Transcript Personality Disorders, Eating Disorders, and Sexual Disorders

Personality Disorders,
Eating Disorders & Sexual
Disorders
Nur 305
Personality
 is a set of deeply
ingrained, enduring
patterns of thinking,
acting, & behaving.
Personality Disorder
Definition:
 The individual has few strategies for
relating and his or her approach to
relationships and to the environment is
inflexible and maladaptive.
 Prevalence of personality disorders in the
general population is 10-18%
A “healthy personality” means:
 Maintaining healthy relationships
 Experiencing intimacy while maintaining
own separate identity
 Maintaining a continuum of dependent and
independent behavior
Adaptive responses
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Solitude
Autonomy
Mutuality
Interdependence
Maladaptive responses
 Manipulation
 Impulsivity
 Narcissism
Personality disorders
(characteristics)
 Chronic, maladaptive social responses
 Can be associated with depression,
substance abuse, and suicide.
Clusters of personality disorders
DSM-IV-TR
 Cluster A includes disorders of an odd or
eccentric nature (paranoid, schizoid,
schizotypal)
 Cluster B includes disorders of an erratic,
dramatic, or emotional nature (antisocial,
borderline,histrionic, narcissistic)
 Cluster C includes those of an anxious or
fearful nature (avoidant, dependent,
obsessive-compulsive)
Cluster A Personality Disorders
 Paranoid: “People will eventually hurt me.”
“People cannot be trusted.”
 Schizoid: “Why should I be close to
people?” “I am my own best friend.”
 Schizotypal: “I am defective.”
Relationships are threatening.”
Paranoid personality disorder
 A pervasive distrust and
suspiciousness of others
without sufficient basis
 Person persistently bears
grudges (unforgiving)
 Person is preoccupied
with unjustified doubts
about the loyalty of
friends
 Person exhibits feelings
of inadequacy
Treatment of Paranoid
Personality
 Establish a therapeutic relationship
 Antipsychotic meds may be useful
 Empathetic response to patient’s anxiety
 Psychotherapy
Schizoid Personality Disorder
 Pervasive pattern of detachment from
social relationships (beginning by early
adulthood).
 Chooses solitary activities
 Lacks close friends other than first degree
relatives
 Emotional coldness, detachment or shows
flat affect
Schizotypal Personality
 Interpersonal deficits, cognitive distortions,
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eccentricities, feeling misunderstood, &
odd beliefs (begins by early adulthood).
Superstitions, beliefs in telepathy or “sixth
sense,” bizarre fantasy or preoccupations.
Lack of close friends
Inappropriate affect
Excessive social anxiety
Schizoid & schizotypal
personality treatments
 Therapist must be patient and proceed at
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a slow pace.
Dysfunctional thought record as a HW
device
Social skills training
Low doses of antipsychotics
Anxiolytics
Cluster B personality disorders
 Antisocial personality:
exploitive & manipulative.
“Rules are meant to be
broken.” “My pleasure
comes first.”
 Borderline personality:
unstable, impulsive,
profound mood shifts, &
self-destructive behavior
Cluster B disorders cont.
 Histrionic personality: attention seeking,
superficial relationships, appearances are
important, excessive emotionality.
 Narcissistic personality: arrogant, need for
admiration, socially exploitive,
manipulative.
Antisocial personality (DSM-IV
criteria)
 A pervasive pattern of disregard for and violation
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of the rights of others occurring since age 15
years.
Failure to conform to social norms with respect
to lawful behaviors
Repeated lying and conning others
Irritable and aggressive
Consistent irresponsibility
Lack of remorse
Antisocial Personality
 Main Defense Mechanism:
 Projection: places responsibility for antisocial
behavior on others.
Borderline Personality
 A pervasive pattern of instability of
interpersonal relationships.
 Main defense mechanisms:
 Splitting: inability to integrate the good and
bad aspects of oneself.
 Projection: projects parts of oneself onto
others.
EBR on families of BP
 Patients view their relationships with their
mothers as highly conflictual, distant, or
uninvolved.
 Both physical and sexual abuse are
common.
 25% of BP patients have a history of
parent-child incest.
EBT Treatments for BD
 DBT: Dialectic Behavioral Therapy
 Partial hospitalization involving group and
individual psychotherapy for 18 months
reduces the number of suicide attempts
and acts of self-harm. Also increases the
quality of social and interpersonal
functioning.
 Medications
Cluster C personality disorders
Anxious; Fearful
 Avoidant: social
inhibition; withdraw
from social and
occupational
situations.
 Dependent:
submissive;low selfesteem,dependency
in relationships
Cluster C disorders cont.
 Obsessive-compulsive: unable to express
affection, overly cold, preoccupation with
trivial detail, orderliness, perfection.
 Treatment: CBT, Psychotherapy
Primary Nursing Diagnoses
 Chronic low self-esteem
 Risk for self-mutilation
 Impaired social interaction
 Risk for self-directed violence
Outcome Identification
 The patient will obtain maximum
interpersonal satisfaction by establishing
and maintaining self enhancing
relationships with others.
Planning & Interventions
 Focus on helping pt. Change the thinking
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and the behavior that result from the
personality disorder
Set mutual goals
Protection from self-harm
Family and staff consistency
Set limits and structure environment
Focus on patient’s strengths
Eating Disorders
Chapter 25
Predisposing Factors
 Biological: dysregulation of neurochemical
mechanism for appetite
 Low serotonin level
 Decreased dopamine receptor
 Genetics: 52% risk in monozygotic twins
 Psychological: low self-esteem, body
image dissatisfaction, alcohol & substance
abuse, perfectionism.
Diagnosis & Classification:
Anorexia Nervosa
 AN
 Refusal to maintain body wt at or above
minimal normal wt for age and height.
 Intense fear of gaining wt
 Distorted body image
 Amenorrhea (3 cycles)
Diagnosis & Classification (AN)
 AN Subtypes:
 Restricting Type:
limited intake of
food
 Binge
eating/purging
types
Key features of AN (without
binging or purging)
 Rare vomiting
 More severe wt loss
 More introverted
 Sexually inactive
 Hunger denied
 Death form starvation
 Amenorrhea
Diagnosis: Bulimia Nervosa
 Fear of not being thin.
 Recurrent episodes of binge eating.
 Recurrent inappropriate compensatory
behaviors at least 2X/week for 3 months
(self-induced vomiting, laxative use,
diuretics, enemas, fasting or excessive
exercise).
 A persistent fixation with body shape and
weight.
Key Features of Bulimia
 Frequent vomiting
 Less weight loss
 More extraverted
 More sexually active
 Irregular menses or absent
 Obsessional features
 Death from hypokalemia or suicide
Other Eating Disorders
 Binge eating disorder
(absence of purging
or fasting)
 Obesity
 Pica (eating non-food
items)
 Rumination
(regurgitation &
rechewing food)
Complications of AN & BN
 Bradycardia, arrhythmias, CHF
 Electrolyte disturbance (low K)
 Loss of dental enamel, osteo (lack of Ca)
 Hair loss
 Anemia, leukopenia
 Delayed gastric mobility (r/t chronic
laxative use)
 pancreatitis
Eating Disorders Co-morbidity
 AN may be co-morbid with histrionic or
obsessive-compulsive personality disorder
 Bulimia is co-morbid with borderline and
major depression
Eating Disorder Assessment
 Eating pattern
 Body image
 Binge/purging
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episodes
Current and ideal
body weight
Exercise pattern
Coping resources
Motivation to change
Eating Disorder Coping
mechanism
 Denial
 Avoidance
 Intellectualization
Cognitive distortions in
maladaptive eating
 Magnification of the significance of
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undesired events
Superstitious thinking
Dichotomous or all-or-none thinking:
thinking in extremes
Selective abstraction: basing a conclusion
on isolated details
Overgeneralization
Nursing Diagnoses related to
eating disorders
 Anxiety
 Disturbed body image
 Imbalanced nutrition
 Powerlessness
 Low self-esteem
 Risk for self-mutilation
Treatment goals
 Nutritional stabilization
 Identification of precipitating factors
 Re-establishment of normal eating
behavior
Treatment of AN
 Medical: SSRI’s for relapse prevention
 Weight restoration
 Psycho-education on nutrition and health
 Behavioral and cognitive interventions
 Involve pt’s family
 Long term prognosis is poorer than bulimia
Treatment for Bulimia
 Antidepressants produce short-term
reductions in binge eating and purging
(Prozac).
 CBT is most effective in eliminating core
features of Bulimia.
Sexual Disorders
Criteria for adaptive sexual
responses
 Two consenting adults
 Mutually satisfying to both
 Not psychologically or physically harmful
to either
 Lacking in coercion
 Conducted in private
Criteria for maladaptive sexual
responses
 Dysfunction in sexual performance
 Harmful, forceful sexual behavior
 Not conducted in private
 Non-consenting between two adults
Behaviors related to sexual
responses
 Heterosexuality: sexual attraction to members of
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the opposite sex.
Homosexuality: sexual attraction to members of
the same sex.
Bisexuality:sexual orientation or attraction to
both men and women.
Transvestism: cross-dressing or dressing in the
clothes of the opposite sex.
Transsexualism: one has a profound discomfort
with his/her own sex and a strong identification
with the opposite gender.
Stages of the sexual response
cycle
 Stage 1: Desire
 Stage 2: Excitement
 Stage 3: Orgasm
 Stage 4: Resolution
Sexual dysfunction
More common in women than men
 Vaginismus: painful involuntary spasm
 Lack of orgasm
Problems seen in males:
Erectile dysfunction (impotence)
Ejaculatory disorders
Precipitating Stressors
 Physical illness or injury ( post MI, CA
hysterectomy)
 Psychiatric illness (depression,
hypersexuality, manic)
 Medications (antihypertensives,
antihistamines, anticholinergics, chemo
agents)
 Aging process
Coping Mechanisms
 Fantasy
 Rationalization
 Denial
 Projection
Primary Nursing Diagnosed related to
variations in sexual response
 Sexual dysfunction
 Ineffective sexuality pattern
Medical Diagnoses
 Sexual dysfunctions
 Paraphilias
 Gender disorders
Paraphilia
 A persistent association, lasting at least 6
months, between intense sexual arousal,
desire, acts, or fantasies.
Medical diagnoses related to paraphilia’s
(sexual perversion or deviation)
 Exhibitionism: sexual arousal when exposing
genitals to stranger
 Fetishism: persistent assoc. between sexual
arousal and non-living objects; such as female
underwear
 Frotteurism: persistent assoc. between sexual
arousal and rubbing against a non-consenting
person
 Pedophilia: sexual arousal assoc.with one or
more children aged 13 or under (criminal)
Medical Diagnoses cont.
 Sexual masochism: sexual arousal assoc.
with being humiliated, beaten, or being
made to suffer.
 Sexual sadism: sexual arousal assoc with
real or simulated psycho-physical
suffering.
 Voyeurism: observing unsuspecting
people who are naked or engaging in
sexual activity
Outcome Identification
 The patient will obtain a maximum level of
adaptive sexual responses to maintain
health.
Treatments for sexual disorders
 Cognitive
 Behavioral
 CBT
 Somatic treatments that lower
testosterone levels,such as medroxyprogesterone are also somewhat effective.
Sexual dysfunction treatment
 Erectile disorders Pharmacological
(sidenafil) and SSRI’s.
Response of the nurse; difficulties with
sexual orientation
 Homosexuality is NOT a disorder of mental
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illness
Society’s lack of acceptance is a factor in the
increased risk for suicide for homosexuals and
bisexuals.
Avoid negative attitudes and irrational fears
(homophobia).
Show acceptance and sensitvity of sexual
orientation.
Ensure quality care.
Do not make the heterosexism assumption.