Personality Disorders

OverviewLifelong, inflexible, and dysfunctional

patterns of relating and behaving Patterns interfere with daily life Client often does not recognize own

dysfunction Interpersonal and occupational problems

result

Overview

Diagnosis is on Axis II If admitted to an inpatient facility must have an Axis I

diagnosis also (e.g. alcoholism, depression)

Difficult to treat Most are treated outpatient in individual or

group therapy Often seen in drug treatment centers

Overview: Interpersonal Characteristics Relationships

Often experience conflict with others

May have difficulty initiating or sustaining relationships

Cause distress to others only become distressed when

others react to them negatively

Affective/Cognitive Characteristics

Anxiety: Varies in the different clusters. Behavior is way of coping with anxiety and the

individual does not consider how their behavior will affect others.

Cognitive issues: Rigidity of responses--difficulty in adapting to the

new or unexpected Mistakes in judgment Lack of insight

Gender and Personality Disorder Diagnoses

Female: greater percentage of Borderline or Histrionic diagnoses

Male: greater Percentage of Paranoid, Schizoid, Antisocial, and Narcissistic dx.

Grouped by the Three Clusters of Behavior in the DSM IV-TR

Cluster A Exhibit odd and eccentric behaviors

Cluster B Exhibit dramatic, emotional and erratic

behaviors. Cluster C

Exhibit anxious, fearful behaviors

Cluster A (Odd-Eccentric)

Characteristics: odd, eccentric behavior, suspicious ideations, and social isolation. Know this cluster as a group (do not have to recognize each individually) Schizoid P.D. Schizotypal P.D. Paranoid P.D.

Cluster A Overview Similarities to schizophrenia But no fixed delusions or hallucinations May have transient psychotic symptoms

when under acute stress May have biological family member with

schizophrenia

Cluster A, cont’d Schizoid

Lacks desire to be close to others

Lacks close friends Solitary activities Little interest in sexual

activity Appears cold and

detached Appears indifferent to

praise or criticism

Schizotypal Ideas of reference Magical thinking or odd

beliefs Unusual perceptual

experiences including bodily illusions

Odd thinking and speech Odd or eccentric

appearance or behavior Suspicious, social

anxiety Few close relationships

Cluster A, cont’d

Secretive, fearful and distrustful. Reads hidden meaning into benign statements or

events Reluctant to confide in others; fears information will

be used against him/her Suspicious about fidelity of spouse or S.O. without

justification Perceived attacks on character or reputation Bears grudges; responds to threats with anger

Paranoid P.D.

Photo from film: “Meet the Parents” with Ben Stiller and Robert De Niro

Cluster A: Nurse-client Relationship Building trust is most important Be honest; keep it simple Do not intrude on privacy, if possible Do not challenge odd beliefs or appearance

Cluster A: Milieu Do not push into social or group activities,

but give gentle encouragement Choose groups that are non-threatening

What Should the Nurse Say/Do?

A recently admitted client is refusing to eat in the cafeteria with others, stating,

“The cafeteria food is different. And those people don’t want me. Why can’t I eat here?”

Cont’d (Choose all that apply)A) “There is nothing wrong with the cafeteria

food.”B) “You need to go over to the cafeteria if

you want to eat.”C) “I’ll walk with you to the cafeteria.” D) “Why do you think they don’t want you?”E) “It can be hard to get comfortable when

you are new.”

Cluster B (Dramatic, Emotional, Erratic)

Characteristics: Impulsive, dramatic behavior, intolerance of frustration, and exploitative interpersonal relationships. (Know Antisocial, Borderline and Narcissistic) Histrionic P.D. Narcissistic P.D. Antisocial P.D. Borderline P.D.

Is most commonly dx’d. P.D.

Cluster B Histrionic

Needs to be center of attention

Dramatic and provocative

Overreacts to minor events

Easily influenced by others

Superficial relationships

Narcissistic Grandiose Fantasies of

unlimited power, success or brilliance

Needs to be admired Sense of entitlement

(deserves special treatment)

Lacks empathy Takes advantage of

others to meet own needs

Interventions for Histrionic or Narcissistic P.D. Set appropriate limits Be consistent in approach Be matter-of-fact Focus on here-and-now Use supportive confrontation for

discrepancies and contradictions Support self-esteem (does this seem like a

contradiction?)

What Should the Nurse Do/Say?1) Client (stomps foot and makes faces while

talking): “I need the day room for my exercise routine. You people have to realize that I am in modeling and this is important to my career.”

(Use matter-of-fact approach)

What Should the Nurse Do/Say?

2) Client: “I am depressed because I have no true friends in my life. And even my roommate here is so rude to me. What a fat slob! I want to room with someone else.”

(Use supportive confrontation)

Cluster B, cont’d Antisocial Personality Disorder

Diagnosis is based on disordered behavior: Pattern of disregard of the rights of others Non-conforming to rules Often found in criminal justice system rather

than in mental health services May seek hospitalization to avoid the law

Antisocial Personality Disorder: Cognitive and Affective Aspects

Low tolerance for frustration; cannot delay gratification of impulses

Unable to make long-range plans Deny and rationalize behavior Little guilt or remorse May be aggressive or abusive

Antisocial Personality: Interpersonal Aspects

May appear charming and confident, but with little personal involvement

Self-interest comes before needs of others Unable to sustain close personal relationships. Sex life is impersonal and impulsive.

Antisocial Personality: Etiology Genetic: inherited trait or predisposition CNS

ANS under-responds to stress Low activity in frontal lobe

Unable to learn from rewards and punishment History of disordered life functioning

Parent-child relationship often is unstable Childhood characteristics of lying, stealing and being

truant.

Client Scenario A 24 year old unemployed male was admitted

from jail to the mental health unit after a suicide attempt in his cell. Was awaiting sentencing for burglary: stole from the apt. of his former girlfriend. States to the nurse that his problems started after she broke up with him. Client was using alcohol and cocaine heavily. Explains, “She owed me and so I took some cash and stuff.” The client has a distressed affect when discussing current situation. He states, “Now they’re putting a label of ‘crazy,’ on me.”

Antisocial Personality Disorder: Interventions

Essential for staff to agree on rules and stick with them

Will try to play one staff or shift against another Set firm limits Point out effect of behavior on others Point out consequences of behavior

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

What Should the Nurse Say/Do? A client who is involuntarily in treatment on

the inpatient unit was found smoking in the bathroom. A few days later the client’s visitor smuggles in some alcohol, which he and roommate consume.

A hospitalized client is verbally abusive and uncooperative with select staff members but is friendly and cooperative with others. Complains to you about the “nasty” staff.

Cluster B, cont’d: Borderline Personality

Disorder

Most commonly diagnosed Personality Disorder

Borderline Personality Disorder: Overview

Characterized by: Extremely intense and variable moods Disturbed sense of self; often self-negative Impulsivity, often with self-destructive behavior Use of “splitting” (also called “black or white

thinking”) as defense mechanism

Borderline Personality Disorder DSM IV-TR

Criteria Fear of abandonment and frantic efforts

to avoid it Unstable, intense relationships Marked identity disturbance Chronic feelings of emptiness Impulsivity that may be self-damaging

These behaviors help them to feel better for a short period of time

Borderline Personality Disorder DSM-IV TR Criteria

When under stress may experience transient, paranoid thoughts or delusions, or dissociative symptoms These will resolve when the stress is relieved

DSM IV-TR Criteria, cont’d. Recurrent Self-Destructive

Behavior Suicidal threats & gestures Self-Injurious Behavior (SIB)

Affective instability Rapid mood shifts Low frustration tolerance

Problems with anger

Borderline PD: Etiology A predisposition plus childhood experiences is

current accepted theory Childhood Environment: often chaotic or

neglectful Strong evidence for abuse, trauma history Neurobiological: (cause or result of stress?)

Serotonin dysregulation cholinergic and adrenergic abnormalities lack of integration of right and left hemispheres smaller hippocampal volume

Issues for Borderline Personality: Splitting Phenomenon

Low tolerance for ambivalence Inability to cope with conflict Get a sense of identity from the other Result in this perspective:I Either you are good or you are bad (no in-

betweens) When you are not perfect, you have failed me

and you are bad (that means I’m no good, either)

Issues for Borderline, cont’d Interpersonal Relationships

Unstable and intense Characterized by over-idealizing or

devaluation of others Cannot resolve feelings that others are not

perfect and cannot meet all of their needs Fear being abandoned; may be needy and

dependent

Issues for Borderline PD, cont’d Functions of Self-injury:

Is self-punishment Relieves tension Improves mood Is evidence that they are real, and can feel

Suicide risk is high due to: Self-injuring behaviors Severe emotional pain Impulsivity

BPD: Nurse-client Relationship Consistency, trust, honesty Explain and then Enforce unit rules Team approach: Minimize splitting of staff Be accepting, Be matter of fact, Do not

show anger or irritation. (Transference phenomenon is common in these clients)

Convey empathy

Nurse-client Relationship, cont’d

Discuss how to express and handle feelings Encourage self-responsibility and appropriate

behaviors Offer choices, when possible Give positive feedback for accomplishments and

progress Don’t get discouraged by opposite behaviors Do not minimize or ignore SIB; assess for suicide

Borderline Personality: Milieu Provide safe environment based on ongoing

assessment; suicide precautions if necessary Groups: Coping skills, Expressive Arts Journaling: Promotes safe identification of own

thoughts, feelings and actions

Issues for Therapy Frequently have long-term issues of abuse,

trauma, neglect An advanced practice Health Care Provider can

assist the client in talking about these events in individual or group therapy on long-term basis

BPD: Group Therapy Clients make good group members; can be

very insightful for others Decreases transference issues. Feedback

from group can be helpful in dealing with unrealistic expectations.

Attention-seeking behavior and entitlement issues are dealt with better in group.

What Should the Nurse Say/Do? A client with a history of self-injuring

behavior visited earlier this evening with family. She is later found in her room, having cut her abdomen with the broken end of a plastic fork she had taken from her meal tray. She says to the nurse, “They told me I can’t come back home because they can’t handle me.”

What Should the Nurse Say/Do? The client is placed on Close Observation

status for SIB. At midnight, she expresses anger to the night shift nurse that she can’t sleep due to staff having to watch her. “I am being treated like a criminal. If the evening shift nurses really cared about me they would not have done this to me. ”

Legal-Ethical Critical Thinking

If a client who self injures has a history of abuse or trauma, what are the implications for use of restraints and emergency management?

BPD: Community Resources AA, ACOA Family education and support groups, too

Cluster C: (Anxious-Fearful)

Dependent Personality Disorder Pervasive, excessive need to be taken care of

Feels unable to care for self, little self-confidence

Fears being alone and helpless Unable to make decisions without much

support Fears loss of approval; will agree or will

perform tasks to avoid rejection

Cluster C, cont’d Avoidant Personality

Disorder Fears making

mistakes Fears disapproval and

rejection Severe shyness and

feelings of inadequacy and being disliked

Socially uncomfortable and withdrawn

Obsessive Compulsive Personality Disorder Perfectionistic and

inflexible Preoccupied with

details Too busy to have fun

or friends Hoards objects and

money

Nursing Interventions for Cluster C

Assist in setting small, achievable goals Discuss fears and feelings prior to meeting a

goal Assist to explore feelings Assist to try new activities Assist to decrease anxiety and need for

perfection

Cluster C: Milieu Management Groups: Assertiveness training, Stress

management, Leisure skills Most clients seen as outpatients

What Should the Nurse Say/Do? A client with Cluster C traits is trying to learn how to be

more confident and assertive and has a list of goals he wrote after attending a group on the unit. He asks the nurse what goal he should choose to work on first. Here is the list:

1) improve my life 2) eat breakfast with other people every other

day 3) identify one good thing about myself 5) find a woman who really cares

What Should the Nurse Do/Say?

A) “Oops, you missed putting a # 4 on the list.”

B) “#3 is a good goal. Try that one first.” C) “What other ways can you work on your

issues than writing a list?”

Personality DisordersPharmacological

Interventions Medications address severe, disabling symptoms. Medications do not cure P.D.s Primarily used when client in emergency or crisis

(PRN or short-term) Examples: Suicidal behavior

Transient psychosis

Assaultive behavior

Severe anxiety episode

Personality Disorders Psychopharmacology,

cont’d Low doses of some medications may be

indicated e.g. antipsychotic agents for paranoia; mood stabilizers or SSRIs for Borderline Personality Disorder, etc.

Treat co-morbid Axis I diagnoses: Depression, Anxiety Disorders, Bipolar Disorder, etc.

Evaluation of Interventions How can the nurse evaluate effectiveness

of interventions for the person who has a personality disorder?

Expectations (i.e. your goals) should be realistic

What behaviors can change within a short-term hospital stay?