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Chapter 18
Personality Disorders
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Personality
• Ingrained enduring pattern of behaving and relating to
self, others, environment
• Perceptions, attitudes, emotions
• Usually not consciously aware of own personality
• Personality disorders: traits inflexible and maladaptive;
significant interference with functioning or cause of
emotional distress
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Maladaptive or Dysfunctional Personality
Traits Include:
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Negative behavior toward others
Anger and/or hostility
Irritable/labile moods
Lack of guilt, remorse or emotionally cold, and uncaring
Impulsive, poor judgment
Irresponsible, not accountable for own actions
Risk-taking, thrill-seeking behaviors
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Personality Disorders
• Schizotypal personality disorder
• Borderline personality disorder
• Antisocial personality disorder
• Narcissistic personality disorder
• Obsessive–compulsive personality disorder
• Avoidant personality disorder
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Related Personality Disorders and
Behaviors
• Paranoid personality disorder
• Schizoid personality disorder
• Histrionic personality disorder
• Dependent personality disorder
• Depressive behavior
• Passive-aggressive behavior
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Onset and Clinical Course
• Relatively common (10% to 20% of general population)
– Incidence higher in lower socioeconomic groups
• 40% to 45% of people with primary diagnosis of major
mental illness also with coexisting personality disorder
that significantly complicates treatment
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Onset and Clinical Course (cont.)
• Description of being “treatment resistant”
• Lack of perception by person that behavior is problem
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Etiology
• Biologic theories
– Temperament (harm avoidance, novelty seeking,
reward dependence, persistence)
• Psychodynamic theories
– Character
• Self-directedness (responsible, goal oriented)
• Cooperativeness (integral part of society)
• Self-transcendence (integral part of the universe)
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Cultural Considerations
• Personality viewed with consideration of ethnic, cultural,
social background
– Guarded or defensive behavior due to language
barriers
– Different views of avoidant and dependent behavior
– Cultural value of work, productivity
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Question
• Is the following statement true or false?
• When discussing personality disorders, the term
“treatment resistant” refers to a lack of response to
medications prescribed.
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Answer
• False
• Rationale: The term “treatment resistant” refers to the
fact that it is difficult to change a person’s personality.
Changes occur slowly and over time. It is true that there
is no “magic pill” that will result in a change in someone’s
personality for the better.
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Treatment
• Psychopharmacology (symptom focus)
– Cognitive–perceptual distortions
– Affective symptoms and mood dysregulation
– Aggression and behavioral dysfunction
– Anxiety (see Table 18.1)
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Treatment (cont.)
• Group, individual therapies
– Cognitive–behavioral therapy (cognitive restructuring
techniques)
– Dialectical behavior therapy (borderline personality
disorder)
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Personality Disorders
• Antisocial 
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•
•
•
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Borderline 
Schizotypal
Narcissistic
Obsessive–compulsive
Avoidant
denote
those personality disorders most commonly
encountered by nurses.
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Antisocial Personality Disorder and
Nursing Process Application
• Assessment:
– Deceit/manipulation
– False emotions; no empathy
– Narrowed view of world
– Poor judgment; no insight
– Egocentric, but actual self-shallow and empty
– Relationships as serving own needs
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Antisocial Personality Disorder and
Nursing Process Application (cont.)
• Data analysis/nursing diagnoses
• Outcome identification
• Intervention
– Therapeutic relationship; responsible behavior (limit
setting, confrontation)
– Problem solving; control of emotions (timeout)
– Enhancing role performance
• Evaluation
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Question
• Which of the following would a nurse expect to assess in
a patient with antisocial personality disorder?
– A. Overwhelming empathy
–
B. High self-esteem
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C. Manipulative behaviors
–
D. Pervasive suspiciousness
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Answer
•
C. Manipulative behaviors
• Rationale: A patient with antisocial personality disorder
typically exhibits manipulative behaviors, lack of
empathy, and low self-esteem.
– Suspiciousness would be assessed in a patient with
paranoid personality disorder.
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Borderline Personality Disorder and
Nursing Process Application
• Assessment
– Unstable interpersonal relationships, self-image, and
affect; marked impulsivity
– Wide range of behavior, appearance
– Dysphoric mood
– Polarized extreme thinking (splitting); dissociation
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Borderline Personality Disorder and
Nursing Process Application (cont.)
• Assessment (cont.)
– Impaired judgment; safety not a concern
– Threats of self-harm
– Social isolation
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Borderline Personality Disorder and
Nursing Process Application (cont.)
• Data analysis/nursing diagnoses
• Outcome identification
• Interventions
– Safety (no self-harm contract)
– Therapeutic relationship (structured, with limit
setting)
– Strict adherence to boundaries
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Borderline Personality Disorder and
Nursing Process Application (cont.)
• Interventions (cont.)
– Communication skills
– Coping, emotion control
– Reshape thinking patterns (cognitive restructuring,
thought stopping, positive self-talk,
decatastrophizing)
– Structuring of daily activities
• Evaluation
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Personality Disorders (cont.)
• Schizotypal personality disorder
– Clinical picture: social and interpersonal deficits;
behavioral eccentricities; cognitive or perceptual
distortions; odd appearance; inability to respond to
normal social cues
– Nursing interventions: self-care, social skills,
community functioning
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Personality Disorders (cont.)
• Narcissistic personality disorder
– Clinical picture: grandiosity; need for admiration;
lack of empathy; arrogant or haughty attitude;
superior view; fragile, vulnerable self-esteem;
ambitious
– Nursing interventions: self-awareness skills to avoid
anger and frustration; matter-of-fact approach; limit
setting
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Personality Disorders (cont.)
• Avoidant personality disorder
– Clinical picture: social discomfort; low self-esteem;
hypersensitivity to negative evaluation
– Nursing interventions: self-affirmations; positive selftalk; support and reassurance;
reframing/decatastrophizing; social skills training
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Personality Disorders (cont.)
• Obsessive–compulsive personality disorder
– Clinical picture: perfectionism; formal, serious;
orderliness a priority; problems with decision
making, judgments; low self-esteem; harsh selfevaluations
– Nursing interventions: different perspective view;
cognitive restructuring; risk taking
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Question
• Is the following statement true or false?
• A patient with narcissistic personality disorder typically
likes to be the center of attention.
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Answer
• False
• Rationale: Being the center of attention is a finding
typically associated with a patient with a histrionic
personality disorder.
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Related Personality Disorders
• Paranoid personality disorder
– Clinical picture: pervasive mistrust/suspiciousness;
use of projection; conflict with authority
– Nursing interventions: formal, business-like
approach; involvement in plan of care; idea
validation before action
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Related Personality Disorders (cont.)
• Histrionic personality disorder
– Clinical picture: excessive emotionality and attention
seeking; insincerity; center of attention;
exaggeration of relationships
– Nursing interventions: feedback about social
interactions; social skills training through roleplaying; exploration of strengths, assets
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Related Personality Disorders (cont.)
• Schizoid personality disorder
– Clinical picture: social detachment; restricted
emotions; intellectual
– Nursing interventions: improved functioning in
community
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Other Related Personality Disorders
• Dependent personality disorder
– Clinical picture: need to be taken care of;
submissive; clinging
– Nursing interventions: expression of feelings;
autonomy/self-reliance; cognitive restructuring;
problem solving
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Related Personality Disorders/Behaviors
• Depressive personality behavior
– Clinical picture: pervasive depressive cognitions and
behaviors (less severe than major depression);
pessimistic, negative thinking; low self-esteem
– Nursing interventions: safety; involvement in
activities; factual feedback
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Related Personality Disorder/Behaviors
(cont.)
• Passive-aggressive personality behavior
– Clinical picture: negative attitude, passive resistance
to demands for adequate social and occupational
performance; blaming of others
– Nursing interventions: identification and expression
of feelings
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Mental Health Promotion
• Unmet needs: self-care, sexual expression, budgeting,
psychotic symptoms, psychological distress
– Care for first three areas possibly resulting in greater
sense of well-being and improved health
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Mental Health Promotion (cont.)
• Children with greater number of “protective factors” less
likely to develop antisocial behavior as adults
• Emphasis of care on protective factors of school
commitment or importance of school, parent, and/or
peer disapproval of antisocial behavior, involvement in
religious community
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Self-Awareness Issues
• Avoid patient attempts to manipulate.
• Use clear communication.
• Set limits, boundaries.
• Deal with frustration: patients change slowly yet “look”
like they are capable of better behavior.
• Work effectively as part of team; consistency is essential.
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