Chapter 32
Personality Disorders
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Introduction
• Personality Defined
– The totality of emotional and behavioral
characteristics that are particular to a specific
person and that remain somewhat stable and
predictable over time
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Introduction (cont.)
• Personality traits are characteristics with
which an individual is born or develops early
in life.
• They influence the way in which he or she
perceives and relates to the environment
and are quite stable over time.
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Introduction (cont.)
• Personality disorders occur when these
traits become rigid and inflexible and
contribute to maladaptive patterns of
behavior or impairment in functioning.
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Introduction (cont.)
• Personality development occurs in response
to a number of biological and psychological
influences:
–
–
–
–
Heredity
Temperament
Experiential learning
Social interaction
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Introduction (cont.)
• People with personality disorders are not
often treated in acute care settings in
cases in which the personality disorder is
their primary psychiatric disorder.
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Introduction (cont.)
• Many clients with other psychiatric and
medical diagnoses manifest symptoms of
personality disorders.
• Nurses are frequently likely
to encounter clients with
these personality
characteristics in all healthcare settings.
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Historical Aspects
• The first recognition that personality
disorders, apart from psychosis, were cause
for special concern was in 1801 with the
recognition that an individual can behave
irrationally even when the powers of intellect
are intact.
• Ten specific types of personality disorders are
identified in the DSM-5.
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Types of Personality Disorders
Paranoid Personality Disorder
• Definition: A pervasive, persistent, and
inappropriate mistrust of others
– Individuals with this disorder are suspicious of
others’ motives and assume that others intend
to exploit, harm, or deceive them.
– The disorder is more common in men than in
women.
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Types of Personality Disorders (cont.)
Paranoid Personality Disorder (cont.)
• Clinical Picture
–
–
–
–
–
Constantly on guard
Hypervigilant
Ready for any real or imagined threat
Trusts no one
Constantly tests the honesty of others
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Types of Personality Disorders (cont.)
Paranoid Personality Disorder (cont.)
• Clinical Picture (cont.)
– Insensitive to the feelings of others
– Oversensitive
– Tends to misinterpret minute cues
– Magnifies and distorts cues in the environment
– Does not accept responsibility for his/her own
behavior
– Attributes shortcomings to others
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Types of Personality Disorders (cont.)
Paranoid Personality Disorder (cont.)
• Predisposing Factors
– Possible hereditary link
– Subject to early parental antagonism and
harassment
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Types of Personality Disorders (cont.)
Schizoid Personality Disorder
• Definition
– Characterized primarily by a profound defect in
the ability to form personal relationships.
– Failure to respond to others in a meaningful
emotional way.
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Types of Personality Disorders (cont.)
Schizoid Personality Disorder (cont.)
• Definition
– Diagnosis occurs more frequently in men than in
women.
– Prevalence within the general population has
been estimated at 3 to 7.5 percent.
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Types of Personality Disorders (cont.)
Schizoid Personality Disorder (cont.)
• Clinical Picture
– Aloof and indifferent to others
– Emotionally cold
– No close friends, prefers to be alone
– Appears shy, anxious, or uneasy in the presence
of others
– Inappropriately serious about everything and has
difficulty acting in a light-hearted manner
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Types of Personality Disorders (cont.)
Schizoid Personality Disorder (cont.)
•
Predisposing Factors
– Possible hereditary factor
– Childhood has been characterized as:
•
•
•
•
Bleak
Cold
Unempathic
Notably lacking in nurturing
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Types of Personality Disorders (cont.)
Schizotypal Personality Disorder
• Definition
– A graver form of the pathologically less severe
schizoid personality pattern
– Affects approximately 1 to 2 percent of the
population.
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Types of Personality Disorders (cont.)
Schizotypal Personality Disorder (cont.)
• Clinical Picture
– Clients are aloof and isolated.
– Clients behave in a bland and apathetic manner.
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Types of Personality Disorders (cont.)
Schizotypal Personality Disorder (cont.)
• Clinical Picture
– Symptoms include:
•
•
•
•
•
•
Magical thinking
Ideas of reference
Illusions
Depersonalization
Superstitiousness
Withdrawal into the self
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Types of Personality Disorders (cont.)
Schizotypal Personality Disorder (cont.)
• Clinical Picture (cont.)
– Exhibits bizarre speech pattern.
– When under stress, may decompensate and
demonstrate psychotic symptoms.
– Demonstrates bland, inappropriate affect.
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Types of Personality Disorders (cont.)
Schizotypal Personality Disorder (cont.)
• Predisposing Factors
– Possible hereditary factor
– Possible physiological influence such as anatomic
deficits or neurochemical dysfunctions within
certain areas of the brain
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Types of Personality Disorders (cont.)
Schizotypal Personality Disorder (cont.)
• Predisposing Factors (cont.)
– Early family dynamics characterized by:
• Indifference
• Impassivity
• Formality
– These factors lead to a pattern of discomfort with
personal affection and closeness.
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Types of Personality Disorders (cont.)
Antisocial Personality Disorder
• Definition
– A pattern of behavior that is:
• Socially irresponsible
• Exploitative
• Without remorse
– Behavior reflects a disregard for the rights of
others.
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Types of Personality Disorders (cont.)
Antisocial Personality Disorder (cont.)
• Clinical Picture
– Fails to sustain consistent employment.
– Fails to conform to the law.
– Exploits and manipulates others for personal gain.
– Fails to develop stable relationships.
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Types of Personality Disorders (cont.)
Antisocial Personality Disorder (cont.)
• Definition
– Prevalence estimates in the United States
range from 2 to 4 percent in men to about 1
percent in women.
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Types of Personality Disorders (cont.)
Borderline Personality Disorder
• Definition
– Characterized by a pattern of intense and chaotic
relationships with affective instability
– Fluctuating and extreme attitudes regarding other
people
– Highly impulsive
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Types of Personality Disorders (cont.)
Borderline Personality Disorder (cont.)
• Definition (cont.)
– Emotionally unstable
– Directly and indirectly self-destructive
– Lacks a clear sense of identity
– Affects about 1 to 2 percent of the population
– More common in women than in men
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Types of Personality Disorders (cont.)
Histrionic Personality Disorder
• Definition
– Behavior is:
•
•
•
•
•
Excitable
Emotional
Colorful
Dramatic
Extroverted
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Types of Personality Disorders (cont.)
Histrionic Personality Disorder (cont.)
• Definition (cont.)
– Prevalence is thought to be about 2 to 3 percent.
– More common in women than in men
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Types of Personality Disorders (cont.)
Histrionic Personality Disorder (cont.)
• Clinical Picture
• Self-dramatizing
• Attention-seeking
• Overly gregarious
• Seductive
• Manipulative
• Exhibitionistic
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Types of Personality Disorders (cont.)
Histrionic Personality Disorder (cont.)
• Clinical Picture (cont.)
• Highly distractible
• Difficulty paying attention to detail
• Easily influenced by others
• Difficulty forming close relationships
• Strongly dependent
• Somatic complaints are common.
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Types of Personality Disorders (cont.)
Histrionic Personality Disorder (cont.)
• Predisposing Factors
– Possible link to the noradrenergic and
serotonergic systems
– Possible hereditary factor
– Biogenetically determined temperament
– Learned behavior patterns
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Types of Personality Disorders (cont.)
Narcissistic Personality Disorder
• Definition
– Characterized by an exaggerated sense of selfworth
– Lack of empathy
– Clients believe they have the inalienable right to
receive special consideration.
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Types of Personality Disorders (cont.)
Narcissistic Personality Disorder (cont.)
• Definition (cont.)
– Prevalence of the disorder is estimated at
about 6 percent.
– Diagnosed more often in men than in women
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Types of Personality Disorders (cont.)
Narcissistic Personality Disorder (cont.)
• Clinical Picture
– Overly self-centered
– Exploit others in an effort to fulfill their own
desires.
– Mood, which is often grounded in grandiosity, is
usually optimistic, relaxed, cheerful, and carefree.
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Types of Personality Disorders (cont.)
Narcissistic Personality Disorder (cont.)
• Clinical Picture (cont.)
– Because of fragile self-esteem, mood can easily
change if they do not:
• Meet self-expectations
• Receive the positive feedback they expect
– Criticism from others may cause them to respond
with rage, shame, and humiliation.
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Types of Personality Disorders (cont.)
Narcissistic Personality Disorder (cont.)
• Predisposing Factors
– As children, their fears, failures, or dependency
needs were responded to with criticism, disdain,
or neglect
– Parents were often narcissistic themselves
– Parents may have overindulged their child and
failed to set limits on inappropriate behavior
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Types of Personality Disorders (cont.)
Avoidant Personality Disorder
• Definition
– Characterized by:
• Extreme sensitivity to rejection
• Social withdrawal
– Prevalence is about 1 percent and is equally
common in men and women.
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Types of Personality Disorders (cont.)
Avoidant Personality Disorder (cont.)
• Clinical Picture
– Awkward and uncomfortable in social situations
– Desire close relationships but avoid them because
of their fear of being rejected.
– Perceived as timid, withdrawn, or cold and
strange
– They are often lonely and feel unwanted.
– They view others as critical and betraying.
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Types of Personality Disorders (cont.)
Avoidant Personality Disorder (cont.)
• Predisposing Factors
– No clear cause is known.
– May be a combination of biological, genetic, and
psychosocial influences
– Primary psychosocial influences are parental
rejection and censure, which are often reinforced
by peers.
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Types of Personality Disorders (cont.)
1. When assessing a client diagnosed with
narcissistic personality disorder, the nurse
expects to identify which characteristic
behavior?
A.
B.
C.
D.
Odd beliefs and magical thinking
Grandiose sense of self importance
Pattern of intense and chaotic relationships
Submissive and clinging behaviors
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Types of Personality Disorders (cont.)
• Correct answer: B
– Clients diagnosed with narcissistic personality
disorder have an exaggerated sense of self-worth.
They are often grandiose and believe they have
an inalienable right to receive special
consideration.
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Types of Personality Disorders (cont.)
Dependent Personality Disorder
• Definition
– Characterized by a pattern of relying on others for
emotional support
– Relatively common within the population
– More common among women than men
– More common in the youngest children of a
family than in the older ones
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Types of Personality Disorders (cont.)
Dependent Personality Disorder (cont.)
• Clinical Picture
– They have a notable lack of self-confidence that is
often apparent in their:
• Posture
• Voice
• Mannerisms
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Types of Personality Disorders (cont.)
Dependent Personality Disorder (cont.)
• Clinical Picture (cont.)
– Typically passive and acquiescent to desires of
others
– Overly generous and thoughtful while
underplaying their own attractiveness and
achievements
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Types of Personality Disorders (cont.)
Dependent Personality Disorder (cont.)
• Clinical Picture (cont.)
– Low self-worth and easily hurt by criticism and
disapproval
– Avoid positions of responsibility and become
anxious when forced into them
– Assume passive and submissive roles in
relationships
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Types of Personality Disorders (cont.)
Dependent Personality Disorder (cont.)
• Predisposing Factors
– Possible hereditary influence
– Stimulation and nurturance are experienced
exclusively from one source.
– A singular attachment is made by the infant to the
exclusion of all others.
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Types of Personality Disorders (cont.)
Obsessive/Compulsive Personality Disorder
• Definition
– Characterized by inflexibility about the way in
which things must be done
– Devotion to productivity to the exclusion of
personal pleasure
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Types of Personality Disorders (cont.)
Obsessive-Compulsive Personality Disorder
(cont.)
• Definition (cont.)
– Relatively common
– Occurs more often in men than in women.
– Within the family constellation, it appears to be
most common in oldest children.
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Types of Personality Disorders (cont.)
Obsessive-Compulsive Personality
Disorder (cont.)
• Clinical Picture
– Especially concerned with matters of organization
and efficiency
– Tend to be rigid and unbending
– Socially polite and formal
– Rank-conscious:
• Ingratiating with authority figures
• Autocratic and condemnatory with subordinates
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Types of Personality Disorders (cont.)
Obsessive-Compulsive Personality
Disorder (cont.)
• Clinical Picture (cont.)
– On the surface, they appear to be very calm and
controlled.
– Underneath there is a great deal of:
• Ambivalence
• Conflict
• Hostility
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Types of Personality Disorders (cont.)
Obsessive-Compulsive Personality Disorder
(cont.)
• Predisposing Factors
– Overcontrol by parents
– Notable parental lack of positive reinforcement for
acceptable behavior
– Frequent punishment for undesirable behavior
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Types of Personality Disorders (cont.)
2. A client diagnosed with a personality disorder
is cold, aloof, and avoids others on the unit.
The nurse recognizes that this behavior is
symptomatic of which personality disorder?
A.
B.
C.
D.
Schizoid personality disorder
Dependent personality disorder
Borderline personality disorder
Antisocial personality disorder
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Types of Personality Disorders (cont.)
• Correct answer: A
– A hallmark of the schizoid personality is a marked
withdrawal from social contact. The client
behaviors presented in the question are indicative
of schizoid personality disorder.
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Application of the Nursing Process
Assessment
• Borderline Personality Disorder
– Designated as “borderline” because of the
tendency of these clients to fall on the border
between neuroses and psychoses.
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Assessment (cont.)
• Borderline Personality Disorder (cont.)
– Instability of interpersonal relationships
– Unstable self-image
– Marked impulsivity
– Intensity of affect and behavior
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Assessment (cont.)
• Borderline Personality Disorder (cont.)
– Common behaviors
•
•
•
•
•
•
•
Chronic depression
Inability to be alone
Clinging and distancing behaviors
Splitting
Manipulation
Self-destructive behaviors
Impulsivity
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Application of the Nursing Process
• Borderline Personality Disorder (cont.)
– Predisposing factors
• Biological influences
– Biochemical: Possible serotonergic defect
– Genetic: Possible familial connection with
depression
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Application of the Nursing Process
(cont.)
• Borderline Personality Disorder (cont.)
– Predisposing factors (cont.)
• Psychosocial influences
– Childhood trauma and abuse
– Developmental factors
• Fixed in the rapprochement phase of
development (16 to 24 months old). The child
fails to achieve task of autonomy.
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Application of the Nursing Process
(cont.)
3. A client diagnosed with borderline personality
disorder is admitted to a psychiatric unit.
Which behavior pattern would the nurse
expect to observe?
A.
B.
C.
D.
Social isolation
Suspiciousness of others
Bizarre speech patterns
Generates conflict among the staff
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Application of the Nursing Process
(cont.)
• Correct answer: D
– Clients diagnosed with borderline personality
disorder, having little empathy toward others, are
unable to accept both positive and negative
feelings, and view others as all good or all bad.
They tend to split staff, generating conflict.
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Application of the Nursing Process
(cont.)
4. In assessing a client diagnosed with
borderline personality disorder, which
characteristic would the nurse expect to
observe?
A.
B.
C.
D.
Predictability
Controlled anger
Little tolerance for being alone
Stable and satisfactory relationships
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Application of the Nursing Process
(cont.)
• Correct answer: C
– Clients diagnosed with borderline personality
disorder have little tolerance for being alone.
They prefer a frantic search for companionship no
matter how unsatisfactory rather than experience
feelings of loneliness, emptiness, and boredom.
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Nursing Diagnosis: Borderline
Personality Disorder
• Risk for self-mutilation related to parental
emotional deprivation
• Risk for suicide related to unresolved grief
• Risk for other-directed violence related to
underlying rage
• Complicated grieving related to maternal
deprivation during rapprochement phase of
development internalized as a loss with
fixation in anger stage of grieving process
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Nursing Diagnosis: Borderline
Personality Disorder (cont.)
• Impaired social interaction related to extreme fears
of abandonment and engulfment
• Disturbed personal identity related to
underdeveloped ego
• Anxiety (severe to panic) related to unconscious
conflicts based on fear of abandonment
• Chronic low self-esteem related to lack of positive
feedback
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Outcomes: Borderline Personality
Disorder
• The Client:
– Has not harmed self
– Seeks out staff when desire for self-mutilation is
strong
– Is able to identify true source of anger
– Expresses anger appropriately
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Outcomes: Borderline Personality
Disorder (cont.)
• The Client:
– Relates to more than one staff member
– Completes activities of daily living independently
– Does not manipulate one staff member against
the other to fulfill own desires
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Planning/Implementation
• Nursing intervention for the client with
Borderline Personality Disorder is aimed at
protection of the client from self-harm.
• The nurse also seeks to assist the client to
advance in the development of personality by
confronting his or her true source of
internalized anger.
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Evaluation
• Evaluation of care for the client with borderline
personality disorder is based on accomplishment
of previously established outcome criteria.
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Nursing Process: Assessment
• Antisocial Personality Disorder
– Not often seen in most clinical settings.
– Most frequently encountered in prisons, jails, and
rehabilitation services.
– When clients are seen, it is commonly a way to
avoid legal consequences.
– Sometimes they are admitted to the health-care
system by court order for psychological
evaluation.
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Assessment (cont.)
• Antisocial Personality Disorder (cont.)
– Common behaviors
• Exploitation and manipulation of others for personal
gain
• Belligerent and argumentative
• Lacks remorse.
• Unable to delay gratification
• Low frustration tolerance
• Inconsistent work or academic performance
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Assessment (cont.)
• Antisocial Personality Disorder (cont.)
– Common behaviors (cont.)
•
•
•
•
Failure to conform to societal norms
Impulsive and reckless
Inability to function as a responsible parent
Inability to form lasting monogamous relationship
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Predisposing Factors to Antisocial
Personality Disorder
– Possible genetic influence
– Having a disruptive behavior disorder as a child
(ADHD, conduct disorder)
– History of severe physical abuse
– Absent or inconsistent parental discipline
– Extreme poverty
– Removal from the home
– Growing up without parental figures of both genders
– Always being rescued when in trouble
– Maternal deprivation
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Antisocial Personality (cont.)
5. An individual, with a history of antisocial
personality disorder, was arrested for driving
under the influence of alcohol and causing a
serious car accident. Which comment on this
behavior would be expected?
A. “It's not my fault.”
B. “I'm too ashamed to talk about it.”
C. “I just don't remember doing it.”
D. “I'm really sorry about all the people I've
hurt.”
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Antisocial Personality (cont.)
• Correct answer: A
– Individuals diagnosed with antisocial personality
disorder lack remorse about their actions and view
themselves as victims. This individual would most
likely refuse to acknowledge responsibility for the
accident.
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Nursing Diagnosis: Antisocial
Personality Disorder
• Risk for other-directed violence related to
rage reactions, negative role-modeling,
inability to tolerate frustration
• Defensive coping related to dysfunctional
family system
• Chronic low self-esteem related to repeated
negative feedback resulting in diminished selfworth
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Nursing Diagnosis: Antisocial
Personality Disorder
• Impaired social interaction related to
negative role modeling and low self-esteem
• Ineffective health maintenance evidenced by
demonstration of inability to take
responsibility for meeting basic health
practices
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Outcomes: Antisocial Personality
Disorder
• The Client:
– Discusses angry feelings with staff and in group
sessions
– Has not harmed self or others
– Can rechannel hostility into socially acceptable
behaviors
– Follows rules and regulations of the therapy
environment
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Outcomes: Antisocial Personality
Disorder (cont.)
• The Client:
– Can verbalize which of his or her behaviors are not
acceptable
– Shows regard for the rights of others by delaying
gratification of own desires when appropriate
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Outcomes: Antisocial Personality
Disorder (cont.)
• The Client:
– Does not manipulate others in an attempt to increase
feeling of self-worth.
– Verbalizes understanding of knowledge required to
maintain basic health needs.
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Planning/Intervention
• Nursing care of the client with antisocial
personality disorder is aimed at:
– Ensuring the safety of client and others
– Helping client recognize and decrease
unacceptable behaviors
– Assisting client to gain insight into own behaviors
– Helping client to learn to delay gratification
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Evaluation
• Evaluation of care for the client with antisocial
personality disorder is based on accomplishment
of previously established outcome criteria.
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Treatment Modalities for Personality
Disorders
•
•
•
•
•
•
Interpersonal Psychotherapy
Psychoanalytical Psychotherapy
Milieu or Group Therapy
Cognitive/Behavioral Therapy
Dialectical Behavior Therapy
Psychopharmacology
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