Psychiatric Nursing
Personality Disorders
Chapter 22
S
1
Objectives
S Define personality vs. personality disorders
S Identify various types of personality disorders
2
Personality
S The individual qualities, including habitual
behavior patterns, that make a person unique.
S It is an ingrained enduring pattern of behaving and relating
to self, others, and the environment; it includes perceptions,
attitudes, and emotions.
S These behaviors and characteristics are consistent across a
broad range of situations and do not change easily.
S A person usually is not consciously aware of her or his
personality
Personality Disorders
• Personality traits (features):
• Is a set of characteristics possessed by a person that uniquely
influences his or her cognitions, emotions, interpersonal
orientation, motivation, and behaviors in various situations).
•When does personality disorder happen?
•When personality traits are inflexible and maladaptive and cause
significant functional impairment or distress, they constitute as
personality disorders. Set of characteristics that combine to
negatively affect your life.
S
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Personality Disorders
S Rigid, stereotyped behavior pattern
S Persists throughout the person’s life
S Pattern of perceiving, thinking, and relating that
impairs social or occupational functioning
S Axis II diagnoses
Personality Traits
S Persistent behavioral patterns that do not
significantly interfere with one’s life, even though
the behaviors may be annoying or frustrating to
others
Common Characteristics
S Failure to accept the consequences of behavior
S Lack of insight
S External response to stress
Essential Characteristics
S Chronicity
S Pervasiveness
S Maladaptation
Biologic Factors
S Personality develops through the interaction of hereditary
dispositions and environmental influences.
S Temperamentb refers to the biologic processes of
sensation, association, and motivation that underlie the
integration of skills and habits based on emotion.
S The four temperament traits are harm avoidance, novelty
seeking, reward dependence, and persistence.
S Each of these four genetically influenced traits affects a
person’s automatic responses to certain situations.
S These response patterns are ingrained by 2 to 3 years of age
S Alterations in hormone & platelet monoamine
oxidase (MAO) levels
S Smooth-pursuit eye movements
S Neurotransmitter changes
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Biologic Factors (cont'd)
S Electroencephalographic (EEG) changes
S Structural brain changes
S Diminished blood flow and inflammation
Genetic Factors
S Familial tendencies
S Cluster B correlated with mood disorders,
alcoholism, and somatization
S Genetic variation
Psychosocial Factors
S Parent-child interactions
S Intrapsychic theory
S Enmeshment
S Abandonment
S Identity diffusion
Humanistic Theory
S Personality disorders are a combination of
multiple factors.
S Diagnosis is made when the person exhibits enduring
behavioral patterns that deviate from cultural expectations
in two or more of the following areas:
• Ways of perceiving and interpreting self, other people, and
events (cognition)
• Range, intensity, lability, and appropriateness of emotional
response (affect)
• Interpersonal functioning
• Ability to control impulses or express behavior at the
appropriate time and place (impulse
control)
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S Some people with personality disorders believe their
problems stem from others or the world in general; they do
not recognize their own behavior as the source of difficulty.
S For these reasons, people with personality disorders are
difficult to treat, which may be frustrating for the nurse and
other caregivers as well as for family and friends.
S There are also difficulties in diagnosing and treating clients
with personality disorders because of similarities and subtle
differences between categories or types. Types often overlap,
and many people with personality disorders also have
coexisting mental illnesses.
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Personality Disorders
S
The nurse should understand normal personality development
before learning what is considered dysfunctional (remember
Freud, Sullivan, Erikson, etc.).
S
What are the factors affecting personality development?
Factors that affect personality development (heredity, experiential
learning, social interaction).
S
Individual with personality disorders are not often treated in
acute care setting for their personality disorder as their
primary diagnosis.
S
DSM-IV-TR (APA) groups the personality disorders into three
categories: Cluster A, Cluster B, & Cluster C.
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18
Personality Disorders
1.
Cluster A: odd or eccentric behavior.
•
Paranoid personality disorder
•
Schizoid personality disorder
•
Schizotypal personality disorder
2.
Cluster B: dramatic, emotional behavior
•
Antisocial personality disorder
•
Borderline personality disorder
•
Histrionic personality disorder
•
Narcissistic personality disorder
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Personality Disorder
3. Cluster C: anxious and fearful behavior
• Avoidant personality disorder
• Dependent personality disorder
• Obsessive-compulsive personality disorder
• Passive-aggressive personality disorder
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1 (A). Paranoid personality disorders
S
Definition: Pervasive (spreading throughout) distrust and
suspiciousness of others such that their motives are
interpreted as malevolent, beginning by early adulthood.
S
Long-standing irrational suspiciousness and mistrust of
people.
S
Prevalence is difficult to establish, because individual
with the disorder seldom seek assistance for their problem
or require hospitalization.
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Paranoid personality disorders
S
When they present for treatment at the insistence of
others, they may be able to pull themselves together
so their behavior does not appear maladaptive.
S
More common among men than women
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Paranoid personality disorders
Clinical Picture
S Long-standing suspiciousness and mistrust of people,
consistently on guard (cautious), hyper-vigilant (very
attentive), and ready for any threat.
S They appear tense and irritable, (immune) insensitive to
the feelings of others, oversensitive and misinterpret
events, envious and hostile (unfriendly) to others who are
successful.
S They trust no one, therefore, they consistently testing the
honesty of others. Always feel that others are there to
take advantage of them. Perceive the world as harsh and
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unkind.
Paranoid personality disorders
S Paranoid PD: clinical picture continue
S Hostile to others who are successful & believe the only
reason they are not successful is because they have been
treated unfairly.
S They are consistently in the defensive. They learned to
attack first (aggression and violence).
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Paranoid personality disorders
S Causes:
 Hereditary,
 Parental antagonism (against the children) &
harassment (persistent attack of criticism). Due to
harsh parental treatment they learned to perceive the
world as harsh and unkind.
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2 (A). Schizoid personality disorders
S This disorder characterized by a profound (deep/strong)
defect in the ability to perform personal relationships or to
respond to others in any meaningful, emotional way.
S Prevalence (3-7.5% of general population) and does not
need primary hospitalization.
S
Clinical picture
S Social withdrawal, discomfort with human
interaction, cold and aloof (not emotional).
S Prefer to work in isolation, unsociable, little need or
desire for emotional ties.
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2 (A). Schizoid personality disorders
Schizoid PD: Clinical Picture continue
S In the presence of other they appear shy, anxious, uneasy,
inappropriately serious about everything and unable to
experience pleasure sometimes.
S They are cold and un-empathetic.
S Their behavior and conversation exhibit little or no
spontaneity (not free/not comfortable).
S They don’t display any sexual desire of others.
S They don’t like group therapy and they don’t look for
treatment.
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2 (A). Schizoid personality disorders
S Cause:
 Hereditary characteristics.
 Early interactional patterns that the person found to
be cold and unsatisfying.
 The childhoods of these individuals have often been
characterized as bleak (offering no excitement), cold,
& lacking empathy.
 A child brought up with this type of parenting may
become a schizoid adult.
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3 (A). Schizotypal personality disorders
S Described as ‘’latent (potential) schizophrenics’’. Their behavior
is odd and eccentric, but not to the level of schizophrenia. 3% of
the population has this disorder. They need for social isolation.
S Clinical Picture
S Aloof and isolated, have bland (flat) and apathetic (no
emotions) manner.
S They have magical thinking, idea of reference, illusions, and
depersonalizations are part of their everyday world.
S They show disorders in speech pattern some times.
S When they are under stress, they may decompensate and
demonstrate psychotic symptoms such as delusional thoughts,
hallucination for brief period of time.
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3 (A). Schizotypal personality disorders
Causes:
S Heredity: more common among the first degree
biological relatives of people with schizophrenia.
S They were likely shunned (avoided), ignored, rejected,
and humiliated by others resulting in feelings of low
self- esteem and marked distrust of personal relations.
Having failed to cope with these, they began to
withdraw and reduce contact with individuals that
evoke (produce) sadness and humiliation.
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4 (B). Antisocial personality disorders
S A pattern of socially irresponsible and guiltless behavior
that reflects a disregard for and violation of the rights of
others.
Clinical Picture:
S The person use and manipulate others for personal gain
and have a general disregard for the law.
S They have difficulty sustaining consistent employment
and developing stable relationships.
S The prevalence is 3% for men and 1% for women.
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5 (B). Borderline personality disorders
(emotionally unstable PD)
S Characterized by a pattern of intense & chaotic
(unorganized) relationships, with affective instability &
fluctuating (irregular) attitudes toward other people.
S Clinical Picture:
S The individuals are impulsive (they don’t think before
they act) and self-destructive.
S The prevalence is 2-3% of the population.
S Common twice in women than men.
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6 (B). Histrionic personality disorders
This disorder characterized by colorful, dramatic, and extra
emotionality and attention seeking. They have difficulty
maintaining long-life relationships & need constant
affirmation of approval and acceptance from others.
S Clinical Picture
S Self-dramatizing, attention-seeking, overly and
inappropriately seductive.
S People with this disorder often demonstrate what our
society tend to admire: to be well liked, successful,
popular, attractive, & sociable, however, beneath this is a
driven quality, a consuming need for approval or attract
attention at all costs.
S Failure to evoke the attention results in anxiety.
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6 (B). Histrionic personality disorders
S Clinical Picture continue
S Highly distractible and have difficulty in paying attention
to the details.
S Highly suggestible, strongly dependent, & easily
influenced by others.
S Interpersonal relationships are superficial
S They might have somatic complains and episodes of
psychosis may occur during periods of extreme stress.
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6 (B). Histrionic personality disorders
S Causes:
S Neurobiological: low basal dopaminergic activity,
sympathetic arousal, adrenal hyperactivity, and
neurochemical imbalance.
S Hereditary.
S Learning experiences during childhood (parents are
likely to give positive or negative feedback).
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7 (B). Narcissistic personality disorders
S Individual with this disorder have exaggerated sense of self-
worth (vanity). They lack empathy and are hypersensitive
to the evaluation of others. They believe that they have the
right to receive special consideration & their desire is
sufficient justification for possessing whatever they seek.
S Men more than women
S Clinical Picture
S Overly self-centered and exploiting others to fulfill their
own desires.
S Because they view themselves as ‘’superior’’, they believe
they are entitled to special rights & privileges.
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7 (B). Narcissistic personality disorders
S Clinical Picture continue
S Impaired interpersonal relationships, their mood is
usually optimistic, relaxed, cheerful. Mood easily
change.
S They seek persons who provide them with positive
feedback that they require, and who will not ask
much in return.
S Cause:
S Hereditary-parents have narcissism
S Parents were demanding perfection and placed
unrealistic expectation on the child.
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8 (C). Avoidant personality disorders
S Those are extremely sensitive to rejection, and therefore
have socially withdrawn life. Their extreme shyness &
fear of rejection lead them to be socially withdrawn.
They have feelings of inadequacy.
S Equal in men and women
S Clinical Picture
S Awkward & uncomfortable in social situations
S Their speech is usually slow & constrained, with
frequent hesitations, fragmentary thought sequences
S Often lonely and express feeling of being unwanted
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8 (C). Avoidant personality disorders
Clinical Picture continue
S May develop depression, anger, & anxiety
at oneself for failing to develop social
relations.
S They desire to have close relationships but
avoid that because of their fear of being
rejected.
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9 (C). Dependent personality disorders
S Pervasive and excessive need to be taken care of that leads
to fears of separation. Allow others to take decisions, feel
helpless when they are alone. Depend on other people to
meet their emotional and physical needs.
S Clinical Picture
S Tolerate miss treatment by others
S Cannot be assertive
S Lack of self-confidence (posture, voice), passive, they
easily be hurt by criticism.
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9 (C). Dependent personality disorders
S Clinical Picture continue
S They are overly generous & thoughtful & underplay their
S
S
S
S
own attractiveness & achievement.
They may appear to others that they are happy and
enjoying life but when they are alone they may feel
pessimistic and discouraged
They let others make their important decisions. They have
passive role in their relationships.
They feel incapable of caring for themselves.
Avoid positions and responsibility & feel anxious when
forced into them.
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9 (C). Dependent personality disorders
S Causes:
S Hereditary
S The problem may o arise when parents become over
protective and discourage independent behavior on the
part of the child.
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10 (C). Obsessive-compulsive personality
disorders
S Those are serious and formal individuals who have
difficulty expressing emotions. They are overly disciplined,
perfectionist, and preoccupied with rules. The intense fear
of making mistakes leads to difficulty with decisions.
S More common in men
S Clinical Picture
S Inflexible and lack of spontaneity, they work patiently at
tasks that require accuracy and discipline.
S Tend to be polite and formal.
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10 (C). Obsessive-compulsive personality
disorders
Clinical Picture continue
SConcerned with organization & efficiency“company
man”
SCommonly use the defense mechanism of reaction
formation (presenting the opposite thought).
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Personality disorders test
S http://www.4degreez.com/miscpersonality_disorder_test.mv
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Borderline personality disorder: nursing care
Nursing Diagnoses:
1.
Risk for self mutilation
2.
Dysfunctional grieving
3.
Impaired social interaction
4.
Disturbed personal identity
5.
Anxiety
6.
Low self-esteem
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Antisocial personality disorder: nursing care
Nursing Diagnoses:
1.
Risk for other-directed violence
2.
Defensive coping
3.
Low self-esteem
4.
Impaired social interaction
5.
Knowledge deficit
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Personality disorders: Treatment modalities
1.
Interpersonal psychotherapy
2.
Psychoanalytical psychotherapy
3.
Milieu or group therapy
4.
Cognitive and behavioral therapy
5.
Psychopharmacology (antipsychotic medication can be
helpful in the treatment of the paranoid, schizotypal and
borderline personality disorders)
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11 (C). Passive-aggressive personality
disorders
S Pervasive pattern of negativistic attitudes and passive
resistance to demands for adequate performance in social and
occupational situations.
S Some people passively expressing covert regression
S Clinical Picture
S They feel cheated and unappreciated, life unkind to them
while others are having an easy life.
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11 (C). Passive-aggressive personality
disorders
Clinical Picture continue
S They often switch among the roles of the martyr,
affronted, aggrieved, misunderstood, guilt-ridden,
sickly, & overworked.
S Causes: parental attitude.
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Application of the Nursing
Process
S Safety
S Consistency
S Boundary setting
S Appropriate self-disclosure
Difficult Behaviors
S Manipulation
S Narcissism
S Impulsiveness
Interventions for Paranoid
Personality Disorder
S Respect personal space.
S Respect client’s preference.
S Give feedback based on nonverbal cues.
S Provide client with a daily schedule of activities
and inform client of changes.
Interventions for Paranoid
Personality Disorder
(cont'd)
S Help client identify adaptive diversionary
activities.
S Use role-playing.
S Use an objective, matter-of-fact approach with
client.
S Use concrete, specific words rather than global
abstractions.
Interventions for the Angry
Client
S Use a calm, unhurried approach.
S Do not touch client indiscriminately.
S Respect personal space.
S Use active listening skills.
S Remain aware of personal feelings.
Interventions for Antisocial
Personality Disorder
S Use a concerned, matter-of-fact approach.
S Set, communicate, and maintain consistent rules
and regulations.
S Do not argue, bargain, or rationalize.
Interventions for the
Antisocial Personality
Disorder (cont'd)
S Confront inappropriate behaviors.
S Do not seek approval or coax; use choices and
consequences.
S Be alert for flattery or verbal attacks.
Interventions for
Manipulative Behavior
S Assign one primary staff member.
S Maintain realistic limits with enforceable
consequences.
S Give a rationale for limits and consequences.
Interventions for
Manipulative Behavior
(cont'd)
S Model respect, honesty, openness, and
assertiveness.
S Confront client each time manipulation occurs.
Interventions for
Dependent Personality
Disorder
S Evaluate client’s ability for self-care.
S Avoid doing things the client is capable of doing.
S Help client identify assets and liabilities.
Interventions for
Dependent Personality
Disorder (cont'd)
S Emphasize strengths and potential.
S Encourage client to take responsibility for own
opinions.
S Point out when client negates own feelings or
opinions.
The Nurse’s Response
S Self-awareness
S Countertransference
S Labels and stigma
S Supervision
THANK YOU
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