Personality Disorders

Definition of a Personality Disorder 

Long-term patterns of behavior and inner experiences that differ significantly from what is expected 

Personality

Collective emotional qualities and behaviors that make a person unique

Cluster A

Odd and Eccentric

Cluster B 

Dramatic, Emotional and Erratic 

Cluster C

Anxious and Fearful

Cluster A Personality Disorders Include

1. Paranoid Personality Disorder

2. Schizoid Personality Disorder

3. Schizotypal Personality Disorder

Cluster B Personality Disorder Include: 

1. Antisocial Personality Disorder 

2. Borderline Personality Disorder 

3. Histrionic Personality Disorder

4. Narcissistic Personality Disorder 

Cluster C Personality Disorders Include:

1. Avoidant Personality Disorder

2. Dependent Personality Disorder

3. Obsessive-Compulsive Disorder

Etiology and Epidemiology

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

• Greater impairment of functional skills

• Higher rates of relapse

• Poorer prognosis

• Poor adherence to treatment regimen

• Increased risk of suicide

Cluster A Comorbidities

• MDD

• Substance Use Disorder 

• OCD 

• Agoraphobia 

• Anxiety Disorders 

• Schizophrenia 

• Delusional Disorders 

• Bipolar Disorder 

• Phobias 

• PTSD 

Cluster B Comorbidities

• Social Phobias

• GAD

• Substance Use Disorder

• Anxiety Disorders

• Mood Disorders

Cluster C Comorbidities 

• Mood Disorders

• Social Phobias 

• OCD

• Anorexia Nervosa 

• Substance Use Disorders 

Cluster A Treatment Approach

Focus on finding and maintaining interpersonal relationships

Cluster B Treatment Approach 

Focus on emotional regulation and teaching the clients on set limits on dramatic behaviors 

Cluster C Treatment Approach

Focus on decreasing anxiety

General Risk Factors

• Genetic:

  • Fairly tendency

  • Clients with first-generation relatives with personality disorders or mental health disorders have higher risk of diagnosis of personality disorder

• Environmental:

  • Can occur across lifespan

  • Especially influential during childhood (ACEs)

    • Physical abuse

    • Neglect

    • Sexual abuse

    • Emotional abuse

Paranoid Personality Disorder 

A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning in early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

• Reads hidden demeaning or threatening meaning into benign remarks or events

• Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights)

• Perceives attacks on his or her character or reputation and is quick to react angrily

• Has recurrent suspicions, w/o justification, regarding fidelity of spouse or sexual partner

Schizoid Personality Disorder 

A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

• Takes pleasure in few, if any, activities

• Lacks close friends or confidants other than first-degree relatives

• Apparent indifferent to the praise or criticism of others

• Shows emotional coldness, detachment, or flattened affectivity

• They do not feel connected nor do they want to

  • Takes pleasure in few or if any activities

  • Indifferent to praise or criticism

Schizotypal Personality Disorder

A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

• Ideas of reference - thinking something is happening because you

  • I.e. driving and a random street light turns on and you think it did because of you

• Odd beliefs or magical thinking

  • i.e. I can read everyone's mind

• Unusual perceptual experiences, including body illusions - not a hallucination but feeling like something/someone is there (delusion w/o VH/AH)

• Odd thinking and speech (e.g. vague, circumstantial, metaphorical, over elaborative, or stereotyped)

  • Very vague

  • Abstract

  • Not necessarily making a point

  • Metaphorical

• Suspicious or paranoid ideation

• Inappropriate or constricted affect

  • Flat affect

  • Expression is off

    • I.e. laughing during inappropriate times

• Behavior of appearance that is odd, eccentric, or peculiar

• Lack of close friends or confidants other than first-degree relatives

• Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self

  • Associated with low self-esteem

• COMORBIDIITY: MDD

  • Antidepressants

  • Antipsychotic meds

  • Some form of therapy:

    • Psychotherapy

    • CBT

• Doesn't has the same psychosis of schizophrenia:

  • NO AH/VH

  • No delusions that remove them from reality

Antisocial Personality Disorder

A pervasive pattern of disregard for and violation of the rights of others, since age 15 years, as indicated by three (or more) of the following:

• Failure to conform to social norms with respect to lawful behaviors

  • Repeatedly committing acts that results in arrest

• Deceitfulness - lying, cheating, making up stories to get out of their own way, conning others

• Impulsivity or failure to plan ahead

  • Everything is someone else's fault

  • No sense of ownership

• Irritability and aggressiveness

• Reckless disregard for the safety or self or others

• Consistent irresponsibility

  • Lots of failure when it comes to work

• Lack of remorse

• Beneficial technique to utilize inpatient - SETTING BOUNDARIES

  • They want to stir the pot

  • Can take advantage of other patients

• Think Ted Bundy: came across as charming to victims to gain their trust and manipulate them

Borderline Personality Disorder

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early childhood as indicated by five (or more) of the following:

• Frantic efforts to avoid real or imagined abandonment

• A pattern of unstable and intense interpersonal relationships characterized by alternating b/w extremes of idealization and devaluation

• Recurrnet suicidal behavior, gestures, threats, or self-mutilating behavior

• Affective instability due to marked reactivity of mood

• Chronic feelings of emptiness

  • Void like

  • Dysphoria

  • Anxiety

• Inappropriate, intense anger, or difficulty controlling anger

  • Recurring arguments

  • Hard time with perception of self

• EXTREMELY fearful of being abandoned

  • Origin = Sensitivity to rejection as a child

    • Trauma

• Extreme fluctuation in relationships (good to bad)

• Unstable relationships

• These are the disorders that typically have a lot of self-harm and impulsiveness to manipulate individuals i.e. cutting

• Impulsivity can lead to poor decisions:

  • Reckless driving

  • Binge eating

  • Substance use

• Treatment:

  • CBT has been seen to be beneficial

Histrionic Personality Disorder

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood, as indicated by 5 (or more) of the following:

• Is uncomfortable in situations in which he/she is not the center of attention

• Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior

• Displays rapidly shifting and shallow expression or emotions

• Consistently uses physical appearance to draw attention to self

• Has a style of speech that is excessively impressionistic and lacking in detail

  • Talk a lot and use big words that has no true meaning

• Shows self-dramatization, theatricality, and exaggerated expression of emotion

• Is suggestible (i.e., easily influenced by others or circumstances)

• Considers relationships to be more intimate than they actually are

Narcissistic Personality Disorder

A pervasive pattern of grandiosity, need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following:

• Has grandiose sense of self-importance

• Preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love

• Believes that he or she is "special" and unique and can only be understood by/associate with other special or high-status people

• Requires excessive admiration

• Has a sense of entitlement

• Is interpersonally exploitative

• Lacks empathy

• Is often envious of others or believes that others are envious of them

• Shows arrogant, haughty behaviors or attitudes

  • Sense of entitlement

  • Talks down to people

    • i.e. "you are just the nurse - I want to speak to the dr."

• Utilize boundaries with clients

• Can be overcompensating

  • i.e. "they fired me but they'll be begging for me back within a week."

• Takes advantages of others for their own needs

Avoidant Personality Disorder

Pervasive patterns of social inhibition, feeling of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

• Avoids occupational activities that involve interpersonal contact

• Unwilling to get involved w/ people unless certain they are liked

  • Shows restraint in relationships due to fear of being ridiculed

• Shows restraint with intimate relationships

• Is preoccupied with being criticized or rejected in social situations

• Is inhibited in new interpersonal situations because of feelings of inadequacy

• Views self as socially inept, personally unappealing, or inferior to others

• Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

• Lack close friends, avoid social activities, anxious/embarrassed otto be around people

• Interpersonal therapy beneficial in improving patient's relationships

Dependent Personality Disorder 

Pervasive, excessive need to be taken care of leading to submissive and clinging behavior and fears of separation, as indicated by five(or more) of the following:

• Difficulty making everyday decisions w/o an excessive amount of advice and reassurance from others

• Needs others to assume responsibility for most major areas of their life

• Difficulty expressing disagreement with others due to fear of loss of support/approval

• Difficulty initiating projects or doing things on their own

  • Can't make everyday decisions on their own

• Goes to obsessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant

• Feels uncomfortable/helpless when alone because of exaggerated fears of being unable to care for themselves

• Urgently seeks another relationship as a source of care and support when a close relationship ends

• Unrealistically preoccupied with fears of being left to take care of themselves

OCD

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

• Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost

• Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because their own overly strict standards are not met)

• Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships

• Is overconscientious, scrupulous, and inflexible about matters or morality, ethics, or values

• Is unable to discard worn-out or worthless objects when they have no sentimental value

• Is reluctant to delegate tasks or to work with others unless they submit exactly to his or her way of doing things

• Adopts a miserly spending style toward both self and others

• Fixated on a ritual and cannot get passed it

  • Interferes with daily living

• COMORBITIDY: Anorexia Nervosa

  • Can see ritualistic behaviors in food

Diagnostic Tools

• DSM-5

• Minnesota Multiphasic Personality Inventory (MMPI)

• Eysenick Personality Inventory

• Personality Diagnostic Questionnaire

• Gerontological Personality Disorder Scale

  • Most appropriate diagnostic test for older adults

    • Specific scale for older clients due to dramatic unusual events that occur in their life

• Laboratory tests

  • Sexually transmitted infections (if suspected)

  • Toxicology tests for substances may be ordered

    • Substance use disorder is especially common with some personality disorders

 

Treatment

• 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 (Interpersonal)

  • Supportive therapy

  • Social skills training

• Certain meds:

  • Antipsychotics, Antianxiety

Nurse’s Role 

Equitable and sensitive care 

• Self-awareness 

• Client-centered care 

• Prevention 

• Teaching 

• Therapeutic Presence 

  • Unique individual treatment for each patient

Self-Awareness

• Implicit bias

  • Unconscious discriminatory attitudes

    • Trigger negative reactions/fear

  • Can create disparities in care

    • Ethnic, racial, minority groups

  • Stereotyping

    • Based on previous experiences with anger

• Patient's can analyze staff better than staff analyze them because they are familiar with the system - can pick up on biases

Client-Centered Care

• 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

  • Respond with empathy and sensitivity

Prevention

• 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

• Community resources/involvement to help address and reduce rates of childhood trauma, abuse, violence, etc.

Teaching for Personality Disorder

• 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

  • Typically done in individuals with a cluster B or cluster C disorders

• After educating client:

  • Assess their understanding (teach-back)

  • Document it

Therapeutic Presence

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

  • Empathy 

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

  • SET BOUNDARIES

  • Empathy

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

  • Empowering patients to have confidence

 

Take Action

• Therapeutic communication

  • Chart what patient responds to assess level of communication

    • Are they improving? 

• Model good communication skills

  • Boundaries set

• Administer meds as prescribed

• Coordinate care

• Document carefully to show progress

  • Capture client's exact words

Outcomes for 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

  • Get them to a functional state