CHAPTER 8 :PERSONALITY DISORDERS
INTRODUCTION

Each of us is born with a set of traits, temperament, and patterns of behavior that
are unique characteristics that make us who we are.

Our thoughts, feelings, and attitudes toward ourselves and the world around us are
the distinguishing aspects of our personality.

Personality traits are persistent ways in which we view and relate to other people
and to society as a whole.

Those with healthy personalities are able to adapt to life stressors and form
interpersonal relationships with reasonable expectations.

Some personality traits are seen as negative and may be demonstrated by the
difficult people we sometimes face in social or work settings.

These same negative traits are more severe and more extreme for individuals with
personality disorders, creating difficulty for the individuals in adapting to the world
around them.
DEFINITION OF PERSONALITY DISORDERS
Personality disorders are deeply rooted, persistent, inflexible, and maladaptive patterns
of behavior that are in conflict with a cultural norm.
TYPES OF PERSONALITY

According to the DSM-IV-TR, three cluster groups of personality disorders have been
identified.

Regardless of the disorder; commonalities exist between the groups:
1. All tend to view the world from an ambivalent perspective
2. All conforming to rigid thinking that objects, people, and events are either all
good or all bad.
3. This tunnel vision rejects the possibility of these two extremes coexisting in
one situation.
4. With this mindset, the individual offer passively and indirectly projects
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hostility to others in subtle, deceitful ways to avoid feelings of inadequacy
and incompetence.

The DSM-IV-TR groups these disorders into three clusters:
1- Cluster A: Paranoid PD, Schizoid PD, Schizotypal PD
2- Cluster B: Antisocial PD, Borderline PD, Narcissistic PD, Histrionic PD
3- Cluster C: Avoidant, Dependent, Obsessive-compulsive
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CLUSTER A PERSONALITY DISORDERS

Cluster A disorders include paranoid, schizoid, and Schizotypal Personality
Disorders.

People with these disorders tend to demonstrate odd and eccentric behaviors
1. PARANOID PERSONALITY DISORDER
Definition
A persistent pattern of suspicion and mistrust in which the actions or motives of others
are seen as intentionally threatening or humiliating to the person
Incidence and Etiology

More prevalent in men

Typical behaviors are often seen by early adulthood

A possible genetic link to schizophrenia is seen in the tendency for those with this
disorder to develop delusional thinking or actual schizophrenia
Signs and Symptoms of Paranoid Personality Disorder
1. Cold and unfriendly
2. Rigid and inflexible
3. Doubt the loyalty and honesty of others
4. Watchful and guarded
5. Resentful, bitter, accusing, and argumentative
6. Mistrustful and unable to disclose to others
7. Inability to tolerate criticism
8. Maintenance of grudges against others
9. Controlling relationships
10. Extreme jealousy
11. Projection of faults to others
12. Inability to perceive self as a problem
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2. SCHIZOID PERSONALITY DISORDER
Definition
A persistent pattern of self-absorbed and solitary behaviors in which affect they have a
plain and unresponsive affect to positive emotions in others
Incidence and Etiology

More prevalent in men than women

There is an increased incidence in those who have a family history of schizophrenia
or other personality disorders

The behavior characteristics are seen in most aspects of the person's life by the early
adult years
Signs and Symptoms
1. Withdrawn, Secluded, and Loners
2. Preference for solitary activities
3. Self-absorbed in their own feelings and thoughts
4. Indifference toward social relationships
5. Emotions such as elation or anger are seldom felt or displayed
6. Avoid close relationships and intimacy
7. Decreased interest in sexual experiences
3. SCHIZOTYPAL PERSONALITY DISORDER
Definition
A persistent strange and unusual patterns of thinking and communicating in which
become secluded and withdrawn from social situations
Incidence and Etiology

It is more common in men than in women

Typical behaviors are apparent during childhood and adolescence

The odd behavior is often the target of ridicule by other children, leading to early
social isolation

Prevalence is also seen in first-degree biologic relatives of people with
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schizophrenia

Treatment is usually sought for symptoms of anxiety or depression rather than for
the symptoms of the personality disorder itself

It is believed that this disorder is a mild form of schizophrenia but without the
continuous thought alterations.
Signs and Symptoms
1. Weird and bizarre thinking and beliefs
2. Paranoid and suspiciousness
3. Magical thinking
4. Ideas of reference
5. Perceptual distortions, illusions
6. Inflexible emotions
7. Eccentric dress habits
8. Remorse over lack of social relationships
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CLUSTER B PERSONALITY DISORDERS

The category includes antisocial, borderline, narcissistic, and histrionic Personality
Disorders.

Cluster B Personality Disorders are characterized with Dynamic, emotional, or
erratic behavior
1. ANTISOCIAL PERSONALITY DISORDER
Definition
A persistent pattern of antisocial behavior that characterized by disregard to others, to
ethics, and to the law without any feelings of remorse or regret.
Incidence and Etiology

The disorder is more prevalent in men than in women

Most people with antisocial personality disorder have a history of conduct disorder
with an onset before the age of 15.

Situations of child abuse, unstable parenting, and inconsistent parental discipline
may increase the chances of a person developing antisocial personality disorder by
the age of 18.

It is most often associated with those in low socioeconomic classes and crowded
living situations.

There is a higher incidence among the prison population and those who have a
history of substance abuse.

There tends to be a familiar pattern with the disorder occurring more often in those
who have first-degree biologic relatives with antisocial personality disorder.

The disorder tends to be chronic but may become less evident as the person ages.

Those with an antisocial personality disorder exhibit a persistent pattern of
disregard and violation of the rights of others in a society.

A false sense of privileged revenge against others is demonstrated by their basic cold
indifference to the laws of society and humanity.

The person with antisocial personality disorder is selfish and seemingly has no
conscience.
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
Lying and stealing are common, along with a failure to accept and do his
responsibilities of everyday living, parenting, or work-related tasks.

A childhood and early adolescence stained with abuse and neglect add to the risk of
adults with antisocial behaviors.

The disorder tends to be chronic and perhaps one of the most difficult to treat.
Signs and Symptoms
1. Suspiciousness of others
2. Impulsive and reckless behavior
3. Vandalism, fighting
4. Explosive anger
5. Deceitfulness and dishonesty
6. Lying
7. Coldness and insensitivity
8. Arrogance
9. Violation of rights of others
10. Lack of remorse or guilt
11. Manipulation
12. Projection of blame
13. Irresponsibility
14. Pseudonyms names
15. Charm and scheming
16. Recklessness
17. Sexual exploitation
2. BORDERLINE PERSONALITY DISORDER
Definition
People diagnosed with borderline personality disorder have a persistent pattern of
unstable interpersonal relationships, insecure self-image, mood swings, and impulsive
and intense outbursts of anger
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Incidence and Etiology

Borderline personality disorder tends to occur more in women than in men.

It is more common in those with a family history of the disorder.

There seems to be more instability during the early adult years, with some
stabilization of moods seen by the 30- to 40-year-old age group.

The incidence of suicide in this group is the highest during young adulthood.

The exact cause of this condition is not known. It is believed that parental neglect,
separation from the primary caregiver, and child abuse may contribute to
development of the disorder.

An infant who is suddenly removed from the emotional attachment of his mother
learns that a comfortable trusting relationship is followed by anxiety when that
person is no longer available.

Trust is lost and the separation is viewed as abandonment.

Once the security and comfort of the good relationship change to anxiety in a bad
situation, the child learns to see "all good" and "all bad."

There is continued difficulty in being able to integrate these two conditions as
coexistent in the same person.

This leads to splitting, in which the person reacts to people in either a very positive
or a very negative way.
Signs and Symptoms of Borderline Personality Disorder
1. Unstable relationships
2. Insecure self-image
3. Mood swings
4. Dissociation
5. Impulsive outbursts of anger
6. Chronic sense of abandonment
7. Clingy, dependent behavior • Splitting
8. "Jekyll and Hyde" characteristic
9. Self-mutilating acts
10. Suicide threats and gestures
11. Inability to delay gratification of needs
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3. NARCISSISTIC PERSONALITY DISORDER
Definition
The person with a narcissistic personality disorder has a continued need for excessive
attention and admiration with little regard for the feelings of others. The term
narcissism is a Greek word, meaning "excessive love and attention given to one's own
self-image.. Other people may be used unfairly to satisfy this person's desires”
Incidence and Etiology

Narcissistic personality disorder is more common in men than in women and
usually has an onset during early adulthood.

Although there is a tendency for adolescents to have a narcissistic view of
themselves as they search for their identity, this does not mean that a personality
disorder exists.

It is only when the narcissistic traits become inflexible and maladaptive enough to
cause dysfunction in the person's life that a disorder may be diagnosed.

People who develop the disorder rarely seek treatment and often blame the negative
results of their behavior on society.
Signs and Symptoms
1. Grandiose sense of self-importance
2. Intense need for admiration and approval
3. Lock of empathy for others
4. Exploitation of others for own needs
5. Sense of entitlement
6. Demand for the best of everything
7. Fantasies of power, beauty, success
8. Underlying feelings of inferiority
9. Hypersensitivity to criticism
10. Anxiety
11. Social withdrawal
12. Poor insight into behavior
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4. HISTRIONIC PERSONALITY DISORDER
Definition
Typically, the person with histrionic personality disorder displays a pattern of
egocentric and excessive emotion in a demanding manner to gain personal attention.
Individuals with this disorder are uncomfortable in situations where center stage is not
afforded to them.
Incidence and Etiology

Histrionic personality disorder tends to occur more often in women but is seen also
in men and is usually evident by early adulthood.

It is also common for these clients to demonstrate several personality features of
other disorders, such as Somatization, manipulative behavior, sexual promiscuity,
and self-indulgence.

There is speculation that symptoms may stem from the childhood experiences in
which recognition was only received if parental expectations were met.

Only when the histrionic traits of the person become maladaptive and impair
functioning is it considered a disorder.
Signs and Symptoms
1. Attention-seeking behavior
2. Extreme egocentricity
3. Overly dramatic and exaggerated behavior Shallow, superficial relationships
4. Provocative sexual behavior
5. Melodramatic but vague speech
6. Manipulation
7. Unmet dependency needs
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CLUSTER C PERSONALITY DISORDERS

Cluster C Personality Disorders include Avoidant, Dependent, and Obsessivecompulsive personality disorders

People with cluster C personality disorders exhibit anxious and fearful types of
behavior
1. AVOIDANT PERSONALITY DISORDER
Definition
The person with avoidant personality disorder is typically shy and very sensitive to
negative comments from others. Feelings of inadequacy and intense discomfort are felt
in social situations that involve people other than family.
Incidence and Etiology

Avoidant personality disorder is equally frequent in men and women.

Shyness and fear of new situations exhibited in childhood tend to increase by
adolescence individuals with this disorder.

There is some evidence that it decreases with age.

People who demonstrate avoidant behaviors often have associated social phobia.
Signs and Symptoms
1. Extreme shyness
2. Sensitivity to rejection
3. Feelings of social inadequacy
4. Social withdrawal/isolation
5. Self-doubt
6. Fear of criticism or embarrassment
7. Intense anxiety in social setting
8. Feelings of inferiority
9. Low self-esteem
10. Lack of trust in others
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11. Lack of close friends
12. Fear of intimate relationship
13. Reluctance to take risks or try new things
2. DEPENDENT PERSONALITY DISORDER
Definition
People with dependent personality disorder demonstrate a consistent and extreme
need to be cared for that leads to a reliance on others. At the same time, they perceive
themselves as helpless and incompetent. If one relationship ends, there is immediately a
pressing need to begin a new one.
Incidence and Etiology

Dependent personality disorder is diagnosed more often in women than in men.

The disorder usually occurs by early adulthood and follows a chronic pattern.

It is one of the most frequently reported personality disorders.

Age and cultural factors can contribute to the behavior.

In some cultures, women are expected to be subservient to men.

The distinction between what is considered respectful and what is excessive must be
made.

Children and adolescents who experience chronic physical illnesses or separation
anxiety disorder have an increased risk of developing this disorder.
Signs and Symptoms
1. Inability to make decisions
2. Extreme reliance on others
3. Insecurity and self-doubt
4. Extreme fear of being alone
5. Excessive anxiety
6. Feelings of incompetence
7. Constant need for reassurance
8. Self –sacrificing behavior
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9. Relinquishment of control to others
10. Submissive behavior
3. OBSESSIVE-COMPULSIVE PERSONALITY DISORDER
Definition
People with obsessive-compulsive personality disorder are conscientious, highly
organized, and preoccupied with order and perfection. They are usually dependable but
want rigid control and lack the flexibility to allow for compromise.
Incidence and Etiology

Obsessive-compulsive personality disorder is seen twice as often in men than in
women.

The disorder tends to appear in the late teen years in males, and early twenties in
females.

People with this disorder are often employed in situations such as research where
precision and detail are required.

They rarely seek treatment because to do so would require change.

Any diversion from their rigid nature is highly threatening to them.

There is usually little insight into the psychological origin of their discomfort.
Signs and Symptoms
1. Preoccupation with orderliness
2. Rigidness and controlling behavior
3. Focus on details
4. Unrealistic expectations
5. Missed deadlines
6. Inability to relax
7. Rigid moral and ethical standards
8. Hoarding of items
9. Inability to delegate
10. Stubbornness
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TREATMENT OF PERSONALITY DISORDERS
GENERAL GUIDELINES FOR THERAPY
1. Reducing environmental stress is often the first step in treatment goals.
2. Disorders that involve dependency, mistrust, manipulation, and arrogance need
longer course of treatment.
3. Resistance to change is greater and outcomes are less favorable because many of
these individuals have deeply ingrained beliefs and attitudes,
4. A combination of psychotherapy and medication is the preferred approach to
treatment of personality disorders, although the symptoms of these disorders
are less responsive to drugs.
5. Treating PD need a multidisciplinary Team efforts including doctors, nurses,
psychotherapist, social workers, occupational therapists, art therapists,
recreational therapists
6. The first step in therapy is helping the client to gain perspective into the problem
underlying his or her maladaptive response to the world, but this is usually
difficult because most people with these disorders lack insight and resist
attempts to impose change.
7. Many individuals with personality issues also have trouble trusting others,
which leads to difficulty in their social relationships. This factor often prevents
them from forming a therapeutic relationship with a therapist.
8. The type of therapy used for any client will depend on the underlying mental
problem.
9. Treating personality disorders is prolonged process and requires diligent
patience and understanding on the part of the therapist and/or family members
and friends.
TREATMENT MODALITIES
1. Individual therapy

Help clients gain insight into their thinking and how their thoughts and perceptions
are distorted.

Teach client ways that can help them to modify their behavior to a more functional
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level.

But usually is limited because of the lack of trust in others
2. Cognitive-behavioral therapy

Deals with one's thinking in relation to subsequent actions
3. Interpersonal therapy

Focuses on human relationships
4. Behavior therapy

Help the clients understand their actions while working toward improved adaptive
behaviors.
5. Group therapy and behavior modification

Help clients improve interaction skills in addition to gaining an understanding of
how they are perceived by others.

Clients can learn how to ventilate anxiety and trust others in a safe environment.

Problem-solving methods can be practiced within the group to resolve community
issues.
6. Occupational therapy

Allows clients to increase their level of functioning so they can become more
independent.

Task completion skills can also be evaluated and enhanced by these activities.
7. Recreation therapy

Can assist clients to express feelings and increase socialization skills.

Interaction and guidance by the therapist can provide clients with constructive ways
to deal with anger and other self-destructive behaviors.
8. Antipsychotic Medications

Thinking errors can be improved with antipsychotic medications such as Risperione
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(Risperdal) and Olanzapinc (Zyprexa).

Anxiety and depression can be treated with Antianxiety and Antidepressant agents.
9. Family therapy

Typically, treatment also involves family members and friends of the client.

Often, the actions of those most closely associated with the person may affect the
behavior issues and are useful in the treatment process.
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APPLICATION OF THE NURSING PROCESS FOR A CLIENT WITH A
PERSONALITY DISORDER
ASSESSMENT

It is not often that a client is admitted with a personality disorder as a primary cause
for treatment.

Treatment may be sought by the person or family members as the maladaptive traits
become problematic and disrupt the person's life.

Other disorders such as depression, substance abuse, or suicidal acts may be the
trigger that leads to admission.

It is important to first develop a trusting relationship by using an empathetic and
nonjudgmental approach.

Some assessment techniques that could be used with individuals with personality
disorders may include:
1. Use direct questions to find out what events or behaviors led to the admission.
2. Observe nonverbal behaviors and symptoms that indicate appropriate affect.
3. Assess thought processes for content and clarity, distorted thinking, magical
thinking, or narcissism.
4. Look for inconsistencies between what is said and mannerisms or behavior.
5. Determine social habits and present or past relationships in which the person Is
involved
6. Assess the level of anxiety and emotional state during the initial history intake
7. Note any resistance to questioning or indication of impulsive reaction to
requested information
8. Ask about usual coping methods used to deal with life stressors
9. Note any scars or cuts that may indicate self- mutilating behaviors
10. Ask if suicidal thoughts have occurred and verify whether a plan has been made
11. Establish what type of situations may have led to the self-destructive behavior.

Because clients with personality disorders tend to be irritating to others and
demanding, it is important for you to recognize and deal with your own feelings
toward such clients.
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
The client with a personality disorder can be manipulative and connining with
nurses and other clients.

It is important to view the situation objectively.

Therapeutic intervention can only occur if self- awareness allows you to project an
appropriate attitude of caring and concern for the well-being of the client.
SELECTED NURSING DIAGNOSES

A nursing diagnosis is made after a thorough analysis of the data collected through
the nursing assessment process.

Any data that can provide new or useful information should be considered when
developing the diagnosis statement.

Nursing diagnoses may be applicable for more than one personality disorder
because many share similar symptoms and problems and may include:
1. Social Isolation, related to suspicious view of others
2. Anxiety; related to unconscious conflicts
3. Communication, Impaired Verbal, related to social withdrawal
4. Coping, Ineffective, related to suspiciousness, ambivalence, or projection
5. Social Interaction, Impaired, related to indifference toward others
6. Identity, Disturbed Personal, related to social withdrawal
7. Violence, Self-Directed, Risk for, related to self- mutilating behaviors
8. Violence, Other-Directed, Risk for, related to rage and inability to tolerate
frustration
9. Self-esteem, Situational Low, Actual, related to unmet dependency needs
10. Powerlessness, related to extreme feelings of dependency
11. Decisional conflict, related to ineffective problem- solving ability
12. Family Coping, Compromised, related to maladaptive relationships
13. Hopelessness, related to feelings of inadequacy and incompetence
EXPECTED OUTCOMES

Expected outcomes provide criteria by which the effectiveness of nursing
interventions can be measured.

Nurses and clients work together to facilitate change within a reasonable time.
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
If the expected changes have not occurred within the given timeframe, the plan of
care is revised at the time of evaluation.

Expected outcomes for a client with a personality disorder may include
1. Expresses thoughts and feelings appropriately
2. Increases interaction with others
3. Exhibits decreased hostility and anger
4. Exhibits relaxed posture
5. Participates in unit activities
6. Conforms to unit rules
7. Gains control over impulses
8. Decreases manipulative behaviors
9. Manages anxiety without acting-out behaviors
10. Refrains from harming self or others
11. Associates anxiety with precipitating factors
12. Refrains from using splitting or clinging behaviors
13. Claims ownership of own feelings and thoughts
14. Verbalizes positive qualities about self
15. Makes independent decisions about self-care
NURSING INTERVENTIONS

Providing nursing care for people with personality disorders is very challenging.
Identify personal feelings about the client's behaviors and maintain a continuous
awareness to provide appropriate interventions.

Nursing interventions for the client with a personality disorder may include
1. Show acceptance of the person at all times by separating the person from the
behaviors
2. Provide a safe environment: this is especially important for clients who exhibit
self-mutilating behavior
3. Set and maintain limits with consequences.
4. Explain all unit rules and enforce them fairly and consistently.
5. Require the client to take responsibility for his or her own behavior.
6. Identify inappropriate behavior and discuss possible alternative behavior with
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the client.
7. Do not make exceptions or show favoritism.
8. Encourage the client to openly express feelings and thoughts.
9. Identify triggers of acting-out behaviors.
10. Maintain alertness to client's manipulative behaviors.
11. Communicate problems with manipulative clients to other team members.
12. Provide positive feedback to clients who are making efforts to change behavior.
13. Approach clients from the front and speak clearly. This is especially true for the
client with paranoia.
14. Monitor for checking of medication.
15. Encourage the client to participate in unit activities.
16. Assess for suicidal ideation.
17. Develop a no-harm contract with the client with self-destructive tendencies.
18. Assist and educate the client in the problem-solv- ing process.
19. Demonstrate a matter-of-fact attitude when cli- ents act out or exaggerate
events.
20. Point out all-or-none behavior to the client when it occurs.
21. Encourage the client to keep a private journal of thoughts and feelings.
22. Discuss with the client how his or her behavior affects others and assist to
explore alternative actions.
23. Observe and intervene before escalation of behavior occurs.
24. Use time-out for curbing acting-out behavior if client is resistant to redirection.
25. Educate client and family on information resources about the disorder
EVALUATION

The effectiveness of implemented interventions for clients with personality
disorders is difficult to measure.

Changes do not occur quickly and are often not recognizable during the brief
treatment period.

Your ability to set boundaries and maintain a therapeutic approach to the behaviors
is often one indicator of progress.

Short- term outcomes that involve interaction with other clients and impulse control
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can be evaluated within the confined milieu.

The client's behavior following discharge will demonstrate whether actual
improvement has occurred.

Regardless of efforts expended by the mental health team, the potential for
improvement is limited by the deeply ingrained patterns of pervasive behaviors that
have developed over time.

Unlike an acute medical problem, maladaptive personality traits are usually hidden
to those who exhibit them.

They cannot solve the problem because they are unable to identify the reason for the
problem.

Personality traits and characteristics that I deeply embedded, inflexible, and
maladaptive are the defining picture of the personality disorder. The paradox is that
although the feelings that accompany the disorder cause misery, the person usually
does not recognize the problem and sees the behavior as normal.

Failure to identify the problem is what contradicts the benefit of treatment
programs and interventions. Most people with personality disorders endure a
lifetime of unsuccessful attempts to secure stability in their personal and social
situations.
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