16. Personality Disorders

Differentiate personality traits and styles from personality disorders.
Evaluate the effects of the nurse’s emotional responses on the nursing care of individuals who have personality disorders.
Organize the nursing process in providing care for individuals having a specific personality disorder.
Apply nursing interventions for individuals who display personality traits that are suspicious, manipulative, dependent, and/or anxious.
Apply nursing interventions for moderating the environment to decrease potential conflict.
Plan nursing interventions for individuals who are angry or aggressive.

Personality: An enduring pattern of behavior that is both conscious and unconscious, reflecting a means of adapting to a particular environment along with its cultural, ethnic, and community standards.

Self-awareness: Sees own strengths and weaknesses.
Boundary identification: Identifies own boundaries.
Emotional recognition: Recognizes interactions and thoughts that lead to strong emotions.
Independent interaction: Interacts with others without expecting them to meet all needs.
Balance: Seeks balance in work and play.
Goal accomplishment: Accomplishes goals.
Spiritual expression: Defines and expresses spirituality.

How does a personality become pathological?
- Individuals possess personality traits, which create a unique pattern of perceiving or interacting with their environment.
- Traits develop from a combination of inherited characteristics, experiences, and learned behaviors, as suggested by the Diathesis-Stress Model.
- Personality traits become disorders when behavior patterns become rigid, inflexible or extremely unstable.

Personality disorders constitute one of the most complex and challenging groups of disorders to treat.

Cluster A: Odd and Eccentric
- Paranoid Personality Disorder
- Schizoid Personality Disorder
- Schizotypal Personality Disorder
Cluster B: Dramatic and Unpredictable
- Antisocial Personality Disorder
- Narcissistic Personality Disorder
- Borderline Personality Disorder
- Histrionic Personality Disorder
Cluster C: Anxious and Fearful
- Avoidant Personality Disorder
- Dependent Personality Disorder
- Obsessive-Compulsive Personality Disorder

Schizotypal Personality Disorder
- Odd beliefs and eccentric appearance, inability to understand usual interpersonal cues, leads to inappropriate social interactions, and intense anxiety in social relationships.
- Involves magical thinking and perceptual distortions, but not delusions or hallucinations.
Schizoid Personality Disorder
- Emotionally detached, does not enjoy relationships, indifferent to praise or criticism, seeks solitary occupations.
Paranoid Personality Disorder
- Distrust toward others based on a belief that others want to exploit, harm, or deceive them.

Neutrality: Remain “matter of fact” and neutral.
Kindness: Be kind but avoid being “overly friendly.”
Conciseness: Provide straightforward explanations to avoid misinterpretation.
Hard evidence: Provide educational materials in written form.
Accept isolation: Do not force socialization; accept their need for solitude.
Awareness: Stay aware of their suspicions.

Antisocial Personality Disorder
- Characterized by consistent disregard for others, impulsivity, charm, lack of remorse, often diagnosed with ODD/CD in childhood.
Narcissistic Personality Disorder
- Need for admiration, grandiosity, lack of empathy, critical, with an underlying feeling of shame and insecurity.
Borderline Personality Disorder
- Instability in affect, engages in self-destructive behavior, fear of abandonment, intense interpersonal relationships, lability in emotions, and feelings of emptiness.
Histrionic Personality Disorder
- Attention-seeking behavior, impulsive, provocative, and seductive, with a tendency to dramatize situations.

Antisocial:
- Set and maintain firm boundaries, reduce manipulation, document interactions.
Narcissistic:
- Remain neutral and avoid power struggles, convey self-confidence without challenging their views.
Histrionic:
- Maintain professionalism, encourage clear communication, avoid suggestive language.
Borderline:
- Priority on safety, monitor for self-harm, stay consistent emotionally since they are often labile.
- Watch for inappropriate closeness and ensure firm boundaries with clear consequences.

Goal: Increase the individual’s ability to manage distress and decrease self-destructive behavior.
Combines mindfulness with cognitive behavioral therapy (CBT) to enhance awareness and intention in thoughts.
Family therapy is integrated into the DBT-A version for adolescents at high risk of developing BPD.

Avoidant Personality Disorder
- Avoidance of criticism, social inhibition, and feelings of inadequacy.
Dependent Personality Disorder
- Extreme dependency on others for support, reluctance to disagree, and excessive efforts to gain nurturance.
Obsessive-Compulsive Personality Disorder
- Preoccupation with rules and order, perfectionism, often resulting in diminished leisure and relationships.

Identify stressors and genuine needs.
Set limits that do not feel punitive.
Promote empowerment and model assertiveness while maintaining self-awareness due to countertransference.

Medications such as SSRIs, low-dose antipsychotics, mood stabilizers, MAO inhibitors, and tricyclics may help manage co-morbid disorders but therapy is the primary recommendation for treatment.

Establish an environment that reduces frustration and monitors aggression signs.
Encourage patients to seek assistance from nursing staff.
Help patients express anger adaptively, identify triggers, and provide physical outlets for anger while preventing physical harm to everyone involved.

Set clear expectations and consequences on the unit.
Discuss desirable behaviors with patients relating to specific situations.
Engage in reflective feedback without judgment, ensuring staff consists of a unified approach to expectations and consequences.