MH unit6 Psychiatric Nursing Study Notes: Personality Disorders
Overview of Personality and Personality Disorders
Definition of Personality:
An ingrained, enduring pattern of behaving and relating to oneself, others, and the environment.
Encompasses perceptions, attitudes, and emotions unique to each individual.
Operates largely outside of conscious awareness; individuals are typically not consciously aware of their personality structure on a daily basis.
Distinguished from temporary mood swings: personality does not change easily or quickly and requires significant, long-term effort to modify due to its foundation in temperament.
Definition of Personality Disorders:
Long-standing, deeply ingrained maladaptive patterns of behavior.
Cannot be cured with medication.
Diagnosed when personality traits cause significant functional impairment, maladaptive behaviors, identity problems, or dysfunctional interpersonal relationships.
Clients typically fail to acknowledge their own role in problems, routinely blaming or causing harm to others.
Common Maladaptive Personality Traits:
Anger, hostility, and irritability.
Lack of guilt, remorse, or empathy.
Impulsivity and poor judgment.
Irresponsibility and risk-taking behaviors.
Mistrust, entitlement, and extreme dependency.
Primary Goals of Treatment:
Treatment does not aim to fundamentally change the person's core personality.
Focuses on improving overall day-to-day functioning and quality of life.
Builds healthier coping skills and improves interpersonal relationships.
Reduces harmful behaviors while increasing personal independence and safety.
Related Maladaptive Behavioral Patterns:
Depressive Behavior:
Characterized by a pervasive pattern of depressive thoughts and behaviors occurring across multiple contexts.
Significantly more common in individuals with first-degree relatives who have Major Depressive Disorder (MDD).
Clients frequently seek treatment voluntarily due to personal distress.
Passive-Aggressive Behavior:
Characterized by a pervasive negative attitude and passive resistance to demands for adequate social and occupational performance.
Directly impairs social and work functioning.
Onset, Course, Prognosis, and Epidemiology
Diagnostic Age Threshold:
Personality disorders are never diagnosed until after age .
Although maladaptive traits manifest earlier in development, personality is not considered fully formed until after age .
Clinical Course and Prognosis:
Personality disorders follow a chronic, long-term course.
Typically highly treatment-resistant; clients rarely seek help voluntarily.
Age-Related Behavioral Improvement:
Antisocial Personality Disorder: Symptoms often decrease in severity after age ; individuals frequently become less criminal and less physically aggressive.
Borderline Personality Disorder: Clients often become less impulsive and more emotionally stable as they age.
Life-Long Stability: Disorders such as Paranoid, Schizotypal, Avoidant, and Obsessive-Compulsive Personality Disorders tend to remain rigid and stable throughout life.
Gender Predispositions and Diagnostic Bias:
Antisocial Personality Disorder: Diagnosed significantly more often in males (frequently tied to criminal behavior patterns).
Borderline Personality Disorder: Diagnosed significantly more often in females.
Nursing Assessment Role: Nurses conduct extensive assessments and must account for cultural norms and gender roles to prevent diagnostic bias.
Theoretical Frameworks: Biologic Temperament and Psychodynamic Character
Biologic Theory (Temperament):
Temperament consists of inherited, biological predisposition patterns established by age to .
Four Temperament Dimensions:
Harm Avoidance:
High Harm Avoidance: Anxious, fearful, inhibited, cautious.
Low Harm Avoidance: Carefree, outgoing, energetic, optimistic.
Novelty Seeking:
High Novelty Seeking: Impulsive, thrill-seeking, easily bored, quick-tempered.
Low Novelty Seeking: Rigid, systematic, deliberate, prefers routine.
Reward Dependence:
High Reward Dependence: Approval-seeking, warm, persistent, highly sensitive to social cues.
Low Reward Dependence: Socially withdrawn, cold, detached, independent.
Persistence:
High Persistence: Hardworking, ambitious, overachieving, motivated by challenges.
Low Persistence: Unmotivated, easily discouraged, gives up quickly.
Psychodynamic Theory (Character):
Character develops over time through life experiences and environmental interactions.
Three Character Dimensions:
Self-Directedness:
High: Responsible, reliable, resourceful, goal-oriented, self-confident.
Low: Blaming, helpless, irresponsible, unreliable.
Cooperativeness (View of Self in Society):
High: Empathetic, compassionate, tolerant, ethical, supportive.
Low: Self-absorbed, intolerant, critical, opportunistic, vengeful.
Self-Transcendence (View of Self in the Universe):
High: Spiritual, humble, fulfilled, resilient during suffering and loss.
Low: Self-conscious, materialistic, controlling, struggles with suffering and loss.
Cultural and Diagnostic Considerations
Differentiating Pathology from Cultural Norms:
Guarded Behavior: Guarded or cautious behavior is not automatically paranoia; it can result from language barriers or past negative healthcare experiences (e.g., severe discomfort during a blood draw or IV insertion).
Spiritual Beliefs: Cultural or religious practices (e.g., speaking in tongues, attributing illness to evil spirits) do not equal Schizotypal Personality Disorder.
Work Drive: High ambition and strong work drive in professional settings do not equate to Obsessive-Compulsive Personality Disorder (OCPD).
Cluster A Personality Disorders ("Odd / Eccentric / Weird")
Overview of Cluster A:
Primary descriptor: Odd, eccentric, or "weird" behaviors.
Includes: Paranoid, Schizoid, and Schizotypal Personality Disorders.
1. Paranoid Personality Disorder:
Clinical Presentation:
Pervasive, unwarranted mistrust and suspicion of others.
Hostile, hypervigilant, guarded, and constantly scanning the environment for threats.
Uses projection as a primary defense mechanism; exhibits a restricted affect.
Frequently suspects healthcare staff of malice or poisoning, leading to medication refusal.
Environmental Cue: Chooses seating directly near exits/doors to ensure a rapid escape route.
Nursing Care & Interventions:
Maintain a strictly serious, straightforward, and professional approach.
Avoid jokes, sarcasm, vague statements, or whispering near the client.
Do not write notes directly in front of the client to avoid triggering paranoia.
Respect the client's legal right to refuse medication; notify the healthcare provider rather than forcing adherence.
Involve the client directly in treatment planning to enhance feelings of control.
Teach reality validation (guiding the client to evaluate whether a perceived threat is supported by actual evidence before reacting).
Treatment Focus: Trust-building, reality validation, and low-dose antipsychotic medications if indicated.
2. Schizoid Personality Disorder:
Clinical Presentation:
Low reward-dependence temperament.
Pervasive detachment from social relationships and a restricted range of emotional expression.
Prefers objects and solitary tasks over people ("things over people").
Has zero desire for social interaction or close relationships; completely indifferent to praise or criticism.
Nursing Care & Interventions:
Do not force social interaction or group participation.
Utilize written or indirect communication methods if preferred by the client.
Assign a case manager to support basic community functioning.
Treatment Focus: Supportive care focused solely on functional stability.
3. Schizotypal Personality Disorder:
Clinical Presentation:
Low reward-dependence temperament characterized by eccentric, bizarre behavior, disheveled appearance, and severe social anxiety.
Experiences cognitive and perceptual distortions similar to schizophrenia but significantly less severe (e.g., magical thinking, ideas of reference).
Key Differentiating Factor: Retains the baseline ability to function in society (unlike schizophrenia).
Nursing Care & Interventions:
Assist in establishing basic daily hygiene routines.
Practice social skills and role-play real-life community interactions.
Support community skill development.
Treatment Focus: Low-dose antipsychotic medications for cognitive/perceptual distortions, alongside social skills training.
Cluster B Personality Disorders ("Erratic / Dramatic / Wild")
Overview of Cluster B:
Primary descriptor: Dramatic, erratic, emotional, or "wild" behaviors.
Includes: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders.
1. Antisocial Personality Disorder:
Clinical Presentation:
Historically referred to informally as sociopathy or psychopathy.
High novelty-seeking temperament combined with disregard for laws, social norms, and the rights of others.
Deceitful, manipulative, charming, risk-taking, and completely lacking remorse or guilt.
Extensive history of legal troubles, poor work stability, and frequent job-hopping.
Nursing Care & Interventions:
Validate and verify all information provided by the client due to high rates of lying and manipulation.
Maintain absolute consistency among all staff members to prevent manipulation.
Enforce Limit Setting using a strict 3-step process:
State the specific behavioral limit (explicitly state what behavior is unacceptable).
Identify the immediate consequences if the behavior continues.
State the expected acceptable behavior (tell the client what they should do instead).
Confront unacceptable behaviors in a neutral, matter-of-fact manner without anger, accusation, or harshness.
Utilize "Time-Outs" (removing the client from a stimulus to a neutral area) to reduce impulsive reactions, prevent angry outbursts, regain emotional control, and promote problem-solving.
Treatment Focus: Behavior-focused treatment operating within highly structured environments.
2. Borderline Personality Disorder (BPD):
Clinical Presentation:
Pervasive pattern of instability in interpersonal relationships, self-image, and affect.
High novelty-seeking temperament, intense impulsivity, recurrent self-harm, suicidal gestures, and extreme fear of abandonment.
Engages in Splitting: Viewing staff, people, or situations as strictly all-good or all-bad ("good cop / bad cop"), causing severe interpersonal conflict among care teams.
Experiences chronic feelings of emptiness, boredom, and disconnection.
Nursing Care & Safety Interventions:
Prioritize client physical safety above all else.
Self-Harm vs. Suicide: Recognize that self-harm behaviors are often performed to relieve intense emotional pain, regain emotional control, or feel something when emotionally numb, rather than as a primary lethal attempt. However, all self-injury and threats must be treated with high clinical seriousness due to elevated baseline suicide risk.
Apply limit setting and staff consistency to prevent splitting.
Cognitive Restructuring Techniques:
Decatastrophizing: Guiding the client to evaluate situations realistically rather than assuming the worst-case scenario.
Thought Stopping: Teaching the client to interrupt negative or self-harm thoughts by saying "STOP" out loud initially, progressing to mental visualization cues (e.g., a stop sign image), and substituting positive thoughts.
Positive Self-Talk: Reframing negative cognitive errors into realistic, positive affirmations (e.g., "I made a mistake, but it is not the end of the world; next time I will know what to do").
Provide structured daily routines.
Treatment Focus:
Dialectical Behavior Therapy (DBT): The gold-standard treatment modality developed specifically for BPD. Focuses on 4 core skill modules:
Emotional Regulation: Learning to identify and manage intense emotions.
Distress Tolerance: Building healthy coping mechanisms for emotional pain and crises.
Interpersonal Effectiveness: Enhancing communication, boundary-setting, and relationship stability.
Mindfulness: Remaining non-judgmentally grounded in the present moment.
Low-dose antipsychotics if stress-induced psychotic symptoms manifest.
3. Histrionic Personality Disorder:
Clinical Presentation:
Pervasive, excessive emotionality and attention-seeking behavior.
Becomes uncomfortable and acts out dramatically if not the center of attention.
Nursing Care & Interventions:
Teach appropriate social skills and interpersonal boundaries.
Provide clear, factual feedback regarding social interactions.
Deep, intensive psychotherapy is unnecessary.
4. Narcissistic Personality Disorder:
Clinical Presentation:
Pervasive pattern of grandiosity, belief in personal omnipotence/power, strong sense of entitlement, constant need for admiration, and complete lack of empathy.
Arrogant, rude, critical, demanding, impatient, and manipulative.
Nursing Care & Interventions:
Do not take client insults, criticism, or rude behavior personally.
Use clear, matter-of-fact communication and enforce limit setting.
Maintain firm structural boundaries; avoid challenging the client's ego directly.
Cluster C Personality Disorders ("Anxious / Fearful / Worry")
Overview of Cluster C:
Primary descriptor: Anxious, fearful, or "worry" behaviors.
Includes: Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders.
1. Avoidant Personality Disorder:
Clinical Presentation:
High harm-avoidance temperament, extreme social inhibition, severe feelings of inadequacy, and hypersensitivity to negative evaluation.
Key Differentiating Factor: Strongly desires social relationships and closeness, but avoids them due to overwhelming fear of rejection and low self-esteem (unlike Cluster A Schizoid clients, who lack desire for relationships).
Nursing Care & Interventions:
Provide explicit support, positive reinforcement, and reassurance.
Utilize cognitive restructuring (decatastrophizing and positive self-talk).
Treatment Focus: Cognitive Behavioral Therapy (CBT) is highly effective for addressing low self-esteem and fear of rejection.
2. Dependent Personality Disorder:
Clinical Presentation:
High harm-avoidance temperament resulting in an excessive, pervasive need to be taken care of.
Submissive, overly clingy, and fears separation or making independent decisions.
Nursing Care & Interventions:
Promote autonomy, self-reliance, and independent decision-making.
Guide problem-solving steps using cognitive restructuring.
Refuse to make daily decisions for the client; encourage incremental independence.
3. Obsessive-Compulsive Personality Disorder (OCPD):
Clinical Presentation:
Preoccupation with orderliness, perfectionism, rules, details, and control at the expense of flexibility, openness, and efficiency.
Rigid, inflexible, highly indecisive, and struggles to complete tasks due to impossibly high personal standards.
Key Differentiating Factor: Distinct from Obsessive-Compulsive Disorder (OCD) because OCPD lacks discrete obsessions and compulsions; it is an overarching personality style.
Nursing Care & Interventions:
Establish firm deadlines for tasks to shift focus to completion over perfection.
Use cognitive restructuring to reinforce that "good enough is better than perfection."
Encourage client to practice behavioral and cognitive flexibility.
Comprehensive Treatment Modalities and Pharmacotherapy
Treatment Settings:
Outpatient Setting: Primary and most common setting for managing personality disorders.
Inpatient Hospitalization: Strictly reserved for acute crisis stabilization when safety is threatened (e.g., active suicidality, severe self-harm in BPD, or immediate danger to others).
Pharmacotherapy Principles:
Medications do not cure or alter the core personality disorder.
Pharmacotherapy targets specific, symptom categories to improve functioning.
Four Targeted Symptom Categories & Medication Approaches:
Cognitive-Perceptual Distortions (magical thinking, odd beliefs, suspiciousness, ideas of reference):
Indicated: Low-dose antipsychotic medications.
Aggression and Behavioral Dysfunction (impulsivity, predatory behavior, cruelty, overt violence):
Indicated: Mood stabilizers or antipsychotics.
Contraindication: Avoid Benzodiazepines due to risks of disinhibition, abuse, and dependence.
Mood Dysregulation (emotional instability, severe mood swings, depression, emotional detachment):
Indicated: Mood stabilizers, SSRI antidepressants, or low-dose antipsychotics.
Anxiety (chronic cognitive anxiety, somatic anxiety, acute severe panic):
Indicated: SSRI antidepressants; low-dose antipsychotics may be added for acute, severe anxiety.
Major Psychotherapeutic Modalities:
Cognitive Behavioral Therapy (CBT): Focuses on altering cognitive distortions through thought stopping, positive self-talk, and decatastrophizing.
Dialectical Behavior Therapy (DBT): Standard of care for BPD; targets emotional regulation, distress tolerance, interpersonal effectiveness, and mindfulness.
Schema Therapy: Focuses on identifying unmet emotional childhood needs and modifying deeply ingrained negative thought pattern schemas to improve self-worth and life goals.
Social Skills Training: Focuses on behavioral role-playing to restore acceptable interpersonal functional communication.
Nursing Professional Guidelines and Self-Awareness
Self-Awareness: Critical for nurses caring for clients with personality disorders to avoid personal burnout and emotional manipulation.
Communication Standards: Avoid vague, ambiguous, or secretive communication around clients.
Boundary Management: Maintain absolute consistency across all multidisciplinary team members; enforce firm limit setting without exception.
Confrontation Skills: Develop comfort with constructive confrontation—delivering firm, neutral, matter-of-fact statements regarding unacceptable behavior without displaying anger, judgment, or accusation.
Emotional Detachment: Never take client behaviors, hostility, rude remarks, or manipulative attempts personally.