PSYCHIATRIC NURSING PERSONALITY DISORDERS

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PSYCHIATRIC NURSINGPERSONALITY DISORDERS

• Sources Psychiatric Mental Health Nursing,
  Fortinash Holoday-Worret, Mosby-Year Book Inc.,
  1996 Mental Health Nursing, 4th ed., Fontaine
  Fletcher, Addison Wesley Longman Inc., 1999
• Instructor Doris O. Aghazarian

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PERSONALITY DISORDERSIntroduction

• Clients with personality disorders are among the
  most difficult to treat.
• Most will never enter a psychiatric hospital,
  seek or receive outpatient treatment, or even
  undergo a diagnostic evaluation.
• Some will enter the mental health system through
  family pressure or because of a court order.

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PERSONALITY DISORDERSIntroduction (contd)

• In the majority of cases, people with personality
  disorders perceive their problems and
  difficulties in dealing with other people to be
  external to them.
• They feel victimized and blame others.
• Those who develop an awareness of their
  self-defeating behaviour still remain at a loss
  as to how they got that way or how to begin to
  change.

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PERSONALITY DISORDERSIntroduction (contd)

• There is a high degree of overlap among the
  personality disorders and many individuals
  exhibit traits of several disorders.
• Typically, personality disorders become apparent
  before or during adolescence and persist
  throughout life.
• In some cases, the symptoms become less obvious
  by middle or old age.

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PERSONALITY DISORDERSIntroduction (contd)

• It is extremely difficult to estimate the
  incidence of personality disorders.
• Currently the most commonly diagnosed is
  borderline personality disorder.
• This group accounts for 50 of the diagnoses and
  all the other disorders together make up the
  remaining 50

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PERSONALITY DISORDERSTYPES

• There are ten personality disorders, grouped into
  THREE CLUSTERS.
• The disorders within each cluster are considered
  to have similar characteristics.

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PERSONALITY DISORDERSClusters

• The clusters and corresponding disorders are
• CLUSTER A
• Paranoid
• Schizoid
• Schizotypal
• CLUSTER B
• Antisocial
• Borderline
• Histrionic
• Narcissistic
• CLUSTER C
• Avoidant
• Dependent
• Obsessive-compulsive

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PERSONALITY DISORDERSClusters (contd)

• General description
• CLUSTER A appear eccentric, exhibit much
  withdrawal behaviour
• CLUSTER B appear dramatic, emotional or erratic.
  Tend to be very exploitative in their behaviour
• CLUSTER C appear anxious or fearful. Behaviour
  pattern one of compliance.

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PERSONALITY DISORDERSSpecial note

• The three unstable disorders of category B
  borderline, histrionic and narcissistic
  personality disorders, can barely be
  distinguished from one another.
• More so than with other disorders, the diagnosis
  may be influenced by personal bias, gender
  stereotypes and cultural prejudices on the part
  of the professional
• Antisocial personality is easier to diagnose

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PERSONALITY DISORDERSCluster A Paranoid
Personality D.

• Very secretive-not likely to trust anyone or
  confide in anyone
• Hyperalert to danger
• Argumentative-keep distance that way
• Rarely seek help
• Severe jealousy
• Seldom require hospitalization

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PERSONALITY DISORDERSCluster A Schizoid
Personality D.

• Prefer solitary activities social situations
  increase their anxiety
• Can perform in a job that does not require
  interaction with others (e.g. night watch)
• Their affect is blunted or flat do not express
  feelings verbally or nonverbally. Passive.

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PERSONALITY DISORDERSCluster A Schizotypal P.D.

• Have a considerable disability
• Have the most severe distortions of any of the
  personality disorders inappropriate affect, odd
  beliefs, magical thinking, illusions (such as
  seeing people in the shadows). Preoccupation with
  paranormal phenomena and magical control.
• Peculiarities of ideation, appearance and
  behaviour restrict their lives
• Very isolative and usually avoided by others
• Related to schizophrenia but not as severe
  appears among biological relatives of people
  suffering from schizophrenia for some reason

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PERSONALITY DISORDERSCluster B Antisocial
Personality D.

• A diagnosis of antisocial personality disorder
  (ASPD) requires that the characteristic appear
  before the age of 15, and the client is usually
  given the diagnosis of conduct disorder
• The diagnosis ASPD is not applied until after the
  age of 18
• Behaviour includes lying, stealing, truancy,
  vandalism, fighting, running away from home
• In adulthood, obligations and rules pose a
  problem. Hard to keep a steady job or
  relationship or to honour commitments.
• Grandiose ideation, irritability, aggression, no
  guilt, low tolerance for frustration.
• Hard to learn from own mistakes

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PERSONALITY DISORDERSCluster B Borderline
Personality D.

• People with BPD are characterized by identity
  disturbances. Their vision of themselves and body
  image keeps changing
• Often practice self-mutilation
• They are unable to see both good and bad at the
  same time
• Great overlap with other personality disorders
• Psychotic episodes are common for some and result
  in repeated hospitalizations
• Appears early in boys and later in girls but two
  thirds of diagnosed people are female. The
  explanation for this may be societys
  expectations of girls and women

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PERSONALITY DISORDERSCluster B Histrionic
Personality D.

• People with HPD characteristically seek
  stimulation and excitement in life they are on
  a rollercoaster of joy and despair
• Very self-centered and exaggerate their
  experiences. Verbose, dramatic, emotional
  although arrogant, submissive to authority
  figures.
• Flights of romantic fantasy and
• a lot of acting out
• Seek attention through seduction
• Exaggerated attentiveness to
• own physical appearance
• Suicidal gestures and threat to get
• attention

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PERSONALITY DISORDERSCluster B Narcissistic P.
D.

• People with NPD strive for power and success.
  Their perfectionistic standards make failure
  intolerable.
• Preoccupied with fantasies of success
• brilliance and ideal love
• Arrogant and egotistical. Exploit others.
  Emotionally shallow.
• Exaggerate their accomplishments. Expect special
  treatment, whether or not they achieve anything.

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PERSONALITY DISORDERSCluster C Avoidant P. D.

• Social discomfort and avoiding all contact
• Fearful and shy. Easily hurt by criticism
• Often depressed and anxious
• Overly sensitive to opinions
• of others low self-esteem

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PERSONALITY DISORDERSCluster C Dependent P. D.

• Dependent and submissive
• Do not do things alone and always agree with
  others
• Volunteer to do unpleasant
• and demeaning things
• Severe lack of self-
• confidence
• Avoid all decisions

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PERSONALITY DISORDERSCluster C
Obsessive-compulsive P.D.

• People with OCPD exhibit perfectionism and
  inflexibility
• They need to check and recheck objects and
  situations. Rule-conscious behaviour
• Industrious workers, but uncreative
• Very polite and emotionally distant
• Very protective of their status and possessions
  difficulty sharing anything
• Unable to express emotions
• Preoccupation with logic and intellect
• Torment themselves with guilt and negative
  thoughts
• Has many differences with OCD, especially passion
  for productivity and excessive devotion to work.
• OCD is ego-dystonic while OCPD is ego-syntonic.

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PERSONALITY DISORDERSNot otherwise specified
(NOS)

• The label personality disorder not otherwise
  specified is used when a person does not meet the
  full criteria for any one personality disorder,
  yet there is significant impairment in social or
  occupational functioning or in subjective
  distress.

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PERSONALITY DISORDERSConcomitant disorders

• There is a high correlation between substance
  abuse and antisocial personality disorder.
• It is difficult to separate between
• these disorders.
• Substance abusers are divided into two groups
  primary antisocial addicts (antisocial behaviour
  independent of the need to obtain drugs) and
  secondary antisocial addicts (antisocial
  behaviour directly related to drug use)

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PERSONALITY DISORDERSConcomitant disorders
(contd)

• Psychotic disorders occur with schizotypal,
  borderline and dependent personality disorders
• Mood disorders occur more often with avoidant and
  borderline personality disorders
• Anxiety disorders occur with avoidant, dependent
  and borderline personalities
• Suicides occur when there are episodes of
  depression, substance abuse or both

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PERSONALITY DISORDERSPrognosis and Onset

• Guarded.
• By definition, individuals with personality
  disorders have demonstrated pervasive and
  inflexible behaviours and thoughts that are
  characterized by long-standing, maladaptive
  patterns of relating to others, which deviate
  markedly from the expectations of the
  individuals culture.
• Onset is before adolescence, in adolescence or in
  early adulthood.

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PERSONALITY DISORDERSNursing intervention

• The nurse can play a very important role by
  helping in self-exploration and substitution of
  dysfunctional patterns with functional ones
  through cognitive and long-term treatment aimed
  at educating the client, particularly in the area
  of problem-solving.

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PERSONALITY DISORDERSFocused nursing assessment

• Always make sure to conduct assessment of the
  following areas in all mental health conditions
• BEHAVIOUR
• AFFECT
• COGNITIVE PATTERNS
• SOCIAL SKILLS
• SPIRITUAL COMFORT OR DISTRESS

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PERSONALITY DISORDERSDischarge criteria

• Individuals with personality disorders who are
  hospitalized often have more than one psychiatric
  diagnosis.
• Clients with personality disorders are routinely
  treated in outpatient hospital units, clinics and
  private practices.
• Discharge from hospital is based on the
  evaluation of suicide risk, the securing of
  follow-up and the understanding of the need for
  taking prescribed medication as well as an
  improved understanding of own condition.

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PERSONALITY DISORDERSTherapies

• Occupational
• Art
• Music
• Movement
• Recreational
• Medication
• Individual
• Group
• Family
• Milieu

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PERSONALITY DISORDERSTherapy goals

• Impulse control training assisting the patient
  to gain control of impulses through reflection
• Limit setting establishing the parameters of
  desirable and acceptable behaviour
• Behaviour modification gaining social skills and
  improving interaction. Developing healthy peer
  and other relationships.
• Anxiety reduction minimizing apprehension,
  dread, foreboding or uneasiness related to
  identified or unidentified sources of anticipated
  danger.

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PERSONALITY DISORDERSOutcome identification

• Nurse and client identify goals to work for. You
  decide together, how to measure progress and how
  progress can be determined by you, the client and
  significant others.
• The following outcomes are often desired
• Reduction of self-destructive behaviour
• Decrease in incidents of threatening with
  self-mutilation
• Expression of problem-solving strategies
• Verbalizing internal locus of control
• Interacting socially with others
• Verbalizing decreased anxiety
• Decrease in perfectionistic, secretive,

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PERSONALITY DISORDERSEvaluation

• Keep in mind that clients may respond to
  intervention very slowly
• Define small steps at a time toward the
  achievement of therapeutic goals
• Some clients are in so much pain that they wish
  to grow and change
• Others do not perceive themselves as having a
  problem and choose not to become involved in the
  therapy
• Suicide risk is high in the 20 age bracket and
  keeps decreasing with age

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PERSONALITY DISORDERSChange cannot be forced ...