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PSYCH/MENTAL HEALTH Study Guide - Exam 3
Compare and contrast the main characteristics of the following personality disorders: Antisocial, Narcissistic, Avoidant, Schizoid, Schizotypal, Paranoid, and
Borderline including signs and symptoms, behaviors, assessment, nursing interventions, and communication.
CLUSTER A DISORDERS
Odd or eccentric traits| unusual beliefs | avoid personal relationships | often indifferent
● SCHIZOID
○ Psychotic thinking/behavior
○ Impaired functioning (school, work, self-care, relationships)
○ Affect: Flat | Indifferent | Detachment | Disinterest | Uncooperative
○ May invest enormous energy in nonhuman interests (mathematics, astronomy)
■ often connect more with animals | are creative and original thinkers.
○ Tend to isolate - respect their decision.
● SCHIZOTYPAL
○ Impaired personality and functioning (NOT as severe as schizophrenia)
○ Odd Beliefs | Interpersonal Difficulties | Eccentric Appearance | Magical Thinking | Perceptual Distortions | Delusions/Hallucinations
○ Resembles schizophrenia without psychosis
○ Usually unhappy about their lack of relationships
○ Tend to isolate - respect their decision
● PARANOID
○ Appear businesslike and efficient, but generate fear and conflict in others
○ Find malice in benign comments and behaviors (ideas of reference) – often offended
○ Pervasive | Persistent | Inappropriate Suspiciousness and Distrust of Others (Unjustified) | Hostile | Irritable | Injustice Collectors | Jealous
| Lacking Warmth
Define and discuss and give examples of patient behaviors seen in cluster b personality disorders such as problems with impulse control, manipulation, splitting
and discuss best nursing interventions and most appropriate initial outcomes for patients exhibiting these behaviors.
CLUSTER B DISORDERS
Dramatic, emotional, or erratic traits | reactive | Poor impulse control | manipulation | unclear sense of identity
● ANTISOCIAL
○ Disregard for others with exploitation, lack of empathy,
○ Violation of others’ rights without remorse | lack responsibility | unlawful actions
○ Manipulative | Callous | Impulsive | Risky | Seductive
○ Sense of entitlement | Deceitfulness | Verbally charming and engaging
● NARCISSISTIC
○ Sense of entitlement | Lack Empathy | Sensitive to criticism
○ Arrogant | Grandiose views of self-importance and personal achievements
○ Haughty | Envious | Splitting or tantrums | Sadistic w/ paranoid tendencies | Exploiting others to meet their own needs
○ Expect special treatment | Attention Seekers | Needs consistent admiration
● BORDERLINE
○ Unstable Affect | Identity | Mood | Relationships
○ Splitting Behaviors | Manipulation (dishonesty to support their own agenda) | Impulsiveness | Fear of Abandonment
○ Self-Injurious/Suicidal | Emotional Lability | Emotional Dysregulation | Chronic Depression | Demands | Stormy Relationships
○ SPLITTING: inability to reconcile negative and positive attributes of self or others into a cohesive image client tends to characterize
people or things as all good or all bad at any particular moment.
■ Example “You are the worst person in the world.” Later that day, “You are the best, but the nurse from the last shift is
absolutely terrible.”
CLUSTER C DISORDERS
HIGHLY anxious, avoidant, fearful, insecure, inadequacy | inhibited, internalizing blame even if it’s not their fault
● AVOIDANT
○ Social inhibition | avoidance of all situations requiring interpersonal contact | Anxious
○ Feelings of inadequacy | Fear of rejection | low self-worth | hypersensitive to criticism | Social phobia | Withdrawn
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Caring for Patients with Personality Disorders
○ Defense mechanisms = repression, suppression, regression, undoing, and splitting.
○ RN - Perform Self-assessment
■ Clients can evoke intense emotions | repeat self-assessment after stressful client behavior
○ Therapeutic relationship is challenging d/t the client’s distrust or hostility, (loss of control, feeling threatened) have a firm/supportive
approach + consistent care
○ Use limit-setting and consistency when pt. is manipulative.
■ Set limits on manipulative behaviors such as arguing, begging, flattery, attention seeking, constant engagement in power
struggles, angry and/or demanding behavior. Intervene in manipulative behavior. Document behavior. Provide clear boundaries
and consequences and enforce them. All limits should be adhered to by staff.
■ Avoid promising to keep a secret, accepting gifts, doing favors for pt, discussing yourself or other staff with pt. Identify needs and
feelings preceding impulsive acts. Identify situations that trigger impulsivity, and discuss alternate behaviors.
○ Use Psychotherapy | Group therapy | Cognitive Behavior Therapy | Dialectical Behavior Therapy
MEDICATIONS FOR PERSONALITY DISORDERS
● Medications are not available for the treatment of PD per se, but treating the symptoms is helpful
● Medications with low toxicity are MOST appropriate due to the fact that those with personality disorders are at greatest risk for Self-Harm
○ Psychotropic Agents → provide relief from manifestations.
○ Antidepressant, Anxiolytic, Antipsychotic, or Mood Stabilizers
○ Benzodiazepines (maintenance dosing) for anxiety are not appropriate because of the potential for abuse and overdose; they may be used
in only emergency situations.
○ Selective Serotonin Reuptake inhibitors (SSRIs)—treat comorbidity depression and panic attacks.
○ Trazodone and venlafaxine—have low toxicity in overdose.
○ Carbamazepine—targets impulsivity, aggression, and self-harm.
○ Lithium, Anticonvulsants, SSRIs—minimize aggression.
○ Atypical Antipsychotics—help with psychotic features in Borderline Personality Disorder under stress.
● Nursing Diagnosis for Personality Disorders → Ineffective coping | Risk for other-directed violence | Impared parenting | Hopelessness | Risk for
Suicide | Noncompliance | Spiritual Distress
Define and give examples of dialectical behavior therapy and cognitive behavioral therapy discussing important components of the therapy their use in
borderline personality disorder.
● DIALECTICAL BEHAVIOR THERAPY →
○ Components: cognitive-behavioral therapy for clients who have a personality disorder and exhibit self-injurious behavior. This therapy
focuses on gradual behavior changes and provides acceptance and validation for these clients.
■ Focus is → Stabilizing patient, achieving behavioral control, regulating emotions, developing distress tolerance skills, and
constantly using crisis interventions
● Decreasing life-threatening suicidal behaviors, therapy-interfering behaviors, quality of life interfering behaviors,
increasing behavioral skills.
■ This is the MOST EFFECTIVE in patients with Borderline Personality Disorder and helping patients gain hope and QOL
○ Examples: DBT Coach provides support in “opposite action”, which focuses on changing unwanted negative emotions in the moment by
behaving in ways that are counter to the emotion’s action urge.
● COGNITIVE BEHAVIORAL THERAPY →
○ Components of therapy for BPD: uses both cognitive and behavioral approaches to assist a client with anxiety management. This therapy
takes into account what clients think influences their feelings and behaviors. focuses on individual thoughts and behaviors to solve current
problems. The belief is that thoughts come before feelings and actions. It treats depression, anxiety, eating disorders, and other issues that
can improve by changing a client’s attitude toward life experiences. Use of Cognitive reframing to help the client identify negative thoughts
that produce anxiety, examine the cause, and develop supportive ideas that replace negative self-talk.
○ Examples: Helpful for Depression, anxiety, eating disorders
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Discuss the best medication classification for treatment of depression for the patient diagnosed with borderline personality who may have control and
compliance issues related to medication. Discuss, define and give examples of common traits of individuals diagnosed with borderline personality disorder
such as fear of abandonment, chronic feelings of emptiness and the impact of anxiety producing thoughts, events and situations and the resulting maladaptive
behavioral responses.
● Borderline Personality Disorder → Characterized by instability of affect, identity, relationships, splitting behavior, manipulation, impulsiveness.
● Traits → Fear of abandonment | Chronic feelings of emptiness | Anxiety producing thoughts (Impact: ) | Self-injurious and potentially suicidal| Ideas
of reference are common | Very unstable relationships | Unstable affect
○ Cutting or sabotaging their treatment in some way
● Events & situations resulting in Maladaptive Behavior responses → Poor impulse control- example: overspending, reckless driving, substance abuse
reckless sexual behavior | Feelings of abandonment and emptiness- characterized by intense neediness and mistrust, overinvolvement followed by
withdrawal, idealization and devaluement- the demands drive people away
Treatment of Depression in patient with Borderline Personality Disorder
● Medication Classification:
○ Mood Stabilizers → Lithium carbonate or Anticonvulsants that act as mood stabilizers: valproate and carbamazepine (can also target
impulsivity, uncontrolled behaviors and self-harm; pg 178) treat acute mania | lamotrigine is used for maintenance therapy in bipolar
mania.
○ First-generation Antipsychotic Medications:
○ Second-generation Antipsychotic Medications: olanzapine and risperidone
○ Antidepressants: such as the SSRI fluoxetine, used to manage a major depressive episode
○ SSRI Trazodone and venlafaxine are good choices for depression because it is least toxic in overdose (pg 178)
○ Lithium, anticonvulsants and SSRI are helpful to minimize aggression (pg 178)
● Control Issues with medication: Medications with low toxicity are MOST appropriate due to the fact that those with personality disorders are at
greatest risk for Self-Harm (NOT MAOIs due to strict adherence to diet)
● Compliance Issues with medication:
Discuss Anorexia and Bulimia Nervosa identifying symptoms and characteristics of each, hospitalization criteria, treatment modalities, outcome criteria and the
highest priorities in terms of nursing diagnosis based on your physical assessment of each.
Eating disorders → Irrational misperception of body image.
● ANOREXIA NERVOSA
○ Symptoms: extreme thinness, amenorrhea, lanugo, cold intolerance, brittle hair/nails, constipation, lethargy decreased HR, RR, BP → Fear
of weight gain.
■ Self induced vomiting: use of laxatives and diuretics | Judges self-worth by weight | Controls what they eat to feel powerful to
overcome feelings of helplessness | Lanugo | Cachectic | Prominent parotid glands, if purging
■ Orthostatic changes, Bradycardia, Cardiac problems, Prolonged QT interval, WBC alterations, Electrolyte imbalances,
Osteoporosis, Fatty degeneration of the liver, Amenorrhea, Hematuria, Proteinuria, elevated cholesterol, abnormal functioning
thyroid, HYPOKALEMIA (volume depletion, stimulating aldosterone production, stimulates further potassium excretion from the
kidneys, indirect renal loss of potassium as well as loss via purging)
○ Characteristics: disturbance in self-perceived weight
■ Persistent energy intake restriction leading to significantly low body weight in context of age, sex, developmental path,
and physical health
■ body weight that < 85% of expected normal weight.
■ Fear of gaining weight or becoming fat | Disturbance in self-perceived weight or shape
■ Preoccupied with food and the rituals of eating, along with a voluntary refusal to eat.
■ Eating disorders are connected with underlying emotions of Anxiety | Dysphoria | Low self-esteem | lack of control
■ Peculiar handling of food: Cutting food into small bits | Pushing food around the plate| Maintaining a rigorous exercise regimen
○ Hospitalization criteria: Electrolyte abnormalities, HR<40 BPM, SBP< 70, arrhythmias, temp< 96 degrees, <75% of ideal body weight, loss o
>30% of body weight within 6 months, body fat < 10%, refusal to eat, inadequate response to outpatient therapy
○ Treatment Modalities: Treatment of underlying anxiety | Maintain healthy body weight | therapy with individual, family, and groups
○ Assessment: Appears in early-middle adolescence | Acknowledge emotional and physical difficulties | Assess for suicidal thoughts |
Monitor physiologic parameters (vitals, electrolytes) | Weight the patient using strict protocol | Monitor DURING and AFTER meals to
