Chpt 24- Personality disorder and impulsivity

Histrionic personality

"Attention seeking," "excitable," and "emotional" are terms used to describe people with histrionic personality disorder. Histrionic personality disorder is more likely in women. Affected individuals are lively and dramatic and draw attention to themselves by their enthusiasm, dress, and apparent openness. They are the "life of the party" and, on the surface, seem interested in others. Their insatiable need for attention and approval quickly becomes obvious. Their need to be "center stage" arises in two ways: (1) their interests and topics of conversation focus on their own desires and activities, and (2) their behavior, including their speech pattern, continually calls attention to themselves. These needs are inflexible and persistent even after others attempt to meet them. Persons with histrionic personality disorders are quick to form new friendships and just as quick to become demanding. Because they are trusting and easily influenced by other opinions, their behavior often appears inconsistent. Their strong dependency need makes them overly trusting and gullible. They are moody and often experience a sense of helplessness when others are uninterested in them. They are sexually seductive in their attempts to gain attention and often are uncomfortable within a single relationship. Their appearance is provocative and their speech dramatic. They express strong opinions without supporting facts. Loyalty and fidelity are lacking. Gender influences the manifestations of this disorder. Women dress seductively, may express dependency on selected men, and may "play" a submissive role. Men may dress in a very masculine manner and seek attention by bragging about athletic skills or successes in their jobs. Individuals with this disorder have difficulty achieving any true intimacy in interpersonal relationships. They seem to possess an innate sensitivity to the moods and thoughts of those they wish to please. This hyperalertness enables them to maneuver quickly to gain their attention. They then attempt to control relationships by their seductiveness at one level but become extremely dependent on their friends at another level. Their demand for constant attention quickly alienates their friends. They become depressed when they are not the center of attention

Personality

A personality disorder is "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment" These rates are of public health significance because of the extreme social dysfunction and high health care use of persons with personality disorders. Many others do not seek treatment for the distress or impairment related to their personality disorder because they do not perceive themselves as having a problem. However, they frequently seek help for concurrent medical or mental health disorders. At present, 10 personality disorders are recognized in the DSM-5 within three clusters. Cluster A disorders are characterized by odd or eccentric behavior; Cluster B disorders are characterized by dramatic, emotional, or erratic behavior; and in Cluster C disorders, individuals appear anxious or fearful

Key diagnosis

A pervasive pattern of instability of interpersonal relationships, self-image, and diminished affect, 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. Associated Behavioral Findings Pattern of undermining self at the moment a goal is to be realized Possible psychotic-like symptoms during times of stress Recurrent job losses, interrupted education, and broken marriages History of physical and sexual abuse, neglect, hostile conflict, and early parental loss or separation

EBN Antisocial personality disorder

ASPD does not significantly impair physical functioning except in the presence of coexisting substance use disorder or another psychiatric diagnosis involved. Because substance abuse is a major problem with this population, the physical effects of chronic use of addictive substances must be considered. Conversely, someone who has health problems secondary to chronic substance misuse should also be assessed for concurrent personality disorders. Many patients with ASPD are committed to mental health care by the court system. Eliciting psychosocial data from persons with ASPD may be difficult because of their basic mistrust about authority figures. They may not give an accurate history or may embellish aspects to project themselves in a more positive light. They often deny any criminal activity even if they are admitted in police custody. Key areas of assessment are determining the quality of relationships, impulsivity, and the extent of aggression. These individuals do not assume responsibility for their own actions and often blame others for their misfortune. Their disregard for others is manifested in their interactions. For example, one patient with human immunodeficiency virus was engaging in unprotected sex with several different women because he wanted to "have fun as long as I can." He was completely unconcerned about the possibility of transmitting the virus. These individuals often make good first impressions. Self-awareness is especially important for the nurse because of the initial charming quality of many of these individuals. When these patients realize that the nurse cannot be used or manipulated, they lose interest in the nurse and revert to their normal, egocentric behaviors.

Comorbidity

ASPD is associated with several other psychiatric disorders, including mood, anxiety, and other personality disorders. ASPD is strongly associated with alcohol and drug abuse. However, a diagnosis of ASPD is not warranted if the antisocial behavior occurs only in the context of substance abuse. For example, some people who misuse substances sometimes engage in criminal behavior, such as stealing or prostitution, only when in pursuit of drugs. Therefore, it is crucial to assess whether the person with possible ASPD has engaged in illegal activities at times other than when pursuing or using substances. Biologic Theories Perhaps more than any other personality disorder, an extensive number of biologically oriented studies explore the genetic bases, neuropsychological factors, and arousal levels among this group of pathologies. Many of these studies show changes associated with personality disorders or characteristics, but we do not have evidence that these changes caused the disorder. These studies often overlap with studies of aggression, temperament, and substance use These findings support the neural basis of fearlessness in these individuals. Impairment in moral judgment is associated with dysfunction of the prefrontal cortex. In adolescence, antisocial behavior is related to increased amygdala reactivity to interpersonal threats, which may lead to anger-related behavior Psychosocial Theories Temperament Scientists believe temperament is neurobiologically determined, and many believe that it is central to understanding personality disorders. A temperament, the natural predisposition to express feelings and actions, is evident during the first few months of life and remains stable through development. For example, whereas some infants are more relaxed or calm and sleep a lot, others are extremely alert, startled by the slightest noise, cry more, and sleep less. Difficult temperaments are common in ASPD and are often at the basis of their aggression and impulsivity. Temperaments consist of two behavioral dimensions that interact with each other. The activity spectrum varies from intense to passive. The adaptability spectrum varies from having a positive attitude about new stimuli with high flexibility to withdrawal from new stimuli and minimal flexibility in response to change. A strong relationship is found between difficult temperament and ASPD behaviors

Antisocial personality disorder

ASPD is defined as "a pervasive pattern of disregard for, and violation of, the rights of others occurring since age 15 years". This diagnosis is given to individuals 18 years of age or older who fail to follow society's rules—that is, they do not believe that society's rules are made for them and so are consistently irresponsible. For many, evidence suggests a conduct disorder (introduced later in the chapter) before the age of 15 years. The term psychopath, or sociopath, a person with a tendency toward antisocial and criminal behavior with little regard for others, is often used in describing the behaviors of people with ASPD. ASPD has a chronic course, but the antisocial behaviors tend to diminish later in life, particularly after the age of 40 years. Individuals with ASPD are arrogant and self-centered and feel privileged and entitled. They are self-serving, and they exploit and seek power over others. They can be interpersonally engaging and charming, which is often mistaken for a genuine sense of concern for other people. In reality, they lack empathy; are unable to express human compassion; and tend to be insensitive, callous, and contemptuous of others. Deceit and manipulation for personal profit or pleasure are central features associated with this disorder. They are behaviorally impulsive and interpersonally irresponsible. Many with this disorder repeatedly perform acts that are grounds for arrest (whether they are arrested or not), such as destroying property, harassing others, stealing, or pursuing other illegal occupations. They act hastily and spontaneously, are temperamentally aggressive and shortsighted, and fail to plan ahead or consider alternatives. They fail to adapt to the ethical and social standards of the community. They lack a sense of personal obligation to fulfill social and financial responsibilities, including those involved with being a spouse, parent, employee, friend, or member of the community. They lack remorse for their transgressions. Some of these individuals openly and flagrantly violate laws and end up in jail. But most people with ASPD never come in conflict with the law and instead find a niche in society, such as in business, the military, or politics that rewards their competitively tough behavior. Although ASPD is characterized by continual antisocial acts, the disorder is not synonymous with criminality

Psychosocial interventions

Addressing Abandonment and Intimacy Fears One key to helping patients with BPD is recognizing their fears of both abandonment and intimacy. Informing the patient of the length of the therapeutic relationship as much as possible allows the patient to engage in and prepare for termination with the least pain of abandonment. If the patient's hospitalization is time limited, it is important to acknowledge the limit overtly and remind the patient with each contact how many sessions remain. In day treatment and outpatient settings, the duration of treatment may be indeterminate, but the nurse may not be available that entire time. The termination process cannot be casual; this would stimulate abandonment fears. However, some patients end prematurely when the nurse informs them of the impending end as a way to leave before being rejected. The best approach is to explore these anticipated feelings with the patient. After careful planning, the nurse and patient discuss how to cope with anticipated feelings, including the wish to run away, review the progress the patient has made, and summarize what the patient has learned from the relationship that can be generalized to future encounters. Establishing Personal Boundaries and Limitations Personal boundaries are highly context specific; for example, stroking the hair of a stranger on the bus would be inappropriate, but stroking the hair and face of one's intimate partner while sitting together would be appropriate. Clarifying limits requires making explicit what is usually implicit. This may mean having a standing time during each shift that the nurse will talk with the patient. The nurse should refrain from offering personal information, which is frequently confusing to the person with BPD. At times, the person may present in a somewhat arrogant and seemingly entitled way. It is important for the nurse to recognize such a presentation as reflective of internal confusion and dissonance. Responding in a very neutral manner avoids confrontation and a power struggle, which might also unwittingly reinforce the patient's internal sense of inferiority. Some additional strategies for establishing the boundaries of the relationship include the following: Documenting in the patient's chart the agreed-on appointment expectations Sharing the treatment plan with the patient Confronting violations of the agreement in a nonpunitive way Discussing the purpose of limits in the therapeutic relationship and applicability to other relationships When patients violate boundaries, it is important to respond right away but without taking the behavior personally. For example, if a patient is flirtatious, simply say something like, "X, I feel uncomfortable with your overly friendly behavior. It seems out of place because we have a professional relationship. That would be more fitting for an intimate relationship that we will never have."

Anger management and support

Aggressive behavior is often a problem for these individuals and their family members. Similar to patients with BPD, people with ASPD tend to be impulsive. Instead of self-injury, these individuals are more likely to strike out at those who are perceived to be interfering with their immediate gratification. Anger-control assistance (helping to express anger in an adaptive, nonviolent manner) becomes a priority intervention. Because the expression of anger and aggression develops during a lifetime, these individuals can benefit from anger management techniques. Social support for these individuals is often minimal, just as it is for individuals with BPD, but the reasons are different. These individuals have often taken advantage of friends and relatives who, in turn, no longer trust them. Helping the patient build a new support system after new skills are learned is usually the only option. For these individuals to develop friends and re-engage family members, they must learn to interact in new ways, develop empathy, and risk an attachment. For many, this never truly becomes a reality.

Ways to communicate and building social skills and self esteem

Another important area of patient education is teaching communication skills. Patients lack interpersonal skill in relating because they often had inadequate modeling and few opportunities to practice. The goals of relationship skill development are to identify problematic behavior that interferes with relationships and to use appropriate behaviors in improving relationships. The starting point is with communication. The nurse teaches the patient basic communication approaches, such as making "I" statements, paraphrasing what the other party says before responding, checking the accuracy of perceptions with others, compromising and seeking common ground, listening actively, and offering and accepting reactions. Besides modeling the behaviors, the nurse guides patients in practicing a variety of communication approaches for common situations. When role-playing, the nurse needs to discuss not only what the skills are and how to perform them but also the feelings patients have before, during, and after the role-play. In day treatment and outpatient settings, the nurse can give the patient homework, such as keeping a journal, applying role-playing skills to actual situations, and observing behaviors in others. In the hospital, the patient can experience the same process, where the nurse is available to offer immediate feedback. Whatever the setting or whatever the specific problems addressed, the nurse must keep in mind and remind the patient that change occurs slowly. Thus, working on the problems occurs gradually, with severity of symptoms as the guide to deciding how fast and how much change to expect. Building Social Skills and Self-Esteem. In the hospital, the nurse can use group therapy to discuss feelings and ways to cope with them. Women with BPD benefit from assertiveness classes and women's health issues classes. Many of the women are involved in abusive relationships and lack the ability to resolve these relationships because of their extreme anxiety regarding separating from those they love and their extreme need to feel connected. These women verbalize desires to do it, but they do not have the strength and self-confidence needed to leave. Exposing them to a different style of interaction as well as validation from other people increases their self-esteem and ability to get away from negative influences.

EBN with APD

Assessment of these individuals reveals a lack of social contacts, a fear of being criticized, and evidence of chronic low self-esteem. The focus of nursing care will be issues of self-esteem and being socially isolated. The person's ability to cope with stress may need to be strengthened also. The establishment of a therapeutic relationship is necessary to be able to help these individuals meet their treatment outcomes. The development of the nurse-patient relationship is a slow process and requires an extreme amount of patience on the part of the nurse. These individuals may not have had positive interpersonal relationships and need time to be able to be sure that the nurse will not criticize and demean them. Interventions should focus on refraining from any negative criticism, assisting the patient to identify positive responses from others, exploring previous achievements of success, and exploring reasons for self-criticism. The patient's social dimension should be examined for activities that increase self-esteem and interventions focused on increasing these self-esteem-enhancing activities. Social skills training may help reduce symptoms. Long-term therapy is ideal for patients with avoidant personality disorder because it takes time to make changes in one's behavior. Mental health nurses may initially see these individuals for other health problems. Encouraging the patient to continue with therapy and contacting the therapist when necessary are important in maintaining continuity of care. These patients are hospitalized only for a coexisting disorder.

Cluster C (Avoidant, Dependent, Obsessive-compulsive)

Avoidant personality disorder is characterized by staying out of social situations in which interpersonal contact with others may be expected. Individuals appear timid, shy, and hesitant; they also fear criticism and feel inadequate. These individuals are extremely sensitive to negative comments and disapproval and appraise situations more negatively than others do. This behavior becomes problematic when it restricts their social activities and work opportunities because of their extreme fear of rejection. In childhood, they are shy, but instead of growing out of the shyness, it becomes worse in adulthood. They perceive themselves as socially inept, inadequate, and inferior, which in turn justifies their isolation and rejection by others. Vocationally, people with avoidant personality disorder often take jobs on the sidelines, rarely obtaining personal advancement or exercising much authority, but to employers, they seem shy and eager to please. They are reluctant to enter relationships unless they are given strong assurance of uncritical acceptances, so they consequently often have no close friends or confidants The problem with examining the epidemiology of avoidant personality disorder is its potential overlap with generalized social phobia. Several studies found that a significant portion of the patients with diagnoses of social phobia also met criteria for avoidant personality disorder Experts speculate that individuals with avoidant personality disorder experience aversive stimuli more intensely and more frequently than others do because they may possess an overabundance of neurons in the aversive center of the limbic system

Recovery

BPD is a very complex disorder that requires collaboration of treatment by the entire mental health care team. Because BPD patients view the world in absolutes, nurses and other treatment team members are alternately categorized as all good or all bad. This defense is called splitting and presents clinicians with a challenge to work openly with each other as well as the patient until the issue can be resolved through team meetings and clinical supervision. People with BPD are inadvertently highly stigmatized by many clinicians. Staff often accuse these individuals of "manipulation" to get attention and say so in a very derogatory manner. In reality, all of us want attention from significant people in our lives. Most of us have the necessary skills to successfully meet our need for closeness and attention without alienating the very people who are important to us. People with BPD are unsuccessful in developing long-term meaningful relationships or getting what they want because their approach alienates others. Their need for attention and closeness to others is very normal: it is how they seek attention that is problematic. Psychotherapy is needed to help the individual with BPD manage the dysfunctional moods, impulsive behavior, and self-injurious behaviors. Specially trained therapists who are comfortable with the many demands of these patients are needed. These therapists represent a variety of mental health disciplines, including psychology, social work, and advanced practice nursing. This is a life-long disorder requiring ongoing treatment as the individual copes with multiple interpersonal crises. Several types of medications are usually needed, including mood stabilizers, antidepressants, and anxiolytics; careful medication monitoring is necessary.

Cluster B: Borderline, Antisocial, Histrionic, and Narcissistic

Borderline:Have problems regulating their moods, developing a self-identity, maintaining interpersonal relationships, maintaining reality-based thinking, and avoiding impulsive or destructive behavior. The severity and difficulty in treating the disorder leads to enormous public health costs from health care utilization and functional disability Individuals with BPD appear more competent than they actually are and often set unrealistically high expectations for themselves. When these expectations are not met, they experience intense shame, self-hate, and self-directed anger. Their lives are like soap operas—one crisis after another. Some of the crises are caused by the individual's dysfunctional lifestyle or inadequate social milieu, but many are caused by fate—the death of a spouse or a diagnosis of an illness. They react emotionally with minimal coping skills. The intensity of their emotions often frightens them and others. Friends, family members, and coworkers limit their contact with the person, which furthers the sense of aloneness, abandonment, and self-hatred. It also diminishes opportunities for learning self-corrective measures. Remissions from the acute symptoms (e.g., self-injurious behaviors, suicide attempts, or threats about suicide) are fairly common and the relapse rate is relatively low compared to other disorders. However, psychosocial functioning does not necessarily improve as symptoms decrease. Younger age and higher education levels predict higher functioning BPD is 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

Schizoid personality disorder

Characterized as being expressively impassive and interpersonally disengaged. They tend to be unable to experience the joyful and pleasurable aspects of life. They are introverted, reclusive, and clinically seem distant, aloof, apathetic, and emotionally detached. Typically life-long loners, they have difficulty making friends, seem uninterested in social activities, and appear to gain little satisfaction in personal relationships. In fact, they appear to be incapable of forming social relationships. Their interests are directed at objects, things, and abstractions. They may do well at solitary jobs other people might find difficulty to tolerate. Often people with schizoid personality disorders may daydream excessively and become attached to animals, and they frequently do not marry or even form long-lasting romantic relationships. As children, they engage primarily in solitary activities, such as stamp collecting, computer games, electronic equipment, or academic pursuits such as mathematics or engineering. In addition, they seem to have a cognitive deficit characterized by obscure thought processes, particularly about social matters. Communication with others is confused and lacks focus. These individuals reveal minimum introspection and self-awareness, and interpersonal experiences are described in a very mechanical way. Schizoid personality disorder is rarely diagnosed in clinical settings The etiologic processes are speculative. There may be defects in either the limbic or reticular regions of the brain that may result in the development of the schizoid pattern. The defects of this personality may stem from an adrenergic-cholinergic imbalance in which the parasympathetic division of the autonomic nervous system is functionally dominant. Excesses or deficiencies in acetylcholine and norepinephrine may result in the proliferation and scattering of neural impulses that may be responsible for the cognitive "slippage" or affective deficits. EBN Difficulty with social relations and low self-esteem are typical nursing priorities of patients with schizoid personality disorder. Major treatment goals are to enhance the experience of pleasure, prevent social isolation, and increase emotional responsiveness to others. Because these individuals often lack customary social skills, social skills training is useful in enhancing their ability to relate in interpersonal situations. The primary focus is to increase the patient's ability to feel pleasure. The nurse balances interventions between encouraging enough social activity to prevent the individual from retreating into a fantasy world and too much social activity that becomes intolerable to the patient. The nurse may find working with such individuals unrewarding and as a result, the attending nurses may become frustrated, feel helpless, or become bored during the interactions. It is difficult to establish a therapeutic relationship with these individuals because they tend to shy away from interactions and are rarely motivated about treatment. Evaluation of outcomes should be in terms of increasing the patient's feelings of satisfaction with solitary activities. People with schizoid personalities are rarely hospitalized unless they have a comorbid disorder. Family members may seek treatment for them in an outpatient setting.

Maladaptive cognitive process Social theories: Biosocial theories

Cognitive schemata are patterns of thought that determine how a person interprets events. Each person's cognitive schemata screen, code, and evaluate incoming stimuli. In personality disorders, maladaptive cognitive schemata cause misinterpretation of other people's actions or reactions and of events that result in dysfunctional ways of responding. Cognitive schemata are important in understanding BPD (and ASPD as well). Individuals with BPD develop dysfunctional beliefs and maladaptive schemata early in life, leading them to misinterpret environmental stimuli continuously, which in turn leads to rigid and inflexible behavior patterns in response to new situations and people. Because those with BPD have been conditioned to anticipate rejection and disappointment in the past, they become entrenched in a pattern of fear and anxiety regarding encountering new people or situations. They have fears that disaster is going to strike at any minute. The work of cognitive therapists is to challenge distortions in thinking patterns and replace them with realistic ones. The biosocial viewpoint proposed by Marsha Linehan and colleagues sees BPD as a multifaceted problem, a combination of innate emotional vulnerability (sensitivity and reactivity to environmental stress), emotional dysregulation (inability to control emotions in social interactions), and the environment The emotional dysregulation and aggressive impulsivity entail both social learning and biologic regulation. Much of the neurobiologic research is directed at corticolimbic function and other cerebral function. In fact, restoring balance in these systems permits more consistent neural firing between the limbic system and the frontal and prefrontal cortices. When these circuits are functional, the person has a greater capacity to think about his or her emotions and modulate behavior more responsibly The emotional dysregulation and aggressive impulsivity entail both social learning and biologic regulation. Much of the neurobiologic research is directed at corticolimbic function and other cerebral function. In fact, restoring balance in these systems permits more consistent neural firing between the limbic system and the frontal and prefrontal cortices. When these circuits are functional, the person has a greater capacity to think about his or her emotions and modulate behavior more responsibly.

Epidemiology

Common in boys and low SES and urban The disorder appears to be fairly consistent across various countries that differ in race and ethnicity. Prevalence rates rise from childhood to adolescence and are higher among males than among females. Males with conduct disorder frequently are involved in fighting, stealing, vandalism, and school disciplinary problems. Females with the diagnosis are more likely to practice lying, truancy, running away, substance use, and prostitution. Whereas males tend to exhibit both physical aggression and relational aggression (i.e., behaviors that harm social relations of others), females tend to exhibit relatively more relational aggression. Conduct disorder is one of the most frequently diagnosed disorders in children in mental health facilities. Individuals with conduct disorder are at greater risk for experiencing The etiologies of oppositional defiant disorder and conduct disorder are complex. More attention has been paid to conduct disorder, probably because it is the more serious of the two.

Self esteem and coping skills

Coping with stressful situations is one of the major problems of people with BPD. Assessment of their coping skills and their ability to deal with stressful situations is important. Self-esteem is closely related to identifying with health care workers. Patients with BPD perceive their families and friends as being weary of their numerous crises and their seeming unwillingness to break the vicious self-destructive cycle. Feeling rejected by their natural support system, these individuals create one within the health system. During periods of crisis, especially during the late evening, early morning, or on weekends, they may call or visit various psychiatric units asking to speak to specific personnel who formerly cared for them. They even know different nurses' scheduled days off and make the rounds to several hospitals and clinics. Sometimes they bring gifts to nurses or call them at home. Because their newly created social support system cannot provide the support that is needed, the patient continues to feel rejected. One of the treatment goals is to help the individual establish a more natural support network. Functional Assessment. Some individuals with BPD can function very well except during periods when symptoms erupt. They hold jobs, are active in communities, and can perform well. During periods of stress, symptoms often appear. Conversely, some individuals with severe BPD function poorly; they seem to be always in a crisis, which often they have created. Social Support Systems. Identification of social supports (e.g., family, friends, religious organizations) is the purpose in assessing resources. Knowing how the patient obtains social support is important in understanding the quality of interpersonal relationships. For example, some patients consider as their "best friends" nurses, physicians, and other health care personnel. Because these are false friendships (i.e., not reciprocated), they inevitably lead to frustration and disappointment. However, helping the patient find ways to meet other people and encouraging the patient's efforts are more realistic.

Behavioral pattern in BPD

Emotional vulnerability. Person experiences a pattern of pervasive difficulties in regulating negative emotions, including high sensitivity to negative emotional stimuli, high emotional intensity, and slow return to emotional baseline. Self-invalidation. Person fails to recognize one's own emotional responses, thoughts, beliefs, and behaviors and sets unrealistically high standards and expectations for self. May include intense shame, self-hate, and self-directed anger. Person has no personal awareness and tends to blame social environment for unrealistic expectations and demands. Unrelenting crises. Person experiences pattern of frequent, stressful, negative environmental events, disruptions, and roadblocks—some caused by the individual's dysfunctional lifestyle, others by an inadequate social milieu, and many by fate or chance. Inhibited grieving. Person tries to inhibit and overcontrol negative emotional responses, especially those associated with grief and loss, including sadness, anger, guilt, shame, anxiety, and panic. Active passivity. Person fails to engage actively in solving of own life problems but will actively seek problem solving from others in the environment; learned helplessness, hopelessness. Apparent competence. Tendency for the individual to appear deceptively more competent than he or she actually is; usually because of failure of competencies to generalize across expected moods, situations, and time. Person fails to display adequate nonverbal cues of emotional distress.

Intermittent explosive disorder

Episodes of aggressiveness that result in assault or destruction of property characterize people with intermittent explosive disorder. The severity of aggressiveness is out of proportion to the provocation. The episodes can have serious psychosocial consequences, including job loss, interpersonal relationship problems, school expulsion, divorce, automobile accidents, or jail. This diagnosis is given only after all other disorders with aggressive components (e.g., delirium, dementia, head injury, BPD, ASPD, substance abuse) have been excluded. Little is known about this disorder, but it is a more common condition than previously thought The onset is most common in childhood or adolescence and rarely begins for the first time after the age 40 years. The mean age at onset is 14 years. It is more prevalent in individuals with a high school education or less (APA, 2013). The anger experience and expression of anger contribute to suicidality The treatment of this disorder is multifaceted. Psychopharmacologic agents are sometimes used as an adjunct to psychotherapeutic, behavioral, and social interventions. Serotonergic antidepressants and gamma-aminobutyric acid (GABA)-ergic mood stabilizers have been used. Anxiolytics are used to treat obsessive patients who experience tension states and explosive outbursts. Medication alone is insufficient, and anger management should be included in the treatment plan.

Evaluation

Evaluation and Treatment Outcomes The outcomes of interventions for patients with ASPD need to be evaluated in terms of management of specific problems, such as maintaining employment or developing a meaningful interpersonal relationship. The nurse will most likely see these patients for other health care problems, so adherence to treatment recommendations and development of health care practices (e.g., reducing smoking and alcohol consumption) can also be factored into the evaluation of outcomes. Continuum of Care People with ASPD rarely seek mental health care unless there is a comorbid condition such as depression. Nurses are most likely to see these patients in medical-surgical settings for comorbid conditions. Consistency in interventions is necessary in treating the patient throughout the continuum of care.

Evaluation Continuum of care

Evaluation and treatment outcomes vary depending on the severity of the disorder, the presence of comorbid disorders, and the availability of resources. For a patient with severe symptoms or continual self-injury, keeping the patient safe and alive may be a realistic outcome. Helping the patient resist parasuicidal urges may take years. In contrast, individuals who rarely need hospitalization and have adequate resources can expect to recover from the self-destructive impulses and learn positive interaction skills that promote a high-quality lifestyle. Most patients fall somewhere in between, with periods of symptom exacerbation and remission. In these patients, increasing the symptom-free time may be the best indicator of outcomes. Treatment and recovery involve long-term therapy. Hospitalization is sometimes necessary during acute episodes involving parasuicidal behavior, but after this behavior is controlled, patients are discharged. It is important for these individuals to continue with treatment in the outpatient or day treatment setting. Because these individuals often appear more competent and in control than they are, nurses must not be deceived by these outward appearances. These individuals need continued follow-up and long-term therapy, including individual therapy, psychoeducation, and positive role models.

Biologic theories Psychosocial theories

Evidence of central nervous system dysfunction in BPD is now clear, including possible structural changes. Biologic abnormalities are associated with three BPD characteristics: affective instability; transient psychotic episodes; and impulsive, aggressive, and suicidal behavior. Associated brain dysfunction occurs in the limbic system and frontal lobe and increases the behaviors of impulsiveness, parasuicide, and mood disturbance Using psychoanalytic methodology suggests persons with BPD have not achieved the normal and healthy developmental stage of separation-individuation, during which a child develops a sense of self, a permanent sense of significant others (object constancy), and integration of seeing both bad and good components of oneself. Those with BPD lack the ability to separate from the primary caregiver and develop a separate and distinct personality or self-identity. Projective identification is believed to play an important role in the development of BPD and is a defense mechanism by which people with BPD protect their fragile self-image. For example, when overwhelmed by anxiety or anger at being disregarded by another, they defend against the intensity of these feelings by unconsciously blaming others for what happens to them. They project their feelings onto a significant other with the unconscious hope that that person knows how to deal with it. Projective identification becomes a defensive way of interacting with the world, which leads to more rejection.

Self responsibility

Facilitating self-responsibility (i.e., encouraging a patient to assume more responsibility for personal behavior) is an important intervention. The nursing activities that are particularly helpful include holding the patient responsible for his or her behavior, monitoring the extent that self-responsibility is assumed, and discussing the consequences of not dealing with responsibilities. The nurse needs to refrain from arguing or bargaining about the unit rules, such as time for meals, use of the television room, and smoking. Instead, positive feedback is given to the patient for accepting additional responsibility or changing behavior. Enhancing Self-Awareness Enhancing self-awareness (i.e., exploring and understanding personal thoughts, feelings, motivation, and behaviors) is another nursing intervention that is helpful in developing an understanding about relating peacefully to the rest of the world. Encouraging patients to recognize and discuss their thoughts and feelings helps the nurse understand how the patient views the world. Some evidence indicates that substance misuse can be improved through cognitive behavioral treatment, but there is little evidence that the core problems of this disorder (aggression, reconviction, global functioning, and social functioning) are improved with psychological interventions Teaching points Patient education efforts have to be creative and thought provoking. In teaching a person with ASPD, a direct approach is best, but the nurse must avoid "lecturing," which the patient will resent. In teaching the patient about positive health care practices, impulse control, and anger management, the best approach is to engage the patient in a discussion about the issue and then direct the topic to the major teaching points. These patients often take great delight in arguing or showing how the rules of life do not apply to them. A sense of humor is important, as are clear teaching goals and avoiding being sidetracked

Narcissistic personality disorder

Grandiose, have an inexhaustible need for admiration, and lack empathy. Beginning in childhood, these individuals believe that they are superior, special, or unique and that others should recognize them in this way Often preoccupied with fantasies of unlimited success, power, beauty, or ideal love. They overvalue their personal worth, direct their affections toward themselves, and expect others to hold them in high esteem. They define the world through their own self-centered view. Their sense of entitlement is striking. People with narcissistic personality disorder are benignly arrogant and feel themselves above the conventions of their cultural group. They handle criticism poorly and may become enraged if someone dares to criticize them or else they may appear totally indifferent to criticism. They believe they are entitled to be served and that it is their inalienable right to receive special considerations. People with this disorder want to have their own way and are frequently ambitious for fame and fortune. These individuals are often successful in their jobs but may alienate their significant others, who grow tired of their narcissism. They cannot show empathy, and they feign sympathy only for their own benefit to achieve their selfish ends. Clinically, those with narcissistic personality disorder show overlapping characteristics of BPD and ASPD

Group interventions

Group interventions are more effective than individual modalities because other patients and staff can validate or challenge the patient's view of a situation. Problem-solving groups that focus on identifying a problem and developing a variety of alternative solutions are particularly helpful because patient self-responsibility is reinforced when patients remind each other of better alternatives. Patients are likely to confront each other with dysfunctional schemata or thinking patterns. Teaching patients with ASPD the same communication techniques as those with BPD will also encourage self-responsibility. These patients often attend groups that focus on the development of empathy.

Impulsivity and Cognitive Disturbances

Impulsivity can be identified by asking the patient whether he or she does things impulsively or spur of the moment. For example: "Have there been times when you were hurt by your actions or were sorry later that you acted in the way you did?" Direct questions about gambling, choices in sexual partners, sexual activities, fights, arguments, arrests, and habits related to consumption of alcohol can also help in identifying areas of impulsive behavior. From a neurophysiologic perspective, impulsively acting before thinking seems to be mediated by rapid nerve firing in the mesolimbic area. This activates psychomotor responses before pathways reach the prefrontal cortex Teaching the patient strategies to slow down automatic responses (e.g., deep breathing, counting to 10) buys time to think before acting. Cognitive Disturbances. The mental status examination of those with BPD usually reveals normal thought processes that are not disorganized or confused except during periods of stress. Those with BPD usually exhibit dichotomous thinking, or a tendency to view things as absolute, either black or white, good or bad, with no perception of compromise. Dichotomous thinking can be assessed by asking patients how they view other people. Evidence of dichotomous thinking is indicated with responses of "good" or "bad," "wonderful" or "terrible."

Disruptive, impulse control and conduct disorders

Impulsivity, acting without considering consequences or alternative actions, results when neurobiologic overactivity is stimulated by psychological, personality, or social factors related to personal needs of the individual Impulse-control disorders often coexist with other disorders and are characterized by an inability to resist an impulse or temptation to complete an activity that is considered harmful to oneself or others. Tension increases before the individual commits the act and derives excitement or gratification when the act is committed. The release of tension is perceived as pleasurable, but remorse and regret usually follow the act. The disruptive behavior disorders, which include oppositional defiant disorder and conduct disorder, are a group of conditions marked by significant problems of conduct. Oppositional defiant disorder is characterized by a persistent pattern of disobedience, argumentativeness, angry outbursts, low tolerance for frustration, and tendency to blame others for misfortunes, large and small. Children with oppositional defiant disorder have trouble making friends and often find themselves in conflict with adults Conduct disorder is characterized by more serious violations of social norms, including aggressive behavior, destruction of property, and cruelty to animals. Children and adolescents with conduct disorder often lie to achieve short-term ends, may be truant from school, may run away from home, and may engage in petty larceny or even mugging.

Solving, parent management

In contrast to social skills training, which proposes that problems of conduct are the result of poor interpersonal skills, problem-solving therapy conceptualizes conduct problems as the result of deficiencies in cognitive processes. These processes include assessment of situations, interpretation of events, and expectations of others that are congruent with behavior. These children often misinterpret the intentions of others and may perceive hostility with little or no cause. Problem-solving skills training teaches these children to generate alternative solutions to social situations, sharpen thinking concerning the consequences of those choices, and evaluate responses after interpersonal conflicts. Parent training begins with educating parents about disruptive behavior disorders, focusing particularly on impulsiveness, impaired judgment, and self-control. Children with long-standing problems in these areas often elicit punitive responses and negative attributions about their behavior from their parents. Ironically, because these parental responses focus on the child's failure, they may contribute to the child's behavior problems. An important second step is to clarify parental expectations and interpretation of the child's behavior. Parent management training may be offered to a group of parents or to individuals. The aims of education are to provide parents with new ways of understanding their child's behavior and to promote improved interactions between parent and child. The most commonly presented techniques include the importance of positive reinforcement (praise and tangible rewards) for adaptive behavior, clear limits for unacceptable behavior, and use of mild punishment (timeout)

Etiologt

In infancy and early childhood, these individuals are extremely alert and emotionally responsive. The tendencies for sensory alertness may be traced to responses of the limbic and reticular systems. They demonstrate a high degree of dependence on others and a type of dissociation in which they have reduced awareness of their behavior in relation to others It is believed that these highly alert and responsive infants seek more gratification from external stimulation during their first few months of life. Depending on the responsiveness of caregivers to them, they develop behavior patterns in response to their caregivers. It is believed that these children experience brief, highly charged, and irregular reinforcement from multiple caregivers (parents, siblings, grandparents, foster parents) who are unable to provide consistent experiences. Parental behavior and role modeling are also believed to contribute to the development of histrionic personality disorder. Many of the women with this disorder reported that they are just like their mother, who is emotionally labile, bored with the routines of home life, flirtatious with men, and clever in dealing with people. It is believed that through role modeling, these children learn and mimic the behaviors observed in caregivers or adults

Kleptomania

Individuals cannot resist the urge to steal, so they independently steal items that they could easily afford. These items are not particularly useful or wanted. The underlying issue is the act of stealing. The term kleptomania was first used in 1838 to describe the behavior of several kings who stole worthless objects Because it is considered a "secret" disorder, little is known about it, but it is believed to last for years despite numerous convictions for shoplifting. It appears that kleptomania often has its onset during adolescence Some shoplifting appears to be related to anxiety and stress in that it serves to relieve symptoms. In a few instances, brain damage has been associated with kleptomania Depression- compulsive shoplifter Kleptomania is difficult to detect and treat and means of treatment are little known. It appears that behavior therapy is frequently used. Medication that helps relieve the depression has been successful in some cases. More investigation is needed

Continuum of care

Individuals with paranoid personalities are unlikely to participate in treatment or recovery plans. If they have other comorbid disorders and are forced to seek treatment (through loss of their job or being ordered by a court in connection with an offense of a chargeable nature), they may seek help for depression or psychosis.

Pyromania

Irresistible impulses to start fires characterize pyromania, repeated fire setting with tension or arousal before setting fires; fascination or attraction to the fires; and gratification when setting, witnessing, or participating in the aftermath of fire. These individuals often are regular "fire watchers" or even firefighters. They are not motivated by aggression, anger, suicidal ideation, or political ideology. Little is known about this disorder because only a small number of deliberate fire starters are apprehended, and of those individuals, only a few undergo a psychiatric evaluation. The prevalence of fire setting in the general population is about 1%, but most fire setting is not done by people with pyromania, which occurs infrequently, mostly in men. However, those with a history of fire setting are most likely male, young, and never married and are more likely to have other psychiatric issues such as ASPD, substance use, and impulsivity. Prevalence rates are lower among African Americans and Hispanic Early research demonstrated low serotonin and norepinephrine levels associated with arson. Little is known about treatment, and as with the other impulse-control disorders, no approach is uniformly effective. Historically, fire starters generally possess poor interpersonal skills, exhibit low self-esteem, battle depression, and have difficulty managing anger. Education, parenting training, behavior contracting with token reinforcement, problem-solving skills training, and relaxation exercises may all be used in the management of the patient's responses

Risk assessment: Suicide or Self injury Priority care

It is critical that patients with BPD be assessed for suicidal and self-damaging behavior, including alcohol and drug abuse. The assessment should include direct questions, such as asking whether the patient thinks about or engages in self-injurious behaviors. If so, the nurse should continue to explore the behaviors: what is done, how is it done, how frequently is it done, and what are the circumstances surrounding the self-injurious behavior. It is helpful to explain briefly to the patient that sometimes people cut, scratch, or pick at themselves as a way of bringing some relief and comfort. Although the behavior brings temporary relief, it also places the person at risk for infection. Approaching the assessment in this way conveys a sense of understanding and is more likely to invite the patient to disclose honestly. The first priority in care is safety of the patient. Self-injury and suicide ideation should be considered when establishing recovery goals. If the patient is not experiencing suicidal or self-injury thoughts or behavior, the patient thought processes (dissociation) or ability to cope with everyday stress may emerge as priorities of care, especially if these interfere with daily living. If the individual copes with stressful situations by dissociating or hallucinating, the nurse should begin to help the patient identify other coping strategies. Patients who are very emotional sometimes find that they will be able to cope if they learn emotional regulation strategies. For other patients, identity issues, anxiety, or low self-esteem may become priorities of care. Identified strengths should be included in the priorities. By including a person's strengths, such as being motivated to manage self-destructive thoughts, the nurse can channel these attributes to deal with the specific issues.

Time out procedure

Labeling behavior: Identify the behavior that the child is expected to perform or cease. The aim of this statement is to make clear what is required of the child. It typically takes the form of a simple declarative sentence: "Threatening is not acceptable." Warning: In this step, the child is informed that if he or she does not perform the expected behavior or stop the unacceptable behavior, he or she will be given a "time out." "This is a warning: if you continue threatening to hit people, you'll have a time out." Time out: If the child does not heed the warning, he or she is told to take a time out in simple straightforward terms: "Take a time out." Duration: The usual duration for a time out is 5 minutes for children 5 years of age or older. Location: The child sits in a designated time-out chair without toys and without talking. The chair should be located away from general activity but within view. A kitchen timer can be used to mark the time, but the clock does not start until the child sits quietly in the designated spot. Follow-up: The child is asked to recount why he or she was given the time out. The explanation need not be detailed, and no further discussion of the matter is required. Indeed, long discourse about the child's behavior is not helpful and should be avoided.

Pharmacologic interventions

Limiting medication is better for people with BPD. Patients should take medications only for target symptoms for a short time (e.g., an antidepressant for a bout with depression) because they may be taking many medications, particularly if they have a comorbid disorder, such as a mood disorder or substance abuse. Medications are used to control emotional dysregulation, impulsive aggression, cognitive disturbances, and anxiety as an adjunct to psychotherapy, but limited studies support the treatment of BPD with medication. Recent evidence shows some benefit from atypical antipsychotics but little recent evidence to support the use of mood stabilizers. The evidence to support or exclude SSRIs remains weak Administering and Monitoring Medications. In inpatient settings, it is relatively easy to control medications; in other settings, however, patients must be aware that it is their responsibility to take their medication and monitor the number and type of drugs being taken. Patients who rely on medication to help them deal with stress and those who are periodically suicidal are at high risk for abuse of medications. Patients who experience unusual side effects are also at high risk for noncompliance. The nurse determines whether the patient is actually taking medication, whether the medication is being taken as prescribed, its effect on target symptoms, and the use of any OTC drugs (e.g., antihistamines, sleeping pills or herbal supplements with similar pharmacologic activity). Managing Side Effects. Patients with BPD appear to be sensitive to many medications, so the dosage may need to be adjusted based on the side effects they experience. Listen carefully to the patient's description of the side effects. Any unusual side effects should be accurately documented and reported to the prescriber. Patients should be educated about the prescribed medications and their interactions with other drugs and substances, but they should be encouraged to avoid relying on medication alone. Interventions include teaching patients about the medication and how and where it acts in the brain and body, helping establish a routine for taking prescribed medication, reporting side effects, and facilitating the development of positive coping strategies to deal with daily stresses rather than relying on medications. Eliciting the patient's partnership in care improves adherence and thereby outcomes.

Epidemiology and risk

Males with alcohol use disorder and those released from substance abuse clinics, prisons, or other forensic settings have the highest rates. Adverse socioeconomic (i.e., poverty) or sociocultural (i.e., migration) factors also are associated with higher prevalence To be diagnosed with ASPD, the individual must be at least 18 years old and must have exhibited one or more childhood behavioral characteristics of conduct disorder before the age of 15 years, such as aggression to people or animals, destruction of property, deceitfulness or theft, or serious violation of rules. The likelihood of developing adult ASPD is increased if onset of conduct disorder is seen before the age of 10 years as well as an accompanying childhood attention deficit hyperactivity disorder (ADHD) diagnosis 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:Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.Impulsivity or failure to plan ahead.Irritability and aggressiveness, as indicated by repeated physical fights or assaults.Reckless disregard for safety of self or others.Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. The individual is at least 18 years of age. There is evidence of conduct disorder with onset before the age of 15 years. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder. Associated Findings Lacking empathy Callous, cynical, and contemptuous of the feelings, rights, and suffering of others Inflated and arrogant self-appraisal Excessively opinionated, self-assured, or cocky Glib, superficial charm; impressive verbal ability Irresponsible and exploitative in sexual relationships; history of multiple sexual partners and lack of a sustained monogamous relationship Possible dysphoria, including complaints of tension, inability to tolerate boredom, and depressed mood

Borderline personality

Many children and adolescents show symptoms similar to those of BPD, such as moodiness, self-destruction, impulsiveness, lack of temper control, and rejection sensitivity. If a family member has BPD, the adolescent should be carefully assessed for this disorder. Because symptoms of BPD begin in adolescence, it makes sense that some children and adolescents would meet the criteria for BPD even though it is not diagnosed before young adulthood. More likely, some personality traits, such as impulsivity and mood instability, in many adolescents should be recognized and treated whether or not BPD eventually develops. The estimated prevalence of BPD is roughly 1.0% in community settings. In clinical settings, the prevalence of BPD is approximately 12% in outpatient mental health clinics and 22% in inpatient psychiatric settings, with a higher proportion of women. One possible explanation for more women being diagnosed more often is that it is more socially acceptable for women than men to seek help from the health care system. Another reason is that childhood sexual abuse, which more commonly affects girls, is one of the strongest risk factors for BPD. Another explanation is that because eating disorders are more common in women with BPD, they have a greater likelihood of also having a mood, anxiety, or posttraumatic stress disorder. Men with BPD are more likely to have a substance use problem and intermittent explosive disorder. Other studies cite parental loss and separation as risk factors. Clearly, more research is needed to identify risk factors for the development of BPD Ample clinical reports show the coexistence of personality disorders with other mental disorders such as mood, substance abuse, eating, dissociative, and anxiety disorders and other personality disorders. The coexistence of BPD with other disorders presents clinicians with the difficult choice of which disorder receives treatment priority. Symptoms associated with this disorder often provoke negative reactions on the part of clinicians, which interfere with clinicians' ability to provide effective care Evidence supports a biopsychosocial etiology. Studies suggest that BPD traits are heritable, although the specific genetic factors remain unclear. There is clear evidence of differences in brain functioning between those with and without BPD. There is also clear evidence that psychological and social factors contribute to the development of the disorder

Milieu interventions

Milieu interventions, such as providing a structured environment with rules that are consistently applied to patients who are responsible for their own behavior, are important. While living in close proximity to others, the individual with ASPD will demonstrate dysfunctional social patterns that can be identified and targeted for correction. For example, these patients often violate ward rules, such as no smoking or limitations on the number of visitors, and may bring contraband, such as illegal drugs, into the unit. In an inpatient unit, interventions can be more intense and focus on helping the patient develop positive interaction skills and experience a consistent environment. For example, the focus of nursing interventions may be the patient's continual disregard of the rights of others. On one unit, a patient continually placed orders for pizzas in the name of another patient who had limited intelligence and was genuinely afraid of the person with ASPD. The victimized patient always paid for the pizza. When the nursing staff realized what was happening, they confronted the patient with ASPD about the behavior and revoked his unit privileges.

Epidemiology Etiology

Narcissistic personality disorder can be found in professionals who are highly respected such as those in law, medicine, and science and those associated with celebrity status. Persons with this disorder may impart an unrealistic sense of omnipotence, grandiosity, beauty, and talent to their children; therefore, children of parents with a narcissistic personality disorder have a higher than usual risk of developing the disorder themselves. It also commonly occurs in only children and among first-born boys in cultural groups in which males have special privileges Limited evidence suggests biologic factors contribute to the development of this disorder. One notion about its development is that it is the result of parents' overvaluation and overindulgence of a child. These children are overly pampered and indulged, with every whim catered to. They learn to view themselves as special beings and to expect special treatment and subservience from others. They do not learn how to cooperate, share, or consider others' desires and interests. An alternate explanation is that the child never truly separated emotionally from his or her primary caregiver and therefore cannot envision functioning independently. According to another set of theories, these individuals try to avoid or reduce intense feelings of shame and engage in diverse strategies to gain attention for themselves

Epidemiology and Risk

No gender differences arise in the occurrence of this disorder; however, this diagnosis is seen more frequently in women than men clinically. Risk of occurrence of this disorder is greater among African Americans than whites. Low-income groups and less educated persons are also at higher risk for occurrence of histrionic personality disorder. Widowed, separated, divorced, or people who never married are at greater risk than married ones. This disorder occurs concurrently with other mental disorders; anxiety disorder, obsessive-compulsive syndromes, somatoform syndromes, substance use disorder, and mood disorders in which they overplay their feelings of dysthymia by expressing them through dramatic and eye-catching gestures

EBN with DPD

Nurses can determine the extent of dependency by assessment of self-worth, interpersonal relationships, and social behavior. They should determine whether there is currently someone on whom the person relies (parent, spouse) or whether there has been a separation from a significant relationship by death or divorce. Priorities of care that are usually identified include low self-esteem, difficulties in social situations, and coping with stresses of everyday life. Home management skills may be a priority if the patient does not have these skills and has to make decisions related to finances, shopping, cooking, and cleaning. The challenge of caring for these patients is to help them recognize their dependent patterns; motivate them to want to change; and teach them adult skills that have not been developed, such as balancing a checkbook, planning a weekly menu, and paying bills when they are due. Occasionally, if a patient is extremely fatigued, lethargic, or anxious, the disorder interferes with efforts at developing greater independence, antidepressants or antianxiety agents may be used in therapy. These patients readily engage in a nurse-patient relationship and initially look to the nurse to make all decisions. The nurse can support patients to make their own decisions by resisting the urge to tell them what to do. Ideally, these patients are in individual psychotherapy and working toward long-term personality changes. The nurse can encourage patients to stay in therapy and to practice the new skills that are being learned. Assertiveness training is helpful. Individuals with dependent personality disorder readily seek out therapy and are likely to spend years seeking therapy. Hospitalization occurs for comorbid conditions such as depression.

OCD

Obsessive-compulsive personality disorder (OCPD) stands out because it bears close resemblance to obsessive-compulsive disorder (OCD), and is closely related to anxiety disorder. Although these disorders have similar names, the clinical manifestations are quite different. A distinguishing difference is that those with the OCD tend to use obsessive thoughts and compulsions when anxious but less so when anxiety decreases. Persons with OCPD do not demonstrate obsessions and compulsions but rather a pervasive pattern of preoccupation with orderliness, perfectionism, and control. They also have the capacity to delay rewards; whereas those with OCD do not They may be completely devoted to work, which typically has a rigid character, such as maintaining financial records or tracking inventory. They are uncomfortable with unstructured leisure time, especially vacations. Their leisure activities are likely to be formalized (e.g., season tickets to sports, organized tour groups). Hobbies are approached seriously. Behaviorally, individuals with OCPD are perfectionists, maintaining a regulated, highly structured, strictly organized life. A need to control others and situations is common in their personal and work lives. They are prone to repetition and have difficulty making decisions and completing tasks because they become so involved in the details. They can be overly conscientious about morality and ethics and value polite, formal, and correct interpersonal relationships. They also tend to be rigid, stubborn, and indecisive and are unable to accept new ideas and customs. Their mood is tense and joyless. Warm feelings are restrained, and they tightly control the expression of emotions

Attachment and family issues

One of the leading explanations of ASPD is that unsatisfactory attachments in early relationships lead to antisocial behavior in later life. Attachment, attaining and retaining interpersonal connection to a significant person, begins at birth. In a secure attachment, a child feels safe, loved, and valued and develops the self-confidence to interact with the rest of the world. Experiences within the context of secure relationships enable the child to develop trust in others. Strong attachments between parents and child may lower the risk of delinquency, assault, and other offenses that are characteristic of those who develop antisocial behavior In individuals with ASPD, a failure to make or sustain stable attachments in early childhood can lead to avoidance of future attachments. Risk factors for developing dysfunctional attachments include parental abandonment or neglect, loss of a parent or primary caregiver, and physical or sexual abuse. Parents who lacked secure attachment relationships in their own childhoods may be unable to form secure attachment relationships with their own children. In many cases, individuals with ASPD come from chaotic families in which alcoholism and violence are the norm. Individuals who have been victims of abuse or neglect, live in a foster home, or had several primary caregivers are more likely to be victimized by antisocial behaviors, especially aggression. Child abuse and growing up in a home with domestic violence increase risk of antisocial behavior. However, it is difficult to separate the influence of social factors on the development of the disorder because the symptoms of ASPD are expressed as social manifestations, including unemployment, multiple divorces and separations, and violence.

Cluster A: Paranoid, Schizoid, and Schizotypal Personality disorder

Paranoid personality disorder is characterized by a long-standing suspiciousness and mistrust of people in general. Individuals with these traits refuse to assume personal responsibility for their own feelings, assign responsibility to others, and avoid relationships in which they are not in control or power. These individuals are suspicious, guarded, and hostile. They are consistently mistrustful of others' motives, even those of relatives and close friends. Actions of others are often misinterpreted as deception, deprecation, and betrayal, especially regarding loyalty or trustworthiness of friends and associates People with paranoid personality disorder are unforgiving and hold grudges; their typical emotional responses are anger and hostility. They distance themselves from others and are outwardly argumentative and abrasive; internally, they feel powerless, fearful, and vulnerable. Other hallmark features of paranoid personality disorder are persistent ideas of self-importance and the tendency to be rigid and controlling. Blind to their own unattractive behaviors and characteristics, they often attribute these same traits to others. Their outward demeanor often seems cold, sullen, and humorless. They want to appear controlled and objective, yet often they react emotionally, displaying signs of nervousness, anger, envy, and jealousy. Orderly by nature, they are hypervigilant to any environmental changes that may loosen their control on the world. Occupational problems are common. In clinical populations, paranoid personality disorder is one of the strongest predictors of aggressive behavior, often associated with violence and stalking. People with this disorder do not seek mental health care until they have symptoms of comorbid disorders

Epidemiology and risk

Paranoid personality disorder is the second most prevalent personality disorder after obsessive-compulsive personality disorder The etiologic factors of paranoid personality remain unclear, but a genetic predisposition for an irregular maturation may be involved. As children, these individuals tend to be active and intrusive, difficult to manage, hyperactive, irritable, and have frequent outbursts of temper. EBN Nurses most likely see these patients about other health problems but formulate nursing approaches based on the patient's underlying paranoia. Assessment of these individuals reveals disturbed or illogical thoughts that demonstrate misinterpretation of environmental stimuli. For example, a man was convinced that his wife was having an affair with the neighbor because his wife and the neighbor left their homes for work at the same time each morning. Although the man's beliefs were illogical, he never once considered that he was wrong. He frequently followed them but never caught them together. He continued to believe they were having an affair. Because of their inability to develop relationships, these patients are often socially isolated and lack social support systems. Nursing interventions based on the establishment of a therapeutic relationship are difficult to implement because of the patient's mistrust. If a trusting relationship is established, the nurse helps the patient identify problematic areas, such as getting along with others or keeping a job. Through therapeutic techniques such as acceptance, confrontation, and reflection, the nurse and patient examine a problematic area to gain another view of the situation. Changing thought patterns takes time. Patient outcomes are evaluated in terms of small changes in thinking and behavior

Psychoeducation

Patient education within the context of a therapeutic relationship is one of the most important, empowering interventions for the generalist psychiatric-mental health nurse to use. Teaching patients skills to resist parasuicidal urges, improve emotional regulation, enhance interpersonal relationships, tolerate stress, and enhance overall quality of life provide the foundation for long-term behavioral changes. These skills can be taught in any treatment setting as a part of the overall facility program If nurses are practicing in a facility where DBT is the treatment model, they can be trained in DBT and can serve as group skills leaders A major goal of cognitive therapeutic interventions is emotional regulation—recognizing and controlling the expression of feelings. Patients often fail even to recognize their feelings; instead, they respond quickly without thinking about the consequences. Remember, the time needed for taking action is shorter than the time needed for thinking before acting. Pausing makes up for the momentary lag between the limbic and autonomic response and the prefrontal response. Another element of emotional regulation is learning to delay gratification. When the patient wants something that is not immediately available, the nurse can teach patients to distract themselves, find alternate ways of meeting the need, and think about what would happen if they have to wait to meet the need.

Physical indicators and medication assessment

Patients with BPD should be assessed for self-injurious behavior or suicide attempts. It is important to ask the patient about specific self-abusive behaviors, such as cutting, scratching, or swallowing foreign objects. The patient may wear long sleeves to hide injury to the arms. Specifically, asking about thoughts of hurting oneself when experiencing a major upset provides an opportunity for prevention and for coaching the patient toward alternative self-soothing measures. Patients with BPD may be taking several medications. For example, one patient may be taking a small dose of an antipsychotic and a mood stabilizer. Another may be taking a selective serotonin reuptake inhibitor (SSRI). Initially, patients may be reluctant to disclose all the medications they are taking because, for many of them, trial and error has led to repeated prescription. They are fearful of having medication taken away from them. Development of rapport with special attention to a nonjudgmental approach is especially important when eliciting current medication practices. The effectiveness of the medication in relieving the target symptom needs to be determined. Use of alcohol, OTC medications, and street drugs should be carefully assessed to determine drug interactions.

Recovery

People rarely seek mental health care for ASPD but rather for treatment of depression, substance abuse, uncontrolled anger, or forensic-related problems. Patients with psychiatric disorders who are admitted through the courts often have a comorbid diagnosis of ASPD. Antisocial personality-disordered patients usually present for treatment as a result of an ultimatum. Treatment is often a choice between losing a job, being expelled from school, ending a marriage or relationship with children, or giving up on a chance at probation and psychological treatment. Under these circumstances treatment is usually forced on them; most prisons and other correctional facilities require inmates to attend psychotherapy sessions. In either case working with people with ASPD is likely to be a frustrating and exasperating experience for the nurse due to the patient's clear lack of insight and/or motivation to change. Treatment is difficult and involves helping the patient alter his or her cognitive schemata. The overall treatment goals are to develop a nurturing sense of attachment and empathy for other people and situations and to live within the norms of society. Safety Issues Although they can be interpersonally charming, these patients can become verbally and physically abusive if their expectations are not met. Protection of other patients and staff is a priority.

Priority of care Therapeutic relationship

People with ASPD are often admitted to psychiatric units following a violent incident such as a physical confrontation or a suicide attempt. As with any patient, safety is a priority. One of the first priorities is to establish a safe environment for the patient and staff. After safety is established, other mutually agreed-upon priorities can be considered, such as improving interpersonal communication with family members or addressing anger issues. Outcomes should be short term and relevant to a specific problem. For example, if a patient has been chronically unemployed, a reasonable short-term outcome is to set up job interviews rather than obtain a job. Therapeutic relationships are difficult to establish because these individuals do not attach themselves to others and are often unable to use a relationship to change behavior. The goal of the therapeutic relationship is to identify dysfunctional thinking patterns and develop new problem-solving behaviors. After the first few meetings with these patients, the nurse may believe that the relationship has a good start, but in reality, a superficial alliance is usually formed. Additional sessions reveal the lack of patient commitment to the relationship. These patients begin to revisit topics discussed in previous sessions or lose interest in trying to work on problems. By using self-awareness skills and accessing supervision regularly, the nurse can identify blocks in the development of a therapeutic relationship (or lack of) and his or her response to the relationship. Mental Health Nursing Interventions In instances in which there are concurrent disorders, the patient with ASPD may actually interfere with interventions aimed at improving physical functioning. For example, a patient with schizophrenia and ASPD may not develop enough trust within a relationship to examine his or her delusional thoughts or other aspects of dysfunction, such as alcohol or drug abuse.

Unstable interpersonal relationships

People with BPD have an extreme fear of abandonment as well as a history of unstable or insecure attachments. Most have never experienced a consistently secure, nurturing relationship and are constantly seeking reassurance and validation. In an attempt to meet their interpersonal needs, they idealize others and establish intense relationships that violate others' interpersonal boundaries, which leads to rejection. When these relationships do not live up to their expectations, they devalue the person. Continually disappointed in relationships, these individuals, who are already intensely emotional and have a poor sense of self, feel estranged from others and inadequate in the face of perceived social standards. Intense shame and self-hate follow. These feelings often result in self-injurious behaviors, such as wrist cutting, self-burning, or head banging.

Psychosocial assessment

People with BPD have usually experienced significant losses in their lives that shape their view of the world. They experience inhibited grieving, "a pattern of repetitive, significant trauma and loss, together with an inability to fully experience and personally integrate or resolve these events". They have unresolved grief that can last for years and will avoid situations that evoke those feelings of separation and loss. During the assessment, the nurse can identify the losses (real or perceived) and explore the patient's experience during these losses, paying particular attention to whether the patient has reached resolution. A history of physical or sexual abuse and early separation from significant caregivers may provide important clues to the severity of the disturbances. Appearance and activity level generally reflect the person's mood and psychomotor activity. Many of those with BPD have been physically or sexually abused and thus should be assessed for depression. A disheveled appearance can reflect depression or an agitated state. When feeling good, these patients can be very engaging; they tend to be dramatic in their style of dress and attract attention, such as by wearing an unusual hairstyle or heavy makeup. Because physical appearance reflects identity, patients may experiment with their appearance and seek affirmation and acceptance from others. Body piercing, tattoos, and other perceived adornments provide a mechanism to define self.

Cognitive dysfunction

People with BPD often have dichotomous thinking. That is, they evaluate experiences, people, and objects in terms of mutually exclusive categories (e.g., good or bad, success or failure, trustworthy or deceitful). Their interpretation of normally occurring events is usually extremely positive or extremely negative. Sometimes their thinking becomes disorganized with irrelevant, bizarre notions and vague or scattered thought connections as well as delusions and hallucinations. Another cognitive dysfunction common in BPD is dissociation, or times when thinking, feeling, or behaviors occur outside a person's awareness. It is a coping strategy for avoiding disturbing events. In dissociating, the person does not have to be aware of or remember traumatic events. There is evidence of functional changes in the frontolimbic regions (amygdala, anterior cingulate, inferior frontal gyrus, medial, and dorsolateral prefrontal cortices) and temporoparietal areas Impaired Problem Solving In BPD, affected people often fail to engage in active problem solving. Instead, problem solving is attempted by soliciting help from others in a helplessly hopeless manner. Suggestions offered are rarely taken up. Impulsivity These individuals often have difficulty delaying gratification or thinking through the consequences before acting on their feelings; their actions are often unpredictable. Essentially, they act in the moment and clean up the mess afterward. Gambling, spending money irresponsibly, binge eating, engaging in unsafe sex, and abusing substances are typical of these individuals. They can also be physically or verbally aggressive. Job losses, interrupted education, and unsuccessful relationships are common. Self-Harm Behaviors The turmoil and unsuccessful interpersonal relationships and social experiences associated with BPD may lead the person to undermine him- or herself when a goal is about to be reached. The most serious consequences are suicide attempts or parasuicidal behavior (i.e., deliberate self-injury with intent to harm oneself). Self-harm behavior can be compulsive (e.g., hair pulling), episodic, or repetitive (e.g., cutting wrists, arms, other body parts) and is more likely to occur when the individual with BPD is depressed; has highly unstable interpersonal relationships, especially problems with intimacy and sociability; and is paranoid, hypervigilant (i.e., alert, watchful), and resentful. It is not unusual for persons with this disorder to self-harm in unusual ways such as swallowing pens, staples, and even razor blades, or banging one's head against a brick wall. All self-harm behaviors should be considered potentially life threatening and taken seriously.

Dependent Personality disorder

People with dependent personality disorder cling to others in a desperate attempt to keep them close. Their need to be taken care of is so great that it leads to doing anything to maintain the closeness, including total submission and disregard for themselves. Decision-making is difficult or nonexistent. They adapt their behavior to please those to whom they are attached. They lean on others to guide their lives. They ingratiate themselves with others and denigrate themselves and their accomplishments. Their self-esteem is determined by others. Behaviorally, they withdraw from adult responsibilities by acting helpless and seeking nurturance from others. In interpersonal relationships, they need excessive advice and reassurance. They are compliant, conciliatory, and placating. They rarely disagree with others and are easily persuaded. Friends describe them as gullible. They are warm, tender, and noncompetitive. They timidly avoid social tension and interpersonal conflicts.However, these individuals are at risk for suicide and parasuicide, perpetration of child abuse, perpetration of domestic violence (in men), and victimization by a partner The diagnosis is made more frequently in women than in men. This gender difference may represent a sex bias by clinicians because when standardized instruments are used, men and women receive diagnoses at equal rates. The risk of dependent personality disorder is greater for the least educated and for widowed, divorced, separated, and never married women It is likely that a biologic predisposition exists to develop the dependency attachments of this disorder. However, no research studies support a biologic hypothesis. Dependent personality disorder is most often explained as a result of parents' genuine affection, extreme attachment, and overprotection. Children then learn to rely on others to meet their basic needs and do not learn the necessary skills for autonomous behavior. Persons with chronic physical illnesses in childhood may be prone to developing this disorder.

EBN with BPD

Physical Health Assessment People with BPD are usually able to maintain personal hygiene and physical functioning. Because of the comorbidity of BPD and eating disorders and substance abuse, however, a nutritional assessment may be needed. The assessment should also include the use of caffeinated beverages (e.g., coffee, tea, cola, energy drinks) and alcohol. In patients who engage in binging or purging, assessment should include examining the teeth for pitting and discoloration, as well as the hands and fingers for redness and calluses caused by inducing vomiting. The patient should be queried about physiologic responses of emotion. Sleep patterns also should be assessed because sleep alterations may suggest coexisting depression or mania Response Patterns of Persons With Borderline Personality Disorder Affective (mood) dysregulation Mood lability Problems with anger Interpersonal dysregulation Chaotic relationships Fears of abandonment Self-dysregulation Difficulties with sense of self Sense of emptiness Behavioral dysregulation Parasuicidal behavior or threats Impulsive behavior Cognitive dysregulation Dissociative responses Paranoid ideation

Care, interventions, and social skills

Priority of Care After patient and staff safety are established, improving communication and coping skills should be the patient's priorities. The nurse can help the patient develop insight into the need for enhanced communication and positive coping. Nursing Interventions Children with oppositional defiant disorder or conduct disorder who also have specific neurodevelopmental disorders should be placed in appropriate programs for remediation. If a diagnosis of ADHD or depression emerges from the evaluation, appropriate pharmacotherapy should be considered Social Skills Training The nurse should communicate behavioral expectations clearly and enforce them consistently. Consequences of appropriate and inappropriate actions also should be clear. Specific approaches for improving social and problem-solving skills are fundamental features for school-aged children and adolescents. Insofar as children and adolescents with conduct problems fail to recognize the adverse effects of their verbal and nonverbal behavior, their deficit can be formulated as an interpersonal problem. Social skills training teaches adolescents with these behavior disorders to recognize the ways in which their actions affect others. Training involves techniques such as role-playing, modeling by the therapist, and giving positive reinforcement to improve interpersonal relationships and enhance social outcomes.

EBN with BPD

Psychiatric-mental health registered nurses do not function as the patient's primary therapists, but they do need to establish a therapeutic relationship that strengthens the patient's coping skills and self-esteem and also supports individual psychotherapy. The therapeutic relationship helps the patient to experience a model of healthy interaction with consistency, limit setting, caring, and respect (both self-respect and respect for the patient). Patients who have low self-esteem need help in recognizing genuine respect from others and reciprocating with respect for others. In the therapeutic relationship, the nurse models self-respect by observing personal limits, being assertive, and clearly communicating expectations. The nurse should always avoid using stigmatizing language, such as describing the person's behavior as manipulating instead of reporting or documenting specific behaviors. Nurses should use their own self-awareness skills to examine their personal response to the patient. How the nurse responds to the patient can often be a clue to how others perceive and respond to the person. For example, if the nurse feels irritated or impatient during the interview that is a sign that others respond to this person in the same way; conversely, if the nurse feels empathy or closeness, chances are this patient can evoke these same feelings in others. Sleep Hygiene. Disturbed sleep patterns are common in association with BPD. The nurse can intervene by helping the person establish a regular bedtime routine by teaching sleep hygiene strategies such avoiding foods and drinks that could interfere with sleep. If relaxation exercises are used, they should be adapted to the tolerance of the individual. Special consideration must be made for persons who have been physically and sexually abused and who may be unable to put themselves in a vulnerable position (e.g., lying down in a room with other people or closing their eyes). These patients may need additional safeguards to help them sleep, such as a night light or repositioning the furniture in the room to allow a quick exit.

Recovery

Psychotherapy is needed to help the individual with BPD manage the dysfunctional moods, impulsive behavior, and self-injurious behaviors. Specially trained therapists who are comfortable with the many demands of these patients are needed. These therapists represent a variety of mental health disciplines, including psychology, social work, and advanced practice nursing. This is a life-long disorder requiring ongoing treatment as the individual copes with multiple interpersonal crises. Several types of medications are usually needed, including mood stabilizers, antidepressants, and anxiolytics; careful medication monitoring is necessary. Dialectical behavior therapy (DBT) combines cognitive and behavior therapy strategies with acceptance-based practice drawn from Zen and humanistic approaches; it was developed for persons with BPD. Core interventions include problem solving, exposure techniques (i.e., gradual exposure to cues that set off aversive emotions), skills training, contingency management (i.e., reinforcement of positive behavior), and cognitive modification. Skills groups are an integral part of DBT and are taught in group settings in which patients practice emotional regulation, interpersonal effectiveness, distress tolerance, core mindfulness, and self-management skills. Weekly individual therapy sessions focus on enhancing motivation and improving competence Mentalization-based therapy (MBT) is a psychodynamic psychotherapy that is used in both individual and group formats. In MBT, borderline personality symptoms are viewed as a result of distortion or reduction in mentalizing, which is the ability to understand the mental states of oneself and others, including thoughts, feelings, that lead to actions. The goal of MBT is to improve patients' capacity to accurately understand others' actions and develop self-awareness skills through a therapeutic relationship Safety Persons with BPD can be extremely volatile emotionally. Because they experience emotions so intensely, they are at high risk for self-harm and suicide. Self-harm threats should be taken very seriously.

Schizotypal personality disorder

Schizotypal personality disorder is characterized by a pattern of social and interpersonal deficits. The term schizotypy refers to traits that are similar to the symptoms of schizophrenia but are less severe. Cognitive perceptual symptoms are a primary characteristic and include magical beliefs (similar to delusions) and perceptual aberrations (similar to hallucinations). Other common symptoms include referential thinking (interpreting insignificant events as personally relevant) and paranoia (suspicion of others). Schizotypal personality-disordered persons are more dramatically eccentric than those with schizoid personality disorder who are characteristically flat, colorless, and dull. These individuals are perceived as strikingly odd or strange in both appearance and behavior, even to laypersons. They may have unusual mannerisms, an unkempt manner of dress that does not quite "fit together," and inattention to usual social conventions (e.g., avoiding eye contact, wearing clothes that are stained or ill fitting, and being unable to join in the give-and-take banter of coworkers). Devoid of any close friends other than first-degree relatives, their mood is constricted or inappropriate, with excessive social anxieties. They usually exhibit an avoidant behavior pattern. Persons with schizotypal personality disorder may respond to stress with transient psychotic episodes (lasting minutes to hours). Because of their short duration, the symptoms mirror but fall short of features that would justify the diagnosis of schizophrenia. Many individuals (30% to 50%) with schizotypal personality disorder also have a co-occurring major depressive disorder diagnosis when admitted to a hospital More common in males The lifetime prevalence of schizotypal personality disorder is 3.9% with higher rates among men (4.2%) than women. There is cultural variation with black women and low-income individuals having a greater risk than others Magnetic resonance imaging (MRI) studies of individuals with schizotypal personality disorder show smaller gray matter volume, which are correlated with negative symptoms. Studies also show changes in temporal gyrus volume asymmetry and in the white matter tracts. There is also evidence that trauma-exposed individuals have a greater risk of developing schizotypal disorder EBN Depending on the amount of decompensation (i.e., deterioration of functioning and exacerbation of symptoms), the assessment of a patient with a schizotypal personality disorder can generate a range of nursing diagnoses. If a person has severe symptoms, such as delusional thinking or perceptual disturbances, the nursing priorities are similar to those for a person with schizophrenia If symptoms are mild, social isolation, coping with stress and daily living, low self-esteem, and difficult social interactions are the focus of nursing care. People with schizotypal personality disorder need help in developing recovery-oriented strategies to increase their sense of self-worth and recognize their positive attributes. They can benefit from social skills training and environmental management that increases their psychosocial functioning. Their eccentric thoughts and behaviors alienate them from others. Reinforcing socially appropriate dress and behavior can improve their overall appearance and ability to relate in the environment. Because they have a hard time generalizing from one situation to another, attention to cognitive skills is important. Quality of life for a patient with schizotypal personality disorder can be improved with supportive psychotherapy, but their suspiciousness, lack of trust, or impaired social interactions make it difficult to establish a therapeutic relationship. These individuals do not usually seek treatment unless more serious symptoms appear, such as depression or anxiety. Medications are not generally used unless the individual has coexisting anxiety or depression. Nursing care is often provided in a home or clinic setting, with the personality disorder being secondary to the purpose of the care. This means that nurses are focusing on other aspects of patient care and may miss the underlying psychiatric disorder. A psychiatric nursing consult may be needed for these patients to help identify the disorder.

Social theories: Biosocial theories

The ability to control emotion is partly learned from private experiences and encounters with the social environment. BPD is believed to develop when emotionally vulnerable individuals interact with an invalidating environment, a social situation that negates private emotional responses and communication. When core emotional responses and communications are continuously dismissed, trivialized, devalued, punished, and discredited (invalidated) by respected or valued persons, the vulnerable individual becomes unsure about his or her feelings. A minor example of an invalidating environment or response follows: The parents of Emily, a 4-year-old girl, tell her that the family is going to grandmother's house for a family meal. The child responds, "I am not going to Gramma's. I hate Stevie (her cousin)." The parents reply, "You don't hate Stevie. He is a wonderful child. He is your cousin, and only a spoiled and selfish little girl would say such a thing." The parents have devalued Emily's feelings and discredited her comments, thereby invalidating her feelings and sense of personal worth. The most severe form of invalidation occurs in situations of child sexual abuse. Often, the abusing adult has told the child that this is a "special secret" between them. The child experiences feelings of fear, pain, and sadness, yet this trusted adult continuously dismisses the child's true feelings and tells the child what he or she should feel.

Behavorial interventions

The goal of behavioral interventions is to replace dysfunctional behaviors with positive ones. The nurse has an important role in helping patients control emotions and behaviors by acknowledging and validating desired behaviors and ignoring or confronting undesired behaviors. Patients often test the nurse for a response, so nurses must decide how to respond to particular behaviors. This can be tricky because even negative responses can be viewed as positive reinforcement by the patient. In some instances, if the behavior is irritating but not harmful or demeaning, it is best to ignore, rather than focus, on it. However, grossly inappropriate and disrespectful behaviors require confrontation. If a patient throws a glass of water on an assistant because she is angry at the treatment team for refusing to increase her hospital privileges, an appropriate intervention would include confronting the patient with her behavior and issuing the consequences, such as losing her privileges and apologizing to the assistant. However, such an incident can be used to help the patient understand why such behavior is inappropriate and how it can be changed. The nurse should explore with the patient what happened, what events led up to the behavior, what the consequences were, and what feelings were aroused. Advanced practice nurses or other therapists explore the origins of the patient's behaviors and responses, but the generalist nurse needs to help the patient explore ways to change behaviors involved in the current situation. The laboriousness of this analytic process may be a sufficient incentive for the patient to abandon the dysfunctional behavior. In problem solving, the nurse might encourage the patient to debate both sides of the problem and then search for common ground. Practicing communication and negotiation skills through role-playing helps the patient make mistakes and correct them without harm to her or his self-esteem. The nurse also encourages patients to use these skills in their everyday lives and report back on the results, asking patients how they feel applying the skills and how doing so affects their self-perceptions. Success, even partial success, builds a sense of competence and self-esteem

Evaluate

The nurse can review treatment goals and objectives to assess the child's progress with respect to verbal and physical aggression, socially appropriate resolution of conflicts, compliance with rules and expectations, and better management of frustration. As is true for the initial assessment, evaluation of treatment outcomes relies on input from parents, teachers, and other health care team members. Children and adolescents with conduct disorders may be involved with many different agencies in the community, such as child welfare services, school authorities, and the legal system. Mental health services are requested when a child or adolescent's behavior is out of control or a when comorbid disorder is suspected. Helping the patient and family negotiate their way through this maze of services may be an essential part of the treatment plan.

EBN with disruptive, impulse control, and conduct disorder

The nurse gathers data from multiple sources. Adolescents with these disorders are at high risk for physical injury as a result of fighting and impulsive behavior. Sexual promiscuity is common, resulting in an increased frequency of pregnancy and sexually transmitted diseases. An important aspect of assessment is to rule out comorbid conditions that may partially explain or complicate the person's lack of behavioral control. These conditions include ADHD, learning disabilities, chemical dependency, depression, bipolar illness, or generalized anxiety disorder. Young people who are chronically depressed may be irritable and easily frustrated. Given the tendency of adolescents to act out their frustration, chronic depression may exacerbate their behavior. Conduct problems can also elevate the risk for depression because young people who regularly elicit negative attention from parents and teachers and are constantly at odds with their environment may become despondent. Adolescents with conduct problems are usually brought or forced into the mental health system by family, school, or the court system because of fighting, truancy, speeding tickets, car accidents, petty crimes, substance abuse, or suicide attempts. These young people may be hostile, sarcastic, defensive, and provocative. At the same time, they may appear calm, outgoing, and engaging. Inconsistencies, distortions, and misrepresentations of the truth are common when interviewing these children, so obtaining a clear history may be difficult. Therefore, instead of asking whether an event or behavior occurred, it may be better to ask when it occurred. These adolescents are adept at changing the subject and diverting discussions from sensitive issues. They often use denial, projection, and externalization of anger as defense mechanisms when asked for self-disclosure. The assessment, which may take several sessions, should be conducted in a nonjudgmental fashion. High levels of marital conflict, parental substance abuse, and parental antisocial behavior often mark family history. In planning interventions for patients with oppositional defiant disorder or conduct disorder, the focus is on problem behaviors. Therapeutic progress may be slow, at least partly because these patients often lack trust in authority figures.

EBN with NPD

The nurse usually encounters persons with narcissism in medical settings and in psychiatric settings with a coexisting psychiatric disorder. They are difficult patients who often appear snobbish, condescending, and patronizing in their attitudes. It is unlikely that these individuals are motivated to develop sensitivity to others and socially cooperative attitudes and behaviors. Building a therapeutic relationship is a slow process because these patients avoid self-reflection and often reject the clinician's approaches. Nurses need to use their self-awareness skills in interacting with these patients. The nursing process focuses on the coexisting responses to other health care problems Similar to patients with histrionic disorder, those with narcissistic personality disorder do not seek mental health care unless they have a coexisting medical or mental disorder. They are likely to be treated within the community for most of their lives, with the exception of short hospitalizations for nonpsychiatric problems.

Nutrition and Preventing self harm

The nutritional status of the person with BPD can quickly become a priority, particularly if the patient has coexisting eating disorders, mood disorders, schizophrenia, or substance abuse. Eating is often a response to stress, so patients can quickly become overweight. This is especially a problem when the patient has also been taking medications that promote weight gain, such as antipsychotics, antidepressants, or mood stabilizers. Helping the patient learn the basics of nutrition, make reasonable choices, and develop other coping strategies are useful interventions. If patients are engaging in purging or severe dieting practices, teaching the patient about the dangers of both of these practices is important. Referral to an eating disorders specialist may be needed Patients with BPD are usually admitted to the inpatient setting because of threats of self-harm. Observing for antecedents of self-injurious behavior and intervening before an episode are important safety interventions. Patients can learn to identify situations leading to self-destructive behavior and develop preventive strategies. Remembering that self-harm is an effort to self-soothe by activating endogenous endorphins, the nurse can assist the patient to find more productive and enduring ways to find comfort. Linehan suggests using the Five Senses Exercise. Vision (e.g., go outside and look at the stars or flowers or autumn leaves) Hearing (e.g., listen to beautiful or invigorating music or the sounds of nature) Smell (e.g., light a scented candle, boil a cinnamon stick in water) Taste (e.g., drink a soothing, warm, nonalcoholic beverage) Touch (e.g., take a hot bubble bath, pet your dog or cat, get a massage)

EBN Histrionic personality disorder

The ultimate treatment goal for patients with histrionic personality disorder is to correct the tendency to expect others to fulfill all of their needs. When these individuals seek mental health care, they have usually experienced a period of social disapproval or deprivation. Their hope is that the mental health providers will help fulfill their needs. Specific goals are needed to protect the person from becoming dependent on a mental health system. In the nursing assessment, the nurse focuses on the quality of the individual's interpersonal relationships. It is common that the person is dissatisfied with his or her partner, and sexual relations may be nonexistent. During the assessment, the patient will make statements that indicate low self-esteem. Because these individuals believe that they are incapable of handling life's demands and have been waiting for a truly competent person to take care of them, they have not developed a positive self-concept or adequate problem-solving abilities. Priority of care areas for persons with this disorder include focusing on self-esteem and coping patterns. Outcomes focus on helping the patient develop autonomy, a positive self-concept, and mature problem-solving skills. A variety of interventions support the outcomes. A nurse-patient relationship that allows the patient to explore positive personality characteristics and develop independent decision-making skills forms the basis of the interventions. Reinforcing personal strengths, conveying confidence in the patient's ability to handle situations, and examining the patient's negative perceptions of him- or herself can be done within the therapeutic relationship. Encouraging the patient to act autonomously can also improve the individual's sense of self-worth. Attending assertiveness groups can help increase the individual's self-confidence and improve self-esteem.

Unstable self image and unstable affect

These patients appear to have no sense of their own identity and direction; this becomes a source of great distress to them and is often manifested by chronic feelings of emptiness and boredom. It is not unusual for people with BPD to direct their actions in accord with the wishes of other people. For example, one woman with BPD describes herself: "I am a singer because my mother wanted me to be. I live in the city because my manager thought that I should. I become whatever anyone tells me to be. Whenever someone recommends a song, I wonder why I didn't think of that. My boyfriend tells me what to wear." Affective instability (i.e., rapid and extreme shift in mood) is a core characteristic of BPD and is evidenced by erratic emotional responses to situations and intense sensitivity to criticism or perceived slights. For example, a person may greet a casual acquaintance with intense affection yet later be aloof with the same acquaintance. Friends describe individuals with BPD as moody, irresponsible, or intense. These individuals often fail to recognize their own emotional responses, thoughts, beliefs, and behaviors and have difficulty interpreting the facial affects of others. In this disorder recognizing emotions in others is altered

Epidemiology and risk

This disorder is associated with higher education, employment, and marriage. Subjects with the disorder had a higher income than did those without the disorder. As with some other personality disorders, evidence for a biologic formulation is scant. The basis of the compulsive patterns that characterize OCPD is parental overcontrol and overprotection that is consistently restrictive and sets distinct limits on the child's behavior. Parents teach these children a deep sense of responsibility to others and to feel guilty when these responsibilities are not met. Play is viewed as shameful, sinful, and irresponsible, leading to dire consequences. They are encouraged to resist the natural inclinations toward play and impulse gratification, and parents try to impose guilt on the child to control behavior. These individuals seek mental health care when they have attacks of anxiety, spells of immobilization, sexual impotence, and excessive fatigue. The nursing assessment focuses on the patient's physical symptoms (sleep, eating, sexual), interpersonal relationships, and social problems. There may be multiple nursing care priorities such as anxiety, loneliness, decision-making, sexual problems, insomnia, and interpersonal relationships. People with OCPD realize that they can improve their quality of life, but they find it extremely anxiety provoking to make the necessary changes. To change the compulsive pattern, psychotherapy is needed. There may be short-term pharmacologic intervention with an antidepressant or anxiolytic as an adjunct may take place. A supportive nurse-patient relationship based on acceptance of the patient's need for order and rigidity will help the person have enough confidence to try new behaviors. Examining the patient's belief that underlies the dysfunctional behaviors can set the stage for challenging the childhood thinking. Because the compulsive pattern was established in childhood, it will take a long time to modify the behavior.

Identity disturbance and dissociation and transient psychotic episodes Interpersonal skills

Unstable self-image is often manifested as an identity disturbance or identity diffusion, a loss of the capacity for self-definition and commitment to values, goals, or relationships. The nurse can recognize identity diffusion if the patient reports an ongoing "emptiness" or contradictory behavior. "I know I should not have gone out with him, but he wanted to see me." The person's thoughts and behavior will seem fragmented and superficial With BPD, periods of dissociation and transient psychotic episodes may occur. Dissociation can be assessed by asking if there is ever a time when the patient does not remember events or has the feeling of being separate from his or her body. Some patients refer to this as "spacing out." By asking specific information about how often, how long, and when dissociation first was used, the nurse can get an idea of how important dissociation is as a coping skill. It is important to ask the person what is happening in the environment when dissociation occurs. Frequent dissociation indicates a highly habitual coping mechanism that is difficult to change. Because transient psychotic states occur, it is also important to elicit data regarding the presence of hallucinations or delusions and their frequency and circumstances. Assessment of the person's ability to relate to others is important because interpersonal problems are linked to dissociation and self-injurious behavior. Information about friendships, frequency of contact, and intimate relationships provide data about the person's ability to relate to others. Patients with BPD often are sexually active and may have numerous sexual partners. Their need for closeness clouds their judgment about sexual partners, so it is not unusual to find these patients in abusive, destructive relationships with people with ASPD.