Download PERSONALITY DISORDER

PERSONALITY
DISORDER
May 25, 2017
 The DSM – IV – TR (American Psychiatric
Association, 2000) defines personality traits as
“Enduring patterns of perceiving, relating to, &
thinking about the environment & oneself that are
exhibited in a wide range of social & personal
contexts.”
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Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Avoidance Personality Disorder
Dependent Personality Disorder
Obsessive-compulsive Personality
Disorder
11. Passive-aggressive Personality
Disorder
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The DSM-IV-TR defines paranoid
personality disorder as “a pervasive distrust &
suspiciousness of others such that their motives are
interpreted as malevolent, beginning by early
adulthood & present in a variety of contexts” (APA,
2000).
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The prevalence of paranoid personality
disorders is estimated at 0.5% to2.5% of the general
population, it’s more common in males.
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The hallmarks of paranoid personality disorder are
suspicion & distrust of others’ motives. Other features
include:
Refusal to confide in others
Inability to collaborate with others
Hypersensitivity
Inability to relax (hypervigilance)
Self-righteousness
Detachment & social isolation
Poor self – image
Sullenness, hostility, coldness & detachment
Humorlessness
Anger, jealousy & envy
Bad temper, hyperactivity & irritability
Lack of social support systems.
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The specific cause of paranoid personality
disorder is unknown. Its higher incidence in
families with a schizophrenic member suggests a
possible genetic influence.
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Some expert believe that the disorder result (at
least partly) from negative childhood experiences &
a threatening domestic atmosphere – for example,
extreme unfounded rage or condescension by the
parents, which can produce profound insecurity in
the child.
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Schizoid personality disorder is
characterized primarily by a profound defect in the
ability to form personal relationships or to respond
to others in any meaningful, emotional way
(Phillips, Yen, & Gunderson, 2003). These individual
displays a lifelong pattern of social withdrawal &
their discomfort with human interaction is very
apparent.
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Epidemiological Statistics:-
The prevalence of schizoid personality
disorder within general population has been
estimated at between 3 & 7.5%. it is diagnosed more
frequently in men.
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Clinical Features
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Emotional detachment
Inability to experience pleasure
Lack of strong emotions & little observable change in mood
Avoidance of activities that involve significant interpersonal contact
Little desire for or enjoyment of close relationships
No desire to be part of a family
Strong preference for solitary activities
Little or no interest in sexual experiences with another person
Lack of close friends or confidants other than immediate family
members
Shyness, distrust & discomfort with intimacy
feeling of superiority
loneliness
self-consciousness
Oversensitivity to slights.
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Predisposing Factors
As with the other personality disorders, the
exact cause of schizoid personality disorder isn’t
known. Some researchers think it may be inherited.
Other possible causes may include:
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A sustained history of isolation during
infancy & childhood
Cold or grossly deficient early parenting
Parental modeling of interpersonal
withdrawal, indifference, & detachment.
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SCHIZOTYPAL PERSONALITY
DISORDER
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DEFINITION:-
SCHIZOTYPAL PERSONALITY
DISORDER IS MARKED BY A PERVASIVE
PATTERN OF SOCIAL &
INTERPERSONAL DEFICITS, ALONG
WITH ACUTE DISCOMFORT WITH
OTHERS. PEOPLE WITH THIS DISORDER
HAVE ODD THOUGHT & BEHAVIOURAL
PATTERNS.
Epidemiological Statistics:Schizotypal personality disorder is found
in about 3% of the general population. it’s slightly
more common in men than in women.
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 Odd or eccentric behaviour or appearance
 Inaccurate beliefs that other’s behaviour or environmental
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phenomena are meant to have an effect on the patient
Odd beliefs or magical thinking (such as thinking that one’s
thought or desires can influence the environment or cause
events to occur)
Unusual perceptual experiences, including bodily illusions
Vague, circumstantiallty, or stereotypical speech or
thinking
Unfounded suspicious of being followed, talked about,
persecuted, or under surveillance
Inappropriate or constricted affect
Lack of close relationships other than immediate family
members
Social isolation
Excessive social anxiety
A sense of feeling different & not fitting in with others easily
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Predisposing Factors:Schizotypal personality disorder may have a genetic basis. Family, twin &
adoption studies show an increased risk of the condition in people with a
family history of schizophrenia. Environmental factors (such as severe
stress) may determine whether schizotypal personality disorder or
schizophrenia manifests.
Dopamine Deviance: Some evidence suggests that patients with
schizotypal personality disorder have poor regulation of dopamine
pathways in the brain.
Psychological & Cognitive theories: psychological & cognitive
explanations for schizotypal personality disorder focus on deficits in
attention & information processing. These patients perform poorly on tests
that assess continuous performance tasks, which require the ability to
maintain attention on one object & to look at new stimuli selectively.
Psychoanalytic theories: One proposes that patients with this disorder
have ego boundary problems; the other, that these patients were raised by
patients with inadequate parenting skills, poor communication skills &
loose association of words.
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ANTISOCIAL PERSONALITY DISORDER
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Definition:The highlight of antisocial personality disorder is
chronic antisocial behaviour that violates other’s rights or
generally accepted social norms. This disorder
predisposes a person toward criminal behaviour.
Epidemiological Statistics:In the general population, the prevalence of
antisocial personality disorder is about 2% to 3%.
Roughly one-half of people with this disorder have a
history of arrest. It affects three to four times as many
males than females.
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Clinical Features:A patient with antisocial personality disorder has a long-standing pattern of
disregarding other’s right & society’s values. Other assessment finding may
include:
 Repeatedly performing unlawful acts
 Reckless disregard for his own or others’ safety
 Deceitfulness
 Lack of remorse
 Consistent irresponsibility
 Power-seeking behaviour
 Destructive tendencies
 Impulsivity & failure to plan ahead
 Superficial charm
 Manipulative nature
 Inflated, arrogant self-appraisal
 Irritability & aggressiveness
 Inability to maintain close personal or sexual relationships
 Disconnection between feelings & behaviours
 Substance abuse
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Predisposing Factors:Genetic & biological factors may influence the development of antisocial personality
disorder. Biological factors include:
 Poor serotonin regulation in certain brain regions, which may decrease behavioural
inhibition.
 Reduce autonomic activity & developmental or acquired abnormalities in the
prefronatal brain systems.
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Such biological factors may underlie the low arousal, poor fear
conditioning & decision-making deficits seen in patients with antisocial
personality disorder.
Children at risk
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Other possible causes or risk factors include attention deficit hyperactivity
disorder, large families & childhood exposure to these conditions:
 Substance abuse
 Criminal behaviour
 Physical or sexual abuse
 Neglectful or unstable parenting
 Social isolation
 Transient friendships
 Low socioeconomic status
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A disorder of poor regulation of emotions,
borderline personality disorder is marked by a pattern of
instability in interpersonal relationships, mood,
behaviour & self image. Although people with this
disorder may experience it in various ways, most find it
hard to distinguish reality from their own misperceptions
of the world. Their emotions overwhelm their cognitive
functioning, creating many conflicts with others.
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Epidemiological Statistics:The prevalence of borderline personality disorder affects 2% to 3% of
the general population, about 11% of psychiatric outpatients, & nearly 20%
of psychiatric inpatients. It’s three times more common in females than in
males.
Clinical Features:Major signs & symptoms of borderline personality disorder fall into
four main categories – unstable relationships, unstable self-image, unstable
emotions, & impulsivity. Symptoms are more acute when the patient feels
isolated & without social support.
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Assessment findings may include:
A pattern of unstable & intense interpersonal relationships
Splitting (viewing others as either extremely good or extremely bad)
Intense fear of abandonment, as displayed in clinging & distancing
maneuvers
Rapidly shifting attitudes about friends & loved ones
Desperate attempts to maintain relationships
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Unstable perceptions of relationships
Manipulation, as in pitting people against one another
Limited coping skills
Dissociation (separating objects from their emotional significance)
Transient, stress-related paranoid ideation or severe dissociative symptoms
Inability to develop a healthy sense of oneself
Uncertainty about major issues, such as self-image, identity, life goals, sexual
orientation, values, career choices or types of friends
Imitative behaviour
Rapid, dramatic mood swings, from euphoria to intense anxiety to rage, within hours
or days
Acting out of feelings instead of expressing them appropriately or verbally
Inappropriate, intense anger or difficulty controlling anger
Chronic feelings of emptiness
Unpredictable self-damaging behaviour, such as driving dangerously, gambling,
sexual promiscuity, overeating, spending & abusing substances
Self-destructive behaviour, such as physical fights, recurrent accidents, selfmutilation & suicidal gestures
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The precise causes of borderline personality
disorder are unknown, but several theories are being
investigated. Because it’s five time more common in firstdegree relatives of people who have it, researchers suspect
genetic may play a role.
Biological factors may involve:
Dysfunction in the brain’s limbic system or frontal lobe
Decreased serotonin activity
Increased activity in alpha-2-noradrenergic receptors.
Early losses & abuse:Prolonged separation from their parents, other major
losses early in life, & physical, sexual, or emotional abuse or
neglect seem to be more common in patients with this
disorder than in the general population.
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Definition:This disorder is characterized by colorful, dramatic,
& extroverted behaviour in excitable, emotional people.
They have difficulty maintaining long-lasting
relationships, although they require constant
affirmation of approval & acceptance from others.
Epidemiological Statistics:The prevalence of the disorder is thought to be
about 2 to 3%, & it is more common in women than in
men.
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may reveal:
Assessment of a patient with histrionic personality disorder
Constant craving for attention, stimulation, & excitement
Intense affect
Shallow, rapidly shifting expression of emotions
Flirting & seductive behaviour
Overinvestment in appearance
Exaggerated, vague speech
Self-dramatization
Impulsivity
Exhibitionism
Suggestibility & impressionability
Egocentricity, self-indulgence, & lack of consideration for
others
 Intolerance of frustration, disappointment, & delayed
gratification
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Somatic (physical) preoccupations & symptoms
Angry outbursts & tantrums
Sudden enraged, despairing, or fearful states
Intense anger toward people viewed as withholding
Divisive, manipulative behaviour
Intolerance of being alone
Suppression or denial of internal distress, weakness,
depression or hostility
Dread of growing old
Demanding & manipulative nature
Use of alcohol or drugs to quickly alter negative feelings
Depression
Suicidal gestures & threats.
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The cause of histrionic personality disorder
isn’t known. A genetic component may be involved,
as hysterical traits are more common in relatives of
those with this disorder. However, little research
has been done on the biological origins of this
disorder.
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Childhood events may come into play as well.
Psychoanalytic theories focus on seductive &
authoritarian attitudes by fathers of these patients.
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Definition:Persons with narcissistic personality disorder have
an exaggerated sense of self-worth. They lack empathy, &
are hypersensitive to the evaluation of others. They
believe that they have the inalienable right to receive
special consideration & that their desire is justification
for possessing whatever they seek.
Epidemiological Statistics:Narcissistic personality disorder is found in less
than 1% of the general population. It affects about three
times as many males as females.
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In a patient with narcissistic personality disorder,
assessment finding may include:
Arrogance or naughtiness
Self-centeredness
Unreasonable expectations of favorable treatment
Grandiose sense of self-importance
Exaggeration of achievements & talents
Preoccupation with fantasies of success, power, beauty, brilliance
or ideal love
Manipulative behaviour
Constant desire for attention & admiration
Lack of empathy
Lack of concern over whom he offends
Taking advantage of others to achieve his own goals
Rage, shame or humiliation in response to criticism
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 The exact cause of narcissistic personality disorder is
unknown. A psychodynamic theory purposes that it arises
when a child’s basic needs go unmet.
 Love thyself, hate thyself:
 Another theory holds that patients with this disorder
have an ambivalent self-perception: an idealized (or
overidealized) view of the self coexists with deep
feelings of inferiority & low self-esteem. Thus, the
grandiose image is an effort to cover feelings of
inferiority.
 According to this theory, the patient received little
encouragement & support from his parents during
childhood & tends to internalize the process by looking
for these feelings within him-self.
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Definition:Avoidant personality disorder is marked by feelings
of inadequacy, extreme social anxiety, social withdrawal,
& hypersensitivity to other’s opinions. People with this
disorder have low self-esteem & poor self-confidence.
They dwell on the negative & have difficulty viewing
situations & interactions objectively.
Epidemiological Statistics:The prevalence of the disorder in the general
population is between 0.5 & 1%, & it appears to be
equally common in men & women.
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A patient with avoidant personality disorder may exhibit or report:
Shyness, timidity, & social withdrawal
Behaviour or appearance that’s meant to drive others away (which gives him a
sense of control)
overtalkativeness
Constant mistrust or wariness of others
Testing of others’ sincerity
Difficulty starting & maintaining relationships
Perfectionism
Rejection of people who don’t live up his impossibly high standards
Limited emotional expression
Tenseness & anxiety
Low self-esteem
Feelings of being unworthy of successful relationships
Self-consciousness
Loneliness
Reluctance to take personal risks or engage in new activities
Frequent escapes into fantasy, such as by excessive reading, watching TV, or
daydreaming.
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Avoidant personality disorder most likely results from a
combination of genetic, biological, environmental, & other factors –
although the evidence for genetic & biological causes is weak. From
a psychodynamic view, the disorder has been attributed to an overly
critical parental style
 Avoidant personality disorder is closely linked to temperament.
Studies of children under age 2 found that some have an
apparently inborn tendency to withdraw from new situation or
people. In fact, roughly 10% of toddlers are habitually fearful &
withdrawn when exposed to new people & situation. Some
evidence suggests that a timid temperament in infancy may
predispose a person to developing avoidant personality disorder
later in life.
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- Information overload: The inherited tendency to be shy may
result from overstimulation or an excess of incoming
information. The patient cant’s cope with the excess
information & withdraws in defense. Inability to cope with
the information overload may stem from a low autonomic
arousal threshold.
- Low threshold, grater response: Research suggests that in
people with this disorder, certain structures in the brain’s
limbic system may have a lower threshold of arousal & a
more pronounced response when activated.
 Some expert believe that significant environmental
influences during childhood, such as rejections or peers,
leads to the full development of avoidant personality
disorder.
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Dependent personality disorder is
characterized by “a pervasive & excessive need to be
taken care of that leads to submissive & clinging
behaviour & fear of separation”.
Epidemiological Statistics:In the general population, its prevalence is
about 1.5%. it affects slightly more females than
males.
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Assessment findings in a patient with dependent personality
disorder may include:
 Submissiveness
 Self-effacing, apologetic manner
 Low self-esteem
 Lack of self-confidence
 Lack of initiative
 Incompetence & a need for constant assistance
 Intense, unremitting need to be loved in a stable longterm
relationship that goes through minimal change
 Anxiety & insecurity, especially when deprived of a significant
relationship
 Feelings of inferiority, & unworthiness
 Hypersensitivity to criticism
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 In females, little need to overtly control or complete
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with others
Demanding behaviour
Use of cajolery, bribery, promises to change, & even
threats to maintain key relationships
Fear & anxiety over losing a relationship or being alone
Dependence on a number of people, any one of whom
could substitute for the other
Difficulty making everyday decisions without advice &
reassurance
Avoidance of change & new situations
Exaggerated fear of losing support & approval.
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 The exact cause of dependent personality disorder isn’t known.
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Because it tends to run in families, it may involve a genetic
component.
According to some expert, authoritarian or overprotective
parenting may lead to high levels of dependency. These parenting
styles may cause the child to believe that she can’t function
without other’s guidance & protection & that the way to maintain
relationships is to give in to others’ demand
Possible contributing factors may include:
Childhood trauma
Closed family system that discourages outside relationships
Childhood physical or sexual abuse
Social isolation
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OBSESSIVE – COMPUSIVE
PERSONALITY DISORDER
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Individual with obsessive –compulsive personality
disorder are very serious & formal & have difficulty
expressing emotions. They are overly disciplined,
perfectionistic, & preoccupied with rules. They are
inflexible about the way in which things must be done &
have a devotion to productivity to the exclusion of
personal pleasure.
The prevalence of the disorder in the general
population is 1.5%, - about twice as many males as
females.
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A patient with obsessive-compulsive personality disorder may describe his
symptoms in a logical way, attaching little emotion to any physical
discomfort. Assessment findings commonly include:
 Behavioural, emotional, & cognitive rigidity
 Perfectionism
 Severe self-criticism
 Indecisiveness
 Controlling manner
 Difficulty expressing tender feelings
 Poor sense of humor
 Cool, distant, formal manner
 Emotional constriction
 Excessive discipline
 Aggression, competitiveness, & impatience
 Bouts of intense anger when things stray from the patient’s idea of how
things “should be”
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Difficulty incorporating new information into his life
Psychosomatic complaints
Hypochondriasis
Sexual dysfunction
Chronic sense of time pressure & inability to relax
Indirect expression of anger despite an apparent
undercurrent of hostility
hoarding of memory & other possessions
Preoccupation with orderliness, neatness & cleanliness
Discuss about morality, ethics or values
Signs & symptoms of depression
Physical complaints (commonly stemming from
overwork).
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Genetic & developmental factors may play a
role in the development of this disorder. A twin &
adoption study suggests that it runs in families.
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Psychodynamic theories view the patient as
needing control as a defense against feelings of
powerlessness or shame.
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Definition:-
The DSM-IV-TR defines this disorder as a
pervasive pattern of negativistic attitudes & passive
resistance to demands for adequate performance in
social & occupational situations that begins by early
adulthood & occurs in a variety of contexts.
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Features:-
Feels cheated & unappreciated
Passively resists fulfilling routine social & occupational tasks
Complains of being misunderstood & unappreciated by others
Argumentative
Unreasonably criticizes & scorns authority
Expresses envy & resentment toward those apparently more
fortunate
 Voices exaggerated & persistent complaints of personal misfortune.
 Alternates between hostile defiance & contrition
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Contradictory parental attitude &
behaviour are implicated in the predisposing to
passive-aggressive personality disorder.
Through this type of environment,
children learn to control their anger for fear of
provoking parental withdrawal & not receiving love
& support – even on an inconsistent basis. Overtly
the child appears polite & undemanding; hostility
& inefficiency are manifested only covertly &
indirectly.
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Most clinicians
believe it best to strive for
lessening the inflexibility of
the maladaptive traits &
reducing their interference
with everyday functioning &
meaningful relationship.
Selection of intervention is
generally based on the area
of greatest dysfunction, such
as cognitive, affect,
behaviour or interpersonal
relations.
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Interpersonal psychotherapy may be particularly
appropriate because personality disorders largely reflect
problems in interpersonal style. Long-term psychotherapy
attempts to understand & modify the maladjusted behaviours,
cognition, & affects of clients with personality disorders that
dominate their personal lives & relationships.
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The core element of treatment is the establishment of an
empathic therapist-client relationship, based on collaboration &
guided discovery in which the therapist functions as a role
model for the client.
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Interpersonal psychotherapy is suggested for clients with
paranoid, schizoid, schizotypal, borderline, dependent,
narcissistic, & obsessive-compulsive personality disorders
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The treatment of choice for individuals
with histrionic personality disorder has been
psychoanalytical psychotherapy. Treatment focuses
on the unconscious motivation for seeking total
satisfaction from others & for being unable to
commit oneself to a stable, meaningful relationship.
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This treatment is especially appropriate for
individuals with antisocial personality disorder, who
respond more adaptively to support & feedback from
peers. In milieu or group therapy, feedback from peers
is more effective than in one-to-one interaction with a
therapist.
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Group therapy – particularly homogeneous
supportive groups that emphasize the development of
social skills – may be helpful in overcoming social
anxiety & developing interpersonal trust & rapport in
clients with avoidant personality disorder.
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Behavioural strategies offer reinforcement for
positive change. Social skills training &
assertiveness training teach alternative ways to
deal with frustration.
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Cognitive strategies help the client recognize &
correct inaccurate internal mental schemata.
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This type of therapy may be useful for clients
with obsessive-compulsive, passive-aggressive,
antisocial, & avoidant personality disorders.
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Drugs have no effect in the treatment of the disorder itself,
some symptomatic relief can be achieved
Antipsychotic medications are helpful in the treatment of
psychotic decompensation experienced by clients with paranoid,
schizotypal, & borderline personality disorder. Antipsychotic have
resulted in improvement in illusions, ideas of reference, paranoid
thinking, anxiety & hostility in some clients.
The selective serotonin reuptake inhibitors (SSRIs) & monoamine
oxidase inhibitors (MAOIs) have been successful in decreasing
impulsivity & self-destructive acts in the clients with borderline
personality disorder.
Lithium carbonate & propranolol (Inderal) may be useful for the
violent episodes observed in the clients with antisocial personality
disorder.
Anxiolytics are useful for clients with avoidant personality
disorder
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1.
R/t rage reactions, negative rolemodeling, and inability to tolerate frustration.
 Convey an accepting attitude towards this client. Work on
development of trust, keep all promises & convey the message
that it is not him or her but the behaviour that is unacceptable.
 Maintain low level of stimuli in client’s environment (low lighting,
few people, simple décor, low noise level).
 Observe client’s behaviour frequently during routine activities &
interactions, avoid appearing watchful & suspicious.
 Remove all dangerous objects from client’s environment.
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 Help client identify the true object of his or her hostility.
 Encourage client to verbalize hostile feelings gradually.
 Explore with client alternative ways of handling
frustration.
 Staff should maintain & convey a calm attitude.
 Administer tranquilizing medications as ordered by
physician or obtain an order if necessary. Monitor for
effectiveness & for adverse side effects.
 If client is not calmed by “talking down” or by
medication, use of mechanical restraints may be
necessary.
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R/t dysfunctional family system,
evidenced by disregards for societal norms & laws,
absence of guilty feelings, or inability to delay
gratification.
 From the onset, client should be made aware of which
behaviour are acceptable & which are not. Explain
consequences of violation of the limits.
 Do not attempt to coax or convince client to do the “right
thing.” Do not use the words “you should (or
shouldn’t)….”,
 Provide positive feedback or reward for acceptable
behaviours.
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 Being to increase the length of time requirement for
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acceptable behaviour in order to achieve the reward.
A milieu unit provides the appropriate environment for
the client with antisocial personality.
Help client to gain insight into his or her own
behaviours.
Talk about past behaviours with client. Discuss
behaviours that are acceptable by society & those which
are not.
Throughout relationship with client, maintain attitude of
“It is not you, but your behaviour, that is unacceptable.”
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3. Chronic low self-esteem R/t repeated negative feedback
resulting in diminished self-worth, evidenced by
manipulation of others to fulfill own desires or inability
to form close, personal relationships.
4. Impaired social interaction R/t to negative role
modeling & low self-esteem, evidenced by inability to
develop a satisfactory, enduring, intimate relationship
with another.
5. Deficient knowledge (self-care activities to achieve &
maintain optimal wellness) R/t lack of interest in
learning & denial of need for information, evidenced by
demonstration of inability to take responsibility for
meeting basic health practices.
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THANK YOU
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