- Intermittent Explosive Disorder (IED)
- Oppositional Defiant Disorder (ODD)
- Related Disorders: Kleptomania, Pyromania
These disorders involve the inability of an individual to regulate their emotions or behaviors, characterized by persistent behavioral patterns of anger, hostility, and/or aggression towards other people or property.
Oppositional Defiant Disorder
ODD consists of an enduring pattern of uncooperative, defiant, disobedient, and hostile behavior toward authority figures without major antisocial violations. Some of the behaviors presented may be normal in some age groups and with the appropriate frequencies, but abnormal behaviors are frequent, intensive, and cause dysfunction in social, academic, or work situations. Often, these behaviors are worse within the home environment than it is outside.
- Onset, Incidence, and Etiology: Due to difficulties in distinguishing negative behaviors from ODD, estimates range from 2% to 15% of adolescents having it, averaging 3%. Males are more likely to be diagnosed with ODD. It is believed that a combination of genes, temperament, and adverse social conditions interact to create ODD.
Manifestations
- Children with ODD often have lower self-concepts and lack competence in social situations.
- Limitations in associating their behaviors with both positive and negative consequences (lacking Judgment), indicating a decreased sensitivity to reward and punishment.
- Impaired problem-solving abilities.
- Deficient attention, flexible thinking, and decision-making.
- All the previous manifestations are even greater in children with ODD.
- Early onset results in worse symptoms, and comorbid conditions (often ADHD, anxiety, mood disorders) are associated with poorer long-term outcomes. Development of conduct disorders and antisocial personality disorder are more likely
Treatment and Management
- Parent Management Training Models of Behavioral Interventions are used because of a belief that problem behaviors are inadvertently trained and reinforced in the home or school environment.
- A hierarchy of problem behaviors is created, and the most disruptive or problematic behaviors are targeted.
- Parents should learn to ignore maladaptive behaviors rather than providing negative attention. Positive behaviors are rewarded with praise and reinforcers.
- Consistent consequences for the child’s defiant behaviors are implemented for every occurrence of the behavior.
- Adolescent children benefit from interventions that utilize personal strengths to improve behavioral and social functioning, such as the Coping Power Program.
- Individual Therapy may also be beneficial for older children.
- Psychopharmacologic Treatment has not been found to be useful for ODD, but is useful for comorbid conditions, the resolution of which may reduce the severity of ODD symptoms.
- Parent support also improves overall outcomes. As the behavior may be overwhelming, demanding, and unrelenting, two major challenges for caregivers are managing aggressive, defiant, and deceitful behaviors and interacting frequently with service providers and agencies.
Intermittent Explosive Disorder
IED is characterized by repeated episodes of impulsive, aggressive, violent behavior, and angry verbal outbursts, often lasting less than 30 minutes. Physical injury to the self and others, and property destruction may occur. Notably, emotional outbursts and reactions are out of proportion with the stimuli. After episodes, remorse and embarrassment may be felt, but this does not deter future episodes from occurring.
- Onset, Incidence, Etiology: IED may begin at any age, but is common during adolescence and young adulthood. It is related to childhood exposure to trauma, neglect, or maltreatment. Other potential causes include neurotransmitter imbalances esp. of serotonin, plasma tryptophan depletion, and frontal lobe dysfunction.
- Most people with IED have a concomitant psychiatric condition e.g. (most commonly) substance use/abuse, ADHD, ODD, conduct disorder, anxiety disorders, and depression.
Treatment and Management
- Pharmacologic Treatment:
- Fluoxene (Prozac)
- Lithium
- Anticonvulsant Mood Stabilizers e.g. Valproic Acid (Depakote), Phenytoin (Dilantin), Topiramate (Topamax), and Oxcarbazepine (Trileptal).
- Serotonin Reuptake Inhibitors Antidepressants (SSRIs) seem to reduce aggressive impulses and irritability in many people, but do not eliminate the outbursts.
- Other treatments may be used such as cognitive behavioral therapy, anger management strategies, avoidance of alcohol and other substances, and relaxation techniques.
Conduct Disorder
A disorder characterized by a persistent behavior that violates societal norms, rules, laws, and the rights of others. Significant impairment of social, academic, or occupational functioning occurs, with manifestations being categorized into four areas: aggression to people and animals, destruction of property, deceitfulness and theft, and serious violations of rules.
- Onset, Incidence, Etiology: These behaviors occur before the age of 10 primarily for boys, and onset afterwards occurs for both boys and girls. As many as 40% of these children will be diagnosed with antisocial personality disorder as adults. Genetic vulnerability, environmental adversity, and factors such as poor coping interact to cause this disorder.
- Risk Factors: poor parenting, child abuse, marital problems, lack of interest in treatment, low academic achievement, poor peer relationships, and low self-esteem.
Manifestations
- Children with conduct disorders often exhibit callous and unemotional traits, similar to adults with antisocial personality disorder. Empathy is minimal, there is lessened guilt or remorse, and shallow or superficial emotions.
- Performance at home, school, or work does not concern these individuals.
- Low self-esteem, poor frustration tolerance, and temper outbursts are displayed.
- Early sexual behavior, drinking, smoking, and the use of illegal substances among other risky behaviors are related with conduct behavior.
| Classification | Behavior | Examples |
|---|---|---|
| Mild | Some conduct problems that cause relatively minor harm to others. | Repeated lying, truancy, minor shoplifting, and staying out late without permission. |
| Moderate | Increased number of conduct problems and harm to others. | Vandalism, conning others, running away from home, verbal bullying and intimidation, drinking alcohol, and sexual promiscuity. |
| Severe | Many conduct problems with considerable harm to others. | Forced sex, cruelty to others, physical fights, cruelty to peers, use of a weapon, burglary, robbery, and violation of previous parole or probation requirements. |
Clinical Course
Two subtypes of conduct disorder depend on onset, and both have varying clinical courses:
- Childhood-Onset Conduct Disorder: an onset before 10 years of age, including physical aggression and disturbed peer relationships. Persistent conduct disorder and development of antisocial personality disorder are more common in this subtype. Even without antisocial personality disorder, these individuals as adults may lead troubled lives with difficult interpersonal relationships, unhealthy lifestyles, and an inability to support themselves.
- Adolescent-Onset Conduct Disorder: an onset after 10 years of age, which feature less aggression, more normal peer relationships, and less persistent conduct disorder and development of antisocial personality disorder. Adequate social relationships and academic or occupational success may be achieved.