personality disorder

1. Personality disorder and its
management

2. Introduction
• Personality disorder, also known as “character
disorder”, is the possession of one or more personality
traits that deviates from the normal that they interfere
with the individual’s well- being or adjustment to
society and require psychiatric attention. Personality
disorder is not the same as mental illness, so to speak.
The symptoms of mental illness are not continuous, but
mostly episodic. The symptoms of personality disorders
are continuous and start from adolescence or even
before.

3. Definition
Personality
• The totality of emotional and behavioral
characteristics that are particular to a specific
person and that remain somewhat stable and
predictable over time
Personality traits
• Personality traits enduring patterns of perceiving,
relating and thinking about the environment and
oneself that are exhibited in a wide range of social
and personal contexts. (APA, 2000)

4. Personality disorder
A personality disorder is a type of mental
disorder in which you have a rigid and unhealthy
pattern of thinking, functioning and behaving. A
person with a personality disorder has trouble
perceiving and relating to situations and to
people. This causes significant problems and
limitations in relationships, social encounters,
work and school

5. Characteristics of personality
disorders
a) It is not a mental illness.
b) It is a maladaptive/rigid/pervasive/chronic behavior.
c) It is the possession of abnormal personality traits.
d) It is a long lasting, most of the time life-long problem
e) It causes significant impairment in social or occupational
functioning.
f) It produces distress to the individual and others.
g) His/her behaviour deviates from cultural standards.
h) The behaviour is consistent over time.

6. Personality disorders diagnosis
a) These patterns of behavior must be chronic and
pervasive, affecting many different aspects of the
individual’s life, including social functioning, work,
school and close relationships.
b) The individual must exhibit symptoms that affect
two or more of the following areas: thoughts,
emotions, interpersonal functioning and impulse
control.

7. Cont….
c) The pattern of behaviors must be stable across
time and have an onset that can be traced back to
adolescence or early adulthood.
d) These behaviors cannot be explained by any
other mental disorders, substance abuse or
medical conditions.

8. Etiology
• The exact cause of personality disorder is
unknown; most likely, they represent a
combination of genetic, biological, social,
psychological, developmental and
environmental factors.

9. Genetic factor
• Certain personality traits may be passed on to us
by our parents through inherited genes. These
traits are sometimes called temperament.
Biological factors
• Some researchers suspect that poor regulation of
the brain circuits that control emotion increases
the risk for a personality disorder when combined
with such factors as abuse, neglect or separation.

10. Environment
• This involves the surroundings one grew up in,
events that occurred, and relationships with
family members and others.
• Personality disorders are thought to be caused by
a combination of these genetic and environmental
influences. Your genes may make you vulnerable
to developing a personality disorder, and a life
situation may trigger the actual development.

11. Risk factors
• Family history of personality disorders or other
mental illness.
• Low level of education and lower social and
economic status
• Verbal, physical or sexual abuse during childhood
• Neglect or an unstable or chaotic family life
during childhood
• Being diagnosed with childhood conduct disorder
• Variations in brain chemistry and structure

12. Symptoms of personality disorders
• Symptoms of personality disorders are
grouped according to the types of the disorder.
Types of personality disorders are grouped into
three (3) clusters, based on similar
characteristics and symptoms. However, many
people with one personality disorder also have
signs and symptoms of at least one additional
personality disorder.

13. Types of personality disorders
CLUSTER A
(odd, eccentric thinking or behavior)
• 1. Paranoid personality disorder
• 2. Schizoid personality disorder
• 3. Schizotypal personality disorder

14. • CLUSTER B (dramatic, flamboyant, erratic,
overly emotional or unpredictable thinking)
• 1. Antisocial/Psychopath/Sociopath/Dissocial
personality disorder
• 2. Borderline personality disorder
• 3. Histrionic personality disorder
• 4. Narcissistic personality disorder

15. CLUSTER C (anxious, fearful thinking or
behavior)
• 1. Avoidant/Anxious personality disorder
• 2. Dependent personality disorder
• 3. Obsessive-compulsive/Anankastic
personality disorder

16. Paranoid personality disorder
• Pervasive distrust (mistrust) and suspicion of others
and their motives.
• Unjustified belief that others are trying to harm or
deceive him/her.
• Unjustified suspicion of the loyalty or trust worthiness
of others.
• Hesitant or unwillingness to confide in others due to
unreasonable fear that others will use the information
against him/her.
• Paranoid personality disorder

17. Paranoid personality disorder
• Perception of innocent remarks or nonthreatening
situations as personal insults or attacks.
• Angry or hostile reaction to perceived slights or
insults.
• Tendency to hold grudges/unforgiving of insults.
• Unjustified, recurrent suspicion that spouse or
sexual partner is unfaithful.
• Argumentative; stubborn

18. Schizoid personality disorder
• Lack of interest in social or personal relationships,
preferring to be alone
• Limited range of emotional expression
• Inability to take pleasure in most activities
• Inability to pick up normal social cues
• Appearance of being cold or indifferent to others
• Little or no interest in having sex with another person

19. Schizotypal personality disorder
• Peculiar dress, thinking, beliefs, speech or behavior.
• Odd perceptual experiences, such as hearing a voice
whisper his/her name, i.e., has ideas of reference.
• Flat emotions or inappropriate emotional responses.
• Social anxiety and a lack of or discomfort with close
relationships.
• Indifferent, inappropriate or suspicious response to
others

20. Antisocial personality disorder
• Disregard for others’ needs or feelings.
• Persistent lying, stealing, using aliases,
conning others.
• Recurring problems with the law.
• Repeated violation of the rights of others.
• Fails to plan ahead

21. • Aggressive, often violent behavior
• Disregard for the safety of self or others
• Impulsive behaviour
• Consistently irresponsible
• Lack of remorse for behaviour
• Appear intelligent or charming

22. Borderline personality disorder
• Impulsive and risky behavior, such as having
unsafe sex, gambling or binge eating
• Unstable or fragile self-image
• Unstable and intense relationships
• Up and down moods, often as a reaction to
interpersonal stress
• Suicidal behavior or threats of self-injury

23. • Intense fear of being alone or abandoned
• On-going feelings of emptiness
• Frequent, intense displays of anger
• Stress-related paranoia that comes and goes
• Difficulty controlling anger
• Assumes little responsibility for problems

24. Histrionic personality disorder
• Constantly seeking attention
• Excessively emotional, dramatic or sexually provocative
to gain attention
• Speaks dramatically with strong opinions, but few facts
or details to back them up
• Easily influenced by others or circumstances
• Shallow, rapidly changing emotions
• Excessive concern with physical appearance
• Thinks relationships with others are closer than they
really are
• Use repression to ignore unpleasant feelings, i.e.,
unconscious forgetting of events.

25. Narcissistic personality disorder
Belief that s/he is special and more important than others.
• Fantasies about power, success and attractiveness.
• Failure to recognize others’ needs and feelings.
• Exaggeration of achievements or talents.
• Expects to be given preferential treatment over
• Expectation of constant praise and admiration.
• Arrogance.
• Unreasonable expectations of favors and advantages,
often taking advantage of others.
• Envy of others or belief that others envy him/her.
• Only concern with selfish pursuits.

26. Avoidant personality disorder
• Too sensitive to criticism or rejection
• Feeling inadequate, inferior or unattractive
• Avoidance of work activities that require
interpersonal contact
• Social inhibition, timidity and isolation, especially
avoiding new activities or meeting strangers
• Has sense of inferiority complex
• Extreme shyness in social situations and personal
relationships

27. • Fear of disapproval, embarrassment or ridicule
• Unusually reluctant to take personal risks or to
engage in any new activities because they may
prove embarrassing.
• Differ from schizoid personality disorder because
s/he does desire friendship.

28. Dependent personality disorder
• Excessive dependence on others and feels the
need to be taken care of.
• Submissive or clingy behavior toward others.
• Fear of having to provide self-care or fend for
him/herself if left alone.
• Lack of self-confidence, requiring excessive
advice and reassurance from others to make even
small decision

29. • Difficulty starting or doing projects on his/her
own due to lack of self-confidence.
• Difficulty disagreeing with others, fearing
disapproval.
• Tolerance of poor or abusive treatment, even
when other options are available.
• Urgent need to start a new relationship when a
close one has ended.

30. Obsessive-compulsive personality
disorder
• Preoccupation with details, orderliness and rules
• Extreme perfectionism, resulting in dysfunction and
distress when perfection is not achieved, such as
feeling unable to finish a project because s/he doesn’t
meet his/her own strict standards.
• Desire to be in control of people, tasks and situations
and inability to delegate tasks.
• Neglect of friends and enjoyable activities because of
excessive commitment to work or a project.

31. • Inability to discard broken or worthless objects, i.e.,
difficulty throwing away of unnecessary items.
• Rigid and stubborn.
• Inflexible about morality, ethics or values.
• Tight, miserly control over budgeting and spending
money.

32. Passive-aggressive personality
disorder
• These people procrastinate, do not perform tasks
adequately, and make excuses for their behaviour.
• They manipulate themselves into dependent
positions and force others to become responsible
for them.
• Friends become angry and frustrated with these
people and often feel manipulated.

33. • They deny unacceptable feelings by adopting
the opposite attitude.
• Unreasonably criticizes and scares authority.
• Complains of being misunderstood or
unappreciated by others.
• Envy towards those who are ahead of him.
• They are pessimistic and generally lack self-
confidence.

34. Depressive personality disorder
• These people are chronically unhappy, anhedonic,
and generally pessimistic.
• Their lives are usually described as lonely and sad.
• They tend to feel hopeless and inadequate with
frequent self-doubting.
• Their personality traits are consistent with
depressive symptoms.

35. TREATMENT OF PERSONALITY
DISORDERS
Psychotherapy
• Talk therapy
• Insight therapy
• Group therapy
• Counselling therapy

36. Medical treatment
Antidepressants
• Antidepressants may be useful if you have a
depressed mood, anger, impulsivity, irritability
or hopelessness, which may be associated with
personality disorders.
Mood stabilizers
• As their name suggests, mood stabilizers can
help even out mood swings or reduce
irritability, impulsivity and aggression.

37. Antipsychotics
• To treat any perceptual disturbances; reduce
aggressiveness.
Anti-anxiety medications
• These may help if the individual has anxiety,
agitation or insomnia. But in some cases, they
can increase impulsive behavior, so they’re
avoided in some personality disorders.

38. ANTISOCIAL (AMORAL, DISSOCIAL,
SOCIOPATH, PSYCHOPATH) PERSONALITY
DISORDER
• New evidence points to the possibility that
children often develop antisocial personality
disorder as a result of environmental as well as
genetic influence.
• The individual must be at least 18 years of age
to be diagnosed with this disorder.
• The prevalence of this disorder is 3% in males
and 1% from females, as stated in the DSM IV-
TR.

39. Types of Antisocial personality
disorder
Intelligent/Creative Psychopath
• These individuals appear very creative and
can be charming, lie with straight face, and
talk their way out of trouble. They are
irresistible, believe their own lies, extremely
persuasive, talented, and also have the ability
to manipulate well

40. • Passive Psychopath
• These individuals are very inadequate who
fail to adapt to the requirements of the society.
They are cold, inept, passive and unresponsive.
They hover around aimlessly in the community
with no place to stay permanently.

41. • Secondary psychopaths
• Who may feel slight emotions of worry or
guilt. These are avid risk-takers, exposing
themselves to more stress and danger than the
average person, who play by their own rules.

42. • Aggressive Psychopaths
• These individuals are easily prone to violent acts
and demonstrate hostility to people. They may
engage in criminal activities, yet fail to change
their behaviour even after being punished for it.
They may also violate the conditions of their
release from lawful custody. They act out their
frustrations with the least provocation and as a
result do not have long lasting relationships

43. Symptom criteria required for a
diagnosis of antisocial personality
disorder
• Being at least 18 years old
• Having had symptoms of conduct disorder
before age 15, which may include such acts as
stealing, vandalism, violence, cruelty to
animals and bullying
• Repeatedly breaking the law
• Repeatedly conning or lying to others

44. • Being irritable and aggressive, repeatedly
engaging in physical fights or assaults
• Feeling no remorse — or justifying behavior
— after harming others Having no regard for
the safety of self or others
• Acting impulsively and not planning ahead
• Being irresponsible and repeatedly failing to
honour work or financial obligations

45. Assessment and Diagnostic Finding
Toxicology screen.
• Substance abuse is common in many
personality disorders, and intoxication can lead
patients to present with some features of
personality disorders.
• Screening for
HIV

46. CT scanning.
• Computed tomography scanning with
appropriate blood work can be carried out if
organic etiology is suspected.
Radiography.
• Radiography can be indicated for injuries from
fighting, motor vehicle accidents, or self-
mutilation.

47. Medical Management
• Caregivers should be vigilant about suicidal
potential and should document their assessments
in the medical record at each visit.
Psychotherapy
• 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.

48. • Inpatient care
• Because the underlying disorder remains basically
unchanged by inpatient interventions, length of stay
should be minimized to avoid dependency that subverts
recovery from the circumstances prompting the
hospitalization
• Transfers
• Some patients hospitalized in the psychiatric units of
general hospitals, where stays are generally shorter than
2 weeks, may require transfer to psychiatric hospitals
that can provide long-term care.

49. • Pharmacologic Management
• Medications are in no way curative for any
personality disorder; they should be viewed as an
adjunct to psychotherapy so that the patient may
productively engage in psychotherapy.
• Antidepressants Common antidepressants used
with personality disorders include sertraline
(Zoloft®), fluoxetine (Prozac®), paroxetine
(Paxil®), nefazodone (Serzone®), escitalopram
(Lexapro®), and Mirtazapine (Remeron®).

50. Mood-Stabilizing Medications
• These medications are prescribed for
emotional lability, irritability, aggression, and
impulse control. Common medications used
with personality disorders include valproic
acid (Depakote®) and lithium.

51. • Mood-Stabilizing Medications
• These medications are prescribed for
emotional lability, irritability, aggression, and
impulse control. Common medications used
with personality disorders include valproic
acid (Depakote®) and lithium.

52. • Anticonvulsants
• These agents are useful for stabilizing the
affective extremes in patients with bipolar
disorder, but they are less effective in doing so
in patients with personality disorders; they
have some demonstrated efficacy in
suppressing impulsive and particularly
aggressive behavior in patients with
personality disorder.

53. Antipsychotics
• The use of antipsychotics is generally brief to
treat psychotic symptoms or transient
psychotic episodes. They may also be effective
with anger and anxiety. Common medications
used in personality disorders include
risperidone (Risperdal®), quetiapine
(Seroquel®), and olanzapine (Zyprexa®).

54. NURSING ASSESSMENT
• History
• Many of these clients report disturbed early
relationships with their parents that often begin
at 18 to 30 months of age; 50% of these clients
have experienced childhood sexual abuse;
others have experienced physical and verbal
abuse and parental alcoholism

55. Mood and affect
• The pervasive mood is dysphoric, involving
unhappiness, restlessness, and malaise; clients often
report intense loneliness, boredom, frustration, and
feeling “empty”.
• Thought process and content
• Thinking about self and others is often polarized and
extreme, which is sometimes referred to as splitting;
clients tend to adore and idealize other people even
after a brief acquaintance but then quickly devalue
them if these others do not meet their expectations is
some way.

56. • Sensorium and intellectual process
• Intellectual capacities are intact, and clients are
fully oriented to reality.

57. Nursing management of the client
with PD
• Effective communication strategies
• Maintain an honest, respectful, non-retaliatory stance
• Avoid labelling the client as manipulative; establish a
pattern of behaviour that can be changed
• Avoid ultimatums or control struggles
• Encourage putting feeling into words rather than action
• Offer empathetic statement
• Confront the client who tries to undermine other client’s
treatment
• Monitor your own reactions to avoid becoming defensive
• Discuss neutral and less emotionally charged topics
• Encourage control over daily decisions