Disruptive, impulse-control, and conduct disorders

Disruptive disorder, impulse-control disorder, and conduct disorder are a group of psychiatric conditions that affect the self-regulation of emotions and behaviors beginning in childhood or adolescence. Affected individuals behave in a way that makes others uncomfortable (e.g., aggression, destruction of property) and/or in a way that significantly conflicts with societal norms or authority figures. The disturbance in behavior significantly impairs social, academic, and/or occupational functioning. Genetic, environmental (e.g., in utero exposure to toxins), psychological, and social factors (e.g., physical abuse, neglect) have been found to play a role in the development of these disorders. The disorders within this category discussed here are conduct disorder (CD), oppositional defiant disorder (ODD), intermittent explosive disorder, pyromania, and kleptomania. While ODD and CD both manifest with defiance and resistance to authority in childhood and/or adolescence, individuals with CD are more likely to engage in criminal behavior. The onset of ODD often precedes CD, and affected individuals are at increased risk of developing depression and anxiety disorders in adulthood. Individuals with intermittent explosive disorder present with outbursts of impulsive aggression (verbal or physical) that are unplanned and out of proportion to the circumstances; these cause the affected individual significant distress and impair psychosocial functioning. Pyromania (compulsive fire setting) and kleptomania (compulsive stealing) are uncontrollable impulses and often result in harm to property, other individuals, and legal consequences. Treatment of disruptive disorder, impulse-control disorder, and conduct disorder involves cognitive-behavioral therapy (CBT), parent management training for pediatric patients, and pharmacotherapy.

A relatively new diagnosis is disruptive mood dysregulation disorder (DMDD), which is classified as a depressive disorder. Patients with this condition present with persistent irritability or anger and recurrent, severe angry 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.

Most common impulse-control disorders ^[1][2][3]

Other impulse-control disorders ^[1]

• Types and diagnostic criteria (according to DSM-5)
  • Pyromania
    • Individuals cannot control the impulse to set fire, resulting in multiple episodes of intentional fire setting.
    • Individuals experience internal tension before setting a fire and relief after starting or witnessing a fire.
    • The fire setting is not aimed at secondary gains such as money, not driven by sociopolitical factors, not an expression of anger or vengeance, and not a response to a delusion or hallucination.
  • Kleptomania
    • Individuals cannot control the impulse to steal objects, which are not needed for personal use or for their monetary value.
    • Individuals experience internal tension before stealing and relief at the time of committing theft.
    • The stealing is not motivated by anger or vengeance and is not in response to a delusion or hallucination.
• Treatment
  • CBT
  • There is currently no pharmacotherapy available.

When differentiating between Oppositional Defiant Disorder and Conduct Disorder remember: “Arguing is just ODD, but stealing CDs is a crime”. Patients with CD are more likely to be physically aggressive and engage in criminal behavior.

Behavior (e.g., tantrums, irritability) is considered pathological if it impairs normal, daily functioning and violates age-appropriate norms.

• Definition: a disruptive behavior that violates the basic rights of others and/or age-appropriate social norms
• Epidemiology
  • Onset during childhood or adolescence
  • ♂ > ♀
• Etiology: associated with genetic, environmental, psychological, and/or social factors (e.g., abuse, exposure to toxins, positive family history, neglectful parents, family instability)
• Diagnostic criteria (according to DSM-5) ^[1]
  • Aggression toward people and animals (e.g., bullying, physical fights, use of weapons)
  • Destruction of property (e.g., fire setting)
  • Deceitfulness or theft
  • Serious rule violation (e.g., truancy, running away from home)
  • The disturbance in behavior lasts ≥ 12 months and significantly impairs social, academic, and/or occupational functioning.
  • The diagnosis is only applied to patients < 18 years of age.
• Treatment
  • CBT, parent management training, social skills programs
  • Pharmacotherapy (e.g., psychostimulants in comorbid ADHD, antipsychotic medications or mood stabilizers in cases of severe aggression)
• Prognosis: Individuals with CD are at increased risk of developing antisocial personality disorder in adulthood. If an individual's CD symptoms persist after 18 years of age, their diagnosis is changed to antisocial personality disorder.

“C and D come before E”: Conduct Disorder is diagnosed before Eighteen years.

• Definition: anger, irritable mood, and defiant behavior toward authority figures that significantly impairs social and/or academic functioning
• Epidemiology
  • Onset is usually during late preschool or elementary school years
  • Before puberty ♂ > ♀, after puberty ♂ = ♀
  • Frequent comorbidity of ADHD, anxiety disorder, mood disorders, and/or learning disorders
• Etiology: associated with genetic, environmental, psychological, and/or social factors (e.g., abuse, exposure to toxins, positive family history, neglectful parents, family instability)
• Diagnostic criteria (according to DSM-5) ^[1]
  • ≥ 4 of the following symptoms for ≥ 6 months when interacting with ≥ 1 individual who is not a sibling (e.g., teachers, parents):
    • Frequent loss of temper
    • Easily annoyed
    • Resentful or angry mood
    • Argumentative with authority figures
    • Defies rules or refuses to comply with requests from authority figures
    • ≥ 2 episodes of vindictive or spiteful behavior within the past 6 months
    • Deliberately annoying
    • Blames others for one's own mistakes
  • Disruptive mood dysregulation disorder should be ruled out.
  • 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 the onset of conduct disorder

• Definition: a condition of extreme irritability and severe recurrent outbursts of anger (verbal or behavioral)
• Epidemiology ^[1]
  • ♂ > ♀
  • Age at onset: < 10 years
  • ODD and depressive disorders are common comorbidities. ^[4]
• Etiology: Some of the causes currently being investigated include psychological trauma and/or abuse, malnutrition, vitamin deficiencies, and neurological problems (e.g., migraine).
• Diagnostic criteria (according to DSM-5) ^[1]
  • Severe outbursts of anger (verbal or behavioral) lasting for ≥ 12 months; (without interruption for ≥ 3 consecutive months) on average ≥ 3 times/week that are grossly disproportionate in intensity or duration to the situation and the child's developmental level
  • Persistent anger or irritability in between outbursts which is observable by others (e.g., parents, teachers, peers)
  • Trouble functioning due to irritability in various situations (e.g., at home, school, with peers)
  • The patient has to be between 6–18 years of age for this diagnosis to be considered.
• Treatment
  • Individual and family psychotherapy (e.g., CBT)
  • Parent management training
  • Pharmacotherapy to address irritability and mood problems (e.g., stimulants, antidepressants, atypical antipsychotics)
• Prognosis: : Individuals with DMDD are at increased risk of developing major depressive disorder and anxiety disorders in adulthood.

• Definition: : a condition characterized by outbursts of impulsive aggression (verbal or physical) that are intermittent, unplanned, and out of proportion to the circumstances, causing the individual significant distress, and impairing psychosocial functioning
• Epidemiology
  • ♂ > ♀
  • Age at onset: 14–17 years ^[5]
  • Prevalence: up to 7% of the general population ^[6]
• Etiology: associated with genetic, neurobiological, inflammatory, infectious (e.g., Toxoplasma gondii), psychological, and/or social factors (e.g., history of abuse)
• Diagnostic criteria (according to DSM-5) ^[7][8]
  • Sudden aggressive outbursts (verbal or physical) grossly disproportionate to the triggering stressor, occurring either:
    • ≥ 2 times/week for a period of 3 months with no physical injury to humans or animals and no destruction of property
      or
    • ≥ 3 times/year with physical injury to humans or animals and/or destruction of property
  • The aggressive behavior is grossly disproportionate to the stressor.
  • The patient has to be at least 6 years of age for this diagnosis to be considered.
  • Adjustment disorder should be excluded in children 6–18 years of age.
  • The disturbance causes significant distress or negatively impacts the individual's functioning and legal or financial situation.
• Additional feature: The outbursts typically last < 30 minutes and provide a sense of relief, followed by feelings of remorse.
• Treatment
  • CBT
  • Pharmacotherapy (e.g., SSRIs, mood stabilizers)
• Prognosis: Self-harm can occur and aggression may continue throughout the patient's life.

Feelings of remorse, regret, and embarrassment following an outburst are typical.

Perform a urine toxicology test to screen for intoxication with alcohol, phencyclidine, cocaine, or other stimulants, which must be ruled out in patients presenting with symptoms of intermittent explosive disorder.