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Personality Disorder


Personality Disorders Client suffers from lifelong, inflexible and dysfunctional patterns of relating and behaving Patterns are excessive and interfere with daily ... – PowerPoint PPT presentation

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Title: Personality Disorder

Personality Disorder
Personality Disorders
  • Client suffers from lifelong, inflexible and
    dysfunctional patterns of relating and behaving
  • Patterns are excessive and interfere with daily
  • Relationships
  • Dysfunctional patterns and behaviors of the
  • Cause distress to others
  • Client does not recognize dysfunction and only
    becomes distressed when others react to them

Behavioral Characteristics
  • Personality Disorder is a way of relating to the
    world. An enduring pattern of acting and
  • Narcissism- speak and act as if their own needs
    are paramount. Normal in Adolescents.
  • Annoying Tend to Get under your skin.
  • Problems in interpersonal situations.

Personality Disorder
  • Personality Disorders are difficult to treat
  • Most are not in Psychiatric Hospitals
  • May be admitted to an inpatient facility but must
    have an Axis I diagnosis also (alcoholism,
    depression and anxiety)
  • The most common personality disorder inpatient is
    Borderline Personality Disorder
  • Most are treated outpatient in individual or
    group therapy
  • May be in drug treatment center
  • Axis II Diagnosis
  • Used to designate
  • Personality disorders or traits
  • Developmental Disorders
  • Habitual use of Particular defense Mechanism

Affective/Cognitive Characteristics
  • Anxiety Varies in the different clusters.
  • Behavior is their way of coping with anxiety and
    the individual does not consider how their
    behavior will effect others.
  • Cognitive issues
  • Rigidity of responses often causes individual to
    not reach their potential.
  • Inflexibility leads to mistakes in judgment
    making them prone to job problems.

  • Believe problems in their lives are other
    peoples fault or the rest of the world.
  • History of broken relationships, family and
    marital problems.
  • Alcoholism and drugs
  • Age of onset Adolescence, tend to decrease in
    middle age. What is normal in adolescence is not

Grouped by the Three Clusters of Behavior in the
  • Cluster A
  • Exhibit odd and eccentric behaviors includes
    schizoid, schizotypal, and paranoid disorders.
  • Cluster B
  • Exhibit dramatic emotional and erratic behaviors
    includes Narcissistic, histrionic, antisocial,
    and borderline disorders.
  • Cluster C
  • Exhibit anxious fearful behaviors includes
    dependant, avoidant and obsessive-compulsive

Gender and Personality Disorders
  • Female greater percentage of Borderline or
  • Male Greater Percentage of Paranoid, Schizoid,
    Antisocial, and Narcissistic

This Presentation
  • Cluster A will be reviewed first
  • Cluster C will be reviewed second
  • Cluster B will be the most comprehensive review
  • Borderline Personality Disorder will be reviewed
    last in this presentation. This disorder is the
    most common Axis II disorder encountered by the
    Mental Health Nurse.

Cluster A
  • Characteristics odd, eccentric behavior,
    suspicious ideations, and social isolation. Know
    this cluster as a group (do not have to recognize
    each individually)
  • Paranoid
  • Schizoid
  • Schizotypal

Cluster A
  • Schizoid
  • Lacks desire to be close to others
  • Lacks close friends
  • Solitary activities
  • Little interest in sexual activity
  • Avoids activities
  • Appears cold and detached
  • Appears indifferent to praise or criticism
  • Schizotypical
  • Ideas of reference
  • Magical thinking or odd beliefs
  • Unusual perceptual experiences including bodily
  • Odd thinking and speech
  • Suspicious social anxiety
  • Few close relationships

  • Behaviorally often alcoholic, secretive,
    argumentative and fearful of people. Hyper-alert
    to danger and rarely seek help.
  • Angry, Controlling, and judgmental.
  • Cognitively very guarded none of your
  • Difficulty in intimate relationships. Cold aloof
    manner, Often litigious.
  • Holds grudges lacks trust in others

Cluster C
  • Dependent Personality Disorder
  • Pervasive, excessive need to be taken care of
  • Submissive and clinging
  • Fears of separation
  • Avoids responsibility
  • Expresses helplessness
  • Interventions
  • Nurse assists client to increase responsibility
    in daily living
  • Needs assistance with anxiety
  • Teach assertiveness and verbalization of feelings

Cluster C
  • Avoidant Personality Disorder
  • Severe shyness and avoidant behavior
  • Socially uncomfortable and withdrawn
  • Nurse helps by assisting the client in setting
    small goals
  • Discusses fears and feelings prior to meeting a
  • Obsessive Compulsive Personality Disorder
  • Perfectionist and inflexible
  • Preoccupied with trivial details and procedures
  • Difficulty expressing warmth and kindness
  • Having fun is difficult
  • Nurse helps by assisting the client to explore
    feelings and try new activities
  • Teach that making mistakes is normal to decrease
    need for perfection

Cluster B
  • Characteristics are impulsive, dramatic
    behavior, intolerance of frustration, and
    exploitative interpersonal relationships. (Know
    Antisocial Borderline and Narcissistic)
  • Histrionic
  • Narcissistic
  • Also occasionally seen in inpatient treatment)
  • Antisocial
  • Borderline
  • (most often Personality Disorder seen in
    inpatient treatment)

Cluster B
  • Histrionic
  • Dramatizes and draws attention to self
  • Feels helpless and needs reassurance
  • Extroverted and thrives on attention
  • Lacks insight
  • Temper tantrums, outbursts of anger over minor
  • The nurse gives positive reinforcement for acts
    that are focused on others
  • The nurse facilitates independence in problem
    solving and daily functioning
  • Narcisistic
  • Grandiosity and exageration about accomplishments
  • Needs to be admired
  • Indifferent to criticism
  • A sense of entitlement (should be rewarded
    despite the lack of effort or work)
  • Lack of empathy for others
  • The nurse uses supportive confrontation of
    discrepancies limit setting and a consistent

Antisocial Personality Disorder
  • Pattern of disregard of the rights of others
  • Poor boundaries
  • Does not have a good understanding of where they
    stop and the next person begins.
  • History of disordered life functioning
  • Parent child relationship is unstable
  • Vacillates between permissiveness and severe
  • Poor understanding of limits on there behavior
    because limits are very inconsistent
  • Genetic predisposition

  • Predominant childhood characteristic of lying,
    stealing and being truant.
  • High correlation between this disorder and
    substance abuse.
  • Conform to rules when it suits their purpose.
  • Express themselves easily, but with little
    personal involvement.
  • Professes undying love one moment rejection the
    next. Irritating , aggressive, low guilt.
  • Often in the criminal justice system and NOT the
    Mental Health system.
  • Example of lack of guilt or remorse
  • Client will state they needed to rob a store with
    a gun because of their low income and inability
    to support themselves.
  • The reason why the are in jail is because they
    were caught. It is the mistakes they made that
    led them to be caught that is the problem NOT
    the crime.

Antisocial/ Cognitive Socially
  • Initially appear to be charming and intellectual
  • Smooth talker
  • Deny and rationalize their behavior
  • Egocentric and grandiose
  • Confident everything will work out
  • Ego-syntonic Cannot delay gratification and make
    no long range plans
  • Unable to sustain close relationship.
  • Sex life is impersonal and impulsive.
  • Quick anger, lack of guilt, abusive
  • Hospitalized to avoid the law

Treatment of Anti-social Personality Disorder
  • Drug Treatment center, jails and prisons
  • Essential for staff to agree on rules and stick
    with them.
  • Will try to play one staff or shift against
  • Best form of Treatment Peer counseling and
    self-help groups, like AA.

Borderline Personality Disorder
Borderline Personality Disorder DSM IV TR Criteria
  • Unstable, intense relationships characterized by
    over-idealizing and devaluation others
  • Intense ambiguous feelings.
  • This is when two feelings such as love and hate
    are present at the same time
  • Client with BPD cannot resolve feelings that
    others are not perfect and cannot meet all of
    their needs
  • Impulsiveness and self-destructive
  • Substance abuse
  • Sexual promiscuity
  • These behaviors help them to feel better for a
    short period of time

DSM IV TR Criteria Cont.
  • Recurrent suicidal threats gestures
  • Self-Injurious Behavior (SIB)
  • Affective instability
  • anxiety to depression
  • Inappropriate displays of anger

DSM IV TR Criteria Cont.
  • Marked persistent identity disturbance in two
    areas career, friends, values
  • Chronic feelings of emptiness and boredom.
  • Frantic efforts to avoid abandonment
  • Transient, stress related, psychotic symptoms or
    sense dissociative.

Etiology of Borderline Personality Disorder
  • Mastersons theory Child tries to separate and
    mom withdraws love. Child clings and mom rewards.
    Child unsure of affection. Fathers may be
    distant, alcoholic or unavailable.
  • Neglect of the child
  • Split occurs Good me-Bad me
  • Invalidating, chaotic environment
  • No object constancy (consistency in care giving
    of the child). Develops a low tolerance of
  • 75 of clients with BPD are women and victims of
    childhood sexual abuse

Issues for Borderline
  • Identity
  • Intimacy
  • No sense of who they are
  • Feel very empty
  • See themselves as all good or all bad
  • Very needy
  • fearful
  • abandonment fear

  • Self-mutilation
  • Clients discuss feelings of depersonalization
  • To prove they are alive, they cut until they feel
  • May also state that the physical pain alleviates
    the emotional pain
  • Anhedonia
  • Cannot enjoy life in conventional way
  • Impulsiveness
  • Cannot soothe self very intense emotions
  • Try to teach coping skills.

Borderline Personality Disorder and
  • Positive Countertransference
  • Lack of a sense of identity and inability to meet
    their own needs
  • Look to others as being all good and seek to
    get others to meet their needs
  • Negative Countertransference
  • Other people will eventually fail in attempting
    to meet all the needs of an individual with BPD
  • Results in malice/rage
  • Aversion More serious problem
  • Working with these problems is the responsibility
    of an advanced practice Health Care Provider

  • Clients have long-term issues of abuse and
  • An advanced practice Health Care Provider can
    assist the client in talking about these events
    in individual or group therapy
  • The nurse stays in the here and now
  • This is very therapeutic
  • Can assist the client in identifying how their
    behavior results in unwanted responses from
  • Helps the client to identify coping strategies
    and understand the disorder through teaching

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
  • Attention seeking behavior and entitlement issues
    are dealt with better in group.
  • AA, ACOA, groups are very useful.

Nursing Interventions
  • Safety
  • Clients in the acute care setting are in crisis
  • Keep environment free of contraband
  • Assess for suicidal thoughts frequently
  • Observe closely
  • Limit Setting
  • Maintain clear boundaries
  • Therapeutic Relationship
  • Acknowledge emotional pain
  • Offer support and empower to understand and
    change dysfunctional behavior
  • Review What happened? How did you react
    (behave)? How did that work for you? What can
    you do next time?
  • Prevent Splitting
  • Be consistent
  • Follow all rules of the unit
  • Follow the clients treatment plan
  • Prevent Triangulation
  • Clients will try to get the nurse to engage in
    complaints about another staff (a third person)
  • Refer the client back to the staff they have a
    problem with
  • Offer to talk about the client

Treatment and Individual Therapy
  • Working with the client to change behaviors can
    be like a roller coaster for the health care
  • Client trusts is improving, then panics fearing
  • Experiences abandonment depression, clings to
    others and then distances.
  • Clinging the therapist is all good
  • Distancing anger the therapist is all bad

BPD Ups and Downs
  • Example
  • Client appears better
  • Ready for discharge
  • Fears abandonment
  • Makes suicide gesture
  • This is not personal (it is not the nurses
    responsibility this behavior is generated by a
    fear of abandonment
  • Client believes they are getting worse and needs
    reassurance and reminder of progressregression
    can be temporary
  • The nurse needs to be OBJECTIVE not emotional
    MATTER of FACT in the approach to the client

Interventions and Milieu
  • Contracts with specific goals and
    responsibilities are important.
  • Never discuss another staff member with these
  • Goal is reintegrate the split
  • Can remind client of the other side (all people
    have both good and bad qualities)

Treatment and Milieu
  • Hold Client responsible for actions while
    maintaining positive expectations. Have
    consequences identified on plan and stay with
  • Remain CALM and MATTER-OF-FACT
  • Realize this is clients illness, behavior are
    not personal.
  • Role is with day to day activities. One person
    process issues with client

National Education Alliance for Borderline
Personality Disorder
  • New group that has begun
  • Had a national conference in Houston, Feb. 2006.
  • Latest research on pathophysiology
  • Uses an educational approach, family support
  • Believes trauma is important in the development
    of BPD

The End