1. Prepared by:
Eric F. Pazziuagan, RN, MAN

3.  A spectrum of maladaptive traits that
produce or influence considerable
psychological and emotional
disturbance and impair relationships.
 An enduring pattern of feelings
(emotions), thinking (cognitive
distortions), and behaving
(maladaptive in nature) that become
rigid and stable over time.

4.  All
individuals have personality traits and
characteristics that make them unique and
interesting human beings.
 Traits: exhibited in the way individuals think about
themselves and others and in the way they behave.
 If traits are inflexible and dysfunctional, individuals
generally have problems in functioning and
experience subjective distress.
 Personality: characteristic traits that are
generally predictable in their influence on
cognitive, affective, and behavioral patterns of
human beings.
 Develop and evolve over time, are conscious or
unconscious, and affect adaptation and response to
the environment.

5.  Character: generated by early life experience
and is represented by learned personality traits
that influence behavioral patterns.
 Patients with personality disorders suffer
lifelong, inflexible, and dysfunctional patterns of
relating and behaving.
 Might suffer lifelong, inflexible, and dysfunctional
problems of relating and behaving.
 Usually causes distress to others (ego syntonic)
 Individuals might not find their behaviors distressing to
themselves.
 They become distressed because of other people’s behavior or
reactions toward them.
 Causes immense emotional pain and discomfort.

6.  The nurse should convey acceptance of the
individual and empathy for emotional
pain, regardless of the patient’s behavior.
 Patients do not seek treatment to their
personality but want help for
depression, anxiety, alcoholism, and for
difficulties in work and personal relationships.
 Comorbidity: anxiety and mood disorders.
 Personality disorders are often listed under axis
II:
 Used to designate developmental
disorders, personality traits, or habitual use of
particular defense mechanisms.

7.  Individuals must have disturbances in
two of the following areas:
 Cognition
 Affect
 Interpersonal functioning
 Impulse control
 Placed ina separate category (Axis II)
apart from other disorders because the
underlying causes and presenting
behaviors are different and require
different treatment approaches.

9.  10- 15 years ago: causes were thought to
be only psychological in origin
 Social environment, coupled with
psychological vulnerability, strongly
influences the individual.
 Important in the genesis of personality
disorders: effects of societal changes, a
stressful environment, and negative
childhood experiences, along with
biologic factors.

11.  Cluster A: Schizoid, schizotypal, and paranoid
disorders, characterized by odd or eccentric
behavior.
 Cluster B:
narcissistic, histrionic, antisocial, and
borderline disorders, characterized by
dramatic emotional, or erratic behaviors.
 Cluster C: dependent, avoidant, obsessive-
compulsive disorders, characterized by
anxious or fearful behaviors.

13. Cognition (thinking about
self, people, and events)
Affectivity
(range, intensity, lability, and
appropriateness of emotional
response)
Interpersonal functioning
Impulse control

15.  Suspicious of others
 Doubts trustworthiness or loyalty of friends and
others
 Fear of confiding in others
 Suspicious, without justification, of spouse’s or
sexual partner’s fidelity
 Interprets remarks as demeaning or threatening
 Holds grudges towards others
 Becomes angry and threatening when he or she
perceived being attacked by others

16.  Hypersensitive to other people’s motives and often
act in defense of a fragile self- concept.
 May think that others are treating them unfairly
 Unable to laugh at themselves and are often
humorless, and serious
 Blunted affect: might appear to be cold. But
capable of close relationship of selected few
 Do not have fixed delusions or hallucinations
 Transient psychotic symptoms: precipitated by
extreme stress
 May be hospitalized when behavior is out of
control
 Tends to occur of biologic relatives of identified
patients with schizophrenia; more on men.

18.  Lacks desire for close relationships or
friends
 Chooses solitary activities
 Little interest in sexual experiences
 Avoids activities
 Appears cold and detached
 Lacks close friends
 Appears indifferent to praise or criticism

19.  Do not want to be involved in interpersonal or
social relationships and keep people at an
emotional distance
 Appear uncomfortable interacting with others
 May be thought as hermits: shyness and
introversion
 Respond with short answers
 Respond with short answers to questions and
do not initiate spontaneous conversation
 Can function at work successfully, especially if
little verbal interaction is required.
 Reality oriented; fantasy and daydreaming
might be more gratifying

20. Nurse patient relationship:
 Focus initially on building trust
 Identification and appropriate verbal
expression and feelings
 Slowly involve patient in milieu and
group activities: help social skills.

22.  Ideas of reference
 Magical thinking or odd beliefs
 Unusual perceptual experiences, including bodily
illusions
 Odd thinking and vague, stereotypical
overelaborate speech
 Suspicious
 Odd or eccentric appearance or behavior
 Few close relationships
 Excessive social anxiety

23.  Appears similar to patients with schizophrenia;
major exception: psychotic episodes are
infrequent and less severe.
 Have problems in thinking, perceiving and
communicating
 Outward appearance is eccentric and behavior is
odd
 Fantasies about imaginary relationships might be
substituted for real relationships.
 Uncomfortable around people but are interested in
others
 More common in the biologic relatives of
schizophrenics

24.  Interventions:
 Offer support, kindness, and gentle
suggestions to help become involved in
activities
 Help the patient improve interpersonal
relations, social skills and appropriate
behavior
 Careful orchestrated interaction in socializing
experiences
 Vocational counseling and job placement
 Low doses of antipsychotics: transient
psychotic states in relation to
thinking, perception, and anxiety

27.  Deceitfulness, as seen in lying or conning
others
 Engages in illegal activities
 Aggressive behavior
 Lack of guilt or remorse
 Irresponsible in work and with finances
 Impulsiveness
 Reckless disregard of safety for self or
others

28. A pattern of disregard for the rights of others:
repeated violations of the law (as evidenced by
driving while intoxicated and engaging in spouse
or child abuse)
 Before age of 15: diagnosed as conduct disorder
 Promiscuous and feel no guilt about hurting
others
 Lying, cheating, and stealing are common
 Criminal behavior places them within the
judicial and prison systems more than it does in
the mental system
 Diagnosis: history of disordered life functioning
rather than on mental status.

29.  Might experience distress and anxiety because
of other’s hostility towards them, but they see
the problem as being in others and not
themselves
 Might appear to be charming and intellectual;
smooth talkers and deny and rationalize their
behavior
 Expected anxiety over their predicament is
absent
 Guilt, sorrow for offenses, or loyalty is
nonexistent, as if they do not have a conscience
 Do not behave as responsible, mature, and
independent adults

30.  Both geneticsand the environment are
known to influence the development:
 Parent- child relationship is unstable
 Genetic predisposition
 Highly correlated with substance abuse and
dependency problems
 Weak response to stress in ANS
 Insensitive to emotional connotations of
language: inability to learn form reward and
punishment
 Lower than average activity in the frontal
lobes (govern judgment and decision
making)

31. Nurse- patient relationship:
 Long- term treatment is necessary
 For short- term hospitalization:
 Set firm limits (may manipulate staff and
bend rules for their own desires and needs)
 Be steadfast and consistent in confronting
behaviors and enforcing rules and policies
 Consequences of behavior (both for unit and
the patient’s life) are also a point of focus
 Help the patient be aware of consequences
 Point out the effects of the behavior on
others

32.  Let the patient understand how others
feel and react to his behaviors, and why
they react in the they do
 Avoid moralizing and assist the patient in
identifying and verbalizing feelings that
might reflect anxiety and depression
 Membership in groups (more effective if
grouped with individuals with the same
diagnosis)
 Key: consistency by the nursing staff
and accountability by the patient

34.  Grandiose self- importance
 Fantasies of unlimited power, success or brilliance
 Believes he or she is special or unique
 Needs to be admired
 Sense of entitlement (i.e., deserves to be favored or
given special treatment)
 Takes advantage of others for own benefit
 Envious of others or others are envious of him or her
 Arrogant or haughty
 Grandiosity: based somewhat on reality but is
distorted, embellished, or convoluted to meet the
patient’s need of self importance.

35.  Patient overvalues himself; needs to be admired; is
arrogant; self- centered and self- absorbed; and
seems indifferent to the criticisms of others
 Feels superior and has a sense of
entitlement, demanding attention, admiration, and
special favors
 Might appear nonchalant or indifferent to criticism
while hiding feelings of anger, rage or emptiness
 Constant reinforcement is needed to boost the self-
image
 Relationship with others seem shallow but might
be meaningful if the patient’s self- esteem is
positively enhanced

36.  Cannot emphatize with others, and the
feelings of others are not understood or
considered
 Uses rationalization to blame others, makes
excuses, and provides alibis for self-
centered behaviors.
 Self- centered person is arrested in
emotional development because the parents
fail to mirror that which is appropriate or
inappropriate back to the child.

37.  Nurse- patient-relationship:
 Decrease constant recitation of self-
importance and grandiosity
 Nurse must mirror what the patient sounds
like, especially if contradictions exist, and
help the patient focus on the identification
and verbal expression of feelings.
 Supportive confrontation
 Limit setting and consistency in approach
 Realistic short- term goals focused on the
here and now: decreases fantasy and
rationalization and to increase responsibility
for self

38.  Teach patient everyone has worth, even he
or she makes mistakes and has
imperfections
 Group therapy: provides the opportunity
for the patient to see how his or her
behavior affects others, and how for the
first time, gives the patient a chance to
become involved with the problems of
others.
 Caution must be exercised to not give the
patient free rein to talk about himself or
herself.

40.  Needs to be center of attention
 Displays sexually seductive or provocative
behaviors
 Shallow, rapidly shifting emotions
 Uses physical appearance to draw attention
 Uses speech to impress others but is lacking in
depth
 Dramatic expression of emotion
 Easily influenced by others

41.  Exaggerates degree of intimacy with others.
 Extroverted and thrives on being center of
attention
 Behavior is silly, colorful, frivolous, and seductive
 Speech is vague, and overembellished but lack
details, ensight, and depth
 Seems to be in a hurry and restless
 Temper tantrums and outbursts of anger are seen
 Overreactions to minor events
 Uses somatic complaints to avoid responsibility
and support dependency
 Dissociation is common defense to avoid feelings

42.  Cannot deal with his or her true feelings
 Views relationship with others as special
or possess greater intimacy than is real:
recently met individuals are thought to
be as dear friends
 Causes:
 Unknown
 Probably a result of many factors
 Mother negates the child’s inner feelings in the
early mother- child relationship
 Child turns to father for nurturance, and the father
responds to the child’s dramatic emotional
behaviors

43.  Nurse- patient relationship:
 Positive reinforcement in the form of
attention, recognition, or praise is given for
unselfish or other- centered behaviors.
 Provide support to facilitate independent
problem solving and daily functioning
 Help client clarify own feelings and help the
patient learn appropriate ways to express
them
 Working with these patients can be
frustrating for the nurse because the patient
needs time to internalize the meaning of
what the nurse is trying to accomplish

45.  Frantic avoidance of abandonment, real or imagined
 Unstable and intense personal relationships
 Identity disturbance
 Impulsivity
 Affective instability
 Recurrent suicidal behavior or self- mutilating
behavior
 Rapid mood shifts
 Chronic feelings of emptiness
 Problems with anger
 Transient dissociative and paranoid symptoms

46.  Features:
 Emotional dysregulation, anger, impulsivity, intense
psychological pain, impairment in interpersonal or
occupational functioning, identity or self- image
disturbances, abandonment fears, and self- injurious
behaviors.
 The most commonly treated.
 Difficult to appreciate the complexity of the
individual’s disorders.
 Require hospitalization when they are in crisis
or exhibit self- injurious or suicidal behaviors.

47.  Have problems with identity, self- image,
relationships, thinking, mood, and impulsive
behaviors.
 Identity: uncertain about self- image, career goals,
personal values, and sexual orientation.
 Interpersonal relationships: chaotic and problems
exist in choosing unhealthy relationships and short-
term intimate relationships
 Alternates between overidealization and devaluation
of individuals
 “falls in love” with the perfect person and, shortly thereafter,
can find no redeeming qualities in the formerly idealized
person
 Cannot appreciate the mixed bag of qualities that most people
have
 Manipulation and dependency commonly occur.
 Difficulty in being alone and seeks intense but brief
relationships

48.  Mood disturbances: symptoms of depression,
intense anger, and labile mood.
 Projective identification: displace angry feelings
towards others to justify their own feelings
 Blaming others helps in dealing with feelings though
dysfunctional and inappropriate
 Intense emotional pain contributes to mood shifts,
which range from euphoria to crying to acting out
behaviors, such as displays of temper and physical
fights, self- mutilation, and suicidal behaviors
 Impulsiveness:
use of substances and a
tendency towards anorexia- bulimia
 Others: overspending, promiscuity, compulsive
overeating, and unhealthy risk taking and decision
making.

49.  Self- injury: frantic
efforts to avoid abandonment
and attempts to cope with effective dysregulation
and impulsive aggression
 75%: women and victims of childhood sexual
abuse
 Splitting: inability to view both the self and others as
having both good and bad qualities.
 All good or all bad
 Helps the individual avoid the pain and feelings associated with
past abuse and current situations involving threats of rejection
or abandonment
 Complexity can include severe symptoms of PTSD and
dissociative disorders
 Might exhibita need for attention and affection by
contradictory behaviors of
manipulation, dependency, or acting out.

50.  Frustration on the part of the staff might be seen as
rejection.
 Leads to increased anger and withdrawal because of fear of abandonment
 Shifts between depression, anxiety, euphoria, and anger are seen in the
patient’s labile mood
 During times of stress: May regress to immature
behaviors and is unable to cope with conflict.
 May vacillate between clinging and disengaged
behaviors, as demonstrated by wanting the staff to solve
all problems or by the patient viewing the inpatient
treatment as unnecessary and meaningless.
 When progress seem to be occurring, the patient with a
BPD might suddenly exhibit opposite behaviors, and it
might seem as if the staff will need to restart all over.
 Uses self mutilation or self- injurious behavior for the
purpose of self- punishment, tension
reduction, improvement in mood, and distraction from
intolerable effects.
 Cutting, burning, and severe skin scratching
 After self- mutilation, patient is better and appear relieved

51.  Serious risk for suicide
 Feelings of hopelessness, despair, and depression
contribute to their suicidality
 At risk because of:
depression, aggression, impulsivity, underestimation
of the lethality of their behavior and more frequent
occurrence of suicidal thoughts
 Don’t interpret mutilation as manipulation or
attention- seeking behavior
 Lethality of individuals who self- mutilate and
attempt suicide is as serious as those who do not
self-mutilate and attempt suicide
 Self- mutilation and suicide attempts should never be
minimized or ignored
 1 in 10 completes suicide and risk is at highest with
comorbid substance- related and depressive
disorders.

52.  Unique causes:
 Combination of temperament, childhood
experiences, and neurologic and biochemical
dysfunction
 Biologic, environmental, and stress- related factors
contribute to the complexity of the disorder.
 Neurotransmitter dysregulation of the serotonin
system: affective disturbances and impulsive
behaviors
 Abnormal cholinergic and adrenergic systems:
predisposes to dysphoria, emotional lability, and
hyperreactivity to the environement, which might
contribute to affective instability.

53.  Environmental factors: chaotic home environment,
neglect of the child’s feelings and needs, and verbal,
emotional, physical and sexual abuse.
 Stress- related events might trigger the individual’s
genetically based vulnerable temperament and
create misery and frustration
 Is reminded of earlier stress or trauma, which
results in the development of the borderline
symptoms and condition
 Early trauma and stress affect the hippocampus
 Lack of integration of the right and left
hemispheres results in abused children using their
right hemispheres for frightening memories and
left hemispheres when thinking of neutral
memories: splitting

54.  Nurse- Patient Relationship
 Use empathy while maintaining clear boundaries-
important in establishing a relationship with the patient.
 Nurse is not a friend but a health care professional
 Acknowledge reality of pain, offer support, and empower
patient to understand, control, and change dysfunctional
behavior.
 Identify and verbalize feelings, control negative
behaviors, and slowly begin to replace them with more
appropriate actions.
 Conduct a suicide assessment and provide a safe
environment to decrease self- harm and contain impulses
and then work with patient to find less destructive ways
to handle anger, rage, and psychic pain.
 Help patient identify feelings and verbally express them
nonaggresively.
 Discuss alternative methods to handle feelings.
 Use of behavioral contract.

55.  Have patient write a notebook or a
journal in a daily basis.
 Patients who are victims of abuse
need to talk about their trauma in a
safe environment.
 Consistency, limit setting, and
supportive confrontation.
 Enforce unit rules, provide clear
structure, and place the responsibility for
appropriate behaviors on the patient.
 Help to develop realistic short- term
goals.

56.  Psychopharmacology
 Used for specific symptoms:
 Cognitive- perceptive- antipsychotics for 3 to 12
weeks
 Affective or emotional dysregulation- SSRIs for
anger, chronic emptiness, and temper
outbusrsts; Clonazepam for anxiety
management; Lithium, valproic acid, and
carbamazepine for rapid mood swings
 Impulse- behavioral self- control: SSRIs to
decrease impulse behaviors

57.  Milieu management
 Firm limits, consistency, and clear
structure
 Consistent communication among staff
members
 Group sessions: dialectal behavior
therapy, assertiveness training, problem
solving, stress management, and anger
management
 Referral to self- help groups for
alcoholism, drug addiction, eating
disorders, and victimization
 Vocational counseling and training

60.  Unable to make daily decisions without much
advice and reassurance
 Needs others to be responsible for important
areas of life
 Seldom disagrees with others because for fear of
loss of support or approval
 Problems with initiating projects or doing things
on own because of little self- confidence
 Performs unpleasant tasks to obtain support form
others
 Anxious or helpless when alone because of fear of
being unable to care for self

61.  Urgently seeks another relationship for
support and care after a close relationship
ends
 Preoccupied with fear of being alone to care
for self
 Pervasive and excessive need to be taken
care of that leads to submissive and clinging
behaviors and fears of separation.
 Dependent individuals want others to make
daily decisions for them.
 Needs direction and reassurance.
 Feel inferior and cling to others excessively
because they need to rely on others

62.  Perceive themselves as being unable to function
without the help of others.
 Expects that they perform good deeds for others,
they will be rewarded by someone doing
something for them.
 An intimate relationship with spouse who is
abusive, unfaithful, or an alcoholic is tolerated so as
not to disturb the sense of attachment.
 Means of avoiding conflict: passivity and
concealing of sexual feelings.
 Unique causes:
 Psychosocial theories consider culture to be the basis of the
development of this disorder.
 E.g. Women should maintain a dependent role.
 Child should not exhibit autonomous behaviors.

63. Nurse- patient relationship:
 Nurse slowly works on decision making
with the patient to increase
responsibility for self for daily living.
 Needs assistance with managing anxiety
because it will increase as the patient
assumes more responsibility for self.
 Assertiveness: an important area of the
nurse’s teaching which enables the
patient to clearly state his or her feelings,
needs and desires.
 Verbalization of feelings.

65.  Avoids occupations involving interpersonal contact
because of fears of disapproval or rejection
 Uninvolved with others unless certain of being liked
 Fears intimate relationships because of fear of
shame or ridicule
 Preoccupied with being criticized or rejected in
social situations.
 Inhibited and feels inadequate in new interpersonal
situations
 Believes self to be socially inept, unappealing, or
inferior of others
 Very reluctant to take risks or engage in new
activities because of possibility of being
embarrassed.

66.  Timid, socially uncomfortable, and
withdrawn.
 Feels inadequate and are hypersensitive to
criticism.
 Desires relationship but need to be certain
of being liked before making social contacts.
 Avoids situations in which they might be
disappointed or rejected.
 Sounds uncertain and lacks self- confidence
and also afraid to ask questions or speak up
in public, withdraws from social
support, and conveys helplessness.

67.  Nurse- patient relationship:
 Increased shyness and avoidant behavior during
adolescence might lead to this disorder.
 Gradually help patient to confront his fears.
 Discuss patient’s feelings and fears before and after
doing something that he or she is afraid to do.
 Support patient in accomplishing small goals.
 Help patient to be assertive be assertive and
develop social skills when necessary.
 Include patient in interaction with others and then
progress to small groups.
 Relaxation techniques.
 Give positive feedback for any real success and for
any attempts to engage in interaction with others.

69.  Preoccupation with details, rules, lists, organization
 Perfectionism that interferes with task completion
 Too busy working to have friends or leisure activities
 Overconscientious and inflexible
 Unable to disregard worthless or worn- out objects
 Others must do things his or her way in work- or
task- related activity
 Reluctant to spend and hoards money
 Rigid and stubborn
 Perfectionist and inflexible.
 Overly strict and often set standards for themselves
(too high); thus their work is never good enough

70.  Preoccupied with rules, trivial details, and
procedures.
 Difficult to express warmth or tender emotions
 Little give and take in their interactions
 Rigid, controlling, and cold.
 Serious about his activities, so having fun or
experiencing pleasure is difficult
 Indecisive or will put off decisions until all facts
have been obtained
 Affect is constricted, might speak in a monotone
 Unique causes:
 Issues of autonomy, control, and authority during
childhood: predisposing factors
 Might be genetically inherited

71.  Nurse- patient relationship:
 Support patient in exploring his or her feelings
and in attempting new experiences and
situations
 Help with decision making and encourage follow-
through behavior
 Confront procrastination and intellectualization
 Teach the importance of leisure activities and
exploring interests in this area
 Needs to look at and understand other’s view of
him
 Teach the patient that he is a human and that it is
alright to make mistakes.

74.  Enduring pattern of
disobedience, argumentativeness, explosive angry
outbursts, low frustration tolerance, and a
tendency to blame others for quarrels or
accidents.
 Might begin early in the development.
 Most common diagnosis among preschoolers.
 Tends to be associated with comorbid diagnoses
of anxiety and mood disorders and either a single
or comorbid diagnosis of ADHD.
 Frequently in conflict with adults.
 Trouble maintaining friendships.

76.  Characterized by more serious violations of
social standards, such as
aggression, vandalism, cruelty to
animals, stealing, lying, truancy.
 Comorbidity: ADHD, depression, learning
disorder.
 Relationship between ADHD and CD points out
the potential contirbution of family genetic
studies.
 An enduring set of behaviors that evolves over
time, usually characterized by aggression and
violation of the rights of others.