Personality Disorders (PD) West Coast University Psychiatric / Mental Health Nursing NURS 204 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 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 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 PD: Common Characteristics Onset in adolescence or early adulthood. Tendency to foster vicious cycles (crisis orientation) 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 PD: Common Characteristics Manipulation Narcissism Impulsiveness Biologic Factors Alterations in hormone & platelet monoamine oxidase (MAO) levels Neurotransmitter changes Electroencephalographic (EEG) changes Structural brain changes Diminished blood flow and inflammation Chronic inflammation, as evidenced by the presence of elevated levels of C-reactive protein Genetic Factors Familial tendencies Cluster B correlated with mood disorders, alcoholism, & somatization Genetic variation Psychosocial Factors Parent–child interactions Intrapsychic theory Enmeshment Abandonment Identity diffusion Cluster A Personality Disorder Odd or Eccentric Paranoid personality disorder Schizoid personality disorder Schizotypal personality disorder 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. E.g. Richard Nixon Film: “The Caine Mutiny” (1953) Paranoid PD Characteristics Suspiciousness and Mistrust Rigidity Hypervigilance Distortions of reality Restricted affect Exclusion 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 Nursing Guidelines Avoid being to nice or friendly Give clear and straight forward explanations of tests and procedures beforehand Use simple, clear language; avoid ambiguity Respect personal space and client’s preference Provide client with a daily schedule of activities and inform client of changes or reasons for delays 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: Mr. Spock in the original Star Trek series Schizoid PD Characteristics Detached Aloof social style Experience transient psychotic episodes Experience anxiety, depression, and dysphoric affect Isolative Deny interest in relationships Humorless Schema for Schizoid PD There are few reasons to be close to people I am my own best friend Stay calm Displays of emotions are unnecessary and embarrassing What others say is of little interest or importance to me 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 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: “Kramer” on “Seinfeld” “Phoebe” on “Friends” Film: “Psycho” (1960) 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 Social anxiety Nursing Guidelines Respect patient’s need for social isolation Be aware of patient’s suspiciousness and employ appropriate interventions Nursing Process Nursing Diagnosis Ineffective Coping Impaired social interaction Outcome identification Participate in activity groups Copes effectively with stressful situation Approaches staff and other clients without encouragement Verbalizes thoughts and feelings that interfere with socialization Cluster B Dramatic, emotional, or erratic Antisocial Borderline Narcissistic Histrionic Antisocial Personality Disorder A pervasive pattern of disregard for and violation of the rights of others occurring since age 15, as indicated by the following: Career Criminals Film: “The God Father” Antisocial PD Characteristics Failure to conform to social norms Deceitfulness Impulsive Irritability and aggressiveness Reckless Irresponsible Lack of remorse Schema for Antisocial PD Rules are meant for others Only fools follow all of 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 whatever I want I am really smarter than most everybody else 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 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: 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 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 (by flight or suicide 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 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: “Frazier Crane” on “Frazier” “Jerry Seinfeld” on “Seinfeld” 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 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 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. Histrionic Personality Disorder A pervasive pattern of excessive emotionality and attention seeking, beginning in early adulthood and present in a variety of contexts: Judy Garland, Liza Minnelli, Robin Williams “Jack” and “Karen” on “Will” and “Grace” 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 Schema for Histrionic PD Appearances 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 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 Cluster C Anxious and fearful Dependent Obsessive-compulsive Avoidant Dependent A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fear of separation, beginning by early adulthood and present in a variety of context 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 Unrealistically preoccupied with fears or being left to take care of him/herself Urgently seeks another relationship as a source of care and support 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 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 Obsessive-compulsive 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: “Niles” on “Frasier” Martha Stewart 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 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 Nursing Guidelines Guard against engaging in power struggles with client. Need for control is very high in these clients Intellectualization, rationalization, and reaction formation are the most common defense mechanisms 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: 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 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 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 Application of the Nursing Process Safety Consistency Boundary setting Appropriate self-disclosure The Nurse’s Response Self-awareness Countertransference Labels and stigma Supervision Resources http://www.bpdcentral.com Borderline Personality Disorder Central is an organization with information and resources for people who care about someone who may have borderline personality disorder (BPD). http://www.bpdresourcecenter.org The Borderline Personality Disorder Resource Center (BPDRC) at New York–Presbyterian Hospital has been set up to help those impacted by the disorder find the most current, accurate information on the nature of BPD and on sources of treatment. http://www.mentalhelp.net/poc/center_index.php?id=8 This Mental Help Net link contains information about personality disorders: types, treatment, research, literature, and resources.