18.3 Nursing Care and Treatment Approaches

Medications Used for Specific Symptoms

There are no medications specifically approved by the Food and Drug Administration (FDA) to treat personality disorders (Fariba et al., 2023). However, several types of psychiatric medications may help with various personality disorder symptoms:

• Antidepressants: Antidepressants, including SSRIs, such as fluoxetine and sertraline, may be useful for those with a depressed mood, anger, impulsivity, irritability, or hopelessness.
• Mood stabilizers: As their name suggests, mood stabilizers, such as valproate or lamotrigine, can help even out mood swings or reduce irritability, impulsivity, and aggression. Prescribing these, along with potential augmentation with second-generation antipsychotics, can be effective for schizoid and schizotypal types.
• Antipsychotic medications: Also called neuroleptics, these may be helpful if symptoms include losing touch with reality (psychosis) or, in some cases, if there are anxiety or anger problems. Examples include olanzapine and quetiapine.
• Antianxiety medications: These may help with anxiety, agitation, or insomnia. But in some cases, they can increase impulsive behavior, so they’re not prescribed for certain types of personality disorders. Examples of these medications include clonazepam and buspirone.

With respect to medication, nursing care includes educating clients on the medicine, including the purpose, potential benefits, and possible side effects. Monitor the client’s response to medication closely, and assess for any changes in symptoms, side effects, or adverse reactions. Monitor medication adherence, and communicate any concerns or observations to the prescribing health-care provider. Document all related information thoroughly.

Psychosocial Therapies

Psychotherapy is the primary form of treatment for personality disorders. Various modalities, such as CBT, DBT, and psychodynamic therapy, have proven effective. These therapies help individuals identify and change maladaptive thoughts, beliefs, and behaviors; develop healthier coping strategies; improve social and interpersonal skills; and enhance self-awareness.

Different personality disorders will have different goals in therapy and will require different tactics. For example, due to their paranoia and lack of trust, clients with cluster A disorders tend to do much better with individual therapy than group therapy (Fariba et al., 2023). Those suffering from cluster B disorders, such as borderline personality disorder, can greatly benefit from group therapy.

Self-Care and Coping Strategies

Engaging in self-help strategies, such as maintaining a healthy lifestyle, practicing stress management techniques, developing healthy relationships, and engaging in activities that promote self-care and personal growth, can be beneficial for individuals with personality disorders.

Challenges to the Treatment of Personality Disorders

There are multiple issues with personality disorders that make them among the most difficult of psychiatric disorders to treat. Many individuals with a personality disorder lack insight into their condition and do not recognize their own emotional dysregulation, so they may exhibit treatment resistance. For example, clients with narcissistic personality disorder (NPD) rarely, if ever, come in for treatment and tend to be resistant to all suggestions (APA, 2022a), although they would benefit from intensive psychotherapy.

Issues of stigma may also prevent clients with suspected or diagnosed personality disorders from seeking treatment. Personality disorders still face stigma and misconceptions in society. Individuals with antisocial personality disorder, for instance, may experience stigma due to societal perceptions of them as “criminals” or “untrustworthy.” This stigma can discourage them from seeking treatment and create barriers to accessing the help they need.

Another challenge is the chronic nature of personality disorders and the deeply ingrained nature of associated thoughts, feelings, and behaviors. For example, clients with avoidant personality disorder may require long-term therapy to address their fear of social interaction and develop healthier coping mechanisms. Maintaining motivation and engagement in treatment over an extended period can be challenging for both the individual and the nurse.

Many individuals with personality disorders may also struggle with comorbid conditions, such as depression, anxiety, or substance use disorders. For example, a nurse working with a client with narcissistic personality disorder and alcohol use disorder must address both the grandiosity and entitlement associated with narcissism and the underlying issues contributing to substance misuse. Treating both the personality disorder and the other diagnoses simultaneously is complex and requires integrated treatment approaches.

A nurse’s attitudes and feelings about clients with personality disorders can significantly affect their ability to plan and deliver effective nursing care. Attitudes and biases may arise due to personal experiences, societal stereotypes, or the challenging nature of working with individuals who have personality disorders. It is essential for nurses to recognize and address these biases to ensure the provision of compassionate and unbiased care. Addressing personal biases is an ongoing process that requires commitment and self-awareness. By adopting strategies to address their own biases, nurses can create a more inclusive and empathetic care environment for individuals with personality disorders, ultimately enhancing the quality of nursing care provided.

Interpersonal Relationships

Clients with personality disorders often struggle with interpersonal relationships due to their patterns of thinking and behavior (Cleveland Clinic, 2022). Symptoms, such as intense and unstable emotions, difficulty recognizing and maintaining boundaries, or a tendency toward social isolation, can result in unstable relationships. Coping with a personality disorder in personal relationships requires cooperation from both the client and their loved ones. It is crucial for loved ones to develop an understanding of the specific personality disorder and its associated symptoms. Educating themselves about the challenges the client faces helps them differentiate the person from the disorder, fostering empathy, and reducing the likelihood of taking behaviors personally (Kasalova et al., 2018). Individuals with personality disorders often struggle with their own emotional pain. Encouraging empathy and compassion among loved ones, while educating them to set and respect boundaries, can promote healthier relationship dynamics. Recognizing the underlying challenges the client faces allows for more understanding and support.

Given that communication can be a significant challenge in relationships affected by personality disorders, clients should focus on developing effective communication skills. Additionally, recognizing and working on emotional sensitivity and regulation can help prevent unnecessary conflicts. Setting clear and healthy boundaries is essential to protect the well-being of both the individual and their loved ones. Open and honest communication regarding acceptable behavior is vital. Consistency in enforcing these boundaries is key to maintaining healthier relationship dynamics.

In the Workplace

Self-awareness and self-management are the keys for individuals with a personality disorder who are learning to cope in the workplace. It is essential for these clients to develop self-awareness regarding their symptoms, triggers, and coping mechanisms. Understanding one’s own strengths and limitations can help in managing symptoms and minimizing their impact on work interactions. Additionally, practicing self-management techniques, such as stress reduction strategies and emotion regulation skills, can contribute to a more stable and productive work environment.

Deciding whether or not to disclose a personality disorder in the workplace is a personal choice (Job Accommodation Network, 2023). If an individual chooses to disclose, it can be helpful to have open and honest communication with a trusted supervisor or human resources department. This can facilitate the implementation of workplace accommodations or adjustments that support the individual’s needs. For example, a client with a personality disorder might benefit from a private, quiet area for grounding or reflection. Establishing clear communication channels and expressing any specific requirements or triggers can foster a more understanding and supportive work environment.

Clients with a personality disorder may benefit from seeking other support within the workplace. This can include connecting with employee assistance programs, seeking out mentorship or coaching opportunities, or joining support groups. Having a support network can provide emotional support, guidance, and practical strategies for coping with workplace challenges.

Identifying and leveraging personal strengths can contribute to success in the workplace. Recognizing areas where one excels and capitalizing on those strengths can boost confidence and job performance. Actively seeking professional development opportunities can enhance skills and knowledge, leading to increased confidence and job satisfaction. Pursuing relevant training, attending workshops, or engaging in ongoing learning can provide individuals with the tools to navigate workplace challenges and adapt to changing work environments.

Maintaining healthy boundaries at work is crucial for individuals with a personality disorder. Setting clear expectations regarding workload, personal space, and interpersonal interactions can help manage stress and prevent burnout. Communicating boundaries assertively and respectfully can contribute to a more harmonious and productive work environment.

Overall, it is important to manage stress and perform regular self-care and stress management techniques. This can include engaging in activities outside of work that promote relaxation, setting boundaries between work and personal life, and seeking therapy or counseling to address specific work-related concerns. Taking care of one’s physical and mental well-being can enhance resilience and coping abilities in the workplace and help the client with better stress management.

Issues in Children

Managing a personality disorder in children can be a complex and challenging task that requires a multidimensional approach. It’s important to note that personality disorders are typically not diagnosed in children, as they are considered more ingrained, stable patterns of behavior that develop during adolescence or adulthood and last over time (APA, 2022a). Antisocial personality disorder is never diagnosed in children under age eighteen. Children may, however, exhibit traits or behaviors that resemble those associated with personality disorders. For example, a child with conduct disorder may engage in such behaviors as bullying and physically threatening others, behavior that is associated with antisocial personality disorder. (See Children and Adolescents for more information on conduct disorder.) There are several general guidelines for treating children with such challenging personality traits.

Early intervention and professional assessment are critical in the treatment of childhood personality issues. If a child displays persistent and extreme patterns of behavior that are causing significant distress or impairment, it is important to seek professional help. Mental health professionals experienced in working with children can conduct a comprehensive assessment to determine the underlying causes and appropriate interventions.

Developing an individualized treatment plan is key for effectively managing behavioral disorders in children with characteristics of personality disorders (Mayo Foundation for Medical Education and Research, 2022). The plan may include various components, such as therapy, behavior management techniques, and support for the child and their family. Collaborate closely with mental health professionals to tailor the treatment approach to the child’s specific needs. As with adults, psychotherapy can be beneficial in helping children with personality disorder-like traits develop healthier coping mechanisms, emotional regulation skills, and improved social interactions. Different therapeutic approaches, such as play therapy or family therapy, may also be effective, depending on the child’s age, symptoms, and individual circumstances.

It’s important to communicate and collaborate with teachers and school staff to ensure appropriate support and accommodations for the child. Sharing information about the child’s behaviors, challenges, and treatment plan can help create a supportive learning environment and facilitate targeted interventions if needed.

Consistency in parenting practices and setting clear boundaries is important for children with personality disorder-like traits. Providing a nurturing and structured environment with clear rules and expectations can help them develop a sense of security and stability. Positive reinforcement and constructive discipline techniques are essential for promoting healthy behaviors and emotional well-being.

It is also important to consider the caregivers when treating a child with personality disorder-like traits. It can be emotionally demanding for the caregivers; therefore, it is essential for them to prioritize their own well-being and seek support when needed. Engaging in self-care activities, accessing support groups or counseling for themselves, and finding assistance can help caregivers maintain their own mental and emotional well-being.

Nursing Diagnoses

After thoroughly assessing clients, nurses create individualized nursing care plans based on the client’s response to their mental health disorder(s). Common nursing diagnoses related to the clusters of personality disorders include the following:

• Cluster A: social isolation, disturbed thought process, risk for loneliness
• Cluster B: risk for suicide, risk for self-directed violence, social isolation, chronic low self-esteem, ineffective coping
• Cluster C: anxiety, risk for loneliness, social isolation

Examples of common nursing diagnoses for clients diagnosed with borderline personality disorder are described in (Table 18.1).

Outcomes and Goals

When working with clients with personality disorders, goals should address the nursing diagnoses with priority on safety. One way to do this is through the use of SMART objectives:

• S = specific
• M = measurable
• A = attainable
• R = realistic
• T = time specific

(Substance Abuse and Mental Health Administration, 2024).

For example, if the client is hospitalized and receiving acute care, and has a nursing diagnosis of risk for self-mutilation, a SMART outcome could be, “The client will refrain from intentional self-inflicted injury during hospitalization.” For a client receiving long-term outpatient therapy, with a nursing diagnosis of social isolation, a SMART outcome could be, “The client will meet a friend for coffee by the end of the month.” Examples of other SMART outcomes for clients with a personality disorder may include the following: the client will seek help from staff when experiencing urges to self-mutilate during hospitalization, the client will identify three triggers to displays of violence by the end of the day, and the client will describe two preferred healthy coping strategies by the end of the week.

Implementing Interventions

When implementing planned interventions for clients with personality disorders, the nurse must always consider safety first. Develop a crisis/safety plan with the client that includes components such as these: thoughts or behaviors that increase the risk of harming self or others; people, events, or situations that trigger those thoughts or behaviors; and coping strategies and resources.

For example, if a client performs superficial self-injurious behavior, the nurse should act based on agency policy while remaining neutral and dressing the client’s self-inflicted wounds in a matter-of-fact manner. The client may be asked to write down the sequence of events leading up to the injuries, as well as the consequences, before staff will discuss the event. This cognitive exercise encourages the client to think independently about their triggers and behaviors and facilitates discussion about alternative actions.

De-escalation is an important intervention for certain clients with personality disorder. De-escalation is the use of strategies and communication techniques to calm and reduce agitation or aggression in individuals experiencing heightened emotional distress or crisis (The Joint Commission, 2019).

Other interventions for clients with personality disorders should ultimately focus on strategies to assist with the regulation of emotions and improving interpersonal relationships (Drescher, 2022). Table 18.2 lists some of these strategies.

Self-Reflection by Nurses

Caring for clients with a personality disorder can be challenging both mentally and emotionally for the nurse (Bekelepi & Martin, 2022). When providing nursing care for such clients, it is necessary to self-reflect frequently to ensure that the nurse-client relationship remains therapeutic and the treatment plan is progressing. Self-reflection allows nurses to identify and understand their own biases, assumptions, and prejudices that may influence their interactions with clients. It helps them recognize any negative attitudes or judgments they may hold toward individuals with personality disorders. By becoming aware of these biases, nurses can work toward providing nonjudgmental and unbiased care.

When working with clients with personality disorders, transference and countertransference dynamics can arise (see Psychoanalytical Theories and Therapies). For example, a client with dependent personality disorder may develop strong feelings of dependency on their nurse, while the nurse may experience countertransference feelings of overprotectiveness or frustration. Managing these relationships requires nurses to deal with their own complex emotions while maintaining appropriate boundaries with the client.

Personality disorders often involve deeply ingrained patterns of behavior and emotional difficulties. Self-reflection helps nurses develop empathy and compassion by encouraging them to put themselves in the client’s shoes and understand the challenges they face. This empathy can lead to more client-centered care and help build a therapeutic alliance with the client.

Support for Nurses Treating a Client with Personality Disorder

Clients can work for years to receive adequate treatment for a personality disorder. Navigating the emotional intensity, treatment resistance, interpersonal difficulties, and boundary issues can be challenging not just for the client but for the nurse as well (Bekelepi & Martin, 2022). It is important for nurses to seek support and resources when dealing with clients with personality disorders. Here are some avenues for receiving support:

• Consult with colleagues: Discuss the challenges and concerns with colleagues, especially those who have experienced working with similar client populations. They may provide insights, guidance, or suggestions based on their own experiences.
• Supervision and mentoring: Seek supervision or mentoring from more experienced nurses or nurse leaders. They can offer guidance, support, and feedback on challenging situations with clients with personality disorders.
• Professional development and training: Take advantage of professional development opportunities, such as workshops, seminars, or online courses, that focus on understanding personality disorders and developing effective strategies for working with this population. Enhancing knowledge and skills can increase confidence and ability to provide quality care.
• Consult the mental health team: Reach out to the mental health team within the health-care facility, including psychiatrists, nurse practitioners, psychologists, or social workers. They can provide consultation and guidance specific to the client’s diagnosis and help nurses understand and manage the challenges they encounter.
• Employee assistance programs (EAP): Many health-care organizations have EAPs that offer counseling and support services to employees. EAPs can provide confidential assistance for dealing with work-related stress, burnout, or difficult client situations. They make connections with mental health professionals who can offer guidance and support.
• Support groups or peer networks: Seek out support groups or peer networks specifically designed for health-care professionals who work with clients with personality disorders or challenging mental health conditions. These forums provide a space to share experiences, exchange advice, and receive support from others facing similar challenges.
• Personal therapy: Consider seeking personal therapy or counseling to address any emotional or psychological impacts of working with challenging client populations. Therapy can provide a confidential space to process feelings, develop coping strategies, and gain insights into reactions and boundaries.

Remember that seeking support is not a sign of weakness but a proactive step toward maintaining a nurse’s well-being and providing optimal care to clients. Nurses should take care of themselves both professionally and personally, and utilize the available resources to navigate the unique challenges associated with clients with personality disorders.