Personality Disorders - Comprehensive Notes

PERSONALITY DISORDER

Personality

• Definition: An ingrained, enduring pattern of behaving and relating to self, others, and the environment.

• Encompasses perceptions, attitudes, and emotions.

• Individuals are usually not consciously aware of their own personality.

• Personality Disorders:

  • Traits are inflexible and maladaptive.

  • Cause significant interference with functioning or emotional distress.

Maladaptive or Dysfunctional Personality Traits

• Negative behavior toward others.

• Anger and/or hostility.

• Irritable/labile moods.

• Lack of guilt, remorse, or emotionally cold and uncaring.

• Impulsive, poor judgment.

• Irresponsible, not accountable for own actions.

• Risk-taking, thrill-seeking behaviors.

Personality Disorders Covered

• Borderline Personality Disorder

• Antisocial Personality Disorder

Onset and Clinical Course

• Prevalence in the general population: 10% to 20%.

• Higher incidence in lower socioeconomic groups.

• Comorbidity: 40% to 45% of people with a primary diagnosis of major mental illness also have a coexisting personality disorder, which significantly complicates treatment.

• Clients are frequently described as being "treatment resistant."

• Lack of perception by the person that their behavior is problematic.

Impact of Personality Disorders

• Higher death rates, especially due to suicide.

• Higher rates of suicide attempts, accidents, and emergency department visits.

• Increased rates of separation, divorce, and involvement in legal proceedings regarding child custody.

• Increased rates of criminal behavior, alcoholism, and drug abuse.

Etiology

Biologic Theories

• Temperament:

  • Harm avoidance

  • Novelty seeking

  • Reward dependence

  • Persistence

Psychodynamic Theories

• Character

  • Self-directedness (responsible, goal-oriented)

  • Cooperativeness (integral part of society)

  • Self-transcendence (integral part of the universe)

Cultural Considerations

• Personality must be viewed with consideration of ethnic, cultural, and social background.

• Guarded or defensive behavior may be due to language barriers.

• Different cultures have different views of avoidant and dependent behavior.

• Cultural value of work, productivity.

Treatment

Psychopharmacology

• Focus: Symptom-focused, considering type and severity.

• Cognitive-Perceptual Disturbances:

  • Symptoms: Magical thinking, odd beliefs, illusions, suspiciousness, ideas of reference, and low-grade psychotic symptoms.

  • Medications: Low-dose antipsychotic medications.

• Mood Dysregulation:

  • Symptoms: Emotional instability, emotional detachment, depression, and dysphoria.

  • Medications: Lithium, carbamazepine (Tegretol), valproate (Depakote), low-dose haloperidol, SSRIs, atypical antipsychotics, MAOIs.

• Aggression:

  • Symptoms: Predatory or cruel behavior, impulsivity, poor social judgment, and emotional lability.

  • Medications: Lithium, anticonvulsant mood stabilizers, benzodiazepines, and low-dose haloperidol.

• Anxiety:

  • Medications: SSRIs or low-dose antipsychotics, MAOIs.

Therapies

• Group and individual therapies.

• Cognitive-Behavioral Therapy (CBT):

  • Cognitive restructuring techniques such as thought-stopping, positive self-talk, and decatastrophizing.

• Dialectical Behavior Therapy (DBT):

  • Specifically for borderline personality disorder.

  • Focuses on mindfulness.

Antisocial Personality Disorder - Nursing Process Application

Assessment

• Deceit/manipulation

• False emotions; no empathy

• Narrowed view of world

• Poor judgment; no insight

• Egocentric, self-shallow, and empty

• Relationships viewed as serving own needs

Nursing Interventions

• Therapeutic relationship; responsible behavior (limit setting, confrontation).

• Problem-solving; control of emotions (time-out).

• Enhancing role performance.

NCLEX Question Example (Antisocial PD)

• Question: A client diagnosed with antisocial personality disorder is observed smoking in a non-smoking area. Which initial nursing intervention is appropriate?

• Correct Answer: B. Confront the client about the behavior

NCLEX Question Example (Antisocial PD - Characteristics)

• Question: A client has been diagnosed with antisocial personality disorder based on a long history of difficulties with the legal system and cruelty to others. Which one of the following characteristics would you expect to assess in this client?

• Correct Answer: A. Lack of guilt or wrong doing

Borderline Personality Disorder - Nursing Process Application

Assessment

• Unstable interpersonal relationships, self-image, and affect; marked impulsivity.

• Wide range of behavior, appearance.

• Dysphoric mood.

• Polarized extreme thinking (splitting); dissociation.

• Impaired judgment; safety not a concern.

• Threats of self-harm.

• Social isolation.

Nursing Interventions

• Safety (no self-harm contract).

• Therapeutic relationship (structured, with limit setting).

• Strict adherence to boundaries.

• Long-term therapy to resolve family dysfunction and abuse.

• Hospitalization when client is exhibiting self-harm behaviors or having intense symptoms.

• Brief hospitalizations to stabilize condition.

• Communication skills.

• Coping, emotion control.

• Reshape thinking patterns (cognitive restructuring, thought stopping, positive self-talk, decatastrophizing).

• Structuring of daily activities.

NCLEX Question Example (Borderline PD)

• Question: A client with borderline personality disorder says to the nurse, “I feel so comfortable talking with you. You seem to have a special way about you that really helps me.” Which would be the most appropriate response by the nurse?

• Correct Answer: C. “I’m here to help you just as all the staff are.”

NCLEX Question Example (Personality Disorder)

• Question: When caring for a client with a personality disorder, it is important for the nurse to remember which of the following?

• Correct Answer: D. The client’s behavior often provokes negative feelings in others.

Antisocial vs. Borderline Personality Disorder

Antisocial

• Assessment: Deceit, manipulation, false emotion, no empathy, narrow world view, poor judgment, no insight, egocentric, self-shallow and empty, relationship serves own needs.

• Intervention: Therapeutic relationship, limit setting, confrontation, responsible behavior, problem-solving, control emotions (time-out), enhancing role performance.

Borderline

• Assessment: Unstable interpersonal relationships, self-image, and affect, marked impulsivity, wide range of behavior and appearance, dysphoric mood, polarized thinking, dissociation, impaired judgment, safety not a concern, threat to self, social isolation.

• Intervention: Safety, no self-harm contract, therapeutic relationship, limit setting, strict adherence to boundaries, long-term therapy to resolve family dysfunction and abuse, hospitalized if self-harm behavior or intense symptoms, hospitalized briefly to stabilize condition.

Obsessive-Compulsive Personality Disorder

Clinical Picture

• Perfectionism

• Formal, serious demeanor

• Orderliness a priority

• Problems with decision making, judgment

• Low self-esteem; harsh self-evaluations

Nursing Interventions

• Different perspective view

• Cognitive restructuring

• Risk-taking encouragement

Mental Health Promotion

• Clients with personality disorders have greater unmet needs in:

  • Self-care (keeping clean and tidy)

  • Sexual expression (dissatisfaction with sex life)

  • Budgeting (managing daily finances)

  • Psychotic symptoms

  • Psychological distress

• Addressing self-care, sexual expression, and budgeting might result in a greater sense of well-being and improved health.

• Children with more "protective factors" are less likely to develop antisocial behavior as adults.

• Care could emphasize protective factors such as:

  • School commitment/importance of school

  • Parent and/or peer disapproval of antisocial behavior

  • Involvement in a religious community

Self-Awareness Issues for Nurses

• Avoid client attempts to manipulate.

• Clear communication is crucial.

• Setting limits and boundaries.

• Dealing with frustration: Clients change slowly yet “look” like they are capable of better behavior.

• Working effectively as part of the team; consistency is essential.