Disruptive impulse control disorders

Describe Conduct Disorder

• Dx Criteria (4) (7,2,3,3)

• Subtypes

• Etiology

• Consequences

• What is different in females

Dx Criteria:

• Pattern of behavior in which basic rights of others or major age-appropriate societal norms or rules are violated; as indicated by 3 or more of following criteria for 12 months + at least ONE Criterion present w/in past 6 months 

  • Aggression to people and animals

    • often bullies, threatens or intimidates others

    • often initiates physical fights

    • has used a weapon that can cause serious physical harm to others

    • has been physically cruel to people

    • has been physically cruel to animals

    • has stolen while confronting a victim

    • has forced someone into sexual activity

  • Destruction of property

    • deliberately engaged in fire setting with the intention of causing serious damage

    • deliberately destroyed others’ property

  • Deceitfulness or theft

    • broken into someone else’s house building or car

    • lies to obtain goods or favors or to avoid obligations (i.e. “cons” others)

    • stolen items of nontrivial value without confronting a victim (e.g. shoplifting, forgery)

  • Serious violation of rules

    • often stays out at night despite parental prohibitions, beginning before age 13 years

    • has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)

    • truant from school, beginning before age 13 years

---

Subtypes

• Childhood-Onset Type

  • Onset of at least one criterion before age 10

  • more guarded prognosis

• Adolescent-Onset Type

  • Absence of any criterion characteristic of Conduct Disorder before age 10

  • More likely to have favorable outcome

• Unspecified Onset

  • Age at onset is not known

---

Multifactorial Etiology

• Antisocial disorder, mood disorders, substance abuse and learning disorders in families

• Physical/sex. Abuse from parents

• Adopted children have a higher incidence

• Risk Factors:

  • parental separation or divorce,

  • parental substance abuse, 

  • poor parenting or inconsistent or excessively harsh discipline, 

  • peer rejection, 

  • association with delinquent peer group

• Positive relationship w/ parent/family member or import. adult = protective factor

---

Consequences

• Have difficulty conforming

• School performance average to poor

• Outer veneer of toughness and rebellion

• Often have profound feelings of self-doubt and worthlessness

---

Female Conduct Disorder

• Engage in more covert conduct-disordered behaviors 

• Higher rates of 

  • tobacco, alcohol and marijuana dependence

• Higher rates of 

  • STD + early pregnancy

• More medical problems and poorer self- ratings of overall health

Describe Conduct Disorder

• Psych characteristics (7)

• Management

Psychological Characteristics

• Attention deficits

• Learning disorders

• Impulsivity

• Impaired mood: sullenness, impulsive anger

• Impaired cognition: 

  • Lack of or distorted connection between prior events and consequences;

  •  limited problem-solving ability

• Pathological defense mechanisms

  • Minimizing

  • Avoiding

  • Externalizing

  • Unconscious manipulating

  • Denial

  • Identification with the aggressor

• Interpersonal impairment

  • Suspiciousness or paranoia, with cognitive distortions

  • Misperceptions of others’ actions as hostile

  • Difficulty relating to peers and adults

  • Lack of guilt/empathy

---

Management

• Mild cases: 

  • individual and family therapy

• Severe cases: 

  • removal from the home and placement in a group home or juvenile detention facility

• Psychotherapy

  • improving communication skills, problems-solving skills, impulse control and anger management

  • Encourage school attendance and achievement

• Typically involves parent training

  • Communication skills; address problems

  • Appropriate and consistent discipline

  • Monitoring child’s whereabouts

  • Keeping child away from bad peers

  • Enhance family relationships

• Medications:

  • Not typically used for CD unless substantial aggression

  • Lithium, psychostimulants, second-generation antipsychotics

  • Useful for comorbid conditions, especially ADHD

Describe Oppositional Defiant Disorder

• Dx criteria (3;3,4,1)

• Pt Characteristics

• Management

Dx Criteria:

• Pattern of  angry/irritable mood + argumentative/defiant behavior + Vindictiveness ; Indicated by 4 + exhibited during interaction w/ at least one nonsibling:

  • Angry/Irritable Mood

    • often loses temper

    • often touchy or easily annoyed by others

    • often angry and resentful

  • Argumentative/Defiant Behavior

    • often argues with authority figures, 

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

    • often deliberately annoys people

    • often blames others for his or her mistakes or misbehavior

  • Vindictiveness

    • often spiteful or vindictive

• Lasts at least 6 months 

• Disturbance = Distress in immediate social context OR impacts negatively on functioning 

---

Pt Characteristics

• No serious violation of others’ rights

• Will forfeit a toy or privilege rather than lose a battle or argument

• Parents may giving up or become overly harsh

---

Management

• Problem-solving skills training

• Parent management training

• Psychotropic medication reserved for comorbid disorders

Describe Intermittent Explosive Disorder

• Dx criteria

• Tx

Dx Criteria:

• Recurrent behavioral outbursts b/c failure of controlling aggressive impulses; as indicated by ONE:

  • Verbal aggression or physical aggression for period of 3 months;

    • DOES NOT result in damage/destruction/injury

  • Three behavioral outbursts involving damage/destruction/injury during a 12 month period 

• Magnitude of aggressiveness = out or proportion

• Not premeditated or has an objective

• At least 6 Y/O

---

Management

• CBT

  • learn to recognize signs they are angry

  • learn to identify and diffuse the triggers

• Medication

  • SSRI’s

  • Mood stabilizers

  • Beta-blockers

  • Second generation antipsychotics

  • Benzodiazepines

    • May reduce tension that leads to outbursts

    • May cause disinhibition

Describe Kleptomania

• Dx criteria (4)

• Management

Dx Criteria:

• Failure to resist stealing something; 

• Increasing sense of tension immediately before committing theft

• Pleasure, gratification or relief @ time of the theft

• Stealing = purposeless

---

Management

• Behavioral:

  • Aversive therapy

  • Covert sensitization

  • Self-imposed ban on shopping

• Psychodynamic psychotherapy

• Medication

  • Naltrexone: 

    • may reduce stealing urges and behaviors

  • Antidepressants and mood stabilizers: 

    • conflicting results

Describe Pyromania

• Dx Criteria (4)

• Management

Pyromania

• Dx Criteria:

  • Deliberate + Purposeless fire setting on >1 occasion

  • Tension or affective arousal before the act

  • Fascinated to Fire (content/characteristics)

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

---

Management

• Treat comorbid conditions

• Education

  • Exposure to consequences of fire

• Family therapy 

• Psychotherapy 

  • Stress coping skills