The following presentation will provide an overview of personality disorders in general and the specific nursing management of Paranoid, Antisocial, borderline, histrionic, and narcissitic
One definition of personality and personality disorder is offered by Groves (2004)APA definition of personality disorderPeople with PDs present the most complex, difficult behavioral challenges for themselves and people around them. In the health care community a “difficult patient” is almost always an individual with a PD, which is also among the most frequently treated disorders by psychiatrists (Zimmerman et al., 2005), although the initial focus of treatment is usually a co-occurring symptom or disorder. Personality disorders range from mild to severe.
The tendency to evoke intense interpersonal conflict. Because people with PDs fail to see themselves objectively, and they lack the desire to alter aspects of their behavior to enrich or maintain important relationships. Relationships are often marked by intense emotional upheavals and hostility that lead to serious interpersonal conflict, and in some cases violence (self-violence or violence toward others).The tendency to evoke intense interpersonal conflict. Because people with PDs fail to see themselves objectively, and they lack the desire to alter aspects of their behavior to enrich or maintain important relationships. Relationships are often marked by intense emotional upheavals and hostility that lead to serious interpersonal conflict, and in some cases violence (self-violence or violence toward others).
FOUR CHARACTERISTICS IN COMMON TO ALL PDS:1. Inflexible and maladaptive responses to stress. Individuals have difficulty responding flexibly and adaptively to the environment and to the changing demands of life. They often are unable to cope with stress and react by using maladaptive behaviors, which exposes the disorder.2. Disability in working and loving, which is generally more serious and pervasive than the similar disability found in other disorders.Individuals with PDs assume that everyone thinks and functions as they do; therefore, within relationships, they do not see their behavior as a problem, nor do they see a need to make changes or accommodate others. They believe that they are normal and that others have a problem. This thinking leads to problems with self-concept, relationships, and ability to function in society. Although some individuals with PDs may desire closer relationships with others, some of the reasons personal and work relationships often fail are:•Avoidance and fear of rejection•Blurring of boundaries between the self and others so that closeness seems to lead to fusion, which may terrify both parties•Insensitivity to the needs of others•Demanding and fault finding•Inability to trust•Lack of individual accountabilityCapacity to “get under the skin” of others. People with PDs often have an uncanny ability to merge personal boundaries with others, which has an intense and undesirable effect on others
Paranoid Personality DisorderCharacteristics: suspicious of others; fear others will exploit, harm, or deceive them; fear of confiding in others (fear personal information will be used against them); misread compliments as manipulation; hypervigilant; prone to counterattack; hostile and aloof. Psychotic episodes may occur in times of stress. To counteract patient fear, nurses should give straightforward explanations of tests, history taking, procedures, side effects of drugs, changes in treatment plan, and possible further procedures.Schizoid Personality DisorderCharacteristics: avoids close relationships, is socially isolated, has poor occupational functioning, and appears cold, aloof, and detached. Social awareness is lacking, and relationships generate fear and confusion in the patient. Nurses should strive for simplification and clarity to help decrease patient anxiety.Schizotypal Personality DisorderCharacteristics: ideas of reference; magical thinking or odd beliefs; perceptual distortions; vague, stereotyped speech; frightened, suspicious, blunted affect; distant and strained social relationships. These patients tend to be frightened and suspicious in social situations. Explanations can ease their anxiety.
Antisocial Personality DisorderCharacteristics: has superficial charm, violates rights of others, exploits others, lies, cheats, lacks guilt or remorse, is impulsive, acts out, and lacks empathy. As patients, these individuals are extremely manipulative and aggressive. Nurses must establish and adhere to a plan of care and maintain clear boundaries if they are to minimize patient manipulation and acting outBorderline Personality Characteristics: unstable, intense relationships; identity disturbances; impulsivity; self-mutilation; rapid mood shifts; chronic emptiness; intense fear of abandonment; splitting; and anger. A major defense is splitting (alternating between idealizing and devaluing). Self-mutilation and suicide-prone behavior are frequently seen. Anger is intense and pervasive, and help with anger management is an important intervention. Relationship building, safety, and limit setting are other foci.Histrionic Personality DisorderCharacteristics: center of attention; flamboyant; seductive or provocative behaviors; shallow, rapidly shifting emotions; dramatic expression of emotions; overly concerned with impressing others; exaggerates degree of intimacy with others; self-aggrandizing; preoccupied with own appearance. Experience depression when admiration of others is not given. Suicide gestures may result in patient entry into the health care system. A thorough assessment of suicide potential must be undertaken and support offered in the form of clear parameters of psychotherapy.Narcissistic Personality DisorderCharacteristics: grandiosity, fantasies of power or brilliance, need to be admired, sense of entitlement, arrogant, patronizing, rude, overestimates self and underestimates others. This behavior covers a fragile ego. In health care setting, such a patient demands the best of everything. When patient is corrected, when boundaries are defined, or when limits are set on patient’s behavior, patient feels humiliated, degraded, and empty. To lower anxiety, the patient may launch a counterattack. The nurse should gently help the patient identify sense of entitlement, attempts to seek and become perfect, grandiose behavior.
Avoidant Personality DisorderCharacteristics: social inhibition, feelings of inadequacy, hypersensitivity to criticism, preoccupation with fear of rejection and criticism, and self perceived to be socially inept.Low self-esteem and hypersensitivity grow as support networks decrease. Demands of workplace often overwhelming. Project that caregivers will harm them through disapproval and perceive rejection where none exists. Nurses can teach socialization skills, provide positive feedback, and build self-esteem.Dependent Personality DisorderCharacteristics: inability to make daily decisions without advice and reassurance, need of others to be responsible for important areas of life, anxious and helpless when alone, and submissive. Solicit care taking by clinging. Fear abandonment if they are too competent. Experience anxiety and may have coexisting depression.Obsessive-Compulsive Personality DisorderCharacteristics: preoccupied with rules, perfectionistic, too busy to have friends, rigid control, and superficial relationships. Complains about others’ inefficiencies and gives others directions
Etiology and comorbidityIn the general population, is 10% to 15%, depending on severity. Personality disorders are predisposing factors for many other psychiatric disorders and may coexist with depression, panic disorder, substance use disorder, eating disorder, anxiety disorder, PTSD, somatization, and impulse control disorders.It’s unlikely that there is a single cause for a discrete personality disorder. These disorders are the result of complex biological and psychosocial phenomena that are influenced by multifaceted variables involving genetics, neurobiology, chemistry and environmental factors
Patient HistoryThe nurse should seek information about the medical history; suicidal or homicidal ideation; current use of medications and other substances, food, and money; involvement with the courts; and current or past physical, sexual, or emotional abuse. Information about the patient’s current level of crisis and dysfunctional coping styles should be sought.The preferred method for determining a diagnosis of personality disorder is the semi-structured interview obtained by clinicians. The Minnesota Multiphasic Personality Inventory (MMPI) is useful to evaluate personality via self-reportingSelf-AssessmentThe nurse may experience intense feelings of confusion, helplessness, anger, and frustration. The patient may attempt to manipulate or disparage the nurse, create conflict via splitting or faction forming. Support and supervision for the nurse are essential.
DiagnosisUseful diagnoses include Ineffective coping, Anxiety, Risk for other-directed violence, Risk for self-directed violence, Impaired social interaction, Social isolation, Fear, Disturbed thought processes, Defensive coping, Self-mutilation, Chronic low self-esteem, and Ineffective therapeutic regimen management.
Realistic goal setting is important because change occurs so slowly. Small steps are necessary. Examples include minimizing self-destructive or aggressive behavior; reducing the effect of manipulative behaviors; linking consequences to both functional and dysfunctional behaviors; initiating
Patients with personality disorder are usually admitted to psychiatric institutions for reasons other than their personality disorder. Most often seen are borderline and antisocial patients. The former are impulsive, suicidal, self-mutilating, aggressive, manipulative, and even psychotic under stress. The latter are manipulative, aggressive, and impulsive.
Ambivalent negative feelings and self concept, fear of abandonment
Self destructive behaviors
ImplementationManagement of behaviors/limit settingWhen patients blame and attack others, the nurse needs to understand the context—that the attacks spring from feeling threatened. The nurse must orient the patient to reality whenever the patient imputes malevolent intentions to the nurse or others and reassure the patient that even though the caregiver has been insulted or threatened, the patient will still be helped and protected. The nurse must explain how people, systems, families, and relationships work and acknowledge shortcomings and limitations.Milieu ManagementThe goal of milieu therapy is affect management within a group context. Nurses must help patients verbalize feelings rather than act them out.Pharmacological InterventionsPatients with personality disorders my be helped by a broad array of psychotropic agents, all geared toward maintaining cognitive function and relieving symptoms. Antipsychotics may be useful for brief periods to control agitation, rage, and brief psychotic episodes. Medication compliance is usually an important issue; patients with PD are fearful about taking something over which they have no control.Case ManagementCase management is geared toward reducing the necessity for hospitalization.Advanced Practice InterventionsResearch shows that treatment can be effective for many individuals with personality disorders, especially when a comorbid major mental disorder is targeted. PsychotherapyDialectical behavior therapy (DBT) has shown favorable results with patients with personality disorders. It combines cognitive and behavioral techniques with mindfulness, which emphasizes being aware of thoughts and actively shaping them.EvaluationThe nurse should not measure personal self-esteem based on a patient’s ability to change, since the ability to change is severely limited in patients with PD.
Concept map puts together all of the classifications, characteristics (nursing diagnosis) and theories involved in the management of an individual with personality disorders
People with PD present complex behavioral challenges for people around themPeople with PD have (1) inflexible and maladaptive responses to stress (2) disability in working and loving(3) ability to evoke strong intense personal conflict (4) capacity to “get under the skin”PDs often occur with axis 1 comorbiditiesDo not believe there is anything wrong with themUse more primitive defenses in response to stressSelf assessment when working with PD patients
Personality disordersa voiceover sp12
Personality Disorders SPRING 2012
Personality• is essentially the “style” of how a person deals with the world. Personality traits then are stylistic peculiarities that all people bring to social relationships, including traits such as shyness, seductiveness, rigidity, or suspiciousness (Groves, 2004). In people with a personality disorder (PD), these traits are exaggerated to the point that they cause dysfunction in their relationships (Groves, 2004).• The DSM-IV-TR classifies personality disorders as Axis II diagnoses (along with mental retardation). It also defines a PD as: An enduring pattern of inner experience and behavior that deviates markedly form the expectations of the individuals culture, is pervasive and inflexible, has an onset in adolescent or early adulthood, is stable over time and leads to distress or impairment.
Clinical Picture• Personality disorders (PDs) involve long-term and repetitive use of maladaptive and often self- defeating behaviors.• Do not recognize their symptoms as uncomfortable; thus they do not seek treatment unless a severe crisis occurs.
Clinical Picture• All PDs have four characteristics in common: (1) inflexible and maladaptive response to stress; (2) disability in working and loving; (3) ability to evoke interpersonal conflict; (4) capacity to frustrate others.• Tend to be perceived as aggravating and demanding by health care workers, so the potential for value judgments is high, and effective care is at risk.
Personality disorders• DSM-IV-TR Cluster A Disorders—Odd or Eccentric Behavior
Epidemiology and Comorbidity• In the general population, is 10% to 15%, depending on severity.• Personality disorders are predisposing factors for many other psychiatric disorders• Etiology
Assessment• Patient History o Suicidal or homicidal ideation o Current use of medications and other substances, food, and money o Involvement with the courts; and current or past physical, sexual, or emotional abuse. o Information about the patient’s current level of crisis and dysfunctional coping styles• Self-Assessment
Diagnosis• Ineffective coping• Anxiety• Risk for other-directed violence• Risk for self-directed violence• Impaired social interaction, Social isolation• Fear, Disturbed thought processes• Defensive coping• Self-mutilation
Outcomes Identification• Realistic goal setting (change occurs so slowly)• Small steps are necessary• Minimizing self-destructive or aggressive behavior• Reducing the effect of manipulative behaviors• linking consequences to both functional and dysfunctional behaviors• Initiating functional alternatives to prevent a crisis• Ongoing management of anger, anxiety, shame, and happiness
Planning• Patients with personality disorder are usually admitted to the hospital for reasons other than their personality disorder (borderline, antisocial).• Plan for the following Behaviors:• impulsive, suicidal, self- mutilating, aggressive, manipulative• Possibly psychotic under stress• manipulative, aggressive, and impulsive.
Implementation/Evaluation• Management of behaviors/limit setting• Milieu Management• Pharmacological Interventions• Case Management• Psychotherapy• Evaluation
Summary• People with PD present complex behavioral challenges for people around them• People with PD have (1) inflexible and maladaptive responses to stress (2) disability in working and loving• (3) ability to evoke strong intense personal conflict (4) capacity to “get under the skin”• PDs often occur with axis 1 comorbidities• Do not believe there is anything wrong with them• Use more primitive defenses in response to stress• Self assessment when working with PD patients