• Clinical science

Disruptive, impulse-control, and conduct disorders

Abstract

Disruptive, impulse-control, and conduct disorders are a group of psychiatric conditions that affect the self-regulation of emotions and behaviors and tend to have their onset in childhood or adolescence. Affected individuals violate the rights of others (e.g., aggression, destruction of property) and/or are in significant conflict with societal norms or authority figures. The disturbance in behavior significantly impairs social, academic, and/or occupational functioning. Causes are multifactorial and include genetic, environmental, psychological, and social factors (e.g., physical abuse, neglect, or exposure to toxins during pregnancy). Disorders included in this category, which will be discussed below, are oppositional defiant disorder (ODD), conduct disorder (CD), pathological fire-setting (pyromania), and pathological stealing (kleptomania). While ODD and CD both present with excessive defiance and resistance to authority in childhood and/or adolescence, patients with CD are more likely to engage in criminal behavior. ODD often precedes CD and affected individuals may develop depressive or anxiety disorders in adulthood. Pyromania and kleptomania are uncontrollable actions and primarily cause damage to the affected individual and potentially others. Treatment of disruptive, impulse-control, and conduct disorders involves cognitive behavioral therapy, parent management training, and pharmacotherapy.

A relatively new diagnosis is disruptive mood dysregulation disorder (DMDD). Patients with this condition present with persistent irritability or anger and recurrent, severe temper outbursts at least three times per week for at least one year. Patients with DMDD are likely to develop major depressive disorder or anxiety disorders in adulthood.

Overview

Important findings Prognosis
Conduct disorder (CD)
  • Severe rule violation (e.g., truancy)
  • Aggression towards people, animals, and property
  • Criminal behavior (e.g., theft, fire setting, rape)
  • Over period of ≥ 12 months
Oppositional defiant disorder (ODD)
  • Argumentative, vindictive, and defiant behavior towards authority figures (e.g., teacher, parent)
  • Angry, irritable mood
  • Over period of ≥ 6 months
Disruptive mood dysregulation disorder (DMDD)
  • Severe temper outbursts (verbal or behavioral) ≥ 3 times/week
  • Severe, persistent irritability or anger in between outbursts
  • Over period of ≥ 12 months
Normal development
  • Temper tantrums
    • common from age 2–5
    • Characterized by e.g., stomping, screaming, but no physical harm to others
    • Often only happen with parents (not e.g., in daycare)
    • Child behaves normally between tantrums
  • Should stop by around age 5

Other impulse-control disorders

  • Types
    • Pathological fire-setting: (pyromania) comprised of DSM-5: Presence of multiple episodes of deliberate and purposeful fire setting; . Individual experiences tension or affective arousal before setting a fire; and experiences pleasure, gratification, or relief when setting the fire, or
      witnessing its effects.
    • Pathological stealing (kleptomania) comprised of DSM-5: Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value. Increasing internal tension before committing the theft and pleasure, gratification, or relief at the time of committing the theft.
  • Treatment: cognitive behavioral therapy (CBT); ; no psychopharmacological treatment approved by the FDA

The most important finding to differentiate normal behavior from a psychiatric disorder is whether or not the behavior (e.g., tantrums, irritability) impairs normal, daily functioning and violates age-appropriate norms.

References:[1][2][3][4][5]

Conduct disorder (CD)

  • Definition: A repetitive and persistent pattern of disruptive behavior for ≥ 12 months that violates basic rights of others or age-appropriate societal norms or rules.
  • Epidemiology
    • Onset during childhood or adolescence; the diagnosis is only applied to patients < 18 years.
    • >
  • Etiology: multifactorial
  • Diagnostic criteria (based on DSM-5):
    • Aggression to people and animals
    • Destruction of property
    • Deceitfulness or theft
    • Serious rule violation
    • The disturbance in behavior significantly impairs social, academic, and/or occupational functioning.
  • Treatment
  • Prognosis: Patients with CD are at increased risk of developing antisocial personality disorder in adulthood

Patients with either CD or ODD exhibit aggressive, argumentative, or vindictive behavior, but patients with CD are more likely to also be physically aggressive and engage in criminal behavior!References:[6][1][7][2][3]

Oppositional defiant disorder (ODD)

  • Definition: Anger, irritable mood, and defiant behavior towards figures of authority lasting ≥ 6 months. Significantly impairs social and/or academic functioning.
  • Epidemiology:
    • Usually appears in late preschool; or elementary school
    • > at onset; equal incidence after puberty
    • Frequent comorbidity of ADHD, anxiety, mood disorders, and/or learning disorders
  • Etiology: multifactorial
  • Diagnostic criteria (based on DSM-5)
    • ≥ 4 of the following symptoms for ≥ 6 months with ≥ 1 individual who is not a sibling (e.g., teachers, parents)
      • Losing temper frequently
      • Easily annoyed
      • Resentful or angry mood
      • Argumentative with authority figures
      • Defiant or refusal to comply with requests from authority figures
      • Deliberately annoying
      • Blaming others for one's own mistakes
      • ≥ 2 episodes of vindictive or spiteful behavior in the past 6 months
    • The criteria for a disruptive mood dysregulation disorder should not be met
    • The disturbance should negatively impact the individual's functioning or cause distress to other individuals
  • Treatment: psychotherapy (individual and family), parent management training, social-skills programs
  • Prognosis: often precedes conduct disorder

References:[1][8]

Disruptive mood dysregulation disorder (DMDD)

  • Definition: Condition of extreme irritability, anger, and severe recurrent outbursts of temper (verbal or behavioral) for ≥ 12 months (without interruption > 3 months).
  • Epidemiology
  • Etiology: multifactorial
  • Diagnostic criteria (based on DSM-5):
    • Severe temper outbursts (verbal or behavioral) at an average of ≥ 3 times/week that are grossly disproportionate in intensity or duration to the situation and the child's developmental level
    • Persistent angry or irritable mood in between outbursts; observable by others (e.g., parents, teachers, peers)
    • Trouble functioning due to irritability in various situations (e.g., home, school, with peers)
  • Treatment:
    • Psychotherapy (individual and family), parent management training
    • Pharmacotherapy to address irritability and mood problems
  • Prognosis: children may develop major depressive disorder or anxiety disorders in adulthood

References:[9][1][10]