PERSONALITY DISORDERS

1. PERSONALITY DISORDER
PREPARED BY
LIJI C MARIA 1ST YEAR MSc (N) MENTAL
HEALTH
GOVT.COLLEGE OF NURSING KOTTAYAM

2. PERSONALITY DISORDER

3. • The word personality is derived from the
Greek word persona, it was used to describe
the mask worn by some dramatic actors at
that time.
• Personality refers to enduring qualities of an
individual that are shown in ways of behaving
in a wide variety of circumstances.
– It refers to individual differences in characteristic
patterns of thinking, feeling and behaving.

4. DEFINITION OF PERSONALITY
DISORDER
Personality disorder are a class of mental
disorder characterized by maladaptive patterns
of behaviour, cognition and inner experiences
exhibited across many contexts and deviating
markedly from those accepted by the individual
culture. These patterns develop early, are
inflexible and are associated with significant
distress or disability. (APA)

5. ETIOLOGICAL FACTORS
BILOGICAL
FACTORS
PSYCHODYNAMIC
THEORIES
OTHER FACTORS

6. A. BIOLOGICAL FACTORS
1. GENETIC FACTORS
• Cluster A personality disorders (paranoid, schizoid, and schizotypal )
are common in the biological relatives of patients with
schizophrenia
• Cluster B personality disorders (antisocial, borderline, histrionic,
and narcissistic) apparently have a genetic base. Antisocial
personality disorder is associated with alcohol use disorders of the
family members. Depression is more common in the family
backgrounds of patients with borderline personality disorders.
• Cluster C personality disorders (avoidant, dependent, obsessive-
compulsive and not otherwise specified) may also have a genetic
base. patients with avoidant personality disorder often have a high
anxiety levels of close relatives.

7. 2. HORMONAL FACTORS
• People who exhibit impulsive traits also often
show increased levels of testosterone, 17-
estradiol, and estrone.
• Platelet Monoamine Oxidase
Low platelet MAO levels have also been noted
in some patients with schizotypal disorders.

8. 3. Neurotransmitters
• Endorphins - High endogenous endorphin levels may be associated
• 5- hydroxy indoleacetic - low in people who attempt suicide and
in patients who are impulsive and aggressive.
• serotonin – Increased levels with serotonergic agents may produce
dramatic changes in some character traits of personality.
4. Electrophysiology
Changes in electrical conductance on the electroencephalogram
(EEG) occur in some patients personality disorders, most commonly
antisocial and borderline types; these changes appear as slow-wave
activity on EEG

9. 5. NEURO ANATOMICAL
• Childhood central nervous system
dysfunctions associated with soft neurological
signs are most common in people with
antisocial and borderline personality
disorders.
• Children with minimal brain damage are
at risk for personality disorders, particularly
antisocial personality disorder.

10. B. PSYCHODYNAMIC FACTORS
Sigmund Freud suggested that personality traits
are related to a fixation at one psychosexual stage of
development.
Those with an oral character are passive and dependent
because they are fixated at the oral stage, when the
dependence on others for food is prominent.
Those with an anal character are stubborn and highly
conscientious because of struggles over toilet training
during the anal period.

12. C. OTHER FACTORS
• Maternal deprivation- antisocial personality.
• Failure to resolve oedipal complex - histrionic
Personality
• Children suffering from abuse or trauma or
children living in homes in which there is
domestic abuse, divorce, separation, or
parental absence - borderline Personality

13. • Fixation in oral stage of development -
dependent personality
• Lack of parental affection and persistent
rejection in childhood – paranoid personality

14. CLASSIFICATION OF
PERSONALITY
DISORDERS

15. ICD 10
• F60-F69 : Disorders of adult personality and behaviour
• F60 : Specific personality disorders
• F60.0 : Paranoid personality disorder
• F60.1 : Schizoid personality disorder
• F60.2 : Dissocial personality disorder
• F60.3 : Emotionally unstable personality disorder
• F60.4 : Histrionic personality disorder
• F60.5 : Anankastic personality disorder
• F60.6 : Anxious (Avoidant) personality disorder
• F60.7 : Dependent personality disorder
• F60.8 : Other specific personality disorder
• F60.9 : Personality disorder, unspecified

16. DSM5 CLASSIFICATION
CLUSTER A
Paranoid
personality
disorder
Schizoid
personality
disorder
Schizotypal
personality
disorder
CLUSTER B
Histrionic
personality
disorder
Narcisstic
personality
disorder
Antisocial
personality
disorder
Borderline
personality
disorder
CLUSTER C
Dependent
personality
disorder
Avoidant
personality
disorder
Obsessive -
compulsive
personality
disorder

17. CLUSTER A PERSONALITY DISORDER
1.PARANOID PERSONALITY DISORDER
Definition
Paranoid personality disorder (PPD) is a mental
illness characterized by paranoid delusions, and
a pervasive, long-standing suspiciousness and
generalized mistrust of others.

18. CLINICAL FEATURES
• Suspiciousness
• mistrust
• hypervigilant, and ready for any real or imagined
threat.
• Stubborn and jealous
• Appear tensed and irritable.
• Always feel that others are taking advantage of them
• Oversensitive and tend to misinterpret minute cues
within environment

20. • Constantly testing the honesty of others
• Maintain self esteem by attributing their short coming
to others
• Persons with this disorder suspect that others are
acting to harm, or exploit them.
• The disorder may be manifested by irritability, unusual
defensive or self-protective behaviours (eg. locking
doors and closing windows, hiding papers or
documents)
• They doubt the loyalty or trustworthiness of friends
and partners, and check their behaviour repeatedly.

21. • Avoid interactions with others.
• Magnifying and distorting them into thoughts
of trickery.
• They are envious and hostile toward others.
• They bear grudges and unwilling to forgive the
insults, injuries, from others.

22. CLUSTER A
2. SCHIZOID PERSONALITY DISORDER
Definition
Schizoid personality is characterized by a lack of
interest in social relationships, a tendency
towards a solitary or sheltered lifestyle,
secretiveness, emotional coldness, detachment
and apathy.

24. CLINICAL FEATURES
• Emotionally cold
• Detached
• Aloof
• Humorless
• Introspective
• No enjoyment or close relationship
• Inability to experience pleasure

25. CLUSTER A
3. SCHISOTYPAL PERSONALITY
DISORDER
DEFINITION
Schizotypal personality disorder is a mental
disorder characterized by odd thinking and
behaviour, severe social anxiety, thought
disorder, paranoid ideation, The essential
features of people with this disorder are a
pervasive pattern of detachment from social
relationships and a restricted range of
expression of emotions in interpersonal settings.

26. CLINICAL FEATURES
• Behaviour or appearance that is odd, eccentric or
peculiar
• Poor rapport with others and a tendency to
withdraw socially
• Odd beliefs or magical thinking, influencing
behaviour and inconsistent with subcultural
norms;
• Suspiciousness or paranoid ideas;
• Obsessive ruminations without inner resistance

28. TREATMENT
• Psychotherapy
Psychotherapy is the most effective
form of treatment for paranoid personality
disorder. It is a form of counselling will focus on
increasing general coping skills, improving social
interaction, communication, and self-esteem of
the individual.

29. Pharmacotherapy
Antianxiety agents such as Diazepam (Valium)
Antipsychotics such as Thioridazine or
Haloperidol can be used for reducing severe
agitation.

30. CLUSTER B PERSONALITY DISORDER
1. ANTISOCIAL PERSONALITY
DISORDER
( Dissocial PD disorder)
Definition
Antisocial personality disorder is a pattern
of socially irresponsible, exploitative, and
guiltless behaviour, evident in the tendency to
fail to conform to the law and violate the rights
of others.

31. CLINICAL FEATURES
• Unconcern for the feelings of others;
• Gross and persistent attitude of irresponsibility and
disregard for social norms, rules, and obligations
• Incapacity to maintain enduring relationships, though
having no difficulty in establishing them
• Very low tolerance to frustration and a low threshold
for discharge of aggression, including violence
• Incapacity to experience guilt or to profit from
experience, particularly punishment
• Marked readiness to blame others

32. TREATMENT
• Psychotherapy
• self help groups have been more useful than
have jails in alleviating the disorder. Before
treatment begins, firm limits are essential.
Therapists must find ways of dealing with
patient’s self-destructive behaviour.

33. • Pharmacotherapy
• SSRI, Lithium, Carbamazepine, Clonazepam
and other anticonvulsants have been used to
control aggressive behaviour
• If a patient shows evidence of ADHD,
psychostimulants such as methylphenidate
(Ritalin) may be of use.

34. NURSING INTERVENTIONS
Convey an accepting attitude, be honest and
keep the promises
Maintain low level of stimuli in the environment
Remove all dangerous objects from the
environment
Encourage to verbalization of hostile feelings

35. • Channelize the hostile energy into a
productive function
• Have sufficient staff to show of strength
• Explain consequences if the limits are
violated, and all staff must be consistent in
enforcing it.
• Help patient to gain insight into his own
behaviour

36. • Administer tranquillizing medications as
prescribed
• Use mechanical restrains if necessary

37. CLUSTER B
2. HISTRIONIC PERSONALITY
DISORDER
DEFINITION
Histrionic personality disorder (HPD) is
characterized by a pattern of excessive
attention-seeking emotions, usually beginning in
early adulthood, including inappropriately
seductive behaviour and an excessive need for
approval.

38. CLINICAL FEATURES
• Self-dramatization
• Exaggerated expression of emotions
• Suggestibility
• Egocentricity
• Over concern with physical attractiveness
• Lack of consideration for others
• Easily hurt feelings
• Continuous seeking for appreciation, excitement
and attention.

39. 3.BORDERLINE PERSONALITY
DISORDER (EUPD – Emotionally
unstable personality disorder)
DEFINITION
BPD is marked by a pattern of instability in
interpersonal relationship, mood, behaviour and
self image.

40. CLINICAL FEATURES
• Their unstable mood is a mixture of depressed
affect, anger, loneliness, and emptiness.
• Cognitive style are easily suggestible and
frequently change their decisions.
• Mood swings are common.
• Patients can be argumentative at one moment,
depressed at the next and later complain of
having no feelings

41. • Marked tendency to engage in quarrelsome
behaviour and to have conflicts with others,
especially when impulsive acts are thwarted
or criticized;
• Liability to outbursts of anger or violence

42. Treatment
• Psychotherapy
Long-term psychotherapy is currently the treatment of
choice for BPD. Supportive psychotherapy is suggested for
more fragile borderline patients, who are prone to serious
regression in treatment.
• Hospitalization
Patients with borderline personality disorder often do well in
a hospital setting in which they receive intensive
psychotherapy on both an individual and a group basis. In a
hospital, they can also interact with trained staff members
from a variety of disciplines and can be provided with
occupational, recreational, and vocational therapy

43. • Cognitive behavioural therapy
• This type of therapy relies on changing people's
behaviours and beliefs by identifying problems from
the disorder.
• Social skill training
• Social skill training, especially with videotape playback,
is helpful to enable patients to see how their actions
affect others and thereby to improve their
interpersonal behaviour.
• Ask to select a situation, write diary, discuses with
diary
• Relaxation exercise, role play.

44. Pharmacotherapy
• Antipsychotics have been used to control anger, hostility, and brief
psychotic episodes. Olanzepine more effective.
• Antidepressants improve the depressed mood common in patients
with BPD.
• Monoamine oxidase inhibitors have been effective in modulating
impulsive behaviour in some patients.
• Benzodiazepines particularly alprazolam help anxiety and
depression.
• Anticonvulsants such as carbamazepine (Tegretol) may improve
global functioning for some patients.
• Serotonergic agents such as fluoxetine have been helpful in some
cases.
•

45. CLUSTER B
4.NARCISSTIC PERSONALITY
DISORDER
DEFINITION
It is characterized by a long-term pattern of
exaggerated feelings of self-importance, an
excessive need for admiration, and a lack of
empathy toward other people.

46. CLINICAL FEATURES
• Grandiosity with expectations of superior treatment from
other people
• Fixated on fantasies of power, success, intelligence,
attractiveness, etc.
• Self-perception of being unique, superior, and associated
with high-status people and institutions
• Needing continual admiration from others
• Sense of entitlement to special treatment and to obedience
from others
• Exploitative of others to achieve personal gain
• Unwilling to empathize with the feelings, wishes, and needs
of other people

47. CLINICAL FEATURES
• Avoidant people are characterized by extreme shyness.
• Hypersensitivity to rejection by others is the central feature
of avoidant personality disorder.
• They appear distant from others and do not express wishes,
demands, or opinions.
• People with this disorder are easily hurt and humiliated by
comments from others, which they misinterpret as
degrading and disapproving.
• They tend to be shy, quiet, and inhibited.
• They react strongly to any possible indications of criticism.

48. • They usually appear anxious, self-doubting, and
insecure when speaking, often use self-defeating
expressions, and try to please others.
• They are concerned with reacting to scrutiny by
blushing or crying, which is a cause of further
interpersonal avoidance.
• They lacks intimate relationships with friends.
• They tend to see others as negative and
potentially harmful.

49. CLUSTER C
1. ANXIOUS AVOIDANT PD
DEFINITION
ANXIOUS AVOIDANT PD is marked by feelings of
inadequacy, extreme social anxiety, social
withdrawal and hyperactivity.

50. Clinical features
• Avoidant people are characterized by extreme
shyness.
• Hypersensitivity to rejection by others is the
central feature of avoidant personality disorder.
• They appear distant from others and do not
express wishes, demands, or opinions.
• People with this disorder are easily hurt and
humiliated by comments from others, which they
misinterpret as degrading and disapproving.

51. • They tend to be shy, quiet, and inhibited.
• They react strongly to any possible indications of
criticism.
• They usually appear anxious, self-doubting, and
insecure when speaking, often use self-defeating
expressions, and try to please others.
• They are concerned with reacting to scrutiny by
blushing or crying, which is a cause of further
interpersonal avoidance.
• They lacks intimate relationships with friends.
• They tend to see others as negative and potentially
harmful

52. CLUSTER C
2. DEPENDENT PERSONALITY
DISORDER (Asthenic personality
disorder)

53. DEFINITION
Dependent personality disorder (DPD) is a
personality disorder that is characterized by a
pervasive and excessive need to be taken care of
that leads to submissive and clinging behaviour
and fears of separation.

54. CLINICAL FEATURES
• Dependent patients are characterized by pervasive
pattern of dependent and submissive behaviour.
• They cannot make decisions without an advice and
reassurance from others.
• They rarely express needs or feelings, especially those
that are sexual or aggressive.
• They tend to avoid responsibilities or decisions in
major areas of their lives, such as work and financial or
interpersonal relationships.
• They manifest self-doubt, pessimism, and a need for
affection.

55. • They lack aggressiveness and appear helpless.
• These patients seek intensely for companionship and
do not tolerate being alone.
• They may function at an adequate level if in a close and
protective relationship, but when left alone they are
unable to survive,
• They believe that they are incapable of functioning
independently and require constant assistance.
• They accept unpleasant tasks, are self-sacrificing, and
tolerate verbal, physical or sexual abuse.
• An excessive and unrealistic fear of abandonment is
constant in dependent individuals.

56. Treatment
• Psychotherapy
• Insight oriented therapies enable patients to understand the
antecedents of their behaviour, and, with the support of a therapist,
patients can become more independent, assertive, and self-reliant.
• Behavioural therapy, assertiveness training, family therapy, and
group therapy have all been used, with successful outcomes in many
cases.
• Pharmacotherapy
• Pharmacotherapy has been used to deal with specific symptoms
such as anxiety and depression. Patients who experience panic attacks or
who have high levels of separation anxiety may be helped by imipramine
(Tofranil). Benzodiazepines and Serotonergic agents have also been useful.

57. 3.OBSESSIVE-COMPULSIVE
(ANANKASTIC) PERSONALITY
DISORDER
Obsessive–compulsive personality disorder
(OCPD) is characterized by excessive concern
with orderliness, perfectionism, attention to
details, mental and interpersonal control, and a
need for control over one's environment, which
interferes with flexibility, openness to
experience, and efficiency, as well as
interpersonal relationships.

58. • Clinical features
• Inflexible and lack of spontaneity.
• Very solicitous with authority figures.
• Very rank conscious and social behaviour is polite and
formal.
• Patients with obsessional personalities often produce
their own detailed lists of symptoms and are annoyed
if any item is neglected or misinterpreted.
• They are preoccupied with rules, regulations,
orderliness, neatness and the achievement of
perfection.

59. • They repeat actions and check for mistakes.
• They focus on work and productivity.
• They do not enjoy leisure time, which they may consider a waste of
time.
• They insist on perfect performance of sports or games and
transform them into a serious task.
• Stubbornness is another characteristic of these people.
• They need things to be done in their way, and realistic arguments
do not usually make them change their insistence.
• They believe that no one can do the tasks as perfectly as they can.
• They give detailed instructions, insisting that their way is the only
way of doing things, and are irritated if others suggest alternatives

60. Treatment
Psychotherapy
• Group therapy and behaviour therapy
Pharmacotherapy
• Clonazepam, a benzodiazepine
• Clomipramine and such serotonergic agents
as fluoxetine usually at dosages of 60 to 80 mg
a day.

61. PERSONALITY ASSESSMENT METHODS
1.Subjective methods
• Autobiography
• Case history
• Interview
• Questionnaire
• Inventory

62. 2.Objective methods
• Miniature life situation
• Unobserved observation ( observed through a
one way mirror)
• Rating scale

63. 3. Projective technique
• Rorschach ink blot test
• Thematic apperception test
• Children Thematic apperception test
• Play technique
• Word association
• Picture association
• Sentence completion

64. • GENERAL MANAGEMENT
• Prevent self harm
• Milleu therapy
• Limit sett
• Focusing on strength to enhance self esteem and positive coping
skill
• Journal writing
• Diary writing –review it
• Social skill training
• Anger management
• DBT – psychological education, problem solving, exercise in
monitoring mood, modeling ,meditation, home work
• Medications-

65. • NURSING MANAGEMENT OF PATIENTS WITH
PERSONALITY DISORDERS
1) Risk for Self directed violence related to impulsive
behaviour or inability to verbally express feelings
• Outcome: client remains safely
• Interventions
• Observe the client’s behaviour frequently
• Assess client’s history of self – mutilation such as types
of mutilating behaviours, frequency of behaviours.

66. • Set and maintain limits on acceptable behaviour and make clear
client’s responsibilities
• Secure a verbal contract from client that he or she will seek out a
staff member when the urge for self-mutilation is experienced
• Encourage the client to talk about feelings he or she was having just
before this behaviour occurred.
• Act as a role model for the appropriate expression of angry feelings,
and give positive reinforcement to the client when attempts to
conform are made.
• Remove all dangerous objects from the client’s environment.
• Have sufficient staff available to indicate a show of strength to the
client if it becomes necessary.
• Administer tranquilizing medications as per physicians order.

67. • 2) Risk for other directed violence related to suspeciousness
• Outcome: others remain safe
• Interventions
• Maintain a low level of stimuli
• Convey an accepting attitude and work on development of trust
• Observe the clients behaviour frequently
• Remove all dangerous object from the client
• Encourage to verbalize hostile feelings
• Explore the alternative ways to handling frustration
• Have sufficient staff to present a show of strength
• Use mechanical or chemical restraints as per order
• Assess the readiness to remove restraint frequently
•

68. • 3) Disturbed self esteem related to personal identity disturbance
• Outcome: client maintains normal level of self esteem
• Interventions
• Assess client’s level of dependence in a variety of areas.
• Help the client to gain insight into her behaviour
• Positively reinforce the client’s in independent behaviour.
• Encourage independent decision making in accordance with client’s
level of progress.
• Offer the client choices whenever possible.
• Engage the client in physical activities that offer quick rewards such
as brisk walks, exercises.
• Help the client to set realistic, attainable goals.

69. • Assess the degree of the client’s isolation and level of
progress in the self-imposed treatment regimen.
• Engage in short, simple verbal instructions with the client.
• Sit with the client for brief periods, interrupting silence only
if it appears uncomfortable for the client.
• Involve family, friends and other support systems in the
client’s social activities.
• Encourage the client to participate in therapeutic group
activities such as assertiveness training, behaviour therapy.
• Explore with the client realistic and unrealistic components
of the client’s perceptions about situations and events that
cause him or her to withdraw.

70. • 3) Impaired social interaction related to disruptive family background
• Outcome: client maintains effective social interaction process
• Interventions
• Assess the extent of the client’s self-imposed isolation.
• Structure each day to include planned times for brief interactions and
activities with the client.
• Engage the client in meaningful, non challenging interactions.
• Assess the need for and encourage skills training
• Expand limits by clarifying expectations for clients in a number of settings.
• Provide the client with stimulation from recreational and other milieu
activities
• Help the client seek out other clients to socialize with who have similar
interests.
• Praise the client for attempts to seek out others for interactions and
activities and to respond to others attempts to engage the client.

71. • 4) Ineffective individual coping related to psychosocial stressors or
intense emotional state
• Outcome: client maintains normal level of individual coping mechanism
• Interventions
• Identify behavioural limits and behaviours that are expected.
• Approach the client in a consistent manner in all interactions.
• Refrain from sharing personal information with the client.
• Encourage the client to explore feelings and concerns.
• Be non-judgemental and respectful when listening to client’s feelings,
thoughts, or complaints.
• Assist the client in coping skills training such as anger management skills,
emotional regulation skills and interpersonal skills.
• Praise the client ‘s continued use of mature behaviour and social skills.
• Encourage the client to participate in pleasurable activities, such as
games, sports, and field trips.