Module 6

Personality
Disorders
Learning
Objectives
 Discuss each personality disorders as to
 General appearance and motor behavior
 Mood and affect
 Thought process and content
 Sensorium and intellectual processes
 Sensory-perceptual alterations
 Judgment and insight
 Self-concept
 Roles and relationships
 Physiologic and self-care ability
 Specific medical and nursing management

READ Chapter 18 Personality Disorders pages 328 to 353 to fully understand the Disorder.

Personality: an ingrained, enduring pattern of behaving and relating to self, others, and the environment
Personality disorders: when personality traits become inflexible and maladaptive and significantly interfere
with how a person functions in society or cause the person emotional distress; maladaptive behavior can be
traced to early childhood or adolescence

DSM-V Categories
 Cluster A: people whose behavior is odd or eccentric (paranoid, schizoid, schizotypal)
 Cluster B: people who appear dramatic, emotional, or erratic (antisocial, borderline, histrionic, narcissistic)
 Cluster C: people who are anxious or fearful (avoidant, dependent, obsessive-
compulsive) Disorders being considered for inclusion are depressive and passive-
aggressive

Onset and Clinical Course

 Personality disorders occur in 10% to 20% of the general population (Boland & Verduin, 2022)
 Incidence is even higher in lower socioeconomic groups, unstable or disadvantaged populations
 Of all psychiatric in patients, 15% have a primary diagnosis of a personality disorder
 40% to 45% of people with a primary diagnosis of major mental illness also have a
coexisting personality disorder that significantly complicates treatment
 Clients with personality disorders have:
 Higher death rates, especially as a result of suicide
 Higher rates of suicide attempts, accidents, and emergency department visits
 Increased rates of separation, divorce, and involvement in legal proceedings regarding child custody
 Highly correlated with criminal behavior, alcoholism, and drug abuse
 Treatment resistant; difficult to change one’s personality; do not perceive their dysfunctional behavior as
a problem.
Etiology

 Genetics/hereditary dispositions influences

Temperament
4 temperamental traits: harm avoidance, novelty seeking, reward dependence and persistence.
 Psychodynamic theories/ environmental influences
3 Character traits: self-directedness, cooperativeness, and self- transcendence

Treatment
 Many people with personality disorders do not seek treatment because they don’t believe they have
a problem.
 Individual and group therapy may be helpful to those desiring change, but any changes are slow.
 Improvement in relationships, improved basic living skills, relief of anxiety may be goals of therapy
 Cognitive-behavioral techniques such as thought-stopping, positive self-talk, and
decatastrophizing can be effective.
 Dialectical behavior therapy by Dr. Marsha Linehan for Borderline Personality Disorder (BPD);
the underlying problem are due to distorted thinking and behavior based on the assumption of
poorly regulated emotions.
 Schema therapy to help individuals deal with unmet emotional needs and to identify the thought
and behavioral patterns that perpetuate their emotional distress and dysfunction.
 Pharmacologic treatment is based on the type and severity of symptoms rather than the personality
disorder itself.

Four symptom categories include:

 Cognitive-perceptual distortions includes magical thinking, odd beliefs, illusions, suspiciousness, ideas of
reference and low – grade psychotic symptoms – respond to low dose antipsychotic medications.
 Affective dysregulation, detachment and cognitive disturbances are attributed to low reward dependence
personality.
 Impulsiveness and Aggression is for high novelty seeking behaviors.
 Anxiety and depression symptoms correlate to high harm avoidance personality
Pharmacologic Treatment for Symptoms
 Cognitive-perceptual disturbances (magical thinking, odd beliefs, illusions, suspiciousness, ideas
of reference, and low-grade psychotic symptoms)
 Low-dose antipsychotic medications
 Mood dysregulation (emotional instability, emotional detachment, depression, and dysphoria)
 Lithium, carbamazepine (Tegretol), valproate (Depakote), low-dose neuroleptics, SSRIs, MAOIs,
atypical antipsychotics
 Aggression (predatory or cruel behavior, impulsivity, poor social judgment, and emotional
lability)
 Lithium, anticonvulsant mood stabilizers, benzodiazepines, and low-dose neuroleptics
 Anxiety
 SSRIs, MAOIs, or low-dose
antipsychotics Individual and Group
Psychotherapy
Focus is on building trust, teaching basic living skills, providing support, decreasing
distressing symptoms, and improving interpersonal relationships.
Cognitive-behavioral therapy
 Basic living skills for people with cluster A personality disorders
 Inpatient hospitalization to provide safety for people with borderline personality disorder
 Assertiveness training groups for people with cluster C personality disorders
 Relaxation or meditation techniques for people with cluster C personality disorders

Cluster A Personality Disorders

 Paranoid Personality Disorder
Clinical Picture
Mistrust and suspiciousness, aloof and withdrawn, guarded or hypervigilant, restricted affect, use the
defense mechanism of projection
Nursing Interventions
Approach in a formal, business-like manner, keep commitments, be straightforward, involve them in
formulating their care plans, help them learn to validate ideas before taking action
 Schizoid Personality Disorder
Clinical Picture
Detached from social relationships, restricted affect, aloof and indifferent, no leisure or pleasurable
activities, do not report feeling distressed about lack of emotion, intellectual and accomplished with solitary
interests, indifferent to praise or criticism, dissociate from or no bodily or sensory pleasures
Nursing Interventions
Improve functioning in the community, make referrals to social services, provide care that accommodates the
desire for solitude
 Schizotypal Personality Disorder
Clinical Picture
Acute discomfort in relationships, cognitive or perceptual distortions, eccentric behavior, bizarre speech,
affect flat and sometimes inappropriate
Nursing Interventions
Promote self-care, social skills, and improved functioning in the community

Cluster B Personality Disorders

 Antisocial Personality Disorder
Clinical Picture
Pervasive pattern of disregard for and violation of rights of others, deceit and
manipulation Application of the Nursing Process
Assessment
History: lying, truancy, vandalism, sexual promiscuity, and substance use in childhood and adolescence
General appearance and motor behavior: appears “normal,” may be charming and engaging, trying to manipulate
Mood and affect: shallow emotions, “chooses” emotions to work to their advantage, no genuine feelings of
empathy, no guilt, only remorseful if caught
Thought processes and content: views the world as cold and hostile, thinks everyone else is as ruthless as he
or she is, so trusts no one
Sensorium and intellectual processes: intact
Judgment and insight: lacks insight, poor judgment due to inability to delay gratification, impulsivity, or
ethical/legal considerations of actions
Self-concept: superficially appears self-assured and confident, even arrogant, but this covers low self-
esteem; poor relationships due to exploitation and using others
Roles and relationships: has trouble keeping jobs, being a parent, staying married, and so forth
Intervention
Forming therapeutic
relationship Limit
setting Confrontation
Promoting responsible
behavior Helping client solve
problems and control
emotions Enhancing role
performance
 Borderline Personality Disorder
Clinical Picture
Pervasive pattern of unstable interpersonal
relationships, self-image, affect, and marked
impulsivity
Application of the Nursing Process
Assessment
History: disturbed early relationships with parents; punitive responses from parents; family history of
abuse and alcoholism
General appearance and motor behavior: mildly dysfunctional clients appear normal; severely affected
clients may be disheveled, unable to sit still, crying, out of control; very labile emotions
Mood and affect: dysphoric mood; unhappy, restless, malaise; intense feeling of loneliness; boredom;
frustration; abandonment by others; mood is labile and feelings are intense
Thought processes and content: polarized thinking/splitting; others are “adored” after a brief acquaintance,
then despised if they don’t meet client’s expectations; obsessive and ruminative thoughts about
abandonment, suicide, and self-harm; may have dissociative episodes
Sensorium and intellectual processes: oriented; intellectual functions intact; may experience transient
psychotic symptoms such as hallucinations under severe stress; may have flashbacks of abuse (consistent
with PTSD diagnosis) Judgment and insight: judgment is poor; impulsive and reckless behaviors such as
lying, shoplifting, gambling are common; limited insight: believes problems are due to others “failing” them
Self-concept: unstable and shifts rapidly--needy one minute, hostile and rejecting the next; frequent self-
injury; lacks consistent view of self
Roles and relationships: difficulty fulfilling roles, especially involving mundane tasks (school, work);
relationships are stormy given client’s behavior, but client blames others; clings to people, then rejects
them angrily; desires relationships/friendships, but behavior drives others away
Data Analysis
Nursing diagnoses include:
Risk for Suicide
Risk for Self-Mutilation
Risk for Other-Directed
Violence Ineffective
Coping Social Isolation

Intervention
Long-term therapy to resolve family dysfunction and abuse
Hospitalization when client is exhibiting self-harm behaviors or having intense
symptoms Brief hospitalizations to stabilize condition
Promoting the client’s
safety No-self-harm
contract
Promoting the therapeutic relationship
Establishing boundaries in relationships
Teaching effective communication skills
Helping the client to cope and control
emotions Reshaping thinking patterns
Cognitive restructuring
Thought stopping
Positive self-talk
Decatastrophizing
Structuring daily
activities
  Histrionic Personality Disorder
Clinical Picture
Excessive emotionality and attention seeking; colorful and theatrical speech; overly concerned with
impressing others; emotionally expressive, gregarious, and effusive; emotions are insincere and shallow; self-
absorbed; uncomfortable when they are not the center of attention and go to great lengths to gain that status
Nursing Interventions
Give feedback about social interactions; teach social skills through role playing
 Narcissistic Personality Disorder
Clinical Picture
Grandiose; lack of empathy; need for admiration; arrogant or haughty attitude;
disparage, belittle, or discount the feelings of others; view their problems as the fault of others;
hypersensitive to criticism and need constant attention
and admiration
Nursing Interventions
Use self-awareness skills to avoid anger and frustration; use matter-of-fact manner; set limits on rude or
verbally abusive behavior

Cluster C Personality Disorders

 Avoidant Personality Disorder

Clinical Picture
Social inhibitions; feelings of inadequacy; hypersensitivity to negative evaluation; avoid situations or
relationships that may result in rejection, criticism, shame, or disapproval; strongly desire closeness and
intimacy but fear possible rejection and humiliation
Nursing Interventions
Explore positive self-aspects and reasons for self-criticism; practice self-affirmations and positive self-talk;
cognitive restructuring techniques, such as reframing and decatastrophizing; teach social skills

 Dependent Personality Disorder

Clinical Picture
Submissive and clinging behavior; excessive need to be taken care of; pessimistic and self-critical; other
people hurt their feelings easily; report feeling unhappy or depressed; difficulty making decisions; seek advice
and repeated reassurances Nursing Interventions
Help identify strengths and needs; use cognitive restructuring; assist in daily functioning; teach problem
solving and decision making; refrain from giving advice

 Obsessive-Compulsive Personality Disorder

Clinical Picture
Preoccupation with orderliness, perfectionism, and control; formal and serious demeanor; constricted
emotions; stubborn; preoccupied with details, rules, lists, and schedules; believe they are right; problems
with judgment and decision making
Nursing Interventions
Help accept or tolerate less-than-perfect work; use cognitive restructuring techniques; encourage to take
risks; practice negotiation

Related Disorders
 Depressive Personality Disorder
Clinical Picture
Sad, gloomy, or dejected affect; persistent unhappiness, cheerlessness, and hopelessness; inability to
experience joy or pleasure in any activity; cannot relax; do not display a sense of humor; brood and worry
over all aspects of daily life; thinking is negative and pessimistic
Nursing Interventions
Assess risk for self-harm; encourage to become involved in activities; give factual feedback; use cognitive
restructuring techniques; teach effective social skills
 Passive-Aggressive Personality Disorder
Clinical Picture
Negative attitudes; resent, oppose, and resist demands expected by others; express resistance through
procrastination, forgetfulness, stubbornness, and intentional inefficiency
Nursing Interventions
Help examine the relationship between feelings and subsequent actions; teach appropriate ways to
express feelings directly
 Activities:
1. Study the Module
2. Supplement the module by reading e-book by Videbeck - Psychiatric-Mental Health Nursing.
3. Module Assessment Self-

Check Module Assessment Self-

Personality Disorders Test I

1.
Check 4Violation of the rights of others, rules and laws; Impulsivity, lacks judgment A. Paranoid
2. Tendency for self-harm and mutilation behaviors, Uses transitional objects B. Schizoid
to feel safe C. Schizotypal
3. Social inhibitions; feelings of inadequacy; hypersensitive to negative evaluation D. Antisocial
4. Submissive and clinging behavior; excessive need to be taken care of. E. Narcissistic
5. Preoccupation with orderliness, perfectionism, and control F. Histrionic
6. Excessive emotionality and attention seeking G. Obsessive-compulsive
7. Mistrust and suspicious of others, Uses projective mechanism H. Dependent
8. Detached from social relationships; Appears cold and aloof, Uses daydreaming I. Borderline
9. Has cognitive or perceptual distortions; eccentric behavior, Odd appearance J. Avoidant
10. Grandiose, lack of empathy; need for K. Depressive
admiration Attitude Therapy L. Aggressive -depressive
11. withdrawn, apathetic, fearful, non combative client Test II
12. paranoid, suspicious client M. kind firmness
13. depressed, sad, hopeless N. passive friendliness
14. manipulative, demanding, and elated affect O. active friendliness
15. assaultive, violent clients P. no demand attitude
Q. matter of fact