390 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERS
status. When dysfunction is severe, clients may ap-
pear disheveled and be unable to sit still. Or they may
display very labile emotions. In other cases, initial
appearance and motor behavior may seem normal.
The client seen in the emergency room threatening
suicide or self-harm may seem out of control, whereas
a client seen in an outpatient clinic may appear fairly
calm and rational.
MOOD AND AFFECT
The pervasive mood is dysphoricinvolving unhappi-
ness, 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 usually are hyper-
sensitive 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 vacation.
THOUGHT PROCESS AND CONTENT
Thinking about self and others is often polarized and
extreme, which is sometime referred to as splitting.
Clients tend to adore and idealize other people even
after a brief acquaintance then quickly devalue them
if others do not meet expectations in some way.
Clients have excessive and chronic fears of abandon-
ment even in normal situations; this reflects their in-
tolerance of being alone. They also may engage in ob-
sessive 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 dur-
ing these dissociative episodes, although other times
clients may be fully aware of injuring themselves. As
stated earlier, under extreme stress, clients may de-
velop 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 psy-
chotic 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 borderline
personality disorder (see Chap. 11).◗ SYMPTOMS OFBORDERLINE
PERSONALITYDISORDER- Fear of abandonment, real or perceived
- Unstable and intense relationships
- Unstable self-image
- Impulsivity or recklessness
- Recurrent self-mutilating behavior or suicidal
threats or gestures - Chronic feelings of emptiness and boredom
- Labile mood
- Irritability
- Polarized thinking about self and others
(“splitting”) - Impaired judgment
- Lack of insight
- Transient psychotic symptoms such as hallucina-
tions demanding self-harm.
Unstable, unhappy affect of borderline
personality disorder