personality disorders

Personality

complex pattern of characteristics, largely outside of the person’s awareness, which compromise the individual’s distinctive pattern of perceiving, feeling, thinking, coping and behavior.

personality traits

—prominent aspects of personality that are exhibited in a wide range of social & personal contexts.

Personality and Personality Traits

tend to be stable over time

—Personality Traits are enduring patterns of…

—Perceiving

—Relating to

—Thinking about environment and oneself

personality involves…

—Cognition- ways of perceiving and assigning meaning to self, others, and events

—Affectivity- the range, intensity, and appropriateness of emotionality

—Interpersonal behavior

Impulse control           

Personality Development

—Response to a number of Biological and Psychological Influences

—Heredity

—Temperament

—Experiential Learning

—Social Interaction

Prevalence and Comorbidity of Personality Disorders

—Personality Disorders manifest in adolescence and early adulthood

— Prevalence within general population has been estimated at 9.6%

—Often  co-occur with depression and anxiety

—Onset usually occurs before other psychiatric disorders

—Varying personality disorders often coexist

—Difficult to verify number of population affected by Personality Disorders due to significant numbers of individuals not seeking professional help.

Prevalence of Personality Disorders

—Gender – can be a major risk factor for the   development of certain Personality Disorders

—Women are at increased risk for avoidant, dependent, and paranoid personality disorders

—Men are at risk for antisocial personality disorder

—African American & Native American heritage, young adults, low socioeconomic status, divorced, separated, widowed, never married

Personality Disorder Definition

—Is a rigid, stereotyped behavioral pattern that persists throughout a person’s life. Chronic maladaptive pattern of perceiving, thinking and relating that impairs social or occupational functioning causing inner distress. Deviates markedly from the expectations of a person’s culture.

—Is serious and at risk for psychiatric co-morbidities Mood Disorders, Anxiety, Substance abuse, Injuries to Self and/or Others.

—Personality disorders occur  when personality traits become;

—Inflexible and rigid

—Maladaptive

—Cause significant dysfunction or severe impairment and subjective distress

—A lifelong behavioral pattern that negatively affects many areas of life, causes problems, and is not produced by another disorder or illness.

Individuals with Personality Disorders

—Lack insight, lack understanding of the impact of their behavior on their environment, fail to accept consequences for their own behaviors

—When threatened attempt to manipulate or change their environment to decrease stress instead of changing the behavior

—Many individuals with other psychiatric and medical diagnoses manifest symptoms of personality disorders

—Nurses most likely will encounter individuals with personality disorders in all healthcare settings

Psychoanalytic theory on personality disorders

empathize importance of nurturing from immediate caregivers and loved ones for fostering positive personality traits

biologic theory on personality disorder

stress influence of genetic transmission combined with environmental exposures for the formation of personality

Social learning and cognitive perspectives theory on personality disorder

—people acquire personality characteristics through thought and interaction with their environment

—When development is stalled, disrupted or becomes negative ….

theres risk for problems

A personality disorder must meet these overarching criteria:

—Significant impairment in self or interpersonal functions.

—One or more pathological personality trait.

—Impairments are stable over time/ across situations.

—Personality traits or trait expressions are not normative for developmental stage or cultural environment.

—Not due to use of a substance or medical condition.

cluster A personality disorders

—Represent behaviors that are described as; Odd or Eccentric

—Paranoid Personality Disorder

—Schizoid Personality Disorder

—Schizotypal Personality Disorder

cluster B personality disorders

—Represent behaviors that are described as; Dramatic, Emotional, or Erratic

—Antisocial Personality Disorder

—Borderline Personality Disorder

—Histrionic Personality Disorder

—Narcissistic Personality Disorder

cluster c personality disorders

Represent behaviors that are described as; Anxious or Fearful

—Avoidant Personality Disorder

—Dependent Personality Disorder

—Obsessive-Compulsive Disorder (will be covered in Anxiety presentation)

Paranoid Personality Disorder

—A pervasive distrust and suspiciousness of others such that others’ motives are interpreted as malevolent. Quick to take offense

—Do not acknowledge their negative feelings

—Project negative feelings on others, look for hidden meanings in conversations

—Condition begins by early adulthood and                    presents in a variety of contexts

Clinical Observations : Paranoid Personality Disorder

—Constantly on guard

—Hyper vigilant, guarded, oversensitive to surroundings and interactions

—Ready for any real or imagined threat mistrusts and misinterprets cues.

—Magnifies and distorts environmental cues

—Trusts no one -  has few if any friends

—Constantly tests the honesty of others

—Do not lose contact with reality

Predisposing Factors paranoid personality disorder

Possibly hereditary link. Subjected to early parental antagonism and harassment. Estimated 4.4% of general population

Schizoid Personality Disorder

—Show indifference to social relationships

—Characterized primarily by a profound defect in the ability to form personal relationships.

—Failure to respond to others in a meaningful emotional way.

—Flattened affectivity, cold, unsociable, seclusive demeanor

—Prevalence within the general population has been estimated at 3.1%.

Clinical Observations: Schizoid Personality Disorder

—Indifferent to others and environment

—Client is aloof, withdraws from social events

—Client is emotionally cold, flat affect

—In the presence of others, clients appear shy, anxious, or uneasy

—Inappropriately serious about everything and has difficulty acting in a light-hearted manner.

Predisposing Factors of schizoid personality disorder

Possible hereditary factor Childhood has been characterized as: Bleak, Cold, Unempathic, Notably lacking in nurturing

Schizotypal Personality Disorder

—displays an enduring and pervasive pattern and interpersonal deficits with extreme discomfort and intolerance for close relationships

—Thought Patterns are disturbed, odd behaviors

—A graver form of the pathologically of the less severe schizoid personality pattern

—Affects about 3 percent of the population.

clinical observations schizotypical

—Exhibits bizarre speech pattern.

—Aloof, isolative, inappropriate affect, social anxiety

—When under stress, may decompensate and demonstrate psychotic symptoms.

—Demonstrates bland and apathetic manners

—Everyday world manifests with magical thinking and Ideas of Reference

Delusions, Depersonalization

Schizotypical predisposing factors

possible hereditary factor and or possible physiological influence such as anatomic deficits or neurochemical dysfunctions within certain areas of the brain (dysregulation of dopaminergic pathways)

Early family dynamics of  indifference, impassivity (void of emotion) parental patterns of discomfort with personal affection and closeness

Cluster B Disorders (recap)

—Dramatic, Emotional, Attention Seeking Behaviors

—Moods are labile and shallow

—Become involved in intense interpersonal conflicts

—Antisocial traits more common in men

—Borderline and Histrionic traits more common in females

Antisocial Personality Disorder

—aggressive and irresponsible behaviors, superficially charming, lack genuine warmth

Prevalence estimates in the United States range from 3% in men to about 1% in women (18 or older ). Conduct D/O 15 yr. old or younger.

A pattern of :

—Socially irresponsible, domestic violence, fights, stealing, substance abuse, 

—Exploitative, manipulative  

—Guiltless behavior that reflects a disregard for the rights of others. Failure to conform to society laws and norms

Predisposing Factors: antisocial

—Possible genetic influence

—Sociopathic or alcoholic mother / father

—Aggressive temperament as a child

—Parental deprivation during the first 5 years of life

—History of ADHD or conduct disorder during childhood or adolescence

—Absence of parental discipline or influence, Erratic and inconsistent methods

—Extreme poverty

—Removal from the home

—Being “rescued” each time they are in trouble (never having to suffer the consequences of their own behavior)

—Maternal / Paternal deprivation

Clinical Observations: Antisocial

—Fails to sustain consistent employment.

—Exploits and manipulates others for personal gain

—Cold, callous, intimidating

—Inconsistent work or academic performance

—Failure to conform to societal norms

—Cruel and malicious

—Inability to form lasting monogamous relationship

—Low levels of behavioral inhibitions

—Very difficult diagnose and treat

—Lack fear, decision-making

Borderline Personality Disorder

Characterized by a pattern of intense and chaotic

 relationships with affective instability. Have fluctuating

 and extreme attitudes and moods regarding other people. View life experiences and relationships to the extremes of either very good or very bad. This tendency is known as splitting. View themselves as victims, Highly impulsive, mood swings, depression, anger, anxiety, if feelings of being ignored can self mutilate, harm self, become aggressive  for attention or numb emotions.

borderline personality disorder predisposing factors

—Predisposing influences possible history of childhood abuse, neglect and separation from caregivers or loved ones, others with psychiatric disorders in the home

—Biochemical: Some research has shown changes in certain areas of the brain involved in emotion regulation, impulsivity and aggression. In addition, certain brain chemicals that help regulate mood, such as serotonin, may not function properly.

—Genetic: Possible hereditary factor

Borderline Personality Disorder

Most common form of personality disorder

—Emotionally unstable

—2% of general population with 75% being female

—Identity disturbances in body image, sexuality, long term goals and careers

—Extreme affective instability usually lasting a few hours and usually no longer than a day

clinical observations Borderline Personality Disorder

—Always seems to be in a state of crisis.

—Affect is one of extreme intensity

—Behavior reflects frequent changeability

—Self-destructive behaviors present

—Clients are most strikingly identified by the intensity and instability of their affect and behavior

—Common behaviors

—Depression

—Inability to be alone, attention seeking behaviors

—Clinging and distancing behaviors

—Splitting

—Manipulation

Histrionic Personality Disorder Cluster B

—long standing pattern of excessive emotionally charged interactions and attention seeking behaviors. Strive to be center of attention, speech is superficial, lacks detail. Seductive, insecure, dependent on approval of others, naïve, easily influenced, low tolerance to frustration, blame disappointments on others, suppress feelings r/t past events and lack insight

—1.8% population affected, Women more than men

Histrionic Cluster B predisposing factors

—Possible link to the noradrenergic and serotonergic systems

—Possible hereditary factor

—Learned behavior patterns

Clinical Observations: Histrionic

—Highly Distractible

—Difficulty paying attention to detail

—Flamboyant in dress and speech, exhibitionistic

—Easily influenced by others

—Difficulty forming close relationships

—Excitable

—Emotional

—Colorful

—Dramatic, manipulative, attention seeking,

—Extroverted in behavior, seductive

 Narcissistic Personality Disorder

—lifelong pattern of self-centeredness, self-absorption, inability to empathize, insensitive of others, grandiose, extreme desires for admiration, feel special and important and have the rights for special treatment, exaggerate successes, self - esteem is fragile, oversensitive to  comments, envious of others and believe others envy them

—About 6% of population

More common in men (75%)than women 

Narcissistic Personality Disorders Predisposing Factors

—They tend to be overly pampered and indulged. Learn to view themselves as special and grow to expect special treatment from others.

—Parents were often narcissistic themselves.

Clinical Observations: Narcissistic

—Mood can easily change because of fragile self-esteem if they do not:

—Meet self-expectations.

—Receive positive feedback from others.

—Criticism from others may cause them to respond with rage, shame, and humiliation

—Clients are overly self-centered, overly sensitive to what others think, insensitive to others needs, lack empathy

—Exploit others in an effort to fulfill their own desires.

—Mood, which is often grounded in grandiosity, is usually optimistic, relaxed, cheerful, and care-free

Avoidant Personality Disorder

—pattern in early adulthood of social discomfort, timid, fear of rejection and negative feedback, will only form relationships if acceptance is guaranteed, self-perception of unattractiveness, inferior, socially inept, avoid social demands, feelings of shame, embarrassment, ridicule trying new activities

—Avoidant personality d/o involves all social activities whereas social phobia involves specific situations

—2-4% general population. Equally common for both sexes

Avoidant Personality Disorder predisposing factors

—Possible hereditary influences

—Parental rejection and criticism

Avoidant Personality Disorder clinical observations

—Awkward and uncomfortable in social situations.

—Desire close relationships but avoid them because of their fear of being rejected

—Inappropriate displays of anger, dissociative, paranoid ideation, preoccupied being criticized or rejected

Dependent Personality Disorder

—excessive need to be taken care of, pervasive, submissive and clinging behaviors, fears of separation, difficulty in making independent decisions and starting projects, lack trust in one’s judgments, helpless, hopeless, relationships are based on being cared for. Will stay in relationship even if abused.

—More common among women than men.

—0.5% general population

—More common in the youngest children of a family than in the oldest ones

Dependent Personality Disorder —Predisposing Factors

—Possible hereditary influence.

—Stimulation and nurturance are experienced exclusively from one source.

—A singular attachment is made by the infant to the exclusion of all others

Clinical Observations: Dependent Personality

—They have a notable lack of self-confidence that is often apparent in their: Posture, Voice, Mannerisms

—Typically passive and acquiescent to desires of others.

—Overly generous and thoughtful, while underplaying their own attractiveness and achievements.

—Assume passive and submissive roles in relationships.

—Avoid positions of responsibility and become anxious when forced into them

Treatments For Personality Disorders

—Interpersonal Psychotherapy

—Psychoanalytical Psychotherapy

—Milieu or Group Therapy

—Cognitive/Behavioral Therapy

—DBT (Dialectical Behavior Therapy) for Borderline PD

—Case management

—Psychopharmacology

—Personality Disorders Cluster A symptoms

—suspicious, paranoid, distrustful, preoccupied, reluctant or unable to trust, reads into interactions as having hidden negative agendas, isolative, flat affect, blunted or limited emotional response, limited to no meaningful relationships, detached from activities, socially detached, odd thinking, speech, behaviors, social anxiety, negative self judgments 

—Personality Disorders Cluster A goals

solve immediate crisis or problem, and complete social skills training

—Personality Disorders Cluster B symptoms

—disregards and violates rights and safety of others, failure to conform to social norms, deceitful, erratic work patterns if any, instability in relationships, reckless disregard, irresponsible, aggressive towards self and/or others, manipulative, mood swings, instability of emotions(labile), unstable self –image, theatrical, exaggerated speech and manners, impulsive, attention seeking, must be center of attention, feelings of emptiness

—Personality Disorders Cluster B goals

prevent suicide & harm, gain insight, improve coping, gain insight into feelings and behaviors and unrealistic expectations /fears

—Personality Disorders Cluster C symptoms

avoidant of social activities d/t fears of criticism, disapproval or rejection, feelings of inadequacies, fear of being shamed or ridiculed in intimate relationships, difficult decision making, inappropriate anger with displays of temper, excessive needs to be taken care of, difficulty with expressing disagreements with others, lack of self-confidence, lack of initiating projects or relationships, goes to any length to be nurtured and cared for, helplessness and insecure when alone

—Personality Disorders Cluster C goals

enhance social functioning, solve immediate crisis, assertiveness training, cognitive reconstruction

approach to Guarded, Suspicious, Argumentative

Acknowledge their perception without debate or agreement. Focus attention on treatment. Be respectful, maintain professional distance and approach

Aloof, Uninvolved approach

•Demonstrate understanding and respect privacy. Explain rationale for personal questioning. Do not push for social interaction

Idiosyncratic, Eccentric approach

•Consistent approach addressing complaints and beliefs, do not challenge or reinforce perspectives

•Demanding approach

•SET LIMITS- minimize excessive or realistic demands

Dramatic, Emotionally Involved, Seductive approach

—Supportive attitude. Maintain professional boundaries to prevent unprovoked responses

Superior Clients approach

—Recognize and support strengths. Show interest in opinions, demonstrate competence.

Sociopathic approach

Set realistic limits on visits. Do not tolerate aggressive behaviors, develop treatment plan to address aggressive behavior.

•Orderly, controlled, controlling approach

Clearly state treatment approaches, options, rationales, give as much details as possible, avoid struggle of who is in charge

Anxiously avoidant, Clinging, dependent approach

•Demonstrate patience, empathy towards fears

•Frequent brief encounters, forewarn of any milieu changes

Controlling, avoidant, dependent approach

•Directly address concerns about behaviors, identifying underlying feelings about their illness and treatment, avoid feeling resentful about “acting out” behaviors

Nursing Considerations

—Safety

—Trust

—Protection for Vulnerable Population

—Hygiene and Nutrition

—Communication and Social Skills

—Normal communication skills are compromised by emotions. (appropriate communication skills are necessary for successful relationships).

Nursing Diagnoses For Personality Disorders

—Risk for Self- or Other -Directed Violence

—Risk for Self- Mutilation

—Ineffective Coping

—Disturbed Thought Process

—Anxiety

—Fear

—Impaired Social Interaction

—Chronic Low Self–Esteem

—Ineffective Therapeutic Regimen Management

—Ineffective Family Coping