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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 life
Relationships Dysfunctional patterns and behaviors of the client
Cause distress to others Client does not recognize dysfunction and only
becomes distressed when others react to them negatively
Behavioral Characteristics
Personality Disorder is a way of relating to the world. An enduring pattern of acting and responding,
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.
Socioculturally
Believe problems in their lives are other people’s 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 later.
Grouped by the Three Clusters of Behavior in the DSM IV TR
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 disorders.
Gender and Personality Disorders
Female: greater percentage of Borderline or Histrionic
Male: Greater Percentage of Paranoid, Schizoid, Antisocial, and Narcissistic
This Presentation
1. Cluster A will be reviewed first
2. Cluster C will be reviewed second
3. 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 illusions
Odd thinking and speech
Suspicious; social anxiety
Few close relationships
Paranoid 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
Business.” 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 goal
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 events 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 approach
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 punishment
Poor understanding of limits on there behavior because limits are very inconsistent
Genetic predisposition
Antisocial 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
another. 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
Masterson’s 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 ambivalence.
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
Symptoms Self-mutilation
Clients discuss feelings of depersonalization To prove they are alive, they cut until they feel pain 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 Countertransference
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
Therapy
Clients have long-term issues of abuse and neglect
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 others
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 expectations.
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 client’s 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 provider. Client trusts is improving, then panics fearing
separation 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 nurse’s responsibility; this behavior is generated by a fear of abandonment
Client believes they are getting worse and needs reassurance and reminder of progress…regression 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 client
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 them.
Remain CALM and MATTER-OF-FACT Realize this is client’s 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