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Week 5 Definitions Personality • Is an individual's characteristic patterns of relatively permanent thoughts, feelings, and behaviours that define the quality of experiences and relationships In mental health nursing there are two key underlying concepts related to an individual's personality • Personality trait and personality type Personality trait • Is a stable characteristic of a person, such as an extraversion, openness to experience, agreeableness, and conscientiousness • These can be compared to personality states, which are temporary behaviours and feelings Personality type • Is a way to describe a cluster of traits Epidemiology of personality disorders • Estimated in 10% of the population • More frequently seen in people receiving extensive medical and psychiatric services • Frequently coexisting with other psychiatric disorders • More common in those incarcerated • Childhood trauma identified as a risk factor • APA has classified characteristics into the 10 disorders, divided into 3 clusters Comorbidity • Personality disorders frequently co-occur with disorders of mood and eating, anxiety and substance related disorders • Personality disorders often amplify emotional dysregulation, a term that describes poorly modulated mood characterized by mood swings • Life crises of any kind may be risk factors, for instance any grief, loss, or trauma Etiology of personality disorders Personality disorders are the result of complex biological and psychosocial phenomena that are influenced by multifaceted variables involving genetic, neurobiological, neurochemical, and environmental factors Psychological factors • Several psychological theories may help to explain the development of personality disorders • Learning theory emphasizes that children develop maladaptive responses based on modelling of or reinforcement by important people in the child's life • Cognitive theories emphasize the role of beliefs and assumptions in creating emotional and behavioural responses that influence one's experiences within the family environment • Psychoanalytic theory focuses on the use of primitive defence mechanisms by individuals with personality disorders Environmental factors • Behavioural genetics research has shown that about half of the variance accounting for personality traits emerges from the environment • These findings suggest that while the family environment is influential on development, there are other environmental factors besides upbringing that shape an individual's personality • Childhood neglect and trauma have been established as risk factors for personality disorders • This association has been linked to possible biological mechanisms involving corticotropin-releasing hormone in response to early life stress and emotional reactivity Diathesis–Stress Model • A general theory that explains psychopathology using a systems approach • This theory helps us understand how personality disorders emerge from the multifaceted factors of biology and environment • Diathesis refers to genetic and biological vulnerabilities and includes personality traits and temperament • In this model, stress refers to immediate influences on personality such as the physical, social, psychological, and emotional environment • Stress also includes what happened in the past, such as growing up in one's family with exposure to unique experiences and patterns of interaction Cluster A Individuals with these disorders demonstrate odd or eccentric behaviours (e.g. social isolation, detachment) They may also display perception distortion, unusual levels of suspiciousness, magical thinking and cognitive distortions Paranoid personality disorder • Characterized by a long-standing distrust and suspiciousness of others based on the belief, which is unsupported by evidence, that others want to exploit, harm, or deceive the person • These individuals are hypervigilant, anticipate hostility, and may provoke hostile responses by initiating a counterattack • Relatives of patients with schizophrenia are more frequently affected with this disorder • A diagnosis of paranoid personality disorder often precedes a schizophrenia diagnosis Guidelines for nursing care • Appointments, and schedules should be strictly adhered to • Being too nice or friendly may be met with suspicion. Instead, give clear and straightforward explanations of tests and procedures beforehand • Use simple language and project a neutral but kind affect • Limit setting is essential when threatening behaviours are present Guidelines for nursing care • Nurses should avoid being too “nice” or “friendly” • Do not try to increase socialization • Patients may be open to discussing topics such as coping and anxiety • Conduct a thorough assessment to identify symptoms the patient is reluctant to discuss • Protect against ridicule from group members due to patient's distinctive interests or ideas Treatment • Psychotherapy can help improve sensitivity to others' social cues • Group therapy may also be helpful, even though the patient may frequently be silent • Group therapy provides experience in practicing interactions with and receiving feedback from others • May be the only form of socialization patient has • 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 • Do not blend in with the crowd • Symptoms are strikingly strange and unusual  Magical thinking, odd beliefs, strange speech patterns, and inappropriate affect are hallmarks of this disorder • It is more common in men than women • Abnormalities in brain structure, physiology, chemistry, and functioning are similar to schizophrenia • For example, both disorders share reduced cortical volume Treatment • The principles of psychotherapy used are similar to those for schizoid personality disorder • 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 • Depression and anxiety may be treated with antidepressants and antianxiety agents Cluster B Respond to life’s demands with dramatic, erratic and at times chaotic traits Problems with impulse control, emotion processing and regulation, and interpersonal difficulties characterize this cluster of disorders Insight may be limited Borderline personality disorder • Major features of this disorder are patterns of marked instability in emotion regulation, unstable interpersonal relationships, identity or self-image distortions, and unstable mood • People with BPD seek out treatment for depression, anxiety, suicidal and self- harming behaviours • With effective treatment, people with BPD can experience high rates of remission and low rates of relapse Guidelines for nursing care • A therapeutic relationship is essential with patients who have BPD because most of them have experienced failed relationships, including therapeutic alliances • 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 • People with BPD are usually admitted to psychiatric treatment programs because of symptoms with comorbid disorders or dangerous behaviour • 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 • The more intense the complaints are, the greater the patients' fear of potential harm or loss is • Be aware of potential manipulative behaviours such as flattery, seductiveness, and instilling guilt Antisocial personality disorder • Antisocial personality disorder is a pattern of disregard for, and violation of, the rights of others • This diagnosis is reserved for adults, but symptoms are evident by the mid-teens • While the disorder is much more common in men (3% versus 1%), women may be underdiagnosed due to the traditional close association of this disorder with males • Antisocial personality disorder is genetically linked - It is likely that the genetic predisposition for characteristics of antisocial personality disorder such as a lack of empathy occur because of childhood maltreatment • Criminal misconduct and substance misuse are common in this population Treatment • Provide consistency, support, boundaries, and limits • Providing realistic choices (e.g., selection of a particular group activity) may enhance adherence to treatment • Set clear and realistic boundaries and consequences, and ensure that all staff follow these limits • The safety of patients and staff is a prime consideration in working with individuals in this population Histrionic personality disorder • “Excitable” and “dramatic” yet are often high functioning • Classic characteristics of this population include extraversion, flamboyancy, low frustration tolerance, and excessive emotionality • Despite this bold exterior, those with histrionic personality disorder tend to have limited ability to develop meaningful relationships • In general, individuals with this disorder do not believe they need psychiatric help • They may go into treatment for associated problems such as depression, which may be precipitated by losses such as the end of a relationship Guidelines for nursing care • Nursing care should reflect an understanding that seductive behaviour is a response to distress • Professional boundaries essential to maintain • Encourage and model the use of concrete and descriptive rather than vague and impressionistic language • Assist patients to clarify feelings because they often have difficulty identifying them • Teach and role model assertiveness • Assess for suicidal ideation. What was intended as a suicide gesture may inadvertently result in death. Guidelines for nursing care • Remain neutral and recognize the source of narcissistic behaviour—shame and fear of abandonment • Use the therapeutic nurse–patient relationship as an opportunity to practice engaging in meaningful interaction • Avoid engaging in power struggles or becoming defensive in response to the patient's disparaging remarks • Role model empathy Treatment • Because individuals are not likely to seek help for their own problems, they are more likely to be involved in couples or family therapy than in individual treatments • In these family-oriented approaches, narcissistic individuals are likely to deflect suggestions that they contribute to family problems and will instead blame others • Individual cognitive behavioural therapy is helpful in deconstructing faulty thinking • Group therapy can assist the person in sharing with others, seeing their own qualities in others, and learning empathy • There are no approved medications for treating narcissistic personality disorder Cluster C Individuals with cluster C personality disorders have a pervasive pattern of anxious behaviours, with: Rigid patterns of social shyness Hypersensitivity Need for orderliness Relationship dependency 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 • Antidepressant medications, such as SSRIs like citalopram (Celexa) and serotonin–norepinephrine reuptake inhibitors (SNRIs) like venlafaxine (Effexor), may reduce social anxiety Dependent personality disorder • Dependent personality disorder is characterized by a pattern of submissive and clinging behaviour related to an overwhelming need to be cared for - this need results in intense fears of separation • Dependent personality disorder is rare and may be the result of chronic physical illness or punishment for independent behaviour in childhood • People with dependent personality disorder have a high need to be taken care of • Because they lack confidence in their own ability or judgement, those with dependent personality disorder may manipulate others to assume responsibility for such activities as finances or child rearing Guidelines for nursing care • 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 Obsessive-compulsive personality disorder • There is a difference between obsessive-compulsive disorder and obsessive-compulsive personality disorder • Obsessive-compulsive disorder is characterized by obsessive thoughts and by repetition or adherence to rituals. Those with obsessive- compulsive disorder are aware that these thoughts and actions are unreasonable • 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 Guidelines for nursing care • Guard against power struggles with patients • Patients with this disorder have difficulty coping with changes • Provide structure, yet allow patients extra time to complete habitual behaviour • Assist patients to identify ineffective coping and to develop effective coping techniques Treatment • Typically, patients seek help for obsessive-compulsive personality disorder, as they are aware of their own suffering • They may also seek treatment for anxiety or depression • 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 NURSING AND THERAPY GUIDELINES FOR PERSONALITY DISORDER BY CLUSTER: PERSONALITY DISORDER CHARACTERISTICS NURSING GUIDELINES SUGGESTED THERAPIES Cluster A Manifestation of ideas 1. Respect patient's need for social isolation Supportive psychotherapy + Paranoid personali f reference 2. Be aware of patient's suspiciousness, and employ appropriate interventions. Cognitive and behavioural measures disorder Cognitive and Perform careful diagnostic assessment as needed to uncover any other medical or psychological Group therapy to try to improve social slalls * Schizoid personality perceptual distortions symptoms that may need intervention (e.g., suicidal thoughts). Low-dose antipsychotics and antidepressants disorder Social inepiness © Schizotypal personal Anxiety disorder Odd and eccentric behaviours Cluster B Ability to seem normal 1 ent or reduce untoward effects of manipulation (flattery, seductiveness, instilling of Individual psychotherapy * Borderline personality Manipulative Dialectical behaviour therapy disorder Expleitive of others a. Set clear and realistic limits on specific behaviour. Group the: * Narcissistic personality Disparaging b. Ensure that limits are adhered to by all staff Pharmacotherapy for anxiety, depression disorder Inpuls 2, selé- cament signs of manipulation or aggression. Careful use of addictive agents (2.g., benzodiazepines) © Histrionic personality mutilation) Anticonvulsants may help impul disorder Splitting (adoring then +, Provide clear boundaries and consequen: chosis psychotics to control anger and brief psy * Antisocial personality devaluing people! 2. Be aware that patients can instill guilt when they are not getting what they want. Guard against disorder Grandiose ‘being manipulated through feelings of guilt: Filled with rage 3. Use clear and straightforward communication. Very sensitive to 4. When behavioural problems emerge, calmly review the therapeutic goals and boundaries of rejection, criticism treatment. Inability to experience jecting or rescuing empathy 6, Assess for suicidal and self- mutilating behaviours, especially during times of stress. 7. Remain neutral; avoid engaging in power struggles or becoming defensive in response to the patient's disparaging remarks 8, Convey unassuming self-confidence Cluster C Excessively ardous in 1. Being pushed into social situations can cause extreme and severe anxisty. Supportive or insightful psychotherapy + Avoidant personality social situations 2. Guard against power struggles with patient. Need for control is very high Group the disorder Hypersensitive to 3. A friendly, accepting, reassuring approach is the best way to treat patients. Assertiveness training negative evaluation The most common defence mechanisms are intellectualization, rationalization, reaction formation Antidepressants Desiring of social isolation, and undoing Antianndety agents interaction Beta-adrenergic receptor antagon personality disord Perfectionistic Has need for contzol Inflexible, rigid Precceupied with details Highly critical of self and ethers autonomic nervous Box 19-1 —a NIC Interventions for Manipulative Behaviour Limit Setting Definition of limit setting: Establishing the parameters of desirable and acceptable personal behaviour Activities": * Discuss concerns about behaviour with person. * Identify (with input when appropriate) undesirable personal behaviour. * Discuss with person, when appropriate, what desirable behaviour is in a given situation or setting. * Establish consequences (with person's input when appropriate) for occurrence or nonoccurrence of desired behaviours. * Communicate established behavioural expectations and consequences to person in language that is easily understood and nonpunitive. * Refrain from arguing or bargaining with person about established behavioural expectations and consequences. * Monitor person for occurrence or nonoccurrence of desired behaviour. * Modify behavioural expectations and consequences, as needed, to accommodate reasonable changes in person's situation. “Partial list. Source: Bulechek, G. M., Butcher, HK, & Dochterman, J. M_ (2013). Nursing interventions classification (NIC) (6th ed). Toronto: Elsevier. Implementati on • Safety and teamwork • Boundaries • Splitting • Pharmacological interventions • Case management