Personality Disorders
Borderline personality disorder (BPD) Verified · Sep 2026StatPearls: "Personality disorders are currently described as pervasive, maladaptive, and chronic patterns of behavior, thinking, and feeling." In our own words: a long-lasting, rigid way of thinking, feeling and acting that is far out of step with the person's culture, starts by adolescence or early adulthood, and causes distress or impairment.
People with personality disorders often do not see their own patterns as the problem, and staff often feel pulled between rescuing and rejecting them. The nurse keeps everyone safe, screens for suicide at every contact, sets clear limits that the whole team enforces the same way, stays calm and neutral, and supports psychotherapy — the treatment that actually helps.
What’s going wrong in the body
The normal physiology, where it fails, and why the body’s compensation backfires.
01 What makes a personality pattern a disorder
"Patients with personality disorders often have distorted perceptions of reality and abnormal affective behavior, manifesting in maladaptive coping mechanisms and distress" (StatPearls). The pattern is pervasive, rigid and long-lasting rather than a reaction to one situation.
Insight is often poor. "Generally, individuals with personality disorders have a poor understanding of how their behaviors are related to their feelings, dysregulated emotions, and interpersonal difficulties." "Often, individuals request treatment at the behest of a first-degree relative or friend. Generally, this occurs after maladaptive behaviors have created stress on another rather than internal distress from the individual with a personality disorder" (StatPearls).
Onset. "The features of personality disorders typically start emerging in adolescence, and worsening pathological behaviors may increase through early adulthood before they become an inflexible pattern of thinking and action" (StatPearls). Open RN: "Formal diagnosis of a personality disorder is not made before age 18, but traits may be present earlier."
Three clusters. "The 10 personality disorders are classified into 3 clusters. Cluster A includes paranoid, schizoid, and schizotypal personality disorders. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders" (StatPearls). "Despite the historical division of personality disorders into clusters, this approach has limitations and lacks consistent validation in the literature."
02 [BPD] Borderline personality disorder — emotion, abandonment and splitting
NIMH: "Borderline personality disorder is a serious mental illness that affects how a person feels about themselves and others and makes it hard to function in everyday life. The disorder often involves difficulty regulating emotions, leading to impulsivity, an unstable or often changing sense of self, and troubled relationships with others."
All-or-nothing thinking. People with BPD "tend to view things in extremes, such as all good or all bad. This is often seen in social interactions, which may swing from extreme closeness to extreme dislike, resulting in unstable relationships and emotional pain" (NIMH). StatPearls: "Splitting is a defense mechanism in which a person cannot form a realistic view of another person."
Abandonment fear. "Fear of abandonment can drive maladaptive behaviors, including impulsivity, self-harm, and suicidal behavior" (StatPearls). "Individuals with BPD may display marked emotional lability, including the potential to react strongly and become angry, violent, or suicidal."
The brain. "Top-down control abnormalities are seen in borderline personality disorder, showing that cortical activity to moderate the amygdala (and other limbic areas) is impaired. Instead, behavior is driven from the bottom-up, meaning that amygdala activation is unmoderated by higher-level cortical functions" (StatPearls).
Causes. "research suggests that genetic, physical, environmental, and social factors may increase the risk of developing the disorder"; "Many people with borderline personality disorder report experiencing traumatic life events, such as abuse, neglect, maltreatment, abandonment, or hardship during childhood" (NIMH).
03 [ASPD] Antisocial personality disorder
"Antisocial personality disorder (ASPD) encompasses a chronic pattern of disregard for the rights of others, impaired empathy, deceitfulness, impulsivity, and persistent behavioral dysfunction that often begins with conduct disorder in childhood or adolescence." "Individuals with ASPD often manipulate others for personal gain, lack empathy, and seldom feel remorse for their actions" (StatPearls). In our own words: the diagnosis is made in adults, with conduct problems beginning in childhood.
Conduct disorder. "While most children with conduct disorder will not develop ASPD, conduct disorder is a significant risk factor for its development," with "males being more likely than females to progress to ASPD in adulthood" (StatPearls).
Biology and environment. "Underarousal of the autonomic nervous system has been hypothesized as a pathophysiological mechanism for antisocial personality disorder" (StatPearls). "Specifically, maltreated children with the low-activity variant of the MAO-A gene were significantly more likely to develop conduct disorder and ASPD."
Psychopathy is related but narrower. "While most individuals meeting the criteria for psychopathy also meet the criteria for ASPD, the reverse is not true" (StatPearls).
Treatment goals. "Early treatment for children with conduct disorder is considered the most effective and least costly way to prevent or treat ASPD." "Since ASPD is unlikely to remit, treatment should focus on reducing interpersonal conflict and stabilizing psychosocial functioning" (StatPearls).
Causes & risk factors
Modifiable factors are teaching targets — the patient can act on them.
Signs & symptoms
Each finding tied to the mechanism that produces it — and the triage it calls for.
Diagnostics
Complications
Medications for this condition
Why each class is prescribed here — every card links to its full pharmacology page.
Adjunct for specific symptoms only — no FDA-approved drug treats a personality disorder. "No medications are approved by the US Food and Drug Administration for the treatment of BPD" (StatPearls). NIMH: medication "is not a first-line treatment" but may help as an add-on for "co-occurring conditions such as mood swings or depression." StatPearls: serotonin reuptake inhibitors, mood stabilizers and antipsychotics "showed limited effectiveness for controlling transient symptoms of anxiety, sleep disturbance, depression, or agitation."
Low dose for cognitive-perceptual symptoms (Open RN). "Cognitive-perceptual symptoms (e.g., hallucinations and paranoid ideation): Treated with low-dose antipsychotics such as aripiprazole, risperidone, and quetiapine." "Medications that can be fatal in overdose should be avoided or used with caution."
Valproate or lamotrigine for impulsivity (Open RN). "Impulsivity and behavioral dysregulation may be treated with mood stabilizers (such as valproate and lamotrigine)." For ASPD, StatPearls notes that evidence for medications "is limited and inconsistent, and none are FDA-approved for the treatment of ASPD."
Beyond medications
- [BPD] Psychotherapy is first-line. "The first-line treatment for BPD is psychotherapy" (StatPearls). NIMH: "Psychotherapy, or talk therapy, is the primary treatment for borderline personality disorder."
- [BPD] Dialectical behavior therapy (DBT). "This treatment was developed specifically for people with borderline personality disorder. DBT uses concepts of mindfulness or awareness of one’s present situation and emotional state. DBT also teaches skills to help people control intense emotions, reduce self-destructive behaviors, and improve relationships" (NIMH). "Treatment with DBT combines individual therapy, group therapy, and weekly team consultations for the therapists" (StatPearls). Open RN: "It is considered the gold standard for treating borderline personality disorder and is also used for other types of disorders."
- [BPD] Other therapies. Mentalization-based therapy "helps patients with BPD regulate emotions by increasing their mentalizing capacity and reflective functioning" (StatPearls); "CBT can help reduce mood swings, anxiety symptoms, and self-harming or suicidal behaviors" (NIMH).
- [ASPD] Realistic goals. "Psychotherapy for ASPD has limited evidence of efficacy, in large part due to poor patient motivation, lack of insight, and difficulty forming a therapeutic alliance" (StatPearls); the aim is harm reduction and better functioning.
- Case management and family. "Case management can assist patients with personality disorders in maintaining income, shelter, and connection to medical and mental health services" (StatPearls). "Involving the patient's family is another way of monitoring for decompensation."
- Stay in treatment. "It is also important to not only seek out—but stick with—treatment" (NIMH).
Nursing considerations
The RN-specific layer — each action paired with the reason it matters.
How a real nurse thinks
The clinical-judgment loop, worked for a typical presentation — reasoning, not reference.
- 1 Recognize cues
A comment suggesting thoughts of death, new self-harm, rapid mood swings, splitting (one nurse ideal, another useless), and a limit that was bent by the team.
- 2 Analyze cues
Self-harm "is a risk factor for future suicide" and must be assessed "for intent to die" (StatPearls). Splitting divides staff, and inconsistent limits feed it (Open RN).
- 3 Prioritize
Safety first: assess suicide risk and the new wound now. Then restore a consistent limit and unify the team.
- 4 Generate solutions
Suicide assessment with the provider; neutral wound care; update the safety plan; calmly restate the phone rule; share the splitting pattern and agree one approach at handoff.
- 5 Take action
Ask directly about suicidal thoughts and intent, notify the provider, increase observation per policy, dress the scratch in a matter-of-fact way, and restate the limit calmly without arguing. Report the team inconsistency.
- 6 Evaluate
Her safety plan is updated with coping steps she chose, staff give the same answer about the phone rule, and she attends the next DBT skills group.
Scenario — you’re the nurse
Work each question before revealing the answer. Rationales explain the wrong options too.
A 23-year-old woman with borderline personality disorder was admitted after superficial cuts to her forearm following a breakup. On the day shift she praised one nurse as ‘the only one who understands me.’
Q1 Select all that apply Which nursing actions are appropriate for a client with borderline personality disorder who splits staff? Select all that apply. - A. Set clear limits and have the whole team enforce them the same way
- B. Share information at handoff and avoid taking sides
- C. Let the "favorite" nurse make exceptions to keep the client calm
- D. Use calm, neutral, non-reactive language
- E. Argue until the client admits the behavior is wrong
Reveal answer & rationale
Q2 Multiple choice A client with BPD says, ‘Nobody would care if I died.’ What is the nurse’s priority action? - A. Change the subject to reduce attention-seeking
- B. Ask directly about suicidal thoughts and intent and keep the client safe while notifying the provider
- C. Document it and review at the next weekly meeting
- D. Tell the client that people care about her
Reveal answer & rationale
Q3 Multiple choice Which statement about treatment for borderline personality disorder is accurate? - A. An FDA-approved medication is the first-line treatment
- B. Psychotherapy is first-line; DBT was developed specifically for BPD
- C. Hospitalization cures the disorder
- D. BPD never improves
Reveal answer & rationale
Q4 Multiple choice A client with antisocial personality disorder asks to be admitted to ‘work on his personality.’ Which fact guides the response? - A. Admission is the main treatment for ASPD
- B. Hospitalization gives little benefit for ASPD itself and is reserved for concurrent conditions or complications
- C. A mood stabilizer cures ASPD
- D. ASPD always remits by age 25
Reveal answer & rationale
Common questions
What causes personality disorders?
What are the early signs of personality disorders?
Do people with borderline personality disorder get better?
Is there a medication for personality disorders?
Why does the whole team need the same rules?
Are hallucinations part of personality disorders?
Sources
- Borderline Personality Disorder (brochure, revised 2025) — National Institute of Mental Health (NIH)
- Borderline Personality Disorder — health topic (last reviewed December 2024) — National Institute of Mental Health (NIH)
- Personality Disorder — StatPearls — StatPearls (NCBI Bookshelf)
- Borderline Personality Disorder — StatPearls — StatPearls (NCBI Bookshelf)
- Antisocial Personality Disorder — StatPearls — StatPearls (NCBI Bookshelf)
- Personality Disorders — Open RN Nursing: Mental Health and Community Concepts, 2e (Ch. 10) — Open RN (NCBI Bookshelf)
Reviewed by Hae Suk Lee, RN
Educational summary for nursing students. Scenarios are fictional teaching cases. Always verify against current guidelines and your institution's protocols before acting in practice. Not medical advice.