Personality and Impulse-Control Disorders

Chapter 20

What is it?Personality

• Complex pattern of characteristics, largely outside of the person’s awareness

• Distinctive patterns of perceiving, feeling, thinking, coping and behaving

• Emerges within biopsychosocial framework

Personality Disorder

• An enduring pattern of deviant inner experiences and behavior

• Differ from cultural expectations

• Pervasive, inflexible and stable

• Leads to distress or impairment

Types of Personality Disorders• Cluster A - odd-eccentric

– Paranoid Personality Disorder

– Schizoid Personality Disorder

– Schizotypal Personality Disorder

• Cluster B - dramatic and emotional (impulsivity)

– Antisocial Personality Disorder

– Borderline Personality Disorder

– Histrionic Personality Disorder

– Narcissistic Personality Disorder

• Cluster C - anxious-fearfulness

– Avoidant Personality Disorder

– Dependent Personality Disorder

– Obsessive-compulsive Disorder

Common Features and Diagnostic Criteria

• Abnormal, inflexible behavior patterns of long duration, traced back to adolescence and early adulthood

• Pervasive across a broad range of personal & social situations

• Deviate in the following:

– Cognitive abilities (schema)

– Affectivity and emotional stability (emotions)

– Interpersonal functioning/self-identity

– Impulse control and destructive behavior

Severity Criteria

• Tenuous stability - exaggerated emotions, unable to cope with normal stressful events

• Adaptive inflexibility - rigidity in interactions with others

• Vicious circles - because of inflexibility, generate and perpetuate dilemmas

Cluster A Disorders Paranoid Personality Disorder

• Features

– Mistrustful, avoid relationships that cannot control

– Persistent ideas of self-importance

• Epidemiology

– 0.5 to 2.5% in general populations

– More often in men

• Etiology: unclear, genetic predisposition?

Cluster A Disorders Paranoid Personality Disorder

Nursing Management

– Patients seen for other health problems

– Nsg DX: Disturbed thought process, social isolation

– Nursing Interventions

• It can be difficult to establish nurse-patient relationship.

• If trust is established, help patient identify problem areas.

• Changing thought patterns takes time.

Cluster A Disorders Schizoid Personality Disorder

• Features– Expressively impassive and interpersonally unengaged

– Introverted and reclusive, engage in solitary activities

– Communication sometimes confused

– Incapable of forming social relationships

– Minimum introspection, self-awareness and interpersonal experiences

• Epidemiology– Rarely diagnosed in clinical settings

– Avoidant personality disorder occurs in 30 to 35% of cases

• Etiology: speculative

Cluster A Disorders Schizoid Personality Disorder

Nursing Management

• Nursing Diagnosis: Impaired social interactions and chronic low self-esteem

• Goal: To enhance experience of pleasure

• Interventions– Provide social skill training.– Encourage social interactions.

Cluster A DisordersSchizotypal Personality Disorder

• Features

– Eccentric

– Pattern of social and interpersonal deficits

– Void of close friends

– Odd beliefs

– Ideas of reference

– When psychotic, symptoms mimic schizophrenia.

• Epidemiology

• 0.7 to 5.1% prevalence

• Etiology: unknown

• Speculation that this is a part of a continuum of schizophrenia-related disorders

Cluster A DisordersSchizotypal Personality Disorder

Nursing Management

• Similar to that with schizophrenia

• Increase self-worth.

• Provide social skills training.

• Reinforce socially appropriate dress and behavior.

• Focus on enhancing cognitive skills.

Borderline Personality DisordersClinical Course

• Pervasive patterns of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity that begins by early adulthood and is present in a variety of contexts

• Problem areas

– Regulating moods

– Developing a sense of self

– Maintaining interpersonal relationships

– Maintaining reality-based cognitive processes

– Impulsive or destructive behavior

• Appear more competent than they are

• Live from crisis to crisis

Borderline Personality Disorder• Affective instability - shifts in moods

• Identity disturbance (identify diffusion)– Role absorption - narrow definition of self

– Painful incoherence - internal disharmony

– Inconsistency in thoughts, feelings and actions

– Lack of commitment

• Unstable interpersonal relationships– Fear of abandonment

– Unstable, insecure attachments

– Over idealize/intense relationships

Borderline Personality Disorder

• Cognitive Dysfunctions– Dichotomous thinking

– Dissociation

• Dysfunctional Behaviors– Impaired problem-solving

– Impulsivity

– Self-injurious behaviors (parasuicidal behavior)

• Compulsive

• Episodic

• Repetitive

Borderline Personality Disorder in Special Populations

• Many children and adolescents show symptoms similar to those with BPD.

• Symptoms begin in adolescents.

Epidemiology

• 0.4 to 2.0% prevalence in general populations

• In clinical populations, BPD is the most frequently diagnosed personality disorder.

• Mostly women (77%)

• Mean age of diagnosis is mid-20s.

• Coexistence of personality disorders with Axis I disorders (mood, substance abuse eating, dissociative and anxiety disorders)

Risk Factors

• Physical and sexual abuse

• Parental loss or separation

Etiology• Biologic

– Abnormalities associated with affective instability, transient psychotic episodes, and impulsive, aggressive and suicidal behavior

• Psychological

– Psychoanalytic theory (separation-individuation; projective identification)

– Maladaptive cognitive processes

Etiology: Biosocial Theories• Millon -

– Distinct disorder that develops as a result of both biologic and psychological factors.

– Personality is shaped by a) active-passive behavior, b) pleasure-pain and c) sensitivity to self or others.

• Linehan

– Emotional vulnerability, self-invalidation, unrelenting crises, inhibited grieving, active passivity and apparent competence (Text Box 20.1)

Risk Factors

• Physical and sexual abuse

• Separation or loss of parent at an early age (same sex for men)

Interdisciplinary Treatment

• Requires the whole mental health care team

• Requires a variety of medications including mood stabilizers, antidepressants and, at times, anxiolytics

• Psychotherapy

Dialectical Behavior Therapy

• Combines numerous cognitive behavioral approaches

• Requires monitoring and commitment by patient

• Individual therapy

• Building skills through skills group

– Mindfulness

– Interpersonal effectiveness

– Emotion regulation

– Distress tolerance skills

– Self-management

Priority Care

Safety!!!

Response Patterns

• Affective dysregulation

• Mood lability

• Problems with anger

• Interpersonal dysregulation

• Chaotic relationships

• Fears of abandonment

• Self-dysregulation

• Identity disturbance

• Sense of emptiness

• Behavioral dysregulation

• Parasuicide behavior

• Impulsive behavior

• Cognitive dysregulation

• Dissociative responses

• Paranoid ideation

Nursing Management:Biologic Domain

Assessment• Systems review and physical functioning

– Nutrition and eating

– Sleep patterns

– Physical responses to emotions

• Physical indicators of self-injurious behaviors– Cutting, scratching or swallowing

• Pharmacologic assessment, including OTC and illicit drugs

Nursing Diagnosis:Biologic Domain

• Self-mutilations, risk for self-mutilation

• Disturbed sleep pattern

• Ineffective therapeutic regimen management

Nursing Interventions:Biologic Domain

• Sleep enhancement

– Enhance regular sleep-wake cycles.

– Moderate exercise

– Avoid touching those who have been physically, sexually abused.

• Nutritional enhancement

• Prevention and treatment of self-injury

– Observe for antecedents of self-injurious behavior, intervening before an episode.

– Help develop strategies to prevent behavior.

– Five sense exercise

Pharmacologic Interventions

• Controlling emotional dysregulations

– MAOIs

– SSRIs

– Others - SNEIs

• Reducing impulsivity - mood stabilizers

• Transient psychotic episodes - antipsychotics

• Reducing self-injurious behavior

– Naltrexone for dissociative symptoms has been studied.

– Atypical antipsychotics

• Decreasing anxiety

– Buspirone, careful use of benzodiazepines

Nursing Management: Psychological Domain

Assessment• Appearance and activity level

– Reflect mood and psychomotor activity

– Usually experience depression

• Moods

– Inhibited grieving

– Mood fluctuations

• Impulsivity

• Cognitive disturbance

– Dichotomous thinking

Nursing Management:Psychological Domain

Assessment (cont.)• Dissociation and transient psychotic episodes

• Interpersonal skills

– Assessment of person’s ability to relate to others

– Determine sexual partners

• Self-esteem and coping skills

• Risk for suicide or self-injury

Nursing Diagnosis Psychological Domain

• Risk for self-mutilation

• Disturbed thought process

• Ineffective coping

Pharmacologic Interventions

• Monitoring and administration of medications

– Easy to monitor in inpatient

– Outpatients may have high rate of noncompliance.

• Side effect monitoring and management

– Patients appear to be more sensitive to side effects.

• Drug-drug interaction

– Patients tend to be prone to drug interactions.

• Teaching points

Nursing Interventions: Psychological Domain

• Nurse-patient relationship– Establish trust.

– Recognize conflicting fears of abandonment and intimacy.

– Establish personal boundaries and limitations.

• Abandonment and intimacy fears – Recognize conflict.

– Any termination needs to be planned carefully.

• Establish personal boundaries and limitations.

• Management of dissociative states – Determine triggers.

Nursing Interventions: Psychological Domain (cont.)

• Behavioral interventions– Goal is to replace dysfunctional behaviors with positive ones.

– Validate positives; avoid confrontation if possible.

• Cognitive interventions – Emotional regulation

– Communication triad

– Distraction or thought triad

– Challenging dysfunctional thinking

• Management of transient psychotic episodes

• Patient episodes

Nursing Management:Social Domain

Assessment• Functional status

– Current job

– Community activities

• Social support systems

• Family assessment

Nursing Interventions:Social Domain

• Milieu management

• Group interventions

• Family and social support

Nursing Management Psychological Assessment

• Appearance and activity level

• Moods - inhibited grieving

• Impulsivity

• Suicide and/or self-injurious behavior

– Dichotomous thinking

– Dissociation and psychotic episodes

• Self-esteem and coping skills

Nursing Management Social Assessment

• Family

• Interpersonal skills

• Social support systems

Nursing Diagnosis

• Risk for self-mutilation

• Altered thought processes

• Ineffective coping

• Personal identity disturbance

• Anxiety

• Grief

• Low self-esteem

• Powerlessness

• Social isolation

• Spiritual distress

Biologic Interventions

• Sleep management

• Nutrition

• Management of psychotic episodes

• Prevention of self-injury

• Pharmacologic management

Psychological Interventions: Cognitive

• Communication triad

– An “I” statement to identify and express their feelings

– A nonjudgmental statement of the emotional trigger

– What could be done differently or what would restore comfort to the situation

• Thought stopping

• Challenging dysfunctional thinking (Text Box 22-4)

• Education

Social Interventions

• Milieu management

• Group interventions

• Family and social support

Antisocial Personality Disorder

• Pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence

• Behaviorally impulsive

• Interpersonally irresponsible

• Fail to adapt to the ethical and social standards of community

• Interpersonally engaging, but in reality lack empathy

• Easily irritated, often aggressive

Epidemiology and Risk Factors

• 0.2 to 3% of the population

• Age of onset - exhibit antisocial behavior before 15

• Men more often diagnosed (See Text Box 22-6.)

• Present in all cultures

• Comorbid with alcohol and drug abuse

Etiology• Biologic

– Genetic component – Five times more common in first-degree relatives

– Biochemical - not well understood

• Psychological

– Insecure attachments

– Difficult temperament

• Social

– Chaotic families

– Abuse

Nursing ManagementAssessment

• Difficult to establish a relationship

• Determine quality of relationships

• Impulsivity

• Aggression

• Ability to assume responsibility for their actions

• Amount of blaming others

Nursing Diagnosis

• Altered role performance

• Ineffective individual coping

• Impaired communication

• Impaired social interactions

• Defensive self-esteem

• Risk for violence

Nursing Management• Biologic - physical effects of chronic use of addictive

substances

• Psychological

– Self-responsibility facilitation

– Self-awareness enhancement

– Anger management

– Patient education

• Social

– Group

– Milieu

Family Interventions

• Help families establish boundaries.

• Help families recognize patient’s responsibility for his or her actions.

Histrionic Personality Disorder

• Attention seeking, life of the party, uncomfortable with single relationship

• Women - dress seductively

• Men - dress - “macho”

• Become depressed when not center of attention

Histrionic Personality Disorder

• 2 to 3% of population

• Highly alert individuals

• Parent modeling - “like mom”

• Nursing intervention

– Develop a sense of self without validation of others

Narcissistic Personality Disorder

• Grandiose

• Inexhaustible need for attention

• Fantasies about power, unlimited success

• 1% of population

• Etiology - unknown

• Rarely encounter them

Cluster C Disorders• Avoidant personality disorder

– Avoiding interpersonal contacts and social situation

– Perceiving themselves as socially inept

• Dependent– Submissive pattern

– Cling to others to be taken care of

– Prevalent in clinical samples

• Obsessive-compulsive– Different than OCD. Not as many obsessions and compulsions, but

rigidity, perfectionism and control

Impulse Control Disorders

• Intermittent explosive disorder

• Kleptomania

• Pyromania

• Pathologic gambling

• Trichotillomania