Personality Disorders

Personality

complex pattern of characteristics, largely outside of the person's awareness, which compromise the individual's distinctive pattern of perceiving, feeling, thinking, coping and behavior

Personality traits

prominent aspects of personality that are exhibited in a wide range of social & personal contexts

Personality and personality traits

tend to be stable over time

Personality traits are enduring patterns of

perceiving, relating to, and thinking about environment and oneself

Personality involves

cognition, affectivity, interpersonal behavior, and impulse control

Cognition

ways of perceiving and assigning meaning to self, others, and events

Affectivity

the range, intensity, and appropriateness of emotionality

Manifestation of personality disorders

adolescence and early adulthood and usually occurs before other psychiatric disorders

Personality disorders often co-occur with

depression and anxiety

Gender

can be a major risk factor for the development of certain personality disorders

Women

at increased risk for avoidant, dependent, and paranoid personality disorders

Men

at risk for antisocial personality disorder

Risk factors for personality disorders

african american & native american heritage, young adults, low socioeconomic status, divorced, separated, widowed, never married

Personality disorder

a rigid, stereotyped behavioral pattern that persists throughout a person’s life; chronic maladaptive pattern of perceiving, thinking and relating that impairs social or occupational functioning causing inner distress; deviates markedly from the expectations of a person’s culture

People with personality disorders are at risk for

psychiatric co-morbidities-- mood disorders, anxiety, substance abuse, injuries to self and/or others

Personality disorders occur when personality traits become

inflexible and rigid, maladaptive, cause significant dysfunction or severe impairment and subjective distress, a lifelong behavioral pattern that negatively affects many areas of life, causes problems, and is not produced by another disorder or illness

Individuals with personality disorders lack

insight, lack understanding of the impact of their behavior on their environment, fail to accept consequences for their own behaviors

What happens when individuals with personality disorders are threatened?

attempt to manipulate or change their environment to decrease stress instead of changing the behavior

Psychoanalytic theory

empathize importance of nurturing from immediate caregivers and loved ones for fostering positive personality traits

Biologic theory

stress influence of genetic transmission combined with environmental exposures for the formation of personality

Social learning and cognitive perspectives theory

people acquire personality characteristics through thought and interaction with their environment

DSM V & personality disorders

significant impairment in self or interpersonal functions, one or more pathological personality trait, impairments are stable over time/ across situations, personality traits or trait expressions are not normative for developmental stage or cultural environment, not due to use of a substance or medical condition

Cluster A

represent behaviors that are described as; odd or eccentric

Cluster A includes

paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder

Cluster B

represent behaviors that are described as; dramatic, emotional, or erratic

Cluster B includes

antisocial personality disorder, borderline personality disorder, histrionic personality disorder, narcissistic personality disorder

Cluster C

represent behaviors that are described as; anxious or fearful

Cluster C includes

avoidant personality disorder, dependent personality disorder

obsessive-compulsive disorder

Paranoid personality disorder

a pervasive distrust and suspiciousness of others such that others' motives are interpreted as malevolent; quick to take offense

Characteristics of paranoid personality disorder

do not acknowledge their negative feelings, project negative feelings on others, look for hidden meanings in conversations

Start of paranoid personality disorder

begins by early adulthood and presents in a variety of contexts

Clinical observations of paranoid personality disorder

constantly on guard, hyper vigilant, guarded, oversensitive to surroundings and interactions, ready for any real or imagined threat mistrusts and misinterprets cues, magnifies and distorts environmental cues, trusts no one - has few if any friends, constantly tests the honesty of others, do not lose contact with reality

Predisposing factors to paranoid personality disorder

possibly hereditary link, subjected to early parental antagonism and harassment, estimated 4.4% of general population

Schizoid personality disorder

show indifference to social relationships, characterized primarily by a profound defect in the ability to form personal relationships; failure to respond to others in a meaningful emotional way, flattened affectivity, cold, unsociable, seclusive demeanor

Clinical manifestations of schizoid personality disorder

indifferent to others and environment, client is aloof, withdraws from social events, client is emotionally cold, flat affect, in the presence of others, clients appear shy, anxious, or uneasy, inappropriately serious about everything and has difficulty acting in a light-hearted manner

Predisposing factors of schizoid personality disorder

possible hereditary factor, childhood has been characterized as: bleak, cold, unempathic, notably lacking in nurturing

Schizotypal personality disorder

displays an enduring and pervasive pattern and interpersonal deficits with extreme discomfort and intolerance for close relationships, thought patterns are disturbed, odd behaviors; a graver form of the pathologically of the less severe schizoid personality pattern

Clinical observations of schizotypal personality disorder

exhibits bizarre speech pattern, aloof, isolative, inappropriate affect, social anxiety; when under stress, may decompensate and demonstrate psychotic symptoms, demonstrates bland and apathetic manners, everyday world manifests with magical thinking and ideas of reference

delusions, depersonalization

Predisposing factors to schizotypal personality disorders

possible hereditary factor and or possible physiological influence such as anatomic deficits or neurochemical dysfunctions within certain areas of the brain (dysregulation of dopaminergic pathways); early family dynamics of indifference, impassivity (void of emotion) parental patterns of discomfort with personal affection and closeness

Summary of cluster B disorders

dramatic, emotional, attention seeking behaviors, moods are labile and shallow, become involved in intense interpersonal conflicts, antisocial traits more common in men, borderline and histrionic traits more common in females

Antisocial personality disorder (anti-social, A-social psychopath, sociopath)

aggressive and irresponsible behaviors, superficially charming, lack genuine warmth

Antisocial personality disorder is a pattern of

socially irresponsible, domestic violence, fights, stealing, substance abuse, exploitative, manipulative, guiltless behavior that reflects a disregard for the rights of others; failure to conform to society laws and norms

Predisposing factors to antisocial personality disorder

possible genetic influence, sociopathic or alcoholic mother / father, aggressive temperament as a child, parental deprivation during the first 5 years of life, history of ADHD or conduct disorder during childhood or adolescence, absence of parental discipline or influence, erratic and inconsistent methods, extreme poverty, removal from the home, being "rescued" each time they are in trouble (never having to suffer the consequences of their own behavior), maternal / paternal deprivation

Clinical observations of antisocial personality disorder

fails to sustain consistent employment, exploits and manipulates others for personal gain, cold, callous, intimidating, inconsistent work or academic performance, failure to conform to societal norms, cruel and malicious, inability to form lasting monogamous relationship, low levels of behavioral inhibitions, very difficult diagnose and treat, lack fear, decision-making

Borderline personality disorder

characterized by a pattern of intense and chaotic

relationships with affective instability; have fluctuating

and extreme attitudes and moods regarding other people; view life experiences and relationships to the extremes of either very good or very bad-- this tendency is known as splitting; view themselves as victims, highly impulsive, mood swings, depression, anger, anxiety, if feelings of being ignored can self mutilate, harm self, become aggressive for attention or numb emotions

Predisposing factors to borderline personality disorder

possible history of childhood abuse, neglect and separation from caregivers or loved ones, others with psychiatric disorders in the home

Biochemical predisposing influences for borderline personality disorder

some research has shown changes in certain areas of the brain involved in emotion regulation, impulsivity and aggression; in addition, certain brain chemicals that help regulate mood, such as serotonin, may not function properly

Genetic predisposing influences for borderline personality disorder

possible hereditary factor

Characteristics of borderline personality disorder

most common form of personality disorder, emotionally unstable, mostly females, identity disturbances in body image, sexuality, long term goals and careers, extreme affective instability usually lasting a few hours and usually no longer than a day

Clinical observations of borderline personality disorder

always seems to be in a state of crisis-- affect is one of extreme intensity, behavior reflects frequent changeability, self-destructive behaviors present; clients are most strikingly identified by the intensity and instability of their affect and behavior

Common behaviors in borderline personality disorder

depression, inability to be alone, attention seeking behaviors, clinging and distancing behaviors, splitting, manipulation

Histrionic personality disorder

long standing pattern of excessive emotionally charged interactions and attention seeking behaviors; strive to be center of attention, speech is superficial, lacks detail; seductive, insecure, dependent on approval of others, naïve, easily influenced, low tolerance to frustration, blame disappointments on others, suppress feelings r/t past events and lack insight

Predisposing factors to histrionic personality disorder

possible link to the noradrenergic

and serotonergic systems, possible hereditary factor, learned behavior patterns

Clinical observations of histrionic personality disorder

highly distractible, difficulty paying attention to detail, flamboyant in dress and speech, exhibitionistic, easily influenced by others, difficulty forming close relationships-- excitable, emotional, colorful, dramatic, manipulative, attention seeking, extroverted in behavior, seductive

Narcissistic personality disorder

lifelong pattern of self-centeredness, self-absorption, inability to empathize, insensitive of others, grandiose, extreme desires for admiration, feel special and important and have the rights for special treatment, exaggerate successes, self - esteem is fragile, oversensitive to comments, envious of others and believe others envy them

Histrionic personality disorder more common in

women

Narcissistic personality disorder more common in

men

Predisposing factors to narcissistic personality disorder

they tend to be overly pampered and indulged, learn to view themselves as special and grow to expect special treatment from others, parents were often narcissistic

themselves

Clinical observations of narcissistic personality disorder

mood can easily change because of fragile self-esteem if they do not: meet self-expectations, receive positive feedback from others; criticism from others may cause them to respond with rage, shame, and humiliation, clients are overly self-centered, overly sensitive to what others think, insensitive to others needs, lack empathy, exploit others in an effort to fulfill their own desires; mood, which is often grounded in grandiosity, is usually optimistic, relaxed, cheerful, and care-free

Avoidant personality disorder

pattern in early adulthood of social discomfort, timid, fear of rejection and negative feedback, will only form relationships if acceptance is guaranteed, self-perception of unattractiveness, inferior, socially inept, avoid social demands, feelings of shame, embarrassment, ridicule trying new activities

Avoidant personality disorder involves

all social activities

Social phobia involves

specific situations

Avoidant personality disorder and gender

equally common for both sexes

Predisposing factors for avoidant personality disorders

possible hereditary influences, parental rejection and criticism

Clinical observations of avoidant personality disorders

awkward and uncomfortable in social situations, desire close relationships but avoid them because of their fear of being rejected, inappropriate displays of anger, dissociative, paranoid ideation, preoccupied being criticized or rejected

Dependent personality disorder

excessive need to be taken care of, pervasive, submissive and clinging behaviors, fears of separation, difficulty in making independent decisions and starting projects, lack trust in one's judgments, helpless, hopeless, relationships are based on being cared for; will stay in relationship even if abused

Dependent personality disorder more common in

women and the youngest children of a family

Predisposing factors to dependent personality disorder

possible hereditary influence, stimulation and nurturance are experienced exclusively

from one source, a singular attachment is made by the infant to the exclusion of all others

Clinical observations of dependent personality disorder

they have a notable lack of self-confidence that is often apparent in their: posture, voice, mannerisms, typically passive and acquiescent to desires of others, overly generous and thoughtful, while underplaying their own attractiveness and achievements, assume passive and submissive roles in relationships, avoid positions of responsibility and become anxious when forced into them

Tx for personality disorders

interpersonal psychotherapy, psychoanalytical psychotherapy, milieu or group therapy, cognitive/behavioral therapy, DBT (dialectical behavior therapy) for borderline PD, case management, psychopharmacology

Symptoms of cluster A personality disorders

suspicious, paranoid, distrustful, preoccupied, reluctant or unable to trust, reads into interactions as having hidden negative agendas, isolative, flat affect, blunted or limited emotional response, limited to no meaningful relationships, detached from activities, socially detached, odd thinking, speech, behaviors, social anxiety, negative self judgments

Goals for cluster A personality disorders

solve immediate crisis or problem, and complete social skills training

Symptoms of cluster B personality disorders

disregards and violates rights and safety of others, failure to conform to social norms, deceitful, erratic work patterns if any, instability in relationships, reckless disregard, irresponsible, aggressive towards self and/or others, manipulative, mood swings, instability of emotions(labile), unstable self -image, theatrical, exaggerated speech and manners, impulsive, attention seeking, must be center of attention, feelings of emptiness

Goals for cluster B personality disorders

prevent suicide & harm, gain insight, improve coping, gain insight into feelings and behaviors and unrealistic expectations /fears

Symptoms for cluster C personality disorders

avoidant of social activities d/t fears of criticism, disapproval or rejection, feelings of inadequacies, fear of being shamed or ridiculed in intimate relationships, difficult decision making, inappropriate anger with displays of temper, excessive needs to be taken care of, difficulty with expressing disagreements with others, lack of self-confidence, lack of initiating projects or relationships, goes to any length to be nurtured and cared for, helplessness and insecure when alone

Goals for cluster C personality disorders

enhance social functioning, solve immediate crisis, assertiveness training, cognitive reconstruction

Approach to guarded, suspicious, or argumentative personality

acknowledge their perception without debate or agreement; focus attention on treatment; be respectful, maintain professional distance and approach

Approach to aloof, uninvolved personality

demonstrate understanding and respect privacy, explain rationale for personal questioning, do not push for social interaction

Approach to idiosyncratic, eccentric personality type

consistent approach addressing complaints and beliefs, do not challenge or reinforce perspectives

Personality types for cluster A

guarded, suspicious, argumentative, aloof, uninvolved, idiosyncratic, eccentric

Personality types for cluster B

demanding, dramatic, emotionally involved, seductive, superior clients, sociopathic

Approach to demanding personality

SET LIMITS- minimize excessive or realistic demands

Approach to dramatic, emotionally involved, seductive personality

supportive attitude, maintain professional boundaries to prevent unprovoked responses

Approach to superior clients personality

recognize and support strengths. Show interest in opinions, demonstrate competence

Approach to sociopathic personality

set realistic limits on visits, do not tolerate aggressive behaviors, develop treatment plan to address aggressive behavior

Personality types for cluster C

orderly, controlled, controlling, anxiously avoidant, clinging, dependent, controlling, avoidant, dependent

Approach to orderly, controlled, controlling personality

clearly state treatment approaches, options, rationales, give as much details as possible, avoid struggle of who is in charge

Approach to anxiously avoidant, clinging, dependent personality

demonstrate patience, empathy towards fears, frequent brief encounters, forewarn of any milieu changes

Approach to controlling, avoidant, dependent personality

directly address concerns about behaviors, identifying underlying feelings about their illness and treatment, avoid feeling resentful about "acting out" behaviors

Nursing considerations for personality disorders

safety, trust, protection for vulnerable population, hygiene and nutrition, communication and social skills, normal communication skills are compromised by emotions. (appropriate communication skills are necessary for successful relationships)

Nursing diagnoses for personality disorders

risk for Self- or other -directed violence, risk for self- mutilation, ineffective coping, disturbed thought process, anxiety, fear, impaired social interaction, chronic low self-esteem, ineffective therapeutic regimen management, ineffective family coping

Conduct disorder

diagnosis given to individual 15 yrs or younger who is exhibiting antisocial personality disorder symptoms