Chapter 21
Personality Disorders
Part I
Introduction

DSM-IV-TR defined Personality traits as
“Enduring patterns of perceiving, relating to
, and thinking about the environment and
oneself that are exhibited in a wide range of
social and personal context.”
Introduction (cont.)

Personality development occurs in response
to a number of biological and psychological
influences, such as
◦
◦
◦
◦
Heredity
Temperament
Experiential learning
Social interaction
Introduction (cont.)

Personality disorders occur when these traits
become:
◦ Inflexible
◦ Maladaptive
 The cause of significant functional impairment or
subjective distress
Introduction (cont.)

People with personality disorders are not
often treated in acute care settings, for which
personality disorder is their primary
psychiatric disorder.
Introduction (cont.)
Many clients with other psychiatric and
medical diagnosis manifest symptoms of
personality disorders.
 Nurses are likely to frequently encounter
clients with these personality characteristics
in all healthcare settings.

Personality Disorders

Cluster A: Behaviors that are described as
odd or eccentric
◦ Paranoid personality disorder
◦ Schizoid personality disorder
◦ Schizotypal personality disorder
Personality Disorders (cont.)

Cluster B: Behaviors that are described as
dramatic, emotional, or erratic
◦
◦
◦
◦
Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder
Personality Disorders (cont.)

Cluster C: Behaviors that are described as
anxious or fearful
◦ Avoidant personality disorder
◦ Dependent personality disorder
◦ Obsessive-compulsive personality disorder
Types of Personality Disorders

Paranoid
◦ Definition: A pervasive distrust and
suspiciousness such that the motives of others are
interpreted as malevolent; condition begins by
early adulthood and presents in a variety of
contexts
◦ It is more common in men than in women
Paranoid (cont.)

Clinical Picture
◦
◦
◦
◦
◦
Constantly on guard
Hyper vigilant
Tense and irritable
Ready for any real or imagined threat
Trusts no one
Paranoid (cont.)

Clinical Picture (cont.)
◦
◦
◦
◦
◦
Oversensitive
Constantly tests the honesty of others
Insensitive to the feelings of others
Tends to misinterpret minute cues
Magnifies and distorts cues in the environment
Paranoid (cont.)

Etiological Implications
◦ Possible hereditary link: the studies revealed a
higher incidence of paranoid personality disorder
among relatives of client with schizophrenia than
among control subjects.
◦ Subject to early parental antagonism and
aggression: they learned to perceive the world as
harsh and unkind, a place calling for protective
vigilance and mistrust
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
◦ Diagnosis occurs more frequently in men than in
women.
◦ Prevalence within the general population has been
estimated at 3% to 7.5%
Schizoid Personality Disorder(cont.)

Clinical Picture
◦
◦
◦
◦
Indifferent to others
Client aloof (distant, detached, unfriendly)
Client emotionally cold
In presence of others, clients appear shy, anxious,
or uneasy
◦ Inappropriately serious about everything and have
difficulty acting in a light-hearted manner
Schizoid Personality Disorder (cont.)
Etiological Implications

◦
◦
Possible hereditary factor
Childhood has been characterized as




Shy, anxious, introverted
Bleak (miserable, depressive)
Cold
Notably lacking empathy and nurturing
Schizotypal Personality Disorder

Definition
◦ Described as “ latent schizophrenics”
◦ A graver form of the pathologically less severe
schizoid personality pattern
◦ Recent studies indicate that approximately 3%
of the population has this disorder
Schizotypal Personality Disorder
(cont.)

Clinical Picture
◦ Clients aloof and isolated
◦ Behave in a bland (weak, tasteless) and apathetic
manner
Schizotypal Personality Disorder
(cont.)

Clinical Picture (cont.)
◦ Everyday world manifests




Magical thinking
Ideas of reference
Illusions
Depersonalization
Schizotypal Personality Disorder
(cont.)

Clinical Picture (cont.)
◦ Exhibits bizarre speech pattern
◦ When under stress, may decompensate and
demonstrate psychotic symptoms
◦ Demonstrates blunt, inappropriate affect
Schizotypal Personality Disorder
(cont.)

Etiological Implications
◦ Possible hereditary factor
◦ Possible physiological influence, such as anatomical
deficits or neurochemical dysfunctions resulting in
diminished activation, minimal pleasure- pain
sensibilities, and impaired cognitive functions.
Schizotypal Personality Disorder
(cont.)

Etiological Implications (cont.)
◦ Early family dynamics characterized by:
 Indifference
 Impassivity (cold, emotionless)
 Formality
 Pattern of discomfort with personal affection and
closeness
Antisocial Personality Disorder
◦ Definition
 A pattern of
 Socially irresponsible
 Exploitative
 Guiltless behavior
that reflects a disregard for the rights of others.
o
Prevalence estimates in the United States range from
3% in men to less than 1% in women
Antisocial Personality Disorder
(cont.)

Clinical Picture
◦ Fails to sustain consistent employment
◦ Exploits and manipulates others for personal gain
◦ Has a general disregard for the law
Borderline Personality Disorder

Borderline
◦ Definition
 Characterized by a pattern of intense and
chaotic (messy, disorganized) relationships with
affective instability
 Clients have fluctuating and extreme attitudes
regarding other people
 Clients highly impulsive
Borderline Personality Disorder
(cont.)

Definition (cont.)
◦
◦
◦
◦
Most common form of personality disorder
Emotionally unstable
Lacks a clear sense of identity
It is more common in women than in men with 4:1
ratio
Histrionic Personality
Disorder

Definition (cont.)
◦ Personality is
 Excitable
 Emotional
 Colorful
 Dramatic
 Extroverted in behavior
◦ Prevalence thought to be about 2% to 3%
◦ More common in women than men
Histrionic Personality Disorder
(cont.)

Clinical picture
◦ Affected clients are
 Self-dramatizing
 Attention-seeking
 Overly gregarious (expressive, extroverted)
 Seductive
 Manipulative
 Exhibitionistic
Histrionic Personality Disordr
(cont.)

Clinical picture (cont.)
◦ Affected clients (cont.)
 Are highly distractible
 Have difficulty paying attention to detail
 Are easily influenced by others
 Have difficulty forming close relationships
Histrionic Personality
Disorder (cont.)

Etiological Implications:
◦ Possible link to the noreadrenargic activity and
decrease serotonergic activity
◦ Possible hereditary factor
◦ Learned behavior patterns:
 When a child is not a center of a parents attention,
neglect, lack of bonding, and deprivation leaves one
starving for attention, approval, praise, and reassurance
Narcissistic Personality Disorder

Definition
◦ Characterized by an exaggerated sense of selfworth
◦ Lacks empathy
◦ Believes has inalienable (absolute) right to receive
special consideration
Narcissistic Personality Disorder
(cont.)

Definition
◦ Prevalence of the disorder from 2% to 16% in the
clinical population
◦ Less than 1% in the general population is
narcissistic
◦ Disorder more common in men than women
Narcissistic Personality
Disorder (cont.)

Clinical Picture
◦ Client overly self-centered
◦ Exploits others in an effort to fulfill own desires
◦ Mood, which is often grounded in grandiosity, is
usually optimistic
◦ Client relaxed, cheerful, and care-free
Narcissistic Personality Disorder
(cont.)

Clinical picture (cont.)
◦ Mood can easily change because of fragile selfesteem if client does not:
 Meet self-expectations
 Receive positive feedback expected from others
◦ Responds to negative feedback from others with
rage (anger), shame, and humiliation (disgrace,
embarrassment)
Narcissistic (cont.)

Etiological Implications
◦ As children, these people have had their fears,
failures, or dependency needs responded to with
criticism, disdain, or neglect.
◦ Parents were often narcissistic themselves.
Avoidant Personality Disorder

Definition
◦ Characterized by
 Extreme sensitivity to rejection
 Social withdrawal
◦ Prevalence is between 0.5% and 1% and is equally
common in both men and women.
Avoidant Personality Disorder
(cont.)

Clinical Picture
◦ Awkward and uncomfortable in social situations
◦ Desires close relationships but avoid them because
of fear of being rejected
Avoidant Personality Disorder
(cont.)

Etiological Implications
◦ Possible hereditary influences
◦ Parental rejection and criticism
Dependent Personality Disorder

Definition
◦ Characterized by a pervasive (persistent) and
excessive need to be taken care of that leads to
submissive (obedient, passive) and clinging behavior
and fears of separation
Dependent Personality Disorder
(cont.)

Definition (cont.)
◦ Relatively common within the population
◦ More common among women than men
◦ More common in the youngest children of a family
than in the oldest ones
Dependent Personality
Disorder (cont.)

Clinical Picture
◦ Client has a notable lack of self-confidence that is
often apparent in
 Posture
 Voice
 mannerism (trait, gesture)
Dependent Personality Disorder
(cont.)

Clinical Picture (cont.)
◦ Typically passive and acquiescent (agreeable) to
desires of others
◦ Assumes passive and submissive roles in
relationships
◦ Avoids positions of responsibility and becomes
anxious when forced into them
Dependent Personality Disorder
(cont.)

Etiological Implications
◦ Possible hereditary influence
◦ A singular attachment is made by the infant to the
exclusion of all others
◦ This exclusive attachment continues as the child
grows, the dependency is nurtured.
Obsessive/Compulsive Personality
Disorders
◦ Definition
 Characterized by inflexibility about the way in
which things must be done
 Devotion to productivity at the exclusion of
personal pleasure
Obsessive/Compulsive Personality
Disorders (cont.)

Definition
◦ Relatively common and occurs more often in men
than women
◦ Within family constellation, appears to be most
common in the oldest children
Obsessive/Compulsive Personality
Disorders (cont.)

Clinical Picture
◦ Especially concerned with matters of organization
and efficiency
◦ Tends to be rigid and unbending
◦ Client polite and formal
◦ Client rank-conscious (ingratiating with authority
figures)
Obsessive-Compulsive Personality
Disorder(cont.)

Clinical Picture (cont.)
◦ Appears to be very calm and controlled
◦ Underneath there is a great deal of
 Ambivalence
 Conflict
 Hostility
Obsessive-Compulsive Personality
Disorder (cont.)

Etiological Implications
◦ Overcontrol by parents
◦ Notable parental lack of positive reinforcement for
acceptable behavior
◦ Frequent punishment for undesirable behavior
Passive-Aggressive Personality
Disorder

Definition
◦ Exhibits a pervasive pattern of negativistic
attitudes and passive resistance
◦ Reacts badly to demands for adequate
performance in social and occupational situations
Passive-Aggressive Personality
Disorder (cont.)

Clinical Picture
◦ Exhibits passive resistance
◦ Exhibits general obstructive response (unhelpful)
◦ Commonly switches among the roles of the
martyr (victim), the affronted (insulted), the
aggrieved (hurted, injured), the misunderstood, the
contrite (ashamed), the guilt-ridden, the sickly, and
the overworked
Passive-Aggressive Personality
Disorder (cont.)

Clinical Picture (cont.)
◦ Able to vent anger and resentment subtly while
gaining the attention, reassurance, and dependency
that are craved
Passive-Aggressive Personality
Disorder (cont.)

Etiological Implications
◦ Contradictory parental attitudes and behavior are
implicated in predisposition to passive-aggressive
personality disorder
◦ Parental responses are inconsistence and
unpredictable, and the children internalize the
conflicting attitudes toward themselves and others
Passive-Aggressive Personality
Disorder (cont.)

Etiological Implications
◦ Children learn to control their anger for fear of
not receiving love or support . They appear polite
and underdemanding
◦ Hostility and insufficiency are manifested only
covertly and indirectly