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Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 20: Personality Disorders Instructor’s Manual Thoughts About Teaching the Topic Students may have had little experience in relating to individuals with personality disorders (PDs). The behaviours demonstrated by these patients are among the most challenging for novices to understand and deal with therapeutically. It is helpful for students to have an opportunity to operationalize intervention strategies in a safe environment via use of roleplaying or case studies before working with a patient. Role-playing can be used to demonstrate manipulation, impulsiveness, splitting, devaluation of others, suspiciousness, blaming and accusing others, and demanding behaviours. Key Terms and Concepts antisocial personality disorder avoidant personality disorder borderline personality disorder dialectical behaviour therapy (DBT) narcissistic personality disorder obsessive-compulsive personality disorder persona personality personality disorders schizotypal personality disorder splitting Objectives Analyze the interaction of biological determinants and psychosocial stress factors in the etiology of personality disorders. Identify and distinguish among the three clusters of personality disorders. Identify six personality disorders. Describe the major characteristics of schizotypal, antisocial, borderline, narcissistic, avoidant, and obsessive-compulsive personality disorders and give an example of each. Describe the emotional and clinical needs of nurses and other staff when working with patients who meet criteria for personality disorders. Formulate a nursing diagnosis for each of the personality disorders. Discuss two nursing outcomes for patients with borderline personality disorder. Plan basic nursing care interventions for a patient with impulsive, aggressive, or manipulative behaviours. Instructor’s Manual 20-2 Identify the role of the advanced-practice nurse when working with patients with personality disorders. Chapter Outline Teaching Strategies Clinical Picture Personality disorders (PDs) involve long-term and repetitive use of maladaptive and often self-defeating behaviours. People with PDs do not recognize their symptoms as uncomfortable; thus they do not seek treatment unless a severe crisis occurs. All PDs have four characteristics in common: (1) inflexible and maladaptive response to stress, (2) disability in working and loving, (3) ability to evoke interpersonal conflict, and (4) capacity to frustrate others. People with PDs tend to be perceived as aggravating and demanding by health care workers, so the potential for value judgements is high, and effective care is at risk. Cluster A Personality Disorders Characteristics of patients with the various cluster A disorders are listed below. Paranoid Personality Disorder Characteristics: suspicious of others; fear others will exploit, harm, or deceive them; fear of confiding in others (fear personal information will be used against them); misread compliments as manipulation; hypervigilant; prone to counterattack; hostile and aloof. Psychotic episodes may occur in times of stress. To counteract patient fear, nurses should give straightforward explanations of tests, history taking, procedures, adverse effects of drugs, changes in treatment plan, and possible further procedures. Schizoid Personality Disorder Characteristics: avoids close relationships, is socially isolated, has poor occupational functioning, and appears cold, aloof, and detached. Social awareness is lacking, and relationships generate fear and confusion in the patient. Nurses should strive for simplification and clarity to help decrease patient anxiety. Schizotypal Personality Disorder Characteristics: ideas of reference; magical thinking or odd beliefs; perceptual distortions; vague, stereotyped speech; frightened, suspicious, blunted affect; distant and strained social relationships. These patients tend to be frightened and suspicious in social situations. Explanations can ease their anxiety. Cluster B Personality Disorders The clinical characteristics of patients with cluster B disorders follow. Antisocial Personality Disorder Characteristics: has superficial charm, violates rights of others, exploits others, lies, cheats, lacks guilt or remorse, is impulsive, acts out, and lacks empathy. As patients, these individuals are extremely manipulative and aggressive. Nurses must establish and adhere to a plan of care and maintain clear boundaries if they are to minimize patient manipulation and acting out. Borderline Personality Disorder Characteristics: unstable, intense relationships; identity disturbances; impulsivity; self-mutilation; rapid mood shifts; chronic emptiness; intense fear of abandonment; splitting; and anger. A major defence is splitting (alternating between idealizing and devaluing). Self-mutilation and suicide-prone behaviour are frequently seen. Anger is intense and pervasive, and help with anger management is an important intervention. Relationship building, safety, and limit setting are other foci. Histrionic Personality Disorder Characteristics: centre of attention; flamboyant; seductive or provocative behaviours; shallow, rapidly shifting emotions; dramatic expression of emotions; overly concerned with impressing others; exaggerates degree of intimacy with others; self-aggrandizing; preoccupied with own appearance. Experience depression when admiration of others is not given. Suicide gestures may result in patient entry into the health care system. A thorough assessment of suicide potential must be undertaken and support offered in the form of clear parameters of psychotherapy. Narcissistic Personality Disorder Characteristics: grandiosity, fantasies of power or brilliance, need to be admired, sense of entitlement, arrogant, patronizing, rude, overestimates self and underestimates others. This behaviour covers a fragile ego. In health care setting, such a patient demands the best of everything. When patient is corrected, when boundaries are defined, or when limits are set on patient’s behaviour, patient feels humiliated, degraded, and empty. To lower anxiety, the patient may launch a counterattack. The nurse should gently help the patient identify sense of entitlement, attempts to seek and become perfect, grandiose behaviour. Cluster C Personality Disorders Characteristics found in patients with cluster C disorders follow. Avoidant Personality Disorder Characteristics: social inhibition, feelings of inadequacy, hypersensitivity to criticism, preoccupation with fear of rejection and criticism, and self-perceived to be socially inept. Low self-esteem and hypersensitivity grow as support networks decrease. Demands of workplace often overwhelming. Project that caregivers will harm them through disapproval and perceive rejection where none exists. Nurses can teach socialization skills, provide positive feedback, and build selfesteem. Dependent Personality Disorder Characteristics: inability to make daily decisions without advice and reassurance, need of others to be responsible for important areas of life, anxious and helpless when alone, and submissive. Solicit caretaking by clinging. Fear abandonment if they are too competent. Experience anxiety and may have coexisting depression. Obsessive-Compulsive Personality Disorder Characteristics: preoccupied with rules, perfectionistic, too busy to have friends, rigid control, and superficial relationships. Complains about others’ inefficiencies and gives others directions. Epidemiology and CoMorbidity In the general population, is 10% to 15%, depending on severity. Personality disorders are predisposing factors for many other psychiatric disorders and may coexist with depression, panic disorder, substance use disorders, eating disorders, anxiety disorders, PTSD, somatic symptom disorders, dissociative disorders, and impulse control disorders. Etiology It’s unlikely that there is a single cause for a discrete personality disorder. These disorders are the result of complex biological and psychosocial phenomena that are influenced by multifaceted variables involving genetics, neurobiology, chemistry, and environmental factors. Biological Factors Genetics Genetics are thought to influence the development of personality disorders, but individual genes are not believed to be associated with particular personality traits. Neurobiological Influences on the development of personality disorders likely incorporate a complex interaction of genetics, neurobiology, and neurochemistry. Psychological Factors Learning theory, cognitive theories, and psychoanalytic theory may help to explain the development of personality disorders. Diathesis–Stress Model This model explains psychopathology using a systems approach. Under times of stress, this model proposes that the personality development becomes maladaptive for some people, resulting in the emergence of a personality disorder. Many studies have suggested a strong correlation between trauma, neglect, and other dysfunctional family or social patterns of interaction and the development of personality disorders. Assessment The preferred method for determining a diagnosis of personality disorder is the semi-structured interview obtained by clinicians. The Minnesota Multiphasic Personality Inventory (MMPI) is useful to evaluate personality via self-reporting. Patient History The nurse should seek information about the medical history; suicidal or homicidal ideation; current use of medications and other substances, food, and money; involvement with the courts; and current or past physical, sexual, or emotional abuse. Information about the patient’s current level of crisis and dysfunctional coping styles should be sought. Self-Assessment The nurse may experience intense feelings of confusion, helplessness, anger, and frustration. The patient may attempt to manipulate or disparage the nurse, create conflict via splitting or faction forming. Support and supervision for the nurse are essential. Diagnosis Useful diagnoses include Ineffective coping, Anxiety, Risk for other-directed violence, Risk for self-directed violence, Impaired social interaction, Social isolation, Fear, Disturbed thought processes, Defensive coping, Self-mutilation, Chronic low self-esteem, and Ineffective therapeutic regimen management. Outcomes Identification Realistic goal setting is important because change occurs so slowly. Small steps are necessary. Examples include minimizing self-destructive or aggressive behaviour; reducing the effect of manipulative behaviours; linking consequences to both functional and dysfunctional behaviours; initiating functional alternatives to prevent a crisis; ongoing management of anger, anxiety, shame, and happiness. Planning Patients with personality disorders are usually admitted to psychiatric institutions for reasons other than their personality disorder. Most often seen are borderline and antisocial patients. The former are impulsive, suicidal, self-mutilating, aggressive, manipulative, and even psychotic under stress. The latter are manipulative, aggressive, and impulsive. Implementation When patients blame and attack others, the nurse needs to understand the context—that the attacks spring from feeling threatened. The nurse must orient the patient to reality whenever the patient imputes malevolent intentions to the nurse or others and reassure the patient that even though the caregiver has been insulted or threatened, the patient will still be helped and protected. The nurse must explain how people, systems, families, and relationships work and acknowledge shortcomings and limitations. Milieu Management The goal of milieu therapy is affect management within a group context. Nurses must help patients verbalize feelings rather than act them out. Pharmacological Interventions Patients with personality disorders may be helped by a broad array of psychotropic agents, all geared toward maintaining cognitive function and relieving symptoms. Antipsychotics may be useful for brief periods to control agitation, rage, and brief psychotic episodes. Medication compliance is usually an important issue; patients with PD are fearful about taking something over which they have no control. Case Management Case management is geared toward reducing the necessity for hospitalization. Advanced-Practice Interventions Research shows that treatment can be effective for many individuals with personality disorders, especially when a comorbid major mental disorder is targeted. Psychotherapy Dialectical behaviour therapy (DBT) has shown favourable results with patients with personality disorders. It combines cognitive and behavioural techniques with mindfulness, which emphasizes being aware of thoughts and actively shaping them. Evaluation The nurse should not measure personal self-esteem based on a patient’s ability to change, since the ability to change is severely limited in patients with PD. Some students, especially those who are visually oriented, find using a concept map helpful in learning. Following is a concept map for PDs. Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 21: Sleep–Wake Disorders Instructor’s Manual Thoughts About Teaching the Topic Many faculty will choose not to use lecture time for the topic of sleep disorders and instead assign the chapter as required or recommended reading. Others may integrate the material into other contexts that include sleep disorders. Key Terms and Concepts confusional arousal disorders dyssomnias excessive sleepiness (ES) hypersomnia disorder insomnia disorder sleep architecture sleep continuity sleep deprivation sleep efficiency sleep fragmentation sleep hygiene sleep latency sleep restriction stimulus control Objectives Discuss the impact of inadequate sleep on health and well-being. Describe the social and economic impact of sleep disturbance and chronic sleep deprivation. Identify the risks to personal and community safety imposed by sleep disturbance and chronic sleep deprivation. Describe normal sleep physiology, and explain the variations in normal sleep. Differentiate between insomnia and hypersomnia, and identify at least two examples of each. Identify the predisposing, precipitating, and perpetuating factors for patients with insomnia. Identify and describe the use of two assessment tools in the evaluation of patients experiencing sleep disturbance. Develop a teaching plan for a patient with insomnia, incorporating principles of sleep restriction, stimulus control, and cognitive-behavioural therapy. Formulate three nursing diagnoses for persons experiencing a sleep disturbance. Develop a nursing care plan for the person experiencing sleep disturbance incorporating basic sleep hygiene principles. Chapter Outline Teaching Strategies Sleep The National Sleep Foundation (2008) recommends that the average adult get seven to nine hours of sleep each night, yet epidemiological surveys suggest that mean sleep duration among Canadian adults has decreased during the past century (Hurst, 2008; Williams, 2001), and over three million Canadians report ongoing difficulties with sleep (Morin, LeBlanc, Belanger, et al., 2011). Sleep deprivation means that people are not getting an optimal amount of sleep every night, which can lead to chronic fatigue, memory problems, energy deficit, mood difficulties, and feeling generally out of sorts. Many attribute this problem to the fact that we now have 24-hour-a-day access to supermarkets, airports, and other services. Nurses, physicians, and other personnel work rotating shifts, averaging only 5 hours of sleep nightly. During the last century, it is estimated that the average nightly sleeping time has been reduced by 2 hours. Consequences of Sleep Loss The major consequence of acute or chronic sleep curtailment is excessive sleepiness. This is serious enough to impact social and vocational functioning and increase the risk for accident or injury. Normal Sleep Cycle REM (rapid eye movement) sleep is different from NREM (non– rapid eye movement) sleep. NREM is a peaceful state compared to wakefulness; REM sleep is characterized by a high level of brain activity and physiological activity levels that are similar to the waking state. During a night’s sleep, people usually begin with NREM sleep and proceed to the REM latency period. The cycling between NREM and REM sleep is regular, with REM sleep occurring every 90 to100 minutes. The first REM cycles each night usually last less than 10 minutes, whereas the following REM periods the rest of the night can last from 15 to 40 minutes each. Regulation of Sleep Researchers have identified anatomic areas that promote sleep, but regulation of sleep is not totally understood. It is thought that any change in neurotransmitters such as serotonin, norepinephrine, and acetylcholine can have an impact on the sleep cycle. Functions of Sleep It is believed that sleep serves to restore and maintain homeostasis. Sleep Requirements Requirements for sleep are individual. Some people are considered short sleepers, whereas others are considered long sleepers. Most adults require 7 to 8 hours of sleep for optimal functioning, but a small percentage of individuals are “long sleepers,” requiring 10 or more hours a night, or “short sleepers,” needing less than 5 hours a night. The body has a natural internal clock that follows a 25-hour cycle. Biological rhythms, including a woman’s menstrual cycle, also influence sleep. The myth that a daytime nap compensates for lack of night-time sleeping is untrue. This is important to note for those who work in occupations that require shift rotation. The average of several nights’ undisturbed sleep is probably a good estimate of total sleep requirement (Epstein, 2007). Sleep Patterns Sleep patterns evolve over a person’s lifetimefrom newborns, where REM sleep comprises more than 50% of total sleep time, through advancing age, where sleep becomes lighter and includes less REM sleep. Sleep–Wake Disorders The DSM-5 classifies sleep–wake disorders—broadly called dyssomnias—into three major categories: insomnia, hypersomnia, and confusional arousal disorders, with a variety of subtypes for each (Reynolds, Redline, & DSM-V Sleep-Wake Disorders Workgroup and Advisors, 2010). Additional clusters of sleep–wake disorders include those related to breathing and circadian rhythm. Diagnostic criteria for all include disturbed sleep causing marked distress and impaired daytime functioning. Primary Sleep Disorders Dyssomnias Dyssomnias are problems initiating or maintaining sleep. Insomnias In primary insomnia, individuals have difficulty falling asleep and staying asleep. This type of sleep is also nonrestorative. This condition must last for 1 month and is not related to any known physical or medical condition. In order to diagnose any sleep disorder, there must be a thorough medical and psychiatric history. It is necessary to explore the entire 24-hour period with respect to sleep–wake behaviours. The principal diagnostic tool for primary insomnia is polysomnography. The treatment of primary insomnia includes several effective approaches, such as the use of medications: alprazolam (Xanax), chlordiazepoxide (Librium, Novapam), triazolam (Halcion), and others. Increasingly, melatonin is being used by older adults to deal with insomnia, and there are nonpharmacological interventions, including various relaxation therapies. Sleep restriction therapy is another intervention that is useful in dealing with insomnia and is directed at reducing the amount of time spent awake in bed. Hypersomnias Confusional Arousal Disorders Parasomnias are characterized by unusual or undesirable behaviours that intrude into sleep or occur at the threshold between waking and sleeping. Treatment for parasomnias includes reduction of stress and other measures to protect the patient, such as use of a dental bite plate for sleep-related bruxism. Some medications can also be used for treatment of parasomnias. Other Sleep Disorders Epidemiology An estimated three million Canadians suffer from a chronic disorder of sleep and wakefulness (Tjepkema, 2005). Sleep-related problems are highly prevalent and occur across all age groups, cultures, and genders. Co-Morbidity Sleep apnea is associated with hypertension, heart failure, and diabetes. Sleep deprivation leads to the production of fewer infection-fighting antibodies, thereby increasing our vulnerability to infection. Chronic sleep loss might lead to earlier onset and an increase in severity of diabetes and obesity. Age-related diseases such as arthritis and Alzheimer’s disease are affected by sleep as well. Sleep loss diminishes safety and results in loss of lives and property, especially when individuals are working in occupations where they are expected to work shifts around the clock. Prolonged sleep deprivation is linked to hallucinations and delusions. Current research indicates a relationship between sleep and dream disturbances and post-traumatic stress disorder. There is also a correlation between sleep and relapse to alcoholism and drug addiction. Application of the Nursing Process A sleep assessment allows the nurse to identify short- and long-term health risks associated with sleep disorders and sleep deprivation, provide health teaching and counselling regarding sleep needs, and improve clinical outcomes in patients with a sleep disturbance. Assessment Sleep Patterns In assessing the patient with a sleep complaint, it is important to recognize the 24-hour nature of the sleep disturbance. Identifying Sleep Disorders It is helpful to think about sleep disorders according to the predominant symptoms of insomnia, hypersomnia, and confusional arousal disorders (Box 21-2). Functioning and Safety The nurse can ask the patient to keep a sleep diary (see sample in text) to begin to look for patterns and find solutions to the sleep problems identified. There is also a set of important questions to ask the patient who is having difficulty with a sleep disorder. These are listed in the text and include a variety of screening tools. Self-Assessment Rotating, long shifts and night work make nurses particularly vulnerable to sleep deprivation and sleep disruption. Inadequate sleep time and quality impair judgement and performance. Attention to issues of sleep hygiene, overtime work, and shift work is essential. Diagnosis Four nursing diagnoses are appropriate for sleep disturbance : Sleep deprivation, Insomnia, Readiness for Enhanced Sleep, and Risk for Injury (NANDA 1, 2011). Outcomes Identification The Nursing Outcomes Classification (NOC) identifies a number of appropriate outcomes for the patient experiencing primary insomnia, including Rest, Sleep, Risk control, and Personal well-being. See Table 21-1. Planning Most patients with sleep disorders are treated in the community unless the patient has a primary psychiatric disorder or a medical condition that requires hospitalization. The role of the nurse is generally to conduct a full assessment, to provide support to the patient and family while interventions are determined, and to teach the patient and family strategies that may improve sleep. Implementation Counselling This begins with the assessment of the sleep disorder and support and assurance that the sleep problems are amenable to treatment. Health Teaching and Health Promotion There are many myths regarding sleep and what “good sleep” really is. The nurse’s role as a health teacher cannot be overemphasized. See Box 21-1 for educational points for teaching how to obtain good sleep. The nurse can also teach the patient relaxation techniques and effective use of medications. Pharmacological Interventions Many patients will use medication for sleep problems. The nurse can provide education about the benefits of a particular drug, adverse effects, untoward effects, and the fact that medications are usually prescribed for no more than 2 weeks because of the dangers of tolerance and withdrawal. Advanced-Practice Interventions The advanced-practice nurse may be involved in cognitivebehavioural therapy to improve sleep. Evaluation The evaluation is based on whether or not the patient experiences improved sleep quality and can be accomplished through patient report and through the maintenance of the sleep diary. The patient’s perception is also an important part of the evaluation process. Instructor Manual for Varcaroliss Canadian Psychiatric Mental Health Nursing Margaret J. Halter, Cheryl L. Pollard, Susan L. Ray, Mary Haase, Sonya Jakubec, Elizabeth M. Varcarolis 9781926648330, 9781771721400

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