PERSONALITY, essentially, refers to who a person is and how that person behaves. It influences an individual’s thoughts, feelings, attitudes, values, motivations, and behaviors. Personality affects how a person deals with stressors and how he or she forms and maintains relationships (American Psychiatric Association [APA], 2013).

Everyone has a unique collection of personality characteristics or traits. PERSONALITY TRAITS can be defined as a distinct set of qualities demonstrated over an extended period of time that characterize an individual. The specific traits and the degree to which these traits are exhibited vary from person to person. Biological as well as environmental factors affect personality development. People tend to react to situations in an individual but consistent way.

Personality traits are different from PERSONALITY DISORDERS. A personality disorder refers to a long-term maladaptive way of thinking and behaving that is ingrained and inflexible. Personality traits can be considered personality disorders when the following criteria are met: The traits are maladaptive, rigid, and enduring, and produce impairment in functioning or individual distress. Individuals with a personality disorder tend to be unbending and respond in a maladaptive way to problems. This can lead to difficulty in their relationships with others. People with personality disorders have trouble with the changes and demands of life. Most individuals with personality disorders are distressed with their life and relationships, but are generally unaware that their thoughts and behaviors are inappropriate. In addition, individuals with personality disorders tend to blame others for their circumstances. Moreover, an individual with a personality disorder demonstrates a dysfunctional pattern of coping that is not consistent with the person’s culture, ethnicity, and social background (APA, 2013). Personality disorders are classified into Clusters A, B, or C based on the predominant symptoms.

This chapter addresses the historical perspectives and epidemiology of personality disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5, APA, 2013). Current psychosocial and biological etiological influences of personality disorders are addressed along with current treatment modalities. Application of the nursing process from an interpersonal perspective is presented, including a nursing plan of care for a patient with a personality disorder.

HISTORICAL PERSPECTIVES

In the fourth century BCE, Hippocrates, known as the Father of Medicine, observed and classified four fundamental personality styles that he believed resulted from surpluses in the four bodily humors: the irritable and hostile choleric (yellow bile); the sad melancholic (black bile); optimistic and extroverted sanguine (blood); and the apathetic phlegmatic (phlegm). However, it was not until the early 19th century that formal efforts were made by American and European psychiatrists to describe abnormal personality traits. Further strides were made in 1952 with the first publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I). This publication included seven different categories of personality disorders. In 1980, personality disorders were eventually given their own axis, Axis II, in the multiaxial evaluation system in the DSM-III. The DSM-III provided diagnostic criteria for 11 distinct personality disorders. The number of categories of personality disorders was decreased to 10 in 1994 with the publication of the fourth edition of the DSM. Passive-aggressive personality disorder was removed from the list. The list identified in 1994 did not change with the publication of the DSM-5. However, the DSM-5 has moved from a multiaxial system in an effort to eliminate the arbitrary distinction between mental disorders and personality disorders.

EPIDEMIOLOGY

Personality disorders usually begin in early adolescence or early adulthood. Although it is unusual, children and adolescents may be diagnosed with personality disorders. Some personality disorders have been described as “common.” However, it was not until recently that the prevalence of personality disorders in the general population of the United States became known. Approximately 10% of adults in the United States and between 6.1% and 13.4% of adults in other countries have a personality disorder as outlined by the DSM-5 (Sansone & Sansone, 2011). The most common personality disorder can vary from culture to culture. For instance, obsessive-compulsive personality disorder is the most common personality disorder in the United States and Australia (Sansone & Sansone, 2011). Yet, avoidant personality disorder is the most frequent in Norway; and schizotypal personality disorder is the most common in Iceland (Sansone & Sansone, 2011).

An association between personality disorders and co-occurring major mental disorders has been identified by research (Friborg et al., 2014). Personality disorders have also been linked to alcohol use and misuse. Research has shown that individuals with personality disorders are more likely to use and misuse alcohol (Maclean & French, 2014). In addition, borderline, antisocial, narcissistic, and histrionic personality disorders have the strongest association with alcohol use and misuse (Maclean & French, 2014). According to the DSM-5, antisocial personality disorder is more prevalent in samples influenced by poverty or sociocultural factors.

DIAGNOSTIC CRITERIA

Although characteristics of personality disorders may describe traits that anyone may exhibit in varying amounts, a genuine personality disorder must meet specific criteria. To be diagnosed with a personality disorder, a person must demonstrate a persisting pattern that differs from the cultural norms of the individual. Those patterns are rigid and pervasive across a wide range of situations and leads to distress or impairment of functioning (APA, 2013). This pattern of behavior cannot be explained by another mental disorder or attributed to the effects of substance use or a medical condition (APA, 2013).

The DSM-5 describes three different clusters of personality disorders based on characteristic features. Cluster A personality disorders include individuals who appear odd or eccentric. Cluster B personality disorders include individuals who appear dramatic, emotional, or erratic. Cluster C personality disorders include individuals who appear anxious or fearful (APA, 2013).

Paranoid Personality Disorder

The characteristic behaviors and symptoms of a paranoid personality disorder include a persistent mistrust and suspiciousness of others. Individuals tend to believe that others are out to harm, take advantage of, or betray them. They feel this way despite having no evidence to support their claims. They are worried with unsubstantiated doubts about the sincerity of their colleagues and friends. They fear that the information they share will be used against them. They misinterpret benign comments as being mean or hostile and are fast to respond with anger (APA, 2013).

Schizoid Personality Disorder

Characteristic behaviors and symptoms of a schizoid personality disorder include a persistent pattern of aloofness from relationships and decreased emotional expression. Individuals desire solitary activities and do not want or like close relationships including family relationships. They do not have many friends or pleasures in life. They appear to lack any desire for sexual experiences and appear emotionally distant and detached. They are apathetic when they receive praise or criticism from others (APA, 2013).

Schizotypal Personality Disorder

Characteristic behaviors and symptoms of a schizotypal personality disorder include a persistent pattern involving difficulty with relationships as evidenced by severe uneasiness with and decreased ability for intimate relationships. This results in a lack of close friends. Their behavior is strange, eccentric, or peculiar. These individuals misinterpret events as having special meaning for them. They tend to be superstitious and have odd beliefs or MAGICAL THINKING (belief that thoughts are all-powerful). They have unusual perceptions, bizarre thinking and speech, suspicious or paranoid ideation, and inappropriate or limited affect. They tend to have social anxiety and paranoid worries that persist despite familiarity (APA, 2013). When individuals with schizotypal personality disorder experience extreme stress, they may decompensate, become psychotic, and require hospitalization.

Antisocial Personality Disorder

Characteristic behaviors and symptoms of an antisocial personality disorder include a persistent pattern of not conforming to social norms. Individuals have a disregard for and violate the rights of others. They are dishonest as evidenced by frequent lying and deceiving others for personal gain or pleasure. They are impulsive, irritable, aggressive, reckless, irresponsible, and lack remorse (APA, 2013).

Individuals with childhood or adolescent deviant behavior or conduct disorders often go on to develop a permanent antisocial psychopathology. A large percentage of individuals diagnosed with antisocial personality disorder have recognizable behaviors before adulthood. These behaviors include difficulty with authority figures, legal troubles, cruelty to animals, fire setting, and disregard for authority. Unfortunately, individuals diagnosed with antisocial personality disorder do not remiss as readily as some of the other personality disorders. These individuals frequently end up in prison, which only reinforces the behavior.

Borderline Personality Disorder

Characteristic behaviors and symptoms of a borderline personality disorder include a persistent pattern of volatile interactions with others. Individuals are extremely impulsive and make frenzied attempts to prevent genuine or imagined abandonment. They have intense, unstable relationships that swing between extremes of admiration and deprecation. They engage in frequent repeated self-mutilating behavior or suicidal behavior or threats. In addition, they can express feelings of emptiness, intense anger, and brief, stress-related paranoid thoughts or dissociative symptoms (APA, 2013). SPLITTING is a common clinical manifestation in which individuals tend to view reality in polarized categories. They alternately idealize and devalue others rather than see people as a mixture of good and bad traits. In a matter of minutes, the person can go from loving an individual to hating that person (APA, 2013).

Histrionic Personality Disorder

Characteristic behaviors and symptoms of a histrionic personality disorder include a persistent pattern of extreme attention-seeking behavior. Individuals are uneasy in situations unless they are the center of attention. They are often provocative and use their physical appearance to draw attention to themselves. They are very dramatic and theatrical. They are impressionable and easily swayed by others. They tend to think relationships are closer than they really are (APA, 2013).

Narcissistic Personality Disorder

Characteristic behaviors and symptoms of a narcissistic personality disorder include a persistent pattern of pretentiousness and need for approval and high regard. Individuals have a sense of entitlement and take advantage of other people for their own personal gain. They have no empathy and believe that people are jealous of them. They have an exaggerated sense of self-worth. They are fixated on fantasies of extreme accomplishment, authority, intelligence, attractiveness, or perfect romantic involvement (APA, 2013).

When narcissistic individuals feel degraded by another person, they experience what is termed a narcissistic injury. In response to that injury, they will fly into a “narcissist rage” in which they may scream, distort the facts, and make groundless accusations to decrease the self-worth of others and thus make themselves feel more powerful (APA, 2013). The rage impairs their judgment and thinking.

Avoidant Personality Disorder

Characteristic behaviors and symptoms of an avoidant personality disorder include a persistent pattern of shyness, feelings of incompetence, and extreme sensitivity to criticism. Individuals will avoid situations that involve interaction with other people due to fear of negative evaluation and rejection. They are different from individuals diagnosed with schizoid and schizotypal personality disorders in that the latter would desire to form relationships. These individuals tend not to get involved with others except if they are certain they will be accepted. Individuals diagnosed with avoidant personality have difficulty forming intimate relationships. They do not like to talk about themselves and withhold their thoughts and feelings for fear of being ridiculed. In addition, these individuals think of themselves as unattractive, inferior, and useless in comparison with others. They do not like to take risks or join in new activities for fear of embarrassment. Finally, they tend to be preoccupied with thoughts of being disparaged and unwanted (APA, 2013).

Dependent Personality Disorder

Characteristic behaviors and symptoms of a dependent personality disorder include a persistent and extreme desire to have someone take care of them. Individuals tend to exhibit subservient and clinging behavior and to have fears of abandonment. They have difficulty making decisions and require lots of encouragement and guidance from others. Individuals diagnosed with dependent personality disorder want others to assume responsibility for their lives. These people do not like to disagree with others for fear of not being liked. They lack the self-confidence needed to start projects or do things on their own. In addition, these individuals fear that they will not be able to care for themselves, which leads to feelings of uneasiness and helplessness. They are extremely worried about having to take care of themselves. Should their relationship end, they will immediately look for another relationship that will offer reassurance and support (APA, 2013).

Obsessive-Compulsive Personality Disorder

Characteristic behaviors and symptoms of an obsessive-compulsive personality disorder include a persistent pattern of concern and worry over the orderliness, perfectionism, control, and details of an activity so much so that the aim of the task is lost. The need for perfectionism prevents the completion of the tasks at hand. Individuals tend to forego leisure activities and relationships because they are extremely focused on work and productivity. They tend to be painstakingly meticulous, conscientious, and rigid regarding issues of principles and values. These individuals do not like to throw away meaningless, valueless objects. They tend to save money for misfortunes that might happen later in their lives. Individuals are stubborn and rigid and do not like to delegate tasks to others unless they can guarantee that they will do it to their liking (APA, 2013). Individuals with obsessive-compulsive personality disorders usually require treatment due to complaints of anxiety and may be diagnosed with a concurrent anxiety disorder.

Other Personality Disorders

The DSM-5 has developed this category to cover three additional classifications for individuals who do not meet the criteria for any of the specific personality disorders already noted. These three classifications are personality change due to another medical condition, other specified personality disorder, and unspecified personality disorder.

Malingering

Although not a personality disorder, malingering is mentioned here as a condition that is associated with psychiatric disorders. Malingering can be defined as the deliberate creation of fake or overstated symptoms, motivated by incentives such as evading work, gaining compensation, avoiding criminal prosecution, or attaining medications (Mason, Cardell, & Armstrong, 2013). Malingering can be associated with antisocial behavior. However, of note, malingering occurs more frequently in the public setting than in the forensic setting (Mason et al., 2013).

ETIOLOGY

There is no one commonly accepted understanding about the etiology of personality disorders. Most likely, it is a multifaceted process involving both biological and environmental factors. Psychodynamic and biological influences are presented here.

Psychodynamic Theories

According to psychodynamic theory, a lack of psychosexual development and inability to attain object constancy can lead to a personality disorder. Historically, it was thought that personality disorders arise when an individual does not successfully advance through phases of psychosexual development. For example, fixation in the oral phase was believed to cause a demanding and dependent personality such as a dependent personality disorder. Fixation in the anal phase fixation was believed to cause an obsessive, rigid, aloof personality such as an obsessive-compulsive personality disorder. Fixation in the phallic phase was thought to result in a histrionic personality in that the individual was shallow and unable to engage in meaningful relationships.

Evidence supports five psychosocial risk factors for borderline personality disorder (Keinanen, Johnson, Richards, & Courtney, 2012). They are childhood abuse/trauma, unfavorable parenting, hostile object relations, insecure attachment relations, and limited symbolization–reflectiveness capacity (Keinanen et al., 2012).

Biological Theories

In the past, personality disorders were thought to be due to primarily environmental issues including factors such as dysfunctional family life, erratic discipline by authority figures, antisocial behavior of the parents, and lack of parental involvement. However, researchers are beginning to examine biomarkers. Although currently no biomarkers have been identified for personality disorders, or any major mental disorder for that matter, possible biomarkers for personality disorders may be detected by irregularities in gene sequences, neurotransmission, neuropsychological measures, and neuroimaging (Paris, 2015; Perez-Rodriguez, Zaluda, & New, 2013; Reichborn-Kjennerud, 2010). More specifically, it is probable that the heritability of personality disorders is related to a large number of interacting genes (Paris, 2015). Data support a relationship between irregular serotonin activity and impulsive characteristics in patients who have personality disorders (Paris, 2015). Neuropsychological testing supports that impulsive personality disorders (i.e., antisocial and borderline personality disorders) are related to a failure of the prefrontal cortex to inhibit impulses from the amygdala and limbic system (Paris, 2015; Raine, 2013). Neuroimaging research confirms reduced activity in the prefrontal cortex as well as decreased volume in the hippocampus and amygdala in patients diagnosed with borderline personality disorder (Mauchnik & Schmahl, 2010; Paris, 2015; Ruocco, Amirthavasagam, & Zakzanis, 2012). And, neuroimaging studies support a malfunction of prefrontal inhibition in patients diagnosed with antisocial personality disorder as well as atypical neuroconnectivity (Paris, 2015; Raine, 2013).

TREATMENT OPTIONS

Until fairly recently, many in the psychology field did not feel that treatment would help individuals with personality disorders. Just as the personality traits take years to develop, so too can maladaptive personality traits and personality disorders take years to treat. There is no short-term treatment that can cure personality disorders. Many different treatment options are available such as individual, group, or family psychotherapy, cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and psychopharmacology. Treatment is typically long term and aimed at alleviating symptoms of self-destructive ways.

Psychotherapy

Individual psychotherapy with a trained psychiatric-mental health professional such as an advanced practice psychiatric-mental health nurse is intended to help individuals see the unconscious conflicts that are leading to their symptoms (Dimaggio, 2014; Levey & Scala, 2015). It is aimed at helping the individual become more flexible, thereby decreasing the behaviors interfering with everyday life. Group therapy may also be used as it uses group dynamics and peer communication to foster an improved understanding and increased social skills. Family therapy is intended to assist families to function in a more affirming and helpful manner. This is accomplished by looking at patterns of verbal and nonverbal interactions and offering support and education. (See Chapter 9 for a more in-depth discussion of group and family therapy.)

Cognitive Behavioral Therapy

Research studies support CBT as a useful treatment modality for reducing symptoms and improving functional outcomes with patients diagnosed with personality disorders (Matusiewicz, Hopwood, Banducci, & Lejuez, 2010). CBT is designed to improve an individual’s mood and behavior by focusing on distorted patterns of thinking. The goal is to assist patients in altering their usual thoughts that automatically arise and play a role in their dysfunctional thinking. This therapy helps the individual understand that thoughts produce feelings and moods that can affect behavior. CBT helps the individual recognize the underlying thoughts that have resulted in some disruptive behavior. The emphasis is in changing the patient’s current thinking without attempting to determine how the patient developed his or her thinking patterns. The patient learns to substitute this thinking with thoughts that will lead to more appropriate behaviors and emotions (Levey & Scala, 2015).

Dialectical Behavior Therapy

DIALECTICAL BEHAVIOR THERAPY (DBT) is a CBT aimed at treating individuals who have been diagnosed with borderline personality disorder or individuals who deliberately partake in self-destructive behavior or have suicidal thoughts (Burroughs & Somerville, 2013; Feigenbaum, 2010; Johnson, Gentile, & Correll, 2010). DBT helps individuals regulate their emotions and take responsibility for their own behavior and problems. It teaches an individual how to cope with conflict, negative feelings, and impulsivity, thereby enhancing the patient’s capabilities and improving his or her motivation, which leads to a decrease in dysfunctional behavior.

Psychopharmacology

Psychopharmacology is also used to treat specific symptoms of personality disorders (Crawford et al., 2011). The American Psychiatric Association’s practice guidelines for the treatment of borderline personality disorders (APA, 2005) recommend the use of psychotherapy in conjunction with symptom-targeted psychopharmacology. Psychopharmacology treats the symptoms such as anxiety and altered perceptions, not the personality traits themselves. A partial list of common medications that may be used is found in Drug Summary 14-1. Although additional research is necessary to help identify effective pharmacological strategies for treating personality disorders, the following classifications of medication are often used (D’Silva et al., 2013; Inman, 2013):

Benzodiazepines are not the medication of choice to treat symptoms of a personality disorder. Benzodiazepine use should be minimized due to a high potential for abuse and dependency in this population.

APPLYING THE NURSING PROCESS FROM AN INTERPERSONAL PERSPECTIVE

Nurses can expect to provide care for individuals with personality disorders in all specialty areas and practice settings. In general, nurses working on inpatient psychiatric units will often encounter patients with antisocial, borderline, and schizotypal type personality disorders as a diagnosis. Evidence-Based Practice 14-1 summarizes a qualitative study about how organizations can improve the delivery of services to individuals with personality disorders (Fanaian, Lewis, & Grenyer, 2013).

Recognizing the differences between normal difficulties and personality disorders can be crucial to the nurse’s decision-making process in navigating the interpersonal process. Because of the struggles these individuals have in establishing and maintaining healthy relationships, developing therapeutic interpersonal relationships with them can be challenging. Nurses will find their relationship skills challenged, boundaries tested, and patience tried. Despite this, patient-centered care is essential as nurses need to partner with patients and their families to ensure the best possible patient experience and improved outcomes. Plan of Care 14-1 provides an example of a patient with personality disorder.

Strategies for Optimal Assessment: Therapeutic Use of Self and Self-Awareness

When beginning a therapeutic relationship with any patient, the development of the nurse’s self-awareness is essential (Bowen & Mason, 2012; Johnson et al., 2010; McNee, Donoghue, & Coppola, 2014; White & Byrt, 2013; Wright & Jones, 2012). This knowledge of one’s own values and attitudes is especially important when working with individuals with personality disorders. The psychiatric-mental health nurse will be challenged because these patients have trouble building and sustaining healthy relationships (Bowen & Mason, 2012; Johnson et al., 2010; McNee et al., 2014; White & Byrt, 2013; Wright & Jones, 2012). The nurse may feel that he or she lacks the skills to interact effectively with the patient, leading to feelings of inadequacy and failure. The nurse’s self-awareness and self-reflection of knowledge, values, and attitudes can significantly impact his or her behaviors and actions. Applying the therapeutic use of self allows the psychiatric-mental health nurse to evaluate and reflect on the consequences of his or her values, attitudes, and practice in working with patients. Such awareness will help the nurse develop insight into his or her own behavior (Bowen & Mason, 2012; Johnson et al., 2010; McNee et al., 2014; White & Byrt, 2013; Wright & Jones, 2012).

The nurse and the patient meet as strangers and begin a relationship that involves getting to know one another to promote the development of trust (McNee et al., 2014; Peplau, 1991). After the nurse introduces himself or herself and describes the unit and services, the nurse assesses the patient to gain an appreciation of the situation (Peplau, 1991).

Patients with personality disorders can be challenging because they can exhibit intense feelings and may evoke strong emotions in the nurse. Consumer Perspective 14-1 provides a personal perspective of what it is like to have a borderline personality disorder. Maintain self-awareness and be alert to personal signals of frustration that the patient’s behaviors can elicit. Be cognizant of personal feelings and do not allow them to interfere with the care of the patient (Peplau, 1991; Wright & Jones, 2012). Nurses need to acknowledge and accept their own emotional responses. Avoid internalizing these feelings or taking them personally.

Environmental Management

Making the environment conducive to assessment is important to ensure that rapport and trust develop between the patient and the nurse and that the information collected is comprehensive and accurate. When meeting with the patient, allow for adequate interpersonal space during the assessment process. Patients with personality disorders often experience difficulties with boundaries. Therefore, it is essential for the nurse to establish boundaries at the outset (White & Byrt, 2013). Arrange to interview the patient in a comfortable, quiet, and safe environment that has minimal interruptions. Doing so prevents adding to the patient’s already odd, dramatic, or fearful behavior. Make certain that you do not sit too close to the patient as the patient may also have some concerns about personal space. In this regard, it is often useful to ask the patient about the desired distance in order to build trust in the relationship. Also, approach the person in a calm and reassuring manner and remain nonjudgmental and nonconfrontational. If the patient’s behavior starts to escalate, then offer him or her a break.

Mental health assessments often include questions that may be uncomfortable for persons with personality disorders, so priority setting is important. Brief, focused assessments may be necessary. In addition, be consistent and follow through on comments, suggestions, or promises. Doing so will help to foster a sense of trust. In addition, be alert for signs of agitation or fear that can impact the patient’s safety.

 

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