Lecture 10 - Personality Disorders Flashcards
What is personality?
A complex pattern of characteristics, largely outside of the person’s awareness.
–> Distinctive and stable patterns of perceiving, feeling, thinking, coping and behaving.
–> Emerges within biopsychosocial framework
What is a personality disorder?
An enduring pattern of deviant inner experiences and behaviours
–> Differ from cultural expectations. Is pervasive, inflexible, and stable
–> Leads to distress or impairment
*Often co-morbid to other psychiatric disorders
What are common features of personality disorders?
Cognitive Alterations
–> Altered interpretation of actions, relationships caused by maladaptive coping that results in dysfunctional ways of responding
Altered emotional stability
–> Alterations in person’s emotional arousal patterns which decreases one’s ability to accurately perceive one’s environment
Altered interpersonal functioning & self-identity
–> Identity may be disturbed or even absent
–> W/o adequately formed identity, an individual’s goal-directed behaviour is impaired and relationships are disrupted
Altered control of impulses - results in destructive behaviours
–> Inability to delay reactions and consider the consequences of their actions
With which three factors do we determine severity of a personality disorder?
Tenuous emotional stability
Interpersonal inflexibility
Tendency to become trapped
Tenuous emotional stability is a factor in determining severity of a personality disorder. What is meant by this?
Fragile personality patterns that lack resiliency under subjective stress.
Exaggerated emotions, unable to cope with normal stressful events.
Interpersonal inflexibility is a factor in determining severity of a personality disorder. What is meant by this?
People with healthy personality patters learn to be flexible in interactions with other people (relationships) and their environment.
People with unhealthy personality patters may not adapt effectively to interactions with others (doesn’t necessarily alter their social functioning)
Tendency to become trapped is a factor in determining severity of a personality disorder. What is meant by this?
Inflexibility generates and perpetuates dilemmas.
Exaggerated emotional reaction, followed by an impulsive action may lead to an unwanted sequence of events.
What are the cluster A personality disorders?
Paranoid, schizoid, schizotypical
What are the cluster B personality disorders?
Borderline, antisocial, histrionic, narcissistic
What are the cluster C personality disorders?
Avoidant, dependent, OC
What are the features of paranoid personality disorder?
How do those with it interpret intentions and how is their insight?
Mistrustful, avoid relationships that cannot control (prefers solitude, avoids intimacy, secretive).
Incidents are often misinterpreted as having sinister or hidden meaning.
Tend to lack insight into their behaviours and may be hypercritical and attribute these traits to others (projection).
What is the etiology of paranoid personality disorder?
Possible genetic link
–> relatives of persons with schizophrenia
–> persons with paranoid personality disorder may have been the source of parental conflicts and victims of some sort of harassment (due to odd behaviours)
How can we treat paranoid personality disorder?
Psychotherapy
–> focused on developing trust in relationships
Role play
–> may be initially perceived as threatening
Reality checks
Pharmacotherapy: as needed for symptom management of anxiety and sporadic delusions
What nursing assessment and interventions are helpful for paranoid personality disorders?
Nurse -Client relationship may be challenging to establish
Use straight forward communication - being to friendly or joyful can be perceived as joyful
–> Setting boundaries
–> Use of acceptance, reflection, confrontation
Goal is to assess problematic areas, gain another view of the situation and gently confront through reality checks and use of unhealthy coping mechanisms
What are features of schizoid personality disorder?
How are their social relationships?
Expressively impassive (unable to experience the pleasurable aspects of life), indecisive and interpersonally unengaged.
Blunted or flat affect.
Introverted, reclusive and heightened anxiety when engaging in social activities.
Often incapable of forming social relationships or react appropriately (emotionally) to others.
Rejection of intimacy.
–> If friendship or intimacy is established = delusional content may be divulged (e.g., imaginary friends)
Depersonalization and detachment –> life observers, not participants
What is the etiology of schizoid personality disorder?
Unexplained role of heredity
–> w schizophrenia and schizotypal personality disorder
Associated with detachment and neglect during childhood
–> Alone in school and have poor academic results
How can we treat schizoid personality disorder?
Psychotherapy
–> Individual and group to improve interpersonal relationships
Pharmacotherapy
–> Antidepressants for impassivity
–> Antipsychotics to improve expressiveness
What is the goal of care with schizoid personality disorder?
Enhance the pleasure and increase emotional responsiveness to others
What nursing assessments and interventions should be used for schizoid personality disorder?
Assessments:
MSE aimed at identifying symptoms such as delusions with goal to address fears in order to increase pleasure
Interventions:
Do not encourage social interactions, work only on anxiety and coping
Have realistic expected outcomes to increase the pt’s satisfaction with solitary activities
Milieu therapy to protect the patient against being ridiculed/intimidated.
What are features of schizotypal personality disorder?
Eccentric
–> without attaining the level of decompensated schizophrenia.
Pattern of social and interpersonal deficits
–> no close friends – seeks solitude.
Cognitive and perceptual distortions
–> magical thinking, ideas of reference, illusions, bizarre communication – paranoia (people out to get them)
Constricted and inadequate affect.
Difference with schizophrenia: these people can be made aware of their perceptual disturbances.
What is the difference between type A PDs and schizophrenia?
PDs tend to remain stable throughout the person’s life (including childhood)
Schizophrenia is dynamic and evolves, with cognitive decline that is not present in PDs.
Level of behaviour “oddness” - schizoid - schizotypal - schizophrenia
What is the etiology of schizotypal personality disorder?
First degree relatives with schizophrenia
Brain abnormalities consistent with those with schizophrenia
What treatment is used for schizotypal personality disorder?
psychotherapy
–> Interpersonal and group for interpersonal relationships
Pharmacotherapy
–> Low dose antipsychotics to help with positive symptoms and improve day-to-day function
What assessments and interventions can be helpful for those with schizotypal personality disorder?
Assessment:
MSE focus on addressing symptoms requiring immediate action such as command hallucinations, thoughts of self harm/suicide, and delusions that might put themselves of others in danger
Intervention:
Similar to management of schizophrenia
–> Respect of person’s need for solitude
Respect and be aware the bizarre beliefs or associations with groups and cults may be an integral part of a person’s life
–> May be source of interpersonal satisfaction out of these groups
What are the features of BPD?
Instability of interpersonal relationships
–> fear of abandonment, unstable self-image, emotions, identity
Ambivalence
–> from solitude to need for intense social support
–> from idealization of others to intense devaluing
When personal expectations are not met: intense shame, self-hate and self directed anger
–> substance use, frequent self-harm and suicide attempts (in periods of dissociation) – possible psychotic episodes.
Intense and lability in affect
–> frequent depression and anxiety, anger, feeling of emptiness (feeling numb), emotional manipulation, impulsivity, splitting, self-centeredness.
–> Impulsivity
Dichotomous thinking, projective identification (blame others for what happens to them).
What is the etiology of BPD?
Consider both upbringing and biological factors.
Invalidating environment where one’s feelings are constantly devalued this creates confusion about one’s own feelings (self-invalidation).
Separation-individuation process disruption (overly attached or indifferent caregivers = attachment issues)
Biological
–> Decreased serotonin leads to increased impulsivity/aggression
–> Changes in prefrontal cortex and limbic regions of the brain
How is BPD treated?
DBT
–> Goal is to tolerate distress
Pharmacological therapy
–> Antidepressants for emotional instability and anxiety
–> Mood stabilizers to reduce impulsivity
–> Antipsychotics for transient psychotic episodes, and to reduce impulsivity
What assessments should we focus on for BPD?
Focus on Hx of abuse and explore thoughts of harm and suicide
–> Be specific about self-injurious behaviours to create opportunity for intervention
What interventions can be helpful for those with BPD?
Establishing a Stable therapeutic relationship
–> Initial idealization and subsequent devaluation of providers d/t unmet expectations
–> Important to clearly the day, time and duration of each contact and to remain consistent
–> Communication of treatment plan
–> Discuss purpose of limit setting
Prevention of self Injurious behaviours and management of dissociative states
–> five senses and breathing exercises
Sleep
–> Enhance regular sleep-wake cycles
–> Moderate exercise
–> Special considerations for individuals who have been physically or sexually abused
What are features of antisocial PD?
Interpersonally engaging and charming, but lack empathy and remorse - lack of regard for other people’s rights
Pervasive pattern of disregard for, and violation of, the rights of others
Impulsive and interpersonally irresponsible – exploitation of others (violence)
Manipulative, lying, impersonal sexual relationships, detachment, hostility.
Fail to adapt to the ethical and social standards of community – self-centeredness, unstable social and professional life
Easily irritated, often aggressive – seeks immediate gratification (disinhibition)
What is the etiology of antisocial PD?
Genetic predisposition set in motion by environmental factors such as inconsistent parent, abuse, significant neglect.
Impulse control and conduct problems as children
What is the specific treatment for antisocial PD?
No specific treatment
What nursing assessments should be prioritized in antisocial PD?
Assess for life stressors, history of patterns of violence and substance use
What nursing interventions can be helpful for those with antisocial PD?
Those with antisocial PD are typically involuntarily admitted to inpatient forensic units - in this case the priority is safety of staff and other patients
Milieu Interventions
–> Structured environment with rules
–> Establish clear boundaries during the develop phase of the therapeutic relationships
Role of the nurse is to be consistent, offer support and boundaries regarding socially appropriate behaviours and limits regarding relationships - listen and validate emotions expressed by patients.
What are features of histrionic PD?
Attention seeking, life of the party, extraverted, exaggerated and theatrical behaviours
Excitable and emotional person
Externally validated
–> seeks immediate gratification and has propensity towards seduction, manipulation, self-centeredness, validation, attention and comfort
Uncomfortable with single relationship
Become distressed when not centre of attention
What is the etiology of histrionic PD?
Some biological theories, nothing clearly defined
What treatment is effective for histrionic PD?
Psychotherapy
–> Focus on emotional clarification that may be explored through individual and group therapy.
Although Group therapy context may be problematic
What should be focused on for an assessment of histrionic PD?
MSE should focus on thoughts of suicide
What nursing interventions can be helpful for those with histrionic PD?
Help the patient develop a sense of self without the validation of others - reinforce personal strengths
–> Seductive behaviours are linked to distress
Ensure that the pt does not become dependent on the mental health system
–> encourage the patient to act autonomously and role model assertiveness
Use clear, descriptive and concrete explanation rather than abstract language
What are the features of NPD?
Grandiose, inexhaustible need for admiration, arrogance, manipulative, exploits others, seeks success and lack of empathy
Believe that they are superior, unique, special (inflated self-worth)
They define the world through their own self-centred view - often seen with absent insight
Hyper sensible to evaluations others make of them; incapable of accepting critique – fear lack of power
–> In reality, these people’s self-esteem is very low (overcompensation), feel intense shame and have a fear of abandonment
Not always a huge violation of rights of other people
What is the etiology of NPD?
Familial Tendency
–> Children of parents with NPD have a tendency to be more prone to this illness
What treatment is used for NPD?
No not see themselves as having problems - but may be seen in other types of therapy such as family or couples
If in individual therapy
–> CBT for destructuring faulty thinking
No approved pharmacological therapies
What nursing interventions can be helpful for those with NPD?
Avoid engaging in power-struggled or being defensive
Remain neutral and recognize low self-esteem and fear of shame in persons with narcissistic personality disorders
Role model empathy, healthy relationships, foster interpersonal exchanges and set realistic expectations and support the patient through healthy processing of criticisms and failures
What are features of avoidant PD?
Very sensitive to rejection and critique
Constantly feels inferior and rejected (very low self-esteem)
Avoiding interpersonal contacts and social situation (very rigid routine)
Perceive themselves as socially inept
What is the etiology of avoidant PD?
May be hereditary influences, but primary psychosocial influence could be rejection and critique from parents
How is avoidant PD treated?
Psychotherapy
–> Individual or group to focus on trust and assertiveness to process anxiety provoking symptoms
Pharmacotherapy
–> Anxiolytics
–> B-adrenergic antagonist (hyperactivity)
–> Antidepressants (social anxiety)
–> Serotonergic agents (sensitivity to rejection)
What nursing interventions can help someone with avoidant PD?
Reassurance, acceptance and assertiveness (to learn how to express needs)
Refrain from pushing persons with avoidant personality disorders in fear provoking social environments (severe anxiety)
Focus on refraining negative criticism.
Explore previous achievements of success.
What are the features of dependent PD?
Submissive pattern
–> incapacity to make decisions; constantly in need of advice and comfort; fearful of separation and abandonment
Cling to others – needs to be cared for
Tendency to devalue one self
What is the etiology of dependent PD?
Chronic physical illness or chronic punishment for independence during childhood
What treatment is effective for dependent PD?
Psychotherapy
–> CBT to target thoughts that result in fearful behaviour
Pharmacotherapy for symptom management
What should we prioritize in assessment with someone with dependent PD
Vulnerability and exploitation and explore stressors
What nursing interventions can be helpful for someone with dependent PD?
Support autonomy and help with coping mechanisms targeting anxiety and modelling assertiveness skills
Be aware of counter-transference linked to numerous demands and crisis management needs
What are the features of OCPD?
Rigidity, perfectionism, and control are part of the clinical picture.
–> Prioritize work and productivity.
Too disciplines and perfectionist – excessive preoccupation with rules, details
–> incapacity to meet deadlines
Tendency to be dominant, rigid and inflexible
–> Related to the fear of making mistakes or to lose control
Difficulty to share emotions
What is the etiology of OCPD?
An authoritative parenting style
What treatment can be effective for OCPD?
Consider both psychotherapy and pharmacotherapy.
Psychotherapy
–> Group therapy and behavioural therapy to learn coping skills and manage anxiety
Pharmacotherapy:
–> Clomipramine and other serotonergic agents to manage obsessions, anxiety, and depression
What nursing interventions are helpful for those with OCPD?
Avoid power struggles and support with changes and transitions using a friendly, accepting, and reassuring approach
Help identify defense mechanisms such as isolation, intellectualization, rationalization and help change perfectionist coping mechanisms for more effecting coping techniques
Milieu - provide structure and leave enough time for persons to complete the actions they need to complete
What is the difference between OCDP and OCD?
OCD
–> Obsessive thoughts and compulsions, but acknowledge that obsessions and compulsions are unreasonable
OCPD
–> Unhealthy focus on perfectionism, and patient believes that their actions are right and feel comfort in these self-imposed rules ad perfectionism.
What did Dickens et al. study in their education intervention program concerning care for those with BPD?
People with a diagnosis of BPD are some of the most frequent
users of mental health services. They and their families are fully aware that they receive a poorer service than other mental health service users.
Further education and resources are required for nurses to provide high quality care and eradicate stigma towards those with bpd
Personality disorders often occur in comorbidity with what other psychiatric disorders?
EDs, mood, anxiety, substance use.
What is the dominant defense mechanism used by those with paranoid PD? What kinds of relationships do they have as adults?
Projection
–> Relationships can be challenging d/t jealousy, controlling behaviour, and unwillingness to forgive
Eccentric practices, beliefs, and groups may be an important part of the lives of patients with which personality disorder?
STPD
According to Margaret Mahler, what is the etiology for BPD?
Disruption in the process of healthy separation from the primary caregiver (mother)
What is the primary defense mechanism used by those with BPD?
Splitting
–> Inability to incorporate positive and negative aspects of oneself or others into a whole image
What are the five dimensions of personality?
Extraversions vs Introversion
Antagonist vs Adherence
Constraint vs Impulsivity
Emotional Dysregulation vs Stability
Unconventionality vs Closedness to Experience
