Personality
- ingrained, enduring pattern of behaving and relating to self, others, and the environment; personality includes perceptions, attitudes, and emotions.
- Develops as individuals adjust to their physical, emotional, social, and spiritual environments
- Personality traits o patterns are reflected in how individuals cope with feelings and impulses, see themselves and others, respond to their surroundings, and find meaning in relationships
Personality Disorders
- diagnosed when personality patterns or traits are inflexible, enduring, pervasive, maladaptive, and cause significant functional impairment or subjective distress
- Diagnosis is made when the person exhibits enduring behavioral patterns that deviate from cultural expectations in two or more of the following areas:
- Cognition: Ways of perceiving and interpreting self, other people, and events
- Affect: Range, intensity, lability, and appropriateness of emotional response
- Interpersonal functioning
- Impulse control: Ability to control impulses or express behavior at the appropriate time and place
- Are coded under axis II disorders (personality disorders or mental retardation) using the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fourth edition – Text Revision (DSM IV-TR)
II. Categories of Personality Disorders
Cluster A: odd or eccentric
- Paranoid personality disorders
- Schizoid personality disorders
- schizotypal personality disorders
Cluster B: dramatic, emotional, or erratic
- antisocial personality disorders
- borderline personality disorders
- histrionic personality disorders
- narcissistic personality disorders
Cluster C: anxious or fearful
- avoidant personality disorders
- dependent personality disorders
- obsessive-compulsive personality disorders
III. Cluster A: odd or eccentric
A. Paranoid personality disorders
- Pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent
- Secretive, hyperalert to danger, argumentative to maintain safe distance between self and others - May be hostile, aloof
- May be rigid, critical, and controlling of others
- Tendency to look for hidden, demeaning, or threatening meanings and to respond by criticizing others
- Uses defense mechanism of projection
Special Nursing Intervention:
- Serious, straightforward approach
- teach client to validate ideas before taking action c. involve client in treatment planning
B. Schizoid Personality disorders
- Pattern of detachment from social relationships and a restricted range of emotions - Neither desire nor enjoy relationship with others
- inability to form warm, close social relationships - Interest in solitary activities
- Aloof and indifferent
Special Nursing Intervention:
- Improve client’s functioning in the community
- assist client to find case manager - The case manager can help the client to obtain services and health care, manage finances, etc.
C. Schizotypal Personality Disorder
- is characterized by the display of abnormal or highly unusual thoughts, perceptions, speech, and behavior patterns
- milder form of schizophrenia (NO Hallucinations)
- exhibits odd/eccentric behavior and speech that is coherent but often tangential, vague, or overelaborate
- Magical thinking
- Odd thinking and speech
- Suspiciousness and paranoia
- Uncomfortable with intimacy and avoid relationships with others; usually avoided by others because of their odd/eccentric behavior
Special Nursing Intervention:
- Develop self-care skills
- improve community functioning
- social skills training
Cluster A-specific nursing interventions
- approach people in a gentle, interested, but nonintrusive manner respect client’s needs distance and privacy
- Be mindful of own nonverbal communication as a client may perceive others as threatening Gradually encourage interaction with others, if appropriate
IV. Cluster B: dramatic, emotional, or erratic
A. Antisocial personality disorder
- is characterized by a pervasive pattern of disregard for and violation of the rights of others and with the central characteristics of deceit and manipulation
- irresponsible and antisocial behavior, selfishness, an inability to maintain lasting relationships, poor sexual adjustment, a failure to accept social norms, and a tendency toward irritability and aggressiveness
- Perceives the world as hostile - Superficial charm and hostility
- No shame or guilt and Self-centered - Unreliable and easily bored
- Poor work history
- Inability to tolerate frustration
- View others as objects to be manipulated - Poor judgment and impulsive
Special Nursing Intervention
- Limit-setting
- Confrontation
- teach client to solve problems effectively d. manage emotions of anger or frustration
Consistent limit-setting
- in a matter-of-fact, nonjudgmental manner. Limit-setting involves three steps:
- Stating the behavioral limit (describing the unacceptable behavior)
- Identifying the consequences if the limit is exceeded
- Identifying the expected or desired behavior
Confrontation
- is another technique designed to manage manipulative or deceptive behavior. The nurse points out a client’s problematic behavior while remaining neutral and matter-of-fact; he or she avoids accusing the client
Helping clients solve problems
- Problem-solving skills include:
- Scenario: a client’s car isn’t running so he stopped going to work
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- identifying the problem - transportation to work
- exploring alternative solutions and related consequences - taking the bus, asking a coworker for a ride, and getting the car fixed
- choosing and implementing an alternative
- evaluating the results
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Managing emotions
- identify sources of frustration, how they respond to it, and the consequences
- taking a Time-out – leaving the area and going to a neutral place to regain internal control
B. Borderline Personality Disorder
- characterized by instability in interpersonal relationships, unstable mood and self-image, and impulsive and unpredictable behavior
- Unclear identity
- Unstable and intense
- Extreme shifts in mood - Easily angered
- Easily bored
- Argumentative - Depression
- Self-destructive behavior; High-risk for suicide and self-mutilation because of feelings of emptiness or rage
- Manipulation
- Inability to tolerate anxiety
- Chronic feelings of emptiness and fear of being alone
- Splitting—sees others as all good or all bad; creates conflict between individuals by playing one person against another
Special Nursing Interventions:
- Promote safety - seriously consider suicidal ideation with the presence of a plan, access to means for enacting the plan, and self-harm behaviors and institute appropriate interventions
- help client to cope and control emotions
- cognitive restructuring techniques - used to change the way the client thinks about self and others
- thought stopping - the client stops negative thought patterns
- positive self-talk - designed to change negative self-messages
- decatastrophizing - teaches the client to view life events more realistically not as catastrophes
- structure time
- teach social skills
C. Histrionic Personality Disorder
- characterized by overly dramatic, intensely expressive behavior, and attention-seeking
- Lively and dramatic and enjoys being the center of attention
- Has poor and shallow interpersonal relations; exaggerate the closeness of relationships
- May be sexually seductive or provocative
- Dramatizes his or her life and may appear theatrical
- Overly concerned with appearance
- Easily bored
Special Nursing Interventions:
- Teach social skills
- provide factual feedback about behavior
D. Narcissistic Personality Disorder
- characterized by a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy
- increased sense of self-importance and preoccupation with fantasies and unlimited success - Need for admiration and inflation of accomplishments
- Overestimation of abilities and underestimation of contributions of others - Lack of empathy and sensitivity to needs of others
- arrogant, sees self as more important/special than others
Special Nursing Interventions:
- Matter-of-fact approach
- gain cooperation with needed treatment c. teach client any needed self-care skills
Cluster B-specific nursing interventions
- Safety is always the priority of care – protect client from suicide and self-mutilation until they can protect themselves
- Be patient as clients display emotional and erratic behavior
- Provide a consistent and structured milieu to avoid manipulation and power struggles
- Set limits as necessary to help clients maintain impulse control in order to protect themselves and other from injury
- Engage in frequent staff conferences to counteract client’s ability to play one staff member against the other
- Help clients recognize and discuss their fear of abandonment
- Help clients recognize the presence of dichotomous thinking or splitting, in which self and others are perceived as all good or all bad
- Encourage direct communication to minimize attention-seeking through the use of dramatic, seductive behavior
- Help clients who display a sense of entitlement to acknowledge the needs of others
V. Cluster C: anxious or fearful
A. Avoidant Personality disorders
- characterized by a pervasive pattern of social discomfort and reticence, low self-esteem, and hypersensitivity to negative evaluation.
- Avoid interpersonal contact and new situations related to fear of rejection and embarrassment
- Lack self—confidence and are extremely sensitive to rejection; view self as inadequate and inferior - Fearful of shame, criticism and ridicule; shy and hurt by criticism
Special Nursing Interventions:
- Support and reassurance
- explore positive self-aspects, positive responses from others, and possible reasons for self-criticism
- cognitive restructuring techniques- used to change the way the client thinks about self and others
- thought stopping - the client stops negative thought patterns
- positive self-talk - designed to change negative self-messages
- decatastrophizing - teaches the client to view life events more realistically not as catastrophes
- promote self-esteem
B. Dependent Personality Disorder
- characterized by a pervasive and excessive need to be taken care of, which leads to submissive and clinging behavior and fears of separation
- intense lack of self-confidence, low self-esteem, and inability to function independently
- the individual passively allows others to make decisions and assume responsibility for major areas in the person’s life
- the dependent client has great difficulty making decisions
- difficulty of disagreeing with others related to fear of rejection and abandonment
- anxious when left alone because of fear of being unable to do things for themselves
Special Nursing Interventions:
- Foster client’s self-reliance and autonomy
- teach problem-solving and decision-making skills
- cognitive restructuring techniques - used to change the way the client thinks about self and others
- thought stopping - the client stops negative thought patterns
- positive self-talk - designed to change negative self-messages
- decatastrophizing - teaches the client to view life events more realistically not as catastrophes
C. Obsessive-compulsive Personality Disorder
- characterized by a pervasive pattern of preoccupation with perfectionism, mental and interpersonal control, and orderliness at the expense of flexibility, openness, and efficiency
- Overly conscientious - High need for routine
- Inflexible and preoccupied with details and rules
- Extremely devoted to work to the exclusion of leisure activities and friendships
- Miserly and stubborn; Hoarding behavior – unable to discard worthless objects; Engages in rituals
- Decreased ability to focus on the major goal of any activity as becomes overly involved in details
- Difficulty with task completion related to a need for perfection
- Unable to delegate for fear that others will not perform tasks correctly
Special Nursing Interventions:
- Encourage negotiation with others
- assist client to make timely decisions and complete work
- cognitive restructuring techniques - used to change the way the client thinks about self and others
- thought stopping - the client stops negative thought patterns
- positive self-talk - designed to change negative self-messages
- decatastrophizing - teaches the client to view life events more realistically not as catastrophe
Cluster C-specific nursing interventions
- Point out avoidance behaviors and related losses and secondary gains
- Provide problem-solving and assertiveness training to increase self-confidence and independence Encourage expression of feelings to decrease rigidity and need for control
- Help clients recognize any impairment or distress related to their need for perfection and control
- Help clients acknowledge and discuss their sense of inadequacy and fear of rejection
VI. General Interventions for a Client with a Personality disorder
- Maintain safety against self-destructive behaviors.
- Allow the client to make choices and be as independent as possible.
- Encourage the client to discuss feelings rather than act them out.
- Provide consistency in response to the client’s acting-out behaviors.
- Discuss expectations and responsibilities with the client.
- Discuss the consequences that will follow certain behaviors.
- Inform the client that harm to self, others, and property is unacceptable.
- Identify splitting behavior.
- Assist the client to deal directly with anger.
- Develop a written safety or behavioral contract with the client.
- Encourage the client to keep a journal recording daily feelings.
- Encourage the client to participate in group activities, and praise nonmanipulative behavior
- Set and maintain limits to decrease manipulative behavior.
- Remove the client from group situations in which attention-seeking behaviors occur.
- Provide realistic praise for positive behaviors in social situations.
VII. Psychopharmacology
- Antipsychotic agents may be prescribed on a short-term basis to alleviate psychotic symptoms associated with schizotypal or borderline personality disorders
- Selective serotonin reuptake inhibitors may be prescribed to diminish the rapid mood swings, impulsive, aggressive, and self-destructive behavior associated with borderline personality disorder
- SSRIs may be prescribed to treat the obsessive rumination associated with certain personality disorders
