PERSONALITY DISORDERS

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

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 a spectrum of maladaptive traits that produce or influence considerable psychological and emotional disturbance and impair relationships Kernberg (1984) Enduring pattern of feeling (emotion), thinking (cognitive distortions), and behaving (maladaptive in nature) that become rigid and stable over time DSM-IV-TR (APA 2000)

EGO SYNTONIC : comfortable for the individual but usually uncomfortable for others

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, obsessivecompulsive) 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

Etiology
Biologic Hormones Neurotransmitters Temperament (innate, genetically based aspects of
personality)

Psychoanalytic Factors
Freud

Psychosocial factors (Character) Self-directedness(responsible, reliable,

resourceful, goal directed, and self-confident)

Cooperativeness (an integral part of the society) Self-transcendence (an integral part of the
universe)

Cultural Considerations
Guarded or defensive behavior may be displayed as a result of language barriers or previous negative experiences and should not be confused with paranoid personality disorder People with religious or spiritual beliefs, such as clairvoyance, speaking in tongues, or evil spirits as a cause of disease, could be misinterpreted as having schizotypal personality disorder

Cultural Considerations (contd)

An emphasis on deference, passivity, and politeness should not be confused with a dependent personality disorder Cultures that value work and productivity may produce citizens with a strong emphasis in these areas; this should not be confused with obsessive-compulsive personality disorder Social stereotypes about gender roles and behaviors can influence diagnosis of certain personality disorders

Treatment
Many people with personality disorders do not seek treatment because they dont 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

Pharmacologic Treatment for Symptoms

Cognitive-perceptual disturbances (magical thinking, odd beliefs, illusions, suspiciousness, ideas of reference, and low-grade psychotic symptoms)
Low-dose antipsychotic medications

Mood dysregulation (emotional instability, emotional detachment, depression, and dysphoria)

Lithium, carbamazepine (Tegretol), valproate (Depakote), low-dose neuroleptics, SSRIs, MAOIs, atypical antipsychotics

Aggression (predatory or cruel behavior, impulsivity, poor social judgment, and emotional lability)
Lithium, anticonvulsant mood stabilizers, benzodiazepines, and lowdose neuroleptics

Anxiety
SSRIs, MAOIs, or low-dose antipsychotics

Individual and Group Psychotherapy

Focus is on building trust, teaching basic living skills, providing support, decreasing distressing symptoms, and improving interpersonal relationships. Basic living skills for people with cluster A personality disorders Inpatient hospitalization to provide safety for people with borderline personality disorder Assertiveness training groups for people with cluster C personality disorders Relaxation or meditation techniques for people with cluster C personality disorders

Cluster A Personality Disorders

Paranoid personality disorder
Schizoid personality disorder

Schizotypal personality disorder

Paranoid Personality Disorder

Clinical Picture
Mistrust and suspiciousness

aloof and withdrawn

restricted affect
defense mechanism of projection

guarded or hypervigilant

Paranoid Personality Disorder

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 Detached from social relationships restricted affect aloof and indifferent no leisure or pleasurable activities do not report feeling distressed about lack of emotion intellectual and accomplished with solitary interests indifferent to praise or criticism dissociate from or no bodily or sensory pleasures

Schizotypal Personality Disorder

Clinical Picture
Acute discomfort in relationships Cognitive or perceptual distortions
Superstitious beliefs in clairvoyance Sixth sense

Eccentric behavior Bizarre speech Affect flat and sometimes inappropriate

Schizotypal & Schizoid PD

Nursing Interventions Approach the client in a calm manner Maintain a comfortable distance based on the clients verbal and nonverbal communication Engage supportive groups to provide feedback on the clients behavior Provide for structured social interactions provide care that accommodates the desire for solitude Improve functioning in the community Administer antipsychotic

Cluster B Personality Disorders

Antisocial Borderline Narcissistic Histrionic

Antisocial Personality Disorder

Clinical Picture Pervasive pattern of disregard for and violation of rights of others deceit and manipulation History of lying, truancy, vandalism, sexual promiscuity, substance use in childhood and adolescence appears normal, may be charming and engaging, trying to manipulate

Antisocial Personality Disorder

> shallow emotions, chooses emotions to work to their advantage, > no genuine feelings of empathy > no guilt, only remorseful if caught > views the world as cold and hostile, thinks everyone else is as ruthless as he or she is, so trusts no one

Antisocial Personality Disorder

lacks insight, poor judgment due to inability to delay gratification, impulsivity, or ethical/legal considerations of actions superficially appears self-assured and confident, even arrogant, but this covers low self-esteem poor relationships due to exploitation and using others has trouble keeping jobs, being a parent, staying married, and so forth

Antisocial Personality Disorder

Intervention Forming therapeutic relationship Limit setting Confrontation Promoting responsible behavior Helping client solve problems and control emotions Enhancing role performance

Borderline Personality Disorder

Clinical Picture Pervasive pattern of unstable interpersonal relationships, marked impulsivity polarized thinking/splitting

Borderline Personality Disorder

Assessment History of disturbed early relationships with parents, punitive responses from parents, family history of abuse and alcoholism mildly dysfunctional clients appear normal mood is labile and feelings intense feeling of loneliness; boredom; frustration difficulty fulfilling roles, especially involving mundane tasks (school, work);

Borderline Personality Disorder

others are adored after a brief acquaintance, then despised if they dont meet clients expectations; obsessive and ruminative thoughts about abandonment, suicide, and self-harm; may have dissociative episodes relationships are stormy given clients behavior, but client blames others;

Borderline Personality Disorder

Intervention Long-term therapy to resolve family dysfunction and abuse Hospitalization when client is exhibiting self-harm behaviors or having intense symptoms Brief hospitalizations to stabilize condition

Borderline Personality Disorder

Promoting the clients safety (No-self-harm contract) Promoting the therapeutic relationship Establishing boundaries in relationships Teaching effective communication skills Helping the client to cope and control emotions Structuring daily activities Reshaping thinking patterns
Cognitive restructuring Positive self-talk Decatastrophizing

Histrionic Personality Disorder

Clinical Picture 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

Histrionic Personality Disorder

Nursing Interventions Give feedback about social interactions Teach social skills through role playing

Narcissistic Personality Disorder

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

Narcissistic Personality Disorder

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

Cluster C Personality Disorders

Avoidant personality disorder Dependent personality disorder Obsessive-compulsive personality disorder

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

Avoidant Personality Disorder

Nursing Interventions
Explore positive self-aspects and reasons for self-criticism; practice self-affirmations and positive selftalk; 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

Dependent Personality Disorder

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

Obsessive-Compulsive Personality Disorder

Nursing Interventions
Help accept or tolerate less-than-perfect work; use cognitive restructuring techniques; encourage to take risks; practice negotiation

Related Disorders
Depressive personality disorder Passive-aggressive personality disorder

Depressive Personality Disorder

Clinical Picture
Sad, gloomy, persistent unhappiness, cheerlessness, and hopelessness; inability to experience joy or pleasure in any activity; cannot relax; do not display a sense of humor; brood and worry over all aspects of daily life; thinking is negative and pessimistic

Depressive Personality Disorder

Nursing Interventions
Assess risk for self-harm; encourage to become involved in activities; give factual feedback; use cognitive restructuring techniques; teach effective social skills

Passive-Aggressive Personality Disorder Clinical Picture

Negative attitudes; resent, oppose, and resist demands expected by others; express resistance through procrastination, forgetfulness, stubbornness, and intentional inefficiency

Passive-Aggressive Personality Disorder

Nursing Interventions
Help examine the relationship between feelings and subsequent actions; teach appropriate ways to express feelings directly

Elder Considerations
Personality disorders from Clusters A and C are more prevalent in older age and are closely correlated with depression

Self-Awareness Issues
Avoiding client attempts to manipulate Engaging in clear communication Setting limits and boundaries Dealing with frustration: clients change slowly yet look like they are capable of better behavior Working effectively as part of the team; consistency is essential

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