Interpersonal relationship behaviors may be represented on a continuum that ranges from healthy interdependent interactions to those involving no real contact with other people (Figure 21-2). At the midpoint of the continuum, a person experiences loneliness, withdrawal, and dependence. The maladaptive end of the continuum includes the behaviors of manipulation, impulsiveness, and narcissism. People with these responses often have a history of problematic relationships in the family, on the job, and in the social arena.

Critical Reasoning

Compare the relationships you have had with family, friends, and patients. How are they alike and different?

Assessment

Behaviors

Personality is a set of deeply ingrained, enduring patterns of thinking, feeling, and behaving. A personality disorder is a set of patterns or traits that hinder a person’s ability to maintain meaningful relationships, feel fulfilled, and enjoy life (Newton-Howes et al, 2008). It begins in adolescence or early adulthood, is stable over time, and leads to distress or impairment (Oldham, 2005).

Personality disorders are attitudes toward self, others, and the world expressed in everything a person thinks, feels, and does. They often decrease in severity as a person ages, mainly because of corrective life experiences. Personality disorders are continuous across a wide range of circumstances in the individual’s life, although the appearance and severity of a particular symptom can vary over time.

The concept of personality “disorder” suggests that one knows what a normal personality is even though it is very difficult to define. A healthy individual is able to adjust and adapt to the demands or expectations of different people and different situations. Individuals with personality disorders have a significant and persistent impairment in their interpersonal relationships and other aspects of functioning.

The following are three key features of personality disorders:

1. The individual has an inflexible and maladaptive approach to relationships and the environment.

2. The individual’s needs, perceptions, and behavior tend to foster cycles that promote unhelpful patterns and provoke negative reactions from others.

3. The individual’s coping skills are unstable and fragile, and there is a lack of resilience when faced with stressful situations.

It is estimated that about 4% of the general population and as many as 20% in clinical populations have personality disorders, often with significant morbidity (Kernberg and Michels, 2009). Some of these disorders are associated with a high mortality rate because of suicide. Suicide victims with personality disorders almost always also have a depressive illness, substance use disorder, or both.

Many individuals with a current alcohol use disorder have at least one personality disorder, and the association is even stronger with a current drug use disorder. A comorbid personality disorder also prolongs the course of major depression (Skodol et al, 2011).

An essential element of the diagnosis is that the symptoms of personality disorders are fixed and long lasting. Even with treatment, it is not possible to completely change someone’s personality. However, it is possible to help people with personality disorders improve the quality of their lives. Treatment can lead to significant improvement in the symptoms, distress, and general functioning of patients with personality disorders.

Personality disorders are characterized by chronic, maladaptive social responses. The DSM-IV-TR (American Psychiatric Association, 2000) has grouped personality disorders into three clusters:

1. Cluster A includes personality disorders of an odd or eccentric nature (paranoid, schizoid, and schizotypal personality disorders).

2. Cluster B disorders are of an erratic, dramatic, or emotional nature (antisocial, borderline, histrionic, and narcissistic personality disorders).

3. Cluster C includes disorders of an anxious or fearful nature (avoidant, dependent, and obsessive-compulsive personality disorders).

QUALITY AND SAFETY ALERT

• Patients with borderline and antisocial personality disorders are more likely to attempt suicide.

The nursing assessment and implementation of care for people with antisocial, borderline, and narcissistic personality disorders are emphasized in this chapter. Common maladaptive responses of people with cluster B personality disorders include manipulation, narcissism, and the impulsivity that often overlaps both.

Manipulation

People who use manipulative behaviors present a particularly difficult nursing problem. Manipulation is a behavior in which people treat others as objects and form relationships that center around control issues. Their behavior is easily misunderstood, as illustrated in the following clinical example.

CLINICAL EXAMPLE

Mr. Y was a 20-year-old single man who was committed to an inpatient psychiatric unit by a judge for a psychiatric evaluation. He had been charged with the sale of illicit drugs, statutory rape of his 15-year-old pregnant girlfriend, and contributing to the delinquency of a minor. He had been arrested on the grounds of a junior high school, where he was selling PCP and barbiturates to a group of young teenagers.

In jail Mr. Y had been observed to be “crazy” by the guards. He paced his cell, chanted, and threw his food on the floor. Because of this behavior, the judge agreed to order a psychiatric evaluation. On arrival at the psychiatric unit, Mr. Y continued to behave in the same manner. However, his behavior did not seem typical of psychosis. There was no evidence of hallucinations or disorders of thought or affect. When unaware that he was being observed, Mr. Y seemed relaxed and was noted at one time to be talking with another patient.

By the day after admission he seemed to be free of his symptoms. At this point the staff began to describe him as a “nice guy.” He complimented female staff members and behaved toward them in a pleasant but slightly seductive manner. He was respectful to the physicians and agreed to abide by all rules. He was helpful with other patients. In group meetings he admitted that he had behaved badly in the past and described how his friends had led him astray. He said he became involved in drugs because he wanted to be “one of the gang” and he needed money so he “had to” start selling drugs even though he knew better. He began to receive the sympathy of the other patients and the staff.

Four days after admission, after visiting hours, it was noted that Mr. Y and two other patients looked lethargic. Their speech was slurred and their gaits ataxic. The nursing staff immediately collected urine and blood specimens for toxicological analysis. The unit was searched for hidden drugs, but none were found. The results of the toxicology screening tests were positive for barbiturates.

Suspicion was immediately focused on Mr. Y, because the other patients involved were young adolescents with no history of drug abuse. When confronted, Mr. Y seemed amazed and hurt that he could be suspected and pointed out his past behavior as a model patient. He admitted that he had behaved strangely and wondered whether someone had “slipped” him some drugs. He was convincing but was warned that if he was involved in any way with drugs, he would be sent directly back to jail.

Mr. Y convinced his parents of his good intentions, and they agreed to allow him to move into their house. On the basis of his positive behavioral change, Mr. Y received a recommendation for probation, which was carried out by the judge.

Three months after discharge from the hospital, Mr. Y and a friend were arrested for operating a PCP manufacturing laboratory in a friend’s garage.

Selected Nursing Diagnoses

• Defensive coping related to need for control, as evidenced by illegal behavior and treating people like objects

• Impaired social interactions related to inability to identify relationship problems, as evidenced by manipulation of others

Manipulative patients usually have little motivation to change because manipulative behavior often has rewards for them; they are getting what they want. Manipulators are goal oriented or self oriented, not other oriented. However, they are skilled at giving the impression that they care about others. In this clinical example, Mr. Y was able to gain the confidence of the staff in order to escape a jail sentence. This is typical of a person with an antisocial personality disorder.

The manipulative person is unaware of a lack of relatedness and assumes that interpersonal relationships are formed to take advantage of others. This person cannot imagine an intimate, sharing relationship. The manipulator believes in maintaining control at all times to avoid being controlled.

Antisocial personality disorder is a complex disorder that is difficult to diagnose and treat. To meet DSM-IV-TR criteria, an individual must be at least 18 years old but must demonstrate a pattern of breaking rules since the age of 15 (American Psychiatric Association, 2000). The diagnosis is applied when an individual consistently ignores social rules; is manipulative, exploitative, or dishonest; lacks remorse for actions; and is involved in criminal activity. Although this diagnosis occurs in only 3% of men and 1% of women, these individuals are responsible for a large proportion of crime, violence, and social distress.

Patients with borderline and antisocial personality disorders are often manipulative. This results in their inability to participate in mature interpersonal relationships, as illustrated in the next clinical example.

Clinical Example

Ms. S was a 23-year-old woman who was admitted to a general hospital psychiatric unit. She had cut her wrists superficially three times during the week before admission. Each time she cut herself, she telephoned her therapist, a psychiatric advanced practice nurse. Because the therapist was about to leave for vacation and was concerned for the safety of Ms. S, she decided to hospitalize her.

On admission Ms. S appeared mildly depressed. She gave the impression of a guilty child who had been punished. She denied any current self-destructive thoughts. During the physical assessment the nurse noted that there were many scars on the patient’s body. When asked about these, she claimed she was abused as a child. Her therapist’s records described the scars as the result of much self-mutilation since the age of 16 years. This had been her main reason for seeking therapy. There was also a history of sexual promiscuity.

Ms. S described herself as a failure, stating that she had “the best parents in the world, but they did not get the daughter they deserve.” She said she was a drifter who had never been able to settle on a career, a lifestyle, or any consistent friends. She didn’t know who or what she was. When asked how she felt, she responded, “Most of the time, I don’t feel anything, just empty.” She had no signs of psychosis.

Ms. S was placed on constant observation to prevent further cutting. All sharp objects were removed from the room. At first she was very cooperative and superficially friendly to other patients. Because of her smooth adjustment, constant observation was discontinued after 2 days. She was also given a schedule of activities and informed that she was responsible for following it. The next day, an X-Acto knife was missing from the activities therapy room. Ms. S was found in the bathroom, bleeding from several small cuts on her ankles. This sequence was repeated several times. Each time the constant observation was discontinued, she found a sharp object and cut herself.

Ms. S was also very labile emotionally. She had unpredictable outbursts of anger, similar to temper tantrums. However, these outbursts passed as quickly as they came, never lasting more than a few minutes. She also began to categorize the staff as “good guys and bad guys.” When she was with staff members she liked, she was pleasant, complimenting them on their kind and understanding attitudes toward her. With staff she disliked, she was sullen and uncooperative, comparing them unfavorably with the others. Eventually the staff began to bicker about her care, some believing she was spoiled and others that she was neglected.

Ms. S remained in the hospital during her therapist’s absence. When the therapist returned, Ms. S refused to see her. The frequency of angry outbursts increased dramatically. However, after frequent visits from her therapist, Ms. S began to request discharge. Behavioral criteria for discharge were set, including no self-mutilation and no temper tantrums. She met the criteria and was discharged back to outpatient treatment.

Selected Nursing Diagnoses

• Risk for self-mutilation related to anxiety about therapist’s vacation, as evidenced by cutting

• Chronic low self-esteem related to unclear goals and expectations, as evidenced by describing herself as a failure

• Impaired social interaction related to inability to tolerate close relationships, as evidenced by splitting staff into “good guys” and “bad guys”

The diagnosis of borderline personality disorder occurs in 1% to 6% of the general population and is the most prevalent personality disorder (15% to 25%) in mental health settings (Gunderson, 2009). The diagnosis is made more often in women than in men. Developmental theory suggests that the borderline person does not achieve object constancy during the separation-individuation stage of psychosocial development. People who fail to complete separation from the mother (or primary caretaker) and develop autonomy in childhood often repeat this developmental crisis at adolescence. Behaviors characteristic of this phase include the following:

• Clinging

• Depression accompanied by rage and defended by acting out

• Detachment and withdrawal

Many of these behaviors can be seen in the preceding clinical example. Borderline personality disorder has one of the highest suicide rates of all the personality disorders. Impulsive aggression is the hallmark of borderline personality disorder, and it is seen in the borderline person’s self-mutilation, unstable relationships, violence, and completed suicides.

These patients can be frustrating for nursing staff to interact with and treat because they are manipulative and unable to become involved in reciprocal interpersonal relationships. However, nurses must remember that this behavior is not consciously planned but is a defense against a fear of loneliness.

Critical Reasoning

Do you know someone who is manipulative in relating to you? If so, how do you respond to them?

Narcissism

The term narcissism comes from the Greek myth of Narcissus, who fell in love with his own reflection in the water and died. The flower that bears his name sprang up at the site of his death.

Many successful people are narcissistic. Acting, modeling, professional sports, and politics are usually attractive occupations to people with this personality trait. However, problems occur when people do not gain the status they think is deserved or lose status. The frustration caused by lack or loss of recognition may be expressed as anger, depression, substance abuse, or other maladaptive behaviors.

People with narcissistic personality disorders have fragile self-esteem, driving them to search constantly for praise, appreciation, and admiration (Kay, 2008; Ronningstam, 2011). The following clinical example demonstrates narcissistic entitlement, which describes an egocentric attitude, envy, and rage when others are seen as critical or not supportive.

CLINICAL EXAMPLE

The psychiatric nurse was called to the emergency department to see a new patient, Mr. F, who was accompanied by his wife. The nurse knew from the intake form that Mr. F was a 44-year-old man with no psychiatric history. His chief complaint was that he had gone into a “blind rage” when he had an argument with his wife earlier in the evening and had punched her on the arm. He was frightened by his loss of control and said that he felt like a failure. Both Mr. and Mrs. F denied any history of violence, although Mr. F said that his first marriage ended “because of my anger.”

Mr. F appeared quite anxious; he was tapping his foot and wringing his hands, and he avoided eye contact with the nurse. After a short time, however, he became more verbal, and he willingly explained what had led to the “blowup.” He had been self-employed for the past 10 years and had been “highly successful,” expanding his company nationally. He told the nurse that his father was a “multimillionaire” and that he had been on his way to exceeding his father’s wealth. It seemed important to impress the nurse by dropping the names of well-known people, whom he described as his friends.

Mrs. F angrily interrupted him, saying, “That’s what’s important to you—who you know and how it looks.” Mrs. F then explained that business began slipping 2 years ago. Despite several profitable years, he had never invested or saved money. When sales fell, instead of cutting expenses and downsizing the company, he continued to live lavishly, making extravagant purchases. It was this situation that led to their argument. When Mrs. F accused her husband of taking them to the brink of financial collapse, he went into a rage and punched her.

Mrs. F began sobbing, and Mr. F seemed not to notice. He said he felt like his life was falling apart and that he must be the failure his father always said he was. He angrily referred to his “rich brother,” who, in his father’s eyes, was the perfect son. He became tearful, and Mrs. F then turned to her husband, attempting to provide support and reassurance.

Selected Nursing Diagnoses

• Impaired social interaction related to the need for approval by others, as evidenced by attempts to impress others and inability to respond to wife’s distress

• Risk for other-directed violence related to impulsivity, as evidenced by acts engaged in during “blind rage”

• Interrupted family processes related to inconsistency between goals of husband and wife, as evidenced by wife’s reaction to patient’s description of his problem

• Defensive coping related to fear of failure, as evidenced by bragging and name dropping

• Chronic low self-esteem related to perceived lack of caring and approval from father, as evidenced by stated need to exceed his father’s success and description of himself as “a failure” in his father’s eyes

Mr. F’s impulsiveness was seen in his extravagance, inability to establish and follow a life plan, failure to learn by experience, poor judgment, and unreliability.

The behaviors related to maladaptive social responses are summarized in Table 21-1. Patients often exhibit combinations of these behaviors. The nurse should be able to identify the complex behaviors associated with high levels of stress and anxiety. In some cases a usual mode of behavior, such as manipulation, may be exaggerated or combined with a change in behavior.

TABLE 21-1

BEHAVIOR	CHARACTERISTICS
Manipulation	Others are treated as objects Relationships center around control issues Person is self oriented or goal oriented, not other oriented
Narcissism	Fragile self-esteem Constant seeking of praise and admiration Egocentric attitude Envy Rage when others are not supportive
Impulsivity	Inability to plan Inability to learn from experience Poor judgment Unreliability