Disruptive, Impulse-Control, and Conduct Disorders PDF

Disruptive , impulse- Control, and conduct disorders Week 10 Disruptive, Impulse- Control, and Conduct Disorders Conditions involving problems in the self-control of emotions and behaviors. these problems are manifested in behaviors that violate the rights of others (e.g., aggressi...

Disruptive , impulse- Control, and conduct disorders Week 10 Disruptive, Impulse- Control, and Conduct Disorders Conditions involving problems in the self-control of emotions and behaviors. these problems are manifested in behaviors that violate the rights of others (e.g., aggression, destruction of property) and/or that bring the individual into significant conflict with societal norms or authority figures The underlying causes of the problems in the self-control of emotions and behaviors can vary greatly across the disorders in this chapter and among individuals within a given diagnostic category. Oppositional defiant disorder Intermittent explosive disorder Conduct disorder, antisocial personality disorder (which is described in the chapter ''Personality Disorders") Pyromania Kleptomania Other specified and unspecified disruptive, impulse- control, and conduct disorders.  The disruptive, impulse-control, and conduct disorders all tend to be more common in males than in females, although the relative degree of male predominance may differ both across disorders and within a disorder at different ages. The disorders in this chapter tend to have first onset in childhood or adolescence. In fact, it is very rare for either conduct disorder or oppositional defiant disorder to first emerge in adulthood. There is a developmental relationship between oppositional defiant disorder and conduct disorder, in that most cases of conduct disorder previously would have met criteria for oppositional defiant disorder, at least in those cases in which conduct disorder emerges prior to adolescence. However, most children with oppositional defiant disorder do not eventually develop conduct disorder. Furthermore, children with oppositional defiant disorder are at risk for eventually developing other problems besides conduct disorder, including anxiety and depressive disorders.  1. Oppositional Defiant Disorder The criteria are more evenly distributed between emotions (anger and irritation) and behaviors (argumentativeness and defiance). Diagnostic Criteria: 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. 7. Often blames others for his or her mistakes or misbehavior Vindictiveness 8. Has been spiteful or vindictive at least twice within the past  Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic. 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 AS). 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 that is 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 on 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. Severe: Some symptoms are present in three or more settings.  Differential Diagnosis Conduct disorder. Conduct disorder and oppositional defiant disorder are both related to conduct problems that bring the individual in conflict with adults and other authority figures (e.g., teachers, work supervisors). The behaviors of oppositional defiant disorder are typically of a less severe nature than those of conduct disorder and do not include aggression toward people or animals, destruction of property, or a pattern of theft or deceit. Furthermore, oppositional defiant disorder includes problems of emotional dysregulation (i.e., angry and irritable mood) that are not included in the definition of conduct disorder. Attention-deficit/hyperactivity disorder. ADHD is often comorbid with oppositional defiant disorder. To make the additional diagnosis of oppositional defiant disorder, it is important to determine that the individual's failure to conform to requests of others is not solely in situations that demand sustained effort and attention or demand that the individual sit still. Depressive and bipolar disorders. Depressive and bipolar disorders often involve negative affect and irritability. As a result, a diagnosis of oppositional defiant disorder should not be made if the symptoms occur exclusively during the course of a mood disorder. Disruptive mood dysregulation disorder. Oppositional defiant disorder shares with disruptive mood dysregulation disorder the symptoms of chronic negative mood and temper bout bursts. However, the severity, frequency, and chronicity of temper outbursts are more severe in individuals with disruptive mood dysregulation disorder than in those with oppositional defiant disorder. Thus, only a minority of children and adolescents whose symptoms meet criteria for oppositional defiant disorder would also be diagnosed with disruptive mood dysregulation disorder. When the mood disturbance is severe enough to meet criteria for disruptive mood dysregulation disorder, a diagnosis of oppositional defiant disorder is not given, even if all criteria for oppositional defiant disorder are met. Intermittent explosive disorder. Intermittent explosive disorder also involves high rates of anger. However, individuals with this disorder show serious aggression toward others that is not part of the definition of oppositional defiant disorder. Intellectual disability (intellectual developmental disorder). In individuals with intellectual disability, a diagnosis of oppositional defiant disorder is given only if the oppositional behavior is markedly greater than is commonly observed among individuals of comparable mental age and with comparable severity of intellectual disability. Language disorder. Oppositional defiant disorder must also be distinguished from a failure to follow directions that is the result of impaired language comprehension (e.g., hearing loss). Social anxiety disorder (social phobia). Oppositional defiant disorder must also be distinguished from defiance due to fear of negative evaluation associated with social anxiety disorder.  2. Intermittent Explosive Disorder The criteria for intermittent explosive disorder focus largely on such poorly controlled emotion, outbursts of anger that are disproportionate to the interpersonal or other provocation or to other psychosocial stressors. Diagnostic Criteria: 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. The physical 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 no committed to achieve some tangible objective (e.g., 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 to the physiological effects of a substance (e.g., a drug of abuse, a medication). For children ages 6-18 years, aggressive behavior that occurs as part of an adjustment disorder should not be considered for this diagnosis.. Attention-deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder, or autism spectrum disorder. Individuals with any of these childhood-onset disorders may exhibit impulsive aggressive outbursts. Individuals with ADHD are typically impulsive and, as a result, may also exhibit impulsive aggressive outbursts. While individuals with conduct disorder can exhibit impulsive aggressive outbursts, the form of aggression characterized by the diagnostic criteria is proactive and predatory. Aggression in oppositional defiant disorder is typically characterized by temper tantrums and verbal arguments with authority figures, whereas impulsive aggressive outbursts in intermittent explosive disorder are in response to a broader array of provocation and include physical assault. The level of impulsive aggression in individuals with a history of one or more of these disorders has been reported as lower than that in comparable individuals whose symptoms also meet intermittent explosive disorder Criteria A through E. Accordingly, if Criteria A through E are also met, and the impulsive aggressive outbursts warrant independent clinical attention, a diagnosis of intermittent explosive disorder may be given.  3. Conduct Disorder The criteria for conduct disorder focus largely on poorly controlled behaviors that violate the rights of others or that violate major societal norms. Many of the behavioral symptoms (e.g., aggression) can be a result of poorly controlled emotions such as anger. Diagnostic Criteria: 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 categories below, 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). 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 or 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. Differential Diagnosis Oppositional defiant disorder. Conduct disorder and oppositional defiant disorder are both related to symptoms that bring the individual in conflict with adults and other authority figures (e.g., parents, teachers, work supervisors). The behaviors of oppositional defiant disorder are typically of a less severe nature than those of individuals with conduct disorder and do not include aggression toward individuals or animals, destruction of property, or a pattern of theft or deceit. Furthermore, oppositional defiant disorder includes problems of emotional dysregulation (i.e., angry and irritable mood) that are not included in the definition of conduct disorder. When criteria are met for both oppositional defiant disorder and conduct disorder, both diagnoses can be given. Attention-deficit/hyperactivity disorder. Although children with ADHD often exhibit hyperactive and impulsive behavior that may be disruptive, this behavior does not by itself violate societal norms or the rights of others and therefore does not usually meet criteria for conduct disorder. When criteria are met for both ADHD and conduct disorder, both diagnoses should be given.  Antisocial Personality Disorder Pyromania A. Deliberate and purposeful fire setting on more Differential Diagnosis than one occasion. Other causes of intentional fire setting. It is important to rule out other causes of fire setting B. Tension or affective arousal before the act. before giving the diagnosis of pyromania. Intentional fire setting may occur for profit, sabotage, or revenge; to conceal a crime; to C. Fascination with, interest in, curiosity about, or make a political statement (e.g., an act of attraction to fire and its situational contexts (e.g., terrorism or protest); or to attract attention or paraphernalia, uses, consequences). recognition (e.g., setting a fire in order to discover it and save the day). Fire setting may D. Pleasure, gratification, or relief when setting also occur as part of developmental experimentation in childhood (e.g., playing with fires or when witnessing or participating in their matches, lighters, or fire). aftermath. Other mental disorders. A separate diagnosis of E. The fire setting is not done for monetary gain, pyromania is not given when fire setting occurs as an expression of sociopolitical ideology, to as part of conduct disorder, a manic episode, conceal criminal activity, to express anger or or antisocial personality disorder, or if it occurs in vengeance, to improve one’s living response to a delusion or a hallucination (e.g., in circumstances, in response to a delusion or schizophrenia) or is attributable to the physiological effects of another medical hallucination, or as a result of impaired judgment condition (e.g., epilepsy). The diagnosis of (e.g., in major neurocognitive disorder, pyromania should also not be given when fire intellectual disability [intellectual developmental setting results from impaired judgment disorder], substance intoxication). associated with major neurocognitive disorder, intellectual disability, or substance intoxication. F. The fire setting is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.  Kleptomania Differential Diagnosis Ordinary theft. Kleptomania should be distinguished from ordinary acts of theft or shoplifting. Ordinary theft (whether planned or impulsive) is deliberate Diagnostic Criteria and is motivated by the usefulness of the object or A. Recurrent failure to resist impulses its monetary worth. Some individuals, especially to steal objects that are not needed adolescents, may also steal on a dare, as an act of for personal use or for their monetary rebellion, or as a rite of passage. The diagnosis is not made unless other characteristic features of value. kleptomania are also present. Kleptomania is exceedingly rare, whereas shoplifting is relatively B. Increasing sense of tension common. immediately before committing the theft. Malingering. In malingering, individuals may simulate the symptoms of kleptomania to avoid C. Pleasure, gratification, or relief at criminal prosecution. the time of committing the theft. Antisocial personality disorder and conduct D. The stealing is not committed to disorder. Antisocial personality disorder and conduct disorder are distinguished from express anger or vengeance and is kleptomania by a general pattern of antisocial not in response to a delusion or a behavior. hallucination. Manic episodes, psychotic episodes, and major E. The stealing is not better neurocognitive disorder. Kleptomania should be explained by conduct disorder, a distinguished from intentional or inadvertent stealing manic episode, or antisocial that may occur during a manic episode, in personality disorder. response to delusions or hallucinations (as in, e.g., schizophrenia), or as a result of a major neurocognitive disorder. Reference American Psychological Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.