Michele Personality Disorder Basics

Well here we are, welcome to week four. This week we are going to be discussing personality disorders, and there are nine personality disorders that we will be talking about. If we begin by just defining what personality order is, it’s gonna help us understand what a personality disorder is. So what is a personality? Well a personality is a distinct set of traits that a person has, behaviour styles and patterns that make up their individual character. So how we perceive the world, our attitudes, thoughts and feelings, are all part of our personality. So a normal personality would be, the ability to cope with normal stressors, and have no problems forming relationships with family, friends, or people that we work with. So what is a personality disorder, then? It is an enduring pattern of experiences and behaviours that deviate significantly from what’s expected of a person in our society. So individuals who are diagnosed with a personality disorder will exhibit three main areas of concern in their day to day functioning, and that is: They’ll have disruptive thoughts and emotions, they will have difficulty participating in relationships, and they will have difficulty managing their impulses. So these areas of difficulty create significant problems in their ability to live, and it disrupts the quality of their life, for the person who has the personality disorder, and for all their family and friends, or others that they interact with. So there is no cure for a personality disorder, and personality disorders are how they are, so it’s very difficult for us to change those disorders, because that is internal being that has been created over time. So we have to remember that personality disorders are not diagnosed typically until after the age of 18, because the brain is still developing and is not fully developed until a person is 21-22 years of age, so therefore the thought is that the personality could change while they are growing up, and so therefore it’s usually not diagnosed until after 18. So here’s a slide regarding the prevalence of personality disorders and the comorbidity issues with that. So 10 to 15% of the general population has some type of personality disorder, it often coexists with depression and anxiety because they are not able to deal with everyday stressors and they don’t have appropriate coping mechanisms, again, onset usually occurs before the onset of actual psychiatric disorders, or mental health illnesses, so a personality disorder may be the first thing that is diagnosed, and it may progress to a more severe mental health disorder. Sometimes personality disorders can coexist, so for instance maybe, you have an anti- social personality disorder combined with an avoidant. Okay, and we’ll get into the specific personality disorders in the upcoming lectures, for now we’re just kinda talking in general terms. So personality disorders are common, research has shown that approximately one in ten persons meet the criteria for having a personality disorder. Most people who have a personality disorder also struggle with depression, anxiety, maybe eating disorders, and substance abuse. Again, here’s that theme, substance abuse seems to come into every conversation when we’re talking about mental illness. There always seems to be a coexistence of substance abuse, so that shouldn’t become a surprise anymore that that is one of the comorbidities. Most patients who have a personality disorder often display traits of another personality disorder, which we kind of already talked about. So common characteristics of a personality disorder, is there’s gonna be some type of stress in their life, and since they have an inability to cope with stress in a positive manner, what they’re gonna exhibit is rigid, inflexible, and maladaptive coping behaviours, which then will lead to problems related to working, relationships, and being able to participate in society. So they are unable to respond to change or demands in life, and that’s what starts this cycle. Persistent patterns of thought, emotion, and behaviours that are not experienced as uncomfortable, or disorganized, by the individual, they feel that their behaviour is normal, so they do not see that they have a personality disorder, or that their emotions, thoughts, or behaviours are different than anybody else, they cannot see that. They have difficulty dealing with other people, they lack insight into how others are perceiving them, or how they should be acting in certain situations, and all of them, all of them, have some type of self-esteem issue, which results in them having difficulty participating in social events. So what our goals, as nurses, are going to be, is not to be their friend, but to provide professional care. It’s difficult to treat people with personality disorders because they are resistant to change, and there are no meds that will affect a personality disorder, so our goal, basically, is to provide professional care, and they will have to be referred to some kind of long-term counseling or psychotherapy to deal with their maladaptive thought processes. So what is the Etiology of personality disorders? Well, there is some thought that genetics plays a role in this, genetics are thought to influence the development of a personality disorder, but they haven’t actually found an individual gene that they can pinpoint to say, “Well this is the gene that causes this personality disorder.” But they do believe that there is some association between genetics and personality traits. Again, neurobiological, they have found that the size and function of the different brain regions is different in people with personality disorders. They have found abnormalities with the frontal lobe, temporal lobe, and parietal lobes, in these individuals. As far as neurotransmitter activity goes, they believe that there is an impact, or a decrease in serotonin levels, and a decrease in the MAO enzyme that causes this personality disorders. There is some thought, also, that there are environmental factors, so it is believed that children learn maladaptive behaviours over time from the parents, through modeling and reinforcement. They have also found that children that are harshly disciplined, have a negative home environment, or have experienced some trauma. So that can be abuse: physical, emotional, or sexual abuse, do tend to develop personality disorders. So what are some common defense mechanisms that people develop over time to deal with their problems that causes these personality disorders? Well, repression is one, and that is where it’s a temporary forgetting of the unpleasant or unwanted experiences. So an example of repression would be: After fighting with her husband, the wife forgets to pick up his dry-cleaning, that’s a repressive kind of behaviour. Suppression is another maladaptive coping mechanism, and that’s just a conscious denial of what is going on, so you’re just suppressing your feelings regarding the situation. So this might be, say, a teen doesn’t want to get her period after having, Err… no, excuse me, the teen doesn’t get her period after having unprotected sex, but consciously she denies that she is pregnant, and she suppresses that, she does not seek medical help. So it’s a conscious denial of the facts. Another maladaptive is undoing, that’s when a person makes up for an act or a communication. So an example of this is: If a person, a woman, is flirting with another man, and her husband finds out, she might buy him a gift to make up for her bad behaviour. That would be an undoing kind of coping mechanism. So splitting is a very common one, splitting means that, you might be this person’s best friend, until you do something that makes them angry, and then you’re all bad. So an example of this would be: A new client might like you, and talk to you, and tell all the other staff that you’re the best person, the best nurse in the whole wide world. But then, the minute you disappoint them, or frustrate the patient, they quickly shift, and start talking bad about you to the other staff, how you really stink. So that would be an instance of splitting. So where are we going with all these different maladaptive coping mechanisms? Well, interventions for us, the nurse, is going to be, to identify what these coping mechanisms are that the person is using, and then, we are going to put steps in place to try and stop that behaviour. So, manipulation is a very common mechanism that people with personality disorders will try and use to get what they want, so what nursing might do, is to make plans where there is only one nurse that handles that particular patient, because what they will do when they’re trying to manipulate, is they will try to play between the nurses, so they might try and get something from one nurse, and if that nurse says no, then they may go to a different nurse, and that is how they try to manipulate the situation. So by identifying one nurse that deals with all of that patient’s needs and concerns eliminates this possibility for them to create conflict between the staff. We want to keep open communication with the client, and ongoing supervision. So when we’re assessing personality disorders, we’re going to want to get a full medical history again, the full medical history will help us determine if the problem is psychiatric, medical, or possibly both. We’re going to take a psycho-social history, past physical, sexual, or emotional abuse is going to be important, any thoughts of risk, to harming themselves, or harming anybody else, would require an immediate intervention on our part, to keep the patient and others safe. We’re going to evaluate if they take any medication, because depending on what medication they are on, it would be a good indicator for us, if there is some psychopharmalogical agents that can clue us in to some possible other problems that the patient may not be sharing with us. All of our patients are going to be at risk, all of the personality disorder patients are going to be at risk for suicide, substance abuse, accidental injury, if they are having changes in their perceptions and their thought processes, they’re going to be in danger of taking part in risky behaviours, which can result in injury. They are all at risk for depression, and possibly homicide, especially if they are having paranoid or antisocial kind of thought processes going on. So, very common, when we’re doing our psycho-social history, we’re gonna want to ask them about any difficulties they have with handling money, if they’ve had any legal interactions in the past, and again of that abuse. Those three components are very common in personality disorders, so the first thing that might clue you in, or clue them in or family members in, is them having difficulty being able to handle money. What we’re going to be looking at, is have they ever been through any outpatient therapy, or have they ever been referred for therapy. Typically, if we are referring people for cognitive behavioural therapy, it would be, like, one time a week, and usually those sessions last six to twenty weeks, and that is to address those thoughts and behaviours that are being affected through the personality disorders. Okay, I’m gonna stop there, and our next lecture is going to focus on Cluster A personality disorders.

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