Personality Disorder

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Personality disorders

Personality – specific character traits-

temperament, emotional reactivity, fairness,

interpersonal relations establishment, needs,

expectations, stinginess, generosity, arrogance,

independence and others...

typical for concrete person.

• formed by early adulthood, persist throughout

life

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Personality Traits

• The DSM-IV-TR (American Psychiatric Association [APA], 2000) defines personality traits as

• “enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts.”

• Personality disorders occur when these traits become inflexible and maladaptive and cause either significant functional impairment or subjective distress.

• These disorders are coded on axis II of the multiaxial diagnostic system used by the APA.

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• Personality development occurs in response to a number of biological and psychological influences.

• These variables include heredity, temperament, experiential learning, and social interaction.

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Personality Disorders Clusters

• The DSM-IV-TR groups the personality disorders into three clusters:

1. Cluster A: Behaviors described as odd or eccentric. a. Paranoid personality disorder b. Schizoid personality disorder c. Schizotypal personality disorder

2. Cluster B: Behaviors described as dramatic, emotional, or erratic.

a. Antisocial personality disorder b. Borderline personality disorder c. Histrionic personality disorder d. Narcissistic personality disorder

3. Cluster C: Behaviors described as anxious or fearful.

a. Avoidant personality disorder b. Dependent personality disorder c. Obsessive–compulsive personality disorder

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TYPES OF PERSONALITY DISORDERS

• Paranoid Personality Disorder: “a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts”.

• Prevalence is difficult to establish because individuals with the disorder seldom seek assistance for their problem or require hospitalization.

• When they present for treatment at the insistence of others, they may be able to pull themselves together sufficiently so that their behavior does not appear maladaptive.

• The disorder is more commonly diagnosed in men than in women.

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paranoid personality disorder

• Constantly on guard, hypervigilant, and ready for any real or imagined threat.

• They appear tense and irritable. • They have developed a hard exterior and become

immune or insensitive to the feelings of others. • They avoid interactions with other people, lest

they be forced to relinquish some of their own power.

• They always feel that others are there to take advantage of them.

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• They are extremely oversensitive and tend to misinterpret even minute cues within the environment, magnifying and distorting them into thoughts of trickery and deception.

• Because they trust no one, they are constantly “testing” the honesty of others.

• Their intimidating manner provokes exasperation and anger in almost everyone with whom they come in contact.

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• Individuals with paranoid personality disorder maintain their self-esteem by attributing their shortcomings to others.

• They do not accept responsibility for their own behaviors and feelings and project this responsibility on to others.

• They are envious and hostile toward others who are highly successful and believe the only reason they are not as successful is because they have been treated unfairly.

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Etiological Implications

• Research has indicated a possible hereditary link in paranoid personality disorder. Studies have revealed a higher incidence of paranoid personality disorder among relatives of clients with schizophrenia than among control subjects.

• Psychosocially, people with paranoid personality disorder may have been subjected to parental antagonism and harassment.

• They likely served as scapegoats for displaced parental aggression and gradually relinquished all hope of affection and approval.

• They learned to perceive the world as harsh and unkind, a place calling for protective vigilance and mistrust.

• They entered the world with a “chip-on-the-shoulder” attitude and were met with many rebuffs and rejections from others.

• Anticipating humiliation and betrayal by others, the paranoid person learned to attack first.

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Schizoid Personality Disorder

• characterized primarily by a profound defect in the ability to form personal relationships or to respond to others in any meaningful, emotional way.

• These individuals display a lifelong pattern of social withdrawal, and their discomfort with human interaction is apparent.

• Prevalence of schizoid personality disorder within the general population has been estimated at between 3 and 7.5 percent.

• Significant numbers of people with the disorder are never observed in a clinical setting.

• Gender ratio of the disorder is unknown, although it is diagnosed more frequently in men.

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Clinical Picture

• appear cold, aloof, and indifferent to others. • They prefer to work in isolation and are unsociable, with

little need or desire for emotional ties. • They are able to invest enormous affective energy in

intellectual pursuits. • In the presence of others, they appear shy, anxious, or

uneasy. • They are inappropriately serious about everything and

have difficulty acting in a lighthearted manner. • Their behavior and conversation exhibit little or no

spontaneity. • Typically, they are unable to experience pleasure, and their

affect is commonly bland and constricted.

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Etiological Implications

• Unknown about heredity…

• Parenting…

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Schizotypal Personality Disorder

• Their behavior is odd and eccentric but does not decompensate to the level of schizophrenia.

• Schizotypal personality is a graver form of the pathologically less severe schizoid personality pattern.

• Studies indicate that approximately 3 percent of the population has this disorder

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Clinical Picture

• Individuals with schizotypal personality disorder are aloof and isolated and behave in a bland and apathetic manner.

• Magical thinking, ideas of reference, illusions, and depersonalization are part of their everyday world. – Examples include superstitiousness, belief in clairvoyance, telepathy, or “sixth

sense”; and beliefs that “others can feel my feelings”

• The speech pattern is sometimes bizarre. • People with this disorder often cannot orient their thoughts logically and

become lost in personal irrelevancies and in tangential asides that seem vague, digressive, and not pertinent to the topic at hand.

• Under stress, these individuals may decompensate and demonstrate psychotic symptoms, such as delusional thoughts, hallucinations, or bizarre behaviors, but these are usually of brief duration

• They often talk or gesture to themselves, as if “living in their own world.” • Their affect is bland or inappropriate, such as laughing at their own

problems or at a situation that most people would consider sad.

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Etiological Implications

• Some evidence suggests that schizotypal personality disorder is more common among the first-degree biological relatives of people with schizophrenia than among the general population, indicating a possible hereditary factor

• Anatomical deficits or neurochemical dysfunctions resulting in diminished activation, minimal pleasure–pain sensibilities, and impaired cognitive functions.

• The early family dynamics….

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Antisocial Personality Disorder

• is a pattern of socially irresponsible, exploitative, and guiltless behavior that reflects a disregard for the rights of others.

• These individuals exploit and manipulate others for personal gain and have a general disregard for the law.

• They have difficulty sustaining consistent employment and in developing stable relationships.

• It is one of the oldest and best researched of the personality disorders

• In the United States, prevalence estimates range from 3 percent in men to about 1 percent in women.

• The disorder is more common among the lower socioeconomic classes.

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Etiological Implications

• Biological Influences • Family dynamic: • Examples of circumstances that may influence the

predisposition to antisocial personality disorder: – Absence of parental discipline – Extreme poverty – Removal from the home – Growing up without parental figures of both sexes – Erratic and inconsistent methods of discipline – Being “rescued” each time they are in trouble (never

having to suffer the consequences of one’s own behavior) – Maternal deprivation

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Diagnosis/Outcome Identification

• Risk for other-directed violence

• Defensive

• Chronic low self-esteem

• Impaired social interaction

• Deficient knowledge (self-care activities to achieve and maintain optimal wellness)

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• Outcome

• Planning/Implementation:

• Evaluation

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Borderline Personality Disorder

• characterized by a pattern of intense and chaotic relationships, with affective instability and fluctuating attitudes toward other people.

• These individuals are impulsive, directly and indirectly self-destructive, and lack a clear sense of identity.

• Prevalence estimates of borderline personality range from 2 to 3 percent of the population.

• It is the most common form of personality disorder, occurring in every culture

• It is more common in women than in men, with female to- male ratios being estimated as high as 4 to 1.

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Clinical picture

• Chronic Depression • Inability to Be Alone • Patterns of Interaction

– Clinging and Distancing – Splitting – Splitting is a primitive ego defense mechanism that is

common in people with borderline personality disorder. • It arises from their lack of achievement of object constancy and is

manifested by an inability to integrate and accept both positive and negative feelings.

– Manipulation – Self-Destructive Behaviors – Impulsivity : poor impulse control (drug abuse)

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Etiological implication

• Biochemical

• Genetics

• Childhood trauma

• Developmental factor: Mahler theory… rapprochement phase…

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Nursing Diagnosis

• Risk for self-mutilation

• Complicated grieving

• Impaired social interaction

• Disturbed personal identity

• Anxiety (severe to panic)

• Chronic low self-esteem

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• Outcome…

• Planning an Evaluation…

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Histrionic Personality Disorder

• characterized by colorful, dramatic, and extroverted behavior in excitable, emotional people.

• They have difficulty maintaining long-lasting relationships, although they require constant affirmation of approval and acceptance from others.

• Prevalence of the disorder is thought to be about 2 to 3 percent, and it is more common in women than in men.

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Clinical Picture

• People with histrionic personality disorder tend to be self-dramatizing, attention seeking, overly gregarious, and seductive.

• They use manipulative and exhibitionistic behaviors in their demands to be the center of attention.

• People with histrionic personality disorder often demonstrate, in mild pathological form, what our society tends to foster and admire in its members: to be well liked, successful, popular, extroverted, attractive, and sociable.

• Individuals with this disorder are highly distractible and flighty by nature.

• Interpersonal relationships are fleeting and superficial.

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Etiological Implications

• Neurobiological correlates have been proposed in the predisposition to histrionic personality disorder.

• Heredity also may be a factor because the disorder is apparently more common among first-degree biological relatives of people with the disorder than in the general population.

• psychosocial perspective: – learning experiences may contribute to the development of histrionic – personality disorder. – The child may have learned that positive reinforcement was

contingent on the ability to perform parentally approved and admired behaviors.

– It is likely that the child rarely received either positive or negative feedback.

– Parental acceptance and approval came inconsistently and only when the behaviors met parental expectations.

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Narcissistic Personality Disorder

• Persons with narcissistic personality disorder have an exaggerated sense of self-worth.

• They lack empathy, and are hypersensitive to the evaluation of others.

• They believe that they have the inalienable right to receive special consideration and that their desire is sufficient justification for possessing whatever they seek.

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Clinical Picture

• Individuals with narcissistic personality disorder appear to lack humility, being overly self-centered and exploiting others to fulfill their own desires.

• They often do not conceive of their behavior as being inappropriate or objectionable.

• Because they view themselves as “superior” beings, they believe they are entitled to special rights and privileges.

• Although often grounded in grandiose distortions of reality, their mood is usually optimistic, relaxed, cheerful, and carefree.

• This mood can easily change, however, because of their fragile self-esteem.

• If they do not meet self-expectations, do not receive the positive feedback they expect from others, or draw criticism from others, they may respond with rage, shame, humiliation, or dejection.

• They may turn inward and fantasize rationalizations that convince them of their continued stature and perfection.

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Etiological Implications

• Childhood…

• suggests that the parents of individuals with narcissistic personality disorder were often narcissistic themselves.

• Narcissism may also develop from an environment in which parents attempt to live their lives vicariously through their child

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Avoidant Personality Disorder

• They extremely sensitive to rejection and because of this may lead a very socially withdrawn life.

• It is not that he or she is asocial; in fact, there may be a strong desire for companionship.

• The extreme shyness and fear of rejection, however, create needs for unusually strong guarantees of uncritical acceptance

• Prevalence of the disorder in the general population is between 0.5 and 1 percent, and it appears to be equally common in men and women

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Clinical Picture

• Individuals with this disorder are awkward and uncomfortable in social situations.

• From a distance, others may perceive them as timid, withdrawn, or perhaps cold and strange.

• Those who have closer relationships with them, however, soon learn of their sensitivities, touchiness, evasiveness, and mistrustful qualities.

• Their speech is usually slow and constrained, with frequent hesitations, fragmentary thought sequences, and occasional confused and irrelevant digressions.

• They are often lonely, and express feelings of being unwanted. • They view others as critical, betraying, and humiliating. • They desire to have close relationships but avoid them because of their

fear of being rejected. • Depression, anxiety, and anger at oneself for failing to develop social

relations are commonly experienced.

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Etiological Implications

• hereditary influence with avoidant personality disorder because it seems to occur more frequently in certain families.

• Some infants who exhibit traits of hyperirritability, crankiness, tension, and withdrawal behaviors may possess a temperamental disposition toward an avoidant pattern.

• The primary psychosocial predisposing influence to avoidant personality disorder is parental rejection and censure, which is often reinforced by peers

• These children are often reared in a family in which they are belittled, abandoned, and criticized, such that any natural optimism is extinguished and replaced with feelings of low self worth and social alienation.

• They learn to be suspicious and to view the world as hostile and dangerous.

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Dependent Personality Disorder

• characterized by “a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation”

• These characteristics are evident in the: – tendency to allow others to make decisions – to feel helpless when alone – to act submissively, to subordinate needs to others – to tolerate mistreatment by others – to demean oneself to gain acceptance – and to fail to function adequately in situations that require

assertive or dominant behavior.

• It is more common in women than in men and more common in the youngest children of a family.

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Clinical Picture

• lack of self-confidence that is often apparent in their posture, voice, and mannerisms.

• They are typically passive and acquiescent to the desires of others. • They are overly generous and thoughtful and underplay their own attractiveness

and achievements. • They may appear to others to “see the world through rose-colored glasses,” but

when alone, they may feel pessimistic, discouraged, and dejected. • Others are not made aware of these feelings; their “suffering” is done in silence. • Assume the passive and submissive role in relationships. • They are willing to let others make their important decisions. • Should the dependent relationship end, they feel helpless and fearful because

they feel incapable of caring for themselves • They avoid positions of responsibility and become anxious when forced into them • They have feelings of low self-worth and are easily hurt by criticism and

disapproval. • They will do almost anything, even if it is unpleasant or demeaning, to earn the

acceptance of others.

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Etiological Implications

• An infant may be genetically predisposed to a dependent temperament. • Twin studies… • Psychosocially, dependency is fostered in infancy when stimulation and

nurturance are experienced exclusively from one source. • The infant becomes attached to one source to the exclusion of all others. • If this exclusive attachment continues as the child grows, the dependency

is nurtured. • A problem may arise when parents become overprotective and discourage

independent behaviors on the part of the child. • Parents who make new experiences unnecessarily easy for the child and

refuse to allow him or her to learn by experience encourage their child to give up efforts at achieving autonomy.

• Dependent behaviors may be subtly rewarded in this environment, and the child may come to fear a loss of love or attachment from the parental figure if independent behaviors are attempted.

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Obsessive-Compulsive Personality Disorder

• They are very serious and formal and have difficulty expressing emotions.

• They are overly disciplined, perfectionistic, and preoccupied with rules.

• They are inflexible about the way in which things must be done and have a devotion to productivity to the exclusion of personal pleasure.

• An intense fear of making mistakes leads to difficulty with decision-making.

• The disorder is relatively common and occurs more often in men than in women.

• Within the family constellation, it appears to be most common in oldest children.

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Clinical Picture

• are inflexible and lack spontaneity • They are especially concerned with matters of organization and efficiency

and tend to be rigid and unbending about rules and procedures. • Social behavior tends to be polite and formal. • Emotional behavior is considered immature and irresponsible. • Although on the surface these individuals appear to be calm and

controlled, underneath this exterior lies a great deal of ambivalence, conflict, and hostility. Individuals

• with this disorder commonly use the defense mechanism of reaction formation.

• Not daring to expose their true feelings of defiance and anger, they withhold these feelings so strongly that the opposite feelings come forth

• The defenses of isolation, intellectualization, rationalization, reaction formation, and undoing are also commonly evident

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Etiological Implications

• parenting style in which the individual with obsessive–compulsive personality disorder was reared is one of over-control.

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Passive–Aggressive Personality Disorder

• Pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance in social and occupational situations that begins by early adulthood and occurs in a variety of contexts.

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Clinical Picture

• Passive–aggressive individuals feel cheated and unappreciated.

• They believe that life has been unkind to them, and they express envy and resentment over the “easy life” that they perceive others having.

• They demonstrate passive resistance and general obstructiveness in response to the expectations of others.

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Etiological Implications

• Contradictory parental attitudes and behavior are implicated in the predisposition to passive–aggressive personality disorder. In the nuclear family dynamics, at any moment and without provocation, these children may receive the kindness and support they crave or hostility and rejection.

• Parental responses are inconsistent and unpredictable, and these children internalize the conflicting attitudes toward themselves and others.

• Expressions of concern and affection may be verbalized, only to be negated and undone through subtle and devious behavioral manifestations.

• Through this type of environment, children learn to control their anger for fear of provoking parental withdrawal and not receiving love and support—even on an inconsistent basis.

• Overtly the child appears polite and undemanding; hostility and inefficiency are manifested only covertly and indirectly.

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TREATMENT MODALITIES

• Interpersonal Psychotherapy: Depending on the therapeutic goals, interpersonal psychotherapy with personality disorders is brief and time-limited, or it may involve long-term exploratory psychotherapy.

• Interpersonal psychotherapy may be particularly appropriate because personality disorders largely reflect problems in interpersonal style.

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• Psychoanalytical Psychotherapy: The treatment of choice for individuals with histrionic personality disorder has been psychoanalytical psychotherapy

• Milieu or Group Therapy: This treatment is especially appropriate for individuals with antisocial personality disorder, who respond more adaptively to support and feedback from peers.

• Cognitive/Behavioral Therapy: Behavioral strategies offer reinforcement for positive change. Social skills training and assertiveness training teach alternative ways to deal with frustration.

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Psychopharmacology

• Psychopharmacology may be helpful in some instances. • some symptomatic relief can be achieved. • Antipsychotic medications are helpful in the treatment of psychotic

decompensations experienced by clients with paranoid, schizotypal, and borderline personality disorders

• A variety of pharmacological interventions have been used with borderline personality disorder. – The selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase

inhibitors (MAOIs) have been successful in decreasing impulsivity and self-destructive acts in these clients.

– The MAOIs are not commonly used, however, because of concerns about violations of dietary restrictions and the higher risk of fatality with overdose

– The SSRIs also have been successful in reducing anger, impulsiveness, and mood instability in clients with borderline personality disorder

– Antipsychotics have resulted in improvement in illusions, ideas of reference, paranoid thinking, anxiety, and hostility in some clients.

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• Lithium carbonate and propranolol (Inderal) may be useful for the violent episodes observed in clients with antisocial personality disorder

• Caution must be given to prescribing medications outside the structured setting because of the high risk for substance abuse by these individuals.

• For the client with avoidant personality disorder, anxiolytics are sometimes helpful whenever previously avoided behavior is being attempted.

• Antidepressants, such as sertraline (Zoloft) and paroxetine (Paxil), may be useful with these clients if panic disorder develops.

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