PERSONALITY

DISORDERS: IDENTITY TO
REALITY
JOLO R. GALABAY, RM,RN ,MSN

OVERVIEW OF PSYCHIATRIC NURSING

Theoretical Models for Understanding Behavior

SITUATIONS

SITUATION
PERSISTS

Mental
Mechanisms/Defense
Mechanisms

MAN

EXPERIENCES

ANXIETY
Therapeutic use of self
-therapeutic communication

Schizophrenic Disorders
Paranoid Disorders

Anxiety Disorders
Somatization Disorders
Dissociative Disorders
Personality Disorders
Substance Use
Disorders
Mood Disorders

Organic Mental Disorders

DYSFUNCTIONALITYEating Disorders

Abuse & Violence

Application of the Nursing Process:

Assessment: Classical signs &

symptoms Interventions/
Therapies Pharmacology

Sexual Disorders

OBJECTIVES:

1. Define and differentiate between

personality styles, traits, and disorders.
2. Identify the essential features of the
different personality disorders.
3. Identify some prominent personality traits
in yourself, your peers, and people
surrounding you.
4. Develop some strategies in dealing with
the people having Personality Disorder.

PERSONALITY
The quality or state of being
a person
The totality of a persons
unique biopsychosocial
emotional and spiritual traits
that influences ones
behavior.

DISORDER
The disturbance

of regular
or normal function
An abnormal physical or
mental condition

PERSONALITY DISORDER
Maladaptive

traits
influenced by psychological
and emotional disturbance
and impaired interpersonal
relationship.

The Diagnostic and

Statistical Manual of
Mental Disorders-Text
Revision (DSM-IV-TR)
(American Psychiatric
Association [APA],
2000)

PERSONALITY DISORDERS: DIAGNOSIS

Made when the person exhibits enduring
behavioral patterns that deviate from cultural
expectations in two or more of the following
areas:
1. Ways of perceiving and interpreting self, other
people, and events (cognition)
2. Appropriateness of emotional response (affect)
3. Interpersonal functioning
4. Ability to express behavior at the appropriate
time and place (impulse control)

CHARACTERISTICS:
1.
2.
3.
4.
5.

Poor self-esteem
Poor relationship
skills
Low tolerance for
anxiety
Manipulative and
demanding
Self destructive
behavior

ETIOLOGY:
Genetic

factors
Environmental factors
Biological factors (neurotransmitters)
Psychoanalytic factors

CLUSTER A:
THE ECCENTRIC,
ODD AND MAD
GROUP

PARANOID

Signs and symptoms

Distrustful/Extreme

mistrust

Suspicious
Short

tempered
Hypersensitive to criticism
Prone to angry or aggressive
outburst
Jealous
very private

Management:

Establish

rapport
Help them recognize
and accept their own
feelings
Support adaptation

SCHIZOID

Signs and Symptoms

Withdrawn,

introvert, aloof,
has solitary lifestyle
Loner and passive
Sexual experiences is not of interest
Friendships are few
Emotionally cold and detached
take jobs with little person contact
Humorless

Management:
Initiate

structural social
interactions
Positive therapeutic nurse
client relationship

SCHIZOTYPAL
Signs

M:

and Symptoms:

Magical thinking or odd beliefs

E: Experiences unusual perceptions
P: Paranoid ideation
E: Eccentric behavior or appearance
C: Constricted (or inappropriate) affect
U: Unusual (odd) thinking and speech
L: Lacks close friends
I: Ideas of reference
A: Anxiety in social situations
R: Rule out psychotic disorders and pervasive
developmental disorder

 Management

Medications-

antipsychotic

drugs
Must accept his/her
condition
Avoid extreme stress
Start structured social
interactions

CLUSTER B:
THE ERRATIC
AND BAD
GROUP

ANTISOCIAL

Signs and symptom:

Violates and Exploits rights, feelings
and safety of others
Violent and aggressive behaviors
Does not show any guilt for their action
Engaged in real intimacy to other
person
Very good in displaying superficial
charm
Lack of loyalty, honesty and fidelity

ANTI-SOCIAL

Interventions: Confrontation
Points out a clients
problematic behavior while
remaining neutral and matter-offact
Avoids accusing the client.
Use confrontation to keep
clients focused on the topic and in
the present.

Interventions: Limit Setting

1. Stating the behavioral limit
(describing the
unacceptable behavior) e.g.
It is not acceptable for you
to ask personal questions.
2. Identifying the
consequences if the limit is Nurse: Youve said youre
exceeded e.g. If you
interested in learning to manage
continue, I will terminate
angry outbursts, but youve
our interaction.
missed the last three group
3. Identifying the expected or meetings.
desired behavior e.g. We Client: Well, I can tell no one in
the group likes me. Why bother?
need to use this time to
Nurse: The group meetings are
work on solving your jobdesigned to help you and the
related problems.
others, but you cant work on
issues if youre not there.

ANTI SOCIAL
Interventions:
Problem-Solving
1. Identify the
problem.
2. Explore alternative
solutions and related
consequences.
3. Choose and
implement an
alternative.
4. Evaluate the results.

Interventions: Manage
Emotions
When frustrated,
teach the client to
take a time out or
leave the area and go
to a neutral place to
regain internal
control to engage in
constructive problem
solving.

BORDERLINE

Signs and Symptoms

Impulsive

and Risky behavior

Threatens and often engaged self mutilation
Wide mode swing
Inappropriate anger
Difficulty in controlling emotion
Feels misunderstood, neglected, alone and
helpless
Fears being alone
Feelings of self-hate
Suicidal attempt

SUICIDE
THE ACT OF KILLING ONESELF USUALLY BECAUSE OF A
STRESS PERCEIVED AS OVERWHELMING SUICIDE
Who will commit Suicide?
TRIAD

Sex Male (more successful)/ female (hesitant)Loss of

spouse
Age 15 24 y/o or above 45
Loss of
job
Depression
Aloneness
Patient with previous attempt

Ethanol abuse alcoholics are most

vulnerable
Is Patient
is SUICIDAL; nurse should:
DIE
Rational thinking that is impaired

Direct question Are you going to

Social support that is impaired commit suicide?
Irregular interval of visit to pt. room
Organized plan greater risk Early AM and period of
endorsement
No Spouse or worse, nagging spouse
family the time pts commit
suicide

Sickness, esp. chronic or terminal


1.
2.
3.
4.

INDICATIVE SIGNS:
Once easy to get along with, now sullen
and angry
Gives away important, personal items
Gets affairs in order, wills, insurances,
finances
Direct verbalization of Im no good; Im
better off dead
NURSING DIAGNOSIS: Potential for injury
to self related to poor impulse control
NURSING GOAL: Client will not harm self

 IMPLEMENTATION:
1. Determine lethality potential
ask: Have you thought of suicide/
ask: How would you do it?
2. Determine if the client has the means to carry it out
3. Determine how in touch with reality the client is
4. Determine if the client is still communicating
5. Determine the clients support system
6. Provide suicide precautions:
@ one-to-one 24-hour precautions
@ contract
@hospitalization
7. Offer support, safety,

esteem

HISTRIONIC

Signs and symptoms:

Keep

self the center of attraction

Excessive emotionality
Rapidly shifting emotions
Seductive behavior
Self dramatization
Suicidal threats and actions
Expressionistic speech

NARCISSISTIC PERSONALITY DISORDER

NARCISSSISTIC

Signs and symptoms:

Sense

of grandiose self-importance
Excessive self admiration
Lacks empathy
Fantasies of unlimited power, beauty or
brilliance
Interpersonally exploitive
Envious of others or believes others are
envious of him or her

CLUSTER C:
THE ANXIOUS
AND SAD
GROUP

AVOIDANT:

Signs and Symptoms:

Fears criticism and

rejection
Escapes intimate relationship
Avoidance of social events
Reluctant to encourage in new
activities

DEPENDENT

Signs and symptoms:

Passively

allows other to assume

responsibility for his/her life.
Marked dependence
Lacks self-confidence
Intense pre-occupation and fear of
abandonment
Avoid disagreement , may even
tolerate mistreatment and abuse

Management
Reduce

anxiety
psychotherapy
Facilitates expression of ideas and
feelings
Offer assistance only when needed

OBSESSIVE-COMPULSIVE

Signs and symptoms:

Pervasive rigidity and preoccupation with
control and power and an exaggerated fear
of losing control
perfectionist
Management:
Assist in coping with compulsive behavior
(accept rituals as interruption will increase
anxiety)
Reduce anxiety
Self-limits to destructive acts
Encourage alternative activity

Obsessive-Compulsive
(perfectionist) PD
Preoccupied with
Obsessive-Compulsive Disorder
orderliness, perfectionism,
(OCD)
inflexibility, need to be in
Obsessions: Recurrent thoughts,
control
ideas, visualizations, or
Formal and serious
inappropriate impulses that
disturb a persons life; has no
interpersonal relationship
control over them.
Judgmental of self and
Compulsions: Behaviors or rituals
others
continuously carried out to get
rid of the obsessive thoughts and OCPD clients do not see
reduce anxiety.
that there is any problem
OCD is an anxiety disorder that
with their excessive detail
is ego-dystonic (uncomfortable
or controllingways. They do
to person), whereas OCPD is a
not see that they need to
rigid way of functioning in the
change.
world.

Nursing interventions:
Remember, a

lot of the time people feel guilty about their

thoughts and behaviors.
Do not try to stop the act unless the act is harmful
(dangerous)
Talk to them! Use I statements
If they are too down on themselveslimit your time with
them. For instance, I hate myself. No one cares about
me. Im fat and ugly. The nurse would then say, I am
going to come back in 30 minutes. In that time frame, I
want you to think of your good qualities.
Do not argue with OCD person.
Inject reality. If a teenager thinks she is pregnant despite
a negative pregnancy test, tell her the TEST IS NEGATIVE.
Take them back into reality.
If they repetitively do an act over and over again; help
them set a goal. For instance, Lets try to only wash your
hands once every ten minutes.

NURSING INTERVENTIONS

Work with the client to increase coping

skills and identify need for improved
coping
Respond to clients specific symptoms and
needs
Keep communication clear and consistent
Client may require physical restraints,
seclusion/observation room, one to one
supervision .Follow policies and
procedures
Keep client involved in treatment planning

Behavior contract may be used for

anger and aggression, suicidal
ideation, manipulation, or
isolation
Require that the client take
responsibility for his/her own
behavior and the consequences
for actions.

CLIENT AND FAMILY EDUCATION

Discuss with the client and family
the possible environment and
situational causes, contributing
factors, and triggers
Help the client and family to
identify the internal and external
indicators of personality
disorders

 Educate

the client and

family about the
following:
Coping

skills
anger management
Stress management
Problem solving
Medication adherence

THANK
YOU FOR
LISTENING!

TRAITS:
Poor interpersonal relationship
Suspiciousness
Social anxiety
Failure to conform to social norms
Self-destructive behaviors
Demanding and Manipulative
Inappropriate response to stress
and inflexible approach to problem
solving

Long term difficulties in relating to

others, in school and in work situations
Ability t cause others to react with
extreme annoyance or irritability
Depression
Anger and aggression
Difficulty with adherence to treatment
Harm to self or others (suicidal
ideation, self mutilation, violence
towards others, or threats)
Egocentric

 Overwhelming

fears of

abandonment
Pessimistic, immature,
lonely , and impulsive

NURSING INTERVENTIONS

Work with the client to increase coping

skills and identify need for improved
coping
Respond to clients specific symptoms and
needs
Keep communication clear and consistent
Client may require physical restraints,
seclusion/observation room, one to one
supervision .Follow policies and
procedures
Keep client involved in treatment planning

Behavior contract may be used for

anger and aggression, suicidal
ideation, manipulation, or
isolation
Require that the client take
responsibility for his/her own
behavior and the consequences
for actions.

CLIENT AND FAMILY EDUCATION

Discuss with the client and family
the possible environment and
situational causes, contributing
factors, and triggers
Help the client and family to
identify the internal and external
indicators of personality
disorders

 Educate

the client and

family about the
following:
Coping

skills
anger management
Stress management
Problem solving
Medication adherence