Ch 21: Impulse Control Disorders

What are the three core domains of symptoms in Oppositional Defiant Disorder (ODD)?

angry/irritable mood, argumentative/defiant behavior, and vindictiveness

How long must symptoms last to meet DSM-5 criteria for ODD?

at least 6 months

How many symptoms are required for an ODD diagnosis according to DSM-5?

At least 4 symptoms from any of the 3 domains.

What is a key relationship qualifier for diagnosing ODD?

Symptoms must occur with at least one individual who is not a sibling

DSM-5 Angry/Irritable Mood symptom #1

often loses temper

DSM-5 Angry/Irritable Mood symptom #2

is often touchy or easily annoyed

DSM-5 Angry/Irritable Mood symptom #3

is often angry and resentful

DSM-5 Argumentative/Defiant Behavior symptom #4

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

DSM-5 Argumentative/Defiant Behavior symptom #5

often actively defies or refuses to comply with requests from authority figures or with rules

DSM-5 Argumentative/Defiant Behavior symptom #6

often deliberately annoys others

DSM-5 Argumentative/Defiant Behavior symptom #7

often blames others for his or her mistakes or misbehavior

DSM-5 Vindictiveness symptom #8

Has been spiteful or vindictive at least twice within the past 6 months

What distinguishes ODD behavior from typical developmental behavior?

persistence, frequency, and whether behavior is outside developmental, gender, and cultural norms

What are the functional impacts required for an ODD diagnosis (Criterion B)?

The behavior must cause distress in the individual or others, or negatively impact social, educational, or occupational functioning.

What disorders must be ruled out before diagnosing ODD (Criterion C)?

Psychotic, substance use, depressive, bipolar, and disruptive mood dysregulation disorder.

How is severity of ODD specified?

• Mild: Symptoms in 1 setting

• Moderate: Symptoms in 2 settings

• Severe: Symptoms in 3 or more settings

At what average age is Oppositional Defiant Disorder (ODD) typically diagnosed?

Around age 8

What is the earliest age ODD symptoms may appear?

as early as age 3

ODD is rarely diagnosed after what developmental period?

early adolescence

What gender-related behavioral differences may influence ODD diagnosis?

Boys are more likely to annoy and blame, while girls are more likely to argue.

How might cultural or clinician bias affect ODD diagnosis?

Aggression in boys may be viewed as more socially acceptable, leading to more frequent diagnosis in males.

What is the most common comorbid disorder with ODD?

Attention-deficit/hyperactivity disorder (ADHD)

Besides ADHD, what other disorders are commonly comorbid with ODD?

Anxiety and depressive disorders.

What depressive disorder shares symptoms with ODD and may not be diagnosed concurrently?

Disruptive Mood Dysregulation Disorder (DMDD)

What are key symptoms of Disruptive Mood Dysregulation Disorder (DMDD)?

Chronic negative mood and frequent temper outbursts.

How do the symptoms of DMDD differ from those of ODD?

DMDD symptoms are more severe and mood-focused, while ODD symptoms are more behaviorally based

What is a suggested revision to the classification of DMDD in relation to ODD?

Some researchers propose DMDD be used as a specifier for ODD rather than as a separate diagnosis.

What brain region shows reduced gray matter density in individuals with ODD?

The left prefrontal cortex.

What neurochemical changes are associated with ODD?

Altered serotonin, noradrenaline, and dopamine function

How do individuals with ODD typically respond to stress in terms of cortisol?

They show reduced cortisol reactivity to stress.

What does learning theory suggest about the origin of oppositional behaviors?

They are acquired through negative reinforcement modeled by parents or authority figures.

What early life experiences are strongly associated with ODD?

Adverse childhood experiences (ACEs) like abuse, neglect, and family conflict.

What is the core behavioral pattern seen in Conduct Disorder?

A repetitive and persistent pattern of violating others' rights or major age-appropriate rules/norms.

How many total symptoms are required for a DSM-5 diagnosis of conduct disorder

At least 3 of 15 symptoms in the past 12 months, with 1 present in the last 6 months.

List 3 examples of aggression to people or animals in conduct disorder

Bullying/intimidating, initiating fights, using weapons

What are additional examples of aggressive behavior in conduct disorder?

Physical cruelty to people or animals, mugging, or forcing sexual activity.

What are the two behaviors under "Destruction of Property" in conduct disorder?

1) Deliberate fire setting intending serious damage

2) deliberate destruction of property by other means.

What are examples of deceitfulness or theft in conduct disorder?

Breaking into homes or cars, lying to obtain favors ("cons"), stealing without direct confrontation.

What are examples of serious rule violations in conduct disorder?

Staying out late before age 13, running away from home, or truancy starting before age 13.

What is the age-based subtype for conduct disorder if symptoms begin before age 10?

Childhood-onset type.

What subtype applies when no symptoms occur before age 10?

Adolescent-onset type.

What does the “Unspecified onset” subtype indicate?

There’s not enough information to determine if symptoms started before or after age 10.

What specifier is used when a person with conduct disorder shows a lack of remorse or empathy?

With limited prosocial emotions.

How is severity of conduct disorder classified?

• Mild: Few problems, minor harm

• Moderate: Intermediate impact

• Severe: Many problems or serious harm to others

What condition must not be met if a person over 18 is diagnosed with conduct disorder?

Criteria for antisocial personality disorder must not be met.

What two disorders are commonly comorbid with conduct disorder and predict worse outcomes?

ADHD and oppositional defiant disorder (ODD).

What other psychiatric conditions are often comorbid with conduct disorder?

Specific learning disorder, anxiety disorders, depressive or bipolar disorders, and substance use disorders

How does genetics contribute to conduct disorder?

Children with a biological parent or sibling with the disorder have an increased risk.

What adverse childhood experiences (ACEs) are commonly associated with conduct disorder?

Parental rejection, neglect, harsh discipline, early institutional living, chaotic home life, large family size, absent father, and parental substance use.

What social/environmental influences increase the risk for conduct disorder?

Peer rejection, violent neighborhoods, and association with delinquent peers.

What characterizes the behavioral outbursts in intermittent explosive disorder (IED)?

Inability to control aggressive impulses, either verbal or physical, directed toward people, animals, property, or self.

What types of triggers can provoke an episode of intermittent explosive disorder?

Almost anything—often minor frustrations or environmental stimuli (e.g., misplacing an item, traffic delays, sports losses).

What is a common pattern of behavior seen in Intermittent Explosive Disorder episodes?

A cycle of tension/arousal → explosive outburst → relief → remorse or regret.

How might someone with Intermittent Explosive Disorder react during an episode triggered by a minor frustration, like losing a video game?

They may physically lash out, destroy property, or attack others who intervene.

What are common emotional consequences following an IED episode?

Feelings of relief during or immediately after, followed by remorse, regret, and embarrassment.

What areas of life can be impaired by IED?

Interpersonal relationships, occupational performance, and legal standing.

What health conditions have been linked to IED?

Hypertension and diabetes—possibly due to chronic stress and arousal

What underlying emotional issue is typically seen in IED?

General emotional dysregulation—not just excessive anger, but intense experience of a range of emotions.

What are the most common comorbid psychiatric disorders associated with intermittent explosive disorder?

Depressive disorders, anxiety disorders, and substance use disorders

What personality and behavioral disorders are often comorbid with IED?

Antisocial personality disorder, borderline personality disorder, ADHD, conduct disorder, and oppositional defiant disorder.

What inflammatory biomarkers are elevated in individuals with IED?

C-reactive protein (CRP) and interleukin-6 (IL-6).

How might elevated inflammatory markers contribute to IED?

They may facilitate aggression by affecting neurotransmitter systems.

What hormone has been associated with increased aggression in IED?

testosterone

What neurobiological changes are associated with IED?

Loss of neurons in the amygdala and hippocampus; abnormal serotonin activity in the limbic system.

What type of family environment is a risk factor for developing IED?

Exposure to violence, trauma, addiction, and substance use in the family of origin.

What types of childhood abuse are linked to IED development?

Physical abuse (strongest association) and sexual abuse.

What traits common in IED are also risk factors for suicide?

impulsivity and aggression (self-directed or external)

What is pyromania?

Repeated, deliberate fire setting for pleasure, gratification, or relief—not for monetary gain or to conceal a crime.

What emotional experience typically precedes fire setting in pyromania?

Tension or emotional arousal.

What emotional experience typically follows fire setting in pyromania?

Pleasure, gratification, or relief.

What demographic is most commonly affected by pyromania?

Males, especially those with poor social skills and learning difficulties

What conditions are commonly associated with juvenile fire setting?

Conduct disorder and ADHD.

What other behavior is often part of the clinical picture in individuals with pyromania?

A history of alcohol or substance use.

What is kleptomania?

A recurrent failure to resist the impulse to steal items not needed for personal use or monetary value

What emotional experiences typically precede and follow a theft in kleptomania?

Preceded by tension; followed by pleasure, gratification, or relief.

Are the stolen items in kleptomania usually needed or valuable?

No, they are not needed for personal use or monetary value.

With which disorders is kleptomania commonly associated?

Impulse control disorders, substance use disorders, major depressive disorder, anxiety disorders, bulimia nervosa, and personality disorders.

What can Oppositional Defiant Disorder progress to if untreated?

Conduct disorder in later years

What are the two onset types of Conduct Disorder, and how do they differ in prognosis?

Childhood onset (<10 years) has a worse prognosis; adolescent onset has no symptoms before age 10.

What are the clinical features of Conduct Disorder?

Unimpulsive violation of rights of others, aggression to people/animals, destruction of property, deceitfulness, rule violations

At what age can Intermittent Explosive Disorder (IED) be diagnosed, and what is the mean age of onset?

May be diagnosed at age 6; mean age of onset 13–21 years.

What are the clinical features of Intermittent Explosive Disorder?

Impulsive and unwarranted emotional outbursts, violence, and destruction of property.

What is a key note about the treatment of Intermittent Explosive Disorder?

Early treatment may prevent worsening pathology.

What should be identified when assessing Oppositional Defiant Disorder (ODD)?

Issues that cause power struggles and triggers for outbursts, including when they begin and how they are handled.

How should a child’s or adolescent’s view of their behavior be assessed in ODD?

Assess their perception of behavior impact at home, school, and with peers; explore feelings of empathy and remorse.

What control and responsibility factors are assessed in ODD?

Ability to exercise control, take responsibility, problem-solve, plan for future, barriers, motivation to change, and use of rewards.

What are key areas to assess in Conduct Disorder (CD)?

Seriousness, types, initiation of disruptive behavior, and management history.

Which emotional and motivational factors are important to assess in CD?

Levels of anxiety, aggression, anger, motivation, and impulse control.

What moral and cognitive aspects are assessed in CD?

Moral development, problem solving, belief system, spirituality, empathy, and remorse.

What therapeutic engagement abilities are assessed in CD?

Ability to form therapeutic relationships and commit to behavioral change (e.g., contracts, drug testing, following home rules).

What substance use history is important in CD assessment?

Past and present substance use

What should be assessed about violent outbursts in Intermittent Explosive Disorder (IED)?

History, frequency, and triggers of violent outbursts.

What positive control factors are assessed in IED?

Times when the patient maintained control in situations that usually trigger loss of control.

What social support factors are important to assess in IED?

Actual and potential sources of support at home and socially.

What is important to assess regarding substance use in IED?

past and present substance use

What are signs of Risk for Suicide in patients with impulse control disorders?

History of suicide attempts, aggression, impulsivity, conflictual relationships, statements like “If I have to stay here, I’m going to kill myself.”

What is the desired outcome for Risk for Suicide?

Decreased suicide risk: expresses feelings, verbalizes suicidal ideas, refrains from suicide attempts, plans for the future.

What are signs of Risk for Violence in impulse control disorders?

Rigid posture, clenched fists/jaw, pacing, invading personal space, cruelty to animals, fire setting, ACEs, vengeful statements like “I don’t get mad, I get even.”

What is the desired outcome for Risk for Violence?

No violence: identifies harmful impulsive behaviors, controls impulses, refrains from aggression, identifies social support.

What are signs of Impaired Impulse Control?

Hostile laughter, blaming others, grandiosity, difficulty with relationships, statements like “That nurse pushed me over the edge.”