Chapter 24

Personality Disorders
 Objectives
 Identify characteristics of each of the 10
personality disorders.
 Discuss guidelines for nursing care
associated with each of the 10 personality
disorders.
 Analyze the interaction of biological
determinants and psychosocial risk factors in
the development of personality disorders.
 Personality Disorders
 Cluster A: Eccentric  Cluster C: Anxious
 Paranoid  Avoidant
 Schizoid  Dependent
 Schizotypal  Obsessive-
 Cluster B: Erratic compulsive
 Borderline
 Narcissistic
 Histrionic
 Antisocial
Cluster A Personality Disorders

 Paranoid
 Schizoid
 Schizotypal
 Paranoid Personality
Disorder
 Prevalence: 2% to 4%
 Characteristics
 Longstanding distrust and suspicion of others
 May be apparent in childhood
 Social anxiety in childhood
 Jealous, controlling as adults
 Unwillingness to forgive and projection of feelings
Paranoid Personality
Disorder (Cont.)

 Guidelines for Nursing Care

 Counteracting mistrust
• Adhere to schedules
• Avoid being overly friendly
• Use simple, direct language
• Project a neutral but kind affect
 Paranoid Personality
Disorder (Cont.)

 Treatment
 Psychotherapy versus group therapy
 Antianxiety agents (Diazepam)
 Antipsychotics for more severe delusions
• Haloperidol (Haldol)
• Pimozide (Orap)
 Schizoid Personality
Disorder
 Prevalence: Nearly 5% of population
 Characteristics
 Symptoms appear in childhood and adolescence
 Loners, poor academic performance
 Increased prevalence of disordered family life
 Avoid close relationships
 Depersonalization, detachment
 Schizoid Personality
Disorder (Cont.)
 Guidelines for nurses
 Avoid being too “nice” or “friendly”
 Do not try to increase socialization
 Assess for symptoms the patient is reluctant to
discuss
 Protect against group’s ridicule
 Treatment
 Psychotherapy
 Group therapy
 Antidepressants, 2nd-generation antipsychotics
 Schizotypal Personality
Disorder
 Prevalence: Varies from 0.6 to 4.6% population
 Characteristics
 Severe social and interpersonal deficits
 Anxiety in social situations
 Rambling conversation
 Paranoia, suspiciousness, anxiety, distrust
 Brief, intermittent episodes of hallucination or delusion
 Can be made aware of their own odd beliefs
 May be vulnerable to involvement with cults or
unusual religious/occult groups
 Schizotypal Personality
Disorder (Cont.)
 Nursing care guidelines
 Respect patient’s need for social isolation.
 Be aware of and intervene appropriately with patient’s
suspiciousness.
 Perform careful diagnostic assessment for symptoms
that may need intervention (e.g., suicidal thoughts).
 Withhold judgment or ridicule.
 Treatment
 Supportive psychological care (investigate possible
involvement with cults)
 Low-dose antipsychotics
Cluster B (Erratic)

 Histrionic
 Narcissistic
 Special Considerations

 The Two Most Challenging Cluster B Disorders

 Borderline Personality Disorder
 Antisocial Personality Disorder
 These will be discussed at the end of this
chapter for special focus.
 Case Study
Jim and Mercedes begin marriage counseling
together in hopes, Mercedes says, of saving their
marriage.
The therapist quickly notices that Jim seems to
think a lot of himself, while putting Meredith down.
When she expresses hurt, he either laughs or
manipulates her into feeling guilty or backing
down.
The therapist also notices that Jim frequently
boasts about how successful he is, as if he needs
the therapist to know and admire this about him.
 Histrionic Personality
Disorder
 Prevalence: Nearly 2% of population
 Characteristics
 Excitable, dramatic; often high functioning
 Bold external behaviors
 Limited ability to develop meaningful relationships
 Attention-seeking, self-centered; low-frustration level
 Excessive emotions; may be provocative; smothering
 No insight into disorder or role in ruining relationships
 Histrionic Personality
Disorder (Cont.)
 Treatment
 Psychotherapy is treatment of choice
 Guidelines for nursing care
 Know that seductive behavior is a response to
distress.
 Keep interactions professional; ignore flirtations.
 Model concrete language.
 Help patient clarify inner feelings
 Teach and role-model assertiveness.
 Assess for suicidal ideation.
 Case Study
As Jim and Meredith’s marriage therapist
continues to work with them, she quickly discerns
that Jim is not interested in changing his attitude or
behaviors toward his wife.
Although Meredith, like Jim, is financially
successful, Jim manages all their finances and
Meredith feels he exploits her income for his own
advantage.
Jim is hypersensitive to criticism and feels that
“as the smarter male partner” he is entitled to a
greater share of control over their funds.
 Narcissistic Personality Disorder
 Prevalence: For 0% to 6%
 Characteristics
 Feelings of entitlement, exaggerated self importance
 Lack of empathy; tendency to exploit others
 Weak self-esteem and hypersensitivity to criticism
 Constant need for admiration
 Less functional impairment than other personality
disorders
 Case Study

Jim is diagnosed with narcissistic personality

disorder. Given what you know about the
characteristics of this disorder, what intervention
strategies would you predict to be most helpful in
working with Jim?
 Narcissistic Personality Disorder
 Guidelines for Nursing Care
 Remain neutral.
 Promote a stronger patient self-identity
 Avoid power struggles or becoming defensive.
 Role-model empathy.
 Treatment
 Difficult to treat: patients not likely to seek help or
confront shortcomings
 Cognitive-behavioral therapy (CBT) to deconstruct
faulty thinking
 Group therapy; lithium for mood swings
 Objectives
 Describe the emotional and clinical needs of
nurses and other staff who work with patients
who have personality disorders.
 Formulate a nursing diagnosis for each of
the personality disorders.
 Objectives (Cont.)
 Plan basic interventions for a patient with
impulsive, aggressive, or manipulative
behaviors.
 Identify biological treatments and
psychological therapies for each of the
personality disorders.
 Cluster C (Anxious)

 Avoidant
 Dependent
 Obsessive-compulsive
 Avoidant Personality
Disorder
 Prevalence: 2.4%
 Characteristics
 Low self-esteem
 Shyness that increases with age
 Feelings of inferiority
 Reluctance to engage with new people
 Subject to depression, anxiety, and anger
 Preoccupied with rejection, humiliation, and failure
 Avoidant Personality
Disorder (Cont.)
 Guidelines for nursing care
 Friendly, accepting, reassuring approach
 Don’t push!
 Acceptance of patient fears
 Group therapy
 Exercises to enhance new social skills
 Design exercises to prevent failures
 Assertiveness training
 Avoidant Personality
Disorder (Cont.)
 Treatment Modalities
 Individual therapy
• Trust building
• Assertiveness training
 Group therapy
 Antianxiety agents
 Antidepressants
 Dependent Personality
Disorder

 Prevalence: 0.5%
 Characteristics
 High need to be taken care of
 Submissiveness
 Fears of separation and abandonment
 Manipulating others to take responsibilities
 Intense anxiety when left alone even briefly
 Dependent Personality
Disorder (Cont.)
 Guidelines for nursing care
 Help address current stressors
 Set limits that don’t make the patient feel punished
 Be aware of strong countertransference
 Use therapeutic relationship as a testing ground for
assertiveness training
 Treatment
 Psychotherapy is treatment of choice
 Obsessive-Compulsive
Personality Disorder

 Prevalence: 2% to 8%
 Characteristics
 Rigidity; inflexible standards for others and self
 Constant rehearsal of social responses
 Excessive goal-seeking that is self-defeating or
relationship-defeating
 Strict standards interfere with project completion
 Unhealthy focus on perfection
 Obsessive-Compulsive
Personality Disorder (Cont.)
 Guidelines for nursing care
 Guard against power struggles
 Remember that the patient has difficulty dealing with
unexpected changes
 Provide structure, but with time to complete habitual
behaviors
 Treatment
 Group and behavioral therapy
 Clomipramine or fluoxetine for obsessions, anxiety,
and depression
 Discussion

 A patient admitted to your unit has a personality

disorder. What are some important areas to
assess?
 Special Considerations

 The Two Most Challenging Personality Disorders

 Borderline Personality Disorder
 Antisocial Personality Disorder
• Both are Cluster B Disorders
 Objectives

 Discuss two nursing outcomes for

patients with borderline and
antisocial personality disorder.
 Case Study
Sydney, 27, is dropped near an emergency department
—literally dropped. Two of her roommates force her bodily
from their car and drop two large plastic garbage bags on
the grass. Sydney, who is very unkempt, stands shrieking,
and an EMT standing near the outside entrance, takes a
few running steps to stop the car as it backs out.
“What’s happening here?” he says.
“Sorry,” says one of the women, “but we just can’t take it
anymore. She’s uncontrollable, and we’re both afraid of her.
She needs help.”
 Borderline Personality
Disorder
 Cluster B Disorder
 Clinical picture
 Severe impairments in functioning
 Emotional lability
 Impulsivity
 Self-destructive behaviors
 Antagonism
 Splitting: Inability to view both positive and negative
aspects of others as part of a whole
 Borderline Personality
Disorder (Cont.)
 Prevalence: 1.6%
 Epidemiology and comorbidity
 10% suicide and mortality rate
 70% will attempt suicide
 BPD patients often have another mental illness
 Substance use disorders: >50%
 Risk Factors
 High genetic association
 Neurobiological
 Cognitive: Separation-individuation
 Case Study
Sydney, the young woman who was dropped near
an emergency department by her roommates is
brought into the ED, sobbing and shrieking the entire
time.
She has evidence of “cutting” up and down her
arms, and she shouts curses at each female nurse
and refuses to cooperate saying that she is tired of
everyone trying to tell her what to do. She calms
down a little when a male nurse approaches.
When asked why that helps, she says, “Women
are jerks. Never trust other women. They’re all
mean!”
 Audience Response Question
Sydney is admitted to the psych unit for evaluation.
Which behaviors would be consistent with a
diagnosis of borderline personality disorder?
A. Splitting
B. Inflexible standards
C. Lack of empathy
D. Absence of remorse
E. A and B
 Application of the Nursing Process
for BPD
 Assessment
 Semi-structured interview
 Use of MMPI
 Self-assessment
 Nursing diagnoses
 Risk for self-mutilation
 Risk for suicide
 Risk for violence
 Social isolation
 Impaired socialization
 Disturbed personal identity
 Difficulty coping
 Nursing Process (Cont.)
 Outcomes and planning
 Nursing Outcomes Classification (NOC) scales for
measuring improvement
 Importance of the therapeutic relationship
 Avoid manipulative behaviors
 Implementation
 Provide clear and consistent boundaries
 Use clear, straightforward communication
 Calmly review therapeutic goals
 Teamwork and safety
 Respond matter-of-factly to superficial self-injuries
 Treatment Modalities
 Biological Treatment
 Psychotropics geared toward symptom relief
 Psychological Therapies
 CBT
 Dialectical behavior therapy (DBT)
 Schema-focused therapy
 Audience Response Question
Which behavior indicates that Sydney, our patient
diagnosed with borderline personality disorder, is
improving?

A. She cries when her roommate refuses to go to the

dining room with her.
B. She yells at the group facilitator when he points out
that she is monopolizing the group.
C. She informs a staff member that she is having
thoughts of harming herself.
D. She tells the evening staff that the day staff excused
her from group to smoke when she got upset.
Antisocial Personality Disorder

 Cluster B Disorder
 Prevalence: 1.1%
 Characteristics
 Antagonistic behaviors
 Disinhibited behaviors
 Profound lack of empathy
 Absence of remorse or guilt
 Symptoms peak mid-teens to 20s; symptoms may
abate and improve on their own by age 40
Application of the Nursing Process
for Antisocial Personality Disorder
 Assessment
 Patients with antisocial PD become
defensive and do not tend to answer
honestly
 Self-assessment
 Nursing diagnoses
 Risk for violence
 Impaired impulse control
 Impaired social interaction
 Nursing Process (Cont.)

 Outcomes
 Abusive behavior self-restraint
 Aggression self-restraint
 Coping, social interaction, social isolation knowledge
 Health promotion knowledge
 Health promoting behavior
 These will be difficult to accomplishment.
 Maintaining safety is the priority.
 Nursing Process (Cont.)

 Planning and Implementation

 Boundaries, consistency, support, and limits
 Realistic choices
 Therapeutic communication vs. manipulation
 Teamwork and safety (prime)
 Pharmacological interventions (mood stabilizers)
 Evaluation…
 is difficult and may be unknowable
 Motivation patients may learn to change behaviors
 Antisocial Personality
Disorder (Cont.)

 Treatment Modalities
 No specific medications
 Mood-stabilizers may help with aggression
 Also possible: SSRIs, benzodiazepines, or Ritalin
 Psychological Therapies
 Some evidence that this patient population may bond
with psychotherapists
 CBT, MBT, or DBT
 Audience Response Questions
Perfectionism is a trait likely to be evident in a
person with which personality disorder?

A. Obsessive-compulsive
B. Narcissistic
C. Antisocial
D. Avoidant
 Audience Response Questions
Antisocial, obsessive-compulsive, and schizotypal
personality disorders occur most frequently in

A. adolescents.
B. children.
C. women.
D. men.