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10.4 Applying the Nursing Process to Personality Disorders

The nursing process is crucial in the care of patients with personality disorders due to its structured and systematic approach that ensures comprehensive and individualized care.

Assessment (Recognize Cues)

As previously discussed in this chapter, there are ten different personality disorders that are categorized into three clusters (A, B, and C) in the DSM-5. Personality disorders within each cluster have similar patterns of behavior.  Cluster A personality disorders include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder. Cluster A is characterized as the odd, eccentric cluster. Individuals with these types of disorders often experience social awkwardness. Cluster B personality disorders include antisocial, borderline, histrionic, and narcissistic personality disorders. Cluster B personality disorders are characterized by dramatic, overly emotional, or unpredictable thinking or behavior. Cluster C personality disorders include avoidant, dependent, and obsessive-compulsive personality disorders. Cluster C personality disorders are characterized by anxious, fearful thinking or behavior. Furthermore, personality disorders are often ego-syntonic, meaning that the behaviors and thoughts are consistent with the individual’s self-perception and are not seen as problematic by the individual.

Assessing a client with a personality disorder focuses on both verbal and nonverbal assessments. As the nurse conducts follow-up assessments, findings are compared to baseline admission assessments.  Assessment includes several components, such as a mental status examination, psychosocial assessment, cultural assessment, spiritual assessment, screening with validated tools, and review of laboratory testing results while also considering lifespan considerations. Review information about performing a mental status examination and psychosocial assessment in the “Application of the Nursing Process in Mental Health Care” chapter.

Mental Status Examination

See Table 10.4a for common themes when assessing a client with a personality disorder. Review information about a mental status examination in the “Assessment” section in Chapter 4.

Table 10.4a Common Findings During A Mental Status Examination Of A Client With A Personality Disorder

Mental Status Examination Component Common Themes in Personality Disorders

 
Signs of Distress Clients with personality disorders may have suicidal ideation, perform self-harm like cutting, or have violence or homicidal ideation.

*Increased risk for self-injury, suicide, or injury to others must be promptly reported to provider. Do not leave clients alone if statements such as these are being made.
Level of Consciousness and Orientation Clients with personality disorders are typically alert and oriented to person, place, time, and situation. Cognitive functioning is typically intact unless complicated by comorbid conditions or dissociative episodes
Appearance and General Behavior Behaviors varies by type of personality disorder. Clients may display anger, anxiety, hypersensitivity, emotional lability, or detachment. Behavior may appear dramatic, guarded, rigid, seductive, or odd depending on the subtype. Poor eye contact or unusual mannerisms may be seen in cluster A disorders. In cluster B, the client may present as flamboyant, provocative, or emotionally labile.  For example, individuals with borderline personality disorder (BPD) may show intense distress over perceived rejection. In cluster C, the client may present with anxious behaviors.
Speech Clients with narcissistic or histrionic traits may dominate conversations or speak in an exaggerated manner. Those with paranoid traits may speak with suspicion or defensiveness.
Motor Activity Clients with BPD or antisocial traits may appear restless or agitated. Minimal movement may be seen in avoidant or schizoid types due to anxiety or withdrawal.
Mood and Affect Mood may appear anxious, irritable, dysphoric, or constricted depending on the disorder. Mood is often labile or reactive in cluster B disorders (especially in BPD). Clients with BPD often experience feelings of emptiness, intense feelings of abandonment, extreme mood shifts that occur in a matter of hours or days, intense and unstable relationships  impulsive behavior such as reckless driving, unsafe sex, substance use, gambling, overspending, or binge eating.[1]
Thought and Perception Thought processes in clients with personality disorders may be rigid or inflexible. Paranoid ideation or transient dissociation may be present under stress. Clients with schizotypal traits may express magical thinking or odd beliefs.
Attitude and Insight Attitude may be guarded, defensive, manipulative, seductive, or overly compliant based on the disorder. Insight is often limited; clients may externalize blame and minimize their role in conflicts.
Cognitive Abilities and Level of Judgment Attention, memory, and abstract thinking are typically intact. However, some may show poor judgment or difficulty with impulse control (such as in BPD or antisocial personality disorders). Cognitive distortions are common across all types.

Psychosocial Assessment

As previously discussed in the “Application of the Nursing Process in Mental Health Care” chapter, a psychosocial assessment obtains additional subjective data that detects risks and identifies treatment opportunities and resources.[2],[3]:

  • Reason for seeking health care (i.e., “chief complaint”)
  • Thoughts of self-harm or suicide (both current and historical)
  • Cultural assessment
  • Spiritual assessment
  • Family dynamics
  • Current and past medical history
  • Current medications
  • History of previously diagnosed mental health disorders
  • Previous hospitalizations
  • Educational background
  • Occupational background
  • History of exposure to psychological trauma, violence, and domestic abuse
  • Substance use (tobacco, alcohol, recreational drugs, misused prescription drugs)
  • Family history of mental illness
  • Coping mechanisms
  • Functional ability/Activities of daily living

Additional focused questions are used to obtain detailed information used to plan care. The mnemonic PQRSTU can be used to ask questions in an organized fashion. See Table 10.4b for a sample PQRST assessment for clients with a borderline personality disorder and sample responses.

Table 10.4b Sample PQRSTU Questions for Assessing Clients With a Borderline Personality Disorder

PQRSTU Sample Questions Sample Client Response
Provocation/Palliation

 

 “What seems to trigger or worsen your emotional pain or distress? What helps you feel better?” “It usually starts when I feel like someone is ignoring me or pulling away. I hate being alone—it makes everything worse. Sometimes yelling or cutting makes me feel better, but then I feel ashamed.”
Quality “Can you describe what your emotional pain feels like?” “It’s like a storm inside—so intense I can’t control it. One minute I’m fine, the next I’m crying, screaming, or wanting to disappear. It feels like I’m broken or empty.”
Region “Do you feel any physical symptoms?” “I feel like I can’t breathe when I get really upset. Sometimes I feel shaky. I’ve had stomachaches or headaches after a fight with my boyfriend.”
Severity “On a scale of 0 to 10, how intense is your distress when it happens?” “It’s a 10. I feel totally out of control, like I’ll explode or do something I’ll regret later.”
Timing/Treatment

 

 “When did these feelings or episodes start? How long do they usually last?”

 

 “I’ve felt like this ever since I was a teenager. The episodes can come on fast, like after a text from my boyfriend, and can last for hours or days.”
Understanding “How do you explain what you’re going through?” “I’m very sensitive. I know I can be intense or push people away, but I can’t help it. If people leave me, I don’t know how to handle it. It’s like I feel everything too much.”

Suicide and Self Injury Screening

Clients being evaluated or treated for personality disorders may have suicidal ideation. It is important for the nurse to introduce suicide screening in a way that helps the client understand its purpose and normalize questions that might otherwise seem intrusive. The Patient Safety Screener (PSS-3) is an example of a brief screening tool to detect suicide risk in all client presenting to acute care settings.[4]

Non-suicidal self-injury (NSSI) refers to intentional self-inflicted destruction of body tissue without suicidal intention and for purposes not socially sanctioned. Common forms of NSSI include behaviors such as cutting, burning, scratching, and self-hitting. It is considered a maladaptive coping strategy without the desire to die. NSSI is a common finding among adolescents and young adults in psychiatric inpatient settings.[5]

Review information about suicide screening, the Patient Safety Screener, and screening for non-suicidal self-injury (NSSI) in the “Assessment” section of the Applying the Nursing Process to Mental Health Care” chapter.

Cultural Assessment

Cultural Formulation Interview (CFI) questions help nurses understand a client’s cultural background and how it influences their experience of mental health symptoms, including personality disorders.[6] Sample CFI questions focused specifically on understanding depression within a cultural context include the following:

  • Cultural Definition of the Problem
    • “How would you describe the problems you’re having with relationships or emotions?”
    • “What do your family or friend call these difficulties?”
    • “Do others see your behavior or emotions as a problem? If so, how?”
  • Cultural Perceptions of Cause, Context, and Support
    • “What do you think causes your emotional ups and downs or relationship conflicts?”
    • “How does your family or cultural group view traits like being very emotional, needing control, being distrustful, or acting out?”
    • “Are there things happening in your life right now that are making these problems worse?”
  • Cultural Factors Affecting Coping and Help-Seeking
    • “What have you done to manage these emotions on your own?”
    • “Have you talked to family members, elders, or religious/spiritual leaders about these issues?”
    • “What kind of help do you think would work best for you?”
    • “Are there treatments or approaches you’re uncomfortable with, based on your beliefs or past experiences?”
  • Cultural Features of the Nurse–Client Relationship
    • “Are there things about your cultural background that would help me understand you better or make you feel more comfortable?”
    • “Have you had any past experiences with mental health or medical providers that affect how you feel about treatment now?”
    • “Would you prefer working with a provider of a certain background or gender?”

Findings from the cultural formulation interview are used to individualize a client’s plan of care to their preferences, values, beliefs, and goals.

Spiritual Assessment

The FICA Spiritual History Tool is a widely used assessment model for evaluating a client’s spiritual beliefs and how they may influence health, illness, and coping.  FICA© is a mnemonic for the domains of Faith, Importance, Community, and Address in Care.[7] The data obtained from a FICA assessment can be helpful in understanding how clients with personality disorders draw on spirituality or religion for support. Spiritual distress is very common for clients experiencing serious illness, and nurses assist clients to adopt healthy coping strategies to deal with these life events. Addressing a client’s spirituality and advocating spiritual care have been shown to improve clients’ health and quality of life.[8],[9]

Table 10.4c summarizes a sample spiritual assessment questions and sample responses from a client experiencing depression.

Table 10.4c Sample FICA Spiritual Assessment Questions for Clients with Personality Disorders

Domain Sample Assessment Question Sample Client Response
Faith “Do you consider yourself spiritual or religious? What gives your life meaning?” “Lately, I’ve been feeling disconnected from everyone and everything. I pray sometimes, but it feels like no one’s listening.”
Importance “How important is faith or religious belief in your life?” “My faith used to help me feel strong, especially during hard times. Now, I feel like I’ve lost that connection. I feel too broken to be helped.”
Community “Are you part of a spiritual or religious community? Does participation in this community provide support when you’re feeling sad or in a low mood?” “I haven’t gone to church in months. Some people from church have reached out, but I just feel like being alone when I am home after work.”
Address in Care “Would you like me (or the health care team) to address spiritual issues during your care? Would you like to speak with a chaplain?” “Maybe.  I don’t want to feel judged for how I feel or for having doubts.”

Feelings of abandonment and spiritual distress are common in individuals experiencing personality disorders and may compound their symptoms. Nurses may recognize cues of spiritual distress and offer to connect the client with a chaplain or spiritual care services. Spiritual goals may be included in the nursing care plan if the client finds them valuable.

Family Dynamics

Family dynamics are included in a psychosocial assessment, especially for children, adolescents, and older adults. Family dynamics refers to the patterns of interactions among relatives, their roles and relationships, and the various factors that shape their interactions. Because family members rely on each other for emotional, physical, and economic support, they are primary sources of relationship security or stress. Family dynamics and the quality of family relationships can have either a positive or negative impact on an individual’s health. For example, secure and supportive family relationships can provide love, advice, and care, whereas stressful family relationships can be burdened with arguments, unhealthy relationships, and a lack of support.[10]

Unhealthy family dynamics can cause children to experience trauma and stress as they grow up. This type of exposure, known as adverse childhood experiences (ACEs), is linked to an increased risk of developing mental health disorders.[11] Review information about adverse childhood experiences (ACEs) in the “Mental Health and Mental Illness” section of Chapter 1.

Laboratory Testing

There is no specific laboratory test that diagnoses personality disorders. Laboratory or diagnostic tests may be used to rule out other possible causes for the behaviors the client is exhibiting. For example, a thyroid stimulating hormone (TSH) test may be ordered because thyroid disorders can affect mood.

Life Span Considerations

Children and Adolescents

Formal diagnosis of a personality disorder is not made before age 18, but traits may be present earlier, such as emerging patterns of emotional instability, conduct issues, or rigid thinking. Children and adolescents may demonstrate increased conflict with authority figures or manipulative behavior, impulsivity, or self-harm.

Older Adults

Personality changes in late life may suggest neurocognitive disorder, stroke, or side effects from medications. Personality traits such as paranoia, rigidity, dependency, or social isolation may become more prominent as the individual experiences loss or isolation.

Diagnosis (Analyze Cues)

Mental health disorders are diagnosed by mental health providers using the diagnostic criteria in the DSM-5-TR. Personality disorder diagnoses are typically not made until late adolescence or over the age of 18 because it is important to determine if the symptoms are traits of a developmental stage or pervasive traits of a personality disorder in multiple contexts. Nurses customize nursing diagnoses based on their type of personality disorder, their current signs and symptoms, and the effects on their and their family’s functioning.

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

Common nursing diagnoses for clients diagnosed and hospitalized with personality disorders are further described in Table 10.4d.

Table 10.4d Common Nursing Diagnoses for Clients With Personality Disorders[12],[13]

Nursing Diagnosis Definition Selected Defining Characteristics and/or Risk Factors
Risk for Suicide  Susceptible to self-inflicted, life-threatening injury.
  • Reports desire to die
  • Statements regarding killing self
  • Hopelessness
  • Social isolation
Risk for Self-Mutilation Deliberate self-injurious behavior causing tissue damage with the intent of causing nonfatal injury to attain relief of tension.
  • Cuts or scratches on body
  • Ingestion or inhalation of harmful substances
  • Self-inflicted burns
Risk for Other-Directed Violence  Susceptible to behaviors in which an individual demonstrates they can be physically, emotionally, and/or sexually harmful to others.
  • History of childhood abuse
  • History of cruelty to animals
  • History of witnessing family violence
  • History of fire-setting
Ineffective Coping  A pattern of invalid appraisal of stressors, with cognitive and/or behavioral efforts, that fails to manage demands related to well-being.
  • Destructive behavior toward self or others
  • Ineffective coping strategies
  • Ineffective problem-solving skills
Defensive Coping Repeated projection of falsely positive self-evaluation based on a self-protective pattern that defends against underlying perceived threats to positive self-regard.
  • Difficulty maintaining relationships
  • Hypersensitivity to criticism
  • Projection of blame
  • Projection of responsibility
Social Isolation Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state.
  • Hostility
  • Values incongruent with cultural norms
  • History of rejection
Ineffective Family Health Management r/t manipulative behavior Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state.
  • Impaired communication patterns
  • Disturbed thought processes
  • Delusional thinking
Risk for Spiritual Distress as manifested by poor relationships A state of suffering related to the impaired ability to experience meaning in life through connections with self, others, the world, or a superior being.
  • Ineffective coping strategies
  • Perceived insufficient meaning in life
  • Hopelessness
  • Social alienation

Outcome Identification (Generate Solutions)

Outcomes should address the established nursing diagnoses for each client with prioritization on safety. For example, if the client has a nursing diagnosis of Risk for Self-Mutilation, a SMART outcome could be, “The client will refrain from intentional self-inflicted injury.” Read more information about setting SMART outcomes in the “Application of the Nursing Process in Mental Health Care” chapter.

Examples of other SMART outcomes for clients with personality disorders may include the following[14]:

  • The client will remain safe and free of injury.
  • The client will seek help when experiencing urges to self-mutilate.
  • The client will identify three triggers to self-mutilation after the teaching session.
  • The client will describe two preferred healthy coping strategies after the teaching session.

Planning (Generate Solutions)

Evidence-based interventions are critical and should focus on managing the client’s behaviors. Interventions may include establishing clear boundaries, using specific communication styles, and providing reassurance. Pharmacotherapy may be used to manage specific symptoms, although no medications are specifically approved for personality disorders.

Promoting Safety

Individuals diagnosed with personality disorder may be suicidal, self-mutilating, impulsive, angry, manipulative, or aggressive. Nurses plan interventions according to the symptoms the client is currently exhibiting with the goal of keeping the client. others, and themselves safe and free of injury. Any threats should be taken seriously. Review interventions for clients diagnosed with Risk of Suicide in the “Application of the Nursing Process in Mental Health Care” chapter.

Clear boundaries and limits should be set and consistently reinforced by the health care team. When behavioral problems emerge, the nurse should calmly review therapeutic goals, limits, and boundaries with the client.[15]

A crisis/safety plan must be developed with the client that includes the following components:

  • Identifying thoughts or behaviors that increase the risk of harming self or others
  • Identifying people, events, or situations that trigger those thoughts or behaviors
  • Implementing coping strategies
  • Reaching out to other coping 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.[16]

Review information regarding developing a safety plan in the “Establishing Safety” section of the “Foundational Mental Health Concepts” chapter.

Implementation (Take Action)

As previously discussed in this chapter, there are ten different personality disorders that are categorized into three clusters (A, B, and C) in the DSM-5. Personality disorders within each cluster have similar patterns of behavior.  Cluster A personality disorders include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder. Cluster A is characterized as the odd, eccentric cluster. Individuals with these types of disorders often experience social awkwardness. Cluster B personality disorders include antisocial, borderline, histrionic, and narcissistic personality disorders. Cluster B personality disorders are characterized by dramatic, overly emotional, or unpredictable thinking or behavior. Cluster C personality disorders include avoidant, dependent, and obsessive-compulsive personality disorders. Cluster C personality disorders are characterized by anxious, fearful thinking or behavior.

These disorders are often ego-syntonic, meaning that the behaviors and thoughts are consistent with the individual’s self-perception and are not seen as problematic by the individual, despite causing significant issues in their life. This characteristic of personality disorders can make it challenging to implement nursing interventions when the client does not believe a problem exists.

Nursing Interventions for Personality Disorders Based on Categories of the APNA Implementation Standard

Nursing interventions for clients with personality disorders can be categorized based on the American Psychiatric Nurses Association (APNA) standard for Implementation that includes the Coordination of Care; Health Teaching and Health Promotion; Pharmacological, Biological, and Integrative Therapies; Milieu Therapy; and Therapeutic Relationship and Counseling. Read more about these subcategories in the “Application of the Nursing Process in Mental Health Care” chapter. See examples of interventions for each of these categories for clients with depressive disorders in Table 10.4e.

Table 10.4e Examples of Nursing Interventions For Personality Disorders Based on Subcategories of APNA Implementation Standard

Subcategory of the APNA Standard of Implementation The nurse will … Rationale
Coordination of Care – Collaborate with mental health professionals (e.g., therapists, psychiatrists) to ensure continuity of care.

– Communicate changes in behavior or mood with the health care provider.
– Facilitate referrals to community support resources such as support groups.
– Assist with care transitions (e.g., hospital discharge to long-term care or other community-based facilities).

 Personality disorders often require long-term, structured treatment involving multiple providers. Coordinated care ensures consistency and promotes better outcomes.
Health Teaching and Health Promotion -Educate clients on emotional regulation, interpersonal effectiveness, and stress management strategies (e.g., using DBT skills).
– Teach clients about triggers, patterns of behavior, and consequences.
– Promote self-care routines and adaptive coping techniques.		 Many clients with personality disorders struggle with emotional impulsivity and poor coping skills. Health teaching can enhance insight and self-management, thus reducing crises and potential hospitalizations.
Pharmacological, Biological, and Integrative Therapies – Administer prescribed medications for symptoms (e.g., mood stabilizers for impulsivity, SSRIs for depression/anxiety).
– Educate the client on the purposes of the medications-Monitor for side effects and adherence
– Encourage integrative therapies (e.g., mindfulness, journaling) to supplement psychotherapy.		 While medications do not cure personality disorders, they can manage co-occurring symptoms. Combined with therapy and self-care strategies, they improve overall stability.
Milieu Therapy – Create a structured and predictable environment to promote safety and reduce chaos.
– Model and reinforce appropriate social behaviors in group settings.
– Establish clear, consistent boundaries and behavioral expectations.		 Clients with personality disorders often test limits or experience emotional dysregulation. A therapeutic milieu with structure and consistency supports stability and learning.
Therapeutic Relationship and Counseling – Build trust using empathy, consistency, and nonjudgmental communication.
– Set and maintain professional boundaries to avoid manipulation or dependency.
– Use therapeutic communication to explore core beliefs and relational patterns.
– Encourage participation in long-term psychotherapy (e.g., DBT, CBT).		 Clients often have a history of unstable or maladaptive relationships. A consistent, respectful therapeutic relationship helps model healthy interaction and provides a secure base for growth.

Nursing Interventions for Physiological Signs of Personality Disorders

Although personality disorders are primarily psychiatric in nature, they often contribute to physiological symptoms such as sleep disturbances, somatic complaints, self-harm behaviors, disordered eating, and fatigue.  See common interventions for these conditions in Table 10.4f.

Table 10.4f Nursing Interventions Targeting Physiological Signs of Personality Disorders[17]

Problem/Intervention Rationale
Nutrition and Eating Behaviors

  • Assess for disordered eating patterns (e.g., binging or restrictive intake).
  • Collaborate with dietitian for nutritional planning.
  • Monitor intake/output and weight if needed.
  • Support body positivity and emotional awareness around food.
 Disordered eating may be associated with efforts to control overwhelming emotions. Balanced nutrition helps stabilize mood and reduce health complications.
Sleep

  • Assess sleep patterns and contributing factors (e.g., anxiety, racing thoughts, substance use).
  • Encourage regular sleep routines and calming bedtime rituals.
  • Provide education on sleep hygiene (e.g., limiting screen time, reducing caffeine).
  • Consult provider for possible medications.
 Many clients with personality disorders experience insomnia due to emotional dysregulation, anxiety, or impulsivity. Improving sleep enhances mood stability and reduces irritability and impulsive behavior.
Elimination (Gastrointestinal Discomfort)

  • Validate physical symptoms without reinforcing excessive health anxiety.
  • Rule out medical causes in collaboration with the healthcare team.
  • Educate on the mind–body connection and introduce relaxation techniques.
 Clients, especially those with borderline or somatization traits, may express emotional distress through physical symptoms like gastrointestinal (GI) complaints. Acknowledging the GI complaint while promoting coping reduces unnecessary interventions and increases insight.
Fatigue/Energy Deficit

  • Assess energy levels and daily activity patterns.
  • Encourage structured routines with scheduled rest and activity.
  • Promote moderate physical activity to increase energy and reduce tension.
  • Monitor for medication side effects contributing to fatigue.
 Emotional volatility and poor sleep can result in persistent fatigue. Routines help regulate biological rhythms, while physical activity improves mood and energy.
Self Care Deficits: Self-Harm or Injury

  • Monitor for and document signs of cutting, burning, or other non-suicidal self-injury (NSSI).
  • Remove or limit access to sharp objects or means of injury.
  • Engage client in developing a safety plan and alternative coping strategies (e.g., using ice, rubber bands).
  • Refer client to DBT-based interventions.
 Self-injury is a maladaptive coping mechanism to relieve emotional pain or dissociation, especially in borderline personality disorder. Safety monitoring and skill-building reduce risk and promote healthier regulation.

Communication Tips for Clients with Personality Disorders

Helpful communication techniques for clients with personality disorders and their rationale are described in the following box.

Communication Tips: Personality Disorders[18],[19]

  • Establish and maintain clear, consistent boundaries.
    • Rationale: Clients with personality disorders —especially those with borderline or antisocial traits—may test or violate boundaries. Consistent enforcement of limits fosters safety, trust, and structure.
  • Use calm, neutral, and non-reactive language.
    • Rationale: Emotional neutrality helps prevent escalation when clients display anger, impulsivity, or mood instability. It also reduces reinforcement of attention-seeking or manipulative behaviors.
  • Avoid power struggles or confrontation.
    • Rationale: Clients with narcissistic or paranoid traits may become defensive or combative. Use collaborative, non-authoritarian language to de-escalate and preserve the therapeutic alliance. Read more about de-escalating in the following subsection.
  • Validate feelings without encouraging distorted behaviors.
    • Rationale: Statements like “I can see that you’re really upset” acknowledge emotional pain without reinforcing maladaptive coping (e.g., threats, splitting, self-harm).
  • Be direct, honest, and transparent.
    • Rationale: Clear and open communication reduces misinterpretation and builds trust, especially with clients who have suspicious or paranoid tendencies.
  • Focus on the present.
    • Rationale: Redirect conversations from historical grievances or perceived slights to current goals or feelings. This helps reduce rumination and increases emotional regulation.
  • Avoid over-involvement or “rescuing” behaviors.
    • Rationale: Maintain professional boundaries to promote client autonomy and reduce dependency.
  • Watch for splitting behaviors among staff.
    • Rationale: Clients may view staff as all good or all bad, leading to division. Maintain team communication and a unified, consistent approach. Avoid taking sides or reacting emotionally.
  • Encourage reflection instead of impulsive reaction.
    • Rationale: Help the client slow down and explore what they’re feeling before acting. For example, “Let’s pause for a moment and talk about what just happened.”
  • Reinforce positive coping and interpersonal efforts.
    • Rationale: Recognize and praise the client’s use of healthy communication, emotional control, or insight to supports behavior change and build self-esteem.

De-Escalating

The nurse should implement de-escalation strategies if the client exhibits signs of increasing levels of anxiety or agitation. Strategies include the following:

  • Speaking in a calm voice
  • Avoiding overreacting
  • Implementing active listening
  • Expressing support and concern
  • Avoiding continuous eye contact
  • Asking how you can help
  • Reducing stimuli
  • Moving slowly
  • Remaining patient and not rushing them
  • Offering options instead of trying to take control
  • Avoiding touching the client without permission
  • Verbalizing actions before initiating them
  • Providing space so the client doesn’t feel trapped
  • Avoiding arguing and judgmental comments
  • Setting limits early and enforcing them consistently across team members
  • Addressing manipulative behaviors therapeutically

If the client continues to escalate, measures must be taken to keep the client and others safe. Review signs of crisis and crisis interventions in the “Stress, Coping, and Crisis Intervention” chapter. If interventions are not effective in de-escalating a client at risk to themselves or others, seclusion or restraints may be required. Review using seclusion and restraints in the “Psychosis and Schizophrenia” chapter. Review ANA guidelines on using restraints in the “Client Rights” section of the “Legal and Ethical Considerations in Mental Health Care” chapter and information on safely implementing restraints in the “Workplace Violence” section of the “Trauma, Abuse, and Violence” chapter.

Coping Strategies

Teaching self-care and coping strategies is helpful for people diagnosed with personality disorders and their loved ones.[20] Read about stress management and coping strategies in the “Stress, Coping, and Crisis Intervention” chapter.

For clients seeking immediate relief from intense symptoms such as panic or depersonalization, nurses can teach how to stimulate the parasympathetic nervous system. Stimulation of the vagal nerve can result in an immediate, direct relief of intense emotions. This can be accomplished by doing the following[21]:

  • Applying ice or ice-cold water to the face
  • Performing paced-breathing techniques in which the exhalation phase is at least two to four counts longer than the inhalation phase. For example, advise the client to inhale while counting to four and then exhale while counting to eight.

Collaborative Interventions

The nurse encourages collaboration with other disciplines and encourage psychotherapy and pharmacotherapy as directed by the healthcare provider.  For more information on psychotherapy and pharmacotherapy in regard to treating personality disorders, see  the “Treatment for Personality Disorders” section of this chapter.

Evaluation (Evaluate Outcomes)

Refer to the SMART outcomes established for each individual client to evaluate the effectiveness of the planned interventions. Modification of the established nursing care plan may be required based on the effectiveness of the interventions.

In general, the nurse can evaluate the effectiveness of interventions in clients with personality disorders with the following questions:

  • Does client recognize symptoms are related to their mental health condition?
  • Is the client successfully implementing adaptive coping strategies to manage their mental health disorder?
  • Is the client following their prescribed treatment plan?
  • Is the client adequately performing self-care activities?
  • Is the client able to maintain satisfying interpersonal relationships?
  • Is the client able to successfully function socially or other important areas of functioning?
  1. Mayo Clinic. (2024). Borderline personality disorder. https://www.mayoclinic.org/diseases-conditions/borderline-personality-disorder/symptoms-causes/syc-20370237 ↵
  2. Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder. (2017). What is cognitive behavioral treatment? American Psychological Association. https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral ↵
  3. Halter, M. (2022). Varcarolis’ foundations of psychiatric-mental health nursing (9th ed.). Saunders. ↵
  4. Suicide Prevention Resource Center. (n.d.). The patient safety screener: A brief tool to detect suicide risk. https://sprc.org/micro-learning/patientsafetyscreener ↵
  5. Cipriano, A., Cella, S., & Cotrufo, P. (2017). Nonsuicidal self-injury: A systematic review. Frontiers in Psychology, 8. https://www.frontiersin.org/articles/10.3389/fpsyg.2017.01946/full ↵
  6. DeSilva, R., Aggarwall, N. K., & Lewis-Fernandez, R. (2015). The DSM-5 cultural formulation interview and the evolution of cultural assessment in psychiatry. Psychiatric Times, 32(6). https://www.psychiatrictimes.com/view/dsm-5-cultural-formulation-interview-and-evolution-cultural-assessment-psychiatry ↵
  7. GW School of Medicine & Health Sciences. (n.d.). Clinical FICA tool. https://smhs.gwu.edu/spirituality-health/program/transforming-practice-health-settings/clinical-fica-tool ↵
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