PSYCHIATRY
Disruptive, Impulse-Control And Conduct Disorders
DR. PAGADDU JANUARY 2020
Six conditions comprise the category of disruptive, impulse-control
and conducts disorders
(1) ODD
(2) Conduct Disorder
(3)intermittent explosive disorder
(4) kleptomania,
(5) pyromania,
§ characterized by the inability to resist an intense impulse,
drive, or temptation to perform a particular act that is
obviously harmful to self or others, or both
§ before the event, the individual usually experiences
mounting tension and arousal, sometimes “but not
consistently” mingled with conscious anticipatory pleasure
§ completing the action brings immediate gratification and
relief
§ afterward, the individual experiences a conflation of
remorse, guilt, self-reproach, and dread
Etiology
ú Psychodynamic, psychosocial, and biological factors all
play an important role in impulse-control disorders
ú the primary causal factor remains unknown
ú Some impulse-control disorders may have common
underlying neurobiological mechanisms
ú Fatigue, incessant stimulation, and psychic trauma can
lower a person's resistance to control impulses
Psychodynamic Factors
ú An impulse is a disposition to act to decrease heightened
tension caused by the buildup of instinctual drives or by
diminished ego defenses against the drives.
ú The impulse disorders have in common an attempt to
bypass the experience of disabling symptoms or painful
affects by acting on the environment.
ú August Aichhorn: described impulsive behavior as related
to a weak superego and weak ego structures associated
with psychic trauma produced by childhood deprivation
ú Otto Fenichel: linked impulsive behavior to attempts to
master anxiety, guilt, depression, and other painful affects
by means of action
ú Heinz Kohut: to be related to an incomplete sense of self
ú Donald Winnicott: impulsive or deviant behavior in
children is a way for them to try to recapture a primitive
maternal relationship
Psychosocial Factors
ú are related to early-life events
ú may have had improper models for identification, such as
parents who had difficulty controlling impulses
ú others include exposure to violence in the home,
alcohol abuse, promiscuity, and antisocial behavior
Biological Factors
ú Experiments have shown that impulsive and violent
activity is associated with specific brain regions, such
as the limbic system, and that the inhibition of such
behaviors is associated with other brain regions
ú An association between Low CSF levels of 5-
hydroxyindoleacetic acid (5-HIAA) and impulsive
aggression
ú Testosterone has also been associated with violent and
aggressive behavior.
ú a relation between temporal lobe epilepsy and certain
impulsive violent behaviors, as well as an association of
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aggressive behavior in patients who have histories of
head trauma
ú serotonin neurotransmitter system mediates
symptoms evident in impulse-control disorders
Intermittent Explosive Disorder____________
§ manifests as discrete episodes of losing control of
aggressive impulses; these episodes can result in
serious assault or the destruction of property
§ aggressiveness expressed is grossly out of proportion
to any stressors that may have helped elicit the
episode
§ spells or attacks, appear within minutes or hours and,
regardless of duration, remit spontaneously and
quickly
§ after each episode, patients usually show genuine
regret or self-reproach, and signs of generalized
impulsivity or aggressiveness are absent between
episodes
§ The term epileptoid personality has been used to
convey the seizure-like quality of the characteristic
outbursts, which are not typical of the patient's usual
behavior, and to convey the suspicion of an organic
disease process
§ associated features suggesting possibility of an
epileptoid state: the presence of auras; postictal-like
changes in the sensorium, including partial or spotty
amnesia; and hypersensitivity to photic, aural, or
auditory stimuli
Epidemiology
§ M >W
§ Men are likely to be found in correctional institutions
and the women in psychiatric facilities
§ More common in first-degree biological relatives of
persons with the disorder
Comorbidity
§ high rates of fire setting in patients with intermittent
explosive disorder
§ substance use
§ mood, anxiety, and eating disorders
Etiology
§ Psychodynamic Factors
-occur as a defense against narcissistic injurious
events
§ Psychosocial Factors
o physically large, but dependent, men whose sense
of masculine identity is poor
o a sense of being useless and impotent or of being
unable to change the environment often precedes
an episode of physical violence, and a high level of
anxiety, guilt, and depression usually follows an
episode
o an unfavorable childhood environment often filled
with alcohol dependence, beatings, and threats to
life is usual in these patients
o Predisposing factors in infancy and
childhood:perinatal trauma, infantile seizures, head
trauma, encephalitis, minimal brain dysfunction,
and hyperactivity
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 PSYCHIATRY
Disruptive, Impulse-Control And Conduct Disorders
DR. PAGADDU JANUARY 2020
o identification with assaultive parental figures as
symbols of the target for violence
o early frustration, oppression, and hostility have
been noted as predisposing factors
§ Biological Factors
o disordered brain physiology, particularly in the
limbic system, is involved in most cases of episodic
violence
§ Familial and Genetic Factors
o First-degree relatives of patients with intermittent
explosive disorder have higher rates of impulse-
control disorders, depressive disorders, and
substance use disorders.
o Biological relatives of patients with the disorder
were more likely to have histories of temper or
explosive outbursts
DSM-5 DIAGNOSTIC CRITERIA FOR INTERMITTENT EXPLOSIVE
DISORDER
A. Recurrent behavioral outbursts representing a failure to
control aggressive impulses as manifested by either of the
following:
1. Verbal aggression (e.g., temper tantrums, tirades, verbal
arguments or fights) or physical aggression towards
property, animals, or other individuals, occurring twice
weekly, on average, for a period of 3 months. The physical
aggression does not result in damage or destruction of
property and does not result in physical injury to animals
or other individuals.
2. Three behavioral outbursts involving damage or
destruction of property and/or physical assault involving
physical injury against animals or other individuals occurring
within a 12-month period.
B. The magnitude of aggressiveness expressed during the recurrent
outbursts is grossly out of proportion to the provocation or to any
precipitating psychosocial stressors.
C. The recurrent aggressive outbursts are not premeditated (i.e.,
they are impulsive and/or anger-based) and are not committed to
achieve some tangible objective (e.g., money, power, intimidation).
D. The recurrent aggressive outbursts cause either marked distress
in the individual or impairment in occupational or interpersonal
functioning, or are associated with financial or legal consequences.
E. Chronological age is at least 6 years (or equivalent developmental
level).
F. The recurrent aggressive outbursts are 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 the physiological effects of a
substance (e.g., a drug of abuse, a medication). For children ages 6-1
8 years, aggressive behavior that occurs as part of an adjustment
disorder should not be considered for this diagnosis.
Note: This diagnosis can be made in addition to the diagnosis of
attention-deficit/hyperactivity disorder, conduct disorder,
oppositional defiant disorder, or autism spectrum disorder when
recurrent impulsive aggressive outbursts are in excess of those
usually seen in these disorders and warrant independent clinical
attention.
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Physical Findings and Laboratory Examination
ú a high incidence of soft neurological signs (e.g., reflex
asymmetries), nonspecific EEG findings, abnormal
neuropsychological testing results (e.g., letter reversal
difficulties), and accident susceptibility
ú Blood chemistry (liver and thyroid function tests, fasting
blood glucose, electrolytes), urinalysis (including drug
toxicology), and syphilis serology may help rule out other
causes of aggression.
ú MRI may reveal changes in the prefrontal cortex, which is
associated with loss of impulse control
Differential Diagnosis
ú psychotic disorders
ú personality change because of a GMC
ú antisocial or borderline personality disorder
ú substance intoxication (e.g., alcohol, barbiturates,
hallucinogens, and amphetamines)
ú epilepsy, brain tumors, degenerative diseases, and
endocrine disorders
ú conduct disorder
ú mania
ú amok
Course and Prognosis
ú may begin at any stage of life, but usually appears
between late adolescence and early adulthood
ú can be sudden or insidious
ú the course can be episodic or chronic
Treatment
ú combined pharmacological and psychotherapeutic
approach has the best chance of success
ú psychotherapy with patients who have intermittent
explosive disorder is
ú Group psychotherapy may be helpful, and family
therapy is useful
ú 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
ú Anticonvulsants
ú Lithium (Eskalith)
ú Benzodiazepines are sometimes used but have been
reported to produce a paradoxical reaction of
dyscontrol
ú Antipsychotics and tricyclic drugs have been effective in
some cases
ú SSRIs, trazodone , and buspirone are useful in reducing
impulsivity and aggression
ú Propranolol and other beta-adrenergic receptor
antagonists and calcium channel inhibitors have also
been effective in some cases
Kleptomania_________________________
○ a recurrent failure to resist impulses to steal objects
not needed for personal use or for monetary value
○ objects taken are often given away, returned
surreptitiously, or kept and hidden
○ characterized by mounting tension before the act,
followed by gratification and lessening of tension with
or without guilt, remorse, or depression after the act
○ stealing is not planned and does not involve others
○ may feel guilt and anxiety after the theft, but they do
not feel anger or vengeance
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 PSYCHIATRY
Disruptive, Impulse-Control And Conduct Disorders
DR. PAGADDU JANUARY 2020
○ the act of stealing is itself the goal
Epidemiology
§ prevalence is not known
§ estimated to be about 0.6%
§ male-to-female ratio is 1:3
§ the frequency of stealing ranged from less than 1 to 120
episodes a month
Comorbidity
§ have a high lifetime comorbidity of major affective illness
(usually, but not exclusively, depressive) and various
anxiety disorders
§ also include other impulse-control disorders (notably,
pathological gambling and compulsive shopping), eating
disorders, and substance abuse disorders ( naltrexone
alcoholism)
Etiology:
Psychosocial Factors
§ tend to appear in times of significant stress
§ those who focus on symbolism see meaning in the act
itself, the object stolen, and the victim of the theft
§ Anna Freud: the first thefts from mother's purse
indicate the degree to which all stealing is rooted in the
oneness between mother and child.
§ Karl Abraham : central feeling of being neglected,
injured, or unwanted.
SEVEN CATEGORIES OF STEALING IN CHRONICALLY ACTING-OUT
CHILDREN:
1. As a means of restoring the lost mother-child relationship
2. As an aggressive act
3. As a defense against fears of being damaged (perhaps a search by
girls for a penis or a protection against castration anxiety in boys)
4. As a means of seeking punishment
5. As a means of restoring or adding to self-esteem
6. In connection with, and as a reaction to, a family secret
7. As excitement (lust angst) and a substitute for a sexual act
Biological Factors
ú Brain diseases and mental retardation have been
associated with kleptomania
ú focal neurological signs, cortical atrophy, and enlarged
lateral ventricles have been found
ú disturbances in monoamine metabolism, particularly of
serotonin
Family and Genetic Factors
ú 7 % of first-degree relatives had obsessive-compulsive
disorder (OCD)
ú a higher rate of mood disorders has been reported in
family members
Differential Diagnosis
ú during psychotic illness, for example, acute mania,
major depression with psychotic features, or
schizophrenia
ú antisocial personality disorder
ú Shoplifting
ú Acute intoxication with drugs or alcohol
ú Alzheimer's disease or other dementing organic illness
ú Malingering
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Course and Prognosis
ú May begin in childhood
ú Onset in late adolescence
ú waxes and wanes
ú tends to be chronic
ú prognosis with treatment can be good, but few patients
come for help of their own accord
Treatment
ú Insight-oriented psychotherapy and psychoanalysis have
been successful, but depend on patients' motivations.
ú Behavior therapy, including systematic desensitization,
aversive conditioning, and a combination of aversive
conditioning and altered social contingencies, has been
reported successful,
ú SSRIs, tricyclic drugs, trazodone, lithium, valproate, and
ú ECT
Pyromania_______________________
o the recurrent, deliberate, and purposeful setting of fires
o include tension or affective arousal before setting the
fires; fascination with, interest in, curiosity about, or
attraction to fire and the activities and equipment
associated with firefighting; and pleasure, gratification,
or relief when setting fires or when witnessing or
participating in their aftermath
o Pyromania differs from arson in that the latter is done
for financial gain, revenge, or other reasons and is
planned beforehand.
Epidemiology
§ more often in men than in women with a male to
female ratio of approximately 8 to 1
§ More than 40% of arrested arsonists are younger than
18 years of age
§ Commonly associated features include alcohol
intoxication, sexual dysfunctions, below-average
intelligence quotient (IQ), chronic personal frustration,
and resentment toward authority figures.
§ Some fire setters become sexually aroused by the fire.
Comorbidity
§ significantly associated with:
§ substance abuse disorder (especially alcoholism);
§ affective disorders, depressive or bipolar;
§ other impulse control disorders, such as kleptomania
§ various personality disturbances, such as inadequate
and borderline personality disorders.
§ Attention-deficit disorder and learning disabilities;
§ mildly retarded
§ ADHD or adjustment disorders
Etiology:
Psychosocial
§ Freud: fire as a symbol of sexuality
§ Others: associated pyromania with an abnormal craving
for power and social prestige
§ several studies have noted that the fathers of patients
with pyromania were absent from the home. Thus, one
explanation of fire setting is that it represents a wish for
the absent father to return home as a rescuer, to put
out the fire, and to save the child from a difficult
existence.
§ delinquent trends in female fire setters include
promiscuity without pleasure and petty stealing, often
approaching kleptomania
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 PSYCHIATRY
Disruptive, Impulse-Control And Conduct Disorders
DR. PAGADDU JANUARY 2020
Biological Factors
§ Significantly low CSF levels of 5-HIAA and 3-methoxy-4-
hydroxyphenylglycol (MHPG) have been found in fire
setters, which suggests possible serotonergic or
adrenergic involvement.
§ presence of reactive hypoglycemia, based on blood
glucose concentrations on glucose tolerance tests, has
been put forward as a cause of pyromania
Differential Diagnosis
§ distinguishing between pyromania and the fascination
of many young children with matches, lighters, and fire
as part of the normal investigation of their
environments
§ must also be separated from incendiary acts of sabotage
carried out by dissident political extremists or by paid
torches, termed arsonists in the legal system
§ in conduct disorder and antisocial personality disorder,
it is a deliberate act, not a failure to resist an impulse
§ with schizophrenia or mania may set fires in response to
delusions or hallucinations
§ with brain dysfunction (e.g., dementia), mental
retardation, or substance intoxication may set fires
because of a failure to appreciate the consequences of
the act
Course and Prognosis
§ the typical age of onset of pyromania is unknown
§ onset is in adolescence or adulthood, the fire setting
tends to be deliberately destructive
§ episodic and may wax and wane in frequency
§ prognosis for treated children is good
§ complete remission is a realistic goal
§ prognosis for adults is guarded, because they frequently
deny their actions, refuse to take responsibility, are
dependent on alcohol, and lack insight
Treatment
§ treating fire setters has been difficult because of their
lack of motivation
§ NO single treatment has been proved effective
§ a number of modalities, including behavioral approaches,
should be tried
§ Incarceration may be the only method of preventing a
recurrence
§ in the case of children and adolescents, treatment of
pyromania or fire setting should include family therapy
Otherwise Specified or Unspecified Disorders
=
§ Stand between impulsive and compulsive disorders
§ An impulse is a tension state that can exist without an
action; a compulsion is a tension state that always has an
action component
§ the disorders are classified here as compulsions because
the patients feel “compelled” to act out their pathological
behavior; they cannot resist the impulse to do so
§ Impulses are acted on with the expectation of receiving
pleasure; compulsions are usually ego-dystonic
§ Repeated acting out of impulses leads to psychosocial
impairment
§ Compulsion does not always carry out the risk
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INTERNET COMPULSION___________________________________
ú called Internet Addiction
ú persons spend almost all their waking hours at the
computer terminal
ú Repetitive and constant , unable to resist strong urges to
use the computer or “surf the Web”
Proposed in DS M-5 internet gaming disorder
ú 4-10% of users meet the criteria
ú Having at least five of the following:
Treatment
§ Education
§ Online counseling
MOBILE OR CELL PHONE COMPULSION_______________________
§ some persons compulsively use mobile phones to call
others, friends, acquaintances, or business associates
§ they justify their need to contact others by giving plausible
reasons for calling
§ underlying conflicts may be expressed in the behavior,
such as fear of being alone, the need to satisfy
unconscious dependency needs, or undoing a hostile wish
toward a loved one, among others
REPETITIVE SELF-MUTILATION_______________________________
§ Persons who repeatedly cut themselves or do damage to
their bodies may do so in a compulsive manner
§ Parasuicidal behavior is common in borderline personality
disorder
§ Compulsive body piercing or tattooing may be a symptom
of a paraphilia or a depressive equivalent
§ In DSM-5 proposed diagnosis of “non-suicidal self injury”
COMPULSIVE SEXUAL BEHAVIOR___________________
§ some persons repeatedly seek out sexual
gratification, often in perverse ways (e.g.,
exhibitionism)
§ they are unable to control their behavior and
may not experience feelings of guilt after an
episode of acting-out behavior
§ sometimes called sexual addiction
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