16 PERSONALITYDISORDERS 389
Evaluation
The nurse evaluates the effectiveness of treatment
based on attainment of or progress toward outcomes.
If a client can maintain a job with acceptable perfor-
mance, meet basic family responsibilities, and avoid
committing illegal or immoral acts, then treatment
has been successful.
BORDERLINE PERSONALITY
DISORDER
Borderline personality disorderis character-
ized by a pervasive pattern of unstable interper-
sonal relationships, self-image, and affect as well as
marked impulsivity. About 2% to 3% of the general
population has borderline personality disorder; it is
five times more common in those with a first-degree
relative with the diagnosis. Borderline personality
disorder is the most common personality disorder
found in clinical settings. It is three times more
common in women than in men. Under stress, tran-
sient psychotic symptoms are common. Eight percent
to 10% of people with this diagnosis commit suicide,
and many more suffer permanent damage from self-
mutilation injuries such as cutting or burning (APA,
2000). Typically, recurrent self-mutilation is a cry
for help, an expression of intense anger or helpless-
ness, 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 expe-
rience physical pain in the face of emotional numb-
ing (Brown, Comtois, & Linehan, 2002).
Working with clients who have borderline per-
sonality disorder can be frustrating. They may cling
and ask for help one minute then become angry, act
out, and reject all offers of help in the next minute.
They may attempt to manipulate staff to gain imme-
diate 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
Assessment
HISTORY
Many of these clients report disturbed early relation-
ships 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. Fifty
percent of these clients have experienced childhood
sexual abuse; others have experienced physical and
verbal abuse and parental alcoholism (Gabbard,
2000). Clients tend to use transitional objects (e.g.,
teddy bears, pillows, blankets, 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.GENERAL APPEARANCE AND
MOTOR BEHAVIOR
Clients experience a wide range of dysfunction—
from severe to mild. Initial behavior and presenta-
tion may vary widely depending on a client’s present◗ CLIENT/FAMILYTEACHING FOR
ANTISOCIALPERSONALITYDISORDER- Avoiding use of alcohol and other drugs
- Appropriate social skills
- Effective problem-solving skills
- Managing emotions such as anger and frustration
- Taking time out to avoid stressful situations
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 bladeCLINICALVIGNETTE: BORDERLINEPERSONALITYDISORDER
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 ther-
apist 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.