Personality Disorders

Subtypes of personality disorders include antisocial, histrionic, narcissistic, avoidant, and dependent personalities. A personality disorder is a syndrome in which the person’s inner difficulties are revealed through general behaviors and by a pattern of living that seeks immediate gratification of impulses and instinctual needs without regard to society’s laws, mores, and customs and without censorship of personal conscience.

Borderline personality disorder is a subtype in which the client is unstable in many areas: she or he has unstable but intense interpersonal relationships, impulsive and unpredictable behavior, wide mood swings, chronic feelings of boredom or emptiness, intolerance of being alone, and uncertainty about identity, and is physically self-damaging.

Concepts and principles related to antisocial personality disorders:
1. One defense against severe anxiety is “acting out,” or dealing with distressful feelings or issues through action.
2. Faulty or arrested emotional development in preoedipal period has interfered with development of adequate social control or superego.
3. Because there is a malfunctioning or weakened superego, there is little internal demand and therefore no tension between ego and superego to evoke guilt feelings.
4. The defect is not intellectual; person shows lack of moral responsibility, inability to control emotions and impulses, and deficiency in normal feeling responses.
5. “Pleasure principle” is dominant.
6. Initial stage of treatment is most crucial; treatment situation is very threatening because it mobilizes client’s anxiety, and client ends treatment abruptly. Key underlying emotion: fear of closeness, with threat of exploitation, control, and abandonment.
Assessment of antisocial personality disorders:
1. Onset before age 15.
2. History of behavior that conflicts with society: truancy, expulsion, or suspension from school for misconduct; delinquency, thefts, vandalism, running away from home; persistent lying; repeated substance abuse; initiating fights; chronic violation of rules at home or school; school grades below IQ level.
3. Inability to sustain consistent work behavior (e.g., frequent job changes or absenteeism).
4. Lack of ability to function as responsible parent (evidence of child’s malnutrition or illness due to lack of minimal hygiene standards; failure to obtain medical care for seriously ill child; failure to arrange for caretaker when parent is away from home).
5. Failure to accept social norms with respect to lawful behavior (e.g., thefts, multiple arrests).
6. Inability to maintain enduring intimate relationship (e.g., multiple relations, desertion, multiple divorces); lack of respect or loyalty.
7. Irritability and aggressiveness (spouse, child abuse; repeated physical fights).
8. Failure to honor financial obligations.
9. Failure to plan ahead.
10. Disregard for truth (lying, “conning" others for personal gain).
11. Recklessness (driving while intoxicated, recurrent speeding).
12. Violating rights of others.
13. Does not appear to profit from experience; repeats same punishable or antisocial behavior; usually does not feel guilt or depression.
14. Exhibits poor judgment; may have intellectual, but not emotional, insight to guide judgments. Inadequate problem solving and reality testing.
15. Uses manipulative behavior patterns in treatment setting.
  1. Demands and controls.
  2. Pressures and coerces, threatens.
  3. Violates rules, routines, procedures.
  4. Requests special privileges.
  5. Betrays confidences and lies.
  6. Ingratiates.
  7. Monopolizes conversation.
Analysis/nursing diagnosis:
1. Ineffective individual coping related to:
  1. Inability to tolerate frustration (altered conduct/impulse processes).
  2. Verbal, nonverbal manipulation.
  3. Destructive behavior toward self (e.g., in borderline personality disorder) or others.
  4. Cognitive distortions (e.g., overuse of denial, projection, rationalization, intellectualization, persecutory thoughts).
  5. Inability to learn from experience.
2. Personal identity disturbance related to:
  1. Self-esteem disturbance as evidenced by grandiosity, depression, extreme mood changes.
  2. Lack of: responsibility, accountability, commitment, tolerance of rejection.
  3. Distancing relationships.
3. Social intrusiveness related to fear of real or potential loss.
4. Noncompliance related to excess need for independence.
Nursing care plan/implementation in personality disorders:
1. Long-term goal: help person accept responsibility and consequences of own actions.
2. Short-term goal: minimize manipulation and acting out.
3. Set fair, firm, consistent limits and follow through on consequences of behavior; let client know what she or he can expect from staff and what the unit’s regulations are, as well as the consequences of violations. Be explicit.
4. Avoid letting staff be played against one another by a particular client; staff should present a unified approach.
5. Nurses should control their own feelings of anger and defensiveness aroused by any person’s manipulative behavior.
6. Change focus when client persists in raising inappropriate subjects (such as personal life of a nurse).
7. Encourage expression of feelings as an alternative to acting out.
8. Aid client in realizing and accepting responsibility for own actions and social responsibility to others.
9. Use group therapy as a means of peer control and multiple feedback about behavior.
10. Health teaching: teach family how to use behavior modification techniques to reward client’s acceptable behavior (e.g., when he or she accepts responsibility for own behavior, is responsive to rights of others, adheres to social and legal norms).
Evaluation/outcome criteria: less use of lying, blaming others for own behavior; more evidence of following rules; less impulsive, explosive behavior.