Chapter 23

Personality Disorders
Mrs. Roberson Fall 2015
Introduction
Personality is defined as the totality of emotional and behavioral
characteristics that are particular to a specific person and that remain
somewhat stable and predictable over time.
Personality traits are characteristics with which an individual is born or
develops early in life.
They influence the way in which he or she perceives and relates to the
environment and are quite stable over time.
Personality disorders occur when these traits become rigid and inflexible and
contribute to maladaptive patterns of behavior or impairment in functioning.
Personality development occurs in response to a number of biological and
psychological influences
o
Heredity
o
Temperament
o
Experiential learning
o
Social interaction
People with personality disorders are not often treated in acute care settings
in cases in which the personality disorder is their primary psychiatric disorder.
Many clients with other psychiatric and medical diagnoses manifest
symptoms of personality disorders.
Nurses are likely to encounter clients with these personality characteristics
frequently
in all health-care settings.
Historical Aspects
The first recognition that personality disorders, apart from psychosis, were
cause for their own special concern was in 1801, with the recognition that an
individual can behave irrationally even when the powers of intellect are
intact.
Ten specific types of personality disorders are identified in the DSM-5.
Types of Personality Disorders
Paranoid Personality Disorder

Characterized by a pervasive, persistent, and inappropriate mistrust of

others.

Individuals with this disorder are suspicious of others motives and

assume that others intend to exploit, harm, or deceive them.

The disorder is more common in men than in women.

Clinical picture:

Constantly on guard

Hypervigilant

Ready for any real or imagined threat

Trusts no one

Constantly tests the honesty of others

Insensitive to the feelings of others

Oversensitive
Tends to misinterpret minute cues
Magnifies and distorts cues in the environment
Does not accept responsibility for his/her own behavior
Attributes shortcomings to others
Predisposing factors
Possible hereditary link
Subject to early parental antagonism and harassment

Schizoid Personality Disorder

Characterized primarily by a profound defect in the ability to form

personal relationships

Failure to respond to others in a meaningful emotional way

Diagnosis occurs more frequently in men than in women

Prevalence within the general population has been estimated at 3 to

7.5 percent

Clinical picture:

Aloof and indifferent to others

Emotionally cold

No close friends; prefers to be alone

Appears shy, anxious, or uneasy in the presence of others

Inappropriately serious about everything and difficulty acting in

a light-hearted manner

Predisposing factors

Possible hereditary factor

Childhood has been characterized as

Bleak

Cold

Unempathic

Notably lacking in nurturing

Schizotypal Personality Disorder

A graver form of the pathologically less severe schizoid personality

pattern.

Affects approximately 1 to 2 percent of the population.

Clinical picture:

Clients are aloof and isolated

Behave in a bland and apathetic manner

Symptoms include:

Magical thinking

Ideas of reference

Illusions

Depersonalization

Superstitiousness

Withdrawal into the self

Exhibits bizarre speech pattern

When under stress, may decompensate and demonstrate

psychotic symptoms

Demonstrates bland, inappropriate affect

Predisposing factors

Possible hereditary factor

Possible physiological influence, such as anatomic deficits or

neurochemical dysfunctions within certain areas of the brain

Early family dynamics characterized by

Indifference

Impassivity

Formality

Leading to a pattern of discomfort with personal affection and

closeness
**Schizotypal: http://www.youtube.com/watch?v=H8PzoXVXMTk

Antisocial Personality Disorder

A pattern of behavior that is

o
Socially irresponsible
o
Exploitative
o
Without remorse

Behavior reflects a disregard for the rights of others

Clinical picture

Fails to sustain consistent employment

Fails to conform to the law

Exploits and manipulates others for personal gain

Fails to develop stable relationships

Prevalence estimates in the United States range from 2 to 4 percent in

men to about 1 percent in women.
Borderline Personality Disorder
Characterized by a pattern of intense and chaotic relationships with affective
instability
Fluctuating and extreme attitudes regarding other people
Highly impulsive
Emotionally unstable
Directly and indirectly self-destructive
Lacks a clear sense of identity
Affects about 1 to 2 percent of the population
More common in women than in men
**Borderline PD: http://www.youtube.com/watch?v=_-nQ7qWO6Ts
Histrionic Personality Disorder

Behavior is

Excitable

Emotional

Colorful

Dramatic

Extroverted

Prevalence is thought to be about 2 to 3 percent

More common in women than in men

Clinical picture:

Self-dramatizing
Attention-seeking
Overly gregarious
Seductive
Manipulative
Exhibitionistic
Highly distractible
Difficulty paying attention to detail
Easily influenced by others
Difficulty forming close relationships
Strongly dependent
Somatic complaints are common

Predisposing factors

Possible link to the noradrenergic and serotonergic systems

Possible hereditary factor

Biogenetically determined temperament

Learned behavior patterns

**Histrionic Personality: http://www.youtube.com/watch?v=XDiMHz4nZwQ

Narcissistic Personality Disorder

Characterized by an exaggerated sense of self-worth

Lack of empathy

Belief in an inalienable right to receive special consideration

Prevalence of the disorder is estimated at about 6 percent

Diagnosed more often in men than in women

Clinical picture:

Overly self-centered

Exploit others in an effort to fulfill their own desires

Mood, which is often grounded in grandiosity, is usually

optimistic, relaxed, cheerful, and care-free

Because of fragile self-esteem, mood can easily change if they

do not

Meet self-expectations

Receive the positive feedback they expect

Criticism from others may cause them to respond with rage,

shame, and humiliation

Predisposing factors

As children, their fears, failures, or dependency needs were

responded to with criticism, disdain, or neglect

Parents were often narcissistic themselves

Parents may have overindulged their child and failed to set limits
on inappropriate behavior
**Narcissistic Personality Disorder: http://www.youtube.com/watch?v=aUPwjE-IVqQ
Avoidant Personality Disorder

Characterized by

Extreme sensitivity to rejection

Social withdrawal

Prevalence is about 1 percent and is equally common in men and

women

Clinical picture:

Awkward and uncomfortable in social situations

Desire close relationships but avoid them because of their fear

of being rejected

Perceived as timid, withdrawn, or cold and strange

They are often lonely and feel unwanted

They view others as critical and betraying

Predisposing factors

No clear cause is known

May be a combination of biological, genetic, and psychosocial

influences

Primary psychosocial influence: parental rejection and censure,

which are often reinforced by peers

Dependent Personality Disorder

Characterized by a pattern of relying on others for emotional support

Relatively common within the population

More common among women than men

More common in the youngest children of a family than in the older

ones

Clinical picture :

They have a notable lack of self-confidence that is often

apparent in their

Posture

Voice

Mannerisms

Typically passive and acquiescent to desires of others

Overly generous and thoughtful, while underplaying their own

attractiveness and achievements

Low self-worth and easily hurt by criticism and disapproval

Avoid positions of responsibility and become anxious when

forced into them

Assume passive and submissive roles in relationships

Predisposing factors

Possible hereditary influence

Stimulation and nurturance are experienced exclusively from

one source

A singular attachment is made by the infant to the exclusion of

all others
Obsessive-Compulsive Personality Disorder

Characterized by inflexibility about the way in which things must

be done

Devotion to productivity at the exclusion of personal pleasure

Relatively common

Occurs more often in men than in women

Within the family constellation, it appears to be most common in oldest

children

Clinical picture:

Especially concerned with matters of organization and efficiency

Tend to be rigid and unbending

Socially polite and formal

Rank-conscious

Ingratiating with authority figures

Autocratic and condemnatory with subordinates

On the surface, appear to be very calm and controlled

Underneath there is a great deal of

Ambivalence

Conflict

Hostility

Predisposing factors

Over-control by parents

Notable parental lack of positive reinforcement for acceptable

behavior

Frequent punishment for undesirable behavior

**OCD: http://www.youtube.com/watch?v=Qsr__wnzM4U
Application of the Nursing Process: Assessment
Borderline Personality Disorder

Designated as borderline because of the tendency of these

clients to fall on the border between neuroses and psychoses
Instability of interpersonal relationships
Unstable self-image
Marked impulsivity
Intensity of affect and behavior
Common behaviors

Chronic depression

Inability to be alone

Clinging and distancing behaviors

Splitting

Manipulation

Self-destructive behaviors

Impulsivity
Predisposing factors

Biological influences

Biochemical: possible serotonergic defect

Genetic: possible familial connection with depression

Psychosocial influences

Childhood trauma and abuse

Developmental factors: fixed in the rapprochement phase

of development (16 to 24 months old). The child fails to achieve task of
autonomy.
Nursing Diagnosis: Borderline Personality Disorder
o Risk for self-mutilation related to parental emotional deprivation

Risk for suicide related to unresolved grief

Risk for other-directed violence related to underlying rage
Complicated grieving related to maternal deprivation during
rapprochement phase of development internalized as a loss, with fixation
in anger stage of grieving process
o Impaired social interaction related to extreme fears of abandonment and
engulfment
o Disturbed personal identity related to underdeveloped ego
o Anxiety (severe to panic) related to unconscious conflicts based on fear of
abandonment
o Chronic low self-esteem related to lack of positive feedback
Outcomes: Borderline Personality Disorder
o
The client
Has not harmed self
Seeks out staff when desire for self-mutilation is strong
Is able to identify true source of anger
Expresses anger appropriately
Relates to more than one staff member
Completes activities of daily living independently
Does not manipulate one staff member against the other to fulfill own
desires
Planning/Implementation
o Nursing intervention for the client with borderline personality disorder is
aimed at protection of the client from self-harm.
o The nurse also seeks to assist the client to advance in the development of
personality by confronting his or her true source of internalized anger.
Evaluation
o Evaluation of care for the client with borderline personality disorder is
based on accomplishment of previously established outcome criteria.
o
o
o

Antisocial Personality Disorder

Not often seen in most clinical settings

Most frequently encountered in prisons, jails, and rehabilitation

services

When clients are seen, it is commonly a way to avoid legal

consequences

Sometimes they are admitted to the health- care system by court order
for psychological evaluation

Common behaviors

Exploitation and manipulation of others for personal gain

Belligerent and argumentative

Lacks remorse

Unable to delay gratification

Low frustration tolerance

Inconsistent work or academic performance

Failure to conform to societal norms

Impulsive and reckless

Inability to function as a responsible parent

Inability to form lasting monogamous relationship

Predisposing Factors to Antisocial Personality Disorder
o
Possible genetic influence
o
Having a disruptive behavior disorder as a child (ADHD; conduct
disorder)
o
History of severe physical abuse
o
Absent or inconsistent parental discipline
o
Extreme poverty
o
Removal from the home
o
Growing up without parental figures of both sexes
o
Always being rescued when in trouble
o
Maternal deprivation
Nursing Diagnosis: Antisocial Personality Disorder
o Risk for other-directed violence related to rage reactions, negative rolemodeling, inability to tolerate frustration
o Defensive coping related to dysfunctional family system
o Chronic low self-esteem related to repeated negative feedback resulting in
diminished self-worth
o Impaired social interaction related to negative role modeling and low selfesteem
o Ineffective health maintenance, evidenced by demonstration of inability to
take responsibility for meeting basic health practices
Outcomes: Antisocial Personality Disorder
o The client
Discusses angry feelings with staff and in group sessions
Has not harmed self or others
Can rechannel hostility into socially acceptable behaviors
Follows rules and regulations of the therapy environment
Can verbalize which of his or her behaviors are not acceptable
Shows regard for the rights of others by delaying gratification of own
desires when appropriate
Does not manipulate others in an attempt to increase feeling of selfworth
Verbalizes understanding of knowledge required to maintain basic
health needs
Planning/Intervention
o Nursing care of the client with antisocial personality disorder is aimed at
Ensuring the safety of client and others
Helping client recognize and decrease unacceptable behaviors
Assisting client to gain insight into own behaviors
Helping client to learn to delay gratification
Evaluation
o Evaluation of care for the client with antisocial personality disorder is
based on accomplishment of previously established outcome criteria.

Treatment Modalities for Personality Disorders

Interpersonal psychotherapy
Psychoanalytical psychotherapy

Milieu or group therapy

Cognitive/behavioral therapy
Dialectical behavior therapy
Psychopharmacology