Chapter 16: Personality Disorders

Chapter 16: Personality Disorders

Personality disorder = pathological personality characteristics

Involves impairments in:

• Self-identity / self-direction

• Interpersonal functioning

Key Features

• Maladaptive behaviors:

  • Not always recognized by the individual as dysfunctional

  • Some areas of functioning may remain adequate

Comorbidity

• Commonly co-occur with:

  • Depression

  • Anxiety

  • Eating disorders

  • Substance use disorders

Personality Disorders Risk Factors

Comorbidities: Often substance use disorders; history of both nonviolent and violent crimes (including sex offenses)

Psychosocial influences: Childhood abuse, trauma, developmental/parenting factors

Biological influences: Genetic and biochemical factors

Personality Disorders Expected Findings

Inflexibility/maladaptive stress responses

Compulsiveness & lack of social restraint

Inability to emotionally connect in relationships (social/professional)

Tendency to provoke interpersonal conflict

Defense Mechanisms

• Common: Repression, suppression, regression, undoing, splitting

• Splitting (hallmark of borderline personality disorder):

  • Inability to integrate positive & negative aspects of self/others into a whole

  • Seen often in acute mental health settings

  • “All good” vs. “all bad” thinking (e.g., calling someone the best one moment and terrible the next)

Lifespan Considerations

• Children: Difficulty forming peer relationships, struggles in schoolwork

• Adolescents: Risk of bullying due to odd habits/behaviors/ideas

• Adults: Trouble forming intimate relationships, maintaining careers, and mentoring future generations

A nurse is caring for a client who has borderline personality disorder. The client says, “The nurse on the evening shift is always nice! You are the meanest nurse ever!” The nurse should recognize the client’s statement as an example of which of the following defense mechanisms?

a

Regression

b

Splitting

c

Undoing

d

Identification

b Splitting

Splitting occurs when a person is unable to see both positive and negative qualities at the same time. The client who has borderline personality disorder tends to see a person as all bad one time and all good another time.

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Regression refers to resorting to an earlier way of functioning (having a temper tantrum).

Undoing is a behavior that is intended to undo or reverse unacceptable thoughts or acts (buying a gift for a spouse after having an extramarital affair).

In identification, the person imitates the behavior of someone admired or feared.

The 10 Personality Disorders

Cluster A (Odd or Eccentric Traits)

• Paranoid: Distrust, suspicion, unfounded beliefs that others intend harm; hostile, exploitative, deceitful

• Schizoid: Emotional detachment, disinterest in relationships, indifferent to praise/criticism, uncooperative

• Schizotypal: Odd beliefs, eccentric appearance, magical thinking, perceptual distortions (not full delusions/hallucinations)

Cluster B (Dramatic, Emotional, Erratic Traits)

• Antisocial: Disregard for others, lack of empathy, repeated unlawful acts, deceit, irresponsibility, manipulative, impulsive; history of conduct disorder before age 15

• Borderline: Instability in affect/identity/relationships, splitting behaviors, impulsivity, fear of abandonment, self-injury, suicidal tendencies, ideas of reference

• Histrionic: Attention-seeking, emotional, needs to be center of attention, seductive/flirtatious

• Narcissistic: Arrogance, grandiose self-image, need for admiration, lack of empathy, strained relationships, sensitive to criticism

Cluster C (Anxious or Fearful Traits — Insecurity & Inadequacy)

• Avoidant: Social inhibition, avoids relationships due to fear of rejection, feelings of inadequacy, anxious in social settings

• Dependent: Extreme dependency, urgent need to replace relationships, difficulty with independence

• Obsessive-Compulsive (OCPD): Perfectionism, orderliness, control; indecisive; difficulty completing tasks due to perfectionist standards

(Odd or Eccentric Traits)

• Paranoid: Distrust, suspicion, unfounded beliefs that others intend harm; hostile, exploitative, deceitful

• Schizoid: Emotional detachment, disinterest in relationships, indifferent to praise/criticism, uncooperative

• Schizotypal: Odd beliefs, eccentric appearance, magical thinking, perceptual distortions (not full delusions/hallucinations)

Cluster A

(Dramatic, Emotional, Erratic Traits)

• Antisocial: Disregard for others, lack of empathy, repeated unlawful acts, deceit, irresponsibility, manipulative, impulsive; history of conduct disorder before age 15

• Borderline: Instability in affect/identity/relationships, splitting behaviors, impulsivity, fear of abandonment, self-injury, suicidal tendencies, ideas of reference

• Histrionic: Attention-seeking, emotional, needs to be center of attention, seductive/flirtatious

• Narcissistic: Arrogance, grandiose self-image, need for admiration, lack of empathy, strained relationships, sensitive to criticism

Cluster B

(Anxious or Fearful Traits — Insecurity & Inadequacy)

• Avoidant: Social inhibition, avoids relationships due to fear of rejection, feelings of inadequacy, anxious in social settings

• Dependent: Extreme dependency, urgent need to replace relationships, difficulty with independence

• Obsessive-Compulsive (OCPD): Perfectionism, orderliness, control; indecisive; difficulty completing tasks due to perfectionist standards

Cluster C

Personality Disorders Nursing Care

Self-assessment (before care):

• Personality disorder clients may evoke intense nurse emotions

• Awareness of nurse reactions promotes effective care

• Use therapeutic communication/intervention when behaviors anticipated

• Repeat self-assessment if stress reaction occurs

Milieu management: Focus on appropriate social interaction in groups

Safety:

• Borderline PD: Higher risk for self-injury

• Antisocial PD: Higher risk for harm to others

Plan of care (by cluster):

• Cluster A: Build interpersonal relationship skills

• Cluster B: Limit-setting to reduce dramatic/inappropriate behavior

• Cluster C: Teach anxiety management strategies

Communication Strategies

• Firm, supportive, consistent approach → strengthens therapeutic relationship

• Offer realistic choices → increases client sense of control

• Limit-setting & consistency → critical with manipulative clients (borderline, antisocial)

• Dependent & histrionic PD: Benefit from assertiveness training, modeling, psychotherapy

• Schizoid & schizotypal PD: Tend to isolate → nurse should respect need

• Psychotherapy: Improves ability to respond to social cues

• Histrionic PD: Nurse must maintain professional boundaries (client may be flirtatious)

• Dependent PD: Nurse should self-assess for countertransference

Personality Disorders Medications

Used for symptom relief (not cure):

• Antidepressants (STaMiNA)

• Anxiolytics (e.g., Benzos)

• Antipsychotics

• Mood stabilizers

Personality Disorders Interprofessional Care

Psychobiological Interventions

• Therapies: Psychotherapy, group therapy, CBT effective

• Dialectical Behavior Therapy (DBT): For borderline PD; reduces self-injury, supports gradual behavior change, promotes acceptance/validation

• Case Management: For persistent/severe PD

  • Acute care: Obtain history, stabilize, reintegrate with family, transition to outpatient care

  • Long-term facilities: Reduce hospitalization via resources, crisis services, social support enhancement

A nurse is caring for a client who has avoidant personality disorder. Which of the following statements is expected from a client who has this type of personality disorder?

a

“I’m scared that you’re going to leave me.”

b

“I’ll go to group therapy if you’ll let me smoke.”

c

“I need to feel that everyone admires me.”

d

“I sometimes feel better if I cut myself.”

a “I’m scared that you’re going to leave me.”

Clients who have avoidant personality disorder often have a fear of abandonment. This type of statement is expected.

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This statement indicates manipulation, which is expected from a client who has antisocial personality disorder

This statement indicates a need for admiration, which is expected from a client who has narcissistic personality disorder.

This statement indicates a risk for self-injury, which is expected from a client who has borderline personality disorder.

A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect?

Select all that apply.

a

Demonstrates extreme anxiety when placed in a social situation

b

Often engages in magical thinking

c

Attempts to convince other clients to relinquish their belongings

d

Becomes agitated if personal area is not neat and orderly

e

Blames others for personal past and current problems

c Attempts to convince other clients to relinquish their belongings

e Blames others for personal past and current problems

Exploitation and manipulation of others is an expected finding of antisocial personality disorder.

Failure to accept personal responsibility is an expected finding of clients who have antisocial personality disorder.

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Anxiety in social situations is an expected finding of clients who have avoidant personality disorder.

Magical thinking and odd beliefs are findings observed in clients who have schizotypal personality disorder.

Perfectionism with a focus on orderliness and control is an expected finding of clients who have obsessive-compulsive personality disorder.

A charge nurse is preparing a staff education session on personality disorders. Which of the following personality characteristics associated with all of the personality disorders should the charge nurse include in the teaching?

Select all that apply.

a

Difficulty in getting along with other members of a group

b

Belief in the ability to become invisible during times of stress

c

Display of defense mechanisms when routines are changed

d

Claiming to be more important than other persons

e

Difficulty understanding why it is inappropriate to have a personal relationship with staff

a Difficulty in getting along with other members of a group

c Display of defense mechanisms when routines are changed

e Difficulty understanding why it is inappropriate to have a personal relationship with staff

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Clients who have schizotypal personality disorder can display magical thinking or delusions. However, this is not associated with all personality disorder types.

Clients who have narcissistic personality disorder can display grandiose thinking. However, this is not associated with all personality disorder types.

A nurse manager is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

a

“I can promote my client’s sense of control by establishing a schedule.”

b

”I should encourage clients who have a schizoid personality disorder to increase socialization.”

c

“I should practice limit-setting to help prevent client manipulation.”

d

“I should implement assertiveness training with clients who have antisocial personality disorder.”

c “I should practice limit-setting to help prevent client manipulation.”

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Avoid trying to increase socialization for a client who has a schizoid personality disorder.

Implement assertiveness training for clients who have dependent and histrionic personality disorders.

Sort the following characteristics to the appropriate personality disorder.

Fear of abandonment

Need for consistent admiration

Splitting behaviors​​​​​​​

Instability of affect

Arrogance​​​​​​​

Sense of entitlement

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Antisocial

Borderline

Narcissistic

Antisocial

• Sense of entitlement

Borderline

• Fear of abandonment

• Splitting behaviors​​​​​​​

• Instability of affect

Narcissistic

• Need for consistent admiration

• Arrogance