Diagnoses for disruptive, impulse-control and conduct disorders include:
Each of these disorders is characterized by the inability to resist an intense impulse, drive, or temptation to perform a particular act that is harmful to oneself and/or others. Shameful secretiveness about the repeated impulsive activity frequently expand to pervade the individual’s entire life, often significantly delaying treatment.
In addition to the disorders listed above, a diagnosis of “other specified” or “unspecified” disruptive, impulse-control, or conduct disorder may be given to an individual who shows some symptoms of one of these behavioral disorders but not enough to meet the full criteria for any single disorder.
“Oppositional defiant disorder” is a pattern or an angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four of the following symptoms, and demonstrated during interaction with at least one individual who is not a sibling:
For children younger than 5 years, the behavior should occur on most days for a period of at least 6 months to qualify as oppositional defiant disorder. For individuals 5 years or older, the behavior should occur at least once per week for at least 6 months. The behavior is associated with distress in the individual or others in his or her immediate social environment (e.g., family, peer group, work colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioning. In addition, the behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder.
The primary treatment for oppositional defiant disorder in children is family education. The goal is to reinforce more prosocial behaviors in the child while diminishing undesired behaviors. Children with oppositional defiant disorder may also benefit from individual psychotherapy in which they role-play and practice more appropriate responses. In the therapeutic relationship, the child can learn new strategies to develop a sense of mastery and success in social situations with family members and peers. Often, self-esteem must be restored before a child with oppositional defiant disorder can make more positive responses. Also, parent-child conflict strongly predicts conduct problems. Patterns of harsh physical and verbal punishment particularly evoke aggression in children. Replacing harsh, punitive parenting and increasing positive parent-child interactions may positively influence the course of oppositional and defiant behaviors.
A diagnosis of “conduct disorder” is given to an individual with a repetitive and persistent pattern of behavior in which the basic rights of others or age-appropriate societal norms or rules are violated, as demonstrated by at least three of following criteria in the past 12 months, including one in the past 6 months:
The behavior causes significant impairment in social, academic, or occupational functioning. If the individual is 18 years or older, criteria are not met for antisocial personality disorder.
Treatment strategies for young children that focus on increasing social behavior and social competence are believed to reduce aggressive behavior. Studies show that cognitive behavioral therapy can result in significant reductions in conduct disorder symptoms in children and adolescents. Parental education is also important.
Pharmacotherapy may be helpful in treating aggression in youth associated with disruptive behavior disorders. Risperidone has proven effective for this purpose. Conduct disorder, including impulsivity and aggression, may occur in many childhood psychiatric disorders, ranging from ADHD to major depression to bipolar disorder and specific learning disorders. Mood disorders are often present in children who demonstrate irritability and aggressive behavior. Antipsychotics can decrease aggressive and assaultive behaviors in children with a variety of psychiatric disorders. Atypical antipsychotics, including risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), and aripiprazole (Abilify) are often effective and well tolerated. Selective serotonin reuptake inhibitors (SSRIs) including fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and citalopram (Celexa) are used to target symptoms of impulsivity, irritability, and mood swings, which frequently accompany conduct disorder.
A diagnosis of “intermittent explosive disorder”is given to individuals at least 6 years old who have recurrent behavioral outbursts with a failure to control aggressive impulses shown by either of the following:
The magnitude of aggressiveness expressed during the outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors. The aggressive outbursts are not premediated and are not committed to achieve some tangible objective (e.g., money, power, intimidation). The recurrent outbursts cause either marked distress in the individual or impairment in occupational or interpersonal functioning,or are associated with financial or legal consequences. The behavior is not better explained by another mental disorder (e.g., major depressive disorder, bipolar disorder, disruptive mood dysregulation disorder, a psychotic disorder, antisocial personality disorder, borderline personality disorder) and are not attributable to another medical condition (e.g., head trauma, Alzheimer’s disease) or to the physiological effects of a substance (e.g., a drug of abuse or medication). For children ages 6-18 years, aggressive behavior that occurs as part of an adjustment disorder should not be considered for this diagnosis.
A combination of pharmacotherapy and psychotherapy has the best chance of success in treating an individual with intermittent explosive disorder. Group psychotherapy and family therapy may also be helpful. A goal of therapy is to have the patient recognize and verbalize the thoughts or feelings that precede the explosive outbursts instead of acting them out.
Anticonvulsants have been used with mixed results in treating explosive patients. Lithium (Eskalith) has been reported useful in generally lessening aggressive behavior. Carbamazepine, valproate (Depakene) or divalproex (Depakote) and phenytoin (Dilantin) have also proven helpful. Selective serotonin reuptake inhibitors (SSRIs), trazodone (Desyrel), and buspirone (BuSpar) are useful in reducing impulsivity and aggression. Propranolol (Inderal) and other B-adrenergic receptor antagonists and calcium channel inhibitors have also been effective in some cases.
A diagnosis of “pyromania” applies to a person who performs deliberate and purposeful fire setting on more than on occasion. In addition, the individual:
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, in response to a delusion or hallucination, or as a result of impaired judgment (e.g., in major neurocognitive disorder, intellectual disability, substance intoxication).
No single treatment has proven effective in treating pyromania. Because of the recurrent nature of pyromania, any treatment program should include supervision of the patient to prevent a repeated episode of fire setting. Incarceration may be the only method preventing a recurrence. Behavior therapy can then be administered in the institution.
Fire setting by children must be treated with the utmost seriousness. Intensive interventions should be undertaken when possible as therapeutic and preventive measures, not as punishment. In the case of children and adolescents, treatment should include family therapy.
Pyromania is often associated with substance abuse disorder (especially alcoholism), depressive or bipolar disorders, other impulse-control disorders, such as kleptomania in female fire setters, and Pyromania is often associated with substance abuse disorders (especially alcoholism), depressive or bipolar disorders, other impulse-control disorders, such as kleptomania in female fire setters, and various personality disturbances, such as inadequate and borderline personality disorders. Attention-deficit/hyperactivity disorder (ADHD) and learning disabilities may be especially associated with childhood pyromania. Fire setters also tend to have a history of antisocial traits, such as truancy, running way from home, and delinquency. Co-existing conditions also need to be treated as appropriate.
A diagnosis of “kleptomania” is given to a person who repeatedly steals objects that are not needed for personal use or for their monetary value. The individual:
The stealing is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.
Behavior therapy, including systematic desensitization and aversive conditioning, has proven successful in treating patients with kleptomania. Those who feel guilt and shame may be helped by insight-oriented psychotherapy. Pharmacotherapy may also be helpful. Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac) and fluvoxamine (Luvox) appear to be effective in some patients. Case reports have also indicated successful treatment using tricyclic drugs, trazodone, lithium, valproate, and naltrexone.
Psychological, social and biological factors all play a role in impulse-control disorders, which include intermittent explosive disorder, kleptomania, and pyromania.
Psychological factors often include psychic trauma from childhood, including exposure to violence in the home, abuse, alcohol abuse, promiscuity, and antisocial behavior. Impulsive behavior may be an attempt to master anxiety, guilt, depression, or an incomplete sense of self.
Research concerning biological factors associates violent and aggressive behavior with abnormal brain chemistry and certain hormones, especially testosterone. Individuals diagnosed with childhood attention-deficit hyperactivity disorder (ADHD) may have impulse-control disorder symptoms that continue into adulthood. In addition, lifelong or acquired mental deficiency, epilepsy, and even reversible brain syndromes have long been implicated in persons with impulse control problems.
In some cases, genetic factors may also play a role. First-degree relatives of patients with intermittent explosive disorder have higher rates of impulse-control disorders, depressive disorders, and substance use disorders.