Personality Disorder, Nursing Management of Personality Disorder, 4 Nursing Care Plans for Personality Disorder, and Nursing Interventions for Personality Disorder

Personality Disorder, Nursing Management of Personality Disorder, 4 Nursing Care Plans for Personality Disorder, and Nursing Interventions for Personality Disorder

This study guide is about Personality Disorder, Nursing Management of Personality Disorder, 4 Nursing Care Plans for Personality Disorder, and Nursing Interventions for Personality Disorder. It can be used to create educational nursing care plans for personality disorders.

Personality Disorder

Personality Disorder, Nursing Management of Personality Disorder, 4 Nursing Care Plans for Personality Disorder, and Nursing Interventions for Personality Disorder
Personality Disorder

What is personality disorder?

Personality disorder is defined as the totality of a person’s unique biopsychosocial and spiritual traits that consistently influence behavior.

The following traits are likely in individuals with a personality disorder:

  1. Interpersonal relations that ranges from distant to overprotective.
  2. Suspiciousness
  3. Social anxiety
  4. Failure to conform to social norms.
  5. Self-destructive behaviors
  6. Manipulation and splitting.

Prognosis is poor, and clients experience long term disability and may have other psychiatric disorders.

What are the 3 types of personality disorders?

Personality Disorder, Nursing Management of Personality Disorder, 4 Nursing Care Plans for Personality Disorder, and Nursing Interventions for Personality Disorder
types of personality disorders

Cluster A: Personality Disorders ( The Eccentric and Mad group)

1. Paranoid Personality disorder– People with a paranoid personality disorder are characterized by an overly suspicious and mistrustful behavior.

Clinical Manifestation

  1. Aloof and withdrawn
  2. Appear guarded and hypervigilant
  3. Have a restricted affect
  4. Unable to demonstrate a warm and empathetic emotional responses
  5. Shows constant mistrust and suspicion
  6. Frequently see malevolence in the actions when none exists
  7. Spends disproportionate time examining and analyzing the behavior and motive of others to discover hidden and threatening meanings
  8. Often feel attacked by others
  9. Devises plans or fantasies for protection
  10. Uses the defense mechanism of projection (blaming other people, institution or events for their own difficulties)

2. Schizoid Personality Disorder- People who are showing a pervasive pattern of social relationship detachment and a limited range of emotional expression in the interpersonal settings falls under this type of personality disorder.

Clinical Manifestations:

  1. Displays restricted affect
  2. Shows little emotion
  3. Aloof, emotionally cold and uncaring
  4. Have rich and extensive fantasy life
  5. Accomplished intellectually and often involved with computers or electronics in hobbies or job
  6. Spends long hours solving puzzles and mathematical problems
  7. Indecisive
  8. Lacks future goals or direction
  9. Impaired insight
  10. Self-absorbed and loners
  11. Lacks desire for involvement with others
  12. No disordered or delusional thought processes present

3. Schizotypal Personality Disorder– Schizoid and schizotypal personality disorder are both characterized by pervasive pattern of social and interpersonal deficits, however, the latter is noted with cognitive and perceptual distortions and behavioral eccentricities.

Clinical Manifestations:

  1. Odd appearance (stained or dirty clothes, unkempt and disheveled)
  2. Wander aimlessly
  3. Loose, bizarre or vague speech
  4. Restricted range of emotions
  5. Ideas or reference and magical thinking is noted
  6. Expresses ideas of suspicions regarding the motives of others
  7. Experiences anxiety with people

Cluster B: Personality Disorders ( The Erratic and Bad group)

1. Antisocial Personality Disorder– Antisocial Personality disorder is characterized by a persistent pattern of violation and disregard for the rights of others, deceit and manipulation

Clinical Manifestations:

  1. Violation of the rights of others
  2. Lack of remorse for behaviors
  3. Shallow emotions
  4. Lying
  5. Rationalization of own behavior
  6. Poor judgment
  7. Impulsivity
  8. Irritability and aggressiveness
  9. Lack of insight
  10. Thrill seeking behaviors
  11. Exploitation of people in relationships
  12. Poor work history
  13. Consistent irresponsibility

2. Borderline Personality Disorder– Borderline personality disorder is the most common personality disorder found in clinical settings. This disorder is characterized by a persistent pattern of unstable relationships, self image, affect and has marked impulsivity. It is more common in females than in males. Self-mutilation injuries such ascutting or burning are noted in this type of personality disorder.

Clinical manifestations:

  1. Fear of abandonment (real or perceived)
  2. Unstable and intense relationship
  3. Unstable self-image
  4. Impulsivity or recklessness
  5. Recurrent self-mutilating behavior or suicidal threats or gestures
  6. Chronic feelings of emptiness and boredom
  7. Labile mood
  8. Irritability
  9. Splitting
  10. Impaired judgment
  11. Lack of insight
  12. Transient psychotic symptoms such as hallucinations demanding self-harm

3. Narcissistic Personality Disorder– A person with a narcissistic personality disorder shows a persistent pattern of grandiosity either in fantasy or behavior, a need for admiration and a lack of empathy.

Clinical Manifestations:

  1. Arrogant and haughty attitude
  2. Lack the ability to recognize or to empathize with the feelings of others
  3. Express envy and begrudge others of any recognition of material success (they believe it rightfully should be theirs)
  4. Belittle or disparage other’s feelings
  5. Expresses grandiosity overtly
  6. Expect to be recognized for their perceived greatness
  7. Preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love
  8. Compares themselves with famous or privileged people
  9. Poor or limited insight
  10. Fragile and vulnerable self-esteem
  11. Ambitious and confident
  12. Exploit relationships to elevate their own status

4. Histrionic Personality disorder– Excessive emotionality and attention-seeking behaviors are pervasive patterns noted in people with a histrionic personality disorder.

Clinical manifestations:

  1. Exaggerate closeness of relationships or intimacy
  2. Uses colorful speech
  3. Tends to overdress
  4. Concerned with impressing others
  5. Emotionally expressive
  6. Experiences rapid mood and emotion shifts
  7. Self-absorbed
  8. Highly suggestible and will agree with almost anyone to gain attention
  9. Always want to be the center of attraction

Cluster C: Personality Disorders ( The anxious and Sad group)

1. Avoidant Personality Disorder

Avoidant personality disorder is characterized by a persistent pattern of:

  1. Social uneasiness and reticence
  2. Low self-esteem
  3. Hypersensitivity to negative reaction

Clinical Manifestations

  1. Shy
  2. Unusually fearful of rejection, criticism, shame or disapproval
  3. Socially awkward
  4. Easily devastated by real or perceived criticism
  5. Have a very low self-esteem
  6. Believes that they are inferior

2. Dependent Personality Disorder– People who are noted to excessively need someone to take care of them that lead to their persistent clingy and submissive behavior have a dependent personality disorder. These individuals have fear of being separated from the person whom they cling on to. The behavior elicits caretaking from others.

Clinical Manifestations

  1. Pessimistic
  2. Self-critical
  3. Can be easily be hurt by other people
  4. Frequently reports feeling unhappy or depressed ( due to actual or perceived loss of support from a person)
  5. Preoccupied with unrealistic fears of being alone and left alone to take care for themselves
  6. Has difficulty deciding on their own even how simple the problem is
  7. Constantly seeks advice from others and repeated assurances about all types of decisions
  8. Lacks confidence
  9. Uncomfortable and helpless when alone
  10. Has difficulty initiating  or completing simple daily tasks on their own

3. Obsessive Compulsive Personality Disorder– Individuals who are preoccupied with perfectionism, mental and interpersonal control and orderliness have an obsessive compulsive personality disorder. Persons with an obsessive compulsive personality are serious and formal and answer questions with precision and much detail. These people often seek treatment because of their recognition that life has no pleasure or because they are experiencing problems at work and in their relationships.

Clinical Manifestations

  1. Formal and serious
  2. Precise and detail-oriented
  3. Perfectionist
  4. Constricted emotional range (has difficulty expressing emotions)
  5. Stubborn and reluctant to relinquish control
  6. Restricted affect
  7. Preoccupation to orderliness
  8. Have low self-esteem
  9. Harsh
  10. Have difficulty in relationships

Statistics and Incidences

Personality disorders are relatively common, occurring in 10% to 13% of the general population.

• 15% of all psychiatric inpatients have a primary diagnosis of a personality disorder.
• 40% to 45% of those with a primary diagnosis of major mental illness also have a coexisting personality disorder that significantly complicates the treatment.
• In mental health outpatient settings, the incidence of personality disorder is 30% to 50%.
• 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 correlated highly with criminal behavior (70% to 85% of criminals have personality disorders), alcoholism (60% to 70% alcoholics have personality disorders), and drug abuse (70% to 90% of those who abuse drugs have personality disorders).

What are the Signs and Symptoms of personality disorder?

  1. Inappropriate response to stress and inflexible approach to problem solving.
  2. Long term difficulties in relating to others, in school and in work situations.
  3. Demanding and manipulative.
  4. Ability to cause others to react with extreme annoyance or irritability.
  5. Poor interpersonal skills.
  6. Anxiety
  7. Depression
  8. Anger and aggression
  9. Difficulty with adherence to treatment.
  10. Harm to self or others.

Nursing Management of Personality Disorder

Personality Disorder, Nursing Management of Personality Disorder, 4 Nursing Care Plans for Personality Disorder, and Nursing Interventions for Personality Disorder
Nursing Management of Personality Disorder

The nursing management of a patient with personality disorder include the following:

Nursing Assessment of Personality Disorder

How do you assess personality disorder?

Assessment of the patient include:
• History. Many of these clients report disturbed early relationships with their parents that often begin at 18 to 30 months of age; 50% of these clients have experienced childhood sexual abuse; others have experienced physical and verbal abuse and parental alcoholism.
• Mood and affect. The pervasive mood is dysphoric, involving unhappiness, restlessness, and malaise; clients often report intense loneliness, boredom, frustration, and feeling “empty”.
• Thought process and content. Thinking about self and others is often polarized and extreme, which 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 is some way.
• Sensorium and intellectual process. Intellectual capacities are intact, and clients are fully oriented to reality.

Nursing Diagnosis of Personality Disorder

How is personality disorder usually diagnosed?

Nursing diagnoses for clients with personality disorder include the following:

• Risk for suicide related to low frustration tolerance.
• Risk for self-mutilation related to impulsive behavior.
• Risk for other directed violence related to lack of feelings of remorse.
• Ineffective coping related to failure to learn or change behavior based on past experience or punishment.
• Social isolation related to ineffective interpersonal relationships.

4 Nursing Care Plans for Personality Disorder

What are some appropriate nursing care plans for a patient with personality disorder?

Here are four (4) nursing care plans (NCP) for personality disorders:

  1. Risk For Self-Mutilation
  2. Chronic Low Self-Esteem
  3. Impaired Social Interaction
  4. Ineffective Coping

Risk For Self-Mutilation

Nursing Diagnosis

  • Risk For Self-Mutilation

Risk factors

  • Desperate need for attention.
  • Emotionally disturbed or battered children.
  • Feelings of depression, rejection, self-hatred, separation anxiety, guilt, and depersonalization.
  • History of self-injury.
  • History of physical, emotional, or sexual abuse.
  • High-risk populations (BPD, psychotic states).
  • Impulsive behavior.
  • Inability to verbally express feelings.
  • Ineffective coping skills.
  • Mentally retarded and autistic children.

Possibly evidenced by

  • Fresh superficial slashes on wrists or other parts of the body.
  • Intense rage focused inward.
  • Signs of old scars on wrists and other parts of the body (cigarette burns, superficial knife/razor marks).
  • Statements as to self-mutilation behaviors.

Desired Outcomes

  • Patient will be free of self-inflicted injury.
  • Patient will participate in impulse control training.
  • Patient will participate in coping skills training.
  • Patient will seek help when experiencing self-destructive impulses.
  • Patient will discuss alternative ways a client can meet demands of current situation.
  • Patient will express feelings related to stress and tension instead of acting-out behaviors.
  • Patient will sign a “no-harm” contract that identifies steps he or she will take when urges return.
  • Patient will respond to external limits.
  • Patient will participate in the therapeutic regimen.
  • Patient will demonstrate a decrease in frequency and intensity of self-inflicted injury.
  • Patient will demonstrate two new coping skills that work for the client for when tension mounts and impulse returns.
Nursing Interventions Rationale
Assess client’s history of self-mutilation:

  1. Types of mutilating behaviors.
  2. Frequency of behaviors.
  3. Stressors preceding behavior.
Identifying patterns and circumstances surrounding self-injury can help the nurse plan interventions and teaching strategies suitable to the client.
Identify feelings experienced before and around the act of self-mutilation. Feelings are a guideline for future intervention (e.g., rage at feeling left out or abandoned).
Explore with the client what these feelings might mean. Self-mutilation might also be:

  1. A way to gain control over others.
  2. A way to feel alive through pain.
  3. An expression of self-hate or guilt.
Secure a written or verbal no-harm contract with the client. Identify specific steps (e.g., persons to call upon when prompted to self-mutilate). Client is encouraged to take responsibility for healthier behavior. Talking to others and learning alternative coping skills can reduce frequency and severity until such behavior ceases.
Set and maintain limits on acceptable behavior and make clear client’s responsibilities. If the client is hospitalized at the time, be clear regarding the unit rules. Clear and nonpunitive limit setting is essential for decreasing negative behaviors.
Be consistent in maintaining and enforcing the limits, using a nonpunitive approach. Consistency can establish a sense of security.
Use a matter-of-fact approach when self-mutilation occurs. Avoid criticizing or giving sympathy. A neutral approach prevents blaming, which increases anxiety, giving special attention that encourages acting out.
After the treatment of the wound, discuss what happened right before, and the thoughts and feelings that the client had immediately before self-mutilating. identify dynamics for both client and clinician. Allows the identification of less harmful responses to help relieve intense tensions.
Work out a plan identifying alternatives to self-mutilating behaviors.

  1. Anticipate certain situations that might lead to increased stress (e.g., tension or rage).
  2. Identify actions that might modify the intensity of such situations.
  3. Identify two or three people whom the client can contact to discuss and examine intense feelings (rage, self hate) when they arise.
Plan is periodically reviewed and evaluated. Offers a chance to deal with feelings and struggles that arise.

Chronic Low Self-Esteem

Nursing Diagnosis

  • Chronic Low Self-Esteem

May be related to

  • Avoidant and dependent patterns.
  • Childhood physical, sexual, psychological abuse and/ or neglect.
  • Dysfunctional family of origin.
  • Lack of realistic ego boundaries.
  • Persistent lack of integrated self-view, with splitting as a defense.
  • Shame and guilt.
  • Substance abuse.

Possibly evidenced by

  • Evaluates self as unable to deal with events.
  • Excessively seeks reassurance.
  • Expresses longstanding shame/guilt.
  • Hesitant to try new things/situations.
  • Longstanding or chronic self-neglecting verbalizations; expressions of shame and guilt.
  • Overly conforming, dependent on others’ opinions, indecisive.
  • Rationalizes away/ rejects positive feedback and exaggerates negative feedback about self.

Desired Outcomes

  • Patient will identify one skill he or she will work on to meet future goals.
  • Patient will identify two cognitive distortions that affect self-image.
  • Patient will identify three strengths in work/school life.
  • Patient will reframe and dispute one cognitive distortion with nurse.
  • Patient will set one realistic goal with nurse that he or she wishes to pursue.
  • Patient will state a willingness to work on two realistic future goals.
  • Patient will identify one new skills he or she has learned to help meet personal goals.
  • Patient will demonstrate ability to reframe and dispute cognitive distortions with assistance of a nurse/clinician.
Nursing Interventions Rationale
Assess with clients their self perception. Target different areas of the client’s life:

  1. Strengths and weaknesses in performance at work/school and daily-life tasks.
  2. Strengths and weaknesses as to physical appearance, sexuality, personality.
Identify with client with realistic areas of strength and weaknesses. Client and nurse can work on the realities of the self-appraisal, and target those areas of assessment that do not appear accurate.
Maintain a neutral, calm, and respectful manner, although with some clients this is easier said than done. Helps client see himself or herself as respected as a person even when behavior might not be appropriate.
Review with the client the types of cognitive distortions that affect self-esteem (e.g., self-blame, mind reading, overgeneralization, selective inattention, all-or-none thinking). These are the most common cognitive distortions people use. Identifying them is the first step to correcting distortions that form one’s self-view.
Teach client to reframe and dispute cognitive distortions. Disputes need to be strong, specific, and nonjudgmental. Practice and belief in the disputes over time help clients gain a more realistic appraisal of events, the world, and themselves.
Work with client to recognize cognitive distortions. Encourage client to keep a log. Cognitive distortions are automatic. Keeping a log helps make automatic, unconscious thinking clear.
Keep in mind clients with personality disorders might defend against feeling of low-self-esteem through blaming, projection, anger, passivity, and demanding behaviors. Many behaviors seen in PD clients cover a fragile sense of self. Often these behaviors are the crux of clients’ interpersonal difficulties in all their relationships.
Discourage client from making repetitive self-blaming and negative remarks. Unacceptable behavior does not make the client a bad person, it means that the client made some poor choices in the past.
Discourage client from dwelling on and “relieving” past mistakes. The past cannot be changed. Dwelling on past mistakes prevents the client from appraising the present and planning for the future.
Discuss with client his or her plans for the future. Work with client to set realistic short-term goals. Identify skills to be learned to help client reach his or her goals. Looking toward the future minimizes dwelling on the past and negative self-rumination. When realistic short-term goals are met, client can gain a sense of accomplishment, direction, and purpose in life. Accomplishing goals can bolster a sense of control and enhance self-perception.
Focus questions in a positive and active light; helps client refocus on the present and look to the future. For example. “What can you do differently now?” or “What have you learned from that experience?”. Allows client to look at past behaviors differently, and gives the client a sense that he or she has choices in the future.
Give the client honest and genuine feedback regarding your observations as to his or her strengths, and areas that could use additional skills. Feedback helps give clients a more accurate view of self, strengths, areas to work on, as well as a sense that someone is trying to understand them.
Do not flatter or be dishonest in your appraisals. Dishonesty and insincerity undermine trust and negatively affect any therapeutic alliance.
Set goals realistically, and renegotiate goals frequently. Remember that client’s negative self-view and distrust of the world took years to develop. Unrealistic goals can set up hopelessness in clients and frustrations in nurse clinicians. Clients might blame the nurse for not “helping them,” and nurses might blame the client for not “getting better”.

Impaired Social Interaction

Nursing Diagnosis

  • Impaired Social Interaction

May be related to

  • Biochemical changes in the brain.
  • Disruptive or abusive early family background.
  • Genetic factors.
  • Immature interests.
  • Unacceptable social behavior or values.

Possibly evidenced by

  • Alienating others through angry, clinging, demeaning, and/or manipulative behavior or ridicule toward others.
  • Destructive behavior toward self or others.
  • Dysfunctional interaction with peers, family, and/or others.
  • Observed use of unsuccessful social interaction behaviors.

Desired Outcomes

  • Patient will identify and express feelings as they occur with nurse.
  • Patient will identify two personal behaviors that are responsible for relationship difficulties within two weeks.
  • Patient will identify one specific area that requires change.
  • Patient will verbalize decreased suspicions and increased security.
  • Patient will begin to demonstrate an increase in nonviolent behaviors as evidenced by a reduction in reported outbursts.
  • Patient will begin to demonstrate a reduction in manipulative behaviors as evidenced by nurse/staff.
  • Patient will state that he or she is willing to continue in follow up therapy.
  • Patient will keep follow-up appointments.
  • Patient will demonstrate, with the aid of the nurse/clinician, the ability to identify at least two unacceptable social behavior (manipulation, splitting, demeaning attitudes, angry acting out) that client is willing to change.
  • Patient will work with the nurse/clinician on substituting positive behaviors for those unacceptable behaviors identified earlier on an ongoing basis.
Nursing Interventions Rationale
Set limits on any manipulative behaviors:

  1. Arguing or begging.
  2. Flattery or seductiveness.
  3. Instilling guilt, clinging.
  4. Constantly seeking attention.
  5. Pitting one person, staff, group against another.
  6. Frequently disregarding the rules.
  7. Constant engagement in power struggles.
  8. Angry, demanding behaviors.
From the beginning, limits need to be clear. It will be necessary to refer to these limits frequently, because it is to be expected that the client will test these limits repeatedly.
Expand limits by clarifying expectations for clients in a number of settings. When time is taken in initial meetings to clarify expectations, confrontations, and power struggles with clients can be minimized and even avoided.
In a respectful, neutral manner, explain expected client behaviors, limits, and responsibilities during sessions with nurse clinician. Clearly state the rules and regulations of the institution, and the consequences when these rules are not adhered to. From the beginning, clients need to have explicit guidelines and boundaries for expected behaviors on their part, as well as what client can expect from the nurse. Clients need to be fully aware that they will be held responsible for their behaviors.
Monitor own thoughts and feelings constantly regarding your response to the PD client. Supervision is strongly recommended for new and seasoned clinicians alike when working with PD clients. Strong and intense countertransference reactions to PD clients are bound to occur. When the nurse is enmeshed in his or her own strong reactions toward the client (either positive or negative), nurse effectiveness suffers, and the therapeutic alliance might be threatened.
Collaborate with the client, as well as the multidisciplinary team, to establish a reward system for compliance with clearly defined expectations. Tangible reinforcement for meeting expectations can strengthen the client’s positive behaviors.
Assess need for and encourage skills training workshop. Skills training workshops offer the client wats to increase social skills through role play and interactions with others who are learning similar skills. This often acts as a motivating factor where positive feedback and helpful suggestions are readily available.
Problem solve and role play with client acceptable social skills that will help obtain needs effectively and appropriately. Over time, alternative ways of experiencing interpersonal relationships might emerge. Take one small skill that client is willing to work on, break it down into small parts, and work on it with the client.
Understand that PD clients in particular will be resistant to change and that this is symptomatic of PDs. This is particularly true in the beginning phases of therapy. Responding to client’s resistance and seeming lack of change in a neutral manner is part of the foundation for trust. In other words, the nurse does not have a vested interest in the client “getting better.”. The nurse remains focused on the client’s needs and issues in any event.
Intervene in manipulative behavior.

  1. All limits should be adhered to by all staff involved.
  2. Objective physical signs in managing clinical problems should be carefully documented.
  3. Behaviors should be documented objectively (give times, dates, circumstances).
  4. Provide clear boundaries and consequences.
  5. Enforce the consequences.
Client will test limits, and, once they understand that the limits are solid, this understanding can motivate them to work on other ways to get their needs met. Hopefully, this will be done with the nurse clinician throughout problem-solving alternative behaviors and learning new effective communication skills.

Ineffective Coping

Nursing Diagnosis

  • Ineffective Coping

May be related to

  • Failure to intend to change behavior.
  • Intense emotional state.
  • Lack of motivation to change behaviors.
  • Negative attitudes toward health behavior.
  • Neurologic factors.
  • Trauma early in life (physical, emotional, or sexual abuse).

Possibly evidenced by

  • Anger or hostility.
  • Demonstration of nonacceptance of health status.
  • Dependency.
  • Dishonesty.
  • Extreme distrust to others.
  • Failure to learn or change behavior based on past experience or punishment.
  • Failure to achieve an optimal sense of control.
  • Intense emotional dysregulation.
  • Manipulation of others.
  • Poor judgment.
  • Superficial relationship with others.

Desired Outcomes

  • Patient will identify behaviors leading to hospitalization.
  • Patient will have an increased in frequency of expressing needs directly without ulterior motives.
  • Patient will learn and master skills that facilitate functional behavior.
  • Patient will demonstrate an increase in impulse control.
  • Patient will demonstrate a use of a newly learned coping skill to modify anxiety and frustration.
  • Patient will demonstrate decreased manipulative, attention speaking behaviors.
  • Patient will not act out anger toward others while hospitalized.
  • Patient will remain safe while hospitalized.
  • Patient will spend time with the nurse and focus on one thing he or she would like to change.
  • Patient will state that he/she will continue the treatment on an outpatient basis.
  • Patient will talk about feelings and perceptions and not act on them at least twice.
  • Patient will focus on one problem and work through the problem-solving process with the nurse.
  • Patient will practice the substitution of functional skills for times of increased anxiety with the nurse.
Nursing Interventions Rationale
General Interventions for All Personality Disorders:
Review intervention guidelines for each personality disorder in this chapter. All clients are individuals, even within the same diagnostic category. However, guidelines for specific categories are helpful for planning.
Identify behavioral limits and behaviors that are expected. Client needs clear structure. Expect frequent testing of limits initially. Maintaining limits can enhance feelings of safety in the client.
Identify what the client sees as the behaviors and circumstances that lead to the hospitalization. Ascertain client’s understanding of behaviors and responsibility for own action.
Ascertain from family/friends how the person interacts with significant people. Is the client always withdrawn, distrustful, hostile, have continuous physical complaints? Identifying baseline behaviors helps with setting goals.
Approach the client in a consistent manner in all interactions. Enhances feelings of security and provides structure. Exceptions encourage a manipulative behavior.
Refrain from sharing personal information with the client. Open up areas for manipulation and undermines professional boundaries.
Be aware of flattery as an attempt to feed into your needs to feel special. Giving into client’s thinking that you are “the best” or “the only one” can pit you against other staff and undermine client’s need for limits.
Do not receive any gift from the client. Again, clouds the boundaries and can give the client the idea that he or she is due special consideration.
If the client becomes seductive, reiterate the therapeutic goals and boundaries of treatment. The client is in the hospital/clinic for a reason. Being taken in by seductive behavior undermines effectiveness of the treatment.
Be clear with the client as to the unit/hospital/clinic policies. Give brief concrete reasons for the rules, if asked, and then move on. Institutional policies provide structure and safety.
Be very clear about the consequences if policies/limits are not adhered to. Client needs to understand the consequences of breaking the rules.
When limit or policies are not followed, enforce the consequences in a matter-of-fact, nonjudgmental manner. Enforces that the client is responsible for his or her own actions.
Make a clear and concrete written plan of care so other staff can follow. Helps minimize manipulations and might help encourage cooperation.
If feasible, devise a care plan with the client. If goals and interventions are agreed upon, cooperation with the plan is optimized.
If the client becomes hostile or projects blame onto you or staff, project a neutral, calm demeanor, and avoid power struggles. Focus on the client’s underlying feelings. Defuses tension and opens up productive interaction.
When appropriate, try to understand underlying feelings prompting inappropriate behaviors. Often acting out behaviors stem from underlying feelings of anger, fear, shame, insecurity, loneliness, etc. Talking about feeling can lead to problem solving and growth for the client.
Some clients might attempt to instill guilt when they do not get what they want. Remain neutral but firm. Nurses often want to be seen as “nice” However, being professional and maintaining limits is the better therapeutic approach.
Keep goals very realistic and go in small steps. There are no overnight successes with people with personality disorders. It can take a long time to positively change ingrained, life-long, maladaptive habits; however, change is always possible.
Work with the client on problem-solving skills using a situation that is bothering the client. Go step by step:

  1. Define the problem.
  2. Explore alternatives.
  3. Make decisions.
Client might not know how to articulate the problem. Helping identify alternatives gives the client a sense of control. Evaluating the pros and cons of the alternatives facilitates choosing potential solutions.
When the client is ready and interested, teach client coping skills to help defuse tension and trouble feelings (e.g., anxiety reduction, assertiveness skills). Increasing skills helps the client use healthier ways to defuse tensions and get needs met.
Guard against personal feelings of frustration and lack of progress. Change if often very slow and may seem to take longer than it actually is. Nurture yourself outside the job. Keep your “bucket” full of laughter and high regard from family and friends.
Understand that many people with personality disorders do not stay with the treatment and often come to facilities because of crisis or court order. Even short encounters with therapeutic persons can make a difference when a client is ready to learn more adaptive ways of living his or her life.
Give the client positive attention when behaviors are appropriate and productive. Avoid giving any attention (when possible and not dangerous to self or others) when client’s behaviors are inappropriate. Reinforcing positive behaviors might increase the likelihood of repetition. Ignoring negative behaviors (when feasible) robs client of even negative attention.
Borderline Personality Disorder (BPD):
Assess for self-mutilating or suicide thoughts or behaviors. Self-mutilating and suicide threats are common behaviors for clients with BPD.
Clients with BPD can be manipulative. Consistent limit setting helps provide structure and decrease negative behaviors.
Encourage the client to explore feelings and concerns (e.g., identify fears, loneliness, self-hate). Client is used to acting out feelings.
Be nonjudgmental and respectful when listening to client’s feelings, thoughts, or complaints. Clients have an intense fear of rejection.
Use assertiveness when setting limits on client’s unreasonable demands for attention and time. Firm, clear, nonjudgmental limits give client structure.
Interventions often call for responses to client’s intense and labile mood swings, irritability, depression, and anxiety: Many of the dysfunctional behaviors of BPD clients (e.g., parasuicidal, anger, manipulation, substance abuse) are used as “behavioral solutions” to intense pain.
  • Irritability, anger: Use interventions early before anxiety and anger escalate.
Clients with BPD are extremely uncomfortable and want immediate relief from painful feelings. Anger is a response to this pain. Intervening early can help avoid escalation.
  • Depression: Client might need medications to help curb depression. Observe for side effects and mood level.
Most clients with BPD suffer profound depression.
  • Anxiety: Teach stress-reduction techniques such as deep breathing relaxation, meditation, and exercise.
Clients experience intense anxiety and fear of abandonment. Stress reduction techniques help the client focus more clearly.
Provide and encourage the client to use professionals in other in other disciplines such as social services, vocational rehabilitation, social work, or the law. Clients with BPD often have multiple social problems. Often they do not know how to obtain these services.
Clients with BPD benefit from coping skills training (e.g., anger management skills, emotional regulation skills, interpersonal skills). Provide referrals and/or involve professional experts. Client learns to refine skills in changing behaviors, emotions, and thinking patterns associated with problems in living that are causing distress and misery.
Clients with BPD often drop out of treatment prematurely. However, when they return, they can still draw upon what they have learned from previous encounters with health care personnel. Clients might become impatient and leave, then return in a crisis situation. It is a good thing when they are able to tolerate longer periods of learning.
Treatment of substance abuse is best handled by well-organized treatment systems, not by an individual nurse/clinician. Keeping detailed records and having a team involved with each client can minimize manipulation.

Nursing Interventions for Personality Disorder

Personality Disorder, Nursing Management of Personality Disorder, 4 Nursing Care Plans for Personality Disorder, and Nursing Interventions for Personality Disorder
Nursing Interventions for Personality Disorder

What interventions are used when caring for clients diagnosed with a personality disorder?

Clients with personality disorder often are involved in long-term psychotherapy to address issues of family dysfunction and abuse.

  • Promoting client’s safety. 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 institute appropriate interventions.
  • Promoting therapeutic relationship. Regardless of the cllinical setting, the nurse must provide structure and limit setting in the therapeutic relationship; in a clinic 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.
  • Establishing boundaries in relationships. 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.
  • 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.
  • Helping clients to cope and to control emotions. The nurse can help the clients to 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.
  • Reshaping thinking patterns. Cognitive restructuring is a technique useful in changing patterns of thinking by helping clients to recognize negative thoughts and feelings and to replace them with positive patterns of thinking; thought stopping is a technique to alter the process of negative or self-critical thought patterns.
  • Structuring the client’s daily activities. Minimizing unstructured time by planning activities can help clients to manage time alone; clients can make a written schedule that includes appointments, shopping, reading the paper, and going for a walk.

Evaluation

Goals are met as evidenced by:

  • The client will be safe and free of 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 his or her own needs.
  • The client will demonstrate problem-solving skills.
  •  The client will verbalize greater satisfaction with relationships.

Documentation Guidelines

Documentation in a client with personality disorder include:

  • Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
  • Cultural and religious beliefs, and expectations.
  • Plan of care.
  • Teaching plan.
  • Responses to interventions, teaching, and actions performed.
  • Attainment or progress toward the desired outcome.

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