Personality

Personality is all about the most essential psychological aspects of a persons life our thoughts, feelings, motives, skills, and behaviors. The term is coined from the Latin word persona meaning mask. Personality disorder are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of important social and personal contexts that cause significant functional impairment or subjective distress Personality disorder characteristics It is EGO SYNTONIC FEELS LIKE NORMAL PART OF ONES SELF Itis stable with time, and leads to distress or impairment It is RIGIDpervasive and inflexible it has an onset in adolescence or early adulthood Other features: Most have interpersonal problems Can be difficult to diagnose in initial session INTRACTABLEwhich makes it difficult to treat Can affect treatment of other disorders PROBLEMS SEEN IN PERSONALITY DISORDER Poor impulsive control Dysphoria(disorder of affect characterized by depression and anguish ) Impaired judgment Distorted self-perception Attention, concentration, retention are often impaired Speech lacks clarity and focus Difficulty in maintaining a healthy lifestyle Lack of hygieneand poor grooming Excessive sleep and Chronic inactivity

POSSIBLE CAUSES OF PERSONALITY DISORDER 1. BIOLOGICAL FACTOR Genetic/Hereditary factors Person who has family history of psychiatric disorder such as alcoholism, drug addiction or schizophrenia have a genetic predisposition to PD that fit cluster A. Cluster B PD has a higher incidence in identical twins. Brain Chemistry. Disturbance or imbalance of dopamine and serotonin neurotransmitter.

Autonomic Nervous system Hypothalamus hypometabolism. According to Kerberg( 1933 ), pain activates the punishing center of the hypothalamus. Ex. Infant whose orientation to is based on hurtingtend to cope by using greater amount of aggression. It is this excessive aggression that powers the development of borderline, passive-aggressive, histrionic, and narcissistic personality disorders. Hormonal Increased level of androgens (substance that stimulates or produce male characteristics, as the male hormone) Increase level of estrone, estradioland testosterone (seen in people with impulsive behavior) Increased noradrenergic metabolites (seen in gamblers and people demonstrating sensation seeking behavior). 2. SOCIOCULTURAL FACTORS Paranoid individuals have often been subjected to parental antagonism, serving as scapegoat for displaced parental aggression. Schizoid individuals have childhood that is bleak, cold unemphaticand devoid of nurturance and support. Schizotypalindividuals have family dynamics characterized by parental indifference, impassivity or formality, closeness feels neither natural nor comfortable, and social skills are not developed. Antisocial individuals are seen to come from a chaotic home, environment in which the intermittent appearance of impulsive parentsdoes more harm than good. The prominent feature of families of children who later develop obsessivecompulsion was parental over control. (Parents expected their children to live up impossible standards and then condemned them when they failed) Contradictory parental attitudesand inconsistent training method as major factors in the development of passive-aggressive PD. (children may received the kindness and support they crave, or they may be the recipient of hostility and rejection at any moment without provocation.) 3. PSYCHODYNAMIC FACTOR Underdeveloped EGO and SUPEREGO Inadequate and inconsistent parenting result in individuals who do not complete developmental task related to autonomy and separation. Clients who developed PD encounter difficulties at the individuals separation stage of development, (18 month to 2 years) 4. BEHAVIORAL FACTOR Behaviors are learned. Children repeat actions that bring those rewards and avoid actions that incur punishments.

Behaviorthat has been consistently rewarded (IGNORED)from infancy and before the development of understanding, cognition, and language, is the most difficult to unlearn or modify.

DSM-IV GENERAL CRITERIA FOR PERSONALITY DISORDER A.Enduring pattern of inner C.Pattern leads to clinically experience and behavior that significant impairment or distress deviates markedly from cultural expectations. Manifested in two or D.Pattern is stable and of long more of the following areas: duration and onset can be traced 1)Cognition to adolescence or early childhood 2)Affect 3)Interpersonal functioning E.Pattern not better accounted for 4)Impulse control as a manifestation of another disorder B.Pattern is inflexible and pervasive across a broad range of F.Not due to substance abuse or personal and social situations general medical condition (e.g., head trauma) Person must meet the general criteria before a specific PD is diagnosed Coded on Axis II CLUSTER ORGANIZATION IN DSM-IV TR PDs are classified within clusters defined by common features 1)Cluster A Main feature is odd or eccentric in nature 3 PDs in this cluster: PARANOID PDcharacterized by irrational suspicions and mistrust of others. SCHIZOID PDlack of interest in social relationships, seeing no point in sharing time with others, anhedonia, introspection SCHIZOTYPAL PDcharacterized by odd behavior or thinking 2)Cluster B Main feature is dramatic, emotional, or erratic 4 PDs in this cluster: ANTISOCIAL PDa pervasive disregard for the law and the rights of others BORDERLINE PDextreme "black and white" thinking, instability in relationships, selfimage, identity and behavior and mood impulsivity HISTRIONIC PDpervasive attention-seeking behavior including inappropriate sexual seductiveness and shallow or exaggerated emotions

NARCISSISTIC PDgrandiosity, need for admiration, self-centered, NO EMPATHY 3)Cluster C Main feature involves anxiety or fearfulness 3 PDs in this cluster: DEPENDENT PD submissive, pervasive need to be taken cared of by others

AVIOIDANT PD social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation and avoidance of social interaction OBSESSIVE-COMPULSIVE PD orderliness, perfectionism, needs to control things, characterized by rigid conformity to rules, moral codes and excessive orderliness

Paranoid personality Paranoid personality disorder is characterized by a distrust of others and a constant suspicionthat people around you have sinister motives. People with this disorder tend to have excessive trust in their own knowledge and abilities and usually avoid close relationships with others. They search for hidden meanings in everything and read hostile intentions into the actions of others. They are quick to challenge the loyalties of friends and loved ones and often appear cold and distant to others. They usually shift blame to others and tend to carry long grudges. PARANOID PERSONALITY DISORDER CHARACTERISTICS BASED ON DSM-IV TR Suspects without sufficient basis that others are exploiting, harming or deceiving him Is preoccupied with unjustified doubts about the loyaltyand trustworthiness of friends or associates, spouseor sexual partners Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him Reads hidden demeaning or threatening meanings into benign remarks or events Persistently bears grudges that is, is unforgiving of insults, injuries, or slights Perceives attacks on his character or reputation that are not apparent to others and is quick to react angrily or to counterattack FUNCTION: Extreme mistrust and suspiciousness. Very private and uses projectionas a defense mechanism. HYPERVIGILANT Characteristic: SUSPECT S: Suspicious of others U: Unforgiving

S: Spousal infidelity suspected P: Perceives attack and reacts quickly E: Enemy or friend ONLY C: Confiding in others not possible T: Threatened by benign events NURSING INTERVENTION ESTABLISH RAPPORT Business like approach Being on time Keeping commitments Being particularly straightforward INDIVIDUAL PSYCHOTHERAPY Teach client to validate ideas before taking action Involve client in the treatment plan PSYCHOPHARMACOLOGY Low dose antipsychotics for chronic cognitive problems and perceptual Antianxiety/Anxiolytics Antidepressants

SCHIZOID PERSONALITY DISORDER People with schizoid personality disorder avoid relationships and do not show much emotion. They genuinely prefer to be alone and do not secretly wish for popularity. They tend to seek jobs that require little social contact. Their social skills are often weak and they do not show a need for attention or acceptance. They are perceived as humorless and distant and often are termed loners SCHIZOID PERSONALITY DISORDER CHARACTERISTERICS BASED ON DSM-IV TR They choose solitary activities that do not require much participation with others They may be very adept at computer or mathematical games There is little interest in sexual activity with another person There are no close friends except possibly first degree relatives They dont care about others opinion Affect is flattened appearing cold and aloof FUNCTION: Withdrawn, last to catch up in fashion, introverted, aloof, has solitary lifestyle. Characteristic: DISTANT D: Detached (flattened affect) I: Indifference to criticism and praise S: Sexual experience of little interest T: Task done solitarily

A: Absence of close friends N: Neither desires nor enjoys close relations T: Takes pleasure in some preferred activities Computer games NURSING INTERVENTIONS Improve client functioning in the community The client has a greater chance of success if he/she can relate or confide his/her needs to one person PSYCHOPHARMACOLOGY: Antipsychotics Antidepressants Anxiolytics

SCHIZOTYPAL PERSONALITY DISORDER Many believe that schizotypalpersonality disorder represents mild schizophrenia. The disorder is characterized by odd forms of thinking and perceiving, and individuals with this disorder often seek isolation from others. They sometimes believe to have extra sensory ability or that unrelated events relate to them in some important way. They generally engage in eccentric behavior and have difficulty concentrating for long periods of time. Their speech is often over elaborate and difficult to follow. SCHIZOTYPAL PERSONALITY DISORDER CHARACTERISTERICS BASED ON DSM-IV TR Ideas of reference (excluding delusions of reference) Odd beliefs or magical thinking that influences behavior and is inconsistent with sub-cultural norms, superstitious beliefs in Clairvoyance Telepathy Sixth sense Odd thinking and speech Vague Circumstantial Metaphorical Overelaborate Inappropriate or constricted affect FUNCTIONS: Poorly developed social skills, odd eccentric behavior. Characteristic: PECULIAR P: Paranoid ideation E: Eccentric behavior or appearance

C: Constricted or inappropriate affect U: Unusual (odd) thinking and speech L: Lacks close friends I: Ideas of reference A: Anxiety in social situations R: Rule out psychotic disorders and pervasive developmental disorder NURSING INTERVENTIONS Develop self-care skills Establish a daily routine for hygiene and grooming Improve community functioning Help client function in the community with minimal discomfort Social skills training Teaching client in communicating with others and to avoid/reduce bizarre conversation help client with whom she/he can discuss unusual or bizarre beliefs PSYCHOPHARMACOLOGY: Low dose of atypical antipsychotics

BORDERLINE PERSONALITY DISORDER

Borderline personality disorder is characterized by mood instability and poor selfimage. People with this disorder are prone to constant mood swings and bouts of anger. Often, they will take their anger out on themselves, causing themselves injury. Suicidal threats and actions are not uncommon. They think in very black and white terms and often form intense, conflict-ridden relationships. They are quick to anger when their expectations are not met. BORDERLINE PERSONALITY DISORDER CHARACTERISTERICS BASED ON DSM-IV TR Attempts to avoid abandonment, either real or imagined, that are frantic Alternating extremes of idealization and devaluation leading to relationship instability Poor and unstable self-image and sense of self Self-damaging impulsivity in at least two areas such as spending, sexual behavior, substance abuse, reckless drinking, or binge eating Gestures, threats, self-mutilation, or actual suicidal behavior, that is recurrent Marked mood reactivity, lasting a few hours to days Chronic feelings of emptiness Anger that is inappropriately intense, uncontrolled, and frequent Stress-related paranoid thinking or severe dissociative symptoms that are transient FUNCTIONS: Fears separation, impulsive, unstable but intense relationship, hypochondrial. SPLITTING Characteristics: SUICIDEAL S. Suicidal (self mutilating) behavior

U. Unstable and intense relationship I. Impulsivity C. Control of anger is absent I. Identity disturbance D. Dissociative (paranoid) symptoms that are transient and stress related E. Emptiness (chronic feeling of being alone) A. Abandonment is feared L. Labile Mood (marked reactivity of mood) NURSING INTERVENTION PROMOTE SAFETY Help client to cope and control emotions Help client to identify their feelings and learn to tolerate them without exaggerated responses such as destruction of property or self-harm Cognitive restructuring techniques Thought stopping technique to alter the process of negative or self-critical thought patterns ( shout STOP) Decatastrophizing Techniques that involves learning to assess situations realistically rather than assuming a catastrophe will happen Positive self-talk therapeutic approach by reframing (-) thought to (+) thought Structure time Making written schedule of activities such as appointments, shopping, reading a newspaper, etc Making a list of solitary activities to combat boredom Teach social skills Maintaining personal boundaries because clients often have unrealistic expectations Realistic expectations of relationships PSYCHOPHARMACOLOGY SSRI For anger and depression ANTICONVULSANT (Carbamazepine Tegretol) For lack of control and self-harm LOW DOSE ANTIPSYCHOTIC For cognitive disturbance

HISTRIONIC PERSONALITY DISORDER

People with histrionic personality disorder are constant attention seekers. They need to be the center of attention all the time, often interrupting others in order to dominate the conversation. They use grandiose language to discribeeveryday events and seek constant praise. They may dress provacativelyor exaggerate illnesses in order to gain attention. They also tend to exaggerate friendships and relationships, believing that everyone loves them. They watch other people watch them. They are often manipulative. HISTRIONIC PERSONALITY DISORDER CHARACTERISTERICS BASED ON DSM-IV TR

Discomfort in situations where he is not the center of attention Inappropriate sexually seductive behavior with others Rapidly shifting and shallow emotional expressions Excessively impressionistic style of speech that lacks detail Self-dramatization, theatrics, or exaggerated emotional expressions Suggestibility Attitude that relationships are more intimate than they are FUNCTIONS: Overly concerned with appearance, attention seeking, and extrovert. Characteristics: PRAISE ME P: Provocative (sexually seductive) behavior R: Relationship (Considered more intimate than they are) A: Attention (Uncomfortable when not the center of attention) I: Influenced easily S: Style of speech E: Emotion (Rapid shifting and shallow) M: Made up (physical appearance used to draw attention to self) E: Emotion exaggerated (theatrical) NURSING INTERVENTIONS Teach social skills Provide a factual feedback about behavior Nurse gives client feedback about their social interactions with others, manner of dressing and non-verbal behavior Feedback should focus on appropriate alternatives not criticism PSYCHOPHARMACOLOGY: Antidepressant as needed

NARCISSISTIC PERSONALITY DISORDER

Narcissistic personality disorder is characterized by self-centeredness. Like histrionic disorder, people with this disorder seek attention and praise. They exaggerate their achievements, expecting others to recognize them as being superior. They tend to be choosy about picking friends, since they believe that not just anyone is worthy of being their friend. They tend to make good first impressions, yet have difficulty maintaining long-lasting relationships. They are generally uninterested in the feelings of others and may take advantage of them. NARCISSISTIC PERSONALITY DISORDER CHARACTERISTERICS BASED ON DSM-IV TR Has a grandiose sense of self-importance Exaggerates achievements and talents Expects to be recognized as superior without commensurate achievement

Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love Believes that he is special and unique and can only be understood by, or should associate with, other special or high-status people (or institutions) Requires excessive admiration Has sense of entitlement, that is, unreasonable expectations of especially favorable treatment or automatic compliance with his expectations Is interpersonally exploitive, that is, takes advantage of others to achieve his own ends Lacks empathy; is unwilling to recognize or identify with the feelings and needs of others Is often envious of others or believes that others are envious of them Shows arrogant, haughty behaviors or attitude FUNCTIONS: Self love, believe that they are special and demand special attention. Characteristic: SPECIAL S: Special (believes she or he is special and unique) P: Preoccupied with fantasies (of unlimited power, beauty and success) E: Entitlement C: Conceited (grandiose sense of self importance) I: Interpersonal exploitation A: Arrogant L: Lacks empathy NURSING INTERVENTIONS Matter of fact approach Set limits on rude or verbally abusive behavior and explain what is expected of him/her Teach client any needed self-care skills Learn to consider feelings of others Gain cooperation with needed treatment Treatment: insight oriented psychotherapy

ANTISOCIAL PERSONALITY DISORDER

A common misconception is that antisocial personality disorder refers to people who have poor social skills. The opposite is often the case. Instead, antisocial personality disorder is characterized by a lack of conscience. People with this disorder are prone to criminal behavior, believing that their victims are weak and deserving of being taken advantage of. They tend to lie and steal. Often, they are careless with money and take action without thinking about consequences. They are often aggressive and are much more concerned with their own needs than the needs of others.

ANTISOCIAL PERSONALITY DISORDER CHARACTERISTERICS BASED ON DSM-IV TR Pattern of disregard for and violation of the rights of others occurring since age 15 as indicated by 3 or more of the following: failure to conform to social norms repeated lying/conning impulsivity or failure to plan ahead irritability and aggressiveness reckless disregard for safety consistent irresponsibility lack of remorse Individual is at least 18 years old Evidence of Conduct Disorder before age 15 Occurrence of antisocial behavior not exclusively during course of schizophrenia or a manic episode FUNCTIONS Habitually breaks the law with low self esteem, lack sense of guilt. Characteristic:CORRUPT C: Conformity to law lacking O: Obligations and rights are ignored R: Reckless disregard of safety of self or others R: Remorseless U: Underhanded (deceitful, lies, irresponsible) P: Planning is insufficient (impulsive) T: Temper flares (irritable and aggressive) NURSING INTERVENTION Limit setting Stating unacceptable behavior (don'ts) Identifying consequences of behavior (effects) Identifying expected or desired behavior (dos) Confrontation Nurse points out problematic behavior Used to manage manipulative or deceptive behavior Teach client to solve problem effectively and manage emotions of anger or frustration PSYCHOPHARMACOLOGY: Lithium, anticonvulsant, SSRI for aggression

DEPENDENT PERSONALITY DISORDER

Dependent personality disorder is characterized by a need to be taken care of. People with this disorder tend to cling to people and fear losing them. They may become suicidal when a break-up is imminent. They tend to let others make important decisions for them and often jump from relationship to relationship. They often remain in abusive relationships. They are overly sensitive to disapproval. They often feel helpless and depressed. Unable to make daily decisions without much advice and reassurance Needs others to be responsible for important areas of life Seldom disagrees with others because of fear of loss of support approval

Problem with initiating projects or doing thing on own because of little self confidence Performs unpleasant tasks to obtain support from others Anxious or helpless when alone because of fear of being unable to care for self Urgently seeks another relationship for support and care after relationship ends Preoccupied with fear of being alone to care for self NURSING INTERVENTIONS Supportive therapy Foster clients self reliance and autonomy Help clients identify their strengths and needs Teach problem-solving and decision making skills Help clients explore problems, serve as a sounding board for discussion of alternatives Provide support and positive feedback for effort in this area Cognitive restructuring techniques Positive reframing Decatastrophizing

AVOIDANT PERSONALITY DISORDER

Avoidant personality disorder is characterized by extreme social anxiety. People with this disorder often feel inadequate, avoid social situations, and seek out jobs with little contact with others. They are fearful of being rejectedand worry about embarrassing themselves in front of others. They exaggerate the potential difficulties of new situations to rationalize avoiding them. Often, they will create fantasy worlds to substitute for the real one. Unlike schizoid personality disorder, avoidant people yearn for social relations yet feel they are unable to obtain them. They are frequently depressed and have low self-confidence. FUNCTIONS Avoidant fears rejection remains aloof in relationship feels inferior to others. Characteristic: CRINGES C: Certainly (being liked before willingness to get involved with others) R: Rejection (or criticism) preoccupies ones thought in social situations I: Intimate relationship (Restrain due to fear of being shamed) N: New interpersonal relationship (is inhibited) G: Gets around occupational activity (Involved significant interpersonal contact) E: Embarrassment (potential) prevents new personal risk S: Self viewed as unappealing or inferior. NURSING INTERVENTIONS Support and reassurance Help client to explore (+) self-aspects, (+) responses from others and possible reason for self-criticism Promote self esteem Improved decision making Manage anxiety Assertiveness training Positive reinforcement Cognitive restructuring techniques Help client to practice self-affirmation and (+) self talk Desensitization PSYCHOPHARMACOLOGY: MAOI Antidepressant for panic attack, high levels of separation anxiety.

OBSESSIVE COMPULSIVE PERSONALITY DISORDER

Obsessive-Compulsive personality disorder is similar to obsessive-compulsive anxiety disorder. People with this disorder are overly focused on orderliness and perfection. Their need to do everything "right" often interferes with their productivity. They tend to get caught up in the details and miss the bigger picture. They set unreasonably high standards for themselves and others, and tend to be very critical of others when they do not live up to these high standards. They avoid working in teams, believing others to be too careless or incompetent. They avoid making decisions because they fear making mistakes and are rarely generous with their time or money. They often have difficulty expressing emotion. FUNCTIONS Excessively devoted word and productivity, perfectionist inflexible rigid. Characteristic: FIRM LAWS F: Friendship and leisure activities excluded (due to preoccupation on work) I: Inflexible, scrupulous, over conscientious (on ethics and values) R: Reluctant to delegate (Unless submit to exact guidelines) M: Misery (Towards self and others) L: Loses point of activity (due to preoccupation of details) A: Ability to compare task (Compromise by perfectionism) W: Worthless object (Unable to discard) S: Stubbornness and rigidity. NURSING INTERVENTIONS Encourage decision making and negotiation with others Assist client to make timely decision and complete work Help clients to accept/tolerate less than perfect work or decision made on time Cognitive restructuring techniques Positive reframing (gain insight of their behavior Confront patient procrastination and intellectualization Increase patient awareness of how she/he affects others Help patient decrease irrational beliefs PSYCHOPHARMACOLOGY TCA (ClomipramineAnafranil) SSRI ( FluoxetineProzac) Benzodiazepine e.g. clorazepam(Cloneped) Serotonergicagents e.g. flouxetine(prozac)

IMPULSE-CONTROL DISORDERS
Impulse Control Disorders are a specific group of impulsive behavioursthat have been accepted as psychiatric disorders under the DSM-IV-TR. Although they have been grouped together in this diagnostic category, there are striking differences as well as similarities between these disorders. An Impulse Control Disorder can be loosely defined as the failure to resist an impulsive act or behaviourthat may be harmful to self or others. For purposes of this definition, an impulsive behaviouror act is considered to be one that is not

premeditated or not considered in advance and one over which the individual has little or no control. While anyone can be capable of impulsive behavioursand/or actions at any given point, this particular diagnosis is used when there is a mental health issue present. In many cases, the individual may have more than one formal psychiatric diagnosis. The impulsive behavioursor actions refer to violent behavior, sexual behavior, gambling behaviour, fire starting, stealing, and self-abusive behaviors. Defense Mechanism: Displacement PSYCHODYNAMIC: a cry for help need attention & love need to release anger THE FOLLOWING IMPULSE-CONTROL DISORDERS HAVE BEEN IDENIFIED IN DSM -IV Kleptomania -intense drive to steal Pyromania -intense drive to set fire Megalomania -intense drive to acquire power Trichotillomania-intense drive to pull ones hair Dermatillomania-intense drive to pick skin Onychophagia-intense drive to nailbite Pathological Gambling Intermittent Explosive Disorder NURSING INTERVENTIONS Reduce anxiety Redirect clients attention away from self Use empathy, not sympathy Increase socialization activities Set limit on patients unacceptable behavior