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What are some common characteristics of personality disorders?
- Needy
- Pose many challenges to care providers
- Often lack ability to change
- Unable to tolerate frustration, pain
- Overreact to stimuli
- Unable to identify feelings properly
- Occur in 10-18% of population
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Four primary characteristics of personality disorders?
- Maladaptive responses to stress (stress reducing strategies may not work)
- Disability in working and loving
- Evokes interpersonal conflicts
- Has an intense effect on others
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DSM IV-TR criteria for personality disorders
- Pattern is manifest in two or more areas:
- Cognition-thinking
- ways of perceiving self, others and events
- Affect -feeling
- range, intensity, labiality and appropriateness of emotional response
- Poor interpersonal functioning
- Poor impulse control
- Affects personal, social, and occupational functioning, but maybe not to the point of not being able to function at all.
- Clinically significant distress
- Onset can be traced to adolescence or early adulthood
- Inability to attach to others
- Manipulative of others
- Gets into power struggles
- Fears closeness
- Disturbance in “who they are” (self-identity)
- Personality disorder vs. characteristics or traits
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What are some nursing interventions for personality disorders?
- Protection from self-harm
- Establishing a therapeutic relationship
- Family involvement
- Milieu therapy
- Limit setting and structure, and boundaries. Don't get manipulated.
- Focusing on strengths
- Behavioral interventions
- Coping skills
- Dialectical Behavioral Therapy*
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DSM IV Paranoid personality disorder
- Pattern of suspicion with 4 or more of:
- Expects exploitation
- Preoccupied with unjustified doubts about loyalty of others, hypervigilant for betrayal
- Reluctantly confides in others
- Fears others will use info against them
- Reads hidden meaning into benign remarks
- Bears grudges
- Perceives attacks on character not apparent to others; quick to counterattack
- Suspicious without justification
- Cold, aloof, objective
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Nursing interventions for paranoid personality disorder?
- Build relationship – with skill and caution! (Again, remember boundaries)
- --Follow through with promises
- --Maintain boundaries
- Teach
- --Clarification and validation/restatement
- --Constructive outlets for stress
- --Social skills
- Give permission to have feelings and help them cope appropriately
- Confront excessive self-importance if needed
- Ask indirect questions & let them set the interpersonal distance
- Be consistent as a team of care providers
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Antisocial personality disorder?
- Disregards and violates rights of others since age 15 (Until age 18 -- Conduct Disorder)
- Possess 3 of:
- --Failure to conform to social norms/law
- --Deceitful, repeated lying or conning of others
- --Highly impulsive
- --Irritable and aggressive; gets into fights
- --Disregards the safety of others
- --Irresponsible, unable to work or honor financial obligations
- --Lack of remorse
- --Does not profit from experience – a key component
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Nursing interventions for antisocial?
- Intervene in manipulation and impulsivity
- Direct confrontation. Don't beat around the bush and make sure there are definite and immediate consequences.
- Point out responsibility
- Set limits and establish consequences
- Encourage to talk things out rather than act out
- Encourage pt to accept responsibility for behavior
- Teach social skills
- Group therapy preferred
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Borderline personality disorder
- Has unstable interpersonal relationships
- Highly impulsive, ie inappropriate, intense anger, frequent displays of temper -- impulsive aggression is the hallmark
- Poor self-esteem
- 5 of:
- --Avoids abandonment
- --Identity disturbances
- --Unstable, intense relationships: overvalues and devalues others
- --Excess behaviors: spending, sex, substance abuse, reckless driving, binge eating
- --Suicidal behavior or self-mutilating
- --Affect instability or emotional labiality
- Chronic feelings of emptiness
- Suspiciousness or dissociative symptoms
- Uses splitting with others-
- Switches between opposite sides of conflicts, overvaluing/devaluing, denies responsibility for acting out, devalues others to make self look better, idealizes positive traits in others, projects parts of self onto others and acts out the parts
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Nursing interventions for Borderline PD?
- Dialectical Behavioral Therapy: life skills, 1:1 therapy, 12 weeks therapy groups.
- Social skills
- --Anger management strategies
- --Mindfulness
- --Stress management
- Avoid splitting, use consistency among staff
- Avoid being alone with them if possible
- Support staff who are the brunt of their anger and acting out
- Set limits on impulsivity
- Group therapy
- Monitor suicidality – How?
- Monitor self-mutilation – How?
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What is Narcissistic PD?
- Grandiose but with underlying fragile self-esteem
- Lacks empathy
- 5 of:
- Exaggerated self-importance
- Preoccupied with fantasies of unlimited success
- Believes they are “special”
- Requires excessive admiration
- “Entitled”
- Exploitative
- Envious of others
- Arrogant and haughty
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Nursing interventions for pt with Narcissistic PD?
- Gain a therapeutic alliance-Will they listen to you?
- Teach social skills
- Assist with appropriate self-esteem
- Assist in putting self in others place
- Deal with manipulations
- Confront exaggerated self-importance – offer a reality check!
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What is Histrionic PD?
- Excessively emotional
- Seeks constant attention
- 5 of:
- Seek to be the center of attention
- Seductive
- Rapid shifts in emotion; can be shallow or exaggerated
- Uses appearance to draw attention
- Dramatic, theatrical
- Is suggestible
- Considers relationships more intimate than they are
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Nursing interventions for Histrionic PD?
- Give attention when not demanding it
- Withdraw attention when behavior is inappropriate
- If threatens self-harm, take action
- Point out inappropriate behavior
- Protect staff members of opposite sex from patient’s advances. Do not treat pt with opposite sex nurse and work in pairs.
- Remove from “audience” if needed
- Set limits on seductiveness
- Focus attention away from somatic complaints
- Assist to focus on own problems
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What is Dependent PD?
- Excessive need to be taken care of
- Is submissive and clingy
- Fears separation
- 5 of:
- Has difficulty making decisions
- Needs excessive advice
- Needs others to assume responsibility for major life areas
- Has trouble disagreeing
- Has trouble initiating projects
- Goes to lengths to obtain nurturance and support
- Feels helpless when alone
- Exaggerated fears of not being able to care for self
- Seeks another caretaking relationship when one ends
- Unrealistically preoccupied with fears of being alone and taking care of self
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Nursing interventions for Dependent PD?
- Ascertain level of functioning and set realistic goals with patient
- Teach problem-solving
- Teach self-reliance
- Reward any independent action
- If necessary, relocate away from people who tend to keep patient dependent
- Meet some dependency needs and move toward independence
- Acknowledge and allow to express feelings safely
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What is Obsessive-Compulsive PD?
- Preoccupied with orderliness, perfectionism, and interpersonal control at the expense of efficiency and emotional availability
- 4 of:
- Preoccupied with details, organization
- Perfectionism that interferes with task completion
- Excessively devoted to work, excludes play and people
- Overly conscientious
- Inflexible
- Cannot delegate tasks unless others submit exactly to their way of doing things
- has a miserly spending style
- is rigid and stubborn
- the job is important, relationships are not
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What are some nursing interventions for a pt with OCPD?
- Assist to become aware of and deal with feelings
- avoid power struggles
- teach assertive skills
- help them to “lighten up”
- build in positive structure
- assist with decision making
- teach empathy (place in other’s shoes)
- guard against their manipulation
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What is avoidant PD?
- Pattern of social inhibition
- Feels inadequate
- Is hypersensitive to criticism
- Has 4 of:
- Avoids work where there is criticism, disapproval, rejection
- Need guaranteed acceptance/liking before will invest in friends
- Restrained with intimate relationships
- Sensitive to criticism or rejection
- Views self as socially inept, takes few risks
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Nursing interventions for Avoidant PD?
- Assist in improvement of self-image
- Teach social skills
- Support interaction with others
- Support risk taking with others
- Teach assertiveness
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What is the #1 intervention for patients with personality disorders?
- Dialectic Behavioral Therapy.
- Other primary therapies are:
- Protection from self-harm
- Establishing a therapeutic relationship
- Family involvement
- Milieu therapy
- Limit setting and structure
- Focusing on strengths
- Behavioral interventions
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T/F: Drugs are not typically helpful for pts with PDs.
- True.
- They are prescribed anyway, i.e.:
- SSRIs
- Benzos
- Antipsychotics
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