A spectrum of maladaptive traits that produce or influence considerable psychological and emotional disturbance and impair relationships. An enduring pattern of feelings (emotions), thinking (cognitive distortions), and behaving (maladaptive in nature) that become rigid and stable over time.
All individuals have personality traits and characteristics that make them unique and interesting human beings. Traits: exhibited in the way individuals think about themselves and others and in the way they behave. If traits are inflexible and dysfunctional, individuals generally have problems in functioning and experience subjective distress. Personality: characteristic traits that are generally predictable in their influence on cognitive, affective, and behavioral patterns of human beings. Develop and evolve over time, are conscious or unconscious, and affect adaptation and response to the environment.
Character: generated by early life experience and is represented by learned personality traits that influence behavioral patterns. Patients with personality disorders suffer lifelong, inflexible, and dysfunctional patterns of relating and behaving. Might suffer lifelong, inflexible, and dysfunctional problems of relating and behaving. Usually causes distress to others (ego syntonic) Individuals might not find their behaviors distressing to themselves. They become distressed because of other people’s behavior or reactions toward them. Causes immense emotional pain and discomfort.
The nurse should convey acceptance of the individual and empathy for emotional pain, regardless of the patient’s behavior. Patients do not seek treatment to their personality but want help for depression, anxiety, alcoholism, and for difficulties in work and personal relationships. Comorbidity: anxiety and mood disorders. Personality disorders are often listed under axis II: Used to designate developmental disorders, personality traits, or habitual use of particular defense mechanisms.
Individuals must have disturbances in two of the following areas: Cognition Affect Interpersonal functioning Impulse control Placed ina separate category (Axis II) apart from other disorders because the underlying causes and presenting behaviors are different and require different treatment approaches.
10- 15 years ago: causes were thought to be only psychological in origin Social environment, coupled with psychological vulnerability, strongly influences the individual. Important in the genesis of personality disorders: effects of societal changes, a stressful environment, and negative childhood experiences, along with biologic factors.
Cluster A: Schizoid, schizotypal, and paranoid disorders, characterized by odd or eccentric behavior. Cluster B: narcissistic, histrionic, antisocial, and borderline disorders, characterized by dramatic emotional, or erratic behaviors. Cluster C: dependent, avoidant, obsessive- compulsive disorders, characterized by anxious or fearful behaviors.
Cognition (thinking about self, people, and events)Affectivity (range, intensity, lability, and appropriateness of emotional response)Interpersonal functioningImpulse control
Suspicious of others Doubts trustworthiness or loyalty of friends and others Fear of confiding in others Suspicious, without justification, of spouse’s or sexual partner’s fidelity Interprets remarks as demeaning or threatening Holds grudges towards others Becomes angry and threatening when he or she perceived being attacked by others
Hypersensitive to other people’s motives and often act in defense of a fragile self- concept. May think that others are treating them unfairly Unable to laugh at themselves and are often humorless, and serious Blunted affect: might appear to be cold. But capable of close relationship of selected few Do not have fixed delusions or hallucinations Transient psychotic symptoms: precipitated by extreme stress May be hospitalized when behavior is out of control Tends to occur of biologic relatives of identified patients with schizophrenia; more on men.
Lacks desire for close relationships or friends Chooses solitary activities Little interest in sexual experiences Avoids activities Appears cold and detached Lacks close friends Appears indifferent to praise or criticism
Do not want to be involved in interpersonal or social relationships and keep people at an emotional distance Appear uncomfortable interacting with others May be thought as hermits: shyness and introversion Respond with short answers Respond with short answers to questions and do not initiate spontaneous conversation Can function at work successfully, especially if little verbal interaction is required. Reality oriented; fantasy and daydreaming might be more gratifying
Nurse patient relationship: Focus initially on building trust Identification and appropriate verbal expression and feelings Slowly involve patient in milieu and group activities: help social skills.
Ideas of reference Magical thinking or odd beliefs Unusual perceptual experiences, including bodily illusions Odd thinking and vague, stereotypical overelaborate speech Suspicious Odd or eccentric appearance or behavior Few close relationships Excessive social anxiety
Appears similar to patients with schizophrenia; major exception: psychotic episodes are infrequent and less severe. Have problems in thinking, perceiving and communicating Outward appearance is eccentric and behavior is odd Fantasies about imaginary relationships might be substituted for real relationships. Uncomfortable around people but are interested in others More common in the biologic relatives of schizophrenics
Interventions: Offer support, kindness, and gentle suggestions to help become involved in activities Help the patient improve interpersonal relations, social skills and appropriate behavior Careful orchestrated interaction in socializing experiences Vocational counseling and job placement Low doses of antipsychotics: transient psychotic states in relation to thinking, perception, and anxiety
Deceitfulness, as seen in lying or conning others Engages in illegal activities Aggressive behavior Lack of guilt or remorse Irresponsible in work and with finances Impulsiveness Reckless disregard of safety for self or others
A pattern of disregard for the rights of others: repeated violations of the law (as evidenced by driving while intoxicated and engaging in spouse or child abuse) Before age of 15: diagnosed as conduct disorder Promiscuous and feel no guilt about hurting others Lying, cheating, and stealing are common Criminal behavior places them within the judicial and prison systems more than it does in the mental system Diagnosis: history of disordered life functioning rather than on mental status.
Might experience distress and anxiety because of other’s hostility towards them, but they see the problem as being in others and not themselves Might appear to be charming and intellectual; smooth talkers and deny and rationalize their behavior Expected anxiety over their predicament is absent Guilt, sorrow for offenses, or loyalty is nonexistent, as if they do not have a conscience Do not behave as responsible, mature, and independent adults
Both geneticsand the environment are known to influence the development: Parent- child relationship is unstable Genetic predisposition Highly correlated with substance abuse and dependency problems Weak response to stress in ANS Insensitive to emotional connotations of language: inability to learn form reward and punishment Lower than average activity in the frontal lobes (govern judgment and decision making)
Nurse- patient relationship: Long- term treatment is necessary For short- term hospitalization: Set firm limits (may manipulate staff and bend rules for their own desires and needs) Be steadfast and consistent in confronting behaviors and enforcing rules and policies Consequences of behavior (both for unit and the patient’s life) are also a point of focus Help the patient be aware of consequences Point out the effects of the behavior on others
Let the patient understand how others feel and react to his behaviors, and why they react in the they do Avoid moralizing and assist the patient in identifying and verbalizing feelings that might reflect anxiety and depression Membership in groups (more effective if grouped with individuals with the same diagnosis) Key: consistency by the nursing staff and accountability by the patient
Grandiose self- importance Fantasies of unlimited power, success or brilliance Believes he or she is special or unique Needs to be admired Sense of entitlement (i.e., deserves to be favored or given special treatment) Takes advantage of others for own benefit Envious of others or others are envious of him or her Arrogant or haughty Grandiosity: based somewhat on reality but is distorted, embellished, or convoluted to meet the patient’s need of self importance.
Patient overvalues himself; needs to be admired; is arrogant; self- centered and self- absorbed; and seems indifferent to the criticisms of others Feels superior and has a sense of entitlement, demanding attention, admiration, and special favors Might appear nonchalant or indifferent to criticism while hiding feelings of anger, rage or emptiness Constant reinforcement is needed to boost the self- image Relationship with others seem shallow but might be meaningful if the patient’s self- esteem is positively enhanced
Cannot emphatize with others, and the feelings of others are not understood or considered Uses rationalization to blame others, makes excuses, and provides alibis for self- centered behaviors. Self- centered person is arrested in emotional development because the parents fail to mirror that which is appropriate or inappropriate back to the child.
Nurse- patient-relationship: Decrease constant recitation of self- importance and grandiosity Nurse must mirror what the patient sounds like, especially if contradictions exist, and help the patient focus on the identification and verbal expression of feelings. Supportive confrontation Limit setting and consistency in approach Realistic short- term goals focused on the here and now: decreases fantasy and rationalization and to increase responsibility for self
Teach patient everyone has worth, even he or she makes mistakes and has imperfections Group therapy: provides the opportunity for the patient to see how his or her behavior affects others, and how for the first time, gives the patient a chance to become involved with the problems of others. Caution must be exercised to not give the patient free rein to talk about himself or herself.
Needs to be center of attention Displays sexually seductive or provocative behaviors Shallow, rapidly shifting emotions Uses physical appearance to draw attention Uses speech to impress others but is lacking in depth Dramatic expression of emotion Easily influenced by others
Exaggerates degree of intimacy with others. Extroverted and thrives on being center of attention Behavior is silly, colorful, frivolous, and seductive Speech is vague, and overembellished but lack details, ensight, and depth Seems to be in a hurry and restless Temper tantrums and outbursts of anger are seen Overreactions to minor events Uses somatic complaints to avoid responsibility and support dependency Dissociation is common defense to avoid feelings
Cannot deal with his or her true feelings Views relationship with others as special or possess greater intimacy than is real: recently met individuals are thought to be as dear friends Causes: Unknown Probably a result of many factors Mother negates the child’s inner feelings in the early mother- child relationship Child turns to father for nurturance, and the father responds to the child’s dramatic emotional behaviors
Nurse- patient relationship: Positive reinforcement in the form of attention, recognition, or praise is given for unselfish or other- centered behaviors. Provide support to facilitate independent problem solving and daily functioning Help client clarify own feelings and help the patient learn appropriate ways to express them Working with these patients can be frustrating for the nurse because the patient needs time to internalize the meaning of what the nurse is trying to accomplish
Frantic avoidance of abandonment, real or imagined Unstable and intense personal relationships Identity disturbance Impulsivity Affective instability Recurrent suicidal behavior or self- mutilating behavior Rapid mood shifts Chronic feelings of emptiness Problems with anger Transient dissociative and paranoid symptoms
Features: Emotional dysregulation, anger, impulsivity, intense psychological pain, impairment in interpersonal or occupational functioning, identity or self- image disturbances, abandonment fears, and self- injurious behaviors. The most commonly treated. Difficult to appreciate the complexity of the individual’s disorders. Require hospitalization when they are in crisis or exhibit self- injurious or suicidal behaviors.
Have problems with identity, self- image, relationships, thinking, mood, and impulsive behaviors. Identity: uncertain about self- image, career goals, personal values, and sexual orientation. Interpersonal relationships: chaotic and problems exist in choosing unhealthy relationships and short- term intimate relationships Alternates between overidealization and devaluation of individuals “falls in love” with the perfect person and, shortly thereafter, can find no redeeming qualities in the formerly idealized person Cannot appreciate the mixed bag of qualities that most people have Manipulation and dependency commonly occur. Difficulty in being alone and seeks intense but brief relationships
Mood disturbances: symptoms of depression, intense anger, and labile mood. Projective identification: displace angry feelings towards others to justify their own feelings Blaming others helps in dealing with feelings though dysfunctional and inappropriate Intense emotional pain contributes to mood shifts, which range from euphoria to crying to acting out behaviors, such as displays of temper and physical fights, self- mutilation, and suicidal behaviors Impulsiveness: use of substances and a tendency towards anorexia- bulimia Others: overspending, promiscuity, compulsive overeating, and unhealthy risk taking and decision making.
Self- injury: frantic efforts to avoid abandonment and attempts to cope with effective dysregulation and impulsive aggression 75%: women and victims of childhood sexual abuse Splitting: inability to view both the self and others as having both good and bad qualities. All good or all bad Helps the individual avoid the pain and feelings associated with past abuse and current situations involving threats of rejection or abandonment Complexity can include severe symptoms of PTSD and dissociative disorders Might exhibita need for attention and affection by contradictory behaviors of manipulation, dependency, or acting out.
Frustration on the part of the staff might be seen as rejection. Leads to increased anger and withdrawal because of fear of abandonment Shifts between depression, anxiety, euphoria, and anger are seen in the patient’s labile mood During times of stress: May regress to immature behaviors and is unable to cope with conflict. May vacillate between clinging and disengaged behaviors, as demonstrated by wanting the staff to solve all problems or by the patient viewing the inpatient treatment as unnecessary and meaningless. When progress seem to be occurring, the patient with a BPD might suddenly exhibit opposite behaviors, and it might seem as if the staff will need to restart all over. Uses self mutilation or self- injurious behavior for the purpose of self- punishment, tension reduction, improvement in mood, and distraction from intolerable effects. Cutting, burning, and severe skin scratching After self- mutilation, patient is better and appear relieved
Serious risk for suicide Feelings of hopelessness, despair, and depression contribute to their suicidality At risk because of: depression, aggression, impulsivity, underestimation of the lethality of their behavior and more frequent occurrence of suicidal thoughts Don’t interpret mutilation as manipulation or attention- seeking behavior Lethality of individuals who self- mutilate and attempt suicide is as serious as those who do not self-mutilate and attempt suicide Self- mutilation and suicide attempts should never be minimized or ignored 1 in 10 completes suicide and risk is at highest with comorbid substance- related and depressive disorders.
Unique causes: Combination of temperament, childhood experiences, and neurologic and biochemical dysfunction Biologic, environmental, and stress- related factors contribute to the complexity of the disorder. Neurotransmitter dysregulation of the serotonin system: affective disturbances and impulsive behaviors Abnormal cholinergic and adrenergic systems: predisposes to dysphoria, emotional lability, and hyperreactivity to the environement, which might contribute to affective instability.
Environmental factors: chaotic home environment, neglect of the child’s feelings and needs, and verbal, emotional, physical and sexual abuse. Stress- related events might trigger the individual’s genetically based vulnerable temperament and create misery and frustration Is reminded of earlier stress or trauma, which results in the development of the borderline symptoms and condition Early trauma and stress affect the hippocampus Lack of integration of the right and left hemispheres results in abused children using their right hemispheres for frightening memories and left hemispheres when thinking of neutral memories: splitting
Nurse- Patient Relationship Use empathy while maintaining clear boundaries- important in establishing a relationship with the patient. Nurse is not a friend but a health care professional Acknowledge reality of pain, offer support, and empower patient to understand, control, and change dysfunctional behavior. Identify and verbalize feelings, control negative behaviors, and slowly begin to replace them with more appropriate actions. Conduct a suicide assessment and provide a safe environment to decrease self- harm and contain impulses and then work with patient to find less destructive ways to handle anger, rage, and psychic pain. Help patient identify feelings and verbally express them nonaggresively. Discuss alternative methods to handle feelings. Use of behavioral contract.
Have patient write a notebook or a journal in a daily basis. Patients who are victims of abuse need to talk about their trauma in a safe environment. Consistency, limit setting, and supportive confrontation. Enforce unit rules, provide clear structure, and place the responsibility for appropriate behaviors on the patient. Help to develop realistic short- term goals.
Psychopharmacology Used for specific symptoms: Cognitive- perceptive- antipsychotics for 3 to 12 weeks Affective or emotional dysregulation- SSRIs for anger, chronic emptiness, and temper outbusrsts; Clonazepam for anxiety management; Lithium, valproic acid, and carbamazepine for rapid mood swings Impulse- behavioral self- control: SSRIs to decrease impulse behaviors
Milieu management Firm limits, consistency, and clear structure Consistent communication among staff members Group sessions: dialectal behavior therapy, assertiveness training, problem solving, stress management, and anger management Referral to self- help groups for alcoholism, drug addiction, eating disorders, and victimization Vocational counseling and training
Unable to make daily decisions without much advice and reassurance Needs others to be responsible for important areas of life Seldom disagrees with others because for fear of loss of support or approval Problems with initiating projects or doing things on own because of little self- confidence Performs unpleasant tasks to obtain support form others Anxious or helpless when alone because of fear of being unable to care for self
Urgently seeks another relationship for support and care after a close relationship ends Preoccupied with fear of being alone to care for self Pervasive and excessive need to be taken care of that leads to submissive and clinging behaviors and fears of separation. Dependent individuals want others to make daily decisions for them. Needs direction and reassurance. Feel inferior and cling to others excessively because they need to rely on others
Perceive themselves as being unable to function without the help of others. Expects that they perform good deeds for others, they will be rewarded by someone doing something for them. An intimate relationship with spouse who is abusive, unfaithful, or an alcoholic is tolerated so as not to disturb the sense of attachment. Means of avoiding conflict: passivity and concealing of sexual feelings. Unique causes: Psychosocial theories consider culture to be the basis of the development of this disorder. E.g. Women should maintain a dependent role. Child should not exhibit autonomous behaviors.
Nurse- patient relationship: Nurse slowly works on decision making with the patient to increase responsibility for self for daily living. Needs assistance with managing anxiety because it will increase as the patient assumes more responsibility for self. Assertiveness: an important area of the nurse’s teaching which enables the patient to clearly state his or her feelings, needs and desires. Verbalization of feelings.
Avoids occupations involving interpersonal contact because of fears of disapproval or rejection Uninvolved with others unless certain of being liked Fears intimate relationships because of fear of shame or ridicule Preoccupied with being criticized or rejected in social situations. Inhibited and feels inadequate in new interpersonal situations Believes self to be socially inept, unappealing, or inferior of others Very reluctant to take risks or engage in new activities because of possibility of being embarrassed.
Timid, socially uncomfortable, and withdrawn. Feels inadequate and are hypersensitive to criticism. Desires relationship but need to be certain of being liked before making social contacts. Avoids situations in which they might be disappointed or rejected. Sounds uncertain and lacks self- confidence and also afraid to ask questions or speak up in public, withdraws from social support, and conveys helplessness.
Nurse- patient relationship: Increased shyness and avoidant behavior during adolescence might lead to this disorder. Gradually help patient to confront his fears. Discuss patient’s feelings and fears before and after doing something that he or she is afraid to do. Support patient in accomplishing small goals. Help patient to be assertive be assertive and develop social skills when necessary. Include patient in interaction with others and then progress to small groups. Relaxation techniques. Give positive feedback for any real success and for any attempts to engage in interaction with others.
Preoccupation with details, rules, lists, organization Perfectionism that interferes with task completion Too busy working to have friends or leisure activities Overconscientious and inflexible Unable to disregard worthless or worn- out objects Others must do things his or her way in work- or task- related activity Reluctant to spend and hoards money Rigid and stubborn Perfectionist and inflexible. Overly strict and often set standards for themselves (too high); thus their work is never good enough
Preoccupied with rules, trivial details, and procedures. Difficult to express warmth or tender emotions Little give and take in their interactions Rigid, controlling, and cold. Serious about his activities, so having fun or experiencing pleasure is difficult Indecisive or will put off decisions until all facts have been obtained Affect is constricted, might speak in a monotone Unique causes: Issues of autonomy, control, and authority during childhood: predisposing factors Might be genetically inherited
Nurse- patient relationship: Support patient in exploring his or her feelings and in attempting new experiences and situations Help with decision making and encourage follow- through behavior Confront procrastination and intellectualization Teach the importance of leisure activities and exploring interests in this area Needs to look at and understand other’s view of him Teach the patient that he is a human and that it is alright to make mistakes.
Enduring pattern of disobedience, argumentativeness, explosive angry outbursts, low frustration tolerance, and a tendency to blame others for quarrels or accidents. Might begin early in the development. Most common diagnosis among preschoolers. Tends to be associated with comorbid diagnoses of anxiety and mood disorders and either a single or comorbid diagnosis of ADHD. Frequently in conflict with adults. Trouble maintaining friendships.
Characterized by more serious violations of social standards, such as aggression, vandalism, cruelty to animals, stealing, lying, truancy. Comorbidity: ADHD, depression, learning disorder. Relationship between ADHD and CD points out the potential contirbution of family genetic studies. An enduring set of behaviors that evolves over time, usually characterized by aggression and violation of the rights of others.