Personality disorder for nursing student# subject# mental health nursing#

1. PERSONALITY DISORDER

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Personality :
A set of qualities that makes a person (or thing ) distinct from
another.
Personality:
Personality is defined as a deeply ingrained patterns of behavior
that include mode of perception, relating to and thinking about oneself and the
surrounding environment.

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Personality disorders are defined as “the enduring of inner experience and
behavior that deviates markedly from the expectations of the culture of the
individual who exhibits it.”
- American Psychiatric Association
Personality is the sum total of a person’s intellectual emotional and volitional
traits , revealed by his appearance, behavior ,habits and relationship with other
people which differentiate him as a unique individual.
Personality traits
Personality traits are normal prominent aspects of personality.

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Personality Traits:
Personality traits are normal prominent aspects of personality that are
exhibited in a wide range of important social and personal context.
-APA 2000
Characteristics of Personality
 It is not a mental illness.
 It is maladaptive behavior.
 It is a possession abnormal personality.
 It is specific and unique for each and every individual.
 It is long lasting ,most of the time life long problem.
 It causes significant impairment in social or occupational functioning.
 It produces distress to the individual and to others.

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Causes of Personality disorder
1. Genetic factors:
o Chromosomal abnormality
o Interaction of hereditary dispositions ,malfunctioning gene and
environmental influences develop personality disorder such as obsessive
compulsive personality disorder, antisocial personality disorder, paranoid ,
schizotypal and schizoid personality disorder.

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2. Psychosocial Factors :
e.g. disturbed parent child relationship, lack of discipline in children, strict
discipline, stress.
3. Environmental Factors:
e.g. low socio economic class, broken home , war , employment problem.
4. Sexual abuse : common risk factor for borderline personality disorder.
5. Childhood head injuries : may influence the development of personality
disorder.

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Types /Catagories of personality disorder
DSM-V classifies personality disorder into “cluster “.i.e.
I. Cluster A : includes people whose behavior appears odd or eccentric and
includes paranoid ,schizoid, and schizotypal personality disorders.
II. Cluster B: includes people who appear dramatic , emotional or erratic
(unpredictable) and includes antisocial , borderline , histrionic and
narcissistic personality.
III. Cluster C : includes people who appear anxious or fearful and includes
avoidant ,dependent, and obsessive –compulsive personality disorder.

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1. Cluster A personality disorder :
a. Paranoid personality disorder:
Personality with paranoid personality disorder suspects other people will
harm him, does not trust others, believes that other is trying to harm him . It
is common in male. For .eg. :A person may suspicious of his wife , co-
workers or some of his neighbors.
Sign and symptoms
 Belief that other are lying ,cheating , exploiting or trying to harm .
 Interpret remarks as demanding or threatening.
 Inability to work collaboratively with others.
 Emotional detachment.

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 Hostility toward other.
 Fear of confiding in others.
 Suspicious without justification, of spouse’s or sexual partner’s fidelity.
 Become angry and threatening when they perceive they are attacked by
others.
 Tendency to experience excessive self- importance, manifest in a persistent
self referential attitude.

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Management of paranoid personality disorder
 The goal of management is to decrease the individual's suspiciousness and
isolation.
 Initially, supportive psychotherapy may be the treatment of choice.
 Individuals with severe paranoid ideation may be responsive to low doses
of antipsychotic medicine.

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Nursing Intervention
 Develop therapeutic and trusting relationship.
 Serious and straightforward approach should be done.
 Teach client to validate ideas before taking action.
 Involve the client in treatment planning.

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b. Schizoid Personality disorder:
It is primarily characterized by a very limited range of
emotion , both in expression of an experiencing , indifferent to social
relationship and particularly feelings of anger or aggression.
Sign and symptoms
 Lacks desire for close relationships including being part of a family.
 Chooses solitary activities.
 Fantasing .
 Extreme introversion.
 Emotional detachment.
 Lacks of close friends.

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 Little interest in sexual experiences.
 Limited capacity to express either warm , tender feeling or anger toward
others.
 Avoid activities.
 Appear cold and detached .
 Appear indifferent to praise or criticism of others.

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Management of Schizoid Personality disorder:
 The goal of treatment is to facilitate greater pleasure in life
through more meaningful relations with others.
 Individual psychotherapy is the initial treatment of choice.
 Antidepressant medicine may be beneficial for individual wih
marked anhedonia .

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Nursing Intervention
 Develop therapeutic relationship.
 Improve clients functioning in the community.

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c. Schizotypal Personality disorder :
Peculiarities of thinking ,odd beliefs and
eccentricities of appearance , behaviors, interpersonal style , and thought.
Sign and symptoms:
 Indifference to and withdrawal from others.
 Magical thinking or odd beliefs.
 Odd ,elaborate style of dressing ,speaking and interacting with others.odd
thinking and speech.

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 Belief that message are hidden for you in public speeches and displays.
 Suspicious or paranoid ideas.
 Unusual perceptual experiences ,including bodily illusions, derealization .
 Few close relationships (reduced capacity for close relationships.
 Excessive social anxiety.
 Inappropriate affect.
 Typical experience occupational and Social difficulties.

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Management of schizotypal personality disorder :
 Psychoanalysis or psychoanalytic psychotherapy .
 Individual psychotherapy.
 Drug therapy: antipsychotic medicine.
Nursing Intervention
 Develop self care.
 Improve community functioning.
 Social skills training

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2. Cluster B personality disorders
It includes : antisocial personality disorder; histrionic personality disorder ;
narcissistic personality disorder; and borderline personality disorder.
a. Antisocial (Sociopathic , dissocial personality disorder ):
Lack of regard for the moral or legal standards in the local culture ,
marked inability to get along with other or abide by social rules.
Sometimes called psychopaths or sociopaths. A person must be at least
18 years old and have displayed evidence of conduct disorder before the
age of 15.

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Sign and symptoms
 Chronic irresponsibility and unreliability in work and with finances.
 Lack of regard for the law and for others right .(engages in illegal
activities)
 Persistent lying and stealing .
 Aggressive , often violent behavior.
 Lack of guilt or remorse for hunting others.
 Lack of concern for the safety of yourself and others.
 Very low tolerance to frustration .

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Management of antisocial personality disorder
 Individual psychotherapy
 Psychoanalysis
 Group psychotherapy and self help group.
Nursing Intervention
 Limit setting : State the behavioral limit ,identify the consequences that will
occur if the limit is exceeded and identify the behavior that is expected or
desired.
 Confrontation regarding behavioral effects on other.
 Teach client to solve problems effectively and manage emotions of anger or
frustration.

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b. Histrionic personality disorder:
The client of this personality disorders are dramatic , emotionality (emotion
black mail, demonstrative suicide attempts etc); have attention seeking
behavior extreme emotional and liable mood, attempts to attract to
themselves, over dramatic and are excessively influenced by others.
Sign and symptoms
 Excessive sensitivity to others approval.
 Attention grabbing often sexually provocative clothing and behaviors.
(Continual seeking for excitement and activities)

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 Excessive concern with physical appearance (attractiveness).
 False sense of intimacy with others.
 Constant ,sudden emotional shifts.
 Self dramatization , theatrically, exaggerated expression of emotion.
 Is suggestible, i. e. easily influenced by other’s or circumstances.
 Exaggerated and often inappropriate displays of emotional reactions
,approaching theatricality, in every day behavior. Sudden and rapidly
shifting emotional expressions.

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Management of histrionic Personality disorder
 The goal of treatment is to decrease behaviors used to inappropriately seek
attention.
 Individual psychodynamic therapy with a focus on exploring underlying
motivations for behavior.
Nursing Intervention
 Teach social skills.
 Provide factual feedback about behavior.

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c. Narcissistic Personality disorder :
A pervasive sense of grandiosity , need for admiration , lack of empathy
and chronic intense envy.
Signs and symptoms
 Inflated sense of self importance
 Constant attention grabbing and admiration seeking behaviour.
 Lack of empathy .
 Unable to face criticism .
 Explorative behavior.
 Easily depressed by minor events.
 Needs constant praise.

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Management of Narcissistic personality disorder
 Individual psychotherapy
 Creating insight on their own behaviors.
Nursing Intervention
 Matter of fact approach should be done.
 Gain cooperation with needed treatment.
 Teach client any needed self- care skills.

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d. Borderline Personality disorder
Pervasive and excessive instability of affects , self image , and
interpersonal relationships as well as marked impulsitivity.
Signs and symptoms
 Difficulty controlling emotions or impulses (e.g. Spending ,sex, substance
abuse ,binge eating ,reckless driving) .
 Frequent dramatic changes in mood, opinions and planes.
 Stormy relationships involving frequent intense anger or difficulty
controlling angers, possible physical fights.
 Fear of being alone despite a tendency to push people way.
 Feeling of emptiness inside.
 Suicide attempts or suicidal gestures or threats or self mutilating.

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Management of Borderline personality disorder
 Supportive personality disorder.
Nursing Intervention
 Promoting client’s safety.
 Helping client cope and control emotions.
 Structuring time .
 Teaching social skills.
 Therapeutic relationship e.g. limits settings ,confrontation.
 Cognitive restructuring techniques such as Decatastrophizing, thought
stopping.

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3. Cluster C
It includes: avoidant personality disorder ,dependant personality disorder;
and obsessive –compulsive personality disorder.
a. Anxious /Avoidant personality disorder:
Characterized by pervasive and excessive hypersensitivity to negative
evaluation, social inhibition and feelings of inadequacy. Impairment can
be severe and typically includes occupational and social difficulties.

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Sign and symptoms
 Feeling of inferiority complex.
 Excessive preoccupation with being criticized or rejected in social situation.
 Self imposed social isolation.
 Extreme shyness in social situation.
 Persistent feeling of tension and apprehension.

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Managements of anxious /avoidant personality disorder
 The goal of treatment is to decrease sensitivity to criticism and improve self
–confidence.
 Individual and group psychotherapy.
 Pharmacotherapy – anxiolytic medicines are useful to control severe
anxiety in social situation.
Nursing Intervention
 Support and reassurance.
 Cognitive restructuring techniques.
 Promote self esteem.

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b. Dependent Personality disorder
It is pervasive ,extreme need of other people to a point where the person is
unable to make any decisions or take an independent stand on his or her own.
Fear of separation and submissive behavior.
Sign and symptoms
 Excessive dependence on others to meet your physical and emotional need.
 Inability to take decision.
 Feeling uncomfortable or helpless when alone.
 Tolerance of poor, even abusive treatment in order to stay in relationships.
 Could not able to have leadership .
 Avoid initiating activities independently.
 Allow other to take responsibilities important for the important decision.

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Management of dependent personality disorder
 The goal of management is to decrease inappropriate dependency on others
and to improve self-esteem.
 Cognitive behavioral therapy and psychodynamic psychotherapy.
Nursing Intervention
 Foster client’s elf reliance and autonomy.
 Teach problem solving and decision making skills.
 Cognitive restructuring techniques.

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d. Obsessive compulsive personality disorder
It is pervasive preoccupation with orderliness, perfectionism, and mental
interpersonal control, at the expense of flexibility, openness, and efficiency.
It is anankastic (repetitive ) characterized by rigid conformity to rules
,moral codes and excessive orderliness.
Sign and symptoms
 Excessive concern with order, rules, schedules and lists.
 Feeling of excessive doubt and caution.
 Perfectionisms, often so pronounced that you cant complete tasks because
your standards are impossible to meet .(perfectionism that interferes with
task completion).

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 Inability to throw out even broken, worthless objects.
 Inability to share responsibility with others.
 Financial stinginess.(willing to donates)
 Discomfort with emotion and aspects of personal relationships they you cant
control.
 Rigidity and stubbornness.
 People often seek treatment because they recognize that their life is pleasure
less or they are experiencing problems with work or relationship.
 Common in male.

36. CONTD…
Management of obsessive –compulsive personality disorder
 The goal of management is to decrease behavioral rigidity and increase
enjoyment in life.
 Psychoanalysis
 Group therapy
 Antidepressant medicine.
Nursing Intervention
 Encourage negotiation with others.
 Assist client to make timely decisions and complete work.
 Cognitive restructuring technique.

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Diagnosis of personality disorder
 History taking (ask questions about symptoms , personal history and emotional
well being) and may talk to friends and relatives bout the client.
 MSE(mental status examination)
 Personality test.
Treatment
Treatment for most personality disorders in with a combination of
psychotherapy and medications.
 Psychotherapy:
- Individual therapy
- Group therapy

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- Family therapy
- Supportive therapy
 Cognitive behaviour therapy.
 Psychoanalysis
 Medications that may offer support during therapy include:
- Antidepressants commonly prescribe selective serotonin reuptake
inhibitors (SSRIS) such as flouxetine, citalopram.
- Anticonvulsants: these medication may help suppress impulsive and
aggressive behavior. commonly prescribe carbamazepine , or valporic acid.
 Antipsychotics : resperidone , olanzepine , haloperidol , etc.
 Other medication: Antianxiety medication such as Alprazolam.
 Mood stabilizer such as lithium.

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Nursing care of clients with Personality Disorder
Assessment
 Level of social and occupational functioning.
 Individual’s perception of problem.
 Reason for seeking treatment.
 Level of anxiety.
 Pending criminal charges.
 Drug and alcohol abuse.
 History of suicidal gestures and present risk.

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Nursing Diagnosis
 Manipulative behavior related to anger or hostility / personality disorder.
 Low self –esteem related to feeling of worthlessness.
 Difficulty with interpersonal relationship related to ineffective
communication.
 Lack of insight related to denial of problems.

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Planning/ Implementation
 Maintain consistency ,concern, and a professional relationship.
 Accept the individual as is; do not react if provoked; manage counter
transference.
 Protect the individual from others while protecting others from the
individual.
 Place realistic limits on behaviour ; make known what those limits are.
 Strive for consistency among health team members; avoid splitting of staff .
 Initiate cognitive , behavioral and dialectic behavioral strategies.
 Decrease the client’s attention seeking behavior, acting out and secondary
gains.

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 Decrease the client’s feelings of worthlessness by encouraging
verbalization of feelings and providing support to the client.
Evaluation
 Demonstrates decrease episodes of acting out.
 Verbalizes decreased in anxiety.
 Accepts and continues long term therapy.
 Recognizes and functions within limits of personality.
 Maintains his or her optimum level of functioning.
 Establish and maintain mature, non manipulative relationships and patterns
of dealing with other people and situations.

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Complications of personality disorder
 Substance abuse ( cluster B personality disorder)
 Suicide borderline personality disorder are particularly at risk.
 Depression , anxiety and eating disorder.
 Increased risk of physical , emotional, and sexual abuse.(dependent
personality disorder)
 Violence and homicide (in paranoid and antisocial personality disorder)
 Self destructive behavior of engaging in dangerous behaviors such as risky
sex and gambling. (common in borderline personality disorder)
 Incarceration (antisocial personality disorder are at risk at increased risk at
committing serious crime).
 Social isolation: lack of desire for closeness or extreme shyness.