Personality Disorders #2

Personality

Enduring characteristic patterns of thinking, feeling and behavior that make an individual unique and are largely outside one’s awareness
- begin to take shape in childhood, set by early adulthood

Personality traits

Elements that make up one’s personality

Personality disorder (PD)

Established personality patterns result in repeated conflicts with others and impair ability to function in society
- PDs are independent of mental disorders and substance use
disorders
- not due to a medical condition or physiologic effects of substances
- generally consistent over time and across varying situations

PD patho 

Typically manifest during adolescence, continue throughout lifespan
Symptoms
- Interpersonal difficulties
- Identity problems
- Lack of intimate relationships
- Poor social skills

Individuals with PD often diagnosed with more than one
Common behaviors of all individuals with PDs
1.
2.
3.
Ego-syntonic

Ego-syntonic

Behave according to beliefs, desires, values that concur with their disorder

PD etio

Studies on PDs are hampered by several factors
- Lack of diagnostic uniformity makes it hard to define samples, replicate previous studies
- Most individuals with PDs do not come to attention of mental health professionals
- Genetics
- Trauma
Intrapersonal factors
- Projection
- Malnutrition
Sociocultural factors
- Enmeshment
- Disengagement

PD risk factors

- Relatives diagnosed with a PD or other mental illness
- Unstable home life or parental loss via death or divorce
during childhood
- History of childhood abuse or neglect
- Diagnosis of other disorders, such as childhood conduct disorder
- Low socioeconomic status
- Diagnosing PDs in children challenging

PD prevention 

- Identification of developing patterns of behavior, feeling, and thought before they become set
Prevention programs
- Address developmental and environmental risk factors
Screening and Intervention
- Focus on parenting skills to address aggressive and antisocial behaviors, promote positive parent–child interactions
- Classroom management for teachers to teach social skills
- Build positive correlation between sociable behavior and child’s self- esteem.

DSM-5 specifies that individuals with PDs

- Must exhibit dysfunctional behavior toward self and others
- Must maintain persistent, rigid thoughts and beliefs that are incongruent with sociocultural norms

Each PD seen as clinically distinct syndrome but have general characteristics in common

Stable pattern of perceptions, behaviors out of line with cultural
expectations and occur in two or more areas
- Patterns must not be consistent with any other psychiatric disorder
or underlying medical illnesses or use/abuse of medications or
substances

Cluster A

Odd or eccentric behaviors

Cluster B

Dramatic, erratic, or emotional behaviors

Cluster C

Avoidant, dependent, or anxious behaviors

Antisocial Personality Disorder

Propensity to manipulate or violate rights of others
with disregard for their feelings and/or the consequences
- Four times more common in men than women
- Commonly seen in prison, substance use programs

Antisocial Personality Disorder risk factors

- Having caregiver with ASPD or alcoholism
- Being victim of child abuse

Avoidant Personality Disorder 

Characterized by extreme shyness and fear of rejection
Desire to connect and bond with others undercut by
insecurities, concern for other people’s perception of them
Other characteristics
- Low self-esteem
- Poor social skills
- Extreme sensitivity to criticism
- Unrealistic expectations
- Profound distrust of other people’s interest in relationship building
- Intense worry and anxiety

BPD etio

 75% of diagnosed cases are women
 Prevalence
 70-75% of patients have a history of at least one deliberate act
of self-harm; completed suicide rate is about 9%
 Carries a lot of stigma even among mental health professionals

BPD risk factors

- Childhood abuse and abandonment
- Strong genetic link

BPD

Unstable interpersonal relationships, self-image and affects and
impulsivity
Manifested by 5 of the following:
- Efforts to avoid real or imagined abandonment
- Idealizing and devaluing others
- Persistently unstable sense of self
- Self-damaging behaviors
- Recurrent suicidal or self-injurious behavior
- Mood instability
- Chronic feelings of emptiness
- Inappropriate intense anger
- Stress-related paranoia or dissociative symptoms

Dependent Personality Disorder

Pervasive need to be cared for
Difficulty with decision-making
Separation anxiety
- Anxious or helpless when alone
- Impaired self-confidence
- Tend to seek out dominant partners who will dictate decision-
making and choices
- Often acquiesce to wants and needs of others, often in attempt
to build or maintain a relationship
- Diagnosed more frequently in women than men
- May experience mild impairment in occupational and social
relationships that require independence

Histrionic Personality Disorder

- Self-centered, dramatic, attention-seeking
- May behave erratically, act silly or flamboyantly
- Strong sense of inadequacy, helplessness behind behaviors
- Motivation rooted in search for excitement and activity
- Difficulty establishing interpersonal relationships
- Need for love and reassurance counterbalanced by failure to
show empathy, consideration for significant others
- Focus on self interferes with establishing, maintaining
relationships
- Family members, caregivers may experience burnout
- May demonstrate highly sexualized behaviors
- May act out with suicidal behaviors

Narcissistic Personality Disorder

Arrogant; indifferent to criticism while hiding anger, rage or
emptiness
- Unable to feel or demonstrate empathy
- Attention-seeking behaviors
- May have co-occurring substance use, eating disorders,
depression, dysthymia, social withdrawal
- Extreme reliance on others’ perceptions and/or inflated sense of
self (grandiosity)
- Approval seeking and extremely low or high personal standards
- Failure to identify with others, their emotions → difficulty
developing meaningful relationships

Obsessive-Compulsive Personality Disorder

Significant impairments in social functioning and relationships
- All-consuming desire to achieve perfection
Not the same as OCD but shares traits
- People with OCPD see nothing dysfunctional about their way of
thinking or acting
- People with OCD recognize that their thoughts are disruptive, not
normal so are more likely to seek treatment
- May demonstrate great productivity at work
- Symptoms put strain on interpersonal relationships
- Men twice as likely to be diagnosed as women

Paranoid Personality Disorder

- Inability to trust others
- Actions of others assumed to be malevolent
- Others are viewed as deceptive and disloyal
- Pathologic jealousy can damage relationships with significant
others
- Tend to be prejudicial, judgmental
- Rigid, inflexible worldviews
- Reject logic or proof that contradicts their beliefs
- Hypervigilant

Schizoid Personality Disorder

- Aloofness
- Tendency to prefer solitary activities
- Absence of humor
- Lack of interest in forming relationships, including romantic
ones
- Disengaged, uninterested in social interaction
- May seem cognitively impaired, have difficulty working
- Functional abilities and levels of adjustment vary among patients

Schizotypal Personality Disorder

- Extreme social anxiety and eccentric behavior
- Feel disconnected from things or people around them
- Few friends
- Blunted or flat emotions; peculiar patterns of speaking
- Unkempt appearance; odd clothing
- Often misinterpret other people’s actions, emotions
- Lack understanding of how own behavior affects others
- Anxiety, lack of trust → difficulty establishing intimate relationships
- Common disorder among biological relatives of schizophrenic

PD collaboration 

Cultural considerations
Treatment for PD requires collaboration with
- Patient
- Interprofessional team
- Primary healthcare provider
- Psychiatrist or psychologist
- Licensed mental health professional
- Advanced practice nurse specializing in psychiatric mental health care
- Family members
Treatment for PD challenging

PD Diagnostic tests

No one test used to diagnose PDs
Diagnosis through interview
- Symptoms
- Family history
- Thoughts of violence, suicide, or self-injury
- May require more than one interview, spaced over time
- Physical exam and lab tests to rule out other factors
- Determining the specific PD can be complicated
- Personality inventory tests may be used (MMPI)
- Hospitalization needed if person can’t provide self-care or is high risk of injuring self or others

PD pharmacologic therapy

Medications may be used to control symptoms
- Selective serotonin reuptake inhibitors (SSRIs) to reduce
impulsivity and aggressive behaviors
- Low-dose antipsychotics to treat psychosis and decrease agitation
- Naltrexone in borderline personality disorder
- Medications should be used as part of comprehensive treatment
plan that includes therapy

Cognitive-behavioral therapy (CBT)

- Combines cognitive aspects to change thoughts, beliefs with
behavioral aspects to change problematic action patterns
- Focuses on skill training, problem solving
- Therapist guides patients to recognize harmful thoughts,
behavior patterns; adopt positive behaviors, interactions
- Reduce symptoms by helping patient to develop concrete coping strategies
- Can help patients with mood disorders to recognize when mood
about to shift, apply coping strategies

Dialectical behavioral therapy (DBT)

- Originally developed to treat individuals with suicidal thoughts
- Dialectical: striking balance between two extremes
- Patients made responsible for changing unhealthy patterns
- Effective in treating BPD
- Patient learns to accept things as they are, apply techniques to control strong emotions
- Mindfulness
- Emotional regulation, stress tolerance
- Combination of individual and group sessions
- Traditional and cognitive approaches used in conjunction to help
patients foster better relationships with others

Group therapy

- Helpful for strengthening empathic skills for patients with ASPD
- STEPPS program combined with pharmacologic treatments,
psychotherapy may alleviate depression, improve quality of life
for patients with BPD

Family focused therapy

- Useful for family members of patients with PDs to cope with
stress of living with someone with a PD, avoid behaviors that might
worsen patient’s condition
- Educates family members, helps them play active supportive role
- Some programs address needs, concerns of family members
- DBT family therapy teaches skills, strategies, participation in patient’s treatment

Complementary Health Approaches

No specific integrative therapies for PDs
CHA may provide relief from certain symptoms
- Patients with anxiety
- Yoga
- Meditation
- Breathing exercises
- Chamomile tea
- Depression
- Vitamin B12
- Omega-3 fatty acids
- Psychosis
- Omega-3 fatty acids may prevent full emergence in young people who show signs of developing disorder.

PD children

- PD traits that appear in childhood might not persist into adult life
- PD may be diagnosed when child’s maladaptive traits appear to be
pervasive, persistent, unlikely to be limited to a particular developmental stage or be connected to another mental disorder
- Features must be present ≥1 year for diagnosis
- Exception: antisocial personality disorder cannot be diagnosed
in someone under age 18
- Research focusing on pertinent characteristics displayed early in
life by children with conduct disorders
- Cluster C avoidant behavior characteristics often start in infancy
or childhood

PD Adolescents and young adults

PD features typically become recognizable in adolescence or early
adulthood
Cluster A disorders
- May present in childhood or adolescence
- May display characteristics such as solitariness, poor peer relationships, social anxiety, academic underachievement, hypersensitivity, peculiar thoughts and
language, idiosyncratic fantasies
Cluster B disorders
- Patients often overuse health and mental health related resources
- Those with BPD: chronically unstable behavior in early adulthood
- Impairment, suicide risk highest in young adult years
Cluster C disorders
- Become increasingly shy during adolescence, early adulthood
- Keep in mind that behaviors may be developmentally appropriate

PD older adults 

• Some people with PDs may escape clinical attention until
  middle-aged or later
  - Loss of significant support person or stabilizing social situation may worsen disorder, cause the individual to seek treatment
  - Trained clinician should evaluate personality changes in middle adulthood or later to assess for medical conditions, substance use issues
  - Some types of PDs become less evident with age
  - Particularly when individual enters 40s
  - Risk of suicide gradually wanes with age

Nursing Process: Assessment

- Care will be specific to each patient, manifestations of the disorder
- Symptoms may make it difficult to develop nurse–client relationship
- Assessment complicated by certain patient characteristics
Primary goals
- Identify behaviors, beliefs, thought patterns that disrupt patient's
social, professional, personal life
When patient lacks insight
- Information may be obtained from reports by family members, others
- Must maintain patient confidentiality, avoid overstepping patient’s
personal and legal boundaries

Assessment

Nursing history
- Work history
- Behavior problems
- Including violence toward self, others
- Suicidal ideation
- Methods of resolving conflict
- Alcohol, drug use
- Nature of relationships with family members, coworkers, friends
- Ask questions that encourage self-description
Physical examination
- Assess for signs of self-directed violence
- Assess for evidence of alcohol, drug use

Analysis 

- Risk of Injury
- Self-Directed Violence
- Violence Directed at Others
- Potential for Self-Mutilation
- Inadequate Coping Skills
- Social Isolation
- Anxiety
- Disturbed Personal Identity
- Impaired Family Functioning

Planning

Goals may include that client will:
- Remain free from injury
- Refrain from violent behaviors
- Report a reduction in anxiety
- Adhere to established rules and guidelines
- Actively participate in one-one and/or group therapy sessions

Promote safety hospital

- Ensure that patient’s environment is free from items that can be used to harm self, others
- Provide close supervision and monitoring
- Encourage patients to seek help from healthcare team when patient needs to process feelings
- Including when stress levels rising
- Encourage patient to participate actively in therapy and groups

Promote safety community 

- Provide medication teaching
- With adolescent, young adult patients, make sure patient and family are aware of black box warnings on SSRIs
- Ensure that patients who engage in non-suicidal self-injury know to
contact healthcare provider if experience increase in occurrence or
severity of behaviors
- Ensure that patients live in safe environment where they will not be
exposed to violence or will not be financially or emotionally
supported

Promote the therapeutic relationship

- Ineffective social skills, impaired perceptions common in PDs
create challenges
- Unplanned admission to hospital or treatment center creates
anxiety, mistrust
- Consistency with patient care, demonstration of respect for patient
may help to build trust
- Avoid stigmatizing patient
- Balance flexibility with firmness
- Focus on strengths of individual, family system

Establish boundaries

In context of nurse–patient relationship
- Healthy boundaries establish sense of safety, predictability for patient
- Manage splitting behaviors
Teach patient about healthy boundaries
- Assess patient coping skills
- Healthy responses to boundary violations
Help patient understand, set healthy boundaries
- Teaching
- Role playing
Regardless of patient’s behaviors, nurse is responsible for maintaining healthy professional boundaries
- Choosing what information is appropriate to share with patient
- Oversharing creates unnecessary, unethical burden for patient

Evaluation

Expected outcomes may include
- Patient remains free from injury
- Patient does not demonstrate violent behaviors toward self or others
- Patient verbalizes understanding of the concept of boundaries
- Patient verbalizes understanding of the principles of respecting
boundaries
- Patient actively participates in therapy
Many PDs are treatment-resistant with therapies that are long,
challenging even for motivated patients
- If treatment is ineffective
- Reevaluate plan of care
- Strengths-based assessment of patients, supports