PERSONALITY DISORDERS: IDENTITY TO

REALITY

JOLO R. GALABAY, RM,RN ,MSN

MAN

SITUATION

PERSISTSANXIETY

DYSFUNCTIONALITY

Application of the Nursing Process:

Assessment: Classical signs & symptoms Interventions/ Therapies Pharmacology

Therapeutic use of self

-therapeutic communication

Theoretical Models for Understanding Behavior

Mental Mechanisms/Defense Mechanisms

OVERVIEW OF PSYCHIATRIC NURSING

Schizophrenic Disorders

Paranoid Disorders

Organic Mental Disorders

Eating Disorders

Abuse & Violence

Sexual Disorders

Anxiety Disorders

Somatization Disorders

Dissociative Disorders

Personality Disorders

Substance Use Disorders

Mood Disorders

SITUATIONS

EXPERIENCES

OBJECTIVES: 1.  Define and differentiate between personality styles, traits, and disorders. 

2.  Identify the essential features of the different personality disorders.  

3.  Identify some prominent personality traits in yourself, your peers, and people surrounding you. 

4.  Develop some strategies in dealing with the people having Personality Disorder.

PERSONALITY- The quality or state of being a person

- The totality of a person’s unique biopsychosocial emotional and spiritual traits that influences one’s behavior.

DISORDER- The disturbance of regular or normal function

- An abnormal physical or mental condition

PERSONALITY DISORDER Maladaptive traits influenced by psychological and emotional disturbance and impaired interpersonal relationship.

The Diagnostic and Statistical Manual of

Mental Disorders-Text Revision (DSM-

IV-TR) (American Psychiatric

Association [APA], 2000)

PERSONALITY DISORDERS: DIAGNOSIS

Made when the person exhibits enduring behavioral patterns that deviate from cultural expectations in two or more of the following areas:

1. Ways of perceiving and interpreting self, other people, and events (cognition)

2. Appropriateness of emotional response (affect)

3. Interpersonal functioning 4. Ability to express behavior at the

appropriate time and place (impulse control)

CHARACTERISTICS:1. Poor self-esteem2. Poor relationship

skills3. Low tolerance for

anxiety4. Manipulative and

demanding5. Self destructive

behavior

ETIOLOGY: Genetic factors Environmental factors Biological factors

(neurotransmitters)

Psychoanalytic factors

CLUSTER A: THE

ECCENTRIC, ODD AND

MAD GROUP

PARANOID Signs and symptomsDistrustful/Extreme mistrustSuspiciousShort temperedHypersensitive to criticismProne to angry or aggressive outburst

Jealous very private

Management:

Establish rapportHelp them recognize and accept their own feelings

Support adaptation

SCHIZOID Signs and Symptoms

Withdrawn, introvert, aloof, has solitary lifestyleLoner and passiveSexual experiences is not of interest

Friendships are fewEmotionally cold and detachedtake jobs with little person contactHumorless

Management:Initiate structural social interactions

Positive therapeutic nurse client relationship

SCHIZOTYPAL

Signs and Symptoms:

M: Magical thinking or odd beliefsE: Experiences unusual perceptions

P: Paranoid ideationE: Eccentric behavior or appearanceC: Constricted (or inappropriate) affectU: Unusual (odd) thinking and speechL: Lacks close friendsI: Ideas of referenceA: Anxiety in social situationsR: Rule out psychotic disorders and pervasive developmental disorder

ManagementMedications- antipsychotic drugs

Must accept his/her condition

Avoid extreme stress Start structured social interactions

CLUSTER B: THE

ERRATIC AND BAD GROUP

ANTISOCIAL Signs and symptom:

Violates and Exploits rights, feelings and safety of others

Violent and aggressive behaviorsDoes not show any guilt for their action

Engaged in real intimacy to other person

Very good in displaying superficial charm

Lack of loyalty, honesty and fidelity

ANTI-SOCIALInterventions: Limit

Setting 1. Stating the behavioral

limit (describing the unacceptable behavior) e.g. “It is not acceptable for you to ask personal questions.‖

2. Identifying the consequences if the limit is exceeded e.g. “If you continue, I will terminate our interaction.‖

3. Identifying the expected or desired behavior e.g. “We need to use this time to work on solving your job-related problems.”

Interventions: Confrontation Points out a client’s

problematic behavior while remaining neutral and matter-of-fact

Avoids accusing the client. Use confrontation to keep

clients focused on the topic and in the present.

Nurse: ―You’ve said you’re interested in learning to manage angry outbursts, but you’ve missed the last three group meetings.‖

Client: ―Well, I can tell no one in the group likes me. Why bother?‖

Nurse: ―The group meetings are designed to help you and the others, but you can’t work on issues if you’re not there.‖

ANTI SOCIAL Interventions:

Problem-Solving 1. Identify the

problem. 2. Explore alternative

solutions and related consequences.

3. Choose and implement an alternative.

4. Evaluate the results.

Interventions: Manage Emotions

When frustrated, teach the client to take a time out or leave the area and go to a neutral place to regain internal control to engage in constructive problem solving.

BORDERLINE

Signs and SymptomsImpulsive and Risky behaviorThreatens and often engaged self mutilation

Wide “mode swing”Inappropriate angerDifficulty in controlling emotionFeels misunderstood, neglected, alone and helpless

Fears being aloneFeelings of self-hateSuicidal attempt

SUICIDETHE ACT OF KILLING ONESELF USUALLY BECAUSE

OF A STRESS PERCEIVED AS OVERWHELMING Who will commit Suicide?

Sex – Male (more successful)/ female (hesitant)

Age – 15 –24 y/o or above 45

Depression

Patient with previous attempt

Ethanol abuse – alcoholics are most vulnerable

Rational thinking that is impaired

Social support that is impaired

Organized plan greater risk

No Spouse or worse, nagging spouse family

Sickness, esp. chronic or terminal

SUICIDE TRIAD•Loss of spouse•Loss of job•Aloneness

Is Patient is SUICIDAL; nurse should: DIE•Direct question – “Are you going to commit suicide?”•Irregular interval of visit to pt. room•Early AM and period of endorsement – the time pt’s commit suicide

INDICATIVE SIGNS:1. Once easy to get along with, now sullen

and angry2. Gives away important, personal items3. Gets affairs in order, wills, insurances,

finances4. Direct verbalization of “I’m no good; “I’m

better off dead” NURSING DIAGNOSIS: Potential for

injury to self related to poor impulse control

NURSING GOAL: Client will not harm self

• IMPLEMENTATION:

1. Determine lethality potential

ask: “Have you thought of suicide/”

ask: “How would you do it?”

2. Determine if the client has the means to carry it out

3. Determine how in touch with reality the client is

4. Determine if the client is still communicating

5. Determine the client’s support system

6. Provide suicide precautions:

@ one-to-one 24-hour precautions

@ contract

@hospitalization

7. Offer support, safety, esteem

HISTRIONIC

Signs and symptoms:Keep self the center of attractionExcessive emotionalityRapidly shifting emotionsSeductive behaviorSelf dramatizationSuicidal threats and actionsExpressionistic speech

NARCISSISTIC PERSONALITY DISORDER

NARCISSSISTIC Signs and symptoms:

Sense of grandiose self-importanceExcessive self admirationLacks empathyFantasies of unlimited power, beauty or brilliance

Interpersonally exploitiveEnvious of others or believes others are envious of him or her

CLUSTER C: THE

ANXIOUS AND SAD GROUP

AVOIDANT: Signs and Symptoms:Fears criticism and rejection

Escapes intimate relationship

Avoidance of social eventsReluctant to encourage in new activities

DEPENDENT Signs and symptoms:

Passively allows other to assume responsibility for his/her life.

Marked dependenceLacks self-confidenceIntense pre-occupation and fear of abandonment

Avoid disagreement , may even tolerate mistreatment and abuse

ManagementReduce anxietypsychotherapyFacilitates expression of ideas and feelings

Offer assistance only when needed

OBSESSIVE-COMPULSIVE

Signs and symptoms:Pervasive rigidity and preoccupation

with control and power and an exaggerated fear of losing control

perfectionist Management:

Assist in coping with compulsive behavior (accept rituals as interruption will increase anxiety)

Reduce anxietySelf-limits to destructive actsEncourage alternative activity

Obsessive-Compulsive Disorder (OCD)

Obsessions: Recurrent thoughts, ideas, visualizations, or inappropriate impulses that disturb a person’s life; has no control over them.

Compulsions: Behaviors or rituals continuously carried out to get rid of the obsessive thoughts and reduce anxiety.

OCD is an anxiety disorder that is ego-dystonic (uncomfortable to person), whereas OCPD is a rigid way of functioning in the world.

Obsessive-Compulsive (perfectionist) PD

Preoccupied with orderliness, perfectionism, inflexibility, need to be in control

Formal and serious interpersonal relationship Judgmental of self and others

OCPD clients do not see that there is any problem with their excessive detail or controllingways. They do not see that they need to change.

Nursing interventions: Remember, a lot of the time people feel guilty about

their thoughts and behaviors. Do not try to stop the act unless the act is harmful

(dangerous) Talk to them! Use “I” statements If they are too down on themselves—limit your time

with them. For instance, “I hate myself. No one cares about me. I’m fat and ugly.” The nurse would then say, “I am going to come back in 30 minutes. In that time frame, I want you to think of your good qualities.”

Do not argue with OCD person. Inject reality. If a teenager thinks she is pregnant

despite a negative pregnancy test, tell her the TEST IS NEGATIVE. Take them back into reality.

If they repetitively do an act over and over again; help them set a goal. For instance, “Let’s try to only wash your hands once every ten minutes.”

NURSING INTERVENTIONS

Work with the client to increase coping skills and identify need for improved coping

Respond to client’s specific symptoms and needs

Keep communication clear and consistent Client may require physical restraints,

seclusion/observation room, one to one supervision .Follow policies and procedures

Keep client involved in treatment planning

Behavior contract may be used for anger and aggression, suicidal ideation, manipulation, or isolation

Require that the client take responsibility for his/her own behavior and the consequences for actions.

CLIENT AND FAMILY EDUCATION Discuss with the client and family the possible environment and situational causes, contributing factors, and triggers

Help the client and family to identify the internal and external indicators of personality disorders

Educate the client and family about the following:Coping skills anger managementStress managementProblem solvingMedication adherence

THANK YOU FOR LISTENIN

G!

TRAITS: Poor interpersonal relationship Suspiciousness Social anxiety Failure to conform to social norms

Self-destructive behaviors Demanding and Manipulative Inappropriate response to stress and inflexible approach to problem solving

Long term difficulties in relating to others, in school and in work situations

Ability t cause others to react with extreme annoyance or irritability

Depression Anger and aggression Difficulty with adherence to

treatment Harm to self or others (suicidal

ideation, self mutilation, violence towards others, or threats)

Egocentric

Overwhelming fears of abandonment

Pessimistic, immature, lonely , and impulsive

NURSING INTERVENTIONS

Work with the client to increase coping skills and identify need for improved coping

Respond to client’s specific symptoms and needs

Keep communication clear and consistent Client may require physical restraints,

seclusion/observation room, one to one supervision .Follow policies and procedures

Keep client involved in treatment planning

Behavior contract may be used for anger and aggression, suicidal ideation, manipulation, or isolation

Require that the client take responsibility for his/her own behavior and the consequences for actions.

CLIENT AND FAMILY EDUCATION Discuss with the client and family the possible environment and situational causes, contributing factors, and triggers

Help the client and family to identify the internal and external indicators of personality disorders

Educate the client and family about the following:Coping skills anger managementStress managementProblem solvingMedication adherence