CAMHS 2 - conduct disorder Flashcards
when was conduct disorder first in DSM
DSM-4 (2000)
formally known as externalising disorders (in childhood/adolescent) - due to it being hard to express struggles e.g. depression
2 types of disruptive behaviour disorders
conduct disorder (CD)
oppositional defiant disorder (ODD)
CD –> before 10 years old = childhood
ODD - characteristics (3 categories)
oppositional defiant disorder
Angry and irritable mood:
- Often and easily loses temper
- Is frequently touchy and easily annoyed by others
- Is often angry and resentful
Argumentative and defiant behaviour:
- Often argues with adults or people in authority
- Often actively defies or refuses to comply with adults’ requests or rules
- Often deliberately annoys or upsets people
- Often blames others for his or her mistakes or misbehaviour
Vindictiveness:
- Is often spiteful or vindictive
- Has shown spiteful or vindictive behaviour at least twice in the past six months
issue of NHS medicalising bad behaviour
idea that not doing what your told is not a mental disorder
report showed 1/18 (12.8%) of english children have mental disorders
doubt if ODD is real due to it just being bad behaviour at a young age
quality of life and conduct disorder (CD) (5 categories) (3 age groups)
categories:
- comorbid with psychiatric and physical disorders, learning difficulties, and medical consequences
- criminal behaviour
- social and family impairments
- academic/occupational problems
- risky and irresponsible behaviours
different levels of these with age, examples:
childhood:
- ADHD, ODD
- peer rejection
- school exclusion
adolescence:
- depression
- criminal behaviour
- intimate partner violence
- unplanned pregnancy
adulthood:
- premature mortality
- ASPD
- suicide attempts
- poor parenting
- unemployment
- STDs
incidence and heritability of CD
1- 2.5% worldwide incidence
5 - 74% heritability
heritability in more extensive studies = 40-50%
heritability in those with CU traits = 45-67%
often comorbid with ADHD
32,000 symptom profiles can give rise to a diagnosis
environmental risk factors for CD (in vitro, birth, family, non-familial)
in vitro (maternal factors):
- smoking
- alcohol
- drug use
- stress
birth:
- birth complications
- maternal or paternal psychopathy
- malnutrition
childhood + adolescence:
familial:
- harsh and inconsistent discipline
- parent-child conflict
- maltreatment
- low SES and poverty
extra-familial:
- community violence
- association with deviant peers
genetic risk factors for CD (5 categories it can effect)
- autonomic
- neurocognitive
- social information processing
- temperament
- personality traits
gene-environment interplay and correlations in CD
different types of gene-environment correlations (3)
passive = association between inherited genes and environment in which they are raised e.g. smart parents provide intellectually stimulating environments; parents who smoke/drink around their kids
active = seek out environments that support genetic tendencies e.g. smart children may take more challenging classes; may spend more time with others who also smoke/drink/are antisocial
evocative = association between gene influenced behaviour and others reactions to you - multiplier effect e.g. you are argumentative which makes others more aggressive with you back
genome-wide association study (GWAS)
observational study of a genome-wide set of genetic variants in different individuals to see if any variant is associated with a trait
associations between single-nucleotide polymorphisms (SNPs) and traits like major human diseases
can also be applied to any other genetic variants and any other organisms
GWA studies compare the DNA of participants having varying phenotypes for a particular trait or disease
participants may be people with a disease (cases) and similar people without the disease (controls)
phenotypefirst approach:
- clinical used to classify before genes
- if one type of variant is more frequent in people with a disease = associated
- associated SNPs = mark region of genome that may influence risk of disease
single nucleotide polymorphism
DNA molecules differ by a singe base-pair location
(like an allele)
GWAS finding genes which we don’t understand yet with CD
DONT NEED TO KNOW - JUST AN EXAMPLE OF A GENE THAT ISN’T UNDERSTOOD
RBFOX1 = associated with CD
Fox-1 homolog A, also known as:
* ataxin 2-binding protein 1 (A2BP1)
* hexaribonucleotide-binding protein 1 (HRNBP1)
* RNA binding protein fox-1 homolog (Rbfox1)
protein encoded by RBFOX1 gene
different genes associated with CD (5)
RBFOX1 - development
GABRA2 - gaba (inhibitory)
SLAC6A4 – serotonin receptor
Oxytocin receptor OXTR
C1QTNF7 – glucose metabolism and insulin signalling
mono amine oxidase (MAO)
MAO = enzyme that breaks down monoamine neurotransmitters
different forms of MAO gene e.g. MAO-L = low, less active
gene-environment interaction in CD with maltreatment
low mono amine oxidase gene (MAO-L) = more CD
severe maltreatment = more CD
these two interact so severe maltreatment and MAO-L = highest rates of CD
neurocognitive features of CD (5)
- Verbal IQ
- Working Memory
- Executive functions
- Emotion recognition
- less sensitive to punishment cues, particularly when they are already keen for a reward
overly sensitive to reward
OR can be overly sensitive to punishment and insensitive to reward
idea that the systems are dysregulated - can be up or down
brain areas and functions
DIAGRAM ON SLIDE
all details aren’t needed
general idea of frontal areas ( do similar things) and amygdala and striatum (dopaminergic - decision making, reward)
emotion and empathy:
- amygdala
- striatum
- ventromedial PFC
- ventral anterior cingulate cortex
- superior/middle frontal gyrus
- middle/inferior temporal gyrus
- fusiform gyrus
- insula
reinforcement learning/decision making:
- ventromedial PFC
- striatum
- medial PFC
- dorsal anterior cingulate cortex
- supplementary motor area
- insula
executive functions:
- dorsal anterior cingulate cortex
- superior/middle temporal gyrus
- insula
- precuneus
threat response:
- amygdala
- vm PFC
- dorsal anterior cingulate cortex
- insula
resting state activity
- amygdala
- medial PFC
- posterior cingulate cortex
- precuneus
gene influence on CD - brain function and amygdala
high amygdala activity = MAO-L gene
bigger differences between MAO-L and high in men than in women
cognitive hostile attributional bias
tendency of individuals to interpret not only ambiguous cues as signalling hostility, but also many cues that are generated with benign intentions
anterior cingulate activity and MAOA genotype
MAO-L = low/no activity in anterior cingulate
MAO high = negative activity in anterior cingulate
LOOK AT SLIDE 31 - BRAIN STRUCTURE DIAGRAMS
management of CD without comorbid disorders in early and late childhood
DSM-V or ICD-11 diagnosis of CD and assessment for LPE (limited prosocial emotions)
psychosocial interventions:
without LPE:
- early childhood = social learning theory based parent training
- late childhood/adolescence = social learning theory based parent training and child skills training
with LPE:
- early childhood = social learning theory based parent training - additional training focused on parental warmth and child empathy skills
- same in later childhood but with more general child skills training too
if response to these is poor, add medication:
- risperidone (without ADHD)
- psychostimulants and/or risperidone (CD with comorbid ADHD)
management of CD with comorbid disorders (3 categories)
all start with psychosocial intervention and if not, do these
internalizing comorbidity (e.g. anxiety, depression, PTSD)
–> evidence based disorder specific psychosocial intervention, or psychotherapy and/or disorder-specific medication (SSRI)
externalising comorbidity (e.g. ADHD, ODD)
–> first line = stimulant for ADHD (may reduce impulsive aggression and so can be beneficial alongside psychosocial interventions for CD and ADHD)
–> second line = risperidone for impulsive-aggressive behaviour and hyperactivity (first line in children with comorbid ID)
comorbid developmental disorders (e.g. elimination disorders, language disorders)
–> evidence based intervention for respective disorder
pharmacological therapies for CD
stimulants - Ritalin
antipsychotics
do boot camps work for CD
no
if you do not fear punishment that wont change it
