Personality Disorders

Psychiatric Mental Health Nursing

 Introduction

“Personality characteristics are formed very early in

life and are difficult, if not impossible, to change. The
goal is to decrease inflexibility of the maladaptive
traits and reduce their interference with everyday
functioning and meaningful relationships. “
(Townsend, 2009)
 What is “Personality?”
Personality traits are “enduring patterns of perceiving,
relating to, and thinking about the environment and
oneself that are exhibited in a wide range of social and
personal contexts.”
Personality disorders occur when these traits become
inflexible and maladaptive and cause significant
functional impairment or subjective distress in:
1. cognition 3. interpersonal relations
2. affect 4. impulse control
 Characteristics of a Healthy
Personality
Identifies one’s own strengths, weaknesses, limitations
Recognizes interactions and thoughts that lead to
strong emotions
Does not expect others to meet all needs
Seeks a balance of work and play
Accomplishes goals
Defines and expresses one’s sense of self within the
context of the larger picture
 Clusters
Personality disorders are classified into 3 clusters:
-Cluster A: paranoid, schizoid, schizotypal (odd or
eccentric)
-Cluster B: antisocial, borderline, histrionic, narcissistic
(dramatic, emotional, or erratic)
-Cluster C: avoidant, dependent, obsessive-compulsive
(anxious or fearful)
 Common Characteristics of all
Personality Disorders
Inflexible and maladaptive response to stress
Disability in working and demonstrating care of others
Ability to evoke interpersonal conflicts
Capacity to “get under the skin” of others
 Diagnosing Personality Disorders

Please consider the individual’s ethnic, cultural, and

social background before labeling with a personality
disorder.
 Prevalence and Comorbidities
Ranges from 10-15% in the general population
Onset usually predates the start of a primary
psychiatric disorder
Comorbidities include mood disorders, generalized
anxiety disorder, agoraphobia, obsessive-compulsive
disorder, substance use, ADHD, PTSD, eating
disorders, somatization disorder
 Cluster A: Paranoid, Schizoid and
Schizotypal Personality Disorders
Referred to as “odd or eccentric” behaviors
Paranoid P.D. – characteristic feature is “long-
standing suspiciousness and mistrust of people”
(Sadock & Sadock, 2007)
More common in men than women
Hypervigilant, tense, irritable, intimidating
Insensitive to the feelings of others
Feel as though others are going to take advantage of
them
Oversensitive; misinterpret cues
Blame others for shortcomings
 Paranoid Personality Disorder
Four or more of the following:
Suspects without basis that others are exploiting,
harming, or deceiving them
Preoccupied with unjustified doubts about the loyalty of
friends/associates
Reluctant to confide in others for fear that info will be
used against them
Reads hidden or threatening meanings into benign
remarks or events
Persistently bears grudges (unforgiving)
 Paranoid Personality Disorder
Perceives attacks on character or reputation that are not
apparent to others and quick to react angrily (will
attack first)
Recurrent suspicions without justification, regarding
fidelity of spouse or partner
Characteristics do not occur exclusively with
schizophrenia, mood disorder with psychosis,
psychosis NOS, or medical condition
Possible hereditary link with increased incidence among
relatives of clients with schizophrenia
Clients were subjected to parental aggression, abuse
 Schizoid Personality Disorder
Profound defect in one’s ability to form personal
relationships or to respond to others in a meaningful,
emotional way.
Social withdrawal, discomfort with human interaction
Diagnosed more frequently in men
Clinical Profile: aloof, indifferent; work in isolation;
unsociable; invest energy in intellectual pursuits; affect
is bland and constricted
Occurs in adults who experienced cold, neglectful
relationships in early childhood
 Schizoid Personality Disorder
 Pervasive pattern of detachment from social relationships
and a restricted range of expression of emotions in
interpersonal settings, beginning by early adulthood,
indicated by four or more of the following:
1. Does not desire nor enjoy close relationships
2. Almost always chooses solitary activities
3. Little, if any interest in sexual experiences
4. Takes pleasure in few activities
5. Lacks close friends
6. Appears indifferent to praise or criticism
7. Shows emotional coldness, detachment
 Schizotypal Personality Disorder
More severe than schizoid personality disorder
Includes magical thinking or perceptual distortions that
are not clear illusions, delusions or hallucinations
Belief in telepathy (“Others can feel my feelings”)
Personalized style of speech; eccentric appearance
Can become psychotic under stress
Close link with schizophrenia (biological/hereditary
factors)
 Schizotypal Personality Disorder
Pervasive pattern of social & interpersonal deficits with
acute discomfort and inability to form close relationships;
cognitive or perceptual distortions; eccentricities of
behavior beginning by early childhood; five or more of the
following:
Ideas of reference
Odd beliefs or magical thinking
Unusual perceptual experiences (bodily illusions)
Odd thinking and speech
Suspiciousness or paranoid ideation
Inappropriate or constricted affect
 Schizotypal Personality Disorder

Odd, eccentric, or peculiar behavior or appearance

Lack of close friends other than first-degree relatives
Excessive social anxiety that does not diminish with
familiarity and tends to be associated with paranoid
fears rather than negative judgments about self
 Cluster B: Antisocial, Borderline,
Histrionic, Narcissistic P.Ds.
Exhibit dramatic, emotional, or erratic behaviors
Antisocial P.D. – “pattern of socially irresponsible,
exploitative, and guiltless behavior that reflects a
disregard for the rights of others” (Skodol &
Gunderson, 2008):
DSM-5: 3 or more of the following:
Failure to conform to social norms with respect to
lawful behaviors (repeated arrests)
Deceitfulness, with repeated lying, use of aliases, or
conning others for personal profit/pleasure
 Antisocial Personality Disorder
Impulsivity or failure to plan ahead
Irritability and aggressiveness (physical fights, assaults)
Reckless disregard for safety of self or others
Consistent irresponsibility by disregarding obligations
Lack of remorse by being indifferent to having hurt,
mistreated, or stolen from others
Behaviors exhibited between ages 15 and 18; conduct
disorder diagnosed before age 15
When seen in clinical settings, a way to avoid legal
consequences; can be court ordered for a psych evaluation
 Antisocial Personality Disorder
 Intimidating, argumentative
 Difficulty sustaining consistent employment
 Lack warmth and compassion
 Low tolerance for frustration
 Unable to delay gratification
 “Thrill-seeking”
 Exploit others to fulfill their own desires
 Do not accept responsibility for behaviors
 Cannot develop interpersonal relationships
 Biological influences
 Chaotic home environment; severe physical abuse
 Borderline Personality Disorder
Pattern of intense and chaotic relationships with affective
instability and fluctuating attitudes toward others
Impulsive: substance abuse, gambling, promiscuity,
binging & purging, reckless driving
Self-destructive: suicide attempts, cutting, scratching,
burning
Manipulation: to allay fears of abandonment by parent in
early childhood; little tolerance for being alone
Always in a state of crisis
Chronic depression is common
Lacks a clear sense of identity
 Borderline Personality Disorder
Splitting: primitive ego defense mechanism with an inability
to integrate and accept both positive and negative feelings
(good vs. bad)
Biological/genetic influences: decrease in serotonin;
relatives with mood disorders
Childhood trauma: sexual and physical abuse; PTSD-like s/s
NANDA dxs: Risk for self-mutilation, self-directed
violence, risk for suicide, other-directed violence,
complicated grieving, impaired social interaction
ICD-10 identifies BPD as “emotionally unstable personality
disorder.”
 Borderline Personality Disorder
Pervasive pattern of instability of interpersonal
relationships, self-image, and affects, and marked
impulsivity beginning by early adulthood; 5 or more of
the following:
Unstable and intense interpersonal relationships
characterized by alternating between extremes of
idealization and devaluation.
Identity disturbance: unstable self-image or sense of self
Frantic efforts to avoid real or imagined abandonment.
Impulsivity in at least two areas that are potentially self-
damaging
 Borderline Personality Disorder
Recurrent suicidal behavior, gestures, or threats, or self-
mutilating behavior
Affective instability due to marked reactivity of mood
(intense episodic dysphoria, irritability, anxiety lasting
a few hours and rarely more than a few days)
Chronic feelings of emptiness
Inappropriate, intense anger or difficulty controlling
anger
Transient, stress-related paranoid ideation or severe
dissociative symptoms
 Histrionic Personality Disorder
Pervasive pattern of excessive emotionality and
attention seeking behavior, with early adulthood onset;
5 or more of the following:
Uncomfortable in situations in which the person is not
the center of attention
Interaction with others is characterized by inappropriate
sexually seductive or provocative behavior
Rapidly shifting emotions
Excessively impressionistic style of speech, lacking in
detail
 Histrionic Personality Disorder
Uses physical appearance to draw attention to self
Dramatic, theatrical, exaggerated expression of emotion
Easily influenced by others or circumstances
Considers relationships to be more intimate than they are
Predisposing Factors:
a. Decreased serotonin, heightened noradrenergic activity
b. Common among first-degree biological relatives
c. Learned behavior (lack of positive or negative feedback)
d. “Starving for attention, approval, praise, reassurance”
 Narcissistic Personality Disorder
Overly self-centered and exploitative due to their
fragile self-esteem
View themselves as “superior” with special rights
Do not see their behavior as objectionable
Choose partners who provide continual praise and do
not ask for much in return
Exaggerated sense of self-worth
Diagnosed more often in men than women
 Narcissistic Personality Disorder
Pervasive pattern of grandiosity, need for admiration,
lack of empathy, beginning by early adulthood; 5 or
more of the following:
Grandiose sense of self-importance
Preoccupied with fantasies of unlimited success, power,
brilliance, beauty, or ideal love
Belief in being special, unique or should associate with
high-status people
Requires excessive admiration
Sense of entitlement
 Narcissistic Personality Disorder
Interpersonally exploitative
Lacks empathy: unwilling to recognize or identify with
the feelings/needs of others
Envious of others or believes others are envious of them
Arrogant behaviors and attitudes
Predisposing Factors:
a. Narcissistic parents (modeling)-critical, perfectionistic
b. Parents overindulge their children or are inconsistent
c. Child’s dependency needs responded to with disdain
 Cluster C: Avoidant, Dependent,
Obsessive-Compulsive P.Ds.
Reflect anxious or fearful behaviors
Avoidant P.D.:
Awkward and uncomfortable in social situations
Sensitive to rejection, extreme shyness
Slow and constrained speech with frequent hesitations
Fragmented thoughts
Feelings of being unwanted and lonely
Parental rejection, criticism, low self-worth
View the world as hostile and dangerous
 Avoidant Personality Disorder
Pervasive pattern of social inhibition, feelings of
inadequacy, and hypersensitivity to negative evaluation,
beginning by early adulthood; 4 or more of the
following:
Avoids occupational activities that involve significant
interpersonal contact, due to fear of criticism,
disapproval, or rejection.
Unwilling to get involved with people unless certain of
being liked.
Shows restraint within intimate relationships due to the
fear of being shamed or ridiculed.
 Avoidant Personality Disorder
Preoccupied with being criticized or rejected in social
situations.
Inhibited in new interpersonal situations due to feelings
of inadequacy.
Views self as socially inept, unappealing, inferior.
Reluctant to take personal risks or to engage in new
activities that may prove to be embarrassing .
Equally common in men and women.
 Dependent Personality Disorder

Pervasive and excessive need to be taken care of that leads

to submissive and clinging behavior, fears of separation,
beginning by early adulthood; 5 or more of the following:
Difficulty making everyday decisions without an excessive
amount of advice and reassurance from others
Difficulty expressing disagreement with others due to fear
of loss of support or approval
Needs others to assume responsibility for most major areas
of life
 Dependent Personality Disorder
Difficulty initiating projects or doing things on one’s own due
to a lack in self-confidence
Goes to excessive lengths to obtain nurturance and support
from others, to the point of volunteering to do unpleasant
tasks
Feels uncomfortable or helpless when alone due to exaggerated
fears of being unable to care for oneself
Urgently seeks another relationship as a source of care and
support when a close relationship ends
Unrealistically preoccupied with fears of being left to take care
of oneself
The most commonly seen P.D. in the clinical setting for
anxiety/mood disorders.
 Obsessive-Compulsive Personality
Disorder
Pervasive pattern of preoccupation with orderliness,
perfectionism, and mental and interpersonal control, at
the expense of flexibility, openness, and efficiency,
beginning by early adulthood; 4 or more of the
following:
Preoccupied with details, rules, lists, order, organization,
or schedules to the extent that the major point of the
activity is lost.
Shows perfectionism that interferes with task completion
(strict standards interfere with project)
Excessively devoted to work and productivity to the
exclusion of leisure activities and friendships
 Obsessive-Compulsive Personality
Disorder
Overly conscientious, scrupulous, inflexible about matters
of morality, ethics, values.
Unable to discard worn-out or worthless objects even when
they have no sentimental value.
Reluctant to delegate tasks or to work with others unless
they submit to exactly his or her way of doing things.
Adopts a miserly spending style toward both self and
others.
Shows rigidity and stubbornness.
Internally fearful; seeks treatment for anxiety and mood
disorders.
 OCD: Predisposing Factors
Parenting style of being “over-controlling”
Imposed standards of conduct by parents with
condemnation
Children learn what they must do to avoid punishment
rather than what they can do to receive praise and
attention
Rigid restrictions and rules
Positive achievements are expected by parents and not
necessarily acknowledged
 Nursing Assessment
Always assess for suicidal/homicidal ideation or plan
Identify medical and psychiatric disorders, substance-
related disorders
Identify risk factors and specific triggers that may be
responsible for current symptoms
Consider the patient’s sociocultural experience,
childhood abuse, trauma
Evaluate for a change in personality in middle or late
adulthood, requiring the need for a thorough medical
workup
 Nursing Implications for Care
Acute care usually focuses on the primary psychiatric
disorder
Chronic behavior problems require therapeutic
feedback and consistency from the psychiatric team
Patients should be provided with realistic choices to
feel a sense of control over their situation and to
support adherence to the treatment plan
Staff require debriefing meetings to ventilate feelings
and establish realistic goals for treatment
Motivated patients may learn to change behaviors
 Specific Nursing Diagnoses
Risk for self or other-directed violence
Risk for suicide
Self-mutilation
Disturbed sensory perception
Disturbed thought processes
Ineffective coping
Anxiety
Noncompliance
 Nursing Diagnoses
Impaired parenting
Disabled family coping
Social isolation
Fear
Defensive coping
Hopelessness
Chronic low self-esteem
Spiritual distress
Ineffective self-health management
 Treatment Modalities
Interpersonal psychotherapy
Milieu or group therapy
Cognitive behavioral therapy
Dialectical behavior therapy
Psychopharmacology for symptomatic relief
 Dialectical Behavior Therapy
Form of psychotherapy developed by Marsha Linehan,
PhD
Treatment for chronic self-injurious behavior of clients
with borderline personality disorder
Combination of cognitive, behavioral and
interpersonal therapies with Eastern mindfulness
practices
 Functions of DBT
Enhance behavioral capabilities
Improve motivation to change
Ensure that new capabilities can be adapted to the
normal environment
Structure treatment to enhance the reinforcement of
effective behaviors
Enhance therapist capabilities and motivation to treat
clients effectively
Primary Modes of Treatment in DBT
Group skills training
Individual psychotherapy
Meditative practices
Telephone contact
Therapist consultation/team meeting
 Psychopharmacology
Drugs have no effect in the direct treatment of the specific
personality disorder
Symptomatic relief can be attained
Antipsychotics used for psychosis in paranoid,
schizotypal, and borderline personality disorders
SSRIs and MAOIs show some success in decreasing
impulsive acts, self-mutilation
Higher risk of fatality from overdose on MAOIs
SSRI + atypical antipsychotic used to treat dysphoria,
mood instability, impulsivity with borderline personality
disorder