1. Nursing Care for Patient with Personality Disorders
Jiraporn Rakkarn, MNS, RN
Division of Mental Health and Psychiatric Nursing
College of Nursing and Health, Suan Sunandha Rajabhat University

2. Definition
Personality is essentially an enduring pattern of perceiving relating and thinking about the environment.
Personality is the “style” a person adopts to deal with the world.
Personality traits are stylistic peculiarities that all people bring to social relationships, including shyness, seductiveness, rigidity, suspiciousness, or passive-aggressive.
Personality traits are flexible and adaptive.
(Varcarolis, 2013: 214)
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

3. Definition
Personality disorders are diagnosed when personality traits become inflexible and maladaptive and significantly interfere with how a person functions in society or cause the person emotional distress. (Vidibeck, 2014)
Personality disorders are diagnosed when personality traits exaggerated and rigid to point that they cause dysfunction in their relationship. (Varcarolis, 2013: 214)
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

4. General Criteria for a Personality Disorders
A. An enduring pattern of inner experience and behavior the deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
Cognition (i.e., way of perceiving and interpreting self, other people and events)
Affectivity (i.e., the range, intensity, liability, and appropriateness of emotional response)
Interpersonal functioning
Impulse control
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

5. General Criteria for a Personality Disorder
B. The enduring pattern is inflexible and pervasive across a board range of personal and social situations.
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

6. General Criteria for a Personality Disorder
E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug abuse, a medication) or a general medical condition (e.g., head trauma)
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

7. Cause Biological factors genetic/familial factors
neurotransmitter dysregulation: Serotonin , Dopamine
Environment factors
Parenting raising
Emotional abuse
Psychological factors
Psychoanalytic theory ---> Psychosexual development, Structure of mind
Learning theory ---> Modeling
Cognitive theory
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

8. Categories of Personality Disorders
DSM-IV TR (2002) Categories of Personality Disorders
Cluster A: Individuals whose behavior appears odd or eccentric (paranoid, schizoid, and schizotypal personality disorders)
Cluster B: Individuals who appear dramatic, emotional, or erratic (antisocial, borderline, histrionic, and narcissistic personality disorders)
Cluster C: Individuals who appear anxious or fearful (avoidant, dependent, and Obsessive-compulsive personality disorders)
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

9. DSM-IV TR Diagnostic criteria: Symptoms of Dependent personality disorder
A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
needs others to assume responsibility for most major areas of his or her life
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

10. DSM-IV TR Diagnostic criteria: Symptoms of Dependent personality disorder
has difficulty expressing disagreement with others because of fear of loss of support or approval. Note: Do not include realistic fears of retribution.
has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)
goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

11. DSM-IV TR Diagnostic criteria: Symptoms of Dependent personality disorder
feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself
urgently seeks another relationship as a source of care and support when a close relationship ends
is unrealistically preoccupied with fears of being left to take care of himself or herself
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

12. DSM-IV TR Diagnostic criteria: Symptoms of Antisocial personality disorder
There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:
failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
impulsivity or failure to plan ahead
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

13. DSM-IV TR Diagnostic criteria: Symptoms of Antisocial personality disorder
irritability and aggressiveness, as indicated by repeated physical fights or assaults
reckless disregard for safety of self or others
consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

14. DSM-IV TR Diagnostic criteria: Symptoms of Borderline personality disorder
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood are present in a variety of contexts, as indicated by five (or more) of the following:
frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criteria 5
a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

15. DSM-IV TR Diagnostic criteria: Symptoms of Borderline personality disorder
identity disturbance: markedly and persistently unstable self-image or sense of self
impulsivity in at least two areas that are potentially self-damaging
recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
affective instability due to a marked reactivity of mood
inappropriate, intense anger or difficultly controlling anger
transient, stress-related paranoid ideation or severe dissociative symptoms
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

16. Treatment Medication Psychotherapy Behavior therapy Milieu therapy
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

17. Nursing Process
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

18. Assessment Assessment guidelines (Varcarolis, 2013)
Assess for suicidal or homicidal thoughts. If these are present, the patient will need immediate attention.
Determine whether the patient has a medical disorder or another psychiatric disorder that may be responsible for the symptoms.
View the assessment of personality functioning from within the person’s ethic, cultural, and social background.
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

19. Assessment Assessment guidelines (Varcarolis, 2013)
Ascertain whether the patient experienced a recent important loss. PDs are often exacerbated after the loss of a significant supporting person or as the result of a disruptive social situation.
Evaluate for a change in personality in middle adulthood or later, which signals the need for a thorough medical workup or assessment for unrecognized substance use disorder.
Assess for current use of medicines and illegal substances.
Assess for ability to handle money and legal history.
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

20. Nursing Diagnosis NANDA Nursing Diagnosis (Ackley & Ladwig, 2014)
Personality disorders
Ineffective activity planning related to unrealistic perception of events
Impaired individual resilience related to psychological disorder
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

21. Nursing Process NANDA Nursing Diagnosis (Ackley & Ladwig, 2014)
Dependent personality disorder
Ineffective coping
Chronic low self-esteem
Impair social interaction
Social Isolation
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

22. Nursing Diagnosis NANDA Nursing Diagnosis (Ackley & Ladwig, 2014)
Antisocial personality disorder
Defensive coping related to excessive use of projection
Ineffective coping related to frequently violating the norms and rules of society
Impaired social interaction related to sociocultural conflict, inability to form relationships
Risk for self-mutilation: Risk factor: self-hatred
Risk for other-directed violence: Risk factor: history of violence, altered thought patterns
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

23. Nursing Diagnosis NANDA Nursing Diagnosis (Ackley & Ladwig, 2014)
Borderline personality disorder
Ineffective activity planning related to unrealistic perception of events
Defensive coping related to difficulty with relationships, inability to accept blame for own behavior
Ineffective coping related to use of maladjusted defense mechanisms (projection, denial)
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

24. Nursing Diagnosis NANDA Nursing Diagnosis (Ackley & Ladwig, 2014)
Borderline personality disorder
Social isolation related to immature interests: Risk for self-mutilation:
Risk factor: ineffective coping, feelings of self-hatred
Risk for self-directed violence: Risk factor: feelings of need to punish self, manipulative behavior
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

25. Planning
Appropriate goals for caring for a person with a personality disorder in a community or hospital setting include:
Develop a relationship with the person based on empathy and trust, whilst also maintaining appropriate boundaries.
Ensure duty of care responsibilities are appropriately addressed, with regards to treatment for the presenting medical and physical issues and by remaining alert to suicide risk.
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

26. Planning
Promote effective and functional coping and problem solving skills, in a way that is empowering to the person.
Promote the person’s development of and engagement with their support network, including access to appropriate service providers.
Support and promote self-care activities for families and career of the person with the personality disorder
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

27. Nursing Intervention
Nursing Intervention for Dependent personality disorder
Foster client’s self-reliance and autonomy
Teach problem-solving and decision-making skills
Cognitive restructuring technique
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

28. Nursing Intervention
Nursing Intervention for Antisocial personality disorder
Limit setting
Confrontation
Teach client to solve problems effectively and manage emotions of anger or frustration
Consistent adherence to rules and treatment plan
Enhancing role performance
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

29. Nursing Intervention
Nursing Intervention for Borderline personality disorder
Promote client’s safety: No-self-harm contract, Safe expression of feelings and emotions
Help client to cope and control emotions
Cognitive restructuring techniques
Teach social skills
Teaching effective communication skills
Therapeutic relationship
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

30. Evaluation
The client will demonstrate behaviors that lead to resolution of identified problems.
The client will explore coping skills and work to develop appropriate solutions to problems.
The client will interact with people and become involved in both social and therapeutic activities.
The client will identify and discuss feelings that impede social interactions.
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

31. Evaluation
The client will begin to participate in both social and therapeutic activities.
The client will report the absence of self-destructive thoughts and behaviors.
The client will learn to express strong feelings in a nondestructive manner.
The client will demonstrate the skills necessary to develop and sustain interpersonal relationships.
The client will verbalize a realistic assessment of life situations and ask for assistance to solve problems as needed.
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

32. Reference
รณชัย คงสกนธ์. (2555). บุคลิกภาพผิดปกติ. ใน มาโนช หล่อตระกูล และปราโมทย์ สุคนิชย์ (บรรณาธิการ), จิตเวชศาสตร์ รามาธิบดี (หน้า ). (พิมพ์ครั้งที่ 3). กรุงเทพมหานคร: ภาควิชาจิตเวชศาสตร์ คณะแพทยศาสตร์ โรงพยาบาลรามาธิบดี มหาวิทยาลัยมหิดล.
นภวัลย์ กัมพลาศิริ. (2557). การพยาบาลบุคคลที่มีบุคลิกภาพแปรปรวน (Nursing Care for Persons with Personality Disorders). ใน อัจฉราพร สี่หิรัญวงศ์, ประภา ยุทธไตร, พวงเพชร เกสรสมุทร และวารีรัตน์ ถาน้อย (บรรณาธิการ), การพยาบาลจิตเวชศาสตร์ (Psychiatric Nursing) (หน้า ). กรุงเทพมหานคร: สายธุรกิจโรงพิมพ์ บริษัท อมรินทร์พริ้นติ้งแอนด์พับลิชชิ่ง.
มาโนช หล่อตระกูล และปราโมทย์ สุคนิชย์. จิตเวชศาสตร์ รามาธิบดี. (พิมพ์ครั้งที่ 3). กรุงเทพมหานคร: ภาควิชาจิตเวชศาสตร์ คณะแพทยศาสตร์ โรงพยาบาลรามาธิบดี มหาวิทยาลัยมหิดล
สุวนีย์ เกี่ยวกิ่งแก้ว. (2554). การพยาบาลจิตเวช. (พิมพ์ครั้งที่ 2). กรุงเทพมหานคร: โรงพิมพ์มหาวิทยาลัยธรรมศาสตร์.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders. (4th ed., text reversion). Washington DC: American Psychiatric Association.
Ackley, B. J. & Ladwig, G. B. (2014). Nursing Diagnosis Handbook: An Evidence-Base Guide to Planning Care. (10th ed.). Maryland Heights, MO: Elsevier Mosby.
Varcarolis, E, M. (2013). Essentials of Psychiatric Mental Health Nursing. St. Louis, MS: Elsevier Saunders.
Videbeck, S. L. (2014). Psychiatric-Mental Health Nursing. (4th ed). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Videbeck, S. L. (2014). Psychiatric-Mental Health Nursing. (6th ed). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn

33. Thank you
College of Nursing and Health, Suan Sunandha Rajabhat University Jiraporn Rakkarn