Core Concepts Personality disorders (PDs) are enduring, ingrained, maladaptive patterns of behavior and relating to others that severely impair functioning. Diagnosed only after age 18, traits are inflexible, making treatment slow and difficult. Patients rarely recognize their behavior as problematic, often blaming external circumstances.

The 3 Diagnostic Clusters

• Cluster A (Odd/Eccentric): Paranoid (pervasive mistrust/suspicion), Schizoid (detached, unemotional loners), Schizotypal (cognitive distortions, magical thinking, eccentric behavior).
• Cluster B (Erratic/Dramatic): Antisocial, Borderline, Histrionic (excessive emotionality, attention-seeking), Narcissistic (grandiosity, need for admiration, lack of empathy).
• Cluster C (Anxious/Fearful): Avoidant (socially inhibited, hypersensitive to rejection), Dependent (excessively submissive, clinging), Obsessive-Compulsive (preoccupied with order, perfection, and mental control).

Highest Yield: Borderline Personality Disorder (BPD)

• Features: Severe instability in mood, self-image, and relationships. Patients exhibit intense impulsivity, fear of abandonment, chronic emptiness, and "splitting" (polarized, all-or-nothing thinking).
• Nursing Priorities: Patients frequently engage in nonsuicidal self-injury or make suicidal threats. Physical safety is the highest priority; nurses must continually assess suicide risk. Crucial interventions include maintaining strict professional boundaries, minimizing unstructured time with schedules, and teaching cognitive restructuring (thought stopping, positive self-talk, decatastrophizing) to manage dysregulation.

Highest Yield: Antisocial Personality Disorder

• Features: Blatant disregard for the rights of others, deceit, manipulation, impulsivity, and lack of remorse. They often act for personal gain and lack insight.
• Nursing Priorities: The core action is strict limit setting (state the rule, the consequence, and the expected behavior clearly). Use confrontation to address manipulative behavior in a neutral, nonjudgmental tone. Teach step-by-step problem-solving and the use of time-outs for anger management.

Pharmacology & Milieu Management Medications do not cure PDs but target specific symptoms. Aggression and mood dysregulation are treated with lithium, anticonvulsants, or antipsychotics. Chronic anxiety or depression is managed with SSRIs or MAOIs. Patients with BPD and Antisocial PD often attempt "splitting" to divide staff. Consistent team communication and unwavering adherence to the care plan are essential to prevent manipulation and maintain a safe milieu. Nurses must practice self-awareness, as caring for PDs is highly frustrating and can cause burnout; processing emotions with colleagues keeps care objective.