Detailed Study Notes: Personality Disorders (Chapter 13)
Definition of Personality and Personality Disorders
Definition of Personality: - Personality refers to individual differences in how a person exists within the world and interacts in social relationships. - Contexts include interaction with families, work environments, friends, and other social spheres. - Specific personality terms include being an "introvert" or an "extrovert," which do not inherently indicate a disorder but describe social interaction styles.
Defining a Personality Disorder: - Inflexibility and Rigidity: Individuals with personality disorders display personality traits that are highly inflexible and rigid. - Relationship Impairment: These traits impair the way individuals interact within their social relationships. - Social Dysfunction: The condition leads to dysfunction in social circles, including work, family, and friendships. - Maladaptive Behaviors: Traits lead to behaviors that are harmful or inappropriate for the social context. - Lack of Insight: A hallmark of personality disorder is that the individual is unable to have insight into the traits or behaviors they are portraying to others. - Diagnostic Difficulty: These are difficult diagnoses to make because individuals typically do not recognize or see their own personality traits as problematic.
Categorization by Clusters
Personality disorders are categorized into three distinct clusters (A, B, and C) based on shared commonalities in behaviors and traits.
Cluster A: Odd or Eccentric Behaviors
General Characteristics: Individuals in this cluster often appear odd or eccentric to others.
Paranoid Personality Disorder: - Characterized by extreme suspicion of others. - Belief that others are lying, trying to deceive, or trying to get something from them. - Persistent doubt regarding other individuals. - Suspicion and untrustworthiness are described as "unjustifiable."
Schizoid Personality Disorder: - Associated with being "devoid of all emotion." - Difficulty establishing any type of relationship. - Inability to take pleasure in things that others typically enjoy. - Indifference toward the social sphere; the individual is content living on the "outskirts of society."
Schizotypal Personality Disorder: - High likelihood of potentially converting to schizophrenia. - Displays signs and symptoms similar to schizophrenia, including odd thoughts and beliefs. - Presence of "magical thinking" and content that is not within the context of typical communication. - Significant lack of friends and difficulty interacting within society.
Treatment and Nursing Approaches for Cluster A: - Therapy: Traditionally the first line of treatment. - Medications: Used only as an adjunct to treat other comorbid mental health conditions. - Communication Style: Nurses should be caring and respectful but maintain a "businesslike approach" that is more "cold." - Rationale: Overly warm or friendly behavior may trigger suspicion in Cluster A individuals. - Space and Autonomy: Nurses must acknowledge the patient's concerns or perceptions and respect their need for physical and emotional space. Forcing interaction can cause the individual to withdraw from the treatment plan.
Cluster B: Dramatic, Emotional, and Erratic Behaviors
General Characteristics: This group includes mood-related disorders where individuals are emotional or erratic in their social behavior.
Antisocial Personality Disorder: - Diagnostic Age Requirement: The individual must be at least years old to receive this diagnosis. - History: Must have evidence of "conduct disorder" by the age of . - Traits: No regard for ethics or remorse for violating the civil rights of others. - Behavior: They will do whatever is necessary to get what they want. - Social Nature: Contrary to the name, they are not "anti-social" in terms of social interaction; they can be "social butterflies" to manipulate and achieve their goals. They often interact with the legal system and may be arrested for their behaviors.
Borderline Personality Disorder (BPD): - Highly prevalent in clinical careers. - Characterized by unstable moods and a fragile self-image. - Splitting: A primary defense mechanism where the individual sees things in extreme "black or white" terms. - Examples of Splitting: If a therapist cancels an appointment due to an emergency, the BPD patient may immediately think, "This individual hates me" or "They're never gonna see me again." - Risks: Increased risk for suicidal ideation and self-harming behaviors. - Relationships: Described as "hot or not" or highly unstable, particularly in intimate contexts.
Histrionic Personality Disorder: - Currently subject to speculation regarding its status as a disorder; some consider it a cultural norm. - Traits: Extremely attention-seeking; individuals love to be the center of attention. - Behavior: Displays inappropriate and sexually seductive behaviors. - Speculated Examples: Kardashians, Marilyn Monroe, and Anna Nicole Smith (considered type-A Hollywood actress behavior).
Narcissistic Personality Disorder: - Self-inflated sense of own importance. - Consider themselves "special" and can be very arrogant. - High need for admiration from others. - Exploitation: Will exploit others to meet their own needs. May seek out individuals with "Dependent Personality Disorder." - Deficit: Marked lack of empathy.
Treatment and Nursing Approaches for Cluster B: - Building Rapport: Essential for progress. - Avoiding "Why" Questions: These questions lead to defensiveness and should be avoided. - Handling Challenges: These individuals do not like to be challenged. - Boundaries: Consistency in professional boundaries is vital, as patients may try to establish overly friendly relationships to cross boundaries. - Managing Splitting: Minimize splitting behaviors (pitting staff against each other). It is recommended that only to clinicians preside over the care of a BPD patient in outpatient settings to reduce the likelihood of splitting. - Limit Setting: Clear policies and procedures must be applied consistently to all patients.
Cluster C: Anxious or Fearful Behaviors
General Characteristics: Characterized by anxious behaviors.
Avoidant Personality Disorder: - Avoidance of all social circumstances. - High sensitivity to any type of rejection; avoidance is a preemptive measure to ensure rejection does not occur.
Dependent Personality Disorder: - Search for relationships that provide support and nurturance. - Difficulty making almost any life decisions (e.g., what to eat for breakfast or what clothes to wear). - Rely on others for Activities of Daily Living (ADLs). - Often described as "clingy."
Obsessive-Compulsive Personality Disorder (OCPD): - Distinction: Different from the OCD discussed in week . - Traits: Preoccupied with rules, details, and perfectionism. - Interference: Perfectionism interferes with life; for example, if a project or schoolwork is not "perfect," they will not submit it at all.
Treatment and Nursing Approaches for Cluster C: - Trust: Development of a trusting relationship is the foundation. - Social Skills: Encouraging the integration of social skills and friendships. - Avoidant Intervention: Small steps toward social integration. - Dependent Intervention: Encourage assumption of responsibility for their own decisions. - Incremental Progress Example (Dependent): Start with a goal for the patient to choose their own socks while others choose the rest of the outfit, eventually working toward choosing the entire outfit independently.
Clinical Assessment Guidelines
Recognition Gap: Patients have difficulty recognizing that their traits or behaviors are problematic.
Medical History: A full history must be taken for every patient.
Childhood Evaluation: Assessment for abuse or Adverse Childhood Experiences (ACEs), which increase the likelihood of developing personality disorders.
Substance Use: Evaluate for substance use, which may serve as a maladaptive coping mechanism.
Safety Assessments: Conduct standard suicidal and homicidal (SI/HI) assessments.
Triggers: Determine if a recent loss triggered the onset or exacerbation of symptoms.
Nursing Interventions and Ethical Mindset
Labeling and Bias: Nurses must assess their own values and beliefs, particularly regarding Borderline Personality Disorder and the label of "manipulative."
Interaction-Specific Assessment: Evaluate each interaction individually before labeling a behavior as manipulative.
Therapeutic Approach: If limits must be set on inappropriate behaviors, do so within a therapeutic framework.
Self-Disclosure: Nurses should be very cognizant not to discuss personal information. BPD patients may use personal data to manipulate staff or cause division among the care team.
Primary Treatment Modalities
Therapy as Mainstay: Psychotherapy is the primary treatment for personality disorders.
Medications: Used primarily for comorbid conditions like anxiety and depression.
Motivational Interviewing: A patient-centric approach that encourages individuals to challenge their own traits and create change.
Psychodynamic Psychotherapy: A Freudian-based therapy focusing on childhood abuse and complications that lead to current behaviors.
Cognitive Behavioral Therapy (CBT): An option for restructuring thought patterns.
Dialectical Behavioral Therapy (DBT): - Specifically developed for Borderline Personality Disorder. - Focuses on the reframing of the individual’s mindset. - Core Concept: Helps the individual overcome intense emotions by realizing, "I am not my emotions." - There are stages of DBT (though full stage details are not required for current testing).
Additional Resources
Personality disorder presentations and brochures are available for review in the D2L portal.