DEPRESSIVE PERSONALITY DISORDER
Depressive personality disorder is characterized by a perva-sive pattern of depressive cognitions and behaviors in vari-ous contexts. It occurs equally in men and women and more often in people with relatives who have major depressive dis-orders. People with depressive personality disorders often seek treatment for their distress and generally have a favor-able response to antidepressant medications (APA, 2000).
Although clients with depressive personality disorder may seem to have similar behavior characteristics as cli-ents with major depression (e.g., moodiness, brooding, joylessness, or pessimism), the personality disorder is much less severe. Clients with depressive personality dis-order usually do not experience the severity and long duration of major depression or the hallmark symptoms of sleep disturbances, loss of appetite, recurrent thoughts of death, and total disinterest in all activities.
These clients have a sad, gloomy, or dejected affect. They express persistent unhappiness, cheerlessness, and hopelessness, regardless of the situation. They often report the inability to experience joy or pleasure in any activity; they cannot relax and do not display a sense of humor. Clients may repress or not express anger. They brood and worry over all aspects of daily life. Thinking is negative and pessimistic; these clients rarely see any hope for future improvement. They view this pessimism as “being realis-tic.” Regardless of positive outcomes in a given situation, negative thinking continues. Judgment or decision-making skills are usually intact but dominated by pessimistic thinking; clients often blame themselves or others unjustly for situations beyond anyone’s control.
Self-esteem is quite low, with feelings of worthlessness and inadequacy even when clients have been successful. Self-criticism often leads to punitive behavior 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 situation. 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, actu-ally drive others away; this reinforces feelings of being unworthy of anyone’s attention.
When working with clients who report depressed feelings, it is always important to assess whether there is risk for self-harm. If a client expresses suicidal ideation or has urges for self-injury, the nurse must provide interventions and plan care as indicated .
The nurse explains that the client must take action, rather than wait, to feel better. Encouraging the client to become involved in activities or engaged with others pro-vides opportunities to interrupt the cyclical, negative thought patterns.
Giving factual feedback, rather than general praise, reinforces attempts to interact with others and gives spe-cific positive information about improved behaviors. An example of general praise is
“Oh, you’re doing so well today.”
This statement does not identify specific positive behav-iors. Allowing the client to identify specific positive behav-iors 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 message 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 previously) also can enhance self-esteem. Clients learn to recognize nega-tive 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, or 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 threatening. Another simple but effective technique is to help the client practice giving others com-pliments. This requires the client to identify something positive rather than negative in others. Giving compli-ments also promotes receiving compliments, which fur-ther enhances positive feelings.