Personality Disorders

1. Personality Disorders Morganne Napoleoni Kati Tessmer Binisha Shrestha Judy Ndambuki Ron Person

2. Nine Types of Personality Disorders Schizoid Personality Disorder Paranoid Personality Disorder Schizotypal Personality Disorder Antisocial Personality Disorder Borderline Personality Disorder Narcissistic Personality Disorder Avoidant Personality Disorder Dependent Personality Disorder Obsessive-Compulsive Personality Disorder (NMHA, 2006)

3. Characteristics of Personality Disorders • Patients with Personality Disorders tend to disregard their physicians and their instructions. • They see others as inferior to themselves • Manipulative, exploitative, uncomfortable with the idea of trusting, sharing and loving • This phenomenon is quite stable, but affects all the aspects of the patient’s life (Open-Site)

4. Characteristics Continued • Depression and anxiety disorder surfaces sometimes • Patient themselves unaware or unacceptable of their illness • Risky behaviors and substance abuse most prominently seen • Blame others, create imaginary world, conform surroundings to shoot their situation • No hallucinations, illusions, or delusions present (except for Borderline PD) • Senses are fully functional with good memory skills and normal functioning of the vital organs (Open-Site)

5. Common Symptoms and Manifestations of Personality Disorder • Distrust others, emotional detachment, and hostility (Paranoid) • Showing no interest to others (Schizoid) • Peculiar nature, inappropriate emotional responses, magical thinking, indifference to others (Schizotypal) • Aggressive, violent, law breaker, lying, stealing, disrespect others (Antisocial) • Impulsive, suicidal, volatile, and risky behavior (Borderline) • Attention seeker, conscious about appearance, moody (Histrionic)

6. Common Symptoms/Manifestations Continued • Over-confidence, indifferent towards others’ emotions and feelings (Narcissistic) • Hypersensitive to criticism or rejection, and shy (Avoidant) • Dependent nature, tolerant toward abusive treatments, constantly looking for new relationship when one ends (Dependent) • Perfectionism, not flexible, controlling nature (Obsessive-compulsive) (Mayo Clinic, 2009)

7. Case Study • Norman, age 9, brought to the hospital by his parents for increasingly disturbing behavior • Has been described as a “troubled child” since the age of 2 • Family • Father  Successful business man, embarrassed and confused by his son’s behavior • Mother  Actress/Entertainer, babied Norman • Parents argued over the manner in which Norman should be disciplined • Parents finally divorced when Norman was 9 years old

8. Case Study Continued • Norman began to fail school in the 2nd grade • School Psychologist suggested treatment • Norman attended sessions with a psychotherapist from the age of 7 until he was 9 • Grades did not improve and behavior became increasingly frenzied, Norman’s therapist suggested the family seek treatment at a children’s hospital

9. Case Study Continued • Intake interview at the Children’s Hospital • Norman talked incessantly and rapidly • Psychological testing showed fluctuating attention, word misusages, neologisms and disturbed associative processes • Beginning to fill his inner world with fantasies and withdraw from reality • IQ • Age 6: 120 • Age 9: 110 • Initially diagnosed with childhood schizophrenia, later downgraded to a personality disorder

10. Case Study Continued • The treatment team thought Norman would be able to tolerate and participate in psychoanalysis because he had not fully withdrawn into fantasies • Treatment plan  Psychologists believed the best course of treatment was to treat Norman as an inpatient, this would allow him a break from the strains of school and family life

11. Case Study Continued • Treatment begins • After becoming acquainted with the staff and hospital setting Norman openly spoke to his psychiatrist about what he described as serious problems • This was the last time that Norman was cooperative for the better part of 3 years of his 5 year stay • Four months into treatment Norman’s psychiatrist informed him she was going to take a vacation in 2 weeks • After the psychiatrist’s vacation there was a notable change in behavior

12. Case Study Continued • 16 months into treatment • Norman had calmed down enough to transfer treatment from the playroom to the psychiatrist’s office • 2 years into treatment • Began to express interest in doctor’s life • Both parents are planning to remarry at this point • 3 years into treatment • Norman becomes more open to directly talking about his emotions • 4 years into treatment • 5 years into treatment • Started thinking over his problems on his own and then reporting the results to the psychiatrist • Termination begins • End results • By removing Norman from the environment for a period of time his disorder and the manifestations were able to be significantly reduced (Appelbaum & Stein, 2009)

13. Treatment • It may take years to change a behavior, if any change is able to occur at all • Personality disorders are very resistant to change, often people with personality disorders do not recognize that they present maladaptive behaviors (Townsend, 2009)

14. Interpersonal Psychotherapy • Can be brief or long term • Long term  attempts to understand and modify the maladjusted behaviors, cognition and affects, the core element is the establishment of an empathetic therapist-client relationship • Particularly appropriate because personality disorders largely reflect problems in interpersonal style • It is suggested for clients with paranoid, schizoid, schizotypal, borderline, dependent, narcissist and obsessive compulsive personality disorders (Townsend, 2009)

15. Psychoanalytical Psychotherapy • The treatment of choice for those with histrionic personality disorders • Focuses on the unconscious motivation for seeking the total satisfaction from others and for being to be unable to commit oneself to a stable, meaningful relationship (Townsend, 2009)

16. Milieu or Group Therapy • Is especially appropriate for antisocial personality disorders • Main thing here is that one is getting feedback from peers • Emphasizes the development of social skills (Townsend, 2009)

17. Cognitive Behavioral Therapy • Behavior strategies offer reinforcement for positive change • Social skills training • Assertiveness training • Alternate ways to deal with frustration • Helps the client recognize and correct inaccurate internal mental schemata (Townsend, 2009)

18. Psychopharmacology • Pharmaceutical treatments • This approach does not have any effect in the direct treatment of the disorder but symptomatic relief can be achieved • This is helpful with paranoid, schizotypal and borderline personality disorders • SSRIs and MAOIs are examples (Townsend, 2009) • Patients with borderline personality disorder typically receive psychiatric medication (Fonagy, 2007) • Antidepressants • Anti-Anxiety medication • Anti-Psychotic medication

19. Treatment Phases(Multiple Personality Disorders) • Phase I: Development of trust • Phase II: Therapist educating the client on the nature and function of the disorder • Assist in improving cooperation between alters to decrease unwanted or intrusive switching • Phase III: Focuses on reintegrating or fusing the alters with each other and the host (Allers & Golson, 1994)

20. Descriptions of Personality Disorders • Cluster A—odd or eccentric Paranoid Pervasive pattern of mistrust and suspiciousness Begins in early adulthood Presents in a variety of contexts Schizoid Detachment from social relationships Restricted range of emotional expressions Schizotypal Social and interpersonal deficits Cognitive or perceptual distortions and eccentricities Cluster B—dramatic, emotional, or erratic Antisocial Disregard for rights of others Violation of rights of others Lack of remorse for wrongdoing Lack of empathy Borderline Instability of interpersonal relationships, self-image, and affects Marked impulsivity Histrionic Excessive emotionality Attention-seeking behavior Narcissistic Grandiosity Need for admiration • Cluster C—anxious or fearful Avoidant Social inhibition Feelings of inadequacy Hypersensitivity to criticism Dependent Excessive need to be taken care of Submissive behavior Fear of separation Obsessive-compulsive Preoccupation with orderliness and perfectionism Mental and interpersonal control

21. Assessment • The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), is published by the American Psychiatric Association. It is the manual that mental health professionals most commonly use to diagnose mental disorders • The Ten Item Personality Inventory (TIPI)

22. TIPI • 1 = Disagree strongly •  2 = Disagree moderately •  3 = Disagree a little •  4 = Neither agree nor disagree •  5 = Agree a little •  6 = Agree moderately •  7 = Agree strongly • I see myself as: • 1. _____ Extraverted, enthusiastic. • 2. _____ Critical, quarrelsome. • 3. _____ Dependable, self-disciplined. • 4. _____ Anxious, easily upset. • 5. _____ Open to new experiences, complex. • 6. _____ Reserved, quiet. • 7. _____ Sympathetic, warm. • 8. _____ Disorganized, careless. • 9. _____ Calm, emotionally stable. • 10. _____ Conventional, uncreative. _____________________________________________________________________________  TIPI scale scoring (“R” denotes reverse-scored items):  Extraversion: 1, 6R; Agreeableness: 2R, 7; Conscientiousness; 3, 8R; Emotional Stability: 4R, 9; Openness to Experiences: 5, 10R.

23. Intervention • Build trust between therapist and client • Maintain quiet environment for interaction between therapist and client • Administer tranquilizing medications as ordered by the physician or obtain order if necessary • Assist client in evaluating the positive and negative aspect in their life • Have sufficient staff available to present a sow of strength to the client if necessary • Frequently examine patient’s behavior to insure safety and security • Encourage clients to speak of past behaviors • Provide positive feedback for acceptable behaviors • The staff should maintain and display a calm attitude toward the client (Townsend, 2009)

24. Referrals • Physician • Psychiatrist • Psychologist • Social worker • Clinical psychiatric nurse • Dietician (Townsend, 2009)

25. References (2008,September,11). Personality Disorder. Retrieved January 31, 2009, from Mayo Clinic Web site: http://www.mayoclinic.com/health/personality-disorders/DS00562/DSECTION=symptoms Allers, C.T. & Golson, J. (1994). Multiple personality disorder: Treatment from an Adlerian perspective. Individual Psychology, 50 (3), 262-270 Fonagy, P. (2007). Personality disorder. Journal of Mental Health, 16 (1), 1-4. Hallsell Appelbaum, A., & Stein, H. (2009). The Impact of Shame on the Psychoanalysis of a Borderline Child. American Psychological Association, 26(1), 26-41. Retrieved January 26, 2009, from the JSTOR database. National Mental Health America (NMHA). (2006). Factsheet:Personality Disorders. Retrieved January 31, 2009, from http://www.nmha.org/index.cfm?objectId=C7DF8E96-1372- 4D20-C87D9CD4FB6BE82F Personality Disorder. Retrieved January 31, 2009, from Open-Site Web site: http://www.nmha.org/index.cfm?objectId=C7DF8E96-1372-4D20-C87D9CD4FB6BE82F Townsend, Mary (2009). Psychiatric mental health nursing: concepts of care in evidence-based practice. Philadelphia, PA: F.A. Davis Company.