Transcript Chapter 019

Chapter 19
PERSONALITY DISORDERS
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
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Personality
• The individual qualities, including
habitual behavior patterns, that make a
person unique
• Personality traits is a persistent
behavioral patterns that do not
significantly interfere with one’s life, even
though the behaviors may be annoying or
frustrating to others
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Definition of Personality
Disorder
• Traits and habits that comprise the
personality are inflexible (rigid) and
damaging
• Pathology/impairment will affect the
individual and those who interact with
the individual
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Definition of Personality Disorder
• Enduring pattern of inner experience and
behavior that deviates from the expectations of
the person’s culture, that is pervasive and
inflexible. Manifested in two or more of the
following areas:
– Cognition
– Affect
– Interpersonal functioning
– Impulse control
– Social or occupational
– Relationship
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Common Characteristics of
Personality Disorders (PDs)
• Difficulty in three areas of day-to-day
functioning
– Thoughts and emotions
– Participation in interpersonal relationships
– Managing impulses
– Tendency to foster vicious cycles (crisis
orientation)
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PD: Common Characteristics
• Onset in adolescence or early adulthood
• Persists throughout the person’s life
(chronicity)
• Lack insight: not aware of their pathology
• Intense transference/counter-transference
reaction
• Failure to accept the consequences of behavior
• Pattern of perceiving, thinking, and relating that
impairs social or occupational functioning
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Biologic Factors
• Alterations in hormone & platelet
monoamine oxidase (MAO) levels
• Neurotransmitter changes
• Electroencephalographic (EEG)
changes
• Structural brain changes
• Diminished blood flow and
inflammation
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Genetic Factors
• Familial tendencies
• Cluster B correlated with mood
disorders, alcoholism, & somatization
• Genetic variation
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Psychosocial Factors
• Parent–child interactions
• Intrapsychic theory
• Enmeshment
• Abandonment
• Identity diffusion
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Cluster A Personality Disorders
• Eccentric and odd behavior
• Unusual levels of suspiciousness
• Magical thinking
• Cognitive impairment
• Examples
– Paranoid PD
– Schizoid PD
– Schizotypal PD
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Paranoid Personality Disorder
• A pervasive distrust and
suspiciousness of others such that
their motives are interpreted as
malevolent, beginning by early
adulthood and present in a variety of
contexts.
– Rigidity
– Hypervigilance
– Distortion of reality
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Schema for Paranoid PD
• People will eventually try to hurt me
• People can’t be trusted. They will always take
advantage of me
• People will try to bother or annoy me
• Don’t get mad, get even
• Any insult, no matter how slight, directed at me
should be punished
• Always be prepared for the worst
• If I get close to people they can find out my
weaknesses
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Nursing Guidelines
• Avoid being too “nice” or too “ friendly”
• Give clear and straight forward explanations
of tests and procedures beforehand
• Use simple, clear language; avoid ambiguity
• Project a neutral but caring affect
• Provide client with a daily schedule of
activities and inform client of changes or
reasons for delays
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Schizoid Personality Disorder
• A pervasive pattern of detachment from
social relationships and a restricted
range of expression interpersonal
settings, beginning by early adulthood
and present in a variety of contexts:
– Detached, aloof, isolative, Humorless
– Experience transient psychotic episodes
– Experience anxiety, depression, and
dysphoric affect
– Deny interest in relationships
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Schema for Schizoid PD
• There are few reasons to be close to
people
• I am my own best friend
• Displays of emotions are unnecessary
and embarrassing
• What others say is of little interest or
importance to me
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Nursing Guidelines
• Avoid being too nice or friendly
• Do not try to increase socialization
• Perform thorough diagnostic
assessment as needed to identify
symptoms of disorders that the patient
is reluctant to discuss
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Schizotypal Personality Disorder
• A pervasive pattern of social and
interpersonal deficits marked by acute
discomfort with, and reduced capacity
for, close relationships as well as by
cognitive or perceptual distortions and
eccentricities of behavior, beginning by
early adulthood and present in a variety
of context
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Schizotypal PD Characteristics
• Ideas of reference
• Odd beliefs or magical thinking
(clairvoyance, telepathy, or “sixth sense”)
• Vague, circumstantial, metaphorical,
overelaborate, or stereotyped
• Suspiciousness or paranoid ideation
• Odd appearance, eccentric or peculiar
• Lack close friends or confidants
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Nursing Guidelines
• Respect patient’s need for social
isolation
• Be aware of patient’s suspiciousness
and employ appropriate interventions
• Perform a careful diagnostic
assessment to uncover and medical or
psychological symptoms.
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Cluster B Personality Disorders
• Dramatic, emotional, erratic behavior
• Problems with impulse control
• Examples
– Antisocial PD
– Borderline PD
– Histrionic PD
– Narcissistic PD
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Antisocial Personality Disorder
• A pervasive pattern of disregard for
and violation of the rights of others
occurring since age 15
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Antisocial PD Characteristics
• Failure to conform to social norms
• Deceitfulness
• Impulsive
• Irritability and aggressiveness
• Reckeless
• Irresponsible
• Lacks remorse
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Schema for Antisocial PD
• Rules are meant for others
• Only fools follow all the rules
• Rules are meant to be broken
• My pleasure comes first
• I will not allow myself to be frustrated
• I will do whatever I must to get what I
want
• I am smarter that most everybody else
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Nursing Guidelines
• Be alert to manipulation such as flattery,
seductiveness, instilling of guilt or verbal
attacks
• Set clear and realistic limits of specific
behavior
• Ensure that all limits are adhered to by all staff
involved
• Do not seek approval or coax, provide clear
boundaries and consequences
• Do not argue, bargain, or rationalize
• Confront
inappropriate behaviors
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Borderline Personality Disorder
• A pervasive pattern of instability of
interpersonal relationship, self-image,
and affects, and marked impulsivity
beginning in early adulthood and
present in a variety of contexts:
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Borderline PD
• Frantic efforts to avoid real or imagined
abandonment
• Unstable and intense interpersonal
relationships
• Identity disturbance
• Impulsivity
• Recurrent suicidal behavior, gestures, or
threats, or self-mutilation
• Chronic feeling of emptiness
• Intense anger or difficulty controlling anger
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Schema for Borderline PD
• I am not sure who I am
• I will eventually be abandoned
• My pain is so intense that I can’t bear it
• My anger controls me. I can’t modulate
my feelings
• When I am overwhelmed I must escape
(running away or suicide)
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Nursing Guidelines
• Set realistic goals, use clear action words
• Be aware of manipulative behaviors, such as
flattery, seductiveness, instilling of guilt
• Provide a clear and consistent boundaries and
limits
• Avoid rejecting or rescuing
• Assess for suicidal and self-mutilating
behaviors, especially during times of stress
• Use a nonjudgmental attitude when client
discusses suicidal/self-destructive thoughts
• Implement
safety precautions
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Narcissistic Personality Disorder
• A pervasive pattern of grandiosity (in
fantasy and behavior), need for
admiration, and lack of empathy,
beginning in early adulthood and
present in a variety of contexts:
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Narcissistic PD
• Grandiose sense of self-importance
• Preoccupied with fantasies or unlimited
success, power, brilliance, beauty, or ideal love
• Believes that he or she is special and important
• Require excessive admiration
• Sense of entitlement
• Exploitative, Lack empathy
• Envious of others
• Shows arrogant, haughty behavior or attitudes
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Schema for Narcissistic PD
• I must have my way in every interaction
• I am more special than anyone else
• I should only have to relate to people
like me
• I must be admired
• No one should have more of anything
that I have
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Nursing Guidelines
• Remain neutral; avoid engaging in
power struggles or becoming defensive
in response to the patient’s disparaging
remarks, no matter how provocative the
situation may be.
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Histrionic Personality Disorder
• A pervasive pattern of excessive
emotionality and attention seeking,
beginning in early adulthood and
present in a variety of contexts:
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Histrionic PD
• Uncomfortable in situations in which he or
she is not the center of attention
• Interaction are characterized by inappropriate
sexually seductive or provocative behavior
• Rapid shifting and shallow expressions of
emotions
• Use physical appearance to draw attention
• Shows dramatization, exaggerated
expressions
• Easily influenced by others
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Schema for Histrionic PD
• Appearance are important
• People are judged on external
appearance
• I must be noticed
• I must never be frustrated in life
• I must get everything I think that I want
• Beauty is the most important
consideration in judging someone
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Nursing Guidelines
• Understand seductive behavior as a
response to distress
• Keep communication and interactions
professional, despite temptation to
conspire with the patient in a flirtatious
and misleading manner
• Encourage and model the use of
concrete and descriptive rather than
vague and impressionistic language
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Cluster C Personality Disorders
• Anxious or fearful behavior
• Rigid patterns of social shyness
• Examples
– Avoidant PD
– Dependent PD
– Obsessive-compulsive PD
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Avoidant
• A pervasive pattern of social inhibition,
feelings of inadequacy, and
hypersensitivity to negative evaluation,
beginning by early adulthood and
present in a variety of context:
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Avoidant PD
• Avoids occupational activity
• Unwilling to get involve with people
• Avoids intimate relationship
• Afraid of being criticized or rejected in social
situation
• Views self as socially inept, personally
unappealing, or inferior to others
• Reluctant to take personal risks or to engage
in any new activities
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Schema for Avoidant PD
• I must be liked
• I must not look foolish to myself or
others at any time
• The world is a dangerous place
• I must depend on others to take care of
me
• Isolation is preferable to being put at
risk of being hurt
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Nursing Guidelines
• A friendly, gentle reassuring approach
is the best way to treat clients
• Being pushed into social situations can
cause extreme and severe anxiety
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Dependent PD
• Difficulty making everyday decisions
• Needs others to assume responsibility
• Difficulty expressing disagreement with others
• Difficulty initiating projects
• Goes to excessive lengths to obtain support
from others
• Feels helpless and uncomfortable when alone
• Urgently seeks another relationship as a source
of care and support
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Schema of Dependent PD
• I can’t function without the support of others
• Without the advice and reassurance of
others I can’t exist
• In any situation, I am probably wrong
• Anger expression, people will abandon me
• If I am abandoned, I will be destroyed
• I must keep people near me
• If I am alone, I may be hurt
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Nursing Guidelines
• Identify and help address current stressors
• Be aware that strong counter-transference often
develops in clinicians because of client’s
excessive clinging.
• Evaluate client’s ability for self-care.
• Avoid doing things the client is capable of doing
• Help client identify assets and liabilities
• Emphasize strengths and potential.
• Point out when client negates own feelings or
opinions
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Obsessive-compulsive PD
• A pervasive pattern of preoccupation
with orderliness, perfectionism, and
mental and interpersonal control, at the
expense of flexibility, openness, and
efficiency, beginning by early
adulthood and present in a variety of
context
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Obsessive-Compulsive PD
• Preoccupied with details, rules, lists, order,
organization, or schedules
• Shows perfectionism that interferes with task
completion
• Excessively devoted to work and productivity
• Overconscientious, scrupulous, inflexible
• Unable to discard worn-out or worthless objects
• Reluctant to delegate tasks or work with others
• Adopts a miserly spending style
• Rigid and stubborn
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Schema for OCPD
• There are strict rules in life
• By focusing on details of a situation, one will
reduce the chances of making errors
• A person is defined by what they do
• The better the job you do the better person you
are
• Rules must be adhered to without alteration
• Emotions must be controlled
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Nursing Guidelines
• Guard against engaging in power
struggles with client. Need for control
is very high in these clients
• Intellectualization, rationalization, and
reaction formation, ioslation, and
undoing are the most common defense
mechanisms
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Epidemiology and Comorbidity
• 13% in general populations
• Frequently co-occur with
– Disorders of mood
– Anxiety
– Eating
– Substance abuse
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Etiology
• Biological factors
– Genetic
– Neurobiological
• Psychological factors
• Environmental factors
• Diathesis-stress model
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Assessment of PDs
• Semi-structured interview preferred
• Minnesota Multiphasic Personality
Inventory (MMPI) to evaluate personality
• Patient history
– Medical history
– Past physical, sexual, or emotional abuse
– Risk of self- or other-directed harm
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Outcomes Identification
• Pertinent categories based on
– Aggression self-control
– Impulse self-control
– Social interaction skills
– Fear level
– Abusive behavior self-restraint
– Self-mutilation restraint
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Interventions
• Basic level interventions
– Milieu management
– Pharmacological interventions
– Case management
• Advanced practice interventions
– Dialectical behavioral therapy (DBT)
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Evaluation
• Evaluating treatment effectiveness in
this patient population is difficult
• Short-term outcomes may be
accomplished
• Patient can be given message of hope
that quality of life can always be
improved
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