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Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
CHAPTER 14
PERSONALITY DISORDERS
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Objectives
Discuss disorders affecting a patient’s
mental/emotional health.
 Define personality.
 Define personality disorders.
 Describe the following personality disorders:
 Antisocial Personality Disorder
 Borderline Personality Disorder
Describe symptoms of the disorders.
Discuss nursing diagnoses & interventions for
these 2 disorders.
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Personality
 Thoughts, feelings, and attitudes that make up
each individual
 What influences personality?
 What are personality traits?
 Some theorists believe personality is developed
at a very young age; some believe it evolves and
changes throughout life
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Personality Disorder
 Maladaptive behavior leads to significant functional impairment
or subjective distress
 Ineffective personality development and overuse of defense
mechanisms
 Affects the way humans interpret and respond to the world and
themselves
 Significant impairments in self (identity or self-direction) and
interpersonal (empathy or intimacy) functioning.
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
 Most major theorists agree: personality disorders
originate in early childhood
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Causes
 Personality disorders often have their roots in
difficult relationships with parental figures
 Though each disorder has its own dynamics, this
parental relationship is the thread that runs
through all of them
 Genetics may be a factor in some of these
disorders as well
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Types of Personality Disorders (DSM5)
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Antisocial/sociopathic personality disorder
Avoidant personality disorder
Borderline personality disorder (most common)
Dependent personality disorder
Histrionic personality disorder
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Types of Personality Disorders (DSM5)
(cont’d)
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Narcissistic personality disorder
Obsessive-compulsive personality disorder
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
 We will focus on two of these personality
disorders:
 Antisocial Personality Disorder
 Borderline Personality Disorder
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Antisocial Personality Disorder
 A pattern of irresponsible, exploitive, and
guiltless behavior with tendency to fail to conform
to the law and exploit and manipulate others for
personal gain; popularly known as sociopathic
 Difficulty following rules: fail to conform to social
norms
 High association with criminal behavior
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Antisocial Personality Disorder
 Criteria
 Impairments in self-functioning:
 Egocentrism: self-esteem from personal gain,
power or pleasure
 Self Direction: goal setting based on personal
gratification; absence of moral compass
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
 Impairments in interpersonal functioning:
 Lack of empathy: lack of concern & remorse
 Incapable of Intimacy: exploitation is primary way
individual relates to others How? – deceit,
coercion, intimidation
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
 Pathological Personality Traits:
 Antagonism - Manipulative, Deceitful, Callous,
Hostile
 Can be very charming in order to get their way,
but become hostile due to frustration.
 Disinhibition - Irresponsible, Impulsive, Risk
Taker
 Poor tolerance for Boredom
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Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
 These behaviors are stable over time and
consistent.
 Usually begins around 8, peaks 20-30 years of
age.
 Males > Females
 Substance Abuse present in 80%
 Conduct Disorder diagnosed prior to 15 years
old.
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Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Treatments
 Tend not to work. Why?
 External Reasons for Seeking TX – trouble with
the law, or relationships (personal +or
professional)
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Etiology
 No definitive reasons
 Genetic
 Parental Abuse or Neglect as a Young Child
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Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Characteristics of Families
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Moved Frequently
Family Breakups
Large Families
Poverty
Urban Settings
Emotional Deprivation
Physical +/or Sexual Abuse
At least one caretaker w substance abuse issues
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Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Mother’s Characteristics
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Depressive
Weak
Masochistic
Somatizing
Personality Disordered
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Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Father’s Characteristics
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Explosive
Inconsistent
Sadistic
Alcoholic
Criminal History
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Possible Nursing Diagnoses
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Risk for Violence
Ineffective Coping
Chronic Low Self Esteem
Ineffective Family Coping
Impaired Social Interaction
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Nursing Interventions for Clients
with Antisocial Personality
Disorders
 Set limits.
 Promote positive, professional interpersonal
relationship with client.
 Avoid negotiating rewards.
 Monitor for violent behaviors.
 Provide feedback on negative behaviors.
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Nursing Interventions for Clients
with Antisocial Personality
Disorders
 Encourage appropriate expression of angry
feelings.
 Support analysis of feelings.
 Explore impact of manipulative behaviors.
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Borderline Personality Disorder
 Unstable behavior
 Exhibits both clinging and distancing behaviors
as they struggle with fears of abandonment.
 Known to use manipulation to reduce their
anxiety to achieve goal
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Borderline Personality Disorder
 Criteria:
 Impairments in self-functioning:
 Identity- impoverished; poor self image; excessive
self criticism. Chronic feelings of emptiness;
dissociative states under stress.
 Self- Direction – instability in goals, aspirations,
values or career plans.
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Borderline Personality Disorder
 Impairments in interpersonal functioning:
 Empathy – misinterprets other’s feelings – very
sensitive to own, feels insulted easily
 Intimacy – intense, unstable and conflicted close
relationships. Anxious about abandonment issues.
Sees people as all good or all bad; alternates
between involvement and withdrawal (splitting)
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Borderline Personality Disorder
 Pathological Personality Traits:
 Negative Affectivity:
 Emotional Liability – frequent mood changes
 Anxious – Fearful of uncertainty or losing control.
 Separation Insecurity – Fearful of rejection, fearful
of dependency, doesn’t want to lose autonomy.
 Depressive – feelings of hopelessness and
pessimism.
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Borderline Personality Disorder
 Pathological Personality Traits continued…
 Disinhibition:
 Impulsivity – acts on immediate stimuli; difficulty
planning; can self harm under emotional distress.
 Risk Taking – denies personal danger
Antagonism:
Hostility – anger or irritability
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Borderline Personality Disorder
 Females > Males
 Begins in adolescence or even childhood.
 Co-occuring mental illness diseases are
common, such as anxiety, depression, or eating
disorders.
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Etiology
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Genetics
Unstable Families
Hx of Abuse
Family HX of Mental Illness
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Treatment
 Psychotherapy
 CBT
 DBT
Medications to treat anxiety and depression.
Sometimes use antipsychotics.
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
CBT - Cognitive Behavior Therapy
 Focuses on examining the relationships between
thoughts, feelings and behaviors.
 CBT is a type of psychotherapy that is different
from traditional psychotherapy in that the
therapist and the patient will actively work
together to help the patient recover from their
mental illness.
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
 People who seek CBT can expect their therapist
to be problem-focused, and goal-directed in
addressing the challenging symptoms of mental
illnesses.
 CBT is an active intervention, so one can also
expect to do homework or practice outside of
sessions.
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
DBT – Dialectical Behavior Therapy
 Modified form of CBT
 Created by psychologist Marsha Linehan in
2001.
 Emphasis on validation and acceptance.
 Use mindfulness as a tool.
 Like CBT, uses “homework” and classes to teach
skills. Have classes for families as well.
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Possible Nursing Diagnoses
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Risk for Self Directed Violence
Risk for Violence
Anxiety
Chronic Low Self Esteem
Powerlessness
Ineffective Coping
Social Isolation
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Nursing Interventions for Clients
with BPD
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Build trusting relationship with client.
Remain neutral but caring during client’s drama.
Set limits.
Be aware of manipulative behaviors.
Avoid becoming involved with “splitting” of staff.
Demonstrate positive role modeling.
Monitor for self injurious behaviors.
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Nursing Interventions for Clients
with BPD
 Provide safety.
 Communicate a consistent plan of care among
the entire staff.
 Encourage patient to verbalize feelings.
 Avoid power struggles.
 Involve family and significant others in care.
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Clicker Question
1. Which personality disorder is most associated
with erratic, demanding, manipulative behavior?
A. Antisocial
B. Narcissistic
C. Borderline
D. Schizotypal
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Answer
Correct answer: C
Rationale: Borderline personality disorder is
characterized by unstable, erratic behavior that
often leads to dramatic and manipulative behaviors
to achieve one’s goals
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Medical Treatment for Personality Disorders
 Difficult to treat; rarely hospitalized, unless for a
separate medical or surgical condition
 People with personality disorders may not seek out
mental health treatment for their disorder until it drains
their coping reserves
 Patients don’t perceive they have a problem
 Medications to treat depression, anxiety, delusions may
be helpful
 Group therapy (peer pressure helps modify behavior)
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Goal of Medical and Nursing Treatment
 Increase motivation and socialization
 Make efforts to avoid stereotyping or judging
the patient based on information that he/she
has a personality disorder
 Patients with these disorders can present
challenges for the health care professional
as maladaptive mechanisms are used to
cope with the stresses of their illnesses
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Nursing Interventions
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Promote trust
Set limits
Use effective therapeutic communication
Confront behavior as necessary
Model positive behaviors
Maintain calm, safe milieu
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Clicker Question
2. Which nursing intervention is usually most
appropriate with borderline personality?
A. Maintain close, intense relationship with patient
to develop trust
B. Set limits
C. Have different staff care for patient
D. Administer anxiolytics frequently
Copyright © 2014. F.A. Davis Company
Gorman and Anwar
Neeb’s Fundamentals of Mental Health Nursing, 4th Edition
Answer
Correct answer: B
Rationale: Setting limits is the most common
intervention needed with patients with personality
disorders. The other choices hide or reinforce
negative behaviors.
Copyright © 2014. F.A. Davis Company