CHAPTER 18

Personality Disorders
Key Terms

antisocial personality disorder

avoidant personality disorder
borderline personality disorder (BPD)
character
cognitive restructuring
confrontation
decatastrophizing
dependent personality disorder
depressive behavior
dysphoric
histrionic personality disorder
limit setting
narcissistic personality disorder
nonsuicidal self-injury
obsessive–compulsive personality disorder
paranoid personality disorder
passive-aggressive behavior
personality
personality disorders
positive self-talk
schema therapy
schizoid personality disorder
schizotypal personality disorder
temperament
thought stopping
time-out
Learning Objectives
After reading this chapter, you should be able to:

1. Describe personality disorders in terms of the client’s difficulty in

perceiving, relating to, and thinking about self, others, and the
environment.

2. Discuss factors thought to influence the development of

personality disorders.

3. Plan care for clients with personality disorders.

4. Provide education to clients, families, and community members to

increase their knowledge and understanding of personality
disorders.

5. Evaluate personal feelings, attitudes, and responses to clients

with personality disorders.

Nursing Concepts

Behaviors
Self

INTRODUCTION
Personality can be defined as an ingrained, enduring pattern of behaving
and relating to the self, others, and the environment; it includes perceptions,
attitudes, and emotions. These behaviors and characteristics are consistent
across a broad range of situations and do not change easily. A person is
often not consciously aware of their personality. Many factors influence
personality; some stem from biologic and genetic makeup, while others are
acquired as a person develops and interacts with the environment and other
people.
Personality disorders are diagnosed when there is impairment of
personality functioning and personality traits that are maladaptive.
Individuals have identity problems such as egocentrism, or being self-
centered, and their sense of self-esteem comes from gaining power or
pleasure that is often at the expense of others. Their behavior often fails to
conform to cultural, social, or legal norms, and they are motivated by
personal gratification. Relationships with others are dysfunctional and often
characterized by deceit, coercion, or intimidation by the individual with a
personality disorder. They are not capable of mutual, intimate relationships
and lack the capacity for empathy, remorse, or concern for others (Boland &
Verduin, 2022).
Maladaptive or dysfunctional personality traits exhibited by individuals
with a personality disorder may include:
Negative behaviors toward others, such as being manipulative, dishonest,
deceitful, or lying
Anger and/or hostility
Irritable, labile moods
Lack of guilt or remorse, emotionally cold and uncaring
Impulsivity, distractibility, poor judgment
Irresponsible, not accountable for own actions
Risk-taking, thrill-seeking behaviors
Mistrust
Exhibitionism
Entitlement
Dependency, insecurity
Eccentric perceptions
Certainly, not all these traits are a problem for each person diagnosed
with a personality disorder. The traits that are present or that predominate
for a given person are the basis for distinguishing the disorders from each
other.
Personality disorders are not diagnosed until adulthood, that is, at age
18, when personality is more completely formed. Nevertheless, maladaptive
behavioral patterns can often be traced to early childhood or adolescence.
Although there can be great variance among clients with personality
disorders, many experience significant impairment in fulfilling family,
academic, employment, and other functional roles.
Personality disorders are long-standing because personality
characteristics do not change easily. Thus, clients with personality disorders
continue to behave in their same familiar ways even when these behaviors
cause them difficulties or distress. No specific medication alters personality,
and therapy designed to help clients make changes is often long term with
slow progress. Some people with personality disorders believe their
problems stem from others or the world in general; they do not recognize
their own behavior as the source of difficulty. For these reasons, people
with personality disorders are difficult to treat, which may be frustrating for
the nurse and other caregivers as well as for family and friends. Many
people with personality disorders also have coexisting mental illnesses.

PERSONALITY DISORDERS
During the revision and development process for Diagnostic and Statistical
Manual of Mental Disorders, fifth edition, much discussion surrounded the
personality disorder diagnoses. In the end, a proposed hybrid model for
personality disorders was not adopted but remains as an alternative section
at the back of the diagnostic manual (Sleep et al., 2020). Box 18.1
summarizes the hybrid model alternative.

BOX 18.1 Hybrid Model for Personality Disorders

Personality disorder is a generalized pattern of behaviors, thoughts, and emotions that

begins in adolescence, remains stable over time, and causes stress or psychological
damage. They are characterized by:
Impaired personality functioning (areas of identity, self-direction, empathy, and
intimacy)
Pathological personality factors (negative affectivity, detachment, antagonism,
disinhibition, and psychoticism)
The personality disorders included in this proposed model are antisocial, borderline,
avoidant, narcissistic, obsessive–compulsive, and schizotypal.
Adapted from Sleep, C. E., Weiss, B., Lynam, D. R., & Miller, J. D. (2020). The DSM-5
section III personality disorder criterion in relation to both pathological and general
personality traits. Personality disorders, 11(3), 202-212. [Link]

Personality disorder diagnoses are organized according to clusters

around a predominant type of behavioral pattern. The clusters and the
diagnoses in each are as follows:
Cluster A—odd or eccentric behaviors
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder
 Cluster B—erratic or dramatic behaviors
Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder
Cluster C—anxious or fearful behaviors
Avoidant personality disorder
Dependent personality disorder
Obsessive personality disorder
In psychiatric settings, nurses most often encounter clients with
antisocial and borderline personality disorders (BPDs). Thus, these two
disorders are the primary focus of this chapter. Clients with antisocial
personality disorder may enter a psychiatric setting as part of a court-
ordered evaluation or as an alternative to jail. Clients with BPD are often
hospitalized because their emotional instability may lead to self-inflicted
injuries and/or suicidality.
This chapter discusses the other personality disorders briefly. Most
clients with these disorders are not treated in acute care settings for these
personality disorders. Nurses may encounter these clients in any health care
setting or in the psychiatric setting when a client is already hospitalized for
another major mental illness.

Other Behaviors
Other clusters of behavior related to maladaptive personality traits include
the following:
Depressive behavior is characterized by a pervasive pattern of
depressive cognitions and behaviors in various contexts. It occurs more
often in people with relatives who have major depressive disorders.
People with depressive personality disorders often seek treatment for
their distress.
Passive-aggressive behavior is characterized by a negative attitude and
a pervasive pattern of passive resistance to demands for adequate social
and occupational performance. These clients may appear cooperative,
even ingratiating, or sullen and withdrawn, depending on the
 circumstances. Their mood may fluctuate rapidly and erratically, and they
may be easily upset or offended.

Onset and Clinical Course

Personality disorders are relatively common, occurring in 10% to 20% of
the general population (Boland & Verduin, 2022). Incidence is even higher
for people in lower socioeconomic groups and unstable or disadvantaged
populations—for example, people in prison or those dealing with substance
abuse. Of all psychiatric inpatients, 15% have a primary diagnosis of a
personality disorder. Of those with a primary diagnosis of major mental
illness, 40% to 45% also have a coexisting personality disorder that
significantly complicates treatment. In mental health outpatient settings, the
incidence of personality disorder is 30% to 50% (Black & Andreasen,
2021). 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 emergency department visits and increased rates of
separation, divorce, and involvement in legal proceedings regarding child
custody. Personality disorders have been highly correlated with criminal
behavior, alcoholism, and drug abuse.
People with personality disorders are often described as “treatment
resistant.” This is not surprising, considering that personality characteristics
and behavioral patterns are deeply ingrained. It is difficult to change one’s
personality; if such changes occur, they evolve slowly. The slow course of
treatment can be frustrating for family, friends, and health care providers.
Another barrier to treatment is that many clients with personality
disorders do not perceive their dysfunctional or maladaptive behaviors as a
problem; indeed, sometimes these behaviors are a source of pride. For
example, a belligerent or aggressive person may perceive themself as
having a strong personality and as being someone who can’t be taken
advantage 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 disorders persist throughout
young and middle adulthood but tend to diminish in the 40s and 50s,
although that is not always the case. 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 disorder (BPD) tend to demonstrate
decreased impulsive behavior, increased adaptive behavior, and more stable
relationships by age 50. This increased stability and improved behavior can
occur even without treatment. Some personality disorders, such as
schizotypal avoidant and obsessive–compulsive, tend to remain consistent
throughout life.

ETIOLOGY
Biologic Theories
Personality develops through the interaction of hereditary dispositions and
environmental influences. Temperament refers to the biologic processes of
sensation, association, and motivation that underlie the integration of skills
and habits based on emotion. Genetic differences account for about 50% of
the variances 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.
People with high harm avoidance exhibit fear of uncertainty, social
inhibition, shyness with strangers, rapid fatigability, and pessimistic worry
in anticipation 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 (Cloninger et al., 1993).
A high novelty-seeking temperament results in someone who is quick-
tempered, curious, easily bored, impulsive, extravagant, and disorderly.
They 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, stoic, reflective, frugal, reserved, orderly, and tolerant of
monotony; they may adhere to a routine of activities.
 Reward dependence defines how a person responds to social cues.
People high in reward dependence are tenderhearted, sensitive, sociable,
and socially dependent. They may become overly dependent on approval
from others and readily assume the ideas or wishes of others without regard
for their own beliefs or desires. People with low reward dependence are
practical, tough-minded, cold, socially insensitive, irresolute, and
indifferent to being alone. Social withdrawal, detachment, aloofness, and
disinterest in others can result.
Highly persistent people are hardworking and ambitious overachievers
who respond to fatigue or frustration as a personal challenge. They may
persevere even when a situation dictates they should change or stop. People
with low persistence are inactive, indolent, unstable, and erratic. They tend
to give up easily when frustrated and rarely strive for higher
accomplishments.
These four genetically independent temperament traits occur in all
possible combinations. Some of the previous descriptions of high and low
levels of traits correspond closely with the descriptions of the various
personality disorders. For example, people with antisocial personality
disorder are low in harm avoidance traits and high in novelty-seeking traits,
while people with avoidant personality disorder are high in reward
dependence traits and harm avoidance traits.

DSM-5-TR DIAGNOSTIC Borderline Personality

CRITERIA: Disorder (F60.3)
A pervasive pattern of instability of interpersonal relationships, self-image, and affects,
and 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. (Note: Do not include
suicidal or self-mutilating behavior covered in Criterion 5.)
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.,
spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not
include suicidal or self-mutilating behavior covered in Criterion 5.)
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
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, intense anger or difficulty controlling anger (e.g., frequent
displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
Reprinted with permission Diagnostic and statistical manual of mental disorders (5th ed.,
text revision). Author.

Psychodynamic Theories
Although temperament is largely inherited, social learning, culture, and
random life events unique to each person influence character. Character
consists of concepts about the self and the external world. It develops over
time as a person comes into contact with people and situations and
confronts challenges. Three major character traits have been distinguished:
self-directedness, cooperativeness, and self-transcendence. When fully
developed, these character traits define a mature personality (Cloninger et
al., 1993).
Self-directedness is the extent to which a person is responsible, reliable,
resourceful, goal oriented, and self-confident. Self-directed people are
realistic and effective and can adapt their behavior to achieve goals. People
low in self-directedness are blaming, helpless, irresponsible, and unreliable.
They cannot set and pursue meaningful goals.
Cooperativeness refers to the extent to which a person sees themself as
an integral part of human society. Highly cooperative people are described
as empathic, tolerant, compassionate, supportive, and principled. People
with low cooperativeness are self-absorbed, intolerant, critical, unhelpful,
revengeful, and opportunistic; that is, they look out for themselves without
regard for the rights and feelings of others.
Self-transcendence describes the extent to which a person considers
themself to be an integral part of the universe. Self-transcendent people are
spiritual, unpretentious, humble, and fulfilled. These traits are helpful when
dealing with suffering, illness, or death. People low in self-transcendence
are practical, self-conscious, materialistic, and controlling. They may have
difficulty accepting suffering, loss of control, personal and material losses,
and death.
Character matures in stepwise stages from infancy through late
adulthood. Chapter 3 discusses psychological development according to
Freud, Erikson, and others. Each stage has an associated developmental task
that the person must perform for mature personality development. Failure to
complete a developmental task jeopardizes the person’s ability to achieve
future developmental tasks. For example, if the task of basic trust is not
achieved in infancy, mistrust results and subsequently interferes with
achievement of all future tasks.
Experiences with family, peers, and others can significantly influence
psychosocial development. Social education in the family creates an
environment that can support or oppress specific character development.
For example, a family environment that does not value and demonstrate
cooperation with others (compassion or tolerance) fails to support the
development of that trait in its children. Likewise, the person with
nonsupportive or difficult peer relationships growing up may have lifelong
difficulty relating to others and forming satisfactory relationships.
In summary, personality develops in response to inherited dispositions
(temperament) and environmental influences (character), which are
experiences unique to each person. Personality disorders result when the
combination of temperament and character development produces
maladaptive, inflexible ways of viewing self, coping with the world, and
relating to others.
Concept Mastery Alert
Although a personality disorder is a psychiatric diagnosis, it is important to remember
that it is not an illness with treatable symptoms in the way other mental disorders are.
The personality traits are ingrained ways of being and thinking. Although some change
may occur slowly over time, there will be no significant improvement or quick resolution
of problematic behavior.

Cultural Considerations
Judgments about personality functioning must involve a consideration of
the person’s ethnic, cultural, and social background. Members of minority
groups, immigrants, political refugees, and people from different ethnic
backgrounds may display guarded or defensive behavior as a result of
language barriers or previous negative experiences; this should not be
confused with emotional coldness or lack of concern for others. People with
religious or spiritual beliefs, such as clairvoyance, speaking in tongues, or
evil spirits as a cause of disease, could be misinterpreted as having
schizotypal personality disorder.
There is also a difference in how some cultural groups view avoidance
or dependent behavior, particularly for women. An emphasis on deference,
passivity, and politeness should not be confused with avoidant personality
disorder. Cultures that value work and productivity may produce citizens
with a strong emphasis in these areas; this should not be confused with
obsessive–compulsive personality disorder.
Certain personality disorders—for example, antisocial personality
disorder—are diagnosed more often in men. BPD is diagnosed more often
in women. Social stereotypes about typical gender roles and behaviors can
influence diagnostic decisions if clinicians are unaware of such biases.

TREATMENT
Several treatment strategies are used with clients with personality disorders;
these strategies are based on the disorder’s type and severity or the amount
of distress or functional impairment the client experiences. Combinations of
medication and group and individual therapies are more likely to be
effective than is any single treatment. Not all people with personality
disorders seek treatment, however, even when significant others or family
members urge them to do so. Typically, people with schizotypal,
narcissistic, or obsessive–compulsive personality disorders are least likely
to engage or remain in any treatment. They see other people, rather than
their own behavior, as the cause of their problems.

Psychopharmacology
Pharmacologic treatment of clients with personality disorders focuses on
the client’s symptoms rather than the particular subtype. The four symptom
categories that underlie personality disorders are cognitive–perceptual
distortions, including psychotic symptoms; affective symptoms and mood
dysregulation; aggression and behavioral dysfunction; and anxiety. These
four symptom categories relate to the underlying temperaments associated
with personality disorders (Svrakic et al., 2019):
 Low reward dependence corresponds to the categories of affective
dysregulation, detachment, and cognitive disturbances.
High novelty seeking corresponds to the target symptoms of
impulsiveness and aggression.
High harm avoidance corresponds to the categories of anxiety and
depression symptoms.
Cognitive–perceptual disturbances include magical thinking, odd beliefs,
illusions, suspiciousness, ideas of reference, and low-grade psychotic
symptoms. These chronic symptoms usually respond to low-dose
antipsychotic medications.
Several types of aggression have been described in people with
personality disorders. Aggression may occur in impulsive people (some
with a normal electroencephalogram and some with an abnormal one);
people who exhibit predatory or cruel behavior; or people with organic-like
impulsivity, poor social judgment, and emotional lability. Lithium,
valproate, and antipsychotics are used most often to treat aggression. Low-
dose neuroleptics may be useful in modifying predatory aggression.
Benzodiazepines should be avoided due to their potential for abuse (Black
& Andreasen, 2021).
Mood dysregulation symptoms include emotional instability, emotional
detachment, depression, and dysphoria (Euler et al., 2021). Emotional
instability and mood swings respond favorably to lithium, carbamazepine
(Tegretol), valproate (Depakote), or low-dose neuroleptics such as
haloperidol (Haldol). Emotional detachment, cold and aloof emotions, and
disinterest in social relations often respond to selective serotonin reuptake
inhibitors (SSRIs) or atypical antipsychotics such as risperidone
(Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel). Atypical
depression is often treated with SSRIs, monoamine oxidase inhibitor
(MAOI) antidepressants, or low-dose antipsychotic medications.
Anxiety seen with personality disorders may be chronic cognitive
anxiety, chronic somatic anxiety, or severe acute anxiety. Chronic cognitive
anxiety responds to SSRIs and MAOIs, as does chronic somatic anxiety or
anxiety manifested as multiple physical complaints. Episodes of severe
acute anxiety are best treated with MAOIs or low-dose antipsychotic
medications.
Table 18.1 summarizes drug choices for various target symptoms of
personality disorders. These drugs, including side effects and nursing
considerations, are discussed in detail in Chapter 2.

TABLE 18.1 Drug Choices for Symptoms of Personality Disorders

Target Symptom Drug of Choice

Aggression/impulsivity
Affective aggression (normal) Lithium
Anticonvulsants
Low-dose antipsychotics
Predatory (hostility/cruelty) Antipsychotics
Lithium
Organic-like aggression Cholinergic agonists (donepezil)
Imipramine (Tofranil)
Ictal aggression (abnormal) Carbamazepine (Tegretol)
Diphenylhydantoin (Dilantin)
Benzodiazepines

Mood dysregulation
Emotional lability Lithium
Carbamazepine (Tegretol)
Antipsychotics
Atypical depression/dysphoria MAOIs
SSRIs
Antipsychotics
Emotional detachment SSRIs
Atypical antipsychotics

Anxiety
Chronic cognitive SSRIs
MAOIs
Benzodiazepines
Chronic somatic MAOIs
SSRIs
Severe anxiety MAOIs
Low-dose antipsychotics

Psychotic symptoms
Acute and psychosis Antipsychotics
Chronic and low-level psychotic-like Low-dose antipsychotics
symptoms
MAOIs, monoamine oxidase inhibitors; SSRIs, selective serotonin reuptake inhibitors.
Individual and Group Psychotherapy
Therapy helpful to clients with personality disorders varies according to the
type and severity of symptoms and the particular disorder (Boland &
Verduin, 2022). Inpatient hospitalization is usually indicated when safety is
a concern, for example, when a person with BPD has suicidal ideas or
engages in self-injury. Otherwise, hospitalization is not useful and may
even result in dependence on the hospital and staff.
Individual and group psychotherapy goals for clients with personality
disorders focus on building trust, teaching basic living skills, providing
support, decreasing distressing symptoms such as anxiety, and improving
interpersonal relationships. Relaxation or meditation techniques can help
manage anxiety for clients. Improvement in basic living skills through the
relationship with a case manager or therapist can improve the functional
skills of people with schizotypal personality disorder. Assertiveness training
groups can assist people to have more satisfying relationships with others
and to build self-esteem when that is needed.
Cognitive–behavioral therapy has been particularly helpful for clients
with personality disorders. Several cognitive restructuring techniques are
used to change the way the client thinks about themself and others: thought
stopping, in which the client stops negative thought patterns; positive self-
talk, designed to change negative self-messages; and decatastrophizing,
which teaches the client to view life events more realistically and not as
catastrophes. Examples of these techniques are presented later in this
chapter.
Dialectical behavior therapy was designed for clients with BPD by Dr.
Marsha Linehan. It focuses on distorted thinking and behavior based on the
assumption that poorly regulated emotions are the underlying problem
(Heerebrand et al., 2021).
Schema therapy is designed to help individuals deal with unmet
emotional needs and to identify the thought and behavioral patterns that
perpetuate their emotional distress and dysfunction. During this therapy,
clients work on developing a greater sense of self-worth, ability to form
nurturing relationships, and achieving goals related to a healthier, happier
life (Koppers et al., 2020).
Table 18.2 summarizes the symptoms of and nursing actions for
personality disorders.
 TABLE 18.2 Summary of Symptoms and Nursing Interventions for Personality
Disorders and Behaviors

Personality Symptoms/Characteristics Nursing Interventions

Disorder
Paranoid Mistrust and suspicions of others; Serious, straightforward approach;
guarded, restricted affect teach client to validate ideas
before taking action; involve client
in treatment planning
Schizoid Detached from social relationships; Improve client’s functioning in the
restricted affect; involved with community; assist client in finding
things more than people case manager
Schizotypal Acute discomfort in relationships; Develop self-care skills; improve
cognitive or perceptual community functioning; social
distortions; eccentric behavior skills training
Antisocial Disregard for rights of others, rules, Limit setting; confrontation; teach
and laws client to solve problems
effectively and manage emotions
of anger or frustration
Borderline Unstable relationships, self-image, Promote safety; help client to cope
and affect; impulsivity; self- and control emotions; cognitive
mutilation restructuring techniques; structure
time; teach social skills
Histrionic Excessive emotionality and Teach social skills; provide factual
attention seeking feedback about behavior
Narcissistic Grandiose; lack of empathy; need Matter-of-fact approach; gain
for admiration cooperation with needed
treatment; teach client any
needed self-care skills
Avoidant Social inhibitions; feelings of Support and reassurance; cognitive
inadequacy; hypersensitive to restructuring techniques; promote
negative evaluation self-esteem
Dependent Submissive and clinging behavior; Foster client’s self-reliance and
excessive need to be taken care autonomy; teach problem-solving
of and decision-making skills;
cognitive restructuring techniques
Obsessive– Preoccupation with orderliness, Encourage negotiation with others;
compulsive perfectionism, and control assist client in making timely
decisions and completing work;
cognitive restructuring techniques

PARANOID PERSONALITY DISORDER

Clinical Picture
Paranoid personality disorder is characterized by pervasive mistrust and
suspiciousness of others. Clients with this disorder interpret others’ actions
as potentially harmful. During periods of stress, they may develop transient
psychotic symptoms. Incidence is estimated at 2% to 4% of the general
population; the disorder is more common in males than in females. Data
about prognosis are limited because most people do not readily seek or
remain in treatment (Black & Andreasen, 2021). Generally, they tend to
have lifelong problems living and working with others.
Clients appear aloof and withdrawn and may remain a considerable
physical distance from the nurse; they view this as necessary for their
protection. Clients may also appear guarded or hypervigilant; they may
survey the room and its contents, look behind furniture or doors, and
generally appear alert to any impending danger. They may choose to sit
near the door to have ready access to an exit or with their backs against the
wall to prevent anyone from sneaking up behind them. They may have a
restricted affect and may be unable to demonstrate warmth or empathic
emotional responses such as “You look nice today” or “I’m sorry you’re
having a bad day.” Mood may be labile, quickly changing from quietly
suspicious to angry or hostile. Responses may become sarcastic for no
apparent reason. The constant mistrust and suspicion that clients feel toward
others and the environment distorts thoughts, thought processing, and
content. Clients frequently see malevolence in the actions of others where
none exists. They may spend disproportionate time examining and
analyzing the behavior and motives of others to discover hidden and
threatening meanings. Clients often feel attacked by others and may devise
elaborate plans or fantasies for protection.
These clients use the defense mechanism of projection, which is
blaming other people, institutions, or events for their own difficulties. It is
common for such clients to blame the government for personal problems.
For example, the client who gets a parking ticket says it is part of a plot by
the police to drive them out of the neighborhood. They may engage in
fantasies of retribution or devise elaborate and sometimes violent plans to
get even. Although most clients do not carry out such plans, there is a
potential danger.
Conflict with authority figures on the job is common; clients may even
resent being given directions from a supervisor. Paranoia may extend to
feelings of being singled out for menial tasks, treated as stupid, or more
closely monitored than other employees.

Nursing Actions
Forming an effective working relationship with paranoid or suspicious
clients is difficult. The nurse must remember that these clients take
everything seriously and are particularly sensitive to the reactions and
motivations of others. Therefore, the nurse must approach these clients in a
formal, businesslike manner and refrain from social chitchat or jokes. Being
on time, keeping commitments, and being especially straightforward are
essential to the success of the nurse–client relationship.
Because these clients need to feel in control, it is important to involve
them in formulating their care plan. The nurse asks what the client would
like to accomplish in concrete terms, such as minimizing problems at work
or getting along with others. Clients are more likely to engage in the
therapeutic process if they believe they have something to gain. One of the
most effective actions is helping clients validate ideas before taking action;
however, this requires the ability to trust and listen to one person. The
rationale for this action is that clients can avoid problems if they can refrain
from taking action until they have validated their ideas with another person.
This helps prevent clients from acting on paranoid ideas or beliefs. It also
assists them in starting to base decisions and actions on reality, rather than
distorted ideas or perceptions.

SCHIZOID PERSONALITY DISORDER

Clinical Picture
Schizoid personality disorder is characterized by a pervasive pattern of
detachment from social relationships and a restricted range of emotional
expression in interpersonal settings. It may affect 5% of the general
population and is more common in males than females (Boland & Verduin,
2022). People with schizoid personality disorder avoid treatment as much as
they avoid other relationships, unless their life circumstances change
significantly.
 Clients with schizoid personality disorder display a constricted affect
and little, if any, emotion. They are aloof and indifferent, appearing
emotionally cold, uncaring, or unfeeling. They report no leisure or
pleasurable activities because they rarely experience enjoyment. Even under
stress or adverse circumstances, their response appears passive and
disinterested. There is marked difficulty experiencing and expressing
emotions, particularly anger or aggression. Clients do not report feeling
distressed about this lack of emotion; it is more distressing to family
members. Clients usually have a rich and extensive fantasy life, although
they may be reluctant to reveal that information to the nurse or anyone else.
The ideal relationships that occur in the client’s fantasies are rewarding and
gratifying; these fantasies, however, are in stark contrast to real-life
experiences. The fantasy relationship often includes someone the client has
met only briefly. Nevertheless, these clients can distinguish fantasies from
reality, and no disordered or delusional thought processes are evident.
Clients are generally accomplished intellectually and often involved
with computers or electronics for work or to pass their time. They may
spend long hours solving puzzles or mathematical problems, although they
see these pursuits as useful or productive rather than fun.
Clients may be indecisive and lack future goals or direction. They see
no need for planning and have no aspirations. They have little opportunity
to exercise judgment or decision-making because they rarely engage in
these activities. Insight might be described as impaired, at least by the
social standards of others; these clients do not see their situation as a
problem and fail to understand why their lack of emotion or social
involvement troubles others. They are self-absorbed and loners in almost all
aspects of daily life. Given an opportunity to engage with other people, they
often decline. They are also indifferent to praise or criticism and are
relatively unaffected by the emotions or opinions of others. They also
experience dissociation from or no bodily or sensory pleasures. For
example, the client has little reaction to beautiful scenery, a sunset, or a
walk on the beach.
Clients have a pervasive lack of desire for involvement with others in
all aspects of life. They do not have or desire friends, rarely date or marry,
and have little or no sexual contact. They may have some connection with a
first-degree relative, often a parent. Clients may remain in the parental
home well into adulthood if they can maintain adequate separation and
distance from other family members. They have few social skills, are
oblivious to the social cues or overtures of others, and do not engage in
social conversation.

Nursing Actions
Nursing actions focus on improved functioning in the community. If a client
needs housing or a change in living circumstances, the nurse can make
referrals to social services or appropriate local agencies for assistance. The
nurse can help agency personnel find suitable housing that accommodates
the client’s desire and need for solitude. For example, the client with a
schizoid personality disorder would function best in a board and care
facility, which provides meals and laundry service but requires little social
interaction. Facilities designed to promote socialization through group
activities would be less desirable.
If the client has an identified family member as their primary
relationship, the nurse must ascertain whether that person can continue in
that role. If the person cannot, the client may need to establish at least a
working relationship with a case manager in the community. The case
manager can then help the client obtain services and health care, manage
finances, and so on. The client has a greater chance of success if they can
relate their needs to one person (as opposed to neglecting important areas of
daily life).

SCHIZOTYPAL PERSONALITY DISORDER

Clinical Picture
Schizotypal personality disorder is characterized by a pervasive pattern of
social and interpersonal deficits marked by acute discomfort with and
reduced capacity for close relationships as well as by cognitive or
perceptual distortions and behavioral eccentricities. Incidence is about 4%
to 5% of the population (Boland & Verduin, 2022). Clients may experience
transient psychotic episodes in response to extreme stress. Persons with
schizotypal personality disorder may develop schizophrenia.
 Clients often have an odd appearance that causes others to notice them.
They may be unkempt and disheveled, and their clothes are often ill-fitting,
do not match, and may be stained or dirty. They may wander aimlessly and,
at times, become preoccupied with some environmental detail. Speech is
coherent, but may be loose, digressive, or vague. Clients often provide
unsatisfactory answers to questions and may be unable to specify or to
describe information clearly. They frequently use words incorrectly, making
their speech sound bizarre. For example, in response to a question about
sleeping habits, the client might respond, “Sleep is slow, the REMs don’t
flow.” These clients have a restricted range of emotions; that is, they lack
the ability to experience and to express a full range of emotions such as
anger, happiness, and pleasure. Affect is often flat and is sometimes silly or
inappropriate.
Cognitive distortions include ideas of reference, magical thinking, odd
or unfounded beliefs, and a preoccupation with parapsychology, including
extrasensory perception and clairvoyance. Ideas of reference usually
involve the client’s belief that events have special meaning for them;
however, these ideas are not firmly fixed and delusional, as may be seen in
clients with schizophrenia. In magical thinking, which is normal in small
children, a client believes they have special powers—that by thinking about
something, they can make it happen. In addition, clients may express ideas
that indicate paranoid thinking and suspiciousness, usually about the
motives of other people (Boland & Verduin, 2022).
Clients experience great anxiety around other people, especially those
who are unfamiliar. This does not improve with time or repeated exposures;
rather, the anxiety may intensify. This results from the belief that strangers
cannot be trusted. Clients do not view their anxiety as a problem that arises
from a threatened sense of self. Interpersonal relationships are troublesome;
therefore, clients may have only one significant relationship, usually with a
first-degree relative. They may remain in their parents’ home well into the
adult years. They have a limited capacity for close relationships, even
though they may be unhappy being alone.
Clients cannot respond to normal social cues and hence cannot engage
in superficial conversation. They may have skills that could be useful in a
vocational setting, but they are not often successful in employment without
support or assistance. Mistrust of others, bizarre thinking and ideas, and
unkempt appearance can make it difficult for these clients to get and to keep
jobs.

Nursing Actions
The focus of nursing care for clients with schizotypal personality disorder is
development of self-care and social skills and improved functioning in the
community. The nurse encourages clients to establish a daily routine for
hygiene and grooming. Such a routine is important because it does not
depend on the client to decide when hygiene and grooming tasks are
necessary. It is useful for clients to have an appearance that is not bizarre or
disheveled because stares or comments from others can increase
discomfort. Because these clients are uncomfortable around others and this
is not likely to change, the nurse must help them function in the community
with minimal discomfort. It may help to ask clients to prepare a list of
people in the community with whom they must have contact, such as a
landlord, store clerk, or pharmacist. The nurse can then role-play
interactions that clients would have with each of these people; this allows
clients to practice making clear and logical requests to obtain services or to
conduct personal business. Because face-to-face contact is more
uncomfortable, clients may be able to make written requests or to use the
telephone for business. Social skills training may help clients talk clearly
with others and to reduce bizarre conversations. It helps to identify one
person with whom clients can discuss unusual or bizarre beliefs, such as a
social worker or a family member. Given an acceptable outlet for these
topics, clients may be able to refrain from these conversations with people
who might react negatively.

ANTISOCIAL PERSONALITY DISORDER

Antisocial personality disorder is characterized by a pervasive pattern of
disregard for and violation of the rights of others—and by the central
characteristics of deceit and manipulation. This pattern has also been
referred to as psychopathy, sociopathy, or dyssocial personality disorder. It
occurs in about 3% of the general population and up to 30% in clinical
settings and is three to four times more common in men than in women. In
prison populations, about 75% are diagnosed with antisocial personality
disorder. Antisocial behaviors tend to peak in the 20s and diminish
significantly after 45 years of age in many individuals.

Care of Clients With Antisocial Personality

Disorder
Assessment Data
Clients are skillful at deceiving others, so during assessment it helps to
check and validate information from other sources.

History
Onset is in childhood or adolescence, although formal diagnosis is not
made until the client is 18 years old. Childhood histories of enuresis,
sleepwalking, and syntonic acts of cruelty are characteristic predictors. In
adolescence, clients may have engaged in lying, truancy, sexual
promiscuity, cigarette smoking, substance use, and illegal activities that
brought them into contact with police. Families have high rates of
depression, substance abuse, antisocial personality disorder, poverty, and
divorce. Erratic, neglectful, harsh, or even abusive parenting frequently
marks the childhoods of these clients (DeLisi et al., 2019).

General Appearance and Motor Behavior

Appearance is usually normal; these clients may be quite engaging and
even charming. Depending on the circumstances of the interview, they
may exhibit signs of mild or moderate anxiety, especially if another
person or agency arranged the assessment.

Mood and Affect

Clients often display false emotions chosen to suit the occasion or to
work to their advantage. For example, a client who is forced to seek
treatment instead of going to jail may appear engaging or try to evoke
sympathy by sadly relating a story of their “terrible childhood.” The
client’s actual emotions are quite shallow.
These clients cannot empathize with the feelings of others, and this
enables them to exploit others without guilt. Usually, they feel remorse
only if they are caught breaking the law or exploiting someone.

Thought Process and Content

Clients do not experience disordered thoughts, but their views of the
world are narrow and distorted. Because coercion and personal profit
motivate them, they tend to believe that others are similarly governed.
They view the world as cold and hostile and therefore rationalize their
behavior. Clichés such as “It’s a dog-eat-dog world” represent their
viewpoint. Clients believe they are only taking care of themselves
because no one else will.

Sensorium and Intellectual Processes

Clients are oriented, have no sensory–perceptual alterations, and have
average or above-average IQs.

Judgment and Insight

These clients generally exercise poor judgment for various reasons. They
pay no attention to the legality of their actions and do not consider
morals or ethics when making decisions. Their behavior is determined
primarily by what they want, and they perceive their needs as immediate.
In addition to seeking immediate gratification, these clients are
impulsive. Such impulsivity ranges from simple failure to use normal
caution (waiting for a green light to cross a busy street) to extreme thrill-
seeking behaviors such as driving recklessly.
Clients lack insight and almost never see their actions as the cause of
their problems. It is always someone else’s fault; some external source is
responsible for their situation or behavior.

Self-Concept
Superficially, clients appear confident, self-assured, and accomplished,
perhaps even flip or arrogant. They feel fearless, disregard their own
vulnerability, and usually believe they cannot be caught in lies, deceit, or
illegal actions. They may be described as egocentric, but actually the self
is quite shallow and empty; these clients are devoid of personal
emotions. They realistically appraise their own strengths and
weaknesses.
Roles and Relationships
Clients manipulate and exploit those around them. They view
relationships as serving their needs and pursue others only for personal
gain. They never think about the repercussions of their actions on others.
For example, a client is caught scamming an older person out of their
entire life savings. The client’s only comment when caught is “Can you
believe that’s all the money I got? I was cheated! There should have been
more.”
These clients are often involved in many relationships, sometimes
simultaneously. They may marry and have children, but they cannot
sustain long-term commitments. They are usually unsuccessful as
spouses and parents and leave others abandoned and disappointed. They
may obtain employment readily with their adept use of superficial social
skills, but over time their work history is poor. Problems may result from
absenteeism, theft, or embezzlement, or they may quit simply out of
boredom.

Data Analysis and Priorities

People with antisocial personality disorder generally do not seek
treatment voluntarily unless they perceive some personal gain from
doing so. For example, a client may choose a treatment setting as an
alternative to jail or to gain sympathy from an employer; they may cite
stress as a reason for absenteeism or poor performance. Inpatient
treatment settings are not necessarily effective for these clients and may
in fact bring out their worst qualities.
Common problems when working with these clients include
Ineffective coping
Unable to fulfil life roles
Risk for violence

Outcome Identification
The treatment focus is often behavioral change. Although treatment is
unlikely to affect the client’s insight or view of the world and others, it is
possible to make changes in behavior. Treatment outcomes may include
the following:
 The client will demonstrate nondestructive ways to express feelings
and frustration.
The client will identify ways to meet their own needs that do not
infringe on the rights of others.
The client will achieve or maintain satisfactory role performance (e.g.,
at work or as a parent).

Action
Forming a Therapeutic Relationship and Promoting
Responsible Behavior
The nurse must provide structure in the therapeutic relationship, identify
acceptable and expected behaviors, and be consistent in those
expectations. The nurse must minimize attempts by these clients to
manipulate and control the relationship.
Limit setting is an effective technique that involves three steps:
1. Stating the behavioral limit (describing the unacceptable behavior)
2. Identifying the consequences if the limit is exceeded
3. Identifying the expected or desired behavior
Consistent limit setting in a matter-of-fact nonjudgmental manner is
crucial to success. For example, a client may approach the nurse
flirtatiously and attempt to gain personal information. The nurse would
use limit setting by saying,

“It is not acceptable for you to ask personal questions. If you

continue, I will terminate our interaction. We need to use this
time to work on solving your job-related problems.”

The nurse should not become angry or respond to the client harshly
or punitively.
Confrontation is another technique designed to manage
manipulative or deceptive behavior, confronting the incongruence
between client statements and behavior. The nurse points out a client’s
problematic behavior while remaining neutral and matter-of-fact; they
avoid accusing the client. The nurse can also use confrontation to keep
clients focused on the topic and in the present. The nurse can focus on
the behavior itself rather than on attempts by clients to justify it. For
example:

Nurse: “You’ve said you’re interested in learning to manage

angry outbursts, but you’ve missed the last three group
meetings.”
Client: “Well, I can tell no one in the group likes me. Why
should I bother?”
Nurse: “The group meetings are designed to help you and the
others, but you can’t work on issues if you’re not there.”

Helping Clients Solve Problems and Control Emotions

Clients with antisocial personality disorder have an established pattern of
reacting impulsively when confronted with problems. The nurse can
teach problem-solving skills and help clients practice them. Problem-
solving skills include identifying the problem, exploring alternative
solutions and related consequences, choosing and implementing an
alternative, and evaluating the results. Although these clients have the
cognitive ability to solve problems, they need to learn a step-by-step
approach to deal with them. For example, a client’s car isn’t running, so
they stop going to work. The problem is transportation to work;
alternative solutions might be taking the bus, asking a coworker for a
ride, and getting the car fixed. The nurse can help the client discuss the
various options and choose one so they can go back to work.
Managing emotions, especially anger and frustration, can be a major
problem. When clients are calm and not upset, the nurse can encourage
them to identify sources of frustration, how they respond to it, and the
consequences. In this way, the nurse assists clients in anticipating
stressful situations and to learn ways to avoid negative future
consequences. Taking a time-out or leaving the area and going to a
neutral place to regain internal control is often a helpful strategy. Time-
outs help clients to avoid impulsive reactions and angry outbursts in
emotionally charged situations, regain control of emotions, and engage in
constructive problem-solving.

Improving Role Performance

The nurse helps clients to identify specific problems at work or home
that are barriers to success in fulfilling roles. Assessing use of alcohol
and other drugs is essential when examining role performance because
many clients use or abuse these substances. These clients tend to blame
others for their failures and difficulties, and the nurse must redirect them
to examine the source of their problems realistically. Referrals to
vocational or job programs may be indicated.

NURSING ACTIONS
For Antisocial Personality Disorder
Promoting responsible behavior
Limit setting
State the limit.
Identify the consequences of exceeding the limit.
Identify the expected or acceptable behavior.
Consistent adherence to rules and treatment plan
Confrontation
Point out the problem behavior.
Keep the client focused on themself.
Help clients solve problems and control emotions.
Effective problem-solving skills
Decreased impulsivity
Expressing negative emotions such as anger or frustration
Taking a time-out from stressful situations
Improving role performance
Identifying barriers to role fulfillment
Decreasing or eliminating use of drugs and alcohol

CLINICAL VIGNETTE: Antisocial Personality Disorder

S. found himself in the local jail again after being arrested for burglary. He had told the
police it wasn’t breaking and entering; he had his friend’s permission to use his
parents’ home, but they’d just forgotten to leave the key. S. has a long juvenile record
of truancy, fighting, and marijuana use, which he blames on “having the wrong
friends.” This is his third arrest, and S. claims the police have been picking on him
ever since an older adult in the community gave him $5,000 when he was out of work.
He intends to pay her back when his ship comes in. S.’s wife of 3 years left him
recently, claiming he couldn’t hold a decent job and was running up bills they couldn’t
pay. S. was tired of her nagging and was ready for a new relationship anyway. He
wishes he could win the lottery and find a beautiful girl to love him. He’s tired of
people demanding that he grow up, get a job, and settle down. They just don’t
understand that he’s got more exciting things to do.
PLAN OF CARE FOR A CLIENT WITH ANTISOCIAL
PERSONALITY DISORDER
Problem: Ineffective coping

ASSESSMENT DATA
Low frustration tolerance
Impulsive behavior
Inability to delay gratification
Poor judgment
Conflict with authority
Difficulty following rules and obeying laws
Lack of feelings of remorse
Socially unacceptable behavior
Dishonesty
Ineffective interpersonal relationships
Manipulative behavior
Failure to learn or change behavior based on past experience or punishment
Failure to accept or handle responsibility

EXPECTED OUTCOMES
Immediate
The client will
Refrain from harming self or others throughout hospitalization.
Identify behaviors leading to the current situation within 24 to 48 hours.
Function within the limits of the environment; for example, follow no-smoking rules,
participate in group activities within 2 to 3 days.
Stabilization
The client will
Demonstrate nondestructive ways to deal with stress and frustration.
Identify ways to meet own needs that do not infringe on the rights of others.
Community
The client will
Achieve or maintain satisfactory work performance.
Meet own needs without exploiting or infringing on the rights of others.

IMPLEMENTATION

Nursing Actions Rationale—Thinking Like a

Nurse
Encourage the client to identify These clients frequently deny
the actions that precipitated responsibility for the
current situation (e.g., debts, consequences of their own
marital problems, law violation). actions.
Nursing Actions Rationale—Thinking Like a
Nurse
Give positive feedback for Honest identification of the
honesty. The client may try to consequences of the client’s
avoid responsibility by acting as behavior is necessary for future
though they are “sick” or behavior change.
helpless.
Identify unacceptable behaviors, You must supply clear, concrete
either general (stealing others’ limits when the client is unable or
possessions) or specific unwilling to do so.
(embarrassing another by telling
lewd jokes).
Avoid any discussion about why The client may attempt to bend
requirements exist. State the the rules “just this once” with
requirement in a matter-of-fact numerous excuses and
manner. Avoid arguing with the justifications. Your refusal to be
client. manipulated or charmed will help
decrease manipulative behavior.
Inform the client of unacceptable The client must be aware of
behaviors and the resulting expectations and consequences.
consequences before they occur.
Communicate and document in The client may attempt to gain
the client’s care plan all behaviors favor with individual staff
and consequences in specific members or play one staff
terms. member against another (“Last
night, the nurse told me I could
do that”). If all team members
follow the written plan, the client
will not be able to manipulate
changes.
Avoid discussing another staff The client may try to manipulate
member’s actions or statements staff members or focus attention
unless the other staff member is on others to decrease attention to
present. themself.
Nursing Actions Rationale—Thinking Like a
Nurse
Be consistent and firm with the Consistency is essential. If the
care plan. Do not make client can find just one person to
independent changes in rules or make independent changes, any
consequences. Any change plan will become ineffective.
should be made by the staff as a
group and conveyed to all staff
members working with this
client. (You may designate a
primary staff person to be
responsible for minor decisions
and refer all questions to this
person.)
Avoid trying to coax or convince The client must decide to accept
the client to do the “right thing.” responsibility for their behavior
and its consequences.
When the client exceeds a limit, Consequences are most effective
provide consequences when they closely follow the
immediately after the behavior in unacceptable behavior. Do not
a matter-of-fact manner. react to the client in an angry or
punitive manner. If you show
anger toward the client, they may
take advantage of it. It is better to
get out of the situation if possible
and let someone else handle it.
Point out the client’s The client needs to learn the
responsibility for their behavior connection between behavior and
in a nonjudgmental manner. the consequences, but blame and
judgment are not appropriate.
Provide immediate positive Immediate positive feedback will
feedback or reward for acceptable help increase acceptable
behavior. behavior. The client must receive
attention for positive behaviors,
not just unacceptable ones.
Nursing Actions Rationale—Thinking Like a
Nurse
Gradually, require longer periods This gradual progression will
of acceptable behavior and help develop the client’s ability to
greater rewards, and inform the delay gratification. This is
client of changes as decisions are necessary if the client is to
made. function effectively in society.
Encourage the client to identify This may facilitate the client’s
sources of frustration, how they ability to accept responsibility for
dealt with it previously, and any their own behavior.
unpleasant consequences that
resulted.
Explore alternative, socially, and The client has the opportunity to
legally acceptable methods of learn to make alternative choices.
dealing with identified
frustrations.
Help the client try alternatives as The client can role-play
situations arise. Give positive alternatives in a nonthreatening
feedback when the client uses environment.
alternatives successfully.
Discuss job seeking, work Dealing with consequences and
attendance, court appearances, working are responsible
and so forth when working with behaviors. The client may have
the client in anticipation of return had little or no successful
to the community. experience in these areas and
may benefit from assistance.
Problem-solving skills

CLIENT AND FAMILY EDUCATION

 For Antisocial Personality Disorder
Avoiding use of alcohol and other drugs
Appropriate social skills
Effective problem-solving skills
Managing emotions such as anger and frustration
Taking a time-out to avoid stressful situations

Evaluation
The nurse evaluates the effectiveness of treatment based on attainment of
or progress toward outcomes. If a client can maintain a job with
acceptable performance, meet basic family responsibilities, and avoid
committing illegal or immoral acts, then treatment has been successful.

BORDERLINE PERSONALITY DISORDER

BPD is characterized by a pervasive pattern of unstable interpersonal
relationships, self-image, and affect as well as marked impulsivity. About
2% to 3% of the general population has BPD; it is five times more common
in those with a first-degree relative with the diagnosis. BPD is the most
common personality disorder found in clinical settings. It is three times
more common in women than in men. Under stress, transient psychotic
symptoms are common. Between 8% and 10% of people with this diagnosis
commit suicide, and many more suffer permanent damage from self-
mutilation injuries, such as cutting or burning. Up to three-quarters of
clients with BPD engage in deliberate self-harm, sometimes called
nonsuicidal self-injury (Levine et al., 2020). Typically, recurrent self-
mutilation is a cry for help, an expression of intense anger or helplessness,
or a form of self-punishment. The resulting physical pain is also a means to
block emotional pain. Clients who engage in self-mutilation do so to
reinforce that they are still alive; they seek to experience physical pain in
the face of emotional numbing.
Working with clients who have BPD can be frustrating. They may cling
and ask for help one minute and then become angry, act out, and reject all
offers of help in the next minute. They may attempt to manipulate staff to
gain immediate gratification of needs and, at times, sabotage their own
treatment plans by purposely failing to do what they have agreed. Their
labile mood, unpredictability, and diverse behaviors can make it seem as if
the staff is always “back to square one” with them.

Care of Clients With Borderline Personality

Disorder
Assessment Data
History
Many of these clients report disturbed early relationships with their
parents that often begin at 18 to 30 months of age. Commonly, early
attempts by these clients to achieve developmental independence were
met with punitive responses from parents or threats of withdrawal of
parental support and approval. Of these clients, 50% have experienced
childhood sexual abuse; others have experienced physical and verbal
abuse and parental alcoholism. Clients tend to use transitional objects
(e.g., teddy bears, pillows, blankets, and dolls) extensively; this may
continue into adulthood. Transitional objects are often similar to favorite
items from childhood that the client used for comfort or security (Lucre
& Clapton, 2021).

General Appearance and Motor Behavior

Clients experience a wide range of dysfunction from severe to mild.
Initial behavior and presentation may vary widely depending on a client’s
present status. When dysfunction is severe, clients may appear
disheveled and may be unable to sit still, or they may display labile
emotions. In other cases, initial appearance and motor behavior may
seem normal. The client seen in the emergency department threatening
suicide or self-harm may seem out of control, while a client seen in an
outpatient clinic may appear fairly calm and rational.

Mood and Affect

The pervasive mood is dysphoric, involving unhappiness, restlessness,
and malaise. Clients often report intense loneliness, boredom, frustration,
and feeling “empty.” They rarely experience periods of satisfaction or
well-being. Although there is a pervasive depressed affect, it is unstable
and erratic. Clients may become irritable, even hostile or sarcastic, and
complain of episodes of panic anxiety. They experience intense emotions
such as anger and rage but rarely express them productively or usefully.
They are usually hypersensitive to others’ emotions, which can easily
trigger reactions. Minor changes may precipitate a severe emotional
crisis, for example, when an appointment must be changed from one day
to the next. Commonly, these clients experience major emotional trauma
when their therapists take vacations.
Unstable, unhappy affect of borderline personality disorder

Thought Process and Content

Thinking about oneself and others is often polarized and extreme, and
this is sometimes referred to as splitting. Clients tend to adore and
idealize other people even after a brief acquaintance but then quickly
devalue them if these others do not meet their expectations in some way.
Clients have excessive and chronic fears of abandonment even in normal
situations; this reflects their intolerance of being alone. They may also
engage in obsessive rumination about almost anything, regardless of the
issue’s relative importance.
Clients may experience dissociative episodes (periods of wakefulness
when they are unaware of their actions). Self-harm behaviors often occur
during these dissociative episodes, although, at other times, clients may
be fully aware of injuring themselves. As stated earlier, under extreme
stress, clients may develop transient psychotic symptoms such as
delusions or hallucinations.

Sensorium and Intellectual Processes

Intellectual capacities are intact, and clients are fully oriented to reality.
The exception is transient psychotic symptoms; during such episodes,
reports of auditory hallucinations encouraging or demanding self-harm
are most common. These symptoms usually abate when the stress is
relieved. Many clients also report flashbacks of previous abuse or
trauma. These experiences are consistent with posttraumatic stress
disorder, which is common in clients with BPD (see Chapter 13).

Judgment and Insight

Clients frequently report behaviors consistent with impaired judgment
and lack of care and concern for safety, such as gambling, shoplifting,
and reckless driving. They make decisions impulsively on the basis of
emotions rather than facts.
Clients have difficulty accepting responsibility for meeting needs outside
a relationship. They see life’s problems and failures as a result of others’
shortcomings. Because others are always to blame, insight is limited. A
typical reaction to a problem is “I wouldn’t have gotten into this mess if
so-and-so had been there when I needed them.”

Self-Concept
Clients have an unstable view of themselves that shifts dramatically and
suddenly. They may appear needy and dependent one moment and angry,
hostile, and rejecting the next. Sudden changes in opinions and plans
about career, sexual identity, values, and types of friends are common.
Clients view themselves as inherently bad or evil and often report feeling
as if they don’t really exist at all.
Suicidal threats, gestures, and attempts are common. Self-harm and
mutilation, such as cutting, punching, or burning, are common. These
behaviors must be taken seriously because these clients are at increased
risk for completed suicide, even if numerous previous attempts have not
been life-threatening. These self-inflicted injuries cause much pain and
often require extensive treatment; some result in massive scarring or
permanent disability such as paralysis or loss of mobility from injury to
nerves, tendons, and other essential structures.

Roles and Relationships

Clients hate being alone, but their erratic, labile, and sometimes
dangerous behaviors often isolate them. Relationships are unstable,
stormy, and intense; the cycle repeats itself continually. These clients
have extreme fears of abandonment and difficulty believing a
relationship still exists once the person is away from them. They engage
in many desperate behaviors, even suicide attempts, to gain or maintain
relationships. Feelings for others are often distorted, erratic, and
inappropriate. For example, they may view someone they have met only
once or twice as their best and only friend or the “love of my life.” If
another person does not immediately reciprocate their feelings, the client
may feel rejected, become hostile, and declare that person to be their
enemy. These erratic emotional changes can occur in the space of an
hour. Often, these situations precipitate self-mutilating behavior;
occasionally, clients may attempt to harm others physically.
Clients usually have a history of poor school and work performance
because of constantly changing career goals and shifts in identity or
aspirations, preoccupation with maintaining relationships, and fear of
real or perceived abandonment. Clients lack the concentration and self-
discipline to follow through on sometimes mundane tasks associated
with work or school.

Physiological and Self-Care Considerations

In addition to suicidal and self-harm behavior, clients may engage in
binging (excessive overeating) and purging (self-induced vomiting),
substance abuse, unprotected sex, or reckless behavior such as driving
while intoxicated. They usually have difficulty sleeping.

Data Analysis and Priorities

Nursing problems for clients with BPD may include
Risk for suicide
Risk for nonsuicidal self-injury
Risk for violence
Ineffective coping
Social isolation
If clients are threatening suicide or violence toward others, that is
always a priority. But even if the client denies suicidal ideation or urges
to self-injure, the nurse should be alert to the possibility of either,
because these clients are impulsive in their actions. It is never safe to
assume that these behaviors will not occur.

Outcome Identification
Treatment outcomes may include the following:
The client will be safe and free from significant injury.
The client will not harm others or destroy property.
The client will demonstrate increased control of impulsive behavior.
The client will take appropriate steps to meet their own needs.
The client will demonstrate problem-solving skills.

Actions
Clients with BPD are often involved in long-term psychotherapy to
address issues of family dysfunction and abuse. The nurse is most likely
to have contact with these clients during crises, when they are exhibiting
self-harm behaviors or transient psychotic symptoms. Brief
hospitalizations are often used to manage these difficulties and to
stabilize the client’s condition.

Promoting Clients’ Safety

Clients’ physical safety is always a priority. The nurse must always
seriously consider suicidal ideation with the presence of a plan, access to
means for enacting the plan, and self-harm behaviors and must institute
appropriate interventions (see Chapter 17). Clients often experience
chronic suicidality or ongoing intermittent ideas of suicide over months
or years. The challenge for the nurse, in concert with clients, is to
determine when suicidal ideas are likely to be translated into action.
Clients may enact nonsuicidal self-injury urges by cutting, burning,
or punching themselves, which sometimes causes permanent physical
damage. Self-injury can occur when a client is enraged or experiencing
dissociative episodes or psychotic symptoms, or it may occur for no
readily apparent reason. Helping clients avoid self-injury can be difficult
when antecedent conditions vary greatly. Sometimes, clients may discuss
self-harm urges with the nurse if they feel comfortable doing so. The
nurse must remain nonjudgmental when discussing this topic.

CLINICAL VIGNETTES: Borderline Personality

Disorder
G. had been calling her therapist all day, ever since their session this morning. But the
therapist hadn’t called her back, even though all her messages said this was an
emergency. She was sure her therapist was angry at her and was probably going to
drop her as a client. Then she’d have no one; she’d be abandoned by the only person
in the world she could talk to. G. was upset and crying as she began to run the razor
blade across her arm. As the blood trickled out, she began to calm down. Then her
therapist called and asked what the problem was. G. was sobbing as she told her
therapist that she was cutting her arm because the therapist didn’t care anymore, that
she was abandoning G. like everyone else in her life—her parents, her best friend,
every man she had a relationship with. No one was ever there for her when she
needed them.

PLAN OF CARE FOR A CLIENT WITH BORDERLINE

PERSONALITY DISORDER
Problem: Risk for nonsuicidal self-injury

RISK FACTORS
Impulsive displays of temper
Inability to express feelings verbally
Physically self-damaging acts
Attention-seeking behavior
Ineffective coping skills
EXPECTED OUTCOMES
Immediate
The client will
Be safe and free from injury.
Refrain from harming others or destroying property.
Respond to external limits within 24 to 48 hours.
Participate in treatment plan; for example, talk with staff or participate in group activities for
at least 30 minutes twice a day within 24 to 48 hours.
Stabilization
The client will
Eliminate acting-out behaviors (temper tantrums, self-harm, suicidal threats).
Develop a schedule or daily routine that includes socialization and daily responsibilities.
Community
The client will
Independently control urges toward self-injurious behavior.
Demonstrate alternative ways of expressing feelings, such as contact with a therapist or
significant other.

IMPLEMENTATION

Nursing Actions Rationale—Thinking Like a

Nurse
In your initial assessment, find The client’s physical safety is a
out if they have any history of priority. Although absence of a
suicidal behavior or present suicidal history does not preclude
suicidal ideation or plans. risk, presence of a suicidal
history increases risk. The client
with a history of self-harm can
also be at risk for suicide. Do not
underestimate the suicidal risk
for the client by only focusing on
self-harm behaviors.
Place the client in a room near the The client is easier to observe
nursing station or where the client and has less chance to leave the
can be observed easily, rather area undetected.
than a room near an exit or
stairwell, and so forth.
Nursing Actions Rationale—Thinking Like a
Nurse
Assess the client for the presence The client has a pattern of
of self-harm urges and history of injurious behavior and is likely to
scratching, cutting, or burning engage in similar self-harm
behaviors. behaviors when stressed.
Closely supervise the client’s use The client may use these items
of sharp or other potentially for self-destructive acts.
dangerous objects.
Be consistent with the client. Set Consistent limit setting is
and maintain limits regarding essential to decrease negative
behavior, responsibilities, rules, behaviors.
and so forth.
Withdraw your attention as much Withdrawing your attention will
as possible if the client acts out tend to decrease acting-out
(if the client’s safety is not at behaviors.
risk).
Encourage the client to identify The client may be unaware of
feelings that are related to self- feelings or experiences that
destructive behaviors. Encourage trigger self-destructive behavior
the client to express these and needs to develop more
feelings directly. effective skills to avoid self-
destructive behavior in the future.
When talking with the client, If the client is blaming others for
focus on self-responsibility and their problems, it is unlikely that
active approaches that the client the client will accept
can take. Avoid reinforcing the responsibility for making
client’s passivity, feelings of changes.
hopelessness, and so forth.
 Nursing Actions Rationale—Thinking Like a
Nurse
Help the client identify strengths The client’s self-perception may
and successful coping behaviors be one of hopelessness or
that they have used in the past. It helplessness. The client needs
may help to have the client make your assistance to recognize
a written list. Encourage the strengths.
client to try to use these coping
behaviors in present and future
situations.
Teach the client additional The client may have limited or no
positive coping strategies and knowledge of stress management
stress management skills, such as techniques or may not have used
increasing physical exercise, positive techniques in the past. If
expressing feelings verbally or in the client tries to build skills in
a journal, or meditation the treatment setting, they can
techniques. Encourage the client experience success and receive
to practice these skills while in positive feedback for their
the hospital. efforts.

It has been common practice in many settings to encourage clients to

enter into a no–self-harm contract, in which the client promises not to
engage in self-injury and to report to the nurse when they are losing
control. The no–self-harm contract is not a promise to the nurse but the
client’s promise to themself to be safe. Although not legally binding,
such a contract was thought to be beneficial to the client’s treatment by
promoting self-responsibility and encouraging dialogue between client
and nurse. However, there is no evidence to support the effectiveness of
these contracts, and, in fact, some believe they may give staff a false
sense of security. When clients are relatively calm and thinking clearly, it
is helpful for the nurse to explore self-harm behavior. The nurse avoids
sensational aspects of the injury; the focus is on identifying mood and
affect, level of agitation and distress, and circumstances surrounding the
incident. In this way, clients can begin to identify trigger situations,
moods, or emotions that precede self-injury and to use more effective
coping skills to deal with the trigger issues.
 If clients do injure themselves, the nurse assesses the injury and need
for treatment in a calm, matter-of-fact manner. Lecturing or chastising
clients is punitive and has no positive effect on self-injury behaviors.
Deflecting attention from the actual physical act is usually desirable.

Promoting the Therapeutic Relationship

Regardless of the clinical setting, the nurse must provide structure and
limit setting in the therapeutic relationship. In a clinical setting, this may
mean seeing the client for scheduled appointments of a predetermined
length rather than whenever the client appears and demands the nurse’s
immediate attention. In the hospital setting, the nurse would plan to
spend a specific amount of time with the client working on issues or
coping strategies rather than giving the client exclusive access when they
have had an outburst. Limit setting and confrontation techniques,
described earlier, are also helpful.

Establishing Boundaries in Relationships

Clients have difficulty maintaining satisfying interpersonal relationships.
Personal boundaries are unclear, and clients often have unrealistic
expectations. Erratic patterns of thinking and behaving often alienate
them from others. This may be true for both professional and personal
relationships. Clients can easily misinterpret the nurse’s genuine interest
and caring as a personal friendship, and the nurse may feel flattered by a
client’s compliments. The nurse must be quite clear about establishing
the boundaries of the therapeutic relationship to ensure that neither the
client’s nor the nurse’s boundaries are violated. For example:

NURSING ACTIONS
For BPD
Promoting client’s safety
Discuss self-injury thoughts and urges
Safe expression of feelings and emotions
Helping client to cope and control emotions
Identifying feelings
Journal entries
Moderating emotional responses
Decreasing impulsivity
Delaying gratification
Cognitive restructuring techniques
 Thought stopping
Decatastrophizing
Structuring time
Teaching social skills
Teaching effective communication skills
Entering therapeutic relationship
Limit setting
Confrontation

Client: “You’re better than my family and the doctors. You

understand me more than anyone else.”
Nurse: “I’m interested in helping you get better just as the
other staff members are.” (establishing boundaries)

Teaching Effective Communication Skills

It is important to teach basic communication skills such as eye contact,
active listening, taking turns talking, validating the meaning of another’s
communication, and using “I” statements (“I think…,” “I feel…,” “I
need...”). The nurse can model these techniques and engage in role-
playing with clients. The nurse asks how clients feel when interacting
and gives feedback about nonverbal behavior, such as “I noticed you
were looking at the floor when discussing your feelings.”

Helping Clients to Cope and to Control Emotions

Clients often react to situations with extreme emotional responses
without actually recognizing their feelings. The nurse can help clients
identify their feelings and learn to tolerate them without exaggerated
responses such as destruction of property or self-harm. Keeping a journal
often helps clients gain awareness of feelings. The nurse can review
journal entries as a basis for discussion.
Another aspect of emotional regulation is decreasing impulsivity and
learning to delay gratification. When clients have an immediate desire or
request, they must learn that it is unreasonable to expect it to be granted
without delay. Clients can use distraction such as taking a walk or
listening to music to deal with the delay, or they can think about ways to
meet needs themselves. Clients can write in their journals about their
feelings when gratification is delayed.

Reshaping Thinking Patterns

These clients view everything, people and situations, in extremes—
totally good or totally bad. Cognitive restructuring is a technique useful
in changing patterns of thinking by helping clients recognize negative
thoughts and feelings and replacing them with positive patterns of
thinking. Thought stopping is a technique to alter the process of
negative or self-critical thought patterns, such as “I’m dumb, I’m stupid,
I can’t do anything right.” When the thoughts begin, the client may
actually say “Stop!” in a loud voice to stop the negative thoughts. Later,
more subtle means such as forming a visual image of a stop sign will be
a cue to interrupt the negative thoughts. The client then learns to replace
recurrent negative thoughts of worthlessness with more positive thinking.
In positive self-talk, the client reframes negative thoughts into positive
ones: “I made a mistake, but it’s not the end of the world. Next time, I’ll
know what to do.”
Decatastrophizing is a technique that involves learning to assess
situations realistically rather than always assuming a catastrophe will
happen. The nurse asks, “So what is the worst thing that could happen?”
or “How likely do you think that is?” or “How do you suppose other
people might deal with that?” or “Can you think of any exceptions to
that?” In this way, the client must consider other points of view and
actually think about the situation; in time, their thinking may become
less rigid and inflexible.

Structuring the Clients’ Daily Activities

Feelings of chronic boredom and emptiness, fear of abandonment, and
intolerance of being alone are common problems. Clients are often at a
loss to manage unstructured time, become unhappy and ruminative, and
may engage in frantic and desperate behaviors (e.g., self-injury) to
change the situation. Minimizing unstructured time by planning activities
can help clients manage time alone. Clients can make a written schedule
that includes appointments, shopping, reading the paper, and going for a
walk. They are more likely to follow the plan if it is in written form. This
can also help clients plan ahead to spend time with others instead of
frantically calling others when in distress. The written schedule also
allows the nurse to help clients engage in more healthful behaviors, such
as exercising, planning meals, and cooking nutritious food.
 CLIENT AND FAMILY EDUCATION
For BPD
Teaching social skills
Maintaining personal boundaries
Realistic expectations of relationships
Teaching time structuring
Making a written schedule of activities
Making a list of solitary activities to combat boredom
Teaching self-management through cognitive restructuring
Decatastrophizing situation
Thought stopping
Positive self-talk
Using assertiveness techniques, such as “I” statements
Using distraction, such as walking or listening to music

Evaluation
As with any personality disorder, changes may be small and slow. The
degree of functional impairment of clients with BPD may vary widely.
Clients with severe impairment may be evaluated in terms of their ability
to be safe and refrain from self-injury. Other clients may be employed
and have fairly stable interpersonal relationships. Generally, when clients
experience fewer crises less frequently over time, treatment is effective.

HISTRIONIC PERSONALITY DISORDER

Clinical Picture
Histrionic personality disorder is characterized by a pervasive pattern of
excessive emotionality and attention seeking. It is found in about 2% of the
general population but in as much as 10% to 15% of inpatient populations.
Clients often seek assistance for depression, unexplained physical
problems, and difficulties with relationships. However, clients do not see
how their own behavior has an impact on their current difficulties. This
disorder is diagnosed more frequently in females than in males (Black &
Andreasen, 2021).
 The tendency of these clients to exaggerate the closeness of
relationships or to dramatize relatively minor occurrences can result in
unreliable data. Speech is usually colorful and theatrical, full of superlative
adjectives. It becomes apparent, however, that although colorful and
entertaining, descriptions are vague and lack detail. Overall appearance is
normal, although clients may overdress (e.g., wear an evening dress and
high heels for a clinical interview). Clients are overly concerned with
impressing others with their appearance and spend inordinate time, energy,
and money to this end. Dress and flirtatious behavior are not limited to
social situations or relationships but also occur in occupational and
professional settings. The nurse may think these clients are charming or
even seductive.
Clients are emotionally expressive, gregarious, and effusive. They often
exaggerate emotions inappropriately. For example, a client says, “He is the
most wonderful doctor! He is so fantastic! He has changed my life!” to
describe a physician she has seen once or twice. In such a case, the client
cannot specify why she views the doctor so highly. Expressed emotions,
although colorful, are insincere and shallow; this is readily apparent to
others but not to clients. They experience rapid shifts in moods and
emotions and may be laughing uproariously one moment and sobbing the
next. Thus, their displays of emotion may seem phony or forced to
observers. Clients are self-absorbed and focus most of their thinking on
themselves, with little or no thought about the needs of others. They are
highly suggestible and will agree with almost anyone to get attention. They
express strong opinions firmly, but because they base them on little
evidence or facts, the opinions often shift under the influence of someone
they are trying to impress.
Clients are uncomfortable when they are not the center of attention and
go to great lengths to gain that status. They use their physical appearance
and dress to gain attention. At times, they may fish for compliments in
unsubtle ways, fabricate unbelievable stories, or create public scenes to
attract attention. They may even faint, become ill, or fall to the floor. They
brighten considerably when given attention after some of these behaviors;
this leaves others feeling they have been used. Any comment or statement
that could be interpreted as uncomplimentary or unflattering may produce a
strong response such as a temper tantrum or crying outburst.
 Clients tend to exaggerate the intimacy of relationships. They refer to
almost all acquaintances as “dear, dear friends.” They may embarrass
family members or friends by flamboyant and inappropriate public behavior
such as hugging and kissing someone who has just been introduced or
sobbing uncontrollably over a minor incident. Clients may ignore old
friends if someone new and interesting has been introduced. People with
whom these clients have relationships often describe being used,
manipulated, or exploited shamelessly.
Clients may have a wide variety of vague physical complaints or relate
exaggerated versions of physical illness. These episodes usually involve the
attention the client received (or failed to receive) rather than any particular
physiological concern.

Nursing Actions
The nurse gives clients feedback about their social interactions with others,
including manner of dress and nonverbal behavior. Feedback should focus
on appropriate alternatives, not merely criticism. For example, the nurse
might say,

“When you embrace and kiss other people on first meeting

them, they may interpret your behavior in a sexual manner. It
would be more acceptable to stand at least 2 ft away from
them and to shake hands.”

It may also help to discuss social situations to explore clients’

perceptions of others’ reactions and behavior. Teaching social skills and
role-playing those skills in a safe, nonthreatening environment can help
clients gain confidence in their ability to interact socially. The nurse must
be specific in describing and modeling social skills, including establishing
eye contact, engaging in active listening, and respecting personal space. It
also helps to outline topics of discussion appropriate for casual
acquaintances, closer friends or family, and the nurse only.
Clients may be quite sensitive to discussing self-esteem and may
respond with exaggerated emotions. It is important to explore personal
strengths and assets and to give specific feedback about positive
characteristics. Encouraging clients to use assertive communication, such as
“I” statements, may promote self-esteem and help them get their needs met
more appropriately. The nurse must convey genuine confidence in the
client’s abilities.

NARCISSISTIC PERSONALITY DISORDER

Clinical Picture
Narcissistic personality disorder is characterized by a pervasive pattern of
grandiosity (in fantasy or behavior), need for admiration, and lack of
empathy. It occurs in an estimated 6% of the general population. The
majority of people with this diagnosis are men (Black & Andreasen, 2021).
Narcissistic traits are common in adolescence and do not necessarily
indicate that a personality disorder will develop in adulthood. Individual
psychotherapy is the most effective treatment, and hospitalization is rare
unless comorbid conditions exist for which the client requires inpatient
treatment.
Clients may display an arrogant or haughty attitude. They lack the
ability to recognize or empathize with the feelings of others. They may
express envy and begrudge others any recognition or material success
because they believe it rightfully should be theirs. Clients tend to disparage,
belittle, or discount the feelings of others. They may express their
grandiosity overtly or may quietly expect to be recognized for their
perceived greatness. They are often preoccupied with fantasies of unlimited
success, power, brilliance, beauty, or ideal love. These fantasies reinforce
their sense of superiority. Clients may ruminate about long-overdue
admiration and privilege and compare themselves favorably with famous or
privileged people (Diamond et al., 2021).
Narcissistic personality disorder
 Thought processing is intact, but insight is limited or poor. Clients
believe themselves to be superior and special and are unlikely to consider
that their behavior has any relation to their problems; they view their
problems as the fault of others.
Underlying self-esteem is almost always fragile and vulnerable. These
clients are hypersensitive to criticism and need constant attention and
admiration. They often display a sense of entitlement (unrealistic
expectation of special treatment or automatic compliance with wishes).
They may believe that only special or privileged people can appreciate their
unique qualities or are worthy of their friendship. They expect special
treatment from others and are often puzzled or even angry when they do not
receive it. They often form and exploit relationships to elevate their own
status. Clients assume total concern from others about their welfare. They
discuss their own concerns in lengthy detail with no regard for the needs
and feelings of others and often become impatient or contemptuous of those
who discuss their own needs and concerns.
At work, these clients may experience some success because they are
ambitious and confident. Difficulties are common, however, because they
have trouble working with others (whom they consider to be inferior) and
have limited ability to accept criticism or feedback. They are also likely to
believe they are underpaid and underappreciated or should have a higher
position of authority even though they are not qualified.

Nursing Actions
Clients with narcissistic personality disorder can present one of the greatest
challenges to the nurse. The nurse must use self-awareness skills to avoid
the anger and frustration that these clients’ behavior and attitude can
engender. Clients may be rude and arrogant, unwilling to wait, and harsh
and critical of the nurse. The nurse must not internalize such criticism or
take it personally. The goal is to gain the cooperation of these clients with
other treatment as indicated. The nurse teaches about comorbid medical or
psychiatric conditions, medication regimen, and any needed self-care skills
in a matter-of-fact manner. They set limits on rude or verbally abusive
behavior and explain their expectations of the client.
AVOIDANT PERSONALITY DISORDER
Clinical Picture
Avoidant personality disorder is characterized by a pervasive pattern of
social discomfort and reticence, low self-esteem, and hypersensitivity to
negative evaluation. It occurs in 2% to 3% of the general population. It is
equally common in men and women (Boland & Verduin, 2022). Clients are
good candidates for individual psychotherapy.
These clients are likely to report being overly inhibited as children and
that they often avoid unfamiliar situations and people with an intensity
beyond that expected for their developmental stage. This inhibition, which
may have continued throughout upbringing, contributes to low self-esteem
and social alienation. Clients are apt to be anxious and may fidget in chairs
and make poor eye contact with the nurse. They may be reluctant to ask
questions or to make requests. They may appear sad as well as anxious.
They describe being shy, fearful, socially awkward, and easily devastated
by real or perceived criticism. Their usual response to these feelings is to
become more reticent and withdrawn.
Clients with avoidant personality disorder have low self-esteem. They
are hypersensitive to negative evaluation from others and readily believe
themselves to be inferior. Clients are reluctant to do anything perceived as
risky, which for them is almost anything. They are fearful and convinced
they will make a mistake, be humiliated, or embarrass themselves and
others. Because they are unusually fearful of rejection, criticism, shame, or
disapproval, they tend to avoid situations or relationships that may result in
these feelings. They usually strongly desire social acceptance and human
companionship; they wish for closeness and intimacy but fear possible
rejection and humiliation. These fears hinder socialization, which makes
clients seem awkward and socially inept and reinforce their beliefs about
themselves. They may need excessive reassurance of guaranteed acceptance
before they are willing to risk forming a relationship.
Clients may report some success in occupational roles because they are
so eager to please or to win a supervisor’s approval. Shyness, awkwardness,
or fear of failure, however, may prevent them from seeking jobs that might
be more suitable, challenging, or rewarding. For example, a client may
reject a promotion and remain in an entry-level position for years, even
though they are well qualified to advance.

Nursing Actions
These clients require much support and reassurance from the nurse. In the
nonthreatening context of the relationship, the nurse can help them explore
positive self-aspects, positive responses from others, and possible reasons
for self-criticism. Helping clients practice self-affirmations and positive
self-talk may be useful in promoting self-esteem. Other cognitive
restructuring techniques such as reframing and decatastrophizing (described
previously) can enhance self-worth. The nurse can teach social skills and
help clients practice them in the safety of the nurse–client relationship.
Although these clients have many social fears, those are often
counterbalanced by their desire for meaningful social contact and
relationships. The nurse must be careful and patient with clients and not
expect them to implement social skills too rapidly.

DEPENDENT PERSONALITY DISORDER

Clinical Picture
Dependent personality disorder is characterized by a pervasive and
excessive need to be taken care of, which leads to submissive and clinging
behavior and fears of separation. These behaviors are designed to elicit
caretaking from others. This disorder occurs in about 1% of the population
(Boland & Verduin, 2022). It runs in families and is more common in the
youngest child. People with dependent personality disorder may seek
treatment for anxious, depressed, or somatic symptoms.
Clients are frequently anxious and may be mildly uncomfortable. They
are often pessimistic and self-critical; other people hurt their feelings easily.
They commonly report feeling unhappy or depressed; this is associated
most likely with the actual or threatened loss of support from another. They
are excessively preoccupied with unrealistic fears of being left alone to care
for themselves. They believe they would fail on their own, so keeping or
finding a relationship occupies much of their time. They have tremendous
difficulty making decisions, no matter how minor. They seek advice and
repeated reassurances about all types of decisions, from what to wear to
what type of job to pursue. Although they can make judgments and
decisions, they lack the confidence to do so.
Clients perceive themselves as unable to function outside a relationship
with someone who can tell them what to do. They are uncomfortable and
feel helpless when alone, even if the current relationship is intact. They
have difficulty initiating projects or completing simple daily tasks
independently. They believe they need someone else to assume
responsibility for them, a belief that far exceeds what is age or situation
appropriate. They may even fear gaining competence because doing so
would mean an eventual loss of support from the person on whom they
depend. They may do almost anything to sustain a relationship, even one of
poor quality. This includes doing unpleasant tasks, going places they
dislike, or, in extreme cases, tolerating abuse. Clients are reluctant to
express disagreement for fear of losing the other person’s support or
approval; they may even consent to activities that are wrong or illegal to
avoid that loss.
When these clients do experience the end of a relationship, they
urgently and desperately seek another. The unspoken motto seems to be
“any relationship is better than no relationship at all.”

Nursing Actions
The nurse must help clients express feelings of grief and loss over the end
of a relationship while fostering autonomy and self-reliance. Helping clients
identify their strengths and needs is more helpful than encouraging the
overwhelming belief that “I can’t do anything alone!” Cognitive
restructuring techniques such as reframing and decatastrophizing may be
beneficial.
Clients may need assistance in daily functioning if they have little or no
past success in this area. Included are such things as planning menus, doing
the weekly shopping, budgeting money, balancing a checkbook, and paying
bills. Careful assessment to determine areas of need is essential. Depending
on the client’s abilities and limitations, referral to agencies for services or
assistance may be indicated.
 The nurse may also need to teach problem-solving and decision-making
and help clients apply them to daily life.
The nurse must refrain from giving advice about problems or making
decisions for clients, even though clients may ask the nurse to do so. The
nurse can help the client explore problems, serve as a sounding board for
discussion of alternatives, and provide support and positive feedback for the
client’s efforts in these areas.

OBSESSIVE–COMPULSIVE PERSONALITY
DISORDER
Clinical Picture
Obsessive–compulsive personality disorder is characterized by a
pervasive pattern of preoccupation with perfectionism, mental and
interpersonal control, and orderliness at the expense of flexibility, openness,
and efficiency. It is one of the most prevalent personality disorders,
occurring in about 2% to 8% of the population, affecting twice as many
men as women (Boland & Verduin, 2022). Incidence is higher in oldest
children and people in professions involving facts, figures, or methodical
focus on detail. These people often seek treatment because they recognize
that their life is pleasureless or they are experiencing problems with work or
relationships. Clients frequently benefit from individual therapy.
The demeanor of these clients is formal and serious, and they answer
questions with precision and much detail. They often report feeling the need
to be perfect beginning in childhood. They were expected to be good and do
the right thing to win parental approval. Expressing emotions or asserting
independence was probably met with harsh disapproval and emotional
consequences. Emotional range is usually quite constricted. They have
difficulty expressing emotions, and any emotions they do express are rigid,
stiff, and formal, lacking spontaneity. Clients can be stubborn and reluctant
to relinquish control, making it difficult for them to be vulnerable to others
by expressing feelings. Affect is also restricted; they usually appear anxious
and fretful or stiff and reluctant to reveal underlying emotions.
Clients are preoccupied with orderliness and try to maintain it in all
areas of life. They strive for perfection as though it were attainable and are
preoccupied with details, rules, lists, and schedules to the point of often
missing “the big picture.” They become absorbed in their own perspective,
believe they are right, and do not listen carefully to others because they
have already dismissed what is being said. Clients check and recheck the
details of any project or activity; often, they never complete the project
because of “trying to get it right.” They have problems with judgment and
decision-making—specifically, actually reaching a decision. They consider
and reconsider alternatives, and the desire for perfection prevents a decision
from being reached. Clients interpret rules or guidelines literally and cannot
be flexible or modify decisions based on circumstances. They prefer written
rules for each and every activity at work. Insight is limited, and they are
often oblivious that their behavior annoys or frustrates others. If confronted
with this annoyance, these clients are stunned, unable to believe others
“don’t want me to do a good job.”
These clients have low self-esteem and are always harsh, critical, and
judgmental of themselves; they believe that they “could have done better”
regardless of how well the job has been done. Praise and reassurance do not
change this belief. Clients are burdened by extremely high and unattainable
standards and expectations. Although no one could live up to these
expectations, they feel guilty and worthless for being unable to achieve
them. They tend to evaluate self and others solely on the basis of deeds or
actions without regard for personal qualities.
These clients have much difficulty in relationships, few friends, and
little social life. They do not express warm or tender feelings to others;
attempts to do so are stiff and formal and may sound insincere. For
example, if a significant other expresses love and affection, a client’s
response might be “The feeling is mutual.”
Marital and parent–child relationships are often difficult because these
clients can be harsh and unrelenting. For example, most clients are frugal,
do not give gifts or want to discard old items, and insist that those around
them do the same. Shopping for something new to wear may seem frivolous
and wasteful. Clients cannot tolerate lack of control and hence may
organize family outings to the point that no one enjoys them. These
behaviors can cause daily strife and discord in family life.
At work, clients may experience some success, particularly in fields
where precision and attention to detail are desirable. They may miss
deadlines, however, while trying to achieve perfection or may fail to make
needed decisions while searching for more data. They fail to make timely
decisions because of continually striving for perfection. They have
difficulty working collaboratively, preferring to do it themselves so that it is
done “correctly.” If clients do accept help from others, they may give such
detailed instructions and watch the other person so closely that coworkers
are insulted, annoyed, and refuse to work with them. Given this excessive
need for routine and control, new situations and compromise are also
difficult.

Nursing Actions
Nurses may be able to help clients view decision-making and completion of
projects from a different perspective. Rather than striving for the goal of
perfection, clients can set a goal of completing the project or making the
decision by a specified deadline. Helping clients accept or tolerate less-
than-perfect work or decisions made on time may alleviate some difficulties
at work or home. Clients may benefit from cognitive restructuring
techniques. The nurse can ask, “What is the worst that could happen?” or
“How might your boss (or your partner) see this situation?” These questions
may challenge some rigid and inflexible thinking.
Encouraging clients to take risks, such as letting someone else plan a
family activity, may improve relationships. Practicing negotiation with
family or friends may also help clients relinquish some of their need for
control.

AGE-RELATED CONSIDERATIONS
As discussed previously, personality disorders are not formally diagnosed
until 18 years of age. However, because personality is formed throughout
childhood and adolescence, traits or behaviors that may resemble behaviors
of a certain personality may be observed. Often this is not a major concern;
some behavior in children is normally self-centered or immature because
they are still developing children. Of most concern are the disruptive
behavior disorders of childhood and adolescence because they can develop
into antisocial personality disorder. See Chapter 23 for a thorough
discussion of these disorders.
 Personality disorders are not first diagnosed in older adults but may
persist from young adulthood into older age. Some individuals with
personality disorders tend to stabilize and experience fewer difficulties in
later life. Others are described as “aging badly”; that is, they are unable or
unwilling to acknowledge limitations that come with aging, refuse to accept
help when needed, and do not make reasonable decisions about their health
care, finances, or living situation. These individuals seem chronically angry,
unhappy, or dissatisfied, resulting in strained relationships and even
alienation from family, friends, caregivers, and health care providers,
resulting in social isolation. In a review of multiple studies, the most
common personality disorders reported in later life are paranoid, avoidant,
and obsessive–compulsive (Penders et al., 2020). Older adults with
personality disorders are at increased risk for depression, suicide, and
dementia.

COMMUNITY-BASED CARE
Caring for clients with personality disorders occurs primarily in
community-based settings. Acute psychiatric settings such as hospitals are
useful for safety concerns for short periods. The nurse uses skills to deal
with clients who have personality disorders in clinics, outpatient settings,
doctors’ offices, and many medical settings. Often, the personality disorder
is not the focus of attention; rather, the client may be seeking treatment for a
physical condition.
Most people with personality disorders are treated in group or
individual therapy settings, community support programs, or self-help
groups. Others will not seek treatment for their personality disorder but may
be treated for a major mental illness. Wherever the nurse encounters clients
with personality disorders, including in their own life, the actions discussed
in this chapter can prove useful.

MENTAL HEALTH PROMOTION

The treatment of individuals with a personality disorder often focuses on
mood stabilization, decreasing impulsivity, and developing social and
relationship skills. In addition, clients perceive unmet needs in a variety of
areas, such as self-care (keeping clean and tidy), sexual expression
(dissatisfaction with sex life), budgeting (managing daily finances),
psychotic symptoms, and psychological distress. Typically, psychotic
symptoms and psychological distress are often the only areas addressed by
health care providers. Perhaps dealing with those other areas in the
treatment of a client might result in a greater sense of well-being and
improved health.

EVIDENCE-BASED PRACTICE:
Mentalization-Based Treatment for Adolescents
Though personality disorders are not formally diagnosed until age 18 years, pathological
personality traits can be observed during adolescence. Mentalization is a treatment
approach that has been successful in treating clients with borderline personality
disorders. These authors found that for adolescents with personality pathology
symptoms, use of the mentalization-based treatment for adolescents (MBT-A) had
significant and positive outcomes. Mentalization is a process of examining thoughts,
beliefs, and feelings, and then linking that to actions and behaviors, to develop insight into
self. Because the personality of an adolescent is not fully formed, there is an opportunity
to help them make changes in the way they view the self and the world.

Adapted from Tromp, N., van Dijk, R., Saunders, R., & Fogany, P. (2021). Mentalization-
based treatment in adolescent inpatients: A naturalistic multi-informant study of
outcomes. Journal of Personality Disorders, 35(6), 1–21.
[Link]

Children who have a greater number of “protective factors” are less

likely to develop antisocial behavior as adults. These protective factors
include school commitment or importance of school, positive peer
relationships, parent or peer disapproval of antisocial behavior, functional
family relationship, and effective parenting skills. Interestingly, the study
found that children at risk for abuse and those not at risk were less likely to
have antisocial behavior as adults if these protective factors were present in
their environment. Children lacking these protective factors are much more
likely to develop antisocial behavior as adults.

SELF-AWARENESS ISSUES
Because clients with personality disorders take a long time to change their
behaviors, attitudes, or coping skills, nurses working with them can easily
become frustrated or angry. These clients continually test the limits of the
nurse–client relationship with attempts at manipulation. Nurses must
discuss feelings of anger or frustration with colleagues to help them
recognize and cope with their own feelings.
The overall appearance of clients with personality disorders can be
misleading. Unlike clients who are psychotic or severely depressed, clients
with personality disorders look as though they are capable of functioning
more effectively. The nurse can easily but mistakenly believe the client
simply lacks motivation or the willingness to make changes and may feel
frustrated or angry. It is easy for the nurse to think, “Why does the client
continue to do that? Can’t they see it only causes difficulties?” This reaction
is similar to those the client has probably received from others.
Clients with personality disorders also challenge the ability of
therapeutic staff to work as a team. For example, clients with antisocial or
borderline personalities often manipulate staff members by splitting them—
that is, causing staff members to disagree with or contradict one another in
terms of the limits of the treatment plan. This can be quite disruptive. In
addition, team members may have differing opinions about individual
clients. One staff member may believe that a client needs assistance, while
another may believe the client is overly dependent. Ongoing
communication is necessary to remain firm and consistent about
expectations for clients.

Points to Consider When Working With

Clients With Personality Disorders
Talking to colleagues about feelings of frustration will help you deal with
your emotional responses so you can be more effective with clients.
Clear, frequent communication with other health care providers can help
diminish the client’s manipulation.
Do not take undue flattery or harsh criticism personally; it is a result of
the client’s personality disorder.
Set realistic goals, and remember that behavior changes in clients with
personality disorders take a long time. Progress can be slow.
CRITICAL THINKING QUESTIONS

1. Where do you see yourself in relation to the four types of temperament

(harm avoidance, novelty seeking, reward dependence, and persistence)?
2. There is a significant correlation between the diagnosis of antisocial
personality disorder and criminal behavior. The description of this
disorder includes violation of social norms, the rights of others, and
sometimes the law. Is this personality disorder more a social than a
mental health problem? Why?

KEY POINTS

People with personality disorders have traits that are inflexible

and maladaptive and cause either significant functional
impairment or subjective distress.
Personality disorders are relatively common and diagnosed in
early adulthood, although some behaviors are evident in
childhood or adolescence.
Rapid or substantial changes in personality are unlikely. This can
be a primary source of frustration for family members, friends, and
health care professionals.
Schizotypal personality disorder is characterized by social and
interpersonal deficits, cognitive and perceptual distortions, and
eccentric behavior.
People with antisocial personality disorder often appear glib and
charming, but they are suspicious, insensitive, and uncaring and
often exploit others for their own gain.
People with BPD have markedly unstable mood, affect, self-
image, interpersonal relationships, and impulsivity; they often
engage in self-harm behavior.
People with obsessive–compulsive personality disorder are
preoccupied with orderliness, perfection, and interpersonal control
 at the expense of flexibility, openness, and efficiency.
Narcissistic personality disorder is characterized by grandiosity,
need for admiration, lack of empathy for others, and a sense of
entitlement.
Avoidant personality disorder is characterized by social discomfort
and reticence in all situations, low self-esteem, and
hypersensitivity to negative evaluation.
The therapeutic relationship is crucial in caring for clients with
personality disorders. Nurses can help clients identify their
feelings and dysfunctional behaviors and develop appropriate
coping skills and positive behaviors. Therapeutic communication
and role modeling help promote appropriate social interactions,
which help improve interpersonal relationships.
Several therapeutic strategies are effective when working with
clients with personality disorders. Cognitive restructuring
techniques such as thought stopping, positive self-talk, and
decatastrophizing are useful; self-help skills aid the client in
functioning better in the community.
Psychotropic medications are prescribed for clients with
personality disorders based on the type and severity of symptoms
the client experiences in aggression and impulsivity, mood
dysregulation, anxiety, and psychotic symptoms.
Clients with BPD often have self-harm urges that they enact by
cutting, burning, or punching themselves; this behavior sometimes
causes permanent physical damage. The nurse can encourage
the client to enter into a no–self-harm contract in which the client
promises to try to keep from harming themself and to report to the
nurse when they are having self-harm urges.
Nurses must use self-awareness skills to minimize client
manipulation and deal with feelings of frustration.

REFERENCES
Black, D. W., & Andreasen, N. C. (2021). Introductory textbook of psychiatry (7th ed.). American
Psychiatric Publishing. [Link]
Boland, R., & Verduin, M. L. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters
Kluwer.
Cloninger, C. R., Svrakic, D. M., & Przybeck, T. R. (1993). A psychobiological model of
temperament and character. Archives of General Psychiatry, 50(12), 975–990.
[Link]
DeLisi, M., Drury, A. J., & Elbert, M. J. (2019). The etiology of antisocial personality disorder: The
differential roles of adverse childhood experiences and childhood psychopathology.
Comprehensive Psychiatry, 92, 1–6. [Link]
Diamond, D., Yeomans, F., & Keefe, J. R. (2021). Transference-focused psychotherapy for
pathological narcissism and narcissistic personality disorder (TFP-N). Psychodynamic Psychiatry,
49(2), 244–272. [Link]
Euler, S., Nolte, T., Conctantinou, M., Griem, J., Montague, P. R., & Fonagy, P. (2021). Interpersona;
problems in borderline personality disorder: Associations with mentalizing, emotion regulation,
and impulsiveness. Journal of Personality Disorders, 35(2), 177–193.
[Link]
Heerebrand, S. L., Bray, Jemma, Ulbrich, C., Roberts, R. M., & Edwards, S. (2021). Effectiveness of
dialectical behavior therapy skills training group for adults with borderline personality disorder.
Journal of Clinical Psychology, 77(7), 1573–1590. [Link]
Koppers, D., Van, H. Peen, J., & Dekker, J. J. M. (2020). Psychological Symptoms, early
maladaptive schemas, and schema modes: Predictors of the outcomes of group schema therapy in
patients with personality disorders. Psychotherapy Research, 31(7), 1–12.
[Link]
Levine, A. Z., Allabari, R., Dalrymple, K., & Zimmerman, M. (2020). Nonsuicidal self-injury and
suicide: Differences between those with and without borderline personality disorder. Journal of
Personality Disorders, 34(1), 131–144. [Link]
Lucre, K., & Clapton, N. (2021). The compassion kitbag: A creative and integrative approach to
compassion-focused therapy. Psychology and Psychotherapy, 94(Suppl 2), 497–516.
[Link]
Penders, K. A. P., Peeters, I. G. P., Metsemakers, J. F. M., & van Alphen, S. P. J. (2020). Personality
disorders in older adults: A review of epidemiology, assessment, and treatment. Current Psychiatry
Reports, 22(3), 14. [Link]
Sleep, C. E., Weiss, B., Lynam, D. B., & Miller, J. D. (2020). Personality Disorders, 11(3); 202–212.
[Link]
Svrakic, D., Divac-Jovanovic, M., & Azhar, N. (2019). An integrative model and dynamic nosology
of personality disorder: Part 2: Symptom-based pharmacotherapy, 31(1), 2–17.
[Link]

Chapter Study Guide

MULTIPLE CHOICE QUESTIONS
Select the best answer for each.
1. When working with a client with a narcissistic personality disorder, the
nurse would use which approach?
a. Cheerful
b. Friendly
c. Matter-of-fact
d. Supportive
2. Which underlying emotion is commonly seen in an avoidant
personality disorder?
a. Depression
b. Fear
c. Guilt
d. Insecurity
3. Cognitive restructuring techniques include all of the following, except
a. decatastrophizing.
b. positive self-talk.
c. reframing.
d. relaxation.
4. Transient psychotic symptoms that occur with borderline personality
disorder are most likely treated with which type of drug?
a. Anticonvulsant mood stabilizers
b. Antipsychotics
c. Benzodiazepines
d. Lithium
5. Clients with a schizotypal personality disorder are most likely to
benefit from which nursing action?
a. Cognitive restructuring techniques
b. Improving community functioning
c. Providing emotional support
d. Teaching social skills
 6. When interviewing any client with a personality disorder, the nurse
would assess for which?
a. Ability to charm and manipulate people
b. Desire for interpersonal relationships
c. Disruption in some aspects of their life
d. Increased need for approval from others
7. The nurse would assess for which characteristics in a client with
narcissistic personality disorder?
a. Entitlement
b. Fear of abandonment
c. Hypersensitivity
d. Suspiciousness
8. The most important short-term goal for the client who tries to
manipulate others would be to
a. acknowledge own behavior.
b. express feelings verbally.
c. stop initiating arguments.
d. sustain lasting relationships.

MULTIPLE RESPONSE QUESTIONS

Select all that apply.
1. When working with a client with a personality disorder, the nurse
would expect to assess which?
a. High levels of self-awareness
b. Impaired interpersonal relationships
c. Inability to empathize with others
d. Minimal insight
e. Motivation to change
f. Poor reality testing
2. The nurse working with a client with antisocial personality disorder
would expect which behaviors?
a. Compliance with expectations and rules
b. Exploitation of other clients
 c. Seeking special privileges
d. Superficial friendliness toward others
e. Utilization of rituals to allay anxiety
f. Withdrawal from social activities

CLINICAL EXAMPLE
S. M., 25 years of age, is diagnosed with borderline personality disorder.
She has been attending college sporadically but has only 15 completed
credits and no real career goal. She is angry because her parents have told
her she must get a job to support herself. Last week, she met a man in the
park and fell in love with him on the first date. She has been calling him
repeatedly, but he will not return her calls. Declaring that her parents have
deserted her and her boyfriend doesn’t love her anymore, she slashes her
forearms with a sharp knife. She then calls 911, stating, “I’m about to die!
Please help me!” She is taken by ambulance to the emergency department
and is admitted to the inpatient psychiatry unit.

1. Identify two priority problems that would be appropriate for S. on her

admission to the unit.

2. Write an expected outcome for each of the identified priority problems.

3. List three nursing actions for each of the identified priority problems.

4. What community resources or referrals would be beneficial for Susan?