Personality Disorders

Definition & Impact

  • Personality disorder: long-term, pervasive patterns of thoughts/behaviors that deviate markedly from cultural expectations
  • Onset: usually late adolescence–early adulthood; rarely diagnosed in children
  • Impairments: relationships, work, self-care, ↑ suicide risk, poorer prognosis when comorbid

Personality Development

  • Freud: five psychosexual stages (oral → genital) must resolve successfully
  • Erikson: eight psychosocial crises (e.g., 0-1.5 yr Trust vs Mistrust → 65+ yr Integrity vs Despair)
  • Five-Factor Model ("Big 5"): openness, conscientiousness, extraversion, agreeableness, neuroticism

Cluster Framework

  • Cluster A (odd/eccentric): Paranoid, Schizoid, Schizotypal
  • Cluster B (dramatic/emotional/erratic): Antisocial, Borderline, Histrionic, Narcissistic
  • Cluster C (anxious/fearful): Avoidant, Dependent, Obsessive-Compulsive (OCPD)

DSM-5 Hallmarks (selected)

• Cluster A

  • Paranoid PD: chronic distrust, bears grudges, perceives threats
  • Schizoid PD: detachment, solitary, limited affect
  • Schizotypal PD: social deficits + cognitive/perceptual distortion, odd beliefs/speech
    • Cluster B
  • Antisocial PD: rights violations, deceit, irresponsibility, no remorse (≥ 18 yr, conduct d/o before 15)
  • Borderline PD: instability in relationships/self-image, impulsivity, self-harm, fear of abandonment
  • Histrionic PD: excessive emotion, attention-seeking, provocative, impressionistic speech
  • Narcissistic PD: grandiosity, need admiration, lack empathy, entitlement
    • Cluster C
  • Avoidant PD: social inhibition, feelings of inadequacy, hypersensitive to criticism
  • Dependent PD: need to be cared for, submissive, fear separation, difficulty deciding
  • OCPD: preoccupation with order/perfection/control at expense of flexibility

Common Comorbidities

  • Cluster A: MDD, SUD, OCD, anxiety, schizophrenia-spectrum, PTSD
  • Cluster B: anxiety d/o, mood d/o, social phobia, SUD
  • Cluster C: mood d/o, social phobia, OCD, anorexia, SUD

Etiology & Risk Factors

  • Diathesis–stress: genetic vulnerability + environmental stressors
  • Genetic/family tendency
  • Childhood abuse, neglect, hostility, trauma

Assessment & Diagnostics

  • DSM-5 criteria (gold standard)
  • Inventories: MMPI, Eysenck, Personality Diagnostic Questionnaire, Gerontological PD Scale (older adults)
  • Labs/toxicology to rule out STI, substance use

Treatment Overview

  • Primary: psychotherapy (CBT, DBT, psychodynamic, supportive, social-skills training)
  • Meds: symptom-targeted (impulsivity, mood lability, anxiety)

Nursing Priorities

  • Equitable, bias-free, client-centered care; self-awareness of implicit bias
  • Prevention: advocate for violence reduction, early intervention in youth
  • Teaching: disorder features, coping, community resources; caregiver education re self-harm
  • Therapeutic presence:
    • Cluster A – build trust, facilitate expression
    • Cluster B – set clear boundaries, model emotional regulation
    • Cluster C – reduce anxiety, empower decision-making

Nursing Process Highlights

Recognize Cues

  • Aggression/self-harm risk (B), compulsions/rigidity (C), odd/anxious behaviors (A)
    Analyze & Prioritize
  • Goals: A → relationships; B → safety & limit setting; C → anxiety reduction
    Plan / Generate Solutions
  • Cluster A: social-skills building
  • Cluster B: safety contracts, boundary setting, emotion-regulation strategies
  • Cluster C: gradual exposure, assertiveness training
    Implement
  • Therapeutic communication, medication admin, care coordination, precise documentation (use client quotes)
    Evaluate
  • Ongoing; clients may need intermittent lifelong follow-up