Chapter 16

Personality Disorders
Personality: an ingrained, enduring pattern
of behaving and relating to self, others, and
the environment; behaviors and
characteristics are consistent across a broad
range of situations and do not change easily
Personality disorders: when personality
traits become inflexible and maladaptive and
significantly interfere with how a person
functions in society or cause the person
emotional distress; usually not diagnosed
until adulthood; maladaptive behavior can be
traced to early childhood or adolescence
DSM-IV-TR Categories
• Cluster A: people whose behavior is odd or
eccentric (paranoid, schizoid, schizotypal)
• Cluster B: people who appear dramatic,
emotional, or erratic (antisocial, borderline,
histrionic, narcissistic)
• Cluster C: people who are anxious or fearful
(avoidant, dependent, obsessive-compulsive)
• Disorders being considered for inclusion are
depressive and passive-aggressive
Onset and Clinical Course
• Personality disorders occur in 10% to
13% of the general population
• Incidence is even higher in lower
socioeconomic groups
• 40% to 45% of people with a primary
diagnosis of major mental illness also
have a coexisting personality disorder
that significantly complicates treatment
• Clients with personality disorders have:
– Higher death rates, especially as a result of
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
• Genetics
– Temperament
• Psychosocial factors
– Character
– Self-directedness
– Cooperativeness
– Self-transcendence
Cultural Considerations
• Guarded or defensive behavior may be
displayed as a result of language barriers or
previous negative experiences and should
not be confused with paranoid personality
disorder
• People with religious or spiritual beliefs, such
as clairvoyance, speaking in tongues, or evil
spirits as a cause of disease, could be
misinterpreted as having schizotypal
personality disorder
Cultural Considerations (cont’d)
• An emphasis on deference, passivity, and
politeness should not be confused with a
dependent personality disorder
• Cultures that value work and productivity
may produce citizens with a strong emphasis
in these areas; this should not be confused
with obsessive-compulsive personality
disorder
• Social stereotypes about gender roles and
behaviors can influence diagnosis of certain
personality disorders
Treatment
• Many people with personality disorders do not
seek treatment because they don’t believe
they have a problem
• Individual and group therapy may be helpful
to those desiring change, but any changes
are slow
• Improvement in relationships, improved basic
living skills, relief of anxiety may be goals of
therapy
• Cognitive-behavioral techniques such as
thought-stopping, positive self-talk, and
decatastrophizing can be effective
Pharmacologic treatment is based on the
type and severity of symptoms rather
than the particular personality disorder
itself.
Four symptom categories include:
• Cognitive-perceptual distortions including psychotic
symptoms
• Affective symptoms and mood dysregulation
• Aggression and behavioral dysfunction
• Anxiety
Pharmacologic Treatment for Symptoms
• Cognitive-perceptual disturbances (magical thinking, odd
beliefs, illusions, suspiciousness, ideas of reference, and low-
grade psychotic symptoms)
– Low-dose antipsychotic medications
• Mood dysregulation (emotional instability, emotional
detachment, depression, and dysphoria)
– Lithium, carbamazepine (Tegretol), valproate (Depakote),
low-dose neuroleptics, SSRIs, MAOIs, atypical
antipsychotics
• Aggression (predatory or cruel behavior, impulsivity, poor
social judgment, and emotional lability)
– Lithium, anticonvulsant mood stabilizers, benzodiazepines,
and low-dose neuroleptics
• Anxiety
– SSRIs, MAOIs, or low-dose antipsychotics
Individual and Group Psychotherapy
Focus is on building trust, teaching basic living skills,
providing support, decreasing distressing symptoms, and
improving interpersonal relationships.
• Cognitive-behavioral therapy
• Basic living skills for people with cluster A personality
disorders
• Inpatient hospitalization to provide safety for people with
borderline personality disorder
• Assertiveness training groups for people with cluster C
personality disorders
• Relaxation or meditation techniques for people with
cluster C personality disorders
Cluster A Personality Disorders
• Paranoid personality disorder
• Schizoid personality disorder
• Schizotypal personality disorder
Paranoid Personality Disorder
Clinical Picture
• Mistrust and suspiciousness, aloof and withdrawn,
guarded or hypervigilant, restricted affect, use the
defense mechanism of projection

Nursing Interventions
• Approach in a formal, business-like manner, keep
commitments, be straightforward, involve them in
formulating their care plans, help them learn to
validate ideas before taking action
Schizoid Personality Disorder
Clinical Picture
• Detached from social relationships, restricted affect,
aloof and indifferent, no leisure or pleasurable
activities, do not report feeling distressed about lack
of emotion, intellectual and accomplished with
solitary interests, indifferent to praise or criticism,
dissociate from or no bodily or sensory pleasures

Nursing Interventions
• Improve functioning in the community, make
referrals to social services, provide care that
accommodates the desire for solitude
Schizotypal Personality Disorder
Clinical Picture
• Acute discomfort in relationships, cognitive or
perceptual distortions, eccentric behavior, bizarre
speech, affect flat and sometimes inappropriate

Nursing Interventions
• Promote self-care, social skills, and improved functioning
in the community
Cluster B Personality Disorders
• Antisocial
• Borderline
• Narcissistic
• Histrionic
Antisocial Personality Disorder

Clinical Picture
• Pervasive pattern of disregard for and
violation of rights of others, deceit and
manipulation
Application of the Nursing Process
Assessment
• History: lying, truancy, vandalism, sexual
promiscuity, and substance use in childhood and
adolescence
• General appearance and motor behavior: appears
“normal,” may be charming and engaging, trying to
manipulate
• Mood and affect: shallow emotions, “chooses”
emotions to work to their advantage, no genuine
feelings of empathy, no guilt, only remorseful if
caught
Application of the Nursing Process
(cont’d)
Assessment (cont’d)
• Thought processes and content: views the world as
cold and hostile, thinks everyone else is as ruthless
as he or she is, so trusts no one
• Sensorium and intellectual processes: intact
• Judgment and insight: lacks insight, poor judgment
due to inability to delay gratification, impulsivity, or
ethical/legal considerations of actions
Application of the Nursing Process
(cont’d)
Assessment (cont’d)
• Self-concept: superficially appears self-assured and
confident, even arrogant, but this covers low self-
esteem; poor relationships due to exploitation and
using others
• Roles and relationships: has trouble keeping jobs,
being a parent, staying married, and so forth
Application of the Nursing Process
(cont’d)
Data Analysis
Nursing diagnoses include:
• Ineffective Individual Coping
• Ineffective Role Performance
• Risk for Other-Directed Violence
Application of the Nursing Process
(cont’d)
Outcomes
The client will:
• Demonstrate nondestructive ways to
express feelings and frustration
• Identify ways to meet own needs
without infringing on rights of others
• Achieve satisfactory role performance
Application of the Nursing Process
(cont’d)
Intervention
• Forming therapeutic relationship
– Limit setting
– Confrontation

• Promoting responsible behavior

• Helping client solve problems
and control emotions
• Enhancing role
performance
Application of the Nursing Process
(cont’d)
Evaluation
Can client maintain a job with
acceptable performance?
Can client meet basic family
responsibilities?
Can client avoid committing illegal or
immoral acts?
Borderline Personality Disorder
Clinical Picture
• Pervasive pattern of unstable
interpersonal relationships, self-image,
affect, and
marked
impulsivity
Application of the Nursing Process
Assessment
• History: disturbed early relationships with parents;
punitive responses from parents; family history of
abuse and alcoholism
• General appearance and motor behavior: mildly
dysfunctional clients appear normal; severely
affected clients may be disheveled, unable to sit
still, crying, out of control; very labile emotions
• Mood and affect: dysphoric mood; unhappy,
restless, malaise; intense feeling of loneliness;
boredom; frustration; abandonment by others;
mood is labile and feelings are intense
Application of the Nursing Process
(cont’d)
Assessment (cont’d)
• Thought processes and content: polarized
thinking/splitting; others are “adored” after a brief
acquaintance, then despised if they don’t meet
client’s expectations; obsessive and ruminative
thoughts about abandonment, suicide, and self-
harm; may have dissociative episodes
• Sensorium and intellectual processes: oriented;
intellectual functions intact; may experience
transient psychotic symptoms such as hallucinations
under severe stress; may have flashbacks of abuse
(consistent with PTSD diagnosis)
Application of the Nursing Process
(cont’d)
Assessment (cont’d)
• Judgment and insight: judgment is poor; impulsive and
reckless behaviors such as lying, shoplifting, gambling are
common; limited insight: believes problems are due to
others “failing” them
• Self-concept: unstable and shifts rapidly--needy one
minute, hostile and rejecting the next; frequent self-
injury; lacks consistent view of self
• Roles and relationships: difficulty fulfilling roles, especially
involving mundane tasks (school, work); relationships are
stormy given client’s behavior, but client blames others;
clings to people, then rejects them angrily; desires
relationships/friendships, but behavior drives others away
Application of the Nursing Process
(cont’d)
Assessment (cont’d)
• Roles and relationships: difficulty fulfilling roles,
especially involving mundane tasks (school, work);
relationships are stormy given client’s behavior, but
client blames others; clings to people, then rejects
them angrily; desires relationships/friendships, but
behavior drives others away
• Physiologic and self-care considerations: in addition
to self-mutilation, bingeing and purging are
common; abuse of alcohol or drugs, unprotected
sex, reckless behavior; usually difficulty sleeping
Application of the Nursing Process
(cont’d)
Data Analysis
Nursing diagnoses include:
• Risk for Suicide
• Risk for Self-Mutilation
• Risk for Other-Directed Violence
• Ineffective Coping
• Social Isolation
Application of the Nursing Process
(cont’d)
Outcomes
The client will:
• Be safe and free of significant injury
• Not harm others or destroy property
• Demonstrate increased control of impulsive behavior
• Take appropriate steps to meet his or her own needs
• Demonstrate problem-solving skills
• Verbalize greater satisfaction with relationships
Application of the Nursing Process
(cont’d)
Intervention
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
Application of the Nursing Process
(cont’d)
Intervention (cont’d)
• Promoting the client’s safety
– No-self-harm contract

• Promoting the therapeutic relationship

• Establishing boundaries in relationships
• Teaching effective communication skills
Application of the Nursing Process
(cont’d)
Intervention (cont’d)
• Helping the client to cope and control
emotions
• Reshaping thinking patterns
– Cognitive restructuring
– Thought stopping
– Positive self-talk
– Decatastrophizing

• Structuring daily activities

Application of the Nursing Process
(cont’d)
Evaluation
Is the client able to be safe and refrain
from self-injury?
Can the client maintain employment?
Can the client have fairly stable
interpersonal relationships?
Is the client experiencing fewer crises
less frequently over time?
Histrionic Personality Disorder
Clinical Picture
• Excessive emotionality and attention seeking;
colorful and theatrical speech; overly concerned with
impressing others; emotionally expressive,
gregarious, and effusive; emotions are insincere and
shallow; self-absorbed; uncomfortable when they
are not the center of attention and go to great
lengths to gain that status

Nursing Interventions
• Give feedback about social interactions; teach social
skills through role playing
Narcissistic Personality Disorder
Clinical Picture
• Grandiose; lack of empathy; need for admiration;
arrogant or haughty attitude; disparage, belittle,
or discount the feelings of
others; view their problems as the
fault of others; hypersensitive to
criticism and need constant attention
and admiration

Nursing Interventions
• Use self-awareness skills to avoid anger
and frustration; use matter-of-fact manner; set
limits on rude or verbally abusive behavior
Cluster C Personality Disorders
• Avoidant personality disorder
• Dependent personality disorder
• Obsessive-compulsive personality
disorder
Avoidant Personality Disorder
Clinical Picture
• Social inhibitions; feelings of inadequacy;
hypersensitivity to negative evaluation; avoid
situations or relationships that may result in rejection,
criticism, shame, or disapproval; strongly desire
closeness and intimacy but fear possible rejection and
humiliation

Nursing Interventions
• Explore positive self-aspects and reasons for self-
criticism; practice self-affirmations and positive self-
talk; cognitive restructuring techniques, such as
reframing and decatastrophizing; teach social skills
Dependent Personality Disorder
Clinical Picture
• Submissive and clinging behavior; excessive need to
be taken care of; pessimistic and self-critical; other
people hurt their feelings easily; report feeling
unhappy or depressed; difficulty making decisions;
seek advice and repeated reassurances

Nursing Interventions
• Help identify strengths and needs; use cognitive
restructuring; assist in daily functioning; teach
problem solving and decision making; refrain from
giving advice
Obsessive-Compulsive Personality Disorder
Clinical Picture
• Preoccupation with orderliness, perfectionism, and
control; formal and serious demeanor; constricted
emotions; stubborn; preoccupied with details, rules,
lists, and schedules; believe they are right;
problems with judgment and decision making

Nursing Interventions
• Help accept or tolerate less-than-perfect work; use
cognitive restructuring techniques; encourage to
take risks; practice negotiation
Related Disorders

• Depressive personality disorder

• Passive-aggressive personality disorder
Depressive Personality Disorder
Clinical Picture
• Sad, gloomy, or dejected affect; persistent
unhappiness, cheerlessness, and hopelessness;
inability to experience joy or pleasure in any
activity; cannot relax; do not display a sense of
humor; brood and worry over all aspects of daily
life; thinking is negative and pessimistic

Nursing Interventions
• Assess risk for self-harm; encourage to become
involved in activities; give factual feedback; use
cognitive restructuring techniques; teach effective
social skills
Passive-Aggressive Personality Disorder

Clinical Picture
• Negative attitudes; resent, oppose, and resist
demands expected by others; express resistance
through procrastination, forgetfulness,
stubbornness, and intentional inefficiency

Nursing Interventions
• Help examine the relationship between feelings and
subsequent actions; teach appropriate ways to
express feelings directly
Elder Considerations

• Personality disorders from Clusters A

and C are more prevalent in older age
and are closely correlated with
depression
Community-Based Care
• Caring for clients with personality disorders
occurs primarily in community-based settings
• Acute psychiatric settings such as the hospital
are useful for safety concerns for short periods
• Often the personality disorder is not the focus of
attention; rather, the client may be seeking
treatment for a physical condition
• Most people with personality disorders are
treated in group or individual therapy settings,
community support programs, or self-help
groups
Mental Health Promotion
• Identify behaviors in children and adolescents that
correlate with the development of personality
disorders as adults
– Adolescents exhibiting Cluster A and Cluster B traits are
more likely to commit violent acts in adulthood
– Children at risk for Cluster B personality disorders
demonstrate dramatic emotional responses to other
people while paradoxically showing self-centeredness and
utter disregard for the feelings of others

• Employ prevention strategies

– Activities that are structured, met regularly, involve skill
mastery, and led by one or more adults
Self-Awareness Issues
• Avoiding client attempts to manipulate
• Engaging in clear communication
• 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