PD in Wizard of Ox

Cluster A
Personality Disorders
Axis II

Patricia E. Freed
Psychiatric Mental Health Nursing

Personality Personality Traits

5 Dimensions
• The essence of a person’s character
• Neuroticism
• Introversion vs extroversion
• “What he/she is really like” • Closedness vs openeness
• Antagonism vs agreeableness
• Conscientiousness

Personality Disorders Personality Disorders

• Specific behavioral patterns • Inflexible and maladaptive traits
– DSM IV-TR “enduring patterns of perceiving, – Difficulties in:
relating to, and thinking about the • relating to
environment and oneself” • working with
• loving others
• Emerge early in life

• Develop over time • Impairment in functioning

• Manifested in a broad range of experiences • Self-focused and self-serving behaviors

1
 Personality Disorders (cont.) Personality Disorders (cont.)
• Troubling to others / society • See change as unnecessary
• Ego syntonic
• Manifest during adolescence or early
– Behavior so long-standing it feels comfortable
to the person adulthood and persist throughout life

– Not viewed as a problem by the person with – Rarely make a diagnosis prior to age 18
the disorder

– Believes that he/she is right and the world is

wrong

Predisposing Factors Coping Mechanisms

Manipulation Acting Out
• Genetic / familial factors
– Higher incidence in first degree relatives Cycle: Unmet needs leads to ‘Acting out‘ means acting out
Frustration which one’s inner desires and
• Neurotransmitters
– Decreased serotonin level in suicidal behavior Increases Anxiety urges. We thus cope with
– Increase dopamine level in aggressive/violent behavior the pressure to do what we
The Needs of the Other
• Psychodynamic Disregarded as a believe is wrong by giving in
– Fixation at psychosexual development stages to the desire.
Manipulation is Attempted.
• Object Relations • Sublimation is the opposite
– Individuation/separation obstruction of acting out.
If Successful, anxiety is
• Psychosocial/Environment decreased and • Developmental Example –
– Poor parental /child bonding Temper Tantrums
– Environment factors (e.g. poverty, stressors) manipulation is reinforced.
– Deviant behaviors learned from others in the environment

DSM IV-TR Categories of Cluster A

Personality Disorders
• Behaviors described as odd or eccentric
• Personality disorders are categorized
into three clusters – Paranoid personality disorder

– Schizoid personality disorder

– Schizotypal personality disorder

2
 Cluster B Cluster C
• Behaviors described as dramatic, • Behaviors described as anxious or fearful
emotional, or erratic
– Avoidant personality disorder
– Antisocial personality disorder
– Dependent personality disorder
– Borderline personality disorder
– Obsessive-compulsive personality disorder
– Histrionic personality disorder

– Narcissistic personality disorder

Paranoid Personality
Personality
Disorders • More common in men

DSM IV TR • Pervasive distrust / suspiciousness of others

11 PD’s
• Guarded / hypervigilent

• Testing the honesty of others

Paranoid Personality (cont.) Example: Paranoid Personality

• Insensitive to feelings of others • Mr. C., comes into the emergency department
with chest pains. He refuses to give
background information “because the
• Hypersensitive to criticism information could be used against me.” He is
haughty and demeaning to the nurse saying,
“Get someone in here who knows something.”
• Tend to misinterpret events in the When the nurse turns her back to Mr. C. to talk
environment to the doctor, Mr. C. shouts, “What lies is she
telling you about me?”

3
 Schizoid Personality Disorder Example: Schizoid Personality

• Prevalence: 3-7.5%, more frequent in men • Mr. S. is mugged on his way home from work.
A bystander calls 911 and Mr. S. is taken to the
ER. Once awake, he answers in monosyllables
• Inability to form relationships never making eye contact. When spoken to,
Mr. S. looks away and does not respond. He is
• Aloof, detached compliant and remains passive during
treatment. He rejects all nursing interventions
aimed at increasing socialization.
• Shy, anxious, and uneasy

Schizotypal Personality Disorder Example: Schizotypal Personailty

• Prevalence estimated around 3% • Ms. G. lives alone, and is receiving social
security benefits. She goes to the grocery
• Social and interpersonal deficits store only after dark because “their magic
does not work at night.” She dresses in several
layers of multicolored and mismatched clothes
• Cognitive or perceptual distortions and even in warm weather. She wears a turban on
eccentricities her head to “keep them from seeing my
– Magical thinking, ideas of reference, illusions, thoughts.” Each night she tells the grocer in a
depersonalizations, bizarre speech, delusions, flat and formal manner that one day she will
hallucinations, and withdrawal into self be a famous actor and director.

Antisocial Personality Disorder Antisocial Personality (cont.)

Sociopathic/Psychopathic
• Prevalence estimates: 3% (men), > 1% (women)
• Chronic irresponsibility and unreliability
• Disregard for rights of others

• Violation of the rights of others • Reckless disregard for safety of self or others
• Lack of remorse for wrongdoings
• Persistent lying and stealing
• Lack of empathy

• Exploitative/Manipulative • Deceitfulness, use of alias, conning others for

personal profit or pleasure
• May be witty, charming, and seductive

4
 Example: Antisocial Personality Borderline Personality Disorder
• Prevalence estimates range from 2-3%
• Mr. R. has been extorting money from lonely
widows by charming them. He helps them • Difficulty controlling emotions
with their finances, promises to marry them,
and then takes off with their money. When in • Stormy relationships involving intense anger
court, he laughs when asked if he felt guilty
for taking the widows’ life savings. Mr. R. • Identity disturbances, markedly and persistently
unstable self-image
replies, “Hey, I gave them what they wanted.”
Fingerprints reveal that he is Oliver Torres, • Appear to be in a perpetual state of crises
and has a history of assaults and burglaries.
• During extreme stress, may experience transient
psychotic symptoms

Borderline Personality (cont.) Borderline Personality (cont.)

• Chronic depression (rage • Manipulation (playing one
turned inward) person against another) • Predisposing Factors
• Inability to be alone (chronic • Self-destructive behavior – Object relations theory (Mahler)
fear of abandonment) (self-mutilation, suicide
attempts) – Fixation in the Rapproachement Phase
• Clinging (overidealize) and
distancing behavior • Impulsivity (substance
(devaluation) abuse, promiscuity, binging – History of childhood abuse and trauma
& purging)
• Splitting (inability to accept
both positive & negative
feelings)

Object Relations Theory Brain Abnormalities in BPD

• Emotional trauma at a time when the brain
• Autistic (birth-1 month) - survival & comfort isn't fully developed may cause changes to the
• Symbiotic (1-5 months) - psychic fusion (mother) brain and decrease a person's ability to deal
with stressful situations later in life.
• Differentiation (5-10 months) - recognizes separateness
• You have a first-degree relative — a parent,
• Practicing (10-16 months) - locomotor functioning &
increase separateness sibling or child — who was diagnosed with
• Rapprochement (16-24 months) - increase
borderline personality disorder.
separateness & mother for “emotional refueling”
• You were physically or sexually abused or grew
• On the Way to Object Constancy (24-36 months) - up in an environment with fighting and
separateness & ability to internalize mother when out
of sight (Separation Anxiety Resolved) conflict.

5
 Being Borderline Example: Borderline Personality
• Mrs. T. is twice divorced and has been
hospitalized several times for suicidal ideation
and self-injury. Her therapist is leaving for a 2-
week vacation and has been preparing Mrs. T.
for the separation for weeks. Mrs. T. comes in
with fresh razor marks on her arms. She tells
her therapist to “Go have a good time, I might
not be here when you get back.” She storms
out of the office and refuses to answer the
phone all day long.

Histrionic Personality Disorder Example: Histrionic Personality

• Prevalence 2.2%, twice as common in women
• Ms. D. meets her therapist for the first time
• Excessive emotionality dressed in a tight top and short skirt. She
becomes flirtatious with her therapist and
• Attention-seeking behavior tells him that she wants extra time today
because she is more interesting than his
• Self-dramatizing
other patients. When the therapist reminds
• Labile Ms. D. that they have only 20 minutes
remaining, she becomes angry and insulting,
• Demanding demanding that he refer her to another male
therapist.
• Difficulty forming close relationships

• May complain of physical symptoms

Narcissistic Personality Disorder Narcissistic Personality (cont.)

• More common in men • Unreasonable expectations for special
• Inflated sense of importance, achievement, treatment or compliance with wishes
and talents (grandiosity)
• Self-centered
• Admiration seeking behaviors
• Exploit others in an effort to fulfill their
• No regard for the feelings of others own desires
• Arrogant and haughty manner towards others

6
Example: Narcissistic Personality Avoidant Personality Disorder
• Mr. E. is the vice president of a successful • Prevalence 0.5-1 %, equally common in men and
business. He is very arrogant and always women
reminds people of what he has done for the
company. Frequently, he takes credit for the • Extreme sensitivity to rejection
ideas and suggestions made by his co-workers.
He is known to lose his temper on the • Self-imposed social isolation
slightest provocations, such as having to wait
for someone to start a meeting. By the same • Awkward and uncomfortable in social situations
token, he is usually late for meetings and
appointments. • Desire companionship but fear that relationships
will result in pain and disillusionment

Example: Avoidant Personality Dependent Personality

• Mr. J. is a computer programmer. He is • More common among women than
excessively shy, and rarely speaks with co-
workers. He tries to avoid social situations.
men, and among youngest children
Sometimes the group invites him to go out
• A pattern of relying excessively on
after work, but Mr. J. always makes excuses.
He seeks therapy for his intolerable loneliness. others for emotional support, advice,
and reassurance

Example: Dependent
Dependent Personality (cont.)
Personality
• Lack of self-confidence
• Mr. C. has lived with his mother since high
– apparent in their posture, voice, school. His mother cooks, cleans, and shops for
mannerisms him. For 30 years, he has worked as a shipping
dock clerk. Each day, he asks his mother’s
• Avoid positions of responsibility advice on what to wear to work. He is
extremely anxious and fearful because his
mother needs an operation and will be away
• Low self-worth for 5 days.
– sensitive to criticism and disapproval

7
Obsessive-Compulsive Personality Obsessive-Compulsive
Disorder Personality Disorder (cont.)
• Preoccupation with details, rules, lists, order, • Financial stinginess
or organization
• Inability to throw out even broken,
• Perfectionism so pronounced that tasks worthless, objects
cannot be completed
• Discomfort with emotions and aspect of
• Inability to share responsibility with others personal relationships that the person
• Devotion to productivity at the exclusion of cannot control
personal pleasure.

Example: Obsessive-Compulsive
Personality

• Mr. G. works 7 days a week. His need for Nursing Process

perfection results in missed deadlines.
Recently, Mr. G. has been complaining of
heart burn. His wife asks Mr. G. to see a
Borderline Personality Disorder
doctor. However, Mr. G. resists telling her
that he will go only after his projects are
finished. He also admits that he hates to Antisocial Personality Disorder
“waste” his money on doctors.

Borderline Personality Disorder

Risk for Self-Mutilation
Nursing Diagnoses
• Observe client’s behavior during routine
• Risk for self-mutilation activities
• Secure a verbal contract to seek out staff when
experiences urge for self-mutilation
• Dysfunctional grieving
• Encourage verbalization of feelings prior to
behavior
• Impaired social interaction
• Role model appropriate expression of feelings
• May need one to one supervision

8
Self Injury- Cutting, Burning, Piercing, Tattooing
Dysfunctional Grieving
Not part of a • Encourage expression of feelings
Religious rite

Not a rite of passage • Identify function of anger/rage and

encourage expression within reason
Not for body adornment
• Explore ways to appropriately express anger
Not for occupational
• Explore grieving process and issues related to
enhancement.
abandonment
• Set limits on acting out behavior/ understand
that client may displace anger toward nurse
NEED HELP – 1-800 DONTCUT

Antisocial Personality Disorder

Impaired Social Interaction
Nursing Diagnoses
• Develop nurse client relationship without
reinforcing dependent behavior • Risk for violence toward others
• Give positive reinforcement for
independent behavior • Defensive coping
• Rotate staff to avoid dependency

• Assist client to work toward achievement of

object constancy

Risk for Violence Directed At Others Defensive Coping

• Observe client’s behavior, but avoid appearing • Set limits-client should be aware of behaviors that
watchful or suspicious are acceptable and those that are not

• Remove all dangerous objects • Provide positive feedback for acceptable behavior

• Help client identify the true object of his hostility • Discuss behaviors that are acceptable by society
and those that are not
• Explore alternative ways of handling frustration
• Explore how he/she has exploited others and how
• Have sufficient staff if show of strength is necessary they might feel if the situation were reversed
• Administer tranquilizing medications or restraints if • Maintain an attitude that it is the behavior that is
client is not calmed by “talking down” unacceptable not the person

9
 Sociopath

"I'm the most cold-blooded sonofabitch you'll ever meet,“

"I just liked to kill, I wanted to kill."

10