PERSONALITY DISORDERS

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PERSONALITY DISORDERS

• Mercedes A Perez-Millan MSN, ARNP

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PERSONALITY

• Personality is a consistent way of thinking and
  feeling which results from the interaction of a
  persons genetic
• make-up his level of education
• and past experiences.
• Largely unconscious
• Cannot be changed easily

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PERSONALITY DISORDERS

• Occur when traits become inflexible and
  maladaptive but stable over time.
• Cause either significant functional impairment or
  subjective distress. However they stay in the
  main stream of society.
• Present with symptoms more subtle than other
  disorders.
• Onset in adolescence or early adulthood.

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DSM-IV-TR CRITERIA

• Axis II disorder
• Enduring pattern of inner experience and behavior
  that deviates markedly from an individuals
  culture manifesting in two or more of the
  following areas
• Cognition
• Affect
• Interpersonal functioning
• Impulse control

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DSM-IV-TR CRITERIA Continued

• Enduring pattern is
• Inflexible/pervasive personal/social situations
• Significant distress in social, occupational,
  other areas of functioning
• Of stable and long duration
• Not due to physiological effects of substance or
  medical condition

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Prevalence and Co-morbidity

• 10 to 15 in general populations
• Often co-occur with depression and anxiety
• Onset usually occurs before onset of other
  psychiatric disorders
• Various PDs often coexist

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Biological Determinants

• Certain inherited traits may
• be present at birth.
• Genetic alterations may result
• in an extreme variation.
• Unfavorable environmental
• conditions may affect the
• development of the disorder.

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PERSONALITY TRAITS

• Specific behaviors or mannerisms specific
  
• to an individual which may be inherited
• Harm avoidance
• Persistence
• Neuroticism (negative affect)
• Dependence versus independence
• Introversion versus extraversion
• Conscientiousness versus undependability
• Antagonism versus agreeableness
• Closeness versus openness to experiences

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Psychosocial Factors

• Learning theory
• Cognitive theory
• Psychoanalytic theory
• Environmental factors

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Assessment

• Minnesota Multiphasic Personality Inventory
  (MMPI) to evaluate personality
• Full medical history
• Psychosocial history
• Suicidal or aggressive thoughts
• Risk of harm from self or others
• Use of medications or illegal substances
• Ability to handle money
• Legal history
• Current or past abuse

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Impact of PD Clients Behaviors on Caregivers

• Overwhelming needs of clients may also be
  overwhelming for caregivers
• Caregivers may feel
• Confused
• Helpless
• Angry
• Frustrated

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Splitting Behaviors of Clients

• Primary defense used by clients with borderline
  PD
• Client labels individuals either all good or
  all bad
• When all-good person does not met client's needs,
  that person becomes all bad
• Someone else then labeled all good, others all
  bad
• Creates conflict in staff members
• To decrease conflict among staff
• Open communication in staff meetings
• Ongoing clinical supervision

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COMMON BEHAVIORS IN PERSONALITY DISORDERS

• Manipulative and self-centered
• Struggles for power and control
• Rigidity and Inflexibility
• Poor ability to self-regulate
• Disability in working and loving
• Ability to evoke interpersonal conflict
• Capacity to "get under the skin" of others

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DSM IV- CATEGORIES

• CLUSTER A Behaviors that are described as odd
  or eccentric
• Paranoid
• Schizoid
• Schizotypal

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DSM IV- CATEGORIES

• CLUSTER B Behaviors that are described as
  dramatic, emotional, or erratic
• Antisocial
• Borderline
• Histrionic
• Narcissistic

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DSM IV- CATEGORIES

• CLUSTER C Behaviors that are described as
  anxious or fearful
• Avoidant
• Dependent
• Obsessive compulsive

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Outcomes

• The patient will be able
• Use adaptive coping strategies to deal with
  conflict.
• Accept responsibilities for own actions/
  behaviors.
• Communicates needs appropiately.
• Demonstrates self-restrain of compulsive or
  impulsive behavior. see table 16-5

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Nursing Diagnosis

• Ineffective Coping
• Severe/ Panic Levels of Anxiety
• Self-Mutilation
• Risk for Other Directed violence
• Impaired Parenting
• Social Isolation
• Defensive Coping
• Chronic Low Self-Esteem
• Non-Compliance see table 16-4

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NURSING CARE

• Usually not admitted for P.D.
• Axis I psychiatric diagnosis needed for admission
  PD axis II
• Realistically behavior probably will not change
  significantly.

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NURSING CARE- ODD, ECCENTRIC

• Objective, matter of fact.
• Avoid being too nice or friendly.
• Clear, simple, consistent verbal-non-verbal
  communication.
• Give clear straightforward explanations.
• Warn about changes, side effects, etc.
• Help identify feelings.
• Assist with problem solving.
• Gradually involve in group situations but do not
  insist. Respect need for social isolation.

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NURSING CAREDAMATIC, ERRATIC

• Prevent self-harm. No-harm contract.
• Set limits on inappropriate or manipulative
  behavior.
• Provide clear consistent boundaries.
• Assist in examining consequences of behavior.
• Consistent approach by staff.
• Do not rescue or reject.
• Remain neutral, avoid engaging in power struggles
  or becoming defensive to pts comments.
• Give recognition for goal achievement.

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NURSING CAREDAMATIC, ERRATICContinuation

• Explore feelings.
• Teach problem solving and role model
  assertiveness.
• Encourage and model concrete and descriptive
  communication.
• Document behaviors and incidents objectively.
• Encourage follow up treatment

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NURSING CAREANXIOUS, FEARFUL

• Caring consistent approach
• Clear expectations for behavior
• Expect patient to make decisions
• Teach assertiveness
• Encourage to identify () attributes
• Provide () feedback for increased interactions
  in social situations
• Teach stress management and relaxation techniques

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Interventions for Manipulative, Aggressive, or
Impulsive Behavior

• Manipulative behavior (Box 16-2)
• Aggressive behavior (Box 16-3)
• Impulsive behavior (Box 16-4)

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• Basic Level Interventions
• Milieu therapy
• Psychobiological interventions
• Case management
• Advanced Practice Interventions
• Dialectical behavioral therapy (DBT)
• Skills-oriented psychotherapy
• Supportive psychotherapy
• Group therapy