Unit 11: Personality Disorders
Personality: ingrained enduring pattern of behaving and relating to self, others, and environment
• Includes perceptions, attitudes, and emotions
• Usually not consciously aware of own personality
Personality disorders: generalized pattern of behaviors, thoughts, and emotions beginning in adolescence and remains
stable over time
• Causes stress or psychological damage
• Although a personality disorder is a psych diagnosis, it’s not an illness w/ treatable symptoms
o Personality traits are ingrained ways of being and thinking
o Some changes may occur slowly over time w/ no significant improvement or quick resolution of
problematic behavior
• Characterized by:
o Impaired personality functioning –
§ Areas of identity, self-direction, empathy, intimacy
o Pathological personality factors –
§ Negative affectivity, detachment, antagonism
§ Disinhibition, psychoticism
o Maladaptive/dysfunctional personality traits –
§ Negative behaviors toward others
§ Anger or hostility
§ Irritable, labile moods
§ Lack of guilt or remorse, emotionally cold, uncaring
§ Impulsivity, poor judgement – intelligence isn’t affected
§ Irresponsible – not accountable for own actions
§ Risk-taking, thrill-seeking behaviors
§ Mistrust, exhibitionism, entitlement
§ Dependency, insecurity, eccentric perceptions
o Identity problems occur
o Relationships are dysfunctional
• Onset and clinical course –
o Relatively common – 10-20% of general population
§ Incidence is higher in lower SE groups
o 40-45% of people w/ primary diagnosis of major mental illness have co-existing personality disorder
§ Significantly complicates treatment
§ Often described as being ‘treatment resistant’
o Lack of perception by person that behavior is a problem
§ Sometimes the behavior is a point of pride
• Etiology – personality develops through the interaction of hereditary dispositions and environmental influences
o Biologic theories –
§ Temperament –
• Low reward dependence – affective dysregulation, detachment, cognitive disturbances
• High novelty seeking – symptoms of impulsiveness and aggression
• High harm avoidance – anxiety and depression symptoms
§ Each of these influence a person’s automatic response to certain situations
§ Genetic differences account for about 50% of the variance in temperament traits
o Psychodynamic theories –
§ Character – concepts about self and external world; develops over time
• Self-directedness – responsible, reliable, resourceful, goal-oriented
• Cooperativeness – sees oneself as an integral part of society
o Empathetic, tolerant
o Compassionate, supportive
• Self-transcendence – integral part of the universe
, o Spiritual, unpretentious, humble
o Difficulty accepting suffering/loss of control
• Cultural considerations – judgments of personality must be viewed w/ consideration of ethnic, cultural, and social
background
o Guarded or defensive behavior – may be due to language barriers
o Religious or spiritual beliefs
o Different views of avoidant and dependent behavior
o Cultural value of work and productivity
o Gender roles and behaviors
• Elder considerations – disorders persist into older age
o Some may stabilize, while others ‘age badly’
§ Chronically become angry, unhappy, or dissatisfied
o Higher risk for – depression, suicide, dementia
• Treatment –
o Psychopharmacology – symptom focused related to underlying temperaments associated w/ disorders
§ Cognitive-perceptual distortions –
• Includes –
o Magical thinking, odd beliefs, illusions, suspiciousness
o Ideas of reference, low-grade psychotic symptoms
• Respond to low-dose antipsychotic meds
§ Affective symptoms and mood dysregulation
§ Aggression and behavioral dysfunction
§ Anxiety
§ Antidepressants – regulate mood, arousal, attention, sensory processing, and appetite
• SSRIs – 1st line treatment
• Tricyclic and related cyclic antidepressants
• MAOIs
• desvenlafaxine (Pristiq), venlafaxine (Effexor), bupropion (Wellbutrin)
• duloxetine (Cymbalta), trazodone (Desyrel), nefazodone (Serzone)
o Individual/group psychotherapy – focus on building trust
§ Cognitive behavioral therapy – cognitive restructuring techniques
• Thought stopping – pt stops negative thought patterns
• Positive self-talk – change negative self-messages
• Decatastrophizing – teaches pt to view life events more realistically and not as
catastrophes
• Organized according to clusters around predominant type of behavioral pattern
o Cluster A – odd or eccentric
§ Paranoid personality disorder: pervasive mistrust/suspiciousness, use of projection, conflict w/
authority figures
• Nursing interventions – formal, business-like approach
o Pt involvement in POC
o Validate idea before action
§ Schizoid personality disorder: pervasive pattern of social detachment
• Constricted affect – little emotion
• Usually have rich and extensive fantasy life, but reluctant to reveal
• Nursing interventions – focus on improved functioning in community
o Greater chance of success if pt can relate their needs to one person
§ Schizotypal personality disorder: pervasive pattern of social and interpersonal deficits
• Cognitive or perceptual distortions
• Behavioral eccentricities
• Odd appearance, restricted range of emotions
• Nursing interventions – focus on self-care and social skills
, o Encouragement of daily routines
o Identifying appropriate outlets for discussing unusual beliefs
o Cluster B – erratic or dramatic
§ Antisocial personality disorder: characterized by disregard for rights of others, deceit, and
manipulation
• History – acts of cruelty, abusive parenting
• General appearance/motor behavior – usually normal
• Mood/affect – display of false emotions
• Thought process/content – narrowed view of world
• Sensorium/intellectual processes – oriented, average or above average IQ
• Judgment/insight – no consideration of morals or ethics
• Self-concept – appears confident, but self is shallow and empty
• Roles/relationships – manipulate and exploit those around them
• Nursing interventions –
o Therapeutic relationship – promote responsible behavior via limit
setting/confrontation
o Problem-solving, control of emotions – taking a time-out
o Enhancing role performance
§ Borderline personality disorder: pervasive pattern of unstable interpersonal relationships, self-
image, and affect w/ marked impulsivity
• Occurs in early adulthood and requires 5 or more present:
1. Frantic efforts to avoid real or imagined abandonment
2. Pattern of unstable/intense interpersonal relationships characterized by
alternating idealization + devaluation
3. Identity disturbance (unstable self-image or sense of self that is
marked/persistent)
4. Impulsivity in at least 2 areas – spending, sex, substance use, reckless driving,
binge eating
5. Recurrent suicidal behavior, self-mutilating
6. Affective instability related to reactivity mood – episodic euphoria, irritability,
anxiety
7. Chronic feelings of emptiness
8. Inappropriate intense anger or difficulty controlling it
9. Transient, stress-related paranoid ideation or severe dissociative symptoms
• History – disturbed early relationships w/ parents
• General appearance/motor behavior – wide range of dysfunction
• Mood/affect – dysphoric
• Thought process/content – polarized, extreme thinking about self and others, dissociative
episodes
• Sensorium/intellectual processes – fully oriented to reality
o Exception is transient psychotic symptoms
• Judgment/insight – impaired judgment, lack of concern for safety
• Self-concept – unstable view of self, self-harm
• Roles/relationships – hate being alone but experience social isolation
• Physiological/self-care – reckless behavior
• Nursing interventions – promote safety via no-self-harm contract
o Therapeutic relationship – structured w/ limit setting
o Strict adherence to boundaries
o Communication skills
o Coping, emotion control
o Reshaping thinking patterns
o Structuring of daily activities
Personality: ingrained enduring pattern of behaving and relating to self, others, and environment
• Includes perceptions, attitudes, and emotions
• Usually not consciously aware of own personality
Personality disorders: generalized pattern of behaviors, thoughts, and emotions beginning in adolescence and remains
stable over time
• Causes stress or psychological damage
• Although a personality disorder is a psych diagnosis, it’s not an illness w/ treatable symptoms
o Personality traits are ingrained ways of being and thinking
o Some changes may occur slowly over time w/ no significant improvement or quick resolution of
problematic behavior
• Characterized by:
o Impaired personality functioning –
§ Areas of identity, self-direction, empathy, intimacy
o Pathological personality factors –
§ Negative affectivity, detachment, antagonism
§ Disinhibition, psychoticism
o Maladaptive/dysfunctional personality traits –
§ Negative behaviors toward others
§ Anger or hostility
§ Irritable, labile moods
§ Lack of guilt or remorse, emotionally cold, uncaring
§ Impulsivity, poor judgement – intelligence isn’t affected
§ Irresponsible – not accountable for own actions
§ Risk-taking, thrill-seeking behaviors
§ Mistrust, exhibitionism, entitlement
§ Dependency, insecurity, eccentric perceptions
o Identity problems occur
o Relationships are dysfunctional
• Onset and clinical course –
o Relatively common – 10-20% of general population
§ Incidence is higher in lower SE groups
o 40-45% of people w/ primary diagnosis of major mental illness have co-existing personality disorder
§ Significantly complicates treatment
§ Often described as being ‘treatment resistant’
o Lack of perception by person that behavior is a problem
§ Sometimes the behavior is a point of pride
• Etiology – personality develops through the interaction of hereditary dispositions and environmental influences
o Biologic theories –
§ Temperament –
• Low reward dependence – affective dysregulation, detachment, cognitive disturbances
• High novelty seeking – symptoms of impulsiveness and aggression
• High harm avoidance – anxiety and depression symptoms
§ Each of these influence a person’s automatic response to certain situations
§ Genetic differences account for about 50% of the variance in temperament traits
o Psychodynamic theories –
§ Character – concepts about self and external world; develops over time
• Self-directedness – responsible, reliable, resourceful, goal-oriented
• Cooperativeness – sees oneself as an integral part of society
o Empathetic, tolerant
o Compassionate, supportive
• Self-transcendence – integral part of the universe
, o Spiritual, unpretentious, humble
o Difficulty accepting suffering/loss of control
• Cultural considerations – judgments of personality must be viewed w/ consideration of ethnic, cultural, and social
background
o Guarded or defensive behavior – may be due to language barriers
o Religious or spiritual beliefs
o Different views of avoidant and dependent behavior
o Cultural value of work and productivity
o Gender roles and behaviors
• Elder considerations – disorders persist into older age
o Some may stabilize, while others ‘age badly’
§ Chronically become angry, unhappy, or dissatisfied
o Higher risk for – depression, suicide, dementia
• Treatment –
o Psychopharmacology – symptom focused related to underlying temperaments associated w/ disorders
§ Cognitive-perceptual distortions –
• Includes –
o Magical thinking, odd beliefs, illusions, suspiciousness
o Ideas of reference, low-grade psychotic symptoms
• Respond to low-dose antipsychotic meds
§ Affective symptoms and mood dysregulation
§ Aggression and behavioral dysfunction
§ Anxiety
§ Antidepressants – regulate mood, arousal, attention, sensory processing, and appetite
• SSRIs – 1st line treatment
• Tricyclic and related cyclic antidepressants
• MAOIs
• desvenlafaxine (Pristiq), venlafaxine (Effexor), bupropion (Wellbutrin)
• duloxetine (Cymbalta), trazodone (Desyrel), nefazodone (Serzone)
o Individual/group psychotherapy – focus on building trust
§ Cognitive behavioral therapy – cognitive restructuring techniques
• Thought stopping – pt stops negative thought patterns
• Positive self-talk – change negative self-messages
• Decatastrophizing – teaches pt to view life events more realistically and not as
catastrophes
• Organized according to clusters around predominant type of behavioral pattern
o Cluster A – odd or eccentric
§ Paranoid personality disorder: pervasive mistrust/suspiciousness, use of projection, conflict w/
authority figures
• Nursing interventions – formal, business-like approach
o Pt involvement in POC
o Validate idea before action
§ Schizoid personality disorder: pervasive pattern of social detachment
• Constricted affect – little emotion
• Usually have rich and extensive fantasy life, but reluctant to reveal
• Nursing interventions – focus on improved functioning in community
o Greater chance of success if pt can relate their needs to one person
§ Schizotypal personality disorder: pervasive pattern of social and interpersonal deficits
• Cognitive or perceptual distortions
• Behavioral eccentricities
• Odd appearance, restricted range of emotions
• Nursing interventions – focus on self-care and social skills
, o Encouragement of daily routines
o Identifying appropriate outlets for discussing unusual beliefs
o Cluster B – erratic or dramatic
§ Antisocial personality disorder: characterized by disregard for rights of others, deceit, and
manipulation
• History – acts of cruelty, abusive parenting
• General appearance/motor behavior – usually normal
• Mood/affect – display of false emotions
• Thought process/content – narrowed view of world
• Sensorium/intellectual processes – oriented, average or above average IQ
• Judgment/insight – no consideration of morals or ethics
• Self-concept – appears confident, but self is shallow and empty
• Roles/relationships – manipulate and exploit those around them
• Nursing interventions –
o Therapeutic relationship – promote responsible behavior via limit
setting/confrontation
o Problem-solving, control of emotions – taking a time-out
o Enhancing role performance
§ Borderline personality disorder: pervasive pattern of unstable interpersonal relationships, self-
image, and affect w/ marked impulsivity
• Occurs in early adulthood and requires 5 or more present:
1. Frantic efforts to avoid real or imagined abandonment
2. Pattern of unstable/intense interpersonal relationships characterized by
alternating idealization + devaluation
3. Identity disturbance (unstable self-image or sense of self that is
marked/persistent)
4. Impulsivity in at least 2 areas – spending, sex, substance use, reckless driving,
binge eating
5. Recurrent suicidal behavior, self-mutilating
6. Affective instability related to reactivity mood – episodic euphoria, irritability,
anxiety
7. Chronic feelings of emptiness
8. Inappropriate intense anger or difficulty controlling it
9. Transient, stress-related paranoid ideation or severe dissociative symptoms
• History – disturbed early relationships w/ parents
• General appearance/motor behavior – wide range of dysfunction
• Mood/affect – dysphoric
• Thought process/content – polarized, extreme thinking about self and others, dissociative
episodes
• Sensorium/intellectual processes – fully oriented to reality
o Exception is transient psychotic symptoms
• Judgment/insight – impaired judgment, lack of concern for safety
• Self-concept – unstable view of self, self-harm
• Roles/relationships – hate being alone but experience social isolation
• Physiological/self-care – reckless behavior
• Nursing interventions – promote safety via no-self-harm contract
o Therapeutic relationship – structured w/ limit setting
o Strict adherence to boundaries
o Communication skills
o Coping, emotion control
o Reshaping thinking patterns
o Structuring of daily activities
