Personality Disorders | Antisocial, Borderline, Histrionic, Narcissistic, Avoidant, Dependent.

INTRODUCTION

Individual’s characteristics are combined product of heredity, early life experience and environmental influences. Healthy individual will be able to adjust and adopt / accommodate to the changes which are occurring in the life and its environmental situations, when personality disorder occurs individual will have fixed fantasies, rigid and ongoing patterns of thought and action; the inflexibility and alteration in behavioural patterns causes serious personal and social difficulties; in socially distressing ways, which often limits their ability and function in relationships and at work.   Indeed, personality disorders are aggravated by stressors, external or self-induced. Individuals may have more than 1 personality disorder.

DEFINITION: 

“An enduring pattern of inner experiences and behaviour that deviates markedly from expectations of the culture of the individual who exhibits it.”

~        American Psychiatric association

EPIDEMIOLOGY

International occurrence

• Cluster A - Schizoid personality disorder is slightly more common in males than in females
• Cluster B - Antisocial personality disorder is 3 times more prevalent in men than in women; borderline personality disorder is 3 times more common in women than in men; of patients with narcissistic personality disorder, 50-75% are male
• Cluster C - Obsessive-compulsive personality disorder is diagnosed twice as often in men as in women

Age-related differences in incidence

Personality disorders generally should not be diagnosed in children and adolescents because personality development is not complete and symptomatic traits may not persist into adulthood. Therefore, the rule of thumb is that personality diagnosis cannot be made until the person is at least 18 years of age. Because the criteria for diagnosis of personality disorders are closely related to behaviours of young and middle adulthood, DSM-IV-TR diagnoses of personality disorders are notoriously unreliable in the elderly population.

TYPES

1.      CLUSTER A (ODD, ECCENTRIC)

      i.            Paranoid personality disorder:

Individuals with this disorder display pervasive distrust and suspiciousness, with a tendency to attribute malevolent motives to others, to be preoccupied with unjustified doubts, and to persistently bear grudges. Common beliefs include the following:

• Others are exploiting or deceiving the person
• Friends and associates are untrustworthy
• Information confided to others will be used maliciously
• There is hidden meaning in remarks or events others perceive as benign
• Attacks are being made on the person’s character or reputation that are not apparent to others
• The person’s spouse or partner is unfaithful

    ii.            Schizoid personality disorder:

This type of personality disorder is uncommon in clinical settings. A person with this disorder is markedly detached from others and has little desire for close relationships, choosing solitary activities. The person's life is marked by little pleasure in activities and little interest in sexual relations. People with this disorder appear indifferent to the praise or criticism of others and often seem cold or aloof.

  iii.            Schizotypal personality disorder:

People with this disorder exhibit marked eccentricities of thought, perception, and behaviour. Typical examples are as follows:

• Ideas of reference – i.e., believing that public messages are directed personally at them
• Odd beliefs or magical thinking
• Vague, circumstantial, or stereotyped speech
• Excessive social anxiety that does not diminish with familiarity
• Idiosyncratic perceptual experiences or bodily illusions

2.      CLUSTER B (DRAMATIC, EMOTIONAL)

      i.            Antisocial personality disorder:

Individuals with an antisocial personality disorder display a pervasive pattern of disregard for and violation of the rights of others and the rules of society. Although the formal diagnosis of antisocial personality disorder is made only after one is aged at least 18 years, the following features must start to be exhibited by age 15 years or earlier:

• Repeated violations of the law
• Pervasive lying and deception
• Physical aggressiveness
• Reckless disregard for safety of self or others
• Consistent irresponsibility in work and family environments
• Lack of remorse

    ii.            Borderline personality disorder

The central feature of borderline personality disorder is a pervasive pattern of unstable and intense interpersonal relationships, self-perception, and moods. Impulse control is markedly impaired. Transiently, such patients may appear psychotic because of the intensity of their distortions. Diagnostic criteria require at least 5 of the following features:

• Frantic efforts to avoid expected abandonment
• Unstable and intense interpersonal relationships
• Markedly and persistently unstable self-image
• Impulsivity in at least 2 areas that are potentially self-damaging - E.g., sex, substance abuse, and reckless driving
• Recurrent suicidal behaviours or threats or self-mutilation
• Affective instability
• Chronic feelings of emptiness
• Inappropriate and intense anger
• Transient paranoia or dissociation

Borderline personality disorder is, however, one of the most commonly overused diagnoses in DSM-IV-TR.

  iii.            Histrionic personality disorder

Major traits of this condition include the following:

• Need to be the centre of attention with self-dramatization
•  Inappropriate sexual seductiveness
• Speech lacks detail
• Aggrandizing, but insincere, relationships
• Suggestibility

  iv.            Narcissistic personality disorder

Narcissistic patients are grandiose and require admiration from others. Particular features of the disorder include the following:

• Exaggeration of their own talents or accomplishments
• Preoccupation with fantasies of success, beauty, and love
• Sense of entitlement
• Exploitation of others
• Lack of empathy
• Envy of others
• An arrogant, haughty attitude

AETIOLOGY

The origin of personality disorders is a matter of considerable controversy. Traditional thinking holds that these maladaptive patterns are the result of dysfunctional early environments that prevent the evolution of adaptive patterns of perception, response, and defence. A body of data points toward genetic and psychobiologic contributions to the symptomology of these disorders; however, the inconsistency of the data prevents authorities from drawing definite conclusions.

Paranoid personality disorder:

A genetic contribution to paranoid traits and a possible genetic link between this personality disorder and schizophrenia exist. Psychosocial theories implicate projection of negative internal feelings and parental modelling. Schizoid personality disorder Support for the heritability of this disorder exists.

Schizotypal personality disorder:

This disorder is genetically linked with schizophrenia. Evidence for deregulation of dopaminergic pathways in these patients exists.

Antisocial personality disorder:

A genetic contribution to antisocial behaviours is strongly supported. Low levels of behavioural inhibition may be mediated by serotonergic deregulation in the septohippocampal system. There may also be developmental or acquired abnormalities in the prefrontal brain systems and reduced autonomic activity in antisocial personality disorder. This may underlie the low arousal, poor fear conditioning, and decision-making deficits described in antisocial personality disorder.

Borderline personality disorder:

Psychosocial formulations point to the high prevalence of early abuse (sexual, physical, and emotional) in these patients, and the borderline syndrome is often formulated as a variant of posttraumatic stress disorder. Mood disorders in first-degree relatives are strongly linked.

Biologic factors, such as abnormal monoaminergic functioning (especially in serotonergic function) and prefrontal neuropsychological dysfunction, have been implicated but have not been well established by research.

Histrionic personality disorder:

Little research has been conducted to determine the biologic sources of this disorder. Psychoanalytic theories incriminate seductive and authoritarian attitudes by fathers of these patients.

Narcissistic personality disorder:

No data on biologic features of this disorder are available. In the classic model, narcissism functions as a defence against awareness of low self-esteem. More modern psychodynamic models postulate that this disorder can arise from an imbalance between positive mirroring of the developing child and the presence of an adult figure who can be idealized.

  

Avoidant personality disorder:

This personality disorder appears to be an expression of extreme traits of introversion and neuroticism. No data on biologic causes are available, although a diagnostic overlap with social phobia probably exists.

Dependent personality disorder:

No studies of genetics or of biologic traits of these patients have been conducted. Central to their psychodynamic constellation is an insecure form of attachment to others, which may be the result of clinging parental behaviour.

Obsessive-compulsive personality disorder:

Modest evidence points toward the heritability of this disorder. Psycho-dynamically, these patients are viewed as needing control as a defence against shame or powerlessness.

CLINICAL FEATURES

Types of personality disorders are grouped into three clusters, based on similar characteristics and symptoms. Many people with one personality disorder also have signs and symptoms of at least one additional personality disorder.

Cluster A personality disorders:       

Cluster A personality disorders are characterized by odd, eccentric thinking or behaviour. They include paranoid personality disorder, schizoid personality disorder and schizotypal personality disorder. It's not necessary to exhibit all the signs and symptoms listed for a disorder to be diagnosed.

Paranoid personality disorder:

A pervasive distrust and suspicion of others and their motives Unjustified belief that others are trying to harm or deceive you Unjustified suspicion of the loyalty or trustworthiness of others Hesitant to confide in others due to unreasonable fear that others will use the information against you. Perception of innocent remarks or non-threatening situations as personal insults or attacks Angry or hostile reaction to perceived slights or insults Tendency to hold grudges Unjustified, recurrent suspicion that spouse or sexual partner is unfaithful.

Schizoid personality disorder:

• Lack of interest in social or personal relationships, preferring to be alone
• Limited range of emotional expression
• Inability to take pleasure in most activities 
• Inability to pick up normal social cues
• Appearance of being cold or indifferent to others
• Little or no interest in having sex with another person

Schizotypal personality disorder:

• Peculiar dress, thinking, beliefs, speech or behaviour.
• Odd perceptual experiences, such as hearing a voice whisper your name.
• Flat emotions or inappropriate emotional responses.
• Social anxiety and a lack of or discomfort with close relationships.
• Indifferent, inappropriate or suspicious response to others.
•  "Magical thinking" — believing you can influence people and events with your thoughts.
• The belief that certain casual incidents or events have hidden messages meant specifically for you.

Cluster B personality disorders:

Cluster B personality disorders are characterized by dramatic, overly emotional or unpredictable thinking or behaviour. They include antisocial personality disorder, borderline personality disorder, histrionic personality disorder and narcissistic personality disorder. It's not necessary to exhibit all the signs and symptoms listed for a disorder to be diagnosed.

Antisocial personality disorder:

·         Disregard for others' needs or feelings

·         Persistent lying, stealing, using aliases, conning others

·         Recurring problems with the law

·         Repeated violation of the rights of others

·         Aggressive, often violent behaviour

·         Disregard for the safety of self or others

·         Impulsive behaviour

·         Consistently irresponsible

·         Lack of remorse for behaviour

Borderline personality disorder:

·         Impulsive and risky behaviour, such as having unsafe sex, gambling or binge eating

·         Unstable or fragile self-image

·         Unstable and intense relationships

·         Up and down moods, often as a reaction to interpersonal stress

·         Suicidal behaviour or threats of self-injury

·         Intense fear of being alone or abandoned

·         Ongoing feelings of emptiness

·         Frequent, intense displays of anger

·         Stress-related paranoia that comes and goes

Histrionic personality disorder

·         Constantly seeking attention

·         Excessively emotional, dramatic or sexually provocative to gain attention

·         Speaks dramatically with strong opinions, but few facts or details to back them up

·         Easily influenced by others

·         Shallow, rapidly changing emotions

·         Excessive concern with physical appearance

·         Thinks relationships with others are closer than they really are

Narcissistic personality disorder

·         Belief that you're special and more important than others

·         Fantasies about power, success and attractiveness

·         Failure to recognize others' needs and feelings

·         Exaggeration of achievements or talents

·         Expectation of constant praise and admiration

·         Arrogance

·         Unreasonable expectations of favours and advantages, often taking advantage of others

·         Envy of others or belief that others envy you

MEDICAL MANAGEMENT

Medications are in no way curative for any personality disorder. They should be viewed as an adjunct to psychotherapy so that the patient may productively engage in psychotherapy.

If patients without a true psychotic condition are treated with antipsychotic agents, serious neurologic effects, such as tardive dyskinesia or neuroleptic malignant syndrome, can result. The physician should carefully document the indication for the use of such agents, and these drugs should be discontinued as soon as possible.

Medication is rarely necessary to treat personality disorders. Indeed, differentiating personality disorders from pure mood disorders is important because patients with mood disorders will benefit from medication, particularly selective serotonin reuptake inhibitors (SSRIs). Patients with personality disorders and manifesting comorbid mood disorder require close medical supervision in terms of initiation and following of medication therapy.

Medications are in no way curative for any personality disorder. They should be viewed as an adjunct to psychotherapy so that the patient may productively engage in psychotherapy.

The focus is on the treatment of symptom clusters such as cognitive-perceptual symptoms, effective deregulation, and impulsive-behavioural decontrol. These symptoms may complicate almost all personality disorders to varying degrees, and all of them have been noted in borderline personality disorder.

The assumption is that neurotransmitter abnormalities that transcend the concepts of axis I and axis II disorders underlie these symptom clusters. The strongest evidence for the efficacy of pharmacologic treatment of personality disorders has been for borderline personality disorder, but even this is based on a fairly small database of studies.

 

ANTIDEPRESSANTS

Because of overdose risk, tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) are usually not prescribed for patients with personality disorders. The selective serotonin reuptake inhibitors (SSRIs) and newer antidepressants are safe and reasonably effective. However, because the depression of most patients with personality disorders stems from their limited range of coping capacities, antidepressants are usually less effective than in patients with uncomplicated major depression. Antidepressants are most often prescribed for a limited time in patients with serious depressive episodes lasting longer than a few weeks.

Sertraline (Zoloft)

This agent selectively inhibits presynaptic serotonin reuptake.

Paroxetine (Paxil, Pexeva)

Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake. Also has a weak effect on norepinephrine and dopamine neuronal reuptake.

Fluoxetine (Prozac)

Fluoxetine selectively inhibits presynaptic serotonin reuptake with minimal or no effect on the reuptake of norepinephrine or dopamine.

Escitalopram (Lexapro)

This agent is an SSRI and an S-enantiomer of citalopram that is used for the treatment of depression. Escitalopram enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane. Its mechanism of action is thought to be the potentiation of serotonergic activity in the central nervous system (CNS) through the inhibition of CNS neuronal reuptake of serotonin. The onset of depression relief may occur after 1-2 weeks, which is faster than the relief obtained from other antidepressants.

Nefazodone

An antagonist at the 5-HT2 receptor, nefazodone inhibits the reuptake of 5-HT. In addition, this agent has a negligible affinity for cholinergic and histaminergic receptors.

Mirtazapine (Remeron)

Mirtazapine increases the availability of serotonin and norepinephrine.

NURSING MANAGEMENT

(Paranoid Personality Disorder)

NURSING DIAGNOSIS

• Disturbed Thought Processes
• Defensive coping
• Impaired social interaction
• Ineffective therapeutic regimen management 

DISTURBED THOUGHT PROCESSES

ASSESSMENT:

o   Non reality based thinking

o   Disorganised, illogical thoughts

o   Impaired judgement

o   Impaired problem solving

o   Alterations in perceptions ( Hallucination, Ideas of references)

o   Suicidal ideation

GOAL:

Immediate:       . The client will:

·         Be free from self-inflicted harm.

·         Not harm others

·         Demonstrate decreased psychotic symptoms

Stabilization:    . The Clint will:

·         Verbalize recognition that others do not share his or her paranoid ideas

·         Demonstrate reality based thinking

Community      . The Clint will:

·       Act on reality based-thinking, not paranoid ideas.

·       Validate ideas with a trusted people , such as a significant others or case manager

IMPLEMENTATION

Nursing Intervention	Rationale
Search the client belongings carefully for weapons; also, search the client’s vehicle, if at the facility.	Paranoid client may carry on conceal weapon
Be calm and non-threatening in all your approaches to the client, using a quiet voice; do not surprise the client	If the client is feeling threatened, he or she may perceive any person or stimulus as a threat
Observe the client closely for agitation, and decrease stimulus or move the client to a less stimulating areas or seclusion area if indicated.	Whenever possible, its best to intervene before the client loses control. The client’s ability to deal with stimuli may be impaired.
Observe the clients interactions with the visitors. The length the no. of frequency of visits may need to be limited.	The client ability to deal with other people may be impaired.

CONCLUSION

The personality disorder is costly to the society. In general, patients with PDs have the considerable disability in performing family, academics, employment and other functional roles. There are well-established relations between personality and crime (70-80 % of criminals have PDs), (60-70% of alcoholism have PDs) and (70-90 % of drug abusers have PDs). A person with PDs has an increased mortality rates, especially due to suicide and accidents. They also have elevated rates of separation, divorce and child custody proceedings

REFERENCES:

• Bienenfeld D., & Ahmed I., Personality disorders clinical presentation, Medscape Reference, doi: 
• Jackson B. R., (2014). Nursing management of personality disorders, Journal of Addictive Disorders, St. Albert, Canada.
• Mary C.T., (2009) Psychiatric mental health nursing concepts of care in evidence-based practice, F. A. Davis Company. 6E. 
• Neeraja K.P, Essentials of mental health and psychiatric nursing, Volume 2, Jaypee Brothers Medical Publishers.
• Sreevani R., A guide to mental health and psychiatric nursing, Jaypee Medical Publishers
• Vyas J.N., & Ahuja N., Textbook of postgraduate psychiatry, Volume 1, Jaypee Medical Publishers, 2E.

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What is Personality Disorder? | Types of Personality Disorders | Lesson Plan | Lecture Notes | Handouts | Cluster A Cluster B Personality disorder | Aetiology | Clinical Features | Nursing Management | Medical Management |