Chapter 20

Personality Disorders

Introduction

• Personality traits are enduring patterns of:

– Perceiving

– Relating to

– Thinking about the environment and oneself.

• Personality disorders occur when these traits become

– Inflexible

– Maladaptive

– The cause of significant functional impairment or subjective distress

Introduction (cont.)

• People with personality disorders are not often treated in acute care settings, for which personality disorder is their primary psychiatric disorder.

• May be problematic when hospitalized or in a clinic situation if challenged

• Nurses are likely to frequently encounter clients with these personality characteristics in all healthcare settings.

Personality Disorders

• Cluster A: Behaviors that are described as odd or eccentric

– Paranoid personality disorder

– Schizoid personality disorder

– Schizotypal personality disorder

Personality Disorders (cont.)

• Cluster B: Behaviors that are described as dramatic, emotional, or erratic

– Antisocial personality disorder

– Borderline personality disorder

– Histrionic personality disorder

– Narcissistic personality disorder

Personality Disorders (cont.)

• Cluster C: Behaviors that are described as anxious or fearful

– Avoidant personality disorder

– Dependent personality disorder

– Obsessive-compulsive personality disorder

Types of Personality Disorders
(Cluster A)

• Paranoid

– Definition: A pervasive distrust and suspiciousness such that the motives of others are interpreted as malevolent; condition begins by early adulthood and presents in a variety of contexts

Paranoid (cont.)

• Clinical Picture

– Constantly on guard

– Hypervigilant

– Ready for any real or imagined threat

– Trusts no one

– Constantly tests the honesty of others

– Tends to misinterpret minute cues

– Magnifies Oversensitive

– and distorts cues in the environment

– More men than women

Schizoid

• Definition

– Characterized primarily by a profound defect in the ability to form personal relationships

– Failure to respond to others in a meaningful emotional way

Schizoid (cont.)

• Clinical Picture

– Indifferent to others

– Client aloof

– Client emotionally cold

– In presence of others, clients appear shy, anxious, or uneasy

– Inappropriately serious about everything and have difficulty acting in a light-hearted manner

Schizotypal

• Definition

– A graver form of the pathologically less severe schizoid personality pattern

Types of Personality Disorders
(Cluster B)

• Antisocial

– Definition

• A pattern of

– Socially irresponsible

– Exploitative

– Guiltless behavior

that reflects a disregard for the rights of others.

– Cold, callous, intimidating

– Inconsistent work or academic performance

– Failure to conform to societal norms

– Cruel and malicious

– Inability to form lasting monogamous relationship

Antisocial

• Clinical Picture

– Fails to sustain consistent employment

– Exploits and manipulates others for personal gain

– Has a general disregard for the law

– More men than women

Borderline

– Definition

• Characterized by a pattern of intense and chaotic relationships with affective instability

• Clients have fluctuating and extreme attitudes regarding other people

• Clients highly impulsive

• Most common form of personality disorder

– Emotionally unstable

– Lacks a clear sense of identity

Borderline

Real saftey issues

Often self injure, ( cut, burn, scratch) may die from self inflicted wounds

Common behaviors

• Depression

• Inability to be alone

• Clinging and distancing

• Splitting

• Manipulation

Histrionic

• Definition

– Personality is

• Excitable

• Emotional

• Colorful

• Dramatic

• Extroverted in behavior

Histrionic (cont.)

• Clinical picture

– Affected clients are

• Self-dramatizing

• Attention-seeking

• Overly gregarious

• Seductive

• Manipulative

• Exhibitionistic

Histrionic (cont.)

• Etiological Implications

– Possible link to the dopaminergic neurotransmitter system

– Possible hereditary factor

– Learned behavior patterns

Narcissistic

• Definition

– Characterized by an exaggerated sense of self-worth

– Lacks empathy

– Believes has inalienable right to receive special consideration

– More men than women

– Client overly self-centered

– Exploits others in an effort to fulfill own desires

– Mood, which is often grounded in grandiosity, is usually optimistic

– Responds to negative feedback from others with rage, shame, and humiliation

Types of Personality Disorders (Cluster C)

• Avoidant

– Characterized by

• Extreme sensitivity to rejection

• Social withdrawal

– Prevalence is between 0.5% and 1% and is equally common in both men and women.

– Awkward and uncomfortable in social situations

– Desires close relationships but avoid them because of fear of being rejected

Dependent

• Definition

– Characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation

– Relatively common within the population

– More common among women than men

– More common in the youngest children of a family than in the oldest ones

Dependent (cont.)

• Clinical Picture

– Client has a notable lack of self-confidence that is often apparent in

• Posture

• Voice

• Mannerisms

– Typically passive and acquiescent to desires of others

– Overly generous and thoughtful while underplaying own attractiveness and achievements

Dependent (cont.)

• Clinical Picture (cont.)

– Assumes passive and submissive roles in relationships

– Avoids positions of responsibility and becomes anxious when forced into them

OCD

• Obsessive/Compulsive

– Definition

• Characterized by inflexibility about the way in which things must be done

• Devotion to productivity at the exclusion of personal pleasure

• Definition

– Relatively common and occurs more often in men than women

– Within family constellation, appears to be most common in the oldest children

Obsessive-Compulsive (cont.)

• Clinical Picture

– Especially concerned with matters of organization and efficiency

– Tends to be rigid and unbending

– polite and formal

– rank-conscious (ingratiating with authority figures)

– Appears to be very calm and controlled

– Underneath there is a great deal of

• Ambivalence

• Conflict

• Hostility

Passive-Aggressive

• Definition

– Exhibits a pervasive pattern of negativistic attitudes and passive resistance

– Reacts badly to demands for adequate performance in social and occupational situations

– Exhibits passive resistance

– Exhibits general obstructiveness

– Commonly switches among the roles of the martyr, the affronted, the aggrieved,

the misunderstood, the contrite,

the guilt-ridden, the sickly, and the

overworked

Passive-Aggressive (cont.)

• Clinical Picture

– Exhibits passive resistance

– Exhibits general obstructiveness

– Commonly switches among the roles of the martyr, the affronted, the aggrieved,

the misunderstood, the contrite,

the guilt-ridden, the sickly, and the

overworked

Passive-Aggressive (cont.)

• Clinical Picture (cont.)

– Able to vent anger and resentment subtly while gaining the attention, reassurance, and dependency that are craved

Etiology

• No single cause

• Limited research due to clients not seeking treatment Genetic-a biological tendency to react intensely to low levels of stress

• Neurobiological

• Limbic system dysregulation and CNS irritability may lower impulse control Decreased 5-HT associated with self mutilation, rage, aggressiveness

• Neurobiological

• Limbic system dysregulation and CNS irritability may lower impulse control Decreased 5-HT associated with self mutilation, rage, aggressiveness

• Increase in NE associated with hypersensitivity to environment

• Interpersonal

• Projection of hostility toward self on to others resulting in withdrawal to avoid being hurt

• High standards imposed in childhood may set up perfectionism

• Social Theory

• A changing social system with personal needs being viewed as more important than group needs

• Social oppression leading to low self esteem, and poor identity

• Family Theory

• Inability to manage conflict, inadequate role modeling, inconsistent parenting

• Multigenerational enmeshed family system

• Feminist theory

Nursing Interventions

• Approach in a gentle, interested but non intrusive way Respect client’s need for distance

• Encourage interaction (group), but do not push Be as neutral as possible as client perceives others as threatening

• Be patient with client’s extreme emotional behaviors Provide a consistent and structured milieu to decrease power struggles Protect client from suicide and self mutilation Set clear limits to maintain impulse control

• Teach problem solving and assertiveness training Teach expression of feelings

• Help client to recognize distress related to the need for perfection and control Help client discuss feelings of inadequacy and fear of rejection

• Impulse Control Training

• Safety- suicide precautions

• Match client’s developmental stage

• No harm contract-self monitoring

• Help them identify and label feelings

• Identify triggers and patterns in ther behaviors (journaling)

• Problem solving and teach ability to tolerate uncomfortable feelings

• Antipsychotics for brief psychotic episodes

• SSRIs to decrease mood swings, and impulsive, aggressive, self destructive behaviors

• Groups

• To help client increase self awareness

• Self help groups

• Limit setting

• Clear ground rules- explain reasons and consequences

• Social skills

• Group therapy

• Assertiveness skills

• Involve them in the decisions, so they have “buy in” to their plan

• No changing of the rules- be consistent it creates a feeling of safety

• Business like approach- not a “friend”, not parental

• Focus on behavior, not the reasons for the behavior

• Anxiety Reduction

• Increase their sense of worth and competence by having them make their own decisions

• Teach the problem solving process

• Facilitate their taking responsibility for their own behavior Explore feelings and decisions with them

• Teach them how to ask for help

• Teach relaxation techniques-breathing, progressive muscle relaxation