Personality disorders

People with personality disorders are often frustrating and even infuriating to people around
them (including physicians). Most are distressed about their lives and have impaired work or
social relationships. Personality disorders often coexist with mood, anxiety, substance abuse, and
eating disorders. People with severe personality disorders are at high risk of hypochondriasis and
violent or self-destructive behaviors. They may have inconsistent, detached, overemotional,
abusive, or irresponsible styles of parenting, leading to physical and mental problems in their
children.

Personality: an ingrained, enduring pattern of behaving and relating to self, others, and the
environment; behaviors and characteristics are consistent across a broad range of situations and
do not change easily . another definition: The aggregate of the physical and mental qualities of the
individual as these interact in characteristic fashion with his environment” Taylor, Cecilia

Personality disorders: when personality traits become inflexible and maladaptive and
significantly interfere with how a person functions in society or cause the person emotional
distress; usually not diagnosed until adulthood; maladaptive behavior can be traced to early
childhood or adolescence.

In summary:

 Personality disturbances that come together to create a pervasive pattern of behavior and
inner experience that is quite different from the norms of the culture

 They have disturbances in self-image

 Decreased ability to have successful relationships

Characteristic of personality disorders:

 Maladaptive traits often prevent the person’s interpersonal relationships and they increase
the level of anxiety or internal stress

 MALADAPTIVE BEHAVIORAL patterns are the hallmark of personality disorders

 Maladaptive traits are often RIGID and INFLEXIBLE that exist in attitudes and behavior
of the person

 Once a personality trait is established, it is extremely resistant but NOT IMPOSSIBLE

to change

DSM-IV-TR Categories

• Cluster A: people whose behavior is odd or eccentric (paranoid, schizoid, schizotypal)

 • Cluster B: people who appear dramatic, emotional, or erratic (antisocial, borderline,
histrionic, narcissistic)

• Cluster C: people who are anxious or fearful (avoidant, dependent, obsessive-

compulsive)

• Disorders being considered for inclusion are depressive and passive-aggressive

Onset and Clinical Course

• Personality disorders occur in 10% to 13% of the general population

• Incidence is even higher in lower socioeconomic groups

• 40% to 45% of people with a primary diagnosis of major mental illness also have a
coexisting personality disorder that significantly complicates treatment

• Clients with personality disorders have:

• Higher death rates, especially as a result of suicide

• Higher rates of suicide attempts, accidents, and emergency department visits

• Increased rates of separation, divorce, and involvement in legal proceedings

regarding child custody

• Increased rates of criminal behavior, alcoholism, and drug abuse

Treatment

• Many people with personality disorders do not seek treatment because they don’t believe
they have a problem

• Individual and group therapy may be helpful to those desiring change, but any changes
are slow

• Improvement in relationships, improved basic living skills, relief of anxiety may be goals
of therapy

• Cognitive-behavioral techniques such as thought-stopping, positive self-talk, and

decatastrophizing can be effective

Cluster A Personality Disorders

• Paranoid personality disorder :

Clinical Picture
 • Mistrust and suspiciousness, aloof and withdrawn, guarded or hyper-vigilant, restricted
affect, use the defense mechanism of projection

Nursing Interventions

• Approach in a formal, business-like manner, keep commitments, be straightforward,

involve them in formulating their care plans, help them learn to validate ideas before
taking action

• Schizoid personality disorder :

Clinical Picture

• Acute discomfort in relationships, cognitive or perceptual distortions, eccentric behavior,

bizarre speech, affect flat and sometimes inappropriate

Nursing Interventions

• Promote self-care, social skills, and improved functioning in the community

• Schizotypal personality disorder :

Clinical Picture

• Acute discomfort in relationships, cognitive or perceptual distortions, eccentric behavior,

bizarre speech, affect flat and sometimes inappropriate

Nursing Interventions

• Promote self-care, social skills, and improved functioning in the community

Cluster B Personality Disorders

• Antisocial : Pervasive pattern of disregard for and violation of rights of others, deceit and
manipulation

• Borderline : Pervasive pattern of unstable interpersonal relationships, self-image,

affect, and marked impulsivity

• Narcissistic: Clinical Picture

• Grandiose; lack of empathy; need for admiration; arrogant or haughty attitude; disparage,
belittle, or discount the feelings of others; view their problems as the fault of others;
hypersensitive to criticism and need constant attention and admiration

• Nursing Interventions
• Use self-awareness skills to avoid anger and frustration; use matter-of-fact manner; set
limits on rude or verbally abusive behavior

• Histrionic: Excessive emotionality and attention seeking; colorful and theatrical speech;
overly concerned with impressing others; emotionally expressive, gregarious, and effusive;
emotions are insincere and shallow; self-absorbed; uncomfortable when they are not the center of
attention and go to great lengths to gain that status

• Nursing Interventions

• Give feedback about social interactions; teach social skills through role playing

Cluster C Personality Disorders

• Avoidant personality disorder

• Clinical Picture

• Social inhibitions; feelings of inadequacy; hypersensitivity to negative evaluation; avoid

situations or relationships that may result in rejection, criticism, shame, or disapproval;
strongly desire closeness and intimacy but fear possible rejection and humiliation

• Nursing Interventions

• Explore positive self-aspects and reasons for self-criticism; practice self-affirmations and
positive self-talk; cognitive restructuring techniques, such as reframing and
decatastrophizing; teach social skills

• Dependent personality disorder

• Clinical Picture

• Submissive and clinging behavior; excessive need to be taken care of; pessimistic and
self-critical; other people hurt their feelings easily; report feeling unhappy or depressed;
difficulty making decisions; seek advice and repeated reassurances

• Nursing Interventions

• Help identify strengths and needs; use cognitive restructuring; assist in daily functioning;
teach problem solving and decision making; refrain from giving advice

• Obsessive-compulsive personality disorder

• Clinical Picture
 • Preoccupation with orderliness, perfectionism, and control; formal and serious demeanor;
constricted emotions; stubborn; preoccupied with details, rules, lists, and schedules;
believe they are right; problems with judgment and decision making

• Nursing Interventions

• Help accept or tolerate less-than-perfect work; use cognitive restructuring techniques;

encourage to take risks; practice negotiation

The following table summarizes personality disorders and the necessary nursing
interventions.

PERSONALITY DISORDERS (PDs)

A personality disorder is an enduring pattern of inner experience and behavior that: 1. Deviates markedly from the expectations of one’s culture 2.
Is pervasive, maladaptive and inflexible, 3. Has an onset in adolescent or early adulthood 4. Is stable over time and 5. Leads to distress or
impairment
CONCEPT ALL PERSONALITY DISORDERS have four common characteristics:
-Inflexibility/maladaptive responses to stress
-Disability in social and professional relationships
-Tendency to provoke interpersonal conflict
-Capacity to cause irritation or distress in others

CLUSTERS CLUSTER A CLUSTER B CLUSTER C

Odd or Excentric Traits Dramatic, Emotional, or Erratic Traits Anxious or Fearful Traits; Insecurity and
Inadequacy
PERSONALITY
TYPES PARANOID SCHIZOI SCHIZO ANTISOCI BORDER HISTRION NARCISSIS AVOIDA DEPENDE OBSSESIV
D TYPAL AL LINE IC TIC NT NT E-
COMPULS
IVE
Characterize Characteri Character Characteriz Characteri Characteriz Characterize Characteri Characteriz Characteriz
d by zed ized by ed by zed by ed by d by zed by ed by ed by
Distrust Emotional Odd consistent Instabilit Emotional Arrogance, Social Extreme Perfectioni
And Detachme Beliefs, Disregard y of Attention- Grandiose Inhibition Dependenc sm with a
Suspiciousn nt, leading to for Others Affect, Seeking Views of and y in a close focus on
ess Towards disinterest interperso with identity Behavior, Self- Avoidance Relationshi orderliness
Others, in close nal exploitatio and in which Importance, of all p with an and
FEATURES based on the relationshi difficultie n and Relations the person the need for situations urgent control
belief ps, and s, an repeated hips; fear needs to be constant that search to .They
(unsupported indifferenc eccentric unlawful of the center admiration require find a become so
by evidence) e to praise appearan actions, abandonm of along with a interperson replacement preoccupie
that others or ce, and deceit and ent, attention; lack of al contact, when one d with
want to criticism; magical failure to splitting often empathy for despite relationship details and
exploit, often thinking accept behavior, seductive others that wanting ends; the rules that
harm, or uncooperat or personal manipulat and strains most close most they may
deceive the ive. perceptua responsibili ion, and flirtatious, relationships relationshi frequently- not be able
person. The l ty. impulsive the ; often ps, due to seen to
These person distortion Previously ness; histrionic sensitive to extreme personality accomplish
individuals with this s that are called often tries person is criticism. fear of disorder in a given
are: disorder not clear Psychopath self- impulsive Underneath rejection; the clinical task.
- does not delusions s or mutilation and the surface often very setting. Persons
Hypervigilan seek out or or Sociopaths. and may melodrama of arrogance, anxious in Individuals with
t enjoy close hallucinat There is a be tic. narcissistics social with Obsessive-
-Anticipate relationshi ions. clear suicidal. Relationshi feel intense situations. Dependent Compulsive
hostility ps. These history of Individual ps do not shame and Because in PD have PD feel
-May individuals conduct s w/ last b/c fear that if their social difficulty genuine
provoke may be disorder in Borderlin their they are presentatio making affection
hostile able to childhood, e PD partner “bad” they n they independent for friends
responses by function in and the desperatel often feels will be appear decisions and family,
initiating a a solitary individual y seek smothered abandoned. timid and and are and don’t
 “counterattac occupation show no relationsh or reacts to They are with low constantly have
k” . remorse for ips to the afraid of self- seeking insight
- hurting avoid insensitivit their own esteem and reassurance. about their
Demonstrate Schizoid others. feelings y of the mistakes, as poor self- Their own
jealousy, PD can be They of histrionic well as the care, they submissiven difficult
controlling a precursor repeatedly: abandone person. The mistakes of are often ess makes behavior
behaviors, to -Neglect d, but individual others. May mistreated them creating
and schizophre responsibili often with seek help, in groups. vulnerable tension in
unwillingnes nia or ties drive histrionic feeling that If they do to abusive their close
s to forgive. delusional -Tell lies others PD has no loved ones develop relationship relationship
**Paranoid disorder. -Perform away b/c insight into do not show relationshi s. The have s, in which
people are There is destructive of their his role in enough ps, they a deeply the person
difficult to increased or illegal excessive breaking up appreciation cling to held tries to
interview b/c prevalence acts, demands, relationship of their their conviction control the
they are of the without impulsive s. In the special partners in of personal partner.
reluctant to disorder in developing behavior, treatment qualities. a incompeten
share families any insight and their setting, the dependent ce that they
information with into frequent person way. They cannot
about schizophre predictable use of demands are seen in survive on
themselves. nia or consequenc splitting. “the best of Tx for their own.
schizotypal es. everything” symptoms
PD. and can be of anxiety.
very
critical

1. Minnesota Multiphasic Personality Inventory (MMPI)

ASSESSMENT
2. Full medical history to rule out medical causes
3. Psychosocial history :
• Suicidal, homicidal, or aggressive thoughts.
• Current use of medicines and illegal substances
• History of current or abuse
• Legal history
• Ability to handle money
• Current or past physical, sexual, or emotional abuse
• Risk of harm of self and others
EXPECTED The patient will be able to:
OUTCOMES • Use adaptive coping strategies to deal with conflict
• Accept responsibilities for own actions/behaviors
• Communicates needs appropriately
• Demonstrate self-restrain of compulsive or impulsive behavior
*Usually not admitted for Personality Disorders. For a patient to be eligible for admission to the hospital, must have an AXIS I psychiatric
diagnosis, plus the AXIS II Personality Disorder.
*Realistically, behavior probably will not change significantly
CLUSTER A CLUSTER B CLUSTER C
Odd or Excentric Traits Dramatic, Emotional, or Erratic Traits Anxious or Fearful Traits; Insecurity and
• Objective, matter-of-fact • Prevent self-harm. No harm contract. Inadequacy
approach • Set limits on inappropriate or manipulative • Caring consistent approach
• Avoid being too “nice or behaviors • Clear expectations for behavior
friendly” • Provide clear, consistent boundaries • Expect patient to make
• Clear, simple, consistent • Assist examining consequences of behavior. decisions
INTERVENTIONS verbal-non-verbal •
• Consistent approach by staff Teach assertiveness
communication • Do not rescue or reject • Encourage to identify positive
• Give clear straightforward • Remain neutral, avoid engaging in power attributes
explanations struggles or be coming defensive to patient’s • Provide positive feedback for
• Warn about changes, side comments increased interactions in social
effects etc • Give recognition for goal achievement situations
• Help identify feelings • Explore feelings • Teach stress management and
• Assist with problem-solving • Teach problem solving and role model relaxation techniques
• Gradually involve in group assertiveness
situations but do not insist. • Encourage and model concrete and AGGRESSIVE BEHAVIOR
Respect need for social descriptive communication ANGER CONTROL ASSISTANCE!!
isolation. -Determine appropriate behavioral
 MANIPULATIVE BEHAVIOR
SET LIMITS!!
INTERVENTIONS -Discuss concerns about behavior with
FOR: patient
-identify undesirable behavior, and
discuss with patient what is desirable
behavior in a give situation or setting
-Establish consequences for occurrence
or nonoccurrence of desired behavior in
a non punitive ad easily understood
way
-Refrain from arguing or bargaining
with patient about established
behavioral expectations and
consequences
-Modify behavioral expectations as
needed based on reasonable changes in
patient’s situations
• Document behaviors and incidents objectively
• Encourage follow up treatment
IMPULSIVE BEHAVIOR
IMPULSE CONTROL TRAINING!!
-Assist pt to: Identify problem or situation that requires
thoughtful action, and courses of possible actions, their
costs or benefits
-Teach pt to cue himself to “stop and think” before acting
impulsively
-Assist pt to evaluate the outcome of the chosen course
or action
-Provide positive reinforcement for successful outcomes
(e.g. praise and rewards)
-Provide opportunities for pt to practice problem
solving in social and interpersonal situations outside the
therapeutic environment
expectations for expressions of anger,
given pt’s level of cognitive and physical
functioning
-Limit access to frustrating situations until
pt is able to express anger in an adaptive
manner
-Encourage pt to seek assistance from
nursing staff during periods of increasing
tension
-Monitor potential for inappropriate
aggression and intervene before its
expression
-Assist pt in identifying source of anger
-Prevent physical harm if anger is directed
towards self or others
-Provide physical outlets for expressions of
anger or tension (e.g. pushing bag, sports,
clay, journal writing)

PSYCHOBIOLOGICAL INTERVENTIONS: Clients with Personality Disorders usually do not like taking medications unless it calms them down;
MEDICATIONS they are fearful about taking something over which they have no control. They worry if they don’t have an adequate supply, but have difficulty
organizing themselves to fill a prescription. Dependent on the chief complaint, psychotropic agents that are geared toward maintaining cognitive
function and relieving symptoms may be used. These include: ANTIDEPRESSANTS, ANXIOLYTICS, ANTIPSYCHOTICS, or a combination of
these.
MILIEU THERAPY: When individuals with PDs are in hospital, partial hospitalization, or day treatment settings, Milieu Therapy is a significant
part of treatment.
MISC The primary goal of Milieu Therapy is affect management in a group context. Community meetings, coping skills groups, and socializing groups
are all helpful for these clients.
CASE MANAGEMENT: CM is beneficial for clients who have PDs and are persistently and severely impaired. In Acute Care Facilities: CM
focuses on obtaining pertinent history from current or previous providers, supporting integration with the family/significant other, and ensuring
appropriate referrals to outpatient care.
In long-term outpatient facilities, case management goals include reducing hospitalization by providing resources for crisis services and enhancing
the social support system.