Disruptive, Impulse-Control, and Conduct Disorders in DSM 5-TR

Disruptive, Impulse-Control, and Conduct Disorders

1. Oppositional Defiant Disorder

2. Intermittent Explosive Disorder

3. Conduct Disorder

4. Antisocial Personality Disorder

5. Pyromania

6. Kleptomania

7. Other Specified Disruptive, Impulse-Control, and Conduct Disorder

8. Unspecified Disruptive, Impulse-Control, and Conduct Disorder

   • In this category, are disorders previously in “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” (i.e., oppositional defiant disorder; conduct disorder; and disruptive behavior disorder not otherwise specified, now categorized as other specified and unspecified disruptive, impulse-control, and conduct disorders) and the chapter “Impulse-Control Disorders Not Otherwise Specified” (i.e., intermittent explosive disorder, pyromania, and kleptomania).

   • Disorders in this category are distinguished by problems of impulsivity, self-regulation and emotional and behavioral control

   • Disorders in this category are unique because these problems violate the rights of others (e.g., aggression, destruction of property) and bring individual into conflict with societal norms or authority figures.

Oppositional Defiant Disorder (ODD)

A. Pattern of angry/irritable mood, argumentative, defiant behavior, or vindictiveness lasting at least 6 months as evidenced four symptoms from any of categories. (Criteria A with at least four symptoms from following angry or irritable mood, argumentative or defiant behavior, and vindictiveness categories:)

• Angry/irritable mood

  • Often loses temper

  • Often touchy or easily annoyed

  • Often angry and resentful

• Argumentative/defiant behavior

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

  • Often actively defies or refused to comply with requests from authority figures or with rules

  • Often deliberately annoys others

  • Often blames others for his or her mistakes or misbehavior

• Vindictiveness

  • Spiteful or vindictive at least twice within the past 6 months

    • Children younger than 5, behavior should occur on most days for 6 months

    • 5 and older behavior should occur at least once per week for at least 6 months

    • Normative for culture, development and gender

B. Associated with distress in individual or others in immediate social context or negativity impacts social, occupational, or other important areas of function

C. Do not occur in course of psychotic, substance use, depressive or bipolar disorder. Criteria for DMDD not met.

• Distinguish these behaviors from that in normal limits by the persistence and frequency of client behaviors.

• Children under 5 years, behavior should occur on most days for a period of at least 6 months

• Those 5 and older once per week for at least 6 months

• Symptoms may be confined to one setting, for instance home

• May be difficult to detangle these behaviors from problematic relationships

Cannot diagnose ODD and DMDD together

ODD Specifiers

• Mild

  • Confined to only one setting

• Moderate

  • Symptoms appear in two settings

• Severe

  • Present in three or more settings

Intermittent Explosive Disorder

The essential features of the disorder is impulsive or anger based aggressive outbursts that have a rapid onset and  little or no prodromal period. Most of these outbursts less than 30 minutes and are the result of a minor stimulus or provocation.

A. Recurrent behavioral outbursts representing a failure to control aggressive impulses  by either of

• Verbal or physical aggression for period of 3 months

• Three behavioral outbursts involving damage or destruction of property involving physical injury against animals or individuals occurring within 12 month period

B. Magnitude of aggressiveness expressed during outbursts grossly out of proportion to provocation or stressors

C. Recurrent aggressive outbursts not premeditated or to achieve objectives, money, power, intimidation

D. Recurrent aggressive outbursts cause marked distress or problems in functioning, or financial or legal consequences

E. Age must be at least 6 years or equivalent developmental period

F. Outbursts are not explained by mental disorder, medical condition, or substance abuse

• Children 6 to 18 occurs as part of adjustment disorder not this diagnosis

Conduct Disorder

Onset of conduct disorder may occur as early as preschool years, but the first significant symptoms generally emerge in middle childhood  to middle adolescence. ODD is a common precursor of this disorder. Conduct Disorder may be diagnosed in adults. This disorder may abate or resolve by adulthood in many persons

Persons with the disorder or predisposed to adult onsetmood, psychotic , anxiety disorders, as well as substance related disorders.

A. Repetitive and persistent pattern of behaviors 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 criteria in the past 12 months from any of the following categories

• Aggression to people and animals

  • Bullies, threatens, or intimidates others

  • Initiates physical fights

  • Used a weapon that can cause serious physical harm

  • Been physically cruel to people

  • Been physically cruel to animals

  • Stolen while confronting a victim

  • Forced someone into sexual activity

• Destruction of property

  • Deliberately engaged in fire setting to cause harm

  • Deliberately destroyed property

• Deceitfulness or theft

  • Broken into someone else’s house, building, etc.

  • Deliberately destroyed others’ property

• Serious violations of rules

  • Often stays out at night despite parental prohibitions before age of 13

  • Run away from home overnight at least twice while living in parental or caregiver home

    Truant from school before age 13

B. Clinically significant impairment

C. 18 years or older, if the criteria not met for antisocial personality

Conduct Disorder Onset Specifiers

• Childhood onset type— (F91.1)

  • One symptom of CD prior to age 10

• Adolescent onset type— (F91.2)

  • No symptoms of CD prior to age 10

• Unspecified onset type— (F91.9)

  • Criteria met for CD but not enough information when symptoms appeared

Conduct Disorder Specify If

• Limited prosocial emotions

  • Must have displayed two following for at least 12 months in multiple settings

• Lack of remorse or guilt

  • No concern about inappropriate behaviors

• Callous—lack of empathy

  • Disregards and is unconcerned about others feelings, cold and uncaring

• Unconcerned about performance

  • No concern about poor performance in school, work, or other activities

• Shallow or deficient affect

  • No feelings or emotions to others, superficial or false emotions

Conduct Disorder Severity Specifiers

• Mild

  • Few if any conduct problems in excess of those required to make diagnosis, minor harm

• Moderate

  • Number of conduct problems and the effect on others intermediate

• Severe

  • Many conduct problems in excess of those required to make diagnosis, considerable harm to others

Risk Facts for Conduct Disorder

• Early maternal rejection and neglect;

• Separation from parents, without an adequate alternative caregiver;

• Parent or parents incarcerated

• Alcohol and other drug use in home or residences

• Early institutionalization

• Family neglect

• Abuse or violence in home

• Parental mental illness

• Spousal abuse and extreme discord in home

• Very large family size

• Crowding in home

• Extra people in home

• Lack of stable structure or daily schedule

• Poverty and deprivation.

Children with Conduct Disorder

• Higher rates of depression, suicidal thoughts, suicide attempts, and suicide;

• Academic difficulties;

• Poor relationships with peers or adults;

• Sexually transmitted diseases;

• Higher rates of illicit drug use

• Higher rates of violence against these children

• Difficulty staying in adoptive, foster, or group homes; and

• Higher rates of injuries, school expulsions, and problems with the law.

Antisocial Personality Disorder

Antisocial personality disorder is included due to its  relationship to conduct disorder.

Antisocial personality disorder is listed in this category and also in the personality disorders as was in previous editions of the DSM Cluster 

A. Pervasive pattern of disregard of rights of others since age 15.

• Three or more of the following:

• Failure to conform to social norms with respect to lawful behaviors, as indicated by acts, grounds for arrest

• Deceitfulness (lying, aliases, conning others)

• Impulsivity or failure to plan

• Irritability or aggressiveness (fights or assaults)

• Reckless or disregard of the safety of others

• Consistently irresponsible (failure work behaviors or financial obligations)

• Lack of remorse

B. Must be 18 years of age for diagnosis

C. Evidence of conduct disorder with onset before 15 years

D. Not exclusively during course of schizophrenia or bipolar disorder

Listed in Personality disorders as well, the essential feature of antisocial personality disorder is a pervasive pattern of disregard for and violation of the rights of others that begin in childhood and early adolescence and continues into adulthood.

This pattern has  been referred to psychopathy, sociopathy, or dyssocial personality disorder .

Characteristics of Antisocial Personality Disorder

• Lack empathy  and indifferent to their victims or others in general

• Tend to be disrespectful of others, regardless of position

• Trouble with authority figures & rules

• Disregard for right and wrong

• Persistent lying or deceit

• Using charm or wit to manipulate others

• Intimidation of others

• Aggressive, impulsive and/or violent behavior

• May be arrogant, cynical, & contemptuous of others 

• Opinionated & cocky even when ignorant of a topic

• Irresponsible work behavior

• Consistently & extremely irresponsible in daily life

• Superficial charm, glib, verbally facile

• Sexually exploitive & irresponsible

Pyromania

Multiple episodes of purposeful fire setting characterize the disorder. Those diagnosed with the disorder have a fascination with and an attraction to fire, fire contexts, and those associated with fire.

A. Deliberate and purposeful fire setting on one or more occasion

B. Tension or affective arousal before he act

C. Fascination  with, interest in, curiosity about or attraction to fire and its contexts

D. Pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath

E. Not done for or because of

• monetary gain,

• expression of sociopolitical ideology,

• conceal criminal activity, to express anger or vengeance,

• to improve one’s living circumstances,

• response to hallucination or delusion,

• result of impaired judgment, such as neurocognitive disorder

• substance abuse

F. Not better explained by conduct disorder, manic episode, or antisocial personality disorder

Kleptomania

Characterized by recurrent failure to resist impulses to steal even if the items are not needed for use or personal gain. The disorder may begin in adolescence, but may begin in childhood.

A. Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value

B. Increasing sense of tension immediately before committing the theft

C. Pleasure, gratification, or relief at the time of committing the theft

D. Stealing is not committed to express anger or vengeance and is not in response to delusion of hallucination

E. Stealing not better explained by

• conduct disorder

• manic episode

• antisocial personality

Other Specified Disruptive, Impulse-Control and Conduct Disorder (F91.8)

Presentations when symptoms characterize a disruptive-impulse control, and conduct disorder that causes distress and impairment, but does not meet the full criteria for the disorders in this category.

Unspecified Disruptive, Impulse-Control and Conduct Disorder (F91.9)

Presentations when symptoms characterize a disruptive-impulse control, and conduct disorder that causes distress and impairment, but does not meet the full criteria for the disorders in this category. Used when clinician choses not to specify why criteria not met (e.g., in emergency room).