Disruptive, Impulse-Control, and Conduct Disorders DSM 5TR

Disruptive, Impulse-Control, and Conduct Disorders

• Oppositional Defiant Disorder

• Intermittent Explosive Disorder

• Conduct Disorder

• Antisocial Personality Disorder

• Pyromania

• Kleptomania

• Other

• Unspecified

Disruptive, Impulse-Control, and Conduct Disorders in DSM

• Previously in “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescences”

• Disorders in this category are distinguished by problems of impulsivity, self-regulation, and emotional and behavioral control

• Disorders in this category are unique because these problems violate the rights of others and bring individual into conflict with societal norms or authority figures

Oppositional Defiant Disorder

• A. Pattern of angry/irritable mood, argumentative, defiant behavior, or vindictiveness lasting at least 6 months as evidenced by four symptoms from any of the categories

  • Angry/Irritable Mood

    • Often loses temper

    • Is often touchy or easily annoyed

    • Is often angry and resentful

  • Argumentative/Defiant Behavior

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

    • often actively defies and refuses to comply with requests form authority figures or with rules

    • Often deliberately annoys others

    • Often blames others for his or her mistakes or misbehaviors

  • Vindictiveness

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

• B. Associated with distress in individual or others in immediate social context or negatively impacts social, occupational, or other important areas of function

• C. Do not occur in course of psychotic, substance use, depressive or bipolar disorder, DMDD is NOT met

ODD Features

• Distinguish these behaviors from that in normal limits by the persistence and frequency of client behaviors

• Children under 5 years old, behavior should occur on most days for a period of at least 6 months

• Those 5 and older once a week for 6 months

• Symptoms may be confined to one setting, for instance home

• May be difficult to detangle these behaviors from problematic relationships

ODD specifiers

• Mild

  • Confined to only one setting

• Moderate

  • Symptoms in two settings

• Severe

  • Present in three or more settings

Intermittent Explosive Disorder

• A. Recurrent behavioral outbursts representing a failure to control aggressive impulses by either of

  • verbal or physical aggression for a period of 3 months

  • Three behavioral outbursts involving damage or destruction of property involving physical injury against animals or individuals occurring within 12 month period

• B. Magnitude of aggressiveness expressed during outbursts grossly out of proportion to provocation or stressors

• C. Recurrent aggressive outbursts not premeditated or to achieve objectives, money, power, intimidation

• D. Recurrent aggressive outbursts cause marked distress or problems in functioning, or financial or legal consequences

• E. Age must be at least 6 years or equivalent developmental period

• F. Outbursts are not explained by mental disorder, medical condition, or substance abuse

  • Children 6 - 18, aggressive behavior that occurs as part of adjustment disorder is not this diagnosis

Conduct Disorder

• A. Repetitive and persistent pattern of behaviors 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 three of the following criteria in the past 12 months from any of the following categories

  • Aggression to people and animals

    • Bullies, threatens, or intimidates others

    • Initiates physical fights

    • Used a weapon that can cause serious physical harm

    • Been physically cruel to people

    • Been physically cruel to animals

    • Stolen while confronting a victim

    • Forced someone into sexual activity

  • Destruction of property

    • Deliberately engaged in fire setting to cause harm

    • Deliberately destroyed property

  • Deceitfulness of theft

    • broken into someone else’s home, building, etc

    • deliberately destroyed others’ property

  • Serious violations of rules

    • Often stays out at night despite parental prohibitions before age of 13

    • Run away form home overnight at least twice while living in parental or caregiver home

    • Truant form school before age of 13

• B. Clinically significant impairment

• C. 18 years or older, if the criteria is not met for antisocial personality disorder

Conduct Disorder Specifiers

• Childhood onset type

  • one symptom before age 10

• Adolescent onset type

  • no symptoms until after age 10

• Unspecified onset type

  • criteria met but not enough information when symptoms appeared

• Limited prosocial emotions

  • must have displayed two characteristics for at least 12 months in multiple settings

• Lack of remorse or guilt

  • no concern about inappropriate behaviors

• Callous - lack of empathy

  • disregards and is unconcerned about others feelings, cold and uncaring

• Unconcerned about performance

  • no concern about poor performance in school, work, or other activities

• Shallow or deficient affect

  • no feelings or emotions to others, superficial or false emotions

• Mild

  • few if any conduct problems in excess of those required to make diagnosis, minor harm

• Moderate

  • Number of conduct problems and the effect on others intermediate

• Severe

  • Many conduct problems in excess of those required to make diagnosis, considerable harm to others

Risk Factors for CD

• Early maternal rejection and neglect

• Separation from parents, without an adequate alternative caregiver

• Parent or parents incarcerated

• Alcohol and other drug use in home or residences

• Early institutionalization

• Family neglect

• Abuse or violence in home

• Parental mental illness

• Spousal abuse and extreme discord in home

• Very large family size

• Crowding in home

• Extra people in home

• Lack of stable structure or daily schedule

• Poverty and deprivation

Children with CD

• Higher rates of depression, suicidal thoughts, suicide attempts, and suicide

• Academic difficulties

• Poor relationships with peers or adults

• Sexually transmitted diseases

• Higher rates of violence against these children

• difficulty staying in adoptive, foster, or group homes

• Higher rates of injuries, school expulsions, and problems with the law

Antisocial Personality Disorder

• A. Pervasive pattern of disregard of rights of others since age 15

  • Three or more of the following

    • Failure to conform to social norms with respect to lawful behaviors, as indicated by acts, grounds for arrest

    • Deceitfulness

    • Impulsivity or failure to plan

    • Irritability or aggressiveness

    • Reckless or disregard of the safety of others

    • Consistently irresponsible

    • Lack of remorse

• B. Must be at least 18 to be diagnosed

• C. Evidence of conduct disorder with onset before 15 years old

• D. Not exclusively during course of schizophrenia or bipolar disorder

Characteristics of APD

• Lack empathy and indifferent to their victims or others in general

• Tend to be disrespectful of others, regardless of position

• Trouble with authority figures & rules

• Disregard for right and wrong

• Persistent lying or deceit

• Using charm or wit to manipulate others

• Intimidation of others

• Aggressive, impulsive and/or violent behavior

• May be arrogant, cynical, & contemptuous of others

• Opinionated & cocky even when ignorant of a topic

• Irresponsible work behavior

• Consistently & extremely irresponsible in daily life

• Superficial charm, glib, verbally facile

• Sexually exploitive & irresponsible

Pyromania

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

• B. Tension or affective arousal before the act

• C. Fascination with, interest in, curiosity about or attraction to fire and its contexts

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

• E. Not done for or because of

  • Monetary gain

  • Expression of sociopolitical ideology

  • Conceal criminal activity, to express anger or vengeance

  • To improve one’s living circumstances

  • Response to hallucination or delusion

  • Result of impaired judgment, such as neurocognitive disorder

• F. Not better explained by conduct disorder, manic episode, or APD

Kleptomania

• 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. Stealing is not committed to express anger or vengeance and is not in response to delusion of hallucination

• E. Stealing not better explained by

  • Conduct disorder

  • Manic episode

  • APD

Other Specified Disruptive, Impulse-Control, and Conduct disorder

Presentations when symptoms characterize a disruptive-impulse control, and conduct disorder that causes distress and impairment, but does not meet the full criteria for the disorders in this category

Unspecified Disruptive, Impulse-Control, and Conduct disorder

Presentations when symptoms characterize a disruptive-impulse control, and conduct disorder that causes distress and impairment, but does not meet the full criteria for the disorders in this category. Used when clinician choses not to specify why criteria not met (e.g., in emergency room)