1. Personality Disorders (PD) West Coast University Psychiatric / Mental Health Nursing NURS 204

2. Personality The individual qualities, including habitual behavior patterns, that make a person unique 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 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

3. Definition of Personality Disorder Traits and habits that comprise the personality are inflexible (rigid) and damaging 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 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: 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 Cognition Affect Affect Interpersonal functioning Interpersonal functioning Impulse control Impulse control Social or occupational Social or occupational Relationship Relationship

4. PD: Common Characteristics Onset in adolescence or early adulthood. Onset in adolescence or early adulthood. Tendency to foster vicious cycles (crisis orientation) Tendency to foster vicious cycles (crisis orientation) Persists throughout the person’s life (chronicity) Persists throughout the person’s life (chronicity) Lack insight: not aware of their pathology Lack insight: not aware of their pathology Intense transference/counter-transference reaction Intense transference/counter-transference reaction Failure to accept the consequences of behavior Failure to accept the consequences of behavior Pattern of perceiving, thinking, and relating that impairs social or occupational functioning Pattern of perceiving, thinking, and relating that impairs social or occupational functioning

5. PD: Common Characteristics Manipulation Manipulation Narcissism Narcissism Impulsiveness Impulsiveness

6. Biologic Factors Alterations in hormone & platelet monoamine oxidase (MAO) levels Alterations in hormone & platelet monoamine oxidase (MAO) levels Neurotransmitter changes Neurotransmitter changes Electroencephalographic (EEG) changes Electroencephalographic (EEG) changes Structural brain changes Structural brain changes Diminished blood flow and inflammation Diminished blood flow and inflammation Chronic inflammation, as evidenced by the presence of elevated levels of C-reactive protein Chronic inflammation, as evidenced by the presence of elevated levels of C-reactive protein

7. Genetic Factors Familial tendencies Familial tendencies Cluster B correlated with mood disorders, alcoholism, & somatization Cluster B correlated with mood disorders, alcoholism, & somatization Genetic variation Genetic variation

8. Psychosocial Factors Parent–child interactions Parent–child interactions Intrapsychic theory Intrapsychic theory Enmeshment Enmeshment Abandonment Abandonment Identity diffusion Identity diffusion

9. Cluster A Personality Disorder Odd or Eccentric Odd or Eccentric Paranoid personality disorder Paranoid personality disorder Schizoid personality disorder Schizoid personality disorder Schizotypal personality disorder Schizotypal personality disorder

10. 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. 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 E.g. Richard Nixon Film: “The Caine Mutiny” (1953) Film: “The Caine Mutiny” (1953)

11. Paranoid PD Characteristics Suspiciousness and Mistrust Suspiciousness and Mistrust Rigidity Rigidity Hypervigilance Hypervigilance Distortions of reality Distortions of reality Restricted affect Restricted affect Exclusion Exclusion

12. Schema for Paranoid PD People will eventually try to hurt me People will eventually try to hurt me People can’t be trusted. They will always take advantage of me People can’t be trusted. They will always take advantage of me People will try to bother or annoy me People will try to bother or annoy me Don’t get mad, get even Don’t get mad, get even Any insult, no matter how slight, directed at me should be punished Any insult, no matter how slight, directed at me should be punished Always be prepared for the worst Always be prepared for the worst If I get close to people they can find out my weaknesses If I get close to people they can find out my weaknesses

13. Nursing Guidelines Avoid being to nice or friendly Avoid being to nice or friendly Give clear and straight forward explanations of tests and procedures beforehand Give clear and straight forward explanations of tests and procedures beforehand Use simple, clear language; avoid ambiguity Use simple, clear language; avoid ambiguity Respect personal space and client’s preference Respect personal space and client’s preference Provide client with a daily schedule of activities and inform client of changes or reasons for delays Provide client with a daily schedule of activities and inform client of changes or reasons for delays

14. 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: 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 Mr. Spock in the original Star Trek series

15. Schizoid PD Characteristics Detached Detached Aloof social style Aloof social style Experience transient psychotic episodes Experience transient psychotic episodes Experience anxiety, depression, and dysphoric affect Experience anxiety, depression, and dysphoric affect Isolative Isolative Deny interest in relationships Deny interest in relationships Humorless Humorless

16. Schema for Schizoid PD There are few reasons to be close to people There are few reasons to be close to people I am my own best friend I am my own best friend Stay calm Stay calm Displays of emotions are unnecessary and embarrassing Displays of emotions are unnecessary and embarrassing What others say is of little interest or importance to me What others say is of little interest or importance to me

17. Nursing Guidelines Avoid being too nice or friendly Avoid being too nice or friendly Do not try to increase socialization Do not try to increase socialization Perform thorough diagnostic assessment as needed to identify symptoms of disorders that the patient is reluctant to discuss Perform thorough diagnostic assessment as needed to identify symptoms of disorders that the patient is reluctant to discuss

18. 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: 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” “Kramer” on “Seinfeld” “Phoebe” on “Friends” “Phoebe” on “Friends” Film: “Psycho” (1960) Film: “Psycho” (1960)

19. Schizotypal PD Characteristics Ideas of reference Ideas of reference Odd beliefs or magical thinking (clairvoyance, telepathy, or “sixth sense”) Odd beliefs or magical thinking (clairvoyance, telepathy, or “sixth sense”) Vague, circumstantial, metaphorical, overelaborate, or stereotyped Vague, circumstantial, metaphorical, overelaborate, or stereotyped Suspiciousness or paranoid ideation Suspiciousness or paranoid ideation Odd appearance, eccentric or peculiar Odd appearance, eccentric or peculiar Lack close friends or confidants Lack close friends or confidants Social anxiety Social anxiety

20. Nursing Guidelines Respect patient’s need for social isolation Respect patient’s need for social isolation Be aware of patient’s suspiciousness and employ appropriate interventions Be aware of patient’s suspiciousness and employ appropriate interventions

21. Nursing Process Nursing Diagnosis Nursing Diagnosis Ineffective Coping Ineffective Coping Impaired social interaction Impaired social interaction Outcome identification Outcome identification Participate in activity groups Participate in activity groups Copes effectively with stressful situation Copes effectively with stressful situation Approaches staff and other clients without encouragement Approaches staff and other clients without encouragement Verbalizes thoughts and feelings that interfere with socialization Verbalizes thoughts and feelings that interfere with socialization

22. Cluster B Dramatic, emotional, or erratic Dramatic, emotional, or erratic Antisocial Antisocial Borderline Borderline Narcissistic Narcissistic Histrionic Histrionic

23. 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: A pervasive pattern of disregard for and violation of the rights of others occurring since age 15, as indicated by the following: Career Criminals Career Criminals Film: “The God Father” Film: “The God Father”

24. Antisocial PD Characteristics Failure to conform to social norms Failure to conform to social norms Deceitfulness Deceitfulness Impulsive Impulsive Irritability and aggressiveness Irritability and aggressiveness Reckless Reckless Irresponsible Irresponsible Lack of remorse Lack of remorse

25. Schema for Antisocial PD Rules are meant for others Rules are meant for others Only fools follow all of the rules Only fools follow all of the rules Rules are meant to be broken Rules are meant to be broken My pleasure comes first My pleasure comes first I will not allow myself to be frustrated I will not allow myself to be frustrated I will do whatever I must to get whatever I want I will do whatever I must to get whatever I want I am really smarter than most everybody else I am really smarter than most everybody else

26. Nursing Guidelines Be alert to manipulation such as flattery, seductiveness, instilling of guilt or verbal attacks Be alert to manipulation such as flattery, seductiveness, instilling of guilt or verbal attacks Set clear and realistic limits of specific behavior Set clear and realistic limits of specific behavior Ensure that all limits are adhered to by all staff involved Ensure that all limits are adhered to by all staff involved Do not seek approval or coax, provide clear boundaries and consequences Do not seek approval or coax, provide clear boundaries and consequences Do not argue, bargain, or rationalize Do not argue, bargain, or rationalize Confront inappropriate behaviors Confront inappropriate behaviors

27. 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: 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:

28. Borderline PD Frantic efforts to avoid real or imagined abandonment Frantic efforts to avoid real or imagined abandonment Unstable and intense interpersonal relationships Unstable and intense interpersonal relationships Identity disturbance Identity disturbance Impulsivity Impulsivity Recurrent suicidal behavior, gestures, or threats, or self mutilation Recurrent suicidal behavior, gestures, or threats, or self mutilation Chronic feeling of emptiness Chronic feeling of emptiness Intense anger or difficulty controlling anger Intense anger or difficulty controlling anger

29. Schema for Borderline PD I am not sure who I am I am not sure who I am I will eventually be abandoned I will eventually be abandoned My pain is so intense that I can’t bear it My pain is so intense that I can’t bear it My anger controls me. I can’t modulate my feelings My anger controls me. I can’t modulate my feelings When I am overwhelmed I must escape (by flight or suicide When I am overwhelmed I must escape (by flight or suicide

30. Nursing Guidelines Set realistic goals, use clear action words Set realistic goals, use clear action words Be aware of manipulative behaviors, such as flattery, seductiveness, instilling of guilt Be aware of manipulative behaviors, such as flattery, seductiveness, instilling of guilt Provide a clear and consistent boundaries and limits Provide a clear and consistent boundaries and limits Avoid rejecting or rescuing Avoid rejecting or rescuing Assess for suicidal and self-mutilating behaviors, especially during times of stress Assess for suicidal and self-mutilating behaviors, especially during times of stress Use a nonjudgmental attitude when client discusses suicidal/self-destructive thoughts Use a nonjudgmental attitude when client discusses suicidal/self-destructive thoughts Implement safety precautions Implement safety precautions

31. 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: 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” “Frazier Crane” on “Frazier” “Jerry Seinfeld” on “Seinfeld” “Jerry Seinfeld” on “Seinfeld”

32. Narcissistic PD Grandiose sense of self-importance Grandiose sense of self-importance Preoccupied with fantasies or unlimited success, power, brilliance, beauty, or ideal love Preoccupied with fantasies or unlimited success, power, brilliance, beauty, or ideal love Believes that he or she is special and important Believes that he or she is special and important Require excessive admiration Require excessive admiration Sense of entitlement Sense of entitlement Exploitative Exploitative Lack empathy Lack empathy Envious of others Envious of others Shows arrogant, haughty behavior or attitudes Shows arrogant, haughty behavior or attitudes

33. Schema for Narcissistic PD I must have my way in every interaction I must have my way in every interaction I am more special than anyone else I am more special than anyone else I should only have to relate to people like me I should only have to relate to people like me I must be admired I must be admired No one should have more of anything that I have No one should have more of anything that I have

34. 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. 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.

35. Histrionic Personality Disorder A pervasive pattern of excessive emotionality and attention seeking, beginning in early adulthood and present in a variety of contexts: 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 Judy Garland, Liza Minnelli, Robin Williams “Jack” and “Karen” on “Will” and “Grace” “Jack” and “Karen” on “Will” and “Grace”

36. Histrionic PD Uncomfortable in situations in which he or she is not the center of attention Uncomfortable in situations in which he or she is not the center of attention Interaction are characterized by inappropriate sexually seductive or provocative behavior Interaction are characterized by inappropriate sexually seductive or provocative behavior Rapid shifting and shallow expressions of emotions Rapid shifting and shallow expressions of emotions Use physical appearance to draw attention Use physical appearance to draw attention Shows dramatization, exaggerated expressions Shows dramatization, exaggerated expressions Easily influenced by others Easily influenced by others

37. Schema for Histrionic PD Appearances are important Appearances are important People are judged on external appearance People are judged on external appearance I must be noticed I must be noticed I must never be frustrated in life I must never be frustrated in life I must get everything I think that I want I must get everything I think that I want Beauty is the most important consideration in judging someone Beauty is the most important consideration in judging someone

38. Nursing Guidelines Understand seductive behavior as a response to distress 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 Keep communication and interactions professional, despite temptation to conspire with the patient in a flirtatious and misleading manner

39. Cluster C Anxious and fearful Anxious and fearful Dependent Dependent Obsessive-compulsive Obsessive-compulsive Avoidant Avoidant

40. 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 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

41. Dependent PD Difficulty making everyday decisions Difficulty making everyday decisions Needs others to assume responsibility Needs others to assume responsibility Difficulty expressing disagreement with others Difficulty expressing disagreement with others Difficulty initiating projects Difficulty initiating projects Goes to excessive lengths to obtain support from others Goes to excessive lengths to obtain support from others Feels helpless and uncomfortable when alone Feels helpless and uncomfortable when alone Unrealistically preoccupied with fears or being left to take care of him/herself Unrealistically preoccupied with fears or being left to take care of him/herself Urgently seeks another relationship as a source of care and support Urgently seeks another relationship as a source of care and support

42. Schema of Dependent PD I can’t function without the support of others I can’t function without the support of others Without the advice and reassurance of others I can’t exist Without the advice and reassurance of others I can’t exist In any situation, I am probably wrong In any situation, I am probably wrong Anger expression, people will abandon me Anger expression, people will abandon me If I am abandoned, I will be destroyed If I am abandoned, I will be destroyed I must keep people near me I must keep people near me If I am alone, I may be hurt If I am alone, I may be hurt

43. Nursing Guidelines Identify and help address current stressors Identify and help address current stressors Be aware that strong counter-transference often develops in clinicians because of client’s excessive clinging. Be aware that strong counter-transference often develops in clinicians because of client’s excessive clinging. Evaluate client’s ability for self-care. Evaluate client’s ability for self-care. Avoid doing things the client is capable of doing Avoid doing things the client is capable of doing Help client identify assets and liabilities Help client identify assets and liabilities Emphasize strengths and potential. Emphasize strengths and potential. Point out when client negates own feelings or opinions Point out when client negates own feelings or opinions

44. 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: 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” “Niles” on “Frasier” Martha Stewart Martha Stewart

45. Obsessive-Compulsive PD Preoccupied with details, rules, lists, order, organization, or schedules Preoccupied with details, rules, lists, order, organization, or schedules Shows perfectionism that interferes with task completion Shows perfectionism that interferes with task completion Excessively devoted to work and productivity Excessively devoted to work and productivity Overconscientious, scrupulous, inflexible Overconscientious, scrupulous, inflexible Unable to discard worn-out or worthless objects Unable to discard worn-out or worthless objects Reluctant to delegate tasks or work with others Reluctant to delegate tasks or work with others Adopts a miserly spending style Adopts a miserly spending style Rigid and stubborn Rigid and stubborn

46. Schema for OCPD There are strict rules in life There are strict rules in life By focusing on details of a situation, one will reduce the chances of making errors By focusing on details of a situation, one will reduce the chances of making errors A person is defined by what they do A person is defined by what they do The better the job you do the better person you are The better the job you do the better person you are Rules must be adhered to without alteration Rules must be adhered to without alteration Emotions must be controlled Emotions must be controlled

47. Nursing Guidelines Guard against engaging in power struggles with client. Need for control is very high in these clients 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 Intellectualization, rationalization, and reaction formation are the most common defense mechanisms

48. 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: 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:

49. Avoidant PD Avoids occupational activity Avoids occupational activity Unwilling to get involve with people Unwilling to get involve with people Avoids intimate relationship Avoids intimate relationship Afraid of being criticized or rejected in social situation Afraid of being criticized or rejected in social situation Views self as socially inept, personally unappealing, or inferior to others Views self as socially inept, personally unappealing, or inferior to others Reluctant to take personal risks or to engage in any new activities Reluctant to take personal risks or to engage in any new activities

50. Schema for Avoidant PD I must be liked I must be liked I must not look foolish to myself or others at any time I must not look foolish to myself or others at any time The world is a dangerous place The world is a dangerous place I must depend on others to take care of me I must depend on others to take care of me Isolation is preferable to being put at risk of being hurt Isolation is preferable to being put at risk of being hurt

51. Nursing Guidelines A friendly, gentle reassuring approach is the best way to treat clients A friendly, gentle reassuring approach is the best way to treat clients Being pushed into social situations can cause extreme and severe anxiety Being pushed into social situations can cause extreme and severe anxiety

52. Application of the Nursing Process Safety Safety Consistency Consistency Boundary setting Boundary setting Appropriate self-disclosure Appropriate self-disclosure

53. The Nurse’s Response Self-awareness Self-awareness Countertransference Countertransference Labels and stigma Labels and stigma Supervision Supervision

54. Resources http://www.bpdcentral.com http://www.bpdcentral.com 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 http://www.bpdresourcecenter.org 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 http://www.mentalhelp.net/poc/center_index.php?id=8 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.