Disruptive, Impulse-Control, and Conduct Disorders

Covered Disorders

• Oppositional Defiant Disorder (ODD)

• Intermittent Explosive Disorder (IED)

• Conduct Disorder (CD)

• Pyromania

• Kleptomania

  
  

Study Pointer:
Focus on age of onset, behavioral patterns, motivation behind acts (e.g., impulsivity vs. planning), and comorbidities.

Typical Development of Aggression

• Newborn Crying = Early communication

• Anger appears by 2–6 months

• Aggression = Self-defense and communication tool in toddlers

• Normally declines by adolescence

  
  

Study Pointer:
Recognize when aggression is part of normal development vs. pathological.

Oppositional Defiant Disorder (ODD)

Diagnostic Criteria (≥4 for ≥6 months):

Angry/Irritable Mood:

• Loses temper

• Easily annoyed

• Angry and resentful

  
  

Argumentative/Defiant Behavior:

• Argues with authority

• Defies rules

• Deliberately annoys

• Blames others

  
  

Vindictiveness:

• Spiteful or vindictive ≥2× in past 6 months

• Causes significant impairment

• Not better explained by mood, psychotic, or conduct disorder

  
  

Severity:

• Mild: One setting

• Moderate: Two settings

• Severe: Three or more settings

  
  

Gender Differences:

• Boys: More overt aggression (yelling, arguing)

• Girls: More covert (lying, passive resistance)

  
  

Study Pointer:
ODD is non-delinquent and often comorbid with mood disorders or ADHD.

ODD Etiology

Biological:

• Family history of ADHD, ODD, CD, mood disorders, substance use

• Brain impairments (judgment, impulse control)

• Neurochemical imbalances

  
  

Psychological:

• Poor parental attachment

• Difficulty forming social relationships

  
  

Social:

• Poverty, abuse, neglect, lack of supervision, chaotic homes

  
  

Study Pointer:
Use a biopsychosocial model when assessing cause and planning treatment.

ODD Treatment

• Parent Management Training: Teaches discipline and communication

• CBT: Teaches coping, emotion regulation

• Social Skills Training: For peer interactions

• Medication: Only for comorbidities (e.g., ADHD)

  • Alpha-2 agonists (Clonidine, Guanfacine)

  • SSRIs, stimulants, or atypical antipsychotics (Risperdal)

    
    

Prognosis:

• 67% improve with treatment in 3 years

• 30% progress to Conduct Disorder

• Greater risk if diagnosed in preschool

• 10% develop Antisocial Personality Disorder

  
  

Study Pointer:
Early intervention and family-based therapy prevent escalation to CD or ASPD.

Intermittent Explosive Disorder (IED)

Core Features:

• Repeated impulsive aggressive outbursts (verbal/physical)

• Outbursts disproportionate to provocation

• Not premeditated or goal-directed

• Causes impairment or distress

  
  

Criteria:

• Verbal/physical outbursts ≥2×/week for 3 months

• Destruction/assault events within 12 months

• Must be ≥6 years old

  
  

Symptoms:

• Sudden episodes lasting <30 minutes

• Regret, embarrassment often follow

  
  

Risk Factors:

• Childhood trauma

• Genetic predisposition

• Serotonin abnormalities in limbic areas (e.g., amygdala, orbitofrontal cortex)

  
  

Comorbidities:

• Depression, anxiety, substance use, ASPD, BPD

• ADHD, CD, ODD

  
  

Study Pointer:
IED is impulsive and emotion-based. Aggression isn’t preplanned or for gain.

IED Treatment

• CBT: Restructure thoughts, teach coping

• Group Therapy: Reduces symptoms and aggression

• School-Based Programs: Early prevention in teens

  
  

Pharmacotherapy:

• SSRIs (e.g., Prozac): Early aggression reduction

• Mood stabilizers (Lithium, Trileptal)

• Antipsychotics (if severe)

  
  

Challenge:
Many seek treatment late or only after violence has occurred.

Conduct Disorder (CD)

Core Feature:

Persistent violation of rights of others or societal norms

Diagnostic Criteria (≥3 in 12 months; 1 in last 6 months):

Aggression:

• Bullying, fights, weapons, cruelty, forced sex

  
  

Property Destruction:

• Fire setting, vandalism

  
  

Deceit/Theft:

• Breaking in, lying, stealing

  
  

Rule Violations:

• Running away, truancy, staying out late before age 13

  
  

Types:

• Childhood-Onset: ≥1 symptom before age 10

• Adolescent-Onset: No symptom before age 10

• Unspecified

  
  

Specifier: "With Limited Prosocial Emotions"

• Lacks guilt, empathy, shallow affect

  
  

Severity:

• Mild, moderate, severe based on harm and impact

Study Pointer:
CD has the highest risk of transitioning to Antisocial Personality Disorder in adulthood.

CD Risk Factors

• Temperament: Difficult infant temperament, low verbal IQ

• Environment: Abuse, neglect, inconsistent discipline

• Genetic: Parental criminality, psychiatric disorders

  
  

Prevalence:

• 2–10% (4:1 male-to-female ratio)

• Worldwide: 3.2%

• 25–50% develop ASPD/BPD

CD Treatment

• CBT: Behavior management and emotion regulation

• Family Therapy: Improves communication and parenting

• Peer Group Therapy: Builds empathy and social skills

• Medication: Only for comorbid conditions (e.g., ADHD)

  
  

Comorbidities:

• ADHD, ODD, SLD, Anxiety, Depression, Bipolar, Substance Use

Study Pointer:
Early-onset CD is more severe and long-lasting. Family intervention is critical.

Pyromania

Key Features:

• Deliberate fire setting on >1 occasion

• Arousal before, pleasure/relief after fire

• Fascination with fire-related objects

• Not done for money, revenge, or psychosis

  
  

Risk Factors:

• Male, ≥18 years old

• Learning/social skill deficits

  
  

Etiology:

• Unknown; linked to brain chemistry, genetics, trauma

Kleptomania

Key Features:

• Recurrent impulse to steal unneeded items

• Tension before theft; relief after

• Not for anger, vengeance, or psychosis

  
  

Other Features:

• Items are unused or returned

• Occurs alone, spontaneously

  
  

Causes:

• Low serotonin, dopamine release, opioid imbalance

  
  

Risk Factors:

• Family history, other mental illnesses (e.g., Bipolar, OCD, EDs)

Treatment for Pyromania & Kleptomania

• CBT: Core intervention

• Pharmacotherapy: Limited data

  • Naltrexone (opioid antagonist)

  • Antiepileptics, lithium, antipsychotics (proposed)

    
    

Study Pointer:
Differentiate impulse disorders from planned behaviors. Motivation is tension relief, not gain.

Final Study Tips

• Know diagnostic criteria, duration, severity levels for all 5 disorders

• Distinguish impulsive vs. premeditated acts

• Learn the trajectory from ODD → CD → ASPD

• Understand comorbidities and family/environmental risks

• Remember CBT is central to treatment across disorders