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Title: PSYCHIATRIC NURSING (Lecture Series) PERSONALITY DISORDERS


1
PSYCHIATRIC NURSING(Lecture Series)PERSONALITY
DISORDERS
www.arnelsalgado.com www.ifeet.com.ph www.ifeet.or
g
DR. ARNEL BANAGA SALGADO, Ed.D., D.Sc., RN, MA,
B.Sc, Cert .Ed, MAT (Psychology) Doctor of
Science (USA) Doctor of Education (Phl) Master of
Arts in Nursing (Phl) Master of Arts in Teaching
Psychology (PNU) Registered Nurse (Phl, Mal,
UAE) Licensed/Registered Teacher (Phl)
Certificate in Teaching, Bachelor of Science in
Nursing
2
(No Transcript)
3
Learning Objectives
  • Define and classify various personality disorders
  • Describe the main features of various personality
    disorders
  • Formulate the nursing diagnoses for behaviours
    that lead to hospitalization
  • Discuss the basic interventions for a patient
    with personality disorder

4
I. Overview / Theories
  • Personality
  • Composed of enduring patterns or traits that
    determine how individuals perceive, relate to,
    and think about the environment and themselves
  • PERSONALITY TRAITS or patterns are reflected in
    how individuals cope with feelings and impulses,
    see themselves and others, respond to their
    surroundings, and find meaning in relationships.

5
I. Overview / Theories
  • B. Personality Disorders
  • PD are diagnosed when personality patterns or
    traits are inflexible, enduring, pervasive,
    maladaptive and cause significant functional
    impairment or subjective distress
  • Reflect patterns of inner experience and behavior
    that differ from cultural expectations
  • 3. Client frequently experience their personality
    patterns as natural or comfortable (ego-syntonic)
    rather than uncomfortable (ego-dystonic)

6
5. If personality patterns are experience as
egosyntonic, clients rarely seek treatment as
they tend to externalize the cause of any
functional impairment or subjective distress 6.
If personality patterns are experience as
egodystonic, clients are more likely to seek
treatment to ease their distress 7. Coded under
Axis II disorders (PD or mental retardation and
DSM-IV)
7
8. Frequently Overlap individuals may exhibit
patterns or traits associated with more than one
personality disorder 9. Develop before or during
adolescence and persists throughout life
symptoms may become less obvious my middle or old
age.
8
  • 10. Occur in 6 to 13 per cent of the general
    population
  • 11. May coexist with clinical disorders coded as
  • Axis I (Mood and thought disorders) using DSM IV
  • 12. Are organized into 3 diagnostic clusters
  • Cluster A disorders individuals with these
    disorders appear odd and eccentric
  • Cluster B disorders individuals with these
    disorders appear dramatic and erratic
  • Cluster C disorders individuals with these
    disorders appear anxious and fearful

9
  • CHARACTERISTICS OF PD
  • Behavioral Manifestations include patterns of
    day-to-day behavior and impulse control
  • Affective manifestations include the range,
    intensity, lability, and appropriateness of
    emotional response
  • Cognitive Manifestations reflect how the self,
    others and events are interpreted
  • Socio-cultural Manifestations interpersonal
    functioning

10
SPECIFIC DISORDERS
Cluster A (Using DSM IVTR) (appear odd and
eccentric)
11
SPECIFIC DISORDERS
  • Paranoid Personality Disorder patterns of
    distrust of suspiciousness such that others
    motives are interpreted as malevolent
  • Behavioral Manifestations
  • Secretive
  • Hyper alert to danger
  • Argumentative to maintain a safe distance between
    themselves and others
  • b. Affective manifestations
  • Avoid sharing feelings except for quick
    expressions of anger, bear grudges
  • Rarely forgive perceived slights
  • Fear losing power or control to others

12
SPECIFIC DISORDERS
  • c. Cognitive Manifestations
  • Pervasive distrust and suspicious
  • Expect to be used or harassed
  • Tendency to look for hidden, demeaning, or
    threatening meanings and to respond by
    criticizing others
  • d. Sociocultural Manifestations
  • Interact in cold and aloof manner to avoid
    intimacy
  • Expect to be harmed or exploited by others and
    question the loyalty or trustworthiness of family
    or friends
  • Often pathologically jealous of a significant
    others

13
SPECIFIC DISORDERS
  • 2. Schizoid Personality Disorder patterns of
    detachment from social relationship and a
    restricted range of emotions
  • Behavioral Manifestations
  • Neither desire nor enjoy relationship with others
  • Have little interest in activities or sexual
    relationships
  • b. Affective manifestations
  • Mood stable but restricted range of expression of
    emotions
  • May become anxious if forced into a close
    interaction
  • Affect is bland, blunted, or flat

14
SPECIFIC DISORDERS
  • c. Cognitive manifestations
  • Appear to have poverty of thought
  • Expressed thoughts are often vague
  • Indifferent to attitudes and feelings of others
  • Not influenced by praise or criticism
  • d. Sociocultural Manifestations
  • Interact with others in a cold, aloof manner
  • Desire no close friends

15
SPECIFIC DISORDERS
  • 3. Schizotypal Personality Disorder patterns of
    acute discomfort in close relationships,
    cognitive or perceptual distortions, and
    eccentricities of behavior
  • Behavioral Manifestations
  • Exhibit odd/eccentric behavior and speech that is
    coherent but often tangential, vague, or over
    elaborate
  • Maybe mild form of schizophrenia
  • May display transient psychotic symptoms
  • b. Affective manifestations
  • Emotionally constricted
  • Affect maybe inappropriate

16
SPECIFIC DISORDERS
  • c. Cognitive manifestations
  • Paranoid ideation may be present
  • Ideas of reference may be present
  • Illusions may be present
  • Magical thinking may be present
  • d. Sociocultural Manifestations
  • Are uncomfortable with intimacy and avoid
    relationship with others
  • Are usually avoided by others because of their
    pod/eccentric behavior

17
SPECIFIC DISORDERS
  • Cluster B (Using DSM IVTR)
  • appear dramatic and erratic

18
SPECIFIC DISORDERS
  • Antisocial Personality Disorder patterns of
    patterns of disregard for and violation of the
    rights of others
  • Behavioral Manifestations childhood
    manifestations are lying, stealing, truancy,
    vandalism, fighting and running away from home
    adults fail to conform to social norms such as
    functioning within the law lie pathologically
    and con others for personal profit consistent
    irresponsibility related to financial obligations
    and work behavior impulsive and reckless in
    regard to own safety and that of others
  • b. Affective manifestations superficial
    expression of emotion lack of guilt or remorse
    related to inappropriate behavior irritable and
    aggressive

19
SPECIFIC DISORDERS
c. Cognitive Manifestations egocentric and
grandiose perceive themselves as more clever
than others d. Sociocultural Manifestations
consistently violate the rights of others as well
as the values of society unable to sustain
personal relationships maybe abusive
20
SPECIFIC DISORDERS
  • 2. Borderline Personality Disorder pattern of
    instability in interpersonal relationships,
    self-image, and affect, and marked impulsivity
  • Behavioral Manifestations
  • Unpredictable
  • Fear of real or imagined abandonment
  • Engage in self-destructive behaviors such as
    reckless driving, substance abuse and
    binge-eating
  • High risk for suicide and self-mutilation because
    of feeling of emptiness or rage
  • Behavior may vary from one moment to the nest

21
SPECIFIC DISORDERS
  • 2. Affective Manifestations
  • Mood are intense and unstable
  • Difficulty ion moderating anger
  • 3. Cognitive Manifestations
  • Identity disturbance
  • Splitting or dichotomous thinking present tend
    to see self and others as all good or all bad
  • Paranoid ideation or dissociation may be present
  • 4. Socio cultural Manifestations intense,
    unstable interpersonal relationships alternating
    between extremes of idealization and devaluation
    of others

22
SPECIFIC DISORDERS
  • 3. Histrionic Personality Disorder pattern of
    excessive emotionality and attention seeking
  • 1. Behavioral Manifestations
  • Uncomfortable unless the center of attention
  • Display seductive and other attention seeking
    behavior when interacting with others
  • Conversation is superficial
  • 2. Affective Manifestations
  • Overly dramatic Rapidly shifting
  • Shallow expression of emotion
  • 3. Cognitive Manifestations guided by feelings
    rather than logic
  • Assume role of victim or princess in
    relationships
  • Consider relationships to be more intimate than
    they are

23
SPECIFIC DISORDERS
  • 3. Narcissistic Personality Disorder pattern of
    grandiosity, need for admiration, and lack of
    empathy
  • 1. Behavioral Manifestations
  • Pre occupied with fantasies of power, success
  • Extremely grandiose and exploit others to achieve
    personal goals
  • Seek constant admiration
  • Sense of entitlement
  • 2. Affective Manifestations labile moods varying
    from anger to anxiety

24
SPECIFIC DISORDERS
  • 3. Cognitive Manifestations
  • Arrogant, egotistical, sees self as more
    important/special than others
  • Lack empathy
  • May think others are envious or maybe envious of
    others
  • 4. Socio cultural Manifestations
  • Disturbed relationships as a result of using
    others to meet own goals
  • Own needs are perceived as more important than
    the needs of others

25
SPECIFIC DISORDERS
  • Cluster C (Using DSM IVTR)
  • anxious and fearful

26
SPECIFIC DISORDERS
  • Avoidant Personality Disorder patterns social
    inhibition, feelings of inadequacy, and
    hypersensitivity to negative evaluation
  • Behavioral Manifestations Avoid interpersonal
    contact and new situations related to fear of
    rejection and embarrassment lack of
    self-confidence and are extremely sensitive to
    rejection
  • Affective manifestations fearful shy hurt by
    criticism
  • Cognitive Manifestations view self as
    inadequate, inferior fearful of shame and
    ridicule
  • Sociocultural Manifestation few close friends
    desire relationship but reluctant to enter to it

27
SPECIFIC DISORDERS
  • 2. Dependent Personality Disorder patterns of
    submissive and clinging behavior related to the
    need to be taken care of.
  • Behavioral Manifestations Desire to help with
    everyday decision, and want others to take care
    of them difficulty in disagreeing with others
    related to fear of rejection and abandonment
  • Affective manifestations Anxious when left alone
  • Cognitive Manifestations Lack of
    self-confidence pre-occupied of fear of being
    abandoned
  • Sociocultural Manifestation Constantly strive to
    obtain support from others uncomfortable unless
    involved in a supportive relationship

28
SPECIFIC DISORDERS
  • 3. Obsessive-Compulsive Personality Disorder
    patterns of pre-occupation with orderliness,
    perfectionism and control
  • Behavioral Manifestations
  • High need for routine
  • Decreased ability to focus on the major goal of
    activity as becomes overly involve in details
  • Difficulty with task completion related to a need
    of perfection
  • Inflexibility related to moral and ethical issues
  • Unable to discard worthless objects
  • Unable to delegate for fear that others will not
    perform tasks correctly

29
SPECIFIC DISORDERS
  • 2. Affective Manifestation rigid, stubborn, and
    emotionally constricted
  • Cognitive Manifestations Believe in a correct
    solution for every problem procrastinate because
    fearful of making mistakes
  • Sociocultural Manifestation impaired
    interpersonal relationships and absence of
    leisure activities due to the devotion to work
    and productivity

30
SPECIFIC DISORDERS
D. Concomitant Disorders there is a
correlation between certain personality disorders
and some axis I disorders such as substance
abuse, mood disorders, anxiety disorders and
psychotic disorders
31
II. ETIOLOGY
  • Neurobiological theories
  • Limbic system dysregulation and CNS irritability
    may result in decrease impulse control
  • Decreased levels of serotonin (5-HT) have been
    associated with a tendency to self-mutilate,
    experience intense rage, and behave aggressively
    toward others
  • Elevated levels of norepinepohrine have been
    associated with hypersensitivity to the
    environment
  • Abnormal levels of dopamine may explain the
    psychotic episodes associated with borderline and
    schizoid personality disorders
  • Physiological under arousal may contribute to the
    risk taking associated with some disorders
  • Schizotypal personality disorder maybe a milder
    form of schizophrenia
  • Genetic factor

32
  • Intrapersonal Theories
  • Hostility toward the self may be projected onto
    others resulting in fear, mistrust, and defensive
    withdrawal to avoid being hurt
  • Individuals may try to live to perfectionist
    standards imposed on them by their parents or
    others during childhood
  • An underdeveloped superego may result in failure
    to both internalize authority and cultural morals
    and to experience guilt when violating rules
  • Inadequate parenting and unsatisfied needs
  • Anxiety may manifest itself as personality
    disorder

33
  • C. Social Theories
  • Social oppression may have a negative effect on
    the development of self-esteem and a healthy
    identity
  • A changing societal value system with personal
    needs being viewed as more important than group
    needs, maybe reflected in the behavior associated
    with cluster B disorders

34
  • D. Family Theories
  • Inability to manage conflict
  • Growing up in multigenerational enmeshed family
  • A chaotic and abusive environment
  • E. Feminist Theory
  • The diagnosis of a personality disorder reflects
    the influence of rigid gender role stereotyping
    rather than of genetic factors

35
III. ASSSESSMENT
  • General Guidelines
  • Maintain sensitivity so that the client may not
    be defensive
  • Interview family members
  • Specific Guidelines assess clients level of
    function in the areas of affect, cognition
    (including impulse control), and sociocultural
    adaptation (interpersonal relationships)

36
IV. Nursing Dx/Analysis
  • Cluster A Disorders (paranoid personality,
    schizoid personality, and Schizotypal)
  • Ineffective individual coping related to
    inability to trust
  • Fear related to perceived threats from others or
    the environment
  • Social isolation related to craving of solitude
  • Spiritual distress related to lack of
    connectedness to others
  • Cluster B (antisocial, borderline, histrionic and
    narcissistic)
  • Impaired social interaction
  • High risk for violence self-directed
  • High risk for violence directed to others
  • Personal identity disturbance
  • Fear related to feeling of abandonment

37
  • C. Cluster C (Avoidant , Dependent, OCD)
  • Ineffective individual coping related to high
    dependency needs, rigid behavior
  • Fear related to feelings of abandonment

38
V. Planning and Implementation
  • Basic Principles of Nursing Intervention
  • Recognize that clients have the right to change
    or not to change if pattern of behavior are
    egocentonic, clients may lack motivation required
    to effect change.
  • Help clients to see how behavior affects their
    lives to motivate them to develop a more adaptive
    lifestyle.
  • Remember that personality traits are to ingrained
    to expect radical, long term behavioral change
    interventions should be based on short term goals
    and focus on small steps designed to improve role
    functioning and decrease distress
  • Maintain hope for each clients improvement all
    clients have the potential for change
  • Identify your own emotional responses

39
  • Specific Strategies a cluster specific nursing
    interventions can be individualized for each
    client
  • Cluster A disorders (paranoid, schizoid,
    Schizotypal)
  • Approach people in gentle, interested, but
    non-intrusive manner
  • Respect client's needs for distance and privacy
  • Be mindful of own non verbal communication as a
    client may perceive others as threatening
  • Gradually encourage interaction with others, if
    appropriate
  • Cluster B disorders (antisocial, borderline,
    histrionic, narcissistic)
  • Be patient as client displays emotional and
    erratic behavior
  • Provide a consistent structured milieu to avoid
    manipulation and power struggles

40
  • Safety is always the first priority of care
  • Set limits as necessary to help clients maintain
    impulse control in order to protect themselves
    and other from injury
  • Engage in frequent staff conferences to
    counteract clients ability to play one staff
    member against the other
  • Help clients recognize and discuss their fear
    of abandonment
  • Help clients recognize the presence of
    dichotomous thinking or splitting, in which self
    and others are perceived as good or all bad.
  • Encourage direct communication
  • Encourage self-entitlement of needs

41
  • 3. Cluster C (Avoidant, Dependent, OCD)
  • Point out avoidance behavior
  • Provide problem solving and assertiveness
    training
  • Encourage expression of feelings
  • Help recognize impairment
  • Discuss their sense of inadequacy
  • Discuss fear of rejection

42
  • C Psychopharmacology
  • Antipsychotic agents maybe prescribed on a short
    term basis to alleviate psychotic symptoms
    associated with Schizotypal or borderline
    personality disorder
  • Selective serotonin Reuptake Inhibitors (SSRI) to
    diminish mood swing, impulsive, aggressive and
    self-destructive behavior associated with
    borderline
  • SSRI may be prescribed to threat obsessive
    rumination associated with certain personality
    disorders
  • Individual Group Therapy
  • Behavioral Therapy
  • Impulse control Training
  • Limit setting
  • Behavioral Modification social skills
  • F. Psychological Comfort Promotion anxiety
    Reduction

43
VI. Evaluation/Outcomes
  1. BASED ON ASSESSMENT of behavioral, affective,
    cognitive and sociocultural manifestations,
    identify realistic, specific and measurable short
    term goals for nursing interventions.
  2. BE AWARE THAT REALISTIC GOALS must reflect steps
    to improve function and decreasing subjective
    distress personality traits are too integrated
    to expect immediate, radical, long term change
  3. EVALUATE EFFECTIVENESS of the nursing
    interventions in related to states outcomes

44
"Love cures two people, the person who gives it
and the person who receives it - Karl Menninger
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