10.4 Applying the Nursing Process to Personality Disorders

Mental health disorders are diagnosed by mental health providers using the diagnostic criteria in the DSM-5. Personality disorder diagnoses are typically not made until late adolescence or over the age of 18 because it is important to determine if the symptoms are traits of a developmental stage or pervasive traits of a personality disorder in multiple contexts. Cultural and ethnic norms must be taken into consideration before diagnosis.

Nurses create individualized nursing care plans based on the client’s response to their mental health disorder(s). Common nursing concerns related to the clusters of personality disorders include the following:

• Cluster A: Social Isolation, Disturbed Thought Process, Risk for Loneliness
• Cluster B: Risk for Suicide, Risk for Self-Directed Violence, Social Isolation, Chronic Low Self-Esteem, Ineffective Coping
• Cluster C: Anxiety, Risk for Loneliness, Social Isolation

Most individuals with personality disorders are not admitted to behavioral healthcare facilities. Their symptoms may not present any danger to themselves or others, thus they do not come to the attention of healthcare providers or law enforcement. Two disorders, however, present safety and wellbeing challenges that necessitate hospitalization for stabilization and safety. This section will apply the nursing process to caring for a patient diagnosed with borderline personality disorder and one who is diagnosed with antisocial personality disorder. These disorders fall into Cluster B, characterized by erratic, emotional, and sometimes unsafe behaviors.

Borderline Personality Disorder

Recognizing Cues

Assessment includes interviewing the patient, observing verbal and nonverbal behaviors, completing a mental status examination, and performing a psychosocial assessment. Review information about performing a mental status examination and psychosocial assessment in Chapter 3. Patients with borderline personality disorder are often admitted due to suicidal ideation or an attempt or self-injurious behaviors.

Assessment findings for patients hospitalized with borderline personality disorder may include the following^[1]:

• Feelings of emptiness
• Self-mutilation and self-harm
• Suicidal behaviors, gestures, or threats
• Extreme mood shifts that occur in a matter of hours or days
• Impulsive behavior such as reckless driving, unsafe sex, substance use, gambling, overspending, or binge eating
• Intense feelings of abandonment
• A tendency towards anger, sarcasm, and bitterness
• Intense and unstable relationships

Diagnostic and Laboratory Testing

There is no specific laboratory test that diagnoses personality disorders. Laboratory or diagnostic tests may be used to rule out other possible causes for the behaviors the patient is exhibiting. For example, a thyroid stimulating hormone (TSH) test may be ordered because thyroid disorders can affect mood. If substance intoxication or abuse is suspected, a urine toxicology screening may be done.

Analyzing Cues and Generating Hypotheses

Common nursing cues/hypotheses for patients diagnosed and hospitalized with borderline personality disorder are further described in Table 10.1.

Table 10.1 Common Nursing Concerns for Clients With Borderline Personality Disorder^[2],[3]

In the acute care setting, the focus for setting goals and outcomes is the reason for admission, which may include conditions such as suicidal ideation, self-injurious behavior, severe depression, or severe anxiety. Individuals diagnosed with borderline personality disorder may be suicidal, self-mutilating, impulsive, angry, manipulative, or aggressive. Functioning is severely impaired and they may exhibit behaviors that are challenging to the staff. Emotional lability is a hallmark; patients may swing from one extreme to another, with the emotional responses being out of proportion to the circumstances. Often they are extremely sensitive to perceived rejection. They may have poor tolerance for waiting for medications or provider visits and may be disruptive in groups. They may exhibit the defense mechanism of splitting. As discussed in Chapter 2, splitting is a response to anxiety and ambivalence that results in people or objects as either all good or all bad.^[4] For example, a patient may view one nurse as “good” and another as “bad.”

Prioritizing

Outcomes should address the priority of safety. For example, if the patient has a nursing hypothesis of Risk for Self-Mutilation, a SMART outcome could be, “The patient will refrain from intentional self-inflicted injury during hospitalization.”

Examples of other SMART outcomes for clients hospitalized with borderline personality disorder may include the following^[5]:

• The patient will remain safe and free of injury during their hospital stay.
• The patient will seek help from staff when experiencing urges to self-mutilate during hospitalization.
• The patient will identify three triggers to self-mutilation by the end of the shift.
• The patient will describe two preferred healthy coping strategies by the end of the week.

Generating Solutions and Taking Actions

Nurses plan interventions according to the symptoms the patient is currently exhibiting with the goal of keeping the patient and others safe and free of injury. Review interventions for patients who are at risk for self-harm in Chapter 2. Clear boundaries and limits should be set and consistently reinforced by the health care team as a whole. the risk of splitting of the staff is less when everyone is aware of the plan of care. When behavioral problems emerge, the nurse should present a calm, neutral approach to review therapeutic goals, limits, and boundaries with the client.^[6]

Promoting Safety

When implementing planned actions, the nurse must always consider safety. Develop a crisis/safety plan with the patient that includes components such as these:

• Identifying thoughts or behaviors that increase the risk of harming self or others
• Identifying people, events, or situations that trigger those thoughts or behaviors
• Implementing coping strategies
• Reaching out to other coping resources

For example, if a patient performs superficial self-injurious behavior, the nurse should act based on agency policy while remaining neutral and dressing the patient’s self-inflicted wounds in a matter-of-fact manner. The patient may be asked to write down the sequence of events leading up to the injuries, as well as the consequences, before staff will discuss the event. This cognitive exercise encourages the patient to think independently about their triggers and behaviors and facilitates discussion about alternative actions.^[7]

De-Escalating

The nurse should implement de-escalation strategies if the patient exhibits early signs of increasing levels of anxiety or agitation. Strategies include the following:

• Speaking in a calm voice
• Avoiding overreacting
• Implementing active listening
• Expressing support and concern
• Avoiding continuous eye contact
• Asking how you can help
• Reducing stimuli
• Moving slowly
• Remaining patient and not rushing them
• Offering options instead of trying to take control
• Avoiding touching the patient without permission
• Verbalizing actions before initiating them
• Providing space so the patient doesn’t feel trapped
• Avoiding arguing and judgmental comments
• Setting limits early and enforcing them consistently across team members
• Addressing manipulative behaviors therapeutically

If the patient continues to escalate, measures must be taken to keep the patient and others safe. This may include administering medication, secluding the patient, and notifying the provider.

Teaching self-care and coping strategies is helpful for people diagnosed with personality disorders and their loved ones.^[8]

For patients seeking immediate relief from intense symptoms such as panic or depersonalization, nurses can teach how to stimulate the parasympathetic nervous system. Stimulation of the vagal nerve can result in an immediate, direct relief of intense emotions. This can be accomplished by doing the following^[9]:

• Applying ice or ice-cold water to the face
• Performing paced-breathing techniques in which the exhalation phase is at least two to four counts longer than the inhalation phase. For example, advise the patient to inhale while counting to four and then exhale while counting to eight.

Evaluation

Refer to the outcomes established for each individual patient to evaluate the effectiveness of the actions. Modification of the established nursing care plan may be required based on the effectiveness. Always make sure to inform the entire team of any changes and to document the plan.

Collaborative Interventions

Psychotherapy

First-line treatment for personality disorders is psychotherapy. Examples of psychotherapy used with clients with personality disorders are cognitive behavioral therapy, dialectical behavioral therapy, interpersonal therapy, mentalization-based therapy, psychodynamic psychotherapy, and psychoeducation. Read more about these treatments in the “Treatment for Personality Disorders” section of this chapter.

Pharmacotherapy

There are no specific medications approved to treat personality disorders. However, patients may be treated for symptoms associated with personality disorders that cause them significant impairment and distress. Patients with borderline personality disorder are often prescribed antidepressants and antianxiety agents.  They may also be prescribed mood stabilizing medications. Read more information about common medications used to treat symptoms of personality disorders in the “Treatment for Personality Disorders” section of this chapter.

Antisocial Personality Disorder

Diagnostic and Laboratory Testing

There is no specific laboratory test that diagnoses personality disorders. Laboratory or diagnostic tests may be used to rule out other possible causes for the behaviors the patient is exhibiting. For example, a thyroid stimulating hormone (TSH) test may be ordered because thyroid disorders can affect mood. If substance intoxication or abuse is suspected, a urine toxicology screening may be done. Patients are at a higher risk of contracting sexually transmitted infections, including hepatitis C and human immunodeficiency virus.

Analyzing Cues and Generating Hypotheses

Most of the needs of antisocial personality disorder are addressable in the outpatient setting. Hospitalization generally provides minimal benefit to the patient and may be disruptive and harmful to to the milieu or the hospital. Hospitalization is is required if comorbid conditions , such as substance intoxication, are in question. Insufficient evidence exists to support any particular psychological intervention in adults. Many types of therapy, including cognitive behavioral therapy have been used. There is some evidence that antisocial traits mellow with age.

Pharmacotherapy

No pharmacological interventions have been shown to treat antisocial personality disorder, but co-occurring disorders may be targets of treatment. Aggressive behavior may be lessened through use of second-generation antipsychotics as first-line therapy, including risperidone (2 to 4 mg/day), quetiapine (100 to 300 mg/day). Second and third-line therapies for aggression include selective serotonin reuptake inhibitors (SSRIs), including sertraline or fluoxetine,. Mood stabilizers such as lithium, and carbamazepine . Anticonvulsants, such as oxcarbazepine and carbamazepine, can be used to aid with impulsivity. Buproprion and atomoxetine are often used to treat associated comorbid ADHD due to their non-addictive nature.