Personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment (DSM-V).
Personality can be defined as an ingrained enduring pattern of behaving and relating to self, others, and the environment; personality includes perceptions, attitudes, and emotions.
• Personality disorders are diagnosed when personality traits become inflexible and maladaptive and significantly interfere with how a person functions in society or cause the person emotional distress.
• They usually are not diagnosed until adulthood, when personality is more completely formed.
• No specific medication alters personality, and therapy designed to help clients make changes is often long-term with very slow progress.
The DSM-V lists personality disorders as a separate and distinct category from other major mental illness; they are on axis II of the multiaxial classification system.
• Cluster A. Cluster A includes people whose behavior appears odd or eccentric and includes paranoid, schizotypal, and schizoid personality disorders.
• Cluster B. Cluster B includes people who appear dramatic, emotional, or erratic and includes antisocial, borderline, histrionic, and narcissistic personality disorders.
• Cluster C. Cluster C includes people who appear anxious or fearful and includes avoidant, dependent, and obsessive-compulsive personality disorders.
Cluster A: Personality Disorders
• Paranoid Personality Disorder. This personality is characterized by pervasive mistrust and suspiciousness of others; clients with this disorder interpret others actions as potentially harmful.
• Schizoid Personality Disorder. This is characterized by a pervasive pattern of detachment from social relationships and a restricted range of emotional expression in interpersonal settings.
• Schizotypal Personality Disorder. This disorder is characterized by a pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships as well as by cognitive or perceptual distortions and behavioral eccentricities.
Cluster B: Personality Disorders
• Antisocial Personality Disorder. This disorder is characterized by a pervasive pattern of disregard for and violation of the rights of others- and with the central characteristics of deceit and manipulation.
• Borderline Personality Disorder. This disorder is characterized by a pervasive pattern of unstable interpersonal relationships, self-image, and affect, as well as marked impulsivity; borderline personality disorder is the most common personality disorder found in clinical settings.
• Histrionic Personality Disorder. This is characterized by a pervasive pattern of excessive emotionality and attention-seeking; clients usually seek treatment for depression, unexplained physical problems, and difficulties in relationships.
• Narcissistic Personality Disorder. This disorder is characterized by a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy.
Cluster C: Personality Disorders
• Avoidant Personality Disorder. This disorder is characterized by a pervasive pattern of social discomfort and reticence, low self-esteem, and hypersensitivity to negative evaluation.
• Dependent Personality Disorder. This is characterized by a pervasive and excessive need to be taken care of, which leads to submissive and clinging behavior and fears of separation; these behaviors are designed to elicit caretaking from others.
• Obsessive-Compulsive Personality Disorder. This disorder is characterized by a pervasive pattern of preoccupation with perfectionism, mental and interpersonal control, and orderliness at the expense of flexibility, openness, and efficiency.
Statistics and Incidences
Personality disorders are relatively common, occurring in 10% to 13% of the general population.
• 15% of all psychiatric inpatients have a primary diagnosis of a personality disorder.
• 40% to 45% of those with a primary diagnosis of major mental illness also have a coexisting personality disorder that significantly complicates the treatment.
• In mental health outpatient settings, the incidence of personality disorder is 30% to 50%.
• Clients with personality disorders have a higher death rate, especially as a result of suicide; they also have higher rates of suicide attempts, accidents, and emergency department visits and increased rates of separation, divorce, and involvement in legal proceedings regarding child custody.
• Personality disorders have been correlated highly with criminal behavior (70% to 85% of criminals have personality disorders), alcoholism (60% to 70% alcoholics have personality disorders), and drug abuse (70% to 90% of those who abuse drugs have personality disorders).
The clinical manifestations of a person with personality disorder include:
• Paranoid. Mistrusts and is suspicious of others; has guarded, restricted affect.
• Schizoid. Detached from social relationships; has restricted affect; involved with things more than people.
• Schizotypal. Acute discomfort in relationships; cognitive or perceptual distortions; eccentric behavior.
• Antisocial. Disregard for rights of others, rule, and laws.
• Borderline. Unstable relationships, self-image, and affect; impulsivity; self-mutilation.
• Histrionic. Excessive emotionality and attention-seeking.
• Narcissistic. Grandiose; lack of empathy; need for admiration.
• Avoidant. Social inhibitions; feelings of inadequacy; hypersensitive to negative evaluation.
• Dependent. Submissive and clinging behavior; excessive need to be taken care of.
• Obsessive-compulsive. Preoccupation with orderliness, perfectionism, and control.
• Depressive. Pattern of depressive cognitions and behaviors in a variety of contexts.
• Passive-aggressive. Pattern of negative attitudes and passive resistance to demands for adequate performance in social and occupational situations.
Assessment and Diagnostic Findings
The following tests can be used in the diagnosis of personality disorders:
- 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 and other sexually transmitted diseases. Patients with personality disorders often exhibit impulse control, and may act without regard to risk; such behavior can lead to infection with a sexually transmitted disease.
- 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.
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.
- 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.
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. The selective serotonin reuptake inhibitors (SSRIs) and newer antidepressants are safe and reasonable effective; however, because the depression of most patients with personality disorders stems from their limited range of coping capacities, antidepressants are usually less effective than in patients with uncomplicated major depression.
- 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.
- Antipsychotics. Response to antipsychotics in patients with a personality disorder is less dramatic than it is in true psychotic axis I disorders, but symptoms such as anxiety, hostility, and sensitivity to rejection may be reduced.
Nursing Management of Personality Disorders
The nursing management of a patient with personality disorder include the following:
Assessment of the patient include:
• 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.
• 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.
• Sensorium and intellectual process. Intellectual capacities are intact, and clients are fully oriented to reality.
Nursing diagnoses for clients with personality disorder include the following:
• Risk for suicide related to low frustration tolerance.
• Risk for self-mutilation related to impulsive behavior.
• Risk for other directed violence related to lack of feelings of remorse.
• Ineffective coping related to failure to learn or change behavior based on past experience or punishment.
• Social isolation related to ineffective interpersonal relationships.
Nursing Care Planning and Goals
Main Article: 4 Personality Disorders Nursing Care Plans
Nursing care plan goals for personality disorders may include:
• The client will be safe and free of significant injury.
• The client will not harm others or destroy property.
• The client will demonstrate increased control of impulsive behavior.
• The client will take appropriate steps to meet his or her own needs.
• The client will demonstrate problem-solving skills.
• The client will verbalize greater satisfaction with relationships.
Clients with personality disorder often are involved in long-term psychotherapy to address issues of family dysfunction and abuse.
- Promoting client’s safety. The nurse must always seriously consider suicidal ideation with the presence of a plan, access to means for enacting the plan, and self-harm behaviors and institute appropriate interventions.
- Promoting therapeutic relationship. Regardless of the cllinical setting, the nurse must provide structure and limit setting in the therapeutic relationship; in a clinic setting, this may mean seeing the client for scheduled appointments of a predetermined length rather than whenever the client appears and demands the nurse’s immediate attention.
- Establishing boundaries in relationships. The nurse must be quite clear about establishing the boundaries of the therapeutic relationship to ensure that neither the client’s nor the nurse’s boundaries are violated.
- Teaching effective communication skills. It is important to teach basic communication skills such as eye contact, active listening, taking turns talking, validating the meaning of another’s communication, and using “I” statements.
- Helping clients to cope and to control emotions. The nurse can help the clients to identify their feelings and learn to tolerate them without exaggerated responses such as destruction of property or self-harm; keeping a journal often helps clients gain awareness of feelings.
- Reshaping thinking patterns. Cognitive restructuring is a technique useful in changing patterns of thinking by helping clients to recognize negative thoughts and feelings and to replace them with positive patterns of thinking; thought stopping is a technique to alter the process of negative or self-critical thought patterns.
- Structuring the client’s daily activities. Minimizing unstructured time by planning activities can help clients to manage time alone; clients can make a written schedule that includes appointments, shopping, reading the paper, and going for a walk.
Goals are met as evidenced by:
- The client will be safe and free of significant injury.
- The client will not harm others or destroy property.
- The client will demonstrate increased control of impulsive behavior.
- The client will take appropriate steps to meet his or her own needs.
- The client will demonstrate problem-solving skills.
- The client will verbalize greater satisfaction with relationships.
Documentation in a client with personality disorder include:
- Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
- Cultural and religious beliefs, and expectations.
- Plan of care.
- Teaching plan.
- Responses to interventions, teaching, and actions performed.
- Attainment or progress toward the desired outcome.
Practice Quiz: Personality Disorders
1. Clients with personality disorders have difficulties in their social and occupational functions. Clients with a personality disorder will most likely:
A. Responsd to anti anxiety medication
B. Recover with therapeutic intervention
C. Seek treatment willingly from some personally distressing symptoms
D. Manifest enduring patterns of inflexible behaviors
1. Answer: D. Manifest enduring patterns of inflexible behaviors.
- Option D: Personality disorders are characterized by inflexible traits and characteristics that are lifelong.
- Option A: Medications are generally not recommended for personality disorders.
- Options B and C: This disorder is manifested by life-long patterns of behavior. The client with this disorder will not likely present himself for treatment unless something has gone wrong in his life so he may not recover from therapeutic intervention.
2. A client tends to be insensitive to others, engages in abusive behaviors and does not have a sense of remorse. Which personality disorder is he likely to have?
2. Answer: A. Antisocial
- Option A: These are the characteristics of an individual with an antisocial personality.
- Option B: Individuals with histrionic have excessive emotionality and attention-seeking behaviors.
- Option C: Individuals with paranoid personality demonstrate a pattern of distrust and suspiciousness and interprets others motives as threatening.
- Option D: Narcissistic personality disorder is characterized by grandiosity and a need for constant admiration from others.
3. A teenage girl is diagnosed to have a borderline personality disorder. Which manifestations support the diagnosis?
A. Social withdrawal, inadequacy, sensitivity to rejection and criticism
B. Lack of self-esteem, strong dependency needs, and impulsive behavior
C. Suspicious, hypervigilance and coldness
D. Preoccupation with perfectionism, orderliness, and need for control
3. Answer: B. Lack of self-esteem, strong dependency needs, and impulsive behavior.
- Option B: These are the characteristics of a client with borderline personality.
- Option A: This describes the avoidant personality.
- Option C: These are the characteristics of a client with paranoid personality.
- Option D: This describes the obsessive compulsive personality.
4. The plan of care for clients with borderline personality should include:
A. Restricting her from other clients
B. Ensuring she adheres to certain restrictions
C. Limit setting and flexibility in schedule
D. Giving medications to prevent acting out
4. Answer: B. Ensuring she adheres to certain restrictions.
- Option B: The client is manipulative. The client must be informed about the policies, expectations, rules and regulation upon admission.
- Option A: This is not part of the care plan. Interaction with other clients are allowed, but the client should be observed and given limits in her attempt to manipulate and dominate others.
- Option C: Limits should be firmly and consistently implemented. Flexibility and bargaining are not therapeutic in dealing with a manipulative client.
- Option D: There is no specific medication prescribed for this condition.
5. A hospitalized client, diagnosed with a borderline personality disorder, consistently breaks the unit’s rules. This behavior should be confronted because it will help the client:
A. Set realistic goals
B. Control anger
C. Become more self-aware
D. Reduce anxiety
5. Answer: C. Become more self-aware.
- Option C: Client must first become aware of their behavior before they can change it. Occurs after the client is aware of the behavior and has a desire to change the behavior.