DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT DISORDERS

The ADHD and Disruptive Behavior Disorders Work Group, chaired by David Shaffer of Columbia University and F. Xavier Castellanos of New York University, consisted of 10 members [37]. The group, charged with working on a broad set of conditions, broke into three subgroups. One subgroup focused on disorders now contained in the DSM-5 chapter entitled Disruptive,

Impulse-Control, and Conduct Disorders. First, the subgroup considered whether there was sufficient evidence to justify dividing oppositional defiant disorder (ODD) and conduct disorder (CD) into separate disorders. Second, the subgroup evaluated the diagnostic criteria of conduct disorder and anti- social personality disorder to determine whether they could be modified to achieve additional concordance. Finally, the subgroup considered whether to define a category of psychopathy, perhaps as a subcategory of CD [38].

DSM-5 brought together disorders from several DSM-IV chapters. Kleptomania and pyromania (previously in the DSM-IV chapter titled Impulse-Control Disorders Not Elsewhere Classified) remained unchanged in the DSM-5. ODD and CD remained as separate disorders because of their differential associations with other disorders. The diagnostic criteria of CD remained largely unchanged from the DSM-IV. To address the concept of psychopathy, the group added a “with limited prosocial emotions” specifier for individuals with persistent evidence for at least 12 months of two of the following:  “lack of remorse or guilt,” “lack of empathy,” “unconcern about performance,” and “shallow or deficient affect.”

Of the eight diagnoses included in this chapter, the work group made the most significant changes to ODD and intermittent explosive disorder (IED). ODD’s A criteria are now grouped into three categories defined as “angry/ irritable mood,” “argumentative/defiant behavior,” and “vindictiveness” to emphasize the possible presence of both emotional and behavioral symp- toms. After the A criteria, a note reads, “The persistence and frequency of these behaviors should be used to distinguish a behavior that is within nor- mal limits from a behavior that is symptomatic” [2 (p462)]. DSM-5 no longer excludes the option to diagnosis ODD if the individual meets criteria for CD, so individuals can now be diagnosed with both concurrently. The work group also added severity specifiers (mild, moderate, severe) based on research showing that symptom pervasiveness is a useful indicator of severity [3] .

DSM-5 criteria for IED are significantly expanded compared with DSM-IV. Criterion A  now includes acts of verbal aggression, whereas DSM-IV only acknowledged assaultive and noninjurious physical aggres- sion. The frequency of behavioral outbursts includes descriptors of both the number and duration of aggressive acts required to establish the diag- nosis. Criterion B emphasizes that the magnitude of aggression is grossly out of proportion to the stressor and is impulsive in nature. However, the text does not provide guidance on how to objectively evaluate whether an individual’s reaction is grossly out of proportion to a stressor. Furthermore, aggression is not considered impulsive if premeditated and performed to achieve some tangible objective (such as money, power, or intimidation). Individuals cannot be diagnosed with IED unless they are at least 6 years old and have impairment in functioning or negative consequences result- ing from the outbursts.

A separate note in DSM-5 states that IED may be diagnosed concurrently to ADHD, CD, ODD, or ASD when the impulsive outbursts are “in excess of those usually seen in these disorders and warrant independent clinical atten- tion” [2 (p466)]. This guideline may prove problematic because the DSM-5 does not delineate the expected number or severity of impulsive outbursts in these other conditions.

Because CD and ODD both have a high prevalence of impulsive aggressive acts, the evaluator may find it difficult to clearly determine when an indi- vidual should be additionally diagnosed with IED [39]. DSM-5 also does not specifically exclude diagnosing IED in individuals with antisocial personal- ity disorder or borderline personality disorder and describes that the impul- sive aggression in these two disorders is “lower than that in individuals with intermittent explosive disorder” [2 (p468)]. How clinicians and evaluators will determine the level of impulsive aggression that is “lower than” what is expected for IED is unclear. Based on DSM-5, a clinician could make a diag- nosis of both IED and a personality disorder.

The following vignette demonstrates some of the possible implications of the changes to the Disruptive, Impulse-Control, and Conduct Disorders:

J.E.  is a 13-year-old boy whose parents bring him to the outpatient clinic for a psychiatric evaluation after his teachers reported a range of worsening behavioral problems. Over the last two years, he has repeatedly lost his tem- per when not getting his way, cursed out his teachers over homework assign- ments, blamed other children for his inability to complete tasks during class time, and gleefully thrown spitballs at his peers. Over the last few months, J.E. has been truant from class with no explanation. During his sessions with a therapist, J.E. reveals that since age 11 he has been fascinated with killing small mammals with a hatchet. He also relishes lighting fires in the woods to see how much foliage he can burn. J.E. states that he does not feel remorseful about these behaviors, despite the harm or pain they cause. He states that he gets away with it by lying to his parents, usually telling them that he is doing homework at a friend’s house.

Using DSM-IV criteria, J.E.  would be diagnosed with conduct disorder, adolescent-onset type, moderate. Now that ODD and CD can be diagnosed together based on DSM-5, he would receive diagnoses of oppositional defiant disorder, moderate severity, and conduct disorder, adolescent-onset type, moderate. In addition, due to his profound lack of remorse and lack of con- cerns about his performance in daily tasks at school and home over the last 12 months, he meets criteria for the specifier, “with limited prosocial emo- tions” [2 (p470)].

Because J.E. shows evidence of impulsive, aggressive behaviors such as verbal sparring with his teachers, he could also meet criteria for IED. Given DSM-5’s

somewhat unclear criteria about the magnitude of aggression that is out of proportion to the provocation (teachers scolding him for not completing home- work) and excessiveness of impulsive, aggressive outbursts seen in his comorbid disorders (ODD and CD), the evaluator would have to subjectively determine whether J.E. meets criteria for IED in addition to his other diagnoses.