Chapter #22
Kim has a diagnosis of BPD. She often exhibits alternating clinging and distancing behaviors. Which of the following is the most appropriate nursing intervention with this type of behavior? A. Encourage Kim to establish trust in one staff person with whom all therapeutic interaction should take place. B. Secure a verbal contract from Kim that she will discontinue these behaviors. C. Withdraw attention if these behaviors continue. D. Rotate staff members who work with Kim so that she will learn to relate to more than one person.
D. Rotate staff members who work with Kim so that she will learn to relate to more than one person.
Are antipsychotics able to help relive paranoid within patients diagnosed with Cluster A Paranoid Personality Disorder?
antipsychotics are NOT able to relieve paranoia as patients with this disorder see the world as such all the time, constantly being "on guard"
Types of Personality Disorders: Cluster C
characterizes behaviors described as anxious or fearful including Dependent Personality Disorder
Types of Personality Disorders: Cluster B
characterizes behaviors described as dramatic/emotional or erratic including Antisocial Personality Disorder, Borderline Personality Disorder, Histrionic Personality Disorder, and Narcissistic Personality Disorder
Types of Personality Disorders: Cluster A
characterizes behaviors described as odd or eccentric including Paranoid Personality Disorder, Schizoid Personality Disorder, and Schizotypal Personality Disorder
Types of Personality Disorders: Cluster A- Schizotypal Personality
defined as a MORE severe form of Schizoid Personality Disorder as the client isn't only aloof but isolated as well, bland behavior, apathetic mannerisms, possible hereditary link, early family dynamics of indifference (overall nurture issues), patterns of discomfort with personal affection/closeness, and may be part of the Schizophrenia Spectrum SCHIZOPHRENIA SPECTRUM = possible psychological influence (ex. anatomic deficits or neurochemical dysfunction) with certain areas of the brain
Types of Personality Disorders: Cluster C- Dependent Personality
defined as a pattern developed from childhood of extreme reliance on others for emotional support & decisions and is relatively common within the population but more common in WOMEN (as well as the YOUNGEST CHILD); clinical manifestations include a low self-worth, easily hurt by criticism/disapproval, avoids positions of responsibility or become anxious when forced into hem, assumption of passive/submissive roles in relationships, and are consistent with NOT making their own decisions
Types of Personality Disorders: Cluster B- Antisocial Personality
defined as a pattern of socially irresponsible, exploitative, and guiltless behavior which reflects a disregard for the rights of others (ex. psycho/sociopath)
Types of Personality Disorders: Cluster B- Narcissistic Personality
defined as an exaggerated sense of self-worth, intense absorption of self, lack of empathy, belief of the inalienable right to receive special consideration, and more common in MEN; development is dependent on one's childhood environment as their fear, failures, or dependency needs were responded to with criticism, disdain, or neglect (narcissistic parents)
Types of Personality Disorders: Cluster B- Histrionic Personality
defined as dramatization of feelings and symptoms to obtain attention, connected to Somatization Disorder, and is more common in WOMEN
Types of Personality Disorders: Cluster A- Paranoid Personality
defined as pervasive distrust & suspiciousness, motives of others are interpreted as malevolent, more common in MEN, develops early in childhood with a possible hereditary link, and patients were probably subject to early parental antagonism + aggression
Types of Personality Disorders: Cluster B- Borderline Personality
defined upon the patient's pattern of coping, relating to others, and emotional regulation which results in many interpersonal issues; treatment focuses on turning patient personality into positive strengths
Personality Traits
enduring/stable patterns of perceiving, relating to, and thinking about the environment as well as oneself
Etiology of Cluster B Antisocial Personality Disorder
etiological implications of Antisocial Personality Disorder includes a possible genetic influence, sociopathic or alcoholic parent (deprivation during the FIRST FIVE years of life), aggressive childhood temperament, extreme poverty, removal from the home, erratic/inconsistent methods of discipline, and overall early childhood INSTABILITY
Etiology of Cluster B Borderline Personality Disorder
etiological implications of Cluster B Personality Disorder include the psychosocial influenced of childhood trauma or abuse, instability of developmental factors, and may NOT have learned a healthy sense of autonomy related to their chaotic or abusive childhood environment
Nursing Interventions for the Patient with a Cluster A Personality Disorder
for patients with a Cluster A Personality Disorder, focus on creating structure, remaining calm, promoting a trustworthy relationship through the presentation of reality in an objective manner, encouragement of social skills/interaction at the patient level, and help with communication by translating words into feelings
Nursing Interventions for the Patient with a Cluster B Personality Disorders
for the patient with a Cluster B Personality Disorder, focus on creating structure through remaining calm & trustworthy (same as Cluster A), encourage appropriate social skills/interactions with others, give BOTH positive & negative feedback (ex. focusing on behavior when inappropriate), and help communicate with boundary establishment ex. "No one is going to sit with you at lunch because you're being rude, so you have to eat in your room."
Nursing Interventions for the Patient with a Cluster C Dependent Personality Disorder
for the patient with a Dependent Personality Disorder, focus on coping skills, encouraging appropriate social/skills interactions while maintaining an ASSERTIVE demeanor, and that the patient will take responsibility for their own decisions it's important to maintain PROFESSIONAL BOUNDARIES with these patients as they will often try to make healthcare providers make decisions for them
Psychoanalytic Psychotherapy is used for patients with which Cluster B Personality Disorder?
histrionic
Types of Personality Disorders
includes Clusters A-C
Nursing Interventions for the Patient with a Cluster B Antisocial Personality Disorder
interventions for patients with Antisocial Personality Disorder include ensuring safety of the patient + others, helping the patient recognize as well as decrease unacceptable behavior (ex. working with healthcare providers to remain unemotional while enforcing rules), assisting the patient to gain insight into their own behavior, and helping the client to learn delayed gratification; remember that these patients are AWARE that they are alone and have NO emotional connection with others
What is an important Nursing Intervention for a patient with Cluster A Paranoid Personality Disorder?
making it important for them to learn that others can be trusted
Manifestations of Cluster B Antisocial Personality Disorder
manifestations of patients with Antisocial Personality Disorder include exploitation of others, using others with a disregard of their rights (manipulation), guiltless, general disregard of the law, cold/callous, intimidating demeanor, cruel/malicious, and inability to form satisfying interpersonal relationships with others patients are typically seem due to LEGAL ISSUES
Manifestations of Cluster B Borderline Personality Disorder
manifestations of patients with Borderline Personality Disorder include patterns of intense relationships with affective instability, fluctuation of extreme attitudes regarding others (ex. people are either ALL good OR ALL bad = SPLITTING), impulsivity/spontaneity, trouble regulating emotions, boundary issues, self-destruction, intensity v. instability of affect & behavior, short-term episodes of alternating depression, DIFFICULTY BEING ALONE, and the use of manipulation to have needs met patients can fall on the border between neuroses-psychoses, designating them as "borderline"
Manifestations of Cluster B Histrionic Personality Disorder
manifestations of patients with Histrionic Personality Disorder include excitability, emotional (ex. dramatic reactions), "colorful," extroverted behavior, self-dramatization, seductive, manipulative, exhibitionistic, highly distracted, difficulty paying attention to detail, easily influence by others, and have difficulty forming close relationships as they are caught up in drama (inability to connect due to instability) MAIN GOAL = attention
Manifestations of Cluster B Narcissistic Personality Disorder
manifestations of patients with Narcissistic Personality Disorder are overly self-centered, exploit others in an effort to fulfill own desires, relaxed/care-free, cheerful, and grandiose optimistic mood which can easily change due to self-esteem fragility FRAGILITY = NOT meeting self-expectations, positive feedback from others, or responds to negative feedback with rage or shame/humiliation (becomes upset if NOT recognized by others as special)
Manifestations of Cluster A Paranoid Personality Disorder
manifestations of patients with Paranoid Personality Disorder includes constantly on guard, hypervigilant/anxious, prepared for real or imagined threats, trusting of no one, oversensitivity, misinterprets/distorts & magnifies minute cues, and is always on the lookout for others who are aggressive toward them
Manifestations of Cluster A Schizoid Personality Disorder
manifestations of patients with Schizoid Personality Disorder includes indifference to others (unable to connect with others), aloof, emotionally cold, inappropriately serious about all matters, difficulty acting in a light-hearted manner, and appears shy/anxious or uneasy when in the presence of others
Manifestations of Cluster A Schizotypal Personality Disorder
manifestations of patients with Schizotypal Personality Disorder include magical thinking, ideas of reference (ex. news is talking directly to them), illusions, bizarre speech patterns, decompensation or demonstration of psychotic symptoms when under stress, bland + inappropriate affect, and ability to reason though mild psychotic symptoms
Cluster B Borderline Personality Disorder v. Bipolar Disorder
many of these patients have issues with mood swings + boundaries which makes it confused often with Bipolar Disorder Borderline Personality Disorder is NOT a mood disorder and is NOT caused by a neurotransmitter (biochemical) imbalance, BPD characteristics are ALWAYS PRESENT
Personality Disorders & Other Diagnoses
many patients with other psychiatric or medical diagnoses manifest Personality Disorder symptoms, so they will most likely be treated for their other diagnoses as Personality Disorder patients do NOT seek help for it as they do NOT see it as a problem; nurses are likely to frequently encounter patients with these personality characteristics in all settings
Nursing Interventions for the Patient with a Cluster B Borderline Personality Disorder
nursing interventions for the patient with Borderline Personality Disorder are prioritized for patient safety considering the patient's risk for self-harm, suicide, and risky behaviors; assist the patient to confront their true source of internalized anger, and allow the patient to direct feelings into constructive ways of coping PATIENT OUTCOMES = the patient will related to more than one staff member by independently completing ADLs, NO manipulation of staff members against the other to fulfill own desires (assertion), emotional regulation by self, and NO splitting of staff members
Personality Disorders
occur when engrained personality traits become inflexible, maladaptive, and a cause of significant functional impairment or subjective stress; the patient will be unable to cope well enough with a changing environment and different types of people some symptoms might be helped with medication, but the disorder can NOT
Personality Development
occurs in response to a number of biological & psychological influences such as heredity, temperament, experiential learning, and social interaction
Types of Personality Disorders: Cluster A- Schizoid Personality
primarily defined by a profound defect in the ability to form personal relationships, failure to respond to others in a meaningful or emotional way, more frequent in MEN, and a childhood characterized as notably lacking in nurture (cold)
Overall Personality Disorder Treatment
treatment options for patients with a Personality Disorder include Interpersonal Psychotherapy, Psychoanalytical Psychotherapy, Milieu or Group Therapy, Cognitive/Behavioral Therapy, Dialectical Behavior Therapy, or Psychopharmacology (symptom-based)
Overall Personality Disorder Treatment: Psychoanalytic Psychotherapy
used for patients with a Cluster B Histrionic Personality Disorder in order to address unconscious symbolism for drama and their need for attention
Overall Personality Disorder Treatment: Dialectical Behavior Therapy Program (DBT)
used in Cluster B Personality Disorders to work on building a sponsorship-like stable connection, performing a "reality check," and working through emotional regulation as well as relationships A. Group Skills Training (ex. self-soothing skills) B. Weekly Individual Psychotherapy (ex. telephone therapist availability) C. Therapist Team Meetings
Overall Personality Disorder Treatment: Cognitive/Behavioral Therapy
used to build social skills and address patient thoughts through relaxation exercises as well as working on assertiveness
Nursing Diagnoses for the Patient with Cluster B Antisocial Personality Disorder
1. Risk for Other-Directed Violence; related to rage reactions, negative role-modeling, and inability to tolerate frustration. 2. Defensive Coping; related to dysfunctional family system, always automatically self-protective. 3. Chronic Low Self-Esteem; related to repeated negative feedback resulting in diminished self-worth.
Nursing Diagnoses for the Patient with Cluster B Borderline Personality Disorder
1. Risk for Self-Mutilation; related to emotions. 2. Complicated Grieving; related to a fixation in the grieving process stage of anger. 3. Impaired Social Interaction; related to extreme fears of abandonment. 4. Disturbed Personality Identity; related to fear of disturbance due to poor boundaries. 5. Anxiety; severe-panic related to unconscious conflicts based on fear of abandonment. 6. Chronic Low Self-Esteem; related to lack of positive feedback.
Kim, a client diagnosed with BPD, manipulates the staff in an effort to fulfill her own desires. All of the following may be examples of manipulative behaviors in the borderline client except? A. Refusal to stay in room alone, stating, "It's so lonely." B. Asking Nurse Jones for cigarettes after 30 minutes, knowing the assigned nurse has explained she must wait 1 hour. C. Stating to Nurse Jones, "I really like having you for my nurse. You're the best one around here." D. Cutting arms with razor blade after discussing dismissal plans with physician.
A. Refusal to stay in room alone, stating, "It's so lonely."
Treatment of the Patient with Cluster B Borderline Personality Disorder
A. SSRI w/ Therapy (mood regulation, reduce self-harm) B. Anticonvulsants w/ Emotional Treatment (short-term mood stabilization)
Dialectical Behavior Therapy Program (DBT) is used for patients with which Personality Disorder Clusters?
CLUSTER B (due to emotion difficulty and relationship connection)
Which of the following behavioral patterns is characteristic of individuals with schizotypal personality disorder? A. Belittling themselves and their abilities B. A lifelong pattern of social withdrawal C. Suspiciousness and mistrust of others D. Overreacting inappropriately to minor stimuli
B. A lifelong pattern of social withdrawal
Milieu therapy is a good choice for clients with antisocial personality disorder because it? A. Provides a system of punishment and rewards or behavior modification. B. Emulates a social community in which the client may learn to live harmoniously with others. C. Provides mostly one-to-one interaction between the client and therapist. D. Provides a structures setting in which the clients have very little input into the planning of their care.
B. Emulates a social community in which the client may learn to live harmoniously with others.
