Disruptive, impulse control, and conduct disorders
AssessmentsDisruptive, impulse control, and conduct disorders
Disruptive, impulse control, and conduct disorders
USMLE® Step 1 style questions USMLE
A 9-year-old girl is brought to the pediatrician’s office by her parents for evaluation of irritability. The patient has been having 3-4 temper tantrums each week, which consist of breaking small objects and throwing books and papers around for 30 minutes. The parents describe the inciting event as typically something small such as “being unable to operate the TV remote control.” Additionally, the patient has a baseline irritable mood most days of the week, and as a result, her teachers and classmates have found it difficult to engage with her. Past medical history is noncontributory. Vitals and physical examination are within normal limits. Which of the following is the most likely diagnosis?
Disruptive, impulse control, and conduct disorders exam links
Content Reviewers:Rishi Desai, MD, MPH, Tanner Marshall, MS
Contributors:Vincent Waldman, PhD
The Diagnostic and Statistical Manual of Mental Disorders, the 5th edition, or DSM 5, has a relatively new category called “Disruptive, Impulse Control, and Conduct Disorders” or DIC for short, which were previously organized into different sections. This category includes a number of disorders like oppositional defiant disorder, conduct disorder, antisocial personality disorder, intermittent explosive disorder, as well as other impulse control disorders like the compulsive desire to start fires, or pyromania, and the compulsive desire to steal things, or kleptomania. The common thread that runs through all of these is that they all involve impulsive behaviors, or a lack of self-control. These disorders tend to start in childhood or adolescence, and persist into adulthood.
Oppositional defiant disorder, or ODD, is defined by defiant behavior that’s both persistent and willful, and can be thought of in terms of emotional, behavioral, and cognitive patterns. People with ODD have emotional dysregulation which can lead them to feel irritable and resentful towards others. These emotions can lead to behaviors like frequent arguments, angry outbursts, and refusing to go along with the requests of authority figures - like teachers. People with ODD might even deliberately annoy their family or friends, purposefully defying anyone who tries to control their behavior. Cognitively, these people often fall into a pattern of vindictiveness and spitefulness, believing that others are to blame for their own behaviors. In order to meet the criteria for ODD, these emotional, behavioral, and cognitive patterns must be ongoing for at least 6 months, and must interfere with family, school, and other social interactions.
Conduct disorder has a lot of overlap with oppositional defiant disorder with one key additional feature - aggressive behavior towards people and animals. For example, people with conduct disorder might violently destroy property, steal things, or hurt pets, causing grief and frustration for those around them. These are considered antisocial behaviors because they completely break the boundaries of social norms. There are two main types of conduct disorder, childhood-onset type, where the abnormal behaviors start before the age of ten and adolescent-onset type, which starts between age ten and age 18. Typically the earlier the symptoms, the more severe the behavioral problems.
Alright, so next, there’s antisocial personality disorder—and this is where people disregard moral values and societal norms, have little empathy, and poor impulse control. This combination makes them willing to hurt others if it helps them, making them prone to aggressive and unlawful behavior, at times earning the label sociopath or psychopath. In fact, individuals with this disorder tend to be overrepresented in prison populations and have higher rates of substance use. These people typically fail to show remorse or guilt and rarely accept responsibility for any of the harm that they cause others. That said, they can be superficially charming and often use that to manipulate others for their personal gain. To be diagnosed with this disorder, individuals must be over 18 years old and have a history of conduct disorder. Interestingly, this disorder fits into two categories, and can also be found in the personality disorders section of the DSM-5.
While there is certainly a relationship between oppositional defiant disorder, conduct disorder, and antisocial personality disorder, it is important to note that not all individuals with oppositional defiant disorder will go on to develop conduct disorder, and not all individuals with conduct disorder will go on to develop antisocial personality disorder.
Alright, another disorder is intermittent explosive disorder, or IED. IED is characterized by recurrent explosive outbursts of intense anger and violence, sometimes causing injury to themselves or others. These outbursts are usually brief and not premeditated, can appear in response to any real or perceived provocation, and are almost always out of proportion to the situation. To diagnose IED, an individual has to be over six years old to distinguish these from temper tantrums, and must have these outbursts twice a week for at least three months, or have three outbursts in a year that result in physical injury or property damage.
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