Personality disorders fall into three groups, or clusters, shown in this chart. Clients with cluster A personality
disorders are characteristically aloof and restrained in relationships; others may describe them as odd or strange.
Clients with cluster B disorders typically are dramatic, unrestrained, and unpredictable. Those with cluster C
disorders are overly apprehensive about the present and future and worry about failing.
PERSONALITY DISORDER CLIENT DESCRIPTION
Schizotypal personality disorder • Has some cognitive and perceptual distortion
• May be viewed as odd or eccentric in speech and behavior
• Has poorly developed social skills
• Has strained and uncomfortable relationships
• Is easily overwhelmed by too much social or interpersonal stimuli
Paranold personality disorder • Uses projection
• Is extremely suspicious of other’s motives
• Is very guarded in relationships and finds hidden meanings
• Is very private
• Expects to be exploited or harmed by others
• Questions others loyalty
• Reads hidden meaning into harmless remarks or events
• Doesn’t forgive slights, insults, or injuries
Schizold personality disorder • Is emotionally cold and detached
• Is withdrawn and controlled
• Can’t form warm, spontaneous relationships
• Usually lives alone or in parents’ home
• Has little need for friendships or intimacy
• Has a solitary lifestyle
• Seems indifferent to praise or criticism
Narcisstic personality disorder • Can’t empathize with others because of intense need for love and
• Demands much time and attention from others
• Feels entitled or special
• Is arrogant, haughty, and envious
Histrionic personality disorder • Controls anxiety through dramatic presentation of self
• Uses attention – seeking behaviors and flattery to get others to meet
• Is overly concerned with physical attractiveness
• Can’t tolerate delayed gratification
• Has a seductive appearance or behavior
• Becomes anxious when limits are placed on attention – seeking
Borderline personality disorder • Has a poorly developed sense of self and is easily influenced by
• Struggles with overwhelming feelings of anger and anxiety
• Views situation in extremes (all good or all bad)
• Has intense fear of abandonment
• Feels empty and devoid of substance
• Needs others around to maintain a sense of self (you + me = self)
Paranoid personality disorder
PARANOID PERSONALITY DISORDER is characterized by extreme distrust of others. Paranoid people
avoid relationships in which they aren’t in control or have the potential of losing control.
• Genetic predisposition
• Neurochemical alteration
• Parental antagonism
• Feelings of being deceived
• Suspiciousness, mistrust of friends and relatives
• Refusal to confide in others
• Emotional reactions, including nervousness, jealousy, anger, or envy
• Self – righteousness
• Social isolation
• Sullen attitude
• Lack of social support systems
• Hyperactivity, especially in children
• Delusional thinking
• Lack of humor
• Major distortions of reality
• Need to be in control
There are no specific tests for paranoid personality disorder.
Ineffective individual coping
Chronic low self – esteem
SCHIZOPHRENIC AND DELUSIONAL DISORDERS
People with major distortions in ego functioning experience serious disturbance in all areas of their lives,
having impaired reality testing and a compromised ability to relate with others. Common signs of impairment in
reality testing include bizarre behaviors, inability to assume responsibility for oneself, and misinterpretation of
Major disturbances in ego functioning can result from functional causes, such as acute psychosis, or
from underlying organic causes related to drug ingestion, high fever, an accumulation of toxins in the body, or
SCHIZOPHRENIA is a brain disease characterized by nueurotransmitter imbalances and structural
changes within the brain. Distorted though processes make living with this disease a challenge. Symptoms from
schizophrenia may be characterized a positive or negative. Positive symptoms focus on a distortion of normal
functions; negative symptoms focus on a loss of normal functions.
A. Characterized by disordered thinking, delusions, hallucinations, depersonalization (feelings of being
strange, not oneself), impaired reality testing (psychosis), and impaired interpersonal relationships.
B. Regression to the earliest stages of development is often noted (e.g., incontinence, mutism)
C. Onset is usually in adolescence/early adulthood.
D. Client may be seriously impaired and unable to perform ADL.
E. Etiology is not known; theories include
1. Genetic: 1% of population; risk approximately 15% with one schizophrenic parent,
approximately 30% with two.
2. Family; double – bind communication; message sent in negated.
3. Biochemical; increased dopamine activation.
4. Interaction of predisposing risk and environmental stress.
5. Psychoanalytic; fragile ego resorts to dysfunctional use of defense mechanisms (e.g.,
F. Prior to onset (premorbid) client may have been suspicious, eccentric, or withdrawn.
A. Disorganized: incoherent; delusions are not organized; social withdrawal; affect blunted, silly or
B. Catatonic: psychomotor disturbances
1. Stupor: mute, little reaction or movement
2. Excitement: purposeless, excited motor activity
3. Posturing: voluntary, inappropriate, bizarre postures
C. Paranoid: delusions and hallucinations of persecution/grandeur
D. Undifferentiated: disorganized behaviors, delusions and hallucinations
• A fragile ego, which can’t withstand the demands of external reality
• Brain abnormalities
• Developmental involvement
• Genetic factors
• Neurotransmitter abnormalities
• Social or environmental stress, interacting with the person’s inherited biological makeup.
A. Four A’s
1. Affect: flat, blunted
2. Associative looseness: verbalizations are disorganized
3. Ambivalence: cannot choose between conflicting emotions
4. Autistic thinking: thoughts on self, extreme withdrawal, unable to relate to outside world
B. Any changes in thought, speech, affect
C. Ability to perform self – care activities, nutritional deficits
D. Suicide potential
G. Impaired communication
Nursing diagnoses for clients with schizophrenic disorders may include
B. Impaired verbal communication
C. Ineffective individual/family coping
D. Potential for injury
E. Altered nutrition
G. Self – care deficit
H. Self – esteem disturbance
I. Sensory perceptual alteration
J. Sleep pattern disturbance
K. Social isolation
L. Potential for violence
Planning and implementation
A. Develop a trusting/therapeutic relationship with nurse
B. Be oriented, able to test reality.
C. Be protected from injury
D. Be able to recognize impending loss of control.
E. Adhere to medication regimen.
F. Participate in activities.
G. Increase ability to care for self.
A. Offer self in development of therapeutic relationship
B. Use silence.
C. Set time for interaction with client.
D. Encourage reality orientation but understand that delusions/hallucinations are real to client.
E. Assist with feeding/dressing as necessary
F. Check on client frequently, remove potentially harmful objects.
G. Contract with client to tell you when anxiety is becoming so high that loss of control is possible.
H. Administer antipsychotic medications as ordered.
1. Reduction of hallucinations, delusions, agitation
2. Postural hypotension
a. Obtain baseline blood pressure and monitor sitting/standing.
b. Client must lie prone for 1 hour following injection.
c. Teach client to sit up or stand up slowly.
d. Elevate client’s legs while seated.
e. Withhold drug if systolic pressure drops more than 20 – 30 mm Hg from previous
a. Advise use of sun screen.
b. Avoid exposure to sunlight.
a. Instruct client to report sore throat or fever.
b. Institute reverse isolation if necessary.
a. Measure I & O
b. Check bladder distention.
c. Keep bowel record.
a. Avoid use of heavy machinery.
b. Do not drive.
7. Extrapyramidal symptoms
a. Dystonic ractions
1. sudden contractions of face, tongue extraocular muscles.
2. administer antiparkinson agents prn (e.g benztropine [Gogentin] 1 – 8 mg or
diphenhydramine [Bendryl] 10 – 50 mg). which can be given PO or IM for faster
relief; trihexyphenidyl [Artane] 3 – 15 mg PO only, can also be used prn).
3. remain with client; this is a frightening experience and
usually occurs when medication is started.
• The client experiences less confusion in thinking or thought processes.
• The client talks about situations and issues that reinforce reality.
• The client independently manages daily care
• The client doesn’t place self at risk for harm.
• The client interacts appropriately with staff, selected peers, and visitors.
• Family therapy
• Group therapy
• Milieu therapy
• Psychoeducational programs
• Social skills training
• Stress management
• Supportive psychotherapy
Symptom classification of schizophrenia
Here are example of positive and negative symptoms of schizophrenia.
• Bizarre, disorganized, or catatonic behavior
• Disorganized speech
• Loose associations
• Disorganized thinking process
• Flat affect
• Inability to have pleasure (anhedonia)
• Lack of motivation
• Lack of self – initiated behaviors (avolition)
• Poverty of speech (alogia)
• Social withdrawal
Drug Acute Symptom Maintenance/
Range/Day Profound Side
25 – 100 mg IM q1
– 4 h prn
200 – 600 mg PO 25 – 2000 mg PO Sedation
effects: dry mouth,
200 – 600 MG PO
in divided doses
1.25 mg IM, max 10
mg IM, divided
150 – 300 mg PO
1 – 5 mg PO
50 – 800 mg PO
1 – 30 mg PO
tongue, face, throat;
1 – 2 mg IM q4h;
2 – 4 mg PO, max
10 mg qd
25 mg Im q2wk
2 – 4 mg PO
25 – 100 mg IM
2 – 80 mg PO
10 – 75 mg IM 50 – 150 mg PO/IM 50 – 150 mg PO/IM Sedation,
5 – 10 mg IM q6h,
max 30 mg IM qd
16 – 64 mg PO 4 – 64 mg PO Extrapyramidal
2 – 10 mg IM in
2 – 8 mg PO 1 – 100 mg PO Extrapyramidal
8 – 16 mg IM in
6 – 10 mg PO 6 – 60 mg PO Extrapyramidal
Loxapine (Loxitane) -- 60 – 100 mg PO 30 – 250 mg PO Extrapyramidal
Clozapine (Clozaril) -- 300 – 450 mg PO 75 – 700 mg PO Agranulocytosis;
available only with
testing and client
Helping the client cope with hallucinations
This table details the progression of behaviors and sensations that a schizophrenic client may experience just
before and during a hallucination and describes nursing interventions that may help the client cope with these
occurrences. After a hallucination, the client may be exhausted. Be sure to allow time for the client to rest or
BEHAVIORS AND SENSATION TRUSTING INTERVENTIONS
The client feels anxious or lonely and attempts to cope
by daydreaming or seeking out a trusted person.
• Lack of structure and feelings of loneliness
may precipitate hallucinations. Therefore,
provide the client with a highly structured daily
routine and engage the client in a structured
activity to dissipate anxiety and feelings of
• Don’t allow the client hours of free time.
The client experiences increasing anxiety, which leads
to a state of alertness. The client becomes preoccupied
with internal sensations (such as voices and images)
and starts to respond to them. Aware that the
sensations are internal, the client attempts to control
• Help the client compare internal sensations
with external reality.
• Engage the client in a structured activity.
• Teach the client to hum, whistle, or talk but
loud to “crowd out” internal sensations.
• Ask the client to identify concrete things in the
As internal sensations become increasingly dominant,
the client has trouble controlling them and eventually
yields to them.
• Talk to the client about external reality.
• Ask the client to compare the hallucination
with external reality.
• Use self as a focal point to get the client’s
attention and the client to focus on what you’re
doing and saying.
• Instruct the client to firmly tell the
hallucination to go away.
• Engage the client in a large – muscle activity.
The client becomes immersed in internal sensations
and feels powerless over them. Depending on the
nature of the hallucination, the client may become
• Have the client focus on external reality.
• Do whatever is necessary to get the client’s
• Maintain a firm but kindly tone of voice.
A delusion is a false belief to which a person adheres despite contradictory evidence. Clients with
DELUSIONAL DISORDER hold firmly to false beliefs despite contradictory information. The client with
delusional disorder tends to be intelligent and can have a high level of competence but has impaired social and
personal relationships. One indication of delusional disorder is an absence of hallucination.
The most common types of delusions include:
• Delusions of grandeur – belief that one is highly important, famous, or powerful
• Delusions of persecution – belief that one is being persecuted or harmed by others.
• Delusions of reference – belief that one is connected to events unrelated to himself.
Planning and goals
• The client won’t harm self or others.
• The client will learn alternative coping strategies.
• The client will regain normal level of functioning.
• Formulate realistic, modest goals with the client to help diminish suspicion while increasing the client’s
self – esteem and sense of control.
• Establish a therapeutic relationship to foster trust.
• Explore event that trigger delusions to help you understand the dynamics of the client’s delusional
system. Discuss anxiety associated with triggering events.
• Don’t directly attack the delusion to avoid increasing the client’s anxiety instead, be patient in
formulating a trusting relationship.
• Once the dynamics of the delusions are understood, discourage repetitious talk about delusions and
refocus the conversation on the client’s underlying feelings. As the client identifies and explores
feelings, he’ll decrease reliance on delusional thought.
• Recognize delusion as the client’s perception of the environment. Avoid getting into arguments with the
client regarding the content of delusions to foster trust.
• Teach the client alternative coping mechanisms to handle periods of increased anxiety and enhance the
client’s self – esteem and self – control.
• Review key teaching topics with the client and family members to ensure adequate knowledge about the
condition and treatment, including:
o Learning decision – making, problem – solving, and negotiating skills.
o Understanding potential adverse effects of medication.
• The client doesn’t harm self or others.
• The client demonstrates less suspicious behavior.
• The client can identify signs and symptoms of anxiety.
• The client identifies factors that precipitate delusions and alternative coping mechanism to handle
Cocaine – use disorder
Cocaine – use disorder results from the potent euphoric effects of the drug. Individuals exposed to cocaine
develop dependence after a very short time. Maladaptive behavior follows, resulting in social dysfunction.
History of abuse, depression, or anxiety
Assault or violent behavior
Elevated energy and mood
Impaired social functioning
Drug screening is positive for cocaine.
Risk for violence: Self – directed
Risk for violence: Directed at others
Ineffective health maintenance
Imbalanced nutrition: Less than body requirements.
• Rehabilitation (inpatient or out patient)
• Narcotics Anonymous
• Individual therapy
Drug therapy option
• Anxiolytic agent: alprazolam (Xanax),lorazepam (Ativan)
• Dopamine agent: bromocriptine(Pardonel)
• Seletive serotonin reuptake inhibator: fluoxetine (Prozac), Paroxetine (Paxil)
Planning and goals
• The client will learn the adverse effects of cocaine on the body.
• The client will have adequate nutritionalk intake.
• The client won’t harm self or others.
• Establish a trusting relationship with the client to alleviate any anxiety or paranoia.
• Provide the client with well- balanced meals to compensate for nutritional deficits.
• Provide a safe environment. The client may pose a risk to self or others.
• Set limits on the client’s attempts to rationalize behavior to reduce inappropriate behavior
• Review key teaching topics with the client and family members to ensureb adequate knowledge about
the condition and treatment, including:
- contacting narcotics anonymous
- coping strategies
- managing stress
• The client relates the adverse effects of cocaine and verbalizes plans for lifestyle changes and follow –up
• The client has sufficient nutritional intake
• The client doesn’t harm self or others during hospitalization
Substance abuse disorder
Substance abuse disorder includes all patterns of abuse excluding alcohol and cocaine. Abuse disorders have a
great deal in common, although symptoms vary depending on the abused substance
• Familial tendency
• Gender ( female have increased likelihood of abusing prescription drugs; males have generally increase
likelihood of addiction)
• History of abuse, depression. or anxiety
• Influence of nationality and ethnicity
• Personality disorders
• Attempts to avoid anxiety and other emotions
• Attempts to avoid conscious feelings of guilt and anger
• Attempts to meet needs by influencing others
• Blaming others for problems
• Development of biological or psychological need for a substance
• Dysfunction anger
• Feelings of grandiosity
• Manipulation and deceit
• Need for immediate gratification
• Pattern of negative interactions
• Possible malnutrition
• Symptoms of withdrawal
• Use of denial and rationalization to explain consequences of behavior
• Positive blood and urine drug screening results confirm the diagnosis
• Standard alcoholism screening tools, such as the CAGE questionnaire and the Michigan Alcoholism
Screening test, in adequate alcoholism
• Ineffective health maintenance
• Imbalanced nutrition: Less than body requirements
• Risk for violence: self directed
• Risk for violence: Directed at others
Drug Therapy option
• Clonidine (catapres) for opiate withdrawal symptoms
• Metyhadone maintenance for opiate addiction detoxification
Planning and Goals
• The client will learn the adverse effects of substance abuse on the body
• The client will have adequate nutritional intake
• The client won’t harm self or others
• The client will commit to a recovery program and get assistance to maintain abstinence and coping skills
• Ensure a safe, quiet environment free from stimuli to provide a therapeutic setting and to alleviate
• Monitor for withdrawal symptoms, such as delirium, tremors, seizures, or anxiety, to provide the most
comfortable environment possible
• Assess the client for polysubstance abuse to plan appropriate interventions
• Help the client to understand the ultimate consequences of substance abuse to assist recovery
• Provide measures to induce sleep to help the client manage the discomfort of withdrawal.