PMH Nursing_Personality Disorders.ppt

2
Objectives
 1. Identify behaviors associated with personality disorders.
 2. Distinguish between the symptoms of different Personality
Disorders.
 3. Formulate nursing diagnoses related to personality disorders.
 4. Identify expected outcomes and short term nursing goals
related to personality disorders.
 5. Analyze nursing interventions related to personality disorders.
 6. Evaluate nursing care related to personality disorders.

3
Personality
 “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 biologic
dispositions, psychological experiences, and
environmental situations.” Boyd

4
Personality
 Is a set of deeply ingrained, enduring
patterns of thinking, feeling, and
behaving. Stuart, p. 385

5
Personality Traits- The Big 5

6
Continuum of Social Responses
 Levels of relationships range from
intimacy to casual contact. Analysis of
relationships is based on the degree of
involvement, comfort, & well-being.
– Connectedness; disconnectedness;
parallelism; & enmeshment.
– Connectedness: active relationship
characterized by belonging, mutuality,
reciprocity & interdependence

7
Degrees of Involvement in
relationships
– Connectedness: active relationship characterized
by belonging, mutuality, reciprocity &
interdependence
– Disconnectedness: lack of involvement that is not
satisfying to the person.
– Parallelism: lack of involvement that is comfortable
& acceptable to the person.
– Enmeshment: person is involved in the
relationship but is unable to maintain ego
boundaries & a unique sense of self.

8
Personality development through the life
cycle
 Stages of Development when personality
development occurs.
– Symbiotic 3-18 months
– Individuation 18 months to 3 years
– Childhood 6 to 10 years
– Preadolescence
– Adolescence
– Young adulthood
– Middle adulthood
– Late adulthood

9
Personality development through the life
cycle
 Infancy= symbiotic stage: trust develops in
unconditionally loving relationship with
caregiver.
 Preschool years= individuation: child
develops internal psychological structure &
growing sense of separateness.
 Childhood = develops morality & empathic
feelings for others. Growing sense of positive
self concept.
 Preadolescence= intimate relationship with
friend of same gender.

Personality development through
the life cycle
 Adolescence= develops dependent relationship with
person of opposite gender and begins asserting
independence from parents. Ends when person is
self-sufficient.
 Young Adulthood= independent decision making,
marriage, new family, occupational plans & career.
 Middle Adulthood= parenting, adult friendships,
fostering independence in others, self-reliance,
freedom to pursue new activities.
 Late adulthood= looses, aging, death of parents, loss
of occupation, retirement, death of spouse & friends.
New relationships can develop, grandchildren, strives
to retain as much independence as possible.
10

11
Factors in the development of
personality
 Most social scientists assume that personality
and social behavior result from a blending of
heredity and social environmental influences.
 They believe that environmental factors have the
greatest influence.
 Heredity, birth order, parents,and cultural
environment are among the principal factors
that social scientists see influencing personality
and behavior

12
Family Influences
 Parents influence their children’s personalities. The age of the
parent can have an influence on children’s development.
 Other parental characteristics like level of education, religious
orientation, economic status, occupation, and cultural heritage can
influence a child’s personality and their social behavior.
 Attachment theory: “The fundamental assumption in attachment
research on human infants is that sensitive responding by the
parent to the infant's needs results in an infant who demonstrates
secure attachment, while lack of such sensitive responding results
in insecure attachment” (Lamb, Thompson, Gardner, Charnov, &
Estes, 1984).
 Insecure attachment in infancy/childhood may lead to difficulty with
trust and problems with emotional regulation. Securing and
maintaining healthy relationships during the life span may be
enormously challenging.

13
Cultural influences
 Culture has a strong influence on personality
development. The cultural environment determines
the basic types of personalities that will be found in a
society.
 Each culture gives rise to a series of personality traits
– model personalities – that are typical of members of
that society.

14
Personality Disorders
“An enduring pattern of inner
experience and behavior that deviates
markedly from the expectations of the
individual’s culture, it is pervasive and
inflexible, it has an onset in
adolescence or early adulthood, & it is
stable over time and leads to distress
or impairment in functioning”.
DSM V (2013)

DSM 5 Personality Disorders
 The number of personality types was reduced in the DSM 5 and now
includes a four part assessment of personality which includes:
1. Severity scale. Rated from zero (no impairment) to four (extreme
impairment)
2. Type match. To what degree does a patient’s personality match one of
the five remaining personality types, from one (no match) to five (a
good match)
3. Trait domains and facets. Each personality type may have up to six
“trait domains”—negative emotionality, introversion, antagonism,
disinhibition, compulsivity, and schizotypal. Each trait domain is further
broken down to more specific “trait facets.” You then rate each trait on
a scale from zero (very little or not at all descriptive) to three (extremely
descriptive)
4. Personality disorder. Finally, you determine: “Does the person meet
criteria for a specific personality disorder?”
15

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Key features in personality disorders
 1) the person has an inflexible & maladaptive
approach to relationships and the
environment.
 2) the person’s needs, perceptions, &
behavior tend to foster cycles that promote
unhelpful patterns & provoke negative
reactions from others.
 3) the person’s coping skills are unstable &
fragile, & there is a lack of resilience when
faced with stressful situations. Stuart, p. 385

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Personality Disorders are:
 Manifested in two or more of the following areas:
1. Cognition (perceptions and interpretations of
others, events and self…their thinking about an event
or person is distorted by a pattern of engrained false
perception)
2. Affectively (characterized by emotional intensity
which is usually charged, range which can be wide,
appropriateness which can be odd & strange and
mood fluctuations with or without cause)
3. Interpersonal functioning (varies from enmeshment
to disconnectedness)
4. Impulse control (is poor, resulting in the person
with a personality disorder being a risk for injury to
self or other)

18
Diagnosis and Identification
 Often takes several admissions or sessions to
identify the patterns of behavior. Some argue that
theory and diagnosis of personality disorders are
based strictly on social, or even sociopolitical, cultural
and economic considerations.

19
More Features of Personality
Disorders
 Impairment of social, emotional and
occupational functioning.
 Individual exhibits a lack of insight into their
own behavior.
 Exhibit a variety of fixed defense mechanisms
in their daily behavior. Often using denial,
projection, splitting, & blaming others.
 Prognosis depends on level of insight,
motivation to change and quality/consistency
of therapy

20
Behaviors Related to Maladaptive
Social Responses
 Manipulation: Others are treated as objects;
relationships are centered around control issues; &
the person is self oriented or goal oriented, not other
oriented.
 Narcissism: Present is a fragile self-esteem;
Constant seeking of praise & admiration; egocentric
attitude & envy; Rage is provoked when others are
not supportive.
 Impulsivity: Inability to plan; Inability to learn from
experience; Poor judgment; & Unreliability. Boyd

21
Coping Mechanisms to control
anxiety related to loneliness.
 Projection- places responsibility for one’s behavior
outside of oneself.
 Splitting- is the inability to integrate the good & bad
aspects of oneself & objects outside the self that one
is attached to. Different staff see patient in different
ways as a result.
 Projective Identification- complex defense
mechanism that is often unconscious. The person
projected on may begin to behave like the projected
parts. It is a very powerful defense mechanism.
 And staff may begin to act out the projected parts
because of transference & counter-transference.
Particularly seen in young inexperienced staff.

22
Three Clusters of Personality Disorders
(grouped by behavioral traits)
 Cluster A
– Odd, eccentric behaviors
– Paranoid, Schizoid & Schizotypal
 Cluster B
– Dramatic, erratic, emotional behaviors
– Antisocial, Borderline, Histrionic, Narcissistic Disorders
 Cluster C
– Anxious, fearful, controlling behaviors
– Avoidant, Dependent, Obsessive-Compulsive Disorders

Other Personality Disorders
1. Personality change due to a medical condition-
Disturbance due to the direct physiological effects of a
medical condition (e.g., frontal lobe lesion).
2. Other Specified or unspecified personality
disorders- Personality pattern meets criteria for
personality disorder and/but traits from several
personality disorders are present, but the traits do not
meet the criteria for a specific personality disorder. Or
individual is considered to have a personality disorder
that is not included in the DSM 5 (e.g. passive-
aggressive personality disorder or depressive
personality disorder, which had separate classification
in DSM IV)
23

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Cluster A - Paranoid, Schizoid,
Schizotypal Disorders
 Gender: more common in males
 Be aware of cultural interpretations of behavior
 Onset – Often presents in childhood and
adolescence characterized by solitariness, poor peer
relationships, underachievement in school and
subject of teasing. Individual is seen as odd or
eccentric.
 Etiology - Neurophysiology, genetics
 Familial pattern: increased prevalence of
schizophrenia and delusional disorders in family
system.

Schizotypal Personality Disorder
 A pervasive pattern of social
and interpersonal deficits
marked by acute discomfort
with, and reduced capacity
for, close relationships as well
as by cognitive or perceptual
distortions and eccentricities
of behavior beginning in early
adulthood and present in a
variety on contexts (see next
slide)
25

26
Schizotypal Disorder patients:
 “ ideas of reference”- believes others are
talking about them, even the TV and songs
on the radio are about them, and often feels
others stare at them.
 Believe they receive special messages, have
experiences with the supernatural and can
make things happen by wishing (magical
thinking).
 Their behavior or appearance is odd,
eccentric or peculiar.
 Affect is constricted or inappropriate.
 No close friends or confidants.
 Excessive social anxiety.

27
Schizotypal Personality Disorder
 Odd and peculiar speech and
appearance
 Inappropriate affect - i.e., silly during
serious moments
 Strange, unsupported beliefs -
clairvoyance, UFO’s, etc.
 Sometimes appears to be a milder form
of schizophrenia

Paranoid Personality Disorder
 A pervasive distrust and
suspiciousness of
others such that their
motives are interpreted
as malevolent,
beginning in early
adulthood and present
in a variety of contexts
(see next slide).
28

29
Paranoid Personality Disorder
 Suspicious, without basis, that others are
exploiting, harming or deceiving them,
mistrustful of others
 Tend to hold grudges and takes a long time
to forgive people that may have insulted
them.
 Unable to form intimate relationships, and
when they do, often suspect partner has
been unfaithful
 Usually either aloof and removed or angry
and aggressive, especially when feels
criticized.

Schizoid Personality Disorder
 A pervasive pattern of
detachment from social
relationships and restricted
range of expression of
emotions in interpersonal
settings, beginning by early
adulthood and present in a
variety of contexts (see
next slide).
30

31
Schizoid Personality Disorder
 Neither desires or enjoys close relationships,
including being part of a family.
 Almost always chooses solitary activities.
 Has little interest in having sexual
experiences with another person.
 Indifferent to praise or criticism.
 Flattened affect, claims nothing really makes
them very happy or sad, and few things give
them pleasure.

32
Cluster A -- Interventions
 Rarely seek psychiatric treatment
 Attempt to establish trust (can take
years)
 Establish rapport with family member
 Be honest, open (but not too warm)
 Ignore or gently confront odd beliefs or
behaviors
 Suggest cognitive-behavior therapy to
enhance social skills

33
Cluster B - Antisocial, Borderline,
Histrionic, Narcissistic
 Gender
– Male - Antisocial PD
– Female - Borderline PD, Histrionic PD
 Age – All diagnosed after age 18 and may
see some decrease in symptoms at midlife.
 Etiology - Neurophysiology, genetics
 High rates of depression, substance abuse

Borderline Personality Disorder
 A pervasive pattern on
instability of
interpersonal
relationships, self-image,
affect and impulsivity,
beginning in early
adulthood and present in
a variety of contexts (see
next slide)
34

 Frantic efforts to avoid real or imagined
abandonment.
 Extreme ups and downs in relationships.
 Identity disturbance, frequently changing beliefs
and goals.
 Impulsivity can include unsafe sex, substance
abuse, spending, eating or driving reckless.
 Suicidal gestures and/or self mutilation common.
 Sudden mood changes, temper outbursts and
feeling empty inside.
35

36
Developmental Factors:
 Developmental theory suggests that the
borderline person fails to achieve object
constancy during the separation-individuation
stage of psychosocial development (the
period between 18 months & 3 years of age).
Fail to complete separation from primary
caretaker & fail to achieve autonomy in
childhood.
 Often emotionally, physically or sexually
abused. 25% also have diagnosis of PTSD
(Stuart, 2013).

37
Example: Borderline Personality
Disorder
 http://www.youtube.com/watch?v=eOph
gCJX1FY

38
Nursing Diagnoses for Borderline
Personality Disorder
 Risk for self injury; self-mutilation
 Dysfunctional grieving
 Impaired social interaction
 Anxiety (severe to panic)
 Self-esteem disturbance
 Uncontrollable anger- throwing objects or
hitting common.
 When feeling stressed, becomes suspicious
(paranoid) or spaced out (dissociative)

39
Caring for the patient with Borderline
 Do:
 Be open and nonjudgmental- keep
in mind these patients have
developed these disorders as a
result of complex genetic and
environmental factors (insecure
attachments, chaos, neglect,
abuse)
 Control your emotional reactivity,
be calm
 Practice kindness, listen to their
concerns and their story with
sensitivity
 Be aware that these patients are
experts at eliciting a rejecting
response and respond with
calmness, solidness and genuine
concern for them
 Don’t:
 Close off and decide you don’t
like the person
 Form instant negative
associations when you hear that
someone has a Borderline PD
 Take things personally- their
behaviors are well entrenched
and they have difficulty
controlling their intense
emotions. They are
manipulative & unable to
tolerate reciprocal interpersonal
relationships.
 Try not to let them drive you
away- they are testing whether
you will care for them

40
Caring for the patient with Borderline
Personality Disorder (con’t)
 Be aware that these patients have learned to resort to manipulation and
splitting to get their needs met. Set limits in a fair and non-emotionally
charged way- it is important that the team remain solid and not allow
splitting to result in fragmentations and emotional chaos
 Continuously assess and monitor the patient for self-injurious behaviors
such as self-mutilating (cutting) and suicide attempts- place on 1:1
Suicide Precautions as needed
 Elicit information about substance abuse (a very common co-occurring
disorder)- make referrals for substance abuse treatment
 Encourage the patient to participate in on-going psychotherapy,
particularly therapy that incorporates CBT and interpersonal techniques
 Encourage the use of psychotropic medications for symptoms such as
dysphoria, emotional instability, anxiety and PTSD symptoms

41
Histrionic Personality Disorder
excessive emotionality
and attention seeking,
beginning in early
in a variety of contexts
(see next slide).

Histrionic Personality Disorder
 Likes to be the center of attention and feels
uncomfortable when not.
 Sexually provocative, inappropriately seductive.
 Tries to draw attention to self by the way they
dress or look and displays dramatic emotions.
 Suggestible, often changing their mind about
things based on things they’ve read or seen on
TV.
 Considers relationships to be more intimate
then they really are (lots of very close friends?)
42

43
Narcissistic Personality Disorder
grandiosity (in
behavior or fantasy),
need for admiration,
lack of empathy,
beginning by early
adulthood and
present in a variety of
contexts
(see next slide).

Narcissistic Personality Disorder
 Grandiose sense of self-importance, exaggerates
achievements and talents.
 Preoccupation with fantasies of success, power,
fame, brilliance, beauty or ideal love.
 Feels special, entitled and deserves privilege and
that there are few people worth their attention.
 Exploitive- takes advantage of others to achieve
own desires “steps on toes”.
 Not interested in other people’s feelings or
problems, lacking empathy.
 Often envious of others or believes others are
envious of them.
44

45
Greek myth of Narcissus- fell in love
with own reflection.
 Many successful people are narcissistic.
 Persons with this personality trait are
attracted to acting, modeling, professional
sports, politics, & broadcasting. Historical
example is Hitler.
 Have fragile self esteems, driving them to
constantly seek appreciation and admiration,
egocentric attitude, envy, rage with others do
not support them.

Antisocial Personality Disorder
 Evidence of conduct
disorder before age 15.
 There is a pervasive
disregard for and
violation of the rights of
others occurring since
age 15.
46

47
 Must be at least age 18, but there is evidence of Conduct
Disorder with onset before age 15, includes:
 Fighting, bullying, weapons use including a bat, sticks,
broken bottle, bricks, rocks, knife or gun.
 Deliberately cause suffering, pain or torture to other people
or animals.
 Stole while confronting victim such as mugging, purse
snatching, extortion or armed robbery.
 Forced someone into sexual activity.
 Set fires or vandalized or broke into property.
 Stole items of nontrivial value while shoplifting, theft, forgery.
 Ran away from home at least twice while living in parental or
parental surrogate home.
 Staying out very late at night despite parental prohibitions or
often skipping school before the age of 13.

 If evidence of Conduct Disorder before age 15,
since age 15 has there been 3 or more of the
following:
 Deceitfulness, lying, use of aliases for profit or
pleasure.
 Impulsivity, failure to plan ahead, like quitting a job
without having a new one or having no regular place
to live or no regular job.
 Aggressiveness, fighting, assaults, partner or child
abuse.
 Reckless driving or unsafe, frequent sex.
 Consistent irresponsibility with financial obligations.
 Lack of remorse for those hurt by behaviors. 48

49
 Emotional shallowness
 Not all commit violent acts
 Often substance abusers, beginning early in life; may
be involved in drug trafficking
 No concern for and frequent violation of the rights of
others
 Engage in illegal, irresponsible behavior with no
remorse
 May be dangerous - physically and emotionally

50
Example: Antisocial Personality
Disorder: Conduct Disorder as child
 http://www.youtube.com/watch?v=iPux
DYOWvj0

51
Biological Abnormalities and
Brain Function
 Diminished stress response
 Weak startle reflex in response to
distress cues
 Not as sensitive to the emotional
connotations of language
 Difficulty recognizing facial expressions
of anger, fright, disgust

52
Nursing Intervention for Antisocial
 Protect others from client’s aggression,
manipulation and hostility
 Assist client to delay gratification by
setting limits on unacceptable behavior

53
Cluster C- Avoidant, Dependent,
Obsessive-Compulsive
 Gender
– Male - OCPD 2:1
– Female - Dependent
 Etiology - Genetic, environment

54
Avoidant Personality Disorder
social inhibition,
feelings of inadequacy
and hypersensitivity to
negative evaluation
beginning in early
in a variety on contexts
(see next slide).

Avoidant Personality Disorder
 Avoids jobs or tasks that involve interpersonal
contact because of fear of criticism, disapproval or
rejection.
 Unwilling to take initiative or become involved with
someone unless certain that they will be liked.
 Find it very difficult to be honest about thoughts and
feelings with anyone out of fear of being ridiculed.
 Fear about being criticized in social situations.
 Believes that they are not as good, smart, attractive
as most other people.
 Reluctant to try new activities or meet new people.
55

56
Dependent Personality Disorder
 A pervasive and
excessive need to be
taken care of that leads
to submissive, clinging
behavior and fears of
separation beginning in
early adulthood and
contexts
(see next slide)

Dependent Personality Disorder
 Needs advice or reassurance before making
everyday decisions like what to wear or what to order
at a restaurant.
 Depends on others to handle responsibilities such as
finances, childcare, living arrangements.
 Finds it difficult to disagree with others even when
you think they are wrong, wanting their approval.
 Finds it difficult to start or work on tasks if no one is
there to help, due to lack of self-confidence.
 Will volunteer to do unpleasant tasks solely to gain
approval from others.
 Preoccupied fears of being left alone or being unable
to take care of one’s self if relationship ends.
57

58
Preoccupation with
orderliness,
perfectionism and
mental and
interpersonal control, at
the expense of
flexibility, openness and
efficiency, beginning in
early adulthood and
contexts.
(see next slide)

 Preoccupied with details, lists, order, rules,
organization or schedules, to the extent that the
major point of the activity is lost.
 Shows perfectionism to the point of having trouble
finishing tasks because the spend so much time
trying to get things exactly right.
 So devoted to school or work, never taking time to
just have fun or spend money on self or others.
 Inflexible on matters of morality, ethics, or values.
 Unable to discard items, even if space is cluttered.
 Stubborn and rigid with others and reluctant to
delegate tasks out of fear they won’t do it right. 59

 Is not Obsessive Compulsive
Disorder (quick video, 1:11 min. that
shows distinction)
http://www.youtube.com/watch?v=iOVSlD
n3Els
60

Other Specified or unspecified
personality disorders-
 Personality pattern meets criteria for personality
disorder and traits from several personality disorders
are present, but not meeting criteria for a specific
personality disorder, thus Dx would be “Other
Personality Disorder”
 Individual is considered to have a personality
disorder that was not included in the DSM 5 (e.g.
passive-aggressive personality disorder or
depressive personality disorder, which were
classified in DSM IV)
61

Other Specified or unspecified
personality disorders-
 Passive-Aggressive Personality Symptoms-
Passively resists fulfilling routine social or
occupational tasks, pretends to forget, or just does a
bad job on purpose. Exaggerates personal
misfortune, expresses envy, resentments and it’s not
fair.
 Depressive Personality Symptoms-Mood dominated
by dejection, joylessness, unhappiness. Self-concept
centers around beliefs of inadequacy, worthlessness
and puts self down.
 Brooding over past and pessimistic about future.
62

63
Treatment Modalities
 Psychotherapy
 Milieu therapy
 Group therapy
 Cognitive/Behavioral Therapy
 Psychopharmacology

64
Treatment Modalities-Milieu
Therapy
 Assistance with decision making
 Opportunity to gain insight
 Opportunity to learn from others, especially
the effect they have on others
 Limit-setting

65
More on Limit Setting
 The nurse must not view limits as a way to control the
patient.
 Limit setting must occur in the context of the patient
and nurse working together toward the process of
change. The emphasis is on the idea that the control
and decisions belong to the patient. The nurse
presents options and assists the patient in making
ever more healthy choices from those options.
 Hold manipulative patients responsible for their
behavior. Staff & family members must collaborate in
enforcing clearly stated limits. Failure to meet the
standards of healthy behavior should be identified
and acting out confronted.

Management of increasing signs of
agitation
 Remove patient to less stimulating
environment. Offer quiet room.
 Asking patient what can be done to help them
with the problem that is bothering them.
 PRN oral medication can be offered.
 PRN IM medication can be offered.
 If previous interventions fail, involuntary
medication can be given & only when patient
behavior presents as danger to themselves or
others.
66

67
Milieu Therapy-Role of the Nurse
 Provide a structured environment- scheduled
activities and daily predictable routine
 Provide opportunity to vent feelings- appropriately in
a safe environment.
 Assistance with emotional regulation- identify when
emotions & resulting behaviors are reaching levels
that require correction. Suggest time out, zoning, and
removal from stimulation or need for prn.
 Clarify and assist with conflicts and their resolution-
through one to one and group discussion.
 Helping the patient to gain a healthier and more
accurate perspective- through discussion,
clarification, and CBT.

68
Pharmacologic Treatment
 Patients with borderline personality
disorder may benefit from an SSRI
and/or an antipsychotic
 For schizotypal personality disorder -
antipsychotics may reduce paranoia,
odd communication, and ideas of
reference through effects on dopamine

69
Client Outcomes
 Recognizes impact of behavior on
relationships
 Sets goals to achieve adaptive behavior
 Substitutes more effective ways of relating
to others
 Makes commitment to treatment of
unhealthy behaviors
 Does not harm self or others
 Identifies sources of support to enhance
coping

 Resources:
 http://childrenatrisk.org
 www.advocatesfor youth.org/glbtq.htm
 www.safe4all.org/resource-list/index?category=16
 http://www.rainn.org
 Brausch & Gutierrez (2010). Differences in non-suicidal self
injury & suicide attempts in adolescents. Journal of Youth &
Adolescence, 39, 233-242.
71

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