515 Personality Disorders (Full)-1-1.pdf

PERSONALITY DISORDERS Bryan R. Hansen, PhD, RN, APRN-CNS CLASS OBJECTIVES • Explore coping behaviors used by patients with personality disorders • Respond therapeutically to patients’ maladaptive behaviors • Discuss the principles underlying limit setting and structure for patients with personalit...

PERSONALITY DISORDERS Bryan R. Hansen, PhD, RN, APRN-CNS CLASS OBJECTIVES • Explore coping behaviors used by patients with personality disorders • Respond therapeutically to patients’ maladaptive behaviors • Discuss the principles underlying limit setting and structure for patients with personality disorders • Formulate a plan to maintain patient safety and manage patients who engage in self-destructive behavior • Apply selected therapeutic communication strategies in working with patients with personality disorders Epidemiology • Prevalence: About 6% of global population • Seen in up to 50% of psychiatric patients • About 15% of people in US are estimated to have at least one personality disorder • Risk factors – – – – – Genetic Neurobiological Psychological Environmental Diathesis-stress model Characteristics of Personality Disorders • A lifelong pattern of dysfunctional behaviors develops in relating and interacting with others. • Behaviors deviate from the normal pattern of personal and social interactions within the context of the person’s culture. • Behaviors tend to jeopardize relationships and often result in isolation or depression. Characteristics of Personality Disorders (Cont.) • Personality disorders cannot be traced to a physiological source, substance use medication, or medical condition. • Personality disorders are not easily treated because of their lack of physiological source and their ingrained nature. • The DSM-5 has eliminated the multiaxial scale, so personality disorders are no longer considered an Axis II diagnosis. Cluster A: Odd-Eccentric • Paranoid personality disorder – Suspiciousness and mistrust • Schizoid personality disorder – Aloneness and a hermit-like lifestyle • Schizotypal personality disorder – Symptoms similar to but less severe than symptoms of schizophrenia Cluster B: Dramatic-Erratic • Antisocial personality disorder – Disregard of others’ rights without guilt • Borderline personality disorder – Problems with identity, interpersonal relationships, emotional dysregulation, and self-injury • Narcissistic personality disorder – Over-evaluation of self, arrogance, and indifference to the criticism of others • Histrionic personality disorder – Dramatic, attention seeking, and superficiality Cluster C: Anxious-Fearful • Dependent personality disorder – Submissive, helpless, fear of responsibility, and reliance on others for decision-making • Avoidant personality disorder – Timid, socially withdrawn, and hypersensitive to criticism • Obsessive-compulsive personality disorder – Indecisive, perfectionist, inflexible, and has difficulty expressing feelings Case Study • Jean is a 26-year-old woman who has been labeled with borderline personality disorder. She asks the nurse, “Why can’t I ever find a friend worth keeping? Every time I make a new friend, they are, like, the best person I have ever met, and then first thing I know all these flaws come out and I hate them. Same things happen at work. I start a new job and everyone’s awesome, and then they all turn into stupid idiots. I get blamed for supposedly throwing tantrums, but is it my fault that so many stupid people get these good jobs? It’s all so hopeless, I feel like just, what the heck, just shoot myself.” • What symptoms are being demonstrated? Nursing Assessment and Interventions • Assess patient for self-harm or risk for suicide (cutting scars, threats, prior attempts). • Assess the patient’s level of anger and history of violence (protect patient and staff). • Teach patient strategies for managing impulsive feelings and erratic behaviors. – Count to 10 before responding. – Take slow deep breaths until impulse passes. • Teach patient healthy interactive behaviors. Audience Response Question Which nursing action would the nurse do first when working with an individual with borderline personality disorder? A. Set limits. B. Determine boundaries. C. Assess for self-harm. D. Assess relationship system. Therapeutic Modalities • Individual interactions with staff and other patients • Group activities – Therapeutic recreation – Occupational therapy – Cognitive-behavioral therapy – Community groups – Groups that address dual diagnoses Pharmacology • Selective serotonin reuptake inhibitors (SSRIs) are antidepressants typically used for impulsivity, depressed mood, anger, or feelings of loss of control. • Benzodiazepines and antipsychotics are used for aggressiveness, violence, or extreme impulsive behaviors. Case Study • Our patient Jean is admitted to the psychiatric unit after cutting her wrists. She has just had a recent breakup of a significant friendship. She feels the staff do not understand what she is feeling. She refuses to go to group sessions and is not participating in the milieu. Audience Response Question What would be the best therapeutic interaction with Jean? A. “If you stay in your bedroom, you will be discharged sooner for not participating in the milieu.” B. “There are rules in the therapeutic milieu that are important to follow—you must go to the group.” C. “Going to group will give you feedback on your relationships with others on the unit.” D. “Your difficulty with others is showing up on the unit—go to the groups now.” References • Johnson, K. M. (2018). Chapter 29: Personality disorders. In Keltner, N. L., & Steele, D. (Eds.). (2018). Psychiatric nursing (8th ed., pp. 350-362). St. Louis, MO: Elsevier. • Tackett, C. A., Halter, M. J., & Cihlar, C. A. (2018). Chapter 24: Personality disorders. In M. J. Halter & E. M.Varcarolis (Eds.), Varcarolis' foundations of psychiatric mental health nursing: A clinical approach (8 ed., pp. 451-473). St. Louis, MO: Elsevier Saunders.