13. Personality disorders

Personality traits are patterns of behavior that reflect how people perceive, relate to, and think about themselves and their environments. These traits enable people to navigate their environments and adjust to social and personal stressors. It's only when personality traits become rigid, self-defeating, or maladaptive and cause serious impairment or anxiety that they are considered personality disorders.

With a personality disorder, one s internal experience and behaviors are noted to differ markedly from the norms of one's culture. According to the DSM-IV diagnostic criteria, a problematic pattern is displayed in two or more of the following areas: cognition, affectivity, interpersonal functioning, and impulse control. This pattern results in distress with social, occupational, or general functioning. Impairment is usually manifested in activities of daily living because dysfunctional behavior is the vehicle used to relate to others and to fulfill basic needs. (For further information, see Personality Clusters.)

Cluster A Personality Disorders

DSM-IV CATEGORIES

301.0 Paranoid personality disorder

301.20 Schizoid personality disorder

301.22 Schizotypal personality disorder

PARANOID PERSONALITY DISORDER

The basic feature of paranoid personality disorder is a pervasive mistrust and suspicion of other people. There's constant preoccupation with the idea that others will play tricks, exploit, or inflict harm. People with the disorder are on guard for ever-present dangers perceived to be all around them. They're secretive, hypersensitive, jealous, argumentative, and aggressive. Difficulties seem exaggerated, criticism isn't well accepted, and the insults and injuries that these people sustain are never forgiven. Their interactions are noted to be highly critical, rigid, defensive, cold and uncompromising. Others find them excessively objective, to the exclusion of emotion. They make those around them feel uncomfortable in social situations, and they lack a sense of humor. Because people with this personality disorder are inclined to avoid intimate relationships and demonstrate exaggerated self-importance and self-sufficiency, they're often lonely. They have difficulty accepting others in positions of authority or power, and relationships with peers and coworkers are frequently nonexistent. Paranoid personality disorder is seen most often in men.

PERSONALITY CLUSTERS
The three main clusters ol personality disorders according to the DSM IV are listed below.
	Cluster A	Cluster B	Cluster C
Characteristics	Odd or eccentric behavior	Dramatic, emotinal or erratic behaviors	Anxious or fearful behaviors
Disorders	Paranoid Schizoid Schizotypal	Antisocial Borderline Histronic Narcissistic	Avoidant Dependant

SCHIZOID PERSONALITY DISORDER

The basic features of schizoid personality disorder are indifference to interpersonal relationships and an inability to experience a normal range of emotions. People with this disorder have no desire for and don't derive pleasure from social interactions, preferring to engage in solitary activities. They're considered loners with no need for intimacy either inside or outside the family. There's little or no interest in having a sexual relationship with another person. Clients with schizoid personality disorder are often viewed as being shy, aloof and self-centered. Neither accolades nor criticism from others has meaning for them. They can’t experience or express strong emotions, such as happiness and anger. They manifest a flat affect and appear emotionally stilted or cold to other people. Because of impaired social skills and an introverted lifestyle, they experience difficulty with occupations that require interpersonal contact but may succeed at those that rely mostly on mechanical or abstract reasoning skills. Schizoid personality disorder is seen in both women and men.

SCHIZOTYPAL PERSONALITY DISORDER

The basic features of schizoid personality disorder are a reduced capacity for interpersonal relationships and cognitive and perceptual distortions that lead to oddities in speech, behavior, and appearance. People with this disorder have symptoms similar to those of schizophrenia, but the symptoms aren't severe enough to warrant diagnosis of schizophrenia. The problems of relating to other people begin early in adulthood. There's a disturbance in perception and thought content manifested by paranoid ideation, suspicion, magical thinking, and ideas of reference (the belief that the casual speech or acts of others have unusual meaning when, in fact, they don't). People with this disorder demonstrate odd thinking, strange mannerisms, speech peculiarities, and a disheveled and eccentric appearance. They often experience unusual perceptual experiences, such as hearing a voice calling to them. Their thoughts are often vague or inappropriately expressed, and they periodically talk to themselves. In social settings, these people are unable to display a range of typical emotions and can't recognize and respond to usual social cues. Even being in familiar situations generates social anxiety, which is associated with mistrust about the motivations of others. If placed in extremely stressful circumstances, they may briefly experience psychotic symptoms. There's a tendency toward social isolation

Scientists believe that personality disorders are caused by a combination of psychosocial, situational, and biological components. In schizotypal personality disorder, the biological findings are similar to those in schizophrenia (for example, neurotransmitter abnormalities and abnormalities in frontal and limbic systems. cortical regions, and straitum). (See chapter 6, Schizophrenia and other Psychotic Disorders.) Clients also manifest characteristic impairment in information processing and abnormal eye movements.

COMMUNICATION STRATEGIES - FOR CLIENTS WITH CLUSTER A PERSONALITY DISORDERS

• Make statements that reinforce reality.
• Limit discussion to concrete, familiar topics.
• Use clear, simple messages to prevent misinterpretation of words or phrases.
• Resist trying to provide logic to counteract the client's inappropriate statements or behaviors because a power struggle may ensue in which the client works vehemently to defend himself
• Maintain a non-defensive position when the client verbalizes anger or makes hostile comments.
• Discuss non-controversial topics, avoiding such issues as religion and politics.
• Don't use humor.
• Acknowledge the practical difficulties, such as the occupational impairment and lack of friendships, that the client experiences as a result of the disorder.
• Acknowledge the client's pain and fears.
• Don't focus on the interaction of distorted perceptions because pointing out these perceptions may generate paranoid fears.
• Offer gentle reassurance when perceptions are frightening.
• Don't touch the client. If touch is necessary, ask the client's permission because touch may be misinterpreted as physical or sexual assault.
• Accept the client's positive and negative feelings, and acknowledge that emotions can be painful.
• Help the client redirect energy in appropriate ways.

NURSING DIAGNOSIS: INEFFECTIVE INDIVIDUAL COPING

Probable Causes	Defining Characteristics
Situational or maturational crises Lack of a support system Unmet needs or expectations Dysfunctional family of origin	Eccentric behaviors Anxiety Rigid adherence to known routines Inability to make decisions

Long-Term Goal The client will demonstrate behaviors that lead to resolution of identified problems.

Short-Term Goal #1: The client will discuss problems with his current life situation.

Interventions and Rationales

• Help the client identify problems and areas of concern. It's important that the client's perspective be understood and what is perceived as stressful be clearly identified.
• Encourage the client to identify problems without labeling himself or others as good or bad. Clients must learn how to appraise problems realistically rather than taking a defensive position.
• Have the client talk about needs that aren't being met, and help the client decide which are most important. When clients decide which of their needs are most important, they are more likely to change their behavior to meet those needs.

Short-Term Goal #2: The client will explore coping skills and work to develop appropriate solutions to problems.

Interventions and Rationales

• Help the client identify behaviors that are helpful in handling problematic situations, such as naming a problem correctly and refraining from labeling himself or others as good or bad. Identification of strengths enhances self-esteem and allows the client to build on established coping skills.
• Help the client identify behaviors that are inappropriate for dealing with identified problems. The client needs to identify behaviors that escalate problems and contribute to dysfunctional coping.
• Help the client identify the coping strategies that are normality used to handle problems. These clients have a limited repertoire of coping skills.
• Teach the client and provide opportunities to practice problem-solving, social, and communication skills. Knowledge and comfort in the ability to use these skills increase the likelihood that the client will use them.

NURSING DIAGNOSIS: IMPAIRED SOCIAL INTERACTION

Probable Causes	Defining Characteristics
Lack of relationship with early caretaker Chaotic family relationships Under developed ego Absence of parental role	Immature behaviors and feelings Verbalization of inadequacy Disruptive speech Odd behaviors, such as going models to great lengths to prove a point and being guarded or secretive around others

Long-Term Goal The client will interact with people and become involved in both social and therapeutic activities.

Short-Term Goal #1: The client will identify and discuss feelings that impede social interactions.

Interventions and Rationales

• Encourage the client to express thoughts and feelings about social interactions with others. To control inappropriate social behaviors, the client needs to be aware of thoughts and feelings that precede the behaviors.
• Identify and discuss appropriate rules for behavior. By exploring rules for behavior, the client can begin to compare personal behavior with what is considered socially acceptable and identify areas of concern.
• Have the client talk about feelings related to social rules. Examining feelings associated with social rules enables the client to identify personal concerns about being accepted.
• Help the client assess behavior that impairs socialization. Identifying inappropriate behavior is the first step toward changing it.
• Have the client discuss social situations that are uncomfortable. Discussions about uncomfortable situations can facilitate understanding of the client's concerns, leading to identification of strategies for handling these situations.
• Help the client identify negative behaviors that interfere with the development of mutually satisfying relationships. Clients need to develop an awareness of how their unacceptable behaviors impact on others and prevent relationships from being established.

Short-Term Goal #2: The client will begin to participate in both social and therapeutic activities.

Interventions and Rationales

• Help the client develop a daily schedule that includes participating in activities and interacting with others. The client benefits from a schedule because it prevents procrastination and can decrease the anxiety about becoming involved in therapeutic and social interactions and activities.
• Instruct and help the client practice strategies that facilitate the development of social skills. The client needs to learn and practice social skills to gain comfort with them.
• Encourage the client to establish a schedule of group activities. such as support groups, group therapy, games, sports, and volunteer work, in which interactions with others will occur. Engaging in these activities can decrease isolation and provide opportunities for developing social skills and other useful behaviors.
• Provide the client with feedback about social skills, focusing or, reinforcing progress and working on areas that need improvement. Feedback is essential for reinforcing positive change.

THERAPIES

It is unlikely that clients will pursue therapy because they are usually unaware of the features of the personality disorder. If help is obtained, it's often sought only when the client experiences a mood disorder, anxiety disorder, or dissociative symptoms as the result of a significant stressor, such as divorce, bereavement trauma, and occupational loss. These clients don't usually remain in therapy for long. The overall purpose of therapy is to establish a helping relationship that provides support and guidance in social situations and relationships.

Individual Therapy

• Work to establish a rapport with the client.
• Establish a trust relationship.
• Encourage the client to learn and practice decision making.
• Provide support, and work to keep the client functioning comfortably.
• Help the client develop appropriate interpersonal skills and break the rigid and inflexible pattern of self-defeating behaviors.
• Refer to social and occupational rehabilitation as necessary.

MEDICATIONS

• Medications such as phenothiazines may be used for clients who are fearful or anxious.
• Antidepressants, such as tricyclics, serotonin reuptake inhibitors, and monoamine oxidase inhibitors, are used to treat depression.
• Low-dose neuroleptic agents are used to treat delusions, ideas of reference, and anxiety and cognitive symptoms in clients with schizotypal personality disorder. (See Appendix D for medication information.)

FAMILY CARE

• Explain to family members the characteristics of the personality disorder and how to manage the eccentric behavior.
• Encourage the family to help the client take care of physical needs because the client may not focus on self-care.
• Discuss how to facilitate the client's social needs because the client tends to restrict interactions and daily activities.
• Work with the family to aid the client with decision making.

Cluster B Personality Disorders

DSM-IV CATEGORIES

301.7 Antisocial personality disorder

301.83 Borderline personality disorder

301.50 Histrionic personality disorder

301.81 Narcissistic personality disorder

ANTISOCIAL PERSONALITY DISORDER

The primary features of antisocial personality disorder are irresponsible and asocial behavior, including disregard for the rights of others. These behaviors begin during childhood or early adolescence and persist into adult life. To be diagnosed with antisocial personality disorder, clients must be at least 18 years old and have a history of conduct disorder before age 15. Some typical behaviors during childhood are truancy, stealing, vandalism, running away, substance abuse, fist fights, weapons, use arson, cruelty and brutality to people and animals, and sexual aggression. Adults with antisocial personality disorder are irritable, aggressive, and reckless and seek immediate gratification. They act out by abusing others, stealing, destroying property, getting into debt, and engaging in criminal behaviors. Often, these inappropriate actions are preludes to confrontation with law enforcement agencies. Although people with antisocial personality disorder may be superficially charming, they have a blatant disregard for the truth, fail to conform to social norms, have no feelings of remorse or regret, and often express justification for mistreating others. The deceitful and manipulative behaviors are consistently used to secure pleasure, power, or profit.

BORDERLINE PERSONALITY DISORDER

The primary feature of borderline personality disorder is a marked instability in interpersonal relationships, self-concept, and mood as a reaction to the fear of real or imagined abandonment. Clients may experience transient paranoid ideation or severe dissociative symptoms during periods of intense stress. There's an alteration between the extreme positions of idealizing other people and devaluing them. This defense mechanism is known as splitting.

People with this disorder are impulsive, reckless, and cognitively impaired: they act out in self-destructive ways, such as shoplifting, self-abuse, and binge eating. In the clinical setting they can present as extremely anxious, unstable, angry, impulsive, and destructive of themselves and others. Many clients perform self-mutilating actions and have recurrent suicidal thoughts or behaviors. The dramatic behaviors may be for the purpose of manipulating others, or they may result from intense anger or extreme stress.

HISTRIONIC PERSONALLY DISORDER

The major characteristic of histrionic personality disorder is excessively dramatic, attention-seeking behavior that begins early in the adult years. People with this disorder have a driving need to be the center of attention and become uncomfortable when they aren't in this position, regardless of whether this is appropriate for the situation. These clients also display exaggerated emotional responses and overreaction to minor frustrations and annoyances. Their opinions are dramatically expressed without rationale or supportive information. People with histrionic personalities are self-absorbed, often exhibiting temper tantrums when immediate gratification of their needs doesn't occur. They're unable to have successful relationships because they are inconsiderate, dependent, and controlling. They exhibit superficial and rapidly shifting emotional expression. People with histrionic personalities may have difficulty forming a lasting sexual partnership because they may resort to sexually provocative behavior with occupational colleagues or social acquaintances in order to be the center of attention. Even in casual, everyday contact with others, clients with histrionic personality disorder create situations so that they're competing with people of the same sex and seducing people of the opposite sex.

NARCISSISTIC PERSONALITY DISORDER

The key characteristic of narcissistic personality disorder is an exaggerated sense of self-importance. There's a powerful feeling of entitlement and a desire for special attention and constant admiration. People with this disorder overrate their own talents arc accomplishments, are arrogant, and exploit others for the purpose of meeting their personal goals. They're preoccupied with, dreams of success, power, wealth, brilliance, physical appeal, and ideal love. Because these clients believe that they're special they think that they can only be understood or appreciated by other unique individuals. Typically, they believe that others are envious of them, and they can easily become envious of others. Interpersonal relationships are fraught with difficulty because friendships are often formed with the goal of exploiting the other person. There's also a limited ability to be warm, genuine, or empathetic. This disorder occurs in both women and men, but it's much more prevalent in men.

Recent neurobiological research has found evidence of abnormalities in serotonin and dopamine levels in clients with antisocial and borderline personality disorders. Low serotonin levels ha\ e been associated with high levels of aggression and impulsiveness Excessive dopamine levels resulting from impaired metabolism of this chemical also occurs in people with border-line and antisocial personality disorders. The significance of this finding is undetermined. EEC studies disclose abnormal wave patterns in the frontal and temporal lobes in people with borderline personality disorder.

COMMUNICATION STRATEGIES FOR CLIENTS WITH CLUSTER B PERSONALITY DISORDERS

• Do not argue, bargain, or rationalize.
• Remain calm, and refrain from responding emotionally to provocation or manipulation by the client.
• Communicate expectations to the client.
• Avoid power struggles by enforcing rules and limits consistently and by refusing to respond to manipulative behavior.
• Help the client identify personal strengths.
• Have the client focus on thoughts and feelings behind self-destructive actions.
• Demonstrate consistent, serious interest in the client's concerns, even when the client is unable to demonstrate adequate concern.
• Confront inappropriate behavior that may be initiated by fear or misunderstanding of external events.
• Confront the client about inappropriate, attention-seeking behavior.
• When confronted with the client's excessive emotionality, refrain from mirroring the emotions. Be compassionately objective.
• Give positive feedback whenever the client reduces or eliminates attention-seeking behavior or appearance.
• Help the client identify and address the issues behind strong feelings.
• Help the client stay focused on the topic of discussion.
• Interpret the use of rationalization to explain problems.
• Point out when the client is condescending.
• Discuss the client's attitude of superiority.
• Help the client deal with feelings of humiliation.
• Explore ways to tolerate anxiety.

NURSING DIAGNOSIS: RISK FOR VIOLENCE, SELF-DIRECTED OR DIRECTED AT OTHERS

Probable Causes	Defining Characteristics
History of family violence Strong hostile or angry feelings Low self-esteem History of thwarted attempts to meet basic needs History of violent behavior toward self or others	Aggressive body language Hostile verbalizations Self-mutilation behavior Suicidal thoughts or behaviors Possession of weapons or other implements of harm

Long-Term Goal The client will report the absence of self-destructive thoughts and behaviors.

Short-Term Goal #1: The client will verbalize the desire to hurt himself or others rather than actually doing it.

Interventions and Rationales

• Construct a safe environment by removing all potentially dangerous items from the client and surroundings. Safety is the first priority for a client with destructive tendencies.
• Make the client's environment quiet and non-stimulating. A quiet, non-stimulating environment decreases the client's aggressive behavior.
• Encourage the client to verbalize aggressive feelings. Verbalizing angry feelings helps the client get in touch with painful situations.
• Help the client discover the origin of the anger and pain. Often. the aggressive person displaces negative feelings into unrelated situations rather than feeling conscious anger at a real previous injury.
• Have the client formulate a contract in which the nurse or other mental health professional is informed of the desire to act out destructively. A contract helps the client handle feelings of being out of control and diminishes the tendency to engage in vioient behavior toward self or others.
• Help the client identify persona] speech habits and behavior that usually accompany anger and escalating anxiety. Identification of cues of distress can serve as a warning mechanism for preventing the client from acting out, thus facilitating prompt nursing intervention.

Short-Term Goal #2: The client will learn to express strong feelings in a nondestructive manner.

Interventions and Rationales

• Talk with the client about appropriate ways to handle frustration and anger, such as channeling energy into socially acceptable activities. Social activities provide outlets for energy and car. help relieve the client's distress.
• Encourage the client to write about distressful situations and feelings in a daily journal. Recording daily events can help the client see the relationship among feelings, behaviors, and unresolvec issues.
• Help the client develop strategies for handling the identified external and internal cues that promote aggressive or destructive behaviors. The development of coping strategies gives the client c sense of self-control and mastery over negative feelings.
• Help the client recognize circumstances that led to destructive behavior in the past and plan different ways to handle similar situations. The client needs assistance in the form of a workab.e plan to break the cycle of destructive behavior.
• Teach the client coping skills, such as stress-reduction techniques, negotiation skills, and ways to appropriately communicate anger. Using effective coping skills decreases the likelihood of the client's resorting to violent behaviors.

NURSING DIAGNOSIS: SELF-ESTEEM DISTURBANCE

Probable Causes	Defining Characteristics
Dysfunctional family History of negative messages about self from Severe anxiety or depression History of abandonment or rejection	Negative self-talk Self-destructive behaviors Rationalization of negative or inappropriate behavior Lack of close interpersonal relationships

Long-Term Goal The client will verbalize a positive view of self and be able to identify past accomplishments and future goals.

Short-Term Goal #1: The client will express feelings and fears.

Interventions and Rationales

• Encourage the client to talk about situations that evoke uncomfortable feelings. Acknowledging negative feelings or unresolved problems can help the client deal with issues of concern.
• Encourage the client to discuss fear of failure and aspects of himself that are thought to be undesirable. Self-exploration can provide insight into problematic areas and identify unresolved issues from the past.
• Encourage the client to develop specific plans to change dysfunctional behavior or solve problems. The client may have limited ability to formulate strategies for changing dysfunctional behaviors or may not be able to see alternate ways of solving problems without assistance.
• Help the client establish plans for handling specific situations that evoke negative feelings or fear of failure. With situational planning for new tasks, the client can see that actions can be taken to yield positive consequences.

Short-Term Goal #2: The client will identify and discuss positive aspects of self

Interventions and Rationales

• Encourage the client to look at strengths, past accomplishments, and future potential. Identification of positive aspects of self begins to build self-esteem.
• Have the client establish and work toward realistic goals. Goal attainment enhances self-confidence. Encouraging the client to discover which goals are unrealistic avoids the loss of self-esteem that occurs when these goals aren’t reached.
• Have the client make decisions and use problem-solving skills on stressors or other issues of concern. The client needs to practice handling problems to see progress in his own abilities.
• Suggest that the client keep a journal about daily experiences and identify the feelings related to those experiences. Keeping a journal helps the client see repeating patterns that can be altered and also helps in problem solving stressful situations.

THERAPIES

Clients with cluster B personality disorders usually don't engage in therapy for their primary disorder unless their behaviors (substance abuse, self-mutilation) cause difficulties that mandate treatment. Clients may also seek treatment for accompanying affective symptoms, such as depression, anxiety, and transient stress-related dissociation. These clients are poorly motivated.

Individual Therapy

• Build a trust relationship.
• Develop with the client a plan for safety that prevents the client from acting on aggressive thoughts and impulses.
• Work with the client to stop self-destructive behaviors by helping the client identify triggers for harmful behaviors.
• Establish a structured plan of care that focuses on consistency of behavior.
• Role-play with client’s ways to appropriately ask for help from others.
• Work with the client to see the consequences of unacceptable behaviors.
• Help the client establish and use a system of support.
• Help the client develop skills for social adaptation.

MEDICATIONS

Drugs are used only to manage clinical symptoms. Many clients with antisocial or borderline personality disorders become addicted to medications.

• If the client displays hostility, severe disorganization, or paranoid thinking or has periods of psychotic thinking, antipsychotic drugs may be ordered.
• For severe depression, antidepressant medications, such as the tricyclics, serotonin reuptake inhibitors, and monoamine oxidase inhibitors, may be ordered.
• If a client has bipolar characteristics, lithium may be given. (See Appendix D for medication information.)

FAMILY CARE

• Explain to family members the characteristics of the personality disorder and how to manage the antisocial, dramatic, or emotional behavior. Alert family members that brief periods of psychotic behavior may occur.
• Discuss how the family dynamics may facilitate or encourage negative client behavior, and formulate a plan to stop reinforcing inappropriate client behavior.
• Work with the family to assist the client in social situations because social skills and judgment may be severely limited.
• Explore with the family methods for handling the client's anxiety, low tolerance for frustration, tendency to self-mutilate, exaggerated sense of self and low self-esteem.
• Engage the family in developing strategies for coping with the client's escalating anxiety to prevent the client from using self-destructive behaviors as an outlet for stress.
• Refer to the Family Care section in chapter 5, Substance-Related Disorders, if substance abuse management is needed.

Cluster C Personality Disorders

DSM-IV CATEGORIES

301.82 Avoidant personality disorder

301.6 Dependent personality disorder

301.4 Obsessive-compulsive personality disorder

AVOIDANT PERSONALITY DISORDER

The primary features of avoidant personality disorder are pervasive and repetitive feelings of social discomfort, repetitive feelings of inadequacy in social situations, timid behavior, and abnormal acute sensitivity to criticism. Any remarks or behavior by others that are suggestive of disapproval are automatically interpreted as rejection. An overwhelming fear of non acceptance, disapproval, or rejection causes a strong hesitancy to enter into relationships; hence, people with this disorder usually have no significant others except immediate family members. This personality disorder affects both men and women equally.

DEPENDENT PERSONALITY DISORDER

The primary features of dependent personality disorder are a pervasive and excessive need to be taken care of by others and submissive, clinging behavior toward those people perceived to be the source of care. Clients with dependent personality disorder demonstrate a consistent submissive pattern of allowing others to make decisions for them and run their lives. This over reliance on other people prevents them from accomplishing tasks on their own. They are unable to make everyday decisions without an excessive amount of guidance and reassurance. Dependent personalities are uncomfortable when left alone; they become preoccupied with fear of abandonment or the fear of having to take care of themselves. Criticism by others hurts them severely, yet they frequently agree with the critics, especially if the critic is also the caregiver. The disorder is more frequently diagnosed in women than in men.

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

The main feature of obsessive-compulsive personality disorder is the person's preoccupation with rules, regulations, and perfection. Inflexible adherence to rules and order permeates all tasks and goals at the expense of flexibility and spontaneity. The person's perfectionism often interferes with completing the task. Frequently, no matter how perfectly detailed an accomplishment is, the person with this disorder believes that the result isn't good enough and continues to look for ways to improve it. Typically, this person is focused on work and goal attainment to the exclusion of friendships and leisure activities. Men are more commonly affected with obsessive-compulsive personality disorder than are women.

COMMUNICATION STRATEGIES FOR CLIENTS WITH CLUSTER C PERSONALITY DISORDERS

• Encourage the client to examine the consequences of self-induced social isolation.
• Help the client explore how misinterpretation of the ordinary remarks and actions of others is often viewed as criticism.
• Discuss and role-model assertive behaviors.
• Encourage the client to recognize depression, loneliness, or anxiety, which may be present due to lack of self-confidence and fear of being left alone to care for himself.
• Work with the client on expressing feelings.
• Encourage the client to recall and discuss past participation in spontaneous relaxation activities or unplanned tasks in which there were no rules or standards of achievement.
• Help the client focus on feelings to decrease the usual preoccupation on details.
• Talk to the client about a plan to help decrease the time interval between the compulsive behaviors.
• Discuss with the client how to be flexible.
• Have the client explore ways to have fun.

NURSING DIAGNOSIS: SOCIAL ISOLATION

Probable Causes	Defining Characteristics
Dysfunctional family history Low self-esteem History of physical or mental illness for social contact Communication difficulties	Observable discomfort with other people Withdrawal from opportunities Inability to communicate in social situations Refusal to make eye contact

Long-Term Goal The client will demonstrate the skills necessary to develop and sustain interpersonal relationships.

Short-Term Goal #1: The client will verbalize an understanding of the skills needed for developing relationships.

Interventions and Rationales

• Have the client explore personal feelings and insecurities about interacting with others. The client must be able to identify and discuss negative feelings to change the thoughts and behaviors associated with them.
• Help the client examine past relationships and evaluate how isolationist behavior may have led to loneliness and lack of social support. Once the client understands the consequences of isolating social behavior, the client can choose to change that behavior.
• Help the client recognize current social skills and patterns of socializing with others. Recognition of positive behaviors can occur as well as identification of areas in need of change.
• Encourage the client to identify the difference between consistent self-esteem and self-care and relying on others for approval or care. Clients need to identify situations in which they abandon self-esteem and self-care and allow others to assume control over them.
• Encourage the client to identify interactions in which the need for care and approval leads to exploitation or manipulation of others. Exploitation and manipulation of others become less attractive when clients discover that they can assume control over their own lives.

Short-Term Goal #2: The client will make social contact with at least one person and interact on a regular basis.

Interventions and Rationales

• Establish a mutually acceptable time and place for interacting with the client when evaluation and feedback can be given on social skills. Practice and feedback on performance can enhance skills already mastered and provide opportunities to learn new skills.
• Help the client set up brief interaction opportunities that are non-threatening. The client is more at ease practicing social skills in an environment that's nonthreatening.
• Offer reassurance, and stay near the client during initial interactions with others. The nurse s presence promotes feelings of security and support during early attempts at interacting with others.
• As the client's comfort level increases, have the client become involved in activities that are longer in duration, progressing to simple social group interactions. As the client experiences success with socializing, it's essential to build on these successes and introduce group interactions.

NURSING DIAGNOSIS: DEFENSIVE COPING

Probable Causes	Defining Characteristics
Dysfunctional family History of abuse No role model or no experience with expressing feelings History of few or no relationships	Use of rationalization to explain dysfunctional behavior Projection of blame or responsibility for problems Sensitivity to criticism Inability to ask for assistance

Long-Term Goal The client will verbalize a realistic assessment of life situations and ask for assistance to solve problems as needed.

Short-Term Goal #1: The client will identify personal feelings and behaviors that occur in threatening situations.

Interventions and Rationales

• Ask the client to discuss personal feelings about stressful or threatening events. Identification of feelings enables the client to get in touch with threats to self-esteem.
• Have the client identify personal, familial, or social expectations and determine whether these expectations are realistic. Unrealistic expectations can decrease self-esteem and force the client to resort to defensive coping.
• Have the client explore the need to be either perfect or right about things. Exploring perfectionistic tendencies enables the client to see how unrealistic standards of performance can lead to the experience of inner stress and dysfunctional behaviors.
• Encourage the client to identify personal beliefs and feelings that prevent asking for assistance with particularly stressful issues. This intervention allows the client to develop awareness of uncomfortable feelings and begin to examine how to overcome resistance to requesting assistance with problems.

Short-Term Goal #2: The client will learn and practice healthy coping strategies.

Interventions and Rationales

• Work with the client to assess and evaluate current coping skills. Evaluation of coping skills enables the client to identify ma.-adaptive coping patterns.
• Help the client understand how defensive coping behaviors, such as denial of problems, projection of blame, and inability to seek help, interfere with the ability to meet his own needs. The client is more able to give up defensive coping when he realizes that it's harmful to self and others.
• Teach the client how to communicate in a clear and direct manner and to talk about stressors, feelings, and fears. The client needs to practice and develop comfort with verbalizing inner thoughts, feelings, and fears about himself.
• Work with the client to learn and practice decision-making skills. Making decisions can enhance self-esteem and a sense of personal control.
• Encourage the client to pursue humor-related diversions, such as viewing comedic films. Humor can decrease the seriousness of situations and enable the client to let go of some of the tension associated with the stressor.

THERAPIES

Clients with cluster C personality disorders are typically unaware that their frequent feelings of anxiety and fear are caused by the inflexible behavior patterns of a personality disorder. When clients do enter therapy, it's often for relief of mood or anxiety disorders that arise as a response to unusual stress in the client’s life.

Individual Therapy

• Recognize signs and symptoms of anxiety and use strategies to effectively manage stress.
• Work with the client to build a strong sense of self
• Examine the level of self-care that the client can perform, and work with the client to increase responsibility for self.
• Have the client identify inappropriate defense mechanisms and focus on developing adaptive coping strategies for handling anxiety, anger, and other emotions.
• Help the client recognize and eliminate unrealistic expectations of self or others and negative thinking patterns.
• Formulate a plan to deal with the client's potential for loneliness or isolation from others.
• Teach the client social, communication, assertiveness, and problem-solving skills.
• Encourage the client to take time for self and to develop activities for leisure time.

MEDICATIONS

• Antianxiety medications are useful for the anxious client.
• Clomipramine (Anafranil) or fluoxetine (Prozac) may be used for the client with an obsessive-compulsive personality disorder. (See Appendix D for medication information.)

FAMILY CARE

• Explain to family members the characteristics of the personality disorder and how to manage the anxious and fearful behavior.
• Help the family evaluate rules and roles that reinforce dysfunctional client behaviors.
• Work with the family to develop alternative coping strategies to handle stress.
• Encourage family members to learn or enhance their level of communication skills.
• Focus on identification and appropriate expression of both positive and negative feelings.
• Reevaluate expectations to ensure that they're realistic and promote health in family members.