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Square Pegs Psych Article
Square Pegs Psych Article
The author has disclosed that she has no significant relationships with or financial interest in any commercial companies that pertain to this
educational activity.
TOM MCGUIRE, 37, is a lab tech working Mental Disorders, 4th edition (DSM-IV),
second shift at a large pharmaceutical defines personality disorders as “enduring
firm. He’s single, has no close friends or patterns of inner experience and behavior”
confidants, is estranged from his siblings, that can destroy a person’s ability to function
and never socializes with his colleagues. in family, social, and occupational situations.
In fact, he seldom even makes eye contact. Cognition, mood, behavior, and interperson-
He appears to sleepwalk through his shift. al relationships are most affected. A patient
Throughout his entire adult life, people suffering from a personality disorder dis-
have used words like “eccentric,” “loner,” plays rigid, maladaptive, and fixed dysfunc-
and “oddball” to describe him. tional patterns that cause him significant
That’s how he appears to the outside emotional pain.
world. But Mr. McGuire isn’t just an eccen- As a nurse, you may encounter patients
tric, all-work-and-no-play kind of guy who’s with a personality disorder in pretty much
content in his solitude. He very likely has a any health care setting. That’s why it’s
personality disorder, and beneath that cool important for you to recognize and under-
exterior, he’s miserable and barely able to stand these disorders so you can deliver the
cope with life. best care and work effectively with these
The Diagnostic and Statistical Manual of often challenging individuals.
Quite a variety!
The DSM-IV divides personality disorders
into three clusters. The disorders are
grouped according to similarity of symp-
toms:
■ Cluster A includes paranoid, schizoid,
and schizotypal personality disorders.
These disorders are distinguished by odd
or eccentric behavior.
■ Cluster B includes antisocial, histrionic,
borderline, and narcissistic personality dis-
orders. These disorders are characterized
by dramatic, highly emotional, and unsta-
ble behaviors.
■ Cluster C includes avoidant, obsessive-
compulsive, passive-aggressive, and de-
pendent personality disorders. These dis-
orders are marked by fearful, anxiety-
ridden behavior.
The clusters are useful for making a clini-
cal diagnosis, but keep in mind that a patient
may have traits from all three (see Common
features of personality disorders for more infor-
mation).
To be diagnosed with a personality disor-
der, the patient must have dysfunctional
behavior in at least two of the following
areas: perception and interpretation of self
and others; intensity, duration, and appro-
priateness of feelings; ability to carry out
social, family, and occupational interactions;
for him to maintain a relationship because pline and perfectionism like a life raft. He’s
of his need for constant approval and atten- preoccupied with rules and regulations for
tion. Beneath this flamboyance, however, a himself and others, and he’s completely
person with narcissistic personality disor- inflexible. He appears calm and controlled
der is insecure, forever yearning for the on the surface, but lurking beneath the sur-
approval of others. face are strong feelings of hostility and con-
flict. His relentless anxiety about things not
Cluster C: being perfect torments him constantly.
Hand-wringing anxiety People with this disorder can often function
An individual with avoidant personality well enough for a while to be successful in
disorder is hypersensitive to others’ opin- business.
ions of him. He suffers from severe anxi- In passive-aggressive personality dis-
ety in social situations—he’s apt to be a order, the individual uses stealth methods to
wallflower at a social gathering. Though express his feelings. For example, instead of
he often expresses the desire to have a saying he’s furious about a business deci-
close relationship, his deep fear of rejec- sion, he’ll be late for an important meeting.
tion leads him to avoid situations with the He has a negative outlook on life, and he
potential to lead to one. This personality uses a campaign of passive resistance against
disorder is often combined with other psy- others’ expectations of his performance.
chiatric disorders, like social phobia, Although he mostly sabotages himself, he
schizoid or dependent personality disor- feels cheated and underappreciated by oth-
der, agoraphobia, obsessive-compulsive ers. Enormous discipline allows him to con-
disorder, generalized anxiety disorder, trol his anger for a while to avoid loss of
dysthymia, major depressive disorder, so- affection.
matoform disorders, dissociative disorder, What’s the origin of personality disorders
and schizophrenia. It’s diagnosed twice as like these? Let’s take a look.
often in men.
A person with dependent personality dis- Nature and nurture
order has an excessive need to be taken care It’s theorized that multiple factors may
of, difficulty making decisions, low self- contribute to the development of a person-
esteem, submissive and clingy behavior, and ality disorder, including the following:
an inability to maintain a stable social role. ■ negative childhood experiences
Separation anxiety may make him prone to ■ separation or abandonment
remain in a dysfunctional or abusive rela- ■ emotional and/or physical abuse
tionship. ■ significant loss of parenting.
An individual with obsessive-compulsive Most experts agree there’s often a genetic
personality disorder clings to excessive disci- component that mixes in with learned
the disorder—cognition, mood, behavior, or experiences. It’s thought that when someone
interpersonal relationships. Transference- experiences trauma, like child sexual abuse,
based psychotherapy; cognitive behavioral the memory of it can become ingrained in
therapy, including dialectical behavioral the psyche, influencing all aspects of life. The
therapy; social skills training; eye movement process of EMDR purportedly helps these
desensitization and reprocessing (EMDR); memories become accessible to healing. The
and medical treatments are options currently client is instructed to think of the traumatic
in use. Hospitalization is generally reserved event while simultaneously focusing on an
for a patient who’s an imminent danger to external visual stimulus, like a moving pen-
self or others, has an inability to care for cil. The resultant rapid eye movement is
basic needs, or has psychosocial stressors believed to cause the traumatic memory to
that overwhelm the capacity to cope. dissipate from the brain, allowing for posi-
Transference-based psychotherapy focuses tive change to occur.
on changing the way a person experiences Social skills training is used most effec-
self, others, and the environment. The goal is tively for patients who experience significant
to stop destructive behavior. The therapist problems in interpersonal relationships.
guides the patient to an understanding of the Learning to start a conversation, shop for
feelings and anxieties that trigger the trou- food, talk on the phone, and pick up peo-
blesome conduct. As therapy progresses, the ple’s behavior cues are important aspects of
patient should learn better ways of relating this treatment. As I described earlier,
to people and reacting to situations. patients with a personality disorder tend to
Because some experts see trauma as one of underreact or overreact to social situations.
the causes of personality disorder, EMDR is In social skills training, the patient can prac-
sometimes used to help to heal the psycho- tice his social skills in a nonthreatening, sup-
logical wounds caused by these damaging portive environment. Effective ways to
lation, or other pathologic behaviors. Set- Psychiatric Nursing Made Incredibly Easy! Philadelphia, Pa.,
Lippincott Williams & Wilkins, 2004.
ting boundaries and maintaining your Ward RK. Assessment and management of personality disor-
professional behavior are important. ders. American Family Physician. 70(8):1505-1512, October 2004.
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Square pegs: Managing personality disorders
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