Personality Disorders

  1. What is personality?
    • A characteristic way in which a person thinks, feels, and behaves
    • His/Her style of life or way of being
    • Diagnostic criteria - defining characteristics used to classify individual into a clinical category
    • Personality traits - long-standing pattern of behavior across time and situations; born with traits
    • Personality disorder - many traits occurring together
    • Prototype - all characteristics taken together, classic example
  2. Personality disorders (axis II)
    • Deviate from social norms
    • Behavior presents as extremes on the continuum of normal personality dimensions
    • Traits are inflexible, enduring, pervasive and maladaptive and cause significant functional impairment or subjective distress
    • Grouped into three clusters based on descriptive characteristics
    • Disability in work and love
    • Ability to evoke interpersonal conflict, negative reactions in people (negative countertransference)
    • Prevents achievement of goals
    • Hard to treat because disorder develops gradually
    • Ego-syntonic - think nothing is wrong with them, think there is something wrong with the world (ego-dystonic - OCD)
    • Gradually evolves over years
  3. Theories of etiology
    • Combo of genetics and environmental risk factors
    • Biological determinants - traits born with; introvert vs. extrovert; neurotic vs. emotional stability, etc.
    • Chronic trauma - stress
    • Psychodynamic - certain parenting styles predispose person; parental neglect and abuse; blurring of boundary to roles in family
    • Neurotransmitters found to be variable in personality disorders
  4. Characteristics
    • Manifested in impairment in four areas:
    • Behavioral
    • Affective
    • Cognitive
    • Sociocultural
  5. Cluster A
    • Odd or eccentric behavior; not psychotic
    • Usually won't seek treatment because they don't trust people
    • Characterized by ineffective coping, inability to trust, fear, perceived threats from others or environment, social isolation, spiritual distress, lack of connection to others
    • Paranoid
    • Schizoid
    • Schizotypal
  6. Paranoid personality disorder
    • Long standing distrust and suspiciousness, look for hidden meaning
    • Seldom requires hospitalization; present for treatment at insistence of others
    • Behavior - secretive, hyperalert, argumentative, guarded, suspicious
    • Affective - irritable and tense, poised to attack first, hold grudges, fear losing power or control of others
    • Sociocultural - cold and aloof to avoid intimacy
    • Overpersonalize - think get personal meaning from something someone said even when there wasn't any
    • Projection - defense mechanism; has self hate and projects it onto other person (they think that person hates them)
    • As children, had history of parental antagonism, harassment, and aggression; raised in unpredictable home
    • Explain procedures to these patients; don't use a lot of jargon; don't be overly friendly just be matter of fact
  7. Schizoid personality disorder
    • Defect in ability to form personal relationships or respond to others in a meaningful way
    • Behavioral - social withdrawal; little interest in social activities
    • Affective - restricted range of emotional expression, anxious, flat affect
    • Cognitive - vague, indifferent to praise, criticism
    • Sociocultural - cold, aloof, no desire for close friends
    • Emotionally detached (most likely don't have a spouse because of this)
    • May have some poverty of thought (no depth to conversation, shallow and concrete thinking)
  8. Schizotypal personality disorder
    • More impaired than schizoid but less impaired than schizophrenia (don't have persistent psychosis)
    • Behavioral - odd, eccentric, vague, elaborate speech
    • Affective - emotionally constricted, inappropriate
    • Cognitive - paranoid ideations, ideas of reference, illusions
    • Sociocultural - discomfort with intimacy, others avoid them
    • History of being overlooked, rejected, and often have low self-esteem
  9. Nursing interventions for cluster A
    • Client autonomy - respect that they have personality disorders and you aren't going to change them
    • Help recognize affect of behavior
    • Long term
    • Recognize potential
    • Self-assessment - avoid negative countertransference; they may try to project their thoughts onto you
    • Body language should be congruent with verbal
    • Low doses of antipsychotics can help
    • Be clear, consistent, genuine, gentle, nonintrusive
    • Respect distance and privacy
    • Encourage interaction
  10. Cluster B
    • Dramatic, emotional or erratic
    • Characterized by impaired social interaction related to manipulation of others, unstable mood, poor impulse control, extreme emotional reactions, seductive behavior
    • High risk of self-directed violence and violence at others related to intense emotional pain including anxiety, rage, sense of emptiness, poor impulse control
    • Cognitive distortions
    • Disturbed sense of self; can't describe themselves
    • Anxiety related to feelings of abandonment or perceived abandonment (reaction can be in form of self-mutilation)
    • Antisocial
    • Borderline
    • Histrionic
    • Narcissistic
  11. Antisocial personality disorder
    • Pattern of disregard for and violation of the rights of others, socially irresponsible, exploitive, guiltless behavior
    • Commit crimes, violate laws, steal, manipulative
    • No remorse
    • Tend to label people or group of people
    • Use rationalization defense mechanism
    • Childhood - lying, stealing, vandalism, fighting, running away; usually have unstable home; parental deprivation (never develop moral stage of Kohlberg development)
    • Adult - failure to conform to law and maintain consistent employment; easily bored
    • Affective - superficial emotions, no guilt, irritable, aggressive
    • Cognitive - egocentric, grandiose, no conscience
    • Highest risk for perpetrating domestic violence, stealing, having sex with patients on unit
    • Impaired social interaction related to disregard of others
  12. Nursing interventions for antisocial personality
    • Important to have self-awareness
    • Strict limit setting
    • Have one primary nurse (any change in rules needs to go through this one person to avoid staff splitting)
    • Provide external structure for them until they develop internal controls
  13. Borderline personality disorder
    • Emotional dysregulation
    • Pattern of instability in interpersonal relationships
    • Behavioral - unpredictable, manipulative, self-destructive, self-mutilation
    • Affective - intense, unstable mood
    • Cognitive - feelings of emptiness, lack of sense of self, dichotomous (all or nothing thinking)
    • 5x more likely in 1st degree relatives
    • 3x more likely in women
    • Tend to repress memories; have very exaggerated response if memories are brought up abruptly
    • Can't stand to be alone because of dysregulated sense of self
    • Chronic depression
    • Easily bored
    • Self mutilation to decr anxiety - don't respond to their cutting with empathy or give attention to it
    • Fear of abandonment or perceived abandonment
    • Often will fire their therapist because are afraid of rejection
    • Risk for suicide because of extreme emotional response
  14. Dialectical Behavioral Therapy
    • One of few treatments affective for borderline personality
    • Cognitive behavioral approach that points out discrepancies in pt's thinking (cognitive distortions)
    • Teach skills so before self-mutilate, they should call their coach to discuss other options
    • 5 categories of dysregulation:
    • Emotions
    • Relationships
    • Behavior
    • Cognition
    • Sense of self
  15. Histrionic personality disorder
    • Pattern of excessive emotionality and attention seeking
    • Very dramatic, theatrical
    • Behavioral - center of attention, superficial
    • Cognitive - feelings as opposed to logic
    • Sociocultural - victim, require constant approval/acceptance
    • Vain, self-indulgent, demanding
    • Self-mutilation for attention
    • Tend to use regression
  16. Narcissistic personality disorder
    • Pattern of grandiosity, need for admiration, lack of empathy, exaggerated sense of self-worth
    • Labile mood varying from anger to anxiety
    • Very sensitive to criticism
    • Arrogant, egotistical
    • Disturbed relationships due to use of others, own needs more important
  17. Strategies for Cluster B
    • Patience
    • Consistent and structured; primary nurse
    • Safety
    • Set limits to give external structure
    • Staff conferences, supervision
    • Help client recognize fear of abandonment, distortions, signs of anxiety
    • Help client recognize dichotomous thinking
    • Encourage direct communication
    • Help client recognize needs of others
    • Teach regulation of behavior, emotions, thinking
    • Don't personalize their behaviors
  18. Cluster C
    • Anxious or fearful
    • Ineffective coping related to high dependency needs, rigid behavior and thoughts, fear of rejection
    • Fear of abandonment, disapproval, or losing control
    • Avoidant
    • Dependent
    • Obsessive-compulsive
    • Passive aggressive
  19. Avoidant personality disorder
    • Pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation
    • Behavior - avoid others and new situations, sensitive to rejection
    • Affective - fearful, shy, low self-esteem
    • Cognitive - view of self as inferior, fear of shame and criticism
    • Sociocultural - few close friends
    • Socially uncomfortable, so may abuse substances
    • Won't seek tx unless parent or friends brings them
  20. Dependent personality disorder
    • Pattern of permissive and clinging behavior related to need to be taken care of
    • Very dependent, want to be taken care of
    • Will be very compliant as long as you take care of them
    • Lack of self-confidence
    • Strive to obtain support
  21. Obsessive compulsive personality disorder
    • Pattern of preoccupation with orderliness, perfectionism and control
    • Routine, overly involved with details, perfectionistic, inflexibility
    • Rigid, stubborn, emotionally constricted
    • Not as impaired as OCD
    • Can't delegate
  22. Strategies for Cluster C
    • Point out avoidance
    • Provide problem-solving and assertiveness
    • Encourage expression
    • Help to recognize need for control
    • Help to recognize feelings of inadequacy
    • Encourage functional expression instead of drama and avoidance
  23. Psychopharmacology
    • No pharm tx other than to treat symptoms
    • Antipsychotic meds - low doses for agitation, rage, brief psychotic episodes (cluster A and borderline)
    • Tricyclic antidepressants - cardiotoxic in overdose, so avoid giving to person with poor impulse control
    • Effexor, fenlafaxine - cardiotoxic
    • SSRIs for OCD
    • Benzos - danger of overdose and abuse
    • Buspar (antianxiety) - not as effective because are slow acting
    • Lithium and other mood stabilizers - decr mood and aggressiveness in cluster B
Card Set
Personality Disorders
Psych Exam 3 - Personality Disorders