Chapter II PERSONALITY DISORDERS Every human being has personality traits and characteristics that make us unique and

interesting human beings. Our traits are almost and always exhibited in the way we think about ourselves and others and in how we behave in a world we live in.

Personality: Can be defined as an ingrained (thoroughly imbued, wet or stained), enduring (deeply rooted lasting or existing for a long time) pattern of behaving and relating to oneself and others that includes ones perceptions, attitudes, and emotions regarding oneself and the world. And very often, these behaviors and characteristics are consistently displayed across a broad range of situations and are not easily changed.

What is Character ?

The total quality of a persons behavior, as revealed in his habits of thoughts and expression, his attitudes and interests, his actions, and his personal philosophy of life. The qualities that distinguish one person from another ( National Characters: ex; national heroes). Is influenced by social learning, culture, and random life events unique to each person. And character is developed over time as one comes into contact with people and situations and confronts challenges, producing concepts about the self and the external world. And when fully developed, these character traits define a mature personality.

Important Facts about Personality: Usually, people are not consciously aware of their personality. Many factors influence ones personality
Some stem from our biologic and genetic makeup, and others are acquired as one develops and interacts

with the environment and other people. Personality Disorders: are diagnosed when a persons personality traits- behavioral patterns that reflect how a person perceives and relates to others and himself- become inflexible (rigid and fixed), maladaptive and significantly interfere with how the person functions in society or cause the person emotional distress. The disorder affects the persons cognition, behavior, and style of interacting w/ others. Although many people are affected w/ personality disorders, it can have a great deal of variance, and what is common in most clients is their significant impairment in fulfilling family responsibilities, academic performances, employment, and many other functional roles. Important Facts About Personality disorders:

1. Personality disorders are longstanding conditions because personality traits or characteristics are not
easily changed. This means that clients with personality disorders continue to behave in their same familiar ways, even when these behaviors cause them problems, difficulties or distress.
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There is no specific medication that alters a persons personality. Therapy designed to help the client make changes is often long term, and with very slow progress. Some people with personality disorders believe that their problems stem from other people or the world in general, not recognizing that their own behavior is causing difficulties for them and for others. And for these reasons, these people are difficult to treat and their conditions can be frustrating for the nurse and other caregivers, as well as family and friends. There are difficulties in diagnosing and treating clients with personality disorders because of similarities and subtle differences between the categories or types. Overlaps are uncommon because some clients with

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personality disorders also have coexisting major mental illness (such as substance abuse, mood and anxiety disorders).
5. When mild, personality disorders may have little effect on a persons social, family or work life. However, if symptoms persist or get worse- as they commonly do during times of increased stress- the disorder can seriously interfere with the clients emotional, psychological, social and occupational functioning. And thus, can result to hospitalization, poor work performance, lost productivity, domestic violence, child abuse, and imprisonment. Their emotional toll ( or Mental baggages) such as unhappiness, disturbed or unhealthy relationships, and even suicide- is equally staggering.

6. In psychiatric settings, nurses most often encounter clients with borderline and antisocial personality
disorders.

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

7. Personality disorders are not usually diagnosed until adulthood, when ones personality is more completely
formed, but these maladaptive patterns of behavior can often be traced back to adolescence or early childhood stage.

8. People with personality disorder, usually, do not have the same personal and social expectations as others
do; they typically have difficulty getting along with others, who are forced to adjust to their behaviors and expectations. If others dont or cant adjust, people with the disorder may become angry, frustrated, or withdrawn. The diagnosis is made when the person exhibits pervasive (spread throughout) and enduring patterns of behavior that deviate or differs markedly from the expectations of the clients culture or ethnic background in two or more of the following areas:(Most people with personality disorders share several features).
A. Ways of perceiving and interpreting oneself, other people and events (Cognition).

Disturbance in self image Maladaptive ways of perceiving self, others and the world Inappropriate range of emotions Maybe irritable, hostile, demanding, fearful dependent and manipulative

B. Range, intensity, lability, and appropriateness of emotional response (Affect)

A. Interpersonal functioning Longstanding problems in personal relationship, ranging from dependency to withdrawal and isolation Difficulty in getting along with others ( others are forced to adjust to their behavior) Typically have inadequate coping mechanism, trouble dealing with everyday stresses and strained relationships
C. Ability to control impulses or express behavior at the appropriate time and place (Poor Impulse Control)

Sexually promiscuous (engage in casual or indiscriminate sex) Insensitive or disregard to the feelings of others Usually do not experience feelings of remorse

Onset and Clinical course: A. Personality disorders are relatively common: Occurring in 10% to 15% of the general population. The incidence is even higher for persons in lower socio-economic group or disadvantaged population. Fifteen percent ( 15%) of all psychiatric inpatients have a primary diagnosis of personality disorder. 40% - 45% of those with a primary diagnosis of major mental illness also have a coexisting personality disorder that significantly complicates treatment. In mental health outpatient settings, the incidence of personality disorder is 30% to 50%. Clients with personality disorders have a higher death rate, especially as a result of suicide; they also have higher rates of suicide attempts, accidents, and emergency room visits and increased rates of separation, divorce, and involvement in legal proceedings regarding child custody.

B. Personality disorders have been highly correlated with criminal behaviors

 75% to 85% of criminals have personality disorders 60% to 70% of alcoholics have personality disorders 70% to 90% of drug abusers have personality disorders

C. People with personality disorders are often described as treatment-resistant. One reason is because personality characteristics or patterns of behavior are deeply ingrained and to make
changes in ones personality can be very difficult; if ever they occur, they evolve slowly. And this can prove frustrating for families and friends as well as for health care providers. Another reason is that, these people often do not perceive their dysfunctional or maladaptive behaviors as a problem; indeed, sometimes these behaviors are a source of pride to the person. For example: a belligerent or an aggressive person may perceive himself or herself as one having a strong personality and being someone who cant be taken advantage or pushed around. These people often do not see the need to change their behavior because making changes may be view as a threat or make them feel weak.

D. The difficulties associated with personality disorder persist throughout young and middle adulthood but tend to
diminish in the 40s and 50s.

Those with antisocial personality disorder are less likely to engage in criminal behavior by age 40s 50s but their
problems with substance abuse and disregard for others feelings persist.

People with borderline personality disorders tend to demonstrate decreased impulsive behavior, increased
adaptive behavior, and more stable relationships by age 50. The increased stability and decreased problem behavior can occur even without treatment. Some personality disorders such as schizoid, schizotypal, paranoid, avoidant, and obsessive- compulsive, tend to remain consistent throughout the persons life. Causes: A. General information: The exact cause of personality disorders is unknown Since personality develops through the interaction of hereditary disposition and environmental influence, most likely, they represent a combination of genetic, biological, social, psychological, developmental, and environmental factors. B. Genetic factors: Genetic factors influence the biological basis of brain function as well as basic personality structure (id, ego, and superego) In turn, personality structure affects how a person responds to and interacts with life experiences and the social environment. Over time, each person develops distinctive ways of perceiving the world and of feeling, thinking, and behaving. C. Biological Factors:

Some researchers suspect the poor regulation of the brain circuits that control emotion increases the risk for a
personality disorder- especially when combined with risk factors such as abuse, neglect, or separation.

For a biologically predisposed person, the major developmental challenges of adolescence and adulthood (such as
separation from the parents, identity crisis and struggle for independence) may trigger a personality disorder. D. Psychodynamic theories:

Psychodynamic theories propose that personality disorder stem from deficiencies in ego and superego
development. - These deficiencies may relate to mother-child relationship marked by unresponsiveness, over-protectiveness, or early separation. E. Social theories:

Personality disorders reflect the responses learned through the process of reinforcement, modeling, and aversive
stimuli.

With even low levels of stress, chronic trauma or long term stresses may create new neuro-chemical pathways. As a result the person acts out old patterns.

Diagnostic test for Personality disorders: Personality tests and Projective test can elicit responses that provide insight into mood, personality, or psychopathology. Such tests include the ff: - BDI (Beck Depression Inventory): a self-administered and self-scored Test) where questions are focused on how often client experienced symptoms of depression, such as poor concentration, suicidal thoughts, feeling of guilt, and crying. -MMPI-2(Minnosota Multiphasic Personality Inventory): has 567 questions to complete in 60-90 minutes, designed to help determine disorder type, and severity.

-Sentence Completion Test: the client completes a series of partial questions. Ex., When I get angrythe clients response may reveal the clients fantasies, fears, aspirations or anxieties. -Thematic Apperception Test: the client views a series of pictures depicting ambiguous situations and tells a story describing each picture. It is designed to help analyzed the clients personality, particularly regarding interpersonal relationships and conflicts. - Draw a person test: the client draws two human figures, one of each gender. Diagnosis confirmed if DSM-IV-TR criteria met Common technical words used to describe and differentiate personality disorders:

1. Subtle: hard to grasp; difficult to define or distinguish; elusive 2. Pervasive: spread throughout and into every part 3. Enduring: last for a long time; deeply rooted; hold out 4. Eccentric: someone who behaves unconventionally; off center or deviating from circular motion 5. Odd: unusual; noticeable; not fitting in to the accepted pattern 6. Erratic : unstable; unbalance; uneven in quality 7. Longstanding : has long existed 8. Ingrained : thoroughly imbued; deeply rooted; totally filled in with an emotion 9. Belligerent: war raging ( person); quarrelsome; hot tempered or quick to anger 10. Fickle : inconstant ( not constant); unreliable; ruled by whims 11. Stoical : able to endure hardship and adversity ( challenges) 12. Frugal : economical 13. Irresolute: hesitant; undecided; lacking firmness 14. Indolent : dislike exerting effort; lazy 15. Tolerant: willing to permit, allow or accept 16. Persevering : persistent; to try hard and continuously in spite of obstacles 17. Compassion : pity aroused by distress of others with a desire to help 18. Self-indulgent: weakening of ones moral strength by satisfying ones desire and appetite too readily 19. Vain : thinking too highly of ones appearance, attainment or abilities 20. Tense demeanor: strained outward behavior 21. Solemn: arousing or expressing serious or profound thoughts 22. Capricious : ruled by whims; unreliable 23. Egocentric: selfish; self-centered person; looking at everything only to see how it affects oneself 24. Haughtiness: displaying overbearing pride

25. High functioning patient:

26. Self-effacing: low profile; keeping oneself modestly or discretely in the background 27. Procrastination: to keep delaying or putting things off 28. Sullenness: gloomy; ill humored and unsociable

Personality Disorder Clusters: The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision ( DSM-IV-TR) groups personality disorders into three clusters:
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Cluster A: Individuals whose behavior appears odd or eccentric (off centered, unconventional, not conforming to standard of normality, or not following the mainstream of society) and include the ff: 1. Paranoid
Characterized by pervasive mistrust and suspiciousness of others, which they tend to interpret

others actions as harmful or threatening; or invariably expect to be exploited or harmed in some way. Appear aloof and withdrawn and thus maintain a considerable physical distance from the nurse and others and view this as necessary for protection. Maybe hypersensitive to criticism, avoid accepting blame, no sense of humor, emotional coldness, and inability to relax. May experienced ideas of reference or false beliefs that peoples conversations and thoughts are centered on them, usually in a negative way. Appear guarded and hyper-vigilant ( surveys the room and look behind doors and furniture; sit near door to have ready access to exit and their back against the wall to prevent anyone from sneaking up behind them. Spend disproportionate time examining and analyzing the behavior and motives of others to discover hidden and threatening meanings. Use projection as defense mechanism, which is blaming others for their difficulties and misfortunes. Such clients externalize their own emotions, and attribute to others impulses and thoughts that they are unable to accept in themselves. Ex., excessive fault finding, sensitivity to criticism, prejudice and hypersensitive to injustice. Very difficult to treat but may respond to both pharmacological and psychosocial interventions

Nursing Interventions: Forming an effective working relationship with paranoid or suspicious client is quite difficult and challenging. The nurse must remember that these types of clients take everything seriously and can be sensitive to the reactions and motivations of others. a. Approach client in a serious, business-like manner and refrain from social chit-chat or jokes. This means the nurse must be on time on her/ his appointment w/ client Must keep commitments and particularly straight forward in her dealings with the client Rationale: Being honest and reliable makes the nurse trustworthy and therefore essential in forming relationship and to the success of the NPR. b. Meet clients need to feel in control. Involving client in formulating their own plans of care by asking what the client would like to accomplish in concrete terms such as, minimizing problems at work or getting along w/ others. Rationale: Usually client would engage in the therapeutic process if they believe they have something to gain. c. Helping client to learn to validate ideas before taking action. Make an agreement w/ client to consult or validate first their ideas w/ another reliable person before acting on them. Rationale: 1. Client can avoid problems if they can refrain from taking action until they have validated their ideas w/ another person. 2. It also assists them to start basing decisions and action on reality. 2. Schizoid Pervasive pattern of detachment from social relationships and restricted range of emotional expression in interpersonal settings. -Such clients do not have or desire for friends, rarely date or marry or have little or no sexual contact.

-They remain in the parental homes well into adulthood.

Display a constricted affect and little, if any emotion. Theres marked difficulty in experiencing and

expressing emotions, particularly of anger or aggression Aloof and indifferent, appearing emotionally cold, uncaring, or unfeeling but do not have paranoid ideas No leisure and do not engage in pleasurable activities because they rarely experienced enjoyment Usually have rich and extensive fantasy life but client may be reluctant to reveal information about his/her fantasy to anyone else. Though the ideal relationships that occurs in the clients fantasy are rewarding and gratifying for them, the fantasies are actually in stark contrast to real- life experiences. Nevertheless, the client can distinguish fantasies from reality, and may show no evidence of disordered or delusional thought processes. Clients of this type are accomplished intellectually and often involved with computers or electronics. They spend long hours solving puzzles or mathematical problems which the client see as useful and productive rather than fun.
They are self-absorbed and loners in almost all aspect of daily life. Given the opportunity to engage with

other people, these clients will decline.

They are indifferent to praise or criticism and are not affected by the emotions or opinions of others.

Nursing Interventions: a. The nurse focus on improving clients functioning in the community. Through referrals to social services or appropriate local agencies for assistance such as finding suitable housing that will accommodate clients desire and need for solitude but also requires little social interaction or socialization. Assist the client find a case manager. The nurse must ascertain if the client still has identified family members as his/her primary relationship, if none, the client may need to establish a working relationship with a case manager in the community. The case manager help the client to obtain services and health care, manage finances, and other aspects.
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3. Schizotypal: a. Defining Characteristics: Characterized by a pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships as well as cognitive or perceptual distortions

Schizotypal patients commonly exhibit eccentric behavior and have difficulty concentrating for long periods
a. May have peculiar mannerism and dress - odd appearance that causes others to notice them (ex.,wears ill fitting clothes that do not match, maybe stained and dirty - unkempt and disheveled (bizarre) b. May have unusual speech thats overly elaborate, vague, metaphorical and hard to follow. c. May have magical thinking, strange fantasies, odd beliefs.. - such as thinking they have extrasensory abilities, unusual perceptions and bodily illusions, social isolation, and paranoid ideas

Some experts think Schizotypal personality disorder represents mild schizophrenia; however, schizoptypal patients arent psychotic in the sense, they dont experience hallucinations, delusions, or grossly disorganized thought and speech). During times of extreme stress, some patients do experience cognitive or perceptual disturbances buta. Not as fully developed as in schizophrenia b. Generally short-lived, resolving with use of antipsychotic drugs.

Typically, schizoptypal patients have severe social anxiety, usually because theyre paranoid about others
motivations. a. Sometimes may relate to others in a stiff or inappropriate way b. May fail to respond to normal interpersonal cues. Some with this disorder marry; but most patients have no more than one person they relate to closely The disorder takes a chronic course and in some patients progresses to schizophrenia a. Major depression found in 30-50 % of patients b. Another personality disorder (especially paranoid, or avoidant) is found in many patients.

Schizotypal personality disorder is found in about 3% of the general population; its slightly more common in
men than it is in women

Causes: Possible genetic basis: - studies show increased risk in people with family history of schizophrenia Environmental factor such as severe stress - Some evidence of poor regulation of dopamine pathways in the brain of patient with disorder Psychological and cognitive theories - focus on deficits in attention and information processing) Diagnosis: No specific tests for identifying and diagnosing Personality tests, such as: - MMPI-2(Minnosota Multiphasic - Thematic Apperception Test Treatment: Individual psychotherapy, family therapy, group therapy, cognitive-behavioral therapy, self-help measures, and medications. Social skills training and other behavioral approaches that emphasize the basic of social interactions Psychoanalytic intervention focusing on defining ego boundaries Cognitive-behavioral therapy attempting to help the patient interpret his odd beliefs, and teach him valuable coping and interpersonal skills Individual therapy ( preferred ) a. Includes establishing a warm, supportive, patient-centered approach b. Requires avoiding any direct challenge of patients delusional or inappropriate thoughts Group therapy as the patient progresses initially, tolerating a group may be difficult due to distrust and suspiciousness Low-dose antipsychotic drugs, such as Clozapine ( Clozaril), to treat psychotic symptoms SSRIs shown effective for mood or anxiety symptoms Nursing Interventions: For Schizotypal PD Help client develop self care skills - The nurse encourages clients to establish a daily routine for hygiene and grooming rather than depending on the client to decide when he wants to. Rationale: It is useful for client to have an appearance that is not bizarre or disheveled, because stares and comments from others can increase discomfort. Improve clients community functioning Because client can be uncomfortable around with others and most likely is not going to change, the nurse must help them function in the community with minimal discomfort. - Ask the client to prepare a list of people with whom they must have contact ( such as the landlord, pharmacist, store clerk, ect.). So the nurse can then role- play the interactions that clients would have with each of these people; these allow the client to practice clear and logical request to obtain services or to conduct personal business. - If face to face contact is uncomfortable for the client, the nurse can suggest that client conduct personal business through hand written request or to use the telephone. Provide client with social skills training and reinforce appropriate behavior - Social skills training may help client to talk clearly with others and reduce bizarre conversation. Give him plenty of time to make difficult decisions, or decisions that seem difficult only to the patient Be aware that the patient may relate unusually well to certain staff members but not at all to others - Remind staff not to take this personally Recognize and respect the patients need for physical and emotional distance Encourage the patients expression of feelings, self-analysis of behavior, and accountability for actions Avoid defensiveness and arguing
II- Cluster B: Individuals who appear Dramatic(theater like, falsely heightened emphasis to ordinary events),

emotional (showing deep feeling or emotion), or erratic(unstable or unbalanced or lacking consistency). (Such as the antisocial, borderline, histrionic, and narcissistic personality disorders). 1. ANTISOCIAL: Defining Characteristics: Characterized by continual or chronic antisocial behavior that violates others rights or the inability to conform generally accepted social norms that involves many aspects of the clients adolescent and adult development, thus predisposes the affected person to criminal acts or behaviors that can result to many arrests (long history of truancy, expulsion from school, fighting and thefts, all before age 15). Can be domineering and aggressive and therefore cannot maintain an enduring attachment to a sexual partner. This pattern has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder

Occurs in about 3% of the general population Four times more common in men than in women 50% of prisoners have a diagnosis of antisocial personality disorder Tend to peak in the 20s and diminish significantly after age 45

Key signs and symptoms of Antisocial PD: Repeatedly performing unlawful acts Reckless disregard for own or others safety Deceitfulness Lack of remorse or empathy Consistent irresponsibility Power-seeking behavior Destructive tendencies Impulsivity and failure to plan ahead Superficial Charm Inflated Self-image, arrogant, self appraisal Irritability and aggressiveness Inability to maintain close personal or sexual relationships Disconnection between feelings and behaviors Causes of Antisocial PD:

1. Possible biological factors (may underlie low arousal, poor fear conditioning, and decision-making deficits) Poor Serotonin regulation in certain brain regions, which may decrease behavioral inhibition
Reduced autonomic activity and developmental or acquired abnormalities in the prefrontal brain system.

2. Possible genetic influence, more common in first degree biological relatives than in general population. 3. Other possible causes or risk factors: Attention-deficit hyperactivity disorder, large families.
Key Childhood Risk Factors: Substance abuse Criminal behavior Physical or sexual abuse Neglectful or unstable parenting (because of large families) Social Isolation Transient Friendships Low socioeconomic groups Treatment: Focus: helping the patient make connections between his/her feelings and behaviors by gaining better access to and experiencing such feelings. - Reinforcing appropriate behaviors - Helping the patient develop victim empathy - Experiencing intense affect usually a sign of progress Psychotherapy (Treatment of choice) Group therapy Family therapy Self-help support groups Inpatient hospitalization (rare) Specialized treatment programs Drugs: such as - Lithium for control of manic behaviors - Anticonvulsants (Tegretol, Valproic Acid) serve as mood stabilizers - Beta-adrenergic blockers Nursing Interventions: For Antisocial PD 1. Forming a therapeutic relationship and promoting responsible behavior. The nurse provide structure in the therapeutic relationship, identify acceptable and expected behaviors, and be consistent in those expectations. a. Limit Setting: Set limits on the patients behavior involving 3 steps - Describing the unacceptable behavior - Identifying the consequences if the limit is exceeded - Identifying the expected or desired behavior b. Consistent adherence to rules and treatment plan

- Using a straightforward (business like), matter-of fact approach (casual but not indifferent) and nonjudgmental manner (acceptance and focus on clients behavior and not on the personality).For ex., If client approach the nurse flirtatiously and attempt to gain personal information, the nurse should not get angry or respond harshly or punitively but ratherClearly conveying your expectations of the patient as well as the consequences if he fails to meet them. - Establishing a behavioral contract to communicate to the patient that other behavior options are available - Anticipate manipulative efforts. Keep in mind that patient may seem charming and convincing; help the patient identify such behaviors so he can learn that other people are not extensions of himself. - Expect the patient to refuse to cooperate in an effort to gain control. 2. Helping the client solve problems and control Emotions. a. The nurse can teach problem-solving skills and help clients to practice them. - Problem solving includes identifying the problem, exploring alternative solutions and related consequences b. The nurse helps clients manage his anger and frustration. When client is calm and not upset, the nurse can encourage him/her to identify sources of frustrations, how he/she respond to it, and their consequences. In this way, the client can anticipate stressful situations and how to manage them, such as taking a time- out(going to neutral area) to regain internal control, avoid impulsive reactions, and angry outbursts in an emotionally charged situations. Enhancing Role Performance a. The nurse helps client to identify specific problems at work or home that are barriers to success in fulfilling roles - Assessed the clients use of alcohol and drugs - Redirect their difficulties and help them examine the source of their problems realistically. Teach the patient social skills, and reinforce appropriate behavior Encourage the patient to express his feelings, analyze his own behavior, and be accountable for his actions.

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2. BORDERLINE Personality Disorder: Defining Characteristics: A disorder of poor regulation of emotion, characterized by a pervasive pattern of unstable interpersonal relationships, self-image, behavior and affect and marked impulsivity. The most common personality disorder found in clinical settings. Five times more common in those with a first degree relatives with the diagnosis. People with this disorder may experience it in various ways: a. May have cognitive problems due to overwhelming emotions b. Commonly have alternating extremes of anger, anxiety, depression and emptiness (intense bout of emotion typically last only hours, or at most a day) c. May cause conflict with others d. May have transient brief psychotic-like experiences or episodes such as auditory hallucinations (encouraging or demanding self-harm) . Distortions in cognition and sense of self can lead to frequent changes in long-term goals, jobs and career plans, friendships, values, and even sex identity. A person with this disorder may see herself as fundamentally bad or unworthy, feeling misunderstood, mistreated, bored and empty, with little idea who he/she really is. Have difficulty distinguishing reality from their own misperceptions of the world (for instance, have difficulty viewing events and relationships from perspective of others). People with borderline personality disorder tend to act impulsively, without considering the consequences. a. May include promiscuity, substance abuse, and eating or spending binges. b. May prompt outburst of intense anger that leads to violence (easily triggered when others criticize or thwart their impulsive act)

People with borderline personality disorder tends to have intense and stormy relationships, alternating between a
black and white view (splitting) of others.

 A person of this disorder is extremely sensitive to rejection, possibly reacting with anger and distress to even
mild separation from loved ones (such as with family vacations, business trips, or a sudden change in plans or appointments with her therapist). May resort to self-destructive behavior, such as self-mutilation (cutting or burning), substance abuse, eating disorders, and suicide attempts to escape inner turmoil or to experience physical pain in the face of emotional numbness or to reinforce the fact that he/she is still alive. - Recurrent self-mutilation is a cry for help, an expression of intense anger or helplessness, or a form of selfpunishment. - Commonly triggered by fear of abandonment (Hates being alone but their erratic, labile and sometimes dangerous behaviors often isolate them). BPD affects 2-3 % of the general population; 11% of the psychiatric outpatients and nearly 20% of the psychiatric inpatients Three times more common in females than it is in males The disorder usually begins in early childhood and peaks in adolescence and early adulthood. Though by 30s and 40s, some stability achieved in work and personal life ( but significant areas of dysfunction remain). Borderline personality disorder commonly overlaps with other personality disorders as well as bipolar disorder, depression, anxiety disorders, and substance abuse.

Causes: Precise cause is unknown; several theories are being investigated Possible genetic components (five times more common in first-degree relatives of people with the disorder) Possible biological factors: a. Dysfunction in brains limbic system or frontal lobe b. Decreased Serotonin activity c. Increased activity in alpha-2-noradrenergic receptors Such factors may make the disorder appear more common in patients than in general population if they experience a. Prolonged separation from parents b. Other major losses early in life c. Physical, sexual or emotional abuse or neglect Key Signs and Symptoms: Four main categories of major signs and symptoms a. Unstable Relationship (Stormy and intense and the cycle repeats itself continually).

b. Unstable View of Self and others (Thinking about self and others is often polarized and extreme which is
sometime referred to as splitting or the black and white view). For example, client tend to adore people of new acquaintances, then quickly devalue them if they dont meet his/her expectations in some way or if others do not reciprocate his/her feelings, they may feel rejected.

c. Unstable Emotions (Shift dramatically and sudden and can occur in the space of 1 hr.). For example, one
moment may appear needy and dependent, then may become angry, hostile, and rejecting the next. - Because client has an extreme fear of abandonment, clients engage in many desperate behaviors, even suicide attempts just to gain or maintain relationships; occasionally may attempt to harm others physically. - Most acute when patient feels isolated and without social support, causing her to make frantic efforts to avoid being alone d. Impulsivity (They make decisions impulsively based on emotions rather than facts. Clients report behaviors consistent with impaired judgment and lack of care and concern for safety such as gambling, shopping binges, shoplifting, and reckless driving). Other possible assessment findings for Borderline Personality disorder: a. Intense fear of abandonment, as displayed in clinging and distancing maneuvers b. Rapidly shifting attitudes about friends and loved ones c. Desperate attempts to maintain relationships d. Manipulation, as in pitting people against one another e. Limited coping skills f. Dissociation or dissociative episodes (separating objects from their emotional significance or periods when client is unaware of their actions). g. Uncertainty about major issues ( such as self-image; identity, life goals, sexual orientation, values, career choices, or types of friends h. Imitative behavior i. Rapid, dramatic mood swings- from euphoria to intense anxiety to rage- within hours or days j. Acting out of feelings instead of expressing them appropriately or verbally k. Inappropriate, intense anger or difficulty controlling anger

l. Chronic feelings of emptiness m. Unpredictable, self-damaging behavior ( such as driving dangerously, gambling, sexual promiscuity, overeating, overspending, and abusing substances) n. Self-destructive behavior Diagnosis: Standard psychological test, possibly revealing high degree of dissociation Diagnosis confirmed if DSM-IV-TR criteria met Key Treatment Options for Borderline Personality Disorder: May be multifaceted Psychotherapy (Treatment of choice) Psychosocial treatment called dialectical behavior therapy- developed specifically to treat borderline personality disorder- the patient is taught to better control her life and emotions through self-knowledge, emotion regulation, and cognitive restructuring. Social learning theory and conflict resolution therapies to treat borderline personality disorders. Inpatient Hospitalization -rarely indicated or appropriate. During episode of acute depression or another crisis, patient may be seen in an emergency department, inpatient unit, or local community health center. Partial hospitalization and day treatment programs- (to provide a safe environment, offering support, feedback and structure during the day and patient usually returns home in the evening.) Milieu Therapy Self-help support groups (To help patients to cope better on their own, thereby avoiding situational crises) Drugs a. Antidepressant drugs such as SSRIs ( Fluoxetine- PROZAC ), MAOIs to treat depression. b. Antianxiety drugs such as Buspiron ( BuSpar) to ease anxiety c. Antipsychotic drugs such as Risperidone or Olanzapine, to ease dissociative symptoms or self-destructive impulses. d. Antimanic medications such as Lithium or Valproic Acid ( Depakote) to treat mood swings e. Naltrexone ( ReVia ) to reduce self-mutilating behaviors Nursing Interventions: For BPD Promoting the clients safety - The clients safety is always a priority - The nurse in concert with the patient, determines when suicidal ideas are likely to be translated into action. Promoting the therapeutic relationship The nurse must provide structure and limit setting in the therapeutic relationship. Because of clients erratic patterns of thinking and behaving, they can have unrealistic expectations and which most often alienate them from others. - It also includes seeing the client for scheduled appointments for a predetermined length of time (to work on issues or coping strategies) rather than only when the client appears and demand the nurses immediate attention.

Helping client to cope and control emotions. The nurse can help the client identify their feelings and learn to tolerate them without exaggerated responses, such as destruction of properties or self-harm. - The nurse also help the client to decrease impulsivity and learning to delay gratification through the use of distraction techniques such as taking a walk or listening to music. Teaching the client effective communication. The nurse stress the importance of basic communication skills, such as eye contact, active listening, taking turns talking, validating the meaning of anothers communication, and using the I statement (I think, I feel.., I need..). The nurse can also model these techniques and engage in role playing with clients. Reshaping the clients thinking pattern. Since these clients view everything, people and situations in extremes- as totally good or totally bad, Cognitive restructuring is necessary. This technique is useful in changing pattern of thinking by helping clients to recognize negative thoughts and feelings and to replace them with positive patterns of thinking. For ex., if patient is intrude with negative or self-critical thoughts such as Im dumb, or Im stupid .., the patient can use the Thought Stopping technique by saying Stop , then engage in a positive self-talk. Structuring the clients daily activities. Since feelings of chronic boredom and emptiness, fear of abandonment, and intolerance of being alone are common problems, clients are at a loss about how to manage unstructured time and may become unhappy, ruminative, and may engage in frantic and desperate behaviors (self-harm) to change the situation.

The nurse minimizes the unstructured time by planning activities so client can manage time alone. Client can make a written list of schedules that includes appointments, shopping, reading the paper, or going for a walk. The written schedule allows the client to plan ahead to spend time with others and allows the nurse to help the client engage in a more healthful behaviors such as exercises, planning meals, and cooking nutritious food.

Encourage the patient to take responsibility for herself; dont try to rescue her from the consequences of her actions (except suicidal and self-mutilating behaviors). Convey empathy and support, but dont try to solve problems she can solve herself. Maintain a consistent approach in all interactions with the patient, and ensure that other team members use the same approach. Avoid sympathetic nurturing responses Recognize and avoid unconsciously reinforcing behaviors used to manipulate people. Set appropriate expectations for social interactions, and praise the patient when she meets these expectations. To promote trust, respect the patients personal space. Be aware that the patient may idealize some staff members and devalue others Dont take sides in the patients disputes with staff members Avoid defensiveness and arguing Try to limit the patients interactions to assigned staff to decrease splitting behaviors; use only consistent staff members. If patient is taking medication, monitor for cheeking and hoarding medications Encourage the patient to express her feelings, analyze her behavior, and be accountable for her actions. Help the patient develop problem-solving skills Teach and encourage relaxation techniques Suggest that the patient start an exercise regimen ( exercise promotes stability by decreasing mood swings and aiding the release of anger).

Other Cluster B Personality Disorders: 3. Histrionic Personality Disorder: Defining characteristic: Patients with histrionic personality disorder characteristically have a pervasive pattern of excessive emotionality and attention -seeking behavior, and are drawn to momentary excitements and fleeting adventures (transient, passing swiftly). Charming, dramatic, and expensive, such patients can be easily hurt, vain, demanding, capricious, excitable, self-indulgent, and inconsiderate. a. Typically come across as manipulative and phony or plastic (words and expressed feelings seem shallow, not real or deep). b. Can shift instantly from rage to friendliness Their style of speech is excessively impressionistic, if not theatrical, and their gestures are exaggerated. a. Use grandiose language to describe everyday events b. Value words for their emotional content than for their factual accuracy People with histrionic personality disorder need to be the center of attention at all times a. Exaggerate illness to gain attention b. Interrupt others so they can dominate conversation c. Seek constant praise d. Place great emphasis on physical appearance, commonly dressing provocatively and behaving seductively With limited self-knowledge, these patients may have no sense of who they are, aside from their identification with others; they commonly change their attitudes and values based on the views of significant others. a. Rarely gain an understanding of others b. Devote intense observation skills to determine which behaviors and attitudes, or feelings are most likely to win others admiration and approval c. View relationships as closer or more significant than really are. Because they dont view others realistically, people with histrionic personality disorder have difficulty developing and sustaining satisfactory relationships. a. Tendency to idealize the significant others early in the relationship If significant other start pulling back from patients incessant demands, patient may become dramatic and demonstrative in attempt to bind other person to the relationship b. To avoid rejection, may resort to crying, coercion, temper tantrums, assault, and suicidal gestures c. Despite their attempts to bind others to them, they often lack fidelity and loyalty

HPD affects an estimated 2-3 % of the general population, commonly diagnosed in women but may be just as common in men. - Without treatment, the disorder can lead to social, occupational, and functional impairments - Many are able to function at a high level and succeed at work (although frequent interruption of intimate relationships is common). - Commonly coexist with somatoform and mood disorders. -Uses dissociation as a defense mechanism (replacement of unpleasant affects with pleasant ones). Causes: Cause unknown Possible genetic component (hysterical traits more common in relatives of those with disorder) Biological factors: little research done Childhood events may play a role Psychoanalytic theories: focus is on seductive and authoritarian attitudes by fathers of patients.

Signs and Symptoms: Constant craving for attention, stimulation, and excitement Intense affect Shallow, rapidly shifting expression of emotions Flirtatious, seductive behavior Vanity, over investment in appearance, exhibitionism Exaggerated, vague speech Self-dramatization Impulsivity Suggestibility and impressionability Egocentricity, self-indulgence (What he/she does is for the client personal gratification; self-service), and lack of consideration for others Intolerance of being alone Dread of growing old Suppression or denial of internal distress, weakness, depression or hostility May be manipulative, divisive and demanding Use of alcohol or drugs to quickly alter negative feelings Depression Suicidal gestures and threats Diagnosis:

No specific diagnostic test, personality and projective test can be helpful Must rule out physiologic disorders in patients with somatic complaints Diagnosis confirmed if DSM-IV-TR criteria met

Treatment: Rarely seeks treatment unless a crisis occurs or a situational factor causes functional impairment and ineffective coping. Goal: To relieve the worst elements of the patients behavior, rather than to cure her. Psychotherapy (treatment of choice) a. Focuses on solving problems in patients life rather than producing long-term personality changes b. Individual therapy is preferred over group, family or self-help groups (group environment may trigger dramatic, attention -seeking behavior ) c. While establishing rapport and trust, therapist must avoid dependent situation with needy patient who sees the therapist as her rescuer d. Therapist must try to help patient view her interactions objectively; and explore and clarify emotions Medications to relieve associated symptoms such as anxiety or depression; careful monitoring is required during therapy because, a. In a crisis may seek drugs for self-destructive or harmful purposes b. May respond to side effects of medication with intense, dramatic overreactions Nursing Interventions: For HPD Give the patient choices in care options, and incorporate her wishes into the treatment plan as much as possible, increasing her sense of self-control may help lower anxiety. Anticipate the patients tendency to try to win over caregivers ( may be responsive and cooperative, at least initially. Teach the patient appropriate social skills, and reinforce appropriate behavior Help the patient learn to think more clearly

 Promote the patients expression of feelings, analysis of her behavior, and accountability of her actions. Encourage warmth, genuineness, and empathy Teach the patient stress- reducing techniques, such as deep breathing and an exercise regimen Help her to mange crises and the feelings that trigger them Monitor the patient for suicidal thoughts and behavior.

4. Narcissistic Personality Disorder: Defining Characteristic: A person with narcissistic personality disorder is self-centered, self-absorbed, and lacking in empathy for others; he/she typically takes advantage of people to achieve his own ends, and uses them without regard to their feelings.

a. Has inflated or heightened sense of self-importance and a pervasive pattern of grandiose feelings of
uniqueness (both in fantasy and behavior), and intense need for admiration.

b. Tries to maintain image of perfection and invincibility to prevent others from discovering weaknesses and
imperfection (beneath the image, basically insecure with low self-esteem). c. They lack empathy and can be hypersensitive to the evaluation of others Narcissistic people expects to be recognized as superior a. Preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love, because it reinforces their sense of superiority b. Believes hes special and entitled to favored treatment and compares themselves favorably with famous and privileged people. c. Expects others to comply with wishes automatically, and believes he should associate only with other special or high status people. Many narcissists are driven and achievement oriented a. At work, clients may experience some success because they are ambitious and confident. However, client may soon experience difficulties because they have trouble working with others whom they consider to be inferior, and also because they have limited ability to accept criticism or feedback. Narcissistic personality disorder is found in less 1% of the general population and affects about three times as many males as it does with females. a. Develops by early adulthood but may not be identified until midlife, when person experiences sense of loss of opportunity or faces personal limitations. b. In many cases, occurs in those with histrionic or borderline personality disorder.

Signs and Symptoms: Arrogance and haughtiness (displaying overbearing pride) Self-centeredness Unreasonable expectations of favorable outcome Grandiose sense of self-importance Exaggeration of achievements and talents Preoccupation with fantasies of success, power, beauty, brilliance, or ideal love Constant desire for attention and admiration Lack of empathy or concern toward those he offends Taking advantage of others to achieve own goals May also exhibit rage, shame or humiliation in response to criticism In severe cases, may have self-destructive tendencies and poor reality testing Diagnosis: No specific diagnostic tests; patient should undergo psychological evaluation and personality and projective testing Diagnosis confirmed if DSM-IV-TR criteria met Treatment: Most narcissists seek treatment only in times of crisis and terminate treatment as soon as their symptoms ease Those not terminating treatment may be seeking help for depression or interpersonal difficulties Long term psychotherapy (treatment of choice) to help establish a strong alliance between the patient and therapist) Group therapy not effective because the patient typically dominate the group a. May be tiring to others, who have to hear about his accomplishments and talents b. May drop out of group if criticized by others Hospitalization may be necessary for severe symptoms such as self-destructive behavior and poor reality testing when needed; it should be brief and treatment should be symptom-specific

Long-term therapy for those who lack motivation for outpatient treatment and for those with destructive, acting-out, and chaotic lifestyles. a. May involve intensive milieu therapy, individual psychotherapy, family involvement or specialized residential environment. b. May be appropriate for patients with severe ego weakness, helping them to improve self-concept.

Nursing Interventions: For NPD 1. Convey respect and acknowledge the patients sense of self-importance so he can reestablish a coherent sense of self. 2. Avoid reinforcing either pathologic grandiosity or weakness 3. Focus on the patients positive traits or on his feelings of pain, loss or rejection ( because of possible shattered ego) 4. If the patient makes unreasonable demands or has unreasonable expectations, tell him so in a matter of fact manner or way. 5. Remain non-judgmental (a critical attitude may make him even more demanding and difficult). The client may behave in a rude and arrogant manner, may be harsh and critical of the nurse. The nurse must not internalize such criticism or take the clients behavior personally. But limit should be set on rude or verbally abusive behavior and should explain what is expected from the patient. 6. Dont avoid the patient (this could increase his maladaptive attention-seeking behavior) 7. Avoid defensiveness and arguing 8. Offer persistent, consistent, and flexible care; this includes taking a direct, involved approach to gain the patient' trust and cooperation. 9. Teach the patient social skills and reinforce appropriate behavior. Cluster C: Individuals who appear anxious or fearful. 1. Avoidant Personality Disorder: Defining characteristic: Is marked by feelings of inadequacy, extreme social anxiety, social withdrawal, and hypersensitivity to negative evaluation or rejection by others. People with this disorder have low self-esteem and poor self- confidence; they readily believe that he or she is inferior to others; they dwell on the negative and have difficulty viewing situations and interactions objectively. a. To rationalize their avoidance of new situations, clients may exaggerate potential difficulties involved. b. May create fantasy worlds to substitute for the real one. The avoidant person is shy but yearns for social relationships but at the same time, fears also being rejected or embarrassed in front of others. (Because the client is unusually fearful of rejection, criticism, shame, or disapproval, he or she tends to avoid situations or relationships that may result in these feelings). a. Is not willing to enter into social relationship without assurance of uncritical acceptance. b. Seeks out jobs that require little contact with others. Many people with avoidant personality disorder also have other psychiatric disorders a. Social phobia b. Schizoid personality disorder c. Agoraphobia ( fear of open space) d. Obsessive-compulsive disorder; Generalized anxiety disorder e. Major depressive disorder; Somatoform disorders(characterized by multiple physical symptoms that suggest medical condition but without demonstrable organic basis to fully account for).Ex.,conversion disorder; pain disorder; hypochondriasis; body dysmorphic disorder (client feels that his/her nose is too large or teeth are crooked and unattractive). f. Dissociative disorder (disruption in the integrated functions of consciousness, memory, identity, or environmental perceptions. Ex.,dissociative amnesia ( cannot remember traumatic event; fugue (sudden leaving the home, place of work or travel to another city without explanation and worst will not remember his past or identity; identity disorder ( formerly multiple personality disorder);depersonalization (persistent and recurrent feeling of being detach from his/her mental processes or body) g. Schizophrenia found in an estimated 0.5 % to 1 % of the general population; it affects males and females equally and develops by early adulthood. Causes: Most likely results from combination of genetic, biological, environmental, and other factors. Psychodynamic view attributes disorder to overly critical parenting style. Genetic and biological theories: a. Linked to timid temperament during infancy may predisposed a person to avoidant personality disorder b. Some have apparently inborn tendency to withdraw from new situation or people c. Over stimulation or excess incoming information may be cause of inherited tendency to be shy Can not cope with excess information and withdraw in defense May stem from low autonomic arousal threshold (certain structure in brains limbic system may have lower threshold of arousal and more pronounced response when activated). Environmental factors:

a. Full development of disorder possibly resulting from significant environmental influences during childhood (such
as rejection by the parents or peers). Signs and Symptoms: Shyness, timidity, and social withdrawal behavior or appearance thats meant to drive others away (gives patient sense of control) Reluctant to speak, or conversely, overly talkative Constant mistrust or wariness of others Testing of others sincerity Difficulty starting and maintaining relationships Perfectionism Rejection of people who dont live up to his impossibly high standard Limited emotional expression; Tenseness and anxiety Low self-esteem; Feelings of being unworthy of successful relationship Loneliness; Reluctance to take personal risks or engage in new activities May also report frequent escape into fantasy, such as by excessive reading or watching television or daydreaming. Diagnosis: No specific diagnostic tests; patient should undergo psychological evaluation and personality and projective tests Diagnosis confirmed if DSM-IV-TR criteria met Treatment: People rarely seek treatment unless something goes wrong in their lives to indicate they arent coping adequately. Psychotherapy for high- functioning patients, while others benefit from a combination of medication and psychotherapy. Goal: to improve social interaction and increase confidence in interpersonal relationships using various techniques, a. Enhance self-esteem b. Improving social interaction and increasing confidence in interpersonal relationships c. Desensitizing reaction to criticism d. Decreasing resistance to change e. Improving coping f. Achieving cognitive restructuring g. Developing appropriate affect and expression of emotions Individual Psychotherapy ( preferred treatment) ; most effective when its short term and focused on solving specific life problems. Medications as an adjunct to psychotherapy if patient has moderate to severe functional impairments. Commonly observed: a. Positive response to MAO inhibitors ( Phenelzine=Nardil, to improve self-confidence and assertiveness in social settings). b. Medications may interfere with effective psychotherapy management if patient feels disconnected from emotions. Nursing Interventions: For APD The nurse provides the client with much support and reassurance. - The nurse can help the client to explore positive self-aspects, positive responses from others and possible reasons for self-criticism. - Helping client practice self-affirmations and positive self-talk The nurse makes use of cognitive restructuring techniques such as the reframing techniques and decatastrophizing techniques to enhance self-worth. The nurse can teach social skills and help clients to practice them in the safety of the nurse-patient relationship. Prepare the patient for upcoming procedures well in advance (giving him plenty of time to adjust) as patients with avoidant personality disorder dont handle surprises well. Inform the patient when you will and wont be available if he needs assistance - Initially, give the patient explicit directives rather than asking him to make decisions; gradually encourage him to make easy decision, and continue to provide support and reassurance as his decision-making ability improves. Encourage the patients expression of feelings, analysis of behavior, and accountability for his actions. Teach the patient relaxation and stress-management techniques to help him manage his anxiety level and cope in times of stress. 2. Dependent Personality Disorder: Defining Characteristic: Characterized by an extreme need to be taken care of, which leads to submissive, clinging behavior and a fear of separation or rejection.

People with this disorder let others make important decisions for them and have a strong need for constant reassurance and support. a. Feel helpless and incompetent, complying passively and transferring responsibility to others. b. Seek others to dominate and protect them Some stay in abusive relationships and are willing to tolerate mistreatment a. May become suicidal when the breakup of a romantic relationship is imminent b. Urgently seeks another relationship as a source of care and support after a close relationships ends Behaviors typically arise from the perception that the patient cant function adequately without others. Overly sensitive to disapproval, often feels helpless and depressed a. Belittle her own abilities and is racked with self-doubt b. Views criticism and disapproval as proof that shes worthless

A dependent person is likely to avoid position of responsibility Dependent personality disorder occurs in about 1.5 % of the general population; it affects slightly more females than it does males Causes: Exact cause unknown, tends to run in families ( may have genetic component) Possible link with overprotective or authoritarian parenting leading to high levels of dependency a. May cause the child to believe she cant function without others guidance and protection b. May lead to child maintaining relationships by giving into others demands Contributing factors a. Childhood trauma b. Closed family system that discourage outside relationships c. Childhood physical or sexual abuse d. Social isolation Signs and Symptoms: Submissiveness Self-effacing (modestly staying in the background; considered gone; opposite of assertive) Apologetic manner Low self-esteem; Lack of confidence; Lack of initiative Incompetence and a need for constant assistance Feelings of pessimism, inferiority, and unworthiness Anxiety and insecurity especially when deprived of a significant relationship (fear of being alone) Hypersensitivity to criticism Clinging, demanding behavior Use bribery, promises to change , and even threats, all to maintain key relationships Difficulty making everyday decisions without advice or reassurance Avoidance of change or new situations Exaggerated fear of losing support and approval Possible complaints of fatigue, lethargy and depression Diagnosis: Psychological evaluation and Projective tests, as indicated Medical evaluation and diagnostic tests to rule out underlying medical condition ( somatic complaint) Diagnosis Confirmed if DSM-IV-TR criteria met Treatment: Rarely seek treatment for dependency or help; typically complaint of anxiety, tension, or depression Individual psychotherapy, behavioral therapy, and support groups and medications to manage associated symptoms Individual and group therapy

Assertiveness training ( behavior modification using assertiveness techniques). Self-help support groups to allow patients to share their experiences and feelings. Medications to treat associated symptoms such as low energy, fatigue and depression a. Antidepressants ( SSRIs, MAOIs, Tricyclics) b. Antianxiety ( Benzodiazepines)

Nursing Interventions: For DPD Foster clients self-reliance and autonomy - The nurse must help clients to express feelings of grief and loss over the end of a relationship - Helping clients to identify their strengths and needs is more encouraging Cognitive restructuring techniques such as reframing and decatastrophizing are beneficial Teach client problem-solving and decision- making skills and help clients apply them to daily life. - Encourage activities that require decisionmaking ( such as balancing a checkbook, planning meals, and paying bills) and help the patient establish and work toward goals to promote a sense of autonomy.. - The nurse must refrain from giving advice about problems of the client even if ask for. - The nurse can help to explore problems, serve as a sounding board for discussion of alternatives, and provide support and positive feedback for the clients efforts in these areas. Help the client express her ideas assertively. Monitor then patients medication regimen: a. Teaching her about the prescribed medications, including exactly what each medication is prescribed for b. Emphasizing that there are no magical drug effects c. If the patient is receiving benzodiazepines, check for signs and symptoms of physiologic and psychological dependence.

3. Obsessive- Compulsive PD: Defining characteristics: Is characterized by a pervasive pattern of preoccupation with perfectionism, mental and interpersonal control and orderliness at the expense of flexibility, openness, and efficiency. a. Characteristically view the world as black and white b. Associated with relentless anxiety about not getting things perfect c. Interferes with interpersonal relationships and daily routines The patient with obsessive-compulsive personality disorder places a great deal of pressure on himself and others not to commit mistakes a. May have a constant sense of righteousness and feel anger and contempt for anyone who disagrees with him. b. Believes his way of doing something is the only right way c. May force himself and others to follow rigid moral principles and to conform to extremely high standards of performance d. May insist on literal compliance with authority and rules A person with OCPD has an overwhelming need to control the environment but agonizes over the process, as a result; a. May suffer from severe procrastination( keep on delaying and putting things off) and indecisiveness because he cant determine with certainty which choice is correct. b. May have difficulty starting a task because of his need to sort out the priorities correctly A lifelong pattern of rigid thinking may lead to poor social skills; symptoms may cause extreme distress and may interfere with the patients occupational and social functioning. Many patients with OCPD have one or both of the other cluster C personality disorders (Avoidant and dependent personality disorders); some also have paranoid personality disorder as well as various types of anxiety, somatoform, and depressive disorders. Differentiated from OCD. Obsessive-compulsive disorders involve obsessions(thoughts, images, or impulses) that causes marked anxiety or compulsions (repetitive behaviors or mental acts) that neutralize anxiety.

Causes: Possible roles of genetic and developmental factors; tendency to run in families. Psychodynamic theories: patients viewed as needing control as a defense against feelings of powerlessness or shame. Signs and Symptoms: Behavioral, emotional, cognitive rigidity Perfectionism Indecisiveness Severe self-criticism Controlling manner Difficulty expressing tender feelings Poor sense of humor Cool, distant, formal manner Solemn, tense demeanor

Emotional constriction Excessive discipline Aggression, competitiveness, and impatience Bouts of intense anger when things stay from the patients idea of things should be Difficulty incorporating new information into life Preoccupation with orderliness, neatness, and cleanliness Scrupulousness about morality, ethics or values Miserliness and hoarding of money and other possessions

Diagnosis: Psychological Evaluation, including personality and projective tests Diagnosis confirmed if DSM-IV-TR criteria met Treatment: Typically seeks treatment only if depressed, unproductive, or under extreme stress ( circumstances that tax his limited coping skills) Individual psychotherapy, in conjunction with medication. Long term work on changing the personality commonly unrealistic because of the inherent nature of obsessivecompulsive personality disorder makes it especially resistant to change. Creative techniques to help the patient truly experience his feelings a. Encouraging the patient to express how various situations, events, and daily occurrences make him feel (rather than simply describing his feelings) b. Having the patient keep a daily journal of feelings to help him remember how he felt at any given time Group therapy usually intolerable for the patient, because group members may ostracize the patient if he points out their deficits and perceived incorrect ways of doing things. Generally, poor response to medication, if a patient suffers from depression However, SSRIs and other antidepressants may be helpful. Nursing Interventions: For OCPD Encourage negotiations with others - Encouraging the client to take risks, such as letting someone else plan a family activity may somehow improve relationships - Helping the client practice negotiations with family members, or friends may also help the client to relinquish some of their need for control. Assist client to make timely decisions and complete work - The nurse can help the client to view decision making and completion of projects from a different perspective. Rather than strive for the goal of perfection, the nurse can recommend clients to set a goal of completing a project or making decision by a specified deadline. Cognitive restructuring can also be beneficial Teach the patient social skills and reinforce appropriate behavior Teach him about prescribed medications Encourage him to continue therapy for optimal results

Cluster C: Individuals who appear anxious or fearful ( avoidant, dependent and obsessive-compulsive personality disorders).

Note: Each disorder produces characteristic signs and symptoms, which may vary among patients and even within the same patient at different times.

Onset and Clinical course: E. Personality disorders are relatively common; Occurring in 10% to 15% of the general population. The incidence is even higher for persons in lower socio-economic group or disadvantaged population. Fifteen percent ( 15%) of all psychiatric inpatients have a primary diagnosis of personality disorder. 40% - 45% of those with a primary diagnosis of major mental illness also have a coexisting personality disorder that significantly complicates treatment. In mental health outpatient settings, the incidence of personality disorder is 30% to 50%. Clients with personality disorders have a higher death rate, especially as a result of suicide; they also have higher rates of suicide attempts, accidents, and emergency room visits and increased rates of separation, divorce, and involvement in legal proceedings regarding child custody.

F.

Personality disorders have been highly correlated with criminal behavior 75% to 85% of criminals have personality disorders 60% to 70% of alcoholics have personality disorders 70% to 90% of drug abusers have personality disorders

G. People with personality disorders are often described as treatment-resistant.

One reason is because personality characteristics or patterns of behavior are deeply ingrained and to make changes in ones personality can be very difficult; if ever they occur, they evolve slowly. And this can prove frustrating for families and friends as well as health care providers. Another reason is that, these people often do not perceive their dysfunctional or maladaptive behaviors as a problemindeed, sometimes these behaviors are a source of pride to the person. For example: a belligerent or an aggressive person may perceive himself or herself as one having a strong personality and being someone who cant be taken advantage or pushed around. These people often do not see the need to change their behavior because making changes may be view as a threat or make them feel weak.

H. The difficulties associated with personality disorder persist throughout young and middle adulthood but tend to
diminish in the 40s and 50s. Those with antisocial personality disorder are less likely to engage in criminal behavior by age 40s 50s but their problems with substance abuse and disregard for others feelings persist. People with borderline personality disorders tend to demonstrate decreased impulsive behavior, increased adaptive behavior, and more stable relationships by age 50. The increased stability and decreased problem behavior can occur even without treatment. Some personality disorders such as schizoid, schizotypal, paranoid, avoidant, and obsessive- compulsive , tend to remain consistent throughout the persons life. Causes: F. General information: The exact cause of personality disorders is unknown Since personality develops through the interaction hereditary disposition and environmental influence, most likely, they represent a combination of genetic, biological, social, psychological, developmental, and environmental factors. G. Genetic factors: Genetic factors influence the biological basis of brain function as well as basic personality structure In turn, personality structure affects how a person responds to and interacts with life experiences and the social environment. Over time, each person develops distinctive ways of perceiving the world and of feeling, thinking, and behaving. H. Biological Factors:

Some researchers suspect the poor regulation of the brain circuits that control emotion increases the risk for a
personality disorder- when combined with risk factors such as abuse, neglect, or separation. For a biologically predisposed person, the major developmental challenges of adolescence and adulthood ( such as separation from the parents, identity and independence) may trigger a personality disorder. I. Psychodynamic theories: Psychodynamic theories propose that personality disorder stem from deficiencies in ego and superego development. These deficiencies may relate to mother-child relationships marked by unresponsiveness, over-protectiveness, or early separation. J. Social theories:

Personality disorders reflect the responses learned through the process of reinforcement, modeling, and aversive
stimuli. With even low levels of stress, chronic trauma or long term stresses may create new neurochemical pathways

As a result the person acts out old patterns

Temperament: ( Temperament traits are highly inherited)

 Corresponds to the biologic processes of sensation, association, and motivation that underlie the integration of skills and habits based on emotion.

The characteristic of the physiological and emotional state of an individual, which tends to condition his responses
to the various situations in life.

The Four Temperament Traits: are genetically independent dimensions that occur in all possible combinations. 1. Harm Avoidance:

High Harm Avoidance- exhibits fear of uncertainty, social inhibition, shyness with strangers, rapid fatigability, and
pessimistic worry in anticipation of problem. High harm avoidance behaviors result in maladaptive inhibition and excessive anxiety.

Low Harm Avoidance- are carefree, energetic, outgoing, and optimistic. Low harm avoidance behaviors may result
in unwarranted optimism and unresponsiveness to potential harm or danger. 2. Novelty Seeking:

High Novelty Seeking- temperament results in someone who is quick-tempered, curious, easily bored, impulsive,
extravagant, and disorderly. He/she may become easily bored and distracted with daily life, is prone to angry outburst, and may be fickle in relationships.

Low Novelty Seeking- is slow tempered, stoical, reflective, frugal, reserved, orderly, and tolerant; he/she may
adhere to a routine of activities.

3. Reward Dependence: defines how persons respond to social cues. High Reward Dependence- are tender hearted, sensitive, sociable, and socially dependent people. They may
become overly dependent on the approval of others and readily take on the ideas or wishes of others without regard for their own beliefs or desires.

Low Reward Dependence- are practical, tough-minded, cold, socially insensitive, irresolute, and indifferent to being
alone; social withdrawal, detachment, aloofness, and disinterest in others can result 4. Persistence:

High Persistence- Highly persistent people are hard working, persevering, and ambitious, overachievers who respond
to fatigue or frustration as a personal challenge. They may persevere even when the situation dictates they should change or stop what they are doing.

Low Persistence- Low persistent people are inactive, indolent, unstable, and erratic. They tend to give up easily
when frustrated, and they rarely strive for higher accomplishments.

Character: The total quality of a persons behavior, as revealed in his habits of thoughts and expression, his attitudes and interests, his actions, and his personal philosophy of life. Is influenced by social learning, culture, and random life events unique to each person. And character is developed over time as one comes into contact with people and situations and confronts challenges, producing concepts about the self and the external world. And when fully developed, these character traits define a mature personality.

Since character matures in a stepwise manner in stages from infancy through late adulthood, according to Freud and Erikson and others, each stage has an associated developmental task that must be performed for the mature development

of the personality. Failure to complete a developmental task jeopardizes the persons ability to achieve future or higher development task. For example: If the tasks of basic trust is not achieved in infancy, mistrust results and subsequently interfere with the achievement of all future tasks. Likewise a persons experiences with family, peers, and others in the world can have a meaningful impact on his or her psychosocial development. Social education in the family creates an environment that can support or oppress specific character formation or development. For example: a family environment where cooperation with others ( compassion, tolerance) is not demonstrated or valued does not support development of that trait in children. And same thing will happen to a person who has a non-supportive or difficult peer relationships when growing up, most likely will also have difficulty relating to others and forming satisfactory relationships.

The Three Character Traits: resourceful, goal oriented, and self-confident.

1. Self-Directedness: defines the extend to which a person is responsible, reliable

High Self-directed people- are realistic and effective, and can adapt their behavior to achieve goals. Low Self directed people- are blaming, helpless, irresponsible and unreliable and cannot set and pursue meaningful goals.

2. 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.

Low Cooperative people 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.

3. Self-Transcendence: described the extent to which a person considers himself or

herself to be an integral part of the universe as a whole.

High Self-transcendence people are spiritual, unpretentious, humble, and fulfilled.

These traits are helpful when dealing with sufferings, illness, or death.

Low Self-transcendence are practical, self-conscious, materialistic, and controlling.

Such people may have difficulty accepting suffering, loss of control, personal and material losses, and death.

Evaluation exam:

A. Physical examination A patient with a suspected personality disorder should undergo a physical examination to rule out an underlying physical or organic cause for his symptoms Personality change may be the first sign of a serious neurologic, endocrine, or other physiologic illness that may be reversible if detected early. B. Psychological examination: A psychological evaluation can exclude other psychiatric disorders- or it may suggest additional ones Psychological test such as the: a. Minnesota Multiphasic Personality Inventory-2( MMPI-2) b. Millon Clinical Multiaxial Inventory-III( MCMI-III), may support or guide the diagnosis c. Structured Clinical Interview for DSM-IV-TR for axis II disorders also aids in diagnosis. Official diagnosis of a personality disorder is confirmed only if the criteria established in DSM-IV-TR are met. Some patients meet the criteria for more than one personality disorder, making diagnosis a particular challenge.

C. Substance Screening: Toxicology screening may be warranted a. Intoxication with certain substances can mimic the features of a personality disorder

Treatment: General Information: 1. Several treatment strategies are used with clients with personality disorders, based on the type and severity of the disorder or the amount of distress or functional impairment the client experiences.

2. Combinations of medications and group and individual therapy are more likely to be effective than any single
treatment. However, not all people with personality disorders seek treatment, even when urge by their family to do so. 3. Typically, persons with paranoid, schizoid, schizotypal, narcissistic, and passive-aggressive personality disorders are least likely to engage in or remain in treatment of any kind; simply because, these people see their problems as caused by others rather than due to their own behavior.

4. Personality disorders are among the most challenging psychiatric disorders to treat because the personality is an integral part of what defines the individual and his self-perceptions. 5. Rather than cure, treatment typically focuses on: enhancing the patients coping skills solving short term problems and building relationship skills through psychotherapy and education. a. Psychotherapy: Traditionally, long-term psychotherapy has been the treatment of choice. Effective psychotherapy always requires a trusting relationship with the therapist. b. Adjunctive medication: Many patients also receive drugs to relieve associated symptoms such as acute anxiety or depression. Drugs are only prescribed as an adjunct to psychotherapy- not as a cure for the personality disorder Cluster A disorders- may benefit from antidepressant and low-dosage antipsychotic agents. Cluster B disorders patients who suffer marked mood reactivity, impulsivity, or rejection hypersensitivity may respond well to anticonvulsant mood stabilizing agents and MAOI agents. Cluster C disorders may benefit from antianxiety agents Cultural Considerations :

Judgment about personality functioning must take into account the persons ethnic background, cultural, and social background. Members of minority groups, immigrants, political refugees, or from different ethnic backgrounds may display guarded or defensive behavior as a result of language barriers or previous negative experiences; this should not be confused with paranoid disorder.

People with religious or spiritual beliefs such as clairvoyance, speaking in tongues, or evil spirits as a cause of disease could be misinterpreted as having a schizotypal personality disorder.

Likewise, cultures that value work and productivity may produce citizens with a strong emphasis in these areas, and this should not be confused with obsessive-compulsive personality disorder.

* * Types of Personality Disorders * * 1. ANTISOCIAL Personality Disorder:

a. Defining Characteristics: Antisocial personality disorder is characterized by chronic antisocial behavior that violates others rights or
b. generally accepted social norms, which predisposes the affected person to criminal behavior. This pattern has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder Occurs in about 3% of the general population Four times more common in men than in women 50% of prisoners have a diagnosis of antisocial personality disorder Tend to peak in the 20s and diminish significantly after age 45 Key signs and symptoms of Antisocial personality disorder: Repeatedly performing unlawful acts Reckless disregard for own or others safety Deceitfulness Lack of remorse or empathy Consistent irresponsibility Power-seeking behavior Destructive tendencies Impulsivity and failure to plan ahead Superficial Charm Inflated, arrogant, self appraisal Irritability and aggressiveness Inability to maintain close personal or sexual relationships Disconnection between feelings and behaviors

c. Common Causes of Antisocial Personality disorder: 4. Possible biological factors ( may underlie low arousal, poor fear conditioning, and decision-making deficits) Poor Serotonin regulation in certain brain regions, which may decrease behavioral inhibition Reduced autonomic activity and developmental or acquired abnormalities in the prefrontal brain system. 5. Possible genetic influence, more common in first degree biological relatives than in general population. 6. Other possible causes or risk factors: Attention-deficit hyperactivity disorder, large families d. Key Childhood Risk Factors: Substance abuse Criminal behavior Physical or sexual abuse Neglectful or unstable parenting Social Isolation Transient Friendships Low socioeconomic groups

e. Diagnosis: Formal psychological testing as with the MMPI-2 Diagnosis confirmed if DSM-IV-TR criteria are met f. Treatment: Focus: helping the patient make connections between his feelings and behaviors by gaining better access to and experiencing such feelings. 6. Reinforcing appropriate behaviors 7. Helping the patient develop victim empathy 8. Experiencing intense affect usually a sign of progress Psychotherapy ( Treatment of choice) Group therapy Family therapy Self-help support groups Inpatient hospitalization ( rare) Specialized treatment programs

Drugs ( such as lithium, anticonvulsants, beta-adrenergic blockers)

g. Nursing Interventions: For Antisocial PD 9. Set limits on the patients behavior Using a straightforward, matter-of fact approach Clearly conveying your expectations of the patient, as well as the consequences if he fails to meet them Establishing a behavioral contract to communicate to the patient that other behavior options are available Encouraging and reinforcing positive behavior Holding the patient responsible for his behavior to promote the development of a collaborative relationship 10. Anticipate manipulative efforts Keep in mind that patient may seem charming and convincing Help the patient identify such behaviors so he can learn that other people are not extensions of himself. 11. Expect the patient to refuse to cooperate in an effort to gain control 12. Avoid power struggle and confrontations to maintain the opportunity for therapeutic communication 13. Avoid defensiveness and arguing 14. Observe for physical and verbal signs of agitation 15. Help the patient manage his anger 16. Teach the patient social skills, and reinforce appropriate behavior 17. Encourage the patient to express his feelings, analyze his own behavior, and be accountable for his actions.

2. BORDERLINE Personality Disorder:

a. Defining Characteristics: A disorder of poor regulation of emotion, characterized by a pervasive pattern of unstable interpersonal relationships, self-image, behavior and affects and marked impulsivity. The most common personality disorder found in clinical settings Five times more common in those with a first degree relatives with the diagnosis People with this disorder may experience it in various ways: e. May have cognitive problems due to overwhelming emotions f. Commonly have alternating extremes of anger, anxiety, depression and emptiness ( intense bout of emotion typically last only hours, or at most a day) g. May cause conflict with others h. May have brief psychotic-like experiences or episodes Distortions in cognition and sense of self can lead to frequent changes in long-term goals, jobs and career plans, friendships, values, and even sex identity. A person with this disorder may see herself as fundamentally bad or unworthy, feeling misunderstood, mistreated, bored and empty, with little idea who she really is. . Have difficulty distinguishing reality from their own misperceptions of the world ( for instance, have difficulty viewing events and relationships from perspective of others). People with borderline personality disorder tend to act impulsively, without considering the consequences. c. May include promiscuity, substance abuse, and eating or spending binges. d. May prompt outburst of intense anger that leads to violence ( easily triggered when others criticize or thwart their impulsive act) People with borderline personality disorder tends to have intense and stormy relationships, alternating between a black and white view of others. A person of this disorder is extremely sensitive to rejection, possibly reacting with anger and distress to even mild separation from loved ones ( such as with vacations, business trips, or a sudden change in plans). a. May resort to self-destructive behavior, such as self-mutilation ( cutting or burning), substance abuse, eating disorders, and suicide attempts to escape inner turmoil. b. Recurrent self-mutilation is a cry for help, an expression of intense anger or helplessness, or a form of selfpunishment. c. Commonly triggered by fear of abandonment BPD affects 2-3 % of the general population; 11% of the psychiatric outpatients and nearly 20% of the psychiatric inpatients Three times more common in females than it is in males


b.

The disorder usually begins in early childhood and peaks in adolescence and early adulthood. Though by 30s and 40s, some stability achieved in work and personal life ( but significant areas of dysfunction remain). Borderline personality disorder commonly overlaps with other personality disorders as well as bipolar disorder, depression, anxiety disorders, and substance abuse. Causes: Precise cause is unknown; several theories are being investigated Possible genetic components ( five times more common in first-degree relatives of people with the disorder) Possible biological factors d. Dysfunction in brains limbic system or frontal lobe e. Decreased serotonin activity f. Increased activity in alpha-2-noradrenergic receptors Factors may appear more common in patients than in general population d. Prolonged separation from parents e. Other major losses early in life f. Physical, sexual or emotional abuse or neglect

c. Signs and Symptoms: Four main categories of major signs and symptoms d. Unstable relationship e. Unstable Self-Image f. Unstable Emotions g. Impulsivity Most acute when patient feels isolated and without social support, causing her to make frantic efforts to avoid being alone Possible assessment findings: o. Pattern of unstable and intense interpersonal relationships p. Intense fear of abandonment, as displayed in clinging and distancing maneuvers q. Rapidly shifting attitudes about friends and loved ones r. Desperate attempts to maintain relationships s. Manipulation, as in pitting people against one another t. Limited coping skills u. Dissociation ( separating objects from their emotional significance ) v. Uncertainty about major issues ( such as self-image; identity, life goals, sexual orientation, values, career choices, or types of friends w. Imitative behavior x. Rapid, dramatic mood swings- from euphoria to intense anxiety to rage- within hours or days y. Acting out of feelings instead of expressing them appropriately or verbally z. Inappropriate, intense anger or difficulty controlling anger aa. Chronic feelings of emptiness bb. Unpredictable, self-damaging behavior ( such as driving dangerously, gambling, sexual promiscuity, overeating, overspending, and abusing substances) cc. Self-destructive behavior

c. Diagnosis: Standard psychological test, possibly revealing high degree of dissociation Diagnosis confirmed if DSM-IV-TR criteria met d. Key Treatment Options for Borderline Personality Disorder: May be multifaceted Psychotherapy ( Treatment of choice) Structured therapeutic setting a. Requires establishing boundaries for the relationship when therapy begins ( patient may initially try to test therapists limits b. Requires cooperation of everyone involved in patients care to maintain consistent boundaries

Psychosocial treatment called dialectical behavior therapy- developed specifically to treat borderline personality disorder- the patient is taught to better control her life and emotions through self-knowledge, emotion regulation, and cognitive restructuring. Social learning theory and conflict resolution therapies to treat borderline personality disorder Inpatient Hospitalization -rarely indicated or appropriate. During episode of acute depression or another crisis, patient may be seen in an emergency department, inpatient unit, or local community health center. Partial hospitalization and day treatment programs- (to provide a safe environment, offering support, feedback and structure during the day and patient usually returns home in the evening.)

Milieu Therapy Self-help support groups ( To help patients to cope better on their own, thereby avoiding situational crises) Drugs f. Antidepressant drugs such as SSRIs ( Fluoxetine- PROZAC ), MAOIs to treat depression. g. Antianxiety drugs such as Buspiron ( BuSpar) to ease anxiety h. Antipsychotic drugs such as Risperidone or Olanzapine, to ease dissociative symptoms or self-destructive impulses. i. Antimanic medications such as Lithium or Valproic Acid ( Depakote) to treat mood swings j. Naltrexone ( ReVia ) to reduce self-mutilating behaviors

e. Nursing Interventions:For BPD Encourage the patient to take responsibility for herself; dont try to rescue her from the consequences of her actions ( except suicidal and self-mutilating behaviors). Convey empathy and support, but dont try to solve problems she can solve herself. Maintain a consistent approach in all interactions with the patient, and ensure that other team members use the same approach. Avoid sympathetic nurturing responses Recognize and avoid unconsciously reinforcing behaviors used to manipulate people. Set appropriate expectations for social interactions, and praise the patient when she meets these expectations. To promote trust, respect the patients personal space. Be aware that the patient may idealize some staff members and devalue others Dont take sides in the patients disputes with staff members Avoid defensiveness and arguing Try to limit the patients interactions to assigned staff to decrease splitting behaviors; use only consistent staff members. If patient is taking medication, monitor for cheeking and hoarding medications Encourage the patient to express her feelings, analyze her behavior, and be accountable for her actions. Help the patient develop problem-solving skills Teach and encourage relaxation techniques Suggest that the patient start an exercise regimen ( exercise promotes stability by decreasing mood swings and aiding the release of anger).

f. Other Cluster B Personality Disorders: 3. Histrionic Personality Disorder: a. Defining characteristic:

Patients with histrionic personality disorder characteristically have a pervasive pattern of excessive emotionality and attention -seeking behavior, and are drawn to momentary excitements and fleeting adventures. Charming, dramatic, and expensive, such patients can be easily hurt, vain, demanding, capricious, excitable, self-indulgent, and inconsiderate. c. Typically come across as manipulative and phony (words and expressed feelings seem shallow, not real or deep). d. Can shift instantly from rage to friendliness

Their style of speech is excessively impressionistic, if not theatrical, and their gestures are exaggerated. c. Use grandiose language to describe everyday events d. Value words for their emotional content than for their factual accuracy

People with histrionic personality disorder need to be the center of attention at all times e. Exaggerate illness to gain attention f. Interrupt others so they can dominate conversation g. Seek constant praise h. Place great emphasis on physical appearance, commonly dressing provocatively and behaving seductively With limited self-knowledge, these patients may have no sense of who they are aside from their identification with others; they commonly change their attitudes and values based on the views of significant others. d. Rarely gain an understanding of others e. Devote intense observation skills to determine which behaviors and attitudes, or feelings are most likely to win others admiration and approval f. View relationships as closer or more significant than really are.

 d.
e. f. g.

h.
i. a. b.

Because they dont view others realistically, people with histrionic personality disorder have difficulty developing and sustaining satisfactory relationships. Tendency to idealize the significant other early in the relationship If significant other start pulling back from patients incessant demands, patient may become dramatic and demonstrative in attempt to bind other person to the relationship To avoid rejection, may resort to crying, coercion, temper tantrums, assault, and suicidal gestures Despite their attempts to bind others to them, they often lack fidelity and loyalty HPD affects an estimated 2-3 % of the general population, commonly diagnosed in women but may be just as common in men. Without treatment, the disorder can lead to social, occupational, and functional impairments Many are able to function at a high level and succeed at work ( although frequent interruption of intimate relationships is common). Commonly coexist with somatoform and mood disorders

c. Causes: Cause unknown Possible genetic component ( hysterical traits more common in relatives of those with disorder) Biological factors: little research done Childhood events may play a role Psychoanalytic theories: focus is on seductive and authoritarian attitudes by fathers of patients. d. Signs and Symptoms: Constant craving for attention, stimulation, and excitement Intense affect Shallow, rapidly shifting expression of emotions Flirtatious, seductive behavior Vanity, over investment in appearance, exhibitionism Exaggerated, vague speech Self-dramatization Impulsivity Suggestibility and impressionability Egocentricity, self-indulgence, and lack of consideration for others Intolerance of being alone Dread of growing old Suppression or denial of internal distress, weakness, depression or hostility May be manipulative, divisive and demanding Use of alcohol or drugs to quickly alter negative feelings Depression Suicidal gestures and threats e. Diagnosis: No specific diagnostic test, personality and projective test can be helpful Must rule out physiologic disorders in patients with somatic complaints Diagnosis confirmed if DSM-IV-TR criteria met f. Treatment: Rarely seeks treatment unless a crisis occurs or a situational factors causes functional impairment and ineffective coping. Goal: To relieve the worst elements of the patients behavior, rather than to cure her. Psychotherapy ( treatment of choice) e. Focuses on solving problems in patients life rather than producing long-term personality changes f. Individual therapy is preferred over group, family or self-help groups ( group environment may trigger dramatic, attention -seeking behavior ) g. While establishing rapport and trust, therapist must avoid dependent situation with needy patient who sees the therapist as her rescuer h. Therapist must try to help patient view her interactions objectively; and explore and clarify emotions Medications to relieve associated symptoms such as anxiety or depression; careful monitoring is required during therapy because, c. In a crisis may seek drugs for self-destructive or harmful purposes d. May respond to side effects of medication with intense , dramatic overreactions

g. Nursing Interventions: For HPD Give the patient choices in care options, and incorporate her wishes into the

treatment plan as much as possible, increasing her sense of self-control may help lower anxiety. Anticipate the patients tendency to try to win over caregivers ( may be responsive and cooperative, at least initially. Teach the patient appropriate social skills, and reinforce appropriate behavior Help the patient learn to think more clearly Promote the patients expression of feelings, analysis of her behavior, and accountability of her actions. Encourage warmth, genuineness, and empathy Teach the patient stress- reducing techniques, such as deep breathing and an exercise regimen Help her to mange crises and the feelings that trigger them Monitor the patient for suicidal thoughts and behavior.

4. Narcissistic Personality Disorder: a. Defining Characteristic: A person with narcissistic personality disorder is self-centered, self-absorbed, and lacking in empathy for others, he typically takes advantage of people to achieve his own ends, and uses them without regard to their feelings. d. Has inflated sense of himself and intense need for admiration e. Tries to maintain image of perfection and invincibility to prevent others from discovering weaknesses and imperfection ( beneath the image, basically insecure with low self-esteem ) Narcissistic people expects to be recognized as superior d. Preoccupied with fantasies of brilliance and unlimited success or power e. Believes hes special and entitled to favored treatment f. Expects others to comply with wishes automatically, and believes he should associate only with other special or high status people. Many narcissists are driven and achievement oriented The narcissists delusion of greatness may be shattered by a threat to his ego, making him feel as though his life is unraveling, and possibly triggering a panic attack a. Physical illness b. Loss of a job or relationship c. Feeling of emptiness and depression despite material wealth and success. Narcissistic personality disorder is found in less 1% of the general population and affects about three times as many males as it does with females. c. Develops by early adulthood but may not be identified until midlife, when person experiences sense of loss of opportunity or faces personal limitations. d. In many cases, occurs in those with histrionic or borderline personality disorder.

b. Signs and Symptoms: Arrogance and haughtiness Self-centeredness Unreasonable expectations of favorable outcome Grandiose sense of self-importance Exaggeration of achievements and talents Preoccupation with fantasies of success, power, beauty, brilliance, or ideal love Constant desire for attention and admiration Lack of empathy or concern toward those he offends Taking advantage of others to achieve own goals May also exhibit rage, shame or humiliation in response to criticism In severe cases, may have self-destructive tendencies and poor reality testing c. Diagnosis: No specific diagnostic tests; patient should undergo psychological evaluation and personality and projective testing Diagnosis confirmed if DSM-IV-TR criteria met d. Treatment: Most narcissists seek treatment only in times of crisis and terminate treatment as soon as their symptoms ease Those not terminating treatment may be seeking help for depression or interpersonal difficulties Long term psychotherapy ( treatment of choice) to help establish a strong alliance between the patient and therapist) Group therapy not effective because the patient typically dominate the group c. May be tiring to others, who have to hear about his accomplishments and talents d. May drop out of group if criticized by others

Hospitalization may be necessary for severe symptoms such as self-destructive behavior and poor reality testing when needed; it should be brief and treatment should be symptom-specific Long-term therapy for those who lack motivation for outpatient treatment and for those with destructive, acting-out, and chaotic lifestyles. c. May involve intensive milieu therapy, individual psychotherapy, family involvement or specialized residential environment. d. May be appropriate for patients with severe ego weakness, helping them to improve self-concept.

e. Nursing Interventions: For NPD 10. Convey respect and acknowledge the patients sense of self-importance so he can reestablish a coherent sense of self. 11. Avoid reinforcing either pathologic grandiosity or weakness 12. Focus on the patients positive traits or on his feelings of pain, loss or rejection 13. If the patient makes unreasonable demands or has unreasonable expectations, tell him so in a matter of fact way. 14. Remain non-judgmental ( a critical attitude may make him even more demanding and difficult). The client may behave in a rude and arrogant manner, may be harsh and critical of the nurse. The nurse must not internalize such criticism or take the clients behavior personally. But limit should be set on rude or verbally abusive behavior and should explain what is expected from the patient. 15. Dont avoid the patient ( this could increase his maladaptive attention-seeking behavior) 16. Avoid defensiveness and arguing 17. Offer persistent, consistent, and flexible care; this includes taking a direct, involved approach to gain the patient' trust and cooperation. 18. Teach the patient social skills and reinforce appropriate behavior. Cluster C Personality Disorders: 4. Avoidant Personality Disorder: a. Defining characteristic: Is marked by feelings of inadequacy, extreme social anxiety, social withdrawal, and hypersensitivity to negative evaluation or to others opinion.

People with this disorder have low self-esteem and poor self- confidence; they readily believes that he or she is inferior to others; they dwell on the negative and have difficulty viewing situations and interactions objectively. c. To rationalize their avoidance of new situations, clients may exaggerate potential difficulties involved . d. May create fantasy worlds to substitute for the real one.

The avoidant person yearns for social relationships but fears being rejected or embarrassed in front of others. (Because the client is unusually fearful of rejection, crticism, shame, or disapproval, he or she tends to avoid situations or relationships that may result in these feelings). c. Is not willing to enter into social relationship without assurance of uncritical acceptance. d. Seeks out jobs that require little contact with others. Many people with avoidant personality disorder also have other psychiatric disorders h. Social phobia i. Schizoid personality disorder j. Agoraphobia k. Obsessive-compulsive disorder; Generalized anxiety disorder l. Major depressive disorder; Somatoform disorders m. Dissociative disorder and Schizophrenia Found in an estimated 0.5 % to 1 % of the general population; it affects males and females equally and develops by early adulthood.

b. Causes: Most likely results from combination of genetic, biological, environmental, and other factors Psychodynamic view attributes disorder to overly critical parenting style. Genetic and biological theories: d. disorder to closely linked to temperament e. Some have apparently inborn tendency to withdraw from new situation or people f. Overstimulation or excess incoming information may be cause of inherited tendency to be shy cant cope with excess information and withdraw in defense may stem from low autonomic arousal threshold of arousal ( certain structure in brains limbic system may have lower threshold of arousal and more pronounced response when activated ).

Environmental factors:

b. Full development of disorder possibly resulting from significant environmental influences during childhood
( such as rejection by the parents or peers). c. Signs and Symptoms: Shyness, timidity, and social withdrawal behavior or appearance thats meant to drive others away ( gives patient sense of control) Reluctant to speak, or conversely, overly talkative Constant mistrust or wariness of others Testing of others sincerity Difficulty starting and maintaining relationships Perfectionism Rejection of people who dont live up to his impossibly high standard Limited emotional expression; Tenseness and anxiety Low self-esteem; Feelings of being unworthy of successful relationship Loneliness; Reluctance to take personal risks or engage in new activities May also report frequent escape into fantasy, such as by excessive reading or watching television or daydreaming. d. Diagnosis: No specific diagnostic tests; patient should undergo psychological evaluation and personality and projective tests Diagnosis confirmed if DSM-IV-TR criteria met e. Treatment: People rarely seek treatment unless something goes wrong in their lives to indicate they arent coping adequately.

Psychotherapy for high- functioning patients, while others benefit from a combination of medication and psychotherapy. Goal: to improve social interaction and increase confidence in interpersonal relationships using various techniques, h. Enhance self-esteem i. Improving social interaction and increasing confidence in interpersonal relationships j. Desensitizing reaction to criticism k. Decreasing resistance to change l. Improving coping m. Achieving cognitive restructuring n. Developing appropriate affect and expression of emotions Individual Psychotherapy ( preferred treatment) ; most effective when its short term and focused on solving specific life problems. Medications as an adjunct to psychotherapy if patient has moderate to severe functional impairments. Commonly observed: c. Positive response to MAO inhibitors ( Phenelzine=Nardil, to improve self-confidence and assertiveness in social settings). d. Medications may interfere with effective psychotherapy management if patient feels disconnected from emotions.

f. Nursing Interventions: For APD Offer persistent, consistent, and flexible care, take a direct, involved approach to gain the patients trust Be aware that the patient may become dependent on the few staff members he feels he can trust. Avoid actions that foster dependency, and encourage self-care. Assess the patient for signs of depression because social impairment increases the risk for depression. Prepare the patient for upcoming procedures well in advance ( giving him plenty of time to adjust) as patients with avoidant personality disorder dont handle surprises well. Inform the patient when you will and wont be available if he needs assistance Initially, give the patient explicit directives rather than asking him to make decisions; gradually encourage him to make easy decision, and continue to provide support and reassurance as his decision-making ability improves. Encourage the patients expression of feelings, analysis of behavior, and a accountability for his actions. Teach the patient relaxation and stress-management techniques to help him manage his anxiety level and cope in times of stress.

5. Dependent Personality Disorder:

a. Defining Characteristic: Characterized by an extreme need to be taken care of, which leads to submissive, clinging behavior and a fear of separation or rejection. People with this disorder let others make important decisions for them and have a strong need for constant reassurance and support. c. Feel helpless and incompetent, complying passively and transferring responsibility to others. d. Seek others to dominate and protect them Some stay in abusive relationships and are willing to tolerate mistreatment c. May become suicidal when the breakup of a romantic relationship is imminent d. Urgently seeks another relationship as a source of care and support after a close relationships ends Behaviors typically arise from the perception that the patient cant function adequately without others. Overly sensitive to disapproval, often feels helpless and depressed c. Belittle her own abilities and is racked with self-doubt d. Views criticism and disapproval as proof that shes worthless A dependent person is likely to avoid position of responsibility Dependent personality disorder occurs in about 1.5 % of the general population; it affects slightly more females than it does males

b. Causes: Exact cause unknown, tends to run in families ( may have genetic component) Possible link with overprotective or authoritarian parenting leading to high levels of dependency c. May cause the child to believe she cant function without others guidance and protection d. May lead to child maintaining relationships by giving into others demands Contributing factors e. Childhood trauma f. Closed family system that discourage outside relationships g. Childhood physical or sexual abuse h. Social isolation c. Signs and Symptoms: Submissiveness Self-effacing, apologetic manner Low self-esteem; Lack of confidence; Lack of initiative Incompetence and a need for constant assistance Feelings of pessimism, inferiority, and unworthiness Anxiety and insecurity especially when deprived of a significant relationship ( fear of being alone) Hypersensitivity to criticism Clinging, demanding behavior Use bribery, promises to change , and even threats, all to maintain key relationships Difficulty making everyday decisions without advice or reassurance Avoidance of change or new situations Exaggerated fear of losing support and approval Possible complaints of fatigue, lethargy and depression d. Diagnosis: Psychological evaluation and Projective tests, as indicated Medical evaluation and diagnostic tests to rule out underlying medical condition ( somatic complaint) Diagnosis Confirmed if DSM-IV-TR criteria met e. Treatment: Rarely seek treatment for dependency or help; typically complaint of anxiety, tension, or depression Individual psychotherapy, behavioral therapy, and support groups and medications to manage associated symptoms Individual and group therapy Assertiveness training ( behavior modification using assertiveness techniques). Self-help support groups to allow patients to share their experiences and feelings. Medications to treat associated symptoms such as low energy, fatigue and depression c. Antidepressants ( SSRIs, MAOIs, Tricyclics) d. Antianxiety ( Benzodiazepines)

f. Nursing Interventions: For DPD Offer a persistent, consistent and flexible care; take a direct, involved approach to gain the patients trust Give the patient as much opportunity as possible to control her treatment; offer options and allow her to choose Verify the patients approval before initiating specific treatments Limit caregivers to a few consistent staff members to increase patients sense of security Encourage activities that require decision-making ( such as balancing a checkbook, planning meals, and paying bills) and help the patient establish and work toward goals to promote a sense of autonomy.. Help the client express her ideas assertively. Be aware that onwardly, the patient may seem compliant or overly compliant; however, it is always possible that despite her passivity, she may fail to make real gains in therapy, because her compliance is usually superficial. Monitor then patients medication regimen: d. Teaching her about the prescribed medications, including exactly what each medication is prescribed for e. Emphasizing that there are no magical drug effects f. If the patient is receiving benzodiazepines, check for signs and symptoms of physiologic and psychological dependence. 6. Obsessive- Compulsive Personality Disorder: a. Defining characteristics: Is characterized by a pervasive pattern of preoccupation with orderliness, perfectionism, mental and interpersonal control at the expense of flexibility, openness, and efficiency. d. Characteristically view the world as black and white e. Associated with relentless anxiety about not getting things perfect f. Interferes with interpersonal relationships and daily routines The patient with obsessive-compulsive personality disorder places a great deal of pressure on himself and others not to commit mistakes e. May have a constant sense of righteousness and feel anger and contempt for anyone who disagrees with him . f. Believes his way of doing something is the only right way g. May force himself and others to follow rigid moral principles and to conform to extremely high standards of performance h. May insist on literal compliance with authority and rules A person with OCD has an overwhelming need to control the environment but agonizes over the process, as a result; c. May suffer from severe procrastination and indecisiveness because he cant determine with certainty which choice is correct. d. May have difficulty starting a task because of his need to sort out the priorities correctly A lifelong pattern of rigid thinking may lead to poor social skills; symptoms may cause extreme distress and may interfere with the patients occupational and social functioning. Many patients with OCD have one or both of the other cluster C personality disorders ( Avoidant and dependent personality disorders); some also have paranoid personality disorder as well as various types of anxiety, somatoform, and depressive disorders. b. Causes: Possible roles of genetic and developmental factors; tendency to run in families. Psychodynamic theories: patients viewed as needing control as a defense against feelings of powerlessness or shame. c. Signs and Symptoms: Behavioral, emotional, cognitive rigidity Perfectionism Indecisiveness Severe self-criticism Controlling manner Difficulty expressing tender feelings Poor sense of humor Cool, distant, formal manner Solemn, tense demeanor Emotional constriction Excessive discipline Aggression, competitiveness, and impatience Bouts of intense anger when things stay from the patients idea of things should be Difficulty incorporating new information into life Preoccupation with orderliness, neatness, and cleanliness Scrupulousness about morality, ethics or values Miserliness and hoarding of money and other possessions Some patient reports:

a. b. c. d.

S/S of depression Sexual dysfunction Physical complaints ( Commonly stemming from overwork) Psychosomatic complaints

d. Diagnosis: Psychological Evaluation, including personality and projective tests Diagnosis confirmed if DSM-IV-TR criteria met e. Treatment: Typically seeks treatment only if depressed, unproductive, or under extreme stress ( circumstances that tax his limited coping skills) Individual psychotherapy, in conjunction with medication. Discussion of the nature of the disease process and explanation of typical treatment by the therapist in a businesslike, factual rather than giving a vague impressions Long term work on changing the personality commonly unrealistic because of the inherent nature of obsessivecompulsive personality disorder makes it especially resistant to change. Creative techniques to help the patient truly experience his feelings c. Encouraging the patient to express how various situations, events, and daily occurrences make him feel ( rather than simply describing his feelings) d. Having the patient keep a daily journal of feelings to help him remember how he felt at any given time Cognitive approaches rarely works ( patients are likely to use this type of therapy to verbally attack the therapist) Group therapy usually intolerable for the patient, because group members may ostracize the patient if he points out their deficits and perceived incorrect ways of doing things. Generally, poor response to medication, if a patient suffers from depression however, SSRIs and other antidepressants may be helpful. e. Nursing Interventions: For OCD Offer persistent, consistent, and flexible care, involves taking a direct, involved approach to gain the patients trust. Let the patient control his own treatment plan by giving him choices whenever possible Maintain a professional attitude, avoid informality as the patient demands strict attention to detail. Recognize and respect the patients need for physical and emotional distance Be prepared for long monologues centering on the patients goals and ambitions, and reasons that family members , friends and work subordinates need to be rigidly controlled; try to remain attentive Use tolerance and ordinary kindness when dealing with the patient ( remember that hes used to causing exasperation in others but doesnt fully understand why) Avoid defensiveness and arguing If appropriate, encourage the patient to record his feelings in a journal Remember that the patients defensive structure ( which makes him seen arrogant and argumentative) is a cover for his vulnerability to shame, humiliation and dread Teach the patient social skills and reinforce appropriate behavior Teach him about prescribed medications Encourage him to continue therapy for optimal results

Cluster A Personality Disorders: 1. Paranoid Personality Disorder: a. Defining Characteristic: Is characterized by a pervasive mistrust and suspiciousness of others ( the person interprets the action of others as potential harmful to himself or herself). They search for hidden meanings and hostile intentions in everything others say and do Patients are quick to challenge the loyalties of friends and loved ones a. May seem cold and distant b. Commonly shift blame to others and carry long grudges c. Have tendency to drive people away d. During periods of stress, transient psychotic symptoms may develop The prevalence of paranoid personality disorder is estimated at 0.5% to 2.5% of the general population In clinical samples, and possibly in the general population, paranoid personality disorder is more common in males. Common Causes: Exact cause unknown Possible genetic influence as suggested by a higher incidence in families with a member with schizophrenia.

May result ( at least partly) from inconsistent attachment or poorly established or maintained parent-child attachment, which can produce profound insecurity in the child

b.

Signs and Symptoms: Suspicion and distrust of others motives ( hallmark sign) Refusal to confide in others Inability to collaborate with others Hypersensitivity Inability to relax ( hypervigilance) Need to be in control Self-righteousness Detachment and social isolation Poor self-image Sullenness, hostility, and coldness Humorless Anger, jealousy, and envy Bad temper, hyperactivity, and irritability Lack of social support system

c. Diagnosis: MMPI-2 and other psychological tests for diagnosis Diagnosis confirmed if DSM-IV-TR criteria met d. Treatment: Few seek treatment on their own, and when they do, health care providers may have difficulty establishing rapport because of the patients suspicious and distrustful nature. Individual psychotherapy preferred over group therapy ( because of the patients suspicious nature) a. Psychotherpay involving simple, honest, businesslike approach rather than an insight-oriented approach b. Initially focuses on the current problem that brought the patient to therapy c. As therapy progresses and patient begins developing trust, may focus on disclosing paranoid ideas Pharmacologic Therapy: a. Should be limited to briefest course possible b. Antipsychotic drugs ( Risperidone) to treat severe agitation or delusional thinking ( given in one tenth- one fourth the usual dosage used in psychotic patient) c. SSRIs such as flouxetine ( Prozac) to treat irritability, anger, and obsessional thinking d. Antianxiety drugs to treat severe anxiety that interferes with normal functioning Because of the patients distrust of medications and resentment of the suggestion that antipsychotic drug is needed, some therapist delay giving medication until patient asks about it. Thorough teaching about possible adverse effects, so he doesnt grow more suspicious if these occur. e. Nursing Interventions: PPD Use a straightforward, honest, professional approach rather than a casual or friendly approach. Offer, persistent, consistent, and flexible care. Provide a supportive, nonjudgmental environment in which the patient can safely explore his feelings; avoid defensiveness and arguing Establish a therapeutic relationship by actively listening and responding Avoid inquiring too deeply into his life or history unless its relevant to clinical treatment Dont challenge the patients paranoid beliefs; such beliefs are delusional and are not reality-based, so its useless to argue from a rational point of view Avoid situations that threatens the patients autonomy Be aware that the patient may not respond well to interviewing Use humor cautiously ( a paranoid patient may misinterpret a remark that was meant to be humorous) Encourage the patient to interact socially to expose him to others perceptions and realities and to promote development of social skills Help the patient identify negative behaviors that interfere with his relationships so he can see how his behavior affects others Encourage the patients expression of feelings, analysis of his behavior and accountability for his actions Respect the patients need for physical and emotional distance Assess the patients coping skills, and encourage him to use any existing ( effective) coping skills; teach him effective strategies to alleviate stress and reduce anxiety Teach the patient about his prescribed medications Encourage him to continue drug therapy for optimal results

2. Schizoid Personality Disorder: Defining Characteristics: Is characterized by a pervasive pattern of detachment from social relationship and a restricted range of expression of emotions in interpersonal settings. Characterized by detachment and social withdrawal. People with this disorder are commonly described as loners, with solitary interest and occupations and no close friends; typically, they maintain a social distance even from family members, and seem unconcerned about others praise and criticism. Most people with this disorder function adequately in everyday life but dont develop many meaningful relationships a. Fare poorly in groups b. May excel in positions requiring only minimal contact with others. Some people have additional personality disorders- most commonly schizotypal, paranoid, or avoidant personality disorder. The disorder occurs in only about 0.7% of the general population, although it affects more men than women, but more impairment in women

b. Causes: Exact cause is unknown; may be inherited Sustained history of isolation during infancy and childhood. Circumstances that interfere with warm , effective early parenting. Parental modeling of interpersonal withdrawal, indifference, and detachment c. Signs and Symptoms: Emotional detachment and social withdrawal Lack of strong emotions and little observable change in mood Indifference to others feelings, praise and criticism Strong preference for solitary activities Avoidance of activities that involve significant interpersonal contact Little desire for or enjoyment of close relationships Lack of close friends or confidants other than immediate family members No desire to be part of a family Little or no interest in sexual experiences with another person Inability to experience pleasure Shyness, distrust, and discomfort with intimacy Loneliness Feelings of utter unworthiness coexisting with feelings of superiority Self-consciousness and feeling ill at ease with people c. Diagnosis: No specific diagnostic tests; requires full psychological evaluation along with personality and projective tests ( such as MMPI-2 and MCMI-III ) Must be distinguished from schizotypal and avoidant personality disorders, which also involve social isolation and withdrawal Diagnosis confirmed if DSM-IV-TR criteria met d. Treatment: Typically wont seek treatment unless under great stress Based on individual and group therapy, and focuses on several goals a. Helping the patient find the most comfortable solitary niche and cultivate satisfying hobbies that allows him to be on his own b. Decreasing his resistance to change c. Reducing social isolation and improving social interactions d. Enhancing self-esteem Short- term individual psychotherapy; focusing on solving the patients immediate concerns or problems Cognitive restructuring ( cognitive therapy) to deal with illogical thoughts that impede with the patients coping ability and functioning Incorporating group therapy into the treatment plan after the patient has developed adequate social skills and a tolerance for interacting within a group setting

Self-help support groups to promote healthier social relationships, enhance functioning, cope better with unexpected stressors, and reduced fears of closeness and feelings of isolation ( the setting allows the patient to try out new coping skills) Medications for overlapping psychiatric disorders, such as major depression. Or if the patient needs relief from other acute symptoms a. For patient with psychotic ideations, possible benefit from low dose treatment with atypical antipsychotic drug, such as olanzapine or risperidone. b. Long term drug treatment generally avoided

f. Nursing Interventions: For Schizoid PD Respect the patients need for privacy; slowly build a trusting therapeutic relationship so he finds more pleasure than fear in relating to you Offer persistent, consistent, and flexible care; take a direct, involved approach to gain the patients trust Recognize the patients needs for physical and emotional distance; remember that he needs close human contact but is easily overwhelmed Teach the patient social skills and reinforce appropriate behavior Encourage the patient to express his feelings, analyze his behavior and take accountability for his actions; give him plenty of time to express his feelings as pushing him to do so before hes ready may cause him to retreat Avoid defensiveness and arguing 3. Schizotypal Personality Disorder: b. Defining Characteristics: Characterized by a pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships, as well as cognitive or perceptual distortions and eccentricities of behavior. Schizotypal patients commonly exhibit eccentric behavior and have difficulty concentrating for long periods d. May have peculiar mannerism and dress e. May have unusual speech thats overly elaborate, vague, metaphorical and hard to follow f. May have magical thinking, strange fantasies, odd beliefs ( such as thinking they have extrasensory abilities), unusual perceptions and bodily illusions, social isolation, and paranoid ideas Some experts think schizotypal personality disorder represents mild schizophrenia; however, schizoptypal patients arent psychotic in the sense, they dont experience hallucinations, delusions, or grossly disorganized thought and speech) During times of extreme stress, some patients do experience cognitive or perceptual disturbances butc. Not as fully developed as in schizophrenia d. Generally short-lived, resolving with use of an antipsychotic drug. Typically, schizoptypal patients have severe social anxiety, usually because theyre paranoid about others motivations. c. Sometimes may relate to others in a stiff or inappropriate way d. May fail to respond to normal interpersonal cues. Some with this disorder marry; but most patients have no more than one person they relate to closely The disorder takes a chronic course and in some patients progresses to schizophrenia c. Major depression found in 30-50 % of patients d. Another personality disorder ( especially paranoid, or avoidant ) is found in may patients Schizotypal personality disorder is found in about 3% of the general population; its slightly more common in men than it is in women

b. Causes: Possible genetic basis; studies show increased risk in people with family history of schizophrenia Environmental factor such as severe stress Some evidence of poor regulation of dopamine pathways in the brain of patient with disorder Psychological and cognitive theories ( focus on deficits in attention and information processing) a. Typically perform poorly on tests that assess continuous performance tasks ( require ability to maintain attention on one object and look at new stimuli selectively) b. Tend to do poorly on tasks involving emotionally laden words, suggesting cognitive bias toward neutral words Two psychoanalytic theories: a. Patients with disorder have ego boundary problems b. Patients raised by parents with inadequate parenting skills, poor communication skills c. Signs and Symptoms: Disturbed thinking:

a. Inaccurate beliefs that others behavior or environmental phenomena are meant to have an effect on the patient b. Odd beliefs or magical thinking ( such as thinking that ones thought or desires can influence the environment
or cause events to occur). c. Unusual perceptual experiences, including bodily illusions d. Vague , circumstantial, metaphorical, overly elaborate, or stereotypical speech or thinking e. Unfounded suspicion of being followed, talked about, persecuted, or under surveillance Behavioral disturbances: a. Odd or eccentric behavior or appearance b. Inappropriate or flat affect c. Lack of close relationships, other than those with immediate family members d. Social isolation e. Excessive social anxiety that doesnt abate with familiarity f. Sense of feeling different and not fitting in easily with others Diagnosis: No specific tests for identifying and diagnosing Personality tests, such as the MMPI-2 and MCMI-III , help to determine disorder type, and severity Diagnosis confirmed if DSM-IV-TR criteria met

d.

e. Treatment: Individual psychotherapy, family therapy, group therapy, cognitive-behavioral therapy, self-help measures, and medications.

Social skills training and other behavioral approaches that emphasize the basic of social interactions Psychoanalytic intervention focusing on defining ego boundaries Cognitive-behavioral therapy attempting to help the patient interpret his odd beliefs, and teach him valuable coping and interpersonal skills Individual therapy ( preferred ) c. Includes establishing a warm, supportive, patient-centered approach d. Requires avoiding any direct challenge of patients delusional or inappropriate thoughts Group therapy as the patient progresses initially, tolerating a group may be difficult due to distrust and suspiciousness Low-dose antipsychotic drugs, such as Clozapine ( Clozaril), to treat psychotic symptoms SSRIs shown effective for mood or anxiety symptoms

f. Nursing Interventions: For Schizotypal PD

Offer persistent, consistent, flexible care; be sure to take a direct, involved approach to promote the patients trust. Keep in mind that the patient is easily overwhelmed by stress. Give him plenty of time to make difficult decisions, or decisions that seem difficult only to the patient Be aware that the patient may relate unusually well to certain staff members but not at all to others; remind staff not to take this personally Recognize and respect the patients need for physical and emotional distance Teach the patient social skills and reinforce appropriate behavior Encourage the patients expression of feelings, self-analysis of behavior, and accountability for actions Avoid defensiveness and arguing

** Personality and Projective Tests ** Elicit patient responses that provide insight into mood, personality, or psychopathology. These tests include the following: often they experience symptoms of depression, such as poor concentration, suicidal thoughts, feelings of guilt, and crying. Questions focus also on cognitive symptoms such as impaired decision-making and physical symptoms such as appetite loss.

A. Beck Depression Inventory (BDI)= is a self-administered, self-scored test, where the patients are ask to rate how

B. Draw A-Person Test = the patient draws two (2) human figures one of each gender. The psychologist interprets the
drawings systematically and correlates the interpretation with the diagnosis. This test also provides an estimate of a childs developmental level.

C. Minnesota Multiphasic Personality Inventory- 2 (MMPI-2)= is a structured, paper and pencil test that provides a
practical way to assess personality traits and ego function in adolescents and adults. The MMPI-2 has 567 questions and takes 60-90 minutes to complete. The psychologist translates the patients answers into a psychological profile and then combines the profiles with data gathered from the interview. Test results shed light on the patients coping strategies, defenses, personality strengths and weaknesses, sexual identification and self-esteem and may strongly suggest diagnostic category. The MMPI-2 may also identify certain personality disturbances or mental deficits caused by neurologic problems.

D. Sentence Completion Test: In the Sentence-Completion Test, the patient completes a series of partial sentences. A
sentence might begin, When I get angry, I. The response may reveal the patients fantasies, fears, aspirations or anxieties.

E. Thematic Apperception Test: In the Thematic Apperception Test, the patient views a series of pictures depicting
ambiguous situations, and then tells a story describing each picture. The psychologist evaluates these stories systematically to help analyze the patients personality, particularly regarding interpersonal relationships and conflicts.