Exam 3: Personality, impulse, control, and conduct disorders Flashcards
key terms
-personality: a complex pattern of characteristics, largely outside of the person’s awareness, that comprise the individual’s distinctive pattern of perceiving, feeling, thinking, coping, and behaving.
-personality traits: prominent aspects of personality that are exhibited in a wide range of social and personal contexts-intrinsic and pervasive, personality traits emerge from a complicated interaction of biologic dispositions, psychological experiences, and environmental situations that ultimately comprise a distinctive personality.
-personalities are viewed on a continuum from normal. many of the same processes involved in the development of a “normal” personality are responsible for the development of a personality disorder.
personality disorder diagnosis
based on abnormally inflexible behavior patterns of long duration, traced to adolescence or early adulthood, that deviate from acceptable cultural norms.
-leads to distress or impairment
oppositional defiant disorder and conduct disorder are CHILDHOOD DIAGNOSES.
-many do not seek treatment for the distress or impairment related to their personality disorder because they do not perceive themselves as having a problem
-frequently seek help for concurrent medical or mental health disorders
personality disorder clusters
cluster A: exhibit odd or eccentric behavior
-paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder
cluster B: exhibit dramatic, emotional, or erratic behavior
-borderline, antisocial, histrionic, narcissistic personality disorders
cluster c: appear anxious or fearful
-avoidant, dependent personality disorders
cluster b: borderline personality disorder
disruptive/pervasive pattern of instability related to self-identity, interpersonal relationships, and affect, combined with marked impulsivity and destructive behavior.
manifestations of borderline personality disorder
-often set unrealistically high expectations for themselves. when these are not met, they experience intense shame, self-hate, and self-directed anger
-react emotionally with minimal coping skills, the intensity of their emotions often frightens them and others.
-DICHOTOMOUS THINKING: cognitively, they evaluate experiences, people, and objects in terms of mutually exclusive categories (good or bad, success or failure, trustworthy or deceitful), which results in extreme interpretations of events that would normally be viewed as including both positive and negative aspects
-problems with mood regulation, self-identity, maintaining interpersonal relationships, maintaining reality-based thinking, and avoiding impulsive or destructive behavior
-problems include unstable relationships, self-image, and affects as well as cognitive dysfunctions (dichotomous thinking, dissociation to avoid awareness of disturbing events) and impulsivity
-self harm behaviors are characteristic when under stress and used to relieve this
-co-exists with other mental disorders such as mood, substance abuse, eating , dissociative, and anxiety disorders, and other personality disorders
-extreme fear of abandonment, difficulties regulating emotions, chaotic behavior, intense shame and self-hate
-NUTRITIONAL PATTERNS due to high occurrence of eating disorder
-frantic efforts to avoid real or imagined abandonment
-pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
-identity disturbance: markedly and persistently unstable self-image or sense of self
-impulsivity in at least two areas that are potentially self-damaging, such as spending, sex, substance use, reckless driving, binge eating
-recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
-affective instability due to marked reactivity of mood (intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days
-chronic feelings of emptiness
-inappropriate intense anger of difficulty controlling anger- frequent displays of temper, constant anger, recurrent physical fights
-transient stress- related paranoid ideation or severe dissociative symptoms
-everything is someone else’s fault
-splitting: viewing the world in absolutes (ex-nurses are alternately categorized as all good or all bad
-thinking and behavior are disrelated, aggressive impulsivity, problems in daily living, including maintaining intimate relationships, keeping a job, and living within the law
etiology of cluster B: borderline personality disorder
-evidence of CNS dysfunction, including possible structural changes
-psychoanalytic methodology suggests persons with BPD have not achieved the normal and health developmental stage of separation-individuation
-emotional dysregulation: inability to control emotions in social interactions- invalidating environment: negates emotional responses
-physical and sexual abuse seem to be significant risk factors
-traumatic life events such as parental divorce, illness, or parental psychopathology may be risk factors
-women more often diagnosed
-usually late adolescence or early adulthood diagnosis
treatment of BPD
-psychotherapy needed to help the individual with BPD manage the dysfunctional moods, impulsive behavior, and self-injurious behaviors
-PATIENTS AT HIGH RISK FOR SELF HARM AND SUICIDE
-requires collaboration of the entire mental health care team. due to seeing the world in absolutes, nurses and team members are alternately categorized as all good or all bad. this presents as a challenge to working openly with each other as well as with the patient until the issue can be resolved through team meetings and clinical supervision.
DBT IS NUMBER ONE FORM OF TREATMENT FOR BORDERLINE PERSONALITY DISORDER
-inadvertent stigma for people with BPD by clinicians, often times in crisis settings such as the ED, crisis clinics, or general psychiatric inpatient wards- typically these are not treatment settings so biased perspective is developed (few clinicians see patients improve over time)
-medications include mood stabilizers, antidepressants, and atypical antipsychotics
psychological assessment for BPD
-inhibited grieving-pattern of repetitive, significant trauma and loss- unresolved grief
-disheveled appearance can reflect depression or an agitated state, tend to be dramatic in style of dress with unusual hairstyles of heavy makeup.
-impulsivity
-dichotomous thinking- cognitive disturbances
-identity disturbance: loss of capacity for self-definition
-dissociation and transient psychotic symptoms
-interpersonal skills: ask about intimate relationships, as need for closeness clouds judgment of others
-limiting coping ability
BPD patients and the nurse
psychiatric mental health RNs do not!!! function as the patient’s primary therapists
-nurse models self-respect by observing personal limits, being assertive, and clearly communicating expectations.
care of the patient with BPD
-physical care: sleep hygiene, nutritional balance, preventing self-harm, use five sense exercise
-pharmacologic interventions and monitoring
-prevent and treat self-harm- assess for drugs or alcohol and ask direct questions
-psychosocial interventions: address abandonment and intimacy fears, boundaries, limits, behavioral interventions, challenge dysfunctional thinking, educate patient and DBT!
-ask open ended questions, find patterns, help find coping skills
treatment strategies: DEARMAN= describe, express, assert, reinforce, mindful, appear confident, negotiate: how to ask for something of someone while maintaining a relationship with them.
cluster B: antisocial personality disorder (ASPD)
marked pattern of disregard for and violation of the rights of others
-lack of regard for others, lack of compassion, may show compassion as a facade -manipulative
-anti “social norms”
-previously references as psycho or sociopath
-chronic course
-arrogant, self-centered, feel privileged and entitled
-interpersonally engaging and charming
-lack empathy or human compassion
-deceitful and manipulative
-hasty, temperamentally aggressive, short-sited
ASPD diagnosis
-must be at least 18 years old and have exhibited one or more childhood behavioral characteristics of conduct disorder before the age of 15: aggression to people or animals, destruction of property, deceitfulness or theft, or serious violation of rules
-associated with mood, anxiety, and other personality disorders
-strongly associated with alcohol and drug abuse- DIAGNOSIS IS NOT WARRANTED IF THE ANTISOCIAL BEHAVIOR OCCURS ONLY IN THE CONTEXT OF SUBSTANCE ABUSE
-deceit and manipulation for personal profit or pleasure are central features associated with this disorder
etiology of aspd
-biologic: MRI studies support neural basis of fearlessness in individuals
-psychological: unsatisfactory attachments in early relationships, difficult temperament
-social: chaotic families, abuse or neglect, domestic violence, alcoholism and violence in home.
-failure to make or sustain stable attachments in early childhood can lead to avoidance of future attachments. risk factors include parental abandonment or neglect, loss of parent or primary caregiver, physical or sexual abuse. parents with attachment problems may be unable to form them with own children.
nursing care for aspd
-self responsibility
-self awareness
-education
-promoting safety
-anger management
-group modalities
-milieu interventions offer structured environment
-consistent rules
-wellness strategies
-smoking cessation
-family interventions
-establishing boundaries (especially with family due to long term pattern of interaction and family potentially feeling responsible for client’s behavior)
cluster b: histrionic personality disorder
attention seeking, excitable, emotional, insatiable need for attention and approval,
-moody, sense of helplessness when others disinterested
-sexually seductive to gain attention, uncomfortable with single relationship, provocative appearance, dramatic speech
-lack of loyalty and fidelity
-affected individuals are lively and dramatic and draw attention to themselves by their enthusiasm, dress, and apparent openness. they are life of the party and on the surface seem interested in others. their insatiable need for attention and approval quickly becomes obvious- strong need to be center stage.
nursing management of histrionic personality
-assess social disapproval or deprivation- may prompt person to seek mental health care, focus on quality of individuals interpersonal relationships
-interventions: specific goal establishment, prevent dependency on mental health system, foster therapeutic relationship allowing patient to explore positive personality characteristics and develop independent decision making, covey confidence in patient ability to handle situations, reinforce personal strengths, encourage autonomous action, assertiveness groups
-may indicate low self-esteem in assessment, as they believe they are incapable of handling life’s demands and have been waiting for someone to take care of them- have not developed positive self-concept or adequate problem-solving abilities
care of patients with histrionic personality
priority of care areas for people include focusing on self-esteem and coping patterns. outcomes focus on helping the patient develop autonomy, a positive self-concept, and mature problem-solving skills.
-reinforce personal strengths
-encourage patient to act autonomously
-REDIRECT! sometimes, pay no mind to them.
cluster B: narcissistic personality disorder
grandiose with an inexhaustible need for admiration
-view self as superior, special, self-centered, entitled, arrogant, unable to show empathy, avoid self- reflection. striking sense of entitlement. often preoccupied with fantasies of unlimited success, power, beauty, or ideal love. overvalue personal worth, direct affections toward themselves, and expect others to hold them in high esteem. define the world through their own self-centered ciew.
-often successful in jobs but may alienate their significant others who grow tired of their narcissism.
etiology: little evidence of biological factors, possible result of parents’ overevaluation and overindulgence of child
nursing management of narcissistic personality disorder
-nurse self-awareness
-focus on coexisting responses to other health care problems
-likely to be treated within the community for most of their lives
cluster C: avoidant personality disorder
avoidance of social situations, timid, shy, hesitant, fear of criticism, and feelings of inadequacy.
-extremely sensitive to negative comments and disapproval, extreme fear of rejection
-perceive self as socially inept, inadequate, inferior
-engage in interpersonal relationships only when assured of uncritical acceptance
etiology: may possess an overabundance of neurons in the aversive center of limbic system, resulting in experiencing aversive stimuli more intensely and more frequently than others
nursing care of avoidant personality disorder
assessment: lack of social contacts, fear of criticism, chronic low self esteem
interventions: no negative criticism, help patient identify positive responses from others, explore previous achievements, explore reasons for self-criticism, social skills training.
cluster C: dependent personality disorder
cling to others in a desperate attempt to keep them close; intense need to be taken care of
-total submission and disregard for self
-decision making difficult or nonexistent
-withdrawal from adult responsibilities
etiology: biologic predisposition likely, but currently there is no evidence of biologic hypothesis; usually explained as a result of parents’ genuine affection, extreme attachment, and overprotection, teaching child to rely on others to meet basic needs.
nursing care for dependent personality disorder
assessment: self-worth, interpersonal relationships, social behavior
interventions: help recognize dependent patterns, motivate desire for change, teach adult skills that have not been developed, support patient to make own decisions, administer meds such as antidepressants or antianxiety agents, assertiveness training- patients readily seek treatment and likely spend years seeking therapy. hospitalization may occur for comorbid conditions such as depression.
cluster C: obsessive compulsive personality disorder
different from OCD as there are no obsessions and compulsions.
pervasive pattern of preoccupation with orderliness, perfectionism, and control- may be completely devoted to work, uncomfortable with unstructured leisure time, formalized leisure activities, serious approach to hobbies, conscious of appearance, constant need of control
distinct features:
1-need for order and control over others
2-hoarding and indecision where they are prone to repetition, and difficulty making decisions due to over-involvement with details
-may be over conscientious regarding morality, ethics, tendency to be rigid, stubborn, and unable to accept new ideas.
-tense, joyless mood
-associated with higher education, employment, and marriage
etiology: no apparent biologic connection, restrictive parental-over control and overprotection, with children learning a deep sense of responsibility to others and feeling guilty when responsibilities are not met
