Personality disorders

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Personality disorders

  1. 1. Prepared by:Eric F. Pazziuagan, RN, MAN
  2. 2.  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.
  3. 3.  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.
  4. 4.  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.
  5. 5.  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.
  6. 6.  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.
  7. 7.  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.
  8. 8.  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.
  9. 9. Cognition (thinking about self, people, and events)Affectivity (range, intensity, lability, and appropriateness of emotional response)Interpersonal functioningImpulse control
  10. 10.  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
  11. 11.  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.
  12. 12.  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
  13. 13.  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
  14. 14. 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.
  15. 15.  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
  16. 16.  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
  17. 17.  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
  18. 18.  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
  19. 19. 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.
  20. 20.  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
  21. 21.  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)
  22. 22. 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
  23. 23.  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
  24. 24.  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.
  25. 25.  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
  26. 26.  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.
  27. 27.  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
  28. 28.  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.
  29. 29.  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
  30. 30.  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
  31. 31.  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
  32. 32.  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
  33. 33.  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
  34. 34.  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.
  35. 35.  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
  36. 36.  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.
  37. 37.  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.
  38. 38.  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
  39. 39.  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.
  40. 40.  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.
  41. 41.  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
  42. 42.  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.
  43. 43.  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.
  44. 44.  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
  45. 45.  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
  46. 46.  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
  47. 47.  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
  48. 48.  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.
  49. 49. 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.
  50. 50.  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.
  51. 51.  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.
  52. 52.  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.
  53. 53.  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
  54. 54.  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
  55. 55.  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.
  56. 56.  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.
  57. 57.  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.

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