Chapter 24: Personality and
Impulse-Control Disorders:
Personality and
Impulse-Control Disorders
Glenn Adams, APRN, FNP-C
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Williams & Wilkins
Personality Disorders: Key Terms
Personality is a complex pattern of characteristics,
largely outside of the person's awareness, that
comprise the individual's distinctive pattern of
perceiving, feeling, thinking, coping, and behaving
Personality traits are prominent aspects of
personality that are exhibited in a wide range of
social and personal contexts
o Intrinsic and pervasive, personality traits
emerge from a complicated interaction of
biologic dispositions, psychological experiences,
and environmental situations that ultimately
comprise a distinctive personality
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Overview of Personality Disorders
Personality disorder characteristics
o Pattern of inner experience and behavior that
deviates from cultural norm
o Pervasive and inflexible
o Onset in adolescence or early adulthood
o Stable over time
o Leads to distress or impairment
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Overview of Personality Disorders
DSM-5 recognizes 10 personality disorders
organized in three clusters
o Cluster A disorders: characterized by odd or
eccentric behavior
 Paranoid, Schizoid, Schizotypal
o Cluster B disorders: characterized by
dramatic, emotional, or erratic behavior
 Borderline, Antisocial, Histrionic, Narcissistic
o Cluster C: individuals appear anxious or
fearful
 Avoidant, Dependent, Obsessive-Compulsive
Personality
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Paranoid Personality Disorder
Long-standing suspiciousness and mistrust of
others, refuse to take responsibility for their own
feelings
Guarded, hostile, angry, unforgiving, holds
grudges
Persistent ideas of self-importance and the
tendency to be rigid and controlling
Orderly by nature, they are hypervigilant to any
environmental changes that may loosen their
control on the world
Etiology: unclear, possible genetic predisposition
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Paranoid Personality Disorder
 Nursing interventions
o Therapeutic relationship
o Identification of problem areas if trust establisher
o Techniques: such as acceptance, confrontation, and
reflection
 Continuum of Care
o Difficult due to lack of trust or understanding of situation
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Schizoid Personality Disorder
 Individuals are characterized as being expressively
impassive and unengaged; tend to be unable to experience
joy and pleasure in life
 Introverted, reclusive, distant, apathetic, emotionally
detached, engage in solitary activities; lifelong loners,
difficulty making friends, uninterested in social activities,
gains little satisfaction in personal relationships
 Interest are directed at objects, things, and abstractions
 Etiology: Speculative
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Schizoid Personality Disorder
Nursing care
o Nursing priorities: difficulty with social relations
and low self-esteem
o Major treatment goals: enhance the experience
of pleasure, prevent social isolation, increase
emotional responsiveness to others
o Teach social skills (enhances their ability to
relate in interpersonal situations)
o Primary focus: increase patient’s ability to feel
pleasure
Continuum of Care
o Rarely hospitalized unless they have a comorbid
disorder
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Schizotypal Personality Disorder
 Characterized by a pattern of social and interpersonal deficits
 Refers to traits that are similar to the symptoms of
schizophrenia but are less severe
o Cognitive perceptual symptoms include magical beliefs and
perceptual aberrations (similar to hallucinations)
o Referential thinking (interpreting insignificant events as
personally relevant)
o Paranoia (suspicion of others)
 Dramatically eccentric; perceived as strikingly odd or strange in
both appearance and behavior; may have unusual mannerisms;
unkempt; avoidant behavior pattern, devoid of any close friends
other than first degree relatives
 Severe stress - respond to stress with transient psychotic
episodes
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Schizotypal Personality Disorder cont’d
 Nursing care:
o Dependent on degree of decompensation
 Continuum of care
o Supportive psychotherapy
o Properly identifying underlying psychiatric disorder
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Borderline Personality Disorder (BPD)
Difficulties regulating their moods, self-identity,
maintaining interpersonal relationship, maintaining
reality-based thinking, and impulsive or destructive
behavior
Characterized by disruptive pattern of instability
Often set unrealistically high expectations for
themselves.
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Borderline Personality Disorder (BPD)
 Diagnostic criteria (Key Diagnostic Characteristics 24.1)
o
Unstable interpersonal relationships - have an extreme fear of
abandonment
o
Unstable self image - no sense of their own identity and direction
o
Unstable affect - rapid and extreme shift in mood often described as
moody, irresponsible and intense
o
Cognitive dysfunction
 Dichotomous thinking – they evaluate experiences, people and objects
in terms of mutually exclusive categories (good or bad, success or
failure, trustworthy or deceitful) “I was a complete failure in school”
 Dissociation or times when thinking, feeling, or behaviors occur outside
a person’s awareness
 Impaired problem solving
 Marked impulsivity beginning by early childhood (they act in the
moment and clean up the mess later)
 Self-harm behavior – most serious is suicide attempts or parasuicidal
behavior (deliberate self-injury with intent to harm oneself)
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Borderline Personality Disorder (BPD)
 Family response to BPD
o Often feel captive to patients
o “Burn-out” and withdrawal from patient which adds to
patient’s feelings of abandonment
 Teamwork and Collaboration: Working Toward
Recovery
o Psychotherapy
o Splitting –view the world in absolutes, nurses and other
treatment team members are all good or all bad
o Dialectical behavior therapy – combines cognitive and
behavioral therapy strategies
o Mentalization-based therapy - goal is to improve patient’s
capacity to accurately understand other’s actions and
develop self-awareness skills
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Borderline Personality Disorder (BPD)
Safety issues:
o Extremely volatile emotionally
o High risk for self-harm and suicide
o Must take threats of suicide and self harm very
seriously
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Evidence-Based Nursing Care: BPD
Mental Health Nursing Assessment
o Physical health assessment
 Nutritional assessment (a priority)
 Dental assessment
 Sleep patterns
o Physical indicators of self-injurious behaviors
o Medication assessment
 Drug interactions
 Use of alcohol, OTC medications, street drugs
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Evidence-Based Nursing Care: BPD
 Mental Health Nursing Assessment
o
Psychosocial assessment
 Any unresolved grief
 History of physical and/or sexual abuse
 History of early separation from caregiver(s)
 Mood fluctuations
 Appearance and activity level
 Impulsivity
 Cognitive disturbances
 Identity disturbance
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Evidence-Based Nursing Care: BPD
 Mental Health Nursing Assessment
o
Psychosocial assessment
 Dissociation and transient psychotic episodes
 Dissociation can be assessed by asking if there is ever a time when
the patient does not remember events or has the feeling of being
separate from his or her body referred to as “spacing out” . It is
important to ask what is happening in the environment when
dissociation occurs
 Interpersonal skills
 In abusive, destructive relationships?
 Self-esteem and coping skills
 Functional assessment
 Social support systems
o
Risk assessment: suicide or self-injury
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Evidence-Based Nursing Care: BPD
 Mental Health Nursing Assessment
o Psychosocial assessment
 Strength assessment
 Priority of care
o Safety of patient
o Ability to cope
o Emotional regulation strategies
o Identity issues
o Anxiety
o Low self-esteem
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Evidence-Based Nursing Care: BPD
 Therapeutic relationship
o Strengthen coping skills and self-esteem
o Model healthy interaction
 Mental health interventions
o Physical care
 Sleep hygiene
 Teaching nutritional balance
 Preventing and treating self-harm
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Evidence-Based Nursing Care: BPD
Mental health interventions
o Pharmacologic interventions
 Administering and monitoring medications
 Managing side effects
 Teaching points
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Evidence-Based Nursing Care: BPD
Psychosocial care
o Addressing abandonment and intimacy fears
o Establishing personal boundaries and limitations
o Using behavioral interventions
o Challenging dysfunction thinking (Box 24.5 and
Table 24.1)
o Psychoeducation (Box 24.6)
o Teaching emotional regulation
o Teaching effective ways to communicate
o Building social skills and self-esteem
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Antisocial Personality Disorder (ASPD)
“A pervasive pattern of disregard for, and
violation of, the rights of others occurring
since age 15 years”
The diagnosis is given to individuals 18 years
or older who fail to follow society’s rules
Often referred to as psychopath or sociopath, a
person with a tendency toward antisocial and
criminal behavior with little regard of others
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Antisocial Personality Disorder (ASPD)
 Clinical Course and Diagnostic Criteria
o Chronic course
o Arrogant, self-centered, feel privileged and entitled.
o They are self-serving and they exploit and seek power over
others
o Interpersonally engaging; lack empathy or human
compassion
o Deceit, manipulation
o Lack of guilt for wrongdoing
o Hasty, temperamentally aggressive, and short sighted
o Key Diagnostic Characteristics 24.2
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Antisocial Personality Disorder (ASPD)
Age of Onset
o Must be at least 18 years old and exhibited one
or more childhood behavioral characteristics of
conduct disorder before the age of 15 years
o Aggression to people or animals, destruction of
property, deceitfulness or theft, or serious
violation of rules
o Likelihood of developing increased if onset of
conduct disorder is seen before age 10 and
childhood ADHD
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Antisocial Personality Disorder (ASPD)
Family Response to ASPD
o If present, have probably been abused,
mistreated, or intimidated by patients
o May be fiercely loyal to patient and blame self for
patient’s shortcomings
Teamwork and Collaboration: Working toward
Recovery
o Patient’s usually seek treatment for depression,
substance abuse, uncontrolled anger, or forensicrelated problems
o Overall goal: develop nurturing sense of
attachment and empathy for others; live within
norms of society
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Evidence-Based Nursing Care: ASPD
Mental Health Nursing Assessment
o No significant impairment in biologic dimension
o Physical effects of chronic use of addictive
substances
o Difficult to elicit data due to mistrust about
authority figures
o Key areas
 Quality of relationships
 Impulsivity
 Extent of aggression
 Disregard for others
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Evidence-Based Nursing Care: ASPD
Priority of Care
o First priority: establish safe environment for
patient and staff
o Other mutually agreed-upon priorities can then be
considered
o Outcomes should be short-term and relevant to
specific problem
Therapeutic relationship
o Goal: identify dysfunctional thinking patterns and
develop new problem-solving behaviors
o Nurse should use self-awareness skills and access
supervision regularly to help identify blocks
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Evidence-Based Nursing Care: ASPD
Mental Health Nursing Interventions
o Facilitating self-responsibility
o Enhancing self-awareness
o Teaching points – direct approach is best, avoid
lecturing (Box 24.8, Box 24.9)
o Group interventions
o Milieu interventions
o Anger management
o Social support
o Interventions for family members
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Evidence-Based Nursing Care: ASPD
Evaluation and Treatment Outcomes
o Evaluate in terms of management of specific
problem
o Adherence to treatment recommendations for
comorbid conditions
o Development of health care practices
Continuum of Care
o Patients rarely seek mental health care unless
comorbid condition
o Consistency in interventions necessary
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Histrionic Personality Disorder
Attention seeking, dramatic, excitable, emotional,
insatiable need for attention and approval “they are
the life of the party”
Moody; sense of helplessness when others
disinterested
Sexually seductive to gain attention, uncomfortable
with single relationship, provocative appearance,
dramatic speech
Lack of loyalty and fidelity
Difficulty achieving any true intimacy in interpersonal
relationships
Depressed when not the center of attention
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Histrionic Personality Disorder
Nursing care
o Set goals to protect person from becoming
dependent on mental health system
o Assessment: Focus on quality of the individual’s
interpersonal relationships
o Interventions: therapeutic relationship,
independent decision making, confident in ability
to handle situations, reinforcement of personal
strengths, autonomous action, assertiveness
groups
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Narcissistic Personality Disorder
Clinical course and diagnostic criteria
o Grandiose with an inexhaustible need for
admiration
o Lacking empathy
o Believe they are superior, special, or unique and
others should recognize them in this way
o Self-centered view
o Sense of entitlement
o Cannot show empathy
o Often show overlapping characteristics of BPD
and Antisocial Personality Disorder (ASPD)
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Narcissistic Personality Disorder
Nursing Care
o Building therapeutic relationship slow process
due to patient’s avoidance of self-reflection
o Difficult patients as they are unwilling to make
changes
o Nurse must use self-awareness
o Focus on coexisting responses to other health
care problems
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Avoidant Personality Disorder
Clinical Course and Diagnostic Criteria
o Characterized by avoidance of social situations
o Individuals are timid, shy, hesitant, fear of
criticism, and feelings of inadequacy
o Extremely sensitive to negative comments and
disapproval
o Perceive self as socially inept, inadequate and
inferior
o Reluctant to enter relationships unless given
strong assurance of uncritical acceptances
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Avoidant Personality Disorder
Nursing care
o Assessment
 Lack of social contacts
 A fear of being criticized
 Evidence of chronic low self-esteem
o Therapeutic relationship
 Slow process
 Requires extreme amount of patience
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Avoidant Personality Disorder
Nursing care
o Interventions
 No negative criticism
 Identification of positive responses from
others
 Exploration of previous achievements
 Exploration of reasons for self-criticism
 Social skills training
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Dependent Personality Disorder
Clinical Course and Diagnostic Criteria
o Cling to others in a desperate attempt to keep
them close
o Intense need to be taken care of
o Total submission and disregard for self
o Decision making difficult or nonexistent decision
making
o Withdrawal from adult responsibilities
o At risk for suicide and parasuicide, perpetration
of child abuse, perpetration of domestic violence
(in men), victimization by a partner (in women)
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Dependent Personality Disorder
Epidemiology
o When diagnosis are made using standardized
instruments women = men
o Risk greater for least educated, widowed,
divorced, separated, and never married women
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Dependent Personality Disorder
Etiology
o Biologic predisposition
o No research support for biologic hypothesis
o Result of parents’ genuine affection, extreme
attachment, and overprotection
o Children do not learn necessary skills for
autonomous behavior
o Children with chronic physical illnesses may be
prone to develop disorder
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Dependent Personality Disorder
 Nursing Care
o Assessment: self-worth, interpersonal relationships,
and social behavior
o Priorities of care: identified low self-esteem,
difficulties in social situations, coping with stresses of
everyday life, home management skills
o Interventions: help recognize dependent patterns,
motivate them to want to change, teach adult skills
that have not been developed, support to make their
own decisions, administer possible antidepressants
or antianxiety agents
o Encourage individual to make own decisions
o Individual psychotherapy
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Dependent Personality Disorder
Continuum of Care
o Individuals readily seek out therapy
o Likely to spend years seeking therapy
o Hospitalization occurs for comorbid conditions
such as depression
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Obsessive-Compulsive Personality
Disorder (OCPD)
 Clinical Course and Diagnostic Criteria
o Closely resembles obsessive-compulsive disorder OCD,
closely related to anxiety disorder, clinical manifestations
quite different
o Pervasive pattern of preoccupation with orderliness,
perfectionism, and control
o Capacity to delay rewards
o Attempt to maintain control by careful attention to rules,
trivial details, procedures, and lists
o Completely devoted to work
o Uncomfortable with unstructured leisure time
o Formalized leisure activities
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Obsessive-Compulsive Personality
Disorder (OCPD)
Clinical Course and Diagnostic Criteria
o Perfectionists
o Maintain regulated, highly structured, strictly
organized life
o Need to control others and situations
o Prone to repetition, difficulty making decisions
o Overly conscientious
o Rigid, stubborn, indecisive, unable to accept new
ideas or customs
o Mood is tense and joyless; restrained warm
feelings, tight control of emotions
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Obsessive-Compulsive Personality
Disorder (OCPD)
Epidemiology
o Associated with higher education, employment,
and marriage
Etiology
o No biologic connection
o Parental overcontrol and overprotection
 Teach deep sense of responsibility to others
and feel guilt when not met
 Encourage resisting natural inclinations
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Obsessive-Compulsive Personality
Disorder (OCPD)
Nursing care
o Seek care for attacks of anxiety, spells of
immobilization, sexual impotence, excessive
fatigue
o Assessment: focus on patient’s physical
symptoms
o Short-term pharmacologic intervention with
antidepressant or anxiolytic
o Supportive nurse-patient relationship
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Obsessive-Compulsive Personality
Disorder (OCPD)
Continuum of Care
o Treated primarily in community
o Long-term psychotherapy to help change
compulsive pattern
o Short hospitalization stay for possible depression
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Disruptive, Impulse-Control, and Conduct
Disorders
Essential feature of irresistible impulsivity
o Oppositional defiant disorder
o Conduct disorder
o Intermittent explosive disorder
o Kleptomania
o Pyromania
Behaviors violate the rights of others and/or
are in conflict with societal norms
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Disruptive, Impulse-Control, and Conduct
Disorders
 Impulsivity - acting without considering consequences or
alternative actions; results when neurobiologic overactivity is
stimulated by psychological, personality, or social factors
related to personal needs of individual
 Impulse-control disorders often coexist with other disorders
 Oppositional defiant disorder - a persistent pattern of
disobedience, argumentativeness, angry outburst, low
tolerance for frustration, and tendency to blame others for
misfortunes
 Conduct disorder: characterized by more serious violations of
social norms, aggressive behavior, destruction of property
cruelty to animals
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Disruptive, Impulse-Control, and Conduct
Disorders
Epidemiology
o More common in boys
o Associated with lower socioeconomic status and
urban living
o Common in school-aged children
o Are frequent presenting complaints in child
psychiatric treatment settings
o Prevalence: 2% to 10% with median of 4%
o Most frequently diagnosed disorder in children in
mental health facilities
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Disruptive, Impulse-Control, and Conduct
Disorders
Etiology
o Appear to have both genetic and environmental
components
Mental health nursing assessment
o Rule out comorbid conditions: ADHD,
learning disabilities, chemical dependency,
depression, bipolar illness, generalized anxiety
disorder
o Usually involuntary admission - brought into
mental health system by family, school, or court
system
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Disruptive, Impulse-Control, and Conduct
Disorders
Mental health nursing assessment
o Determine when an event or behavior occurred
o Conducted in several sessions in nonjudgmental
fashion
o Family history may include marital conflict,
parental substance abuse, parental antisocial
behavior
Priority of Care
o Patient and staff safety
o Improving communication and coping skills
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Disruptive, Impulse-Control, and Conduct
Disorders
Mental Health Nursing Interventions
o Place in appropriate programs for remediation if
also have neurodevelopmental disorders
o Appropriate pharmacotherapy if ADHD or
depression also noted
Psychosocial Interventions
o Focus on problem behaviors; progress may be
slow
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Disruptive, Impulse-Control, and Conduct
Disorders
Social Skills Training
o Communicate behavioral expectations clearly
and enforce consistently
o Consequences of appropriate and inappropriate
actions should be clear
o Role-playing, modeling by therapist, giving
positive reinforcement
Problem Solving Therapy
o Conceptualizes conduct problems as result of
deficiencies in cognitive processes
o Generate alternative solutions, sharpen thinking,
evaluate responses
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Disruptive, Impulse-Control, and Conduct
Disorders
Parent Management Training and Education
o Educate parents about disruptive behavior
disorders, focusing particularly on
impulsiveness, impaired judgment, self-control
o Parents have often contributed to disorder
o Provide parents with new ways of understanding
situation (Box 24.11)
Referral to Family Therapy
o Assist family with altering maladaptive patterns
of interaction or improving adjustment to
stressors
o Multisystem therapy showing promise
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Disruptive, Impulse-Control, and Conduct
Disorders
Evaluation and Treatment Outcome
o Review treatment guide and objectives to assess
child’s progress
o Relies on input from parents, teachers, health
care team members
Continuum of Care
o Many different agencies in community: child
welfare services, school, legal system
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Intermittent Explosive Disorder
Severity of aggressiveness is out of proportion to
provocation
Can have serious psychosocial consequences
Diagnosis given after all other disorders excluded
Little is known
Onset: most common in childhood, mean age 14
Contributes to suicidality
Multifaceted treatment: psychopharmacologic,
anger management
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Kleptomania
Individuals cannot resist urge to steal
Occurs in approximately 0.3% to 0.6% shoplifters
Females outnumber males 3 to 1
Little is known due to secrecy
Appears to have onset in adolescence
Depression common accompanying symptom
Difficult to detect and treat
Behavior therapy frequently used
Medication for depression
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Pyromania
Irresistible impulses to start fires
Are often regular “fire watchers” or even firefighters
Little is known about disorder
Prevalence in general population about 1%
Most likely male, young, never married, have other
psychiatric issues: ASPD, substance use, impulsivity
Little known about treatment
May use education, parenting training, behavior
contracting with token reinforcement, problemsolving skills training, relaxation exercises
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Continuum of Care for Disruptive,
Impulse-Control Disorders
Require long-term treatment, usually outpatient
setting
Group therapy
Hospitalization rare unless comorbid psychiatric or
medical condition
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