-
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
-
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
-
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
-
Characteristics
- Manifested in impairment in four areas:
- Behavioral
- Affective
- Cognitive
- Sociocultural
-
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
-
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
-
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)
-
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
|
|
