Personality Disorders

Personality

• Personality refers to the collective emotional qualities and behaviors that make a person unique.

• The five-factor model of personality (FFM) theorizes that personality is framed by a set of five domains, also referred to as “the big 5.”

• Personality development

• One must progress successfully through developmental stages to become a well-functioning adult

• Ericksons 8 stages with developmental tasks 

• Complications during any of these stages, such as repression or fixation, may impact personality development 

• 0 to 1.5 years

• Trust vs. Mistrust

• Form a bond with primary caregiver as a foundation for trust in others later in life

• 1.5 to 3 years

• Autonomy vs. Shame

• Find a sense of self-control and independence, such as toilet training

• 3 to 5 years

• Initiative vs. Guilt

• Assert oneself, often through social interactions and by directing play

• 5 to 12 years

• Industry vs. Inferiority

• Develop skills at school, social and physical skills

• 12 to 18 years

• Identity vs. Role Confusion

• Develop a sense of identity, explore personal beliefs, values, and goals

• 18 to 40 years

• Intimacy vs. Isolation

• Form intimate and loving relationships with others

• 40 to 65 years

• Generativity vs. Stagnation

• Fulfill goals, nurture those who are part of the next generation

• 65 years and older

• Ego Integrity vs. Despair

• Develop integrity and reflect on a successful life

• Cluster A

• Odd, eccentric 

  • Paranoid

  • Schizoid

  • Schizotypal

• Cluster B

• Dramatic, emotional, erratic 

  • Antisocial 

  • Borderline

  • Histironic 

  • Narcissistic 

• Cluster C

• Anxious, fearful 

  • Avoidant

  • Dependant

  • Obsessive- compulsive 

• Personality Disorders Across the Lifespan

• Children may find it difficult to make friends at school or be successful at classwork due to personality traits.

• The adolescent who has a personality disorder may find that their peers will tease them for having odd habits, ideas, or behaviors.

• Adult clients who have personality disorders may have trouble forming intimate relationships or keeping a job for an extended time.

• Personality disorders are not usually diagnosed in children, as personality is fluid in children and they are learning to adapt to life’s challenges (Bienenfeld, 2021).

• However, as a client ages and exhibits odd, dramatic, or anxious behaviors that create dysfunction in their lives, differential diagnosis is possible.

• Etiology and Epidemiology of personality disorders 

  • Comorbidities

• Clients who have a personality disorder that is accompanied by one or more comorbidities are at risk for a number of complications.

  • Greater impairment of functional skills

  • Higher rates of relapse

  • Poorer prognosis

  • Poor adherence to treatment regimen

  • Increased risk of suicide 

• Comorbidities - Cluster A

• Major depressive disorder

• Substance use disorder

• Obsessive compulsive disorder 

• Agoraphobia 

• Anxiety disorders 

• Schizophrenia 

• Delusional disorders 

• Bipolar

• Phobias 

• PTSD

• Comorbidities - Cluster B

• Social phobias 

• General anxiety disorder 

• Substance use disorder 

• Anxiety disorder 

• Mood disorders 

• Comorbidities - Cluster C

• Mood disorders 

• Social phobias 

• Obsessive compulsive disorder

• Anorexia nervosa 

• Substance use disorder 

• Risk Factors for personality disorders

• While each of the 10 identified personality disorders has unique risk factors, there are some general risk factors that present with personality disorders. 

  • Genetic

    • Family tendency (Individuals with first-generation relatives who have personality disorders are more likely to be diagnoses with a personality disorder.)

  • Environmental (occurs across the lifespan but are especially influential in childhood) 

    • Physical, emotional, verbal, and sexual abuse 

    • Neglect

    • Hostility 

Etiology of personality disorders

• Not well understand

• Several theories

• Diatheses stress model: theorizes that everyone possesses genetic and biological vulnerabilities to certain illnesses such as personality disorders (Health Research Funding, 2017). 

• When a client experiences a trigger, their vulnerability to illness may increase. 

Diatheses stress model:

heorizes that everyone possesses genetic and biological vulnerabilities to certain illnesses such as personality disorders

• Paranoid personality disorder (DSM-5)

• A long-term pattern of distrust and suspicion of others, beginning in early adulthood and occurring across many situations. This is shown by four or more of the following:

  • Believes others intend harm or deception without evidence

  • Doubts the loyalty or trustworthiness of others

  • Avoids confiding in others out of fear information will be used against them

  • Misinterprets harmless remarks as threatening or insulting

  • Holds grudges and is unforgiving

  • Reacts angrily to perceived attacks on character

  • Suspects partner infidelity without justification

• Signs of Paranoid personality disorder 

• Secrecy 

• Suspicion 

• Sensitivity to criticism 

• Hostility 

• Defensiveness

• Difficulty relaxing 

• Difficulty with introspection 

• Difficulty with teamwork

• Tendency to hold grudges 

• Argumentative nature 

• Schizoid personality disorder (dsm-5)

• A long-term pattern of social detachment and limited emotional expression, beginning in early adulthood and present across many situations. This is shown by four or more of the following:

  • Does not desire or enjoy close relationships, including family

  • Prefers solitary activities

  • Little to no interest in sexual relationships

  • Takes pleasure in few activities

  • Has few or no close friends outside immediate family

  • Is indifferent to praise or criticism

  • Shows emotional coldness or flat affect

• Signs of schizoid personality disorder

• Doesnt want or enjoy close relationships 

• Has indifference to praise or criticism by others 

• Rarely expresses strong emotions 

• Little or no desire for sexual activiity 

• Solitary hobbies 

• Schizotypal Personality Disorder (DSM-5)

• A long-term pattern of social and interpersonal difficulties marked by discomfort with close relationships, unusual thinking or perceptions, and eccentric behavior, beginning in early adulthood and occurring across many settings. This is shown by five or more of the following:

  • Ideas of reference (not delusional)

  • Odd beliefs or magical thinking

  • Unusual perceptual experiences

  • Odd thinking or speech

  • Suspicious or paranoid thinking

  • Inappropriate or limited emotional expression

  • Eccentric or peculiar behavior or appearance

  • Few or no close friends outside immediate family

  • Excessive social anxiety linked to paranoia

• Signs of schizotypal personality disorder 

• Difficulty making friends 

• Serous social anxiety 

• Social awkwardness 

• Vague odd speech 

• Eccentric clothing 

• Magical beliefs 

• Paranoia 

• Odd perceptions 

• Odd emotions 

• Ideas of reference 

• Antisocial personality disorder (DSM-5)

• A long-term pattern of violating the rights of others and ignoring social rules, beginning by age 15. This is shown by three or more of the following:

  • Repeated unlawful behavior

  • Deceitfulness (lying, using aliases, conning others)

  • Impulsivity or poor planning

  • Irritability and aggression

  • Reckless disregard for safety

  • Ongoing irresponsibility (work or financial)

  • Lack of remorse for harming others

• Signs of antisocial personality disorder 

• Reckless behavior 

• Physical aggression 

• Manipulation of others

• Destruction of property 

• Lack of remorse 

• Borderline personality disorder (dsm-5)

• A long-term pattern of unstable relationships, self-image, and emotions with marked impulsivity, beginning early in life. This is shown by five or more of the following:

  • Intense fear of real or imagined abandonment

  • Unstable, intense relationships (idealization ↔ devaluation)

  • Unstable self-image or identity

  • Impulsivity in self-damaging behaviors

  • Recurrent suicidal or self-injuring behavior

  • Rapid mood shifts and emotional reactivity

  • Chronic feelings of emptiness

  • Intense or poorly controlled anger

• Signs of Bipolar personality disorder 

• Fear of abandonment 

• Unstable, intense relationships 

• Unstable self image

• Rapid mood changes 

• Impulsive or dangerous behavior 

• Repeated self harm or suicidal behavior 

• Persistent feelings of emptiness

• Anger management issues 

• Temporary paranoid thoughts 

• Histrionic Personality Disorder (DSM-5)

• A long-term pattern of excessive emotionality and attention-seeking behavior, beginning in early adulthood. This is shown by five or more of the following:

  • Discomfort when not the center of attention

  • Inappropriately sexually seductive or provocative behavior

  • Rapidly shifting, shallow emotions

  • Uses physical appearance to draw attention

  • Vague, impressionistic speech

  • Dramatic, theatrical, exaggerated emotions

  • Easily influenced by others

  • Overestimates the closeness of relationships

• Signs of Histrionic Personality Disorder

• Needs to be the center of attention 

• Seductive or provocative behavior 

• Shifting and shallow emotions 

• Uses appearance to draw attention 

• Impressionistic and vague speech 

• Dramatic or exaggeraticed emotions 

• Easily influenced by others 

• Thinks relationships are closer than they are 

• Narcissistic personality disorder (DSM-5)

• A long-term pattern of grandiosity, need for admiration, and lack of empathy, beginning in early adulthood and present across many settings. This is shown by five or more of the following:

  • Inflated sense of self-importance

  • Fantasies of unlimited success, power, or ideal love

  • Belief in being special or superior

  • Excessive need for admiration

  • Sense of entitlement

  • Exploits others for personal gain

  • Lack of empathy

  • Envy of others or belief others envy them

  • Arrogant or haughty behavior

• Signs of Narcissistic personality disorder

• Grandiose sense of self importance 

• Frequent fantasies about having or deserving 

• Belief in superiority

• Need for admiration 

• Entitlement 

• Willingness to exploit others 

• Lack of empathy 

• Frequent envy 

• Avoidant personality disorder (DSM-5)

• A long-term pattern of social avoidance, feelings of inadequacy, and sensitivity to criticism, beginning in early adulthood and present across many settings. This is shown by four or more of the following:

  • Avoids jobs or activities involving social interaction due to fear of criticism or rejection

  • Avoids relationships unless certain of being liked

  • Restrained in close relationships for fear of shame or ridicule

  • Preoccupied with being criticized or rejected

  • Avoids new situations due to feelings of inadequacy

  • Views self as socially inept or inferior

  • Avoids risks or new activities to prevent embarrassment

• Signs of avoidant personality disorder 

• Choosing isolation over social situations 

• Hypersensitive to criticism 

• Fear of being embarrassed 

• Poor self image 

• Dependent Personality Disorder – Dsm5

• A long-term pattern of excessive need to be cared for, leading to submissive, clingy behavior and fear of separation. This is shown by five or more of the following:

  • Difficulty making everyday decisions without reassurance

  • Needs others to take responsibility for major areas of life

  • Avoids disagreeing for fear of losing support

  • Trouble starting tasks or acting independently

  • Goes to extreme lengths to gain care or approval

  • Feels helpless or uncomfortable when alone

  • Quickly seeks another relationship when one ends

  • Excessive fear of being left to care for oneself

• Signs of dependant personality disorder 

• Trouble making decisions without reassurance 

• Fear that they cant care for themselves 

• Trouble expressing disagreement 

• Difficulty being alone

• Obsessive compulsive personality disorder (DSM5)

• A long-term pattern of perfectionism, need for control, and focus on order at the expense of flexibility and efficiency, beginning in early adulthood and present across many settings. This is shown by four or more of the following:

  • Preoccupation with rules, details, lists, or organization

  • Perfectionism that prevents task completion

  • Excessive devotion to work over leisure or relationships

  • Rigid moral or ethical standards

  • Difficulty discarding worthless items

  • Reluctance to delegate unless others follow exact rules

  • Miserly spending toward self and others

• Signs of Obsessive compulsive personality disorder 

• Excessive doubt and indesiciveness 

• Being unwilling to compromise 

• Being unwilling to throw out broken or worthless options 

• Perfectionism that interferes with completing tasks 

• Becoming overly fixated on a single idea, task, belief

• Difficulty coping with criticism 

• Diagnostic tools for personality disorders 

• DSM-5

• Minnesota Multiphasic Personality Inventory (MMPI)

• Eysenck Personality Inventory

• Personality Diagnostic Questionnaire

• Gerontological Personality Disorder Scale

  • Most appropriate diagnostic test for older adults

• Laboratory tests

  • Sexually transmitted infections (if suspected)

  • Toxicology tests for substances may be ordered 

  • Substance use disorder is especially common with some personality disorders (Bienenfeld, 2021)

• Treatment for personality disorders 

• The main treatment for all 10 personality disorders is psychotherapy

• Some of the most common types of psychotherapy that are used

  • - Cognitive behavioral therapy

  • - Dialectical behavior therapy

  • - Psychodynamic psychotherapy

  • - Supportive therapy

  • - Social skills training

• The type of therapy that is best for the client is based on their diagnosis and manifestations 

• Nurse’s Role in personalty disorders

• Equitable and sensitive care 

  • Self-awareness

  • Client-centered care

  • Prevention

  • Teaching

  • Therapeutic presence

• The nurse must collaborate often with other members of the treatment team not only to prevent splitting and manipulation, but also to uphold the client’s holistic case management.

Implicit bias

• the first step in changing bias is to admit it exists

• Unconscious discriminatory attitudes

• Trigger negative reactions/fear

• Can create disparities in care

  • Ethic, racial, minority groups

Stereotyping

• Based on previous experiences with anger

• Client-Centered Care- Personality disorders

• The nurse uses knowledge of specific personality disorders to assess

  • Degree of current dysfunction 

  • Coping skills 

  • Comorbidity, effectiveness of treatment 

  • Willingness to change

  • Social support systems

• From these insights, the nurse can then develop a plan of care

• Use empathy and sensitivity

  • Believe the client has the ability to effect changes that improve their lives(Dean et al., 2018).

• Prevention- personality disorders 

• Ideally, it is best to take actions to prevent personality disorders before they develop.

• Advocate to decrease violence in the community, trauma in the home, and health disparities that lead to children not receiving early interventions for emotional and behavioral problems.

• Early treatment and empowering clients to solve problems productively and to manage both emotions and behavior can lead to improved relationships, careers, and mental health.

• Teaching- personality disorders 

• Specific education related to the client’s disorder

• Recognition of common clinical manifestations

• Resources and support groups available for the client in their community

• The nurse may also educate caregivers of clients who have a personality disorder, including parents of adolescent clients, on signs and symptoms of self-harm.( Meshkinyazd, Heydari, and Fayyazi Bordbar, 2020)

• Clients who have cluster A personality disorders often have trouble relating to others.

• An empathetic nurse can help clients process feelings and emotions that they often cannot share with others.

• Clients who have cluster B personality disorders may find that others shun their dramatic behaviors.

• An empathetic nurse can help clients process their needs while setting boundaries.

• Clients who have cluster C personality disorders have trouble taking on responsibilities that lead to success due to fear.

• An empathetic nurse can decrease anxiety, suggest coping skills, and empower the clients.

• Analyze cues/prioritize hypothesis- Cluster A

• Focus on finding and maintaining interpersonal relationships

• Analyze cues/prioritize hypothesis- Cluster B

• - Focus on teaching clients to set limits on dramatic and inappropriate behaviors

• - Emotional regulation

• Analyze cues/prioritize hypothesis- Cluster C

• Focus on decreasing anxiety

• Goals for clients- Cluster A

• Finding and maintaining interpersonal relationships 

• Goals for clients- Cluster B

• Safety and maintaining appropriate boundaries 

• Goals for clients- Cluster C

• Decreasing anxiety 

• Interventions- personality disorders 

• Therapeutic communication.

•  Model good communication skills.

• Administer medications as prescribed.

• Coordinate care.

• Document carefully to show progress.

  • Capture client’s exact words.

• Outcomes- personality disorders 

• A client with a personality disorder may never be truly discharged from care; they may need to return to health care providers occasionally as needed.

• PARANONID PERSONALITY DISORDER

• INTENSE PARANOIA

• HIGHLY SUSPICIOUS OF OTHERS

• Schizoid personality disorder

• Prefers to be alone (may detach from others)

• Problems creating /maintaining relationships

• May not seek help

• SCHIZOTYPICAL PERSONAILTY DISORDER

• Strong connection to Schizophrenia (potentially may have a relative with this disorder) 

• Strange beliefs or fantasies

• ANTISOCIAL PERSONALITY DISORDER

• Blatant disregard for others

• Impulsive

• Manipulative

• Lack remorse

• Is on a spectrum, most serious cases are psychopaths

• Narcissistic Personality Disorder

•  Lack empathy

• Arrogance, entitlement

• Believe they are special or unique

• Grandiose sense of importance and superiority

• Histrionic Personality Disorder

• Excessively seek out attention, life of the party

• Seductive or provocative behavior

• Think relationships are close than they are

• Borderline Personality Disorder

• Rapid mood swings

• May engage in risky activities including suicide attempts

• Anger management issues

• Temporary paranoid thoughts

• Avoidant Personality Disorder

• Choose isolation over social interactions

• Hypersensitive to criticism

• Fear of embarrassment

• Dependent Personality Disorder

• Trouble making decisions without reassurance

• Fear that they can not take care of themselves

• Difficulty being alone

• Rely on others for emotions support and validation

• Obsessive Compulsive Personality Disorder

• Preoccupied with perfection

• Obsessed with making lists and organized details

• Unwilling to compromise