Disruptive, Impulse-Control, and Conduct Disorders

Disruptive, Impulse-Control, and Conduct Disorders

• include conditions involv ing problems in the self-control of emotions and behaviors.

• may also involve problems in emotional and/or behavioral regulation, the disorders in this chapter are unique in that 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.

males

The disruptive, impulse-control, and conduct disorders all tend to be more common in

childhood or adolescence.

The disorders in this chapter tend to have first onset in —

Oppositional Defiant Disorder

• is a mental health condition characterized by a persistent pattern of negative, defiant, and hostile behavior towards authority figures.

• is a frequent and persistent pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness

• 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 cate gories, 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 6 months.

  • 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 A8). While these frequency criteria provide guidance on a minimal lev el 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 nor mative 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 neg atively 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.

Diagnostic Criteria for Oppositional Defiant Disorder

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criteria A for ODD: A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least — months as evidenced by at least four symptoms from any of the following cate gories, and exhibited during interaction with at least one individual who is not a sibling.

6 months

(ODD) For children younger than 5 years, the behavior should occur on most days for a period of at least — unless otherwise noted (Criterion A8).

once per week for at least 6 months

(ODD) For individuals 5 years or older, the behavior should occur at least — , unless otherwise noted (Criterion A8).

Mild (ODD)

(ODD) Symptoms are confined to only one setting (e.g., at home, at school, at work, with peers).

Moderate (ODD)

(ODD) Some symptoms are present in at least two settings.

Severe (ODD)

Some symptoms are present in three or more settings.

ADHD

Rates of oppositional defiant disorder are much higher in samples of children, adoles cents, and adults with —

Intermittent Explosive Disorder

• is a mental health condition that causes people to have frequent, impulsive, and aggressive outbursts.

• These outbursts can be verbal or physical, and can include temper tantrums, fights, or property destruction. They are often triggered by minor things, like frustration or anger, and can be out of proportion to the situation.

• 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 re sult 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 occur ring 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 not 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 finan cial 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 disor der (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, Alz heimer’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.

Diagnostic Criteria for Intermittent Explosive Disorder

1. twice weekly

2. 3(IED

(IED) Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or physical aggression toward property, animals, or other individuals, occurring 1. —, on average, for a period of — months.

12

(IED) Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occur ring within a --month period.

Depressive disorders, anxiety disorders, and substance use disorders

are most commonly comorbid with intermittent explosive disorder.

Conduct Disorder

• is a mental health condition characterized by a persistent pattern of behavior that violates the rights of others or major age-appropriate societal norms or rules

• A. A repetitive and persistent pattern of behavior in which the basic rights of others or ma jor 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 cate gories 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 pa rental surrogate home, or once without returning for a lengthy period. 1

    • 5. Is often truant from school, beginning before age 13 years.

• B. The disturbance in behavior causes clinically significant impairment in social, aca demic, or occupational functioning.

• C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

Diagnostic Criteria for Conduct Disorder

Childhood-onset type

Individuals show at least one symptom characteristic of conduct disorder prior to age 10 years.

Adolescent-onset type

Individuals show no symptom characteristic of conduct disorder prior to age 10 years.

Unspecified onset

Criteria for a diagnosis of conduct disorder are met, but there is not enough information available to determine whether the onset of the first symptom was before or after age 10 years

with limited prosocial emotions

• To qualify for this specifier, an individual must have dis played at least two of the following characteristics (lack of remorse or guilt, callous, unconcerned about performance, shallow or deficient affect) persistently over at least 12 months and in multiple relationships and settings.

• These characteristics reflect the individual’s typical pattern of interpersonal and emotional functioning over this period and not just occasional occurrences in some situations.

lack of remorse or guilt

• Does not feel bad or guilty when he or she does some thing wrong (exclude remorse when expressed only when caught and/or facing punishment).

• The individual shows a general lack of concern about the negative consequences of his or her actions.

• For example, the individual is not remorseful after hurting someone or does not care about the consequences of breaking rules.

callous—lack of empathy

• Disregards and is unconcerned about the feelings of others. The individual is described as cold and uncaring.

• The person appears more concerned about the effects of his or her actions on himself or herself, rather than their effects on others, even when they result in substantial harm to others.

Unconcerned about performance

• Does not show concern about poor/problem atic performance at school, at work, or in other important activities.

• The individual does not put forth the effort necessary to perform well, even when expectations are clear, and typically blames others for his or her poor performance.

shallow or deficient affect

Does not express feelings or show emotions to others, except in ways that seem shallow, insincere, or superficial (e.g., actions contradict the emotion displayed; can turn emotions “on” or “off” quickly) or when emotional expres sions are used for gain (e.g., emotions displayed to manipulate or intimidate others).

Mild (CD)

Few if any conduct problems in excess of those required to make the diagnosis are present, and conduct problems cause relatively minor harm to others (e.g., lying, truancy, staying out after dark without permission, other rule breaking).

Moderate (CD)

The number of conduct problems and the effect on others are intermediate between those specified in “mild” and those in “severe” (e.g., stealing without confront ing a victim, vandalism).

Severe (CD)

Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems cause considerable harm to others (e.g., forced sex, physical cruelty, use of a weapon, stealing while confronting a victim, breaking and entering).

male

In childhood-onset conduct disorder, individuals are usually — , frequently display physical aggression toward others, have disturbed peer relationships

Oppositional defiant disorder (2)

is a common precursor to the child hood-onset type of conduct disorder

ADHD and oppositional defiant disorder

are both common in individuals with conduct disorder, and this comorbid presentation predicts worse outcomes

Pyromania

• is a mental health condition characterized by a compulsive urge to set fires.

• experience intense pleasure or relief after setting a fire

• A. Deliberate and purposeful fire setting on more than one occasion.

• B. Tension or affective arousal before the act.

• C. Fascination with, interest in, curiosity about, or attraction to fire and its situational con texts (e.g., paraphernalia, uses, consequences).

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

• E. The fire setting is not done for monetary gain, as an expression of sociopolitical ideol ogy, to conceal criminal activity, to express anger or vengeance, to improve one’s living circumstances, in response to a delusion or hallucination, or as a result of impaired judgment (e.g., in major neurocognitive disorder, intellectual disability [intellectual de velopmental disorder], substance intoxication).

• F. The fire setting is not better explained by conduct disorder, a manic episode, or anti social personality disorder

Diagnostic Criteria for Pyromania

males

Pyromania occurs much more often in — , especially those with poorer social skills and learning difficulties.

Kleptomania

• is a mental health condition characterized by the inability to resist the urge to steal items, even when the items are not needed or can be easily afforded.

• People with — often feel a sense of tension or excitement before stealing and a sense of relief or pleasure after the act.

• 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. The stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination.

• E. The stealing is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.

Diagnostic Criteria for Kleptomania

shoplifting

Kleptomania occurs in about 4%–24% of individuals arrested for —