Personality Disorders

Definition

Personality disorder is defined as the totality of a person’s unique biopsychosocial and spiritual traits that consistently influence behavior.
The following traits are likely in individuals with a personality disorder:

1. Interpersonal relations that ranges from distant to overprotective.
2. Suspiciousness
3. Social anxiety
4. Failure to conform to social norms.
5. Self-destructive behaviors
6. Manipulation and splitting.

Prognosis is poor, and clients experience long term disability and may have other psychiatric disorders.

Diagnosis

A personality disorder is diagnosed when a person exhibits deviation on the following areas:

1. Cognition – ways a person interprets and perceives him or herself, other people and events.
2. Affect – ranges, lability and appropriateness of emotional response
3. Impulse control – ability to control impulses or express behavior at the appropriate time and place.

Cluster A: Personality Disorders ( The Eccentric and Mad group)

1. Paranoid Personality disorder– People with a paranoid personality disorder are characterized by an overly suspicious and mistrustful behavior.

Clinical Manifestation

1. Aloof and withdrawn
2. Appear guarded and hypervigilant
3. Have a restricted affect
4. Unable to demonstrate a warm and empathetic emotional responses
5. Shows constant mistrust and suspicion
6. Frequently see malevolence in the actions when none exists
7. Spends disproportionate time examining and analyzing the behavior and motive of others to discover hidden and threatening meanings
8. Often feel attacked by others
9. Devises plans or fantasies for protection
10. Uses the defense mechanism of projection (blaming other people, institution or events for their own difficulties)

2. Schizoid Personality Disorder- People who are showing a pervasive pattern of social relationship detachment and a limited range of emotional expression in the interpersonal settings falls under this type of personality disorder.
Clinical Manifestations:

1. Displays restricted affect
2. Shows little emotion
3. Aloof, emotionally cold and uncaring
4. Have rich and extensive fantasy life
5. Accomplished intellectually and often involved with computers or electronics in hobbies or job
6. Spends long hours solving puzzles and mathematical problems
7. Indecisive
8. Lacks future goals or direction
9. Impaired insight
10. Self-absorbed and loners
11. Lacks desire for involvement with others
12. No disordered or delusional thought processes present

3. Schizotypal Personality Disorder– Schizoid and schizotypal personality disorder are both characterized by pervasive pattern of social and interpersonal deficits, however, the latter is noted with cognitive and perceptual distortions and behavioral eccentricities.
Clinical Manifestations:

1. Odd appearance (stained or dirty clothes, unkempt and disheveled)
2. Wander aimlessly
3. Loose, bizarre or vague speech
4. Restricted range of emotions
5. Ideas or reference and magical thinking is noted
6. Expresses ideas of suspicions regarding the motives of others
7. Experiences anxiety with people

Cluster B: Personality Disorders ( The Erratic and Bad group)

1. Antisocial Personality Disorder– Antisocial Personality disorder is characterized by a persistent pattern of violation and disregard for the rights of others, deceit and manipulation
Clinical Manifestations:

1. Violation of the rights of others
2. Lack of remorse for behaviors
3. Shallow emotions
4. Lying
5. Rationalization of own behavior
6. Poor judgment
7. Impulsivity
8. Irritability and aggressiveness
9. Lack of insight
10. Thrill seeking behaviors
11. Exploitation of people in relationships
12. Poor work history
13. Consistent irresponsibility

2. Borderline Personality Disorder– Borderline personality disorder is the most common personality disorder found in clinical settings. This disorder is characterized by a persistent pattern of unstable relationships, self image, affect and has marked impulsivity. It is more common in females than in males. Self-mutilation injuries such ascutting or burning are noted in this type of personality disorder.
Clinical manifestations:

1. Fear of abandonment (real or perceived)
2. Unstable and intense relationship
3. Unstable self-image
4. Impulsivity or recklessness
5. Recurrent self-mutilating behavior or suicidal threats or gestures
6. Chronic feelings of emptiness and boredom
7. Labile mood
8. Irritability
9. Splitting
10. Impaired judgment
11. Lack of insight
12. Transient psychotic symptoms such as hallucinations demanding self-harm

3. Narcissistic Personality Disorder– A person with a narcissistic personality disorder shows a persistent pattern of grandiosity either in fantasy or behavior, a need for admiration and a lack of empathy.
Clinical Manifestations:

1. Arrogant and haughty attitude
2. Lack the ability to recognize or to empathize with the feelings of others
3. Express envy and begrudge others of any recognition of material success (they believe it rightfully should be theirs)
4. Belittle or disparage other’s feelings
5. Expresses grandiosity overtly
6. Expect to be recognized for their perceived greatness
7. Preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love
8. Compares themselves with famous or privileged people
9. Poor or limited insight
10. Fragile and vulnerable self-esteem
11. Ambitious and confident
12. Exploit relationships to elevate their own status

4. Histrionic Personality disorder– Excessive emotionality and attention-seeking behaviors are pervasive patterns noted in people with a histrionic personality disorder.
Clinical manifestations:

1. Exaggerate closeness of relationships or intimacy
2. Uses colorful speech
3. Tends to overdress
4. Concerned with impressing others
5. Emotionally expressive
6. Experiences rapid mood and emotion shifts
7. Self-absorbed
8. Highly suggestible and will agree with almost anyone to gain attention
9. Always want to be the center of attraction

Cluster C: Personality Disorders ( The anxious and Sad group)

1. Avoidant Personality Disorder
Avoidant personality disorder is characterized by a persistent pattern of:

1. Social uneasiness and reticence
2. Low self-esteem
3. Hypersensitivity to negative reaction

Clinical Manifestations

1. Shy
2. Unusually fearful of rejection, criticism, shame or disapproval
3. Socially awkward
4. Easily devastated by real or perceived criticism
5. Have a very low self-esteem
6. Believes that they are inferior

2. Dependent Personality Disorder– People who are noted to excessively need someone to take care of them that lead to their persistent clingy and submissive behavior have a dependent personality disorder. These individuals have fear of being separated from the person whom they cling on to. The behavior elicits caretaking from others.
Clinical Manifestations

1. Pessimistic
2. Self-critical
3. Can be easily be hurt by other people
4. Frequently reports feeling unhappy or depressed ( due to actual or perceived loss of support from a person)
5. Preoccupied with unrealistic fears of being alone and left alone to take care for themselves
6. Has difficulty deciding on their own even how simple the problem is
7. Constantly seeks advice from others and repeated assurances about all types of decisions
8. Lacks confidence
9. Uncomfortable and helpless when alone
10. Has difficulty initiating  or completing simple daily tasks on their own

3. Obsessive Compulsive Personality Disorder– Individuals who are preoccupied with perfectionism, mental and interpersonal control and orderliness have an obsessive compulsive personality disorder. Persons with an obsessive compulsive personality are serious and formal and answer questions with precision and much detail. These people often seek treatment because of their recognition that life has no pleasure or because they are experiencing problems at work and in their relationships.
Clinical Manifestations

1. Formal and serious
2. Precise and detail-oriented
3. Perfectionist
4. Constricted emotional range (has difficulty expressing emotions)
5. Stubborn and reluctant to relinquish control
6. Restricted affect
7. Preoccupation to orderliness
8. Have low self-esteem
9. Harsh
10. Have difficulty in relationships

Signs and Symptoms

1. Inappropriate response to stress and inflexible approach to problem solving.
2. Long term difficulties in relating to others, in school and in work situations.
3. Demanding and manipulative.
4. Ability to cause others to react with extreme annoyance or irritability.
5. Poor interpersonal skills.
6. Anxiety
7. Depression
8. Anger and aggression
9. Difficulty with adherence to treatment.
10. Harm to self or others.

Nursing Diagnoses

• Ineffective individual coping
• Social isolation
• Impaired social interaction
• High risk for violence to self or others
• Anxiety

Nursing Interventions

1. Work with the client to increase coping skills and identify need for improvement coping.
2. Respond to the client’s specific symptoms and needs.
3. Keep communication clear and consistent.
4. Client may require physical restraints, seclusion/observation room, one to one supervision.
5. Keep the client involved in treatment planning.
6. Avoid becoming victim to the client’s involvement in appropriate self-help groups.
7. Require the client take responsibility for his/her own behavior and the consequences for actions.
8. Discuss with the client and family the possible environment and situational causes, contributing factors, and triggers.

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Paraphilias

Definition

Paraphilias are complex psychiatric disorders that are manifested as unusual sexual behavior. Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR) defined it as a “recurrent, intensely sexually arousing fantasies, sexual urges, or behaviors generally involving:

• Inanimate objects (non-human objects)
• Suffering or humiliation of oneself or partner
• Children
• Nonconsenting person

Diagnosis

The criteria for diagnosing this disorder are:
Criterion A: the unusual sexual behavior should occur over a period of 6 months
Criterion B: the sexual behavior caused a clinically significant distress or impairment in social, occupational or other important areas of functioning. Criterion B differs in for some disorders.

• For pedophilia, voyeurism, exhibitionism and frotteurism, the diagnosis is formulated if acting out on these urges or if the urge itself caused a significant distress or interpersonal difficulty.
• For sadism, a diagnosis is made if these urges are done to a nonconsenting person.
• For the other paraphilias, a diagnosis created when the sexual behavior, urges or fantasies caused a clinically significant distress or impairment in social, occupational or other important areas of functioning.

Eight specific disorders of paraphilia

1. Exhibitionism – the repeated urge or behavior of exposing one’s genitals to strangers or masturbating in public areas.
2. Exhibitionism – this is characterized by the use of inanimate objects (fetish) to achieve orgasm or gain sexual excitement. Common fetishes are women’s undergarments (brassiere, lingerie, and panty), shoes and other apparels. An individual with this disorder masturbates while holding or rubbing the object to them.
3. Frotteurism – persistent urges of touching or rubbing against a nonconsenting person in a place where a person with this disorder can make a quick escape (e.g. crowded places, public transportation, shopping mall or a crowded sidewalk). The person rubs his hands against a victim’s breasts or genitalia or he can rub his genitals against the victim’s thigh or buttocks.
4. Pedophilia – a sexual activity done with a child 13 years younger is a characteristic of this disorder. The pedophile should be at least 16 years old or at least 5 years older than the victim.
5. Sexual masochism – the intense and persistent sexual urge involving acts of suffering (beaten or bound) and being humiliated.
6. Sexual sadism – sexual urge involving acts in which the pain, suffering or humiliation of a partner is arousing a person.
7. Transvestic fetishism – sexual fantasies, urge and behaviors involving cross-dressing by a heterosexual male.
8. Voyeurism – sexual arousal by observing an unsuspecting person who is naked, in the process of undressing or engaging in sexual activity.

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Oppositional Defiant Disorder

Definition

The American Psychiatric Association’s Diagnostic and Statistical Manual, Fourth Edition (DSM IV), defines oppositional defiant disorder (ODD) as a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that persists for at least 6 months. ODD is a condition in which a child displays an ongoing pattern of uncooperative, defiant, hostile, and annoying behavior toward people in authority. The child’s behavior often disrupts the child’s normal daily activities, including activities within the family and at school.

Causes and Risk Factors

The causative factors can be divided into categories, namely:

• Biological Factor. Aggressive behavior may be caused by alterations in the neurotransmitter activity of the brain. Neurotransmitters help nerve cells in the brain communicate with each other. If these chemicals are out of balance or not working properly, messages may not make it through the brain correctly, leading to symptoms of ODD, and other mental illnesses. Also, some studies suggest that defects in or injuries to certain areas of the brain can lead to serious behavioral problems in children.
• Familial Factor. Familial influences on child development may be genetically linked, attributed to conflict in the family home or based on parent-child interactions. Additionally, a parent’s prior aggressive behavior (in childhood) has been shown to manifest itself in their child at the same age.
• Genetics. Many children and teens with ODD have close family members with mental illnesses, including mood disorders, anxiety disorders, and personality disorders. This suggests that a vulnerability to develop ODD may be inherited.
• Environmental. Factors such as a dysfunctional family life, a family history of mental illnesses and/or substance abuse and inconsistent discipline by parents may contribute to the development of behavior disorders.

Clinical Manifestations

• Actively does not follow adults’ requests
• Angry and resentful of others
• Argues with adults
• Blames others for own mistakes
• Has few or no friends or has lost friends
• Is in constant trouble in school
• Loses temper
• Spiteful or seeks revenge
• Touchy or easily annoyed

Diagnosis

To fit this diagnosis, the pattern must last for at least 6 months and must be characterized by the frequent occurrence of at least four of the following behaviors: losing temper, arguing with adults, actively defying or refusing to comply with the requests or rules of adults, deliberately doing things that will annoy other people, blaming others for his or her own mistakes or misbehavior, being touchy or easily annoyed by others, being angry and resentful, or being spiteful or vindictive.

Management of Children with ODD

• Behavior management techniques. Use behavior contracts.
• Be fair but be firm, give respect to get respect.
• Using a consistent approach to discipline and following through with positive reinforcement of appropriate behaviors. Apply effective contingencies that are consistent responses to the child’s behavior, following through with appropriate rewards and consequences when these are needed.

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Obsessive Compulsive Disorder (OCD)

Description

Obsessive Compulsive Disorder (OCD) is characterized by persistent thought and urges to perform repeated acts or rituals, usually as a means of releasing tension or anxiety. The frequency and intensity of the ritualistic behaviors, such as handwashing, ordering, or checking, are time consuming (taking more than one hour per day) and cause marked distress, significant impairment, or interfere with daily living.

1. Obsession
   • The person experiences recurrent and persistent thoughts, impulses, images that are intrusive, disturbing, inappropriate, and usually triggered by anxiety.
   • The thoughts, images, and impulses are not simply excessive worries about real life problems.
   • The person recognizes the thoughts, images, and impulses are from within own mind.
2. Compulsion
   • Repetitive behaviors or mental acts that a person feels driven to perform, which usually adhere to a rigid and specifically defined routine.
   • The behaviors and ideations are typically aimed at reducing anxiety or preventing some dreaded situation from occurring.

Specific Biological Factors

• There is some evidence that indicates OCD is linked to a deficiency in serotonin.
• Clients have also been shown to have abnormalities in frontal lobes and basal ganglia; it is unclear what the implications are for clinical care.

Signs and Symptoms

• Obsessions – recurrent, persistent ideas, thoughts or impulses, involuntarily coming to awareness.
• Ruminations – forced preoccupation with thoughts about a particular topic, associated with brooding and inconclusive speculation.
• Cognitive rituals – elaborate series of mental acts the client feels compelled to complete.
• Compulsive motor rituals – elaborate rituals of everyday functioning such as grooming, dressing, eating, washing or checking doors or appliances.
• Other symptoms – chronic anxiety, low self-esteem, difficulty expressing positive feelings and depressed mood.

Nursing Diagnoses

• Anxiety
• Powerlessness
• Ineffective verbal communication
• Self-esteem disturbance
• Impaired social interaction
• Risk for injury
• Sleep pattern disturbances
• Ineffective breathing pattern

Nursing Interventions

1. Limit, but do not interrupt, the compulsive acts.
2. Teach the client to use alternate coping methods to decrease anxiety.
3. Client’s behavior maybe frustrating to staff and family. Power struggles often result. Consistency to the approach to care is critical.
4. Assess the client’s needs carefully.
5. Provide an environment that has structure and predictability as a strategy to decrease anxiety.
6. Risk associated with the use of alcohol and drug abuse.

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Major Depressive Disorder

Description

• A mood disorder may include symptoms of depressed mood, feelings or hopelessness and helplessness, decreased interest in usual activities, disinterest in relationship with others or cycles of depression and mania.
• Depression is often concurrent with other psychiatric diagnoses. Almost have of clients with major depressive disorders have histories of non-mood psychiatric disorders.
• A high incidence exists for persons with chronic illness or prolonges hospitalization or institutional care.

Risk Factors

1. Biological factors – brainchemicals
2. Family genetics – parent with depression, child 10-13% risk of depression.
3. Gender – higher rate for women
4. Age – often less than 40 when begins
5. Marital status – more frequently single, widowed
6. Season of year – Seasonal Affective Disorder (SAD) occurs when client experiences recurrent depression that occurs annually at the same time.
7. Psychological influences – low self-esteem, unresolved grief.
8. Environmental factors – lack of social support, stressful life events.
9. Medical co-morbidity – clients with chronic or terminal illness, postpartum, and current substance abuse are especially prone to becoming depresses.

Signs and Symptoms

1. Sexual disinterest
2. Suicidal and homicidal ideations
3. Decrease in personal hygiene
4. Tearfulness, crying, and melancholy
5. Altered thought process; difficulty concentrating, self-destructive behavior.
6. Loss of energy or restlessness
7. Anhedonia or loss of pleasure
8. Gain or loss of weight
9. Anger, self-directed
10. Psychomotor retardation or agitation
11. Insomnia or hypersomnia
12. Feelings of hopelessness, worthlessness, and helplessness.

Nursing Diagnoses

• Risk for violence, self-directed or directed at others
• Impaired verbal communication
• Decisional conflict
• Altered role performance
• Hopelessness
• Deficit in diversional activity
• Fatigue
• Sel-care deficit
• Altered thought processes
• Self-esteem
• Anxiety

Therapeutic Nursing Management

1. Safe environment
2. Psychological treatment
   • Individual psychotherapy – long –term therapeutic approach or short term solution-oriented, may focus on in-depth exploration, specific stress situations, or problem solving.
   • Behavioral therapy – modifying behavior to assist in reducing depressive symptoms and increasing coping skills.
   • Behavioral contacts – focus on specific client problems and need to help the client resolve them.
3. Social treatment
   • Milieu therapy – incorporates day to day living experiences in a therapeutic environment to expect changes in perception and behavior.
   • Family therapy – aimed at assisting the family cope with the client’s illness and supporting the client in therapeutic ways.
   • Group therapy – focuses on assisting clients with interpersonal communication, coping, and problem-solving skills.
4. Psychopharmacologic and Somatic treatments
   • Administer antidepressant medications
   • Continued assessment by monitoring client’s mental health status is critical, particularly interms of agitation and suicidal ideation.
   • Electroconvulsive therapy

Nursing Interventions

1. Priority for care is always the client’s safety.
2. Use of behavioral contacts. Use this technique to meet outcomes relating to “no self-harm” or no suicidal ideation or plan.
3. Assess regularly for suicidal ideation or plan.
4. Observe client for distorted, negative thinking.
5. Assist client to learn and use problem solving and stress management skills.
6. Avoid doing too much for the client, as this will only increase client’s dependence and decrease self-esteem.
7. The nurse’s role in the physical care of the client experiencing major depressive disorder is to provide assessment and interventions related to appropriate nutrition, fluids, sleep, exercise, and hygieme, and to provide health education.
8. Explore meaningful losses in the client’s life.
9. Help the client and family to identify the internal and external indicators of major depressive disorder.

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Diseases Common Signs and Symptoms

Name of Disease Signs and Symptoms ACROMEGALY Coarse facial feature ADDISON’S DISEASE bronze like skin pigmentation ANGINA Crushing stubbing pain relieved by NTG APPENDICITIS rebound tenderness ASTHMA wheezing on expiration BLADDER CA painless hematuria BPH reduced size & force of urine BULIMIA chipmunk face CATARACT Painless vision loss, Opacity of the lens, blurring of vision CHICKEN POX Vesicular Rash (central to distal) dew drop on rose petal CHOLERA rice watery stool CUSHING’S SYNDROME moon face appearance and buffalo hump. CYSTIC FIBROSIS Salty skin CYSTITIS burning on urination DENGUE petechiae or (+) Herman’s sign. DIPTHERIA pseudo membrane formation DKA Kussmauls breathing (Deep Rapid RR) DM polyuria, polydypsia, polyphagia DOWN SYNDROME protruding tongue DUCHENNE’S MUSCULAR DYSTROPHY Gowers’ sign (use of hands to push one’s self from the floor) DVT Homan’s Sign EMPHYSEMA barrel chest EPIGLOTITIS 3Ds’ Drooling, Dysphonia, Dysphagia FIBRIN HYALIN Expiratory Grunt GERD Barretts esophagus (erosion of the lower portion of the esophageal mucosa) GLAUCOMA Painfull vision loss, tunnel/gun barrel/halo vision (Peripheral Vision Loss) Guillain Barre Syndrome ascending muscle weakness HEPATIC ENCEPHALOPATHY Flapping tremors HODGKIN’S DSE/LYMPHOMA painless, progressive enlargement of spleen & lymph tissues, Reedstenberg Cells HYDROCEPHALUS Bossing sign (prominent forehead) HYPERTHYROIDISM/GRAVE’S DISEASE exopthalmus HYPOCALCEMIA Chvostek & Trosseaus sign INCREASE ICP HYPERtension BRADYpnea BRADYcardia (Cushing’s Triad) INFECTIOUS MONONUCLEOSIS Hallmark: sore throat, cervical lymph adenopathy, fever INTUSSUSCEPTION sausage shaped mass, Dance Sign (empty portion of RLQ) KAWASAKI SYNDROME strawberry tongue LEPROSY lioning face LIVER CIRRHOSIS spider like varices LTB inspiratory stridor LYME’S DSE Bull’s eye rash MALARIA stepladder like fever with chills MEASLES koplik’s spots. MENIERE’S DSE Vertigo, Tinnitus MENINGITIS Kernig’s sign (leg flex then leg pain on extension), Brudzinski sign (neck flex = lower leg flex). MG descending muscle weakness MI Crushing stubbing pain which radiates to left shoulder, neck, arms, unrelieved by NTG MS Charcot’s Triad (IAN) PANCREATITIS Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners spots. PARKINSON’S Pill-rolling tremors PDA machine like murmur PEMPHIGUS VULGARIS Nikolsky’s sign (separation of epidermis caused by rubbing of the skin) PERNICIOUS ANEMIA red beefy tongue PNEUMONIA rusty sputum PTB low-grade afternoon fever PYLORIC STENOSIS olive like mass RETINAL DETACHMENT Visual Floaters, flashes of light, curtain vision RETINO BLASTOMA Cat’s eye reflex (grayish discoloration of pupils) SHOCK HYPOtension TACHYpnea TACHYcardia SLE butterfly rashes TEF 4Cs’ Coughing, Choking, Cyanosis, Continous Drooling TETANUS risus sardonicus. TETANY hypocalcemia (+) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm) TYPHOID rose spots in abdomen. ULCERATIVE COLITIS recurrent bloody diarrhea

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