NERD ALERT!!! The purpose of this post is to review various conduct disorders in the DSM-5 manual…..
Paper #1: IED, ODD, & CD….
Similarities & Differences
Intermittent Explosive Disorder (IED), Oppositional Defiant Disorder (ODD), and Conduct Disorder (CD) together fall under a new classification of diagnoses in the DSM5 titled “Disruptive Impulse-Control and Conduct Disorders” (American Psychiatric Association, 2013). Diagnoses that fall under this category present with symptoms of poor behavioral and emotional impulse control (American Psychiatric Association, 2013). Behaviors associated with these diagnoses “violate the rights of others…and bring the individual into significant conflict with societal norms or authority figures” (American Psychiatric Association, 2013, p461). ODD, CD, and IED vary in the degree and type of poor impulse control that predominates (American Psychiatric Association, 2013). A review of these diagnoses is next:
Oppositional Defiant Disorder (ODD)
ODD has three categories of symptoms including: (1) an angry mood, (2) vindictiveness, and (3) defiant behavior (American Psychiatric Association, 2013). The DSM5 has expounded upon its definition of ODD with guidelines on how to assess the frequency and pervasiveness of symptoms (American Psychiatric Association, 2013). ODD is intermediate in severity between CD and IED and is associated with difficulties in both behavioral and emotional self-control (American Psychiatric Association, 2013). Additionally, while CD focuses more on behavioral impulse control, IED focuses primarily on dysregulated emotional outbursts (American Psychiatric Association, 2013). One final point of differentiation between these diagnoses exists in the nature of aggressive behaviors. The aggression associated with ODD is generally less severe than CD (American Psychiatric Association, 2013). Additionally, ODD triggers are much more specific than IED and pertain to interactions with authority figures (American Psychiatric Association, 2013)
As stated earlier, Conduct Disorder focuses on poorly controlled behavioral impulses that violate societal norms and the rights of others (American Psychiatric Association, 2013). The DSM5 describes four types of behavioral impulses as symptomatic of Conduct Disorder, including: “(1) aggression to people and animals… (2) destruction of property…(3) deceitfulness and theft…(4) serious rules violation” (American Psychiatric Association 2013, p470). Specifiers that pertain to the assessment of limited pro-social emotions shed light on how this diagnosis differs from ODD and IED. CD is associated with a lack of guilt, empathy, and remorse as well as shallow emotions (American Psychiatric Association, 2013). A callous interpersonal style and tendency to “misperceive the intentions of others” (American Psychiatric Association, 2013, p472) also underlies the symptomatology of this disorder. Factors such as these appear to be a root cause of CD symptoms, while ODD and IED are caused by dysregulated emotions (American Psychiatric Association, 2013)
Intermittent Explosive Disorder
IED diagnosis is characterized by symptoms of poorly controlled emotional outbursts that are out of proportion with triggering events experienced as distressing (American Psychiatric Association, 3103). Unlike ODD, the aggressive outbursts associated with IED are the result of a broader array of triggers (American Psychiatric Association, 2013). Additionally, the premeditated form of aggression associated with conducted disorder isn’t present in IED (American Psychiatric Association 2013). Instead, poorly regulated emotions exist as the root cause of IED symptomatology (American Psychiatric Association, 2013).
An Example of Co-Morbidity
Morrison, (2014) states that comorbid diagnoses should be considered if a primary diagnoses fails to address certain elements of observed symptoms. Additionally, the presence of two mental disorders in the same diagnostic category “indicates underlying common pathology” (Morrison, 2014, p59). One example of comorbid diagnoses can include an observation of Oppositional Defiant Disorder alongside Conduct Disorder. Criterion C of the DSM-IV-TR states clients are not to be diagnosed with ODD if they also fit criterion for CD (American Psychiatric Association, 2000). In contrast, the DSM-5 has dropped this criterion C. This change is an acknowledgement of research that indicates that ODD can develop into CD, and in certain cases exist as comorbid diagnoses (American Psychiatric Association, 2013).
Paper #2: Comparing ODD & CD….
Conduct & Oppositional Defiant Disorder
According to Netherton, Holmes & Walker, noncompliant behaviors tend to be the most common reasons for children being referred to for help (Netherton, et al, 1999, 118). An awareness of diagnoses falling under the category of disruptive behavior is therefore vital. This paper takes a look at two such disorders and will begin with a comparative description of each.
Oppositional Defiant Disorder
“Annoying or aversive interpersonal behaviors, noncompliance with authority….defiance of social norms and physically aggressive behaviors” are just a few common complaints of children with disruptive behavior disorders. (Netherton, 1999, 118). Other common features can include social skill deficits, and impulsive and overactive behavior. So what is it that differentiates oppositional defiant disorder from conduct disorder?
Children with oppositional defiant disorder present a consistent pattern of hostility and noncompliance towards authority (Karnik, et al, 2006, 100). According to the DSM-IV-TR, a diagnosis of ODD, requires such behaviors be present for at least six months and occur with a resultant functional impairment (Karnik, et al, 2006; Netherton, et al, 1999). Essentially, it appears that underlying ODD symptomatology is a child who is easily angered and resentful towards behavioral controls (Karnik, et al, 2006).
A key point of differentiation for conduct disorder, are that presenting symptoms all manage to violate the basic rights of others, and defy societal norms (Karnik, et al, 2006; Netherton, et al, 1999). The DSM-IV-TR diagnostic criterion includes a presentation of such symptoms for at least six months of time (Netherton, et al, 1999). Additionally, for a CD diagnosis, it is expected that the child should experience significant impairments functionally (Netherton, et al, 1999). Common behavior patterns of children with conduct disorder include bullying, substance abuse, precocious sexual activity, physical aggression, and even property destruction (Karnik, et al, 2006, 102).
Society defines what is pathological or criminal. For example, society regards stealing, robbery, and violence as unacceptable. These social mores and rules are not naturally ingrained, but need to be learned. Individuals incorporate such values and social rules developmentally over time. Actions markedly outside such expectations may be perceived as psychopathological, depending on the circumstance. (Karnik et al, 2006, 99)
As the above quote alludes to, it appears this diagnostic category is based on a preconception of society’s norms of acceptable behavior (Karnik et al, 2006; Nock, et al, 2007). The reason underlying this is that norms can help define the measure of acceptable behavior, against which the child assessed from an adaptive standpoint. For example, OCD can be characterized as a milder form of defiant behavior, diagnosed in childhood with a higher likelihood of remitting (Greene et al, 1999; Karnik et al, 2006; Nock, et al, 2007). Conduct disorders, on the other hand, tends to be more stable over time, presenting in late adolescence, and can develop into ASPD (Karnik, et al, 2006, 100). Therefore, if OCD symptoms appear “closest to normal” (Nock, 2007, 703), then CD symptoms can be seen comparatively as more highly deviant (Karnik, et al, 2006).
On the basis of all this, it appears symptoms underlying these disorders are differentiated on basis of severity and degree of functional impairment. Indeed, several resources for this paper characterize disruptive behavior disorders as existing a developmental trajectory, with a spectrum of diagnoses (Karnik, et al, 2006; Nock, et al, 2007):
The Diagnostic and Statistical Manual of Psychiatric Disorders, 4th Edition, Text Revision, includes a spectrum of diagnoses relating to varying degrees of maladaptive aggression, antisocial behavior, and criminal behavior…These diagnoses represent what is often considered a developmental trajectory that begins in childhood with oppositional behavior, evolves into law-breaking with CD, and eventually becomes a characterologic pattern of behavior in adults, who are then diagnosed with APSD. (Karnik, 2006, 99)
Prognosis for ODD.
With all this in mind, what can be said about the comparative prognosis for adults with these disorders? In the case of ODD, while this disorder amenable to remittance over time, it is also associated with a higher likelihood of developing subsequent disorders (Nock, 2007, 713). Despite this fact, what bodes well for individual’s with this diagnosis is that it tends to be associated with reactive aggression. Unlike proactive variety, it doesn’t usually involve a premediated decision to act aggressively without remorse (Karnik, et al, 2006, 100). Instead, this form of aggression involves a reactionary control problem, with a heightened tendency toward anger.
Prognosis for CD.
In comparison to oppositional defiant disorder, conduct disorder poses a higher likelihood of developing into Antisocial Personality Disorder. Additionally, it can be characterized as involving a recurrent violation of others rights and societal norms. As a result, it is more strongly associated with a proactive aggression. Involving a greater degree of decisive action, aggressive acts underlying this disorder are more likely to be taken without remorse and greater degree of forethought (Karnik, et al, 2006, 100). Assessing the long-term prognosis of those with conduct disorder, involves differentiating between its forms and age of onset (Odgers, et al, 2007, 1241). Additionally, family history assessments provide other powerful indicators of a person’s prognosis long-term (Odgers, et al, 2007, 1241).
Complex Transactional Etiologies
The issue of treating ODD and CD involves first understanding the etiology of these disorders. In reality, this means taking things beyond a DSM-based psychological assessment. Consideration should also be made of “a broad range of possible explanations” (Merton, et al, 2004, p727) from an array of theoretical perspectives. In fact, if one thing is clear, it is that there are many potential etiological perspectives of these disorders. What follows is an overview of a few causal etiologies underlying ODD and CD.
Biological and genetic factors are one causal factor often cited in research underlying a diagnosis ODD and CD. For example, one resource cites the increased occurrence of neurotransmitter abnormalities and deficits in the autonomic nervous system in individuals with these disorders (Karnik, et al, 2006, 104). Still others cite issues such as deficient prenatal development due to poor nutrition and maternal drug use. (Morton, et al, 736) These factors are said to be linked to key deficiencies in verbal and executive functions resulting in an inability to effectively control behavior. (Morton, et al, 736).
A key factor associated with both conduct and oppositional defiant disorder, is compromised self-regulation and affect modulation. (Greene, et al, 1999, 133). In fact this compromised ability to self-regulate is cited in research as an underlying cause of the aggressive coping style that is definitive of these disorders. (Kranik, et al, 2006, 104). Other proposed psychological factors in research point at deficiencies in cognitive process, including perceptions of others, as well as selection and evaluation of alternative responses (Krol, et al, 2004, 739).
Coercive Parenting Practices
From a transactional perspective, the nature of the parent-child interaction is a key factor underlying ODD and CD. In particular, from this perspective it is the parenting styles in conjunction with a child’s characteristics that can result in the development of these disorders (Greene, et al 1999; Morton, et al 2004). What underlies these parent-child relationships is a coercive way of relating that is mutually incompatible. Inadequate disciplinary models and negative reinforcement systems utilized by parents, are met with a rise in oppositional behavior. (Greene, et al, 1999, 137).
A final etiological factor that warrants mention is the social environment of the child. In fact, the family environment is cited in several resources as being of primary influence in the development of these disorders, (Kranik, et al, 2006; Merton, et al, 2004). For example, research correlates criminal activity, and substance use, and a hostile unstable home environment as key factors associated often with these disorders (Kranik, et al, 2006, 103). Why is this?
To better understand of the reasons for this strong correlation between, a few underlying etiological explanations have been uncovered. One source cites difficulties in learning to process social information, pointing at a hyper-vigilance for cues of potential hostility (Merton, et al, 2004, 731). Still another points at problems with the intergenerational attachment relationships, as another key etiological factor (Odgers, et al, 2007).
If one thing is it is that the etiologies underlying these conditions are quite complex. Its for this reason, a thorough assessment, and understanding of all relevant factors is key. A multidimensional approach reflecting these assorted etiological factors should be considered.