Personality Disorders Note-Taking Outline
Lifelong, inflexible, and dysfunctional patterns of relating and behaving
 Patterns interfere with daily life, relationships, occupational functioning
 Client often does not recognize own dysfunction
 Diagnosis is on Axis II
Overview
 If admitted to inpatient facility, must have an Axis I diagnosis also



Most treated as outpatient
Often seen in drug treatment centers
Interpersonal Characteristics
Relationships
 Often experience conflict with others
 Cause distress to others
 only become distressed when others react to them negatively
 May have difficulty initiating or sustaining relationships
Affective/Cognitive Characteristics
 Anxiety: Presence of anxiety varies depending on type of PD
 Behavior often is way of coping with anxiety; individual does not consider how their
behavior will affect others
 Difficulty adapting to the new or unexpected
 Mistakes in judgment
 Lack of insight
Grouped by the Three Clusters of Behavior in the DSM IV-TR
 Cluster A
 Exhibit odd and eccentric behaviors
 Cluster B
 Exhibit dramatic, emotional and erratic behaviors.
 Cluster C
 Exhibit anxious, fearful behaviors
Cluster A (Odd-Eccentric)
Characteristics: odd, eccentric behavior, suspicious ideations, and social isolation.
Know this cluster as a group (do not have to recognize each individually)
 Schizoid P.D.
 Schizotypal P.D.
 Paranoid P.D.
Cluster A Overview
 Similarities to schizophrenia, but
 No fixed delusions or hallucinations
 May have transient psychotic symptoms when under acute stress
 May have biological family member with schizophrenia
Cluster A
 Types: Schizoid PD-withdrawn, isolative, cannot relate to others
Schizoptypal PD-odd, eccentric thoughts and behaviors
Paranoid PD-suspicious, interprets hidden meanings, fearful, bears grudges
Cluster A: Nurse-client Relationship
 Building trust is most important
 Be honest; keep it simple
 Do not intrude on privacy, if possible
 Do not challenge odd beliefs or appearance
 Expect inappropriate anger, hostility and altered interpretations of reality when pt.’s
anxiety is high
Cluster A: Milieu
 Do not push into social or group activities, but give gentle encouragement
 Choose groups that are non-threatening
Cluster B (Dramatic, Emotional, Erratic)
Characteristics: Impulsive, dramatic behavior, intolerance of frustration, exploitative
interpersonal relationships.
 Narcissistic P.D.
 Histrionic P.D.
 Antisocial P.D.
 Borderline P.D Is most commonly dx’d. P.D.
Cluster B Types
 Histrionic PD-wants to be center of attention, provocative, overreacts
 Narcissistic PD-needs to be admired, grandiose, sense of entitlement, takes
advantage of others
Interventions for Histrionic or Narcissistic P.D.
 Set appropriate limits
 Be consistent in approach




Be matter-of-fact
Focus on here-and-now
Use supportive confrontation for discrepancies and contradictions
Support self-esteem (does this seem like a contradiction?)
 Antisocial Personality Disorder (APD)
 Pattern of disregard of the rights of others
 Non-conforming to rules
 Often found in criminal justice system rather than in mental health services
 May seek hospitalization to avoid the law
Antisocial Personality Disorder: Cognitive and Affective Aspects
 Low tolerance for frustration; cannot delay gratification of impulses
 Unable to make long-range plans
 Deny and rationalize behavior
 Little guilt or remorse
 May be aggressive, sexually inappropriate or abusive
Antisocial Personality: Interpersonal Aspects
 May appear charming and confident
 Self-interest comes before needs of others
 Unable to sustain close personal relationships.
 Sex life is impersonal and impulsive.
Antisocial Personality: Etiology
 Biological
 Genetic: inherited trait or predisposition
 ANS under-responds to stress
 Low activity in frontal lobe
 Unable to learn from rewards and punishment
 History of disordered life functioning
 Parent-child relationship often is unstable
 Childhood characteristics of lying, stealing and being truant.
Client Profile: APD

A 24 year old unemployed male was admitted from jail to the mental health unit
after a suicide attempt in his cell. Was awaiting sentencing for burglary: stole from the
apt. of his former girlfriend. States to the nurse that his problems started after she broke
up with him. Client was using alcohol and cocaine heavily. Explains, “She owed me and
so I took some cash and stuff.” The client has a distressed affect when discussing
current situation. He states, “Now they’re putting a label of crazy on me.” DSM IV-TR
Dx = Axis 1: Mood Disorder NOS, Polysubstance Abuse; Axis 2: Antisocial PD
Antisocial Personality Disorder: Nursing/Milieu Interventions
 Essential for staff to agree on rules and stick with them
 Will try to play one staff or shift against another
Set firm limits
 Point out effect of behavior on others
 Point out consequences of behavior
 Best form of treatment: Peer counseling and self-help groups like AA, where peers can
confront and offer feedback

Borderline Personality Disorder
Overview
 Characterized by:
 Extremely intense and variable moods
 Disturbed sense of self; often self-negative
 Impulsivity, often with self-destructive behavior
 Use of “splitting” (also called “black or white thinking”) as defense mechanism
Borderline Personality Disorder DSM IV-TR Criteria
 Fear of abandonment and frantic efforts to avoid it
 Unstable, intense relationships
 Marked identity disturbance
 Chronic feelings of emptiness
 Impulsivity that may be self-damaging
 When under stress may experience transient, paranoid thoughts or delusions, or
dissociative symptoms
 Recurrent Self-Destructive Behavior
Suicidal threats & gestures
 Self-Injurious Behavior (SIB)
 Affective instability
 Rapid mood shifts
 Low frustration tolerance
 Problems with anger

Borderline PD: Etiology
A predisposition plus childhood experiences is current accepted theory
 Childhood environment: often chaotic or neglectful
 Strong evidence for abuse, trauma history
 Neurobiological: (cause or result of stress?)
 Serotonin dysregulation
 cholinergic and adrenergic abnormalities


lack of integration of right and left hemispheres
smaller hippocampal volume
Issues for Borderline Personality: Splitting Phenomenon
 Low tolerance for ambivalence
 Inability to cope with conflict
 Sense of inner emptiness
 Identity is obtained from other person
 Issues: Interpersonal Relationships
 Unstable and intense
 Characterized by over-idealizing or devaluation of others
 Cannot resolve feelings that others are not perfect and cannot meet all of their
needs
 Fear being abandoned; may be needy and dependent
 Issues: Self-injury: (serves several functions)




Is self-punishment
Relieves tension
Improves mood
Is evidence that they are real, and can feel
 Suicide risk is high due to:



Self-injuring behaviors
Severe emotional pain
Impulsivity
BPD: Nurse-client Relationship
 Consistency, trust, honesty
 Explain and then Enforce unit rules matter-of-factly
 Team approach: Minimize splitting of staff
 Be accepting, convey empathy
 Discuss how to express and handle feelings
 Encourage self-responsibility and appropriate behaviors
 Offer choices, when possible
 Give positive feedback for accomplishments and progress
 Don’t get discouraged by “backsliding”
 Do not minimize or ignore SIB
Client Profile: Borderline Personality
A 27 year-old divorced female was admitted for severe mood swings & suicidal thoughts
with a plan to overdose on pills and alcohol. The patient recently lost job due to
excessive absences. Has unstable job history-frequently quits or is fired. Pt. uses
marijuana episodically when depressed. Long history of outpt. tx. for depression and
cutting self on legs. Identifies current stressors as financial issues, therapist leaving
position at MH clinic. DSM IV-TR diagnoses: Axis I Major Depressive Episode; Axis II
Borderline Personality Disorder
Borderline Personality: Milieu
 Provide safe environment based on ongoing assessment;
 suicide or self-injury precautions prn
 Groups: Coping skills, Expressive Arts
 Journaling: Promotes safe identification of own thoughts, feelings and actions
BPD: Community Resources
 Individual and group therapy with specialist: CBT and Dialectical Behavior Therapy
(DBT)
 Family education and support; couples counseling: NAMI, Al-anon, etc.
 AA, NA, ACOA for substance abuse issues
Cluster C: (Anxious-Fearful)
 Dependent Personality Disorder

Pervasive, excessive need to be taken care of
 Fears being alone and helpless
 Unable to make decisions without much support
 Avoidant Personality Disorder



Fears making mistakes, rejection
Shyness and inadequacy
Socially uncomfortable
 Obsessive-Compulsive Personality Disorder




Perfectionistic and inflexible
Preoccupied with details
Too busy to have fun or friends
Hoards objects and money
Nursing Interventions for Cluster C
 Assist in setting small, achievable goals
 Assist to explore feelings
 Encourage and assist to try new activities
 Assist to decrease anxiety and need for perfection
Cluster C: Milieu Management
 Groups: Assertiveness training, Stress management skills, Leisure skills
 Most clients seen as outpatients
Personality Disorders
Pharmacological Interventions
 Medications to address severe, disabling symptoms/distress
 Assess need for emergency, prn or short term medications when in crisis
Examples: Suicidal behavior
Transient psychosis
Assaultive behavior
Severe anxiety episode
 Treat co-morbid Axis I diagnoses: Depression, Anxiety Disorders, Bipolar Disorder,
etc.
Evaluation of Interventions
 What behaviors are targets for tx. within a short-term hospital stay?
 How can the nurse evaluate effectiveness of interventions for the person who has a
personality disorder?