Personality Disorders

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 • 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 theThree Clustersof 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

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

Cluster A, cont’d • Paranoid P.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 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) • “There is nothing wrong with the cafeteria food.” • “You need to go over to the cafeteria if you want to eat.” • “I’ll walk with you to the cafeteria.”  • “Why do you think they don’t want you?” • “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.

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 Cluster B

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 DisorderDSM-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 predispositionplus 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

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 Cluster C, cont’d

Nursing Interventionsfor 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

Personality Disorders