Disruptive, Impulse-Control, and Conduct Disorders; Dissociative and Somatic Symptom-Related Disorders

Psychopathology and Diagnostic Reasoning- Week 5/ Module 2

Disruptive, impulse-control, and conduct disorders

Disorders characterized by problems with emotional and behavioral self-control involving aggression, destruction, defiance, or violation of rights and societal norms

What is the core feature of disruptive, impulse-control, and conduct disorders?

Persistent difficulty controlling emotions and behaviors that violate the rights of others or societal norms

What domains should the PMHNP assess when evaluating disruptive behavior?

Aggression, anger, destruction, defiance, deceitfulness, impulsivity, rule violations, and functional impairment

Why can assessment of disruptive and conduct disorders be challenging?

Patients may be aggressive, unpredictable, oppositional, or difficult to engage, requiring deliberate and controlled interviewing

What is important when interviewing an aggressive or disruptive patient?

Maintain self-control, remain deliberate and nonconfrontational, establish safety, and obtain collateral information when appropriate

What type of diagnostic interviews may assist assessment of disruptive disorders?

Structured or semistructured clinical interviews, with parent interviews particularly important for children

Why is collateral information especially important when assessing children with disruptive behavior?

Symptoms may occur across settings and caregivers, teachers, and parents can provide developmental and behavioral history

What behaviors characterize conduct-related pathology?

Aggression toward people or animals, destruction of property, deceitfulness or theft, and serious rule violations

What clinical behaviors in Tim suggest conduct pathology?

Aggression toward others and animals, property destruction, dangerous behavior, fire-setting, and repeated school suspensions

Why is Tim's fire-setting clinically significant?

Deliberate dangerous behavior and serious violation of safety norms may indicate severe conduct problems

Why is Tim's behavior toward the family dog clinically concerning?

Cruelty toward animals is a conduct-related behavior involving violation of another living being's rights

Why are repeated school suspensions relevant diagnostically?

They demonstrate recurrent behavioral impairment and consequences across an important functional setting

What additional history is important when evaluating a child with disruptive behavior?

Onset, duration, severity, settings, triggers, developmental history, family history, trauma, school functioning, comorbidities, and collateral reports

What does dissociation involve?

A disruption or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, or behavior

What domains can become disconnected in dissociative disorders?

Identity, memories, perception, environment, consciousness, and sense of time

What is the core diagnostic theme of dissociative disorders?

Disruption in the normal integration of consciousness, memory, identity, emotion, perception, and related functions

What is an important differential consideration when evaluating dissociative symptoms?

Medical conditions, substances, neurological disorders, trauma-related conditions, and other psychiatric disorders must be considered

What clinical finding in Wallace raises concern beyond uncomplicated depression?

New-onset disorientation and inability to navigate home after living there for 15 years

Why is Wallace's getting lost on a familiar route clinically significant?

It suggests possible cognitive impairment requiring medical and neurologic evaluation rather than assuming symptoms are purely psychiatric

What are somatic symptom and related disorders characterized by?

Excessive thoughts, feelings, or behaviors related to physical symptoms

Are somatic symptom disorders defined by symptoms being medically unexplained?

No, the focus is excessive thoughts, feelings, or behaviors related to symptoms, which may occur with or without an identified medical condition

What is the key diagnostic shift in somatic symptom disorder?

The diagnosis focuses on disproportionate psychological and behavioral responses to symptoms rather than whether symptoms are medically explained

What is a major PMHNP assessment principle for somatic symptoms?

Take symptoms seriously, evaluate for medical causes, and assess excessive health-related thoughts, anxiety, and behaviors

What is factitious disorder?

Intentional falsification or induction of physical or psychological symptoms to assume the sick role

What distinguishes factitious disorder from malingering?

Factitious disorder involves assuming the sick role, whereas malingering involves intentional symptom production for external incentives

What distinguishes somatic symptom disorder from factitious disorder?

Somatic symptoms are experienced with excessive thoughts, feelings, or behaviors, while factitious disorder involves intentional falsification or induction of symptoms

What distinguishes somatic symptom disorder from malingering?

Somatic symptom disorder does not require intentional fabrication for an external reward, whereas malingering involves intentional deception for external gain

What is the key clinical approach to patients with somatic symptoms?

Establish a therapeutic alliance, validate distress, coordinate appropriate medical care, and avoid unnecessary repeated testing

Why should the PMHNP avoid dismissing physical symptoms as imaginary?

Patients may have genuine medical symptoms, and dismissive communication can damage the therapeutic alliance and delay appropriate care

What is the primary diagnostic concern when psychiatric symptoms may reflect a medical condition?

Rule out relevant medical, neurologic, and substance-related causes before attributing symptoms solely to a psychiatric disorder

What major principle applies across all three disorder groupings?

Diagnosis requires careful assessment of symptoms, duration, impairment, developmental context, medical causes, and differential diagnoses

What is the most important developmental consideration when diagnosing disruptive behavior disorders in children?

Distinguish developmentally expected misbehavior from persistent, severe, impairing patterns that exceed developmental norms

What is essential when assessing disruptive behavior in adolescents?

Evaluate developmental stage, peer relationships, school functioning, substance use, family conflict, risk-taking, and legal or behavioral consequences

What is essential when assessing disruptive behavior in adults?

Assess occupational functioning, intimate and family relationships, legal problems, aggression, impulsivity, substance use, and longstanding childhood patterns

What is essential when assessing disruptive behavior in older adults?

Consider medical and neurologic causes, medication effects, cognitive changes, delirium, dementia, and late-onset behavioral changes

What does a new onset of severe aggression or disinhibition in an older adult require?

Evaluation for neurologic, medical, medication-related, substance-related, or neurocognitive causes rather than assuming a lifelong disruptive disorder

How should childhood disruptive behavior be evaluated across settings?

Determine whether symptoms occur at home, school, with peers, and in other environments, using collateral reports when possible

What developmental history is important when evaluating conduct problems?

Early temperament, developmental milestones, attachment, family environment, trauma, school behavior, peer relationships, and previous behavioral problems

What is an important assessment distinction for oppositional behavior in children?

Determine whether defiance is persistent and impairing versus developmentally typical limit-testing

What should the PMHNP assess when aggression is present across the lifespan?

Target, frequency, severity, triggers, intent, access to weapons, injuries, property destruction, threats, and risk to self or others

What should be assessed when a patient reports loss of control over aggressive impulses?

Precipitating factors, warning signs, ability to delay or stop behavior, consequences, substance use, psychiatric comorbidity, and safety risk

What is a key differential for severe irritability and aggression in children?

ADHD, autism spectrum disorder, mood disorders, anxiety disorders, trauma-related disorders, psychotic disorders, and disruptive disorders

What is a key differential for new behavioral dysregulation in adults?

Mood disorders, substance use, trauma-related disorders, psychotic disorders, personality disorders, neurologic disease, and medication effects

What is a key differential for behavioral changes in older adults?

Delirium, major or mild neurocognitive disorder, depression, medication effects, substance-related conditions, and neurologic disease

What does developmental psychopathology emphasize?

Symptoms and disorders must be interpreted within the individual's developmental stage and expected age-related behavior

What is the major diagnostic concern when disruptive symptoms occur only during substance intoxication?

Consider a substance-induced condition rather than automatically diagnosing a primary disruptive disorder

What should the PMHNP assess before diagnosing a psychiatric cause for new behavioral symptoms?

Medical conditions, medications, substances, neurologic disorders, developmental factors, and environmental stressors

What is the lifespan pattern of many disruptive behavior disorders?

Symptoms commonly begin in childhood or adolescence, while manifestations and functional consequences may change with developmental stage

How can disruptive behavior manifest differently in younger children?

Tantrums, aggression, destruction, defiance, cruelty, dangerous behavior, and severe difficulty following rules

How can disruptive behavior manifest differently in adolescents?

Aggression, serious rule violations, truancy, risky behaviors, theft, substance use, peer conflict, and legal problems

How can disruptive behavior manifest differently in adults?

Interpersonal conflict, occupational dysfunction, aggression, impulsivity, deceitfulness, property destruction, and legal difficulties

How can disruptive behavior manifest differently in older adults?

Behavioral disinhibition, aggression, impulsivity, personality change, or loss of social norms may signal neurocognitive or neurologic disease

What is a key principle when evaluating dissociation in children?

Assess developmental capacity, trauma exposure, attachment, memory development, and alternative explanations for unusual behavior

What is a key principle when evaluating dissociation in adolescents?

Assess trauma, identity development, self-harm, substance use, mood symptoms, and functional impairment

What is a key principle when evaluating dissociation in adults?

Assess trauma history, dissociative symptoms, memory gaps, identity disruption, depersonalization, derealization, and functional impairment

What is a key principle when evaluating dissociation in older adults?

Carefully distinguish dissociation from delirium, neurocognitive disorders, neurologic disease, medication effects, and normal age-related memory changes

What is depersonalization?

A feeling of unreality or detachment from oneself, such as feeling like an outside observer of one's thoughts or body

What is derealization?

A feeling that the external world is unreal, dreamlike, foggy, or visually distorted

What is dissociative amnesia?

Inability to recall important autobiographical information, usually of a traumatic or stressful nature, beyond ordinary forgetting

What is dissociative identity disorder?

Disruption of identity characterized by two or more distinct personality states with discontinuity in sense of self and associated alterations in affect, behavior, consciousness, memory, perception, cognition, or sensory-motor function

What is a key feature of dissociative identity disorder involving memory?

Recurrent gaps in recall of everyday events, important personal information, and traumatic events inconsistent with ordinary forgetting

What is the key distinction between dissociative amnesia and ordinary forgetfulness?

Dissociative amnesia involves clinically significant inability to recall important autobiographical information beyond normal forgetting

What is a key feature of depersonalization/derealization disorder?

Persistent or recurrent depersonalization, derealization, or both with intact reality testing

What does intact reality testing mean in depersonalization/derealization disorder?

The person recognizes that the altered experience is subjective and not an actual change in reality

What is the most important assessment priority with unexplained memory loss?

Exclude neurologic, medical, substance-related, and neurocognitive causes before attributing symptoms to dissociation

How does somatic symptom disorder present across the lifespan?

Physical symptoms may occur at any age, but assessment must account for developmental stage, medical illness burden, and age-related changes

What is especially important when evaluating somatic symptoms in children?

Obtain information from caregivers, assess developmental communication abilities, and evaluate family responses to illness

What is especially important when evaluating somatic symptoms in adolescents?

Assess school avoidance, family dynamics, peer stress, anxiety, depression, self-harm, and health-related behaviors

What is especially important when evaluating somatic symptoms in adults?

Assess symptom-related distress, excessive health anxiety, repeated healthcare utilization, functional impairment, and comorbid psychiatric conditions

What is especially important when evaluating somatic symptoms in older adults?

Account for increased medical comorbidity and distinguish excessive symptom-related concern from legitimate illness burden

Why is somatic symptom disorder particularly challenging in older adults?

Genuine medical illnesses are more prevalent, making careful assessment necessary to distinguish illness burden from disproportionate thoughts, feelings, or behaviors

What is illness anxiety disorder?

Preoccupation with having or acquiring a serious illness with minimal or absent somatic symptoms and excessive health-related anxiety or behaviors

What distinguishes illness anxiety disorder from somatic symptom disorder?

Illness anxiety centers on fear or preoccupation with disease, while somatic symptom disorder centers on distress and excessive responses to significant somatic symptoms

What is conversion disorder also called?

Functional neurological symptom disorder

What is the core feature of functional neurological symptom disorder?

One or more symptoms of altered voluntary motor or sensory function that suggest a neurologic or medical condition but are incompatible with recognized neurologic disease

What symptoms may occur in functional neurological symptom disorder?

Weakness, paralysis, abnormal movements, sensory loss, visual symptoms, speech symptoms, seizures, or altered consciousness

What is factitious disorder imposed on self?

Falsification or induction of physical or psychological signs or symptoms associated with identified deception

What is factitious disorder imposed on another?

Falsification or induction of physical or psychological symptoms in another person, typically a dependent, with deception

What is the key motivational feature of factitious disorder?

The primary motivation is assuming the sick role rather than obtaining an external reward

What is malingering?

Intentional production or exaggeration of symptoms for an external incentive, such as financial gain, medications, avoiding responsibilities, or legal advantage

What should the PMHNP do when factitious disorder is suspected?

Document objective findings carefully, maintain appropriate boundaries, coordinate care, and avoid unnecessary invasive interventions

What should the PMHNP assess when malingering is suspected?

Objective findings, inconsistencies, external incentives, secondary gain, collateral information, and alternative psychiatric or medical explanations

What is a critical communication principle for somatic symptom-related disorders?

Validate the patient's suffering without reinforcing catastrophic interpretations or unnecessary medical interventions

What is a useful treatment principle for somatic symptom-related disorders?

Establish regular scheduled follow-up with one coordinating clinician while addressing symptoms, functioning, and comorbid psychiatric conditions

What is the role of psychotherapy in somatic symptom-related disorders?

Psychotherapy can reduce symptom-related distress and maladaptive thoughts and behaviors while improving functioning and coping

What psychiatric comorbidities commonly require assessment in somatic symptom presentations?

Anxiety disorders, depressive disorders, trauma-related disorders, and other psychiatric conditions that may amplify symptom distress

What is a key safety consideration in all disruptive behavior presentations?

Assess immediate risk of harm to self, others, animals, or property and implement appropriate safety measures

What is a key safety consideration when evaluating dissociation?

Assess self-harm, suicidality, accidental harm, impaired awareness, substance use, and vulnerability during dissociative episodes

What is a key safety consideration with severe somatic preoccupation?

Assess suicidality, self-neglect, medication misuse, unnecessary procedures, and functional deterioration

What are the four DSM-5-TR disruptive, impulse-control, and conduct disorders most associated with aggression or rule violation?

Oppositional defiant disorder, intermittent explosive disorder, conduct disorder, and pyromania

What is oppositional defiant disorder?

A persistent pattern of angry or irritable mood, argumentative or defiant behavior, or vindictiveness toward authority figures or others

What is the minimum duration for oppositional defiant disorder?

At least 6 months

What are the three symptom domains of oppositional defiant disorder?

Angry or irritable mood, argumentative or defiant behavior, and vindictiveness

How many symptoms are required for oppositional defiant disorder?

At least 4 symptoms from the three symptom domains

Who can be the target of oppositional defiant disorder behavior?

At least one individual who is not a sibling

What is the age-specific frequency criterion for oppositional defiant disorder?

For children under 5, behavior should occur most days, while for individuals 5 or older it should occur at least weekly

What is a key diagnostic distinction between oppositional defiant disorder and conduct disorder?

ODD involves defiance, hostility, and irritability without the more severe violation of others' rights or major societal norms characteristic of conduct disorder

Can oppositional defiant disorder be diagnosed if conduct disorder is present?

No, ODD is not diagnosed when the criteria for conduct disorder are met

What is the DSM-5-TR severity specification for oppositional defiant disorder?

Mild involves one setting, moderate involves two settings, and severe involves three or more settings

What is intermittent explosive disorder?

Recurrent behavioral outbursts representing a failure to control aggressive impulses