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PERSONALITY DISORDERS

If the person develops a positive self-concept, body image, and sense of self-worth, and is able to
relate to others openly and honestly she or he is said to have characteristics of a healthy personality.
Should the person develop inflexible, maladaptive behaviors that interfere with social or occupational
functioning, the person exhibits signs and symptoms of a personality disorder.

A personality disorder is described as a non-psychotic illness characterized by maladaptive behaviors,


which the person uses to fulfill his or her needs and bring satisfaction to him or herself.

Cluster A Disorders
People who exhibit paranoid, schizoid and schizotypal personality disorders are considered “odd” or
eccentric in the vernacular and are grouped in the first cluster.

Cluster B Disorders
These are people with antisocial, borderline, histrionic, and narcissistic personality disorders. They are
considered to be emotional, erratic, or dramatic in behavior.

Cluster C Disorders
Anxious or fearful behaviors are often present in the third cluster, which includes obsessive-compulsive,
dependent, and avoidant personality disorders.

Personality Disorders, Not Otherwise Specified (NOS)


This category is reserved for those disorders that do not fit into any of the three clusters

CLUSTER A DISORDERS: ODD, ECCENTRIC BEHAVIOR


 Chronic hostility projected towards others
 Unwarrantedly suspicious and mistrusts people
 Suspect attempts to trick or harm him/her
 Questions loyalty of others
 Displays pathological jealousy
Paranoid Personality Disorder  Observes the environment for any signs of threat
 Displays secretiveness
− Prevalence is 0.5% - 2.5% of  Hypersensitive
 Displays excessive feelings of self-importance
the general population
 Appears to be unemotional
− Seen more frequently in men
 Lacks a sense of humor, and ability to relax
 Poor interpersonal relationships, especially when relating to
authority figures or co-workers – lifelong interpersonal, marital and
occupational problems.

 No desire for social involvement


Schizoid Personality Disorder  Pervasive pattern of detachment from social relationships
 Restricted range of emotional expression in interpersonal settings
− “introvert” or “loner”  Avoids close relationships
− Prevalence is 7.5% of the  Chooses solitary activities
general population  Has little interest in sexual experiences
− Males are twice as likely to  Does not take pleasure in activities
develop this type of  Lacks close friends or confidants
 Appears indifferent to praise or criticism
personality disorder
 Exhibits emotional coldness such as detachment or flattened effect
 Attention is usually focused on objects rather than people

 Exhibits a disturbance in thought process referred to as magical


thinking, superstitiousness, or telepathy (sixth sense)
Schizotypal Personality Disorder  Experiences ideas of reference
 Limits social contacts
− Symptoms are similar but not  Described perceptual disturbance such as illusions or
severe enough to meet the depersonalization
criteria for schizophrenia  Demonstrates peculiarity in speech but no loosening of association
− Approximately 3% if the  Appears aloof or cold because they exhibit an inappropriate affect.
population but the sex ratio is  Paranoid ideation
unknown  Odd or eccentric behavior or appearance
 Excessive social anxiety

CLUSTER B DISORDERS: EMOTIONAL, ERRATIC, OR DRAMATIC BEHAVIOR


 Conduct Disorder: truancy, misbehaviors at school, delinquency,
Antisocial Personality Disorder
substance abuse, vandalism, cruelty and disobedience.
 Lack of remorse or indifference to people whom one has hurt or
− Sociopathic disorder mistreated, or from whom one has stolen
− Psychopathic disorder  Expects immediate gratification
− Semantic disorder  Fails to accept social norms
− Between ages 15 and 40  Impulsive
years old  Consistent irresponsibility
− Diagnosis of conduct  Aggressive behavior
disorder is given to clients  Lack of respect for social norms
who exhibit clinical  Repeated lying
symptoms before age 18  Reckless behavior that disregards the safety of others
− 80% - 90% of all crime is
commited by individuals with
antisocial personality
disorder
− More prevalent in men (3%)
than in women (1%)
 Almost always appear to be in a state of crisis
 Disillusioned and experiences rage, fear of abandonment and
depression
Borderline Personality Disorder  Biologic defect of the amygdale (area of the brain that regulates
emotion) causing severe mood swings and abnormal behavior
− Latent, ambulatory and  Impulsive, unpredictable behavior related to gambling, shoplifting,
abortive schizophrenics sex and substance abuse
− Symptoms fall between  Inappropriate intense anger contributing to unstable intense
moderate neurosis and frank interpersonal relationships
psychosis  Unstable affect reflecting depression, dysphoria or anxiety
− Occurs in all races  Disturbance in self-concept, including gender identity
 Unable to control emotions
− Affects 1% to 2% of the
population  Paranoid ideation, severe dissociation, masochism, frantic efforts to
avoid real or imagined abandonment and suicidal ideation.
− Prevalent in women (female-  Reports feeling empty, lonely, unable to experience pleasure and
to-male ratios as high as 4:1) unable to maintain employment
− Presents in late adolescence  Self-mutilating behavior

 Inappropriate sexually seductive or provocative behavior


 Self-dramatization and emotional exaggeration to draw attention to
Histrionic Personality Disorder self.
 Style of speech is excessively impressionistic
− Theatrical or overly dramatic  Lacking in detail as the client exhibits labile emotions
behavior  Easily influenced by others or by circumstances
− More frequently in women  Considers relationships to be more intimate than they really are
− Approximately 2% to 3% of  Creative and imaginative
the general population  Exhibits dependency and helplessness
 Handles feelings of criticism freely

Narcissistic Personality Disorder  Preoccupied with fantasies of unlimited success, power and beauty
 Believes he/she is unique and should associate with other high-
− Exaggerated or grandiose status individuals
sense of self importance  Displays arrogance
− Symptoms usually develop  Displays sense of entitlement
early childhood  Lack of empathy as he or she exploits other
 Values beauty, strength and youthful attributes
− Prevalence is less than 1%
 Aging is handled poorly
and occurs predominantly in
 Prone to extreme mood swings
men
− Risk for suicide is higher
compared with individuals
with other personality
disorders

CLUSTER C DISORDERS: ANXIOUS, FEARFUL BEHAVIOR


 Preoccupied with rules and regulations
Obsessive-Compulsive  Overly concerned with organizational and trivial detail
Personality Disorder  Excessively devoted to their work and productivity
 Preoccupied with details, lists, and rules to the extent that the major
− Prevalence is unknown point of the activity is lost
− Most common in men  Perfectionism interferes with task completion
− Diagnosed most often in first-  Overly conscientious, scrupulous, inflexible and reluctant to
born children delegate duties to others
− More frequently in first-  Excessive devotion to work and productivity
degree biologic relatives of  Commonly experiences depression
clients with the disorder than
in the general population
 Thoughtful and considerate, faithful and devoted, agreeable and
Dependent Personality Disorder cooperative; however
 Lacks self confidence
 Unable to function in an independent role
− Also referred to as passive-
 Allows others to become responsible for their lives because they
dependent personality
experience difficulty making everyday decisions, disagreeing with
disorder others and initiating projects or doing things independently
− People with recurrent or  Client goes though excessive lengths to obtain nurturance and
chronic illness in childhood support from others
are most prone  Unrealistically preoccupied with fears of being left alone to care for
− More frequently in women himself/herself

 Highly sensitive to rejection, criticism, humiliation, disapproval,


shame, appearing devastated by the slightest amount of
disapproval
 Extreme sensitivity interferes with participation in occupational
Avoidant Personality Disorder activities, development of interpersonal relationships and ability to
take personal risks or engage in new activities
− Prevalent in 1% to 10% of  Client views him or herself as socially inept, personally unappealing
the general population and in or inferior to others
approximately 10% of clients  Experiences difficulty in adjusting to loose, unpredictable
seen in mental health clinics environment, especially those requiring social activities or public
appearances
 Feelings of anxiety, anger and depression
 Social phobia may occur when withdrawal and hypersensitivity
persist over time

PERSONALITY DISORDER, NOT OTHERWISE SPECIFIED


Passive-Aggressive Personality  Exhibits covert obstructionism through manipulative behavior,
Disorder procrastination, stubbornness and inefficiency due to dependency
upon others
− Also referred to as  Lacks self-confidence and are pessimistic about the future
negativistic personality
disorder
Depressive Personality Disorder  Chronically unhappy
 Exhibits low self-esteem
− Exhibits life-long depressive  Self-critical and denigrating about their work, themselves and their
symptoms relationships
 Exhibits poor posture, raspy hoarse voice, flat or blunted affect and
psychomotor retardation

SCREENING AND ASSESSMENT TOOLS

Millon Clinical Multiaxial Inventory (MCMI-III)


− Designed to help assess both Axis I disorders (clinical disorders and conditions such as anxiety
and depression) and Axis II disorders (personality disorders and mental retardation)
− Assists in the diagnosis and development of a treatment approach that takes into account the
clients personality style and coping behavior

Structured Interview for DSM-IV Personality (SIDP-IV)


− Uses questions to examine behavior and personality traits from the clients perspectives
− Helps distinguish lifelong behavior from temporary states that can result from an episodic
psychiatric disorder
− Assists in the diagnosis and development of a treatment approach to improve the clients quality
of life.

MANAGING SYMPTOMS OF CLIENTS WITH PERSONALITY DISORDERS

For clients with disturbance in cognition


Reinforce reality if the client verbalizes illusions or feelings of depersonalization. Help the client
select someone he or she trusts to minimize suspicious or delusional thoughts.
Encourage the client to validate perceptions before taking action that may precipitate difficulties.
Explore with the client present maladaptive coping mechanisms and the purpose they serve.
Explore alternate coping mechanisms to reduce stress.
Assist the client to develop insight regarding the purpose of nursing interventions.

For clients with disturbance in affect


Encourage the client to verbalize feelings of anger, hostility, worthlessness, or hopelessness.
Give attention and support when the client expresses feelings honestly and openly.
Encourage the client to share his or her feelings with others.
Provide a safe environment if the client expresses suicidal ideation or exhibits self-mutilation
behavior.

For the clients with disturbance in interpersonal functioning


Explore reasons the client has difficulty establishing interpersonal relationships.
Explore the client’s self-concept and self-esteem.
Explore the client’s perception of how others view him or her.
Provide positive feedback regarding your observations of the client’s strengths.
Encourage the client to socialize with at least one person daily.
For the clients who exhibits dysfunctional behavior indicative of poor impulse control
State limits and behavior expected from the client.
Enforce all limits without apologizing.
Be direct, confronting the client when limits are not observed.
Discuss consequences of client’s failure to observe limits.
Discuss behavior with the client in a nonjudgmental manner.

DRUGS USED FOR PERSONALITY DISORDERS

Antipsychotics – haloperidol (Haldol); clanzapine (Zyprexa)


− For paranoia, psychoses, aggression and post traumatic stress

Anticonvulsants – carbamazepine (Tegretol); valproate (Depakote)


− For aggression, impulsivity, mood disorders and suicidality

Antidepressants – venlafaxine (Effexor)


− For depression, anxiety, panic attacks

Antianxiety Agents – clomipramine (Anafranil); clonazepam (Klonopin)

REFERENCE: BASIC CONCEPTS OF PSYCHIATRIC-MENTAL HEALTH NURSING pp. 408-425