1. Personality Disorders
Chapter 23
Personality Disorders

2. Introduction Personality, defined:
The totality of emotional and behavioral characteristics that are particular to a specific person and that remain somewhat stable and predictable over time.

3. Introduction (cont’d)
Personality traits are characteristics with which an individual is born or develops early in life.
They influence the way in which he or she perceives and relates to the environment and are quite stable over time.

4. Introduction (cont’d)
Personality disorders occur when these traits become rigid and inflexible and contribute to maladaptive patterns of behavior or impairment in functioning.

5. Introduction (cont’d)
Personality development occurs in response to a number of biological and psychological influences
Heredity
Temperament
Experiential learning
Social interaction

6. Introduction (cont’d)
People with personality disorders are not often treated in acute care settings in cases in which the personality disorder is their primary psychiatric disorder.
Nurses are likely to encounter clients with these personality characteristics frequently in all health-care settings.

7. Types Cluster A (odd or eccentric behaviors)
Paranoid PD
Schizoid PD
Schizotypal PD
Cluster B (dramatic, emotional, erratic behaviors)
Antisocial PD
Borderline PD
Histrionic PD
Narcissistic PD

8. Types Class C (anxious or fearful behaviors) Avoidant PD Dependent PD
Obsessive-compulsive PD

9. Types of Personality Disorders
Paranoid Personality Disorder
Characterized by a pervasive, persistent, and inappropriate mistrust of others.
Individuals with this disorder are suspicious of others’ motives and assume that others intend to exploit, harm, or deceive them.
The disorder is more common in men than in women.

10. Types of Personality Disorders (cont’d)
Paranoid Personality Disorder (cont’d)
Clinical picture
Constantly on guard and Hypervigilant
Ready for any real or imagined threat
Trusts no one
Constantly tests the honesty of others
Insensitive to the feelings of others
Oversensitive

11. Types of Personality Disorders (cont’d)
Paranoid Personality Disorder (cont’d)
Clinical picture (cont’d)
Tends to misinterpret minute (minor) cues
Magnifies and distorts cues in the environment
Does not accept responsibility for his/her own behavior
Attributes shortcomings to others
Envy and hostile toward others’ success

12. Types of Personality Disorders (cont’d)
Schizoid Personality Disorder
Characterized primarily by a profound defect in the ability to form personal relationships
Failure to respond to others in a meaningful emotional way
Lifelong pattern of social withdrawal
Diagnosis occurs more frequently in men than in women

13. Types of Personality Disorders (cont’d)
Schizoid Personality Disorder (cont’d)
Clinical picture
Aloof and indifferent to others
Emotionally cold
No close friends; prefers to be alone
Appears shy, anxious, or uneasy in the presence of others
Inappropriately serious about everything and difficulty acting in a light-hearted manner

14. Types of Personality Disorders (cont’d)
Schizotypal Personality Disorder
A graver (more serious) form of the pathologically less severe schizoid personality pattern.
Affects approximately 1 to 2 percent of the population.

15. Types of Personality Disorders (cont’d)
Schizotypal Personality Disorder (cont’d)
Clinical picture
Clients are aloof and isolated
Symptoms include
Magical thinking
Ideas of reference
Illusions
Depersonalization
Belief in telepathy, sixth sense

16. Types of Personality Disorders (cont’d)
Schizotypal Personality Disorder (cont’d)
Clinical picture (cont’d)
Exhibits bizarre speech pattern
When under stress, may decompensate and demonstrate psychotic symptoms
Demonstrates bland, inappropriate affect

17. Types of Personality Disorders (cont’d)
Antisocial Personality Disorder
A pattern of behavior that is
Socially irresponsible
Exploitative
Without remorse
Behavior reflects a disregard for the rights of others

18. Types of Personality Disorders (cont’d)
Antisocial Personality Disorder (cont’d)
Clinical picture
Fails to sustain consistent employment
Fails to conform to the law
Exploits and manipulates others for personal gain
Fails to develop stable relationships

19. Types of Personality Disorders (cont’d)
Antisocial Personality Disorder (cont’d)
Prevalence estimates in the United States range from 2 to 4 percent in men to about 1 percent in women.
More common in lower socioeconomic status people

20. Types of Personality Disorders (cont’d)
Borderline Personality Disorder
Characterized by a pattern of intense and chaotic relationships with affective instability
Fluctuating and extreme attitudes regarding other people
Highly impulsive
Chronic depression
Inability to be alone

21. Types of Personality Disorders (cont’d)
Borderline Personality Disorder (cont’d)
Emotionally unstable
Directly and indirectly self-destructive
Lacks a clear sense of identity
Clinging and distancing behaviors
Manipulation
Most common PD
More common in women than in men

22. Types of Personality Disorders (cont’d)
Histrionic Personality Disorder
Behavior is
Excitable
Emotional
Colorful
Dramatic
Extroverted
More common in women than in men

23. Types of Personality Disorders (cont’d)
Histrionic Personality Disorder (cont’d)
Clinical picture
Self-dramatizing
Attention-seeking
Overly gregarious
Seductive
Manipulative
Exhibitionistic

24. Types of Personality Disorders (cont’d)
Histrionic Personality Disorder (cont’d)
Clinical picture (cont’d)
Highly distractible
Difficulty paying attention to detail
Easily influenced by others
Difficulty forming close relationships
Strongly dependent
Somatic complaints are common

25. Types of Personality Disorders (cont’d)
Narcissistic Personality Disorder
Characterized by an exaggerated sense of self-worth
Lack of empathy
Belief in an inalienable right to receive special consideration

26. Types of Personality Disorders (cont’d)
Narcissistic Personality Disorder (cont’d)
Prevalence of the disorder is estimated at about 6 percent
Diagnosed more often in men than in women

27. Types of Personality Disorders (cont’d)
Narcissistic Personality Disorder (cont’d)
Clinical picture
Overly self-centered
Exploit others in an effort to fulfill their own desires
Mood, which is often grounded in grandiosity, is usually optimistic, relaxed, cheerful, and care-free

28. Types of Personality Disorders (cont’d)
Narcissistic Personality Disorder (cont’d)
Clinical picture (cont’d)
Because of fragile self-esteem, mood can easily change if they do not
Meet self-expectations
Receive the positive feedback they expect
Criticism from others may cause them to respond with rage, shame, and humiliation

29. Types of Personality Disorders (cont’d)
Avoidant Personality Disorder
Characterized by
Extreme sensitivity to rejection
Social withdrawal

30. Types of Personality Disorders (cont’d)
Avoidant Personality Disorder (cont’d)
Clinical picture
Awkward and uncomfortable in social situations
Desire close relationships but avoid them because of their fear of being rejected
Perceived as timid, withdrawn, or cold and strange
They are often lonely and feel unwanted
They view others as critical and betraying

31. Types of Personality Disorders (cont’d)
1. When assessing a client diagnosed
with narcissistic personality
disorder, the nurse expects to
identify which characteristic behavior?
a) Odd beliefs and magical thinking
b) Grandiose sense of self-importance
c) Pattern of intense and chaotic relationships
d) Submissive and clinging behaviors

32. Types of Personality Disorders (cont’d)
Correct answer: B
Clients diagnosed with narcissistic personality disorder have an exaggerated sense of self-worth. They are often grandiose and believe they have an inalienable right to receive special consideration.

33. Types of Personality Disorders (cont’d)
Dependent Personality Disorder
Characterized by a pattern of relying on others for emotional support
More common among women than men
More common in the youngest children of a family than in the older ones

34. Types of Personality Disorders (cont’d)
Dependent Personality Disorder (cont’d)
Clinical picture
They have a notable lack of self-confidence that is often apparent in their
Posture
Voice
Mannerisms

35. Types of Personality Disorders (cont’d)
Dependent Personality Disorder (cont’d)
Clinical picture (cont’d)
Typically passive and acquiescent to desires of others
Overly generous and thoughtful, while underplaying their own attractiveness and achievements

36. Types of Personality Disorders (cont’d)
Dependent Personality Disorder (cont’d)
Clinical picture (cont’d)
Low self-worth and easily hurt by criticism and disapproval
Avoid positions of responsibility and become anxious when forced into them
Assume passive and submissive roles in relationships

37. Types of Personality Disorders (cont’d)
Obsessive-Compulsive Personality Disorder
Characterized by inflexibility about the way in which things must be done
Devotion to productivity at the exclusion of personal pleasure
Overly disciplined, perfectionist, and preoccupied with rules

38. Types of Personality Disorders (cont’d)
Obsessive-Compulsive Personality Disorder (cont’d)
Occurs more often in men than in women
Within the family constellation, it appears to be most common in oldest children

39. Types of Personality Disorders (cont’d)
Obsessive-Compulsive Personality Disorder (cont’d)
Clinical picture
Especially concerned with matters of organization and efficiency
Tend to be rigid and unbending
Socially polite and formal
Rank-conscious
Ingratiating with authority figures
Autocratic and condemnatory with subordinates

40. Types of Personality Disorders (cont’d)
Obsessive-Compulsive Personality Disorder (cont’d)
Clinical picture (cont’d)
On the surface, appear to be very calm and controlled
Underneath there is a great deal of
Ambivalence
Conflict
Hostility

41. Types of Personality Disorders (cont’d)
2. A client diagnosed with a
personality disorder is cold, aloof,
and avoids others on the unit. The nurse recognizes that this behavior is symptomatic of which personality disorder?
a) Schizoid personality disorder
b) Dependent personality disorder
c) Borderline personality disorder
d) Antisocial personality disorder

42. Types of Personality Disorders (cont’d)
Correct answer: A
A hallmark of the schizoid personality is a marked withdrawal from social contact. The client behaviors presented in the question are indicative of schizoid personality disorder.

43. Application of the Nursing Process
Assessment
Borderline Personality Disorder
Designated as “borderline” because of the tendency of these clients to fall on the border between neuroses and psychoses

44. Assessment (cont’d) Borderline Personality Disorder (cont’d)
Instability of interpersonal relationships
Unstable self-image
Marked impulsivity
Intensity of affect and behavior

45. Assessment (cont’d) Borderline Personality Disorder (cont’d)
Common behaviors
Chronic depression
Inability to be alone
Clinging and distancing behaviors
Splitting
Manipulation
Self-destructive behaviors
Impulsivity

46. Application of the Nursing Process (cont’d)
Borderline Personality Disorder (cont’d)
Predisposing factors (cont’d)
Psychosocial influences
Childhood trauma and abuse
Developmental factors: fixed in the rapprochement phase of development (16 to 24 months old). The child fails to achieve task of autonomy.

47. Application of the Nursing Process (cont’d)
3. A client diagnosed with borderline
personality disorder is admitted to a
psychiatric unit. Which behavior
pattern would the nurse expect to
observe?
a) Social isolation
b) Suspiciousness of others
c) Bizarre speech patterns
d) Generates conflict among the staff

48. Application of the Nursing Process (cont’d)
Correct answer: D
Clients diagnosed with borderline personality disorder, having little empathy toward others, are unable to accept both positive and negative feelings, and view others as all good or all bad. They tend to split staff, generating conflict.

49. Application of the Nursing Process (cont’d)
4. In assessing a client diagnosed
with borderline personality disorder,
which characteristic would the nurse
expect to observe?
a) Predictability
b) Controlled anger
c) Little tolerance for being alone
d) Stable and satisfactory relationships

50. Application of the Nursing Process (cont’d)
Correct answer: C
Clients diagnosed with borderline personality disorder have little tolerance for being alone. They prefer a frantic search for companionship, no matter how unsatisfactory, rather than experiencing feelings of loneliness, emptiness, and boredom.

51. Nursing Diagnosis: Borderline Personality Disorder
Risk for self-mutilation related to parental emotional deprivation
Risk for suicide related to unresolved grief
Risk for other-directed violence related to underlying rage
Complicated grieving related to maternal deprivation during rapprochement phase of development internalized as a loss, with fixation in anger stage of grieving process

52. Nursing Diagnosis: Borderline Personality Disorder (cont’d)
Impaired social interaction related to extreme fears of abandonment and engulfment
Disturbed personal identity related to underdeveloped ego
Anxiety (severe to panic) related to unconscious conflicts based on fear of abandonment
Chronic low self-esteem related to lack of positive feedback

53. Outcomes: Borderline Personality Disorder
The client
Has not harmed self
Seeks out staff when desire for self-mutilation is strong
Is able to identify true source of anger
Expresses anger appropriately

54. Outcomes: Borderline Personality Disorder (cont’d)
The client (cont’d)
Relates to more than one staff member
Completes activities of daily living independently
Does not manipulate one staff member against the other to fulfill own desires

55. Planning/Implementation
Nursing intervention for the client with borderline personality disorder is aimed at protection of the client from self-harm.
The nurse also seeks to assist the client to advance in the development of personality by confronting his or her true source of internalized anger.

56. Evaluation
Evaluation of care for the client with borderline personality disorder is based on accomplishment of previously established outcome criteria.

57. Nursing Process: Assessment
Antisocial Personality Disorder
Not often seen in most clinical settings
Most frequently encountered in prisons, jails, and rehabilitation services
When clients are seen, it is commonly a way to avoid legal consequences
Sometimes they are admitted to the health- care system by court order for psychological evaluation

58. Assessment (cont’d) Antisocial Personality Disorder (cont’d)
Common behaviors
Exploitation and manipulation of others for personal gain
Belligerent and argumentative
Lacks remorse
Unable to delay gratification
Low frustration tolerance
Inconsistent work or academic performance

59. Assessment (cont’d) Antisocial Personality Disorder (cont’d)
Common behaviors (cont’d)
Failure to conform to societal norms
Impulsive and reckless
Inability to function as a responsible parent
Inability to form lasting monogamous relationship

60. Predisposing Factors to Antisocial Personality Disorder
Possible genetic influence
Having a disruptive behavior disorder as a child (ADHD; conduct disorder)
History of severe physical abuse
Absent or inconsistent parental discipline
Extreme poverty
Removal from the home
Growing up without parental figures of both sexes
Always being rescued when in trouble
Maternal deprivation

61. Antisocial Personality (cont’d)
5. An individual with a history of antisocial
personality disorder was arrested for driving under the influence of alcohol and causing a serious car accident. Which comment on this behavior would be expected?
a) “It's not my fault.”
b) “I'm too ashamed to talk about it.”
c) “I just don't remember doing it.”
d) “I'm really sorry about all the people I've hurt.”

62. Antisocial Personality (cont’d)
Correct answer: A
Individuals diagnosed with antisocial personality disorder lack remorse about their actions and view themselves as victims. This individual would most likely refuse to acknowledge responsibility for the accident.

63. Nursing Diagnosis: Antisocial Personality Disorder
Risk for other-directed violence related to rage reactions, negative role-modeling, inability to tolerate frustration
Defensive coping related to dysfunctional family system
Chronic low self-esteem related to repeated negative feedback resulting in diminished self-worth

64. Nursing Diagnosis: Antisocial Personality Disorder (cont’d)
Impaired social interaction related to negative role modeling and low self-esteem
Ineffective health maintenance, evidenced by demonstration of inability to take responsibility for meeting basic health practices

65. Outcomes: Antisocial Personality Disorder
The client
Discusses angry feelings with staff and in group sessions
Has not harmed self or others
Can rechannel hostility into socially acceptable behaviors
Follows rules and regulations of the therapy environment

66. Outcomes: Antisocial Personality Disorder (cont’d)
The client (cont’d)
Can verbalize which of his or her behaviors are not acceptable
Shows regard for the rights of others by delaying gratification of own desires when appropriate

67. Outcomes: Antisocial Personality Disorder (cont’d)
The client (cont’d)
Does not manipulate others in an attempt to increase feeling of self-worth
Verbalizes understanding of knowledge required to maintain basic health needs

68. Planning/Intervention
Nursing care of the client with antisocial personality disorder is aimed at
Ensuring the safety of client and others
Helping client recognize and decrease unacceptable behaviors
Assisting client to gain insight into own behaviors
Helping client to learn to delay gratification

69. Evaluation
Evaluation of care for the client with antisocial personality disorder is based on accomplishment of previously established outcome criteria.

70. Treatment Modalities for Personality Disorders
Interpersonal psychotherapy
Psychoanalytical psychotherapy
Milieu or group therapy
Cognitive/behavioral therapy
Dialectical behavior therapy
Psychopharmacology