PERSONALITY DISORDER

INTRODUCTION
The word personality is derived from the Greek termpersona. It was used originally to
describe the theatricalmask worn by some dramatic actors at the time. Overthe years, it lost its
connotation of pretense and illusionand came to represent the person behind themask—the “real”
person.Each person has his or her own personality and characteristic personality traits or qualities
that make one unique Some are shy and retiring–Others loud and boisterous–Full of humor, Rather
morose, Some are spontaneous in action Others thoughtful and considerate. Personality
development occurs in response to anumber of biological and psychological influences.These
variables include (but are not limited to) heredity, temperament, experiential learning, and social
interaction.A number of theorists have attempted toprovide information about personality
development.Most suggest that it occurs in an orderly, stepwise fashion.These stages overlap,
however, as maturation occursat different rates in different individuals.

DICTIONARY DEFINITION
 A difficulty in social adjustment
 Accompanied by poor coping skills
 And lack of insight

DSM IV DEFINITION
 Enduring pattern of
 “Behavior” [observable] and
 “Inner experience” [feelings]
 Pervasive and inflexible: Stable over time
 Deviates markedly from person’s cultural norms
 Onset in teens/early adulthood
 “Leads to distress or impairment”
AMERICAN PSYCHIATRIC ASSOCIATION DEFINITION
An enduring pattern of inner experience and behavior that deviated markedly from the
expectations of the culture of the individual who exhibits it.
JAMES PRITCHARD (FATHER OF PERSONALITY DISORDER)-DEFINITION
A morbid perversion of natural feelings afflictions, inclinations, temper, habits, moral
disposition and natural impulses without any remarkable disorder or intellect defects or knowing
and reasoning faculties and particularly without any insane illusion or hallucination
PREVALENCE AND INCIDENCE

 10% of the population.

 60% of inpatient psychiatry patients.
 12-100% of psychiatric outpatients with mood disorders.
 6-9% of population have one or more personality disorder
 Prevalence higher among people with other mental disorders
 Most people with personality disorders never come to the attention of mental health
professionals

HISTORICAL ASPECTS
The concept of a personality disorder has been described for thousands of years
(Phillips, Yen, & Gunderson,2003). In the 4th century B.C., Hippocrates concluded that all disease
stemmed from an excess of or imbalance among four bodily humors: yellow bile, black bile, blood,
and phlegm. Hippocrates identified four fundamental personality styles that he concluded stemmed
from excesses in the four humors: the irritable and hostile choleric (yellow bile); the pessimistic
melancholic (black bile); the overly optimistic and extraverted sanguine (blood); and the apathetic
phlegmatic(phlegm).Within the profession of medicine, the first recognition that personality
disorders, apart from psychosis, were cause for their own special concern was in 1801,with the
recognition that an individual can behave irrationally even when the powers of intellect are
intact .Nineteenth-century psychiatrists embraced the term moral insanity, the concept of which
defines what we know today as personality disorders. A major difficulty for psychiatrists has been
the establishment of a classification of personality disorders.

CLASSIFICATION
DSM-IV-TR provides specific criteria for diagnosing these disorders. The DSM-IV-TR
groups the Personality disorders into three clusters. These clusters, and the disorders classified
under each, are described as follows:
Cluster A
 1. Paranoid: Seeks autonomy
 2. Schizoid: Seeks solitude
 3. Schizotypal: Seeks self-expression
Schizotypal
Reduced capacity for close interpersonal relationships, eccentric behavior, and peculiar
thought patterns
Schizoid
Inability and lack of desire to form attachments to others; impaired social relationships
Paranoid
Suspiciousness and mistrust of others; tendency to see self as blameless; on guard for
perceived attacks by others

Cluster B
Angry, self-centered, manipulative, demanding.
 1. Antisocial: Seeks excitement/thrills
 2. Borderline: Seeks love
 3. Histrionic: Seeks attention
 4. Narcissistic: Seeks admiration
Borderline :
Disregard for and violation of rights of others; Lack of moral development; deceitfulness;
shameless manipulation of others-Antisocial Instability in interpersonal relationships, affect, and
self-image, impulsiveness; chronic feelings of boredom; attempts at self-mutilation or suicide
Narcissistic:
Grandiosity and need for admiration; self promoting; lack of empathy
Histrionic
Excessive emotionality and attention seeking behavior; sexually provocative and seductive;
theatrical; overly concerned re: own attractiveness

Cluster C
Eager to please
 1. Avoidant: Seeks approval
 2. Dependent: Seeks parenting
 3. Obsessive-compulsive: Seeks control
Obsessive compulsive:
Excessive concern with perfectionism, order, rules, and trivial details; lack of
expressiveness and warmth; difficulty in relaxing and having fun
Dependent
Excessive need to be taken care of leading to submissive and clinging behavior;
indecisiveness– need others to make decisions for them or reassure them; to avoid losing approval,
never disagree
Avoidant
 Social inhibition and hypersensitivity to negative evaluation; shyness; intimate relationships
difficult without guarantee of acceptance
ICD 10 CLASSIFICATION
F60-F69Disorders of adult personality and behavior
F60 Specific personality disorders
F60.0 Paranoid personality disorder
F60.1 Schizoid personality disorder
F60.2 Dissocial personality disorder
F60.3 Emotionally unstable personality disorder
.30 Impulsive type
.31 Borderline type
F60.4 Histrionic personality disorder
F60.5 Anankastic personality disorder
F60.6 Anxious [avoidant] personality disorder
F60.7 Dependent personality disorder
F60.8 other specific personality disorders
F60.9 Personality disorder, unspecified
F61 Mixed and other personality disorders
F61.0 Mixed personality disorders
F61.1 Troublesome personality changes
F62 Enduring personality changes, not attributable to brain damage and disease
F62.0 Enduring personality change after catastrophic experience
F62.1 Enduring personality change after psychiatric illness
F62.8 Other enduring personality changes
F62.9 Enduring personality change, unspecified
CHARACTERISTICS
Personality disorders characterized by:
• Chronic interpersonal difficulties(interpersonal disorders)
• Problems with identity or sense of self
• Maladaptive traits that are enduring,inflexible and pervasive across a broad range of
personal and social situations
• Onset traced back at least to adolescence or early childhood Symptoms can be:
Ego dystonic
• Inconsistent with a person’s sense of self
• Unwanted
Ego syntonic
 • “Symptoms” are not alien to the person
• Part of who the person is

ETIOLOGY
Genetics or heredity
 Obsessive compulsive personality disorder
 Paranoid personality disorder
 Schizoid personality disorder
Family history
 Borderline personality disorder
 Antisocial personality disorder
Brain dysfunction
 Abnormal brain processing of emotionally discharged
 Low threshold of excitability of the limbic system
 Alteration in levels of neurotransmitters, release of toxic chemical substances
 Post traumatic stress disorder
 Developmental factors
 Child neglect
 Childhood trauma
 Parental rejection
 Chronic psychiatric illness
 Socio-cultural factors
 Broken families

RISK FACTORS

 Women may develop borderline personality disorder

 History of childhood abuse
 Family history of schizophrenia, personality disorders
 Child hood head injury
 Unstable family life
COMPLICATIONS
 Social isolation
 Substance abuse
 Depression, anxiety and eating disorders
 Self destructive behaviour. E.g. suicidal tendencies
  Violence and homicide
 Incarceration (committing serious crimes)

PARANOID PERSONALITY DISORDER

PPD is a type of psychological personality disorder characterized by an extreme level of
distrust and suspicion of others. Paranoid personalities are generally difficult to get along with, and
their combative and distrustful nature often elicits hostility in others. The negative social
interactions that result from their behavior then serve to confirm and reinforce their original
pessimistic expectations. Persons with PPD are unlikely to form many close relationships and are
typically perceived as cold and distant. They are quick to challenge the loyalty of friends and loved
ones and tend to carry long grudges (Dobbert 2007, Kantor 2004).
Paranoid personality disorder is a psychiatric diagnosis characterized by paranoia and a
pervasive, long-standing suspiciousness and generalized mistrust of others.

ETIOLOGY
 Chronic schizophrenia
 Delusional disorder
 Interpersonal causes
 Stressful environment
 Childhood includes a controlling parent who was abusive, cruel and/or sadistic
 Child learns to be fearful and mistrusting
 Learns not to ask for help, not to cry and to remain independent
INCIDENCE
It is more common in men than in women.

SUBTYPES
Theodore Millon identified five subtypes of paranoid. Any individual paranoid may exhibit
none or one of the following:
 fanatic paranoid- including narcissistic features
 malignant paranoid - including sadistic features
 objurgate paranoid - including compulsive features
 querulous paranoid - including negativistic (passive-aggressive) features
 insular paranoid - including avoidant features
FEATURES
 Suspicious
  Mistrustful
 Jealous
 Sensitive
 Resentful
 Bears grudges
 Self-importance
Diagnosis

The World Health Organization's ICD-10 lists paranoid personality disorder as (F60.0) Paranoid
personality disorder.
It is characterized by at least 3 of the following:
1. Excessive sensitivity to setbacks and rebuffs;
2. Tendency to bear grudges persistently, i.e. refusal to forgive insults and injuries or
slights;
3. Suspiciousness and a pervasive tendency to distort experience by misconstruing the
neutral or friendly actions of others as hostile or contemptuous;
4. A combative and tenacious sense of personal rights out of keeping with the actual
situation;
5. Recurrent suspicions, without justification, regarding sexual fidelity of spouse or
sexual partner;
6. Tendency to experience excessive self-importance, manifest in a persistent self-
referential attitude;
7. Preoccupation with unsubstantiated "conspiratorial" explanations of events both
immediate to the patient and in the world at large.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American
Psychiatric Association, 1994, pp. 637-638) describes Paranoid Personality Disorder as a pervasive
distrust and suspiciousness of others such that their motives are interpreted as malevolent,
beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of
the following:
 Suspects, without sufficient basis, that others are exploiting, harming, or deceiving
him or her;
 Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends
or associates;
 Is reluctant to confide in others because of unwarranted fear that the information
will be used maliciously against him or her;
 Reads hidden demeaning or threatening meanings into benign remarks or events;
  Persistently bears grudges, i.e., is unforgiving of insults , injuries, or slights
perceives attacks on his or her character or reputation that are not apparent to others
and is quick to react angrily or to counterattack;
 Have recurrent suspicions, without justification, regarding fidelity of spouse or
sexual partner.

TREATMENT
Counseling and Psychotherapy
Psychotherapy is the most promising method of treatment for Paranoid Personality
Disorder. People afflicted with this disorder have deep foundational problems that necessitate
intense therapy. A confident therapist-client relationship offers the most benefit to people with the
disorder, yet is extremely difficult to establish due to the dramatic skepticism of patients with this
condition. People with paranoid personality disorder rarely initiate treatment and often terminate it
prematurely. Likewise, building therapist-client trust requires great care and is complicated to
maintain even after a confidence level has been founded.
The long-term projection for people with paranoid personality disorder is bleak. Most
patients experience predominant symptoms of the disorder for the duration of their lifetime and
require consistent therapy.
Group therapy
Include family members encourage them to meet the self help group dedicated to recover
from this disorder
Supportive psychotherapy
Analyze the problem in dealing with other people, the patient’s motivations and possible
sources of paranoid traits, never challenge the patient’s thoughts too directly
Medications
 For anxious client -anti anxiety drugs prescribed
 During high stress or extreme agitation- low dose antipsychotic and neuroleptic
given
 For angry irritated and suspicious client- selective serotonin reuptake inhibitors
 To reduce symptoms- anti depressants given
PROGNOSIS
Chronic lifelong condition
NURSING MANAGEMENT
 Develop and maintain therapeutic nurse patient relationship
 Encourage the client for effective communication
 Monitor the client’s behavior
  Provide safe and conducive environment to protect self and others
 Teach alternative ways of coping strategies and problem solving techniques in overcoming
the problematic situations
 Family education activities are carried out to assist the client in dealing with the sensitive
situation
 Encourage for healthy interactions and identify the stressors for the frustration
 Never whisper or criticize in front of the client
 Encourage the client not to have inhibitions, hesitation, support the client in stressful time
 Provide support and guidance to the client, where he is performing the activities in a
desirable manner
 Motivate the client to express his feelings openly, outwardly
 Sincerity, honesty, concern to the clients feelings is required, be consistent and firm
 Be nonjudgmental, avoid any discussions about the rules or requirements, counsel the
client, teach the alternative strategies to cope up.

SCHIZOID PERSONALITY DISORDER

Schizoid personality disorder (SPD) is a personality disorder characterized by a lack of

interest in social relationships, a tendency towards a solitary lifestyle, secretiveness, and emotional
coldnessSchizoid personality disorder is a psychiatric condition in which a person has a lifelong
pattern of indifference to others and social isolation.

Schizoid personality disorder is characterized by a persistent withdrawal from social

relationships and lack of emotional responsiveness in most situations. It is sometimes referred to as
a "pleasure deficiency" because of the seeming inability of the person affected to experience joyful
or pleasurable responses to life situations.

CAUSES
 The schizoid personality disorder has its roots in the family of the affected person.
 These families are typically emotionally reserved, have a high degree of formality, and have
a communication style that is aloof and impersonal.
 Parents usually express inadequate amounts of affection to the child and provide
insufficient amounts of emotional stimulus. This lack of stimulus during the first year of life
is thought to be largely responsible for the person's disinterest in forming close, meaningful
relationships later in life.
  People with schizoid personality disorder have learned to imitate the style of interpersonal
relationships modeled in their families. In this environment, affected people fail to learn
basic communication skills that would enable them to develop relationships and interact
effectively with others.
 Their communication is often vague and fragmented, which others find confusing. Many
individuals with schizoid personality disorder feel misunderstood by others.

SYMPTOMS
 Avoids close relationships: People with this disorder show no interest or enjoyment in
developing interpersonal relationships; this may also include family members. They
perceive themselves as social misfits and believe they can function best when not dependent
on anyone except themselves. They rarely date, often do not marry, and have few, if any,
friends.
 Prefers solitude: They prefer and choose activities that they can do by themselves without
dependence upon or involvement by others. Examples of activities they might choose
include mechanical or abstract tasks such as computer or mathematical games.
 Avoids sex: There is typically little or no interest in having a sexual experience with
another person. This would include a spouse if the affected person is married.
 Lacks pleasure: There is an absence of pleasure in most activities. A person with schizoid
personality disorder seems unable to experience the full range of emotion accessible to most
people.
 Lacks close friends: People affected with this disorder typically do not have the social
skills necessary to develop meaningful interpersonal relationships. This results in few
ongoing social relationships outside of immediate family members.
 Indifferent to praise or criticism: Neither positive nor negative comments made by others
elicit an emotionally expressive reaction. They don't appear concerned about what others
might think of them. Despite their tendency to turn inward to escape social contact, they
practice little introspection.
 Emotional detachment: Their emotional style is aloof and perceived by others as distant or
"cold." They seem unable or uninterested in expressing empathy and concern for others.
Emotions are significantly restricted and most social contacts would describe their
personality as very bland, dull or humorless. The person with schizoid personality disorder
rarely picks up on or reciprocates normal communicational cues such as facial expressions,
head nods, or smiles.
DSM
The Diagnostic and Statistical Manual of Mental Disorders fourth edition, a widely used manual
for diagnosing mental disorders, defines schizoid personality disorder (in Axis II Cluster A) as
A. A pervasive pattern of detachment from social relationships and a restricted range of
expression of emotions in interpersonal settings, beginning by early adulthood (age eighteen
or older) and present in a variety of contexts, as indicated by four (or more) of the
following:
1. neither desires nor enjoys close relationships, including being part of a family
2. almost always chooses solitary activities
3. has little, if any, interest in having sexual experiences with another person
4. takes pleasure in few, if any, activities
5. lacks close friends or confidants other than first-degree relatives
6. appears indifferent to the praise or criticism of others
7. shows emotional coldness, detachment, or flattened affect
B. Does not occur exclusively during the course of schizophrenia, a mood disorder with
psychotic features, another psychotic disorder, or a pervasive developmental disorder and is
not due to the direct physiological effects of a general medical condition.

The World Health Organization'sICD-10 lists schizoid personality disorder as (F60.1) Schizoid
personality disorder
It is characterized by at least four of the following criteria:
1. Emotional coldness, detachment or reduced affection.
2. Limited capacity to express either positive or negative emotions towards others.
3. Consistent preference for solitary activities.
4. Very few, if any, close friends or relationships, and a lack of desire for such.
5. Indifference to either praise or criticism.
6. Taking pleasure in few, if any, activities.
7. Indifference to social norms and conventions.
8. Preoccupation with fantasy and introspection.
9. Lack of desire for sexual experiences with another person.

SUBTYPES
Theodore Millon identified four subtypes of schizoid. Any individual schizoid may exhibit
none or one of the following:
  languid schizoid - including depressive features
 remote schizoid - including avoidant, schizotypal features
 depersonalized schizoid - including schizotypal features
 affectless schizoid - including compulsive features

DIAGNOSIS
The symptoms of schizoid personality disorder may begin in childhood or adolescence
showing as poor peer relationships, a tendency toward self-isolation, and underachievement in
school. Children with these tendencies appear socially out-of-step with peers and often become the
object of malicious teasing by their peers, which increases the feelings of isolation and social
ineptness they feel.
The diagnosis is based on a clinical interview to assess symptomatic behavior. Other
assessment tools helpful in diagnosing schizoid personality disorder include:
 Minnesota Multiphasic Personality Inventory (MMPI-2)
 Millon Clinical Multiaxial Inventory (MCMI-II)
 Rorschach Psychodiagnostic Test
 Thematic Apperception Test (TAT)

TREATMENTS

A major goal of treating a patient diagnosed with schizoid personality disorder is to combat
the tendencies toward social withdrawal. Strategies should focus on enhancing self-awareness and
sensitivity to their relational contacts and environment.
Psychodynamically oriented therapies
A psychodynamic approach would typically not be the first choice of treatment due to the
patient's poor ability to explore his or her thoughts, emotions, and behavior. When this treatment is
used, it usually centers around building a therapeutic relationship with the patient that can act as a
model for use in other relationships.
Cognitive-behavioral therapy
Attempting to cognitively restructure the patient's thoughts can enhance self-insight.
Constructive ways of accomplishing this would include concrete assignments such as keeping daily
records of problematic behaviors or thoughts. Another helpful method can be teaching social skills
through role-playing. This might enable individuals to become more conscious of communication
cues given by others and sensitize them to others' needs.
Group therapy
Group therapy may provide the patient with a socializing experience that exposes them to
feedback from others in a safe, controlled environment. It can also provide a means of learning and
practicing social skills in which they are deficient. Since the patient usually avoids social contact,
timing of group therapy is of particular importance. It is best to develop first a therapeutic
relationship between therapist and patient before starting a group therapy treatment.
Family and marital therapy
It is unlikely that a person with schizoid personality disorder will seek family therapy or
marital therapy. If pursued, it is usually on the initiative of the spouse or other family member.
Many people with this disorder do not marry and end up living with and are dependent upon first-
degree family members. In this case, therapy may be recommended for family members to educate
them on aspects of change or ways to facilitate communication. Marital therapy (also called
couples therapy ) may focus on helping the couple to become more involved in each other's lives or
improve communication patterns.

Medications
Some patients with this disorder show signs of anxiety and depression which may prompt
the use of medication to counteract these symptoms. In general, there is to date no definitive
medication that is used to treat schizoid symptoms.

PROGNOSIS
Since a person with schizoid personality disorder seeks to be isolated from others, which
includes those who might provide treatment, there is only a slight chance that most patients will
seek help on their own initiative. Those who do may stop treatment prematurely because of their
difficulty maintaining a relationship with the professional or their lack of motivation for change.
If the degree of social impairment is mild, treatment might succeed if its focus is on
maintenance of relationships related to the patient's employment. The patient's need to support him-
or herself financially can act as a higher incentive for pursuit of treatment outcomes.
Once treatment ends, it is highly likely the patient will relapse into a lifestyle of social
isolation similar to that before treatment.

PREVENTION
Since schizoid personality disorder originates in the patient's family of origin, the only
known preventative measure is a nurturing, emotionally stimulating and expressive caretaking
environment.
 SCHIZOTYPAL PERSONALITY DISORDER

Schizotypal personality disorder, or simply schizotypal disorder, is a personality disorder

that is characterized by a need for social isolation, odd behavior and thinking, and often
unconventional beliefs. Behavior pattern characterized by inability to form close relationships and
pattern of cognitive and perceptual distortions and eccentricities

ETIOLOGY
Genetic cause
schizotypal PD is an "extended phenotype" that helps geneticists track the familial or
genetic transmission of the genes that are implicated in schizophrenia

Social / Environmental
People with schizotypal PD, like patients with schizophrenia, may be quite sensitive to
interpersonal criticism and hostility, and there is now evidence to suggest that parenting styles,
early separation, and early childhood neglect can lead to the development of schizotypal traits

INCIDENCE
Most maintain their personality

 3% of the population.
 Sex ratio is unknown.
 Greater association among biological relatives of schizophrenic patients.
 The premorbid personality of the schizophrenic patient.

SUBTYPES
Theodore Millon identified two subtypes of schizotypal . Any individual schizotypal may
exhibit none or one of the following:
Insipid schizotypal - a structural exaggeration of the passive-detached pattern. They include
schizoid, depressive, dependent features.
Timorous schizotypal- a structural exaggeration of the active-detached pattern. They include
avoidant, negativistic (passive-aggressive) features
ESSENTIAL FEATURES

 Demonstrates pervasive pattern of acute discomfort with social and interpersonal

 Exhibits cognitive or perceptual distortions
 Must exhibit 5 of the following

o Ideas of reference
 o Odd beliefs or magical thinking
o Unusual perceptual experiences
o Odd speech
o Suspiciousness or paranoid ideation
o Behavior or appearance that is odd, eccentric
o Excessive social anxiety
o Lacks ability to form close relationship

CHARACTERISTICS

 Ideas of reference (excluding delusions of reference).

 Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural
norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”).
 Unusual perceptual experiences, including bodily illusions.
 Odd thinking and speech (e.g., vague, circumstantial, metaphorical, over elaborate, or
stereotyped).
 Suspiciousness or paranoid ideation.
 Inappropriate or constricted affect.
 Behavior or appearance that is odd, eccentric. Or peculiar.
 Lack of close friends or confidants other than first-degree relatives.
 Excessive social anxiety that does not diminish with familiarity and tends to be associated
with paranoid fears rather than negative judgments about self.

DIAGNOSIS

The World Health Organization's ICD-10 lists schizotypal personality disorder as (F21.)
Schizotypal disorder.
A disorder characterized by eccentric behavior and anomalies of thinking and affect which
resemble those seen in schizophrenia, though no definite and characteristic schizophrenic
anomalies have occurred at any stage. There is no dominant or typical disturbance, but any of the
following may be present:
 Inappropriate or constricted affect (the individual appears cold and aloof);
 Behavior or appearance that is odd, eccentric, or peculiar;
 Poor rapport with others and a tendency to social withdrawal;
  Odd beliefs or magical thinking, influencing behaviour and inconsistent with
subcultural norms;
 Suspiciousness or paranoid ideas;
 Obsessive ruminations without inner resistance, often with dysmorphophobic,
sexual or aggressive contents;
 Unusual perceptual experiences including somatosensory (bodily) or other illusions,
depersonalization or derealization;
 Vague, circumstantial, metaphorical, overelaborate, or stereotyped thinking,
manifested by odd speech or in other ways, without gross incoherence;
 Occasional transient quasi-psychotic episodes with intense illusions, auditory or
other hallucinations, and delusion-like ideas, usually occurring without external
provocation.
DIFFERENTIAL DIAGNOSIS
There is a high rate of comorbidity with other personality disorders. McGlashan et al.
(2000) stated that this may be due to overlapping criteria with other personality disorders, such as
avoidant personality disorder, paranoid personality disorder and borderline personality disorder.
There are many similarities between the schizotypal and schizoid personalities. Most notable of the
similarities is the inability to initiate or maintain relationships

NURSING MANAGEMENT
 Do not ridicule or judge.
 Respect their need for privacy.
 Nurse should offer time and support,unconditionally
 Nurse should provide unconditional acceptance, realistic feedback

ANTISOCIAL PERSONALITY DISORDER

Antisocial Personality Disorder (ASPD or APD) is defined by the American Psychiatric

Association's Diagnostic and Statistical Manual as "...a pervasive pattern of disregard for, and
violation of, the rights of others that begins in childhood or early adolescence and continues into
adulthood.
Antisocial personality disorder is specifically a pervasive pattern of disregarding and
violating the rights of others and may include symptoms such as breaking laws, frequent lying,
starting fights, lack of guilt and taking personal responsibility, and the presence of irritability and
impulsivity.
CHARACTERISTICS
1. Acting out or acting on – aggression
2. Getting “over on” – power and control
3. Lack of concern and sensitivity for others – Exploitive of others
4. Lack of self-care
5. Emotional deprivation
6. Inability to self-stimulate
7. Perception of self as victim, disowning responsibility, Lack of guilt
8. Persistent lying or stealing
9. Cruelty to animals
10. Poor behavioral controls — expressions of irritability, annoyance, impatience, threats,
aggression, and verbal abuse; inadequate control of anger and temper
11. A history of childhood conduct disorder
12. Recurring difficulties with the law
13. Tendency to violate the boundaries and rights of others
14. Substance abuse
15. Aggressive, often violent behavior; prone to getting involved in fights
16. Inability to tolerate boredom
17. Disregard for safety
ETIOLOGY

Antisocial personality disorder tends to be the result of a combination of biologic/genetic and

environmental factors.
 In those with antisocial personality disorder, the part of the brain that is primarily
responsible for learning from one's mistakes and for responding to sad and fearful facial
expressions (the amygdala) tends to be smaller and respond less robustly to the happy, sad,
or fearful facial expressions of others. That lack of response may have something to do with
the lack of empathy that antisocial individuals tend to have with the feelings, rights, and
suffering of others.
 While some individuals may be more vulnerable to developing antisocial personality
disorder as a result of their particular genetic background, that is thought to be a factor only
when the person is also exposed to life events such as abuse or neglect that tend to put the
person at risk for development of the disorder..
  Other conditions that are thought to be risk factors for antisocial personality disorder
include substance abuse, attention deficit hyperactivity disorder (ADHD), and a reading
disorder or conduct disorder, which is diagnosed in children.
 People who experience a temporary or permanent brain dysfunction, also called organic
brain damage, are at risk for developing violent or otherwise criminal behaviors. Examples
of such life experiences include a history of childhood physical, sexual, or emotional abuse;
neglect; deprivation or abandonment; associating with peers who engage in antisocial
behavior; or a parent who is either antisocial or alcoholic
DIAGNOSIS
The Diagnostic and Statistical Manual of Mental Disorders fourth edition, DSM IV-TR
= 301.7, a widely used manual for diagnosing mental disorders, defines antisocial personality
disorder (in Axis II Cluster B) as:
A) There is a pervasive pattern of disregard for and the rights of others occurring since the
age of 15, as indicated by three (or more) of the following:
1. failure to conform to social norms with respect to lawful behaviors as indicated by
repeatedly performing acts that are grounds for arrest;
2. deceitfulness, as indicated by repeatedly lying, use of aliases, or conning others for
personal profit or pleasure;
3. impulsivity or failure to plan ahead;
4. irritability and aggressiveness, as indicated by repeated physical fights or assaults;
5. reckless disregard for safety of self or others;
6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work
behavior or honor financial obligations;
7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt,
mistreated, or stolen from another.
B) The individual is at least 18 years of age.
C) There is evidence of Conduct disorder with onset before age 15.
D) The occurrence of antisocial behavior is not exclusively during the course of
schizophrenia or a manic episode.

Other important characteristics of this disorder include that it is not diagnosed in children
(individuals younger than 18 years of age), but the affected person must have shown symptoms of
this diagnosis at least since 15 years of age.
WHO ICD 10
The World Health Organization's ICD-10 defines a conceptually similar disorder to
antisocial personality disorder called (F60.2) Dissocial personality disorder.
It is characterized by at least 3 of the following:
1. Callous unconcern for the feelings of others and lack of the capacity for empathy.
2. Gross and persistent attitude of irresponsibility and disregard for social norms, rules,
and obligations.
3. Incapacity to maintain enduring relationships.
4. Very low tolerance to frustration and a low threshold for discharge of aggression,
including violence.
5. Incapacity to experience guilt and to profit from experience, particularly
punishment.
6. Markedly prone to blame others or to offer plausible rationalizations for the
behavior bringing the subject into conflict. Persistent irritability
TREATMENT
Antisocial often have poor insight and may reject the diagnosis or deny their symptoms.
Antisocial patients who seek help (or are referred) can be offered evaluation and treatment
as outpatients. Patients can be offered an array of services, including
 Neuropsychological Assessment,
 Individual Psychotherapy,
 Medication Management, And
 Family or Marital Counseling.
Psychotherapy
Psychotherapy for people with ASP should focus on helping the individual understand the nature
and consequences of his disorder so he can be helped to control his behavior.
Cognitive therapy
 Cognitive therapy — first developed to help patients with depression — has recently been
applied to ASP.
 The therapist should set guidelines for the patient’s involvement, including regular
attendance, active participation and completion of any necessary work outside of office
visits.
 The patient who submits to therapy only to avoid a jail term is not intent on improving.
 The cognitive therapy’s major goal is to help the patient understand how he creates his own
problems and how his distorted perceptions prevent him from seeing himself the way others
view him.
  Therapists must be aware of their own feelings and remain vigilant to prevent their
emotional responses to their patients from disrupting the therapy process.
 No matter how determined the therapist may be to help an antisocial patient, it is possible
that the patient’s criminal past, irresponsibility and unpredictable tendency toward violence
may render him thoroughly unlikable.
 The best treatment prospects come with professionals well versed in ASP, who can
anticipate their emotions and present an attitude of acceptance without moralizing.

PROGNOSIS
Symptoms tend to peak during the late teenage years and early 20's. They may improve on
their own by a person's 40's.
COMPLICATIONS
Complications can include imprisonment and drug abuse.
PREVENTION

 Encourage social interaction, no punitive techniques, set definitive rules

 Decrease the development of problematicbehavior
 Reduce negative methods of behavior modification technique
 Formulate and inform rules for discipline and conduct
 Encourage study habits, minimize failures
 Guidance and counseling services
 Motivate the client to develop social interaction consistent approach, provide respect for

NURSING MANAGEMENT
 Observe the behaviour, set limits which are not acceptable
 Provide congenial safe and calm environment to express their feelings
 Explain in slow tone, the ways of unacceptable behaviour which is harmful to both, self and
to others
 Teach relaxation exercises and motivate them practice
 Teach self control behaviour modification techniques, allow him to practice
 Provide positive feedback for healthy independent behaviour.
 Enhance problem-solving skills, client’s strengths, coping skills.
 Teach the client how to adjust themselves in difficult situations.

HISTRIONIC PERSONALITY DISORDER

 Histrionic personality disorder, often abbreviated as HPD, is a type of personality disorder in
which the affected individual displays an enduring pattern of attention-seeking and excessively
dramatic behaviors beginning in early adulthood and present across a broad range of
situations.Individuals with HPD are highly emotional, charming, energetic, manipulative,
seductive, impulsive, erratic, and demanding.
It is a disorder characterized by a pattern of excessive emotionality and attention seeking
including an excessive need for approval and inappropriate seductiveness.
CAUSES
Neurochemical and physiological causes.
The tendency towards an excessively emotional reaction to rejection, common among patients
with HPD, may be attributed to a malfunction in a group of neurotransmitters called
catecholamines. (Norepinephrine belongs to this group of neurotransmitters.)
Developmental causes
 Early psychoanalysts proposed that the genital phase, Freud's fifth or last stage of
psychosexual development, is a determinant of HPD.
 Later psychoanalysts considered the oral phase, Freud's first stage of psychosexual
development, to be a more important determinant of HPD.
 Most psychoanalysts agree that a traumatic childhood contributes towards the development
of HPD.
 Some theorists suggest that the more severe forms of HPD derive from disapproval in the
early mother-child relationship.
Bio social learning causes.
 A biosocial model in psychology asserts that social and biological factors contribute to the
development of personality. Biosocial learning models of HPD suggest that individuals
may acquire HPD from inconsistent interpersonal reinforcement offered by parents.
 Proponents of biosocial learning models indicate that individuals with HPD have learned to
get what they want from others by drawing attention to themselves.

Socio cultural causes.

Studies of specific cultures with high rates of HPD suggest social and cultural causes of HPD.
For example, some researchers would expect to find this disorder more often among cultures that
tend to value uninhibited displays of emotion.

Personal variables:
 Researchers have found some connections between the age of individuals with HPD and the
behavior displayed by these individuals. The symptoms of HPD are long-lasting; however,
histrionic character traits that are exhibited may change with age.

SYMPTOMS
 Dramatic dress, striking makeup, theatrical entrance, seductive boasting about sexual
promiscuity
 Constantly seeks attention through excesses of emotional expression
 Crave being the center of attention
 Gain attention by talking or behaving seductively and dressing in ways that call attention to
themselves
 Personality is exaggerated but shallow
 May Cause Embarrassment To Others By Dramatic Public Displays
 Rapid EmotionalSwing,
 Seductive Behavior
 Inability to form close interpersonal relationships
 Uncomfortable in situations where he/she is not the center of attention
 Inappropriate sexually seductive behavior
 Has rapid shifts of emotions
 Considers relationships to be more intimated than they really are
 Leads to significant distress or impairment in social, occupational, or other important areas of
functioning

DSM-IV-TR LISTS EIGHT SYMPTOMS THAT FORM THE DIAGNOSTIC CRITERIA

FOR HPD:
 Center of attention: Patients with HPD experience discomfort when they are not the center of
attention.
 Sexually seductive: Patients with HPD displays inappropriate sexually seductive or provocative
behaviors towards others.
 Shifting emotions: The expression of emotions of patients with HPD tends to be shallow and to
shift rapidly.
 Physical appearance: Individuals with HPD consistently employ physical appearance to gain
attention for themselves.
 Speech style: The speech style of patients with HPD lacks detail. Individuals with HPD tend to
generalize, and when these individuals speak, they aim to please and impress.
 Dramatic behaviors: Patients with HPD display self-dramatization and exaggerate their
emotions.
 Suggestibility: Other individuals or circumstances can easily influence patients with HPD.
 Overestimation of intimacy: Patients with HPD overestimate the level of intimacy in a
relationship.
HIGH-RISK POPULATIONS

Individuals who have experienced pervasive trauma during childhood have been shown to be at
a greater risk for developing HPD as well as for developing other personality disorders.
CROSS-CULTURAL ISSUES
HPD may be diagnosed more frequently in Hispanic and Latin-American cultures and less
frequently in Asian cultures. Further research is needed on the effects of culture upon the
symptoms of HPD.
GENDER ISSUES
Clinicians tend to diagnose HPD more frequently in females; however, when structured
assessments are used to diagnose HPD, clinicians report approximately equal prevalence rates for
males and females. In considering the prevalence of HPD, it is important to recognize that gender
role stereotypes may influence the behavioral display of HPD and that women and men may
display HPD symptoms differently.
DIAGNOSIS
The diagnosis of HPD is frequently made on the basis of an individual's history and results from
unstructured and semi-structured interviews. (observation of appearance, behaviour, collection of
history, psychological evaluation)
TIME OF ONSET/SYMPTOM DURATION
Some psychoanalysts propose that the determinants of HPD date back as early as early
childhood. The pattern of craving attention and displaying dramatic behavior for an individual with
HPD begins by early adulthood. Symptoms can last a lifetime, but may decrease or change their
form with age
PSYCHOLOGICAL MEASURES
In addition to the interviews mentioned previously, self-report inventories and projective tests
can also be used to help the clinician diagnose HPD. The Minnesota Multiphasic Personality
Inventory-2 (MMPI-2) and the Millon Clinical Multiaxial Inventory-III (MCMI-III) are self-
report inventories with a lot of empirical support. Results of intelligence examinations for
individuals with HPD may indicate a lack of perseverance on arithmetic or on tasks that require
concentration.
DUAL DIAGNOSES
HPD has been associated with alcoholism and with higher rates of somatization disorder,
conversion disorder, and major depressive disorder. Personality disorders such as borderline,
narcissistic, antisocial, and dependent can occur with HPD.
Psychological measures
In addition to the interviews mentioned previously, self-report inventories and projective tests
can also be used to help the clinician diagnose HPD. The Minnesota Multiphasic Personality
Inventory-2 (MMPI-2) and the Millon Clinical Multiaxial Inventory-III (MCMI-III) are self-report
inventories with a lot of empirical support. Results of intelligence examinations for individuals
with HPD may indicate a lack of perseverance on arithmetic or on tasks that require concentration.
TREATMENTS
Psychodynamic therapy
 HPD, like other personality disorders, may require several years of therapy and may affect
individuals throughout their lives.
 Some professionals believe that psychoanalytic therapy is a treatment of choice for HPD
because it assists patients to become aware of their own feelings.
 Long-term psychodynamic therapy needs to target the underlying conflicts of individuals
with HPD and to assist patients in decreasing their emotional reactivity.
 Therapists work with thematic dream material related to intimacy and recall. Individuals
with HPD may have difficulty recalling because of their tendency to repress material.
Cognitive-behavioral therapy
Cognitive therapy
 Is a treatment directed at reducing the dysfunctional thoughts of individuals with HPD.
Such thoughts include themes about not being able to take care of oneself.
 Cognitive therapy for HPD focuses on a shift from global, suggestible thinking to a more
methodical, systematic, and structured focus on problems. Cognitive-behavioral training in
relaxation for an individual with HPD emphasizes challenging automatic thoughts about
inferiority and not being able to handle one's life.
 Cognitive-behavioral therapy teaches individuals with HPD to identify automatic thoughts,
to work on impulsive behavior, and to develop better problem-solving skills.
 Behavioral therapists employ assertiveness training to assist individuals with HPD to learn
to cope using their own resources. Behavioral therapists use response cost to decrease the
excessively dramatic behaviors of these individuals. Response cost is a behavioral
technique that involves removing a stimulus from an individual's environment so that the
response that directly precedes the removal is weakened.
Behavioral therapy
For HPD includes techniques such as modeling and behavioral rehearsal to teach patients about
the effect of their theatrical behavior on others in a work setting.

Group therapy
Group therapy is suggested to assist individuals with HPD to work on interpersonal
relationships. Psychodrama techniques or group role play can assist individuals with HPD to
practice problems at work and to learn to decrease the display of excessively dramatic behaviors.
Using role-playing, individuals with HPD can explore interpersonal relationships and outcomes to
understand better the process associated with different scenarios. Group therapists need to monitor
the group because individuals with HPD tend to take over and dominate others.

Family therapy
To teach assertion rather than avoidance of conflict, family therapists need to direct individuals
with HPD to speak directly to other family members. Family therapy can support family members
to meet their own needs without supporting the histrionic behavior of the individual with HPD who
uses dramatic crises to keep the family closely connected.
Medications
Pharmacotherapy is not a treatment of choice for individuals with HPD unless HPD occurs with
another disorder. For example, if HPD occurs with depression, antidepressants may be prescribed.
Medication needs to be monitored for abuse.
Alternativetherapies
Meditation has been used to assist extroverted patients with HPD to relax and to focus on their
own inner feelings. Some therapists employ hypnosis to assist individuals with HPD to relax when
they experience a fast heart rate or palpitations during an expression of excessively dramatic,
emotional, and excitable behavior.
PROGNOSIS
The personality characteristics of individuals with HPD are long-lasting. Individuals with HPD
utilize medical services frequently, but they usually do not stay in psychotherapeutic treatment
long enough to make changes. They tend to set vague goals and to move toward something more
exciting. Treatment for HPD can take a minimum of one to three years and tends to take longer
than treatment for disorders that are not personality disorders, such as anxiety disorders or mood
disorders.
 As individuals with HPD age, they display fewer symptoms. Some research suggests that the
difference between older and younger individuals may be attributed to the fact that older
individuals have less energy.
Research indicates that a relationship exists between poor treatment outcomes and premature
termination from treatment for individuals with Cluster B personality disorders. Some researchers
suggest that studies that link HPD to continuation in treatment need to consider the connection
between overestimates of intimacy and premature termination from therapy.

PREVENTION
Early diagnosis can assist patients and family members to recognize the pervasive pattern of
reactive emotion among individuals with HPD. Educating people, particularly mental health
professionals, about the enduring character traits of individuals with HPD may prevent some cases
of mild histrionic behavior from developing into full-blown cases of maladaptive HPD. Further
research in prevention needs to investigate the relationship between variables such as age, gender,
culture, and ethnicity and HPD.

NURSING MANAGEMENT

 Establish and maintain therapeutic nurse patient relationshippromote effective communication

strategies and healthy interactions
 Provide safe and calm (non- stimulating) environment
 Assist the client to understand the relationships realistically
 Encourage to take sufficient time in taking decisions

NARCISSITIC PERSONALITY DISORDER

DEFINITION
Narcissistic personality disorder (NPD) is defined by the Fourth Edition Text Revision of the
Diagnostic and Statistical Manual of Mental Disorders as one of ten personality disorders. As a
group, these disorders are described by DSM-IV-TR as "enduring pattern[s] of inner experience
and behavior" that are sufficiently rigid and deep-seated to bring a person into repeated conflicts
with his or her social and occupational environment.
NPD is defined more specifically as a pattern of grandiosity (exaggerated claims to talents,
importance, or specialness) in the patient's private fantasies or outward behavior; a need for
constant admiration from others; and a lack of empathy for others.
 The term narcissistic is derived from an ancient Greek legend, the story of Echo and Narcissus.
According to the legend, Echo was a woodland nymph who fell in love with Narcissus, who was
an uncommonly handsome but also uncommonly vain young man. He contemptuously rejected her
expressions of love. She pined away and died. The god Apollo was angered by Narcissus' pride and
self-satisfaction, and condemned him to die without ever knowing human love. One day, Narcissus
was feeling thirsty, saw a pool of clear water nearby, and knelt beside it in order to dip his hands in
the water and drink. He saw his face reflected on the surface of the water and fell in love with the
reflection. Unable to win a response from the image in the water, Narcissus eventually died beside
the pool.

CAUSES

Family origin causes. if the parents fail to provide appropriate opportunities for idealization and
mirroring, the child remains "stuck" at a developmental stage in which his or her sense of self
remains grandiose and unrealistic while at the same time he or she remains dependent on approval
from others for self-esteem.
Emotionally hungry and angry at the depriving parents, the child withdraws into a part of the
self that the parents value, whether looks, intellectual ability, or some other skill or talent. This part
of the self becomes hyperinflated and grandiose. Any perceived weaknesses are "split off" into a
hidden part of the self. Splitting gives rise to a lifelong tendency to swing between extremes of
grandiosity and feelings of emptiness and worthlessness.In both accounts, the child emerges into
adult life with a history of unsatisfactory relationships with others.

Macrosocial causes
In short, they argued that the advanced industrial societies contributed to the development of
narcissistic disorders in individuals in a number of respects. Some of the trends they noted include
the following:
 The mass media's preoccupation with "lifestyles of the rich and famous" rather than with
ordinary or average people.
 Social approval of open displays of money, status, or accomplishments ("if you've got it, flaunt
it") rather than modesty and self-restraint.
 Preference for a leadership style that emphasizes the leader's outward appearance and
personality rather than his or her inner beliefs and values.
 The growth of large corporations and government bureaucracies that favor a managerial style
based on "impression management" rather than objective measurements of performance.
 Social trends that encourage parents to be self-centered and to resent their children's legitimate
needs.
 The weakening of churches, synagogues, and other religious or social institutions that
traditionally helped children to see themselves as members of a community rather than as isolated
individuals.

SYMPTOMS
 A history of intense but short-term relationships with others; inability to make or sustain
genuinely intimate relationships
 A tendency to be attracted to leadership or high-profile positions or occupations
 A pattern of alternating between unrealistic idealization of others and equally unrealistic
devaluation of them
 Assessment of others in terms of usefulness
 A need to be the center of attention or admiration in a working group or social situation
 Hypersensitivity to criticism, however mild, or rejection from others
 An unstable view of the self that fluctuates between extremes of self-praise and self-contempt
 Preoccupation with outward appearance, "image," or public opinion rather than inner reality
 Painful emotions based on shame (dislike of who one is) rather than guilt (regret for what one
has done)

SUBTYPES
 Craving narcissists. These are people who feel emotionally needy and undernourished, and may
well appear clingy or demanding to those around them.
 Paranoid narcissists. This type of narcissist feels intense contempt for him- or herself, but
projects it outward onto others. Paranoid narcissists frequently drive other people away from them
by hypercritical and jealous comments and behaviors.
 Manipulative narcissists. These people enjoy "putting something over" on others, obtaining
their feelings of superiority by lying to and manipulating them.
 Phallic narcissists. Almost all narcissists in this subgroup are male. They tend to be aggressive,
athletic, and exhibitionistic; they enjoy showing off their bodies, clothes, and overall "manliness."
DIAGNOSIS
Diagnosis of NPD is usually made on the basis of several sources of information: the patient's
history and self-description, information from family members and others, and the results of
diagnostic questionnaires. One questionnaire that is often used in the process of differential
diagnosis is the Structured Clinical Interview for DSM-III-R Disorders, known as the SCID-II.
The most common diagnostic instrument used for narcissistic NPD is the Narcissistic
Personality Inventory (NPI). First published by Robert R. Raskin and Calvin S. Hall in 1979, the
NPI consists of 223 items consisting of paired statements, one reflecting narcissistic traits and the
other nonnarcissistic. Subjects are required to choose one of the two items. The NPI is widely used
in research as well as diagnostic assessment.

DIAGNOSTIC CRITERIA
DSM-IV-TR specifies nine diagnostic criteria for NPD. For the clinician to make the diagnosis, an
individual must fit five or more of the following descriptions:
 He or she has a grandiose sense of self-importance (exaggerates accomplishments and demands
to be considered superior without real evidence of achievement).
 He or she lives in a dream world of exceptional success, power, beauty, genius, or "perfect"
love.
 He or she thinks of him- or herself as "special" or privileged, and that he or she can only be
understood by other special or high-status people.
 He or she demands excessive amounts of praise or admiration from others.
 He or she feels entitled to automatic deference, compliance , or favorable treatment from others.
 He or she is exploitative towards others and takes advantage of them.
 He or she lacks empathy and does not recognize or identify with others' feelings.
 He or she is frequently envious of others or thinks that they are envious of him or her.
 He or she "has an attitude" or frequently acts in haughty or arrogant ways.

TREATMENTS
Treatments for NPD include a variety of pharmacologic, individual, and group approaches

Medication
Patients with NPD who are also depressed or anxious may be given drugs for relief of those
symptoms. There are anecdotal reports in the medical literature that the selective serotonin
reuptake inhibitors, or SSRIs, which are frequently prescribed for depression, reinforce narcissistic
grandiosity and lack of empathy with others.
Psychotherapy
Several different approaches to individual therapy have been tried with NPD patients, ranging
from classical psychoanalysis and Adlerian therapy to rational emotive approaches and Gestalt
therapy . The consensus that has emerged is that therapists should set modest goals for treatment
with NPD patients. Most of them cannot form a sufficiently deep bond with a therapist to allow
healing of early-childhood injuries.
An additional factor that complicates psychotherapy with NPD patients is the lack of agreement
among psychiatrists about the causes and course of the disorder. One researcher has commented
that much more research is necessary to validate DSM-IV-TR 's description of NPD before
outcome studies can be done comparing different techniques of treatment.

Hospitalization
Low-functioning patients with NPD may require inpatient treatment, particularly those with
severe self-harming behaviors or lack of impulse control. Hospital treatment, however, appears to
be most helpful when it is focused on the immediate crisis and its symptoms rather than the
patient's underlying long-term difficulties.

PROGNOSIS
The outlook for long-standing NPD, however, is largely negative. Some narcissists are able,
particularly as they approach their midlife years, to accept their own limitations and those of
others, to resolve their problems with envy, and to accept their own mortality.
Most patients with NPD, on the other hand, become increasingly depressed as they grow older
within a youth-oriented culture and lose their looks and overall vitality. The retirement years are
especially painful for patients with NPD because they must yield their positions in the working
world to the next generation. In addition, they do not have the network of intimate family ties and
friendships that sustain most older people.

PREVENTION
 The best hope for prevention of NPD lies with parents and other caregivers who are close to
children during the early preschool years.
 Parents must be able to demonstrate empathy in their interactions with the child and with each
other.
 They must also be able to show that they love their children for who they are, not for their
appearance or their achievements.
 And they must focus their parenting efforts on meeting the child's changing needs as he or she
matures, rather than demanding that the child meet their needs for status, comfort, or convenience.
 Nursing management
 Develop and maintain therapeutic nurse-patient relationship
 Encourage the family members to have healthier interaction and relationship with their children
 Promote “ emotional bondage” among family members
 Enhance “parent –child relationship”
 Set clear realistic goals, where the child can achieve it
 Set limitations for unacceptable behaviour
 Adopt consistent approach

BORDER LINE PERSONALITY DISORDER

Borderline personality disorder (BPD) is a personality disorder defined in DSM-IV and
described as a prolonged disturbance of personality function in a person (generally over the age of
eighteen years, although it is also found in adolescents), characterized by depth and variability of
moods
A mental illness is characterized by emotional deregulations, extreme ‘black and white’ thinking
or splitting and chaotic relationships.
A pervasive pattern of instability of interpersonal relationship, self image and marked
impulsivity, beginning in early adulthood and present in a variety of contexts

SUBTYPES
Theodore Millon identified four subtypes of borderline. Any individual borderline may exhibit
none, or one or more of the following:
 Discouraged borderline — including avoidant, depressive or dependent features
 Impulsive borderline — including histrionic or antisocial features
 Petulant borderline — including negativistic (passive-aggressive) features
 Self-destructive borderline — including depressive or masochistic features

CAUSES
 Biologically, individuals with BPD are more likely to have an overactive amygdala, the area of
the brain that is understood to regulate emotions.
 Psychologically, BPD seems to make a person more vulnerable to difficulty managing their
emotions, particularly impulsive aggression.
 Socially, this disorder predisposes sufferers to be more likely to excessively expect to be
criticized or rejected and negatively personalize disinterest or inattention from others.
 In addition to these issues, people with BPD are more likely to have suffered from childhood
abuse or neglect.

RISK FACTORS
 Adults that come from families of origin where divorce, neglect, sexual abuse, substance abuse,
or death occurred are at higher risk of developing BPD.
 Children also appear to be at risk for developing this disorder when they have a learning
problem or certain temperaments.
 Adolescents who develop an alcohol-use disorder are also apparently at higher risk of
developing BPD compared to those who do not.

SYMPTOMS
 Unstable self-image, in that they may drastically and rapidly change in the way they perceive
their own likes, dislikes, strengths, weaknesses, goals, and intrinsic value as a person
 Unstable relationships, in that individuals with this disorder rapidly, drastically, and often
frequently change from seeing another person as nearly perfect (idealizing) to seeing the other
person as being virtually worthless (devaluing)
 Unstable emotions (affects), in that the sufferer experiences marked, rapid changes in feelings
(for example, anger, joy, euphoria, anxiety, and depression) that are stress related, even if the
stresses may be seen as minor or negligible to others
 Desperate efforts to avoid being abandoned, whether the abandonment is real or imagined
 Significant impulsivity, in that the person with BPD tends to act before thinking to the point that
it is self-damaging (for example, sexual behaviors, spending habits, eating habits, driving
behaviors, or in the use of substances)
 Recurring suicidal behaviors, threats, or attempts
 Chronic feelings of emptiness
 Inappropriate, intense anger or difficulty managing their anger when it occurs
 Transient, stress-related paranoia or severe dissociation (lapses in memory)

DIAGNOSIS
 Self reported experience of the client
 A comprehensive personal and family history
 A physical examination
 Blood tests to exclude HIV or syphilis
 EEG, CT scan to exclude epilepsy and brain lesions
 The Diagnostic and Statistical Manual of Mental Disorders fourth edition, DSM IV-TR, a
widely used manual for diagnosing mental disorders, defines borderline personality disorder
(In Axis II Cluster B) as:
A pervasive pattern of instability of interpersonal relationships, self-image and affects, as well
as marked impulsivity, beginning by early adulthood and present in a variety of contexts, as
indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating
between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex, eating
disorders, binge eating, substance abuse, reckless driving).
5. Recurrent suicidal behavior, gestures, threats or self-injuring behavior such as cutting,
interfering with the healing of scars (excoriation) or picking at oneself.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,
irritability or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness
8. Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant
anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms

INTERNATIONAL CLASSIFICATION OF DISEASE

The World Health Organization's ICD-10 defines a conceptually similar disorder to borderline
personality disorder called (F60.3) Emotionally unstable personality disorder. It has two subtypes
described below.

F60.30 Impulsive type

At least three of the following must be present, one of which must be (2):
1. Marked tendency to act unexpectedly and without consideration of the consequences;
2. Marked tendency to quarrelsome behaviour and to conflicts with others, especially when
impulsive acts are thwarted or criticized;
3. Liability to outbursts of anger or violence, with inability to control the resulting behavioural
explosions;
4. Difficulty in maintaining any course of action that offers no immediate reward;
5. Unstable and capricious mood.

F60.31 Borderline type

At least three of the symptoms mentioned in F60.30 Impulsive type must be present, with at
least two of the following in addition:
1. Disturbances in and uncertainty about self-image, aims, and internal preferences (including
sexual);
2. Liability to become involved in intense and unstable relationships, often leading to emotional
crisis;
3. Excessive efforts to avoid abandonment;
4. Recurrent threats or acts of self-harm;
5. Chronic feelings of emptiness.

TREATMENT
Different forms of psychotherapy have been found to effectively treat BPD.
Dialectical behavior therapy(DBT) is an approach to psychotherapy in which the therapist
specifically addresses four areas that tend to be particularly problematic for individuals with BPD:
self-image, impulsive behaviors, mood instability, and problems in relating to others. To address
those areas, DBT tries to build four major behavioral skill areas:
 Mindfulness,
 Distress tolerance,
 Emotional regulation, and
 Interpersonal effectiveness.

Talk therapy that focuses on helping the person understand how their thoughts and behaviors
affect each other
Cognitive behavioral therapyhas also been found to be effective treatment for BPD.
Interpersonal psychotherapy (IPT)
ITP is an approach that focuses on how the person's symptoms are related to the problems that
person has in relating to others.
Psychoanalytic therapy, which seeks to help the individual understand and better manage his or
her ways of defending against negative emotions, has been found to be effective in addressing
BPD, especially when the therapist is more active or vocal than in traditional psychoanalytic
treatment and is used in the context of current rather than past relationships.
The use of psychiatric medications, like antidepressants (for example, fluoxetine [Prozac],
sertraline [Zoloft], citalopram [Celexa], escitalopram [Lexapro], or trazodone [Desyrel]),
Mood stabilizers (for example, divalproex sodium [Depakote], carbamazepine [Tegretol], or
lamotrigine [Lamictal]) or
Antipsychotics(for example, olanzapine [Zyprexa], risperidone [Risperdal], aripiprazole [Abilify],
or paliperidone [Invega])may be useful in addressing some of the symptoms of BPD but do not
manage the illness in its entirety.

Partial hospitalization is an intervention that involves the individual with mental illness being in a
hospital-like environment during the day but returning home each evening.
 In addition to providing a safe environment and frequent monitoring by mental-health
professionals, partial hospitalization programs allow for more frequent mental-health interventions
like professional assessments, psychotherapy, and medication treatment.
 While funding for a long-term stay in a partial hospitalization may be difficult, research shows
that when it is provided using a psychoanalytic approach it may help the person with BPD enjoy a
decrease in the severity of anxiety and depression, the frequency of suicide attempts and full
hospitalizations, as well as developing improved relationships with others.

COMPLICATIONS

 Post traumatic stress disorder

 Suicidal attempt
 Antisocial personality disorder

PROGNOSIS
Steady employment or school status, once symptoms of BPD, once symptoms of BPD subside
(remit) tends to protect BPD sufferers from experiencing a future relapse.

NURSING MANAGEMENT

 Place the client near to the nurses’ station

 Have a keen insight into client’s behaviour in all the means
 Based on client’s need one- to – one relationship has to be maintained
 Identify the stressors which promote undesirable behaviour of the client, try to avoid them
 If the client is developing destructive behavioural tendency, observe closely, never allow the
client to keep potentially dangerous objects in the client’s environment
 Give positive reinforcement for client’s appropriate behaviour
 Never do argument or criticism for client’s activities

AVOIDANCE PERSONALITY DISORDER

Avoidance personality disorder (AvPD (or anxious personality disorder) is a personality

disorder recognized in the DSM-IV TR handbook in a person over the age of eighteen years as
characterized by a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity
to negative evaluation, and avoidance of social interaction.

A pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative

evaluation, begins by early adulthood and present in a variety of contexts
-American Psychiatric Association

CAUSES

 Perceived or actual criticism or repeated rejection by parent or peers in childhood.

 Interpersonal difficulties
 A combination of social, genetic and biological factors
 Temperamental factors: anxiety disorders in childhood and adolescence have been
associated with temperament characterized by behavioral inhibition
 Chronic parental or societal criticism or rejection: The need to bond with rejecting parents
or peers makes the person with AvPD hungry for relationships, but their longing gradually
develops into a defensive shell of self protection against respected criticisms.

SIGNS AND SYMPTOMS

People with AvPD are preoccupied with their own shortcomings and form relationships with
others only if they believe they will not be rejected. Loss and rejection are so painful that these
individuals will choose to be lonely rather than risk trying to connect with others.
 Hypersensitivity to criticism or rejection
 Self-imposed social isolation
 Extreme shyness or social anxiety in social situations, though feels a strong desire for close
relationships
 Avoids physical contact because it has been associated with an unpleasant or painful stimulus
 Avoids interpersonal relationships
 Feelings of inadequacy
 Severe low self-esteem
 Self-loathing
 Mistrust of others
 Emotional distancing related to intimacy
 Highly self-conscious
 Self-critical about their problems relating to others
 Problems in occupational functioning
 Lonely self-perception
 Feeling inferior to others
 In some more extreme cases-- Agoraphobia
 Utilizes fantasy as a form of escapism and to interrupt painful thoughts
 Susceptibility to substance abuse as a way of escapism.

DIAGNOSIS
The World Health Organization's ICD-10 lists avoidant personality disorder as (F60.6) Anxious
(avoidant) personality disorder
It is characterized by at least 3 of the following:
1. persistent and pervasive feelings of tension and apprehension;
2. belief that one is socially inept, personally unappealing, or inferior to others;
3. excessive preoccupation with being criticized or rejected in social situations;
4. unwillingness to become involved with people unless certain of being liked;
5. restrictions in lifestyle because of need to have physical security;
6. avoidance of social or occupational activities that involve significant interpersonal contact
because of fear of criticism, disapproval, or rejection.

SUBTYPES
Psychologist Theodore Millon identified four subtypes of avoidant personality disorder. Any
individual avoidant may exhibit none or one of the following:

 Conflicted avoidant - including negativistic (passive-aggressive) features

The conflicted avoidant feels ambivalent towards themselves and others. They can idealize those
close to them but under stress they may feel under-appreciated or misunderstood and wish to hurt
others in revenge. They may be perceived as petulant or to be sulking.

Hypersensitive avoidant- including paranoid features

The hypersensitive avoidant experiences paranoia, mistrustfulness and fear, but to a lesser extent
than an individual with paranoid personality disorder. They may be perceived as petulant or "high-
strung".

 Phobic avoidant - including dependent features

 Self-deserting avoidant - including depressive features

DIFFERENTIAL DIAGNOSIS
 Chronic social anxiety disorder
 Anxiety disorders,
 Panic disorder
 Generalized anxiety disorder
 Obsessive-compulsive disorder.
 Borderline personality disorder

COMPLICATIONS

 Increased risk of: depression;

 Alcohol or drug abuse;
 Physical, emotional, or sexual abuse.
 Occupational functioning is impaired.
 Social relations tend to be limited

COMORBIDITY:

1. Mood Disorders,
2. Anxiety Disorders,
3. Adjustment Disorder, and
4. Other Personality Disorders (especially Borderline, Avoidant, and Histrionic)

PREVALENCE:
This disorder is more frequent in females, and is present in about 0.5% of the general population.

TREATMENT

Treatment of AvPD can employ various techniques, such as

 Social skills training,
 Cognitive therapy,
 Exposure treatment to gradually increase social contacts,
 Group therapy for practicing social skills,
 Drug therapy.

A key issue in treatment is gaining and keeping the patient's trust, since people with AvPD will
often start to avoid treatment sessions if they distrust the therapist or fear rejection.

The primary purpose of both individual therapy and social skills group training is for individuals
with AvPD to begin challenging their exaggeratedly negative beliefs about themselves.

DEPENDENT PERSONALITY DISORDER

Dependent personality disorder (DPD), formerly known as asthenic personality disorder, is a

personality disorder that is characterized by a pervasive psychological dependence on other people

A pervasive and excessive need to be taken care of that leads to a submissive and clinging
behaviour as well as fears of separation. The dependent and submissive behaviors are designed to
elicit care giving and arise from a self perceptions of being unable to function adequately without
the help of others.

INCIDENCE
Common in women than men, it begins in early adulthood is present in a variety of contexts.
ESSENTIAL FEATURES

 Has difficulty making everyday decisions

 Needs others to assume responsibility for major areas of his/her life
  Has difficulty expressing disagreement
 Has difficulty initiating projects
 Goes to excessive lengths to obtain nurturance from others
 Feels uncomfortable or helpless when alone
 Urgently seeks relationships as a source of care or support
 Unrealistically preoccupied with fears of being left to take care of self
 Has a need to be taken care of by others
 Clinging and submissive
 Has trouble making decisions
 Has trouble expressing disagreements with others
 Are not independent
 Problematic oral habits: Eating, smoking, drinking, addictions

ETIOLOGY
 Early childhood, parents did not stop nurturing the child when it was
developmentally appropriate to do so
 Offered too much protectiveness
 Child becomes incompetent and begins to believe he/she cannot do anything
 Clinging parental behavior

DIAGNOSIS

The World Health Organization's ICD-10 lists dependent personality disorder as (F60.7)
Dependent personality disorder.
It is characterized by at least 3 of the following:
1. encouraging or allowing others to make most of one's important life decisions;
2. subordination of one's own needs to those of others on whom one is dependent, and
undue compliance with their wishes;
3. unwillingness to make even reasonable demands on the people one depends on;
4. feeling uncomfortable or helpless when alone, because of exaggerated fears of
inability to care for oneself;
5. preoccupation with fears of being abandoned by a person with whom one has a
close relationship, and of being left to care for oneself;
6. limited capacity to make everyday decisions without an excessive amount of advice
and reassurance from others.
 Associated features may include perceiving oneself as helpless, incompetent, and lacking
stamina.

SUBTYPES

Psychologist Theodore Millon identified five adult subtypes of dependent personality disorder.
Any individual dependent may exhibit none or one of the following:
 disquieted dependant — including avoidant features
 accommodating dependant — including histrionic features
 immature dependant — variant of pure pattern
 ineffectual dependant — including schizoid features
 selfless dependant — including masochistic features

DIFFERENTIAL DIAGNOSIS
The following conditions commonly coexist (comorbid) with dependent personality disorder
 mood disorders
 anxiety disorders
 adjustment disorder
 borderline personality disorder
 avoidant personality disorder
 histrionic personality disorder

TREATMENT
Treatment goals:
 preventing further deterioration,
 regaining an adaptive equilibrium,
 alleviating symptoms,
 restoring lost skills, and
 fostering improved adaptive capacity
Treatment interventions
 Teach more adaptive methods of managing distress
 Improving interpersonal effectiveness
 Building skills for effective regulation
Group therapy:
Most clinicians use weekly sessions of an hour to an hour and a half. Treatment generally lasts
several years.
Biological therapies:
Selective serotonin reuptake inhibitor treatment has found important in improvement of self
reported dependent symptoms.
Residential and day treatment therapies:
Active treatment days varied from 4 to 5 days per week over a range of 17 – 30 weeks usually
involved group and individual sessions, most within a dynamic framework.
Drug therapy- antidepressants, sedatives and tranquillizers
NURSING MANAGEMENT
 Assess behaviour pattern of an individual
 Provide guidance and counseling, individual psychotherapy may be of helpful
 Identify the abilities, strengths and motivate them to utilize it in overcoming or handling
stressful situations
 Encourage them to solve their problems on their own efforts and lead an independent life
 Motivate family members to provide situational support, concern, love in the time of need
 Certain behavior modification techniques can be used to substitute maladaptive behaviour
in to adaptive strategies and assertiveness techniques
 Family members have to help to raise the self confidence of the client
 Encourage the significant personalities to give supporting hand by making the client ot be
assertive and independent

OBSESSIVE COMPULSIVE PERSONALITY DISORDER

Obsessive-Compulsive Personality Disorder is characterized by a preoccupation with

orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility,
openness, and efficiency
An anxiety disorder, characterized by a subject’s obsessive distressing, intrusive thoughts and
related compulsions (tasks or rituals) which attempt to neutralize the obsessions.

Obsessive-compulsive personality disorder (OCPD) is a type of personality disorder marked by

rigidity, control, perfectionism, and an overconcern with work at the expense of close interpersonal
relationships. Persons with this disorder often have trouble relaxing because they are preoccupied
with details, rules, and productivity. They are often perceived by others as stubborn, stingy, self-
righteous, and uncooperative.
SYMPTOMS
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and
interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early
adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
 Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that
the major point of the activity is lost
 Shows perfectionism that interferes with task completion (e.g., is unable to complete a
project because his or her own overly strict standards are not met)
 Is excessively devoted to work and productivity to the exclusion of leisure activities and
friendships (not accounted for by obvious economic necessity)
 Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values
(not accounted for by cultural or religious identification)
 Is unable to discard worn-out or worthless objects even when they have no sentimental
value
 Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her
way of doing things
 Adopts a miserly spending style toward both self and others; money is viewed as something
to be hoarded for future catastrophes
 Shows significant rigidity and stubbornness

CAUSES
 No single specific cause of OCPD has been identified.,
 Faulty parenting has been viewed as a major factor in the development of personality
disorders.
 Patients with OCPD often recall their parents as being emotionally withholding and either
overprotective or overcontrolling.
 People with OCPD appear to have been punished by their parents for every transgression of
a rule, no matter how minor, and rewarded for almost nothing. As a result, the child is
unable to safely develop or express a sense of joy, spontaneity, or independent thought, and
begins to develop the symptoms of OCPD as a strategy for avoiding punishment.
 Genetic contributions to OCPD have not been well documented.
  Cultural influences may, however, play a part in the development of OCPD. That is,
cultures that are highly authoritarian and rule-bound may encourage child-rearing practices
that contribute to the development of OCPD.

SUBTYPES

Theodore Millon identified five subtypes of compulsive. Any individual compulsive may exhibit
none or one of the following:
 conscientious compulsive- including dependent features
 Puritanical compulsive - including paranoid features.
 bureaucratic compulsive- including narcissistic features
 Parsimonious compulsive- including schizoid features.
 bedeviled compulsive - including negativistic (passive-aggressive) features

DIAGNOSTIC CRITERIA
Diagnosis of OCPD depends on careful observation and appropriate assessment of the
individual's behavior; the person must not only give evidence of the attitudes and behaviors
associated with OCPD, but these must be severe enough to interfere with their occupational and
interpersonal functioning.
A person who meets the DSMIV-TR criteria for OCPD must display at least four of them:
 Preoccupation with details, rules, lists, order, organization, or schedules to the point at
which the major goal of the activity is lost.
 Excessive concern for perfection in small details that interferes with the completion of
projects.
 Dedication to work and productivity that shuts out friendships and leisure-time activities,
when the long hours of work cannot be explained by financial necessity.
 Excessive moral rigidity and inflexibility in matters of ethics and values that cannot be
accounted for by the standards of the person's religion or culture.
 Hoarding things, or saving worn-out or useless objects even when they have no sentimental
or likely monetary value.
 Insistence that tasks be completed according to one's personal preferences.
 Stinginess with the self and others.
 Excessive rigidity and obstinacy.
TREATMENTS

Psychotherapy
 Psychotherapeutic approaches to the treatment of OCPD have found insight-oriented
psychodynamic techniques and cognitive behavioral therapy to be helpful for many
patients.
 Learning to find satisfaction in life through close relationships and recreational outlets,
instead of only through work-related activities, can greatly enrich the OCPD patient's
quality of life.
 Specific training in relaxation techniques may help patients diagnosed with OCPD.

Behavioral psychotherapy:

 Discussing with a psychotherapist ways of changing compulsions into healthier, productive

behaviors. An effective form of this therapy has been found to be cognitive analytic therapy
 Exposure and ritual prevention technique involves gradually learning to tolerate the anxiety
associated with not performing the ritual behaviour.

Cognitive therapy

Medications
 More recent studies, however, indicate that treatment with specific drugs may be a useful
adjunct (help) to psychotherapy. In particular, the medications known as selective serotonin
reuptake inhibitors (SSRIs) appear to help the OCPD patient with his or her rigidity and
compulsiveness, even when the patient did not show signs of pre-existing depression.
 Medication can also help the patient to think more clearly and make decisions better and
faster without being so distracted by minor details. While symptom control may not "cure"
the underlying personality disorder, medication does enable some OCPD patients to
function with less distress.

PROGNOSIS
Individuals with OCPD often experience a moderate level of professional success, but
relationships with a spouse or children may be strained due to their combination of emotional
detachment and controlling behaviors.
NURSING MANAGEMENT
  Guidance and counseling plays a significant role. Explain the situation and encourage the
client to substitute maladaptive behaviour and energies into adaptive or coping strategies to
overcome the problem
 Individual psychotherapy also plays vital role. Teach how their behaviour has to be
modified.
 Encourage them to constantly observe their behaviour and teach them to utilize self control
technique to overcome ritualistic behaviour and ask them to diver their mind and energies
into useful activities.

PASSIVE AGGRESSIVE PERSONALITY DISORDER

It is a personality trait marked by a pervasive pattern of negative attitudes and passive, usually
disavowed resistance in interpersonal or occupational situations.
Passive–aggressive behavior, a personality trait, is passive, sometimes obstructionist resistance
to following through with expectations in interpersonal or occupational situations.

SYMPTOMS
 Ambiguity or speaking cryptically: a means of engendering a feeling of insecurity in others
 Chronically being late and forgetting things: another way to exert control or to punish.
 Fear of competition
 Fear of dependency
 Fear of intimacy as a means to act out anger: The passive aggressive often cannot trust.
Because of this, they guard themselves against becoming intimately attached to someone.
 Making chaotic situations
 Making excuses for non-performance in work teams
 Obstructionism
 Procrastination
 Sulking
 Victimization response: instead of recognizing one's own weaknesses, tendency to blame
others for own failures
 Acting sullen
 Avoiding responsibility by claiming forgetfulness
 Being inefficient on purpose
 Blaming others
 Complaining
 Feeling resentment
 Having a fear of authority
  Having unexpressed anger or hostility
 Procrastinating
 Resisting other people's suggestions

CAUSES
 Frustration or provoked
 Interpersonal conflicts
 Disruptive relationships
 Familial abuse
 Neurobiological and psychosocial under pinning
 Sub cortical region may serve to signal other critical nodes
 Release of serotonin, a neurotransmitter or blockades the reuptake and direct agonism of 5-
HT2 receptors, resulted in blunted hormone responses in personality disorder
 Disconnection between inhibitory centers and limbic centers involved in the generation of
aggression may be responsible for the disinhibition of aggression

TREATMENT

Cognitive behavioral therapies

 To validate and understand the intense affects experienced by people with these personality

disorder

 Provides alternative ways of channelizing the impulses generated by these intense feelings

away from self injurious or aggressive behaviour toward more interpersonally effective

coping strategies

Psychoanalytic therapies

Uses exploration of unconscious conflict in here and now distortions of the transference to help

shift deeply ingrained assumptions and strategies

Drug therapy
  It is used to reduce the diathesis to impulsive aggression may facilitate the intra psychics

shifts, e.g. Selective serotonin reuptake inhibitors- may reduce irritability and aggression

consistent

 Mood stabilizers that dampen limbic irritability reduce the susceptibility to react to

provocation or threatening stimuli by overt action of limbic system.e.g. amygdale,

Carbamaxepine, diphenylhydantoin can be used.

NURSING PROCESS APPLICATION

 Risk for self-mutilation related to parental emotional deprivation (unresolved fears of

abandonment)

 Complicated grieving related to maternal deprivation during rapprochement phase of

development (internalized as a loss, with fixation in anger stage of grieving process),

evidenced by depressed mood, acting-out behaviors

 Impaired social interaction related to extreme fears of abandonment and engulfment

evidenced by alternating clinging and distancing behaviors

 Disturbed personal identity related to underdeveloped ego evidenced by feelings of

depersonalization and derealization

 Anxiety (severe to panic) related to unconscious conflicts based on fear of abandonment

evidenced by transient psychotic symptoms (disorganized thinking; misinterpretation of the

environment)

 Chronic low self-esteem related to lack of positive feedback evidenced by manipulation of

others and inability to tolerate being alone

JOURNAL ABSTRACT
 1. Trajectories of Attention Deficit Hyperactivity Disorderand Oppositional Defiant
Disorder Symptoms as Precursorsof Borderline Personality Disorder Symptoms in
AdolescentGirls
Abstract
Little empirical evidence exists regarding thedevelopmental links between childhood
psychopathologyand borderline personality disorder (BPD) in adolescence.The current study
addresses this gap by examiningsymptoms of attention deficit hyperactivity disorder(ADHD) and
oppositional defiant disorder (ODD) aspotential precursors. ADHD and BPD share clinicalfeatures
of impulsivity, poor self-regulation, and executivedysfunction, while ODD and BPD share features
of angerand interpersonal turmoil. The study is based on annual,longitudinal data from the two
oldest cohorts in thePittsburgh Girls Study (N=1,233). We used piecewise latentgrowth curve
models of ADHD and ODD scores from age8 to 10 and 10 to 13 years to examine the
prospectiveassociations between dual trajectories of ADHD and ODDsymptom severity and later
BPD symptoms at age 14 ingirls. To examine the specificity of these associations, wealso included
conduct disorder and depression symptom
Severity at age 14 as additional outcomes. We found thathigher levels of ADHD and ODD scores
at age 8 uniquelypredicted BPD symptoms at age 14. Additionally, the rateof growth in ADHD
scores from age 10 to 13 and the rateof growth in ODD scores from 8 to 10 uniquely
predictedhigher BPD symptoms at age 14. This study adds to theliterature on the early
development of BPD by providingthe first longitudinal study to examine ADHD and
ODDsymptom trajectories as specific childhood precursors ofBPD symptoms in adolescent girls.

2. The heritability of avoidant and dependent personality disorder assessed by personal

interview and questionnaire

Abstract

Objective: Personality disorders (PDs) have been shown to be modestly heritable. Accurate
heritability estimates are, however, dependent on reliable measurement methods, as measurement
error deflates heritability. The aim of this study was to estimate the heritability of DSM-IV
avoidant and dependent personality disorder, by including two measures of the PDs at two time
points.
Method: Data were obtained from a population-based cohort of young adult Norwegian twins, of
whom 8045 had completed a self-report questionnaire assessing PD traits. 2794 of these twins
subsequently underwent a structured diagnostic interview for DSM-IV PDs. Questionnaire items
predicting interview results were selected by multiple regression, and measurement models of the
PDs were fitted in Mx.
Results: The heritabilities of the PD factors were 0.64 for avoidant PD and 0.66 for dependent PD.
No evidence of common environment, that is, environmental factors that are shared between twins
and make them similar, was found. Genetic and environmental contributions to avoidant and
dependent PD seemed to be the same across sexes.
Conclusion: The combination of both a questionnaire- and an interview assessment of avoidant
and dependent PD results in substantially higher heritabilities than previously found using single-
occasion interviews only.

3. Metacognitive Interpersonal Therapy for Narcissistic Personality Disorder and

Associated Perfectionism
Abstract
Treating narcissistic personality disorder (NPD) successfully is possible but requires a
thorough understanding of the pathology and appropriate clinical procedures. Perfectionism is one
prominent feature often associated with narcissistic difficulties. Metacognitive Interpersonal
Therapy (MIT) for NPD adopts manualized step-by-step procedures aimed at progressively
dismantling narcissistic processes by first stimulating an autobiographical mode of thinking and
then improving access to inner states and awareness of dysfunctional patterns. Finally, adaptive
patterns of thinking, feeling, and acting are promoted, together with a sense of autonomy and
agency and a reduction of perfectionistic regulatory strategies. Throughout, there needs to be
constant attention to regulation of the therapy relationship to avoid ruptures and maximize
cooperation. We describe here a successful case of MIT applied to a man in his early 20's with

narcissism, perfectionism, and significant co-occurrence of Axis I and Axis II disorders.

CONCLUSION

Personality disorders are common.If we diagnosis one, we have to look for more in that
person.The diagnosis is usually not apparent until we have had several contacts. The person may
be incapable of change. But that shouldn’t be taken personally. We should understand limits,
boundaries, support, and perfect our interpersonal/communication skills.

BIBLIOGRAPHY
1. Gail Stuart, ‘Principles and Practice of Psychiatric Nursing’, 8 th Edition, Mosby
Publication.
2. Niraj Ahuja, ‘ A short Textbook of Psychiatry’, 5 th Edition, Jaypee Brothers Publication,
New Delhi.
 3. Lalitha, ‘Textbook of Psychiatric Nursing’, 1st Edition, 2004, Bangalore.
4. Neeraja, ‘Essentials of Mental Health and Psychiatric Nursing’,1 st Edition, Volume I,
JayPee Publication.
5. James Scully, ‘Psychiatry’, 3rd Edition, B.I. Waverly Ltd, New Delhi
6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.
4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.
7. Bockian, Neil, Ph.D., and Arthur E. Jongsma, Jr., Ph.D. The Personality Disorders
Treatment Planner. New York: Wiley, 2001.

JOURNALS
1. Billingham, Robert E. "Narcissistic Injury and Sexual Victimization among Women College
Students." College Student Journal 33: 62-70.
2. Coid, J. W. "Aetiological Risk Factors for Personality Disorders." British Journal of
Psychiatry 174 (June 1999): 530-538.
3. Gunderson, J. G., and E. Ronningstam. "Differentiating Narcissistic and Antisocial
Personality Disorders." Journal of Personality Disorders 15 (April 2001): 103-109.
4. Imperio, Winnie Anne. "Don't Ignore Colleagues' Psychiatric Disorders." OB/GYN News
(March 1, 2001): 36.

ELECTRONIC VERSION
1. http://www.minddisorders.com/Kau-Nu/Narcissistic-personality-
disorder.html#ixzz0ryo4s7s5
2. psychcentral.com/disorders/sx13.htm
3. www.psychologytoday.com/.../dependent-personality-disorder
4. www.mayoclinic.com/health/personality-disorders/DS00562
5. www.mind.org.uk › ... › Diagnoses and conditions