Disruptive, Impulse-Control, and Conduct Disorders

In 2013, the 5th revision to the DSM (DSM-5) added a chapter on disruptive, impulse-control, and conduct disorders. It brings together several disorders that were previously included in other chapters (such as oppositional defiant disorder, conduct disorder, intermittent explosive disorder, pyromania, and kleptomania) into one single category. In addition, antisocial personality disorder is listed both here and in the chapter on personality disorders. All of the disorders listed under this chapter are marked by behavioral and emotional disturbances specifically related to self-control. 

Defining Conduct Disorder

Conduct disorder (CD) is a psychological disorder diagnosed in childhood or adolescence that presents itself through a repetitive and persistent pattern of behavior in which the basic rights of others, or major age-appropriate norms, are violated. These behaviors are often referred to as "antisocial behaviors." It is often seen as the precursor to antisocial personality disorder, which is not diagnosed until the individual is 18 years old. The child diagnosed with CD often presents with a lack of empathy, or the ability to recognize the feelings of others. Because the child with CD is unable to place themselves in the other person's shoes, they are unable to understand their consequences.

DSM-5 Diagnostic Criteria

CD is diagnosed in the DSM-5 based on a prolonged pattern of antisocial behavior such as serious violation of laws and social norms and rules. According to DSM-5 criteria, there are four categories that could be present in the child's behavior: aggression to people and animals, destruction of property, deceitfulness or theft, and serious violation of rules. Almost all adolescents who have a substance use disorder have conduct disorder-like traits; therefore it is important to exclude a substance-induced cause before diagnosing CD.

Etiology

Several domains have been implicated in the development of conduct disorder including cognitive variables, neurological factors, personality factors, familial and peer influences, and wider contextual factors. These factors may also vary based on the age of onset, with different variables related to early (e.g., neurodevelopmental basis) and adolescent (e.g., social/peer relationships) onset.

Treatment

The most effective treatment for an individual with conduct disorder is one that seeks to integrate individual, school, and family settings. Additionally, treatment should also seek to address familial conflict such as marital discord or maternal depression. In this manner, a treatment would serve to address many of the possible triggers of conduct problems. Several treatments currently exist, the most effective of which is multi-systemic treatment (MST), an intensive, integrative treatment that emphasizes how an individual's conduct problems fit within a broader context. 

Defining Oppositional Defiant Disorder

Oppositional defiant disorder (ODD) involves patterns of anger, irritability, argumentative or defiant behavior, and/or vindictiveness. Unlike children with conduct disorder (CD), children with oppositional defiant disorder are not aggressive toward people or animals, do not destroy property, and do not show a pattern of theft or deceit.

DSM-5 Diagnostic Criteria

Symptoms for ODD are of three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness. For a child or adolescent to qualify for a diagnosis of ODD, behaviors must cause considerable distress for the family or interfere significantly with academic or social functioning. Interference might take the form of preventing the child or adolescent from learning at school or making friends, or placing him or her in harmful situations. These behaviors must also persist for at least six months. Effects of ODD can be greatly amplified by the presence of other disorders such as ADHD, depression, or substance use disorders.

Etiology

The cause of ODD is unknown, but it is believed that a combination of biological, psychological, and environmental factors may contribute to the condition. Research indicates a degree of heritability that varies by age, age of onset, and other factors. Adoption and twin studies indicate that 50% or more of the variance causing antisocial behavior is attributable to heredity for both males and females. Factors such as a family history of mental illnesses and/or substance abuse, inconsistent discipline by a parent or guardian, and insecure parent-child attachments may contribute to the development of behavior disorders. A difficult temperament, impulsivity, and a tendency to seek rewards can also increase the risk of developing ODD. 

Many pregnancy and birth problems are related to the development of conduct problems; however, strong evidence for causation is lacking. Malnutrition, specifically protein deficiency, lead poisoning, and mother’s use of nicotine, marijuana, alcohol or other substances during pregnancy may increase the risk of developing ODD. Deficits and injuries to certain areas of the brain can also lead to serious behavioral problems in children. Brain imaging studies have suggested that children with ODD may have subtle differences in the part of the brain responsible for reasoning, judgment and impulse control.

Treatment

Approaches to the treatment of ODD include parent management training, individual psychotherapy, family therapy, cognitive behavioral therapy, and social skills training. According to the American Academy of Child and Adolescent Psychiatry, treatments for ODD are tailored specifically to the individual child, and different treatment techniques are applied for pre-schoolers and adolescents. Several preventative programs have had a positive effect on those at high risk for ODD. Both home visitation and programs such as Head Start have shown some effectiveness in preschool children. Social skills training, parent management training, and anger management programs have been used as prevention programs for school-age children at risk for ODD. For adolescents at risk for ODD, cognitive interventions, vocational training, and academic tutoring have shown preventative effectiveness.

Disorders in Childhood

Conduct and oppositional defiant disorders are often seen in childhood, and involve a range of anti-social symptoms.

Defining Intermittent Explosive Disorder

Intermittent explosive disorder (IED) is a behavioral disorder characterized by explosive outbursts of anger, often to the point of rage, that are disproportionate to the situation at hand (e.g., impulsive screaming triggered by relatively inconsequential events). Impulsive aggression is unpremeditated and is defined by a disproportionate reaction to any provocation, real or perceived. The disorder itself is not easily characterized and often exhibits comorbidity with other mood disorders, particularly bipolar disorder. Individuals diagnosed with IED report their outbursts as being brief (lasting less than an hour), with a variety of bodily symptoms (sweating, stuttering, chest tightness, twitching, palpitations) reported by a third of one sample. Aggressive acts are frequently reported accompanied by a sensation of relief and in some cases pleasure, but often followed by later remorse.

DSM-5 Diagnostic Criteria

The current DSM-5 criteria for a diagnosis of IED include recurrent outbursts that demonstrate an inability to control impulses. These can either include: 

• verbal aggression (tantrums, verbal arguments, or fights) or physical aggression that occurs twice in a week-long period for at least three months and does not lead to destruction of property or physical injury; or 
• three outbursts that involve injury or destruction within a year-long period.

In addition, the person must experience aggressive behavior that is grossly disproportionate to the magnitude of the psychosocial stressors. The outbursts cannot be premeditated and must cause distress or impairment of functioning, or lead to financial or legal consequences. The diagnosis can only be given to individuals 6 years of age or older, and the recurrent outbursts cannot be explained by another mental disorder and are not the result of another medical disorder or substance use.

Etiology

Impulsive behavior, and especially impulsive violence predisposition, has been correlated to differences in levels of serotonin in the brain. IED may also be associated with lesions in the prefrontal cortex, with damage to these areas, including the amygdala, increasing the incidence of impulsive and aggressive behavior and the inability to predict the outcomes of an individual's own actions. Lesions in these areas are also associated with improper blood sugar control, leading to decreased brain function in these areas, which are associated with planning and decision making.

Treatment

Treatments are often attempted through both cognitive behavioral therapy and psychotropic medication regimens, though the pharmaceutical options have shown limited success. Therapy aids in helping the patient recognize the impulses in hopes of achieving a level of awareness and control of the outbursts, along with treating the emotional stress that accompanies these episodes. 

Other Impulse-Control Disorders

In addition to those listed above, the DSM-5 lists several other impulse-control disorders under this chapter. Pyromania is characterized by impulsive and repetitive urges to deliberately start fires. Studies done on children and adolescents suffering from pyromania have reported its prevalence to be between 2.4%-3.5% in the United States. Kleptomania is characterized by an impulsive urge to steal purely for the sake of gratification. In the U.S. the presence of kleptomania is unknown, but has been estimated at around 6 per 1,000 individuals.