Social Responses and Personality Disorders



Social Responses and Personality Disorders


Gail W. Stuart




Learning Objectives



1. Describe the continuum of adaptive and maladaptive social responses.


2. Identify behaviors associated with social responses.


3. Analyze predisposing factors, precipitating stressors, and appraisal of stressors related to social responses.


4. Describe coping resources and coping mechanisms related to social responses.


5. Formulate nursing diagnoses related to social responses.


6. Examine the relationship between nursing diagnoses and medical diagnoses related to social responses.


7. Identify expected outcomes and short-term nursing goals related to social responses.


8. Develop a patient education plan to promote adaptive social responses.


9. Analyze nursing interventions related to social responses.


10. Evaluate nursing care related to social responses.



To find satisfaction in life, people must have healthy interpersonal relationships, experiencing closeness with others while keeping their own separate identities. This closeness or intimacy includes sensitivity to the other person’s needs, open communication of feelings, acceptance of the other person as valued and separate, and empathic understanding.


To become intimately involved with another person, an individual must risk revealing private thoughts and feelings. This can be frightening, especially if one has had past difficulty sharing feelings with other people. People who have extreme difficulty in relating intimately to others may have behaviors that are characteristic of a personality disorder.



Continuum of Social Responses


The levels of relationships range from intimacy to casual contact. Intimate and interdependent relationships provide security and instill the self-confidence necessary to cope with the demands of daily life. A lack of intimacy with family members and friends leaves only superficial encounters and can exclude many of life’s most meaningful experiences.


A person’s relationships with others can be analyzed based on the degree of involvement, comfort, and well-being (Figure 21-1):


image
FIG 21-1 States of relatedness. (From Hagerty BMK et al: Image J Nurs Sch 25:291, 1993.)




LEARNING FROM A CLINICAL CASE


This case can help you understand some of the issues you will be reading about. Read the case background and then, as you read the chapter, think about your answers to the Case Critical Reasoning Questions. Case outcomes are presented at the end of the chapter.



Case Background


They were so happy to have found each other. While he was 10 years younger and not very experienced in love, she had much experience and the charm he had been wanting. She had struggled to raise two children alone. Her children were now adults, and she had hoped to find someone to share her life, someone stable and successful, which he certainly was. Her first husband had been a gambler and an alcoholic and just could not be depended upon.


But he was anxious and she was depressed. They had each been struggling with issues related to these symptoms for years but now wanted treatment to make this partnership work. They came in individually and were assessed, diagnosed, and treated with antidepressants. The treatment was successful, and he began to feel more relaxed and confident; her mood was improved, and she became more active in solving problems in her life and more engaged in her work.


He was an accountant, and she ran a nonprofit service for abused children. She poured her creativity into her work. He had the perfect house that needed a family. He was lonely. And she had the family and no house. She needed his stability. They thought they were a match and suddenly announced that they were getting married right away. They had known each other for 6 months.


Soon after they married, her daughter broke up with her boyfriend and needed a place to stay while she got back on her feet. Almost simultaneously, her grant was not refunded because of administrative irregularities, and she found herself without a job. She was delighted her daughter was there and began throwing dinner parties. She loved a house full of life of which she was the center.


But he became very upset. He didn’t want all of these people in his house. He was very particular. People scuffed up his floor and left water rings on his coffee table. Her daughter left her curlers out in the bathroom and didn’t hang up her towel right. She said if she sat down a glass of water she was drinking, he grabbed it, poured out the water, and put the glass in the dishwasher when she hadn’t even finished drinking the water.


They called for an emergency appointment and came in getting in a heated debate about how to put decorative pillows on the bed. He had always put them vertically in front of the other pillows and she said, everyone knows you put them horizontally on the bed. “How could he be so stupid.” He had found out, much to her distress, that she was hopelessly in debt. They were at an impasse. It became obvious that they each had a personality disorder.




Adaptive and Maladaptive Responses


Within a relationship people usually develop a balance of dependent and independent behavior, described as interdependence. The interdependent person can decide when to rely on others and when to be independent. An interdependent person can let another be dependent or independent without needing to control that person’s behavior.


All people are responsible for controlling their own behavior while receiving support and help from significant others as needed. Adaptive social responses include the ability to tolerate solitude and the expression of autonomy, mutuality, and interdependence. Establishing strong affective bonds with others is crucial to the development of a mature personality.


Interpersonal relationship behaviors may be represented on a continuum that ranges from healthy interdependent interactions to those involving no real contact with other people (Figure 21-2). At the midpoint of the continuum, a person experiences loneliness, withdrawal, and dependence. The maladaptive end of the continuum includes the behaviors of manipulation, impulsiveness, and narcissism. People with these responses often have a history of problematic relationships in the family, on the job, and in the social arena.


image
FIG 21-2 Continuum of social responses.


Critical Reasoning


Compare the relationships you have had with family, friends, and patients. How are they alike and different?



Development Through the Life Cycle


Personality is shaped by biology and social learning. The seed of personality is temperament, which is a set of hereditary biological dispositions, evident almost from birth. Temperament affects mood and activity level, attention span, and responsiveness to stimulation.




Preschool Years


The period between 18 months and 3 years of age is the separation-individuation stage of development. Separation includes all the experiences and events that promote a sense of being separate and unique. Individuation is the development of the child’s internal psychological structure and growing sense of separateness, wholeness, and capability.


In this developmental stage the toddler ventures away from the mother to explore the environment and a sense of object constancy develops. This means that the child knows that a valued person or object continues to exist even when it cannot be seen. Games such as peek-a-boo teach object constancy. The child seeks the parents’ reassurance, support, and encouragement. If the response is positive and reinforcing, it helps build a solid sense of self and a capacity for interpersonal growth.








Late Adulthood


Change continues during late adulthood. Losses occur, such as the physical changes of aging, the death of parents, loss of occupation through retirement, and later the deaths of friends and one’s spouse. This can result in loneliness or eccentric behavior (Magoteaux and Bonnivier, 2009; Theeke, 2009). The need for relatedness still must be satisfied. The mature person grieves over these losses and recognizes that the support of others can help resolve the grief.


However, new possibilities arise, even with a loss. Old friends and relatives cannot be replaced, but new relationships can be developed. Grandchildren may become important to the grandparent, who may delight in spending time with them. The aging person also may find a sense of relatedness to society as a whole. Life has deeper meaning as one reviews personal accomplishments and contributions.


The mature elderly person can accept whatever increase in dependence is necessary but also strives to retain as much independence as possible. Even loss of physical health does not necessarily force the person to give up all independence. The ability to maintain mature relatedness throughout life enhances one’s self-esteem.



Assessment


Behaviors


Personality is a set of deeply ingrained, enduring patterns of thinking, feeling, and behaving. A personality disorder is a set of patterns or traits that hinder a person’s ability to maintain meaningful relationships, feel fulfilled, and enjoy life (Newton-Howes et al, 2008). It begins in adolescence or early adulthood, is stable over time, and leads to distress or impairment (Oldham, 2005).


Personality disorders are attitudes toward self, others, and the world expressed in everything a person thinks, feels, and does. They often decrease in severity as a person ages, mainly because of corrective life experiences. Personality disorders are continuous across a wide range of circumstances in the individual’s life, although the appearance and severity of a particular symptom can vary over time.


The concept of personality “disorder” suggests that one knows what a normal personality is even though it is very difficult to define. A healthy individual is able to adjust and adapt to the demands or expectations of different people and different situations. Individuals with personality disorders have a significant and persistent impairment in their interpersonal relationships and other aspects of functioning.


The following are three key features of personality disorders:



It is estimated that about 4% of the general population and as many as 20% in clinical populations have personality disorders, often with significant morbidity (Kernberg and Michels, 2009). Some of these disorders are associated with a high mortality rate because of suicide. Suicide victims with personality disorders almost always also have a depressive illness, substance use disorder, or both.


Many individuals with a current alcohol use disorder have at least one personality disorder, and the association is even stronger with a current drug use disorder. A comorbid personality disorder also prolongs the course of major depression (Skodol et al, 2011).


An essential element of the diagnosis is that the symptoms of personality disorders are fixed and long lasting. Even with treatment, it is not possible to completely change someone’s personality. However, it is possible to help people with personality disorders improve the quality of their lives. Treatment can lead to significant improvement in the symptoms, distress, and general functioning of patients with personality disorders.


Personality disorders are characterized by chronic, maladaptive social responses. The DSM-IV-TR (American Psychiatric Association, 2000) has grouped personality disorders into three clusters:




imageQUALITY AND SAFETY ALERT




The nursing assessment and implementation of care for people with antisocial, borderline, and narcissistic personality disorders are emphasized in this chapter. Common maladaptive responses of people with cluster B personality disorders include manipulation, narcissism, and the impulsivity that often overlaps both.



Manipulation


People who use manipulative behaviors present a particularly difficult nursing problem. Manipulation is a behavior in which people treat others as objects and form relationships that center around control issues. Their behavior is easily misunderstood, as illustrated in the following clinical example.



CLINICAL EXAMPLE


Mr. Y was a 20-year-old single man who was committed to an inpatient psychiatric unit by a judge for a psychiatric evaluation. He had been charged with the sale of illicit drugs, statutory rape of his 15-year-old pregnant girlfriend, and contributing to the delinquency of a minor. He had been arrested on the grounds of a junior high school, where he was selling PCP and barbiturates to a group of young teenagers.


In jail Mr. Y had been observed to be “crazy” by the guards. He paced his cell, chanted, and threw his food on the floor. Because of this behavior, the judge agreed to order a psychiatric evaluation. On arrival at the psychiatric unit, Mr. Y continued to behave in the same manner. However, his behavior did not seem typical of psychosis. There was no evidence of hallucinations or disorders of thought or affect. When unaware that he was being observed, Mr. Y seemed relaxed and was noted at one time to be talking with another patient.


By the day after admission he seemed to be free of his symptoms. At this point the staff began to describe him as a “nice guy.” He complimented female staff members and behaved toward them in a pleasant but slightly seductive manner. He was respectful to the physicians and agreed to abide by all rules. He was helpful with other patients. In group meetings he admitted that he had behaved badly in the past and described how his friends had led him astray. He said he became involved in drugs because he wanted to be “one of the gang” and he needed money so he “had to” start selling drugs even though he knew better. He began to receive the sympathy of the other patients and the staff.


Four days after admission, after visiting hours, it was noted that Mr. Y and two other patients looked lethargic. Their speech was slurred and their gaits ataxic. The nursing staff immediately collected urine and blood specimens for toxicological analysis. The unit was searched for hidden drugs, but none were found. The results of the toxicology screening tests were positive for barbiturates.


Suspicion was immediately focused on Mr. Y, because the other patients involved were young adolescents with no history of drug abuse. When confronted, Mr. Y seemed amazed and hurt that he could be suspected and pointed out his past behavior as a model patient. He admitted that he had behaved strangely and wondered whether someone had “slipped” him some drugs. He was convincing but was warned that if he was involved in any way with drugs, he would be sent directly back to jail.


Mr. Y convinced his parents of his good intentions, and they agreed to allow him to move into their house. On the basis of his positive behavioral change, Mr. Y received a recommendation for probation, which was carried out by the judge.


Three months after discharge from the hospital, Mr. Y and a friend were arrested for operating a PCP manufacturing laboratory in a friend’s garage.



Manipulative patients usually have little motivation to change because manipulative behavior often has rewards for them; they are getting what they want. Manipulators are goal oriented or self oriented, not other oriented. However, they are skilled at giving the impression that they care about others. In this clinical example, Mr. Y was able to gain the confidence of the staff in order to escape a jail sentence. This is typical of a person with an antisocial personality disorder.


The manipulative person is unaware of a lack of relatedness and assumes that interpersonal relationships are formed to take advantage of others. This person cannot imagine an intimate, sharing relationship. The manipulator believes in maintaining control at all times to avoid being controlled.


Antisocial personality disorder is a complex disorder that is difficult to diagnose and treat. To meet DSM-IV-TR criteria, an individual must be at least 18 years old but must demonstrate a pattern of breaking rules since the age of 15 (American Psychiatric Association, 2000). The diagnosis is applied when an individual consistently ignores social rules; is manipulative, exploitative, or dishonest; lacks remorse for actions; and is involved in criminal activity. Although this diagnosis occurs in only 3% of men and 1% of women, these individuals are responsible for a large proportion of crime, violence, and social distress.


Patients with borderline and antisocial personality disorders are often manipulative. This results in their inability to participate in mature interpersonal relationships, as illustrated in the next clinical example.



Clinical Example


Ms. S was a 23-year-old woman who was admitted to a general hospital psychiatric unit. She had cut her wrists superficially three times during the week before admission. Each time she cut herself, she telephoned her therapist, a psychiatric advanced practice nurse. Because the therapist was about to leave for vacation and was concerned for the safety of Ms. S, she decided to hospitalize her.


On admission Ms. S appeared mildly depressed. She gave the impression of a guilty child who had been punished. She denied any current self-destructive thoughts. During the physical assessment the nurse noted that there were many scars on the patient’s body. When asked about these, she claimed she was abused as a child. Her therapist’s records described the scars as the result of much self-mutilation since the age of 16 years. This had been her main reason for seeking therapy. There was also a history of sexual promiscuity.


Ms. S described herself as a failure, stating that she had “the best parents in the world, but they did not get the daughter they deserve.” She said she was a drifter who had never been able to settle on a career, a lifestyle, or any consistent friends. She didn’t know who or what she was. When asked how she felt, she responded, “Most of the time, I don’t feel anything, just empty.” She had no signs of psychosis.


Ms. S was placed on constant observation to prevent further cutting. All sharp objects were removed from the room. At first she was very cooperative and superficially friendly to other patients. Because of her smooth adjustment, constant observation was discontinued after 2 days. She was also given a schedule of activities and informed that she was responsible for following it. The next day, an X-Acto knife was missing from the activities therapy room. Ms. S was found in the bathroom, bleeding from several small cuts on her ankles. This sequence was repeated several times. Each time the constant observation was discontinued, she found a sharp object and cut herself.


Ms. S was also very labile emotionally. She had unpredictable outbursts of anger, similar to temper tantrums. However, these outbursts passed as quickly as they came, never lasting more than a few minutes. She also began to categorize the staff as “good guys and bad guys.” When she was with staff members she liked, she was pleasant, complimenting them on their kind and understanding attitudes toward her. With staff she disliked, she was sullen and uncooperative, comparing them unfavorably with the others. Eventually the staff began to bicker about her care, some believing she was spoiled and others that she was neglected.


Ms. S remained in the hospital during her therapist’s absence. When the therapist returned, Ms. S refused to see her. The frequency of angry outbursts increased dramatically. However, after frequent visits from her therapist, Ms. S began to request discharge. Behavioral criteria for discharge were set, including no self-mutilation and no temper tantrums. She met the criteria and was discharged back to outpatient treatment.



The diagnosis of borderline personality disorder occurs in 1% to 6% of the general population and is the most prevalent personality disorder (15% to 25%) in mental health settings (Gunderson, 2009). The diagnosis is made more often in women than in men. Developmental theory suggests that the borderline person does not achieve object constancy during the separation-individuation stage of psychosocial development. People who fail to complete separation from the mother (or primary caretaker) and develop autonomy in childhood often repeat this developmental crisis at adolescence. Behaviors characteristic of this phase include the following:



Many of these behaviors can be seen in the preceding clinical example. Borderline personality disorder has one of the highest suicide rates of all the personality disorders. Impulsive aggression is the hallmark of borderline personality disorder, and it is seen in the borderline person’s self-mutilation, unstable relationships, violence, and completed suicides.


These patients can be frustrating for nursing staff to interact with and treat because they are manipulative and unable to become involved in reciprocal interpersonal relationships. However, nurses must remember that this behavior is not consciously planned but is a defense against a fear of loneliness.



Critical Reasoning


Do you know someone who is manipulative in relating to you? If so, how do you respond to them?



Narcissism


The term narcissism comes from the Greek myth of Narcissus, who fell in love with his own reflection in the water and died. The flower that bears his name sprang up at the site of his death.


Many successful people are narcissistic. Acting, modeling, professional sports, and politics are usually attractive occupations to people with this personality trait. However, problems occur when people do not gain the status they think is deserved or lose status. The frustration caused by lack or loss of recognition may be expressed as anger, depression, substance abuse, or other maladaptive behaviors.


People with narcissistic personality disorders have fragile self-esteem, driving them to search constantly for praise, appreciation, and admiration (Kay, 2008; Ronningstam, 2011). The following clinical example demonstrates narcissistic entitlement, which describes an egocentric attitude, envy, and rage when others are seen as critical or not supportive.



CLINICAL EXAMPLE


The psychiatric nurse was called to the emergency department to see a new patient, Mr. F, who was accompanied by his wife. The nurse knew from the intake form that Mr. F was a 44-year-old man with no psychiatric history. His chief complaint was that he had gone into a “blind rage” when he had an argument with his wife earlier in the evening and had punched her on the arm. He was frightened by his loss of control and said that he felt like a failure. Both Mr. and Mrs. F denied any history of violence, although Mr. F said that his first marriage ended “because of my anger.”


Mr. F appeared quite anxious; he was tapping his foot and wringing his hands, and he avoided eye contact with the nurse. After a short time, however, he became more verbal, and he willingly explained what had led to the “blowup.” He had been self-employed for the past 10 years and had been “highly successful,” expanding his company nationally. He told the nurse that his father was a “multimillionaire” and that he had been on his way to exceeding his father’s wealth. It seemed important to impress the nurse by dropping the names of well-known people, whom he described as his friends.


Mrs. F angrily interrupted him, saying, “That’s what’s important to you—who you know and how it looks.” Mrs. F then explained that business began slipping 2 years ago. Despite several profitable years, he had never invested or saved money. When sales fell, instead of cutting expenses and downsizing the company, he continued to live lavishly, making extravagant purchases. It was this situation that led to their argument. When Mrs. F accused her husband of taking them to the brink of financial collapse, he went into a rage and punched her.


Mrs. F began sobbing, and Mr. F seemed not to notice. He said he felt like his life was falling apart and that he must be the failure his father always said he was. He angrily referred to his “rich brother,” who, in his father’s eyes, was the perfect son. He became tearful, and Mrs. F then turned to her husband, attempting to provide support and reassurance.



Mr. F’s impulsiveness was seen in his extravagance, inability to establish and follow a life plan, failure to learn by experience, poor judgment, and unreliability.


The behaviors related to maladaptive social responses are summarized in Table 21-1. Patients often exhibit combinations of these behaviors. The nurse should be able to identify the complex behaviors associated with high levels of stress and anxiety. In some cases a usual mode of behavior, such as manipulation, may be exaggerated or combined with a change in behavior.



For instance, manipulative people may withdraw when confronted about their manipulations and may be rejected by those they have been trying to manipulate. In other instances, the behavior resulting from stress may be different from the person’s usual style of relatedness. A person who is usually agreeable may become critical and defensive when under great stress. It is therefore helpful to include a description of the patient’s usual relationships in the nursing assessment. This provides a baseline of behavior for that person against which the nurse measures the patient’s progress.



Predisposing Factors


Personality is composed of temperament, which is inherited, and character, which is learned. Personality disorders develop from a variety of predisposing neurobiological, early developmental, and sociocultural factors. The nurse should explore all relevant areas during the nursing assessment.



Critical Reasoning


Describe one of your own personality traits that is due to temperament and one that is due to character. How has each affected your life?



Biological Factors


Many researchers believe that there is a strong inherited biological vulnerability or a genetic susceptibility for these disorders, which sets the stage for environmental influences. Studies suggest a genetic link for antisocial personality disorder and a biological hypothesis that impulsive and violent behavior may be caused by brain dysfunction, a low threshold of excitability in the limbic system, low levels of serotonin, or toxic chemical substances.


Other studies have found that people with antisocial personality disorder have reduced prefrontal gray matter volume and lower than average activity in the frontal lobes of their brain. This results in low arousal, poor fear conditioning, lack of conscience, and decision-making deficits.


Personality disorders also have been linked to alcohol and drug abuse. Findings reveal that first-degree relatives of people with personality disorders have a higher than normal rate of substance abuse; therefore, they are considered to have a probable genetic link. Borderline personality disorder and antisocial personality disorder in particular are associated with a wide variety of substance use disorders, and the combination results in severe impairment.


Researchers are looking for the biological basis of very early infant and childhood characteristics. For instance, about 20% of children are inhibited from an early age and can be upset easily by the age of 41⁄2 months. Evidence shows that these children have an accelerated heart rate, even in the womb, and that their amygdalas (the brain region that governs learned fear and emotion) may be more excitable than average.


In contrast, antisocial personality appears to be correlated with abnormal brain processing of emotionally charged words, an unusually low heart rate, and slow responses to experimental rewards and punishments from an early age. Further research is needed to clarify the role of inheritance and that of brain structure and function in the development of personality disorders.

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