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1. Child and Adolescent Psychiatry > Disruptive/Impulse/Conduct Disorders: Part 1 (General, ODD, IED, Conduct) > Flashcards

Disruptive/Impulse/Conduct Disorders: Part 1 (General, ODD, IED, Conduct) Flashcards

1
Q

what is different about the disorders in this chapter

A

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

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2
Q

what disorder is included in this DSM chapter but is actually described elsewhere

A

antisocial PD

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3
Q

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?

A

CD–> behaviours

IED–> emotions

ODD–> more even mix of both

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4
Q

the disruptive/impulse control/conduct disorders generally tend to be more common in which gender

A

males

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5
Q

when do the disruptive/impulse control/conduct disorders tend to have their onset

A

childhood or adolescence

–> very rare for ODD or CD to first emerge in adulthood

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6
Q

what is the relationship between CD and ODD

A

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)

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7
Q

do most children with ODD go on to develop CD?

A

no, most do not

are at risk for eventually developing other conditions, like anxiety and depression

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8
Q

the disruptive/impulse control/conduct disorders have been linked to a common spectrum of what personality dimensions

A

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

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9
Q

what are the 3 categories of symptoms in criterion A for ODD

A

angry/irritable mood

argumentative/defiant behaviour

vindictiveness

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10
Q

how many symptoms from the 3 symptom clusters are required to fulfill criterion A for ODD

A

4+

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11
Q

what are the symptoms listed in the “angry/irritable mood” cluster for criterion A for ODD

A
  1. often loses temper
  2. is often touchy or easily annoyed
  3. is often angry or resentful
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12
Q

what are the symptoms listed in the “argumentative/defiant behaviour” cluster for criterion A for ODD

A
  1. often argues with authority figures or, for kids and teens, with adults
  2. often actively defies or refuses to comply with requests from authority figures or with rules
  3. often deliberately annoys others
  4. often blames others for his or her mistakes or misbehaviour
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13
Q

what are the symptoms listed in the “vindictiveness” cluster for criterion A for ODD

A

has been spiteful or vindictive at least TWICE in the past 6 months

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14
Q

what is criterion A for ODD

A

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)

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15
Q

how do you distinguish a behaviour that is within normal limits from a behaviour that is symptomatic in the case of ODD

A

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

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16
Q

criterion B for ODD

A

assoc. with distress in the individual or others in his or her immediate context or impacts functioning

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17
Q

criterion C for ODD

A

not exclusively during course of psychotic, SUD, depressive, bipolar d/o

criteria NOT met for DMDD

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18
Q

how do you determine severity for ODD

A

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

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19
Q

can you diagnose ODD if sx only occur at home and with family members

A

yes–> this is not uncommon

but pervasiveness of symptoms is an indicator of the severity of the disorder

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20
Q

how do people with ODD typically view themselves

A

typically do not regard themselves as angry, oppositional or defiant

often justify their behaviour as a response to unreasonable demands or circumstances

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21
Q

ODD is more common in which type of settings or families

A

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

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22
Q

what are 2 of the most common co occurring conditions with ODD

A

ADHD

conduct disorder

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23
Q

how does ODD affect risk of suicide

A

increases risk of suicide attempts

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24
Q

what is the prevalence of ODD

A

ranges from 1-11%–> average around 3.3%

(slight male preponderance but overall fairly equal male:female)

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25
Q

when do first sx of ODD usually appear

A

during preschool years

rarely later in adolescence

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26
Q

ODD conveys risk for development of what other disorders in the future

A

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

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27
Q

what temperamental factors is felt to be predictive of ODD

A

problems in emotion regulation–> high levels of emotional reactivity, poor frustration tolerance

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28
Q

list neurobiological markers that have been associated with ODD

A

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

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29
Q

ddx ODD

A

conduct disorder

ADHD

depressive d/o

bipolar d/o

DMDD

IED

intellectual disability

language disorder

social anxiety disorder

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30
Q

how does CD differ from ODD

A

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

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31
Q

how does IED differ from ODD

A

in IED, shows SERIOUS aggression towards other unlike in ODD

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32
Q

rates of ODD are much higher in what population

A

those with ADHD

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33
Q

criterion A for IED

A

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

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34
Q

criterion B for IED

A

MAGNITUDE of the aggressiveness expressed during the recurrent outbursts is grossly OUT OF PROPORTION to the provocation or to any precipitating psychosocial stressors

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35
Q

criterion C IED

A

recurrent outbursts are NOT PREMEDITATED (are impulsive or anger based) and are not committed to achieve some tangible objective (i.e money, power, intimidation)

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36
Q

criterion D IED

A

recurrent oubursts cause either marked distress in the person or impairment in occupational or interpersonal functioning or have financial or legal consequences

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37
Q

what is the minimum age for diagnosis of IED

A

chronological age is at least 6 years old (or equivalent developmental level)

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38
Q

how quickly do the outbursts in IED arise, and how long do they typically last

A

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

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39
Q

can you have both DMDD and IED

A

no

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40
Q

what is the one year prevalence of IED in the USA

A

about 2.7%

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41
Q

in which populations is IED more common

A

younger (below 35-40 years)

those with high school education or less

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42
Q

when does IED usually have its onset

A

most common in late childhood or adolescence

rarely begins after age 40

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43
Q

what is the typical course of IED

A

typically persistent and continue for many years

may be episodic

appears to follow chronic and persistent course over many years

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44
Q

what is an environmental risk factor for IED

A

ppl with hx physical and emotional trauma during FIRST TWO DECADES of life are at higher risk for IED

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45
Q

is there a genetic vulnerability to IED

A

yes–> first degree relatives of those with IED are at increased risk of having it themselves

twin studies–> “substantial genetic influence for impulsive aggression”

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46
Q

what types of neurological abnormalities are seen in those with IED

A

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

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47
Q

ddx IED

A

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

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48
Q

how does the level of impulsive aggression compare between ASPD and IED

A

higher in IED

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49
Q

how does the type of aggression displayed differ between IED and CD

A

IED–> impulsive, not premeditated

CD–> proactive and predatory

50
Q

what disorders are commonly comorbid with IED

A

depressive

anxiety

substance

51
Q

what are the 4 symptom clusters in criterion A for CD

A
  1. aggression to people and animals (7 sx)
  2. destruction of property (2 sx)
  3. deceitfulness or theft (3 sx)
  4. serious violations of rules (3 sx)

15 sx total in criterion A

52
Q

how many of the 15 possible symptoms in criterion A are required for a diagnosis of CD

A

at least THREE in the past 12 months, with at least 1 in the last 6 months

53
Q

what is criterion A for CD

A

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

54
Q

list the symptoms that fall under the “aggression to people and animals” symptom cluster for criterion A of CD

A
  1. often BULLIES, threatens, or intimidates others
  2. often initiates physical FIGHTS
  3. has used a WEAPON that can cause serious physical harm to others (i.e bat, brick, broken bottle, knife, gun)
  4. has been physically cruel to people
  5. has been physically CRUEL to animals
  6. has STOLEN while confronting a victim (i.e mugging, purse snatching, extortion, armed robbery)
  7. has FORCED someone into sexual activity
55
Q

list the symptoms that fall under the “destruction of property” symptom cluster for criterion A of CD

A
  1. has deliberately engaged in FIRE SETTING with the INTENTION of causing serious damage
  2. has deliberately destroyed others property other than by fire setting
56
Q

list the symptoms that fall under the “deceitfulness or theft” symptom cluster for criterion A of CD

A
  1. has BROKEN INTO someone elses house, building or car
  2. often LIES to obtain goods or favors or to avoid obligations
  3. has STOLEN items of nontrivial value without confronting a victim (forgery, shoplifting)
57
Q

list the symptoms that fall under the “serious violations of rules” symptom cluster for criterion A of CD

A
  1. often STAYS OUT at night despite parental prohibitions, beginning BEFORE AGE 13
  2. 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
  3. is often TRUANT from school beginning before age 13
58
Q

criterion B for CD

A

clinically significant impairment

59
Q

criterion C for CD

A

if person is 18+, criteria are not met for ASPD

60
Q

can you dx both CD and ASPD in an adult?

A

no (ASPD would “take over” if criteria are met, but if criteria are met or CD but not ASPD, then dx would be CD)

61
Q

what specifiers are available for CD

A
  1. childhood onset type
  2. adolescent onset type
  3. unspecified onset
  1. 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

62
Q

define childhood onset type CD

A

at least one symptom shown before age 10

63
Q

define adolescent onset CD

A

no symptoms prior to age 10

64
Q

define the CD specifier “with limited prosocial emotions”

A

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

  1. 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
  2. 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
  3. UNCONCERNED about performance–> does not put forth effort necessary to do well, even when expectations are clear, and typically blames others for poor performance
  4. 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
65
Q

estimates of age of onset are often how different from actual age of onset of CD symptoms

A

estimates are often TWO years later than actual onset

66
Q

those with CD + specifier “with limited prosocial emotions” are more likely than others with CD to engage in what type of behaviour

A

aggression that is planned for instrumental gain

67
Q

in ambiguous situations, how are those with CD more likely to interpret others intentions

A

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

68
Q

what other features of temperament often co occur with CD

A

negative emotionality

poor self control

insensivitity to punishment

thrill seeking

temper outbursts

irritability

poor frustration tolerance

suspiciousness

recklessness

69
Q

is suicide more common in CD

A

yes–> SI/SAs/completed suicides occur at higher than expected levels

70
Q

what is the estimated prevalence of CD

A

2-10% one year–> median 4%

higher among males

71
Q

when do the first significant symptoms of CD usually start

A

middle childhood through middle adolescence

onset rare after age 16

72
Q

what is the typical course of CD

A

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

73
Q

list some factors that indicate worse prognisis with CD

A

earlier age at onset

more damaging behaviours at earlier age

74
Q

list two temperamental risk factors for CD

A

difficult undercontrolled infant temperament

lower than average intelligence–> especially with regard to VERBAL IQ

75
Q

list family level risk factors for CD

A

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

76
Q

list community level risk factors for CD

A

peer rejection

association with delinquent peer group

neighborhood exposure to violence

77
Q

does having biological parent with CD increase risk for developing the disorder? what about having an adoptive parent with CD?

A

BOTH having a biological and/or adoptive parents with CD increases risk of developing CD

78
Q

CD is more common in children of parents with which psych disorders (other than CD)

A

severe SUD

depressive

bipolar

schiziphrenia

ADHD

79
Q

what marker has been shown in individuals with CD that has not been characteristic of any other mental disorder

A

slower resting HR

(+ reduced autonomic fear conditioning, esp. low skin conductance)

these are NOT diagnostic

80
Q

structural and functional differences in what areas of the brain have been shown in those with CD

A

brain areas associated with AFFECT REGULATION and AFFECT PROCESSING

esp fronto-temporal-limbic connections

81
Q

list factors that increase risk CD will persist into adulthood

A

childhood onset type

those with specifier “with limited prosocial emotions”

if have co occurring ADHD

if have substance abuse

82
Q

can you be diagnosed with both ODD and CD

A

yes

83
Q

how does the academic achievement of kids with CD typically compare to those without the disorder

A

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)

84
Q

criterion A for pyromania

A

deliberate and purposeful fire setting on more than one occasion

85
Q

criterion B for pyromania

A

tension or affective arousal before the act

86
Q

criterion C for pyromania

A

fascination with, interest in, curiosity about, or attraction to fire and its situational contexts

87
Q

criterion D for pyromania

A

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

88
Q

criterion E for pyromania

A

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)

89
Q

criterion F for pyromania

A

not better explained by another mental disorder like CD, manic episode, ASPD

90
Q

individuals who impulsively set fires (who may or may not have pyromania) often have a current or past history of what disorder

A

AUD

91
Q

what are the most common comorbidities with fire setting (not necessarily pyromania)

A

ASPD

SUD

bipolar disorder

pathological gambling

92
Q

how common is pyromania as a primary diagnosis

A

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

93
Q

what % of those arrested for arson in the USA were under 18

A

over 40%–> usually associated with CD, ADHD or adjustment disorder rather than pyromania

94
Q

is pyromania more common in males or females

A

males–> esp those with POOR SOCIAL SKILLS and LEARNING DIFFICULTIES

95
Q

criterion A for kleptomania

A

recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value

96
Q

criterion B for kleptomania

A

increasing sense of tension immediately before committing theft

97
Q

criterion C for kleptomania

A

pleasure, gratification or relief at the time of committing the theft

98
Q

criterion D for kleptomania

A

stealing is not committed to express anger or vengeance and is not in response to a delusion or hallucination

99
Q

criterion E for kleptomania

A

stealing not better explained by CD, manic episode, ASPD

100
Q

what does someone wiht kleptomania typically do with the object they steal

A

give them away or discard them

occasionally may hoard them or surrepticiously return them

101
Q

are people with kleptomania aware stealing is wrong/the act is senseless

A

yes typically, and typically they try and resist the urge to steal

frequently fears being apprehended

102
Q

what neurotransmitter pathways are implicated in kleptomania

A

serotonin, dopamine and opioid systems–> associated with behavioural addictions

103
Q

kleptomania occurs in what % of those arrested for shoplifting

A

4-24%

prevalence in general population in very rare (0.3-0.6%)

104
Q

what is the gender distribution in kleptomania

A

females:males 3:1

105
Q

when does kleptomania often begin

A

adolescence

106
Q

first degree family. members of those with kleptomania may have higher rates of what disorder compared to general population

A

OCD

SUDs

107
Q

what comorbidities in particular are associated with kleptomania

A

compulsive buying

MDD

eating disorders–> esp. BN

SUDs–> esp. AUD

personality disorders

depressive and bipolar disorders

anxiety disorders

108
Q

what % of kids with CD may become adults with ASPD

A

about 40%

109
Q

what is a mnemonic to remember the 15 symptoms in criterion A for CD

A

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

110
Q

what is a mnemonic to remember the four categories of conduct disorder

A

TRAP

Trespassing and theft
Rule breaking
Aggression
Property destruction

111
Q

which gender generally shows the childhood onset of CD

A

males

112
Q

what is a screening scale for CD

A

the Conduct Disorder Scale (CDS)

113
Q

are there any pharmacotherapies to treat CD

A

no

some evidence to support treatment of CD aggression with RISPERIDONE

also some conditional evidence for valproate

(but treat comorbidities like ADHD)

114
Q

participation in what programs can reduce association between CD and ASPD in adulthood

A

participation in high school sports

115
Q

what are first line interventions for CD (after comorbidities have been treated)

A

psychosocial interventions are first line

ideally refer to a psychologist who can implement these long term

116
Q

how do you treat kleptomania

A

SSRIs may be prescribed

naltrexone has been investigated

cognitive strategies including ERP (similar to OCD) have been investigated

117
Q

what is a mnemonic for the symptoms of ODD

A

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

118
Q

what are some treatments for ODD (psychDB)

A

consider risperidone if needed for aggression

Parent Management training (i.e Confident parents thriving kids)

Behavioural modification

119
Q

are there any approved pharmacological interventions for IED

A

no–> but mood stabilizers, antipsychotics, beta blockers, alpha 2 agonists, phenytoin and antidepressants may be helpful

120
Q

what is a mnemonic to remember the 15 symptoms in criterion A for CD

A

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

1. Child and Adolescent Psychiatry (32 decks)

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