Personality and Impulse-Control Disorders

1. Personality and Impulse-Control Disorders Chapter 20

2. Personality Complex pattern of characteristics, largely outside of the person’s awareness Distinctive patterns of perceiving, feeling, thinking, coping and behaving Emerges within biopsychosocial framework Personality Disorder An enduring pattern of deviant inner experiences and behavior Differ from cultural expectations Pervasive, inflexible and stable Leads to distress or impairment What is it?

3. Types of Personality Disorders • Cluster A - odd-eccentric • Paranoid Personality Disorder • Schizoid Personality Disorder • Schizotypal Personality Disorder • Cluster B - dramatic and emotional (impulsivity) • Antisocial Personality Disorder • Borderline Personality Disorder • Histrionic Personality Disorder • Narcissistic Personality Disorder • Cluster C - anxious-fearfulness • Avoidant Personality Disorder • Dependent Personality Disorder • Obsessive-compulsive Disorder

4. Common Features and Diagnostic Criteria • Abnormal, inflexible behavior patterns of long duration, traced back to adolescence and early adulthood • Pervasive across a broad range of personal & social situations • Deviate in the following: • Cognitive abilities (schema) • Affectivity and emotional stability (emotions) • Interpersonal functioning/self-identity • Impulse control and destructive behavior

5. Severity Criteria • Tenuous stability - exaggerated emotions, unable to cope with normal stressful events • Adaptive inflexibility - rigidity in interactions with others • Vicious circles - because of inflexibility, generate and perpetuate dilemmas

6. Cluster A Disorders Paranoid Personality Disorder • Features • Mistrustful, avoid relationships that cannot control • Persistent ideas of self-importance • Epidemiology • 0.5 to 2.5% in general populations • More often in men • Etiology: unclear, genetic predisposition?

7. Cluster A Disorders Paranoid Personality Disorder Nursing Management • Patients seen for other health problems • Nsg DX: Disturbed thought process, social isolation • Nursing Interventions • It can be difficult to establish nurse-patient relationship. • If trust is established, help patient identify problem areas. • Changing thought patterns takes time.

8. Cluster A Disorders Schizoid Personality Disorder • Features • Expressively impassive and interpersonally unengaged • Introverted and reclusive, engage in solitary activities • Communication sometimes confused • Incapable of forming social relationships • Minimum introspection, self-awareness and interpersonal experiences • Epidemiology • Rarely diagnosed in clinical settings • Avoidant personality disorder occurs in 30 to 35% of cases • Etiology: speculative

9. Cluster A Disorders Schizoid Personality Disorder Nursing Management • Nursing Diagnosis: Impaired social interactions and chronic low self-esteem • Goal: To enhance experience of pleasure • Interventions • Provide social skill training. • Encourage social interactions.

10. Cluster A DisordersSchizotypal Personality Disorder • Features • Eccentric • Pattern of social and interpersonal deficits • Void of close friends • Odd beliefs • Ideas of reference • When psychotic, symptoms mimic schizophrenia. • Epidemiology • 0.7 to 5.1% prevalence • Etiology: unknown • Speculation that this is a part of a continuum of schizophrenia-related disorders

11. Cluster A DisordersSchizotypal Personality Disorder Nursing Management • Similar to that with schizophrenia • Increase self-worth. • Provide social skills training. • Reinforce socially appropriate dress and behavior. • Focus on enhancing cognitive skills.

12. Borderline Personality DisordersClinical Course • Pervasive patterns of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity that begins by early adulthood and is present in a variety of contexts • Problem areas • Regulating moods • Developing a sense of self • Maintaining interpersonal relationships • Maintaining reality-based cognitive processes • Impulsive or destructive behavior • Appear more competent than they are • Live from crisis to crisis

13. Borderline Personality Disorder • Affective instability - shifts in moods • Identity disturbance (identify diffusion) • Role absorption - narrow definition of self • Painful incoherence - internal disharmony • Inconsistency in thoughts, feelings and actions • Lack of commitment • Unstable interpersonal relationships • Fear of abandonment • Unstable, insecure attachments • Over idealize/intense relationships

14. Borderline Personality Disorder • Cognitive Dysfunctions • Dichotomous thinking • Dissociation • Dysfunctional Behaviors • Impaired problem-solving • Impulsivity • Self-injurious behaviors (parasuicidal behavior) • Compulsive • Episodic • Repetitive

15. Borderline Personality Disorder in Special Populations • Many children and adolescents show symptoms similar to those with BPD. • Symptoms begin in adolescents.

16. Epidemiology • 0.4 to 2.0% prevalence in general populations • In clinical populations, BPD is the most frequently diagnosed personality disorder. • Mostly women (77%) • Mean age of diagnosis is mid-20s. • Coexistence of personality disorders with Axis I disorders (mood, substance abuse eating, dissociative and anxiety disorders)

17. Risk Factors • Physical and sexual abuse • Parental loss or separation

18. Etiology • Biologic • Abnormalities associated with affective instability, transient psychotic episodes, and impulsive, aggressive and suicidal behavior • Psychological • Psychoanalytic theory (separation-individuation; projective identification) • Maladaptive cognitive processes

19. Etiology: Biosocial Theories • Millon - • Distinct disorder that develops as a result of both biologic and psychological factors. • Personality is shaped by a) active-passive behavior, b) pleasure-pain and c) sensitivity to self or others. • Linehan • Emotional vulnerability, self-invalidation, unrelenting crises, inhibited grieving, active passivity and apparent competence (Text Box 20.1)

20. Risk Factors • Physical and sexual abuse • Separation or loss of parent at an early age (same sex for men)

21. Interdisciplinary Treatment • Requires the whole mental health care team • Requires a variety of medications including mood stabilizers, antidepressants and, at times, anxiolytics • Psychotherapy

22. Dialectical Behavior Therapy • Combines numerous cognitive behavioral approaches • Requires monitoring and commitment by patient • Individual therapy • Building skills through skills group • Mindfulness • Interpersonal effectiveness • Emotion regulation • Distress tolerance skills • Self-management

23. Priority Care Safety!!!

24. Affective dysregulation Mood lability Problems with anger Interpersonal dysregulation Chaotic relationships Fears of abandonment Self-dysregulation Identity disturbance Sense of emptiness Behavioral dysregulation Parasuicide behavior Impulsive behavior Cognitive dysregulation Dissociative responses Paranoid ideation Response Patterns

25. Nursing Management:Biologic DomainAssessment • Systems review and physical functioning • Nutrition and eating • Sleep patterns • Physical responses to emotions • Physical indicators of self-injurious behaviors • Cutting, scratching or swallowing • Pharmacologic assessment, including OTC and illicit drugs

26. Nursing Diagnosis:Biologic Domain • Self-mutilations, risk for self-mutilation • Disturbed sleep pattern • Ineffective therapeutic regimen management

27. Nursing Interventions:Biologic Domain • Sleep enhancement • Enhance regular sleep-wake cycles. • Moderate exercise • Avoid touching those who have been physically, sexually abused. • Nutritional enhancement • Prevention and treatment of self-injury • Observe for antecedents of self-injurious behavior, intervening before an episode. • Help develop strategies to prevent behavior. • Five sense exercise

28. Pharmacologic Interventions • Controlling emotional dysregulations • MAOIs • SSRIs • Others - SNEIs • Reducing impulsivity - mood stabilizers • Transient psychotic episodes - antipsychotics • Reducing self-injurious behavior • Naltrexone for dissociative symptoms has been studied. • Atypical antipsychotics • Decreasing anxiety • Buspirone, careful use of benzodiazepines

29. Nursing Management: Psychological DomainAssessment • Appearance and activity level • Reflect mood and psychomotor activity • Usually experience depression • Moods • Inhibited grieving • Mood fluctuations • Impulsivity • Cognitive disturbance • Dichotomous thinking

30. Nursing Management:Psychological DomainAssessment (cont.) • Dissociation and transient psychotic episodes • Interpersonal skills • Assessment of person’s ability to relate to others • Determine sexual partners • Self-esteem and coping skills • Risk for suicide or self-injury

31. Nursing Diagnosis Psychological Domain • Risk for self-mutilation • Disturbed thought process • Ineffective coping

32. Pharmacologic Interventions • Monitoring and administration of medications • Easy to monitor in inpatient • Outpatients may have high rate of noncompliance. • Side effect monitoring and management • Patients appear to be more sensitive to side effects. • Drug-drug interaction • Patients tend to be prone to drug interactions. • Teaching points

33. Nursing Interventions: Psychological Domain • Nurse-patient relationship • Establish trust. • Recognize conflicting fears of abandonment and intimacy. • Establish personal boundaries and limitations. • Abandonment and intimacy fears • Recognize conflict. • Any termination needs to be planned carefully. • Establish personal boundaries and limitations. • Management of dissociative states • Determine triggers.

34. Nursing Interventions: Psychological Domain (cont.) • Behavioral interventions • Goal is to replace dysfunctional behaviors with positive ones. • Validate positives; avoid confrontation if possible. • Cognitive interventions • Emotional regulation • Communication triad • Distraction or thought triad • Challenging dysfunctional thinking • Management of transient psychotic episodes • Patient episodes

35. Nursing Management:Social DomainAssessment • Functional status • Current job • Community activities • Social support systems • Family assessment

36. Nursing Interventions:Social Domain • Milieu management • Group interventions • Family and social support

37. Nursing Management Psychological Assessment • Appearance and activity level • Moods - inhibited grieving • Impulsivity • Suicide and/or self-injurious behavior • Dichotomous thinking • Dissociation and psychotic episodes • Self-esteem and coping skills

38. Nursing Management Social Assessment • Family • Interpersonal skills • Social support systems

39. Nursing Diagnosis • Risk for self-mutilation • Altered thought processes • Ineffective coping • Personal identity disturbance • Anxiety • Grief • Low self-esteem • Powerlessness • Social isolation • Spiritual distress

40. Biologic Interventions • Sleep management • Nutrition • Management of psychotic episodes • Prevention of self-injury • Pharmacologic management

41. Psychological Interventions: Cognitive • Communication triad • An “I” statement to identify and express their feelings • A nonjudgmental statement of the emotional trigger • What could be done differently or what would restore comfort to the situation • Thought stopping • Challenging dysfunctional thinking (Text Box 22-4) • Education

42. Social Interventions • Milieu management • Group interventions • Family and social support

43. Antisocial Personality Disorder • Pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence • Behaviorally impulsive • Interpersonally irresponsible • Fail to adapt to the ethical and social standards of community • Interpersonally engaging, but in reality lack empathy • Easily irritated, often aggressive

44. Epidemiology and Risk Factors • 0.2 to 3% of the population • Age of onset - exhibit antisocial behavior before 15 • Men more often diagnosed (See Text Box 22-6.) • Present in all cultures • Comorbid with alcohol and drug abuse

45. Etiology • Biologic • Genetic component – Five times more common in first-degree relatives • Biochemical - not well understood • Psychological • Insecure attachments • Difficult temperament • Social • Chaotic families • Abuse

46. Nursing ManagementAssessment • Difficult to establish a relationship • Determine quality of relationships • Impulsivity • Aggression • Ability to assume responsibility for their actions • Amount of blaming others

47. Nursing Diagnosis • Altered role performance • Ineffective individual coping • Impaired communication • Impaired social interactions • Defensive self-esteem • Risk for violence

48. Nursing Management • Biologic - physical effects of chronic use of addictive substances • Psychological • Self-responsibility facilitation • Self-awareness enhancement • Anger management • Patient education • Social • Group • Milieu

49. Family Interventions • Help families establish boundaries. • Help families recognize patient’s responsibility for his or her actions.

50. Histrionic Personality Disorder • Attention seeking, life of the party, uncomfortable with single relationship • Women - dress seductively • Men - dress - “macho” • Become depressed when not center of attention