anxiety, cognitive, somatoform, personality

8/7/2019 anxiety, cognitive, somatoform, personality

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Anxiety-Related

Disorders


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Primary gain refers to the

persons desire to relieve anxiety to

feel better and more secureSecondary gain refers to the

attention or support the person

derives from others because ofillness


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GENERALIZED

ANXIETYDISORDER


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DSM IV Criteria

Excessive worry and anxiety(6mos)

Difficulty in controlling the worry

Anxiety and worry are evident in 3 ormore of the ff:

Restlessness Decreased concentration

Fatigue Muscle tension

Irritability Disturbed sleep


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Interventions

Provide calm and quiet environmentAsk patients to identify how they feel

Encourage to discuss their feelings

Help them to identify possible causesof their feelings

Listen to patients expressions of

helplessness and hopelessnessAsk whether they have suicidal plans

Plan and involve them in activities


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Psychopharmacology

SSRIs and SSNRIs most effective for

treating GAD

Antidepressants are better thanbenzodiazepines because it has lesser

possibility for dependency and tolerance

Benzodiazepines are used in a short-term basis until the antidepressant

takes effect


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Milieu Management

Stress management

Problem-solving skills

Self-esteem, assertiveness, andgoal setting

Therapeutic touch

Acupressure


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2. Panic Disorder

Recurrent, unexpected panicattacks

Panic attacks followed by a monthor more of worry about havingadditional attacks, worry aboutthe results of the attacks, and

behavior changes related to theattacks

Panic disorder possibly

accompanied by agoraphobia


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Panic Disorder

displays 4 or more of the following

symptoms:

palpitations sweatingtremors shortness of breath

sense of suffocation chest pain

nausea abdominal distress

dizziness paresthesias

chills hot flashes


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Panic Disorder

the onset peaks in late adolescence and the

mid-30s

the memory of the panic attack coupled with

the fear of having more can lead to

avoidance behavior (aka agoraphobia) fearof the market place

TREATMENT: cognitive-behavioral

techniques, deep breathing and relaxation,medications such as benzodiazepines, SSRI,

TCAs and antihypertensives such as clonidine

(Catapres) and propanolol (Inderal)


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Interventions for Panic Attack

Stay with the patient andacknowledge the patients

discomfortMaintain a calm style and

demeanor

Speak in short, simple sentencesand give one direction at a time in a

calm tone of voice


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If the patient is hyperventilating,provide a brown paper bag and

focus on breathing with the patientAllow patient to pace or cry for

release of tension and energy

Communicate to patient that youare in control and that nothing willhappen to him


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Move patient to a quieter, less

stimulating environment. Avoid

touchingAsk patients to express their

perceptions or fears about what is

happening to them


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3. OBSESSIVE-COMPULSIVE

DISORDER

Obsessions recurrent, persistent,

intrusive and unwanted thoughts,

images, or impulses that cause marked

anxiety and interfere with interpersonal,

social or occupational function

Compulsi

ons ritualistic or repetitivebehaviors or mental acts that a person

carries out continuously in an attempt to

neutralize anxiety


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OCD

The theme of the ritual is associated withthe obsession.

Common compulsions include:

Checking rituals Counting ritualshoarding items Ordering

Washing until the skin is raw

Hoarding items Praying or chanting

Touching, rubbing or tapping

Exhibiting rigid performance


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OCD

OCD is diagnosed only when thesethoughts, images and impulsesconsume the person or he or she iscompelled to act out the behaviors to a

point that it interferes normal functioningOnset: starts in childhood, more

common in males. In females, it begins

in the twentiesTreatment: combination of medications

and behavior therapy


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Etiology

Genetic transmission

Increased brain activity in the

frontal lobe and the basal gangliaSerotonin dysregulation


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Interventions for OCD

Ensure that basic needs of food,rest, and grooming are met.

Provide patients with time toperform rituals

Explain expectations, routines and

changesBe empathetic toward patients and

be aware of their need to performrituals


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Assist patients with connecting

behaviors and feelings

Structure simple activities, games,or tasks for patients

Reinforce and recognize positive

nonritualistic behaviors


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Psychopharmacology

Clomipramine (Anafranil)

SSRIs: Prozac (fluoxetine)

Zoloft (sertraline)

Paxil (Luvox)


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PHOBIC DISORDERS

PHOBIA an illogical, intense,

persistent fear of a specific object or a

social situation that causes extreme

distress and interferes with normal

functioning

People with phobias understand that

their fear is unusual and irrational and

may even joke about how silly it is

but they feel powerless to stop it


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Flooding a form of rapid

desensitization in which a

behavioral therapist confronts theclient with the phobic object until it

no longer produces anxiety


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Etiology

Theories states that specific

individual, environmental, family

and genetic factors underlie phobicdisorders


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Interventions for Phobic Disorders

Accept patients and their fears with anoncritical attitude

Provide and involve patients inactivities that do not increase anxiety

but increase involvement

Help with physical safety and comfort

Help them recognize that theirbehavior is a method of avoidinganxiety


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POSTTRAUMATIC STRESS

DISORDER (PTSD)

This can occur in a person who has

witnessed an extraordinarily terrifying

and potentially deadly eventAfter the traumatic event, the person

re-experiences all or some of it

through dreams or wakingrecollections and responds

defensively to these flashbacks


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POSTTRAUMATIC STRESS

DISORDER

New behaviors develop related to

the trauma, such as sleep

difficulties, hypervigilance, thinking

difficulties, severe startle response

and agitation

Persons develop symptoms 3

months or more after the trauma


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ACUTE STRESS DISORDER

Similar to PTSD in that the personhas experienced a traumatic situation

but the response is more dissociative

The person has a sense that the

event was unreal, believes he or she

is unreal, and forgets some aspects

of the event through amnesia,

emotional detachment, and muddled

obliviousness to the environment


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Interventions for PTSD and ASD

Be nonjudgmental and honest; offerempathy and support

Assure patients that their feelingsare typical reactions to serioustrauma

Help them recognize theconnections between the traumaexperience and their currentfeelings


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SOMATOFORM

DISORDERS


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Somatization defined as thetransference of mental experiencesand states into bodily symptoms

Somatoform disorders characterized as the presence ofphysical symptoms that suggest a

medical condition without ademonstrable organic basis toaccount fully for them


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5 Specific Somatoform Disorders:

Somatization disorder

Conversion disorderPain disorder

Hypochondriasis

Body dysmorphic disorder


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Somatization disorder multiple

physical symptoms; begins by age

30, extends for several years,includes a combination of pain and

GI, sexual and pseudoneurologic

symptoms


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Conversion disorder aka

conversion reaction; involves

unexplained, usually suddendeficits in sensory or motor function

(blindness, paralysis)

The symptom often is determinedby the situation that produced it


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Pain disorder has the primary

physical symptom of pain, which

generally is unrelieved byanalgesics and greatly affected by

psychological factors in terms of

onset, severity, exacerbation andmaintenance


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Hypochondriasis preoccupation

with the fear that one has a serious

disease (disease conviction) or willget a serious disease (disease

phobia); preoccupation persists

despite medical evaluation andreassurance


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Body dysmorphic disorder

preoccupation with an imagined or

exaggerated defect in physicalappearance such as thinking ones

nose is too big, etc.


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Related disorders:

Malingering the intentionalproduction of false or grosslyexaggerated physical or

psychological symptoms; motivatedby external incentives such asavoiding work, evading criminal

prosecution, obtaining financialcompensation, or obtaining drugs.


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Factitious disorder occurs when a

person intentionally produces or feignsphysical or psychological symptomssolely to gain attention. They mayeven inflict injury on themselves toreceive attention.

Aka Munchausen syndrome

Munchausen syndrome by proxy aperson inflicts illness or injury onsomeone else to gain the attentionof emergency medical personnel or

to be a hero for saving the victim


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Etiology

Psychosocial Theories

People with somatoform disorders keep

anxiety, stress, or frustration insiderather than expressing them outwardly

(internalization)

Clients express these internalized

feelings and stress through physical

symptoms (somatization)

Both somatization and internalization

are unconscious defense mechanisms


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Biologic Theories

These clients cannot sort relevant

from irrelevant stimuli and respond

equally to both typesToo little inhibition of sensory input

amplifies awareness of physical

symptoms and exaggeratesresponse to bodily sensations


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Treatment

SSRIsPain management such as visual

imaging and relaxation

Physical therapy services tomaintain and build muscle tone to

help to improve functional abilities


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Interventions for Somatoform

DisordersUse a matter-of-fact, caring approach

when providing care for physical sx

Ask them to describe their feelingsAssist in developing more appropriate

ways to verbalize feelings and needs

Use positive reinforcement and setlimits by withdraw attention when they

focus on physical complaints


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Be consistent

Use diversion by including them inmilieu activities and recreational

games

Do not push awareness of or

insight into conflicts or problems


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DISSOCIATIVE

DISORDERS


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DISSOCIATION

The removal from conscious

awareness of painful feelings,

memories, thoughts or aspects ofidentity, is an unconscious defense

mechanism that protects the

individual from the emotional painthat have been repressed


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Criteria for Dissociative

DisordersDissociative amnesia loss of

memory of important personal

events that were traumatic or

stressful in events

Anterograde amnesia

Retrograde amnesia


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Dissociative fugue sudden,

unexpected travel away from home

or work with a loss of memoryabout the past; confusion about

identity or assumption of partial or

completely new identity is present


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Depersonalization experiences

of feeling detached from, or an

outside observer of, ones body ormental processes; reality testing is

intact


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Dissociative identity disorder

presence of 2 or more identities or

personalities (alters) that takecontrol of the persons behavior;

loss of memory for important

personal information


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Interventions

Establish trust and support

Gather data regarding feelings,

conflicts, or situations that patientsexperienced before the amnesia or

fugue state


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COGNITIVEDISORDERS


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The term cognition (Latin:cognoscere, "to know" or "torecognize") refers to a faculty for the

processing ofinformation, applyingknowledge, and changingpreferences. Cognition, or cognitiveprocesses, can be natural or artificial,

conscious or unconscious.


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MCI is a regression in cognition that is nota result of normal aging

The transitional zone between normal

aging and very probable early Alzheimersdisease for those who ultimately developthe disease

Of 80 patients with MCI, 27 (34%) develop

AD after 32 monthsForgetfulness is the hallmark behavior


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No meds. are specifically indicated for

MCI, but many clinical trial are under

way.

Antioxidants such as Vitamins C and E,

estrogen, ibuprofen, etc are being

tested


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The patient with MCI should stay active,

exercise at the appropriate level, eat a

well-balanced diet, curb alcohol

consumption, and stop tobacco usage

Challenging the brain with mental

exercises such as comparing and

contrasting is also therapeutic


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Literally means out of ones furrow,which refers to the dramatic behavioral

changes that the person might experience

Hallmark sign is its acuteonset, which iskey because the disorder rapidly develops

in most cases


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1. Disturbances of consciousness withreduced ability to focus, sustain, or

shift attention

2. Changes in cognition (memory deficit,disorientation, language disturbance,

perceptual disturbance)

3.D

evelopments over a short period oftime (hours to days) and with a

tendency to fluctuate during the

course of the day


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The development of multiple cognitivedeficits manifested by both

1. memory impairment

2. one or more of the ff. disturbances:A. aphasia language disturbance

B. apraxia motor disturbance

C. agnosia failure to recognizethings/objects

D. disturbance of executive functioning


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Charac-

teristics

DELIRIUM DEMENTIA

Onset Occurs quickly, is

obvious

Slow, unnoticeable

at first

ourse cute:ra i evt;

ours to ays,

ay last foront s

ronic: slow evt

over ont s an

years, eterioration-1 years until

eat


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Thought

content

Matches LOC Normal at first;

later might be

difficult to assessbecauseof

confusion, aphasia

and poverty of

content

Thought

process

Logical

alternating

illogical

Logical at first, then

loss of abstraction

Speech Slurred speech Normal speech


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Percep-

tual

differen-ces

Hallucinations

visual, tactile

Misidentification,

hallucinations at

the later stage

Mood Anxiety and fear Wide range offeelings

Affect Appears

bewildered,frightned

Appearance

matches feelings


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ALZHEIMERS DISEASE

Most prevalent form of dementia

Named after Alois Alzheimer, a

German neurologistThe course from onset to death of a

patient might exceed 10 years

Average life expectancy from onset ofdisease to death is 8 years


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Risk factors

Age

History of head injury

Lower levels of educationBeing female

Longevity

Smaller head size


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3 Stages of AD

Mild 2 to 3 years

Moderate 3 to 4 years

Severe 5 to 10 years

Page 450


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Etiology

Cholinergic hypothesis

- Decreased level of acetylcholine in

the brain Deposits of beta amyloid plaque

caused by an abnormality in DNA

cell death results fromoverabundance of these plaque

formations


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Classic Behaviors

Memory loss impairment ofST memory

occurs first

Word-finding difficulty

Misinterpreting the environment visual

hallucination in patients with visual

problems

Sundowning usually in the afternoon andearly evening the patient becomes more

agitated and less redirectable


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Nurse-Patient Relationship

Communication strategies

Scheduling strategies

Nutritional strategiesToileting strategies

Wandering strategies


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Personality

Disorders

Personality defined as an ingrained


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Personality defined as an ingrained

enduring pattern of behaving and relating

to self, others, and the environmentincludes perceptions, attitudes, and

emotions.

A person usually is not consciously awareof her or his personality.

Personality disorders are diagnosed when

personality traits become inflexible andmaladaptive and significantly interfere with

how a person functions in society or cause

the person emotional distress.


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Diagnosis is made when the person exhibits

enduring behavioral patterns that deviate

from cultural expectations in two or more ofthe following areas:

ways of perceiving and interpreting self, other

people, and events (cognition) range, intensity, lability and appropriateness

of emotional response (affect)

interpersonal functioning ability to control impulses or express

behavior at the appropriate time and place

(impulse control)


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Personality disorders are

longstanding because personalitycharacteristics do not change easily

No specific medication alters

personality, and therapy designedto help clients make changes is

often long term with very slow

progress


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Personality Disorder Categories

Cluster A: individuals whose

behavior appears odd or eccentric*paranoid

*schizoid

*schizotypal


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ClusterB: individuals who appear

dramatic, emotional or erratic

*antisocial*borderline

*histrionic

*narcissistic


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ClusterC: individuals who appear

anxious or fearful

*avoidant*dependent

*obsessive-compulsive


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ONSET AND CLINICAL COURSE

Occurs in 10%-13% of the general pop.

15% of all psychiatric inpatients have aprimary diagnosis of a personality disorder

30% to 50% occurrence in mental healthoutpatient settings

Higher death rate, related to suicide

Higher rates of suicide attempts,accidents, and ER visits, increased ratesof separation, divorce, etc


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70% to 85% of criminals.

60% to 70% of alcoholics70% to 90% of those who abuse

drugs

They are labeled as treatment

resistant

Persist throughout young and

middle adulthood but tend to

diminish in the forties and fifties


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Cluster A: Personality Disorders

PARANOID

Characterized by pervasive

mistrust and suspiciousness ofothers; they interpret others action

as potentially harmful

During periods of stress, they maydevelop transient psychotic

symptoms


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Incidence is 0.5% to 2.5% of the

general population; more

common in men than in women

People with this disorder do not

readily seek or remain in

treatment

Cli i l i t


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Clinical picture:

Clients appear aloof and withdrawnand may remain a considerable

physical distance from the nurse;

they view this as necessary for their

protection

They appear guarded or

hypervigilant; they may survey theroom and its contents, look behind

furniture or doors, and appear alert

to any impending danger


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They may choose to sit near the

door to have ready access to anexit or with their backs against the

wall to prevent anyone from

sneaking up behind them

They have a restricted affect and

may be unable to demonstrate

warm or empathic emotionalresponses


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Mood may be labile, quickly

changing from quietly suspicious toangry or hostile

Responses may be sarcastic

They spend disproportionate timeexamining and analyzing the

behavior and motives of others to

discover threatening meanings


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They use the defense mechanism

ofPROJECTION, blaming otherpeople, institutions, or events for

their difficulties.

Conflict with authority figures is

very common


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SCHIZOID PERSONALITY


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DISORDER

Characterized by a pervasive

pattern of detachment from social

relationships and a restricted rangeof emotional expression in

interpersonal settings

Occurs in 0.5% to 7% of thegeneral population; more common

in men than in women


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Clinical picture:

They display a constricted affectand little, if any, emotion; involved

with things more than people

They are aloof and indifferent,appearing emotionally cold,

uncaring, or unfeeling

They report no leisure orpleasurable activities because they

rarely experience enjoyment

There is a marked difficulty


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There is a marked difficulty

experiencing and expressing emotions

particularly anger and aggression

They usually have a rich and extensive

fantasy life, although they may be

reluctant to reveal that information toanyone else

Clients are generally accomplished

intellectually and often involved withcomputers or electronics in hobbies or

work


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Nursing interventions:

Focused on improving functioning

in the community

SCHIZOTYPAL


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SCHIZOTYPAL

Characterized by a pervasive patternof social and interpersonal deficits

marked by acute discomfort and

reduced capacity for closerelationships as well as by cognitive or

perceptual distortions and behavioral

eccentricitiesIncidence is about 3% to 5% of the

population; more common in men than

in women


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Client may experience transient

psychotic episodes in response toextreme stress

10% to 20% of people with

schizotypal personality disorderdevelop schizophrenia

Clinical picture:

Clients often have an oddappearance that causes others to

notice them

They can be unkempt, and their


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They can be unkempt, and their

clothes are often ill-fitting, do not

match and may be stained or dirty

They may wander aimlessly, and

become preoccupied with some

environment detail

Speech is coherent but may be loose,

or vagueEngage in odd thinking, speech, and

behavior, may ramble or use words

and phrases in unusual ways

They provide unsatisfactory answers


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ey p o de u sat s acto y a s e s

to questions and may be unable to

specify or to describe informationclearly

Cognitive distortions include ideas of

reference, magical thinking, odd belief

They experience great anxiety around

other people, especially those whoare unfamiliar

They only have one significant

relationship



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The focus of nursing care is ondevelopment of self-care and social

skills and improved functioning in

the communityEncourage to establish a daily

routine for hygiene and grooming

because stares or commentsregarding their hygiene can

increase discomfort


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Help them function in the

community with minimal

discomfort

Because face to face contact is

uncomfortable, clients may be

able to make written requests orto use the telephone for business

ANTISOCIAL


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ANTISOCIAL

Characterized by a pervasive pattern ofdisregard for and violation of the rights

of others and with the central

characteristics of deceit and

manipulation

Incidence is about 3% of the general

population and is 3-4 times more

common in men than in women

Peak in the 20s and diminish

significantly after 45 years of age

Assessment


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Assessment

History

Onset is in childhood or adolescence,

formal diagnosis is not made until the

client is 18 years of age

Childhood histories of enuresis,

sleepwalking, and acts of cruelty are

characteristic predictors

In adolescence lying, truancy,

vandalism, sexual promiscuity, and

substance use


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General appearance and motor

behavior

Appearance usually is normal;they may be quite engaging and

even charming

They may exhibit signs of mild ormoderate anxiety


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Thought Process and Content

Their view of the world is narrow

and distorted

They view the world as cold and

hostile and therefore rationalize

their behavior

They believe they must take care of

themselves because no one elsewill


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Sensorium and Intellectual Process

They are oriented, have no

sensory-perceptual alterationsand have average or above

average IQs

J d t d I i ht


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Judgment and Insight

They generally exercise poorjudgment

They pay no attention to the legality

of their actions and do not considermorals or ethics when making

decisions; seek immediate

gratification

Clients lack insight and almost

never see their actions as the

cause of their problems


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Self concept

Clients appear confident, self-

assured, and accomplished,

perhaps arrogant

They feel fearless, disregard their

own vulnerability and they believe

they can not be caught in lies,deceit, or illegal actions


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Roles and Relationships

Clients manipulate and exploit

those around them

They often are involved in many

relationships. They may marry and

have children but they can not

sustain long-term commitments


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Interventions

Forming a therapeutic relationshipand promoting responsible

behavior

Consistent limit setting in a matter-of-fact nonjudgmental manner is

crucial to success

Confrontation is a techniquedesigned to manage manipulative

or deceptive behavior

Helping clients solve problems and control


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emotions

Problem solving skills include identifyingthe problem, exploring alternative solutions

and related consequences, choosing and

implementing an alternative, and

evaluating the results

Encourage them to identify sources of

frustration, how they respond to it, and the

consequences Taking a time-out or leaving the area and

going to a neutral place to regain internal

control is often a helpful strategy

BORDERLINE


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BORDERLINE

Characterized by pervasive pattern

of unstable interpersonal

relationships, self-image and affect

as well as marked impulsivity

2% to 3% of the general population,

5 times more common in those withfirst-degree relative with the

diagnosis


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Most common personality disorder

found in clinical settings; 3 timesmore common in women than in

men

8% to 10% of people with thisdiagnosis commit suicide, and

many suffer permanent damage

from self-mutilation injuries such ascutting or burning

Clinical picture:


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Recurrent self-mutilation is a cry for help,

an expression of intense anger orhelplessness, or a form of self-punishment

The use of physical pain is also a means to

block emotional painWorking with these clients can be

frustrating

They may cling and ask for help oneminute and then become angry, act our,

and reject all offers of help in the next

minute

Assessment


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History

Disturbed early relationships with

parents that begin at 18 to 30 months of

age

Punitive responses from parents

50% have experienced childhood sexual

abuse, verbal or physical abuse and

parental alcoholism They use transitional objects extensively

that may continue until adulthood (pillows,

toys

General Appearance and Motor


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General Appearance and Motor

BehaviorMood is dysphoric, involving

unhappiness, restlessness and

malaise

Intense loneliness, boredom,

frustration, and feeling empty

May become irritable, even hostileor sarcastic and complain of

episodes of panic anxiety

Th ht P d C t t


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Thought Process and Content

Splitting thinking about self andothers is often polarized and

extreme

Chronic fears of abandonmenteven in normal situations

Under extreme stress, may develop

transient psychotic symptoms suchas delusions or hallucinations

S i d I t ll t l P


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Sensorium and Intellectual Process

Intact intellectual capacities, fullyoriented to reality

Many clients report flashbacks of

previous abuse or traumaThese experiences are consistent

with PTSD, which is common in

clients with borderline personalitydisorder


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R l d R l i hi


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Roles and Relationships

Unstable relationships, intenseand stormy

Extreme fears of abandonment

and difficulty believing arelationship still exists once the

person is away from them

History of poor school and work

performance

Interventions


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Interventions

Promote clients safetyPromote therapeutic relationship

Establish boundaries in

relationshipsTeach social skills

Maintaining personal boundaries

Realistic expectation of

relationships

Teach time restructuring


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Making written schedule of activities

Making a list of solitary activities to combatboredom

Teach self-management through cognitive

restructuring

Decatastrophizing

Thought stopping

Positive self-talk

Assertiveness techniques

Use of distraction such as walking or

listening to music

HISTRIONIC


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HISTRIONIC

Characterized by pervasive pattern of

excessive emotionality and attention

seeking

Occurs in 2% to 3% of the general

population and 10% to 15% of the

clinical population

Seen more often in women but men

usually seek treatment for depression

and difficulties in relationships

Clinical picture:


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p

Their speech is colorful, full of superlative

adjectives but lack details

Overall appearance is normal, although

sometimes they overdress

Overly concerned with impressing othersand spend much time, energy, and money

for this

Emotionally expressive, often exaggerateemotions inappropriately

He is the most wonderful guy. He has

changed my life.


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Rapid shifts in moods and emotions

Self-absorbed and focus most oftheir thinking on themselves with

little or no thought about the needsof others

Uncomfortable when they are not

the center of attention and go greatlengths when to gain that status



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g

The nurse gives clients feedback about

their social interactions with others,

including manner of dress and

nonverbal behavior

Discuss social situations to exploreclients perceptions of others reactions

and behavior

Teach social skillsExplore personal strengths and assets

and give specific feedback about

positive characteristics


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Clinical picture:


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p

Display an arrogant or haughtyattitude

Lack the ability to empathize with

others

Tend to belittle others

May express their grandiosity overtly

Preoccupied with fantasies ofunlimited success, power, brilliance

beauty and ideal love

Thought-processing is intact but


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Thought processing is intact but

insight is limited or poorThey view their problems as the fault

of others

Self-esteem is almost always fragileand vulnerable

Hypersensitive to criticism and need

constant attention and admiration



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Use self-awareness skills to avoid the

anger and frustration that these clientsbehavior and attitude can engender

Do not take the clients internalize or

take personally the clients criticismThe goal is to gain cooperation with

other treatments as indicated

Set limits on rude and verbally abusivebehavior and explain his expectations

of the client

AVOIDANT


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AVOIDANT

Characterized by a pervasive pattern of

social discomfort, low self-esteem and

hypersensitive to negative evaluation

Report being overly inhibited as childrenand they often avoid unfamiliar situations

Apt to be anxious and may fidget in chairs

and make poor eye contactReluctant to ask questions and make

requests

Appear sad as well as anxious


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Appear sad as well as anxious

Have very low self-esteem, believethemselves to be inferior

Reluctant to do anything as risky for

they are afraid to make mistakes, behumiliated or be embarrassed

Wish for possible closeness and

intimacy but fear possible rejectionand humiliation


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g

They require much support andreassurance from the nurse

Help them to explore positive self-

aspects, positive responses from

others and possible reason for self-

criticism

Reframing and decatastrophizing can

enhance self-worth

The nurse must be careful and be

patient with them

DEPENDENT


147/152

Pervasive and excessive need to be

taken care of, which leads to clinging

and submissive behavior and fears of

separation

Occurs in 15% of the population; 3

times more common in women

Most common in youngest children

They seek treatment for anxious,

depressed or somatic symptoms

Frequently anxious and


148/152

Frequently anxious and

uncomfortable

Pessimistic and self-critical, easily

hurt

Report feeling unhappy or depressed;believe they would fail on their own

Difficulty in making decisions no

matter how minorDifficulty initiating projects or

completing simple daily tasks

They need someone else to assume


149/152

responsibility for them

Their motto is any relationship is

better than none at all


Help to express feelings of grief

and loss over the end of a

relationship

Cognitive restructuring techniques

such as reframing and

decatastrophizing


150/152

Difficulty expressing emotions, and


151/152

when they do express, they are rigid,

stiff, formal and lack spontaneity

Preoccupied with orderliness and

maintain that in all areas of life

Check and recheck details of any

project or activity

Consider and reconsider alternatives

and the desire for perfection prevents

reaching a decision

Have low self-esteem and are always


152/152

harsh, critical, and judgmental of

themselves

Difficulty in relationships, few friends

and little social life


Help clients to tolerate or accept

less-than-perfect work

Cognitive restructuring techniques

anxiety, cognitive, somatoform, personality

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