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NR202 Test 5 Dysfunction in Self-Pattern: Personality Disorders


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Explain Personality
Personality is a complex pattern of deeply embedded characteristics
Largely unconscious
Cannot be eradicated easily
Express themselves automatically
Can be seen in almost every facet of functioning
Explain personality traits
Personality traits are enduring patterns of perceiving, relating to and thinking about the environment & oneself that are exhibited in a wide range of social and personal contexts.
When do personality disorders occur
Personality disorders occur when these traits become inflexible and maladaptive and cause either significant functional impairment or subjective distress.
What is the mental health illness continuum
Explain the adaptive responses to the maladaptive responses
1. Adaptive Responses
-Logical thought
-Accurate Perceptions
-Emotions consistent with experience
-Appropriate behavior
-Social relatedness

2. Midway between the two
-Occasional distorted thought
-Emotional overreaction or underreaction
-Odd or unusual behavior

3. Maladaptive Responses
-Thought disorder
-Disorganized behavior
-Social isolation
Personality Disorder Clusters
Cluster A
Cluster A: Behaviors described as odd or eccentric
-Paranoid Personality Disorder
-Schizoid Personality disorder
-Schizotypal Personality disorder
Personality Disorder Clusters
Cluster B
Cluster B: Behaviors
Behaviors described as dramatic, emotional, or erratic
-Antisocial personality disorder
-Borderline personality disorder
-Histrionic personality disorder
-Narcissitic personality disorder
Personality Disorder Clusters
Cluster C:
Cluster C: Behaviors
Behaviors described as anxious or fearful
-Avoidant personality disorder
-Dependent personality disorder
-Obsessive-compulsive personality disorder
Paranoid Personality Disorder-Cluster A, B, or C ?

Explain the disorder
Cluster A
Definition and Epidemiology
A pattern of behavior, beginning by early adulthood and present in a variety of contexts, of pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent
More common in Men (7 men to five women)
Predisposing factors
Possible genetic link
Subject to early parental antagonism and aggression.
Obsessive Compulsive personality Disorder-
Cluster A, B, or C?
Explain the disorder
Cluster C
Definition and Epidemiology: Inflexibility about the way in which things must be done and a devotion to productivity at the exclusion of personal pleasure
Relatively common, occurs more often in men than in women
Most common in oldest children
Predisposing Factors
Over-Control by parent, with notable lack of positive reinforcement for acceptable behavior and frequent punishment for undesirable behavior
Schizoid personality disorder-
Cluster A, B, or C?
Explain the disorder
Cluster A
Definition and epidimiology
Characterized primarily by a profound defect in the ability to form personal relationships or to respond to others by any meaningful, emotional way.
Mostly in men, 3% to 7.5% of the general population
Predisposing Factors
Possible heredity factor
Childhood characterized as bleak, cold, unempathetic and lacking nurturing
Paranoid Personality disorder
Clinical picture
Constantly on guard, hypervigilant, and ready for any real or imagined threat...trusts no one, constantly test the honesty of others.
Insensitive to the feelings of others but are themselves oversensitive and tend to misinterpret even minute cues within the environment and distorting them into thoughts of trickery and deception.

odd, eccentric, bizarre, Howard Hughs, hypervigilant
Schizoid Personality Disorder-Clinical picture
Indifferent to others, aloof, detached, and unresponsive to praise, criticism, or any other feeling expressed by others
No close friends and prefers to be alone
In the presence of others may apear shy, anxious, or uneasy.
Obsessive compulsive personality disorder-Clinical picture
Especially concerned with matters of organization, efficiency, tend to be rigid, unbending about rules and procedures.
Social behavior tends to be polite and formal
Very rank conscious
Very ingratiating with authority figures but autocratic and condemnatory with subordinates
On the surface, these individuals appear to be very calm and controlled, while underneath this exterior lies a great deal of ambivalence, conflict, and hostility
Egosyntonic i.e. comforting and sees no problem
Antisocial Personality Disorder. Cluster A, B, or C and explain
Cluster B
Definition and epidemiological statistics
A pattern of socially irresponsible, exploitative, and guiltless behavior, evident in the tendency to fail to conform to the law and sustain consistent employment, exploit and manipulate others for personal gain, deceive, and fail to develop stable relationships
Prevalence estimates in the U.S. range from 3% in men to less than 1% in women
Predisposing factors for antisocial personality disorder
Possible genetic influence
Sociopathic or alcoholic father
Behavior disordered as a child
Antisocial Personality Disorder: clinical Picture
Exploitation and manipulation for personal Gain
Beligerant and argumentative
Lacks remorse
Unable to delay gratification
Low tolerance for frustration
Inconsistent work or academic performance
Failure to conform to societal norms
Impulsive and reckless
Inability to function as a responsible parent
Inability to form lasting monogamous relationship
Nursing Diagnosis Antisocial Personality
Risk of Violence
Defensive Coping
Self Esteem Disturbance
Impaired Social Interaction
Avoidant Personality Disorder
Cluster A, B, or C?
Definition and epidemiology
Predisposing factors
Cluster C
Def. and Epidemiology:
-Extreme sensitivity to rejection and social withdrawal
Prevelance between 0.5% and 1%. Equally common in men and women.
Predisposing Factors
-Possible heredity influence
-Parental rejection and depreciation
Clinical Picture for Avoidant personality disorder
-Awkward and uncomfortable in social situations
-Desires to have social relationships but cannot help believing that such these will end up in pain and dissilusionment
May be perceived by others as timid, withdrawn, or perhaps cold and strange
-Often lonely, expresses feeling of being unwanted
-View others as critical, betraying, humiliating
Dependent Personality Disorder: Clluster A, B, or C?
Cluster C
Definition and epidemiology:
Pattern of relying excessively on others for emotional support, advice, and reassurance
Relatively common
More common among women
More common in youngest children of a family
Predisposing factors
Possible hereditary influences
Stimulation and nurturance are experienced exclusively from one source, and a singular attachment is made by the infant to the exclusion of all others
Clinical Picture of Dependent Personality Disorder
Notable lack of self-confidence that is often apparent in posture, voice, and mannerisms
Typically passive and acquiescent to the desires of others
Avoid positions of responsibility and become anxious when forced into them
Low self-worth and easily hurt by criticism and disapproval
Avoidant of responsibility for decisions and solicits advice over minor issues.
Borderline Personality Disorder
Cluster A, B, or C?
Definition and epidemiology
Cluster B
Definition and epidemiology
Pattern of intense and chaotic relationships with affective instability, fluctuating and extreme attitudes regarding other people, impulsivity, directly, and indirectly self destructive behavior, and lack of a clear or certain sense of identity, life plan, or values
Ranges from 2% to 4% of general population
Predisposing factors of Borderline Personality disorder
Fixed in the developmental stage of rapprochement phase (16-24 months)
child fails to achieve the task of identity and autonomy
Invalidating early environment
Attachment conflicts of abandonment vs engulfment
Genetic and biochemistry predisposition
Clinical Picture of Borderline personality disorder
-Chronic depression
-Exhibitions of affect
-Chronic feelings of emptiness
-Fears of abandonement
-Intense Anger, rage

-Apparent competency
-Clinging and distancing
-Unhealthy manipulation
-Intolerance of being alone

misinterpretations of others and environment
-Faulty Processing
-Impaired ability to retain due to depersonalization and dissociation
-dichotomous thinking
-Identity diffusion (lack of sense of self or identity)

-Projective Identification

Nursing Diagnosis Borderline Personality
Risk for self mutilation related to depersonalization
Impaired social interaction related to overuse of splitting defense mechanisms
Identity disturbance related to lack of completion of developmental tasks
Ineffective coping related to affect instability and dysregulation
Histrionic Personality disorder
Cluster A, B, or C
Definition and Epidemiology
Predisposing Factors
Cluster B
Definition and Epidemiology
Characterized by colorful, dramatic, and extroverted behavior in excitable, emotional persons
Prevalence is thought to be about 2.2% and is twice as common in women than in men

Predisposing factors:
Possible ease of sympathetic arousal, adrenal hyperactivity and neurochemical imbalances
Learned behavior of patterns
Clinical Picture of Histrionic Personality disorder
Self-Dramatizing, attention seeking, overly gregarious, seductive, manipulative, exhibitionistic, shallow, labile, vain, and demanding
Highly distractible, difficulty paying attention to detail, influenced by others, difficulty forming close relationships and may complain of physical symptoms
Narcissistic Personality disorder
Cluster A, B, or C
Definition and Epidemiology
Predisposing Factors
Cluster B
Exaggerated sense of self worth
More common in men than in women

Predisposing factors
Family dynamics fostering feelings of omnipotence and grandiosity through total indulgence of the child
Clinical Picture of Narcissistic Personality disorder
-Overly self centered and exploits others in effort to fulfill own desires
-Mood often grounded in grandiosity, is usually optimistic, relaxed, cheerful, and carefree
-Mood can change because of fragile self-esteem
Clinical Management tips for the "Difficult Patient"
-Maintain honest, respectful, and nonretalitory stance
-Avoid ultimatums, arguments, or control struggles by offering choices
-Monitor your own reactions (use supervision)
-Set clear and realistic expectations and limits on unacceptable or inappropriate behaviors
Actively promote patient involvement in treatment planning
Top Ten Clinical Management tips for the Difficult patient
1. Develop and provide written schedules, plans, and behavior contracts
2. Recognize healthy decisions and behaviors
3. Offer 1:1 private time regularly
4. Identify stressors, predict responses and prepare a plan
5. Connect: thinking + feelings + Actions + Effects
Treatment Modalities:
Interpersonal therapy
psychoanalytical psychotherapy
Milieu or group therapy
Interpersonal therapy
-encourages more flexible and adaptive functioning
-Insight oriented
-Solution focused

Psychoanalytical psychotherapy
-focus on unconscious motivation

Milieu or group therapy
-Support and feedback from other members of the group
-Overcome social anxiety, develop trust and rapport
-Deal with anti-social behavior
Treatment Modalities:
Behavior therapy
Behavior therapy
-Reinforce positive change
-Social skills training
-Assertiveness training
-Teach alternative ways to deal with frustration

-Medications have no direct effect in the treatment of personality disorders
Some symptom relief can be achieved
Used to managed targeted symptoms
Schizotypal Personality disorder Cluster A, B, or C and give the Definition and Epidemiology
A graver form of the pathologically less severe schizoid personality pattern
Recent studies indicate that approximately 3% of the population have this disorder.
Schizotypal Personality. State the predisposing factors
Possible heredity factor
Possible psychological influence, such as anatomic deficits or neurochemical dysfunctions within certain areas of the brain.
Early family dynamics characterized by indifference, passivity, or formality, leading to a pattern of discomfort with personal affection and closeness.
Schizotypal Personality
Clinical Picture
Aloof, isolated, and behave in a bland and apathetic manner
Experience few pleasures
Symptoms include magical thinking, ideas of reference, illusions, depersonalization, superstitiousness, bizarre speech, delusions, hallucinations, and withdrawal into the self.
What are the 4 common characteristics of personality disorders
1. Inflexible and maladaptive responses to stress.
2. Disability in working and loving
3. Ability to evoke interpersonal conflict in health care providers as well as family and friends
4. Capacity to have an intense effect on others (this process is often unconscious and generally produces undesirable results).
What are the common nursing diagnoses of personality disorders
1. Self mutilation
2. Low self-esteem
3. impaired social interaction
4. ineffective coping
presenting signs and symptoms of Paranoid personality disorder
1. Bear grudges, are unforgiving of insults, injuries, or slights
2. Read hidden, demeaning, or threatening meanings into benign remarks or events
3. Have difficulty establishing close relationships; usually work alone
4. Perceived as cold and unemotional, and do not share their thoughts with others; lack a sense of humor
5. Very critical of others but have a great deal of difficulty accepting criticism
6. Are prone to file suit
Nursing guidelines: Working with those who have Paranoid PD
1. Avoid being too "nice" or "friendly."
2. Give clear and straightforward explanations of tests and procedures beforehand.
3. Use simple, clear language; avoid ambiguity
4. Project a neutral but kind affect
5. Warn about any changes, S.E. of medications, and reasons for delay. Such interventions might help allay anxiety and minimize suspiciousness
6. A written plan of treatment might help encourage cooperation
Treatment for Paranoid personality Disorder
Paranoid clients will initially mistrust their therapist's motives and find it difficult to share personal information. For that reason, therapy is often not sought or sustained among these clients.
However, when a person with PPD does enter therapy, initially supportive therapy might help the client feel trust and even begin to feel some amount of safety in an interpersonal relationship....
The focus is on enhancing coping strategies and relieving stress and worry that are expressed as hypervigilance and social withdrawal.
Nursing guidelines for working with a schizoid PD?
1. Avoid being too "nice" or "friendly"
2. Do not try to re-socialize these clients
3. A thorough diagnostic assessment might be needed to identify symptoms or disorders that the client is reluctant to discuss.
1. A nurse caring for a client who has been diagnosed with a personality disorder should expect that the client will exhibit which of the following characteristics?
A. Frequent episodes of psychosis
B. Constant involvement with the needs of
C. Inflexible and maladaptive responses to stress
Personality patterns persist unmodified over long periods of time. Characteristics of inflexible and maladaptive response to stress is one of these characteristics for individuals with personality disorder.
2. Which statement is descriptive of clients with personality disorders?
A. They are resistant to behavioral change.
B. They have an ability to tolerate frustration and pain.
C. They usually seek help to change maladaptive behaviors. <
A. They are resistant to behavioral change.
Personality disorders are deeply ingrained and pervasive. Clients with personality disorders find it very difficult, if not nearly impossible, to change. Change proceeds very slowly.
3. Research has indicated that antisocial personality may be associated with the neurotransmitter systems and
A. appropriate use of effective communication techniques.
B. overuse of primitive defense mechanisms.
C. learning difficultie
B. overuse of primitive defense mechanisms.
As noted in the two previous chapters on anxiety and dissociative disorders, repeated trauma leads to altered neurotransmitter systems and overuse of primitive defense mechanisms.
4. The primary goal of milieu therapy for clients with personality disorders is
A. affect management in a group context.
B. one-on-one therapy.
C. to help the client remain uninvolved with other patients.
D. a laissez faire attit
A. affect management in a group context.
The primary goal of milieu therapy is affect management in a group context.
5. Characteristic behaviors the nurse will assess in the narcissistic client are
A. dramatic expression of emotion, being easily led.
B. perfectionism and preoccupation with detail.
C. grandiose, exploitive, and rage-filled behavior. <
C. grandiose, exploitive, and rage-filled behavior.
Narcissistic clients give the impression of being invulnerable and superior to others to protect their fragile self-esteem.
6. Which client with a personality disorder is most likely to be admitted to a psychiatric unit?
A. Mr. A, with paranoid personality disorder who is suspicious of his neighbors
B. Mr. B, with narcissistic personality disorder who is highly s
C. Ms. C, with borderline personality disorder who is impulsive
Clients with borderline disorder can decompensate into psychotic states under stress. Hospitalization is needed at these times.
7. Characteristics the nurse will assess in the client with antisocial personality disorder are
A. deceitfulness, impulsiveness, and lack of empathy.
B. perfectionism, preoccupation with detail, and verbosity.
C. avoidance of interpers
A. deceitfulness, impulsiveness, and lack of empathy.
Antisocial clients have no conscience. Their sense of right and wrong is impaired, and they tend to do whatever serves them best without consideration for the rights or feelings of others.
8. Playing one staff member against another is an example of
A. devaluation.
B. manipulation.
C. impulsiveness.
D. social ineptitude.
B. manipulation.
Manipulation often involves setting up individuals or groups to disagree. While the two parties are busy disagreeing, they are too busy to maintain consistent limits for the manipulative client. The client can enjoy the spectacle and do as he or she pleases.
9. Splitting is a process in which the client
A. unconsciously represses undesirable aspects of self.
B. places responsibility for his or her behavior outside the self.
C. sees things as divided into "all good" or "all b
C. sees things as divided into "all good" or "all bad."
Splitting demonstrates the failure to integrate the positive and negative into a cohesive whole. An individual is not seen as a person with good and bad traits, but rather as all good or all bad.
10. A 16-year-old has stolen money from his invalid grandmother, uses drugs and alcohol, and frequently beats up acquaintances who disagree with him. Arrested for an assault in which he beat a classmate and caused brain damage, he stated in court "T
A. antisocial personality disorder.
Clients with antisocial personality act out feelings without consideration for the rights of others. They feel no remorse for their antisocial acts.
1. Which behavior would be inconsistent with defining characteristics for the nursing diagnosis of ineffective coping?
A. Difficulty in relationships
B. High levels of anxiety
C. Manipulation
D. Interdependence
D. Interdependence
The characteristics for the diagnosis of ineffective coping include crisis, high levels of anxiety, anger and aggression; child, elder, or spouse abuse; and difficulty in relationships and manipulation. Interdependence would not be considered a symptom for ineffective coping.
2. A nurse is assigned to work with a client with borderline personality disorder. The nurse will need to consider strategies for dealing with the client's
A. mood shifts, impulsivity, and splitting.
B. grief, anger, and social isolation.
A. mood shifts, impulsivity, and splitting.
Borderline personality disorder has the central characteristic of instability in affect, identity, and relationships. Borderline individuals desperately seek relationships to avoid feeling abandoned. But they often drive others away with excessive demands, impulsive behavior, or uncontrolled anger. Their frequent use of the defense of splitting strains personal relationships and creates turmoil in health care settings.
3. A client has been diagnosed with dependent personality disorder. Which behavior descriptions can the nurse expect to assess?
A. Anxious, fearful
B. Odd, eccentric
C. Dramatic, emotional, erratic
D. Disoriented, disorganized
A. Anxious, fearful
Dependent personality disorder has a primary feature of extreme dependency in a close relationship, with an urgent search to find a replacement when one relationship ends. These individuals have difficulty making independent decisions and are constantly seeking reassurance. They have deeply held convictions of personal incompetence, with the fear that they cannot survive on their own. They frequently seek treatment for anxiety or mood disorders related to a loss.
4. A newly admitted client has an axis II diagnosis of schizoid personality disorder. The nursing intervention of highest priority will be to
A. set firm limits on behavior.
B. respect need for social isolation.
C. encourage expression
B. respect need for social isolation.
Schizoid personality disorder has the primary feature of emotional detachment. The person does not seek out or enjoy close relationships. They are reclusive, avoidant, and uncooperative. They do not do well with resocialization.
5. A client with dependent personality disorder who had been living with her newly married son was admitted a week ago for treatment of depression, which began after her son suggested that she move out. Which remark by the client would the nurse evaluate
C. "I'm adjusting my budget to see if I can afford to rent an apartment."
Dependent personality disorder has a primary feature of extreme dependency in a close relationship, with an urgent search to find a replacement when one relationship ends. Clients have a deeply held conviction of personal incompetence, with the fear that they cannot survive on their won. Option 3 would indicate improvement in the client's condition.
6. A client with histrionic personality disorder winks at an attractive nurse and states, "You and I should be able to turn those resident physicians into jelly if you'd wear your skirts about two inches shorter." The nurse's reply should be ba
A. a response to stress.
The histrionic person is impulsive and melodramatic and may act flirtatious or provocative to get the spotlight.
7. A client with obsessive-compulsive personality disorder takes the nurse aside and mentions "I've observed you interacting with Mr. D. You are not approaching him properly. You should be more forceful with him." The best response for the nurs
A. "I will be continuing to follow the care plan for Mr. D."
Obsessive-compulsive personality disorder has the key factor of perfectionism with a focus on orderliness and control. These individuals get so preoccupied with details and rules that they may not be able to accomplish the tasks. Guard against engaging in power struggles with a client with obsessive-compulsive disorder.
8. The priority nursing intervention for a client with borderline personality disorder is to
A. protect other clients from manipulation.
B. respect the client's need for social isolation.
C. assess for suicidal and self-mutilating beha
C. assess for suicidal and self-mutilating behaviors.
One of the primary nursing guidelines/interventions for clients with a personality disorder is to assess for suicidal and self-mutilating behaviors, especially during times of stress.
9. A danger of working with a client who idealizes the nurse is
A. becoming overinvolved and being protective and indulgent.
B. becoming indecisive about planned interventions.
C. developing a prejudicial, blaming orientation.
A. becoming overinvolved and being protective and indulgent.
Finding an approach for helping clients with personality disorders who have overwhelming needs can be overwhelming for caregivers. For example, a borderline female client may briefly idealize her male nurse on the inpatient unit, telling staff and clients alike that she is "the luckiest client because she has the best nurse in the hospital." The rest of the team initially realizes that this behavior is an exaggeration, and they have a neutral response. But after days of constant dramatic praise, some members of the team may start to feel inadequate and jealous of the nurse. They begin to make critical remarks about minor events to prove that the nurse is not perfect. Open communication in staff meetings and ongoing clinical supervision are important aspects of self-care for the nurse working with these clients to maintain objectivity.
10. Clients with personality disorders have various self-defeating behaviors and interpersonal problems despite having near-normal ego functioning and intact reality testing. A nursing diagnosis that addresses this sort of interpersonal dysfunction is
C. impaired social interaction.
For a client who has difficulty in relationships and is very manipulative, the nursing diagnosis of impaired social interaction would be used.
Treatment of a schizoid individual
A schizoid individual is apt to seek treatment only in a crisis situation, and only then seek relief from acute symptoms. In some cases, supportive psychotherapy and cognitive behavioral techniques can help reinforce socially outgoing behaviors.
Social skills training groups might be an effective intervention.
Nursing guidelines: schizotypal personality disorder
1. Respect the client's need for social isolation
2. Be aware of client's suspiciousness and employ appropriate interventions
3. As with the schizoid client, careful diagnostic assessment might be needed to uncover any other medical or psychological symptoms that might need intervention.

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