Psychiatry and Behavioral Health Rotation

Psychiatry EOR: Conduct disorder

Patient will present as → a 16-year-old male who has demonstrated significant behavioral and impulsive problems since early childhood, which were manifested more prominently when he was four. During this time he was removed from his mothers care due to her continuous substance abuse. She reported using alcohol, cocaine, and crack cocaine during her pregnancy. He has a history of repeated violations of school rules and disruption in class. He often was aggressive and cut school. He also reported torturing animals and doing “sexual things” to them. He once set his grandmother's bed on fire while she was sleeping in it. Another disclosure involved playing in the backyard of his grandmother’s home where he burned several toys. Psychological testing was carried out and his results indicated an average IQ using the Wechsler Intelligence Scale for Children. His scale scores included a verbal score of 93, performance score of 104 and a full scale score of 95. Further testing revealed his struggles with an extremely low self-esteem. He also provided somewhat odd answers on a sentence completion assessment, mentioning several times “that I wish I was never born.”

Key Points:

  • Aggression towards people, animals, and property. Deceit and rule violation.
  • Manifested by the presence of at least three of the following 15 criteria in the past 12 months 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.

DSM-5 Diagnostic Criteria

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 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:

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.

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.

Treatment for conduct disorder is based on many factors, including the child's age, the severity of symptoms, as well as the child's ability to participate in and tolerate specific therapies.

  • 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.
  • A specialized therapy technique called parent management training (PMT) teaches parents ways to positively alter their child's behavior in the home.
  • Medication: Although there is no medication formally approved to treat conduct disorder, various drugs may be used to treat some of its distressing symptoms, as well as any other mental illnesses that may be present, such as ADHD or major depression.
Question 1
The diagnosis of conduct disorder is made when which of the following criteria is (are) fulfilled?
A
repetitive and persistent patterns of behavior that violate the rights of others
B
stealing
C
lying
D
vandalism
E
a and any two of b, c, and d
Question 1 Explanation: 
The diagnosis of conduct disorder requires a repetitive and persistent pattern of behavior that violates the basic rights of others or age-appropriate rules of society, manifested by at least three of the following behaviors:
  1. stealing
  2. running away from home
  3. staying out after dark without permission
  4. lying so as to “con” people
  5. deliberately setting fires
  6. repeatedly being truant (beginning before the age of 13 years)
  7. vandalizing
  8. being cruel to animals
  9. bullying
  10. being physically aggressive
  11. forcing someone else into sexual activity
Conduct disorder is a purely descriptive label for a heterogeneous group of children and adolescents. Many of these individuals also lack appropriate feelings of guilt or remorse, empathy for others, and a feeling of responsibility for their own behavior.
Question 2
Which of the following disorders often appear together in the same individual at various life stages?
A
mental retardation, attention-deficit/ hyperactivity disorder (ADHD), and learning disability
B
childhood depression, ADHD, and early-onset adult schizophrenia
C
ADHD, conduct disorder, and antisocial personality disorder
D
adjustment disorder, ADHD, and major depression
E
ADHD, bipolar disorder, and conduct disorder
Question 2 Explanation: 
ADHD commonly leads to conduct disorder. Adolescents who have conduct disorder are predisposed to the development of antisocial personality disorder or alcoholism as adults.
Question 3
Conduct disorder appears to result from an interaction of which of the following factors?  
A
temperament
B
attention to problem behavior and ignoring of good behavior
C
association with a delinquent peer group
D
a and c
E
a, b, and c
Question 3 Explanation: 
Conduct disorder appears to result from an interaction among the following factors: (1) temperament, (2) parents who provide attention to problem behavior and ignore good behavior, (3) association with a delinquent peer group, (4) a parent “role model” of impulsivity and rule-breaking behavior, (5) genetic predisposition, (6) marital disharmony in the family, (7) placement outside of the home as an infant or toddler, (8) poverty, and (9) low intelligence quotient or brain damage.
Question 4
Which treatment( s) is (are) used to manage symptoms of conduct disorder?
A
behavioral therapy
B
mood stabilizers
C
alpha agonists
D
beta blockers
E
all of the above
Question 4 Explanation: 
Although behavioral therapy is the mainstay for treatment of the core symptoms of conduct disorder, target symptoms such as aggression and agitation may be treated with medications such as alpha agonists, mood stabilizers, beta blockers, and antipsychotics. Of course, it is also crucial to identify and to treat comorbid disorders.
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