PERSONALITY DISORDERS

Tuesday, May 14, 2024 11:03 AM

- Can be defined as an ingrained enduring pattern of behaving and relating to self, others, and the
environment.
- Personality includes:perceptions, attitudes, and emotions.
- These behaviors and characteristics are consistent across a broad range of situations and do not
change easily.
- A person usually is not consciously aware of her or his personality. Many factors influence
personality : some stem from biologic,and genetic make up,whereas some are acquired as a
person develops and interacts,with the environment and other people.

AMERICAN PSYCHIATRIC ASSOCIATION (APA)

- lists personality disorders as a separate and distinct category of other major mental illnesses.
They are on AXIS II of the multi axial classsification system,The DSM IV-TR classifies personality
disorders into “clusters” or categories, based on the predominant or identifying features

CLUSTER A
- includes people whose behavior appears odd or eccentric and includes, paranoid, schizoid ,and
schizotypal personality disorders.

CLUSTER B
- includes people who appear dramatic, emotional, or erratic and includes antisocial, borderline,
histrionic, and narcissistic personality disorders.

CLUSTER C
- includes people who appear anxious or fearful and includes avoidant, dependent, and obsessive,
compulsive personality disorders.
- In psychiatric settings nurses most often encounter clients with antisocial and borderline
personality disorders. Clients with antisocial personality disorders may enter a psychiatric setting
as part of court ordered evaluation or as an alternative to jail. Clients with borderline personality
disorders often are hospitalized because their emotional instability may lead to self-inflicted
injuries. Two disorders currently being studied for inclusion as personality disorders are
depressive and passive aggressive personality disorders both of which are included in the DSMR-
IV-TR. Diagnostic and Statistical Manual of Mental Disorders 9th [Link] Revision:American
Psychiatric Association(APA,2020)

DSMR-IV-TR PERSONALITY DISORDER CATEGORIES

- CLUSTER A
○ Individuals whose behavior appears odd or eccentric (paranoid, schizoid,and schizotypal
personality disorders)
- CLUSTER B
○ Individuals who appear dramatic, emotional, or erratic (antisocial, borderline, histrionic,
and narcissistic personality disorders.
- CLUSTER C
- Individuals who appear anxious or fearful (avoidant, dependent, and obsessive, dependent,
and obsessive-compulsive personality disorders)
Proposed Personality disorder categories: depressive and passive- aggressive personality
disorders.

DSM-IV-TR DIAGNOSTIC CRITERIA SYMPTOMS OF ANTISOCIAL PERSONALITY DISORDER

1. Violation of the rights of others

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 1. Violation of the rights of others
2. Lack of remorse of his behavior.
3. shallow emotions
4. Lying
5. rationalization of own behavior
6. poor judgment
7. Impulsivity
8. irritability and aggressiveness
9. lack of insight
10. thrill-seeking behaviors
11. exploitation of people in relationship
12. poor work history
13. consistent irresponsibility

- People with antisocial personality disorder generally do not seek treatment voluntarily unless they
perceive some personal gain from doing so.
- Example:A client may choose atreatment setting as an alternative to jail or to gain sympathy
from an employer; they may cite stress as a reason for absenteeism or poor performance.
Inpatient treatment settings are not necessarily effective for these clients , and may infact,bring
out their worst qualities.

NURSING DIAGNOSES
- Ineffective Coping
- Ineffective Role Performance
- Risk for Other-Directed Violence

DSM-IV-TR DIAGNOSTIC CRITERIA SYMPTOMS OF BORDERLINE PERSONALITY DISORDER

1. Fear of abandonement
2. Unstable and intensive relationships
3. Unstable self-image
4. Impulsivity and recklessness
5. recurrent-self mutilating behavior or suicidal threats or gestures.
6. Chronic feelings of emptiness and boredom
7. Labile mood
8. Irritability
9. Polarized thinking about self and others (“spitting”)
10. Impaired judgment
11. Lack of insight
12. Transient psychotic symptoms such as hallucinations demanding self-harm

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CLUSTER A
- ODD OR ECCENTRIC
A. SCHIZOID PERSONALITY DISORDER
i. characterized by inability to form close relationship
ii. Social determent/solitary life
iii. Aloof and indifferent
iv. Restricted expression of emotion
v. Lack interest in others
B. SCHIZOTYPAL PERSONALITY DISORDER
i. characterized by/exhibit abnormal/ unusual thoughts, perception, speech, behavior
patterns.
ii. Suspicious
iii. Paranoid
iv. Magical Thinking
v. Odd thinking/speech
vi. Relationship deficits
C. PARANOID PERSONALITY DISORDER
i. Characterized by suspiciousness, mistrust of others.
ii. Argumentative
iii. Holistic aloofness
iv. Rigid critical, controlling of others
v. Grandiosity

CLUSTER B
- ERRATIC & DRAMATIC
A. HISTRIONIC PERSONALITY DISORDER
i. characterized by dramatic, intensely expressive.
ii. Enjoys being the center of attention
iii. Poor interpersonal relationship
iv. Romantic fantasies and control of partners.
v. Easily bored
vi. Displays dependency
B. NARCISSISTIC PERSONALITY DISORDER
i. characterized by increased sense of self-importance

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 i. characterized by increased sense of self-importance
ii. Preoccupied with fantasies/unlimited success/ constant need for attention and
admiration.
iii. Grandiosity/inflate accomplishments
iv. Lacks empathy /sensitivity to others needs
C. ANTISOCIAL PERSONALITY DISORDER
i. characterized by unresponsible and anti to delay gratification-social behavior.
ii. self-centered , inability to maintain relationships.
iii. Poor sexual adjustment/inability to delay gratification
iv. Aggressive, impulsive, manipulative
v. poor judgment
vi. Conflict with authority
vii. Poor work history
viii. Failure to handle responsibility
▪ NURSING DIAGNOSIS
□ Ineffective coping r/t inability to form valid
□ appraisal of stressors, inability to use available resources.
▪ EXPECTED OUTCOMES
□ The client will:
 Immediate-Not harm self/others
 Identify behaviors leading to hospitalization
 Functions within limits of therapeutic milieu
□ Stabilization
 Demonstrate nondestructive urge to deal with stress and frustrations.
 Identify ways to to meet own needs that do not infringe on the rights of
others.
□ Community
 Achieve, maintain satisfactory work preference
 Meet own needs without exploiting or infringing on the rights of others
▪ INTERVENTION
□ Provide model for mature appropriate behavior.
□ Observe limit setting technique by all staff.
□ Be consistent and firm with care plan essential.
□ Demonstrate success/interest.
□ Reinforce positive behavior (socialization conforming to limits).
□ Avoid power struggles
D. BORDERLINE PERSONALITY DISORDER
i. Characterized by unstable interpersonal relationships.
ii. impulsive/unpredictable behavior.
iii. Chronic feeling of emptiness.
iv. Extreme shifts in mood/depression.
v. Easily bored/argumentative .
vi. Self destructive behavior.
vii. Splitting, manipulation.
viii. Inability to tolerate anxiety.
▪ NURSING DIAGNOSIS
□ Risk for Self-Mutilation- related to impulsive behavior ; displays temper.
□ Inability to express verbally, physically self-damaging acts, Attention seeking
behavior. Ineffective coping skills.
□ Ineffective coping related to inability to form invalid appraisal of stressors;
inability to use available resources
□ Social Isolation related to chronic feelings of boredom/emptiness.; Manipulation
of others ;alternate clinging/avoidance behavior
▪ EXPECTED OUTCOMES:

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 ▪ EXPECTED OUTCOMES:
□ The client will:
 Immediate: Be free from immediate injury;Not harm others or destroy
property; Diminish efforts to manipulate staff or other clients(splitting
behaviors).
□ Stabilization:
 Eliminate acting -out behaviors
 Verbalization of plans to moderate lifestyle.
 Community: Demonstrate effective problem-solving ; Develop social
support outside hospital
▪ NURSING INTERVENTION:
□ Protect from Self-mutilation
□ Establish therapeutic relationship
□ Calm approach
□ Set Limits
□ Consistent staff/planning
□ Prevent client from manipulating other clients/visitors.
□ Teach relaxation techniques.
E. PASSIVE AGGRESSIVE PERSONALUTY DISORDER
i. characterized by passively expresses covert aggression rather than dealing with it
directly.
ii. Procrastinator
iii. Stubborn
iv. Intentional inefficiency
v. Forgetfulness
vi. Dependency

CLUSTER C
- ANXIOUS AND FEARFUL
A. AVOIDANT PERSONALITY DISORDER
i. characterized by social withdrawal
ii. hypersensitive to rejection/criticism
iii. Feels inadequate
iv. Social Inhibition
v. Lack support system
B. OBSESSIVE COMPULSIVE DISORDER
i. need to control others
ii. difficulty expressing warmth/tenderness
iii. Reflects perfectionism/devoted to work
iv. overly conscientious /inflexible
v. Lack support system
vi. Preoccupied with details
vii. May hoard worthless objects
C. DEPENDENT PERSONALITY DISORDER
i. characterized by lack of self confidence
ii. fear independence /lack autonomy
iii. Passively allows others to make decisions and assume responsibility for other areas
of their life.
iv. cannot tolerate being alone
v. needs others to make decisions

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ECT
Tuesday, May 14, 2024 11:41 AM

HISTORY
- Paracelsus – 1500s – oral camphor given to induce seizures to treat psychiatric illness
- Camphor convulsive therapy – late 1700s to mid-1800s
- Ladislaus von Meduna: the brains of epileptic patients have a greater number of glial cells and
schizophrenic patients had fewer
○ 1934 – first catatonic patient was successfully treated with IM injections of camphor oi
- Lucio Bini and Ugo Cerletti – electricity to produce seizures ○ 1938 – first ECT given to a delusional
and incoherent patient – improved after 1 treatment, remission after 11 treatments
○ 1940s – total shift from chemical induction to electrical induction
- Became the treatment for drug-resistant psychiatric disorders and in cases of life threatening
illness due to severe suicidal symptoms, or catatonia
- 1980’s to 1990-’s ensured uniformly high standards of practice

CURRENTLY
- Work is being done on the underlying mechanisms and biological characteristics of effective ECT
treatments
- 100,000 patients receive the treatment
- Still stigmatized – Paul Greengard has suggested the use of the term electrocortical therapy
- Much safer today

ECT
- Procedure done under general anesthesia
- small electric currents are passed through the brain to trigger brief seizure intentionally
- Believed to cause changes in brain chemistry reversing symptoms of certain mental health
conditions
- Seen to be highly effective and safe, even life saving

INDICATIONS
- Major diagnostic indications
○ Major depression, especially if suicidal or refusing to eat
▪ Psychotic depression in particular
▪ Treatment resistant depression
○ Severe Mania
○ Schizophrenia, with acute exacerbation
▪ Catatonic subtype
▪ Schizoaffective disorder
▪ Other diagnostic indications
□ Parkinson’s disease
□ Neuroleptic malignant disorder
- PRIMARY USE CLINICAL INDICATIONS
○ Rapid definitive response required on medical or psychiatric grounds
○ Risks of alternative treatments outweigh the benefits
○ Past history of poor response to psychotropics or good response to ECT
○ Patient preference
- SECONDARY USE CLINICAL INDICATIONS
○ Failure to respond to pharmacotherapy in the current episode
○ Intolerance of pharmacotherapy in the current episode
Rapid definitive response necessitated by deterioration of the patient’s condition

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 ○ Rapid definitive response necessitated by deterioration of the patient’s condition

CONTRAINDICATIONS
- No absolute contraindications
- MI in the past 6 months
- Aneurysm
- Recent cerebral infarction
- Increased intracranial pressure
- Pregnancy is not a contraindication

MECHANISM OF ACTION
- ECT affects the cellular mechanisms of memory and mood regulation
- Clue to mechanism (neurochemical): Focus on changes in neurotransmitter receptors and second-
messenger systems
- All neurotransmitters systems are affected by ECT
- Best effect from high-intensity, bilateral stimulation
- Weakest effect from low-intensity, unilateral stimulation
- Exact mechanism of action is still unknown

CLINICAL GUIDELINES
- Informed-consent procedures must be documented in the patient’s medical records
- Use printed literature and videotapes to help with obtaining consent
- Pretreatment evaluation
○ Standard physical, neurological, and pre-anesthesia examinations, with complete medical
history
○ Lab evaluations: blood and urine chemistries, a chest x-ray, and ECG
○ Dental exam for elderly patients, and patients with inadequate dental care
○ X-ray of spine if with evidence of spinal disorder
○ CT/MRI if seizure disorder or space-occupying lesion is suspected (not an absolute
contraindication anymore but ECT must be done by expert)
- Concomitant Medications
○ Interactions with induction of a seizure
○ For effects on seizure threshold (e.g. lithium)
○ TCAs, MAOIs, and antipsychotics generally acceptable
- Withdraw
○ Benzodiazapines (they are anticonvulsants!)
○ Clozapine and bupropion – associated with late-appearing seizures
- Lidocaine – decrease threshold, decrease seizure duration
- Theophylline is CONTRAINDICATED – increases duration of seizures

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CLINICAL GUIDELINES - PREMEDICATIONS
- Premedications, Anesthetics, and Muscle Relaxants
○ NPO 6 hours prior to treatment
○ Check for dentures
○ Insert IV line
○ Use a bite block
○ 100% O2 is administered at 5lpm during procedure until spontaneous respiration returns
○ Ready with emergency airway
- Muscarinic Anticholinergic Drugs – given to reduce secretions and to block bradycardias and
asystoles
○ Usually atropine: 0.3 – 0.6 mg per IM or SC 30-60 minutes prior to anesthetic OR 0.4 to
1.0mg IV 2-3 minutes prior to anesthetic
- GA and oxygenation required
- Should be as light as possible to minimize adverse effects and avoid elevating seizure threshold
- Options:
○ Methohexital (0.75-1.0mg/kg IV bolus)
○ Thiopental (2-3mg/kg IV)
○ Etomidate (0.15-0.3mg/kg IV)

CLINICAL GUIDELINES - MONITORING SEIZURES

- Must have an objective measure that a seizure has occurred
- A good seizure lasts at least 25 seconds
- Failure to induce seizures
○ Up to 4 attempts at seizure induction
○ May be delayed by 20-30 seconds
○ Check skin placement
○ Change anesthetic agent
○ Hyperventilation or administration of caffeine sodium benzoate 5-10 minutes before the
stimulus can lower the seizure threshold

CLINICAL GUIDELINES - NUMBER AND SPACING

- 2-3 times a week
- MDD – 6-12 treatments (up to 20 sessions possible)
- Manic episodes – 8-20 treatments
- Schizophrenia – >15 treatments
- Catatonia and delirium – 1-4 treatments
- Treatment should be continued until maximal therapeutic response is achieved (as determined by
the patient)

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RISKS AND SIDE EFFECTS
- Impairment and Cognition
○ Period of Confusion immediately after ECT May not know where you are or why you are
there Generally lasts few minutes to several hours
- Memory Loss
○ May forget weeks/months before treatment, during treatment, or after treatment has
stopped Usually improves within couple of months Permanent in relatively rare cases
- Medical complications
○ Heart problems
○ Small risk of death (same as other procedures using anesthesia)
- Physical Symptoms
○ Nausea
○ Vomiting
○ Headache
○ Muscle
○ Ache
○ Jaw pain
○ Memory loss

MORTALITY
- 1/10000 (according to American Psychiatric Association Guidelines)
- Death is usually from CV complications in patients with previous pre-morbids

NURSING CARE IN ECT

- Providing educational and emotional support
○ Explain procedure, informed consent, educate the patient, respond to concerns and feelings
- Pre-Treatment Planning and Assessment
○ Complete pre-treatment checklist, check identity, safekeep valuables, NPO for min of 4
hours, hygiene, remove dentures, pass urine
- Preparing and monitoring patients during actual procedure
○ Apply electrodes, BP cuff, pulse oximeter, restraint, prepare shoulder and arms, apply
mouthguard and jelly to electrodes, administer oxygen, take note of convulsions, suctioning
- Post treatment care and evaluation
○ Observe and record vs, place pt on side lying position, clean secretions, transfer pt to
recovery room, reorientation, DOCUMENT PROCEDURE

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PERSONALITY DISORDERS
Tuesday, May 14, 2024 12:05 PM

- are diagnosed when personality traits becomes inflexible and maladaptive and significantly
interfere with how a person functions in society or cause the person emotional distress.
- With Personality Disorder, a person experiences thoughts that diminish his/her abiltiy to face and
adapt to stress, connect and bond with other people and effectively solve problems

CLUSTER A
- ODD, ECCENTRIC, "WEIRD", MAD
○ PARANOID PERSONALITY DISORDER
▪ SUSPECT (4 CRITERIA)
□ S: Spouse fidelity suspected
□ U: Unforgiving (bears grudges)
□ P: Perceives attacks (and reacts quickly)
□ E: “Enemy or friend (suspects associates, friends)
□ C: Confiding in others feared
□ T: Threats perceived in benign events
○ SCHIZOID PERSONALITY DISORDER
▪ DISTANT (4 CRITERIA)
□ D: Detached or flattened affect
□ I: Indifferent to criticism and praise
□ S: Sexual experiences of little interest
□ T: Task (activities) done solitarily
□ A: Absence of close friends
□ N: Neither desires nor enjoys close relations
□ T: Takes pleasures in few activities
○ SCHIZOTYPAL PERSONALITY DISORDER
▪ ME PECULIAR (5 CRITERIA)
□ M: Magical thinking or odd beliefs
□ E: Experiences unusual perceptions
□ P: Paranoid ideation
□ E: Eccentric behaviour or appearance
□ C Constricted (or inappropriate) affect
□ U: Unusual (odd)thinking and speech
□ L: Lacks close friends
□ I: Ideas of reference

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 □ I: Ideas of reference
□ A: Anxiety in social situations
□ R: Rule out psychotic disorders and pervasive developmental disorder

CLUSTER B
- DRAMATIC, EMOTIONAL, ERRATIC, WILD, BAD
○ ANTISOCIAL PERSONALITY DISORDER
▪ CORRUPT (3 CRITERIA)
□ C: Conformity to law lacking
□ O: Obligations ignored
□ R: Reckless disregard for safety of self or others
□ R: Remorse lacking
□ U: Underhanded (deceitful, lies, cons others)
□ P: Planning insufficient (impulsive
□ T: Temper (irritable and aggressive)
▪ There is evidence of conduct disorder with onset before age 15 years
▪ Conduct Disorder- TRAP
□ T: Theft: Breaking and entering (B&E), deceiving, non - confrontational stealing
□ R: Rule Breaking- running awar , skipping school , out late
□ A: Aggression: people. animals. weapons, forced sex
□ P: Property Destruction
○ BORDERLINE PERSONALITY DISORDER
▪ AM SUICIDE (5 CRITERIA)
□ A: Abandonment
□ M: Mood instability (marked reactivity of mood)
□ S: Suicidal (or self-mutilation) behaviour
□ U: Unstable and intense relationship
□ I: Impulsitivity (in two potentially self- damaging areas)
□ C: Control of anger
□ I: Identity disturbance
□ D: Dissociative (or paranoid) symptoms that are transient and stress- related
□ E: Emptiness (Chronic feelings of)
○ HISTRIONIC PERSONALITY DISORDER
▪ PRAISE ME (5 CRITERIA)
□ P: Provocative (or sexually seductive)behavior
□ R: Relationships (considered more intimate than they are)
□ A: Attention (uncomfortable when not the center of attention)
□ I: Influenced easily
□ S: Style of speech (impressionistic, lacks detail)
□ E: Emotions (rapidly shifting and shallow)
□ M: Made up (physical appearance used to draw attention to self)
□ E: Emotions exaggerated (theatrical)
○ NARCISSISTIC PERSONALITY DISORDER
▪ SPECIAL (5 CRITERIA)
□ S: Special (believes he or she is special and unique)
□ P: Preoccupied with fantasies (of unlimited success, power, brilliance, beauty, or
ideal love)
□ E: Entitlement
□ C: Conceited (grandiose sense of self- importance)
□ I: Interpersonal exploitation
□ A: Arrogant (haughty)
□ L: Lacks empathy

CLUSTER C

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CLUSTER C
- ANXIOUS, FEARFUL, WORRIED, SAD
○ AVOIDANT
▪ CRINGES (4 CRITERIA)
□ C: Certainty (of being liked required before willing to get involved with others)
□ R: Rejection (or criticism) preoccupies one’s thoughts in social situations
□ I: Intimate relationships (restraint in intimate relationships due to fear of being
shamed)
□ N: New interpersonal relationships (is inhibited in)
□ G: Gets around occupational activity (involving significant interpersonal contact)
□ E: Embarassment (potential) prevents new activity or taking personal risks
□ S: Self viewed as unappealing, inept, or inferior
○ DEPENDENT
▪ RELIANCE (5 CRITERIA)
□ R: Reassurance required for decisions
□ E: Expressing disagreement difficult (due to fear of loss of support or approval)
□ L: Life responsibilities (needs to have these assumed by others)
□ I: Initiating projects difficult (due to lack of self-confidence)
□ A: Alone (feels helpless and discomfort when alone)
□ N: Nurturance (goes to excessive lengths to obtain nurturance and support)
□ C: Companionship (another relationship) sought urgently when close
relationship ends
□ E: Exaggerated fears of being left to care for self
○ OCPD
▪ LAW FIRMS (4 CRITERIA)
□ L: Loses point of activity (due to preoccupation with detail)
□ A: Ability to complete tasks (compromised by perfectionism)
□ W: Worthless objects (unable to discard)
□ F: Friendships (and leisure activities) excluded (due to a preoccupation with
work)
□ I: Inflexible , scrupulous , overconscientious (on ethics, values, or morality not
accounted for by religion or culture)
□ R: Reluctant to delegate (unless others submit to exact guidelines)
□ M: Miserly (toward self and others)
□ S: Stubbornness (and rigidity)

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ATTITUDE THERAPY
Tuesday, May 14, 2024 12:21 PM

- Attitude indicates a set of feelings, faith, and behaviour toward an individual or incident.
- A person’s attitude comprises of their beliefs, emotions and behaviors towards an object, person,
thing or event.
- Attitudes can be shaped by one’s experiences and upbringing.
Attitude represents our personality. If we show negative attitude towards others, it will express
the harmful nature of the individuals.
- The attitude of others towards us shows the behavior or action.
- Attitude therapy is an approach to psychological care that focuses on changing the way a person
thinks about a situation or issue. It is based on the idea that our thoughts, feelings and behaviors
are all affected by our attitudes and beliefs.
- The goal of attitude therapy is to help individuals recognize and replace negative thoughts and
beliefs with more positive ones.
- Attitude therapy has been used to treat a wide range of psychological conditions, including
depression, anxiety, post-traumatic stress disorder, and substance abuse. It is also used to address
issues such as self-esteem, communication skills, and interpersonal relationships
- Attitude therapy can be used in individual or group settings and may involve cognitive-behavioral
techniques, such as relaxation techniques, guided imagery, and positive self-talk.
- Attitude therapy is prescribed the designed therapeutic attitude that every individual should have.
- The patient is interviewed to assess his emotional and psychological state and activity level
- Before the therapy, family members address the attitude therapy they are using for the patient
that same you have to apply for the patient to bring the desired changes into the patient.
- A staff meeting is held when all mental health team members are present.
- All team members use one main line of approach at a time

FIVE CODES FOR ATTITUDES

- ACTIVE FRIENDLINESS
• The basic principle is to give attention to the patient before the patient request it
• It is usually the attitude prescribes for the patients on the Reality Orientation Program
• advisable for: withdrawn, apathetic patients usually schizophrenics
• Assume the initiative in showing a consistent, genuine interest in the patients and their
needs 24 hours a day
• These patients are treated with tender loving care and their personal needs are attended to,
like bathing, combing hair, cutting fingernails, etc.
• Give sincere praise for accomplishment that shows progress
• Seek patient out and spend extra time with him/her
• Therapist makes even the simplest decision because the patient would not be allowed to fail
• Give them a reason to want to be active and not withdrawn
• Therapist needs to be very verbally supportive
- PASSIVE FRIENDLINESS
• Indicated for suspicious or paranoid patients, with latent homosexual problems
• frightened by active friendliness or closeness
• Suspicious patients see the environment as being against them
• Nurse must maintain distance because paranoid patient hates too much closeness but make
the patient feels that you are just around and willing anytime he needs you
• Real interest is shown by being available and alert but not pushing
• Wait for the patient to make the first move and respond accordingly
• Therapist needs to make it very obvious they are always available
• Pick an activity for them to engage in that they will be immediately successful in
• The therapist uses an approach of casualness in interaction, especially in requests,

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 • The therapist uses an approach of casualness in interaction, especially in requests,
manipulative behaviors. Reassurances and emotional responses are avoided. Hysterical
patients, manic patients.
• Do not give false reassurance to the patient.
• Non-judgmental, no judgments are passed on the way of the patient’s thought, felt, and
behaved.
- KIND FIRMNESS
• Purpose: To put a depressed patient to work in monotonous, ungratifying repetitive work
and to criticize not the patient but the way he is doing the job
• Indicated for depressed patient with suicidal tendencies, whose primary is depression.
Usually, the purpose of kind firmness and insistence upon under gratifying work is to help
him turn his hostility outward
• This type of patients have inner hostility hence, the approach activities provided must help
these patients.
• Requires that the nurse convey a feeling of assurance ot the patient that she knows what is
to be done and expects her requests to be carried out.
• The nurse’s statement should be direct, clear , and quietly confident, but never overbearing
and challenging
• To be firm with depressed patients and instead of sympathizing with their misery to make
them work on monotonous, ungratifying repetitive work. The work gives them some muscle
action and something else to focus on besides on his own miseries.
- MATTER OF FACT ATTITUDE
• Indicated for manipulative and demanding patients.
• Stick to the rules and regulations
• Be firm and consistent with your approaches or with what you say to these patients.
• Indicated for: character disorders such as alcoholic, drug addicts and passive individuals.
These people are impatient with life. Their therapeutic need is to learn that manipulation in
unrewarding. We teach them to grow up and meet their responsibilities.
• Therapist has to state and stick to what they say and NOT deviate from what they say
- NO DEMAND ATTITUDE
• Indicated for assaultive/ combative patients
• Never approach the patient alone or he might perceive that you are challenging him to fight
• Ask the help of the members of the team and surround the patient so that his hostilities
may not be focused to the object of his anger. Likewise, a large group surrounding him shall
help diffuse his hostilities.
• Tell the patient that you (and the group) will not harm him instead you are all there to help
him.
• Therapist needs to show caring behaviors to show the person they won’t hurt them
• When they get out of control the therapist does nothing but just come back to them later

SUMMARY
1. Active Friendliness- withdrawn patient
2. Passive Friendliness- Paranoid patient
3. Kind Firmness- Depressed clients
4. Matter-of-fact- Manipulative/Demanding client related
5. No demand - furious in rage

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