Presented by

Michelle Jackson, PT, B.A.

 Personality Disorders
Learning Objectives
⚫ The student will be able to:

1. In general, be able to give a definition of the term

personality.

2. Explain the difference between the terms ego-dystonic

and ego-syntonic.

3. List the criteria for a personality disorder.

4. Categorize the personality disorders into the three

categories and list the common features are in each
category. Revised 4/21

2
 Personality Disorders
Learning Objectives
5. Discuss the three other personality disorders.

6. Explain each of the 10 personality disorders-criteria,

associated features, prevalence, sex ratio, gender
features, predisposing factors, nursing
interventions, medical treatment, and psychosocial
treatment.

3
PERSONALITY DISORDERS
• What is personality?
The combination or characteristics or qualities that form an
individual’s distinctive character (The Oxford American
College Dictionary, 2002).
Personality is defined as “an enduring pattern of behavior
that is considered to be both conscious and unconscious
and reflects a means of adapting to a particular environment
and its cultural, ethnic, and community standards”
(Varcarolis et al., 2006).

4
“Personality can be described operationally in terms of
functioning. Personality, then, determines the quality of
experiences among people and serves as a guide for one-
to-one interaction and in social groups” (Varcarolis and
Jordan Halter 2010).

“Personality can be defined as an ingrained, enduring

pattern of behaving and related to self, others, and the
environment: it includes perceptions, attitudes, and
emotions. These behaviors and characteristics are
consistent across a broad range of situations and do not
change easily. A person is usually not consciously aware of
her of his personality. Many factors influence personality:
some stem from biologic and genetic makeup, whereas
others are acquired as a person develops and interacts with
the environment and other people (Videbeck 2017).
5
• Some experts believe that the personality is
basically developed by the age of 5.

• A study done in 2010 by a PhD candidate at

the University of California, Riverside showed
that personality traits observed of first graders
are basically the same traits people have as
adults throughout their life.
• Freud once defined a successful mature adult
as someone “who is able to love and to work.”
People with personality disorders tend to fail
at both.
6
 Ego-dystonic versus Ego-syntonic
• Ego-dystonic – client is emotionally distressed with
disorder or situation. This person is more likely to
seek help.
• Ego-syntonic – emotionally comfortable with the
disorder or situation. They are comfortable with
their symptoms and behaviors. This person is less
likely to seek help.

7
 PERSONALITY DISORDERS
• General diagnostic criteria for a Personality
Disorder (PD)

A. An enduring pattern of inner experience and behavior

that deviates markedly from the expectations of the
individual’s culture. This pattern is manifested in two
(or more) of the following areas:

1. Cognition (i.e., ways of perceiving and

interpreting self, other people, and events)
2. Affectivity (i.e., the range, intensity, lability, and
appropriateness of emotional response)
8
 3. Interpersonal functioning ( is usually
affected)

4. Impulse control (cluster B: Antisocial &

Borderline)

B. The enduring pattern is inflexible and

pervasive across a broad range of personal
and social situations.
C. The enduring pattern leads to clinically
significant distress of impairment in social,
occupational, or other important areas of
functioning.
⚫9
D. The pattern is stable and of long duration,
and its onset can be traced back at least to
adolescence or early adulthood.
E. The enduring pattern is not better
accounted for as a manifestation or
consequence of another mental disorder.
F. The enduring pattern is not due to the
direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a
general medical condition (e.g., head
trauma).

10
• There are 10 personality disorders.
• Prevalence 10-15% of the general population
may have a personality disorder.

• Age at onset – Adolescence, early adult life,

and characteristic of most of adult life.
Personality disorders tend to be chronic,
although there is some evidence that
symptoms of Borderline and Antisocial
Personality Disorders wane or remit when the
individual is in the 40s.
11
• Impairment – People with personality
disorders many times are never hospitalized
since it doesn’t impair them to the point of not
being able to function. Most are not in a
psychiatric facility, but in society. Also, the
impairment may be episodic.
• Associated features-In general, many also
experience anxiety and depression are
common symptoms.

12
• Personality Disorders (and Mental Retardation,
which is now referred to as Intellectual
Disabilities in the DSM-5) used to be recorded
on Axis II of the DSM-IV-TR multiaxial system.
• They were separated from Axis I since they tend to
start at a young age, be chronic, and are less
responsive to treatment. Also, focus was given to
the possible presence of Personality Disorders and
Mental Retardation that might otherwise be
overlooked when attention is directed to the more
florid Axis I disorders.
• Code 301.xx is used for Personality Disorders
• A personality disorder and stress could result in
psychosis.
13
• PDs may co-exist with extreme psychopathology.
For example:
Axis I – Schizophrenia
Axis II – Antisocial Personality Disorder
• Or without extreme psychopathology:
Axis I – None
Axis II – Antisocial Personality Disorder
• Or there can be more than one PD:
Axis I – Major Depressive Disorder
Axis II – Borderline Personality Disorder,
Histrionic Personality Disorder
• Or there can be features of a PD listed on Axis II:
Axis I – Pedophilia
Axis II – Narcissistic Personality Disorder
14
• Personality disorders are divided into three groups or
clusters which are based on common symptoms.

• Cluster A
1. Paranoid Personality Disorder
2. Schizoid Personality Disorder
(No delusions)
3. Schizotypal Personality Disorder
(delusions are present)
• Common characteristics- odd or eccentric
(weird/ different)
15
• Cluster B
1. Antisocial Personality Disorder (don’t like
people)

2. Borderline Personality Disorder (flip)

3. Histrionic Personality Disorder
4. Narcissistic Personality Disorder
Common characteristics – dramatic, emotional,
erratic (impulsive) lack good judgment, lack
insight.

16
• Cluster C

1. Avoidant Personality Disorder

2. Dependent Personality Disorder

3. Obsessive Compulsive Personality

Disorder (mild form)

Common characteristics – anxious, fearful,

passive aggressive personality disorder
17
18
 Other Personality Disorders

• Personality Change Due to Another Medical

Condition-there is evidence that the disturbance
is caused by a medical condition
• Other Specified Personality Disorder-not
enough criteria to meet a PD diagnosis;
clinician chooses to state the reason (e.g.,
mixed personality features) that the criteria are
not met
• Unspecified Personality Disorder-not enough
criteria to meet a PD diagnosis; clinician
chooses not to state the reason that the criteria
are not met
19
• Personality disorders most commonly seen in a hospital
setting – Schizotypal, Borderline and Antisocial
Personality Disorder (most common)
• THEY TEND TO BE ANNOYING!!!!
• Identifying with 1 or 2 symptoms does not mean a
person has a PD like medical school syndrome or
“. . .itis.”
• There is no specific medication to treat PDs.
• Antidepressants, anti-anxiety, antipsychotics, and mood
stabilizers are sometimes used to treat the symptoms.
• GOAL: To reduce inflexibility of personality traits that
interfere with functioning and relationships
20
 PPD
Cluster A Personality Disorders
The essential feature of this disorder is to interpret actions
of people as deliberately demeaning or threatening.
301.0 Paranoid Personality Disorder (PPD)
A. A pervasive distrust and suspiciousness of others
such that their motives are interpreted as
malevolent, beginning by early childhood and present in
a variety of contexts, as indicated by four or more of
the following:

20
 PPD
1. Suspects, without sufficient basis, that others are
exploiting, harming or deceiving them.
2. Is preoccupied with unjustified doubts about the
loyalty or trustworthiness of friends or associates.

3. Is reluctant to confide in others because of

unwarranted fear that the information will be used
maliciously against them.
4. Reads hidden demeaning or threatening meanings
into benign remarks or events.
5. Persistently bears grudges, i.e., is unforgiving of
insults, injuries, or slights.

22
 PPD
6. Perceives attacks on their character or reputation that
are not apparent to others and is quick to react angrily
or to counter attack.
7. Has recurrent suspicions, without justification,
regarding infidelity of spouse or sexual partner.
B. Does not occur exclusively during the course of
schizophrenia, a mood disorder with psychotic
features, or another psychotic disorder and is not due
to the direct physiological effects of a general medical
condition.

Note: If criteria are met prior to the onset of

schizophrenia, add “premorbid,” i.e., “paranoid
personality disorder (premorbid).”
23
 PPD
Associated Features
1. Restricts feelings – may take pride in being cold and
unemotional, doesn’t show tender feelings.
2. May appear tense, has a difficult time relaxing, lacks
sense of humor.
3. Suspicious, but not delusional.
4. Uses the defense mechanism projection. (Attributes
to others the unacceptable thoughts and feelings
that they themselves are experiencing).
5. Excessive need to be self-sufficient and a strong
sense of autonomy since they lack trust in others.
Needs to control others around them.
6. May frequently become engaged in legal disputes.
7. They become dedicated racial, religious, and political
fanatics.
24
 PPD
Prevalence – 2.3%-4.4%
Sex Ratio – More commonly diagnosed in men.
Predisposing Factors:
(1) Higher incidence of PPD among relatives of
clients with schizophrenia than the general
population. Also familial relationship with
Delusional Disorder, Persecutory Type.

(2) Parents may have harassed them, scapegoats for

parental aggression, no hope for affection/approval.

(3) They learn to see the world as harsh/unkind.

They anticipate humiliation and betrayal by others.
They learn to attack first.
25
 PPD
Nursing Interventions
Nursing Diagnosis:
“Risk for violence: directed toward others R/T suspicious
thoughts.”

1. Remain calm, non-threatening, and nonjudgmental

in all interactions. If they get violent, use clear, calm
statements and a confident physical stance

2. Accept person’s beliefs but don’t confirm them or

argue with them.

3. A business-like approach and atmosphere is more

effective

4. Give clear information regarding confidentiality and

job-related consequences of counseling sessions.
26
 PPD
5. Respond to suspicious ideas by focusing on feelings,
i.e., “It must be distressing when . . . .” or “You
see him as vindictive.”

6. Care givers frequently dislike this type of person.

(People keep their distance from paranoids, which
reinforces their general distrust of others.)**
Medical Treatment
1. Medication, in general, may not help since the patient
will be suspicious of them.

2. If they are accepting of medication, give detailed

accurate information regarding side effects since they
expect the worst, but feel better knowing about it.
27
 PPD
3. Benzodiazepines may be helpful for brief crisis
management.

4. Antipsychotics may help psychosis and severe

agitation.

Psychosocial Treatment
1. Supportive psychotherapy is the choice of treatment,
although this will take a lot of time since the client
has issues of trust and intimacy.

2. Paranoid patients do not do well in group therapy.

28
 PPD
Movies

The Caine Bounty The Assassination of

Richard Nixon
Land of Plenty

Famous People Who May Had PPD or

Symptoms

Adolf Hitler Richard Nixon

Saddam Hussein Josef Stalin

29
 SPD
Schizoid Personality Disorder
The fundamental characteristic of this disorder is the
inability to form social relationships and a restricted
range of emotion.
301.20 Schizoid Personality Disorder (SPD)

A. A pervasive pattern of detachment from social

relationships and a restricted range of expression of
emotions in interpersonal settings beginning by early
adulthood and present in a variety of contexts, as
indicated by four (or more) of the following:

30
 SPD
1. Neither desires nor enjoys close relationships,
including being part of a family. They have a history of
being neglected as children.

2. Almost always chooses solitary activities.

3. Has little, if any, interest in having sexual experiences

with another person.

4. Takes pleasure in few, if any, activities.

5. Lacks close friends or confidants other than first-

degree relatives.

6. Appears indifferent to the praise or criticism of others.

7. Shows emotional coldness, detachment, or

flattened affect.
31
Associated Features
SPD
1. Vague about goals and are indecisive.
2. Males rarely date or marry while females may passively
accept courtship and marry.
3. Occupational functioning may be impaired but may do
well working in social isolation.
4. What may appear to be aloofness may actually be
profound shyness.
5. They are seen as absent minded, a loner, in a “fog,”
detached from others, “not connected.”
6. May be common on skid row.
7. This disorder may precede Delusional Disorder or
schizophrenia.
32
 SPD
8. Most often occurs with schizotypal, paranoid,
and avoidant personality disorder.
9. Resembles avoidant personality disorder but
avoidant personality disorder wants friends
while schizoid personality disorder doesn’t want
friends.
10. They do not exhibit eccentricities of speech,
behavior, or thinking as in schizotypal personality
disorder.
11. Not all people who have this disorder will
progress to having schizophrenia, but most people
with schizophrenia will show some of these
symptoms in the prodromal stage.

33
 Bobby Fisher
Chess champion

34
 Predisposing Factors SPD
Prevalence – 3.1%-
1. Diagnosed more in relatives
4.9% Low in clinical
with schizophrenia or schizotypal
settings. Seen more in
disorder.
jobs with no contact
with others or living in 2. Childhoods – bleak, cold, un-
skid-row areas of cities. empathetic, lacking in nurturing.

Gender ratio – As adults they see relationships

Diagnosed slightly more that are not valuable or not
in persons identifying worth pursuing.
with being male, and 3. May have had poor peer
may cause more relationships; were under-
impairment in them. achievers when young and may
have been teased.
35
 SPD
Nursing Interventions:
Nsg. Dx: Social isolation R/T inability to relate to others
1. Assign the same staff member to client to
develop trust and rapport.
2. Encourage client to attend and participate in
group activities-begin with ones that have limited
interaction and progress to those that are more
verbal. (Treatment goal: client shows increased
socialization with peers).
3. Treatment may be more palliative than curative.

35
Medical Treatment SPD
⚫ Medication is not useful except for temporary periods of
excessive anxiety.
Psychosocial Treatment

1. Most people will not seek professional help or will do so

for other problems: depression, substance abuse or other
issues.

2. Long-term psychotherapy has been useful in some

cases. If client is motivated, behavioral techniques
may be helpful, such as graded exposure to a variety of
social tasks.

3. Group therapy can be useful-a social network can help

them overcome fears and feelings of isolation. 37
 SPD
Movies
The English Patient Sex, Lies, and
Videotapes

Remains of the Day

Famous People Who May Had/Have SPD or

Symptoms
Jeffrey Dahmer Sigmund Freud

Charles Darwin Bill Gates

Albert Einstein Karl Marx

Bobby Fisher (chess champion) Lee Harvey Oswald

38
 STPD

Schizotypal Personality Disorder

(STPD)
The key notability of this disorder is a pattern of
deficits involving communication, appearance
and behavior.

*Schizotypal and schizoid Personality Disorders

are both detached and aloof but the schizotypal
personality disorder has more cognitive
impairment.
39
301.22 Schizotypal Personality Disorder STPD
A. A pervasive pattern of social and interpersonal deficits
marked by acute discomfort with, and reduced capacity
for, close relationships as well as by cognitive or
perceptual distortions and eccentricities of behavior,
beginning by early adulthood and present in a variety of
contexts, as indicated by five (or more) of the following:

1. Ideas of reference (excluding delusions of reference).

2. Odd beliefs or magical thinking that influences behavior
and is inconsistent with subcultural norms
(e.g., superstitious, belief in clairvoyance, telepathy, or
“sixth sense”; in children and adolescents, bizarre
fantasies or preoccupations).

40
 STPD
3. Distorted and unusual perceptual experiences,
including bodily illusions. Ex: “I am
getting a message from the beyond that
we have been involved with each other in a previous
life.”

4. Odd thinking and speech. Excessive social anxiety.

5. Suspiciousness or paranoid ideation.

6. Inappropriate or constricted affect.

7. Behavior or appearance that is odd, eccentric, or

peculiar.
Socially lonely
Behavior AND
Odd thinking 41
 STPD
8. Lack of close friends or confidants other than
first-degree relatives.

9. Excessive social anxiety that does not diminish

with familiarity and tends to be associated with
paranoid fears rather than negative judgments about self.

Associated Features
1. Over half may have a history of a least one Major
Depressive Episode.

2. Often unkempt (dirty).

3. Display unusual mannerisms and talk to

themselves.
42
 STPD

4. Flat or inappropriate affect-laugh at sad

situation.
5. May be aloof, isolated, bland or have an
apathetic manner.
6. Speech pattern may be bizarre, tangential,
vague, digressive.
7. May become psychotic but usually it’s brief.
8. Only a small number of them go on to develop
schizophrenia-may be anxious around people,
especially if more than three people are
together or they are around unfamiliar people.
43
 STPD
Prevalence – Has been reported to occur in approximately 4-
6% of the population. This disorder is uncommon in clinical
settings: 0%-1.9%.
Sex Ratio – May be slightly more common in males and may
cause more impairment in them.
Predisposing Factors
1. More prevalent among first-degree biological relatives of
individuals with schizophrenia.
2. Childhood-they may have been shunned, overlooked,
rejected, disgraced by others. Grew up withdrawn and reduced
contact with people. Their inner world provided them with a
more significant and potentially rewarding existence than the
one experienced in reality.

⚫ 44
 STPD
Nursing Interventions
1. Establish trust; and use clear, concise communication.

2. Consistency is important.
3. Any intervention that would increase self esteem.
4. Respect the patient’s need for periods of social
isolation.

Medical Treatment

1. Antipsychotic medication may be useful if the patient has

pronounced psychotic manifestations, particularly during
stress.
45
 STPD
Psychosocial Treatment
1. These individuals require a supportive group experience.
2. Social skills training may be helpful.

3. Group psychotherapy may be seen as overly

threatening.

Movies: Taxi Driver

Famous People Who May Had/Have STPD or
Symptoms
Jeffrey Dahmer John Hinckley, Jr.
Emily Dickerson James Holmes
Albert Einstein Vincent Van Gogh
46
 ASPD
CLUSTER B Personality Disorders
Antisocial Personality Disorder (ASPD)
The necessary trait of this disorder is a pattern of
irresponsible and antisocial behavior that begins in
childhood or early adolescence and continues into
adulthood. To be diagnosed with this disorder, the person
has to be at least 18 years old and had a history of conduct
disorder before the age of 15 (i.e., truant, initiated fights,
cruel to animals or people, lied, engaged in thievery,
destroyed other people’s property, ran away from home or
was a fire setter). This person is frequently described as
being without a conscience. Old labels for this disorder are
psychopath, sociopath, or dissocial personality disorder.
This disorder can overlap with narcissistic personality
disorder. 47
 ASPD
Adult Antisocial Behavior: It is important to mention
that this disorder is a V Code. A patient may have this as a
diagnosis but it is probably not the only diagnosis. It is not a
personality disorder but does overlap with ASPD.

Disorders in the DSM-5 that are V codes are not actual

psychiatric diagnoses but are referred to as “Other Conditions
That May Be a Focus of Clinical Attention.” Examples are
malingering, borderline intellectual functioning, homelessness,
academic or educational problem, adult physical abuse, child
abuse, etc.)

V71.01-Adult Antisocial Behavior

This category can be used when the focus of clinical attention

is adult antisocial behavior that is not due to a mental disorder
(e.g., conduct disorder, antisocial personality disorder).
Examples include the behavior of some professional thieves,
racketeers, or dealers in illegal substances. 48
 ASPD
This is probably the hardest personality disorder to treat.
It is the oldest and most researched personality disorder.

301.7 Antisocial Personality Disorder

A. There is a pervasive pattern of disregard and violation
of the right of others occurring since 15 years, as
indicated by three (or more) of the following:

1. Failure to conform to social norms with respect to lawful

behaviors as indicated by repeatedly performing acts that
are grounds for arrest.

2. Deceitfulness, as indicated by repeated lying, use of

aliases, or conning others for personal profit or pleasure.

49
 ASPD

3. Impulsivity or failure to plan ahead.

4. Irritability and aggressiveness, as indicated by

repeated physical fights or assaults.

5. Reckless disregard for safety or self or others.

6. Consistent irresponsibility, as indicated by

repeated failure to sustain consistent work
behavior or honor financial obligations.

7. Lack of remorse, as indicated by being

indifferent toward, or rationalizing having hurt,
mistreated, or stole from another.
50
 ASPD
B. The individual is at least age 18 years.

C. There is evidence of Conduct Disorder with onset

before age 15 years.

D. The occurrence of antisocial behavior is not

exclusively during the course of schizophrenia or a
manic episode.

Associated Features
1. Unlawful behavior may involve destroying property,
stealing, harassing others, or selling drugs.

2. If a parent, may not be a responsible one

(e.g., neglect related to malnutrition, hygiene or lack
of medical attention).
51
 ASPD
3. May have a history of many sexual partners and
may never have had a monogamous relationship.

4. May be arrogant, excessively opinionated, self-

assured, cocky, superficially charming, manipulative
and have inflated self esteem.

5. May repeatedly lie, use an alias, con others or be a

malingerer (fake illness to get out of prison).

6. May have spent many years institutionalized-more

penal and psychiatric.

7. They have shorter life expectancies – injuries from

fights/accidents, and substance dependence. They
also experience depression, suicidal threats and about
5% commit suicide. Most common in prisons.
52
 ASPD
8. Tend to use rationalization and projection.
Examples:
“Life’s unfair.”
“He had it coming anyway.”
“He should have known better.”
“Losers deserve to lose.”
“Good guys come in last.”
“I wouldn’t have raped her if she wasn’t
wearing red lipstick.”

53
 ASPD
9. Easily bored, argumentative, often take
chances, thrill seekers.
10. Can be concrete thinkers: “Why do I rob banks?
Because that’s where the money is.”

11. Often meet criteria for other Cluster “B” PDs.

12. May receive dishonorable discharge from the

Armed services, may fail to be self-supporting, may
become impoverished or even homeless.

13. May have other psychiatric diagnoses: anxiety

disorders, depressive disorders, pathological
gambling, substance abuse disorders, somatic
symptom disorder.
54
 ASPD
Prevalence – 0.2%-3.3% while there are higher rates in
substance abuse settings, prison and forensic settings (as much
as 70%).

Sex Ratio – 3% of males and 1% of females in the general

population. DSM-5 no longer gives percentages. Some believe
the disorder maybe underdiagnosed in females due to the
aggressive items in the definition of conduct disorder.
Predisposing Factors
1. Some come from stable and loving homes.
2. Severe physical abuse growing up
3. Extreme poverty (stealing, committing fraud)
4. Removal from the home (placed in foster care)
5. Growing up without either parental figures (all
genders) 55
 ASPD
6. Erratic/inconsistent methods of discipline
7. Being rescued when they get into trouble

8. ADHD may be a predisposing factor and having

Conduct Disorder may also be a predisposing factor,
especially before the age of 10.

9. Growing up without parental figures of both sexes

10. Low levels of serotonin may cause aggression.
Nursing Interventions
1. Maintain consistent rules and regulations – “overly
compliant” and covertly non-complaint.”

2. Confront inappropriate behaviors without anger or

punitiveness. DO NOT tolerate abuse or cursing.
56
 ASPD
3. Set limits on all interactions. (External limits/controls
are necessary while internal controls are developed).
Ensure “at risk” clients are not being manipulated.
4. Be alert for flattery or verbal remarks.
5. Do not argue, bargain or rationalize. Do not permit
patient to dictate treatment.
7. Use behavioral contracts and relaxation
techniques to teach the individual how to delay
immediate gratification and impulsiveness (too much
domination by the Id).
8. Participate in staff meetings to work through
transference and countertransference issues.
Medical Treatment
1. Treatment with medications have not been proven
to be effective. 57
 ASPD
Psychosocial Treatment
1. Successful treatment programs consist of a long-term
in-patient, strictly structured hierarchical setting where
the client works on issues of trust, feelings, and learning.
2. Group therapy may be good due to feedback from
peers-this may be more effective than from the
therapist.

3. Substance abuse must be addressed since it

increases antisocial behavior.
4. A tough love approach can decrease some of the
problems.
5. Prevention is the key – early detection in
children/adolescents is important and needs to be treated
promptly.
58
 ASPD
Movies:
Kalifornia Fargo Cape Fear

Collateral Black Widow Tin Men

Primal Fear A Few Good Men The Family

Orphan A Simple Favor Gone Girl

Disturbia Basic Instinct Misery

Natural Born Killers American Psycho Mr. Brooks

Hard Candy Single White Female

No Country for Old Men The Talented Mr. Ripley

The Silence of the Lambs One Flew Over the Cuckoo’s Nest

59
 ASPD
Famous People Who May Have/Had
ASPD or Symptoms
Rodney Alcala Albert Fish
Andrew Cunanan John Wayne Gacy
Richard Allen Davis Gary Gilmore
Jeffery Dahmer Richard Ramirez
Diane Downs
Ted Bundy

Aileen Wuornos
60
 BPD
BORDERLINE PERSONALITY
DISORDER (BPD)
The basic peculiarity of this disorder is a pattern of
mood swings, poor self-image, and unstable
interpersonal relationships.
301.83 Borderline Personality Disorder
A pervasive pattern of instability of interpersonal
relationships, self-image, and affects, and marked
impulsivity beginning by early adulthood and present in
a variety of contexts, as indicated by 5 (or more) of the
following:
1. Frantic attempts to avoid real or imagined
abandonment. Note: Do not include suicide or self-
mutilating behavior covered in Criterion 5.
61
 BPD
BORDERLINE 3. Identity disturbance:
PERSONALITY markedly and persistently
unstable self-image or
DISORDER (BPD) sense of self.
2. A pattern of unstable 4. Impulsivity in at least
and intense two areas that are
interpersonal potentially self-damaging
relationships (e.g., spending, sex,
characterized by substance abuse,
alternating between reckless driving, binge
eating). Note: Do not
extremes of
include suicidal or self-
idealization and mutilating behavior
devaluation. covered in Criterion 5.

62
 BPD
5. Recurrent suicidal
behavior, gestures, or
threats, or self-
mutilating behavior.
6. Affective instability
due to a marked
reactivity or mood
(e.g., intense episodic
dysphoria, irritability,
or anxiety using
lasting a few hours
and only rarely more
than a few days).

63
64
7. Chronic feelings of emptiness. BPD
8. Inappropriate intense anger or difficulty controlling
anger (e.g., frequent displays of anger, constant
anger, recurrent physical fights).

9. Transient, stress-related paranoid ideation or severe

dissociative symptoms.

Associated Features
1. May have a pattern of undermining themselves at
the moment a goal is to be reached (e.g., dropping out
of school just before graduation).

2. Recurrent job losses, interrupted education; broken

marriages are common. Always looking for the
perfect partner.**
65
 BPD
3. Physical handicaps may result from self-inflicted abuse
behaviors or failed suicide attempts. (Ten percent of
BPD people commit suicide.) Most likely to be hospitalized.

4. Childhood history may include physical or sexual abuse,

neglect, hostile conflict, early parental loss or
separation.

5. May have hypochondriacal tendencies.

6. Common Axis I diagnoses include Mood Disorders,

Substance Abuse Disorders, PTSD, ASPD, eating disorders
(especially bulimia).

7. Under stress and fear of abandonment, some may harm

themselves to get the person to stay. Some become psychotic.

8. Use the Defense Mechanism of “splitting” by cutting or

harming self to bring anxiety to manageable levels. 66
 BPD

Prevalence – Approximately 1.6%-5.9% of the general

population, about 6% in primary care settings, about
10% among individuals seen in outpatient mental health
clinics, and about 20% among psychiatric inpatients.
Sex Ratio – Approximately 75% are females.
Predisposing Factors:
1. Approximately 5 times more common among first
degree biological relatives of those with the disorder
than the general population. Also, there is an
increased risk for ASPD, depressive or bipolar
disorders.

67
 BPD
2. Trauma (PTSD) – Some experts nowadays believe
that some of the people diagnosed with BPD really
have PTSD.

3. Physical or sexual abuse (40-71% of BPD clients

report having been sexually abused, usually by a
non-caregiver). One study found that people with
BPD have a 13 times higher rate of childhood
abuse than the general population.

4. Serious parental psychopathology – substance abuse

or Anti-Social Personality Disorder

68
5. Mahler’s Theory of Object Relations –
Rapprochement Phase: BPD
16-24 months: The infant at is becoming aware of
separateness. He/she wants to be own individual but wants
mother there for “emotional refueling” and security.

24-36 months: The child completes this individuation

process. Learns to related to objects in an effective,
consistent manner. Separateness is established. The child
can internalize an image of the loved object or person when
out of sight. Separation anxiety is resolved.

With BPD, the mother feels secure when the child is

dependent but feels threatened by child’s independence.
They may feel abandoned. Mother rewards clingy/
dependent behaviors and punishes independent behavior.
Child behaves to satisfy mother. The result is unresolved
fears of abandonment.
69
Nursing Interventions BPD
*This client can be frustrating to work with.

1. This client is prone to establish close relationships quickly

but becomes upset or angry over insignificant matters. Avoid
a close relationship because the client develops unrealistic
expectations.

2. Nursing care must be consistent as these individuals

attempt to “split” staff frequently. Maintain consistency by open
communication to avoid staff manipulation. There should be
one primary staff person assigned to client. (Ensure all staff
remain impersonal with BPD client)***

3. Set limits when the client exhibits threats of self-damaging

behaviors; Enforce limits when patient attempts to manipulate.
The suicidal gestures try to evoke a rescue response from
others. Utilize suicide precautions as necessary. 70
 Nursing Interventions BPD
Nursing Diagnosis:
Risk for self-mutilation
5. When rules are broken confront client to help them develop
self-awareness

6. Have client contract with staff to notify them when client

has thoughts related to suicide or self-mutilation. Assist the
patient to identify the trigger situation and choose a
coping strategy. Explore ways to express anger &
frustration in appropriate ways. Acceptance without judging
helps.

8. Tend to injuries in a matter-of-fact manner. Be empathetic,

while addressing specific client behaviors

9. Give attention when client does not harm self. 71

 BPD
Medical Treatment

1. Low does of antipsychotic medication may be

helpful during brief reactive psychosis or to treat
anger.
2. Antidepressants (SSRIs – Prozac, Paxil, Zoloft)
have been found to be effective in decreasing intense
anxiety and depression.
3. MAOIs have been prescribed to treat clients who
are very sensitive to rejection.
4. Antianxiety medications may be used to treat the
episodic, intense anxiety of these clients.
5. Lithium has been prescribed to treat impulsive
behavior and rage; and carbamazepine (Tegretol)
may be used for self-mutilation. 72
Psychosocial Treatment BPD
1. Long-term therapy should focus on two issues: the setting of
limits and reality-oriented problem-solving. Long-term
psychotherapy can be very demanding – the therapist
must be able to tolerate the patient’s rage, distrust, and fear.
2. Dialectical Behavior Therapy:
A. Weekly individualized psychotherapy sessions
B. Weekly group social skills training
C. Teaching access to therapist-coaching during crisis events
D. Weekly consultation group for all therapists involved in the
treatment.
3. Group therapy should be supportive rather than exploratory.
Current literature suggests that there is hope for BPD
through psychotherapies such as DBT. 73
 BPD
Book
Don’t Leave Me, I Hate You – Jerold Kreisman

Website – borderlinepersonalitydisorder.org
Movies
A Streetcar Named Desire Play Misty for Me

Fatal Attraction Prozac Nation

Frances Silver Linings Playbook

Girl, Interrupted Welcome to Me

Looking for Mr. Goodbar What About Bob?

74
 BPD
Famous People Who May Have/Had
BPD or Symptoms
Jim Carrey Princess Diana

Peter Davidson Britney Spears

Brandon Marshall

Marilyn Monroe

May is Amy Winehouse

Borderline
Personality ←
Awareness
Month.

75
 HISTRONIC PERSONALITY DISORDER (HPD)
The essential feature of this disorder is a pattern of
extremely emotional and attention-seeking behavior. This
disorder used to be called Hysterical personality
Disorder. (Drama queen)

301.50 Histrionic Personality Disorder

A pervasive pattern of excessively emotionally and
attention seeking, beginning by early adulthood and is
present in a variety of contexts, as indicated by five (or
more) of the following:
1. Is uncomfortable in situations when he/she is not the
center of attention.
2. Interactions with others are often characterized by
inappropriate sexually seductive or provocative behavior
76
 HPD
3. Displays rapidly shifting emotions and shallow expression of
emotions.
4. Consistently uses physical appearance to draw to attention to
self through flamboyant attire, spiked heels, and theatrical makeup.
5. Style of speech is excessively impressionistic and lacking in
detail; exaggerated expression of emotion.
6. Shows self-dramatization, theatricality, and Constantly seeking
attention.
7. Is suggestible, i.e., easily influenced by others or
circumstances.
8. Considers relationships to be more intimate than they actually
are.

77
Histrionic Personality Disorder

78
Associated Features HPD
1. May have difficulty achieving emotional intimacy in
romantic or sexual relationships.

2. Often has impaired relationships with same-sex friends

due to sexually provocative interpersonal style threatening
their friends’ relationships. Often alienates friends with
demands for constant attention.

3. May carve novelty stimulation and excitement, and

have a tendency to become bored with their usual routine.

4. Often intolerant of situations that involve delaying

gratification and their actions are often directed at
obtaining immediate satisfaction.

5. The actual risk of suicide is not known, but these

individuals may be at increased risk for suicidal gestures
and threats to get attention.
79
 6. Often initiate a job or project with great enthusiasm HPD
but their interest may decrease quickly.
7. Common for this disorder to be associated with
somatization
8. May have a substance-use disorder.
9. Tend to be creative and imaginative rather than analytical
or academic.
10. Difficult to get detailed information.

Prevalence – Approximately 1.84%. Rates of about

10%-15% have been reported in inpatient and out-patient
mental health settings when structured assessment is used.

Sex Ratio – More common in females in clinical settings

but may be equal in the general population. 80
Predisposing Factors
HPD

1. Parental acceptance and approval came inconsistently

and only when the behaviors met parental expectations.
Nursing Interventions
Many of the interventions are the same as for BPD.
1. Set firm limits since they tend to manipulate.
2. Ignore sexual provocations.
3. Since they have the potential for suicide, implement
necessary suicidal precautions.
Medical Treatment
Medications are not indicated in the chronic treatment of
HPD. 81
 HPD
Psychosocial Treatment

1. Long-term psychotherapy is the treatment

of choice but may not be effective for those
individuals who have severe symptoms of the
disorder.

2. Some therapists advocate a supportive,

problem-solving approach or a cognitive
approach to deal with distorted thinking
(i.e., inflated self-image) and to minimize the
counterproductive effects of frequent
excessive emotional outpouring.
82
Movies
HPD

A Streetcar Named Desire Bullets over

Broadway

Anywhere but Here Gypsy

Bad Teacher Sunset Blvd.
Basic Instinct Gone with the Wind
Famous People Who May Had/Have HPD or
Symptoms:
Miley Cyrus → Jessica Simpson
Meagan Fox Anna Nicole
Smith

Kim Kardashian Kanye West 83

 NARCISSISTIC PERSONALITY DISORDER (NPD)
301.81 Narcissistic Personality Disorder
The essential feature of NPD is a pervasive pattern of
grandiosity, need for admiration, and lack of empathy that
begins by early adulthood and is present in a variety of
contexts.

A pervasive pattern of grandiosity (in fantasy or behavior)

need for admiration, and lack of empathy, beginning by early
adulthood and present in a variety of contexts, as indicated by
five (or more) of the following:

1. Has a grandiose sense of self-importance (i.e.,

exaggerates achievements and talents, expects to be
recognized as superior without commensurate
84
achievements).
 NPD
2. Is preoccupied with fantasies of unlimited success,
power, brilliance, beauty or ideal love.
3. Believes that he or she is “special” and unique and
can only be understand by, or should associate with,
other special or high-status people (or institutions).
4. Requires excessive admiration due to inflated self-
esteem.
5. Has a sense of entitlement, (i.e., unreasonable
expectations of especially favorable treatment or
automatic compliance with his or her expectations).
6. Is interpersonally exploitative, (i.e., takes advantage
of others to achieve his or her own ends).
7. Lacks empathy: is unwilling to recognize or identify
with the feelings and needs of others.
85
 NPD
8. Is often envious of others or believes that
others are envious of him/her/them.

9. Shows arrogant, haughty behaviors or attitudes.

Associated Features
1. May be very sensitive to criticism or defeat and
may leave them feeling humiliated, degraded,
hollow, and without empathy.

2. May react with defiance, disdain, rage, or

counterattack. Violently act out and be revengeful.

3. Interpersonal relationships are typically impaired

due to problems of entitlement, need for admiration,
and the disregard for the sensitivities of others.
86
 NPD
4. May be associated with Anorexia Nervosa and
Substance Related Disorders (especially cocaine) and
other co-occurring Cluster B Personality Disorders.

5. May have perverse sexual fantasies, be

promiscuous or be homosexual.

Prevalence – 0%-6.2% in the general population and from

2% to 16% in the clinical setting.

Sex Ratio – 50%-75% are male

Predisposing Factors

1. Parents were often narcissistic themselves. They

were demanding, perfectionistic, critical and placed
unrealistic expectations on the child.
87
 NPD
2. May be from abuse.

3. The parents may have lived vicariously through

child – may have overindulged them, no limits,
inconsistent parenting.

88
 NPD
Nursing Interventions
*Many of the interventions are the same as for BPD.
1. Firm limit-setting is essential since they feel
entitled to more attention than would be normally
given to them.
2. Be consistent and professional

3. Help the client work through abandonment,

rejection, shame and self-doubt.

4. Assist the client in accepting feedback without

defensiveness and rationalization. Help him or her
to increase his or her capacity to tolerate frustration
and disappointment.
89
 NPD
5. What approach to use with a patient with NPD when
discrepancies exist between what the client states
and what actually exists?

**Use supportive confrontation with the client to

point out discrepancies between what the client states
and what actually exists to increase responsibility for
self.

90
 NPD
Psychosocial Treatment:

1. Hospitalization is indicated for those individuals who

have severe symptoms or who have poor motivation for
outpatient treatment

2. They rarely seek treatment. If they do, its usually due to

depression or a medical illness threatens their grandiosity.

3. If they do seek individual or group therapy treatment,

they may have reluctance, negative therapeutic reactions &
drop out early. They may also monopolize group therapy

91
 NPD
Famous People Who May Have/Had
NPD or Symptoms
Rodney Alcala John Hinckley, Jr.
Beyoncé Kylie Jenner
Justin Bieber Angeline Jolie
Napoleon Bonaparte Kim Kardashian
Ted Bundy Madonna
Mariah CareyO.J. Simpson
Miley Cyrus ← Charlie Sheen
Drake Donald Trump
Paris Hilton

92
 AVPD
CLUSTER C PERSONALITY
DISORDERS
Avoidant Personality Disorder (AVPD)
The primary peculiarity of this disorder is a pattern of
discomfort, timidity, and is easily hurt by criticism.

DSM-5 Diagnostic criteria for 301.82 Avoidant

Personality Disorder
A pervasive pattern of social inhibition, feelings of inadequacy,
and hypersensitivity to negative evaluation, beginning by early
adulthood and present in a variety of contexts as indicated by
four (or more) of the following:
1. Avoids occupational activities that involve significant
interpersonal contact, because of criticism, disapproval, or
rejection.
93
 AVPD
2. Is unwilling to get involved with people unless certain
of being liked.
3. Shows a restraint within intimate relationships
because of the fear of being shamed or ridiculed.

4. Is preoccupied with being criticized or rejected in

social situations. They may appreciate a compliment, but
later fear rejection and humiliation

5. Is inhibited in new interpersonal situations because of

feelings of inadequacy.

6. Views self as socially inept, personally unappealing,

or inferior to others.

7. Is usually reluctant to take personal risks or to

engage in any new activities because they may prove
embarrassing. 94
 AVPD
Associated Features
1. Often have no close friends because it is difficult for
them to enter into relationships unless they have a
strong sense they will be accepted without any
criticism. This is not realistic.

2. They appear overly serious, humorless, and

painfully shy.

3. They exaggerate difficulties or risks of ordinary

activities outside their normal routine.

4. They may have a disfiguring illness.

5. The most common PD correlated with weight loss

surgery is Avoidant Personality Disorder.
95
AVPD

96
 AVPD
Prevalence – About 2.4% in the general population
and about 10% seen in mental health clinics.

Sex Ratio – Equally frequent in all genders.

Predisposing Factors
1. Parental rejection which is often reinforced by peers.
2. Family may have belittled them, abandoned, criticized.
They have low self-worth and feel alienated. They learn to be
suspicious and to view the world as hostile and dangerous.

Nursing Interventions
1. They may avoid seeking treatment because it’s going to
be a social situation and will cause anxiety.
2. They need support, time, and encouragement to
cooperate. 97
 AVPD
3. A warm caring approach may help with the mistrust.
4. Systematic desensitization techniques are used to assist
client in forming relationships.
5. Behavioral techniques (i.e., contracting with client to
network with others in support groups and employment
activities) may also help.

Medical Treatment
⚫ MAOIs may be helpful, especially for social phobias.

Psychosocial Treatment
1. Long-term psychotherapy may be useful and group
therapy may desensitize the client to the exaggerated threat
of rejection.
2. Patients with AVPD tend to be well-liked and get much
support in therapy groups. 98
 AVPD
Movies:

The Glass Menagerie

Finding Forrester
Zelig
AVPD

Famous People Who May

Had/Have AVPD or Symptoms
Kim Basinger
Donny Osmond

Michael Jackson
99
 DPD
301.6 DEPENDENT PERSONALITY DISORDER
The essential feature of this disorder is a pattern of
dependent and submissive behavior.
DSM-5 Diagnostic criteria for 301.6 Dependent
Personality Disorder (DPD)
A pervasive and excessive need to be taken care of that
leads to submissive and clinging behavior and fears of
separation, beginning by early adulthood and present in a
variety of contexts, as indicated by five (or more) of the
following:
1. Has difficulty making everyday decisions without an
excessive amount of advice and reassurance from others.

100
 DPD
2. Needs others to assume responsibility for most major
areas of his or her life.

3. Has difficulty expressing disagreement with others

because of fear of loss of support or approval.

Note: Do not include realistic fears of retribution.

4. Had difficulty initiating projects of doing things on his or

her own (because of a lack of self-confidence in
judgment or abilities rather than a lack of motivation or
energy).

5. Goes to excessive lengths to obtain nurturance and

support from others, to the point of volunteering to do
things that are unpleasant.

6. Feels uncomfortable or helpless when alone because of

exaggerated fears of being unable to care for himself or
herself. 101
 DPD
7. Urgently seeks another relationship as a source
of care and support when a close relationship ends.
8. Is unrealistically preoccupied with fears of being left
to take care of himself or herself.

Associated Features
1. Tend to belittle their abilities and assets, and may
constantly refer to themselves as “stupid.”
2. They may avoid positions of responsibility and
become anxious when faced with decisions.
However, may be productive if supervised.
3. Often seek help for anxiety or mood disorders (i.e.,
Depression) related to a loss.

102
 DPD
4. May co-exist with Histrionic, Schizotypal,
Narcissistic, and Avoidant Personality Disorders.

Predisposing Factors
1. Chronic physical illness or Separation Anxiety
Disorder in childhood or adolescence may
predispose the individual to the development of
this disorder.
2. May have a medical disability that requires them
to depend on others for care.
3. The inherited trait of submissiveness has been to
found to be heritable by as much as 45%.

103
 DPD
4. Oral stage of psychosexual development-
overindulged or frustrated wished during the oral
phase. Oral features-constant demand for
attention, passivity, dependency, dread of decision
making, a fear of autonomy and oral behavior (i.e.,
smoking, drinking, overeating).

5. More common with the youngest child of the

family.
6. Parents who overprotect their children and don’t
allow them to have new experiences. They
reinforce dependent behaviors and/or punish
independent behavior in childhood.
7. Example, a physically healthy client who lives
with parents and relies on public transportation

104
 Needs guidance
on every decision

Very needy
Exaggerated
portrayal of
Extreme dependency

105
 DPD
Prevalence-This disorder is among the most
frequently reported Personality Disorders encountered in
mental health clinics. In the general population about
0.49% – 0.6%.

Sex Ratio-In clinical settings, this disorder has been

diagnosed more frequently in females but some studies
suggest similar prevalence rates among males and
females and all genders.

Nursing Interventions
1. It may be tempting to help the client make decisions
but avoid doing this. Encourage self-responsibility.

106
 DPD
2. Make them aware that they have choices

3. Teach problem-solving techniques, setting

goals and evaluation consequences
4. Teach and role made assertive behavior.
5. Give positive reinforcement for successful
achievements.

6. Countertransference issues may arise due to

client’s needy, clinging, demanding behavior.
Medical Treatment

⚫ Antidepressants and anti-anxiety medication are

used for specific symptoms. Imipramine (Tofranil) can
treat panic attacks.
107
 DPD
Psychosocial Treatment
1. More insightful clients may benefit from
psycho-dynamic psychotherapy. Less
psychologically-minded clients, or those not
wanting psychotherapy, may benefit from
supportive group therapy or assertiveness
training.
2. May call therapist’s office often for advice,
clarification, and to schedule extra
appointments. Clear limits must be set at the
beginning of treatment to avoid hurt and angry
feelings.
108
 DPD
Movie
When a Man Loves A Woman

Famous People Who May Have/Had DPD or

Symptoms Susan Smith (drowned her 2 sons
Charles Ng (tortured to be with a new boyfriend)
& killed multiple women)

109
 OCPD
301.4 Obsessive Compulsive Personality
Disorder (OCPD)
The fundamental feature of this disorder is a pattern of
perfectionism and inflexibility. This is a milder form of
Compulsive Disorder. There is an association of this
disorder with the “Type A” personality.

DSM-5 Diagnostic criteria for 301.3 Obsessive

Compulsive Personality Disorder

A pervasive pattern of preoccupation with orderliness,

perfectionism, and mental and interpersonal control, at the
expense of flexibility, openness, and efficiency, beginning
by early adulthood and present in a variety of contexts, as
indicated by four (or more) of the following:
110
 OCPD
1. Is preoccupied with details, rules, lists, order,
organization, or schedules to the extent that the
major point of the activity is lost.
2. Is preoccupied with details, rules, lists, order,
organization, or schedules to the extent that the
major point of the activity is lost.
3. Shows perfectionism that interferes with task
completion (e.g., is unable to complete a
project because his or her own overly strict standards
are not met).
4. Is excessively devoted to work and productivity to
the exclusion of leisure activities and
friendships (not accounted for by obvious economic
necessity) 111
5. Is over-conscientious, scrupulous, and inflexible OCPD
about matters of mortality ethics, or values (not
accounted for by cultural or religious identification).

6. Is unable to discard worn-out or worthless objects

even when they have no sentimental value.

7. Is reluctant to delegate tasks or work with others

unless they submit to exactly his or her way of doing
things. Is critical of family and co-workers.

8. Adopts a miserly spending style toward both self and

others, money is viewed as something to be hoarded for
future catastrophes. Called “Pack Rats.

9. Show rigidity and stubbornness. They become very

upset about changes in routines. “You can’t make these
kinds of changes!” 112
OCPD

113
 OCPD
Associated Features
1. They have difficulty expressing tender feelings, paying compliments.
Emotional behavior may be seen as immature/irresponsible. Externally they
appear calm and in control. Internally they feel ambivalence, conflict, and
hostility.
2. Defense mechanisms – Rationalization, reaction formation, undoing, and
intellectualization
3. They carefully hold themselves back until they are sure whatever they will
say will be perfect.
4. A lack of generosity in giving time, money and gifts when no personal gain
is likely to result. “Pack rats.”

114
 OCPD

5. Only 6% of patients with OCD also have OCPD.

6. Co-occurring disorders: Generalized Anxiety Disorder, Obsessive-
Compulsive Disorder, Social and Specific Phobias, mood and eating
disorders.

Predisposing Factors
1. Parents were very controlling and critical.
2. Praise was not as much as punishment for undesirable behavior.
3. Positive achievements were expected, taken for granted, and only
acknowledged occasionally.

115
 OCPD

4. Psychoanalytically they are seen as arrested at the anal

stage of development.
5. Only 6% of patients with OCD also have OCPD.
Prevalence – One of the most prevalent personality disorders
in the general population. Approximately 2.1%-7.9% in
community samples and about 3%-10% in individuals presenting
in mental health clinics.
Sex Ratio – Appears to be diagnosed about twice as often
among males and in the oldest sibling.

116
 OCPD
Nursing Interventions
1. Show approval when the client gets involved with leisure or
recreational activities but do not demand that he/she/they engage/s
in them (client will “work” at them instead of enjoying them).
2. Help client identify and differentiate between “shoulds”
(behaviors expected by others) and “wants” (desirable activities).
3. Encourage verbalization of feelings especially those of anger
and resentment.
4. Help the client to identify alternative coping methods to deal with
stressful situations.
5. Avoid power struggles with the client.

(
117
 OCPD
Medical Treatment
1. Tricyclics and MAOIs have caused dramatic improvement
in severely disabled obsessive- compulsive clients.
2. clompriamine (Anafranil) and SSRIs are prescribed for
obsessional thinking and depression.

Psychosocial Treatment
1. They may seek help for anxiety and mood disorders.
2. Compulsive people are difficult to treat mainly because
their obsessiveness paralyzes therapy. They tend to go on
and on in answering the health care professional’s questions.
They tend to be concrete whereas psychology is abstract.

118
 OCPD
3. Long-term psychotherapy is the treatment of choice. It must focus
on feelings rather than thoughts.
4. The therapist should pay attention to detail to form an alliance with
the client. Complete explanations should be given of what will happen
during evaluation and progress should be measured in terms of
changed behavior, not insight.
5. Behavioral techniques may be effective such as “flooding,”
“implosion” and “saturation.”
6. Family therapy is important in helping the family members with
emotional support, reassurance, explanation and advice on how to
manage and respond to the client.

119
(
 OCPD

Movie
The Odd Couple

Famous People Who May

Have/Had OCPD or Symptoms
David Beckham
Steve Jobs
Howard Stern

Justin Timberlake
Jessica Alba

120
 WORKS CITED
Diagnostic and Statistical Manual of Mental Disorders: DSM-5,5th
ed., American Psychiatric Association, 2013.
Grimaldi, Diane and Deborah Van Etten. “Psychosocial Adjustments
Following Weight Loss Surgery.” Journal of Psychosocial Nursing
and Mental Health Services. 48.3 (2010): 24-29.
Maxmen, Jerrold S. and Nicolas G. Ward. Essential
Psychopathology and Its Treatment. 2nd ed., W.W. Norton &
Company,1995.
Ren Kneisl, Carol and Eileen Trigoboff. Contemporary Psychiatric -
Mental Heath Nursing. 3rd ed., Pearson, 2013.

(
121
 Townsend, Mary C. Psychiatric Mental Health Nursing: Concepts of
Care in Evidence-Based Practice. 5th ed., F.A. Davis Co., 2006.
Varcarolis, Elizabeth M. et al. Foundations of Psychiatric Mental
Health Nursing: A Clinical Approach. 5th ed., Saunders Elsevier,
2006.
Varcarolis, Elizabeth M. and Margaret Jordan Halter. Foundations of
Psychiatric Mental Health Nursing: A Clinical Approach. 6th ed.
Saunders Elsevier, 2010.
Videbeck, Sheila L. Psychiatric-Mental Health Nursing. 7th ed.
Wolters Kluwer, 2017.

122
(
Post this for them to use as a flash card on Canvas
on the week of the lecture on Personality Disorders

123