TCA 9

PERSONALITY DISORDERS
- LIFELONG BEHAVIORS
- DO NOT SEEK TREATMENT UNLESS A SEVERE CRISIS OR TRAUMA PRECIPITATES OTHER SYMPTOMSAND THEY NEED
TO GET HELP
- CODED ON AXIS 2

4 COMMON CHARACTERISTICS
- INFLEXIBLE OR MALADAPTIVE RESPONSE TO STRESS
- DISABILITY IN WORKING OR LOVING
- CAPACITY TO “GET UNDER THE SKIN” OF OTHERS – DIFFICULT TO BE ARROUND, IRRITATIVE
- ABILITY TO EASILY EVOKE INTERPERSONAL CONFLICT

- MANY USE DRUGS AND COMMIT CRIMES SUCH AS MURDER

SECONDARY PREVENTIONS – CANNOT PREVENT, BUT CAN PREVENT FROM GETTING WORSE
- RECOGNIZING THE SYMPTOMS
- DECREASE STRESS
- CRISIS INTERVENTION

PERSONALITY DISORDERS
• CLIENT IS NOT OUT OF TOUCH WITH REALITY AS WITH SCHIZOPHRENIA
• THEY ARE LIFE LONG DISORDERS. THEIR WAY OF LIFE
• DIFFICULT TO TREAT***
• PEOPLE CAN HAVE A SEVERE OR MILD FORM OF A DISORDER
• THEY ARE CODED ON AXIS II**
• MEDICATIONS ARE ONLY USED TO TREAT SYMPTOMS
• THESE PEOPLE ARE NOT OUT OF TOUCH WITH REALITY; THEY ARE AWARE OF THEIR BEHAVIOR
• SEEN IN ALL HEALTHCARE SETTINGS
• NOT ADMITTED TO PSYCH UNIT. THEY ARE NOT TREATED IN AN ACUTE CARE SETTING??
• BORDERLINE OR ACTING OUT BEHAVIOR IS THE REASON THEY ARE ADMITTED TO THE UNIT

PSYCHOTHERAPY
• GROUP THERAPY
O ANTISOCIAL PERSONALITY WOULD INTERFERE WITH GROUP PROCESS
• ANGER MANAGEMENT
• SOCIAL SKILLS TRAINING

IMPAIRED SOCIAL INTERACTION FOR MANIPULATIVE CLIETNS

• SPELL OUT ACCEPTABLE BEHAVIOR
• WRITTEN CONSEQUENCES OF BREAKING RULES
• WRITTEN COPY OF RULES
• BE FIRM
• SET LIMITS AND ENFORCE THEM
• HOLD THEM ACCOUNTABLE WITH CONSEQUENCES THAT ARE MEANINGFUL TO THEM

Cause Of Personality Disorders

• MAY BE GENETIC
• MAY BE A LEARNED BEHAVIOR – MODELING AFTER PARENTS
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• UNHEALTHY INTERPERSONAL RELATIONSHIPS

CLUSTER “A”
BEHAVIORS DESCRIBED AS ODD OR ECCENTRIC (EQUATE WITH A PARANOID SCHIZOPHRENIC)
• GENETICALLY UNHEALTHY INTERPERSONAL RELATIONSHIPS
• PROBABLY HAVE BEEN REJECTED MORE. THEY HAVE BEEN REJECTED BY OTHER PEOPLE, SO THEY DO NOT
TRUST THEM.

PARANOID
• #1 PROJECTION
• SUSPICIOUS AND VERY MISTRUSTFUL
• HYPERSENSITIVE – VERY SENSITIVE
• JEALOUS
O DON’T LIKE IT WHEN GOOD HAPPENS TO SOMEONE ELSE
• TENSE, FIND IT DIFFICULT TO RELAX Cluster A
• NO TRUE SENSE OF HUMOR Personalities have
• CANNOT ESTABLISH WARM, LASTING RELATIONSHIPS problems with
relationships
O CANNOT TRUST
• USUALLY LACK SOFT, SENTIMENTAL FEELINGS
• USE PROJECTION
O BLAME SOMEONE ELSE
O PLACE UNDESIRED FEELINGS YOU HAVE AND PLACE ON SOMEONE ELSE
O EX. PT SAYS “MY FAMILY HATES ME”, PT MEANS “I HATE THEM”
• SUPPORTIVE PSYCHOTHERAPY, GROUP THERAPY, COGNITIVE BEHAVIOR THERAPY MIGHT HELP THIS CIENT.
• IF SEVERE ENOUGH, LOW DOSE ANTIPSYCHOTICS MAY HELP TO STOP THE PARANOID THINKING. THESE CLIENTS
ARE NOT PSYCHOTIC, THEY ARE JUST VERY SUSPICIOUS AND THIS WILL AFFECT THEIR INTERPERSONAL
RELATIONSHIPS.
• THIS WILL AFFECT THEIR DAILY LIVING BY CAUSING SOCIAL PROBLEMS OR PROBLEMS WITH SOCIAL INTERACTIONS
• AS A NURSE, ARE YOU GOING TO BE FRIENDLY AND REASSURING TO THIS CLIENT? NO, THEY WILL THINK THAT
YOU ARE UP TO SOMETHING. THEREFORE, WITH THESE CLIENTS, YOU NEED TO BE NEUTRAL AND “MATTER OF
FACT”. NEED TO EXPLAIN WHAT IS GOING TO BE DONE TO THIS CLIENT. IF THERE IS EVER ANY CHANGE MADE
IN THIS CLIENT’S ROUTINE, THIS NEEDS TO BE EXPLAINED TO THEM.
• IF THIS CLIENT IS IN THE HOSPITAL, YOU WANT TO TEACH THEM ABOUT THE SIDE EFFECTS OF THEIR
MEDICATIONS. THEREFORE, THEY WILL BE PREPARED FOR THEM.
• DO NOT BE OVERLY FRIENDLY WITH THIS CLIENT.

SCHIZOID
• SON OF SAM
O LONER – NO ONE KNEW HIM, NO CLOSE FRIENDS
• PROBABLY HAD A VERY COLD AND NEGLECTFUL EARLY CHILDHOOD RELATIONSHIPS
• DEFECT IN CAPACITY TO FORM SOCIAL RELATIONSHIPS
• ABSENCE OF WARM AND TENDER FEELINGS FOR OTHERS
• INDIFFERENCE TO PRAISE, CRITICISM, AND THE FEELINGS OF OTHERS
O DON’T CARE IF YOU PRAISE OF CRITICIZE THEM
• LONERS AND HAVE FEW FRIENDS, IF ANY, CLOSE FRIENDS
• PURSUE SOLITARY INTEREST OR HOBBIES
• APPEAR “COLD” AND ALOOF
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• APPEAR RESERVED AND WITHDRAWN

• OFTEN UNABLE TO EXPRESS FEELINGS OR HOSTILITY
• EXCESSIVE DAYDREAMING AND FANTASIZING
O AUTISTIC – TRYING TO ESCAPE FROM REALITY (PRE-PSYCHOTIC)
• SELF ABSORBED, ABSENT-MINDED
• THESE PEOPLE ARE VERY HARD TO RESOCIALIZE – THEY MAY NEVER MEET THEIR GOAL OF HAVING
SATISFACTORY INTERPERSONAL RELATIONSHIP
• NOT PSYCHOTIC
O ISOLATED AND STAY WITH SELF, AVOID OTHERS AND DO NOT CARE FOR OTHERS. VERY COLD.
WORK WHERE THEY DO NOT HAVE TO BE WITH OTHERS. WORK AT POSTAL OFFICE AT NIGHT.
• NURSING DIAGNOSIS – IMPAIRED SOCIAL INTERACTION
• BE NEUTRAL WITH THIS CLIENT
• TELL THIS CLIENT WHAT TO EXPECT ON A TASK BY TASK BASIS. TELL THIS PERSON EXACTLY WHAT HE NEEDS
TO DO AND WHAT IS EXPECTED OF HIM

SCHIZOTYPAL
• 25% OF PEOPLE WITH THIS TYPE OF PERSONALITY DISORDER GO ON TO BECOME SCHIZOPHRENIC.
• CLOSE AS BEING PSYCHOTIC AS YOU CAN GET
• CLOSEST OF THE 3 CLUSTER A PESONALITIES TO PARANOID SCHIZOPHRENIA
• ODDITIES OF THOUGHT, PERCEPTION, AND BEHAVIOR SUCH AS IDEAS OF REFERENCE, ILLUSIONS,
DEPERSONALIZATION, AND PECULIAR SPEECH. DO NOT HAVE DELUSIONS OR HALLUCINATIONS
• SOCIAL ISOLATION
• POSSIBLY REJECTED BY PARENTS
• SUSPICIOUS
• MAGICAL THINKING
O MAY THINK YOU HAVE A CERTAIN POWER “STEP ON A CRACK” OR “I HAVE A 6 SENSE”TH

O MAY BE VAGUE OR OVER ELABORATE IN CONVERSATION, CIRCUMSTANTIALITIES

O STILL IN TOUCH WITH REALITY
• LOW DOSE ANTIPSYCHOTICS
• THERE PROBLEM IS GOING TO BE SOCIAL
• NURSING DIAGNOSIS -
• INTERVENTIONS
O ESTABLISH TRUST
O DO WHAT YOU SAY THAT YOU ARE GOING TO DO
O BE VERY “MATTER OF FACT”
O EXPLAIN EVERYTHING
O DON’T BE TOO FRIENDLY

CLUSTER “B”
BEHAVIORS DESCRIBED AS DRAMATIC, EMOTIONAL, OR ERRATIC
• GENETIC LINK IS AN UNHEALTHY INTERPERSONAL RELATIONSHIP

Histrionic
• LIVELY AND DRAMATIC
• PRONE TO EXAGGERATION
• BEHAVIOR OVERLY REACTIVE AND INTENSELY EXPRESSED
O A PERSON WHO WOULD GO TO A CASUAL PARTY WITH A RED DRESS AND 3” HEELS.
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• CRAVE EXCITEMENT AND BECOME BORED WITH NORMAL ROUTINES

• THEY LOVE CRISIS
• SEEN BY OTHERS AS SHALLOW AND LACKING GENUINENESS
• SELF-INDULGENT AND INCONSIDERATE OF OTHERS
• DEMANDING
• DEPENDENT, HELPLESS – WHEN YOU MEET THEM THEY SEEM TO HAVE A WONDERFUL SELF CONCEPT
• THIS CLIENT HAS THE BELIEF THAT IF PEOPLE DON’T PAY ATTENTION TO ME, I AM A NOBODY. THIS IS THEIR
DYSFUNCTIONAL THINKING, SO THEY WANT A LOT OF ATTENTION.
• UNDERSTAND SEDUCTIVE BEHAVIOR AS A RESPONSE TO STRESS
• PRONE TO MANIPULATIVE SUICIDAL THREATS, GESTURES, OR ATTEMPTS (TAKE SERIOUSLY)
O EVERY TIME I SAY I WILL BREAK UP SHE SAYS SHE WILL KILL HERSELF
O AT FIRST YOU THINK THEY ARE INDEPENDENT BUT THEY ARE NOT
O MORE WITH WOMEN
O THEY WANT TO BE CENTER OF ATTENTION
O TAMMY FAYE BAKER
• ND
O INEFFECTIVE INDIVIDUAL COPING
• INTERVENTIONS
O THIS PERSON USES SEDUCTION A LOT. THIS IS THE WAY THAT THEY LEARN TO RESPOND TO STRESS.
THIS IS INAPPROPRIATE THE MAJORITY OF THE TIME. SO THE RELATIONSHIP NEEDS TO REMAIN VERY
PROFESSIONAL.
O ENCOURAGE THIS CLIENT TO USE CONCRETE DESCRIPTIVE LANGUAGE – THIS IS INSTEAD OF THEIR
DRAMATIC EXPRESSION OF EMOTIONS. THESE CLIENTS WILL BECOME VERY EMOTIONAL AND
OVERREACT. THEY NEED TO LEARN TO TELL SOMEONE THAT THEY ARE GETTING UPSET INSTEAD OF
HAVING A DRAMATIC EMOTIONAL BREAKDOWN.
O WILL BENEFIT FROM ASSERTIVENESS. THIS WILL HELP THEM LEARN TO EXPRESS THEIR FEELINGS
APPROPRIATELY, AS OPPOSED TO THE SEDUCTIVE TYPE OF BEHAVIOR.
• IF THIS PERSON IS IN A GROUP THERAPY SITUATION, THE LEADER PROBABLY WILL NEED TO TALK TO THIS CLIENT
ON A ONE TO ONE BASIS BECAUSE THE HISTRIONIC PERSON WILL TEND TO TAKE OVER THE GROUP.

BORDERLINE
• ON BORDER OF BEING PSYCHOTIC
• UNPREDICTABLE IN AREAS THAT ARE POTENTIALLY SELF-DAMAGING
May Be Caused By
O SPENDING -Learned behavior
O GAMBLING
O SEX -See violence
everyday and become
O OVEREATING numb to it.
O SHOPLIFTING, ETC.
-Child who has no
• VERY IMPULSIVE – MOST LIKELY TO COMMIT SUICIDE restraints
• CONSTANTLY WANT TO BE AROUND OTHER PEOPLE
-Inconsistent discipline
O TAKE ON CHARACTERISTICS OF THE PEOPLE THEY ARE AROUND
• PROBLEMS WITH RELATIONSHIPS
O PATTERN OF UNSTABLE AND INTENSE INTERPERSONAL RELATIONSHIPS
O LOVE ONE DAY AND HATE THE NEXT DAY
• CONSTANT ANGER AND FREQUENT DISPLAYS OF TEMPER
• IDENTITY DISTURBANCE
• MARKED SHIFTS IN MOOD - LABILE
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• DEPRESSED WHEN ALONE

• CHRONIC FEELINGS OF EMPTINESS AND BOREDOM
• PHYSICALLY SELF-DAMAGING ACTS
• HAVE A PROBLEM CONTROLLING ANGER
• VERY MANIPULATIVE
• LOVE TO HATE
• SEES SOMEONE AS ALL GOOD OR ALL BAD (NO MIDDLE GROUND) – “SPLITTING”
• THESE PEOPLE HAVE VERY STORMY INTERPERSONAL RELATIONSHIPS
• “FATAL ATTRACTION” IS AN EXAMPLE OF BORDERLINE
• THESE CLIENTS ARE THEIR OWN WORST ENEMY – THEY NEED TO LEARN TO COPE A LITTLE BETTER, THEY HAVE
VERY POOR COPING SKILLS.
• THE CAUSE OF THEIR BEHAVIOR IS PROBABLY ABUSE IN CHILDHOOD
• ONE OF THE REASONS THAT THEY CALL THIS PATIENT BORDERLINE IS THAT THEY ARE ALMOST PSYCHOTIC, BUT
NOT QUITE
• MEDICATIONS
O SSRI’S
O TEGRETOL OR LOW DOSE ANTIPSYCHOTICS
• NURSING DIAGNOSIS – IMPAIRED SOCIAL INTERACTION, RISK FOR OTHER OR SELF DIRECTED VIOLENCE,
INEFFECTIVE COPING
• BORDERLINES OFTEN SELF MUTILATE JUST TO GET ATTENTION. THEY WILL ATTEMPT SUICIDE JUST TO GET
ATTENTION. THEY ARE DOING THIS TO MANIPULATE OTHER PEOPLE.
• SELF MUTILATION IS ALSO A WAY OF EXPRESSING THEIR FEELINGS
• THEY HAVE TROUBLE WITH ANGER BECAUSE THEY CANNOT EXPRESS IT APPROPRIATELY
• IMPULSIVE BEHAVIOR INTERVENTIONS
O IDENTIFY WHAT THEIR NEEDS OR FEELINGS ARE BEFORE SOMETHING HAPPENS
O DISCUSS WHAT CURRENT/PREVIOUS IMPULSIVE ACTS (SELF MUTILATION)
O EXPLORE IMPACT ON SELF AND OTHERS (WILL THIS REALLY HURT YOUR BOYFRIEND?)
O RECOGNIZE CUES TO IMPULSIVE BEHAVIORS
O DISCUSS ALTERNATIVES TO IMPULSIVE BEHAVIORS
O ROLE PLAY NEW SKILLS AND PROVIDE FEEDBACK
O IDENTIFY STRENGTHS AND EFFECTIVE COMMUNICATION
• BORDERLINE PERSONALITY DISORDERS INTERVENTIONS (SPECIFIC)
O SET CLEAR, REALISTIC GOALS
O BE AWARE OF MANIPULATIVE BEHAVIOR
O SET CLEAR CONSISTENT BOUNDARIES AND LIMITS
O BEHAVIOR PROBLEMS, REIVEW THERAPEUTIC GOALS AND TREATMENT BOUNDARIES
O AVOID REJECTING OR RESCUING
O ASSESS FOR SUICIDAL, SELF MUTILATING BEHAVIOR

NARCISSISTIC
• LOVE OF SELF
• IN CHILDREN IT IS OK
• GRANDIOSE SENSE OF OWN IMPORTANCE
• PREOCCUPIED WITH FANTASIES OF UNLIMITED SUCCESS
• REQUIRES CONSTANT ATTENTION AND ADMIRATION
• LACK OF EMPATHY
• INTENSE ENVY OF OTHERS
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• GETS JEALOUS IF SOMETHING GOOD HAPPENS TO SOMEONE ELSE

• MORE OFTEN THIS CLIENT IS MALE
• VERY SELF CENTERED
• USES PEOPLE AS OBJECTS
• NURSING DIAGNOSIS – IMPAIRED SOCIAL INTERACTION
• INTERVENTIONS
O STAY NEUTRAL
O AVOID POWER STRUGGLES
O THESE CLIENTS ARE GOING TO INSULT YOU – DON’T BE DEFENSIVE WHEN INSULTED BY THEM
O CONVEY UNASSUMING SELF CONFIDENCE – DON’T LET THEM SEE THAT YOU DON’T HAVE SELF
CONFIDENCE
ANTISOCIAL
• WEAK SUPEREGO - HAVE NO CONSCIOUS***
• HARDEST ONE TO DEAL WITH
• THESE CLIENTS EITHER HAD A VERY ABUSIVE CHILDHOOD OR THEIR PARENTS DID NOT DISCIPLINE THEM AT ALL.
THESE ADULTS DO NOT HAVE A CONSCIOUS. CONDUCT DISORDER IS A PRECURSOR OF THIS, IF THEY DO NOT
GET HELP EARLY IT MIGHT DEVELOP INTO THIS.
• THESE PEOPLE, MOST OF THE TIME ARE TREATED BY THE LAW BECAUSE THEY COMMIT CRIMES. THESE CAN BE
MASS MURDERERS OR SERIAL KILLERS.
• DOES NOT FEEL BAD IF THEY DO SOMETHING WRONG
• VIEW PEOPLE AS OBJECTS – THEY USE PEOPLE JUST TO MEET THEIR NEEDS. THIS IS THE ONLY VALUE THAT
PEOPLE HAVE FOR THEM.
• WHAT CAN YOU DO FOR ME. FEELS NO GUILT
• NO CAPACITY FOR FORMING CLOSE RELATIONSHIPS
• SELF-CENTERED AND SELFISH
• INSENSITIVE TO FEELINGS OF OTHERS
• LACK OF GUILT AND SHAME
• UNABLE TO TOLERATE FRUSTRATION OF HIS WISHES
• DOES NOT ASSUME RESPONSIBILITY FOR BEHAVIOR
• DOES NOT LEARN FROM EXPERIENCE
• GET UPSET IF THINGS DON’T GO THEIR WAY
• SUPERFICIAL CHARM AND GOOD INTELLIGENCE
O VERY IMPRESSED WHEN YOU FIRST MEET THEM
• NO CAPACITY FOR LOVE
• LACK OF INSIGHT
• PUNISHMENT DOES NOT ALTER BEHAVIOR
• DEMANDING AND UNGRATEFUL
• LIVE FOR PLEASURE AND GRATIFICATION
• OFTEN UNFAITHFUL IN MARRIAGE AND DIVORCE IS COMMON
• LIE, CHEAT, AND STEAL
• MANIPULATIVE
• NOTHING IS HIS FAULT
• CRIMINALS THAT ARE ANTISOCIAL SHOULD NOT BE PAROLED
O BECAUSE THEY DON’T FEEL GUILTY ABOUT WHAT THEY HAVE DONE. WILL NOT BE
REHABILITATED.
• NOT ALL ANTISOCIAL ARE CRIMINALS
O VERY SUCCESSFUL BUSINESSMEN – JR EWING
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• THE ANTISOCIAL DOES DECREASE WITH AGE. SAY LIKE AT 50 YEARS OLD, THE PERSON MAY BE LESS
ANTISOCIAL. THIS MAY OR MAY NOT HAPPEN.
• MEDICAL PLAN OF CARE FOR THE ANTISOCIAL
O LITHIUM
O ANTICONVULSANTS – USED AS MOOD STABILIZERS
O SSRI’S
• THESE CLIENTS YOU WILL SEE IN THE HOSPITAL WITH AN AXIS I DIAGNOSIS. UNDER AXIS II, YOU WILL SEE
ANTISOCIAL PERSONALITY DISORDER. THEY MAY HAVE SCHIZOPHRENIA UNDER THEIR AXIS I DIAGNOSIS AND
ANTISOCIAL PERSONALITY UNDER AXIS II. IN THEIR HISTORY SOMEWHERE, YOU WILL SEE THAT THEY HAVE
KILLED SOMEBODY.
• IN THE HOSPITAL, THE STAFF HAS TO BE VERY UNITED IN THEIR TREATMENT PLAN (ABOUT SETTING LIMITS).
THESE CLIENTS ARE VERY MANIPULATIVE AND THEY GET THEIR WAY BEFORE YOU REALIZE IT. AS A NURSE, YOU
HAVE TO BE VERY AWARE OF WHEN YOU ARE BEING MANIPULATED. BEHAVIOR TYPE OF THERAPY MIGHT BE
USED FOR THAT. THERE WILL BE LIMIT SETTING. YOU NEED TO BE CLEAR. THEY NEED TO RECEIVE A SET OF
THE RULES. THEY NEED TO KNOW WHAT IS EXPECTED. NEED TO BE CONSISTENT AND ENFORCABLE. THE
STAFF NEEDS TO WORK AS A TEAM WITH THIS CLIENT. CLEAR CONSEQUENCES MUST BE KNOWN AND ENFORCED
FOR EXCEEDING THE LIMITS GIVEN. THESE PEOPLE RESPOND TO BEING GIVEN EXTRA CIGARETTE TIME. THEY
DO NOT RESPOND TO VERBAL PRAISE. GIVE THEM A REWARD THAT THEY WILL TRULY APPRECIATE. DO NOT
ACT AS IF YOU ARE PUNISHING THEM, BE VERY “MATTER OF FACT”. EXAMPLE – “YOU WERE AGGRESSIVE TO
MR. JONES THIS MORNING, SO YOU WILL NOT GET YOUR EXTRA CIGARETTED TODAY.” DO NOT GET INTO A
POWER STRUGGLE WITH THIS CLIENT.
• THESE PEOPLE HAVE WONDERFUL SOCIAL SKILLS AND INTERACT WELL. WHAT THEY WILL DO IS CALLED
“SPLITTING STAFF”. THE ANTISOCIAL AND THE BORDERLINE PATIENT WILL SPLIT STAFF. IN OTHER WORDS
THEY ARE VERY COMPLIMENTARY TO ONE NURSE AND THEY GET HER ON THEIR SIDE AND THEN THIS NURSE WILL
NOT ENFORCE THE LIMITS. THE OTHER PART OF THE TEAM IS TRYING TO SET LIMITS AND THEY END UP JUST
WORKING AGAINST EACH OTHER. BE AWARE OF THIS AS A MEANS OF TRYING TO GET THEIR WAY.
• NURSING DIAGNOSIS – INEFFECTIVE INDIVIDUAL COPING, IMPAIRED SOCIAL INTERACTION AND RISK FOR
VIOLENCE
• INTERVENTIONS
O LIMIT SET – BY ALL OF THE STAFF
O DOCUMENT AND CHART EXACTLY WHAT THEY HAVE SAID TO YOU OR EXACTLY WHAT THEY DID TO
ANOTHER CLIENT.
O ESTABLISH CLEAR BOUNDARIES AND CONSEQUENCES
O DON’T LET THE CLIENT MAKE YOU FEEL GUILTY – THIS IS BEING MANIPULATED

CLUSTER C
BEHAVIOR DESCRIBED AS ANXIOUS OR FEARFUL
• HAVE A CAUSE OF PARENTAL REJECTION AND CRITISIZISM
• NO PARENTAL DISCIPLINE AT ALL
• EITHER BEEN REJECTED EARLY IN LIFE AND HAVE NOT HAD VERY GOOD OR SATISFACTORY INTERPERSONAL
RELATIONSHIPS
• THERE IS ALSO A GENETIC LINK

AVOIDANT
• SHY, INTROVERTED, LACKS SELF-CONFIDENCE, AND IS EXTREMELY SENSITIVE TO REJECTION
• TEND TO AVOID RELATIONSHIPS WITH OTHERS
• AVOIDS SOCIAL SITUATIONS
• THERE MAIN PROBLEM IS SOCIAL

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• IF THEY CHOOSE TO GET THERAPY, THEY COULD POSSIBLY USE SUPPORTIVE PSYCHOTHERAPY OR SOME TYPE OF
COGNITIVE BEHAVIOR THERAPY (WHICH MIGHT BE SOCIAL SKILLS TRAINING AND ASSERTIVENESS TRAINING)
• THESE CLIENTS WILL AVOID A SITUATION RATHER THAN ASK TO GET THEIR NEEDS MET.
• MEDICATIONS – MAINLY ANTIDEPRESSANTS (SSRI’S OR MAOI’S) OR ANTIANXIETY MEDICATIONS.
• THE MAIN NURSING DIAGNOSIS WOULD BE IMPAIRED SOCIAL INTERACTION
• AS A NURSE, HAVE A FRIENDLY REASSURING APPROACH TO THIS CLIENT SO THEY WILL FEEL COMFORTABLE WITH
YOU.
• IF YOU PUSH THIS CLIENT INTO A SOCIAL SITUATION, THIS CAN CAUSE ANXIETY, THEREFORE THEY MIGHT ALSO
NEED ANXIETY MEDICATION ALSO LIKE ATIVAN.

DEPENDENT
• CLINGING VINE
• HELPLESS
• A LOT OF SECONDARY GAIN
• LACKS SELF-CONFIDENCE, ALLOWS OTHER TO ASSUME RESPONSIBILITY FOR MAJOR AREAS OF HIS OR
HER LIFE.
• CANNOT FUNCTION INDEPENDENTLY, AND BELITTLES SELF
O EX. A WOMAN WHO LETS HUSBAND DECIDE IF SHE CAN WORK, WHAT THEY WILL WEAR, CAN
SHE DRIVE.
O A LOT OF SECONDARY GAIN
• NURSING DIAGNOSIS – INEFFECTIVE INDIVIDUAL COPING. THIS PERSON HAS NEVER REALLY BEEN
RESPONSIBLE OR TAKEN CHARGE OF A SITUATION. THEY ARE ALWAYS LETTING SOMEONE ELSE DO IT.
• IF THIS PERSON IS IN THE HOSPITAL OR IF YOU ARE WORKING WITH THEM ON AN OUTPATIENT BASIS, DO NOT BE
A RESCUER AND DO EVERYTHING FOR THIS CLIENT. THIS CLIENT WILL CERTAINLY LET YOU DO EVERYTHING FOR
THEM. THIS DOES NOT HELP THE CLIENT AT ALL. SO WITH THIS CLIENT, YOU MAY NEED TO:
O SET SOME LIMITS – “I WILL BE HAPPY TO HELP YOU WITH THIS, BUT I CANNOT DO IT FOR YOU.”
• THIS PERSON WILL ABOVE ALL BENEFIT FROM ASSERTIVENESS TRAINING.

OBSESSIVE – COMPULSIVE
• JUST PERSONALITY
• EXCESSIVE DEVOTION TO WORK, PERFECTIONIST, RESTRICTED ABILITY TO EXPRESS WARM, TENDER
EMOTIONS, INDECISIVE, PRONE TO SELF-DOUBT, MORE AT EASE WITH THINGS THAN PEOPLE.
• LOVE TO WORK
• CANNOT MAKE DECISIONS BECAUSE THEY ARE A PERFECTIONIST, THEY WANT TO MAKE A PERFECT
DECISION
• CHILDREN OFTEN WILL DEVELOP THIS VERY CONTROLLED, CONFLICTED BEHAVIOR TO AVOID PARENTS BEING
CRITICAL. THEY FEEL THAT IF THEY ACT PERFECTLY, THEN THEIR PARENTS WON’T HAVE ANY REASON TO
CRITISIZE, SHAME THEM OR DISCIPLINE THEM. THIS MIGHT BE HOW THIS CHARACTERISTIC DEVELOPS.
• MEDICAL PLAN OF CARE
O ANAFRANIL IF THEY NEED IT
• NURSING DIAGNOSIS – INEFFECTIVE INDIVIDUAL COPING
• DO NOT WANT TO GET INTO A POWER STRUGGLE WITH THESE CLIENTS. BECAUSE THEY NEED TO BE IN
CONTROL. THESE ARE LIFELONG BEHAVIORS. IF THEY CAN BE INCONTROL OF A SITUATION, THEN THEY DO NOT
GET ANXIOUS.

PASSIVE AGGRESSIVE
(NOT INCLUDED IN DSM –IV) AS A PERSONALITY DISORDER
• RESISTANT TO DEMANDS FOR ADEQUATE PERFORMANCE, PROCRASTINATE, STUBBORN
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• INTENTIONAL INEFFICIENCY
O WELL, I’LL DO IT BUT IT WONT BE ANY GOOD
• “FORGETFULNESS”
• INEFFECTIVE BOTH SOCIALLY AND OCCUPATIONALLY
• DEPENDENT, LACK OF SELF-CONFIDENCE
• PESSIMISTIC
O ALWAYS NEGATIVE
O THEY TEND TO PULL YOU DOWN TO FEEL LIKE THEM
• RESENTMENT OF AUTHORITY FIGURES
• SELF-DEFEATING BEHAVIOR
O NO ONE GAINS FROM THIS TYPE OF BEHAVIOR, CAUSES SOCIAL AND JOB PROBLEMS

PERSONALITY DISORDER, NOT OTHERWISE SPECIFIED

• MEETS GENERAL CRITERIA BUT DOES NOT MEET SPECIFIC CRITERIA OF ANY OF THE SUBTYPES

Treatment For Personality Disorders

• NOT EASY TO TREAT
• LIFELONG DISORDER “THIS IS THE WAY I AM”
• EARLY TREATMENT IS NECESSARY
• MOST OF THE TIME THESE PEOPLE DON’T THINK ANYTHING IS WRONG WITH THEM.
• 2 TYPES SEEN ON WARDS MOST OFTEN BORDERLINE AND ANTISOCIAL
• ANTISOCIAL
O NO GUILT OR SHAME, NOT UPSET ABOUT BEHAVIOR THEY CANNOT RELATE TO THERAPIST
O “NO PROBLEM HERE” WON’T STAY IN THERAPY

Therapy
• INDIVIDUAL PSYCHOTHERAPY
• GROUP THERAPY
O IF ANTISOCIAL THEY WILL CONTROL THE GROUP AND COMPLETELY DESTROY THE GROUP
PROCESS
• PSYCHOANALYTIC
O VERY EXPENSIVE
• BEHAVIOR THERAPY
O REWARDS FOR APPROPRIATE BEHAVIOR
O IMPOSING CONSEQUENCES FOR INAPPROPRIATE BEHAVIOR
• ASSERTIVENESS TRAINING
O USED FOR DEPENDENT INDIVIDUAL
• SOCIAL SKILLS TRAINING
O ALL OF THEM (HOW TO RELATE TO OTHERS)
• ANGER MANAGEMENT
O FOR BORDERLINE
• DRUGS MAY BE USED
O WILL ONLY BE USED TO TREAT THE SYMPTOMS
 SCHIZOTYPAL, MAY HAVE ILLUSIONS OR IDEAS OF REFERENCE; THEY MAY BE ON A
DOSE OF ANTIPSYCHOTIC
 BORDERLINE MIGHT HAVE TO HAVE A MOOD STABILIZER
 DEPRESSED MAY HAVE AN ANTIDEPRESSANT
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Cluster A And Dependent Group Therapy For Problems With Relationships

Nursing Diagnosis
• DISTURBANCE IN SELF-ESTEEM

• IMPAIRED SOCIAL INTERACTIONS

O THIS DIAGNOSIS APPLIES TO DISORDERS THAT CAN MANIPULATE
O THINGS YOU MUST DO:
 RECOGNIZE YOU ARE BEING MANIPULATED
 WHEN THE PATIENT COMES TO THE UNIT YOU NEED TO TELL THEM WHAT IS
ACCEPTABLE AND WHAT IS NOT ACCEPTABLE.
 GIVE THEM A WRITTEN COPY OF THE RULES AND GO OVER WITH THEM WHEN 1 ST

ADMITTED
 TELL THEM WHAT THE CONSEQUENCES WILL BE WHEN THEY BREAK THE RULES
 YOU MUST ENFORCE THE RULES
 MUST BE CONSISTENT BY ALL NURSES INVOLVED
O IF CLIENT SAYS “I’M SORRY I DID NOT KNOW I COULDN’T SMOKE IN THE ROOM” YOU WOULD
SAY, “I GAVE YOU A LIST OF THE RULES, YOU KNOW SMOKING IN THE ROOMS IS NOT
ALLOWED, YOU WILL BE RESTRICTED TO THE UNIT FOR THE WEEKEND” – YOU HAVE TO DO
THAT – EVERYONE HAS TO BE CONSISTENT
O ANTISOCIAL TRIES TO MANIPULATE
O THE PATIENT MUST BE HELD RESPONSIBLE FOR BEHAVIOR
O TALK WITH OTHER STAFF MEMBERS RE: BEHAVIOR “SPLITS STAFF” GROUP MEETINGS IMPORTANT
“ MR JONES SAID THIS TO ME”, “OH HE SAID THAT TO YOU ALSO”
O “BRING ME CANDY” NO I CAN’T DO THAT IT IS AGAINST THE RULES
• R/F INJURY OR VIOLENCE TO SELF OR OTHERS
O HISTRIONIC OR BORDERLINE

WITH ANTISOCIAL REWARD AND APPROPRIATE CONSEQUENCES FOR BREAKING THE RULES

REWARDS
• NEED TO BE CONCRETE NOT EMOTIONAL NEVER “I AM DISAPPOINTED IN YOU”, “I AM PROUD OF YOU”,
THEY JUST DO NOT CARE
• YOU CAN STAY OUT AN HOUR LATER ON THE GROUND TODAY. BUT MAKE SURE IT IS SOMETHING YOU
CAN FOLLOW THROUGH ON.
• WEEKEND PASS
• SOMETHING THAT MEANS SOMETHING TO THEM

CONSEQUENCES – TAKE AWAY PRIVILEGES

CLUSTER A INTERVENTIONS
- AWARE OF ISOLATION, SUSPICIOUSNESS
- AVOID BEING “TOO NICE”, OVERLY FRIENDLY
- USE NEUTRAL, KIND APPROACH
- CLEAR, STRAIGHTFORWARD EXPLANATIONS
- SIMPLE, CLEAR LANGUAGE
- GIVE WARNING ABOUT CHANGES, REASONS FOR DELAY

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ANTISOCIAL MEDS – LITHIUM, ANTIDEPRESSANTS, SSRI’S

NARCISSISTIC
- STAY NEUTRAL, AVOID POWER STRUGGLES
- DON’T BE DEFENSIVE WHEN DISPARAGED
- CONVEY UNASSUMING SELF-CONFIDENCE

BORDERLINE MEDS – SSRI, TEGRETOL, LOW DOSE ANTIPSYCHOTICS

- ID NEEDS AND FEELINGS
- DISCUSS CURRENT/PREVIOUS IMPULSIVE ACTS
- EXPLORE IMPACT ON SELF TO OTHERS
- RECOGNIZE CUES TO IMPULSIVE BEHAVIOR
- REFER OR TEACH NEEDED COPING SKILLS

AVOIDANT MEDS – ANTIANXIETY, SSRI’S, MAOI

DEPENDENT – NO MEDS
- ASSERTIVENESS TRAINING
- INEFFECTIVE INDIVIDUAL COPING

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1- WHAT ARE THE PERSONALITY DISORDERS?

• PARANOID PD, SCHIZOTYPAL PD, ANTISOCIAL PD, BORDERLINE PD, NARCISSISTIC PD
• HISTRIONIC PD, DEPENDENT PD, OCD PD, AVOIDANT PD

2- WHAT AXIS ARE THEY CODED ON?

• AXIS II

3- WHAT ARE THE 3 CLUSTERS OF PERSONALITY DISORDERS?

• ODD OR ECCENTRIC WHICH ARE PARANOID, SCHIZOID, AND SCHIZOTYPAL
• DRAMATIC, EMOTIONAL, ERRATIC
• ANXIOUS OR FEARFUL

4- DESCRIBE BEHAVIORS CHARACTERISTIC OF CLUSTER A DISORDERS?

• ODD AND ECCENTRIC

5- WHAT 3 DISORDERS ARE INCLUDED IN CLUSTER A

• PARANOID, SCHIZOID, SCHIZOTYPAL

6- DESCRIBE 2 GENERAL CAUSES OF THE DISORDERS IN CLUSTER A

• FAMILY HISTORY
• HARM, BETRAYAL, ISOLATION

7- DESCRIBE CHARACTERISTICS OF THE PARANOID PERSONALITY DISORDER

• BEARS GRUDGES, DISTRUSTFUL, AND SUSPICIOUSNESS
• RELUCTANT TO CONFIDE IN OTHERS. SUSPICIOUS AND DISTRUSTING
• ARGUMENTATIVE, HOSTILE ALOOFNESS, RIGID, CRITICAL, AND CONTROLLING OF OTHERS, GRANDIOSITY.

8- DESCRIBE CHARACTERISTICS OF THE SCHIZOID PERSONALITY

• FLAT AFFECT, DETACHED FROM SOCIAL RELATIONSHIPS, AND A RESTRICTED RANGE OF EXPRESSIONS IN
INTERPERSONAL SETTINGS.
• SOCIAL DETACHMENT AND LACK OF CLOSE RELATIONSHIPS. INTEREST IN SOLITARY ACTIVITIES, ALOOF AND
INDIFFERENT, RESTRICTED EXPRESSION OF EMOTIONS, LACK OF INTEREST IN OTHERS

9- DESCRIBE CHARACTERISTICS OF THE SCHIZOTYPAL PERSONALITY

• SOCIAL AND INTERPERSONAL DEFICITS MARKED BY ACUTE DISCOMFORT WITH AND REDUCED CAPACITY
FOR RELATIONSHIPS AS WELL AS BY COGNITIVE OR PERCEPTUAL DISTORTIONS AND ECCENTRICITIES OF
BEHAVIOR.
• EXHIBITS ABNORMAL OR HIGHLY UNUSUAL THOUGHTS, PERCEPTIONS, SPEECH, AND BEHAVIOR PATTERNS.
• SUSPICIOUS, PARANOID, MAGICAL THINKING, ODD THINKING AND SPEECH, RELATIONSHIP DEFICITS.

10-DESCRIBE BEHAVIORS IN CLUSTER B

• THEY OFTEN APPEAR DRAMATIC, EMOTIONAL, OR ERRATIC

11-DESCRIBE CHARACTERISTICS OF THE HISTRIONIC PERSONALITY

• A PERVASIVE PATTERN OF EXCESSIVE EMOTIONALITY AND ATTENTION SEEKING, BEGINNING IN EARLY
ADULTHOOD AND PRESENT IN A VARIETY OF CONTEXTS. ATTENTION SEEKING, NEEDS TO BE THE CENTER
OF ATTENTION
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• SEXUALLY SEDUCTIVE OR PROVOCATIVE, SELF-DRAMATIZING AND THEATRICAL, OVERLY CONCERNED WITH

APPEARANCE, HAS ROMANTIC FANTASIES AND CONTROLS PARTNERS, BORES EASILY, DISPLAYS
DEPENDENCY.

12-DESCRIBE THE CHARACTERISTICS OF THE NARCISSISTIC PERSONALITY

• A PERVASIVE PATTERN OF GRANDIOSITY (IN FANTASY AND BEHAVIOR), NEED FOR ADMIRATION AND LACK
OF EMPATHY.
• BEGINNING IN EARLY ADULTHOOD AND PRESENT IN A VARIETY OF CONTEXTS
• GRANDIOSITY, REQUIRES ADMIRATION AND INFLATED ACCOMPLISHMENTS, OVERESTIMATES ABILITIES AND
UNDERESTIMATES CONTRIBUTIONS OF OTHERS, LACKS EMPATHY AND SENSITIVITY TO NEEDS OF OTHERS.

13-DESCRIBE THE CHARACTERISTICS OF THE ANTISOCIAL PERSONALITY

• A PERVASIVE PATTERN OF DISREGARD FOR AND VIOLATION OF THE RIGHTS OF OTHERS OCCURRING
SINCE AGE 15.
• A PATTERN OF IRRESPONSIBLE AND ANTISOCIAL BEHAVIOR, CHARACTERIZED BY SELFISHNESS, INABILITY TO
MAINTAIN LASTING RELATIONSHIPS, POOR SEXUAL ADJUSTMENT, FAILURE TO ACCEPT SOCIAL NORMAL,
IRRITABILITY AND AGGRESSIVENESS.
• PERCEIVES THE WORLD AS HOSTILE, SUPERFICIAL CHARM AND HOSTILITY, NO SHAME OR GUILT, SELF
CENTERED, UNRELIABLE, EASILY BORED, POOR WORK HISTORY, UNABLE TO TOLERATE FRUSTRATION
• VIEWS OTHERS AS OBJECTS TO BE MANIPULATED, POOR JUDGMENT, IMPULSIVE.

14-WHAT IS CONSIDERED THE PROBABLE CAUSE OF THIS DISORDER?

• GENETIC AND ENVIRONMENTAL FACTORS CONTRIBUTE TO THE RISK OF DEVELOPING AS PD

15-DESCRIBE THE CHARACTERISTICS OF THE BORDERLINE PERSONALITY

• A PERVASIVE PATTERN OF INSTABILITY OF INTERPERSONAL RELATIONSHIPS, SELF IMAGE, AND AFFECTS
AND MARKED IMPASSIVITY BEGINNING IN EARLY ADULTHOOD AND PRESENT IN A VARIETY OF CONTEXTS.
• UNCLEAR IDENTITY, UNSTABLE AND INTENSE, EXTREME SHIFTS IN MOOD, EASILY ANGERED, EASILY
BORED, ARGUMENTATIVE, DEPRESSION, SELF-DESTRUCTIVE BEHAVIOR, MANIPULATIONS, UNABLE TO
TOLERATE ANXIETY, CHRONIC FEELINGS OF EMPTINESS AND FEAR OF BEING ALONE. SPLITTING

16-DESCRIBE BEHAVIOR OF CLUSTER C DISORDERS

• ANXIOUS AND FEARFUL

17-DESCRIBE CHARACTERISTICS OF THE AVOIDANCE PERSONALITY

• SHYNESS AND AVOIDANCE OF CONFLICT, RISK AND NEW SITUATIONS, LITTLE TOLERANCE FOR GROUP
PROCESS.
• CHARACTERIZED BY SOCIAL WITHDRAWAL AND EXTREME SENSITIVITY TO POTENTIAL REJECTION. FEELINGS
OF INADEQUACY, HYPERSENSITIVE TO REACTIONS OF OTHERS AND REACTS POORLY TO CRITICISM,
SOCIAL INHIBITION, LACK OF SUPPORT SYSTEM.

18-DESCRIBE THE DEPENDENT PERSONALITY

• SELF-SACRIFICE OR TOLERATION OF PHYSICAL, SEXUAL OR EMOTIONAL ABUSE.
• THE INDIVIDUAL LACKS SELF CONFIDENCE AND THE ABILITY TO FUNCTION INDEPENDENTLY
• PASSIVELY ALLOWS OTHERS TO MAKE DECISIONS AND ASSUME RESPONSIBILITY FOR MAJOR AREAS IN
THEIR LIFE.
• DIFFICULTY MAKING DECISIONS, LACKS AUTONOMY, CANNOT TOLERATE BEING ALONE AND MUST ALWAYS
HAVE A CLOSE RELATIONSHIP, NEEDS OTHERS TO ASSUME RESPONSIBILITY AND MAKE DECISIONS.
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19-WHAT ARE THE POSSIBLE CAUSES OF THIS DISORDER?

• THIS DISORDER COMMONLY OCCURS IN INDIVIDUALS WHO HAVE A GENERAL MEDICAL CONDITION OR A
DISABILITY THAT REQUIRES THEM TO BE DEPENDENT ON OTHERS
• LONG-TERM INABILITY TO CARE INDEPENDENTLY FOR THE SELF ERODES CONFIDENCE, AUTONOMY, AND
PERSONAL INTEGRITY.

20-DESCRIBE THE OBSESSIVE COMPULSIVE PERSONALITY TYPE

• PREOCCUPATION WITH ORDERLINESS, PERFECTIONISM, AND MENTAL AND INTERPERSONAL CONTROL, AT
THE EXPENSE OF FLEXIBILITY, OPENNESS, AND EFFICIENCY, BEGINNING BY EARLY ADULTHOOD.
• THIS CLIENT HAS DIFFICULTY EXPRESSING WARM AND TENDER EMOTIONS AND REFLECTS PERFECTIONISM,
STUBBORNNESS, THE NEED TO CONTROL OTHERS, AND A DEVOTION TO WORK. ORDERLINESS AND
PERFECTIONISM, OVERLY CONSCIENTIOUS, INFLEXIBLE AND PREOCCUPIED WITH DETAILS AND RULES,
DEVOTED TO WORK AND LACKS LEISURE ACTIVITIES AND FRIENDSHIPS, MISERLY AND STUBBORN, HOARDS
WORTHLESS OBJECTS.

21-DESCRIBE CHARACTERISTICS OF PASSIVE AGGRESSIVE PD

• INDIRECT EXPRESSION OF ANGER. BEHAVIOR MAY SEEM PASSIVE BUT IS MOTIVATED BY UNCONSCIOUS
ANGER, OFTEN TRIGGERING ANGER AND FRUSTRATION IN OTHERS.
• EXAMPLES OF PA BEHAVIOR INCLUDE LATENESS, FORGETTING, “MISTAKES” AND OBTUSENESS.
• CHARACTERIZED BY A PASSIVELY EXPRESSING COVERT AGGRESSION RATHER THAN DEALING WITH IT
DIRECTLY.
• THE BEHAVIOR CAN INTERFERE WITH BOTH SOCIAL AND WORK ACTIVITIES.
• PROCRASTINATION, STUBBORNNESS, INTENTIONAL INEFFICIENCY, FORGETFULNESS, DEPENDENCY

22-WHY ARE CLIENT WITH PERSONALITY DISORDER DIFFICULT TO TREAT

• IT IS OFTEN DIFFICULT TO CREATE A THERAPEUTIC RELATIONSHIP WITH CLIENTS WITH PD

23-DESCRIBE TREATMENT MODALITIES USED FOR CLIENTS WITH PD

• COUNSELING – BASIC LEVEL
• AUTHENTICITY – WORDS MATCH ACTIONS
• TRUSTWORTHINESS
• SETTING LIMITS
• DEALING WITH MANIPULATION
• MILIEU THERAPY
• PSYCHOBIOLOGICAL THERAPY = BASIC LEVEL
• CASE MANAGEMENT – BASIC LEVEL

24-REFER TO THE NURSING DIAGNOSES HANDOUT AND DEVELOP A PLAN OF CARE FOR CLIENTS WHO
HAVE PD.
• DISTURBANCE IN SELF ESTEEM R/T UNMET DEPENDENCY NEEDS

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