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 (Merza,
Papp,
Molnar, & Szabo, 2017). 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 1 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.
APPLICATION OF THE NURSING
PROCESS: BORDERLINE
PERSONALITY DISORDER
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Assessment
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 (Kiefer et al., 2017).
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.
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Unstable, unhappy affect of borderline personality disorder
Thought Process and Content
Thinking about oneself 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 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, though, at other times, clients may be
fully aware of injuring themselves. As stated earlier, under extreme stress,
775
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.”
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.
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Concept Mastery Alert
Borderline Personality Disorder
People with borderline personality disorder (BPD) have an extreme fear of
abandonment and a history of unstable, insecure attachments. These individuals,
who already are intensely emotional and have a poor sense of self, feel estranged
from others and inadequate in meeting perceived social standards. The pervasive
mood is dysphoric, involving unhappiness, restlessness, and malaise. Clients often
report intense loneliness and feeling “empty,” which causes them to rarely
experience periods of satisfaction or well-being that would lead to exaggerated
self-image. Clients tend to have an unstable view of themselves that shifts
dramatically and suddenly, often from needy and dependent one moment to angry,
hostile, and rejecting the next.
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, they may feel rejected,
become
hostile, and declare him or her 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
selfdiscipline
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),
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substance abuse, unprotected sex, or reckless behavior such as driving
while intoxicated. They usually have difficulty sleeping.
Data Analysis
Nursing diagnoses for clients with BPD may include:
• Risk for suicide
• Risk for self-mutilation
• Risk for other-directed violence
• Ineffective coping
• Social isolation
CLINICAL VIGNETTE: Borderline
Personality Disorder
Sally 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. Sally 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. Sally
was sobbing as she told her therapist that she was cutting her arm
because the therapist didn’t care anymore, that she was abandoning
Sally just 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.
NURSING CARE PLAN: PERSONALITY
DISORDER
Nursing Diagnosis
Risk for Self-Mutilation: Behaviors that indicate potential for
deliberate physical damage to self that is not intended to be fatal
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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 throughout hospitalization.
• Refrain from harming others or destroying property throughout
hospitalization.
• 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 for self-harming behavior.
• Demonstrate alternative ways of expressing feelings, such as contact
with a therapist or significant other.
IMPLEMENTATION
Nursing Interventions* Rationale
In your initial assessment, find out if he
or she has any history of suicidal
The client’s physical safety is a priority. Although
absence of a suicidal history does not preclude
risk, presence of a suicidal history increases risk.
The client with a history of self-harm can also be
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plans. 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
nursing station or where the client can
be observed easily, rather than a room
near an exit or stairwell, and so forth.
The client is easier to observe and has less chance
to leave the area undetected.
Assess the client for the presence of selfharm
urges and history of scratching,
cutting, or burning behaviors.
The client has a pattern of injurious behavior and
is likely to engage in similar self-harm behaviors
when stressed.
Closely supervise the client’s use of
sharp or other potentially dangerous
objects.
The client may use these items for self-destructive
acts.
Be consistent with the client. Set and
maintain limits regarding behavior,
responsibilities, rules, and so forth.
Consistent limit setting is essential to decrease
negative behaviors.
Withdraw your attention as much as
possible if the client acts out (if the
client’s safety is not at risk).
Withdrawing your attention will tend to decrease
acting-out behaviors.
Encourage the client to identify feelings
that are related to self-mutilating or selfdestructive
behaviors. Encourage the
client to express these feelings directly.
The client may be unaware of feelings or
experiences that trigger self-destructive behavior
and needs to develop more effective skills to
avoid self-destructive behavior in the future.
When talking with the client, focus on
self-responsibility and active approaches
that the client can take. Avoid
reinforcing the client’s passivity,
feelings of hopelessness, and so forth.
If the client is blaming others for his or her
problems, it is unlikely that the client will accept
responsibility for making changes.
Help the client identify strengths and
successful coping behaviors that he or
she has used in the past. It may help to
have the client make a written list.
Encourage the client to try to use these
coping behaviors in present and future
situations.
The client’s self-perception may be one of
hopelessness or helplessness. The client needs
your assistance to recognize strengths.
Teach the client additional positive
coping strategies and stress management
skills, such as increasing physical
exercise, expressing feelings verbally or
The client may have limited or no knowledge of
stress management techniques or may not have
used positive techniques in the past. If the client
tries to build skills in the treatment setting, he or
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in a journal, or meditation techniques.
Encourage the client to practice these
skills while in the hospital.
tries to build skills in the treatment setting, he or
she can experience success and receive positive
feedback for his or her efforts.
*Collaborative interventions.
Adapted from Schultz, J. M., & Videbeck, S. L. (2013). Lippincott’s manual of
psychiatric care plans (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Outcome Identification
Treatment outcomes may include:
• 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 his or her own needs.
• The client will demonstrate problem-solving skills.
• The client will verbalize greater satisfaction with relationships.
Interventions
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 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 self-harm urges by cutting, burning, or punching
themselves, which sometimes causes permanent physical damage.
Selfinjury
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
781
with the nurse if they feel comfortable doing so. The nurse must remain
nonjudgmental when discussing this topic.
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-harm and to report to the nurse when he or she is losing
control. The no-self-harm contract is not a promise to the nurse but the
client’s promise to him or herself to be safe. Although not legally binding,
such a contract is 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-harm 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-harm 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 he or she
has
had an outburst. Limit setting and confrontation techniques, described
earlier, are also helpful.
NURSING INTERVENTIONS
For BPD
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• Promoting client’s safety
• No-self-harm contract
• 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
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:
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
783
communication, and using “I” statements (“I think…,” “I feel…,” “I
need…”). The nurse can model these techniques and engage in
roleplaying
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?”
784
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, his or her 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 about how to manage unstructured time, become unhappy and
ruminative, and may engage in frantic and desperate behaviors (e.g.,
selfharm)
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
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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 1% to 3% 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 (Cloninger & Svrakic, 2017).
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 though 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,
though 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
selfabsorbed
and focus most of their thinking on themselves with little or no
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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 Interventions
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
787
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 1% to 6% of the general population. Of people with this
diagnosis,
50% to 75% are men. 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.
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Narcissistic personality disorder
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 they 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 (Miller, Lynam,
Hyatt,
& Campbell, 2017).
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
789
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 Interventions
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-offact
manner. He or she sets limits on rude or verbally abusive behavior and
explains his or her expectations of the client.