Disruptive, Impulse-Control, and Conduct Disorders-Case Studies

Learning Objective: Diagnosis

A mother brings in her 5-year-old son and informs you that he often loses his temper and is easily annoyed. She also reports that he has a pattern of deliberately annoying others. When he makes mistakes or misbehaves, he always blames others. His behavior is driving his friends away. There is no history of any other psychiatric symptoms.

Which of the following is the most likely diagnosis?

A. Pyromania

B. Conduct Disorder

C. Kleptomania

D. Oppositional Defiant Disorder

E. Intermittent Explosive Disorder

Answer and Rationale

The answer is D. This child’s reported behavior meets the criteria for Oppositional Defiant Disorder. He does not set fires, does not steal, and does not behave aggressively toward people or animals. He is less than six years old.

Learning Objective: Treatment

A 10-year-old child with a history of Conduct Disorder presents with extreme episodes of aggression, during which he has severely injured both his peers and caregivers.

Which of the following with be the BEST medication to prescribe?

A. Risperidone

B. Imipramine

C. Alprazolam

D. Methylphenidate

E. Fluoxetine

Answer and Rationale

The answer is A. This atypical antipsychotic is often prescribed for aggression in children with Conduct Disorder. The antidepressants would not likely be as effective. A CNS stimulant is indicated for Attention Deficit Hyperactivity Disorder (ADHD), and a sedating benzodiazepine might cause even more disinhibition.

Learning Objective: Diagnosis

A mother brings her 7-year-old son to you with complaints that he is an unruly child. She thinks he may need some “hyperactive medication.” He has frequent temper tantrums, usually triggered by not getting his way. He provokes others, and he now has few friends. He scores well on standardized tests, and his grades are excellent. Since his sister was born when he was two, he has consistently been aggressive toward her. His mom believes his behavior has worsened since she began dating again as a divorced single parent.

What is the most likely diagnosis?

A. Oppositional Defiant Disorder

B. Conduct Disorder

C. Kleptomania

D. Pyromania

Answer and Rationale

The answer is A. This child meets the criteria for Oppositional Defiant Disorder, but his behaviors are not severe enough to meet the criteria for Conduct Disorder at this time. Moreover, there is no history of stealing or firesetting.

Learning Objectives: Diagnosis, Treatment, and Complications

A 14-year-old male patient of yours was recently arrested for setting fire to his friends’ treehouse. History reveals that he has been fascinated with fire for as long as he can remember. He reports that he feels an irresistible urge before setting a fire and great after getting the fire going. He has a history of Attention Deficit Hyperactivity Disorder (ADHD) and a recurring pattern of skipping school and running away from home. He expresses no remorse. “They deserved what they got.”

Which of the following statements about this disorder is true?

A. This disorder tends to wax and wane, and the prognosis for treated children is poor.

B. The M:F ratio of this disorder is 2:1.

C. Cognitive-Behavioral Therapy (CBT) and SSRI antidepressants are effective treatments for this disorder.

D. Commonly associated features include a below-average intelligence quotient (IQ) and resentment toward authority.

Answer and Rationale

The answer is D. Sexual dysfunction, substance use disorders, and chronic frustration are also common. The prognosis for treated children is good, and complete remission is realistic, but the same is not valid for adults. The M:F ratio is 8:1, and female fire setters may also have kleptomania. No evidence-based treatments have emerged, and the treatment team should consider a multimodal approach.

Learning Objectives: Diagnosis and Treatment

A 14-year-old daughter of a wealthy physician colleague was recently arrested for shoplifting for the third time in Walmart. Your colleague, the patient’s mother, brings her daughter in for you to “help her get out of this mess.” “She’s just a kid, and everyone knows kids do stupid things.” The patient admits that she is a “shopaholic” and tells you she cannot resist the urge to steal, even though she has a zero balance and a $10,000.00 limit on her mother’s credit card in her purse. She began stealing at age 10, and she steals 10-30 times a month.

Which of the following statements is true about this disorder?

A. These patients are more likely to steal from friends and family than from retail stores.

B. These patients feel guilty, ashamed, embarrassed, anxious, and depressed; these feelings are good prognostic indicators.

C. Many psychoactive medications have been tried, but they are not effective.

D. This disorder is common and increasing among teenagers.

Answer and Rationale

The answer is B. These feelings are good prognostic indicators. This disorder is rare; shoplifting for kicks or desired merchandise is common. The SSRI antidepressants may be helpful in this disorder. These patients are more likely to steal from retail stores.

Learning Objective: Treatment

A 17-year-old girl presents to your office accompanied by her mother. The girl refuses to have her mother join her in the exam room. The patient tells you nothing is wrong with her, that this is all her mother’s problem. When you persuade the patient to let her mother join you, the mother tells you the patient has an “anger problem.” Her daughter often gets in fights at school, breaks things, and kicks out the walls at home. The mother tells you these episodes come on suddenly and are disproportionate to the triggering frustration.

Which of the following statements about the treatment of this disorder is correct?

A. Angry outbursts infrequently interfere with counseling sessions.

B. Lithium should be avoided because of nonadherence concerns.

C. Antidepressants are often helpful in controlling anger attacks.

D. The combination of counseling and medication is usually the best approach.

Answer and Rationale

The answer is D. This approach generally works best, but nonadherence is a significant challenge. Anticonvulsants are more helpful for these patients’ behavioral outbursts. Lithium is somewhat challenging to take, but it is underutilized in chronically suicidal patients. Unmanaged anger frequently complicates the treatment process with these patients.

Learning Objective: Complication

You have decided to prescribe a selective serotonin reuptake inhibitor (SSRI) for target symptoms of irritability, mood liability, and extreme impulsivity in a 15-year-old patient with Conduct Disorder. Both the patient and her parents are concerned about weight gain.

Which of the following antidepressants has the highest risk of weight gain?

A. Escitalopram

B. Fluoxetine

C. Mirtazapine

D. Vilazodone

Answer and Rationale

The answer is C. This alpha 2, serotonin 2C, and histamine 1 antagonist is associated with short- and long-term weight gain. While weight gain may occur with vilazodone, it is less likely with this drug and many other antidepressants. Some patients experience short-term weight loss with fluoxetine. The risk of short- and long-term weight gain with escitalopram is low.

Learning Objective: Treatment

A colleague has asked you to evaluate a 14-year-old girl who has been tried on two different atypical antipsychotics for repeated episodes of aggression. She gained significant weight on both. Her mother has been researching on the Internet and wants to try a typical antipsychotic. She asks you to explain the differences between them.

Which of the following is the BEST description of the differences in typical and atypical antipsychotics?

A. They have different therapeutic and side-effect profiles.

B. They have different therapeutic profiles but similar side-effect profiles.

C. They have similar therapeutic and side-effect profiles.

D. They have similar therapeutic profiles but different side-effect profiles.

Answer and Rationale

The answer is D. While individual patients’ reactions may differ, these drugs share the same mechanism of action—dopamine 2 receptor blockade. Differing muscarinic, histaminergic, and alpha-adrenergic receptor antagonism can produce different side effects. The side-effect profiles differ because of the drugs’ secondary mechanisms of action, but the therapeutic profiles are similar.

Learning Objective: Complication

Because of reoccurring episodes of intense aggression, you have prescribed risperidone for an 11-year-old patient. His parents agree that a drug trial is probably necessary. Still, they are reluctant to give him any medication, and they want to know what drug side effects they may expect if they agree with your beginning this atypical antipsychotic.

Which of the following side effects of risperidone is LEAST common in children?

A. Increased thirst

B. Sedation

C. Weight gain

D. Vomiting

E. Urinary incontinence

Answer and Rationale

The answer is A. Increased thirst occurs in 7% of these patients, and urinary incontinence occurs in 16%. Vomiting occurs in 20%, and weight gain occurs in 33%. Sedation occurs in 63% of the patients taking this medication.

Learning Objective: Diagnosis

A 14-year-old girl, who lives with her grandparents, has been repeatedly expelled from school for fighting. She has seen several counselors, but she has refused to follow up with anyone regularly. She has set numerous fires and been in and out of juvenile detention for stealing. Her grandparents want to know whether she is at increased risk for developing other psychiatric disorders.

Which of the following disorders is MOST likely to develop later?

A. Paranoid Personality Disorder

B. Schizoid Personality Disorder

C. Schizotypal Personality Disorder

D. Antisocial Personality Disorder

E. Borderline Personality Disorder

The answer is D. Earlier onset of Conduct Disorder increases the risk of developing Antisocial Personality Disorder (ASPD) later in life. The diagnosis of Conduct Disorder does not predispose patients to the later development of these other psychiatric disorders.

Learning Objective: Diagnosis

The court refers a 13-year-old boy for evaluation. He skips school, stays out late, and verbally abuses his adoptive parents. He constantly fights with other kids, and he has an explosive, violent temper. His parents suspect he has started several fires in the neighborhood, but he has never been caught. He is sullen and uncooperative. His parents are at their wits’ end.

Which of the following diagnoses is MOST likely to accompany this disorder?

A. Substance Use Disorder

B. Schizophrenia

C. Anxiety Disorder

D. Eating Disorder

E. Somatoform Disorder

Answer and Rationale

The answer is A. These disorders are commonly associated with Conduct Disorder. Schizophrenia may occur with Conduct Disorder, but it is not more common than overall. Anxiety disorders are not more common in patients with Conduct Disorders, nor is the risk for an eating disorder increased in these patients. The prevalence of Somatoform Disorder in these patients is the same as in the general population.

Learning Objective: Complications

The parents of your 12-year-old patient with a history of worsening aggressive, assaultive, and destructive behavior have now reluctantly agreed that a trial of risperidone is needed. These patients have read about the drug’s side effects, and they are concerned about the possibility of weight gain and the development of the metabolic syndrome.

Which of the following pharmacological properties of this medication creates this risk for the patients taking it?

A. Serotonin 2B antagonism

B. Dopamine 2 antagonism

C. Serotonin 2A antagonism

D. Serotonin 2C antagonism

E. Alpha 1 adrenergic antagonism

Answer and Rationale

The answer is A. Antagonism of serotonin 2B receptors is associated with weight gain, perhaps because of appetite stimulation in the hypothalamus. This finding is especially true when combined with histamine 1 antagonism. Dopamine 2 blockade is associated with therapeutic and side effects, but it has not been linked to weight gain.

Learning Objective: Complications

Your 15-year-old patient with a history of shoplifting presents to your office accompanied by her mother. The patient’s mother reports that her daughter has become increasingly depressed. The patient tells you that she has read that certain antidepressants may decrease her urges to steal from stores, but she is worried that these drugs are also associated with weight gain.

Which of the following drugs is most commonly associated with weight gain with both short-term and long-term use?

A. Sertraline

B. Fluoxetine

C. Citalopram

D. Paroxetine

Answer and Rationale

The answer is D. Although some SSRIs are associated with weight loss at first, long-term use of SSRIs is associated with weight gain. Long-term use is considered a treatment course that lasts longer than six months. Of the SSRIs listed above, paroxetine is most commonly associated with weight gain with both long-term and short-term use.

Learning Objective: Diagnosis

The court refers a 14-year-old boy to you for an evaluation. The referral form lists a diagnosis of Substance Use Disorder, Unspecified. This boy tells you that he uses any drug he can get his hands on. He smokes marijuana every day, and he has been sneaking alcohol since he was 12. He has tried cocaine with his stepfather and benzodiazepines with his mother. He admits he has a bad temper and often gets into fights. He also tells you he enjoys setting things on fire and watching them burn. He says he has no problems and feels just fine.

Which of the following mental disorders likely accompanies his substance abuse?

A. Somatoform Disorder

B. Conduct Disorder

C. Obsessive-Compulsive Disorder

D. Anorexia Nervosa

Answer and Rationale

The answer is B. Conduct Disorder and Substance Use Disorders are often comorbid, and this boy also appears to meet the criteria for Conduct Disorder. There is no history of obsessions, compulsions, weight loss, or prominent somatic symptoms.