copyright © 2014. f.a. davis company personality disorders chapter 32

Copyright © 2014. F.A. Davis Company

PersonalityPersonality DisordersDisordersChapter 32Chapter 32


IntroductionIntroduction

• Personality Defined– The totality of emotional and behavioral

characteristics that are particular to a specific person and that remain somewhat stable and predictable over time


• Personality traits are characteristics with which an individual is born or develops early in life.

• They influence the way in which he or she perceives and relates to the environment and are quite stable over time.

Introduction Introduction (cont.)(cont.)



• Personality disorders occur when these traits become rigid and inflexible and contribute to maladaptive patterns of behavior or impairment in functioning.



• Personality development occurs in response to a number of biological and psychological influences:– Heredity– Temperament– Experiential learning – Social interaction



• People with personality disorders are not often treated in acute care settings in cases in which the personality disorder is their primary psychiatric disorder.


Introduction (Introduction (contcont.).)

• Many clients with other psychiatric and medical diagnoses manifest symptoms of personality disorders.

• Nurses are frequently likely to encounter clients with these personality characteristics in all health-care settings.


Historical AspectsHistorical Aspects

• The first recognition that personality disorders, apart from psychosis, were cause for special concern was in 1801 with the recognition that an individual can behave irrationally even when the powers of intellect are intact.

• Ten specific types of personality disorders are identified in the DSM-5.


Types of Personality Disorders Types of Personality Disorders

Paranoid Personality Disorder

• Definition: A pervasive, persistent, and inappropriate mistrust of others

– Individuals with this disorder are suspicious of others’ motives and assume that others intend to exploit, harm, or deceive them.

– The disorder is more common in men than in women.


Types of Personality Disorders Types of Personality Disorders (cont.)(cont.)

Paranoid Personality Disorder (cont.)• Clinical Picture– Constantly on guard– Hypervigilant– Ready for any real or imagined threat– Trusts no one– Constantly tests the honesty of others



Paranoid Personality Disorder (cont.)• Clinical Picture (cont.)– Insensitive to the feelings of others– Oversensitive– Tends to misinterpret minute cues– Magnifies and distorts cues in the environment– Does not accept responsibility for his/her own

behavior– Attributes shortcomings to others



Paranoid Personality Disorder (cont.)• Predisposing Factors– Possible hereditary link– Subject to early parental antagonism and

harassment



Schizoid Personality Disorder• Definition– Characterized primarily by a profound defect in

the ability to form personal relationships.– Failure to respond to others in a meaningful

emotional way.



Schizoid Personality Disorder (cont.)• Definition– Diagnosis occurs more frequently in men than in

women.– Prevalence within the general population has

been estimated at 3 to 7.5 percent.



Schizoid Personality Disorder (cont.)• Clinical Picture– Aloof and indifferent to others– Emotionally cold– No close friends, prefers to be alone– Appears shy, anxious, or uneasy in the presence of

others– Inappropriately serious about everything and has

difficulty acting in a light-hearted manner



Schizoid Personality Disorder (cont.)• Predisposing Factors– Possible hereditary factor– Childhood has been characterized as: • Bleak • Cold • Unempathic• Notably lacking in nurturing



Schizotypal Personality Disorder• Definition– A graver form of the pathologically less severe

schizoid personality pattern– Affects approximately 1 to 2 percent of the

population.



Schizotypal Personality Disorder (cont.)• Clinical Picture– Clients are aloof and isolated.– Clients behave in a bland and apathetic manner.



Schizotypal Personality Disorder (cont.)• Clinical Picture– Symptoms include:• Magical thinking• Ideas of reference• Illusions • Depersonalization• Superstitiousness• Withdrawal into the self



Schizotypal Personality Disorder (cont.)• Clinical Picture (cont.)– Exhibits bizarre speech pattern.– When under stress, may decompensate and

demonstrate psychotic symptoms.– Demonstrates bland, inappropriate affect.



Schizotypal Personality Disorder (cont.)• Predisposing Factors– Possible hereditary factor– Possible physiological influence such as anatomic

deficits or neurochemical dysfunctions within certain areas of the brain



Schizotypal Personality Disorder (cont.)• Predisposing Factors (cont.)– Early family dynamics characterized by: • Indifference• Impassivity • Formality

– These factors lead to a pattern of discomfort with personal affection and closeness.


Antisocial Personality Disorder• Definition– A pattern of behavior that is:• Socially irresponsible • Exploitative • Without remorse

– Behavior reflects a disregard for the rights of others.




Antisocial Personality Disorder (cont.)• Clinical Picture– Fails to sustain consistent employment.– Fails to conform to the law.– Exploits and manipulates others for personal gain.– Fails to develop stable relationships.



Antisocial Personality Disorder (cont.)• Definition– Prevalence estimates in the United States

range from 2 to 4 percent in men to about 1 percent in women.


Borderline Personality Disorder• Definition– Characterized by a pattern of intense and chaotic

relationships with affective instability– Fluctuating and extreme attitudes regarding other

people– Highly impulsive




Borderline Personality Disorder (cont.)

• Definition (cont.)– Emotionally unstable– Directly and indirectly self-destructive– Lacks a clear sense of identity– Affects about 1 to 2 percent of the population– More common in women than in men



Histrionic Personality Disorder• Definition– Behavior is:• Excitable• Emotional • Colorful • Dramatic • Extroverted



Histrionic Personality Disorder (cont.)• Definition (cont.)– Prevalence is thought to be about 2 to 3 percent. – More common in women than in men



Histrionic Personality Disorder (cont.)• Clinical Picture

• Self-dramatizing• Attention-seeking• Overly gregarious• Seductive• Manipulative• Exhibitionistic



Histrionic Personality Disorder (cont.)• Clinical Picture (cont.)

• Highly distractible • Difficulty paying attention to detail• Easily influenced by others• Difficulty forming close relationships• Strongly dependent• Somatic complaints are common.



Histrionic Personality Disorder (cont.)• Predisposing Factors– Possible link to the noradrenergic and

serotonergic systems– Possible hereditary factor– Biogenetically determined temperament– Learned behavior patterns



Narcissistic Personality Disorder• Definition– Characterized by an exaggerated sense of self-

worth– Lack of empathy– Clients believe they have the inalienable right to

receive special consideration.



Narcissistic Personality Disorder (cont.)• Definition (cont.)– Prevalence of the disorder is estimated at

about 6 percent.– Diagnosed more often in men than in women



Narcissistic Personality Disorder (cont.)• Clinical Picture– Overly self-centered– Exploit others in an effort to fulfill their own

desires.– Mood, which is often grounded in grandiosity, is

usually optimistic, relaxed, cheerful, and carefree.



Narcissistic Personality Disorder (cont.)• Clinical Picture (cont.)– Because of fragile self-esteem, mood can easily

change if they do not: • Meet self-expectations• Receive the positive feedback they expect

– Criticism from others may cause them to respond with rage, shame, and humiliation.



Narcissistic Personality Disorder (cont.)• Predisposing Factors– As children, their fears, failures, or dependency

needs were responded to with criticism, disdain, or neglect

– Parents were often narcissistic themselves– Parents may have overindulged their child and

failed to set limits on inappropriate behavior



Avoidant Personality Disorder• Definition– Characterized by: • Extreme sensitivity to rejection• Social withdrawal

– Prevalence is about 1 percent and is equally common in men and women.



Avoidant Personality Disorder (cont.)• Clinical Picture– Awkward and uncomfortable in social situations– Desire close relationships but avoid them because

of their fear of being rejected.– Perceived as timid, withdrawn, or cold and

strange– They are often lonely and feel unwanted.– They view others as critical and betraying.



Avoidant Personality Disorder (cont.)• Predisposing Factors– No clear cause is known.– May be a combination of biological, genetic, and

psychosocial influences– Primary psychosocial influences are parental

rejection and censure, which are often reinforced by peers.



1. When assessing a client diagnosed with narcissistic personality disorder, the nurse expects to identify which characteristic behavior?

A. Odd beliefs and magical thinkingB. Grandiose sense of self importanceC. Pattern of intense and chaotic relationshipsD. Submissive and clinging behaviors



• Correct answer: B– Clients diagnosed with narcissistic personality

disorder have an exaggerated sense of self-worth. They are often grandiose and believe they have an inalienable right to receive special consideration.



Dependent Personality Disorder• Definition– Characterized by a pattern of relying on others for

emotional support– Relatively common within the population– More common among women than men – More common in the youngest children of a

family than in the older ones



Dependent Personality Disorder (cont.)• Clinical Picture– They have a notable lack of self-confidence that is

often apparent in their: • Posture• Voice• Mannerisms



Dependent Personality Disorder (cont.)• Clinical Picture (cont.)– Typically passive and acquiescent to desires of

others– Overly generous and thoughtful while

underplaying their own attractiveness and achievements



Dependent Personality Disorder (cont.)• Clinical Picture (cont.)– Low self-worth and easily hurt by criticism and

disapproval– Avoid positions of responsibility and become

anxious when forced into them– Assume passive and submissive roles in

relationships



Dependent Personality Disorder (cont.)• Predisposing Factors– Possible hereditary influence

– Stimulation and nurturance are experienced exclusively from one source.

– A singular attachment is made by the infant to the exclusion of all others.


Obsessive/Compulsive Personality Disorder•Definition– Characterized by inflexibility about the way in

which things must be done – Devotion to productivity to the exclusion of

personal pleasure




Obsessive-Compulsive Personality Disorder (cont.)•Definition (cont.)– Relatively common

– Occurs more often in men than in women.

– Within the family constellation, it appears to be most common in oldest children.



Obsessive-Compulsive Personality Disorder (cont.)•Clinical Picture– Especially concerned with matters of organization

and efficiency – Tend to be rigid and unbending– Socially polite and formal– Rank-conscious: • Ingratiating with authority figures• Autocratic and condemnatory with subordinates



Obsessive-Compulsive Personality Disorder (cont.)•Clinical Picture (cont.)– On the surface, they appear to be very calm and

controlled.– Underneath there is a great deal of:• Ambivalence • Conflict • Hostility



Obsessive-Compulsive Personality Disorder (cont.)•Predisposing Factors– Overcontrol by parents – Notable parental lack of positive reinforcement for

acceptable behavior– Frequent punishment for undesirable behavior



2. A client diagnosed with a personality disorder is cold, aloof, and avoids others on the unit. The nurse recognizes that this behavior is symptomatic of which personality disorder?

A. Schizoid personality disorderB. Dependent personality disorderC. Borderline personality disorderD. Antisocial personality disorder



• Correct answer: A– A hallmark of the schizoid personality is a marked

withdrawal from social contact. The client behaviors presented in the question are indicative of schizoid personality disorder.


Application of the Nursing ProcessApplication of the Nursing Process

Assessment• Borderline Personality Disorder– Designated as “borderline” because of the

tendency of these clients to fall on the border between neuroses and psychoses.


Assessment (Assessment (contcont.).)

• Borderline Personality Disorder (cont.)– Instability of interpersonal relationships– Unstable self-image– Marked impulsivity– Intensity of affect and behavior


• Borderline Personality Disorder (cont.)– Common behaviors• Chronic depression• Inability to be alone• Clinging and distancing behaviors• Splitting • Manipulation• Self-destructive behaviors• Impulsivity



• Borderline Personality Disorder (cont.)– Predisposing factors• Biological influences– Biochemical: Possible serotonergic defect– Genetic: Possible familial connection with

depression

Application of the Nursing ProcessApplication of the Nursing Process


• Borderline Personality Disorder (cont.)– Predisposing factors (cont.)• Psychosocial influences– Childhood trauma and abuse– Developmental factors• Fixed in the rapprochement phase of

development (16 to 24 months old). The child fails to achieve task of autonomy.

Application of the Nursing Process Application of the Nursing Process (cont.)(cont.)


3. A client diagnosed with borderline personality disorder is admitted to a psychiatric unit. Which behavior pattern would the nurse expect to observe?

A. Social isolationB. Suspiciousness of othersC. Bizarre speech patternsD. Generates conflict among the staff



• Correct answer: D– Clients diagnosed with borderline personality

disorder, having little empathy toward others, are unable to accept both positive and negative feelings, and view others as all good or all bad. They tend to split staff, generating conflict.



4. In assessing a client diagnosed with borderline personality disorder, which characteristic would the nurse expect to observe?

A. PredictabilityB. Controlled angerC. Little tolerance for being aloneD. Stable and satisfactory relationships



• Correct answer: C– Clients diagnosed with borderline personality

disorder have little tolerance for being alone. They prefer a frantic search for companionship no matter how unsatisfactory rather than experience feelings of loneliness, emptiness, and boredom.



Nursing Diagnosis: Borderline Nursing Diagnosis: Borderline Personality DisorderPersonality Disorder

• Risk for self-mutilation related to parental emotional deprivation

• Risk for suicide related to unresolved grief• Risk for other-directed violence related to

underlying rage• Complicated grieving related to maternal

deprivation during rapprochement phase of development internalized as a loss with fixation in anger stage of grieving process


• Impaired social interaction related to extreme fears of abandonment and engulfment

• Disturbed personal identity related to underdeveloped ego

• Anxiety (severe to panic) related to unconscious conflicts based on fear of abandonment

• Chronic low self-esteem related to lack of positive feedback

Nursing Diagnosis: Borderline Nursing Diagnosis: Borderline Personality Disorder Personality Disorder (cont.)(cont.)


Outcomes: Borderline Personality Outcomes: Borderline Personality Disorder Disorder

• The Client:

– Has not harmed self– Seeks out staff when desire for self-mutilation is

strong– Is able to identify true source of anger– Expresses anger appropriately


• The Client:

– Relates to more than one staff member– Completes activities of daily living independently– Does not manipulate one staff member against

the other to fulfill own desires

Outcomes: Borderline Personality Outcomes: Borderline Personality Disorder Disorder (cont.)(cont.)


Planning/ImplementationPlanning/Implementation

• Nursing intervention for the client with Borderline Personality Disorder is aimed at protection of the client from self-harm.

• The nurse also seeks to assist the client to advance in the development of personality by confronting his or her true source of internalized anger.


EvaluationEvaluation

• Evaluation of care for the client with borderline personality disorder is based on accomplishment of previously established outcome criteria.


Nursing Process: AssessmentNursing Process: Assessment

• Antisocial Personality Disorder– Not often seen in most clinical settings.– Most frequently encountered in prisons, jails, and

rehabilitation services.– When clients are seen, it is commonly a way to

avoid legal consequences.– Sometimes they are admitted to the health-care

system by court order for psychological evaluation.



• Antisocial Personality Disorder (cont.)– Common behaviors• Exploitation and manipulation of others for personal

gain• Belligerent and argumentative• Lacks remorse.• Unable to delay gratification• Low frustration tolerance• Inconsistent work or academic performance



• Antisocial Personality Disorder (cont.)

– Common behaviors (cont.)• Failure to conform to societal norms• Impulsive and reckless• Inability to function as a responsible parent• Inability to form lasting monogamous relationship


Predisposing Factors to Antisocial Predisposing Factors to Antisocial Personality DisorderPersonality Disorder

– Possible genetic influence– Having a disruptive behavior disorder as a child

(ADHD, conduct disorder)– History of severe physical abuse– Absent or inconsistent parental discipline– Extreme poverty– Removal from the home– Growing up without parental figures of both genders– Always being rescued when in trouble– Maternal deprivation


Antisocial Personality Antisocial Personality (cont.)(cont.)

5. An individual, with a history of antisocial personality disorder, was arrested for driving under the influence of alcohol and causing a serious car accident. Which comment on this behavior would be expected?

A. “It's not my fault.”B. “I'm too ashamed to talk about it.”C. “I just don't remember doing it.”D. “I'm really sorry about all the people I've

hurt.”


Antisocial Personality Antisocial Personality (cont.)(cont.)

• Correct answer: A– Individuals diagnosed with antisocial personality

disorder lack remorse about their actions and view themselves as victims. This individual would most likely refuse to acknowledge responsibility for the accident.


Nursing Diagnosis: Antisocial Nursing Diagnosis: Antisocial Personality DisorderPersonality Disorder

• Risk for other-directed violence related to rage reactions, negative role-modeling, inability to tolerate frustration

• Defensive coping related to dysfunctional family system

• Chronic low self-esteem related to repeated negative feedback resulting in diminished self-worth


• Impaired social interaction related to negative role modeling and low self-esteem

• Ineffective health maintenance evidenced by demonstration of inability to take responsibility for meeting basic health practices

Nursing Diagnosis: Antisocial Nursing Diagnosis: Antisocial Personality DisorderPersonality Disorder


Outcomes: Antisocial Personality Outcomes: Antisocial Personality DisorderDisorder

• The Client:– Discusses angry feelings with staff and in group

sessions– Has not harmed self or others– Can rechannel hostility into socially acceptable

behaviors– Follows rules and regulations of the therapy

environment


• The Client:

– Can verbalize which of his or her behaviors are not acceptable

– Shows regard for the rights of others by delaying gratification of own desires when appropriate

Outcomes: Antisocial Personality Outcomes: Antisocial Personality Disorder Disorder (cont.)(cont.)


• The Client:

– Does not manipulate others in an attempt to increase feeling of self-worth.

– Verbalizes understanding of knowledge required to maintain basic health needs.

Outcomes: Antisocial Personality Outcomes: Antisocial Personality Disorder Disorder (cont.)(cont.)


Planning/InterventionPlanning/Intervention

• Nursing care of the client with antisocial personality disorder is aimed at:– Ensuring the safety of client and others– Helping client recognize and decrease

unacceptable behaviors– Assisting client to gain insight into own behaviors– Helping client to learn to delay gratification


EvaluationEvaluation

• Evaluation of care for the client with antisocial personality disorder is based on accomplishment of previously established outcome criteria.


Treatment Modalities for Personality Treatment Modalities for Personality DisordersDisorders

• Interpersonal Psychotherapy• Psychoanalytical Psychotherapy• Milieu or Group Therapy• Cognitive/Behavioral Therapy• Dialectical Behavior Therapy• Psychopharmacology

copyright © 2014. f.a. davis company personality disorders chapter 32

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