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.