Psychiatry and Behavioral Health Rotation

Psychiatry EOR: Oppositional defiant disorder

Patient will present as → a 10-year-old boy whose parents c/o constant arguments. His parents state that he has “been a handful.” He argues all the time. He is always angry and is easily agitated. He seems to enjoy making others upset. At school, he does not listen to his teachers and argues with them all the time. His parents report that they are “fed up" with him and his behavior is "putting a lot of strain on our marriage.” Past medical history is significant for ADHD with panic disorder.

Key Points:

  • 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 conformation to rules and regulation
    • Intentional exasperation of others
    • Easily annoyed by others.
    • Revenge-seeking & vindictiveness
    • Angry attitude
    • Harsh and unkind.
  • It is more common in boys than in girls. Children with mood disorders, conduct disorder, and ADHD are susceptible to ODD
  • 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

DSM-5 Diagnostic Criteria

A. 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.

Angry/Irritable Mood

  • Often loses temper.
  • Is often touchy or easily annoyed.
  • Is often angry and resentful.

Argumentative/Defiant Behavior

  • 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

  • Has been spiteful or vindictive at least twice within the past 6 months.

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 behaviors do 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.

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.
Psychiatry EOR: Conduct disorder (Prev Lesson)
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