personality_disorders final

8/12/2019 Personality_Disorders Final

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Personality Disorders


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Personality

The totality of emotional and behavioral traits that

characterize the person in day-to-day living

under ordinary conditions.

Relatively stable and predictable. Personality Disorders:

is a group of mental disorder characterized by

deeply mal adaptive behavior ,generally life longin duration that cause significant functional

impairment or subjective distress.


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Definition

Personality disorder =Deeply ingrained,

inflexible, and maladaptive patterns of

relating to and perceiving both the

environment and themselves.

Influence cognition, affect, behavior and

interpersonal style, Cause subjective

distress or significant functionalimpairment.


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Personality Disorders

Symptoms are alloplastic ( try to change theenvironment in difficult situations )andegosyntonic. (try to fulfill own desires )

5-10% of the population. 60% of inpatient psychiatry patients.

12-100% of psychiatric outpatients

with mood disorders.

Having an understanding of personalitydisorders will improve the relationship, enhancecompliance, and reduce their stress


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DSM-IV General criteria for

personality disorder

Enduring pattern of inner experience and

behavior that deviates markedly from

cultural expectations. Manifested in two

or more of the following areas:

1) Cognition

2) Affectivity

3) Interpersonal functioning

4) Impulse control


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Causes

Genetic factors

Temperamental factors

Biological factors Psychodynamic factors: Internal factors:

developmental factors or fixation

Lack of Defense mechanisms.


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General criteria (cont.)

Pattern is inflexible and pervasive across a broad rangeof personal and social situations.

Pattern leads to clinically significant impairment ordistress

Pattern is stable and of long duration and onset can betraced to adolescence or early childhood

Pattern not better accounted for as a manifestation ofanother disorder

Not due to substance or GMC (e.g. head trauma) Person must meet the general criteria before a specific

PD is diagnosed

Coded on Axis II


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Other Features

Lack insight into PD (seek treatment forAxis I problem or relationship problems)

PD symptoms are ego syntonic = feels like

a normal part of oneself Most have interpersonal problems

Can be difficult to diagnose in initial

session. Intractable, difficult to treat; can affect

treatment of other disorders.


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Clusters (cont.)

2) Cluster B

Main feature is dramatic, emotional, or erratic

4 PDs in this cluster:

Antisocial PDdisregard for social norms andrights of others

Borderline PDinstability in relationships, self-image, and mood; impulsivity

Histrionic PDexcessive emotionality andattention seeking

Narcissistic PDgrandiosity, need for admiration,self-centered


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Clusters (cont.)

3) Cluster C

Main feature involves anxiety or fearfulness

3 PDs in this cluster:

Dependent PDsubmissive, need to be taken

care of.

Avoidant PDsocial inhibition and inadequacy

Obsessive-compulsive PDorderliness,perfectionism, need to control things


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Paranoid Personality

0.5-2.5% of the population.

Men > Women.

Higher incidence in relatives of schizophrenics.

Higher among minorities, immigrants, and the deaf.

Paranoid Personality Disorder-

Criteria Suspects, without sufficient basis that others are exploiting,

harming, or deceiving him or her.

Is preoccupied with unjustified doubts about the loyalty ortrustworthiness of friends or associates.

Is reluctant to confide in others because of unwarranted fear thatthe information will be used maliciously against him or her.

Reads hidden demeaning or threatening meanings into benignremarks or events.


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Has recurrent suspicions, without justification, regardingfidelity of spouse or sexual partner.

Persistently bears grudges, i.e., is unforgiving of insults,injuries, or slights.

Paranoid Personality interactions and management Acknowledge mistakes.

Be open and honest.

Have a professional and not overly warm style.

Dont confront. Set limits.

Clearly explain procedures, medications and results.


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Schizoid Personality

Disorder 7.5% of the population.

2-to-1 male-to-female ratio.

Criteria

Neither desires nor enjoys close relationships,including being part of a family.

Almost always chooses solitary activities.

Has little, if any, interest in having sexualexperiences with another person.

Takes pleasure in few, if any, activities. Lacks close friends or confidants other than first-

degree relatives.


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Cont

Appears indifferent to the praise and criticism of others.

Shows emotional coldness, detachment, or flattenedaffectivity.

Does not occur exclusively during the course of a

Psychotic Disorder, or a Pervasive Developmental Disorder and is not due to ageneral medical condition.

Nursing management

Understand their need for isolation.

Minimize new contacts and intrusions. Maintain a quiet, reassuring, and considerate interest in

them.

Dont insist on reciprocal responses.


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Schizotypal Personality

3% of the population.

Sex ratio is unknown.

Greater association among biological relatives ofschizophrenic patients.

The premorbid personality of the schizophrenic patient. Ideas of reference (excludingdelusions of reference).

Odd beliefs or magical thinking that influences behaviorand is inconsistent with subcultural norms(e.g.superstitiousness, belief in clairvoyance, telepathy,

or sixth sense). Unusual perceptual experiences, including bodily

illusions.


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Con..

Odd thinking and speech (e.g., vague,

circumstantial, metaphorical, or

stereotyped).

Suspiciousness or paranoid ideation.


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Schizotypal Personality

Disorder-Criteria

Inappropriate or constricted affect.

Behavior or appearance that is odd, eccentric orpeculiar.

Lack of close friends or confidants other than first-degree relatives.

Excessive social anxiety that does not diminish

with familiarity and tends to be associated with

Paranoid fears rather than negative judgments

about self. Does not occur exclusively during the course of a

Psychotic Disorder or a Pervasive Developmental


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Nursing Management

Similar to Schizoid PD.

Misperceptions of physical symptoms

and treatment. Do not ridicule or judge.

Respect their need for privacy


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Antisocial Personality Disorder

3% in men and 1% in women.

Most common in poor urban areas.

75% in prison populations.

Familial pattern present.

Antisocial Personality Disorder-Criteria

Failure to conform to social norms with respect to lawfulbehaviors as indicated by repeatedly performing actsthat are grounds for arrest.

Deceitfulness, as indicated by repeated lying, use ofaliases, or conning others for personal profit or

pleasure.


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Cont.

Impulsivity or failure to plan ahead.

Irritability and aggressiveness, as indicated by

repeated physical fights or assaults.

Reckless disregard for safety of self or others.

Consistent irresponsibility, as indicated by repeatedfailure to sustain consistent work behavior or honorfinancial obligations.

Lack of remorse, as indicated by being indifferent to orrationalizing having hurt, mistreated, or

stolen from another. o The individual is at least age 18 years, and there is

evidence of Conduct Disorder with onset before

age 15 years.


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Cont

ASPD diagnosis stems from Cleckleys

description ofpsychopathy:

1. Superficial charm

2. Absence of delusions and irrational thinking3. Absence of nervousness

4. Unreliability

5. Untruthfulness and insincerity

6. Lack of remorse or shame

7. Inadequately motivated antisocial behavior

8. Poor judgment and failure to learn by experience


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Psychopathy (cont.)

9. Pathological egocentricity and incapacity forlove

10.General poverty in major affective reactions

11.Specific loss of insight12.Unresponsiveness in general interpersonal

relations

13.Fantastic and uninviting behavior with drink

14.Suicide rarely carried out15.Sex life impersonal, trivial, and poorly

integrated

16.Failure to follow any life plan


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(cont.)

ASPD definition based on Cleckleys view

appeared in DSM-II

Psychopathy is now a separate construct with an

antisocial (ASPD-like) component Lee Robins work in mid-1960s formed basis of

current ASPD criteria

Found that most antisocial adults were antisocial in

childhood

Most antisocial children are not antisocial as adults


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(cont.)

ASPD vs. criminality

criminal is a legal term denoting conviction

for breaking a law:

Not all people with ASPD are criminals (or in jails)

Not all people in jail or considered criminal have

ASPD

Not all people with ASPD are psychopaths


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Nursing management and

interaction Set firm limits.

Try not to be manipulated.

Have high level of skepticism.

Be careful not to prescribe excessive and/orunnecessary medications

Most dont seek treatment for ASPD (usuallysubstance abuse)

No treatment shown to be efficacious

More likely to end up in jail than in treatment

Focus is on preventiontarget antisocialchildren

Borderline Personality


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Disorder

1-2% of the population.

Twice as common in women as in men.

Increased prevalence of Major Depressive

Disorder, Alcohol abuse/Dependence, andSubstance Abuse found in first-degreerelatives.

Borderline Personality Disorder-Criteria Frantic efforts to avoid real or imagined

abandonment.



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Disorder-Criteria

A pattern of unstable and intense interpersonalrelationships characterized by alternating betweenextremes of idealization and devaluation.

Identity disturbance: markedly and persistently

unstable self-image or sense of self. Impulsivity in at least two areas that are

potentially self-damaging (e.g., spending, sex,

substance abuse, reckless driving, binge eating).

Chronic feelings of emptiness. Borderline Personality


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Disorder-Criteria

Recurrent suicidal behavior, gestures, or threats,

Recurrent suicidal behavior, gestures, or threats,

or self-mutilating behavior.

Affective instability due to a marked reactivity of

mood (e.g., intense episodic dysphoria, irritability,Inappropriate, intense anger or difficulty

controlling anger (e.g., frequent displays of

temper, constant anger, recurrent physical fights).

o Transient, stress-related paranoid ideation or

severe dissociative symptoms


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Management

Be aware of and anticipate defenses.

Often regress.

Open and continuous communication with staff.

Stable and calm reaction.

Gently confront. Set fair and consistent limits on acting out.


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Histrionic Personality Disorder

2-3%.population

Diagnosed more frequently in women than in men.

Associated with Somatization Disorder and Alcohol

Abuse/Dependence.

Histrionic Personality Disorder-Criteria

Is uncomfortable in situations in which he

or she is not the center of attention.

Interaction with others is often characterized byinappropriate sexually

seductive or provocative behavior.


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Histrionic Personality Disorder

Displays rapidly shifting and shallow expression ofemotions.

Consistently uses physical appearance to draw attentionto self.

Has a style of speech that is excessively impressionisticand lacking in detail.

Shows self-dramatization, theatricality, and exaggeratedexpression.

Is suggestible, i.e., easily influenced by others orcircumstances.

Considers relationships to be more intimate that theyactually are.


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Management

Similar to Borderline PD.

Medical illnesses threaten their sense

of attractiveness and self-image.

Narcissistic Personality

Disorder

2-16% in the clinical population.

1% in the general population.

Number of cases increasing steadily.


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Cont

Requires excessive admiration. Has a sense of entitlement, i.e. unreasonable

expectations of especially favorable treatment or

automatic compliance with his or herexpectations.

Is interpersonally exploitative, i.e., takes

advantage of others to achieve his or her ownends.

Lacks empathy: is unwilling to recognize or

identify with the feelings and needs of others.


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Cont

Shows arrogant, haughty behavior or attitudes.

Narcissistic Personality Disorder management

Handle criticism poorly.

Become easily enraged.

Medical illnesses can be a blow to their self-

steem.

Reinforce that they are respected andappreciated.

Set limits on demanding behavior


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Avoidant Personality

Disorder 1-10% of the population. No information on sex ratio or familial pattern.

Infants with a timid temperament may be more likely todevelop Avoids occupational activities that involvesignificant interpersonal contact, because of fears ofcriticism, disapproval, or rejection.

Is unwilling to get involved with people unless certain ofbeing liked.

Shows restraint within intimate relationships because ofthe fear of being shamed or ridiculed.

Is preoccupied with being criticized or rejected in socialsituations.

Is inhibited in new interpersonal situations because offeelings of inadequacy


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Nursing Management and

interaction

Have patience and understanding. Medical illnesses may be embarrassing.

Minimize new and unfamiliar staff contacts.

Respond with a calm and reassuring demeanor.

Do not criticize them.

Dependent Personality Disorder

Epidemiology is unknown.

More common in women than men. Children with chronic physical illnesses may be

more prone.


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Cont

Has difficulty making everyday decisions without anexcessive amount of advice and reassurance fromothers.

Needs others to assume responsibility for most major

areas of his or her life. Has difficulty expressing disagreement with others

because of fear of loss of support or approval.

Has difficulty initiating projects or doing things on his orher own

lack of self confidence in judgment or abilities

lack of motivation or energy).


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Dependent Personality

Disorder-Criteria

Goes to excessive lengths to obtain nurturance andsupport from others, to the point of volunteering to do

things that are unpleasant.

Feels uncomfortable or helpless when alone

because of exaggerated fears of being unable to

care for himself or herself.

Urgently seeks another relationship as a source of care

and support when a close relationship ends . Isunrealistically preoccupied with fears of being left to take

care of himself or herself.


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Management

Respect their feelings of attachment.

Be careful when encouraging a patient to change thedynamics of an abusive relationship.

When medically ill they may become frustrated that they

are not being helped. Be active in the treatment planning.

Obsessive-Compulsive Personality Disorder

Epidemiology unknown.

More common in men than in women. Diagnosed more in oldest children.

Often a history of harsh discipline as a child.


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Is preoccupied with details,rules,,order ,organization, orschedules to the extent that the major point of the activityis lost.

Shows perfectionism that interferes with task

completion (e.g., is unable to complete a projectbecause his or her own overtly strict standards

are not met).

Is excessively devoted to work and also during off time

over conscious, scrupulous (very care full), and inflexibleabout matters of morality, ethics, or values.

Is unable to discard worthless objects even when theyhave no sentimental value.


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Is reluctant to delegate tasks or to work with others

Adopts a miserly spending style toward both self andothers; money is viewed as something to be hoarded forfuture catastrophes.

Shows rigidity and stubborness.Management and interaction

Give precise and rational explanations.

Value efficiency and punctuality.

Medical illnesses create a disruption in the patientswork, orderly lifestyle, and sense of control.


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Management

may have harmful consequences.

Allow the patient to control his or her care asmuch as possible.

Provide them with information. Avoid power struggles.

Understand their need for order and control.

Acknowledge the importance of work, but point

out how avoiding treatment

N i t f lit


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Nursing management of personality

disorder Nursing process:1 assessment:a) Assess client for according criteria of personality disorder

b) Assess Acknowledge the importance of work, but point out howavoiding treatment

2.Nursing diagnosis:focus on Acknowledge the importance of

work, but point out how avoiding treatmenta) Disturbed thought process related to auditory hallucination

b) Hopelessness related to low self esteem

c) Ineffective coping related to lack of control impulses .

d) Risk for others directed violence related to low frustration .

3.Planning:a) Client will verbalize increase insight in to his /her behavior.b) Client will demonstrate decreased manipulative behavior .

c) Client will demonstrate alternative ways to deal with frustration .

4 Implementation :


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4.Implementation :

a) provide an supporting environment

b) Nurse should understand the client needs .

c) Nurse should examine his/her own feeling

d) Reinforce the reality of the environment

e) Verbalize feelings of illusion or hopelessness

f) Helps thee client to select some one for trust to decrease suspiciousnessand illusion .

g) encourage verbalization of feelings of anger ,hostility or worthlessnessh) State limits and behavior of client .

i) Explore reasons for lack of interpersonal relationships .

j) Give medication :psychotropic drugs for specific clinical symptoms.

k) Provide interactive therapies : combination of psychotherapy andmedication . Helps according age and development level and task.

l) Cognitive behavior therapy.

m) Enhance family and friends relationship in border line personalitydisorder .

n) Provide supportive therapy .


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Evaluation

Evaluation of plananed goals is difficult due to

complexity of symptoms and client resist to treatment .

It will take several years to accomplish stated goals . But

nurse should continue the treatment and care .

Personality Disorder Not Specified:

Passive-Aggressive Personality Disorder.

Depressive Personality Disorder.

Specific traits or behaviors (sadism or masochism). Patient with features of more than one Personality

Disorder


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Summary

PDs are enduring, maladaptive patterns of

relating to the world and to others

General criteria for PD, then specific PD

DSM-IV arranges PDs in 3 clusters

according to shared characteristics

Lack of insightusually do not seek

treatment for the PD; PD can impact

treatment of other disorders

personality_disorders final

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