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The Healthy Personality
A popular description of the components of the personality are borrowed from
a psychiatrist E. Berne, who wrote the book Games People Play. His work was
in developing Transactional Analysis, which is the study of the communication
or transaction that takes place between people. He described the concept of
EGO states. In his theory the three ego states that make up the personality
are the parent ego state, the adult ego state, and the child ego state. The
ego state is a consistent pattern of feeling, experiencing, and behaving. The
'parent' incorporates all the attitudes and behaviors that are taught by the
parent or parent substitute, the 'adult' deals with reality in a logical,
rational, reality oriented manner, and the 'child 'contains all the feelings
an individual has as a child. These feelings from the past can be remembered
or brought back by present experiences and re-experienced under some
circumstances.
A healthy personality can be described as the person who is involved in
positive interpersonal relationships, who can experience closeness and at the
same time maintain a separate identity. This closeness is what we call
intimacy and involves a sensitivity to the feelings of others and a mutual
validation. An interdependence in relationships, between dependence and
independence, creates a balance that is present in healthy relationships. The
acceptance of another person and openness to one's own feelings that are a
part of closeness, can be threatening to some and involve a risk that make
inimacy and closeness difficult or impossible to achieve.
People who have characteristics of a personality disorder have extreme
difficulty relating to others in a functional, intimate, and close fashion.
From 6-13% of the population in the U.S. that have a personality disorder.
Many of those go untreated ( 1/5 of these receive treatment) and many are
victims of suicide. Recent studies describe drug abuse and depression
prevalent among those with personality disorder who were victims of suicide.
A definition of personality: Deeply ingrained personal patterns of behavior,
traits, and thoughts that evolve, both consciously and unconsciously, as a
person's style and way of adapting to the environment. (Varcarolis, 1998).
Review Erik Erickson's stages of development for the test. He was a
psychoanalyist that followed Freud, expanding on Freud's stages to include
the full life cycle. Freud viewed the personality as being established by 5
years old and developed his theory from the study of neurotic and disturbed
personalities. Erickson's study of the healthy personality gave input to the
acceptance of stages from infancy to the aging years and death.
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Infancy (0-1 ½ yrs)
Early Childhood (1 1/2-3 yrs)
Late Childhood (3-6 yrs)
School Age ( 6-12 yrs)
Adolescence (12-20 yrs)
Early Adulthood (20-35 yrs)
Middle Adulthood (35-65 yrs)
Later Years ( 65 yr to Death)
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Trust vs Mistrust
Autonomy vs Shame and Doubt
Initiative vs. Guilt
Industry vs Inferiority
Identy vs. Role Confusion
Intimacy vs Isolation
Generativity vs Self-Absorption
Integrity vs Despair
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Be aware of Freud's stages:
Primary Conflict
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Oral (0-1 yr)
Anal (1-3 yrs)
Phallic (3-6 yrs)
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Weaning
Toilet Ttraining
Oedipus and Electra Complexes
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Tasks
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Latency (6-12 yrs)
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Growth of Ego Function to cope with the environment
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Genital (12 yrs and up)
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Developing satisfying emotional and sexual
relationships, emancipation from parents
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Personality
Disorganization in a Crises
Stressful events are a common part of life, as are crises. The onset of these
circumstances are unexpected and unwanted, but whether they are social,
psychological or biological they do occur in everyone's life. Nurse's make up
the largest body of health care workers, and are with the patient in all phases
of health care delivery. Nurse's are most often called upon to help people in
crises.
In 1961, a report on the Joint Commission on Mental Illness and Mental Health
brough out the need for Community mental health centers. From this report
came the establishment of Crises Centers, and the availability of crises
services. A crises is a disturbance caused by a stressful event or a
perceived event. The person's usual way of coping becomes ineffective causing
anxiety.
The Crises Theory was developed in the 1940's and in the 1960's crises
intervention was outlined. This crises theory, which has given us a sound way
of looking at the effects of crises on individuals, constitutes a sound basis
for applying the nursing process. An understanding of these three areas is
important:
1. Types of crises- Maturational, Situational, Adventitious ( crises from a
disaster, not everyday events) Common problems from crises are Post-traumatic
stress syndrome, depression.
2. Phases of a crises- Stress, anxiety, severe anxiety, (Crises) Personality
disorganization.
3. Aspects of a crises that have revelance for nurses ( involves knowledge of
crises ie self limiting, resolution levels, goals of crises intervention,
etc.)
4. A person may be going through two types of crises at the same time. For
example a 52 yo woman going through the mid-life crises may have just learned
her husband has cancer. This would be an example of a maturational crises and
a situational crises.
Later on in the course we will go over the focused and
time-limited treatment strategy that is helpful in assisting people cope with
stressful events. For this topic on Personality Disorders it is important to
bring this up as in the time of crises in a persons life, developmental
changes can result, or a personality disorganization can occur should the
stress from the crises be greater than the individual can cope with.
Personality Disorders
Persons with a personality disorder have difficulty developing healthy,
intimate relationships. In the range of human personality, there are healthy
characteristics that are independent and dependent, adaptive and tolerant of
solitude and working mutually with others. On the maladaptive end of the
spectrum involves a predominance of too much of one characteristic with a
lack of flexibility to move from one end of the spectrum to another. For
example the person with a personality disorder may be manipulative,
impulsive, narcisstic and have a history of problematic relationships.
Biological determinants
The most recent advances in psychobiology have shown that the development of
major personality disorders has a genetic component. Both environmental and
biological factors contribute to the onset of abnormal behavior due to a
personality disorder. A study done in 1993 measured preexisting temperment
and personality and came up with four inheritable traits:
1. Novelty seeking
2. Harm avoidance
3. Reward dependence
4. Persistence
This same research showed that people are born with their own unique
tolerance to stimulation or stress. Living in a family of similar personality
types may give one a feeling of familiarity, closeness, being connected and
understood. Being born into a family whose personality types differ may
predispose a person to feeling isolated and generally misunderstood. Such an
individual may become the scapegoat of the family and the target of the
others aggression.
One study of the antisocial personality found that genetic factors were more
important than environment. Low levels of serotonin have been found in
individuals with aggressive and impulsive behavior. Twin studies have shown
that antisocial behavior is inheritable. It shows how a biological
predisposition towards being antisocial and having in the environment
aggressive, hostile parents , deficient parental role modeling, can bring to
the surface this antisocial personality disorder.
There has also been found a close tie in between those with a borderline
personality and mood disorders. Findings have shown many biochemical
disruptions in those with abnormal behavior due to a personality or thought
disorder
Cultural factors Americans and
lonliness
Asians and homogenicity
Common Features
Patients with a personality disorder are challanging to nurses as they have
many needs. The nurse needs to understand the presenting problem, to make an
objective needs assessment, to be able to give skills instructions and
assistance in problem solving with follow through, and to evaluate the
nursing interventions. The emphasis on the nurse is that he/she has an
understanding of the psychodynamic, cultural and biological basis for their
maladaption to their internal world.
Commonly these individuals have a lack of ability to implement or tolerate
change. Also common is the inability to tolerate frustration and pain, making
the need for 'instant gratification' apparent in these patients. The other
characteristic that goes along with this is overreacting to stimuli. For
example a small, seemingly insignificant event may be perceived a a personal
crises with subsequent 'crises-like' behavior. Also a stressor may
precipitate a crises, when the normally adjusted personality may easily cope
with the stressor. For example a new job may be difficult to adjust to, as a
person is confronted with many new people and events and may precipitate a
depression or other personality crises.
Clusters The DSM IV has grouped the personality disorders into three
clusters due to similarities:
Cluster A- aloofness, anger, anxiety in social situations, eccentric
behavior, paranoid and suspicion of others, isolation, inability to form
social relationships, hyperactivity.
Cluster B-chronic irritability, frequent suicidal thoughts, poor
frustration tolerance, erratic alternating social withdrawal and
overinvolvement, manipulativeness, impulsiveness, detachment from loved ones,
anxiety, history of multiple jobs, controlling behavior, hypersensitivity to
criticism.
Cluster C-isolation, withdrawal, compulsive work habits, preoccupation
with work, inability to have fun with leisure activities, extreme criticism
of others, anxiety, fearfulness, inability to assume responsibility for
behavior.
Cluster A: Eccentric Personality disorders
These individuals greatly fear that others will exploit them, cause harm or
deceive them. Even in the absence of all evidence, these people interpret all
experiense from the lens that shows irreversable damage will be done by
others. For example one case is a 63 yo gentleman who never fell in love and
married because he was convinced that all marriages fail, that his wife would
take advantage of him and not let him be himself, and when they divorced she
would take all his money. His fears seem to be around losing his power. This
gentleman lives alone and is very reluctant to share information about his
life. Jealousy, controlling behaviors, and an unwillingness to forgive are
also common with this individual. All these are common characteristics of the
Personality Disordered individual. Psychotic episodes can occur during times
of stress, such as mourning, divorce, illness, change .frustration and
aggravation accelerate their already existing high level of fear.
The nursing process and the person with paranoia: Obtain background
assessment data.
Mr. Cortez, a 45 yo office worker, is seem in the ER with c/o chest pain and
SOB. He refuses to have his blood drawn,, to have any tests done, or to
answer questions about himself or his illness. He began a long monologue
about his opinion of today's managed care. The nurse explained calmly, in a
reassuring way, that all his questions would be answered, and on the
necessity for all the information be given about his chest pain.
Nursing care that included getting permission from Mr. Cortez for each task (
ie blood draw, EKG, Admission questionaire) would better assure his
compliance with admit routine. Also, getting his permission would increase
his sense of power and control over the situation which would decrease his
paranoia in this stressful situation. Such persons are hypervigilant, are
always on guard. They trust no one and are constantly testing one's honesty.
Predisposing factors: 1.There is a possible genetic link. 2. May be due in
part to early parental antagonism and aggression.
Dramatic-Erratic Personality Disorders
Cluster B includes antisocial, borderline, histrionic, and narcissistic
Personality Disorders.
Drama, emotional, and erratic behaviors are typical of this type Anti-social
personality in the past has been called the Psychopath, sociopath, because it
is characterized by deceit, manipulation, revenge, and harm to others. People
with antisocial PD have a sense of entitlement, they believe they have a
right ot hurt others. These individuals may appear to be charming, but lack
empathy ant have contempt for others. The superficial charm allows them to
get involved with others while planning a manipulation of deceit. They
frequently feel frustration, and frequently are involved with obsessive
behavior around food, gambling, alcohol and sex.
Both genetic and environmental factors contribute to this risk. Mr. Arnold, a
24 yo un-employed truck driver, is admitted with a broken pelvis, after an
episode of drunken driving. He is on bed rest and in traction. When bathed,
he asked the nurse to give sexual contact. He complains loudly when his
requests for pain meds are not met immediately, then screams loudly and
throws objects around the room. His call light is always on, and the staff
has begun avoiding him.
Nursing process and the anti-social personality disorder
To avoid staff burn out and provide the best care for these patients, a
written care plan posted in the room that lists the patients daily routine
will help staff establish a sense of boundries. The clarity of this schedule
will also help staff to be consistent. Consistency and clear limits are the
most important guidelines to bring about a behavior change. This willalso
help the patient learn to delay gratification. They help minimize Mr.
Arnold's acting out behaviors. The responses given by staff should be
matter-of-fact so as to not give extra "wanted "attention.
Nursing process and the borderline personality disorder( on the border
between neurosis and psychosis)
Nursing care for these individuals is aimed at protection from self-harm ie
self-mutilation, self-destructive behavior, suicide.
The nurse helps the patient advance in the development of their personality
with feedback, relality orientation, bringing them closer to realizing true
feelings. People with borderline personality disorder experience overwhelming
internal as well as external needs, which they seek to have met in
relationships. A major defense is splitting, alternating between idealizing a
person or situation and devaluating the same. Splitting is a failure to
integrate the positive and negative qualities of self or others. At the first
sign of disappointment they shift from idealizing to devaluating, without
appreciating the in between. Internally these individuals exist in a constant
battle with abandonment. They experience feelings of worthlessness and low
self-esteem. For example: " My boss asked me for my typed job
description, that isn't done yet. They shouldn't have hired me for a job I
can't do. Why are they making it impossible for me. I need to find a better
job where they appreciate me."
People with this disorder rarely experience self satisfaction or well-being,
and quit jobs that are going well or leaving school before graduating. Common
co-occuring problems mood disorders ( depression), substance abuse ( to
decrease anxiety), eating disorders, and post-traumatic stress disorder.
These folks are high users of the mental health resources, going from one
crises to another. Authorities have stated that there are no good drug
treatments for this disorder. The best use of medications is to target
symptoms: antipsychotics for cognitive impairment, valproic acid for mood
swings, Tegretol to decrease behavioral outbursts and mood swings, and
antidepressants for depression.
Nursing process for self-destructive behavior Patients with borderline
personality disorder are most often hospitalized because of impulsive
attempts at self-mutilation or suicide.
Approximately 25,000 individuals die by suicide each year and is the 9th
leading cause of death. It is the third leading cause of death among the
15-24 yo age group. The highest suicide rate is for those over 65 yo. The
lowest frequency of suicide rates is among practicing members of most
religious groups. Women attempt more times, but more men succeed. Individuals
with the highest and the lowest economic status have higher suicide rates
than those in the middle. A theory of suicide is that it is a result of
intense self-hate and a loss of hope.
Completed suicide: includes all willful, self-inflicted,
life-threatening acts that led to death.
Suicide attempt: all willful, self-inflicted, life-threatening
attempts that did not end in death.
Suicidal ideation: the person is thinking about harming her/himself.
Other forms of self-destructive behavior is cutting, drug taking, reckless
driving ( driving alone on a rainy night in the mountains and
speeding-wearing no seatbelt) and others. Nursing implications are to assess
in the suicidal patient the degree of risk; is there a plan, an intent, and
availability of means.
Nursing intervention should be aimed at: establishing a therapeutic
relationship with the patient. Journal writing is a nursing intervention that
can help patients become more aware of their feelings and identify aspects of
their interpersonal relationships over time. A strategy is to help these
individuals in group or a one-to -one to identify strengths and and how to
positively use them in their lives. This can help develop closer
interpersonal relationships and the much needed support system.
Interventions are as follows: Communicating the patient's intentions to the
other staff members Staying with the patient at all times Accepting the
person, being non-judgmental.
Ask the patient to 'contract for safety' and if patient is unable to contract
for safety ( doesn't feel he/she can say they won't harm themselves) let the
other staff know. Give the individual a message of hope Give the person
something to do, attempt to change their thoughts with a task, thereby change
their mood from a self-destructive one. Evaluation is based on the outcome of
the above.
Cluster C
Avoidant personality disorder, dependent personality disorder,
obsessive-compulsive personality disorder, passive-aggressive personality
disorder. These individuals, often appear anxious and fearful.
Within each person is the capacity for passive, assertive, and aggressive
behavior. In a threatening situation the choice is to be passive and fearful
and to run, to be aggressive and angry and to fight, or to be assertive and
self-confident and confront the situation directly. Passive people will often
subordinate their own rights to their beliefs of the rights of others. When a
passive person becomes angry, they hide it, increasing their own tension and
discomfort with a situation. (Pages 619-620 Stuart and Sundeen)
They have a very difficult time confronting issues. At the opposite of the
continuum is the aggressive person who ignores the rights of others. . They
assume they must fight for their rights. And expect the same behavior from
others.
By helping these people develop a positive self-regard and to develop ways to
avoid seeing events and people as a"threat" to themselves this
passive/aggressive response to others can be minimized. Through
self-awareness and therapy in times of stress or difficulty with others the
person may learn how to handle their feelings in more productive ways.
NANDA nursing diagnosis associative with personality disturbances are;
personal identity disturbance, self-esteem disturbance, risk for
self-mutilation, risk for suicide, impaired social interaction, risk for violence,
as well as others.
Outcome objectives: example-The patient will obtain maximum interpersonal
satisfaction by establishing and maintaining satisfying relationships with
others. It is difficult to set goals with the person who fears closeness and
has a tendency towards unrelatedness. The nurse may have to initiate the
goals and be realistic as many of these maladaptive behaviors serve as coping
mechanisms so the individual is not prone to wanting to change. Identifying
immediate specific problems will be the best place to start.
The planning for interventions need to be made with the usual nursing staff
and care givers in mind. This is especially important when working with
people with behavioral and acting-out socially maladaptive responses. The aim
of care planning is to protect others from the patient's aggression and
acting out. The nurse can help the patient learn to delay gratification by
setting limits on unacceptable behavior.
Implementation: The nurse must be physically present with the patient
regularly so there is the opportunity for interaction and the develop\ment of
the therapeutic relationship. Psychological closeness must at least in part
be present, as the nurse needs to show an interest in the patient. It is
difficult to treat individuals in the hospital as treatment requires much
time. The community as a resource is the usual form as therapy. Milieu
Therapy, as found in treatment centers, helps patients gain insight into
their behavior. Limit setting, and feedback from others are helpful in the
in-patient setting.
Important patient education is stress reduction techniques, learning the
consequences of impulsive behavior, learning their behaviors that are due to
anxiety and how to connect this feeling with impulsive behavior, find alternative
responses to impulsive behavior.
Treatment Modalities for Personality Disordered Individuals
Interpersonal psychotherapy
Psychoanalytic therapy
Milieu or group therapy
Behavior therapy
Psychopharmacology
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