PERSONALITY DISORDERS

Abnormal Psychology - Let's start with a question. NORMAL - what does it mean to you? This word seems to mean very different things to different people and especially, in different situations.How many of us here would say we are normal? What if asked to evaluate your own intelligence - would you say your intelligence level or ability is "normal"? Is normal average? Certainly the word average constitutes the majority, and isn't it the majority that determines what is normal? Is normality simply fitting within the confines of the majority - in other words, being average? I. Basic Issues A. What is "abnormal" behavior? 1. Contributes to maladaptiveness in an individual 2. Considered deviant by a culture (thus it is culture specific) 3. Leads to personal psychological distress 4. unusual, rare, but not necessarily bizarre B. What are some common myths about abnormality? 1. Bizarre 2. Different in kind 3. dangerous 4. Shameful 5. Self-induced C. Let's take a closer Look at each component 1. Maladaptive Behavior a) an inability to handle daily life events For example, many people drink, but when drinking interferes with social and/or professional life it can be considered maladaptive. b) this is a very important component in diagnosing problems such as drug abuse 2. Deviant Behavior a) behavior that falls outside the boundaries deemed acceptable by a culture For example: *men wear kilts in Scotland, *living arrangements in villages in Papua New Guinea 3. Personal Psychological Distress y not necessarily overt behavior...reports of feelings of sadness, anxiety, etc., to friends and/or family. y important in determining and diagnosing psychological disorders 4. Unusual but not necessarily bizarre like deviant behavior, this is often governed by the culture. But, now we also include personal history, experiences, race, religion, etc. Behavior on a Continuum Many textbooks do good jobs of explaining how behavior can be viewed on a continuum from normal to abnormal as opposed to ONLY normal or abnormal. WHY this is important: 1. It is difficult to accurately distinguish normal from abnormal On occasion don't we all have some personal distress? 2. We have ALL displayed some abnormal behavior at some point in our lives
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**the key is how much of each and how often do they occur. Introduction A group of mental conditions characterized by abnormal experiences or behavior with respect to thinking, mood, personal relations and impulse control. People with personality disorders have a long-term history of behaviors and experiences that don't conform to the expectations of their culture or society. The behavior of sufferers can cause them stress or reduced ability with respect to their personal, social and working life. Examples of personality disorders include avoidant personality disorder and obsessivecompulsive personality disorder. Definition: A personality disorder is a type of mental illness in which you have trouble perceiving and relating to situations and to people including yourself. There are many specific types of personality disorders. The totality of emotional and behavioral characteristics that are particular to a specific person and that remain somewhat stable and predictable over time. In general, having a personality disorder means you have a rigid and unhealthy pattern of thinking and behaving no matter what the situation. This leads to significant problems and limitations in relationships, social encounters, work and school. In some cases, you may not realize that you have a personality disorder because your way of thinking and behaving seems natural to you, and you may blame others for the challenges you face. Historical aspects The concept of a personality disorder has been described for thousands of years (Phillips, Yen, & Gunderson, 2003). In the 4th century B.C., Hippocrates concluded that all disease stemmed from an excess of or imbalance among four bodily humors: yellow bile, black bile, blood, and phlegm. Hippocrates identified four fundamental personality styles that he concluded stemmed from excesses in the four humors: the irritable and hostile choleric (yellow bile); the pessimistic melancholic (black bile); the overly optimistic and extraverted sanguine (blood); and the apathetic phlegmatic (phlegm). Within the profession of medicine, the first recognition that personality disorders, apart from psychosis, were cause for their own special concern was in 1801, with the recognition that an individual can behave irrationally even when the powers of intellect are intact. Nineteenth-century psychiatrists embraced the term moral insanity, the concept of which defines what we know today as personality disorders.Historically, individuals with personality disorders have been labeled as bad or immoral and as deviants in the range of normal personality dimensions. Symptoms: Clinical Symptoms and Diagnostic Characteristics: Clinical Symptoms CHANGES IN THE FOLLOWING AREAS: y Cognition y Emotional responses (affect) y Interpersonal functioning y Impulse control
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Diagnostic Characteristics y Evidence of an enduring pattern of behavior and inner experience in at least above y Stable, long-lasting pattern exhibited as a marked deviation from that which individual's culture y Onset most likely traceable to adolescence or early adulthood y Pattern widespread, occurring over personal and social situations y Resultant distress in important areas of functioning y Pattern not associated with or due to a medical condition or another mental General symptoms of a personality disorder Personality disorder symptoms include: y y y y y Frequent mood swings Stormy relationships Social isolation Angry outbursts Suspicion and mistrust of others y y y y y Difficulty making friends A need for instant gratification Poor impulse control Alcohol or substance abuse Specific types of personality disorders

III. DSM-III-R Diagnostic Categories The DSM-III-R groups the personality disorders into three clusters: Cluster A: disorders marked by odd or eccentric behaviors.  Paranoid  Schizoid  Schizotypal Cluster B: disorders characterized by dramatic, emotional or erratic behaviors.  Antisocial  Borderline  Histrionic  Narcissistic Cluster C: disorders characterized by anxious or fearful behaviors.  Avoidant  Dependent  Obsessive compulsive  Passive aggressive Cluster A personality disorders These are personality disorders characterized by odd, eccentric thinking or behavior and include: a) Paranoid personality disorder Prevalence is difficult to establish because individuals with the disorder seldom seek assistance for their problem or require hospitalization. The disorder is more commonly diagnosed in men than in women y Distrust and suspicion of others
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y Believing that others are trying to harm you y Emotional detachment y Hostility,stubborn, and defensive y rigid and uncompromising b) Schizoid personality disorder Prevalence of schizoid personality disorder within the general population has been estimated at between 3 and 7.5 percentdiagnosed more frequently in men. y Lack of interest in social relationships y Limited range of emotional expression y Inability to pick up normal social cues y Appearing dull or indifferent to others c) Schizotypal personality disorder Studies indicate that approximately 3 percent of the population has this disorder y Peculiar dress, thinking, beliefs or behavior y Perceptual alterations, such as those affecting touch y Discomfort in close relationships y Flat emotions or inappropriate emotional responses d) Indifference to others y "Magical thinking" believing you can influence people and events with your thoughts y Believing that messages are hidden for you in public speeches or displays Cluster B personality disorders These are personality disorders characterized by dramatic, overly emotional thinking or behavior and include: a) Antisocial (formerly called sociopathic) personality disorder 3 percent in men to about 1 percent in women more common among the lower socioeconomic classes, particularly so among highly mobile residents of impoverished urban areas y Disregard for others y Persistent lying or stealing y Recurring difficulties with the law y Repeatedly violating the rights of others y Aggressive, often violent behavior y Disregard for the safety of self or others b) Borderline personality disorder Prevalence estimates of borderline personality range from 2 to 3 percent of the population. It is the most common form of personality disorder, occurring in every culture (Phillips, Yen, & Gunderson, 2003). It is more common in women than in men, with female to male ratios being estimated as high as 4 to 1. y Impulsive and risky behavior y Volatile relationships y Unstable mood y Suicidal behavior
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y Fear of being alone c) Histrionic personality disorder Prevalence of the disorder is thought to be about 2 to 3 percent, and it is more common in women than in men. y Constantly seeking attention y Excessively emotional y Extreme sensitivity to others' approval y Unstable mood y Excessive concern with physical appearance d) Narcissistic personality disorder It occurs in 2 to 16 percent of the clinical population and less than 1 percent of the general population. It is diagnosed more often in men than in women. y Believing that you're better than others y Fantasizing about power, success and attractiveness y Exaggerating your achievements or talents y Expecting constant praise and admiration y Failing to recognize other people's emotions and feelings Cluster C personality disorders These are personality disorders characterized by anxious, fearful thinking or behavior and include: a) Avoidant personality disorder Prevalence of the disorder in the general population is between 0.5 and 1 percentappears to be equally common in men and women. y Hypersensitivity to criticism or rejection y Feeling inadequate y Social isolation y Extreme shyness in social situations y Timidity b) Dependent personality disorder More common in women than in men and more common in the youngest children of a family. y Excessive dependence on others y Submissiveness toward others y A desire to be taken care of y Tolerance of poor or abusive treatment y Urgent need to start a new relationship when one has ended c) Obsessive-compulsive personality disorder Relatively common and occurs more often in men than in women. Within the family constellation, it appears to be most common in oldest children. y Preoccupation with orderliness and rules y Extreme perfectionism
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y y y

Desire to be in control of situations Inability to discard broken or worthless objects Inflexibility

Obsessive-compulsive personality disorder isn't the same as obsessive-compulsive disorder, a type of anxiety disorder. d) Passive Aggressive Personality Disorder An individual with this disorder is indirect in his/her communications and actions. Rather than just saying "no, I don't want to", he/she engages in all sorts of indirect resistances. She/he finds ways of not doing what she/he is supposed to, but never through direct refusal; rather she/he procrastinates, dawdles, makes mistakes, etc. The name of this disorder implies that the passive behaviors are a cover for feelings of resentfulness and hostility. So, rather than directly expressing the anger, the person passively expresses it through indirect means. Prevalence and sex ratio: Unknown

When to see a doctor

y If you have any signs or symptoms of a personality disorder, see your doctor, mental health provider or other health care professional. Untreated, personality disorders can cause significant problems in your life, and they may get worse without treatment. Helping a loved one If you have a loved one who you think may have symptoms of a personality disorder, have an open and honest discussion about your concerns. You may not be able to force someone to seek professional care, but you can offer encouragement and support. You can also help your loved one find a qualified doctor or mental health provider and make an appointment. You may even be able to go to an appointment with him or her. If you have a loved one who has harmed himself or herself, or is seriously considering doing so, take him or her to the hospital or call for emergency help.

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Causes
Personality is the combination of thoughts, emotions and behaviors that makes you unique. It's the way you view, understand and relate to the outside world, as well as how you see yourself. Personality forms during childhood, shaped through an interaction of two factors: 1. Inherited tendencies, or your genes. These are aspects of your personality passed on to you by your parents, such as shyness or having a happy outlook. This is sometimes called your temperament. It's the "nature" part of the nature vs. nurture debate. 2. Environment, or your life situations. This is the surroundings you grew up in, events that occurred, and relationships with family members and others. It includes such things as the type of parenting you had, whether loving or abusive. This is the "nurture" part of the nature vs. nurture debate.

Personality disorders are thought to be caused by a combination of these genetic and environmental influences. You may have a genetic vulnerability to developing a personality disorder and your life situation may trigger the actual development of a personality disorder. Risk factors Although the precise cause of personality disorders isn't known, certain factors seem to increase the risk of developing or triggering personality disorders, including:        A family history of personality disorders or other mental illness Low socioeconomic status Verbal, physical or sexual abuse during childhood Neglect during childhood An unstable or chaotic family life during childhood Being diagnosed with childhood conduct disorder Loss of parents through death or traumatic divorce during childhood

Personality disorders often begin in childhood and last through adulthood. There's reluctance to diagnose personality disorders in a child, though, because the patterns of behavior and thinking could simply reflect adolescent experimentation or temporary developmental phases.

Complications
Complications and problems that personality disorders may cause or be associated with include: y y y y y y y Depression Anxiety Eating disorders Suicidal behavior Self-injury Reckless behavior Risky sexual behavior y y y y y y y Alcohol or substance abuse Aggression or violence Incarceration Relationship difficulties Social isolation School and work problems Preparing for your appointment

Child abuse In some cases, a health care provider or other professional may ask you about your mood, thoughts or behavior. Your doctor may bring it up during a routine medical appointment if you seem to be sad, agitated or angry, for instance. Or you may decide to schedule an appointment with your family doctor or primary care provider to talk about your concerns. In either case, because personality disorders often require specialized care, you may be referred to a mental health provider, such as a psychiatrist or psychologist, for evaluation and treatment. In other cases, you may seek out a mental health provider on your own first. What you can do Being an active participant in your care can help your efforts to manage your personality disorder. One way to do this is by preparing for your appointment. This may be especially important when you have a personality disorder that tends to create difficult relationships with medical professionals.
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Think about your needs and goals for treatment. Also, write down a list of questions to ask. These may include:          What type of personality disorder might I have? Why can't I get over a personality disorder on my own? How do you treat my type of personality disorder? Will psychotherapy help? Are there medications that might help? How long will treatment take? What can I do to help myself? Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

In addition to the questions that you've prepared to ask, don't hesitate to ask questions at any time during your appointment if you don't understand something. What to expect from your doctor During your appointment, your doctor or mental health provider is likely to ask you a number of questions about your mood, thoughts, behavior and urges. You may be asked such questions as:          When did you first notice symptoms? How is your daily life affected by your symptoms? What other treatment, if any, have you had? What have you tried on your own to feel better or control your symptoms? What things make you feel worse? Have your family members or friends commented on your mood or behavior? Have any relatives had a mental illness? What do you hope to gain from treatment? What medications or over-the-counter herbs and supplements do you take?

Tests and diagnosis When doctors believe someone has a personality disorder, they typically run a series of medical and psychological tests and exams. These can help rule out other problems that could be causing your symptoms, pinpoint a diagnosis and also check for any related complications. These exams and tests generally include: a) Physical exam. This may include measuring height and weight, checking vital signs, such as heart rate, blood pressure and temperature, listening to your heart and lungs, and examining your abdomen. b) Laboratory tests. These may include a complete blood count (CBC), a screening test for alcohol and drugs, and a check of your thyroid function. c) Psychological evaluation. A doctor or mental health provider talks to you about your thoughts, feelings, relationships and behavior patterns. He or she asks about your symptoms, including when they started, how severe they are, how they affect your daily life and whether you've had similar episodes in the past. You'll also discuss any thoughts you may have of suicide, self-injury or harming others.
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Diagnostic criteria The symptoms and clinical features for each personality disorder are detailed in a book called the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental illnesses and by insurance companies to reimburse for treatment. To be diagnosed with a particular personality disorder, you must meet the criteria for that disorder listed in the DSM. Each personality disorder has its own set of diagnostic criteria.

Treatments and drugs

The treatment that's best for you depends on your particular personality disorder, its severity and your life situation. Often, a team approach is appropriate to make sure all of your psychiatric, medical and social needs are met. Because personality disorders tend to be chronic and can sometimes last much of your adult life, you may need long-term treatment. The team involved in treatment may include your:       Family doctor or primary care provider Psychiatrist Psychotherapist Pharmacist Family members Social workers

If you have mild symptoms that are well controlled, you may need treatment from only your family doctor, a psychiatrist or a therapist. If possible, find medical and mental health providers with experience in treating personality disorders. Several treatments are available for personality disorders. They include:     Psychotherapy Medications Hospitalization Successful treatment depends on your active participation in your care.

Psychotherapy Psychotherapy is the main way to treat personality disorders. Psychotherapy is a general term for the process of treating personality disorders by talking about your condition and related issues with a mental health provider. During psychotherapy, you learn about your condition and your mood, feelings, thoughts and behavior. Using the insight and knowledge you gain in psychotherapy, you can learn healthy ways to manage your symptoms. Types of psychotherapy used to treat personality disorders may include: 1. Cognitive behavioral therapy. This combines features of both cognitive and behavior therapies to help you identify unhealthy, negative beliefs and behaviors and replace them with healthy, positive ones.
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2. Dialectical behavior therapy. This is a type of cognitive behavioral therapy that teaches behavioral skills to help you tolerate stress, regulate your emotions and improve your relationships with others. 3. Psychodynamic psychotherapy. This therapy focuses on increasing your awareness of unconscious thoughts and behaviors, developing new insights into your motivations, and resolving conflicts to live a happier life. 4. Psychoeducation. This therapy teaches you and sometimes family and friends about your illness, including treatments, coping strategies and problem-solving skills. Psychotherapy may be provided in individual sessions, in group therapy or in sessions that include family or even friends. The type of psychotherapy that's right for you depends on your individual situation. Medications There are no medications specifically approved by the Food and Drug Administration to treat personality disorders. However, several types of psychiatric medications may help with variouspersonality disorder symptoms. 1. Antidepressant medications. Antidepressants may be useful if you have a depressed mood, anger, impulsivity, irritability or hopelessness, which may be associated with personality disorders. 2. Mood-stabilizing medications. As their name suggests, mood stabilizers can help even out mood swings or reduce irritability, impulsivity and aggression. 3. Anti-anxiety medications. These may help if you have anxiety, agitation or insomnia. But in some cases, they can increase impulsive behavior. 4. Antipsychotic medications. Also called neuroleptics, these may be helpful if your symptoms include losing touch with reality (psychosis) or in some cases if you have anxiety or anger problems. Hospitalization and residential treatment programs In some cases, a personality disorder may be so severe that you require psychiatric hospitalization. Psychiatric hospitalization is generally recommended only when you aren't able to care for yourself properly or when you're in immediate danger of harming yourself or someone else. Psychiatric hospitalization options include 24-hour inpatient care, partial or day hospitalization, or residential treatment, which offers a supportive place to live. Participating in your own care Try to be an active participant in your treatment. Working together, you and your doctor or therapist can decide which treatment options may be best for your situation, depending on your type of personality disorder, your symptoms and their severity, your personal preferences, insurance coverage, affordability, treatment side effects, and other factors. In some cases, a personality disorder may be so severe that a doctor, loved one or guardian may need to guide your care until you're well enough to participate in decision making. Lifestyle and home remedies You can do some things for yourself that build on your professional treatment plan. Along with professional treatment, consider following these lifestyle and self-care steps for personality disorders:
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1. Stick to your treatment plan. Don't skip therapy sessions, even if you don't feel like going. 2. Take your medications as directed. Even if you're feeling well, resist any temptation to skip your medications. If you stop, symptoms may come back. You could also experience withdrawal-like symptoms from stopping a medication too suddenly. 3. Learn about your condition. Education about your condition can empower you and motivate you to stick to your treatment plan. 4. Pay attention to warning signs. Work with your doctor or therapist to learn what might trigger your symptoms. Make a plan so that you know what to do if symptoms return. Contact your doctor or therapist if you notice any changes in symptoms or how you feel. Consider involving family members or friends in watching for warning signs. 5. Get active. Physical activity and exercise can help manage many symptoms, such as depression, stress and anxiety. Activity can also counteract the effects of some psychiatric medications that may cause weight gain. Consider walking, jogging, swimming, gardening or taking up another form of physical activity that you enjoy. 6. Avoid drugs and alcohol. Alcohol and illegal drugs can worsen personality disorder symptoms or interact with medications. 7. Get routine medical care. Don't neglect checkups or skip visits to your family doctor, especially if you aren't feeling well. You may have a new health problem that needs to be addressed, or you may be experiencing side effects of medication. Coping and support Coping with a personality disorder can be challenging. Having a personality disorder makes it hard to engage in the behavior and activities that may help you feel better. Talk to your doctor or therapist about improving your coping skills, and consider these tips: 1. 2. 3. 4. Simplify your life. Cut back on obligations when possible, and set reasonable schedules for goals. Write in a journal to express pain, anger, fear or other emotions. Read reputable self-help books and consider talking about them to your doctor or therapist. Don't become isolated. Try to participate in normal activities and get together with family or friends regularly. 5. Take care of yourself by eating a healthy diet and getting sufficient sleep. 6. Join a support group for people with your type of personality disorder so that you can connect to others facing similar challenges. 7. Stay focused on your goals. Recovery from a personality disorder is an ongoing process. Stay motivated by keeping your recovery goals in mind. Remind yourself that you're responsible for managing your illness and working toward your goals. 8. Learn relaxation and stress management. Try such stress-reduction techniques as meditation, yoga or tai chi. 9. Structure your time. Plan your day and activities. Try to stay organized. You may find it helpful to make a list of daily tasks. 10. Time your big decisions. Don't make important decisions when you're in the depths of a personality disorder, since you may not be thinking clearly.

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11. If you have a loved one with a personality disorder, work with his or her mental health provider to find out how you can most effectively offer support and encouragement. You may also benefit from talking with a mental health provider about the distress you almost certainly experience from being close to a person with a personality disorder. Mental illness can significantly disrupt the lives of both the affected person and those who care about him or her, and it's normal and healthy to need help coping. A mental health provider also can help you develop boundaries and self-care strategies so that you're able to enjoy and succeed in your own life without guilt. Prevention There's no sure way to prevent personality disorders. Trying to identify those most at risk, such as children living with neglect or abuse, and offering early intervention may help. Taking steps to control your stress, increase your resilience and boost low self-esteem also may offer benefits. Getting appropriate treatment early, and sticking with it for the long term, may prevent personality disorder symptoms from worsening. Nursing management of the Symptoms of Clients with Personality disorders For the client with a disturbance in cognition, helpful interventions may include the following. y Reinforce reality if the client verbalizes illusions or feelings of depersonalization. Help the client select someone he or she trusts to minimize suspicious or delusional thoughts. y Encourage the client to validate perceptions before taking action that may difficulties. y Explore with the client present maladaptive coping mechanisms and the purpose they serve. y Explore alternate coping mechanisms to reduce stress. y Assist the client to develop insight regarding the purpose of nursing interventions. If the client displays a disturbance in affect, try the following: y Encourage the client to verbalize feelings of anger, hostility, worthlessness, or hopelessness. y Give attention and support when the client expresses feelings honestly and openly. y Encourage the client to share his or her feelings with others. y Provide a safe environment if the client expresses suicidal ideation or exhibits behavior. For the client with a disturbance in interpersonal functioning, possible interventions following: y Explore reasons the client has difficulty establishing interpersonal relationships. y Explore the client's self-concept and self-esteem. y Explore the client's perception of how others view him or her. y Provide positive feedback regarding your observations of the client's strengths. y Encourage the client to socialize with at least one person daily. When the client exhibits dysfunctional behavior indicative of poor impulse control, interventions may be helpful: y State limits and behavior expected from the client. y Enforce all limits without apologizing. y Be direct, confronting the client when limits are not observed. y Discuss consequences of client's failure to observe limits. y Discuss behavior with the client in a nonjudgmental manner.
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Conclusion Clients with personality disorders are undoubtedly some of the most difficult ones health care workers are likely to encounter. Personality characteristics are formed very early in life and are difficult, if not impossible, to change. Nursing care of the client with a personality disorder is accomplished using the steps of the nursing process. Nurses who work in all types of clinical settings should be familiar with the characteristics associated with personality-disordered individuals. Nurses working in psychiatry must be knowledgeable about appropriate intervention with these clients, for it is unlikely that they will encounter a greater professional challenge than these clients present. References Book: 1. Mary Townsend, Psychiatric Mental Health Nursing, 5th edition, 2007, Jaypee brothers medical publishers, Page no: 715-43 2. Shives, Louise Rebraca, Basic Concepts of Psychiatric-Mental Health Nursing, 6th Edition 3. Copyright 2005, published by Lippincott Williams & Wilkins, page no: 335-54 4. Kaplan &Sadock. Comprehensive Textbook of Psychiatry, 8th Edition, Copyright 2005 Lippincott Williams & Wilkins, 2080-101 5. Clifford, Richard, introduction to psychology, 2004, Tata McGraw-Hill Publishing Company Limited, page no: 659-62. 6. Ernest R. Hilgard, Richard C. Atkinson, Introduction to Psychology, fifth edition, 1971, Harcourt Brace Jovanovich, Inc, page no:414-418 Net: 1. http://www.mayoclinic.com/print/personality-disorders/DS00562/METHOD=print&DSECTION=all 2. http://www.wrongdiagnosis.com/p/personality_disorders/intro.htm 3. http://www.alleydog.com/101notes/abnormal.html

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