culty making decisions, no matter how minor. They
seek advice and repeated reassurances about all types
of decisions, from what to wear to what type of job to
pursue. Although they can make judgments and deci-
sions, they lack the confidence to do so.
Clients perceive themselves as unable to func-
tion outside a relationship with someone who can tell
them what to do. They are very uncomfortable and
feel helpless when alone, even if the current rela-
tionship is intact. They have difficulty initiating proj-
ects or completing simple daily tasks independently.
They believe that they need someone else to assume
responsibility for them, a belief that far exceeds what
is age- or situation-appropriate. They may even fear
gaining competence because doing so would mean an
eventual loss of support from the person on whom
they depend. They may do almost anything to sus-
tain a relationship, even one of poor quality. This in-
cludes doing unpleasant tasks, going places they dis-
like, or in extreme cases, tolerating abuse. Clients
are reluctant to express disagreement for fear of los-
ing the other person’s support or approval; they may
even consent to activities that are wrong or illegal to
avoid that loss.
When these clients do experience the end of a
relationship, they urgently and desperately seek
another. The unspoken motto seems to be “Any re-
lationship is better than none at all.”
Nursing Interventions
The nurse must help clients to express feelings of
grief and loss over the end of a relationship while fos-
tering autonomy and self-reliance. Helping clients to
identify their strengths and needs is more helpful
than encouraging the overwhelming belief that “I
can’t do anything alone!” Cognitive restructuring
techniques such as reframing and decatastrophizing
may be beneficial.
Clients may need assistance in daily functioning
if they have little or no past success in this area. In-
cluded are such things as planning menus, doing
the weekly shopping, budgeting money, balancing a
checkbook, and paying bills. Careful assessment to
determine areas of need is essential. Depending on
the client’s abilities and limitations, referral to agen-
cies for services or assistance may be indicated.
The nurse also may need to teach problem-solving
and decision-making and help clients apply them to
daily life. He or she must refrain from giving advice
about problems or making decisions for clients even
though clients may ask the nurse to do so. The nurse
can help the client to explore problems, serve as a
sounding board for discussion of alternatives, and
provide support and positive feedback for the client’s
efforts in these areas.
OBSESSIVE-COMPULSIVE
PERSONALITY DISORDER
Clinical Picture
Obsessive-compulsive personality disorderis
characterized by a pervasive pattern of preoccupation
with perfectionism, mental and interpersonal control,
and orderliness at the expense of flexibility, openness,
and efficiency. It occurs in about 1% to 2% of the pop-
ulation, affecting twice as many men as women. This
rises to 3% to 10% in clients in mental health settings.
Incidence is increased in oldest children and people in
professions involving facts, figures, or methodical
focus on detail. These people often seek treatment be-
cause they recognize that their life is pleasureless or
they are experiencing problems with work or rela-
tionships. Clients frequently benefit from individual
therapy (APA, 2000).
The demeanor of these clients is formal and seri-
ous, and they answer questions with precision and
much detail. They often report feeling the need to be
perfect beginning in childhood. They were expected to
be good and to do the right thing to win parental ap-
proval. Expressing emotions or asserting indepen-
dence was probably met with harsh disapproval and
emotional consequences. Emotional range is usually
quite constricted. They have difficulty expressing emo-
tions and those emotions expressed are rigid, stiff, and
formal, lacking spontaneity. Clients can be very stub-
born and reluctant to relinquish control, which makes
it difficult for them to be vulnerable to others by ex-
pressing feelings. Affect is also restricted: they usually
appear anxious and fretful, or stiff and reluctant to
reveal underlying emotions.
Clients are preoccupied with orderliness and try
to maintain it in all areas of life. They strive for per-
fection as though it were attainable and are preoccu-
pied with details, rules, lists, and schedules to the
point of often missing “the big picture.” They be-
come absorbed in their own perspective, believe they
are right, and do not listen carefully to others because
they have already dismissed what is being said.
Clients check and recheck the details of any project
or activity; often they never complete the project be-
cause of “trying to get it right.” They have problems
with judgment and decision-making—specifically ac-
tually reaching a decision. They consider and recon-
sider alternatives, and the desire for perfection pre-
vents reaching a decision. Clients interpret rules or
guidelines literally and cannot be flexible or modify
decisions based on circumstances. They prefer writ-
ten rules for each and every activity at work. Insight
is limited, and they are often oblivious that their be-
havior annoys or frustrates others. If confronted with
this annoyance, these clients are stunned, unable to
believe others “don’t want me to do a good job.”16 PERSONALITYDISORDERS 397