Personality disorders and the Five-Factor Model

• Personality disorders are the focus of this chapter, specifically in inpatient psychiatric settings and outpatient programs.
• It is important to note that treatment options and efficacy are greatly impacted by personality disorders.
• Interventions focus primarily on the nurse-patient relationship unique to each personality disorder

Personality

• Personality traits and characteristics make individuals unique and interesting
• Traits are exhibited through thoughts about themselves, others, and behaviors
• Though experience varies behaviors and cognition are persistent across humanity
• Personality can be dimensionalized because traits are evident across the diversity of humanity
• The five-factor model categorizes these as emotional stability, extroversion, agreeableness, conscientiousness, and openness

5 Factor Model

• Emotional stability is contrasted with negative affectivity or neuroticism which is associated with negative emotion and pessimism
• A person with excessive neuroticism has a high probability of having a mental illness
• Extroversion reflects the degree of positive emotion and optimism a person possesses
• Extroverted people favor interacting with others and are responsive to positive reinforcement
• Introverted individuals prefer a solitary existence with little social interaction and are less influenced by certain types of positive encouragement
• Agreeableness is an interpersonal trait
• People high in agreeableness are cooperative and easygoing
• People with low agreeableness are oppositional, easy to anger, and prone to contentious relationships
• Conscientiousness reflects the level of self-control and focus an individual has
• High conscientiousness manifests itself in an organized, goal-oriented approach to life
• People with low conscientiousness are impulsive, disorganized, and prefer immediate gratification
• Openness is associated with curiosity and imagination
• People with high openness are interested and engaged in a variety of intellectual and cultural pursuits
• Individuals with difficulties regulating their openness can exhibit psychoticism
• Personality traits are usually ego syntonic, meaning they are consistent and acceptable to one's sense of self
• Individuals with personality disorders have traits and habits that are rigidly fixed on one end of the five-factor model spectrum
• Personality's features become inflexible and dysfunctional
• Individuals with personality disorders exhibit lifelong, inflexible, dysfunctional patterns of relating and behaving
• The dysfunctional patterns and behaviors usually cause distress to others, but individuals with personality disorders might not find their behaviors distressing to themselves
• They become distressed because of other people's reactions or behaviors toward them, causing immense emotional pain and discomfort
• Patients seek treatment to help with depression, anxiety, somatic symptoms, alcohol and chemical dependency, and difficulties in work and personal relationships, not to change their personalities
• DSM-5 criteria for a personality disorder include experiences and behaviors that are very different from those that are usually expected in an individual's culture

DSM-5 General Personality Disorder Criteria

• An enduring pattern of inner experience and behavior deviates markedly from the individual's cultural background
• The pattern is manifested in two (or more) of the following areas: cognition, affectivity, interpersonal functioning, and impulse control.
• The enduring pattern is inflexible and pervasive across personal and social situations.
• The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The pattern is stable and of long duration, with its onset traceable back to adolescence or early adulthood.
• The enduring pattern isn't better explained as a manifestation or consequence of another mental disorder.
• The enduring pattern isn't attributable to the physiologic effects of a substance or medical condition.
• The DSM-5 model for personality disorders characterizes impairments across personality functioning and pathologic personality traits
• Personality functioning involves self-functioning and interpersonal functioning
• Self-functioning involves identity and self-direction, whereas interpersonal functioning includes empathy and intimacy
• Pathologic personality traits are organized into five domains: negative affectivity, detachment, antagonism, disinhibition, and psychoticism
• Regardless of the model used, personality disorders display an enduring pattern of dysfunction that can be traced back to adolescence or early adulthood
• For these reasons, most personality disorders, although in evidence, are usually not diagnosed before age 18

Etiology and Pathology

• Historically, the causes of personality disorders were thought to be only psychological in origin based on problems experienced in childhood, family, and environmental factors
• Current biologic research and neuroimaging studies have produced data that add to understanding of the psychopathology
• Childhood trauma and disordered attachment affect the prefrontal cortex, secretion of cortisol, and neurotransmitter functioning (particularly serotonin)
• Adverse childhood experiences affect functioning of the amygdala and alter perceptions of risk
• Evidence suggests gene expression is influenced by environment.
• Genetic studies of twin or adoptive siblings and family history data suggest a genetic predisposition
• The social environment, coupled with psychological vulnerability, strongly influences the individual. Along with biologic factors, and negative childhood experiences are important in its genesis

Personality Disorder Clusters

• Personality disorders are grouped into three clusters based on descriptive features -Cluster A (schizoid, schizotypal, and paranoid disorders) is characterized by odd or eccentric behaviors
• B (narcissistic, histrionic, antisocial, and borderline disorders) is characterized by dramatic, emotional, or erratic behaviors -Cluster C (dependent, avoidant, and obsessive-compulsive disorders) is characterized by anxious or fearful behaviors
• They may be remembered as "Odd, Angry, and Anxious."
• Cluster A disorders have a prevalence of 5.7%, cluster B has 1.5%, and cluster C has 6%.
• Prevalance data suggests that 15% of Americans have at least one personality disorder

Paranoid Personality Disorder

• Suspiciousness and mistrust of people characterize a person with paranoid personality disorder Individuals interpret others' actions as personal threats, increasing anxiety and need for defensiveness
• People with paranoid personality disorder are unable to laugh they are often humorless, rigid, and guarded
• Speech is logical and goal-directed, basis of an argument may be false
• Individuals have a blunted affect, may also be suspicious and jealous
• People with paranoid personality disorder do not have fixed delusions or hallucinations
• Hospitalization occurrs when their behavior is out of control and they are quick to respond with anger
• Paranoid personality disorder tends to occur in relatives of those with schizophrenia and is diagnosed more often in men

Schizoid Personality Disorder

• People with schizoid personalities do not want to be involved in interpersonal or social relationships and keep people at an emotional distance
• People are hermits or loners because of their shyness and introversion
• Solitary activities are more gratifying compared with social situations
• Research is still ongoing to differentiate this disoder and autism spectrum disorder
• Schizoid personality symptoms may be an indicator that the individual is a variant of high functioning autism
• The nurse-patient relationship should focus on building trust and appropriate verbal expression of feelings
• Slowly involving such patients in milieu and group activities, if possible, might help to improve their social skills

Schizotypal Personality Disorder

• Individuals with schizotypal personality disorder appear similar to patients with mild schizophrenia, but do not meet enough criteria for psychosis or schizophrenia
• Their outward appearance might be eccentric, and thinking and behavior may be odd
• Paranoid ideation, ideas of reference, and odd beliefs are some of the most prevalent and unchangeable criteria for this disorder
• When a person with schizotypal personality disorder is hospitalized interventions offering support, kindness, and gentle suggestions help the patient become involved in activities with others
• A relationship with a family member with schizophrenia increases risk for developing schizotypal personality disorder
• Decreased gray matter in the temporal cortex, parahippocampus, frontal lobe, and cingulate gyrus have been found in patients with schizophrenia and those with schizotypal personality disorder
• Those with schizotypal personality disorder have increased gray matter in other prefrontal regions, suggesting that these alterations may be a protective factor from psychosis

Antisocial Personality Disorder

• The main feature of antisocial personality disorder (ASPD) is a pattern of disregard for the rights of others, usually demonstrated by repeated violations of the law
• Before the age of 15 years, these behaviors are diagnosed as conduct disorder
• Affected individuals engage in unlawful behavior and abuse alcohol and other substances and can be promiscuous and feel no guilt about hurting others
• Criminal behavior places them within the judicial and prison systems
• The diagnosis of ASPD is based on a history of disordered life functioning rather than on mental status.
• Smoothing talkers who deny and rationalize their behavior -Expected anxiety over their predicament is absent and guilt, sorrow for offenses, or loyalty is nonexistent
• Genetics and the environment influence the development of ASPD
• Having a genetic predisposition to ASPD from an antisocial parent who mistreats the child is a large factor
• The gene C-521 T, involved in the creation of the dopamine 4 receptor, has been implicated in novelty-seeking behavior and impulsivity
• An abnormality of the monoamine oxidase A gene (MAOA) has also been linked to antisocial behavior dysfunctional gene produces less MAO to break down dopamine and serotonin

Nursing Interventions

• Long-term treatment is necessary for lasting change
• Firm limits need to be set and the nurse set on being consistent with consequences of behavior, both on the unit and for the patient's life, are also a point of focus
• The nurse avoids moralizing and assists the patient in identifying and verbalizing feelings that might reflect anxiety and depression

Borderline Personality Disorder

• Individuals with borderline personality disorder (BPD) display a pattern of unstable relationships, identity or self-image disturbances, and labile affect along with increased impulsivity
• People display high emotionality and may display anger, self-harm, and suicidality
• Individuals use self-defeating behaviors to test those around them will leave them
• Individuals have an intense fear of abandonment and have a difficult time alone.
• Relationships are intense and often short-lived and superficial
• The person's mood can toggle between extreme emotional responses
• Projective identification is used to protect the limited self-esteem they possess
• BPD are at risk for suicide because of their depression, aggression, impulsivity
• The development of BPD is multifactorial.
• Heredity, genetics, environmental factors, childhood experiences, neurological and biochemical dysfunction contribute to it
• Research indicates that early trauma and stress alter brain structure and functioning, resulting in early trauma and stress

BPD Nursing Interventions

• The nurse's use of empathy while maintaining clear boundaries is important, to help understand, control, and change dysfunctional behaviors
• The patient is usually in a crisis situation when hospitalized (suicidal behavior, self-mutilation, acute personality disorganization, or inability to function)
• The nurse helps the patient identify feelings and verbally express them nonaggressively; recognizes behavioral and emotional cues
• Linehan developed Dialectical behavioral therapy (DBT) specifically for the treatment of BPD
• Therapeutic activities include assertiveness training, problem solving, stress management, and anger management
• Psychopharmacology is employed for specific symptoms and may be part of a comprehensive treatment plan

Narcissistic Personality Disorder

• People with narcissistic personality disorder have increased interpersonal antagonism or low agreeableness
• Manifests itself in a lack of empathy, a sense of entitlement, arrogance, and a need for admiration
• There are two key components of narcissistic PD: grandisosity and narcissistic vulnerability
• Someone with vulnerable narcissism might appear nonchalant or indifferent to criticism while hiding feelings of anger, rage, or emptiness
• Constant reinforcement from others is needed to boost such a person's self-esteem
• A therapeutic nurse-patient relationship may be difficult to achieve, as the patient with narcissistic PD feels that he or she has nothing to learn from the nurse.
• Limit setting and consistency are used to decrease manipulation and entitlement behaviors
• Cluster C: Anxious-Fearful

Histrionic Personality Disorder

• A person with histrionic personality disorder dramatizes events and draws attention to self
• The person is extroverted and thrives on being the center of attention. Behavior is flirty, silly, frivolous, and seductive
• Speech is exaggerated and theatrical but lacking in depth and insight
• They are notorious name-droppers who regard people they just met as dear friends
• The person is highly excitable and energized, always in a hurry and restless with overreactions to minor events

Nursing Interventions

• It is important to foster and be consistent so the patients are able to make desicions themselves but strike a blend between encouraging without over valuing them
• The nurse should provide positive reinforcement for appropriate behaviors and expressions of feelings that foster independence

Dependent Personality Disorder

• Main component is a pervasive and excessive need to be taken care of that leads to submissive, clinging behaviors, and fears of separation.
• Dependent individuals want others to make daily decisions for them, and need direction and reassurance
• Avoidant Personality Disorder
• Patients are avoidant, timid, socially uncomfortable, and withdrawn. They feel inadequate and are hypersensitive to criticism
• Patients need to be certain of being liked before making social contacts
• Lack self confidence and may lack public speaking skills

Nursing Interventions

• Help patient express their feelings and fears
• The nurse help the patient gradually confront his or her fears to develop social skills
• Patients with the avoidant PD are timid, socially uncomfort- able, and withdrawn. They feel inadequate and are hypersen- sitive to criticism

Obsessive Compulsive Personality Disorder

• Individuals with obsessive-compulsive personality disorder are perfectionistic and inflexible
• These individuals are overly strict and often set standards for themselves that are too high
• Because the person is afraid of making mistakes, he can be indecisive or put off decisions until all the facts have been obtained
• Teach the importance of leasure activites