Personality disorders and defense mechanisms

Introduction
Defense mechanisms
According to sigmoid Freud, the mind personality is made up of: Id – pleasure seeker to satisfy
biological needs e.g. sex, aggression, hunger. Operates according to the pleasure principle-
Pleasure principle operates to satisfy drives and avoid pain without regard to logic, reason. It is
an unconscious process. Ego is the second component. Is the executive negotiator between the
ID and the SUPEREGO. Enables control of wishes, drives. Ego finds socially acceptable means
of satisfying ID desires and negotiates between the ID wants and superego restrictions/
prohibitions. It is usually conscious and follows the reality principle i.e. satisfies needs in a
socially acceptable way. Ego resolves conflict that arises because of different goals of the ID
and superego. Ego is an executive negotiation that operates in a reasonable, logical and socially
acceptable way in finding outlet for satisfaction
Super ego: Is the regulator. Occurs when children learn to follow rules and regulations in
satisfying their needs .Develops in early childhood. Its goal is to apply the moral values and
standards of one’s parents /carefully and society in satisfying ones wishes. It’s the moral
guardian/ conscience that try to regulate or control ID wishes and impulses. NB: ID and
Superego may conflict in their goals; hence the ego comes as the executive negotiator to resolve
the conflict. These mental processes that the ego uses to mediate the ID and the super ego are
called defense mechanisms Anxiety which is uncomfortable feelings results from inner conflicts
between primitive desires of the ID and the moral goals of the superego. The ego tries to reduce
the anxious feelings by using a number of mental processes –defense mechanisms. These are
used if the anxiety cannot be managed by direct action. These defense mechanisms are
unconscious defenses in order to ward off awareness of the conflict. Everyone experience
dangers and therefore uses defense mechanism, hence they are not especially maladaptive
behavior. Everybody uses defense mechanism. They become pathological if used excessively
and in maladaptive patterns
Examples of defense mechanisms
1. Rationalisation
Covering up the true reasons for actions thought or feelings by making excuses or incorrect
explanations -e.g. student may say that by going to a party tonight, he will be motivated to study

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2. Denial
Refusing to recognize some anxiety –provoking events or piece of information that is clear to
others. E.g. Smokers disregard evidence that cigarette smoking causes lung cancer
3. Repression
Blocking and pushing unacceptable or threatening feelings wishes or experiences from conscious
awareness into the unconscious e.g. Jealous about your friends academic achievements
4. Projection – Man who feels filthy of desire for incident
Falsely and unconsciously attributes your own unacceptable feelings, traits, thoughts to
individuals, objects e.g. lateness in claims – your friend put off your clock.
5 Reaction formation: substituting behaviors, thoughts or feelings that are the direct opposite of
acceptable ones e.g. one feel guilty of engaging in sex many use reaction formation by joining a
religious group – nun hood that bans sex. Hate someone you love because you cannot access
him/her e.g. nun.
6. Displacement
Transferring feelings about, or response to, an object that causes anxiety to another person or
object that is less threatening. Father – mother – child – dog – cat – rat. Middle – level manager
may displace his anger to cleaner when anyone by the boss.
7. Sublimation
Involves redirecting a threatening or forbidden desire usually sexual into socially acceptable
one.Channelling potentially maladaptive feelings or impulses into socially acceptable behaviors.
8. Regression
Going back to earlier ways of behaving that were characteristic of a previous department level
e.g. eating a lot or sucking thumb when stressed.
9. Intellectualization
Dealing with problems in a way that you explain them rapidly e.g. alcoholics who didn’t go to
church because of drinking say that not all who go church are perfect or go to heaven.
1. Suppression: Intentionally avoiding thinking about disturbing problems, wishes, feelings, or
experience.
2. Altruism: Dedicating life to meeting the needs of others – relieving gratification either
vicariously or from the response of others

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13. Autistic fantasy: Excessive day dreaming as a substitute for human relationships, more
effective action or problem solving.
14 Dissociation: Experiencing a breakdown in the usual integrated functions of consciousness,
memory, perception of self and environment, or sensory and motor behavior.
Defense mechanisms are unconscious such that people deny them. They can be harmful or
helpful e.g. may help cope with anxiety and conflict as we try to resolve the anxiety but overuse
may prevent us from working on real causes or anxiety.

Learning activity: Read further how the above and other defense mechanisms can be
classified into defense levels

PERSONALITY DISORDERS
Introduction
Personality
Is a complex pattern of characteristics, largely outside of the person’s awareness, that comprise
the individual’s distinctive pattern of perceiving, feeling, thinking, coping and behaving. The
personality emerges from a complicated interaction of biological dispositions, psychological
experiences and environmental situations. A complex pattern of psychological characteristics
largely outside the person’s awareness that are not easily altered. Personality traits are prominent
aspect of personality that are exhibited in a wide range of important social and personal contexts
Changing lifestyle personality patterns is difficult and requires much understanding by clinicians
and support. The characteristics / traits include the individual’s style of perceiving, thinking and
feeling about self, others and the environment. These traits are expressed in all facet / areas of
functioning e.g. social, personal etc. These traits are intrinsic and pervasive and emerge as a
result of interaction of biological, psychological and environmental factors which make
individual’s distinctive personality. Deep ingrained pattern of relating to others are maladaptive
Personality disorders
No sharp division exist between normal and abnormal personality instead, personalities are
viewed in a continuum Development of personality disorders is determined by same factors as
normal personality. American psychiatric association(2000) defines personality disorder as an
enduring pattern of inner experience and behavior that deviates markedly from expectations of

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culture, is pervasive, and inflexible, has an onset in adolescent or early adulthood, is stable
overtime and leads to distress and impairment. Personality disorder develops when enduring,
deeply ingrained trait/patterns become maladaptive, inflexible causing difficult for the persons in
relating to, working with, and loving others. Social and occupational functioning is usually

interfered with.

Etiology and epidemiology

The etiology is multifactorial, to include genetical factors, neurochemical e.g. schizoid have
reduced acetylcholine, hence lack emotional expressions-, Reduced dopamine, increased
testosterone associated APD .Others have unknown cause. Psychological theories e.g. poor
attachment early in life can lead to APD. Personality disorders prevalence in general population
is 1%.

Classification of personality disorders

Psychiatric personalities are clustered into three:
Cluster A: Characterizes by odd, peculiar, eccentric (conspicuous) misfits e.g. paranoid,
schizoid schizotypal personality disorders. Associated with psychotic symptoms.
Cluster B: Characterized by impulsivity (acting without considering the consequences of their
action or alternative actions) and emotionality. They are dramatic, emotional, and inconsistent.
Example includes: antisocial, borderline, histrionic, and narcissistic personality disorders. Their
behavior is erratic / dramatic and inconsistent. Associated with mood disorders.
Cluster C: Characterized by anxiety and fearfulness .Examples include: avoidance, defendant
and obsessive –compulsive
Personality disorders not otherwise specified
These includes Passive –aggressive personality disorder, depressive, sadomasochistic, sadistic
personality disorder
Note: personality disorders may be related to medical conditions such as
neurodegenerative disorders

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Characteristics
Based in manifestation of abnormal inflexible behavior patterns of long duration, traced to or
early adulthood. These abnormal behavior patterns must deviate markedly from expectations of
individuals culture and must manifest in two or more of the following areas: cognition (cognitive
schema); ways of perceiving / interpreting self, other people and events, affectivity, self-identity-
minimal/ absent, range, intensity, liability, appropriateness of emotion responses, impulse
control, interpersonal functioning. With others and inability to learn new mechanisms
NB: Behavours assessed in relationship to ones cultural set up; otherwise diagnosis is delayed till
after adjustment period

General DSM-5 criteria

 Pattern of behaviors/ inner experience that deviates from person’s culture and is
manifested in two or more of the following: cognition, affect, personal relations.-impulse
control
 The pattern: Is pervasive and inflexible in bread of situation; is a stable with onset not
later than adolescence and early adulthood; leads to distress in finding; is not accounted
for by another mental/medical illness or by use of substance.

Possible Nursing Diagnoses

Low self esteem, impaired social interactions, ineffective copping, social isolation, risk for
violence, impaired communication

Remember:
Treatment of psychiatric disorders is more difficult for a person who has a personality disorder.
E.g. treating a mood disorder is more difficult if patient has antisocial [dissocial] personality
disorder. Patients with personality disorder have symptoms that are ego-syntonic (hence lack
insight about their problems) i.e. those elements of a person’s behavior, thought, impulses, drives
and attitudes that agree with the standards of the ego and are consistent with the total
personality .Ego-dystonic: are at variance with the standards of ego and inconsistent with total
personality i.e. they are ego -alien, self- alien. Personality disorders are difficult to treat because

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the clients lack of insight. Disorders are chronic and lifelong. Pharmacological treatment has
limited usefulness except a few types – except in treating co- existing symptoms s of depression;
anxiety etc.The most useful therapy is psychotherapy –individual and group.

Clinical features of abnormal personalities and their management

1. Paranoid personality disorders-cluster A
Central features include: suspiciousness –especially sexual, sensitivity- distracting of others;
mistrustful- impaired relationships; argumentative,-stubborn,-self important; misinterprets others
actions; reluctance to confide to others.
Management: Social skill training, Psychotherapy, anxiolytics, antipsychotics
2. Schizoid personality disorder-cluster A
Characterized by: emotionally cold, no rapport –cannot express affection and tenderness;
detached from other people, self sufficient; aloof –social withdrawal, eccentric, reclusive;-
humorless- indifference practice / critics; -introverted/introspective – engage in fantasy rather
than take action; has got some schizophrenia features; cannot make intimate relationships and
therefore remain unmarried; more intellectual than practical more concerned with intellectual
problems than with ideas about other people – some advantage
Management: social skills taught; vital because frustrating to work with them because they shy
away from interactions; Psychotherapy- group therapy; low dose of antipsychotic and
antidepressants
3. Schizotypal personality disorder – cluster A
Features: social anxiety –doesn’t – with familiarity; inability to make close relationships except
1ST degree relationships; eccentric behaviors; oddities of thoughts e.g. speech that is vague and
excessively abstract; inappropriate affect; -magical thinking ideas of reference – interpret events
has having special /personal meaning; related to schizophrenia more closely than
schizoid ;circumstantial thinking, posturing , fantasy ,hallucinations, delusions ,wet/ soil bed.
May develop disorganized schizophrenia.
Management: Social skill training; cognitive skills; reinforce behavior that is positive; self-care
assistance; psychotherapy low dose of antipsychotics.
4. Antisocial/ psychopathic/dissocial personality disorder –cluster B

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Pervasive pattern of disregard for, and violation of rights of others that begins in childhood or
adolescent and continues to adulthood. Characteristics: -failure to sustain relationships;
disregarded of the feelings of others;-impulsive actions; low tolerance of frustration –no
persistence to goal; tendency to violence;-lack of guilt;-failure to learn from experience;-age is at
least15/ 18 years old.
Characteristics: failure to make loving relationships accompanied by self-centeredness and
heartlessness -/gets friends –intimacy first; can be cruel and callous; sexual activity is without
evidence of tender feelings; marriage marked by lack of concern for the partner and some
physical violence- end up with separation or divorce; impulsive behavior reflected by unstable
work record – frequent dismissals; impulsive behavior attack of guilt or remorse often
associated with repeated offences against the law; usually behavior starts in adolescent – made
worse by efforts of alcohol and drugs; -poor family management ; chronic in nature tend to
diminish after 40 years
Co -morbidity
Strongly associated with alcohol and drug abuse – depression, schizophrenia may occur. It’s the
associated problem that makes the patient seek treatment not the personality disorder itself.
Possible nursing diagnosis
Ineffective role performance /unemployment; ineffective individual coping; impaired
communication; impaired social interactions; -low self esteem; risk for violence
Management: may require treatment associated with substance abuse. Psychotherapy, social
skill training,
Self- responsibility facilitation -accept consequences of personal behaviors; Self awareness
enhancement- -motivations, feelings, thoughts behaviors are understood
Psycho education -anger control, maintenance of employment, interaction skills, substance abuse
control. Group therapy-patient monitors each other. Milieu interventions-structured environment
with rules.

5. Borderline personality disorder- cluster B

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Is an emotionally instable personality characterized: unstable relationships; impulsive behavior
that is harmful to the person e.g. reckless spending, binge eating, or sexual behavior; -variable
moods; lack of control of anger;-recurrent suicidal threats or behaviors; uncertainty about
personal identity; -chronic feelings of emptiness; efforts to avoid real or imagined abandonment;
transient stress related paranoid ideas or severe dissociative symptoms. Some features above can
fit in other personality disorders e.g. antisocial, narcissistic, and histrionic personality disorders.
Management: Promote sleep- moderate exercise 3-4 before asleep, use bedroom for sex and
sleep only, avoid caffeine. Nutrition care-when it co –exists with substance abuse, eating
disorder, usually overweight is the problem – especially due to medications. Prevention and
treatment of self injury –safety, intervention, assess any warning.Pharmacological interventions -
used to control emotional dysregulation, impulsive behavours, cognitive disturbance, and anxiety
so that patient can be amenable to psychotherapy. Drugs used include Antidepressants; lithium
/carbamazepine for impulsivity; antipsychotics for misinterpretation of reality. Identify situations
that trigger self injury behavour.Behavour interventions, Abandonment and intimacy fears-
update patient on discharge schedule .Establish personal boundaries and limitations. Emotion
and regulation-control feelings of anger e.g. use communication traid like I feel angry when you
interrupt me and wish you apologies, distraction or thought stopping delays gratification,
challenging dysfunctioning thinking- e.g. dichotomous or catastrophic thinking. Group therapy
and milieu management are also useful
6. Historic personality disorder –cluster B
Featured by; emotional; self- dramatization- attention seeking; portray what is not self unaware
that people know about them; craving for novelty and excitement – hence reliantly seek new
experiences; short lived enthusiasms; self-centered –inconsiderate , demanding force people to
follow their wishes only , thinking of their own interests; unrestrained emotional display –display
emotion readily exhausting others with tantrums of range or dramatic expressions of despair feel
little of the emissions they express and recover quickly; -self receiving; continue believing that
they are right against all facts to the contrary; able to maintain elaborate lies long after people
have seen through them. This pattern of behavior is observed in its most extreme form in lairs
and swindlers. Some of these qualities common in children e.g. transient enthusiasm, easy
change from laughter to tears, enjoyment of make believe (hence sometimes this personality
called immature personality disorders.-Sexuality affected-Sexual provocation combines with

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frigidity i.e. in women –engage –display of affection and flirtations but incapable of
experiencing deep feelings hence cannot reach orgasm.
Management: Seek treatment after social disapproval / deprivation, assertiveness training,-
reinforce strengths, sex therapy,-psychotherapy, pharmacotherapy
Further reading: Narcissistic personality disorder, Anxious/avoidant personality disorder,
dependent personality disorder and passive –aggressive personality disorder.

7. Obsessive-Compulsive Personality Disorder Symptoms

Obsessive-Compulsive Personality Disorder is characterized by a preoccupation with orderliness,

perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and
efficiency.

When rules and established procedures do not dictate the correct answer, decision making may
become a time-consuming, often painful process. Individuals with Obsessive-Compulsive
Personality Disorder may have such difficulty deciding which tasks take priority or what is the
best way of doing some particular task that they may never get started on anything.

They are prone to become upset or angry in situations in which they are not able to maintain
control of their physical or interpersonal environment, although the anger is typically not
expressed directly. For example, a person may be angry when service in a restaurant is poor, but
instead of complaining to the management, the individual ruminates about how much to leave as
a tip. On other occasions, anger may be expressed with righteous indignation over a seemingly
minor matter.

People with this disorder may be especially attentive to their relative status in dominance-
submission relationships and may display excessive deference to an authority they respect and
excessive resistance to authority that they do not respect.

Individuals with this disorder usually express affection in a highly controlled or stilted fashion
and may be very uncomfortable in the presence of others who are emotionally expressive. Their
everyday relationships have a formal and serious quality, and they may be stiff in situations in
which others would smile and be happy (e.g., greeting a lover at the airport). They carefully hold

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themselves back until they are sure that whatever they say will be perfect. They may be
preoccupied with logic and intellect.

A personality disorder is an enduring pattern of inner experience and behavior that deviates from
the norm of the individual’s culture. The pattern is seen in two or more of the following areas:
cognition; affect; interpersonal functioning; or impulse control. The enduring pattern is inflexible
and pervasive across a broad range of personal and social situations. It typically leads to
significant distress or impairment in social, work or other areas of functioning. The pattern is
stable and of long duration, and its onset can be traced back to early adulthood or adolescence.

Symptoms of Obsessive-Compulsive Personality Disorder

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and

interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early
adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

 Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that
the major point of the activity is lost
 Shows perfectionism that interferes with task completion (e.g., is unable to complete a
project because his or her own overly strict standards are not met)
 Is excessively devoted to work and productivity to the exclusion of leisure activities and
friendships (not accounted for by obvious economic necessity)
 Is over conscientious, scrupulous, and inflexible about matters of morality, ethics, or
values (not accounted for by cultural or religious identification)
 Is unable to discard worn-out or worthless objects even when they have no sentimental
value
 Is reluctant to delegate tasks or to work with others unless they submit to exactly his or
her way of doing things
 Adopts a miserly spending style toward both self and others; money is viewed as
something to be hoarded for future catastrophes
 Shows significant rigidity and stubbornness

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Because personality disorders describe long-standing and enduring patterns of behavior, they are
most often diagnosed in adulthood. It is uncommon for them to be diagnosed in childhood or
adolescence, because a child or teen is under constant development, personality changes and
maturation. However, if it is diagnosed in a child or teen, the features must have been present for
at least 1 year.

Obsessive-Compulsive personality disorder is approximately twice as prevalent in males as

females, and occurs in between 2.1 and 7.9 percent of the general population.

Like most personality disorders, Obsessive-Compulsive personality disorder typically will

decrease in intensity with age, with many people experiencing few of the most extreme
symptoms by the time they are in the 40s or 50s.

How is obsessive-compulsive personality disorder diagnosed?

Personality disorders such as obsessive-compulsive personality disorder are typically diagnosed

by a trained mental health professional, such as a psychologist or  psychiatrist. Family physicians
and general practitioners are generally not trained or well-equipped to make this type of
psychological diagnosis. So while you can initially consult a family physician about this
problem, they should refer you to a mental health professional for diagnosis and treatment. There
is no laboratory, blood or genetic tests that are used to diagnose obsessive-
compulsive personality disorder.

Many people with obsessive-compulsive personality disorder don’t seek out treatment. People
with personality disorders, in general, do not often seek out treatment until the disorder starts to
significantly interfere or otherwise impact a person’s life. This most often happens when a
person’s coping resources are stretched too thin to deal with stress or other life events.

A diagnosis for obsessive-compulsive   personality disorder is made by a mental health

professional comparing your symptoms and life history with those listed here. They will make a
determination whether your symptoms meet the criteria necessary for a personality disorder
diagnosis.

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Causes of obsessive-compulsive personality disorder

Researchers today don’t know what causes obsessive-compulsive personality disorder.  There are

many theories, however, about the possible causes of obsessive-compulsive personality disorder. 
Most professionals subscribe to a biopsychosocial model of causation — that is, the causes of are
likely due to biological and genetic factors, social factors (such as how a person interacts in their
early development with their family and friends and other children), and psychological factors
(the individual’s personality and temperament, shaped by their environment and learned coping
skills to deal with stress). This suggests that no single factor is responsible — rather, it is the
complex and likely intertwined nature of all three factors that are important. If a person has this
personality disorder, research suggests that there is a slightly increased risk   for this disorder to
be “passed down” to their children.

Treatment of obsessive-compulsive personality disorder

Treatment of obsessive-compulsive personality disorder typically involves long-term

psychotherapy with a therapist that has experience in treating this kind of personality disorder.
Medications may also be prescribed to help with specific troubling and debilitating symptoms E
depression and anxiety

    

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