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Personality Disorders Overview Lifelong, inflexible, and dysfunctional patterns of relating and behaving Patterns interfere with daily life Client often does not recognize own dysfunction Interpersonal and occupational problems result Overview Diagnosis is on Axis II If admitted to an inpatient facility must have an Axis I diagnosis also (e.g. alcoholism, depression) Difficult to treat Most are treated outpatient in individual or group therapy Often seen in drug treatment centers Overview: Interpersonal Characteristics Relationships Often experience conflict with others May have difficulty initiating or sustaining relationships Cause distress to others only become distressed when others react to them negatively Affective/Cognitive Characteristics Anxiety: Varies in the different clusters. Behavior is way of coping with anxiety and the individual does not consider how their behavior will affect others. Cognitive issues: Rigidity of responses--difficulty in adapting to the new or unexpected Mistakes in judgment Lack of insight Gender and Personality Disorder Diagnoses Female: greater percentage of Borderline or Histrionic diagnoses Male: greater Percentage of Paranoid, Schizoid, Antisocial, and Narcissistic dx. Grouped by the Three Clusters of Behavior in the DSM IV-TR Cluster A Cluster B Exhibit odd and eccentric behaviors Exhibit dramatic, emotional and erratic behaviors. Cluster C Exhibit anxious, fearful behaviors Cluster A (Odd-Eccentric) Characteristics: odd, eccentric behavior, suspicious ideations, and social isolation. Know this cluster as a group (do not have to recognize each individually) Schizoid P.D. Schizotypal P.D. Paranoid P.D. Cluster A Overview Similarities to schizophrenia But no fixed delusions or hallucinations May have transient psychotic symptoms when under acute stress May have biological family member with schizophrenia Cluster A, cont’d Schizoid Lacks desire to be close to others Lacks close friends Solitary activities Little interest in sexual activity Appears cold and detached Appears indifferent to praise or criticism Schizotypal Ideas of reference Magical thinking or odd beliefs Unusual perceptual experiences including bodily illusions Odd thinking and speech Odd or eccentric appearance or behavior Suspicious, social anxiety Few close relationships Cluster A, cont’d Paranoid P.D. Secretive, fearful and distrustful. Reads hidden meaning into benign statements or events Reluctant to confide in others; fears information will be used against him/her Suspicious about fidelity of spouse or S.O. without justification Perceived attacks on character or reputation Bears grudges; responds to threats with anger Photo from film: “Meet the Parents” with Ben Stiller and Robert De Niro Cluster A: Nurse-client Relationship Building trust is most important Be honest; keep it simple Do not intrude on privacy, if possible Do not challenge odd beliefs or appearance Cluster A: Milieu Do not push into social or group activities, but give gentle encouragement Choose groups that are non-threatening What Should the Nurse Say/Do? A recently admitted client is refusing to eat in the cafeteria with others, stating, “The cafeteria food is different. And those people don’t want me. Why can’t I eat on the unit?” Cont’d A) B) C) D) E) (Choose all that apply) “There is nothing wrong with the cafeteria food.” “You need to go over to the cafeteria if you want to eat.” “I’ll walk with you to the cafeteria.” “Why do you think they don’t want you?” “It can be hard to get comfortable when you are new.” Cluster B (Dramatic, Emotional, Erratic) Characteristics: Impulsive, dramatic behavior, intolerance of frustration, and exploitative interpersonal relationships. (Know Antisocial, Borderline and Narcissistic) Histrionic P.D. Narcissistic P.D. Antisocial P.D. Borderline P.D. Is most commonly dx’d. P.D. Cluster B Histrionic Needs to be center of attention Dramatic and provocative Overreacts to minor events Easily influenced by others Superficial relationships Narcissistic Grandiose Fantasies of unlimited power, success or brilliance Needs to be admired Sense of entitlement (deserves special treatment) Lacks empathy Takes advantage of others to meet own needs Interventions for Histrionic or Narcissistic P.D. Set appropriate limits Be consistent in approach Be matter-of-fact Focus on here-and-now Use supportive confrontation for discrepancies and contradictions Support self-esteem (does this seem like a contradiction?) What Should the Nurse Do/Say? 1) Client (stomps foot and makes faces while talking): “I need the day room for my exercise routine. You people have to realize that I am in modeling and this is important to my career.” (Nurse uses a matter-of-fact approach) What Should the Nurse Do/Say? 2) Client: “I am depressed because I have no true friends in my life. And even my roommate here is so rude to me. What a fat slob! I want to room with someone else.” (Use supportive confrontation) Cluster B, cont’d Antisocial Personality Disorder Diagnosis is based on disordered behavior: Pattern of disregard of the rights of others Non-conforming to rules Often found in criminal justice system rather than in mental health services May seek hospitalization to avoid the law Antisocial Personality Disorder: Cognitive and Affective Aspects Low tolerance for frustration; cannot delay gratification of impulses Unable to make long-range plans Deny and rationalize behavior Little guilt or remorse May be aggressive or abusive Antisocial Personality: Interpersonal Aspects May appear charming and confident, but with little personal involvement Self-interest comes before needs of others Unable to sustain close personal relationships. Sex life is impersonal and impulsive. Antisocial Personality: Etiology Genetic: inherited trait or predisposition CNS ANS under-responds to stress Low activity in frontal lobe Unable to learn from rewards and punishment History of disordered life functioning Parent-child relationship often is unstable Childhood characteristics of lying, stealing and being truant. Client Scenario A 24 year old unemployed male was admitted from jail to the mental health unit after a suicide attempt in his cell. In jail, was awaiting sentencing for burglary: stole from the apt. of his former girlfriend; also was abusing cocaine. States to the nurse that his problems started after she broke up with him: “She owed me, and so I took some cash and stuff.” The client has a distressed affect when discussing current situation: “Now they’re putting a label of ‘crazy,’ on me.” Antisocial Personality Disorder: Interventions Essential for staff to agree on rules and stick with them Will try to play one staff or shift against another Set firm limits Point out effect of behavior on others Point out consequences of behavior Best form of treatment: Peer counseling and self-help groups like AA, where peers can confront and offer feedback What Should the Nurse Say/Do? A client who is involuntarily in treatment on the inpatient unit was found smoking in the bathroom. A few days later the client’s visitor smuggles in some alcohol, which he and roommate consume. A hospitalized client is verbally abusive and uncooperative with select staff members, but is friendly and cooperative with others. Complains to you about the “nasty staff.” Cluster B, cont’d: Borderline Personality Disorder Most commonly diagnosed Personality Disorder Borderline Personality Disorder: Overview Characterized by: Extremely intense and variable moods Disturbed sense of self; often self-negative Impulsivity, often with self-destructive behavior Use of “splitting” (also called “black or white thinking”) as defense mechanism Borderline Personality Disorder DSM IV-TR Criteria Fear of abandonment and frantic efforts to avoid it Unstable, intense relationships Marked identity disturbance Chronic feelings of emptiness Impulsivity that may be self-damaging These behaviors help them to feel better for a short period of time Borderline Personality Disorder DSM-IV TR Criteria When under stress may experience transient, paranoid thoughts or delusions, or dissociative symptoms These will resolve when the stress is relieved DSM IV-TR Criteria, cont’d. Recurrent Self-Destructive Behavior Affective instability Suicidal threats & gestures Self-Injurious Behavior (SIB) Rapid mood shifts Low frustration tolerance Problems with anger Borderline PD: Etiology A predisposition, plus childhood experiences, is current accepted theory Childhood Environment: often chaotic or neglectful Strong evidence for abuse, trauma history Neurobiological: (cause or result of stress?) Serotonin dysregulation cholinergic and adrenergic abnormalities lack of integration of right and left hemispheres smaller hippocampal volume decreased volume of prefrontal cortex Issues for Borderline Personality: Splitting Phenomenon Low tolerance for ambivalence Inability to cope with conflict Sense of identity is obtained from others Result in this perspective: I Either you are good or you are bad (no inbetweens) When you are not perfect, you have failed me and you are bad (that means I’m no good, either) Issues for Borderline, cont’d Interpersonal Relationships Unstable and intense Characterized by over-idealizing or devaluation of others Cannot resolve feelings that others are not perfect and cannot meet all of their needs Fear being abandoned; may be needy and dependent Issues for Borderline PD, cont’d Functions of Self-injury: Is self-punishment Relieves tension Improves mood Is evidence that they are real, and can feel Suicide risk is high due to: Self-injuring behaviors Severe emotional pain Impulsivity BPD: Nurse-client Relationship Consistency, trust, honesty Explain and then Enforce unit rules Team approach: Minimize splitting of staff Be accepting, Be matter of fact, Do not show anger or irritation. (Transference phenomenon is common in these clients) Convey empathy Nurse-client Relationship, cont’d Discuss how to express and handle feelings Encourage self-responsibility and appropriate behaviors Offer choices, when possible Give positive feedback for accomplishments and progress Don’t get discouraged by opposite behaviors Do not minimize or ignore SIB; assess for suicide Borderline Personality: Milieu Provide safe environment based on ongoing assessment; suicide precautions if necessary Groups: Coping skills, Expressive Arts Journaling: Promotes safe identification of own thoughts, feelings and actions Issues for Therapy Frequently have long-term issues of abuse, trauma, neglect An advanced practice Health Care Provider can assist the client in talking about these events in individual or group therapy on long-term basis BPD: Group Therapy Clients make good group members; can be very insightful for others Decreases transference issues. Feedback from group can be helpful in dealing with unrealistic expectations. Attention-seeking behavior and entitlement issues are dealt with better in group. What Should the Nurse Say/Do? A client with a history of self-injury visited this evening with family. She is later found in her room, having cut her abdomen with a plastic fork she had taken from her meal tray. She says to the nurse, “My parents told me I can’t come back home because they can’t handle me.” What Should the Nurse Say/Do? The client is placed on Close Observation status for SIB and has a sitter. At midnight, she expresses anger to the night shift nurse that she can’t sleep due to staff having to watch her. “I am being treated like a criminal. If the evening shift nurses really cared about me they would not have done this to me. ” Legal-Ethical Critical Thinking If a client who self-injures has a history of abuse or trauma, what are the implications for use of restraints and emergency management? BPD: Community Resources AA, ACOA Family education and support groups, too Cluster C: (Anxious-Fearful) Dependent Personality Disorder Pervasive, excessive need to be taken care of Feels unable to care for self, little selfconfidence Fears being alone and helpless Unable to make decisions without much support Fears loss of approval; will agree or will perform tasks to avoid rejection Cluster C, cont’d Avoidant Personality Disorder Fears making mistakes Fears disapproval and rejection Severe shyness and feelings of inadequacy and being disliked Socially uncomfortable and withdrawn Obsessive Compulsive Personality Disorder Perfectionistic and inflexible Preoccupied with details Too busy to have fun or friends Hoards objects and money Nursing Interventions for Cluster C Assist in setting small, achievable goals Discuss fears and feelings prior to meeting a goal Assist to explore feelings Assist to try new activities Assist to decrease anxiety and need for perfection Cluster C: Milieu Management Groups: Assertiveness training, Stress management, Leisure skills Most clients seen as outpatients What Should the Nurse Say/Do? A client with Cluster C traits is trying to learn how to be more confident and assertive and has a list of goals he wrote after attending a group on the unit. He asks the nurse what goal he should choose to work on first. Here is the client’s list: 1) improve my life 2) eat breakfast with other people every other day 3) identify one good thing about myself 5) find a woman who really cares What Should the Nurse Do/Say? A) “Oops, you missed putting a # 4 on the list.” B) “#3 is a good goal. Try that one first.” C) “What other ways can you work on your issues than writing a list?” (Can you identify a more helpful response? What is the rationale for the response?) Personality Disorders Pharmacological Interventions Medications address severe, disabling symptoms. Medications do not cure P.D.s Primarily used when client in emergency or crisis (PRN or short-term) Examples: Suicidal behavior Transient psychosis Assaultive behavior Severe anxiety episode Personality Disorders Psychopharmacology, cont’d Low doses of some medications may be indicated e.g. antipsychotic agents for paranoia; mood stabilizers or SSRIs for Borderline Personality Disorder, etc. Treat co-morbid Axis I diagnoses: Depression, Anxiety Disorders, Bipolar Disorder, etc. Evaluation of Interventions How can the nurse evaluate effectiveness of interventions for the person who has a personality disorder? Expectations (i.e. your goals) should be realistic What behaviors can change within a shortterm hospital stay?