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Withdrawal: is an adaptive or coping mechanism that involves physically pulling away from, or
psychologically losing interest in, an anxiety-producing situation, person or environment.
Common scenes:
o Child: who consistently plays alone than with a friend
o Adolescence: becomes absorbed into reading instead of being involved with
o Young adult: jogs alone to avoid personal contact with others
o Adult: who recluse who shuts windows and locks doors to close-out the world
This might be normal but when pattern is consistently used to distance or isolate self from
people or anxiety provoking situation, stressful situation, withdrawal becomes unhealthy. And
being withdrawn is usually found unhappy people and giving them the sense of bitterness and





Devalues and
depreciates self

Self-respect is lost

Extremely selfcentered

Defense mechanism To avoid frustrations,

embarrassment and
Save self-esteem

Feels unworthy
Gives up to many

Withdraws from

Regression to
helpless child
Waits to be cared for

Blaming failures
and and

Proud and selfish

Little energy to love
or feel affection

Uses the cool,

detached style to
cover-up and a
form of being

Person suffering from

organic and
intellectual decline


Defensive style


Stays home more

Minimal social

Avoids contact with


Waits for support

Lives in secrecy

Inability to reciprocate feelings in an interpersonal manner
Developmentally, infantile or child like
Lacks trust of others and self



Inability to show emotions or responds appropriately

Feeling of anxiety
Communicates in a terse but adequate style
Can't maintain relationships
Involves in job that doesn't require acquaintance with others
Never been engaged in dating

Facial expression as an indicator of the affect of Normal and Withdrawn person




Range of affect

Capacity of expressing a wide

range of emotions in
interpersonal emotions

Capacity for expressing wide range if

emotions is limited. Reserved and distant in
interpersonal emotions

Mobility of affect

Orderly and spontaneous

movement. Feelings conveyed by
variety of behavioral clues.
Smooth transition from one
emotional state to another

Limited movement of affect. Slow to express

feelings. Apathy, distance, seriousness, lack
of reciprocation,

Appropriateness of

Congruity between ideas or

content of situation and affective

Consistency between ideas and emotional

response present at times. Unable to
express warmth and positive feeling
consistently in response to others behaviors

Communicability of

Ability to produce affective

response in another

Leaves others with cold, angry or apathetic

emotional response. Inconsistent in ability to
convey emotion through non verbal clues

Theories in the development of a withdrawn personality

1. Freudian concept (Psychoanalytic)

a. Level of consciousness (conscious, subconscious, unconscious)

o the here and now as it relates to the person and the environment
o functions when we are awake
o concerned with thoughts, feelings, sensations
o directs our behavior
o ideas and reactions that are stored and partially forgotten
o acts as a watchman because it prevents certain unacceptable disturbing
unconscious memories from reaching the conscious mind



o largest part of our mind
o storehouse of all memories
o feelings and responses experienced during the individuals entire life
o materials stored continuously act as dynamic, motivating forces

Human mind never actually forgets any experience but stores in the depths of the
unconscious mind. This includes knowledge, experiences, information and feelings. But
these memories can sometimes not be recalled at will. Sometimes only presented
through dreams, slips of tongue, unexplained behavioral responses, jokes, body
language, and memory lapses.
All behaviors have meaning. No behavior occurs by accident or by chance. Rather, all
behavior is an expression of feelings or needs of which the individual is frequently not
aware of

b. Structure of personality (id, ego, superego)



pleasure principle
avoids pain and seeks pleasure
individual is id at birth
striving for pleasure through the use of fantasies and images
compulsive and without morals

came from the environment

reality testing
deals with the demands of reality
rational reasonable conscious part of the personality
can be viewed as:
Ego-syntonic - instincts or ideas that are acceptable to the self; that are
compatible with one's values and ways of thinking. They are consistent
with one's fundamental personality and beliefs
Ego-dystonic - thoughts, impulses, and behaviors that are felt to be
repugnant, distressing, unacceptable or inconsistent with one's selfconcept.
o came from the socialization process
o inhibitor of the id



o has conscience and ego ideal which punishes and rewards

o can be viewed as:
Punitive superego acts as a persons guilt
Rewarding superego as long as the person does not achieve perfection,
he/she is not deserving of any reward

When the individual does not develop an ego strong enough to arbitrate effectively
between the id and the superego, he or she will surely develop intrapersonal and
interpersonal conflicts. When the id is not controlled effectively, the individual functions
in antisocial, lawless ways because primitive impulses are expressed freely. If the
superego is so strong that the individuals life is dominated by its restrictions on
behavior, the person is likely to be inhibited, repressed, unhappy, withdrawn and guilt
ridden. Thus a mature, effective, stable adult life depends on the development of an ego
powerful enough to test reality adequately and then to mediate successfully between
the demands of the id and the superego
Personality is developed by early childhood

c. Defense mechanisms
therefore if there is no equilibrium between an individuals personality, he/she will
experience anxiety that will force him to cope by using defense mechanisms
Narcissistic defenses
o Denial
o Projection
o Distortion
o Projective identification
o Primitive idealization
o Splitting
Immature defenses
o Acting out
o Passive-aggressive behavior
o Blocking out
o Regression
o Hypochondriasis
o Schizoid fantasy
o Identification
o Somatization
o Introjection
o Turning against the self
Neurotic defenses
o Controlling
o Isolation
o Displacement
o Rationalization
o Dissociation
o Reaction formation
o Externalization
o Repression
o Inhibition
o Sexualization
o Intellectualization
o Undoing


Mature defenses
o Altruism
o Anticipation
o Asceticism


o Humor
o Sublimation
o Suppression

d. Love and intimacy (together with Rollo May)

Psychological health could be determined by a persons ability to function well in two

spheres: work and love
A person able to receive and give love with a minimum of fear and conflict has the
capacity to develop genuinely intimate relationships with others.
Emphasizes the value of sexual love as expansion of self-awareness; tenderness as an
increase of self-affirmation and pride; and orgasm to lose the feeling of separateness
When conflicts arise, there is a decrease ability of person to fuse tenderness and
passionate impulses thus inhibiting the expression of sexuality and closeness to other
people and diminishing the sense of adequacy and self-esteem. If they become severe,
it could prevent the formation of intimate relationships

Eriksonian concept

a. Developmental model
model that spans the total life cycle from birth to death

Life stage
1. Trust vs. Mistrust

Adult behavior reflecting mastery

-realistic trust of self and others
-sharing openly with others

2. Autonomy vs. Shame and Doubt


-self-control and willpower

-pride and sense and good will
-simple cooperativeness
-knowing when to give and take
-delayed gratification when necessary

3. Initiative vs. Guilt


-adequate conscience
-appropriate social behaviors
-curiosity and exploration
-healthy competitiveness



4. Industry vs. Inferiority


-sense of competence
-completion of tasks
-balance of work and play
-cooperate and compromise
-identification with admired others

5. Identity vs. Role Confusion

(12-18 or 20)

-confidence of self
-commitment to peer group values
-emotional stability
-developmental or personal values
-sense of having a place in society
-establishing relationship with the opposite
-testing out adult roles
-exploration of risk-taking behaviors and

6. Intimacy vs. Isolation


-person reaches full maturity

-young, middle and late adulthood
Child-rearing / Parenthood
-ability to give and receive love
-commitment and mutuality with others
--collaboration in work and affiliations
-sacrificing for others
-responsible sexual behaviors
-commitment to career and long-term goals
-the intimacy of sexual relations, friendships,
and all deep associations are not frightening
to the person with a resolved identity crisis
-in contrast, the person who reaches the adult
years in a state of continued role confusion is
unable to become involved in intense and
long-term relationships. Without these
connections, a person may become selfabsorbed and self-indulgent. As a result, a
sense of isolation may grow.
-through this stage, a person should be able to
transcend from being dependent to being



mutually connected with an extended and

more diverse social group
-at middle adulthood, people start to take life
more seriously
-40 is considered the noon of life
-as the children grow older, parents feeling of
needing work will return
-females feel masculine and males feel
7. Generativity vs. Stagnation

8. Integrity vs. Despair

(65-to death)

-productive, constructive, creative activity

-personal and professional growth
-parental societal responsibilities
-not only being able to raise their
children/family well but also being able to
contribute to the community
-frustrations may develop when people realize
they can no longer achieve new work
-feelings of self-acceptance
-sense of dignity, worth and importance
-adaptation to life according to limitations
-valuing ones life
-sharing of wisdom
-exploration of philosophy of life and death

biologic, psychological, social, and environmental factors influence personality

development throughout the life cycle of a person
growth involves resolution of critical tasks at each of the eight developmental stages
lack of resolution of tasks causes incomplete development and difficulties in
change is a process of growth

Sullivans concept
a. observable data



three modes of experiencing and thinking about the world

o prototaxic
undifferentiated thought
not seeing the whole in parts or symbols
usually in infancy
o parataxic
events are causally related because of temporal or serial connections
o syntaxic
logical, rational, and most mature type of cognitive functioning of which a
person is capable of
all three types of thinking and experiencing occur and function side by side in all persons

b. interpersonal theory

The total configuration of traits Self-esteem, which develops in various stages and is
the outgrow of interpersonal stages rather than intrapsychic forces

Infancy (birth to years)
Childhood(1/2 to 6 years)

Juvenile (6-9 years)

Anxiety occurs for the first time as a result of the infants
failure to achieve satisfaction f his her primary needs
The main tasks are to become educated as to the
requirements of the culture and to learn how to deal with
powerful adults
Child has a need for and must learn how to deal with peers


Pre-adolescence (9-12 years)

Early-adolescence (12- 14
Later adolescence ( 14-21


Development of the capacity for love and collaboration with

another person of the same sex develops. CHUM periodprototype of for sense of intimacy
Separation from ones family. Development of standards and
values, and the transition of heterosexuality.
Learns to form lasting sexual relationships

Franz Alexander

developed the concept of corrective emotional experience

people modify the results of their past traumatic events in the analytic situations in
which, with the support and trust from people around, they are able to master the past
traumas and grow from the experience

Gordon Allport

represents the humanistic school of psychology

a sense of self is the only personal guarantee of a person for existence
selfhood develops in stages through:
o propriem- maintenance of self-esteem and identity
o traits-units of personal structure that are common to same culture
o personal dispositions-essence of personality that is unique in every individual
o maturity-greatley extended sense of self and the capacity to relate warmly and
intimately to others.
therefore, people who have developed maturely have zest, enthusiasm,humor, insight,
and security

Eric Berne

developed the so-called transactional analysis

every situation should be recognize as a game or play
with each game, a person is considered a child, an adult or a parent
as a person grows older, he or she should be able to learn and recognize the game and
function as the right kind of player in every game

Erich Fromm

five dominant characters that are possessed and found in every individual
o Receptive-passive
o Exploitative-manipulative



o Marketing-opportunistic and changeable

o Hoarding-saves and stores
o Productive- enjoys love and work
all types are normal, but a person should be able to control it and strengthen it in an
ethical sense

Kurt Goldstein

developed the idea of holoceonosis

every individual strives for fulfillment of ones personalities but as an individual we all
have dynamic properties in which when faced with tensions or disequilibrium, we
always attempt to return to our previous state
when catastrophic situations occur, people have the instinct of becoming fearful,
agitated and regressive and therefore refuses to perform normal and simple tasks which
may lead to permanent failure to cope.

Karen Horney

the three kinds of self-actual, ideal and real

every person has the so-called pride system which pushes the overemphasis of prestige,
intellect, power, strength, appearance and sexual prowess. If not achieved, this could
lead to self-hatred, self-contempt and self- effacement

Abraham Maslow

a hierarchical organization of needs is present in each person.

Physiologic needs, safety needs, love and belongingness, self-esteem and selfactualization



Gender and Withdrawn Behavior

Between men and women, men are more prone to withdrawing than women. This phenomenon
can be attributed to their different gender roles. Freud has theorized that peoples childhood
experiences affect his/her characteristics when they reach adulthood. His theory may be related to a
persons psychosexual factors. Psychosexual factors include a persons sexual identity, gender identity
and gender roles. Sexual identity is defined as the anatomical and physiological characteristics one
possess. This includes the infants external genitalia and genetic influence, which is physiologically active
by the 6th week of fetal life and completed by the end of the 3rd month. Gender identity is the sense of
oneself as being male or female. This is determined by parental and cultural attitudes and physical
characteristics. Gender roles are based on the expectations of the society. This is the public expression
of gender identity. This includes everything that one says or does to indicate to others the degree to
which one is male or female. Gender roles are learned upon observing the behavior of others.
Differences of how men and female relate to emotional or behavioral responses are considered learned

Men and women respond differently to stressful situations. Women tend to share their stress
with others in the hopes of gaining the empathy of others and expect that other females would rely on
them if the roles were reversed. Men, on the other hand, tend to withdraw and act as an individual and
become more egocentric. (Tomova, von Dawans, Heinrichs, Silani & Lamm, 2014). Men have been
discouraged from being emotional since they were kids. They are usually teased when they show their
emotions. Since they are not used to handling emotions, when faced with intense emotions or stressors,
adult men become overwhelmed and confused around these emotions. It takes them more time to
understand and then adapt to emotions, thus causing them to withdraw from a particular situation or a

Associated Disorders
1. Schizophrenia
Withdrawn behavior can be manifested in patients with Schizophrenia. Schizophrenia is the
deterioration of ones personality. This can be attributed to the imbalance, usually due to high amounts,
of dopamine levels in the brain. Bleulers Four As are symptoms that are usually manifested with
schizophrenic patients and includes: Affective disturbance (inappropriate, blunted or flat affect); Autism
(preoccupation with self, little concern for external reality); Associative looseness (stringing together of
unrelated topics) and; Ambivalence (simultaneous opposite feelings). DSM-IV-TR Criteria for
Schizophrenia include: A. At least 2 of the following: delusions, hallucinations, disorganized speech,
grossly disorganized or catatonic behavior or negative symptoms (alogia, anhedonia, apathy, blunted



affect, catatonia, flat affect and avolition); B. Social-occupational dysfunction: work, interpersonal &
self-care functioning below the level achieved before the onset; C. Duration: continuous signs of the
disturbances for at least 6 months; D. Schizoaffective and mood disorders not present and not
responsible for the signs & symptoms and; E. Not caused by substance abuse or a general medical

Kit does not have Schizophrenia. Based on the case, Kit has not had any reports of delusions,
hallucinations, disorganized speech nor grossly disorganized behaviors. But, based on the case, he has
shown some negative symptomsanhedonia, apathy and avolition. Also, it cannot be concluded that he
has had a social-occupational dysfunction because there was no evidence shown that he was more
social before than he is upon physical work up.

2. Personality Disorder
Personality disorders are lifelong, inflexible and dysfunctional patterns of behaving and relating.
DSM-IV-TR Criteria for a Personality Disorder would include the presence of at least two of the
following: A. Cognition (thinking about self, people and events); B. Affectivity (range, intensity, lability
and appropriateness of emotional response); C. Interpersonal functioning or; D. Impulse control.
Personality disorders are divided into three clusters namely: Cluster A: Odd-Eccentric behaviors, which
includes paranoid, schizoid and schizotypal personality disorders; Cluster B: Dramatic, Emotional, Erratic
behaviors that includes antisocial, borderline, narcissistic, and histrionic personality disorders and;
Cluster C: Anxious-Fearful behaviors that includes dependent, avoidant and obsessive-compulsive
personality disorders. Cluster A personality disorders are associated with withdrawn behavior.

2.1. Paranoid Personality Disorder

Paranoid personality disorder are those who are suspicious of others, doubts trustworthiness or
loyalty of friends and others, fears confiding in others, interprets remarks as demeaning or threatening,
holds grudges toward others and becomes angry & threatening when he/she perceives being attacked
by others. These people tend to withdraw because of their distrust in the people around them.

Kit does not have a paranoid personality disorder because it was not stated whether he was
suspicious of others. Plus, as seen in the criteria, paranoid personality disorders still have interpersonal
relationships with others and they are still open to the idea of intimacy.

2.2. Schizotypal Personality Disorder



Criteria for schizotypal personality disorders include: ideas of reference, magical thinking or odd
beliefs, unusual perceptual experiences (bodily illusions), odd thinking & vague, stereotypical,
overelaborate speech, suspicious, blunted or inappropriate affect, odd or eccentric appearance or
behavior, few close relationships and excessive social anxiety. They are uncomfortable around others
but are interested in other people. These people tend to withdraw because social situations are
uncomfortable because of the reactions of others to the persons appearance and behavior.

Based from the case, Kit does not have a schizotypal personality because none of the criteria for
schizotypal personality disorders matches him.

2.3. Schizoid Personality Disorder

People suffering from schizoid personality disorder manifests with a lack of desire for close
relationships or friends, chooses solitary activities, little interest in sexual experiences, avoids activities,
appears cold and detached, lacks close friends, appears indifferent to praise or criticism. They become
loners, vagrants or hermits. They may have a preference for numbers rather than people and may
function well as mathematicians or with computers. Their isolation makes them prone to depression.
These people withdraw because of the fact that they do not enjoy social interactions.

Based on the results of Kits physical work-up, he can be considered to have a schizoid
personality. This is evidences by the fact that he has no contact with his family, him not maintaining any
friendships, choosing to live alone, apathy regarding dearth of social structures, never having engaged in
dating or other social activities, preference to work alone at home, inability to name any hobbies or
activities that he finds enjoyable and the fact that he works as a data encoder on a night shift.




1. Active Friendliness:
Other terms are tender loving care and giving and love unsolicited. Patients needs are attended
to like bathing, combing hair, cutting fingernails
Since the patient is withdrawn and doesnt approach anybody, the approach has to be made from
the nurses side and many attempts will have to be made to initiate any conversation or
Doing everything within our power to give pleasure to the patient
Attention is given to the patient before he requests it
Used with individuals who are withdrawn and apathetic

1. Make contact or link with the patient. Therapeutic use of family or close friends may be helpful.
2. Establish and maintain a trusting relationship. Staff must be aware that this may be a lengthy
process requiring patience and perseverance and that the patient may initially reject them.
3. Respect the patients need for silence and inform the patient that the staff is always available when
he/she has a need to communicate.
4. Touch may be used therapeutically by staff who feel comfortable with touch and according to the
patients reception of touch.
5. Maintain consistency regarding appointment times.
6. Give the patient a positive feedback to both verbal and non-verbal responses.
7. Avoid comments like Seeing you arent busy to a colleague sitting with a withdrawn patient.
8. Gradually introduce the patient to other people and then explore feelings with regard to contact
made with others.
9. Gradually introduce and involve the patient in lifestyle activities again.
10. Use friends and family as a link with the community.


Nursing Interventions
Initially encourage the client to spend short
periods of time with other person


At first client will deal more readily with
minimal stimulation

Initially encourage the client to express himself Nonverbal communication usually is less
or herself nonverbally
threatening than verbalization
Encourage the client to talk about these
nonverbal communication and progress to
more direct verbal communication as
tolerated. Encourage the client to express
feelings as much as possible.

By asking the client about writings or drawings

rather than directly about himself or herself or
emotional issues, you minimize the clients
perception of threat. Gradually direct verbal
communication becomes tolerable to the

Interact on a one-to-one basis initially, and

then help the client progress to small groups,
then larger groups as tolerated.

Gradual introduction of other people

minimizes the threat perceived by the client.

Explain any task in short, simple steps

A complex task will be easier for the client if it

is broken down into a series of steps.

Using clear, direct sentence, instruct the client

to do one part of the task at a time.
Tell the client your expectations directly. Do
not ask the client to choose unnecessarily. Tell
the client it is time to eat or dressed rather
than asking if she or he wants to eat or dress.
Do not confuse the client with reasons as to
why things are to be done.

The client may not be able to remember all the

steps at once.

The client may not be able to make choices or

make poor choices

Abstract ideas will not be comprehended and

will interfere with task completion.

Allow the client ample time to complete the


It may take the client longer to complete tasks

because of lack of concentration and short
attention span.

Remain with the client throughout the task; do

not attempt to hurry the client. Assist the
client throughout the task; do not attempt to
hurry the client.

Trying to rush the client will frustrate him or

her and make completion of the task

Assist the client as needed to maintain daily

functions and adequate personal hygiene.

The clients sense of dignity and well- being is

enhanced if she or he is clean, smells good,
looks nice and so forth.

Teach the client social skills, and encourage

practice with staff members and other clients.

Increasing the clients social skills and


Give the client feedback about interactions.
Encourage the client to identify and build
relationship with supportive group outside of
the primary care given by the nurse.
Gradually withdraw assistance and supervise
the clients grooming or other self-care skills.
Praise the client for initiating and completing
activities of daily living.
Teach the client social skills. Describe and
demonstrate specific skills, such as eye
contact, attentive listening, nodding, and so
forth. Discuss topics appropriate for casual
social conversation, such as weather, local
events, news, and so forth.
*Assist the client to approach someone and
ask a question. Use real-life situations, such as
seeking assistance in a store, asking directions,
or renting an apartment.
Practice giving and receiving compliments with
the client. Make sure compliments are sincere.

*Role play situations in which the client must

accept no to a request and in which the
client must appropriately refuse a request
from someone else.


confidence can help decrease social isolation.

Increasing the clients support system may

help prevent withdrawn behavior in the

It is important fort he client to gain

independence as soon as possible. Positive
reinforcement increases the likelihood or

The client may have little or no knowledge of

social interaction skills. Modeling provides a
concrete example of the desired skills.

Asking questions is an essential skill in daily

life. Using real situations makes the exercise
more meaningful for the client.

Chronically mentally ill clients rarely notice

things about other people without practicing
that skill. Receiving compliments can be
awkward due to low self-esteem.
Low frustration tolerance makes hearing a
negative answer difficult for the client. Clients
frequently comply with requests from others,
then regret doing so because they are unable
to refuse in a socially appropriate manner.


Arrange nonthreatening activities that involve these patients in doing something like painting
Arrange furniture in a semicircle or around a table this forces patients to sit with someone.
This will permit interactions but should never be demanded
Provide psychosocial rehabilitation that is training in community living, social skills and health
care skills




Behaviour Therapy
Cognitive Therapy
Dialectical Behavioural Therapy
Interpersonal Therapy
Psychodynamic Therapy
Family Therapy
Group Therapy

BEHAVIOUR THERAPY focused on helping an individual understand that when they change their
behaviour it can lead to changes in how they are feeling.
a. SELF MONITORING person is asked to keep a detailed log of all their activities during the day. The
therapist can see exactly the person is doing.
b. SCHEDULE OF WEEKLY ACTIVITIES the patient and the therapist work together to develop new
activities that will provide the patient with chances of positive experience.
c. ROLE PLAYING used to help person develop new skills and anticipate issues that may come up in
social interactions
d. BEHAVIOUR MODIFICATION patient will receive a reward for engaging in a positive behaviour.

INTERPERSONAL THERAPY focuses on the interpersonal relationships

a. IDENTIFICATION OF EMOTION helping the person identify what their emotion is and where is it
coming from
b. EXPRESSION OF EMOTION involves helping the person express their emotions in a healthy way.
c. DEALING WITH EMOTIONAL BAGGAGE often, people bring unresolved issues from past
relationships to their present relationships.
GROUP THERAPY a therapist and six to twelve participants with related problems
ACTIVITY THERAPIES self-expressive, interactive and with acceptance



a. ART AND MUSIC THERAPY increases self-esteem, openness, expression of feeling and reduce
b. RECREATIONAL THERAPY fun and relives tension
c. EXERCISE promote physical and mental health
*Challenging activities are not encouraged for withdrawn patients especially in early phase because not
being able to accomplished the activities will lead to decrease self-esteem thus patient may become
more withdrawn.

ASSERTIVENESS TRAINING first used in behaviour therapy to countercondition social anxiety.

ASSERTIVESS BEHAVIOR enables a person to act in his or her own best interest, to stand up for himself
or herself without undue anxiety, to express honest feelings comfortably and to exercise personal rights
without denying the rights of others.
ASSERTIVENESS COMMUNITY TREATMENT intensive and highly integrated approach for community
mental health service delivery
-serve outpatients
- array of services provided by community-based, mobile mental health treatment teams
- designed to provide comprehensive, community-based psychiatric treatment, rehabilitation, and
support to persons with serious and persistent mental illness who live in the community.

Programs include are:

Personal wellness assessments

Goal setting and motivational counselling
Group physical activity / exercise programs
Group health and wellness learning sessions
Self-management peer support programs
Wellness Navigation to help individuals and families to find appropriate services, support, or
programs that are needed to support health and wellness