PERSONALITY DISORDERS

- Impairment of personality functioning and personality traits that are maladaptive

PERSONALITY
Is the pattern of behaving and relating to self, others, and the environment:
It includes perceptions, attitudes, and emotions
A person usually is not consciously aware of her or his personality
MALADAPTATION
 Mistrust
 Exhibitionism
Eccentric- odd; uncommon

Cluster -according to predominant type of behavioral pattern

 CLUSTER A-ODD OR ECCENTRIC
 Paranoid PD
 Schizoid PD
 Schizotypal PD
 CLUSTER B-ERRATIC OR DRAMATIC
 Antisocial PD
 Borderline PD
 Histrionic PD
 Narcissistic PD
 Cluster C - ANXIOUS OR FEARFUL
 Avoidant PD
 Dependent PD
 Obsessive PD
Other Maladaptive behaviors
 Depressive behavior
 Characterized by a pervasive pattern of depressive cognitions and behaviors.
 Occurs in people with relatives who have major depressive d/o.
 Passive-aggressive behaviors
 Characterized by a negative attitude and a pervasive pattern of passive resistance to demands for
adequate social and occupational performance.
 Clients may appear cooperative, even ingratiating, or sullen and withdrawn depending on the
circumstances
Etiology
 Biologic Theories
1. Temperament - biologic processes of sensation, association, and motivation that underlie the integration
of skills and habits based on emotion
 four temperament traits are:
 harm avoidance, -HIGH avoidant pd (Shy, worry a lot, social inhibition) LOW -
Antisocial (carefree, danger)
 novelty seeking, -HIGH - ANTISOCIAL (Impulsive) Low-Orderly, have
routines (Obsessive)
 reward dependence, and HIGH – Avoidant PD (socially dependent) ; LOW
Schizoid (cold, detach, Aloof)
 persistence-HIGH (hardworking -Frustration mmay result -NARCISSistic
Low-Avoidant (unstable, give up easily, Idle (Indolent)
2. Psychodynamic
 Character -consists of concepts about the self and the external world.
 It develops over time as a person comes into contact with people and situations and
confronts challenges.
 SELF –DIRECTEDNESS- the extent to which the person is responsible, reliable, resourceful, goal-
oriented,& self-confident.
  COOPERATIVENESS- person sees himself/herself as part of the human society.
 - described as empathic,tolerant, compassionate,supportive, and principled.
 SELF-TRANSCENDENCE- person considers himself/herself to be an integral part of the universe.
 -are spiritual, unpretentious, humble, and fulfilled

ONSET
 Incidence is even higher for people in lower socioeconomic groups and unstable or disadvantaged
populations.
 higher death rate, especially as a result of suicide;
 Higher rates of suicide attempts, accidents , and emergency department visits
 Increased rate of separation, divorce, and involvement in legal proceedings regarding child custody.
 have been correlated highly with criminal behavior, alcoholism and drug abuse
 They are described as “treatment resistant”
TREATMENT

1. Psychopharmacology
 Mood stabilizer e.g. Lithium, anticonvulsant, and benzodiazepines are used most often to treat
aggression.
 lithium, Anticonvulsant e.g. carbamazepine (Tegretol), valproate (Depakote), Typical
Antipsychotic, e.g. haloperidol(Haldol)for emotional instability & mood swings
 SSRI’S & Atypical Antipsychotics e.g. risperidone(Risperdal),olanzapine(Zyprexa)&
quetiapine(Seroquel), for emotional detachment & disinterest in social relations
 Pharmacologic treatment focuses on the client’s symptoms rather than the particular
subtype.
 Benzodiazepines- e.g. alprazolam(Xanax), diazepam (Valium), lorazepam (Ativan), clonazepam
(Klonopin)
 Anticonvulsants work by calming hyperactivity in the brain
 SSRI’s- Antidepressants, e.g. fluoxetine (Prozac or Oxactin); escitalopram (Lexapro),
fluvoxamine (Luvox), paroxetine (Paxil), Prozac, and sertraline (Zoloft)
3 major Psychotropic drugs
 Antidepressants. The selective serotonin reuptake inhibitors (SSRIs) and newer antidepressants are safe
and reasonable effective; however, because the depression of most patients with personality disorders stems
from their limited range of coping capacities, antidepressants are usually less effective than in patients with
uncomplicated major depression.
 Anticonvulsants. These agents are useful for stabilizing the affective extremes in patients with bipolar
disorder, but they are less effective in doing so in patients with personality disorders; they have some
demonstrated efficacy in suppressing impulsive and particularly aggressive behavior in patients with
personality disorder.
 Antipsychotics. Response to antipsychotics in patients with a personality disorder is less dramatic than it is
in true psychotic axis I disorders, but symptoms such as anxiety, hostility, and sensitivity to rejection may
be reduced.

2. Individual and Group Psychotherapy
 Goals:
 focus on building trust,
 teaching basic living skills,
 providing support,
 decreasing distressing symptoms such as anxiety,
 improving interpersonal relationships.
1. Cognitive–behavioral therapy
 Cognitive restructuring = techniques are used to change the way the client thinks about self and
others
 thought stopping = the client stops negative thought patterns
  positive self-talk = designed to change negative self-messages
 decatastrophizing = ("what if" technique); realistically confront the feared negative
outcome; teaches the client to view life events more realistically and not as catastrophes.
 “ Dialectical behavior therapy
 designed for clients with borderline personality disorder
 It focuses on distorted thinking and behavior based on the assumption that poorly regulated
emotions are the underlying problem
 CBT primarily helps clients recognize and change problematic patterns of thinking and behaving.
 DBT primarily helps clients regulate intense emotions and improve interpersonal relationships through
validation, acceptance and behavior change.
 Ex. Group therapy where patients are taught behavioral skills by completing homework assignments and
role-playing new ways of interacting with others.

CLUSTER A
1. Paranoid personality disorder
 Is characterized by pervasive mistrust and suspiciousness of others.
 Client interpret other’s actions as potentially harmful.
 They develop “transient” psychotic symptoms.
 Client’s appear aloof and withdrawn, remain distant from the nurse, appear guarded or
hypervigilant, have restricted affect, labile mood, sarcastic response
 Uses PROJECTION defense mechanism
Nursing Interventions:
 Nurse must approach client in a formal manner
 Being on time, keeping commitments, being straightforward
 Involve client in their plan of care
 One of the most effective interventions is helping client validate ideas before taking
actions.
2. Schizoid personality disorder
 Characterized by detachment from social relationships and a restricted range of emotional
expression in interpersonal setting.
 They avoid treatment as much as they avoid other relationships.
S-Solitary Lifestyle
I-Indifferent
R-Relationship-no interest
S-Sexual Experiences-No interest
A-Activities-None
F-Friends (lacking)
E-Emotionsally cold
 Nursing Interventions:
Improve clients functioning in the community
3. SCHIZOTYPAL PERSONALITY DISORDER
 is characterized by
  a pervasive pattern of social and interpersonal deficits marked by acute discomfort and reduced
capacity for close relationships
 cognitive or perceptual distortions and behavioral eccentricities
 odd appearance
 unkempt and disheveled
 their clothes are often ill-fitting, do not match, and may be stained or dirty
 may wander aimlessly
 Cognitive distortions include ideas of reference, magical thinking, odd or unfounded beliefs, and a
preoccupation with parapsychology, including extrasensory perception and clairvoyance.
 paranoid thinking and suspiciousness
 Affect is flat or sometimes silly or inappropriate
 Clients may experience transient psychotic episodes in response to extreme stress.
 people with schizotypal personality disorder eventually develop schizophrenia
 Clients often have an odd appearance that causes others to notice them.
 Clairvoyance- second sight; sixth sense
 Parapsychology- (such as hypnosis, telepathy-transmission of information from one person to another)
 Nursing Interventions:
 development of self-care and social skills and improved functioning in the community.
 encourage to establish a daily routine for hygiene and grooming
 Social skills training may help clients to talk clearly with others and to reduce bizarre
conversations.
CLUSTER B
1. ANTISOCIAL PERSONALITY DISORDER
 is characterized by a pervasive pattern of disregard for and violation of the rights of others—and with the
central characteristics of deceit and manipulation.
 also referred to as psychopathy, sociopathy, or dissocial personality disorder
 Psychopathy- deficient emotional responses, lack of empathy, and poor behavioral controls
 A psychopath doesn’t have a conscience. If he lies to you so he can steal your money, he won’t feel any
moral qualms, though he may pretend to. He may observe others and then act the way they do so he’s not
“found out,”
 A sociopath typically has a conscience, but it’s weak. They may know that taking your money is wrong,
and they might feel some guilt or remorse, but that won’t stop their behavior.
 Dissocial personality d/o- exhibit traits of impulsivity, high negative emotionality, low conscientiousness
and associated behaviours, including irresponsible and exploitative behaviour, recklessness and
deceitfulness
 Intervention
 Forming a Therapeutic Relationship and Promoting Responsible Behavior
 Limit setting is an effective technique that involves three steps:
 Stating the behavioral limit (describing the unacceptable behavior)
 Identifying the consequences if the limit is exceeded
 Identifying the expected or desired behavior
 “It is not acceptable for you to ask personal questions. If you continue, I will terminate our interaction. We
need to use this time to work on solving your job-related problems.”
 time-out or leaving the area and going to a neutral place to regain internal control is often a
helpful strategy.
 Time-outs help clients to
 avoid impulsive reactions and angry outbursts in emotionally charged situations,
 regain control of emotions, and
 engage in constructive problem-solving.
2. BORDERLINE PERSONALITY DISORDER
 is characterized by a pervasive pattern of unstable interpersonal relationships, self-image, and affect as well
as marked impulsivity.
  is the most common personality disorder found in clinical settings
 three times more common in women than in men.
 suicidal
 clingy
 manipulative
 Splitting - A split is typically triggered by an event that causes a person with BPD to take extreme
emotional viewpoints. These events may be relatively ordinary, such as having to travel on a
business trip or getting in an argument with someone.
 Interventions
1. Promoting Clients’ Safety
 Clients’ physical safety is always a priority.
 consider suicidal ideation with the presence of a plan, access to means for enacting the
plan, and self-harm behaviors and institute appropriate interventions
 no-self-harm contract = a client promises to not engage in self-harm and to report to the nurse
when he or she is losing control.
 promote self-responsibility
 Lecturing or chastising clients is avoided
 The no-self-harm contract is not a promise to the nurse but is the client’s promise to himself or herself to be
safe.
 Chastising- reprimand severely
2. Promoting the Therapeutic Relationship
 Provide structure and limit setting in the therapeutic relationship
 nurse would plan to spend a specific amount of time with the client working on issues or
coping strategies
 Confrontation techniques
3. Establishing Boundaries in Relationships
 Clients have difficulty maintaining satisfying interpersonal relationships
 Client: “You’re better than my family and the doctors. You understand me more
than anyone else.”
 Nurse: “I’m interested in helping you get better, just as the other staff members
are.” (establishing boundaries)
4. Helping Clients to Cope and to Control Emotions
 Journaling = to help clients gain awareness of feelings.
 Decreasing impulsivity and learning to delay gratification
 distraction such as taking a walk or listening to music to deal with the delay
5. Structuring the Clients’ Daily Activities
 Help clients make a written schedule that includes appointments, shopping, reading the
paper, and going for a walk.
3. Histrionic personality disorder
 Characterized by excessive emotionality and attention seeking.
 They seek treatment for depression, unexplained physical problems, and difficulties in
relationship.
Personality of Histrionic
1. Attention seeker
2. Dramatic
3. Seductive
4. Inconsistent Mood and emotions
5. Discomfort with lack of attention
6. Focus on physical appearance
7. Seeking reassurance
8. easily influenced
9. Believes relationship are closer than expected
10. Suicidal if lack of attention
INERVENTION
Psychotherapy (talk therapy) is generally the treatment of choice for histrionic or other personality disorders. The
goal of treatment is to help the person uncover the motivations and fears associated with their thoughts and behavior
and to help the person learn to relate to others more positively
Provide factual feedback
improve social skills

 4. NARCISSISTIC PERSONALITY DISORDER- is characterized by a pervasive pattern of

 grandiosity (in fantasy or behavior),
 need for admiration, and
 lack of empathy.
Nursing Interventions
 nurse must use self-awareness skills
 nurse should not internalize such criticism or take it personally.
 nurse uses matter-of-fact manner.
 set limits on rude or verbally abusive behavior

CLUSTER C
1. AVOIDANT PERSONALITY DISORDER
 is characterized by a pervasive pattern of
 social discomfort and reticence/reserve,
 low self-esteem,
 hypersensitivity to negative evaluation.
INTERVENTIONS
 clients require much support and reassurance from the nurse
 explore positive self-aspects, positive responses from others, and possible reasons for self-
criticism.
 Help clients to practice self-affirmations and positive self-talk
 Affirmations are positive reminders or statements that can be used to encourage and motivate
yourself or others.
 2. Dependent personality disorder
 Characterized by an excessive need to be taken care of, which leads to submissive and clinging
behavior and fears of separation.
 They seek treatment for anxiety, depression, and somatic symptoms.
INTERVENTIONS
Schema therapy, a psychotherapy approach designed to treat personality disorders, is the most effective treatment
for DPD, according to one study. Schema therapy aims to help people understand their unhelpful patterns and
coping strategies and replace them with helpful ones.
Schema therapy (ST) is an integrative approach that brings together elements from cognitive behavioral therapy,
attachment and object relations theories, and Gestalt and experiential therapies. It was introduced by Jeff Young in
1990 and has been developed and refined since then.

SCHEMA THERAPY MODEL

1. Core emotional needs
2. Early maladaptive schemas
3. maladaptive coping styles
4. Schema modes
  2. OBSESSIVE–COMPULSIVE PERSONALITY
DISORDER- is characterized by a pervasive pattern of
 preoccupation with perfectionism,
 mental and interpersonal control, and
 orderliness at the expense of flexibility, openness, and efficiency
 Nursing Interventions
 set a goal of completing the project or making the decision by a specified deadline
 Help clients to accept or to tolerate less-than-perfect work or decisions made on time
 Cognitive restructuring techniques

Nursing Interventions

Clients with personality disorder often are involved in long-term psychotherapy to address issues of family
dysfunction and abuse.

 Promoting client’s safety. The nurse must always seriously consider suicidal ideation with the presence of
a plan, access to means for enacting the plan, and self-harm behaviors and institute appropriate
interventions.
 Promoting therapeutic relationship. Regardless of the cllinical setting, the nurse must provide structure
and limit setting in the therapeutic relationship; in a clinic setting, this may mean seeing the client for
scheduled appointments of a predetermined length rather than whenever the client appears and demands the
nurse’s immediate attention.
 Establishing boundaries in relationships. The nurse must be quite clear about establishing the boundaries
of the therapeutic relationship to ensure that neither the client’s nor the nurse’s boundaries are violated.
 Teaching effective communication skills. It is important to teach basic communication skills such
as eye contact, active listening, taking turns talking, validating the meaning of another’s communication,
and using “I” statements.
 Helping clients to cope and to control emotions. The nurse can help the clients to identify their feelings
and learn to tolerate them without exaggerated responses such as destruction of property or self-harm;
keeping a journal often helps clients gain awareness of feelings.
 Reshaping thinking patterns. Cognitive restructuring is a technique useful in changing patterns of
thinking by helping clients to recognize negative thoughts and feelings and to replace them with positive
patterns of thinking; thought stopping is a technique to alter the process of negative or self-critical thought
patterns.
 Structuring the client’s daily activities. Minimizing unstructured time by planning activities can help
clients to manage time alone; clients can make a written schedule that includes appointments, shopping,
reading the paper, and going for a walk.
Evaluation

Goals are met as evidenced by:

 The client will be safe and free of significant injury.

 The client will not harm others or destroy property.
  The client will demonstrate increased control of impulsive behavior.
  The client will take appropriate steps to meet his or her own needs.
 The client will demonstrate problem-solving skills.
  The client will verbalize greater satisfaction with relationships.