Case study on conduct disorder

Conduct disorder

1. Identification Data Name - Shib Kumar Panda Age - 15yr Gender - male Marital status - Unmarried Religion - Hindu Education - 10 th Occupation - Student Address - At- west medinapur , West Bengal Date of admission – 30/06/2018 Diagnosis – Conduct Disorder Ip no:- -- 180630035

2. CHIEF COMPLAINTS :- According to patient I have no interest in studying. I do not want to go to the school. I like to eat gutkha . According to Informants He becomes angry at simple things since 3-4 months. He beats his younger brother most of the time without any reason. He is taking gutkha and pan regularly since 1 year. He was also stealing things of neighbor since 1 year. He does not want to go to school. He was telling lie in everything.

3. According to observer Slurred speech Lack of interest in study Irritability Injury on left upper eyelid Insomnia

4. HISTORY OF PRESENT ILLNESS:- Patient had irritability and aggressiveness before 4 moths ago. But suddenly he started arguing on sily things , he started stealing things from neighbor more frequently. Day before admission he had beat severely to his younger brother. IV. Treatment history He was taking medication for his behavior from local doctor. V. PAST ILLNESS History of past psychiatric illness: Before one year ago he developed violent behavior for which he got admitted in hospital in West Bengal.

5. PERINATAL HISTORY No abnormality found. The patient had cleft lip which was corrected after a surgery after 6 months. FAMILY HISTORY His grand father had the history of mental illness.

6. MENTAL STATUS EXAMINATION Appearance: Patients height is 170cm and weight is 66 kg. He has moderate body built. His grooming was appropriate to the time of the day. Behavior: He had the aggressive behaviour towards his Father.

7. Attitude He was very open and cooperative . Level of consciousness: Conscious and alert Orientation: He is fully oriented to time, place but not to date. Speech and Language: The patient was talking very rapidly with adequate volume and there was fluctuation in speech.

8. Mood Subjective Student nurse :How are you feeling? Patient : I not feeling well and want to go home. Student Nurse : Do you feel depressed. Patient : No and said why should I feel depressed? objective : Looking tensed. (f) Affect Fluctuation : Elevated Range : Broad Appropriateness : Appropriate

9. g) Thought Student Nurse : What type of the ideas comes in your mind? Client : I want to go home. Student Nurse: Are you worried about something? Client: I don’t want to study anymore. Student Nurse: Do you think someone or some group intend to harm you in some way? Client : No, Not at all. Remark : Felling depressed . Content Student nurse : Do you think that you are having power to do the things what others can’t? Client : No I don’t think so. Remarks : Delusion of grandiosity is not present there.

10. Perception Hallucinations Student Nurse : Sometimes some of the people listen various sounds and visualize the things which is not recognized by others, do you have any of the problem like those? Client :No I don’t listen or visualize the things like you said.. Remarks : Hallucination is absent.

11. Cognitive Functions Orientation Person Student Nurse : Who is sitting near by you? Client : My Father. Remarks : Oriented to person Place Student Nurse : Where are you now? Client : At Sum Hospital Remarks :oriented to place . iii.Time Student Nurse : What is the time now? Client : About 9-10 AM Remarks : Oriented to time.

12. Attention Student Nurse : Can you say 5 words in English which starts with T. Client : Tiger, Time, Timber, true,Truck . Remarks : Attention is present. Concentration Student Nurse : Name the months in backward? Client : Told correctly. Remarks : Concentration is intact . Memory Immediate Student Nurse : Repeat the word what I say bucket, Pen, mobile, ball Client : Pen, mobile, ball Remarks : Immediate memory intact.

13. Recent Student Nurse :Have you taken your morning medication? Client : Yes I have taken. Remarks : Patient’s mother said that he has taken medication. So Recent memory intact. iii . Remote Student Nurse : Which year you passed 5 th ? Client : I don’t know Remarks : Remote memory impaired.

14. Abstraction Student Nurse : What is the similarity between apple and ball. Client : Both are round. Remark : Abstraction is present. Insight: Student Nurse : Do you accept your illness and require treatment? Client : Yes I suddenly get angry for that I have come to this hospital. Remark : Grade 4 insight.

15. (k) Judgment: Test:- Student Nurse : What will you do if there is fire in this room? Client : I will poor water. Personal test:- Student Nurse : what will you do if you find a letter on road with address? Client:- :I will read the name and will give in post office. Social:- Student nurse :what will you do when a marriage party is there in your neighbor. Client :I will go there and eat food. Remarks :judgment is intact.  

16. Physical examination: There was injury in the left fore head. Left hand was paining during movement. Neurological examination: Patient was unable to perform Romberg test.

17. Literature review Definition: The essential feature of this disorder as a “repetitive and persistent pattern of conduct in which the basic rights of others or major age-appropriate societal norms or rules are violated” (APA, 2000).

18. The conduct is more serious than the ordinary mischief and pranks of children and adolescents. The disorder is more common in boys than in girls, and the behaviors may continue into adulthood, often meeting the criteria for antisocial personality disorder. Conduct disorder is divided into two subtypes based on the age at onset: childhood-onset type (onset of symptoms before age 10 years) and adolescent-onset type (absence of symptoms befor age 10 years).

19. Etiology According to Book Picture: 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. Twin studies have revealed a signifi cantly higher number of conduct disorders among those who have family members with the disorder.

20. 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 longterm adjustment. Studies have shown that poor peer relations during childhood were consistently implicated in the etiology of later deviance (Ladd, 1999). Aggression was found to be the principal cause of peer rejection, thus contributing to a cycle of maladaptive behavior.

21. Theory of Family Dynamics. The following factors related to family dynamics have been implicated as contributors in the predisposition to this disorder Parental rejection ● Inconsistent management with harsh discipline ● Early institutional living ● Frequent shifting of parental fi gures ● Large family size ● Absent father ● Parents with antisocial personality disorder and/or alcohol dependence ● Association with a delinquent subgroup ● Marital confl ict and divorce ● Inadequate communication patterns ● Parental permissiveness

22. Patient Picture: Theory of Family Dynamics Marital conflict between parents and fathers aggressiveness.

23. Clinical features BOOK PICTURE 1 . Uses physical aggression in the violation of the rights of others. 2. The behavior pattern manifests itself in virtually all areas of the child’s life (home, school, with peers, and in the community). 3. Stealing, fighting, lying, and truancy are common problems. 4. There is an absence of feelings of guilt or remorse. 5. The use of tobacco, liquor, or nonprescribed drugs, as well as the participation in sexual activities, occurs earlier than the peer group’s expected age .

24. 6. Projection is a common defense mechanism. 7. Low self-esteem is manifested by a “tough guy” image. Often threatens and intimidates others. 8. Characteristics include poor frustration tolerance, irritability, and frequent temper outbursts. 9. Symptoms of anxiety and depression are not uncommon. 10. Level of academic achievement may be low in relation to age

25. Patient Picture Aggressiveness/Violent behaviour Lying Taking gutkha and pan Stealing things Lack of interest in studies

26. TREATMENT Mood stabilizer Antipsychotics

27. PSYCHOTHERAPY Family therapy Individual therapy Behavioral therapy

28. Nursing Diagnosis According to book: Risk for self directed or other directed violence related to disorganized environment as evidenced by patients aggressive behavior. Defensive coping related to low self esteem as evidenced by denial of obvious problems. Impaired social interaction related to dysfunctional family system as evidenced by use of unsuccessful social interaction behaviors .

29. Ineffective coping related to maturational crisis as evidenced by inability to meet role expectations. Low self esteem related to negative role models as evidenced by lack of eye contact. Impaired social interaction related to dysfunctional family system as evidenced by use of unsuccessful social interaction behaviors Disturbed family process related to mental disorder of a family member as evidenced by knowledge deficit regarding health care support.

30. According to patient Risk for self directed or other directed violence related to disorganized environment as evidenced by patients aggressive behavior. Implementation: The family members are advised not to argue with the patient and inform any aggressive behavior of the patient. Family members and staffs are informed to be watchful for any suicidal behavior.  

31. Advice client to maintain a anger book where client will write the anger arousal frequency in a day. All the dangereous objects are removed from the patients reach area. Inform to the security office to avail 2-3 people to control the patient. After administration of tranquilizers keep eye on side effects of the drug.

32. Defensive coping related to low self esteem as evidenced by denial of obvious problems . Implementation: Through a discussion client should be made to understand various behaviors. Family members and staff are adviced not to threaten in any unacceptable behavior of the patient rather than make him to understand. Client is encouraged during acceptable behaviors. Periodic evaluation of the client behavior and suggesting modification to the client.

33. Impaired social interaction related to dysfunctional family system as evidenced by use of unsuccessful social interaction behaviors . Implementation A trusting relationship is developed with the client . Positive reignforcement is given by encouraging the client .   During unacceptable behavior of the client during interaction, client is observed and given suggestion for improvement .   A group is created and client is encouraged to participate in group conversations. Evaluate the behavior of the client.  

34. Ineffective coping related to maturational crisis as evidenced by inability to meet role expectations . Implementation: Client is encouraged to do physical activities like running, kick boxing, playing games . All the staff and family members are adviced no to bargain or argue with the patient . Client is encouraged to verbalize the feelings of aggression, and provided some strategies like deep breathing and counting numbers etc.

35. Impaired sleeping pattern related to excitement as reported by his mother . Clean wrinkle free bed is given. All the relatives and staff members are adviced not to disturb patient during sleeping. Information is given to the ward incharge to arrange dim light during night time. Patient is adviced to empty urine before sleeping. Inj. Lorazepam is given.

36. Health Education Advised to recognize anger Encourage social interaction. Encourage the patient to share his feelings. Improve the self care needs (personal hygiene) independently. Sleep hygiene techniques. Instruct to use relaxation technique when getting aggressive. Taught about the positive coping methods. Advice to do meditation. Patient has taught some relaxation techniques Advice the patient for regular checks up and follows up.

37. Bibliography 1 Vyas JN Ahuja , Niraj Text book of postgraduate psychiatry.2 nd edn(2008). Jaypee Brothers Medical Publishers (p)Ltd,280-291 2 Videbeck Sheila L.Psychiatric mental health nursing.2 nd edn 461-476 3. Sadock Benjamin James Sadock Virginia Alcott, Kaplan & Sadock’s Synopsis of psychiatry: Behavioral sciences/ cli 4. Gelder MG ,Anderson NC,Lopez-IborJJ,Gelder JR, New Oxford textbook of psychiatry,2 nd edn(2009). vol-II,Oxford university press,992-1064 5. Townsend Mary C Nursing diagnosis in psychiatric nursing,Care plans and psychotropic medications, 7 th edn(2008) FA Davis company,159-176 6. Stuart Gail W Laraia Michele T Principles and practice of psychiatric nursing,8 th edn,(2005). Elsevier,285-299