Personality Disorders

PERSONALITY DISORDERS Personality disorders fall into three groups, or clusters, shown in this chart. Clients with cluster A personality disorders are characteristically aloof and restrained in relationships; others may describe them as odd or strange. Clients with cluster B disorders typically are dramatic, unrestrained, and unpredictable. Those with cluster C disorders are overly apprehensive about the present and future and worry about failing. PERSONALITY DISORDER CLIENT DESCRIPTION Cluster A Schizotypal personality disorder • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Borderline personality disorder • Has some cognitive and perceptual distortion May be viewed as odd or eccentric in speech and behavior Has poorly developed social skills Has strained and uncomfortable relationships Is easily overwhelmed by too much social or interpersonal stimuli Uses projection Is extremely suspicious of other’s motives Is very guarded in relationships and finds hidden meanings Is very private Expects to be exploited or harmed by others Questions others loyalty Reads hidden meaning into harmless remarks or events Doesn’t forgive slights, insults, or injuries Is emotionally cold and detached Is withdrawn and controlled Can’t form warm, spontaneous relationships Usually lives alone or in parents’ home Has little need for friendships or intimacy Has a solitary lifestyle Seems indifferent to praise or criticism Can’t empathize with others because of intense need for love and admiration Demands much time and attention from others Feels entitled or special Is arrogant, haughty, and envious Controls anxiety through dramatic presentation of self Uses attention – seeking behaviors and flattery to get others to meet needs Is overly concerned with physical attractiveness Can’t tolerate delayed gratification Has a seductive appearance or behavior Becomes anxious when limits are placed on attention – seeking behaviors Has a poorly developed sense of self and is easily influenced by other people

Paranold personality disorder

Schizold personality disorder

Cluster B Narcisstic personality disorder

Histrionic personality disorder

• • • • • Paranoid personality disorder

Struggles with overwhelming feelings of anger and anxiety Views situation in extremes (all good or all bad) Has intense fear of abandonment Feels empty and devoid of substance Needs others around to maintain a sense of self (you + me = self)

PARANOID PERSONALITY DISORDER is characterized by extreme distrust of others. Paranoid people avoid relationships in which they aren’t in control or have the potential of losing control. Contributing factors • Genetic predisposition • Neurochemical alteration • Parental antagonism Assessment findings • Feelings of being deceived • Suspiciousness, mistrust of friends and relatives • Refusal to confide in others • Hostility • Emotional reactions, including nervousness, jealousy, anger, or envy • Self – righteousness • Social isolation • Sullen attitude • Lack of social support systems • Hyperactivity, especially in children • Delusional thinking • Hypervigilance • Lack of humor • Major distortions of reality • Need to be in control Diagnostic evaluation There are no specific tests for paranoid personality disorder. Nursing diagnoses Anxiety Ineffective individual coping Chronic low self – esteem Social isolation SCHIZOPHRENIC AND DELUSIONAL DISORDERS People with major distortions in ego functioning experience serious disturbance in all areas of their lives, having impaired reality testing and a compromised ability to relate with others. Common signs of impairment in reality testing include bizarre behaviors, inability to assume responsibility for oneself, and misinterpretation of environmental stimuli.

Major disturbances in ego functioning can result from functional causes, such as acute psychosis, or from underlying organic causes related to drug ingestion, high fever, an accumulation of toxins in the body, or dementia. SCHIZOPHRENIA is a brain disease characterized by nueurotransmitter imbalances and structural changes within the brain. Distorted though processes make living with this disease a challenge. Symptoms from schizophrenia may be characterized a positive or negative. Positive symptoms focus on a distortion of normal functions; negative symptoms focus on a loss of normal functions. Overview A. B. C. D. E. Characterized by disordered thinking, delusions, hallucinations, depersonalization (feelings of being strange, not oneself), impaired reality testing (psychosis), and impaired interpersonal relationships. Regression to the earliest stages of development is often noted (e.g., incontinence, mutism) Onset is usually in adolescence/early adulthood. Client may be seriously impaired and unable to perform ADL. Etiology is not known; theories include 1. Genetic: 1% of population; risk approximately 15% with one schizophrenic parent, approximately 30% with two. 2. Family; double – bind communication; message sent in negated. 3. Biochemical; increased dopamine activation. 4. Interaction of predisposing risk and environmental stress. 5. Psychoanalytic; fragile ego resorts to dysfunctional use of defense mechanisms (e.g., identification, projection). Prior to onset (premorbid) client may have been suspicious, eccentric, or withdrawn.

F.

Classifications A. B. Disorganized: incoherent; delusions are not organized; social withdrawal; affect blunted, silly or inappropriate Catatonic: psychomotor disturbances 1. Stupor: mute, little reaction or movement 2. Excitement: purposeless, excited motor activity 3. Posturing: voluntary, inappropriate, bizarre postures Paranoid: delusions and hallucinations of persecution/grandeur Undifferentiated: disorganized behaviors, delusions and hallucinations

C. D.

Contributing factors • A fragile ego, which can’t withstand the demands of external reality • Brain abnormalities • Developmental involvement • Genetic factors • Neurotransmitter abnormalities • Social or environmental stress, interacting with the person’s inherited biological makeup. Assessment A. Four A’s 1. Affect: flat, blunted 2. Associative looseness: verbalizations are disorganized

B. C. D. E. F. G. Analysis

3. Ambivalence: cannot choose between conflicting emotions 4. Autistic thinking: thoughts on self, extreme withdrawal, unable to relate to outside world Any changes in thought, speech, affect Ability to perform self – care activities, nutritional deficits Suicide potential Aggression Regression Impaired communication

Nursing diagnoses for clients with schizophrenic disorders may include A. Anxiety B. Impaired verbal communication C. Ineffective individual/family coping D. Potential for injury E. Altered nutrition F. Powerlessness G. Self – care deficit H. Self – esteem disturbance I. Sensory perceptual alteration J. Sleep pattern disturbance K. Social isolation L. Potential for violence Planning and implementation Goals Client will A. Develop a trusting/therapeutic relationship with nurse B. Be oriented, able to test reality. C. Be protected from injury D. Be able to recognize impending loss of control. E. Adhere to medication regimen. F. Participate in activities. G. Increase ability to care for self. Interventions A. Offer self in development of therapeutic relationship B. Use silence. C. Set time for interaction with client. D. Encourage reality orientation but understand that delusions/hallucinations are real to client. E. Assist with feeding/dressing as necessary F. Check on client frequently, remove potentially harmful objects. G. Contract with client to tell you when anxiety is becoming so high that loss of control is possible. H. Administer antipsychotic medications as ordered. 1. Reduction of hallucinations, delusions, agitation 2. Postural hypotension a. Obtain baseline blood pressure and monitor sitting/standing. b. Client must lie prone for 1 hour following injection. c. Teach client to sit up or stand up slowly. d. Elevate client’s legs while seated.

3. 4. 5.

6. 7.

e. Withhold drug if systolic pressure drops more than 20 – 30 mm Hg from previous reading. Photosensitivity a. Advise use of sun screen. b. Avoid exposure to sunlight. Aganulocytosis a. Instruct client to report sore throat or fever. b. Institute reverse isolation if necessary. Elimination a. Measure I & O b. Check bladder distention. c. Keep bowel record. Sedation a. Avoid use of heavy machinery. b. Do not drive. Extrapyramidal symptoms a. Dystonic ractions 1. sudden contractions of face, tongue extraocular muscles. 2. administer antiparkinson agents prn (e.g benztropine [Gogentin] 1 – 8 mg or diphenhydramine [Bendryl] 10 – 50 mg). which can be given PO or IM for faster relief; trihexyphenidyl [Artane] 3 – 15 mg PO only, can also be used prn). 3. remain with client; this is a frightening experience and usually occurs when medication is started.

Evaluation • The client experiences less confusion in thinking or thought processes. • The client talks about situations and issues that reinforce reality. • The client independently manages daily care • The client doesn’t place self at risk for harm. • The client interacts appropriately with staff, selected peers, and visitors. Treatment • Family therapy • Group therapy • Milieu therapy • Psychoeducational programs • Social skills training • Stress management • Supportive psychotherapy

Symptom classification of schizophrenia Here are example of positive and negative symptoms of schizophrenia. POSITIVE SYMPTOMS

• • • • • •

Bizarre, disorganized, or catatonic behavior Delusions Disorganized speech Hallucinations Loose associations Paranoia

NEGATIVE SYMPTOMS • Disorganized thinking process • Flat affect • Inability to have pleasure (anhedonia) • Lack of motivation • Lack of self – initiated behaviors (avolition) • Poverty of speech (alogia) • Social withdrawal Antipsychotic Medications Drug Cholorpomazine (Thorazine) Acute Symptom 25 – 100 mg IM q1 – 4 h prn Dosages Maintenance/ Day 200 – 600 mg PO Range/Day 25 – 2000 mg PO Profound Side Effects Sedation Anticholinergic effects: dry mouth, blurred vision, constipation, urinary retention, postural hypotension Sedation Extrapyramidal effects: dystonic reactions (muscular contractions of tongue, face, throat; opisthotonos); tremors, rigid posture; akathisia (restlessness); tardive dyskinesia Extrapyramidal Extrapyramidal Sedation, hypotension Extrapyramidal

Thioridazine (mellaril) Fluphenazine HCI (Prolixin, Permitil)

200 – 600 MG PO in divided doses 1.25 mg IM, max 10 mg IM, divided doses

150 – 300 mg PO 1 – 5 mg PO

50 – 800 mg PO 1 – 30 mg PO

Fluphenazine decanoate/enanthate (prolixin, Permitil) Triflueoperazine (Stelazine) Triflupromazine (Vesprin) Perphenazine (Trilafon)

-1 – 2 mg IM q4h; 2 – 4 mg PO, max 10 mg qd 10 – 75 mg IM 5 – 10 mg IM q6h, max 30 mg IM qd

25 mg Im q2wk 2 – 4 mg PO 50 – 150 mg PO/IM 16 – 64 mg PO

25 – 100 mg IM 2 – 80 mg PO 50 – 150 mg PO/IM 4 – 64 mg PO

Haloperidol (Haldol) Thiothixene (Navane) Loxapine (Loxitane) Clozapine (Clozaril)

2 – 10 mg IM in divided doses 8 – 16 mg IM in divided doses ---

2 – 8 mg PO 6 – 10 mg PO 60 – 100 mg PO 300 – 450 mg PO

1 – 100 mg PO 6 – 60 mg PO 30 – 250 mg PO 75 – 700 mg PO

Extrapyramidal Extrapyramidal Extrapyramidal Agranulocytosis; available only with weekly blood testing and client monitoring

Helping the client cope with hallucinations This table details the progression of behaviors and sensations that a schizophrenic client may experience just before and during a hallucination and describes nursing interventions that may help the client cope with these occurrences. After a hallucination, the client may be exhausted. Be sure to allow time for the client to rest or sleep. BEHAVIORS AND SENSATION The client feels anxious or lonely and attempts to cope by daydreaming or seeking out a trusted person. TRUSTING INTERVENTIONS • Lack of structure and feelings of loneliness may precipitate hallucinations. Therefore, provide the client with a highly structured daily routine and engage the client in a structured activity to dissipate anxiety and feelings of loneliness. • Don’t allow the client hours of free time. • Help the client compare internal sensations with external reality. • Engage the client in a structured activity. • Teach the client to hum, whistle, or talk but loud to “crowd out” internal sensations. • Ask the client to identify concrete things in the external environment. • Talk to the client about external reality. • Ask the client to compare the hallucination with external reality. • Use self as a focal point to get the client’s attention and the client to focus on what you’re doing and saying. • Instruct the client to firmly tell the hallucination to go away. • Engage the client in a large – muscle activity. • Have the client focus on external reality. • Do whatever is necessary to get the client’s attention. • Maintain a firm but kindly tone of voice.

The client experiences increasing anxiety, which leads to a state of alertness. The client becomes preoccupied with internal sensations (such as voices and images) and starts to respond to them. Aware that the sensations are internal, the client attempts to control them. As internal sensations become increasingly dominant, the client has trouble controlling them and eventually yields to them.

The client becomes immersed in internal sensations and feels powerless over them. Depending on the nature of the hallucination, the client may become very frightened.

Delusional disorder A delusion is a false belief to which a person adheres despite contradictory evidence. Clients with DELUSIONAL DISORDER hold firmly to false beliefs despite contradictory information. The client with delusional disorder tends to be intelligent and can have a high level of competence but has impaired social and personal relationships. One indication of delusional disorder is an absence of hallucination. The most common types of delusions include: • Delusions of grandeur – belief that one is highly important, famous, or powerful • Delusions of persecution – belief that one is being persecuted or harmed by others. • Delusions of reference – belief that one is connected to events unrelated to himself. Planning and goals • The client won’t harm self or others. • The client will learn alternative coping strategies. • The client will regain normal level of functioning. Implementation • Formulate realistic, modest goals with the client to help diminish suspicion while increasing the client’s self – esteem and sense of control. • Establish a therapeutic relationship to foster trust. • Explore event that trigger delusions to help you understand the dynamics of the client’s delusional system. Discuss anxiety associated with triggering events. • Don’t directly attack the delusion to avoid increasing the client’s anxiety instead, be patient in formulating a trusting relationship. • Once the dynamics of the delusions are understood, discourage repetitious talk about delusions and refocus the conversation on the client’s underlying feelings. As the client identifies and explores feelings, he’ll decrease reliance on delusional thought. • Recognize delusion as the client’s perception of the environment. Avoid getting into arguments with the client regarding the content of delusions to foster trust. • Teach the client alternative coping mechanisms to handle periods of increased anxiety and enhance the client’s self – esteem and self – control. • Review key teaching topics with the client and family members to ensure adequate knowledge about the condition and treatment, including: o Learning decision – making, problem – solving, and negotiating skills. o Understanding potential adverse effects of medication. Evaluation • The client doesn’t harm self or others. • The client demonstrates less suspicious behavior. • The client can identify signs and symptoms of anxiety. • The client identifies factors that precipitate delusions and alternative coping mechanism to handle anxiety. Cocaine – use disorder

Cocaine – use disorder results from the potent euphoric effects of the drug. Individuals exposed to cocaine develop dependence after a very short time. Maladaptive behavior follows, resulting in social dysfunction. Contributing factors  Genetic predisposition  History of abuse, depression, or anxiety  Personality disorder Assessment findings  Assault or violent behavior  Elevated energy and mood  Grandiose thinking  Impaired judgment  Impaired social functioning Diagnostic evaluation  Drug screening is positive for cocaine. Nursing diagnoses  Risk for violence: Self – directed  Risk for violence: Directed at others  Ineffective health maintenance  Imbalanced nutrition: Less than body requirements.

Treatment • Detoxification • Rehabilitation (inpatient or out patient) • Narcotics Anonymous • Individual therapy Drug therapy option • Anxiolytic agent: alprazolam (Xanax),lorazepam (Ativan) • Dopamine agent: bromocriptine(Pardonel) • Seletive serotonin reuptake inhibator: fluoxetine (Prozac), Paroxetine (Paxil) Planning and goals • The client will learn the adverse effects of cocaine on the body. • The client will have adequate nutritionalk intake. • The client won’t harm self or others. Implementation • Establish a trusting relationship with the client to alleviate any anxiety or paranoia. • Provide the client with well- balanced meals to compensate for nutritional deficits. • Provide a safe environment. The client may pose a risk to self or others. • Set limits on the client’s attempts to rationalize behavior to reduce inappropriate behavior • Review key teaching topics with the client and family members to ensureb adequate knowledge about the condition and treatment, including: - contacting narcotics anonymous - coping strategies - managing stress

Evaluation • The client relates the adverse effects of cocaine and verbalizes plans for lifestyle changes and follow –up support • The client has sufficient nutritional intake • The client doesn’t harm self or others during hospitalization Substance abuse disorder Substance abuse disorder includes all patterns of abuse excluding alcohol and cocaine. Abuse disorders have a great deal in common, although symptoms vary depending on the abused substance Contributing factors • Familial tendency • Gender ( female have increased likelihood of abusing prescription drugs; males have generally increase likelihood of addiction) • History of abuse, depression. or anxiety • Influence of nationality and ethnicity • Personality disorders Assessment findings • Attempts to avoid anxiety and other emotions • Attempts to avoid conscious feelings of guilt and anger • Attempts to meet needs by influencing others • Blaming others for problems • Development of biological or psychological need for a substance • Dysfunction anger • Feelings of grandiosity • Impulsiveness • Manipulation and deceit • Need for immediate gratification • Pattern of negative interactions • Possible malnutrition • Symptoms of withdrawal • Use of denial and rationalization to explain consequences of behavior Diagnostic Evaluation • Positive blood and urine drug screening results confirm the diagnosis • Standard alcoholism screening tools, such as the CAGE questionnaire and the Michigan Alcoholism Screening test, in adequate alcoholism Nursing diagnoses • Ineffective health maintenance • Imbalanced nutrition: Less than body requirements • Risk for violence: self directed • Risk for violence: Directed at others

Drug Therapy option • Clonidine (catapres) for opiate withdrawal symptoms • Metyhadone maintenance for opiate addiction detoxification Planning and Goals • The client will learn the adverse effects of substance abuse on the body • The client will have adequate nutritional intake • The client won’t harm self or others • The client will commit to a recovery program and get assistance to maintain abstinence and coping skills Implementation • Ensure a safe, quiet environment free from stimuli to provide a therapeutic setting and to alleviate withdrawal symptoms • Monitor for withdrawal symptoms, such as delirium, tremors, seizures, or anxiety, to provide the most comfortable environment possible • Assess the client for polysubstance abuse to plan appropriate interventions • Help the client to understand the ultimate consequences of substance abuse to assist recovery • Provide measures to induce sleep to help the client manage the discomfort of withdrawal.