borderline personality disorder

DSM-IV
301.83 borderline personality disorder

“borderline” has been used to identify clients who seem to fall on the border
between the standard categories of neuroses or psychoses. the term has been
refined to indicate a client with a pervasive pattern of instability of interpersonal
relationships, self-image, affect, and control over impulses beginning in early
adulthood, and includes such factors as feelings of abandonment, impulsivity,
reactivity of mood, chronic feelings of emptiness, and problems with anger.

ETIOLOGICAL THEORIES
psychodynamics
unconscious processes that are believed to shape personality are set in motion
by drives or instincts that are then influenced by conflicts among them as well as
instinctual wishes and demands of reality. defensive maneuvers are unconsciously
developed to protect against anxiety arising from this conflict. this personality is seen
as a painstaking but poorly constructed defense.
it is also seen as resulting from a fixation of libido at stages of psychosexual
development associated with certain body parts. although it is difficult to agree on
how personality is formed, severe personality disorders are believed to begin early in
childhood and milder forms are thought to be influenced by factors during later
development.

biological
personality is believed to have a hereditary basis known as “temperament” and
biological dispositions that affect mood and level of activity (e.g., cranky, placid, self-
contained, outgoing, impulsive, cautious). there is little agreement about how this
affects the development of personality disorders.

family dynamics
the child’s social environment, particularly that within the family, is assumed to
be the main force that shapes personality. the theory of object relations provides a
basis for personality development and an explanation of the dynamics that manifest
the borderline characteristics. the individual with borderline personality may be fixed
in the rapprochement phase of development (18–25 months of age). in this phase,
the child is experiencing increasing autonomy, while still requiring “emotional
refueling” from the mothering figure. because the mother feels threatened by the
child’s efforts at independence, she strives to keep the child dependent. nurturing
and emotional support become bargaining tools. they are withheld when the child
exhibits independent behaviors and are used as rewards for clinging, dependent
behaviors. this engenders a deep fear of abandonment in the child that persists into
adulthood as the child continues to view objects (people) as parts—either good or
bad. this is called “splitting,” which is the primary dynamic of borderline personality.
current studies suggest that borderline personality disorders are strongly
associated with a history of physical or sexual abuse by family members, and incest
may be a major reason for the disproportionate ratio (2:1) of female clients.

CLIENT ASSESSMENT DATA BASE

ego integrity
markedly disturbed/distorted sense of self
experiences ambivalence toward being independent; does not like to be alone
(frantic attempts to avoid real or imagined abandonment)
reports feelings of emptiness and boredom; depression, sadness
may conform to current companions, sharing beliefs and values based on imitation

food/fluid
binge eating may be reported (impulsivity)

neurosensory
mental status:
behavior: may be erratic, impulsive, intense, clinging; may indulge in
unpredictable/impulsive behaviors (e.g., irresponsible spending, reckless driving,
gambling, substance abuse)
mood: marked reactivity of mood (e.g., intense episodes of anxiety, irritability,
dysphoria)
emotions: intense emotions with rapid, unpredictable, strong mood swings; quick
to anger (may be intense, inappropriate), lacks ability to control; may exhibit
hostile attitude
affect: may appear genuine but not necessarily be appropriate to the situation
thought processes: displays overall poor reality base with difficulty making
decisions; engages in concrete “all-or-nothing”/black-or-white thinking; lacks
insight and does not learn from past experience; unable to form long-term goals
or values
magical thinking, difficulty in identifying the self; severely impaired self-concept
lying and fabrication habitual, almost delusional
self-centered, often to the point of narcissism, inordinantly hypersensitive, and
inflexible; relationships may be transient, shallow, and/or demanding, with little
flexibility and unstable interpersonal behavior; may use and exploit others; lacks
empathy for others
major defense mechanism used is projection (seeing in others those attitudes one
fails to see in self)
may border on neuroses and psychoses, exhibiting transient psychotic symptoms
when experiencing extreme stress; transient episodes of paranoid ideation or
severe dissociative symptoms
may be associated with other personality disorders that have histrionic, narcissistic,
schizotypal, or antisocial features

safety
may reveal evidence of self-mutilative acts, usually nonlethal actions (e.g., cutting,
burning)
history of recurrent suicidal behavior, gestures, threats

sexuality
may present a profound disturbance in gender identity
sexual promiscuity
possible history of incest/sexual abuse

social interactions
significant impairment in social, marital, and occupational functioning
 interpersonal relationships unstable and intense, alternating between extremes of
overidealization and devaluation
frequently attempts to provoke guilt in others, making endless demands
history of recurrent physical fights

teaching/learning
more prevalent in females
substance abuse (especially alcohol) may be reported
higher incidence found in families with history of both chronic schizophrenia and
major affective disorders

DIAGNOSTIC STUDIES
p-300: a change in brain electrical activity that occurs in most people about 300
milliseconds after they perceive a tone, light, or other signal indicating that they
have to perform a task; may be abnormal, smaller than average, and slightly
delayed.
csf5-hiaa (5-hydroxyindoleacetic acid): decreased in some clients.
prolacting response: diminished response to serotonin-releaser fenfuramine.
drug screen: identifies substance use.

NURSING PRIORITIES
1. limit aggressive behavior; promote socially acceptable responses.
2. encourage assertive behaviors to attain sense of control.
3. assist client to learn healthy ways of controlling anxiety/developing positive self-
concept.
4. promote development of effective coping skills.
5. help client learn alternate, constructive methods of interacting with others.

DISCHARGE GOALS
1. impulsive behavior(s) recognized and controlled.
2. establishes goals and asserts control over own life.
3. problem-solving techniques used constructively to resolve conflicts.
4. interacts with others in socially appropriate manner.
5. client/family involved in behavioral therapy/support programs.
6. plan in place to meet needs after discharge.

nursing diagnosis violence, risk for, directed at self or

others/self-mutilation, risk for
risk factors may include: use of projection as a major defense mechanism
pervasive problem with negative transference
feelings of guilt/need to “punish” self, distorted
sense of self
inability to cope with increased
psychological/physiological tension in a healthy
manner
[possible indicators:] vulnerable self-esteem
 easily agitated, angry when frustrated (may
become assaultive)
provocative behavior: argumentative, dissatisfied,
overreactive, hypersensitive; use of unprovoked
anger, hostility toward others
choice of maladjusted ways of getting needs met
(e.g., splitting, projection, provocation,
depression)
self-mutilative acts; substance abuse
desired outcomes/evaluation criteria— verbalize understanding of why behavior occurs.
client will: recognize precipitating factors.

demonstrate self-control, using appropriate,

assertive coping skills.

clarify feelings of negative transference and

eliminate the use of projection.

ACTIONS/INTERVENTIONS RATIONALE

independent
establish therapeutic nurse/client relationship. building rapport and trust is imperative, although
maintain a firm, consistent approach. difficult, for this client.
determine negative transference feelings and clarify heightens self-awareness of these feelings
to assist
the actual source of anger, hostility. with resolution.
help identify how much anger is “elicited” by becoming aware of the use of projection helps
significant other(s) and how much results from own break this maladjusted pattern. note:
feelings of
unresolved feelings. anger and hostility, not depression, are more
often
the basis for destructive behaviors/suicidal acts.
intervene immediately in a nondefensive manner intervention is critical to prevent dangerous
when acting-out occurs. set firm, consistent limits. situation for client or others. therapeutic
milieu
helps client manage self and develop self-control.

environmental safety provides external control

until internal control is regained.
make an agreement or “no harm” contract to agreeing not to engage in violent behaviors
discuss angry or hurt feelings when they begin, involving self, others, or property promotes safety

instead of “internalizing” and displacing anger/ and enhances feelings of self-worth by having
hurt onto others and acting on the feelings. client assume control of own behavior. helps
 client learn to work through feelings as they
occur,
to prevent intensification and promote resolution.
encourage client to evaluate situations in which needs to listen to recognize/assess inappropriate,

angry feelings develop. discuss whether the amount unwarranted anger directed at others.
of anger is appropriate to the actual event.
explore what client expects from others, and self, in helps client learn to define roles and
recognize
interpersonal relationships. own responsibility in the situation.
define expectations and rules of the situation clearly, structure reduces ambiguity and anxiety,
and state what the client can/cannot do. providing sense of security and minimizing
escalation of violent behavior.
determine prior suicidal gestures/attempts. evaluate it is important to take suicidal threats
seriously,
seriousness of suicidal expressions/ideation. use listening carefully to underlying messages and
scale of 1–10 and prioritize according to seriousness providing a safe environment to prevent
client
of threat, availability of means, timing of previous from following through on plan, especially when
attempts, current age. scale is in upper range. note: risk of suicide
completion is highest during first few years after
initial presentation, declining as client ages.

provide close supervision, as indicated. allows for early recognition of escalating behavior

and timely intervention.

note substance use/withdrawal. (refer to ch. 6, forsubstance use, especially alcohol, increases
specific plan of care, as appropriate.) likelihood of suicide 6-fold.

provide care for client’s wounds, if self-mutilation additional attention and sympathy can provide
occurs, in a matter-of-fact manner. do not offer positive reinforcement for the maladaptive
sympathy or provide additional attention. behavior and may encourage its repetition. a
matter-of-fact attitude can convey
empathy/concern.

collaborative
have client participate in group therapy sessions group setting aids in promoting diffusion of
with feedback given by peers. anger; provides insight as to how negative,
aggressive behaviors affect others, making
feedback easier to digest.
support substance withdrawal. refer to support provides assistance to enable client to maintain
group (e.g., alcohol/narcotics anonymous). abstinence.
administer medication as indicated, e.g., may reduce frequency of impulsive/self-
carbamazepine (tegretol), tranylcypromine destructive acts while other therapeutic
(parnate). interventions are initiated.

nursing diagnosis anxiety [severe to panic]

 may be related to: unconscious conflicts (experience of extreme stress)
perceived threat to self-concept; unmet needs
possibly evidenced by: easy frustration and feelings of hurt
abuse of alcohol/other drugs
transient psychotic symptoms (disorganized
thinking; misinterpretation of environment,
interference with ability to think clearly and
logically)
performing self-mutilating acts
desired outcomes/evaluation criteria— verbalize awareness of feelings of anxiety and
client will: healthy ways to deal with them.
recognize warning signs of increasing anxiety and
validate perceptions before drawing conclusions.
develop and implement effective methods for
decreasing anxiety.
report anxiety reduced to manageable level.
use resources effectively.

ACTIONS/INTERVENTIONS RATIONALE

independent
maintain open communication and provide provides for accurate information and reduces
consistency of care. anxiety.
assess escalating anxiety and observe client contact underlying feelings of worthlessness,
inadequacy,
with reality (e.g., presence/development of powerlessness can lead to increasing anxiety with

resultant inability to think clearly). psychotic symptoms, delusions/hallucinations,

disorganized thinking, confusion, altered
communication patterns. (refer to cp: delusional
disorder.)
note rapid changes in behavior (e.g., from need for immediate gratification can lead to
cooperative to angry, demanding, argumentative). frustration and changes in behavior, which
may
indicate loss of touch with reality.
monitor for substance use; note physical symptoms may cloud symptomatology, potentiate
erratic
of abuse (e.g., slurred speech, mood swings, dilated/ behavior, and interfere with progress,
requiring
constricted pupils, abnormal vital signs, needle marks). therapeutic intervention.
provide information in brief, clear, calm manner. specific instructions and expectations about what
is happening help client maintain contact with reality.
maintain calm, quiet, nonstimulating environment. auditory and visual stimulation may
increase
labile affect and potential for acting-out.
correct misinterpretations of environment as confronting misperceptions honestly, with a
expressed by the client. caring and accepting attitude, provides a
therapeutic orientation to reality and preserves
client’s feelings of dignity and self-worth.
encourage client to identify events that precipitate helps to establish a cause-effect
relationship,
stress/anxious feelings (e.g., real or anticipated enhancing awareness and promoting change.
anxiety about relationships with others).
explore how client has dealt with these feelings, provides an understanding of the relationship
including times when substances were taken to between anxiety and drug use.
relive tension, anxiety.
have client keep an “anger journal” describing when reviewed periodically with primary nurse/
when anger occurs, how it is handled, and outcome therapist, therapeutic writing can provide
insight
of situation. into development of feelings, effectiveness of
response and create opportunity to develop new
coping strategies.
assist in learning to identify early warning signs promotes development of internal control.
that anxiety is escalating and request intervention
before it becomes overwhelming.
ask client to describe events/feelings preceding provides knowledge for adapting new effective
cutting or hurting self. explore ways to relieve coping skills and breaking the pattern of self-
anxiety without self-damaging acts. (refer to nd: destructive acts.
violence, risk for, directed at self or others/self-
mutilation, risk for.)
identify constructive ways of releasing tension (e.g., client needs to learn constructive methods
of
jogging, talking with nurse/therapist, use of coping to replace the maladjusted behaviors that
relaxation/imagery techniques), involvement in have been used. note: exercise does not need to
be
outdoor education programs (e.g., hiking, wall/rock aerobic or intensive to achieve therapeutic
effect.
climbing, caving).
discuss fears involving interactions with parents, knowledge of specific fear may provide insight
spouse, children, or significant other(s). into problem areas.

encourage client to develop a relationship with helps client to achieve object constancy. (client
more than 1 person. may feel abandoned when therapist leaves and
have a feeling that the person ceases to exist.)
dependency can be avoided, and client can begin

to develop independent activities in this

atmosphere.

collaborative
administer medications as indicated:
 antipsychotics, e.g., haloperidol (haldol), may help reduce anxiety, hostility, ideas of
thiothixine (navane), thioridazine (mellaril); reference, illusions, increasing
receptiveness to
other therapeutic approaches.
antidepressants. a number of agents have been used with varying
success to help alleviate symptoms of severe
depression.

nursing diagnosis self esteem, chronic low/personal identity

disturbance
may be related to: lack of positive feedback; unmet dependency
needs
retarded ego development/fixation at an earlier
level of development
possibly evidenced by: difficulty identifying self or defining self-
boundaries; feelings of depersonalization,
derealization
extreme mood changes; lack of tolerance of
rejection or being alone
unhappiness with self, striking out at others
performance of ritualistic, self-damaging acts,
such as “cutting veins and watching the blood
flow to cleanse the soul”; belief in need to punish
self
desired outcomes/evaluation criteria— verbalize a sense of worthwhileness.
client will: demonstrate increased self-worth/respect with
reduction in frequency of punishing/mutilative
behaviors.
use “i” self-image to promote good interpersonal
relationships.

ACTIONS/INTERVENTIONS RATIONALE

independent
encourage client to describe and verbalize feelings aids in assessing in which areas negative
feelings
about self. are most intense.

provide safe, supportive environment to discuss studies suggest a high percentage of these
clients
issues of abuse/incest and ownership of behaviors. may be victims of physical/sexual abuse,
which is
(refer to cp: problems related to abuse or neglect.) a significant factor in the development of
the
disorder. failure to address these issues
potentiates continued problems with relationships
and self-destructive acts.

explore client’s need to punish self. when did this may help to establish a cause-effect relationship
begin, and what events precipitated these acts? for feelings of low self-esteem.

discuss what stressors usually bring on anger/ information can be used to learn and implement
depression. explore ways to deal with feelings effective methods to prevent onset of depression,

before they become overwhelming. destructive acts.

note attitude of superiority, arrogant behaviors, indicative of attempt to compensate for feelings
of
exaggerated sense of self, resentment, and anger. worthlessness, inadequacy, and
powerlessness.
note personality traits such as extreme shyness, research suggests these traits are associated with

chaotic impulsiveness, chronic irascibility, antisocial poor outcomes. recognition of this

provides
tendencies, refusal of treatment for substance abuse. opportunity to deal with these issues,
possibly
influencing therapeutic efforts in a positive
manner to improve individual response.
encourage client to verbalize feelings of insecurity provides insight into sources of
insecurities which
and need for constant reassurance from others. affect image of self as worthwhile individual.
discuss feelings of worthlessness and how these gives client the message that life cannot be spent

feelings relate to need for acceptance by others. trying to meet others’ expectations.
identify situations in which client pushed others pattern of relationships has often been one of
away. help client to look at reality of behavior in approach-avoidance conflicts characterized by
context of this situation. intense feelings, crises, and stormy episodes.
fearing engulfment, client pushes others away,
then, fearing abandonment, tries to draw them
back in. awareness of this pattern of behavior and

underlying dynamics provides opportunity for

change.
identify positive, realistic behaviors the client helps client begin to look at possibility of making
possesses. desired changes to meet needs in a more
satisfying
way.
give feedback regarding nonverbal behaviors. increases awareness of the possibility of double
messages that client may be giving.
encourage increased sense of responsibility for own use of projection has enabled client to
blame
behaviors. others for own problems/consequences of
behavior.
define sexual identity and what areas create helps client assess possible learning needs or
confusion, fears. which direction to take in alleviating anxiety.
assess knowledge of human sexuality and supply provides information appropriate to learning
needed information. needs.

nursing diagnosis powerlessness

may be related to: lifestyle of helplessness; need for control (history
of abuse/incest as a child)
possibly evidenced by: becoming enraged and hurt
manipulative behavior; self-centered and
hypersensitive attitude
provoking guilt in others; making endless
demands; using and exploiting others
ambivalence toward being independent;
alternating clinging and distancing behaviors
desired outcomes/evaluation criteria— express sense of control over present situation
client will: and future outcome.
develop a sense of being in charge of own life.
interact with others without abusing or violating
their rights.
make choices related to and be involved in care.

ACTIONS/INTERVENTIONS RATIONALE

independent
develop alliance with the client and assist to this individual is generally frightened by close
overcome fear of closeness and intimacy. relationships; an alliance demonstrates that it is
possible to trust. note: evidence indicates
incest/physical abuse in childhood are strongly
associated with a poor outcome and high rates of
suicide/violent crime.
identify behaviors used to gain control of others increases awareness of modes of interaction that
(e.g., manipulation, attempts to influence, are used to get own way and feel in control of the

intimidate). situation.
explore areas of life in which client is feeling provides insight into feelings that are necessary
for
inadequate or having no control. learning adaptive behaviors.
encourage verbalization of how feelings of anger, enhances understanding of how the use of
hurt, and loss of control relate to desire to strike out projection has become a pervasive
pattern.
at others.
confront inconsistencies in statements; discuss reinforces that lying and manipulation are
what needs these statements serve. maladaptive and lead to feelings of low
self-esteem.
recognize client manipulations and respond redirection stops the manipulation, allowing for
differently. straight, congruent communication.
provide opportunities to learn how to get needs met promotes inner strength and adaptive
functioning.
in an acceptable, truthful way.
ask client to discuss feelings about someone in life by comparing behaviors, client may
understand
who seems self-centered. compare behaviors. how others perceive self-centeredness and the
feelings about these behaviors.
help client learn to listen to others and consider promotes feelings of empathy for others.
their feelings by putting self in their place.
encourage client to participate in developing aids in promoting a sense of control over life and
treatment plan. helps client assume greater responsibility for own

life.
role-play desired behaviors (e.g., appropriate anger, avoiding angry confrontations,
maintaining sense
admitting mistakes, shared humor). of humor help client learn new ways of control.

nursing diagnosis coping, individual, ineffective

may be related to: use of maladjusted defense mechanisms (e.g.,
projection, denial, externalizing)
chronic feelings of emptiness, boredom
repetitive use of ineffective coping strategies
possibly evidenced by: inability to cope, problem-solve, or ask for
assistance
not learning from previous experiences
inappropriate use of defense mechanisms (e.g.,
projection, manipulation)
relief of anxiety through destructive acts (sexual
promiscuity, impulsive spending, gambling,
substance abuse)
desired outcomes/evaluation criteria— identify ineffective coping behaviors and
client will: consequences.
verbalize awareness of own coping abilities.
meet psychologic needs as evidenced by
appropriate expression of feelings, identification
of options, and effective use of resources.
verbalize feelings congruent with behavior.
ACTIONS/INTERVENTIONS RATIONALE

independent
ask client to describe present coping patterns andrecognizing which defenses are maladjusted,
their consequences. ineffective, and destructive provides opportunity
to effect change.
have client identify problems and perceptions of exposes problem areas in thinking process and
their cause. possible cognitive distortions.
promote development of effective ways to deal with client will need help in learning new
behaviors,
stress, anger, frustration. e.g., appropriate expression of anger, “i-
messages.”
develop with client/have client sign a behavioral fosters collaborative relationship between client
contract to include minimum standards of and nurse that can be generalized to others as
acceptable behaviors, management of anger. progress is made. encourages client to assume
control of own behavior and, as specified
outcomes are achieved, enhances sense of self-
worth and encourages repetition of successful
behaviors.
discuss ways of dismissing feelings of boredom and client needs to get in touch with own
feelings and
assist client to understand that these feelings can be own/be responsible for them before they
can be
controlled. resolved.
be aware of attempts to split staff. avoid staff-splitting can be a major problem. client may
manipulative games and be consistent in dealing behave in one way (quiet/cooperative) with some
with the client. staff and in another way (angry/demanding) with
others.
confront manipulative and other maladaptive consistent confrontation removes the reward and
behaviors. reinforces need for the client to adopt new
behavior and to stop directing anger at others.
consistency in approach provides a stable
environment and reinforces sense of trust.
give feedback on how effectively client is handling may need assistance and guidance in
modifying
situations and discuss suggestions for improvement. behaviors that are not working.
give positive feedback when client demonstrates reinforces use of positive techniques, enhances
use of appropriate, constructive behaviors. self-esteem.
evaluate antisocial behaviors and resulting problems. destructive behaviors may lead to legal
(refer to cp: antisocial personality.) involvements and other problems in which client
needs to learn new behaviors.
encourage client to discuss issues related to family. high incidence of incest/physical abuse is
involve family in therapeutic process when possible. associated with the diagnosis of borderline

personality disorder. additionally, clients whose

 families accept and support them demonstrate
more positive outcomes.

collaborative
involve entire team in planning and evaluating care. when team is committed to a single
approach and
information is shared by all, issues of splitting
and
countertransference can be minimized.

nursing diagnosis social isolation

may be related to: immature interests; unaccepted social behavior
inadequate personal resources
inability to engage in satisfying personal
relationships
possibly evidenced by: alternating clinging and distancing behaviors
difficulty meeting expectations of others
experiencing feelings of difference from others
expressed interests inappropriate to
developmental age
exhibiting behavior unaccepted by dominant
cultural group (including sexual promiscuity)
desired outcomes/evaluation criteria— identify causes and actions to correct isolation.
client will: verbalize willingness to be involved with others.
participate in activities at level of desire.
express increased sense of self-worth.

ACTIONS/INTERVENTIONS RATIONALE

independent
determine presence of factors contributing to sense/ identification of individual factors allows
for
choice of isolation. developing appropriate plan of care/
interventions.
differentiate isolation from solitude and aloneness. the latter are acceptable or by choice, and
this
differentiation helps client identify which is
applicable to self so steps to deal with problem
can
be taken.
let client know the nurse will not abandon her or him. client is often fearful that the therapist will
become angry or discouraged and give up.
ask client to identify significant other(s) with aids in seeing a pattern of interaction that is
whom she or he can talk. if there is no one, ascertain ineffectual.
how this came about.
examine guilt feelings involving significant other(s). may have unrealistic guilt feelings that
need
discuss how these feelings occurred. resolution before work on the relationship can
begin.
discuss/define fears about being alone. develop a provides knowledge for developing adaptive
schedule to “practice” being alone a few minutes coping skills and desensitizes person to feelings
of
each day, gradually increasing the time. anxiety.
identify how fears, anxieties have affected quality reinforces a sense that projection does indeed
and depth of interpersonal relationships. cripple relationships.
develop a plan of action with client (e.g., look at structure of a plan with support of a trusted
available resources, support risk-taking behaviors). person helps client try out new behaviors.
discuss ways to identify and confront inappropriate when plan is agreed on, client is involved
and
behaviors. talk about how others may respond to willing to look at behaviors that create problems
in
these behaviors, and suggest ways client can deal relationships. provides a beginning to
develop
with them. use role-play to practice new skills. more appropriate ways to interact with others.
encourage client to identify positive, realistic as client recognizes that there are already some
behaviors currently being used. positive behaviors to build on, self-confidence is
enhanced, and client may be willing to take more
risks.

collaborative
encourage involvement in classes/group therapy provides opportunity to learn social skills,
enhance
(e.g., assertiveness, vocational, sex education), sense of self-esteem, and promote appropriate
psychotherapy. social involvement.