Donald Mann, a 32-year-old divorced man, is hospitalized for uncontrollable aggressive impulses. On admission, there is no indication of thought disorders, hallucinations, or depressed affect. Mr. Mann is angry because he feels “forced” to admit himself voluntarily to the hospital. His boss stated that if he did not admit himself, Mr. Mann would be fired from his job. Mr. Mann had threatened a fellow history teacher and later assaulted him. The patient states, “I was only arguing a historical point and got carried away.” He smiles and winks his eye as he is relating the course of events to the nurse, Ms. Burke.
Mr. Mann states that he is unable to finish writing a book because his third wife divorced him. When asked about his childhood, he comments, “Fighting is synonymous with being a street kid.” He has a history of wife abuse and frequent barroom fights. For the past year, he has been employed as a teacher of history in a private college. Previously, he held numerous teaching positions in several states. Mr. Mann states that he enjoys teaching and especially likes the students.
On the unit, Mr. Mann is generally cooperative. However, on two occasions, he violates the rules of the unit. Once, he is found with a bottle of alcohol (“I was celebrating one of our famous residents”). In the second incident, he threatens to harm another patient on the unit. On both occasions, his response is a glib “I’m sorry.” The female staff usually have no difficulty dealing with him, but the male staff generally complain about him.
On the third day after admission, Mr. Mann threatens another patient. His infractions of the rules and his aggressiveness are disrupting the unit. The unit coordinator asks Ms. Burke to write a comprehensive care plan for him. Ms. Burke, who admitted him to the unit, has spent time with him over the past few days. She often feels flattered by his attention. He has told her that he finds her to be “the best nurse on the unit.” That afternoon, his case is to be presented at a staff conference.
During the meeting, each female member reports that Mr. Mann has stated that she is his favorite. He would also “tell tales” to each staff member about the other staff members. The female staff would often do special favors for Mr. Mann (e.g., getting him cigarettes, the newspaper, or candy). The male staff members find him argumentative, infuriating, and contemptuous of them. They try to avoid him as much as possible. It is clear that almost everyone has strong positive or negative reactions to Mr. Mann. During the meeting, many of the female staff feel annoyed and angry at being manipulated. The staff decide together on goals and a plan of approach.
Assessment
Objective Data
Had two incidents of infractions of the rules
Has history of spousal abuse
Assaulted co-worker before admission
Has had three marriages
Is argumentative with male staff
Rationalizes improper and aggressive behaviors: sees nothing wrong
Has difficulty with interpersonal relationships at work
Has physically threatened another patient
Is verbally aggressive with male staff
Has made sexual advances toward female staff
Manipulates special favors from female staff
Subjective Data
Sets one staff member against another: “Nurse Y said this about you…”
States that he was “forced into coming to the hospital”
Tells each female nurse that she is his favorite
Diagnosis
Staff think two nursing diagnoses are the most important initially.
Ineffective coping related to inadequate psychological resources, as evidenced by verbal manipulation
Tells each female nurse that she is his favorite
Sets one staff member against another
Manipulates special favors from female nurses
Makes sexual advances toward female staff
Is insincere and superficial
Risk for other-directed violence related to antisocial character, as evidenced by history of overtly aggressive acts.
Is verbally aggressive with male staff
Has threatened physical assault on another patient
Has history of spousal abuse
Rationalizes violent behavior; does not see behavior as undesirable
Has had two episodes of infraction of rules
Assaulted a co-worker before admission
Questions
One of the staff’s key observations of Mr. Mann is his use of manipulation. Which array of disorders is Mr. Mann’s behavior most frequently associated with?
Manipulation can differ from one disorder to the next. Compare and contrast different types of manipulative behaviors seen in patients with personality disorders. How do these help pinpoint Mr. Mann’s psychological needs?
The term “antisocial” is included in Mr. Mann’s description. What behaviors help indicate this diagnosis?
