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Chapter 15. Disruptive, Impulse- Control, and Conduct Disorders https://doi-org.proxy-library.ashford.edu/10.1176/ appi.books.9781585624836.jb15

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Introduction John W. Barnhill, M.D. Executive functions help control and regulate attention, memory, and behavior. They are critical to adaptation, to the initiation and completion of tasks, and to the ability to delay gratification. They inhibit inappropriate, dangerous, and hurtful behaviors. Disruptive, impulse-control, and conduct disorders compose make up a heterogeneous cluster of people who all tend to have impaired executive functioning. The DSM-5 chapter defining these conditions includes oppositional defiant disorder, intermittent explosive disorder, conduct disorder, antisocial personality disorder, pyromania, and kleptomania, as well as categories for people who have clinically relevant symptoms but do not meet criteria for a named disorder. Other DSM-5 disorders are associated with impulsivity, poor planning, and interpersonal conflicts, and these other disorders—ranging from attention-deficit/hyperactivity disorder to substance use disorders to some of the

https://dsm-psychiatryonline-org.proxy-library.ashford.edu/doi/10.1176/appi.books.9781585624836.jb16
https://doi-org.proxy-library.ashford.edu/10.1176/appi.books.9781585624836.jb15
https://doi-org.proxy-library.ashford.edu/10.1176/appi.books.9781585624836.jb15
https://dsm-psychiatryonline-org.proxy-library.ashford.edu/doi/abs/10.1176/appi.books.9781585624836.jb15
personality disorders—are frequently comorbid with the disorders described in this chapter. Furthermore, disruptive impulsivity is associated with substance use, HIV and hepatitis C infections, traumatic brain injury, and all manner of dangerous behavioral patterns that produce direct physiological assaults on executive functioning and can lead to intensifying cycles of dysfunctional behavior. All of these disorders tend to start early in life, which is unsurprising given the relative immaturity of executive functions during childhood and adolescence. If the clinical interview indicates that one of the disruptive, impulse- control, or conduct disorders has suddenly sprouted during the adult years, the individual most likely either has developed a serious neuropsychiatric disorder or has not provided an accurate history. On the other hand, children who present with one of these disorders do not inevitably go on to develop such pervasively damaging diagnoses as antisocial personality disorder or lifelong intermittent explosive disorder. They are at risk for ongoing problems, however, including depressive, anxiety, and substance use disorders. These children are also at risk for encountering a disproportionate amount of societal trouble, and DSM-5 provides a structure for investigating severity. In individuals with oppositional defiant disorder, for example, pervasiveness of symptoms across settings is a useful marker for severity, whereas “limited prosocial emotions” is a specifier for conduct disorder that identifies greater severity and a different treatment response. Poorly controlled behavior and emotions lie on a continuum, and most sporadically impulsive behavior and dysregulated emotions do not indicate a DSM-5 disorder

but rather immaturity intensified by such situational issues as family and interpersonal strife, intoxication, and peer pressure. As is the case throughout DSM-5, the onus is on the clinician to carefully consider when thoughts, feelings, and behaviors cross the line into a level of distress and dysfunction that warrants a diagnosis. Particularly relevant variables include frequency, setting, and duration of the troublesome episodes. An accurate history is necessary to gather this information. Such an investigation can be stymied by the fact that, as is the case with the personality disorders, people other than the identified patient may be more distressed than the patient. Furthermore, psychiatric history tends to depend on patient honesty, and many of these patients are not spontaneously and transparently forthcoming. For these reasons, evaluations are often initiated by family and institutions (school, work, the legal system) and are unlikely to be complete without collateral information. Suggested Readings

• Buitelaar JK, Smeets KC, Herpers P: Conduct disorders. Eur Child Adolesc Psychiatry 22 (suppl 1):S49–S54, 2013 PubMed ID: 23224151

• Hollander E, Stein DJ (eds): Clinical Manual of Impulse-Control Disorders. Washington, DC, American Psychiatric Publishing, 2006

• Pardini DA, Frick PJ, Moffitt TE: Building an evidence base for DSM-5 conceptualizations of oppositional defiant disorder and conduct disorder: introduction to the special section. J Abnorm Psychol 119(4):683–688, 2010 PubMed ID: 21090874

Case 15.1 Doesn’t Know the Rules

Juan D. Pedraza, M.D. Jeffrey H. Newcorn, M.D. Kyle was a 12-year-old boy who reluctantly agreed to admission to a psychiatric unit after getting arrested for breaking into a grocery store. His mother said she was “exhausted,” adding that it was hard to raise a boy who “doesn’t know the rules.” Beginning as a young child, Kyle was unusually aggressive, bullying other children and taking their th