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Personality and Impulse-Control
Disorders
Chapter 20
What is it?
Personality
• Complex pattern of
characteristics, largely
outside of the person’s
awareness
• Distinctive patterns of
perceiving, feeling, thinking,
coping and behaving
• Emerges within
biopsychosocial framework
Personality Disorder
• An enduring pattern of
deviant inner experiences
and behavior
• Differ from cultural
expectations
• Pervasive, inflexible and
stable
• Leads to distress or
impairment
Types of Personality Disorders
•
•
•
Cluster A - odd-eccentric
–
Paranoid Personality Disorder
–
Schizoid Personality Disorder
–
Schizotypal Personality Disorder
Cluster B - dramatic and emotional (impulsivity)
–
Antisocial Personality Disorder
–
Borderline Personality Disorder
–
Histrionic Personality Disorder
–
Narcissistic Personality Disorder
Cluster C - anxious-fearfulness
–
Avoidant Personality Disorder
–
Dependent Personality Disorder
–
Obsessive-compulsive Disorder
Common Features and Diagnostic
Criteria
• Abnormal, inflexible behavior patterns of long duration,
traced back to adolescence and early adulthood
• Pervasive across a broad range of personal & social
situations
• Deviate in the following:
– Cognitive abilities (schema)
– Affectivity and emotional stability (emotions)
– Interpersonal functioning/self-identity
– Impulse control and destructive behavior
Severity Criteria
• Tenuous stability - exaggerated emotions,
unable to cope with normal stressful events
• Adaptive inflexibility - rigidity in interactions
with others
• Vicious circles - because of inflexibility,
generate and perpetuate dilemmas
Cluster A Disorders
Paranoid Personality Disorder
• Features
– Mistrustful, avoid relationships that cannot control
– Persistent ideas of self-importance
• Epidemiology
– 0.5 to 2.5% in general populations
– More often in men
• Etiology: unclear, genetic predisposition?
Cluster A Disorders
Paranoid Personality Disorder
Nursing Management
– Patients seen for other health problems
– Nsg DX: Disturbed thought process, social
isolation
– Nursing Interventions
• It can be difficult to establish nurse-patient relationship.
• If trust is established, help patient identify problem areas.
• Changing thought patterns takes time.
Cluster A Disorders
Schizoid Personality Disorder
• Features
– Expressively impassive and interpersonally unengaged
– Introverted and reclusive, engage in solitary activities
– Communication sometimes confused
– Incapable of forming social relationships
– Minimum introspection, self-awareness and interpersonal
experiences
• Epidemiology
– Rarely diagnosed in clinical settings
– Avoidant personality disorder occurs in 30 to 35% of cases
• Etiology: speculative
Cluster A Disorders
Schizoid Personality Disorder
Nursing Management
• Nursing Diagnosis: Impaired social
interactions and chronic low self-esteem
• Goal: To enhance experience of pleasure
• Interventions
– Provide social skill training.
– Encourage social interactions.
Cluster A Disorders
Schizotypal Personality Disorder
• Features
– Eccentric
– Pattern of social and interpersonal deficits
– Void of close friends
– Odd beliefs
– Ideas of reference
– When psychotic, symptoms mimic schizophrenia.
• Epidemiology
• 0.7 to 5.1% prevalence
• Etiology: unknown
• Speculation that this is a part of a continuum of schizophreniarelated disorders
Cluster A Disorders
Schizotypal Personality Disorder
Nursing Management
• Similar to that with schizophrenia
• Increase self-worth.
• Provide social skills training.
• Reinforce socially appropriate dress and
behavior.
• Focus on enhancing cognitive skills.
Borderline Personality Disorders
Clinical Course
• Pervasive patterns of instability of interpersonal relationships,
self-image and affects, as well as marked impulsivity that begins
by early adulthood and is present in a variety of contexts
• Problem areas
– Regulating moods
– Developing a sense of self
– Maintaining interpersonal relationships
– Maintaining reality-based cognitive processes
– Impulsive or destructive behavior
• Appear more competent than they are
• Live from crisis to crisis
Borderline Personality Disorder
• Affective instability - shifts in moods
• Identity disturbance (identify diffusion)
– Role absorption - narrow definition of self
– Painful incoherence - internal disharmony
– Inconsistency in thoughts, feelings and actions
– Lack of commitment
• Unstable interpersonal relationships
– Fear of abandonment
– Unstable, insecure attachments
– Over idealize/intense relationships
Borderline Personality Disorder
• Cognitive Dysfunctions
– Dichotomous thinking
– Dissociation
• Dysfunctional Behaviors
– Impaired problem-solving
– Impulsivity
– Self-injurious behaviors (parasuicidal behavior)
• Compulsive
• Episodic
• Repetitive
Borderline Personality Disorder
in Special Populations
• Many children and adolescents show
symptoms similar to those with BPD.
• Symptoms begin in adolescents.
Epidemiology
• 0.4 to 2.0% prevalence in general populations
• In clinical populations, BPD is the most
frequently diagnosed personality disorder.
• Mostly women (77%)
• Mean age of diagnosis is mid-20s.
• Coexistence of personality disorders with Axis
I disorders (mood, substance abuse eating,
dissociative and anxiety disorders)
Risk Factors
• Physical and sexual abuse
• Parental loss or separation
Etiology
• Biologic
– Abnormalities associated with affective instability,
transient psychotic episodes, and impulsive,
aggressive and suicidal behavior
• Psychological
– Psychoanalytic theory (separation-individuation;
projective identification)
– Maladaptive cognitive processes
Etiology: Biosocial Theories
• Millon – Distinct disorder that develops as a result of both biologic
and psychological factors.
– Personality is shaped by a) active-passive behavior, b)
pleasure-pain and c) sensitivity to self or others.
• Linehan
– Emotional vulnerability, self-invalidation, unrelenting crises,
inhibited grieving, active passivity and apparent competence
(Text Box 20.1)
Risk Factors
• Physical and sexual abuse
• Separation or loss of parent at an early
age (same sex for men)
Interdisciplinary Treatment
• Requires the whole mental health care
team
• Requires a variety of medications
including mood stabilizers,
antidepressants and, at times,
anxiolytics
• Psychotherapy
Dialectical Behavior Therapy
• Combines numerous cognitive behavioral
approaches
• Requires monitoring and commitment by patient
• Individual therapy
• Building skills through skills group
– Mindfulness
– Interpersonal effectiveness
– Emotion regulation
– Distress tolerance skills
– Self-management
Priority Care
Safety!!!
Response Patterns
• Affective dysregulation
• Identity disturbance
• Mood lability
• Sense of emptiness
• Problems with anger
• Behavioral
dysregulation
• Interpersonal
dysregulation
• Parasuicide behavior
• Chaotic relationships
• Impulsive behavior
• Fears of abandonment
• Cognitive dysregulation
• Self-dysregulation
• Dissociative responses
• Paranoid ideation
Nursing Management:
Biologic Domain
Assessment
• Systems review and physical functioning
– Nutrition and eating
– Sleep patterns
– Physical responses to emotions
• Physical indicators of self-injurious behaviors
– Cutting, scratching or swallowing
• Pharmacologic assessment, including OTC
and illicit drugs
Nursing Diagnosis:
Biologic Domain
• Self-mutilations, risk for self-mutilation
• Disturbed sleep pattern
• Ineffective therapeutic regimen
management
Nursing Interventions:
Biologic Domain
• Sleep enhancement
– Enhance regular sleep-wake cycles.
– Moderate exercise
– Avoid touching those who have been physically, sexually abused.
• Nutritional enhancement
• Prevention and treatment of self-injury
– Observe for antecedents of self-injurious behavior, intervening
before an episode.
– Help develop strategies to prevent behavior.
– Five sense exercise
Pharmacologic Interventions
• Controlling emotional dysregulations
– MAOIs
– SSRIs
– Others - SNEIs
• Reducing impulsivity - mood stabilizers
• Transient psychotic episodes - antipsychotics
• Reducing self-injurious behavior
– Naltrexone for dissociative symptoms has been studied.
– Atypical antipsychotics
• Decreasing anxiety
– Buspirone, careful use of benzodiazepines
Nursing Management:
Psychological Domain
Assessment
• Appearance and activity level
– Reflect mood and psychomotor activity
– Usually experience depression
• Moods
– Inhibited grieving
– Mood fluctuations
• Impulsivity
• Cognitive disturbance
– Dichotomous thinking
Nursing Management:
Psychological Domain
Assessment (cont.)
• Dissociation and transient psychotic episodes
• Interpersonal skills
– Assessment of person’s ability to relate to others
– Determine sexual partners
• Self-esteem and coping skills
• Risk for suicide or self-injury
Nursing Diagnosis
Psychological Domain
• Risk for self-mutilation
• Disturbed thought process
• Ineffective coping
Pharmacologic Interventions
• Monitoring and administration of medications
– Easy to monitor in inpatient
– Outpatients may have high rate of noncompliance.
• Side effect monitoring and management
– Patients appear to be more sensitive to side effects.
• Drug-drug interaction
– Patients tend to be prone to drug interactions.
• Teaching points
Nursing Interventions:
Psychological Domain
• Nurse-patient relationship
– Establish trust.
– Recognize conflicting fears of abandonment and intimacy.
– Establish personal boundaries and limitations.
• Abandonment and intimacy fears
– Recognize conflict.
– Any termination needs to be planned carefully.
• Establish personal boundaries and limitations.
• Management of dissociative states
– Determine triggers.
Nursing Interventions:
Psychological Domain (cont.)
• Behavioral interventions
– Goal is to replace dysfunctional behaviors with positive ones.
– Validate positives; avoid confrontation if possible.
• Cognitive interventions
– Emotional regulation
– Communication triad
– Distraction or thought triad
– Challenging dysfunctional thinking
• Management of transient psychotic episodes
• Patient episodes
Nursing Management:
Social Domain
Assessment
• Functional status
– Current job
– Community activities
• Social support systems
• Family assessment
Nursing Interventions:
Social Domain
• Milieu management
• Group interventions
• Family and social support
Nursing Management
Psychological Assessment
• Appearance and activity level
• Moods - inhibited grieving
• Impulsivity
• Suicide and/or self-injurious behavior
– Dichotomous thinking
– Dissociation and psychotic episodes
• Self-esteem and coping skills
Nursing Management
Social Assessment
• Family
• Interpersonal skills
• Social support systems
Nursing Diagnosis
• Risk for self-mutilation
• Altered thought processes
• Ineffective coping
• Personal identity disturbance
• Anxiety
• Grief
• Low self-esteem
• Powerlessness
• Social isolation
• Spiritual distress
Biologic Interventions
• Sleep management
• Nutrition
• Management of psychotic episodes
• Prevention of self-injury
• Pharmacologic management
Psychological Interventions:
Cognitive
• Communication triad
– An “I” statement to identify and express their feelings
– A nonjudgmental statement of the emotional trigger
– What could be done differently or what would restore comfort
to the situation
• Thought stopping
• Challenging dysfunctional thinking (Text Box 22-4)
• Education
Social Interventions
• Milieu management
• Group interventions
• Family and social support
Antisocial Personality Disorder
• Pervasive pattern of disregard for, and violation of,
the rights of others that begins in childhood or early
adolescence
• Behaviorally impulsive
• Interpersonally irresponsible
• Fail to adapt to the ethical and social standards of
community
• Interpersonally engaging, but in reality lack empathy
• Easily irritated, often aggressive
Epidemiology and Risk Factors
• 0.2 to 3% of the population
• Age of onset - exhibit antisocial behavior
before 15
• Men more often diagnosed (See Text Box 226.)
• Present in all cultures
• Comorbid with alcohol and drug abuse
Etiology
• Biologic
– Genetic component – Five times more common in firstdegree relatives
– Biochemical - not well understood
• Psychological
– Insecure attachments
– Difficult temperament
• Social
– Chaotic families
– Abuse
Nursing Management
Assessment
• Difficult to establish a relationship
• Determine quality of relationships
• Impulsivity
• Aggression
• Ability to assume responsibility for their
actions
• Amount of blaming others
Nursing Diagnosis
• Altered role performance
• Ineffective individual coping
• Impaired communication
• Impaired social interactions
• Defensive self-esteem
• Risk for violence
Nursing Management
• Biologic - physical effects of chronic use of addictive
substances
• Psychological
– Self-responsibility facilitation
– Self-awareness enhancement
– Anger management
– Patient education
• Social
– Group
– Milieu
Family Interventions
• Help families establish boundaries.
• Help families recognize patient’s
responsibility for his or her actions.
Histrionic Personality Disorder
• Attention seeking, life of the party,
uncomfortable with single relationship
• Women - dress seductively
• Men - dress - “macho”
• Become depressed when not center of
attention
Histrionic Personality Disorder
• 2 to 3% of population
• Highly alert individuals
• Parent modeling - “like mom”
• Nursing intervention
– Develop a sense of self without validation
of others
Narcissistic Personality Disorder
• Grandiose
• Inexhaustible need for attention
• Fantasies about power, unlimited success
• 1% of population
• Etiology - unknown
• Rarely encounter them
Cluster C Disorders
• Avoidant personality disorder
– Avoiding interpersonal contacts and social situation
– Perceiving themselves as socially inept
• Dependent
– Submissive pattern
– Cling to others to be taken care of
– Prevalent in clinical samples
• Obsessive-compulsive
– Different than OCD. Not as many obsessions and compulsions, but
rigidity, perfectionism and control
Impulse Control Disorders
• Intermittent explosive disorder
• Kleptomania
• Pyromania
• Pathologic gambling
• Trichotillomania