Chapter 18 Personality DIsorders Mental health

DSM 5 borderline personality disorder

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.) A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. Identity disturbance: markedly and persistently unstable self-image or sense of self. 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.) Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. 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). Chronic feelings of emptiness. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). Transient, stress-related paranoid ideation or severe dissociative symptoms.

Cluster B—erratic or dramatic behaviors

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

Evaluation Borderline Personality D/O

As with any personality disorder, changes may be small and slow. The degree of functional impairment of clients with borderline personality disorder may vary widely. Clients with severe impairment may be evaluated in terms of their ability to be safe and to refrain from self-injury. Other clients may be employed and have fairly stable interpersonal relationships. Generally, when clients experience fewer crises less frequently over time, treatment is effective. (Videbeck 356) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

antisocial personality disorder

Assessment Clients are skillful at deceiving others, so during assessment, it helps to check and to validate information from other sources. History Onset is in childhood or adolescence, although formal diagnosis is not made until the client is 18 years of age. Childhood histories of enuresis, sleepwalking, and syntonic acts of cruelty are characteristic predictors. In adolescence, clients may have engaged in lying, truancy, sexual promiscuity, cigarette smoking, substance use, and illegal activities that brought them into contact with police. Families have high rates of depression, substance abuse, antisocial personality disorder, poverty, and divorce. Erratic, neglectful, harsh, or even abusive parenting frequently marks the childhoods of these clients (Dargis et al., 2015). p. 345 p. 346 General Appearance and Motor Behavior Appearance is usually normal; these clients may be quite engaging and even charming. Depending on the circumstances of the interview, they may exhibit signs of mild or moderate anxiety, especially if another person or agency arranged the assessment. Mood and Affect Clients often display false emotions chosen to suit the occasion or to work to their advantage. For example, a client who is forced to seek treatment instead of going to jail may appear engaging or try to evoke sympathy by sadly relating a story of his or her "terrible childhood." The client's actual emotions are quite shallow. These clients cannot empathize with the feelings of others, which enables them to exploit others without guilt. Usually, they feel remorse only if they are caught breaking the law or exploiting someone. Thought Process and Content Clients do not experience disordered thoughts, but their view of the world is narrow and distorted. Because coercion and personal profit motivate them, they tend to believe that others are similarly governed. They view the world as cold and hostile and therefore rationalize their behavior. Clichés such as "It's a dog-eat-dog world" represent their viewpoint. Clients believe they are only taking care of themselves because no one else will. Sensorium and Intellectual Processes Clients are oriented, have no sensory-perceptual alterations, and have average or above-average IQs. Judgment and Insight These clients generally exercise poor judgment for various reasons. They pay no attention to the legality of their actions and do not consider morals or ethics when making decisions. Their behavior is determined primarily by what they want, and they perceive their needs as immediate. In addition to seeking immediate gratification, these clients also are impulsive. Such impulsivity ranges from simple failure to use normal caution (waiting for a green light to cross a busy street) to extreme thrill-seeking behaviors such as driving recklessly. Clients lack insight and almost never see their actions as the cause of their problems. It is always someone else's fault: some external source is responsible for their situation or behavior. Self-Concept Superficially, clients appear confident, self-assured, and accomplished, perhaps even flip or arrogant. They feel fearless, disregard their own vulnerability, and usually believe they cannot be caught in lies, deceit, or illegal actions. They may be described as egocentric (believing the world revolves around them), but actually the self is quite shallow and empty; these clients are devoid of personal emotions. They realistically appraise their own strengths and weaknesses. (Videbeck 345-346) Roles and Relationships Clients manipulate and exploit those around them. They view relationships as serving their needs and pursue others only for personal gain. They never think about the repercussions of their actions to others. For example, a client is caught scamming an older person out of her entire life savings. The client's only comment when caught is "Can you believe that's all the money I got? I was cheated! There should have been more." These clients are often involved in many relationships, sometimes simultaneously. They may marry and have children, but they cannot sustain long-term commitments. They are usually unsuccessful as spouses and parents, and leave others abandoned and disappointed. They may obtain employment readily with their adept use of superficial social skills, but over time, their work history is poor. Problems may result from absenteeism, theft, or embezzlement, or they may simply quit out of boredom. (Videbeck 346) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Assessment of Borderline Personality Disorder

Assessment History Many of these clients report disturbed early relationships with their parents that often begin at 18 to 30 months of age. Commonly, early attempts by these clients to achieve developmental independence were met with punitive responses from parents or threats of withdrawal of parental support and approval. Fifty percent of these clients have experienced childhood sexual abuse; others have experienced physical and verbal abuse and parental alcoholism. Clients tend to use transitional objects (e.g., teddy bears, pillows, blankets, and dolls) extensively; this may continue into adulthood. Transitional objects are often similar to favorite items from childhood that the client used for comfort or security (Schönfeldt-Lecuona et al., 2015). General Appearance and Motor Behavior Clients experience a wide range of dysfunction—from severe to mild. Initial behavior and presentation may vary widely depending on a client's present status. When dysfunction is severe, clients may appear disheveled and may be unable to sit still, or they may display very labile emotions. In other cases, initial appearance and motor behavior may seem normal. The client seen in the emergency room threatening suicide or self-harm may seem out of control, whereas a client seen in an outpatient clinic may appear fairly calm and rational. Mood and Affect The pervasive mood is dysphoric, involving unhappiness, restlessness, and malaise. Clients often report intense loneliness, boredom, frustration, and feeling "empty." They rarely experience periods of satisfaction or well-being. Although there is a pervasive depressed affect, it is unstable and erratic. Clients may become irritable, even hostile or sarcastic, and complain of episodes of panic anxiety. They experience intense emotions such as anger and rage, but rarely express them productively or usefully. They are usually hypersensitive to others' emotions, which can easily trigger reactions. Minor changes may precipitate a severe emotional crisis, for example, when an appointment must be changed from one day to the next. Commonly, these clients experience major emotional trauma when their therapists take vacations. Thought Process and Content Thinking about self and others is often polarized and extreme, which is sometimes referred to as splitting. Clients tend to adore and idealize other people even after a brief acquaintance, but then quickly devalue them if these others do not meet their expectations in some way. Clients have excessive and chronic fears of abandonment even in normal situations; this reflects their intolerance of being alone. They may also engage in obsessive rumination about almost anything, regardless of the issue's relative importance. Clients may experience dissociative episodes (periods of wakefulness when they are unaware of their actions). Self-harm behaviors often occur during these dissociative episodes, although at other times clients may be fully aware of injuring themselves. As stated earlier, under extreme stress, clients may develop transient psychotic symptoms such as delusions or hallucinations. Sensorium and Intellectual Processes Intellectual capacities are intact, and clients are fully oriented to reality. The exception is transient psychotic symptoms; during such episodes, reports of auditory hallucinations encouraging or demanding self-harm are most common. These symptoms usually abate when the stress is relieved. Many clients also report flashbacks of previous abuse or trauma. These experiences are consistent with posttraumatic stress disorder, which is common in clients with borderline personality disorder (see Chapter 13). Judgment and Insight Clients frequently report behaviors consistent with impaired judgment and lack of care and concern for safety, such as gambling, shoplifting, and reckless driving. They make decisions impulsively on the basis of emotions rather than facts. Clients have difficulty accepting responsibility for meeting needs outside a relationship. They see life's problems and failures as a result of others' shortcomings. Because others are always to blame, insight is limited. A typical reaction to a problem is "I wouldn't have gotten into this mess if so-and-so had been there." Self-Concept Clients have an unstable view of themselves that shifts dramatically and suddenly. They may appear needy and dependent one moment and angry, hostile, and rejecting the next. Sudden changes in opinions and plans about career, sexual identity, values, and types of friends are common. Clients view themselves as inherently bad or evil and often report feeling as if they don't really exist at all. Suicidal threats, gestures, and attempts are common. Self-harm and mutilation, such as cutting, punching, or burning, are common. These behaviors must be taken very seriously because these clients are at increased risk for completed suicide, even if numerous previous attempts have not been life threatening. These self-inflicted injuries cause much pain and often require extensive treatment; some result in massive scarring or permanent disability such as paralysis or loss of mobility from injury to nerves, tendons, and other essential structures. Roles and Relationships Clients hate being alone, but their erratic, labile, and sometimes dangerous behaviors often isolate them. Relationships are unstable, stormy, and intense; the cycle repeats itself continually. These clients have extreme fears of abandonment and difficulty believing a relationship still exists once the person is away from them. They engage in many desperate behaviors, even suicide attempts, to gain or to maintain relationships. Feelings for others are often distorted, erratic, and inappropriate. For example, they may view someone they have met only once or twice as their best and only friend or the "love of my life." If another person does not immediately reciprocate their feelings, they may feel rejected, become hostile, and declare him or her to be their enemy. These erratic emotional changes can occur in the space of 1 hour. Often, these situations precipitate self-mutilating behavior; occasionally, clients may attempt to harm others physically. Clients usually have a history of poor school and work performance because of constantly changing career goals and shifts in identity or aspirations, preoccupation with maintaining relationships, and fear of real or perceived abandonment. Clients lack the concentration and self-discipline to follow through on sometimes mundane tasks associated with work or school. Physiologic and Self-Care Considerations In addition to suicidal and self-harm behavior, clients may also engage in binging (excessive overeating) and purging (self-induced vomiting), substance abuse, unprotected sex, or reckless behavior such as driving while intoxicated. They usually have difficulty sleeping. (Videbeck 352) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Cluster C—anxious or fearful behaviors

Avoidant personality disorder Dependent personality disorder Obsessive personality disorder

borderline personality disorder

Borderline personality disorder is characterized by a pervasive pattern of unstable interpersonal relationships, self-image, and affect as well as marked impulsivity. About 2% to 3% of the general population has borderline personality disorder; it is five times more common in those with a first-degree relative with the diagnosis. Borderline personality disorder is the most common personality disorder found in clinical settings. It is three times more common in women than in men. Under stress, transient psychotic symptoms are common. Between 8% and 10% of people with this diagnosis commit suicide, and many more suffer permanent damage from self-mutilation injuries, such as cutting or burning. Up to three quarters of clients with borderline personality disorder engage in deliberate self-harm, sometimes called nonsuicidal self-injury (Black & Andreasen, 2014). Typically, recurrent self-mutilation is a cry for help, an expression of intense anger or helplessness, or a form of self-punishment. The resulting physical pain is also a means to block emotional pain. Clients who engage in self-mutilation do so to reinforce that they are still alive; they seek to experience physical pain in the face of emotional numbing (Klonsky et al., 2015). Working with clients who have borderline personality disorder can be frustrating. They may cling and ask for help one minute and then become angry, act out, and reject all offers of help in the next minute. They may attempt to manipulate staff to gain immediate gratification of needs and at times sabotage their own treatment plans by purposely failing to do what they have agreed. Their labile mood, unpredictability, and diverse behaviors can make it seem as if the staff is always "back to square one" with them. (Videbeck 351) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Community based care

Caring for clients with personality disorders occurs primarily in community-based settings. Acute psychiatric settings such as hospitals are useful for safety concerns for short periods. The nurse uses skills to deal with clients who have personality disorders in clinics, outpatient settings, doctors' offices, and many medical settings. Often, the personality disorder is not the focus of attention; rather, the client may be seeking treatment for a physical condition. Most people with personality disorders are treated in group or individual therapy settings, community support programs, or self-help groups. Others will not seek treatment for their personality disorder, but may be treated for a major mental illness. Wherever the nurse encounters clients with personality disorders, including in his or her own life, the interventions discussed in this chapter can prove useful. (Videbeck 361) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Interventions borderline personality disorder

Clients with borderline personality disorder are often involved in long-term psychotherapy to address issues of family dysfunction and abuse. The nurse is most likely to have contact with these clients during crises, when they are exhibiting self-harm behaviors or transient psychotic symptoms. Brief hospitalizations are often used to manage these difficulties and to stabilize the client's condition. p. 354 p. 355 Promoting Clients' Safety Clients' physical safety is always a priority. The nurse must always seriously consider suicidal ideation with the presence of a plan, access to means for enacting the plan, and self-harm behaviors and institute appropriate interventions (see Chapter 17). Clients often experience chronic suicidality or ongoing intermittent ideas of suicide over months or years. The challenge for the nurse, in concert with clients, is to determine when suicidal ideas are likely to be translated into action. Clients may enact self-harm urges by cutting, burning, or punching themselves, which sometimes causes permanent physical damage. Self-injury can occur when a client is enraged or experiencing dissociative episodes or psychotic symptoms, or it may occur for no readily apparent reason. Helping clients to avoid self-injury can be difficult when antecedent conditions vary greatly. Sometimes, clients may discuss self-harm urges with the nurse if they feel comfortable doing so. The nurse must remain nonjudgmental when discussing this topic. It has been common practice in many settings to encourage clients to enter into a no-self-harm contract, in which a client promises not to engage in self-harm and to report to the nurse when he or she is losing control. The no-self-harm contract is not a promise to the nurse, but is the client's promise to himself or herself to be safe. Although not legally binding, such a contract is thought to be beneficial to the client's treatment by promoting self-responsibility and encouraging dialogue between client and nurse. However, there is no evidence to support the effectiveness of these contracts, and in fact, some believe they may interfere with the therapeutic relationship (Matarazzo et al., 2014). When clients are relatively calm and thinking clearly, it is helpful for the nurse to explore self-harm behavior. The nurse avoids sensational aspects of the injury; the focus is on identifying mood and affect, level of agitation and distress, and circumstances surrounding the incident. In this way, clients can begin to identify trigger situations, moods, or emotions that precede self-harm and to use more effective coping skills to deal with the trigger issues. If clients do injure themselves, the nurse assesses the injury and need for treatment in a calm, matter-of-fact manner. Lecturing or chastising clients is punitive and has no positive effect on self-harm behaviors. Deflecting attention from the actual physical act is usually desirable. Promoting the Therapeutic Relationship Regardless of the clinical setting, the nurse must provide structure and limit setting in the therapeutic relationship. In a clinical setting, this may mean seeing the client for scheduled appointments of a predetermined length rather than whenever the client appears and demands the nurse's immediate attention. In the hospital setting, the nurse would plan to spend a specific amount of time with the client working on issues or coping strategies rather than giving the client exclusive access when he or she has had an outburst. Limit setting and confrontation techniques, which were described earlier, are also helpful. (Videbeck 354-355) Establishing Boundaries in Relationships Clients have difficulty maintaining satisfying interpersonal relationships. Personal boundaries are unclear, and clients often have unrealistic expectations. Erratic patterns of thinking and behaving often alienate them from others. This may be true for both professional and personal relationships. Clients can easily misinterpret the nurse's genuine interest and caring as a personal friendship, and the nurse may feel flattered by a client's compliments. The nurse must be quite clear about establishing the boundaries of the therapeutic relationship to ensure that neither the client's nor the nurse's boundaries are violated. For example: Client: "You're better than my family and the doctors. You understand me more than anyone else." Nurse: "I'm interested in helping you get better, just as the other staff members are." (establishing boundaries) p. 355 p. 356 Teaching Effective Communication Skills It is important to teach basic communication skills such as eye contact, active listening, taking turns talking, validating the meaning of another's communication, and using "I" statements ("I think...," "I feel...," "I need..."). The nurse can model these techniques and engage in role-playing with clients. The nurse asks how clients feel when interacting, and gives feedback about nonverbal behavior, such as "I noticed you were looking at the floor when discussing your feelings." Helping Clients to Cope and to Control Emotions Clients often react to situations with extreme emotional responses without actually recognizing their feelings. The nurse can help clients to identify their feelings and learn to tolerate them without exaggerated responses such as destruction of property or self-harm. Keeping a journal often helps clients gain awareness of feelings. The nurse can review journal entries as a basis for discussion. Another aspect of emotional regulation is decreasing impulsivity and learning to delay gratification. When clients have an immediate desire or request, they must learn that it is unreasonable to expect it to be granted without delay. Clients can use distraction such as taking a walk or listening to music to deal with the delay, or they can think about ways to meet needs themselves. Clients can write in their journals about their feelings when gratification is delayed. Reshaping Thinking Patterns These clients view everything, people and situations, in extremes—totally good or totally bad. Cognitive restructuring is a technique useful in changing patterns of thinking by helping clients to recognize negative thoughts and feelings and to replace them with positive patterns of thinking. Thought stopping is a technique to alter the process of negative or self-critical thought patterns such as "I'm dumb, I'm stupid, I can't do anything right." When the thoughts begin, the client may actually say "Stop!" in a loud voice to stop the negative thoughts. Later, more subtle means such as forming a visual image of a stop sign will be a cue to interrupt the negative thoughts. The client then learns to replace recurrent negative thoughts of worthlessness with more positive thinking. In positive self-talk, the client reframes negative thoughts into positive ones: "I made a mistake, but it's not the end of the world. Next time, I'll know what to do" Decatastrophizing is a technique that involves learning to assess situations realistically rather than always assuming a catastrophe will happen. The nurse asks, "So what is the worst thing that could happen?" or "How likely do you think that is?" or "How do you suppose other people might deal with that?" or "Can you think of any exceptions to that?" In this way, the client must consider other points of view and actually think about the situation; in time, his or her thinking may become less rigid and inflexible (Black & Andreasen, 2014). Structuring the Clients' Daily Activities Feelings of chronic boredom and emptiness, fear of abandonment, and intolerance of being alone are common problems. Clients are often at a loss about how to manage unstructured time, become unhappy and ruminative, and may engage in frantic and desperate behaviors (e.g., self-harm) to change the situation. Minimizing unstructured time by planning activities can help clients to manage time alone. Clients can make a written schedule that includes appointments, shopping, reading the paper, and going for a walk. They are more likely to follow the plan if it is in written form. This can also help clients to plan ahead to spend time with others instead of frantically calling others when in distress. The written schedule also allows the nurse to help clients to engage in more healthful behaviors such as exercising, planning meals, and cooking nutritious food. (Videbeck 356) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

avoidant personality disorder

Clinical Picture Avoidant personality disorder is characterized by a pervasive pattern of social discomfort and reticence, low self-esteem, and hypersensitivity to negative evaluation. It occurs in 2% to 3% of the general population. It is equally common in men and women. Clients are good candidates for individual psychotherapy (Sadock et al., 2015). These clients are likely to report being overly inhibited as children and that they often avoid unfamiliar situations and people with an intensity beyond that expected for their developmental stage. This inhibition, which may have continued throughout upbringing, contributes to low self-esteem and social alienation. Clients are apt to be anxious and may fidget in chairs and make poor eye contact with the nurse. They may be reluctant to ask questions or to make requests. They may appear sad as well as anxious. They describe being shy, fearful, socially awkward, and easily devastated by real or perceived criticism. Their usual response to these feelings is to become more reticent and withdrawn. p. 358 p. 359 Clients have very low self-esteem. They are hypersensitive to negative evaluation from others and readily believe themselves to be inferior. Clients are reluctant to do anything perceived as risky, which, for them, is almost anything. They are fearful and convinced they will make a mistake, be humiliated, or embarrass themselves and others. Because they are unusually fearful of rejection, criticism, shame, or disapproval, they tend to avoid situations or relationships that may result in these feelings. They usually strongly desire social acceptance and human companionship: they wish for closeness and intimacy, but fear possible rejection and humiliation. These fears hinder socialization, which makes clients seem awkward and socially inept and reinforces their beliefs about themselves. They may need excessive reassurance of guaranteed acceptance before they are willing to risk forming a relationship. Clients may report some success in occupational roles because they are so eager to please or to win a supervisor's approval. Shyness, awkwardness, or fear of failure, however, may prevent them from seeking jobs that might be more suitable, challenging, or rewarding. For example, a client may reject a promotion and continue to remain in an entry-level position for years even though he or she is well qualified to advance. Nursing Interventions These clients require much support and reassurance from the nurse. In the nonthreatening context of the relationship, the nurse can help them to explore positive self-aspects, positive responses from others, and possible reasons for self-criticism. Helping clients to practice self-affirmations and positive self-talk may be useful in promoting self-esteem. Other cognitive restructuring techniques such as reframing and decatastrophizing (described previously) can enhance self-worth. The nurse can teach social skills and help clients to practice them in the safety of the nurse-client relationship. Although these clients have many social fears, those are often counterbalanced by their desire for meaningful social contact and relationships. The nurse must be careful and patient with clients and not expect them to implement social skills too rapidly. (Videbeck 358-359) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

dependent personality disorder

Clinical Picture Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of, which leads to submissive and clinging behavior and fears of separation. These behaviors are designed to elicit caretaking from others. This disorder occurs in about 1% of the population, and is three times more common in females than males. It runs in families and is more common in the youngest child. People with dependent personality disorder may seek treatment for anxious, depressed, or somatic symptoms (Sadock et al., 2015). Clients are frequently anxious and may be mildly uncomfortable. They are often pessimistic and self-critical; other people hurt their feelings easily. They commonly report feeling unhappy or depressed; this is associated most likely with the actual or threatened loss of support from another. They are excessively preoccupied with unrealistic fears of being left alone to care for themselves. They believe they would fail on their own, so keeping or finding a relationship occupies much of their time. They have tremendous difficulty making decisions, no matter how minor. They seek advice and repeated reassurances about all types of decisions, from what to wear to what type of job to pursue. Although they can make judgments and decisions, they lack the confidence to do so. Clients perceive themselves as unable to function outside a relationship with someone who can tell them what to do. They are very uncomfortable and feel helpless when alone, even if the current relationship is intact. They have difficulty initiating projects or completing simple daily tasks independently. They believe they need someone else to assume responsibility for them, a belief that far exceeds what is age or situation appropriate. They may even fear gaining competence because doing so would mean an eventual loss of support from the person on whom they depend. They may do almost anything to sustain a relationship, even one of poor quality. This includes doing unpleasant tasks, going places they dislike, or in extreme cases, tolerating abuse. Clients are reluctant to express disagreement for fear of losing the other person's support or approval; they may even consent to activities that are wrong or illegal to avoid that loss. When these clients do experience the end of a relationship, they urgently and desperately seek another. The unspoken motto seems to be "Any relationship is better than no relationship at all." Nursing Interventions The nurse must help clients to express feelings of grief and loss over the end of a relationship while fostering autonomy and self-reliance. Helping clients to identify their strengths and needs is more helpful than encouraging the overwhelming belief that "I can't do anything alone!" Cognitive restructuring techniques such as reframing and decatastrophizing may be beneficial. Clients may need assistance in daily functioning if they have little or no past success in this area. Included are such things as planning menus, doing the weekly shopping, budgeting money, balancing a checkbook, and paying bills. Careful assessment to determine areas of need is essential. Depending on the client's abilities and limitations, referral to agencies for services or assistance may be indicated. p. 359 p. 360 The nurse may also need to teach problem-solving and decision-making and help clients apply them to daily life. He or she must refrain from giving advice about problems or making decisions for clients even though clients may ask the nurse to do so. The nurse can help the client to explore problems, serve as a sounding board for discussion of alternatives, and provide support and positive feedback for the client's efforts in these areas. (Videbeck 359-360) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

histrionic personality disorder

Clinical Picture Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. It is found in 1% to 3% of the general population, but in as much as 10% to 15% of inpatient populations. Clients often seek assistance for depression, unexplained physical problems, and difficulties with relationships. However, clients do not see how their own behavior has an impact on their current difficulties. This disorder is diagnosed more frequently in females than in males (Sadock et al., 2015). The tendency of these clients to exaggerate the closeness of relationships or to dramatize relatively minor occurrences can result in unreliable data. Speech is usually colorful and theatrical, full of superlative adjectives. It becomes apparent, however, that although colorful and entertaining, descriptions are vague and lack detail. Overall appearance is normal, although clients may overdress (e.g., wear an evening dress and high heels for a clinical interview). Clients are overly concerned with impressing others with their appearance and spend inordinate time, energy, and money to this end. Dress and flirtatious behavior are not limited to social situations or relationships, but also occur in occupational and professional settings. The nurse may think these clients are charming or even seductive. Clients are emotionally expressive, gregarious, and effusive. They often exaggerate emotions inappropriately. For example, a client says, "He is the most wonderful doctor! He is so fantastic! He has changed my life!" to describe a physician she has seen once or twice. In such a case, the client cannot specify why she views the doctor so highly. Expressed emotions, although colorful, are insincere and shallow; this is readily apparent to others but not to clients. They experience rapid shifts in moods and emotions and may be laughing uproariously one moment and sobbing the next. Thus, their displays of emotion may seem phony or forced to observers. Clients are self-absorbed and focus most of their thinking on themselves, with little or no thought about the needs of others. They are highly suggestible and will agree with almost anyone to get attention. They express strong opinions very firmly, but because they base them on little evidence or facts, the opinions often shift under the influence of someone they are trying to impress. Clients are uncomfortable when they are not the center of attention, and go to great lengths to gain that status. They use their physical appearance and dress to gain attention. At times, they may fish for compliments in unsubtle ways, fabricate unbelievable stories, or create public scenes to attract attention. They may even faint, become ill, or fall to the floor. They brighten considerably when given attention after some of these behaviors; this leaves others feeling they have been used. Any comment or statement that could be interpreted as uncomplimentary or unflattering may produce a strong response such as a temper tantrum or crying outburst. Clients tend to exaggerate the intimacy of relationships. They refer to almost all acquaintances as "dear, dear friends." They may embarrass family members or friends by flamboyant and inappropriate public behavior such as hugging and kissing someone who has just been introduced or sobbing uncontrollably over a minor incident. Clients may ignore old friends if someone new and interesting has been introduced. People with whom these clients have relationships often describe being used, manipulated, or exploited shamelessly. Clients may have a wide variety of vague physical complaints or relate exaggerated versions of physical illness. These episodes usually involve the attention the client received (or failed to receive) rather than any particular physiologic concern. Nursing Interventions The nurse gives clients feedback about their social interactions with others, including manner of dress and nonverbal behavior. Feedback should focus on appropriate alternatives, not merely criticism. For example, the nurse might say, "When you embrace and kiss other people on first meeting them, they may interpret your behavior in a sexual manner. It would be more acceptable to stand at least 2 feet away from them and to shake hands." It may also help to discuss social situations to explore clients' perceptions of others' reactions and behavior. Teaching social skills and role-playing those skills in a safe, nonthreatening environment can help clients to gain confidence in their ability to interact socially. The nurse must be specific in describing and modeling social skills, including establishing eye contact, engaging in active listening, and respecting personal space. It also helps to outline topics of discussion appropriate for casual acquaintances, closer friends or family, and the nurse only. Clients may be quite sensitive to discussing self-esteem and may respond with exaggerated emotions. It is important to explore personal strengths and assets and to give specific feedback about positive characteristics. Encouraging clients to use assertive communication, such as "I" statements, may promote self-esteem and help them to get their needs met more appropriately, The nurse must convey genuine confidence in the client's abilities. (Videbeck 357) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

narcissistic personality disorder

Clinical Picture Narcissistic personality disorder is characterized by a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy. It occurs in 1% to 6% of the general population. Fifty to seventy-five percent of people with this diagnosis are men. Narcissistic traits are common in adolescence and do not necessarily indicate that a personality disorder will develop in adulthood. Individual psychotherapy is the most effective treatment, and hospitalization is rare unless comorbid conditions exist for which the client requires inpatient treatment (Sadock et al., 2015). p. 357 p. 358 Narcissistic personality Clients may display an arrogant or haughty attitude. They lack the ability to recognize or to empathize with the feelings of others. They may express envy and begrudge others any recognition or material success because they believe it rightfully should be theirs. Clients tend to disparage, belittle, or discount the feelings of others. They may express their grandiosity overtly, or they may quietly expect to be recognized for their perceived greatness. They are often preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. These fantasies reinforce their sense of superiority. Clients may ruminate about long-overdue admiration and privilege, and compare themselves favorably with famous or privileged people. Thought processing is intact, but insight is limited or poor. Clients believe themselves to be superior and special and are unlikely to consider that their behavior has any relation to their problems: they view their problems as the fault of others. Underlying self-esteem is almost always fragile and vulnerable. These clients are hypersensitive to criticism and need constant attention and admiration. They often display a sense of entitlement (unrealistic expectation of special treatment or automatic compliance with wishes). They may believe that only special or privileged people can appreciate their unique qualities or are worthy of their friendship. They expect special treatment from others and are often puzzled or even angry when they do not receive it. They often form and exploit relationships to elevate their own status. Clients assume total concern from others about their welfare. They discuss their own concerns in lengthy detail with no regard for the needs and feelings of others, and often become impatient or contemptuous of those who discuss their own needs and concerns. At work, these clients may experience some success because they are ambitious and confident. Difficulties are common, however, because they have trouble working with others (whom they consider to be inferior) and have limited ability to accept criticism or feedback. They are also likely to believe they are underpaid and underappreciated or should have a higher position of authority even though they are not qualified. Nursing Interventions Clients with narcissistic personality disorder can present one of the greatest challenges to the nurse. The nurse must use self-awareness skills to avoid the anger and frustration that these clients' behavior and attitude can engender. Clients may be rude and arrogant, unwilling to wait, and harsh and critical of the nurse. The nurse must not internalize such criticism or take it personally. The goal is to gain the cooperation of these clients with other treatment as indicated. The nurse teaches about comorbid medical or psychiatric conditions, medication regimen, and any needed self-care skills in a matter-of-fact manner. He or she sets limits on rude or verbally abusive behavior and explains his or her expectations of the client. (Videbeck 357-358) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

obsessive-compulsive personality disorder

Clinical Picture Obsessive-compulsive personality disorder is characterized by a pervasive pattern of preoccupation with perfectionism, mental and interpersonal control, and orderliness at the expense of flexibility, openness, and efficiency. It occurs in about 2% to 8% of the population, affecting twice as many men as women. Incidence is higher in oldest children and people in professions involving facts, figures, or methodical focus on detail. These people often seek treatment because they recognize that their life is pleasureless or they are experiencing problems with work or relationships. Clients frequently benefit from individual therapy (Sadock et al., 2015). The demeanor of these clients is formal and serious, and they answer questions with precision and much detail. They often report feeling the need to be perfect beginning in childhood. They were expected to be good and to do the right thing to win parental approval. Expressing emotions or asserting independence was probably met with harsh disapproval and emotional consequences. Emotional range is usually quite constricted. They have difficulty expressing emotions, and any emotions they do express are rigid, stiff, and formal, lacking spontaneity. Clients can be very stubborn and reluctant to relinquish control, which makes it difficult for them to be vulnerable to others by expressing feelings. Affect is also restricted: they usually appear anxious and fretful or stiff and reluctant to reveal underlying emotions. Clients are preoccupied with orderliness and try to maintain it in all areas of life. They strive for perfection as though it were attainable and are preoccupied with details, rules, lists, and schedules to the point of often missing "the big picture." They become absorbed in their own perspective, believe they are right, and do not listen carefully to others because they have already dismissed what is being said. Clients check and recheck the details of any project or activity; often, they never complete the project because of "trying to get it right." They have problems with judgment and decision-making—specifically, actually reaching a decision. They consider and reconsider alternatives, and the desire for perfection prevents a decision from being reached. Clients interpret rules or guidelines literally and cannot be flexible or modify decisions based on circumstances. They prefer written rules for each and every activity at work. Insight is limited, and they are often oblivious that their behavior annoys or frustrates others. If confronted with this annoyance, these clients are stunned, unable to believe others "don't want me to do a good job." These clients have low self-esteem and are always harsh, critical, and judgmental of themselves; they believe that they "could have done better" regardless of how well the job has been done. Praise and reassurance do not change this belief. Clients are burdened by extremely high and unattainable standards and expectations. Although no one could live up to these expectations, they feel guilty and worthless for being unable to achieve them. They tend to evaluate self and others solely on the basis of deeds or actions without regard for personal qualities. These clients have much difficulty in relationships, few friends, and little social life. They do not express warm or tender feelings to others; attempts to do so are very stiff and formal and may sound insincere. For example, if a significant other expresses love and affection, a client's response might be "The feeling is mutual." Marital and parent-child relationships are often difficult because these clients can be harsh and unrelenting. For example, most clients are frugal, do not give gifts or want to discard old items, and insist that those around them do the same. Shopping for something new to wear may seem frivolous and wasteful. Clients cannot tolerate lack of control, and hence may organize family outings to the point that no one enjoys them. These behaviors can cause daily strife and discord in family life. At work, clients may experience some success, particularly in fields where precision and attention to detail are desirable. They may miss deadlines, however, while trying to achieve perfection or may fail to make needed decisions while searching for more data. They fail to make timely decisions because of continually striving for perfection. They have difficulty working collaboratively, preferring to "do it myself" so it is done correctly. If clients do accept help from others, they may give such detailed instructions and watch the other person so closely that coworkers are insulted, annoyed, and refuse to work with them. Given this excessive need for routine and control, new situations and compromise are also difficult. Nursing Interventions Nurses may be able to help clients to view decision-making and completion of projects from a different perspective. Rather than striving for the goal of perfection, clients can set a goal of completing the project or making the decision by a specified deadline. Helping clients to accept or to tolerate less-than-perfect work or decisions made on time may alleviate some difficulties at work or home. Clients may benefit from cognitive restructuring techniques. The nurse can ask, "What is the worst that could happen?" or "How might your boss (or your wife) see this situation?" These questions may challenge some rigid and inflexible thinking. p. 360 p. 361 Encouraging clients to take risks, such as letting someone else plan a family activity, may improve relationships. Practicing negotiation with family or friends also may help clients to relinquish some of their need for control. (Videbeck 360-361) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Schizoid personality disorder

Clinical Picture Schizoid personality disorder is characterized by a pervasive pattern of detachment from social relationships and a restricted range of emotional expression in interpersonal settings. It may affect 5% of the general population and is more common in males than females (Sadock et al., 2015). People with schizoid personality disorder avoid treatment as much as they avoid other relationships, unless their life circumstances change significantly. Clients with schizoid personality disorder display a constricted affect and little, if any, emotion. They are aloof and indifferent, appearing emotionally cold, uncaring, or unfeeling. They report no leisure or pleasurable activities because they rarely experience enjoyment. Even under stress or adverse circumstances, their response appears passive and disinterested. There is marked difficulty experiencing and expressing emotions, particularly anger or aggression. Oddly, clients do not report feeling distressed about this lack of emotion; it is more distressing to family members. Clients usually have a rich and extensive fantasy life, although they may be reluctant to reveal that information to the nurse or anyone else. The ideal relationships that occur in the client's fantasies are rewarding and gratifying; these fantasies, though, are in stark contrast to real-life experiences. The fantasy relationship often includes someone the client has met only briefly. Nevertheless, these clients can distinguish fantasies from reality, and no disordered or delusional thought processes are evident. Clients generally are accomplished intellectually and often involved with computers or electronics for work or to pass their time. They may spend long hours solving puzzles or mathematical problems, although they see these pursuits as useful or productive rather than fun. Clients may be indecisive and lack future goals or direction. They see no need for planning and really have no aspirations. They have little opportunity to exercise judgment or decision-making because they rarely engage in these activities. Insight might be described as impaired, at least by the social standards of others; these clients do not see their situation as a problem, and fail to understand why their lack of emotion or social involvement troubles others. They are self-absorbed and loners in almost all aspects of daily life. Given an opportunity to engage with other people, they often decline. They are also indifferent to praise or criticism and are relatively unaffected by the emotions or opinions of others. They also experience dissociation from or no bodily or sensory pleasures. For example, the client has little reaction to beautiful scenery, a sunset, or a walk on the beach. Clients have a pervasive lack of desire for involvement with others in all aspects of life. They do not have or desire friends, rarely date or marry, and have little or no sexual contact. They may have some connection with a first-degree relative, often a parent. Clients may remain in the parental home well into adulthood if they can maintain adequate separation and distance from other family members. They have few social skills, are oblivious to the social cues or overtures of others, and do not engage in social conversation. Nursing Interventions Nursing interventions focus on improved functioning in the community. If a client needs housing or a change in living circumstances, the nurse can make referrals to social services or appropriate local agencies for assistance. The nurse can help agency personnel find suitable housing that accommodates the client's desire and need for solitude. For example, the client with a schizoid personality disorder would function best in a board and care facility, which provides meals and laundry service, but requires little social interaction. Facilities designed to promote socialization through group activities would be less desirable. If the client has an identified family member as his or her primary relationship, the nurse must ascertain whether that person can continue in that role. If the person cannot, the client may need to establish at least a working relationship with a case manager in the community. The case manager can then help the client obtain services and health care, manage finances, and so on. The client has a greater chance of success if he or she can relate his or her needs to one person (as opposed to neglecting important areas of daily life (Videbeck 344) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

antisocial personality disorder

Clinical Picture Schizotypal personality disorder is characterized by a pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships as well as by cognitive or perceptual distortions and behavioral eccentricities. Incidence is about 3% of the population; the disorder is slightly more common in men than in women. Clients may experience transient psychotic episodes in response to extreme stress. Persons with schizotypal personality disorder may develop schizophrenia, but most do not (Sadock et al., 2015). p. 344 p. 345 Clients often have an odd appearance that causes others to notice them. They may be unkempt and disheveled, and their clothes are often ill-fitting, do not match, and may be stained or dirty. They may wander aimlessly and, at times, become preoccupied with some environmental detail. Speech is coherent, but may be loose, digressive, or vague. Clients often provide unsatisfactory answers to questions and may be unable to specify or to describe information clearly. They frequently use words incorrectly, which makes their speech sound bizarre. For example, in response to a question about sleeping habits, the client might respond, "Sleep is slow, the REMs don't flow." These clients have a restricted range of emotions; that is, they lack the ability to experience and to express a full range of emotions such as anger, happiness, and pleasure. Affect is often flat and is sometimes silly or inappropriate. Cognitive distortions include ideas of reference, magical thinking, odd or unfounded beliefs, and a preoccupation with parapsychology, including extrasensory perception and clairvoyance. Ideas of reference usually involve the client's belief that events have special meaning for him or her; however, these ideas are not firmly fixed and delusional, as may be seen in clients with schizophrenia. In magical thinking, which is normal in small children, a client believes he or she has special powers—that by thinking about something, he or she can make it happen. In addition, clients may express ideas that indicate paranoid thinking and suspiciousness, usually about the motives of other people (Rosell et al., 2014). Clients experience great anxiety around other people, especially those who are unfamiliar. This does not improve with time or repeated exposures; rather, the anxiety may intensify. This results from the belief that strangers cannot be trusted. Clients do not view their anxiety as a problem that arises from a threatened sense of self. Interpersonal relationships are troublesome; therefore, clients may have only one significant relationship, usually with a first-degree relative. They may remain in their parents' home well into the adult years. They have a limited capacity for close relationships, even though they may be unhappy being alone. Clients cannot respond to normal social cues and hence cannot engage in superficial conversation. They may have skills that could be useful in a vocational setting, but they are not often successful in employment without support or assistance. Mistrust of others, bizarre thinking and ideas, and unkempt appearance can make it difficult for these clients to get and to keep jobs. Nursing Interventions The focus of nursing care for clients with schizotypal personality disorder is development of self-care and social skills and improved functioning in the community. The nurse encourages clients to establish a daily routine for hygiene and grooming. Such a routine is important because it does not depend on the client to decide when hygiene and grooming tasks are necessary. It is useful for clients to have an appearance that is not bizarre or disheveled because stares or comments from others can increase discomfort. Because these clients are uncomfortable around others and this is not likely to change, the nurse must help them function in the community with minimal discomfort. It may help to ask clients to prepare a list of people in the community with whom they must have contact, such as a landlord, store clerk, or pharmacist. The nurse can then role-play interactions that clients would have with each of these people; this allows clients to practice making clear and logical requests to obtain services or to conduct personal business. Because face-to-face contact is more uncomfortable, clients may be able to make written requests or to use the telephone for business. Social skills training may help clients to talk clearly with others and to reduce bizarre conversations. It helps to identify one person with whom clients can discuss unusual or bizarre beliefs, such as a social worker or a family member. Given an acceptable outlet for these topics, clients may be able to refrain from these conversations with people who might react negatively (Videbeck 344-345) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Data analysis and outcome identification borderline personality disorder

Data Analysis Nursing diagnoses for clients with borderline personality disorder may include the following: Risk for Suicide Risk for Self-Mutilation Risk for Other-Directed Violence Ineffective Coping Social Isolation (Videbeck 352) Outcome Identification Treatment outcomes may include the following: The client will be safe and free from significant injury. The client will not harm others or destroy property. The client will demonstrate increased control of impulsive behavior. The client will take appropriate steps to meet his or her own needs. The client will demonstrate problem-solving skills. The client will verbalize greater satisfaction with relationships. (Videbeck 354) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Data analysis antisocial personality disorder

Data Analysis People with antisocial personality disorder generally do not seek treatment voluntarily unless they perceive some personal gain from doing so. For example, a client may choose a treatment setting as an alternative to jail or to gain sympathy from an employer; they may cite stress as a reason for absenteeism or poor performance. Inpatient treatment settings are not necessarily effective for these clients and may, in fact, bring out their worst qualities. Nursing diagnoses commonly used when working with these clients include the following: Ineffective Coping Ineffective Role Performance Risk for Other-Directed Violence Outcome Identification The treatment focus is often behavioral change. Although treatment is unlikely to affect the client's insight or view of the world and others, it is possible to make changes in behavior. Treatment outcomes may include the following: The client will demonstrate nondestructive ways to express feelings and frustration. The client will identify ways to meet his or her own needs that do not infringe on the rights of others. The client will achieve or maintain satisfactory role performance (e.g., at work or as a parent). (Videbeck 346) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Personality Disorders

During the revision and development process for DSM-5, much discussion surrounded the personality disorder diagnoses. In the end, a proposed hybrid model for personality disorders was not adopted, but remains as an alternative section at the back of the manual (Gotzsche-Astrup & Moskowitz, 2015). Box 18.1 summarizes the hybrid model alternative. Personality disorder diagnoses are organized according to clusters around a predominate type of behavioral pattern. The clusters and the diagnoses in each are as follows: Cluster A—odd or eccentric behaviors Paranoid personality disorder Schizoid personality disorder Schizotypal personality disorder Cluster B—erratic or dramatic behaviors Antisocial personality disorder Borderline personality disorder Histrionic personality disorder Narcissistic personality disorder Cluster C—anxious or fearful behaviors Avoidant personality disorder Dependent personality disorder Obsessive personality disorder In psychiatric settings, nurses most often encounter clients with antisocial and borderline personality disorders. Thus, these two disorders are the primary focus of this chapter. Clients with antisocial personality disorder may enter a psychiatric setting as part of a court-ordered evaluation or as an alternative to jail. Clients with borderline personality disorder are often hospitalized because their emotional instability may lead to self-inflicted injuries. This chapter discusses the other personality disorders briefly. Most clients with these disorders are not treated in acute care settings for these personality disorders. Nurses may encounter these clients in any health care setting or in the psychiatric setting when a client is already hospitalized for another major mental illness

Intervention antisocial personality disorder

Intervention Forming a Therapeutic Relationship and Promoting Responsible Behavior The nurse must provide structure in the therapeutic relationship, identify acceptable and expected behaviors, and be consistent in those expectations. He or she must minimize attempts by these clients to manipulate and to control the relationship. Limit setting is an effective technique that involves three steps: Stating the behavioral limit (describing the unacceptable behavior) Identifying the consequences if the limit is exceeded Identifying the expected or desired behavior Consistent limit setting in a matter-of-fact nonjudgmental manner is crucial to success. For example, a client may approach the nurse flirtatiously and attempt to gain personal information. The nurse would use limit setting by saying, "It is not acceptable for you to ask personal questions. If you continue, I will terminate our interaction. We need to use this time to work on solving your job-related problems." The nurse should not become angry or respond to the client harshly or punitively. Confrontation is another technique designed to manage manipulative or deceptive behavior. The nurse points out a client's problematic behavior while remaining neutral and matter-of-fact; he or she avoids accusing the client. The nurse can also use confrontation to keep clients focused on the topic and in the present. The nurse can focus on the behavior itself rather than on attempts by clients to justify it. For example: (Videbeck 347) Helping Clients Solve Problems and Control Emotions Clients with antisocial personality disorder have an established pattern of reacting impulsively when confronted with problems. The nurse can teach problem-solving skills and help clients to practice them. Problem-solving skills include identifying the problem, exploring alternative solutions and related consequences, choosing and implementing an alternative, and evaluating the results. Although these clients have the cognitive ability to solve problems, they need to learn a step-by-step approach to deal with them. For example, a client's car isn't running, so he stops going to work. The problem is transportation to work; alternative solutions might be taking the bus, asking a coworker for a ride, and getting the car fixed. The nurse can help the client to discuss the various options and choose one so that he can go back to work. (Videbeck 347) Managing emotions, especially anger and frustration, can be a major problem. When clients are calm and not upset, the nurse can encourage them to identify sources of frustration, how they respond to it, and the consequences. In this way, the nurse assists clients to anticipate stressful situations and to learn ways to avoid negative future consequences. Taking a time-out or leaving the area and going to a neutral place to regain internal control is often a helpful strategy. Time-outs help clients to avoid impulsive reactions and angry outbursts in emotionally charged situations, regain control of emotions, and engage in constructive problem solving. Enhancing Role Performance The nurse helps clients to identify specific problems at work or home that are barriers to success in fulfilling roles. Assessing use of alcohol and other drugs is essential when examining role performance because many clients use or abuse these substances. These clients tend to blame others for their failures and difficulties, and the nurse must redirect them to examine the source of their problems realistically. Referrals to vocational or job programs may be indicated. (Videbeck 350) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

cultural considerations

Judgments about personality functioning must involve a consideration of the person's ethnic, cultural, and social background. Members of minority groups, immigrants, political refugees, and people from different ethnic backgrounds may display guarded or defensive behavior as a result of language barriers or previous negative experiences; this should not be confused with emotional coldness or lack of concern for others. People with religious or spiritual beliefs, such as clairvoyance, speaking in tongues, or evil spirits as a cause of disease, could be misinterpreted as having schizotypal personality disorder. p. 340 There is also a difference in how some cultural groups view avoidance or dependent behavior, particularly for women. An emphasis on deference, passivity, and politeness should not be confused with avoidant personality disorder. Cultures that value work and productivity may produce citizens with a strong emphasis in these areas; this should not be confused with obsessive-compulsive personality disorder. Certain personality disorders—for example, antisocial personality disorder—are diagnosed more often in men. Borderline personality disorder is diagnosed more often in women. Social stereotypes about typical gender roles and behaviors can influence diagnostic decisions if clinicians are unaware of such biases.

Mental health promotion

MENTAL HEALTH PROMOTION The treatment of individuals with a personality disorder often focuses on mood stabilization, decreasing impulsivity, and developing social and relationship skills. In addition, clients perceive unmet needs in a variety of areas, such as self-care (keeping clean and tidy), sexual expression (dissatisfaction with sex life), budgeting (managing daily finances), psychotic symptoms, and psychological distress. Typically, psychotic symptoms and psychological distress are often the only areas addressed by health care providers. Perhaps dealing with those other areas in the treatment of a client might result in a greater sense of well-being and improved health. Children who have a greater number of "protective factors" are less likely to develop antisocial behavior as adults. These protective factors include school commitment or importance of school, positive peer relationships, parent or peer disapproval of antisocial behavior, functional family relationship, and effective parenting skills. Interestingly, the study found that children at risk for abuse and those not at risk were less likely to have antisocial behavior as adults if these protective factors were present in their environment. Children lacking these protective factors are much more likely to develop antisocial behavior as adults. BEST PRACTICE: PSYCHOPHARMACOLOGY FOR PERSONALITY DISORDERS Evidence-based studies support the use and efficacy of medication to reduce impulsivity and aggression seen in clients with antisocial or borderline personality disorders. Beginning evidence exists for the reduction of psychotic-like symptoms of schizotypy and the social anxiety seen in avoidant personality disorder. The next step is to further develop the rational, evidence-based approach to pharmacology in the treatment of personality disorders to replace the trial-and-error approach of the past. Ripoll, L. H., Triebwasser, J., & Siever, L. J. (2011). Evidence- based pharmacotherapy for personality disorders. International Journal of Neuropsychopharmacology, 14(9), 1257-1288. SELF-AWARENESS ISSUES Because clients with personality disorders take a long time to change their behaviors, attitudes, or coping skills, nurses working with them can easily become frustrated or angry. These clients continually test the limits, or boundaries, of the nurse-client relationship with attempts at manipulation. Nurses must discuss feelings of anger or frustration with colleagues to help them recognize and cope with their own feelings. The overall appearance of clients with personality disorders can be misleading. Unlike clients who are psychotic or severely depressed, clients with personality disorders look as though they are capable of functioning more effectively. The nurse can easily but mistakenly believe the client simply lacks motivation or the willingness to make changes and may feel frustrated or angry. It is easy for the nurse to think, "Why does the client continue to do that? Can't he see it only gets him into difficulties?" This reaction is similar to reactions the client has probably received from others. p. 361 p. 362 Clients with personality disorders also challenge the ability of therapeutic staff to work as a team. For example, clients with antisocial or borderline personalities often manipulate staff members by splitting them—that is, causing staff members to disagree with or contradict one another in terms of the limits of the treatment plan. This can be quite disruptive. In addition, team members may have differing opinions about individual clients. One staff member may believe that a client needs assistance, whereas another may believe the client is overly dependent. Ongoing communication is necessary to remain firm and consistent about expectations for clients. Points to Consider When Working with Clients with Disruptive Behavior Disorders and Their Families Talking to colleagues about feelings of frustration will help you to deal with your emotional responses so you can be more effective with clients. Clear, frequent communication with other health care providers can help to diminish the client's manipulation. Do not take undue flattery or harsh criticism personally; it is a result of the client's personality disorder. Set realistic goals, and remember that behavior changes in clients with personality disorders take a long time. Progress can be very slow. (Videbeck 361-362) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Other behaviors

Other clusters of behavior related to maladaptive personality traits include the following: Depressive behavior is characterized by a pervasive pattern of depressive cognitions and behaviors in various contexts. It occurs more often in people with relatives who have major depressive disorders. People with depressive personality disorders often seek treatment for their distress. Passive-aggressive behavior is characterized by a negative attitude and a pervasive pattern of passive resistance to demands for adequate social and occupational performance. These clients may appear cooperative, even ingratiating, or sullen and withdrawn, depending on the circumstances. Their mood may fluctuate rapidly and erratically, and they may be easily upset or offended

Cluster A—odd or eccentric behaviors

Paranoid personality disorder Schizoid personality disorder Schizotypal personality disorder

paranoid personality disorder

Paranoid personality disorder is characterized by pervasive mistrust and suspiciousness of others. Clients with this disorder interpret others' actions as potentially harmful. During periods of stress, they may develop transient psychotic symptoms. Incidence is estimated at 2% to 4% of the general population; the disorder is more common in males than females. Data about prognosis is limited because most people do not readily seek or remain in treatment. Generally, they tend to have lifelong problems living and working with others (Sadock et al., 2015). Clients appear aloof and withdrawn and may remain a considerable physical distance from the nurse; they view this as necessary for their protection. Clients may also appear guarded or hypervigilant; they may survey the room and its contents, look behind furniture or doors, and generally appear alert to any impending danger. They may choose to sit near the door to have ready access to an exit, or with their backs against the wall to prevent anyone from sneaking up behind them. They may have a restricted affect and may be unable to demonstrate warmth or empathic emotional responses such as "You look nice today" or "I'm sorry you're having a bad day." Mood may be labile, quickly changing from quietly suspicious to angry or hostile. Responses may become sarcastic for no apparent reason. The constant mistrust and suspicion that clients feel toward others and the environment distorts thoughts, thought processing, and content. Clients frequently see malevolence in the actions of others where none exists. They may spend disproportionate time examining and analyzing the behavior and motives of others to discover hidden and threatening meanings. Clients often feel attacked by others and may devise elaborate plans or fantasies for protection. (Videbeck 342) These clients use the defense mechanism of projection, which is blaming other people, institutions, or events for their own difficulties. It is common for such clients to blame the government for personal problems. For example, the client who gets a parking ticket says it is part of a plot by the police to drive him out of the neighborhood. He may engage in fantasies of retribution or devise elaborate and sometimes violent plans to get even. Although most clients do not carry out such plans, there is a potential danger. Conflict with authority figures on the job is common: clients may even resent being given directions from a supervisor. Paranoia may extend to feelings of being singled out for menial tasks, treated as stupid, or more closely monitored than other employees. Nursing Interventions Forming an effective working relationship with paranoid or suspicious clients is difficult. The nurse must remember that these clients take everything seriously and are particularly sensitive to the reactions and motivations of others. Therefore, the nurse must approach these clients in a formal, businesslike manner and refrain from social chitchat or jokes. Being on time, keeping commitments, and being especially straightforward are essential to the success of the nurse-client relationship. Because these clients need to feel in control, it is important to involve them in formulating their care plan. The nurse asks what the client would like to accomplish in concrete terms, such as minimizing problems at work, or getting along with others. Clients are more likely to engage in the therapeutic process if they believe they have something to gain. One of the most effective interventions is helping clients to validate ideas before taking action; however, this requires the ability to trust and listen to one person. The rationale for this intervention is that clients can avoid problems if they can refrain from taking action until they have validated their ideas with another person. This helps prevent clients from acting on paranoid ideas or beliefs. It also assists them to start basing decisions and actions on reality, rather than distorted ideas or perceptions. (Videbeck 343) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Biologic theories (etiology)

Personality develops through the interaction of hereditary dispositions and environmental influences. Temperament refers to the biologic processes of sensation, association, and motivation that underlie the integration of skills and habits based on emotion. Genetic differences account for about 50% of the variances in temperament traits. The four temperament traits are harm avoidance, novelty seeking, reward dependence, and persistence. Each of these four genetically influenced traits affects a person's automatic responses to certain situations. These response patterns are ingrained by 2 to 3 years of age. People with high harm avoidance exhibit fear of uncertainty, social inhibition, shyness with strangers, rapid fatigability, and pessimistic worry in anticipation of problems. Those with low harm avoidance are carefree, energetic, outgoing, and optimistic. High harm-avoidance behaviors may result in maladaptive inhibition and excessive anxiety. Low harm-avoidance behaviors may result in unwarranted optimism and unresponsiveness to potential harm or danger. p. 339 p. 340 A high novelty-seeking temperament results in someone who is quick-tempered, curious, easily bored, impulsive, extravagant, and disorderly. He or she may be easily bored and distracted with daily life, prone to angry outbursts, and fickle in relationships. The person low in novelty seeking is slow-tempered, stoic, reflective, frugal, reserved, orderly, and tolerant of monotony; he or she may adhere to a routine of activities. Reward dependence defines how a person responds to social cues. People high in reward dependence are tenderhearted, sensitive, sociable, and socially dependent. They may become overly dependent on approval from others and readily assume the ideas or wishes of others without regard for their own beliefs or desires. People with low reward dependence are practical, tough-minded, cold, socially insensitive, irresolute, and indifferent to being alone. Social withdrawal, detachment, aloofness, and disinterest in others can result. Highly persistent people are hardworking and ambitious overachievers who respond to fatigue or frustration as a personal challenge. They may persevere even when a situation dictates they should change or stop. People with low persistence are inactive, indolent, unstable, and erratic. They tend to give up easily when frustrated, and rarely strive for higher accomplishments. These four genetically independent temperament traits occur in all possible combinations. Some of the previous descriptions of high and low levels of traits correspond closely with the descriptions of the various personality disorders. For example, people with antisocial personality disorder are low in harm-avoidance traits and high in novelty-seeking traits, whereas people with avoidant personality disorder are high in reward-dependence traits and harm-avoidance traits.

Elder Considerations

Personality disorders are not first diagnosed in elder persons, but may persist from young adulthood into older age. Some persons with personality disorders tend to stabilize and experience fewer difficulties in later life. Others are described as "aging badly"; that is, they are unable or unwilling to acknowledge limitations that come with aging, refuse to accept help when needed, and do not make reasonable decisions about their health care, finances, or living situation. These individuals seem chronically angry, unhappy, or dissatisfied, resulting in strained relationships and even alienation from family, friends, caregivers, and health care providers, resulting in social isolation. Elder persons with personality disorders are at increased risk for depression, suicide, and dementia (Amad et al., 2013). (Videbeck 361) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

onset and clinical course

Personality disorders are relatively common, occurring in 10% to 20% of the general population. Incidence is even higher for people in lower socioeconomic groups and unstable or disadvantaged populations. Fifteen percent of all psychiatric inpatients have a primary diagnosis of a personality disorder. Forty to forty-five percent of those with a primary diagnosis of major mental illness also have a coexisting personality disorder that significantly complicates treatment. In mental health outpatient settings, the incidence of personality disorder is 30% to 50% (Black & Andreasen, 2014). Clients with personality disorders have a higher death rate, especially as a result of suicide; they also have higher rates of suicide attempts, accidents, and emergency department visits, and increased rates of separation, divorce, and involvement in legal proceedings regarding child custody. Personality disorders have been correlated highly with criminal behavior, alcoholism, and drug abuse. People with personality disorders are often described as "treatment resistant." This is not surprising, considering that personality characteristics and behavioral patterns are deeply ingrained. It is difficult to change one's personality; if such changes occur, they evolve slowly. The slow course of treatment can be very frustrating for family, friends, and health care providers. Another barrier to treatment is that many clients with personality disorders do not perceive their dysfunctional or maladaptive behaviors as a problem; indeed, sometimes these behaviors are a source of pride. For example, a belligerent or aggressive person may perceive himself or herself as having a strong personality and as being someone who can't be taken advantage of or pushed around. Clients with personality disorders frequently fail to understand the need to change their behavior and may view changes as a threat. The difficulties associated with personality disorders persist throughout young and middle adulthood, but tend to diminish in the 40s and 50s. Those with antisocial personality disorder are less likely to engage in criminal behavior, although problems with substance abuse and disregard for the feelings of others persist. Clients with borderline personality disorder tend to demonstrate decreased impulsive behavior, increased adaptive behavior, and more stable relationships by 50 years of age. This increased stability and improved behavior can occur even without treatment. Some personality disorders, such as schizotypal avoidant and obsessive-compulsive, tend to remain consistent throughout life.

psychopharmacology(treatment)

Pharmacologic treatment of clients with personality disorders focuses on the client's symptoms rather than the particular subtype. The four symptom categories that underlie personality disorders are cognitive-perceptual distortions, including psychotic symptoms; affective symptoms and mood dysregulation; aggression and behavioral dysfunction; and anxiety. These four symptom categories relate to the underlying temperaments associated with personality disorders: Low reward dependence corresponds to the categories of affective dysregulation, detachment, and cognitive disturbances. High novelty seeking corresponds to the target symptoms of impulsiveness and aggression. High harm avoidance corresponds to the categories of anxiety and depression symptoms. Cognitive-perceptual disturbances include magical thinking, odd beliefs, illusions, suspiciousness, ideas of reference, and low-grade psychotic symptoms. These chronic symptoms usually respond to low-dose antipsychotic medications (Sadock et al., 2015). Several types of aggression have been described in people with personality disorders. Aggression may occur in impulsive people (some with a normal electroencephalogram and some with an abnormal one); people who exhibit predatory or cruel behavior; or people with organic-like impulsivity, poor social judgment, and emotional lability. Lithium, anticonvulsant mood stabilizers, and benzodiazepines are used most often to treat aggression. Low-dose neuroleptics may be useful in modifying predatory aggression (Black & Andreasen, 2014). Mood dysregulation symptoms include emotional instability, emotional detachment, depression, and dysphoria. Emotional instability and mood swings respond favorably to lithium, carbamazepine (Tegretol), valproate (Depakote), or low-dose neuroleptics such as haloperidol (Haldol). Emotional detachment, cold and aloof emotions, and disinterest in social relations often respond to selective serotonin reuptake inhibitors or atypical antipsychotics such as risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel). Atypical depression is often treated with selective serotonin reuptake inhibitors, monoamine oxidase inhibitor antidepressants, or low-dose antipsychotic medications (Black & Andreasen, 2014). Anxiety seen with personality disorders may be chronic cognitive anxiety, chronic somatic anxiety, or severe acute anxiety. Chronic cognitive anxiety responds to selective serotonin reuptake inhibitors and monoamine oxidase inhibitors, as does chronic somatic anxiety or anxiety manifested as multiple physical complaints. Episodes of severe acute anxiety are best treated with monoamine oxidase inhibitors or low-dose antipsychotic medications. Table 18.1 summarizes drug choices for various target symptoms of personality disorders. These drugs, including side effects and nursing considerations, are discussed in detail in Chapter 2. (Videbeck 341) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Treatment

Several treatment strategies are used with clients with personality disorders; these strategies are based on the disorder's type and severity or the amount of distress or functional impairment the client experiences. Combinations of medication and group and individual therapies are more likely to be effective than is any single treatment (Sadock et al., 2015). Not all people with personality disorders seek treatment, however, even when significant others urge them to do so. Typically, people with schizotypal, narcissistic, or obsessive-compulsive personality disorders are least likely to engage or remain in any treatment. They see other people, rather than their own behavior, as the cause of their problems. (Videbeck 341) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Drug choices for people with personality disorders

Target Symptom Drug of Choice Aggression/Impulsivity Affective aggression (normal) Lithium Anticonvulsants Low-dose antipsychotics Predatory (hostility/cruelty) Antipsychotics Lithium Organic-like aggression Cholinergic agonists (donepezil) Imipramine (Tofranil) Ictal aggression (abnormal) Carbamazepine (Tegretol) Diphenylhydantoin (Dilantin) Benzodiazepines Mood dysregulation Emotional lability Lithium Carbamazepine (Tegretol) Antipsychotics Atypical depression/ dysphoria MAOIs SSRIs Antipsychotics Emotional detachment SSRIs Atypical antipsychotics Anxiety Chronic cognitive SSRIs MAOIs Benzodiazepines Chronic somatic MAOIs SSRIs Severe anxiety MAOIs Low-dose antipsychotics Psychotic symptoms Acute and psychosis Antipsychotics Chronic and low-level psychotic-like symptoms Low-dose antipsychotics (Videbeck 342) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Evaluation antisocial personality disorder

The nurse evaluates the effectiveness of treatment based on attainment of or progress toward outcomes. If a client can maintain a job with acceptable performance, meet basic family responsibilities, and avoid committing illegal or immoral acts, then treatment has been successful. (Videbeck 350) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Individual or group psychotherapy

Therapy helpful to clients with personality disorders varies according to the type and severity of symptoms and the particular disorder. Inpatient hospitalization is usually indicated when safety is a concern, for example, when a person with borderline personality disorder has suicidal ideas or engages in self-injury. Otherwise, hospitalization is not useful and may even result in dependence on the hospital and staff. (Videbeck 341) Individual and group psychotherapy goals for clients with personality disorders focus on building trust, teaching basic living skills, providing support, decreasing distressing symptoms such as anxiety, and improving interpersonal relationships. Relaxation or meditation techniques can help manage anxiety for clients. Improvement in basic living skills through the relationship with a case manager or therapist can improve the functional skills of people with schizotypal personality disorder. Assertiveness training groups can assist people to have more satisfying relationships with others and to build self-esteem when that is needed. Cognitive-behavioral therapy has been particularly helpful for clients with personality disorders (Thoma et al., 2015). Several cognitive restructuring techniques are used to change the way the client thinks about self and others: thought stopping, in which the client stops negative thought patterns; positive self-talk, designed to change negative self-messages; and decatastrophizing, which teaches the client to view life events more realistically and not as catastrophes. Examples of these techniques are presented later in this chapter. Dialectical behavior therapy was designed for clients with borderline personality disorder (Linehan, 1993). It focuses on distorted thinking and behavior based on the assumption that poorly regulated emotions are the underlying problem. Table 18.2 summarizes the symptoms of and nursing interventions for personality disorders. (Videbeck 342) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.