Personality Disorders & Mental-Health Final Review Notes

Personality: Normal vs. Disordered

• Normal personality
  • Enduring patterns of perceiving, thinking, feeling and relating.
  • Begins in infancy, becomes increasingly set by the teens–20s, then changes very little.
  • Pervasive: colors every domain (home, school, work, relationships).
• Personality Disorder (PD)
  • Grouping of dysfunctional, inflexible traits that are maladaptive and cause clinically significant distress or impairment.
  • Key diagnostic adjectives: pervasive, inflexible, maladaptive, long-standing.
  • Spectrum concept: many people exhibit isolated traits without meeting full criteria.
  • Poor insight is the rule; traits may even be a point of pride.
  • Prevalence: 10\%-20\% of the population (mild–severe forms).
  • Always interpret in cultural & spiritual context to avoid mis-labeling culturally sanctioned behavior.

Etiology & Development

• Interaction of genetics + environment.
  • Temperament visible in infancy (easy vs. difficult baby).
  • Attachment style, parenting style, socio-economic hardship (food insecurity, foster care, shifting caregivers).
  • Trauma/adversity ↑ risk; nevertheless, a loving environment is protective.
• “Big Five” personality dimensions (Eysenck / Costa & McCrae) provide conceptual anchor:
  • Neuroticism, Extraversion, Openness, Agreeableness, Conscientiousness.
  • Extreme poles + clustering → possible PD.
• Neuroplasticity: brain can change (esp. in youth), but therapy requires insight & motivation.

Clustering System (DSM-5)

• Cluster A = WEIRD (odd, eccentric, withdrawn) → Paranoid, Schizoid, Schizotypal.
• Cluster B = WILD (dramatic, erratic, emotional) → Antisocial, Borderline, Histrionic, Narcissistic.
• Cluster C = WORRIED (anxious, fearful) → Avoidant, Dependent, Obsessive-Compulsive PD.
  • Classroom mnemonic used: 1️⃣ Weird, 2️⃣ Wild, 3️⃣ Worried.

Cluster A Disorders

Schizotypal Personality Disorder (STPD)

• Core features
  • Social & interpersonal deficits; acute discomfort with close relationships.
  • Cognitive/perceptual distortions: magical thinking, ideas of reference, mild paranoia.
  • Odd speech, eccentric dress, constricted or inappropriate affect.
• Nursing / Teaching
  • Role-model & role-play basic social skills.
  • Build predictable routines; cue appropriate hygiene & ADLs.
  • Offer safe outlets (support group) to discuss unusual beliefs without workplace repercussions.
  • Goal: community integration rather than isolation.

Cluster B Disorders

Antisocial Personality Disorder (ASPD)

• Adult continuation of Conduct Disorder (must evidence CD before age 15).
• Diagnostic hallmarks
  • Violation of the rights of others, deceitfulness, impulsivity, physical aggression, unlawful acts.
  • Lack of guilt/remorse, shallow affect, manipulativeness.
• Interventions
  • Clear, consistent limit-setting; enforce consequences immediately.
  • Time-outs, behavioral contracts; confrontation of distortions.
  • Safety planning for staff & peers; monitor for weapon possession.
  • Low treatment-seeking → therapy often court-mandated.

Borderline Personality Disorder (BPD)

• Key traits (mnemonic = IMPULSIVE): Instability of relationships, Mood reactivity, Paranoia/dissociation under stress, Unstable self-image, Labile affect, Self-harm, Impulsivity, Vulnerability to abandonment, Emptiness.
• “Splitting” (all-good ⟷ all-bad) toward staff & peers.
• High self-harm / suicide attempts.
• Nursing Priorities
  • Safety first: one-to-one observation if self-injury risk; no-harm contracts; wound care.
  • Consistent team approach; identical rules to prevent staff-splitting.
  • Matter-of-fact limit setting; reinforce adaptive behaviors.
• Evidence-based therapy: Dialectical Behavior Therapy (DBT) → teaches mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness.

Brief Notes on Remaining Cluster B

• Histrionic PD: attention-seeking, theatrical, seductive dress.
• Narcissistic PD: grandiosity masking fragile self-esteem; entitlement; lack of empathy.
  • For exam: recognize traits, but main testing emphasis is ASPD & BPD.

Cluster C Disorders

Obsessive-Compulsive Personality Disorder (OCPD)

• NOT the same as OCD (no intrusive thoughts + ritual to reduce anxiety).
• Chronic perfectionism, rigid control, preoccupation with rules/order.
• May procrastinate due to impossible standards; difficulty delegating.
• Interventions
  • Encourage flexibility: assign tasks with firm but achievable deadlines.
  • Teach relaxation, cognitive reframing; explore impact on relationships.

Quick Comparison (Cluster C)

• Avoidant PD: global social inhibition, hypersensitive to rejection (wider than social anxiety disorder).
• Dependent PD: pervasive need to be taken care of, difficulty making even daily decisions.

Dysfunctional Traits Seen Across PDs

• Negative affectivity (anger, hostility, depression).
• Detachment (social withdrawal, restricted affect).
• Antagonism (manipulation, deceit, callousness).
• Disinhibition (impulsivity, risk-taking, poor self-control).
• Eccentricity (odd dress, unusual beliefs).
• Inflexibility (rigid adherence to patterns despite maladaptive consequences).

Treatments & Medications for Personality Disorders

• Primary tool = psychotherapy (long-term):
  • DBT (borderline), CBT (OCPD, avoidant, ASPD skills), group therapy for social skills (Cluster A/C).
• Pharmacology is symptom-driven rather than curative:
  • Mood stabilizers / SSRIs for affective lability or impulsivity.
  • Antipsychotics (typical/atypical) for perceptual distortions, transient psychosis, severe aggression.
  • Benzodiazepines used sparingly (habit-forming, reinforce avoidance).
• Always incorporate education on sleep hygiene, exercise, substance-use screening.

Nursing Concepts & Exam Tips Mentioned

• Core pillars with ANY mental-health client: Safety, Limit Setting, Boundaries, Consistency, Trusting Relationship.
• Document & communicate history of violence/threats within EHR; helps future teams anticipate risk.
• Least-restrictive environment rule → escalate from verbal de-escalation → PRN meds → seclusion/restrain.
• Cultural / spiritual neutrality vs. efficacy vs. harmfulness (Joyce Giger assessment tool).
• Mnemonic recap
  • Clusters: 1 Weird, 2 Wild, 3 Worried.
  • ASPD picks “rights”; BPD fears “abandonment”.
• Insight continuum
  • Highest: OCPD, Avoidant (know they suffer).
  • Lowest: ASPD, Narcissistic (pride in traits).

Final Exam Logistics (from transcript)

• 100 total questions; 6\text{–}7 devoted to personality disorders.
• Canvas practice quiz mirrors final questions (do it!).
• Faculty will be abroad → rely on posted announcements.

Lightning Review of Other Disorders (mentioned in class review)

Anxiety Spectrum

• Levels: Mild → Moderate → Severe → Panic; teaching only effective at mild.
• GAD = chronic free-floating worry; Phobias treated via systematic desensitization.
• Panic Disorder: rule out medical cause; stay with patient; reassure that panic peaks & subsides.
• OCD vs. OCPD difference reiterated.

Mood Disorders

• Major Depressive Disorder (MDD): anhedonia, sleep/appetite change, fatigue.
• Bipolar Spectrum:
  • Bipolar I = Mania ↔ Major Depression.
  • Bipolar II = Hypomania ↔ Major Depression.
  • Cyclothymia = Hypomania ↔ Dysthymia.
  • Meds: Lithium first-line, anticonvulsant mood stabilizers (e.g., Carbamazepine) 2nd-line.

Psychotic Disorders

• Positive vs. Negative symptoms; brief psychotic (
• First-generation antipsychotics → EPS (dystonia, akathisia, pseudo-Parkinsonism, tardive dyskinesia), NMS.
• Clozapine risk: agranulocytosis → CBC monitoring.

Child & Adolescent Topics

• ADHD: inattentive vs. hyperactive; stimulants vs. atomoxetine; growth/appetite concerns.
• Autism Spectrum: stereotypy, narrow food choices, need routine.
• Conduct vs. Oppositional Defiant Disorder (ODD): CD violates societal norms; ODD targets authority figures only.
• Intellectual Disability levels (mild 6th-grade → profound infant level).

Eating Disorders

• Anorexia nervosa: underweight, poor insight, highest mortality; food is the “medication.”
• Bulimia nervosa: normal weight, high insight, purging complications.
• Binge-eating disorder: overweight; behavioral contracts, food logs.

Cultural & Spiritual Care Highlights

• Giger’s 6 factors: Communication, Space, Social Organization, Time, Environmental Control, Biological Variations.
• Neutral practices (e.g., prayer, sacred clothing) should be facilitated; harmful ones (e.g., herb–drug interactions) addressed.

Medication Cheat-Sheet

• Antidepressants: SSRI ➔ SNRI ➔ TCA ➔ MAOI (tyramine → hypertensive crisis).
• Anxiolytics: benzodiazepines (short course) vs. buspirone.
• Mood stabilizers: Lithium (monitor 0.6-1.2\,\text{mEq/L}), valproate, carbamazepine.
• Antipsychotics: Typical (Haldol) vs. Atypical (Risperidone, Olanzapine, Quetiapine).

Ethical & Practical Implications Discussed

• Importance of avoiding paternalism: patients retain right to refuse unless danger.
• Court-ordered treatment possible for safety of self/others.
• Neuroplastic potential argues for providing therapy even when prognosis seems fixed.
• Societal burden: lower SES groups experience higher PD prevalence due to compounded environmental risks.