PERSONALITY DISORDERS

PERSONALITY - refers to a distinctive set of traits, behavior

styles, and patterns that make up our character or individuality.
How we perceive the world, our attitudes, thoughts, and feelings
are all part of our personality. People with healthy personalities are
able to cope with normal stresses and have no trouble forming
relationships with family, friends, and co-workers.
Personality is made up of three parts (i.e., tripartite): the id,
ego superego:
 The id is the primitive and instinctive component of
personality. It consists of all the inherited (i.e., biological)
components of personality present at birth, including the
sex (life) instinct – Eros (which contains the libido), and the aggressive (death) instinct -
Thanatos.
 The ego develops in order to mediate between the unrealistic id and the external real world. It is
the decision making component of personality.
 The superego incorporates the values and morals of society which are learned from one's parents
and others.
 Parts of the unconscious mind (the id and superego) are in constant conflict with the conscious
part of the mind (the ego). This conflict creates anxiety, which could be dealt with by the ego’s
use of defense mechanisms.
PERSONALITY DISORDERS - 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 people. This causes significant problems and limitations in relationships,
social activities, work and school. Although they feel that their behavior patterns are “normal” or “right,”
people with personality disorders tend to have a narrow view of the world.
CAUSES:
Personality forms during childhood, shaped through an interaction of:
• Genes - Certain personality traits may be passed on by parents through inherited genes. These
traits are sometimes called your temperament.
• Environment - This involves the surroundings we 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. Genes make a person vulnerable to developing a personality disorder, and a life situation
may trigger the actual development.
RISK FACTORS:
• Although the precise cause of personality disorders is not known, certain factors seem to increase
the risk of developing or triggering personality disorders, including:
 • Family history of personality disorders or other mental illness
• Abusive, unstable or chaotic family life during childhood
• Being diagnosed with childhood conduct disorder
• Variations in brain chemistry and structure
TYPES OF PERSONALITY DISORDERS
1. Cluster A: Odd or eccentric behavior
2. Cluster B: Dramatic, emotional or erratic behavior
3. Cluster C: Anxious fearful behavior
CLUSTER A - Odd or eccentric behavior
Paranoid Personality Disorder
• Pervasive distrust and suspicion of others and their motives
• Unjustified belief that others are trying to harm or deceive you
• Unjustified suspicion of the loyalty or trustworthiness of others
• Hesitancy to confide in others due to unreasonable fear that others will use the information
against you
• 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
• Unjustified, recurrent suspicion that spouse or sexual partner is unfaithful

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

Schizotypal Personality Disorder

• Peculiar dress, thinking, beliefs, speech or behavior
• Odd perceptual experiences, such as hearing a voice whisper your name
• Flat emotions or inappropriate emotional responses
• Social anxiety and a lack of or discomfort with close relationships
• Indifferent, inappropriate or suspicious response to others
• "Magical thinking" - believing you can influence people and events with your thoughts
• Belief that certain casual incidents or events have hidden messages meant only for you

CLUSTER B - Dramatic, emotional or erratic behaviour

 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
• Aggressive, often violent behavior
• Disregard for the safety of self or others
• Impulsive behavior
• Consistently irresponsible
• Lack of remorse for behaviour

 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
• Intense fear of being alone or abandoned
• Ongoing feelings of emptiness
• Frequent, intense displays of anger
• Stress-related paranoia that comes and goes

 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
• Shallow, rapidly changing emotions
• Excessive concern with physical appearance
• Thinks relationships with others are closer than they really are

 Narcissistic Personality Disorder

• Belief that you're special and more important than others
• Fantasies about power, success and attractiveness
• Failure to recognize others' needs and feelings
• Exaggeration of achievements or talents
• 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 you

CLUSTER C - Anxious fearful behavior

 Avoidant personality disorder

• Too sensitive to criticism or rejection
• Feeling inadequate, inferior or unattractive
• Avoidance of work activities that require interpersonal contact
• Socially inhibited, timid and isolated, avoiding new activities or meeting strangers
• Extreme shyness in social situations and personal relationships
• Fear of disapproval, embarrassment or ridicule

 Dependent personality disorder

 • Excessive dependence on others and feeling the need to be taken care of
• Submissive or clingy behavior toward others
• Fear of having to provide self-care or fend for yourself if left alone
• Lack of self-confidence, requiring excessive advice and reassurance from others to make even
small decisions
• Difficulty starting or doing projects on your 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

 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 you don't meet your 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
• Inability to discard broken or worthless objects
• Rigid and stubborn
• Inflexible about morality, ethics or values
• Tight, miserly control over budgeting and spending money
 Obsessive-compulsive personality disorder is not the same as obsessive-
compulsive disorder, a type of anxiety disorder.

DIAGNOSIS
• Physical exam - The doctor may do a physical exam and ask in-depth questions about health. In
some cases, symptoms may be linked to an underlying physical health problem. The evaluation
may include lab tests and a screening test for alcohol and drugs.
• Psychiatric evaluation - This includes a discussion about thoughts, feelings and behavior and
may include a questionnaire to help pinpoint a diagnosis. With permission, information from
family members or others may be helpful.
• Diagnostic criteria in the DSM-5 - The doctor may compare your symptoms to the criteria in the
Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American
Psychiatric Association.
DIAGNOSTIC CRITERIA
• Each personality disorder has its own set of diagnostic criteria. However, according to the DSM-
5, generally the diagnosis of a personality disorder includes long-term marked deviation from
cultural expectations that leads to significant distress or impairment in at least two of these areas:
• The way a person perceive and interpret himself, other people and events
• The appropriateness of the emotional responses
• How well a person function when dealing with other people and in relationships
• Whether a person can control your impulses
 • Sometimes it can be difficult to determine the type of personality disorder, as some personality
disorders share similar symptoms and more than one type may be present. Other disorders such as
depression, anxiety or substance abuse may further complicate diagnosis. But it's worth the time
and effort to get an accurate diagnosis so that they get appropriate treatment.
MEDICATIONS:
• Antidepressants. Antidepressants may be useful for 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.
• Antipsychotic medications. Also called neuroleptics, these may be helpful if symptoms include
losing touch with reality (psychosis) or in some cases if you have anxiety or anger problems.
• Anti-anxiety medications. These may help if a person have anxiety, agitation or insomnia. But
in some cases, they can increase impulsive behavior, so they're avoided in certain types of
personality disorders.
PSYCHOTHERAPY
• Psychoanalytic/psychodynamic therapy
• Dialectical behavior therapy
• Cognitive behavioral therapy
• Group therapy
• Psychoeducation (teaching the individual and family members about the illness, treatment and
ways of coping)
NURSING DIAGNOSIS AND NURSING INTERVENTIONS FOR PERSONALITY
DISORDERS:

• Risk For Self-Mutilation - At risk for deliberate self-injurious behavior causing tissue damage
with the intent of causing nonfatal injury to attain.

Nursing Interventions Rationale

Assess client’s history of self-mutilation:

1. Types of mutilating behaviors.
2. Frequency of behaviors.
3. Stressors preceding behavior.
Identify feelings experienced before and around the act
of self-mutilation.
Identifying patterns and circumstances surrounding
self-injury can help the nurse plan interventions and
teaching strategies suitable to the client.
Feelings are a guideline for future intervention (e.g.,
rage at feeling left out or abandoned).

Explore with the client what these feelings might mean. Self-mutilation might also be:

Secure a written or verbal no-harm contract with the
client. Identify specific steps (e.g., persons to call upon
when prompted to self-mutilate).
1. A way to gain control over others.
2. A way to feel alive through pain.
3. An expression of self-hate or guilt.
Client is encouraged to take responsibility for healthier
behavior. Talking to others and learning alternative
coping skills can reduce frequency and severity until
such behavior ceases.

Set and maintain limits on acceptable behavior and make

Clear and nonpunitive limit setting is essential for
clear client’s responsibilities. If the client is hospitalized
decreasing negative behaviors.
at the time, be clear regarding the unit rules.

Be consistent in maintaining and enforcing the limits,

Consistency can establish a sense of security.
using a nonpunitive approach.

A neutral approach prevents blaming, which increases

Use a matter-of-fact approach when self-mutilation
anxiety, giving special attention that encourages acting
occurs. Avoid criticizing or giving sympathy.
out.

After the treatment of the wound, discuss what happened identify dynamics for both client and clinician. Allows
right before, and the thoughts and feelings that the client the identification of less harmful responses to help
had immediately before self-mutilating. relieve intense tensions.

Work out a plan identifying alternatives to self-

mutilating behaviors.

1. Anticipate certain situations that might lead

to increased stress (e.g., tension or rage). Plan is periodically reviewed and evaluated. Offers a
2. Identify actions that might modify the chance to deal with feelings and struggles that arise.
intensity of such situations.
3. Identify two or three people whom the client
can contact to discuss and examine intense
feelings (rage,self hate) when ther arise.

• Chronic Low Self-Esteem - Long standing negative self-evaluation/feelings about self or self-
capabilities.

Nursing Interventions Rationale

Assess with clients their self perception. Target

different areas of the client’s life:
1. Strengths and weaknesses in performance at
work/school.daily-life tasks.
Identify with client with realistic areas of strength and
weaknesses. Client and nurse can work on the realities
of the self-appraisal, and target those areas of
assessment that do not appear accurate.
 2. Strengths and weaknesses as to physical
appearance, sexuality, personality.
Maintain a neutral, calm, and respectful manner, Helps client see himself or herself as respected as a
although with some clients this is easier said than done. person even when behavior might not be appropriate.

Review with the client the types of cognitive distortions

These are the most common cognitive distortions people
that affect self-esteem (e.g., self-blame, mind reading,
use. Identifying them is the first step to correcting
overgeneralization, selective inattention, all-or-none
distortions that form one’s self-view.
thinking).

Teach client to reframe and dispute cognitive Practice and belief in the disputes over time help clients
distortions. Disputes need to be strong, specific, and gain a more realistic appraisal of events, the world, and
nonjudgmental. themselves.

Work with client to recognize cognitive distortions. Cognitive distortions are automatic. Keeping a log helps
Encourage client to keep a log. make automatic, unconscious thinking clear.

Keep in mind clients with personality disorders might

Many behaviors seen in PD clients cover a fragile sense
defend against feeling of low-self-esteem through
of self. Often these behaviors are the crux of clients’
blaming, projection, anger, passivity, and demanding
interpersonal difficulties in all their relationships.
behaviors.

Unacceptable behavior does not make the client a bad

Discourage client from making repetitive self-blaming
person, it means that the client made some poor choices
and negative remarks.
in the past.

The past cannot be changed. Dwelling on past mistakes

Discourage client from dwelling on and “relieving” past
prevents the client from appraising the present and
mistakes.
planning for the future.

Looking toward the future minimizes dwelling on the

past and negative self-rumination. When realistic short-
Discuss with client his or her plans for the future. Work
term goals are met, client can gain a sense of
with client to set realistic short-term goals. Identify
accomplishment, direction, and purpose in life.
skills to be learned to help client reach his or her goals.
Accomplishing goals can bolster a sense of control and
enhance self-perception.

Focus questions in a positive and active light; helps

Allows client to look at past behaviors differently, and
client refocus on the present and look to the future. For
gives the client a sense that he or she has choices in the
example. “What can you do differently now?” or “What
future.
have you learned from that experience?”.

Give the client honest and genuine feedback regarding Feedback helps give clients a more accurate view of
your observations as to his or her strengths, and areas self, strengths, areas to work on, as well as a sense that
that could use additional skills. someone is trying to understand them.
 Dishonesty and insincerity undermine trust and
Do not flatter or be dishonest in your appraisals.
negatively affect any therapeutic alliance.

Unrealistic goals can set up hopelessnessin clients and

Set goals realistically, and renegotiate goals frequently.
frustrations in nurse clinicians. Clients might blame the
Remember that client’s negative self-view and distrust
nurse for not “helping them,” and nurses might blame
of the world took years to develop.
the client for not “getting better”.

Impaired Social Interaction - Insufficient or excessive quantity or ineffective quality of social exchange.

Nursing Interventions Rationale

Set limits on any manipulative behaviors:

1. Arguing or begging.
2. Flattery or seductiveness.
From the beginning, limits need to be clear. It will be
3. Instilling guilt, clinging.
necessary to refer to these limits frequently, because it is
4. Constantly seeking attention.
to be expected that the client will test these limits
5. Pitting one person, staff, group against
repeatedly.
another.
6. Frequently disregarding the rules.
7. Constant engagement in power struggles.
8. Angry, demanding behaviors.
When time is taken in initial meetings to clarify
Expand limits by clarifying expectations for clients in a
expectations, confrontations, and power struggles with
number of settings.
clients can be minimized and even avoided.
In a respectful, neutral manner, explain expected client From the beginning, clients need to have explicit
behaviors, limits, and responsibilities during sessions guidelines and boundaries for expected behaviors on
with nurse clinician. Clearly state the rules and their part, as well as what client can expect from the
regulations of the institution, and the consequences nurse. Clients need to be fully aware that they will be
when these rules are not adhered to. held responsible for their behaviors.
Strong and intense countertransference reactions to PD
Monitor own thoughts and feelings constantly regarding
clients are bound to occur. When the nurse is enmeshed
your response to the PD client. Supervision is strongly
in his or her own strong reactions toward the client
recommended for new and seasoned clinicians alike
(either positive or negative), nurse effectivess suffers,
when working with PD clients.
and the therapeutic alliance might be threatened.
Collaborate with the client, as well as the
Tangible reinforcement for meeting expectations can
multidisciplinary team, to establish a reward system for
strenthen the client’s positive behaviors.
compliance with clearly defined expectations.
Skils training workshops offer the client wats to increase
social skills through role play and interactions with
Assess need for and encourage skills training workshop. others who are learning similar skills. This often acts as
a motivating factor where positive feedback and helpful
suggestions are readily available.
 Over time, alternative ways of experiencing
Problem solve and role play with client acceptable
interpersonal relationships might emerge. Take one
social skills that will help obtain needs effectively and
small skill that client is willing to work on, break it
appropriately.
down into small parts, and work on it with the client.
Responding to client’s resistance and seeming lack of
Understand that PD clients in particular will be resistant change in a neutral manner is part of the foundation for
to change and that this is symptomatic of PDs. This is trust. In other words, the nurse does not have a vested
particularly true in the beginning phases of therapy. interest in the client “getting better.”. The nurse remains
focused on the client’s needs and issues in any event.
Intervene in manipulative behavior.
1. All limits should be adhered to by all staff
involved.
Client will test limits, and, once they understand that the
2. Objective physical signs in managing
limits are solid, this understanding can motivate them to
clinical problems should be carefully
work on other ways to get their needs met. Hopefully,
documented.
this will be done with the nurse clinician throughout
3. Behaviors should be documented
problem-solving alternative behaviors and learning new
objectively (give times, dates,
effective communication skills.
circumstances).
4. Provide clear boundaries and consequences.
5. Enforce the consequences.

• Ineffective Coping - Inability to form a valid appraisal of the stressors, inadequate choices of
practiced responses, and/or inability to use available resources.

Nursing Interventions Rationale

General Interventions for All Personality Disorders:

All clients are individuals, even within the same

Review intervention guidelines for each personality disorder
diagnostic category. However, guidelines for
in this chapter.
specific categories are helpful for planning.

Client needs clear structure. Expect frequent

Identify behavioral limits and behaviors that are expected. testing of limits initially. Maintaining limits can
enhance feelings of safety in the client.

Identify what the client sees as the behaviors and Ascertain client’s understanding of behaviors and
circumstances that lead to the hospitalization. responsibility for own action.

Ascertain from family/friends how the person interacts with

Identifying baseline behaviors helps with setting
significant people. Is the client always withdrawn, distrustful,
goals.
hostile, have continuous physical complaints?
 Enhances feelings of security and provides
Approach the client in a consistent manner in all interactions. structure. Exceptions encourage a manipulative
behavior.

Open up areas for manipulation and undermines

Refrain from sharing personal information with the client.
professional boundaries.

Giving into client’s thinking that you are “the

Be aware of flattery as an attempt to feed into your needs to
best” or “the only one” can pit you against other
feel special.
staff and undermine client’s need for limits.

Again, clouds the boundaries and can give the

Do not receive any gift from the client. client the idea that he or she is due special
consideration.

The client is in the hospital/clinic for a reason.

If the client becomes seductive, reiterate the therapeutic goals
Being taken in by seductive behavior undermines
and boundaries of treatment.
effectiveness of the treatment.

Be clear with the client as to the unit/hospital/clinic policies.

Give brief concrete reasons for the rules, if asked, and then Institutional policies provide structure and safety.
move on.

Be very clear about the consequences if policies/limits are not Client needs to understand the consequences of
adhered to. breaking the rules.

When limit or policies are not followed, enforce the Enforces that the client is responsible for his or her
consequences in a matter-of-fact, nonjudgmental manner. own actions.

Make a clear and concrete written plan of care so other staff Helps minimize manipulations and might help
can follow. encourage cooperation.

If goals and interventions are agreed upon,

If feasible, devise a care plan with the client.
cooperation with the plan is optimized.

If the client becomes hostile or projects blame onto you or

Defuses tension and opens up productive
staff, project a neutral, calm demeanor, and avoid power
interaction.
struggles. Focus on the client’s underlying feelings.

When appropriate, try to understand underlying feelings

Often acting out behaviors stem from underlying
prompting inappropriate behaviors.
feelings of anger, fear, shame, insecurity,
 loneliness, etc. Talking about feeling can lead to
problem solving and growth for the client.

Nurses often want to be seen as “nice” However,

Some clients might attempt to instill guilt when they do not
being professional and maintaining limits is the
get what they want. Remain neutral but firm.
better therapeutic approach.

It can take a long time to positively change

Keep goals very realistic and go in small steps. There are no
ingrained, life-long, maladaptive habits; however,
overnight successes with people with personality disorders.
change is always possible.

Work with the client on problem-solving skills using a

Client might not know how to articulate the
situation that is bothering the client. Go step by step:
problem. Helping identify alternatives gives the
client a sense of control. Evaluating the pros and
1. Define the problem.
cons of the alternatives facilitates choosing
2. Explore alternatives.
potential solutions.
3. Make decisions.
When the client is ready and interested, teach client coping
Increasing skills helps the client use healthier
skills to help defuse tension and trouble feelings (e.g., anxiety
ways to defuse tensions and get needs met.
reduction, assertiveness skills).

Change if often very slow and may seem to take

Guard against personal feelings of frustration and lack of longer than it actually is. Nurture yourself outside
progress. the job. Keep your “bucket” full of laughter and
high regard from family and friends.

Understand that many people with personality disorders do Even short encounters with therapeutic persons
not stay with the treatment and often come to facilities can make a difference when a client is ready to
because of crisis or court order. learn more adaptive ways of living his or her life.

Give the client positive attention when behaviors are Reinforcing positive behaviors might increase the
appropriate and productive. Avoid giving any attention (when likelihood of repetition. Ignoring negative
possible and not dangerous to self or others) when client’s behaviors (when feasible) robs client of even
behaviors are inappropriate. negative attention.

Borderline Personality Disorder (BPD):

Self-mutilating and suicide threats are common

Assess for self-mutilating or suicidethoughts or behaviors.
behaviors for clients with BPD.

Consistent limit setting helps provide structure and

Clients with BPD can be manipulative.
decrease negative behaviors.

Encourage the client to explore feelings and concerns (e.g.,

Client is used to acting out feelings.
identify fears, loneliness, self-hate).
 Be nonjudgmental and respectful when listening to client’s
feelings, thoughts, or complaints.
Use assertiveness when setting limits on client’s
unreasonable demands for attention and time.
Interventions often call for responses to client’s intense and
labile mood swings, irritability, depression, and anxiety:
 Irritability, anger: Use interventions early before
anxiety and anger escalate.
 Depression: Client might need medications to
help curb depression. Observe for side effects and
mood level.
 Anxiety: Teach stress-reduction techniques such
as deep breathing relaxation, meditation,
and exercise.
Provide and encourage the client to use professionals in other
in other disciplines such as social services, vocational
rehabilitation, social work, or the law.
Clients with BPD benefit from coping skills training (e.g.,
anger management skills, emotional regulation skills,
interpersonal skills). Provide referrals and/or involve
professional experts.
Clients with BPD often drop out of treatment prematurely.
However, when they return, they can still draw upon what
they have learned from previous encounters with health care
personnel.
Treatment of substance abuse is best handled by well-
organized treatment systems, not by an individual
nurse/clinician.
LIFESTYLE AND HOME REMEDIES
Along with professional treatment plan, consider these lifestyle and self-care strategies:
• Be an active participant in care. This can help efforts to manage personality disorder. Don't
skip therapy sessions, even if a they don't feel like going. Think about the goals for treatment and
work toward achieving them.
Clients have an intense fear of rejection.
Firm, clear, nonjudgmental limits give client
structure.
Many of the dysfunctional behaviors of BPD
clients (e.g., parasuicidal, anger, manipulation,
substance abuse) are used as “behavioral
solutions” to intense pain.
Clients with BPD are extremely uncomfortable
and want immediate relief from painful feelings.
Anger is a response to this pain. Intervening early
can help avoid escalation.
Most clients with BPD suffer profound depression.
Clients experience intense anxiety and fear of
abandonment. Stress reduction techniques help the
client focus more clearly.
Clients with BPD often have multiple social
problems. Often they do not know how to obtain
these services.
Client learns to refine skills in changing behaviors,
emotions, and thinking patterns associated with
problems in living that are causing distress and
misery.
Clients might become impatient and leave, then
return in a crisis situation. It is a good thing when
they are able to tolerate longer periods of learning.
Keeping detailed records and having a team
involved with each client can minimize
manipulation.
• Take your medications as directed. Even if they are not feeling well, they shouldn’t skip
medications. If they stop, symptoms may come back. They could also experience withdrawal-like
symptoms from stopping a medication too suddenly.
• Learn about the condition. Education about their condition can empower them and motivate
them to stick to their treatment plan.
• Get active. Physical activity can help manage many symptoms, such as depression, stress and
anxiety. Activity can also counteract the effects of some psychiatric medications that may cause
weight gain. Consider walking, jogging, swimming, gardening or taking up another form of
physical activity that they enjoy.
• Avoid drugs and alcohol. Alcohol and street drugs can worsen personality disorder symptoms or
interact with medications.
• Get routine medical care. Don't neglect checkups or skip visits to primary care professional,
especially if they aren't feeling well. They may have a new health problem that needs to be
addressed, or may be experiencing side effects of medication.