Self-esteem is quite low with feelings of worth-
lessness and inadequacy even when clients have been
successful. Self-criticism often leads to punitive be-
havior and feelings of guilt or remorse. Clients may
appear overtly quiet and passive; they prefer to follow
others rather than be leaders in any work or social sit-
uation. Although clients feel dependent on approval
from others, they tend to be overly critical and quick
to reject others first. These clients, who need and
want the approval and attention of others, actually
drive others away; this reinforces feelings of being un-
worthy of anyone’s attention.Nursing Interventions
When working with clients who report depressed feel-
ings, it is always important to assess if there is risk for
self-harm. If a client expresses suicidal ideation or has
urges for self-injury, the nurse must provide inter-
ventions and plan care as indicated (see Chapter 15).
The nurse explains that the client must take ac-
tion, rather than wait, to feel better. Encouraging the
client to become involved in activities or engaged
with others provides opportunities to interrupt the
cyclical, negative thought patterns.
Giving factual feedback, rather than general
praise, reinforces attempts to interact with others
and gives specific, positive information about im-
proved behaviors. An example of general praise is
“Oh, you’re doing so well today.”This statement does
not identify specific positive behaviors. Allowing the
client to identify specific positive behaviors often
helps to promote self-esteem. An example of specific
praise is “You talked to Mrs. Jones for 10 minutes,
even though it was difficult. I know that took a lot of
effort.”This statement gives the client a clear mes-
sage about what specific behavior was effective and
positive—the client’s ability to talk to someone else.
Cognitive restructuring techniques such as
thought-stopping or positive self-talk (discussed pre-
viously) also can enhance self-esteem. Clients learn
to recognize negative thoughts and feelings and learn
new, positive patterns of thinking about themselves.
It may be necessary to teach the client effective
social skills such as eye contact, attentive listening,
and topics appropriate for initial social conversation
(e.g., the weather, current events, local news). Even if
the client knows these social skills, practicing them is
important—first with the nurse and then with others.
Practicing with the nurse is initially less threaten-
ing. Another simple but effective technique is to help
the client practice giving others compliments. This
requires the client to identify something positive
rather than negative in others. Giving compliments
also promotes receiving compliments, which further
enhances positive feelings.
PASSIVE-AGGRESSIVE
PERSONALITY DISORDER
Clinical Picture
Passive-aggressive personality disorderis char-
acterized by a negative attitude and a pervasive pat-
tern of passive resistance to demands for adequate
social and occupational performance. It occurs in 1%
to 3% of the general population and in 2% to 8% of the
clinical population. It is thought to be slightly more
prevalent in women than in men (APA, 2000).
These clients may appear cooperative, even in-
gratiating, or sullen and withdrawn, depending on the
circumstances. Their mood may fluctuate rapidly and
erratically, and they may be easily upset or offended.
They may alternate between hostile self-assertion
such as stubbornness or fault-finding, and excessive
dependence, expressing contrition and guilt. There is
a pervasive attitude that is negative, sullen, and de-
featist. Affect may be sad or angry. The negative atti-
tude influences thought content: clients perceive and
anticipate difficulties and disappointments where
none exist. They view the future negatively, believing
that nothing good ever lasts. Ability to make judg-
ments or decisions is often impaired. Clients are fre-
quently ambivalent and indecisive, preferring to allow
others to make decisions that these clients will then
criticize. Insight is also limited: clients tend to blame
others for their own feelings and misfortune. Rather
than accepting reasonable responsibility for the situ-
ation, these clients may alternate blaming behavior
with exaggerated remorse and contrition.
Clients experience intense conflict between de-
pendence on others and a desire for assertion. Self-
confidence is low despite the bravado shown. Clients
may complain that they are misunderstood and un-
appreciated by others and may report feeling cheated,
victimized, and exploited. They habitually resent,
oppose, and resist demands to function at a level ex-
pected by others. This opposition occurs most fre-
quently in work situations but also can be evident
in social functioning. They express such resistance
through procrastination, forgetfulness, stubbornness,
and intentional inefficiency especially in response to
tasks assigned by authority figures. They also may
obstruct the efforts of coworkers by failing to do their
share. In social or family relationships, these clients
may play the role of the martyr who “sacrifices every-
thing for others,” or may be aggrieved and misunder-
stood. These behaviors sometimes are effective in ma-
nipulating others to do as clients wish, without clients
needing to make a direct request.
These clients often have various vague or gener-
alized somatic complaints and may even adopt a sick
role. They then can be angry or bitter, complaining16 PERSONALITYDISORDERS 399