A patient complains that most staff do not like her or care what happens to her, but you are special and she can tell that you are a caring person. She talks with you about being unsure of what she wants to do with her life and her “mixed-up feelings” about relationships. When you tell her that you will be on vacation next week, she becomes very angry. Two hours later, she is found using a curling iron to burn her underarms and explains that it “makes the numbness stop.”Given this presentation, you would deduce that this patient most likely has which personality disorder?
C. Borderline
Histrionic personality disorderis characterized by dramatic behavior and a need to be the center of attention.
Persons with borderline personality disorderhave an unstable sense of self (identity); tend to “split” their view of others into black or white, good or bad (rather than being able to see the person as something in between or as having both good and bad features); have difficulty coping with perceived rejection or strong emotions; cope by “numbing” and relieve numbing (or self-sooth) via self-injurious behavior; and tend to be highly sensitive to perceived rejection or abandonment (here, the nurse’s leaving was perceived as abandonment).
In dependent personality disorder, the person has an intense need for a relationship to place herself in a dependent and submissive position and seeks to be taken care of rather than to live independently.
Persons with schizotypal personality disordermanifest oddities of behavior and thinking such as eccentric speech, social awkwardness or inappropriateness, derealization, and magical thinking; they could be said to share some of the less disabling and less dramatic symptoms of schizophrenia.
Which statement about persons with personality disorders is accurate?
D. They tend not to perceive themselves as having a problem but instead believe their problems are caused by how others behave toward them.
Although some personality disorders are not associated with an increased risk of suicide, several, particularly those involving mood instability and an impaired ability to cope with strong emotions (such as borderline personality disorder and antisocial personality disorder) are associated with a significantly greater risk of suicide.
Most persons with personality disorders tend not to see themselves as being in a position to benefit from changing. Instead they tend to attribute their distress to the behavior of others and as a result may not seek treatment for themselves (and instead tend to enter treatment at the request or order of a loved one, employer, or court).
Although the early focus in theories about personality disorders emphasized intrapersonal and interpersonal responses to early life events, more recent research also addresses genetic and biological factors as playing a role in the etiology of these disorders.
Persons with cluster B disorders, the group most likely to be found in inpatient treatment centers, tend to be very demanding of staff, often idealizing some staff at the expense of others, leading to discord among colleagues and strife about how best to care for the patient.
A patient shows the nurse multiple fresh, serious (but non-life-threatening) self-inflicted cuts on her forearm. Which response would be most therapeutic?
C. Maintain a neutral demeanor while dressing the wounds, and then assign the patient to write a list of circumstances that led to the injury before discussing it further.
Self-injurious behavior is often a response to overwhelming emotions or to “numbing,” in itself a response to such emotions (but one that, as it continues, also becomes intolerable to the patient). The goal in responding to such behavior is to provide for the patient’s safety and increase the patient’s ability to recognize and intervene in its causes, while at the same time avoiding inadvertent reinforcement of the behavior by providing undue attention or support in response to it. In practice, the nurse would provide first-aid in a neutral manner and, instead of processing its causes at that moment, first assign the patient to contemplate and write about events leading up to the self-injury. This is intended to help the patient become more independent in being able to recognize and manage her own emotional responses. Although conveying empathy and support would often be therapeutic in other situations, in this case it is withheld until after the patient has made an independent effort, via the written assignment, to assume responsibility for understanding and controlling her own behavior. It is important not to assume that self-injurious behavior is simply a plea for attention, because it is usually much more complicated than that. Further, withholding all attention (i.e., responsiveness) would tend to make the patient even more desperate for attention and in turn would increase the likelihood of the patient acting out her distress rather than decrease it. In some cases, the dangerousness of a patient’s behavior might leave the staff with little other choice, but placing the patient in seclusion would likely increase the patient’s desperation and subsequent acting out as well, and placing her on one-to-one observation would increase her dependence on staff for coping and remaining safe, rather than promoting independence and coping. As a result, as a general rule the focus is instead on promoting the patient’s own internal controls (rather than relying on external controls that might inadvertently reinforce or aggravate the maladaptive behavior).
A patient is flirting with a peer and is overheard asking him to intercede with staff so that she will be given privileges to leave the inpatient mental health unit. Later she offers a backrub to a nurse if that nurse will give her the prn sedation at 9:00 pm that is not ordered until 10:00 pm. Which response(s) to such behaviors would be most therapeutic? Select all that apply.
1. Label the behavior as undesirable, and explore with the patient more effective ways to meet her needs.
2. By role-playing, demonstrate other approaches the patient could use to meet her needs.
3. Advise the other patients that this patient is being manipulative and that they should ignore the patient when she behaves this way.
4. Bargain with the patient to determine a reasonable compromise regarding how much of such behavior is acceptable before the patient crosses the line.
5. Explain that such behavior is unacceptable, and give the patient specific examples of consequences that will be enacted if the behavior continues.
6. Ignore the behavior for the time being so the patient will find it unrewarding and in turn seek other, and hopefully more adaptive, ways to meet her needs.1,2,5
The patient is demonstrating manipulative behavior. The goal is for the patient to replace maladaptive responses with approaches which are both more effective and more socially acceptable. The process for doing this involves increasing the patient’s self-awareness, identifying and encouraging alternate ways of meeting her needs, and setting limits (with predicable and clear consequences). Labeling the behavior helps identify it as maladaptive, building insight. Exploring and demonstrating (e.g., through role-playing) more effective approaches to meeting one’s needs would give the patient more adaptive alternatives to use in meeting her needs in the future. Explaining to the patient the consequences that would follow for repeating the manipulative behavior in the future (e.g., a delay in getting the privileges she desires) would serve to discourage the maladaptive behavior and would parallel the consequences that would accrue in a natural social setting (e.g., rejection by peers when the patient attempts to manipulate them). Advising other patients of this patient’s manipulative behavior and seeking their assistance would represent a degree of violation of this patient’s confidentiality. Bargaining with the patient would tend to reinforce the manipulative behavior by rewarding the patient with partial success in response to the manipulation. Ignoring the behavior, whether it be by staff or by the patient’s peers, is a passive response that would not be likely to result in either the development of insight or a change in the patient’s behavior.
A patient becomes frustrated and angry when trying to get his MP3 player and headset to function properly and angrily throws it across the room, nearly hitting a peer with it. Which intervention(s) would be the most therapeutic? Select all that apply.
1. Place the patient in seclusion for 1 hour to allow him to de-escalate.
2. Tell the patient that any further outbursts will result in a loss of privileges.
3. Offer to help the patient learn how to operate his music player and headset.
4. Explore with the patient how he was feeling as he worked with the music player.
5. Point out the consequences of such behavior, and note that it cannot be tolerated.
6. Limit the patient’s exposure to frustrating experiences until he attains improved coping skills.
7. Encourage the patient to recognize signs of mounting tension and seek assistance.4,6,7
The patient demonstrated impaired frustration tolerance and a maladaptive response to anger. He was acting out his anger by throwing the music player. Most acting out occurs in response to desperation and an impaired ability to communicate intense feelings via more acceptable means.
Placing the patient in seclusion or threatening to remove his privileges, especially if done in the absence of other interventions, would likely increase his desperation and lead to more acting out rather than less.
Offering to help him learn to operate the music player might enhance the therapeutic relationship and reduce his distress with the music player, but it would not help him learn better ways to manage his anger and frustration.
However, exploring with the patient how he was feeling would help the patient learn to identify the cues that his feelings were intensifying.
Similarly, simply pointing out that his behavior is intolerable without offering alternatives or helping him change his behavior, would only increase his desperation and acting out.
Limiting his exposure to predictably frustrating experiences would further reduce his tolerance.
Assisting the patient to recognize signs of mounting tension and seek help earlier in the process would represent a more adaptive response to distress and would similarly help him avert episodes of dyscontrol.
A nurse caring for a client who has been diagnosed with a personality disorder should expect that the client will exhibit which of the following characteristics?
B. Inflexible and maladaptive responses to stress
Personality patterns persist unmodified over long periods of time. Characteristics of inflexible and maladaptive response to stress is one of these characteristics for individuals with personality disorder. Text page: 434
Which statement is descriptive of clients with personality disorders?
C. They are resistant to behavioral change.
Personality disorders are deeply ingrained and pervasive. Clients with personality disorders find it very difficult, if not nearly impossible, to change. Change proceeds very slowly. Text page: 434
Research has indicated that antisocial personality may be characterized by:
B. lack of remorse.
The antisocial personality exhibits a lack of remorse when confronted with the results of their thoughtless, irresponsible behavior towards others. Text page: 438
The primary goal of milieu therapy for clients with personality disorders is
D. manage the affect behavior has on the entire group.
The primary goal of milieu therapy is affect management in a group context. Text page: 448
Characteristic behaviors the nurse will assess in the narcissistic client are
B. grandiose, exploitive, and rage-filled behavior.
Narcissistic clients give the impression of being invulnerable and superior to others to protect their fragile self-esteem. Text page: 439
Which client with a personality disorder is most likely to be admitted to a psychiatric unit?
B. Ms. C, with borderline personality disorder who is impulsive
Clients with borderline disorder can decompensate into psychotic states under stress. Hospitalization is needed at these times. Text page: 437
Characteristics the nurse will assess in the client with antisocial personality disorder are
A. deceitfulness, impulsiveness, and lack of empathy.
Antisocial clients have no conscience. Their sense of right and wrong is impaired, and they tend to do whatever serves them best without consideration for the rights or feelings of others. Text page: 437
Splitting involves
setting up individuals or groups to disagree. While the two parties are busy disagreeing, they are too busy to maintain consistent limits for the manipulative client. The client can enjoy the spectacle and do as he or she pleases. Text page: 437
Splitting is a process in which the client
C. sees things as divided into "all good" or "all bad."
Splitting demonstrates the failure to integrate the positive and negative into a cohesive whole. An individual is not seen as a person with good and bad traits, but rather as all good or all bad. Text page: 437
Which behavior would be inconsistent with defining characteristics for the nursing diagnosis of ineffective coping?
B. Interdependence
The characteristics for the diagnosis of ineffective coping include crisis, high levels of anxiety, anger and aggression; child, elder, or spouse abuse; and difficulty in relationships and manipulation. Interdependence would not be considered a symptom for ineffective coping. Text page: 447
A nurse is assigned to work with a client with borderline personality disorder. The nurse will need to consider strategies for dealing with the client's
A. mood shifts, impulsivity, and splitting.
Borderline personality disorder has the central characteristic of instability in affect, identity, and relationships. Borderline individuals desperately seek relationships to avoid feeling abandoned. But they often drive others away with excessive demands, impulsive behavior, or uncontrolled anger. Their frequent use of the defense of splitting strains personal relationships and creates turmoil in health care settings. Text pages: 437, 438
A client has been diagnosed with dependent personality disorder. Which behavior descriptions can the nurse expect to assess?
B. Anxious, fearful
Dependent personality disorder has a primary feature of extreme dependency in a close relationship, with an urgent search to find a replacement when one relationship ends. These individuals have difficulty making independent decisions and are constantly seeking reassurance. They have deeply held convictions of personal incompetence, with the fear that they cannot survive on their own. They frequently seek treatment for anxiety or mood disorders related to a loss. Text pages: 440, 441
A newly admitted client has an axis II diagnosis of schizoid personality disorder. The nursing intervention of highest priority will be to
B. respect need for social isolation.
Schizoid personality disorder has the primary feature of emotional detachment. The person does not seek out or enjoy close relationships. They are reclusive, avoidant, and uncooperative. They do not do well with resocialization. Text pages: 436 and 449
A client with dependent personality disorder who had been living with her newly married son was admitted a week ago for treatment of depression, which began after her son suggested that she move out. Which remark by the client would the nurse evaluate as showing improvement in the client's condition?
B. "I'm going to need help to afford to rent an apartment."
Dependent personality disorder has a primary feature of extreme dependency in a close relationship, with an urgent search to find a replacement when one relationship ends. Clients have a deeply held conviction of personal incompetence, with the fear that they cannot survive on their won. Self-reflection on the possibility of moving into an apartment shows improvement. Text pages: 440, 441
A client with histrionic personality disorder winks at an attractive nurse and states, "You and I should be able to turn those resident physicians into jelly if you'd wear your skirts about two inches shorter." The nurse's reply should be based on the understanding that the client's use of seductive behavior is
C. a response to stress.
The histrionic person is impulsive and melodramatic and may act flirtatious or provocative to get the spotlight in an attempt to reduce stress. Text pages: 438, 439
A client with obsessive-compulsive personality disorder takes the nurse aside and mentions "I've observed you interacting with Mr. D. You are not approaching him properly. You should be more forceful with him." The best response for the nurse would be
D. "I will be continuing to follow the care plan for Mr. D."
Obsessive-compulsive personality disorder has the key factor of perfectionism with a focus on orderliness and control. These individuals get so preoccupied with details and rules that they may not be able to accomplish the tasks. Guard against engaging in power struggles with a client with obsessive-compulsive disorder. Text pages: 440, 441
T/F: One of the primary nursing guidelines/interventions for clients with a personality disorder is to assess for suicidal and self-mutilating behaviors, especially during times of stress.
A danger of working with a client who idealizes the nurse is
D. becoming overinvolved and being protective and indulgent.
Finding an approach for helping clients with personality disorders who have overwhelming needs can be overwhelming for caregivers. For example, a borderline female client may briefly idealize her male nurse on the inpatient unit, telling staff and clients alike that she is "the luckiest client because she has the best nurse in the hospital." The rest of the team initially realizes that this behavior is an exaggeration, and they have a neutral response. But after days of constant dramatic praise, some members of the team may start to feel inadequate and jealous of the nurse. They begin to make critical remarks about minor events to prove that the nurse is not perfect. Open communication in staff meetings and ongoing clinical supervision are important aspects of self-care for the nurse working with these clients to maintain objectivity. Text pages: 445, 446
Clients with personality disorders have various self-defeating behaviors and interpersonal problems despite having near-normal ego functioning and intact reality testing. A nursing diagnosis that addresses this sort of interpersonal dysfunction is
C. impaired social interaction.
For a client who has difficulty in relationships and is very manipulative, the nursing diagnosis of impaired social interaction would be used. Text page: 447
Cluster A Personality Disorders
Odd or Eccentric = Cluster A
- Paranoid- 4 or more
- Schizoid- 4 or more; A pervassive pattern of detachment from social relationships
- Schizitypal- 5 or more; A pervassive pattern of social and interpersonal deficits;odd beliefs/magical thinking; suspicious or paranoid ideation; inappropriate or constricted affect
All personality disorders are NOT due to drugs, meds or general medical condition.
Cluster B Personality Disorders
Dramatic, Emotional, Erratic = Cluster B
- Antisocial- disregard for and violation of the rights of other since age 15; Dx at 18
- Borderline- Ineffective and harmful self-soothing habits such as cutting, promiscious sex, and substance abuse; Splitting is primary defense; 10% motality; idolize someone initially, then hate them -can't make a whole, all good or all bad
- Histrionic - emotional attention-seeking; must be the center of attention
- Narcissistic- arroganc eand a grandiose view of self-importance, but feel intense shame and fear of abandonment
Cluster C Personality Disorders
Anxious or Fearful = Cluster C
- Dependent- need to be taken care of
- OCD- orderliness, perfection and mental and interpersonal control; miserly spending style
- Avoidant- social inhibition; feelings of inadequacy; hypersensitivity to negative evaluation