SEMESTER IV, EXAM I; PERSONALITY DISORDERS

What are the 3 day to day areas that someone with a PD have struggles with?
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What are the 3 day to day areas that someone with a PD have struggles with?
-Trouble controlling thoughts and emotions
-Trouble participating in interpersonal relationships
-Trouble managing impulses
Do Personality Disorders evolve over an individual's life?
YES
What are some common comorbidities that people with personality disorders tend to have?
*MOOD DISORDERS:
-Bipolar
-Depressive disorder
*ANXIETY
*EATING DISORDERS
*SUBSTANCE USE DISORDERS
Why do patients who have personality disorders tend to show up with conditions such as untreated HTN, diabetes, etc by the time they finally come to seek help?
They tend to avoid seeking help because of the existing stigma about mental health.
As far as Case Management, what are goals for treating someone w/ a PD in the acute care setting?
- to gather pertinent history from current or previous providers
- to support reintegration with family or loved ones
- to ensure appropriate referrals to outpatient care
As far as Case Management, what are goals for treating someone w/ a PD in a LONG TERM outpatient setting?
-To reduce hospitalization by providing resources for crisis services
-To enhance the social support system
Define psychothrapy
Is a general term referring to a treatment modality based on the development of a trusting relationship between patient & therapist for the purpose of exploring & modifying the patient's behavior
What is cognitive-behavioral therapy?
-Is a psychotherapeutic approach that addresses dysfunctional emotions, maladaptive behaviors, & cognitive processes.
-Cognitive component focuses on patterns of thinking & what one says to oneself internally
-Behavioral component uses consequences & rewards to shape the person's behavior in a more positive or adaptive manner
What is Dialectical Behavior Therapy?
-Dialectical refers to the back-and-forth process in which the clinician accepts the patient without judgment, but also addresses their problematic behavior
-Evidence-based therapy to treat chronically suicidal individuals with BPD
-Combines cognitive and behavioral techniques with mindfulness
-Encourages individual to identify his/her thoughts before acting
What are the treatment goals of Dialectical Behavior Therapy?
-To reduce the frequency of self-destructive acts
-To increase patient's ability to manage and tolerate emotions
-To develop greater effectiveness in handling social relationships
What is Schema-Focused Therapy?-Focuses on ways that people view themselves -Effective with patients with Borderline Personality DisorderThere is a cluster of personality disorders in which all have ODD ECCENTRIC BEHAVIORS, EXPERIENCE SEVERE ILLNESS EFFECTS, AND TEND TO BE RESISTANT TO TREATMENT. The patient will FIRMLY BELIEVE IN THEIR INTERPRETATION OF EVENTS. What are the 3 personality disorders? (CLUSTER A)-Schizotypal Personality Disorder -Paranoid Personality Disorder -Schizoid Personality DisorderWhat is a therapeutic milieu? Name the 4 components.an environment that promotes behavioral changes and improves psychological health & functioning of the individual 4 components of the milieu include - the people - the setting - the structure - the emotional climateWhat is the nurses role in the milieu?-Contact person -See handoutExplain what each component isThe people; Health team and patient The setting; Safe environment, socail The structure; Designed to keep patient safe *no power outlets, curtains, shoe laces, scissors, etc.Is schizotypical personality disorder a latent form of schizophrenia?YESWhat is latent schizophrenia?A condition characterized by symptoms of schizophrenia, but lacking psychotic schizophrenic episode. Ex: phobias, obsessions, ideas of reference (the lamp post), May have hallucinations (prodromal)If you were to come face to face with someone with a schizotypal personality disorder, what are some general personality traits you are looking for?-Has eccentric ideas and unusual beliefs (ex: dresses crazy and believes in Buda) -Has difficulty forming an accurate perception and cognition about his/her world -Anxious and socially inept -May experience prodromal symptoms of schizophreniaWhat can cause a schizotypal personality disorder?-Can be genetic; dysfunctioning neurotransmitters (Brain structure abnormalities/size can cause) -Increased neurotransmitters (ex: increased dopamine causes aggression)What is the goal of ongoing treatment for someone with a Schizotypal Personality Disorder?The goal is to prevent full-blown psychosisWhat are the types of therapy do we use to treat someone with Schizotypal personality disorder?-Psychotherapy: One on one therapist -Cognitive Behavioral Therapy: a type of psychotherapy in which negative patterns of thought about the self and the world are challenged -Group TherapyWhat types of medications are used to treat Schizotypal Personality Disorder?-Antipsychotics -Antidepressants -Antianxiety medsWhat are the 2 second gen antipsychotics we use to treat Schizotypal Personality Disorder? (Treats both + and - symptoms of schizophrenia)RESPIRATE QUIETLY -quetiapine (Seroquel) -risperidone (Risperdal)What is a benefit of using 2nd gen anti-psych meds?Very low chance of Extrapyramidal Symptoms (ex: dystonia)What is a downfall of the 2nd gen anti-psych meds?Side effects are weight gain and diabetesHow are 2nd gen meds administered?POWhy is it important to monitor vital signs before start of and during use of quetiapine and risperidone?Can cause increase in heart rate and BPThere are nursing guidelines when caring for someone with Schizotypal Personality Disorders. Give examples of the guidelines you must follow.-Always assess for suicidality or thoughts of hurting someone else. -Don't argue, reorient to reality -Respect pt's need for social isolation -Be aware of patient's suspiciousnessWhat is the personality of someone with a Paranoid Personality Disorder-Are extremely suspicious of others and always on guard against potential harm -Incapable of trusting anyone -Unable to acknowledge their problem -Project blame on others -Are rigid, defensive, & hostileIs therapy typically successful with someone who has Paranoid Personality Disorder? Why or why not?Therapy NOT typically successful due to difficulty making progress and working toward any kind of lasting change.If you see someone pacing, walking with clenched fists, or displaying symptoms of building frustration, what do you do?Acknowledge. "I see that you are pacing". Check to see what they need. (Maslow's Heirarchy of Needs) May just need to use the bathroom.What is Schizoid Personality Disorder?-Characterized by an indifference to social relationships and a very limited range of emotional experience & expression -Prefer to be alone -Lack desire for acceptance or love -Perceived as cold, reserved, withdrawn, seclusive -Maladaptive to social functioningWhat is the primary feature of Schizoid Personality DisorderEmotional detached- LOTS OF NEGATIVE SYMPTOMSWhat are the 3 personality disorders that are most challenging and very highly demanding? (CLUSTER B)-Antisocial Personality Disorder -Borderline Personality Disorder -Narcissistic Personality DisorderWhat is the common personality seen in patients who are Antisocial, Borderline, or Narcissistic? (Cluster B)-Are dramatic, emotional, or erratic -Have problems with impulse control, emotional processing/regulating, & exhibit interpersonal struggles -Behavior is desperate or entitled, manipulativeWhat are former names of Antisocial Personality Disorder?Sociopath and psychopathWhat are the main characteristics of someone with an Antisocial Personality Disorder?Callus and zero remorse. Charachterized by lack of regard for society's moral or legal standards. -Manipulative, aggressive or seductive -Highly impulsive and lacking capacity for regretWhen does an Antisocial Personality Disorder start?Develops in childhoodWhat types of behavior would this child be displaying?-Lying -Cheating -StealingDo people with Antisocial Personality Disorder learn from their negative experiences?NOCan a person with Antisocial Personality Disorder develop empathy and conscience?NO"Psychopath in the Boardroom" is a co-occuring disorder. What are the 2 personality disorder this person has?Antisocial PD and Narcissistic PDWhat are the personality traits of a "Psychopath in the Boardroom"?TRAITS OF A SERIAL KILLER - superficial charm - lack of conscience & remorse - ruthlessness - manipulation of others - persuasiveness - grandiose sense of self-worthWhat types of jobs would we find a "Psychopath in the Boardroom" doing?Usually found in the corporate world and in politicsHow is Antisocial Personality Disorder caused? (etiology)-Malnutrition in early life (can contribute to abnomalities of brain shape/size) -Abnormally HIGH levels of dopamine and LOW levels of seratonin -Childhood experiences w/ parents who lack parenting skills & who exhibit antisocial behaviors -Childhood environment of significant abuse and extreme neglectWhat do high levels of dopamine and low levels of seratonin contribute to?AgressionIf the brain is abnormally shaped, what's the big deal?-Altered short term memory -Less ability to inhibit aggressionWhat are the goals when treating someone with Antisocial Personality Disorder?-To convince the person that they are responsible for their own behavior -To develop more prosocial ways to satisfy their needs by using their strengthsWhat type of therapies are used to treat someone with Antisocial Personality Disorder?-Psychotherapy -Cognitive Behavioral TherapyWhat type of medication is used to treat Antisocial Personality Disorder? (for rage)Lithobid (Lithium carbonate ER) -mood stabilizerWhat does lithium do specifically?Decreases aggressionHow is Lithium administered?PO with meals and LOTS of waterWhat are adverse effects of Lithium?-Coma -Seizure -Dysrhythmias -O.D.What are the s/s of an overdose of Lithium?-N/V -Diarrhea -Muscular weakness -Incoordination -GiddinessDo we have to be watchful since lithium toxicity can occur close to therapeutic levels?YESShould you have someone do an EKG before Lithium?YESWhat is the therapeutic range for lithium?0.5 to 1.5mEqWhen someone starts on Lithium, how often do blood serum levels need to be drawn?Initially, monitor 2x/week, and then q 8 weeks once therapeutic range is achievedHow does assigning a contact nurse help when taking care of someone with Antisocial Personality Disorder?It provides consistencyWhat are the nursing guidelines when dealing with a patient who has Antisocial Personality Disorder?TO REDUCE AND PREVENT MANIPULATION: - set clear & realistic limits on behavior - provide clear boundaries & consequences - appoint a 'contact' person/coach/primary nurse - ensure that limits are adhered to by all staff - be aware of own feelings & responses to pt behavior - document behaviors & signs of manipulation/aggression Guard against being manipulated through feelings of guiltWhat is Borderline Personality Disorder?Characterized by a pervasive pattern of poor impulse control and instability in mood, interpersonal relationships, and self imageWhat types of behaviors may you see in someone with Borderline Personality Disorder?-Frantic efforts to avoid abandonment (clingy, needy) - Unstable and intense relationships (seperation anxiety) - Impulsivity in areas such as sexuality, spending, or reckless driving - Recurrent suicidal behavior - Chronic feelings of emptiness - Difficulty controlling angerWhat is Splitting?A term used by psychologists to describe the behavior of the individual with Borderline PD.What is the typical behavior of a splitter?Individual is preoccupied with the object of love and desire...when rejected, becomes enraged and hateful. May apply all-good vs all-badHow can we prevent staff splitting?-Attend weekly staff meetings to discuss patients, feelings, conflicts -Include patients in daily staff rounds to set goals and evaluate progress -Set limits and address negative behavior utilize empathic mirroringWhat type of personality disorder would someone have if they were cutting? Besides cutting, what else might you see?Borderline PD. May also bang their heads, burn themselves, or swallow objects. They are temporary maladaptive behaviorsWhat is "cutting"?Self mutilation/self injurous behavior. A suicidal gestureWhy would someone be cutting themselves?-To gain attention from others -To inflict physical pain in an attempt to numb the emotional painExplain nursing care of someone who has been cutting-Change the dressings in neutral, matter-of-fact manner -Instruct patient to write the events that led to the self-mutilation & the consequences, and what they could have done differently instead of cutting -Encourage patient to think about his/her behavior explore & discuss alternative behaviorsWhat are causes of Borderline Personality Disorder? (etiology)-Genetic origin -Brain abnormalities -Abnormalities in neurotransmitters and hormones -History of early abandonment, childhood neglect, traumatic experiences, growing up in an environment w/ marital difficultiesIn what part of the brain will you find abnormalities of someone with Borderline Personality Disorder?Brain abnormalities in the amygdala and prefrontal cortex (Causes difficulty w/ emotional processing and regulation)If a person w/ Borderline PD has abnormalities in neurotransmitters and hormones, what alterations would you see?Altered response to emotions and painWhat are the goals when treating someone w/ Borderline PD?-To help patient develop greater control of emotions and behavior -To reduce the patient's self destructive behaviorHow can a patient develop greater control of emotions and behavior?Through things like journaling and reflectionWhat type of therapies are used to treat someone w/ Borderline PD?-Cognitive Behavioral Therapy -Dialectical Behavior Therapy (helps find alternate ways to deal w/ stress) -Schema-focused therapy (integrative approach to treatment that combines the best aspects of cognitive-behavioral, experiential, interpersonal and psychoanalytic therapies into one unified model)What types of medication are used to treat someone w/ Borderline PD?-Mood stabilizers (Lithium Carbonate) -Atypical antipsychs (Risperdal and Seroquel) -Omega 3-fatty acids -Naltrexone (opioid receptor antagonist)What effect does Naltrexone have on someone w/ Borderline PD?Prevents self injurous behavior; 50mg/dayWhich of the medications is considered "off label" for treating Borderline PD?Omega 3-fatty acidsWhat are the effects of Omega 3-fatty acid supplements on someone w/ Borderline PD?Decreases aggression and feelings of hostilityWhat are the side effects of Omega 3-fatty acid supplements?Taking MORE THAN 3 GRAMS can cause: -Bleeding complications -Loose stools -Upset stomach -Low blood pressureWhat are the nursing guidelines when taking care of someone w/ Borderline PD?-Avoid rejecting or rescuing -Assess for risk of self-injury -Assist pt to identify triggers that lead to maladaptive behavior -Encourage use of coping skills learned in therapy establish clear boundaries, expectations, structure, & support -Be aware of manipulative behaviors -Use clear and straightforward communication -Calmly review therapeutic goals & boundaries of treatment when behavioral problems emergeWhat is Narcissistic Personality Disorder?Characterized by an unrealistic, inflated sense of self-importance and a lack of sensitivity to the needs of other peopleWhat type of personality do you see in someone w/ Narcissistic PD?-See themselves as exceptional & entitled -Main personality trait is antagonism -Set unrealistically high standards for themselves -Derive their self-definition & self-esteem from the way that -They believe other people view them -Unable to empathize with others -Deep-rooted insecurity and need for attentionWhat causes Narcissistic Personality Disorder? (etiology)-Lack of parental support and firm foundation of healthy self -History of childhood neglect and criticismWhat are the goals when treating someone w/ Narcissistic PD?-To guide the patient toward a more realistic appreciation that no one is flawless -To provide reassurance while at the same time encouraging them to develop more realistic view of themselves & other peopleWhat types of therapies are used to treat someone w/ Narcissistic PD?-Group Therapy -Psychotherapy (only AFTER patient acknowledges narcissism)What types of meds are used to treat someone w/ Narcissistic PD?-Lithium (mood stabilizer) -SSRI's (antidepressants) *citalopram (Celexa) *escitalopram (Lexapro) *fluoxetine (Prozac)What are the side effects of SSRI's?-Nausea -Sexual dysfunction -Weight gain -Anticholinergic effects (drymouth, constipation, etc)What are nursing guidelines when taking care of someone w/ Narcissistic PD?-Remain neutral -Avoid engaging in power struggles -Avoid becoming defensive -Convey self-confidenceWhat is Histrionic Personality Disorder?Characterized as taking extreme pleasure in being the center of attention and behave in any way necessary to ensure that this happens. Main feature: seeks attentionWhat type of personality will you see in someone w/ Histrionic PD?-Excessively concerned with their physical appearance -Perceived as seductive and flirtatious -Demand reassurance, praise, and approval of others and become enraged when they don't get it -Their relationships are superficial, but assume the relationships to be intimate and refer to acquaintances as 'dear friendsWhat are the cluster of personality disorders that all show signs of being anxious or fearful, socially shy and hypersensitive, and have a strong need for orderliness? (Cluster C)-Obsessive-Compulsive Personality Disorder -Avoidant Personality Disorder -Dependent Personality DisorderWhat is Obsessive Compulsive Perosnality Disorder?Characterized by intense perfectionism and inflexibility manifested in worrying, indecisiveness, and behavioral rigidityWhat type of personality will you see in someone w/ Obsessive Compulsive PD?-Defines their sense of self and self-worth in terms of their work productivity -Throw themselves into their work to the exclusion of their social relationships -Their work is never good enough -Have high, unrealistic expectations of themselves -Critical of others -Rigidly compulsive -Become fixated on certain routines -Are unproductive; cannot complete a task; self-defeating OCPD ≠ OCDWhy is it that someone who has Obsessive Compulsive PD cannot complete a task?Because the person becomes so fixated on tiny details, that it never gets finished.What causes Obsessive Compulsive PD?Excessive parental criticism, control, & shame which causes individual to strive for perfectionism & orderliness in attempt to control his/her environmentWhat is the goal when treating someone w/ Obsessive Compulsive PD?To help the patient 'take a step back' and learn to identify their problematic ruminative thinking patternsWhat types of therapies are used when treating someone w/ Obsessive Compulsive PD?-Self-help group therapy -Cognitive-Behavioral Therapy (focuses on examining patient's thought processes)What types of medications are used to treat Obsessive Compulsive PD?-clomipramine (Anafranil); (antidepressant) -Prozac (SSRI)What does Clomipramine do?Treats obsessive compulsive disorder - decreases persistent/unwanted thoughts - reduces the urge to perform repeated tasksHow is clomipramine administered?PO w/out regard for foodWhat is a side effect of clomipramine?SeizuresWhat are s/s of clomipramine overdose?-Cardiac arrhythmias -HypotensionWhat are nursing guidelines when taking care of someone w/ Obsessive-Compulsive PD?-Guard against power struggles -Monitor for common defense mechanisms *rationalization *reaction formation *isolation -Encourage thought stopping with the intention of having the patient "stop" when they are overtaken by ruminative worryWhat is Avoidant Personality Disorder?Characterized by the desire for close interpersonal relationships, but are terrified of being publicly embarrassedWhat kind of personality will you see in someone w/ Avoidant Personality Disorder?-Strong feelings of shame and inadequacy, therefore; they avoid all contact -Extremely sensitive to rejection and ridiculeWhat causes Avoidant Personality Disorder?-Parental and peer rejection and criticism -History of anxiety and social phobiaWhat are the goals when treating someone w/ Avoidant PD?-To break the individual's negative cycle of avoidance -To articulate thoughts and dysfunctional attitudes that interfere with their ability to establish relationshipsWhat types of therapies are used to treat someone w/ Avoidant PD?-Cognitive-behavioral therapy *gradual exposure to social situations *skills-training to improve relationships -Individual & group therapy -Assertiveness trainingWhat type of medications are used to treat Avoidant PD?-citalopram (Celexa); (antidepressant) -Venlafaxine; antianxiety agent (SNRI)What are nursing guidelines when taking care of someone w/ Avoidant PD?-Use a friendly, accepting, reassuring approach -Avoid forcing patient into social situationsWhat is Dependent Personality Disorder?-Individual is extremely passive and tends to cling to other people, to the point of being unable to make any decisions or to take any action Extreme doubt of self-made decisions -Perceived as 'clingy' -Go to extremes to avoid having people dislike them when alone, feel despondent and abandonedWhat is Personality Disorder Not Otherwise Specified?-Used for those individuals that are difficult to diagnose -The individuals meet basic criteria for personality disorders, but don't meet the specific criteria for specific personality disorders -Are less disruptive in functioning and quality of lifeExplain a proper self-assessment when taking care of someone w/ a personality disorder-Anticipate the behavior of the personality disorder -Don't take it personally -Be aware of and monitor your own stress responses to patient behaviors to maintain an effective and therapeutic environment -Utilize treatment approaches that are evidence-based & clinically structuredWhen you are performing your nursing assessment on someone who has a personality disorder, what are you assessing?-Level of current risk of harm to self or others -Recent significant loss -Medical conditions/diseases -Current medications -Suicidal or aggressive ideation or actions -Substance use or legal problems -Current or past h/o physical, sexual, emotional abuseWhy do you want to know if someone has had a recent loss?Because it can trigger a personality disorder or increase maladaptive behavior in someone w/ a personality disorder