse Control (Manipulation)Impulse Control (Manipulation)

DSM –IV AXIS IIDSM –IV AXIS II

Cluster ACluster A– Odd or Eccentric behaviorOdd or Eccentric behavior– Paranoid, Schizoid or SchizotypalParanoid, Schizoid or Schizotypal

Cluster BCluster B– Dramatic, emotional or erraticDramatic, emotional or erratic– Antisocial, Borderline, Histrionic or NarcissisticAntisocial, Borderline, Histrionic or Narcissistic

Cluster CCluster C– Anxious or fearfulAnxious or fearful– Avoidant, Dependent or Obsessive CompulsiveAvoidant, Dependent or Obsessive Compulsive

EtiologyEtiology 12% of population 12% of population

– ↑ ↑ risk in ↓↓ socioeconomic/disadvantaged groupsrisk in ↓↓ socioeconomic/disadvantaged groups 50% have other comorbid mental illness50% have other comorbid mental illness ↓↓ ↓↓ 5-HT5-HT

– ↑ ↑ Aggression Aggression ↓ Impulse control↓ Impulse control– ↑ ↑ Substance abuse Substance abuse ↑ Suicide ↑ Suicide

Genetic Genetic – Temperament AbnormalitiesTemperament Abnormalities

Learned responses/ Environmental Influences Learned responses/ Environmental Influences – RT Inadequate parenting RT Inadequate parenting Abuse Abuse TraumaTrauma

Poor ego & superego developmentPoor ego & superego development

Cluster ACluster A ParanoidParanoid

– Mistrust & Persistent suspiciousnessMistrust & Persistent suspiciousness– Aloof & withdrawnAloof & withdrawn– Believe others are exploiting, harming or deceivingBelieve others are exploiting, harming or deceiving– Secretive, Hypervigilent, Jealous & ProjectionSecretive, Hypervigilent, Jealous & Projection

SchizoidSchizoid– Social detachment (Cold & indifferent to praise or criticism)Social detachment (Cold & indifferent to praise or criticism)– Self-Absorbed & Self-Absorbed & ↑ Intellectual & Solitary activities↑ Intellectual & Solitary activities– Neither desires or enjoys close relationshipsNeither desires or enjoys close relationships

SchizotypalSchizotypal– Social deficits (Difficulty feeling understood & accepted)Social deficits (Difficulty feeling understood & accepted)– Eccentric, Paranoid, Ideas of ReferenceEccentric, Paranoid, Ideas of Reference– Magical thinking & SuperstitiousMagical thinking & Superstitious– Bizarre speech & inappropriate affectBizarre speech & inappropriate affect– 20% develop Schizophrenia20% develop Schizophrenia

Cluster BCluster B AntisocialAntisocial

– ““Rules don’t apply to them”Rules don’t apply to them”– Onset @ adolescenceOnset @ adolescence– Verbal & physical outbursts (Verbal & physical outbursts (↑aggressive)↑aggressive)– Socially irresponsible & violates rights of othersSocially irresponsible & violates rights of others

↑↑ ↑↑ Theft & VandalismTheft & Vandalism

– Affective instability: fluctuating & extreme attitudesAffective instability: fluctuating & extreme attitudes Arrogant & Self-assuredArrogant & Self-assured

– ↓ ↓ Tolerance for frustrationTolerance for frustration– Lack of remorse or guiltLack of remorse or guilt– Persistent lying & stealingPersistent lying & stealing– Impulsive & manipulative for personal gainImpulsive & manipulative for personal gain– ↑↑ ↑↑ Substance Abuse & SexualitySubstance Abuse & Sexuality– Fail to learn from experienceFail to learn from experience

Difficulty maintaining relationships or jobsDifficulty maintaining relationships or jobs

Cluster BCluster B BorderlineBorderline

– Intense & chaotic relationshipsIntense & chaotic relationships ↑↑ ↑↑ Efforts to avoid abandonmentEfforts to avoid abandonment

– Affective instability: Fluctuating & extremeAffective instability: Fluctuating & extreme– Impulsive self-destructive behaviorImpulsive self-destructive behavior

↑↑ ↑↑ Eating, shoplifting, gambling, sex & drugsEating, shoplifting, gambling, sex & drugs Self-Mutilation = cutting/suicideSelf-Mutilation = cutting/suicide

– Lack of clear sense of identity or life planLack of clear sense of identity or life plan Fragile ego & Fragile ego & ↓↓ achievements↓↓ achievements

– Fails to develop autonomyFails to develop autonomy– Chronic feelings of emptinessChronic feelings of emptiness– Fear of abandonmentFear of abandonment– SplittingSplitting

Pigeonhole people Pigeonhole people ““All good or All bad”All good or All bad”

Cluster BCluster B HistrionicHistrionic

– ↑↑ ↑↑ Dramatic & attention seekingDramatic & attention seeking– ↑↑ ↑↑ Concern with appearanceConcern with appearance

Flashy clothes, make-up, jewelryFlashy clothes, make-up, jewelry

– Seductive & provocative behaviorSeductive & provocative behavior– Shallow & rapidly shifting emotionsShallow & rapidly shifting emotions

Self-Absorbed & ↑↑sensitive to criticismSelf-Absorbed & ↑↑sensitive to criticism View their problems as the fault of othersView their problems as the fault of others

– Uses theatrical speech to impress othersUses theatrical speech to impress others– Easily influenced by othersEasily influenced by others– Exaggerates degree of intimacy with othersExaggerates degree of intimacy with others

Cluster BCluster B

NarcissisticNarcissistic– Grandiosity RT self-importanceGrandiosity RT self-importance– Overvalues self;Overvalues self;

Fantasies of unlimited power or successFantasies of unlimited power or success

– Sense of entitlement & needs to be admiredSense of entitlement & needs to be admired– Arrogant & uses manipulative & exploitationArrogant & uses manipulative & exploitation– Lacks empathy for othersLacks empathy for others– Hypersensitive to criticismHypersensitive to criticism– View their problems as fault of others.View their problems as fault of others.

Cluster CCluster C

AvoidantAvoidant– Inhibited, withdrawn and timid.Inhibited, withdrawn and timid.– Strongly desire closeness & intimacy but fears Strongly desire closeness & intimacy but fears

possible rejection or disapproval.possible rejection or disapproval.– Fears shame, embarrassment or ridicule.Fears shame, embarrassment or ridicule.– Avoids occupations involving interpersonal contact.Avoids occupations involving interpersonal contact.– Feels socially inept & inferior to others.Feels socially inept & inferior to others.– Highly sensitive to criticismHighly sensitive to criticism– Reluctant to take risks or engage in new Reluctant to take risks or engage in new

activities.activities.

Cluster CCluster C DependentDependent

– Submissive and clinging behaviors.Submissive and clinging behaviors.– Needs to be taken care of.Needs to be taken care of.– Pessimistic and self-criticalPessimistic and self-critical– Relies excessively on others for emotional support.Relies excessively on others for emotional support.– Fears separation and helplessness when alone.Fears separation and helplessness when alone.– ↓↓↓↓ self confidence self confidence ↑↑↑↑anxious anxious ↑↑ sensitive to criticism↑↑ sensitive to criticism– Non-assertiveNon-assertive– ↓↓ ↓↓ Decision making or problem solvingDecision making or problem solving– Seek advice and constant reassuranceSeek advice and constant reassurance

Cluster CCluster C

Obsessive-CompulsiveObsessive-Compulsive– Need order, perfection & controlNeed order, perfection & control– Preoccupied with:Preoccupied with:

Details, rules, lists or schedules.Details, rules, lists or schedules.

– Cold & rigid, formal demeanorCold & rigid, formal demeanor..– Unable to express emotionsUnable to express emotions– Inflexible & stubbornInflexible & stubborn– Superior attitude, believe they are rightSuperior attitude, believe they are right– Unable to share responsibility or delegateUnable to share responsibility or delegate

Related Personality DisorderRelated Personality Disorder

Passive-AggressivePassive-Aggressive– Negative mindset & resents othersNegative mindset & resents others – Resistance expressed indirectly to Resistance expressed indirectly to authorityauthority

Can’t express anger directlyCan’t express anger directly

– ProcrastinateProcrastinate– ForgetfulnessForgetfulness– Intentional inefficiency Intentional inefficiency – Chronic latenessChronic lateness– Complaining & blaming behaviorComplaining & blaming behavior– Argumentative & criticalArgumentative & critical– Ambivalent AffectAmbivalent Affect

Resents others yet c/o being unappreciatedResents others yet c/o being unappreciated

Nursing InterventionsNursing Interventions Establish rapport & be aware of own feelings!Establish rapport & be aware of own feelings! Patience, persistence, consistency & trustPatience, persistence, consistency & trust Structured setting with clear rules & limitsStructured setting with clear rules & limits Identify consequences of (-) behaviorIdentify consequences of (-) behavior Minimize potential for aggressive behaviorMinimize potential for aggressive behavior Protect others from verbal & physical abuseProtect others from verbal & physical abuse Encourage accountability.Encourage accountability. Praise (+) behavior give constructive feedback.Praise (+) behavior give constructive feedback. Define situation as a problem with a solution.Define situation as a problem with a solution. Medications;Medications;

– SSRIs: SSRIs: ↓↓ ↓↓ Anger, anxiety, chronic emptiness & impulsive behaviorsAnger, anxiety, chronic emptiness & impulsive behaviors

– Atypical AntipsychoticsAtypical Antipsychotics:: ↓↓ ↓↓ Hallucinations, suspiciousness, paranoia & delusionsHallucinations, suspiciousness, paranoia & delusions

Eating DisordersEating Disorders Disturbances in eating behaviors (what, when & how)Disturbances in eating behaviors (what, when & how) 8 million people: 1% of pop. 4% women8 million people: 1% of pop. 4% women

– 90% exhibit onset by age 2190% exhibit onset by age 21 Risk factorsRisk factors

– Society reinforces thinness = happiness & successSociety reinforces thinness = happiness & success– ↓↓ ↓↓ Hypothalamic function Hypothalamic function

↑↑ ↑↑ 5-HT & inhibits food intake (Satiety agent)5-HT & inhibits food intake (Satiety agent) ↓↓ ↓↓ opioid activityopioid activity

– Anorexics ↑↑ exercise = ↑↑ endorphinsAnorexics ↑↑ exercise = ↑↑ endorphins– Bulimics crave sweets & carbsBulimics crave sweets & carbs– Genetic Genetic

Hx of depression, eating disorder or substance abuse.Hx of depression, eating disorder or substance abuse.

– Family DynamicsFamily Dynamics Profound disturbances in mother/daughter relationshipProfound disturbances in mother/daughter relationship ↑↑ ↑↑ Values placed on perfection & obedienceValues placed on perfection & obedience Struggles for power, control & independenceStruggles for power, control & independence

Anorexia NervosaAnorexia Nervosa

1/100 women; onset @ 14 – 18 years1/100 women; onset @ 14 – 18 years Intense fear of gaining weight = fatIntense fear of gaining weight = fat Grossly distorted body imageGrossly distorted body image Well educated Well educated

– Refusal to acknowledge the illness existsRefusal to acknowledge the illness exists– Preoccupied with counting calories, cooking mealsPreoccupied with counting calories, cooking meals

Behavioral SymptomsBehavioral SymptomsHigh achieverHigh achiever Well behaved Well behaved PerfectionistPerfectionistDependent on other’s opinion Dependent on other’s opinion Poor self imagePoor self imageFeel emotionally empty Feel emotionally empty Unable to express feelings Unable to express feelingsControlling weight = Controlling weight = ↑↑ Pleasure↑↑ PleasureHyperactivity & Hyperactivity & ↑↑ rigorous exercise↑↑ rigorous exercise↑↑ ↑↑ Anxiety & ↑↑ Depression Anxiety & ↑↑ Depression Socially isolate & Socially isolate &

mistrust mistrust

Anorexia NervosaAnorexia Nervosa

Physical EffectsPhysical Effects– 10 -15% Mortality Rate10 -15% Mortality Rate– Emaciation lose 20-25% of body weightEmaciation lose 20-25% of body weight– Amenorrhea when BMI < 18Amenorrhea when BMI < 18– ↓ ↓ Temp ↓ HR ↓ BPTemp ↓ HR ↓ BP – ↓ ↓ Gastric emptying = fullGastric emptying = full– Dehydration → Electrolyte imbalanceDehydration → Electrolyte imbalance

↓↓ ↓↓ K, Cl, Ca & Mg → Cardiac Arrhythmias → ArrestK, Cl, Ca & Mg → Cardiac Arrhythmias → Arrest

– Lanugo = fine downy hair on bodyLanugo = fine downy hair on body– Blotchy dry skinBlotchy dry skin– ↑↑ ↑↑ Infections RT Leukopenia & AnemiaInfections RT Leukopenia & Anemia– OsteoporosisOsteoporosis

Bulimia NervosaBulimia Nervosa 3% of population onset @ 18-193% of population onset @ 18-19 College educated & High achieverCollege educated & High achiever Aware of abnormal eating patternAware of abnormal eating pattern Weight is maintained close to baselineWeight is maintained close to baseline Feel intense & anxious Feel intense & anxious Hoard food Hoard food Binging (>2 times per week)Binging (>2 times per week)

– Uncontrolled & rapid ingestion ↑ quantities of foodUncontrolled & rapid ingestion ↑ quantities of food– ↑ ↑ Guilt, shame & remorseGuilt, shame & remorse

PurgingPurging– Self induced vomiting or defecationSelf induced vomiting or defecation– Emetics, Laxatives, Enemas, Diuretics → DehydrationEmetics, Laxatives, Enemas, Diuretics → Dehydration

Mood Disorder & Substance abuseMood Disorder & Substance abuse – Amphetamines & CocaineAmphetamines & Cocaine

Bulimia NervosaBulimia Nervosa

Physical EffectsPhysical Effects Electrolyte ImbalancesElectrolyte Imbalances

– Dehydration (Diuretics) Dehydration (Diuretics) – Metabolic Alkalosis (Vomiting)Metabolic Alkalosis (Vomiting)

↓↓ ↓↓ K = Cardiac Arrhythmias → Cardiac ArrestK = Cardiac Arrhythmias → Cardiac Arrest Vomiting (HCL acid) →Vomiting (HCL acid) →

– Dental Caries & enamel erosionDental Caries & enamel erosion– Gingival infectionsGingival infections– EsophagitisEsophagitis– Parotid Edema “Chipmunk Cheeks”Parotid Edema “Chipmunk Cheeks”– ↑ ↑ Risk of Aspiration PNRisk of Aspiration PN – Russell’s SignRussell’s Sign = Callused knuckles= Callused knuckles

RT induced vomitingRT induced vomiting

ObesityObesity

1/5 Americans; women>men1/5 Americans; women>men 10% Population > 35% over ideal body weight10% Population > 35% over ideal body weight Manage (-) feelings with foodManage (-) feelings with food

– Comfort measureComfort measure Food is replacement for relationshipsFood is replacement for relationships ↑↑ ↑↑ LipogenesisLipogenesis Epidemic Health ProblemEpidemic Health Problem

Risk factorsRisk factors– Genetic PredispositionGenetic Predisposition– Hypothalamus Septal lesions Hypothalamus Septal lesions – HypothyroidismHypothyroidism– ↑ ↑ Cortisol & ↓ InsulinCortisol & ↓ Insulin

ObesityObesity

Physical EffectsPhysical Effects– ↑ ↑ Activity IntoleranceActivity Intolerance– ↑ ↑ Risk for Social IsolationRisk for Social Isolation

Fat = Sloppy & ↓ ControlFat = Sloppy & ↓ Control

– ↑ ↑ BPBP – ↑ ↑ DMDM– Hyperlipidemia = CADHyperlipidemia = CAD– Gallbladder DiseaseGallbladder Disease– Arthritis →↓ MobilityArthritis →↓ Mobility

Nursing InterventionsNursing Interventions

11stst Assess Physical Condition Assess Physical Condition– Complete PE, Wt (daily), lab values:Complete PE, Wt (daily), lab values:– K, Cl, Ca, Mg, Thyroid, Cardiac, Renal & CBCK, Cl, Ca, Mg, Thyroid, Cardiac, Renal & CBC

NutritionNutrition– RehydrationRehydration– Anorexia = “Restore Nutrition”Anorexia = “Restore Nutrition”– Provide relaxation before mealsProvide relaxation before meals– Max. time limit on eatingMax. time limit on eating– Vigilant monitoring after meals (30-60 mins)Vigilant monitoring after meals (30-60 mins)– Healthy eating patternsHealthy eating patterns – Appropriate food choicesAppropriate food choices

MedicationsMedicationsAnorexiaAnorexia

– Amitriptyline (Elavil)Amitriptyline (Elavil)– Cyproheptadine (Periactin)Cyproheptadine (Periactin)– Olanzapine (Zyprexa) Olanzapine (Zyprexa) – Fluoxetine (Prozac)Fluoxetine (Prozac)

BulimiaBulimia– Desipramine (Norpramine)Desipramine (Norpramine)– Imipramine (Tofranil) Imipramine (Tofranil) – Amitriptyline (Elavil)Amitriptyline (Elavil)– Nortriptiline (Pamelor)Nortriptiline (Pamelor)– Fluoxetine (Prozac)Fluoxetine (Prozac)

Nursing InterventionsNursing Interventions

Coping SkillsCoping Skills– ↑↑ ↑↑ Self Esteem & Autonomy via ↑ ControlSelf Esteem & Autonomy via ↑ Control– Encourage verbalization of feelings/fearsEncourage verbalization of feelings/fears– Assertiveness trainingAssertiveness training– Reinforce realistic perception of weightReinforce realistic perception of weight– Limit Setting & consistencyLimit Setting & consistency– Cognitive Behavior TherapyCognitive Behavior Therapy– Support GroupsSupport Groups

American Anorexia/Bulimia AssociationAmerican Anorexia/Bulimia Association Anorexia Nervosa & Associated DisordersAnorexia Nervosa & Associated Disorders National Eating Disorders AssociationNational Eating Disorders Association

Nursing InterventionsNursing Interventions

Family TherapyFamily Therapy– ↑↑ ↑↑ Communication to identify conflictsCommunication to identify conflicts– Alternative Problem SolvingAlternative Problem Solving– Non food coping strategiesNon food coping strategies– Encourage Pt to develop (+) Self-imageEncourage Pt to develop (+) Self-image– Education Education

S/S of Eating DisorderS/S of Eating Disorder Healthy Eating patternsHealthy Eating patterns Conflict ManagementConflict Management