Application of the Nursing Process: Antisocial Personality Disorder

APPLICATION OF THE NURSING PROCESS: ANTISOCIAL PERSONALITY DISORDER

Assessment

Clients are skillful at deceiving others, so during assess-ment, it helps to check and to validate information from other sources.

History

Onset is in childhood or adolescence, although formal diagnosis is not made until the client is 18 years of age. Childhood histories of enuresis, sleepwalking, and syn-tonic acts of cruelty are characteristic predictors. In adoles-cence, clients may have engaged in lying, truancy, sexual promiscuity, cigarette smoking, substance use, and illegal activities that brought them into contact with police. Families have high rates of depression, substance abuse, antisocial personality disorder, poverty, and divorce. Erratic, neglectful, harsh, or even abusive parenting frequently marks the childhoods of these clients (Bongers, Koot, van der Ende, & Verhulst, 2007).

General Appearance and Motor Behavior

Appearance usually is normal; these clients may be quite engaging and even charming. Depending on the circumstances of the interview, they may exhibit signs of mild or moderate anxiety, especially if another person or agency arranged the assessment.

Mood and Affect

Clients often display false emotions chosen to suit the occasion or to work to their advantage. For example, a cli-ent who is forced to seek treatment instead of going to jail may appear engaging or try to evoke sympathy by sadly relating a story of his or her “terrible childhood.” The cli-ent’s actual emotions are quite shallow.

These clients cannot empathize with the feelings of others, which enables them to exploit others without guilt. Usually, they feel remorse only if they are caught breaking the law or exploiting someone.

Thought Process and Content

Clients do not experience disordered thoughts, but their view of the world is narrow and distorted. Because coer-cion and personal profit motivate them, they tend to believe that others are similarly governed. They view the world as cold and hostile and therefore rationalize their behavior. Clichés such as “It’s a dog-eat-dog world” repre-sent their viewpoint. Clients believe they are only taking care of themselves because no one else will.

Sensorium and Intellectual Processes

Clients are oriented, have no sensory–perceptual altera-tions, and have average or above-average IQs.

Judgment and Insight

These clients generally exercise poor judgment for various reasons. They pay no attention to the legality of their actions and do not consider morals or ethics when making decisions. Their behavior is determined primarily by what they want, and they perceive their needs as immediate. In addition to seeking immediate gratification, these clients also are impulsive. Such impulsivity ranges from simple failure to use normal caution (waiting for a green light to cross a busy street) to extreme thrill-seeking behaviors such as driving recklessly.

Clients lack insight and almost never see their actions as the cause of their problems. It is always someone else’s fault: some external source is responsible for their situa-tion or behavior.

Self-Concept

Superficially, clients appear confident, self-assured, and accomplished, perhaps even flip or arrogant. They feel fearless, disregard their own vulnerability, and usually believe they cannot be caught in lies, deceit, or illegal actions. They may be described as egocentric (believing the world revolves around them), but actually the self is quite shallow and empty; these clients are devoid of per-sonal emotions. They realistically appraise their own strengths and weaknesses.

Roles and Relationships

Clients manipulate and exploit those around them. They view relationships as serving their needs and pursue oth-ers only for personal gain. They never think about the repercussions of their actions to others. For example, a cli-ent is caught scamming an older person out of her entire life savings. The client’s only comment when caught is “Can you believe that’s all the money I got? I was cheated! There should have been more.”

These clients often are involved in many relationships, sometimes simultaneously. They may marry and have chil-dren, but they cannot sustain long-term commitments. They usually are unsuccessful as spouses and parents and leave others abandoned and disappointed. They may obtain employment readily with their adept use of superfi-cial social skills, but over time their work history is poor. Problems may result from absenteeism, theft, or embezzle-ment, or they may simply quit out of boredom.

Data Analysis

People with antisocial personality disorder generally do not seek treatment voluntarily unless they perceive some personal gain from doing so. For example, a client may choose a treatment setting as an alternative to jail or to gain sympathy from an employer; they may cite stress as a reason for absenteeism or poor performance. Inpatient treatment settings are not necessarily effective for these clients and may, in fact, bring out their worst qualities.

Nursing diagnoses commonly used when working with these clients include the following:

·    Ineffective Coping

·    Ineffective Role Performance

·    Risk for Other-Directed Violence

Outcome Identification

The treatment focus often is behavioral change. Although treatment is unlikely to affect the client’s insight or view of the world and others, it is possible to make changes in behavior. Treatment outcomes may include the following:

·    The client will demonstrate nondestructive ways to ex-press feelings and frustration.

·    The client will identify ways to meet his or her own needs that do not infringe on the rights of others.

·    The client will achieve or maintain satisfactory role per-formance (e.g., at work or as a parent).

Intervention

Forming a Therapeutic Relationship and Promoting Responsible Behavior

The nurse must provide structure in the therapeutic rela-tionship, identify acceptable and expected behaviors, and be consistent in those expectations. He or she must mini-mize attempts by these clients to manipulate and to con-trol the relationship.

Limit setting is an effective technique that involves three steps:

·    Stating the behavioral limit (describing the unaccept-able behavior)

·    Identifying the consequences if the limit is exceeded

·    Identifying the expected or desired behavior

Consistent limit setting in a matter-of-fact nonjudg-mental manner is crucial to success. For example, a client may approach the nurse flirtatiously and attempt to gain personal information. The nurse would use limit setting by saying,

“It is not acceptable for you to ask personal questions. If you continue, I will terminate our interaction. We need to use this time to work on solving your job-related problems.”

The nurse should not become angry or respond to the client harshly or punitively.

Confrontation is another technique designed to man-age manipulative or deceptive behavior. The nurse points out a client’s problematic behavior while remaining neu-tral and matter-of-fact; he or she avoids accusing the cli-ent. The nurse also can use confrontation to keep clients focused on the topic and in the present. The nurse can focus on the behavior itself rather than on attempts by clients to justify it. For example:

Nurse: “You’ve said you’re interested in learning to manage angry outbursts, but you’ve missed the last three group meetings.”

Client: “Well, I can tell no one in the group likes me. Why should I bother?”

Nurse: “The group meetings are designed to help you and the others, but you can’t work on issues if you’re not there.”

Helping Clients Solve Problems and Control Emotions

Clients with antisocial personality disorder have an established pattern of reacting impulsively when con-fronted with problems. The nurse can teach problem-solving skills and help clients to practice them. Problem-solving skills include identifying the problem, exploring alternative solutions and related conse-quences, choosing and implementing an alternative, and evaluating the results. Although these clients have the cognitive ability to solve problems, they need to learn a step-by-step approach to deal with them. For example, a client’s car isn’t running, so he stops going to work. The problem is transportation to work; alterna-tive solutions might be taking the bus, asking a coworker for a ride, and getting the car fixed. The nurse can help the client to discuss the various options and choose one so that he can go back to work.

Managing emotions, especially anger and frustration, can be a major problem. When clients are calm and not upset, the nurse can encourage them to identify sources of frustration, how they respond to it, and the consequences. In this way, the nurse assists clients to anticipate stressful situations and to learn ways to avoid negative future con-sequences. Taking a time-out or leaving the area and going to a neutral place to regain internal control is often a help-ful strategy. Time-outs help clients to avoid impulsive reactions and angry outbursts in emotionally charged situ-ations, regain control of emotions, and engage in construc-tive problem-solving.

Enhancing Role Performance

The nurse helps clients to identify specific problems at work or home that are barriers to success in fulfilling roles. Assess-ing use of alcohol and other drugs is essential when examin-ing role performance because many clients use or abuse these substances. These clients tend to blame others for their failures and difficulties, and the nurse must redirect them to examine the source of their problems realistically. Referrals to vocational or job programs may be indicated.

Evaluation

The nurse evaluates the effectiveness of treatment based on attainment of or progress toward outcomes. If a client can maintain a job with acceptable performance, meet basic family responsibilities, and avoid committing illegal or immoral acts, then treatment has been successful.