Thursday, May 4, 2017

Personality Disorders

Defined as individual traits that reflect chronic, inflexible, and maladaptive patterns of behavior, personality disorders cause social discomfort and impair social and occupational functioning. Although no statistics document the number of cases of personality disorder, these disorders are known to be widespread. Most patients with a personality disorder don’t receive treatment; when they do, they’re typically managed as outpatients.

According to the classification system of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition – Text Revision, personality disorders fall on Axis II. Knowing the features of personality disorders helps provide a more complete picture of the patient and a more accurate diagnosis. For example, many features characteristic of personality disorders are apparent during an episode of another mental disorder (such as a major depressive episode in a patient with compulsive personality features).
Personality disorders typically begin before or during adolescence and early adulthood and persist throughout adult life. The prognosis varies.
Only recently have personality disorders been categorized in detail, and research continues to identify their causes. Various theories attempt to explain the origin of personality disorders.
Biological theories hold that these disorders may stem from chromosomal and neuronal abnormalities or head trauma.
Social theories hold that the disorders reflect learned responses, having much to do with reinforcement, modeling, and aversive stimuli as contributing factors.
Psychodynamic theories hold that personality disorders reflect deficiencies in ego and superego development and are related to poor mother-child relationships that are characterized by unresponsiveness, overprotectiveness, or early separation.
Clinical Features
Each specific personality disorder produces characteristic signs and symptoms, which may vary among patients and within the same patient at different times. In general, the history of the patient with a personality disorder will reveal long-standing difficulties in interpersonal relationships, ranging from dependency to withdrawal, and in occupational functioning, ranging from compulsive perfectionism to intentional sabotage.
The patient with a personality disorder may show any degree of self-confidence, ranging from no self-esteem to arrogance. Convinced that his behavior is normal, he avoids responsibility for its consequences, often resorting to projections and blame.
Personality disorders are difficult to treat. Successful therapy requires a trusting relationship in which the therapist can use a direct approach. The type of therapy chosen depends on the patient’s symptoms.
Drug therapy is ineffective but may be used to relieve acute anxiety and depression. Family and group therapy usually are effective.
Hospital inpatient milieu therapy can be effective in crisis situations and possibly for long-term treatment for borderline personality disorders. Inpatient treatment is controversial, however, because most patients with personality disorders don’t comply with extended therapeutic regimens; for such patients, outpatient therapy may be more useful.
Paranoid personality disorder
  • Avoid situations that threaten the patient’s autonomy.
  • Approach the patient in a straightforward and candid manner, adopting a professional, rather than a casual or friendly, attitude. Remember that remarks intended to be humorous are easily misinterpreted by the paranoid patient.
  • Provide a supportive and nonjudgmental environment in which the patient can safely explore and verbalize his feelings.
Schizoid personality disorder
  • Remember that the schizoid patient needs close human contact but is easily overwhelmed. 
  • Respect the patient’s need for privacy, and slowly build a trusting, therapeutic relationship so that he finds more pleasure than fear in relating to you.
  • Give the patient plenty of time to express his feelings. Keep in mind that if you push him to do so before he’s ready, he may retreat.
Borderline personality disorder
  • Encourage the patient to take responsibility for himself. 
  • Don’t attempt to rescue him from the consequences of his actions
  • Don’t try to solve problems that the patient can solve himself.
  • Maintain a consistent approach in all interactions with the patient, and ensure that other staff members do so as well.
  • Recognize that the patient may idolize some staff members and devalue others.
  • Don’t take sides in the patient’s disputes with other staff members.
Histrionic personality disorder
  • Give the patient choices in care strategies, and incorporate his wishes into the treatment plan as much as possible. By increasing his sense of self-control, you’ll reduce his anxiety.
  • Deal with the patient in a professional way. He may be uncomfortable with a casual approach.
Narcissistic personality disorder
  • Respond positively to the patient’s sense of entitlement. A critical attitude may cause him to become even more demanding and difficult.
  • Focus on positive traits or on feelings of pain, loss, or rejection.
Avoidant personality disorder
  • Assess the patient for signs of depression. Impaired social interaction increases the risk of affective disorders.
  • Establish a trusting relationship with the patient. Be aware that he may become dependent on the few staff members whom he believes he can trust.
  • Make sure that the patient has plenty of time to prepare for all upcoming procedures. This patient can’t handle surprises well.
  • Inform the patient when you will and will not be available if he needs assistance.
Dependent personality disorder
  • Initially, give the patient explicit directives, rather than ask him to make decisions. Later, encourage him to make easy decisions, such as what to wear or which television program to watch. Continue to provide support and reassurance as his decision-making ability improves.
  • Obsessive-compulsive personality disorder
  • Allow the patient to participate in his own treatment plan by offering choices whenever possible.
  • Adopt a professional approach in your interactions with the patient. Avoid informality; this patient expects strict attention to detail.

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