Personality disorders

CHAPTER 24


Personality disorders


Claudia A. Cihlar



Objectives



1. Identify characteristics of each of the 10 personality disorders.


2. Analyze the interaction of biological determinants and psychosocial stress factors in the etiology of personality disorders.


3. Describe the emotional and clinical needs of nurses and other staff when working with patients who meet criteria for personality disorders.


4. Formulate a nursing diagnosis for each of the personality disorders.


5. Discuss two nursing outcomes for patients with antisocial and borderline personality disorder.


6. Plan basic interventions for a patient with impulsive, aggressive, or manipulative behaviors.


7. Identify the role of the advanced practice nurse when working with patients with personality disorders.




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We may often meet someone and think, “She’s quite a strange person” or “What an unusual character he is.” When we make evaluations such as these about other people, we are reacting to their personalities. Personality comes from the Latin word persona, which means mask, and it may refer to what other people see.


Western scholars such as Hippocrates suggested that personality and general health problems were the results of an imbalance of essential bodily fluids. These fluids, or “humors,” were phlegm (mucous), blood, and bile. The scientist Galen proposed that these humors produced personality profiles of phlegmatic (calm and unemotional), sanguine (lighthearted and unemotional), melancholic (creative and depressive), and choleric (energetic and passionate) (Kagan, 2005).


In the 19th century, Sigmund Freud proposed a construct of personality that created a paradigm shift from a biological imbalance to a psychological perspective for both healthy and disordered personality. Freud’s hypothesis that personality emerged from childhood experiences rather than one’s chemistry gave birth to the psychoanalytic movement.


Personality can be described operationally in terms of functioning. We know that personality can be protective for a person in times of difficulty but may also be a liability if one’s personality results in ongoing relationship problems or leads to emotional distress on a regular basis (Clarkin & Huprich, 2011). Personality determines the quality of experiences among people and serves as a guide for one-to-one interaction and in social groups. Based on this description, we can tell when a personality is unhealthy, that is, “when it interferes with, or complicates, social and interpersonal function” (Blais et al., 2008, p. 527). In contemporary society there is a consensus that personality disorders exist on a continuum of severity and likely represent more extreme variations in normal personality development.




Clinical picture


Personality disorders are among the most challenging and complex group of disorders to treat. Individuals who meet criteria for these disorders display significant challenges in self-identity or self-direction, and they have problems with empathy or intimacy within their relationships.


People with these disorders have difficulty recognizing or owning that their difficulties are problems of their personality. They may truly believe the problems originate outside of themselves. Still others may be unaware that their behavior is unusual, and they may not experience any distress (Skodol & Gunderson, 2008).


Judgments about an individual’s personality functioning must take into account the person’s ethnic, cultural, and social background. Patients who differ from the majority culture or the culture of the clinician may be at risk for overdiagnosis of a personality disorder; therefore, it is important to obtain additional information from others knowledgeable of the particular cultural or ethnic norms before determining the presence of a personality disorder.


According to the American Psychiatric Association (2013), there are 10 personality disorders (Box 24-1; also see Table 24-1). Eight of these disorders will be described in terms of prevalence, characteristic pathological responses, and etiology. A vignette is also provided to illustrate each of these disorders. Afterwards, two common and challenging personality disorders, antisocial and borderline, will be described in more depth along with an application of the nursing process.



BOX 24-1      PERSONALITY DISORDERS


Paranoid personality disorder


Schizoid personality disorder


Schizotypal personality disorder


Histrionic personality disorder


Narcissistic personality disorder


Avoidant personality disorder


Dependent personality disorder


Obsessive-compulsive personality disorder


Antisocial personality disorder


Borderline personality disorder




Paranoid personality disorder


Paranoid personality disorder occurs at a prevalence rate of about 1.7% in community samples (Torgersen, 2009). This disorder is characterized by a longstanding distrust and suspiciousness of others based on the belief (unsupported by evidence) that others want to exploit, harm, or deceive the person. These individuals are hypervigilant, anticipate hostility, and may provoke hostile responses by initiating a “counterattack.” They demonstrate jealousy, controlling behaviors, and unwillingness to forgive. Paranoid persons are difficult to interview because they are reluctant to share information about themselves. Underneath the guarded surface, they are actually quite anxious about being harmed.


Paranoid personality disorder may be found in people who grew up in households where they were the objects of excessive rage and humiliation, which resulted in feelings of inadequacy (Skodol & Gunderson, 2008). Projection is the dominant defense mechanism; they blame others for their shortcomings.


People with this disorder tend to reject treatment. Antianxiety agents may be accepted as a method to improve relaxation. Agitation and delusions may be treated with antipsychotic medication.



VIGNETTE


Mrs. Alonzo is a 54-year-old unemployed female who comes to a mental health clinic complaining of depression and pain. She walks stiffly and uses two old, broken canes. She provides elaborate details about “nerve pain” all over her body resulting from an accident 5 years earlier. She states that multiple doctors refused to help her because of instructions from her insurance company. She believes that her health maintenance organization has circulated her medical record to all health care providers in the region to prevent her from being treated. She refuses to give any social history and is reluctant to share her telephone number. When the nurse indicates that the psychiatrist will not prescribe pain medications, she smiles bitterly and says, “So they already got to you.”




Schizoid personality disorder


Schizoid personality disorder is fairly uncommon and is estimated to occur in around 0.9% of the population (Torgersen, 2009). People with schizoid personality disorder exhibit a poor ability to function in their lives. Relationships are particularly affected due to the prominent feature of emotional detachment. People with this disorder do not seek out or enjoy close relationships and are viewed as loners. Neither approval nor rejection from others seems to have much effect. Friendships, dating, and sexual experiences are rare. Employment may be jeopardized if interpersonal interaction is necessary; individuals with this disorder may be able to function well in a solitary occupation such as a security guard on the night shift. Feelings of being an observer rather than a participant in life are common. Depersonalization, or feelings of detachment from oneself and the world, may be present.


From a psychological perspective, people with this disorder are often raised in a cold and neglectful atmosphere in which they may conclude that relationships are unsatisfying and unnecessary. Genetically, this disorder may be based on a predisposition to shyness. Schizoid personality disorder can be a precursor to schizophrenia or delusional disorder, and there is increased prevalence of the disorder in families with a history of schizophrenia or schizotypal personality disorder.


Antidepressants such as bupropion (Wellbutrin) may help to increase pleasure in life. Second-generation antipsychotics, such as risperidone (Risperdal) or olanzapine (Zyprexa) are used to improve flattened emotions. Psychotherapy can help to improve sensitivity to others’ social cues; group therapy provides experience in practicing interactions and feedback from others.



VIGNETTE


Mr. Gray is a 30-year-old single male who is a graduate student in mathematics at a large state university. He lives alone and has never been married. He works as an assistant in a math classroom in which the professor teaches the course via television. He wears thick eyeglasses, and his clothing is inconspicuous. He rarely smiles and seldom looks directly at the students, even when answering questions. He does get somewhat animated when he writes lengthy solutions to math problems on the blackboard. He is content with his low-paying job and has never been in psychiatric treatment.




Schizotypal personality disorder


Schizotypal personality disorder is more common in men than women and occurs at a rate of less than 1% in the general population (Torgersen, 2009). Despite its low prevalence, schizotypal personality disorder is so unusual and debilitating that it is one of the most studied personality disorders (Hummelen et al., 2011). In the Diagnostic and Statistical Manual of Mental Illness, 5th edition (DSM-5) (APA, 2013), it is identified as a both a personality disorder and the first of the schizophrenia spectrum disorders, which are, in general, listed from least to most severe. Chapter 12 discusses the schizophrenia spectrum disorders in greater detail.


Like schizoid personality disorder, persons with schizotypal personality disorder have severe social and interpersonal deficits. They experience extreme anxiety in social situations and contributions to conversations tend to ramble with lengthy, unclear, overly detailed, and abstract content. An additional feature of this disorder is paranoia; individuals with schizotypal personality disorder are overly suspicious and anxious. They tend to misinterpret the motivations of others as being out to get them and blame others for their social isolation. Odd beliefs (e.g., being overly superstitious) or magical thinking (e.g., thinking of themselves as psychic) are also common.


Psychotic symptoms seen in persons with schizophrenia, such as hallucinations and delusions, might also exist with schizotypal personality disorder, but to a lesser degree and only briefly (Skodol et al., 2011). A major difference between this disorder and schizophrenia is that people with schizotypal personality disorder can be made aware of their misinterpretations of reality. Schizophrenia results in a far stronger grip on delusions.


Although schizotypal personality disorder is generally diagnosed in adulthood, signs of the disorder tend to be present in childhood and adolescence. Prominent characteristics include being an underperformer in school and difficulty in connecting with peers. Characteristic communication eccentricities combined with unusual beliefs tend to make the child or adolescent a target for teasing and bullying.


As a schizophrenia spectrum disorder, schizotypal personality disorder is genetically linked. There is a higher incidence of schizophrenia-related disorders in family members of people with schizotypal personality disorder. There is growing evidence to support that persons with schizotypal personality disorder have structural abnormalities of the brain such as ventricular enlargement, reductions in the volume of their striatal structures, and altered dopamine transmission mechanisms (Skodol et al., 2011).


While there is no specific medication for schizotypal personality disorder, associated conditions may be treated. Persons with schizotypal personality disorders seem to benefit from low-dose antipsychotic agents for psychotic-like symptoms and day-to-day functioning (Ripoll et al., 2011). Depression and anxiety may be treated with antidepressants and antianxiety agents.



VIGNETTE


Raymond is a 55-year-old single male who lives with his mother. He is the youngest of seven children raised in a farming community. Three of his siblings are deaf, and Raymond also has some hearing loss. Raymond started therapy with Jenny, an advanced practice registered nurse in psychiatric mental health, after he suffered a career-ending injury from which he is completely disabled. Jenny and Raymond have been working together for several years on quality-of-life issues and depression. Raymond is frequently distressed by his unwavering belief that everyone in his hometown greets him with sexual gestures and believes he is gay. This fixation extends to truck drivers who come through the town; he thinks that they talk about his sexuality on their CB radios. These beliefs create great distress and anxiety for him. He occasionally yells at people or gestures back. Jenny has been helping Raymond to understand how his perceptions may be faulty and how his hearing loss may contribute to his perceptual difficulties and anxiety. Raymond and Jenny have invited his mother into the discussion so she can support him at home.




Histrionic personality disorder


Histrionic personality disorder is thought to occur at a rate of about 1.5 % in community samples (Torgersen, 2009). Persons with histrionic traits do not generally experience a reduction in quality of life. Studies focusing on heritability traits suggest there may be common risk factors for impulsivity, reduced levels of agreeableness and introversion (Skodol et al., 2001). This disorder is characterized by emotional attention-seeking behaviors, including self-centeredness, low frustration tolerance, and excessive emotionality. The person with histrionic personality disorder is often impulsive and melodramatic and may act flirtatiously or provocatively. Relationships do not last, because the partner often feels smothered or reacts to the insensitivity of the histrionic person. The individual with histrionic personality disorder does not have insight into his or her role in breaking up relationships and may seek treatment for depression or another comorbid condition. In the treatment setting, the person demands “the best of everything” and can be very critical.


Histrionic personality disorder has been explained from a psychodynamic perspective as beginning at 3 to 5 years of age with an overly intense attachment to the opposite-sex parent, which results in fear of retaliation by the same-sex parent. Inborn character traits such as emotional expressiveness and egocentricity have also been identified as predisposing an individual to this disorder.


In general, people with this disorder do not think they need psychiatric help. They may go into treatment for associated problems such as depression that may be precipitated by losses, such as loss of a relationship. Psychotherapy is the treatment of choice for this disorder. Medications such as antidepressants and antianxiety agents may be helpful in treating associated symptoms.



VIGNETTE


Ms. Lombard is a 35-year-old, twice-divorced female admitted to an inpatient unit after an overdose of asthma medications and antibiotics. She took all of her pills after her primary care doctor refused to order a sleeping pill for her. On the first night, she is withdrawn and tearful in her room. But the next morning, she is neatly groomed, even wearing makeup, and socializes with everyone. She denies thoughts of self-harm. Over the next 2 days, Ms. Lombard monopolizes the community meetings by talking about how unappreciated she is by her family and physician. She seeks special attention from an evening-shift male RN, asking if he can stay late after his shift to sit with her. When he refuses, she demands to be placed back on one-to-one precautions because she suddenly feels suicidal again.




Narcissistic personality disorder


Narcissistic personality disorder is thought to be one of the least frequently occurring personality disorders. In the community it exists at less than 1%, but it is seen in clinical populations more frequently (Torgersen, 2009). Narcissistic personality disorder is also associated less than other personality disorders with impairment in individual functioning and the quality of one’s life.


These persons come across as arrogant with an inflated view of their self-importance. The individual with this disorder has a need for constant admiration, along with a lack of empathy for others, a factor that strains most relationships over time. A sense of personal entitlement paired with a lack of social empathy may result in the exploitation of other people.


Underneath the surface of arrogance, persons with narcissistic personality disorder feel intense shame and have a fear of abandonment. In keeping with these descriptions, the main pathological personality trait of narcissism is antagonism, represented by the grandiosity and attention-seeking behaviors of these individuals. As a result, narcissistic individuals may seek help for depression or may seek to be validated by therapists and/or loved ones for their emotional pain of not being appreciated enough by others for their efforts or special qualities.


Narcissistic personality disorder may be the result of childhood neglect and criticism. The child does not learn that other people can be the source of comfort and support. As adults, they hide feelings of emptiness with an exterior of invulnerability and self-sufficiency. Little is known about inborn traits or heritability for this disorder.


There is no medication indicated for this disorder. Treatment includes individual cognitive-behavioral therapy, family therapy, and group therapy,



imageCONSIDERING CULTURE


Ageism, Culture of Aging, and Personality Disorders in Older Adults


Ageism, or the discrimination of persons based upon their age, is ubiquitous in our Western culture with its emphasis on youth. This bias even permeates health care settings that are designed to serve the needs of older adults. Stereotypes regarding older adults interfere with accurate assessment of older adults. The presence of personality disorders further complicates the provision of their care.


In addition, aging brings with it natural changes in social relationships, most notably more social isolation and loss. Since personality disorders profoundly affect the ability to function effectively in relationship with others, there is a greater likelihood that issues will become exacerbated and affect their care in later life.


While the traditional belief is that personality disorders “age out,” new research indicates that these problems continue throughout the lifespan. Nurses are more successful in addressing the needs of older adults with personality disorders when they examine their biases about aging and personality disorders. A flexible approach supporting a “goodness of fit” style that recognizes strength-based values of the client, the family members, and the system of care involved with them may be followed.


Magoteaux, A. L., & Bonnivier, J. F. (2009). Distinguishing between personality disorders, stereotypes, and eccentricities in older adults. Journal of Psychosocial Nursing, 47(7), 19–24.




VIGNETTE


Dr. Abigail McLaughlin is a 40-year-old female attending psychiatrist at a university outpatient center. She is twice divorced and has no children. Her grooming and makeup are impeccable, and she likes to chat about her expensive shopping habits. She is quite intelligent and is the only doctor on the staff trained in psychoanalysis. In clinical team meetings, she often discusses this fact, repeatedly telling others that psychoanalysis is the best treatment for mental illness. She frequently makes derogatory remarks to psychiatric residents if they suggest alternative treatment approaches for new cases. She is usually late to staff meetings, and when she is not speaking, she yawns and shifts noisily in her seat. She has a reputation for exhibiting angry outbursts at therapists in the hallway for minor mistakes, such as a scheduling error for a patient. She underwent 7 years of psychoanalysis but does not consider it to have been therapy—it “was only for training purposes.”




Avoidant personality disorder


Avoidant personality disorder is fairly common and is believed to occur in about 1.7% of the U.S. population (Torgersen, 2009). The main pathological personality traits are low self-esteem that is associated with functioning in social situations, feelings of inferiority compared to peers, and a reluctance to engage in unfamiliar activities involving new people.


Avoidant personality disorder has been linked with parental and peer rejection and criticism. A biological predisposition to anxiety and physiological arousal in social situations has also been suggested. Genetically, this disorder may be part of a continuum of disorders related to social anxiety disorder; studies have found a shared association between persons who have avoidant personality disorder and persons with social anxiety disorder (Skodol et al., 2011). A timid temperament in infancy and childhood may also be associated with this disorder.


Persons with avoidant personality disorders seem to respond positively to antidepressant medications such as selective serotonin reuptake inhibitors like citalopram and selective norepinephrine reuptake inhibitors such as venlafaxine (Ripoll et al., 2011). Individual and group therapy is useful in processing anxiety-provoking symptoms and in planning methods to approach and handle anxiety-provoking situations.



VIGNETTE


Ms. Lowell is a 35-year-old single female who works for a computer repair company. As a child, she had few friends and never participated in extracurricular activities. She lives alone in her own apartment and has never had an adult intimate relationship. On the job, she rarely talks to co-workers and prefers to work alone. If she has any questions, she asks the supervisor and carefully follows directions. Although she has 7 years of experience and a good work record, she refuses the offer of a promotion because it would require her to interact with customers.




Dependent personality disorder


The prevalence rate of dependent personality disorder is about 0.7 % in community samples and has been found to be associated with moderate to low problems in functioning (Skodol et al., 2011). However, there are discrepant studies that suggest this disorder may be more common.


Persons with dependent personality disorder have a high need to be taken care of, which can lead to patterns of submissiveness with fears of separation and abandonment by others. This may create problems for sufferers by leaving them more vulnerable to exploitation by others because of their passive and submissive nature. Feelings of insecurity about their self agency may interfere with attempts at becoming more independent in their life roles.


Persons with dependent personality disorder are thought to have early and profound learning experiences during childhood in which disordered attachment and dependency on the caretaker develop. Dependent personality disorder may be the result of chronic physical illness or punishment of independent behavior in childhood. Childhood trauma has been suggested as a stress factor associated with the development of personality disorders in general and, as such, has also been found to be linked to neuroendocrine changes, both cortisol and adrenocorticotropin-releasing hormone (Birgenheir & Pepper, 2011). The inherited trait of submissiveness may also be a factor, which has been found to be 45% heritable.


There are no specific medications indicated for this disorder, but symptoms of depression and anxiety may be treated with the appropriate medications. Psychotherapy is the treatment of choice for this disorder. The goal is for the person to be more independent and to form meaningful relationships. The therapeutic relationship can provide a testing ground for increased assertiveness. Cognitive behavioral therapy can help in the development of new perspectives and attitudes about other people.



VIGNETTE


Ashley is a 32-year-old, married, former engineer, and she is mother to two young children, ages 3 years and 11 months. Her therapist, an advanced practice registered nurse, recommended that she come for brief treatment of depression and anxiety at the partial hospitalization program. Ashley’s depression and anxiety have been more severe since she stopped working. She feels inadequate and overwhelmed by her responsibilities, so her mother moved in with the young family at her daughter’s request. Ashley bonded quickly with her case manager and psychiatrist, both older women. She frequently asks them for reassurance that she is doing the “right thing” by coming to treatment. She seeks them out frequently for extra individual sessions. During her group therapies over the course of treatment, Ashley begins to realize that excessive dependence on her mother contributes to longstanding feelings of ineffectiveness, helplessness, and invalidation of her own parenting skills.




Obsessive-compulsive personality disorder


Obsessive-compulsive personality disorder is the most prevalent personality disorder in the general community and in clinical populations; its prevalence rate is estimated at 2.1% (Torgersen, 2009). Along with borderline personality disorder, this disorder is associated with the highest burden of medical costs, and obsessive-compulsive personality disorder affects workplace productivity losses (Skodol et al., 2011).


The main pathological personality traits are rigidity and inflexible standards of self and others along with persistence to goals long after it is necessary, even if it is self-defeating or relationship-defeating. Persons with obsessive-compulsive personality disorder feel genuine affection for friends and family but do not have insight about their own difficult behavior. Internally, they are fearful of imminent catastrophe. They rehearse over and over how they will respond in social situations. These individuals do not have full-blown obsessions or compulsions but may seek treatment for anxiety or mood disorders. This disorder has been associated with increased relapse rates of depression and an increase in suicidal risks in persons with co-occurring depression.


Obsessive-compulsive personality disorder is associated with excessive parental criticism, control, and shame. The child in this atmosphere responds to this negativity by trying to control his environment through perfectionism and orderliness. Heritable traits such as compulsivity, oppositionality, lack of emotional expressiveness, and perfectionism have all been implicated in this disorder.


Selective serotonin reuptake inhibitors such as fluoxetine (Prozac) are Food and Drug Administration (FDA) approved for the treatment of the more severe version of this disorder, obsessive-compulsive disorder. Drugs such as Prozac may help reduce the obsessions, anxiety, and depression associated with this disorder. Psychotherapy may provide additional support. Group therapy and self-help groups have been found to be especially helpful in sharing and learning from others.



VIGNETTE


Mr. Wright is a 45-year-old single male postal worker in a small town. He lives alone and has never married. He is well groomed and wears a clean, neatly ironed uniform every day. He carefully follows all policies and procedures and is quite resistant whenever there is any update or change. He frequently challenges the supervisor about policy details and has been referred to the regional personnel office countless times for resolution of these conflicts. In staff meetings, he gives excessive circumstantial details and writes extra material on the back of any required report form. When dealing with the public, he sometimes gets into arguments with customers about postal rules or the schedule. The other staff do not consider him to be a team player because he seldom volunteers to help others. Even if he is asked to help someone, he is quick to criticize his peer’s performance. Although he has worked in the same office for 10 years, he has never advanced beyond the front-line position. He is fairly content with his work and has never been in psychiatric treatment.




Epidemiology and comorbidity


While studies vary in their estimates of prevalence depending upon methodologies, personality disorders affect about 6% of the global population (Huang et al., 2009). In the U.S. population the overall prevalence rate of personality disorders among community samples is higher—around 10% (Sansone & Sansone, 2011).


Culture has a definite influence on the rate of diagnosing personality disorders. For example, Australian and North American studies reflect higher prevalence rates (Samuels, 2011). Differences may reflect personality and behavior as being viewed as deviant rather than normative in a particular culture and study methods. It is generally agreed that there are insufficient studies to address the role that ethnicity and race have on the prevalence of personality disorders (McGilloway et al., 2010).


Personality disorders frequently co-occur with disorders of mood and eating, anxiety, and substance abuse. Personality disorders often amplify emotional dysregulation, a term that describes poorly modulated mood characterized by mood swings. Individuals with emotion regulation problems have ongoing difficulty managing painful emotions in ways that are healthy and effective.


Other studies confirm that personality disorders are more common among persons who are homeless or incarcerated. Recent studies have also suggested that personality disorders affecting older adults are more common than originally thought and frequently become evident when accompanied by major depression or anxiety (Magoteaux & Bonnivier, 2009).



Etiology


Personality disorders are the result of complex biological and psychosocial phenomena that are influenced by multifaceted variables involving genetics, neurobiology, chemistry, and environmental factors. An overview of the possible causes of personality disorders is provided.



Biological factors



Genetic

Genetics are thought to influence the development of personality disorders (Skodol & Gunderson, 2008). Recently, studies have led to a consensus that personality disorders represent extreme variations of normal personality traits in four areas: anxious-dependency traits, psychopathy-antisocial, social withdrawal, and compulsivity (Svrakic et al., 2008). These findings support a genetic or inherited trait transmission in families.




Psychological factors


Several psychological theories may help to explain the development of personality disorders. Learning theory emphasizes that the child developed maladaptive responses based on modeling or reinforcement by important people in the child’s life. Cognitive theories emphasize the role of beliefs and assumptions in creating emotional and behavioral responses that influence one’s experiences within the family environment.


Psychoanalytic theory focuses on the use of primitive defense mechanisms by individuals with personality disorders. Defense mechanisms such as repression, suppression, regression, undoing, and splitting have been identified as dominant (Kernberg, 1985). The role of psychoanalytic theory, while historically relevant and interesting, is not confirmable through evidence-based research methods.



Environmental factors


Behavioral genetics research has shown that about half of the variance accounting for personality traits emerges from the environment (Paris, 2005). These findings suggest that while the family environment is influential on development, there are other environmental factors besides family upbringing that shape an individual’s personality. One need only think about the individual differences among siblings raised together to illustrate this point.


Childhood neglect or trauma has been established as a risk factor for personality disorders (Samuels, 2011). This association has been linked to possible biological mechanisms involving corticotropin-releasing hormone in response to early life stress and emotional reactivity (Lee et al., 2011).



Diathesis-stress model


The diathesis-stress model is a general theory that explains psychopathology using a systems approach. This theory helps us understand how personality disorders emerge from the multifaceted factors of biology and environment (Paris, 2005). Diathesis refers to genetic and biological vulnerabilities and includes personality traits and temperament. Temperament is our tendency to respond to challenges in predictable ways. Descriptors of temperament may be “laid back,” referring to a calm temperament, or “uptight,” as an example of an anxious temperament. These characteristics remain stable throughout a person’s life.


In this model, stress refers to immediate influences on personality, such as the physical, social, psychological, and emotional environment. Stress also includes what happened in the past, such as growing up in one’s family with exposure to unique experiences and patterns of interaction. Under conditions of stress, the diathesis-stress model proposes that personality development becomes maladaptive for some people, resulting in the emergence of a personality disorder (Paris, 2005).


There is a two-way directionality among stressors and diatheses. Genetic and biological traits are believed to influence the way an individual responds to the environment, while at the same time, the environment is thought to influence the expression of inherited traits. Many studies have suggested a strong correlation between trauma, neglect, and other dysfunctional family or social patterns of interaction on the development of personality disorders among individuals with certain personality traits and temperament.


Table 24-2 provides an overview of nursing and other therapies for the treatment of all the personality disorders discussed above. Two additional personality disorders, antisocial and borderline, are included in this table for a quick reference, and they are also addressed in more depth in the remainder of the chapter.



TABLE 24-2   


NURSING AND THERAPY GUIDELINES FOR PERSONALITY DISORDERS







































PERSONALITY DISORDER CHARACTERISTICS NURSING GUIDELINES SUGGESTED THERAPIES
Antisocial Can seem normal
Exhibits no anxiety or depression
Manipulative
Exploitive of others
Aggressive
Seductive
Callous toward others

Avoidant Excessively anxious in social situations
Hypersensitive to negative evaluation
Desire social interaction

Borderline Shows separation anxiety
Manifests ideas of reference
Impulsive (suicide, self-mutilation)
Engages in splitting (adoring then devaluing persons)

Dependent Excessively clinging
Self-sacrificing, submissive
Needy, gets others to care for him or her

Histrionic Seductive
Flamboyant
Attention seeking
Shallow
Depressive and suicidal when admiration withdrawn

Narcissistic Exploitive
Grandiose
Disparaging
Filled with rage
Very sensitive to rejection, criticism
Cannot show empathy
Handles aging poorly

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Feb 3, 2017 | Posted by in NURSING | Comments Off on Personality disorders

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