Personality Disorders



Personality Disorders

Personality

ν       Definition:

λ       an enduring pattern of behaving and relating to oneself and others that includes one’s perception, attitudes, and emotions regarding oneself and the world.

Social Response

ν       To find satisfaction in life, people must be able to establish positive and healthy interpersonal relationship.

Adaptive Social Responses

ν       Ability to tolerate solitude

ν       Autonomy

ν       Mutuality

ν       Interdependence

Maladaptive Social Responses

ν       Manipulation

λ       Behavior in which people treat others as objects, and form relationships that center around control issue

ν       Impulsivity

λ       Inability to control impulse or express behavior at the appropriate time and place

ν       Narcissism

λ       an exceptional interest in and admiration for oneself with feelings of excessive pride

Personality disorders

ν      formerly referred to as a Characterological disorder/character disorder

ν       APA definition:

λ       "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it".

Characteristics of

Personality Disorders

ν       An enduring pattern of perceiving, relating to, and thinking about the self & the environment

ν       Patterns are inflexible and pervasive across many situations

ν       Onset in adolescence or early adulthood

ν       Stable overtime & leads to distress or impairment

ν       Inflexibility and pervasiveness of behavioral patterns often cause:

λ        serious personal and social difficulties, and

λ        a general impairment of functioning.

ν       Long standing problems in behavior, mood, perception, and relationships.

ν       Behaviors are characterized by self-centeredness, rigidity, inflexibility, poor ability to regulate

ν       Generally, individuals w/ PD do not need psychiatric treatment & are not hospitalized unless there is a co-existing psychiatric d/o

ν       Person denies maladaptive behaviors exhibited ⋄ way of life.

ν       Minor stress is poorly tolerated ⋄ increased inability to cope w/ anxiety.

ν       Person is in contact w/ reality but has difficulty dealing w/ it.

ν       Disturbance of mood (anxiety/depression) may be present.

ν       Psychiatric help is rarely sought; person is unaware/denies behavior as maladaptive.

Etiologies

λ       Neglect & childhood abuse associated with some personality d/o (borderline p. d.)

λ       Abuse contributes to problems in self-image, mood, stability, intimacy, & trust

λ       Excessive attention ⋄ poorly developed coping skills

λ       Biologic predisposition

ν       Improper nutrition

ν       Neurological defects

ν       Genetic predisposition

λ       Psychoanalytic:

ν       certain personality types developed due to fixation at certain stages

ν       Socially deviant person has defective superegos⋄ inability to control impulsive behavior

ν       A weak superego⋄ incomplete development of or lack of a conscience

ν       Persons w/ immature superego feel no regret or remorse for socially unacceptable behavior

λ       Psychosocial Theory

ν       Childhood experiences foster development of maladaptive behavior

ν       Parental rewarding of behavior

ν       Rigid upbringing

ν       Parental fostering of dependency

ν       Parental/authority figure modeling, imitation, identification

λ       Environmental

ν Urban societies

ν Characterized by low degree of social interaction ⋄ fostering of development of personality d/o

λ       Drive for prestige, power, and possessions ⋄

ν Exploitative, manipulative behavior

ν Ex. Embezzlement and gambling (pathologic)

ν       Classifications/Clusters

λ       Type A – odd, eccentric d/o

λ       Type B – dramatic, emotional, erratic d/o

λ       Type C- anxious and fearful d/o

(DSM-IV) ten personality disorders, grouped into three clusters

ν       Cluster A (odd or eccentric disorders)

λ       Paranoid personality disorder

λ       Schizoid personality disorder

λ       Schizotypal personality disorder

ν       Cluster B (dramatic, emotional, or erratic disorders)

λ       Antisocial personality disorder

λ       Borderline personality disorder

λ       Histrionic personality disorder

λ       Narcissistic personality disorder

ν       Cluster C (anxious or fearful disorders)

λ       Avoidant personality disorder

λ       Dependent personality disorder

λ       Obsessive-compulsive personality disorder (not the same as Obsessive-compulsive disorder)

Type/Cluster A

I. Paranoid personality disorder

ν       A pervasive pattern of distrust & suspiciousness of others such that their motives are interpreted as malevolent

ν       Suspicious ( others are exploiting or deceiving him)

ν       Doubt trustworthiness of others

ν       Fear of confiding in others

ν       Fear personal information will be used against him

ν       Interpret remarks as demeaning or threatening

ν       Holds grudges towards others

ν       Becomes angry and threatening when they perceive to be attacked by others

DSM-IV-TR Diagnostic Criteria

ν       A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent,

ν       begins by early adulthood

ν       present in a variety of contexts, as indicated by four (or more) of the following:

λ       suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her

λ       preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates

λ       reluctant to confide in others due to unwarranted fear that information will be used maliciously against him or her

four (or more)

λ       reads hidden demeaning or threatening meanings in benign remarks or events

λ       persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights

λ       perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack

λ       has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

λ       Exclusionary conditions

ν       Does not occur exclusively during the course of a mood disorder with psychotic features, schizophrenia, or another psychotic disorder.

ν       Is not due to the direct physiological effects of a general medical condition.

Interventions:

λ       centered on building trust

λ       Emphasis on a simple supportive, client-centered approach will be most effective

λ       Serious, straight-forward approach

λ       Teach client to validate ideas before taking action

λ       Involve client in  treatment planning

II. Schizoid personality disorder

ν       characterized by:

λ       a lack of interest in social relationships,

λ       a tendency towards a solitary lifestyle,

λ       secretiveness, and

λ       emotional coldness

DSM-IV-TR definition:

λ       A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings,

λ       begins by early adulthood

λ       A. present in a variety of contexts, as indicated by four (or more) of the following:

ν       neither desires nor enjoys close relationships, including being part of a family

ν       almost always chooses solitary activities

ν       has little, if any, interest in having sexual experiences with another person

ν       takes pleasure in few, if any, activities

ν       lacks close friends or confidants other than first-degree relatives

ν       appears indifferent to the praise or criticism of others

ν       shows emotional coldness, detachment, or flattened affectivity

λ       B. Does not occur exclusively during the course of:

ν Schizophrenia,

ν Mood Disorder with Psychotic Features,

ν another Psychotic Disorder, or

ν a Pervasive developmental disorder

ν and is not due to the direct physiological effects of a general medical condition.

ν       Other characteristics

λ       person may feel sensitive to the opinions of others and may even feel lonely but can not do anything about the loneliness due to the disorder.

Interventions:

λ       Building trust followed by identification & appropriate verbal expression

λ       Improving client’s functioning

III. Schizotypal personality disorder

ν       characterized by:

λ       a need for social isolation,

λ       odd behavior and thinking, and

λ       often unconventional beliefs such as being convinced of having extra sensory abilities.

 

Diagnostic Criteria (DSM IV-TR)

ν       A pervasive pattern of social and interpersonal deficits marked by:

λ        acute discomfort with, and

λ       reduced capacity for close relationships as well as

λ       cognitive or perceptual distortions and eccentricities of behavior,

ν       begins by early adulthood

ν       present in a variety of contexts, as indicated by five (or more) of the following:

ν       ideas of reference (excluding delusions of reference)

ν       odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or preoccupations)

ν       unusual perceptual experiences, including bodily illusions

ν       Diagnostic Criteria

λ       odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped)

λ       suspiciousness or paranoid ideation

λ       inappropriate or constricted affect

λ       behavior or appearance that is odd, eccentric, or peculiar

λ       lack of close friends or confidants other than first-degree relatives

λ       excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self

ν       Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder.

ν       Note: If criteria are met prior to the onset of Schizophrenia, add "Premorbid," e.g., "Schizotypal Personality Disorder (Premorbid).“

ν       Interventions:

ν       Improving:

ν       interpersonal relationships,

ν       Self-care skills

ν       social skills, &

ν       appropriate behaviors

ν       Community functioning

Type/Cluster B

I. Antisocial             

 Personality Disorder

ν       Characterized by an individual's common disregard for social rules, norms, and cultural codes, as well as impulsive behavior, and indifference to the rights and feelings of others.

ν       Dissocial personality disorder (ICD-10)

ν       Person is called “Sociopath”

Diagnostic Criteria DSM-IV

ν       a pervasive pattern of disregard for and violation of the rights of others occurring since age 15, as indicated by three (or more) of the following:

λ       failure to conform to social norms with respect to lawful behaviors

ν       repeatedly performing acts that are grounds for arrest

λ       Deceitfulness

ν       repeated lying, use of aliases, or conning others for personal profit or pleasure

λ       impulsivity or failure to plan ahead

λ       irritability and aggressiveness

ν       repeated physical fights or assaults 

λ       reckless disregard for safety of self or others

λ       consistent irresponsibility

ν       repeated failure to sustain steady work or honor financial obligations

λ       lack of remorse

ν       being indifferent to or rationalizing having hurt, mistreated, or stolen from another

The manual lists the following additional necessary criteria:

ν       Individual is at least 18 years of age.

ν       Evidence of conduct disorder with onset before age 15 years.

ν       Occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode

ν       Common characteristics of people with antisocial personality disorder include:

ν       Persistent lying or stealing

ν       Recurring difficulties with the law

ν       Tendency to violate the rights of others (property, physical, sexual, emotional, legal)

ν       Aggressive, often violent behavior; prone to getting involved in fights

ν       Inability to keep a job

ν       A persistent agitated or depressed feeling (dysphoria)

ν       Inability to tolerate boredom

ν       Disregard for the safety of self or others

ν       A childhood diagnosis of conduct disorders

ν       Lack of remorse for hurting others

ν       Superficial charm

ν       Impulsiveness

ν       A sense of extreme entitlement

ν       Inability to make or keep friends

ν       Lack of guilt

ν       Recklessness, impulsivity

ν       Experience difficulties with authority figures.

Interventions

ν       Consistency

ν       Kind firmness in confronting behaviors and enforcing rules and policies

ν       Limit setting

ν       Decrease impulsivity

ν       Enhance role performance

ν       Effective use confrontation

II. Borderline personality disorder

ν       Characterized by emotional dysregulation, extreme "black and white" thinking, or "splitting", and chaotic relationships.

ν       General profile of the disorder also typically includes:

ν       a pervasive instability in:

λ       (1) mood,

λ       (2) interpersonal relationships,

λ       (3) self-image,

λ       (4) identity, and

λ       (5) behavior, as well as a disturbance in the individual's sense of self ⋄ dissociation in extreme cases.

DSM-IV Diagnostic Criteria:

ν       a pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts.

ν       diagnosis requires any five out of nine criteria to be present for a significant period of time

Criteria: (5)

ν       Frantic efforts to avoid real or imagined abandonment.

ν       A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

ν       Identity disturbance: markedly and persistently unstable self-image or sense of self.

ν       Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, promiscuous sex, eating disorders, substance abuse, reckless driving, binge eating). 

ν       Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior.

ν       Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

ν       Chronic feelings of emptiness.

ν       Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

ν       Transient, stress-related paranoid ideation or severe dissociative symptoms.

Borderline personality disorder Mnemonic

PRAISE:

ν       P - Paranoid ideas

ν       R - Relationship instability

ν       A - Angry outbursts, affective instability, abandonment fears

ν       I - Impulsive behavior, identity disturbance

ν       S - Suicidal behavior

ν       E - Emptiness

Priority Nursing Diagnosis

ν       High risk for injury: self-directed related to self-mutilation behaviors

ν       Coping Mechanism used

ν       Dissociation/Splitting

ν       Person classifies people as either good or bad

Interventions

ν       Use of empathy

ν       Recognize reality of patient’s pain

ν       Offer support

ν       Empower and work with patient to understand control & change dysfunctional behaviors

ν       Provide safe environment

ν       Teach social skills

ν       Provide list of solitary activities to combat boredom

III. Histrionic personality disorder

ν       A personality disorder characterized by:

λ        a pattern of excessive emotionality and attention-seeking,

λ       includes an excessive need for approval and inappropriate seductiveness,

λ       usually begins in early adulthood.

ν       Essential feature

λ       pervasive and excessive pattern of emotionality and attention-seeking behavior.

λ       individuals are lively, dramatic, enthusiastic, and flirtatious.

λ       inappropriately sexually provocative,

λ       express strong emotions with an impressionistic style,

λ       easily influenced by others.

DSM Diagnostic Criteria

ν       a pervasive pattern of excessive emotionality and attention seeking,

ν       begins by early adulthood

ν       present in a variety of contexts, as indicated by five (or more) of the following:

λ       is uncomfortable in situations in which he or she is not the center of attention

λ       interaction with others is often characterized by inappropriate sexually seductive or provocative behavior

λ       displays rapidly shifting and shallow expression of emotions

 

DSM Diagnostic Criteria

ν       consistently uses physical appearance to draw attention to self

ν       has a style of speech: excessively impressionistic and lacking in detail

ν       shows self-dramatization, theatricality, and exaggerated expression of emotion

ν       is suggestible, i.e., easily influenced by others or circumstances

ν       considers relationships to be more intimate than they actually are.

Mnemonic: PRAISE ME

ν       P - provocative (or seductive) behavior

ν       R - relationships, considered more intimate than they are

ν       A - attention, must be at center of

ν       I - influenced easily

ν       S - speech (style) - wants to impress, lacks detail

ν       E - emotional lability, shallowness

ν       M - make-up - physical appearance used to draw attention to self

ν       E - exaggerated emotions - theatrical

Interventions:

ν       Positive reinforcement in the form of:

ν       Attention

ν       Recognition of praise for unselfish or other-centered behaviors

ν       Teach social skills

ν       Provide factual feedback about behavior

IV. Narcissistic personality disorder

ν       is characterized by extreme focus on oneself,

ν       is a maladaptive, rigid, and persistent condition that may cause significant distress and functional impairment.

ν       begins by early adulthood

Diagnostic criteria

ν       At least five of the following forming a pervasive pattern;

λ       has a grandiose sense of self-importance

λ       is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

λ       believes that he or she is "special" and unique and can only be understood by other special people

λ       requires excessive admiration

λ       strong sense of entitlement

λ       takes advantage of others to achieve his or her own ends

λ       lacks empathy

λ       is often envious or believes others are envious of him or her

λ       arrogant affect

“Grandiosity is the hallmark of narcissism.”

Interventions

λ       Matter of fact approach

λ       Supportive confrontation on what patient says and exists

λ       Limit setting

λ       Consistency to decrease manipulation & entitlement behaviors

λ       Remain neutral, avoid power struggles or becoming defensive

λ       Teach self-care skills

                  

Type/Cluster C

I. Dependent Personality Disorder

ν       Characteristics

λ       Pervasive psychological dependence on other people

λ       Difficulty making everyday decisions

λ       Needs others to assume responsibility

λ       Hesitant expressing disagreement

λ       Difficulty doing things his/her own

λ       Feels helpless when alone

λ       Urgently seeks another relationship

λ       Diagnostic criteria (DSM-IV-TR)

λ       a "pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation,

λ       beginning by early adulthood

λ       and present in a variety of contexts, as indicated by five (or more) of the following:

λ       Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others

λ       Needs others to assume responsibility for most major areas of his or her life

λ       Has difficulty expressing disagreement with others because of fear of loss of support or approval (this does not include realistic fears of retribution)

λ       Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)

λ       Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant

λ       Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself

λ       Urgently seeks another relationship as a source of care and support when a close relationship ends

λ       Is unrealistically preoccupied with fears of being left to take care of himself or herself

Mnemonic: DEPENDENT.

ν       D – Difficulty making everyday decisions

ν       E – Excessive lengths to obtain nurturance and support from others

ν       P – Preoccupied with fears of being left to take care of self

ν       E – Exaggerated fears of being unable to care for himself or herself

ν       N – Needs others to assume responsibility for his or her life

ν       D – Difficulty expressing disagreement with others

ν       E – End of a close relationship is the beginning of another relationship

ν       N – Noticeable difficulties in initiating projects or doing things on his or her own

ν       T – “Take care of me” is his or her motto

Interventions

ν       Goals: increase sense of independence and ability to function

ν       Foster client’s self-reliance and autonomy

ν       Increase responsibility for self in day to day living

ν       Teach problem solving and decision making skills

ν       Teach assertiveness skills

ν       Cognitive structuring techniques

II. Avoidant Personality Disorder

ν       Also known as Anxious personality disorder

ν       A personality disorder characterized by:

ν       a pervasive pattern of social inhibition,

ν       feelings of inadequacy,

ν       extreme sensitivity to negative evaluation and

ν       avoiding social interaction.

ν       Persons with the d/o presents the ff:

ν       often consider selves to be socially inept or personally unappealing,

ν       Avoid social interaction for fear of being ridiculed, humiliated, or disliked.

ν       Typically present as loners

ν       Report feeling a sense of alienation from society.

ν       usually first noticed in early adulthood,

ν       is associated with perceived or actual rejection by parent or peers during childhood.

Diagnostic criteria (DSM-IV-TR)

ν       pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation,

ν       begins by early adulthood

ν       present in a variety of contexts, as indicated by four (or more) of the following:

λ       Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection

λ       Is unwilling to get involved with people unless certain of being liked

λ       Shows restraint within intimate relationships because of the fear of being shamed or ridiculed

λ       Is preoccupied with being criticized or rejected in social situations

λ       Is inhibited in new interpersonal situations because of feelings of inadequacy

λ       Views self as socially inept, personally unappealing, or inferior to others

λ       Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

Mnemonic: AVOIDER.

ν       A – Avoids occupational activities

ν       V – Views self as socially inept

ν       O – Occupied with being criticized or rejected

ν       I – Inhibited in new interpersonal situations

ν       D – Declines to get involved with people

ν       E – Embarrassed by engaging in new activities

ν       R – Refrains from intimate relationships

Interventions

ν       Purpose of therapies: challenge the exaggeratedly negative beliefs about the self

ν       social skills training,

ν       group therapy for practicing social skills

ν       cognitive therapy,

ν       exposure treatment to gradually increase social contacts,

ν       Gain and keep the patient's trust

ν       patients avoid treatment sessions if they distrust the therapist for fear of rejection.

III. Obsessive-Compulsive Personality Disorder

ν       a personality disorder characterized by:

λ       a general psychological inflexibility,

λ       rigid conformity to rules and procedures,

λ       perfectionism,

λ       moral code, and/or

λ       excessive orderliness.

Difference between OCD and OCPD

ν       People with OCPD:

λ       do not generally feel the need to repeatedly perform ritualistic actions, a common symptom of OCD.

λ       tend to stress perfectionism above all else, and

λ       feel anxious when they perceive that things are not "right".

Diagnostic criteria (DSM-IV-TR)

ν       Presence of at least four of the following traits:

λ       Preoccupation with details, rules, lists, order, organization, bodily functions, or schedules to the extent that the major point of the activity is lost

λ       Showing perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met)

λ       Excessive devotion to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)

λ       Being overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)

λ       Inability to discard worn-out or worthless objects even when they have no sentimental value

λ       Reluctance to delegate tasks or to work with others unless they submit to exactly his or her way of doing things

λ       Adopting a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes

λ       Showing rigidity and stubbornness

λ       Urge to perfect every little thing

Mnemonic: LAW FIRMS

ν       L – Loses point of activity (due to

             preoccupation with detail)

ν       A – Ability to complete tasks is compromised by

             perfectionism

ν       W – Worthless objects (unable to discard)

ν       F – Friendships (and leisure activities)

             excluded (due to a preoccupation with work)

ν       I – Inflexible, overconscientious (on ethics,  

            values, or morality, not accounted for by                                 religion or culture)

ν       R – Reluctant to delegate (unless others submit          to exact guidelines)

ν       M – Miserly (toward self and others)

ν       S – Stubbornness (and rigidity)

Interventions

ν       Encourage negotiation with others

ν       Assist client to make timely decisions and complete work

ν       Cognitive structuring techniques

ν       Help client when negative thoughts occur & replace them w/ positive patterns of thinking

Personality Disorders considered Controversial &  worthy of further study/NOS

I.                 Passive-aggressive behavior

ν       refers to passive, sometimes obstructionist resistance to following authoritative instructions in interpersonal or occupational situations

ν       Characterized by:

λ       resentment,

λ       stubbornness,

λ       procrastination,

λ       sullenness, or

λ       repeated failure to accomplish requested tasks for which one is assumed, often explicitly, to be responsible.

ν       also called negativistic personality disorder

ν       marked by:

λ       a pervasive pattern of negative attitudes and

λ       passive, usually disavowed resistance in interpersonal or occupational situations.

Interventions

λ       Help client identify feelings & express them directly

λ       Assist client to examine own feelings and behavior realistically

λ       Assist client to recognize the repeated behavior patterns and understand where they come from and why they continue.

II. Depressive Personality Disorder

- a personality disorder with depressive features

Diagnostic criteria (DSM-IV-TR)

ν       A pervasive pattern of depressive cognitions and behaviors

ν       begins by early adulthood

ν       present in a variety of contexts, as indicated by five (or more) of the following:

λ       usual mood is dominated by dejection, gloominess, cheerlessness, joylessness, unhappiness

λ       self-concept centers around beliefs of inadequacy, worthlessness, and low self-esteem

λ       is critical, blaming, and derogatory toward self

λ       is brooding and given to worry

λ       is negativistic, critical, and judgmental toward others

λ       is pessimistic

λ       is prone to feeling guilty or remorseful

ν       Does not occur exclusively during Major Depressive Episodes or Dysthymic Disorder.

Interventions

ν       Assess self-harm risk

ν       Provide factual feedback

ν       Promote self-esteem

ν       Increase involvement in activities

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