PERSONALITY DISORDER DRUG CHOICES FOR SYMPTOMS OF PERSONALITY

DISORDERS
- refers to individual differences in characteristic
patterns of thinking, feeling and behaving. Individual and Group Psychotherapy

Personality trait focus on building trust, teaching basic living skills,

providing support, decreasing distressing symptoms
- Personality is how you expect someone to behave
such as anxiety, and improving interpersonal
across the long-term
relationships.
- is a broad behavioral element that describes your
Trust- nurse-client relationship
personality, such as kind, outgoing, or impatient.
Living skills – relationship with case manager/therapist
Personality Disorder
Decrease symptoms – relaxation and meditation
are diagnosed when personality traits become inflexible
technique
and maladaptive and significantly interfere with how a
person CLUSTER A: PERSONALITY DISORDERS

functions in society or cause the person emotional Paranoid Personality Disorder

distress.
• a relentless mistrust and suspicion of others
Personality Disorder Clusters without adequate reason to be suspicious.
• This disorder often begins in childhood or early
Cluster A: Individuals whose behavior appears odd or
adolescence and appears to be more common
eccentric
in men than in women.
paranoid, schizoid, and schizotypal personality • Studies estimate that PPD affects between 2.3%
disorders and 4.4% of the general population.

Cluster B: Individuals who appear dramatic, emotional, Essential Features

or erratic
• Suspect, without sufficient basis, that others
antisocial, borderline, histrionic, and narcissistic are exploiting, harming, or deceiving them
personality disorders • Preoccupied with unjustified doubts about the
loyalty or trustworthiness of friends or
Cluster C: Individuals who appear anxious or fearful
associates
avoidant, dependent, and obsessive–compulsive • Be reluctant to confide in others because of
personality disorders unwarranted fears that the information will be
used maliciously against them.
Etiological Factors
• Read hidden or demeaning or threatening
Genetic factors- due to inherited traits meanings into benign remarks or events
• Persistently bear grudges
Temperamental factors- due to emotional climate at
• Perceive attacks on their character or
home
reputation that are not apparent to others
Biologic factors- due to imbalance in hormones and • Have recurrent suspicions, without justification,
neurotransmitters regarding fidelity of spouse or sexual partner

Psychoanalytic factors- due to fixation at certain Symptoms

psychosexual stage of development
✓ believing that others have hidden motives or
CULTURAL CONSIDERATIONS are out to harm them

TREATMENT ✓ doubting the loyalty of others

Strategies are based on: ✓ being hypersensitive to criticism

✓ disorder’s type and severity or ✓ having trouble working with others

✓ the amount of distress or ✓ being quick to become angry and hostile

✓ functional impairment the client experiences. ✓ becoming detached or socially isolated

Combinations of medication and group and individual ✓ being argumentative and defensive
therapies are more likely to be effective than single
✓ having trouble seeing their own problems
treatment
✓ having trouble relaxing
Psychopharmacology
Nursing Intervention
Table 16.1
 • the nurse must approach these clients in a
formal, business-like manner and refrain from
social chitchat or jokes.*
• Teach client to validate ideas before taking
• action;
• involve client in treatment planning
• the best nursing approach will be
straightforward, respectful, and unobtrusive
Difficult to have a working relationship but must
understand that they are suspicious
* on time, keeping commitments, and being
straightforward essential to the success of the nurse–
client relationship.
SCHIZOID PERSONALITY DISORDER
• is characterized by a pervasive pattern of
detachment from social relationships and a
restricted range of emotional expression in
interpersonal settings
• avoid treatment as much as they avod other
relationships
Essential Features
• Demonstrates pervasive pattern of detachment
from social relationships
• Exhibits restricted range of emotions
• Must have four or more of the following:
✓ Neither desires nor enjoys close
relationships, including being part of a
family
✓ Chooses solitary activities
✓ Has little (if any) interest in sexual
experiences
✓ Takes pleasure in few (if any) activities
✓ Lacks close friends
✓ Appears indifferent to praise or
criticism
✓ Shows emotional coldness
Nursing Intervention
1. Focus on improved functioning in the
community
2. establish at least a working relationship with a
case manager in the community
SCHIZOTYPAL PERSONALITY DISORDER
Essential Features
Demonstrates pervasive pattern of acute discomfort
with social and interpersonal relationships
Exhibits cognitive or perceptual distortions and
eccentricities of behavior
Must exhibit five of the following:
✓ Ideas of reference
✓ Odd beliefs or magical thinking
✓ Unusual perceptual experiences
✓ Odd thinking and speech
✓ Suspiciousness or paranoid ideation
✓ Behavior or appearance that is odd,
eccentric, or peculiar
✓ Lack of close friends
✓ Excessive social anxiety
Nursing Intervention
1. Develop self-care skills;
✓ nurse encourages clients to establish a
daily routine for hygiene and grooming
2. improve community functioning;
✓ role-play interactions that clients would
have with family members or friends
3. Social skills training
✓ may help clients to talk clearly with
others and to reduce bizarre
conversations.
CLUSTER B: PERSONALITY DISORDERS
ANTISOCIAL PERSONALITY DISORDER
Essential Features
A pervasive pattern of disregard for and violation of the
rights of others
Repeated acts that are grounds for arrest
Repeated lying, use of aliases, or conning others
Impulsivity or failure to plan ahead
Repeated physical fights or assaults
Reckless disregard for safety of self or others
Failure to sustain consistent work behavior or honor
financial obligations
Lack of remorse (at) having hurt, mistreated, or stolen
from another
APPLICATION OF THE NURSING PROCESS
Assessment
✓ Clients are skillful at deceiving, so check and
validate information from other sources.
History
✓ Childhood histories of enuresis, sleepwalking,
and syntonic acts of cruelty are characteristic
predictors
✓ In adolescence, clients may have engaged in
lying, truancy, sexual promiscuity, cigarette
 smoking, substance use, and illegal activities
that brought them into contact with police.
✓ Families have high rates of depression,
substance abuse, poverty, and divorce.
✓ Erratic, neglectful, harsh, or even abusive
parenting
General Appearance and Motor Behavior
✓ Appearance usually is normal; these clients may
be quite engaging and even charming.
Mood and Affect
✓ Clients often display false emotions chosen to
suit the occasion or to work to their advantage.
✓ clients cannot empathize with the feelings of
others, which enables them to exploit others
without guilt.
Thought Process and Content
Clients do not experience disordered thoughts, but their
view of the world is narrow and distorted
✓ view the world as cold and hostile and
therefore rationalize their behavior.
Sensorium and Intellectual Processes
Clients are oriented, have no sensory–perceptual
alterations, and have average or above-average IQs.
Judgment and Insight
✓ They pay no attention to the legality of their
actions and do not consider morals or ethics
when making decisions*
✓ Clients lack insight and almost never see their
actions as the cause of their problems.
* Their behavior is determined primarily by what they
want, and they perceive their needs as immediate
Self-Concept
✓ Superficially, clients appear confident, self-
assured, and accomplished, perhaps even flip or
arrogant, but actually the self is quite shallow
and empty;
It is always someone else’s fault: some external source
is responsible for their situation or behavior.
Roles and Relationships
✓ Clients manipulate and exploit those around
them.
✓ They view relationships as serving their needs
and pursue others only for personal gain.
✓ involved in many relationships
o cannot sustain long-term commitments
o unsuccessful as spouses and parents
and leave others abandoned and
disappointed.
Nursing Diagnosis
• Ineffective Coping
• Ineffective Role Performance
• Risk for Other-Directed Violence
Nursing Intervention
Promoting responsible behavior
1. Limit Settings
✓ State the limit
✓ Identify consequences of exceeding the limit.
✓ Identify expected or acceptable behavior.
2. Consistent adherence to rules and treatment plan
3. Confrontation
✓ Point out problem behavior.
✓ Keep client focused on self.
4. Helping clients solve problems and control emotions
✓ Effective problem-solving skills
✓ Decreased impulsivity
✓ Expressing negative emotions such as anger or
frustration
✓ Taking a time-out from stressful situations
5. Enhancing role performance
✓ Identifying barriers to role fulfillment
✓ Decreasing or eliminating use of drugs and
alcohol
BORDERLINE PERSONALITY DISORDER
Essential Features
✓ Frantic efforts to avoid real or imagined
abandonment
✓ Pattern of unstable interpersonal relationships
✓ Unstable self-image or sense of self
✓ Impulsivity in at least two areas that are
potentially self-damaging
✓ Recurrent suicidal behaviors, gestures, or
threats or self-mutilating behavior
✓ Chronic feelings of emptiness
✓ Inappropriate anger or difficulty controlling
anger
✓ Transient, stress-related paranoid ideation
APPLICATION OF THE NURSING PROCESS
ASSESSMENT
History Roles and Relationships

✓ Fifty percent of these clients have experienced
childhood sexual abuse
✓ others experienced physical and verbal abuse
and parental alcoholism
✓ tend to use transitional objects*
General Appearance and Motor Behavior
✓ Severe - clients may appear disheveled
✓ unable to sit still, or
✓ display very labile emotions.
Mood and Affect
✓ Clients hate being alone, but their erratic, labile
✓ Relationships are unstable, stormy, and intense;
the cycle repeats itself continually.
✓ clients have extreme
✓ fears of abandonment and difficulty believing a
relationship still exists once the person is away
from them*
✓ Feelings for others are often distorted, erratic,
and inappropriate.*
✓ Clients usually have a history of poor school and
work performance*

✓ pervasive mood is dysphoric, involving Physiologic and Self-Care Considerations

unhappiness, restlessness, and malaise.
✓ clients also may engage in binging (excessive
✓ Clients may become irritable, even hostile or overeating) and purging (self-induced
sarcastic, and complain of episodes of panic vomiting),
anxiety.
✓ substance abuse,
✓ They experience intense emotions such as
✓ Unprotected sex, or reckless behavior such as
anger and rage
driving while intoxicated.
Thought Process and Content
Nursing Diagnosis
✓ Clients tend to adore and idealize other people
Risk for Suicide
but then quickly devalue them if they do not
meet their expectations in some way Risk for Self-Mutilation

✓ have excessive and chronic fears of Risk for Other-Directed Violence

abandonment
Ineffective Coping
✓ experience dissociative episodes
Social Isolation
✓ under extreme stress, clients may develop
NURSING INTERVENTIONS
transient psychotic symptoms such as delusions
or hallucinations. 1. Promoting client’s safety
Sensorium and Intellectual Processes ✓ No-self-harm contract
✓ Intellectual capacities are intact, and clients are ✓ Safe expression of feelings and
fully oriented to reality. emotions
✓ clients also report flashbacks of previous abuse 2. Helping client to cope and control emotions
or trauma.
✓ Identifying feelings
Judgment and Insight
✓ Journal entries
✓ Impaired judgment and lack of care and
concern for safety* ✓ Moderating emotional responses

✓ Clients have difficulty accepting responsibility ✓ Decreasing impulsivity

for meeting needs outside a relationship ✓ Delaying gratification
✓ see life’s problems and failures as a result of 3. Cognitive restructuring techniques
others’ shortcomings
✓ Thought stopping
Self-Concept
✓ Decatastrophizing
✓ appear needy and dependent one moment and
angry, hostile, and rejecting the next 4. Structuring time

✓ Sudden changes in opinions and plans* 5. Teaching social skills

✓ Suicidal threats, gestures, and attempts; Self- 6. Teaching effective communication skills
harm and mutilation are common* 7. Entering therapeutic relationship
 ✓ Limit setting ✓ Has a sense of entitlement

✓ Confrontation ✓ Is interpersonally exploitive

HISTRIONIC PERSONALITY DISORDER ✓ Lacks empathy

• is characterized by a pervasive pattern of ✓ Shows arrogance

excessive emotionality and attention seeking.
Nursing Intervention
• It occurs in 2% to 3% of the general population
and in 10% to 15% of the clinical population. ✓ The nurse must use self-awareness skills to
• It is seen more often in women than in men. avoid the anger and frustration that these
clients’ behavior and attitude can engender
Essential Features
✓ The nurse must not internalize such criticism or
✓ Is uncomfortable in situations in which he or
take it personally*
she is not the center of attention
✓ He or she sets limits on rude or verbally abusive
✓ Displays inappropriate sexually seductive or
behavior and explains his or her expectations of
provocative behavior
the client.
✓ Has rapid shifts of emotion
CLUSTER C: PERSONALITY DISORDERS
✓ Uses physical appearance to draw attention to
AVOIDANT PERSONALITY DISORDER
self
• is characterized by a pervasive pattern of social
✓ Shows dramatization or exaggerated expression
discomfort and reticence, low self-esteem, and
of emotion
hypersensitivity to negative evaluation
✓ Is suggestible • It occurs in 0.5% to 1% of the general
population and in 10% of the clinical
✓ Considers relationships to be more intimate
population.
than they really are
• It is equally common in men and women.
Nursing Intervention
Essential Features
✓ nurse gives clients feedback about their social
• Is unwilling to get involved with people unless
interactions with others, including manner of
certain of being liked
dress and nonverbal behavior.*
• Shows restraint in intimate relationships for
✓ The nurse must be specific in describing and fear of being shamed or ridiculed
modeling social skills, including establishing eye • Is inhibited in interpersonal relationships
contact, engaging in active listening, and because of feelings of inadequacy
respecting personal space • Views self as socially inept and inferior to
others
✓ Encouraging clients to use assertive
• Is usually reluctant to take personal risks
communication*
Nursing Intervention
NARCISSISTIC PERSONALITY DISORDER
✓ nurse can help them explore positive self-
• is characterized by a pervasive pattern of
aspects, positive responses from others, and
grandiosity (in fantasy or behavior), need for
possible reasons for self-criticism
admiration, and lack of empathy.
• It occurs in 1% to 2%of the general population ✓ nurse can teach social skills and help clients to
and in 2% to 16% of the clinical population. practice them in the safety of the nurse–client
• 50% to 75% of people with this diagnosis are relationship
men.
DEPENDENT PERSONALITY DISORDER
• Narcissistic traits are common in adolescence
• is characterized by a pervasive and excessive
Essential Features
need to be taken care of, which leads to
✓ Has a grandiose sense of self-importance submissive and clinging behavior and fears of
separation.
✓ Is preoccupied with fantasies of unlimited
• occurs in as much as 15% of the population and
success, power, brilliance, beauty, or ideal love
is seen three times more often in women than
✓ Believes he or she is unique and special and in men.
should only associate with others who are • It runs in families and is most common in the
special or high-status people youngest child

✓ Requires admiration of others Essential Features

 ✓ Has difficulty making everyday decisions ✓ Teach the client to use alternate coping
methods to decrease anxiety.
✓ Needs others to assume responsibility for major
areas of his or her life ✓ Client’s behavior maybe frustrating to staff and
family. Power struggles often result.*
✓ Has difficulty expressing disagreement
✓ Assess the client’s needs carefully.
✓ Has difficulty initiating projects
✓ Provide an environment that has structure and
✓ Goes to excessive lengths to obtain nurturance
predictability as a strategy to decrease anxiety.
from others
✓ Risk associated with the use of alcohol and drug
✓ Feels uncomfortable or helpless when alone
abuse.
✓ Urgently seeks relationships as a source of care
or support

✓ Is unrealistically preoccupied with fears of being

left to take care of

Nursing Intervention

✓ help clients to express feelings of grief and loss

over the end of a relationship while fostering
autonomy and self-reliance.

✓ Helping clients to identify their strengths and

needs is more helpful than encouraging the
overwhelming belief that “I can’t do anything
alone!”*

✓ teach problem-solving and decision-making and

help clients apply them to daily life*

OBSESSIVE–COMPULSIVE PERSONALITY
DISORDER

• is characterized by a pervasive pattern of

preoccupation with perfectionism, mental and
interpersonal control, and orderliness
• at the expense of flexibility, openness, and
efficiency
• occurs in about 1% to 2% of the population,
affecting twice as many men as women

Essential Features

✓ Is preoccupied with details, lists, rules,

organization, or schedules

✓ Aspires to perfectionism that interferes with

task completion

✓ Is excessively devoted to work and productivity

✓ Is overconscientious, scrupulous, and inflexible

about matters of morality, ethics or values

✓ Is unable to discard worn-out and worthless

objects

✓ Is reluctant to delegate tasks

✓ Adopts a miserly spending style

✓ Is rigid and stubborn

Nursing Intervention

✓ Limit, but do not interrupt, the compulsive acts.