Personality Disorder

Personality Disorder

Personality Disorders • Client suffers from lifelong, inflexible and dysfunctional patterns of relating and behaving • Patterns are excessive and interfere with daily life • Relationships • Dysfunctional patterns and behaviors of the client • Cause distress to others • Client does not recognize dysfunction and only becomes distressed when others react to them negatively

Behavioral Characteristics • Personality Disorder is a way of relating to the world. An enduring pattern of acting and responding, • Narcissism- speak and act as if their own needs are paramount. Normal in Adolescents. • Annoying: Tend to “Get under your skin.” • Problems in interpersonal situations.

Personality Disorder • Personality Disorders are difficult to treat • Most are not in Psychiatric Hospitals • May be admitted to an inpatient facility but must have an Axis I diagnosis also (alcoholism, depression and anxiety) • The most common personality disorder inpatient is Borderline Personality Disorder • Most are treated outpatient in individual or group therapy • May be in drug treatment center • Axis II Diagnosis • Used to designate • Personality disorders or traits • Developmental Disorders • Habitual use of Particular defense Mechanism

Affective/Cognitive Characteristics • Anxiety: Varies in the different clusters. • Behavior is their way of coping with anxiety and the individual does not consider how their behavior will effect others. • Cognitive issues: • Rigidity of responses often causes individual to not reach their potential. • Inflexibility leads to mistakes in judgment making them prone to job problems.

Socioculturally • Believe problems in their lives are other people’s fault or the rest of the world. • History of broken relationships, family and marital problems. • Alcoholism and drugs • Age of onset; Adolescence, tend to decrease in middle age. What is normal in adolescence is not later.

Grouped by the Three Clusters of Behavior in the DSM IV TR • Cluster A • Exhibit odd and eccentric behaviors; includes schizoid, schizotypal, and paranoid disorders. • Cluster B • Exhibit dramatic emotional and erratic behaviors; includes Narcissistic, histrionic, antisocial, and borderline disorders. • Cluster C • Exhibit anxious fearful behaviors; includes dependant, avoidant and obsessive-compulsive disorders.

Gender and Personality Disorders • Female: greater percentage of Borderline or Histrionic • Male: Greater Percentage of Paranoid, Schizoid, Antisocial, and Narcissistic

This Presentation • Cluster A will be reviewed first • Cluster C will be reviewed second • Cluster B will be the most comprehensive review • Borderline Personality Disorder will be reviewed last in this presentation. This disorder is the most common Axis II disorder encountered by the Mental Health Nurse.

Cluster A • Characteristics: odd, eccentric behavior, suspicious ideations, and social isolation. Know this cluster as a group (do not have to recognize each individually) • Paranoid • Schizoid • Schizotypal

Schizoid Lacks desire to be close to others Lacks close friends Solitary activities Little interest in sexual activity Avoids activities Appears cold and detached Appears indifferent to praise or criticism Schizotypical Ideas of reference Magical thinking or odd beliefs Unusual perceptual experiences including bodily illusions Odd thinking and speech Suspicious; social anxiety Few close relationships Cluster A

Paranoid • Behaviorally; often alcoholic, secretive, argumentative and fearful of people. Hyper-alert to danger and rarely seek help. • Angry, Controlling, and judgmental. • Cognitively; very guarded “none of your Business.” • Difficulty in intimate relationships. Cold aloof manner, Often litigious. • Holds grudges; lacks trust in others

Cluster C • Dependent Personality Disorder • Pervasive, excessive need to be taken care of • Submissive and clinging • Fears of separation • Avoids responsibility • Expresses helplessness • Interventions • Nurse assists client to increase responsibility in daily living • Needs assistance with anxiety • Teach assertiveness and verbalization of feelings

Avoidant Personality Disorder Severe shyness and avoidant behavior Socially uncomfortable and withdrawn Nurse helps by assisting the client in setting small goals Discusses fears and feelings prior to meeting a goal Obsessive Compulsive Personality Disorder Perfectionist and inflexible Preoccupied with trivial details and procedures Difficulty expressing warmth and kindness Having fun is difficult Nurse helps by assisting the client to explore feelings and try new activities Teach that making mistakes is normal to decrease need for perfection Cluster C

Cluster B • Characteristics are; impulsive, dramatic behavior, intolerance of frustration, and exploitative interpersonal relationships. (Know Antisocial Borderline and Narcissistic) • Histrionic • Narcissistic • Also occasionally seen in inpatient treatment) • Antisocial • Borderline • (most often Personality Disorder seen in inpatient treatment)

Histrionic Dramatizes and draws attention to self Feels helpless and needs reassurance Extroverted and thrives on attention Lacks insight Temper tantrums, outbursts of anger over minor events The nurse gives positive reinforcement for acts that are focused on others The nurse facilitates independence in problem solving and daily functioning Narcisistic Grandiosity and exageration about accomplishments Needs to be admired Indifferent to criticism A sense of entitlement (should be rewarded despite the lack of effort or work) Lack of empathy for others The nurse uses supportive confrontation of discrepancies; limit setting and a consistent approach Cluster B

Antisocial Personality Disorder • Pattern of disregard of the rights of others • Poor boundaries • Does not have a good understanding of where they stop and the next person begins. • History of disordered life functioning • Parent child relationship is unstable • Vacillates between permissiveness and severe punishment • Poor understanding of limits on there behavior because limits are very inconsistent • Genetic predisposition

Antisocial • Predominant childhood characteristic of lying, stealing and being truant. • High correlation between this disorder and substance abuse. • Conform to rules when it suits their purpose. • Express themselves easily, but with little personal involvement. • Professes undying love one moment rejection the next. Irritating , aggressive, low guilt. • Often in the criminal justice system and NOT the Mental Health system. • Example of lack of guilt or remorse: • Client will state they needed to rob a store with a gun because of their low income and inability to support themselves. • The reason why the are in jail is because they were caught. It is the mistakes they made that led them to be caught that is the problem; NOT the crime.

Antisocial/ Cognitive & Socially • Initially appear to be charming and intellectual • Smooth talker • Deny and rationalize their behavior • Egocentric and grandiose • Confident everything will work out • Ego-syntonic; Cannot delay gratification and make no long range plans • Unable to sustain close relationship. • Sex life is impersonal and impulsive. • Quick anger, lack of guilt, abusive • Hospitalized to avoid the law

Treatment of Anti-social Personality Disorder • Drug Treatment center, jails and prisons • Essential for staff to agree on rules and stick with them. • Will try to play one staff or shift against another. • Best form of Treatment; Peer counseling and self-help groups, like AA.

Borderline Personality Disorder

Borderline Personality Disorder DSM IV TR Criteria • Unstable, intense relationships characterized by over-idealizing and devaluation others • Intense ambiguous feelings. • This is when two feelings such as love and hate are present at the same time • Client with BPD cannot resolve feelings that others are not perfect and cannot meet all of their needs • Impulsiveness and self-destructive • Substance abuse • Sexual promiscuity • These behaviors help them to feel better for a short period of time

DSM IV TR Criteria Cont. • Recurrent suicidal threats & gestures • Self-Injurious Behavior (SIB) • Affective instability • anxiety to depression • Inappropriate displays of anger

DSM IV TR Criteria Cont. • Marked persistent identity disturbance in two areas: career, friends, values • Chronic feelings of emptiness and boredom. • Frantic efforts to avoid abandonment • Transient, stress related, psychotic symptoms or sense dissociative.

Etiology of Borderline Personality Disorder • Masterson’s theory: Child tries to separate and mom withdraws love. Child clings and mom rewards. Child unsure of affection. Fathers may be distant, alcoholic or unavailable. • Neglect of the child • Split occurs: Good me-Bad me • Invalidating, chaotic environment • No object constancy (consistency in care giving of the child). Develops a low tolerance of ambivalence. • 75% of clients with BPD are women and victims of childhood sexual abuse

Identity Intimacy No sense of who they are Feel very empty See themselves as all good or all bad Very needy fearful abandonment fear Issues for Borderline

Symptoms • Self-mutilation • Clients discuss feelings of depersonalization • To prove they are alive, they cut until they feel pain • May also state that the physical pain alleviates the emotional pain • Anhedonia • Cannot enjoy life in conventional way • Impulsiveness • Cannot soothe self; very intense emotions • Try to teach coping skills.

Borderline Personality Disorder and Countertransference • Positive Countertransference • Lack of a sense of identity and inability to meet their own needs • Look to others as being “all good” and seek to get others to meet their needs • Negative Countertransference • Other people will eventually fail in attempting to meet all the needs of an individual with BPD • Results in malice/rage • Aversion: More serious problem • Working with these problems is the responsibility of an advanced practice Health Care Provider

Therapy • Clients have long-term issues of abuse and neglect • An advanced practice Health Care Provider can assist the client in talking about these events in individual or group therapy • The nurse stays in the “here and now” • This is very therapeutic • Can assist the client in identifying how their behavior results in unwanted responses from others • Helps the client to identify coping strategies and understand the disorder through teaching

Group Therapy • Clients make good group members; can be very insightful for others • Decreases transference issues. Feedback from group can be helpful in dealing with unrealistic expectations. • Attention seeking behavior and entitlement issues are dealt with better in group. • AA, ACOA, groups are very useful.

Nursing Interventions • Safety • Clients in the acute care setting are in crisis • Keep environment free of contraband • Assess for suicidal thoughts frequently • Observe closely • Limit Setting • Maintain clear boundaries • Therapeutic Relationship • Acknowledge emotional pain • Offer support and empower to understand and change dysfunctional behavior • Review: What happened? How did you react (behave)? How did that work for you? What can you do next time? • Prevent Splitting • Be consistent • Follow all rules of the unit • Follow the client’s treatment plan • Prevent Triangulation • Clients will try to get the nurse to engage in complaints about another staff (a third person) • Refer the client back to the staff they have a problem with • Offer to talk about the client

Treatment and Individual Therapy • Working with the client to change behaviors can be like a roller coaster for the health care provider. • Client trusts is improving, then panics fearing separation • Experiences abandonment depression, clings to others and then distances. • Clinging: the therapist is all good • Distancing: anger; the therapist is all bad

BPD: Ups and Downs • Example: • Client appears better • Ready for discharge • Fears abandonment • Makes suicide gesture • This is not personal (it is not the nurse’s responsibility; this behavior is generated by a fear of abandonment • Client believes they are getting worse and needs reassurance and reminder of progress…regression can be temporary • The nurse needs to be OBJECTIVE not emotional… MATTER of FACT in the approach to the client

Interventions and Milieu • Contracts with specific goals and responsibilities are important. • Never discuss another staff member with these client • Goal is “reintegrate the split” • Can remind client of the other side (all people have both good and bad qualities)

Treatment and Milieu • Hold Client responsible for actions while maintaining positive expectations. Have consequences identified on plan and stay with them. • Remain CALM and MATTER-OF-FACT • Realize this is client’s illness, behavior are not personal. • Role is with day to day activities. One person process issues with client

National Education Alliance for Borderline Personality Disorder • New group that has begun • Had a national conference in Houston, Feb. 2006. • Latest research on pathophysiology • Uses an educational approach, family support • Believes trauma is important in the development of BPD

The End

Personality Disorder