Mental Health Nursing

Care of clients with personality disorders

Learning Outcomes
After this lecture, you are able to:
describe the continuum of adaptive and maladaptive social responses.
identify behaviours associated with social responses.
describe the characteristics of personality disorders and manipulation
formulate nursing diagnoses related to personality disorders.
Personality
Endure patterns of perceiving, feeling, thinking about, and relating to oneself
and the environment
◦ E.g. Outgoing person
◦ E.g. a friend of yours is highly emotional

Individuals with satisfaction in life

◦ Have healthy interpersonal relationship
◦ Experiencing closeness (/intimacy) with others while keeping their own separate identities
◦ be sensitive to the other person’s needs,
◦ Open communication of feelings
◦ Acceptance of the other person as valued and separate
◦ Empathic understanding
Theories of personality
Big Five model
A dimensional perspective that posits that everyone’s personality
 Social responses Theory of Human Relatedness
Relationships with others range from casual to
intimacy
Intimate and interdependent relationships provide
security and necessary to cope with the demands of
daily life
Relatedness: must often to used to describe
interpersonal attachment
◦ Emotional, perceptual and cognitive capacity of a person to
become involved with another person (social responses)
Hagerty et al., 1993, pp.2
◦ Involvement with persons, objects (e.g. plants, dolls),
groups or environment
 Theory of Human
Relatedness
Enmeshment
◦ involved in relationship but is unable to maintain a unique sense of self and
ego boundaries
◦ Discomfort and anxiety e.g. fused family system (unable to communicate)

Parallelism
◦ lack of involvement that is comfortable and acceptable to the individual
◦ Clinician views as isolative, lonely clients
Example
Disconnectedness Parallelism : spouse (not wishing to
think about his/ her spouse but well
◦ lack of involvement that is not satisfactory to person
connected with the environment, by
◦ Psychological pain, loneliness, social isolation spending a weekend alone at the
beach, comfort from the sun and
Connectedness sand.
◦ person is actively involved in satisfying relationships, including high levels of
belonging, mutuality, reciprocity and interdependence
Social responses
Relatedness
◦ A behavioural system
◦ Rooted in early attachment behaviours and patterns
◦ Can be experienced as comfortable and anxiety-reducing

To become intimately with another person

◦ May frightening to reveal private thoughts and feelings
◦ Because of past bad experience
◦ -> Uncomfortable and anxiety-producing

People who have extreme difficulty in relating intimately to others may have
behaviours -> characteristic of a personality disorder
Adaptative vs maladaptive
responses
Adaptative vs maladaptive responses
◦ Relate to the sense of belonging: group/ integral to the system/environment
◦ Adaptative: autonomy, mutuality and interdependence
◦ At midpoint: experience loneliness, withdrawal and dependence
◦ Maladaptive: behaviours of manipulation, impulsiveness and narcissism
◦ Problematic relationships in the family, on the job and in the social arena.

(Stuart,2013, pp.384)
Personality disorders
Personality disorder:
◦ A set of patterns or traits that hinder a person’s ability to maintain meaningful relationships,
feel fulfilled, and enjoy life

beings in adolescence or early adulthood

◦ Lead to distress/impairment
Attitudes toward self, others, and the world expressed in everything a person thinks,
feels, and does
“Disorder”: a significant and persistent impairment in their interpersonal relationships
and other aspects of functioning
Predisposing Factors
- Temperament (inherited, character) ; Personality is learned and is composed of temperament
Biological Factors
◦ Inherited biological vulnerability
◦ Antisocial personality disorder: brain dysfunction: a low threshold of excitability in the limbic
◦ Low levels of serotonin / toxic chemical substances

Developmental Factors
◦ Reported being emotionally, physically, or sexually abused (25% borderline PD had a diagnosis of PTSD)
◦ Abuse, neglect and absence of an early emotional attachment-> antisocial PD

Sociocultural Factors
Distant family relationship
immigration
Precipitation Stressors
- Maladaptive social responses are the result of experiences that have had a negative influence
on the person’s emotional growth
- a series of life events predisposes a person to have relationship problems
- (social) instability in family, e.g. divorces
- (psychological) high anxiety levels -> impaired ability to relate to others
◦ Borderline PD: incapacitating level of anxiety in response to life events that represent increased
autonomy and separation (e.g. high school graduation, going away to camp, marriage, employment)
◦ Narcissistic PD tends to experience high anxiety, causing relationship difficulties
◦ Fragile self-esteem

- loss of significant others, loss of a job

Prevalence of Personality
Disorders
A global systematic review and meta-analysis
- 46 studies, from 1980 to 2018, 21 different countries
- prevalence of any personality disorder: 7.8%
- greater in high-income countries (9.6%) vs low- and middle-income countries
(4.3%)
- 4.4-21.5% in community populations as the Western world
- Global rates of Cluster A: 3.8%; Cluster B: 2.8% and Cluster C: 5.0%
Comorbid: mood disorders, suicide, substance misuse (e.g. alcohol)
Treatment
-It is impossible to completely change someone’s personality

-Possible to help mood regulation, increase quality of life, reduce distress

-Decreases in severity as a person ages, mainly because of corrective life experiences

Three features of personality
disorders
1. inflexible and maladaptive approach to relationships and environment

2. individual’s needs, perceptions, and behaviour tend to foster cycles that

promote unhelpful patterns and provoke negative reactions from others.

3. individual’s coping skills are unstable and fragile, and there is a lack of
resilience when faced with stressful situations.
Manipulation
➢ Manipulation: is a behaviour in which people treat others as objects
and form relationships that center around control issues.
➢ Manipulative patients usually have little motivation to change because
manipulative behaviour often has rewards for them
➢ They are getting what they want
➢ Manipulators are goal-oriented or self-oriented, not other-oriented.
➢ Skills at giving the impression that they care about others
➢ Unaware of a lack of relatedness
➢ Assumes that interpersonal relationships are formed to take advantage of others
➢ Difficult / cannot imagine an intimate, sharing relationship
➢ Believe in maintaining control at all times to avoid being controlled.
Three Groups of PD
Cluster A Cluster B Cluster C
• An odd / • Erratic, dramatic/ • An anxious or
eccentric nature emotional nature fearful nature
• Paranoid • Antisocial • Avoidant
• Schizoid • Borderline • Dependent
• Schizotypal • Histrionic • Obsessive-
• Narcissistic compulsive
 Paranoid Personality Disorder
DSM-5-TR Criteria

Pervasive distrust and suspiciousness of others, leading to the interpretation of their

motives as malevolent, beginning by early adulthood and evident in various contexts, as
indicated by 4 (or more) of the following:
• Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them.
• Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or
associates.
• Is reluctant to confide in others because of unwarranted fear that the information will be used
maliciously against them.
• Reads hidden demeaning or threatening meanings into benign remarks or events.
• Bears grudges persistently, being unforgiving of insults, injuries, or slights.
• Perceives attacks on their character or reputation that are not apparent to others and quickly
reacts angrily or counterattacks.
• Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.
• Does not occur exclusively during the course of schizophrenia, bipolar disorder, depressive
disorder with psychotic features, or another psychotic disorder, and is not attributable to the
physiological effects of another medical condition.

Paranoid Personality Disorder - StatPearls - NCBI Bookshelf

 Schizoid Personality Disorder
DSM-5-TR Criteria
A pervasive pattern of isolation, limited social relationships, and restricted emotional expression is evident in
interpersonal settings. This behavioural pattern begins in early adulthood and persists across various contexts,
manifesting in at least 4 of the following:
• Limited or no enjoyment in close relationships, including with family.
• Nearly always chooses solitary activities.
• Minimal interest in sexual experiences with others.
• Finds pleasure in a few activities.
• Limited close friendships or relationships other than first-degree relatives.
• Indifference to praise and criticism.
• Displays emotional coldness, detachment, and affective flattening.
• These symptoms do not occur during episodes of schizophrenia, bipolar disorder, or a depressive episode
with psychotic features. They are not better explained by autism spectrum disorder or another medical
condition

Schizoid Personality Disorder - StatPearls - NCBI Bookshelf

 Schizotypal Personality Disorder
DSM-5-TR Criteria
A pervasive pattern of social and interpersonal deficits characterized by acute discomfort with, and reduced
capacity for, close relationships, as well as cognitive or perceptual distortions and eccentricities of behavior,
typically beginning in early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the
following:
• Ideas of reference (excluding delusions of reference).
• Odd beliefs or magical thinking that influence behavior and are inconsistent with subcultural norms,
• such as superstitious, belief in clairvoyance, telepathy, or sixth sense; in children and adolescents, bizarre fantasies or preoccupations.
• Unusual perceptual experiences, including bodily illusions.
• Odd thinking and speech, such as vague, circumstantial, metaphorical, overelaborate, or stereotyped.
• Suspiciousness or paranoid ideation.
• Inappropriate or constricted affect.
• Behavior or appearance that is odd, eccentric, or peculiar.
• Lack of close friends or confidants other than first-degree relatives.
• Excessive social anxiety does not diminish with familiarity and tends to be associated with paranoid fears
rather than negative judgments about self.
◦ Does not occur exclusively during the course of schizophrenia, a bipolar disorder or
depressive disorder with psychotic characteristics, another psychotic disorder, or autism
spectrum disorder.

Schizotypal Personality Disorder - StatPearls - NCBI Bookshelf

 Antisocial Personality Disorder
DSM-5-TR Criteria
[Link] presence of a pervasive pattern of disregard for and violation of the rights of others. This behaviour
begins by age 15 and is present in various contexts. Clinical features include ≥3 of the following:
1. Failure to conform to social norms concerning lawful behaviours, such as performing acts that are
grounds for arrest.
2. Deceitfulness, repeated lying, use of aliases, or conning others for pleasure or personal profit.
3. Impulsivity or failure to plan.
4. Irritability and aggressiveness, often with physical fights or assaults.
5. Reckless disregard for the safety of self or others.
6. Consistent irresponsibility, failure to sustain consistent work behaviour, or honour monetary obligations.
7. Lack of remorse, indifference to or rationalising having hurt, mistreated, or stolen from another person.
[Link] individual is at least age 18.
[Link] is evidence of conduct disorder with onset before age 15.
[Link] occurrence of antisocial behaviour is not exclusively during the course of schizophrenia or
bipolar disorder.

Antisocial Personality Disorder - StatPearls - NCBI Bookshelf

 Borderline Personality Disorder
DSM-5-TR Criteria
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by
early adulthood and present in a variety of contexts, as indicated by 5 or more of the following:
1. Frantic efforts to avoid real or imagined abandonment
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of
idealization and devaluation
3. Identity disturbance: markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least 2 areas that are potentially self-damaging, for example, spending, substance abuse, reckless driving,
sex, or binge eating
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behabiour
6. Affective instability due to a marked reactivity of mood, for example, intense episodic dysphoria, anxiety, or irritability,
usually lasting a few hours and rarely more than a few
days
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger, for example, frequent displays of temper, constant anger, or
recurrent physical fights
9. Transient, stress-related paranoid ideation or severe dissociative symptoms

Borderline Personality Disorder - StatPearls - NCBI Bookshelf

Histrionic Personality Disorder
DSM-5-TR Criteria

A pervasive pattern of excessive emotional behavior and attention-seeking begins in early

adulthood and persists across different contexts. Clinical features include at least 5 of the
following behaviors:
• Uncomfortable when not the center of attention
• Interactions with others are overly sexual, inappropriate, or provocative
• Rapidly shifting and shallow emotions
• Consistently utilizes physical appearance to attract attention
• Speech that is impressionistic, vague, and lacks detail
• An exaggerated expression of emotion that is theatrical and self-dramatized
• Easily influenced by others or circumstances
• Perception of relationships as more intimate than they are
 Narcissistic Personality Disorder
DSM-5-TR Criteria

In interpersonal settings, there is a pervasive pattern of grandiosity, need for admiration,

and lack of empathy. This pattern of behaviours onsets in early adulthood and persists
through various contexts. Clinical features include at least 5 of the following:
• Having a grandiose sense of self-importance, such as exaggerating achievements and talents,
expecting to be recognised as superior even without commensurate achievements
• Preoccupation with fantasies of success, power, beauty, and idealisation
• Belief in being "special" and that they can only be understood by or associated with other
high-status people (or institutions)
• Demanding excessive admiration
• Sense of entitlement
• Exploitation behaviors
• Lack of empathy
• Envy towards others or belief that others are envious of them
• Arrogant, haughty behaviours and attitudes

Narcissistic Personality Disorder - StatPearls - NCBI Bookshelf

 Avoidant Personality Disorder
DSM-5-TR Criteria

Meeting the DSM-5-TR diagnostic criteria for AVPD requires the presence of a pervasive pattern of social inhibition,
feelings of inadequacy, and hypersensitivity to negative evaluation, beginning in early adulthood and present in various
contexts. The pattern must be persistent and cause significant distress or impairment in social, occupational, or other
important areas of functioning. Clinical features include at least four of the following:.
1. Avoidance of social, interpersonal, and occupational activities that involve frequent contact due to an underlying fear
of criticism, disapproval, or rejection
2. Unwillingness to become involved with new relationships unless there is a certainty of being liked.
3. Restraint in intimate relationships due to a fear of being ridiculed or shamed.
4. Preoccupation with criticism and rejection.
5. Inhibition in new interpersonal situations due to feelings of inadequacy.
6. Low self-confidence with the belief that they are inherently inferior or unappealing to others.
7. Reluctance to take personal risks or engage in activities that can result in embarrassment or perceived failure.

Avoidant Personality Disorder - StatPearls - NCBI Bookshelf

 Dependent Personality Disorder
DSM-5-TR Criteria
A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of
separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the
following:
[Link] difficulty making everyday decisions without excessive advice and reassurance from others.
[Link] others to assume responsibility for most major areas of his or her life.
[Link] difficulty expressing disagreement with others because of fear of loss of support or approval. (Note: Do not include
realistic fears of retribution.)
[Link] difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or
abilities rather than a lack of motivation or energy).
[Link] to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do unpleasant
things.
[Link] uncomfortable or helpless when alone because of exaggerated fears of being unable to care for oneself.
[Link] seeks another relationship as a source of care and support when a close relationship ends.
[Link] unrealistically preoccupied with fears of being left to care for himself or herself.

Dependent Personality Disorder - StatPearls - NCBI Bookshelf

 Obsessive-
Compulsive Personality Disorder
DSM-5-TR Criteria
Moderate or severe impairment in personality functioning, manifested by characteristic difficulties in 2 or more
of the following areas:
• Identity: The sense of self is derived predominantly from work or productivity; there is a constricted experience of strong
emotions.
• Self-direction: There are difficulties completing tasks and realizing goals associated with rigid and unreasonably high and
inflexible internal standards of behavior; individuals are overly conscientious and have moralistic attitudes.
• Empathy: There is difficulty understanding and appreciating the ideas, feelings, or behaviors of others.
• Intimacy: Relationships are seen as secondary to work and productivity, and interpersonal relationships are negatively
affected by rigidity and stubbornness.

The patient must exhibit rigid perfectionism, defined as a demand for perfection and flawlessness in all tasks
resulting in missed deadlines; a pervasive belief in one correct method; the reluctance to adopt the views of
others; and a focus on detail and order. In addition to rigid perfectionism, the patient must exhibit 2 of the
following 3 traits:
• Perseveration, characterized as persistence at tasks long after the behavior has ceased to be functional or practical.
• Intimacy avoidance, characterized by avoiding close or romantic relationships, interpersonal attachments, and intimate
sexual relationships.
• Restricted affectivity, exhibited as demonstrating little reaction to emotionally arousing situations, a constricted emotional
experience and expression, and indifference or coldness.

Obsessive-Compulsive Personality Disorder - StatPearls - NCBI Bookshelf

Possible Nursing Diagnoses
➢ Defensive coping
➢ Chronic low self-esteem
➢ Risk for self-mutilation
➢ Impaired social interaction
➢ Risk for self-directed violence
➢ Risk for other-directed violence
Nursing interventions
Same as clients with depression, anxiety, alcoholism or difficulties in work or personal relationships
PDs are often seen as difficult to treat and poorly understood
Often is professional bias or stigma against the diagnosis and those who suffer from it
Treatment direction: collaborate with family, psychoeducation, and medication for depression or
anxiety
- be aware of abnormal therapeutic relationship
◦ Transference
◦ (unconscious response patient > nurse)
◦ intense emotional attachment or rejection derived from feelings about earlier personal relationship
◦ Inappropriate intensity of the patient’s response: hostile transference/ dependent transference
◦ Counter-transference
◦ (nurse’s specific emotional response to patients)
◦ Feeling excessive sympathy, impatience, anger or contempt
Nursing interventions
- Prevention of self-destructive, self-mutilating, or suicidal behaviour
- Establish a therapeutic relationship
- Provide a structured environment
- Facilitate adaptive change in behaviour
- implement a clear structure with rules that are fair, firm, and consistently enforced.
- provide an experienced, consistent staff
- Establish control with no option to escape involvement
- provide support while the patient learns to experience painful feelings and try out new behavioural
responses.
- manipulative patients should be held responsible for their behaviour
Nursing interventions
- focus on mobilizing strengths to enhance self-esteem
- use adaptive defenses and positive coping skills
- journal writing can help patients to identify their thoughts and feelings
- behaviour strategies: social skills training, anger management
- mood: cognitive behavioural therapy
Expected outcomes
Short-term goals
- the patient will use verbal communication as an alternative to acting out.
- the patient will verbally identify angry feelings when they occur during a one-to-one
interaction.
Long-term goals
The patient will obtain maximum interpersonal satisfaction by establishing and maintaining self-
enhancing relationships with others