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JMJ Marist Brothers

Notre Dame of Dadiangas University

Graduate School

Marist Avenue, General Santos City

PERSONALITY DISORDER

In Partial Fulfilment

of the Requirements in

Psychiatric Nursing

Submitted to:

Mrs. Lodar Dagoy-Escobillo, RN, MAN

Professor

Submitted by:

John Jasper Sabado

Margie Enojas
Learning Objectives

After the discussion, you will be able to:

• Define personality disorders.

• Etiology of Personality Disorder.

• Name the types of personality disorders.

• List the behavior associated with each personality disorder.

• Diagnosis and therapeutics for Personality Disorder.

• Describe the therapeutic nursing interventions to assist clients with

personality disorders.

Personality disorder

- Is an enduring pattern of inner experience and behavior that differs markedly from the

expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or

early adulthood, is stable over time, and leads to distress or impairment.

- Personality disorders are a long-standing and maladaptive pattern of perceiving and responding

to other people and to stressful circumstances.

- Behavior may be odd or eccentric, dramatic or erratic, or anxious or inhibited.

Etiology – Theoretical perspectives

- Psychodynamic theory
 Psychodynamic theories of personality are heavily influenced by the work of

Sigmund Freud, and emphasize the influence of the unconscious mind and

childhood experiences on personality. Psychodynamic theories include Sigmund

Freud’s psychosexual stage theory and Erik Erikson’s stages of psychosocial

development.

- Attachment theory

 Explain an important evolutionary function of the child–caregiver relationship.

Gene survival was thought to be enhanced by the selection of favoured

attachment behaviours that increased child–caregiver proximity, leading to the

greater likelihood of protection for the child. Particularly for dramatic, emotional,

erratic behaviors.

- Biologic Theory

 Biological approaches suggest that genetics are responsible for personality.

Research on heritability suggests that there is a link between genetics and

personality traits. Particularly for odd, eccentric and dramatic, emotional, erratic

behavior.

Cluster A: Odd or Eccentric Behavior

- Paranoid personality disorder.

 Individuals with this disorder display pervasive distrust and suspiciousness.

Common beliefs include the following:

• Others are exploiting or deceiving the person.

• Friends and associates are untrustworthy.


• Information confided to others will be used maliciously.

• There is hidden meaning in remarks or events others perceive as benign.

• The spouse or partner is unfaithful.

• Restricted affect.

 Common defense mechanism use: Projection.

 Nursing Interventions: serious, straightforward approach; teach client to validate

ideas before taking action; involve client in treatment planning.

- Schizoid personality disorder.

• Detached from others and has little desire for close relationships. This

person's life is marked by little pleasure in activities. People with this

disorder appear indifferent to the praise or criticism of others and often

seem cold or aloof.

• Schizoid personality disorder is slightly more common in males than in

females.

• Restricted affect.

 Common defense mechanism use: Fantasizing, who, in contrast to people with

psychoses, do not believe and thus do not act on their fantasies

 Nursing interventions focus on improved functioning in the community; assist

client to find a case manager.

- Schizotypal personality disorder.

• Exhibit marked eccentricities of thought, perception, and behavior.

Typical examples are as follows:

o Ideas of reference.

o Odd beliefs or magical thinking.


o Vague, circumstantial, or stereotyped speech.

o Excessive social anxiety that does not diminish with familiarity.

o Idiosyncratic perceptual experiences or bodily illusions.

 Common defense mechanism use: Projection.

 Nursing intervention: develop self care skills; improve community functioning;

social skills training.

Cluster B: Dramatic or Erratic Behavior

- Antisocial personality disorder.

 Display a pervasive pattern of disregard for and violation of the rights of others

and the rules of society. Onset must occur by age 15 years and includes the

following features:

• Repeated violations of the law.

• Pervasive lying and deception.

• Physical aggressiveness.

• Reckless disregard for safety of self or others.

• Consistent irresponsibility in work and family environments.

• Lack of remorse.

 Antisocial personality disorder is 3 times more prevalent in men than in women.

 Common defense mechanism use: Projection, Acting out.

 Nursing intervention: limit-setting; confrontation; teach client to solve problems

effectively and manage emotions of anger and frustrations.

- Borderline personality disorder

 Pervasive pattern of unstable and intense interpersonal relationships, self-

perception, and moods. Impulse control is markedly impaired. Transiently, such


patients may appear psychotic because of the intensity of their distortions.

Borderline personality disorder is one of the most commonly overused diagnoses

in DSM-IV-TR. Diagnostic criteria require at least 5 of the following features:

• Frantic efforts to avoid expected abandonment.

• Unstable and intense interpersonal relationships.

• Markedly and persistently unstable self-image.

• Impulsivity in at least 2 areas that are potentially self-damaging (eg, sex,

substance abuse, reckless driving).

• Recurrent suicidal behaviors or threats or self-mutilation.

• Affective instability.

• Chronic feelings of emptiness.

• Inappropriate and intense anger.

• Transient paranoia or dissociation.

 Borderline personality disorder is 3 times more common in women than in men.

 Common defense mechanism use: Projection, Splitting, Acting out, turning,

aggression against self, Hypochondriasis.

 Nursing intervention: promote safety; help client to cope and control emotions;

cognitive restructuring techniques; structure time; teach social skills.

- Histrionic personality disorder.

 Display excessive emotionality and attention-seeking behavior. They are quite

dramatic and often sexually provocative or seductive. Their emotions are labile.

In clinical settings, their tendency to vague and impressionistic speech is often

highlighted.

 Common defense mechanism use: Hypochondriasis.

 Nursing intervention: teach social skills; provide factual feedback about behavior.
- Narcissistic personality disorder.

 Grandiose and require admiration from others. Particular features of the disorder

include the following:

• Exaggeration of their own talents or accomplishments.

• Sense of entitlement.

• Exploitation of others.

• Lack of empathy.

• Envy of others.

• An arrogant, haughty attitude.

 Narcissistic personality disorder, 50-75% are male.

 Common defense mechanism use: Projection, when under acute stress.

 Nursing intervention: matter of fact approach; gain cooperation with needed

treatment; teach client any self care skills.

Cluster C: Anxious or Inhibited Behavior

- Avoidant personality disorder.

 Generally very shy. They display a pattern of social inhibition, feelings of

inadequacy, and hypersensitivity to rejection. Unlike patients with schizoid

personality disorder, they actually desire relationships with others but are

paralyzed by their fear and sensitivity into social isolation.

 Common defense mechanism use: Fantasizing.


 Nursing intervention: support and reassurance; cognitive restructuring

techniques; promote self esteem.

- Dependent personality disorder.

 Excessive need to be taken care of that results in submissive and clinging

behavior, regardless of consequences. Diagnosis requires at least 5 of the

following features:

• Difficulty making decisions without guidance and reassurance

• Need for others to assume responsibility for most major areas of the

person's life.

• Difficulty expressing disagreement with others.

• Difficulty initiating activities because of lack of confidence.

• Excessive measures to obtain nurturance and support.

• Discomfort or helplessness when alone.

• Urgent seeking for another relationship when one has ended.

• Unrealistic preoccupation with fears of being left to fend for themselves.

 Common defense mechanism use: Hypochondriasis.

 Nursing intervention: foster client’s self reliance and autonomy; teach problem

solving decision and decision making skills; cognitive restructuring techniques.

- Obsessive-compulsive personality disorder.

 Preoccupied with orderliness, perfectionism, and control. They lack flexibility or

openness. Their preoccupations interfere with their efficiency despite their focus

on tasks. They are often scrupulous and inflexible about matters of morality,
ethics, and values to a point beyond cultural norms. They are often stingy as well

as stubborn.

 Obsessive-compulsive personality disorder is diagnosed twice as often in men

than in women.

 Nursing intervention: encourage negotiations with others; assist client to make

timely decisions and complete work; cognitive restructuring techniques.

Diagnosis

- In general, patients with personality disorders have wide-ranging problems in social relationships

and mood regulation. These problems have usually been present throughout adult life. These

patients' patterns of perception, thought, and response are fixed and inflexible, although their

behavior is often unpredictable. These patterns markedly deviate from their specific culture's

expectations. To meet the DSM-IV-TR threshold for clinical diagnosis, the pattern must result in

clinically significant distress or impairment in social, occupational, or other important areas of

functioning. Note that the disorder occurs in all settings (eg, social as well as vocationally), and it

not limited to one sphere of activity.

- The diagnosis of a personality disorder on a person's history, specifically, on repetition of

maladaptive thought or behavior patterns. These patterns tend to become apparent because the

person tenaciously resists changing them despite their negative consequences. In addition, a

doctor is likely to notice the person's immature and maladaptive use of mental coping

mechanisms, which interferes with their daily functioning. A doctor may also talk with people who

interact with the person.

- Psychological testing may support or direct the clinical diagnosis.

• The Minnesota Multiphasic Personality Inventory (MMPI) is the best-known psychological

test. The Eysenck Personality Inventory and the Personality Diagnostic Questionnaire are

also used. None of these has been reliably validated against DSM-IV-TR diagnoses.
• The Structured Clinical Interview for DSM-IV-TR for Axis II Disorders (SCID-II) can also be

used to aid in diagnosis.

- According to ICD-10, the diagnosis of a personality disorder must satisfy the following general

criteria, in addition to the specific criteria listed under the specific personality disorder under

consideration:

1. There is evidence that the individual's characteristic and enduring patterns of inner

experience and behavior as a whole deviate markedly from the culturally expected and

accepted range (or "norm"). Such deviation must be manifest in more than one of the

following areas:

A. cognition (i.e., ways of perceiving and interpreting things, people, and events; forming

attitudes and images of self and others);

B. affectivity (range, intensity, and appropriateness of emotional arousal and response);

C. control over impulses and gratification of needs;

D. Manner of relating to others and of handling interpersonal situations.

2. The deviation must manifest itself pervasively as behavior that is inflexible, maladaptive, or

otherwise dysfunctional across a broad range of personal and social situations (i.e., not being

limited to one specific "triggering" stimulus or situation).

3. There is personal distress, or adverse impact on the social environment, or both, clearly

attributable to the behavior referred to in criterion 2.

4. There must be evidence that the deviation is stable and of long duration, having its onset in

late childhood or adolescence.

5. The deviation cannot be explained as a manifestation or consequence of other adult mental

disorders, although episodic or chronic conditions.

6. Organic brain disease, injury, or dysfunction must be excluded as the possible cause of the

deviation.
Pathophysiology

- Traditional thinking holds that these maladaptive patterns are the result of dysfunctional early

environments that prevent the evolution of adaptive patterns of perception, response, and

defense. A body of data points toward genetic and psychobiologic contributions to the

symptomology of these disorders.

Physical

- No specific physical findings are associated with any personality disorders. Physical examination

may reveal findings related to the consequences and sequelae of various personality disorders.

• Patients (particularly those with cluster B disorders) may show signs of prior suicide attempts

or stigmata of substance abuse.

• Substance abuse is a common co-morbidity and may be reflected in the physical stigmata of

alcoholism or drug abuse.

• Suicide attempts may leave scars from self-inflicted wounds.

- Mental status findings: Few of the relevant findings here are the result of direct questioning, but

instead reflect careful observation of the patient while the clinician is eliciting the history.

• Patients with histrionic personality disorder may display la belle indifference, a seemingly

indifferent detachment, while describing dramatic physical symptoms.

• A hostile attitude is typical of patients with antisocial personality disorder. In some instances,

they may become homicidal.

• Patients with cluster B personality disorders, particularly borderline personality disorder,

frequently display affective lability. This lability makes suicide risk high.

• Patients with paranoid personality disorder voice persecutory ideation without the formal

thought disorder observed in schizophrenia. The examiner should investigate thoughts of

harm to the perceived persecutor(s).


• Hallucinations are rare, but patients with borderline personality may experience dissociative

phenomena as if they are hallucinatory.

• Patients with schizotypal personality disorder speak with odd or idiosyncratic use of

language.

• Thought process is generally normal in persons with personality disorders.

• Cognitive functions, including memory, orientation, and intelligence, are usually unimpaired.

• Insight is often limited, as patients attribute their suffering to uncontrollable influences outside

themselves. Judgment can be inferred by the presenting circumstances.

Causes

• Paranoid personality disorder: A genetic contribution to paranoid traits and a possible genetic

link between this personality disorder and schizophrenia exist. Psychosocial theories implicate

projection of negative internal feelings and parental modeling.

• Schizoid personality disorder: Support for the heritability of this disorder exists.

• Schizotypal personality disorder: This disorder is genetically linked with schizophrenia.

Evidence for dysregulation of dopaminergic pathways in these patients exists.

• Antisocial personality disorder: A genetic contribution to antisocial behaviors is strongly

supported. Low levels of behavioral inhibition may be mediated by serotonergic dysregulation in

the septohippocampal system. There may also be developmental or acquired abnormalities in the

prefrontal brain systems and reduced autonomic activity in antisocial personality disorder. This

may underlie the low arousal, poor fear conditioning, and decision-making deficits described in

antisocial personality disorder.

• Borderline personality disorder: Psychosocial formulations point to the high prevalence of early

abuse (sexual, physical, and emotional) in these patients, and the borderline syndrome is often

formulated as a variant of posttraumatic stress disorder. Mood disorders in first-degree relatives

are strongly linked. Biological factors, such as abnormal monoaminergic functioning (especially in
serotonergic function) and prefrontal neuropsychological dysfunction, have been implicated but

have not been well established by research.

• Histrionic personality disorder: Little research has been conducted to determine the biologic

sources of this disorder. Psychoanalytic theories incriminate seductive and authoritarian attitudes

by fathers of these patients.

• Narcissistic personality disorder: No data on biological features of this disorder are available.

In the classic model, narcissism functions as a defence against awareness of low self-esteem.

More modern psychodynamic models postulate that this disorder can arise from an imbalance

between positive mirroring of the developing child and the presence of an idealizable adult figure.

• Avoidant personality disorder: This personality disorder appears to be an expression of

extreme traits of introversion and neuroticism. No data on biological causes are available,

although a diagnostic overlap with social phobia probably exists.

• Dependent personality disorder: No studies of genetics or of biological traits of these patients

have been conducted. Central to their psychodynamic constellation is an insecure form of

attachment to others, which may be the result of clinging parental behavior.

• Obsessive-compulsive personality disorder: Modest evidence points toward the heritability of

this disorder. Psychodynamically, these patients are viewed as needing control as a defence

against shame or powerlessness.

Age

- Personality disorders generally should not be diagnosed in children and adolescents because

personality development is not complete and symptomatic traits may not persist into adulthood.

Therefore, the rule of thumb is that personality diagnosis cannot be made until the person is at

least 18 years of age. Because the criteria for diagnosis of personality disorders are closely

related to behaviors of young and middle adulthood, DSM-IV-TR diagnoses of personality

disorders are notoriously unreliable in the elderly population.

Treatment
- Psychotherapy is at the core of care for personality disorders. Because personality disorders

produce symptoms as a result of poor or limited coping skills, psychotherapy aims to improve

perceptions of and responses to social and environmental stressors.

• Psychodynamic psychotherapy examines the ways that patients perceive events, based on

the assumption that perceptions are shaped by early life experiences. Psychotherapy aims to

identify perceptual distortions and their historical sources and to facilitate the development of

more adaptive modes of perception and response. Treatment is usually extended over a

course of several years at a frequency from several times a week to once a month; it makes

use of transference.

• Cognitive therapy (also called cognitive behavior therapy [CBT]) is based on the idea that

cognitive errors based on long-standing beliefs influence the meaning attached to

interpersonal events. It deals with how people think about their world and their perception of

it. This very active form of therapy identifies the distortions and engages the patient in efforts

to reformulate perceptions and behaviors. This therapy is typically limited to episodes of 6-20

weeks, once weekly. In the case of personality disorders, episodes of therapy are repeated

often over the course of years.

• Interpersonal therapy (IPT) conceives of patients' difficulties resulting from a limited range of

interpersonal problems including such issues as role definition and grief. Current problems

are interpreted narrowly through the screen of these formulations, and solutions are framed in

interpersonal terms. Therapy is usually weekly for a period of 6-20 sessions. Though

empirically validated for anxiety and depression, IPT is not widely practiced, and therapists

conversant in the technique are difficult to locate.

• Group psychotherapy allows interpersonal psychopathology to display itself among peer

patients, whose feedback is used by the therapist to identify and correct maladaptive ideas,

communication, and behavior. Sessions are usually once weekly over a course that may

range from several months to years.


• Dialectical behavior therapy (DBT): This is a skills-based therapy (developed by Marsha

Linehan, PhD) that can be used in both individual and group formats. It has been applied to

borderline personality disorder. The emphasis of this manual-based therapy is on the

development of coping skills to improve affective stability and impulse control and on

reducing self-harmful behavior. This treatment is also being used with other cluster B

personality disorders to reduce impulsive behavior.

Psychopharmacology

- Relief of anxiety, depression, and other distressing symptoms (if present) is the first goal. Drug

therapy can help. Drugs such as selective serotonin reuptake inhibitors (SSRIs) can help both

depression and impulsivity. Anticonvulsant drugs can help reduce impulsive, angry outbursts.

Other drugs such as risperidone have been helpful with both depression and feelings of

depersonalization in people with borderline personality. Reducing environmental stress can also

quickly relieve symptoms.

- The focus is on treatment of symptom clusters such as cognitive-perceptual

symptoms, affective dysregulation, and impulsive-behavioral dyscontrol.

A. Cluster A disorders correspond to the categories of affective dysregulation, detachment

and cognitive disturbances.

B. Cluster B disorders correspond to the target symptoms of impulsiveness and aggression.

C. Cluster C disorders correspond to the categories of anxiety and depression symptoms.

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