PSYC 188 - Midterm #2

Conduct problems

Related to antisocial (goes against society) behavior

• Age-inappropriate actions & attitudes that violate family expectations, societal norms & the personal or property rights of others

• Asocial = not feeling social

Key features of antisocial behaviors

• Some behaviors decrease w/ age (e.g., disobeying at home), talking about small children

  • Must consider developmental factors in order to prevent clinical bias because some behaviors can be normal as a child develops

• Some behaviors increase with age and opportunity (e.g. hanging around kids who get into trouble)

• More common in boys during childhood

• When is it a disorder?

Psychological Dimensions of Conduct Problems

Destructive x covert

•  Destroying things, but covert, kind of undercover, not involving other ppl directly

  • E.g. property violations

Nondestructive x covert

• No destruction on property, people, or animals, but destruction to self?

  • E.g. Substance abuse, swearing, rule breaking

Overt x destructive

• Overaggression

  • E.g. physical assault, fighting, cruelty to animals/people

Overt x nondestructive

• Being annoying, defiant, angry

Reactive aggression

• Engaging in physical violence in response to a threat, frustrating event, or provocation

  • Impulsivity/automaticity

  • No consideration of alternative responses

  • Mostly seen in younger kids and those with ADHD

Proactive aggression

•  Deliberately engaging in an aggressive act to obtain a desired goal

  • Learned through modeling and reinforcement

    • When positively reinforced…

      • E.g. pushing a kid in line to get lunch money

    • When negatively reinforced…

      • E.g. school suspension to get out of school

      • E.g. mom tells child to clean board game they threw off table, they get in mom’s face and she says “fine, i’ll put it away”, this is negative reinforcement

Relational Aggression

• Purposefully leaving a child out of an activity

• Getting mad at someone and excluding him/her from the peer group

• Telling lies about a person so others won’t like him/her

• Telling others you will not like them unless they do what you say

• There’s a stereotype that girls are more likely to do this, but this isn’t backed up by evidence

Oppositional Defiant Disorder

A pattern of angry/irritable mood, argumentative/defiant behavior or vindictiveness lasting at least 6 months as evidenced by at least 4 symptoms from any of the following categories & exhibited during interaction with at least individual who is not a sibling

Why is it important to be 6 months?

• Demonstrating that it’s not just them having a tough time at school or not sleeping well, but it’s how they present themselves most of the time

• Emphasis on not being like this towards a sibling

ODD Severity

• Mild - Symptoms are confined to only setting (e.g., at home, at school, at work, with peers)

• Moderate - Some symptoms are present in at least two settings

• Severe - Some symptoms are present in three or more settings

ODD: Associated Characteristics

• Typically do not regard themselves as angry, oppositional, or defiant

• View their behavior as a justified response to unreasonable demands or circumstances

• May have a history of hostile parenting; hard to know which came first

ODD: Prevalence, Course, and Comorbidities

• 3-5%

• More prevalent in males (prior to adolescence)

• First symptoms usually appear in preschool and rarely later than early adolescence

• Often (but not always) precedes the development of conduct disorder

• Comorbid with anxiety disorders, major depressive disorder, substance use

Conduct Disorders

A repetitive & persistent pattern of behavior 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 3 of the following 15 criteria in the past 12 mos. from any of the categories below, with at least one criterion present in the past 6 mos

CD: Childhood-onset type

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

CD: Adolescent-onset type

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

CD: Unspecified onset

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

CD Severity

Mild: Few if any conduct problems in excess of those required to make the diagnosis are present, & conduct problems cause relatively minor harm to others

Moderate: The number of conduct problems & the effect on others are intermediate between those specified in “mild” & those in “severe”

Severe: Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems cause considerable harm to others

CD: Age of Onset Subtypes

Why limited prosocial emotions (LPE) specifiers?

• Those with LPE more likely to have childhood-onset, severe, violent and chronic CD

• LPE traits are relatively stable from late childhood to early adolescence 

• Behavior therapy alone is less effective for those with LPE traits (stimulant medication + behavioral therapy seems to help)

• The problems of those with LPE traits are more strongly related to dysfunctional parenting practices

• Those with LPE traits show deficits in processing fear and distress signals in others (amygdala hyporeactivity) 

• LPE traits tend to be more heritable

• Reductions in emotional, though not cognitive empathy

CD: Prevalence

• 5-10% for boys, 2-4% for girls

  • Prevalence rates rise from childhood to adolescence 

• More common in boys than in girls

  • Girls less likely to use physical aggression

• Few children with CD receive treatment

• Differentially diagnosed in Black and Latino children?

Antisocial Behavior Causes: Neurobiology

• Decreased NTs:

  • Serotonin

  • Dopamine

• Increased hormones

  • Testosterone

• Low levels of autonomic arousal

  • Under arousal of HPA axis

    • May explain lack of empathy and emotional reactivity to others

    • Limited ability to feel fear and guilt

    • Insensitivity to punishment

    • Less able to experience pleasure, excitement, and exhilaration

Conduct Problems Causes: Temperamental & Psychosocial

• Difficult temperament

• High emotion reactivity

  • Don’t learn effective regulation skills

  • Parents may have trouble responding sensitively & appropriately

  • Can compromise parent-child interaction quality

  • Children may rely on impulsive decision-making

  • Peer rejection, selective affiliation with deviant peers, deviancy training

• Thrill-seeking & recklessness (with CD)

  • Parents may alternate between overly permissive & hostile & angry disciplinary tactics

  • One of the best predictors of CD

  • One of the best predictors of ODD → CD

  • Parents may feel powerless

  • Low parental monitoring

  • Maternal depression, paternal substance abuse

  • High crime neighborhoods

Antisocial Behavior Causes: Cognitive Behavioral

• Rewards for aggression

• Hostile attribution bias

  • See world in scarier lens so that they are ready to defend themselves, quiicker to anger

• May perceive and label their own arousal as anger

• Focus on positive aspects of aggression and lack of responsiveness to emotional stimuli

• Social learning

  • Modeling new aggressive behaviors, disinhibition of aggression

• Reinforcement trap

  • Giving in to a child’s tantrum

  • Mother reinforces child’s behavior and reinforces her own behavior

Antisocial behavior treatment: Parent Management Training (PMT)

• Teach parents the causes of disruptive behavior problems

• Show parents how to attend to and praise appropriate behavior 

• Parent-child interaction therapy (PCIT)

  • Parents and children attend therapy together

  • Parents developing skills: Praising, Reflecting, Imitating, Describing (kind of like narrating what the child is doing), Enthusiasm

  • Parents create more realistic expectations for children’s behavior

    • Give effective

Antisocial behavior treatment: Multisystemic treatment (MST)

• Targets family, school, and peers

• Therapists work in teams of 3-5 and are available to child and family 24/7

• Usually lasts 3 months

• Family

  • Help parents effectively interact with and monitor kids

  • Remove obstacles that interfere

• School

  • Increase parental involvement in education

  • Remove obstacles to academic achievement

• Peers

  • Limit opportunities for interactions with deviant peers

  • Increase interactions with prosocial youths/new peer networks

• Lowers probability of future offenses and arrests

• Only available to ~1% of adolescents with serious conduct problems

• Costly, but not as much as incarceration

Intermittent Explosive Disorder

• Criterion A. Recurrent (doesn’t have to be everyday, but there is a pattern) behavioral outburst representing a failure to control aggressive impulses as manifested by either of the following: 

1. Verbal aggression or physical aggression occurring twice weekly, on average, for a period of 3 months. Does not result in property damage or physical injury

2. Three behavioral outbursts involving property damage or physical injury within a 12-month period

• Criterion B. Aggressiveness grossly out of (way out of) proportion to the situation

  • E.g. child with this can lose a game of monopoly and flip over board and start breaking things with it, start to hurt family members (unlike in ODD)

• Criterion 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)

  • People who are pretty easy going and nice to be around a lot of the time, may even be sweet, but if something sets them off, it’s an intense response that is not well-regulated

Diagnostic Criteria – IED

• Criterion D. Outbursts cause distress in individual, or impairment in occupational or interpersonal functioning, or are associated with financial or legal consequences

  • Other people bothered by it, but person is bothered by it as well

• Criterion E. Chronological age is at least 6 years (or equivalent developmental level)

• Criterion F. The recurrent aggressive outbursts are not better explained by another mental disorder, medical condition, or substance use

IED is …

• Rare condition

• Characterized by frequent aggressive outbursts

• Leads to injury and/or destruction of property

• Few controlled treatment studies

Difference between IED, ODD, & CD

• IED is most consistent with emotional dysregulation

• Conduct disorder is most consistent with behavioral dysregulation

• ODD is somewhere in the middle

IED Assessment

• Keep in mind any other comorbidities: multiple psychiatric diagnoses

• Conduct disorders (ODD/IED/CD) often cluster together with:

  • ADHD

  • Mood disorders

  • Anxiety

  • SUDs

• Comorbid diagnoses tend to predict poorer outcomes

• Unfortunately, it’s rarely “one thing” – can make diagnosis and treatment planning rather complicated

Distinguishing between conduct disorders

• ODD does involve…

• Emotion regulation problems (ODD, IED)

• Conflict with authority (ODD, CD)

• More likely in CD than ODD

  • Significant physical aggression

  • Significant destruction of property

  • Pattern of theft and deceit

• More likely IED than ODD

  • Serious aggression

Pyromania - Background

• Terminology

  • Fire-setting: behavior of setting a fire

  • Arson: criminal act of intentional fire-setting

  • Pyromania: a psychiatric disorder of which intentional-fire setting is a symptom but no sufficient for diagnosis

Pyromania - History

• Has been described in medical reports for at least 200 years

• Name derives from greek fire (pyr) & madness (mania)

• Validity has been debated over time, but it remains scarcely researched

• First appeared in DSM in 1952 as a supplemental item, then re-emerged in DSM-III in 1980 as an impulse-control disorder

Pyromania’s Diagnosis

1. Deliberate and purposeful fire setting on more than one occasion

2. Tension or affective (emotional) arousal before the act

3. Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g., paraphernalia, uses, consequences)

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

5. The fire setting is not done for monetary gain, as an expression of sociopolitical ideology, 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 judgement (e.g., in major neurocognitive disorder, intellectual disability [intellectual developmental disorder], substance intoxication)

6. The fire setting is not better explained by conduct disorder, a manic episode, or antisocial personality disorder

Diagnosis: Pyromaniac fire-setting as an aesthetic behavior?

• Aesthetic behavior

  • Behavior that has no clear extrinsic reward but is intrinsically rewarding to perform

• Fire as an aesthetic stimulus

  • People with pyromania in a study said the fire was like an “amalgam of elements, some of which interact synergetically”

  • Fire destroys and cleanses, it humanizes but also demonizes

  • Fire interacts and transforms elements in its environment

• Personal speculative theory:

  • A person with pyromania has an unusually increased aesthetic response to fire?

Pyromania’s Diagnosis – Associated characteristics

• May make considerable advance preparations for starting a fire

  • It’s their plan for the day to cause fire and experience the fire

• Population prevalence of pyromania is unknown, but lifetime prevalence of fire setting is 1/13%

• Diagnoses in just 3% of arsonists

• Little etiological and treatment research

Pyromania’s Diagnosis - Development & Course

• Limited info

• Although 40% of arson arrests are in those younger than 18yo, pyromania in childhood appears to be rare

• Juvenile fire-setting is usually associated with conduct disorder, ADHD, or an adjustment disorder

Pyromania’s Differential Diagnosis

• Must rule out other causes

  • Rule out other gain related to fire-setting

  • Fire-setting behavior in the context of other disorders

• Must consider other common comorbidities

  • Substance use disorders

  • Gambling disorders

  • Depressive disorders

  • Bipolar disorders

  • Other disruptive, impulse-control, & conduct-disorders

Treatment - Tarasoff warning

• “…a psychotherapist has a duty to protect or warn a third party only if the therapist actually believed or predicted that the patient posed a serious risk of inflicting serious bodily injury upon a reasonably identifiable victim.”

• Tarasoff v. Regents of the University of California

  • A patient confided to his therapist of direct intent to kill an identifiable victim (Tatianna Tarasoff)

  • Therapist alerted campus police of the patient’s intent, but not the victim

  • The patient murdered the victim after being released from police custody

Treatment - Medication & CBT

• Some medication have shown promise in case studies

• CBT may reduce behavior as urge increases

Kleptomania

• DSM diagnosis (since DSM-3)

• Failure to resist urge to steal unnecessary items

• Seems rare, but it is not well studied

• Highly comorbid with mood disorders

• Als0 co-occurs with substance-related problems

Kleptomania: DSM-5 Criteria

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

2. Increasing sense of tension immediately before committing the theft

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

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

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

Kleptomania: Associated Characteristics

• Estimates are difficulty to establish, but seems very rare

• Ration of females to males is estimated as 3:1 (White upper -and upper-middle class women, more specifically)

• Onset most commonly in adolescence

• Can be episodic in course but occur across long periods

Kleptomania: Risk & Prognostic Factors

• May be associated with family history of OCD, & Alcohol Use Disorder

• Neurotransmitter pathways associated with behavioral addictions, appear to play a role in kleptomania

• May affect legal, family, career in negative way

Assessment of Kleptomania: Differential Diagnosis

• Differential Diagnostic Considerations:

  • Nor “ordinary” theft or shoplifting

  • Malingering

  • Antisocial Personality Disorder

  • Manic episodes, psychotic episodes, and major neurocognitive disorder

• Comorbidities

  • Compulsive buying

  • Depressive and bipolar disorders

  • Anxiety disorders

  • Eating disorders (especially bulimia nervosa)

  • Personality disorders

  • SUDs (especially alcohol)

  • Other disruptive, impulse-control, & conduct disorders

Cognitive-Behavioral Treatment of Kleptomania

• Kleptomania can be conceptualized as a set of unwanted behaviors which are the result of operant and respondent conditioning, shaping, behavioral chaining, distorted cognitions & impoverished coping skills

• Functional assessment of stealing behavior

• Cognitions related to shame can be addressed

• Comorbid psychiatric conditions can be treated with CBT, as well