Nursing Care for Patient with Personality Disorders

Transcription

1 Nursing Care for Patient with Personality Disorders, MNS, RN Division of Mental Health and Psychiatric Nursing

2 Definition Personality is essentially an enduring pattern of perceiving relating and thinking about the environment. Personality is the style a person adopts to deal with the world. Personality traits are stylistic peculiarities that all people bring to social relationships, including shyness, seductiveness, rigidity, suspiciousness, or passive-aggressive. Personality traits are flexible and adaptive. (Varcarolis, 2013: 214)

3 Definition Personality disorders are diagnosed when personality traits become inflexible and maladaptive and significantly interfere with how a person functions in society or cause the person emotional distress. (Vidibeck, 2014) Personality disorders are diagnosed when personality traits exaggerated and rigid to point that they cause dysfunction in their relationship. (Varcarolis, 2013: 214)

4 General Criteria for a Personality Disorders A. An enduring pattern of inner experience and behavior the deviates markedly from the expectations of the individual s culture. This pattern is manifested in two (or more) of the following areas: Cognition (i.e., way of perceiving and interpreting self, other people and events) Affectivity (i.e., the range, intensity, liability, and appropriateness of emotional response) Interpersonal functioning Impulse control

5 General Criteria for a Personality Disorder B. The enduring pattern is inflexible and pervasive across a board range of personal and social situations. C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.

6 General Criteria for a Personality Disorder E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug abuse, a medication) or a general medical condition (e.g., head trauma)

7 Cause Biological factors genetic/familial factors neurotransmitter dysregulation: Serotonin Environment factors Parenting raising Emotional abuse Psychological factors, Dopamine Psychoanalytic theory ---> Psychosexual development, Structure of mind Learning theory ---> Modeling Cognitive theory

8 Categories of Personality Disorders DSM-IV TR (2002) Categories of Personality Disorders Cluster A: Individuals whose behavior appears odd or eccentric (paranoid, schizoid, and schizotypal personality disorders) Cluster B: Individuals who appear dramatic, emotional, or erratic (antisocial, borderline, histrionic, and narcissistic personality disorders) Cluster C: Individuals who appear anxious or fearful (avoidant, dependent, and Obsessive-compulsive personality disorders)

9 DSM-IV TR Diagnostic criteria: Symptoms of Dependent personality disorder A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: has difficulty making everyday decisions without an excessive amount of advice and reassurance from others needs others to assume responsibility for most major areas of his or her life

10 DSM-IV TR Diagnostic criteria: Symptoms of Dependent personality disorder has difficulty expressing disagreement with others because of fear of loss of support or approval. Note: Do not include realistic fears of retribution. has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy) goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant

11 DSM-IV TR Diagnostic criteria: Symptoms of Dependent personality disorder feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself urgently seeks another relationship as a source of care and support when a close relationship ends is unrealistically preoccupied with fears of being left to take care of himself or herself

12 DSM-IV TR Diagnostic criteria: Symptoms of Antisocial personality disorder There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following: failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure impulsivity or failure to plan ahead

13 DSM-IV TR Diagnostic criteria: Symptoms of Antisocial personality disorder irritability and aggressiveness, as indicated by repeated physical fights or assaults reckless disregard for safety of self or others consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

14 DSM-IV TR Diagnostic criteria: Symptoms of Borderline personality disorder A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood are present in a variety of contexts, as indicated by five (or more) of the following: frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criteria 5 a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

15 DSM-IV TR Diagnostic criteria: Symptoms of Borderline personality disorder identity disturbance: markedly and persistently unstable self-image or sense of self impulsivity in at least two areas that are potentially self-damaging recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior affective instability due to a marked reactivity of mood inappropriate, intense anger or difficultly controlling anger transient, stress-related paranoid ideation or severe dissociative symptoms

16 Treatment Medication Psychotherapy Behavior therapy Milieu therapy

17 Nursing Process

18 Assessment Assessment guidelines (Varcarolis, 2013) Assess for suicidal or homicidal thoughts. If these are present, the patient will need immediate attention. Determine whether the patient has a medical disorder or another psychiatric disorder that may be responsible for the symptoms. View the assessment of personality functioning from within the person s ethic, cultural, and social background.

19 Assessment Assessment guidelines (Varcarolis, 2013) Ascertain whether the patient experienced a recent important loss. PDs are often exacerbated after the loss of a significant supporting person or as the result of a disruptive social situation. Evaluate for a change in personality in middle adulthood or later, which signals the need for a thorough medical workup or assessment for unrecognized substance use disorder. Assess for current use of medicines and illegal substances. Assess for ability to handle money and legal history.

20 Nursing Diagnosis NANDA Nursing Diagnosis (Ackley & Ladwig, 2014) Personality disorders Ineffective activity planning related to unrealistic perception of events Impaired individual resilience related to psychological disorder

21 Nursing Process NANDA Nursing Diagnosis (Ackley & Ladwig, 2014) Dependent personality disorder Ineffective coping Chronic low self-esteem Impair social interaction Social Isolation

22 Nursing Diagnosis NANDA Nursing Diagnosis (Ackley & Ladwig, 2014) Antisocial personality disorder Defensive coping related to excessive use of projection Ineffective coping related to frequently violating the norms and rules of society Impaired social interaction related to sociocultural conflict, inability to form relationships Risk for self-mutilation: Risk factor: self-hatred Risk for other-directed violence: Risk factor: history of violence, altered thought patterns

23 Nursing Diagnosis NANDA Nursing Diagnosis (Ackley & Ladwig, 2014) Borderline personality disorder Ineffective activity planning related to unrealistic perception of events Defensive coping related to difficulty with relationships, inability to accept blame for own behavior Ineffective coping related to use of maladjusted defense mechanisms (projection, denial)

24 Nursing Diagnosis NANDA Nursing Diagnosis (Ackley & Ladwig, 2014) Borderline personality disorder Social isolation related to immature interests: Risk for self-mutilation: Risk factor: ineffective coping, feelings of self-hatred Risk for self-directed violence: Risk factor: feelings of need to punish self, manipulative behavior

25 Planning Appropriate goals for caring for a person with a personality disorder in a community or hospital setting include: Develop a relationship with the person based on empathy and trust, whilst also maintaining appropriate boundaries. Ensure duty of care responsibilities are appropriately addressed, with regards to treatment for the presenting medical and physical issues and by remaining alert to suicide risk.

26 Planning Promote effective and functional coping and problem solving skills, in a way that is empowering to the person. Promote the person s development of and engagement with their support network, including access to appropriate service providers. Support and promote self-care activities for families and career of the person with the personality disorder

27 Nursing Intervention Nursing Intervention for Dependent personality disorder Foster client s self-reliance and autonomy Teach problem-solving and decision-making skills Cognitive restructuring technique

28 Nursing Intervention Nursing Intervention for Antisocial personality disorder Limit setting Confrontation Teach client to solve problems effectively and manage emotions of anger or frustration Consistent adherence to rules and treatment plan Enhancing role performance

29 Nursing Intervention Nursing Intervention for Borderline personality disorder Promote client s safety: No-self-harm contract, Safe expression of feelings and emotions Help client to cope and control emotions Cognitive restructuring techniques Teach social skills Teaching effective communication skills Therapeutic relationship

30 Evaluation The client will demonstrate behaviors that lead to resolution of identified problems. The client will explore coping skills and work to develop appropriate solutions to problems. The client will interact with people and become involved in both social and therapeutic activities. The client will identify and discuss feelings that impede social interactions.

31 Evaluation The client will begin to participate in both social and therapeutic activities. The client will report the absence of self-destructive thoughts and behaviors. The client will learn to express strong feelings in a nondestructive manner. The client will demonstrate the skills necessary to develop and sustain interpersonal relationships. The client will verbalize a realistic assessment of life situations and ask for assistance to solve problems as needed.

32 Reference รณช ย คงสกนธ. (2555). บ คล กภาพผ ดปกต. ใน มาโนช หล อตระก ล และปราโมทย ส คน ชย (บรรณาธ การ), จ ตเวชศาสตร รามาธ บด (หน า ). (พ มพ คร งท 3). กร งเทพมหานคร: ภาคว ชาจ ตเวชศาสตร คณะแพทยศาสตร โรงพยาบาลรามาธ บด มหาว ทยาล ยมห ดล. นภว ลย ก มพลาศ ร. (2557). การพยาบาลบ คคลท ม บ คล กภาพแปรปรวน (Nursing Care for Persons with Personality Disorders). ใน อ จฉราพร ส ห ร ญวงศ, ประภา ย ทธไตร, พวงเพชร เกสรสม ทร และวาร ร ตน ถาน อย (บรรณาธ การ), การพยาบาลจ ตเวชศาสตร (Psychiatric Nursing) (หน า ). กร งเทพมหานคร: สายธ รก จโรงพ มพ บร ษ ท อมร นทร พร นต งแอนด พ บล ชช ง. มาโนช หล อตระก ล และปราโมทย ส คน ชย. จ ตเวชศาสตร รามาธ บด. (พ มพ คร งท 3). กร งเทพมหานคร: ภาคว ชาจ ตเวชศาสตร คณะแพทยศาสตร โรงพยาบาลรามาธ บด มหาว ทยาล ยมห ดล ส วน ย เก ยวก งแก ว. (2554). การพยาบาลจ ตเวช. (พ มพ คร งท 2). กร งเทพมหานคร: โรงพ มพ มหาว ทยาล ยธรรมศาสตร. American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders. (4 th ed., text reversion). Washington DC: American Psychiatric Association. Ackley, B. J. & Ladwig, G. B. (2014). Nursing Diagnosis Handbook: An Evidence-Base Guide to Planning Care. (10 th ed.). Maryland Heights, MO: Elsevier Mosby. Varcarolis, E, M. (2013). Essentials of Psychiatric Mental Health Nursing. St. Louis, MS: Elsevier Saunders. Videbeck, S. L. (2014). Psychiatric-Mental Health Nursing. (4 th ed). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Videbeck, S. L. (2014). Psychiatric-Mental Health Nursing. (6 th ed). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

33 Thank you