Personality Disorders

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Personality Disorders
2013-02-05 12:00:56

Mental Health
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  1. What are some common characteristics of personality disorders?
    • Needy 
    • Pose many challenges to care providers
    • Often lack ability to change
    • Unable to tolerate frustration, pain
    • Overreact to stimuli
    • Unable to identify feelings properly
    • Occur in 10-18% of population
  2. Four primary characteristics of personality disorders?
    • Maladaptive responses to stress (stress reducing strategies may not work)
    • Disability in working and loving
    • Evokes interpersonal conflicts
    • Has an intense effect on others
  3. DSM IV-TR criteria for personality disorders
    • Pattern is manifest in two or more areas:
    • Cognition-thinking
    • ways of perceiving self, others and events
    • Affect -feeling
    • range, intensity, labiality and appropriateness of emotional response
    • Poor interpersonal functioning 
    • Poor impulse control
    • Affects personal, social, and occupational functioning, but maybe not to the point of not being able to function at all. 
    • Clinically significant distress 
    • Onset can be traced to adolescence or early adulthood
    • Inability to attach to others
    • Manipulative of others
    • Gets into power struggles
    • Fears closeness
    • Disturbance in “who they are” (self-identity)
    • Personality disorder vs. characteristics or traits
  4. What are some nursing interventions for personality disorders?
    • Protection from self-harm
    • Establishing a therapeutic relationship
    • Family involvement
    • Milieu therapy
    • Limit setting and structure, and boundaries. Don't get manipulated.  
    • Focusing on strengths
    • Behavioral interventions
    • Coping skills
    • Dialectical Behavioral Therapy*
  5. DSM IV Paranoid personality disorder
    • Pattern of suspicion with 4 or more of:
    • Expects exploitation
    • Preoccupied with unjustified doubts about loyalty of others, hypervigilant for betrayal
    • Reluctantly confides in others 
    • Fears others will use info against them
    • Reads hidden meaning into benign remarks
    • Bears grudges
    • Perceives attacks on character not apparent to others; quick to counterattack
    • Suspicious without justification
    • Cold, aloof, objective
  6. Nursing interventions for paranoid personality disorder?
    • Build relationship – with skill and caution! (Again, remember boundaries)
    • --Follow through with promises
    • --Maintain boundaries
    • Teach
    • --Clarification and validation/restatement
    • --Constructive outlets for stress
    • --Social skills
    • Give permission to have feelings and help them cope appropriately
    • Confront excessive self-importance if needed
    • Ask indirect questions & let them set the interpersonal distance
    • Be consistent as a team of care providers
  7. Antisocial personality disorder?
    • Disregards and violates rights of others since age 15 (Until age 18 -- Conduct Disorder)
    • Possess 3 of:
    • --Failure to conform to social norms/law
    • --Deceitful, repeated lying or conning of others
    • --Highly impulsive
    • --Irritable and aggressive; gets into fights
    • --Disregards the safety of others
    • --Irresponsible, unable to work or honor financial obligations
    • --Lack of remorse
    • --Does not profit from experience – a key component
  8. Nursing interventions for antisocial?
    • Intervene in manipulation and impulsivity
    • Direct confrontation. Don't beat around the bush and make sure there are definite and immediate consequences. 
    • Point out responsibility
    • Set limits and establish consequences 
    • Encourage to talk things out rather than act out
    • Encourage pt to accept responsibility for behavior
    • Teach social skills
    • Group therapy preferred
  9. Borderline personality disorder
    • Has unstable interpersonal relationships
    • Highly impulsive, ie inappropriate, intense anger, frequent displays of temper  -- impulsive aggression is the hallmark
    • Poor self-esteem
    • 5 of:
    • --Avoids abandonment
    • --Identity disturbances
    • --Unstable, intense relationships: overvalues and devalues others
    • --Excess behaviors: spending, sex, substance abuse, reckless driving, binge eating
    • --Suicidal behavior or self-mutilating
    • --Affect instability or emotional labiality
    • Chronic feelings of emptiness
    • Suspiciousness or dissociative symptoms
    • Uses splitting with others-     
    • Switches between opposite sides of conflicts, overvaluing/devaluing, denies responsibility for acting out, devalues others to make self look better, idealizes positive traits in others,  projects parts of self onto others and acts out the parts
  10. Nursing interventions for Borderline PD?
    • Dialectical Behavioral Therapy: life skills, 1:1 therapy, 12 weeks therapy groups. 
    • Social skills
    • --Anger management strategies
    • --Mindfulness
    • --Stress management
    • Avoid splitting, use consistency among staff
    • Avoid being alone with them if possible
    • Support staff who are the brunt of their anger and acting out
    • Set limits on impulsivity
    • Group therapy
    • Monitor suicidality – How?
    • Monitor self-mutilation – How?
  11. What is Narcissistic PD?
    • Grandiose but with underlying fragile self-esteem
    • Lacks empathy
    • 5 of:
    • Exaggerated self-importance
    • Preoccupied with fantasies of unlimited success
    • Believes they are “special”
    • Requires excessive admiration
    • “Entitled”
    • Exploitative
    • Envious of others
    • Arrogant and haughty
  12. Nursing interventions for pt with Narcissistic PD?
    • Gain a therapeutic alliance-Will they listen to you?
    • Teach social skills
    • Assist with appropriate self-esteem
    • Assist in putting self in others place
    • Deal with manipulations
    • Confront exaggerated self-importance – offer a reality check! 
  13. What is Histrionic PD?
    • Excessively emotional
    • Seeks constant attention             
    • 5 of:
    • Seek to be the center of attention
    • Seductive
    • Rapid shifts in emotion; can be shallow or exaggerated
    • Uses appearance to draw attention
    • Dramatic, theatrical
    • Is suggestible
    • Considers relationships more intimate than they are
  14. Nursing interventions for Histrionic PD?
    • Give attention when not demanding it
    • Withdraw attention when behavior is inappropriate
    • If threatens self-harm, take action
    • Point out inappropriate behavior
    • Protect staff members of opposite sex from patient’s advances. Do not treat pt with opposite sex nurse and work in pairs. 
    • Remove from “audience” if needed
    • Set limits on seductiveness
    • Focus attention away from somatic complaints
    • Assist to focus on own problems
  15. What is Dependent PD?
    • Excessive need to be taken care of
    • Is submissive and clingy
    • Fears separation
    • 5 of:
    • Has difficulty making decisions
    • Needs excessive advice
    • Needs others to assume responsibility for major life areas
    • Has trouble disagreeing 
    • Has trouble initiating projects
    • Goes to lengths to obtain nurturance and support
    • Feels helpless when alone
    • Exaggerated fears of not being able to care for self
    • Seeks another caretaking  relationship when one ends
    • Unrealistically preoccupied with fears of being alone and taking care of self
  16. Nursing interventions for Dependent PD?
    • Ascertain level of functioning and set realistic goals with patient
    • Teach problem-solving
    • Teach self-reliance
    • Reward any independent action
    • If necessary, relocate away from people who tend to keep patient dependent
    • Meet some dependency needs and move toward independence
    • Acknowledge and allow to express feelings safely
  17. What is Obsessive-Compulsive PD?
    • Preoccupied with orderliness, perfectionism, and interpersonal control at the expense of efficiency and emotional availability
    • 4 of:
    • Preoccupied with details, organization
    • Perfectionism that interferes with task completion
    • Excessively devoted to work, excludes play and people
    • Overly conscientious
    • Inflexible
    • Cannot delegate tasks unless others submit exactly to their way of doing things
    • has a miserly spending style
    • is rigid and stubborn   
    • the job is important, relationships are not
  18. What are some nursing interventions for a pt with OCPD?
    • Assist to become aware of and deal with feelings
    • avoid power struggles
    • teach assertive skills
    • help them to “lighten up”
    • build in positive structure
    • assist with decision making
    • teach empathy (place in other’s shoes)
    • guard against their manipulation
  19. What is avoidant PD?
    • Pattern of social inhibition
    • Feels inadequate
    • Is hypersensitive to criticism
    • Has 4 of: 
    • Avoids work where there is criticism, disapproval, rejection
    • Need guaranteed acceptance/liking before will invest in friends
    • Restrained with intimate relationships
    • Sensitive to criticism or rejection
    • Views self as socially inept, takes few risks
  20. Nursing interventions for Avoidant PD?
    • Assist in improvement of self-image
    • Teach social skills
    • Support interaction with others
    • Support risk taking with others
    • Teach assertiveness
  21. What is the #1 intervention for patients with personality disorders?
    • Dialectic Behavioral Therapy. 
    • Other primary therapies are:
    • Protection from self-harm
    • Establishing a therapeutic relationship
    • Family involvement
    • Milieu therapy
    • Limit setting and structure
    • Focusing on strengths
    • Behavioral interventions
  22. T/F: Drugs are not typically helpful for pts with PDs.
    • True. 
    • They are prescribed anyway, i.e.:
    • SSRIs
    • Benzos
    • Antipsychotics