PERSONALITY DISORDERS

PERSONALITY
DISORDERS
PRESENTED BY:- KAJAL CHANDEL

INTRODUCTION
 The word personality is derived from the Greek term
“Persona”. It was originally used to describe the
theatrical mask worn by some dramatic actors at a
time. Over the years, it lost its connotation of
pretense and illusion and came to represent the
person behind the mask- the “Real” person.
 Personality disorders occurs in response to a number
of biological and psychological influences. These
variable include hereditary, temperament, experiential
learning, and social interaction.

HISTORICAL ASPECTS
 The concept of personality disorder has been described for thousand of years.
(Skodal &Gunderson).
 In the fourth century B.C., Hippocrates concluded that all disease stemmed from
an excess of or imbalance among four bodily humors: yellow bile, black bile,
blood, and phlegm. He identified four fundamental personality styles that he
concluded stemmed from excess in the four humors: The irritable and hostile
choleric (yellow bile); the pessimistic melancholic (Black bile); the overly
optimistic and extroverted sanguine (Blood); and the apathetic phlegmatic
(Phlegm)

CONTD….
 The medical profession first recognised personality disorders apart from
psychosis, were cause of their own concern in 1801, with the recognition that
an individual can behave irrationally even when the power of intellect are
intact.
 19th Century psychiatrist embraced the term “ MORAL INSANITY” the
concept of which defines what we know today as personality disorders
 People with personality disorders usually refuse the need of treatment and
deny their problems.

DEFINITION
 PERSONALITY: Personality is defined as deeply ingrained pattern of behavior
that includes modes of perception, related to thinking about oneself and the
surrounding event.
 PERSONALITY TRAITS: Personality traits are normal, prominent aspects of
personality.
 PERSONALITY DISORDERS: Personality disorders results when these
personality traits become abnormal i.e. become inflexible and maladaptive &
cause significant social and occupational impairment, or significant subjective
distress.

 PERSONALITY DISORDERS: Abnormal personality is defined as deeply
ingrained maladaptive pattern of behavior, continuing throughout the most of
adult life, although often becoming less obvious in middle or old age.
According to WHO
OR
 Personality disorders reflects adaptive failure involving impaired sense of self
identity or failure to develop effective interpersonal functioning.

EPIDEMIOLOGICAL STATISTICS
 The prevalence of personality disorders in the general
population is 5- 10%.
 Most personality disorders begins in the teen years,
when the personality further develops and matures.
 Almost all people diagnosed with personality
disorders are above the age of 18.
 Approximately one half of all psychiatric patients
have personality disorders

CLASSIFICATION
ICD-10 CLASSIFICATION
 F60-F69 Disorders of adult personality and behavior
 F60 Specific personality disorders
 F60.0 Paranoid personality disorders
 F60.1 Schizoid personality disorders
 F60.2 Dissocial personality disorders
 F60.3 Emotionally unstable personality disorders
 F60.4 Histrionic personality disorders
 F60.5 Anankastic personality disorders
 F60.6 Anxious personality disorders
 F60.7 Dependent personality disorders

CONTINUE…..
 F60.8 Other specific personality disorders
 F60.9 Personality disorders, unspecified
 F61 Mixed and other personality disorders
 F62Enduring personality changes, not attributable to brain damage and disease
 F63Habit and impulse disorders
 F64Gender identity disorders
 F65Disorders of sexual prefrence

DSM-5 CLASSIFICATION
 In DSM-5 personality disorders are coded on Axis-II. DSM-5groups the 10 types
of personality disorders into 3 clusters (A, B, C) based on similar characteristics
 CLUSTER A (Odd and Eccentric) and on a “Schizophrenic continuum”:
• Paranoid personality disorders
• Schizoid personality disorders
• Schizotypal personality disorders

CONTINUE…..
 CLUSTER B (Dramatic, Emotional and Erratic) and on “Psychopathic
continuum”:
• Antisocial (Dissocial) personality disorders
• Histrionic personality disorders
• Narcissistic personality disorders
• Borderline (Emotionally unstable) personality disorders

CONTINUE…..
 CLUSTER C (Anxious and Fearful) characterized by “Introversion”:
• Avoidant personality disorders
• Dependent personality disorders
• Obsessive-Compulsive (Anankastic) personality disorders

CHARACTERISTICS
 ALLOPLASTIC: Individual react to stress by attempting to change the external
environment/ world rather than themselves. (Able to adapt and alter the external
environment).
 EGO-SYNTONIC: Acceptable to the ego, persons with personality disorders
do not feel anxiety about their maladaptive behavior.
 SELF-IDENTITY PROBLEMS: Unstable self-images, values, goals and
appearance.
 PROBLEMS IN INTERPERSONAL FUNCTIONING: Fail to develop or
sustain close relationship and/or being insensitive to others.

PREDISPOSING FACTORS
The exact cause of personality disorder is unknown; most likely they represent a
combination of genetic, biological, social, psychological, developmental, and
environmental factors.
 GENETIC FACTORS:
• Prevalence among monozygotic twins are several times than dizygotic twins
 BIOLOGICAL FACTORS:
• Some researchers suspect that poor regulation of the brain circuits that control
emotions increases the risk for a personality disorder when combined with such
factors as abuse, neglect or separation. For a biologically predisposed person, the
major developmental challenges of adolescence and early adulthood (such as
separation from the parents, identity and independence) may trigger a
personality disorder.

CONTINUE…..
 NEUROTANSMITTERS:
• High endogenous endorphin levels may be associated with persons who have
personality disorder. Raising serotonin levels with serotogenic agents such as
fluoxetine can produce dramatic changes in some character traits of personality.
 ELECTROPHYSIOLOGY:
• Changes in electrical activities of brain (Slow-wave activity) occur in some patients
with personality disorders.
 OBJECT RELATION THEORY:
• Persons with Personality disorders are identified by particular patterns of
interpersonal relatedness that stop from the internal object relations patterns.

OTHER FACTORS
 Maternal deprivation, especially in antisocial personality
 Borderline personalities are more likely to report physical and sexual abuse in
childhood.
 Histrionic personality is said to occur as a result of failure to resolve oedipal
complex and excessive use of repression as a mechanism of defense.
 Dependent personality may be due to fixation in the oral stage of development.
 Paranoid personality is due to absence of trust, which results from lack of
parental affection in childhood and persistent rejection by parents leading to low
self-esteem.

CLINICAL FEATURES OF ABNORMAL
PERSONALITY
According to DSM-5 the four core features of all personality disorders are:
 1. Distorted thinking patterns
 2. Problematic emotional responses
 3. Over or under regulated impulse control
 4. Interpersonal difficulties

1. PARANOID PERSONALITY DISORDERS
 The DSM-IV-TR defined Paranoid Personality Disorders as a “Pervasive
distrust and suspiciousness of others such that their motives are interpreted as
malevolent, beginning by early adulthood and present in variety of content”

CHARACTERSTIC FEATURE
Sadock and Sadock (2007) identified the characteristic feature as a long standing
suspiciousness and mistrust of people in general.
 Person with this disorder search for hidden meanings and hostile intention in
everything others say or do.
 It is more prevalent in male then females.
 Psychodynamically, the underlying defense mechanism is PROJECTION.

CLINICAL PICTURE
 Appear tensed and irritable
 Insensitive to the feelings of others
 Avoid interactions with other people
 Always feel that others are taking advantage of them
 Unable to forgive and bear grudges.

CONTINUE…..
 Suspecious
 Mistrustful
 Senstive
 Argumentative
 Stubborn
 Self-important
 Hypersenstive
 Jealous and irritable

2. SCHIZOID PERSONALITY DISORDERS
 Schizoid personality disorder is characterized by
detachment and social withdrawal.
 There is profound defect in the ability to form personal
relationships or to respond to others in any meaningful,
emotional way. (Skodal & Gunderson, 2008)
 People with this disorder are commonly described as
loners, with solitary interests & occupations & no close
friends, typically they maintain a social distance even
from family members & seems concerned about other’s
praise or criticism.
 Psychotic features are typically absent.

CLINICAL PICTURE
 Appear cold, aloof and indifferent to others
 Individuals prefer to work on isolation and are unsociable with little need or
desire for emotional ties.
 In the presence of others they appear shy, anxious or uneasy.
 They are inappropriately serious about everything and have difficulty acting in
light hearted manner.
 Affect is commonly bland and constricted.

 They are unable to experience pleasure
 No desire for or enjoyment of close relationship
 Lack of close friends
 Excessive preoccupation with fantasy & introspection
 Almost always choose solitary (alone) activities.

3. SCHIZOTYPAL PERSONALITY DISORDERS
 Individuals with Schizotypal personality disorder were once described as latent
schizophrenics. Their behavior is odd and eccentric but do not decompensate
to level of Schizophrenia.
 Schizotypal Personality disorder is a Graver form of the psychopathologically
less severe Schizoid Personality disorder.
 Schizotypal personality disorder is marked by odd thinking and behavior, a
pervasive pattern of social and interpersonal deficits and acute discomfort with
others.

CONTINUE…..
 It is more commonly seen in individual related to patient with Schizophrenia
and is believed to be a part of the Genetic spectrum of Schizophrenia.
 It usually runs a chronic course.

CLINICAL PICTURE
 Aloof and isolated and behave in a bland and
apathetic manner.
 Magical thinking, ideas of reference, illusions,
and depersonalization are part of everyday
world.
 Example include superstitiousness, belief in
clairvoyance (Clear vision), telepathy, or a “sixth
sense” and belief that “other can feel my
feelings”
 Speech pattern is sometimes bizarre.

CONTINUE…..
 Under stress, these individuals may decompensate and demonstrate psychotic
symptoms, such as delusional thoughts, hallucinations, or bizarre behaviors, but
they are usually of brief duration.
 They often talk or gesture to themselves.
 Their affect is bland or inappropriate, such as laughing at their own problems or
at situation that most people would consider sad.
 People with this disorder often cannot orient their thoughts logically and
become lost in personal irrelevancies.

CLUSTER-B
(DRAMATIC, EMOTIONAL
& ERRATIC)

1. ANTISOCIAL (DISSOCIAL) PERSONALITY
DISORDERS
 Antisocial personality disorder is characterized by chronic antisocial behavior that
violates others rights or social norms which predisposes the affected person to
criminal behavior.
 This disorder is synonymous with previously used terms such as Psychopath and
Sociopath, but does not always means criminal behavior.
 The person is unable to maintain consistent, responsible functioning at work, school
or as a parent.
 These individuals exploit and manipulate others for personal gain and are
unconcerned with obeying the law.
 In ICD-10 it is identified as Dissocial Personality disorder
 Course is usually chronic, decrease in symptoms after 5th decade.

CONTINUE…..
 Earlier antisocial personality disorder or psychopathy was divided into four
clinical types:
1. Aggressive psychopath
2. Inadequate psychopath
3. Creative psychopath,
4. Sexual psychopath
As there are not discrete groups and their characteristic symptoms merge with
one another, they are no longer classified in this manner

CLINICAL PICTURE
 Unable to maintain consistent, responsible functioning at work, school or as a
parent.
 Failure to sustain relationships
 Disregard for the feelings of others
 Impulsive actions
 Low tolerance to frustration
 Tendency to cause violence

CONTINUE…..
 Lack of guilt
 Failure to learn from experiences
 Impulsivity and failure to plan ahead
 Manipulative behaviour for self-gratification
 Inability to maintain close personal or sexual relationship

2. HISTRIONIC PERSONALITY DISORDERS
 Histrionic personality disorder is characterized by colourful, dramatic, and
extroverted behavior in excitable, emotional people.
 They have difficulty in maintaining long-lasting relationships, although they
require constant affirmation of approval and acceptance from others.
 Patients with this disorder characteristically have a pervasive pattern of
excessive emotionality and attention seeking behavior and are drawn to
momentary excitements and fleeting adventures.

CONTINUE…..
 Hysteria (Conversion and dissociative disorder) was previously thought to be
more common in the presence of Histrionic Personality Disorder, but recent
studies have failed to prove this relationship.
 The defence mechanism used most often are ACTING OUT & DISSOCIATION
 This disorder is more common in female gender.

CLINICAL PICTURE
 People with histrionic personality disorder tend to be
self-dramatizing, attention seeking, overly gregarious,
and seductive.
 Use manipulative behaviors in their demands to be
the centre of attention.
 Individuals with this disorder are highly distractible
and flighty by nature.
 Difficulty in paying attention
 Tend to highly suggestible, impressionable and easily
influenced by others.

CONTINUE…..
 Strongly dependent
 Somatic complaints are not uncommon in these
individuals, and fleeting episodes of psychosis may
occur during periods of extreme stress.
 The person with Histrionic Personality disorder,
having failed throughout life to develop the richness
of inner feelings and lacking resources from which
to draw, lacks the ability to provide another with
genuinely sustained affection.

3. NARCISSISTIC PERSONALITY DISORDERS
 People with narcissistic personality disorder have an exaggerated sense of self-
worth. They are hypersensitive to the evaluation of others.
 Patient with narcissistic personality disorder is self-centred, self-absorbed and
lacking in empathy for others.

CONTINUE…..
 Individuals typically takes advantage of people to achieve his own ends, and
uses them without regard to their feelings.
 Narcissistic Personality Disorder is found more commonly in men.
 The cause is unknown but likely involves a combination of genetic and
environmental factors.

CLINICAL PICTURE
 Ideas of grandiosity and inflated sense of self-importance
 Preoccupation with fantasies of unlimited success
 Needs constant praise, and unable to face criticism.
 Lack of empathy with others, with exploitative behavior.
 Shaky self-esteem, underlying sense of inferiority, easily depressed by minor
events.
 Unable to face criticism
 Arrogance
 Being overly centered
 Inflated sense of self-importance

4. BORDERLINE PERSONALITY DISORDERS
 Borderline personality disorder is characterized by a pattern of intense and chaotic
relationship with affective instability and fluctuating attitudes towards other
people.
 Other terminology that has been used in an attempt to identify this disorder
includes ambulatory schizophrenia, pseudoneurotic schizophrenia and
emotionally unstable personality.
 The four main categories of sign and symptoms are:
• Unstable relationships
• Unstable self-image
• Unstable emotions
• Impulsivity

CONTINUE…..
 This disorder is further classified into two types:
1. IMPULSIVE TYPE: It is characterized by emotional instability and lack of
impulse control. Outburst or violence or threatening behavior are common,
particularly in response to criticism by others.
2. BORDERLINE TYPE: It is characterized by emotional instability. In
addition, patient’s own self image, aims, and internal preferences (including
sexual) are often unclear or disturbed.

CLINICAL PICTURE
 Lack of control on anger
 Recurrent suicidal threats or behavior
 Uncertainty about personal identity
 Chronic feelings of emptiness
 Efforts to avoid abandonment
 Transient stress-related paranoid or
dissociative symptoms

CONTINUE…..
 Acting out of feelings instead of expressing them appropriately or verbally.
 Individuals always seem to be in a state of crisis.
 CHRONIC DEPRESSION: Depression is so common with this disorder that
, before the inclusion of Borderline Personality Disorder many of these clients
were diagnosed as depressed.
 INABILITY TO BE ALONE: Because of this chronic fear of abandonment,
clients with Borderline Personality Disorder have little tolerance for being
alone.

CLUSTER-C
(ANXIOUS AND FEARFUL)

1. AVOIDANT PERSONALITY DISORDERS
 The individual with avoidant personality disorders is extremely sensitive to
rejection and this may lead to socially withdrawn life.
 This disorder is marked by feelings of inadequacy, extreme social anxiety, social
withdrawal and hypersensitivity to others opinions

CONTINUE…..
 People with disorder have low self esteem and poor self-confidence; they
dwell on the negative and have difficulty in viewing situations and interactions
objectively.
 It is not that he or she is asocial, in fact, there may be a strong desire for
companionship.
 It appears to be equally common in men and women.

CLINICAL PICTURE
 Individual with this disorder are awkward and uncomfortable in social
situations
 Speech is usually slow and constrained, with frequent hesitations, and
occasional confused and irrelevant digressions.
 They are often lonely, and express feelings of being unwanted.
 View other as critical, betraying, and humiliating
 Inferiority complex

CONTINUE…..
 Desire to have close relationships but avoid them because of fear of being
rejected.
 Persistent feeling of tension and apprehension Many people with avoidant
personality disorder have other psychiatric disorders like social phobia, anxiety
disorder, depressive disorder, somatoform disorder, dissociative disorder and
schizophrenia.

2. DEPENDENT PERSONALITY DISORDERS
 Dependent personality disorder is characterized by “a
pervasive pattern and excessive need to be taken care
of that leads to submissive and clinging behavior and
fear of separation and rejection”. (APA, 2000).
 People with this disorder let others make important
decisions for them and have a strong need for
constant reassurance and support.
 Associated features may include perceiving oneself
as helpless, incompetent and lacking stamina.
 It is more common in women than in men and more
common in the youngest children of a family.

CLINICAL PICTURE
 Individuals have lack of self confidence, that is often apparent in their posture,
voice, and mannerism.
 Overly generous and thoughtful and underplay their own attractiveness and
achievements.
 Willing to let others make their important decisions
 Feels uncomfortable or helpless when alone

CONTINUE…..
 Feel fearful and vulnerable as they have lack of confidence in their ability to
care for themselves.
 Avoid positions of responsibilities and become anxious when forced into them.
 Low self-esteem and lack of self-confidence

3. OBSESSIVE-COMPULSIVE PERSONALITY
DISORDERS
 This disorder is marked by a pervasive desire for perfection and order at the
expense of openness, flexibility and efficiency. The individual places a great deal
of pressure on himself and others not to make mistakes.

CONTINUE…..
 Individuals with obsessive-compulsive personality disorder are very serious
and formal and have difficulty expressing emotions. They are overly
disciplined, perfectionistic, and preoccupied with rules. They are inflexible
about the way in which things must be done and have a devotion to
productivity to the exclusion of personal pleasure.
 This disorder is relatively common and occurs more often in men than women.
Within the family constellation, it appears to be most common in oldest
children.

CLINICAL PICTURE
 Individual are inflexible and lack spontaneity.
 They are meticulous and work diligently and patiently at tasks that require
accuracy and discipline.
 Social behavior tends to be polite and formal.
 They are very “rank conscious”
 High standards

ASSESSMENT
AND
DIAGNOSTIC FINDING

ASSESSMENT AND DIAGNOSTIC FINDINGS
 PHYSICAL EXAMINATION AND PSYCHIATRY HISTORY
COLLECTION
 TOXICOLOGY SCREENING: Substance abuse is common in many
personality disorders, and intoxication can lead patients to present with some
features of personality disorders.
 SCREENING FOR HIV AND OTHER STDs: Patient with personality
disorders often exhibit impulse control, and may act without regard to risk, such
behavior can lead to infection with STDs.

CONTINUE…..
 CT SCAN: Computed tomography scanning with appropriate blood work can
be carried out if organic etiology is suspected.
 RADIOGRAPHY: It can be indicated for injuries from fighting, motor vehicle
accidents or self-mutilation.
 DIAGNOSTIC CRITERIA IN DSM-5 AND ICD 10

DIAGNOSTIC CRITERIAAccording to DSM-5
 Long-term marked deviation from cultural expectations that leads to significant
distress or impairment in atleast two of these areas.
 The way person perceive and interpret self, other people and events.
 The appropriateness of emotional response
 How well one function when dealing with other people and in relationships.
 Whether person can control own impulses.

TREATMENT
AND
NURSING
MANAGEMENT

PHARMACOTHERAPY
 Antipsychotics: Helpful for symptoms such as losing touch with reality
(Psychosis). i.e. Olanzapine, Haloperidol
 Antidepressants: Useful if patient have depressed mood, anger, impulsivity,
irritability or hopelessness.
• Selective serotonin Reuptake Inhibitors (SSRIs): Fluvoxamine
• Monoamine Oxidase Inhibitors (MAOIs): Phenelzine
• Tricyclic Antidepressant (TCAs): Amitriptyline

CONTINUE…..
 Anxiolytics: These may help if patient have
anxiety, agitation or insomnia. But in some cases,
they can increase impulsive behavior, so they are
avoided in certain types of personality disorders. i.e.
Clonazepam
 Mood stabilizers: Helps to control mood swings or
reduce irritability, impulsivity and aggression. i.e.
Lithium carbonate & Sodium valporate

TREATMENT
Most clinicians believe it best to strive for lessening
the inflexibility of the maladaptive traits & reducing
their traits & reducing their interference with
everyday functioning and meaningful relationship.
Selection of intervention is generally based on the
area of greatest dysfunction, such as cognitive,
affect, behavior or interpersonal relations.

PSYCHOTHERAPY:
1. INTERPERSONAL PSYCHOTHERAPY: Interpersonal psychotherapy is
aimed to resolve interpersonal difficulties, improving both social and
occupational functioning. Interpersonal psychotherapy may be particularly
appropriate because personality disorders largely reflect problems in
interpersonal style. Long term psychotherapy attempts to understand & modify
the maladjusted behaviors, cognitions & affect of clients with personality
disorders that dominate their personal lives & relationships.

CONTINUE…..
 Interpersonal psychotherapy is suggested for clients with paranoid, schizoid,
schizotypal, borderline, dependent, narcissistic, & obsessive- compulsive
personality disorders.

CONTINUE…..
 2. PSYCHOANALYTICAL PSYCHOTHERAPY: The treatment of choice
for individuals with histrionic personality disorder has been psychoanalytical
psychotherapy. Treatment focuses on the unconscious motivation for seeking
total satisfaction from others & for being unable to commit oneself to a stable,
meaningful relationship.

CONTINUE…..
 3. MILIEU THERAPY- This treatment is especially
appropriate for individuals with antisocial personality
disorder, who respond more adaptively to support &
feedback from peers. In milieu or group therapy,
feedback from peers is more effective than in one-to-
one interaction with a therapist.
 4. GROUP THERAPY- particularly homogenous
supportive groups that emphasize the development of
social skills- may be helpful in overcoming social
anxiety & developing interpersonal trust & rapport in
clients with avoidant personality disorders.

CONTINUE…..
 4. COGNITIVE/BEHAVIORAL THERAPY:
 Behavioral strategies offer reinforcement for positive changes. Social skills training
& assertiveness training teach alternative ways to deal with frustration.
 Cognitive strategies help the client recognize & correct inaccurate internal mental
schemata.
 This type of therapy may be useful for clients with obsessive-compulsive, antisocial,
& avoidant personality disorders.
 5. DIALECTICAL BEHAVIOR THERAPY: It include group and individual
therapy designed specifically to treat Borderline Personality disorders. Its main goal
is to teach people how to live in the moment, develop healthy ways to cope with
stress, regulate their emotions, and improve their relationship with others.

CONTINUE…..
 6. OCCUPATIONAL THERAPY: Allows patients to increase their level of
functioning so that they become more independent. Task completion skills can
also be evaluated and enhanced by these activities.
 7. RECREATIONAL THERAPY: It can assist patients to ventilate feelings
and increase socialization skills.
 8. INTERACTION AND GUIDANCE by the therapist can provide patients
with constructive ways to deal with anger and other self- destructive behaviors

CONTINUE…..
 9. FAMILY THERAPY: Provides support and education to families dealing
with a family members who has a personality disorders.
 10. INDIVIDUAL THERAPY: Individual therapy helps the person to cope
with the stress and manage behavioral problems.

NURSING MANAGEMENT
Nursing Assessment
Assessment of patient includes:
 Collect past psychiatric or medical history of the patient
 Collect family history of the patient
 Perform Mental Status Examination of the patient
 Assess for the mood and affect
 Assess patient level of anxiety
 Assess the patient level of knowledge

NURSING DIAGNOSIS
 1. Risk for other directed violence related to rage
reactions, negative role modelling and inability to tolerate
frustration.
 2. Defensive coping related to dysfunctional family
system, evidenced by disregards for societal norms &
laws, absence of guilty feelings, or inability to delay
gratification.

CONTINUE…..
 3. Chronic low self-esteem related to negative feedback resulting in diminished
self-worth, evidenced by manipulation of others to fulfil own desires or inability
to form close, personal relationship.
 4. Impaired social interaction related to negative role modelling & low self
esteem, evidenced by inability to develop a satisfactory, enduring, intimate
relationship with another.

PERSONALITY DISORDERS

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