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Psychiatric-Mental Health Nursing

18.1 Identification and Diagnosis

Psychiatric-Mental Health Nursing18.1 Identification and Diagnosis

Learning Objectives

By the end of this section, you will be able to:

  • Outline the general symptoms of personality disorders and how they develop
  • Describe and identify diagnostic criteria for personality disorders

Understanding the symptoms and diagnostic process of personality disorders is essential in recognizing and addressing these complex mental health conditions. Personality disorders are classified into three clusters: cluster A, schizoid personality disorder; cluster B, antisocial personality disorder; and cluster C, avoidant personality disorder. This section explores the general symptoms exhibited by individuals with personality disorders, such as difficulties in interpersonal relationships, emotional instability, and distorted self-image. Additionally, this section will delve into the diagnostic process, which involves a provider comprehensively assessing a person’s symptoms, taking a personal history, and observing behaviors. By gaining insight into the symptoms and diagnostic criteria of personality disorders, nurses can develop a better understanding of these conditions and their impact on individuals’ lives, promoting early recognition and effective intervention.

Symptoms and Signs of Personality Disorders

Personality disorders are characterized by rigid and inflexible traits that are pervasive and persist over time (American Psychiatric Association [APA], 2022a). These patterns are typically stable and consistent, beginning in adolescence or early adulthood and continuing throughout a person’s life. While specific symptoms and signs vary depending on the type of personality disorder, some common features and patterns often exist. Here are some general symptoms and signs that can be associated with personality disorders:

  • Distorted self-perception: Individuals with personality disorders may have an unstable or unclear sense of self, fluctuating self-esteem, and a tendency to define themselves through their relationships or external validation.
  • Dysfunctional relationships: Difficulty establishing and maintaining healthy relationships is often a hallmark of personality disorders. This can manifest as intense, unstable, or conflicted relationships, a fear of abandonment, or patterns of idealization and devaluation.
  • Emotional instability: People with personality disorders may experience intense and fluctuating emotions, such as anger, anxiety, depression, or chronic feelings of emptiness. Emotional regulation may be challenging, leading to impulsive or self-destructive behaviors.
  • Maladaptive coping mechanisms: Individuals with personality disorders may employ maladaptive coping strategies, such as substance misuse, self-harm, or engaging in risky behaviors as a means of managing distress or avoiding emotional pain.
  • Cognitive and perceptual distortions: Distorted thinking patterns, including black-and-white thinking, excessive suspicion, and difficulty with empathy or perspective-taking, are common in personality disorders.
  • Impaired functioning in multiple areas: Personality disorders often interfere with various domains of life, such as work, education, relationships, and self-care.

Clients with personality disorders have symptoms in two or more of the following areas: cognition (ways of perceiving and interpreting self, other people, or events), affectivity (the range, intensity, lability, and appropriateness of emotional response), interpersonal functioning, and impulse control.

Defining Personality and When It Becomes a Disorder

The unique and enduring patterns of thoughts, emotions, and behaviors that characterize individuals and distinguish them from others is a person’s personality (APA, 2022a). It encompasses a person’s consistent ways of perceiving, interpreting, and interacting with the world around them. Personality is shaped by a combination of genetic, biological, and environmental factors, including upbringing, culture, and life experiences. It is considered relatively stable over time, but it can also evolve and change to some extent as individuals grow, learn, and adapt to new circumstances.

The characteristics, whether considered positive or negative, that make up one’s personality are considered their personality traits. A person is considered to have a personality disorder when they exhibit enduring patterns of thoughts, emotions, and behaviors that deviate significantly from cultural norms and these patterns cause significant distress and impairment in functioning (APA, 2022a). These patterns are characterized by rigidity, inflexibility, and maladaptive behaviors that affect various aspects of an individual’s life. The key diagnostic factor is the impact on functioning and well-being. While everyone has unique personality traits, a personality disorder is diagnosed when these traits cause significant distress, disrupt daily life, and lead to difficulties in relationships, work, or other areas of functioning.

Possible Causes of Personality Disorder

Personality disorders are among the least understood mental health conditions (Fariba et al., 2023). Scientists are still trying to figure out precisely what causes them. So far, they believe the following factors may contribute to the development of personality disorders:

  • Genetics: Scientists have identified malfunctioning genes that may be a factor in schizotypal, borderline personality disorder (BPD), antisocial personality disorder (ASPD), and obsessive-compulsive personality disorder (OCPD). They are also researching genetic links to certain emotions, such as aggression, anxiety, and fear, which are traits that can play a role in personality disorders (Cleveland Clinic, 2022).
  • Brain changes: Scientists have been able to identify brain differences in certain people with personality disorders (Cleveland Clinic, 2022). For example, research on paranoid personality disorder has shown altered amygdala functioning. The amygdala is the part of the brain involved in the formation and storage of emotional memories, particularly those associated with fear and aggression.
  • Childhood trauma and abuse: Adverse experiences during childhood, such as abuse, neglect, trauma, or inconsistent parenting, can contribute to the development of personality disorders. For example, people with borderline personality disorder have higher rates of childhood sexual trauma (Cleveland Clinic, 2022).
  • Cultural factors: Cultural factors may also play a role in the development of personality disorders, as demonstrated by the varying rates of personality disorders between different countries.

Cultural Context

Personality Disorders and Cultural Factors

Part of the defining feature of a personality disorder is that the behaviors exhibited must be different from the cultural norms of the client. Different cultures have different standards for what is considered “normal” behavior and this must be taken into account during the diagnostic process. Behavior that is considered normal in one culture can lead to stigma, discrimination, ostracization, and even institutionalization and incarceration in another.

The differences in the prevalence of personality disorders between cultures may be influenced by factors, such as race, ethnicity, social requirements, and the dimension of individualism-collectivism. These standards will influence the personality and behaviors of the population and how personality disorders are diagnosed. Asian cultures tend to be collectivistic, emphasizing cooperation and contribution to the needs of the group above the needs of the individual, which can lead to lower rates of antisocial personality disorders.

Maladaptive and Undesirable Behavior

Patterns of thoughts, emotions, and actions that are ineffective or counterproductive to normal, everyday life are considered maladaptive behavior. Individuals with personality disorders typically turn to maladaptive behaviors as coping mechanisms to help manage distress or avoid emotional pain. For example, individuals with borderline personality disorder may engage in impulsive and self-destructive behaviors, such as self-harm or substance misuse, as a way to regulate intense emotions. These coping strategies may provide temporary relief but can lead to further distress and negative consequences in the long run.

Emotional dysregulation is a common feature of many personality disorders. Individuals may experience intense and rapidly shifting emotions, such as anger, sadness, fear, or emptiness. Their emotional responses may be disproportionate to the situation or difficult to control, leading to impulsive and disruptive behaviors. For instance, individuals with antisocial personality disorder may engage in the financial manipulation or exploitation of others. They often display a lack of remorse or empathy, which allows them to engage in these behaviors.

People with personality disorders often exhibit distorted and maladaptive patterns of thinking. They may hold rigid beliefs, engage in black-and-white thinking, or have a skewed perception of themselves and others. These cognitive distortions can contribute to negative self-image, feelings of worthlessness, and impaired decision-making abilities. For example, individuals with avoidant personality disorder may have an intense fear of rejection or criticism, leading to avoidance of social situations and persistent feelings of inadequacy.

Personality disorders often involve difficulties in forming and maintaining healthy relationships. Individuals may struggle with maintaining boundaries, have intense and unstable relationships, or exhibit manipulative and controlling behaviors. For instance, individuals with narcissistic personality disorder often have an exaggerated sense of self-importance, lack empathy, and exploit others for personal gain. These interpersonal difficulties can lead to conflicts, social isolation, and a cycle of turbulent relationships.

Maladaptive behaviors are not intentional or chosen by individuals with personality disorders. They arise from deep-seated patterns ingrained over time and are often rooted in underlying emotional and psychological struggles. Addressing these behaviors requires a comprehensive and individualized approach that combines therapy, support, and skill-building techniques to promote healthier coping mechanisms, improved interpersonal relationships, and enhanced emotional regulation.

Diagnosis of Personality Disorders

Personality disorders can only be diagnosed by highly trained, qualified professionals—generally a psychiatrist, a psychiatric nurse practitioner, or a clinical psychologist—following a comprehensive and complex history and behavioral assessment of the client. It is important to remember that many clients who are diagnosed with personality disorders do not initially present seeking treatment for personality disorder (Fariba et al., 2023). Many present with other complaints, such as depression, anxiety, issues with interpersonal relationships, or persistent problems at work. It is up to the clinician to perform an accurate diagnosis.

The process usually begins with an initial assessment, during which the clinician gathers information about the individual’s symptoms, medical history, and personal background. They may conduct interviews with the individual and, if possible, obtain information from family members or friends. They might employ certain tests, such as the McLean Screening Instrument for Borderline Personality Disorder (McKay et al., 2022), which is a ten-question yes/no survey questioning feelings and relationships. The clinician will observe the client’s behavior for characteristics, such as appropriate emotional responses during therapy sessions. Other mental diagnoses, such as mood disorders, substance misuse, or anxiety, can have symptoms that mimic personality disorders, and providers must rule them out.

Two of the most defining diagnostic characteristics of personality disorders are their persistence or the length of time that the symptoms have been present and how significantly they impair the client’s life (APA, 2022a). The clinician must consider whether the symptoms and patterns of behavior of the personality disorder appeared before young adulthood; if they are consistent with the client’s long-term functioning; and if they significantly impair the client’s functioning in various areas of life, such as work, relationships, or self-care. Only after gathering all of this relevant information is the clinician able to make an informed decision about the client’s diagnosis.


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