Personality disorders. Definition Enduring patterns Enduring patterns Deviated from expectations Deviated from expectations Pervasive & inflexible Pervasive.

Personality disordersPersonality disorders

DefinitionDefinition

Enduring patternsEnduring patterns Deviated from expectations Deviated from expectations Pervasive & inflexible Pervasive & inflexible Onset in adolescent & early Onset in adolescent & early

adulthood adulthood Leads to distress and impairment Leads to distress and impairment

Personality Trait vs. Personality Trait vs. Personality DisordersPersonality Disorders

* * Personality :Personality : may be described as a persons may be described as a persons characteristics totality of emotional and characteristics totality of emotional and behavioral traits apparent in ordinary life, a behavioral traits apparent in ordinary life, a totality that is usually stable and predictable.totality that is usually stable and predictable.

* * Personality disorders :Personality disorders : are diagnosed when personality traits are diagnosed when personality traits become inflexible and maladaptive and significantly interfere become inflexible and maladaptive and significantly interfere with how a person functions in society or cause the person with how a person functions in society or cause the person emotional distress. They usually are not diagnosed until emotional distress. They usually are not diagnosed until adulthood, when personality is more completely formed.adulthood, when personality is more completely formed.

Personality disorders are organized into three clusters:Personality disorders are organized into three clusters:

1. CLUSTER A1. CLUSTER A: : Individuals whose behavior appears odd or eccentric Individuals whose behavior appears odd or eccentric

(paranoid, schizoid, and schizotypal personality disorders)(paranoid, schizoid, and schizotypal personality disorders) 2.2. CLUSTER BCLUSTER B: : Individuals who appear dramatic, emotional, or Individuals who appear dramatic, emotional, or

erratic (antisocial, borderline, histrionic, and narcissistic personality erratic (antisocial, borderline, histrionic, and narcissistic personality disorders)disorders)

3. CLUSTER C3. CLUSTER C: : Individuals who appear anxious or fearful (avoidant, Individuals who appear anxious or fearful (avoidant, dependent, and obsessive compulsive personality disorders)dependent, and obsessive compulsive personality disorders)

NOT SPECIFIEDNOT SPECIFIED: if not meeting criteria for any : if not meeting criteria for any personality disorder personality disorder

EpidemiologyEpidemiology

10 – 20% 10 – 20% Borderline PD accounts for 30-Borderline PD accounts for 30-

60% of all diagnosed PD60% of all diagnosed PD 75% of borderline PD are 75% of borderline PD are

womenwomen Antisocial PD has to be 18 year Antisocial PD has to be 18 year

EtiologyEtiology

1.1. Developmental factors:Developmental factors: Interruption of any task may lead to PDInterruption of any task may lead to PD Children's who are temperamentally Children's who are temperamentally

fearful may later develop avoidant PD.fearful may later develop avoidant PD. High anxiety levels --- avoidant PDHigh anxiety levels --- avoidant PD

2. Environmental factors:2. Environmental factors: Some attribution between Some attribution between

developmental and environmental developmental and environmental factorsfactors

Etiology cont..Etiology cont..

3. Biogenetic factors: 3. Biogenetic factors: Students with low MAO spent more time in Students with low MAO spent more time in

social activity and sociability. social activity and sociability. Low platelet mono amine oxidase levels Low platelet mono amine oxidase levels

associated with activity and sociability. associated with activity and sociability. People who exhibit impulsive traits --- show People who exhibit impulsive traits --- show

increase levels of testosterone. increase levels of testosterone. Schizotypal --- schizophrenia family Schizotypal --- schizophrenia family Antisocial personality --- alcohol use Antisocial personality --- alcohol use Histrionic personality --- somatization Histrionic personality --- somatization Borderline personality --- is common in the Borderline personality --- is common in the

depressed family. depressed family. Brian injury……. Borderline PDBrian injury……. Borderline PD

DIAGNISTIC CRITERIADIAGNISTIC CRITERIA

PARANOID PERSONALITYPARANOID PERSONALITY Paranoid personality disorder Paranoid personality disorder is characterized by is characterized by

pervasive mistrust and suspiciousness of others. pervasive mistrust and suspiciousness of others. Clients with this disorder interpret others’ actions as Clients with this disorder interpret others’ actions as potentially harmful. During periods of stress, they potentially harmful. During periods of stress, they may develop transient psychotic symptomsmay develop transient psychotic symptoms..

Symptoms/CharacteristicsSymptoms/Characteristics

Mistrust and suspicions of others; guarded, restricted Mistrust and suspicions of others; guarded, restricted affectaffect

Nursing InterventionsNursing Interventions

Forming an effective working relationship with paranoid or suspicious Forming an effective working relationship with paranoid or suspicious clients is difficult. The nurse must remember that these clients take clients is difficult. The nurse must remember that these clients take everything seriously and are particularly sensitive to the reactions andeverything seriously and are particularly sensitive to the reactions and

motivations of others. Therefore, the nurse must approach these clients in a motivations of others. Therefore, the nurse must approach these clients in a formal, business-like manner and refrain from social chitchat or jokes. formal, business-like manner and refrain from social chitchat or jokes. Being on time, keeping commitments, and being particularlyBeing on time, keeping commitments, and being particularly

straightforward are essential to the success of the nurse–client relationship.straightforward are essential to the success of the nurse–client relationship.

One of the most effective interventions is helping clients to learnOne of the most effective interventions is helping clients to learn to validate ideas before taking action; however, thisto validate ideas before taking action; however, this requires the ability to trust and to listen to one person.requires the ability to trust and to listen to one person.

SCHIZOID PD:SCHIZOID PD:

inability to perform relationship, low interest in establishing any inability to perform relationship, low interest in establishing any relationship (marriage) relationship (marriage)

is characterized by a pervasive pattern of detachment from social relationships and a restricted is characterized by a pervasive pattern of detachment from social relationships and a restricted range of emotional expression in interpersonal settings.range of emotional expression in interpersonal settings.

Clients with schizoid personality disorder display a constricted affect and little, if any, Clients with schizoid personality disorder display a constricted affect and little, if any, emotion.emotion.

They are aloof and indifferent, appearing emotionally cold, uncaring, or unfeeling. They They are aloof and indifferent, appearing emotionally cold, uncaring, or unfeeling. They report no leisure or pleasurable activities, because they rarely experience enjoyment. Even report no leisure or pleasurable activities, because they rarely experience enjoyment. Even under stress or adverse circumstances, their response appears passive and disinterested.under stress or adverse circumstances, their response appears passive and disinterested.

There is marked difficulty experiencing and expressing emotions, particularly anger or There is marked difficulty experiencing and expressing emotions, particularly anger or aggression.aggression.

Clients generally are accomplished intellectually and often involved with computers or Clients generally are accomplished intellectually and often involved with computers or electronics in hobbies or work. They may spend long hours solving puzzles or mathematical electronics in hobbies or work. They may spend long hours solving puzzles or mathematical problems, although they seeproblems, although they see

these pursuits as useful or productive rather than fun.these pursuits as useful or productive rather than fun.

Nursing interventionNursing intervention

focus on improved functioning in the community.focus on improved functioning in the community. If a client needs housing or a change in living circumstances, If a client needs housing or a change in living circumstances,

the nurse can make referrals to social services or appropriate the nurse can make referrals to social services or appropriate local agencieslocal agencies

for assistance. for assistance. The nurse can help agency personnel find suitable housing that The nurse can help agency personnel find suitable housing that

will accommodate the client’s desire and need for solitude.will accommodate the client’s desire and need for solitude.

Facilities designed to promote socialization through group Facilities designed to promote socialization through group

activities would be less desirableactivities would be less desirable..

SCHIZOTYPAL PDSCHIZOTYPAL PD

cognitive and perceptual distortioncognitive and perceptual distortion is characterized by a pervasive pattern of social and interpersonalis characterized by a pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close deficits marked by acute discomfort with and reduced capacity for close

relationships as well as by cognitive or perceptual distortions and relationships as well as by cognitive or perceptual distortions and behavioral eccentricities.behavioral eccentricities.

Clients often have an odd appearance that causes others to notice them. Clients often have an odd appearance that causes others to notice them. Clothes are ill fitting, do not match, and may be stained or dirty. Clients Clothes are ill fitting, do not match, and may be stained or dirty. Clients may be unkempt and disheveled. They may wander aimlessly and at times may be unkempt and disheveled. They may wander aimlessly and at times becosming preoccupied with some environmental detail. Speech is becosming preoccupied with some environmental detail. Speech is coherent but may be loose, digressive, or vague.coherent but may be loose, digressive, or vague.

Clients often provide unsatisfactory answers to questions and may be Clients often provide unsatisfactory answers to questions and may be unable to specify or to describe information clearly. They frequentlyunable to specify or to describe information clearly. They frequently

use words incorrectly, which makes their speech sound bizarre .use words incorrectly, which makes their speech sound bizarre .

Nursing interventionNursing intervention

The focus of nursing care for clients with schizotypal The focus of nursing care for clients with schizotypal personality disorder is development of self-care and social personality disorder is development of self-care and social skills and improved functioning in the community.skills and improved functioning in the community.

The nurse encourages clients to establish a daily routine for The nurse encourages clients to establish a daily routine for hygiene and grooming. Such a routine is important rather than hygiene and grooming. Such a routine is important rather than depending on the client to decide when hygiene and grooming depending on the client to decide when hygiene and grooming tasks are necessary.tasks are necessary.

It is useful for clients to have an appearance that is not bizarre It is useful for clients to have an appearance that is not bizarre or disheveled, because stares or comments from others can or disheveled, because stares or comments from others can increase discomfortincrease discomfort

ANTISOCIAL PDANTISOCIAL PD

Aggression in all manners Aggression in all manners Criminal records and multiple Criminal records and multiple sexual relationshipsexual relationship

BORDERLINE PDBORDERLINE PD

Fear of abandonmentFear of abandonment Broke away fearing failure Broke away fearing failure Acting outActing out

HISTRIONIC PDHISTRIONIC PD

Dramatic emotional expression, seeking attention, Dramatic emotional expression, seeking attention, wants to impress otherswants to impress others

is characterized by a pervasive pattern of excessive emotionality and is characterized by a pervasive pattern of excessive emotionality and attention-seeking.attention-seeking.

Clients are emotionally expressive, gregarious,Clients are emotionally expressive, gregarious, and effusive. They often exaggerate emotions inappropriately. The and effusive. They often exaggerate emotions inappropriately. The

tendency of these clients to exaggerate thetendency of these clients to exaggerate the closeness of relationships or to dramatize relativelycloseness of relationships or to dramatize relatively minor occurrences can result in unreliable data.minor occurrences can result in unreliable data. Speech is usually colorful and theatrical, full of superlativeSpeech is usually colorful and theatrical, full of superlative Adjectives Clients are uncomfortable when they are not theAdjectives Clients are uncomfortable when they are not the center of attention and go to great lengths to gain thatcenter of attention and go to great lengths to gain that status. Clients tend to exaggerate the intimacy of relationships.status. Clients tend to exaggerate the intimacy of relationships.

Nursing interventionsNursing interventions It also may help to discuss social situations to exploreIt also may help to discuss social situations to explore the client’s perceptions of other’s reactions andthe client’s perceptions of other’s reactions and behavior. Teaching social skills and role-playingbehavior. Teaching social skills and role-playing The nurse must be specific in describing andThe nurse must be specific in describing and modeling social skills including establishing eye contact,modeling social skills including establishing eye contact, active listening, and respecting personal space. Itactive listening, and respecting personal space. It also helps to outline topics of discussion appropriatealso helps to outline topics of discussion appropriate for casual acquaintances, closer friends or family, andfor casual acquaintances, closer friends or family, and the nurse only.the nurse only. It is important to explore personal strengths and assetsIt is important to explore personal strengths and assets and give specific feedback about positive characteristics.and give specific feedback about positive characteristics. Encouraging clients to use assertive communication,Encouraging clients to use assertive communication, such as “I” statements, may promotesuch as “I” statements, may promote self-esteem and help them to get their needs metself-esteem and help them to get their needs met more appropriately. The nurse must convey genuinemore appropriately. The nurse must convey genuine confidence in the client’sconfidence in the client’s abilities. abilities.

NARCISSISTIC PERSONALITY DISORDERNARCISSISTIC PERSONALITY DISORDER

grandiose self-importance, talk about grandiose self-importance, talk about themselves and neglect others, overreaction themselves and neglect others, overreaction for criticismfor criticism

Clients may display an arrogant or haughty attitude.Clients may display an arrogant or haughty attitude. They lack the ability to recognize or to empathize with the They lack the ability to recognize or to empathize with the

feelings of others. They may express envy and begrudge others feelings of others. They may express envy and begrudge others any recognition or material success because they believe it any recognition or material success because they believe it rightfully should be theirs. Clients tend to disparage, belittle, or rightfully should be theirs. Clients tend to disparage, belittle, or discount the feelings of others. They may express their grandiosity discount the feelings of others. They may express their grandiosity overtly, or they quietly may expect to be recognized for their overtly, or they quietly may expect to be recognized for their perceived greatness. They often are preoccupied with fantasies of perceived greatness. They often are preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. These unlimited success, power, brilliance, beauty, or ideal love. These fantasies reinforce their sense of superiority. Clients may ruminate fantasies reinforce their sense of superiority. Clients may ruminate about long-overdue admiration and privilege and compare about long-overdue admiration and privilege and compare themselves favorably with famous or privileged people.themselves favorably with famous or privileged people.

Nursing interventionsNursing interventions

The nurse must use self-awareness skills to avoid the anger The nurse must use self-awareness skills to avoid the anger and frustration that their behavior and attitude can engender.and frustration that their behavior and attitude can engender.

Clients may be rude and arrogant, unwilling to wait, and Clients may be rude and arrogant, unwilling to wait, and harsh and critical of the nurse. harsh and critical of the nurse.

The nurse must not internalize such criticism or take it The nurse must not internalize such criticism or take it personally.personally.

The goal is to gain cooperation of these clients with other The goal is to gain cooperation of these clients with other treatment as indicated.treatment as indicated.

AVOIDANT PDAVOIDANT PDLow self-esteem, and fear of rejection.Low self-esteem, and fear of rejection. is characterized by a pervasive pattern of social discomfort is characterized by a pervasive pattern of social discomfort

and reticence, low self-esteem, and hypersensitivity to and reticence, low self-esteem, and hypersensitivity to negative evaluation.negative evaluation.

Clients have very low self-esteem. They are hypersensitive Clients have very low self-esteem. They are hypersensitive to negative evaluation from others and readily believe to negative evaluation from others and readily believe themselves inferior. Clients are reluctant to do anything themselves inferior. Clients are reluctant to do anything perceived as risky, which for them is almost anything. They perceived as risky, which for them is almost anything. They are fearful and convinced that they will make a mistake, be are fearful and convinced that they will make a mistake, be humiliated, or embarrass themselves and others. Because humiliated, or embarrass themselves and others. Because they are unusually fearful of rejection, criticism, shame, or they are unusually fearful of rejection, criticism, shame, or disapproval, they tend to avoid situations or relationships disapproval, they tend to avoid situations or relationships that may result in these feelings. They usually strongly that may result in these feelings. They usually strongly desire social acceptance and human companionship:desire social acceptance and human companionship:

they wish for closeness and intimacy but fear possible they wish for closeness and intimacy but fear possible rejection and humiliation.rejection and humiliation.

NURSING INTERVENTIONSNURSING INTERVENTIONS Nursing InterventionsNursing Interventions

These clients require much support and reassuranceThese clients require much support and reassurancefrom the nurse. In the non threatening context of thefrom the nurse. In the non threatening context of therelationship, the nurse can help them to explore relationship, the nurse can help them to explore positivepositiveself-aspects, positive responses from others, andself-aspects, positive responses from others, andpossible reasons for self-criticism. Helping clients topossible reasons for self-criticism. Helping clients topractice self-affirmations and positive self-talk maypractice self-affirmations and positive self-talk maybe useful in promoting self-esteem. Other cognitivebe useful in promoting self-esteem. Other cognitiverestructuring techniques, such as reframing and restructuring techniques, such as reframing and decatastrophizingdecatastrophizing(described previously), can enhance(described previously), can enhanceself-worth. The nurse can teach social skills and helpself-worth. The nurse can teach social skills and helpclients to practice them in the safety of the nurse–clients to practice them in the safety of the nurse–client relationship.client relationship.

DEPENDENT PDDEPENDENT PDExcessive reliance on others for social Excessive reliance on others for social

support, fear separation and avoided support, fear separation and avoided responsibilities.responsibilities.

is characterized by a pervasive and excessive need to be taken care of,is characterized by a pervasive and excessive need to be taken care of,which leads to submissive and clinging behavior andwhich leads to submissive and clinging behavior andfears of separation.fears of separation. These behaviors are designed to elicit caretaking from othersThese behaviors are designed to elicit caretaking from others.. Clients are frequently anxious and may be mildly uncomfortable. Clients are frequently anxious and may be mildly uncomfortable. They are often pessimistic and selfcritical; other people hurt their feelings They are often pessimistic and selfcritical; other people hurt their feelings

easily. They commonly report feeling unhappy or depressed; this is easily. They commonly report feeling unhappy or depressed; this is associated most likely with the actual or threatened loss of support from associated most likely with the actual or threatened loss of support from another. another.

They are preoccupied excessively with unrealistic fears of being left alone They are preoccupied excessively with unrealistic fears of being left alone to care for themselves.to care for themselves.

They believe they would fail on their own, so keeping or finding a They believe they would fail on their own, so keeping or finding a relationship occupies much of their timerelationship occupies much of their time

NURSING INTERVENTIONSNURSING INTERVENTIONS

The nurse must help clients to express feelings of grief and loss over the The nurse must help clients to express feelings of grief and loss over the end of a relationship while fostering autonomy and self-reliance. end of a relationship while fostering autonomy and self-reliance.

Helping clients to identify their strengths and needs is more helpfulHelping clients to identify their strengths and needs is more helpful than encouraging the overwhelming belief that “I can’t do anything alone!” than encouraging the overwhelming belief that “I can’t do anything alone!”

Cognitive restructuring techniques such as reframing and decatastrophizing Cognitive restructuring techniques such as reframing and decatastrophizing may be beneficialmay be beneficial..

The nurse also may need to teach problem-solvingThe nurse also may need to teach problem-solving and decision-making and help clients apply them toand decision-making and help clients apply them to daily lifedaily life The nurse can help the client to explore problems, serve as aThe nurse can help the client to explore problems, serve as a sounding board for discussion of alternatives, andsounding board for discussion of alternatives, and provide support and positive feedback for the client’sprovide support and positive feedback for the client’s efforts in these areasefforts in these areas..