Personality Disorders (Ch. 31)

Schizoid Personality Disorder

characterized primarily by the inability to form close interpersonal relationships

Characteristics of Schizoid Personality

-failure to respond to others in a emotional, meaningful way

-aloof and indifferent to others; emotionally cold

-no close friends; prefer solitude but CAN work with others

-diagnosis occurs more frequently in men than in women

-shy, anxious, uneasy in the presence of others

-difficulty finding humor in situations/conversations

-inappropriately serious about everything

-tend to engage more with animals than with humans; little desire for emotional ties

Paranoid Personality Disorder

characterized by a pervasive, persistent, and inappropriate mistrust of others

Characteristics of Paranoid Personality Disorders

-external locus of control

-desire for vindication can be intense, violence my occur

-anticipate the humiliation and betrayal by others, so they often attack first

***more common in men than in women

Paranoid Behavior

-ready for any threat

-constantly tests the honesty of others (mistrust)

-no filter; insensitive to the feelings of others

-hypersensitivity to criticism

-tends to misinterprets, magnifies, and distorts cues

-attributes shortcomings to others (blaming)

-can be hostile, stubborn, argumentative, judgmental of others

-often hold grudges

Schizotypal Personality Disorder

personality disorder most closely related to schizophrenia

-aloof and isolated

-behave in a bland and apathetic, often inappropriate affect

-patients often "live in their own world"

Schizotypal Personality Behavior

-inappropriate laughter and affect

-ideas of reference

-illusions

-superstitiousness

-magical thinking

-withdrawal into self

-bizarre speech pattern

-depersonalization

-may deteriorate into psychosis and require antipsychotic treatment

-possible inpatient admission but will return to previous state post treatment

Antisocial Personality Disorder

a pattern of socially irresponsible, exploitative, and guiltless behavior, evident in the tendency to fail to conform to the law, develop stable relationships, or sustain consistent employment; exploitation and manipulation of others for personal gain is common

Borderline Personality Disorder

disorder characterized by a pattern of intense and chaotic relationships with affective instability; fluctuating and extreme attitudes regarding other people; impulsivity; direct and indirect self-destructive behavior; and lack of a clear or certain sense of identity, life plan, or values

Borderline Characteristics

-unstable and intense relationships

-have feelings r/t fear of abandonment which may come from complicated grief from childhood (divorce or death)

-labile mood with unstable self image

-chronic sense of emptiness rooted in loss

-frequently generate chaos or outbursts

-splitting behavior that consists of concrete thoughts that idealize or devalue

-easily angered to levels that are intense and pervasive

Histrionic Personality Disorder

type of personality disorder characterized by excessively emotional and attention-seeking behavior, often presented in a colorful and dramatic fashion

Narcissistic Personality Disorder

disorder characterized by an exaggerated sense of self-worth

-NOT THE SAME AS CONFIDENCE

Narcissistic Characteristics

-mood grounded in grandiosity; usually optimistic, relaxed, cheerful, charismatic; lack of empathy

-very fragile self esteem and mood easily changes if pt does not receive the positive feedback they expect

-belief that he or she deserves special consideration or admiration; often entitled, arrogant, rude; overestimates self and underestimates others

-diagnosed more often in men than women

-when redirected, corrected, or given boundaries -> they will counterattack

Dependent Personality Disorder

disorder characterized by pervasive, excessive dependency needs, submissiveness, and exaggerated fears of inability to care for oneself

Avoidant Personality Disorder

disorder characterized by social withdrawal rooted in extreme fear of rejection and feelings of inadequacy

Obsessive Compulsive Personality Disorder

type of personality disorder in which the individual has an intense fear of making mistakes, which manifests in inflexible and perfectionistic behavior

-differentiated from obsessive-compulsive disorder in that there is no evidence of the obsessive-compulsive rituals

Personality

totality of emotional & behavior characteristics that are unique to the individual and remain relatively stable as well as predictable over time; vital to defining who individuals are

Series of Behaviors

attitudes, thoughts, and moods, as well as how these are expressed in interactions with others

What is the foundation for development of a personality disorder?

low self esteem

Personality Traits

characteristics an individual is born with or develops early in life; influences how they perceive and relates to environment

-some are inherited, others are influenced by experiences

-usually "stable" over time

-differentiate traits from disorder; PD often leads to disruptions in interpersonal relationships

Personality Disorder

long-standing patterns of thinking & behaving in a manner that differs from what society considers usual or "normal"

-lead to inflexibility (rigid thinking) that causes distress for the individual and others

-THE DIAGNOSIS IS ONLY MADE WHEN THERE IS SIGNIFICANT FUNCTIONAL IMPAIRMENT OCCURS IN RESPONSE TO PERSONALITY CHARACTERISTICS

Those with PD often have...?

1. ineffective coping skills

-denial, blaming, projection often primary defense mech.

2. difficulty forming healthy relationships

3. maladaptive patterns of behavior and or impairment

Cluster A Personality Disorders

odd/eccentric

1. paranoid

2. schizoid

3. schizotypal

Cluster B Personality Disorders

dramatic, unpredictable

1. antisocial

2. borderline

3. histrionic

4. narcissistic

Cluster C Personality Disorders

anxious, fearful, needy

1. avoidant

2. dependent

3. obsessive-compulsive

Common behaviors of personality disorders

-exploitation & manipulation for personal gain

-belligerent, argumentative behavior

-lack of remorse

-inability to delay gratification (predisposition to violence)

-low frustration tolerance

-inconsistent work and or academic performance

-failure to conform to societal norms

-impulsivity and recklessness

-inability to function as a responsible individual, includes appropriate parenting

-inability to form a lasting monogamous relationshiph

-chronic low self esteem

Cluster A Characteristics

-eccentric, peculiar, odd

-very suspicious of others; believes others are "out to get them"

-can be hostile and aloof

-fear of exploitation, harm, deceit, and confiding in others

-often hypervigilant, prone to counterattack

-misinterpretation of remarks (ex. compliments interpreted as manipulation)

Cluster A Nursing Diagnoses

1. risk for other-directed violence

-especially paranoid PD

2. defensive coping

3. chronic low self esteem

4. impaired social interaction

5. ineffective health maintenance

6. impaired social interaction

7. anxiety (severe or panic)

Cluster B Characteristics

-intense, unpredictable, dramatic

-emotionally labile

-distorted self image

-manipulation of others

-impulsive

-lack of empathy and remorse

-violate rights of others or societal norms

Antisocial Characterisitics

-anti social = against society

-belligerent, argumentative, and often difficult to work with; appropriate to terminate interview if challenged

-failure to conform to societal norms and rules/laws

-NO REMORSE for violations of norms and laws

-inability to delay gratification calculated impulsivity and recklessness

-exploits and manipulates others for personal gain

-failure to develop stable relationships

-most encountered in prisons, jails, addiction rehab services

Histrionic Characterisitics

-labile mood and easily distracted

-attention seeking

-impulsive, melodramatic, flamboyant, provocative, shallow

-need to impress others; preoccupied with appearance

-difficulty forming close interpersonal relationships

-somatic complaints for attention (ex. chest pain)

-suicidal gestures, such as cutting for attention; suicide assessment MUST BE COMPLETED

-when admiration or attention is not given will become depressed or enraged

-easily influenced and strongly dependent

-misinterprets relationships as more intimate

Cluster B Nursing Diagnoses

1. risk for other-directed violence

2. risk for inward directed violence

3. risk for suicide r/t unresolved grief

4. complicated grief

5. defensive coping

6. chronic low self esteem

7. impaired social interaction

8. ineffective health maintenance

9. anxiety (severe to panic)

Cluster C Characteristics

-fearful

-anxious

-needy

-clingy

-fear of rejection

-indecisive

Avoidant Characterisitics

-extreme sensitivity to rejection

-social withdrawal

-awkward and uncomfortable in social situations

-men = women

-often lonely and feel unwanted

-perceived as timid, withdrawn, or cold & odd

-view others as betraying/critical

patients want close relationships but have fear of rejection

Dependent Characterisitics

-extreme reliance on others for emotional support

-relatively common in general population; women > men

-more common in youngest children

-want others to take responsibility/make decisions

-dislikes being alone

-fail to function adequately in situations that require assertiveness or dominant behavior

Obsessive-Compulsive Characteristics

-inflexibility and lack spontaneity

-relatively common in the general population

-low self-esteem, self-worth, and self-confidence

-men > women

-avoids positions of leadership/responsibility

-dedication to productivity at exclusion of personal pleasure

-most common in 1st born children

-assume passive and submissive roles in relationships

-overdisciplined, perfectionism, preoccupation with rules

-difficulty expressing emotions

Cluster C Nursing Diagnoses

1. defensive coping RT dysfunctional family system

2. chronic low self esteem RT persistent negative feedback resulting in diminished self-worth

3. impaired social interaction

4. anxiety (severe to panic)

Nursing Planning & Care for PD

-consistency builds trust

-trust builds effective coping

-cognitive restructuring

-KISS principles EBP communication including teaching

-anticipate resistance, manipulation, anger or attention-seeking behavior, challenges, avoidance, premature termination

-as self esteem begins to build, gradually point out reality

-ensure safety for EVERYONE; set LIMITS

-delayed gratification education & practice

-assist pts to gain insight; anger management

-explore feelings of abandonment & origins of grief

-interpersonal relationship building

-address fears with direct explanations

PD General Assessment

PREFERRED = semi-structured interview

-short and open-ended questioning

-emphasize pt's experience and opinions

-minnesota multiphasic personality inventory (MMPI self reporting scale)

-PMH, medical clearance, suicide/homicide assessment, med reconciliation, substance abuse, legal hx, abuse hx, current state, coping mechanisms, issues of day to day living

Self assessment for nurses working with PD

-possible feelings of frustration, confusion, helplessness, anger

-make sure staff is on same page; patients may attempt to manipulate or demean and create conflict

-debrief throughout shifts

-do NOT measure self-worth on a pt's ability to change; very limited in patients with PD

Dialectical Therapy

type of cognitive behavioral therapy; more specific and focused for extreme and labile behaviors and reactions

Dialectical Therapy Goals

1. to interact in a more objective and less emotional manner

2. feeling safe; empowered vs. impulsive

3. identify triggers

Dialectical therapy was originally intended for...?

borderline pd patients

Cognitive Behavioral Therapy

type of therapy in which the individual is taught to control thought distortions that are considered to be a factor in the development and maintenance of emotional disorders

For CBT to work, a patient must have...?

a sense of trust in the therapist

CBT Goal

to identify and change negative thinking patterns while reframing positive behavioral changes

-encourages logic & reasoning vs emotions

-how the individual thinks/reacts will shape feelings

Milieu Management

-affective management within a structure group context

-nurses help patients verbalize feelings in a civil and socially acceptable manner vs. acting out those feelings

Desired outcomes of psychopharmacology

1. maintain cognitive function while relieving symptoms

2. antipsychotics may be useful for brief periods (18-24 mo) to control agitation, rage, and episodes for schizotypal

-personality disorders are NOT neurotransmitter driven, therefore psychotropic meds will NOT be effective

A nurse is caring for a patient who has borderline personality disorder. Which of the following manifestations should the nurse expect?

a. self-mutilation

b. submission

c. exploitation of others

d. reclusive behavior

a. self mutilation

A nurse is working with a patient who exhibits superstition, elaborate speech patterns, and eccentric behavior. The nurse should identify these features as which of the following personality disorders?

a. paranoid

b. histrionic

c. antisocial

d. schizotypal

d. schizotypal

A nurse is caring for a patient who has antisocial personality disorder. Which of the following actions should the nurse take?

a. encourage patient to attend assertive behavior sessions

b. ensure staff members set limits on behavior

c. tell patient to increase socialization

d. implement measures to increase patient's self esteem

b. ensure staff members set limits on behavior

A nurse is caring for a patient who has BPD. The patient has previously identified another nurse as his favorite, stating, "He's the best nurse ever." When the nurse calls in sick, which of the following statements indicate the patient is using splitting as a coping mechanism?

a. "He is the worse nurse ever"

b. "You're lying to me. He is not really sick"

c. "I'm really worried about him"

d. "If anyone else takes care of me, I will get upset"

a. "He is the worse nurse ever"