Personality Disorders
Chapter 32
Personality
 Complex pattern of characteristics, largely outside of the person’s awareness
 Distinctive patterns of perceiving, feeling, thinking, coping and behaving
 Emerges within biopsychosocial framework
Personality disorder
 An enduring pattern of deviant inner experiences and behavior
 Differ from cultural expectations
 Pervasive, inflexible, and maladaptive
 Stable over time, not episodic
 Leads to distress or impairment
Common Features and Diagnostic Criteria
 Inflexible and maladaptive responses to stress
 Disability in working and loving (more serious and pervasive than found in other
disorders)
 The tendency to evoke intense interpersonal conflict
Types of Personality Disorders
 Cluster A: odd-eccentric
 Paranoid personality disorder
 Schizoid personality disorder
 Schizotypal personality disorder
 Cluster B: dramatic and emotional (impulsive)
 Antisocial personality disorder
 Borderline personality disorder
 Histrionic personality disorder
 Narcissistic personality disorder
 Cluster C: anxious-fearful
 Avoidant personality disorder
 Dependent personality disorder
 Obsessive-compulsive disorder
Cluster A-Odd or Eccentric
 Paranoid
 without schizophrenic symptoms or altered mental status, pervasive unwarranted
suspiciousness
 Schizoid
 self-absorbed, cold, indifferent, neither desires nor enjoys close relationships,
“loner”
 Schizotypal
 cognitive distortions (not usually as severe as schizophrenia), eccentricities, odd
beliefs, magical thinking, social anxiety/isolation, peculiar behavior or appearance
Cluster A: Paranoid Personality Disorder
 Features
 Mistrustful, avoid relationships that cannot control
 Persistent ideas of self-importance
 Nursing management
 Patients seen for other health problems
 Nursing diagnosis: disturbed thought process
 Nursing interventions
 It can be difficult to establish nurse–patient relationship
 If trust is established, help patient identify problem areas
 Changing thought patterns takes time
Cluster A: Schizoid Personality Disorder
 Features
 Expressively impassive and interpersonally unengaged
 Introverted and reclusive, engage in solitary activities
 Communication sometimes confused
 Incapable of forming social relationships
 Minimum introspection, self-awareness, and interpersonal experiences
 Nursing management
 Nursing diagnosis: impaired social interactions and chronic low self-esteem
 Goal: to enhance experience of pleasure, prevent social isolation, and increase
emotional responsiveness to others
 Interventions
 Provide social skill training
 Encourage social interactions
Cluster A: Schizotypal Personality Disorder
 Features
 Eccentric
 Pattern of social and interpersonal deficits
 Void of close friends
 Odd beliefs
 Ideas of reference
 When psychotic, symptoms mimic schizophrenia
 Nursing diagnoses: social isolation, ineffective coping, low self-esteem, and impaired
social interactions
 Nursing management
 Similar to that with schizophrenia
 Increase self-worth
 Provide social skills training
 Reinforce socially appropriate dress and behavior
 Focus on enhancing cognitive skills
Cluster B-Dramatic, Emotional, Erratic
 Antisocial
 disregard for rights of others, exploitative, deceitful
 Borderline
 self-destructive behavior, unstable and intense personal relationships
 Histrionic
 excessive emotion, superficial and stormy relationships, egocentric
 Narcissistic
 Narcissistic-arrogance, lack of empathy, grandiose sense of self-importance
Cluster B: Antisocial Personality Disorder
 A pervasive pattern of disregard for, and violation of, the rights of others that begins in
childhood or early adolescence and continues into adulthood
 Behaviorally impulsive
 Interpersonally irresponsible
 Fail to adapt to the ethical and social standards of community
 Interpersonally engaging, but in reality lack empathy
 Easily irritated, often aggressive
 Co-morbid with mood, anxiety, and other personality disorders, alcohol and drug
abuse
 Assessment
 Pattern of breaking rules
 Manipulative, exploitative, dishonest
 Lacks remorse
 Frequently involved in criminal activity
 Aggressive
Nursing Diagnoses???
 Interventions
 Clarify expectations
 Set personal boundaries
 Encourage talking instead of acting out
 Set limits on behavior
 Guard against manipulation through feeling guilty
 Watch for violence
 Self-help groups
Cluster B: Histrionic Personality Disorder
 Features
 Attention-seeking
 Need for attention and approval
 Sexually seductive
 Loyalty and fidelity are lacking
 Co-occurs with borderline, dependent, and antisocial personality disorders,
anxiety disorders, substance abuse, and mood disorders
 Nursing Assessment
 Social disapproval or deprivation
 Quality of the individual’s interpersonal relationships
 Chronic low self-esteem
 Ineffective individual coping
 Ineffective sexual patterns
 Nursing Interventions
 Allow to explore positive personality characteristics and develop independent
decision making skills
 Reinforce personal strengths
 Convey confidence in ability to handle situations
 Examine negative perceptions of self
 Encourage to act autonomously
 Assertiveness groups
Cluster B: Narcissistic Personality Disorder
 Features
 Grandiose
 Inexhaustible need for attention
 Lack empathy
 Fantasies of unlimited success, power, beauty, or ideal love
 Coexists with other Axis II disorders (antisocial, histrionic, and paranoid
disorders) and Axis I disorders of mood, anxiety, and substance abuse
 Nursing Management
 Do not seek mental health care unless they have a coexisting medical or mental
disorder
 Use self-awareness skills in interacting
 Nursing process focuses on the coexisting responses to other health care problems
Cluster B: Borderline Personality Disorder
 Pervasive patterns of instability of interpersonal relationships, self-image and affects, as
well as marked impulsivity that begins by early adulthood and is present in a variety of
contexts
 Problem areas
 Regulating moods
 Developing a sense of self
 Maintaining interpersonal relationships
 Maintaining reality-based cognitive processes
 Impulsive or destructive behavior
 Appear more competent than they are
 They live from one crisis to another
 Affective instability: shifts in moods
 Identity disturbance (identify diffusion)
 Role absorption: narrow definition of self
 Painful incoherence: internal disharmony
 Inconsistency in thoughts, feelings, and actions
 Lack of commitment
 Unstable interpersonal relationships
 Fear of abandonment
 Unstable, insecure attachments
 Overidealized/intense relationships
 Cognitive dysfunctions
 Dichotomous thinking
 Dissociation
 Dysfunctional behaviors
 Impaired problem-solving
 Impulsivity
 Self-injurious behaviors (parasuicidal behavior)
 Compulsive
 Episodic
 Repetitive
 Coexistence of personality disorders with Axis I disorders (mood, substance
abuse, eating, dissociative and anxiety disorders)
 Assessment Findings
 Nursing Diagnoses
 Disturbed sleep pattern
 Imbalanced nutrition
 Self-mutilation or risk for self-mutilation
 Ineffective therapeutic regimen management
 Interventions
 Requires the whole mental health care team
 Medications
 Controlling emotional dysregulation
 Antidepressants
 Reducing impulsivity
 Anticonvulsants
 Managing transient psychotic episodes
 Antipsychotics
 Decreasing anxiety
 Buspirone, careful use of benzodiazepines
 Interventions
 Be aware of manipulation and splitting
 Set clear boundaries
 Avoid rejecting or rescuing
 Assess for self-mutilation and suicidal ideation, especially under stress
 Identify situations that trigger impulsivity
 Psychotherapy
 Dysfunctional moods
 Impulsive behavior
 Self-injurious behavior
Cluster C Disorders-Anxious or Fearful
 Avoidant personality disorder
 Avoid interpersonal contacts and social situations
 Perceive themselves as socially inept
 Dependent
 Submissive pattern
 Cling to others to be taken care of
 Prevalent in clinical samples
 Obsessive-compulsive
 Different than OCD; not as many obsessions and compulsions, but rigidity,
perfectionism, and control
Cluster C: Avoidant Personality Disorder
 Nursing Management
 Assessment: lack of social contacts, a fear of being criticized, evidence of chronic low
self-esteem
 Nursing diagnoses: chronic low self-esteem, social isolation, and ineffective coping
 Interventions
 Refrain from any negative criticism
 Assist to identify positive responses from others
 Explore previous achievements
 Explore reasons for self-criticism
 Social skills training
Cluster C: Dependent Personality Disorder
 Cling to others in a desperate attempt to keep them close
 Total submission and disregard for self
 Decision making is difficult or nil
 Withdraw from adult responsibilities
 Need excessive advice and reassurance
 Assessment: self-worth, interpersonal relationships, and social behavior
 Nursing diagnoses: ineffective individual coping, low self-esteem, impaired social
interaction, and impaired home maintenance management
 Interventions: help recognize dependent patterns, motivate to want to change, teach adult
skills that have not been developed, support to make their own decisions, antidepressants
or antianxiety agents may be used
Cluster C: Obsessive-Compulsive Personality Disorder
 Do not demonstrate obsessions and compulsions like obsessive-compulsive (anxiety)
disorder (OCD)
 Display overall rigidity, perfectionism, and control
 Completely devoted to work
 Uncomfortable with unstructured leisure time
 Hobbies are approached seriously
 Need to control others
 Difficulty making decisions and completing tasks because they become so involved in the
details
 Mood is tense and joyless
 Nursing Management
 Assessment: physical symptoms (sleep, eating, sexual), interpersonal relationships, and
social problems
 Nursing diagnoses: anxiety, risk for loneliness, decisional conflict, sexual dysfunction,
disturbed sleep pattern, and impaired social interactions
 Interventions: accept the patient’s need for order and rigidity, examine the belief that
underlies the dysfunctional behavior, challenge rigid thinking
General Interventions
 Family involvement
 Limit Setting
 Milieu
 Treat mood disorders
 Legal intervention
 Try not to react emotionally to clients