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Disruptive, Impulse-Control, and Conduct Disorders


The disruptive, impulse-control, and conduct disorders are interrelated sets of psychiatric symptoms characterized by a core deficit in self-regulation of anger, aggression, defiance, and antisocial behaviors. The disruptive, impulse-control, and conduct disorders include oppositional defiant, intermittent explosive, conduct, other specified/unspecified disruptive/impulse control/conduct, and antisocial personality disorders, as well as pyromania and kleptomania.

Description

Oppositional defiant disorder (ODD) is characterized by a pattern lasting at least 6 mo of angry, irritable mood, argumentative/defiant behavior, or vindictiveness exhibited during interaction with at least 1 individual who is not a sibling ( Table 42.1 ). For preschool children, the behavior must occur on most days, whereas in school-age children, the behavior must occur at least once a week. The severity of the disorder is considered mild if symptoms are confined to only 1 setting (e.g., at home, at school, at work, with peers), moderate if symptoms are present in at least 2 settings, and severe if symptoms are present in ≥4 settings.

Table 42.1
From the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association, pp 462–463.
DSM-5 Diagnostic Criteria for Oppositional Defiant Disorder

  • A

    A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 mo as evidenced by at least 4 symptoms from any of the following categories, and exhibited during interaction with at least 1 individual who is not a sibling:

    • Angry/Irritable Mood

      • 1

        Often loses temper.

      • 2

        Is often touchy or easily annoyed.

      • 3

        Is often angry and resentful.

    • Argumentative/Defiant Behavior

      • 4

        Often argues with authority figures or, for children and adolescents, with adults.

      • 5

        Often actively defies or refuses to comply with requests from authority figures or with rules.

      • 6

        Often deliberately annoys others.

      • 7

        Often blames others for his or her mistakes or misbehavior.

    • Vindictiveness

      • 8

        Has been spiteful or vindictive at least twice within the past 6 mo.

        Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic. For children younger than 5 yr, the behavior should occur on most days for a period of at least 6 mo unless otherwise noted (Criterion A8). For individuals 5 yr or older, the behavior should occur at least once per week for at least 6 mo, unless otherwise noted (Criterion A8). While these frequency criteria provide guidance on a minimal level of frequency to define symptoms, other factors should be considered, such as whether the frequency and intensity of the behaviors are outside a range that is normative for the individual's developmental level, gender, and culture.

  • B

    The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g., family, peer group, work colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioning.

  • C

    The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.

Intermittent explosive disorder (IED) is characterized by recurrent verbal or physical aggression that is grossly disproportionate to the provocation or to any precipitating psychosocial stressors ( Table 42.2 ). The outbursts, which are impulsive and/or anger-based rather than premeditated and/or instrumental, typically last <30 min and frequently occur in response to a minor provocation by a close intimate.

Table 42.2
From the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association, p 466.
DSM-5 Diagnostic Criteria for Intermittent Explosive Disorder

  • A

    Recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either of the following:

    • 1

      Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or physical aggression toward property, animals, or other individuals, occurring twice weekly, on average, for a period of 3 mo. The physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals.

    • 2

      Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring with a 12 mo period.

  • B

    The magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors.

  • C

    The recurrent aggressive outbursts are not premeditated (i.e., they are impulsive and/or anger-based) and are not committed to achieve some tangible objective (e.g., money, power, intimidation).

  • D

    The recurrent aggressive outbursts cause either marked distress in the individual or impairment in occupational or interpersonal functioning, or as associated with financial or legal consequences.

  • E

    Chronological age is at least 6 yr (or equivalent developmental level).

  • F

    The recurrent aggressive outbursts are not better explained by another mental disorder (e.g., major depressive disorder, bipolar disorder, disruptive mood dysregulation disorder, a psychotic disorder, antisocial personality disorder, borderline personality disorder) and are not attributable to another medical condition (e.g., head trauma, Alzheimer disease) or to the physiologic effects of a substance (e.g., a drug of abuse, a medication). For children ages 6-18 yr, aggressive behavior that occurs as part of an adjustment disorder should not be considered for this diagnosis.

    Note: This diagnosis can be made in addition to the diagnosis of attention-deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder, or autism spectrum disorder when recurrent impulsive aggressive outbursts are in excess of those usually seen in these disorders and warrant clinical attention.

Conduct disorder (CD) is characterized by a repetitive and persistent pattern over at least 12 mo of serious rule-violating behavior in which the basic rights of others or major societal norms or rules are violated ( Table 42.3 ). The symptoms of CD are divided into 4 major categories: aggression to people and animals, destruction of property, deceitfulness or theft, and serious rule violations (e.g., truancy, running away). Three subtypes of CD (which have different prognostic significance) are based on the age of onset: childhood-onset type, adolescent-onset type, and unspecified. A small proportion of individuals with CD exhibit characteristics (lack of remorse/guilt, callous/lack of empathy, unconcerned about performance, shallow/deficient affect) that qualify for the “with limited prosocial emotions” specifier. CD is classified as mild when few if any symptoms over those required for the diagnosis are present, and the symptoms cause relatively minor harm to others. CD is classified as severe if many symptoms over those required for the diagnosis are present, and the symptoms cause considerable harm to others. Moderate severity is intermediate between mild and severe.

Table 42.3
From the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association, pp 469–471.
DSM-5 Diagnostic Criteria for Conduct Disorder

  • A

    A repetitive and persistent pattern of behavior 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 criteria in the past 12 mo from any of the categories below, with at least 1 criterion present in the past 6 mo:

    • Aggression to People and Animals

      • 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 (e.g., a 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 (e.g., mugging, purse snatching, extortion, armed robbery).

      • 7

        Has forced someone into sexual activity.

    • Destruction of Property

      • 8

        Has deliberately engaged in fire setting with the intention of causing serious damage.

      • 9

        Has deliberately destroyed others' property (other than by fire setting).

    • Deceitfulness or Theft

      • 10

        Has broken into someone else's house, building, or car.

      • 11

        Often lies to obtain good or favors or to avoid obligations (i.e., “cons” others).

      • 12

        Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).

    • Serious Violations of Rules

      • 13

        Often stays out at night despite parental prohibitions, beginning before age 13 yr.

      • 14

        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.

      • 15

        Is often truant from school, beginning before age 13 yr.

  • B

    The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

  • C

    If the individual is age 18 yr or older, criteria are not met for antisocial personality disorder.

Other specified/unspecified disruptive/impulse-control/CD (sub­syndromal disorder) applies to presentations in which symptoms characteristic of the disorders in this class are present and cause clinically significant distress or functional impairment, but do not meet full diagnostic criteria for any of the disorders in this class.

Epidemiology

The prevalence of ODD is approximately 3%, and in preadolescents is more common in males than females (1.4 : 1). One-year prevalence rates for IED and CD approximate 3% and 5%, respectively. For CD, prevalence rates rise from childhood to adolescence and are higher among males than females. The prevalence of these disorders has been shown to be higher in lower socioeconomic classes. This class of disorders constitutes the most frequent referral problem for youth, accounting for one third to one half of all cases seen in mental health clinics. Racial/ethnic minority youth with these disorders utilize specialty mental health services at lower rates than their white peers.

Clinical Course

Oppositional behavior can occur in all children and adolescents at times, particularly during the toddler and early teenage periods when establishing autonomy and independence are normative developmental tasks. Oppositional behavior becomes a concern when it is intense, persistent, and pervasive and when it affects the child's social, family, and academic life.

Some of the earliest manifestations of oppositionality are stubbornness (3 yr), defiance and temper tantrums (4-5 yr), and argumentativeness (6 yr). Approximately 65% of children with ODD exit from the diagnosis after a 3 yr follow-up; earlier age at onset of oppositional symptoms conveys a poorer prognosis. ODD often precedes the development of CD (approximately 30% higher likelihood with comorbid attention-deficit/hyperactivity disorder [ADHD]), but also increases the risk for the development of depressive and anxiety disorders. The defiant and vindictive symptoms carry most of the risk for CD, whereas the angry, irritable mood symptoms carry most of the risk for anxiety and depression.

IED usually begins in late childhood or adolescence and appears to follow a chronic and persistent course over many years.

The onset of CD may occur as early as the preschool years, but the first significant symptoms usually emerge during the period from middle childhood through middle adolescence; onset is rare after age 16 yr. Symptoms of CD vary with age as the individual develops increased physical strength, cognitive abilities, and sexual maturity. Symptoms that emerge first tend to be less serious (e.g., lying), while those emerging later tend to be more severe (e.g., sexual or physical assault). Severe behaviors emerging at an early age convey a poor prognosis. In the majority of individuals, the disorder remits by adulthood; in a substantial fraction, antisocial personality disorder develops. Individuals with CD also are at risk for the later development of mood, anxiety, posttraumatic stress, impulse control, psychotic, somatic symptom, and substance-related disorders.

Differential Diagnosis

The disorders in this diagnostic class share a number of characteristics with each other as well as with disorders from other classes, and as such must be carefully differentiated. ODD can be distinguished from CD by the absence of physical aggression and destructiveness and by the presence of angry, irritable mood. ODD can be distinguished from IED by the lack of serious aggression (physical assault). IED can be distinguished from CD by the lack of predatory aggression and other, nonaggressive symptoms of CD.

The oppositionality seen in ODD must be distinguished from that seen in ADHD, depressive and bipolar disorders (including disruptive mood dysregulation disorder), language disorders, intellectual disability, and social anxiety disorder. ODD should not be diagnosed if the behaviors occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder, or if criteria are met for disruptive mood dysregulation disorder. IED should not be diagnosed if the behavior can be better explained by a depressive, bipolar, disruptive mood dysregulation, psychotic, antisocial personality, or borderline personality disorder. The aggression seen in CD must be distinguished from that seen in ADHD and intermittent explosive, depressive, bipolar, and adjustment disorders.

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