Personality Disorders Nursing Care Management

Personality disorders are pervasive, ingrained patterns of thinking, feeling, and behaving that derail a person's ability to function. They do not respond to a pill, and the therapy that helps is long and slow. On the unit your work is structure, limits, and safety, because these clients carry high rates of suicide, self-mutilation, and impulsive violence.

What are Personality Disorders?

Personality is the enduring pattern of how a person behaves and relates to self, others, and the environment, including perceptions, attitudes, and emotions.

A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from cultural expectations, is pervasive and inflexible, begins in adolescence or early adulthood, stays stable over time, and causes distress or impairment (DSM-V). It is diagnosed when personality traits become inflexible and maladaptive enough to interfere with functioning in society or to cause emotional distress. Diagnosis usually waits until adulthood, when personality is more fully formed. No medication alters personality, and therapy aimed at change is typically long-term with very slow progress.

Categories

DSM-V lists personality disorders as a distinct category on axis II of the multiaxial system, sorted into three clusters.

• Cluster A (odd or eccentric): paranoid, schizotypal, and schizoid.
• Cluster B (dramatic, emotional, or erratic): antisocial, borderline, histrionic, and narcissistic.
• Cluster C (anxious or fearful): avoidant, dependent, and obsessive-compulsive.

Cluster A

• Paranoid. Pervasive mistrust and suspiciousness; interprets others' actions as potentially harmful.
• Schizoid. Detachment from social relationships and restricted emotional expression.
• Schizotypal. Social and interpersonal deficits with acute discomfort in close relationships, plus cognitive or perceptual distortions and behavioral eccentricities.

Cluster B

• Antisocial. Pervasive disregard for and violation of others' rights, centered on deceit and manipulation.
• Borderline. Unstable relationships, self-image, and affect with marked impulsivity. The most common personality disorder in clinical settings.
• Histrionic. Excessive emotionality and attention-seeking; usually presents for depression, unexplained physical problems, or relationship difficulties.
• Narcissistic. Grandiosity (in fantasy or behavior), need for admiration, and lack of empathy.

Cluster C

• Avoidant. Social discomfort and reticence, low self-esteem, and hypersensitivity to negative evaluation.
• Dependent. Excessive need to be cared for, leading to submissive, clinging behavior and fear of separation.
• Obsessive-compulsive. Preoccupation with perfectionism and control at the expense of flexibility, openness, and efficiency.

Statistics and Incidences

Personality disorders are common, affecting 10% to 13% of the general population.

• 15% of psychiatric inpatients have a primary diagnosis of a personality disorder.
• 40% to 45% of those with a primary major mental illness also have a coexisting personality disorder that complicates treatment.
• In mental health outpatient settings, incidence is 30% to 50%.
• These clients have a higher death rate, especially from suicide, plus higher rates of suicide attempts, accidents, ED visits, separation, divorce, and child-custody litigation.
• Strong correlation with criminal behavior (70% to 85% of criminals), alcoholism (60% to 70% of alcoholics), and drug abuse (70% to 90% of those who abuse drugs).

Clinical Manifestations

• Paranoid. Mistrustful and suspicious; guarded, restricted affect.
• Schizoid. Detached; restricted affect; more involved with things than people.
• Schizotypal. Acute discomfort in relationships; cognitive or perceptual distortions; eccentric behavior.
• Antisocial. Disregard for the rights of others, rules, and laws.
• Borderline. Unstable relationships, self-image, and affect; impulsivity; self-mutilation.
• Histrionic. Excessive emotionality and attention-seeking.
• Narcissistic. Grandiose; lacks empathy; needs admiration.
• Avoidant. Social inhibition; feelings of inadequacy; hypersensitive to negative evaluation.
• Dependent. Submissive, clinging; excessive need to be cared for.
• Obsessive-compulsive. Preoccupied with orderliness, perfectionism, and control.
• Depressive. Persistent depressive cognitions and behaviors across contexts.
• Passive-aggressive. Negative attitudes and passive resistance to demands for adequate performance.

Assessment and Diagnostic Findings

• Toxicology screen. Substance abuse is common, and intoxication can mimic features of a personality disorder.
• HIV and STD screening. Poor impulse control and risk-taking can lead to infection.
• CT scanning. With appropriate blood work if an organic etiology is suspected.
• Radiography. For injuries from fighting, motor vehicle accidents, or self-mutilation.

Medical Management

Stay vigilant about suicidal potential and document the assessment at each visit.

• Psychotherapy. The core of care. Because symptoms stem from poor coping skills, therapy targets perception of and response to social and environmental stressors.
• Inpatient care. The underlying disorder does not change much with inpatient treatment, so keep stays short to avoid dependency that undermines recovery.
• Transfers. Patients on general-hospital psychiatric units, where stays usually run shorter than 2 weeks, may need transfer to a facility that provides long-term care.

Pharmacologic Management

Drugs are not curative. They are an adjunct that helps the patient engage in psychotherapy.

• Antidepressants. SSRIs and newer agents are safe and reasonably effective, but generally less effective here than in uncomplicated major depression, because the depression stems from limited coping capacity.
• Anticonvulsants. Stabilize affective extremes and show some efficacy in suppressing impulsive and aggressive behavior.
• Antipsychotics. Less dramatic response than in true psychotic axis I disorders, but may reduce anxiety, hostility, and sensitivity to rejection.

Nursing Management

Nursing Assessment

• History. Many clients report disturbed early relationships with parents that often begin at 18 to 30 months of age; 50% experienced childhood sexual abuse, and others endured physical or verbal abuse and parental alcoholism.
• Mood and affect. Pervasively dysphoric, with unhappiness, restlessness, malaise, intense loneliness, boredom, frustration, and emptiness.
• Thought process and content. Polarized, extreme thinking about self and others (splitting): idealizing people quickly, then devaluing them when they fall short.
• Sensorium and intellectual process. Intellectual capacity is intact and clients are fully oriented to reality.

Nursing Diagnosis

• Risk for Suicide related to low frustration tolerance.
• Risk for Self-Mutilation related to impulsive behavior.
• Risk for Other-Directed Violence related to lack of remorse.
• Ineffective Coping related to failure to learn or change behavior based on past experience.
• Social Isolation related to ineffective interpersonal relationships.

Nursing Care Planning and Goals

The client will stay safe and free of significant injury, will not harm others or destroy property, will show increased control of impulsive behavior, will take appropriate steps to meet their own needs, will demonstrate problem-solving skills, and will verbalize greater satisfaction with relationships.

Nursing Interventions

• Safety first. Take suicidal ideation seriously, especially with a plan, access to means, and self-harm behaviors, and intervene.
• Therapeutic relationship. Provide structure and limit-setting. See the client for scheduled appointments of a set length rather than whenever they appear and demand immediate attention.
• Boundaries. Be clear about the limits of the relationship so neither the client's nor the nurse's boundaries are violated.
• Communication skills. Teach eye contact, active listening, turn-taking, validating others' meaning, and using "I" statements.
• Coping and emotional control. Help the client name feelings and tolerate them without exaggerated responses like property destruction or self-harm. A journal builds awareness.
• Reshape thinking. Use cognitive restructuring to replace negative thoughts with positive ones, and thought-stopping to interrupt self-critical patterns.
• Structure the day. Minimize unstructured time with a written schedule of appointments, shopping, reading, and walks to help the client manage time alone.

Evaluation

The client meets the planning goals: stays safe and uninjured, does not harm others or property, controls impulsive behavior, meets their own needs, demonstrates problem-solving, and reports greater satisfaction with relationships.

Documentation Guidelines

Document individual findings (interactions, nature of social exchanges, specific behaviors), cultural and religious beliefs and expectations, the plan of care, the teaching plan, responses to interventions and teaching, and progress toward the desired outcome.