Objectives

2. Objectives • 1. Identify behaviors associated with personality disorders. • 2. Distinguish between the symptoms of different Personality Disorders. • 3. Formulate nursing diagnoses related to personality disorders. • 4. Identify expected outcomes and short term nursing goals related to personality disorders. • 5. Analyze nursing interventions related to personality disorders. • 6. Evaluate nursing care related to personality disorders.

3. Personality • “a complex pattern of characteristics, largely outside of the person’s awareness, that comprise the individual’s distinctive pattern of perceiving, feeling, thinking, coping and behaving. The personality emerges from a complicated interaction of biologic dispositions, psychological experiences, and environmental situations.” Boyd

4. Personality • Is a set of deeply ingrained, enduring patterns of thinking, feeling, and behaving. Stuart, p. 385

5. Personality Traits- The Big 5

6. Continuum of Social Responses • Levels of relationships range from intimacy to casual contact. Analysis of relationships is based on the degree of involvement, comfort, & well-being. • Connectedness; disconnectedness; parallelism; & enmeshment. • Connectedness: active relationship characterized by belonging, mutuality, reciprocity & interdependence

7. Degrees of Involvement in relationships • Connectedness: active relationship characterized by belonging, mutuality, reciprocity & interdependence • Disconnectedness: lack of involvement that is not satisfying to the person. • Parallelism: lack of involvement that is comfortable & acceptable to the person. • Enmeshment: person is involved in the relationship but is unable to maintain ego boundaries & a unique sense of self.

8. Personality development through the life cycle • Stages of Development when personality development occurs. • Symbiotic 3-18 months • Individuation 18 months to 3 years • Childhood 6 to 10 years • Preadolescence • Adolescence • Young adulthood • Middle adulthood • Late adulthood

9. Personality development through the life cycle • Infancy= symbiotic stage: trust develops in unconditionally loving relationship with caregiver. • Preschool years= individuation: child develops internal psychological structure & growing sense of separateness. • Childhood = develops morality & empathic feelings for others. Growing sense of positive self concept. • Preadolescence= intimate relationship with friend of same gender.

10. Personality development through the life cycle • Adolescence= develops dependent relationship with person of opposite gender and begins asserting independence from parents. Ends when person is self-sufficient. • Young Adulthood= independent decision making, marriage, new family, occupational plans & career. • Middle Adulthood= parenting, adult friendships, fostering independence in others, self-reliance, freedom to pursue new activities. • Late adulthood= looses, aging, death of parents, loss of occupation, retirement, death of spouse & friends. New relationships can develop, grandchildren, strives to retain as much independence as possible.

11. Factors in the development of personality • Most social scientists assume that personality and social behavior result from a blending of heredity and social environmental influences. • They believe that environmental factors have the greatest influence. • Heredity, birth order, parents,and cultural environment are among the principal factors that social scientists see influencing personality and behavior

12. Family Influences • Parents influence their children’s personalities. The age of the parent can have an influence on children’s development. • Other parental characteristics like level of education, religious orientation, economic status, occupation, and cultural heritage can influence a child’s personality and their social behavior. • Attachment theory: “The fundamental assumption in attachment research on human infants is that sensitive responding by the parent to the infant's needs results in an infant who demonstrates secure attachment, while lack of such sensitive responding results in insecure attachment” (Lamb, Thompson, Gardner, Charnov, & Estes, 1984). • Insecure attachment in infancy/childhood may lead to difficulty with trust and problems with emotional regulation. Securing and maintaining healthy relationships during the life span may be enormously challenging.

13. Cultural influences • Culture has a strong influence on personality development. The cultural environment determines the basic types of personalities that will be found in a society. • Each culture gives rise to a series of personality traits – model personalities – that are typical of members of that society.

14. Personality Disorders “An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, it is pervasive and inflexible, it has an onset in adolescence or early adulthood, & it is stable over time and leads to distress or impairment in functioning”. DSM V (2013)

15. DSM 5 Personality Disorders • The number of personality types was reduced in the DSM 5 and now includes a four part assessment of personality which includes: • Severity scale. Rated from zero (no impairment) to four (extreme impairment) • Type match. To what degree does a patient’s personality match one of the five remaining personality types, from one (no match) to five (a good match) • Trait domains and facets. Each personality type may have up to six “trait domains”—negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypal. Each trait domain is further broken down to more specific “trait facets.” You then rate each trait on a scale from zero (very little or not at all descriptive) to three (extremely descriptive) • Personality disorder. Finally, you determine: “Does the person meet criteria for a specific personality disorder?”

16. Key features in personality disorders • 1) the person has an inflexible & maladaptive approach to relationships and the environment. • 2) the person’s needs, perceptions, & behavior tend to foster cycles that promote unhelpful patterns & provoke negative reactions from others. • 3) the person’s coping skills are unstable & fragile, & there is a lack of resilience when faced with stressful situations. Stuart, p. 385

17. Personality Disorders are: • Manifested in two or more of the following areas: 1. Cognition (perceptions and interpretations of others, events and self…their thinking about an event or person is distorted by a pattern of engrained false perception) 2. Affectively (characterized by emotional intensity which is usually charged, range which can be wide, appropriateness which can be odd & strangeand mood fluctuations with or without cause) 3. Interpersonal functioning (varies from enmeshment to disconnectedness) 4. Impulse control (is poor, resulting in the person with a personality disorder being a risk for injury to self or other)

18. Diagnosis and Identification • Often takes several admissions or sessions to identify the patterns of behavior. Some argue that theory and diagnosis of personality disorders are based strictly on social, or even sociopolitical, cultural and economic considerations.

19. More Features of Personality Disorders • Impairment of social, emotional and occupational functioning. • Individual exhibits a lack of insight into their own behavior. • Exhibit a variety of fixed defense mechanisms in their daily behavior. Often using denial, projection, splitting, & blaming others. • Prognosis depends on level of insight, motivation to change and quality/consistency of therapy

20. Behaviors Related to Maladaptive Social Responses • Manipulation: Others are treated as objects; relationships are centered around control issues; & the person is self oriented or goal oriented, not other oriented. • Narcissism: Present is a fragile self-esteem; Constant seeking of praise & admiration; egocentric attitude & envy; Rage is provoked when others are not supportive. • Impulsivity:Inability to plan; Inability to learn from experience; Poor judgment; & Unreliability. Boyd

21. Coping Mechanisms to control anxiety related to loneliness. • Projection- places responsibility for one’s behavior outside of oneself. • Splitting- is the inability to integrate the good & bad aspects of oneself & objects outside the self that one is attached to. Different staff see patient in different ways as a result. • Projective Identification- complex defense mechanism that is often unconscious. The person projected on may begin to behave like the projected parts. It is a very powerful defense mechanism. • And staff may begin to act out the projected parts because of transference & counter-transference. Particularly seen in young inexperienced staff.

22. Three Clusters of Personality Disorders (grouped by behavioral traits) • Cluster A • Odd, eccentric behaviors • Paranoid, Schizoid & Schizotypal • Cluster B • Dramatic, erratic, emotional behaviors • Antisocial, Borderline, Histrionic, Narcissistic Disorders • Cluster C • Anxious, fearful, controlling behaviors • Avoidant, Dependent, Obsessive-Compulsive Disorders

23. Other Personality Disorders • Personality change due to a medical condition- Disturbance due to the direct physiological effects of a medical condition (e.g., frontal lobe lesion). • Other Specified or unspecified personality disorders- Personality pattern meets criteria for personality disorder and/but traits from several personality disorders are present, but the traits do not meet the criteria for a specific personality disorder. Or individual is considered to have a personality disorder that is not included in the DSM 5 (e.g. passive-aggressive personality disorder or depressive personality disorder, which had separate classification in DSM IV)

24. Cluster A - Paranoid, Schizoid, Schizotypal Disorders • Gender: more common in males • Be aware of cultural interpretations of behavior • Onset – Often presents in childhood and adolescence characterized by solitariness, poor peer relationships, underachievement in school and subject of teasing. Individual is seen as odd or eccentric. • Etiology - Neurophysiology, genetics • Familial pattern: increased prevalence of schizophrenia and delusional disorders in family system.

25. 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 in early adulthood and present in a variety on contexts (see next slide)

26. Schizotypal Disorder patients: • “ ideas of reference”- believes others are talking about them, even the TV and songs on the radio are about them, and often feels others stare at them. • Believe they receive special messages, have experiences with the supernatural and can make things happen by wishing (magical thinking). • Their behavior or appearance is odd, eccentric or peculiar. • Affect is constricted or inappropriate. • No close friends or confidants. • Excessive social anxiety.

27. Schizotypal Personality Disorder • Odd and peculiar speech and appearance • Inappropriate affect - i.e., silly during serious moments • Strange, unsupported beliefs - clairvoyance, UFO’s, etc. • Sometimes appears to be a milder form of schizophrenia

28. Paranoid Personality Disorder • A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning in early adulthood and present in a variety of contexts (see next slide).

29. Paranoid Personality Disorder • Suspicious, without basis, that others are exploiting, harming or deceiving them, mistrustful of others • Tend to hold grudges and takes a long time to forgive people that may have insulted them. • Unable to form intimate relationships, and when they do, often suspect partner has been unfaithful • Usually either aloof and removed or angry and aggressive, especially when feels criticized.

30. Schizoid Personality Disorder • A pervasive pattern of detachment from social relationships and restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts (see next slide).

31. Schizoid Personality Disorder • Neither desires or enjoys close relationships, including being part of a family. • Almost always chooses solitary activities. • Has little interest in having sexual experiences with another person. • Indifferent to praise or criticism. • Flattened affect, claims nothing really makes them very happy or sad, and few things give them pleasure.

32. Cluster A -- Interventions • Rarely seek psychiatric treatment • Attempt to establish trust (can take years) • Establish rapport with family member • Be honest, open (but not too warm) • Ignore or gently confront odd beliefs or behaviors • Suggest cognitive-behavior therapy to enhance social skills

33. Cluster B - Antisocial, Borderline, Histrionic, Narcissistic • Gender • Male - Antisocial PD • Female - Borderline PD, Histrionic PD • Age – All diagnosed after age 18 and may see some decrease in symptoms at midlife. • Etiology - Neurophysiology, genetics • High rates of depression, substance abuse

34. Borderline Personality Disorder • A pervasive pattern on instability of interpersonal relationships, self-image, affect and impulsivity, beginning in early adulthood and present in a variety of contexts (see next slide)

35. Borderline Personality Disorder • Frantic efforts to avoid real or imagined abandonment. • Extreme ups and downs in relationships. • Identity disturbance, frequently changing beliefs and goals. • Impulsivity can include unsafe sex, substance abuse, spending, eating or driving reckless. • Suicidal gestures and/or self mutilation common. • Sudden mood changes, temper outbursts and feeling empty inside.

36. Developmental Factors: Borderline Personality Disorder • Developmental theory suggests that the borderline person fails to achieve object constancy during the separation-individuation stage of psychosocial development (the period between 18 months & 3 years of age). Fail to complete separation from primary caretaker & fail to achieve autonomy in childhood. • Often emotionally, physically or sexually abused. 25% also have diagnosis of PTSD (Stuart, 2013).

37. Example: Borderline Personality Disorder • http://www.youtube.com/watch?v=eOphgCJX1FY

38. Nursing Diagnoses for Borderline Personality Disorder • Risk for self injury; self-mutilation • Dysfunctional grieving • Impaired social interaction • Anxiety (severe to panic) • Self-esteem disturbance • Uncontrollable anger- throwing objects or hitting common. • When feeling stressed, becomes suspicious (paranoid) or spaced out (dissociative)

39. Do: Be open and nonjudgmental- keep in mind these patients have developed these disorders as a result of complex genetic and environmental factors (insecure attachments, chaos, neglect, abuse) Control your emotional reactivity, be calm Practice kindness, listen to their concerns and their story with sensitivity Be aware that these patients are experts at eliciting a rejecting response and respond with calmness, solidness and genuine concern for them Don’t: Close off and decide you don’t like the person Form instant negative associations when you hear that someone has a Borderline PD Take things personally- their behaviors are well entrenched and they have difficulty controlling their intense emotions. They are manipulative & unable to tolerate reciprocal interpersonal relationships. Try not to let them drive you away- they are testing whether you will care for them Caring for the patient with Borderline Personality Disorder

40. Caring for the patient with Borderline Personality Disorder (con’t) • Be aware that these patients have learned to resort to manipulation and splitting to get their needs met. Set limits in a fair and non-emotionally charged way- it is important that the team remain solid and not allow splitting to result in fragmentations and emotional chaos • Continuously assess and monitor the patient for self-injurious behaviors such as self-mutilating (cutting) and suicide attempts- place on 1:1 Suicide Precautions as needed • Elicit information about substance abuse (a very common co-occurring disorder)- make referrals for substance abuse treatment • Encourage the patient to participate in on-going psychotherapy, particularly therapy that incorporates CBT and interpersonal techniques • Encourage the use of psychotropic medications for symptoms such as dysphoria, emotional instability, anxiety and PTSD symptoms

41. Histrionic Personality Disorder • A pervasive pattern of excessive emotionality and attention seeking, beginning in early adulthood and present in a variety of contexts (see next slide).

42. Histrionic Personality Disorder • Likes to be the center of attention and feels uncomfortable when not. • Sexually provocative, inappropriately seductive. • Tries to draw attention to self by the way they dress or look and displays dramatic emotions. • Suggestible, often changing their mind about things based on things they’ve read or seen on TV. • Considers relationships to be more intimate then they really are (lots of very close friends?)

43. Narcissistic Personality Disorder • A pervasive pattern of grandiosity (in behavior or fantasy), need for admiration, lack of empathy, beginning by early adulthood and present in a variety of contexts (see next slide).

44. Narcissistic Personality Disorder • Grandiose sense of self-importance, exaggerates achievements and talents. • Preoccupation with fantasies of success, power, fame, brilliance, beauty or ideal love. • Feels special, entitled and deserves privilege and that there are few people worth their attention. • Exploitive- takes advantage of others to achieve own desires “steps on toes”. • Not interested in other people’s feelings or problems, lacking empathy. • Often envious of others or believes others are envious of them.

45. Greek myth of Narcissus- fell in love with own reflection. • Many successful people are narcissistic. • Persons with this personality trait are attracted to acting, modeling, professional sports, politics, & broadcasting. Historical example is Hitler. • Have fragile self esteems, driving them to constantly seek appreciation and admiration, egocentric attitude, envy, rage with others do not support them.

46. Antisocial Personality Disorder • Evidence of conduct disorder before age 15. • There is a pervasive disregard for and violation of the rights of others occurring since age 15.

47. Antisocial Personality Disorder • Must be at least age 18, but there is evidence of Conduct Disorder with onset before age 15, includes: • Fighting, bullying, weapons use including a bat, sticks, broken bottle, bricks, rocks, knife or gun. • Deliberately cause suffering, pain or torture to other people or animals. • Stole while confronting victim such as mugging, purse snatching, extortion or armed robbery. • Forced someone into sexual activity. • Set fires or vandalized or broke into property. • Stole items of nontrivial value while shoplifting, theft, forgery. • Ran away from home at least twice while living in parental or parental surrogate home. • Staying out very late at night despite parental prohibitions or often skipping school before the age of 13.

48. Antisocial Personality Disorder • If evidence of Conduct Disorder before age 15, since age 15 has there been 3 or more of the following: • Deceitfulness, lying, use of aliases for profit or pleasure. • Impulsivity, failure to plan ahead, like quitting a job without having a new one or having no regular place to live or no regular job. • Aggressiveness, fighting, assaults, partner or child abuse. • Reckless driving or unsafe, frequent sex. • Consistent irresponsibility with financial obligations. • Lack of remorse for those hurt by behaviors.

49. Antisocial Personality Disorder • Emotional shallowness • Not all commit violent acts • Often substance abusers, beginning early in life; may be involved in drug trafficking • No concern for and frequent violation of the rights of others • Engage in illegal, irresponsible behavior with no remorse • May be dangerous - physically and emotionally

50. Example: Antisocial Personality Disorder: Conduct Disorder as child • http://www.youtube.com/watch?v=iPuxDYOWvj0