Cluster A personality disorders: Considering the odd-eccentric in psychiatric nursing

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1 Blackwell Publishing AsiaMelbourne, AustraliaINMInternational Journal of Mental Health Nursing Australian and New Zealand College of Mental Health Nurses Inc.? Feature ArticlesCLUS- TER A PERSONALITY DISORDERSB. A. HAYWARD International Journal of Mental Health Nursing (2007) 16, doi: /j x FEATURE ARTICLE Cluster A personality disorders: Considering the odd-eccentric in psychiatric nursing Brent A. Hayward St Vincent s Hospital Melbourne, Victorian Dual Disability Service, Victoria, Australia ABSTRACT: Psychiatric nurses are familiar with the concept of personality disorder because of their contact with persons with the most common personality disorder in clinical settings borderline type, who frequently engage mental health services. Perhaps it is this familiarity that has focused research and clinical attention on borderline personality disorder compared with the other personality disorders. The significance of cluster A personality disorders for nursing is multifaceted because of their severity, prevalence, inaccurate diagnosis, poor response to treatment, and similarities to axis I diagnoses. Despite this, literature reviews have established that relatively few studies have focused on the treatment of the cluster A personality disorders paranoid, schizotypal, and schizoid resulting in a dearth of evidence-based interventions for this group of clients. A discussion of these disorders in the context of personality disorder and their individual characteristics demonstrates the distinctive and challenging engagement techniques required by psychiatric nurses to provide effective treatment and care. It is also strongly indicated that the discipline of psychiatric nursing has not yet begun to address the care of persons with cluster A personality disorders. KEY WORDS: paranoid personality disorder, personality disorders, psychiatric nursing, schizoid personality disorder, schizotypal personality disorder. INTRODUCTION Psychiatric nurses are familiar with the concept of personality disorder because of their frequent contact with persons with the most common personality disorder in clinical settings borderline type (American Psychiatric Association 2001) who frequently engage mental health services. Perhaps it is this familiarity that has focused research and clinical attention on borderline personality disorder compared with other personality disorders (Bender et al. 2001; Derksen 1995; Gabbard & Atkinson 1996; Hirschfeld 1993; Links 1998; Parker 1998; Stanislow Correspondence: Brent A. Hayward, Victorian Dual Disability Service, PO Box 2900, Fitzroy, Vic. 3065, Australia. brent. hayward@svhm.org.au Brent A. Hayward, RN, RPN, MRCNA, MANZCMHN. Accepted February & McGlashan 1998; Stone 1993; Target 1998; Wilberg et al. 1998). Literature reviews have established that relatively few studies have focused on the treatment of cluster A personality disorders (Stanislow & McGlashan 1998; The Quality Assurance Project 1990). Most treatment is guided by clinical experience with the use of case examples to highlight symptoms and course of treatment (e.g. Beck & Freeman 1990; Blackmon 1994; Derksen 1995; The Quality Assurance Project 1990). Some nursing literature claims to consider interventions for personality disorders generally but closer inspection reveals that their samples are taken from limited populations with cluster B diagnoses, such as the review by Woods and Richards (2003). Medical literature is equally disconcerting, with only cursory mention of cluster A personality disorders in discussion of general principles for intervention (e.g. Kosky and Thorne 2001). Likewise, the literature review

2 16 B. A. HAYWARD undertaken for this paper found the majority of articles to be at least a decade old. A number of authors suggest that the publication of these papers coincided with the publication of new versions of the Diagnostic and Statistical Manual that appear to have initiated a stream of new research concerning the personality disorders (Links 1998; Plakun et al. 1985; Samuels et al. 1994; Zimmerman & Coryell 1989). A literature search revealed no articles specifically concerning cluster A personality disorders from nursing sources. This finding underscores the need for nursing research to determine evidence-based interventions for this group of clients. Therefore, this paper outlines the significance of cluster A personality disorders for nursing, describes each of the three cluster A diagnoses, and presents strategies for engagement while highlighting specific areas for further nursing research. THE SIGNIFICANCE FOR NURSING The significance of cluster A personality disorders for nursing is multifaceted. First, the cluster A personality disorders paranoid, schizoid, and schizotypal are considered as more severe (Vaglum et al. 1990; Wilberg et al. 1998) and unhealthy (Leaf et al. 1992) personality pathologies. Second, the prevalence of these disorders varies depending on the setting, with a higher prevalence in outpatient settings (American Psychiatric Association 2000) where nurses commonly case-manage clients and conduct crisis assessment. Third, cluster A personality disorders are considered relatively resistant to treatment (Kosky & Thorne 2001), making them significant issues during treatment and management of coexisting axis I disorders. Fourth, personality disorders are common among those with enduring mental health problems but are often missed or poorly managed (Tredget 2001). And finally, the striking similarities between the symptoms of cluster A personality disorders and axis I diagnoses require nurses from all settings to be familiar with this group of personality disorders in order to accurately distinguish between axis I and axis II traits (American Psychiatric Association 2000; Derksen 1995). This is of particular importance to cluster A personality disorders as they show similarities to schizophrenia (Kalus et al. 1993) and these personality traits may be functioning independently of schizophrenia or other axis I disorders (Rouff 2000). A synopsis of the characteristics of personality disorders provides an appropriate introduction to these three disorders. Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts (American Psychiatric Association 2000; p. 686). These traits are an extreme deviation from the way an average person in a particular culture perceives, thinks, feels, and relates to others (Treatment Protocol Project 1997), and are characterized by the development of pervasive, maladaptive patterns of behaviour (Target 1998). These patterns of behaviour can be considered as hypertrophied, or overdeveloped and other patterns as underdeveloped (Beck & Freeman 1990). This causes subjective distress or significant impairment in social or occupational functioning. The behaviours are ingrained and inflexible, are enduring rather than episodic, and have their onset in adolescence or early adulthood (Lopez-Ibor 2000). These individuals have great difficulty in making and maintaining healthy relationships (Kosky & Thorne 2001) and are often considered as being overly self-centred (Hirschfeld 1993). Most importantly, they see the world rather than themselves as being out of line (Derksen 1995). This final point exemplifies individuals with cluster A personality disorders as they appear odd or eccentric to others but they themselves feel as though they are living in an uncomfortable world. The following discussion expands on each of the three cluster A diagnoses. PARANOID PERSONALITY DISORDER Authors have commented on a lack of clinical information regarding paranoid personality disorder (Meissner 1996; The Quality Assurance Project 1990; Williams 1988). The diagnosis is rare in inpatient populations (Fulton & Winokur 1993; The Quality Assurance Project 1990), which may be a result of clinicians having a too low threshold and therefore underdiagnosing the disorder (Beck & Freeman 1990; The Quality Assurance Project 1990). When the diagnosis is made, it is more common in men (Bernstein et al. 1993; Fulton & Winokur 1993), prisoners, refugees and immigrants, the elderly, and the hearing impaired (Bernstein et al. 1993). It has a prevalence of % in the general population, 10 30% among those in inpatient psychiatric settings, and 2 10% among those in outpatient settings (American Psychiatric Association 2000). Individuals with paranoid personality disorder view others as devious, deceptive, and covertly manipulative. They view themselves as righteous and mistreated by others and vulnerable and open to the possibility of being exploited and therefore need to be on guard. They fear being controlled, demeaned, and discriminated against. As a result, they are wary, suspicious, and looking for cues.

3 CLUSTER A PERSONALITY DISORDERS 17 The main affect is anger over presumed abuse and they may experience anxiety over perceived threats (Beck & Freeman 1990) because of heightened sense of fear and vulnerability (Ward 2004). Others frequently perceive these individuals as argumentative, stubborn, defensive, and uncompromising (Beck & Freeman 1990). The Treatment Protocol Project (1997) lists paranoid behaviours that may be recognized, including: inability to confide in others, hostility if it is perceived they are being schemed against, reluctance to sign documents, excessive concern about confidentiality, and a history of repeated termination of employment. Pathological jealously concerning faithfulness of partners is also common (Carrasco & Lecic-Tosevski 2000). Beck and Freeman (1990) also describe possible symptoms of paranoid personality disorder: tendency to attribute blame to others, difficulties considering alternative explanations, searching intensely and narrowly for evidence, inability to see humour in situations, strong need for independence, and inability to relax and close his or her eyes. Self-protective behaviours may be evident such as locking doors, closing windows and curtains, hiding papers, not forming close relationships, isolating themselves (Carrasco & Lecic-Tosevski 2000), as well as hypervigilance (Beck & Freeman 1990; Bernstein et al. 1993; Meissner 1996). Individuals will be reluctant to engage in treatment (Beck & Freeman 1990; Treatment Protocol Project 1997; Williams 1988) unless they experience a crisis or are persuaded by friends or family. Many authors note that it is extremely difficult to establish a therapeutic relationship (Beck & Freeman 1990; The Quality Assurance Project 1990; Treatment Protocol Project 1997) and many individuals do not disclose their suspicions openly (Beck & Freeman 1990; Carrasco & Lecic-Tosevski 2000). Meissner (1996) notes that the individual's sense of autonomy is fragile and threatened, so much so that issues related to maintaining it permeate all aspects of engagement. Therefore, guidelines for engaging these individuals include clarifying issues before major problems develop (Treatment Protocol Project 1997), not being too friendly, warm, humorous, or inquisitive (The Quality Assurance Project 1990; Treatment Protocol Project 1997; Trimpey & Davidson 1998), and maintaining a formal, honest, open, and professional attitude at all times (Meissner 1996; Treatment Protocol Project 1997; Ward 2004). Allow the individual adequate opportunity to talk about their grievances or concerns (Treatment Protocol Project 1997; Ward 2004) but do not confirm or argue with their paranoid beliefs. Gentle reality testing may be useful if approached very carefully (Derksen 1995; Meissner 1996; The Quality Assurance Project 1990; Treatment Protocol Project 1997). The most useful approach is focusing on the here and now (Treatment Protocol Project 1997). Clinicians, including nurses, must be prepared for accusations, belittling comments, and litigious threats (Meissner 1996; Treatment Protocol Project 1997). As a rule, individuals with this disorder are ready to counterattack, provoking repeated confrontations (Carrasco & Lecic-Tosevski 2000), and their paranoia combined with aggressive behaviour warrants careful assessment. Individuals are also at risk of brief psychotic episodes evidenced by frank delusional ideas or distorted perceptions. Differentiation from delusions may be difficult and often depends on the absence of belief in organized conspiracies (The Quality Assurance Project 1990). One can easily see that the symptoms of paranoid personality disorder can be incorrectly attributed to a schizophrenia-spectrum disorder or another personality disorder such as antisocial type. Individuals with paranoid personality disorder may come to the attention of the authorities and subsequently crisis assessment teams as well as consultation-liaison nurses in the general hospital setting because of arguments, conflict, and fear of harm (Ward 2004). Clinicians may also encounter these individuals while being case-managed for a coexisting axis I diagnosis. SCHIZOID PERSONALITY DISORDER Limited information was located in relation to schizoid personality disorder, a feature supported by The Quality Assurance Project (1990). The two striking features of schizoid personality disorder are first a lack of interpersonal relationships and the lack of desire to obtain such relationships (Beck & Freeman 1990). The second feature is the presence of negative symptoms in the absence of psychotic-like cognitive and perceptual distortions (Kalus et al. 1993). Prevalence figures according to Kalus et al. (1993) range from 0.5% to 7% in the general population and the diagnosis is more commonly made in men (Fulton & Winokur 1993), whereas the disorder is uncommon in inpatient psychiatric settings (American Psychiatric Association 2000; Fulton & Winokur 1993). Individuals construct their lives to limit interactions with others and usually select occupations that require minimal social contact and are sometimes in jobs that are below their level of ability (Beck & Freeman 1990). They have a tendency to turn inwards and away from the

4 18 B. A. HAYWARD external world (Kalus et al. 1993) and see themselves as self-sufficient and independent and will sacrifice intimacy in order to preserve autonomy (Beck & Freeman 1990). They consider themselves to be observers rather than participants in the world around them. Some typical thoughts may include: going through the motions, why bother, who cares, rather do it by myself, emptiness inside, and life is unfulfilling (Beck & Freeman 1990). Despite these thoughts, individuals may believe that they should strive to attain a more conventional lifestyle but recognize that they cannot respond in the same way as others to particular stimuli and may make emotional attachments with animals or inanimate objects (Carrasco & Lecic-Tosevski 2000). Others may see them as shy, withdrawn, reclusive, isolated, dull, uninteresting, and humourless. Their cognitive style is characterized by vagueness and poverty of thought or concrete thoughtform. Typical behaviours include lethargic and unexpressive movements that lack gestures or alternatively, rhythmic movements, slow and monotonous speech, poor spontaneous speech, or poverty of content of speech, limited eye contact, and may appear ill at ease (Beck & Freeman 1990). Although they may appear sad or anxious during close encounters, they are not inclined to show their feelings either verbally or through facial expressions (Beck & Freeman 1990; Carrasco & Lecic-Tosevski 2000). Excessive over- or understimulation may leave these individuals vulnerable to axis I disorders such as anxiety when situations demand social interaction. Depersonalization may occur because of limited contact with, and emotional distance from other people. Others may experience a distorted sense of themselves and their environment. Reduced social contact may result in an increased fantasy life and possible brief psychotic or manic episodes as a reaction to a perceived meaningless existence (Beck & Freeman 1990). The primary strategy of treatment is to reduce the individual's isolation and establish a sense of intimacy (Beck & Freeman 1990) while avoiding overinvolvement in personal and social issues (Ward 2004). The clinician must keep a therapeutic distance from the individual without pushing conversation to enable the relationship to be tolerable (Carrasco & Lecic-Tosevski 2000; Trimpey & Davidson 1998; Ward 2004). Sensitivity and tact are important and the clinician should be supportive and gentle, providing clear explanation that all people are different and that their development has happened to make interactions with others extremely difficult for them (The Quality Assurance Project 1990). Difficulties in working with these individuals include their anxiety as a result of forced contact with the clinician (Ward 2004), their desire for quick symptom relief, their unresponsiveness to praise (Beck & Freeman 1990), and difficulty establishing a relationship (Carrasco & Lecic- Tosevski 2000). They will most likely seek treatment in the context of acute stress or change in life circumstance (Kalus et al. 1993). Care must be taken not to assume that individuals with schizoid personality disorder are simply depressed, have an intellectual disability, or suffer from a schizophrenia-spectrum disorder or another personality disorder such as avoidant type. These individuals may also be encountered in the general hospital setting where they are forced into interpersonal interactions, and have a high likelihood of being a client of a Homeless Outreach Psychiatric Service, where schizoid personality disorder has been estimated to occur in approximately 14% of clients (Rouff 2000). SCHIZOTYPAL PERSONALITY DISORDER A more modest amount of literature is accessible concerning schizotypal personality disorder, a similar finding to The Quality Assurance Project (1990). This disorder is prevalent in approximately 3% of the general population (American Psychiatric Association 2000). Individuals are rarely seen in the psychiatric inpatient setting (McGlashan 1986) but are more common in outpatient settings (Bornstein et al. 1988). The cognitive distortions in these individuals are the most severe of any in the personality disorders and generally consist of suspicious and paranoid ideation, ideas of reference, odd beliefs, magical thinking and illusions. Speech is coherent but may be vague, tangential, circumstantial, or overelaborate, and individuals may engage in emotional reasoning and personalization as a result of their concrete thought-form (Beck & Freeman 1990) while affect is often inappropriate or restricted (Beck & Freeman 1990). Generally, the themes expressed by an individual will be unique to them but common thoughts include: believing they are being watched; knowing what people are thinking; feeling something bad is going to happen; believing that they are not going to be liked by others; supposing there are reasons for everything; and believing they are defective (Beck & Freeman 1990). Inappropriate behaviour contributes to the extreme social isolation associated with this disorder. Common behaviour includes peculiar mannerisms such as excessive hand washing and refusing to touch doorknobs, dressing in an unusual manner, and generally avoiding eye contact (Stone 1985). Individuals will largely desire social relationships and experience great pain as a result of their

5 CLUSTER A PERSONALITY DISORDERS 19 isolation. This along with increased stress results in fewer opportunities for reality testing with others and the possibility of deterioration to a psychotic condition (Beck & Freeman 1990). Individuals may also seek treatment because of depression, dysphoria, anxiety, and substance dependence (Bornstein et al. 1988; Carrasco & Lecic- Tosevski 2000). Individuals with schizotypal personality disorder experience intense anxiety in social situations with unfamiliar people based on suspicion as to the motivations of others (Carrasco & Lecic-Tosevski 2000). The first strategy in treatment is to establish a therapeutic relationship and then reduce social isolation. It is also important to adopt a professional stance, provide clear explanations, tolerate odd beliefs and behaviours, and avoid overinvolvement in personal or social issues (Ward 2004). Other interventions include increasing social appropriateness through modelling appropriate behaviour and speech, providing a structured session or environment, and assisting the individual to look for objective evidence in the environment to evaluate their thoughts rather than relying on emotional responses (Beck & Freeman 1990; Stone 1996). The most significant issue associated with diagnostic uncertainty in schizotypal personality disorder is that the positive and negative symptoms parallel those of schizophrenia (Squires-Wheeler et al. 1997). Care must also be taken not to assume other diagnoses such as autismspectrum disorders and mood disorders with psychotic features. As with the two other cluster A personality disorders, individuals with schizotypal personality disorder can also be clients in other settings but, interestingly, this personality disorder is more common in outpatient settings, where the consequences of odd behaviour and appearance may be contact with community mental health services. CONCLUSION Cluster A personality disorders are an important consideration for psychiatric nursing. Their traits resemble both negative and positive features of psychotic disorders (Kalus et al. 1993; Stone 1993) and require an excellent understanding of both the features of personality disorders as axis II diagnoses and the psychotic features of axis I diagnoses in order to differentiate symptoms. The distinctive recommendations for engaging and working with individuals with paranoid, schizoid, and schizotypal personality disorders are often in conflict with the nurses' standard approach to practice insofar as pursuing the establishment of a therapeutic relationship. Individuals with cluster A personality disorders do not respond appropriately to affective cues and are unable to form connections on a basic emotional level (Ward 2004). As such, principles of interpersonal relations such as empathy and warmth are contraindicated in working with an individual with paranoid personality disorder. Maintaining a certain therapeutic distance during engagement with an individual with schizoid personality disorder and reducing extreme anxiety resulting from the engagement itself with individuals with schizotypal personality disorder may prove challenging for the psychiatric nurse. The relationship with the individual is founded on an attempt to therapeutically challenge the way in which the individual perceives his or her human environment in relation to others, and for the patient it is grounded in an attempt to convince the other of their normalcy... the challenge... is to enable safe and effective delivery of nursing care to this group of individuals in such a way as to enhance the value of the relationship itself as a therapeutic tool... (Melia et al. 1999; pp ) Despite this acknowledgement, no single intervention is likely to meet the multiple aetiological factors and diverse needs of people with cluster A personality disorders (Tredget 2001). Currently, there is no nursing literature that specifically concerns cluster A personality disorders. The literature that is available either is medically based and primarily relates to strategies for assessment, or is psychotherapeutic-based that uses various longer-term structured modalities. Psychiatric nursing should be encouraged to conduct further research to advance both nursing knowledge and the inclusion of the cluster A personality disorders in the general psychiatric nursing literature. It is also necessary to identify modest, client-centred, and short-term interventions that are able to be implemented in multiple settings. These interventions should be based on existing research but not rely heavily on psychotherapeutic principles and be formulated to offer alternative considerations of the nurse patient relationship in the mental health nursing of people with cluster A personality disorders. As individuals with cluster A personality disorders typically do not actively seek treatment (and have subsequently been identified as treatment-rejecting (Tyrer et al. 2003)), they are most likely to come to the attention of mental health services during treatment for coexisting disorders or during crises, where consideration of their underlying personality disorder is required to provide effective nursing care.

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