San Jose Police Crisis TrainingPersonality Disorders May 14, 2008

Phyllis M. Connolly PhD, APRN- BC, CSProfessor of Nursing

San Jose State Universityconnollydr@son.sjsu.edu

408-924-3144

Questions to Consider What behaviors have you observed in folks that you

think might be diagnosed with a personality disorder—your stories?

What are the qualities of a healthy personality? How do symptoms differ for persons with personality

disorders versus behaviors you are likely to encounter in persons with schizophrenia or mood disorders?

What strategies are useful when dealing with anger? How do you respond when you feel as if you are

being manipulated? What can you do for yourself to increase your

effectiveness when dealing with people with personality disorders?

Qualities of Healthy Personality

Positive & accurate body image

Realistic self-ideal Positive self-concept High self-esteem Satisfying role

performance Clear sense of identity

Personality “persona”

Complex pattern psychological characteristics Not easily eradicated Expressed automatically in every facet of

functioning Biological dispositions & experiential learning Distinctive pattern of perceiving, feeling,

thinking & coping

Millon (1981)

Why Do We Behave the Way We Do?

Affective (feelings)

Cognitive (thoughts)

Behavioral (actions)

Interacting System’s Human Behavior

Definition: Personality Disorders

Lasting enduring patterns of behavior Significant social and occupational

impairment Beyond usual personality traits Pervasive in 2 areas of: cognition, affect,

interpersonal relationships, & impulse control Usually begins in adolescence or early

adulthood

Prevalence Personality Disorders Approximately 10 - 13% of general population

70 - 85% Criminals have personality disorder

60 - 70% Alcoholics

70 - 90% Drug abusers

40 - 45% Persons with psychiatric disorder also have a personality disorder

Frequently referred to as “treatment-resistant”

Videbeck, 2001, p. 416

Common Characteristics

Not distressed by their behaviors

Become distressed because of the reactions of others or behaviors towards them by others

Not due to drug or alcohol Not due to medical condition

Etiology: Personality Disorders

Combination of biological, psychological, and social risk factors

Genetics (50% of personality) Life experiences Environment

Schizotypical: ^ homovanillic acid (HVA) metabolite of dopamine neuropsychological abnormalities, ^attention and

information processing impairment, & eye movement abnormalities

Personality Disorders DSM-IV-TR : Clusters: A, B, C

Cluster A, Odd, Eccentric Paranoid Schizoid Schizotypal

Cluster B, Dramatic, Emotional, Erratic

Antisocial Borderline Histrionic Narcissistic

Cluster C, Anxious Fearful

Avoidant Dependent Obsessive-

Compulsive

Antisocial Personality DSM IV –TR 301.7

Pervasive pattern of disregard for and violation of the rights of others since age 15

Failure to conform to social norms, repeating acts--grounds for arrest

Deceitfulness, repeated lying, uses aliases, or conning others for personal profit or pleasure

Borderline Personality DSM-IV-TR, 301.83

Manipulation and dependency common Difficulty being alone--seek intense brief

relationships (Fatal Attraction) Impulsive & self-damaging behaviors

unsafe sex, reckless driving, substance abuse, ED vs Recurrent suicidal or self-mutilating behaviors; death rates

Transient quasi-psychotic symptoms during stress Chronic feelings of emptiness or boredom, absence

of self-satisfaction Intense affect--anger, hostility, depression and/or

anxiety

Borderline Personality: Etiology

Reduced serotonergic activity impulse and aggressive behaviors

Cholinergic dysfunction & increased norepinephrine associated with irritability &

hostility Genetic

5 times more common in 1st degree biological relatives

75% women & victims of childhood sexual abuse

Comparisons Personality Disorders & Mental Symptoms & Treatments

Disorder Hallucinations Delusions Drug RX

Therapy

Antisocial Only if substance abuse

Only if substance abuse

0 Behavioral

Borderline Only if psychotic May X Behavioral

DBT

Obsessive No May X Insight, cog. Behav.

Treatment BPD:Dilectical Behavioral Therapy

Once-weekly psychotherapy session focused on problematic behavior or event from past week; emphasis is on teaching management emotional trauma; TCs to therapists between sessions (Linehan, 1991)

Targets ￬ high-risk suicidal behaviors ￬ responses or behaviors that interfere with therapy ￬ behaviors that interfere with quality of life ￬ dealing with PTS responses enhancing respect for self acquisition of behavioral skills taught in group additional goals set by patient

DBT Continued

Weekly 2.5 hr group therapy focused on Interpersonal effectiveness Distress tolerance/reality acceptance skills Emotion regulation Mindfulness skills

Group therapist is not available TCs; referred to individual therapists

Targeted to symptoms

Some helped with Zyprexa, Seroquel & Risperdal

Effexor, Serzone, Prozac, Zoloft, Celexa, Luvox, Paxil

Anticonvulsants: Lamictal, Topamax, Depakote, Trileptal, Zonegan, Neurontin & Gabitril

Naltrexone

Omega-3 Fatty Acid

Psychopharmacology

Evidence-Based Practice: Remission BPD

10 yr study 275 participants New England inpatient unit Several tools used for diagnosis Interviewed q 2 years 242 reached remisssion

Younger No hospitalizations before diagnosis No history of sexual abuse Less severe childhood abuse or neglect Negative family hx for mood and substance abuse No PTSD and symptoms of Cluster C Low neuroticism High extroversion, high agreeableness, conscientiousness

and good vocational record Zanarini, Frankenburg, Hennen, et al. (2006)

Manipulation Mode of interaction which controls others Self-defeating negatively affects IPR Using flattery, aggressive touching,

playing one person against another Deliberate “forgetting” Power struggles Tearfulness Demanding Seductive behaviors

Strategies for Dealing with Manipulation

Set limits and enforce consistently

Offer constructive opportunities for control, contracting

Use clear and straightforward communication

Avoid rejecting or rescuing Monitor your own reactions

Interventions for Manipulation Cont.

Be honest, respectful, non-retaliatory Avoid labeling Avoid ultimatums Encourage putting feelings into words rather

than action Offer empathic statements Use supervision and consultation with other

staff

RELAX SPEAK SOFTLY AND SLOWLY KEEP YOUR LEGS AND ARMS

UNCROSSED DO NOT CLENCH YOUR FISTS DO NOT PRESS YOUR LIPS TOGETHER

TIGHTLY

Feelings of Appreciation

Identify people, places or things that evoke a deep feeling of appreciation

Your Choice

“I CAN MANAGE MY RESPONSE” “I HAVE BEEN SUCCESSFUL

BEFORE” “WE CAN COME TO AN

AGREEMENT”

“I DON’T UNDERSTAND” LISTEN REPEAT SOMETHING THAT HAS

AGREEMENT TAKE A BREAK USE: “Perhaps,” “maybe,” “sometimes,”

“what if,” “it seems like,” “I wonder,” “I feel,” “I think”

Interventions Dealing With Anger

Calm unhurried approach

Do not touch Protect other people Respect personal

space Use active listening Be aware of

personal feelings Use time-out/one-

one in quiet area

Initially ignore derogatory statements

State desire to assist person to maintain/regain control

DO NOT ARGUE OR CRITICIZE

DO NOT THREATEN PUNITIVE ACTION

Postpone discussion of anger & consequences until in control

Non Verbal Verbal

FOGGING

A way of neither agreeing nor disagreeing “You police don’t know all the facts about any of

this.” “ It probably seems that way to you.”

Use the following phrases for other situations “You may be right…” “It probably seems so” “That is probably true, and we are here to help

sort things out.”

BROKEN RECORD

A repetitive communication in which you continue to say what you want Voice is neutral You are calm Ignore all side issues by the other party

Situation & Date Behavior, body cues, affect, physical

reactions, feelings Behavioral Response

What I did or said What I would like to have done or said

What prevented you from doing what you wanted?

SELF-EVALUATION: KEEP A LOG

Self-Care

Healthy diet and nutrition Exercise and physical activity Adequate sleep patterns Recreation & leisure Balanced lifestyle Meditation Tai Chi Clinical supervision Support groups Critical incident stress debriefing

“Your work makes a difference in people’s

lives”

Thank you