Peronality Disorders and Manipulation
Dependent personality disorder
a pattern of submissive and clinging behavior related to excessive need to be taken care of. DM: introjection "Whatever you say, whatever you want" Don't leave me (you're not right for me) - I don't deserve anyone, even you INTROJECTION:Intense identification in which people incorporate qualities or values of another person or group into their own ego structure. It is one of the earliest mechanisms of the child, important in formation of conscience. Ex:Eight-year-old Jimmy tells his 3-year-old sister,"Don't scribble in your book of nursery rhymes. Just look at the pretty pictures," thus expressing his parents'values. NCLEX: LAck of self esteem, and cannot function on their own so are not independent. So passively allows others to make decisions for them and take up the responsibility for them What about Bob? Helpless, incompetent, Submissive, clinging Don't leave me Concerns about abandonment, self blame Never makes decisions It is your decision Notes:Never make a decision then are not responsible for the decision. Not over dramatic but concerns about borderline. "I need, I need". I cant fxn w/out someone telling me what to do.
Personality
characteristic way of feeling, behaving, thinking
Disorders of Relatedness
lack of emotional depth superficial encounters limited authentic commitments repeatedly provoke rejection by others fearful of rejection sabotage own efforts to achieve goals
Characteristics of Healthy Relatedness
mutual validation of personal worth open communication of feelings acceptance of the other person as valued and separate empathetic understanding
Psychopharmacology
Anti anxiety catergories: (benzo -ativan, Buspar, SSRI (paxil, lexapro) and sedative-hypnotics ) Desyrel (Trazodone -Hydrochloride give HS Antidepressants - (SSRI's PTSD, violence) Lexapro, Zoloft, Paxil, (SNRI) Effexor, Wellbutrin (Bupropion Hcl) Drug Antipsychotics & Mood stabilizers - Seroquel, Zyprexa, (aggression)
CLUSTER B: Dramatic, Emotional, Erratic, And Impulsive
Antisocial personality disorder, Borderline personality disorder, Histrionic personality disorder, Narcissistic personality disorder:
CLUSTER B Dramatic, Emotional, Erratic, & Impulsive
Antisocial personality disorder: a pattern for disregard for, and violation of, the rights & feelings of others. No remorse or guilt. Borderline personality disorder: a pattern of instability in interpersonal relationships, self-image, & affects. Marked impulsivity. Histrionic personality disorder: a pattern of excessive emotionality & attention seeking. Demanding, egocentric behavior. Narcissistic personality disorder: a pattern of grandiosity, need for admiration, exaggerated sense of self-importance, emotional rage, & lack of empathy.
Primary NANDA-I Diagnoses contd
Anxiety Family processes, interrupted Role performance, ineffective Social isolation See examples of expanded nursing diagnoses (Table 21-2)
Coping Mechanisms
Attempts to cope with anxiety related to threatened or actual loneliness Manipulative people view others as objects; their defenses protect them from potential psychological pain People with ANTISOCIAL, BORDERLINE and NARCISSISTIC personality disorders often use ego defenses of PROJECTION, SPLITTING Projection places responsibility for antisocial behavior outside oneself. Splitting looks at situations/people as all good or all bad.
Coping Mechanisms
Attempts to cope with anxiety related to threatened or actual loneliness Manipulative people view others as objects; their defenses protect them from potential psychological pain People with antisocial, borderline and narcissistic personality disorders often use ego defenses of projection, splitting Projection places responsibility for antisocial behavior outside oneself. Splitting looks at situations/people as all good or all bad.
CLUSTER C: Anxious, Fearful
Avoidant personality disorder,Dependent personality disorder, Obsessive-compulsive personality
CLUSTER C: Anxious, Fearful
Avoidant personality disorder: a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Dependent personality disorder: a pattern of submissive and clinging behavior related to excessive need to be taken care of. Obsessive-compulsive personality: a pattern of preoccupation with rules, trivial details, orderliness, perfectionism, and control.
Behavioral Strategies
Behavioral strategies can help decrease antisocial behavior, including social skills training, anger management Because of impatience with delays in gratification, material rewards rather than emotional ones preferred Use concrete, readily available reinforcers If behavior is disruptive and there must be a response, should be a matter-of-fact one not desired by patient -Removal from contact with others can be effective
Behavioral Strategies
Behavioral strategies can help decrease antisocial behavior, including social skills training, anger management Because of impatience with delays in gratification, material rewards rather than emotional ones preferred Use concrete, readily available reinforcers, "you do not have the privilege to leave unit today, talk to your team about tomorrow". If behavior is disruptive and there must be a response, should be a matter-of-fact one not desired by patient Removal from contact with others can be effective
Personality Disorder
personality that is not always disorganized, but a way of being that is maladaptive in some way of reacting to the world.
Hallmark Behaviors all Personality Disorders
• Manipulation • Narcissism • Impulsivity
Borderline Personality Disorder
Clinical picture: -Intense, unstable mood -Chronic, underlying depression -Anger - directed at self & others -Instability in interpersonal relationships -Fear of abandonment Patterns of Interaction -Clinging & Distancing -Splitting -Manipulation -Self-destructive Behaviors -Impulsivity
Personality Disorder Clusters
Cluster A: personality disorders of odd or eccentric nature Cluster B: disorders of erratic, dramatic, or emotional nature Cluster C: disorders of anxious or fearful nature See Handout for descriptions of all disorders
Chronically affected areas 2/4
Cognition Interpersonal relationships Impulse control Affect To have PD need to have 2 out of 4 traits. Interpersonal-family, sig other, work people. Impulse control-prefrontal lobe is not fully developed. Affect-mood If you have a problem with only one then you don't have a PD
Personality Disorders
Continual rather than episodic Pervasive across wide range of circumstances in individual's life Appearance and severity of symptoms can vary over time Essential element of diagnosis: symptoms of personality disorders are fixed, long lasting Even with treatment, not possible to completely change someone's personality but can improve symptoms, distress, general functioning
Structure in Milieu
Deal with loss of control by room restriction, with length of restriction based on seriousness of behavior Role models for appropriate behavior Useful nursing approach is to encourage individuals to identify, use their strengths Focus nursing interventions on mobilizing strengths to enhance self-esteem, using adaptive defenses, positive coping skills
Primary NANDA-I Diagnoses
Defensive coping Chronic low self-esteem Risk for self-mutilation Impaired social interaction Risk for violence (self directed or other directed)
Protection from Self-Harm
Deliberate self-destructive, self-mutilating, or suicidal behavior very difficult to treat Often nursing staff must observe patient constantly to prevent physical harm Patient may have intense dependency needs from unresolved separation-individuation developmental phase Primary nursing particularly effective with patient needing to work through these separation issues
Implementation
Difficult to establish strong relationship with patient who fears intimacy Resistance to change can be very strong Patients with personality disorders come to treatment for help with depression, anxiety, alcoholism, difficulties in work or personal relationships Treatment is not to have their personalities changed Focus of therapy, therefore, is to help patients change maladaptive thinking and behavior that result from personality traits, treat any co-morbid conditions Treatment includes: Psychotherapy (primary treatment) Engaging patients as collaborators Having one clinician in charge of care Psychoeducation Family involvement Limited use of medication Evidence supports effectiveness of atypical antipsychotic medication olanzapine in reducing anger, impulsivity-aggression, possibly depression, interpersonal sensitivity
RN Responsibilities Restraints
Ensure documentation of assessment every 15 minutes. Perform baseline assessment every hour. Attempt least restrictive measures no less than every 4 hours. Document progress note each time restraints are initiated and discontinued. Provide assistance to meet behavioral criteria for discontinuation of restraint. See Care of Restraints Handout Blackboard
Evaluation
Evaluative Questions: Has the patient become less impulsive, manipulative, or narcissistic? Can the patient participate in close relationships? Does the patient express recognition of positive behavioral change? Does the patient express satisfaction with the quality of their relationships? Meaningful employment ? Consistent relationship(s)?
Appraisal of Stressors
Even a mature person who can participate in healthy relationships still vulnerable to psychological stress Appraisal of stressors critically important since a series of losses or one significant loss may lead to problems in establishing future intimate relationships
Outcomes Identification
Expected outcome: Patient will obtain maximum interpersonal satisfaction by establishing and maintaining self-enhancing relationships with others Short-term goals progress from simpler to more complex behavior changes Consider patient's ability to tolerate anxiety before setting goals
Family Involvement
Family involvement is important in promoting and maintaining positive change for the patient and family Because intimate relationships always affected by maladaptive social responses, must involve significant others in plan of care Especially important for manipulative patients, who often shift attention away from themselves by creating conflict between family and staff
Dialectic Behaviorial Therapy
Focus of therapy, therefore, is to help patients change maladaptive thinking and behavior that result from personality traits, treat any co-morbid conditions. Dialectical Behavior Therapy (DBT), developed by Marsha Linehan, Ph.D., ABPP, at the University of Washington, is a comprehensive cognitive-behavioral treatment that was originally developed to treat chronically suicidal individuals suffering from borderline personality disorder (BPD). DBT has been found especially effective for those with suicidal and other multiply occurring severely dysfunctional behaviors. Research has shown DBT to be effective in reducing suicidal behavior, psychiatric hospitalization, treatment dropout, substance abuse, anger, and interpersonal difficulties. Role model role play appropriate behaviors in treatment Notes:Top treatments in the country for borderline personality disorder. ONLY EBP that ahs a success rate. And now using it for many d/o. and insurance will pay for this to be a grp with ppl who have same dx, for 8 weeks, for 2 hours or week and have to have individual therapist and meet them weekly. Insurance incentives: will help prevent hospitalization.
Coping Resources
For some people, when one relationship is problematic, others are available to offer support, reassurance Even those with broad networks of family and friends may need encouragement to reach out for help Creative ways to express feelings: art, music, writing, reading, exercise
Use of Seclusion or restraints
Good nursing care: fulfill basic needs and maintain personal dignity. Recommend: once calm talk with clients about issues that led to psychiatric emergency and identify alternative coping methods to avoid future seclusion/restraint. Staff Debriefing: review events that led to decision to isolate pt. identify future preventive measures to help pt. gain control and promote adaptive functioning staff may need to ventilate or process feelings about the event and clarify rationale for seclusion/restraint.
Behaviors in Milieu
Hold manipulative patients responsible for their behavior, although they are skilled at placing responsibility on others (projection) Communicate with other staff members to give consistent messages Any inconsistency is used by the patient to focus attention on others Staff provide attention and structured discipline Expect patient will meet standards of healthy behavior
Crisis Management
Identify crisis leader Assemble crisis team Notify security officers if necessary Remove all other patients from area Obtain restraints if appropriate Devise a plan to manage crisis and inform team Assign securing of patient limbs to crisis team members
Nursing Care
Identifying cues and triggers to behavior problems allows patient to be more active in therapeutic process Nurses are less judgmental about patient if they understand the source of behaviors, feelings Positive and negative countertransference by staff members can lead to splitting, staff conflict
Identity Diffusion (Chapter 17)
Identity diffusion: failure to integrate childhood identifications into harmonious adult psychosocial identity Important behaviors include: disruptions in relationships, and problems of intimacy Problem of gaining intimacy reflected in isolation, denial, withdrawal from others, lacking empathy
Violate Boundaries
Impulse control Borderline and Sociopath
Impulsive Aggression
Impulsive aggression hallmark of borderline personality disorder; pivotal in self-mutilation, unstable relationships, violence, completed suicides Patients can be frustrating for nursing staff to interact with and treat, but their behavior is defense against fear of loneliness, not consciously planned Patients with borderline and antisocial personality disorders are more likely to attempt suicide
Key Features of Personality Disorders
Individual has few strategies for relating Inflexible, maladaptive approach to relationships, environment Needs, perceptions, behavior foster vicious cycles, promote unhelpful patterns, provoke negative reactions from others Unstable, fragile coping skills Lack of resilience in stressful situations
Characteristics of Personality Disorders
Inflexible-always same way. Maladaptive behavior Long standing Pervasive Difficult to treat (examples treat depression and PD) Ego syntonic - "nothing wrong with me" it's you. You don't understand how I am. Can get cured of depression. But if its difficult to get cured, like a revolving door its b/c of personality d/o which cant be cured. Personality d/o don't have any insight. They are ego syntonic.
Personality and Positive Interpersonal Relationships
Intimate and interdependent relationships -provide security -instill self-confidence -free energy for involvement with others
Seclusion
Involuntary confining of a person alone in a room from which the person is physically prevented from leaving Used only as emergency measure Based on principles of containment, isolation, decrease in sensory input Careful records and observation required
Medications
Limited role in treatment of personality disorders, used primarily to relieve symptoms such as anxiety, mood swings, impulsive aggression Cluster A personality disorders: antipsychotics for subtle psychotic symptoms Cluster B disorders: mood-stabilizing medication or atypical antipsychotic drugs for subtle signs of bipolar disorder Cluster C: anxiety-related personality disorders may benefit from serotonergic antidepressants
Precipitating Stressors
Maladaptive social responses result from experiences that negatively influenced the person's emotional growth Series of life events may predispose person to have relationship problems but others are able to cope Stressors may be sociocultural or psychological
Manipulation
Manipulation: behavior in which people treat others as objects, form relationships centered around control issues Patients usually have little motivation to change because manipulative behavior often has rewards; they are getting what they want Manipulators are goal oriented or self oriented, not other oriented Skilled at giving impression that they care
Manipulative Behavior
Manipulative person unaware of lack of relatedness, assumes interpersonal relationships are formed to take advantage of others Cannot imagine intimate, sharing relationship Believes in always maintaining control to avoid being controlled
Milieu Therapy
Milieu provides patients with opportunity to gain insight into their behavior Nursing functions in milieu therapy: -Provide structured environment -Serve as emotional sounding board -Diagnose conflicts, consequences of actions -Facilitate adaptive change in behavior Milieu work is most effective if it is focused on realistic expectations, decision making, social behaviors in the "here and now"
Now, now now
Milieu work is most effective if it is focused on realistic expectations, decision making, social behaviors in the "here and now"
Narcissism
Narcissism: egocentric attitude, fragile self-esteem, constant seeking of praise and admiration, envy Problems occur when person does not gain status he thinks is deserved or tries to have interpersonal relationships May express frustration caused by lack or loss of recognition as anger, depression, substance abuse, other maladaptive behaviors
Need several characteristics
No two individuals the same even with same label Cluster A: schizoid, paranoid, schizotypal Cluster B: narcissistic, borderline, histrionic, antisocial Cluster C: avoidant, compulsive, dependent Usually have more than one PD at one time Refer to handout on Blackboard for study
Establish Therapeutic Relationship
Nurse must: Be physically and psychologically accessible so there are opportunities for interaction Show genuine interest in patient, try to understand patient by clarifying meanings, validating perceptions Be empathic with focus on appropriate boundaries of relationship
Planning
Nursing treatment plan provides guide for intervention, promotes consistency among treatment staff who provide patient care Particularly important when working with patients with maladaptive social responses Planning also includes attending to educational needs
CLUSTER A: Odd, Eccentric
Paranoid personality disorder, Schizoid PD, Schizotypal PD
CLUSTER A: Odd, Eccentric
Paranoid personality disorder: a pattern of distrust and suspiciousness such that others' motives are interpreted as malevolent. Schizoid personality disorder: a pattern of detachment from social relationships and a restricted range of emotional expression. Schizotypal personality disorder: a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior.
Antisocial Personality Disorder
Particularly difficult to diagnose and treat, with criteria including adults who have broken rules since age 15 Diagnosis applied when individual consistently ignores social rules; is manipulative, exploitative, or dishonest; lacks remorse; is involved in criminal activity Diagnosed in only 3% of men, 1% of women However, these individuals responsible for large proportion of crime, violence, social distress
Impulsivity
People prone to impulsivity have: Inability to create realistic plans Inability to learn from experience Poor judgment Unreliability An impulsive person acts to immediately gratify their needs without considering the consequences of the action. They are at high risk for injury.
Important Points
Personality Disorders are disturbances in relatedness. Individuals have rigid, inflexible, & maladaptive ways of viewing & behaving in the world. Hallmark behaviors of Personality Disorders are manipulation, narcissism, & impulsivity. Behavioral response options to stress include passive, aggressive & assertive (positive coping) behaviors. Prior history of violence is single best predictor of present violence just like prior history of self harm, good predictor of self harm. Safety (suicide/homicide), structuring the milieu, & limit setting are important priorities in handling aggression, manipulation, narcissism, and impulsivity. Violence preventive, anticipatory, & containment strategies move from: recognizing escalating symptoms (anger) verbal interventions seclusion &/or restraint (chemical/physical) crisis management
Assessment: Behaviors
Personality: set of deeply ingrained, enduring patterns of thinking, feeling, behaving Personality disorder: set of patterns or traits that hinder person's ability to maintain meaningful relationships, feel fulfilled, enjoy life
Restraints
Physical - any manual method or physical or mechanical device attached to or adjacent to the patient's body that the patient cannot easily remove and that restricts freedom of movement or normal access to one's body, material, or equipment Chemical - medications used to restrict the patient's freedom of movement or for emergency control of behavior but that are not standard treatments for the patient's medical or psychiatric condition (examples of this meds?) anti-psychotics, benzos in med-surg (ativan use cautiously with elderly)
Milieu Therapy: Personality Disorders
Principles of milieu treatment: -Establish control without option to escape involvement -Provide experienced, consistent staff -Implement clear structure with fair, firm, consistently enforced rules -Provide support while patient learns to experience painful feelings, try out new behavioral responses
Narcissistic Personality Disorders
Reacts to criticism with rage and humiliation Interpersonally exploitative Grandiose Believes problems to be unique Preoccupied with fantasies of greatness Sense of entitlement Constant need for attention Lacks empathy Envious
Limit Setting
Set clear, firm limits on behavior not the person Way the nurse approaches limit setting can make the difference between productive hospital experience and nonproductive or counterproductive one Angry, punitive limit setting confirms patient's expectations Should not be viewed as way to control patient but as working together toward process of change
State vs. Train
State is a temporary feeling such as anger. Trait is a characteristic, it stays all the time. So every aspect of life is seen through an angry lenses
Quality and Safety Alert
The nurses must maintain the patient's safety facilitate the patient's participation in care select the least restrictive intervention support behavior change help the patient assume responsibility for their own actions
Traits like everyone else
Traits pushed to extremes Conscientious good scale Monk , nurse checks meds 10 times Failure to delay gratification ( what part of brain helps with this function?) Flat, overdramatic Avoidant - others superior, I am inferior Narcissist - I am great, everyone inferior The Monk state can be very extreme and your trait can be very flat or dramatic.
Implementation
Treatment includes: Psychotherapy (primary treatment) Engaging patients as collaborators Having one clinician in charge of care Psychoeducation Family involvement Limited medication:Evidence supports effectiveness of atypical antipsychotic medication olanzapine (zyprexa) in reducing anger, impulsivity-aggression, possibly depression, interpersonal sensitivity(SSRIs)
No insight
What I am doing is not wrong Listed in DSM 5 One whole section devoted to PD Started in 1952 Alcoholism a PD Now it is a substance issue
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What are the hallmark behaviors of Personality Disorders? What strategies are useful to deal with these behaviors. Manipulation, Narcissism, and Impulsivity (impulse control) How do nurses manage violence and aggression ? safety, structuring milieu, and limit setting Manipulation means of getting needs met. Nurse response: 'I will do X, but not Y". Boundaries/limits/ behavioral contract (I will breath 10 times deeply when angry before responding). Strategies: splitting, no telling the truth; the strategy is get together with team and let them know what's going on.
Antisocial personality disorder,
a pattern for disregard for, and violation of, the rights and feelings of others. DMs: acting out, projection, splitting "nobody likes me everybody hates me" 'All these other people here intend to hurt me" - I lock them out of the day room. I shred their mail before they get to read it. I push ahead of them in line. I interrupt them because my problems are the priority. Impulsive,irresponsible Deviant, unruly Self serving Disrespectful History of law breaking Goes back often to childhood - risk self harm suicide Fringe of ethical behavior - "I may have been wrong (big) goal Prisons Disrespectful of others rights Motivated to avoid dominance or control Bad boys Prone to legal & vocational Marriage GOOD LUCK! 4% population 50 - 75% prison inmates Brag about crime Acting out, harm, impulsive Disregard social & legal rules Defense mechanism = projection (someone's else's fault) Percocet example clinical
Schizotypal PD
a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior. DM: undoing (After abuse toward another), "no, you misunderstood - let's go away, and I'll buy you something expensive - (on again, off again) - try to "un-make-happen" no, that's not how it went - see, I don't want to hurt you. Or, no, my father didn't really beat me - I deserved it and it was a "spanking" - Cognitive impairments Self absorbed in own thoughts Magical thinking Self conscious Autistic flat Eccentric Eccentric, bizarre, absent Peculiar, odd, disconnected Acute discomfort in close relationships - painful Cognitive & perceptual distortions
Schizoid PD
a pattern of detachment from social relationships and a restricted range of emotional expression. DM: intellectualization "50% of marriages end in divorce - so, it was inevitable." "I'd rather read a book I can learn something from than go drinking with friends" - loner, emotionless - "She asked for it with that mean approach toward me" Flat, no attachment,introvert, apathy Mid-30's not married, home with parents,lousy job, doesn't fit in ??????? Withdrawn, no anger, no sadness Married: spouses lack of intimacy
Paranoid PD
a pattern of distrust and suspiciousness such that others' motives are interpreted as malevolent. Defense mechanism (DM): projection "he's trying to get rid of me" (I'd like to get rid of him); he offered me a book - he wants me to get a paper cut. She offered me a cookie-she put something nasty in it to make me cough. Distrustful Annoyed with others "persecuted" Guarded, paranoid If married to him, in defendant box your whole life Hypervigilant, secretive Sensitive Lawsuits neighbors - takes times for any trust "You did it on purpose, where were you"
Histrionic personality disorder
a pattern of excessive emotionality and attention seeking. Demanding, inconsiderate, egocentric behavior. DM: dissociation I have to be first, my needs have to be met now - egocentric - "he left it there, he must have meant for me to look at it." Zoning out - seeming unaffected by a deeply emotional occurrence; such as another patient crying, screaming in a group session. Dramatic,seductive, shallow Sexual Often Impaired sexually Colorful, attention seeking Center of attention Extraverted Substance related issues Act emotional and erotic way to draw attention to themselves.
Narcissistic PD
a pattern of grandiosity, need for admiration, exaggerated sense of self-importance and lack of empathy. DM: rationalization I'm the best - it's always about me (ruth) - yes the baby's crying, but I want you to help me right now. Yes, he needs a ride to chemo treatment - but you said we'd have lunch today. It's the right thing, because we haven't had lunch in 2 weeks. Egotistical, arrogant Special and better Grandiose Superior, need constant praise How dare you question me? What do you think of me? 'You can't handle the truth!'
Borderline personality disorder
a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity. DM: splitting "it's their fault" - " they all kept the info from me" - I had to walk out in the middle of the shift - they purposely did things to make me angry, sad, etc. Can be one of the most difficult for nursing staff to deal with and most destructive No matter where, you will find someone with this disorder "Feeling in your gut" - take breaths and keep calm, quiet, do not argue Serious, you will meet Manipulative Fear of Abandonment Extreme One direction, or other I Hate you, don't leave me - book Explosive moods Anger, acting out Cannot be both good & bad Poor sense of self and boundaries - impulsive Cutting, suicide hi risk Clients Feels empty 1. paradoxical 2. uncertain of self image 3. history of childhood sexual abuse 4. Splitting - see OTHERS as all good or all bad and can switch (defense mechanisms) 5. "You are the best nurse - the night nurse is horrid". Role model appropriate - "we all have good and bad days 6. SELF KNOWLEDGE as a provider 7. self-harm risk: poor judgment
Behaviors Associated with Identity Diffusion (Seen in Personality Disorders)
-No moral code -Contradictory personality traits -Exploitive interpersonal relationships -Feelings of emptiness -Fluctuating feelings about self -High degree of anxiety -Inability to empathize with others -Lack of authenticity -Problems of intimacy -Gender confusion -Manipulation -Narcissism -Impulsivity
PERSONALITY DISORDERS DESCRIPTION OF CLUSTERS
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Obsessive-compulsive personality
a pattern of preoccupation with rules, trivial details, orderliness, perfectionism, and control. DM: reaction formation You can't color outside the lines! Mother spanked - daughter doesn't believe in it - but spanks her kids when mother visits. "I hate gays!" - (I think I'm gay) 'Just the facts' Restrained, conscientious, respectful Rigid, conventional, regulated Organized, perfectionistic, suppression of emotions, moral, obedient, fears disapproval Notes:Very moral. This si the way. Fear disapproval. Its all about control.
Avoidant personality disorder
a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. DM: fantasy Cries at anything going wrong, it's her fault, fears new situations, imagines successes instead of working to make them actually happen. Hesitant, self conscious, submissive embarrassed Fears rejection, anxious Inept, inferior, unappealing, lonely Thin skinned Fantasy: if only. . . What would a marriage of a Narcissistic and Avoidant PD look like?
