Chapter 24: Personality Disorders

Personality disorders tend to co-occur with what disorders?

Mood Eating Anxiety Substance misuse

Histrionic Personality Disorder

People with this disorder are excitable and dramatic yet are often high functioning. They may be referred to in terms of "drama queen" or "drama major." Classic characteristics of this population include extroversion, flamboyancy, and colorful personalities. Despite this bold exterior, they tend to have limited ability to develop meaningful relationships. Tends to be diagnosed more commonly in women. Inborn character traits such as emotional expressiveness and egocentricity have also been identified as predisposing an individual to this disorder. This disorder is characterized by emotional attention-seeking behaviors including self-centeredness, low frustration tolerance, and excessive emotionality. Is often impulsive and may act flirtatiously or provocatively.

Dependent Personality Disorder

This disorder is characterized by a pattern of submissive and clinging behavior related to an overwhelming need to be cared for. This need results in intense fears of separation. This may be the result of chronic physical illness or punishment for independent behavior in childhood. The inherited trait of submissiveness may also be a factor.

Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective? a. "I think you are the best nurse on the unit." b. "I'm never going to get high on drugs again." c. "I felt empty and wanted to hurt myself, so I called you." d. "I hate my mother. I called her today, and she wasn't home."

c (. "I felt empty and wanted to hurt myself, so I called you.")

As a nurse prepares to administer medication to a patient diagnosed with a borderline personality disorder, the patient says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response? a. Reinforce this assertive action by the patient. Leave the medication on the table as requested. b. Respond to the patient, "I'm worried that you might not take it. I'll come back later." c. Say to the patient, "I must watch you take the medication. Please take it now." d. Ask the patient, "Why don't you want to take your medication now?"

c (. Say to the patient, "I must watch you take the medication. Please take it now.")

A nurse reports to the treatment team that a patient diagnosed with an antisocial personality disorder has displayed the behaviors below. This patient is detached and superficial during counseling sessions. Which behavior by the patient most clearly warrants limit setting? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling

c (. Verbal abuse of another patient)

One month ago, a patient diagnosed with borderline personality disorder and a history of self-mutilation began dialectical behavior therapy. Today the patient phones to say, "I feel empty and want to hurt myself." The nurse should: a. arrange for emergency inpatient hospitalization. b. send the patient to the crisis intervention unit for 8 to 12 hours. c. assist the patient to choose coping strategies for triggering situations. d. advise the patient to take an anti-anxiety medication to decrease the anxiety level.

c (. assist the patient to choose coping strategies for triggering situations.)

A health care provider recently convicted of Medicare fraud says to a nurse, "Sure I overbilled. Everyone takes advantage of the government. There are too many rules to follow and I should get the money." These statements show: a. shame. b. suspiciousness. c. superficial remorse. d. lack of guilt feelings.

d ( lack of guilt feelings.)

A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. In this case, the self-mutilation may have been due to: a. an inherited disorder that manifests itself as an incapacity to tolerate stress. b. use of projective identification and splitting to bring anxiety to manageable levels. c. a constitutional inability to regulate affect, predisposing to psychic disorganization. d. fear of abandonment associated with progress toward autonomy and independence.

d (. fear of abandonment associated with progress toward autonomy and independence.)

For which behavior would limit setting be most essential? The patient who: a. clings to the nurse and asks for advice about inconsequential matters. b. is flirtatious and provocative with staff members of the opposite sex. c. is hypervigilant and refuses to attend unit activities. d. urges a suspicious patient to hit anyone who stares.

d (. urges a suspicious patient to hit anyone who stares.)

Nursing Assessment guidelines for patients with Antisocial Personality Disorder

1. Assess current life stressors. 2. Assess for criminal history. 3. Assess for suicidal, violent, and/or homicidal thoughts. 4. Assess anxiety, aggression, and anger levels. 5. Assess motivation for maintaining control. 6. Assess for substance misuse (past and present).

The three essential therapies for borderline personality disorder:

1. Cognitive-behavioral therapy (CBT) 2. Dialectical behavior therapy (DBT) 3. Schema-focused therapy

According to the American Psychiatric Association how many personality disorders are there?

10; These 10 behaviors are grouped into clusters

Personality disorders are present in what percentage of patients with mental state disorders?

50%

Planning: Borderline Personality Disorder

A therapeutic relationship is essential with patients who have this disorder. The more intense the patients complaints are, the greater their fear of potential harm or loss is. Be aware of manipulative behaviors such as flattery, seductiveness, and instilling guilt.

Etiology of Antisocial Personality Disorder: Neurobiological

An alteration in serotonin transmission has been implicated with the aggression and impulsivity that frequently accompany this disorder. Lower levels of serotonin along with dopamine hyper-function may contribute to aggression, dis-inhibition, and comorbid substance use.

Environmental Factors and personality disorders

Behavioral genetics research has shown that about half of the variance accounting for personality traits emerges from the environment. These findings suggest that, while the family environment is influential on development, there are other environmental factors besides family upbringing that shape an individual's personality. Childhood neglect or trauma has been established as a risk factor for personality disorders This association has been linked to possible biological mechanisms involving corticotropin-releasing hormones in response to early life stress and emotional reactivity.

Cluster B

Behaviors described as dramatic, emotional, or erratic. -Borderline personality disorder -Narcissistic personality disorder -Historic personality disorder -Antisocial personality disorder

Cluster A

Behaviors described as odd or eccentric. -Personality paranoid disorder -Schizoid personality disorder -Schizotypal personality disorder

Cognitive-Behavioral Therapy (CBT): For Borderline Personality Disorder

Can help individuals to identify and change inaccurate core perceptions of themselves and others and relationship problems. May result in a reduction of mood and anxiety symptoms and reduce the number of self-harming or suicidal behaviors.

What influences the rate of diagnosing personality disorders?

Culture

Nursing Diagnosis for patients with antisocial personality disorder

Diagnoses and nursing care plans should be geared toward maintaining safety and providing structure. Nursing diagnoses are focused on the protection of the patient and others from impulsive and premeditated acts and on improving coping skills. *Risk for other-directed violence *Defensive coping *Impaired social interaction *Ineffective health maintenance.

Personality disorders tend to amplify what?

Emotional dysregulation; describes poorly modulated mood characterized by mood swings. Individuals with emotion regulation problems have ongoing difficulty managing painful emotions in ways that are healthy and effective.

Pharmacological Interventions for patients with Antisocial Personality Disorder

In the United States, there are no FDA-approved medications specifically for treating this disorder. Patients with this personality disorder respond to mood-stabilizing medications such as lithium or valproic acid (Depakote) to help with aggression, depression, and impulsivity. SSRIs such as fluoxetine (Prozac) and sertraline (Zoloft) may be used to decrease irritability and help with anxiety and depression. Benzodiazepines may help with anxiety but should be used with caution because they are addictive agents. Methylphenidate (Ritalin) may help if there is a comorbidity of attention-deficit/hyperactivity disorder.

A personality is considered unhealthy when...

Interpersonal and social relationships and functioning are consistently maladaptive, complicated, or dysphoric.

Personality

Is an individual's characteristic pattern of relatively permanent thoughts, feelings, and behaviors that define his or her quality of experiences and relationships.

Epidemiology of Antisocial Personality Disorder

It is the most researched personality disorder probably due to its marked impact on society in the form of criminal activity. The prevalence of this disorder is about 1.1% in community studies Women may be under-diagnosed due to the traditional close association of this disorder with males.

Psychology of Borderline Personality Disorder

Margaret Mahler (1895-1985), a Hungarian-born child psychologist who worked with emotionally disturbed children, developed a framework for this disorder. She believed that psychological problems are a result of the disruption of the normal separation-individuation of the child from the mother.

Avoidant Personality Disorder

People with this personality disorder are extremely sensitive to rejection, feel inadequate, and are socially inhibited. They avoid interpersonal contact due to fears of rejection or criticism. It is found equally among men and women. Symptoms are noticeable in early childhood. These symptoms include shyness and avoidance that, unlike common shyness, increase during adolescence and early adulthood. Some can function in a protective environment. However, if their support system fails, they can suffer from depression, anxiety, and anger.

Nursing Assessment for patients with Anti-social Personality Disorder

People with this personality disorder do not enter the healthcare system for treatment of this disorder unless they have been court-ordered to do so. Psychiatric admissions may be initiated for anxiety and depression. Keep in mind that questions asked during the assessment phase may not always result in accurate responses because the patient may become defensive or simply not tell the truth. Entering treatment may also be a way to avoid or address legal, financial, occupational, or other circumstances.

Treatment for patients with Dependent Personality Disorder

Psychotherapy is the treatment of choice. Cognitive-behavioral therapy can help patients develop more healthy and accurate thinking by examining and challenging automatic thoughts that result in fearful behavior. This process can help in developing new perspectives and attitudes about the need for other people. Symptoms of depression and anxiety may be treated with the appropriate antidepressant and antianxiety agents. Panic attacks can be helped with the tricyclic antidepressant imipramine (Tofranil).

Treatment for patients with histrionic personality disorder

Psychotherapy may promote clarification of inner feelings and appropriate expression. Group therapy may be useful in this population, although distracting symptoms may be disruptive to group functioning. There are no specific pharmacological treatments available for people with histrionic personality disorder. Medications such as antidepressants can be used for depressive or somatic symptoms. Antianxiety agents may be helpful in treating anxiety. Antipsychotics may be used if the patient exhibits derealization or illusions.

Assessment tools for patients with Borderline Personality Disorder

Self-report inventories such as Minnesota Multi-phasic Personality Inventory (MMPI), are useful because they have built-in validity and reliability scales for the clinician to refer to when interpreting test results. Areas of assessment that are typically included on questionnaires and rating scales related to borderline personality disorder include the following: • Feelings of emptiness • An inclination to engage in risky behaviors such as reckless driving, unsafe sex, substance use, binge eating, gambling, or overspending • Intense feelings of abandonment that result in paranoia or feeling spaced out • Idealization of others and becoming close quickly • A tendency toward anger, sarcasm, and bitterness • Self-mutilation and self-harm • Suicidal behaviors, gestures, or threats • Sudden shifts in self-evaluation that result in changing goals, values, and career focus • Extreme mood shifts that occur in a matter of hours or days • Intense, unstable romantic relationships

Etiology of Antisocial Personality Disorder: Cultural Factors

Some studies have found a higher prevalence rate of this personality disorder in African Americans and in individuals with co-occurring substance dependence.

Genetics and personality disorders

The disorders themselves are not inherited. It is the personality traits. Personality disorders may represent extreme variations of normal personality traits in four areas: 1) anxious-dependency traits 2) psychopathy-antisocial 3) social withdrawal 4) compulsivity

Neurobiology and personality disorders

The neurotransmitter theory proposes that certain neurotransmitters, including neurohormones, may regulate and influence temperament. Research in brain imaging has also revealed some differences in the size and function of specific structures of the brain in people with some personality disorders

Teamwork and Safety when working with patients with Borderline Personality Disorder

The primary goal is management of the patient's affect in a group context. Community meetings, coping skills groups, and socializing groups are all helpful for these patients. They have the opportunity to interact with peers and staff to discuss goals and learn problem-solving skills.

Planning when taking care of patients with Antisocial Personality Disorder

The role of the nurse will be to provide consistency, support, boundaries, and limits. Providing realistic choices.

Etiology of Antisocial Personality Disorder: Genetics

This disorder is genetically linked. There are two main dimensions of genetic risk. One is the trait of aggressive-disregard, which refers to violent tendencies without concern for others, and the trait of dis-inhibition, which is a lack of concern for consequences.

Etiology, Genetics of Borderline Personality Disorder

This disorder is highly associated with genetic factors such as hypersensitivity, impulsivity, and emotional dysregulation. The role of genetic vulnerability is at approximately 40%.

Which intervention is appropriate for an individual diagnosed with an antisocial personality disorder who frequently manipulates others? a. Refer requests and questions related to care to the case manager. b. Encourage the patient to discuss feelings of fear and inferiority. c. Provide negative reinforcement for acting-out behavior. d. Ignore, rather than confront, inappropriate behavior.

a ( Refer requests and questions related to care to the case manager.)

What is the priority nursing diagnosis for a patient diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? a. Risk for other-directed violence b. Risk for self-directed violence c. Impaired social interaction d. Ineffective denial

a (. Risk for other-directed violence)

A patient diagnosed with borderline personality disorder was hospitalized several times after self-mutilating episodes. The patient remains impulsive. Which nursing diagnosis is the initial focus of this therapy? a. Risk for self-directed violence b. Impaired skin integrity c. Risk for injury d. Powerlessness

a (. Risk for self-directed violence)

Diathesis-Stress Model

a general theory that explains psychopathology using a systems approach. Diathesis refers to genetic and biological vulnerabilities and includes personality traits and temperament. Temperament is our tendency to respond to challenges in predictable ways. stress refers to immediate influences on personality such as the physical, social, psychological, and emotional environment. Under conditions of stress, the diathesis-stress model proposes that personality development becomes maladaptive for some people, resulting in the emergence of a personality disorder.

A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should: a. maintain a stern and authoritarian affect. b. provide care in a matter-of-fact manner. c. encourage the patient to express anger. d. be very rigid and challenging.

b ( provide care in a matter-of-fact manner.)

What is the most challenging nursing intervention with patients diagnosed with personality disorders who use manipulation? a. Supporting behavioral change b. Maintaining consistent limits c. Monitoring suicide attempts d. Using aversive therapy

b (. Maintaining consistent limits)

A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed? a. Benzodiazepine b. Mood stabilizing medication c. Monoamine oxidase inhibitor (MAOI) d. Serotonin norepinephrine reuptake inhibitor (SNRI)

b (. Mood stabilizing medication)

Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day, never coming out for breaks or lunch. Which term best describes this behavior? a. Narcissistic b. Histrionic c. Avoidant d. Paranoid

c (. Avoidant)

When a patient diagnosed with a personality disorder uses manipulation to get needs met, the staff applies limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the patient's wishes, so assertiveness will develop. c. External controls are necessary due to failure of internal control. d. Anxiety is reduced when staff assumes responsibility for the patient's behavior.

c (. External controls are necessary due to failure of internal control.)

A patient's spouse filed charges after repeatedly being battered. The patient sarcastically says, "I'm sorry for what I did. I need psychiatric help." Which statement by the patient supports an antisocial personality disorder? a. "I have a quick temper, but I can usually keep it under control." b. "I've done some stupid things in my life, but I've learned a lesson." c. "I'm feeling terrible about the way my behavior has hurt my family." d. "I hit because I am tired of being nagged. My spouse deserves the beating."

d ( "I hit because I am tired of being nagged. My spouse deserves the beating.")

When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include: a. preoccupation with minute details; perfectionist. b. charm, drama, seductiveness; seeking admiration. c. difficulty being alone; indecisive, submissiveness. d. grandiosity, self-importance, and a sense of entitlement.

d (. grandiosity, self-importance, and a sense of entitlement.)

The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include: a. arrogant, grandiose, and a sense of self-importance. b. attention seeking, melodramatic, and flirtatious. c. impulsive, restless, socially aggressive behavior. d. socially anxious, rambling stories, peculiar ideas.

d (. socially anxious, rambling stories, peculiar ideas.)

Narcissistic Personality Disorder

is characterized by feelings of entitlement, an exaggerated belief in one's own importance, and a lack of empathy. In reality, people with this disorder suffer from a weak self-esteem and hypersensitivity to criticism. This disorder is associated with less impairment in individual functioning and quality of life than the other personality-based disorders. There may be a familial tendency for this disorder as parents with this disorder may attribute an unrealistic sense of talent, importance, and beauty to their children. These attributions put the children at higher risk. Underneath the surface of arrogance, people with this personality disorder feel intense shame and have a fear of abandonment. The main pathological personality trait is antagonism, represented by the grandiosity and attention-seeking behaviors.

Guidelines for Nursing Care for patients with Paranoid Personality Disorder

• Considering the degree of mistrust, promises, appointments, and schedules should be strictly adhered to. • Being too nice or friendly may be met with suspicion. Instead, give clear and straightforward explanations of tests and procedures beforehand. • Use simple language and project a neutral but kind affect. • Limit setting is essential when threatening behaviors are present.

Guidelines for caring for a patient with Dependent Personality Disorder

• Nurses can help the patient identify and address current stressors. • Be aware that strong countertransference may develop because of patient's demands for extra time and crisis states. • The therapeutic nurse-patient relationship can provide a testing ground for increased assertiveness through role modeling and teaching of assertive skills.

Cluster C

Behaviors described as anxious or fearful. -Avoidant -Dependent -Obsessive-Compulsive

Personality comes from the Latin word...

Persona; which means mask and it may refer to what other people see.

A client diagnosed with obsessive-compulsive personality disorder takes the nurse aside and mentions, "I've observed you interacting with that new patient. You are not approaching him properly. You should be more forceful with him." What response should the nurse provide to address the client's comment? "I will be continuing to follow the care plan for the patient." "I see you are trying to control that patient's therapy as well as your own." "Your eye for perfection extends even to my nursing interventions." "That patient's care is really of no concern to you or to other clients."

"I will be continuing to follow the care plan for the patient."

A 24-year-old patient diagnosed with borderline personality disorder (BPD) is admitted to the inpatient psychiatric unit following a suicide attempt. Which client statements illustrate a primary coping style of persons with BPD? "My provider says I might get out of here tomorrow. Do you think I'm ready to go?" "Last night the nurse let me go outside and smoke. I can't believe you aren't letting me. I used to think you were the best nurse here." "I will never again speak to any of my messed up family members. I know that this will help me to be more functional." "I promise I am not feeling suicidal. I won't hurt myself."

"Last night the nurse let me go outside and smoke. I can't believe you aren't letting me. I used to think you were the best nurse here."

Outcomes Identification for caring for patients with antisocial personality disorder

*abusive behavior self-restraint *aggression self-restraint *coping *social interaction *social isolation *health promotion knowledge *health promoting behavior Successfully achieving these outcomes when working with this population is extremely difficult, but maintaining safety is the priority. Small, incremental changes and progress will likely be the best outcomes.

Cluster C Personality Disorders are

-Anxious or fearful behavior -Rigid patterns of social shyness Examples -Avoidant PD -Dependent PD -Obsessive-compulsive PD

what should nurses be aware of when dealing with a client with Schizoid personality disorder?

-Avoid being too "nice" or "friendly" -Do not try to increase socialization -Assess for symptoms the patient is reluctant to discuss -Protect against group's ridicule

treatment for Narcissistic Personality Disorder

-Difficult to treat: patients not likely to seek help or confront shortcomings -Cognitive-behavioral therapy (CBT) to deconstruct faulty thinking -Group therapy; lithium for mood swings

Cluster B Personality Disorders are

-Dramatic, emotional, erratic behavior -Problems with impulse control Examples: Antisocial PD Borderline PD Histrionic PD Narcissistic PD

what are Guidelines for nursing care for histrionic personality disorder

-Know that seductive behavior is a response to distress. -Keep interactions professional; ignore flirtations. -Model concrete language. -Help patient clarify inner feelings -Teach and role-model assertiveness.

Paranoid Personality Disorder Characteristics

-May be apparent in childhood -Social anxiety in childhood -Jealous, controlling as adults -Unwillingness to forgive and projection of feelings

Guidelines for Nursing Care Narcissistic Personality Disorder

-Remain neutral. -Avoid power struggles or becoming defensive. -Role model empathy.

what are some nursing guidelines for schizotypal personality disorder?

-Respect patient's need for social isolation. -Be aware of and intervene appropriately with patient's suspiciousness. -Perform careful diagnostic assessment for symptoms that may need intervention (e.g., suicidal thoughts). -Withhold judgment or ridicule.

Schizotypal Personality Disorder characteristics

-Severe social and interpersonal deficits -Anxiety in social situations -Rambling conversation -Paranoia, suspiciousness, anxiety, distrust -Brief, intermittent episodes of hallucination or delusion -Can be made aware of their own odd beliefs -May be vulnerable to involvement with cults or unusual religious/occult groups

Schizoid Personality Disorder (Cluster A) characteristics

-Symptoms appear in childhood and adolescence -Loners, poor academic performance -Increased prevalence of disordered family life -Avoid close relationships -Depersonalization, detachment

Assessment Guidelines for Borderline Personality Disorder

1. Assess for suicidal or violent thoughts toward others. If these are present, the patient will need immediate attention. 2. Determine whether the patient has a medical disorder or another psychiatric disorder (especially a substance use disorder) that may be responsible for the symptoms. 3. View the assessment about personality functioning from within the person's ethnic, cultural, and social background. 4. Has the patient experienced a recent important loss? This personality disorder is often exacerbated after the loss of significant supporting people or in a disruptive social situation. 5. Evaluate for a change in personality in middle adulthood or later, which signals the need for a thorough medical workup or assessment for unrecognized substance use disorder.

Prevalence of personality disorders

6% of global population. 10% of the US population.

DSM-5 Criteria For Borderline Personality Disorder

A pervasive pattern of instability of interpersonal relationships, self-image, affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.) 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbances: Markedly and persistently unstable self-image or sense of self. 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.) 5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideations or severe dissociative symptoms.

DSM-5 Criteria for Anti-Social Personality Disorder

A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following: 1. Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest. 2. Deceitfulness as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. 3. Impulsivity or failure to plan ahead. 4. Irritability and aggressiveness as indicated by repeated physical fights or assaults. 5. Reckless disregard for safety of self or others. 6. Consistent irresponsibility as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. 7. Lack of remorse as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. B. The individual is at least age 18 years. C. There is evidence of conduct disorder with onset before age 15 years. D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

what are the Antisocial Personality Disorder Outcomes

Abusive behavior self-restraint Aggression self-restraint Coping, social interaction, social isolation knowledge Health promotion knowledge Health promoting behavior

Which statement is true of pharmacological therapies associated with the treatment of personality disorders? Although there are no FDA-approved drugs specific to the treatment of personality disorders, patients benefit from specific off-label uses of antipsychotics, mood stabilizers, and antidepressants, depending on which personality disorder is evident. Research has shown that currently available psychotropic drugs have not been shown to be effective in treating personality disorders. Patients with narcissistic personality disorder and obsessive-compulsive personality disorder have shown the most benefit from the use of antianxiety medications along with use of selective serotonin reuptake inhibitors. Patients with personality disorders have been shown to be resistant to accepting medication, and as a result most providers do not prescribe psychotropic drugs to these patients.

Although there are no FDA-approved drugs specific to the treatment of personality disorders, patients benefit from specific off-label uses of antipsychotics, mood stabilizers, and antidepressants, depending on which personality disorder is evident.

Dialectical Behavioral Therapy (DBT): For Borderline Personality Disorder

An evidence-based therapy developed by Linehan (1993) to treat chronically suicidal individuals with borderline personality disorder. This combines cognitive and behavioral techniques with mindfulness, which emphasizes being aware of thoughts and actively shaping them.

Borderline Personality Disorder

Another Cluster B diagnosis, the disorder is the most well known and dramatic of the personality disorders. Borderline personality disorder is characterized by severe impairments in functioning. The major features of this disorder are patterns of marked instability in emotional control or regulation, impulsivity, identity or self-image distortions, unstable mood, and unstable interpersonal relationships. One of the primary features of this disorder is emotional lability, that is, rapidly moving from one emotional extreme to another Impulsivity is manifested in acting quickly in response to emotions without considering the consequences. This impulsivity results in damaged relationships and even in suicide attempts. Ineffective and often harmful self-soothing habits such as cutting, promiscuous sexual behavior, and numbing with substances are common and may result in unintentional death. An unusual feature of this disorder is the use of splitting as a primary defense or coping style. Splitting refers to the inability to view both positive and negative aspects of others as part of a whole. This inability results in viewing someone as either a wonderful person or a horrible person.

A client arrested for an assault in which he savagely beat a classmate states, "The guy deserved everything he got." The behaviors described are most consistent with the clinical picture of which disorder? Antisocial personality disorder Borderline personality disorder Schizotypal personality disorder Narcissistic personality disorder

Antisocial personality disorder

Potential Nursing Diagnoses Personality Disorder

Anxiety; Fear; Hopelessness Ineffective Coping; Self-Mutilation Impaired Social Interactions; Social Isolation Chronic Low Self-Esteem; Spiritual Distress Disturbed Sensory Perceptions Risk for Suicide or other directed violence

What is the priority nursing intervention for a client diagnosed with borderline personality disorder? Protect other clients from manipulation. Respect the client's need for attention. Assess for suicidal and self-mutilating behaviors. Provide clear, consistent limits and boundaries.

Assess for suicidal and self-mutilating behaviors.

Interventions Personality Disorder

Basic level interventions Milieu management Pharmacological interventions Case management Advanced practice interventions Dialectical behavioral therapy (DBT)

The client, diagnosed with which personality disorder, will most likely require admission to a psychiatric unit? Paranoid personality disorder Narcissistic personality disorder Borderline personality disorder Dependent personality disorder

Borderline personality disorder

what are some psychotherapy for borderline personality disorder

CBT Dialectical behavior therapy (DBT) Schema-focused therapy

Treatment for Schizotypal Personality Disorder

Clinicians should be aware that these patients may also be actively involved in groups such as cults, unusual religious groups, and engage in occult activities. While there is no specific medication for this disorder, associated conditions may be treated. Patients do benefit from low-dose anti-psychotic agents for psychotic-like symptoms and day-to-day functioning. These agents help with such symptoms as ideas of reference or illusions. Depression and anxiety may be treated with antidepressants and antianxiety agents.

Personality Disorders types

Cluster A: Eccentric Paranoid Schizoid Schizotypal Cluster B: Erratic Borderline Narcissistic Histrionic Antisocial Cluster C: Anxious Avoidant Dependent Obsessive-compulsive

Paranoid Personality Disorder treatment

Counteract mistrust by (a) adhering to schedules (b) avoiding being overly friendly (c) projecting a neutral but kind affect Psychotherapy versus group therapy Short-term antidepressants

Which characteristics will the nurse assess in the client diagnosed with antisocial personality? Deceitfulness, impulsiveness, and lack of empathy Perfectionism, preoccupation with detail, and verbosity Avoidance of interpersonal contact and preoccupation with being criticized A need for others to assume responsibility for decision making and seeking nurture

Deceitfulness, impulsiveness, and lack of empathy

Nursing diagnosis of patients with Borderline Personality Disorder

Emotions such as anxiety, rage, and depression, and behaviors such as withdrawal, paranoia, and manipulation are among the most frequent that healthcare workers must address. The nursing diagnosis Self-mutilation is most often associated with this disorder. Defined as "deliberate self-injurious behavior causing tissue damage with the intent of causing nonfatal injury to attain relief of tension" Characteristics Include: • Disturbed interpersonal relationships • Feels threatened with loss of significant relationship • History of self-directed violence • Impulsivity • Irresistible urge to cut self • Labile behavior • Mounting tension that is intolerable • Use of manipulation to obtain nurturing relationship with others Other Nursing Diagnosis: *Risk for suicide *Risk for self-directed violence *Risk for other-directed violence *Social isolation *Impaired social interaction *Disturbed personal identity Ineffective coping

Avoidant Personality Disorder Guidelines for nursing care

Friendly, accepting, reassuring approach Acceptance of patient fears Group therapy Exercises to enhance new social skills Design exercises to prevent failures Assertiveness training

risk factors for Personality Disorders

Genetic Neurobiological Psychological Environmental Diathesis-stress model

Risk factors for personality disorders

Genetics Neurobiological Psychological Environmental Diathesis-stress model

What characteristic behaviors will the nurse assess in the narcissistic client? Dramatic expression of emotion, being easily led Perfectionism and preoccupation with detail Grandiose, exploitive, and rage-filled behavior Angry, highly suspicious, aloof, withdrawn behavior

Grandiose, exploitive, and rage-filled behavior

Obsessive-Compulsive Personality Disorder Guidelines for nursing care

Guard against power struggles Remember that the patient has difficulty dealing with unexpected changes

Dependent Personality Disorder Guidelines for nursing care

Help address current stressors Set limits that don't make the patient feel punished Be aware of strong countertransference Use therapeutic relationship as a testing ground for assertiveness training

Patient history of a patient with borderline personality disorder

History of suicidal or aggressive ideation or actions, treatment history, and medication (prescribed and illicit) use. Significant areas about which further details must be obtained include current or past physical, sexual, or emotional abuse and level of current risk of harm from self or others. Information regarding prior use of any medication, including psychopharmacological agents, is important.

Clients demonstrating characteristics of personality disorders have various self-defeating behaviors and interpersonal problems despite having near-normal ego functioning and intact reality testing. Which nursing diagnosis best addresses this sort of interpersonal dysfunction? Spiritual distress Defensive coping Impaired social interaction Disturbed sensory perception

Impaired social interaction

Etiology of Antisocial Personality Disorder: Environmental

Inconsistent parenting and discipline, significant abuse, and extreme neglect are associated with this disorder. Virtually all individuals who eventually develop this disorder have a history of impulse control and conduct problems as children and adolescents.

Treatment for patients with Avoidant Personality Disorder

Individual and group therapy is useful in processing anxiety-provoking symptoms and in planning methods to approach and handle anxiety-provoking situations. Psychotherapy focuses on trust and assertiveness training. Antianxiety agents can be helpful. Beta-adrenergic receptor antagonists (e.g., atenolol) help reduce autonomic nervous system hyperactivity. Antidepressant medications such as selective serotonin reuptake inhibitors (SSRIs) like citalopram (Celexa) Serotonin norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine (Effexor) may reduce social anxiety. Serotonergic agents may help individuals feel less sensitive to rejection.

Treatment of Patients with Paranoid Personality Disorder

Individuals with this disorder tend to reject treatment. Psychotherapy is the first line of treatment. Individual therapy focuses on the development of a professional and trusting relationship. Due to their fears, patients may behave in a threatening manner. Therapists should respond by setting limits and dealing with delusional accusations in a realistic manner without humiliating the patients. Group therapy is threatening to people with paranoid personality disorder. However, the group setting may be useful in improving social skills. Role playing and group feedback can help reduce suspiciousness. An antianxiety agent such as diazepam (Valium) may be used to reduce anxiety and agitation. More severe agitation and delusions may be treated with antipsychotic medication such as haloperidol (Haldol) in small doses for brief periods of time to manage the mildly delusional thinking or severe agitation. The first-generation antipsychotic medication pimozide (Orap) may be useful in reducing paranoid ideation.

A nurse caring for a client who has been diagnosed with a personality disorder should expect that the client will exhibit which behaviors? Frequent episodes of psychosis Constant involvement with the needs of significant others Inflexible and maladaptive responses to stress Abnormal ego functioning

Inflexible and maladaptive responses to stress

Epidemiology and Comorbidity For Borderline Personality Disorder

It carries a high mortality rate—nearly 10%— primarily from suicide. This disorder results in extensive utilization of services from the healthcare system. This personality disorder seems to decrease with age. Patients with this disorder experience high rates of remission and low rates of relapse. About 85% of individuals with borderline personality disorder also meet the diagnostic criteria for another psychiatric disorder. Substance use in individuals with borderline personality disorder is extremely common. Nonpsychiatric diagnoses are also associated with borderline personality disorder. They include diabetes, high blood pressure, chronic back pain, fibromyalgia, and arthritis.

Patients diagnosed with BPD exhibit negative effect, which includes rapidly moving from one emotional extreme to another. What term is used to describe this characteristic? Lability Impulsivity Splitting Denial

Lability

Research has indicated that the antisocial personality may be characterized by what behavior? Social isolation Lack of remorse Learning difficulties Difficulty with reality testing

Lack of remorse

When providing care for a client diagnosed with borderline personality disorder, the nurse will need to consider strategies for dealing with which of the client's classic characteristics? Mood shifts, impulsivity, and splitting Grief, anger, and social isolation Altered sensory perceptions and suspicion Perfectionism and preoccupation with detail

Mood shifts, impulsivity, and splitting

Cluster A personality disorders (weird)

Paranoid Personality Disorder -- Characteristics: suspicious of others; fear others will exploit, harm, or deceive them; fear of confiding in others (fear personal information will be used against them); Eccentric and odd behavior -Unusual levels of suspiciousness -Magical thinking -Cognitive impairment Examples -Paranoid PD -Schizoid PD -Schizotypal PD

Obsessive-Compulsive Personality Disorder Treatment

Patients tend to seek help Also seek help for anxiety or depression Group and behavioral therapy Clomipramine or fluoxetine for obsessions, anxiety, and depression

Who is at risk for over-diagnosis of a personality disorder?

Patients who differ from the majority culture or the culture of the clinician.

Psycho-social Interventions for patients with Borderline Personality Disorder

Patients with this personality disorder are impulsive and may be suicidal, self-mutilating, aggressive, manipulative, and even psychotic during periods of stress. Provide clear and consistent boundaries and limits. Use straightforward communication. When behavioral problems emerge, calmly review the therapeutic goals. When responding to superficial self-destructive behaviors. The nurse remains neutral and dresses the wound in a matter-of-fact manner. Then the patient is instructed to write down the sequence of events leading up to the injury, as well as the consequences, before staff will discuss the event.

Schizotypal Personality Disorder

People with this disorder do not blend in with the crowd. Their symptoms are strikingly strange and unusual. Magical thinking, odd beliefs, strange speech patterns, and inappropriate affect are hallmarks of this disorder. Abnormalities in brain structure, physiology, chemistry, and functioning are similar to schizophrenia. For example, both disorders share reduced cortical volume. They experience extreme anxiety in social situations. Contributions to conversations tend to ramble with lengthy, unclear, overly detailed, and abstract content. An additional feature of this disorder is paranoia. Individuals with schizotypal personality disorder are overly suspicious and anxious. They tend to misinterpret the motivations of others as being out to get them and blame others for their social isolation. Odd beliefs (e.g., being overly superstitious) or magical thinking (e.g., "He caught a cold because I wished he would") are also common.

Schizoid Personality Disorder

People with this disorder exhibit a lifelong pattern of social withdrawal. They are somewhat expressionless and operate with a restricted range of emotional expression. People with this disorder do not seek out or enjoy close relationships. If trust is established, the person may divulge numerous imaginary friends and fantasies.

Outcomes Identification: Borderline Personality Disorder

Personality change occurs with one behavioral solution and one learned skill at a time. In the acute-care setting, the focus is on the presenting problem, which may be depression or severe anxiety.

Common Characteristics of Personality Disorders (PDs)

Personality disorders (PDs) involve long-term and repetitive use of maladaptive and often self-defeating behaviors. Difficulty in three areas of day-to-day functioning -Thoughts and emotions -Participation in interpersonal relationships -Managing impulses

Which statement is true regarding antisocial personality disorder (APD)? Select all that apply. It is the least studied of the personality disorders. It is characterized by rigidity and inflexible standards of self and others. Persons with APD display magical thinking. Persons with APD are concerned with personal pleasure and power. It is characterized by deceitfulness, disregard for others, and manipulation. Persons with APD usually present for treatment because of awareness of how their behavior is affecting others. Frontal lobe dysfunction is a brain change identified in APD.

Persons with APD are concerned with personal pleasure and power. It is characterized by deceitfulness, disregard for others, and manipulation. Persons with APD usually present for treatment because of awareness of how their behavior is affecting others. Frontal lobe dysfunction is a brain change identified in APD.

Psychological Factors and personality disorders

Psychoanalytic theory focuses on the use of primitive defense mechanisms by individuals with personality disorders. Defense mechanisms such as: *repression *suppression *regression *undoing *splitting Learning theory emphasizes that children learn maladaptive responses based on modeling or reinforcement by significant others. Cognitive theories emphasize the role of beliefs and assumptions in creating emotional and behavioral responses that influence one's experiences within the family environment.

treatment for Schizoid personality disorder

Psychotherapy Group therapy Antidepressants

treatment for schizotypal personality disorder

Psychotherapy (investigate possible involvement with cults) Low-dose antipsychotics

Treatment of patients with Schizoid Personality Disorder

Psychotherapy can help improve sensitivity to others' social cues. Group therapy may also be helpful even though the patient may frequently be silent. Group therapy provides experience in practicing interactions and feedback from others. Antidepressants such as bupropion (Wellbutrin) may help increase pleasure in life. Second-generation antipsychotics, such as risperidone (Risperdal) or olanzapine (Zyprexa), are used to improve emotional expressiveness.

Treatment Dependent Personality Disorder

Psychotherapy is treatment of choice

treatment for histrionic personality disorder

Psychotherapy is treatment of choice

A newly admitted client has a diagnosis of schizoid personality disorder. The nursing intervention of highest priority will be directed toward which classic client need? Set firm limits on behavior. Respect need for social isolation. Encourage expression of feelings. Involve in milieu and group activities.

Respect need for social isolation.

nursing diagnose for antisocial personality disorder

Risk for other-directed violence Defensive coping Impaired social interaction Ineffective health maintenance

A 37-year-old patient, referred to the mental health clinic with a suspected personality disorder, is withdrawn and suspicious and states, "I've always preferred to be alone" and then adds, "I can read your thoughts whenever I want to." This presentation supports which psychiatric diagnosis? Obsessive-compulsive personality disorder Narcissistic personality disorder Avoidant personality disorder Schizotypal personality disorder (STPD)

Schizotypal personality disorder (STPD)

Splitting is a process in which the client demonstrates what behavior? Unconsciously represses undesirable aspects of self Places responsibility for his or her behavior outside the self Sees things as divided into "all good" or "all bad" Evidences lack of personal boundaries

Sees things as divided into "all good" or "all bad"

nursing diagnoses for borderline personality disorder

Self-mutilation Risk for suicide Risk for self- and/or other-directed violence Impaired social interaction Disturbed personal identity Ineffective coping

what are some assessment used for borderline personality disorder

Semi-structured interview Use of MMPI Self-assessment

Playing one staff member against another is an example of what defense mechanism? Devaluation Splitting Impulsiveness Social ineptitude

Splitting

antisocial personality disorder traits are

The main pathological traits that characterize antisocial personality disorder are antagonistic behaviors, such as being deceitful and manipulative for personal gain or hostile if needs are blocked. The disorder is also characterized by disinhibited behaviors such as high-risk taking, disregard for responsibility, and impulsivity. Criminal misconduct and substance abuse are common in this population.

Teamwork and safety when taking care of a patient with Antisocial Personality Disorder

The safety of patients and staff is a prime consideration in working with individuals in this population. To promote safety, the entire treatment team should follow a solid treatment plan that emphasizes realistic limits on specific behavior, consistency in responses, and consequences for actions. Careful documentation of behaviors will aid in providing effective interventions and in promoting teamwork. Simply noting that the patient truly feels hurt. Showing empathy may also decrease aggressive outbursts if the patient feels that staff members are trying to understand feelings of frustration.

Etiology, Neurobiology of Borderline Personality Disorder

The serotonin transporter gene 5-HTT may have shorter alleles, which have been associated with lower levels of serotonin and increased impulsive aggression. Abnormalities in the prefrontal cortex and limbic regions. The frontal region is implicated in regulatory control processes and the limbic region is essential for emotional processing.

Pharmacological Interventions for patients with Borderline Personality Disorder

There are no medications specifically approved by the FDA for treating this disorder. Psychotropic medications geared toward maintaining patients' cognitive function, symptom relief, and improved quality of life are available. People with this disorder respond to antidepressants such as SSRIs, anti-convulsants, and lithium for mood and emotional dysregulation symptoms. Naltrexone (Revia, Vivitrol), an opioid receptor antagonist, has been found to reduce self-injurious behaviors. Second-generation anti-psychotics may control anger and brief psychosis.

Treatment for patients with Narcissistic Personality Disorder

These patients are more likely to be involved in couples or family therapy than individual treatment. They are likely to deflect suggestions that they contribute to family problems, and will instead blame others. If a person with this personality disorder somehow seeks treatment, individual cognitive-behavioral therapy is helpful for deconstructing faulty thinking. Group therapy can also assist the person in sharing with others, seeing their own qualities in others, and learning empathy. Lithium (Eskalith, Lithobid) has been used in patients who demonstrate mood swings. Antidepressants can also be used if the person has symptoms of depression.

Which statement is descriptive of clients with a personality disorder? They are resistant to behavioral change. They have an ability to tolerate frustration and pain. They usually seek help to change maladaptive behaviors. They have little difficulty with cognitive functioning.

They are resistant to behavioral change.

Antisocial Personality Disorder

This disorder is a pattern of disregard for, and violation of, the rights of others. People with this disorder may be more commonly referred to as sociopaths. The main pathological traits that characterize antisocial personality disorder are antagonistic behaviors such as being deceitful and manipulative for personal gain or hostile if needs are blocked. The disorder is also characterized by dis- inhibited behaviors such as high risk taking, disregard for responsibility, and impulsivity. Criminal misconduct and substance misuse are common in this population. One of the most disturbing qualities associated with this disorder is a profound lack of empathy, also known as callousness. These individuals tend to exhibit a shallow, un-expressive, and superficial affect. They may also be adept at portraying themselves as concerned and caring if these attributes help them to manipulate and exploit others.

Obsessive-Compulsive Personality Disorder

This disorder is characterized by limited emotional expression, stubbornness, perseverance, and indecisiveness. Preoccupation with orderliness, perfectionism, and control are the hallmarks of this disorder. It is one of the most prevalent personality disorders. Has been associated with increased relapse rates of depression and an increase in suicidal risks in people with co-occurring depression. The main pathological personality traits are rigidity and inflexible standards of self and others. They rehearse over and over how they will respond in social situations.

Schema-Focused Therapy: For Borderline Personality Disorder

This therapy combines parts of CBT with other forms of therapy that focus on the ways that individuals view themselves. This reframing of "schemas" is based on the notion that borderline personality disorder is the result of a dysfunctional self-image, probably brought about by a dysfunctional childhood. This dysfunctional self-image affects how individuals respond to stress, react to their environment, and interact with others.

Implementation when taking care of patients with Antisocial Personality Disorder

Try to prevent or reduce untoward effects of manipulation (flattery, seductiveness, instilling of guilt). Set clear and realistic boundaries and consequences and ensure that all staff follow limits. Carefully document behaviors and signs of manipulation. Be aware that these patients can manipulate with feelings of guilt when they are not getting what they want.

Treatment for patients with Obsessive Compulsive Personality Disorder

Typically, patients with this disorder seek help on their own as they are aware of their own suffering. They may also seek treatment for anxiety or depression. Both group therapy and behavioral therapy can be helpful so that patients can learn new coping skills for their anxiety and see direct benefits for change from feedback within the group. Clomipramine (Anafranil) may help reduce the obsessions, anxiety, and depression associated with this disorder. Other serotonergic agents such as fluoxetine (Prozac) may also be effective.

3. What is the current accepted professional view of the effect of culture on the development of a personalitydisorder? a. There aren't sufficient studies to confirm the role that ethnicity and race have on the prevalence ofpersonality disorders. b. The North American and Australian cultures produce higher incidences of personality disorders amongtheir populations. c. Neither culture nor ethnic background is generally considered in the development of personalitydisorders. d. Personality disorders have been found to be primarily the products of genetic factors, not culturalfactors.

a

8. Connor is a 28-year-old student, referred by his university for a psychiatric evaluation. He reports that hehas no friends at the university and people call him a loner. Recently, Connor has been giving lectures to pigeons at the university fountains. Connor is diagnosed as schizotypal, which differs from schizophrenia in that persons diagnosed as schizotypal: a. Can be made aware of their delusions b. Are far more delusional than schizophrenics c. Have a greater need for socialization d. Do not usually respond to antipsychotic medications

a

A patient says, "I get in trouble sometimes because I make quick decisions and act on them." Select the nurse's most therapeutic response. a. "Let's consider the advantages of being able to stop and think before acting." b. "It sounds as though you've developed some insight into your situation." c. "I bet you have some interesting stories to share about overreacting." d. "It's good that you're showing readiness for behavioral change."

a (. "Let's consider the advantages of being able to stop and think before acting.")

What is the priority intervention for a nurse beginning to work with a patient diagnosed with a schizotypal personality disorder? a. Respect the patient's need for periods of social isolation. b. Prevent the patient from violating the nurse's rights. c. Teach the patient how to select clothing for outings. d. Engage the patient in community activities.

a (. Respect the patient's need for periods of social isolation.)

For which patients diagnosed with personality disorders would a family history of similar problems be most likely? Select all that apply. a. Obsessive-compulsive b. Antisocial c. Borderline d. Schizotypal e. Narcissistic

a, b, c, d

4. Which personality disorders are generally associated with behaviors described as "odd or eccentric"?Select all that apply. a. Paranoid b. Schizoid c. Histrionic d. Obsessive-compulsive e. Avoidant

a,b

5. Which behaviors are examples of a primitive defense mechanism often relied upon by those diagnosedwith a personality disorder? Select all that apply. a. Regularly attempts to split the staff b. Attempts to undo feelings of anger by offering to do favors c. Regresses to rocking and humming to sooth themselves when fearful d. Lashes out verbally when confronted with criticism e. Destroys another person's belongings when angry

a,b,c

1. Which statement made by the psychiatric nurse demonstrates an accurate understanding of the factorsthat affect an individual's personality? a. "Therapy will help her identify that her problems are personality related." b. "I'll need to learn more about this patient's cultural beliefs." c. "It's encouraging to know that personality disorders respond well to treatment." d. "A person's personality is fluid and adjusts to current social situations."

b

10. Josie, a 27-year-old patient, complains that most of the staff do not like her. She says she can tell that youare a caring person. Josie is unsure of what she wants to do with her life and her "mixed-up feelings" about relationships. When you tell her that you will be on vacation next week, she becomes very angry. Two hours later, she is found using a curling iron to burn her underarms and explains that it "makes the numbness stop." Given this presentation, which personality disorder would you suspect? a. Obsessive-compulsive b. Borderline c. Antisocial d. Schizotypal

b

6. Personality disorders often co-occur with mood and eating disorders. A young woman is undergoingtreatment at an eating disorders clinic and her nurse suspects the patient may also have a Cluster B personality disorder due to the young woman's: a. Desire to avoid eating b. Dramatic response to frustration c. Excessive exercise routine d. Morose personality traits

b

A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was wrong. You're evil." This outburst can be assessed as: a. denial. b. splitting. c. defensive. d. reaction formation.

b ( splitting.)

A patient says, "The other nurses won't give me my medication early, but you know what it's like to be in pain and don't let your patients suffer. Could you get me my pill now? I won't tell anyone." Which response by the nurse would be most therapeutic? a. "I'm not comfortable doing that," and then ignore subsequent requests for early medication. b. "I understand that you have pain, but giving medicine too soon would not be safe." c. "I'll have to check with your doctor about that; I will get back to you after I do." d. "It would be unsafe to give the medicine early; none of us will do that."

b (. "I understand that you have pain, but giving medicine too soon would not be safe.")

A nursing diagnosis appropriate to consider for a patient diagnosed with any of the personality disorders is: a. noncompliance. b. impaired social interaction. c. disturbed personal identity. d. diversional activity deficit.

b (. impaired social interaction.)

Personality traits most likely to be documented regarding a patient demonstrating characteristics of an obsessive-compulsive personality disorder are: a. affable, generous. b. perfectionist, inflexible. c. suspicious, holds grudges. d. dramatic speech, impulsive.

b (. perfectionist, inflexible.)

A nurse plans care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? Select all that apply. a. Reclusive behavior b. Callous attitude c. Perfectionism d. Aggression e. Clinginess f. Anxiety

b.,d

9. Garret's wife of 8 years is divorcing him because the marriage never developed a warm or lovingatmosphere. Garrett states in therapy, "I have always been a loner," and was never concerned about what others think. The nurse practitioner suggests that Garrett try a trial of bupropion (Wellbutrin) to: a. Improve his flat emotions b. Assist in getting a good night's sleep c. Increase the pleasure of living d. Prepare Garrett for group therapy

c

Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the patient's needs and maintain a therapeutic milieu? a. Ability to achieve true intimacy b. Flexibility and adaptability to stress c. Ability to provoke interpersonal conflict d. Inability to develop trusting relationships

c ( Ability to provoke interpersonal conflict)

A new psychiatric technician says, "Schizophrenia...schizotypal! What's the difference?" The nurse's response should include which information? a. A patient diagnosed with schizophrenia is not usually overtly psychotic. b. In schizotypal personality disorder, the patient remains psychotic much longer. c. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality. d. Schizotypal personality disorder causes more frequent and more prolonged hospitalizations than schizophrenia.

c (. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality.)

What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will: a. identify when feeling angry. b. use manipulation only to get legitimate needs met. c. acknowledge manipulative behavior when it is called to his or her attention. d. accept fulfillment of his or her requests within an hour rather than immediately.

c (. acknowledge manipulative behavior when it is called to his or her attention.)

The history shows that a newly admitted patient is impulsive. The nurse would expect behavior characterized by: a. adherence to a strict moral code. b. manipulative, controlling strategies. c. acting without thought on urges or desires. d. postponing gratification to an appropriate time.

c (. acting without thought on urges or desires.)

Consider this comment to three different nurses by a patient diagnosed with an antisocial personality disorder, "Another nurse said you don't do your job right." Collectively, these interactions can be assessed as: a. seductive. b. detached. c. manipulative. d. guilt-producing.

c (. manipulative.)

Paranoid Personality Disorder

characterized by a longstanding distrust and suspiciousness of others based on the belief, which is unsupported by evidence, that others want to exploit, harm, or deceive the person. These individuals are hypervigilant, anticipate hostility, and may provoke hostile responses by initiating a counterattack. As adults, relationships are difficult due to jealousy, controlling behaviors, and unwillingness to forgive. Projection is the dominant defense mechanism whereby people attribute their own unacknowledged feelings to others. For example, they may accuse their partner of being hypercritical when they themselves are attentively fault finding.

2. When assessing a patient diagnosed with a borderline personality disorder, which statement by thepatient warrants immediate attention? a. "My mother died ten years ago." b. "I haven't needed medication in weeks." c. "My dad never loved me." d. "I'd really like to hurt her for hurting me."

d

7. Larry is from a small town and began displaying aggressive and manipulative traits while still a teenager.Now at 40 years old, Larry is serving a life sentence for the murders of his wife and her brother. John, the prison psychiatric nurse practitioner, recognizes that Larry's treatment will most likely: a. Transform Larry to a model prisoner b. Not improve Larry's coping skills c. Reaffirm Larry's high-risk behaviors d. Manifest as small incremental changes

d

A nurse determines desired outcomes for a patient diagnosed with schizotypal personality disorder. Select the best outcome. The patient will: a. adhere willingly to unit norms. b. report decreased incidence of self-mutilative thoughts. c. demonstrate fewer attempts at splitting or manipulating staff. d. demonstrate ability to introduce self to a stranger in a social situation.

d (. demonstrate ability to introduce self to a stranger in a social situation.)

Narcissistic Personality Disorder -- Characteristics:

grandiosity, fantasies of power or brilliance, need to be admired, sense of entitlement, arrogant, patronizing, rude, overestimates self and underestimates others. This behavior covers a fragile ego. In health care setting, such a patient demands the best of everything. When patient is corrected, when boundaries are defined, or when limits are set on patient's behavior, patient feels humiliated, degraded, and empty. To lower anxiety, the patient may launch a counterattack. The nurse should gently help the patient identify sense of entitlement, attempts to seek and become perfect, grandiose behavior.

Cluster B Personality Disorders Antisocial Personality Disorder -- Characteristics:

has superficial charm, violates rights of others, exploits others, lies, cheats, lacks guilt or remorse, is impulsive, acts out, and lacks empathy. As patients, these individuals are extremely manipulative and aggressive. Nurses must establish and adhere to a plan of care and maintain clear boundaries if they are to minimize patient manipulation and acting out.

Dependent Personality Disorder -- Characteristics:

inability to make daily decisions without advice and reassurance, need of others to be responsible for important areas of life, anxious and helpless when alone, and submissive. Solicit care taking by clinging. Fear abandonment if they are too competent. Experience anxiety and may have coexisting depression.

Obsessive-Compulsive Personality Disorder -- Characteristics:

preoccupied with rules, perfectionistic, too busy to have friends, rigid control, and superficial relationships. Complains about others' inefficiencies and gives others directions.

Cluster C Personality Disorders Avoidant Personality Disorder -- Characteristics:

social inhibition, feelings of inadequacy, hypersensitivity to criticism, preoccupation with fear of rejection and criticism, and self perceived to be socially inept. Low self-esteem and hypersensitivity grow as support networks decrease. Demands of workplace often overwhelming. Project that caregivers will harm them through disapproval and perceive rejection where none exists. Nurses can teach socialization skills, provide positive feedback, and build self-esteem.

Borderline Personality Disorder -- Characteristics:

unstable, intense relationships; identity disturbances; impulsivity; self-mutilation; rapid mood shifts; chronic emptiness; intense fear of abandonment; splitting; and anger. A major defense is splitting (alternating between idealizing and devaluing). Self-mutilation and suicide-prone behavior are frequently seen. Anger is intense and pervasive, and help with anger management is an important intervention. Relationship building, safety, and limit setting are other foci.

Nursing Care for a patient with Schizoid Personality Disorder

• Nurses should avoid being too "nice" or "friendly." • Do not try to increase socialization. • Patients may be open to discussing topics such as coping and anxiety. • Conduct a thorough assessment to identify symptoms the patient is reluctant to discuss. • Protect against ridicule from group members due to patient's distinctive interests or ideas.

Guidelines for Nursing Care of Patients with Obsessive Compulsive Personality Disorder

• Nurses should guard against power struggles with these patients as their need for control is very high. • Patients with this disorder have difficulty dealing with unexpected changes. • Provide structure, yet allow patients extra time to complete habitual behavior. • Assist patients to identify ineffective coping and to develop effective coping techniques.

Guidelines for Nursing care for patients with Narcissistic Personality Disorder

• Nurses should remain neutral and recognize the source of narcissistic behavior—shame and fear of abandonment. • Use the therapeutic nurse-patient relationship as an opportunity to practice how to engage in meaningful interaction. • Avoid engaging in power struggles or becoming defensive in response to the patient's disparaging remarks. • Role model empathy.

Guidelines for nursing care for patients with Avoidant Personality Disorder

• Nurses should use a friendly, accepting, and reassuring approach. • Remember that being pushed into social situations can cause severe anxiety for these patients. • Convey an attitude of acceptance toward patient fears. • Provide the patient exercises to enhance new social skills but use with caution because any failure can increase feelings of poor self-worth. • Assertiveness training can assist the person to learn to express needs.

Guidelines for Nursing Care of patients with Histrionic Personality Disorder

• Nursing care should reflect an understanding that seductive behavior is a response to distress. • Keep communication and interactions professional. • Patients may exaggerate symptoms and have difficulty in functioning. • Encourage and model the use of concrete and descriptive rather than vague and impressionistic language. • Assist the patient to clarify feelings because they often have difficulty identifying them. • Teach and role model assertiveness. • Assess for suicidal ideation. What was intended as a suicide gesture may inadvertently result in death.

Nursing care guidelines for Schizotypal Personality Disorder

• Respect patient's need for social isolation. • Nurses should be aware of patient's suspiciousness and employ appropriate interventions. • Perform careful assessment as needed to uncover any other medical or psychological symptoms that may need intervention (e.g., suicidal thoughts). • Be aware that strange beliefs and activities, like strange religious practices or peculiar thoughts, may be part of the patient's life.