Chapter 18: Personality Disorders

Comprehensive practice flashcards covering Chapter 18 Personality Disorders, including behavioral clusters, diagnostic criteria, psychopharmacology, clinical courses, and specific nursing interventions.

How is personality defined?

An ingrained, enduring pattern of behaving and relating to the self, others, and the environment, which includes perceptions, attitudes, and emotions.

When are personality disorders diagnosed?

When there is impairment of personality functioning and personality traits that are maladaptive.

What identity and interpersonal characteristics define personality disorders?

Egocentrism, deriving self-esteem from power or pleasure at others' expense, failure to conform to norms, motivation by personal gratification, dysfunctional relationships characterized by deceit or coercion, and a lack of empathy or remorse.

What are common maladaptive or dysfunctional personality traits?

Manipulative, dishonest, or deceitful behaviors; anger and hostility; irritable, labile moods; lack of guilt or remorse; impulsivity; distractibility; poor judgment; irresponsibility; risk-taking; mistrust; exhibitionism; entitlement; dependency; and eccentric perceptions.

How are personality disorder diagnoses organized into behavioral clusters?

Cluster A encompasses odd or eccentric behaviors; Cluster B encompasses erratic or dramatic behaviors; and Cluster C encompasses anxious or fearful behaviors.

Which specific personality disorders comprise Cluster A?

Paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder.

Which specific personality disorders comprise Cluster B?

Antisocial personality disorder, borderline personality disorder (BPD), histrionic personality disorder, and narcissistic personality disorder.

Which specific personality disorders comprise Cluster C?

Avoidant personality disorder, dependent personality disorder, and obsessive–compulsive personality disorder.

What alternative classification model was introduced in the DSM-5?

An alternative hybrid model of classification (summarized in Box 18.1), though it is not widely used by clinicians.

How are depressive behavior and passive-aggressive behavior characterized as maladaptive traits?

Depressive behavior is a pervasive pattern of depressive cognitions and behaviors often seen in individuals with relatives having major depressive disorders. Passive-aggressive behavior involves negative attitudes, passive resistance to performance demands, and rapidly fluctuating moods.

What is the prevalence of personality disorders in the general population, and what characterizes their general clinical course?

They occur in $6\%$ to $7\%$ of the general population. They are deeply ingrained and often treatment-resistant, with difficulties persisting through young and middle adulthood and typically diminishing in the 40s and 50s.

How do antisocial and borderline personality disorders specifically change by age $50$?

Clients with antisocial personality disorder display less criminal behavior (though substance use issues persist), while clients with borderline personality disorder exhibit decreased impulsive behavior and increased stability.

Which personality disorders tend to remain consistent throughout life rather than diminishing in middle age?

Paranoid, schizotypal, avoidant, and obsessive–compulsive personality disorders.

In biologic theories of personality development, what is temperament and what proportion is genetic?

Temperament refers to biologic processes of sensation, association, and motivation. Genetic differences account for approximately $50\%$ of temperament traits.

What are the four biologically based temperament traits, and by what age are they ingrained?

Harm avoidance, novelty seeking, reward dependence, and persistence; they are ingrained by age $23$.

What behavioral differences exist between high and low levels of harm avoidance?

High harm avoidance leads to fear of uncertainty, social inhibition, shyness, and pessimistic worry (excessive anxiety). Low harm avoidance leads to carefree, energetic, outgoing, and optimistic behavior, which may cause unresponsiveness to danger.

What behavioral differences exist between high and low levels of novelty seeking?

High novelty seeking produces quick-tempered, curious, impulsive, easily bored, and fickle behavior with angry outbursts. Low novelty seeking produces slow-tempered, stoic, reflective, frugal behavior that adheres to routine and tolerates monotony.

What behavioral differences exist between high and low levels of reward dependence?

High reward dependence manifests as tender-hearted, sensitive, sociable behavior that is overly dependent on others' approval. Low reward dependence manifests as practical, tough-minded, cold, and socially detached or aloof behavior.

What behavioral differences exist between high and low levels of persistence?

High persistence individuals are hardworking, ambitious, and view fatigue as a challenge (sometimes persevering when inappropriate). Low persistence individuals are inactive, indolent, erratic, give up easily, and rarely strive for higher accomplishments.

In psychodynamic theories, what is character and what are its three major traits?

Character consists of concepts about the self and external world that develop over time. Its three major traits are self-directedness, cooperativeness, and self-transcendence.

According to developmental theories, how do personality disorders develop?

Personality disorders result from maladaptive combinations of hereditary temperament and acquired character traits, particularly when nonsupportive environments hinder stage-specific developmental tasks.

What gender biases are observed in the diagnosis of personality disorders?

Antisocial personality disorder is diagnosed more often in males, whereas borderline personality disorder is diagnosed more often in females.

Why are clients with schizotypal, narcissistic, and obsessive–compulsive personality disorders less likely to engage in treatment?

They often perceive other people or external circumstances, rather than their own behaviors, as the cause of their problems.

What is the primary focus of psychopharmacology in treating personality disorders?

It focuses on treating specific target symptoms (cognitive–perceptual distortions, affective dysregulation, aggression, anxiety) rather than the overall personality disorder subtype.

Which medications are indicated for aggression in personality disorders, and which drug class should be avoided?

Lithium, valproate, and antipsychotics are used to treat aggression; benzodiazepines should be avoided due to their misuse potential.

Which pharmacologic agents are prescribed for mood dysregulation symptoms in personality disorders?

Lithium, carbamazepine, valproate, and low-dose neuroleptics for emotional instability and mood swings; SSRIs and atypical antipsychotics for emotional detachment; and SSRIs, MAOIs, or low-dose antipsychotics for atypical depression.

What three cognitive restructuring techniques are commonly utilized in cognitive–behavioral therapy (CBT)?

Thought stopping (halting negative thought patterns), positive self-talk (changing negative self-messages), and decatastrophizing (viewing life events more realistically).

What is dialectical behavior therapy (DBT), and what does it target?

A form of therapy designed specifically for borderline personality disorder that addresses distorted thinking, maladaptive behavior, and poorly regulated emotions.

What is schema therapy designed to address?

Unmet emotional needs by identifying distressing thought and behavioral patterns, helping clients develop greater self-worth, form nurturing relationships, and achieve healthier life goals.

What is the estimated prevalence and sex distribution of paranoid personality disorder?

It affects approximately $0.5\%$ to $4\%$ of the general population and is more common in males than in females.

What are the behavioral and cognitive characteristics of paranoid personality disorder?

Pervasive mistrust and suspiciousness of others, an aloof and guarded demeanor, hypervigilance, restricted affect, labile mood that quickly changes to hostile, distorted thinking, and frequent use of projection.

What communication approach should the nurse maintain with a client diagnosed with paranoid personality disorder?

Use a formal, business-like approach; be straightforward, on time, and reliable; and avoid social chitchat or joking.

Why should nurses help clients with paranoid personality disorder validate ideas before taking action?

To prevent them from acting upon paranoid ideas or delusions and to encourage basing decisions on reality.

What is the prevalence and emotional presentation of schizoid personality disorder?

It affects about $3\%$ to $5\%$ of the population (more common in males) and features a restricted range of emotional expression, emotional coldness, lack of enjoyment, and difficulty expressing anger.

What characterizes the fantasy life and intellectual tendencies of individuals with schizoid personality disorder?

They maintain a rich, gratifying fantasy life (which they distinguish from reality) and are often accomplished intellectually in solitary fields like computers, electronics, puzzles, or mathematics.

What type of community housing is considered ideal for a client with schizoid personality disorder?

A board and care facility, as it provides basic necessities like meals and laundry while accommodating the client's desire for solitude with minimal social interaction.

How does a case manager support community integration for a client with schizoid personality disorder?

By serving as a single point of contact to manage health care, finances, and daily needs, supporting the client's desire for solitude while ensuring essential services are received.

What is the prevalence of schizotypal personality disorder and how do affected clients typically present physically?

It affects approximately $4\%$ of the general population. Clients frequently present with an unkempt, disheveled appearance wearing ill-fitting, mismatched, or dirty clothes.

What speech and affective patterns are characteristic of schizotypal personality disorder?

Speech is coherent but loose, digressive, or vague with bizarre or incorrect word usage; affect is restricted, flat, silly, or inappropriate.

What cognitive distortions and social responses characterize schizotypal personality disorder?

Ideas of reference, magical thinking, preoccupation with parapsychology, and profound social anxiety around strangers that does not diminish with time or familiarity.

What nursing action helps manage bizarre beliefs in a client with schizotypal personality disorder?

Designating one trusted professional or family member (such as a social worker) with whom the client can safely discuss unusual or bizarre beliefs without facing negative social consequences.

By what other names is antisocial personality disorder known?

Psychopathy, sociopathy, or dyssocial personality disorder.

What is the prevalence of antisocial personality disorder across general, clinical, and prison settings?

It occurs in about $3\%$ of the general population, up to $30\%$ in clinical settings, and approximately $70\%$ in prison populations.

What emotional characteristics and remorse patterns are displayed by individuals with antisocial personality disorder?

They display shallow or false emotions suited to their advantage, lack empathy, exploit others without guilt, and only feel remorse if caught breaking the law or being exposed.

What childhood and adolescent behaviors serve as characteristic predictors of antisocial personality disorder?

Childhood histories of enuresis, sleepwalking, and syntonic acts of cruelty; and adolescent behaviors including lying, truancy, sexual promiscuity, substance use, and illegal activities.

What is the minimum age required for a formal diagnosis of antisocial personality disorder?

A formal diagnosis is not made until the client is $18$ years old.

What emotion management and problem-solving actions should the nurse teach a client with antisocial personality disorder?

Identifying sources of frustration, anticipating stressful situations, taking a time-out to regain control, exploring alternative solutions and consequences, and redirecting blame to realistic sources.

What is the prevalence, gender ratio, and suicide mortality rate for borderline personality disorder (BPD)?

BPD affects up to $3\%$ of the population, is three times more common in females than males, and has an $8\%$ to $10\%$ suicide mortality rate.

What motivations underlie deliberate self-harm in borderline personality disorder?

It serves as a cry for help, an expression of anger, self-punishment, or a way to use physical pain to block out emotional pain.

What developmental disruptions and trauma histories are strongly associated with borderline personality disorder?

Disturbed early relationships beginning at $18$ to $30$ months of age with punitive parental threats of withdrawal, parental alcohol use disorder, and a history of childhood sexual abuse in $44\%$ of diagnosed clients.

What is the pervasive mood state in borderline personality disorder, and what items do clients frequently rely on for comfort?

A dysphoric mood marked by unhappiness, restlessness, and malaise; clients frequently rely on transitional objects (such as teddy bears or pillows) well into adulthood.

How does cognitive 'splitting' manifest in borderline personality disorder?

Thinking is polarized and extreme, leading clients to quickly idolize and adore others, only to completely devalue them if their expectations are unmet.

What nursing actions provide structure and limit setting for a client with borderline personality disorder?

Scheduling appointments of predetermined length, designating specific times to discuss issues or coping strategies, discussing self-harm urges nonjudgmentally, and utilizing limit setting and confrontation techniques.

What is the prevalence and gender distribution of histrionic personality disorder?

It affects $2\%$ to $3\%$ of the general population ($10\%$ to $15\%$ in inpatient populations) and is diagnosed four times more frequently in females than in males.

What speech and behavioral characteristics define histrionic personality disorder?

Colorful, theatrical speech lacking in detail, overdressing, flirtatious behavior, rapid mood shifts, self-absorption, high suggestibility, and creating public scenes or fabricating stories to gain attention.

What nursing actions help improve social skills in a client with histrionic personality disorder?

Giving specific feedback on social interactions, role-playing appropriate boundaries, modeling active listening and personal space, and encouraging assertive communication through 'I' statements.

What is the estimated prevalence and primary clinical presentation of narcissistic personality disorder?

It affects approximately $5\%$ of the population (predominantly males) and is characterized by pervasive grandiosity, preoccupation with fantasies of success or power, a need for admiration, and a lack of empathy.

What characterizes the underlying self-esteem of a person with narcissistic personality disorder?

It is fragile and vulnerable, making the client hypersensitive to criticism and constantly in need of attention and admiration.

What nursing strategies are essential when managing arrogant or critical behavior from a client with narcissistic personality disorder?

Using self-awareness skills to avoid taking comments personally, setting limits on rude or verbally abusive behavior, and explaining expectations in a clear, matter-of-fact manner.

What is the prevalence of avoidant personality disorder and what core internal conflict do these clients experience?

It affects $1.5\%$ to $2.5\%$ of the general population equally across sexes; clients strongly desire companionship and intimacy but avoid social contact due to intense fears of rejection, humiliation, and criticism.

How does avoidant personality disorder typically affect occupational performance and advancement?

Clients are eager to please supervisors and may succeed at tasks, but due to fear of failure or criticism, they frequently decline promotions and remain in entry-level positions for years despite being fully qualified.

What nursing interventions support self-esteem in clients with avoidant personality disorder?

Exploring positive self-aspects, practicing self-affirmations and positive self-talk, utilizing cognitive restructuring (reframing and decatastrophizing), and patiently practicing social skills within the therapeutic relationship.

What is the prevalence and family dynamic association of dependent personality disorder?

It occurs in about $1\%$ of the population, runs in families, and is more common in the youngest child.

What behavioral tendencies and fears are central to dependent personality disorder?

A pervasive need to be taken care of, submissive and clinging behaviors, difficulty initiating tasks or making decisions without repeated advice, feeling helpless when alone, and an unrealistic fear of abandonment.

What should the nurse refrain from doing when assisting a client with dependent personality disorder to make decisions?

The nurse must refrain from giving direct advice or making decisions for the client, focusing instead on teaching problem-solving and exploring alternatives to foster autonomy.

What is the prevalence and demographic distribution of obsessive–compulsive personality disorder (OCPD)?

It affects $3\%$ to $8\%$ of the population, is twice as common in males as in females, and shows a higher incidence in oldest children.

What clinical and interpersonal patterns characterize obsessive–compulsive personality disorder?

Preoccupation with perfectionism, orderliness, and control at the expense of flexibility; formal, stiff, and constricted emotional expression; literal rule interpretation; frugality; and reluctance to discard old items.

What cognitive and behavioral interventions assist clients with obsessive–compulsive personality disorder?

Encouraging project deadlines, helping them accept less-than-perfect work, challenging rigid thinking through cognitive restructuring, encouraging risk-taking, and practicing negotiation and relinquishing control with family.

What age-related diagnostic considerations apply to personality disorders across the lifespan?

Personality disorders are not formally diagnosed until age $18$. In older adults, symptoms may persist, with some individuals aging badly and facing increased risks for depression, suicide, dementia, and social isolation.

What childhood protective factors reduce the likelihood of developing antisocial behavior in adulthood?

School commitment, positive peer relationships, parent or peer disapproval of antisocial behavior, functional family relationships, and effective parenting skills.