This chapter discusses the other personality dis-
orders briefly. Most clients with these disorders are
not treated in acute care settings for the primary
diagnosis of personality disorder. Nurses may en-
counter these clients in any health care setting or in
the psychiatric setting when a client is already hos-
pitalized for another major mental illness.
Two disorders currently being studied for in-
clusion as personality disorders are depressive and
passive-aggressive personality disorders. They are
included in the DSM-IV-TR. This chapter discusses
them briefly as well.
ONSET AND CLINICAL COURSE
Personality disorders are relatively common occurring
in 10% to 13% of the general population. Incidence is
even higher for people in lower socioeconomic groups
and unstable or disadvantaged populations. Fifteen
percent of all psychiatric inpatients have a primary di-
agnosis of a personality disorder. Forty percent to 45%
of those with a primary diagnosis of major mental ill-
ness also have a coexisting personality disorder that
significantly complicates treatment. In mental health
outpatient settings, the incidence of personality dis-
order is 30% to 50% (Cloninger & Svrakic, 2000).
Clients with personality disorders have a higher death
rate especially as a result of suicide; they also have
higher rates of suicide attempts, accidents, and emer-
gency department visits and increased rates of sepa-
ration, divorce, and involvement in legal proceedings
regarding child custody (Cloninger & Syrakic, 2000).
Personality disorders have been correlated highly
with criminal behavior (70% to 85% of criminals have
personality disorders), alcoholism (60% to 70% of al-
coholics have personality disorders), and drug abuse
(70% to 90% of those who abuse drugs have personal-
ity disorders) (Cloninger & Syrakic, 2000).
People with personality disorders often are de-
scribed as “treatment-resistant.” This is not surpris-
ing, considering that personality characteristics and
behavioral patterns are deeply ingrained. It is diffi-
cult to change one’s personality; if such changes
occur, they evolve slowly. The slow course of treat-
ment can be very frustrating for family, friends, and
health care providers.
Another barrier to treatment is that many clients
with personality disorders do not perceive their dys-
functional or maladaptive behaviors as a problem; in-
deed, sometimes these behaviors are a source of pride.
For example, a belligerent or aggressive person may
perceive himself or herself as having a strong person-
ality and being someone who can’t be taken advan-
tage of or pushed around. Clients with personality
disorders frequently fail to understand the need to
change their behavior and may view changes as a
threat.
The difficulties associated with personality dis-
orders persist throughout young and middle adult-
hood but tend to diminish in the 40s and 50s. Those
with antisocial personality disorder are less likely to
engage in criminal behavior, although problems with
substance abuse and disregard for the feelings of
others persist. Clients with borderline personality
disordertend to demonstrate decreased impulsive
behavior, increased adaptive behavior, and more
stable relationships by 50 years of age. This in-
creased stability and improved behavior can occur
even without treatment. Some personality disorders,
such as schizoid, schizotypal, paranoid, avoidant, and
obsessive-compulsive, tend to remain consistent
throughout life (Seivewright, Tyrer, & Wright, 2002).ETIOLOGY
Biologic Theories
Personality develops through the interaction of hered-
itary dispositions and environmental influences. Tem-
peramentrefers to the biologic processes of sensa-
tion, association, and motivation that underlie the
integration of skills and habits based on emotion. Ge-
netic differences account for about 50% of the vari-
ances in temperament traits.
The four temperament traits are harm avoidance,
novelty seeking, reward dependence, and persistence.
Each of these four genetically influenced traits affects
a person’s automatic responses to certain situations.
These response patterns are ingrained by 2 to 3 years
of age (Cloninger & Svrakic, 2000).
People with high harm avoidance exhibit fear of
uncertainty, social inhibition, shyness with strangers,
rapid fatigability, and pessimistic worry in anticipa-
tion of problems. Those with low harm avoidance are
carefree, energetic, outgoing, and optimistic. High
harm-avoidance behaviors may result in maladaptive
inhibition and excessive anxiety. Low harm-avoidance
behaviors may result in unwarranted optimism and
unresponsiveness to potential harm or danger.
A high novelty-seeking temperament results in
someone who is quick-tempered, curious, easily bored,
impulsive, extravagant, and disorderly. He or she may
be easily bored and distracted with daily life, prone
to angry outbursts, and fickle in relationships. The
person low in novelty seeking is slow-tempered, sto-
ical, reflective, frugal, reserved, orderly, and tolerant
of monotony; he or she may adhere to a routine of
activities.
Reward dependence defines how a person re-
sponds to social cues. People high in reward depen-
dence are tenderhearted, sensitive, sociable, and376 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERS