psych personality disorders Flashcards
Personality traits:
characteristics that an individual is born with or develops early in life. Sometimes referred to as “temperament traits”. They influence the way we perceive and relate to the environment. Relatively stable over time.
Personality Disorders:
occur when these traits become rigid and inflexible and lead to maladaptive patterns of behavior or impairment in functioning.
Personality disorders differ (generally) from other major psychiatric disorders (e.g. schizophrenia, MDD) in the following ways:
No identifiable time of onset – characteristics are stable and lifelong (at least from early adulthood)
Speech is not disorganized
No hallucinations - not fully psychotic
Pervasive – the disorder is present in virtually everything the client does
personality disorders - features - Interpersonal inflexibility - treatment
a common treatment for this is to have clients “Fake it till you make it” to get them to try something new, like going to groups
personality disorders - boundaries?
Poor interpersonal boundaries
personality disorders - Poor affective range
often rely on one emotional state to deal with all problems, e.g., anger, fear
personality disorders - Impulsivity - how to deal w/ these pts.
Impulsivity is very common (esp cluster B types) – Deal with this by:
Validating client feelings
Emphasizing what is appropriate on this unit; don’t play parent, i.e., “because I say so.” RATHER, say “those are the rules on the unit”.
Reinforcing positive behavior
Setting limits and repeating, repeating, repeating (the rules) esp. for antisocial and borderline
treatment of PD (personality disorders)
Treatment of PDs is considered very challenging. prognosis is not great. Pharmacological interventions are marginally effective, if at all.
PD - substance abuse?
Substance abuse and depression are common comorbidities
PD - at what age to diagnose?
PDs are ‘hardwired’, with many developmental and genetic influences. They should never be diagnosed before adulthood because brain development, i.e., the ‘hardwiring’ continues at least until age 21, and probably even older.
CLUSTER A (odd or eccentric): (more paranoid) - name the 3 types
Schizoid personality, Schizotypal personality (schizophrenia light), Paranoid personality
Schizoid personality (oids avoid)
Main features are social withdrawal and flat affect. These pts are cold and aloof, preferring solitude. Unable to and/or uninterested in forming personal relationships with others. Inappropriately serious about everything and have trouble being lighthearted. Diagnosed more in men. 3-7.5% of the population.
Schizoid personality - defense mechanisms - just 2 (smart to withdraw the oid)
withdrawal, intellectualization.
detachment.
Schizotypal personality (schizophrenia light) (typical magical references)
Main features are ideas of reference, inappropriate affect, and belief in paranormal/magical phenomena. These pts are usually considered bizarre. Higher incidence when a first-degree relative has schizophrenia. Often become schizophrenic when stressed (about 50% lifetime). 1-4% of the population.
Schizotypal personality - defense mechanisms (typical withdrawn fantasies)
withdrawal, fantasy.
may be telepathic, but not extensive delusion.
Paranoid personality - are they normal in public?
Main features are hypervigilance, suspiciousness, and distrust of others’ motives.These folks rarely seek help and can often pull themselves together sufficiently when in public so as not to look maladaptive. Affects about 2-4% of populations, men more than women.
Paranoid personality - defense mechanisms - 3 of them (paranoid pride - prd)
projection, denial, reaction formation.
CLUSTER C (anxious or fearful): never seen inpatient - they can function, but not thriving. - name the 3 personality types
Avoidant personality, Dependent personality, OCD
Avoidant personality - more in men or women?
Main features: hypersensitivity to rejection/criticism, extreme shyness and social awkwardness leading to social withdrawal. Equally common in men and women. Affects 2-5% of the population.
Avoidant personality - defense mechanisms (2) (avoid displacing the projector)
displacement, projection,
Dependent personality
A pervasive and excessive need to be taken care of that leads to submissive, clinging behavior and extreme fear of separation. More common in women. Affects <1% of the population.
Dependent personality - defense mechanisms (Just 2)
(dependent child who avoids)
regression, avoidance.
can’t finish projects, need reassurance.
Obsessive-compulsive personality
Preoccupied with rules, details, orderliness, perfectionism, and control, at the expense of flexibility, openness, and efficiency. More common in men. Relatively common: 2-8% prevalence.
OCD - defense mechanisms - name the 4 (OCDs react w/ intellectual morals)
reaction formation, intellectualization, undoing (often ritualistic behavior), moralizing.
not really obsessed with germs, but they do wash their hands more than normal.
CLUSTER B (dramatic, emotional or erratic): name the 4 types
Narcissistic personality, Histrionic personality (drama queen), Antisocial personality, Borderline personality
Narcissistic personality
Main features: Grandiose, arrogant and entitled. Believes that they are special and requires excessive admiration. Lack of empathy. Hypersensitive to the evaluation of others. Exploitation of others for self-gratification. Frequently learned through parent behavior. Prevalence is estimated to be about 2-6%, more common in men than in women.
Narcissistic personality - defense mechanisms (narcissism splits ppl)
black and white thinking. SPLITTING.***
Histrionic personality (drama queen)
Main features: overly dramatic, attention-seeking and exhibitionistic. Tough on relationships, requiring constant affirmation and approval from others. 1-2% of the population, more common in women.
Histrionic personality - defense mechanisms (historically we regress and repress)
regression, repression
sexually inappropriate. uses physical appearance to get attention. theatrical. relationship issues.
Antisocial personality - what age does this begin?
Estimated prevalence is 3-4% of men/1% of women in the U.S. Higher in lower S/E classes, particularly among highly mobile residents of impoverished urban areas. violation of the rights of others. begins at age 15. getting arrested, lying, impulsivity, aggressive, fights, no concern for safety.
Antisocial personality - defense mechanisms (just 2) - (Aunty, it’s not my fault)
denial, projection
Antisocial personality - major features
Lack of empathy (pts with APD routine exploit others for their own personal gain)
Lack of remorse for wrongdoing
Flagrant disregard for the law and the rights of others (frequently in jail)
Manipulative (don’t document behavior as manipulative), deceitful and impulsive.
Can be aggressive (DTO is a major concern)
Often charming (but often not, especially when others are on to them). Charming vs. threatening, whatever works.
Substance abuse is very common
Working with pts with APD (antisocial personality disorder)
FREQUENT, CONSISTENT LIMIT SETTING from the beginning! Emphasize unit rules. Don’t engage in power struggles.
APD - redirect
Redirect their bad habits with activities; these pts tend to act out when bored
APD (antisocial personality disorder) - what is the one thing you should w/ these patients?
Validate their emotions*** (especially anger) prn. While you never want to reinforce their deplorable behaviors, you do want them to feel understood. Frequently, these pts were themselves victim of severe abuse/neglect as a child and feel very misunderstood.
APD - responsibility
Help them take responsibility for their actions
APD - therapy?
Most therapies do not work with these clients. What seems to work best are confrontational peer groups that combine self-help, vocational rehab and professional guidance, e.g., Walden House and Delancey Street. but most therapies don’t work very well.
APD - aggression - what to do?
Recognize early signs of aggression and intervene immediately (e.g. calling for a “show of support” (other staff or security), offering prn medication, using de-escalation techniques)
APD - meds
Pharmacologic intervention – some evidence that SSRIs, mood stabilizers and atypical antipsychotics might help treat impulsivity and anger associated with personality disorders in general. none are FDA approved.
APD - anger management
Teach anger-management techniques (e.g. taking a deep breath, walking away) and role-model healthy expression of anger (e.g. using “I” statements). look in book about assertive behavior - DESK script.
Borderline personality
1-6% of the population. Seen frequently on inpatient units (10-20%) although BPD pts tend to regress inpatient, and do much better outpatient. Female/male ratio as high as 4:1. 10% mortality rate, mostly from SAs. fear of abandonment. feelings of emptiness, but always burning bridges. usually angry. history of abuse.
borderline - defense mechanisms - just 2
(split the projector on the border)
splitting, projection.
BPD - features
Boundary issues – ‘shaky’ sense of identity
Splitting (devaluation vs. idealization) – hypersensitivity to real or imagined rejection. Folks with BPD are always looking, often with great intensity, for someone they can depend upon, while simultaneously (and often intensely) fearing abandonment.
Sudden, violent outbursts, often self-directed
Impulsivity – drug abuse, binge-eating, reckless driving and/or promiscuous, unsafe sex
Labile mood, often with bouts of intense anger
Brief, turbulent relationships
An irrational fear of abandonment and inability to be alone
Self-injurious behavior (e.g. cutting, scratching, burning). Most of the time, pts with BPD are not truly suicidal, but rather “parasuicidal” (i.e. manipulative suicide gestures done to elicit a rescue response from significant others). However, sometimes even suicide gestures can become fatal.
BPD - assess for what?
Assess for SI and SIB frequently.
BPD - behavior plan
Consider creating a behavior plan for pts when they are inpatient so that they have a clear understanding of behavioral expectations and consequences for acting out. Make sure all staff are on board since pts are notorious for “splitting staff.”
BPD - prevention (think of craig)
Prevent them from acting out and monopolizing your time by letting them know when you will be available to them (e.g. “I’ll be checking on your every hour and we will have 5 minutes to talk each time I check on you).
BPD - activities
Keep them busy – these pts are often very bright, and they get bored easily, resulting in “acting out”
Teach and encourage use of stress reduction techniques (e.g. deep breathing) and coping skills
BPD - validation
Validate their feelings frequently***, but simultaneously encourage them to take responsibility for their actions (remember: their suffering is real, their coping mechanisms just suck) validate the emotion, BUT not the behavior.
BPD - therapy
Use Dialectical Behavioral Therapy (DBT)- this is the only truly effective, evidence-based treatment for BPD
Include patient in planning care. These patients are often very bright and need to have a sense of control.
Respond matter-of-factly to self destructive behaviors.
BPD - how to respond
Respond matter-of-factly to self destructive behaviors. BE CAREFUL NOT TO GIVE PT EXTRA ATTENTION (SECONDARY GAIN) FOR SIB (self injurious behavior) /SUICIDE GESTURES. stay neutral if they’re cutting. Reward good behavior, downplay bad behavior. “you have big emotions, and that’s ok, but we have to learn how to manage those in a healthy way”
BPD - discharge
Prepare LONG in advance for DC (fear of abandonment) and anticipate regression on the day of d/c
BPD - meds
Pharmacologic interventions – Please know that meds generally don’t work as well as DBT, but can be helpful for specific symptoms and comorbidities:
SSRIs/SNRIs may help with anxiety and depressive sxs
mood stabilizing anticonvulsants for irritability/hostility/impulsivity
increasingly, atypical antipsychotics as an adjunct to decrease irrational thinking
