Disruptive impulse-control and conduct disorders DSM 5

Disruptive impulse-control and conduct disorders DSM 5

1. National University of Modern Languages ( NUML ) Subject: P sychodiagnosis 01 Presentation T opic: Disruptive ,impulse control and conduct disorders Date of presentation: 8 May,2021 Submitted to: Mam Noureen Azad Submitted by: M aham Zaib ADCP evening, semester 01

2. Disruptive , impulse control and conduct disorders

3. Definition: Disruptive, impulse-control and conduct disorders refer to a group of disorders that include oppositional defiant disorder, conduct disorder, intermittent explosive disorder, kleptomania and pyromania. These disorders can cause people to behave angrily or aggressively toward people or property. They may have difficulty controlling their emotions and behavior and may break rules or laws.

4. Disruptive behaviors vs typical behaviors The angry, aggressive or disruptive behaviors of people with conduct and disruptive disorders are more extreme than typical behaviors. The behaviors: 1) are frequent 2) are long lasting 3) occur across different situations 4) cause significant problems Disruptive, impulse-control, and conduct disorders are characterized by disturbances in behavioral and emotional self-regulation.

5. OPPOSITIONAL DEFIANT DISORDER In children with oppositional defiant disorder (ODD), there is an ongoing pattern of uncooperative, defiant, and hostile behavior toward authority figures that seriously interferes with the child's day to day functioning .

6. SYMPTOMS: Symptoms of ODD may include : Frequent temper tantrums Excessive arguing with adults Often questioning rules Active defiance and refusal to comply with adult requests and rules Deliberate attempts to annoy or upset people Blaming others for his or her mistakes or misbehavior Often being touchy or easily annoyed by others Frequent anger and resentment Mean and hateful talking when upset Spiteful attitude and revenge seeking

7. Diagnostic criteria of Odd DSM IV Disorder Class: Attention Deficit and Disruptive Behavior Disorders A . A pattern of negativistic; hostile, and defiant behavior lasting at least 6 months, during which four (or more of the following are present: Often loses temper Often argues with adults Often actively defies or refuses to comply with adults requests or rules Often deliberately annoys people DSM 5 Disorder Class: Disruptive, Impulse-Control, and Conduct Disorders A . A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms of the following categories, and exhibited during interaction with at least one individual who is not a sibling: Angry/Irritable Mood Often loses temper Is often touchy and annoyed Is often angry and resentful

8. Diagnostic criteria (cont.) Often blames others for his or her mistakes or misbehavior Is often touchy or easily annoyed by others Is often angry and resentful Is often vindictive Argumentative/Defiant Behavior 4. Often argues with authority figures or, for children and adolescents, 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 misbehavior Vindictiveness 8. Has been spiteful or vindictive at least twice within the past 6 months.

9. Diagnostic criteria (cont.) B . The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. C . The behavior does not occur exclusively during the course of a Psychiatric or Mood Disorder. D . Criteria are not met for Conduct Disorder, and, if the individual is age 18 or older, criteria are not met for Antisocial Personality Disorder 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 behavior does 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. D . dropped

10. Epidemiology Specify  current severity : Mild : Symptoms are confined to only one setting (e.g., at home, at school, at work, with peers). Moderate: Some symptoms are present in at least two settings Severe: Some symptoms are present in three or more settings . PREVALENCE Prevalence : 1-11% , with average prevalence estimate of around 3.3% Boys > girls Symptoms decline after adolescence Rarely diagnosed in older children Estimates vary across countries Majority do not develop conduct disorder High rates of comorbidities

11. Comorbidity Rates of ODD are much higher in samples of children, adolescents and adults with ADHD. ODD often precedes conduct disorder. Individual with ODD are also at increased risk of anxiety disorders and MDD. Adolescents and adults with ODD also show higher rate of substance use disorder.

12. Risk and prognostic features Temperamental : factors related to emotional regulation problems . High levels of emotional reactivity Poor frustration tolerance Different temperamental routes Genetic and physiological: Gene-environment interplay Earlier age of onset of antisocial symptoms Callous and unemotional traits Environment: Rejection by non-deviant peers Social and economic disadvantage Neighborhood violence Negative parenting “Coercive family processes”

13. Differential diagnosis of odd Phobias Other anxiety disorders Obsessive Compulsive Disorder ADHD Autism Depression ODD is common is disturbed families and where neglected child rearing practices are common. Two most common co-occurring conditions with ODD are ADHD and Conduct disorder ASSOCIATED FEATURES

14. Assessment tools Questionnaires Child Adolescent Disruptive Behavior Inventory (CADBI) The Eyberg child behavior inventory (ECBI) The Child Behavior Checklist (CBCL) The Behavior Assessment for Children (BASC-2) Conners Child Behavior Checklist Strengths and Difficulties Questionnaires (SDQ) Semi-structured Interviews The Child ad Adolescent Psychiatric Assessment Structured Interviews The Development and Wellbeing assessment(DAWBA) The Diagnostic Interview Schedule for Children (DISC) Observational Instrument The Disruptive Behavior Diagnostic Observation Schedule

15. Cadbi : 1) Total 25 items, a parent and teacher questionnaire to assess a range of problems. 2) Created by Julie R usby 3) Age range mostly : 3-18 years 4) It is a screening and diagnostic tool 5) 3 subscales that assess; ODD, hyperactivity and inattention 6) 8-point L ikert scale ECBI: 1) Total 36-items measure, designed to assess and provides information about frequency and severity of problem behaviors in children and adolescents. 2) Age range is 2-16 years 3) T wo scales ; Intensity scale and Problem scale

16. CBCL: 1) Behavior Checklist (CBCL) is a checklist parents complete to detect The Child emotional and behavioural problems in children and adolescents . 2) The CBCL is part of the Achenbach System of Empirically Based Assessment (ASEBA). There are two other components of the ASEBA; the Teacher's Report Form (TRF) is to be completed by teachers and the Youth Self-Report (YSR) by the child or adolescent . 3) The CBCL/6-18 is to be used with children aged 6 to 18. 4) It consists of 113 questions, scored on a three-point Likert scale. 5) The 2001 revision also added six DSM-oriented scales consistent with DSM diagnostic categories; affective problems, anxiety problems, somatic problems, ADHD, oppositional defiant problems and conduct problems .

17. Treatment Identify and treat comorbidities Address modifiable risks Parent management training The Incredible Years Triple P (Positive Parenting Program) Alternative approaches School-based interventions Individual therapy (anger management) Medication

18. 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. Symptoms: Intimidating or bullying others committing rape using a weapon Lying stealing Skipping school Run away from home

19. Subtypes of conduct disorder Conduct Disorder is divided into three subtypes based on the age of onset of the disorder. Unspecified – onset disorder : is designated when there is insufficient information to determine the age of onset. Childhood- onset conduct disorder: Usually in males Frequently display of physical aggression toward others Usually have symptoms that meet the full criteria for conduct disorder prior to puberty Individual with this subtype onset are more likely to have persistent conduct disorder into adulthood as compared to adolescent –onset subtype. 3) Adolescent- onset subtype : less likely to display aggressive behaviors and tend to have more normative peer relationships

20. Diagnostic criteria DSM-IV Disorder Class: Attention deficit and disruptive behavior disorders 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 three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months: Aggression to people and animals Destruction of property Deceitfulness or theft Serious violations of rules DSM-5 Disorder Class: Disruptive, Impulse-Control, and Conduct Disorders 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 three (or more) of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months : Same Same Same Same

21. Diagnostic criteria (cont.) B . The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning . C. If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder. B. same C . same Prevalence: 2-10%, with average prevalence estimate of around 4 % Boys > girls Prevalence rates rise from childhood to adolescent Rarely diagnosed in older children Estimates shows it as fairly consistent across different countries

22. Comorbidity risk factors The DSM-5 indicates that CD is comorbid with ADD/ADHD, and substance use disorders . Conduct disorder may also co-occur with one or more of the following mental disorders: Specific learning disorder A nxiety disorder D epressive or bipolar disorder S ubstance –related disorder Temperamental: Difficult uncontrolled infant temperament Lower than average intelligence (verbal IQ) Dysregulation of neurotransmitter Environmental: Parental rejection and neglect ,parental criminality, Harsh discipline, large family size, Physical and sexual abuse Peer rejection , association with delinquent peer group, neighborhood exposure to violence Genetics and physiology: Parents with severe alcohol use disorder, depressive and bipolar, parents with history of ADHD or conduct disorder. Slower resting heart rate is a reliable marker and is not characteristics of any other mental disorder .

23. Differential diagnosis associated features ODD ADHD Depressive and bipolar disorders Intermittent explosive disorder Adjustment disorder Personality features of trait negative emotionality and poor self –control, irritability, temper outbursts, suspiciousness, insensitivity to punishment, and thrill seeking often co-occur with conduct disorder. Substance misuse is also an associated features. Suicidal ideation, suicidal attempts and completed suicide occur at higher rate in individuals with conduct disorder.

24. Assessment and treatment tools The Delinquent Activities Scale (DAS) S tructured interviews : Diagnostic Interview Schedule for Children ( DISC). The Diagnostic Interview for Children and Adolescents The Schedule of Affective Disorders and Schizophrenia for School-Age Children Diagnostic Interview for Children and Adolescents (DICA) Child Behavior Checklist (CBCL) Connors Continuous Performance Test (CPT) CBT Family therapy (Parental management train PMT, Family check-ups FCU) Peer group therapy Medicines (SSRI’s and Atypical antipsychotics) Multisystematic therapy MST

25. Intermittent explosive disorder involves repeated, sudden episodes of impulsive, aggressive, violent behavior or angry verbal outbursts in which you react grossly out of proportion to the situation . Intermittent explosive disorder Symptoms: Aggressive episodes: Rage Irritability Increased energy Racing thoughts Tingling Tremors Palpitations Chest tightness The explosive verbal and behavioral outbursts: Temper tantrums Tirades Heated arguments Shouting Slapping, shoving or pushing Physical fights Property damage Threatening or assaulting people or animals

26. Diagnostic criteria DSM-IV Disorder Class: Impulse-Control Disorders Not Elsewhere Classified A. Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property. DSM-5 Disorder Class: Disruptive, Impulse-Control, and Conduct Disorders A. Recurrent behavioral outburst representing a failure to control aggressive impulses as manifested by either of the following: 1) Verbal aggression, for a period of 3 months . 2) Three behavioral 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.

27. Diagnostic criteria (cont.) B. The degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors . C. The aggressive episodes are not better accounted for by another mental disorder,  and are not because of to the direct physiological effects of a substance or a general medical condition  . B. The magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors . F. The recurrent aggressive outbursts are not better explained by another mental disorder and are not attributable to another medical condition or to the physiological effects of a substance.  For children ages 6 to 18 years, aggressive behavior that occurs as part of an adjustment disorder should not be considered for this diagnosis.

28. Diagnostic criteria of dsm-5(cont .) 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 are associated with financial or legal consequences. E . Chronological age is at least 6 years (or equivalent developmental level).

29. Comorbidity risk factors Intermittent explosive disorder is most often diagnosed with depressive disorders, substance use disorders and post traumatic stress syndrome . Personality disorders, such as borderline personality disorder and antisocial disorder may also be comorbid with intermittent explosive disorder. Individuals with the history of disorders with disruptive behaviors (ADHD, conduct disorder, ODD) Environmental: History of physical or emotional trauma during first two decades of life Genetics and physiological: Neurobiological researches supports the presence of serotonergic abnormalities, specifically in area of limbic system and orbitofrontal cortex of IED individuals.

30. Differential diagnosis associated features Disruptive mood dysregulation disorder Antisocial or borderline personality disorder Delirium Substance intoxication or substance withdrawl ADHD, ODD, conduct disorder or autism spectrum disorder Mood disorders (unipolar) , anxiety disorder, and substance use disorder are associated with IED Prevalence: IED is more prevalent among younger individuals (e.g., younger than 35-40 years)

31. Assessment tools treatment Intermittent explosive disorder screening questionnaire (IED-SQ) Anger (PROMIS Emotional Distress) Social Skills Rating System (SSRS) Reynolds Adolescent Adjustment Screening Inventory (RAASI) Medications Behavioral Therapies CBT Group therapy

32. RASSI: 1) The RASSI is a self- report measure that provides indications of the clinical severity of the most meaningful domains of psychological adjustment problems. 2) Age range is 12-19 years 3) Total 32- items 4) Four factorial derived scales ( Antisocial behavior, Anger control, Emotional distress, and Positive self) SSRS: SSRS has been replaced by the Social Skills Improvement Systems (SSIS) Rating scales. The multi-rater SSIS Rating Scales helps measure: Social behaviors (cooperation, empathy, assertion, self-control, and responsibility) Competing Problem Behaviors (Externalizing, Bullying, Hyperactivity/Inattention, Internalizing, Autism Spectrum) Academic Competence (Reading Achievement, Maths Achievement, Motivation to Learn) Age Range:   3) 3 years to 18 years

33. Pyromania : Pyromania  is an impulse control  disorder  in which individuals repeatedly fail to resist impulses to deliberately start fires, in order to relieve some tension or for instant gratification. Symptoms: S ymptoms include: an uncontrollable urge to set fires fascination and attraction to fires and its paraphernalia pleasure, a rush, or relief when setting or seeing fires tension or excitement around fire-starting

34. Diagnostic criteria The DSM-5 defines pyromania as requiring the following criteria : Deliberate and purposeful fire setting on more than one occasion. Tension or affective arousal before the act. Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g., paraphernalia, uses, consequences). Pleasure , gratification, or relief when setting fires or when witnessing or participating in their aftermath. The fire setting is 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 (e.g., major neurocognitive disorder, intellectual disability, substance intoxication). The fire setting is not better explained by conduct disorder, a manic episode, or antisocial personality disorder . Rule Out Conduct Disorder, Manic Episode, Antisocial Personality Disorder

35. Prevalence comorbidity Pyromania as a primary diagnosis is very rare to be appear. 1.13% in a population sample High co- occurence of substance abuse disorder Gambling disorder Depressive and bipolar disorders Other disruptive, impukse control disorders

36. Assessment tools treatment Fire Setting Scale Fire Proclivity Scale St Andrews Fire and Risk Instrument ( SAFARI) Treatments with selective serotonin reuptake inhibitors, antiepileptic medications, lithium, antiandrogens, or atypical antipsychotics have been proposed . CBT

37. Kleptomania A person with kleptomania has a recurring drive to steal that he or she cannot resist, stealing items for the sake of stealing, not because they need or want the items, or because they cannot afford to buy them. It is quite rare, and not the same thing as shoplifting. Symptoms: Inability to resist powerful urges to steal items that you don't need Feeling increased tension, anxiety or arousal leading up to the theft Feeling pleasure, relief or gratification while stealing Feeling terrible guilt, remorse, self-loathing, shame or fear of arrest after the theft Return of the urges and a repetition of the kleptomania cycle

38. Diagnostic criteria The DSM-5 criteria for a diagnosis of kleptomania include: A . Recurrent impulses to steal—and instances of stealing—objects that are not needed for personal use or financial gain B . Feeling increased tension right before the theft C . Feeling pleasure, gratification, or relief at the time of the theft D . Thefts are not committed in response to delusions or hallucinations, or as expressions of revenge or anger E . Thefts cannot be better explained by Antisocial Personality Disorder, Conduct Disorder, or a manic episode

39. Prevalence associated features 4%-24% arrested for shoplifting Prevalence in general population is very rare, appox . 0.3% - 0.6% Females outnumber the males at a ratio of 3:1 Neurotransmitter pathways associated with behavioral addictions Associated with serotonin , dopamine, opioid systems, appear to play a role in this disorder.

40. Differential diagnosis comorbidity Ordinary theft Malingering Antisocial personality disorder and conduct disorder Manic episodes Kleptomania is often co-diagnosed with anxiety disorders, eating disorders, bipolar and other depressive disorders, personality disorders, substance abuse, compulsive buying disorders, and, of course, other disruptive, impulse control, and conduct disorders.

41. Assessment tools treatment Diagnosis of kleptomania is often based on a combination of patient reports, diagnostic scales, and legal records pertaining to instances of the kleptomaniac being caught during thieving.  P sychometric scales: Yale Brown Obsessive Compulsive Scale, Modified for Kleptomania (K-YBOCS ) Kleptomania Symptom Assessment Scale (K-SAS) C ognitive behavioral therapy Lithium, anti-epileptics, and opioid antagonists have proven effective Selective serotonin reuptake inhibitors (SSRIs ) and Antidepressants may ease the common feelings of shame and self-loathing

42. Thank you