CHAPTER 15 Integrative Management of Disordered Impulse Control

OVERVIEW: CLARIFYING THIS CLUSTER OF DISORDERS

if not prevented or treated it can risk assault, theft, property damage, sexual abuse, and mortality

impulsive and disruptive adolescents outgrow even moderately disruptive behavior

accurately differentiating the postulated etiology, assessing whether responses are mostly reactively impulsive or deliberately antisocial, and applying the most comprehensive approach to lessen them.

Aggression originally was employed to protect human beings—from environmental harm and harm from one another—but also to acquire and protect resources

integrative General Aggression Model (GAM), the most current paradigm, considers developmental, biological, social, environmental, cognitive, and personality factors on appraisal and decision processes, which influence aggressive behavior.

The etiology, expression, and meaning of aggression should be individualized, with the holistic context in mind. In order to encourage the client’s ability to find less harmful ways of interacting, we must find out how power is deployed, or abused, within the client’s world.

acquire more capacities for self-regulation as they grow. Adolescents, however, experience neurological and gonadal upheavals; as neuronal migration from the prefrontal cortex to the occipital cortex occurs, life experiences shape neuronal pruning, and sex hormonal upsurges transform body and brain.

risky behavior often overrides self-inhibition.

balance between expression and inhibition often stabilizes—unless adverse circumstances or unfortunate choices upset this balance—so more clinician listening, training, treating, and therapeutic adjustments are necessary.

Extremely anxious attachment, highly avoidant attachment, and especially disorganized/fearful attachment contribute to destabilizing the infant’s hypothalamic–pituitary–adrenal (HPA) axis stress response. This may predispose clients to develop either “hot” (anxious/impulsive) or “cold” (avoidant/disruptive) responses, although serious cold response is sometimes not devoid of impulsivity. It has long been established that secure attachment relations between the child and their mother is protective of the infant psycho-neuro-immunologically, endocrinologically, physiologically, and socioemotionally, helping them adjust baseline autonomic stability and homeostasis.

postulated that chronic hyperarousal may partially be the result of early anxious attachment expressed later as a “hot” response, while an infant’s avoidant attachment may correspond with subsequent hypo-arousal as a “cold” response. Both may partially be the result of the child’s early insecure attachment experiences. The years of bonding entrainment during the early years usually results in structural and functional neuronal shaping and implications for the immune system, stress responses, homeostasis, neuroendocrine system, sleep, and metabolism.

Interventions consisting of maternal “reorganization” of coping with her traumatic life events and parenting tools should be the first step in achieving a secure attachment with her child, at the earliest age, to prevent compounding problems.

with unanticipated life events—may be shifted by anxious, avoidant, or fearful attachment as life unfolds; this requires the development of further capacities to anchor a feeling of security.

Throughout childhood, earlier intervention is best to prevent problems from growing, from nursery school until the end of middle school. During puberty, there is transformative neuronal migration and myelination with emerging gonadal hormones; accelerated growth; and immunological, epigenetic, educational, and social role transformations, in addition to a growing awareness of the adult world and possible future roles in it. However, behavioral risks which may take individuals off track are also greater, due to wider social circles, less overt parental oversight, intense adolescent peer bonding while developing in semi-synchrony, and altered circadian patterns during brain remodeling.

Some stop acting out after being diagnosed with oppositional defiant disorder (ODD) before adolescence, while others diagnosed with conduct disorder (CD) by adolescence redirect their path during that time, since at 18 they risk being diagnosed with severe delinquency, antisocial personality disorder (APD), and a poorer prognosis.

key vulnerabilities and developmental shapers that can transform child, adolescent, and adult impulsive or disruptive behavior. These include parental health and behaviors, birth factors, environmental exposures, genomic/epigenomic factors, brain structure and function, genetic differential susceptibilities, mother–child neuroendocrine synchrony and hormonal development, mother–child attachment variations and epigenetics, family ecosystem, mentoring “zone of proximal development,” education and peer dynamics, community dynamics, and young adult pathways.

Thematic assessment questions that help guide evaluation include whether your young client has more internalization or externalization, more impulsivity or disruptive behavior, more “hot” (reactive aggression) or more cold (instrumental/predatory aggression), and whether your client has demonstrated more prosocial/empathic tendencies or antisocial (callous-unemotional [CU]) aspects?

more complete sense of the special emotional needs, psychosomatic responses, and coping processes of your client.

borderline personality disorder (BPD) is often anticipated to be the most challenging, the condition is highly treatable with psychotherapy.

EPIDEMIOLOGY OF IMPULSIVE OR DISRUPTIVE DISORDERS

A callousness-unemotionality (CU) subset was added to the DSM-5 CD diagnosis, also called low prosocial emotions (LPE).

frequent comorbidity and symptom overlap between impulsive/disruptive disorders with bipolar I and ADHD. It would make sense to treat the emotional rollercoaster of bipolar I first, then secondarily try to mitigate antisocial behavior thereafter. Impulsivity/disruptiveness can feature in other disorders, particularly BPD, ADHD, mood disorders, substance abuse disorders, eating disorders, obsessive-compulsive disorders (OCD), and less frequently in anxiety disorders.

In about 60% of cases, impulsive/disruptive symptoms will remit

BPD is among the most frequently seen diagnoses clinically, with considerable symptom cluster overlap with bipolar disorder (BP).

etiology of BPD appears to be often associated with early sexual psycho-trauma in girls which destabilizes affect, identity, mood, and behavior, but, most importantly, their relationships. Thus, while BP should usually be treated with mood stabilizers, BPD is often best treated with psychotherapy within the framework of a trusting long-term therapeutic relationship.

functional magnetic imaging (fMRI), BPD was proposed to be recognized as a traumatic stress disorder instead of an enduring personality disorder, since the symptoms can change over time

indicated more internalizing than externalizing symptoms in Asian regions versus Euro-American regions. In the United States, from among a clinical convenience sample of 1,173 youth in residential treatment facilities, Caucasian youth were diagnosed with CD at 24.4%, whereas Hispanic youth were at 43.3%, and African American youth at 34.4%.

mistakenly resigned attitude

VULNERABILITIES AND POSTULATED ETIOLOGIES

more serious CD is associated with low HPA-axis reactivity to stress, neurocognitive impairment (i.e., less grey matter in the amygdala, insula, and OFC), functional abnormalities in emotion-processing and regulation and decision-making, and lower autonomic reactivity to stress. Increased responsiveness to perceived threat or social provocation may be due to altered amygdala responses and/or structural deficits, but not due to frustration.

developing CD is due to environmental factors

Parental Health, Mental Health, and Behavior

Parental medical, mental, social, or economic difficulties can put a child at risk for impulsivity or disruptive behavior and other mental health issues. Young maternal age at birth, low maternal education, history of parental antisocial behavior, extreme family conflict, sparse socioeconomic resources, and community violence can involve the infant or child in multiple adverse childhood events (ACEs).

Maternal and Birth Complications

Infants exposed to some anesthetic agents, as well as prenatal tobacco, alcohol, prescription medications, illicit substances, and often polysubstance misuse at once, can experience withdrawal 48 to 72 hours postpartum after discontinuation of the substance. Untreated newborns are at risk for low birth weight (LBW), interuterine growth restriction (IUGR), and placental anomalies in addition to other maternal physiological, neurological, and behavioral harms.

neurotoxic impact of the anesthetic agents

the fetal brain during the third trimester of pregnancy, but also upon infants’ and developing children’s brains.

Many gestational and birth difficulties can put the infant at risk for developmental delays, social difficulties, and consequent behavioral difficulties.

poor fetal growth and catch-up growth were associated with childhood impulsivity and food fussiness—especially in girls—alongside later risk for diabetes and metabolic syndrome. Early brain development begins with the primary motor and sensory systems before cognitive and executive systems, while well-matured newborns display integrated connection patterns which are further elaborated for higher cognitive functions.

Relative preservation of core connections, but disruption of local connections, is also seen in preadolescents of preterm birth, with neuromotor deficits still seen at 6 months.

Preterm infants have been strongly linked to impulsivity. . The most premature infants (very preterm [VP]/very low below weight [VLBW]) were three times more likely to be diagnosed with ADHD than controls, and extremely preterm (EP)/extremely below weight (ELBW) infants had four times the risk. The explanatory hypothesis is that medical problems, HPA-axis dysregulations, and perinatal systemic inflammation can cause structural and functional brain difficulties, which are expressed in increased impulsivity, cognitive deficits, and emotional dysregulation, especially if paired with parental/environmental adversities.

Parental Behavioral Risk Factors

Childhood aggression is most highly associated with tobacco inhalation (77%), maternal smoking (46%), alcohol consumption (25%), chemical exposures (polychlorinated biphenyls [PCBs], PCDFs; 15%), cognitive deficits, educational attainment.

Nicotine intake is neurotoxic to the fetal brain.

It increases infertility, IUGR, miscarriage, premature birth, sudden infant death syndrome (SIDS), fetal pulmonary dysfunction, impaired hearing, damaged infant cardiac and respiratory functions, and 1,000 deaths annually

Prenatal alcohol risk to the developing brain for aggression

pregnancies were exposed to alcohol, during which gastrulation and neurulation can be disrupted, resulting in craniofacial dysmorphia and brain abnormalities

fetal alcohol spectrum disease (FASD) symptoms in children due to maternal alcohol intake.

FASD damages neurodevelopment through oxidating injury, apoptosis, modulation of genetic expression, and disruption of neuronal migration. Alcohol disrupts neural cell migration and axonal pathfinding by blocking cell adhesion and axonal outgrowth mediated by the L1 neural cell adhesion molecule. Mutations in the L1 gene cause dysgenesis of the corpus callosum, hydrocephalus, and cerebellar dysplasia.

microcephaly by shrinking the pool of neural progenitor cells. In a study of 65 infants who died within a year of FASD, 13% had microcephaly, 8% had dysgenesis of the posterior corpus callosum, and in 6% there was minor heterotopias

FASD, accompanied by executive function deficits, emotional lability, somatic problems, high pain tolerance, destructive behavior, hyperactivity, aggression, social difficulties in friendships, school absences, inconsistency at work, and a higher risk of addictions. Emotional and behavioral dysregulation were severe enough to be deemed a disability and impede schooling, risking delinquent behavior

reduces HPA-axis function’s stress mitigation and alters circadian rhythms through a flatter cortisol response from the adrenals.

Alcohol-induced endocrine dysfunction, disruption of morphogen signaling, and activation of neuro-inflammation impact the developing brain and immune system.

Maternal opioid abuse puts the fetus at risk for neonatal abstinence syndrome (NAS), to suffer undue somatic, neurological, cognitive, and emotional difficulties.

that pregnant mothers with opioid misuse disorder should preferentially be treated with buprenorphine (medication-assisted treatment) during pregnancy to reduce NAS severity, and this has better outcomes than methadone.

need more special education and early intervention services; this also is associated with gastroschisis and ASD.

Environmental Toxins Affect Neurodevelopment and Behavior

Exposomics has largely concluded that epigenetic mechanisms (genes X environment, or GxE) with a neuropsychiatric impact following environmental exposures are often due to synaptic dysfunction, microglia-immune alterations, and gut–brain interactions. Impaired cognition is epidemiologically associated with prenatal exposures to alcohol, polycyclic aromatic hydrocarbons (PAHs), lead, methylmercury, organophosphate pesticides (OPPs), and polychlorinated biphenyl ethers (PBDEs). ADHD and autism are associated with prenatal exposure to the same, but not PAHs or OPPs. Genetic factors are estimated to be only 30% to 40% of all causes of altered neurodevelopment, with environmental factors accounting for 70% to 60%. The risk is greatest upon the developing brain in utero, infancy, and early childhood

alcohol, PAHs, lead, methylmercury (MeHg), OPPs, and PBDEs can impair cognitive development partially via fetal microglia activation, which itself is triggered by maternal immune activation. Chemicals can raise the risk of ADHD, ASD, or disruptive disorder symptoms, especially alcohol, MeHg, OPPs, PBDEs, PCBs, and bisphenol A. Blood lead levels from 5 micrograms/dL in early life have been associated with aggression.

Methylmercury affects neural stem cells and is moderately associated with aggressive behaviors.

prenatal exposures to fetal BPA were associated with higher levels of anxiety, depression, aggression, and hyperactivity, while children’s urine BPA metabolites (up to age 12) were associated with the same symptoms, plus inattention and conduct problems. Phthalates have been linked to neurodevelopmental deficits and behavioral problems due to impaired attention and social interactions. Pesticides inhibit cholinesterase function in the developing brain, harming the regulatory role of acetylcholine before synapse formation.

Permethrine, a common delousing agent, is associated with pediatric neurodevelopmental deficits.

prenatal phthalate exposure in boys to lower cognitive scores, delayed psychomotor development, and problem behavior.

prenatal air pollution and diesel exhaust—also damages neural-glial activation, with maturational delay. Gut–brain microbial dysbiosis affects serotonin and gamma-aminobutyric acid (GABA) production and impacts immune processes.

Genomic/Epigenomic Associations With Impulsivity and Disruptive Behavior

Irritability- increases in males, but decreases in females as they mature. It is associated with family and maternal depression, and there is some genetic overlap. Amygdala dysfunction impacts irritability in children, who can mistake facial euthymia as threatening. CU traits are the most concerning aspects of disruptive behavior and can lead to severe violence.

Genetic studies have linked some genes and enzymes to disruptive disorders: MAOA (the monoamine oxidase A gene codes mitochondrial enzymes.

MAOA has been called the “warrior gene,” meaning it is associated with aggression, and the aggression-linked variant allele is X-linked (MAOA-VNTR), so the effect is higher in men

key factors in antisocial behavior, including CU traits

Valproate (Depakote) upregulates MAOA.

MAOA-L genotype has been presented as a risk factor for criminality

COMT enzyme metabolizes catecholamines (dopamine, norepinephrine, and epinephrine) primarily in the prefrontal cortex (PFC), especially dopamine.

Vasopressin influences circadian rhythms, and hyperactivity of AVPR1a polymorphisms contributes to aggression. Carriers of the D4 7R allele associated with prenatal stress had significantly more trait aggression

With functional enrichment, these genes are involved in the inflammatory/immune system, the endocrine system, and GABAergic neuronal differentiation, which matches previous associations between inflammatory cytokines like C-reactive protein (CRP), interleukin-6 (IL-6), and interleukin-1RAII protein and aggression. These inflammatory pathways of the genes HTR1D, DAT, SLC63A, AVPR1A, GRM5, NR3C1, and CRHBP are also associated with maternal deprivation, child abuse, PTSD, and/or low socioeoconomic status. Hypo- or hyper-GABAergic tone increases aggression, thus emphasizing the importance of excitatory/inhibitory balance in the OFC.

Brain Structure and Function in Impulsive/Disruptive Disorders

Frequent early symptoms seen in many children are anxiety or irritability. Anxiety must be clearly distinguished from symptoms of irritability, which is an increased tendency to exhibit anger toward peers.

anxiety tend to flee the source of danger, while those with irritability tend to approach it.

anxiety has been associated with increased amygdala connectivity to the cingulate, thalamus, and precentral gyrus, irritability has been associated with increased activity in the insula, caudate, dorsolateral and ventrolateral prefrontal cortex, and inferior parietal lobule

Via the cortico-basal ganglia-thalamo-cortical loop (CBGTC loop), disruptive clients were found to have increased activity in the striatum (located in the basal ganglia). The striatum is critical to motor, cognitive, emotional-processing, inhibition or impulsivity, reward, decision-making, planning, and motivational connectomes which connect the limbic system (sense-interpreting, feeling, and memory-creating part of the brain) mainly to the OFC. Glutamate, GABA, and dopamine neurotransmitters circulate within the basal ganglia and its connections, partially composed of the dopamine-producing substantia nigra, olfactory tubercle, putamen and globus pallidus, subthalamic nucleus, and the nucleus accumbens, which is stimulated by a rush of dopamine if a reward is attained. For impulsive behavior, the striatum is often enlarged and hyperactive. Higher anxiety results from greater focus on the threat (decreased amygdala connectivity to the cingulate, thalamus, and precentral gyrus), yet an irritable angry response showed increased widespread neural activation (insula, caudate, dorsolateral, and ventrolateral prefrontal cortex;

The Brain and Callous-Unemotional Traits

Underdevelopment and hyporesponsiveness of the limbic system has been associated with more CU traits in childhood and instrumental/predatory spousal abuse, but not reactive spousal abuse. The amygdala senses immediate danger (generating fear or anger) and is the receiving station for several sensory inputs before and as information is categorized and remembered by the hippocampus and thought through in the prefrontal cortex. If the amygdala is impaired, the fear is blunted, and aggressive and antisocial behavior may emerge due to lack of fear of consequences and CU traits

Lower amygdala volumes have been found in trait aggressivity, especially the left amygdala, but the right amygdala was linked to CU traits and proactive aggression. The striatum integrates cortical input to modulate thalamocortical activity through dopamine and serotonin. When serotonin is low and involved in perceived interpersonal disadvantage, impulsive aggression is more likely. Children diagnosed with CD with CU traits (sometimes leading to increased psychopathy in maturity) have a higher rate of cavum septum pellucidum (CSP), a structural brain deviation.

hypothesize that adult psychopathy can be preceded by early neurodevelopmental limbic system disruption and emotional hyporesponsiveness. This also helps explain the association between CU traits, white matter tract abnormalities, and reduced limbic grey matter.

This indicates that disrupted limbic development can contribute to dimensional affective and interpersonal deficits generally, but CSP is not a sensitive or specific sign of antisocial behavior, low IQ, or substance abuse. However, it can be higher in schizophrenia, BP, and head trauma. Antisocial individuals have been found to have reduced brain volumes, impaired executive functioning, emotion regulation deficits which may impair decision-making, increased volume, and abnormal function of the brain’s nucleus accumbens, which is activated by pleasure or substance abuse. “Cold” hypoarousal, especially when associated with CU traits, is associated with a lesser amount of grey matter volume across cortical and subcortical regions (amygdala, anterior insula), reduced thickness in the ventromedial and OFC, temporal cortex, fusiform gyrus, disrupted white matter in the corpus callosum and uncinate fasciculus, and reduced functional connections in the default mode network (linking the PFC and limbic system), but there is more folding in the insula, ventromedial, and OFC.

Genetic Differential Susceptibility Model: Dandelion, Tulip, and Orchid Children

Those with the long allele (G) were twice as satisfied with their lives, and less sensitive to pain. But newer research found that those with the short allele (A) have greater reactive emotion to environmental stimuli and greater sensitivity, higher cortisol reactivity, and greater physiological response to emotional stimuli, suffering more during adversity, but blossoming more if carefully scaffolded, have supportive marriages, and live in empowering communities

Mother–Child Synchrony: Oxytocin, Vasopressin, Cortisol, Testosterone

key roles of oxytocin and vasopressin in establishing mother–child synchrony, which extends to nurturing fathers as well, to build the infant’s brain, drawing upon close relationships to promote adaptability and resiliency. High oxytocin in women activates labor and maternal feelings and counteracts motherly endogenous testosterone. It also activates the breastmilk let-down response, as well as prerequisite trust prior to pair-bonding and lovemaking. For both men and women, oxytocin is protective of hippocampal neurons and memory in both sexes, enhances prosocial trust and empathy, and infranasal oxytocin decreases task-related aggression in healthy young males.

Low oxytocin levels are a marker of child abuse or neglect in children, which correlates with low eye contact, not responding to social cues, and a higher rate of socioemotional problems. Bakker-Huvenaars found that a lower oxytocin to higher testosterone ratio are correlates of the CU trait. Notably, they drew two-thirds of their sample from ODD/CD boys from youth welfare agencies.

oxytocin gene are associated with persistent and extreme aggression in males

For men, oxytocin can activate pair-bonding and lovemaking, yet when climaxing, vasopressin rises while oxytocin decreases. For men, oxytocin is not merely the “love hormone” as it has been popularized, since it may also activate boundary-making behavior against other males or unrelated outgroup members.

Underreactive, numbed-down systems and avoidant attachment may well set the child up for CU unresponsiveness to others, and dampen the innate empathic response to others’ suffering.

The child’s empathic response is the familial and social basis for collective life.

Cortisol has been found to regulate the stress reaction in acute situations requiring active solutions, but after which the sympathetic nervous system (SNS) must be brought back to a parasympathetic default baseline.

Cortisol helps regulate aggression through modulating the amygdala-PFC fear/threat circuitry. Flatter cortisol slopes are associated with adrenal exhaustion, disrupted suprachiasmatic nucleus, and worse health and mental health outcomes.

Cortisol dysregulation is associated with later obesity, inflammatory/immune dysregulation, cardiovascular disease, diabetes, cancer, mortality, and depression. She also found that maternal and paternal PTSD and flat cortisol levels can cause high cortisol levels and epigenetic changes of the glucocorticoid receptor (GR) gene in their offspring. Excessive glucocorticoids during chronic stress can cause atrophy of the hippocampus and reduce overall neuroplasticity in the brain.

Oxytocin levels are correlated with social cognition and affection/boundaries, cortisol levels are correlated with the acute stress response, and testosterone is correlated with male reproduction, dominance, and aggression. The team found that higher cortisol and testosterone levels correlated with higher CU traits.

Attachment and Epigenomic Processes

ACEs were found to impact lifelong health, with or without high-risk behavior

ACEs have been found to contribute to a premature closure of the early window of plasticity, to delay or accelerate critical periods of development, reflecting GABA maturation, brain-derived neurotropic factors (BDNF), and circadian clock genes, in cross mammalian species inducing circadian misalignment, increasing health and mental health risks

maternal care can permanently alter physiology and behavior, also partially mediated by epigenetic expression.

Family Ecosystem: Family Life Cycle and Zone of Proximal Development

Children mature by interacting within their family ecosystem as a point of reference before expanding their social world.

“scaffolding” is important for a child to develop an understanding of others and refine their empathic identification for others’ tribulations in order to be able to respond sensitively. Parental recognition of their toddler’s state of mind and desires, as well as reference to it, provides “stepping stones” for a child to access other people’s states of mind. This intuitive educational scaffolding of her child’s social learning via “mother–child mental state talk” helps the child’s understanding of others, allows greater emotional intimacy with them, and signifies empathy for their struggles. For children with language, communication, learning, or intellectual disabilities, mother–child mental state talk is even more crucial for the child to be able to integrate socially with siblings, cousins, and typically developing peers. Parents lacking sufficient intuitive socioemotional insight may set the child up for social difficulties and being bullied because his disabilities and educational trajectory will diverge from his peers. Even if the child was not oppositional or angry by temperament, the frustration of dealing with disabilities and their socioemotional sequelae, without at least one parent with empathic insight, can lead to an exacerbation of the child’s obstacles that could deepen oppositionality.

Community Dynamics, Culture, Education

Low income brings many dangers to developing children. In disadvantaged rural areas, where prenatal care is not always easily available or affordable

By middle childhood, exposure to socioeconomic disadvantages and numerous obstacles to socioeconomic ecostasis is linked to difficulties in emotion expression recognition, due to chronic denial and/or unresolvable anger. In particular, angry facial expressions were identified less accurately, especially high intensity anger. Lack of accurate emotion recognition and naming increases the likelihood of social difficulties and behavior problems in school

Raine’s neuromoral theory of antisocial, violent, and psychopathic behavior traces some neural circuitry impairment in areas responsible for moral decision-making

Young Adult to Adult Pathway

By young adulthood, about half of youth with CD with less severe adolescent-onset drop delinquent friends and improve their behavior as they acquire coping and reflective skills. Child disruptive mood dysregulation disorder (DMDD) may be dealt with through treatment, or may establish itself as closer to BP, in which case psychoeducation and long-term mood stabilizers

IED can continue into adulthood through dysregulated bouts of anger while a large proportion of those with IED should be diagnosed carefully so as to identify where the psychodynamic source of the dysregulation and trigger/re-triggering patterns lie.

Intermittent Explosive Disorder

Reactive aggression occurs in response to a social threat which is inescapable; thus, in some clients, anger is activated rather than fear. For adults with intermittent, or subclinical, impulsive or disruptive symptoms such as IED along a spectrum from mild to severe, their personal, social, study, work, or community lives are disrupted by their own outbursts.

Borderline Personality Disorder

maltreated children, emotional reactivity and dysregulation were found to be more prevalent than the norm

act out impulsively and disruptively.

girls or women have been diagnosed with BPD, bouts of anger are triggered by fears of abandonment or more abuse. There is much internalization of anger, leading to self-harm and suicidality, rather than other-harm, yet risky behavior can lead to other harm as well. Symptoms include impulsive risky behavior like reckless driving, substance abuse, excessive spending, and risky sexual activity, as well as intense, but unstable, relationships.

symptoms are identity uncertainty, affective instability, and temporary paranoia or dissociation, which can entail derealization or depersonalization.

Although BPD symptoms may resemble BP symptoms, their etiologies are quite distinct, and their triggers are well defined. Bipolar is a genetically-based neurological disorder, with extraordinary mood highs, lows, and mixed states depending upon the rate of the client’s personal cycle phase. On the other hand, BPD depends upon the quality of the early bonding experience; betrayals of childhood trust, especially due to sexual abuse and/or incest; or subsequent severe betrayals of trust including other parental abuse, which can re-trigger those early responses. An external and internal dynamic of idealization, followed by hatred, can lead to extreme psycho-traumatic responses leading to dissociation symptoms of derealization and depersonalization. There is no mania per se in BPD, and bipolar cycles take place over days and months, not hours as in BPD. Impulsivity in BP is higher when screened. Brain imaging indicates two distinct disorders as well. Whereas in BP, decreased OFC volumes, decreased corpus callosum, and enlarged amygdala and lateral ventricles are consistent findings, in BPD there are decreased amygdala, anterior cingulate, and volumes.

trauma disorder closer to PTSD than a personality disorder.

ENCODED MEANINGS OF AGGRESSION IN THE ADULT WORLD

aggressive act is interpersonal

shared sociocultural, socioeconomic, and sociopolitical meanings that may depersonalize it.

Why More Men?

males are much more likely to act aggressively than women across the globe. The male range of strength, height, weight, and being more likely to act with physically aggressive force than women, at lower provocation thresholds, has a higher range globally. Women, on the whole, are much more fearful, even under severe repeated provocation, yet can more quickly identify and express angry emotion

testosterone level, with corresponding slightly higher facial width-to-height ratio, has been found to be a robust predictor of more aggressive male behavior

Aggression: Outsiders Versus Insiders

employed aggression to defend and sustain the collective, including themselves. The way in which male aggression is conceived, channeled, institutionally structured, and employed, by whom, and for which reasons are developmentally, socially, economically, culturally, and politically shaped.

Violence Against Outsiders

mass shootings and school shootings—are not easily predictable on the basis of prior CD or antisocial assessments.

Youth is a life stage during which impulsivity and disruption are often explored, even by those for whom this is ego dystonic. Delinquent youth groupings exploit the impulsivity and manipulability of disadvantaged and foster youth, and those who are socially marginal or with disabilities.

self-initiated perpetrators of suicide-bombings in the West have mixed grandiose and depressive symptoms

Iraqi-Jewish psychologist Anat Berko, after years interviewing failed suicide-homicide attempters, found BPD symptoms, a worldview which splits the world into absolute good/bad categories, and “identity fusion” with their group, due to transformative group experiences. Related depersonalization and dissociative trance-like symptoms after the decision to commit the suicide-homicide (“sensation of being uplifted”), sometimes with suicidal ideation and self-harm, is propelled forward by heroic visions. If there is an intervention during the trance-like state, the bomber might change his mind.

Polygyny is characteristic of Fragile States fraught with conflict. For youth born into polygynous families, conflicts, insecure attachment, early trauma, and impulsive, disruptive, and borderline features may stem from polygynous family dilemmas.

most terrorists and handlers seem to have core features of severely disruptive and APD traits. They note callousness, lack of empathy, feelings of emptiness, cold rationality, and a yearning for martyrdom and death as a highly rewarding goal. Neuroscience researchers note of terrorists’ neuropathology in structural and functional alterations in prefrontal, orbitofrontal, and insular cortex, amygdala, and hippocampus responsible for controlling the archaic generators of aggression in the hypothalamus and limbic system, which overlap with regions generating prosocial traits like empathy. It is then possible that there may be hedonistic reward in feeling superior when in control of others’ lives.

Violence Against Insiders

less tendency to view aggression against a feminine partner as indicative of disruptive behavior or socially unacceptable.

Female Partner, Daughter, or Sister Killings

Intimate partner violence often involves similar masculine control of family, yet within interlinked intrapersonal (self-regulation) and interpersonal friction across socioeconomic and cultural milieux

Prevention has focused upon deconstructing machismo ideals, and legally reframing the problem as “feminicide,” prohibiting the purchase of firearms by perpetrators, using electronic surveillance devices for offenders, and collecting attitude and murder data rather than scouting out individual psychopathologies

Wife Assault

aggression against wives the result of psychopathology or is it due to simply following behavioral norms shaped by sociocultural, spiritual, and sociopolitical environments?

Cultural Anger and Aggressive Syndromes

global cultural “idioms of distress” that result in impulsive and disruptive behavior, the better able they will be to prevent, assess, and treat these syndromes

modified by intertwined socioeconomic changes, political reversals, Western and traditional medicine interaction, and what the idiom signifies.

while intergenerational traumatic transmission involves damaging parent-child relations, multigenerational trauma signifies an ongoing predicament in which endemic injury, marginalization, or stigmatization occurs over generations anyway.

The current mental health focus upon intergenerational transmission of trauma via epigenetic processes must be qualified. First, epigenetic markers, as already discussed, may be modifiable by early life nurture. Second, children are differentially susceptible. Third, epigenetic markers have experimentally been reversed in nutrition, aging, and cancer research. Fourth, in a comparison between Holocaust survivors and the general Israeli population, while the survivor cohort had higher comorbidities (3.3 to 2.7), longevity was improved for survivors (77.7 compared to 81.7 years). This outcome was particularly remarkable because the general population was noted as having twice the economic resources of the survivors. So, extreme ACEs may have notable health impacts, but, in some cases, do not automatically determine plummeting trajectories. This is due to the child’s catch-up attachments, mentor scaffolding, and own unique agency.

Hwa-byung

Hwa-byung (HB) is a Korean cultural psychiatric “idiom of distress” for a somaticized anger syndrome, produced by long-term pent-up accumulated anger that produces intractable psychiatric symptoms. Translated, it means “illness from fire.” It refers to a familiar syndrome which occurs when individuals have repressed feelings of anger and perceived unfairness. There is an Oriental Medical Evaluation for HB (IOME-HB) one can use to diagnose it

recognized in middle-aged women who suffered a history of abuse and afflicted generations of Korean women during the Japanese invasions and the division of Korea.

not impulsive, it can lead to somatic symptoms of anger and depression.

Tensan (Tension)

“Tensan” (Tension) is a term used in ethnopsychological literature to refer to a somaticizing North Indian idiom of distress

Symptoms are underlying irritation, rumination, frequent anger, and insomnia, due to domestic conflict and urban stressors

Pibloktoq

Pibloktoq (arctic hysteria) is a cultural psychiatric syndrome among circumpolar Inuit of Greenland. Its cluster of hysterical symptoms includes alteration of consciousness, seizures, amnesia, tearing off clothes, glossolalia, and running across the snow and rolling in it.

Windigo or Wendigo, Witiko, Chenoo

creature is an ice giant with a frozen human inside who possesses the soul of a starved person during wintertime and cannibalizes his closest family.

conceptions of “Windigo psychosis” and “Pibloktoq” may reflect misunderstood mental states due to self-justifications that underlay policies of colonization, dispossession, the plundering of children, and cultural destruction.

La Bouffee Delirante

disruptive cultural “idiom of distress” characterized by sudden agitation, aggression, confusion, auditory hallucinations, and paranoia.

Running Amok

begins with rumination, then suddenly breaks into a mass homicide spree, putting themselves at risk for being killed or sometimes ending by suicide. It may have begun with the cultural training for warfare of early Japanese and Malaysians to frighten the enemy to flight.

Ataque de Nervios

cultural psychiatric “idiom of distress,” which often occurs within acutely stressful situations in Latinx cultures, as a sanctioned response to acute suffering, chronic illness, grief, family conflict, external threats, or the breakdown of social networks

cluster of symptoms (uncontrollable shouting, aggression, crying episodes, trembling, heat in the head and chest)

Latinx communities

The Meaning of Aggression in Your Adult Client

ascertain how the client’s past and current cultural, social, economic, and political significance impacts their understanding of their own behavior.

job that requires constant assertiveness bordering on aggression, this behavior may be an effort at self-protection, rather than being merely dysfunctional.

an individual subject to frequent, uncontrollable bouts of impulsivity and seriously disruptive behavior with consequences should seek clinical evaluation. The clinical seriousness of this behavior depends upon its maladaptive degree within the client’s self-coherence, his interpersonal/sociocultural realms of family, social circles, studies, work, and the degree to which partners have been harmed.

must learn new skills to facilitate emotional self-regulation and engage more effectively, whether due to IED or BPD. The development of APD is mostly from adolescents who had CD, yet half of them shift into normative adult lives. The remaining half develop APD.

ASSESSMENT AND INSTRUMENTS

If the child is young and has a lighter range of symptoms, attempting to prevent more severe ones during development is the most valuable treatment goal.

multidisciplinary team, child, parental, and educational sources of information, as well as a variety of instruments and labs, to home in on the sources of the child’s difficulties. Since many ODD and CD clients have underlying medical and/or developmental disorders, obtaining a sensitive and reliable diagnosis is the key to constructing a collaborative treatment plan. Since most of the affected children or youth also have either some cognitive difficulties from ASD (20%) or learning disabilities (around 25%), and many may develop socioemotional difficulties such as those of BP, IED, or DMDD, it is exceedingly important to understand how this particular child’s symptoms developed over time in order to provide an accurate differential diagnosis.

Assessing Intersecting Dimensional Spectrums

distinction between reactive/impulsive aggression (impulsive, rule-breaking, risk-taking) versus instrumental/predatory aggression. Reactive/impulsive aggression is “hot” and associated with higher cortisol levels, physiological hyperarousal, and quick skin reactivity.

reactive/impulsive aggression is correlated with a hyperresponsive amygdala (for social threat), the striatum, and the PFC, but the severity of psychopathology is associated with the extent of the cavum septum pellucidum. Early neurodevelopmental disruption within the limbic system seems to be the most probable neurological developmental effect

“cold” calculation (instrumental aggression) is theorized to aid self-stimulation, and has been associated with flatter cortisol diurnal curves, as well as hypoactive physiological parameters like blood pressure, pulse, and skin reactivity. Flatter cortisol curves have been associated with a dysfunctional suprachiasmatic nucleus (SCN). Insomnia and metabolic ills may be seen with either.

assessment begins by obtaining medical and neurodevelopmental histories, neurological labs, and, in some cases, a neuropsychological battery of tests and/or genetic or genomic testing to disentangle and elucidate the multiple layers of obstacles and struggles the child faces. It is recommended to interview the child first while observing his interactions with the play milieu, while another therapist or social worker interviews the parent(s), then observe the family interacting all together, depending upon what can be said to the parent about the child, as per Health Insurance Portability and Accountability Act (HIPAA) rules. Medical history should include vital signs; genetic screens, if indicated; basic labs; brain imaging/EEG, if indicated; neurological referral, if indicated; basic child, parent, and teacher screens (K-SADS, ASEBA, BASC-C, SDQ); family genogram; contextual socioeconomic, legal and cultural assessments; and more targeted screens for impulsive-disruptive disorders.

Collaboratively working with the child and parents is key, but they often have clashing perspectives regarding oppositional or aggressive behavior. The most well-meaning parents can inadvertently exacerbate the child’s difficulties, since it can be hard for them to experience themselves from their own child’s viewpoint, may have gunny-sacked their frustrations, may feel guilty about the misbehavior, and may be defensive about not knowing what to do. Teaching the parents helpful skills to work with their child’s situation benefits both and can improve symptoms

important to observe the child in naturalistic family interactions, approaching and playing within the therapeutic environment filled with washable toys

The assessment should be supplemented by collateral information from grandparents, teachers, siblings, neighbors, school nurse, school principal, and academic reports and tests, which a social worker can help obtain when working conjointly.

For adolescents, obtaining earlier assessments, their school documents, and any neuropsychiatric assessments, or neuropsychiatric imaging

adults, prior assessments, imaging, academic documents, and medical records, if available, are very helpful.

Physiological Assessment

Assessing Toxic Exposures

To assess fetal alcohol syndrome (FASD) or other toxic exposures, comprehensive physical, sensory, occupational, and neurological assessments

A comprehensive neuropsychological evaluation of IQ, attention, executive function, memory, and visual-motor coordination are indispensable functional indicators

FASD, a neurological examination would include nonspecific, cranial nerve abnormalities, dysarthria, hypotonia, reflex changes, limb and gait ataxia, larger foot angles, increased step width, and greater gait variability.

high epilepsy rates

Physical therapists and occupational therapists may see motor deficits in infants that may be discerned if walking is delayed, with gross and fine motor deficits.

lower manual coordination scores and graphomotor skills, with strong pressure and cross-thumb grasping style when attempting to write or draw. Ophthalmological examinations may reveal optic nerve hypoplasia and tortuosity of retinal vessels, while an audiologist may find sensorineural hearing impairment. Sleep disturbances

suprachiasmatic nucleus (SCN), the central body clock, is damaged, diurnal neuroendocrine secretions and timing of functions in all the body’s cells can become disrupted, period genes and circadian rhythms become altered, melatonin levels are dysregulated (80%), and the child experiences respiratory abnormalities and obstructions, which worsen insomnia and parasomnias.

Assessing Congenital Genetic Syndromes With Impulsive/Disruptive Symptoms

Brunner Syndrome

5-HIAA (5-hydroxy-indoleacetic acid) is a serotonin metabolite in the cerebrospinal fluid (CSF), and when low can raise risks for aggression and suicide in humans

Symptoms of Brunner syndrome in male youth are mild intellectual disability, introversion, obsessive behavior, few friendships, but a history of explosive aggression in childhood, with flushing, headaches, and diarrhea. Diagnosis includes finding high serum serotonin, low urinary 5-HIAA, urinary metanephrines, and vanillylmandelic acid (VMA).

modifying the diet, may help, but psychopharmaceutical MAOIs are contraindicated

22q11.2

The 22q11.2 deletion or duplication syndrome has phenotypic variability, yet is associated with neuropsychiatric disorders like epilepsy, seizures, ADHD, ASD, IDD, anxiety disorders, OCD, early-onset Parkinson’s disease, and a quarter of those with schizophrenia. Both COMT and MAOA genes, associated with antisocial behavior

duplication has been linked to aggression

early intervention and monitoring.

Sturge–Weber Syndrome

Sturge–Weber syndrome, a rare syndrome

vascular malformation after the division of a trigeminal cranial nerve during the first trimester of fetal development. This congenital condition predisposes the child to experience high irritability, inattentiveness, and hyperactivity, and to become oppositional. Seizures

causes atrophy, hypometabolism, and accelerated calcification of brain arteries and veins. Signs and symptoms are dermatological port wine stains on the face ipsilaterally to the angiomatosis, with ocular disorders also appearing ipsilaterally.

may have learning disabilities and borderline intellectual disabilities.

Tuberous Sclerosis

Tuberous sclerosis, a rare syndrome

which normally suppresses tumors. The child may have pervasive developmental disorder (PDD), ASD, a disrupted attention span, aggression, emotional lability, depression, anxiety, and sleep disturbances. Neurologically, the child suffers from seizures.

facial nevi around the nose/mouth area, or impaired cardiovascular, renal, hepatic, and dermal functions.

may have communicative, receptive, and expressive language deficiencies; executive function deficits; memory gaps; and/or fine/gross motor difficulties

Smith–Magenis Syndrome

caused by a heterozygous deletion at chromosome 17

developmental asynchrony and mild to moderate intellectual disability, with distinctive facial features.

sleep disturbances, stereotypies, self-injurious behavior, anxiety, frequent temper tantrums, aggression, oppositionality, and impulsivity.

Thermoregulatory Fear of Harm

Thermoregulatory fear of harm (FOH) mood disorder is a recently elaborated heritable disorder that entails symptoms which could be confused with impulsive or disruptive symptoms, yet have physical thermodysregulation at its core with a typical prodrome and symptoms cluster. It occurs from thermoregulatory disruption, and results by disturbing orexin levels and BDNF gene expression. The child experiences overheating in mild ambient temperature, especially at night; the child is cold in the morning, yet has extreme cold tolerance. This disorder also results in frequent vivid REM sleep nightmares of pursuit, injury, death, and abandonment; parasomnias (night terrors and hypnagogic hallucinations); enuresis; bruxism; sleepwalking; sleep-talking; and morning state inertia. Defensive behaviors develop due to fears, separation anxiety, hypervigilance, perfectionism, and extreme reactive aggression against oneself or others set off by limit-setting, changes in routine, critique, loss, or threat—by mutilating self, breaking objects, cutting, internal injury, fractures, loss of teeth, or verbal violence. It is characterized by a negative self-concept, disrupted attachments, sad periods, and brief manic-like states with increased goal-directed activity (“mission mode”). Individuals have difficulty attending school, lose their friends, and wind up on psychiatric floors (54%). While responses to anxiolytics, antipsychotics, and mood stabilizers

intranasal ketamine administered every 3 days.

this cluster may be a third of pediatric bipolar diagnoses with extreme manias and depressions

Somatic Changes in Structure or Function

Autonomic arousal in proactive aggressors may be so tamped down that initiating an act of violence generates little fear of consequences.

For reactive aggression, the opposite phenomenon rules, especially in IED, DMDD, and BPD as their sympathetic nervous system is usually physiologically aroused at baseline during and after an emotional episode, with relative tachycardia and quick skin conductance, resulting in impulsive outbursts.

Psychiatric Instruments

BP, which has cyclical episodic irritability that is not chronic. Aggression does not exclusively imply a diagnosis of CD. For adult clients, it is best to rule out mood disorders, APDs, psychosis, and PTSD to be able to explore IED or BPD further.

Assessment Process

Assessment should occur in three layers or stages. The first and second stages can be completed by an intake social worker before beginning a comprehensive psychiatric assessment.

The second stage is verifying to what extent the client is living the kind of life with which their inner resources can potentially cope, or to what extent and frequency they get overwhelmed.

The third stage is a comprehensive psychiatric assessment which includes family history and medical history, genogram, genetics, birth history, developmental history, neurological, medical (includes injuries, surgeries, allergies), and so on.

Mindfulness and emotional self-regulation work hand-in-hand to prevent escalating anger from occurring. The first involves an approach employing receptive awareness grounded in the moment, while the second process occurs during intense emotional responses

EARLY PREVENTION AND INTEGRATIVE TREATMENTS

Assessing Which Treatment Is Suitable

Early preventive interventions are the key.

first address medical vulnerabilities, then try to understand how early the deepest source of distress lies, then find out the twists and turns of life unfolding through adverse events. With this background, the clinician can focus upon the handling of emotions and life choices.

Rule of Thumb

The approach of social work is to try to improve client external circumstances. The approach of pastoral counseling is to try to improve client moral strengths. The approach of psychology is to try to improve client coping capacities. The approach of psychiatry is to try to alter affected brain mechanisms.

For children, dyadic and family-based therapies will be most helpful.

cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT), adjusted for age and traumatic ACEs, are incorporated to some degree in many of the child and youth therapies.

joined with additional psychoeducational and behavioral benchmarks

effective interventions to improve behavioral issues had clear aims, targeted domains, and developmental stages; used role-play with coaching; and aimed at improving damage from maltreatment and relationship disruption. These entailed disciplinary consistency, positive reinforcement, trauma psychoeducation, problem-solving, and parent training in empathy, sensitivity, and attunement to their child

Interactive Parent–Child Therapies

Play Therapies: The Incredible Years

therapy lasts from 12 to 20 weeks.

prevent, as well as treat, disruptive behaviors. The Parenting Pyramid is built by strengthening and nurturing parent–child attachment via child-directed play and coaching the child’s growth and problem-solving, increasing limits and rules, while reducing punishments and criticism.

age-appropriate parenting skills that assist children in reaching crucial developmental milestones.

Teaching Pyramid promotes positive management skills and relationships through socioemotional, academic, and persistence coaching, as well as cultivating parent relationships.

children, disruptive behavior can decrease, and prosocial behavior is encouraged to improve.

Parent–Child Interaction Therapy

Parent–Child Interaction Therapy (PCIT) is especially good for 2- to 7-year-olds

combines high nurturance with form control. It begins with coaching the parent—via an earpiece and one-way mirror—as child-directed play with the parent unfolds. Parent responses to positive child behavior, as well as difficult behaviors, are coached

nurtures positive child–parent interactions for dyads whose relationship has already suffered

praise and effective directions is used. This parent benefits from being personally coached by the therapist, requiring each skill to be mastered before the next step

Oregon Model of Parent Management (PMT)

Outcomes of reduction in behavioral problems in toddlers, children, and adolescents

improved parents’ positive parenting, with positive effects

therapist teaches and models key management skills for challenging behaviors during 10 sessions. Families then role-play these skills, practicing at home, with the use of stars—which the child can then use to buy something they desire.

this therapy coaches the family to obtain skills to lessen the child’s difficulties.

PMT with problem-solving skills training for child and adolescents can boost cognition and creativity solving problems.

Triple P (PPP)

Positive Parenting Program (Triple P) boosts parenting information, skills, and behavior for a spectrum of mild to severe parenting deficits, for toddler to adolescent children.

Problem-Solving Skills Training (PSST)

Problem-Solving Skills Training is a CBT training manual for 7- to 13-year-olds, especially for disruptive behaviors.

applies a five-step problem-solving model for challenging situations to assist clients in choosing prosocial responses in their lives.

significant reductions in disruptiveness while increasing the choice of prosocial behaviors.

Coping Power Program

to reduce oppositional, disruptive, and aggressive behavior in middle school children (9–12 years).

teach CBT skills through games, role-playing, and discussions, with individual monthly sessions for attention to each child. Behavior is managed through positive reinforcement for prosocial behaviors, and consequences for disruption, with rules and a regular agenda of goal sheets, organizational skills, emotional awareness, anger management, perspective taking, social problem-solving, and peer relationships, using homework, extra points, quizzes, small to larger prizes, and “strikes” for behavioral problems to withhold prizes.

academic support at home, stress management, praise and ignoring, effective instructions/home rules, discipline and punishment, family cohesion, problem-solving, communication, and long-term planning.

Defiant Teens

first stage, the parent is taught skills to address defiant behavior. The second stage involves teaching the adolescent to alleviate the negative family dynamic. In the third stage, both the adolescent and parents learn to dispel unhelpful beliefs, and learn better communication, negotiation, and problem-solving skills.

Foster Care Treatments: Multidimensional Treatment Foster Care and Treatment Foster Care Oregon

Multidimensional Treatment Foster Care (MTFC) is a comprehensive community-based intervention employed as a viable alternative to residential care or incarceration for seriously disturbed adolescents. The youth is placed with trained foster parents for 6 to 9 months, while the child's own family is trained in parenting skills to help the youth’s transition when they return home.

client receives individual therapy, psychiatric care, and school assistance.

emotional problems, conduct problems, and severe and chronic delinquency

mutually reinforcing one another’s difficulties, weaknesses, and engaging in intense downward spirals, so that when they rejoin, they can reinforce one another positively.

Positive youth outcomes include reduced arrest rate, less fleeing home, spending more time in foster homes, and less violent offenses. The program also leads to separation from deviant peers.

Multisystemic Therapy

success for serious antisocial behavior including sexual assault, referred by the justice system with high risk of out-of-home placement.

goal of lessening the child’s negativity toward self and others, with improved inter-milieux communication and accountability.

effective at reducing antisocial behavior.

Trauma Systems Therapy

intended for traumatized children, which may include impulsive/disruptive children, due to ACEs, chaotic family processes, socioeconomic disadvantage, marginalized ethnic or minority community environment, and association with deviant aggressive peers in the background of impulsive/disruptive behavior. The team insists upon first building the child’s and family’s trust and treatment alliance, then requiring family accountability by stopping drug abuse, legally restraining a violent partner, adherence in psychiatric medications, participating in Social Services investigations, and allowing a home-based team into the home. The treatment team aims at leaving the child and family with skills to improve their own situation, by building upon their own strengths and helping them fix what is broke.

Adult Therapies

assisting the client to solve the situation themselves first, and then trying to work with trait tendencies, moving stepwise from preventable external stressors to internal functioning.

best to help the client aim for the potential of what the grounded client aspires to, considering their strengths and potential, rather than merely to perceive weaknesses and faults.

Their contribution to solving them, rather than expecting life to entertain or exclusively fulfill them, will demonstrate greater maturity in their approach to meaning. The development and growth of a mature soul who strives to meet those larger challenges, accompanied by emotional and/or behavioral skills to learn, may go beyond the unsustainable goal of satisfying themself.

Adult Psychotherapies and Complementary and Alternative Therapies

Tailoring one’s approach to a client’s agitation can help avoid ill-matched pharmaceuticals that are designed to mitigate agitation without regard for what triggered the client. Aggressive states occur when a threat is perceived by the amygdala, locus ceruleus, anterior insula, hypothalamus, bed nucleus of the stria terminalis, and periaqueductal gray to trigger stress hormone release. Perceptions may overestimate or misinterpret the threat, and BPD conditions have notably hypoactive cortical inhibition, so negative agitated appraisals and reactions are more frequent than more flexible responses. A hyperactive HPA-axis can cause copious release of norepinephrine, glutamate, dopamine, and acetylcholine while tamping down serotonin and GABA, both of which otherwise could inhibit negative responses. Increased activation occurs in mania, acute psychosis, and stimulant intoxication, which increase fear or paranoia while reducing the ability to think clearly and modulate responses. In particular, low serotonin metabolite 5-hydroxyindoleacetic acid in cerebrospinal fluid has been found in suicide attempters by violent means and aggressive traits (Miller et al., 2020).

Preventing this agitation upstream is better than overmanaging it once it has occurred. Thus, most IED and mild-to-moderate BPD sufferers, if high functioning, can benefit from regular diaphragmatic breathing and mindfulness, and meditation practice can increase awareness of their own emotional pulse. Emotional self-regulation techniques can be tried to see what works for them. Mindfulness practice includes cognitive reappraisals, articulating associations between internal and external stimuli with thoughts and feelings, emotional reappraisal of an emotionally charged situation or memory, and expressive suppression. Diaphragmatic breathing, progressive muscle relaxation (PMR), somatic experiencing (SE), mindfulness, dialectical behavior therapy (DBT), Schema Therapy (ST), mentalization-based therapy (MBT), and/or group anger management sessions should be first choices, since these maximize self-awareness and behavioral choice within myriad social and cultural contexts. Once clients are hyperaroused and aware of it, deep breathing will not work in acute situations.

Somatic experiencing (SE) increases awareness to one’s physiological expression of emotions and response to others, thus alerting the client of building tension. CBT gives tools to reason out what emotional responses are beyond what matches the actual stimulus to reduce catastrophizing. DBT is an evidence-based treatment for BPD. It helps the client recognize overwhelming fear or anger responses, even when matched proportionally to extreme external pressures. It helps the client keep tabs upon their own moods and lability by constantly checking their own emotional pulse. This involves daily measures of mood, mindfulness, emotion regulation, and distress tolerance to develop greater skills in all. Emotional self-regulation practice involves awareness and understanding of emotional responses, effective coping with negative emotions, distress tolerance, and effective inhibition of impulsivity.

MBT- for BPD. focuses upon a deficit in “mentalization,” meaning understanding others’ and your own perspectives

DBT was more effective in lessening BPD severity, self-harm, and psychosocial functioning; however, MBT was more successful in countering self-harm and suicidality.

Trauma-focused CBT-anger therapy focuses upon redirecting anger expression and learning how to modulate anger.

client cannot manage their distress anxiety or anger, it is best to redirect the excess energy by moderately quick walking; running; doing jumping jacks; dancing; hiking; performing Tai Chi

may recuperate from excess stimulation by lowering work and interpersonal pressure through more frequent “time-outs” with decreased stimulation and enhanced soothing

BPD, the most important key is a therapeutic relationship

BPD, despite its stigmatic reputation and alarming symptoms, is highly treatable, with good clinical recovery without psychopharmaceuticals

therapeutic relationship, with application of DBT or ST, or psychodynamic work. While DBT will work best if there are severe self-harm attempts, Schema Therapy may work well if there is avoidance

moderate to more extreme BPD, PTSD with dissociation, or IED, upping the treatment level may improve results.

dissociation. Phase 1 consists of the therapeutic relationship, assessment, case formulation, treatment planning, working with child parts of the client, approaches to shame, working with angry and hostile parts, and unsafe behavior. Phase 2 consists of working with traumatic memory. Then phase 3 integrates dissociative parts into a cohesive personality and beyond. DBT combined with psychodynamic therapy can be especially good for BPD

Couple Therapy With Borderline Personality Disorder

first work with the BPD client separately, so that they become more cognizant of early trust issues and why they oscillate emotionally and during cognitive appraisal of the spouse, while working on emotional regulation skills

accessing and caring for the inner “wounded child,” aiming to transform conflict into mutual growth.

therapy aims at having clients heed their inner dialogue with more detachment and compassion, so as not to constantly try to eliminate them, so that the suppressed part interferes with the couple connection. The therapy consists of unblending and reinforcing differentiation with connection between the partners, so they can connect through their strengths

IED, while Satir Family Therapy is designed to facilitate loving communication between the couple and within the family, Bowenian Family Therapy places emphasis upon the multigenerational aspects of repeating chronic problems within the expanded family system.

Satir Family Therapy provides many skills to support authentic loving communication.

Music therapists have found that clients suffering from BPD have greater difficulty with interpersonal synchronized improvisation due to their foundational attachment difficulties. With psychodrama therapy, BPD clients with limited insight and verbal skills have much to gain and learn from this therapy, whose results are powerful.

PSYCHOPHARMACOLOGY

Psychopharmacological medications should never be the first-line treatment, but may be helpful for short-term adjustment of unmanageable symptoms, or to accompany parent, family, parent–child, group, or individual psychotherapies.

main goal of the psychotherapy will be working daily on this multiscale self and life improvement project to alleviate symptoms and dysfunction, and preventing further deterioration into more severe diagnoses.

No FDA medications are currently approved for DMDD and only a few studies have been done. Psychotherapeutic treatments for anxiety and ADHD often work for DMDD: CBT, DBT, PMT

Medications often used are stimulants to calm the irritability, or antidepressants (citalopram with methylphenidate) to reduce irritability in DMDD. Second-generation neuroleptics (SGAs) have been used occasionally if other medications have not been effective.

Adolescents with CD episodic irritability, impulsive aggression, suicidal or self-harm ideation, or behavior with comorbid BP may benefit from lithium; however, BP should be ruled out.

Mutations that cause the misfolding of monoamine transporters

have led to mental and physical problems. Pharmacological research has assisted in the correct folding and delivery to the proper locations within the brain for dopamine, norepinephrine, serotonin, glycine, and GABA. These are called pharmaco-chaperones (small molecules assisting monoamine transporters to fold correctly and get them unstuck

to deliver them to cells). DAT has been rescued by bupropion, modafinil, and ibogaine

Adults suffering from IED, if not seen earlier in life, should begin with anger management training and DBT. Family psychoeducation and therapy may be necessary to help understanding and resolve symptom impacts upon family members

trauma-focused CBT-anger treatment

Adults suffering from BPD, if not seen earlier in life, should begin psychodynamic psychotherapy in the context of a trusting, attentive, and supportive relationship with the clinician.

their early attachment, or later attachments, may have had traumatic disruptions or low quality of trust.

DBT therapy, to enable them to become more self-aware and develop greater behavioral options, to manage emotions and their comportment.

Adult Complementary and Alternative Medicine and Psychopharmacotherapy

BPD, no medication has received FDA approval, this disorder is often foundationally based upon early relational psycho-trauma. Yet, omega-3 fatty acids taken on a regular basis may facilitate neuronal communication, which may help rewire old patterns. A range of medications may be useful if symptom clusters are targeted instead of the diagnosis. Bozzatello has listed oxytocin, clonidine, opiate antagonists, antidepressants, mood stabilizers, and antipsychotics that target key symptom clusters

psychotherapies have significantly improved BPD symptoms of psychosocial functioning, severity, reducing self-harming, and suicidal behavior

Quetiapine (Seroquel) is the most frequently prescribed medication given to BPD clients in the hospital

acute agitation in either IED or BPD

due to medical causes like hypoxia, hypoglycemia, seizure attacks, stroke, delirium, other conditions, or medication side effects. The first-line medication class which will enhance the GABAergic tone includes benzodiazepines, particularly lorazepam (Ativan). This must be for clients without substance abuse and only used as an emergency remedy, due to this medication’s addictive properties, unless alcohol has been used, in which case Project BETA (Best Practices in the Evaluation and Treatment of Agitation) recommends haloperidol (Haldol). However, in the case of older adults with delirium or dementia, since antipsychotics have a black box warning of higher mortality with use in seniors, a low dose may be warranted only if absolutely necessary

SUMMARY

Upstream prevention is advocated in prenatal and early life, since epigenetic modifications can become heritably transmitted in response to environmental factors, diet, and toxicant exposures

neuroanatomical findings about alterations in the amygdala’s GABAergic inhibition role in the amygdala-prefrontal pathway, including key deficits in the serotonergic system, dopamine, oxytocin, vasopressin, cortisol, and testosterone

crucial developmental role for nurture. Extremely anxious attachment or highly avoidant attachment, but especially disorganized/fearful attachment, destabilizes the infant’s homeostasis, increases inflammation, alters immune function, and lowers the threshold of tolerating allostatic load. Destabilizing the infant’s HPA-axis stress response contributes to destabilizing an already fragile neurodevelopmental constitution in many fragile infants. It may predispose responses into respective “hot” (anxious attachment)—impulsive and physiologically hyperaroused—or “cold” (avoidant attachment)—disruptive and physiologically hypoaroused—dimensions.

The “hot” attachment profile is associated with a hyperactive amygdala and insula, and predispose the child psycho-neuro-immunologically, endocrinologically, socioemotionally, and, in terms of cardiac health, toward baseline autonomic hyperarousal, internalizing emotions, higher oxytocin, higher cortisol, and physiological hyperarousal. This is correlated mostly with internalizing negative emotions in ODD, yet for DMDD and IED, it can erupt with reactive violence due to a curtailed capacity to regulate negative emotions.

associated with child-onset CD with CU traits, avoidant—or especially disorganized attached—children may have “cold” reduced volume and hypoactive prefrontal cortex, amygdala, folded insula, low default mode connections and activity, autonomic hypoarousal, externalizing instrumental/predatory aggression, low empathy or remorse, and antisocial attitudes and actions and may be at risk for economic insecurity and social distress.

children with developmental disabilities have mental health diagnoses, often with ADHD and/or impulsive/disruptive disorders. Around 90% of children in residential centers have experienced adverse childhood life events (ACEs).

important to seek early prevention beginning prenatally, to prevent deviation from a child’s normative prosocial development, which is a key part of healthy and happy development for the client, yet this also depends upon reinforcing “fragile families” so each can support their closest family member.

“biological reductionism” to imagine that one’s inherited biological equipment is the only factor that counts as an “explanation” for aggression against others.

biological differences and deficits may demarcate differing risk factors, they cannot in themselves constitute a “complete explanation” for behavior. There are multiscale factors: environmental exposures, prenatal parental behavior, mother–child attachment, epigenetic alterations, dyadic partner or friendship bonding, family, social, community, spiritual, cultural, economic, and political responsive shaping and modulations. Socioemotional influences like abusive or negligent parenting and deviant peers have long been recognized as cardinal influences in the development of antisocial behavior since they can shepherd the child’s underlying biological vulnerabilities in a harmful direction

social dynamic has been that older manipulators with more serious antisocial behavior have coerced younger, more vulnerable individuals with disabilities, including self-regulation difficulties, to carry out the older ones’ objectives. This way, the manipulators avoid consequences.

salutogenic “sense of coherency” is encouraged when clinicians take the time and effort to listen regularly to a client’s struggles, instead of writing a prescription without listening.

one’s limited circumstances and capacities, a human being has the agency to deploy his free will and become more grateful of others' contributions.

PEDIATRIC POINTERS

Polypharmacy

collaborative treatment plan should begin with joint or multimodal psychotherapies, and only include psychopharmacology as necessary for the direct benefit of the developing child or youth and/or to ensure safety for others due to immediate threats.

low and slow. Children often have more frequent side effects, with faster hepatic and renal metabolism and excretion. Quicker pharmacokinetics can lead to faster absorption, higher peak drug levels, and peak dose side effects. Children may need to be given drugs in smaller doses several times a day.

If several nonpharmacological therapies have failed for high violence, try risperidone before chlorpromazine. Administer medications only if needed by targeting the client’s symptoms with the lowest effective dose. To switch, slowly cross-titrate over 6 to 8 weeks to avoid overloading or rebounding.

The FDA recommends that when using stimulants for all ages, heart rate and blood pressure should be monitored for changes

AGING ALERTS

The standardized pharmacokinetics, upon which dosage is based, and pharmacodynamics can be altered due to aging, which can lead to adverse events, especially when polypharmacy is used

OVERVIEW: CLARIFYING THIS CLUSTER OF DISORDERS

• Impulsive and disruptive behaviors can lead to risks such as assault, theft, property damage, and sexual abuse if untreated.

• Adolescents often outgrow disruptive behavior.

• Important to differentiate behavior responses—reactive impulsive vs. deliberately antisocial.

• Aggression serves to protect and acquire resources and is influenced by the integrative General Aggression Model (GAM).

• Holistic assessment is crucial for understanding aggressive behavior and finding less harmful coping mechanisms.

• Adolescence involves neurological changes that increase impulsivity and risk-taking.

EPIDEMIOLOGY OF IMPULSIVE OR DISRUPTIVE DISORDERS

• Comorbidity between impulsive/disruptive disorders and conditions like bipolar disorder and ADHD is common.

• Chronic impulsive symptoms remit in about 60% of cases.

• BPD is recognized to have overlapping symptoms with bipolar disorder, especially in females.

VULNERABILITIES AND POSTULATED ETIOLOGIES

• Environmental factors like parental health, maternal complications, and socio-economic factors contribute to impulsive and disruptive behavior.

ASSESSMENT AND INSTRUMENTS

• Accurate diagnosis requires a multidisciplinary approach involving medical, neurodevelopmental histories, and family dynamics.

EARLY PREVENTION AND INTEGRATIVE TREATMENTS

• Early preventive interventions are emphasized, addressing medical vulnerabilities and emotional sources of distress.

• Various therapies such as CBT and DBT are effective for treating children and adolescents with these disorders.

ADULT THERAPIES

• Treatment focuses on helping clients learn self-regulation and emotional management skills within a trust-based therapeutic relationship.

PSYCHOPHARMACOLOGY

• Medications are not the first-line treatment but can assist in managing severe symptoms when necessary.