Flashcards in Antisocial and Other Personality Disorders Deck (78):
Personality Disorders: Cluster B
Dramatic, emotional erratic characteristics
Antisocial Personality Disorder: Dx criteria
Marked pattern of disregard for and violation of the rights of others since age 15, & 3 or more of the following:
– Failure to conform to social norms as indicated by repeatedly performing acts that are grounds for arrest
– Deceitfulness, lying, conning, using aliases
– Impulsivity, failure to plan ahead
– Irritability, aggressiveness, fights assaults
– Reckless disregard for safety of self and others
– Consistent irresponsibility as in work, finances
– Lack of remorse for actions
• Must be at least age 18
• Conduct Disorder onset before age 15
• Differentiate from actions while abusing substances, & schizophrenia & bipolar diagnoses
APD: Associated Findings
– Lack empathy
– Callous, cynical of rights of others
– Inflated arrogant self-appraisal
– Excessively opinionated, self assured or cocky
– Glib superficial charm, impressive verbal ability
– Irresponsible exploitive in sexual relationships, multiple partners & lack of sustained monogamy
– Possible dysphoria, complaints of tension, boredom, depressed mood
• Psychopath, sociopath
• Chronic course- improves after age 40
• Not always in legal trouble can be in business, politics military (competition rewarded rather than cooperation)
• More men- there are gender differences in expression- see page 516, Box 28.2
APD: Epidemiology/Risk Factors
• 0.2 – 3.3% of the population
• Men more often diagnosed
• 12 month prevalence rates greater among Native Americans and lower among Asians compared with whites
• Comorbid with mood, anxiety, and other personality disorders; alcohol and drug abuse
APD: Etiology (Biologic)
– Emotional distancing, aggression, impulsivity from neural dysfunction
– Moral judgment impairment - dysfunction of prefrontal cortex
– Fearlessness- lack of activation of limbic prefrontal circuit during fearful situations
– Unsatisfactory attachments; difficult temperament
– Chaotic families
– Abuse or neglect, domestic violence
APD: Nursing Assessment
• Initial Nursing Assessment
• Mental Status Exam including suicidality (10% completion rate)
• Physical effects of chronic use of addictive substances
• Determine the quality of relationships, impulsivity, and the extent of aggression
• Legal issues
APD: Nursing Dx
• Dysfunctional family processes, alcoholism
• Disturbed thought processes
• Risk for other-directed violence
• Risk for self-directed violence
• Ineffective role performance
• Impaired social interactions
APD: Nursing Interventions
• Help develop positive interaction skills
– Problem-solving groups
– Communication techniques
– Address distorted cognitive schema
– Teach empathy
• Milieu interventions-experience consistency
– Refrain from arguing or bargaining about rules
– Give positive feedback for accepting additional responsibility
• Help build a new support system
• Positive health care practices including appropriate use of substances
• Effective communication & interaction skills
• Impulse control
• Anger management
• Group experience to help develop self-awareness & impact of behavior on others
• Analyzing an issue from another persons’ point of view
• Maintenance of employment
• Interpersonal relationships & social interactions
• Evaluate in terms of specific problems
– (ex. maintaining employment, adherence to treatment recommendations, interpersonal relationship stabilization)
• Often will need to establish a new social network as the previous ones are gone.
Histrionic Personality Disorder
A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, in 5 (or more) of the following:
1. Is uncomfortable in situations in which he or she is not the center of attention.
2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
3. Displays rapidly shifting & shallow emotions.
4. Consistently uses physical appearance to draw attention to self.
5. Has a style of speech that is excessively impressionistic and lacking in detail
6. Shows self-dramatization, theatricality, and exaggerated expression of emotion.
7. Is suggestible (i.e., easily influenced by others or circumstances).
8. Considers relationships to be more intimate than they actually are.
Histrionic Personality Disorder: Etiology
minimal research on biological or genetic factors, parental role model, irregular reinforcement in childhood from multiple caregivers
Histrionic Personality Disorder: Treatment
goal is to correct the expectation that others are needed to fulfill all their needs
Histrionic Personality Disorder: Assessment
childhood social disapproval or deprivation; quality of the individual’s interpersonal relationships, self esteem
Histrionic Personality Disorder: Nursing Dx
chronic low self-esteem, ineffective coping, ineffective sexual patterns
Histrionic Personality Disorder: Interventions
therapeutic relationship, independent decision making, express confidence in ability to handle situations, reinforcement of personal strengths, support autonomous action, assertiveness groups
Histrionic Personality Disorder: Outcomes
Improved confidence & interpersonal relationships, ability to solve own problems and handle own needs
Narcissistic Personality Disorder
Pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Has a grandiose sense of self-importance
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
4. Requires excessive admiration.
5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
8. Is often envious of others or believes that others are envious of him or her.
9. Shows arrogant, haughty behaviors or attitudes.
Narcissistic Personality Disorder: Epidemiology
men 7.7% > women 4.8%
Narcissistic Personality Disorder: Etiology
little evidence of biologic factors; possible result of parents’ overvaluation and overindulgence of a child vs. cannot function independently due to lack of emotional separation from primary caregiver vs. strategy to reduce intense feelings of shame
• Found more often in celebrities & highly respected professions such as law, medicine and science, only children, first born males in cultures where males get special privileges, children of narcissistic people
Narcissistic Personality Disorder: Nursing Management
-Seen in medical settings more than mental health
-World defined through their self-centered view
-Use self-awareness skills & supervision when interacting
-Difficult to establish therapeutic relationship
-Work with their goals
-Focus on responses to other health care problems
Personality Disorders: Cluster A
• Odd or eccentric behavior
Paranoid Personality Disorder
Pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by 4 (or more) of the following:
1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
4. Reads hidden demeaning or threatening meanings into benign remarks or events.
5. Persistently bears grudges
6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.
Does not occur exclusively during the course of a psychotic disorder and is not from the physiological effects of another medical condition.
• Want to appear in control & objective but negative emotions show (nervousness, anger, envy, jealousy)
• Often have job problems
• Uses projection to attribute own feelings to others
• Won’t seek help unless decompensates into psychosis
-->its not usually seen for mental health problems initially
Paranoid Personality Disorder: Prevalence
Paranoid Personality Disorder: Etiology Theories
• Possible neurochemical transmission acceleration
• Genetic predisposition
• Excess limbic & sympathetic nervous system reactivity
Paranoid Personality Disorder: Assessment
Disturbed or illogical thoughts reflecting misinterpretation of environmental stimuli
Paranoid Personality Disorder: Nursing Dx
-Disturbed thought processes
-Social isolation not a relevant nursing diagnosis since they do not meet the defining characteristics of feelings of aloneness rejection desire for contact with people
Paranoid Personality Disorder: Nursing Interventions
-Therapeutic relationship - hard to establish trust
-Identification of problem areas like getting along with others, keeping a job, or other health issues
-Work on a different view of the problem area
-Techniques: acceptance, develop discrepancy (help them deal with their medical issue before their mental health issue), reflection
Paranoid Personality Disorder: Outcomes
-Change occurs over time
-Thought patterns will be less paranoid
Schizoid Personality Disorder
A pervasive pattern of DETACHMENT from social relationships and a restricted range of expression of emotions in interpersonal settings, begins in early adulthood and present in a variety of contexts, as indicated by 4 (or more) of the following:
1. Neither desires nor enjoys close relationships, including being part of a family.
2. Almost always chooses solitary activities.
3. Has little, if any, interest in having sex with another person.
4. Takes pleasure in few, if any, activities.
5. Lacks close friends or confidants other than first-degree relatives.
6. Appears indifferent to the praise or criticism of others.
7. Shows emotional coldness, detachment, or flat affect.
*schizoiD = Detachment
Schizoid Personality Disorder: Etiology
– Possible defects in limbic or reticular regions of brain
• Rarely diagnosed in clinical settings, more seen in med-surg with other health problems
• Working with these clients can be unrewarding and the nurse may feel frustrated or helpless. The nurse needs to focus on being self-aware and seek supervision if this happens.
• May be attached to animals.
Schizoid Personality Disorder: Nursing Assessment
social skills, interpersonal relationships, pleasurable activities
Schizoid Personality Disorder: Nursing Dx
impaired social interaction, chronic low self-esteem
Schizoid Personality Disorder: Interventions
-Provide social skill training
-Encourage social interactions
Schizoid Personality Disorder: Outcomes
-Enhance experience of pleasure
-Prevent social isolation
-Improved social skills
-Increased satisfaction with solitary activities
Schizotypal Personality Disorder
A pervasive pattern of social and interpersonal deficits marked by ACUTE DISCOMFORT with, and reduced capacity for, close relationships as well as by COGNITIVE OR PERCEPTUAL DISTORTIONS and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Ideas of reference (excluding delusions of reference).
-happening to you and only you (but in reality it isn't)
2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (superstitions, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations).
3. Unusual perceptual experiences, including body illusions.
4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).
-not smiling or engaging, cold
5. Suspiciousness or paranoid ideation.
6. Inappropriate or constricted affect.
7. Behavior or appearance that is odd, eccentric, or peculiar.
8. Lack of close friends or confidants other than first-degree relatives.
9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.
Schizotypal Personality Disorder: Epidemiology
lifetime prevalence of 3.9%
men > women
Schizotypal Personality Disorder: Etiology
Magnetic Resonance Imaging-MRI shows REDUCED gray matter in brain but not as much as in schizophrenia
--> Schizotypy refers to traits similar to schizophrenia but less severe
Schizotypal Personality Disorder: Nursing Assessment
-Eccentricities & odd beliefs
-Appearance & behavior
-Pattern of social interactions
-History of psychosis under stress (minutes to hours)
-Depression (30-50% co-morbidity)
--> if you know pt is schizotypal, you'll want to assess for depression too
Schizotypal Personality Disorder: Nursing Dx
Social isolation, ineffective coping, low self-esteem, and impaired social interactions
--> If severe may have disturbed sensory perception
Schizotypal Personality Disorder: Nursing Interventions
Depend on degree of decompensation
-Antipsychotic medications may be useful in reducing some symptoms
-Provide social skills training
-Reinforce appropriate dress & behavior
-Focus on enhancing cognitive skills
Personality Disorders: Cluster C
Appear anxious or fearful
3. Obsessive compulsive
Avoidant Personality Disorder
Pervasive pattern of social inhibition, feelings of INADEQUACY, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.
2. Unwilling to get involved with people unless certain of being liked.
3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
4. Preoccupied with being criticized or rejected in social situations.
5. Inhibited in new interpersonal situations because of feelings of inadequacy.
6. Views self as socially inept, personally unappealing, or inferior to others.
7. Very reluctant to take personal risks or engage in any new activities because they may prove embarrassing
-Timid, shy, hesitant, fear of criticism, and feelings of inadequacy
-Extremely sensitive to negative comments and disapproval
Avoidant Personality Disorder: Epidemiology
prevalence of 2.4% in general population but 10% of outpatients in mental health clinics.
Avoidant Personality Disorder: Etiology
more frequent and excessive response to aversive stimuli, may have more neurons in the aversive center of the limbic system.
Avoidant Personality Disorder: Assessment
lack of social contacts, a fear of being criticized, evidence of chronic low self- esteem
Avoidant Personality Disorder: Nursing Dx
chronic low self-esteem, social isolation, and ineffective coping
Avoidant Personality Disorder: Interventions
-No negative criticism
-Identification of positive responses from others
-Exploration of previous achievements
-Exploration of reasons for self-criticism
-Social skills training
-ID & increase activities that improve self esteem
-Support to stay in long term therapy
Dependent Personality Disorder
Pervasive and EXCESSIVE NEED TO BE TAKEN CARE OF that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
2. Needs others to assume responsibility for major life areas.
3. Difficulty expressing disagreement with others because of fear of loss of support or approval.
4. Difficulty initiating projects or doing things on his or her own (lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).
-ex. ask others to choose their job for them
5. Excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself.
7. Urgently seeks another relationship as a source of care and support when a close relationship ends.
8. Unrealistically preoccupied with fears of being left to take care of himself or herself.
• Withdraws from adult responsibilities
• Warm, tender, gullible
Dependent Personality Disorder: Epidemiology
prevalence of 0.49%
women > men
Dependent Personality Disorder: Etiology
No research supports a biologic predisposition. Result of parents’ genuine affection, extreme attachment, and overprotection causing lack of skill development for autonomy.
Dependent Personality Disorder: Assessment
self-worth, interpersonal relationships, and social behavior, history of therapy
Dependent Personality Disorder: Nursing Dx
ineffective individual coping, low self-esteem, impaired social interaction, impaired home maintenance management
Dependent Personality Disorder: Interventions
help recognize dependent patterns, motivate to change, teach adult skills that have not been developed, support to make their own decisions, define outcomes for therapy as may get dependent on therapist
Dependent Personality Disorder: Outcomes
-Improved decision-making skills (will cling to nurse as well)
-Improved interpersonal relationships.
Pervasive pattern of preoccupation with ORDERLINESS, perfectionism, and mental and interpersonal control, at the EXPENSE OF FLEXIBILITY, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
1. Preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
2. Perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met).
3. Excessively devoted to work and productivity to the exclusion of leisure activities and friendships
4. Overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
5. Unable to discard worn-out or worthless objects even when they have no sentimental value.
6. Reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.
7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for a future catastrophe.
8. Rigid and stubborn.
OCPD vs Obsessive Compulsive ANXIETY Disorder
Obsessive Compulsive Anxiety Disorder: has obsessions and compulsions & lacks the capacity to delay rewards.
• OCPD has the pervasive pattern of preoccupation with orderliness, perfectionism, and control
-Uncomfortable with unstructured leisure time
-Formalized leisure activities (season tickets)
-Need to control others
-Tense, joyless mood
-Capacity to delay rewards
-prevalence of 2.1 -7.9%
-associated with higher education & income, employment, and marriage
no biologic connection; parental over control and overprotection (play is shameful, irresponsible)
• Seek care for attacks of anxiety, spells of immobilization, sexual impotence, excessive fatigue
• They realize they can improve their quality of life.
OCPD: Nursing Assessment
focus on patient’s physical symptoms (sleep, eat, sexual), interpersonal relationships, social problems
OCPD: Nursing Dx
-anxiety, risk for loneliness, decisional conflict
-sexual dysfunction, insomnia
-impaired social interactions
-Teach anxiety reduction measures (relaxation techniques, challenge cognitive distortions)
-Examine beliefs underlying dysfunctional behavior
-Accept the patient’s need for order and rigidity
-Administer pharmacotherapy short term for depression or anxiety
-Support long term psychotherapy
Disruptive, Impulse Control & Conduct Disorders
*not a PERSONALITY disorder
Irresistible impulsivity to do harmful behavior, tension prior to behavior, gratification then remorse.
1. Intermittent Explosive Disorder
(Conduct Disorder & Oppositional Defiant Disorder are childhood disorders covered in the mental health class instead of this one.)
Intermittent Explosive Disorder
Recurrent behavioral outbursts with aggressive impulses as manifested by either of the following:
1. Verbal aggression or physical aggression toward property, animals, or people, occurring twice weekly, on average, for a period of 3 months. The physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or people
2. Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period
B. Aggression is grossly out of proportion to the provocation or to any precipitating psychosocial stressors.
C. Outbursts are not premeditated (i.e., they are impulsive and/or anger-based) and are not committed to achieve some tangible objective (e.g., money, power, intimidation).
D. Outbursts cause either marked distress in the individual or impairment in occupational or interpersonal functioning, or are associated with financial or legal consequences.
E. At least 6 years old (or equivalent developmental level).
F. Outbursts are not part of another mental disorder.
-->assault and property destruction (43X lifetime average)
Intermittent Explosive Disorder: Prevalence/Epidemiology
-Mean childhood onset 14 years old
-More often in those with high school education or less
-Suicidality is a concern
Intermittent Explosive Disorder: Assessment
history of aggression, consequences (personal, legal, financial, occupational)
Intermittent Explosive Disorder: Nursing Dx
potential for injury to self & others, ineffective coping
Intermittent Explosive Disorder: Nursing Interventions
-Antidepressants increasing serotonin
-Anticonvulsants used for mood stabilization
-Mood stabilizers, such as lithium (Lithobid)
-Anti-anxiety agents in the benzodiazepine family however can be addicting
-Anger management training
-Support ongoing psychotherapy
1. Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value.
2. Increasing sense of tension immediately before committing the theft.
3. Pleasure, gratification, or relief at the time of committing the theft.
4. Stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination.
5. Stealing is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.
-Kleptomania coined in 1838 to describe several Kings who compulsively stole worthless objects
-Females outnumber males 3 to 1
-Population prevalence rare 0.3 to 0.6% but it occurs in 4 to 24% of people arrested for shoplifting
-Lasts for years in spite of numerous convictions
-Difficult to detect & treat
1. Deliberate and purposeful fire setting more than once.
2. Tension or affective arousal before the act.
3. Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts
4. Pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath.
5. Not done for monetary gain, to express sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one’s living circumstances, in response to a delusion or hallucination, or as a result of impaired judgment, intellectual disability, intoxication.
6. The fire setting is not better explained by another mental illness.
-May be fire watchers or firefighters
-Mostly men, never married, young, & have other psychiatric problems
-Low serotonin and norepinephrine levels
interpersonal skills, self esteem, depression, management of anger
Risk for other-directed violence
Anger management, problem solving skills, relaxation exercises, behavior management with token reinforcement