Introduction

People with personality disorders exhibit attitudes and behaviours that can be difficult to change and may coexist with another psychiatric disorder. Indeed the individual who has any one of the recognised personality disorders may have no desire to change. These people tread an uneasy path between being seen as deserving treatment and being seen as not having a ‘real’ psychiatric disorder. Nurses managing such patients need appropriate education and training to be able to engage therapeutically with them. This chapter explains the main categories of personality disorders and their diagnosis. Nursing interventions are described, and challenges in working with people who have personality disorder are discussed. Limitations in our understanding of personality disorders, and problems of categorisation, diagnosis and treatment are also discussed.

‘Trait’ versus ‘disorder’

Each of us has a personality and a common sense understanding of what that means. We describe others as ‘outgoing’ or ‘assertive’ or maybe ‘withdrawn’ or ‘shy’. Sometimes the ones we might choose to describe ourselves would not be chosen by those who know us. Some individuals have personalities that seem to draw people to them. They may be described as charismatic, outgoing, friendly, good team players, helpful or kind. Others seem to have difficulty attracting others or maintaining relationships. They appear unreceptive, cold, aloof, isolative, eccentric, or perhaps are moody, aggressive or reckless. Our personality may be thought of as the expression of our feelings, thoughts and patterns of behaviour that evolve over time. Our genetics, life experiences and the environment we are exposed to, all serve to shape our personality. Our personality manifests in our moods, attitudes and opinions and is clearly expressed when we interact with others.

Enduring aspects or features of our personality are referred to as personality traits. These traits are what make us unique and interesting and they differentiate us from each other. Social mores provide unwritten boundaries for what constitutes a ‘normal’ personality trait. For example, if a student expresses concern at having to present their work to the class because they are shy, and public speaking makes them anxious, we regard that as being within the bounds of normal behaviour. It is very common for people to feel uncomfortable at the prospect of standing up in front of an audience, even one composed of their peers. With encouragement and support, most people are able to jump this particular hurdle. However, some individuals feel so strongly about appearing in public that they avoid all social situations where this may be required of them, to the point where they will withdraw from an enjoyable course of study or well-paid employment or even contact with their family. This behaviour is beyond what is socially regarded as shyness. The personality trait has moved beyond normal boundaries to a point where it may be understood in terms of psychopathology. Some individuals display personality traits that seem to be beyond the scope of what is considered reasonable as observed by their behaviour and attitudes to others, and, as in the foregoing example, will do almost anything to avoid feeling ridiculed, rejected or embarrassed.

When these manifestations of personality start to interfere negatively with a person’s life or with the lives of those close to them, the person is diagnosed as suffering from a personality disorder. The challenge for nurses, and indeed for anyone involved with such an individual, lies in determining appropriate behaviour, given that norms relating to behaviour are socially and culturally constructed. When is the expression of someone’s personality to be considered disordered? Let us set the scene for our contemplation of this question by considering the case study of Jodie.

Clearly, Jodie has some problems. In particular, she seems to have trouble with her relationships and with discerning appropriate ways of dealing with disappointment. It is one thing to have unrequited feelings for someone and to feel sad. It is quite another to deal with the situation as Jodie did. Jodie may be exhibiting the features of a personality disorder. In order to determine whether Jodie does have such a disorder, an assessment would need to be conducted that considered more than the events that triggered her attempted overdose and ensuing admission. A full psychosocial history would be obtained to enable clinicians to detect patterns in Jodie’s behaviour over time. Without a comprehensive assessment, Jodie’s behaviour may be interpreted as resulting from a fixed delusion on her boss. The problem is compounded by the fact that we believe that these behaviours are usually enacted unconsciously—that is, sufferers have little or no conscious awareness of their disorder.

However, it is rare for a person who has a personality disorder to present to a clinical setting because of the disorder. Rather, people tend to present to their medical practitioner for secondary mental health issues such as depression, feeling unable to cope or because of the effects of a situational crisis they may find themselves in.

Classification of personality disorders

While each of the personality disorders described in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, DSM-IV-TR (American Psychiatric Association 2000) has particular characteristics, they also have certain features in common. Personality disorders are recognised by persistent and enduring patterns of behaviour that are often destructive and nearly always characterised by maladaptive and inflexible ways of coping with stress (such as Jodie’s response to John’s rejection). As a result, those affected experience significant impairment in their ability to relate satisfactorily to others at work or socially. People with personality disorder also seem to have an outsized capacity to evoke interpersonal conflict and therefore have an intense, often negative, impact on those around them.

One of the difficulties of caring for these people is that they tend to have very little or no insight into their condition. Clinicians often comment that the trouble with working with people with personality disorder is that as far as they are concerned, the problem is yours, not theirs! This lack of insight stems from an inability to empathise with others, which can be seen to be related to impaired cognition, affect, interpersonal functioning and impulse control (APA 2000). Of course we have to acknowledge that this view is the orthodox one and it may simply be that clients are unwilling to share with us how they feel and what they believe.

The DSM-IV-TR groups personality disorders into three clusters: A, B and C. Cluster A is composed of the disorders of an odd or eccentric nature; Cluster B includes dramatic, erratic and emotional disorders and Cluster C the anxious and fearful group. Table 17.1 summarises the disorders covered by each cluster along with the diagnostic criteria used in clinical settings. It should be noted that the DSM-IV also provides a category to accommodate the diagnosis of people whose personality disorders do not fit the criteria for any specific disorder, which is referred to as ‘personality disorder: not otherwise specified’.

Table 17.1 Criteria for classification of the personality disorders

Source: adapted from APA 2000, DSM-IV.

Problems of diagnosis

The rise of evidence-based practice cautions health professionals to acknowledge the individual determinants of disease. Health professionals are urged to look at clients holistically and not reduce them to a label based purely on a collection of signs and symptoms. This is because the application of diagnostic categories has the potential to have a stigmatising effect. That is, people may be treated in a negative way socially and within healthcare systems because of their diagnosis. Markham (2003, p 595) conducted a study in which he evaluated the effect of the label ‘borderline personality disorder’ on registered mental health nurses’ (RMNs) attitudes and perceptions of clients with that diagnosis. Markham (2003, p 595) concluded that RMNs were least optimistic about clients with a borderline personality disorder label and more negative about their experience working with this group compared to other patient groups. For example, RMNs expressed higher levels of social rejection of clients with borderline personality disorder than of those with a diagnosis of schizophrenia (Markham 2003, p 608). They also attributed higher levels of dangerousness to those with the borderline personality disorder label than those with schizophrenia (Markham 2003, p 602). The application of a diagnostic label may also affect the way the client behaves. That is, when people are treated in a particular way they respond in kind. A person may take the labels they have been given and behave in the way that the label suggests is expected of them (Haywood & Bright 1997).

Individual client predicaments and concerns should be given equal weight alongside what the research/diagnostic evidence says, so that together clinicians and clients can make informed choices about what might be the optimum care in a given situation (Farrell 1997, p 1). Psychologists remind us also of the interplay between psychological and physical determinants of illness and treatment outcomes. Yet it appears that psychiatry is moving ever more towards a reductionist approach to illness, whereby mental disorders are categorised into discrete entities, based on the presence of specific symptoms or signs. One only has to review the DSM-IV-TR and compare its present size to that of earlier editions. Each later edition of this manual increases in volume as the diagnostic categories expand to include disorders such as caffeine addiction.

While the layperson may be forgiven for thinking that psychiatric diagnoses are reliable and valid, the mental health nurse should be aware that psychiatric diagnosis is problematic at best and flawed at worst. The DSM-IV (APA 1994) issues a cautionary statement to clinicians regarding the interpretation of its diagnostic categories. It acknowledges that:

The DSM-IV-TR (APA 2000) issues a cautionary statement to clinicians regarding the interpretation of its diagnostic categories; indeed they are advised that specific diagnostic criteria serve only to inform professional judgment, not to override it. This is especially the case in personality disorder, where the diagnosis is often subject to heated debate.

The diagnosis of personality disorder clearly shows the weakness in relying on ‘soft’ or nebulous criteria for its diagnosis that are not usually generated by evidence-based research. The formulations of personality disorders in the DSM are atheoretical—they are simply lists of signs and symptoms and provide little in the way of explanation. The fact that patients are often diagnosed with four or more personality disorders illustrates the difficulties in providing a clear formulation of the disorder (Sadock & Sadock 2003). Tyrer & Simonsen (2003, p 41) quote work by Livesly (1986, 1991) that demonstrates that the key components of personality disorder are distributed among many individual categories and so it is not surprising that comorbidity of personality disorder is so common. In trying to gain an understanding of personality disorder, as with much of psychiatry, we are dealing with open concepts (Pap 1953, p 41)—that is, concepts that are subject to conceptual stretch. These concepts are over-used to the point of rendering them useless due to their breadth of application, thereby leading to confusion or misunderstanding. For instance, where does assertion end and aggression begin?

Personality disorders present problems not only of diagnosis but also of management. Nurses undertaking care of such individuals are advised to base their approach on four key areas of disturbance for such clients:

Epidemiology

The prevalence of a disorder refers to the estimated number of people in the population affected by it. Prevalence represents the number of new and pre-existing people with the disorder alive on a certain date. In the National Survey of Mental Health and Wellbeing undertaken in Australia, Andrews et al (1999) found that approximately 10% of young adult males and 8% of young adult females had a personality disorder.

In general, studies that are available on the prevalence of personality disorder are narrow in focus and lack the robustness of formal epidemiological research (Mattia & Zimmerman 2001, p 107). According to Mattia & Zimmerman (2001) no epidemiological survey of the full range of personality disorders has been conducted since the release of DSM-III. The studies that do exist suffer from problems of definition. Estimating prevalence suffers from the unavailability of standardised assessment tools, as well as the costs associated with conducting broad-based research.

Of all the personality disorders, antisocial personality disorder has received the most attention in epidemiological research. It appears that the median prevalence rate of antisocial personality is 1.2%, with a range of 0–3.7%. Table 17.2 summarises the median prevalence rates for the other types of personality disorders. Note that the medians presented in Table 17.2 are those obtained across all studies reported by Mattia & Zimmermann (2001). These studies were conducted primarily in North America from 1985 to 1995.

Table 17.2 Prevalence of personality disorders

* Most studies report low numbers of subjects or none meeting the criteria for narcissistic personality disorder.

Source: adapted from Mattia & Zimmerman 2001, p 112.

From Table 17.2 it can be seen that the narcissistic personality is the least prevalent personality disorder. Most studies so far reported failed to find participants who merited the diagnosis. Overall, community-based surveys from the United States, Canada, Scandinavia and New Zealand report a lifetime prevalence rate for all personality disorders of 10–13% (Falconer 2001, p 315). There is a paucity of similar studies in Australia.

In both men and women the prevalence of personality disorders decreases with age (Andrews et al 1999, p 31; Samuels et al 2002). The prevalence rate among older adults (65 years and over) in Australia is approxi mately 3%, compared to around 6% for 25–34 year olds (Andrews et al 1999, p 31). This difference is most marked with respect to the Cluster B disorders (Galovski 2003).

The person with personality disorder often experiences considerable impairment in activities of daily living, such as disturbance in relationships and impulsivity. Fifteen per cent of cases had experienced at least two days of impaired functioning in the previous month—more than twice that of the rest of the population (Andrews et al 1999, p 31).

Anecdotally, clinicians report that their caseload of clients with personality disorder is on the rise. Australian estimates suggest that as many as 20% of all mental health hospitalisations may be the result of such conditions (Andrews et al 1999).