personality disorders

Personality disorder

enduring pattern of inner experience and behavior. Pervasive and inflexible, markedly deviates from the individual’s culture 

Cluster A

Paranoid, schizoid, schizotypal

Cluster B

Boderline, antisocial, histronic, narcissistic

Cluster C

Avoidant, dependent, obsessive compulsive

Nursing interventions for cluster a,b,c

Self awareness and maintain sensitivity

Paranoid personality disorder (PDD)

suspicious, guarded, angry and hostile. Mistrust of people in general, unforgiving and hold grudges. Assign responsibility to others and avoid relationships in which they are not in control 

pts outwardly with PDD is

• argumentative and abrasive

Pts with PDD internally is

powerless, fearful, and vulnerable

PDD is associated with

Violence and stalking

Nursing interventions for PDD

brief sessions, objective approach, respect personal space, role-playing, meds

Schizoid personality disorder

seclusive, isolated, introverted, emotionally detached. Life-long loners, daydream excessively and become attached to animals 

Nursing interventions in schizoid personaility disorder

social skills training, balance interventions between encouraging enough social activity and too much social activity 

Schizotypal personality disorder etiology

MRI shows smaller gray matter volume correlated with negative symptoms 

Schizotypal personaility disorder

pattern of social and interpersonal deficits, isolative

Schizotypy Chracteristics

• Magical beliefs

• Referential thinking and paranoia 

• Unkempt manner of dressing, may respond to stress w/ transient psychotic episodes 

Nursing interventions for Schizotypal personaility disorder

similar to person with schizophrenia, social skills training, reinforce socially appropriate dress and behavior 

Risk factors for BPD

Traumatic life events

Characteristics of BPD

• high mortality by suicide 

• Self-injurious behavior 

• Emotional dysregulation 

• Maladaptive cognitive processes -> developed dysfunction beliefs and maladaptive schemata early in life /misinterpret environmental stimuli  /  conditioned to anticipate rejection and disappointment in the past 

Clinical course of BPD

symptoms reduce over time and mostly seen in adolescence 

Comorbidity with BPD

MDD, substance use, anxiety, eating disorder 

S/sx of BPD

1. Unstable affect is MAIN characteristic 

2. Unstable interpersonal relationships : extreme fear of abandonment, unstable or secure attachments

3. Unstable self image

4. Dissociation and dichotomous thinking 

5. Impaired problem solving 

6. Impulsivity 

7. Self harm behaviors 

8. Splitting (see world as all good or all bad)

Tx and management of BPD

1. High risk of suicide and self harm. Should be taken seriously 

2. Nutrition 

3. DBT, MBT, coach or toward alternative self soothing behavior

Physical assessment of BPD

• physical health —> nutritional, sleep patterns, specific behavior or suicide attempts 

• Hx of physical/sexual abuse, early separation from caregivers

• Assess for depression 

• Assess for dichotomous thinking by asking how they view other people 

• Self concept and identity disturbance 

Med tx for BPD 

• mood stabilizers

• Antidepressants (SSRI,SNRI,TCA)

• Atypical antipsychotics (apriprazole or quetiapine)

• Anxiolytics (buspirone)

• Benzodiazepines should be avoided for anxiety 

Antisocial personality disorder (APSD)

consistently irresponsible fail to follow society’s rule, aggression to people or animals, destruction to property, deceitfulness or theft 

Psychosocial theories for APSD

1. Temperament

2. Attachment: unsatisfactory attachments in early relationships lead to antisocial behavior later in life 

3. Family issues: come from chaotic families in which alcoholism and violence are the norm

Age of onset in APSD

18 yrs old or more than one conduct behavior demonstrated before age 15

conduct disorder seen before age 10 with ADHD are at risk for developing

APSD

Clinical course of APSD

diminish later in life after age 40, self-serving exploit and seek power over others

Chracteristics of APSD

• lack of remorse and empathy

• Can be charming and engaging which can be mistaken for genuine concern of other people 

• Arrogant, self centered, feel privileged, impulsive, irresponsible 

Psychosocial assessment for APSD can be

challenging bc mistrust authority figures 

Psychosocial assessment for APSD

• assess for dissociation, how pt copes with stressful situations, support networks 

• Focus on improving coping skills

• Assess for safety, SI, self harm

Nursing interventions for APSD

• set clear and realistic goals 

• Avoid confrontation 

• Anger management 

• Develop rapport 

• Guard against being manipulated 

are there meds for APSD

No

Tx for aggression in APSD can be

SSRI, atypical antipsychotics, lithium

Histrionic personality disorder chracteristics

• can be false and theatrical, sexually seductive in attempts to gain attention 

• Lively dramatic and draw attention to their selves 

• Overly trusting and gullible 

• Need to be life of the party 

• Moody helplessness, get depressed when others aren’t interested in them 

• Difficulty in true intimacy 

Interventions for histrionic personality disorder

• don’t rely on others, be independent 

• Improve self esteem and positive self concept 

• Improve patterns of coping and problem solving 

• Convey confidence in pt ability to handle situation 

What personality disorders does not seek mental health care unless having a coexisting medical or mental disorder 

Histrionic personality disorder, narcissistic personality disorder, dependent personality disorder,

Narcissistic personality disorder characteristics

1. Grandiose inexhaustible need for admiration, lack empathy 

2. Starts in childhood  believing they are unique and should be recognized 

3. Preoccupied with fantasies of unlimited success, power, beauty, ideal love 

4. Successful in their jobs but alienate others 

5. Define their world in their own self centered view and sense of entitlement is striking 

6. Handled criticism poorly, become enraged if someone dares to criticize them

7. May have overlapping characteristics of BPD, ASPD

Etiology of NPD

result of parents overvaluation and overindulgence of a child

Interventions for NPD

• Help pt to identify concrete, realistic and measurable goals that pt identifies as their own 

• Build therapeutic relationship, slow process. Nurse needs to be self-aware 

Avoidant personality disorder (AVPD) characteristics

• Extensive avoidance of social interaction driven by fears of rejection and personal inadequacy 

• Timid, shy, hesitant and extreme fear of criticism and rejection 

• Highest level of impairment in daily functioning compared to other PD

Etiology of AVPD

experience with aversive stimuli more intensely and frequently than others. Over abundance of neurons in the aversive center of the limbic system 

Nursing assessment and interventions for AVPD

• goal is to increase self esteem and decrease social isolation 

• Pt relationship with nurse is slow process and requires patience. They need time to ensure nurse would not demean them 

• Hospitalized only for co-existing disorder 

• Refrain from any negative criticism, assist patient to identify positive responses from others, explore previous achievements of success 

Dependent personality disorder characteristic

anxious and fearful 

Clinical course/diagnostic criteria

• cling to others to keep them close and totally disregard themselves

• Self esteem is determined by others, unable to make decision 

• Need to be taken care of and change their behavior to who they are attached to 

• Unable to make decisions, withdrawal from adult responsibilities 

• Seeking nurturance from others, need excessive advice/reassurance

• Easily persuaded and rarely disagree with others 

• Gullible, non competitive, warm

• Avoids social tension 

Etiology of DPD

result of parents genuine affection, extreme attachment and overprotection

Risk factors For DPD

women, least educated, widowed, divorced, chronic physical illnesses in childhood, separated, never married women 

Nursing assessment/intervention for DPD

• Goal: improve self esteem, develop social skills, and coping skills 

• Identify who pt is dependent on 

• Assertiveness training 

• Readily seek out therapy 

• Encourage pt to make their own decisions 

• Dependent upon nurse to make decisions, pt readily engages in nurse pt relationship 

Obsessive compulsive personality disorder (OCPD) characteristics

Anxious

Clinical course/diagnostic criteria OCPD

• Have capacity to delay rewards but pts with OCD can’t 

• OCPD doesn’t demonstrate obsessions and compulsions instead pervasive pattern of pre-occupation with orderliness, perfectionism, and control is utilized.

• Maintain control by careful attention to rules, trivial details, procedures, and lists.

• Completely devoted to work, perfectionist, regulated, highly structured, strictly organized life.

• Prone to repetition and have difficulty making decisions and completing task tasks.

• Rigid, stubborn and indecisive and are unable to accept new ideas and customs.

• Mood is tense and joyless. Expression of emotions is tightly controlled.

Cause of OCPD

• Parental over control and overprotection that is consistently restrictive and sets distinct limits on the child’s behavior.

• Plays, viewed as shameful, sinful, and irresponsible, leading to dire consequences

• Parents tried to impose guilt on the child to control behavior.

• Treated primarily in the community, experiences periods of depression may require short-term hospitalization

Nursing assessment and interventions for OCPD

• Seek mental health due to attacks of anxiety, spells of immobilization, sexual impotence, and excessive fatigue.

• Assess physical symptoms.

• Goal is to develop self-confidence to initiate change.

• Patients know they can improve their quality of life, but change, provokes, extreme anxiety.

• Determined patients belief in underlying dysfunctional behavior.

• Compulsive pattern was established in childhood, takes a long time to modify behavior

Medication tx for OCPD is

short-term on antidepressant or anxiolytic as an adjunct of psychotherapy