15. Disruptive, Impulse-Control, and Conduct Disorders
15.1. Oppositional Defiant Disorder
15.2. Intermittent Explosive Disorder
15.3. Conduct Disorder
15.4. Antisocial Personality Disorder
Disruptive , impulse -control, and conduct disorders include conditions involving
problems in the self-control of emotions and behaviors. While other disorders in DSM-
5 may also involve problems in emotional and/or behavioral regulation, the disorders in
this chapter are unique in that these problems are manifested in behaviors that violate the
rights of others (e.g., aggression, destruction of property) and/or that bring the individual
into significant conflict with societal norms or authority figures. The underlying causes of
the problems in the self-control of emotions and behaviors can vary greatly across the disorders
in this chapter and among individuals within a given diagnostic category.
The chapter includes oppositional defiant disorder, intermittent explosive disorder, conduct disorder, antisocial personality disorder (which is described in the chapter ''Personality Disorders"), pyromania, kleptomania, and other specified and unspecified disruptive, impulse- control, and conduct disorders. Although all the disorders in the chapter involve problems in both emotional and behavioral regulation, the source of variation among the disorders is the relative emphasis on problems in the two types of self-control. For example, the criteria for conduct disorder focus largely on poorly controlled behaviors that violate the rights of others or that violate major societal norms. Many of the behavioral symptoms (e.g., aggression) can be a result of poorly controlled emotions such as anger. At the other extreme, the criteria for intermittent explosive disorder focus largely on such poorly controlled emotion, outbursts of anger that are disproportionate to the interpersonal or other provocation or to other psychosocial stressors. Intermediate in impact to these two disorders is oppositional defiant disorder, in which the criteria are more evenly distributed between emotions (anger and irritation) and behaviors (argumentativeness and defiance). Pyromania and kleptomania are less commonly used diagnoses characterized by poor impulse control related to specific behaviors (fire setting or stealing) that relieve internal tension. Other specified disruptive, impulse-control, and conduct disorder is a category for conditions in which there are symptoms of conduct disorder, oppositional defiant disorder, or other disruptive, impulse-control, and conduct disorders, but the number of symptoms does not meet ^e diagnostic threshold for any of the disorders in this chapter, even though there is evidence of clinically significant impairment associated with the symptoms.
The disruptive, impulse-control, and conduct disorders all tend to be more common in males than in females, although the relative degree of male predominance may differ both across disorders and within a disorder at different ages. The disorders in this chapter tend to have first onset in childhood or adolescence. In fact, it is very rare for either conduct disorder or oppositional defiant disorder to first emerge in adulthood. There is a developmental relationship between oppositional defiant disorder and conduct disorder, in that most cases of conduct disorder previously would have met criteria for oppositional defiant disorder, at least in those cases in which conduct disorder emerges prior to adolescence. However, most children with oppositional defiant disorder do not eventually develop conduct disorder. Furthermore, children with oppositional defiant disorder are at risk for eventually developing other problems besides conduct disorder, including anxiety and depressive disorders.
Many of the symptoms that define the disruptive, impulse-control, and conduct disorders are behaviors that can occur to some degree in typically developing individuals. Thus, it is critical that the frequency, persistence, pervasiveness across situations, and impairment associated with the behaviors indicative of the diagnosis be considered relative to v^hat is normative for a person's age, gender, and culhire when determining if they are symptomatic of a disorder.
The disruptive, impulse-control, and conduct disorders have been linked to a common externalizing spectrum associated with the personality dimensions labeled as disinhibition and (inversely) constraint and, to a lesser extent, negative emotionality. These shared personality dimensions could account for the high level of comorbidity among these disorders and their frequent comorbidity with substance use disorders and antisocial personality disorder. However, the specific nature of the shared diathesis that constitutes the externalizing spectrum remains unknown.
The essential feature of oppositional defiant disorder is a frequent and persistent pattern
of angry/irritable mood, argumentative/defiant behavior, or vindictiveness (Criterion
A). It is not unusual for individuals with oppositional defiant disorder to show the behavioral
features of the disorder without problems of negative mood. However, individuals
with the disorder who show the angry/irritable mood symptoms typically show the behavioral
features as well.
The symptoms of oppositional defiant disorder may be confined to only one setting, and this is most frequently the home. Individuals who show enough symptoms to meet the diagnostic threshold, even if it is only at home, may be significantly impaired in their social functioning. However, in more severe cases, the symptoms of the disorder are present in multiple settings. Given that the pervasiveness of symptoms is an indicator of the severity of the disorder, it is critical that the individual's behavior be assessed across multiple settings and relationships. Because these behaviors are common among siblings, they must be observed during interactions with persons other than siblings. Also, because symptoms of the disorder are typically more evident in interactions with adults or peers whom the individual knows well, they may not be apparent during a clinical examination. The symptoms of oppositional defiant disorder can occur to some degree in individuals without this disorder. There are several key considerations for determining if the behaviors are symptomatic of oppositional defiant disorder. First, the diagnostic threshold of four or more symptoms within the preceding 6 months must be met. Second, the persistence and frequency of the symptoms should exceed what is normative for an individual's age, gender, and culture. For example, it is not unusual for preschool children to show temper tantrums on a weekly basis. Temper outbursts for a preschool child would be considered a symptom of oppositional defiant disorder only if they occurred on most days for the preceding 6 months, if they occurred with at least three other symptoms of the disorder, and if the temper outbursts contributed to the significant impairment associated with the disorder (e.g., led to destruction of property during outbursts, resulted in the child being asked to leave a preschool).
The symptoms of the disorder often are part of a pattern of problematic interactions with others. Furthermore, individuals with this disorder typically do not regard themselves as angry, oppositional, or defiant. Instead, they often justify their behavior as a response to unreasonable demands or circumstances. Thus, it can be difficult to disentangle the relative contribution of the individual with the disorder to the problematic interactions he or she experiences. For example, children with oppositional defiant disorder may have experienced a history of hostile parenting, and it is often impossible to determine if the child's behavior caused the parents to act in a more hostile manner toward the child, if the parents' hostility led to the child's problematic behavior, or if there was some combination of both. Whether or not the clinician can separate the relative contributions of potential causal factors should not influence whether or not the diagnosis is made. In the event that the child may be living in particularly poor conditions where neglect or mistreatment may occur (e.g., in institutional settings), clinical attention to reducing the contribution of the environment may be helpful.
In children and adolescents, oppositional defiant disorder is more prevalent in families in which child care is disrupted by a succession of different caregivers or in families in which harsh, inconsistent, or neglectful child-rearing practices are common. Two of the most common co-occurring conditions with oppositional defiant disorder are attention-deficit/ hyperactivity disorder (ADHD) and conduct disorder (see the section "Comorbidity" for this disorder). Oppositional defiant disorder has been associated with increased risk for suicide attempts, even after comorbid disorders are controlled for.
The prevalence of oppositional defiant disorder ranges from 1% to 11%, with an average prevalence estimate of around 3.3%. The rate of oppositional defiant disorder may vary depending on the age and gender of the child. The disorder appears to be somewhat more prevalent in males than in females (1.4:1) prior to adolescence. This male predominance is not consistently found in samples of adolescents or adults.
The prevalence of the disorder in children and adolescents is relatively consistent across countries that differ in race and ethnicity.
When oppositional defiant disorder is persistent throughout development, individuals with the disorder experience frequent conflicts with parents, teachers, supervisors, peers, and romantic partners. Such problems often result in significant impairments in the individual's emotional, social, academic, and occupational adjustment.
The impulsive (or anger-based) aggressive outbursts in intermittent explosive disorder have a rapid onset and, typically, little or no prodromal period. Outbursts typically last for less than 30 minutes and commonly occur in response to a minor provocation by a close intimate or associate. Individuals with intermittent explosive disorder often have less severe episodes of verbal and/or nondamaging, nondestructive, or noninjurious physical assault (Criterion Al) in between more severe destructive/assaultive episodes (Criterion A2). Criterion A1 defines frequent (i.e., twice weekly, on average, for a period of 3 months) aggressive outbursts characterized by temper tantrums, tirades, verbal arguments or fights, or assault without damage to objects or without injury to animals or other individuals. Criterion A2 defines infrequent (i.e., three in a 1-year period) impulsive aggressive outbursts characterized by damaging or destroying an object, regardless of its tangible value, or by assaulting/ striking or otherwise causing physical injury to an animal or to another individual. Regardless of the nature of the impulsive aggressive outburst, the core feature of intermittent explosive disorder is failure to control impulsive aggressive behavior in response to subjectively experienced provocation (i.e., psychosocial stressor) that would not typically result in an aggressive outburst (Criterion B). The aggressive outbursts are generally impulsive and/ or anger-based, rather than premeditated or instrumental (Criterion C) and are associated with significant distress or impairment in psychosocial function (Criterion D). A diagnosis of intermittent explosive disorder should not be given to individuals younger than 6 years, or the equivalent developmental level (Criterion E), or to individuals whose aggressive outbursts are better explained by another mental disorder (Criterion F). A diagnosis of intermittent explosive disorder should not be given to individuals with disruptive mood dysregulation disorder or to individuals whose impulsive aggressive outbursts are attributable to another medical condition or to the physiological effects of a substance (Criterion F). In addition, children ages 6-18 years should not receive this diagnosis when impulsive aggressive outbursts occur in the context of an adjustment disorder (Criterion F).
Mood disorders (unipolar), anxiety disorders, and substance use disorders are associated with intermittent explosive disorder, although onset of these disorders is typically later than that of intermittent explosive disorder.
One-year prevalence data for intermittent explosive disorder in the United States is about 2.7% (narrow definition). Intermittent explosive disorder is more prevalent among younger individuals (e.g., younger than 35-40 years), compared with older individuals (older than 50 years), and in individuals with a high school education or less.
The lower prevalence of intermittent explosive disorder in some regions (Asia, Middle East) or countries (Romania, Nigeria), compared with the United States, suggests that information about recurrent, problematic, impulsive aggressive behaviors either is not elicited on questioning or is less likely to be present, because of cultural factors.
In some studies the prevalence of intermittent explosive disorder is greater in males than in females (odds ratio = 1.4-2.3); other studies have found no gender difference.
Social (e.g., loss of friends, relatives, marital instability), occupational (e.g., demotion, loss of employment), financial (e.g., due to value of objects destroyed), and legal (e.g., civil suits as a result of aggressive behavior against person or property; criminal charges for assault) problems often develop as a result of intermittent explosive disorder.
The essential feature of conduct disorder is a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated (Criterion A). These behaviors fall into four main groupings: aggressive conduct that causes or threatens physical harm to other people or animals (Criteria A1-A7); nonaggressive conduct that causes property loss or damage (Criteria A8-A9); deceitfulness or theft (Criteria A10-A12); and serious violations of rules (Criteria A13-A15). Three or more characteristic behaviors must have been present during the past 12 months, with at least one behavior present in the past 6 months. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning (Criterion B). The behavior pattern is usually present in a variety of settings, such as home, at school, or in the community. Because individuals with conduct disorder are likely to minimize their conduct problems, the clinician often must rely on additional informants. However, informants' knowledge of the individual's conduct problems may be limited if they have inadequately supervised the individual or the individual has concealed symptom behaviors. Individuals with conduct disorder often initiate aggressive behavior and react aggressively to others. They may display bullying, threatening, or intimidating behavior (including bullying via messaging on Web-based social media) (Criterion Al); initiate frequent physical fights (Criterion A2); use a weapon that can cause serious physical harm (e.g., a bat, brick, broken bottle, knife, gun) (Criterion A3); be physically cruel to people (Criterion A4) or animals (Criterion A5); steal while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery) (Criterion A6); or force someone into sexual activity (Criterion AT). Physical violence may take the form of rape, assault, or, in rare cases, homicide. Deliberate destruction of others' property may include deliberate fire setting with the intention of causing serious damage (Criterion A8) or deliberate destroying of other people's property in other ways (e.g., smashing car windows, vandalizing school property) (Criterion A9). Acts of deceitfulness or theft may include breaking into someone else's house, building, or car (Criterion AlO); frequently lying or breaking promises to obtain goods or favors or to avoid debts or obligations (e.g., "conning" other individuals) (Criterion All); or stealing items of nontrivial value without confronting the victim (e.g., shoplifting, forgery, fraud) (Criterion A12). Individuals with conduct disorder may also frequently commit serious violations of rules (e.g., school, parental, workplace). Children with conduct disorder often have a pattern, beginning before age 13 years, of staying out late at night despite parental prohibitions (Criterion A13). Children may also show a pattern of running away from home overnight (Criterion A14). To be considered a symptom of conduct disorder, the running away must have occurred at least twice (or only once if the individual did not return for a lengthy period). Runaway episodes that occur as a direct consequence of physical or sexual abuse do not typically qualify for this criterion. Children with conduct disorder may often be truant from school, beginning prior to age 13 years (Criterion A15).
Especially in ambiguous situations, aggressive individuals with conduct disorder frequently misperceive the intentions of others as more hostile and threatening than is the case and respond with aggression that they then feel is reasonable and justified. Personality features of trait negative emotionality and poor self-control, including poor frustration tolerance, irritability, temper outbursts, suspiciousness, insensitivity to punishment, thrill seeking, and recklessness, frequently co-occur with conduct disorder. Substance misuse is often an associated feature, particularly in adolescent females. Suicidal ideation, suicide attempts, and completed suicide occur at a higher-than-expected rate in individuals with conduct disorder.
One-year population prevalence estimates range from 2% to more than 10%, with a median of 4%. The prevalence of conduct disorder appears to be fairly consistent across various countries that differ in race and ethnicity. Prevalence rates rise from childhood to adolescence and are higher among males than among females. Few children with impairing conduct disorder receive treatment.
Conduct disorder diagnosis may at times be potentially misapplied to individuals in settings where patterns of disruptive behavior are viewed as near-normative (e.g., in very threatening, high-crime areas or war zones). Therefore, the context in which the undesirable behaviors have occurred should be considered.
Males with a diagnosis of conduct disorder frequently exhibit fighting, stealing, vandalism, and school discipline problems. Females with a diagnosis of conduct disorder are more likely to exhibit lying, truancy, running away, substance use, and prostitution. Whereas males tend to exhibit both physical aggression and relational aggression (behavior that harms social relationships of others), females tend to exhibit relatively more relational aggression.
Conduct disorder behaviors may lead to school suspension or expulsion, problems in work adjustment, legal difficulties, sexually transmitted diseases, unplanned pregnancy, and physical injury from accidents or fights. These problems may preclude attendance in ordinary schools or living in a parental or foster home. Conduct disorder is often associated with an early onset of sexual behavior, alcohol use, tobacco smoking, use of illegal substances, and reckless and risk-taking acts. Accident rates appear to be higher among individuals with conduct disorder compared with those without the disorder. These functional consequences of conduct disorder may predict health difficulties when individuals reach midlife. It is not uncommon for individuals with conduct disorder to come into contact with the criminal justice system for engaging in illegal behavior. Conduct disorder is a common reason for treatment referral and is frequently diagnosed in mental health facilities for children, especially in forensic practice. It is associated with impairment that is more severe and chronic than that experienced by other clinic-referred children.
Criteria and text for antisocial personality disorder can be found in the chapter ''Personality Disorders." Because this disorder is closely connected to the spectrum of "externalizing" conduct disorders in this chapter, as well as to the disorders in the adjoining chapter "Substance-Related and Addictive Disorders," it is dual coded here as well as in the chapter "Personality Disorders."
The essential feature of pyromania is the presence of multiple episodes of deliberate and purposeful fire setting (Criterion A). Individuals with this disorder experience tension or affective arousal before setting a fire (Criterion B). There is a fascination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g., paraphernalia, uses, consequences) (Criterion C). Individuals with this disorder are often regular "watchers" at fires in their neighborhoods, may set off false alarms, and derive pleasure from institutions, equipment, and personnel associated with fire. They may spend time at the local fire department, set fires to be affiliated with the fire department, or even become firefighters. Individuals with this disorder experience pleasure, gratification, or relief when setting the fire, witnessing its effects, or participating in its aftermath (Criterion D). The fire setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one's living circumstances, or in response to a delusion or a hallucination (Criterion E). The fire setting does not result from impaired judgment (e.g., in major neurocognitive disorder or intellectual disability [intellectual developmental disorder]). The diagnosis is not made if the fire setting is better explained by conduct disorder, a manic episode, or antisocial personality disorder (Criterion F).
Individuals with pyromania may make considerable advance preparation for starting a fire. They may be indifferent to the consequences to life or property caused by the fire, or they may derive satisfaction from the resulting property destruction. The behaviors may lead to property damage, legal consequences, or injury or loss of life to the fire setter or to others. Individuals who impulsively set fires (who may or may not have pyromania) often have a current or past history of alcohol use disorder.
The population prevalence of pyromania is not known. The lifetime prevalence of fire setting, which is just one component of pyromania and not sufficient for a diagnosis by itself, was reported as 1.13% in a population sample, but the most common comorbidities were antisocial personality disorder, substance use disorder, bipolar disorder, and pathological gambling (gambling disorder). In contrast, pyromania as a primary diagnosis appears to be very rare. Among a sample of persons reaching the criminal system with repeated fire setting, only 3.3% had symptoms that met full criteria for pyromania.
Pyromania occurs much more often in males, especially those with poorer social skills and learning difficulties.
The essential feature of kleptomania is the recurrent failure to resist impulses to steal items even though the items are not needed for personal use or for their monetary value (Criterion A). The individual experiences a rising subjective sense of tension before the theft (Criterion B) and feels pleasure, gratification, or relief when committing the theft (Criterion C). The stealing is not committed to express anger or vengeance, is not done in response to a delusion or hallucination (Criterion D), and is not better explained by conduct disorder, a manic episode, or antisocial personality disorder (Criterion E). The objects are stolen despite the fact that they are typically of little value to the individual, who could have afforded to pay for them and often gives them away or discards them. Occasionally the individual may hoard the stolen objects or surreptitiously return them. Although individuals with this disorder will generally avoid stealing when immediate arrest is probable (e.g., in full view of a police officer), they usually do not preplan the thefts or fully take into account the chances of apprehension. The stealing is done without assistance from, or collaboration with, others.
Individuals with kleptomania typically attempt to resist the impulse to steal, and they are aware that the act is wrong and senseless. The individual frequently fears being apprehended and often feels depressed or guilty about the thefts. Neurotransmitter pathways associated with behavioral addictions, including those associated with the serotonin, dopamine, and opioid systems, appear to play a role in kleptomania as well.
Kleptomania occurs in about 4%-24% of individuals arrested for shoplifting. Its prevalence in the general population is very rare, at approximately 0.3%-0.6%. Females outnumber males at a ratio of 3:1.
The disorder may cause legal, family, career, and personal difficulties.