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PERSONALITY CAN BE DEFINED

as an ingrained enduring pattern of behaving and relating to self, others, and the environment; it includes percep-tions, attitudes, and emotions.
- person usually is not consciously aware of her or his personality.

Many factors influence personality:

some stem from biologic and genetic makeup, whereas some are acquired as a person develops and interacts with the environment and other people.

Personality disorders

are diagnosed when personality traits become inflexible and maladaptive and significantly interfere with how a person functions in society or cause the person emotional distress.
- usually not diagnosed until adulthood, when personality is more completely formed.
- maladaptive behavioral patterns often can be traced to early childhood or adolescence.
- great variance among clients with personality disorders, many experience significant impairment in fulfilling family, academic, employment, and other functional roles.

Diagnosis is made when

- when the person exhibits enduring behavioral patterns at deviate from cultural expectations in two or more of the following areas:
• Ways of perceiving and interpreting self, other people, and events (cognition)
• Range, intensity, lability, and appropriateness of emotional response (affect)
• Interpersonal functioning
• Ability to control impulses or express behavior at the appropriate time and place (impulse control)

Personality disorders are

longstanding because
- person characteristics do not change easily.
- No specific medication alters personality,
- therapy designed to help clients make changes is often long term with very slow progress.
- Some believe their problems stem from others or the world in general;
- they do not recognize their own behavior as the source of difficulty.
- are difficult to treat, which may be frustrating for the nurse and other caregivers as well as for family and friends.
- difficulties in diagnosing and treating clients with personality disorders because of similarities and subtle differences between categories or types.
- Types often overlap, and many people with personality disorders also have coexisting mental illnesses.

catagories from DSM IV

- Cluster A: Individuals whose behavior appears odd or eccentric (paranoid, schizoid, and schizotypal person-ality disorders)
- Cluster B: Individuals who appear dramatic, emotional, or erratic (antisocial, borderline, histrionic, and narcis-sistic personality disorders)
- Cluster C: Individuals who appear anxious or fearful (avoidant, dependent, and obsessive-compulsive per-sonality disorders)
- Proposed personality disorder categories: depressive and passive-aggressive personality disorder

Cluster A:

Individuals whose behavior appears odd or eccentric (paranoid, schizoid, and schizotypal person-ality disorders)

Cluster B:

Individuals who appear dramatic, emotional, or erratic (antisocial, borderline, histrionic, and narcis-sistic personality disorders)

Cluster C:

Individuals who appear anxious or fearful (avoidant, dependent, and obsessive-compulsive per-sonality disorders)

In psychiatric settings, nurses most often encounter

clients with antisocial and borderline personality disorders.
- Clients with antisocial personality disorder may enter a psychiatric setting as part of a court-ordered evaluation or as an alternative to jail.
- Clients with borderline personality disorder often are hospitalized because their emotional instability may lead to self-inflicted injuries

Temperament

refers to the biologic processes of sensation, association, and motivation that underlie the integration of skills and habits based on emotion.
- Genetic differences account for about 50% of the variances in temperament traits

4 temperament traits are

harm avoidance, novelty seeking, reward dependence, and persistence.
- Each of these four genetically influenced traits affects a person's automatic responses to certain situations.
- These response patterns are ingrained by 2 to 3 years of age

high harm avoidance

exhibit fear of uncertainty, social inhibition, shyness with strangers, rapid fatigability, and pessimistic worry in anticipation of problems.
- behaviors may result in maladaptive inhibition and excessive anxiety.

low harm avoidance

are carefree, energetic, outgoing, and optimistic.
- behaviors may result in unwarranted optimism and unresponsiveness to potential harm or danger

high novelty-seeking temperament

results in someone who is quick tempered, curious, easily bored, impulsive, extravagant, and disorderly.
- may be easily bored and distracted with daily life, prone to angry outbursts, and fickle in relationships.

Low in novelty seeking

is slow tempered, stoic, reflective, frugal, reserved, orderly, and tolerant of monotony;
- may adhere to a routine of activities

People high in reward dependence

are tender-hearted, sensitive, sociable, and socially dependent.
- may become overly dependent on approval from others and readily assume the ideas or wishes of others without regard for their own beliefs or desires.

Reward dependence

defines how a person responds to social cues.

People with low reward dependence

are practical, tough minded, cold, socially insensitive, irresolute, and indifferent to being alone.
- Social withdrawal, detachment, aloofness, and dis-interest in others can result.

Highly persistent people

are hardworking and ambitious overachievers who respond to fatigue or frustration as a personal challenge.
- may persevere even when a situation dictates they should change or stop.

People with low persistence

are inactive, indolent, unstable, and erratic.
-tend to give up easily when frustrated and rarely strive for higher accomplishments.

Character

consists of concepts about the self and the external world.
- develops over time as a person comes into contact with people and situations and confronts challenges.
- 3 major character traits:
- self-directedness, cooperativeness, and self-transcendence.
- When fully developed, these character traits define a mature personality

Self-directedness

is the extent to which a person is responsible, reliable, resourceful, goal oriented, and self-confident.
-are realistic and effective and can adapt their behavior to achieve goals.
- People low in self-directedness are blaming, helpless, irresponsible, and unreliable.
- cannot set and pursue meaningful goals.

Cooperativeness

refers to the extent to which a person sees himself or herself as an integral part of human society.
- Highly cooperative people are described as empathic, tolerant, compassionate, supportive, and principled.
- People with low cooperativeness are self-absorbed, intolerant, critical, unhelpful, revengeful, and opportunistic; that is, they look out for themselves without regard for the rights and feelings of others

Self-transcendence

describes the extent to which a person considers himself or herself to be an integral part of the universe.
- are spiritual, unpretentious, humble, and fulfilled.
- These traits are helpful when dealing with suffering, illness, or death.
- People low in self- transcendence are practical, self-conscious, materialistic, and controlling. They may have difficulty accepting suffering, loss of control, personal and material losses, and death

The 4 symptom categories that underlie personality disorders

are cognitive-perceptual distortions, including psychotic symptoms;
- affective symptoms and mood dysregulation;
- aggression and behavioral dysfunction;
- and anxiety.

Low reward dependence and cluster A disorders

- correspond to the categories of affective dysregulation, detachment, and cognitive disturbances.
- Cognitive-perceptual disturbances include magical think-ing, odd beliefs, illusions, suspiciousness, ideas of refer-ence, and low-grade psychotic symptoms.
- These chronic symptoms usually respond to low-dose antipsychotic medications

High novelty seeking and cluster B disorders

- correspond to the target symptoms of impulsiveness and aggression.
- Aggression may occur in impulsive people (some with a normal ECG and some with an abnormal one);
- people who exhibit predatory or cruel behavior;
- people with organic-like impulsivity, poor social judgment, and emotional lability.
- Lithium, anticonvulsant mood stabilizers, and benzodiaz-epines are used most often to treat aggression.
- Low-dose neuroleptics may be useful in modifying predatory aggression

High harm avoidance and cluster C disorders

• correspond to the categories of anxiety and depression symptoms.
- Mood dysregulation symptoms include emotional instability, emotional detachment, depression, and dys-phoria.
- Emotional instability and mood swings respond favorably to lithium, carbamazepine (Tegretol), valproate (Depakote), or low-dose neuroleptics such as haloperidol (Haldol).
- Emotional detachment, cold and aloof emotions, and disinterest in social relations often respond to selective serotonin reuptake inhibitors or atypical antipsychotics such as risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel).
- Atypical depression is often treated with selective serotonin reuptake inhibitors, monoamine oxidase inhibitor anti-depressants, or low-dose antipsychotic medications

Anxiety seen with personality disorders

may be chronic cognitive anxiety, chronic somatic anxiety, or severe acute anxiety.
- Chronic cognitive anxiety responds to selective serotonin reuptake inhibitors and monoamine oxidase inhibitors, as does chronic somatic anxiety or anxiety manifested as multiple physical complaints.
- Episodes of severe acute anxiety are best treated with monoamine oxidase inhibitors or low-dose antipsychotic medications

Individual and group psychotherapy

- goals for clients with personality disorders focus on building trust, teaching basic living skills, providing support, decreasing distressing symptoms such as anxiety, and improving interpersonal relationships.
- Relaxation or meditation techniques can help manage anxiety for clients with cluster C personality disorders.
- Improvement in basic living skills through the rela-tionship with a case manager or therapist can improve the functional skills of people with schizotypal and schizoid personality disorders.
- Assertiveness training groups can assist people with dependent and passive-aggressive personality disorders to have more satisfying relationships with others and to build self-esteem

Cognitive-behavioral therapy

has been particularly helpful for clients with personality disorders
- Several cognitive restructuring techniques are used to change the way the client thinks about self and others: thought stopping, in which the client stops negative thought patterns;
- positive self-talk, designed to change negative self-messages; and decatastrophizing, which teaches the client to view life events more realistically and not as catastrophes.

Dialectical behavior therapy

was designed for clients with borderline personality disorder.
- It focuses on distorted thinking and behavior based on the assumption that poorly regulated emotions are the underlying problem.

Paranoid

Symptoms/Characteristics- Mistrust and suspicions of others; guarded, restricted affect
Nursing Interventions- Serious, straightforward approach; teach client to validate ideas before taking action;
involve client in treatment planning
- must approach these clients in a for-mal, business-like manner and refrain from social chitchat or jokes.
- Being on time, keeping commitments, and being particularly straightforward are essential
- most effective interventions is helping clients to learn to validate ideas before taking action-clients can avoid problems if they can refrain from taking action until they have validated their ideas

Schizoid

Symptoms/Characteristics - more common in men than in womenDetached from social relationships; involved with things more than people, display a constricted affect and little, if any, emotion.
- aloof and indifferent, appearing emotionally cold, uncaring, or unfeeling.
- report no leisure or pleasurable activities because they rarely experience enjoyment.
- Even under stress or adverse circumstances, their response appears passive and disinterested.
- marked difficulty experiencing, expressing emotions, particularly anger or aggression.
- Oddly, clients do not report feeling distressed about this lack of emotion; - more distressing to family members.
- have a rich and extensive fantasy life, although they may be reluctant to reveal to anyone .
- The fantasy relationship often includes someone the client has met only briefly
- can distinguish fantasies from reality, and no disordered or delusional thought processes are evident.
- generally are accomplished intellectually and often involved with computers or electronics in hobbies or work. - may spend long hours solving puzzles or mathematical problems, although they see these pursuits as useful or productive rather than fun.
- may be indecisive and lack future goals or direction.
- see no need for planning and really have no aspirations.
- have little opportunity to exercise judgment or decision-making because they rarely engage in these activities.
- Insight might be described as impaired, at least by the social standards of others:
- do not see their situation as a problem
- are self-absorbed and loners in almost all aspects of daily life.
- do not have or desire friends, rarely date or marry, and have little or no sexual contact.
- may remain in the parental home well into adulthood
Nursing Interventions- Improve client's functioning in the community; assist client to find case manager

Schizotypal

Symptoms/Characteristics- Acute discomfort in relationships; cognitive or perceptual distortions; eccentric behavior
- characterized by a pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships as well as by cognitive or perceptual distortions and behavioral eccentricities.
-more common in men than in women.
- may experience transient psychotic episodes in response to extreme stress.
- may be unkempt, disheveled, clothes ill-fitting, dont match, stained or dirty.
- may wander aimlessly, at times, preoccupied with some environmental detail.
- Speech is coherent but may be loose, digressive, or vague.
- often provide unsatisfactory answers to questions
- unable to specify or to describe information clearly.
- frequently use words incorrectly, which makes their speech sound bizarre.
- restricted range of emotions; lack the ability to experience and to express a full range of emotions such as anger, happiness, and pleasure.
- Affect is often flat and sometimes is silly or inappropriate.
- Cognitive distortions include ideas of reference, magical thinking, odd or unfounded beliefs, and a preoccupation with parapsychology, including extrasensory perception and clairvoyance.
- Ideas of reference usually involve the client's belief that events have special meaning for him or her; however, these ideas are not firmly fixed and delusional,
great anxiety around other people, doesn't improve with time or repeated exposures; rather, the anxiety may intensify.
Nursing Interventions- Develop self-care skills;
- encourages clients to establish a daily routine for hygiene and grooming. improve community functioning; social skills training

Antisocial

- characterized by a pervasive pattern of disregard for and violation of the rights of others—and with the central characteristics of deceit and manipulation. Symptoms/Characteristics- Disregard for rights of others, rules, and laws
Lack of remorse for behavior
• Shallow emotions
• Lying
• Rationalization of own behavior
• Poor judgment
• Impulsivity
• Irritability and aggressiveness
• Lack of insight
• Thrill-seeking behaviors
• Exploitation of people in relationships
• Poor work history
• Consistent irresponsibility
Nursing Interventions- Limit setting; confrontation; teach client to solve problems effectively and manage emotions of anger or frustration

Borderline

Symptoms/Characteristics- Unstable relationships, self-image, and affect; impulsivity; self-mutilation
Nursing Interventions- Promote safety; help client to cope and control emotions; cognitive restructuring techniques; structure time; teach social skills

Histrionic

Symptoms/Characteristics- Excessive emotionality and attention seeking
Nursing Interventions- Teach social skills; provide factual feedback about behavior

Narcissistic

Symptoms/Characteristics- Grandiose; lack of empathy; need for admiration
Nursing Interventions- Matter-of-fact approach; gain cooperation with needed treatment; teach client any needed self-care skills

Avoidant

Symptoms/Characteristics - Social inhibitions; feelings of inadequacy; hypersensitive to negative evaluation
Nursing Interventions- Support and reassurance; cognitive restruc-turing techniques; promote self-esteem

Dependent

Symptoms/Characteristics- Submissive and clinging behavior; excessive need to be taken care of
Nursing Interventions- Foster client's self-reliance and autonomy; teach problem-solving and decision-making skills; cognitive restructuring techniques

Obsessive -compulsive

Symptoms/Characteristics- Preoccupation with orderliness, perfectionism, and control
Nursing Interventions- Encourage negotiation with others; assist client to make timely decisions and complete work; cognitive restructuring techniques

Depressive

Symptoms/Characteristics- Pattern of depressive cognitions and behaviors in a variety of contexts
Nursing Interventions- Assess self-harm risk; provide factual feed-back; promote self-esteem; increase involvement in activitiesPassive-aggressivePattern of negative attitudes and passive resistance to demands for adequate perfor-mance in social and occupational situations
Help client to identify feelings and express them directly; assist client to examine own feelings and behavior realistically

Paranoid personality disorder

is characterized by pervasive mistrust and suspiciousness of others.
- Clients with this disorder interpret others' actions as potentially harmful.
- During periods of stress, they may develop transient psychotic symptoms.
- more common in men than in women.
appear aloof, withdrawn, may remain a considerable physical distance from the nurse;
- may appear guarded or hypervigilant;
- may survey the room and its contents, look behind furniture or doors, and generally appear alert to any impending danger.
- may choose to sit near the door to have ready access to an exit or with their backs against the wall to prevent anyone from sneaking up behind them.
- may have a restricted affect,unable to demonstrate warm or empathic emotional responses
- Mood may be labile, quickly changing from quietly suspicious to angry or hostile.
- Responses may become sarcastic for no apparent reason.
- use the defense mechanism of projection, which is blaming other people, institutions, or events for their own difficulties. It is common for such clients to blame the government for personal problems.
- Conflict with authority figures on the job is common;
- may resent being given directions from a supervisor.
- Paranoia may extend to feelings of being singled out for menial tasks, treated as stupid, or more closely monitored than other employees

assessment history of antisocial

Onset is in childhood or adolescence, although formal diagnosis is not made until the client is 18 years of age.
- Childhood histories of enuresis, sleepwalking, and syn-tonic acts of cruelty are characteristic predictors.
- In adolescence, clients may have engaged in lying, truancy, sexual promiscuity, cigarette smoking, substance use, and illegal activities that brought them into contact with police.
- Families have high rates of depression, substance abuse, antisocial personality disorder, poverty, and divorce.
- Erratic, neglectful, harsh, or even abusive parenting frequently marks the childhoods of these clients

assessment of antisocial -
General Appearance and Motor Behavior

Appearance usually is normal;
- may be quite engaging and even charming.
- Depending on the circumstances of the interview, they may exhibit signs of mild or moderate anxiety, especially if another person or agency arranged the assessment

assessment of antisocial -Mood and Affect

Clients often display false emotions chosen to suit the occasion or to work to their advantage.
For example, a client who is forced to seek treatment instead of going to jail may appear engaging or try to evoke sympathy by sadly relating a story of his or her "terrible childhood."
- The client's actual emotions are quite shallow.
- cannot empathize with the feelings of others, which enables them to exploit others without guilt.
- Usually, they feel remorse only if they are caught breaking the law or exploiting someone.

assessment of antisocial-
Thought Process and Content

- do not experience disordered thoughts,
- view of the world is narrow and distorted.
- Because coercion and personal profit motivate them, they tend to believe that others are similarly governed.
- view the world as cold and hostile and therefore rationalize their behavior. Clichés such as "It's a dog-eat-dog world" represent their viewpoint.
- believe they are only taking care of themselves because no one else will.

assessment of antisocial -Sensorium and Intellectual Processes

Clients are oriented, have no sensory-perceptual altera-tions, and have average or above-average IQs

assessment of antisocial - Judgment and Insight

- generally exercise poor judgment for various reasons.
- pay no attention to the legality of their actions and do not consider morals or ethics when making decisions.
- behavior is determined primarily by what they want,
- perceive their needs as immediate.
- are impulsive.- ranges from simple failure to use normal caution (waiting for a green light to cross a busy street) to extreme thrill-seeking behaviors such as driving recklessly.
- lack insight and almost never see their actions as the cause of their problems.
- It is always someone else's fault: some external source is responsible for their situation or behavior

assessment of antisocial - Self-Concept

- appear confident, self-assured, and accomplished, perhaps even flip or arrogant.
- feel fearless, disregard their own vulnerability, and usually believe they cannot be caught in lies, deceit, or illegal actions.
- may be described as egocentric (believing the world revolves around them), but actually the self is quite shallow and empty;
- are devoid of personal emotions.
- realistically appraise their own strengths and weaknesses.

assessment of antisocial- Roles and Relationships

- manipulate and exploit those around them.
- view relationships as serving their needs and pursue others only for personal gain.
- never think about the repercussions of their actions to others.
- often are involved in many relationships, sometimes simultaneously.
- may marry and have children, but they cannot sustain long-term commitments.
- usually are unsuccessful as spouses and parents and leave others abandoned and disappointed.
- may obtain employment readily with their adept use of superficial social skills, but over time their work history is poor. Problems may result from absenteeism, theft, or embezzlement, or they may simply quit out of boredom.

Nursing diagnoses commonly used when working with antisocial

:• Ineffective Coping
• Ineffective Role Performance
• Risk for Other-Directed Violence

Outcome Identification for antisocial

The treatment focus often is behavioral change.
- Although treatment is unlikely to affect the client's insight or view of the world and others, it is possible to make changes in behavior.
Treatment outcomes may include the following:
• The client will demonstrate nondestructive ways to ex-press feelings and frustration.
• The client will identify ways to meet his or her own needs that do not infringe on the rights of others.
• The client will achieve or maintain satisfactory role per-formance (e.g., at work or as a parent).

Nursing Interventions - Encourage the client to identify the actions that pre-cipitated hospitalization (e.g., debts, marital problems, law violation).

Rationale
These clients frequently deny responsibility for con-sequences of their own actions.

intervention - Give positive feedback for honesty. The client may try to avoid responsibility by acting as though he or she is "sick" or helpless

rational
Honest identification of the consequences of the client's behavior is necessary for future behavior change

intervention- Identify unacceptable behaviors, either general (stealing others' possessions) or specific (embarrassing Ms. X by telling lewd jokes).

rational- You must supply clear, concrete limits when the cli-ent is unable or unwilling to do so

intervention - Develop specific consequences for unacceptable behaviors (e.g., the client may not watch television).

rational- Unpleasant consequences may help decrease or eliminate unacceptable behaviors. The consequences must be related to something the client enjoys to be effective

intervention - Avoid any discussion about why requirements exist. State the requirement in a matter-of-fact manner. Avoid arguing with the client.

rational- The client may attempt to bend the rules "just this once" with numerous excuses and justifications. Your refusal to be manipulated or charmed will help decrease manipulative behavior

intervention- Inform the client of unacceptable behaviors and the resulting consequences in advance of their occurrence.

rational- The client must be aware of expectations and consequences.

intervention- *Communicate and document in the client's care plan all behaviors and consequences in specifi c terms

rational- The client may attempt to gain favor with individual staff members or play one staff member against another. ("Last night the nurse told me I could do that.") If all team members follow the written plan, the client will not be able to manipulate changes

intervention-Avoid discussing another staff member's actions or statements unless the other staff member is present.

rational- The client may try to manipulate staff members or focus attention on others to decrease attention to himself or herself

intervention-Be consistent and firm with the care plan. Do not make independent changes in rules or consequences. Any change should be made by the staff as a group and con-veyed to all staff members working with this client. (You may designate a primary staff person to be responsible for minor decisions and refer all questions to this person.)

rational- Consistency is essential. If the client can find just one person to make independent changes, any plan will become ineffective.

intervention-Avoid trying to coax or convince the client to do the "right thing."

rational- The client must decide to accept responsibility for his or her behavior and its consequences.

intervention-When the client exceeds a limit, provide conse-quences immediately after the behavior in a matter-of-fact manner

rational- Consequences are most effective when they closely follow the unacceptable behavior. Do not react to the client in an angry or punitive manner. If you show anger toward the client, the client may take advantage of it. It is better to get out of the situa-tion if possible and let someone else handle it.

intervention-Point out the client's responsibility for his or her behavior in a nonjudgmental manner

rational- The client needs to learn the connection between behavior and the consequences, but blame and judgment are not appropriate.

intervention-Provide immediate positive feedback or reward for acceptable behavior.

rational- Immediate positive feedback will help to increase accept-able behavior. The client must receive attention for positive behaviors, not just unacceptable ones

intervention-Gradually, require longer periods of acceptable behavior and greater rewards, and inform the client of changes as decisions are made. For example, at first the client must demonstrate acceptable behavior for 2 hours to earn 1 hour of television time. Gradually, the client could progress to 5 days of acceptable behavior and earn a 2-day weekend pass

rational- This gradual progression will help to develop the client's ability to delay gratification. This is necessary if the client is to function effectively in society

intervention-Encourage the client to identify sources of frustration, how he or she dealt with it previously, and any unpleasant consequences that resulted

rational- This may facilitate the client's ability to accept responsibility for his or her own behavior.

intervention-Explore alternative, socially and legally acceptable methods of dealing with identifi ed frustrations.

rational- The client has the opportunity to learn to make alter-native choices

intervention-Help the client to try alternatives as situations arise. Give positive feedback when the client uses alternatives successfully.

rational- The client can role-play alternatives in a nonthreatening environment.

intervention-Discuss job seeking, work attendance, court appearances, and so forth when working with the client in anticipation of discharge.

rational- Dealing with consequences and working are respon-sible behaviors. The client may have had little or no successful experience in these areas and may benefi t from assistance.

CLIENT / FAMILY EDUCATION
for Antisocial Personality Disorder

• Avoiding use of alcohol and other drugs
• Appropriate social skills
• Effective problem-solving skills
• Managing emotions such as anger and frustration
• Taking a time-out to avoid stressful situations

Time-out

or leaving the area and going to a neutral place to regain internal control is often a helpful strategy.
- Time-outs help clients to avoid impulsive reactions and angry outbursts in emotionally charged situations, regain control of emotions, and engage in construc-tive problem-solving.

Borderline personality disorder

is characterized by a pervasive pattern of unstable interpersonal relationships, self-image, and affect as well as marked impulsivity.
- more common in women than in men.
- Under stress, transient psychotic symptoms are com-mon.
- 8% and 10% of people with this diagnosis commit suicide, and many more suffer permanent damage from self-mutilation injuries, such as cutting or burning
- recurrent self- mutilation is a cry for help, an expression of intense anger or helplessness, or a form of self-punishment.
-The resulting physical pain is also a means to block emotional pain. Clients who engage in self-mutilation do so to reinforce that they are still alive; they seek to experience physical pain in the face of emotional numbing
• Fear of abandonment, real or perceived
• Unstable and intense relationships
• Unstable self-image
• Impulsivity or recklessness
• Recurrent self-mutilating behavior or suicidal threats or gestures
• Chronic feelings of emptiness and boredom
• Labile mood
• Irritability
• Polarized thinking about self and others ("splitting")
• Impaired judgment
• Lack of insight
• Transient psychotic symptoms such as hallucinations demanding self-harm

Assessment fo borderline personality disorder-
History

Many of these clients report disturbed early relationships with their parents that often begin at 18 to 30 months of age.
- Commonly, early attempts by these clients to achieve developmental independence were met with punitive responses from parents or threats of withdrawal of paren-tal support and approval.
50% of these clients have experienced childhood sexual abuse;
- others have experienced physical and verbal abuse and parental alcoholism
- Clients tend to use transitional objects (e.g., teddy bears, pillows, blankets, and dolls) extensively; this may continue into adulthood.

Assessment fo borderline personality disorder-
General Appearance and Motor Behavior

Clients experience a wide range of dysfunction—from severe to mild.
Initial behavior and presentation may vary widely depending on a client's present status.
- dysfunction is severe,
- may appear disheveled and may be unable to sit still, or
- may display very labile emotions.
- initial appearance and motor behavior may seem normal.
- seen in the ED threatening suicide or self-harm may seem out of control,
- outpatient clinic may appear fairly calm and rational

Assessment fo borderline personality disorder- Mood and Affect

The pervasive mood is dysphoric- involving unhappiness, restlessness, and malaise.
- often report intense loneliness, boredom, frustration, and feeling "empty."
- rarely experience periods of satisfaction or well-being.
- pervasive depressed affect, unstable and erratic.
- may become irritable, even hostile or sarcastic, and complain of episodes of panic an-iety.
- experience intense emotions , anger, rage but rarely express them productively or usefully.
- hypersensitive to others' emotions, which can easily trigger reactions.
Minor changes may precipitate a severe emotional crisis,
- Commonly, these clients experience major emotional trauma when their therapists take vacations.

Assessment fo borderline personality disorder-
Thought Process and Content

- Thinking about self and others often polarized, extreme, referred to as splitting
- tend to adore and idealize other people even after a brief acquaintance
- quickly devalue them if dont meet expectations
- excessive, chronic fears of abandonment
- intolerance of being alone.
- engage in obsessive rumination about almost anything, regardless of the issue's relative importance.
- may experience dissociative episodes (periods of wakefulness when they are unaware of their actions).
- Self-harm behaviors often occur during these dissociative episodes, although other times clients may be fully aware of injuring themselves.

Assessment fo borderline personality disorder- symptoms

• Fear of abandonment, real or perceived
• Unstable and intense relationships
• Unstable self-image
• Impulsivity or recklessness
• Recurrent self-mutilating behavior or suicidal threats or gestures
• Chronic feelings of emptiness and boredom
• Labile mood
• Irritability
• Polarized thinking about self and others ("splitting")
• Impaired judgment
• Lack of insight
• Transient psychotic symptoms such as hallucinations demanding self-harm

Assessment fo borderline personality disorder-Sensorium and Intellectual Processes

Intellectual capacities are intact, and clients are fully oriented to reality.
- exception is transient psychotic symptoms;
- reports of auditory hallucinations encouraging or demanding self-harm = symptoms usually abate when the stress is relieved.
- report flashbacks of previous abuse or trauma.
- consistent with posttraumatic stress disorder, which is common in clients with borderline personality disorder

Assessment fo borderline personality disorder-Judgment and Insight

- report behaviors consistent with impaired judgment and lack of care and concern for safety,
- such as gambling, shoplifting, and reckless driving.
- make decisions impulsively based on emotions rather than facts.
- difficulty accepting responsibility for meeting needs outside a relationship.
- see life's problems and failures as a result of others' shortcomings.
- Because others are always to blame, insight is limited.
- A typical reaction to a problem is "I wouldn't have gotten into this mess if so-and-so had been there."

Assessment fo borderline personality disorder-Self-Concept

- have an unstable view of themselves that shifts dramatically and suddenly.
- may appear needy, dependent one moment, angry, hostile, rejecting the next.
- Sudden changes in opinions and plans about career, sexual identity, values, and types of friends are common.
- view themselves as inherently bad or evil
- often report feeling as if they don't really exist at all.
- Suicidal threats, gestures, and attempts are common.
- Self-harm and mutilation, such as cutting, punching, or burning, are common.
- must be taken very seriously are at increased risk for completed suicide, even if numerous previous attempts have not been life threatening.
- self-inflicted injuries cause much pain , often require extensive treatment; result= massive scarring or permanent disability such as paralysis or loss of mobility from injury to nerves, tendons, and other essential structures

Assessment fo borderline personality disorder- Roles and Relationships

- hate being alone, erratic, labile, and sometimes dangerous behaviors often isolate them.
Relationships are unstable, stormy, and intense;
- cycle repeats itself continually.
have extreme fears of abandonment, difficulty believing a relationship still exists once the person is away from them.
- engage in many desperate behaviors, even suicide attempts, to gain or to maintain relationships.
- Feelings for others are often distorted, erratic, and inappropriate.
- may feel rejected, become hostile, and declare him or her to be their enemy.
- erratic emotional changes can occur in the space of 1 hour.
- may harm others physically.
- have a history of poor school, work performance because of constantly changing career goals and shifts in identity or aspirations, preoccupation with maintaining relationships, and fear of real or perceived abandonment.
- lack the concentration and self-discipline to follow through on sometimes mundane tasks associated with work or school.

Assessment fo borderline personality disorder- Physiologic and Self-Care Considerations

- may engage in binging (excessive overeating) and purging (self-induced vomiting),
- substance abuse,
- unprotected sex,
- reckless behavior such as driving while intoxicated.
- usually have difficulty sleeping.

Nursing diagnoses for clients with borderline personality

Risk for Suicide
• Risk for Self-Mutilation
• Risk for Other-Directed Violence
• Ineffective Coping
• Social Isolation

Outcome Identification- borderline

Treatment outcomes may include the following:
• The client will be safe and free of significant injury
• The client will not harm others or destroy property
• The client will demonstrate increased control of impul-sive behavior.
• The client will take appropriate steps to meet his or her own needs.
• The client will demonstrate problem-solving skills.
• The client will verbalize greater satisfaction with relationships

NURSING INTERVENTIONS
for Borderline Personality Disorder

Promoting client's safety
• No-self-harm contract
• Safe expression of feelings and emotions- Helping client to cope and control emotions
• Identifying feelings
• Journal entries
• Moderating emotional responses
• Decreasing impulsivity
• Delaying gratificationCognitive restructuring techniques
• Thought stopping
• DecatastrophizingStructuring timeTeaching social skills- Teaching effective communication skillsEntering therapeutic relationship
• Limit setting
• Confrontation

CLIENT/FAMILY EDUCATION
for Borderline Personality Disorder

- Teaching social skills
• Maintaining personal boundaries
• Realistic expectations of relationships-Teaching time structuring
• Making a written schedule of activities
• Making a list of solitary activities to combat boredom-Teaching self-management through cognitive restructuring
• Decatastrophizing situation
• Thought stopping
• Positive self-talk- Using assertiveness techniques such as "I" statementsUsing distraction, such as walking or listening to music

Cognitive restructuring

- is a technique useful in changing patterns of thinking by helping clients to recognize negative thoughts and feelings and to replace them with positive patterns of thinking.

Thought stopping

is a technique to alter the process of negative or self-critical thought patterns such as "I'm dumb, I'm stupid, I can't do anything right."
- When the thoughts begin, the client may actually say "Stop!" in a loud voice to stop the negative thoughts.
- Later, more subtle means such as forming a visual image of a stop sign will be a cue to interrupt the negative thoughts.

positive self-talk

- the client reframes negative thoughts into positive ones: "I made a mistake, but it's not the end of the world. Next time, I'll know what to do"

Decatastrophizing

- is a technique that involves learning to assess situations realistically rather than always assuming a catastrophe will happen.
- The nurse asks, "So what is the worst thing that could happen?" or
- "How likely do you think that is?"
- "How do you suppose other people might deal with that?"
- "Can you think of any exceptions to that?"
- In this way, the client must consider other points of view and actually think about the situation; in time, his or her thinking may become less rigid and inflexible

Histrionic personality disorder

is characterized by a pervasive pattern of excessive emotionality and attention seeking.
- occurs in 2% to 3% of the general population and in 10% to 15% of the clinical population.
- more often in women than in men.
- usually seek treatment for depression, unexplained physical problems, and difficulties in relationships
-The tendency of these clients to exaggerate the close-ness of relationships or to dramatize relatively minor occurrences can result in unreliable data.
- Speech is usually colorful and theatrical, full of superlative adjectives.
- It becomes apparent, however, that although colorful and entertaining, descriptions are vague and lack detail.
- Overall appearance is normal, may over-dress (e.g., wear an evening dress and high heels for a clinical interview).
- are overly concerned with impressing others with their appearance and spend inordinate time, energy, and money
- Dress and flirtatious behavior are not limited to social situations or relationships but also occur in occupational and professional settings.
-may feel these clients are charming or even seductive
- emotionally expressive, gregarious, and effusive, often exaggerate emotions inappropriately.
- Expressed emotions, although colorful, are insincere and shallow; this is readily apparent to others but not to clients.
- labile emotion, mood
- self-absorbed and focus most of their thinking on themselves, with little or no thought about the needs of others.
- highly suggestible and will agree with almost anyone to gain attention.
- uncomfortable when they are not the center of attention and go to great lengths to gain that status.
- use their physical appearance and dress to gain atten-tion.
- comment or statement that could be interpreted as uncomplimentary or unflattering may produce a strong response such as a temper tantrum or crying outburst.

Narcissistic personality disorder

is characterized by a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy.
- 50% to 75% of people with this diagnosis are men.
- traits are common in adolescence and do not necessarily indicate that a personality disorder will develop in adulthood.
- Individual psychotherapy is the most effective treatment, and hospitalization is rare unless comorbid conditions exist for which the client requires inpatient treatment
- Clients may display an arrogant or haughty attitude.
- lack the ability to recognize or to empathize, express envy, begrudge others any recognition or material success
- tend to disparage, belittle, or discount the feelings of others.
- may express grandiosity overtly, or they quietly may expect to be recognized for their perceived greatness.
- preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love- reinforce their sense of superiority.
- may ruminate about long-overdue admiration and privilege and compare themselves favorably with famous or privileged people.
- Thought processing is intact,
- insight is limited or poor.
- believe to be superior and special and are unlikely to consider that their behavior has any relation to their problems:
- view their problems as the fault of others.
Underlying self-esteem fragile and vulnerable.
- hypersensitive to criticism, need constant attention, admiration.
- display a sense of entitlement (unrealistic expectation of special treatment or automatic compliance with wishes).
-- believe that only special or privileged people can appreciate their unique qualities or are worthy of their friendship.
- expect special treatment from others and often are puzzled or even angry when they do not receive it.
- form and exploit relationships to elevate status.
- assume total concern from others about their welfare.
- At work, may experience some success because they are ambitious and confident.
- Difficulties are common, trouble working with others (whom they consider to be inferior) and have limited ability to accept criticism or feedback.
- believe they are underpaid and underappreciated or should have a higher position of authority even though they are not qualified.

Nursing Interventions
Clients with narcissistic personality disorder

- can present one of the greatest challenges to the nurse.
- must use self-awareness skills to avoid the anger and frustration that these clients' behavior and attitude can engender.
- Clients may be rude and arrogant, unwilling to wait, and harsh and critical of the nurse.
- The nurse must not internalize such criticism or take it personally.
- The goal is to gain cooperation of these clients with other treatment as indicated.
- The nurse teaches about comorbid medical or psychiatric conditions, medication regimen, and any needed self-care skills in a matter-of-fact manner.
- must sets limits on rude or verbally abusive behavior and explains his or her expectations of the client

Avoidant personality disorder

- is characterized by a pervasive pattern of social discomfort and reticence, low self-esteem, and hypersensitivity to negative evaluation. believe to be inferior.
- common in men and women.
- Clients are good candidates for individual psychotherapy
- likely to report being overly inhibited as children and
- often avoid unfamiliar situations and people with an intensity beyond that expected for their developmental stage.
- are apt to be anxious, may fidget in chairs, make poor eye contact, may be reluctant to ask questions or make requests.
- may appear sad, anxious, shy, fearful, socially awkward, and easily devastated by real or perceived criticism.
-usual response to reticent and withdrawn. to be inferior. Clients are reluctant to do anything perceived as risky, which, for them, is almost anything. They are fearful and convinced they will make a mistake, be humiliated, or embarrass themselves and others. Because they are unusually fearful of rejection, criticism, shame, or disapproval,
- stronge desire 4 social acceptance and human companionship:
- They may need excessive reassurance of guaranteed acceptance before they are willing to risk forming a relationship.
- may report some success in occupational roles because so eager 4 approval.
- Shyness, awkwardness, or fear of failure, however, may prevent them from seeking jobs that might be more suitable, challenging, or rewarding.

Nursing Interventions for advoidance

- require much support and reassurance from the nurse. nonthreatening context - can help them to explore posi-tive self-aspects, positive responses from others, and possible reasons for self-criticism.
- Helping clients to practice self-affirmations and positive self-talk may be useful in promoting self-esteem.
- Other cognitive restructuring techniques such as reframing and decatastrophizing can enhance self-worth.
- can teach social skills and help clients to practice them in the safety of the nurse-client relationship.
- The nurse must be careful and patient with clients and not expect them to implement social skills too rapidly

Dependent personality disorder

- is characterized by a pervasive and excessive need to be taken care of, which leads to submissive and clinging behavior and fears of separation. These behaviors are designed to elicit caretaking from others.
- three times more often in women than in men.
- It runs in families and is most common in the youngest child.
- People with dependent personality disorder often seek treatment for anxious, depressed, or somatic symptoms
- may be mildly uncomfortable.
- pessimistic and selfcritical; other people hurt their feelings easily.
- report feeling unhappy or depressed; this is associated most likely with the actual or threatened loss of support from another.
- preoccupied excessively with unrealistic fears of being left alone to care for themselves.
- believe they would fail on their own, so keeping or finding a relationship occupies much of their time.
- tremendous difficulty making decisions, no matter how minor.
- lack the confidence .
- believe they need someone else to assume responsibility for themwill do anything to keep some one even suffer abuse, consent to activities that are wrong or illegal to avoid that loss.
- "Any relationship is better than none at all."

Nursing Interventions dependent

- must help clients to express feelings of grief and loss over the end of a relationship while fostering autonomy and self-reliance.
- Helping clients to identify their strengths and needs is more helpful than encouraging the overwhelming belief that "I can't do anything alone!"
- Cognitive restructuring techniques such as reframing and decatastrophizing may be beneficial.
- may need assistance in daily functioning if they have little or no past success in this area. Included are such things as planning menus, doing the weekly shopping, budgeting money, balancing a checkbook, and paying bills.
- Careful assessment to determine areas of need is essential.
- may need to teach problem-solving and decision-making and help clients apply them to daily life.
- must refrain from giving advice about problems or making decisions for clients even though clients may ask the nurse to do so.
The nurse can help the client to explore problems, serve as a sounding board for discussion of alternatives, and provide support and positive feed-back for the client's efforts in these areas

SUSPECT

Paranoid personality acronym

DISTANT

Schizoid personality acronym

ME PECULIAR

Schizotypal personality acronym

4

For a person to be diagnosed with paranoid personality disorder, he or she must have at least __ of the symptoms from the acronym "SUSPECT"

paranoid personality criteria

Suspect, Unforgiving, Spouse infidelity, Perceives attacks (and reacts quickly), Enemy or friend (suspects others), Confiding in others feared, Threats perceived in benign events

paranoid personality disorder

etiology is unknown, but genetic link is suspected and could be related to early parental antagonism and aggression. More common in MEN.

4

To be diagnosed with schizoid personality disorder, someone must have at least __ of the criteria.

schizoid personality criteria

Detached affect, Indifferent to criticism and praise, Sexual experiences of little interest, Tasks preferred in solitary, Absence of close friends, Neither desires nor enjoys close relations, Takes pleasure in few activities

schizoid personality disorder

etiology is unknown, but there is thought to be a genetic link, and could be associated with lack of nurturing in childhood. Higher incidence in MEN.

5

To be diagnosed with schizotypal personality disorder, someone must have at least __ of the criteria from the acronym "ME PECULIAR"

schizotypal personality criteria

Magical thinking or odd beliefs, Experiences unusual perceptions, Paranoid ideation, Eccentric, Constricted/inappropriate affect, Unusual thinking and speech, Lacks close friends, Ideas of reference, Anxiety in social situations, Rule out psychotic d/o and PPD

schizotypal personality disorder

has possible hereditary and physiological factors. Indifference & impassive family relationships, formality, discomfort with personal affection.

Odd or eccentric psychotics

Cluster A personality disorder includes the ____ __ _______ ________.

Cluster B

This cluster of personality disorders involves the dramatic, emotional, or erratic. "All the world's a Stage"

CORRUPT

Antisocial personality disorder acronym

AM SUICIDE

Borderline personality disorder acronym

PRAISE ME

Histrionic personality disorder acronym

SPECIAL

Narcissistic personality disorder acronym

3

To be diagnosed with antisocial personality disorder, someone must meet __ of the criteria from the acronym "CORRUPT"

antisocial personality disorder criteria

Conformity to law is lacking, Obligations ignored, Reckless disregard for safety, Remorseless, Underhanded (deceitful, lies, cons), Planning insufficient, Temper (irritable and aggressive)

antisocial personality disorder

Research findings - abnormal EEG in adults. Higher incidence in MALES.

5

To be diagnosed with Borderline personality disorder, a person must have at least __ of the criteria from the acronym "AM SUICIDE"

Borderline personality disorder criteria

Abandonment, Mood instability, Suicidal and self-mutilating behavior, Unstable and intense relationships, Impulsivity (2 or > areas), Control of anger intense, recurrent displays, Identity disturbance, Dissociative, Emptiness

women

Borderline personality disorder has a higher incidence in ______.

5

How many criteria must be met for a person to be diagnosed with Histrionic personality disorder?

Histrionic personality disorder criteria

Proactive behavior (or sexually seductive), Relationships, Attention, Influenced easily, Style of speech, Emotions rapidly shifting and shallow, Made up appearance to draw attention, Emotions exaggerated

serotonin

Histrionic personality disorder is thought to be partially as a result of decreased levels of __________.

women

Histrionic personality disorder is more common in ________.

5

How many criteria must a person meet to be diagnosed with Narcissistic personality disorder?

Narcissistic personality disorder criteria

Special and unique self concept, Preoccupied with fantasies, Entitlement, Conceited, Interpersonal exploitation, Arrogant, Lacks empathy

Men

Narcissistic personality disorder has a higher incidence in ____.

Cluster C

The "Anxious and Fearful" cluster of personality disorders are included in _________ __.

CRINGES

avoidant personality disorder acronym

RELIANCE

dependent personality disorder acronym

LAW FIRMS

Obsessive-compulsive personality disorder acronym

PASSIVE

Passive aggressive personality disorder acronym

4

how many criteria must someone meet to be diagnosed with avoidant personality disorder?

avoidant personality disorder criteria

Certainty of being liked needed preinvolvement with others, Rejection preoccupation in social situations, Intimate relationship restraint, New interpersonal relationship inhibition, Gets around/avoids occupational activities, Embarrassment potential prevents taking risks, Self view

avoidant personality disorder

cluster C personality disorder that is seen equally in both men and women.

5

how many criteria must a person meet to be diagnosed with dependent personality disorder?

dependence personality disorder criteria

Reassurance required for decision making, Expression disagreement difficult, Life responsibilities, Initiating projects difficult, Alone, Nurturance dependency, Companionship urgently sought after breakup, Exaggerated fears of being left to care for self

dependent personality disorder

cluster C personality disorder that is more common among women and young children

4

How many criteria must someone meet to be diagnosed with obsessive-compulsive disorder?

obsessive compulsive disorder criteria

Loses the point of doing an activity, Ability to complete tasks compromised, Worthless objects, Friendships excluded, Inflexible, scrupulous over consciencious, Reluctant to delegate, Miserly toward self and others, Stubbornness and rigidity

4

How many criteria must a person meet to be diagnosed with passive aggressive personality disorder?

passive aggressive personality disorder criteria

Passively resists fulfilling routine social and occupational tasks, Alternates between hostile defiance and contrition, Sullen and argumentative, Scorns and criticizes authority, Is misunderstood and unappreciated by others, Voices exaggerated and persistent c/o misfortune, Expresses envy and resentment to those more fortunate

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