Psych Chapter 24: Personality Disorders

Psychological Therapies for APD

*mentalization behavioral therapy (MBT) A specific form of CBT, mentalization behavioral therapy (MBT), is a long-term treatment that supports individuals' ability to recognize and understand their own and other people's mental states as well as to help them examine thoughts about themselves and others. Dialectical behavior therapy (DBT), which is similar to CBT, focuses on regulating emotions and being mindful; it is also useful in treating antisocial personality disorder.

Meds for avoidant personality disorder.

-Beta blockers -Anti-anxiety meds - SSRIs such as citalopram -SNRI such as venlafaxine Beta-adrenergic receptor antagonists (e.g., atenolol) help reduce autonomic nervous system hyperactivity. Antidepressant medications—including selective serotonin reuptake inhibitors (SSRIs) such as citalopram (Celexa) Serotonin norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine (Effexor)—may reduce social anxiety. Serotonergic agents may help individuals with avoidant personalities feel less sensitive to rejection.

What meds can be used to help a patient with paranoid personality disorder?

-Diazepam -Haloperidol -Pimozide An antianxiety agent such as diazepam (Valium) may be used to reduce a patient's anxiety and agitation. More severe agitation and delusions may be treated with an antipsychotic medication such as haloperidol (Haldol) in small doses for brief periods to manage mildly delusional thinking or severe agitation. The first-generation antipsychotic medication pimozide (Orap) may be useful in reducing paranoid ideation.

Meds to help people with Schizoid Personality Disorder

-bupropion -risperidone -olanzapine As with other personality disorders, there is no medication to improve the patient's functioning. However, depressive symptoms may be treated with antidepressants such as bupropion (Wellbutrin), which can help increase the patient's pleasure in life. Second-generation antipsychotics, such as risperidone (Risperdal) or olanzapine (Zyprexa), are used to improve emotional expressiveness.

Meds that People with schizotypal personality disorder may benefit from include:

-risperidone -olanzapine -Antidepressants Low-dose antipsychotic agents such as risperidone (Risperdal) or olanzapine (Zyprexa) for psychotic-like symptoms and day-to-day functioning. These agents help with symptoms such as ideas of reference or illusions. Major depressive disorder and anxiety disorders may be treated with antidepressants and antianxiety agents.

Paranoid personality disorder is slightly more prevalent in ________________ and often precedes a ____________________ diagnosis.

Men Schizophrenia Paranoid personality disorder is slightly more prevalent in men. Relatives of patients with schizophrenia are more frequently affected with it. A diagnosis of paranoid personality disorder often precedes a schizophrenia diagnosis. Symptoms may be apparent in childhood or adolescence.

Treatment for schizotypal personality disorder

Mostly supportive with med to help associated conditions. Because it is difficult to develop a therapeutic relationship or alliance with such an individual, the goal should be to provide supportive care. Helping to identify cognitive distortions may be useful.

Dependent Personality Disorder

Needy. Dependent personality 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. Dependent personality disorder may be the result of chronic physical illness or punishment for independent behavior in childhood. Because they lack confidence in their own ability or judgment, these individuals may manipulate others to assume responsibility for such activities as dealing with finances or child rearing. This may create problems by leaving them more vulnerable to exploitation by others because of their passive and submissive nature.

How is obsessive-compulsive disorder different from obsessive-compulsive personality disorder.

Obsessive-compulsive disorder is characterized by obsessive thoughts and repetition or adherence to rituals. People so affected are aware that these thoughts and actions are unreasonable. Obsessive-compulsive personality disorder is characterized more by an unhealthy focus on perfectionism. Such people "know" that their actions are right and feel comfortable with their self-imposed systems of rules. OCPD are your "work-a-holics"

Obsessive-Compulsive Personality Disorder

Obsessive-compulsive personality disorder is characterized by limited emotional expression, stubbornness, perseverance, and indecisiveness. Preoccupation with orderliness, perfectionism, and control are the hallmarks of this disorder. Obsessive-compulsive personality disorder is one of the most prevalent personality disorders.

Cluster A: Behaviors described as odd or eccentric

Paranoid personality disorder Schizoid personality disorder Schizotypal personality disorder

Treatment Modalities for Patients with schizoid personality disorder

Patients with schizoid personality disorder tend to be introspective. This trait may make them good, if distant, candidates for psychotherapy Group therapy is not a good first treatment choice, but it may be helpful after individual work. A noninvasive and supportive group can help individuals to overcome fears of closeness and feelings of isolation. Members may become quite important to the person with schizoid personality disorder, and this may be the person's dominant form of socialization.

Meds that may help manage APD

People with antisocial 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. Methylphenidate (Ritalin) may help if there is a comorbidity of attention-deficit/hyperactivity disorder.

Avoidant Personality Disorder

People with avoidant personality disorder are extremely sensitive to rejection, feel inadequate, and are socially inhibited. They avoid interpersonal contact owing to fears of rejection or criticism. Early symptoms of the disorder are often evident in infants and children. These symptoms include shyness and avoidance that, unlike common shyness, increase during adolescence and early adulthood. The main pathological personality traits are low self-esteem associated with poor functioning in social situations, feelings of inferiority compared with peers, and a reluctance to engage in unfamiliar activities involving new people.

Schizoid Personality Disorder

People with schizoid personality disorder exhibit a lifelong pattern of social withdrawal. They are somewhat expressionless and have a restricted range of emotional expression. Males are more often affected. Symptoms of schizoid personality disorder appear in childhood and adolescence. There is an increased prevalence of the disorder in families with a history of schizophrenia or schizotypal personality disorder. Abnormalities in the dopaminergic systems may underlie this problem.

Characteristics of schizoid personality disorder

Relationships are particularly affected because of the prominent feature of emotional detachment. People with this disorder do not seek out or enjoy close relationships. Friendships, dating, and sexual experiences are rare. If trust is established, the person may divulge numerous imaginary friends and fantasies. The employment of persons with this disorder may be jeopardized if interpersonal interaction is required; however, they may be able to function well in a solitary occupation such as being a security guard on the night shift. They often endorse feelings of being an observer rather than a participant in life. They may describe feelings of depersonalization or detachment from self and the world.

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?

Respect need for social isolation. Schizoid personality disorder has the primary feature of emotional detachment. Individuals do not seek out or enjoy close relationships. They are reclusive, avoidant, and uncooperative. They do not do well with resocialization.

Characteristics of Schizotypal Personality Disorder

Severe social and interpersonal deficits. They experience extreme anxiety in social situations. Their contributions to conversations tend to ramble with lengthy, unclear, overly detailed, and abstract content. An additional feature of this disorder is paranoia. Psychotic symptoms seen in people with schizophrenia, such as hallucinations and delusions, can also exist with schizotypal personality disorder, but to a lesser degree and only briefly. A major difference between this disorder and schizophrenia is that people with schizotypal personality disorder can be made aware of their suspiciousness, magical thinking, and odd beliefs.

Margaret Mahler stages

Stage 1 (birth to 1 month): Normal autism. The infant spends most of its time sleeping. • Stage 2 (1 to 5 months): Symbiosis. The infant perceives the mother-infant as a single fused entity. Infants gradually distinguish the inner from the outer world. • Stage 3 (5 to 10 months): Differentiation. The infant recognizes its distinctness from mother. Progressive neurological development and increased alertness draw the infant's attention away from self to the outer world. • Stage 4 (11 to 18 months): Practicing. The ability to walk and explore greatly expands the toddler's sense of separateness. • Stage 5 (18 to 24 months): Rapprochement. Toddlers move away from their mothers and come back for emotional refueling. Periods of helplessness and dependence alternate with the need for independence. • Stage 6 (2 to 5 years): Object constancy, when children comprehend that objects (in this case, the object being the mother) are permanent even when they are not in the child's presence. At this point, the individuation process is complete.

Mahler suggest that such psychological problems are due to disruption of...

The normal separation-individuation between the child and the mother. According to Mahler, an infant's development progresses from complete self-absorption—with an inability to see a difference between the infant and the primary caregiver—to an emotionally and physically differentiated toddler. This support is achieved through a balance of holding (emotionally and physically) a child enough for the child to feel safe while at the same time fostering and encouraging independence and natural exploration.

Larry is from a small town and began displaying aggressive and manipulative traits while still a teenager. Now 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 d. Manifest as small incremental changes

Non-psychiatric diagnoses are also associated with borderline personality disorder. They include...

Diabetes, high blood pressure, fibromyalgia, and arthritis. Chronic pain is strongly associated with this personality disorder.

Schizotypal Personality 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. As in the case of the other cluster A personality disorders, symptoms are evident in young people.

What is the current accepted professional view of the effect of culture on the development of a personality disorder? a. There are not enough studies to confirm the role that ethnicity and race have on the prevalence of personality disorders. b. The North American and Australian cultures produce higher incidences of personality disorders within their populations. c. Neither culture nor ethnic background is generally considered in the development of personality disorders. d. Personality disorders have been found to be primarily the products of genetic factors, not cultural factors.

a. There are not enough studies to confirm the role that ethnicity and race have on the prevalence of personality disorders.

1. Which statement made by the psychiatric nurse demonstrates an accurate understanding of the factors that 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. "I'll need to learn more about this patient's cultural beliefs."

Josie, a 27-year-old patient, complains that most of the staff do not like her. She says she can tell whether you are 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. Borderline

Garret's wife of 8 years is divorcing him because their marriage never developed a warm or loving atmosphere. Garrett states in therapy, "I have always been a loner," and says that he 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. Help him to get a good night's sleep c. Increase the pleasure of living d. Prepare Garrett for group therapy

c. Increase the pleasure of living

When assessing a patient diagnosed with a borderline personality disorder, which statement by the patient 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. "I'd really like to hurt her for hurting me."

BPD is highly associated with genetic factors such as

hypersensitivity, impulsivity, and emotional dysregulation. There is evidence that serotonergic dysfunction may accompany the borderline trait of impulsivity.

Individuals with schizotypal personality may be actively involved in groups that can complicate the clinical picture such as ...

unusual religious sects or occult-type societies.

Tips/guidelines for working with a person with paranoid personality disorder.

• Considering the degree of mistrust felt by these individuals, all prearranged promises, appointments, and schedules should be strictly adhered to. • Being too nice or friendly may be met with suspicion. Instead, clear and straightforward explanations of tests and procedures should be given before they are scheduled. • It is best to use simple language and to project a neutral but kindly affect. • When a patient exhibits threatening behaviors, it is essential to set limits.

Tips/Guidelines for Nursing Care for patients with schizotypal personality disorder

• Respect the patient's need for social isolation. • Nurses should be aware of the patient's suspiciousness and use 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, such as strange religious practices or peculiar thoughts, may be part of the patient's life.

Paranoid personality disorder

Characterized by a long-standing distrust and suspiciousness of others based on the belief, 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.

Meds for OCD

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.

Assessment Guidelines for 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 diagnoses with the most relevance to this disorder include risk for violence, impaired impulse control, and impaired social interaction.

Psychological Therapies for BPD

1. Cognitive behavioral therapy (CBT): CBT can help individuals to identify and change inaccurate core perceptions of themselves and others and relationship problems. 2. Dialectical behavior therapy (DBT) used to treat chronically suicidal individuals with borderline personality disorder. DBT combines cognitive and behavioral techniques with mindfulness, which emphasizes being aware of one's thoughts and actively shaping them. 3. Schema-focused therapy: Schema-focused therapy combines parts of CBT with other forms of therapy that focus on the ways that individuals view themselves.

Cluster B: Behaviors described as dramatic, emotional, or erratic

Borderline personality disorder Narcissistic personality disorder Histrionic personality disorder Antisocial personality disorder

BPD comorbidities

Both physical and psychiatric disorders co-occur in individuals with borderline personality disorder. Psychiatric comorbidities include major depressive disorder, bipolar disorder, anxiety disorders, and sleep disorder. Substance use disorder is extremely common. Women with this disorder are more likely to have major depressive disorder, anxiety disorders, and posttraumatic stress disorder. Men are more likely to have substance use disorders or antisocial personality disorder.

Antisocial Personality Disorder aka sociopaths

Antisocial personality disorder is a pattern of disregard for the rights of others and their frequent violation. Lack of empathy (callous) The main pathological traits that characterize antisocial personality disorder are antagonistic behaviors such as being deceitful and manipulative for personal gain or hostile if one's needs are blocked. The disorder is also characterized by disinhibited behaviors such as risk taking, disregard for responsibility, and impulsivity.

Cluster C: Behaviors described as anxious or fearful

Avoidant Dependent Obsessive-compulsive

Personality disorders often co-occur with mood and eating disorders. A young woman is undergoing treatment at an eating disorders clinic and her nurse suspects that she may also have a cluster B personality disorder because of her: a. Desire to avoid eating b. Dramatic response to frustration c. Excessive exercise routine d. Morose personality traits

B. Dramatic response to frustration

Features of BPD

Emotional lability, that is, rapidly moving from one emotional extreme to another. Responding to situations with emotions that are out of proportion to the circumstances, pathological fear of separation, and intense sensitivity to perceived personal rejection. Impulsivity, or acting quickly in response to emotions without considering the consequences. Ineffective and often harmful self-soothing Splitting as a primary defense mechanism or coping style. It involves an inability to view both positive and negative aspects of others as part of a whole, which results in viewing someone as either a wonderful person or a horrible person. Looks to other to fulfil their needs. However, at the first disappointment or frustration, the individual's status quickly shifts to one of devaluation, and the other person is despised. Transient, stress-related paranoid ideations or severe dissociative symptoms.

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?

Impaired social interaction For a client who has difficulty in relationships and is very manipulative, the nursing diagnosis of impaired social interaction would be used.

Meds for BPD

In the United States, there are no medications specifically approved by the FDA for treating borderline personality disorder. Meds that may help symptoms include: -SSRIs -Anticonvulsants -Lithium -Naltrexon -Second generation anti-psychotics (-pine, -done, and aripiprazole) Naltrexone (Revia, Vivitrol), an opioid receptor antagonist, has been found to reduce self-injurious behaviors. Second-generation antipsychotics may control anger and brief episodes of psychosis.

Treatment Modalities for 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.

Environmental Factors and antisocial personality disorder

It is likely that a genetic predisposition for characteristics of antisocial personality disorder such as a lack of empathy may be set into motion by childhood maltreatment. Inconsistent parenting and discipline, significant abuse, and extreme neglect are associated with this disorder.

Borderline Personality Disorder

Its major features are patterns of marked instability, impulsivity, identity or self-image distortions, unstable mood, and unstable interpersonal relationships. It is marked by emotional dysregulation, a term that describes poorly modulated mood characterized by mood swings.

Hungarian-born child psychologist who worked with emotionally disturbed children, developed a framework that is useful in considering borderline personality disorder.

Margaret Mahler

personality disorders

Personality disorders are among the most challenging and complex group of disorders to treat. People with these disorders have difficulty recognizing or owning that their difficulties are problems of their personalities. Judgments about an individual's personality functioning should take into account the person's ethnic, cultural, and social backgrounds. Patients who differ from the majority culture or the culture of the clinician may be at risk for over-diagnosis of a personality disorder.

Treatment options for a person with paranoid personality disorder.

Psychotherapy is the first line of treatment for paranoid personality disorder. In a group therapy setting role playing and group feedback can help reduce suspiciousness. For example, if the patient says, "I think the therapist is singling me out," other group members may provide a reality check or describe similar feelings in the past. Individuals with paranoid personality disorder tend to reject treatment due to suspicion and fear of being judged and having what they say "used against them" They are also hard to interview.

Treatment for dependent personality disorder

Psychotherapy is the treatment of choice for dependent personality disorder. CBT can help patients develop more healthy and accurate thinking by examining and challenging automatic thoughts that result in fearful behavior. Panic attacks can be helped with the tricyclic antidepressant imipramine (Tofranil).

Histrionic Personality Disorder

This disorder is characterized by emotional attention-seeking behaviors, including self-centeredness, low frustration tolerance, and excessive emotionality. The person with histrionic personality disorder is often impulsive and may act flirtatiously or provocatively. Do not think that they need help nor do they think that they are the problem. People with histrionic personality disorder are excitable and dramatic yet are often also high functioning. They may be referred to as "drama queens" or "drama majors." Classic characteristics of this population include extroversion, flamboyance, and colorful personalities. Despite this bold exterior, they tend to have limited abilities to develop meaningful relationships. More often seen in women than men. 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.

Connor is a 28-year-old student, referred by his university for a psychiatric evaluation. He reports that he has no friends at the university and that people call him a loner. Connor has recently been "giving lectures" to pigeons at the university fountains. He 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. Can be made aware of their delusions

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. Paranoid b. Schizoid

5. Which behaviors are examples of a primitive defense mechanism often relied upon by those diagnosed with 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 self when fearful d. Lashes out verbally when confronted with criticism e. Destroys another person's belongings when angry

a, b, c 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 self when fearful

BPD assessment Self-report inventories, such as the well-known Minnesota Multiphasic Personality Inventory (MMPI), are useful because they have built-in validity and reliability scales for the clinician to refer to when test results are being interpreted. Areas of assessment that are typically included on questionnaires and rating scales related to borderline personality disorder include:

• 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

Guidelines for Nursing Care for 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.

Tips/guidelines for working with a patient who has Schizoid Personality Disorder

• Nurses should avoid being too "nice" or "friendly." • Efforts to promote the patient's socialization are also to be avoided. • Patients may be open to discussing topics such as coping and anxiety. • Conduct a thorough assessment to identify symptoms that the patient is reluctant to discuss. • Protect against ridicule from group members because of the patient's distinctive interests or ideas.

Tips Guidelines for Nursing Care with OCD

• 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. • It is helpful to provide structure yet allow patients extra time to complete habitual behavior. • Help patients to identify ineffective coping and to develop better coping techniques.

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 with exercises to enhance new social skills but use these with caution because any failure can increase the patient's feelings of poor self-worth. • Assertiveness training can help the person learn to express needs.

Tip / Guidelines for Nursing Care for Histrionic Personality Disorder

• Nursing care should reflect an understanding that seductive behavior is a response to distress. • Communication and interactions should always be kept 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. • Help patients to clarify their own feelings, as they often have difficulty identifying them. • Teach and role model assertiveness. • Assess for suicidal ideation. What was intended as a suicidal gesture may inadvertently result in the patient's death.