Disruptive, Impulse Control, and Conduct Disorders PDF

DISRUPTIVE, IMPULSE CONTROL AND CONDUCT DISORDERS Advanced Psychopathology Fall 2023 Dr. Fahey Last Week ■ Mid-semester check in ■ OCD & related disorders – What are obsessions? ■ Recurrent, persistent, invasive thoughts or images which are unwanted, and which the person has difficulty controlling...

DISRUPTIVE, IMPULSE CONTROL AND CONDUCT DISORDERS Advanced Psychopathology Fall 2023 Dr. Fahey Last Week ■ Mid-semester check in ■ OCD & related disorders – What are obsessions? ■ Recurrent, persistent, invasive thoughts or images which are unwanted, and which the person has difficulty controlling – What are compulsions? ■ Repetitive behaviors an individual feels compelled to perform in response to an obsession or rigid rules ■ Eating disorders Questions? Disruptive, Impulse-Control, and Conduct Disorders Oppositional Defiant Disorder Intermittent Explosive Disorder Conduct Disorder Antisocial Personality Disorder Pyromania Kleptomania Other & Unspecified Disruptive, ImpulseControl, and Conduct Disorder Oppositional-Defiant Disorder (ODD) (F91.3) Hallmark features • Pattern of angry/irritable mood, argumentative/defiant behavior or vindictiveness • At least 6 months, at least four symptoms (losing temper, argues with or defies authority, touchy, angry, deliberately annoys others, blames others for own behavior • Behavior causes distress in the individual OR others in immediate social context or impacts important areas of functioning Severity specifiers •Mild: confined to one setting •Not uncommon to only be in the home •Moderate: symptoms in at least two settings •Severe: symptoms in three or more settings Diagnostic Criteria: DSM-5-TR pg. 522 ODD: Additional Considerations ■ Vindictiveness – Younger than 5 years old ■ – Older than 5 years ■ ■ Behavior should occur on most days for a period of at least 6 months Behavior should occur at least once per week for at least 6 months Distress – In individual or others in his/her immediate social context OR – Impacts functioning ■ “Often precedes the development of conduct disorder” but not always ■ More prevalent in boys than girls (1.59:1) (not consistent finding) ■ African American males are diagnosed with ODD at a disproportionately higher rate than other social demographic groups (Feisthamel & Schwartz, 2009 – May result in unfair treatment & discrimination Intermittent Explosive Disorder (F63.81) (IED) ■ Hallmark features: – Recurrent behavioral outbursts as a result of failure to control aggressive impulses – Verbal or physical aggression occurring 2x/week for at least 3 months (no physical injury, destruction, or damage) space OR – Three behavioral outbursts involving damage, injury, or destruction within a 12month period – Outburst is grossly out of proportion to provocation or precipitating factors – Outbursts are impulsive, not pre-meditated and not for secondary gain – Individual is at least 6 years of age – Outbursts cause distress in individual or impairment in functioning Diagnostic Criteria: DSM-5-TR pg. 527 Differentials: Intermittent Explosive Disorder ■ Anxiety disorders – What do they have in common? ■ – ■ How can we tell them apart? ■ No indication of excessive fear or worry ■ *consider client’s comfort level disclosing vulnerable emotions* MDD & PDD – What do they have in common? ■ – ■ Irritability manifested by verbal or maybe even physical outbursts Irritability manifested by verbal or maybe even physical outbursts How can we tell them apart? ■ No indication of sad or empty mood ■ *consider client’s comfort level disclosing vulnerable emotions – males* Disruptive mood dysregulation disorder (DMDD) – – What do they have in common? ■ Temper outbursts (both physical and verbal) ■ Outbursts are grossly out of proportion to the provocation or precipitating event ■ Diagnosis should not be made before age 6 How can we tell them apart? ■ DMDD is characterized by a ”negative mood state” which is present between the outbursts Differentials: Intermittent Explosive Disorder ■ ■ ADHD – What do they have in common? – ■ Impulsive verbal or physical aggression How can we tell them apart? ■ Level of impulsive aggression is reported to be “lower” in individuals with ADHD ■ Presence of other symptoms of ADHD (i.e., difficulty concentrating, disorganization, fidgeting, hyperactivity, etc.) ASD – What do they have in common? ■ – Impulsive verbal or physical aggression How can we tell them apart? ■ Level of impulsive aggression is reported to be “lower” in individuals with ASD ■ Presence of other symptoms of ASD (i.e., deficits in social communication/interaction, restricted interests, etc.) Differentials: Intermittent Explosive Disorder ■ ODD – What do they have in common? – ■ Aggressive outbursts toward others How can we tell them apart? ■ ■ ODD outbursts are typically aimed at ”authority figures” Substance intoxication & withdrawal – What do they have in common? ■ At times, verbal or physical outbursts – How can we tell them apart? ■ IED diagnosis is not made when outbursts are solely while intoxicated or experiencing withdrawal Conduct Disorder (F91.X) Hallmark features • Pattern of behavior in which basic rights of others or major societal rules are violated • At least three criteria in past 12 months, with at least one criterion in past 6 months • Aggression towards people or animals, destruction of property, deceitfulness or theft, & serious violations of rules • Can be assigned to individuals over age 18 only if criteria for ASPD are not met Specifiers • Onset (childhood, adolescence, or unspecified) • Limited prosocial emotions (2 of following: lack of remorse/guilt, empathy, unconcerned about performance, or shallow/deficit affect) • Severity (mild, moderate, or severe based upon # of symptoms and degree of effect) Example Diagnostic Criteria: DSM-5-TR pg. 530 es this o d t a So wh r us as o f n a me rs? provide Diversity Considerations of ODD/CD ■ 70% of the children with conduct disorder in the current study were males ■ Boys are two to three times more likely to be diagnosed with conduct disorder than girls ■ African American children are more likely to be diagnosed with conduct disorder – African American males under 11 years are at the highest risk of inpatient management for conduct disorder and are at higher risk for co-occurring psychosis and depression ■ Children from low-income families are more likely to be diagnosed with conduct disorder ■ Children from families with a median household income below the 50th percentile had a 1.5-fold higher odds of psychiatric hospitalization for conduct disorder ■ Boys diagnosed with conduct disorder were three times more likely to have an anxiety disorder and major depressive disorder, and be dependent on alcohol compared to boys without conduct disorder Fadus, M.C., Ginsburg, K.R., Sobowale, K. et al. Unconscious Bias and the Diagnosis of Disruptive Behavior Disorders and ADHD in African American and Hispanic Youth. Acad Psychiatry 44, 95–102 (2020). https://doi.org/10.1007/s40596-019-01127-6 Odgers CL, Caspi A, Broadbent JM, Dickson N, Hancox RJ, Harrington H, Poulton R, Sears MR, Thomson WM, Moffitt TE Arch Gen Psychiatry. 2007 Apr; 64(4):476-84. Group 1: Small Groups: Oppositional Defiant Disorder & Conduct Disorders • What does DSM-5-TR say about oppositional defiant disorder and conduct disorder and age ranges? • What does it say about etiology? Group 2 • What are your concerns in assigning these diagnoses? • What are the possible consequences for assigning these diagnoses (both positive and negative)? Group 3 • What are possible differential diagnoses? • What do you think treatment might be for these diagnoses? Parent skills training Parent-child interaction therapy (PCIT) Family therapy Cognitive problemsolving training Social skills training Treatment for ODD, IED, & CD Pyromania (F63.1) ■ ■ Hallmark features: – Repeated deliberate and purposeful fire setting on 1+ occasion – Tension or arousal before the act – Fascination/interest/curiosity with fire, its paraphernalia, uses, and/or consequences – Pleasure, gratification, relief when setting fire, when witnessing them, or participating in aftermath Rule out other reasons for deliberate fire setting (etiology)… WHAT ARE SOME EXAMPLES?? – Responding to delusion/hallucination (psychosis) – Monetary gain (insurance money) – Covering up criminal activity – Expressing anger/vengeance – Substance use – Intellectual disability – Manic episode Diagnostic Criteria: DSM-5-TR pg. 537 Pyromania = mental health disorder Arson = a criminal act Pyromania: Treatment & Additional Info •Both are intentional •Pyromania is compulsive/pathological; arson might not be Treatment •CBT has been found to be helpful with this particular diagnosis • Covert sensitization, in which you picture yourself stealing and then facing negative consequences, such as being hurting yourself or your property • Aversion therapy, in which you practice mildly painful techniques, such as holding your breath until you become uncomfortable, when you get an urge to set a fire •Medication •SSRIs •Anti-anxiety meds Kleptomania (F63.2) Hallmark features Rule out other reasons for stealing objects (etiology) ■ Recurrent failure to resist impulse to steal objects not needed for personal use or their monetary value ■ ■ Tension before committing the act ■ Pleasure, gratification or relief at time of committing act Again – this diagnosis only captures the behavior and does not consider the cause What are some possibilities?? – Neglect/poverty – Neurocognitive disorder – Anger – Vengeance – Delusions/hallucinations – Conduct disorder – Mania – ASPD Diagnostic Criteria: DSM-5-TR pg. 539 Treatment for Kleptomania Medication •An addiction treatment medicine called naltrexone, which may reduce the urges and pleasure associated with stealing •An antidepressant — specifically a selective serotonin reuptake inhibitor (SSRI) Psychotherapy • Systematic desensitization and counter-conditioning, in which you practice relaxation techniques and other strategies while in triggering situations to learn how to reduce your urges in a healthy way • Covert sensitization, in which you picture yourself stealing and then facing negative consequences, such as being caught • Aversion therapy, in which you practice mildly painful techniques, such as holding your breath until you become uncomfortable, when you get an urge to steal Avoiding relapses •Have a safety plan •Identify a support person(s) OTHER IMPORTANT DIAGNOSTIC CONSIDERATIONS Bullying others Aggressive Guarded Hurt animals Stealing Irritable Defiant Run away often Don’t like authority Multiple foster placements Beaten by Called “dumb” by his step-father teachers Your Client Molested by brother for 3 years Witnessed DV throughout early childhood Undiagnosed learning disability Basic needs not met Attended 8 different schools) Grandmother died at age 10 (primary caregiver) The Role of Trauma ■ Youth diagnosed with conduct disorder often have a history of exposure to trauma (Greenwald, 2002; Reebye et al., 2000). ■ The high rate of comorbidity between conduct disorder and PTSD diagnoses suggests a link between unprocessed trauma and conduct disorder (Reebye et al., 2000). ■ Greenwald (2000) proposed that a history of trauma is universal to adolescents exhibiting behavior consistent with a CD diagnosis. This claim is supported by research that demonstrates that the externalization of anger and aggression can be considered a symptom of trauma exposure (American Psychological Association, 2013). ■ The experience of unresolved trauma can lead to a host of serious behavioral concerns and psychological symptoms (e.g., high-risk behaviors, hostility, impaired social competence, substance misuse, and engagement in violent or aggressive behavior) (Ariga, Uehara, Takeuchi, Ishige, Nakano, & Mikuni, 2008; Dixon-Gordon, Tull, & Gratz, 2014; Flood et al., 2010; Forbes, Elhai, Miller, & Creamer, 2010; Khoury, Tang, Bradley, Cubells, & Ressler, 2010; Wood, Foy, Goguen, Pynoos, & James, 2002). ■ Persons with CD, especially those with childhood-onset type, are at an increased risk of subsequent development of PTSD later in life (American Psychological Association, 2013). PTSD/ ASD PTSD PTSD CD/ODD ASD Antisocial Personality Disorder: To Include or Not Include…. Included in this section & personality disorders because it is so closely related to both • Both about externalizing behaviors and a pervasive pattern of behavior (PDs) Hallmark features: • Pervasive pattern of disregard for and violation of the rights of others since age 15 • 3+ criteria (failure to conform to social norms, deceitfulness, impulsivity, irritability/aggressiveness, reckless disregard for safety of self/others, irresponsibility, and/or lack of remorse) • At least 18 years of age • Evidence of conduct disorder before age of 15 Also referred to as “psychopathy” and “sociopathy” • DOES NOT MEAN SOMEONE IS SHY OR NOT WANTING TO BE SOCIAL Chronic course but less evidence of disorder as person becomes older, especially after age 40 ADHD & it’s Relationship to this Diagnostic Spectrum ■ Persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent or severe than typical for developmental level – Inattention: difficulty sustaining focus, wandering off task – Hyperactivity: inappropriate, excessive motor activity – Impulsivity: hasty actions without forethought ■ Diagnostic criteria: DSM-5-TR pg. 68 ■ Per Children and Adults with AttentionDeficit/Hyperactivity Disorder (2022), 1/3 to 1/2 of all children diagnosed with ADHD may have co-existing ODD – Can someone have both? ■ Yes! – Does one lead to the development of the other? ■ Perhaps... ADHD & Conduct Disorders: A Golden Thread Between… ■ ADHD ■ Oppositional defiant disorder ■ Conduct disorder ■ Antisocial personality disorder How do you make sense of these connections? ■ Theory of interaction between predisposition and environmental stress (diathesis-stress model) ■ Children with ADHD receive less love/affection from parents due to frustrating behaviors à common correlation to development of ODD/CD ■ Children with ADHD receiving more discipline à common correlation to development of ODD/CD Small Group Exercise Each of you will be randomly split into 1 of 3 groups. As a group, you will write a vignette that describes a person that meets criteria for one of these three disorders: ■ Group 1: Oppositional defiant disorder ■ Group 2: Conduct disorder ■ Group 3: Antisocial personality disorder 1. You will get 35 minutes for this exercise 2. Assign a scribe to create a Word doc of this vignette. Use DSM information about etiology, associated behaviors, and psychosocial factors, etc. to round out your vignette. 3. Include the following: 1) demographics, 2) brief client’s history, 3) major points of the MSE, 4) presenting concerns, 5) symptoms, 6) possible differentials, 7) how you will build rapport, and 8) your treatment plan/interventions 4. Present your “case” to class – each member of the group will take turns presenting a different part of the vignette 5. Class will give feedback and ask questions 6. Email me the vignette (be sure to CC all members of your group on the email) Major Review & Question Time *If you are interested in being the TA for this course next year, please reach out to me toward the end of the semester* What questions do you have on the material we have discussed up until now? ■ Classification and diagnosis in psychopathology ■ Diagnostic interview ■ Neurodevelopmental disorders ■ Schizophrenia spectrum disorders ■ Depressive and bipolar disorders ■ Suicide risk assessment ■ Anxiety disorders ■ Trauma and stressor related disorders ■ Obsessive and compulsive disorders ■ Eating disorders QUESTIONS? NEXT WEEK: PERSONALITY DISORDERS REMINDERS: ATTEND TA MEETINGS WITH DANIELLE (4 REQUIRED FOR THE CLASS TO GET FULL POINTS)