Psychiatric Mental Health Nursing by Videbeck

(Nancy Kaufman) #1
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 self-
absorbed and focus most of their thinking on them-
selves with little or no thought about the needs of
others. They are highly suggestible and will agree with
almost anyone to gain attention. They express strong
opinions very 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 compli-
ments in unsubtle ways, fabricate unbelievable sto-
ries, 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
that they have been used. Any comment or statement
that could be interpreted as uncomplimentary or un-
flattering may produce a strong response such as a
temper tantrum or crying outburst.
Clients tend to exaggerate the intimacy of rela-
tionships. 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 uncontrol-
lably over a minor incident. Clients may ignore old
friends if someone new and interesting has been in-
troduced. People with whom these clients have rela-
tionships often describe being used, manipulated, or
exploited shamelessly.
Clients may have a wide variety of vague physi-
cal complaints or relate exaggerated versions of phys-
ical illness. These episodes usually involve the atten-
tion clients received (or failed to receive) rather than
any particular physiologic 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 ex-
ample, the nurse might say, “When you embrace and
kiss other people on first meeting them, they may in-
terpret your behavior in a sexual manner. It would be
more acceptable to stand at least 2 feet away from
them and to shake hands.”
It also may help to discuss social situations to ex-
plore the client’s perceptions of other’s reactions and
behavior. Teaching social skills and role-playing those

more likely to follow the plan if it is in written form.
This also can help clients to 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 to engage in more healthful behaviors
such as exercise, planning meals, and cooking nutri-
tious food.


Evaluation


As with any personality disorder, changes may be
small and slow. The degree of functional impairment
of clients with borderline personality disorder may
vary widely. Clients with severe impairment may be
evaluated in terms of their ability to be safe and to re-
frain 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 has been effective.


HISTRIONIC PERSONALITY
DISORDER


Clinical Picture


Histrionic personality disorderis characterized
by a pervasive pattern of excessive emotionality and
attention-seeking. It occurs in 2% to 3% of the general
population and 10% to 15% of the clinical population.
It is seen more often in women than in men. Clients
usually seek treatment for depression, unexplained
physical problems, and difficulties in relationships
(APA, 2000).
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 su-
perlative adjectives. It becomes apparent, however,
that although colorful and entertaining, descriptions
are vague and lack detail. Overall appearance is nor-
mal, 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 rela-
tionships but also occur in occupational and profes-
sional settings. The nurse may feel these clients are
charming or even seducing him or her.
Clients are emotionally expressive, gregarious,
and effusive. They often exaggerate emotions in-
appropriately. 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 emo-
tions, although colorful, are insincere and shallow;


394 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERS

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