PSYCHIATRIC NURSING - MIDTERM TOPICS ● A rare but serious mental health disorder that involves

recurrent inability to resist urges to steal items that the

DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT person generally doesn’t really need and that usually
DISORDERS have little value

● Disruptive, impulse-control, and conduct disorders STATISTICS AND INCIDENCES

involve much more critical and constant behaviors than ● Conduct disorder occurs between two and 10 percent of
typical, temporary episodes of most children and the population, with a median prevalence rate of 4
adolescents. percent. Prevalence rates increase from childhood to
● They belong to a group of disorders that involve adolescence and are higher in males than in females.
oppositional defiant disorder, intermittent explosive ● Oppositional defiant disorder occurs between one and 11
disorder, conduct disorder, antisocial personality disorder, percent of the population, though the average
pyromania, and kleptomania. prevalence estimate is around 3.3 percent.
● These disorders can cause individuals to behave violently ● It may be more prevalent in males, with a ratio of
or aggressively toward others or property. approximately 1.4:1 prior to adolescence.
● They may have problems controlling and managing their ● This prevalence does not consistently continue into
sentiments, emotions, and behavior and may violate adolescence or adulthood. Intermittent explosive
rules or laws. disorder occurs in approximately 2.7 percent of the
population and is more prevalent among individuals
DESCRIPTION younger than 35-40 years.
OPPOSITIONAL DEFIANT DISORDER (ODD) ● The prevalence of kleptomania has been estimated at
● A childhood mental health disorder that includes 0.3%–0.6% in the general population.
frequent and persistent pattern of anger, irritability,
arguing, defiance or vindictiveness toward a person and CAUSES
other authority figures. Researchers generally accept that genetic
vulnerability, environmental adversity, and
INTERMITTENT EXPLOSIVE DISORDER (IED) factors such as poor coping interact to cause the
● A disorder that involves repeated, unforeseen episodes disorder
of impulsive, destructive, violent behavior or angry GENETICS
verbal outbursts in which the person reacts grossly out ● There is a genetic risk for conduct disorder, although no
of proportion to the situation. specific gene marker has been identified; the disorder is
more common in children who have a sibling with
CONDUCT DISORDER (CD) conduct disorder or a parent with antisocial personality
● This disorder is characterized by persistent antisocial disorder, substance abuse, mood disorder, schizophrenia,
behavior in children and adolescents that significantly or ADHD.
impairs their ability to function in social, academic, or
occupational areas. BIOLOGIC
● People with conduct disorder have little empathy for ● A lack of reactivity of the autonomic nervous system has
others; they have low self-esteem, poor frustration been found in children with conduct disorder; this
tolerance, and temper outbursts. non-responsiveness is similar to adults with antisocial
● Conduct disorder frequently is associated with early personality disorder.
onset of sexual behavior, drinking, smoking, use of ● Medical and metabolic causes: encephalopathy,
illegal substances, and other reckless or risky behaviors. phenylketonuria, lead poisoning, hyperthyroidism, fragile
x-syndrome, Tourette’s syndrome, brain tumors or
ANTISOCIAL PERSONALITY DISORDER (ASPD history of head trauma.
or APD) ● Teenagers with conduct disorders have been found to be
● A mental condition in which a person has a long-term exposed to cocaine in utero
pattern of manipulating, abusing, or violating the rights
of others without any guilt. PSYCHODYNAMIC
● The child has failed to separate from mother and
PYROMANIA remains in the dependent position.
● A disorder that is characterized by an impulse to set ● Fears of abandonment nurture this dependency.
fires. ● The ego remains in an underdeveloped condition
● The definition focused on the recurrent failure to resist
impulses to set fire in persons who were not psychotic, ENVIRONMENTAL
cognitively impaired, or antisocial. ● Poor family functioning, marital discord, poor parenting,
and a family history of substance abuse and psychiatric
KLEPTOMANIA problems are all associated with the development pf
conduct disorder.
● Theories of family dynamics: contributing factors ● The physical aggression does not result in damage or
✔ Poor parent-child interpersonal relationship destruction of property and does not result in physical
✔ Lack of father figure injury to animals or other individuals.
✔ Parental rejection ● Three behavioral outbursts involving damage or
✔ Lack of secure, permanent family group, as destruction of property and/or physical assault involving
experienced by orphan or foster children during physical injury against animals or other individuals
institutional living. occurring within a 12-month period
✔ Failure to bond during infancy
✔ Incompatibility of the child’s and parents’ SYMPTOMS OF CONDUCT DISORDER INCLUDE:
temperament A repetitive and persistent pattern of behavior in which
✔ Inconsistency in setting limits and disciplining a the basic rights of others or major age-appropriate
child by parents or authority figures. societal norms or rules are violated, as manifested by
✔ Large family size the presence of at least three of the following 15
✔ Association with lower socioeconomic class criteria in the past 12 months from any of the
children, including exposure to ‘delinquent categories below, with at least one criterion present in
groups’. the past 6 months.
✔ Parents with anti-social personality disorders and
or alcohol dependence AGGRESSION TO PEOPLE AND ANIMALS
● Often bullies, threatens, or intimidates others.
CLINICAL MANIFESTATIONS ● Often initiates physical fights.
SYMPTOMS OF OPPOSITIONAL DEFIANT ● Has used a weapon that can cause serious physical harm
DISORDER INCLUDE: to others (e.g., a bat, brick, broken bottle, knife, gun).
A pattern of angry/irritable mood, argumentative/defiant ● Has been physically cruel to people.
behavior, or vindictiveness lasting at least 6 months as ● Has been physically cruel to animals.
evidenced by at least four symptoms from any of the ● Has stolen while confronting a victim (e.g., mugging,
following categories, and exhibited during interaction purse snatching, extortion, armed robbery).
with at least one individual who is not a sibling. ● Has forced someone into sexual activity.

ANGRY AND IRRITABLE MOOD DESTRUCTION OF POVERTY

● Often loses temper. ● Has deliberately engaged in fire setting with the
● Is often touchy or easily annoyed. intention of causing serious damage.
● Is often angry and resentful. ● Has deliberately destroyed others’ property (other than
by fire setting).
ARGUMENTATIVE AND DEFIANT
BEHAVIOR DECEITFULNESS OR THIEF
● Often argues with authority figures or, for children and ● Has broken into someone else’s house, building, or car.
adolescents, with adults. ● Often lies to obtain goods or favors or to avoid
● Often actively defies or refuses to comply with requests obligations (i.e., “cons” others).
from authority figures or with rules. ● Has stolen items of nontrivial value without confronting
● Often deliberately annoys others. a victim (e.g., shoplifting, but without breaking and
● Often blames others for his or her mistakes or entering; forgery).
misbehavior.
SERIOUS VIOLATION OF RULES
VINDICTIVENESS ● Often stays out at night despite parental prohibitions,
● Has been spiteful or vindictive at least twice within the beginning before age 13 years.
past 6 months. ● Has run away from home overnight at least twice while
living in the parental or parental surrogate home, or
SYMPTOMS OF INTERMITTENT EXPLOSVIE once without returning for a lengthy period.
DISORDER ● Is often truant from school, beginning before age 13
OCCUR TWICE WEEKLY, ON AVERAGE, FOR A years.
PERIOD OF 3 MONTHS INCLUDE:
● Verbal aggression SYMPTOMS OF ANTISOCIAL PERSONALITY
● Temper tantrums ● Pervasive pattern of poor social conformity
● Tirades ● Deceitfulness
● Verbal arguments or fights ● Impulsivity
● Physical aggression toward property, animals, or other ● Criminality
individuals. ● Lack of remorse
● Disregard for right and wrong
● Persistent lying
● Being tough, cynical and rude of others includes medication, teaching parenting skills, family
● Using charm or wit to manipulate others for personal therapy, and consultation with the school.
gain or personal pleasure
● Arrogance, a sense of superiority and being extremely PRESCHOOL
opinionated ● Preschool programs result in lower rates of delinquent
● Recurring problems with the law, including criminal behavior and conduct disorder through use of parental
behavior education about normal growth and development,
● Repeatedly violating the rights of others through stimulation for the child, and parental support during
intimidation and dishonesty crises.
● Hostility, significant irritability, agitation, aggression or
violence SCHOOL AGE
● Unnecessary risk-taking or dangerous behavior with no ● For school-aged children with conduct disorder, the child,
regard for the safety of self or others family, and school environment are the focus of
● Poor or abusive relationships treatment; techniques include parenting education,
● Failure to consider the negative consequences of social skills training to improve peer relationships, and
behavior or learn from them attempts to improve academic performance and increase
● Being consistently irresponsible and repeatedly failing to the child’s ability to comply with demands from authority
fulfill work or financial obligations figures.

SYMPTOMS OF PYROMANIA ADOLESCENTS

● Presence of multiple episodes of deliberate and ● Adolescents rely less on their parents and more on
purposeful fire setting and the failure to resist an peers, so treatment for this age group includes individual
impulse to set fires on more than one occasion. therapy.
● Persons with pyromania like watching the fire in their
communities and enjoy setting off false fire alarms. PHARMACOLOGIC MANAGEMENT
● Fascination with, interest in, curiosity about, or attraction In the short term, stimulant medicine has proven
to fire and its situational contexts (e.g., paraphernalia, effective in controlling the specific symptoms of
uses, consequences). inattention, impulsivity, and hyperactivity.
● Pleasure, gratification, or relief when setting fires or
when witnessing or participating in their aftermath STIMULANTS
● Fire setting is not done for monetary gain, as an ● The first choice for treatment is stimulants due to their
expression of sociopolitical ideology, to conceal criminal relatively safe side effect profile however when
activity, to express anger or vengeance, to improve one’s misuse/diversion is a risk the choice of medications that
living circumstances, in response to a delusion or are less abusable such as Daytrana (methylphenidate in
hallucination, or as a result of impaired judgment (e.g., patch form) or Vyvanse (lis-dexamfetamine -medication
in major neurocognitive disorder, intellectual disability is oral however bound to lysine requiring stomach acid
[intellectual developmental disorder], substance digestion in order to be activated).
intoxication).
● Fire setting is not better explained by conduct disorder, a ANTICONVULSANTS
manic episode, or antisocial personality disorder ● Anticonvulsants are considered to be the second group
of medications to be used in nonspecific aggression.
SYMPTOMS OF KLEPTOMANIA
● Failure to resist powerful urges to steal items that you LITHIUM
don’t need. ● Lithium and methylphenidate reduced aggressiveness in
● Feeling increased tension, anxiety or arousal leading up one set of studies; however, in subsequent follow-up
to the theft. research, the effectiveness of lithium could not be
● Feeling pleasure, relief or gratification while stealing. replicated.
● Feeling terrible guilt, remorse, self-loathing, shame or
fear of arrest after the theft. NURSING MANAGEMENT
● Return of the urges and a repetition of the kleptomania NURSING ASSESSMENT
cycle. ● History - Children with conduct disorder have a history
● Stealing is not committed to express anger or vengeance of disturbed relationships with peers, aggression toward
and is not in response to a delusion or a hallucination. people and animals, destruction of property,
● Stealing is not better explained by conduct disorder, a deceitfulness or theft, and serious violation of rules.
manic episode, or antisocial personality disorder. ● General appearance and motor behavior-
Appearance, speech, and motor behavior are typically
MEDICAL MANAGEMENT normal for the age group but may be somewhat
Because of the multifaceted nature of conduct problems, extreme.
particularly related comorbidities, treatment usually
● Mood and affect - Clients may be quiet and reluctant
to talk or openly hostile and angry; their attitude is likely INTERVENTIONS (CONDUCT DISORDER)
to be disrespectful toward parents, nurse, or anyone in a ● Planned interventions should be focused on maintaining
position of authority. safety and helping the child or adolescent develop
● Judgement and insight - Judgement and insight are internal limits, problem-solving skills and
limited for developmental stage; clients consistently self-responsibility for acts of anti-social behavior.
break rules with no regard for the consequences. ● If there is an underlying medical problem, treat it.
● Roles and relationships - Relationships with other, ● Establish trust by being honest
especially those in authority, are disruptive and may be ● Maintain control by setting limits for manipulative,
violent. acting-out behavior.
● Be consistent with limit setting
NURSING DIAGNOSIS ● Respect the child’s age and maintain an adult-child or
Nursing diagnosis commonly used for clients with child-adult relationship, whichever is appropriate
conduct disorders include the following: ● Establish realistic expectations
● Risk for other-directed violence related to aggression to ● Psychotherapy such as group therapy can also benefit
other people or animals. the child
● Noncompliance related to resentment of those in ● Medication can also be used to alleviate symptoms of
authority. depression or other co-morbid disorders like ADHD
● Ineffective coping related to low self-esteem.
● Impaired social interaction related to hostility towards MEDICATIONS
those in authority. ● Antipsychotics
● Chronic low self-esteem related to lack of value to self. ● Stimulants: Ritalin, Amphetamine
● Antidepressants: SSRIs
NURSING CARE PLANNING AND GOALS ● Mood stabilizers: carbamazepine (Tegretol)
Treatment outcomes for clients with conduct disorders ● Alpha adrenergic agonist: Clonidine (Catapres) might
may include the following: help with impulsive and disordered behaviors
● The client will not hurt others or damage property.
● The client will participate in treatment. EVALUATION
● The client will utilize effective problem solving and Goals are met as evidenced by:
coping skills. ● The client was able to not hurt others or damage
● The client will use age-appropriate and acceptable property.
behaviors when interacting with others. ● The client was able to participate in treatment.
● The client will verbalize positive, age-appropriate ● The client was able to effective problem solving and
statements about self. coping skills.
● The client was able to use age-appropriate and
NURSING INTERVENTIONS acceptable behaviors when interacting with others.
Nursing interventions for clients with conduct disorders ● The client was able to verbalize positive, age-appropriate
include the following: statements about self.
● 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.