Understanding Personality Disorders: Symptoms, Diagnosis, and Treatment, Exams of Nursing

Download Understanding Personality Disorders: Symptoms, Diagnosis, and Treatment and more Exams Nursing in PDF only on Docsity! NURS 2145 Chapter 19: Personality Disorders | pp. 432-456 • Personality: an individual’s characteristic patterns of relatively permanent thoughts, feelings, and behaviours that define the quality of experiences and relationships. • Personality trait: a stable characteristic of a person (Ex: neuroticism, agreeableness) • Personality type: s a stable characteristic of a person (Ex: authoritarian personality) • A personality is considered unhealthy when interpersonal and social relationships and functioning are consistently maladaptive, complicated, or dysphoric. CLINICAL PICTURE • Individuals with personality disorders display significant challenges in self-identity or self-direction, and they have problems with empathy, or intimacy within their relationships. • Treating personality disorders is difficult and complex, as people with these disorders have difficulty recognizing the problems. • People with personality disorders may injure themselves (self-harm). • Judgements about an individual’s personality functioning must take into account the person’s ethnic, cultural, and social background (people from different culture = possible overdiagnosis). • There are 10 personality disorders: ➢ Cluster A : Individuals with these disorders share characteristics of eccentric behaviours, such as social isolation and detachment. They may also display perception distortions, unusual levels of suspiciousness, magical thinking, and cognitive impairment. 1. Paranoid personality disorder 2. Schizoid personality disorder 3. Schizotypal personality disorder ➢ Cluster B: these people show patterns of responding to life demands with dramatic, emotional, or erratic behaviour. Problems with impulse control, emotion processing and regulation, and interpersonal difficulties characterize this cluster of disorders. Insight into these issues is generally limited. They can be antisocial, desperate, or manipulative. 1. Borderline personality disorder 2. Narcissistic personality disorder 3. Histrionic personality disorder 4. Antisocial personality disorder ➢ Cluster C: An individual with these types of personality disorders will demonstrate a consistent patterns of anxious and fearful behaviours, rigid patterns of social shyness, hypersensitivity, need for orderliness, and relationship dependency. 1. Avoidant personality disorder 2. Dependent personality disorder 3. Obsessive-compulsive personality disorder EPIDEMIOLOGY • Personality disorders are more frequently seen in people receiving extensive medical and psychiatric services. • Narcissistic and schizotypal personality disorders are rare, borderline and avoidant. • Culture has a definite influence on the rate of diagnosing personality disorders. • Differences may reflect the view of personality and behaviour as deviant rather than normal in a particular culture and within certain study methods. COMORBIDITY • Personality disorders frequently co-occur with disorders of mood and eating, anxiety, and substance misuse. • Personality disorders often amplify emotional dysregulation, a term that describes poorly modulated mood characterized by mood swings. • The dramatic, emotional, or erratic cluster B disorders may mute with age as individuals become less impulsive. • Other disorders such as obsessive-compulsive personality disorder or paranoid personality disorder may worsen with age. ETIOLOGY Biological Factors • While genetics are thought to influence the development of personality disorders, individual genes are not believed to be associated with particular personality traits. • Children are also affected by forces outside the family that influence personality development. • Influences on the development of personality disorders probably incorporate a complex interaction of genetics, neurobiology, and neurochemistry. Psychological Factors • Children develop maladaptive responses based on modelling of or reinforcement by important people in the child’s life. • Psychoanalytic theory focuses on the use of primitive defence mechanisms by individuals with personality disorders. • Cognitive theories emphasize the role of beliefs and assumptions in creating emotional and behavioural responses that influence one’s experiences within the family environment. ➢ Antidepressants such as bupropion (Wellbutrin) may help increase pleasure in life. Second-generation antipsychotics, such as risperidone (Risperdal) or olanzapine (Zyprexa), are used to improve emotional expressiveness. Schizotypal Personality Disorder • STPD symptoms are strikingly strange and unusual. Magical thinking, odd beliefs, strange speech patterns, and inappropriate affect are hallmarks of this disorder. • Like the other Cluster A personality disorders, symptoms are evident in young people. • Reduced cortical volume like schizophrenia. • Like schizoid personality disorder, individuals with STPD have severe social and interpersonal deficits. They experience extreme anxiety in social situations. • They ramble, with long, unclear and overdetailed explanations. They over suspicious and anxious (misinterpret other action and blame others for their isolation). • Odd beliefs (e.g., being overly superstitious) or magical thinking. • Psychotic symptoms seen in people with schizophrenia, such as hallucinations and delusions, may also exist with STPD, but to a lesser degree and only briefly. • Nursing care: ➢ Respect the patient’s need for social isolation. ➢ Nurses should be aware of the patient’s suspiciousness and employ appropriate interventions. ➢ Perform careful assessment as needed to uncover any other medical or psychological symptoms that may need intervention (e.g., suicidal thoughts). ➢ Be aware that strange beliefs and activities, such as strange religious practices or peculiar thoughts, may be part of the patient’s life. • Treatment: ➢ The principles of psychotherapy used are similar to those for schizoid personality disorder. ➢ Patients may be involved in unusual religion groups or cults. ➢ While there is no specific medication for STPD, associated conditions may be treated. People with STPD seem to benefit from low-dose antipsychotic agents for psychotic-like symptoms and day-to-day functioning. ➢ Treat anxiety and depression with meds. CLUSTER B PERSONALITY DISORDERS Borderline Personality Disorder • Characteristics: patterns of marked instability in emotion regulation, unstable interpersonal relationships, identity or self-image distortions, and unstable mood. • These symptoms result in severe functional impairments, a high mortality rate. • People with BPD seek out treatment for depression, anxiety, suicidal and self- harming behaviours, and other impulsive behaviours including substance use. • Genetic factor evident. • There is evidence of serotonergic dysfunction that accompanies the borderline trait of impulsivity. • Abnormalities in the prefrontal cortex and limbic regions. • Stages of separation-individuation process: 1. Birth to 1 month: Normal Autism: The infant spends most of his or her time sleeping. 2. 1 to 5 months: Symbiosis: The infant perceives the mother-infant as a single fused entity. Infants gradually distinguish the inner world from the outer world. 3. 5-10 months: Differentiation: Infant recognises distinctness from the mother. Progressive neurological development and increased alertness draw the infant’s attention away from self to the outer world. 4. 11-18 months: Practising: The ability to walk and explore greatly expands the toddler’s sense of separateness. 5. 18-24 months: Rapprochement: Toddlers move away from their mothers and come back for emotional refuelling. Periods of helplessness and dependence alternate with the need for independence. 6. 2-5 years: Object Constancy: When children comprehend that objects (in this case, the object is the mother) are permanent even when they are not in their presence, the individuation process is complete. • Children who later develop BPD may have had this process disrupted. • One of the pathological personality traits seen in people with BPD is negative affect. . This affect is characterized by emotional lability—that is, moods that alternate rapidly from one emotional extreme to another. • Other characteristics of a negative affect include responding to situations with emotions that are out of proportion to the circumstances, pathological fear of separation, and intense sensitivity to perceived personal rejection. • Impulsivity and antagonism also present. • Suicidal ideation present. • Borderline personality disorder is also characterized by feelings of antagonism, manifested in hostility, anger, and irritability in relationships (physical violence may occur). • Splitting, the primary defence or coping style used by people with BPD, is the inability to incorporate positive and negative aspects of oneself or others into a whole image. • Influenced by exposure to earlier psychological, sexual, or physical trauma • Nursing Care: ➢ A therapeutic relationship is essential. ➢ Conduct a thorough assessment of current or past physical, sexual, or emotional abuse and level of current risk for harm from self or others. ➢ Clinical supervision and additional education are helpful and supportive to health care providers. ➢ Awareness and monitoring of one’s own stress responses to patient behaviours facilitate more effective and therapeutic intervention, regardless of the therapeutic approach being used. • Treatment: ➢ Admitted to psychiatric treatment programs because of symptoms with comorbid disorders. ➢ Emotions such as anxiety, rage, and depression and behaviours such as withdrawal, paranoia, and manipulation are among the most frequent that health care workers must address. ➢ Be aware of manipulative behaviours. ➢ Realistic outcomes are established for individuals. ➢ Provide clear and consistent boundaries and limits. Use straightforward communication. When behavioural problems emerge, calmly review the therapeutic goals. ➢ goals. There are no approved medications for treating BPD. When medications are used, their purposes are to maintain patients’ cognitive function, relieve symptoms, and improve quality of life. ➢ SSRIs, anticonvulsants, and lithium for mood and emotional dysregulation symptoms. ➢ The primary goal is management of the patient’s affect in a group context. Community meetings, coping skills groups, and socializing groups are all helpful for these patients. Antisocial Personality Disorder • Characteristics: a pattern of disregard for, and violation of, the rights of others; referred to as sociopaths. • This diagnosis is reserved for adults, but symptoms are evident by the mid-teens. • Symptoms peak in 20s. • One is the trait of aggressive disregard, which refers to violent tendencies without concern for others; the other is the trait of disinhibition, which is a lack of concern for consequences. • Inconsistent parenting and discipline, significant abuse, and extreme neglect are associated with this disorder. • Virtually all individuals who eventually develop this disorder have a history of impulse control and conduct problems as children and adolescents. • The main pathological traits that characterize antisocial personality disorder are antagonistic behaviours such as being deceitful and manipulative for personal gain or being hostile if needs are blocked. • High level of risk taking, disregard for responsibility, and impulsivity, criminal misconduct. • People with this disorder are mostly concerned with gaining personal power or pleasure, and in relationships they focus on their own gratification to an extreme. CLUSTER C PERSONALITY DISORDERS Avoidant Personality Disorder • Low self-esteem related to functioning in social situations, feelings of inferiority compared with peers, and a reluctance to engage in unfamiliar activities involving new people. • They are especially sensitive to and preoccupied with rejection, humiliation, and failure. They often avoid new interpersonal relationships or activities due to their fears of criticism or disapproval. • Early symptoms of the disorder are often evident in infants and children. These symptoms include shyness and avoidance that, unlike common shyness, increases during adolescence and early adulthood. • Nursing Care: ➢ Nurses should use a friendly, accepting, reassuring approach and remember that being pushed into social situations can cause extreme and severe anxiety for these patients. ➢ Convey an attitude of acceptance toward patient fears. ➢ Provide the patient with exercises to enhance new social skills, but use these with caution because any failure can increase feelings of poor self-worth. ➢ Assertiveness training can assist the person to learn to express needs. • Treatment: ➢ Individual and group therapy is useful in processing anxiety-provoking symptoms and in planning methods to approach and handle anxiety-provoking situations. ➢ Psychotherapy focuses on trust and assertiveness training. ➢ Antianxiety agents can be helpful. Beta-adrenergic receptor antagonists (e.g., atenolol) help reduce autonomic nervous system hyperactivity. ➢ Serotonergic agents may help individuals with avoidant personalities feel less sensitive to rejection. Dependent Personality Disorder • Characteristics: a pattern of submissive and clinging behaviour related to an overwhelming need to be cared for. • May be the result of chronic physical illness or punishment for independent behaviour in childhood. • Stems from a fear of separation. • May be the result of chronic physical illness or punishment for independent behaviour in childhood. • Need to be taken care of, lack confidents, fear of separation and abandonment. • May manipulate others to take care of their responsibilities. • Nursing care: ➢ Nurses can help the patient identify and address current stressors. ➢ Be aware that strong counter-transference may develop because of the patient’s demands for extra time and crisis states. ➢ The therapeutic nurse–patient relationship can provide a testing ground for increased assertiveness through role modelling and teaching of assertive skills. • Treatment: ➢ Psychotherapy is the treatment of choice for dependent personality disorder. ➢ Cognitive behavioural therapy can help patients develop more healthy and accurate thinking by examining and challenging automatic thoughts that result in fearful behaviour. ➢ No specific medications. Obsessive Compulsive Personality Disorder • Characteristics: limited emotional expression, stubbornness, perseverance, and indecisiveness. Preoccupation with orderliness, perfectionism, and control are the hallmarks of this disorder. • More common in men than women. • Risk factors for this disorder include a background of harsh discipline and having a first- degree relative with this disorder. • The main pathological personality traits are rigidity and inflexible standards of self and others. People with obsessive-compulsive personality disorder rehearse over and over how they will respond in social situations. • Different from OCD. OCD is characterized by obsessive thoughts and by repetition or adherence to rituals. • Obsessive-compulsive personality disorder is characterized more by an unhealthy focus on perfectionism. Those with obsessive-compulsive personality disorder think that their actions are right and feel comfortable with such self-imposed systems of rules. • Nursing care: ➢ Nurses should guard against power struggles with these patients, as their need for control is very high. ➢ Patients with this disorder have difficulty dealing with unexpected change. ➢ Provide structure, yet allow patients extra time to complete habitual behaviour. ➢ Assist patients to identify ineffective coping and to develop effective coping techniques. • Treatment: ➢ The treatment course is often long and complicated. ➢ Both group therapy and behavioural therapy can be helpful, so that the person can learn new coping skills for his or her anxiety and see direct benefits for change from feedback within the group. ASSESSMENT Tools • Semi-structured interview by clinician: standard questions and a standard format for asking the questions. These interviews go beyond asking the patient to self-report symptoms because individuals with personality disorders often lack insight into their behaviours and motivations and therefore have difficulty accurately describing themselves. • Cultural norms and expectations also need to be considered when evaluating the presence of a personality disorder. • The five main dimensions of personalities are (1) extraversion versus introversion, (2) antagonism versus compliance, (3) constraint versus impulsivity, (4) emotional dysregulation versus emotional stability, and (5) unconventionality versus closedness to experience. • Open-ended or subjective interviews, which do not have standard questions or a standard question format. • Minnesota Multiphasic Personality Inventory (MMPI): useful to interpret tests: • Assess symptoms: ➢ Feelings of emptiness ➢ An inclination to engage in risky behaviours such as reckless driving, unsafe sex, substance use, binge eating, gambling, or overspending. ➢ Intense feelings of abandonment that result in paranoia or feeling spaced out. ➢ Idealization of others and becoming close quickly. ➢ A tendency toward anger, sarcasm, and bitterness ➢ Self-mutilation and self-harm ➢ Suicidal behaviours, gestures, or threats ➢ Sudden shifts in self-evaluation that result in changing goals, values, and career focus. ➢ Extreme mood shifts that occur in a matter of hours or days. ➢ Intense, unstable romantic relationships ➢ Feelings of insecurity ➢ Rigidity ➢ Perfectionism Patient History • Taking a full medical history can help determine if the problem is a psychiatric one, a nonpsychiatric medical one, or both. • Nonpsychiatric illness should never be ruled out as the cause for problem behaviour until the data support this conclusion. • Important issues in assessing for personality disorders include a history of suicidal or aggressive ideation or actions, current use of medications and illegal substances, ability to handle money, and legal history. • Consider: physical, emotional, sexual abuse. Safety and Teamwork • When patients are actively involved in developing their treatment plans, they typically take more responsibility for themselves and the success of implementing the plan. • Having limits and being confronted about negative behaviour are better accepted by the person if staff members first employ empathic mirroring. • Showing empathy may also decrease aggressive outbursts if the person feels that staff members are trying to understand feelings of frustration. • Acting in accordance with unit policies, the nurse remains neutral and dresses the cutting wound in a matter-of-fact manner. Pharmacological Interventions • People with STPD seem to benefit from low-dose atypical antipsychotic agents for their psychotic-like symptoms and day-to-day functioning. • People with antisocial personality disorder respond to mood-stabilizing medications like lithium to help with aggression and impulsivity. • People with BPD often respond to anticonvulsant mood-stabilizing medications, low- dose antipsychotic medications, and omega-3 supplementation for mood and emotion dysregulation symptoms. Naltrexone hydrochloride, an opioid receptor antagonist, has been found to reduce self-injuring behaviours. • People with avoidant personality disorder seem to respond positively to medications similar to those used for anxiety disorders, such as SSRIs like citalopram (Celexa) and SNRIs such as duloxetine (Cymbalta). Advanced-Practice Interventions • Dialectical behaviour therapy: based on a biosocial theory that views the self-harming behaviour as a behaviour used to cope with or eliminate distress brought on by a negatively perceived environmental event, self-generated behaviours, and individual temperaments. • DBT combines cognitive and behavioural techniques with mindfulness, which emphasizes being aware of thoughts and actively shaping them. • Interventions that are common to DBT and other behaviour therapies include cognitive restructuring, therapist reciprocal vulnerability, skills training, and reinforcement. • DBT encourages balance and synthesis of acceptance and change. • Patients are treated as a whole person; all aspects of their lives are interrelated and influence their behaviour and those around them. • The goals of DBT are to increase the person’s ability to manage distress and improve interpersonal effectiveness. • Treatment focuses on behaviour targets, beginning with identification of and interventions for suicidal behaviours and then progressing to a focus on interrupting destructive behaviours. Case Management • Case management is helpful for individuals with personality disorders who are persistently and severely impaired. • In the acute care setting, case management focuses on three goals: to gather pertinent history from current or previous providers; to support reintegration with family or loved ones as appropriate; and to ensure appropriate referrals to outpatient care, including substance disorder treatment, if needed. • In the long-term outpatient setting, case-management objectives include reducing hospitalization by providing resources for crisis services and enhancing the social support system.