Disruptive/Impulse/Conduct Disorders: Part 1 (General, ODD, IED, Conduct) Flashcards
what is different about the disorders in this chapter
trouble with emotional/behavioural regulation that manifests in behaviours that VIOLATE the rights of others (i.e aggression, destruction of property) and/or that bring the individual into SIGNIFICANT CONFLICT with societal norms or authority figures
what disorder is included in this DSM chapter but is actually described elsewhere
antisocial PD
between CD, IED and ODD, which disorder focuses mostly on poorly controlled behaviours? which focuses mostly on poorly controlled emotions? which disorder is the “middle ground” in which criteria are more evenly distributed between emotions and behaviours?
CD–> behaviours
IED–> emotions
ODD–> more even mix of both
the disruptive/impulse control/conduct disorders generally tend to be more common in which gender
males
when do the disruptive/impulse control/conduct disorders tend to have their onset
childhood or adolescence
–> very rare for ODD or CD to first emerge in adulthood
what is the relationship between CD and ODD
developmental relationship–> most kids who meet criteria for CD would have previously med criteria for ODD (at least in those cases in which CD emerges prior to adolescence)
do most children with ODD go on to develop CD?
no, most do not
are at risk for eventually developing other conditions, like anxiety and depression
the disruptive/impulse control/conduct disorders have been linked to a common spectrum of what personality dimensions
an EXTERNALIZING spectrum with the personality dimensions labeled as DISINHIBITION and CONSTRAINT
and to a lesser extent, negative emotionality
*these shared personality dimensions could account for the high level of comorbidity among these disorders and their frequent comorbidity with SUDs and ASPD
what are the 3 categories of symptoms in criterion A for ODD
angry/irritable mood
argumentative/defiant behaviour
vindictiveness
how many symptoms from the 3 symptom clusters are required to fulfill criterion A for ODD
4+
what are the symptoms listed in the “angry/irritable mood” cluster for criterion A for ODD
- often loses temper
- is often touchy or easily annoyed
- is often angry or resentful
what are the symptoms listed in the “argumentative/defiant behaviour” cluster for criterion A for ODD
- often argues with authority figures or, for kids and teens, with adults
- often actively defies or refuses to comply with requests from authority figures or with rules
- often deliberately annoys others
- often blames others for his or her mistakes or misbehaviour
what are the symptoms listed in the “vindictiveness” cluster for criterion A for ODD
has been spiteful or vindictive at least TWICE in the past 6 months
what is criterion A for ODD
a pattern od angry/irritable mood, argumentative/defiant behaviour, or vindictiveness lasting at least 6 MONTHS as evidenced by at least FOUR symptoms from any of the following categories, and exhibited during interaction with at least ONE individual who is NOT A SIBLING
there are 8 symptoms spread across the three symptom clusters (see other cards)
how do you distinguish a behaviour that is within normal limits from a behaviour that is symptomatic in the case of ODD
the persistence and frequency of the behaviour
kids younger than 5–> behaviour occurs on MOST DAYS for a period of at least 6 months
people aged 5+–> behaviour should occur at least ONCE PER WEEK for at least 6 months
criterion B for ODD
assoc. with distress in the individual or others in his or her immediate context or impacts functioning
criterion C for ODD
not exclusively during course of psychotic, SUD, depressive, bipolar d/o
criteria NOT met for DMDD
how do you determine severity for ODD
number of settings in which symptoms are present
mild–> sx only in 1 setting
moderate–> sx in at least 2 settings
severe–> symptoms in 3+ settings
can you diagnose ODD if sx only occur at home and with family members
yes–> this is not uncommon
but pervasiveness of symptoms is an indicator of the severity of the disorder
how do people with ODD typically view themselves
typically do not regard themselves as angry, oppositional or defiant
often justify their behaviour as a response to unreasonable demands or circumstances
ODD is more common in which type of settings or families
more prevalent in families in which child care is disrupted by a succession of different caregivers
in families in which harsh, inconsistent or neglectful practices are common
what are 2 of the most common co occurring conditions with ODD
ADHD
conduct disorder
how does ODD affect risk of suicide
increases risk of suicide attempts
what is the prevalence of ODD
ranges from 1-11%–> average around 3.3%
(slight male preponderance but overall fairly equal male:female)
when do first sx of ODD usually appear
during preschool years
rarely later in adolescence
ODD conveys risk for development of what other disorders in the future
CD
anxiety
MDD
–> defiant/argumentative + vindictive symptoms = higher risk for CD
–> angry/irritable mood sx = higher risk for emotional disorders
at increased risk of antisocial behaviour, impulse control problems, substance abuse, anxiety and depression as adults
what temperamental factors is felt to be predictive of ODD
problems in emotion regulation–> high levels of emotional reactivity, poor frustration tolerance
list neurobiological markers that have been associated with ODD
lower HR
lower skin conductance reactivity
reduced basal cortisol reactivity
abnormalities in prefrontal cortex and amygdala
*most studies have not separated ODD and CD kids and so its unclear how specific these markers are
ddx ODD
conduct disorder
ADHD
depressive d/o
bipolar d/o
DMDD
IED
intellectual disability
language disorder
social anxiety disorder
how does CD differ from ODD
CD = more intense than ODD, and involves aggression toward people or animals, destruction of property or a pattern of theft or deceit
ODD–> has problems w emotion regulation that are not part of dx of CD
how does IED differ from ODD
in IED, shows SERIOUS aggression towards other unlike in ODD
rates of ODD are much higher in what population
those with ADHD
criterion A for IED
recurrent BEHAVIOURAL OUTBURSTS representing a FAILURE TO CONTROL AGGRESSIVE IMPULSES as manifested by either:
1. VERBAL AGGRESSION (temper tantrums, tirades, verbal arguments, or fights) or PHYSICAL AGGRESSION towards property, animals or other individuals, occurring TWICE WEEKLY on average for a period of THREE MONTHS. Physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals
or
2. THREE behavioural outbursts involving DAMAGE or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12 MONTH period
criterion B for IED
MAGNITUDE of the aggressiveness expressed during the recurrent outbursts is grossly OUT OF PROPORTION to the provocation or to any precipitating psychosocial stressors
criterion C IED
recurrent outbursts are NOT PREMEDITATED (are impulsive or anger based) and are not committed to achieve some tangible objective (i.e money, power, intimidation)
criterion D IED
recurrent oubursts cause either marked distress in the person or impairment in occupational or interpersonal functioning or have financial or legal consequences
what is the minimum age for diagnosis of IED
chronological age is at least 6 years old (or equivalent developmental level)
how quickly do the outbursts in IED arise, and how long do they typically last
rapid onset
typically little or no prodromal period
typically last for less than 30 min
commonly occur in response to a minor provocation by a close intimate associate
can you have both DMDD and IED
no
what is the one year prevalence of IED in the USA
about 2.7%
in which populations is IED more common
younger (below 35-40 years)
those with high school education or less
when does IED usually have its onset
most common in late childhood or adolescence
rarely begins after age 40
what is the typical course of IED
typically persistent and continue for many years
may be episodic
appears to follow chronic and persistent course over many years
what is an environmental risk factor for IED
ppl with hx physical and emotional trauma during FIRST TWO DECADES of life are at higher risk for IED
is there a genetic vulnerability to IED
yes–> first degree relatives of those with IED are at increased risk of having it themselves
twin studies–> “substantial genetic influence for impulsive aggression”
what types of neurological abnormalities are seen in those with IED
serotonergic abnormalities both globally and in the brain–> specifically in limbic system (anterior cingulate) and orbitofrontal cortex
per fMRI, amygdala responses to anger stimuli are higher in those with IED
ddx IED
DMDD
ASPD or BPD
delirium
major NCD
personality change due to another medical condition, aggressive type
substance intox or withdrawal
ADHD
CD
ODD
autism spectrum disorder
how does the level of impulsive aggression compare between ASPD and IED
higher in IED
how does the type of aggression displayed differ between IED and CD
IED–> impulsive, not premeditated
CD–> proactive and predatory
what disorders are commonly comorbid with IED
depressive
anxiety
substance
what are the 4 symptom clusters in criterion A for CD
- aggression to people and animals (7 sx)
- destruction of property (2 sx)
- deceitfulness or theft (3 sx)
- serious violations of rules (3 sx)
15 sx total in criterion A
how many of the 15 possible symptoms in criterion A are required for a diagnosis of CD
at least THREE in the past 12 months, with at least 1 in the last 6 months
what is criterion A for CD
a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated as manifested by the presence of at least 3 of the following 15 symptoms in the past 12 months from any of the categories below (aggression to people and animals, destruction of property, deceitfulness or theft, serious violations of rules) with at least one criterion in the last 6 months
list the symptoms that fall under the “aggression to people and animals” symptom cluster for criterion A of CD
- often BULLIES, threatens, or intimidates others
- often initiates physical FIGHTS
- has used a WEAPON that can cause serious physical harm to others (i.e bat, brick, broken bottle, knife, gun)
- has been physically cruel to people
- has been physically CRUEL to animals
- has STOLEN while confronting a victim (i.e mugging, purse snatching, extortion, armed robbery)
- has FORCED someone into sexual activity
list the symptoms that fall under the “destruction of property” symptom cluster for criterion A of CD
- has deliberately engaged in FIRE SETTING with the INTENTION of causing serious damage
- has deliberately destroyed others property other than by fire setting
list the symptoms that fall under the “deceitfulness or theft” symptom cluster for criterion A of CD
- has BROKEN INTO someone elses house, building or car
- often LIES to obtain goods or favors or to avoid obligations
- has STOLEN items of nontrivial value without confronting a victim (forgery, shoplifting)
list the symptoms that fall under the “serious violations of rules” symptom cluster for criterion A of CD
- often STAYS OUT at night despite parental prohibitions, beginning BEFORE AGE 13
- has RUN AWAY FROM HOME OVERNIGHT at least TWICE while living in the parental or parental surrogate home, or once without returning for a lengthy period
- is often TRUANT from school beginning before age 13
criterion B for CD
clinically significant impairment
criterion C for CD
if person is 18+, criteria are not met for ASPD
can you dx both CD and ASPD in an adult?
no (ASPD would “take over” if criteria are met, but if criteria are met or CD but not ASPD, then dx would be CD)
what specifiers are available for CD
- childhood onset type
- adolescent onset type
- unspecified onset
- with limited prosocial emotions
–> lack of remorse or guilt
–> callous–lack of empathy
–> unconcerned about performance
–>shallow or deficient affect
severity of mild, moderate or severe
define childhood onset type CD
at least one symptom shown before age 10
define adolescent onset CD
no symptoms prior to age 10
define the CD specifier “with limited prosocial emotions”
must have displayed at least TWO of the following characteristics persistently over at least 12 months and in multiple relationships or settings
reflect individuals typical pattern of interpersonal and emotional functioning over this period (not just occasional) –> need reports from multiple people
- LACK OF REMORSE or guilt–> does not feel bad or guilty when he or she does something wrong; lack of general concern about negative consequences of actions
- CALLOUS–lack of empathy–> disregards and is unconcerned about feelings of others; described as COLD and UNCARING; appears more concerned about effect of actions on themselves
- UNCONCERNED about performance–> does not put forth effort necessary to do well, even when expectations are clear, and typically blames others for poor performance
- SHALLOW or deficient affect–> does not express feelings or show emotions to others except in ways that seem shallow, insincere, superficial or when emotional expressions are used for gain
estimates of age of onset are often how different from actual age of onset of CD symptoms
estimates are often TWO years later than actual onset
those with CD + specifier “with limited prosocial emotions” are more likely than others with CD to engage in what type of behaviour
aggression that is planned for instrumental gain
in ambiguous situations, how are those with CD more likely to interpret others intentions
Especially in ambiguous situations, aggressive individuals with conduct disorder frequently MISPERCEIVE the intentions of others as MORE HOSTILE and threatening than is the case and respond with aggression that they then feel is reasonable and justified
what other features of temperament often co occur with CD
negative emotionality
poor self control
insensivitity to punishment
thrill seeking
temper outbursts
irritability
poor frustration tolerance
suspiciousness
recklessness
is suicide more common in CD
yes–> SI/SAs/completed suicides occur at higher than expected levels
what is the estimated prevalence of CD
2-10% one year–> median 4%
higher among males
when do the first significant symptoms of CD usually start
middle childhood through middle adolescence
onset rare after age 16
what is the typical course of CD
variable–> in MAJORITY, it remits by adulthood
many people with CD–especially if adolescent onset type and those with few and milder sx–achieve adequate social and occupational adjustment as adults
early onset type = worse prognosis and increased risk of criminal behaviour, CD, and SUD in adulthood
list some factors that indicate worse prognisis with CD
earlier age at onset
more damaging behaviours at earlier age
list two temperamental risk factors for CD
difficult undercontrolled infant temperament
lower than average intelligence–> especially with regard to VERBAL IQ
list family level risk factors for CD
parental rejection and neglect
inconsistent child rearing practices
harsh discipline
physical or sexual abuse
lack of supervision
early institutional living
frequent changes of caregivers
large family size
parental criminality
some kinds of familial psychopathology ie SUDs
list community level risk factors for CD
peer rejection
association with delinquent peer group
neighborhood exposure to violence
does having biological parent with CD increase risk for developing the disorder? what about having an adoptive parent with CD?
BOTH having a biological and/or adoptive parents with CD increases risk of developing CD
CD is more common in children of parents with which psych disorders (other than CD)
severe SUD
depressive
bipolar
schiziphrenia
ADHD
what marker has been shown in individuals with CD that has not been characteristic of any other mental disorder
slower resting HR
(+ reduced autonomic fear conditioning, esp. low skin conductance)
these are NOT diagnostic
structural and functional differences in what areas of the brain have been shown in those with CD
brain areas associated with AFFECT REGULATION and AFFECT PROCESSING
esp fronto-temporal-limbic connections
list factors that increase risk CD will persist into adulthood
childhood onset type
those with specifier “with limited prosocial emotions”
if have co occurring ADHD
if have substance abuse
can you be diagnosed with both ODD and CD
yes
how does the academic achievement of kids with CD typically compare to those without the disorder
often below level expected of age and intelligence
esp. in reading and other verbal skills
(may justify diagnosis of specific learning disorder or communication disorder)
criterion A for pyromania
deliberate and purposeful fire setting on more than one occasion
criterion B for pyromania
tension or affective arousal before the act
criterion C for pyromania
fascination with, interest in, curiosity about, or attraction to fire and its situational contexts
criterion D for pyromania
pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath
criterion E for pyromania
fire setting not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one’s living circumstances, in response to a delusion or hallucination, or as a result of impaired judgment (ie NCD, ID, substance intox)
criterion F for pyromania
not better explained by another mental disorder like CD, manic episode, ASPD
individuals who impulsively set fires (who may or may not have pyromania) often have a current or past history of what disorder
AUD
what are the most common comorbidities with fire setting (not necessarily pyromania)
ASPD
SUD
bipolar disorder
pathological gambling
how common is pyromania as a primary diagnosis
very rare
*in a sample of people reaching criminal system with repeated fire setting, only 3.3% had symptoms that met full criteria for pyromania
what % of those arrested for arson in the USA were under 18
over 40%–> usually associated with CD, ADHD or adjustment disorder rather than pyromania
is pyromania more common in males or females
males–> esp those with POOR SOCIAL SKILLS and LEARNING DIFFICULTIES
criterion A for kleptomania
recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value
criterion B for kleptomania
increasing sense of tension immediately before committing theft
criterion C for kleptomania
pleasure, gratification or relief at the time of committing the theft
criterion D for kleptomania
stealing is not committed to express anger or vengeance and is not in response to a delusion or hallucination
criterion E for kleptomania
stealing not better explained by CD, manic episode, ASPD
what does someone wiht kleptomania typically do with the object they steal
give them away or discard them
occasionally may hoard them or surrepticiously return them
are people with kleptomania aware stealing is wrong/the act is senseless
yes typically, and typically they try and resist the urge to steal
frequently fears being apprehended
what neurotransmitter pathways are implicated in kleptomania
serotonin, dopamine and opioid systems–> associated with behavioural addictions
kleptomania occurs in what % of those arrested for shoplifting
4-24%
prevalence in general population in very rare (0.3-0.6%)
what is the gender distribution in kleptomania
females:males 3:1
when does kleptomania often begin
adolescence
first degree family. members of those with kleptomania may have higher rates of what disorder compared to general population
OCD
SUDs
what comorbidities in particular are associated with kleptomania
compulsive buying
MDD
eating disorders–> esp. BN
SUDs–> esp. AUD
personality disorders
depressive and bipolar disorders
anxiety disorders
what % of kids with CD may become adults with ASPD
about 40%
what is a mnemonic to remember the 15 symptoms in criterion A for CD
BAD FOR A BUSINESS
Bullying
Animal cruelty
Destroying others property
Fighting
Out late at night
Running away from home
Actively forces sex
Being cruel to people
Using a weapon
Setting fires
Into someone’s car, house, building (breaking into)
Not going to school
Everyday lying or conning others
Stealing while confronting a victim
Stealing while not confronting a victim
what is a mnemonic to remember the 15 symptoms in criterion A for CD
BAD FOR A BUSINESS
Bullying
Animal cruelty
Destroying others property
Fighting
Out late at night
Running away from home
Actively forces sex
Being cruel to people
Using a weapon
Setting fires
Into someone’s car, house, building (breaking into)
Not going to school
Everyday lying or conning others
Stealing while confronting a victim
Stealing while not confronting a victim
what is a mnemonic to remember the four categories of conduct disorder
TRAP
Trespassing and theft
Rule breaking
Aggression
Property destruction
which gender generally shows the childhood onset of CD
males
what is a screening scale for CD
the Conduct Disorder Scale (CDS)
are there any pharmacotherapies to treat CD
no
some evidence to support treatment of CD aggression with RISPERIDONE
also some conditional evidence for valproate
(but treat comorbidities like ADHD)
participation in what programs can reduce association between CD and ASPD in adulthood
participation in high school sports
what are first line interventions for CD (after comorbidities have been treated)
psychosocial interventions are first line
ideally refer to a psychologist who can implement these long term
how do you treat kleptomania
SSRIs may be prescribed
naltrexone has been investigated
cognitive strategies including ERP (similar to OCD) have been investigated
what is a mnemonic for the symptoms of ODD
REAL BADS
Resentful
Easily Annoyed/Touchy
Argues with adults and authority figures
Loses temper often
Blames others for his or her mistakes/misbehaviour
Annoys others deliberately
Defies rules or requests
Spiteful/vindictive
what are some treatments for ODD (psychDB)
consider risperidone if needed for aggression
Parent Management training (i.e Confident parents thriving kids)
Behavioural modification
are there any approved pharmacological interventions for IED
no–> but mood stabilizers, antipsychotics, beta blockers, alpha 2 agonists, phenytoin and antidepressants may be helpful
