Disruptive, Impulse Control, and Conduct Disorders

What is the core characteristic of Disruptive, Impulse Control, and Conduct Disorders?

A lack of control over emotions and behaviors, resulting in conflict with authority, societal norms, or the violation of the rights of others.

What are the risk factors for Disruptive, Impulse Control, and Conduct Disorders?

More common in boys/men, varies across ages but most have first onset in childhood

What are three primary risk factors for Oppositional Defiant Disorder (ODD)?

Emotional reactivity, low frustration tolerance, and harsh, inconsistent, or neglectful parenting.

What is the most common cormid condition with ODD?

Attention Deficit Hyperactivity Disorder

At what age do symptoms of ODD typically emerge?

Preschool age (4-6 years old), though they can develop into early adolescence. Present in more than one place

What are the symptoms of ODD?

angry/irritable mood, argumentative/defiant behavior, and vindictiveness (spiteful at least twice in the last 6 months)

What is the diagnostic criteria of ODD?

At least four specific symptoms for at least 6 months

How does the diagnostic criteria change for children < 5 years and > 5 years old?

< 5 years: present on most days for a period of at least 6 months

> 5 years: present at least once per week for at least 6 months

What is the definition of Conduct Disorder (CD)?

repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated.

What are the risk factors of CD?

harsh parenting/discipline, physical or sexual abuse, exposure to violence, family history, under-controlled infant temperament, lower intelligence

What are the comorbid conditions of CD?

Oppositional defiant disorder and ADHD

What is the typical age of onset for Conduct Disorder?

middle childhood through adolescence; onset is rare after age 16 and unusual in early childhood.

How is Conduct Disorder generally described in relation to Oppositional Defiant Disorder?

It is often thought of as a more severe version of Oppositional Defiant Disorder.

What are the behavioral categories of conduct disorder?

aggression to people and animals, destruction to property, deceitfulness or theft, and serious violation of rules

What is the diagnostic criteria for Conduct Disorder regarding symptom frequency and duration?

at least 3 specific symptoms present in the last 12 months, and at least one present in the past 6 months.

What are the long-term prognosis risks associated with Conduct Disorder?

juvenile justice system, substance use reckless behaviors, and progression to Antisocial Personality Disorder.

What is the first line treatment for ODD and CD?

Targeted psychotherapy involving the parent is always indicated

How does the nonpharmacologic treatment of ODD and CD vary by age?

Preschool (2-5 years): parental management training

Kids (6+): CBT for the child that may include family therapy

When is pharmacologic treatment indicated for ODD and Conduct Disorder?

When there are comorbid disorders (like ADHD, depression, or anxiety) or when severe aggression/irritability does not respond to psychotherapy.

What adjunct therapy is indicated for ADHD?

Stimulants

What adjunct therapy is indicated for Mood/Anxiety Disorder?

SSRI like fluoxetine or citalopram

What adjunct therapy is indicated for Severe Agression/Irritability?

second-generation antipsychotic (SGA) like Risperidone or aripiprazole

Why is Disruptive Mood Dysregulation Disorder (DMDD) classified under depressive disorders?

Due to its prominent mood component, risk for future depression and anxiety, and the need to differentiate it from pediatric bipolar disorder

Who does DMDD most often affect?

Adolescents aged 6-17 years

What is the diagnostic criteria for DMDD?

Frequent temper outbursts 3+ times per week and a persistently irritable or angry mood for 12+ months in at least two of three settings (home, school, peers)

What is the age range for the onset of DMDD?

Onset must be before 10 years of age, but not before 6 years of age.

Which disorders cannot coexist with a diagnosis of DMDD?

Oppositional Defiant Disorder, Intermittent Explosive Disorder, and Bipolar Disorder.

What is a key psychological difference between ODD and DMDD regarding intent?

ODD is associated with intent behind the behavior, whereas children with DMDD do not act out on purpose and may feel remorse after outbursts.

What is the nonpharmacological treatment of DMDD?

Dialectical behavior therapy adapted for children (DBT-C) or CBT

What is the pharmacological treatment for DMDD?

Atomoxetine (ATX) for irritability, stimulants for ADHD, and atypical antipsychotics if severe

What are the risk factors for Intermittent Explosive Disorder?

emotional or physical trauma during the first 20 years of life and a family history (1st degree relative)

What is the presentation of Intermittent Explosive Disorder?

Failure to control aggressive impulses leading to recurrent behavioral outbursts that are out of proportion to triggering event

What is a key differentiating factor of IED outbursts?

They are not premeditated or for personal gain; purely impulsive and anger based

What are the diagnostic requirements of IED?

Must be 6 years or older, marked distress or impairment due to verbal/physical aggression that does or does not result in damage

What is the difference in frequency of IED symptoms that does or does not cause damage?

No damage: twice weekly over a 3-month period

Damage: three times in a 12 month period

What are the comorbidities of Intermittent Explosive Disorder?

Mood disorders, binge-eating, bulimia nervosa, antisocial personality disorder, and borderline personality disorder

What is the standard combination of treatments for Intermittent Explosive Disorder?

A combination of cognitive behavioral therapy (CBT) and pharmacotherapy.

What is the first line pharmacotherapy for Intermittent Explosive Disorder?

Fluoxetine (SSRI)

What is Kleptomania?

Recurrent failure to resist impulses to steal objects that is not committed out of need, anger, or response to delusion/hallucination

What symptoms are associated with Kleptomania?

Patients feel a sense of increased tension prior to the theft, then a sense of pleasure, gratification, or relief after the theft

What is the typical age of onset for Kleptomania?

Adolescence, though it ranges from childhood to adulthood.

What are comorbid conditions associated with Kleptomania?

mood disorders, personality disorders, and eating disorders

What is Pyromania?

deliberate fire-setting preceded by tension/arousal and sensation of pleasure/gratification during fire or witnessing aftermath

What symptom may also be present in Pyromania?

Fascination with or attraction to fire

What are the diagnostic requirements of Pyromania?

Fire-setting on more than one occasion and not done for any other reason aside from compulsion to set fire

What are common comorbidities associated with Pyromania?

Substance use disorders, gambling disorder, mood disorders, and other impulse control disorders.

What is the treatment of Kleptomania and Pyromania?

treating any comorbid psychiatric conditions appropriately plus cognitive behavioral therapy (ERP)

What treatment may be used in Kleptomania?

Naltrexone (opioid antagonist) used to reduce stealin urge