APPLICATION OF THE NURSING PROCESS: BORDERLINE PERSONALITY DISORDER
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 paren-tal support and approval. Fifty percent of these clients have experienced childhood sexual abuse; others have experienced physical and verbal abuse and parental alco-holism (Meissner, 2005). Clients tend to use transitional objects (e.g., teddy bears, pillows, blankets, and dolls) extensively; this may continue into adulthood. Transi-tional objects are often similar to favorite items from child-hood that the client used for comfort or security.
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 dys-function is severe, clients may appear disheveled and may be unable to sit still, or they may display very labile emo-tions. In other cases, initial appearance and motor behav-ior 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.
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 anx-iety. They experience intense emotions such as anger and rage but rarely express them productively or usefully. They usually are hypersensitive to others’ emotions, which can easily trigger reactions. Minor changes may precipitate a severe emotional crisis, for example, when an appoint-ment must be changed from one day to the next. Com-monly, these clients experience major emotional trauma when their therapists take vacations.
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 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 also may 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, although other times clients may be fully aware of injuring themselves. As stated earlier, under extreme stress, clients may develop transient psychotic symptoms such as delusions or hallucinations.
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 borderline personality disorder .
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 based on emotions rather than facts.
Clients have difficulty accepting responsibility for meeting needs outside a relationship. They see life’s prob-lems 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.”
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 very 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.
Clients hate being alone, but their erratic, labile, and sometimes dangerous behaviors often isolate them. Rela-tionships are unstable, stormy, and intense; the cycle repeats itself continually. These clients have extreme fears of abandonment and difficulty believing a relation-ship still exists once the person is away from them. They engage in many desperate behaviors, even suicide attempts, to gain or to 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 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 self discipline to follow through on sometimes mundane tasks associated with work or school.
In addition to suicidal and self-harm behavior, clients also may engage in binging (excessive overeating) and purging (self-induced vomiting), substance abuse, unprotected sex, or reckless behavior such as driving while intoxicated. They usually have difficulty sleeping.
Nursing diagnoses for clients with borderline personality disorder may include the following:
· Risk for Suicide
· Risk for Self-Mutilation
· Risk for Other-Directed Violence
· Ineffective Coping
· Social Isolation
Treatment outcomes may include the following:
· The client will be safe and free of significant injury.
· The client will not harm others or destroy property.
· The client will demonstrate increased control of impul-sive 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.
Clients with borderline personality disorder often are 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 often are used to manage these difficulties and to stabilize the client’s condition.
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 inter-ventions . 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 perma-nent physical damage. Self-injury can occur when a client is enraged or experiencing dissociative episodes or psy-chotic symptoms, or it may occur for no readily apparent reason. Helping clients to avoid self-injury can be difficult when antecedent conditions vary greatly. Sometimes, cli-ents may discuss self-harm urges with the nurse if they feel comfortable doing so. The nurse must remain nonjudg-mental when discussing this topic.
It has been common practice in many settings to encourage clients to enter a no-self-harm contract, in which a client promises to not 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 is the client’s promise to himself or herself to be safe. Though 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, over time, there is no evidence to support the effectiveness of these contracts, and in fact, some believe they may interfere with the therapeutic rela-tionship (McMyler & Pryjmachuk, 2008).
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 dis-tress, 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 effec-tive 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. Deflec-ting attention from the actual physical act is usually desirable.
Regardless of the clinical setting, the nurse must provide structure and limit setting in the therapeutic relation-ship. In a clinic 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 confronta-tion techniques, which are described earlier, are also helpful.
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 rela-tionships. Clients easily can misinterpret the nurse’s genu-ine 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 boundar-ies 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)
It is important to teach basic communication skills such as eye contact, active listening, taking turns talking, validat-ing the meaning of another’s communication, and using “I” statements (“I think …,” “I feel …,” “I need …”). The nurse can model these techniques and engage in role-playing 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.”
Clients often react to situations with extreme emotional responses without actually recognizing their feelings. The nurse can help clients to 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 cli-ents 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.
These clients view everything, people and situations, in extremes—totally good or totally bad. Cognitive restruc-turing is a technique useful in changing patterns of thinking by helping clients to recognize negative thoughts
and feelings and to replace 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 neg-ative thoughts of worthlessness with more positive think-ing. 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” (Andreasen & Black, 2006).
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?” 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 (Andreasen & Black, 2006).
Feelings of chronic boredom and emptiness, fear of aban-donment, and intolerance of being alone are common problems. Clients often are at a loss about how to manage unstructured time, become unhappy and ruminative, and may engage in frantic and desperate behaviors (e.g., self-harm) to change the situation. Minimizing unstructured time by planning activities can help clients to 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 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 health-ful behaviors such as exercising, planning meals, and cooking nutritious food.
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. Cli-ents with severe impairment may be evaluated in terms of their ability to be safe and to refrain from self-injury. Other clients may be employed and have fairly stable interper-sonal relationships. Generally, when clients experience fewer crises less frequently over time, treatment is effective.