Personalities Disorders

Personalities Disorders 150 150 Tony Guo

 

Personalities Disorders

  • Enduring patterns of perceiving and relating
  • Result in significant social and occupational impairment
  • Pattern deviates markedly from the expectations of the individual’s culture

 

Key Features of Personality Disorder

  • Individual has few strategies for relating
  • Inflexible, maladaptive approach to relationships, environment
  • Needs, perceptions, behavior foster vicious cycles; promote unhelpful patterns, provoke negative reactions from others
  • Unstable, fragile coping skills
  • Lack of resilience in stressful situations

 

Etiology

  • Limited research: 
    • Develops according to complex interplay between environment, biological and psychological factors
    • Difficult to conclude one specific neurobiological abnormality as the source

Types

  • Cluster A
  • Cluster B
  • Cluster C

 

Cluster A

  • Behaviors described as odd and eccentric
  1. Paranoid personality disorder
  2. Schizoid personality disorder
  3. Schizotypal personality disorder

 

Paranoid Personality Disorder

  • Pattern of pervasive mistrust and suspicion of others and misinterpretation of others’ motives as malevolent
  • Possible hereditary link and studies revealed high incidences of paranoid disorder among relatives of individuals with schizophrenia and delusional disorder
  • Psychological factors include a history of childhood trauma, including neglect, parental antagonism and harassment (Perceiving the world as harsh and unkind requiring protective vigilance and mistrust)
  • Begins in early adulthood and remains present in a variety of contexts
  • Clinical picture:
    • Suspicious
      • unsupported by evidence
    • Mistrustful
    • “On guard” ( hypervigilant)
    • Fear others will hurt them
    • Lack the “milk of human kindness”
    • Blame others for their shortcomings

Schizoid Personality Disorder

  • Characterized primarily by a profound defect in the ability to form personal relationships, and individuals with this disorder are often seen by others as eccentric, isolated, or lonely
  • Individuals display a lifelong pattern of social withdrawal, and their discomfort with human interaction is apparent.
  • Although it’s not clear if affected by hereditary, the feature of introversion appears to be a highly inheritable characteristic.
  • Childhoods of these individuals have often been characterized as bleak, cold, and notably lacking empathy and nurturing
  • Clinical picture:
    • Lack social and close relationships
    • Usually isolated
    • Self-absorbed
    • Anhedonic
    • Show little emotion
    • Indifferent to praise or criticism
    • Appear emotionally cold or flat
    • “Hermit” like

Schizotypal Personality Disorder

  • Behavior is odd and eccentric but does not decompensate to the level of schizophrenia. (once known as “latent schizohrenics”)
  • More common among the first-degree relatives of people with schizophrenia than among the general population
  • Considered as part of the genetic spectrum of schizophrenia
  • For children with schizotypal personality disorder, their affective blandness, peculiar behaviors, and discomfort with interpersonal relationships may provoke other children to avoid relationships with them, or worse, to engage in bullying, which reinforces their withdrawal from others.
  • Clinical picture:
    • Odd peculiar speech, thought, and behavior
    • Eccentric
    • Cognitive Distortions
    • Behaviors may seem like a milder non-psychotic state of schizophrenia
    • Unusual and Debilitating

 

Cluster B

Behaviors described as dramatic, emotional, or erratic

  1. Antisocial personality disorder
  2. Borderline personality disorder
  3. Histrionic personality disorder
  4. Narcissistic personality disorder

 

Antisocial Personality Disorder

  • Pattern of socially irresponsible, exploitative, and guiltless behavior that reflects a general disregard for the rights of others
  • Lack of concern for rights of others
  • No problem violating rights of others
  • Display irresponsible behaviors
    • Lying
    • Stealing
    • Cheating
    • Physical fights
    • Disregard for others’ safety

Borderline Personality Disorder

  • Pattern of intense and chaotic relationships with affective instability and fluctuating attitudes toward other people.
  • One of the most disruptive personality disorders
  • Unstable and intense interpersonal relationships
  • Hallmark
    • “Splitting”
    • Manipulative
    • Demanding
    • Needy
    • Angry

Histrionic Personality Disorder

  • Characterized by colorful, dramatic, and extroverted behavior in excitable, emotional people.
    • Attention seeking
    • Flamboyant
    • Provocative
    • Portray themselves as victims
  • Some traits may be inherited, whereas others are related to a combination of genetic predisposition and childhood experiences.

Narcissistic Personality Disorder

  • Exaggerated sense of self-worth.
  • Extreme sense of arrogance, entitlement, and self-importance
    • Takes advantage of others
    • Lacks empathy
    • Grandiose
    • Manipulative

 

Cluster C

Behaviors described as anxious or fearful

  1. Avoidant personality disorder
  2. Dependent personality disorder
  3. Obsessive-compulsive personality disorder

 

Avoidant Personality Disorder

  • Extremely sensitive to rejection and consequently may lead a very socially withdrawn life. It is not that he or she is asocial; in fact, there may be a strong desire for companionship.
    • Extreme anxiety
    • Fear of social and intimate relationships
    • Highly sensitive to rejection
    • Isolated
    • Longs for relationships
  • Contributing factors are most likely a combination of biological, genetic, and psychosocial influences like childhood trauma or neglect leading to fears of abandonment or to viewing the world as a hostile and dangerous place.

Dependent Personality Disorder

  • Characterized by lack of self-confidence and extreme reliance on others to take responsibility for them, sometimes to the point of intense discomfort with being alone for even a brief period
    • Over-reliance on others
    • Unable to make decisions and expect others to make them
    • May prefer abusive relationships to being alone
    • Tend to agree with others rather than state a different opinion
  • Dependency is fostered in infancy when stimulation and nurturance are experienced exclusively from one source

Obsessive-Compulsive Personality Disorder

  • Individuals with obsessive-compulsive personality disorder are very serious and formal and have difficulty expressing emotions.
    • Extremely rigid and controlling
    • Perfectionistic
    • Overly organized
    • Pays extreme attention to detail in an exaggerated manner
  • Genetic vulnerability may be a predisposing factor because it is noted to occur more frequently in first-degree biological relatives than in the general population

 

Nursing assessment

  1. Exploitation and manipulation
  2. Belligerent; argumentative
  3. Lack of remorse
  4. Unable to delay gratification
  5. Low frustration tolerance
  6. Inconsistent work and or academic performance
  7. Failure to conform to societal norms
  8. Impulsive; reckless
  9. Inability to form lasting relationship

 

Nursing Diagnosis

  1. Risk for self-mutilation
  • Risk factors: History of self-injurious behavior; history of inability to plan solutions; impulsivity; irresistible urge to damage self; feels threatened with loss of significant relationship
  1. Risk for suicide/Risk for self or other directed violence
  • Risk factors: History of suicide attempts; suicidal ideation; suicidal plan; impulsiveness; childhood abuse; fears of abandonment; internalized rage
  1. Risk for other-directed violence
  • Risk factors: Body language (e.g., rigid posture, clenching of fists and jaw, hyperactivity, pacing, breathlessness, threatening stances); history of childhood abuse; impulsivity; transient psychotic symptomatology
  1. Chronic low-self esteem
  • Dependent on others; excessively seeks reassurance; manipulation of others;inability to tolerate being alone
  1. Defensive coping/Complicated grieving
  • Depression; persistent emotional distress; rumination; separation distress; traumatic distress; verbalizes feeling empty; inappropriate expression of anger
  1. Impaired social reaction
  • Alternating clinging and distancing behaviors; staff splitting; manipulation
  1. Ineffective health maintenance
  2. Disturbed personal identity
  • Feelings of depersonalization and derealization
  1. Anxiety (Severe to panic)
  • Transient psychotic symptoms (disorganized thinking; misinterpretation of the environment); increased tension; decreased perceptual field

Outcomes 

  • Realistic goal setting
  • Identifies origin of anger
  • Seeks out staff when urge to engage in violence/anger/self-harm

 

Implementation

  • Milieu therapy
    • Appropriate for individuals with antisocial personality disorder who respond more adaptively to support and feedback from peers where feedback from peers is more effective than in one-to-one interaction with a therapist.
    • Appropriate for patients  
      • With self-destructive behaviors
      • Who require a structured environment
    • Focuses on
      • Realistic expectations
      • Process of decision making
      • Process of interactional behaviors in the here-and-now
  • Therapeutic communication strategies
    • Manipulative behavior
      • Maintain honest, respectful, and non-retaliatory stance
      • Avoid labeling the patient as manipulative
      • Encourage putting feelings into words
      • Monitor your own reactions and avoid becoming defensive
      • Discuss neutral and less emotionally charged topics
    • Dependent behaviors
      • Convey a sense of optimism about the patient’s abilities
      • Use a patient non-aggressive tone
      • Discourage negative remarks about self that lessen confidence
      • Avoid making decisions for clients
    • Angry behaviors
      • Firmly and calmly instruct the patient to stop the angry behavior
      • Avoid touching the patient
      • Maintain a calm respectful demeanor
      • Do not react angrily or defensively
      • Avoid ultimatums
      • Avoid arguments
  • Promotion of healthy interactions
    • Manipulative behavior
      • Set clear, realistic expectations
      • Determine the goal behind the manipulation
      • Give positive reinforcement 
      • Avoid collusion with “splitting” behaviors
      • Use supervision and consultation with other staff
      • Review patient’s behavior with interdisciplinary staff to promote consistency
    • Dependent behavior
      • Strongly encourage self-care
      • Promote participation in activities that encourage accomplishment
      • Role model taking responsibility for decisions and actions
      • Give positive feedback
      • Point out behaviors that are undermining the patient’s care
    • Angry behaviors
      • Identify triggers to angry remarks and behaviors
      • Role model appropriate behavior
      • Set limits on excessive complaining or degrading remarks
      • Use written contract to reinforce appropriate behaviors
      • Problem solve alternative ways to manage anger
  • Patient and family education
    • Describe characteristics and consequences of maladaptive behavior
    • Describe behaviors characteristic of interpersonal anxiety and relate anxiety to maladaptive behaviors
    • Explain, demonstrate, and role play stress-reduction techniques
    • Identify adaptive responses to anxiety producing situations
  • Strategies for preventing or reducing violence to self or others
    • Address verbal and physical threats of harm
    • Provide a time and space for the patient to collect himself/herself and think about the behavior before discussing it
    • Set limits on dangerous and/or unacceptable behaviors
    • Point out behaviors that are undermining the patient’s care
  • Psychopharmacology
  • Psychotherapy

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