Unit 2- Cluster B Personality Disorders

Cluster B

◦ Emotional reactivity, poor impulse control, manipulation

◦ Unclear sense of identity

Antisocial Personality Disorder

· a pervasive pattern of disregard for and violation of the rights of others, lack of empathy, bloated self-image, manipulative and impulsive behavior

Prevalence – 1.1 %; called conduct disorder until age 18

Characteristics:

· genetically linked;

· can seem normal, is manipulative;

antagonistic;

· exploitive, selfish, callous, self-serving, little to no capacity for intimacy, no conscience, profound lack of empathy, absence of remorse or guilt;

· disrespects societal rules and standards, disinhibited behaviors, long pattern of disregard for other’s rights, recurring difficulties with the law.

S/Sx:

· Symptoms peak mid-teens to 20s; symptoms may abate and improve on their own by age 40.

The main pathological traits that characterize antisocial personality disorder are antagonistic behaviors, such as:

being deceitful and manipulative for personal gain or hostile if needs are blocked.
The disorder is also characterized by disinhibited behaviors such as high-risk taking, disregard for responsibility, and impulsivity.
Criminal misconduct and substance abuse are common in this population.

Nursing guidelines:

· set clear and realistic limits, boundaries, and consistency prevent effects of flattery, seductiveness.

Teach Self care to clients
Educate the patient about the disorder
Explain the consequences of their negative behavior

· provide support;

· realistic choices;

· Therapeutic Communication vs. manipulation;

teamwork and safety (priority)

Treatment:

· groups may be helpful;

· Anticipate and seek team support for aggressive behaviors.

· Reduce patients’ anxiety and anger through physical outlets.

· Some evidence that this patient population may bond with psychotherapists

· Address manipulative behaviors—especially bullying—openly, along with consequences (loss of privileges).

Pharmacological interventions:

· mood stabilizers may help with aggression;

· Also possible: SSRIs, benzodiazepines, or Ritalin;

Nurse/Client relationship

· Essential for staff to agree on rules and stick with them

· Set firm limits

· Will try to play one staff or shift against another

· Point out effect of behavior on others

· Manage aggressive or assaultive behavior

· Best form of treatment: Peer counseling and self-help groups, where peers can confront and offer feedback

Borderline Personality Disorder

· pervasive pattern of instability in relationships, self-image, identity, behavior and affects often leading to self-harm and impulsiveness

· Prevalence – 1.6%

· 10% suicide and mortality rate; 70% will attempt suicide; BPD patients often have another mental illness; Substance use disorders: >50%

Characteristics:

· Frantically fears abandonment;

· shifts rapidly between loving and hating;

· unstable and frequently changing moods (emotional control or regulation problems);

· severe impairments in functioning;

· emotional lability;

· impulsivity;

· self-destructive behaviors;

· antagonism;

· splitting defense mechanism -- inability to view both positive and negative aspects of others as part of a whole with black white thinking/dichotomous thinking;

· unstable, intense relationships;

· identity or self-image distortions;

· problems with anger;

· may have self-injurious behaviors

Nursing guidelines:

· Importance of the therapeutic relationship;

· avoid manipulative behaviors;

· provide clear and consistent boundaries;

· use clear, straightforward communication;

· calmly review therapeutic goals;

· teamwork and safety;

· respond matter-of-factly to superficial self-injuries

Treatment:

· Groups, coping skills, expressive arts, anger management, journaling to discuss feelings and learn ways to cope with them.

· As a lifelong disorder, psychotherapy is needed to help person manage dysfunctional moods, impulsive behaviors and self-injurious behaviors

· Be alert for comorbidities of substance disorder and eating disorder

· Psychotropics geared toward symptom relief;

· CBT;

· Dialectical behavior therapy (DBT).

· Finding the best approach that works with patients in the setting in which they are treated is important. Therapies such as dialectical behavior therapy and mindfulness-based therapies offer staff evidence-based interventions, clinical structure, and formalized support for identifying best practices.

Nurse/Patient Relationship

· Team approach – consistency to minimize splitting

· Show empathy while maintaining boundaries

· Honesty and consistency

· Be matter of fact – do not show anger or irritation

· Discuss how to express and handle feelings

· Encourage self-responsibility and appropriate behaviors

· Give positive feedback for accomplishments and progress

· Do not minimize or ignore SIB – self harm threats should be taken very seriously. Ask direct questions and explore behaviors

· Asking about thoughts of hurting self can provide opportunity for prevention and coaching about self-soothing measures

· Sometimes people cut, scratch or pick at themselves as a way of bringing some relief and comfort by activating endogenous endorphins

Nurse can use “5 Senses Exercise” to find other ways for patient to comfort self

· Mindfulness is a state of mind that brings your attention to the present moment.

· One of the keys to learning how to practice mindfulness in your everyday life is through the grounding technique. Grounding anchors you to your environment by making you acutely aware of your surroundings, and one of the best ways to be more mindful and present is by incorporating all of your five senses (sight, sound, touch, smell, and taste).

Histrionic Personality Disorder

· pervasive pattern of attention-seeking behavior and excessive emotions

· Prevalent: Nearly 2% of the population.

Characteristics:

· Seeks attention, excitable, dramatic;

· Talks dramatically with strong opinions;

· Has rapidly changing and excessive emotions;

· Considers relationships to be more intimate than they are;

· Uses physical appearance to draw attention to self;

· Attention-seeking, self-centered;

· low-frustration level;

· often high functioning;

· bold external behaviors;

· limited ability to develop meaningful relationships;

· may be provocative;

· smothering;

· no insight into disorder or role in ruining relationships.

Nursing guidelines:

· Know that seductive behavior is a response to distress;

· Keep interactions professional and ignore flirtations;

· Model concrete language;

· Help patient clarify inner feelings;

· Teach and role-model assertiveness;

· Assess for suicidal ideation.

Treatment:

Psychotherapy is treatment of choice

Narcissistic Personality Disorder

· a pervasive pattern of grandiosity, need for admiration, and a lack of empathy

· Prevalence: range of 0-6% in community samples.

Characteristics:

· egotistical, arrogant, grandiose;

· sees self as admirable and superior and entitled to special treatment;

· an inflated sense of own importance and deep need for admiration;

· exaggerated self importance;

· lack of empathy;

· tendency to exploit others;

· weak self-esteem and hypersensitivity to criticism;

· constant need for admiration;

· less functional impairment than other personality disorders.

· Narcissism is characterized by an extreme self-interest and promotion with an accompanying lack of concern for the needs of others.

Nursing guidelines:

· Remain neutral;

· promote a stronger patient self-identity;

· avoid power struggles or becoming defensive;

· role-model empathy.

Treatment:

· Difficult to treat patients not likely to seek help or confront shortcomings;

· Cognitive-behavioral therapy (CBT) to deconstruct faulty thinking;

Individualized psychotherapy is talk therapy utilized to focus on improving the client’s behaviors.
Short-term objective focused therapy incorporates principles of positive psychology to assist clients to change by creating solutions and not focusing on their problems.

· Group therapy;

· lithium for mood swings

Support therapy

Outcomes

Outcomes should be realistic, modest, and obtainable.

Criteria might include the following:

· Minimizing self-destructive behaviors

· Reducing manipulating behaviors

· Linking consequences to behaviors

· Initiating alternatives to prevent crisis

· Ongoing management of emotions

· Creating lifestyle that prevents regression