Download Behavioral - San Jose State University

San Jose Police Crisis
Training
Personality Disorders
May 14, 2008
Phyllis M. Connolly PhD, APRN- BC, CS
Professor of Nursing
San Jose State University
[email protected]
408-924-3144
Questions to Consider
 What behaviors have you observed in folks that you
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think might be diagnosed with a personality
disorder—your stories?
What are the qualities of a healthy personality?
How do symptoms differ for persons with
personality disorders versus behaviors you are
likely to encounter in persons with schizophrenia or
mood disorders?
What strategies are useful when dealing with
anger?
How do you respond when you feel as if you are
being manipulated?
What can you do for yourself to increase your
effectiveness when dealing with people with
personality disorders?
Qualities of Healthy Personality
 Positive & accurate
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body image
Realistic self-ideal
Positive self-concept
High self-esteem
Satisfying role
performance
Clear sense of identity
Personality “persona”
 Complex pattern psychological characteristics
 Not easily eradicated
 Expressed automatically in every facet of
functioning
 Biological dispositions & experiential learning
 Distinctive pattern of perceiving, feeling,
thinking & coping
Millon (1981)
Why Do We Behave the Way We Do?
Affective
(feelings)
Behavioral
(actions)
Cognitive
(thoughts)
Interacting System’s
Human Behavior
Definition: Personality Disorders
 Lasting enduring patterns of behavior
 Significant social and occupational
impairment
 Beyond usual personality traits
 Pervasive in 2 areas of: cognition, affect,
interpersonal relationships, & impulse control
 Usually begins in adolescence or early
adulthood
Prevalence Personality Disorders
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Approximately 10 - 13% of general population
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70 - 85% Criminals have personality disorder
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60 - 70% Alcoholics
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70 - 90% Drug abusers
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40 - 45% Persons with psychiatric disorder
also have a personality disorder
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Frequently referred to as “treatment-resistant”
Common Characteristics
 Not distressed by their
behaviors
 Become distressed because
of the reactions of others or
behaviors towards them by
others
 Not due to drug or alcohol
 Not due to medical condition
Etiology: Personality Disorders
 Combination of biological, psychological, and
social risk factors
 Genetics (50% of personality)
 Life experiences
 Environment
 Schizotypical:
 ^ homovanillic acid (HVA) metabolite of dopamine
 neuropsychological abnormalities, ^attention and
information processing impairment, & eye
movement abnormalities
Personality Disorders DSM-IVTR : Clusters: A, B, C
Cluster A, Odd, Eccentric
 Paranoid Schizoid
 Schizotypal
Cluster B, Dramatic, Emotional,
Erratic
 Antisocial
 Borderline
 Histrionic
 Narcissistic
Cluster C, Anxious
Fearful
 Avoidant
 Dependent
 ObsessiveCompulsive
Antisocial Personality
DSM IV –TR 301.7
 Pervasive pattern of
disregard for and violation of
the rights of others since age
15
 Failure to conform to social
norms, repeating acts-grounds for arrest
 Deceitfulness, repeated lying,
uses aliases, or conning
others for personal profit or
pleasure
Borderline Personality DSM-IVTR, 301.83
 Manipulation and dependency common
 Difficulty being alone--seek intense brief
relationships (Fatal Attraction)
 Impulsive & self-damaging behaviors
unsafe sex, reckless driving, substance abuse,
ED vs Recurrent suicidal or self-mutilating
behaviors; death rates
 Transient quasi-psychotic symptoms during stress
 Chronic feelings of emptiness or boredom, absence
of self-satisfaction
 Intense affect--anger, hostility, depression and/or
anxiety
Borderline Personality: Etiology
 Reduced serotonergic activity
 impulse
and aggressive behaviors
 Cholinergic dysfunction & increased
norepinephrine
 associated with irritability &
hostility
 Genetic
 5 times more common in 1st degree
biological relatives
 75% women & victims of childhood
sexual abuse
Comparisons Personality Disorders &
Mental Symptoms & Treatments
Disorder
Hallucinations
Drug
RX
0
Therapy
Antisocial
Only if substance Only if
abuse
substance
abuse
Borderline Only if psychotic May
X
Behavioral
DBT
Obsessive
X
Insight,
cog. Behav.
No
Delusions
May
Behavioral
Treatment BPD:
Dilectical Behavioral Therapy
 Once-weekly psychotherapy session focused on problematic
behavior or event from past week; emphasis is on teaching
management emotional trauma; TCs to therapists between
sessions (Linehan, 1991)
 Targets
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￬ high-risk suicidal behaviors
￬ responses or behaviors that interfere with therapy
￬ behaviors that interfere with quality of life
￬ dealing with PTS responses
enhancing respect for self
acquisition of behavioral skills taught in group
additional goals set by patient
DBT Continued
 Weekly 2.5 hr group therapy focused on
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Interpersonal effectiveness
Distress tolerance/reality acceptance skills
Emotion regulation
Mindfulness skills
 Group therapist is not available TCs;
referred to individual therapists
Psychopharmacology
 Targeted to symptoms
 Some helped with Zyprexa, Seroquel & Risperdal
 Effexor, Serzone, Prozac, Zoloft, Celexa, Luvox,
Paxil
 Anticonvulsants: Lamictal, Topamax, Depakote,
Trileptal, Zonegan, Neurontin & Gabitril
 Naltrexone
 Omega-3 Fatty Acid
Evidence-Based Practice:
Remission BPD
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10 yr study 275 participants
New England inpatient unit
Several tools used for diagnosis
Interviewed q 2 years
242 reached remisssion
 Younger
 No hospitalizations before diagnosis
 No history of sexual abuse
 Less severe childhood abuse or neglect
 Negative family hx for mood and substance abuse
 No PTSD and symptoms of Cluster C
 Low neuroticism
 High extroversion, high agreeableness, conscientiousness
and good vocational record
Zanarini, Frankenburg, Hennen, et al. (2006)
Manipulation
 Mode of interaction which controls others
 Self-defeating negatively affects IPR
 Using flattery, aggressive touching,
playing one person against another
 Deliberate “forgetting”
 Power struggles
 Tearfulness
 Demanding
 Seductive behaviors
Strategies for Dealing with
Manipulation
 Set limits and enforce
consistently
 Offer constructive
opportunities for control,
contracting
 Use clear and straightforward
communication
 Avoid rejecting or rescuing
 Monitor your own reactions
Interventions for
Manipulation Cont.
 Be honest, respectful, non-retaliatory
 Avoid labeling
 Avoid ultimatums
 Encourage putting feelings into words rather
than action
 Offer empathic statements
 Use supervision and consultation with other
staff
RELAX
 SPEAK SOFTLY AND SLOWLY
 KEEP YOUR LEGS AND ARMS
UNCROSSED
 DO NOT CLENCH YOUR FISTS
 DO NOT PRESS YOUR LIPS TOGETHER
TIGHTLY
Feelings of Appreciation
 Identify people, places or things that
evoke a deep feeling of appreciation
Your Choice
 “I CAN MANAGE MY RESPONSE”
 “I HAVE BEEN SUCCESSFUL
BEFORE”
 “WE CAN COME TO AN AGREEMENT”
 “I DON’T UNDERSTAND”
 LISTEN
 REPEAT SOMETHING THAT HAS
AGREEMENT
 TAKE A BREAK
 USE: “Perhaps,” “maybe,” “sometimes,”
“what if,” “it seems like,” “I wonder,” “I feel,”
“I think”
Interventions Dealing With Anger
Verbal
Non Verbal
 Calm unhurried
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approach
Do not touch
Protect other people
Respect personal
space
Use active listening
Be aware of
personal feelings
Use time-out/oneone in quiet area
 Initially ignore derogatory
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statements
State desire to assist person
to maintain/regain control
DO NOT ARGUE OR
CRITICIZE
DO NOT THREATEN
PUNITIVE ACTION
Postpone discussion of
anger & consequences until
in control
FOGGING
 A way of neither agreeing nor disagreeing
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“You police don’t know all the facts about any
of this.”
“ It probably seems that way to you.”
 Use the following phrases for other situations
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“You may be right…”
“It probably seems so”
“That is probably true, and we are here to help
sort things out.”
BROKEN RECORD
 A repetitive communication in which you
continue to say what you want
 Voice is neutral
 You are calm
 Ignore all side issues by the other party
SELF-EVALUATION: KEEP A
LOG
 Situation & Date
 Behavior, body cues, affect, physical
reactions, feelings
 Behavioral Response
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What I did or said
What I would like to have done or said
 What prevented you from doing what
you wanted?
Self-Care
 Healthy diet and nutrition
 Exercise and physical activity
 Adequate sleep patterns
 Recreation & leisure
 Balanced lifestyle
 Meditation
 Tai Chi
 Clinical supervision
 Support groups
 Critical incident stress debriefing
Thank you
“Your work makes a
difference in people’s
lives”