CENTRAL PHILIPPINE UNIVERSITY

COLLEGE OF NURSING
The First Nursing School in the Philippines, 1906
Iloilo City, Philippines 5000
Tel. No. (63-33) 3291971 to 79 Local 1037 / 2133
Website: http://www.cpu.edu.ph | Email: nursing@cpu.edu.ph

Lecture Notes on
NCM 3218
(Care of Clients with Maladaptive Patterns of Behavior-Acute/Chronic)

PERSONALITY DISORDERS
PERSONALITY
 the totality of the person’s internal patterns of adjustment to life, determined in part by the individual’s
genetic makeup and life’s experiences

PERSONALITY TRAITS
 patterns of thinking, perceiving, reacting & relating that are relatively stable over time & in various
situations

THEORIES of PERSONALITY DEVELOPMENT

Freud’s Psychoanalytic Theory Erickson’s Psychosocial Theory Piaget’s Cognitive Theory

 Id  Developmental conflicts in  Sensorimotor
 Ego eight (8) psychosocial  Preoperational
 Superego stages  Concrete operational
 Five (5) psychobiological  Formal operational
processes

PERSONALITY DISORDER
 occurs when personality traits become too rigid & maladaptive & individual uses immature &
maladaptive coping mechanisms that result in the impairment of interpersonal or vocational functioning

ETIOLOGY of PERSONALITY DISORDERS

Biologic Childhood Experiences Psychoanalytic Others

 Improper  Rigid upbringing  Defective egos  Drive for
Nutrition  Rewarding tantrums  Weak superego power/prestige
 High levels of  Creativity is not  Immature  Living in urban
testosterone, 17- encouraged superego cities
estradiol, and  Fostering
estrone dependency
 High levels of  Parents/authority
dopamine and models socially
serotonin unacceptable
 Genetic behavior
predisposition

1 |P e r s o n a l i t y D i s o r d e r s – P r o f . B o r l a d o
COMMON CHARACTERISTICS
1. Inflexible, socially unacceptable behaviors
2. Self-centeredness
3. Manipulative and exploitative behavior
4. Inability to tolerate minor stress, resulting in increased inability to cope with anxiety or depression
5. Lack of individual accountability for behavior, blaming others for their problems
6. Difficulty dealing with reality because of a distorted or superficial understanding of self and the
perceptions of others
7. Vulnerability to other mental disorders such as obsessive–compulsive tendencies and panic attacks

DIAGNOSTIC CRITERIA
1. Long-standing, pervasive, maladaptive pattern of behavior
2. Has an onset in adolescence or early childhood
3. Lack of genuine sense of “self”
4. Look outside themselves for evaluation & opinions to guide them, instead of within

PERSONALITY DISORDERS CATEGORY

CLUSTER PERSONALITY DISORDERS CHARACTERISTIC

Cluster A paranoid, schizoid, and schizotypal odd or eccentric behaviors
Cluster B antisocial, borderline, histrionic, and narcissistic dramatic, emotional, or erratic
personality disorders behaviors
Cluster C avoidant, dependent, and obsessive–compulsive anxious or fearful behaviors
personality disorders
Not Otherwise passive-aggressive, depressive
Specified

CLUSTER A
I. Paranoid Personality Disorder
G – grudges held for long periods
E – exploitation expected (without sufficient basis)
T – trustworthiness of others doubted (extreme suspiciousness, vigilance, mistrust)
F – fidelity of sexual partner questioned
A – attacks on character are perceived
C – confides in others rarely, if at all (Emotional coldness, callous, unsympathetic approach to others,
profound emotional constriction)
T – threatening meanings read into events

 Interventions:
 Individual psychotherapy
 Approach client in a formal, business-like manner
 Help client to learn to validate ideas before taking action
 Avoid rejecting behavior neither argue nor challenge
 Involve client in planning treatment goals

II. Schitzotypal Personality Disorder

U – unusual perceptions (somatic illusions of strength & power)
F – friendless except for family
O – odd beliefs, thinking and speech (magical thinking)
A – affect (inappropriate, constricted)
I – ideas of reference
D – doubts others
E – eccentric (appearance/behavior)
R – reluctant in social situations/anxious
2 |P e r s o n a l i t y D i s o r d e r s – P r o f . B o r l a d o
  Interventions:
 Low dose of antipsychotic meds (Thiotexene-Navane, Perphenazine-Trilafon)
 Acknowledge the person’s need for personal distance
 Establish a trusting relationship
 Develop self-care skills
 Improve community functioning
 Social skills training

III. Schizoid Personality Disorder

S – solitary lifestyle (introvert, loner)
I – indifferent to praise and criticism (blank, affectless facial expression, inability to tolerate eye contact)
R – relationships are of no interest

S – sexual experiences not of interest

A – activities not enjoyed
F – friends lacking (fears intimacy)
E – emotionally cold and detached

 Interventions:
 Individual Psychotherapy (short term)
 Avoid possible disappointments
 Social skills training
 Build trust

CLUSTER B
I. Antisocial Personality Disorder
C – conduct disorder if before age 15; Current age at least 18 yrs old
A – antisocial acts; commits acts that are grounds for Arrest (deliquent & criminal)
L – lies frequently
L – lacks superego (sociopathic, psychopathic, semantic disorder)
O – obligations not honored
U – unstable (can’t plan ahead)
S – safety of self and others ignored (perceives others & world as HOSTILE)

M – money problems
A – aggressive, Assaultive (vandalism, dangerous sports, substance abuse, fighting, truancy, sexual
promiscuity)
N – not occuring exclusively during schizophrenia or mania

 Interventions:
 Psychotherapy (tx of choice)
 SSRI (Zoloft, Prozac, Paxil)
 Strict limit setting in a matter-of-fact, non judgemental behavior
 Recognize emotion outside of anger
 Never threaten patient in an attempt to elicit acceptable behavior
 Confrontation

II. Borderline Personality Disorder

I – identity disturbances

R – relationships are unstable (tend to marry passive & distant partners)

A – abandonment frantically avoided (whether real or imagined)
I – impulsivity (unpredictable behavior related to gambling, shoplifting, sex & subs. abuse)
S – suicidal gestures (threats, self-mutilation)
3 |P e r s o n a l i t y D i s o r d e r s – P r o f . B o r l a d o
 E – emptiness
D – dissociative symptoms

A – affective instability (intense & unstable abrupt mood changes)

P – paranoid ideation
A – anger is poorly controlled (manipulative, self-destructive, binge eating, financial mismanagement,
acting out, psychosomatization)
I – idealization followed by devaluation (SPLITTING)
N – negativistic (undermine themselves with self-defeating behavior)

 Causes:
 Faulty parenting
 CNS irritation ( biologic defect in the amygdala, the area of the brain that helps to
regulate emotions, causing severe mood swings and abnormal behavior)
 Increase level of norepinephrine, abnormal level of dopamine

 Defense mechanisms commonly used:

 denial
 projection
 regression
 splitting
 projective identification

 Interventions:
 Promote safety (no-self harm contract)
 Help client to cope and control emotions
 Cognitive restructuring techniques (thought stopping)
 Structure time
 Teach social skills

III. Histrionic Personality Disorder

I – inappropriate behavior (flight of romantic fantasies)

C – center of attention
R – relationships are seen as closer than they really are
A – appearance is most important
V – vulnerable to others’ suggestions
E – emotional expression is exaggerated

S – shifting emotions; Shallow (roller coaster of joy & despair)

I – impressionistic manner of speaking (lacks details)
N – novelty is craved (colorful, extrovert, seductive individual)

 Causes:
 lack of criticism or discipline
 positive reinforcement for certain behaviors
 unpredictable attention during childhood

 Interventions:
 Psychotherapy (treatment of choice)
 Teach social skills
 Provide factual feedback about behavior

4 |P e r s o n a l i t y D i s o r d e r s – P r o f . B o r l a d o
 IV. Narcissistic Personality Disorder
A – admiration required in excessive amounts (prone to extreme mood swings between self-admiration
& insecurity)

F – fantasizes about unlimited succes, brilliance, etc (strive for power & success)
A – arrogant
M – manipulative
E – envious of others

G – grandiose sense of importance (conceited, overestimating their accomplishment)

A – associate with special people (romantic partners are used as objects to bolster their self-esteem)
M – me frist attitude
E – empathy lacking for others

 Causes:
 excessive pampering
 extremely high parental expectations
 abuse or neglect

 Interventions:
 Psychotherapy (long-term)
 Matter-of-fact approach
 Gain cooperation with needed treatment
 Teach client any needed self-care skills

CLUSTER C
I. Obsessive-Compulsive Personality
L – leisure activity is minimal (lacks humor & affection, cold, self-centered, demanding)
O – organizational focus
W – work and productivity dominate

M – miserly spending habits

I – inflexible around morals, values (critical, self righteous)
R – rigidity and stubborness (uncomfortable to situation that is unpredictable)
T – task completion impaired (perfectionist)
H – hoards ítems (worthless)

 Interventions:
 Behavior modification
 Encourage negotiation with others
 Assist client to make timely decisions and complete work
 Cognitive restructuring techniques

II. Avoidant Personality Disorder

R – restrained with relationships (loner)
I – inhibited in interpersonal situations (oversensitive to the opinion of others)
D – disapproval expected at work
I – inadequate view of self (low self-esteem, pessimistic, shy, easily hurt)
C – criticism is expected in social situations (social discomfort is the primary characteristic)
U – unwilling to get involved (views life through the lens of rejection)
L – longs for attachment to others
E – embarassment is the feard emotion

5 |P e r s o n a l i t y D i s o r d e r s – P r o f . B o r l a d o
  Interventions:
 Relaxation techniques
 Support and reassurance
 Cognitive restructuring techniques
 Promote self-esteem

III. Dependent Personality Disorder

D – disagreement is difficult to express (passive, submissive, clinging manner, fear abandonement)
A – advice (needs excessive input for decision making)
R – responsibility for major areas delegated to others
N – nurturance (seeks excessive degree from others)

H – helplessness when alone

U – unrealistically preoccupied with being left to care for self
R – relationships are desperately sought
T – tasks are difficult to initiate and complete

 Causes:
 authoritarian or overprotective parenting style

 Interventions:
 Relaxation techniques
 Assertive training
 Foster client’s self-reliance and autonomy
 Teach problem-solving and decision-making skills
 Cognitive restructuring techniques

NOT OTHERWISE SPECIFIED

I. Passive-Agressive Personality Disorder
 “Chip-on-the-shoulder-attitude”
 harbor feelings of hostility but are afraid to express due to fear of rejection & retaliation
 agree to perform task they don’t want & subtly undermine completion
 TRAITS
 pessimistic
 procrastinates
 stubborn
 forgetfulness
 dependency
 intentional inefficiency
 CAUSES
 dominant rigid father
 oral character
 fear of rejection when exhibiting aggressive behavior

II. Depressive Personality Disorder

 They would see their lives in grey, black and blue
 They would usually cry
 They are high risk for suicide
 Interventions:
 assess self-harm risk
 provide factual feedback
 promote self-esteem
 increase involvement in activities

6 |P e r s o n a l i t y D i s o r d e r s – P r o f . B o r l a d o
Characteristics of Manipulative Behavior
a. Uses bargains, threats, demands or intimidation to get own way
b. Shows ability & use other people’s weaknesses for own benefit
c. Makes continuous, unrealistic demands
d. Pits one individual against another, e.g., clients against staff & primitive defense mechanism of splitting
e. Pretends to be helpless & sorry for behavior
f. Lies to gain sympathy of staff or other clients
g. Acts out even when given acceptable behavioral alternatives
h. Keeps all relationships on a superficial level
i. Uses flattery, charm & excessive compliments to have needs met
j. Exploits the generosity of others
k. Identifies with staff or authority figure & acts as if he/she is incarcerated
l. Finds a way around the unit rules & expectations
m. Uses sexuality to gain control over others – may even approach that staff sexually

Interventions for Manipulative Behavior

a. Set clear & realistic limits w/ appropriate consequences. Be consistent & firm in setting behavioral
expectations & limits
b. Confront client about the manipulative behavior. Do not out-manipulate; client is a master at it
c. Reinforce adaptive behavior through positive feedback & realistic praise
d. Do not be influenced by client’s charming ways – all directed toward manipulating the nurse
e. Do not be intimidated by the client’s behavior
f. Clearly & consistently communicate care plans & client’s behavior to other staff. Present a united front
g. Accept no flattery, gifts or favors
h. Form a therapeutic nurse-client relationship in which positive behavior is reinforced:
 Encourage the client to discuss feelings rather than act them out
 Provide consistency in response to the client’s acting out behaviors
 Identify splitting behavior
 Assist the client to deal with anger
 Provide the realistic praise for positive behaviors in social situations

Limit Setting
a. Maintain safety against self-destructive behaviors
b. Encourage the client to participate in group activities & praise non-manipulative behavior
c. Remove client from group situations in which attention-seeking behaviors occur
d. Allow the client to make choices & be as independent as possible
e. Discuss the consequences that will follow certain behaviors
f. Inform the client that harm to self, others & property is unacceptable

General Principles for Interactions & Interventions With Patients With Personality Disorder
a. Maintain health & safety
b. Establish a trusting relationship
c. Protect patient from injury to self or others
d. Focus on patients’ strengths, assets & accomplishments
e. Assist patient to control impulsiveness
f. Encourage patient to verbalize anger rather than act in aggressive or passive-aggressive manner
g. Set limits on manipulative behavior when necessary
h. Provide opportunities to learn & practice interactive & socialization skills
i. Reinforce expressions of positive feelings & behaviors
j. Assist patient to reduce procrastination & resistance
k. Reinforce independent, responsible behaviors
l. Praise patient for respecting needs & rights of self & others
m. Teach the patient to identify psychosocial stressors & how to recognize, manage & prevent symptoms

7 |P e r s o n a l i t y D i s o r d e r s – P r o f . B o r l a d o