Disruptive, Impulse Control, and Conduct Disorders

Gambling Disorder diagnostic criteria

• persistent, recurrent problematic gambling

• ≥4 criteria (chasing losses, lying, jeopardizing relationships/jobs, relying on others for money)

• duration ≥1 year

• causes impairment

gambling disorder differential

rule out manic episode before diagnosis gambling disorder

• ex. pt with doubled bets, sleeping 2-3 hrs, grandiose about “system,” irritable, pressured speech

gambling disorder treatment

CBT with motivational enhancement

practical safeguards: self-exclusion from casinos, limit access to finances

• Gamblers anonymous referral

• Naltrexone may help urges

Intermittent explosive disorder

uncharacteristic outbursts followed by guilt

intermittent explosive disorder diagnostic criteria

• recurrent behavioral outbursts (verbal/physical)

• out of proportion to provocation

• not premeditated

• brief episodes, then remorse

• between episodes: no persistent aggression pattern

• age ≥6 years

IED must rule out

• substances, mania, psychosis

• conduct disorder

• antisocial personality disorder

• PTSD with dissociation

IED example

21 y/o with explosive yelling/throwing objects for minutes, then remorse; between episodes calm; no adolescent hx of similar episodes, no conduct disorder

Kleptomania

stealing small things and feeling guilt

kleptomania diagnostic criteria

• recurrent impulse to steal low value items not needed for personal use/monetary value

• tension before theft

• pleasure/relief during theft

• guilt afterward

• often discards

Kleptomania differential

• planned shoplifting for external gain

• conduct disorder

• antisocial personality disorder

• OCD

Kleptomania example

23 y/o caught taking low value items (lip balm, keychains); mounting tension before, relief after, guilt; discards items at home; denies financial problems/resale/accomplices; multiple attempts to stop; no conduct problems before age 15

Pyromania

likes setting fires and watching them, but feels guilt afterwards

pyromania diagnostic criteria

• ≥2 deliberate fire settings

• tension/arousal before

• fascination with fire

• pleasure/relief when setting/witnessing fires

pyromania must rule out

• mania, psychosis, substance intoxication, conduct disorder, antisocial personality disorder

• normal childhood curiosity

• anxiety disorder

• ocd

pyromania example

17 y/o sets 4 small trash can fires over 8 mos; mounting tension beforehand, fascination with fire videos/tools; pleasure/relief then shame; denies revenge/insurance/financial motives; good school conduct, no cruelty/theft/truancy before 15; normal sleep/mood

Oppositional Defiant Disorder

pattern of angry or irritable mood, arfumentative or defiant behavior, or vindictiveness lasting at least 6 months with at least 1 individual who is not a sibling

Oppositional defiant disorder diagnosis

• Angry/irritable mood (loses temper, touchy, easily annoyed, often angry/resentful)

• Argumentative/defiant behavior (argue with authority figures, etc)

• Vindictiveness (spiteful/vindictive 2+ times within 6 mos)

• for children <5 symptoms should occur more days than not for 6 mos

• for children >5, behaior should occur 1+ times per week for 6 mos

Oppositional defiant disorder treatment

• preschool age: treat with behavioral parent management training

• school age: treat with combination of behavioral management training and youth oriented CBT

• adolescents: treat with combination of behavioral parent management training, youth oriented CBT, and family therapy

• adults treat with CBT

• lithium

• 2nd gen antipsychotics

conduct disorder

• disorder defined by repetitive pattern of behavior in which the basic rights of others or major social norms are violated

conduct disorder diagnosis

• aggression to people/animals (bullies, threatens, physical fights, weapon, cruel to people and animals, stealing)

• deceitfulness or theft

• destruction of property

• serious violation of rules (stay out at night, run away from home)

• onset as early as toddler years

• significant symptoms most often appear in early childhood/adolescence

conduct disorder treatment

similar to ODD