Module 3 – Personality & Eating Disorders Study Notes

Conceptual Frameworks & Influencing Factors

  • Functional Ability themes underlying course content:
    • Homeostasis & Regulation (Fluid/Electrolytes, Thermoregulation, Cellular, Hormonal, Glucose, Gas Exchange, Perfusion, Clotting)
    • Protection & Movement (Immunity, Infection, Tissue Integrity, Sensory Perception, Mobility, Resilience, Stress & Coping, Nutrition)
    • Maladaptive Behaviour (Family Dynamics, Mood & Cognition, Mood & Affect, Anxiety, Cognition, Psychosis, Sexuality & Reproduction, Addiction)
  • Systems-level concepts for professional nursing practice:
    • Patient Education, Health Promotion & Self-Management
    • Health Disparities, Adherence, Care Coordination & Collaboration

Personality Disorders (PD) – Overview

  • Definition: Personality traits become so exaggerated/rigid that they create functional impairment or distress, particularly in relationships.
  • Prevalence & co-morbidity:
    • >50%50\% of all patients presenting for medical care may have a PD.
    • In psychiatric populations, 30–50%30\text{–}50\% have a co-occurring PD.
    • Associated with emotional, social & occupational disability.
  • Onset & etiology:
    • Traits visible from infancy ➔ disorder usually emerges in adolescence.
    • Multifactorial: genetic (twin studies show stronger similarity in identical twins), neurobiological (impulsivity, affective instability), psychological (childhood neglect/trauma, harsh discipline, chaotic or sexually abusive homes).

General Clinical Features of PD

  • Core impairments: identity, self-direction, empathy, intimacy.
  • Hallmarks:
    • Fear of rejection, avoidance OR fusion & boundary blurring.
    • Demanding, fault-finding, manipulative, passive-aggressive, distrusting.
    • Limited insight—patients see others as “the problem.”
    • Relationships often volatile; potential for self/other-directed violence.
    • Suffering, under-achievement, social isolation, bizarre/anxious/withdrawn behaviour.

Symptom Clusters

  • Cluster A (“odd/eccentric”): avoidant of relationships, unusual beliefs.
  • Cluster B (“dramatic/manipulative”): emotional reactivity, poor impulse control, unclear identity.
  • Cluster C (“anxious/fearful”): high anxiety, self-blame, inhibition.

Cluster-Specific Disorders & Key Characteristics

  • Cluster A
    • Schizotypal PD – appears like schizophrenia without frank psychosis.
    • Paranoid PD – pervasive unjustified suspiciousness/hostility.
    • Schizoid PD – flat affect, indifferent to praise/criticism, detached relationships.
  • Cluster B
    • Antisocial PD – persistent disregard/violation of others’ rights.
    • Borderline PD – unstable intense relationships, affective lability, splitting (good vs. bad).
    • Narcissistic PD – grandiosity, entitlement, lack of empathy.
    • Histrionic PD – excessive emotion & attention seeking, must be centre stage.
  • Cluster C
    • Avoidant PD – feelings of inadequacy, hypersensitive to criticism.
    • Obsessive-Compulsive PD – perfectionism, orderliness, indecisiveness, emotional constriction.
    • Dependent PD – excessive need for care, fears of being alone.

Passive-Aggressive Personality Trait

  • Chronic irritability, blame-shifting, verbal aggression, negativism, obstructionism.

Primitive Defences in PD (esp. BPD & Antisocial)

  • Used to control inner chaos due to “ego weakness.”
  • Defences: splitting, dissociation, psychotic denial, projective identification, primitive idealisation, omnipotence/devaluation.
  • Manifestations: unmodulated rage, envy, shame ➔ attacking, clinging, lying, impulsivity, identity diffusion, irrationality.

Assessment Guidelines for PD

  • Always assess for suicidal/homicidal ideation.
  • Rule out medical/substance causes.
  • Consider cultural/ethnic context.
  • Look for personality change in mid-life (possible substance use disorder).
  • Anticipate strong counter-transference (nurse’s negative emotions).

Expected Outcomes (Realistic & Modest)

  • Minimise self-destructive acts.
  • Reduce manipulation; link behaviour to consequences.
  • Teach alternatives to crisis; sustain emotional management.
  • Foster a regression-preventing lifestyle.

Communication & Nursing Strategies

  • Core tools: limit-setting, consistency, authenticity, trustworthiness.
  • Teach patients to:
    • Identify triggers & cues preceding impulsive acts.
    • Explore impact on self/others; develop alternative responses.
    • Practise coping skills (anger management, assertiveness).
  • Avoid: secret-keeping, gift acceptance, discussing staff personal info, special favours.

Managing Manipulative or Impulsive Behaviour

  • Brief observation before labelling “manipulative.”
  • Clear boundaries & documented consequences; enforce consistently.
  • Examples of manipulative tactics: arguing, flattery, pitting staff, power struggles.

Milieu & Group Approaches

  • Community meetings, problem-solving, coping skills & socialisation groups.
  • Desensitisation through safe group experience.

Therapeutic Modalities

  • Therapeutic relationship: difficult d/t suspicion/hostility; must understand complaints arise from fear/threat perceptions.
  • STEPPS (Systems Training for Emotional Predictability & Problem-Solving):
    • 2020-week manualised adjunct for BPD.
    • Lowers core symptom intensity; ↓ ED visits & suicide attempts (no change in hospital utilisation/suicidal ideation frequency).
  • Dialectical Behaviour Therapy (DBT) – core for BPD: mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness.

Pharmacologic Symptom Management in PD

  • No medication cures PD; target symptoms with low-toxicity drugs.
  • Avoid long-term benzodiazepines (abuse/OD risk).
  • Options:
    • SSRIs – depression & panic; ↓ aggression when combined with lithium/anticonvulsants.
    • SARI (Trazodone) & SNRI (Venlafaxine) – safer in overdose.
    • Carbamazepine – impulsivity/self-harm.
    • Atypical antipsychotics – transient psychosis under stress.

Neurobiology of Borderline PD & Emotional Dysregulation

  • Altered serotonin (5-HTT short alleles) ➔ ↓ serotonin, ↑ impulsive aggression.
  • Functional MRI: prefrontal cortex hypo-activity (poor regulation), hyper-reactive amygdala/limbic system (prolonged fight-or-flight).
  • Elevated norepinephrine & dopamine during stress.
  • Treatments: DBT (shifts from sympathetic → parasympathetic), SSRIs, anticonvulsants, SGAs, lithium dampen dysregulation.

Case Study – “Gale”

  • 58-year-old professor; Dx: Depression & BPD.
  • Incident: verbal aggression toward faculty, threw books, assaulted staff ➔ crisis unit admission.
  • Behaviour on unit: yelling, threw hot coffee; required seclusion & medication.
  • Audience-response pearls:
    • Best initial nurse intervention: Introduce self & establish working relationship (Option D) – builds trust before limits.
    • When splitting another nurse as “good” vs. primary nurse “cold” ➔ respond with reflecting feelings without reinforcing split: “You seem concerned about how you’re being treated…” (Option A).
    • Day 4 violent outburst, refusing PO meds ➔ likely need IM Haloperidol + IM anxiolytic (Option B) for immediate control.

Self-Care for Nurses Working with PD

  • Common feelings: frustration, anger, helplessness, being “manipulated,” fear of violence, exhaustion.
  • Essential to debrief, set limits, recognise counter-transference, seek supervision.

Eating Disorders – Overview

  • Unified feature: irrational misperception of body image.
  • DSM-5 categories: Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder (BED).
  • High co-morbidity with mood/anxiety disorders, substance abuse, body dysmorphic disorder, impulse control & PDs (esp. BPD & OCPD).
  • AED guideline: always assess for suicide/self-harm risk.

Hospitalisation Criteria for ED

  • Weight loss >30%30\% in 66 months.
  • Hypothermia, dehydration, loss of sub-Q fat.
  • Bradycardia <40\text{ bpm}; Systolic BP <70\text{ mmHg}.
  • Hypokalaemia <3\text{ mEq/L} unresponsive to PO supplement.
  • Psychiatric: suicidal, severe depression, psychosis, family crisis, uncontrolled purging/abuse of laxatives/diuretics/emetics/street drugs.

Anorexia Nervosa

  • Clinical signs
    • Terror of weight gain, food pre-occupation, cutting food into tiny bits.
    • Possible vigorous exercise, vomiting, laxatives/diuretics.
    • Severely underweight (cachexia), lanugo hair, amenorrhoea.
    • CV: bradycardia, murmurs, ECG changes ➔ sudden MI.
    • Hypotension (orthostatic), blood dyscrasias, liver changes, elevated cholesterol, thyroid abnormalities, proteinuria/haematuria.
  • Nursing Diagnoses: imbalanced nutrition < requirements, ↓ cardiac output, risk for electrolyte injury, fluid volume imbalance, distorted body image, anxiety, low self-esteem, ineffective coping, hopelessness.
  • Interventions
    • Acute phase (ICU/ED/CCU): build trust, strict weight & intake monitoring, milieu therapy, link privileges to compliance.
    • Long-term: combo of individual/group/family therapy; periodic brief re-hospitalisations.
  • Cognitive distortions to address: over-generalisation, all-or-nothing, catastrophising, personalisation, emotional reasoning.
    • Example of all-or-nothing: “If I allow myself to gain weight, I’ll be huge.”
  • Medications: limited evidence; Olanzapine may ↑ weight & improve body image; Fluoxetine may aid maintenance/prevent relapse.

Bulimia Nervosa

  • Clinical signs
    • Recurrent bingeing with compensatory purging (vomiting, laxatives, diuretics).
    • History of anorexia common (¼–⅓).
    • Depression, interpersonal issues, impulsivity, possible substance abuse.
    • Physical: parotid enlargement, dental erosion, esophageal tears, Russell’s sign (callused knuckles), ECG changes, metabolic alkalosis, hypokalaemia, dehydration.
  • Nursing Diagnoses: ↓ cardiac output, disturbed body image, powerlessness, chronic low self-esteem, anxiety, ineffective coping.
  • Interventions
    • Acute: inpatient CBT, interrupt binge–purge cycle, normalise eating, treat co-morbidities.
    • Long-term: ongoing therapy, connect with resources (www.anred.com), family involvement.
    • Patient more able to form therapeutic alliance (behaviour is ego-dystonic).
  • Audience Q: Dehydration from vomiting most likely causes hypokalaemia (Option B).

Binge-Eating Disorder (BED)

  • Variant of compulsive overeating; now discrete DSM-5 diagnosis.
  • Episodes of large food intake in short time with loss of control; followed by guilt, disgust, depression.
  • Often linked with obesity & depression.
  • Long-term outpatient focus: healthy weight maintenance, individual/family/group therapy, pharmacology, nutrition counselling; treat co-morbid depression, substance use, PDs.

Health Teaching & Promotion for ED

  • Teach constructive coping, relaxation, social & problem-solving skills.
  • Meal planning, healthy diet/exercise, effects of binging/purging, cognitive distortions.
  • Supervised food shopping, eating out, “forbidden food” exposure.
  • Discharge: living, school, work, finances, outpatient follow-up.

Team-Based Care for ED

  • Core team: Nurse, Psychiatrist, LMHC, Dietician, Internist/Pediatrician, Psychologist, Social Worker, Mental Health Tech.
  • Family, social network & support groups integral.

Medication Notes in ED

  • No agent universally efficacious for EDs.
  • Weight gain/appetite improve when underlying anxiety is treated.
  • Olanzapine: weight gain, cognitive/body-image benefit.
  • Fluoxetine: mixed results in maintenance/relapse prevention.

Milieu, Health Teaching & Psychotherapy Goals (ED)

  • Interrupt pathological eating behaviours, normalise patterns, teach relaxation & coping, correct distortions, discharge planning.

Quick Reference to Audience Response Answers

  1. Gale – best initial intervention ➔ Introduce self / establish nurse relationship (D).
  2. Gale splitting staff ➔ Reflect concern (A).
  3. STEPPS applicability ➔ Borderline PD (C).
  4. Gale violent outburst med ➔ IM Haloperidol + anxiolytic (B).
  5. All-or-nothing cognition ➔ “If I allow myself to gain weight, I’ll be huge.” (A).
  6. Bulimic dehydration complication ➔ Hypokalaemia (B).
  7. Therapeutic alliance blocker in anorexia ➔ Authoritarian disciplined eating approach (A) is least helpful.