Personality Disorder

Personality Disorders

Client suffers from lifelong, inflexible and dysfunctional patterns of relating and behaving

Patterns are excessive and interfere with daily life

Relationships Dysfunctional patterns and behaviors of the client

Cause distress to others Client does not recognize dysfunction and only

becomes distressed when others react to them negatively

Behavioral Characteristics

Personality Disorder is a way of relating to the world. An enduring pattern of acting and responding,

Narcissism- speak and act as if their own needs are paramount. Normal in Adolescents.

Annoying: Tend to “Get under your skin.” Problems in interpersonal situations.

Personality Disorder

Personality Disorders are difficult to treat Most are not in Psychiatric Hospitals May be admitted to an inpatient facility but must have an

Axis I diagnosis also (alcoholism, depression and anxiety) The most common personality disorder inpatient is

Borderline Personality Disorder Most are treated outpatient in individual or group therapy

May be in drug treatment center Axis II Diagnosis

Used to designate Personality disorders or traits Developmental Disorders Habitual use of Particular defense Mechanism

Affective/Cognitive Characteristics

Anxiety: Varies in the different clusters. Behavior is their way of coping with anxiety

and the individual does not consider how their behavior will effect others.

Cognitive issues: Rigidity of responses often causes

individual to not reach their potential. Inflexibility leads to mistakes in judgment

making them prone to job problems.

Socioculturally

Believe problems in their lives are other people’s fault or the rest of the world.

History of broken relationships, family and marital problems.

Alcoholism and drugs Age of onset; Adolescence, tend to

decrease in middle age. What is normal in adolescence is not later.

Grouped by the Three Clusters of Behavior in the DSM IV TR

Cluster A Exhibit odd and eccentric behaviors; includes

schizoid, schizotypal, and paranoid disorders. Cluster B

Exhibit dramatic emotional and erratic behaviors; includes Narcissistic, histrionic, antisocial, and borderline disorders.

Cluster C Exhibit anxious fearful behaviors; includes

dependant, avoidant and obsessive-compulsive disorders.

Gender and Personality Disorders

Female: greater percentage of Borderline or Histrionic

Male: Greater Percentage of Paranoid, Schizoid, Antisocial, and Narcissistic

This Presentation

1. Cluster A will be reviewed first

2. Cluster C will be reviewed second

3. Cluster B will be the most comprehensive review

Borderline Personality Disorder will be reviewed last in this presentation. This disorder is the most common Axis II disorder encountered by the Mental Health Nurse.

Cluster A

Characteristics: odd, eccentric behavior, suspicious ideations, and social isolation. Know this cluster as a group (do not have to recognize each individually) Paranoid Schizoid Schizotypal

Cluster A

Schizoid Lacks desire to be

close to others Lacks close friends Solitary activities Little interest in sexual

activity Avoids activities Appears cold and

detached Appears indifferent to

praise or criticism

Schizotypical Ideas of reference Magical thinking or odd

beliefs Unusual perceptual

experiences including bodily illusions

Odd thinking and speech

Suspicious; social anxiety

Few close relationships

Paranoid Behaviorally; often alcoholic, secretive,

argumentative and fearful of people. Hyper-alert to danger and rarely seek help.

Angry, Controlling, and judgmental. Cognitively; very guarded “none of your

Business.” Difficulty in intimate relationships. Cold

aloof manner, Often litigious. Holds grudges; lacks trust in others

Cluster C

Dependent Personality Disorder Pervasive, excessive need to be taken care of

Submissive and clinging Fears of separation Avoids responsibility Expresses helplessness

Interventions Nurse assists client to increase responsibility in

daily living Needs assistance with anxiety Teach assertiveness and verbalization of feelings

Cluster C

Avoidant Personality Disorder

Severe shyness and avoidant behavior

Socially uncomfortable and withdrawn

Nurse helps by assisting the client in setting small goals

Discusses fears and feelings prior to meeting a goal

Obsessive Compulsive Personality Disorder

Perfectionist and inflexible

Preoccupied with trivial details and procedures

Difficulty expressing warmth and kindness

Having fun is difficult Nurse helps by assisting

the client to explore feelings and try new activities

Teach that making mistakes is normal to decrease need for perfection

Cluster B Characteristics are; impulsive, dramatic

behavior, intolerance of frustration, and exploitative interpersonal relationships. (Know Antisocial Borderline and Narcissistic) Histrionic Narcissistic

Also occasionally seen in inpatient treatment) Antisocial Borderline

(most often Personality Disorder seen in inpatient treatment)

Cluster B

Histrionic Dramatizes and draws

attention to self Feels helpless and needs

reassurance Extroverted and thrives on

attention Lacks insight Temper tantrums, outbursts

of anger over minor events The nurse gives positive

reinforcement for acts that are focused on others

The nurse facilitates independence in problem solving and daily functioning

Narcisistic Grandiosity and exageration

about accomplishments Needs to be admired Indifferent to criticism A sense of entitlement

(should be rewarded despite the lack of effort or work)

Lack of empathy for others The nurse uses supportive

confrontation of discrepancies; limit setting and a consistent approach

Antisocial Personality Disorder

Pattern of disregard of the rights of others Poor boundaries

Does not have a good understanding of where they stop and the next person begins.

History of disordered life functioning Parent child relationship is unstable

Vacillates between permissiveness and severe punishment

Poor understanding of limits on there behavior because limits are very inconsistent

Genetic predisposition

Antisocial Predominant childhood characteristic of lying, stealing and

being truant. High correlation between this disorder and substance abuse. Conform to rules when it suits their purpose.

Express themselves easily, but with little personal involvement. Professes undying love one moment rejection the next.

Irritating , aggressive, low guilt. Often in the criminal justice system and NOT the Mental Health

system. Example of lack of guilt or remorse:

Client will state they needed to rob a store with a gun because of their low income and inability to support themselves.

The reason why the are in jail is because they were caught. It is the mistakes they made that led them to be caught that is the problem; NOT the crime.

Antisocial/ Cognitive & Socially Initially appear to be charming and intellectual

Smooth talker Deny and rationalize their behavior

Egocentric and grandiose Confident everything will work out Ego-syntonic; Cannot delay gratification and

make no long range plans Unable to sustain close relationship. Sex life is impersonal and impulsive. Quick anger, lack of guilt, abusive Hospitalized to avoid the law

Treatment of Anti-social Personality Disorder

Drug Treatment center, jails and prisons Essential for staff to agree on rules and

stick with them. Will try to play one staff or shift against

another. Best form of Treatment; Peer counseling

and self-help groups, like AA.

Borderline Personality Disorder

Borderline Personality Disorder DSM IV TR Criteria

Unstable, intense relationships characterized by over-idealizing and devaluation others Intense ambiguous feelings. This is when two feelings such as love and hate

are present at the same time Client with BPD cannot resolve feelings that others

are not perfect and cannot meet all of their needs Impulsiveness and self-destructive

Substance abuse Sexual promiscuity

These behaviors help them to feel better for a short period of time

DSM IV TR Criteria Cont.

Recurrent suicidal threats & gestures Self-Injurious Behavior (SIB)

Affective instability anxiety to depression

Inappropriate displays of anger

DSM IV TR Criteria Cont.

Marked persistent identity disturbance in two areas: career, friends, values

Chronic feelings of emptiness and boredom.

Frantic efforts to avoid abandonment Transient, stress related, psychotic

symptoms or sense dissociative.

Etiology of Borderline Personality Disorder

Masterson’s theory: Child tries to separate and mom withdraws love. Child clings and mom rewards. Child unsure of affection. Fathers may be distant, alcoholic or unavailable.

Neglect of the child Split occurs: Good me-Bad me Invalidating, chaotic environment No object constancy (consistency in care giving

of the child). Develops a low tolerance of ambivalence.

75% of clients with BPD are women and victims of childhood sexual abuse

Issues for Borderline Identity

Intimacy

No sense of who they are

Feel very empty See themselves as

all good or all bad Very needy fearful abandonment fear

Symptoms Self-mutilation

Clients discuss feelings of depersonalization To prove they are alive, they cut until they feel pain May also state that the physical pain alleviates the

emotional pain Anhedonia

Cannot enjoy life in conventional way Impulsiveness

Cannot soothe self; very intense emotions Try to teach coping skills.

Borderline Personality Disorder and Countertransference

Positive Countertransference Lack of a sense of identity and inability to meet

their own needs Look to others as being “all good” and seek to get

others to meet their needs Negative Countertransference

Other people will eventually fail in attempting to meet all the needs of an individual with BPD

Results in malice/rage Aversion: More serious problem Working with these problems is the responsibility of

an advanced practice Health Care Provider

Therapy

Clients have long-term issues of abuse and neglect

An advanced practice Health Care Provider can assist the client in talking about these events in individual or group therapy

The nurse stays in the “here and now” This is very therapeutic Can assist the client in identifying how their

behavior results in unwanted responses from others

Helps the client to identify coping strategies and understand the disorder through teaching

Group Therapy

Clients make good group members; can be very insightful for others

Decreases transference issues. Feedback from group can be helpful in dealing with unrealistic expectations.

Attention seeking behavior and entitlement issues are dealt with better in group.

AA, ACOA, groups are very useful.

Nursing Interventions

Safety Clients in the acute care setting are in crisis Keep environment free of contraband Assess for suicidal thoughts frequently Observe closely

Limit Setting Maintain clear boundaries

Therapeutic Relationship Acknowledge emotional pain Offer support and empower to understand and change dysfunctional behavior

Review: What happened? How did you react (behave)? How did that work for you? What can you do next time?

Prevent Splitting Be consistent Follow all rules of the unit Follow the client’s treatment plan

Prevent Triangulation Clients will try to get the nurse to engage in complaints about another staff (a third person) Refer the client back to the staff they have a problem with Offer to talk about the client

Treatment and Individual Therapy Working with the client to change behaviors can

be like a roller coaster for the health care provider. Client trusts is improving, then panics fearing

separation Experiences abandonment depression, clings to

others and then distances. Clinging: the therapist is all good Distancing: anger; the therapist is all bad

BPD: Ups and Downs

Example: Client appears better Ready for discharge Fears abandonment Makes suicide gesture

This is not personal (it is not the nurse’s responsibility; this behavior is generated by a fear of abandonment

Client believes they are getting worse and needs reassurance and reminder of progress…regression can be temporary

The nurse needs to be OBJECTIVE not emotional…

MATTER of FACT in the approach to the client

Interventions and Milieu

Contracts with specific goals and responsibilities are important.

Never discuss another staff member with these client

Goal is “reintegrate the split” Can remind client of the other side (all

people have both good and bad qualities)

Treatment and Milieu Hold Client responsible for actions while

maintaining positive expectations. Have consequences identified on plan and stay with them.

Remain CALM and MATTER-OF-FACT Realize this is client’s illness, behavior

are not personal. Role is with day to day activities. One

person process issues with client

National Education Alliance for Borderline Personality Disorder

New group that has begun Had a national conference in Houston,

Feb. 2006. Latest research on pathophysiology Uses an educational approach, family

support Believes trauma is important in the

development of BPD

The End