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CHAPTER 18: PERSONALITY DISORDERS

Chapter 18: Personality Disorders

Key Term:
o Antisocial Personality Disorder: characterized by a pervasive pattern of disregard for and
violation of the rights and with the central characteristics of deceit and manipulation
o Avoidant Personality Disorder: characterized by a pervasive pattern of social discomfort and
reticence, low self-esteem, and hypersensitivity
o Borderline Personality Disorder: pervasive and enduring pattern of unstable interpersonal
relationships, self-image, and affect; marked impulsivity; frequent self-mutilation behavior
o Character: consist of concepts about the self and the external world
o Cognitive Restructuring: therapy that focuses on changing the way one thinks about or interprets
ones self, relationships, and/or environment
o Confrontation: technique designed to highlight the intercongurence between a persons
verbalizations and actual behavior; used to manage manipulative or deceptive behavior
o Decatastrophizing: a technique that involves learning to assess situations realistically rather than
always assuming a catastrophe will happen
o Dependent Personality Disorder: characterized by a pervasive and excessive need to be taken
care of, which leads to submissive and clinging behavior and fears of separation
o Depressive Behavior: characterized by a pervasive pattern of depressive cognitions and
behaviors in various contexts
o Dysphoric: mood that involves unhappiness, restlessness, and malaise
o Histrionic Personality Disorder: characterized by a pervasive pattern of excessive emotionality
and attention seeking
o Limit Setting: an effective technique that involves three steps: stating the behavioral limit
(describing the unacceptable behavior), identifying the consequences if the limit is exceeded, and
identifying the expected or desired behavior
o Narcissistic Personality Disorder: characterized by a pervasive pattern of grandiosity (in fantasy
or behavior), need for admiration and lack of empathy
o Nonsuicidal Self-Injury: intentional physical damage to the body such as cutting or burning;
results from self-harm urges or thoughts; injury is not an attempt at suicide
o No-Self-Harm-Contract: a client promises to not engage in self-harm and to report to the nurse
when he or she is losing control
o Obsessive- Compulsive Personality Disorder: characterized by a pervasive pattern of
preoccupation with perfectionism, mental and interpersonal control, and orderliness at the
expense of flexibility, openness, and efficiency
o Paranoid Personality Disorder: characterized by pervasive mistrust and suspiciousness of others
o Passive-Aggressive Behavior: characterized by a negative attitude and pervasive pattern of
passive resistance to demands for adequate social and occupational performance
o Personality: an ingrained, enduring pattern of behaving and relating to self, others, and the
environment; includes perceptions, attitudes, and emotions
o Personality Disorders: diagnosed when personality traits become inflexible and maladaptive and
significantly interfere with how a person functions in society or cause the person emotional
distress
o Positive Self-Talk: a cognitive-behavioral technique in which the client changes thinking about
the self from negative to positive
o Schizoid Personality Disorder: characterized by a pervasive pattern of detachment from social
relationships and a restricted range of emotional expression in interpersonal settings
o Schizotypal Personality Disorder: characterized by 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 behavioral eccentricities
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CHAPTER 18: PERSONALITY DISORDERS
o Temperament: refers to the biologic process of sensation, association and motivation that
underline the integration of skills and habits based on emotion
o Thought Stopping: a cognitive-behavioral technique to alter the process of negative or self-
critical thought processes
o Time-Out: retreat to a neutral place to give the opportunity to regain self-control
Objectives:
o Describe personality disorders in terms of the clients difficulty in perceiving, relating to, and
thinking about self, others, and the environment
Behaviors and characteristics are consistent across a broad range of situations and do not
change easily
Many factors influence personality: some stem from biologic and genetic make-up,
whereas others are acquired as a person develops and interacts with the environment and
other people
Behavior often fails to conform to cultural, social, or legal norms, and they are motivated
by personal gratification
Relationships with others are dysfunctional and often characterized by deceit, coercion,
or intimidation by the individual with a personality disorder
Not capable of mutual, intimate relationship, and lack the capacity for empathy, remorse,
or concern for others
Maladaptive or dysfunctional personality traits exhibited by individuals with personality
disorder may include:
Negative behaviors towards others, such as manipulative, dishonest, deceitful, or
lying
Anger and/or hostility
Irritable, labile moods
Lack of guilt or remorse, emotionally cold and uncaring
Impulsivity, poor judgement
Irresponsible, not accountable for own actions
Risk-taking, thrill seeking behaviors
Mistrust
Exhibitionism
Entitlement
Dependency
Eccentric perceptions
Not diagnosed until adulthood, at age 18, when personality is more completely formed
No specific medication alters personality and therapy designed to help clients make
changes is often long-term with very slow progress
Hybrid Model For Personality Disorders Box 18.1 pg 338
Diagnoses are organized according to clusters around a predominate type of behavioral
pattern:
Clients with antisocial personality disorder may enter a psychiatric setting as part of a
court ordered evaluation or an alternative to jail, where as those with borderline
personality disorder are oft hospitalized because their emotional instability may lead to
self-inflicted injuries; two of the most common nurses will encounter in a psychiatric
setting
Other clusters of behavior related to maladaptive personality traits include the following:
Depressive Behavior:
o Occurs more often with people with relatives who have major depressive
disorders
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CHAPTER 18: PERSONALITY DISORDERS
o Often seek treatment for their distress
Passive-Aggressive Behavior:
o May appear cooperative, even ingrating, or sullen and withdrawn,
depending on the circumstances
o Mood may fluctuate rapidly and erratically, and they may be easily upset
or offended
Usually not consciously aware of own personality
Personality Disorders:
Schizotypal Personality Disorder
Borderline Personality Disorder
Antisocial Personality Disorder
Narcissistic Personality Disorder
Obsessive-Compulsive Personality Disorder
Avoidant Personality Disorder
Related Disorders:
Paranoid Personality Disorder
Schizoid Personality Disorder
Histrionic Personality Disorder
Dependent Personality Disorder
o Discuss factors through to influence the development of personality disorders
DSM-5 DIAGNOSTIC CRITERIA: Borderline Personality Disorder 301.83 (F60.3) pg
339
Onset and Clinical Course:
Relatively common 10-20% of general population
Higher for people in lower socioeconomic groups and unstable or disadvantaged
population
15% of all psychiatric inpatients have a primary dx of a personality disorder
40-45% of people with primary dx of major mental illness also with coexisting
personality disorder that significantly complicates tx
30-50% in outpatient setting
Higher death rate, especially as a result of suicide; higher rates of suicide
attempts, accidents, and emergency department visits, and increased rates of
separation, divorce, and involvement in legal proceedings regarding child custody
Correlated highly with criminal behavior, alcoholism, and drug abuse
Description of being treatment resistant
Lack of perception by person that behavior is a problem
Etiology:
Biologic Theories
o Personality develops through the interaction of heredity dispositions and
environmental influences
o Genetic differences account for about 50% of variances in temperament
traits
o 4 temperament traits: each affects a persons automatic responses to
certain situations; response patterns are ingrained by 2-3 years of age
Harm Avoidance:
High: fear of uncertainty, social inhibition, shyness with
strangers, rapid fatigability, pessimistic worry in

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CHAPTER 18: PERSONALITY DISORDERS
anticipation of problems; behavior results in maladaptive
inhibition and excessive anxiety
Low: carefree, energetic, outgoing, optimistic; behaviors
result in unwarranted optimism and unresponsiveness to
potential harm or danger
Novelty Seeking:
High: someone who is quick tempered, curious, easily
bored, impulsive, extravagant, and disorderly, prone to
angry outbursts, fickle in relationships
Low: slow tempered, stoic, reflective, frugal, reserved,
orderly, tolerant of monotony; may adhere to routine of
activities
Reward Dependence: defines how a person responds to social cues
High: tender hearted, sensitive, sociable, socially dependent
Low: practical, tough-minded, cold, socially insensitive,
irresolute, indifferent to being alone
Persistence:
High: hardworking and ambitious overachievers who
respond to fatigue or frustration as a personal challenge
Low: inactive, intolerant, unstable, erratic; tend to give up
easily when frustrated and rarely strive for higher
accomplishments
Psychodynamic Theories
o 3 major character traits
Self-directedness: responsible, reliable, goal oriented, self-
confident; realistic and effective, can adapt their behavior to
achieve goals
Cooperativeness: refers to the extent to which a person sees self as
an integral part of human society
High: empathetic, tolerant, compassionate, supportive,
principled
Low: self- absorbed, intolerant, critical, unhelpful,
revengeful, opportunistic
Self-transcendence: describes the extent to which a person
considers self to be an integral part of the universe
Spiritual, unpretentious, humble, fulfilled traits are
helpful when dealing with suffering, illness, death
Low: practical, self-conscious, materialistic, controlling;
have difficulty accepting suffering, loss of control, personal
and material losses, death
o Characters matures in stepwise stages from infancy through late
adulthood failure to complete a developmental task jeopardizes the
persons ability to achieve future developmental tasks
o Apply the nursing process to the care of clients with personality disorders
Antisocial Personality Disorder and Nursing Process Application:
Assessment:
o Deceit/manipulation
o False emotions; no empathy
o Narrowed view of world
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o Poor judgment; no insight
o Egocentric, but actual self-shallow and empty
o Relationships as serving own needs
Data Analysis/ Nursing Diagnoses:
o Generally, dont seek tx voluntarily unless they perceive some personal
gain from doing so
o Inpatient tx setting not necessarily effective, usually brings out worst
qualities
o Nursing Diagnoses:
Ineffective Coping
Ineffective Role Performance
Risk for Other-Directed Violence
Outcome Identification:
o Client will demonstrate nondestructive ways to express feelings and
frustration
o Client will identify ways to meet own needs that dont infringe on rights
of others
o Client will achieve or maintain satisfactory role performance
Interventions:
o Promoting responsible behavior
o Limit setting
State the limit
Identify consequences of exceeding limit
Identify expected or acceptable behavior
o Consistent adherence to rules and tx plan
o Confrontation
Point out problem behavior
Keep client focused on self
Help clients solve problems and control emotions
o Effective problem-solving skills
o Decreased impulsivity
o Expressing negative emotions such as anger or frustration
o Taking a time-out from stressful situations
o Enhancing role performance
o Identifying barriers to role fulfillment
o Decreasing or eliminating use of drugs and alcohol
Evaluation: was the treatment effective, can the client maintain a job with
acceptable performance, is the client meeting basic family responsibilities, and are
they avoiding illegal or immoral acts
Borderline Personality Disorder and Nursing Application:
Assessment:
o Unstable interpersonal relationships, self-image, and affect; marked
impulsivity
o Wide range behavior, appearance
o Dysphoric mood
o Polarized extreme thinking (splitting); dissociation
o Impaired judgement; safety not a concern
o Threats of self-harm
o Social isolation

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CHAPTER 18: PERSONALITY DISORDERS
Data Analysis/ Nursing Diagnoses:
o Risk for Suicide
o Risk for Self-Mutilation
o Risk for Other-Directed Violence
o Ineffective Coping
o Social Isolation
Outcome Identification:
o Client will be safe and free from significant injury
o Client will not harm others or destroy property
o Client will demonstrate increased control of impulsive behavior
o Client will take appropriate steps to meet own needs
o Client will demonstrate problem-solving skills
o Client will verbalize greater satisfaction with relationships
Interventions:
o Promoting clients safety
No-self-harm contract
Safe expression of feelings and emotions
o Helping client to cope and control emotions
Identifying feelings
Journal entries
Moderating emotional responses
Decreased impulsivity
Delaying gratification
o Cognitive restructuring techniques
Thought stopping
Decatastrophizing
o Structuring time
o Teaching social skills
o Teaching effective communication skills
o Entering therapeutic relationship
Limit setting
Confrontation
Evaluation: changes may be small and slow, severe impairment maybe evaluated
in terms of ability to be safe and refrain from self-injury, generally when clients
experience fewer crises less frequently overtime treatment is effective
o Provide education to clients, families, and community members to increase their knowledge and
understanding of personality disorders
Antisocial Personality Disorder:
Avoiding use of alcohol and other drugs
Appropriate social skills
Effective problem-solving skills
Managing emotions such as anger and frustration
Taking a time out to avoid stressful situations
Borderline Personality Disorder:
Teaching social skills
o Maintain personal boundaries
o Realistic expectations of relationships
Teaching time structuring
o Making a written schedule of activities
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o Making a list of solitary activities to combat boredom
Teaching self-management through cognitive restructuring
o Decatastrophizing situation
o Thought stopping
o Positive self-talk
Using assertive techniques such as I statements
Using distraction, such as walking or listening to music
Other Disorders:
Paranoid Personality Disorder: 2-4% of general population, more common in
males, generally tend to have lifelong problems living and working with others
o Clinical Picture:
Pervasive mistrust/suspiciousness
Use of projection
Conflict with authority
Nursing Interventions:
o Formal, businesslike approach
o Involvement in plan of care
o Idea validation before action
Schizoid Personality Disorder: may affect 5% of general population, more
common in males, avoid treatment as much as they avoid relationships
o Clinical Picture:
Social detachment
Restricted emotions
Intellectual
o Nursing Interventions: improved functioning in community
Schizotypal Personality Disorder: 3% of population, slightly more common in
men than in women, may develop schizophrenia most dont
o Clinical Picture:
Social and interpersonal deficits
Behavioral eccentricities
Cognitive or perceptual distortions
Odd appearance
Inability to respond to normal social cues
o Nursing Interventions: self-care, social skills, community functioning
Histrionic Personality Disorder: 1-3% of general population, 10-15% inpatient
population, more common in females
o Clinical Picture:
Excessive emotionally and attention seeking
Insincerity
Center of attention
Exaggeration of relationships
o Nursing Interventions:
Feedback about social interactions
Social skills training through role-playing
Exploration of strengths, assests
Narcissistic Personality Disorder: 1-6% of general population, 50-75% with
diagnosis are men
o Clinical Picture:
Grandiosity
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Need for admiration
Lack of empathy
Arrogant or haughty attitude
Superior view
Fragile, vulnerable self-esteem
Ambitious
o Nursing Interventions:
Self-awareness skills to avoid anger and frustration
Matter-of-fact approach
Limit setting
Avoidant Personality Disorder: 2-3% of general population, equally common in
men and women
o Clinical Picture:
Social discomfort
Low self-esteem
Hypersensitivity to negative evaluation
o Nursing Interventions:
Self-affirmations
Positive self-talk
Support and reassurance
Reframing/decatstrophizing
Social skill training
Dependent Personality Disorder: 1% of general population, 3x more common in
females, runs in families, common in youngest child, may seek tx for anxious
depressed or somatic symptoms
o Clinical Picture:
Need to be taken care of
Submissive
Clinging
o Nursing Interventions:
Expression of feelings
Autonomy/self-reliance
Cognitive restructuring
Problem solving
Obsessive-Compulsive Personality Disorder: 2-8% of general population,
affecting 2x as many men as women
o Clinical Picture:
Perfectionism
Formal, serious
Orderliness a priority
Problems with decision making, judgements
Low self-esteem
Harsh self-evaluations
o Nursing Interventions:
Different perspective view
Cognitive restructuring
Risk taking
o Evaluate personal feelings, attitudes, and responses to clients with personality disorders
Avoid patient attempt to manipulate
Use clear communication
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CHAPTER 18: PERSONALITY DISORDERS
Set limits, boundaries
Deal with frustration: patients change slowly yet look like they are capable of better
behavior
Work effectively as part of team; consistency is essential
o Cultural considerations, treatment, Mental health promotion
Cultural Considerations:
Personality viewed with considerations of ethnic, cultural, social background
o Guarded or defensive behavior due to language barriers
o Different views of avoidant and dependent behavior
o Cultural value of work, productivity
Treatment:
Psychopharmacology:
o Cognitive-Perceptual Distortions
o Affective Symptoms and Mood Dysregulation
Emotional instability and mood swings:
Lithium
Carbamazepine (Tegretol)
Valproate (Depakote)
Low-dose neuroleptics such as Haldol
Emotional detachment, cold and aloof emotions and disinterest in
social relationships:
SSRI
Atypical antipsychotics; risperidone (Risperdal),
olanzapine (Zyprexa), quetiapine (Seroquel)
Atypical depression:
SSRI
MAOI
Low-dose antipsychotics
o Aggression and Behavior Dysfunction
Lithium
Anticonvulsant mood stabilizers
Benzodiazepines
Low dose neuroleptics may be useful in modifying predatory
aggression
o Anxiety:
Drug Choices for Symptoms Table 18.1 pg 342
o 4 categories relating to the underlying temperaments associated with
personality disorders:
Low reward dependence corresponds to the categories of affective
dysregulation, detachment, and cognitive disturbances
High novelty seeking corresponds to the target symptoms of
impulsivity and aggression
High harm avoidance corresponds to categories of anxiety and
depression symptoms
Cognitive-perceptual disturbances include magical thinking, odd
beliefs, illusions, suspiciousness, ideas of reference, low-grade
psychotic symptoms; chronic symptoms usually respond to low-
dose antipsychotics medications
Group and Individual Therapies:
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CHAPTER 18: PERSONALITY DISORDERS
o Cognitive-Behavioral Therapy: cognitive restructuring techniques
o Dialectical Behavior Therapy: borderline personality disorder
o Summary of Symptoms and Nursing Interventions for Personality
Disorders and Behaviors Table 18.2 pg 343
Mental Health Promotion:
o Unmet Needs: self-care, sexual expression, budgeting, psychotic
symptoms, psychological distress
Care for first here areas possibly resulting in greater sense of well-
being and improved health
o Children with greater number of protective factors less likely to develop
antisocial behavior as adults
o Emphasis of care on protective factors of school commitment or
importance of school, parent, and/or peer disapproval of antisocial
behavior, involvement in religious community

UNIT 4: NURSING PRACTICE FOR PSYCHIATRIC DISORDERS

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