PSYCHIATRIC NURSING PERSONALITY DISORDERS

1. PSYCHIATRIC NURSINGPERSONALITY DISORDERS Sources: Psychiatric Mental Health Nursing, Fortinash & Holoday-Worret, Mosby-Year Book Inc., 1996; Mental Health Nursing, 4th ed., Fontaine & Fletcher, Addison Wesley Longman Inc., 1999 Instructor: Doris O. Aghazarian

2. PERSONALITY DISORDERSIntroduction • Clients with personality disorders are among the most difficult to treat. • Most will never enter a psychiatric hospital, seek or receive outpatient treatment, or even undergo a diagnostic evaluation. • Some will enter the mental health system through family pressure or because of a court order.

3. PERSONALITY DISORDERSIntroduction (cont´d) • In the majority of cases, people with personality disorders perceive their problems and difficulties in dealing with other people to be external to them. • They feel victimized and blame others. • Those who develop an awareness of their self-defeating behaviour still remain at a loss as to how they got that way or how to begin to change.

4. PERSONALITY DISORDERSIntroduction (cont´d) • There is a high degree of overlap among the personality disorders and many individuals exhibit traits of several disorders. • Typically, personality disorders become apparent before or during adolescence and persist throughout life. • In some cases, the symptoms become less obvious by middle or old age.

5. PERSONALITY DISORDERSIntroduction (cont´d) • It is extremely difficult to estimate the incidence of personality disorders. • Currently the most commonly diagnosed is borderline personality disorder. • This group accounts for 50% of the diagnoses and all the other disorders together make up the remaining 50%

6. PERSONALITY DISORDERSTYPES • There are ten personality disorders, grouped into THREE CLUSTERS. • The disorders within each cluster are considered to have similar characteristics.

7. PERSONALITY DISORDERSClusters • The clusters and corresponding disorders are: CLUSTER A • Paranoid • Schizoid • Schizotypal CLUSTER B • Antisocial • Borderline • Histrionic • Narcissistic CLUSTER C • Avoidant • Dependent • Obsessive-compulsive

8. PERSONALITY DISORDERSClusters (cont´d) General description CLUSTER A: appear eccentric, exhibit much withdrawal behaviour CLUSTER B: appear dramatic, emotional or erratic. Tend to be very exploitative in their behaviour CLUSTER C: appear anxious or fearful. Behaviour pattern one of compliance.

9. PERSONALITY DISORDERSSpecial note • The three unstable disorders of category B: borderline, histrionic and narcissistic personality disorders, can barely be distinguished from one another. • More so than with other disorders, the diagnosis may be influenced by personal bias, gender stereotypes and cultural prejudices on the part of the professional • Antisocial personality is easier to diagnose

10. PERSONALITY DISORDERSCluster A: Paranoid Personality D. • Very secretive-not likely to trust anyone or confide in anyone • Hyperalert to danger • Argumentative-keep distance that way • Rarely seek help • Severe jealousy • Seldom require hospitalization

11. PERSONALITY DISORDERSCluster A: Schizoid Personality D. • Prefer solitary activities – social situations increase their anxiety • Can perform in a job that does not require interaction with others (e.g. night watch) • Their affect is blunted or flat – do not express feelings verbally or nonverbally. Passive.

12. PERSONALITY DISORDERSCluster A: Schizotypal P.D. • Have a considerable disability • Have the most severe distortions of any of the personality disorders: inappropriate affect, odd beliefs, magical thinking, illusions (such as seeing people in the shadows). Preoccupation with paranormal phenomena and magical control. • Peculiarities of ideation, appearance and behaviour restrict their lives • Very isolative and usually avoided by others • Related to schizophrenia but not as severe – appears among biological relatives of people suffering from schizophrenia for some reason

13. PERSONALITY DISORDERSCluster B: Antisocial Personality D. • A diagnosis of antisocial personality disorder (ASPD) requires that the characteristic appear before the age of 15, and the client is usually given the diagnosis of conduct disorder • The diagnosis ASPD is not applied until after the age of 18 • Behaviour includes lying, stealing, truancy, vandalism, fighting, running away from home • In adulthood, obligations and rules pose a problem. Hard to keep a steady job or relationship or to honour commitments. • Grandiose ideation, irritability, aggression, no guilt, low tolerance for frustration. • Hard to learn from own mistakes

14. PERSONALITY DISORDERSCluster B: Borderline Personality D. • People with BPD are characterized by identity disturbances. Their vision of themselves and body image keeps changing • Often practice self-mutilation • They are unable to see both good and bad at the same time • Great overlap with other personality disorders • Psychotic episodes are common for some and result in repeated hospitalizations • Appears early in boys and later in girls but two thirds of diagnosed people are female. The explanation for this may be society´s expectations of girls and women

15. PERSONALITY DISORDERSCluster B: Histrionic Personality D. • People with HPD characteristically seek stimulation and excitement in life – they are on a rollercoaster of joy and despair • Very self-centered and exaggerate their experiences. Verbose, dramatic, emotional; although arrogant, submissive to authority figures. • Flights of romantic fantasy and a lot of acting out • Seek attention through seduction • Exaggerated attentiveness to own physical appearance • Suicidal gestures and threat to get attention

16. PERSONALITY DISORDERSCluster B: Narcissistic P. D. • People with NPD strive for power and success. Their perfectionistic standards make failure intolerable. • Preoccupied with fantasies of success brilliance and ideal love • Arrogant and egotistical. Exploit others. Emotionally shallow. • Exaggerate their accomplishments. Expect special treatment, whether or not they achieve anything.

17. PERSONALITY DISORDERSCluster C: Avoidant P. D. • Social discomfort and avoiding all contact • Fearful and shy. Easily hurt by criticism • Often depressed and anxious • Overly sensitive to opinions of others – low self-esteem

18. PERSONALITY DISORDERSCluster C: Dependent P. D. • Dependent and submissive • Do not do things alone and always agree with others • Volunteer to do unpleasant and demeaning things • Severe lack of self- confidence • Avoid all decisions

19. PERSONALITY DISORDERSCluster C: Obsessive-compulsive P.D. • People with OCPD exhibit perfectionism and inflexibility • They need to check and recheck objects and situations. Rule-conscious behaviour • Industrious workers, but uncreative • Very polite and emotionally distant • Very protective of their status and possessions – difficulty sharing anything • Unable to express emotions • Preoccupation with logic and intellect • Torment themselves with guilt and negative thoughts • Has many differences with OCD, especially passion for productivity and excessive devotion to work. • OCD is ego-dystonic while OCPD is ego-syntonic.

20. PERSONALITY DISORDERSNot otherwise specified (NOS) • The label personality disorder not otherwise specified is used when a person does not meet the full criteria for any one personality disorder, yet there is significant impairment in social or occupational functioning or in subjective distress.

21. PERSONALITY DISORDERSConcomitant disorders • There is a high correlation between substance abuse and antisocial personality disorder. • It is difficult to separate between these disorders. • Substance abusers are divided into two groups: primary antisocial addicts (antisocial behaviour independent of the need to obtain drugs) and secondary antisocial addicts (antisocial behaviour directly related to drug use)

22. PERSONALITY DISORDERSConcomitant disorders (cont´d) • Psychotic disorders occur with schizotypal, borderline and dependent personality disorders • Mood disorders occur more often with avoidant and borderline personality disorders • Anxiety disorders occur with avoidant, dependent and borderline personalities • Suicides occur when there are episodes of depression, substance abuse or both

23. PERSONALITY DISORDERSPrognosis and Onset • Guarded. • By definition, individuals with personality disorders have demonstrated pervasive and inflexible behaviours and thoughts that are characterized by long-standing, maladaptive patterns of relating to others, which deviate markedly from the expectations of the individual´s culture. • Onset is before adolescence, in adolescence or in early adulthood.

24. PERSONALITY DISORDERSNursing intervention • The nurse can play a very important role by helping in self-exploration and substitution of dysfunctional patterns with functional ones through cognitive and long-term treatment aimed at educating the client, particularly in the area of problem-solving.

25. PERSONALITY DISORDERSFocused nursing assessment • Always make sure to conduct assessment of the following areas in all mental health conditions: • BEHAVIOUR • AFFECT • COGNITIVE PATTERNS • SOCIAL SKILLS • SPIRITUAL COMFORT OR DISTRESS

26. PERSONALITY DISORDERSDischarge criteria • Individuals with personality disorders who are hospitalized often have more than one psychiatric diagnosis. • Clients with personality disorders are routinely treated in outpatient hospital units, clinics and private practices. • Discharge from hospital is based on the evaluation of suicide risk, the securing of follow-up and the understanding of the need for taking prescribed medication as well as an improved understanding of own condition.

27. PERSONALITY DISORDERSTherapies • Occupational • Art • Music • Movement • Recreational • Medication • Individual • Group • Family • Milieu

28. PERSONALITY DISORDERSTherapy goals • Impulse control training: assisting the patient to gain control of impulses through reflection • Limit setting: establishing the parameters of desirable and acceptable behaviour • Behaviour modification: gaining social skills and improving interaction. Developing healthy peer and other relationships. • Anxiety reduction: minimizing apprehension, dread, foreboding or uneasiness related to identified or unidentified sources of anticipated danger.

29. PERSONALITY DISORDERSOutcome identification • Nurse and client identify goals to work for. You decide together, how to measure progress and how progress can be determined by you, the client and significant others. • The following outcomes are often desired: • Reduction of self-destructive behaviour • Decrease in incidents of threatening with self-mutilation • Expression of problem-solving strategies • Verbalizing internal locus of control • Interacting socially with others • Verbalizing decreased anxiety • Decrease in perfectionistic, secretive,

30. PERSONALITY DISORDERSEvaluation • Keep in mind that clients may respond to intervention very slowly • Define small steps at a time toward the achievement of therapeutic goals • Some clients are in so much pain that they wish to grow and change • Others do not perceive themselves as having a problem and choose not to become involved in the therapy • Suicide risk is high in the 20 age bracket and keeps decreasing with age

31. PERSONALITY DISORDERSChange cannot be forced ...