Which personality system would the nurse identify in a patient who is impulsive and lacks control?

Disruptive, impulse-control, and conduct disorders involve much more critical and constant behaviors than typical, temporary episodes of most children and adolescents. They belong to a group of disorders that involve oppositional defiant disorder, intermittent explosive disorder, conduct disorder, antisocial personality disorder, pyromania, and kleptomania. These disorders can cause individuals to behave violently or aggressively toward others or property. They may have problems controlling and managing their sentiments, emotions, and behavior and may violate rules or laws. Review this study guide and learn more about disruptive, impulse-control and conduct disorders, its nursing care management, interventions, and assessment.

• Description
• Statistics and Incidences
• Causes
• Clinical Manifestations
• Medical Management
  • Pharmacologic Management
  • Nursing Management
  • Nursing Assessment
  • Nursing Diagnosis
  • Nursing Care Planning and Goals
  • Nursing Interventions
  • Evaluation
  • Documentation Guidelines
• Practice Quiz: Disruptive, Impulse-Control, and Conduct Disorders
• References

Description

In DSM-5, oppositional defiant disorder and conduct disorder are presently classified with antisocial personality disorder and intermittent explosive disorder, whereby considering emerging data confirming their clinical and biological commonality along a developmental spectrum. Antisocial personality disorder concerns violations of the rights of others. Intermittent explosive disorder is defined by impulsive aggressive and assaultive behaviors that are out of proportion to stressors.

• Oppositional defiant disorder (ODD). A childhood mental health disorder that includes frequent and persistent pattern of anger, irritability, arguing, defiance or vindictiveness toward a person and other authority figures.
• Intermittent explosive disorder (IED). A disorder that involves repeated, unforeseen episodes of impulsive, destructive, violent behavior or angry verbal outbursts in which the person react grossly out of proportion to the situation.
• Conduct disorder (CD). This disorder is characterized by persistent antisocial behavior in children and adolescents that significantly impairs their ability to function in social, academic, or occupational areas. People with conduct disorder have little empathy for others; they have low self-esteem, poor frustration tolerance, and temper outbursts. Conduct disorder frequently is associated with early onset of sexual behavior, drinking, smoking, use of illegal substances, and other reckless or risky behaviors.
• Antisocial personality disorder (ASPD or APD). A mental condition in which a person has a long-term pattern of manipulating, abusing, or violating the rights of others without any guilt.
  
• Pyromania. A disorder that is characterized by an impulse to set fires. The definition focused on the recurrent failure to resist impulses to set fire in persons who were not psychotic, cognitively impaired, or antisocial.
• Kleptomania. A rare but serious mental health disorder that involves recurrent inability to resist urges to steal items that the person generally doesn’t really need and that usually have little value.

Statistics and Incidences

Conduct disorder occurs between two and 10 percent of the population, with a median prevalence rate of 4 percent. Prevalence rates increase from childhood to adolescence and are higher in males than in females. Oppositional defiant disorder occurs between one and 11 percent of the population, though the average prevalence estimate is around 3.3 percent. It may be more prevalent in males, with a ratio of approximately 1.4:1 prior to adolescence. This prevalence does not consistently continue into adolescence or adulthood. Intermittent explosive disorder occurs in approximately 2.7 percent of the population and is more prevalent among individuals younger than 35-40 years. The prevalence of kleptomania has been estimated at 0.3%–0.6% in the general population.

Causes

Researchers generally accept that genetic vulnerability, environmental adversity, and factors such as poor coping interact to cause the disorder.

• Genetics. There is a genetic risk for conduct disorder, although no specific gene marker has been identified; the disorder is more common in children who have a sibling with conduct disorder or a parent with antisocial personality disorder, substance abuse, mood disorder, schizophrenia, or ADHD.
• Biologic. A lack of reactivity of the autonomic nervous system has been found in children with conduct disorder; this non-responsiveness is similar to adults with antisocial personality disorder.
• Environmental. Poor family functioning, marital discord, poor parenting, and a family history of substance abuse and psychiatric problems are all associated with the development pf conduct disorder.

Clinical Manifestations

Symptoms of oppositional defiant disorder include:

A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.

Angry and irritable mood

• Often loses temper.
• Is often touchy or easily annoyed.
• Is often angry and resentful.

Argumentative and defiant behavior

• Often argues with authority figures or, for children and adolescents, with adults.
• Often actively defies or refuses to comply with requests from authority figures or with rules.
• Often deliberately annoys others.
• Often blames others for his or her mistakes or misbehavior.

Vindictiveness

• Has been spiteful or vindictive at least twice within the past 6 months.

Symptoms of intermittent explosive disorder occurring twice weekly, on average, for a period of 3 months include:

• Verbal aggression
• Temper tantrums
• Tirades
• Verbal arguments or fights
• Physical aggression toward property, animals, or other individuals. The physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals.
• Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period

Symptoms of conduct disorder include:

A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months. 

Aggression to people and animals

• Often bullies, threatens, or intimidates others.
• Often initiates physical fights.
• Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).
• Has been physically cruel to people.
• Has been physically cruel to animals.
• Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).
• Has forced someone into sexual activity.

Destruction of property

• Has deliberately engaged in fire setting with the intention of causing serious damage.
• Has deliberately destroyed others’ property (other than by fire setting).

Deceitfulness or theft

• Has broken into someone else’s house, building, or car.
• Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).
• Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).

Serious violations of rules

• Often stays out at night despite parental prohibitions, beginning before age 13 years.
• Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period.
• Is often truant from school, beginning before age 13 years.

Symptoms of antisocial personality disorder include:

• Pervasive pattern of poor social conformity
• Deceitfulness
• Impulsivity
• Criminality
• Lack of remorse
• Disregard for right and wrong
• Persistent lying
• Being tough, cynical and rude of others
• Using charm or wit to manipulate others for personal gain or personal pleasure
• Arrogance, a sense of superiority and being extremely opinionated
• Recurring problems with the law, including criminal behavior
• Repeatedly violating the rights of others through intimidation and dishonesty
• Hostility, significant irritability, agitation, aggression or violence
• Unnecessary risk-taking or dangerous behavior with no regard for the safety of self or others
• Poor or abusive relationships
• Failure to consider the negative consequences of behavior or learn from them
• Being consistently irresponsible and repeatedly failing to fulfill work or financial obligations

Symptoms of pyromania include:

• Presence of multiple episodes of deliberate and purposeful fire setting and the failure to resist an impulse to set fires on more than one occasion.
• Persons with pyromania like watching the fire in their communities and enjoy setting off false fire alarms.
• Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g., paraphernalia, uses, consequences).
• Pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath.
• Fire setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one’s living circumstances, in response to a delusion or hallucination, or as a result of impaired judgment (e.g., in major neurocognitive disorder, intellectual disability [intellectual developmental disorder], substance intoxication).
• Fire setting is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.

Symptoms of kleptomania include:

• Failure to resist powerful urges to steal items that you don’t need.
• Feeling increased tension, anxiety or arousal leading up to the theft.
• Feeling pleasure, relief or gratification while stealing.
• Feeling terrible guilt, remorse, self-loathing, shame or fear of arrest after the theft.
• Return of the urges and a repetition of the kleptomania cycle.
• Stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination.
• Stealing is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.

Medical Management

Because of the multifaceted nature of conduct problems, particularly related comorbidities, treatment usually includes medication, teaching parenting skills, family therapy, and consultation with the school.

• Preschool. Preschool programs such as Head Start result in lower rates of delinquent behavior and conduct disorder through use of parental education about normal growth and development, stimulation for the child, and parental support during crises.
• School age. For school-aged children with conduct disorder, the child, family, and school environment are the focus of treatment; techniques include parenting education, social skills training to improve peer relationships, and attempts to improve academic performance and increase the child’s ability to comply with demands from authority figures.
• Adolescents. Adolescents rely less on their parents and more on peers, so treatment for this age group includes individual therapy.

Pharmacologic Management

In the short term, stimulant medicine has proven effective in controlling the specific symptoms of inattention, impulsivity, and hyperactivity.

• Stimulants. The first choice for treatment is stimulants due to their relatively safe side effect profile however when misuse/diversion is a risk the choice of medications that are less abusable such as Daytrana (methylphenidate in patch form) or Vyvanse (lis-dexamfetamine -medication is oral however bound to lysine requiring stomach acid digestion in order to be activated).
• Anticonvulsants. Anticonvulsants are considered to be the second group of medications to be used in nonspecific aggression.
• Lithium. Lithium and methylphenidate reduced aggressiveness in one set of studies; however, in subsequent follow-up research, the effectiveness of lithium could not be replicated.

Nursing Management

Nursing care of a client with conduct disorder include the following:

Nursing Assessment

Assessment of a client with conduct disorder include:

• History. Children with conduct disorder have a history of disturbed relationships with peers, aggression toward people and animals, destruction of property, deceitfulness or theft, and serious violation of rules.
• General appearance and motor behavior. Appearance, speech, and motor behavior are typically normal for the age group but may be somewhat extreme.
• Mood and affect. Clients may be quiet and reluctant to talk or openly hostile and angry; their attitude is likely to be disrespectful toward parents, nurse, or anyone in a position of authority.
• Judgement and insight. Judgement and insight are limited for developmental stage; clients consistently break rules with no regard for the consequences.
• Roles and relationships. Relationships with other, especially those in authority, are disruptive and may be violent.

Nursing Diagnosis

Nursing diagnosis commonly used for clients with conduct disorders include the following:

• Risk for other-directed violence related to aggression to other people or animals.
• Noncompliance related to resentment of those in authority.
• Ineffective coping related to low self-esteem.
• Impaired social interaction related to hostility towards those in authority.
• Chronic low self esteem related to lack of value to self.

Nursing Care Planning and Goals

Treatment outcomes for clients with conduct disorders may include the following:

• The client will not hurt others or damage property.
• The client will participate in treatment.
• The client will effective problem solving and coping skills.
• The client will use age-appropriate and acceptable behaviors when interacting with others.
• The client will verbalize positive, age-appropriate statements about self.

Nursing Interventions

Nursing interventions for clients with conduct disorders include the following:

• Decreasing violence and increasing compliance with treatment. The nurse must set limits on unacceptable behavior at the beginning of treatment; for limit setting to be effective, the consequences must have meaning for the clients- that is, they must value or desire recreation time.
• Improving coping skills and self-esteem. The nurse must show acceptance of clients as worthwhile persons even if their behavior is unacceptable; this means that the nurse must be matter-of-fact about setting limits and must not make judgmental statements about clients.
• Promoting social interaction. The nurse identifies what is not appropriate, such as profanity and name-calling, and also what is appropriate; positive feedback is essential to let clients know they are meeting expectations.
• Providing client and family interaction. The nurse can teach parents age-appropriate activities and expectations for clients such as reasonable curfews, household responsibilities, and acceptable behavior at home.

Evaluation

Goals are met as evidenced by:

• The client was able to not hurt others or damage property.
• The client was able to participate in treatment.
• The client was able to effective problem solving and coping skills.
• The client was able to use age-appropriate and acceptable behaviors when interacting with others.
• The client was able to verbalize positive, age-appropriate statements about self.

Documentation Guidelines

Documentation in a client with conduct disorders include:

• Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
• Cultural and religious beliefs, and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward the desired outcome.

Practice Quiz: Disruptive, Impulse-Control, and Conduct Disorders

Nursing practice questions for Conduct Disorder. For more practice questions, visit our NCLEX practice questions page.

1. Martin Sanchez is a nine (9)-year-old child admitted to a psychiatric treatment unit accompanied by Mr. and Mrs. Sanchez. To establish trust and position of neutrality, which action would the nurse take?

A. Encourage Mr. and Mrs. Sanchez to leave while Martin is being interviewed.
B. Interview Martin with his parents together, observing their interaction.
C. Provide diversion for Martin, and interview Mr. and Mrs. Sanchez alone.
D. Review the clinical record prior to interviewing Mr. and Mrs. Sanchez.

1. Answer: B. Interview Martin with his parents together, observing their interaction.

• B: It is important for the nurse to be seen as a neutral person who is interested in the family as an adaptive functioning unit. By conducting the admission interview with the parents and child together, the nurse establishes this neutral role from the beginning.
• A&C: The responses on options A and C separate the parents and the child, and thus the nurse does not have an opportunity to establish a position of neutrality.
• D: Although the nurse would review the clinical record, this does not demonstrate to the family that she is an advocate for both parents and the child.

2. Which behavioral assessment in a child is most consistent with a diagnosis of conduct disorder?

A. Arguing with adults.
B. Gross impairment in communication.
C. Physical aggression toward others.
D. Refusal to separate from caretaker.

2. Answer: C. Physical aggression toward others.

• C: Physical aggression toward others is a significant criterion consistent with the diagnoses of conduct disorder.
• A: Arguing with adults may indicate a lesser disorder, oppositional defiant disorder. Conduct disorder is a problem that involves violation of social rules.
• B and D: Gross impairment in communication and refusal to separate from a caretaker are behaviors that are more consistent with other mental disorders that can affect children.

3. A 15-year-old boy was hospitalized in a psychiatric unit because he initiates frequent fights with peers. Which implementation is most appropriate?

A. Anticipate and neutralize potentially explosive situations.
B. Ignore minor infractions of rules against fighting.
C. Isolate the adolescent from contact with peers.
D. Talk to the adolescent each time fighting occurs.

3. Answer: A. Anticipate and neutralize potentially explosive situations.

• A: The nurse is responsible for maintaining a safe environment; therefore, it would be appropriate to observe for signs that an explosive situation is developing and intervening to neutralize the situation, thereby preventing a fight.
• B: Ignoring minor infractions of rules against fighting in a psychiatric unit would not be a minor infraction and should not be ignored. This could lead to unsafe situations that could escalate out of control.
• C: Isolation and seclusion are methods of intervention that can be used as a last resort after less restrictive means are employed.
• D: Talking to the adolescent each time a fight occurs does not indicate that the nurse is setting and enforcing clear, consistent rules. The nurse needs to maintain safety and would not allow fighting to occur if it could be avoided.

4. Nurse Gloria questions the parents of a child with oppositional defiant disorder about the roles of each parent in setting rules of behavior. The purpose for this type of questioning is to assess which element of the family system?

A. Anxiety levels.
B. Generational boundaries.
C. Knowledge of growth and development.
D. Quality of communication.

4. Answer: B. Generational boundaries.

• B: An important element in assessing the family system is determining if the parents establish and maintain appropriate generational boundaries, establishing clear rules and expectations as part of the parental role.
• A: Although the parents may have anxiety regarding the role of parental rule-setting, the nurse’s question is not adequate to assess the anxiety levels.
• C and D: The question concerns the roles of the parents and the child in rule setting. It does not provide data regarding knowledge of growth and development or communication quality.

5. Nurse Tiffany reinforces the behavioral contract for a child having difficulty controlling aggressive behaviors on the psychiatric unit. Which of the following is the best rationale for this method of treatment?

A. It will assist the child to develop more adaptive coping methods.
B. It will avoid having the nurse be responsible for setting the rules.
C. It will maintain the nurse’s role in controlling the child’s behavior.
D. It will prevent the child from manipulating the nurse.

5. Answer: A. It will assist the child to develop more adaptive coping methods.

• A: Behavioral therapy is employed for the purpose of developing adaptive behavior that will improve coping. The nurse works to enhance the child’s self-functioning and responsibility for his own behavior using appropriate means to develop better coping.
• B: The nurse does not avoid setting rules; it is the responsibility of the nurse to establish and maintain appropriate limits.
• C and D: Although reinforcing behavioral contracts will help prevent manipulative behavior by the child; this is not the best rationale for using behavioral treatment, which aims to improve client behavior.

References

Sources and references for this study guide for therapeutic communication, including interesting studies for your further reading: 

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub. [Link]
• Black, J. M., & Hawks, J. H. (2005). Medical-surgical nursing. Elsevier Saunders,. [Link]
• Videbeck, S. L. (2010). Psychiatric-mental health nursing. Lippincott Williams & Wilkins. [Link]

Which personality system would the nurse identify in a patient who is impulsive and lacks control regarding basic desires quizlet?

Which developmental model would the nurse apply when assessing behavior patterns in patients based on age appropriate development?

Which stage of Freud's psychosexual stages of development would the nurse analyze for in a patient with destructive tendencies?

Which behavior model based on Rogers theory of humanism would the nurse apply when caring for patients?