NUR 410 Personality Disorders NOTES

Nursing Guidelines for Paranoid PD

Avoid being too nice or friendly Give clear, straightforward explanations of tests, procedures beforehand Use simple, clear language, avoid ambiguity Project a neutral but kind affect Warn about any changes, side effects of meds, and reasons for delay

Nursing Guidelines for Narcissistic PD

--Remain neutral, avoid engaging in power struggles or becoming defensive in response to pts disparaging remarks --Convey unassuming self-confidence

This is an example of which PD? I always do what other people want me to do. I hate to tell them that I disagree or want to do something else because I'm afraid that they'll get mad. My friends tell me that I have low self-esteem and that I have trouble putting myself first. I just really want to be liked by other people. Sometimes I find myself going along with something that I don't believe in; I'll even volunteer to do things that I don't like. I've even dated boys that I don't like so I don't have to be alone. I really think that I do best when I'm in a relationship. I can't stand being alone. My boss tells me that I ask too many questions and that I should focus on doing my work. He also complains that I spend too much time talking to other people. I talk to them so that I do things right. Maybe someday I'll be able to figure things out on my own.

Dependent -real FEAR of abandonment submissive desire to be liked by others wants to never be alone clingy cant figure out things on own

Interventions for manipulation behavior

Set limits enforce the mileau rules team consistency maintain a therapeutic environment communicate the rules to the pt so they understand do not get into a power struggle allow them to express why they do not like the rules set Establishing the parameters of desirable & acceptable pt behavior • Discuss concerns about behavior w/ pt • Identify undesirable pt behavior • Discuss w/ pt what is desirable behavior in a given setting • Establish consequences for occurrence or nonoccurrence of desired behavior • Communicate established behavioral expectations & consequences to pt in language that is easily understood & nonpunitive • Refrain from arguing or bargaining w/ pt about established behavioral expectations & consequences • Monitor pt for occurrence or nonoccurrence of desired behaviors • Modify behavior expectations & consequences as needs to accommodate reasonable changes in pt situation

Self-Assessment is very important for the nurse with a Borderline PD patient

because these patients can be so exasperating Awareness and monitoring your stress response to their behaviors help to deliver more therapeutic responses/interventions

Outcome criteria for Personality Disorders

change is slow with small steps • minimizing self-destructive or aggressive behavior • reducing the effect of manipulative behaviors • linking consequences to both functional and dysfunctional behaviors • initiating functional alternatives to prevent a crisis • ongoing management of anger, anxiety, shame, and unhappiness

Nursing Guidelines for Antisocial PD

o Try to prevent or reduce untoward effects of manipulations Set clear & realistic limits on specific behavior Ensure limits are adhered by ALL staff Document signs of manipulation or aggression Document behaviors o Be aware that antisocial pts can instill guilt when they are not getting what they want o Substance abuse is best handled through a well-organized Tx program before counseling or therapy is started

Nursing Guidelines for Histrionic PD

o Understand seductive behavior as a response to distress o Keep communication & interactions to professional o Encourage & model use of concrete & descriptive rather than vague & impressionistic language o Teach & role-model assertiveness

SchizoTYPAL PD info

• Bizarre speech patterns • Seek out help during episodes of depression or for anxiety • Biological influences of the dopamine system • PET scans show structural abnormalities of the brain

Obsessive Compulsive PERSONALITY Disorder

• Creates tension in relationships • Genuine affection for friends & family but doesn't have insight about their own difficult behavior • Rehears how they will respond to social situations DIFFERS FROM OCD by 3 symptoms that occur with LESS frequency and intensity: o Hoarding, perfectionism , preoccupation w/ details o Not geared by compulsion o Does not interfere w/ daily living

Histrionic PD info

• Demands the "best of everything" • Partner often feels smothered • Doesn't have insight into role in breaking up relationships • May seek treatment for depression or other comorbid

Other SchizoID PD characteristics

• Emotionally detached • Depersonalization may occur • Precursor to schizophrenia or delusion disorder • Prevalence in families

Avoidant PD additional info

• Extreme sensitivity to rejection • May have been timid in temperament in infancy & childhood

NURSING DIAGNOSIS for Personality Disorders

• Ineffective Health Maintenance (SchizoTYPAL, SchizoID, Avoidance) • Ineffective coping (Borderline) • Anxiety (avoidant, dependent, OCD, some with Borderline) • Risk for other-directed violence (Antisocial) • Risk for self-directed violence (Borderline--suicidality) • Impaired social interaction (ALL of the disorders) • Social isolation (paranoid, schizoid, schizotypal) • Fear (paranoid, schizoid, schizotypal) • Disturbed thought processes (paranoid, schizoid, schizotypal) • Defensive coping • Self-mutilation (borderline) • Chronic low self-esteem (antisocial, borderline, histrionic, narcissistic, avoidant, dependent, obsessive-compulsive) • Ineffective therapeutic regimen management

General Nursing Interventions for personality disorders

• Limit Setting • Manipulation • Anger Interventions • Set Method o support, empathy, truth • Maintain a neutral stance

Narcissistic PD info

• Underneath feels intense shame & fear of abandonment • Afraid of their mistakes & other mistakes • May seek help for depression

Clinical Picture of Personality Disorder

3 clusters—A,B,C (A,B,C not in book, not testable but will help us learn the disorders and understand) o A = Odd or Eccentric paranoid, schizoid, schizotypal o B = Dramatic, Emotional, Erratic antisocial, borderline, histrionic, narcissistic o C = Anxious or Fearful avoidant, dependent, obsessive-compulsive

OUTCOMES

1. Identify the clinical manifestations of the 10 Personality disorders. 2. Discuss common behavioral patterns in the Personality disorders the nurse will need to manage.

This is an example of which PD? I tried to raise my son to know right and wrong. Even when he was little, he didn't seem right. He had a cat that he used to hurt - I don't even like to remember the things he'd do. He started stealing from us; he'd just take money out of my wallet and then deny it. Then he progressed to stealing from others, running away, and then he became a junkie. I never raised him to be that way.

Antisocial Aggressive Hurting animals Stealing Hurting other people Stealing Manipulative Dangerous

Mr. Beech is undergoing surgery for a broken leg. He is suspicious of the staff and believes that the IV he is receiving for hydration and pre anesthesia will be used for harmful purposes. He keeps his eyes closed and refuses to answer or look at his family, who describe him as odd. He has schizotypal PD. A. Explain how being friendly and outgoing may be threatening to Mr. Beech. B. Explain how being matter-of-fact and neutral and sticking to the facts would be effective to Mr. Beech. C. What could be done to give Mr. Beech some control over his situation as a hospitalized patient? D. How could you best handle his beliefs and lack of interpersonal comfort with caregivers so both you and he would feel most comfortable?

A. Because he is paranoid, Mr. Beech will think the nurse is probably up to something and has ulterior motives. B. This demeanor is not too close and not too far. By maintaining this approach, the nurse isn't threatening Mr. Beech's space, and she is not too far away for him to think she doesn't really care about him. C. Give him the opportunity to make some choices whenever possible. D. It's important to remember that the behavior he is demonstrating is part of the disease process, so the nurse must somehow rise above it and realize that his verbalizations are not personal. By maintaining a neutral affect and not responding to his inflammatory remarks, she will avoid having him see her actions as retaliation or otherwise validate his distorted perceptions as true.

Cherie is brought to the ER after slashing her wrist with a razor. She has previously been in the ER for overdose and a hx of addiction. She can be sarcastic, belittling and aggressive to those who try to care for her. Se has a hx of difficulty with interpersonal relationships at her job. When the psych triage nurse comes in to see her, che is initially adoring and compliant, telling him, "youre the best nurse Ive ever had and I truly want to change." But when he refuses to support her request for diazepam and meperidine for "pain", she yells at him. "Youre a stupid nurse, I want to see the Dr immediately." She is borderline PD A. What defense mechanisms is Cherie using? B. How could the nurse handle this situation while setting limits and demonstrating concern?

A. Cherie is demonstrating dichotomous thinking, also known as splitting. B. By maintaining a neutral affect and working with Cherie in a matter-of-fact manner, the nurse will demonstrate that he is not responding to the personal attacks by the patient. This will aid in maintaining a therapeutic relationship as much as possible.

Nursing Interventions for impulsive behavior

Assisting the pt to mediate impulsive behavior through the application of problem solving technique to social & interpersonal situations • Assist pt to identify the problem or situation that requires thoughtful action • Assist pt to identify courses of possible action & their costs & benefits • Teach pt to cue himself or herself to "stop & think" before acting impulsively • Assist pt to evaluate the outcome of the chose course of action • Provide positive reinforcement • Encourage pt to self-reward for successful outcomes • Provide opportunities for pt to practice problem solving w/in the therapeutic environment • Encourage pt to practice problem solving in social & interpersonal situations outside the therapeutic environment followed by evaluation of the outcome

This is an example of which PD? People always said I was a shy kid. They would always announce it, like at a party or family get-together. That really made me quiet. What does a shy child say to that? It's true, though; I never really felt comfortable around other people even though I wanted to be with them. It's not really surprising that I don't go out much.

Avoidant shy uncomfortable around others don't go out much they want relationships but just cant get them

This is an example of which PD? Nobody cares about me. I'm just unlovable, Sometimes I think that my husband wishes I was dead. There's just no point to living - I could kill myself at any time. I have plenty of pills, and I've planned to overdose many times. In the past I would slit my wrists a little, and I have scars from all the cutting. My husband threatened to leave me a few times. If he did leave, he'd be sorry. I started screaming at him the other day. I was really out of control, but I was so mad I couldn't help it. At first I told him to leave. Then I told him I couldn't live without him. Sometimes I really do love him and think he's the greatest man on earth; other times he's a jerk. I don't really understand myself very well. One minute I'm furious, like I could kill someone, the next I'm scared, and the next I'm depressed. I think that's what led to my getting fired from a few jobs. They just wanted someone who was quiet, complacent, and a good little girl. So I was a little outspoken—I have a right to my opinions. Things just got too hard for them to handle.

Borderline --Attention seeking --In-pt setting = will use "splitting" --The MOST challenging PD --Ambivalent is a classic s/s Very impulsive Suicidal--but usually to get attention

Borderline PD info

MOST well-known disorder MOST MANIPULATIVE & DISRUPTIVE LABILE • Severe impairments in functioning & high mortality rate & extensive utilization of the health care system • Co-occurring mood, anxiety or substance disorders complicate the Rx & prognosis DEFENSE MECHANISM: SPLITTING

This is an example of which PD? Crazy—that's what people think of me. Hey, I live my life the way I want. I live on the streets and dress in whatever I can find. I don't need nobody, and I don't need nobody telling me what I can and can't do.

SchizoTYPAL this one looks more like schizophrenia than the Schizoid Hard to hold a job Dress anyway they want Nobody telling me what to do

This is an example of which PD? My daughter has always had to be the "life of the party." She needed the spotlight; in fact, she was a very good actress in her high school play. But she never seems to have close friends. Other people get turned off by her flair and need for attention. She describes them as her "dear" friends, when they don't want to have much to do with her. I don't think she realizes her effect on them.

Histrionic life of the party spotlight good actress flair and need for attention

This is an example of which PD? I have been married three times; women just can't seem to understand me. They don't appreciate my unique style and status. In fact, they didn't appreciate that I was the best thing that ever happened to them. Who needs them anyway? I was just wasting my time with them

Narcissistic --Grandiose Best thing ever happened to them They don't like rejection, become rageful As soon as someone bows at feet, they forget the rage and move on A dependent personality is more prone to marry a nacissist

This is an example of which PD? I've been divorced twice. My ex-wives said I was a "control freak." I just think that there is a place and time for everything. Everything in its place. That's the right way; the way it should be. Like the saying, "Early to bed and early to rise..." It's the same with my boss. I keep telling her how to organize the place and schedule things. If she only realized that my plan is the best way.

Obsessive Compulsive PD **different than OCD*** Need for control control freak my way is best way

This is an example of which PD? I just knew that those people were going to cheat me. I could tell by the way they looked at me. I bet they thought I didn't notice them looking at me and talking about me. I don't know what they want from me.

Paranoid suspicious hostile/violent mistrustful

This is an example of which PD? I don't understand why my son spends all day at his computer. He's been, like that for years. He never had many friends in childhood, but in college he really withdrew from others. At first, I thought he was really into his studying for his degree in computer science. He doesn't have any friends, and he hasn't had a date or gone out to see a movie for years. I can understand his being interested in computers, but he has no social life. He doesn't seem to mind not having any friends, and he doesn't understand why I'm so worried about him. It's not like he's depressed or anything—he's just aloof and apathetic about things. I guess you'd call him a "loner." He's got nobody but me. What will happen to him as he gets older?

SchizoID spends all day at computer never many friends withdrawn from others no social life aloof/apathetic loner

Interventions for Anger or Aggressive behavior

Stay calm during the pts anger empathetic with their feelings stay engaged with the pt The SET method: Support Empathy Trustworthiness Facilitation of the expression of anger in an adaptive, nonviolent manner • Determine appropriate behavioral expectations for expression of anger, given the pts level of cognitive & physical functioning • Limit access to frustrating situations until pt is able to express anger in an adaptive manner • Encourage pt to seek assistance from nursing staff during periods of increasing tension • Monitor potential for inappropriate aggression & intervene before its expression • Prevent physical harm if anger is directed at self or others o Restraint & removal of potential weapons • Provide physical outlets for expression of anger or tension o Punching bag, sports, clay, journal writing • Provide reassurance to pt that nursing staff will intervene to prevent pt from losing control • Assist pt in identifying source of anger • Identify function that anger, frustration & rage serve to pt • Identify consequences of inappropriate expression of anger

Nursing Guidelines for Avoidant PD

o A friendly, accepting, reassuring approach is the best way to treat pts o Being pushed into social situations can cause extreme & sever anxiety

Dependent Personality Disorder Anxious or Fearful Cluster C

o A pervasive & excessive need to be taken care of that leads to submissive & clinging behavior & fear of separation o Beginning in early adulthood & presents in a variety of contexts indicated by 5 or more of the following Has DIFFICULTY MAKING EVERY DAY DECISIONS w/o an excessive amount of advice from others Needs others to assume responsibility for more major areas of life Has difficulty expressing disagreement with others because of fear of loss of support or approval Has difficulty initiating projects or doing things on own bc LACK OF SELF-CONFIDENCE in judgment or abilities rather than a lack of motivation or energy Goes to excessive lengths to obtain nurturance & support from others, to the point of volunteering to do things that are unpleasant Feels uncomfortable or HELPLESS WHEN ALONE bc of exaggerated fears of being unable to care for self Urgently seeks another relationship as a source of care & support when a close relationship ends Is unrealistically preoccupied w/ fears of being left to take care of self -HAVE TO be with others • Submissive, passive, self-doubting • Difficult to sustain autonomy

Borderline Personality Disorder Dramatic, Emotional, Erratic Cluster B

o A pervasive patter of instability of interpersonal relationships, self-image, & affects & marked impulsivity beginning in early adulthood o Presents in a variety of contexts as indicated by 5 or more of the following Frantic efforts to avoid real or IMAGINED ABANDONMENT Don't include suicide or self-mutilating behavior A pattern of unstable & intense interpersonal relationships characterized by alternating between extremes of IDEALIZATION & DEVALUATION Identity disturbances: markedly & persistently unstable self-image or sense of self -"I don't understand myself very well." Impulsivity in at least 2 areas that are potentially self-damaging Spending, sex, substance abuse, reckless driving, binge eating Don't include suicide or self-mutilating RECURRENT SUICIDAL BEHAVIOR, GESTURES, OR THREATS-MUTILATING OF SELF Affective instability due to a marked reactivity of mood Intense episodic dysphoria, irritability, anxiety Usually lasting a few hours, rarely more than a few days Chronic feelings of emptiness Inappropriate INTENSE ANGER or difficulty controlling anger Frequent displays of temper, constant anger, recurrent physical fights Transient stress-related paranoid ideation or sever dissociative symptoms

Histrionic Personality Disorder Dramatic, Emotional, Erratic Cluster B

o A pervasive pattern of excessive emotionally & attention seeking, beginning in early adulthood o Present with a variety of contexts, indicated by % or more of the following Is uncomfortable in situations in which self is not the CENTER OF ATTENTION Interactions w/ others is often characterized by inappropriate sexually seductive or PROVOCATIVE BEHAVIOR Displays rapidly shifting & shallow expression of emotions Has a style of speech that is excessively impressionistic & lacking in detail Shows SELF-DRAMATIZATION, theatrically, & exaggerated expression of emotion Is suggestible, easily influenced by others or circumstances Considers relationships to be MORE IMPORTANT than they ACTUALLY ARE

Narcissistic Personality Disorder Dramatic, Emotional, Erratic Cluster B

o A pervasive pattern of grandiosity (in fantasy & behavior) need for admiration, & lack of empathy, beginning in early adulthood & present in a variety of contexts o Indicated by 5 or more of the following Has a GRANDIOSE SENSE OF SELF-IMPORTANCE Exaggerates achievements & talents, expects to be recognized as superior w/o commensurate achievements Is PREOCCUPIED W/FANTASIES of unlimited success, power, brilliance, beauty, or ideal love Believes that he or she is "SPECIAL & UNIUE" can only be understood by or should be associated with other special or high status people or institutions Requires excessive admiration Has sense of ENTITLEMENT Is impersonally exploitative Takes advantage of others for personal gain LACKS EMPATHY, is unwilling to recognize or identify with the feelings & needs of others Is often envious of others or believes that other are envious of self Shows ARROGANT, haughty behavior or attitude

Obsessive Compulsive PERSONALITY Disorder Anxious or Fearful Cluster C

o A pervasive pattern of preoccupation w/ orderliness, perfectionism, & mental & interpersonal control at the expense of flexibility, openness, & efficiency o Beginning in early adulthood & present in a variety of contexts by 4 or more of the following Is PREOCCUPIED W/DETAILS, RULES, LISTS, ORDER, ORGANIZATION OR SCHEDULES to the extent that the major point of activity is lost Shows PERFECTIONISM THAT INTERFERES W/TASK COMPLETION Is excessively devoted to work & productivity to the exclusion of leisure activities & friendships Is over conscientious, scrupulous, and inflexible about matters of morality, ethics, or values not related to religion Is unable to discard worn-out or worthless objects even when they have no sentimental value Is reluctant to delegate tasks or to work with others unless they submit to exactly to own way of doing things Adopts a miserly spending style towards both self & others, money is viewed as something to be hoarded for future catastrophes Shows RIGIDITY & STUBBORNNESS

SchizoTYPAL Personality Disorder Odd or Eccentric Cluster A

o A pervasive pattern of social & interpersonal deficits marked by acute discomfort w/& reduced capacity for close relationships as well as by cognitive or perceptual distortions & eccentricities of behavior o Beginning in early adulthood and present w/ 5 or more of the following: Ideas of reference Odd beliefs or MAGICAL THINKING that influence behavior & are inconsistent w/ subcultural norms Unusual perceptual experiences, including bodily illusions Suspiciousness or paranoid ideation INAPPROPRIATE OR CONSTRICTED AFFECT Behavior or APPEARANCE THATS ODD, eccentric or peculiar LACK OF CLOSE FRIENDS other than 1st degree relatives Excessive SOCIAL ANXIETY that doesn't diminish w/ familiarity & tends to be associated w/ paranoid fears rather than negative judgments about self

Avoidant Personality Disorder Anxious or Fearful Cluster C

o A pervasive pattern of social inhibition, feelings of inadequacy, & hypersensitivity to negative evaluation o Beginning by early adulthood & present in a variety of contexts indicated by 4 or more of the following: Avoids occupational activities that involve significant interpersonal contact, bc of FEARS OR CRITICISM, DISAPPROVAL OR REJECTION. Is unwilling to get involved with people unless certain of being liked Shows restraint w/in intimate relationships bc of fear of being shamed or ridiculed Is PREOCCUPIED W/BEING CRITICIZED or rejected in social situations Views self as SOCIALLY INEPT, personally unappealing or inferior to others Is unusually RELUCTANT TO TAKE PERSONAL RISKS or to engage in any new activities bc they may prove embarrassing

Nursing Guidelines for SchizoID

o Avoid being too nice or friendly o Don't try to increase socialization o Perform thorough diagnostic assessment as need to identify symptoms or disorders the pt is reluctant to discuss

Nursing Guidelines for Obsessive Compulsive PERSONALITY Disorder

o Guard against power struggles w/ pt, need for control is very high o Intellectualization, rationalization, formation, isolation & undoing are the most commin defense mechanisms

Nursing Guidelines for Dependent personality Disorder

o Identify & help address current stresses o Try to satisfy pts needs at the same time that limits are set up In such a manner that pt doesn't feel punished or withdraw o Be aware that strong countertransference often develop in clinicians bc of pts excessive clinging, therefore supervision is well advised o Teach & role-model assertiveness

Paranoid Personality Disorder Odd or Eccentric Cluster A

o Pervasive distrust & suspiciousness of others such that their motives are interpreted as malevolent o Beginning by early adulthood & present in a variety of contexts as indicated by 4 or more of: --Suspects w/o sufficient basis, that others are exploiting, harming, or deceiving self --Is PREOCCUPIED W/ UNJUSTIFED DOUBTS about the loyalty or trustworthiness of friends or associates --Is reluctant to confide in others bc of unwarranted fear that the info will be used maliciously against self --Persistently bears grudges --PERCEIVES ATTACKS on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack --Has recurrent SUSPICIONS W/O JUSTIFICATION, regarding fidelity of spouse or sexual partner • Jealous, controlling, unwillingness to forgive • Hard to interview bc they are reluctant to share info • Very anxious about being harmed

SchizoID Personality Disorder Odd or Eccentric Cluster A

o Pervasive pattern of detachment from social relationships & a restricted range of expression in interpersonal settings o Beginning by early adulthood & present by 4 or more of the following: Neither desires not enjoys close relationships, including being part of a family Almost always chooses SOLIDARY ACTIVITIES Has little, if any, interest in sexual experiences w/ another person Takes pleasure in few, if any, activities LACKS CLOSE FRIENDS OR CONFIDANTS OTHER THAN 1ST DEGREE RELATIVES Appears indifferent to the praise or criticism of others Shows emotional coldness, detachment or FLATTENED AFFECT

Antisocial Personality Disorder Dramatic, Emotional, Erratic Cluster B

o Pervasive pattern of disregard for &violation of the rights of others occurring since age 15 o As indicated by 3 or more of the following: Failure to conform to social norms to lawful behavior as indicated by repeatedly performing acts that are GROUNDS FOR ARREST DECEITFULNESS as indicated by repeatedly lying, using, aliases or conning others for personal profit or pleasure IMPULSIVITY or failure to plan ahead Irritability & aggressiveness as indicated by repeated PYSICAL FIGHTS OR ASSULTS Reckless disregard for safety of others/self 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 o The individual is at least 18 o There is evidence of conduct disorder w/ onset before the age of 15

Suggested therapies for Paranoid PD

o Psychotherapy first o Cognitive & behavior measures o Group therapy may help w/ social skills o antidepressants or antianxiety, antipsychotics

Nursing Guidelines for SchizoTYPAL PD

o Respect pts need for social isolation o Be aware of pts suspiciousness & employ appropriate interventions o Perform careful diagnostic assessment as need to uncover other medical or psychological symptoms that may need intervention Suicide

Nursing Guidelines for Borderline PD

o Set realistic goals, use clear action words o Be aware of manipulative behaviors o Provide clear & consistent boundaries & limits o Use clear & straightforward communication o When behavioral problems emerge, calmly review the therapeutic goals & boundaries of Tx o Avoid rejecting or rescuing o Assess for suicidal & self-mutilating during times of stress