Personality Disorders

Exam 1 - sem 3

What is personality

Ingrained, enduring patterns of behavior

How one behaves toward

• Self

• Others

• Environment

Personality

A unique way of thinking, feeling, and behaving that is influenced by experiences, environment (surroundings/life situations), and inherited characteristics

Personality traits

May be defined as characteristics with which an individual is born or develops early in life. They influence the way in which he or she perceives and relates to the environment and are quite stable over time

Personality disorder

Occur when these traits become rigid and inflexible and contribute to maladaptive patterns of behavior or impairment in functioning

Personality includes

Perceptions

Attitudes

Emotions

Personality disorders definition from DSM-5

An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment

Developmental theories

Personality development occurs in response to a number of biological and psychological influences. These variables include (but are not limited to) heredity, temperament, experiential learning, and social interaction

Each suggests that personality development occurs in an orderly, stepwise fashion. These stages overlap to account for maturation rates being different individuals

Common characteristics of all personality disorders

• Inflexibility/maladaptive response to stress

• Failure to accept the consequences of behavior

• Compulsiveness and lack of social restraint

• Inability to emotionally connect in all relationships

• Tendency to provoke interpersonal conflict

• Lack of insight, poor boundaries

• Involve reliance on maladaptive coping skill

Diagnosing personality disorder

Enduring pattern of inner experience and behavior that deviates markedly from expectations of cultures

Manifested by 2 or more of the following:

• Thoughts: ways of looking at the world, thinking about self or others. interacting]

• Emotions: appropriateness, intensity, range of emotional functioning

• Interpersonal functioning: relationships, interpersonal skills

• Impulse Control

Personality disorders: diagnostic clusters

Cluster A: odd-eccentric

Cluster B: dramatic-emotional

Cluster C: anxious-fearful

Cluster A: odd-eccentric

Paranoid Personality Disorder

Schizoid Personality Disorder

Schizotypal Personality Disorder

Paranoid Personality disorder

Suspicious; guarded

Hypervigiliant

Ready for any real or imagined threat

Insensitive to feelings of others

Feels that others are taking advantage of them

Trust no one

Constantly tests the honesty of others

Do not accept responsibility for their own behaviors

Envious and hostile toward others that are successful

Bears grudges

Paranoid Personality disorder facts

Prevalence: estimated at 1-4% of the population

Predisposing Factors: 

• Genetic/Hereditary: higher incidence among relatives of individuals diagnosed with schizophrenia, psychosis.

• May have been subjected to parental antagonism and harrassment

• Learned to perceive the world as “harsh and unkind”

• Anticipating humiliation and betrayal by others, the paranoid person has learned to “attack first.”

Schizoid Personality disorder

Profound defect in the ability to form personal relationships and are often seen as eccentric, isolated or lonely

Neither desires or enjoys relationships including family

Chooses solitary activities

Lacks close friends or confidants except first degree relatives

Indifferent to praise or criticism

Emotional coldness, detachment, flat affect.

Appears shy, anxious, uneasy in the presence of others.

Takes pleasure in few, if any, activities

Schizoid Personality disorder facts

Prevalence: estimated at 3-5% of the population

Predisposing Factors: 

• Introversion is believed to be hereditary.

• The development of this disorder is likely influenced by early interactional patterns that the person found to be cold and unsatisfying.

• Childhoods are characterized as bleak, cold, and notably lacking empathy and nurturing

Schizotypal Personality disorder

Ideas of reference

Odd beliefs, magical thinking, superstitious, clairvoyance, bizarre fantasies

Suspicious and paranoid

Inappropriate affect

Behavior or appearance is odd, eccentric or peculiar

Lack of close friends

Excessive social anxiety even in familiar social settings.

Bizarre speech patterns

Described as “latent schizophrenics”

Behavior is odd and eccentric, but not decompensated to the level of schizophrenia.

Schizotypal Personality disorder facts

Prevalence: estimated at around 4% of the population

Predisposing Factors: 

• Genetic link suggests that this disorder is more common among first degree relatives with schizophrenia.

• Anatomical deficits or neurochemical dysfunctions resulting in diminished activation, minimal pleasure-pain sensibilities, and impaired cognitive functions.

• Early family dynamics characterized by indifference, impassivity, or formality, leading to a pattern of discomfort with personal affection and closeness.

Nursing interventions: cluster A personality disorders

• Respect personal space

• Respect client’s preferences

• Give feedback based on non-verbal cues

• Provide client with daily schedules and inform client of changes

• Help client identify adaptive diversionary activities

• Use an objective, matter of fact approach

• Use concrete, specific words rather than global abstractions

Cluster B: dramatic-emotional

Antisocial  Personality Disorder

Borderline Personality Disorder

Histrionic Personality Disorder

Narcissistic Personality Disorder

Antisocial personality disorder

Socially irresponsible, exploitative, guiltless behavior 

General disregard for the rights of others.

Failure to conform to social norms/laws; legal issues, arrests                       

Deceitful, lying, use of aliases, conning others

Charming, witty

Irritable and aggressive, physical fights

Reckless disregard for others

Irresponsible—failure to sustain work or honor financial obligations

Cannot maintain relationships

Seldom seen in clinical settings, or when they are it is to avoid legal consequences. More likely to be in jail, prison

*will make you like them and then kill you without caring

Antisocial personality disorder facts

Prevalence: 2-4 percent of the general population 

Predisposing Factors: 

• Data from twin studies suggests high genetic vulnerability among first degree relatives

• Studies have shown higher prevalence among childhood experiences with parents with alcoholism

• Children with frequent temper tantrums that are undaunted by punishment

• ADHD, Oppositional Defiant Disorder, and Conduct disorders increase risk of antisocial personality disorder as an adult

NANDA: antisocial personality disorder

Risk for other-directed violence

Defensive coping

Chronic low self-esteem

Impaired social interaction

Ineffective Health Maintenance

Nursing interventions: antisoical personailty disorder

• Convey an accepting attitude toward patient

• Use a concerned, matter-of-fact approach

• Set, communicate and maintain consistent rules and regulations

• DO NOT argue, bargain or rationalize

• Confront inappropriate behaviors

• DO NOT seek approval or coax; use choices and consequences

• Be alert for flattery or verbal attacks.

• Maintain low stimuli

• Explore alternative ways to handle behaviors

Borderline personality disorder

Instability of affect, identity and relationships, frequent mood shifts

Unstable and intense relationships starting in early adulthood

“Splitting” behaviors: “All or nothing”,  flatter or favor one staff person over another to get what they want

Manipulation

Impulsiveness: $$, sex, substances, driving, binge disorder

Fear of abandonment

Often uses self injury as a coping mechanism

Often related to dysfunction in childhood (i.e.: abuse)

Borderline personality disorder facts

Prevalence: 1-2 percent of the general population 

Predisposing Factors: 

• Biochemical – serotonergic defect

• Genetic- increased risk of development with depression in family background.

• Family environments characterized by trauma, neglect, and/or separation, exposure to sexual or physical abuse, and serious parental psychopathology such as substance abuse and/or antisocial personality disorder.

• Developmental: struggles with separation and autonomy

NANDA: borderline personality disorder

Risk for self-injury

• attention seeking behavior; coping mechanisms

Complicated grieving (separation distress)

Impaired social interaction

• struggle with having solid relationships; intense too quickly

Disturbed personal identity

Anxiety

Chronic low self-esteem

Nursing interventions: borderline personality disorder

Observe patient’s behaviors closely

Set limits, maintain consistency

• Report in the morning to make sure everyone is on the same page

Convey an accepting attitude and develop trust

Rotate staff working with patient so they do not develop dependence on particular individuals

Histrionic personality disorder

Characterized by colorful, dramatic, and extroverted behavior in excitable and emotional people.

Uncomfortable in situations where he/she is not the center of attention

Interactions characterized by inappropriate sexual seduction

Rapidly shifting and shallow expressions of emotion

Style of speech is impressionistic and lacking in detail

Self dramatization, theatrically exaggerated expression of emotion

Considers relationships to be more intimate than they actually are

Is suggestible (easily influenced by others or circumstances)

Histrionic personality disorder facts

Prevalence: 2-3%of the general population 

Predisposing Factors: 

• Studies suggest correlation with decreased serotonergic activity.

• Heredity studies indicate increased prevalence amongst first-degree relatives.

• Increased risk of development in those that show “an extreme variation of temperamental disposition.”

• Psychosocially, the child may have learned that positive reinforcement was contingent on the ability to perform parentally approved and admired behaviors

Narcissistic personality disorder

Arrogant; grandiose views of self importance

Need for constant admiration

Sense of entitlement

Lack of empathy for others that strains most relationships

Sensitive to criticism

Envious of others and believes that others are envious of him/her

Takes advantage of others for self gain

“All about me”

Narcissistic personality disorder facts

Prevalence: 6% of the general population 

Predisposing Factors: 

• Studies indicate higher prevalence among children who had their fears, failures, or dependency needs responded to with criticism, disdain, or neglect. They grow up with contempt for these behaviors in sources of comfort and support. 

• Studies also indicate increased prevalence among first degree relatives. Narcissism may also develop from an environment in which parents attempt to live their lives vicariously through their child, expecting their child to achieve what they were not able to

Nursing interventions: Cluster B personality disorders

Acknowledge manipulative behaviors

Maintain realistic, consistent, firm limits with enforceable consequences 

Give a rationale for limits and consequences

Maintain consistency among staff members

Confront client each time manipulation occurs:

• Example: both staff confront client when manipulative behavior (ie: splitting) occurs

Cluster C: anxious/fearful

Avoidant Personality Disorder

Dependent Personality Disorder

Obsessive-Compulsive Personality Disorder

Avoidant personality disorder

Avoids social activities r/t fear of criticism, disapproval or rejection

Unwilling to get involved with people unless they are sure to be liked

Shows restraint in intimate relationships due to fear of ridicule

Preoccupied with being criticized or rejected in social situations

Views self as inept, unappealing or inferior

Anxious in social situations

Avoidant personality disorder facts

Prevalence: 2% of the general population 

Predisposing Factors: 

• No clear cause noted but psychosocial studies have shown increased prevalence with parental rejection and censure, which is often reinforced by peers. These children are often reared in families in which they are belittled, abandoned, and criticized such that any natural optimism is extinguished and replaced with feelings of low self-worth and social alienation

Dependent personality disorder

Extreme dependency in a close relationship with an urgent search to find a replacement when one relationship ends.

Difficulty making every-day decisions or taking care of self

Need excessive amounts of advice and reassurance from others

Difficulty initiating projects d/t lack of self confidence

Goes to excessive lengths to obtain reassurance from others

Unrealistically preoccupied with fears of being left alone

Dependent personality disorder facts

Prevalence: 2-4% of the general population 

Predisposing Factors: 

• Psychosocially, dependency is fostered in infancy when stimulation and nurturance are experienced exclusively from one source. The infant becomes attached to one source to the exclusion of all others. If this exclusive attachment continues as the child grows, the dependency is nurtured

Nursing interventions: dependent personality disorder

• Evaluate client’s ability for self-care

• Avoid doing things that the client is capable of doing

• Help client identify assets and liabilities

• Emphasize strengths and potential

• Encourage client to take responsibility for own opinions

• Point out when client negates own feelings or opinions

• Encourage client to make choices 

Obsessive compulsive personality disorder

Pre-occupied with orderliness, perfectionism, control, lists, rules

Perfectionism that interferes with task completion

Excessively devoted to work and productivity

Over conscientious and inflexible

Unable to discard worn out or worthless projects

Reluctant to delegate tasks or work with others

Obessive compulsive personality disorder facts

Prevalence: Relatively common and more prevalent in men than women.

Predisposing Factors:

• The parenting style in which the individual tends to be “over controlled.” Parents expect their children to live up their imposed standards of conduct and condemn them if they do not. Praise for positive behaviors are bestowed on the child with much less frequency than punishment. Children learn and grow the understanding of what “not” to do in order to avoid punishment

• Usually in first borns

OCD vs. OCPD

OCD:  client recognizes OCD behaviors and wants to be rid of them

• Recurrent and persistent thoughts, urges or images and attempts to suppress them

• Obsessions or compulsions are time consuming

• This is when you will wash your hands 5 times before leaving the house even if it means being late for an appointment

OCPD:  Many times the client sees the symptoms as positive and a part of their success.

• Preoccupied with details, lists, rules, organization

• Shows perfectionism

• Excessively devoted to work and productivity

Nursing implications for personality disorders

Identify behavioral patterns or maladaptive symptoms

Acknowledge that patient will rely on maladaptive coping skills

NANDA for personality disorders

Ineffective Coping

Ineffective Role Performance

Risk for Other-Directed Violence

Risk for Self-Injury

Risk for Self-Mutilation

Social Isolation

Self-Esteem Disturbance

Nursing process for personality disorder

SAFETY!!! --number one priority

Consistency

Limit Setting

Boundary Setting

Appropriate self-disclosure

Ongoing staff support and supervision

Pharmacology for personality disorder

No new medications

The medications will be used to treat symptoms and other related psychiatric conditions:

• Antidepressants and anxiety agents for depression/anxiety

• Mood stabilizers and antipsychotics for aggression/mood stabilization

How do you treat personality disorders

Cognitive Behavioral Therapy (CBT) and Dialectical Behavioral Therapy(DBT) are “Gold Standard” treatments

• Teach positive coping skills/strategies

Other psychotherapy (individual), group therapy and case management

Behavioral therapy

Changing behavior is the key to treating problems

Behavior is learned and has consequences.

Teaches ways clients ways to decrease anxiety or avoidant behavior and gives client’s opportunities to practice techniques.

Includes relaxation training and modeling

Cognitive behavioral therapy (CBT)

Aaron Beck – Based on personality theory that asserts how one thinks largely determines how one feels and behaves

Short-term, goal-oriented psychotherapy treatment that takes a hands-on, practical approach to problem-solving.

Changes people’s attitudes and behavior by focusing on the thoughts, images, beliefs and attitudes that are held

GOAL – Modify negative thoughts that lead to dysfunctional emotions and actions.  Recognize dysfunctional cognitions, how the cognitions contribute to one's feelings, and change one’s behavior

Automatic thoughts: thoughts a client has

Schemata – Unique assumptions about ourselves, others and the world around us

Cognitive distortions

Automatic thoughts that are often irritation and lead to false assumptions and misinterpretations

Unhelpful thinking styles

All or nothing thinking

Mental filter

Jumping to conclusions

Emotional reasoning

Labelling

Over generalizing

Disqualifying the positive

Magnification (catastrophising) & minimization

Should/Must

Personalization

CBT example

• SCENERIO – Billy has been in counseling for depression.  His therapist’s secretary called and cancelled this week’s appointment and rescheduled.

• Client’s automatic thought– “My therapist is disgusted with me and wants to avoid me.”

• Emotion – Sadness, rejection, and hopelessness.  

• Behavior-Decides to call off work and return to bed.

• Reframing – There is no evidence to believe that I disgust my therapist.  Why would they have rescheduled if he really didn’t want to see me?

Therapeutic tools used in cognitive therapy

Priority restructuring: assisting clients to identify what requires priority.

Journal keeping: clients can write down stressful thoughts to process

Assertiveness training: teaches client to express feelings and solve problems in a nonaggressive manner.

Monitoring thoughts: helps client to be aware of negative thinking.

Dialectical Behavior Therapy (DBT)

A form of CBT

Developed by Marsha Linehan, PhD. In the 1980’s

Primarily used for personality disorders (Borderline) that include self-injurious and suicidal behaviors. (Ineffective coping skills)

Based on the belief that the primary problem for this client is emotional dysregulation.

More effective treatment for personality disorders than medication.

Gradual behavior changes

Provides acceptance and validation for clients

MODES OF TREATMENT  (Is a year long therapy)

• Group skills training (weekly for up to 1 year)

• Individual psychotherapy

• Telephone contact

• Therapist consultation/team meeting

4 modules (skills) of DBT

Mindfulness

Interpersonal Effectiveness

Distress Tolerance

Emotion Regulation

5 functions of DBT

To enhance behavioral capabilities

To improve motivation to change

To ensure that new capabilities generalize to the natural environment

To structure the treatment environment such that the client and therapist capabilities are supported and effective behaviors are reinforced

To enhance therapist capabilities and motivation to treat clients effectively

Ways to help cope with that emotional toll…

• Talk to colleagues about feelings of frustration

• Clear and frequent communication with all members of the treatment team will minimize manipulation by the client

• Do not take anything personally!

• Set realistic goals and remember that changes in clients with personality disorders takes time.  Be patient!

Caring for personality disorder clients: an emotional toll on nurses

• Understand your own reactivity

• Self-awareness

• Countertransference: the nurse’s behavioral and emotional response to the patient. (ie: may become angry with an antagonistic client or feel flattered when showered with attention from the client)

• Labels of Stigma

• Supervision