Chapter 24: Personality Disorders

Personality disorders tend to co-occur with what disorders?

Mood Eating Anxiety Substance misuse

Histrionic Personality Disorder

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

Dependent Personality Disorder

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

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

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

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

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

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

c (. Verbal abuse of another patient)

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

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

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

d ( lack of guilt feelings.)

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

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

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

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

Nursing Assessment guidelines for patients with Antisocial Personality Disorder

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

Assessment Guidelines for Borderline Personality Disorder

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

The three essential therapies for borderline personality disorder:

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

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

10; These 10 behaviors are grouped into clusters

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

50%

Prevalence of personality disorders

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

DSM-5 Criteria For Borderline Personality Disorder

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

Planning: Borderline Personality Disorder

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

DSM-5 Criteria for Anti-Social Personality Disorder

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

Etiology of Antisocial Personality Disorder: Neurobiological

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

Dialectical Behavioral Therapy (DBT): For Borderline Personality Disorder

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

Borderline Personality Disorder

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

Environmental Factors and personality disorders

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

Cluster B

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

Cluster A

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

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

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

Treatment for Schizotypal Personality Disorder

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

What influences the rate of diagnosing personality disorders?

Culture

Nursing Diagnosis for patients with antisocial personality disorder

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

Personality disorders tend to amplify what?

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

Nursing diagnosis of patients with Borderline Personality Disorder

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

Risk factors for personality disorders

Genetics Neurobiological Psychological Environmental Diathesis-stress model

Patient history of a patient with borderline personality disorder

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

Pharmacological Interventions for patients with Antisocial Personality Disorder

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

Etiology of Antisocial Personality Disorder: Environmental

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

Treatment for patients with Avoidant Personality Disorder

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

Treatment of Patients with Paranoid Personality Disorder

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

A personality is considered unhealthy when...

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

Personality

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

Epidemiology and Comorbidity For Borderline Personality Disorder

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

Epidemiology of Antisocial Personality Disorder

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

Psychology of Borderline Personality Disorder

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

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

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

Psycho-social Interventions for patients with Borderline Personality Disorder

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

Schizotypal Personality Disorder

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

Schizoid Personality Disorder

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

Avoidant Personality Disorder

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

Nursing Assessment for patients with Anti-social Personality Disorder

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

Outcomes Identification: Borderline Personality Disorder

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

Psychological Factors and personality disorders

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

Treatment of patients with Schizoid Personality Disorder

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

Treatment for patients with Dependent Personality Disorder

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

Treatment for patients with histrionic personality disorder

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

Assessment tools for patients with Borderline Personality Disorder

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

Etiology of Antisocial Personality Disorder: Cultural Factors

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

Genetics and personality disorders

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

Neurobiology and personality disorders

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

Teamwork and Safety when working with patients with Borderline Personality Disorder

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

Planning when taking care of patients with Antisocial Personality Disorder

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

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

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

Etiology, Neurobiology of Borderline Personality Disorder

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

Pharmacological Interventions for patients with Borderline Personality Disorder

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

Treatment for patients with Narcissistic Personality Disorder

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

Antisocial Personality Disorder

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

Obsessive-Compulsive Personality Disorder

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

Etiology of Antisocial Personality Disorder: Genetics

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

Etiology, Genetics of Borderline Personality Disorder

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

Schema-Focused Therapy: For Borderline Personality Disorder

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

Implementation when taking care of patients with Antisocial Personality Disorder

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

Treatment for patients with Obsessive Compulsive Personality Disorder

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

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

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

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

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

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

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

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

a (. Risk for other-directed violence)

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

a (. Risk for self-directed violence)

Diathesis-Stress Model

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

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

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

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

b (. Maintaining consistent limits)

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

b (. Mood stabilizing medication)

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

c (. Avoidant)

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

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

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

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

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

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

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

c (. manipulative.)

Paranoid Personality Disorder

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

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

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

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

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

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

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

Narcissistic Personality Disorder

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

Guidelines for Nursing Care for patients with Paranoid Personality Disorder

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

Guidelines for caring for a patient with Dependent Personality Disorder

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

Nursing Care for a patient with Schizoid Personality Disorder

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

Guidelines for Nursing Care of Patients with Obsessive Compulsive Personality Disorder

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

Guidelines for Nursing care for patients with Narcissistic Personality Disorder

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

Guidelines for nursing care for patients with Avoidant Personality Disorder

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

Guidelines for Nursing Care of patients with Histrionic Personality Disorder

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

Nursing care guidelines for Schizotypal Personality Disorder

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

Outcomes Identification for caring for patients with antisocial personality disorder

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

Cluster C

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

Personality comes from the Latin word...

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