Personality Development and Personality Disorders
Personality disorders are among the least understood and recognized disorders in both psychiatry and general medical care. They are among the most common of the severe mental disorders and occur frequently with other illnesses (eg, substance use disorders, mood disorders, anxiety disorders).
Learning objectives
After studying this chapter, you should be able to:
Define the terms personality and personality disorder.
Summarize the concepts of the following theories of personality development: Freud’s psychoanalytic theory, Erikson’s psychosocial theory, and Piaget’s cognitive developmental theory.
Discuss the importance of a working knowledge of personality growth and development in the mental health setting.
Identify factors that may contribute to the development of behavioral disturbances in a client with paranoid personality disorder.
Identify the characteristics of schizoid personality disorder.
Explain the importance of recognizing cultural diversity in clients who exhibit disturbances in cognition, affect, interpersonal relationships, and impulse control.
Articulate four outcomes to reduce behavioral disturbances in a client with the diagnosis of borderline personality disorder.
Reflect on nonproductive reactions a nurse may exhibit when working with clients who exhibit clinical symptoms of antisocial personality disorder.
Develop an educational tool to use when interacting with an elderly client who has clinical symptoms of dependent personality disorder.
Construct a nursing plan of care for a client with the diagnosis of histrionic personality disorder.
Key Terms
Ego
Egocentrism
Id
Personality
Personality disorder
Projective identification
Schemata
Splitting
Superego
Personality refers to a distinctive set of traits, behavior styles, and patterns that make up our character and individuality (National Mental Health Association, 2006). Personality is the total of a person’s internal and external patterns of adjustment to life, determined in part by the individual’s genetic make-up and by life experiences. Thus, the dynamics of personality development become increasingly complex throughout the lifespan as one continually interacts with the environment and experiences various stages of physical and psychological maturation. Factors influencing psychological maturation include genetic endowments such as inherited traits, potentials, and characteristics; environmental stressors including parental relationships, peer relationships, and cultural and social experiences; individual accomplishments that are the results of learning and adaptation; and one’s mental health status at each developmental stage. Thus, a newborn or infant reacts differently to a given environmental stimulus than does an adolescent, a young adult, or an elderly person.
Personality is believed to occur along a continuum, with healthy traits at one end, personality styles at different gradations along the continuum, and personality disorders at the opposite end. Personality disorder is defined as a pervasive pattern of experience and behavior that is abnormal with respect to thinking, mood, personal relations, and the control of impulses (Lebelle, 2006). Personality disorders are long term and can lead to enormous personal and societal costs, including lost productivity, hospitalizations, significant unhappiness, imprisonment, and suicide.
Researchers analyzed data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions. An estimated 30.8 million adult Americans (or 14.8%) met the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) criteria for at least one personality disorder. Of these 30.8 million, 16.4 million had obsessive–compulsive personality disorder; 9.2 million had paranoid personality disorder; 7.6 million had antisocial personality disorder; 6.5 million had schizoid personality disorder; 4.9 million had avoidant personality disorder; 3.8 million had histrionic personality disorder; and 1.0 million had dependent personality disorder (Grant, Hasin, & Stinson, 2004).
This chapter focuses on the theories of personality development and the etiology, clinical symptoms, and diagnostic characteristics of personality disorders. It also addresses the effects of a personality disorder on the client and his or her family, and health care providers. The chapter uses the nursing process to provide information about providing care to clients diagnosed with a specific personality disorder.
Theories of Personality Development
Various theories of personality maturation are presented in developmental psychology classes as part of the curriculum in nursing programs. Generally, these theories are categorized as psychoanalytic, cognitive, behavioristic, and interpersonal. A summary of the more common theories, such as those of Sigmund Freud, Eric Erikson, and Jean Piaget, are presented in this chapter.
Freud’s Psychoanalytic Theory of Personality Development
Freud’s theory of personality development describes three major categories: the development of personality, the organization or structure of personality, and the dynamics of personality. Freud explains the development of the personality by describing three levels of consciousness: the unconscious, preconscious (subconscious), and conscious. The unconscious level consists of drives, feelings, ideas, and urges outside of the person’s awareness. This is the most significant level of consciousness because of its effect on behavior. A considerable amount of psychic energy is used to keep unpleasant memories stored in the unconscious level of the mind. The preconscious or subconscious level, midway between the conscious and unconscious levels, consists of feelings, ideals, drives, and ideas that are out of one’s ongoing awareness but can be recalled readily. The conscious level of the personality is aware of the present and controls purposeful behavior.
The organization or structure of the personality (Freud, 1960) consists of the id, which is an unconscious reservoir of primitive drives and instincts dominated by thinking and the pleasure principle; the ego, which meets and interacts with the outside world as an integrator or mediator and is the executive function of the personality that operates at all three levels of
consciousness; and the superego, which acts as the censoring force or conscience of the personality and is composed of morals, mores, values, and ethics largely derived from one’s parents. The superego operates at all three levels of consciousness.
consciousness; and the superego, which acts as the censoring force or conscience of the personality and is composed of morals, mores, values, and ethics largely derived from one’s parents. The superego operates at all three levels of consciousness.
According to Freud’s explanation of the dynamics of the personality, each person has a certain amount of psychic energy to cope with the problems of everyday living. The id’s energy is used to reduce tension and may be exhibited, for example, by frequency of urination, daydreaming, or eating. The ego’s energy controls the impulsive actions of the id and the moralistic and idealistic actions of the superego. One whose energy is controlled primarily by the superego generally behaves in an overly moralistic manner because the structure of the personality (eg, superego) monopolizes the psychic energy that governs the person’s behavior.
In his psychosexual theory, Freud also describes five phases of the psychobiologic process that have a great impact on personality development: oral, anal, phallic or oedipal, latency, and genital.
The oral phase (0 to 18 months) is a period in which pleasure is derived mainly through the mouth by the actions of sucking or biting.
During the anal phase (18 months to 3 years), attention focuses on the excretory function, and the foundation is laid for the development of the superego.
In the phallic or oedipal stage (3 to 7 years), a stage of growth and development, the child identifies with the parent of the same sex, forms a deep attachment to the parent of the opposite sex, develops a sexual identity of male or female role, and begins to experience guilt.
During the latency phase (7 years to adolescence), the person learns to recognize and handle reality, has a limited sexual image, develops an inner control over aggressive or destructive impulses, and experiences intellectual and social growth.
In the genital phase (puberty or adolescence into adult life), the final stage of psychosexual development, the individual develops the capacity for object love and mature sexuality, and establishes identity and independence.
Erikson’s Psychosocial Theory of Personality Development
Erik Erikson (1968) emphasizes the concept of identity or an inner sense of sameness that perseveres through external changes, identity crises, and identity confusion in the dynamics of personality development. He posits that there are eight psychosocial stages in one’s lifespan. Table 24-1 highlights these stages, focusing on each stage’s area of conflict and resolution, basic virtues or qualities acquired, and positive and negative behavior.
According to Erikson, these developmental stages consist of a series of normative conflicts that every person must handle. The two opposing energies (developmental crisis) must be synthesized in a constructive manner to produce positive expectations for new experiences. If the crisis is unresolved, the person does not develop attitudes that will be helpful in meeting future developmental tasks. Failure to resolve a challenge or conflict also results in negative behavior or developmental problems. An opportunity to resolve such conflicts recurs later in one’s lifespan.
Piaget’s Cognitive Developmental Theory
Jean Piaget’s (1963) theory views intellectual development as a result of constant interaction between environmental influences and genetically determined attributes. Piaget’s research focused on four stages of intellectual growth during childhood, with emphasis on how a child learns and adapts what is learned from the adult world. The four stages are sensorimotor, preoperational thought, concrete operational, and formal operational.
During the sensorimotor stage (0 to 2 years), the infant uses the senses to learn about self and the environment by exploring objects and events and by imitating. The infant also develops schemata, or methods of assimilating and accommodating incoming information; these include looking schema, hearing schema, and sucking schema.
The preoperational thought stage (2 to 7 or 8 years) is subdivided into the preconceptual and intuitive phases. The preconceptual phase, which occurs between the ages of 2 and 4 years, involves the child’s learning to think in mental images, and the development of expressive language and symbolic play. In the intuitive phase, which occurs between the ages of 4 and 7 years, the child exhibits egocentrism, seeing things from his or her own point of view. The child is unable to comprehend the ideas of others if they differ from his or her own. As the child matures, he or she realizes that other people see things differently.
The concrete operational stage begins at approximately 8 years of age and lasts until age 12 years. The
child is able to think more logically as the concepts of moral judgment, numbers, and spatial relationships are developed.
child is able to think more logically as the concepts of moral judgment, numbers, and spatial relationships are developed.
 Table 24.1 Summary of Erikson’s Psychosocial Theory | |||||||||||||||||||||||||||||||||||||||||||||
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The formal operational stage begins at age 12 years and lasts to adulthood. The person develops adult logic and is able to reason, form conclusions, plan for the future, think abstractly, and build ideals.
Etiology of Personality Disorders
During the process of personality development, the person establishes certain traits that enable him or her to observe, interact with, and think about the environment and oneself. If the person develops a positive self-concept, body image, and sense of self-worth, and is able to relate to others openly and honestly, she or he is said to have characteristics of a healthy personality. Should the person develop inflexible, maladaptive behaviors (eg, manipulation, hostility, lying, poor judgment, and alienation) that interfere with social or occupational functioning, the person exhibits signs and symptoms of a personality disorder.
Personality disorders exist on a continuum. They can range from mild to more severe based on how pervasive the symptoms of a particular personality disorder are, and to what extent a person exhibits these symptoms. Although most individuals can live fairly normal lives with mild symptoms of personality disorders, during times of increased stress or external pressures (eg, caused by work, family, or a new relationship), the symptoms will be exacerbated and begin to seriously interfere with the individual’s emotional and psychological functioning. Personality disorders are usually recognizable by adolescence or earlier (ie, borderline personality disorder [BPD] can start as early as age 5), continue throughout adulthood, and become less obvious throughout middle age (National Mental Health Association, 2006).
The potential causes of personality disorders are as numerous as the people who suffer from them. Genetic and biologic factors, as well as a combination of one’s personality, social development, and parental upbringing, are associated with these disorders. Environmental factors may cause a person who is already genetically vulnerable to develop a personality disorder (National Mental Health Association, 2006; Sadock & Sadock, 2003). A discussion of the more common theories regarding the development of personality disorders follows.
Genetic Factors
Although research has not isolated the cause of any specific factor at this time, investigations of 15,000 pairs of twins in the United States revealed that monozygotic twins, living together or apart, develop personality disorders much more frequently than dizygotic twins do. Cluster A personality disorders (eg, paranoid, schizoid, or schizotypal) occur more frequently in biologic relatives of clients with schizophrenia than in control groups. Cluster B personality disorders (eg, antisocial, borderline, histrionic, or narcissistic) apparently have a genetic basis as well.Antisocial personality disorder is associated with alcohol use disorder. Depression is common in the family backgrounds of clients with BPDs. Cluster C personality disorders (eg, obsessive–compulsive or dependent) also may have a genetic basis. Clients with avoidant personality disorders often exhibit clinical symptoms of anxiety and depression (Sadock & Sadock, 2003).
Biologic Factors
Research has also indicated that individuals with high levels of hormones such as testosterone, 17-estradiol, and estrone are thought to be biologically predisposed to the development of a personality disorder. Studies of dopaminergic and serotonergic systems indicate that, although in many persons dopamine and serotonin reduce depression and produce a sense of general well-being, high levels of these neurotransmitters have produced impulsive and aggressive behaviors. Furthermore, changes in electrical conductance on electroencephalograms have been noted in clients with antisocial and BPDs (Sadock & Sadock, 2003).
Psychoanalytic Factors
Each human being’s personality is largely determined by his or her characteristic defense mechanisms. According to Sadock and Sadock (2003), underlying defensive behaviors or mechanisms that are used to resolve conflict include fantasy, dissociation, isolation, projection, splitting, passive aggression, and acting out. When these behaviors or mechanisms are effective, they can abolish anxiety and depression. Therefore, individuals with personality disorders are reluctant to abandon them.
According to Freud’s theory, socially deviant persons have defective egos through which they are unable to control their impulsive behavior. Additionally,
a weak superego results in the incomplete development or lack of a conscience. Persons with immature superegos feel no guilt or remorse for socially unacceptable behavior. The drive for prestige, power, and possessions can result in exploitative, manipulative behavior. Moreover, urban societies—such as inner cities—are characterized by a low degree of social interaction, thereby fostering the development of personality disorders.
a weak superego results in the incomplete development or lack of a conscience. Persons with immature superegos feel no guilt or remorse for socially unacceptable behavior. The drive for prestige, power, and possessions can result in exploitative, manipulative behavior. Moreover, urban societies—such as inner cities—are characterized by a low degree of social interaction, thereby fostering the development of personality disorders.
Childhood Experiences
As noted earlier, according to the various theories of personality development, negative or maladaptive behavior can occur during childhood. Following are examples of childhood experiences that could contribute to the development of a personality disorder:
Parental rewarding of behavior such as a temper tantrum encourages acting out (ie, the parent gives in to a child’s wishes rather than setting limits to stop the behavior).
Creativity is not encouraged in the child; therefore, the child does not have the opportunity to express him- or herself or learn to relate to others. The ability to be creative could provide the child with the opportunity to develop a positive self-concept and sense of self-worth.
Rigid upbringing also has a negative effect on the development of a child’s personality because it discourages experimentation and promotes the development of low self-esteem. It may also cause feelings of hostility and alienation in the child–parent relationship.
Parental fostering of dependency discourages personality development and allows the child to become a conformist, rather than an independent being with an opportunity to develop a positive self-concept.
Parents or authority figures display socially undesirable behavior and the child identifies with them. As a result of this identification process, the child imitates behavior that he or she believes to be acceptable by others. Such behavior frequently puts the child in direct conflict with society.
Characteristics of Personality Disorders
A personality disorder is described as a nonpsychotic illness characterized by maladaptive behavior, which the person uses to fulfill his or her needs and bring satisfaction to him- or herself. Most personality-disordered people experience a permanent stage of anger as a result of frustration, perceived or actual rejection, conflict, or resentment. Their anger is often suppressed or repressed; however, it can be sudden, raging, frightening, and without an apparent provocation by an outside agent. The anger is manifested only when the individual’s defenses are down, incapacitated, or adversely affected by internal or external circumstances. The individual is unable to redirect his or her primitive pent-up anger (Vaknin, 2006). Maladaptive behaviors begin during childhood or adolescence as a way of coping and remain throughout most of adulthood, becoming less obvious during middle or old age. As a result of his or her inability to relate to the environment, the person acts out his or her conflicts socially. Emotional, economic, social, or occupational problems are often seen as a result of maladaptive behavior (American Psychiatric Association [APA], 2000).
Individuals with personality disorders have many common characteristics. They include:
Inflexible, socially unacceptable behaviors
Self-centeredness
Manipulative and exploitative behavior
Inability to tolerate minor stress, resulting in increased inability to cope with anxiety or depression
Lack of individual accountability for behavior, blaming others for their problems
Difficulty dealing with reality because of a distorted or superficial understanding of self and the perceptions of others
Vulnerability to other mental disorders such as obsessive–compulsive tendencies and panic attacks
Individuals with personality disorders rarely seek psychiatric help because the person lacks insight regarding his or her behaviors and does not view them to be maladaptive, contributing to a personality disorder (Lebelle, 2006). Refer to Box 24-1 for a summary of The National Epidemiologic Survey on Alcohol and Related Conditions study on individuals at risk for personality disorders.
Clinical Symptoms and Diagnostic Characteristics of Personality Disorders
The DSM-IV-TR groups personality disorders into three clusters or descriptive categories (APA, 2000). Persons
who exhibit paranoid, schizoid, and schizotypal personality disorders are considered “odd” or eccentric in the vernacular and are grouped in the first cluster, Cluster A. Persons with disorders in the second cluster, Cluster B—antisocial, borderline, histrionic, and narcissistic personality disorders—are considered to be emotional, erratic, or dramatic in behavior. Anxious or fearful behaviors are often present in the third cluster, Cluster C, which includes obsessive–compulsive, dependent, and avoidant personality disorders. The category Personality Disorder, Not Otherwise Specified (NOS), is reserved for those disorders that do not fit into any of the three clusters. See the accompanying Clinical Symptoms and Diagnostic Characteristics box.
who exhibit paranoid, schizoid, and schizotypal personality disorders are considered “odd” or eccentric in the vernacular and are grouped in the first cluster, Cluster A. Persons with disorders in the second cluster, Cluster B—antisocial, borderline, histrionic, and narcissistic personality disorders—are considered to be emotional, erratic, or dramatic in behavior. Anxious or fearful behaviors are often present in the third cluster, Cluster C, which includes obsessive–compulsive, dependent, and avoidant personality disorders. The category Personality Disorder, Not Otherwise Specified (NOS), is reserved for those disorders that do not fit into any of the three clusters. See the accompanying Clinical Symptoms and Diagnostic Characteristics box.
Box 24.1: Results of National Epidemiologic Survey
The National Epidemiologic Survey on Alcohol and Related Conditions (Grant, Hasin, & Stinson, 2004), mentioned earlier in this chapter, surveyed individuals at risk for the development of personality disorders. Trained personnel conducted face-to-face interviews with 43,093 noninstitutionalized U.S. adults. A summary of their findings follows:
Women were more likely than men to have avoidant, dependent, and paranoid personality disorders.
Men were three times more likely than women to have antisocial personality disorders.
Separated/divorced/widowed or never-married individuals were more likely than their counterparts to have avoidant, dependent, paranoid, schizoid, and histrionic personality disorders.
Native Americans were more likely than whites to have avoidant, paranoid, schizoid, and antisocial personality disorders.
White persons were more likely than Asian or Hispanic persons to have obsessive–compulsive personality disorder.
Paranoid, schizoid, and histrionic personality disorders were more prevalent among black persons than among white persons.
Although factors that may contribute to the development of a personality disorder were discussed earlier in this chapter, additional information regarding a specific personality disorder is included with each disorder to clarify the development of clinical symptoms unique to the disorder.
Clinical Symptoms and Diagnostic Characteristics/Personality Disorders
Clinical Symptoms
Changes in the Following Areas:
Cognition
Emotional responses (affect)
Interpersonal functioning
Impulse control
Diagnostic Characteristics
Evidence of an enduring pattern of behavior and inner experience in at least two of the areas above
Stable, long-lasting pattern exhibited as a marked deviation from that which is expected in the individual’s culture
Onset most likely traceable to adolescence or early adulthood
Pattern widespread, occurring over personal and social situations
Resultant distress in important areas of functioning
Pattern not associated with or due to a medical condition or another mental disorder
Cluster A Disorders: Odd, Eccentric Behavior
Paranoid Personality Disorder
Individuals who develop a paranoid personality disorder have chronic hostility that is projected onto others. This hostility develops in childhood as a result of poor interpersonal family relationships. As a result, the person who has experienced much loneliness becomes unwarrantedly suspicious and mistrusts people. The person may suspect attempts to trick or harm him or her, question the loyalty of others, display pathological jealousy, observe the environment for any signs of threat, display secretiveness, become hypersensitive, or display excessive feelings of self-importance. The person also may appear to be unemotional, lack a sense of humor, and lack the ability to relax. Paranoid personality disorder can usually be differentiated from delusional disorder because features such as fixed delusions and hallucinations are absent. Interpersonal relationships
are poor, especially when relating to authority figures or co-workers, contributing to lifelong interpersonal, marital, and occupational problems. See Clinical Example 24-1: The Client With a Paranoid Personality Disorder.
are poor, especially when relating to authority figures or co-workers, contributing to lifelong interpersonal, marital, and occupational problems. See Clinical Example 24-1: The Client With a Paranoid Personality Disorder.
Clients with paranoid personality thrive in an environment in which caution and wariness are rewarded and in which individuals are not required to reveal themselves or otherwise make themselves vulnerable. They falter in environments and relationships that require high levels of trust and interdependence (Paul, 2005). The prevalence of paranoid personality disorder is 0.5% to 2.5% of the general population. This disorder is seen more frequently in men (APA, 2000; Lebelle, 2006; Sadock & Sadock, 2003).
Schizoid Personality Disorder
Synonyms for someone with a schizoid personality disorder include “introvert” and “loner” because the person has no desire for social involvement. The clinical symptoms include a pervasive pattern of detachment from social relationships and a restricted range of emotional expression in interpersonal settings. The individual avoids close relationships with family or others, chooses solitary activities, has little interest in sexual experiences, does not take pleasure in activities, lacks close friends or confidants, appears indifferent to praise or criticism, and exhibits emotional coldness such as detachment or flattened affect. Attention is usually focused on objects such as books and cars rather than people.
Clinical Example 24.1: The Client With a Paranoid Personality Disorder
JV, a 43-year-old Cuban immigrant who worked for a local utility company, was admitted to the hospital for surgery due to a work-related knee injury. During the assessment, the nurse noted that JV was hesitant to answer personal questions related to his medical history and appeared reluctant to provide information about his family. JV’s oldest daughter, who had accompanied him to the hospital, offered to provide the necessary information. She also informed the nurse that her father frequently warned the members of the family to lock the doors and windows because he did not trust his neighbors. He refused to allow his wife to leave the house while he was at work and insisted that his children notify him of their activities when they left home. The nurse learned that JV had emigrated from Cuba when he was 20 years old “to get away from the Castro regime.” According to JV’s daughter, he was a good father who provided well for his family and attended church regularly. Although JV did not verbalize any fixed delusional thoughts, he was very suspicious of strangers or new neighbors.
The client with schizoid personality disorder manages to get ahead in chaotic or challenging environments that do not make emotional demands. He or she may function well in vocations where one generally works alone and is indifferent to approval or criticism of others. The client does not thrive well in corporate environments in which one is expected to be intimate or closely connected to others (Paul, 2005). The prevalence of schizoid personality disorder is estimated to be approximately 7.5% of the general population; some studies report that males are twice as likely to develop this type of personality disorder (APA, 2000; Sadock & Sadock, 2003).
Schizotypal Personality Disorder
The classification of schizotypal personality disorder is used to diagnose persons whose symptoms are similar to, but not severe enough to meet, the criteria for schizophrenia. Clients generally exhibit a disturbance in thought processes referred to as magical thinking, superstitiousness, or telepathy (a “sixth sense”). They experience ideas of reference, limit social contacts to those involved in the performance of everyday tasks, describe perceptual disturbance such as illusions or depersonalization, demonstrate peculiarity in speech but no loosening of association (shifting of speech from one frame of reference to another), and appear aloof or cold because they exhibit an inappropriate affect. Paranoid ideation, odd or eccentric behavior or appearance, and excessive social anxiety associated with paranoid fears are generally present.
Clients with the diagnosis of schizotypal personality disorder succeed in unconventional environments in which their embrace of the unusual or fantastic is applauded. They are unsuccessful in corporate environments that require adherence to conventional codes of behavior (Paul, 2005). This disorder first may be apparent in childhood or adolescence. It has been
reported in approximately 3% of the population but the sex ratio is unknown. Only a small percentage of individuals with this disorder develop schizophrenia or other psychotic disorders (APA, 2000; Sadock & Sadock, 2003).
reported in approximately 3% of the population but the sex ratio is unknown. Only a small percentage of individuals with this disorder develop schizophrenia or other psychotic disorders (APA, 2000; Sadock & Sadock, 2003).
Cluster B Disorders: Emotional, Erratic, or Dramatic Behavior
Individuals with Cluster B personality disorders have the greatest risk for suicide when compared with individuals with Cluster A or Cluster C disorders. The risk is similar for individuals with a major mood disorder but without a personality disorder. Factors contributing to an increased risk of suicide include the presence of comorbid mood or addiction disorders, severity of childhood sexual abuse, degree of antisocial or impulsive characteristics, and a history of irregular psychiatric discharges (Lambert, 2003).
Antisocial Personality Disorder
Synonyms for antisocial personality disorder include sociopathic, psychopathic, and semantic disorder. Several factors have been proposed to explain the development of the antisocial personality, although the exact cause is unknown. These factors include the following:
Genetic or hereditary factors interfere with the development of positive interpersonal relationships during childhood. The child therefore does not learn to respect the rights of others.
Biologic factors such as low levels of serotonin may combine with environmental factors and place the individual at risk for a personality disorder.
The child may become self-indulgent and expect special favors from others, but does not display appreciation or reciprocal behavior.
Brain damage or trauma precipitates the development of antisocial behavior. (See Supporting Evidence for Practice 24-1.)
Low socioeconomic status encourages the development of an antisocial personality; people may turn to maladaptive behaviors, such as stealing, lying, or cheating, just to survive.
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