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Course: Mental Health Nursing

Topic: Personality Disorders

The Nurses International Community

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COPYRIGHT

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Module Goals

Learners will be able to:

Define personality disorder.
Identify the symptoms of personality disorders that are reported by clients.
Identify the clinical manifestations of personality disorders.
Discuss the evidence based management of personality disorders.
Identify the appropriate nursing interventions for clients with personality disorders.

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What is Personality?

Personality is the way of thinking, feeling, and behaving that makes a person different from other people.

An individual’s personality is influenced by

Experiences
Environment (surroundings, living situations)
Inherited characteristics

American Psychiatric Association,2018

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What is a Personality Disorder?

A way of thinking, feeling, and behaving that deviates from the expectations of the culture, causes distress or functional problems, and lasts over time.

Begins by late adolescence or early adulthood.

Affects at least two of the following areas

Way of thinking about oneself and others.
Way of responding emotionally.
Way of relating to other people.
Method of controlling one’s behavior.

American Psychiatric Association, 2018

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Classification of Personality Disorders

The (DSM-IV) Classifications include ten categorical personality disorders that are grouped into three clusters:

A or the “odd-eccentric”

Paranoid, schizoid, and schizotypal personality disorders.

B or the “dramatic-emotional”

Anti-social, borderline, histrionic, and narcissistic personality disorders.

C or the “anxious-fearful”

Avoidant, dependent, and obsessive-compulsive.

Reichborn-Kjennerud, 2010

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Cluster A (“Odd-Eccentric”) Disorders

Paranoid personality disorder

A pattern of being suspicious of others and seeing them as mean or spiteful.
Often assumes people will harm or deceive them so they don’t confide in others.
Begins in early adulthood.

American Psychiatric Association, 2018

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Cluster A (“Odd-Eccentric”) Disorders

Schizoid personality disorder:

Detached from social relationships and expresses little emotion.
Restricted range of emotional expressions.

Schizotypal personality disorder:

A pattern of being very uncomfortable in close relationships.
Distorted thinking and eccentric behavior.
Social and interpersonal deficits.

American Psychiatric Association, 2018

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Cluster B (“Dramatic-Emotional”) Disorders

Antisocial personality disorder:

Violates the rights of others.
Does not conform to social norms.
May repeatedly lie or deceive others.
Lack of empathy.

Borderline personality disorder:

Instability in personal relationships.
Intense emotions, poor self-image, and impulsivity.
May go to great lengths to avoid being abandoned.
Potential for repeated suicide attempts.
Inappropriate, intense anger or ongoing feelings of emptiness.

American Psychiatric Association, 2018

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Case Study:

A client tends to be insensitive to others, engages in abusive behaviors, and does not have a sense of remorse. Which personality disorder is the client likely to have?

Antisocial personality disorder
Histrionic personality disorder
Paranoid personality disorder
Narcissistic personality disorder

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Cluster B (“Dramatic-Emotional”) Disorders

Narcissistic personality disorder:

Need for admiration.
Lack of empathy for others.
Grandiose sense of self-importance.
Sense of entitlement, takes advantage of others.

Histrionic personality disorder:

Excessive emotion and attention-seeking behaviors.
Uncomfortable not being the center of attention.
Use physical appearance to draw attention to themselves.

American Psychiatric Association, 2018

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Cluster C (“Anxious-Fearful”) Disorders

Dependent personality disorder:

Excessive need to be taken care of.
Submissive behavior.
Fear of separation.
Helpless when alone.

Avoidant personality disorder:

A pattern of extreme shyness.
Social inhibition.
Feelings of inadequacy.
Extreme sensitivity to criticism.
May view themselves as not being good enough.

American Psychiatric Association, 2018

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Cluster C (“Anxious-Fearful”) Disorders

Obsessive-compulsive personality disorder:

Preoccupation with orderliness, perfection and control.
Maybe overly focused on details or schedules.
May work excessively, not allowing time for leisure or friends.

American Psychiatric Association, 2018

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Critical Thinking Question

Which of the following behaviors is most likely to be seen in a client with a personality disorder?

The client responds to anti-anxiety medications
The client recovers with therapeutic interventions
The client seeks treatment for personally distressing symptoms
The client manifests enduring patterns of inflexible behaviors

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Common Causes of Personality Disorders

Genetic malfunctioning of genes
Childhood sexual trauma
Significant verbal abuse
High Reactivity

Sensitivity to light, noise, texture, and other stimuli may also play a role.

American Psychological Association, 2010

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Risk Factors

Family history of personality disorders.
Mental illness.
Abusive, unstable, or chaotic family life during childhood.
Diagnosis of childhood conduct disorder.
Variations in brain chemistry and structure.

Mayoclinic. Org, 2016

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Symptoms of Personality Disorders

Common signs of personality disorders

Strange or erratic behavior
Suspicion and distrust
Risk-taking behaviors
Extreme mood swings (angry outbursts)
Difficulty with relationships
Problems at school or work
Need for instant gratification

Health Direct, 2020

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Treatment of Personality Disorders

Psychotherapy methods

Cognitive behavior therapy (CBT)
Dialectical behavior therapy (DBT)
Psychodynamic psychotherapy
Psychoeducation

Medications (for symptom management)
Crisis Management

Emergency assistance
Temporary hospitalization

Health Direct, 2020

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Management Strategies for Personality Disorders

Cluster A personality disorders

Paranoid

Adopt a professional stance.
Provide clear explanations.
Be empathetic to fears.
Avoid direct challenges to paranoid ideations.

Schizoid

Adopt a professional stance.
Provide clear explanations.
Avoid overinvolvement in personal and social issues.

Ward, 2004

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Management Strategies for Personality Disorders

Cluster A personality disorders

Schizotypal

Adopt a professional stance.
Provide clear explanations.
Tolerate odd beliefs and behaviors.
Avoid overinvolvement in personal and social issues.

Ward, 2004

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Management Strategies for Personality Disorders

Cluster B personality disorders

Antisocial

Carefully investigate concerns and motives.
Communicate clearly in a non-punitive manner.
Set clear limits.

Borderline

Avoid excessive familiarity.
Schedule regular visits.
Provide clear, non-technical explanations.
Tolerate angry outbursts, but set limits.
Maintain awareness of personal feeling.
Consult psychiatry as needed.

Ward, 2004

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Management Strategies for Personality Disorders

Cluster B personality disorders

Histrionic

Avoid excessive familiarity.
Show professional concern for feelings.
Emphasize objective issues.

Narcissistic

Validate concerns.
Give attentive and factual responses to questions.
Channel client’s skills into dealing with illness.

Ward, 2004

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Management Strategies for Personality Disorders

Cluster C personality disorders

Avoidant

Provide reassurance
Validate concerns
Encourage reporting of symptoms and concerns

Dependent

Provide reassurance
Schedule regular check-ups
Set realistic limits on availability
Enlist others to support client
Avoid rejection of the client

Ward, 2004

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Management Strategies for Personality Disorders

Obsessive-compulsive

Complete thorough history and examinations.
Provide thorough explanations.
Do not overemphasize uncertainty.
Encourage client participation in treatment.

Ward, 2004

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Critical Thinking Question

Which of the following is the best indicator of success in the long-term management of the client with a personalit y disorder?

The client’s symptoms are replaced by indifference to emotions.
The client participates in diversionary activities.
The client learns to verbalize their feelings and concerns.
The client states that their behaviors are irrational.

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Nursing Assessment

History

Assess family history and/other risk factors

Mood and affect

The pervasive mood is dysphoric and may involve

Unhappiness
Restlessness and malaise
Intense loneliness, boredom, frustration, and feeling “empty”

Thought process and content

Thinking about oneself and others is often polarized and extreme

Sensorium and Intellectual Process

Belleza, 2021

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Goals for Nursing Care

Appropriate goals include

Developing a relationship based on empathy and trust.
Ensuring care responsibilities are appropriately addressed with regards to treatment.
Remaining alert to suicide risk.
Promoting effective coping and problem-solving skills in a way that is empowering to the client.
Promoting the client’s involvement with a support network (access to an appropriate service provider).

Queensland Government, 2010

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Goals for Nursing Care

Ensuring collaboration and communication between staff members and service providers to ensure consistency in treatment and approach.

Supporting and promoting self-care activities for families and caregivers of the client.

Queensland Government, 2010

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Nursing Interventions

Promote client safety

Consider suicidal ideation (a plan, access to means for enacting the plan, and self-harm behaviors).
Institute appropriate interventions for the prevention of suicide.

Establish therapeutic relationship.
Establish boundaries in a relationship.
Help client to cope and control the emotions.
Reshape the thinking process.
Structure the client’s daily activities.

Belleza, 2021

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Nursing Interventions

Educate the client about the disorder
Assess behavior and mental status
Assess social interactions
Administer SSRIs if prescribed
Encourage the client to seek therapy
Teach client self-care

Fisher, Hany & Doerr, 2021

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What Would the Nurse Do?

A client with a personality disorder is being discharged from a hospital short-stay mental health unit. The client says they feel much better and are glad that they have learned new skills that will help them to deal with their “problems.” After the nurse provides discharge instructions, the client asks if they can stop by once in a while to visit the nurse.

Which of the following is the most appropriate response of the nurse?

“Thank you for asking. It would be nice for you to stop by once in a while and let us know how you are doing.”
“This would be fine as long as you call first to see how the workload is on the unit.”
“It has been a pleasure to work with you. Since it is not appropriate or helpful for you to visit after you are discharged, we have scheduled a follow up outpatient appointment with your counselor.”
“I am sorry, but the policy states that you may not visit the unit once you are discharged.”

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References:

American Psychiatric Association. (2018). What are Personality Disorders?. https://www.psychiatry.org/patients-families/personality-disorders/what-are-personality-disorders

American psychological Association.(2010).What causes personality disorders?. https://www.apa.org/topics/personality-disorders/causes

Health Direct. (2020). Personality Disorders : An Overview. https://www.healthdirect.gov.au/personality-disorders

Mayoclinic. Org. (2016). Personality Disorders. https://www.mayoclinic.org/diseases-conditions/personality-disorders/diagnosis-treatment/drc-20354468

Reichborn-Kjennerud T. (2010). The genetic epidemiology of personality disorders. Dialogues in clinical neuroscience, 12(1), 103–114. https://doi.org/10.31887/DCNS.2010.12.1/trkjennerud

Contact info: info@nursesinternational.org

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References

Queensland Government. (2010). Caring for a Person Who has Personality Disorders. Queensland MIND essentials. https://www.health.qld.gov.au/__data/assets/pdf_file/0034/444598/disorders.pdf

Ward R. K. (2004). Assessment and Management of Personality Disorders.American Family Physician. 70(8):1505-1512. https://www.aafp.org/afp/2004/1015/p1505.html

Fisher, K.A., Hany M.,& Doerr, C. (2021). Antisocial Personality Disorder (Nursing). In: StatPearls [Internet]. StatPearls Publishing; 2022 Jan.. https://www.ncbi.nlm.nih.gov/books/NBK568730/

Belleza, M. (2021). Personality Disorders. Nurseslabs. https://nurseslabs.com/personality-disorders/#:~:text=Nursing%20diagnoses%20for%20clients%20with%20personality%20disorder%20include%20the%20following%3A&text=Risk%20for%20suicide%20related%20to%20low%20frustration%20tolerance.&text=Risk%20for%20self%2Dmutilation%20related%20to%20impulsive%20behavior.&text=Risk%20for%20other%20directed%20violence%20related%20to%20lack%20of%20feelings%20of%20remorse.

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