Personality Disorders Study Notes

Chapter 16: Personality Disorders

Overview of Personality Disorders

  • Definition: A personality disorder is characterized by:

    • Pathological personality characteristics.

    • Impairments in self-identity, self-direction, and interpersonal functioning.

  • Comorbidity: Personality disorders frequently co-occur with other mental health diagnoses, including:

    • Depression

    • Anxiety

    • Eating disorders

    • Substance use disorders

  • Clusters of Personality Disorders: Personality disorders are classified into three clusters:

    • Grouped based on similar characteristics, persistent and pervasive patterns of behavior and thinking.

    • Deviate significantly from cultural expectations and cause distress or impairment in functioning.

Cluster A: Odd or Eccentric Traits

  • Key Characteristics:

    • Paranoid, Schizoid, Schizotypal personalities.

    • Emphasizes the development of client skills and resources to maintain interpersonal relationships.

  • Mnemonic:

    • A (Weird) — Paranoid, Schizoid, Schizotypal.

  • Key Traits:

    • Odd/eccentric behavior.

    • Social detachment, cognitive/perceptual distortions.

Medications for Cluster A Disorders:

  • Medication Examples:

    • Risperidone, Quetiapine (Atypical antipsychotics):

    • Action: Decrease suspiciousness and ideas of reference, control brief psychotic-like episodes.

    • Side Effects: Metabolic syndrome, weight gain, extrapyramidal symptoms (EPS), QT prolongation.

    • Client Education: Monitor baseline weight, lipids, glucose; report any stiffness or tremors; avoid alcohol and sedatives.

    • Haloperidol (Typical antipsychotic):

    • Action: Control acute agitation/paranoia.

    • Side Effects: High EPS/dystonia, rare Neuroleptic Malignant Syndrome (NMS).

    • Client Education: Use lowest effective dose for a brief course; monitor for rigidity or fever.

    • Sertraline, Fluoxetine (SSRIs):

    • Action: Address anxiety/depression and social withdrawal.

    • Side Effects: GI upset, changes in sleep patterns, sexual dysfunction, risk of serotonin syndrome.

    • Client Education: Takes 2-4 weeks for effect; avoid abrupt discontinuation; monitor for increased agitation or suicidal thoughts, particularly in the youth.

Disorder Specific Characteristics in Cluster A:

  • Paranoid Personality Disorder:

    • Characterized by distrust and suspicion towards others, based on unfounded beliefs.

  • Schizoid Personality Disorder:

    • Characterized by emotional detachment, lack of interest in relationships, indifferent to feedback.

  • Schizotypal Personality Disorder:

    • Characterized by odd beliefs and interpersonal difficulties; features eccentricity and perceptual distortions.

Cluster B: Dramatic, Emotional, or Erratic Traits

  • Key Characteristics:

    • Antisocial, Borderline, Histrionic, Narcissistic personalities.

    • Develop skills to limit dramatic and inappropriate behaviors.

  • Mnemonic:

    • B (Wild) — Antisocial, Borderline, Histrionic, Narcissistic.

  • Key Traits:

    • Dramatic or erratic behavior.

    • Impulsivity, emotional instability, and unstable interpersonal relationships.

Medications for Cluster B Disorders:

  • Medication Examples:

    • Lithium (Mood stabilizer):

    • Action: Decrease impulsivity, aggression, mood swings.

    • Side Effects: Narrow therapeutic index (TI), tremor, polyuria, renal/thyroid effects; toxic when dehydrated.

    • Client Education: Maintain hydration, regular drug levels, regular renal and TSH labs, maintain consistent salt and fluid intake.

    • Valproate (Divalproex) (Mood stabilizer):

    • Action: Treat affective lability and anger.

    • Side Effects: Hepatotoxicity, thrombocytopenia, weight gain, teratogenic effects.

    • Client Education: Baseline and periodic liver function tests (LFTs) and platelets; pregnancy precautions; take with food.

    • Lamotrigine (Mood stabilizer):

    • Action: Stabilize mood swings; particularly depressive episodes.

    • Side Effects: Risk of serious rash, potential Stevens-Johnson Syndrome (SJS) or Toxic Epidermal Necrolysis (TEN); dizziness.

    • Client Education: Slow dose titration; stop immediately if rash develops.

    • Carbamazepine (Mood stabilizer):

    • Action: Target impulsivity and aggression.

    • Side Effects: Agranulocytosis, hyponatremia; potential drug-drug interactions.

    • Client Education: Complete routine CBC and sodium monitoring; be aware of potential interactions.

    • Quetiapine, Olanzapine, Aripiprazole (Atypical antipsychotics):

    • Action: Manage anger outbursts, transient psychosis, severe emotional instability.

    • Side Effects: Metabolic effects, akathisia especially with aripiprazole.

    • Client Education: Weight and lipid monitoring; lifestyle counseling; report feelings of inner restlessness.

    • Sertraline, Fluoxetine (SSRIs):

    • Action: Treat depression/anxiety in comorbidity.

    • Side Effects: Risk of sexual dysfunction, activation, GI upset.

Disorder Specific Characteristics in Cluster B:

  • Antisocial Personality Disorder (ASPD):

    • Characterized by disregard for the rights of others, lack of empathy, exploitative behaviors, and repeated legal offenses; often charming.

  • Borderline Personality Disorder (BPD):

    • Characterized by instability in emotions, identity, and relationships; features manipulation, impulsivity, and fear of abandonment; significant risk of self-harm.

  • Histrionic Personality Disorder:

    • Characterized by a need for attention, emotional expressiveness, and often includes seductive traits.

  • Narcissistic Personality Disorder:

    • Characterized by self-importance, constant admiration seeking, and lack of empathy for others; sensitive to criticism.

Cluster C: Anxious or Fearful Traits

  • Key Characteristics:

    • Avoidant, Dependent, Obsessive-Compulsive Personality Disorder (OCPD).

    • Focus on reinforcing education and therapies to learn effective management of anxiety.

  • Mnemonic:

    • C (Worried) — Avoidant, Dependent, OCPD.

  • Key Traits:

    • Anxiety, fearfulness, insecurity, and feelings of inadequacy.

Medications for Cluster C Disorders:

  • Medication Examples:

    • Sertraline, Escitalopram (SSRIs):

    • Action: Treat social/generalized anxiety and depressive overlays.

    • Side Effects: GI upset, sexual side effects, risk of serotonin syndrome (rare).

    • Client Education: Daily dosing, delayed onset; do not stop suddenly.

    • Venlafaxine, Duloxetine (SNRIs):

    • Action: Manage anxiety alongside symptoms of anergia or chronic pain.

    • Side Effects: Increased blood pressure or nausea.

    • Client Education: Monitor blood pressure; take with food.

    • Buspirone (Non-benzodiazepine anxiolytic):

    • Action: Manage chronic anxiety without sedation/potential for dependence.

    • Side Effects: Dizziness, headache; delayed onset of effects.

    • Client Education: Take consistently at the same times; does not work on a PRN basis.

    • Propranolol (Beta-blocker):

    • Action: Alleviate somatic symptoms associated with performance/social anxiety.

    • Side Effects: Bradycardia, hypotension, potential for bronchospasm.

    • Client Education: Trial prior to events; avoid in asthma or COPD.

    • Lorazepam (short-term use):

    • Action: Assist in managing acute, brief severe anxiety episodes.

    • Side Effects: Risk for sedation, falls, potential for dependence.

    • Client Education: Limit to short, time-limited use; educate on the risk of falls and avoid alcohol.

Disorder Specific Characteristics in Cluster C:

  • Avoidant Personality Disorder:

    • Characterized by social inhibition and avoidance fueled by extreme fear of rejection along with feelings of inadequacy.

  • Dependent Personality Disorder:

    • Marked by extreme dependency on close relationships and urgent need for replacement when relationships end.

  • Obsessive-Compulsive Personality Disorder (OCPD):

    • Characterized by indecisiveness and perfectionism, with an overemphasis on orderliness and control hindering task completion.

Patient-Centered Care: Nursing Care & Communication Strategies

  • Safety First:

    • Assess risk for self-harm/suicide (notably in BPD) and violence (notably in ASPD/paranoid contexts).

    • Implement safety protocols, including removing hazards and observation as necessary.

  • Establish Boundaries and Limits:

    • Implement clear rules and consistent consequences; maintain a calm, firm approach to limit-setting.

    • Avoid engagement in power struggles.

  • Team Consistency:

    • Ensure a consolidated treatment approach across the care team; effective handoffs during shifts to prevent manipulation or splitting behaviors.

  • Utilize Therapeutic Communication:

    • Employ a matter-of-fact tone without sarcasm; validate clients' feelings while reflecting on content.

    • Set collaborative goals with the clients.

  • Create a Structured Environment:

    • Promote predictable routines, enforce behavioral contracts, and reinforce adaptive behaviors among clients.

Cluster-Tuned Tips:

  • For Cluster A:

    • Use low-stimulation environments, simple language, and respect personal space.

  • For Cluster B:

    • Prioritize safety, tolerance for distress, and consistent limit-setting.

  • For Cluster C:

    • Implement graded exposure techniques, practice assertiveness, and enhance decision-making skills.

Interprofessional Care: Psychological Interventions

Intervention Types:

  • Cognitive Behavioral Therapy (CBT):

    • Focuses on cognitive restructuring and exposure training.

    • Aimed towards improving skills in clients with anxiety from Cluster C disorders.

  • Dialectical Behavior Therapy (DBT):

    • Gold standard for managing Borderline Personality Disorder.

    • Incorporates mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.

    • Aims to reduce self-harm and excessive emergency department usage.

  • Schema Therapy/Mentalization-Based Therapies:

    • Intended to modify core schemas and enhance understanding of self and others, particularly in BPD and Narcissistic Personality Disorders.

  • Group Therapy/Social Skills Training:

    • Role-playing and providing feedback on boundaries; helpful for clients with avoidant or schizoid traits.

Family Education and Support:

  • Family Education:

    • Emphasize boundaries, validation, crisis planning, and prevention of caregiver burnout.

  • Case Management/Social Work:

    • Facilitate access to housing and legal resources (in cases of ASPD), as well as linkage to substance use disorder support and safety planning.

  • Pharmacotherapy:

    • Employ symptom-targeted medications and monitor labs to ensure safety, especially for lithium and anti-epileptics; avoid routine benzodiazepines due to misuse risk in impulsive traits.

NCLEX-Style Exam Pearls:

  • Pearl: Understand the importance of preventing splitting behaviors in BPD — unify treatment plans across all staff.

  • Limit-Setting in ASPD: Effects of consequences must be predictable and non-punitive.

  • Benzodiazepines Caution: Avoid using them habitually in BPD/ASPD to reduce risks.

  • Lithium Safety: Maintain hydration, steady salt intake, and regular monitoring of renal and TSH lab values; be cautious of toxicity during dehydration or NSAID use.

  • Valproate Safety: Conduct baseline and periodic LFTs and platelets; ensure strict contraceptive measures due to teratogenic potential.

  • Lamotrigine Rash: Urgent evaluation required for any rashes that appear due to the risk of SJS/TEN.

  • Atypical Antipsychotics: Continuous monitoring of weight, lipids, and glucose levels is essential, combined with lifestyle counseling to address metabolic risks.