Personality Disorders

Personality: an ingrained, enduring pattern of behaving and relating to self, others, and the environment; behaviors and characteristics are consistent across a broad range of situations and do not change easily
Personality Disorders-disorders characterized by inflexible and enduring behavior patterns that impair social functioning
-usually without anxiety, depression, or delusions
Personality disorders: When personality traits become inflexible and maladaptive and significantly interfere with how a person functions in society or cause the person emotional distress; usually not diagnosed until adulthood; maladaptive behavior can be traced to early childhood or adolescence

Cluster A: people whose behavior is odd or eccentric (paranoid, schizoid, schizotypal)
Cluster B: people who appear dramatic, emotional, or erratic (antisocial, borderline, histrionic, narcissistic)
Cluster C: people who are anxious or fearful (avoidant, dependent, obsessive-compulsive)Disorders being considered for inclusion are depressive and passive-aggressive


☺Cluster A Personality Disorders

*Paranoid personality disorder
Clinical Picture
Mistrust and suspiciousness, aloof and withdrawn, guarded or hypervigilant, restricted affect, use the defense mechanism of projection

Nursing InterventionsApproach in a formal, business-like manner, keep commitments, be straightforward, involve them in formulating their care plans, help them learn to validate ideas before taking action

*Schizoid personality disorderClinical Picture
Detached from social relationships, restricted affect, aloof and indifferent, no leisure or pleasurable activities, do not report feeling distressed about lack of emotion, intellectual and accomplished with solitary interests, indifferent to praise or criticism, dissociate from or no bodily or sensory pleasures

Nursing InterventionsImprove functioning in the community, make referrals to social services, provide care that accommodates the desire for solitude

*Schizotypal personality disorder

Acute discomfort in relationships, cognitive or perceptual distortions, eccentric behavior, bizarre speech, affect flat and sometimes inappropriate
Nursing InterventionsPromote self-care, social skills, and improved functioning in the community



☺Cluster B Personality Disorders

*Antisocial Personality Disorderdisorder in which the person (usually male) exhibits a lack of conscience for wrongdoing, even toward friends and family members
may be aggressive and ruthless or a clever con artist
Clinical Picture
Pervasive pattern of disregard for and violation of rights of others, deceit and manipulation
the person (usually male) exhibits a lack of conscience for wrongdoing, even toward friends and family members
may be aggressive and ruthless or a clever con artist
*Borderline Personality Disorder
Clinical Picture
Pervasive pattern of unstable interpersonal relationships, self-image,affect, and marked
Change Between Anger & Anxiety or Depression and Anxiety

*Narcissistic Personality Disorder

Clinical Picture
Grandiose; lack of empathy; need for admiration; arrogant or haughty attitude; disparage, belittle, or discount the feelings of others; view their problems as the fault of others; hypersensitive to criticism and need constant attention and admiration

Nursing InterventionsUse self-awareness skills to avoid anger and frustration; use matter-of-fact manner; set limits on rude or verbally abusive behavior

*Histrionic Personality Disorder

Excessive emotionality and attention seeking; colorful and theatrical speech; overly concerned with impressing others; emotionally expressive, gregarious, and effusive; emotions are insincere and shallow; self-absorbed; uncomfortable when they are not the center of attention and go to great lengths to gain that status

Nursing Interventions
Give feedback about social interactions; teach social skills through role playing


☺Cluster C Personality Disorders

*Avoidant Personality Disorder

Social inhibitions; feelings of inadequacy; hypersensitivity to negative evaluation; avoid situations or relationships that may result in rejection, criticism, shame, or disapproval; strongly desire closeness and intimacy but fear possible rejection and humiliation

Nursing Interventions
Explore positive self-aspects and reasons for self-criticism; practice self-affirmations and positive self-talk; cognitive restructuring techniques, such as reframing and decatastrophizing; teach social skills

*Dependent Personality Disorder
Submissive and clinging behavior; excessive need to be taken care of; pessimistic and self-critical; other people hurt their feelings easily; report feeling unhappy or depressed; difficulty making decisions; seek advice and repeated reassurances

Nursing Interventions
Help identify strengths and needs; use cognitive restructuring; assist in daily functioning; teach problem solving and decision making; refrain from giving advice

*Obsessive-Compulsive Personality DisorderClinical Picture
Preoccupation with orderliness, perfectionism, and control; formal and serious demeanor; constricted emotions; stubborn; preoccupied with details, rules, lists, and schedules; believe they are right; problems with judgment and decision making

Nursing Interventions
Help accept or tolerate less-than-perfect work; use cognitive restructuring techniques; encourage to take risks; practice negotiation


Related Disorders


*Depressive Personality Disorder

Sad, gloomy, or dejected affect; persistent unhappiness, cheerlessness, and hopelessness; inability to experience joy or pleasure in any activity; cannot relax; do not display a sense of humor; brood and worry over all aspects of daily life; thinking is negative and pessimistic

Nursing Interventions
Assess risk for self-harm; encourage to become involved in activities; give factual feedback; use cognitive restructuring techniques; teach effective social skills


*Passive-Aggressive Personality Disorder

Negative attitudes; resent, oppose, and resist demands expected by others; express resistance through procrastination, forgetfulness, stubbornness, and intentional inefficiency

Nursing Interventions
Help examine the relationship between feelings and subsequent actions; teach appropriate ways to express feelings directly

Onset and Clinical Course

-Personality disorders occur in 10% to 13% of the general population

-Incidence is even higher in lower socioeconomic groups

-40% to 45% of people with a primary diagnosis of major mental illness also have a coexisting personality disorder that significantly complicates treatment

Clients with personality disorders have:


-Higher death rates, especially as a result of suicide
-Higher rates of suicide attempts, accidents, and emergency department visits
-Increased rates of separation, divorce, and involvement in legal proceedings regarding child custody
-Increased rates of criminal behavior, alcoholism, and drug abuse


Etiology

Genetics
Temperament


Psychosocial factors
-Character
-Self-directedness
-Cooperativeness
-Self-transcendence



Cultural Considerations
-Guarded or defensive behavior may be displayed as a result of language barriers or previous negative experiences and should not be confused with paranoid personality disorder
-People with religious or spiritual beliefs, such as clairvoyance, speaking in tongues, or evil spirits as a cause of disease, could be misinterpreted as having schizotypal personality disorder
-An emphasis on deference, passivity, and politeness should not be confused with a dependent personality disorder
-Cultures that value work and productivity may produce citizens with a strong emphasis in these areas; this should not be confused with obsessive-compulsive personality disorder
-Social stereotypes about gender roles and behaviors can influence diagnosis of certain personality disorders


Treatment

-Many people with personality disorders do not seek treatment because they don’t believe they have a problem
-Individual and group therapy may be helpful to those desiring change, but any changes are slow
-Improvement in relationships, improved basic living skills, relief of anxiety may be goals of therapy
-Cognitive-behavioral techniques such as thought-stopping, positive self-talk, and decatastrophizing can be effective


Pharmacologic treatment is based on the type and severity of symptoms rather than the particular personality disorder itself.

Four symptom categories include:


Cognitive-perceptual distortions including psychotic symptoms
Affective symptoms and mood dysregulation
Aggression and behavioral dysfunction
Anxiety



Pharmacologic Treatment for Symptoms


Cognitive-perceptual disturbances (magical thinking, odd beliefs, illusions, suspiciousness, ideas of reference, and low-grade psychotic symptoms)
-Low-dose antipsychotic medications
Mood dysregulation (emotional instability, emotional detachment, depression, and dysphoria)
-Lithium, carbamazepine (Tegretol), valproate (Depakote), low-dose neuroleptics, SSRIs,
MAOIs, atypical antipsychotics
Aggression (predatory or cruel behavior, impulsivity, poor social judgment, and emotional lability)

-Lithium, anticonvulsant mood stabilizers, benzodiazepines, and low-dose neuroleptics
Anxiety
-SSRIs, MAOIs, or low-dose antipsychotics



Individual and Group Psychotherapy

Focus is on building trust, teaching basic living skills, providing support, decreasing distressing symptoms, and improving interpersonal relationships.

-Cognitive-behavioral therapy

-Basic living skills for people with cluster A personality disorders

-Inpatient hospitalization to provide safety for people with borderline personality disorder

-Assertiveness training groups for people with cluster C personality disorders

-Relaxation or meditation techniques for people with cluster C personality disorders

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