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Define personality
- from the latin term persona
- means theatrical mask
- personality disorders are axis 2 diagoses
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Historically, how were personality disorders classified?
- 1801 first recognition, referred to as moral insanity
- An individual can behave irrationally even when their powers of intellect are intact
- previously called character disorders
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What are the four characteristics of personality disorders?
- 1. Inflexible, maladaptive response to stress
- 2. Disability in working and loving
- 3. Ability to evoke interpersonal conflict
- 4. Capacity to get under the skin of others
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Where do personality disorders fall on the mental health continuum?
Fall to the right of the continuum, right before psychosis
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What are the three classifications of the 10 personality disorders according to the DSM 5?
- Cluster A: odd or eccentric behaviors (paranoid, schizoid, schizotypal)
- Cluster B: Dramatic, erratic or emotional behaviors (borderline, histrionic, narcissistic, antisocial)
- Cluster C: Anxious or fearful behaviors (Avoidant, dependent, obsessive-compulsive)
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Describe the odd/eccentric personality disorder (Cluster A)
- Paranoid: people suspicious of others (more men than women)
- Schizoid: people who do not enjoy social relationships and usually have no close friends. (more men than women)
- Schizotypal: the same as schizoid, but they also show eccentric thoughts and behaviors which can be considered a milder version of the symptoms of schizophrenia. Often aloof, bizarre, superstitious, magical thinking
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What criteria does the DSM-5 give for Paranoid Personality Disorders (cluster A)?
- Four of the following:
- expects exploitation
- questions loyalty and trustworthiness of friends
- reads hidden meaning into innocuous events
- holds grudges
- reluctant to confide
- easily slighted, quickly responds with anger
- questions spouses fidelity
- You may also see: constantly on guard, overly sensitive, testing honest of others, hyper vigilant, tense, irritable
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What traits may be displayed by a client with Paranoid personality disorder? Describe treatment
- Intense insecurity r/t real or perceived inferiority
- lack of maternal bonding
- chip on their shoulder
- often used as scapegoats as children
- The rarely seek treatment due to their mistrust, view everyone else as the problem
- Psychotherapy most often used
- Medications often not used because it can arouse suspicion, but anti-anxiety meds may be used for those with high anxiety
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What is the DSM-5 criteria for Schizoid Personality Disorder (cluster A)?
- Four of the following:
- no desire for close relationships
- prefers solitary activities (often intellectual pursuits)
- no strong emotions (detachment)
- indifferent to praise/criticism
- little interest in sexual contact
- flat affect
- inappropriately serious about everything, shy, aloof, no spontaneity
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What is the DSM 5 criteria for Schizotypal PD?
- 5 of the following:
- ideas of reference (excluding delusions of reference)
- odd beliefs/magical thinking that influences behavior and is inconsistent with norms
- Unusual perceptual experience - body illusions
- Odd thinking and speech
- suspicious or paranoid ideation
- (often superstitious with social anxiety)
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What is the schizophrenia continuum?
- Common among first degree relatives of individuals with schizophrenia
- Close link between schizotypal and schizophrenia
- Lack of bonding, families were indifferent, formal, lead to discomfort with affection and closeness
- Lack of social skills: shunner, overlooked, rejected, humiliated by others...begin to tune out reality because fantasy is better. Low self-esteem, distrust of interpersonal relations
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What interventions can be done for Cluster A personality disorders?
- Be aware of client isolation, suspiciousness
- Avoid being too nice, overly friendly
- Use neutral, kind approach
- Clear, straight forward explanations
- Simple, clear language
- Give warning about changes, reasons for delay, medication side effects
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Describe Cluster B disorders
- Borderline (most common PD): intense emotionality, unstable identity and impulsivity. Typically, attitudes and feelings about other people considerably vary for no apparent reason
- Histrionic (formerly hysterical): the key feature of histrionic PD is overy dramatic and attention-seeking behavior
- Narcissistic: people that have a grandiose view of their abilities and are preoccupied with fantasies of great success. They want to be admired. Self centered
- Antisocial (psychopathy) (oldest recognized disorder): disregard for the rights of others. Show irresponsible and antisocial behavior. irritable and aggressive. Absence of empathy and a lack of feelings of guilt after a transgression.
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For anti-social personality disorder, what are the s/s?
- Often a history of conduct prior to age 15
- At least 4 of the following:
- unstable work history
- fails to conform to social norms (illegal actions)
- irritable and aggressive
- fails to honor financial obligations
- fails to plan ahead (homeless)
- no regard for the truth
- irresponsible parenting style
- not able to sustain monogamous relationships
- lacks remorse (charming and intelligent on surface)
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What the DSM-5 criteria for Antisocial PD?
- Since the age of 15 there has been a disregard for and violation of the right's of others, those right's considered normal by the local culture, as indicated by at least 3 of the following:
- -repeated acts that could lead to arrest
- -conning for the pleasure of profit, repeated lying, or the use of aliases
- -failure to plan ahead or being impulsive
- -repeated assaults on others
- -reckless when it comes to their or other's safety
- -Poor work behavior or failure to honor financial obligations
- -Rationalizing the pain they inflict on others
- Must be at least 18 yrs of age
- Evidence of conduct disorder with its onset before the age of 15
- Symptoms not due to another mental disorder
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What factors predispose someone to antisocial PD?
- Often physical abuse
- Absence of parental discipline/erratic discipline
- Extreme poverty
- Removal from the home
- Growing up without parental figures of both sexes
- Maternal deprivation
- Being rescued every time they were in trouble-no consequences
- More men than women
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What interventions can be done for antisocial PD?
- set clear, realistic limits on specific behaviors
- all limits adhere to by all staff
- use of many staff for appearance of strength and control
- document objective physical signs of manipulation or aggression
- provide clear boundaries, consequences
- guard against letting client make you feel guilty
- guard against being manipulated
- Screen for dangerous objects
- Group therapy is best option, but no therapy is truly successful
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What is the DSM-5 criteria for Borderline PD?
- 5 of the following:
- intense fear of abandonment
- unstable, intense personal relationships
- marked impulsivity*
- affective instability
- anger problems
- chronic suicidal ideation, self mutilation
- Boredom
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What are the s/s of Borderline PD?
- intense, unstable mood
- chronic, underlying depression
- anger- directed at staff or others
- Fear of abandonment
- Clinging and distancing
- splitting***
- manipulation
- umpulsivity
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What are the biological and psychodynamic components of borderline PD?
- Biological: genetic predisposition. Relationship with affective disorder. Serotonin disturbance. More women than men
- Psychodynamic: border between neurosis/psychosis
- Mahler's theory of object relations- a child is rewarded for dependent behaviors and punished for independent ones
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What is the most common defense mechanism for clients with borderline PD?
- Cognitive distortions
- Dichotomous thinking or splitting*
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What interventions can be done for borderline PD?
- Set clear, realistic goals
- be aware of manipulative behaviors
- clear, consistent boundaries/limits
- for behavioral problems, review therapeutic goals and treatment boundaries
- avoid rejecting, rescuing
- assess for suicidal, self mutilating behaviors (suicide precautions)
- Long term family, cognitive therapy
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What is the DSM-5 criteria for Histrionic PD?
- 4 of the following:
- constantly seeks attention
- inappropriately sexually seductive
- over concerned with appearance
- expresses emotion with exaggeration
- uncomfortable when NOT the center of attentions
- shifting and shallow emotions (easily angered)
- self-centered*
- superficial
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What is the mnemonic PRAISE ME for histrionic PD?
- P rovacative or seductive behavior
- R elationships considered more intimate than they are
- A ttention, must be the center of attention
- I nfluenced easily
- S peech that impressive, lacks detail
- E motionally labile, shallowness
- M ake-up that puts draws attention to the physical appearance
- E exaggerated emotions, theatrical
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What is the DSM-5 criteria for Narcissistic PD?
- 5 of the following:
- reacts to criticism with rage and humiliation
- exploitative in relationships
- grandiose
- believes their problems are unique
- preoccupied with fantasies of greatness
- sense of entitlement
- lacks empathy
- envious
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What interventions can be done for narcissistic PD?
- Stay neutral, avoid power struggles
- Don't be defensive when disparaged
- Convey unassuming self-confidence
- Group and cognitive therapy
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What interventions can be done for Cluster B personality disorders?
- Focus on SAFETY, maintaining a stable mood, and effective social interactions
- NO primary nursing
- openly discuss manipulation
- MUST communicate between shifts
- limit setting- clear, consistent, enforceable
- avoid power struggle
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Describe Cluster C personality disorders
- Avoidant personality disorder: fear of rejection of criticism
- Dependent personality disorder: excessive reliance on others
- Obsessive-compulsive personality disorder: perfectionistic, detail-oriented style
- *Research of disorders in this cluster have focused on parents. Transmission of fear from parents to child, whether avoidant or dependent relationships
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What is the DSM-5 criteria for Avoidant PD?
- 4 of the following:
- easily hurt, insulted
- no close friends
- unwilling to get involved unless they will be liked
- socially uncomfortable, *sensitive to rejection
- fears being embarrassed
- exaggerates dangers/risks
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What does avoidant PD look like? What are some predisposing factors?
- Awkward individuals
- Slow, fragmented speech
- Lonely and feel unwanted
- Predisposing factors:
- parental rejection, reinforced by peers
- reared in homes where they are belittled, abandoned, criticized
- feelings of low self- worth
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What is the DS-5 criteria for Dependent PD?
- 5 of the following:
- unable to make decisions
- agrees with others, even if they are wrong
- needs others to assume responsibility for major areas of their life
- difficulty initiating anything on own
- volunteers in order to gain acceptance
- uncomfortable being alone
- urgently seeks another relationship when one ends
- unrealistically preoccupied with being abandoned
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What are the s/s of dependent PD?
- Have a lack of self confidence that is apparent in their voice, posture and mannerisms
- Typically passive
- Assume submissive role
- Will do anything to earn the acceptance of others, even if unpleasant
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What is the DSM-5 criteria for Obsessive-compulsive PD?
- 5 of the following:
- perfectionist
- details, rules, lists
- insists on doing it their way (stubborn)
- excessive devotion to work
- inflexible
- restricts affection
- lacks generosity, stingy
- unable to discard old objects
Affects more men than women, common in first borns
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Describe what obsessive-compulsive PD looks like
- Experts at learning what they must do to avoid punishment and receive praise (learned from childhood expectations)
- Often a preoccupation with time/planning
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What interventions can be done for cluster C personality disorders?
- focused on:
- anxiety reduction
- social interaction
- indecisiveness
- problem-solving skills
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Describe Passive Aggressive PD. What is the etiology? Give a example
- Pervasive patterns:
- -negative attitudes and passive resistance
- people are passively expressing covert aggression
- -relatively common
- Etiology:
- -inconsistent responses from parent
- -double bind communication
- Example:
- purposefully being late
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