Personality and Psychotic Disorders

Personality Disorders (Axis II)

• Personality: The toolbox used to navigate life.
• Personality disorders: Dysfunctional patterns of thinking, feeling, and behaving that are ingrained and inflexible.
• Classification: Previously on Axis II because dysfunction didn't fit Axis I criteria.
• Prevalence: Affects approximately one in seven people.
• Etiology:
  • Genetics: Runs in families.
  • Childhood trauma.
  • High reactivity: Reacting impulsively without thinking.
  • Reduced prefrontal cortex activity: Impaired judgment and insight.
  • Overactive limbic system: Heightened emotional reactivity.
• Treatment:
  • Long-term therapy is necessary, but patients often resist due to lack of insight.
  • Medication can manage associated symptoms but doesn't cure the underlying disorder.
• Diagnosis: Typically diagnosed at 18 years or older but can be observed as early as age 5.
• Impact: Plays a significant role (80-90%) in domestic violence cases.
• Characteristics:
  • Lack of insight: Inability to recognize their own problematic behavior.
  • No internal conflict: Absence of self-monitoring or self-criticism.
  • Difficulty stepping back and assessing themselves.
  • Tendency to break agreements and manipulate others.
  • Drama-seeking behavior.
  • Often perceived negatively by others (e.g., as a "jerk," "moron," etc.).

Cluster A: Odd or Eccentric

• Individuals in this cluster may appear nearly psychotic but maintain intact reality testing.
• Often refractory to treatment and may blame professionals.
• Symptoms are poorly defined, leading to confusion.
• Example: Presented the "balsamic hill" as an illustration of personality disorder dynamics.

Core Features

• Personality disorder: A fundamental aspect of who someone is, unlike a psychiatric disorder which is something someone has.
• Behavior: Often demanding and unreasonable.
• Defense Mechanisms: Employ justification and lack insight, internal conflict, or external ego control.
• Impact on Others: Can make others feel "crazy" by deflecting responsibility.
• Identity: Seek drama as a means of defining themselves.

Paranoid Personality Disorder

• Rooted in childhood betrayal.
• Mistrusting and suspicious of others.
• Can be dangerous and violent.
• Believe that friends are disloyal and cannot be trusted.
• Often mandated to treatment.
• Not delusional or hallucinating, but exhibit excessive mistrust.
• Examples: Columbine shooters, spree killers, and possibly President Richard Nixon.

Schizoid Personality Disorder

• Appear detached, reclusive, and zombie-like.
• Lack of desire for relationships.
• Feelings of emptiness.
• Prefer solitary existence with no need for intimacy.
• Example: Ted Kaczynski, the Unabomber.

Schizotypal Personality Disorder

• May be diagnosed initially before progressing to schizophrenia.
• Exhibit strange and eccentric behavior.
• Have limited relationships and poor self-care.
• Prognosis is generally poor.
• Often fail to adhere to social norms.
• Example: Albert Einstein

Cluster B: Dramatic, Emotional, or Erratic

• Characterized by impulsivity, affective instability, and interpersonal difficulties.
• May be encountered in various settings, including work and personal relationships.

Antisocial Personality Disorder

• Also referred to as psychopathy.
• Lack of autonomic nervous system arousal, allowing them to pass lie detector tests.
• Deceitful, manipulative, and devoid of empathy.
• Seek power and control over others.
• Often begin with conduct disorder as children.
• Examples: Serial killers (e.g., Hannibal Lecter, Ted Bundy), domestic violence abusers, con artists.
• Exploitative behavior, such as scamming someone out of money or selling faulty goods.

Borderline Personality Disorder

• More commonly diagnosed in females.
• Characterized by a fear of abandonment.
• Exhibit suicidal or homicidal tendencies.
• Impulsive and emotionally unstable.
• Struggle to maintain stable relationships.
• Examples: Marilyn Monroe, Hitler, Glenn Close's character in Fatal Attraction, and Jodi Arias.

Narcissistic Personality Disorder

• Arrogant, entitled, and lacking in empathy.
• Believe they are superior to others.
• Often unfaithful and have various addictions.
• Brain scans show atrophied empathy centers.
• Associated with professions such as military leadership, medicine, and professional sports.

Histrionic Personality Disorder

• Characterized by dramatic, attention-seeking behavior.
• Seductive and shameless.
• Emotionally exaggerated and overly theatrical.
• Example: Joan Rivers.

Cluster C: Anxious or Fearful

• Characterized by high levels of anxiety and avoidance.
• All include an element of anxiety. If it was an anxiety disorder it'd be on axis one, this is on axis two, though, where their personality has been compromised.

Avoidant Personality Disorder

• Fear negative judgment from others.
• Avoid social situations due to fear of rejection and criticism.
• Easily embarrassed.
• Prefer solitary work environments.
• Seek careers which have little to no human interaction.

Obsessive-Compulsive Personality Disorder

• Not OCD (Axis I), but a personality style.
• Need for control, inflexibility, and perfectionism.
• Preoccupation with rules and order.
• Example: Boss being excessively critical for one being a minute late.

Dependent Personality Disorder

• Excessive need to be taken care of.
• Lack of confidence and inability to make decisions.
• Avoid personal responsibility.
• Example: A 40-year-old living in his parents' basement without a job.

Psychotic Disorders and Schizophrenia

Schizophrenia

• Most common psychosis.
• Onset: Can occur as early as age 5, but more common in late teens and early twenties.
• Etiology: Primarily genetic.
• Positive Symptoms:
  • Hallucinations.
  • Delusions.
  • Bizarre behavior.
  • Thought disorders.
• Negative Symptoms:
  • Poor grooming.
  • Flat or blunted affect.
  • Withdrawal.
  • Slow responsiveness.
• Brain Structure: Changes in brain structure, such as enlarged ventricles.
• Neurotransmission: Imbalance of neurotransmitters (excess dopamine).

Symptoms

• Hallucinations: Sensory experiences without external stimuli (auditory, visual, olfactory, gustatory, tactile).
• Delusions: Fixed, false beliefs (e.g., grandeur, paranoia).
• Ideas of Reference: Belief that external events are related to oneself.
• Formication: Sensation of insects crawling on the skin.
• Poverty of Thought: Slowed or limited thinking.
• Other features:
  • Poor impulse control.
  • Non-compliance with treatment.
  • Comorbidity with substance abuse.
  • Neologisms (making up words).
  • Derealization (feeling that the world is not real).

Diagnosis

• Requires at least two symptoms, including at least one of the following: delusions, hallucinations, or disorganized speech.

Subtypes:

• Catatonic: Psychomotor disturbances, including: Excitement, Stupor, Immobility (can stand in one spot for hours). *Echolalia: Parrot talk. *Echopraxia: Mimic what you do Need frequent safety and nutrition checks. Can have head stay in place after pillow is removed due to a lack of mobility.
  • Disorganized: Disorganized speech, behavior, and affect; vulgar; socially inappropriate.
  • Paranoid: Higher functioning; hallucinations and delusions are congruent; guarded and suspicious; best prognosis.
  • Undifferentiated: Symptoms do not fit specific subtypes.
  • Residual: History of at least one schizophrenic episode; positive symptoms absent, negative symptoms persist.

Phases of Schizophrenia

• Prodrome (At-Risk Phase): Early signs of psychosis, such as social isolation, changes in hygiene, and unusual behaviors.
• Pre-Psychotic: Delusions begin, and the individual wants to be left alone.
• Acute: Positive and negative symptoms, including hallucinations and delusions and total loss of reality.
• Residual: Positive symptoms decrease but are replaced with negative symptoms such as limited energy and a negative outlook.
• Remission: Patient is medicated.

Other Psychotic Disorders

• Brief Psychotic Disorder: Psychosis triggered by extreme stressor/trauma, lasting more than one day but less than one month.
• Delusional Disorder: Non-bizarre delusions for at least one month.
• Schizoaffective Disorder: Combination of schizophrenia and mood disorder (mania or depression).

Nursing Interventions for Psychotic Patients

• Safety: Ensure the safety of the patient and others.
• Trusting relationship: Establish trust and rapport with the patient.
• Reality Orientation: Acknowledge the patient's beliefs but gently redirect to reality.
• Anxiety Management: Help the patient manage anxiety related to their experiences.
• Promote Compliance: Encourage adherence to medication regimen.
• Social Skills: Provide positive feedback for socially appropriate behaviors.
• Education: Educate the patient and family about the disorder and treatment.

Differentiating Schizophrenia and Schizoaffective Disorder

• Schizoaffective Disorder: Has manifestations like schizophrenia but also has bipolar tendencies, becoming depressed and manic
• Schizophrenia: Patients never get manic.
• Schizoaffective Disorder: Can be diagnosed with schizophrenia and then turn into this after another episode.

Differences between Schizoaffective and Bipolar: The psychosis, the hallucinations and delusions, are always going to be present with schizoaffective disorder even when the mood is stable. With Bipolar, psychosis only occurs when they are manic.

Treatment and Goals

• Dose Stabilization: Stabilize the patient on medication.
• Prevent Decline: Prevent future decline and hospitalization.
• Coping Skills: Teach the patient coping strategies.
• Family Education: Educate the family about the disorder.
• Community Resources: Connect the patient with community mental health centers.
• Decanoate Injections: Monthly injections to reduce relapse in those non-compliant with medications.

Medications and Side Effects

• Antipsychotics: Interfere with dopamine pathways.

• Side Effects: Extrapyramidal side effects (EPS).

• High-potency antipsychotics: Cause more EPS.

• First-generation antipsychotics: Cause more side effects.
  Extrapyramidal Side Effects
  **Akathisia: The inability to sit still.
  **Dystonia: Impaired muscle tone.

• Oculogyric crisis: Eyes go up to the top of the head and they can't pull them back down.

• Torticollis: The neck twists down or back.

• laryngeal pharyngeal dystonia: Muscles in the throat get twisted or rigid so they can't breathe.

• Achinesia: Everything is slow.

• Bradykinesia:

  • Dyskinesia: Abnormal facial movements like tongue thrusting.
  • Tardive: Grimacing and grinding teeth.

• Cogentin, Benadryl, and Artane: Shots given for dystonia that reverse symptoms.

• Drug-Induced Parkinsonism: Tremors and rigid muscles that act like Parkinson's.

• Neuroleptic Malignant Syndrome: Fatal extrapyramidal side effect where too much dopamine has been blocked. Sign is a rapid rise in temperature. Also tachycardic and rapid changes in blood pressure. Stop the medicine, lower their BP and temperature

Treating Tardive Dyskinesia

• Arbogil, quetiapine (Seroquel), vitamin E, and AUSTEDO.

Nursing Responsibilities

• Administer drugs and monitor for side effects.

Common Diagnoses

• Disturbed thought process (delusions).
• Disturbed sensory perception (hallucinations).
• Social isolation (withdrawal).