PSYCHIATRIC NURSING Lecture Series PERSONALITY DISORDERS www arnelsalgado

PSYCHIATRIC NURSING (Lecture Series) PERSONALITY DISORDERS www. arnelsalgado. com www. ifeet. com. ph www. ifeet. org DR. ARNEL BANAGA SALGADO, Ed. D. , D. Sc. , RN, MA, B. Sc, Cert. Ed, MAT (Psychology) Doctor of Science (USA) Doctor of Education (Phl) Master of Arts in Nursing (Phl) Master of Arts in Teaching Psychology (PNU) Registered Nurse (Phl, Mal, UAE) Licensed/Registered Teacher (Phl) Certificate in Teaching, Bachelor of Science in Nursing www. arnelsalgado. com

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Learning Objectives Define and classify various personality disorders Describe the main features of various personality disorders Formulate the nursing diagnoses for behaviours that lead to hospitalization Discuss the basic interventions for a patient with personality disorder www. arnelsalgado. com

I. Overview / Theories A. Personality 1. Composed of enduring patterns or traits that determine how individuals perceive, relate to, and think about the environment and themselves 2. PERSONALITY TRAITS or patterns are reflected in how individuals cope with feelings and impulses, see themselves and others, respond to their surroundings, and find meaning in relationships. www. arnelsalgado. com

I. Overview / Theories B. Personality Disorders 1. PD are diagnosed when personality patterns or traits are inflexible, enduring, pervasive, maladaptive and cause significant functional impairment or subjective distress 2. Reflect patterns of inner experience and behavior that differ from cultural expectations 3. Client frequently experience their personality patterns as natural or comfortable (ego-syntonic) rather than uncomfortable (ego-dystonic) www. arnelsalgado. com

5. If personality patterns are experience as egosyntonic, clients rarely seek treatment as they tend to externalize the cause of any functional impairment or subjective distress 6. If personality patterns are experience as egodystonic, clients are more likely to seek treatment to ease their distress 7. Coded under Axis II disorders (PD or mental retardation and DSM-IV) www. arnelsalgado. com

8. Frequently Overlap: individuals may exhibit patterns or traits associated with more than one personality disorder 9. Develop before or during adolescence and persists throughout life; symptoms may become less obvious my middle or old age. www. arnelsalgado. com

10. Occur in 6 to 13 per cent of the general population 11. May coexist with clinical disorders coded as Axis I (Mood and thought disorders) using DSM IV 12. Are organized into 3 diagnostic clusters • Cluster A disorders: individuals with these disorders appear odd and eccentric • Cluster B disorders: individuals with these disorders appear dramatic and erratic • Cluster C disorders: individuals with these disorders appear anxious and fearful www. arnelsalgado. com

CHARACTERISTICS OF PD A. Behavioral Manifestations: include patterns of day-today behavior and impulse control B. Affective manifestations: include the range, intensity, lability, and appropriateness of emotional response C. Cognitive Manifestations: reflect how the self, others and events are interpreted D. Socio-cultural Manifestations: interpersonal functioning www. arnelsalgado. com

SPECIFIC DISORDERS Cluster A (Using DSM IVTR) (appear odd and eccentric) www. arnelsalgado. com

SPECIFIC DISORDERS 1. Paranoid Personality Disorder: patterns of distrust of suspiciousness such that others’ motives are interpreted as malevolent a. Behavioral Manifestations 1. Secretive 2. Hyper alert to danger 3. Argumentative to maintain a safe distance between themselves and others b. Affective manifestations 1. Avoid sharing feelings except for quick expressions of anger, bear grudges 2. Rarely forgive perceived slights 3. Fear losing power or control to others www. arnelsalgado. com

SPECIFIC DISORDERS c. Cognitive Manifestations 1. Pervasive distrust and suspicious 2. Expect to be used or harassed 3. Tendency to look for hidden, demeaning, or threatening meanings and to respond by criticizing others d. Sociocultural Manifestations 1. Interact in cold and aloof manner to avoid intimacy 2. Expect to be harmed or exploited by others and question the loyalty or trustworthiness of family or friends 3. Often pathologically jealous of a significant others www. arnelsalgado. com

SPECIFIC DISORDERS 2. Schizoid Personality Disorder: patterns of detachment from social relationship and a restricted range of emotions a. Behavioral Manifestations 1. Neither desire nor enjoy relationship with others 2. Have little interest in activities or sexual relationships b. Affective manifestations 1. Mood stable but restricted range of expression of emotions 2. May become anxious if forced into a close interaction 3. Affect is bland, blunted, or flat www. arnelsalgado. com

SPECIFIC DISORDERS c. Cognitive manifestations 1. Appear to have poverty of thought 2. Expressed thoughts are often vague 3. Indifferent to attitudes and feelings of others 4. Not influenced by praise or criticism d. Sociocultural Manifestations 1. Interact with others in a cold, aloof manner 2. Desire no close friends www. arnelsalgado. com

SPECIFIC DISORDERS 3. Schizotypal Personality Disorder: patterns of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior a. Behavioral Manifestations 1. Exhibit odd/eccentric behavior and speech that is coherent but often tangential, vague, or over elaborate 2. Maybe mild form of schizophrenia 3. May display transient psychotic symptoms b. Affective manifestations 1. Emotionally constricted 2. Affect maybe inappropriate www. arnelsalgado. com

SPECIFIC DISORDERS c. Cognitive manifestations 1. Paranoid ideation may be present 2. Ideas of reference may be present 3. Illusions may be present 4. Magical thinking may be present d. Sociocultural Manifestations 1. Are uncomfortable with intimacy and avoid relationship with others 2. Are usually avoided by others because of their pod/eccentric behavior www. arnelsalgado. com

SPECIFIC DISORDERS Cluster B (Using DSM IVTR) appear dramatic and erratic www. arnelsalgado. com

SPECIFIC DISORDERS 1. Antisocial Personality Disorder: patterns of disregard for and violation of the rights of others a. Behavioral Manifestations: childhood manifestations are lying, stealing, truancy, vandalism, fighting and running away from home; adults fail to conform to social norms such as functioning within the law; lie pathologically and “con” others for personal profit; consistent irresponsibility related to financial obligations and work behavior; impulsive and reckless in regard to own safety and that of others b. Affective manifestations: superficial expression of emotion; lack of guilt or remorse related to inappropriate behavior; irritable and aggressive www. arnelsalgado. com

SPECIFIC DISORDERS c. Cognitive Manifestations: egocentric and grandiose; perceive themselves as more clever than others d. Sociocultural Manifestations: consistently violate the rights of others as well as the values of society; unable to sustain personal relationships; maybe abusive www. arnelsalgado. com

SPECIFIC DISORDERS 2. Borderline Personality Disorder: pattern of instability in interpersonal relationships, self-image, and affect, and marked impulsivity 1. Behavioral Manifestations: a. Unpredictable b. Fear of real or imagined abandonment c. Engage in self-destructive behaviors such as reckless driving, substance abuse and bingeeating c. High risk for suicide and self-mutilation because of feeling of emptiness or rage d. Behavior may vary from one moment to the nest www. arnelsalgado. com

SPECIFIC DISORDERS 2. Affective Manifestations a. Mood are intense and unstable b. Difficulty ion moderating anger 3. Cognitive Manifestations a. Identity disturbance b. Splitting or dichotomous thinking present –tend to see self and others as all good or all bad c. Paranoid ideation or dissociation may be present 4. Socio cultural Manifestations: intense, unstable interpersonal relationships alternating between extremes of idealization and devaluation of others www. arnelsalgado. com

SPECIFIC DISORDERS 3. Histrionic Personality Disorder: pattern of excessive emotionality and attention seeking 1. Behavioral Manifestations a. Uncomfortable unless the center of attention b. Display seductive and other attention seeking behavior when interacting with others c. Conversation is superficial 2. Affective Manifestations a. Overly dramatic; Rapidly shifting b. Shallow expression of emotion 3. Cognitive Manifestations: guided by feelings rather than logic a. Assume role of victim or princess in relationships b. Consider relationships to be more intimate than they are www. arnelsalgado. com

SPECIFIC DISORDERS 3. Narcissistic Personality Disorder: pattern of grandiosity, need for admiration, and lack of empathy 1. Behavioral Manifestations a. Pre occupied with fantasies of power, success b. Extremely grandiose and exploit others to achieve personal goals c. Seek constant admiration d. Sense of entitlement 2. Affective Manifestations: labile moods varying from anger to anxiety www. arnelsalgado. com

SPECIFIC DISORDERS 3. Cognitive Manifestations a. Arrogant, egotistical, sees self as more important/special than others b. Lack empathy c. May think others are envious or maybe envious of others 4. Socio cultural Manifestations a. Disturbed relationships as a result of using others to meet own goals b. Own needs are perceived as more important than the needs of others www. arnelsalgado. com

SPECIFIC DISORDERS Cluster C (Using DSM IVTR) anxious and fearful www. arnelsalgado. com

SPECIFIC DISORDERS 1. Avoidant Personality Disorder: patterns social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation 1. Behavioral Manifestations: Avoid interpersonal contact and new situations related to fear of rejection and embarrassment; lack of self-confidence and are extremely sensitive to rejection 2. Affective manifestations: fearful; shy; hurt by criticism 3. Cognitive Manifestations: view self as inadequate, inferior; fearful of shame and ridicule 4. Sociocultural Manifestation: few close friends; desire relationship but reluctant to enter to it www. arnelsalgado. com

SPECIFIC DISORDERS 2. Dependent Personality Disorder: patterns of submissive and clinging behavior related to the need to be taken care of. 1. Behavioral Manifestations: Desire to help with everyday decision, and want others to take care of them; difficulty in disagreeing with others related to fear of rejection and abandonment 2. Affective manifestations: Anxious when left alone 3. Cognitive Manifestations: Lack of self-confidence; preoccupied of fear of being abandoned 4. Sociocultural Manifestation: Constantly strive to obtain support from others; uncomfortable unless involved in a supportive relationship www. arnelsalgado. com

SPECIFIC DISORDERS 3. Obsessive-Compulsive Personality Disorder: patterns of pre-occupation with orderliness, perfectionism and control 1. Behavioral Manifestations: a. High need for routine b. Decreased ability to focus on the major goal of activity as becomes overly involve in details c. Difficulty with task completion related to a need of perfection d. Inflexibility related to moral and ethical issues e. Unable to discard worthless objects f. Unable to delegate for fear that others will not perform tasks correctly www. arnelsalgado. com

SPECIFIC DISORDERS 2. Affective Manifestation: rigid, stubborn, and emotionally constricted 3. Cognitive Manifestations: Believe in a correct solution for every problem; procrastinate because fearful of making mistakes 4. Sociocultural Manifestation: impaired interpersonal relationships and absence of leisure activities due to the devotion to work and productivity www. arnelsalgado. com

SPECIFIC DISORDERS D. Concomitant Disorders: there is a correlation between certain personality disorders and some axis I disorders such as substance abuse, mood disorders, anxiety disorders and psychotic disorders www. arnelsalgado. com

II. ETIOLOGY A. Neurobiological theories 1. Limbic system dysregulation and CNS irritability may result in decrease impulse control 2. Decreased levels of serotonin (5 -HT) have been associated with a tendency to self-mutilate, experience intense rage, and behave aggressively toward others 3. Elevated levels of norepinepohrine have been associated with hypersensitivity to the environment 4. Abnormal levels of dopamine may explain the psychotic episodes associated with borderline and schizoid personality disorders 5. Physiological under arousal may contribute to the risk taking associated with some disorders 6. Schizotypal personality disorder maybe a milder form of schizophrenia 7. Genetic factor www. arnelsalgado. com

B. Intrapersonal Theories 1. Hostility toward the self may be projected onto others resulting in fear, mistrust, and defensive withdrawal to avoid being hurt 2. Individuals may try to live to perfectionist standards imposed on them by their parents or others during childhood 3. An underdeveloped superego may result in failure to both internalize authority and cultural morals and to experience guilt when violating rules 4. Inadequate parenting and unsatisfied needs 5. Anxiety manifest itself as personality disorder www. arnelsalgado. com

C. Social Theories 1. Social oppression may have a negative effect on the development of self-esteem and a healthy identity 2. A changing societal value system with personal needs being viewed as more important than group needs, maybe reflected in the behavior associated with cluster B disorders www. arnelsalgado. com

D. Family Theories 1. Inability to manage conflict 2. Growing up in multigenerational enmeshed family 3. A chaotic and abusive environment E. Feminist Theory The diagnosis of a personality disorder reflects the influence of rigid gender role stereotyping rather than of genetic factors www. arnelsalgado. com

III. ASSSESSMENT A. General Guidelines 1. Maintain sensitivity so that the client may not be defensive 2. Interview family members B. Specific Guidelines: assess client’s level of function in the areas of affect, cognition (including impulse control), and sociocultural adaptation (interpersonal relationships) www. arnelsalgado. com

IV. Nursing Dx/Analysis A. Cluster A Disorders (paranoid personality, schizoid personality, and Schizotypal) 1. Ineffective individual coping related to inability to trust 2. Fear related to perceived threats from others or the environment 3. Social isolation related to craving of solitude 4. Spiritual distress related to lack of connectedness to others B. Cluster B (antisocial, borderline, histrionic and narcissistic) 1. Impaired social interaction 2. High risk for violence self-directed 3. High risk for violence directed to others 4. Personal identity disturbance 5. Fear related to feeling of abandonment www. arnelsalgado. com

C. Cluster C (Avoidant , Dependent, OCD) 1. Ineffective individual coping related to high dependency needs, rigid behavior 2. Fear related to feelings of abandonment www. arnelsalgado. com

V. Planning and Implementation A. Basic Principles of Nursing Intervention 1. Recognize that clients have the right to change or not to change; if pattern of behavior are egocentonic, clients may lack motivation required to effect change. 2. Help clients to see how behavior affects their lives to motivate them to develop a more adaptive lifestyle. 3. Remember that personality traits are to ingrained to expect radical, long term behavioral change; interventions should be based on short term goals and focus on small steps designed to improve role functioning and decrease distress 4. Maintain hope for each client’s improvement; all clients have the potential for change 5. Identify your own emotional responses www. arnelsalgado. com

B. Specific Strategies: a cluster specific nursing interventions can be individualized for each client 1. Cluster A disorders (paranoid, schizoid, Schizotypal) • Approach people in gentle, interested, but non-intrusive manner • Respect client's needs for distance and privacy • Be mindful of own non verbal communication as a client may perceive others as threatening • Gradually encourage interaction with others, if appropriate 2. Cluster B disorders (antisocial, borderline, histrionic, narcissistic) • Be patient as client displays emotional and erratic behavior • Provide a consistent structured milieu to avoid manipulation and power struggles www. arnelsalgado. com

• • Safety is always the first priority of care Set limits as necessary to help clients maintain impulse control in order to protect themselves and other from injury Engage in frequent staff conferences to counteract client’s ability to play one staff member against the other Help clients recognize and discuss their fear of abandonment Help clients recognize the presence of dichotomous thinking or splitting, in which self and others are perceived as good or all bad. Encourage direct communication Encourage self-entitlement of needs www. arnelsalgado. com

3. Cluster C: (Avoidant, Dependent, OCD) • Point out avoidance behavior • Provide problem solving and assertiveness training • Encourage expression of feelings • Help recognize impairment • Discuss their sense of inadequacy • Discuss fear of rejection www. arnelsalgado. com

C: Psychopharmacology 1. Antipsychotic agents maybe prescribed on a short term basis to alleviate psychotic symptoms associated with Schizotypal or borderline personality disorder 2. Selective serotonin Reuptake Inhibitors (SSRI) to diminish mood swing, impulsive, aggressive and self-destructive behavior associated with borderline 3. SSRI may be prescribed to threat obsessive rumination associated with certain personality disorders D. Individual Group Therapy E. Behavioral Therapy • Impulse control Training • Limit setting • Behavioral Modification: social skills F. Psychological Comfort Promotion – anxiety Reduction www. arnelsalgado. com

VI. Evaluation/Outcomes A. BASED ON ASSESSMENT of behavioral, affective, cognitive and sociocultural manifestations, identify realistic, specific and measurable short term goals for nursing interventions. B. BE AWARE THAT REALISTIC GOALS must reflect steps to improve function and decreasing subjective distress; personality traits are too integrated to expect immediate, radical, long term change C. EVALUATE EFFECTIVENESS of the nursing interventions in related to states outcomes www. arnelsalgado. com

"Love cures two people, the person who gives it and the person who receives it“ - Karl Menninger www. arnelsalgado. com