ASSESSMENT

History

Onset is in childhood or adolescence, though formal diagnosis is not made until the
client is 18 years old.

Childhood histories of enuresis, sleepwalking, and syntonic acts of cruelty are

characteristic predictors.

In adolescence, 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 (Stevens, 2018).

General Appearance and Motor Behavior

Appearance is usually 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.

Mood and Affect

Clients often display false emotions chosen to suit the occasion or to work to their
advantage. For example, a client 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 client’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 views of the world are narrow
and distorted. Because coercion 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” represent
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 alterations, 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 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 situation 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, but actually the self is quite shallow and empty; these clients are devoid of
personal 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 others only for personal gain. They never think about the
repercussions of their actions to others. For example, a client is caught scamming an
older person out of his or 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 are often involved in many relationships, sometimes simultaneously. They
may marry and have children, but they cannot sustain long-term commitments. They
are usually unsuccessful as spouses and parents and leave others abandoned and
disappointed. They may obtain employment readily with their adept use of superficial
social skills, but over time, their work history is poor. Problems may result from
absenteeism, theft, or embezzlement, or they may quit simply out of boredom.

DIAGNOSIS

There is no test that is used to diagnose antisocial personality disorder. The initial step
is to rule out physiologic and other mental disorders causing the symptoms before
reaching a psychiatric diagnosis.

The psychiatric diagnosis of antisocial personality disorder requires the following:

 The patient is at least 18 years old.

 Since age 15, the patient has demonstrated three or more of the following:
o Failure to sustain consistent employment
o Impulsivity
o Irritability
o Deceitfulness
o Lack of remorse
o Aggressiveness
o Unlawful acts
o Serious rule violations
o Property destruction

NURSING DIAGNOSIS

 Risk for ineffective relationships related to antisocial behavior

 Ineffective coping related to failure to express feelings
 Impaired social interaction related to manipulative behavior
 Risk for other-directed violence
 Defensive coping
 Impaired social interaction
 Ineffective health maintenance.

PLANNING

Immediate

The client will

 Refrain from harming self or others throughout hospitalization.

 Identify behaviors leading to hospitalization within 24 to 48 hours.
  Function within the limits of the therapeutic milieu; for example, follow no-
smoking rules, participate in group activities within 2 to 3 days.

Stabilization

The client will

 Demonstrate nondestructive ways to deal with stress and frustration.

 Identify ways to meet own needs that do not infringe on the rights of others.

Community

The client will

 Achieve or maintain satisfactory work performance.

 Meet own needs without exploiting or infringing on the rights of others.

NURSING INTERVENTION

Forming a Therapeutic Relationship and Promoting Responsible Behavior

The nurse must provide structure in the therapeutic relationship, identify

acceptable and expected behaviors, and be consistent in those expectations. He or she
must minimize attempts by these clients to manipulate and control the relationship.

Limit setting is an effective technique that involves three steps:

1. Stating the behavioral limit (describing the unacceptable behavior)

2. Identifying the consequences if the limit is exceeded
3. Identifying the expected or desired behavior

Consistent limit setting in a matter-of-fact nonjudgmental manner is crucial to

success. For example, a client may approach the nurse flirtatiously and attempt to gain
personal information.

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

Confrontation is another technique designed to manage manipulative or

deceptive behavior. The nurse points out a client’s problematic behavior while
remaining neutral and matter-of-fact; he or she avoids accusing the client. The nurse can
also 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.
Helping Clients Solve Problems and Control Emotions

Clients with antisocial personality disorder have an established pattern of

reacting impulsively when confronted with problems. The nurse can teach problem-
solving skills and help clients practice them. Problem-solving skills include identifying
the problem, exploring alternative solutions and related consequences, 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 or she stops going to work.
The problem is transportation to work; alternative solutions might be taking the bus,
asking a coworker for a ride, and getting the car fixed. The nurse can help the client
discuss the various options and choose one so that he or she 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 in anticipating stressful situations and to learn ways to avoid negative
future consequences. Taking a time-out or leaving the area and going to a neutral place
to regain internal control is often a helpful strategy. Time-outs help clients to avoid
impulsive reactions and angry outbursts in emotionally charged situations, regain
control of emotions, and engage in constructive problem-solving.

 Promoting responsible behavior

 Limit setting
o State the limit.
o Identify the consequences of exceeding the limit.
o Identify the expected or acceptable behavior.
 Consistent adherence to rules and treatment plan
 Confrontation
 Point out the problem behavior.
 Keep the client focused on him or herself.
 Help clients solve problems and control emotions.
 Effective problem-solving skills
 Decreased impulsivity
 Expressing negative emotions such as anger or frustration
 Taking a time-out from stressful situations
 Enhancing role performance
 Identifying barriers to role fulfillment
  Decreasing or eliminating use of drugs and alcohol

EVALUATION

 The client will demonstrate nondestructive ways to express 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 performance (e.g., at work or
as a parent).

REFERENCES

Videbeck, S. L (2020). Psychiatric-Mental Health Nursing Eighth Edition. Wolters

Kluwer
Keogh, K (2014) Psychiatric and Mental Health Nursing Demystified. McGraw-Hill
Education