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Personality Disorders


Title: Borderline Personality Disorder Last modified by: kviek Created Date: 10/28/1996 7:58:44 PM Document presentation format: On-screen Show Other titles – PowerPoint PPT presentation

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Title: Personality Disorders

Personality Disorders
  • ?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

  • Diagnosis is on Axis II
  • If admitted to an inpatient facility must have an
    Axis I diagnosis also (e.g. alcoholism,
  • 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
  • Cause distress to others
  • only become distressed when others react to them

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
  • Exhibit odd and eccentric behaviors
  • Cluster B
  • Exhibit dramatic, emotional and erratic
  • 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

Cluster A, contd
  • 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
  • Odd thinking and speech
  • Odd or eccentric appearance or behavior
  • Suspicious, social anxiety
  • Few close relationships

Cluster A, contd
  • Paranoid P.D.
  • Secretive, fearful and distrustful.
  • Reads hidden meaning into benign statements or
  • 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
  • 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 dont want me. Why cant I eat here?

Contd (Choose all that apply)
  1. There is nothing wrong with the cafeteria food.
  2. You need to go over to the cafeteria if you want
    to eat.
  3. Ill walk with you to the cafeteria. ?
  4. Why do you think they dont want you?
  5. 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 dxd. 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
  • 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

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.
  • (Use 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, contd
  • 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. Was awaiting sentencing for
    burglary stole from the apt. of his former
    girlfriend. States to the nurse that his problems
    started after she broke up with him. Client was
    using alcohol and cocaine heavily. Explains, She
    owed me and so I took some cash and stuff. The
    client has a distressed affect when discussing
    current situation. He states, Now theyre
    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
  • 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 clients 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, contd Borderline Personality
?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
  • 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
  • When under stress may experience transient,
    paranoid thoughts or delusions, or dissociative
  • These will resolve when the stress is relieved

DSM IV-TR Criteria, contd.
  • Recurrent Self-Destructive Behavior
  • Suicidal threats gestures
  • Self-Injurious Behavior (SIB)
  • Affective instability
  • 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
  • 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

Issues for Borderline Personality Splitting
  • Low tolerance for ambivalence
  • Inability to cope with conflict
  • Get a sense of identity from the other
  • Result in this perspective
  • ?I? Either you are good or you are bad (no in-
  • ? When you are not perfect, you have failed
    me and you are bad (that means Im no good,

Issues for Borderline, contd
  • 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, contd
  • 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, contd
  • Discuss how to express and handle feelings
  • Encourage self-responsibility and appropriate
  • Offer choices, when possible
  • Give positive feedback for accomplishments and
  • Dont 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
  • 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-injuring behavior
    visited earlier this evening with family. She is
    later found in her room, having cut her abdomen
    with the broken end of a plastic fork she had
    taken from her meal tray. She says to the nurse,
    They told me I cant come back home because they
    cant handle me.

What Should the Nurse Say/Do?
  • The client is placed on Close Observation status
    for SIB. At midnight, she expresses anger to the
    night shift nurse that she cant 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
  • 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, contd
  • 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
  • Assist to explore feelings
  • Assist to try new activities
  • Assist to decrease anxiety and need for

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 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?

Personality Disorders Pharmacological
  • 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, contd
  • 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
  • What behaviors can change within a short-term
    hospital stay?