Transcript PROGRAMME DIPLOMA IN NURSING

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PSYCHIATRIC NURSING www.ifeet.com.ph
(Lecture Series)
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PERSONALITY DISORDERS
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
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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
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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.
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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 (egosyntonic) rather than uncomfortable (egowww.arnelsalgado.com
dystonic)
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)
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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.
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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
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CHARACTERISTICS OF PD
A. Behavioral Manifestations: include patterns of
day-to-day behavior and impulse control
B. Affective manifestations:
intensity,
lability,
and
emotional response
include the range,
appropriateness
of
C. Cognitive Manifestations: reflect how the self,
others and events are interpreted
D. Socio-cultural
functioning
Manifestations:
interpersonal
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SPECIFIC DISORDERS
Cluster A (Using DSM IVTR)
(appear odd and eccentric)
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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 www.arnelsalgado.com
to others
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
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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
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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
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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
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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
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SPECIFIC DISORDERS
Cluster B (Using DSM IVTR)
appear dramatic and erratic
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SPECIFIC DISORDERS
1. Antisocial Personality Disorder: patterns of 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
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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
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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
binge-eating
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
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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
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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
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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
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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
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SPECIFIC DISORDERS
Cluster C (Using DSM IVTR)
anxious and fearful
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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 selfconfidence 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
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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
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SPECIFIC DISORDERS
3.
Obsessive-Compulsive Personality Disorder:
patterns
of
pre-occupation
perfectionism and control
with
orderliness,
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
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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
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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
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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
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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 may manifest itself as personality disorder
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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
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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
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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)
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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
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C. Cluster C (Avoidant , Dependent, OCD)
1. Ineffective individual coping related
dependency needs, rigid behavior
2. Fear related to feelings of abandonment
to
high
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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
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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 nonintrusive 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
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•
•
•
•
•
•
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
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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
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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
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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
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"Love cures two people, the person
who gives it and the person who
receives it“
- Karl Menninger
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