PERSONALITY

Enduring and consistent attitudes,

beliefs,

desires,

& patterns of behavior.

Acquired in early childhood & become lifelong patterns of behavior.

Determines the quality of experiences among people.

Concepts of Personality

&

Personality Disorders

-Personality is the "style" of how one deals w/the world.

-Personality traits:

-stylistic peculiarities of how one deals w/the world

-Personality Disorders:

-DX under AXIS II in DSM-IV-TR

(not usu. hospitalized).

Personality Disorders

* APA states "an enduring pattern of experience & behavior that deviates significantly from the expectations with in the individual's culture".

*Occur in approx. 10%-15% of the general population.

* Major source of long term disability.

Personality Disorders continued:

Difficulty in 3 areas of day to day functioning:

1) thoughts & emotions

2) interpersonal relationships

3) impulse control

* Leads to clinically sig. distress or impaired social, occupational, or other important areas of functioning.

* Disrupts the quality of life for the person & their families.

can be EGOSYNTONIC: nothing wrong w/me, it is wrong w/you.

PARANOIA: angry outbursts.

ANTISOCIAL: more manipulative; steal

BORDERLNE: self mutilate, anger, emptiness, suicide attempts, sex, drugs, ETOH.

Common Characteristics

of

Personality Disorders

* Inflexible & maladaptive response to stress

* Disability in working & loving

* Ability to evoke interpersonal conflict

* Capacity to "get under skin" of others

* Become deeply ingrained & are very diff. to modify or change.

* Person rarely recognizes that any problem exits; EGO SYTONIC.

can be:

bright & observant, client rings bell all the time, wants RN all the time, multiple relationships and jobs, antisocial=manipulative, interpersonal conflict, deeply ingrained.

Characteristics

of

Personality Disorders

continued:

* Avoidance & fear of rejection

* Blurred boundaries b/t self & others

* Insensitivity to needs of others

* Demanding & fault finding

* Lack of accountability

Personality Disorders:

General Info...

* Comorbidities:

often more than one personality DX

AXIS I disorders common; substance abuse, somatization,eating disorders, PTSD, depression, & anxiety disorders.

Biological Theories

of

Personality Disorders

No single cause is identified

Genetics:

seem to play a role in schizotypal, schizoid, & paranoid personality disorders.

Neurobiological factors:

brain imaging suggests borderline personality disorder r/t abnormality in prefrontal, corticostriatal & limbic systems.

Other Theories

r/t

Personality Disorders

Psychological:

childhood abuse & trauma associated w/all disorders

-Borderline: sexual abuse common

Cultural considerations:

Native Americans, African Americans @ an increased risk

Other factors:

young adults w/low socioeconomic status, divorced, separated, widowed, never married.

Personality Disorder:

Cluster A: Odd or Eccentric

Paranoid

Schizoid

Schizotypal

Eccentric & odd behaviors

May also be perceptual distortions, unusual levels of suspiciousness, & magical thinking.

Stays alone

personality disorders:

Cluster B: Dramatic, Emotional, Erratic

Anitsocial

Borderline

Histrionic

Narcissistic

Probs. w/impulse control, emotion processing, & regulaton, & interpersonal difficulties.

Personality disorders:

Cluster C: Anxoius & Fearful

Avoidant

Dependent

Obessive-Complusive

NOS; dependent need for order

Rigid patterns of social shyness, hypersensitivity, need for orderliness, & relationship dependency

Assessment

of

Personality Disorders

1) (MMP) Minnesota Multiphasic Personality Inventory

to evaluate personality

-read by psychologist

-multi questions yes/no

-semi structured interview

2) FULL medical HX

3) Psychological HX:

suicidal or aggressive thoughts

risk of harm to self or others

use of meds or illegal substances

ability to handle $$$$

legal HX

current or past abuse

NSG process:

Assessment Guidelines 

* Self assessment essential:

dealing w/people w/PD is often diff., challenging, & frustrating.

* Relate personality functions to individuals ethnic/cultural background.

* Determine RECENT IMPORTANT LOSS;

crisis, divorce, etc.

* Do not set limits w/punitive position, want it to be therapeutic.

Effect of clients w/PD

on

caregivers

* Overwhelming needs of clients may also be overwhelming to caregivers

* Caregivers may feel:

confused

helpless

angry

frustrated

NSG process:

DX & Outcomes Identified

* Common Nsg DX:

Ineffective Coping

Risk for other directed violence

Risk for suicide

Risk for self mutilation

* Outcomes Identification:

Recognize that change may be slow, occur w/trial & error

Establish modest & obtainable goals.

Nsg Process:

Outcomes Identification

Pertinent categories based on:

Aggression self-control

Impulse self-control

Social interaction skilss

Fear level

Abusive behavior self-restraint

Self-mutilation restraint

Anxious or fearful

See Tab 19-3

Planning

Cluster A: 19-4

Cluster B: 19-5

Cluster C: 19-6

Nsg Process:

Planning & Implementation

Planning:

people w/PD seen in healthcare setting for other reasons.

Implementation:

RN needs to understand diff. w/creating therapeutic relationship w/client

-give choices

-orient pt to reality

-teach behaviors that build on existing skills.

Nsg Process:

Interventions w/PD client

* Combine limit setting, trustworthiness, & dealing w/manipulation w/own natural self-practice (therapeutic use of self).

* Use established interventions for:

-Manipulitive behaviors

-Implusive beahviors

-Aggressive behaviors

Nsg Process:

Interventions: Milieu Therapy

* Primary goal:

-Affect management in a group setting

* Therapeutic tools:

-community meetings. prob-solving groups, coping skills group, & socializing groups.

Treatment for clients w/PD:

Psychotherapy

* Psychodynamic psychotherapy:

-works toward insight development

* Cognitive Behavioral Therapy:

-Helps pt recognize faulty thinking & influence on problematic behaviors

* Dialectical behavior therapy (DBT):

-Developed by Marsha Linehan (1993) for pts w/borderline PD

-Focus on stabilzing pt & achieving behavioral control.

treatment for pts w/PD:

Medications

for

PD

* Benzodiazepines (BZAs) not appropriate b/c of dependency issues.

* Use of meds. w/low toxicity:

-Antidepressants (SSRIs)

-Lithium

-Anticonvulsants

-Low dose antipsychotics

Cluster B:

Borderline PD

Diff. controlling emotions

Stormy relationships w/anger & fighting

Presistant unstable self image

Use of splitting (idealizing & devaluing the same person).

Cluster B:

Borderline PD

continued

Frantic efforts to avoid real/perceived abandonment

Dramatic mood shifts, changes in opinions & plans

Impulsive, self damaging  behaviors

EX. recurrent suicide attempts or self-mutilation

Cluster B:

Borderline PD:

Gunderson & Singer

Involves intense contact

Hx of impulsive behavior

Superficial social adaptiveness

Brief, psychotic episodes

Primitive personality organization

Cluster B:

Borderline PD:

Underlying Dynamics

* Splitting:

unconsciously separating themselves into good/bad, black/white (all, no grey).

* Primitive Idealization:

derivitive of splitting, defensive; idealize other person..clingy.

* Projection identification:

primitive form of projection used to externalize aggressive feelings. Fear of this person porjected upon, also is coupled w/desire to control this person.

* Denial of ego states:

escaping unpleasant realities by ignoring their existence.

* Omnipotence of self w/devaluation of others:

unlimited power.

Splitting Behaviors

of

clients

w/PD

* Primary defense used by clients w/Borderline PD

* Client labels one person "all good" & the others "all bad"

* When "all good" person has not met the client's needs, that person becomes bad.

* Someone else then labeled "all good", others "all bad"

* Creates conflict in staff members

* To decrease conflict among staff:

-open communication in staff meetings

-ongoing clinical supervision

Cluster B:

Antisocial PD

* Chronic irresponsibilty & unreliability

* Lack of regard for law & rights of others

* Persistant lying & stealing for personal gain

* Conning others for personal gain

* Lack of remorse for hurting others

* Reckless disregard for others' safety.

Cluster B:

Antisocial PD

continued

* Characterized by deceit, manipulation, revenge, & harm to others w/an absence of guilt or anxiety.

* Sense of entitlement

* superfacial charm

* Unable to postpone gratification

* Lack of empathy

* Behaviors that cause conflict w/society

* Inability to sustain consistent work.

* Lack of ability to function as a parent.

* Unable to maintain relationships.

Antisocial PD/Cluster B:

Manipulation

* Process by which one individual influences another to function with his/her needs w/out regard for the others needs or goals.

* Issue of control

* Dehumanizes= I vs. "it" relationship; making person an "it".

NSG interventions

for

antisocial PD

* use cooncern, but matter of fact approach

* Set limits

* DO NOT argue, bargain, or rationalize

* Confront inappropirate behaviors

* Maintain consistent rules

* BE ALERT for flattery or verbal attacks

* Use contracts & relaxation techniques

* Role model self discipline

* Clinical supervision

Interventions

for

Manipulative,

Aggressive,

or

Impulsive Behavior

Manipulation: p. 452 box 19-2

Aggressive behavior: p. 452 box 19-3

Impulsive behavior: p. 452 box 19-4

Paranoid

PD

Fear that others will exploit them, harm, or deceit them to the point of endangering their lives.

Hypervigilance

Anticipate hostility

Usu. aggrumentative, sarcastic, complaining

Psychotic epsisodes can occur

Approaches

to a

client

who has

Paranoid

PD

Neutral matter-of-fact & respectful

Straightforward explainations

Avoid being too friendly or "nice"

Written plan may encourage cooperation

Warn about changes, side effects of meds, & reasons for delays.

Dependent Personality

Deal w/anxiety by behaving in an excessively dependent way.

Copes by clutching others & refusing to let go, this invites rejection.

No faith in ability to rely on self.

Reaction formation.

Fearfulness.

NSG interventions

to

Dependent Personality

Break cycle of avoidance

Set realistic limits

Help client manage anxiety

Teach client to express their ideas & feelings assertively.

ex. groups are helpful for client (outpt), w/specific short term outcomes.

NSG process:

Evaluation

of client

with

Dependent Personality

May be diff. b/c pt may not remain in RX long enough to see results.

Specific, short term outcomes may be accomplished.