1. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 1 Chapter 10 Personality Disorders

2. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 2 Concept of Personality and Personality Disorders Personality is the “style” of how one deals with the world Personality traits –Stylistic peculiarities of how one deals with world Personality disorders –Diagnosed under Axis II in DSM-IV-TR

3. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 3 General Characteristics of Personality Disorders Inflexible, maladaptive responses to stress Disability in working and loving Avoidance and fear of rejection Blurred boundaries between self and other Insensitivity to needs of others Demanding and fault finding Lack of accountability Evoke intense interpersonal conflict

4. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 4 Personality Disorders: General Information Prevalence –Studies indicate 14.8% of a national sample population surveyed met criteria for at least one personality disorder Excluded from this study: borderline, schizotypal, and narcissistic personality disorders

5. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 5 Personality Disorders: General Information Comorbidity –Often more than one personality disorder diagnosed –Axis I disorders common: substance abuse, somatization, eating disorders, PTSD, depression, and anxiety disorders

6. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 6 Biological Theories of Personality Disorders No single cause identified Genetics –Seem to play role in schizotypal, schizoid, and paranoid personality disorders Neurobiological factors –Brain imaging suggests borderline personality disorder related to abnormality in prefrontal, corticostriatal and limbic systems

7. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 7 Other Theories Related to Personality Disorders Psychological –Childhood abuse and trauma associated with all disorders Borderline: sexual abuse common Cultural considerations –Native Americans, African Americans at increased risk –Other risk factors Young adult with low socioeconomic status, divorced, separated, widowed, or never married

8. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 8 Understanding DSM-IV-TR Clusters of Personality Disorders Cluster A: odd or eccentric behaviors –Related to schizophrenia Cluster B: dramatic, emotional, or erratic behaviors –Manipulation is common defense mechanism –Tendency to blame others for one’s problems Cluster C: anxious or fearful behaviors –Related to Axis I anxiety disorders –Internalize blame for problems in life

9. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 9 Cluster A: Paranoid Personality Disorder Believe others are lying, cheating, or exploiting them Perceive hidden malicious meaning in benign comments Inability to work collaboratively with others Emotionally detached Hostile to others

10. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 10 Cluster A: Schizoid Personality Disorder Neither desires nor enjoys human relationships Fixated on personal thought/fantasies Demonstrates emotional coldness, detachment, and flat affect Indifferent to praise or criticism Chooses solitary activities

11. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 11 Cluster A: Schizotypal Personality Disorder Behavior or appearance is odd, eccentric, or peculiar –Odd, elaborate style of dressing, speaking, interacting Magical thinking manifested Unusual perceptual experiences Lacks close friends Excessive and unrelieved social anxiety

12. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 12 Cluster B: Antisocial Personality Disorder Chronic irresponsibility and unreliability Lack of regard for law and rights of others Persistent lying and stealing for personal gain Conning others for personal gain Lack of remorse for hurting others Reckless disregard for others’ safety

13. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 13 Cluster B: Borderline Personality Disorder (BPD) Difficulty controlling emotions Stormy relationships with anger and fighting Persistent unstable self-image Use of splitting (idealizing and devaluing same person)

14. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 14 Cluster B: Borderline Personality Disorder (BPD) Frantic efforts to avoid real/perceived abandonment Dramatic mood shifts, changes in opinions and plans Impulsive, self-damaging behaviors –Recurrent suicide attempts or self-mutilation

15. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 15 Cluster B: Histrionic Personality Disorder Attention grabbing, self-dramatizing expression of emotions Sexually provocative clothing/behaviors Excessive concern with appearance Extreme sensitivity to others approval False sense of intimacy with others Constant sudden emotional shifts Impressionistic speech lacking detail

16. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 16 Cluster B: Narcissistic Personality Disorder Inflated sense of self-importance Constant attention-grabbing behavior Manipulation of others No regard for feelings of others Arrogant manner toward others Unreasonable expectation for special treatment Often envious of others with belief that others are envious of him/her

17. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 17 Cluster C: Avoidant Personality Disorder Hypersensitive to criticism/rejection Self-imposed social isolation Preoccupied with being criticized/rejected Strongly wants relationship but shies away Avoids occupation involving interpersonal contact Views self as socially inept, inferior

18. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 18 Cluster C: Obsessive-Compulsive Personality Disorder Preoccupied with details, rules, lists Perfectionist Unable to share responsibility with others Devoted to work, exclusion of pleasurable activities Financial stinginess Inability to discard useless objects Discomfort with emotions and relationships person can’t control

19. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 19 Cluster C: Dependent Personality Disorder Difficulty with decision making Others assume responsibility for person’s life Fear of disagreeing with others Preoccupied with fear of being left alone

20. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 20 Nursing Process: Assessment Guidelines Self-assessment essential –Dealing with people with personality disorder is often difficult, challenging, frustrating Take full medical history, check for past abuse issues, substance use Determine suicidal/homicidal thoughts Relate personality functions to individual’s ethnic/cultural background Determine recent important loss

21. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 21 Nursing Process: Diagnosis and Outcomes Identification Common nursing diagnosis assigned –Ineffective coping –Risk for other-directed violence –Risk for suicide –Risk for self-mutilation Outcomes Identification –Recognize that change may be slow, occur with trial and error –Establish modest, obtainable goals

22. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 22 Nursing Process: Planning and Implementation Planning –People with personality disorder seen in health care setting for other reasons Implementation –Nurse needs to understand difficulty with creating therapeutic relationship with patient Give choices Orient patient to reality Teach behaviors that build on existing skills

23. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 23 Interventions for Patient with Personality Disorder Combine limit-setting, trustworthiness, and dealing with manipulation with own natural self (therapeutic use of self) Use established interventions for: –Manipulative behaviors –Impulsive behaviors –Aggressive behaviors

24. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 24 Nursing Intervention: Milieu Therapy Primary goal –Affect management in a group setting Therapeutic tools –Community meetings, problem-solving groups, coping skills groups, and socializing groups

25. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 25 Treatment for Personality Disorders: Psychotherapy Psychodynamic psychotherapy –Works toward insight development Cognitive-behavioral therapy –Helps patient recognize faulty thinking and influence on problematic behaviors Dialectical behavior therapy (DBT) –Developed by Marsha Linehan (1993) for patients with borderline personality disorder –Focus on stabilizing patient and achieving behavioral control

26. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 26 Treatment for Personality Disorders: Medications Benzodiazepines (BZAs) not appropriate because of dependency issues Use medications with low toxicity –Antidepressants (SSRIs) –Lithium carbonate –Anticonvulsants –Low-dose antipsychotics

27. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 27 Nursing Process: Evaluation May be difficult because patient may not remain in treatment long enough to see results Specific, short-term outcomes may be accomplished