PANCE Blueprint Psychiatry (6%)

Disruptive, impulse-control, and conduct disorders (PEARLS)

Disruptive, impulse-control, and conduct disorders
Conduct disorder A pattern of repetitive behavior in which the rights of others or social norms are violated
Oppositional defiant disorder A pattern of negativistic, hostile, and defiant behavior, during which a child often loses her or his temper, often argues with adults, and often actively defies or refuses to comply with adults' requests or rules.
*Oppositional defiant disorder is a less intense form of conduct disorder. Children who continue with the chronic behavior are at risk of developing conduct disorder.
Conduct disorder
Patient will present as → a 14-year-old who is referred to your office for unusual animal cruelty and bullying at school. 

A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated

  • Manifested by the presence of at least three 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.
  • It is often seen as the precursor to antisocial personality disorder, which is per definition not diagnosed until the individual is 18 years old.

Aggression to People and Animals

  • Often bullies, threatens, or intimidates others.
  • Often initiates physical fights.
  • Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).
  • Has been physically cruel to people.
  • Has been physically cruel to animals.
  • Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).
  • Has forced someone into sexual activity.

Destruction of Property

  • Has deliberately engaged in fire setting with the intention of causing serious damage.
  • Has deliberately destroyed others’ property (other than by fire setting).

Deceitfulness or Theft

  • Has broken into someone else’s house, building, or car.
  • Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).
  • Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).

Serious Violations of Rules

  • Often stays out at night despite parental prohibitions, beginning before age 13 years.
  • 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.
  • Is often truant from school, beginning before age 13 years.

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 conflicts such as marital discord or maternal depression.

Oppositional defiant disorder
Patient will present as → a 15-year-old who back talks and resists following instruction from parents or authorities.

"Oppositional defiant disorder is a less intense form of conduct disorder. Children who continue with the chronic behavior are at risk of developing conduct disorder. This disorder is most often seen in boys, with problems being worse at school. The behavior can occur at home and with peers."

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

  • Frequent temper tantrums
  • Arguments with adults and authority figures.
  • Does not conform to rules and regulation
  • Intentional exasperation of others
  • Easily annoyed by others.
  • Revenge-seeking & vindictiveness
  • Angry attitude
  • Harsh and unkind.

Unlike children with conduct disorder (CD), children with oppositional defiant disorder are not aggressive towards people or animals, do not destroy property, and do not show a pattern of theft or deceit.

Treatment:

Psychotherapy: is aimed at helping the child learn to express and control anger in more appropriate ways.

  • Cognitive-behavioral therapy aims to reshape the child's thinking (cognition) to improve problem-solving skills, anger management, moral reasoning skills, and impulse control.
  • Family therapy may be used to help improve family interactions and communication among family members. Peer group therapy might also be helpful

Pharmacotherapy to control ODD include mood stabilizers, antipsychotics, and stimulants.

  • Other drugs seen in studies include haloperidol, thioridazine, and methylphenidate which also is effective in treating ADHD, as it is a common comorbidity.
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