Tanta University

Faculty of nursing
Doctoral degree, 2ed semester
2023/2024

Impulsive Control Disorders

Under supervision of

[Link]/ Zebeda Alsherif

Prepared by
Hala Mohammed Ezz

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Out lines

1. Introduction
2. Oppositional Defiant Disorder
3. Intermittent Explosive Disorder
4. Conduct Disorder
5. Keleptomania??
6. Pyromania??
7. Techniques for Managing Disruptive Behaviors
8. advanced Practice Interventions
9. Application of the Nursing Process Assessment

Epidemiology for all ??

Etiology for all ??

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Introduction

Disruptive, impulse control and conduct disorders are characterized by

aggressive behaviors and emotions. Problems relating to others in socially
acceptable ways result in a lack of healthy relationships, leaving the
individual isolated and the family devastated. The behaviors related to these
disorders can have severe criminal consequences and long-lasting negative
personal impacts. Recognizing and treating aggressive and impulsive
behaviors while a person is young can prevent further problems and avoid
interactions with the criminal justice system. Unfortunately, stigma and
misconceptions around mental illness may cause individuals and their
families to conceal these conditions. Concealment can limit help-seeking
and professional care, preventing timely intervention.

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According to the American Psychiatric Association (APA; 2013), major
disorders considered under this umbrella include:

• Oppositional defiant disorder

• Intermittent explosive disorder

• Conduct disorder

1. Oppositional Defiant Disorder

Defined

Oppositional defiant disorder (ODD) is characterized by a pattern of angry

mood and defiant behavior that occurs more frequently than is usually
observed in individuals of comparable age and developmental level and
interferes with social, occupational, or other important areas of functioning
(APA, 2013).

Predisposing factor

1. Physiological

a. Birth Temperament: The term temperament refers to personality traits

that become evident very early in life and may be present at birth. Evidence
suggests a genetic component in temperament and an association between
temperament and behavioral problems later in life.

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b. Genetics: Family, twin, and adoptive studies have revealed a significantly
higher number of conduct disorders among those who have family members
with the disorder.

2. Psychosocial

a. Peer Relationships: Social groups have a significant impact on a child’s

development. Peers play an essential role in the socialization of interpersonal
competence, and skills acquired in this manner affect the child’s long-term
adjustment.

“Considerable research indicates that the deviant peer group provides

training in criminal and delinquent behavior including substance abuse”
(Bernstein, 2014). In addition to evidence that engaging in risk-taking
behaviors can yield reinforcement (acceptance within a peer group),

Bernstein notes that “studies of neural processing show that risk-taking may
be associated with reward-related brain activation.”

b. Theory of Family Dynamics: The following factors related to family

dynamics have been implicated as contributors in the predisposition to
conduct disorder

• Parental rejection

• Inconsistent management with harsh discipline

• Early institutional living

• Frequent shifting of parental figures

• Large family size

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• Absent father

• Parents with antisocial personality disorder and/or alcohol dependence

• Marital conflict and divorce

• Inadequate communication patterns

• Parental permissiveness

DSM-5 Criteria for Oppositional Defiant Disorder

A. 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/Irritable Mood

1. Often loses temper.

2. Is often touchy or easily annoyed.

3. Is often angry and resentful.

Argumentative/Defiant Behavior

4. Often argues with authority figures or, for children and adolescents, with
adults.

5. Often actively defies or refuses to comply with requests from authority

figures or with rules.

6. Often deliberately annoys others.

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7. Often blames others for his or her mistakes or misbehavior.

Vindictiveness

8. Has been spiteful or vindictive at least twice within the past 6 months.
Note: The persistence and frequency of these behaviors should be used to
distinguish a behavior within normal limits from a symptomatic behavior.
For children younger than 5 years, the behavior should occur on most days
for a period of at least 6 months unless otherwise noted (Criterion A8). For
individuals 5 years or older, the behavior should occur at least once per
week for at least 6 months unless otherwise noted (Criterion A8). While
these frequency criteria provide guidance on a minimal level of frequency to
define symptoms, other factors should also be considered such as whether
the frequency and intensity of the behaviors are outside a range normative
for the individual’s developmental level, gender, and culture.

B. The disturbance in behavior is associated with distress in the individual or

others in his or her immediate social context (e.g., family, peer group, work
colleagues) or it impacts negatively social, educational, occupational, or
other important areas of functioning.

C. The behaviors do not occur exclusively during the course of a psychotic,

substance use, depressive, or bipolar disorder. Also, the criteria are not met
for disruptive mood dysregulation disorder.

Specify current severity:

Mild: Symptoms are confined to only one setting (e.g., at home, at school, at
work, with peers).

Moderate: Some symptoms are present in at least two settings.

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Severe: Some symptoms are present in three or more settings.

Epidemiology

 Oppositional defiant disorder is typically diagnosed around 8 years of

age, but it may be seen as early as age 3 and usually not later than
early adolescence.
 The prevalence of oppositional defiant disorder is globally consistent
and similar across race and ethnicity.
 The lifetime prevalence is nearly 13%. Males are diagnosed three
times more often than females.

Treatment Approaches

A. Psychosocial Interventions
1. Psychosocial interventions include parent training, group therapy, and
anger management.
2. Cognitive-behavioral approaches are also helpful.
3. When treating preschool children, parental intervention is an essential
component.
4. Home visits and programs such as Head Start can reduce future
oppositional behaviors and delinquency.
B. Psychobiological Interventions

Pharmacological Treatment

1. The US Food and Drug Administration (FDA) has not approved any
drugs for the treatment of oppositional defiant disorder.
2. Medications available for oppositional defiant disorder are primarily
used for control of anger and aggression rather than disruptive

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 behaviors. Divalproex sodium (Depakote), an antiseizure medication,
has been shown to reduce reactive aggression and irritability.
3. Oppositional defiant disorder is comorbid with several diagnoses that
do have effective pharmacological treatment—attention deficit
/hyperactivity disorder, depression, and anxiety.
4. Medications may be used to address symptoms related to these other
diagnoses.
5. Evidence indicates that psychostimulants work best for disruptive and
aggressive behaviors in addition to core attention-deficit/hyperactivity
symptoms.
6. Some studies support the use of alpha-2 agonists and atomoxetine
(Strattera), a non-stimulant used for attention-deficit/hyperactivity
disorder as well.

2. Intermittent Explosive Disorder

Intermittent explosive disorder is a pattern of behavioral outbursts

characterized by an inability to control aggressive impulses. The aggression
can be verbal or physical and targeted toward other persons, animals,
property, or even themselves.
DSM-5 Criteria for Intermittent Explosive Disorder

A. Recurrent behavioral outbursts representing a failure to control

aggressive impulses as manifested by either of the following:

1. Verbal aggression (e.g., temper tantrums, tirades, verbal arguments, or

fights) or physical aggression toward property, animals, or other individuals,
occurring twice weekly, on average, for a period of 3 months. Physical

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aggression does not result in damage or destruction of property and does not
result in physical injury to animals or other individuals.

2. 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.

B. The magnitude of aggressiveness expressed during the recurrent outbursts

is grossly out of proportion to the provocation or to any precipitating
psychosocial stressors.

C. The recurrent aggressive outbursts are not premeditated (i.e., they are
impulsive and/or anger-based) and are not committed to achieving some
tangible objective (i.e., money, power, intimidation).

D. The recurrent aggressive outbursts cause either marked distress in the

individual or impairment in occupational or interpersonal functioning or are
associated with financial or legal consequences.

E. Chronological age is at least 6 years (or equivalent developmental level).

F. The recurrent aggressive outbursts are not better explained by another
mental disorder (e.g., major depressive disorder, bipolar disorder, disruptive
mood dysregulation disorder, a psychotic disorder, antisocial personality
disorder, borderline personality disorder) and are not attributable to another
medical condition (e.g., head trauma, Alzheimer’s disease) or the
physiological effects of a substance (e.g., a drug of abuse, a medication). For
children aged 6 to 18 years, aggressive behavior that occurs as part of an
adjustment disorder should not be considered for this diagnosis.

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Note: This diagnosis can be made in addition to the diagnosis of attention-
deficit/hyperactivity disorder, conduct disorder, oppositional defiant
disorder, or autism spectrum disorder when recurrent impulsive aggressive
outbursts are more than those usually seen in these disorders and warrant
independent clinical attention.

Epidemiology

The lifetime prevalence of intermittent explosive disorder is about 7%. It is

more common in males than in females.

This disorder tends to begin in childhood and is more prevalent in people

under the age of 50.

Risk Factors

 Physiological
1. Individuals with intermittent explosive disorder have been found to have
higher than normal levels of inflammatory markers . These inflammatory
markers may facilitate aggression by modulating certain
neurotransmitters. Research demonstrates a direct correlation between
high levels of these markers and actual measures of aggression.
2. Also, higher levels of the hormone testosterone have been associated
with intermittent explosive disorder
 Neurobiological
1. Intermittent explosive disorder is associated with the loss of neurons
in both the amygdala and hippocampus. These changes may play a
role in the pathophysiology of impulsive aggression
2. Abnormalities in serotonin in the limbic area of the brain have been
found in individuals with this diagnosis.
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  Environmental
1. Intermittent explosive disorder is associated with conflict and violence in
the family of origin. Being exposed to violence at an early age makes it
more likely that, as the children mature, the behavior will be repeated.
2. It is common for these families to have a history of addiction and
substance abuse.
3. Childhood maltreatment is a factor strongly associated with impulsive
aggression.
4. Physical abuse is a specific risk factor for developing intermittent
explosive disorder .
5. Sexual abuse is also associated with the development of this disorder.

Treatment Approaches

a. Psychosocial Interventions
 Similar to oppositional defiant disorder treatment, a combination of
therapy and psychopharmacology is most beneficial.
 Both individual and group cognitive behavioral therapy has been
shown to be an effective treatment for intermittent explosive disorder .

b. Psychobiological Interventions

Pharmacological Treatment

 Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine

(Prozac) or paroxetine (Paxil) are used based on the premise that
explosive temper is the result of serotonergic dysfunction.
 Another SSRI, escitalopram (Lexapro), has also been shown to
improve social cognition, empathy, and understanding of others.

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  Mood stabilizers, such as lithium, or some of the anticonvulsant
agents, may be used along with an SSRI to increase its beneficial
effects.
 Antipsychotics may also exert a calming effect on the outbursts
associated with intermittent explosive disorder.
 Beta-blocking medications may also help calm individuals with
intermittent explosive disorder by slowing the heart rate and reducing
blood pressure.
 Benzodiazepine medications should be avoided, however, as they may
further reduce inhibitions and self-control in much the same way as
alcohol.

3. Conduct Disorder

Defined

The DSM-5 describes the essential feature of this disorder as a “repetitive

and persistent pattern of behavior in which the basic rights of others or major
age-appropriate societal norms or rules are violated”.

Epidemiology

 Conduct disorder carries a lifetime prevalence of nearly 7%.

 Conduct disorder may be higher in urban settings as compared with
rural areas.
 Childhood onset is more common in males than in females; in
adolescent-onset, the numbers are nearly equal.
 It is stable across races and ethnicities.

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  The diagnosis of conduct disorder is four times more common in
individuals who have previously been diagnosed with oppositional
defiant disorder.

Predisposing Factors

1. Physiological

a. Birth Temperament: The term temperament refers to personality traits

that become evident very early in life and may be present at birth. Evidence
suggests a genetic component in temperament and an association between
temperament and behavioral problems later in life.

b. Genetics: Family, twin, and adoptive studies have revealed a significantly

higher number of conduct disorders among those who have family members
with the disorder.

2. Psychosocial

a. Peer Relationships: Social groups have a significant impact on a child’s

development. Peers play an essential role in the socialization of interpersonal
competence, and skills acquired in this manner affect the child’s long-term
adjustment.

“Considerable research indicates that the deviant peer group provides

training in criminal and delinquent behavior including substance abuse”
(Bernstein, 2014). In addition to evidence that engaging in risk-taking
behaviors can yield reinforcement (acceptance within a peer group),

Bernstein notes that “studies of neural processing show that risk-taking may
be associated with reward-related brain activation.”

14
b. Theory of Family Dynamics: The following factors related to family
dynamics have been implicated as contributors in the predisposition to
conduct disorder:

• Parental rejection
• Inconsistent management with harsh discipline
• Early institutional living
• Frequent shifting of parental figures
• Large family size
• Absent father
• Parents with antisocial personality disorder and/or alcohol dependence
• Marital conflict and divorce
• Inadequate communication patterns
• Parental permissiveness
DSM-5 Criteria for Conduct Disorder

A. 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 following
categories with at least one criterion present in the past 6 months:

Aggression to People and Animals

1. Often bullies, threatens or intimidates others.

2. Often initiates physical fights.
3. Has used a weapon that can cause serious physical harm to others (e.g.,
a bat, brick, broken bottle, knife, gun).

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4. Has been physically cruel to people.
5. Has been physically cruel to animals.
6. Has stolen while confronting a victim (e.g., mugging, purse snatching,
extortion, armed robbery).
7. Has forced someone into sexual activity.
Destruction of Property
8. Has deliberately engaged in fire setting with the intention of causing
serious damage.
9. Has deliberately destroyed others’ property (other than by fire setting).
Deceitfulness or Theft

10. Has broken into someone else’s house, building, or car.

11. Often lies to obtain goods or favors to avoid obligations (i.e., “cons”
others).
12. Has stolen items of nontrivial value without confronting a victim
(e.g., shoplifting but without breaking and entering; forgery).
Serious Violations of Rules

13. Often stays out at night despite parental prohibitions, beginning

before age 13 years.
14. 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.
15. Is often truant from school beginning before age 13 years.
B. The disturbance in behavior causes clinically significant impairment
in social, academic, or occupational functioning.

C. If the individual is age 18 years or older, criteria are not met for
antisocial personality disorder.

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 Specify whether:

Childhood-onset type: Individuals show at least one symptom

characteristic of conduct disorder before age 10 years. Adolescent-onset
type: Individuals show no symptom characteristic of conduct disorder
before age of 10 years.

Unspecified onset: Criteria for a diagnosis of conduct disorder are met,

but there is not enough information available to determine whether the
onset of the first symptom was before or after age 10 years.

Specify if: With limited prosocial emotions .

Specify current severity: Mild, Moderate, Severe

Treatment Approaches

1-Psychosocial Interventions

 Conduct disorder is treated similarly to oppositional defiant disorder.

 Treatment methods are selected based on the behaviors being targeted.
 For example, anger management might be targeted for one individual,
while helping to improve a dysfunctional parent-child relationship
might be the goal for another.
 Parent management skills, problem-solving skills, and multisystemic
therapy are useful in conduct disorder.
 The most successful treatments require parental participation.
 However, if the parents have antisocial traits as well, they are less
likely to be involved in treatment.

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2-Pharmacological Treatment

 Five classes of medications are used for children and adolescents with
conduct disorder: antidepressants, mood stabilizers, stimulants,
antipsychotics, anticonvulsants, and adrenergic medications all show
some efficacy.
 Aripiprazole (Abilify) and risperidone (Risperdal) are two second-
generation antipsychotics that have some proven efficacy in
diminishing aggression associated with conduct disorder.

RELATED DISORDERS

1. Kleptomania is characterized by impulsive, repetitive theft of items

not needed by the person, either for personal use or monetary gain.
Tension and anxiety are high before the theft, and the person feels
relief, exhilaration, or gratification while committing the theft. The
item is often discarded after it is stolen. Kleptomania is more common
in females and often has negative legal, career, family, and social
consequences.
2. Pyromania is characterized by repeated, intentional fire-setting. The
person is fascinated by fire and feels pleasure or relief of tension
while setting and watching the fires. There is neither any monetary
gain nor revenge or other reason, such as concealing other crimes nor
is it associated with another major mental disorder. Pyromania as a
primary disorder is rare. Persons, if caught, become part of the legal
rather than mental health system.

Techniques for Managing Disruptive Behaviors

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1. Behavioral contract: A patient-centered verbal or written agreement
between the patient and nurse or other parties (e.g., family, treatment
team, teacher) about behaviors, expectations, and needs. The contract
is periodically evaluated and reviewed and typically coupled with
rewards and other contingencies, positive and negative.
2. Counseling: Verbal interactions teach, coach, or maintain adaptive
behavior and provide positive reinforcement. It is most effective for
motivated patients and those with well-developed communication and
self-reflective skills.
3. Modeling: A method of learning behaviors or skills by observation
and imitation that can be used in a wide variety of situations. It is
enhanced when the modeler is perceived to be similar (e.g., age,
interests) and attending to the task is required.
4. Role playing: A counseling technique in which the nurse, the patient,
or a group of patients acts out a specified script or role to enhance
their understanding of that role, learn and practice new behaviors or
skills, and practice specific situations. It requires well-developed
expressive and receptive language skills.
5. Planned ignoring: When the staff determines behaviors not to be safe
and only attention seeking, they may be ignored. Additional
interventions may be used in conjunction (e.g., positive reinforcement
for on-task actions).
6. Physical distance and touch control: While touching and closeness
may have a positive effect on many patients, patients with
oppositional defiant, intermittent explosive, and conduct disorders
may need increased personal space and feel threatened by touch.

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7. Redirection: A technique used after an undesirable or inappropriate
behavior to engage or re-engage an individual in an appropriate
activity. It may involve the use of verbal directives (e.g., setting firm
limits), gestures, or physical prompts.
8. Positive feedback: Emotional support and positive feedback are good
for anyone, but they are particularly helpful for individuals who rarely
receive such attention.
9. Clarification as intervention: Sometimes misunderstandings are the
source of frustration and potential loss of control. Helping the patient
to understand the environment and what is happening can reduce
feelings of vulnerability and the urge to strike out.
[Link]: Changing an activity in a way that will decrease the
stimulation or frustration. This requires flexibility and planning to
have an alternative in mind in case the activity is not going well.
11. Limit setting: Involves giving direction, stating an expectation, or
telling the patient what is required. This should be done firmly,
calmly, without judgment or anger, preferably in advance of any
problem behavior occurring, and consistently when in a treatment
setting among multiple staff.
[Link] restitution: Refers to a procedure in which an individual is
required or expected to correct the adverse environmental or relational
effects of his or her misbehavior by restoring the environment to its
prior state, planning to correct his or her actions with the nurse, and
implementing the plan (e.g., apologizing to the persons harmed, fixing
the chairs that are upturned). Simple restitution is not punitive in
nature, and there are typically additional activities involved (e.g.,
counseling).
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 [Link] restraint: Seclusion and restraint may be necessary.

3-Health Teaching and Health Promotion ??

4- Advanced Practice Interventions

1. Cognitive-behavioral therapy (CBT)

Cognitive therapy teaches patients to recognize the onset of the impulse to

explode or act aggressively, to identify circumstances or triggers associated
with the onset, and to develop methods to prevent the maladaptive behaviors
from occurring.

2. Psychodynamic Psychotherapy

Its focus is on underlying feelings and motivations and explores

conscious and unconscious thought processes.

In working with impulse control problems, the therapist may help the
patient to uncover underlying feelings and reasons behind rage or anger.

This may help patients to develop better ways to think about and control
their behavior.

3. Dialectical Behavioral Therapy (DBT)

A specific kind of cognitive-behavioral treatment that has a focus on

Parent Management Training (PMT) impulse control is dialectical
behavioral therapy (DBT).

Skills taught include mindfulness, emotional regulation, distress

tolerance, and personal effectiveness.

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 4. Parent-child interaction Therapy (PCIT)

Therapists such as advanced practice nurses sit behind one-way mirrors and
coach parents through an ear audio device while they interact with their
children.

The advanced practice nurse or other advanced practice provider (e.g.,

psychiatrist, psychologist, counselor, or therapist) can suggest strategies that
reinforce positive behavior in the child or adolescent.

The goal is to improve parenting strategies and thereby reduce problematic

behavior.

5. Parent management training (PMT)

This evidence-based treatment is for children aged 2 to 14 with mild to

severe behavioral problems.

Parents of children with oppositional defiant disorder and conduct disorder

tend to engage in patterns of negative interactions, ineffective harsh
punishments, emotionally charged commands and comments, and poor
modeling of appropriate behaviors.

This treatment targets the parents rather than the child and focuses attention
on reinforcement of positive and prosocial behavior, and on brief, negative
consequences of bad behavior.

6. Multisystemic Therapy (MST)

This evidence-based approach is an intensive family and community-based

program that takes into consideration all of the environments of violent
juvenile offenders.

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Therapists work with caregivers who are on call 24 hours a day, 7 days a
week to go where the child is.

Hanging out with friends is replaced with healthy activities such as sports or
recreational activities.

MST can improve family functioning, school performance, and peer

relationships and can build meaningful social support.

5-Teamwork and Safety???

6-Seclusion and Restraint??

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Application of the Nursing Process Assessment

General Assessment

 Careful assessment is important to separate and understand the

problems.
 With children, interviewing the parents along with the child and then
separately will enrich the value of the assessment.
 Suicide Risk To determine the cause of the distress and the risk of
violence, the nurse must listen carefully to any person expressing the
wish to hurt self or others.
 The number one predictor of suicidal risk is a past suicide attempt.
 Impulsivity and aggression in this population make the possibility of
suicide attempts more likely.
 Areas to explore when assessing suicidal risk include the following:
• Past suicidal thoughts, threats, or attempts
• Existence of a plan, lethality of the plan, and accessibility of the
methods for carrying out the plan
• Feelings of hopelessness, changes in level of energy
• Circumstances, state of mind, and motivation
• Viewpoints about suicide and death (e.g., Has a family member or
friend attempted or completed suicide?)
• Depression and other moods or feelings (e.g., anger, guilt, rejection)
• History of impulsivity, poor judgment, or decreased decision-
making

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Nursing Diagnosis

1. Risk for self or other-directed violence.

As evidenced by :

Body posture rigid, clenches fists and jaw, paces, invades the personal space
of others, history of cruelty to animals, fire setting, and frequent fights,
history of childhood abuse and witnessed family violence; states, “That
wimp of a roommate better stay out of my way.”

Goals/Objectives
Short-term Goals
1. The client will seek out staff at any time if thoughts of harming self or
others should occur.
2. Client will not harm self or others.
Long-term Goal
Client will not harm self or others.
Interventions With Selected Rationales
1. Observe client’s behavior frequently. Do this through routine activities
and interactions to avoid appearing watchful and suspicious. Clients at high
risk for violence require close observation to prevent harm to self or others.
2. Observe for suicidal behaviors: Verbal statements, such as
“I’m going to kill myself” or “Very soon my mother won’t have to worry
herself about me any longer,” or nonverbal behaviors, such as giving away
cherished items or mood swings. Most clients who attempt suicide have
communicated their intent, either verbally or nonverbally.

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3. Determine suicidal intent and available means. Ask, “Do you plan to kill
yourself?” and “How do you plan to do it?” Direct, closed-ended questions
are appropriate in this instance. The client who has a usable plan is at
higher risk than one who does not.
4. Conduct a thorough assessment of risk factors and warning signs for
suicide, including history of ideation and attempts, and engage the patient in
collaborating to identify a safety plan.
5. Help client to recognize when anger occurs and to accept those feelings as
his or her own. Have client keep an “anger notebook,” in which a record of
anger experienced on a 24-hour basis is kept. Information regarding source
of anger, behavioral response, and client’s perception of the situation should
also be noted. Discuss entries with client, suggesting alternative behavioral
responses for those identified as maladaptive.
6. Act as a role model for appropriate expression of angry feelings, and give
positive reinforcement to client for attempting to conform. It is vital that the
client express angry feelings, because suicide and other self-destructive
behaviors are often viewed as a result of anger turned inward on the self.
7. Remove all dangerous objects from client’s environment. The client’s
physical safety is a nursing priority.
8. Try to redirect violent behavior with physical outlets for the client’s
anxiety (e.g., physical exercise, jogging, volleyball). Anxiety and tension can
be relieved safely and with benefit to the client in this manner.
9. Be available to stay with client as anxiety level and tensions begin to rise.
The presence of a trusted individual provides a feeling of security.
10. Staff should maintain and convey a calm attitude to client. Anxiety is
contagious and can be communicated from staff to client and vice versa. A

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calm attitude conveys a sense of control and a feeling of security to the
client.

1. Defensive coping related to impulse control problems.

Possible Etiologies (“related to”)

[Low self-esteem]
[Negative role models]
[Lack of positive feedback]
Defining Characteristics (“evidenced by”)
Denial of obvious problems or weaknesses
Projection of blame or responsibility
Rationalization of failures
Hypersensitivity to criticism
Goals/Objectives

Short-term Goal

Client will verbalize personal responsibility for difficulties experienced in

interpersonal relationships.

Long-term Goal

Client will demonstrate ability to interact with others without becoming

defensive, rationalizing behaviors, or expressing grandiose ideas.

Interventions With Selected Rationales

1. Recognize and support basic ego strengths. Focusing on positive aspects

of the personality may help to improve self-concept.
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2. Encourage client to recognize and verbalize feelings of inadequacy and
need for acceptance from others and to recognize how these feelings
provoke defensive behaviors, such as blaming others for own behaviors.
Recognition of the problem is the first step in the change process toward
resolution.

3. Provide immediate, matter-of-fact, nonthreatening feedback for

unacceptable behaviors. Client may not realize how these behaviors are
being perceived by others. Providing this information in a non-threatening
manner may help to eliminate these undesirable behaviors.

4. Help client identify situations that provoke defensiveness and practice

through role play more appropriate responses. Role playing provides
confidence to deal with difficult situations when they actually occur.

5. Provide immediate positive feedback for acceptable behaviors. Positive

feedback enhances self-esteem and encourages repetition of desirable
behaviors.

6. Help client set realistic, concrete goals and determine appropriate actions
to meet those goals. Success increases self-esteem.

7. With client, evaluate the effectiveness of the new behaviors and discuss
any modifications for improvement. Because of limited problem-solving
ability, assistance may be required to reassess and develop new strategies in
the event that some new coping methods prove ineffective.

3. Impaired Social Interaction

Possible Etiologies (“related to”)

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Self-concept disturbance [Neurological alterations related to premature birth,
fetal distress, precipitated or prolonged labor] [Dysfunctional family system]
[Disorganized or chaotic environments] [Child abuse or neglect]
[Unsatisfactory parent-child relationship] [Negative role models]

Defining Characteristics (“evidenced by”)

[Verbalized or observed] discomfort in social situations [Verbalized or

observed] inability to receive or communicate a satisfying sense of
belonging, caring, interest, or shared history [Observed] use of unsuccessful
social interaction behaviors Dysfunctional interaction with others [Behavior
unacceptable for appropriate age by dominant cultural group]
Goals/Objectives

Short-term Goal

Client will interact in age-appropriate manner with nurse in one to-one

relationship within 1 week.

Long-term Goal

By time of discharge from treatment, client will be able to interact with staff
and peers using age-appropriate, acceptable behaviors.

Interventions With Selected Rationales

1. Develop trusting relationship with client. Be honest; keep all promises;

convey acceptance of the person, separate from unacceptable behaviors (“It
is not you, but your behavior, that is unacceptable.”) Acceptance of the
client increases his or her feelings of self-worth.

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2. Offer to remain with client during initial interactions with others. Presence
of a trusted individual provides a feeling of security.

3. Provide constructive criticism and positive reinforcement for client’s

efforts. Positive feedback enhances self-esteem and encourages repetition of
desirable behaviors.

4. Confront client and withdraw attention when interactions with others are
manipulative or exploitative. Attention to the unacceptable behavior may
reinforce it.

5. Act as a role model for client through appropriate interactions with other
clients and staff members.

6. Provide group situations for client. It is through these group interactions

that client will learn socially acceptable behavior, with positive and negative
feedback from his or her peers.

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adolescent oppositional defiant disorder symptoms in young adult men.
Journal of Child Psychology and Psychiatry. 2013;44(3):264–272.
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features and abnormalities in reward and punishment processing in youth.
Clinical Child and Family Psychology Review. 2013;17(2):125–156.
5. Coccaro E.F, Royce L, Coussons-Read M. Elevated plasma
inflammatory markers in individuals with intermittent explosive disorder
and correlation with aggression in humans. JAMA Psychiatry.
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