What to do when pts are violent: boxes on pgs 835, 829
Box 38.11: Environmental Management: Violence Prevention
Definition: Monitoring and manipulating the physical environment to decrease the
potential of violent behavior directed toward self, others, or environment
Activities
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Remove potential weapons (e.g., sharps, ropelike objects) from the environment.
Search environment routinely to maintain it as hazard free.
Search patient and belongings for weapons or potential weapons during inpatient
admission procedures as appropriate.
Monitor the safety of items that visitors bring to the environment.
Instruct visitors and other caregivers about relevant patient safety issues.
Limit patient use of potential weapons (e.g., sharps, ropelike objects).
Monitor patient during use of potential weapons (e.g., razors).
Place patient with potential for self-harm with a roommate to decrease isolation
and opportunity to act on self-harm thoughts, as appropriate.
Assign single room to patient with potential for violence toward others.
Place patient in a bedroom located near a nursing station.
Limit access to windows, unless locked and shatterproof, as appropriate.
Lock utility and storage rooms.
Provide paper dishes and plastic utensils at meals.
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Place patient in the least restrictive environment that still allows for the necessary
level of observation.
Provide ongoing surveillance of all patient access areas to maintain patient safety
and therapeutically intervene, as needed.
Remove other individuals from the vicinity of a violent or potentially violent
patient.
Maintain a designated safe area (e.g., seclusion room) for patient to be placed
when violent.
Provide plastic, rather than metal, clothes hangers, as appropriate.
Adapted from
Dochterman, J., & Bulechek, G. (2000). Nursing interventions classification (NIC) (4th
ed.). St. Louis: Mosby.
Using Seclusion and Restraint
Seclusion and restraint are used when patients need to be separated from other patients on
the unit. However, as noted in Chapter 10, these are controversial interventions to be used
judiciously and only when other interventions have failed to control the patient's
behavior. Reasons traditionally cited for using them are to protect the patient from injury
to self or others, to help the patient re-establish behavioral control, and to minimize
disruption of unit treatment regimens. Only recently has there been recognition that these
interventions cause considerable psychological damage, in some cases replicating
childhood traumas. Seclusion may be extremely painful to a patient who has already
experienced abandonment and rejection (Holmes, Kennedy, & Perron, 2004). Restraint
may re-create trauma comparable to a rape (“They held me down, they pulled my
drawers down”) (Benson et al., 2003). Gerolamo (2006) strongly argues that restraint use
in acute psychiatric settings should be considered an adverse outcome. The controversy
over these interventions and their potential to be applied punitively provided impetus for
issuance of federal guidelines for their use. American institutions that receive Medicare
or Medicaid reimbursement must adhere to guidelines issued by the Center for Medicare
and Medicaid Services. Restraint-related injuries and deaths have prompted many
facilities to ban their use entirely and train staff in alternative techniques.
Personality Disorders
General characteristics: Deb say: “long standing maladaptive thoughts and behaviors.” Never result of
drugs or other illness/injury.
ATI: concern maladaptive personalities; weird thinking about self, the world, enviro. Chronic d/o, w/ odd
thinking, affect, impulse control, and relating.
Definition: when what manages the ‘totality of a person’s behavior’ is altered severely from the culture,
you get this Dx.
Wiki:
General diagnostic criteria
Diagnosis of a personality disorder must satisfy the following general criteria in addition to the specific
criteria listed under the specific personality disorder under consideration.
A. Experience and behavior that deviates markedly from the expectations of the individual's
culture. This pattern is manifested in two (or more) of the following areas:
cognition (perception and interpretation of self, others and events)
affect (the range, intensity, lability, and appropriateness of emotional response)
interpersonal functioning
impulse control
B. The enduring pattern is inflexible and pervasive across a broad range of personal and social
situations.
C. The enduring pattern leads to clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The pattern is stable and of long duration and its onset can be traced back at least to
adolescence or early adulthood.
E. The enduring pattern is not better accounted for as a manifestation or consequence of another
mental disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance or a general
medical condition such as head injury.
People under 18 years old who fit the criteria of a personality disorder are usually not diagnosed with such
a disorder, although they may be diagnosed with a related disorder. In order to diagnose an individual under
the age of 18 with a personality disorder, symptoms must be present for at least one year. Antisocial
personality disorder, by definition, cannot be diagnosed at all in persons under 18.
Deb says:
 Reactionary, selfish, need impulse rapid gratification
 Make same mistakes over and over
 Accentuated in times of stress
 It’s who they are, they are more painful for others.
 Immature thinking.
 Arise in late childhood, sometimes fade in elderhood.
 See themselves as normal, the rest of the world is messed up.
 Hardest to treat. We’re using more Dialectical Behav. Therapy, and more meds are being used.
 High rates of drug abuse
List of personality disorders defined in the DSM
The DSM-IV lists ten personality disorders, grouped into three clusters. The DSM also contains a category
for behavioral patterns that do not match these ten disorders, but nevertheless exhibit characteristics of a
personality disorder. This category is labeled Personality Disorder NOS (Not Otherwise Specified).
Cluster A (odd or eccentric disorders)
 Paranoid personality disorder: paranoia characterized by a pervasive and long-standing
suspiciousness and generalized mistrust of others. Suspects, without sufficient basis, that others
are exploiting, harming, or deceiving him or her. Is preoccupied with unjustified doubts about the
loyalty or trustworthiness of friends or associates.
Deb say: high functioning. But very paranoid, they find the proof they’re looking for. Suspicious. Report
plots against them, sometimes belong to cults. Distort reality, labile of mood, chronic tension.
Pathologically jealous. suspiciousness
 Scan environment for evidence to support suspicions
 Report plots against them, disloyalty
 Cults or extremist organizations
 Argumentative, rigid, hypervigilant, distort reality
 Guarded and secretive
 Pathologic jealousy
RN interventions: be a little diverted, not to much direct eye contact. Don’t argue,
interpret what they say. Consider your safety, neutral, matter of fact, respectful
questions. Clear directions. Manage privacy and confidentiality. Make, and then
definitely keep a schedule. Avoid becoming the enemy. Begin by setting limits on how
long they can ramble about their paranoia
Schizoid personality disorder: lack of interest in social relationships, a tendency towards a solitary
lifestyle, secretiveness, and emotional coldness.[1] SPD is reasonably rare compared with other
personality disorders.
Deb Says:
o preference for isolation
o Rarely seen in clinical setting: more in the homeless pop.
o Flat or blunted affect
o Thoughts often vague due to self absorption
o Can hold job successfully is there is little social interaction
o Cold, aloof and indifferent
o Sometimes hard to differentiate from autism
RN interventions:
o Tell them where to get food
Schizotypal personality disorder: need for social isolation, odd behaviour and thinking, and often
unconventional beliefs.
Difference: schizoaffective [schizophrenia + mood d/o] that occurs in acute episodes.
o strange, eccentric, bizarre thought patterns, behavior and appearance
o Can have psychotic breaks
o Often have a major depressive disorder
o Superstitious, magical or grandiose beliefs
o Often have major depression over social deficits
o Become suspicious of others who don’t share their reality
o Cannot interpret interpersonal cues
o Often have relatives with schizophrenia
o Deb’s reference is that one crazy guy with the long white hair and pantyhose in the pool
and the sword in the cane in the MD’s office. And torture implements.
Nursing interventions for schizoid and schizotypal PD
 Need to make responsibilities simple and firm
 Less stressful topics are best; don’t irritate them
 Basic hygiene and supplies
 Nutrition counseling, get them services and access to food.
o
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Cluster B (dramatic, emotional, or erratic disorders): those personality disorders having in common
an excessive sense of self importance. High population in jails.
 Antisocial personality disorder: "The essential feature for the diagnosis is a pervasive pattern of
disregard for, and violation of, the rights of others that begins in childhood or early adolescence
and continues into adulthood."[1] Considered essential features of the disorder are deceit and
manipulation.” “Although antisocial personality disorder cannot be formally diagnosed before age
18, three markers for the disorder, known as the Macdonald triad, can be found in some children.
These are, a longer-than-usual period of bedwetting, cruelty to animals, and pyromania” The
DSM-IV confound: some argue that an important distinction has been lost by including both
sociopathy and psychopathy together under APD.
o Antisocial PD: predator
o Appears before 15 (called conduct d/o) but dx after 18
o Chronic indifference to, and violation of rights of others
o Most reliably dx’ed of all PD’s; often docs agree on the cluster
o Hx of illegal or socially disapproved activity beginning before 15
o Fail to show responsibility: financial, social, parenthood
o Irritability, aggressiveness and manipulative
o
o
o
o
o
o
o
o
o
o
o
o
o
Reckless and impulsive behavior
Disregard for the truth
Shallow emotions so able to ignore obligations through lack of love, loyalty and esp.
empathy—lack of guilt or empathy—out to get it all for me
No guilt – contempt for others
Poor judgment and failure to learn from experience
Can be pleasant, charming and convincing - used to manipulate, exploit—these guys will
not feel guilt for lying, and can often pass polygraphs because they feel no guilt.
Big splitting
Nursing interventions:
Clear conscise directions
Whole team does everything consistently
Immediate punishment/response for breaking rules
Point out defense mechanisms…in a group
Relaxation excercises
Borderline personality disorder: Disturbances suffered by those with borderline personality disorder are
wide-ranging. The general profile of the disorder typically includes a pervasive instability in mood,
extreme "black and white" thinking, or "splitting", chaotic and unstable interpersonal relationships, selfimage, identity, and behavior, as well as a disturbance in the individual's sense of self. In extreme cases,
this disturbance in the sense of self can lead to periods of dissociation
Four main characteristics: Fatal Attraction- good movie
1.
difficulty in establishing a secure self-identity – heavily dependent on relationships
devastated when relationship ends
a.
self eval ranges from grandiose to worthless; so low or super high esteem
b.
dichotomous thinking [all or nothing, black/white]
2.
distrust
a.
expect to be abandoned or victimized
b.
may idolize a friend one minute and attack them the next
c.
arrogant and challenging one minute and submissive and eager to please the next
3.
impulsive and self-destructive behavior
a.
manipulative suicide threats and attempts (but at hi risk for completion)
b.
drug abuse, reckless driving, promiscuity, fighting
c.
hx of intense, unstable and manipulative relations
4.
difficulty in controlling anger and other emotions
a.
in a state of perpetual emotional crisis
b.
difficulty managing anxiety
c.
rapid escalation of emotions to rage, despair and hopelessness
d.
unable to experience genuine empathy or guilt: Deb thinks it’s there but it’s hard to
access without help
o Drain on the friend/nurse
o Lack of secure self identity
o Likely to be abandoned or abused
o Often hx of physical and/or sexual abuse as child
o Can experience psychotic episodes. Some say this is the lack of formed identity, or that they
border on psychotic.
o Often encountered in the work place or socially
o Difficult to treat …hopefully that’s changing
o May create problems in therapeutic relationships
o Often accused of splitting
Nursing interventions
 Don’t get drained, don’t give too much, or feel guilty for not giving enough.
 Matter of fact but caring approach
 Among staff; be open about what the pt is being said, what’s happening on the unit,
use collaborative team
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 Dialectical therapy
 Don’t teach when pt is in a state of crisis
 Mindfulness therapy
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Histrionic personality disorder: is a personality disorder characterized by a pattern of excessive
emotionality and attention-seeking, including an excessive need for approval and inappropriate
seductiveness, usually beginning in early adulthood. These individuals are lively, dramatic,
enthusiastic, and flirtatious. They maybe easily influenced by others.
Histrionic PD – self dramatization & attention seeking
o Manipulative display of exaggerated emotions
o Believe they are sensitive; so do the people around them, for a short time. They later
realize the pt is shallow and attention seeking
o Fun loving gregarious people
o initially seen as warm and affectionate but rapidly become oppressively demanding
o taking without giving
o flirtatious and sexually provocative
o vain and immature, over-dependent and selfish
o constantly need love, reassurance and validation
o may act out in suicidal manner to manipulate others
Nursing interventions
 Less attention: remove the audience
 Don’t respond to sexual advances
 Teach safer sex practices
 Suicide assessment
 Teach assertiveness training: teach them to get what they want in a nonaggressive/dramatic way
 Don’t let them get out of responsibilities with their complaints. Most things are
below these people. Including holding their own babies.
Narcissistic personality disorder: "a pervasive pattern of grandiosity, need for admiration, and a
lack of empathy."
o Has a grandiose sense of self-importance
o has a sense of entitlement
o is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
o believes that he or she is "special" and unique
o requires excessive admiration
o is interpersonally exploitative
o lacks empathy
o is often envious of others or believes others are envious of him or her
o shows arrogant, haughty behaviors or attitudes
Narcissistic PD: grandiose sense of self-importance
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Can be very dangerous
Sense of entitlement, interpersonal manipulations, lack of empathy
Constantly check to see how they are regarded by others
Arrogant and egotistical
Exaggerate accomplishments and talents: “I’m like the only person in the world
who can see that this picture is off center”
react to criticism with rage or despair: underneath this is low self esteem
demand lots, affection, sympathy, favors, gifts, yet give little in return
given to exploitation
friends are picked for how they can profit the person; in terms of what that
person offers their image, how much that person compliments them.
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long hx of erratic interpersonal relationships – often these failures are what bring
them to therapy
Nursing interventions:
 Therapeutic relationship. If you critique their haughty manner, you won’t win, be caring with
them.
 These guys terminate therapy too early.
In 2005, psychologists Belinda Board and Katarina Fritzon at the University of Surrey, UK, interviewed
and gave personality tests to high-level British executives and compared their profiles with those of
criminal psychiatric patients at Broadmoor Hospital in the UK. They found that three out of eleven
personality disorders were actually more common in managers than in the disturbed criminals:
histrionic personality disorder: including superficial charm, insincerity, egocentricity and manipulation
narcissistic personality disorder: including grandiosity, self-focused lack of empathy for others,
exploitativeness and independence.
obsessive-compulsive personality disorder: including perfectionism, excessive devotion to work, rigidity,
stubbornness and dictatorial tendencies.
They described the business people as successful psychopaths and the criminals as unsuccessful
psychopaths
Cluster C (anxious or fearful disorders)
Avoidant personality disorder: or Anxious personality disorder is a personality disorder characterized by
a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation
and avoidance of social interaction. People with avoidant personality disorder often consider themselves to
be socially inept or personally unappealing, and avoid social interaction for fear of being ridiculed,
humiliated, or disliked. They typically present themselves as loners and report feeling a sense of alienation
from society.
Avoidant PD: social withdrawal out of fear of rejection
 Want to be loved (unlike A’s) but expect not to be so they avoid it
 Avoid relationships unless assured again and again of uncritical affection
 Watchful for any hint of disapproval – devastated if it occurs
 Overly sensitive to other’s opinions
 Exaggerate their own fears
 Painfully shy
 Devalue own achievements and appear serious, humorless and painfully shy
Nursing interventions
 Therapeutic relationship is hard b/c of shyness. No teasing, be gentle and reassuring.
 Use systematic desensitization for social situations.
 You can contract w/ pts to get social
Dependent personality disorder (not the same as Dysthymia: a mood disorder that falls within the
depression spectrum) pervasive psychological dependence on other people.
o
o
o
o
o
Has difficulty making everyday decisions without an excessive amount of advice and
reassurance from others
Needs others to assume responsibility for most major areas of his or her life
Has difficulty expressing disagreement with others because of fear of loss of support or
approval (this does not include realistic fears of retribution)
Has difficulty initiating projects or doing things on his or her own (because of a lack of
self-confidence in judgment or abilities rather than a lack of motivation or energy)
Goes to excessive lengths to obtain nurturance and support from others, to the point of
volunteering to do things that are unpleasant
o
o
o
Feels uncomfortable or helpless when alone because of exaggerated fears of being unable
to care for himself or herself
Urgently seeks another relationship as a source of care and support when a close
relationship ends
Is unrealistically preoccupied with fears of being left to take care of himself or herself
Dependent PD: pervasive, excessive and unrealistic need to be cared for
Believe they are incapable of surviving if left alone
Clingy and excessively submissive
Wants others to make decisions out of fear of retaliation or abandonment
Lack of self-confidence
Always agreeable and will volunteer to do unpleasant or demeaning things
Great need not to be alone because they feel helpless
Belittle their abilities and achievements
These pts care about their impact on others, but their idea of that impact is inaccurate
Easily hurt by disapproval and devastated when relationship ends
Nursing interventions
 Assist with reassurance and accurate validation of their own abilities.
 Feedback on behavior’s effect on others
 Responsibility for self care
 Assertiveness training for them
 Planning for goal setting, and social skills
Obsessive-compulsive personality disorder aka anankastic (not the same as Obsessive-compulsive
disorder): general psychological inflexibility, rigid conformity to rules and procedures, perfectionism,
moral code, and/or excessive orderliness. It’s not OCD: Those who are suffering from OCPD do not
generally feel the need to repeatedly perform ritualistic actions, a common symptom of OCD. Instead,
people with OCPD tend to stress perfectionism above all else, and feel anxious when they perceive that
things are not "right".
o
o
o
o
o
o
o
Preoccupation with details, rules, lists, order, organization, or schedules to the extent that
the major point of the activity is lost
Showing perfectionism that interferes with task completion (e.g., is unable to complete a
project because his or her own overly strict standards are not met)
Excessive devotion to work and productivity to the exclusion of leisure activities and
friendships (not accounted for by obvious economic necessity)
Being overconscientious, scrupulous, and inflexible about matters of morality, ethics, or
values (not accounted for by cultural or religious identification)
Reluctance to delegate tasks or to work with others unless they submit to exactly his or
her way of doing things
Adopting a miserly spending style toward both self and others; money is viewed as
something to be hoarded for future catastrophes
Shows rigidity and stubbornness
Obsessive compulsive PD – excessive preoccupation with trivial details
 Need to keep world predictable and organized
 Consumed with organizing, following rules, making lists and schedules, often
ceasing to be efficient
 Generally stiff and formal and incapable of genuine pleasure
 Can be mean partners
 Compulsions are milder but more pervasive than with OCD
 Rarely do well in jobs because too occupied with trivial details
 in interpersonal relationships regard themselves as all knowing and all powerful
 compromise is not acceptable
Nursing Interventions
 set goals to evalu
 check in on their satisfaction with life: perfectio leads them to disappointment
 Realistic future planning
 ID anx producing events
 Train them out of compulsive activities
 Journaling; can be an outlet and also for insight.
 Don’t encourage leisure activities
 Limit time spent on rituals, don’t paraphrase their speech
 Role model for social skills
Passive aggressive
Passive aggressive PD (or negativistic PD) – indirectly expressed resistance to for adequate
performance in social/occupational settings. Dawdling, forgetting, procrastination. Resistant and
negativistic behavior
Don’t openly refuse but covertly sabotage
Tend to have troubled marriages and spotty job records
A cover for underlying hostility
Habitually resent, oppose and resist demands to function at levels expected of others
Obstruct others efforts by failing to do their share of the work
Interventions: we don’t have
List of personality disorders defined in ICD-10 (F60-F69)
 (F60.) Specific personality disorders
 (F60.0) Paranoid personality disorder
 (F60.1) Schizoid personality disorder
 (F60.2) Dissocial personality disorder: Dissocial personality disorder is the diagnostic category
established for psychopathy in the ICD-10 diagnostic criteria developed by the World Health
Organization (WHO). It is conceptually similar to the DSM-IV-TR diagnostic criteria for
Antisocial personality disorder.[3]
 Antisocial personality disorder
 (F60.3) Emotionally unstable personality disorder
 Borderline personality disorder
 (F60.4) Histrionic personality disorder
 (F60.5) Anankastic personality disorder
 Obsessive-compulsive personality disorder
 (F60.6) Anxious (avoidant) personality disorder
 (F60.7) Dependent personality disorder
 (F60.8) Other specific personality disorders
Revisions and exclusions from past DSM editions
The revision of the previous edition of the DSM, DSM-III-R, also contained the Passive-Aggressive
Personality Disorder, the Self-Defeating Personality Disorder, and the Sadistic Personality Disorder.
Passive-Aggressive Personality Disorder is a pattern of negative attitudes and passive resistance in
interpersonal situations. Self-defeating personality disorder is characterised by behaviour that consequently
undermines the person's pleasure and goals. Sadistic Personality Disorder is a pervasive pattern of cruel,
demeaning, and aggressive behavior. These categories were removed in the current version of the DSM,
because it is questionable whether these are separate disorders. Passive-Aggressive Personality Disorder
and Depressive personality disorder were placed in an appendix of DSM-IV for research purposes.
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Solve problems in immature manner
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Painful for people in environment
Lack of ability to implement change as result of mistakes
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Over-reaction to stimuli
Long-term disability
Often with other disorders
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Inflexible and maladaptive responses to stress
Disability in working and loving
Interpersonal conflict
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Intense effect on others,
Among the most difficult to treat
High rates of substance abuse
Paranoid
Borderline
Antisoc
Schizoid
Dependent
Compulsive
Passive-aggressive
Commonly Sx from more than one category
Cluster A – odd/eccentric: schizoid, schizotypal, paranoid
Paranoid PD: suspiciousness
Scan environment for evidence to support suspicions
Report plots against them, disloyalty
Cults or extremist organizations
Argumentative, rigid, hypervigilant, distort reality
Guarded and secretive
Pathologic jealousy
Nursing interventions
Schizoid PD: preference for isolation
Rarely seen in clinical setting
Flat of blunted affect
Thoughts often vague due to self absorption
Can hold job successfully is there is little social interaction
Cold, aloof and indifferent
Sometimes hard to differentiate from autism
Schizotypal PD: strange, eccentric, bizarre thought patterns, behavior and appearance
Can have psychotic breaks
Often have a major depressive disorder
Superstitious, magical or grandiose beliefs
Often have major depression over social deficits
Become suspicious of others who don’t share their reality
Cannot interpret interpersonal cues
Often have relatives with schizophrenia
Nursing interventions for schizoid and schizotypal PD
Cluster B – dramatic/emotional
Antisocial PD: predator
Appears before 15 (called conduct d/o) but dx after 18
Chronic indifference to, and violation of rights of others
Most reliably dx of all PD’s
Hx of illegal or socially disapproved activity beginning before 15
Fail to show responsibility
Irritability, aggressiveness and manipulative
Reckless and impulsive behavior
Disregard for the truth
Shallow emotions so able to ignore obligations through lack of love, loyalty and esp. empathy
No guilt – contempt for others
Poor judgment and failure to learn from experience
Can be pleasant, charming and convincing - used to manipulate, exploit
Nursing interventions:
Borderline PD
Four main characteristics
1.
difficulty in establishing a secure self-identity – heavily dependent on relationships
devastated when relationship ends
a.
self eval ranges from grandiose to worthless
b.
dichotomous thinking
2.
distrust
a.
expect to be abandoned or victimized
b.
may idolize a friend one minute and attack them the next
c.
arrogant and challenging one minute and submissive and eager to please the next
3.
impulsive and self-destructive behavior
a.
manipulative suicide threats and attempts (but at hi risk for completion)
b.
drug abuse, reckless driving, promiscuity, fighting
c.
hx of intense, unstable and manipulative relations
4.
difficulty in controlling anger and other emotions
a.
in a state of perpetual emotional crisis
b.
difficulty managing anxiety
c.
rapid escalation of emotions to rage, despair and hopelessness
d.
unable to experience genuine empathy or guilt
Drain
Often hx of physical and/or sexual abuse as child
Can experience psychotic episodes
Often encountered in the work place or socially
Difficult to treat
May create problems in therapeutic relationships
Nursing interventions
Histrionic PD – self dramatization & attention seeking
Manipulative display of exaggerated emotions
Believe they are sensitive
initially seen as warm and affectionate but rapidly become oppressively demanding
taking without giving
flirtatious and sexually provocative
vain and immature, over-dependent and selfish
constantly need love, reassurance and validation
may act out in suicidal manner to manipulate others
Nursing interventions
Narcissistic PD: grandiose sense of self-importance
Sense of entitlement, interpersonal manipulations, lack of empathy
Constantly check to see how they are regarded by others
Arrogant and egotistical
Exaggerate accomplishments and talents
react to criticism with rage or despair
demand lots, affection, sympathy, favors yet give little in return
given to exploitation
friends are picked for how they can profit the person
long hx of erratic interpersonal relationships – often these failures are what bring them to therapy
Nursing interventions
Cluster C – anxious/fearful
Avoidant PD: social withdrawal out of fear of rejection
Want to be loved (unlike A’s) but expect not to be
Avoid relationships unless assured again and again of uncritical affection
Watchful for any hint of disapproval – devastated if it occurs
Overly sensitive to other’s opinions
Devalue own achievements and appear serious, humorless and painfully shy
Nursing interventions
Dependent PD: pervasive, excessive and unrealistic need to be cared for
Believe they are incapable of surviving if left alone
Clingy and excessively submissive
Wants others to make decisions out of fear of retaliation or abandonment
Lack of self-confidence
Always agreeable and will volunteer to do unpleasant or demeaning things
Great need not to be alone because they feel helpless
Belittle their abilities and achievements
Easily hurt by disapproval and devastated when relationship ends
Nursing interventions
Obsessive compulsive PD – excessive preoccupation with trivial details
Need to keep world predictable and organized
Consumed with organizing, following rules, making lists and schedules, often ceasing
to be efficient
Generally stiff and formal and incapable of genuine pleasure
Compulsions are milder but more pervasive than with OCD
Rarely do well in jobs because too occupied with trivial details
in interpersonal relationships regard themselves as all knowing and all powerful
compromise is not acceptable
Nursing Interventions
Passive aggressive PD (or negativistic PD) – indirectly expressed resistance
Don’t openly refuse but covertly sabotage
Tend to have troubled marriages and spotty job records
A cover for underlying hostility
Habitually resent, oppose and resist demands to function at levels expected of others
Obstruct others efforts by failing to do their share of the work
Difficulties are blamed on others, esp those in authority like boss, teacher, parent
Does not include behaviors in isolated situations where assertiveness is discouraged