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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